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Eating disorders in men aged midlife and beyond
Maturitas 81 (2015) 248–255
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Maturitas journal homepage: www.elsevier.com/locate/maturitas
Review
Eating disorders in men aged midlife and beyond Deborah L. Reas ∗ , Kristin Stedal Regional Department for Eating Disorders, Division of Mental Health and Addiction, Oslo University Hospital, PO Box 4950 Nydalen, N-0424 Oslo, Norway
a r t i c l e
i n f o
Article history: Received 27 February 2015 Received in revised form 5 March 2015 Accepted 6 March 2015 Keywords: Eating disorders Males Men Elderly Late life Midlife
a b s t r a c t Eating disorders are serious psychiatric illnesses which can occur across the lifespan. Men aged midlife and beyond are vulnerable to stigma, shame, and stereotypes portraying eating disorders as afflictions of youth and female gender. Historically, men have been neglected in the field of eating disorders owing to traditional and female-centric approaches to conceptualization and classification. In this literature review, we identified 16 case reports of eating disorders in males ranging from the age of 40 to 81 years. The majority of cases reported an earlier onset in life, followed by a variable course of illness with periods of relapse interspersed with remission. Diagnostic crossover or symptom fluctuation was common. High rates of comorbid depression were found, and several cases described a history of weight cycling and premorbid obesity. Precipitating factors included stressors which disproportionately occur in later life, including loss due to death or divorce, changes in financial or housing situation, and medical issues. Very little is known regarding the prevalence of eating disorders in older men, with initial population estimates ranging from 0.02% to 1.6%. Rates of subthreshold eating disordered behavior are higher and appear to be increasing among older individuals and males in the community. Recent revisions in the DSM-5 will likely increase the broader applicability of diagnostic criteria for eating disorders, stimulating improved recognition of diverse presentations occurring across the lifespan for both genders. Eating disorders should be included in the differential diagnosis of unexplained weight gain or weight loss irrespective of age or gender. Multi-site studies are needed for adequate sampling and to allow larger empirical investigations regarding how to improve clinical practices in screening and assessment, as well the provision of differential care for older men suffering from an eating disorder. © 2015 Elsevier Ireland Ltd. All rights reserved.
Contents 1. 2.
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.1. Search strategy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.2. Inclusion criteria and data extraction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3. Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.1. Prevalence of eating disorders in older men: AN, BN, and EDNOS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.2. Binge eating disorder: Older age and male gender . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.3. Mortality risk associated with ED in males . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.4. Data from death certificates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.5. Case reports: An illustration of clinical presentations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.6. Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Conflict of interest statement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Competing interest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Funding information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Provenance and peer review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
∗ Corresponding author. Tel.: +43 664 1880 910. E-mail address: [email protected] (D.L. Reas). http://dx.doi.org/10.1016/j.maturitas.2015.03.004 0378-5122/© 2015 Elsevier Ireland Ltd. All rights reserved.
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1. Introduction Eating disorders are serious psychiatric illnesses characterized by aberrant eating behaviors with severe and chronic effects on quality of life, in addition to life-threatening morbidity and mortality [1]. The main diagnostic categories distinguished in the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders [2] are anorexia nervosa (AN), bulimia nervosa (BN), and recently added binge eating disorder (BED). Although eating disorders typically develop in adolescence or young adulthood, with a highly skewed sex distribution for AN and BN [3], these conditions are known to affect both men and women irrespective of age [4–7]. The past decades have witnessed a rapidly burgeoning literature on aging-related body image concerns and midlife eating disorders in women [8,9], whereas men of all ages remain an understudied, undertreated, and misunderstood population [10,11]. Men aged midlife and older are highly vulnerable to depression, stigma, and shame [10], largely owing to prevailing societal stereotypes associating eating disorders with youth and female gender. In addition to ascertainment bias in clinical settings, men are often excluded from research studies owing to low numbers [12], severely limiting our knowledge regarding evidence-based, best practices for this specific sub-population. In this paper, we review existing literature to identify clinical features and risks of eating disorders occurring in midlife and late life in men. This study represents a novel contribution by specifically focusing on older men. This is a subpopulation affected by eating disorders that has received very scant attention in the literature, also in comparison to male adolescents [13], college-aged men [14] and older women [5,15]. Prevalence data and mortality research are first discussed to highlight what is currently known regarding epidemiology and the risk of premature death from eating disorders among older males. Case studies documenting eating disorders in older men are then summarized to illustrate clinical presentations. This is a descriptive approach to provide an overview of a sparse, yet emerging literature on eating disorders in older males, which is otherwise largely characterized by isolated or supplemental data. We also use the review to identify significant gaps in extant literature as targets for future research. 2. Methods 2.1. Search strategy Literature searches were undertaken using the databases of Ovid Medline(R), PubMed(R), PsychINFO(R) and the Cochrane Library, from inception to the third week of January, 2015. The following keywords were used: (eating disorders/or anorexia nervosa/or binge-eating disorder/or bulimia nervosa/) AND (male or men or man) OR (elderly/or late onset/or geriatric/or elderly/or old). To supplement MEDLINE/PubMed/PsychInfo, we also performed a broad search using Google Scholar, which indexes scholarly papers across disciplines by most major academic publishers and repositories worldwide, further utilizing links to “Related articles” or “Cited by” provided under search results to explore related literature. Literature was also searched by cross-referencing and manuallysearching reference lists, to locate studies published prior to or not covered by online archiving or indexing. 2.2. Inclusion criteria and data extraction Inclusion criteria were (1) male gender, (2) eating disorder diagnosis, and (3) age criterion of 40 years or older. For definitional purposes, midlife was defined as ages 40–59 years and elderly or late life was defined as age 60 or older, consistent
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with a prior study by Lapid et al. [6]. To focus the scope, we did not consider research specific to muscle dysmorphia, which is a form of body dysmorphic disorder occurring almost exclusively in males and characterized by a preoccupation with the idea that one’s body is insufficiently muscular (see [16–18]). We also discarded studies on unintentional weight loss from malnutrition owing to starvation, cachexia or sarcopenia (for a review, see [19]), sometimes called anorexia of the ageing [20], anorexia of the elderly, senile anorexia, or simply, anorexia (loss of appetite). Titles and abstracts of the identified articles were examined and relevant papers were retrieved for further consideration. All identified case reports were screened and considered eligible for inclusion and the data extracted was entirely descriptive. No exclusion criteria or statistical methods were applied in a critical appraisal or synthesis, nor was an assessment of study-level or outcomelevel bias applicable for our purposes. To control for duplicate information, the results were imported and managed with Endnote (Version X6 for Windows, Thompson Reuters, New York, NY).
3. Discussion 3.1. Prevalence of eating disorders in older men: AN, BN, and EDNOS Prevalence data of eating disorders occurring in men aged midlife and older are strikingly few, and as such, our knowledge regarding the extent and consequences of this problem remains very limited. A study investigating discharge diagnoses of 466,590 male veterans with an average age of 60.2 years (SD = 14.2) revealed that 0.02% (N = 98) had an eating disorder based on ICD-9-CM criteria [21]. Ninety-one percent of the male veterans were over 40 years old, and the majority (N = 56) were diagnosed with EDNOS. Data from the Adult Psychiatric Morbidity Survey in the UK found rates of 0.3% for men aged 35–44 years, 0.8% for men aged 45–54, 0.1% for men aged 55–64 years, and 0.3% for men 65–74 years [22]. Those rates are based upon endorsement of two or more items on the SCOFF screening tool [23] plus significant impairment. A secondary analysis of the APMS data based on a positive SCOFF screen (2 or more items) but without impairment yielded rates of 1.6% for men versus 3.5% for women aged 50 years and older [24]. Supplemental data from the US National Comorbidity Replication revealed the lifetime prevalence of AN was 0.0% for men aged 45–59 years and 0.3% for ages 60 or older. The lifetime prevalence of BN was 1.3% for men aged 45–59 years and 0.3% for men aged 60 years or older (see Appendix Tables 1 and 2 in [25]). Although rates of full-threshold diagnoses were consistently 1¾ to 3 times higher for women than men, the NCR data found that the lifetime prevalence of subthreshold binge eating behavior (i.e., binges twice per week for 3 months but no distress or associated features) was 3 times higher for men than women (1.9% versus 0.6%). An Australian community study investigating time-trends reported that the prevalence of objective binge eating behavior in men increased from 2.6% to 4.1% between 1998 and 2008. Data also showed a significant and rapid increase in purging behavior among men and individuals aged 45 and older [26]. These trends indicate that future epidemiological studies should incorporate data on the prevalence and incidence of disordered eating behaviors and associated features, in addition to full-threshold diagnostic entities, as ‘other’ eating disorders may comprise the majority of male cases in the community [27]. Additionally, significant clinical impairment is associated with relatively infrequent levels of binge eating (once per month) among both genders, which is indicative of the public health impact of subtreshold disordered eating at the behavioral level [28].
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3.2. Binge eating disorder: Older age and male gender
3.4. Data from death certificates
Binge eating disorder is characterized by recurrent binge eating in the absence of inappropriate weight compensatory behaviors, and has been included as a formal psychiatric diagnosis in the DSM-5 [2]. Emerging epidemiological data suggests that binge eating disorder has a less skewed age and gender distribution than anorexia and bulimia nervosa, with an average age at treatment presentation in the mid-40s [29]. For example, Franko and colleagues [30] analyzed aggregate data from 11 completed randomized, controlled trials for BED (N = 1325) and found the average age at treatment was 47.0 years (SD = 10.7) for Caucasians, 45.1 years (SD = 11.4) for African Americans, and 42.7 years (SD = 10.1) for Hispanics. Binge eating disorder is estimated to affect 2.0% of adult men in the US [25]. Supplemental age data from the National Comorbidity Survey showed an estimated lifetime prevalence of 2.7% for men aged 45–59 years and 0.9% for men aged 60 or older [25]. In a study of 20 elderly adults aged 65–77 years with DSM-IV binge eating disorder, four (25%) participants were male; notably, 19 of 20 participants were classified as obese, with a mean BMI of 36.4 (10.6) kg/m2 . It was strongly argued that empirical studies of BED in elderly individuals represent a research priority owing to high rates of comorbid obesity, to inform the development of treatment strategies to improve quality of life for this population [31].
Using an alternative approach, some studies have examined death certificates or medical records from population registers to identify deaths associated with AN [37–39]. Hewitt et al. [37] reviewed 10 million U.S. death records from 1986 to 1990 using the National Center for Health Statistics. Risk of death related to AN was 11.03 per 100,000 for females and 2.73 per 100,000 for males. Of records listing anorexia on the death certificate, 79% of deaths occurred in those older than 45 years, and perhaps surprisingly, the median age for male deaths was 80 years. A Norwegian study examined two national registers, the National Patient Register and Causes of Death register for death certificates listing AN as an underlying or associated cause of death between 1992 and 2000. Rates of AN-related deaths in the Norwegian National Patient Register were 3.94 per 100,000 for men and 9.01 per 100,000 for women [39]. Mean age at death for males was 70.7 years (SD: 22.1). Data from the Causes of Death Registry showed comparable findings, with a rate of 3.45/100,000 for male and 16.53/100,000 for female deaths. Mean age at death was 55.3 (28.5) years for males and 47.4 (19.1) for females. The relatively high proportion of older and male deaths in register data was unexpected, and in stark contrast to findings from register-based studies with linkage to a well-defined cohort of ED. It has been argued that unreliability in death certificate diagnoses cannot be ruled out due to misclassification from inappropriate or inaccurate registration procedures associated with this methodological approach, i.e., register-data with no linkage to a clinical sample [39]. Indeed, a careful audit of British death certificates found that only 128 of 230 deaths in which AN was listed as the cause of death (1993–1999) were likely associated with a true psychiatric diagnosis of anorexia nervosa [38]. On the other hand, it should be acknowledged that under-recognition or misclassification of ED symptoms among older men, in particular, may comprise a significant portion of untreated cases. Limitations and methodological uncertainties significantly plague our ability to understand the effects of age and gender on mortality. However, accurate mortality estimates are very important for policy-making, funding allocation, and clinical decision-making [34] and along these lines, we argue that reliable mortality data are especially important to draw attention and resources to more diverse, non-traditional presentations of ED including older men.
3.3. Mortality risk associated with ED in males Recent research has been published investigating mortality risk in ED and collectively, these studies illustrate numerous methodological challenges which severely limit our understanding of risk of premature death due to ED in males. A meta-analysis by Arcelus et al. [32] reported the standard mortality ratio (SMR) was 5.86 (95% CI: 4.2–8.3) for AN, 1.93 (95% CI: 1.44–2.59) for BN, and 1.92 (95% CI: 1.46–2.52) for EDNOS. Of the studies extracted, 10 trials had missing gender data and 23 trials included no men. A recent, large meta-analysis of suicide reported a SMR of 31 (95% CI: 21–44) for AN and 7.5 (1.6–11.6) for BN [33]. No male data were used, in accordance with the majority of participants included in the trials. A meta-analysis by Keshaviah et al. [34] re-extracted and re-analyzed source data from prior meta-analyses [32,33] utilizing a rigorous approach to avoid duplicate entries and include cohorts with zero deaths without artificially altering data through continuity corrections. As done with prior meta-analyses, standard mortality ratios were calculated using official statistics for females aged 24–34 years. Keshaviah et al. [34] estimated that individuals with AN are 5.2 times more likely to die prematurely from any cause and 18.1 times more likely to die by suicide. Interestingly, their examination of study-level predictors of mortality revealed that fewer deaths were observed in studies with a higher percentage of males [34]. Two large-scale follow-up studies have since been published which offer greater insight on mortality rates due to ED in males. An investigation of 1009 AN patients including 23 males hospitalized between 1988 and 2004 reported a SMR of 8.08 (1.62–23.62) for male patients and 10.6 (7.6–14.4) for female patients [35]. Long-term survival did not differ between genders; however, 3year survival data suggested male patients died one year earlier than females (p = 0.017) following discharge from hospitalization. Another study of 2450 (5% men) patients with AN, BN, or BED treated in tertiary care between 1995 and 2010 found a mortality rate of 2.65 per 1000 person-years and a RR of 3.52 (2.44–5.09) for all-cause mortality for the female patients; whereas the mortality rate for males was 9.10 per 1000 person-years and RR for all-cause mortality was 3.63 (95% CI: 1.40–9.41) [36].
3.5. Case reports: An illustration of clinical presentations Our literature search identified 16 case studies documenting eating disorders in men aged 40 years or older. As shown in Table 1, the mean age at treatment presentation was 58.3 years, with a range of 40 to 81 years. Seven cases were diagnosed with AN, 6 cases with BN, 2 were diagnosed with EDNOS, and 1 was diagnosed with BED. The majority of cases had been identified on inpatient psychiatric or geriatric units, or intermediate care or nursing facilities. Table 1 demonstrates high rates of comorbid depressive and anxiety disorders, including two patients who reported suicidal ideation. Of the 9 cases providing information on psychiatric comorbidity, the majority (78%) had a depressive disorder. Three cases were diagnosed with an anxiety disorder or obsessivecompulsive disorder, and 3 cases had a substance abuse disorder. High rates of medical comorbidity were also found, including gastrointestinal problems, osteoarthritis and osteoporosis, electrolyte abnormalities, and cardiovascular and pulmonary problems which included sinus bradycardia [40]. In addition to medical sequelae, evidence of psychosocial impairment directly associated with eating disorders was found. For example, the daughter of the 70-year old man reported that his issues surrounding food and eating were a contributing factor to the dissolution of an earlier marriage [41].
Table 1 Summary of case studies of eating disorders in older men. Treatment setting
Age
Age of onset
Diagnosis
Precipitating events
ED features
Psychiatric comorbidity
Medical comorbidity
Crisp and Toms [77]
St. George’s Hospital, Dep. of Psychiatry, London Department of Psychiatry, University of Iowa College of Medicine
46
30
AN
N/A
Low body weight Restrictive eating
N/A
N/A
45
21
AN
Prior medical illness at age 21 which caused weight loss. Witnessed death of overweight father due to heart attack at age 33 years Unknown
Low body weight 45.3 kg Restricted food intake Ritualistic eating Intense fear of wt. gain Binge eating Suspected laxative abuse
Depression Suicidal ideation
Episodic ataxia Sinus bradycardia
Low body weight 80 lbs Ritualistic eating Food avoidance Laxative misuse Self-induced vomiting Solitary exercising N/A
Anxiety
Osteoarthritis, edema, anemia, malnutrition, post poliomyelitis, constipation
Major depression, OCD; Bipolar disorder, alcohol dependence; Dysthymic disorder alcohol dependence; Agoraphobia w/o panic N/A
N/A
Black and Cadoret [40]
Ronch [66]
Fishkill Health Related Center, Inc., Intermediate Care Facility, Beacon, NY
75
Early onset
AN
Pope and Harrison [78]
McLean Hospital, Harvard Medical School, Boston, MA
41 56 42 40
39 54 34 30
BN BN BN BN
N/A
Barry and Salamon [79]
Skilled inpatient nursing facility, Hofstra University, New York, US
78
Mid 20s
BN
Nagaratnam et al. [47]
Geriatric and Rehabilitation Unit, Blacktown Hospital, Blacktown, New South Wales, Australia
70
Early onset
AN
Dropped out of workforce to care for mother with stomach cancer Abdominal pain and distention, gastrectomy, WWII Prisoner
Riemann et al. [55]
General surgical unit, Veterans Administration Medical Center, Wisconsin, USA
72
Weight gain from 20 s, then onset of restrictive eating at 53 yrs
AN
Premorbid obesity BMI = 33.0 Suffered heart attack at 52 yrs
Binge eating Rapid food intake Self-induced vomiting
Low body weight 31 kg Restrictive eating
N/A
Low body weight BMI = 18.0 Self-induced vomiting Restrictive eating Laxative misuse Excessive exercise Feelings of fatness Weight cycling
Elevated score on Beck Depression Inventory
Diabetes Electrolyte imbalance Fractured hip
D.L. Reas, K. Stedal / Maturitas 81 (2015) 248–255
Author
Muscle atrophy; immobility, low serum zinc, iron, phosphate, protein and albumin concentrations. Raised phosphatase and y-glutamyltransferase. Death during hospitalization N/A
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Table 1 (Continued) Treatment setting
Age
Age of onset
Diagnosis
Precipitating events
ED features
Psychiatric comorbidity
Medical comorbidity
Wills and Olivier [80]
Department of Old Age Psychiatry, Royal Hampshire Country Hospital, Winchester, UK Department of Psychiatry and Behavioral Sciences, University of Kansas School of Medicine, USA
67
N/A
AN
Death of caretaker Change in residence
Low body weight 44.8 kg Body image disturbance Calorie counting Refusal to eat
N/A
N/A
62
Early 30 s
BN
None
Suicidal ideation recurrent depressive disorder
Two fractures (hip and fibular) hypokalemia Asymptomatic bradycardia
Manejias Parke et al. [41]
Department of Psychiatry, University of New Mexico School of Medicine
72
EDNOS
Facial basal cell carcinoma Surgery
Cognitive disorder NOS; Aspergers syndrome; schizotypal traits
Poor wound healing; low cynaocobalamin; low blood count; low levels of iron, ferritin and iron saturation. Bradycardia, aortic valve stenosis, mild pulmonary hypertension
Rapinesi et al. [56]
Villa Rosa Hospital, Viterbo, Italy
41
Family reported an early onset of restrictive eating Onset of self-induced vomiting at 68 yrs AN diagnosed at 19 yrs Onset of binge eating at 39 yrs
Fear of weight gain Excessive exercise Laxative misuse Binge eating Self-induced vomiting Premorbid obesity (BMI = 38.0) History of weight cycling Low body weight BMI = 16.7 Food avoidance Restrictive eating Excessive exercising Self-induced vomiting
BED
Immobility due to severe obesity
Binge eating History of AN-restricting type
Class III obesity (BMI 97.05 kg/m2 ) Immobility
Malik et al. [66]
Redcliffe-Caboolture Mental Health Service, Caboolture Hospital, Australia
81
Unknown 10–12 years of ‘poor appetite’
AN
Death of spouse Health issues
Low body weight BMI = 17.0 Vomiting Food rituals Weight preoccupation Frequent weighing
Bipolar Disorder Depressive mood Psychotic symptoms Depressed mood
McCormack et al. [53]
Department of Psychology, University of Newcastle, Australia
45
At 16 yrs, ‘excessive eating’ and weight gain. Rapid weight loss at 43 yrs prompted tx.
EDNOS
Marital difficulties Death of mother
Restrictive eating Rapid weight loss BMI = 20.9 Self-induced vomiting Diet pills Excessive exercise History of binge eating Fear of fatness Premorbid obesity (BMI = 41.3)
Morgan and Marsh [54]
Depression, alcohol abuse
Note: AN = anorexia nervosa; BN = bulimia nervosa, EDNOS = eating disorder not otherwise specified; OCD = obsessive-compulsive disorder; N/A = data not available; BMI = body mass index (kg/m2 ).
Lumbar spine pain Fall Significant cardiac history (congestive cardiac failure, six myocardial infarctions) Renal cyst Hypophosphataemic (0.58 mmol/l) (ref. range 0.81–1.45) and hypoalbuminaemic (27 g/l) (ref. range 30–50). Small vessel ischaemia in the white matter N/A
D.L. Reas, K. Stedal / Maturitas 81 (2015) 248–255
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D.L. Reas, K. Stedal / Maturitas 81 (2015) 248–255
Clinical features included dietary restriction, food avoidance, ritualistic eating behavior, preoccupation with shape, weight, or calories, as well as binge eating and compensatory behaviors, including excessive exercise and self-induced vomiting. Diagnostic or symptom fluctuation was common. Collectively, these features reflect core diagnostic eating disorder attitudes and behaviors, rather than an atypical presentation or atypical syndrome which has sometimes been ascribed to males with eating disorders. Prior studies have generally reported more similarities than differences in symptomology, at least between younger male and female inpatients [42–44]. This may, however, partially attribute to setting biases, as more salient gender differences in ED phenomenology are likely in community settings versus clinical populations [45], or reflect inadequacies in measurement to assess male-specific constructs, as most assessment measures were originally designed and developed with young females [46]. One exception in clinical presentation was the 70-year old AN case described by Nagaratnam and Ghougassian [47], who presented with severe abdominal pain and a total gastrectomy, and died shortly following hospitalization. This case sparked disagreement regarding the diagnostic conclusions following its publication (e.g., [48]) and is illustrative of notable difficulties in reaching a differential diagnosis in elderly individuals presenting with malnutrition and refusal to eat, which is multi-factorial in etiology [49]. We opted to include this case, yet we underscore the potential for misdiagnosis, or misapplication of the term ‘anorexia’ in elderly individuals, an issue highlighted by others, including Beaumont et al. [50] and Vandereycken [51], who each highlighted several case reports purporting anorexia nervosa in older male patients which were considered lacking in sufficient clinical evidence to warrant this diagnosis (e.g., [52]). Four cases [53–55] reported premorbid or current obesity. The 41-year old male [56] diagnosed with BED and class III obesity reached his highest weight following an earlier episode of AN at the age of 19 years. Collectively, these reports converge with prior research suggesting premorbid obesity is more common among males than females [42]. One prior study, for example, found that 39% of male versus 13% of females admitted for inpatient treatment of AN between 1988 and 2004 were found to a history of overweight (BMI > 25) [35]. A Finnish twin study of lifetime AN found that higher BMI predated AN for the five probands, suggesting that “early overweight in otherwise vulnerable males seemed to have had a crucial role in triggering the dieting, which in turn (may) have led to AN” [57]. Similar to eating disorders occurring in later life among women [5], our review distinguished cases with a protracted, chronic course of illness, those who experience periods of relapse interspersed with remission, and apparent truly late-onset cases. Detailed inspection of the case reports illustrated notable difficulties in establishing age of onset among elderly individuals. For example, the ex-wife and daughter of a 72-year old male with BN revealed that food issues had existed “for more than 20 years, and possibly for as long as 40–50 years,” although his first encounter with mental health services occurred in his 70s [41]. Apparent newer onset cases may have, in fact, represent an exacerbation or reoccurrence of a pre-existing, yet previously undisclosed or unrecognized syndrome, a caveat long warned by Bruch [58]. Potential memory or recall bias affecting reporting behavior may be especially salient for elderly individuals due to cognitive difficulties or due to recalling events which occurred several decades ago. Precipitating events included loss of loved ones through divorce or death, marital difficulties, change of financial or housing situation, and health-related issues, e.g., cancer or surgery. These are issues which differentially occur in later life. Parallel research with older women has emphasized critical life stages such as pregnancy and menopause, breast and gynecological cancer, aging-related
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appearance changes, sexual objectification, and female role transitions [8,59] as triggers for midlife or late-life eating disorders. Research is sorely needed to understand precipitating factors which may be uniquely and specifically relevant to older men to improve clinical practices in detection, assessment, and the development of optimal treatment strategies. Very little is known about specific long-term medical complications of eating disorders in elderly men. Medical consequences generally associated with eating disorders include endocrine abnormalities, gastrointestinal problems, neurological changes, cardiovascular and pulmonary problems, electrolyte abnormalities (e.g., low sodium or potassium), diminished bone mineral density, and dermatological changes (e.g., dry skin and hair loss) [60,61]. Lower serum testosterone levels and decreased libido are generally associated with older age in men [62], and exacerbated effects may arise among those with a prolonged or long-standing history of an eating disorder. Elderly individuals suffering from eating disorders may be less resilient and more prone to severe complications such as fractures. There is evidence suggesting a high risk of osteoporosis in male patients with anorexia nervosa, in particular older males with a long duration of illness and very low BMI [63,64]. Our review identified related complications including osteoarthritis [65], lumbar spine pain [66], fractures and falls [54]. The 62-year old male patient reported by Morgan and Mash [54] had sustained two fractures during excessive exercise in his 50s. Although lower rates of excessive exercise might be expected due to frailty or age-related physical limitations in this population, we identified five cases aged 62–75 years old [41,53–55,65] who engaged in excessive exercise behavior. Future research is needed to determine the prevalence and severity of adverse psychiatric and medical risks of long-term weight-loss driven or muscularity-driven exercise behavior, as well as anabolic–androgenic steroids or supplement use, which is a common feature of eating disorders among younger men [67], not yet systematically examined among older men.
3.6. Conclusions We identified 16 case reports documenting the clinical features of ED in older men. Our work extends research by Lapid et al. [6] who identified six male cases in conjunction with 42 female cases of ED in individuals aged 50 years and older. Eating disorders should be included in the differential diagnosis of unexplained weight loss or weight gain, irrespective of the age or gender of the individual. High rates of depressive symptoms are common, yet coexisting depression should not deter clinicians from a full assessment of eating pathology when otherwise indicated [5]. A careful and comprehensive lifetime weight history is particularly relevant owing to rates of premorbid obesity in men with eating disorders, and family members may provide valuable information regarding illness onset and history. Perhaps surprisingly, a significant proportion of cases engaged in excessive exercise, including five men aged 62 to 75 years old. Excessive exercise behavior may contribute to falls and fractures in an aging population. Lastly, eating disorders in adult men are associated with psychosocial impairment, and relationships may suffer. We draw attention to recent diagnostic changes to the DSM-5, which are likely to increase the broader applicability of diagnostic criteria and spur recognition for the diverse range of individuals affected by these conditions, including post-menarchal women and men [68]. Binge eating disorder has also been recognized as a formal psychiatric diagnosis and is characterized by a far less skewed age and gender distribution. Amenorrhea is no longer a criterion for the diagnosis of anorexia nervosa, and the determination of significantly low weight in AN now occurs within the context of the individual’s age and sex.
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The relative infancy of epidemiological data has yielded few estimates to reliably gauge the prevalence of full-threshold eating disorders in males aged midlife and older, with initial 12-month population estimates ranging from 0.02% to 1.6%. Rates of subthreshold eating disordered behavior are higher and appear to be increasing among older individuals and males in the community. Very little remains known about risk of premature death due to ED in males. The surprisingly high proportion of older, male deaths on death certificates listing anorexia nervosa as an associated or underlying cause of death is incongruent with a meta-analysis observing fewer deaths in studies with a higher percentage of males [34]. Misclassification from inappropriate or inaccurate registration procedures is a likely source of bias when examining death certificates for anorexia nervosa without linkage to a well-defined clinical sample or patient register, although males may indeed comprise a significant portion of untreated cases. This review is limited to English-language case reports mostly published by academic settings over the past few decades. This was a descriptive approach which is limited by the inability to extrapolate findings. The level of detail in reporting symptom presentation and other clinically-relevant information varied considerably across case studies, and data such as age of onset may be particularly affected by recall bias or memory difficulties. Publication bias will also affect the literature base of available case studies, for example, late-onset cases may be overrepresented in journals due to novelty [69]. We lacked individual-level data for case series which appeared to include relevant cases. For example, Berkman et al. [70] observed that 2 of 28 males were, “were aged 40, or more” and Carlat et al. [44] reported a case series of 135 with a range of ages from 6 up to 60 years. We were also unable to locate a report of a 42-year old male treated by Dally [71] found referenced by Bruch [58]. As such, our review of cases has inarguably yielded an underestimate and should not be considered exhaustive. Eating disorders in midlife and later life has been described as a ‘neglected’ problem [72], but a steadily emerging literature suggests the issue is no longer a niche topic. Multi-site studies are needed to ensure adequate sampling and to allow empirical investigations regarding how to improve clinical practices in screening, assessment, and differential care for older men suffering from an eating disorder. Recent qualitative research on treatment experiences has highlighted the need to raise awareness and mental health literacy about men’s eating issues in both the lay public and among health professionals, and clearly outline stigma as an obstacle to help-seeking among males [73–76]. Owing to prevailing societal stereotypes of eating disorders as conditions exclusive to youth and female gender, men aged midlife and beyond might be the most stigmatized group to suffer from an eating disorder. We hope this literature review will promote clinical awareness in both mental health and non-mental health specialty settings providing care for elderly patients, such as primary care, thereby facilitating improved detection and timely management for older men struggling from an eating disorder.
Conflict of interest statement The authors declare no conflict of interest.
Contributors Dr. Deborah L. Reas wrote the manuscript and supervised the project. Dr. Kristin Stedal performed the literature review and prepared a draft of the method and tables. DR and KS have both read and approve the final version of the manuscript.
Competing interest None. Funding information The authors received no funding for this article. Provenance and peer review Commissioned; externally peer reviewed. References [1] AED. Critical points for early recognition and medical risk management in the care of individuals with eating disorders. In: Medical care standards task force report. Academy for Eating Disorders; 2012. [2] APA. Diagnostic and statistical manual of mental disorders. 5th ed. Arlington, VA: American Psychiatric Publishing; 2013. [3] Pedersen CB, Mors O, Bertelsen A, Waltoft BL, Agerbo E, McGrath JJ, et al. A comprehensive nationwide study of the incidence rate and lifetime risk for treated mental disorders. JAMA Psychiatry 2014;71:573–81. [4] Bulik CM. Midlife eating disorders: your journey to recovery. New York, NY: Walker & Company; 2013. [5] Cosford P, Arnold E. Anorexia nervosa in the elderly. Br J Psychiatry 1991;159:296–7. [6] Lapid MI, Prom MC, Burton MC, McAlpine DE, Sutor B, Rummans TA. Eating disorders in the elderly. Int Psychogeriatr 2010;22:523–36. [7] Newton J. Presentations of eating disorders later in life. J Pharm Pract Res 2013;43:231–6. [8] Kilpela L, Becker CB, Wesley N, Stewart TM. Body image in adult women: moving beyond the younger years. Adv Eat Disord, Available online February 23, 2015. [9] Mangweth-Matzek B, Hoek HW, Pope Jr HG. Pathological eating and body dissatisfaction in middle-aged and older women. Curr Opin Psychiatry 2014;27:431–5. [10] Strother E, Lemberg R, Stanford SC, Turberville D. Eating disorders in men: underdiagnosed, undertreated, and misunderstood. Eat Disord 2012;20:346–55. [11] Andersen A. Eating disorders in males: critical questions. In: Lemberg R, Cohn L, editors. Eating disorders: a reference sourcebook. Phoenix, AZ: Oryx Press; 1998. p. 73–8. [12] Andersen A. A brief history of eating disorders in males. In: Cohn L, Lemberg R, editors. Current findings on eating disorders in males. New York, NY: Routledge; 2014. [13] Wooldridge T, Lytle PP. An overview of anorexia nervosa in males. Eat Disord 2012;20:368–78. [14] Olivardia R, Pope Jr HG, Mangweth B, Hudson JI. Eating disorders in college men. Am J Psychiatry 1995;152:1279–85. [15] Joughin N, Crisp AH, Gowers SG, Bhat AV. The clinical features of late onset anorexia nervosa. Postgrad Med J 1991;67:973–7. [16] Kanayama G, Pope Jr HG. Gods, men, and muscle dysmorphia. Harv Rev Psychiatry 2011;19:95–8. [17] Murray SB, Rieger E, Touyz SW, De la Garza Garcia Lic Y. Muscle dysmorphia and the DSM-V conundrum: where does it belong? A review paper. Int J Eat Disord 2010;43:483–91. [18] Olivardia R. Mirror, mirror on the wall, who’s the largest of them all? The features and phenomenology of muscle dysmorphia. Harv Rev Psychiatry 2001;9:254–9. [19] Agarwal E, Miller M, Yaxley A, Isenring E. Malnutrition in the elderly: a narrative review. Maturitas 2013;76:296–302. [20] Malafarina V, Uriz-Otano F, Gil-Guerrero L, Iniesta R. The anorexia of ageing: physiopathology, prevalence, associated comorbidity and mortality. A systematic review. Maturitas 2013;74:293–302. [21] Striegel-Moore RH, Garvin V, Dohm FA, Rosenheck RA. Eating disorders in a national sample of hospitalized female and male veterans: detection rates and psychiatric comorbidity. Int J Eat Disord 1999;25:405–14. [22] McManus S, Meltzer H, Brugha T, Bebbington P, editors. Adult Psychiatric Morbidity in England, 2007: Results of a Household Survey. The NHS Information Centre for Health and Social Care; 2009. [23] Morgan JF, Reid F, Lacey JH. The SCOFF questionnaire: assessment of a new screening tool for eating disorders. BMJ 1999;319:1467–8. [24] Ng IS, Cheung KC, Chou KL. Correlates of eating disorder in middle-aged and older adults: evidence from 2007 British National Psychiatric Morbidity Survey. J Aging Health 2013;25:1106–20. [25] Hudson JI, Hiripi E, Pope Jr HG, Kessler RC. The prevalence and correlates of eating disorders in the National Comorbidity Survey Replication. Biol Psychiatry 2007;61:348–58. [26] Mitchison D, Hay P, Slewa-Younan S, Mond J. The changing demographic profile of eating disorder behaviors in the community. BMC Public Health 2014;14:943.
D.L. Reas, K. Stedal / Maturitas 81 (2015) 248–255 [27] Mond J, Mitchinson D, Hay P. Eating disordered behavior in men: prevalence, impairment in quality of life, and implications for prevenation and health promotion. In: Cohn L, Lemberg R, editors. Current findings on males with eating disorders. New York, NY: Routledge; 2012. [28] Striegel RH, Bedrosian R, Wang C, Schwartz S. Why men should be included in research on binge eating: results from a comparison of psychosocial impairment in men and women. Int J Eat Disord 2012;45:233–40. [29] Grilo CM. The epidemiology and nature of eating and weight disorders. In: Eating and weight disorders. New York, NY: Psychology Press; 2006. p. 27–65. [30] Franko DL, Thompson-Brenner H, Thompson DR, Boisseau CL, Davis A, Forbush KT, et al. Racial/ethnic differences in adults in randomized clinical trials of binge eating disorder. J Consult Clin Psychol 2012;80:186–95. [31] Guerdjikova AI, McElroy SL. Binge eating disorder pharmacotherapy clinical trials—who is left out. Eur Eat Disord Rev 2009;17:101–8. [32] Arcelus J, Mitchell AJ, Wales J, Nielsen S. Mortality rates in patients with anorexia nervosa and other eating disorders. A meta-analysis of 36 studies. Arch Gen Psychiatry 2011;68:724–31. [33] Preti A, Rocchi MB, Sisti D, Camboni MV, Miotto P. A comprehensive metaanalysis of the risk of suicide in eating disorders. Acta Psychiatr Scand 2011;124:6–17. [34] Keshaviah A, Edkins K, Hastings ER, Krishna M, Franko DL, Herzog DB, et al. Reexamining premature mortality in anorexia nervosa: a meta-analysis redux. Compr Psychiatry 2014;55:1773–84. [35] Gueguen J, Godart N, Chambry J, Brun-Eberentz A, Foulon C, Divac Phd SM, et al. Severe anorexia nervosa in men: comparison with severe AN in women and analysis of mortality. Int J Eat Disord 2012;45:537–45. [36] Suokas JT, Suvisaari JM, Gissler M, Lofman R, Linna MS, Raevuori A, et al. Mortality in eating disorders: a follow-up study of adult eating disorder patients treated in tertiary care, 1995–2010. Psychiatry Res 2013;210:1101–6. [37] Hewitt PL, Coren S, Steel GD. Death from anorexia nervosa: age span and sex differences. Aging Ment Health 2001;5:41–6. [38] Muir A, Palmer RL. An audit of a British sample of death certificates in which anorexia nervosa is listed as a cause of death. Int J Eat Disord 2004;36: 356–60. [39] Reas DL, Kjelsas E, Heggestad T, Eriksen L, Nielsen S, Gjertsen F, et al. Characteristics of anorexia nervosa-related deaths in Norway (1992–2000): data from the National Patient Register and the Causes of Death Register. Int J Eat Disord 2005;37:181–7. [40] Black DW, Cadoret RJ. Anorexia nervosa in a 45-year-old man. J Clin Psychiatry 1984;45:405–6. [41] Manejias Parke SG, Yager J, Apfeldorf W. Severe eating disorder initially diagnosed in a 72-year-old man. Int J Eat Disord 2008;41:376–9. [42] Crisp AH, Burns T, Bhat AV. Primary anorexia nervosa in the male and female: a comparison of clinical features and prognosis. Br J Med Psychol 1986;59(Pt 2):123–32. [43] Sterling J, Segal J. Anorexia nervosa in males: a critical review. Int J Eat Disord 1985;4:559–72. [44] Carlat DJ, Camargo Jr CA, Herzog DB. Eating disorders in males: a report on 135 patients. Am J Psychiatry 1997;154:1127–32. [45] Reas DL, Overas M, Ro O. Norms for the eating disorder examination questionnaire (EDE-Q) among high school and university men. Eat Disord 2012;20:437–43. [46] Darcy AM, Lin IH. Are we asking the right questions? A review of assessment of males with eating disorders. Eat Disord 2012;20:416–26. [47] Nagaratnam N, Ghougassian DF. Anorexia nervosa in a 70 year old man. Br Med J Clin Res Ed 1988;296:1443–4. [48] Fahy T. Anorexia nervosa. Br Med J 1988;296:1736. [49] Marcus EL, Berry EM. Refusal to eat in the elderly. Nutr Rev 1998;56:163–71. [50] Beaumont P, Bearwood C, Russell G. The occurrence of the syndrome of anorexia nervosa in male subjects. Psychol Med 1972;2:216–31. [51] Vandereycken W. Anorexia nervosa in adults. In: Blinder B, Chaitin B, Goldstein R, editors. The eating disorders: medical and psychological bases of diagnosis and treatment. New York: PMA Publishing Corp.; 1988. p. 295–304.
255
[52] Carlberger G, Einarsson K, Felig P, Hellstrom K, Wahren J, Wengle B, et al. Severe malnutrition in a middle-aged man with anorexia nervosa. Nutr Metab 1971;13:100–13. [53] McCormack L, Lewis V, Wells JR. Early life loss and trauma: eating disorder onset in a middle-aged male—a case study. Am J Men Health 2014;8:121–36. [54] Morgan CD, Marsh C. Bulimia nervosa in an elderly male: a case report. Int J Eat Disord 2006;39:170–1. [55] Riemann BC, McNally RJ, Meier A. Anorexia nervosa in an elderly man. Int J Eat Disord 1993;14:501–4. [56] Rapinesi C, Del Casale A, Serata D, Caccia F, Pietro SD, Scatena P, et al. Electroconvulsive therapy in a man with comorbid severe obesity, binge eating disorder, and bipolar disorder. J ECT 2013;29:142–4. [57] Raevuori A, Hoek HW, Susser E, Kaprio J, Rissanen A, Keski-Rahkonen A. Epidemiology of anorexia nervosa in men: a nationwide study of Finnish twins. PLoS ONE 2009;4:e4402. [58] Bruch H. Eating disorders: obesity, anorexia, and the person within. New York, NY: Basic Books; 1973. [59] Peat CM, Peyerl NL, Muehlenkamp JJ. Body image and eating disorders in older adults: a review. J Gen Psychol 2008;135:343–58. [60] Meczekalski B, Podfigurna-Stopa A, Katulski K. Long-term consequences of anorexia nervosa. Maturitas 2013;75:215–20. [61] Mitchell JE, Crow S. Medical complications of anorexia nervosa and bulimia nervosa. Curr Opin Psychiatry 2006;19:438–43. [62] Bain J. Testosterone and the aging male: to treat or not to treat? Maturitas 2010;66:16–22. [63] Mehler PS, Sabel AL, Watson T, Andersen AE. High risk of osteoporosis in male patients with eating disorders. Int J Eat Disord 2008;41:666–72. [64] Scurlock H, Timimi S, Robinson P. Case report osteoporosis as a complication of chronic anorexia nervosa in a male. Eur Eat Disord Rev 1997;5:42–6. [65] Ronch JL. Suspected anorexia nervosa in a 75-year-old institutionalized male: issues in diagnosis and intervention. J Aging Ment Health 1985;4:31–8. [66] Malik F, Wijayatunga U, Bruxner GM. A case of anorexia nervosa in an elderly man. Australas Psychiatry 2014;22:285–7. [67] Kanayama G, Hudson JI, Pope Jr HG. Long-term psychiatric and medical consequences of anabolic–androgenic steroid abuse: a looming public health concern. Drug Alcohol Depend 2008;98:1–12. [68] Raevuori A, Keski-Rahkonen A, Hoek HW. A review of eating disorders in males. Curr Opin Psychiatry 2014;27:426–30. [69] Main J, Reddy L, Lazarevic M, Whelan PJ. Are late-onset eating disorders in the elderly really the more common variant? Concerns around publication bias. Int Psychogeriatr 2011;23:670–1. [70] Berkman J. Anorexia nervosa, anorexia, inanition and low basal metabolic rate. Am J Med Sci 1930;180:411–24. [71] Dally P. Anorexia Nervosa. London: William Heineman Medical Books; 1969. [72] Zerbe K. Eating disorders in middle and late life: a neglected problem. Prim Psychiatry 2003;10:76. [73] Thapliyal P, Hay P. Treatment experiences of males with an eating disorder: a systematic review of qualitative studies. Transl Dev Psychiatr 2014;2:25552. [74] Bjork T, Wallin K, Pettersen G. Male experiences of life after recovery from an eating disorder. Eat Disord 2012;20:460–8. [75] Robinson KJ, Mountford VA, Sperlinger DJ. Being men with eating disorders: perspectives of male eating disorder service-users. J Health Psychol 2013;18:176–86. [76] Dearden A, Mulgrew KE. Service provision for men with eating issues in Australia: an analysis of organisations’, practitioners’, and men’s experiences. Aust Soc Work 2013;66:590–606. [77] Crisp AH, Toms DA. Primary anorexia nervosa or weight phobia in the male: report on 13 cases. Br Med J 1972;1:334–8. [78] Pope Jr HG, Hudson JI, Jonas JM. Bulimia in men: a series of fifteen cases. J Nerv Ment Dis 1986;174:117–9. [79] Barry B, Salamon MJ. Psychologically based idiosyncratic bulimia in a 78-yearold institutionalized male. J Aging Ment Health 1987;6:71–3. [80] Wills A, Olivier S. Anorexia nervosa in old age. J Aging Ment Health 1998;2:239–45.
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Review
Eating disorders in men aged midlife and beyond Deborah L. Reas ∗ , Kristin Stedal Regional Department for Eating Disorders, Division of Mental Health and Addiction, Oslo University Hospital, PO Box 4950 Nydalen, N-0424 Oslo, Norway
a r t i c l e
i n f o
Article history: Received 27 February 2015 Received in revised form 5 March 2015 Accepted 6 March 2015 Keywords: Eating disorders Males Men Elderly Late life Midlife
a b s t r a c t Eating disorders are serious psychiatric illnesses which can occur across the lifespan. Men aged midlife and beyond are vulnerable to stigma, shame, and stereotypes portraying eating disorders as afflictions of youth and female gender. Historically, men have been neglected in the field of eating disorders owing to traditional and female-centric approaches to conceptualization and classification. In this literature review, we identified 16 case reports of eating disorders in males ranging from the age of 40 to 81 years. The majority of cases reported an earlier onset in life, followed by a variable course of illness with periods of relapse interspersed with remission. Diagnostic crossover or symptom fluctuation was common. High rates of comorbid depression were found, and several cases described a history of weight cycling and premorbid obesity. Precipitating factors included stressors which disproportionately occur in later life, including loss due to death or divorce, changes in financial or housing situation, and medical issues. Very little is known regarding the prevalence of eating disorders in older men, with initial population estimates ranging from 0.02% to 1.6%. Rates of subthreshold eating disordered behavior are higher and appear to be increasing among older individuals and males in the community. Recent revisions in the DSM-5 will likely increase the broader applicability of diagnostic criteria for eating disorders, stimulating improved recognition of diverse presentations occurring across the lifespan for both genders. Eating disorders should be included in the differential diagnosis of unexplained weight gain or weight loss irrespective of age or gender. Multi-site studies are needed for adequate sampling and to allow larger empirical investigations regarding how to improve clinical practices in screening and assessment, as well the provision of differential care for older men suffering from an eating disorder. © 2015 Elsevier Ireland Ltd. All rights reserved.
Contents 1. 2.
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.1. Search strategy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.2. Inclusion criteria and data extraction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3. Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.1. Prevalence of eating disorders in older men: AN, BN, and EDNOS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.2. Binge eating disorder: Older age and male gender . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.3. Mortality risk associated with ED in males . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.4. Data from death certificates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.5. Case reports: An illustration of clinical presentations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.6. Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Conflict of interest statement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Competing interest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Funding information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Provenance and peer review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
∗ Corresponding author. Tel.: +43 664 1880 910. E-mail address: [email protected] (D.L. Reas). http://dx.doi.org/10.1016/j.maturitas.2015.03.004 0378-5122/© 2015 Elsevier Ireland Ltd. All rights reserved.
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1. Introduction Eating disorders are serious psychiatric illnesses characterized by aberrant eating behaviors with severe and chronic effects on quality of life, in addition to life-threatening morbidity and mortality [1]. The main diagnostic categories distinguished in the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders [2] are anorexia nervosa (AN), bulimia nervosa (BN), and recently added binge eating disorder (BED). Although eating disorders typically develop in adolescence or young adulthood, with a highly skewed sex distribution for AN and BN [3], these conditions are known to affect both men and women irrespective of age [4–7]. The past decades have witnessed a rapidly burgeoning literature on aging-related body image concerns and midlife eating disorders in women [8,9], whereas men of all ages remain an understudied, undertreated, and misunderstood population [10,11]. Men aged midlife and older are highly vulnerable to depression, stigma, and shame [10], largely owing to prevailing societal stereotypes associating eating disorders with youth and female gender. In addition to ascertainment bias in clinical settings, men are often excluded from research studies owing to low numbers [12], severely limiting our knowledge regarding evidence-based, best practices for this specific sub-population. In this paper, we review existing literature to identify clinical features and risks of eating disorders occurring in midlife and late life in men. This study represents a novel contribution by specifically focusing on older men. This is a subpopulation affected by eating disorders that has received very scant attention in the literature, also in comparison to male adolescents [13], college-aged men [14] and older women [5,15]. Prevalence data and mortality research are first discussed to highlight what is currently known regarding epidemiology and the risk of premature death from eating disorders among older males. Case studies documenting eating disorders in older men are then summarized to illustrate clinical presentations. This is a descriptive approach to provide an overview of a sparse, yet emerging literature on eating disorders in older males, which is otherwise largely characterized by isolated or supplemental data. We also use the review to identify significant gaps in extant literature as targets for future research. 2. Methods 2.1. Search strategy Literature searches were undertaken using the databases of Ovid Medline(R), PubMed(R), PsychINFO(R) and the Cochrane Library, from inception to the third week of January, 2015. The following keywords were used: (eating disorders/or anorexia nervosa/or binge-eating disorder/or bulimia nervosa/) AND (male or men or man) OR (elderly/or late onset/or geriatric/or elderly/or old). To supplement MEDLINE/PubMed/PsychInfo, we also performed a broad search using Google Scholar, which indexes scholarly papers across disciplines by most major academic publishers and repositories worldwide, further utilizing links to “Related articles” or “Cited by” provided under search results to explore related literature. Literature was also searched by cross-referencing and manuallysearching reference lists, to locate studies published prior to or not covered by online archiving or indexing. 2.2. Inclusion criteria and data extraction Inclusion criteria were (1) male gender, (2) eating disorder diagnosis, and (3) age criterion of 40 years or older. For definitional purposes, midlife was defined as ages 40–59 years and elderly or late life was defined as age 60 or older, consistent
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with a prior study by Lapid et al. [6]. To focus the scope, we did not consider research specific to muscle dysmorphia, which is a form of body dysmorphic disorder occurring almost exclusively in males and characterized by a preoccupation with the idea that one’s body is insufficiently muscular (see [16–18]). We also discarded studies on unintentional weight loss from malnutrition owing to starvation, cachexia or sarcopenia (for a review, see [19]), sometimes called anorexia of the ageing [20], anorexia of the elderly, senile anorexia, or simply, anorexia (loss of appetite). Titles and abstracts of the identified articles were examined and relevant papers were retrieved for further consideration. All identified case reports were screened and considered eligible for inclusion and the data extracted was entirely descriptive. No exclusion criteria or statistical methods were applied in a critical appraisal or synthesis, nor was an assessment of study-level or outcomelevel bias applicable for our purposes. To control for duplicate information, the results were imported and managed with Endnote (Version X6 for Windows, Thompson Reuters, New York, NY).
3. Discussion 3.1. Prevalence of eating disorders in older men: AN, BN, and EDNOS Prevalence data of eating disorders occurring in men aged midlife and older are strikingly few, and as such, our knowledge regarding the extent and consequences of this problem remains very limited. A study investigating discharge diagnoses of 466,590 male veterans with an average age of 60.2 years (SD = 14.2) revealed that 0.02% (N = 98) had an eating disorder based on ICD-9-CM criteria [21]. Ninety-one percent of the male veterans were over 40 years old, and the majority (N = 56) were diagnosed with EDNOS. Data from the Adult Psychiatric Morbidity Survey in the UK found rates of 0.3% for men aged 35–44 years, 0.8% for men aged 45–54, 0.1% for men aged 55–64 years, and 0.3% for men 65–74 years [22]. Those rates are based upon endorsement of two or more items on the SCOFF screening tool [23] plus significant impairment. A secondary analysis of the APMS data based on a positive SCOFF screen (2 or more items) but without impairment yielded rates of 1.6% for men versus 3.5% for women aged 50 years and older [24]. Supplemental data from the US National Comorbidity Replication revealed the lifetime prevalence of AN was 0.0% for men aged 45–59 years and 0.3% for ages 60 or older. The lifetime prevalence of BN was 1.3% for men aged 45–59 years and 0.3% for men aged 60 years or older (see Appendix Tables 1 and 2 in [25]). Although rates of full-threshold diagnoses were consistently 1¾ to 3 times higher for women than men, the NCR data found that the lifetime prevalence of subthreshold binge eating behavior (i.e., binges twice per week for 3 months but no distress or associated features) was 3 times higher for men than women (1.9% versus 0.6%). An Australian community study investigating time-trends reported that the prevalence of objective binge eating behavior in men increased from 2.6% to 4.1% between 1998 and 2008. Data also showed a significant and rapid increase in purging behavior among men and individuals aged 45 and older [26]. These trends indicate that future epidemiological studies should incorporate data on the prevalence and incidence of disordered eating behaviors and associated features, in addition to full-threshold diagnostic entities, as ‘other’ eating disorders may comprise the majority of male cases in the community [27]. Additionally, significant clinical impairment is associated with relatively infrequent levels of binge eating (once per month) among both genders, which is indicative of the public health impact of subtreshold disordered eating at the behavioral level [28].
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3.2. Binge eating disorder: Older age and male gender
3.4. Data from death certificates
Binge eating disorder is characterized by recurrent binge eating in the absence of inappropriate weight compensatory behaviors, and has been included as a formal psychiatric diagnosis in the DSM-5 [2]. Emerging epidemiological data suggests that binge eating disorder has a less skewed age and gender distribution than anorexia and bulimia nervosa, with an average age at treatment presentation in the mid-40s [29]. For example, Franko and colleagues [30] analyzed aggregate data from 11 completed randomized, controlled trials for BED (N = 1325) and found the average age at treatment was 47.0 years (SD = 10.7) for Caucasians, 45.1 years (SD = 11.4) for African Americans, and 42.7 years (SD = 10.1) for Hispanics. Binge eating disorder is estimated to affect 2.0% of adult men in the US [25]. Supplemental age data from the National Comorbidity Survey showed an estimated lifetime prevalence of 2.7% for men aged 45–59 years and 0.9% for men aged 60 or older [25]. In a study of 20 elderly adults aged 65–77 years with DSM-IV binge eating disorder, four (25%) participants were male; notably, 19 of 20 participants were classified as obese, with a mean BMI of 36.4 (10.6) kg/m2 . It was strongly argued that empirical studies of BED in elderly individuals represent a research priority owing to high rates of comorbid obesity, to inform the development of treatment strategies to improve quality of life for this population [31].
Using an alternative approach, some studies have examined death certificates or medical records from population registers to identify deaths associated with AN [37–39]. Hewitt et al. [37] reviewed 10 million U.S. death records from 1986 to 1990 using the National Center for Health Statistics. Risk of death related to AN was 11.03 per 100,000 for females and 2.73 per 100,000 for males. Of records listing anorexia on the death certificate, 79% of deaths occurred in those older than 45 years, and perhaps surprisingly, the median age for male deaths was 80 years. A Norwegian study examined two national registers, the National Patient Register and Causes of Death register for death certificates listing AN as an underlying or associated cause of death between 1992 and 2000. Rates of AN-related deaths in the Norwegian National Patient Register were 3.94 per 100,000 for men and 9.01 per 100,000 for women [39]. Mean age at death for males was 70.7 years (SD: 22.1). Data from the Causes of Death Registry showed comparable findings, with a rate of 3.45/100,000 for male and 16.53/100,000 for female deaths. Mean age at death was 55.3 (28.5) years for males and 47.4 (19.1) for females. The relatively high proportion of older and male deaths in register data was unexpected, and in stark contrast to findings from register-based studies with linkage to a well-defined cohort of ED. It has been argued that unreliability in death certificate diagnoses cannot be ruled out due to misclassification from inappropriate or inaccurate registration procedures associated with this methodological approach, i.e., register-data with no linkage to a clinical sample [39]. Indeed, a careful audit of British death certificates found that only 128 of 230 deaths in which AN was listed as the cause of death (1993–1999) were likely associated with a true psychiatric diagnosis of anorexia nervosa [38]. On the other hand, it should be acknowledged that under-recognition or misclassification of ED symptoms among older men, in particular, may comprise a significant portion of untreated cases. Limitations and methodological uncertainties significantly plague our ability to understand the effects of age and gender on mortality. However, accurate mortality estimates are very important for policy-making, funding allocation, and clinical decision-making [34] and along these lines, we argue that reliable mortality data are especially important to draw attention and resources to more diverse, non-traditional presentations of ED including older men.
3.3. Mortality risk associated with ED in males Recent research has been published investigating mortality risk in ED and collectively, these studies illustrate numerous methodological challenges which severely limit our understanding of risk of premature death due to ED in males. A meta-analysis by Arcelus et al. [32] reported the standard mortality ratio (SMR) was 5.86 (95% CI: 4.2–8.3) for AN, 1.93 (95% CI: 1.44–2.59) for BN, and 1.92 (95% CI: 1.46–2.52) for EDNOS. Of the studies extracted, 10 trials had missing gender data and 23 trials included no men. A recent, large meta-analysis of suicide reported a SMR of 31 (95% CI: 21–44) for AN and 7.5 (1.6–11.6) for BN [33]. No male data were used, in accordance with the majority of participants included in the trials. A meta-analysis by Keshaviah et al. [34] re-extracted and re-analyzed source data from prior meta-analyses [32,33] utilizing a rigorous approach to avoid duplicate entries and include cohorts with zero deaths without artificially altering data through continuity corrections. As done with prior meta-analyses, standard mortality ratios were calculated using official statistics for females aged 24–34 years. Keshaviah et al. [34] estimated that individuals with AN are 5.2 times more likely to die prematurely from any cause and 18.1 times more likely to die by suicide. Interestingly, their examination of study-level predictors of mortality revealed that fewer deaths were observed in studies with a higher percentage of males [34]. Two large-scale follow-up studies have since been published which offer greater insight on mortality rates due to ED in males. An investigation of 1009 AN patients including 23 males hospitalized between 1988 and 2004 reported a SMR of 8.08 (1.62–23.62) for male patients and 10.6 (7.6–14.4) for female patients [35]. Long-term survival did not differ between genders; however, 3year survival data suggested male patients died one year earlier than females (p = 0.017) following discharge from hospitalization. Another study of 2450 (5% men) patients with AN, BN, or BED treated in tertiary care between 1995 and 2010 found a mortality rate of 2.65 per 1000 person-years and a RR of 3.52 (2.44–5.09) for all-cause mortality for the female patients; whereas the mortality rate for males was 9.10 per 1000 person-years and RR for all-cause mortality was 3.63 (95% CI: 1.40–9.41) [36].
3.5. Case reports: An illustration of clinical presentations Our literature search identified 16 case studies documenting eating disorders in men aged 40 years or older. As shown in Table 1, the mean age at treatment presentation was 58.3 years, with a range of 40 to 81 years. Seven cases were diagnosed with AN, 6 cases with BN, 2 were diagnosed with EDNOS, and 1 was diagnosed with BED. The majority of cases had been identified on inpatient psychiatric or geriatric units, or intermediate care or nursing facilities. Table 1 demonstrates high rates of comorbid depressive and anxiety disorders, including two patients who reported suicidal ideation. Of the 9 cases providing information on psychiatric comorbidity, the majority (78%) had a depressive disorder. Three cases were diagnosed with an anxiety disorder or obsessivecompulsive disorder, and 3 cases had a substance abuse disorder. High rates of medical comorbidity were also found, including gastrointestinal problems, osteoarthritis and osteoporosis, electrolyte abnormalities, and cardiovascular and pulmonary problems which included sinus bradycardia [40]. In addition to medical sequelae, evidence of psychosocial impairment directly associated with eating disorders was found. For example, the daughter of the 70-year old man reported that his issues surrounding food and eating were a contributing factor to the dissolution of an earlier marriage [41].
Table 1 Summary of case studies of eating disorders in older men. Treatment setting
Age
Age of onset
Diagnosis
Precipitating events
ED features
Psychiatric comorbidity
Medical comorbidity
Crisp and Toms [77]
St. George’s Hospital, Dep. of Psychiatry, London Department of Psychiatry, University of Iowa College of Medicine
46
30
AN
N/A
Low body weight Restrictive eating
N/A
N/A
45
21
AN
Prior medical illness at age 21 which caused weight loss. Witnessed death of overweight father due to heart attack at age 33 years Unknown
Low body weight 45.3 kg Restricted food intake Ritualistic eating Intense fear of wt. gain Binge eating Suspected laxative abuse
Depression Suicidal ideation
Episodic ataxia Sinus bradycardia
Low body weight 80 lbs Ritualistic eating Food avoidance Laxative misuse Self-induced vomiting Solitary exercising N/A
Anxiety
Osteoarthritis, edema, anemia, malnutrition, post poliomyelitis, constipation
Major depression, OCD; Bipolar disorder, alcohol dependence; Dysthymic disorder alcohol dependence; Agoraphobia w/o panic N/A
N/A
Black and Cadoret [40]
Ronch [66]
Fishkill Health Related Center, Inc., Intermediate Care Facility, Beacon, NY
75
Early onset
AN
Pope and Harrison [78]
McLean Hospital, Harvard Medical School, Boston, MA
41 56 42 40
39 54 34 30
BN BN BN BN
N/A
Barry and Salamon [79]
Skilled inpatient nursing facility, Hofstra University, New York, US
78
Mid 20s
BN
Nagaratnam et al. [47]
Geriatric and Rehabilitation Unit, Blacktown Hospital, Blacktown, New South Wales, Australia
70
Early onset
AN
Dropped out of workforce to care for mother with stomach cancer Abdominal pain and distention, gastrectomy, WWII Prisoner
Riemann et al. [55]
General surgical unit, Veterans Administration Medical Center, Wisconsin, USA
72
Weight gain from 20 s, then onset of restrictive eating at 53 yrs
AN
Premorbid obesity BMI = 33.0 Suffered heart attack at 52 yrs
Binge eating Rapid food intake Self-induced vomiting
Low body weight 31 kg Restrictive eating
N/A
Low body weight BMI = 18.0 Self-induced vomiting Restrictive eating Laxative misuse Excessive exercise Feelings of fatness Weight cycling
Elevated score on Beck Depression Inventory
Diabetes Electrolyte imbalance Fractured hip
D.L. Reas, K. Stedal / Maturitas 81 (2015) 248–255
Author
Muscle atrophy; immobility, low serum zinc, iron, phosphate, protein and albumin concentrations. Raised phosphatase and y-glutamyltransferase. Death during hospitalization N/A
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Table 1 (Continued) Treatment setting
Age
Age of onset
Diagnosis
Precipitating events
ED features
Psychiatric comorbidity
Medical comorbidity
Wills and Olivier [80]
Department of Old Age Psychiatry, Royal Hampshire Country Hospital, Winchester, UK Department of Psychiatry and Behavioral Sciences, University of Kansas School of Medicine, USA
67
N/A
AN
Death of caretaker Change in residence
Low body weight 44.8 kg Body image disturbance Calorie counting Refusal to eat
N/A
N/A
62
Early 30 s
BN
None
Suicidal ideation recurrent depressive disorder
Two fractures (hip and fibular) hypokalemia Asymptomatic bradycardia
Manejias Parke et al. [41]
Department of Psychiatry, University of New Mexico School of Medicine
72
EDNOS
Facial basal cell carcinoma Surgery
Cognitive disorder NOS; Aspergers syndrome; schizotypal traits
Poor wound healing; low cynaocobalamin; low blood count; low levels of iron, ferritin and iron saturation. Bradycardia, aortic valve stenosis, mild pulmonary hypertension
Rapinesi et al. [56]
Villa Rosa Hospital, Viterbo, Italy
41
Family reported an early onset of restrictive eating Onset of self-induced vomiting at 68 yrs AN diagnosed at 19 yrs Onset of binge eating at 39 yrs
Fear of weight gain Excessive exercise Laxative misuse Binge eating Self-induced vomiting Premorbid obesity (BMI = 38.0) History of weight cycling Low body weight BMI = 16.7 Food avoidance Restrictive eating Excessive exercising Self-induced vomiting
BED
Immobility due to severe obesity
Binge eating History of AN-restricting type
Class III obesity (BMI 97.05 kg/m2 ) Immobility
Malik et al. [66]
Redcliffe-Caboolture Mental Health Service, Caboolture Hospital, Australia
81
Unknown 10–12 years of ‘poor appetite’
AN
Death of spouse Health issues
Low body weight BMI = 17.0 Vomiting Food rituals Weight preoccupation Frequent weighing
Bipolar Disorder Depressive mood Psychotic symptoms Depressed mood
McCormack et al. [53]
Department of Psychology, University of Newcastle, Australia
45
At 16 yrs, ‘excessive eating’ and weight gain. Rapid weight loss at 43 yrs prompted tx.
EDNOS
Marital difficulties Death of mother
Restrictive eating Rapid weight loss BMI = 20.9 Self-induced vomiting Diet pills Excessive exercise History of binge eating Fear of fatness Premorbid obesity (BMI = 41.3)
Morgan and Marsh [54]
Depression, alcohol abuse
Note: AN = anorexia nervosa; BN = bulimia nervosa, EDNOS = eating disorder not otherwise specified; OCD = obsessive-compulsive disorder; N/A = data not available; BMI = body mass index (kg/m2 ).
Lumbar spine pain Fall Significant cardiac history (congestive cardiac failure, six myocardial infarctions) Renal cyst Hypophosphataemic (0.58 mmol/l) (ref. range 0.81–1.45) and hypoalbuminaemic (27 g/l) (ref. range 30–50). Small vessel ischaemia in the white matter N/A
D.L. Reas, K. Stedal / Maturitas 81 (2015) 248–255
Author
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Clinical features included dietary restriction, food avoidance, ritualistic eating behavior, preoccupation with shape, weight, or calories, as well as binge eating and compensatory behaviors, including excessive exercise and self-induced vomiting. Diagnostic or symptom fluctuation was common. Collectively, these features reflect core diagnostic eating disorder attitudes and behaviors, rather than an atypical presentation or atypical syndrome which has sometimes been ascribed to males with eating disorders. Prior studies have generally reported more similarities than differences in symptomology, at least between younger male and female inpatients [42–44]. This may, however, partially attribute to setting biases, as more salient gender differences in ED phenomenology are likely in community settings versus clinical populations [45], or reflect inadequacies in measurement to assess male-specific constructs, as most assessment measures were originally designed and developed with young females [46]. One exception in clinical presentation was the 70-year old AN case described by Nagaratnam and Ghougassian [47], who presented with severe abdominal pain and a total gastrectomy, and died shortly following hospitalization. This case sparked disagreement regarding the diagnostic conclusions following its publication (e.g., [48]) and is illustrative of notable difficulties in reaching a differential diagnosis in elderly individuals presenting with malnutrition and refusal to eat, which is multi-factorial in etiology [49]. We opted to include this case, yet we underscore the potential for misdiagnosis, or misapplication of the term ‘anorexia’ in elderly individuals, an issue highlighted by others, including Beaumont et al. [50] and Vandereycken [51], who each highlighted several case reports purporting anorexia nervosa in older male patients which were considered lacking in sufficient clinical evidence to warrant this diagnosis (e.g., [52]). Four cases [53–55] reported premorbid or current obesity. The 41-year old male [56] diagnosed with BED and class III obesity reached his highest weight following an earlier episode of AN at the age of 19 years. Collectively, these reports converge with prior research suggesting premorbid obesity is more common among males than females [42]. One prior study, for example, found that 39% of male versus 13% of females admitted for inpatient treatment of AN between 1988 and 2004 were found to a history of overweight (BMI > 25) [35]. A Finnish twin study of lifetime AN found that higher BMI predated AN for the five probands, suggesting that “early overweight in otherwise vulnerable males seemed to have had a crucial role in triggering the dieting, which in turn (may) have led to AN” [57]. Similar to eating disorders occurring in later life among women [5], our review distinguished cases with a protracted, chronic course of illness, those who experience periods of relapse interspersed with remission, and apparent truly late-onset cases. Detailed inspection of the case reports illustrated notable difficulties in establishing age of onset among elderly individuals. For example, the ex-wife and daughter of a 72-year old male with BN revealed that food issues had existed “for more than 20 years, and possibly for as long as 40–50 years,” although his first encounter with mental health services occurred in his 70s [41]. Apparent newer onset cases may have, in fact, represent an exacerbation or reoccurrence of a pre-existing, yet previously undisclosed or unrecognized syndrome, a caveat long warned by Bruch [58]. Potential memory or recall bias affecting reporting behavior may be especially salient for elderly individuals due to cognitive difficulties or due to recalling events which occurred several decades ago. Precipitating events included loss of loved ones through divorce or death, marital difficulties, change of financial or housing situation, and health-related issues, e.g., cancer or surgery. These are issues which differentially occur in later life. Parallel research with older women has emphasized critical life stages such as pregnancy and menopause, breast and gynecological cancer, aging-related
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appearance changes, sexual objectification, and female role transitions [8,59] as triggers for midlife or late-life eating disorders. Research is sorely needed to understand precipitating factors which may be uniquely and specifically relevant to older men to improve clinical practices in detection, assessment, and the development of optimal treatment strategies. Very little is known about specific long-term medical complications of eating disorders in elderly men. Medical consequences generally associated with eating disorders include endocrine abnormalities, gastrointestinal problems, neurological changes, cardiovascular and pulmonary problems, electrolyte abnormalities (e.g., low sodium or potassium), diminished bone mineral density, and dermatological changes (e.g., dry skin and hair loss) [60,61]. Lower serum testosterone levels and decreased libido are generally associated with older age in men [62], and exacerbated effects may arise among those with a prolonged or long-standing history of an eating disorder. Elderly individuals suffering from eating disorders may be less resilient and more prone to severe complications such as fractures. There is evidence suggesting a high risk of osteoporosis in male patients with anorexia nervosa, in particular older males with a long duration of illness and very low BMI [63,64]. Our review identified related complications including osteoarthritis [65], lumbar spine pain [66], fractures and falls [54]. The 62-year old male patient reported by Morgan and Mash [54] had sustained two fractures during excessive exercise in his 50s. Although lower rates of excessive exercise might be expected due to frailty or age-related physical limitations in this population, we identified five cases aged 62–75 years old [41,53–55,65] who engaged in excessive exercise behavior. Future research is needed to determine the prevalence and severity of adverse psychiatric and medical risks of long-term weight-loss driven or muscularity-driven exercise behavior, as well as anabolic–androgenic steroids or supplement use, which is a common feature of eating disorders among younger men [67], not yet systematically examined among older men.
3.6. Conclusions We identified 16 case reports documenting the clinical features of ED in older men. Our work extends research by Lapid et al. [6] who identified six male cases in conjunction with 42 female cases of ED in individuals aged 50 years and older. Eating disorders should be included in the differential diagnosis of unexplained weight loss or weight gain, irrespective of the age or gender of the individual. High rates of depressive symptoms are common, yet coexisting depression should not deter clinicians from a full assessment of eating pathology when otherwise indicated [5]. A careful and comprehensive lifetime weight history is particularly relevant owing to rates of premorbid obesity in men with eating disorders, and family members may provide valuable information regarding illness onset and history. Perhaps surprisingly, a significant proportion of cases engaged in excessive exercise, including five men aged 62 to 75 years old. Excessive exercise behavior may contribute to falls and fractures in an aging population. Lastly, eating disorders in adult men are associated with psychosocial impairment, and relationships may suffer. We draw attention to recent diagnostic changes to the DSM-5, which are likely to increase the broader applicability of diagnostic criteria and spur recognition for the diverse range of individuals affected by these conditions, including post-menarchal women and men [68]. Binge eating disorder has also been recognized as a formal psychiatric diagnosis and is characterized by a far less skewed age and gender distribution. Amenorrhea is no longer a criterion for the diagnosis of anorexia nervosa, and the determination of significantly low weight in AN now occurs within the context of the individual’s age and sex.
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The relative infancy of epidemiological data has yielded few estimates to reliably gauge the prevalence of full-threshold eating disorders in males aged midlife and older, with initial 12-month population estimates ranging from 0.02% to 1.6%. Rates of subthreshold eating disordered behavior are higher and appear to be increasing among older individuals and males in the community. Very little remains known about risk of premature death due to ED in males. The surprisingly high proportion of older, male deaths on death certificates listing anorexia nervosa as an associated or underlying cause of death is incongruent with a meta-analysis observing fewer deaths in studies with a higher percentage of males [34]. Misclassification from inappropriate or inaccurate registration procedures is a likely source of bias when examining death certificates for anorexia nervosa without linkage to a well-defined clinical sample or patient register, although males may indeed comprise a significant portion of untreated cases. This review is limited to English-language case reports mostly published by academic settings over the past few decades. This was a descriptive approach which is limited by the inability to extrapolate findings. The level of detail in reporting symptom presentation and other clinically-relevant information varied considerably across case studies, and data such as age of onset may be particularly affected by recall bias or memory difficulties. Publication bias will also affect the literature base of available case studies, for example, late-onset cases may be overrepresented in journals due to novelty [69]. We lacked individual-level data for case series which appeared to include relevant cases. For example, Berkman et al. [70] observed that 2 of 28 males were, “were aged 40, or more” and Carlat et al. [44] reported a case series of 135 with a range of ages from 6 up to 60 years. We were also unable to locate a report of a 42-year old male treated by Dally [71] found referenced by Bruch [58]. As such, our review of cases has inarguably yielded an underestimate and should not be considered exhaustive. Eating disorders in midlife and later life has been described as a ‘neglected’ problem [72], but a steadily emerging literature suggests the issue is no longer a niche topic. Multi-site studies are needed to ensure adequate sampling and to allow empirical investigations regarding how to improve clinical practices in screening, assessment, and differential care for older men suffering from an eating disorder. Recent qualitative research on treatment experiences has highlighted the need to raise awareness and mental health literacy about men’s eating issues in both the lay public and among health professionals, and clearly outline stigma as an obstacle to help-seeking among males [73–76]. Owing to prevailing societal stereotypes of eating disorders as conditions exclusive to youth and female gender, men aged midlife and beyond might be the most stigmatized group to suffer from an eating disorder. We hope this literature review will promote clinical awareness in both mental health and non-mental health specialty settings providing care for elderly patients, such as primary care, thereby facilitating improved detection and timely management for older men struggling from an eating disorder.
Conflict of interest statement The authors declare no conflict of interest.
Contributors Dr. Deborah L. Reas wrote the manuscript and supervised the project. Dr. Kristin Stedal performed the literature review and prepared a draft of the method and tables. DR and KS have both read and approve the final version of the manuscript.
Competing interest None. Funding information The authors received no funding for this article. Provenance and peer review Commissioned; externally peer reviewed. References [1] AED. Critical points for early recognition and medical risk management in the care of individuals with eating disorders. In: Medical care standards task force report. Academy for Eating Disorders; 2012. [2] APA. Diagnostic and statistical manual of mental disorders. 5th ed. Arlington, VA: American Psychiatric Publishing; 2013. [3] Pedersen CB, Mors O, Bertelsen A, Waltoft BL, Agerbo E, McGrath JJ, et al. A comprehensive nationwide study of the incidence rate and lifetime risk for treated mental disorders. JAMA Psychiatry 2014;71:573–81. [4] Bulik CM. Midlife eating disorders: your journey to recovery. New York, NY: Walker & Company; 2013. [5] Cosford P, Arnold E. Anorexia nervosa in the elderly. Br J Psychiatry 1991;159:296–7. [6] Lapid MI, Prom MC, Burton MC, McAlpine DE, Sutor B, Rummans TA. Eating disorders in the elderly. Int Psychogeriatr 2010;22:523–36. [7] Newton J. Presentations of eating disorders later in life. J Pharm Pract Res 2013;43:231–6. [8] Kilpela L, Becker CB, Wesley N, Stewart TM. Body image in adult women: moving beyond the younger years. Adv Eat Disord, Available online February 23, 2015. [9] Mangweth-Matzek B, Hoek HW, Pope Jr HG. Pathological eating and body dissatisfaction in middle-aged and older women. Curr Opin Psychiatry 2014;27:431–5. [10] Strother E, Lemberg R, Stanford SC, Turberville D. Eating disorders in men: underdiagnosed, undertreated, and misunderstood. Eat Disord 2012;20:346–55. [11] Andersen A. Eating disorders in males: critical questions. In: Lemberg R, Cohn L, editors. Eating disorders: a reference sourcebook. Phoenix, AZ: Oryx Press; 1998. p. 73–8. [12] Andersen A. A brief history of eating disorders in males. In: Cohn L, Lemberg R, editors. Current findings on eating disorders in males. New York, NY: Routledge; 2014. [13] Wooldridge T, Lytle PP. An overview of anorexia nervosa in males. Eat Disord 2012;20:368–78. [14] Olivardia R, Pope Jr HG, Mangweth B, Hudson JI. Eating disorders in college men. Am J Psychiatry 1995;152:1279–85. [15] Joughin N, Crisp AH, Gowers SG, Bhat AV. The clinical features of late onset anorexia nervosa. Postgrad Med J 1991;67:973–7. [16] Kanayama G, Pope Jr HG. Gods, men, and muscle dysmorphia. Harv Rev Psychiatry 2011;19:95–8. [17] Murray SB, Rieger E, Touyz SW, De la Garza Garcia Lic Y. Muscle dysmorphia and the DSM-V conundrum: where does it belong? A review paper. Int J Eat Disord 2010;43:483–91. [18] Olivardia R. Mirror, mirror on the wall, who’s the largest of them all? The features and phenomenology of muscle dysmorphia. Harv Rev Psychiatry 2001;9:254–9. [19] Agarwal E, Miller M, Yaxley A, Isenring E. Malnutrition in the elderly: a narrative review. Maturitas 2013;76:296–302. [20] Malafarina V, Uriz-Otano F, Gil-Guerrero L, Iniesta R. The anorexia of ageing: physiopathology, prevalence, associated comorbidity and mortality. A systematic review. Maturitas 2013;74:293–302. [21] Striegel-Moore RH, Garvin V, Dohm FA, Rosenheck RA. Eating disorders in a national sample of hospitalized female and male veterans: detection rates and psychiatric comorbidity. Int J Eat Disord 1999;25:405–14. [22] McManus S, Meltzer H, Brugha T, Bebbington P, editors. Adult Psychiatric Morbidity in England, 2007: Results of a Household Survey. The NHS Information Centre for Health and Social Care; 2009. [23] Morgan JF, Reid F, Lacey JH. The SCOFF questionnaire: assessment of a new screening tool for eating disorders. BMJ 1999;319:1467–8. [24] Ng IS, Cheung KC, Chou KL. Correlates of eating disorder in middle-aged and older adults: evidence from 2007 British National Psychiatric Morbidity Survey. J Aging Health 2013;25:1106–20. [25] Hudson JI, Hiripi E, Pope Jr HG, Kessler RC. The prevalence and correlates of eating disorders in the National Comorbidity Survey Replication. Biol Psychiatry 2007;61:348–58. [26] Mitchison D, Hay P, Slewa-Younan S, Mond J. The changing demographic profile of eating disorder behaviors in the community. BMC Public Health 2014;14:943.
D.L. Reas, K. Stedal / Maturitas 81 (2015) 248–255 [27] Mond J, Mitchinson D, Hay P. Eating disordered behavior in men: prevalence, impairment in quality of life, and implications for prevenation and health promotion. In: Cohn L, Lemberg R, editors. Current findings on males with eating disorders. New York, NY: Routledge; 2012. [28] Striegel RH, Bedrosian R, Wang C, Schwartz S. Why men should be included in research on binge eating: results from a comparison of psychosocial impairment in men and women. Int J Eat Disord 2012;45:233–40. [29] Grilo CM. The epidemiology and nature of eating and weight disorders. In: Eating and weight disorders. New York, NY: Psychology Press; 2006. p. 27–65. [30] Franko DL, Thompson-Brenner H, Thompson DR, Boisseau CL, Davis A, Forbush KT, et al. Racial/ethnic differences in adults in randomized clinical trials of binge eating disorder. J Consult Clin Psychol 2012;80:186–95. [31] Guerdjikova AI, McElroy SL. Binge eating disorder pharmacotherapy clinical trials—who is left out. Eur Eat Disord Rev 2009;17:101–8. [32] Arcelus J, Mitchell AJ, Wales J, Nielsen S. Mortality rates in patients with anorexia nervosa and other eating disorders. A meta-analysis of 36 studies. Arch Gen Psychiatry 2011;68:724–31. [33] Preti A, Rocchi MB, Sisti D, Camboni MV, Miotto P. A comprehensive metaanalysis of the risk of suicide in eating disorders. Acta Psychiatr Scand 2011;124:6–17. [34] Keshaviah A, Edkins K, Hastings ER, Krishna M, Franko DL, Herzog DB, et al. Reexamining premature mortality in anorexia nervosa: a meta-analysis redux. Compr Psychiatry 2014;55:1773–84. [35] Gueguen J, Godart N, Chambry J, Brun-Eberentz A, Foulon C, Divac Phd SM, et al. Severe anorexia nervosa in men: comparison with severe AN in women and analysis of mortality. Int J Eat Disord 2012;45:537–45. [36] Suokas JT, Suvisaari JM, Gissler M, Lofman R, Linna MS, Raevuori A, et al. Mortality in eating disorders: a follow-up study of adult eating disorder patients treated in tertiary care, 1995–2010. Psychiatry Res 2013;210:1101–6. [37] Hewitt PL, Coren S, Steel GD. Death from anorexia nervosa: age span and sex differences. Aging Ment Health 2001;5:41–6. [38] Muir A, Palmer RL. An audit of a British sample of death certificates in which anorexia nervosa is listed as a cause of death. Int J Eat Disord 2004;36: 356–60. [39] Reas DL, Kjelsas E, Heggestad T, Eriksen L, Nielsen S, Gjertsen F, et al. Characteristics of anorexia nervosa-related deaths in Norway (1992–2000): data from the National Patient Register and the Causes of Death Register. Int J Eat Disord 2005;37:181–7. [40] Black DW, Cadoret RJ. Anorexia nervosa in a 45-year-old man. J Clin Psychiatry 1984;45:405–6. [41] Manejias Parke SG, Yager J, Apfeldorf W. Severe eating disorder initially diagnosed in a 72-year-old man. Int J Eat Disord 2008;41:376–9. [42] Crisp AH, Burns T, Bhat AV. Primary anorexia nervosa in the male and female: a comparison of clinical features and prognosis. Br J Med Psychol 1986;59(Pt 2):123–32. [43] Sterling J, Segal J. Anorexia nervosa in males: a critical review. Int J Eat Disord 1985;4:559–72. [44] Carlat DJ, Camargo Jr CA, Herzog DB. Eating disorders in males: a report on 135 patients. Am J Psychiatry 1997;154:1127–32. [45] Reas DL, Overas M, Ro O. Norms for the eating disorder examination questionnaire (EDE-Q) among high school and university men. Eat Disord 2012;20:437–43. [46] Darcy AM, Lin IH. Are we asking the right questions? A review of assessment of males with eating disorders. Eat Disord 2012;20:416–26. [47] Nagaratnam N, Ghougassian DF. Anorexia nervosa in a 70 year old man. Br Med J Clin Res Ed 1988;296:1443–4. [48] Fahy T. Anorexia nervosa. Br Med J 1988;296:1736. [49] Marcus EL, Berry EM. Refusal to eat in the elderly. Nutr Rev 1998;56:163–71. [50] Beaumont P, Bearwood C, Russell G. The occurrence of the syndrome of anorexia nervosa in male subjects. Psychol Med 1972;2:216–31. [51] Vandereycken W. Anorexia nervosa in adults. In: Blinder B, Chaitin B, Goldstein R, editors. The eating disorders: medical and psychological bases of diagnosis and treatment. New York: PMA Publishing Corp.; 1988. p. 295–304.
255
[52] Carlberger G, Einarsson K, Felig P, Hellstrom K, Wahren J, Wengle B, et al. Severe malnutrition in a middle-aged man with anorexia nervosa. Nutr Metab 1971;13:100–13. [53] McCormack L, Lewis V, Wells JR. Early life loss and trauma: eating disorder onset in a middle-aged male—a case study. Am J Men Health 2014;8:121–36. [54] Morgan CD, Marsh C. Bulimia nervosa in an elderly male: a case report. Int J Eat Disord 2006;39:170–1. [55] Riemann BC, McNally RJ, Meier A. Anorexia nervosa in an elderly man. Int J Eat Disord 1993;14:501–4. [56] Rapinesi C, Del Casale A, Serata D, Caccia F, Pietro SD, Scatena P, et al. Electroconvulsive therapy in a man with comorbid severe obesity, binge eating disorder, and bipolar disorder. J ECT 2013;29:142–4. [57] Raevuori A, Hoek HW, Susser E, Kaprio J, Rissanen A, Keski-Rahkonen A. Epidemiology of anorexia nervosa in men: a nationwide study of Finnish twins. PLoS ONE 2009;4:e4402. [58] Bruch H. Eating disorders: obesity, anorexia, and the person within. New York, NY: Basic Books; 1973. [59] Peat CM, Peyerl NL, Muehlenkamp JJ. Body image and eating disorders in older adults: a review. J Gen Psychol 2008;135:343–58. [60] Meczekalski B, Podfigurna-Stopa A, Katulski K. Long-term consequences of anorexia nervosa. Maturitas 2013;75:215–20. [61] Mitchell JE, Crow S. Medical complications of anorexia nervosa and bulimia nervosa. Curr Opin Psychiatry 2006;19:438–43. [62] Bain J. Testosterone and the aging male: to treat or not to treat? Maturitas 2010;66:16–22. [63] Mehler PS, Sabel AL, Watson T, Andersen AE. High risk of osteoporosis in male patients with eating disorders. Int J Eat Disord 2008;41:666–72. [64] Scurlock H, Timimi S, Robinson P. Case report osteoporosis as a complication of chronic anorexia nervosa in a male. Eur Eat Disord Rev 1997;5:42–6. [65] Ronch JL. Suspected anorexia nervosa in a 75-year-old institutionalized male: issues in diagnosis and intervention. J Aging Ment Health 1985;4:31–8. [66] Malik F, Wijayatunga U, Bruxner GM. A case of anorexia nervosa in an elderly man. Australas Psychiatry 2014;22:285–7. [67] Kanayama G, Hudson JI, Pope Jr HG. Long-term psychiatric and medical consequences of anabolic–androgenic steroid abuse: a looming public health concern. Drug Alcohol Depend 2008;98:1–12. [68] Raevuori A, Keski-Rahkonen A, Hoek HW. A review of eating disorders in males. Curr Opin Psychiatry 2014;27:426–30. [69] Main J, Reddy L, Lazarevic M, Whelan PJ. Are late-onset eating disorders in the elderly really the more common variant? Concerns around publication bias. Int Psychogeriatr 2011;23:670–1. [70] Berkman J. Anorexia nervosa, anorexia, inanition and low basal metabolic rate. Am J Med Sci 1930;180:411–24. [71] Dally P. Anorexia Nervosa. London: William Heineman Medical Books; 1969. [72] Zerbe K. Eating disorders in middle and late life: a neglected problem. Prim Psychiatry 2003;10:76. [73] Thapliyal P, Hay P. Treatment experiences of males with an eating disorder: a systematic review of qualitative studies. Transl Dev Psychiatr 2014;2:25552. [74] Bjork T, Wallin K, Pettersen G. Male experiences of life after recovery from an eating disorder. Eat Disord 2012;20:460–8. [75] Robinson KJ, Mountford VA, Sperlinger DJ. Being men with eating disorders: perspectives of male eating disorder service-users. J Health Psychol 2013;18:176–86. [76] Dearden A, Mulgrew KE. Service provision for men with eating issues in Australia: an analysis of organisations’, practitioners’, and men’s experiences. Aust Soc Work 2013;66:590–606. [77] Crisp AH, Toms DA. Primary anorexia nervosa or weight phobia in the male: report on 13 cases. Br Med J 1972;1:334–8. [78] Pope Jr HG, Hudson JI, Jonas JM. Bulimia in men: a series of fifteen cases. J Nerv Ment Dis 1986;174:117–9. [79] Barry B, Salamon MJ. Psychologically based idiosyncratic bulimia in a 78-yearold institutionalized male. J Aging Ment Health 1987;6:71–3. [80] Wills A, Olivier S. Anorexia nervosa in old age. J Aging Ment Health 1998;2:239–45.