TABLE OF CONTENTS
1. Introduction & prevalence
2. Signs and Symptoms
3. History of eating disorders
4. Anorexia Nervosa in Males
5. Bulimia Nervosa in Males
6. Compulsive Overeating in Males
7. Triggers for the development of eating disorders
8. Muscle Dysmorphia
9. Body Dysmorphic Disorder and its relationship with eating disorders
10. Men and their emotions
11. Eating Disorders and associated Depression
12. Sexual orientation and eating disorders
13. Treatment strategies
14. Assistance and support for sufferers and family members
16.1. Appendix A – Clues to eating disorders in men
16.2. Appendix B – Diagnostic criteria anorexia nervosa
16.3. Appendix C – Common symptoms, common physical examination signs for eating disorders
16.4. Appendix D – Common irrational beliefs regarding body size, weight and overall appearance
16.5. Appendix E – Diagnostic criteria bulimia nervosa
16.6. Appendix F – Diagnostic criteria binge eating disorder
16.7. Appendix G – Diagnostic criteria muscle dysmorphia
It is generally accepted that eating disorders are a serious concern among women but we are faced with a severe lack of research into the prevalence of men struggling with their body image. Morgan (2008) purports that at least 10% of people with eating disorders are males and Paterson (2008) estimates figures up to 33%. Sadly many doctors still do not recognize cases of eating disorders in men with the result that fewer than 5% of all referrals to specialist eating disorder clinics are male (Morgan: 2008).
Pollack (1999) discovered that at Harvard Medical School, there is increasing evidence that many men (and probably boys too) are becoming increasingly obsessed with their bodies. Men are beginning to diet in unprecedented numbers with an estimated one million of them suffering from eating disorders (Luciano: 2002). This figure of one million is perceived to be understated as males with eating disorders are for too often under diagnosed.
Andersen et al. (2000) confirms that eating disorders in males has been overlooked and in some treatment centres, the ratio of men to women has changed over the past ten years from almost entirely women to 50:50. In Psychology Today magazine in 1997, an amazing 43%, nearly half of the men in the survey reported that they were dissatisfied with their overall appearance. Of those men surveyed, 63% were dissatisfied with their abdomen, 52% with their weight, 55% with their muscle tone and 38% with their chest (Pope et al: 2000).
There does not seem to be a specific age at which men develop eating disorders, with sufferers as young as eight years old and eating disorders usually appearing around 14-25 years of age (B-eat). Children as young as two years old have already developed damaging eating habits, this can lead to eating disorders as the child ages, with 52,17% of eating disorders persisting into adulthood (Sancho et al: 2007). Morgan (2008) explains that eating disorders and body image problems develop slowly and subtly, but once you start to use eating habits and exercise as a means of dealing with distressing emotions, then there may be a problem. In a Brief History of Eating Disorders (2009) we find that after puberty, one million boys and men will have eating disorders; this coupled with Paterson’s statement that ‘on average, it seems to be approximately six years before men [or boys] will seek help’, it is imperative that we take note of the signs and symptoms of eating disorders in males giving us the ability to diagnose problems earlier.
Signs and Symptoms…
A number of authorities on eating disorders have lists of signs to be aware of in males who may be developing or may already have developed a serious eating disorder. The list of signs supplied below is a combination of symptoms from Abraham (2008), Paterson (2008) and Recognising and responding to binge eating in children (www.bulimia.com).
- Body weight (a noticeable change in size and shape)
- Under- or overweight
- Loose clothing or tight fitting clothing
- Dry skin – sometimes having a yellowish tinge
- Overdeveloped muscles
- Excessive hairiness, especially on the face and forearms (lanugo)
- Calluses on the back of hands or fingers
- Puffy fingers and face
- Enlarged parotid glands
- Peripheral oedema
- Discoloured and damaged teeth
- Cold and blue hands and feet
- Obsessive preoccupation with food, their body, weight or shape
- A limiting or restrictive diet
- Over-exercising or using muscle building supplements
- Vomiting after meals, abuse of laxatives and/or diuretics
- Seeking food in the absence of hunger
- A sense of lack of control over eating
- Seeking food in response to negative emotions
- Sadness, boredom or restlessness
- Seeking food as a reward
- Sneaking or hoarding food
- Absence of purging, fasting or excessive exercise
- Rapid eating of food, eating larger than normal amounts
- Making negative comments about himself
- Spending a great deal of time alone
In addition to the list above, Pope et al. (2000) have outlined some of the extreme weight-loss behaviours of High School boys. In a survey among 211 boys, 17% had tried dieting, 10% had gone on a crash diet, 8% were smoking with the express purpose of suppressing hunger and 6% were vomiting after meals. Smaller percentages of the boys were using laxatives, diet pills and diuretics.
In the event of a number of these signs being noticed in yourself or a family member, Morgan (2008) has outlined the SCOFF questionnaire which, although not a diagnostic questionnaire, can be a staring point in the detection of an eating disorder.
- S – Do I/you make myself/yourself sick because I/you feel uncomfortably full?
- C – Do I/you worry that I/you have lost control over what I/you eat?
- O – Have I/you recently lost more than 6.5kg in a three month period?
- F – Do I/you believe myself/yourself to be fat when others say I am/you are thin?
- F – Would I/you say that food dominates my/your life?
If there is a marked increase in the number of men and boys suffering with eating disorders, what might be some of the dilemmas that boys/men face that might develop into eating disorders? In ‘Making Weight’, Andersen et al. (2000) have outlined these dilemmas as shown below:
- Increasing body weight and body fat
- Body shape concerns
- Eating disorders, such as anorexia nervosa, bulimia and binge eating disorder
- Lack of exercise
- Compulsive exercising
- Low self-esteem about body size or shape, aging, hair loss, height etc.
- Conflicts about sexuality from low body image
- Appearance obsessions
- Using plastic surgery to conform to social expectations
- Psychological damage from childhood teasing about weight, height, shape, appearance, etc.
- Weight prejudice in work and social situations
- Confusion about health and nutrition
- Genetic traits that conflict with media images and fashion trends
Pope et al. (2000), have developed a twenty criteria questionnaire that can be used as a follow up to the SCOFF Questionnaire (see Appendix A – Clues to Eating Disorders in Men). If you score a ‘yes’ response to more than two or three of these questions, it may be indicative of an eating disorder and the necessary steps should be taken towards getting help, which will be outlined later in this document.
Much has already been said about eating disorders and signs and symptoms to look for in people who may be suffering, but where did it all begin, when did we acknowledge and recognize the existence and symptoms of eating disorders; to answer, we look towards the history of eating disorders.
History of eating disorders…
Disordered eating habits have been evident throughout the ages. The time of the Roman Empire saw wealthy individuals eating until their stomachs bulged and subsequent to their indulgence they purged themselves at a vomitorium in order to continue eating (Paterson: 2008). It is noteworthy that the term vomitorium has been used incorrectly here, as it actually referred not to a place for purging but to the aisle between rows of seats at a Colloseum. Ancient Egyptian physician recommended periodical purging (termed purgation) as a means of promoting a healthy practice (A Fear of Food-Anorexia Nervosa). In the Hebrew Talmud, rabbinic scholars make reference to ‘boolmot’, which was a ravenous hunger, and the term ‘bulimy’ at Yom Kippur. In addition, wealthy families in the Middle Ages would vomit during meals as the consumption of large amounts of food was a sign of significant wealth.
During the time of the Ancient Greeks, the ‘ideal’ male physique was that of a young, perfectly formed athletic individual (Paterson: 2008). In the 19th Century, Nietzsche, a philosopher promoted the idea of the ‘super-man’, this ideal was subsequently adopted by the Nazis in the 1930s, adjusted and packaged as the heroic, muscular, emotionless, strong male role model to which all German men should aspire.
During the 12th and 13th Century, dominant interpretations of self-starvation were religious with women who starved themselves gaining high esteem. The origins of their ‘holy anorexia’ was thought to be supernatural, case in point being Saint Catherine of Siena (1347-1380). St. Catherine was infamous for only eating herbs and sticking a twig down her throat to cause herself to vomit. In 1689, Richard Morton described the first case of anorexia nervosa (which was a sixteen year old male) as ‘nervous consumption’. This young man had lost his appetite for no apparent physical reason and was over-working himself. Upon abandoning his studies, he recovered.
The first clinical description for anorexia nervosa dates back to the seventeenth century in the case of Lord Byron, who was described as ‘gloriously handsome except for a double chin’, which is reported to have troubled him immensely (Paterson: 2008, 21). The attending physician, Richard Morton notes Byron’s ‘perceived physical imperfections [causing] him to manipulate his body shape by dietary restraint and excessive exercise’ (Morgan: 2008, 12). Byron resorted to a diet of boiled potatoes and water, but moved in to a cyclical pattern of bingeing and vomiting and ended up with severe obesity and alcohol abuse. In 1790, Dr Robert Willan attended a fourteen year old boy who had refused to eat for seventy-eight days, subsequent to treatment, the boy died (Luciano: 2002).
In 1871, the Belgian astronomer and mathematician Dr Quetelet developed the Quetelet Index (now know as the Body Mass Index – BMI) as an aid to diagnosis of obesity in patients but it is equally effective in diagnosing anorexia. The actual term ‘anorexia nervosa’ was first used by an English physician to Queen Victoria, Sir William Gull in 1873, after working with ‘Miss A’, whom he had first seen seven years earlier.
In 1903, Charles Atlas decided to begin developing his body and by the age of 17 he had developed a technique used by men today to achieve physical fitness (Paterson: 2008). Morris Simmonds, a pathologist from Hamburg, described a case of cachexia (physical wasting) that he attributed to a lesion in the anterior lobe of the pituitary gland in 1914. During the 1940s interpretations of the origins of anorexia nervosa revolved around sexual origins; and Ancel Keys managed to demonstrate the link between dieting and a flawed relationship with food.
In Barlow & Durand (2005), it is noted that ‘eating disorders began to increase during the 1950s or early 1960s’ (p 257). Although Pierre Janet’s patient, Nadja (in 1903) and Ludwig Bins Wanger’s Ellen West, both displayed symptoms of Bulimia Nervosa, it was only first given a detailed description in the 1970s with the first formal paper being written by Gerard Russell in 1979 ‘Bulimia Nervosa: An ominous variant of Anorexia Nervosa’. Historians of psychopathology note that for hundreds of years the vast majority of recorded cases of bulimia nervosa were males.
In 1973 Hilde Bruch, in her work with patients of eating disorders, concluded that patients had delusional proportions of body image and body concept, a disturbance in the ability to recognize nutritional needs, and an almost paralyzing sense of ineffectiveness which pervades all thinking and activities. Anorexia became know as the ‘disorder of the 80s’ and at the same time the prevalence of bulimia was increasing, resulting in the development of treatment for bulimia patients (Barlow & Durand: 2005). It was not until the 1990s that binge eating was recognized as a distinct disorder from bulimia nervosa.
Anorexia Nervosa in Males…
Anorexia nervosa can be a life-threatening condition, with mortality rates quite high, ranging from 6 to 20% (Thompson: 2000). Anorexia is often caused by body image disturbances, when the patient is distressed, having worries and fears about his body (Paterson: 2008). The underlying difference between male and female anorexic sufferers is that it’s more common for male anorexics to focus on the ‘shape’ of their body rather than their ‘weight’ as in the case of females (Morgan: 2008).
Andersen et al. (2000) have outlined four primary reasons that men develop anorexia nervosa:
- To avoid ever being teased again for chubbiness like when they were children, especially if they have particularly sensitive personalities
- To improve athletic performance, which occurs most frequently in sports with weight classes, like wrestling or boxing, but also in gymnastics, rowing and long-distance running
- To avoid developing the medical illnesses their fathers have, especially heart disease, diabetes, or high blood pressure
- To improve a gay relationship
In addition, Paterson (2008) proposes that the anorexic boy or teenager can use the disorder to find a solution to a developing crisis at school or home, to help them deal with a problem in a relationship of gain a sense of control over their lives. As a form of protection from the adult world, the anorexic male becomes the ‘sick’ member of the family and as such is saved having to make decisions for himself. Martin & Costello (2008) confirm that the eating disorders anorexia nervosa and bulimia nervosa (discussed later) tend to begin in the preteen years and worsen in later adolescence.
The physical characteristics of anorexia nervosa specific to males include a low body weight, which is at least 15% below the expected healthy weight for his age and height (see the BMI), a lack of energy leading to fatigue and muscular weakness. As the disorder progresses, a lowered body temperature is noted, with a lower blood pressure and pulse rate and the development of lanugo (soft baby hair) over the whole body. There can be thinning of the hair or loss of hair on the head and irregular heart rate. In males, there is a lowering of testosterone levels which leads to a lack of sexual libido.
Morgan (2008) outlines the three levels for defining anorexia nervosa, there is a psychopathological component, meaning a change in the way the anorexic thinks, a behavioural change and thirdly, a physical change that occurs in the anorexic.
The specific diagnostic criteria for the diagnosis of Anorexia Nervosa (AN) can be viewed in Appendix B. The psychological changes associated with AN include the following:
- feelings of depression and hopelessness
- emotional withdrawal
- intense fear of putting on weight
- black and white thinking
- a need to always feel in control
- difficulty expressing their emotions
- a perfectionistic streak
- problems concentrating and focusing on tasks
- low self-esteem and self worth
Behavioural changes could include some or all of the following:
- restrictive dieting which includes fasting
- a preoccupation with food and weight
- constant weight checks
- unusual food rituals
- compulsive exercising
- deceitful behavior (hiding food etc.)
- an inability to eat with others
- disgust with their own bodies and a strong preoccupation with certain body parts
- a distorted view of their own bodies
- depression and irritability
In addition to the physiological changes mentioned in Paterson (2008), Abraham (2008) includes emaciation of the body, bloating and constipation with swelling of hands and feet (oedema) and often mild anaemia (pale skin). In some severe cases of AN, there is a reduction in the size of the brain due to starvation.
Anorexia in males occurs less frequently than in females (1 in 15) according to Abraham (2008), yet it begins in the same way as in females and its clinical characteristics and course is identical to females. Most males with AN spend hours each day jogging, body building and doing press-ups and other exercises. Males who develop AN are likely to be a heavier weight at onset of the disorder and usually older in age than females, more than 50% of the males induce vomiting and are more likely to binge eat and exercise excessively.
Phillips (2009) purports that people with AN sufferers think they’re too fat and as a result lose too much weight; Veale et al. (2009) adds that they ‘feel normal or fat even though, in reality they are very thin’ (p2). Many boys spend a lot of time wishing that they could have a flat stomach with the six-pack or abdominal muscles that they see on the front covers of magazines…in research among boys as young as eight to twelve Pope et al. (2000) found that one-quarter had tried to lose weight, 36% of third grade boys had tried to lose weight, 26% of high school boys had used an extreme weight-loss method at least occasionally and 9% at least weekly. It is disturbing that Barlow & Durand (2005) note that people with anorexia nervosa are proud of both their diets and their extraordinary control over their bodies and eating habits or lack thereof.
Extreme calorific restriction and excessive exercise has adverse effects on the body and at very low weight, the effects of the exercise is amplified with can result in muscle injuries, stress fractures, low blood sugar levels, confusion, coma and stunted growth. As the circulation in the body is affected, the onset of puberty can be postponed, damage to the kidneys and heart can occur (Morgan: 2008). In addition to over-exercising, the anorexic male may resort to the use of enemas and diuretics, slimming pills and stimulant drugs for manipulating his weight, which can lead to use of amphetamines and cocaine.