ICED 2014 Workshop on Males with Eating Disorders

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Eating disorders in males are understudied, underrecognised and misunderstood. Despite evidence that males constitute 25-33% of diagnoses of anorexia and bulimia nervosa, and up to 50% of diagnoses of …

Eating disorders in males are understudied, underrecognised and misunderstood. Despite evidence that males constitute 25-33% of diagnoses of anorexia and bulimia nervosa, and up to 50% of diagnoses of binge eating disorder, limited research has focused on the “male experience” of eating and body image concerns. In addition, researchers and clinicians have only recently begun to focus on the role that muscularity plays in males with eating and body image psychopathology. We present evidence that disordered eating behaviours are increasing more rapidly in men than in women, particularly with regard to binge eating. We further present a clinical comparison of men with anorexia nervosa and muscle dysmorphia (“reverse anorexia”) and review community-held attitudes and beliefs about people with these conditions. We conclude with a discussion of clinical treatment guidelines for males with eating disorders. This workshop will (1) present an overview of the evidence base pertinent to males with eating disorders, (2) evaluate evidence for the prevalence of disordered eating amongst males, compare the phenomenology of muscle dysmorphia and anorexia nervosa, and review the stigmatization of males with anorexia nervosa and muscle dysmorphia. Finally, this workshop 3) details treatment guidelines for clinicians working with males.

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  • A clinical vignette, which ambiguously depicted the features of muscle dysmorphia in either male or female cases, was presented to a group of 100 clinical practitioners, who provided preliminary diagnoses based on the symptoms depicted. Results: The majority of clinicians conceptualised this cluster of symptoms as an eating disorder phenotype, as opposed to variants of either body dysmorphic disorder or obsessive compulsive disorder. Conclusions: These findings provide some support for the notion that muscledysmorphia may best be conceptualised as an eating disorder phenotype. The findings are discussed in light of their clinical implications.
  • Muscle dysmorphia is the pointy end of a spectrum of disordered behaviour,Mean age: 25 yearsInsight into their preoccupation: 50%Steroid use: ~36% (21.4%, 43%, 44%)Gay: varies; 21%, 0%Current or past history of an eating disorder: ~18% (4%, 29%, 21.4%)Lower quality of life; poorer mental health and interpersonal functioning, Suicide attempts: 50%Lifetime history of substance abuse: 85.7%Lifetime history of a mood disorder: 74% to 85.7%On average, report spending 4 hours per day thinking about getting biggerOn average, check mirrors 13 times per dayThe core symptom of eating disorders is over-evaluation of eating, shape and weight and their control (Fairburn, Shafran & Cooper, 2003)
  • Bulimia nervosa and anorexia nervosa appear to have a core psychopathology, whereas binge eating disorder is conceptualised as primarily a behavioural disorder of recurrent binge eating.Unlike women, the bulk of male body image dissatisfaction is oriented towards the acquisition of body mass, in the form of lean muscularity, rather than losing it.An average weight male more likely to perceive himself as underweight, whereas an average weight woman is more likely to perceive herself as overweight.Boys as young as 6 years of age display a strong preference for mesomorphic body types.
  • "Disordered eating" has become synonymous with calorie restriction, calorie expunging, weight loss, and fat loss
  • methylhexaneamine
  • An investigation of nearly 3000 American adolescents found that 69% of boys and 62% of girls reported changing their eating to increase their muscle mass or tone (Eisenberg et al., 2012).
  • Data from the Australian Needle and Syringe Programme running since 1995.% of people surveyed at needle exchanges who indicated that steroids were the last drug that they injectedIn the years between 2007 and 2012 when steroid use jumped by 10%, heroin use fell by 9 percentage points, methamphetamine use did not change, cocaine dropped by 3 percentage points.Steroid seizures increased by 300% between 2010 and 2012.Data from 1955 male non-medical anabolic steroid users in the United States of AmericaAverage user was 31.1 yearsAverage age of initating steroid use was 25.8 years old.Steroid use is almost an exclusively adult phenomenon; 94% commenced use at age 18 or older.Well-educated; 74.1% held post-secondary degrees.Most employed full-time (77.7%) with an overall employment rate (98.5%)Predominantly employed as professionals (white-collar employees) with a median household income between $60000 and $80000 per year, compared to $44600 for the general populace in 2005).Average length of use was 5.5 yearsNote that the above two findings have consistently emerged in the literature.Ten times more likely to be an IT professional than an athlete or coachMore likely to be an IT professional than in the fitness industry or as a personal trainer.
  • This is a modified version of the EDE-Q completed by a young male diagnosed with muscle dysmorphia.
  • To date, research on admiration for people with eating disorders has been confined to:The positive beliefs held by young women…about women with anorexia nervosa.It is unclear whether sex differences qualify the association between admiration and disordered eatingNeed to examine the beliefs of young menNeed to examine the influence of the sex of the eating disorder suffererNeed to examine the "predominant male experience" of disordered eating/body dissatisfaction Muscle dysmorphia, andMuscularity-oriented disordered eating
  • Data excluded if participants…failed valid-responding checks (n = 21), did not complete more than 50% of the survey (n = 5), were over 25 years of age (n = 17), or were transgender (n = 1).Final sample (N = 499)160 males, 288 females16 to 25 years of age (M = 19)Mostly Australian (56.7%) or Asian (26.4%) backgroundBMI from 15.52 to 47.18 (M = 22.50, SD = 3.87)Men only (M = 23.92, SD = 3.52)Women only (M = 21.74, SD = 3.83)Character descriptions Man ("Michael") or woman ("Kelly") with anorexia nervosa or muscle dysmorphiaAdapted from Griffiths, Mond, Murray & Touyz (2013)Positive beliefs"How much do you admire Kelly/Michael's ability to control his/her eating?""How much do you admire Kelly/Michael's ability to control his/her exercise?""Have you ever thought it might not be too bad to be someone like Kelly/Michael?"Adapted from Mond and colleagues (2004, 2006)Disordered eatingThinness-oriented disordered eating = global score on the EDE-Q Muscularity-oriented disordered eating = global score on the modified EDE-QAdapted from Murray et al. (2012) and Griffiths, Murray, & Touyz (2013)
  • I had 343 male and female undergraduates read a vignette describing a character with anorexia nervosa or muscle dysmorphia named Michael or Kelly. The muscle dysmorphia vignette described a male with an intense fear of losing his muscle mass, and who redoubled his efforts in the gym and with his diet if he found it difficult to control his eating and workouts, and who thought he was scrawny and underweight despite being very muscular with little body fat. Without telling them the diagnosis, I asked them to indicate if they knew anyone who has had a problem like Michael/Kelly.? 343 undergraduates answered this question, meaning there was plenty of power to detect a significant difference in the pattern of responses. However, the differences were not significant, suggesting that people are as familiar with muscularity-focused psychopathology as they are thinness-oriented psychopathology.
  • I had 343 male and female undergraduates read a vignette describing a character with anorexia nervosa or muscle dysmorphia named Michael or Kelly. The muscle dysmorphia vignette described a male with an intense fear of losing his muscle mass, and who redoubled his efforts in the gym and with his diet if he found it difficult to control his eating and workouts, and who thought he was scrawny and underweight despite being very muscular with little body fat. Without telling them the diagnosis, I asked them to indicate if they knew anyone who has had a problem like Michael/Kelly.? 343 undergraduates answered this question, meaning there was plenty of power to detect a significant difference in the pattern of responses. However, the differences were not significant, suggesting that people are as familiar with muscularity-focused psychopathology as they are thinness-oriented psychopathology.
  • I had 343 male and female undergraduates read a vignette describing a character with anorexia nervosa or muscle dysmorphia named Michael or Kelly. The muscle dysmorphia vignette described a male with an intense fear of losing his muscle mass, and who redoubled his efforts in the gym and with his diet if he found it difficult to control his eating and workouts, and who thought he was scrawny and underweight despite being very muscular with little body fat. Without telling them the diagnosis, I asked them to indicate if they knew anyone who has had a problem like Michael/Kelly.? 343 undergraduates answered this question, meaning there was plenty of power to detect a significant difference in the pattern of responses. However, the differences were not significant, suggesting that people are as familiar with muscularity-focused psychopathology as they are thinness-oriented psychopathology.
  • I had 343 male and female undergraduates read a vignette describing a character with anorexia nervosa or muscle dysmorphia named Michael or Kelly. The muscle dysmorphia vignette described a male with an intense fear of losing his muscle mass, and who redoubled his efforts in the gym and with his diet if he found it difficult to control his eating and workouts, and who thought he was scrawny and underweight despite being very muscular with little body fat. Without telling them the diagnosis, I asked them to indicate if they knew anyone who has had a problem like Michael/Kelly.? 343 undergraduates answered this question, meaning there was plenty of power to detect a significant difference in the pattern of responses. However, the differences were not significant, suggesting that people are as familiar with muscularity-focused psychopathology as they are thinness-oriented psychopathology.
  • I had 343 male and female undergraduates read a vignette describing a character with anorexia nervosa or muscle dysmorphia named Michael or Kelly. The muscle dysmorphia vignette described a male with an intense fear of losing his muscle mass, and who redoubled his efforts in the gym and with his diet if he found it difficult to control his eating and workouts, and who thought he was scrawny and underweight despite being very muscular with little body fat. Without telling them the diagnosis, I asked them to indicate if they knew anyone who has had a problem like Michael/Kelly.? 343 undergraduates answered this question, meaning there was plenty of power to detect a significant difference in the pattern of responses. However, the differences were not significant, suggesting that people are as familiar with muscularity-focused psychopathology as they are thinness-oriented psychopathology.
  • I had 343 male and female undergraduates read a vignette describing a character with anorexia nervosa or muscle dysmorphia named Michael or Kelly. The muscle dysmorphia vignette described a male with an intense fear of losing his muscle mass, and who redoubled his efforts in the gym and with his diet if he found it difficult to control his eating and workouts, and who thought he was scrawny and underweight despite being very muscular with little body fat. Without telling them the diagnosis, I asked them to indicate if they knew anyone who has had a problem like Michael/Kelly.? 343 undergraduates answered this question, meaning there was plenty of power to detect a significant difference in the pattern of responses. However, the differences were not significant, suggesting that people are as familiar with muscularity-focused psychopathology as they are thinness-oriented psychopathology.
  • I had 343 male and female undergraduates read a vignette describing a character with anorexia nervosa or muscle dysmorphia named Michael or Kelly. The muscle dysmorphia vignette described a male with an intense fear of losing his muscle mass, and who redoubled his efforts in the gym and with his diet if he found it difficult to control his eating and workouts, and who thought he was scrawny and underweight despite being very muscular with little body fat. Without telling them the diagnosis, I asked them to indicate if they knew anyone who has had a problem like Michael/Kelly.? 343 undergraduates answered this question, meaning there was plenty of power to detect a significant difference in the pattern of responses. However, the differences were not significant, suggesting that people are as familiar with muscularity-focused psychopathology as they are thinness-oriented psychopathology.
  • I had 343 male and female undergraduates read a vignette describing a character with anorexia nervosa or muscle dysmorphia named Michael or Kelly. The muscle dysmorphia vignette described a male with an intense fear of losing his muscle mass, and who redoubled his efforts in the gym and with his diet if he found it difficult to control his eating and workouts, and who thought he was scrawny and underweight despite being very muscular with little body fat. Without telling them the diagnosis, I asked them to indicate if they knew anyone who has had a problem like Michael/Kelly.? 343 undergraduates answered this question, meaning there was plenty of power to detect a significant difference in the pattern of responses. However, the differences were not significant, suggesting that people are as familiar with muscularity-focused psychopathology as they are thinness-oriented psychopathology.
  • ConclusionsThe extent to which anorexia nervosa and muscle dysmorphia are stigmatised along gender role lines may be tied more strongly to perceptions of sufferers' masculinity than feminintyLimitationsFirst year undergraduate psychology sampleCharacter descriptions were not pilot testedDifferences in participants' level of knowledge about muscle dysmorphia and anorexia nervosa were not examined
  • I had 343 male and female undergraduates read a vignette describing a character with anorexia nervosa or muscle dysmorphia named Michael or Kelly. The muscle dysmorphia vignette described a male with an intense fear of losing his muscle mass, and who redoubled his efforts in the gym and with his diet if he found it difficult to control his eating and workouts, and who thought he was scrawny and underweight despite being very muscular with little body fat. Without telling them the diagnosis, I asked them to indicate if they knew anyone who has had a problem like Michael/Kelly.? 343 undergraduates answered this question, meaning there was plenty of power to detect a significant difference in the pattern of responses. However, the differences were not significant, suggesting that people are as familiar with muscularity-focused psychopathology as they are thinness-oriented psychopathology.
  • I had 343 male and female undergraduates read a vignette describing a character with anorexia nervosa or muscle dysmorphia named Michael or Kelly. The muscle dysmorphia vignette described a male with an intense fear of losing his muscle mass, and who redoubled his efforts in the gym and with his diet if he found it difficult to control his eating and workouts, and who thought he was scrawny and underweight despite being very muscular with little body fat. Without telling them the diagnosis, I asked them to indicate if they knew anyone who has had a problem like Michael/Kelly.? 343 undergraduates answered this question, meaning there was plenty of power to detect a significant difference in the pattern of responses. However, the differences were not significant, suggesting that people are as familiar with muscularity-focused psychopathology as they are thinness-oriented psychopathology.
  • I had 343 male and female undergraduates read a vignette describing a character with anorexia nervosa or muscle dysmorphia named Michael or Kelly. The muscle dysmorphia vignette described a male with an intense fear of losing his muscle mass, and who redoubled his efforts in the gym and with his diet if he found it difficult to control his eating and workouts, and who thought he was scrawny and underweight despite being very muscular with little body fat. Without telling them the diagnosis, I asked them to indicate if they knew anyone who has had a problem like Michael/Kelly.? 343 undergraduates answered this question, meaning there was plenty of power to detect a significant difference in the pattern of responses. However, the differences were not significant, suggesting that people are as familiar with muscularity-focused psychopathology as they are thinness-oriented psychopathology.
  • I had 343 male and female undergraduates read a vignette describing a character with anorexia nervosa or muscle dysmorphia named Michael or Kelly. The muscle dysmorphia vignette described a male with an intense fear of losing his muscle mass, and who redoubled his efforts in the gym and with his diet if he found it difficult to control his eating and workouts, and who thought he was scrawny and underweight despite being very muscular with little body fat. Without telling them the diagnosis, I asked them to indicate if they knew anyone who has had a problem like Michael/Kelly.? 343 undergraduates answered this question, meaning there was plenty of power to detect a significant difference in the pattern of responses. However, the differences were not significant, suggesting that people are as familiar with muscularity-focused psychopathology as they are thinness-oriented psychopathology.

Transcript

  • 1. Scott Griffiths Phillipa Hay Stuart Murray Stephen Touyz Ted Weltzin The male experience of eating disorders: Anorexia nervosa, muscle dysmorphia, and everything in- between
  • 2. We have no commercial relationships to disclose.
  • 3. Muscle Dysmorphia What is it, and where does it belong?
  • 4. The Nature of Male Body Image • It was initially thought that male body image disorders were very rare. • Recent research suggests that men are now approaching parity with women in prevalence and severity of body image dissatisfaction. • Unlike women, the bulk of male body image dissatisfaction is oriented towards the acquisition of body mass, in the form of lean muscularity, rather than losing it. • An average weight male more likely to perceive himself as underweight, whereas an average weight woman is more likely to perceive herself as overweight. • Boys as young as 6 years of age display a strong preference for mesomorphic body types.
  • 5. What is Muscle Dysmorphia? • Formerly known as ‘Reverse Anorexia Nervosa’ (Pope at al, 1993). – The core body image disturbance is a belief in one’s body appearing unacceptably small and weak. – Desire a more muscular body build (despite often being highly muscular). – Body shame/disguising/avoidance. • Renamed muscle dysmorphia and placed as a sub-type of body dysmorphic disorderin 1997 (Pope et al, 1997). – Primary disturbance is pathological muscle-building exercise behaviour. – Any eating disturbances are secondary & often unnecessary feature.
  • 6. What is Muscle Dysmorphia? • Symptoms include: – Preoccupation around insufficient muscularity. – Rigid schedule of muscle-building physical activity. – Deviation from this schedule results in intense anxiety around potential loss of muscularity, and immediate attempts at compensation. – Sacrifice of social or occupational activities due to the need to maintain training & diet schedule. – Avoidance of body exposure. – Illicit appearance and performance enhancing substance use. – Continued training despite physical injuries.
  • 7. Does Muscle Dysmorphia Feature Eating Pathology? • Excessive preoccupation around dietary intake is central to presentations of muscle dysmorphia. • Rigid dietary regimen. • This is typically oriented around the cyclical or simultaneous consumption of protein and restriction of calories. • Disruption to dietary practices alone can result in marked escalation of muscle dysmorphia symptomatology, and immediate attempts at compensation (Murray et al., 2012). • Men with muscle dysmorphia report comparable dietary restriction, shape- and weight concern to men with anorexia nervosa (Murray et al., 2012). • Pathological eating practices are now deemed a central feature in muscle dysmorphia (Murray &Touyz, 2013).
  • 8. Review of the Extant Evidence Base • This constellation of symptoms, is a valid diagnostic entity (Olivardia et al, 2000). • Muscle dysmorphia appears to be associated with greater psychopathology than other forms of body dysmorphic disorder (Pope et al, 2005), delineating muscle dysmorphia from other forms of body dysmorphic disorder. • On measures of psychopathology, men with muscle dysmorphia appear similar to men with eating disorders on a wide range of indices, including scores on measures of eating disorder psychopathology (Davis & Scott- Robertson, 2000; Mangweth et al, 2000), and exercise pathology (Murray et al., 2012).
  • 9. Review of the Extant Evidence Base Cont. • Documented similarities between muscle dysmorphia and anorexia nervosa include: – Heavily polarised gender prevalence. – High degree of diagnostic crossover with time. – Response to similar treatment approaches. • Clinicians in the field largely conceptualise this constellation of symptoms as an eating disorder phenotype (Murray &Touyz, 2014).
  • 10. Where does Muscle Dysmorphia Fit Within the Diagnostic Spectrum? • Muscle dysmorphia centrally comprises pathological eating and exercise practices in the pursuit of the ideal muscular body. • Muscle dysmorphia appears conceptually similar to thinness-oriented eating disorders, such as anorexia nervosa, and differs primarily as a function of the antonymic body ideals that the respective disorders propel affected individuals towards. • Muscle dysmorphia may be better placed within the eating disorder spectrum, and may offer more clinical utility in recognising the male experience of eating disorder psychopathology (Murray &Touyz, 2013).
  • 11. Where to from here… • Not enough research exists to firmly conclude that muscle dysmorphia represents an eating disorder phenotype. • However, very little research demonstrates that muscle dysmorphia differs significantly from eating disorders. • Further research is needed in explicating how muscle dysmorphia and muscularity-oriented disordered eating fits into an eating disorder framework. • It is important not to conflate healthful muscle-building endeavours with muscle dysmorphia.
  • 12. Muscularity-oriented eating disorder behaviours Attitudes and beliefs about men with eating disorders Scott Griffiths School of Psychology Sydney, Australia
  • 13. 13 Muscle dysmorphia: The pointy end of a spectrum
  • 14. Muscularity and eating disorders • What is an eating disorder? – What are the essential or defining features of an eating disorder? • The transdiagnostic model of eating disorders – The core psychopathology of eating disorders is overevaluation of eating, shape and weight and their control (Fairburn, Shafran & Cooper, 2003) • Intrinsic to statements about overvaluation of eating, shape, weight and their control is that the thing that is "overvalued" is a thin and skinny body
  • 15. • Eating Disorders Examination - Questionnaire (EDE-Q; Fairburn & Beglin, 1984) • "Have you been deliberately trying to limit the amount of food that you eat?" • "Have you wanted your stomach to be empty?" • "Have you gone for long periods of time (8 hours or more) without eating anything in order to influence your shape or weight?" • "Have you had a definite fear that you might gain weight or become fat?" • "Have you definitely wanted your stomach to be flat?" • "Have you had a strong desire to lose weight?" • "Have you felt fat?" • "Have you taken diuretics to control your shape or weight?" • "Have you taken laxatives to control your shape or weight?" 17 Eating disorder behaviours: Thinness- centric
  • 16. Muscularity-oriented eating disorder behaviours 18
  • 17. Muscularity-oriented eating disorder behaviours 19
  • 18. Muscularity-oriented eating disorder behaviours 20
  • 19. 0% 2% 4% 6% 8% 10% 12% 14% 2006 2007 2008 2009 2010 2011 2012
  • 20. Muscularity-oriented disordered eating = 6 + 6 + 0 + 6 + 6 + 4 + 5 + 0 + 3 + 1 + 6 = 42(mean = 3.9) 22 6 6 6 4 5 3 6 1 6 0 0 Thinness-oriented disordered eating = 0 + 0 + 0 + 6 + 0 + 0 + 0 + 0 + ? + 2 + 1 = 9 (15 if I gift him a 6) (mean = 0.9) 0 0 0 0 0 ? 2 1 Measuring muscularity-oriented disordered eating
  • 21. 23 › Links with poor set shifting and weak central coherence [1] › Links with impairedemotional functioning [2] › Links with increased conformity to traditional masculine gender roles [3,4] › Links with positive beliefs about individuals with muscle dysmorphia[5] › Links with muscle dysmorphia[6] › Treatment using family-based therapy [7] [1] Griffiths, S., Murray, S. B., &Touyz, S. (2013). Drive for muscularity and muscularity-oriented disordered eating in men: the role of set shifting difficulties and weak central coherence. Body Image. [2] Griffiths, S., Angus, D., Murray, S. B., &Touyz, S. (2014). Unique associations between young adult men's emotional functioning and their body dissatisfaction and disordered eating. Body Image. [3] Griffiths, S., Murray, S. B., &Touyz, S. (2014). Extending the masculinity hypothesis: an investigation of gender role conformity, body dissatisfaction, and disordered eating in young heterosexual men. Psychology of Men & Masculinity. [4] Murray, S., Rieger, E., Karlov, L., &Touyz, S. (2013). Masculinity and femininity in the divergence of male body image concerns. Journal of Eating Disorders [5] Griffiths, S., Mond, J. M., Murray, S. B., &Touyz, S. (submitted). Young peoples’ admiration for anorexia nervosa and muscle dysmorphia. [6] Murray, S et al. (2012). A comparison of eating, exercise, shape and weight related symptomatology in males with anorexia nervosa and muscle dysmorphia. Body Image [7] Murray, S. B., & Griffiths, S. (2014). Family-based therapy for muscle dysmorphia: a preliminary case report. Clinical Child Psychology and Psychiatry. Research using muscularity-oriented disordered eating
  • 22. Positive beliefs • People with anorexia nervosa may percieve their symptoms as positive or comforting (Guarda, 2008) – Delayed treatment seeking – Poor engagement with treatment – Treatment refusal • Young people's positive beliefs about people with anorexia nervosa are associated with higher levels of eating disorder symptoms. (Mond, Robertson-Smith, & Vetere, 2006) • To date, research on admiration for people with eating disorders has been confined to: – The positive beliefs held by young women… – about women with anorexia nervosa. 24
  • 23. Anorexia Nervosa Muscle DysmorphiaAnorexia Nervosa Muscle Dysmorphia N = 499
  • 24. 1 2 3 4 5 Admire eating Admire exercise Desire to be like Muscle dysmorphia Anorexia nervosa Positive belief Levelofendorsement • Main effects of character diagnosis – Averaged over participant sex and character sex • Characters with muscle dysmorphia elicited more… – admiration for their ability to control their eating (η2 = .10, large effect) and exercise (η2 = .03, small effect) – desire to be like them (η2 = .03, small effect) *** *** *** *** p< .001
  • 25. 1 2 3 4 5 Admire eating Admire exercise Desire to be like Male participants Female participants Positive belief Levelofendorsement • Main effects of participant sex – Averaged over character sex and character diagnosis • Young women endorsed a stronger desire to be like the characters than young men – η2 = .03 (small effect) ** ** p< .01
  • 26. 1 2 3 4 5 Admire eating Admire exercise Desire to be like Male participants Female participants Positive belief Levelofendorsement • Main effects of character sex – Averaged over participant sex and character diagnosis • No significant main effects of character sex
  • 27. 1. 2. 3. 1. Thinness-oriented disordered eating - .19 2. Muscularity-oriented disordered eating - .24 3. Desire to be someone like the character .58*** .55*** - • Correlation coefficients for male and female participants who read about the characters with anorexia nervosa. • Correlations for male participants and female participants
  • 28. 1. 2. 3. 1. Thinness-oriented disordered eating - .32** 2. Muscularity-oriented disordered eating - .31** 3. Desire to be someone like the character .49*** .48*** - • Correlation coefficients for male and female participants who read about the characters with muscle dysmorphia. • Correlations for male participants and female participants
  • 29. Negative beliefs (stigma) 32 › Negative stereotypes and beliefs exist about people with eating disorders and are widespread › Stigma is frequently given as a reason why so few males come forward with eating disorders › What about muscle dysmorphia? Might anorexia nervosa and muscle dysmorphia be perceived as a “female” and “male” condition respectively? › Little research has examined stigma surrounding masculinity and femininity and eating disorders (see a great qualitative paper by Robinson et al. 2013)
  • 30. 1 2 3 4 5 Anorexia nervosa Muscle dysmorphia Male participants Female participants Character diagnosis Meanperceivedmasculinity • To what extent do you agree with the following statement: Kelly/Michael is masculine – 5 = strongly agree – 4 = agree – 3 = neither agree nor disagree – 2 = disagree – 1 = strongly disagree • Size of this effect size is very large (η2 = .23) – Even stronger for male participants (interaction η2 = .03, p = .002) * *
  • 31. 1 2 3 4 5 Males with AN n = 26 Females with AN n = 192 Meanfrequencyofstigmatisation • How often are you subjected to the attitude or belief that you are “less of a man/woman” because of your eating disorder? – 5 = always – 4 = often – 3 = sometimes – 2 = rarely – 1 = never • Size of this effect is moderate (η2 = .07) *
  • 32. 0 50 100 150 Healthy controls n = 30 Anorexia nervosa n = 24 Meanconformitytomasculinerole • Men with anorexia nervosa report the same amount of conformity to masculine norms relative to healthy control men • Men with muscle dysmorphia report more conformity to masculine norms than men with anorexia nervosa and healthy control men Muscle dysmorphia n= 21 *
  • 33. Summary • There may exist a spectrum of eating disorder behaviour motivated by an overvaluation of muscularity, not thinness • Sex differences in the importance of muscularity to body satisfaction and in ideal body preferences may mean that men are more at risk for developing muscularity-oriented eating disorder behaviours
  • 34. Summary • The distinction between disordered and ordered is easier for some behaviours (steroids; intrinsically harmful), and more difficult for others (eating behaviours and supplements). • Attempts to assess muscularity-oriented disordered eating behaviours (limited as they may be) have revealed links with multiple adverse outcomes
  • 35. Summary • Young men and women express positive beliefs about anorexia and muscle dysmorphia, and there are sex differences in the links between their desire to be like people with these conditions and their own disordered eating • The additional stigmatisation faced by men with eating disorders may be related to their perceived deviation from traditional Western gender roles, particularly with regard to masculinity
  • 36. Concluding comments • The relative absence of men with muscularity- oriented eating disorders/eating disordered behaviour in treatment may not reflect a prevalence gap so much as a knowledge gap • The broad community of eating disorder professionals is particularly well-suited to treat muscularity-oriented eating disordered behaviours
  • 37. 800-767-4411 rogershospital.org Welcome Rogers treats children, adolescents and adults with: • OCD and anxiety disorders • Depression and mood disorders • Eating disorders • Substance use disorders
  • 38. Males with eating disorders: Treatment Update Ted Weltzin, MD, FAED, FAPA Medical Director, Eating Disorder Services Rogers Memorial Hospital
  • 39. Many men have been treated in programs that do not offer a male only component. “I don’t think it’s necessary and it may not benefit some men.” (Eating disorder professional)
  • 40. “It’s so hard having this disease and being a guy. Females with eating disorders are not such a rarity, so they can feel like they fit in. the men-only group gave me a sense of freedom. I felt less exposed and more willing to admit my problems and be introspective” (Male patient) Perspective on treatment of males
  • 41. Steve: Initial Presentation Steve is a twenty year old college student studying engineering and has been admitted for residential treatment because his school placed him of medical leave due to increasing compulsive exercising, restricting, and severe malnutrition. He is currently 5 feet and 8 and half inches tall weighing 114 lbs. On admission he was 72.9% of his Ideal Body Weight and presents with osteopenia and low levels of testosterone. Steve has an admitting BDI score of 25.
  • 42. Steve: Psychosocial Assessment Steve presents with a five year history of Anorexia Nervosa, Restricting Type, which includes symptoms of compulsive exercising, reportedly walking up to three hours a day and restricting food intake to only fruits and vegetables. Steve also reports increased isolation, hopeless, depression, low self worth and perfectionism. Steve reports significant social anxiety and ritualistic behaviors with food. Resident was living alone in a college dorm and currently reports having no friends and finds that his mind is preoccupied by body, weight and shape. Further, he reports having no coping skills besides exercising or school work. Steve reports being overweight as a teenager, approximately 180 pounds, and reports a history of being teased in school. Steve grew up in Ohio with his biological parents and his older brother who suffers from Major Depression. He reports his temperament growing up was shy.
  • 43. Sean: Initial Presentation Sean is a 25 year old college student who was admitted to residential treatment for binge eating, past history of bulimia, depression, and anxiety. Sean is six foot and one inch tall and weighs 267 pounds and currently is 145% of his Ideal Body Weight. Sean presents as overweight with low testosterone. Sean presents with a BDI score of 27.
  • 44. Sean presents with an extensive history of eating disorder behavior beginning at age 19 that includes bingeing, restricting, a history of using Marijuana and Meth to inhibit appetite, as well as diet pills. Sean reports in the last three years he has significantly isolated himself and has gained 100 pounds triggered by his binge eating. He reports depression, social anxiety, and attention deficit disorder beginning at the age of 16. Resident at age 16 also attempted suicide which was triggered by his parents finding out that he was a homosexual. Further, Sean was addicted to ecstasy and ketamine between the ages of 19 to22 and has been in several residential facilities for substance dependency but has been sober from drugs and alcohol for the past three years but reports he continues to have urges to use substances. Sean presents with maladaptive defense systems that he believes pushes people away and reports no significant lasting interpersonal relationships throughout his life. Sean grew up in a military family that moved around a lot and believes this has also interrupted interpersonal relationships to form. Sean: Psychosocial Assessment
  • 45. Ray: Initial Presentation Ray is a 17 year old high school student who admitted to residential programming for more intensive treatment of his eating disorder characterized by restrictive eating and compulsive over exercising. He is 5 foot 4 inches tall weighing 121.8 pounds. Ray is currently at 92% of his IBW and presents with malnutrition and osteopenia.
  • 46. Ray: Psychosocial Assessment 3 year history of restricting, compulsive exercising, purging and chewing and spitting out food. Ray reports signs and symptoms of depression including increased isolation, increased anxiety, anhedonia, and hopelessness. He also presents with anxiety, reporting that he is always worried about something. Ray presents with personal stressors including a sexual assault at age 12 and the recent separation of his mother and father. He reports that he is a perfectionist and a people pleaser which leads him to want to reconnect his family. Ray has been in an inpatient program two years ago that was unsuccessful and has been with an outpatient team since January 2008. Ray grew up with his parents and his two younger siblings in Virginia and is currently living with his siblings and his mother. He reports his temperament as a child growing up to be outgoing.
  • 47. 172 males discharged from the Eating Disorder Center at Rogers Memorial Hospital from 2005 to 2012 the results showed that the mean score was reduced significantly from 19.6 at the start to 14.4 at the end of residential treatment. 19.6 14.4 Adm Disc EDI-3 body dissatisfaction
  • 48. 55 of these males also completed a follow up survey an average of 22 months after discharge from residential treatment and the results Phone responses showed that the shape concerns reached mean scores at discharge (2.4) which are similar to the norms reported for non-eating disorder populations (2.3) and the improvements made during treatment were maintained for an average of 24 months post discharge. 3.7 2.4 2.4 2.3 Adm Disc FU Non-ED EDE-Q shape concerns (N=55)
  • 49. Nutritional Goals Address Obstacles to Recovery Identify and challenge errors in thinking
  • 50. “Ideal” Body Weight For Men 25-59 years of age Height in Feet & Inches Small Frame Medium Frame Large Frame BMI 21 5'7" 138-145 142-154 149-168 5'8" 140-148 145-157 152-172 138 5'9" 142-151 151-163 155-176 142 5'10" 144-154 151-163 158-180 146 5'11" 146-157 154-166 161-184 150 6'0" 149-160 157-170 164-188 155
  • 51. Bean et al., 2004 – Outcome variables for anorexic males and females one year after discharge from residential treatment – Journal of Addictive Disease
  • 52. “Sex and Muscle! Sex and muscle go together like success and beautiful women.”
  • 53. Females Males Moderate dieting 85% 70% Unhealthy dieting 56% 32% Laxatives, Vomiting, Diuretics 12% 4% Dieting behaviors Project EAT – U of M
  • 54. Psychosocial variables associated with binge eating in obese males and females International Journal of Eating Disorders Volume 30, Issue 2, Date: September 2001, Pages: 217-221 Leslie G. Womble, et al.
  • 55. Psychosocial variables associated with binge eating in obese males and females International Journal of Eating Disorders Volume 30, Issue 2, Date: September 2001, Pages: 217-221 Leslie G. Womble, et al.
  • 56. O’Dea & Abraham, 02 – Assessed 93 male college students Worried about weight and shape 20% Body image concerns 9-12% Exercise important to self-esteem 48% Distressed if not exercise enough 34% BED 3% Vomit for weight control 3% BN 2% Exercise disorder 8%
  • 57. George Sheehan (1979) “I have learned there is no need for haste, no need to worry, no need to agonize over the future. The world will wait. Job, family, friends will wait; in fact, they must wait on the outcome. And that outcome depends upon the lifetime that is in every day of running … Can anything have a higher priority than running? It defines me, adds to me, makes me whole. I have a job and family and friends that can attest to that.”
  • 58. Thought Challenging • Probability overestimation Thinking that the possible is inevitable. I COULD have gained weight becomes I AM gaining weight. • Catastrophic thinking – essentially, catastrophizing – Worrying one's way to the worst case scenario. “I am going to gain back to 200 lbs”. In short: it must be true because it feels true.
  • 59. Hierarchy Development • Create an exposure for each difficulty – Specificity and thoroughness improve outcome • Graduated list of assignments – 0 to 7 rating scale – How anxious would it make you to ______? • Start with ratings of 2 or 3 • Higher level assignments become less difficult as easier ones are completed
  • 60. Exposure and Response Prevention • Non-food, Non-weight OC symptoms – Symmetry, exactness and perfectionism – Ordering and arranging • Weight, Size, Shape OC symptoms – Measuring, weighing, checking in mirror, etc. – What causes anxiety? – What reduces anxiety?
  • 61. ERP for Food Related OC Symptoms • Individual Food Exposures – Especially for fats – Exposures can be without actual eating • Shopping and Dining Out – Therapist aided • Response Prevention – Restricting, over-exercising, bingeing, purging – Goal is 100% elimination
  • 62. Habituation Anxiety will decrease on its own if an exposure is performed without interruption by a ritual.
  • 63. Prolonged Exposures • Within Trial Habituation • Goal is 50% reduction in anxiety Anxiety Minutes
  • 64. Repeated Exposures • Between Trial Habituation • Repeat until minimal anxiety • Continue in day to day life Anxiety Minutes
  • 65. Anorexic males versus females: Admission versus discharge 0 5 10 15 20 DT Bul BD I P D IA MF RawEDIScores Females (adm) Female (disch) Males (adm) Male (disch) Non-patient male
  • 66. Findings in males • More likely to be obese/teased when young • Diet to achieve muscular body • Increased gender identity issues • Decreased sexual activity • Increased sexual abuse • Increase weight related sports • Separation or loss of father
  • 67. Conclusions • Most likely males with ED will increase • Little is know about risk for ED • Treatment is effective – Same sex treatment groups – Staff experience with males important • Support of male programs needed – Develop better treatment – Improve research efficiency
  • 68. 800-767-4411 rogershospital.org Thank you Ted Weltzin, MD, FAED, FAPA Medical Director, Eating Disorder Services Rogers Memorial Hospital tweltzin@rogershospital.org