According to the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; American Psychiatric Association, 2013), the symptoms for anorexia nervosa are as follows:
- Restriction of energy intake relative to requirements, leading to a significantly low body weight in the context of age, sex, developmental trajectory, and physical health. Significantly low weight is defined as a weight that is less than minimally normal or, for children and adolescents, less than that minimally expected.
- Intense fear of gaining weight or of becoming fat, or persistent behavior that interferes with weight gain, even though at a significantly low weight.
- Disturbance in the way in which one’s body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or persistent lack of recognition of the seriousness of the current low body weight
If an individual has met all the criteria for anorexia nervosa, subsequent diagnoses for anorexia nervosa can specify whether the client is in partial remission or full remission. If the client is in partial remission, Criterion A has not been met, but either Criterion B or C is still met. Full remission is denoted by none of the criteria being met for a sustained period of time (American Psychiatric Association, 2013).
Lastly, severity level needs to be assessed for the client with anorexia nervosa. Severity level for adults is based on current body mass index (BMI) and, for children and adolescents, it is based on BMI percentile. However, the level of severity can be increased to reflect the degree of functional disability and the need for supervision. The levels of severity are mild, moderate, severe, and extreme (American Psychiatric Association, 2013).
How prevalent is this issue for men?
How does sex/ gender influence the development of this issue? How does gender socialization and gender-specific responses from others (discrimination, prejudice, oppression) relate to the experience and development of this issue? How do men uniquely experience this issue?
Adolescent males scored significantly lower than adolescent females on Weight and Shape Concerns and the Global Eating Disorders Examination score. Additionally, men endorsed specific items less frequently; Social Eating, Empty Stomach, Desire for a Flat Stomach, Eating in Secret, and Desire to Lose Weight Items (Darcy et al., 2012). The significantly fewer endorsements for a desire to lose weight in men is interesting, given that a critically low weight is a main criteria for anorexia nervosa. Weight concerns may not be as common of an issue for males as it is for females. This hypothesis is in line with the idea that men with anorexia nervosa may be preoccupied with attaining an idealized masculine shape rather than trying to be as thin as possible (Darcy et al., 2012). A significantly lower desire for a flat stomach than women may be due to gender socialization in which men are socialized to have prominent abdomen muscles.
Significantly more males than females report self-induced vomiting (Darcy et al., 2012). This may be due to various reasons, but perhaps men are socialized to care less about the physical effects of vomiting on their physical appearance (decreased enamel) than women are or men are expected to eat more in public which causes a greater number of men to resort to vomiting.
Due to the widespread view that anorexia is a women’s disorder, there is a greater incidence of late detection or nondetection of anorexia nervosa in males than females which has led to a high degree of medical abnormalities due to malnutrition (Lindblad et al., 2006). This may be due to a development of shame by male clients who have anorexia to hide their symptoms or it could be due to clinicians overlooking anorexia as a possibility due to their own biases that anorexia only exists in women.
Wooldridge and Lytle (2012) organize anorexia nervosa into four etiological domains; family systems, biological, meaning (culture and gender), and psychodynamic.
Family Systems:
Knowledge about the client's family positively impacts the treatment of anorexia nervosa in that male. Research has shown that boys with anorexia nervosa are significantly more likely to live in a single-parent home or have fathers who live separately or have died (Wooldridge & Lytle, 2012). For those who do interact with their fathers, pressure from their fathers to excel in sports or have a muscular physique and excessive parental expectations were cited as events that contributed to the onset of anorexia nervosa. Family interaction patterns are also vital to explore; the adolescent male having less autonomy and independence than his peers is predictive of anorexia nervosa (Wooldridge & Lytle, 2012). Lastly, "greater conflict, control. and achievement orientation" were linked with an increased risk for developing anorexia nervosa (Wooldridge & Lytle, 2012, p. 370).
Biological:
Malnutrition in adolescent boys leads to a substantial disturbance in the endocrine system. In many individuals, testosterone levels remained significantly lower than normal even after being restored to a healthy weight (Wooldridge & Lytle, 2012). Testosterone is typically a protective factor against osteoporosis. However, due to the decrease in testosterone levels in adolescent males with anorexia nervosa, males with anorexia nervosa, specifically those with the binge-purge subtype, may be at greater risk for osteoporosis than females with anorexia nervosa (Wooldridge & Lytle, 2012).
The majority of boys with anorexia nervosa started developing symptoms just before or after puberty began. Puberty causes weight gain and for those who enter puberty early or quickly, they may become overweight for their age. Being overweight is a risk factor for developing anorexia nervosa in adolescent males (Wooldridge & Lytle, 2012).
Meaning:
The meaning that clients assign to themselves, each other, and their behavior is often interlaced with their struggle with anorexia nervosa. Males with anorexia nervosa perceived themselves as almost twice as overweight than they actually were (Wooldridge & Lytle, 2012). Additionally, our society encourages a perception that muscular and trim bodies for men are ideal which could further lead to a distorted view of one's body. As our society further presents this body type as the only body type of value for men, young men have experienced an increase in body dissatisfaction (Wooldridge & Lytle, 2012). Furthermore, peer criticism about weight is reported as a risk factor for anorexia nervosa in adolescent males (Wooldridge & Lytle, 2012).
Involvement in high risk groups also increases the likelihood that adolescent males will develop anorexia nervosa. High risk groups include appearance-based jobs such as modeling and acting, jobs traditionally held by women such as nursing, and food related jobs such as restaurant management or catering (Wooldridge & Lytle, 2012). Further, Wooldridge and Lytle (2012) discuss research that shows that athletic sports where aesthetics are vital factors, such as dance, body building, horse racing, and running are linked with higher rates of anorexia nervosa.
Homosexuality has also been identified as a risk factor for anorexia nervosa in adolescent boys. Gay men are twice as likely as straight men to have an eating disorder. This may be due to the increased cultural pressures to remain thin and diet. There may also be a culture of weight-specific teasing in the gay community (Wooldridge & Lytle, 2012).
Psychodynamic:
Over-involved caretakers are linked with the development of anorexia nervosa once the boy hits adolescence and starts desiring more independence. Psychodynamic theorists see anorexia nervosa as a way these adolescent boys can exert control over themselves (Wooldridge & Lytle, 2012). Perfectionism has been shown to be a characteristic of anorexia nervosa in both men and women (Wooldridge & Lytle, 2012).
What should counselors know about working with an adolescent male with anorexia nervosa? What approaches/ techniques seem to work best? What assumptions or biases should counselors challenge? What should counselors make sure to attend to?
Working with the client to figure out ways to be independent without returning to anorexia nervosa as a means to exert control over oneself is essential if a client presents with a perfectionistic personality and speaks of growing up in a controlling household. Since many males with anorexia nervosa perceive their bodies as heavier than they actually are, revising their perceptions of their bodies is most likely necessary in counseling to ensure a full recovery. Additionally, active sexual fantasy, masturbation, and general sexual activity are strong predictors of good recovery in males with anorexia nervosa (Wooldridge & Lytle, 2012).
Conceptualizing anorexia nervosa as stemming from multiple etiological factors allows for more comprehensive treatment of the disorder. Integrative problem-centered therapy allows clinicians and clients organize information about a presenting problem (Wooldridge & Lytle, 2012).
Overall, it is important to note that male gender is not an adverse factor in treatment. Psychiatric hospitalization and other psychiatric diagnoses are almost at the same rate as adolescent males without anorexia nervosa which may indicate a favorable prognosis in adolescent males with anorexia nervosa (Lindblad et al., 2006). Compared with women with anorexia nervosa, as a group, men with this disorder seem to exhibit a less severe course of illness (Lindblad et al., 2006).
Annotated Bibliography
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.
- This resource provides diagnostic criteria for mental disorders with potential specifiers for the diagnosis of anorexia nervosa. It is the newest edition of the manual.
Darcy, M. A., Doyle, A. C., Lock, J., Peebles, R., Doyle, P., & Le Grange, D. (2012). The eating disorders examination in adolescent males with anorexia nervosa: How does it compare to adolescent females?. International Journal Of Eating Disorders, 45(1), 110-114.
- This article discussed the differences between men and women with anorexia nervosa who took the Eating Disorders Examination (EDE-12) on different subcategories of the measure. The authors noted the limitations of the EDE-12 in assessing eating disorders in men as the measure is not normed for males. Suggestions for item revisions in order to make the measure more applicable to men were noted.
Lindblad, F., Lindberg, L., & Hjern, A. (2006). Anorexia nervosa in young men: A cohort study. International Journal Of Eating Disorders, 39(8), 662-666. doi:10.1002/eat.20261
- This article considered the similarities and differences of Swedish men who have been hospitalized for anorexia nervosa and those in the general population. Areas such as socioeconomic status, other psychiatric diagnoses, education level, and living situation were compared. The authors noted the limitations of only using a hospitalization sample as these individuals may have a more severe version of anorexia nervosa than those who are not hospitalized.
Wooldridge, T., & Lytle, P. (2012). An overview of anorexia nervosa in males. Eating Disorders, 20(5), 368-378.
- This article presents an overview of multiple studies on anorexia nervosa in males. An integrative understanding of each client’s development of anorexia nervosa is suggested along with four domains that should be explored; family systems, biological, gender and culture, and psychodynamic.