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| Equal Opportunity Destroyer: Males with Eating Disorders |
| Feature Articles - Food Addiction | |
| Friday, 30 November 2001 | |
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Historically, eating disorders have been viewed as a "female problem." While there have been hundreds of books written about eating disorders over the past 20 years, only two titles have been devoted specifically to men. Published in 1990, Arnold Andersen's book Males With Eating Disorders was the first - and it was written for professionals, not sufferers. At that time it was believed that men accounted for approximately one in ten eating disorder cases (Andersen, 1990). John, a recovering bulimic, related to me during a therapy session how years of purging had caused extensive loss of tooth enamel. During a routine dental exam, however, no mention was made of this condition or the possible cause. Another client of mine who is anorexic, Eric, age 14, came to me after months of unsuccessful treatment. The referring psychologist had misdiagnosed him with oppositional defiant disorder because of his refusal to eat. Increasingly, however, men's struggles with food, weight, and shape are receiving attention in popular media and scientific literature. The publication of Making Weight: Men's Conflicts with Food, Weight, Shape and Appearance (Andersen et al., 2000) marked the first book written for men about men's dissatisfaction with their bodies, and is indicative of an overall cultural trend toward recognizing eating disorders among men. There has been an explosion in the numbers of men seeking help for body image conflicts, bulimia, obesity, and compulsive exercise. Recent studies now indicate that nearly one in six eating disorder cases are men (Andersen et al., 2000). Are eating disorders really becoming more common in men, or have they just been in hiding? The answer probably is both. Certainly, many more men are coming forward for help as awareness of the problem in men increases and better treatment becomes available. Beyond this, however, it appears that socio-cultural influences are contributing strongly to the increase in eating disorders among men. Men are under increasing pressure to look great, eat right, and achieve a masculine ideal that may or may not fit with genetic traits and/or personality. Popular men's magazines, such as Men's Health, regularly include articles on topics such as obtaining the right complexion, firming up your "abs," hair loss solutions, and how to please your woman in bed. Some men are now seeking to change their body appearance through plastic surgery options such as pectoral and calf implants (Nemeroff et al., 1994). Once the exclusive domain of women, cultural emphasis on appearance and pressure to obtain and maintain an ideal body size and shape now appears to be affecting men as well. Additionally, men are confused about what it means to be masculine. They are increasingly being asked to be all things to all people - strong, athletic, aggressive, and competitive - and at the same time tender, compassionate, gentle, and caring. Moreover, our culture continues to emphasize the V-shaped muscular body shape as the ideal for men. Male physical strength and prowess are not prerequisites for success in modern-day careers, as they were in frontier and rural society. Young men, trying to understand the meaning of becoming a man in our culture, are confronted daily with an array of confusing and distorted images of masculinity. Gender orientation and sex role confusion are significant contributors to eating disorders among men. I have been working with Bill, age 36, for the past few years on a once or twice per week outpatient therapy basis for treatment of anorexia. Bill has graciously agreed to share some of his experiences so that others may more fully understand the myriad of influences that contribute to disordered eating in men. While Bill's specific manifestation of disordered eating is anorexia, this article emphasizes the central importance of understanding eating disorders from the perspective of an underlying addictive process that serves a self-regulatory or adaptive function for the individual. Why a person would need to have such an adaptive function takes us to the heart of what an eating disorder is all about: a disruption or loss of self. It is this disease of self that is illustrated. "I'm too fat" Waking up in the morning, looking in the mirror, Bill sees fat. He is disgusted by it, appalled by it. The aroma of food cooking on the stove, the clanging of pots and pans, the sights, sounds, and smells of breakfast terrify him. He fights it. He doesn't want the food. He doesn't deserve it, doesn't deserve to take up space in the world. Food is good for you, but only if you're good or if you're perfect, or if everything around you is perfect. One of the hallmark features of disordered eating is preoccupation with weight and shape, along with an intense fear of becoming fat or gaining weight. Body image forms as the infant becomes capable of distinguishing and integrating sensations. Body image is particularly complex because it appears to include attitudes, emotions, and personality reactions of individuals to their bodies, and incorporates cultural and familial attitudes as well. Fisher (1966) states that the body, like all significant objects, can become a convenient "screen" on which one projects one's most intense concerns. In his discussion on temperament, Michael Strober (1991) states that biologically we are uniquely predisposed in our response to stimuli, our orientation to novel situations, our sensitivity to internal and external cues. Men with eating disorders are especially susceptible to body image problems because they innately tend to be extremely sensitive to the needs and feelings of others, hypersensitive to signs of approval and rejection, easily over-aroused by stimulating situations, and slow to recover from emotional stress. These biologically based tendencies enhance the likelihood that a man will have extreme difficulty recognizing his own feelings and needs. He will tend instead to internalize cultural expectations and the feelings and needs of others, and to place blame on himself when others are upset or in pain. Most men with eating disorders report a history of being teased about their bodies (Kearney-Cooke and Steichen-Asch, 1990). As a child, Bill describes himself as "a chubby, round, slow-moving butterball." His nickname in the sixth grade was "big bad Billy belly." One of his earliest memories was of his father talking about the roundness of his belly. Bill recalls that both of his parents talked with him about his weight and their concerns about him gaining weight. Bill's mother instructed the school not to give him second helpings of food at the cafeteria, while other students were allowed to receive additional portions of food if they were hungry. Bill remembers telling his father that there was a duck in his stomach, and fantasized about having the duck removed, in the same way that the farmer opened the wolf and took out the duck in the story Peter and the Wolf. "I never seemed to be able to flush out the duck," Bill confessed. Bill came very early in life to experience his body as "bad" because it was "fat." Over time, emotional pain, problems with siblings, mother's alcoholism, parent's divorce, and conflicting feelings/needs were internalized and experienced as "I'm too fat." "Fat" became the lens through which Bill experienced himself in relationship to the world. The obvious solution for Bill was to diet and exercise, to rid his body of the dreaded fat that signaled his unworthiness. So Bill began to diet and restrict, to "feel better," to "flush out the duck." He believed that if he could just lose weight, everything would be fine. Losing weight did bring rewards. Bill had qualified for a national equestrian competition as a youth and his mother allowed him to participate only if he kept his weight below 100 lbs., which he did. In addition, Bill found that losing weight elicited positive remarks from his minister, teachers, peers, and family members. It was magical! He had found a simple solution to a complex problem. In recovery, I ask my clients to reframe "I feel fat" as "I feel uncomfortable." Bill has had to learn not to restrict food or to exercise when he feels fat, but to sit still, look inside and try to identify the feelings and/or conflicts that he is experiencing. He has begun to develop the ability to differentiate his feelings and needs from the feelings and needs of others, to trust his perceptions, and to communicate his needs to others. Being food for others One of the primary ways that Bill knew of his worthiness as a child was his ability to tend to his mother's needs, to comfort and soothe her, to help her through her alcoholic binges. He welcomed the opportunity to respond to his mother. He was good at it. It came naturally to him. Bill was strongly rewarded for being the "good, caring boy" who would be there when needed. By cueing into his mother's needs, Bill could distract himself from his own unnamed internal pain. In Bill's family, there was scant attention to his feelings and needs. The atmosphere was often tense and chaotic. "My goal was to make myself as little as possible. My needs for love and caring were not going to be met. I wanted to be invisible, thinking that this would make me safe." For Bill, food was the enemy. It reminded him of his body, his needs, his presence in the world, and this was too unbearable to face. Sexuality and gender conflict Kearney-Cooke and Steichen-Asch (1990) found that boys who later develop eating disorders do not conform to the cultural expectations for masculinity. They tend to be more dependent, passive, and nonathletic - traits which may lead to feelings of isolation and disparagement of body. As a child, Bill was well aware that he didn't "fit in" with other boys. Not naturally competitive or aggressive, Bill preferred to spend time with girls who tended to be more gentle, cooperative, and relationship-oriented. At a very early age, Bill already harbored unspoken questions about his masculinity. For much of his life, Bill has followed a rigorous regimen of weight training to strengthen himself, build his body, and to confirm his identity as a male. Conflict over gender identity or over sexual orientation may precipitate the development of an eating disorder in many males (Crisp, 1983). Several authors have noted that homosexual conflict preceded the onset of the eating disorder in up to 50 percent of male patients (Scott, 1986; Dally, 1969; Crisp, 1967). Burns and Crisp (1984) found that male anorexics in their study admitted "obvious relief" at the diminution of their sexual drive during the acute phase of their disease. Around age 12, Bill began to experience a great deal of sexual tension and uncertainty. His interests, his attractions now included boys as well as girls. He masturbated a great deal. "We didn't talk about sex in my family. I had no clue what was going on with me, and I wasn't about to talk to anyone about this." Years later Bill faced a similar dilemma when he admitted himself to a treatment center in 1995. Bill found himself in a group of predominantly young women. He was the only male in the group. "It was very difficult. I was listening to a 14-year-old girl talk about her problems with her boyfriend, and I'm sitting there thinking, I'm 30 years old, married, and worried about whether or not I am gay. There was no way I was going to talk." Eventually, however, Bill was able to talk. In 1998, after more than twenty years of suffering from his illness, he entered a residential treatment program that specializes in treating males with eating disorders. Today, he is maintaining a healthy weight and working a strong recovery program. He has come to know and accept himself and is not defined by others. What is an eating disorder? There is broad consensus that eating disorders in males are clinically similar to, if not indistinguishable from, eating disorders in females (Margo, 1987; Schneider and Agras, 1987; Crisp et al., 1986; Vandereycken and Van der Broucke, 1984). The literature reports that for women, there appears to be a prevalence ratio of .5 to 1.0 percent for anorexia nervosa, and a ratio of 1.0 to 3.0 percent for bulimia nervosa (Thompson, 1996). Binge eating disorder is somewhat more common than bulimia nervosa but occurs equally in males and females. The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM IV), recognizes anorexia nervosa, bulimia nervosa, and binge eating disorder as diagnosable eating disorders. Some common signs and symptoms of eating disorders in men are listed in Figure 1, opposite page. Specific criteria for diagnosing anorexia, bulimia, and binge eating disorder can be found in the DSM IV. In my view, conceptualizing eating disorders as addictive processes that have at their base an underlying disturbance of self provides the most useful framework for understanding and treating the illness. The essential features of addiction: 1) recurrent loss of control over the behavior, and 2) continued use of the behavior despite ongoing harmful consequences, fit exactly with the experiences my eating disordered clients report to me in therapy. Figure 2 applies the DSM IV criteria for addictive disease to eating disorders. An eating disorder essentially is not about food at all, but rather about the pathological relationship of a person to a mood-altering process involving food. Over time the person becomes increasingly committed to using food-related behaviors - bingeing, purging, restricting, weight control measures, excessive exercise, etc., to achieve an inner sense of cohesion and well-being. Eating disordered behaviors serve multiple functions in the service of self-regulation (e.g., tension reduction, containment of painful effect, predictability, distraction, numbing, or protection). The person is not addicted to a substance (food), but to a mood-altering process involving food and weight control. Eating disorder recovery can therefore be defined as "a process of self-integration that involves two processes operating in tension: 1) establishing abstinence (the gradual surrender of eating disorder behaviors), and 2) restoration of internal self-regulation (restoring the "dis-regulated self" to full psycho-social-spiritual functioning)." Establishing abstinence Unlike the alcoholic who can simply "put the cork in the bottle," those recovering from an eating disorder cannot give up food. They must learn a new approach to food that is non-destructive and non-compulsive. Imagine telling a recovering alcoholic, "just have a few drinks each day, but try not to get compulsive or destructive with it!" Even on a "good" day, the person recovering from an eating disorder can always point to the fact that he ate too much, too little, the "wrong" foods, that he is too fat, or needs to exercise more, etc. Abstinence must be viewed as a process rather than an event with eating disorder recovery. The person must abandon the idea of "perfect" abstinence. Instead they should work toward listening to and trusting their inner self as they learn to gradually integrate food and eating. Complete surrender of eating disorder behavior (fully realized abstinence), is a late stage recovery phenomena. In many ways, a person "comes to" abstinence after working a recovery program rather than establishing abstinence first, and then working a recovery program. Restoring internal self-regulation Carolyn Costin (1996) talks about the importance of "putting the eating disorder out of a job." As a person surrenders eating disorder behaviors, agitation, uncertainty, anhedonia, and other symptoms of internal dis-regulation will surface. The recovering person must be taught healthy ways to soothe tension, to tolerate uncomfortable feelings, and also to problem solve effectively. Putting the eating disorder out of a job means uncovering the meaning of eating disorder symptoms and substituting healthier, more adaptive methods of coping. Relapse If abstinence is indeed a process, eating disorder symptoms are likely to present themselves in response to any number of internal or external events throughout the course of the man's life. Rather than seeing eating disorder symptoms as a failure or relapse, taking an approach of careful observance helps him to see symptoms as "signal flares" that can tell him about what may be bound up or in need of attention in his life. Eating disorder symptoms will continue to reappear until the "inside" dynamics are attended to carefully and regularly. Attending to and honoring symptoms in this way tends to bring the eating disorder "closer," rather than "pushing" it away, and as such serves an integrative function. The key is to stay "in the middle." Relapse occurs when tension is lost and the person "disintegrates" by either 1) literally acting out the symptom by engaging in compulsive behavior, and/or 2) failing to attend to the internal dis-regulation embodied by the symptom. You can help him Research has shown that a man who develops an eating disorder presents the following profile: he appears to lack a sense of autonomy, identity, and control over his life; he seems to exist as an extension of others and to do things because he must please others in order to survive emotionally; and he tends to identify with his mother rather than with his father - a pattern which leaves his masculine identity in question and establishes a repulsion of "fat" which he associates with femininity (Kearney-Cooke and Steichen-Asch, 1990). With this in mind, the following suggestions for prevention can be made:
References Andersen, A.E. (Ed.) (1990). Males with eating disorders. New York: Brunner/Mazel. Andersen, A.E., Cohn, L. & Holbrook, T. (2000). Making weight: Men's conflicts with food, weight, shape, and appearance. Carlsbad CA: Gurze Books. Costin, C. (1996). Eating disorder sourcebook. RGA Publishing Group, Los Angeles, CA. Crisp, A.H. (1967). Anorexia Nervosa. Hospital Medicine, 1, 713-718. Crisp, A.H. (1983). Some aspects of the psychopathology of anorexia nervosa. In P.L. Darby et al., (Eds.), Anorexia Nervosa: Recent Developments in Research (pp. 15-28). New York: Alan Liss. Crisp, A.H., et al. (1986). Primary anorexia nervosa in the male and female: A comparison of clinical features and prognosis. British Journal of Medical Psychology, 59, 123-132. Dally, P. (1969). Anorexia Nervosa. London: Heinemann Medical Books. Fisher, S. (1966). Body attention patterns and personality defenses. Psychological Monographs: General and Applied, 80, 9 (617), 1-29. Kearney-Cooke, A. & Steichen-Asch, P. (1990). Men, Body Image, and Eating Disorders. In A. Andersen (Ed.), Males with eating disorders (p. 47). New York: Brunner/Mazel. Margo, J.L. (1987). Anorexia nervosa in males: A comparison with female patients. British Journal of Psychiatry, 151, 80-83. Nemeroff, C.J., et al. (1994). From the Cleavers to the Clintons: Role choices and body orientation as reflected in magazine article content. International Journal of Eating Disorders, 16, 167-176. Schneider, J.A., & Agras, W.S. (1987). Bulimia in males: A matched comparison with females. International Journal of Eating Disorders, 6, 235-242. Scott, D.W. (1986). Anorexia nervosa in the male: A review of the clinical, epidemiological and biological findings. International Journal of Eating Disorders, 5, 799-819. Strober, M. (1991). Disorders of the self in anorexia nervosa: An organismic-development paradigm. In Johnson, C. Ed., Psychodynamic Treatment of Anorexia Nervosa and Bulimia. The Guilford Press: London. Thompson, J. Kevin (Ed.), (1996). Body Image, Eating Disorders, and Obesity. American Psychological Association, Washington, D.C. Vandereycken, W. & Van der Broucke, S. (1984). Anorexia nervosa in males. Acta Psychiatrica Scandinavica, 70, 447-454. figure 1 Common Signs and Symptoms of Eating Disorders in Men
DSM IV Diagnostic Criteria for Addictive Disease (Applied to Eating Disorders) A maladaptive pattern of eating disorder behavior, leading to a clinically significant impairment or distress, as manifested by three (or more) of the following, occurring at any time in the same 12-month period: 1. Tolerance, as defined by either of the following: (a) A need for markedly increased amount or intensity of eating disorder behavior to achieve the desired effect; (b) Markedly diminished effect with continued involvement in eating disorder behavior at the same level of intensity. 2. Withdrawal, as manifested by either of the following: (a) Characteristic psychophysiological withdrawal syndrome of physiologically described changes and/or psychologically described changes upon discontinuation of the eating disorder behavior. (b) The same (or closely related) eating disorder behavior is engaged in to relieve or avoid withdrawal symptoms. 3. The eating disorder behavior is often engaged in over a longer period, in greater quantity, or at a higher level of intensity than was intended. 4. There is a persistent desire or unsuccessful effort to cut down or control the eating disorder behavior. 5. A great deal of time is spent in activities necessary to prepare for the eating disorder behavior, to engage in the behavior, or to recover from its effects. 6. Important social, occupations, or recreational activities are given up or reduced because of the eating disorder behavior. 7. The eating disorder behavior continues despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the behavior.              |
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