Eating disorder research tends to focus on girls and women. Which makes sense: eating disorders disproportionately affect women. However, it isn’t just the research on eating disorders that focuses on women: it’s the entire history of eating disorders as a diagnosis. The first descriptions of anorexia nervosa by William Gull and bulimia nervosa by Gerald Russell were both based primarily on observations of female patients (although Russell did include two men). Therefore, it’s possible that our basic construction of eating disorders is based on a specifically female experience.
One example of this is the focus on weight loss as a cardinal component of eating disorders (barring binge eating disorder). This is often attributed to the pursuit of a “thin ideal” created by our culture; however, this thin ideal doesn’t necessarily apply to men. Whilst women encounter pressure to be thin, evidence suggests that men encounter pressure to be more muscular—a drive that by its nature would not necessarily be associated with the pursuit of weight loss (Olivardia, 2001).
The point at which this pursuit of muscularity becomes a mental illness has traditionally been understood as muscle dysmorphia (MD), a subset of body dysmorphia, which is itself a subset of obsessive-compulsive disorder (OCD). Using the OCD framework, the obsession becomes the muscular body type and the compulsions include engaging in disordered eating behaviours, exercising compulsively, and taking supplements.
Unsurprisingly, researchers have noted that this sounds an awful lot like an eating disorder. In order to clarify this proposition, Murray and colleagues (2013) carried out a study to examine to what extent men with MD fit into Fairburn’s (2003) transdiagnostic model of eating disorders.
THE STUDY
Fairburn’s model proposes four crucial aspects of eating disorders that underline any behaviours:
- Clinical perfectionism
- Low self-esteem
- Interpersonal difficulties
- Mood intolerance
Crucially, this model does not mention weight loss or even specific behaviours, instead proposing that the emotional and cognitive processes that underlie the expression of these behaviours are more crucial to understanding what actually defines an eating disorder.
Murray et al.’s (2013) study used a series of measures to assess each aforementioned domain and MD symptomatology to see whether MD would be better placed in the eating disorder spectrum. In other words, the authors wanted to know whether Fairburn’s transdiagnostic model of EDs would be able to predict MD symptoms.
The study participants were 119 male undergraduate students; 20 participants (17%) were part of another study on MD and met the full diagnostic criteria for MD. Thus, the sample was enriched for individuals with MD relative to the community, but it was more diverse than if the sample were to only have individuals with MD.
THE RESULTS
The study found that low self-esteem, mood intolerance, and clinical perfectionism were significant predictors of MD symptoms. The study distinguished between types of perfectionism: Self-orientated and socially-orientated perfectionism were found to relate to MD symptoms, suggesting that these young men feel pressure both from themselves and from others to pursue a muscular ideal. However, other-orientated perfectionism—the expectation of others to conform to that muscular ideal—was not associated with MD. The authors suggest that this phenomenon of holding oneself to higher standards than other people may lead to a perception of one’s body imperfection as abnormal, contributing to the psychopathology of MD.
The only domain that did not significantly predict MD symptoms was interpersonal difficulties. The authors highlight that this might be due to the lack of methodological tools that are sensitive to MD, which links back to the problems associated with taking existing constructs and applying them to measuring and understanding MD. They also note that a recent model of interpersonal difficulties in eating disorders (the IPT-ED) focuses on the importance of negative self-evaluation by others: something that could relate to this study’s finding of the importance of socially-orientated perfectionism and its possible relationship to low self-esteem (Rieger et al., 2010).
SO, WHAT’S NEXT?
The study results suggest that MD closely fits existing models of eating disorders, which in turn raises the possibility that either MD should be reconceptualised as an eating disorder, or that existing eating disorder diagnoses should be revised in order to more explicitly take account of the drive towards muscularity rather than thinness in men. I think that an important next step would be to take this theoretical proposal and put it into practise by running clinical trials to see whether eating disorder treatments can help individuals diagnosed with MD.
It also raises the possibility that, put simply, our existing understanding of eating disorders is failing men, or, more generally, people who pursue a masculine or muscular ideal. This would be particularly important to identifying eating disorders in athletes, as sports often involve not only pressure to lose weight, but also pressure to gain weight in order to meet a certain weight class or degree of muscularity.
From my perspective, this comes back to an ongoing issue with eating disorder diagnoses: they tend to focus on external appearance and behaviours, rather than underlying emotional and cognitive processes. This is important because individual experiences of eating disorders, especially over a long period of time, tend to fluctuate across different diagnostic categories. It’s entirely possible to receive multiple eating disorder diagnoses as time progresses, and yet my feeling is that these are different behavioural expressions of the same underlying illness. And this study demonstrates that this focus on behaviours doesn’t only lead to confusion over what the right diagnosis for an individual actually is: it may actually be leading to the exclusion of people who don’t exhibit classic eating disorder behaviours.
References
Murray, S., Rieger, E., Karlov, L., & Touyz, S. (2013). An Investigation of the Transdiagnostic Model of Eating Disorders in the Context of Muscle Dysmorphia European Eating Disorders Review, 21 (2), 160-164 DOI: 10.1002/erv.2194
The finding that other-oriented perfectionism was not associated with MD is inline with a paper I wrote about before that found only self- and socially-oriented perfectionism was related to rigid food rules in individuals with EDs. I don’t know much about the perfectionism literature and how well validated these three types of perfectionism are, but it seems to make sense to me on face value.
I didn’t read the original paper, but I am not sure that having overlap with those four components that (according to Fairburn’s paper) maintain the ED behaviours, is enough to suggest that MD is a ED. What if, instead, EDs *and* MD are better reconceptualized as something else entirely? As issues reflecting perfectionism, perhaps low self-esteem, and poor ability to navigate emotions? Do you know what I mean?
I also question whether running trials to see if EDs treatments help those with MDs will do much of anything as far as supporting the proposal that MD should be categorized as an ED. I mean, CBT might be helpful for depression and BN, but it doesn’t mean BN should be categorized with depression. Moreover, AN and BN are both EDs, at least we conceptualize them as such, but treatment for both still differs–it has to to some extent. I do agree with your conclusion that these issues have a lot more similarities than we may originally think they do.
I wonder how much of our general failure to understand and recognize EDs in men, or well, anyone other than a white adolescent female, is simply historical. Is it due to the conceptualization of EDs as a thing silly, vain, privileged white girls suffer from?
I personally think that the men/eating disorders issue really highlights just how not fit for purpose the current diagnoses are. Also the male issue is interesting because, as far as physical ideals are concerned, men are exposed to a different culture than women- and as Andrea’s recent series on culture has pointed out, conceptualising eating disorders solely as a concern with weight and shape (and especially weight loss) may not be appropriate across different cultures.
I do know what you mean about Fairburn’s model, and I think it comes back to the limitations with the current ED diagnoses. I think that because a lot of the current questionnaires and diagnostic tools are based on Fairburn’s model, or very similar assumptions, there’s a danger of a circular validation: only people diagnosed by those questionnaires fit the model. Or, in the case of MD, yes certain people with MD also fit an ED cognitive model, but what about those who don’t? So I think that future research into EDs needs focus on aspects of disordered eating that don’t conform to the existing models- and MD could be an example of that. And a big problem with the existing ED models is that they often validate the concept of EDs as something exclusive to white teenage girls- they create structures of exclusion and prescriptivism that don’t leave room for the individual.
I have to admit that I have a bit of a thing for qualitative methods- I think that there might be some value in going back to the basics and looking more into why individuals pursue certain behaviours using in-depth techniques such as interviews, rather than trying to impose existing models.
Great post, Emma! I like the way you stress the need for going beyond behaviors, and your post is sort of an accessible antidote to a lot of stuff that’s out there about EDs in men. There are many well-meaning websites and blogs that basically say: “Beware the drive for muscularity. This is how EDs look like in men. When they have an ED, they want to gain muscle rather than simply staying thin”. So basically what this does is reproducing the same problematic logic that drives the prevailing understanding of EDs in women: we generalize and stereotype it in terms of body image concerns, separating men and women only with regard to the kind of body image concern they have (whether it’s muscularity or being very thin).
It’s a challenge in our culture, but I always remind myself of how EDs can occur in many different forms both in men and in women, and also how we shouldn’t assume that every kind of behavioral pattern that entails some sort of rigid control over eating or intense anxiety about body image is an ED.
Problematizing the very concept of EDs and trying to frame these issues in a broader perspective as you do is always interesting to me. Thanks!
I agree 100%.
Thanks for this. My ex had MD (ED?!)
It took me about two months of dating him to recognize that there was something off with his thoughts and behaviors. I pointed out to him that the obsession, high impulse, and fixation on food and working out was pretty close to my own experiences. He had a history of being overweight and had lost all of it but then became fixated on bulking and the muscle component. It was almost worse because he both wanted to be thin and wanted to gain muscle at the same time. He also did the “pro-ana” behavior where he would go on bodybuilding blogs and ask for advice and post progress pics while anonymous internet users tore him apart. (I suspect that most people on these forums actually have their own issues….)
From physical appearance, he was a completely normal weight and was very physically fit. He was eating 3000-4000 calories a day to bulk, but would then freak out about the potential weight gain and run 10-12 miles 3x/week. Then get frustrated that they cancelled each other out. But was too anxious to stop doing either behavior.