Anorexia Nervosa in Men

Anorexia nervosa (AN) is an eating disorder that is the exact opposite of obesity. In this condition, the individual starves himself, sometimes to death. It is typically characterized by a very low body weight, a distorted body image and an intense fear of gaining weight. No matter how thin the individual is, there is a perception that the individual is still fat. The disorder is more common in females but in the past 2 decades, it has been increasingly recognized in males. Two decades ago, it was found that for every 15 females with anorexia, there was one male with the same disorder.

 

Today, ratio is 4 females to one male. It is estimated that males generally account for 5-10% of reported cases of anorexia nervosa but this number is an under estimate because the disorder is under diagnosed and under reported. Anorexia nervosa among females has its peak onset during the adolescent years, with the vast majority developing the disorder between the ages of 13 and 20. Relative age of onset of anorexia nervosa in males is still unclear. In the decades past, it was believed that eating disorder was only common in homosexuals, bisexuals or transvestites, but this is only folklore. Today, men in every societal class have been found to be affected with this disorder, regardless of sexual orientation.

 

According to criteria in the American Psychiatric Association's Diagnostic and Statistical Manual (DSM-IV), individuals with anorexia nervosa are less than 85% of expected weight, have an intense fear of gaining weight or becoming fat, and exhibit a significant disturbance in the perception of body weight or size. Another additional criterion for anorexia in postmenarchal females is amenorrhea for at least 3 consecutive menstrual cycles. Unfortunately, males with anorexia do not have amenorrhea and this may be the reason why the disorder is frequently under diagnosed. However, there are many other features of anorexia in males which are similar to females and should lead to a suspicion of anorexia. Males with anorexia have similar mental problems as females. This may include depression, obsessive compulsive or extremely anxious. The biggest difficulty for male anorexics is coming out in the open with the disorder. The reason for hiding in the closet is because society as well as many physicians believe that only females can have anorexia. In addition, men take even more care in hiding their disorder and frequently present much later than the females. As a result, when men are diagnosed with the disorder, the symptoms are quite severe and the disorder is more difficult to treat.

The literature on causes of anorexia and bulimia (another eating disorder) is abound with theories and explanation. Even though the condition was first reported many decades ago, only recently are physicians becoming aware that it is also a problem in males. Why males develop anorexia is unknown but numerous studies link it to psychological aberrations in self image. The condition always starts of as an innocent dieting program, but gradually progresses to extreme and unhealthy weight loss. Other contributing factors which may lead to anorexia are family influences, genetics, neurochemical and developmental factors. Even though most of these males come from upper middle class and well to do families, anorexia has also been found in all levels of society. No race or ethnic group is immune from this destructive illness.

Studies have found that birth boys are indoctrinated with a concept of what man is. They then hold steadfastly to this set of attitudes and behavior that include preoccupation with success, a decent career, physical strength, machismo and courage. When the young males fail to achieve these goals, emotional isolation and torment occurs, which results in problematic behavior. And this is a major finding in many men with anorexia. Individuals who do develop anorexia also have a strong family history of weight problems, physical or psychosomatic illnesses or a variety of mental problems (depression, anxiety, and substance abuse). In many cases, the individuals come from families who have a very rigid upbringing, overly critical father, and intrusive mother and an overly protective family. The child fails to thrive mentally in this environment and seeks refuge in his body.

When evaluated by psychologists, these individuals tend to be very dependent on family/friends and have an immature sense of mental development for their age. Anorexia may also co-exist with other disorders like anxiety, depression and obsessive compulsive personality. The girl friends usually report that the males are very controlling and even become paranoid. Apprehension and anxiety is also common feature in their sexual behavior. Individuals with anorexia may also be socially withdrawn, irritable, moody, and/or depressed. Many of the individuals will also have personality disorders which may include borderline, narcissistic or antisocial. And substance abuse is a common feature. Classification Anorexia is subdivided into two groups—both of which are aimed at weight loss Anorexia nervosa: here the individual severely limits the intake of all foods, especially carbohydrates and fat-containing foods. Bulimia:also called binge-eating/purging type, in this condition, the individual does eat in binges and then induces vomiting and/or takes large amounts of laxatives or other cathartics (medications, through their chemical effects, that serve to increase the clearing of intestinal contents). Some also place their fingers in the mouth to induce gagging and vomiting. The knuckles on the hands generally reveal the teeth marks on examination. Muscle Dysmorphia: Muscle dysmorphia is similar to anorexia. In anorexia the female has an illusion that she is fat; in muscle dysmorphia, the male believes that they do not have enough or big muscles. These males see something in their muscles which is not true and become fitness fanatics. These individuals are muscular and even have a well built body but still refuse to wear shorts or t-shirts. They have such a negative image of their body that it eventually leads to loss of self confidence about their body shape and size. These males are always exercising, constantly checking their weights and size of their muscles. They are generally picky eaters and their entire life is devoted to improving their body mass. The obsession with exercising affects their social life and work. Many of these men turn to anabolic steroids and are frequent visitors to natural health stores- looking for that magical pill to build mass.

The symptoms and signs of anorexia may not be evident in the initial phase. Only when the condition has progressed to moderate or severe weight loss, the symptoms may be evident. The symptoms include - Low body weight (less than 85 percent of normal weight for height and age). - Intense fear of becoming fat even if the individual is thin - Distorted view of one's body weight, size, or shape; sees self as too fat, even when very underweight - Keeps on mentioning that he is fat (even when very thin) - Refuses to eat and very nit picky - Excessive physical activity in order to promote weight loss - Denies feelings of hunger - Preoccupation with food preparation. - Bizarre eating behaviors - Afraid to reveal body - Preoccupation with body building and weight lifting - Continuous muscle toning - Always eats alone Bulimia Nervosa in Males - recurrent episodes of binging eating following by purging, vomiting or exercise - intense preoccupation with food - morbid fear of getting fat - mega dose usage of laxatives, diuretics - hoarding and stealing food - severe dental problems - sexual apprehension - guilty after eating - emotional or anxiety during eating Physical observation When anorexia is chronic, numerous physical signs are evident and they include: - very dry skin which has no fat content - Dehydrated - May have abdominal pain and complain of constipation - Intolerance to cold temperatures - Emaciated - Loss of normal hair and development of fine lanugo hair - Yellow skin - Deformed nails - Bite marks on knuckles

The physical appearance of the individual may lead one to suspect anorexia. Often the condition is reported by teachers or friends but the affected individual’s family of friends may have identified the condition much earlier and may have decided to keep the disorder private and hidden. In most cases the clinical presentation may give the psychiatrist a clue to the diagnosis. Only rarely is psychological testing is required. The earlier the parents report their child to the doctor, the earlier the treatment- which improves the prognosis.

Medical complications that may result from anorexia include, but are not limited to, the following: Heart: many anorexics develop heart problems including a slow heart rate. Low blood pressure and fainting spells are common because of lack of fluid in the body Anemia: The majorities of anorexics develops low blood counts (anemia) and have a difficult time fighting infections also (low white cells) Intestine: to ensure regular movements of the intestine, one has to eat regularly. Anorexics do not eat and thus the intestinal tract slows down. These individuals are constipated and have rock hard poop(lack of water) Kidney: when the anorexics do not take fluids, the urine output decreases and the urine becomes concentrated. Many times, the kidney failure develop which is recovered after fluid is restored. Endocrine: Males who are anorexics for prolonged periods will develop severe growth retardation. Bones: all anorexics have weak bones and are very prone to fractures. The bone density is low in all individuals and osteoporosis is a common end phenomenon.

The treatment of anorexia is difficult and requires a combination of therapies including therapy for the individual, family counseling, behavior modification and food. The treatment is based on the following: - the male’s age - overall health and medical history - severity of the illness - tolerance to specific therapy - a realistic expectation of the prognosis Treatment is always based after a comprehensive evaluation of the adolescent and family. Some medications, like the anti depressants (tricyclics, SSRIs) may be required if the individual is depressed, because medical complications are quite frequent in these individuals during the rehabilitative stage, a nutritionist social worker and a physician must be involved wit the are. The role of the family is essential. In many cases hospitalization is required in severs cases of anorexia and malnutrition. Recently psychotherapy has been used to reach out to the less prevalent, more secretive and resistant subgroup of individuals. Studies reveal that this subpopulation of males with eating disorders is likely to require additional social support, and that a support group can have many positive effects for the men who give it a chance.

So far we have no idea how to prevent anorexia. The only hope is to detect it early and start intervention before the condition gets too severe. This is of importance if we want to improve the quality of the individual’s life, growth and development and social skills. Encouraging healthy eating habits and realistic attitudes toward weight and diet may also be helpful. Conclusion Eating disorders remain largely a female illnesses. However, these disorders are adequately common that even if only 10% of victims are male, hundreds of thousands of young men would be affected, making it an important health problem for males. In addition, some researchers believe that eating disorders may be under diagnosed in males because of under recognition by clinicians or unwillingness of males to seek treatment for these stereotypically female conditions.

 

Although there appear to be more similarities than differences between males and females with eating disorders, much can be learned from the differences between the two groups. Gender differences that have emerged in some studies of patients with eating disorders include a later age at onset of illness in bulimic males, and a higher prevalence of premorbid obesity in males with eating disorders than in females with eating disorders. Extreme sociocultural stress for thinness may by themselves be fervent enough to hasten development of eating disorders in vulnerable men and women. In addition, the glamorizing of the well built male and our body-focused subcultures such as competitive body building and sports may further enhance the development of body Dysmorphic disorder. The world we live is harsh and unforgiving and manipulating. Society will have to come to terms with what we value more- overly thin bodies and mental anguish or overweight and predisposed to all the health complications that go with it: today the choice of being in between these two is easy but difficult to achieve.