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.
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 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.
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