Eating disorders in males are understudied, underrecognised and misunderstood. Despite evidence that males constitute 25-33% of diagnoses of anorexia and bulimia nervosa, and up to 50% of diagnoses of binge eating disorder, limited research has focused on the “male experience” of eating and body image concerns. In addition, researchers and clinicians have only recently begun to focus on the role that muscularity plays in males with eating and body image psychopathology. We present evidence that disordered eating behaviours are increasing more rapidly in men than in women, particularly with regard to binge eating. We further present a clinical comparison of men with anorexia nervosa and muscle dysmorphia (“reverse anorexia”) and review community-held attitudes and beliefs about people with these conditions. We conclude with a discussion of clinical treatment guidelines for males with eating disorders. This workshop will (1) present an overview of the evidence base pertinent to males with eating disorders, (2) evaluate evidence for the prevalence of disordered eating amongst males, compare the phenomenology of muscle dysmorphia and anorexia nervosa, and review the stigmatization of males with anorexia nervosa and muscle dysmorphia. Finally, this workshop 3) details treatment guidelines for clinicians working with males.

1. Scott Griffiths
Phillipa Hay
Stuart Murray
Stephen Touyz
Ted Weltzin
The male experience of eating
disorders: Anorexia nervosa, muscle
dysmorphia, and everything in-
between

2. We have no commercial
relationships to disclose.

3. Muscle Dysmorphia
What is it, and where does it
belong?

4. The Nature of Male Body Image
• It was initially thought that male body
image disorders were very rare.
• Recent research suggests that men are
now approaching parity with women in
prevalence and severity of body image
dissatisfaction.
• Unlike women, the bulk of male body
image dissatisfaction is oriented
towards the acquisition of body mass,
in the form of lean muscularity, rather
than losing it.
• An average weight male more likely to
perceive himself as underweight,
whereas an average weight woman is
more likely to perceive herself as
overweight.
• Boys as young as 6 years of age display
a strong preference for mesomorphic
body types.

5. What is Muscle Dysmorphia?
• Formerly known as ‘Reverse Anorexia Nervosa’ (Pope at al, 1993).
– The core body image disturbance is a belief in one’s body
appearing unacceptably small and weak.
– Desire a more muscular body build (despite often being highly
muscular).
– Body shame/disguising/avoidance.
• Renamed muscle dysmorphia and placed as a sub-type of
body dysmorphic disorderin 1997 (Pope et al, 1997).
– Primary disturbance is pathological muscle-building exercise
behaviour.
– Any eating disturbances are secondary & often
unnecessary feature.

6. What is Muscle Dysmorphia?
• Symptoms include:
– Preoccupation around insufficient muscularity.
– Rigid schedule of muscle-building physical activity.
– Deviation from this schedule results in intense anxiety
around potential loss of muscularity, and immediate
attempts at compensation.
– Sacrifice of social or occupational activities due to the
need to maintain training & diet schedule.
– Avoidance of body exposure.
– Illicit appearance and performance enhancing
substance use.
– Continued training despite physical injuries.

7. Does Muscle Dysmorphia Feature
Eating Pathology?
• Excessive preoccupation around dietary intake is
central to presentations of muscle dysmorphia.
• Rigid dietary regimen.
• This is typically oriented around the cyclical or
simultaneous consumption of protein and
restriction of calories.
• Disruption to dietary practices alone can result in
marked escalation of muscle dysmorphia
symptomatology, and immediate attempts at
compensation (Murray et al., 2012).
• Men with muscle dysmorphia report comparable
dietary restriction, shape- and weight concern to
men with anorexia nervosa (Murray et al., 2012).
• Pathological eating practices are now deemed a
central feature in muscle dysmorphia (Murray
&Touyz, 2013).

8. Review of the Extant Evidence Base
• This constellation of symptoms, is a valid
diagnostic entity (Olivardia et al, 2000).
• Muscle dysmorphia appears to be associated
with greater psychopathology than other
forms of body dysmorphic disorder (Pope et al,
2005), delineating muscle dysmorphia from
other forms of body dysmorphic disorder.
• On measures of psychopathology, men with
muscle dysmorphia appear similar to men
with eating disorders on a wide range of
indices, including scores on measures of
eating disorder psychopathology (Davis & Scott-
Robertson, 2000; Mangweth et al, 2000), and exercise
pathology (Murray et al., 2012).

9. Review of the Extant Evidence Base
Cont.
• Documented similarities between muscle
dysmorphia and anorexia nervosa
include:
– Heavily polarised gender prevalence.
– High degree of diagnostic crossover with
time.
– Response to similar treatment approaches.
• Clinicians in the field largely
conceptualise this constellation of
symptoms as an eating disorder
phenotype (Murray &Touyz, 2014).

10. Where does Muscle Dysmorphia Fit
Within the Diagnostic Spectrum?
• Muscle dysmorphia centrally comprises pathological
eating and exercise practices in the pursuit of the ideal
muscular body.
• Muscle dysmorphia appears conceptually similar to
thinness-oriented eating disorders, such as anorexia
nervosa, and differs primarily as a function of the
antonymic body ideals that the respective disorders
propel affected individuals towards.
• Muscle dysmorphia may be better placed within the
eating disorder spectrum, and may offer more clinical
utility in recognising the male experience of eating
disorder psychopathology (Murray &Touyz, 2013).

11. Where to from here…
• Not enough research exists to firmly conclude that
muscle dysmorphia represents an eating disorder
phenotype.
• However, very little research demonstrates that muscle
dysmorphia differs significantly from eating disorders.
• Further research is needed in explicating how muscle
dysmorphia and muscularity-oriented disordered
eating fits into an eating disorder framework.
• It is important not to conflate healthful muscle-building
endeavours with muscle dysmorphia.

12. Muscularity-oriented eating
disorder behaviours
Attitudes and beliefs about men
with eating disorders
Scott Griffiths
School of Psychology
Sydney, Australia

13. 13
Muscle dysmorphia: The pointy end of a
spectrum

14. Muscularity and eating disorders
• What is an eating disorder?
– What are the essential or defining features of an eating
disorder?
• The transdiagnostic model of eating disorders
– The core psychopathology of eating disorders is
overevaluation of eating, shape and weight and their
control (Fairburn, Shafran & Cooper, 2003)
• Intrinsic to statements about overvaluation of eating,
shape, weight and their control is that the thing that is
"overvalued" is a thin and skinny body

15. • Eating Disorders Examination - Questionnaire (EDE-Q;
Fairburn & Beglin, 1984)
• "Have you been deliberately trying to limit the amount of food that
you eat?"
• "Have you wanted your stomach to be empty?"
• "Have you gone for long periods of time (8 hours or more) without
eating anything in order to influence your shape or weight?"
• "Have you had a definite fear that you might gain weight or become
fat?"
• "Have you definitely wanted your stomach to be flat?"
• "Have you had a strong desire to lose weight?"
• "Have you felt fat?"
• "Have you taken diuretics to control your shape or weight?"
• "Have you taken laxatives to control your shape or weight?"
17
Eating disorder behaviours: Thinness-
centric

16. Muscularity-oriented eating disorder
behaviours
18

17. Muscularity-oriented eating disorder
behaviours
19

18. Muscularity-oriented eating disorder
behaviours
20

19. 0%
2%
4%
6%
8%
10%
12%
14%
2006 2007 2008 2009 2010 2011 2012

20. Muscularity-oriented disordered eating
= 6 + 6 + 0 + 6 + 6 + 4 + 5 + 0 + 3 + 1 + 6
= 42(mean = 3.9)
22
6
6
6
4
5
3
6
1
6
0
0
Thinness-oriented disordered eating
= 0 + 0 + 0 + 6 + 0 + 0 + 0 + 0 + ? + 2 + 1
= 9 (15 if I gift him a 6) (mean = 0.9)
0
0
0
0
0
?
2
1
Measuring muscularity-oriented
disordered eating

21. 23
› Links with poor set shifting and weak central coherence [1]
› Links with impairedemotional functioning [2]
› Links with increased conformity to traditional masculine gender
roles [3,4]
› Links with positive beliefs about individuals with muscle
dysmorphia[5]
› Links with muscle dysmorphia[6]
› Treatment using family-based therapy [7]
[1] Griffiths, S., Murray, S. B., &Touyz, S. (2013). Drive for muscularity and muscularity-oriented disordered eating in men: the role of set shifting difficulties and weak
central coherence. Body Image.
[2] Griffiths, S., Angus, D., Murray, S. B., &Touyz, S. (2014). Unique associations between young adult men's emotional functioning and their body dissatisfaction and
disordered eating. Body Image.
[3] Griffiths, S., Murray, S. B., &Touyz, S. (2014). Extending the masculinity hypothesis: an investigation of gender role conformity, body dissatisfaction, and disordered
eating in young heterosexual men. Psychology of Men & Masculinity.
[4] Murray, S., Rieger, E., Karlov, L., &Touyz, S. (2013). Masculinity and femininity in the divergence of male body image concerns. Journal of Eating Disorders
[5] Griffiths, S., Mond, J. M., Murray, S. B., &Touyz, S. (submitted). Young peoples’ admiration for anorexia nervosa and muscle dysmorphia.
[6] Murray, S et al. (2012). A comparison of eating, exercise, shape and weight related symptomatology in males with anorexia nervosa and muscle dysmorphia. Body
Image
[7] Murray, S. B., & Griffiths, S. (2014). Family-based therapy for muscle dysmorphia: a preliminary case report. Clinical Child Psychology and Psychiatry.
Research using muscularity-oriented
disordered eating

22. Positive beliefs
• People with anorexia nervosa may percieve their symptoms as
positive or comforting (Guarda, 2008)
– Delayed treatment seeking
– Poor engagement with treatment
– Treatment refusal
• Young people's positive beliefs about people with anorexia
nervosa are associated with higher levels of eating disorder
symptoms. (Mond, Robertson-Smith, & Vetere, 2006)
• To date, research on admiration for people with eating disorders
has been confined to:
– The positive beliefs held by young women…
– about women with anorexia nervosa.
24

23. Anorexia Nervosa
Muscle DysmorphiaAnorexia Nervosa
Muscle Dysmorphia
N = 499

24. 1
2
3
4
5
Admire
eating
Admire
exercise
Desire to
be like
Muscle
dysmorphia
Anorexia
nervosa
Positive belief
Levelofendorsement
• Main effects of
character diagnosis
– Averaged over
participant sex
and character sex
• Characters with
muscle dysmorphia
elicited more…
– admiration for
their ability to
control their
eating (η2 =
.10, large effect)
and exercise (η2 =
.03, small effect)
– desire to be like
them (η2 =
.03, small effect)
***
***
***
*** p< .001

25. 1
2
3
4
5
Admire
eating
Admire
exercise
Desire to
be like
Male
participants
Female
participants
Positive belief
Levelofendorsement
• Main effects of
participant sex
– Averaged over
character sex and
character
diagnosis
• Young women
endorsed a
stronger desire to
be like the
characters than
young men
– η2 = .03 (small
effect)
**
** p< .01

26. 1
2
3
4
5
Admire
eating
Admire
exercise
Desire to
be like
Male
participants
Female
participants
Positive belief
Levelofendorsement
• Main effects of
character sex
– Averaged over
participant sex
and character
diagnosis
• No significant
main effects of
character sex

27. 1. 2. 3.
1. Thinness-oriented disordered eating
- .19
2. Muscularity-oriented disordered eating
- .24
3. Desire to be someone like the character
.58*** .55*** -
• Correlation coefficients for male and female participants who
read about the characters with anorexia nervosa.
• Correlations for male participants and female participants

28. 1. 2. 3.
1. Thinness-oriented disordered eating
- .32**
2. Muscularity-oriented disordered eating
- .31**
3. Desire to be someone like the character
.49*** .48*** -
• Correlation coefficients for male and female participants who
read about the characters with muscle dysmorphia.
• Correlations for male participants and female participants

30. Negative beliefs (stigma)
32
› Negative stereotypes and beliefs exist about people with
eating disorders and are widespread
› Stigma is frequently given as a reason why so few males
come forward with eating disorders
› What about muscle dysmorphia? Might anorexia nervosa
and muscle dysmorphia be perceived as a “female” and
“male” condition respectively?
› Little research has examined stigma surrounding
masculinity and femininity and eating disorders (see a
great qualitative paper by Robinson et al. 2013)

31. 1
2
3
4
5
Anorexia
nervosa
Muscle
dysmorphia
Male
participants
Female
participants
Character diagnosis
Meanperceivedmasculinity
• To what extent do you
agree with the following
statement:
Kelly/Michael is
masculine
– 5 = strongly agree
– 4 = agree
– 3 = neither agree nor
disagree
– 2 = disagree
– 1 = strongly disagree
• Size of this effect size is
very large (η2 = .23)
– Even stronger for male
participants (interaction
η2 = .03, p = .002)
*
*

32. 1
2
3
4
5 Males with
AN
n = 26
Females
with AN
n = 192
Meanfrequencyofstigmatisation
• How often are you
subjected to the attitude
or belief that you are
“less of a man/woman”
because of your eating
disorder?
– 5 = always
– 4 = often
– 3 = sometimes
– 2 = rarely
– 1 = never
• Size of this effect is
moderate (η2 = .07)
*

33. 0
50
100
150
Healthy
controls
n = 30
Anorexia
nervosa
n = 24
Meanconformitytomasculinerole
• Men with anorexia
nervosa report the same
amount of conformity to
masculine norms relative
to healthy control men
• Men with muscle
dysmorphia report more
conformity to masculine
norms than men with
anorexia nervosa and
healthy control men
Muscle
dysmorphia
n= 21
*

34. Summary
• There may exist a spectrum of eating disorder
behaviour motivated by an overvaluation of
muscularity, not thinness
• Sex differences in the importance of muscularity
to body satisfaction and in ideal body
preferences may mean that men are more at risk
for developing muscularity-oriented eating
disorder behaviours

35. Summary
• The distinction between disordered and ordered
is easier for some behaviours (steroids;
intrinsically harmful), and more difficult for
others (eating behaviours and supplements).
• Attempts to assess muscularity-oriented
disordered eating behaviours (limited as they
may be) have revealed links with multiple
adverse outcomes

36. Summary
• Young men and women express positive beliefs
about anorexia and muscle dysmorphia, and
there are sex differences in the links between
their desire to be like people with these
conditions and their own disordered eating
• The additional stigmatisation faced by men with
eating disorders may be related to their
perceived deviation from traditional Western
gender roles, particularly with regard to
masculinity

37. Concluding comments
• The relative absence of men with muscularity-
oriented eating disorders/eating disordered
behaviour in treatment may not reflect a
prevalence gap so much as a knowledge gap
• The broad community of eating disorder
professionals is particularly well-suited to treat
muscularity-oriented eating disordered
behaviours

38. 800-767-4411
rogershospital.org
Welcome
Rogers treats children, adolescents
and adults with:
• OCD and anxiety disorders
• Depression and mood disorders
• Eating disorders
• Substance use disorders

39. Males with eating disorders:
Treatment Update
Ted Weltzin, MD, FAED, FAPA
Medical Director, Eating Disorder Services
Rogers Memorial Hospital

40. Many men have been treated in
programs that do not offer a
male only component.
“I don’t think it’s necessary and it
may not benefit some men.”
(Eating disorder professional)

41. “It’s so hard having this disease and being a guy.
Females with eating disorders are not such a
rarity, so they can feel like they fit in. the men-only
group gave me a sense of freedom. I felt less
exposed and more willing to admit my problems
and be introspective” (Male patient)
Perspective on treatment of males

42. Steve: Initial Presentation
Steve is a twenty year old college student studying
engineering and has been admitted for residential
treatment because his school placed him of medical leave
due to increasing compulsive exercising, restricting, and
severe malnutrition. He is currently 5 feet and 8 and half
inches tall weighing 114 lbs. On admission he was 72.9%
of his Ideal Body Weight and presents with osteopenia
and low levels of testosterone. Steve has an admitting
BDI score of 25.

43. Steve: Psychosocial Assessment
Steve presents with a five year history of Anorexia
Nervosa, Restricting Type, which includes symptoms of compulsive
exercising, reportedly walking up to three hours a day and restricting
food intake to only fruits and vegetables. Steve also reports
increased isolation, hopeless, depression, low self worth and
perfectionism. Steve reports significant social anxiety and ritualistic
behaviors with food. Resident was living alone in a college dorm and
currently reports having no friends and finds that his mind is
preoccupied by body, weight and shape. Further, he reports having
no coping skills besides exercising or school work. Steve reports
being overweight as a teenager, approximately 180 pounds, and
reports a history of being teased in school. Steve grew up in Ohio
with his biological parents and his older brother who suffers from
Major Depression. He reports his temperament growing up was shy.

44. Sean: Initial Presentation
Sean is a 25 year old college student who was admitted
to residential treatment for binge eating, past history of
bulimia, depression, and anxiety. Sean is six foot and one
inch tall and weighs 267 pounds and currently is 145% of
his Ideal Body Weight. Sean presents as overweight with
low testosterone. Sean presents with a BDI score of 27.

45. Sean presents with an extensive history of eating disorder behavior beginning at
age 19 that includes bingeing, restricting, a history of using Marijuana and Meth
to inhibit appetite, as well as diet pills. Sean reports in the last three years he has
significantly isolated himself and has gained 100 pounds triggered by his binge
eating. He reports depression, social anxiety, and attention deficit disorder
beginning at the age of 16. Resident at age 16 also attempted suicide which was
triggered by his parents finding out that he was a homosexual. Further, Sean
was addicted to ecstasy and ketamine between the ages of 19 to22 and has
been in several residential facilities for substance dependency but has been
sober from drugs and alcohol for the past three years but reports he continues to
have urges to use substances. Sean presents with maladaptive defense systems
that he believes pushes people away and reports no significant lasting
interpersonal relationships throughout his life. Sean grew up in a military family
that moved around a lot and believes this has also interrupted interpersonal
relationships to form.
Sean: Psychosocial Assessment

46. Ray: Initial Presentation
Ray is a 17 year old high school student who admitted to
residential programming for more intensive treatment of
his eating disorder characterized by restrictive eating and
compulsive over exercising. He is 5 foot 4 inches tall
weighing 121.8 pounds. Ray is currently at 92% of his
IBW and presents with malnutrition and osteopenia.

47. Ray: Psychosocial Assessment
3 year history of restricting, compulsive exercising, purging and chewing and
spitting out food. Ray reports signs and symptoms of depression including
increased isolation, increased anxiety, anhedonia, and hopelessness. He also
presents with anxiety, reporting that he is always worried about something. Ray
presents with personal stressors including a sexual assault at age 12 and the
recent separation of his mother and father. He reports that he is a perfectionist
and a people pleaser which leads him to want to reconnect his family. Ray has
been in an inpatient program two years ago that was unsuccessful and has been
with an outpatient team since January 2008. Ray grew up with his parents and
his two younger siblings in Virginia and is currently living with his siblings and his
mother. He reports his temperament as a child growing up to be outgoing.

48. 172 males discharged from the Eating Disorder Center at
Rogers Memorial Hospital from 2005 to 2012 the results showed
that the mean score was reduced significantly from 19.6 at the
start to 14.4 at the end of residential treatment.
19.6
14.4
Adm Disc
EDI-3 body dissatisfaction

49. 55 of these males also completed a follow up survey an average of
22 months after discharge from residential treatment and the results
Phone responses showed that the shape concerns reached mean
scores at discharge (2.4) which are similar to the norms reported for
non-eating disorder populations (2.3) and the improvements made
during treatment were maintained for an average of 24 months post
discharge.
3.7
2.4 2.4 2.3
Adm Disc FU Non-ED
EDE-Q shape concerns (N=55)

50. Nutritional
Goals
Address
Obstacles to
Recovery
Identify and
challenge
errors in
thinking

51. “Ideal” Body Weight For Men 25-59 years of age
Height
in Feet & Inches
Small
Frame
Medium
Frame
Large
Frame
BMI 21
5'7" 138-145 142-154 149-168
5'8" 140-148 145-157 152-172 138
5'9" 142-151 151-163 155-176 142
5'10" 144-154 151-163 158-180 146
5'11" 146-157 154-166 161-184 150
6'0" 149-160 157-170 164-188 155

53. Bean et al., 2004 – Outcome variables for anorexic males and
females one year after discharge from residential treatment –
Journal of Addictive Disease

56. “Sex and Muscle! Sex and muscle go
together like success and beautiful women.”

57. Females Males
Moderate dieting 85% 70%
Unhealthy dieting 56% 32%
Laxatives, Vomiting,
Diuretics
12% 4%
Dieting behaviors Project EAT – U of M

58. Psychosocial variables associated with binge eating in obese males and females
International Journal of Eating Disorders
Volume 30, Issue 2, Date: September 2001, Pages: 217-221
Leslie G. Womble, et al.

59. Psychosocial variables associated with binge eating in obese males and females
International Journal of Eating Disorders
Volume 30, Issue 2, Date: September 2001, Pages: 217-221
Leslie G. Womble, et al.

60. O’Dea & Abraham, 02 –
Assessed 93 male college students
Worried about weight and shape 20%
Body image concerns 9-12%
Exercise important to self-esteem 48%
Distressed if not exercise enough 34%
BED 3%
Vomit for weight control 3%
BN 2%
Exercise disorder 8%

61. George Sheehan (1979)
“I have learned there is no need for
haste, no need to worry, no need to
agonize over the future. The world will
wait. Job, family, friends will wait; in
fact, they must wait on the outcome. And
that outcome depends upon the lifetime
that is in every day of running … Can
anything have a higher priority than
running? It defines me, adds to
me, makes me whole. I have a job and
family and friends that can attest to that.”

62. Thought Challenging
• Probability overestimation
Thinking that the possible is inevitable.
I COULD have gained weight becomes I AM gaining weight.
• Catastrophic thinking – essentially, catastrophizing –
Worrying one's way to the worst case scenario.
“I am going to gain back to 200 lbs”.
In short: it must be true because it feels true.

63. Hierarchy Development
• Create an exposure for each difficulty
– Specificity and thoroughness improve outcome
• Graduated list of assignments
– 0 to 7 rating scale
– How anxious would it make you to ______?
• Start with ratings of 2 or 3
• Higher level assignments become less difficult
as easier ones are completed

64. Exposure and Response Prevention
• Non-food, Non-weight OC symptoms
– Symmetry, exactness and perfectionism
– Ordering and arranging
• Weight, Size, Shape OC symptoms
– Measuring, weighing, checking in mirror, etc.
– What causes anxiety?
– What reduces anxiety?

65. ERP for Food Related OC Symptoms
• Individual Food Exposures
– Especially for fats
– Exposures can be without actual eating
• Shopping and Dining Out
– Therapist aided
• Response Prevention
– Restricting, over-exercising, bingeing, purging
– Goal is 100% elimination

66. Habituation
Anxiety will decrease on its own if an
exposure is performed without interruption
by a ritual.

67. Prolonged Exposures
• Within Trial Habituation
• Goal is 50% reduction in anxiety
Anxiety
Minutes

68. Repeated Exposures
• Between Trial Habituation
• Repeat until minimal anxiety
• Continue in day to day life
Anxiety
Minutes

69. Anorexic males versus females:
Admission versus discharge
0
5
10
15
20
DT Bul BD I P D IA MF
RawEDIScores
Females (adm)
Female (disch)
Males (adm)
Male (disch)
Non-patient male

70. Findings in males
• More likely to be obese/teased when young
• Diet to achieve muscular body
• Increased gender identity issues
• Decreased sexual activity
• Increased sexual abuse
• Increase weight related sports
• Separation or loss of father

71. Conclusions
• Most likely males with ED will increase
• Little is know about risk for ED
• Treatment is effective
– Same sex treatment groups
– Staff experience with males important
• Support of male programs needed
– Develop better treatment
– Improve research efficiency

72. 800-767-4411
rogershospital.org
Thank you
Ted Weltzin, MD, FAED, FAPA
Medical Director, Eating Disorder Services
Rogers Memorial Hospital
tweltzin@rogershospital.org