Eating disorders: Not just a `woman`s problem`

That boy you are treating for cocaine dependence might have an eating disorder. He might be using the cocaine as an appetite suppressant to facilitate his desire for an ultra skinny, waif-like body, or to numb himself from the shame of having a “woman's problem.”

Anorexia nervosa and bulimia nervosa are typically viewed as women's disorders. As a result, males with eating disorders often live in lonely silence and frequently rely on substances to relieve their internal pain. Healthcare professionals will encounter the combination of eating disorders and substance abuse more often in males as the prevalence of eating disorders increases in men and boys.

Prevalence

According to experts, the ratio of males to females with eating disorders has gone from 1 in 10 to 1 in 6.1 A recent Harvard study even suggested that one-quarter of adults with eating disorders are men.2 The National Institute of Mental Health (NIMH) suggests that roughly 1 million boys and men currently suffer from eating disorders.3 Even if these estimates were high, it still would be reasonable to believe that hundreds of thousands of males have anorexia, bulimia, eating disorder not otherwise specified, or binge eating disorder, with a significant percentage experiencing substance abuse issues as well.

Substances of abuse

A study of 135 male eating disorder patients at Massachusetts General Hospital revealed that across all diagnoses 37% had a comorbid substance use problem, with alcohol abuse the most common problem (seen at a rate roughly three times that of cocaine abuse).4 More specifically, 61% of patients with bulimia had a co-occurring substance abuse problem-they are three times more likely to have this problem than are those with anorexia. A primary reason for this differential is that many patients with anorexia will not drink alcohol or smoke marijuana because of caloric implications.

It is important to note, however, that some patients with most symptoms of anorexia maintain average weight by obtaining most of their calories through alcohol. If they were to stop drinking, their weight loss would reveal a full anorexic picture. More often, though, anorexic patients abuse cocaine or crystal meth because of the effect of decreased appetite. Yet overall, individuals with bulimia are much more likely to abuse substances than are those with anorexia. The remainder of this article will therefore focus on the bulimic end of the eating disorder continuum.

Persons participating in binge eating behavior appear to be two times more likely than their non-bingeing counterparts to experience severe substance use issues.5 Binge eating disorder (BED) is the most commonly diagnosed eating disorder in males, with 40% of male eating disorder patients having this single diagnosis.2 Approximately 57% of males with BED appear to have lifelong substance abuse problems.6

The substances abused by men who binge eat appear to vary, depending on whether the individuals engage in some form of purging behavior as well. Ross and Ivis5 pointed out that men who binge eat without purging are more likely to use alcohol or tobacco, but those who binge eat and purge not only drink and use tobacco products but also use marijuana, barbiturates and hallucinogens. Furthermore, males who binge and purge exhibit an increased number of drunken episodes compared with men who evidence no compensatory behaviors. This might result from the fact that drunkenness frequently results in vomiting, which is a mechanism to eliminate calories-a desired outcome. It also appears that cocaine use itself might be a precursor to bulimia nervosa in males4 and that men who binge eat have a substantially increased likelihood of cocaine abuse compared with binge eating females.7

It is not uncommon to find persons with eating disorders misusing or abusing diuretics, laxatives, ipecac, or diet pills to manipulate their weight. Men with eating disorders seem to use laxatives less often than women with the disorders8, and likely abuse the other over-the-counter products less often as well. Men are much more likely to increase exercise8 than to use “diet products” since the concept of dieting is not as normative for men. However, the focus on exercise can lead to the abuse of yet another substance: steroids. There is a subset of men with eating disorders whose body image obsession is on muscularity. Muscle dysmorphia, an irrational focus on muscle gain (being “ripped”), can result in steroid abuse, since the desired muscle gain usually cannot be attained through natural means.

Links with substance abuse

Brain imaging of individuals with bulimia suggests decreased prefrontal cortex activity coupled with increased activity in the limbic system, resulting in poor insight alongside emotional and behavioral dysregulation.9 The strong food cravings common in those who binge eat are linked to the brain's hedonic system, which regulates risk-taking and novelty-seeking behaviors, self-control, and pain avoidance.10 In short, bingeing behaviors can be seen as resulting from problems in the hedonic system around impulse control.

Bingeing on carbohydrates can bring temporary relief to the emotional distress experienced in the limbic system. When emotional distress returns, males with eating disorders, whose self-restraint is lowered because of decreased prefrontal cortex activity, are set up for finding new ways to regulate emotion. This can frequently take the form of substance abuse. Less than optimal function of multiple brain systems might therefore intertwine and predispose patients to eating and substance use comorbidity.

Coping style could be the most powerful intrapersonal factor directly influenced by, and synergistically working with, the biological mechanisms just discussed. People with eating disorders lack healthy and effective coping skills. For various reasons, they tend to employ avoidance-based coping strategies as opposed to strategies focused on problem solving or healthy emotion regulation. Christiano and Mizes point out that abusing substances is also avoidance-based coping.11 Such strategies are ineffective in that emotion remains unaddressed and related problems go unresolved, thus maintaining the need for substances and eating disorder behaviors in order to cope.

Parental alcoholism appears to be a relational factor increasing the chances of eating disorders in males.12 Sharp and colleagues found that 25% of male anorexic patients in one study had an alcoholic parent, typically the father.8 The exposure to alcohol abuse or dependence normalizes addictive behaviors. Alcoholism also engenders a chaotic family system, which is known to foster eating disorders, particularly bulimia.

Due to their hypersensitivity in relationships, emotional intensity, shame and body image focus, many males with eating disorders experience gender role distress. Males who struggle with gender role conflict show an increased tendency to abuse substances.13 Herein lies just one more of the many bridges connecting eating disorders and substance abuse in men.

Treatment

Biological, psychological, relational and cultural factors have overlapped to create the difficult-to-treat comorbidity of substance abuse and eating disorders in males. Key similarities between the two diagnoses (problematic emotion modulation and impulse control, poor coping skills, and unhealthy relationships) point to Dialectical Behavior Therapy (DBT) as a potential treatment of choice.

DBT14 is a treatment modality targeting emotional, interpersonal, behavioral, cognitive and intrapersonal dysregulation in an individual by teaching a skill set focused on mindfulness, relational effectiveness, distress tolerance and emotional regulation. DBT is comprehensive enough to treat severe comorbidity and has been shown to be effective with eating disorders and substance abuse.

DBT and cognitive-behavioral therapy can be effective on an outpatient basis, but when the behaviors are severe enough to impair physical health, interfere with school, employment or family, or are beginning to involve suicidal or self-injurious behaviors, inpatient placement should be pursued immediately.

Effective treatment, whether inpatient or outpatient, should include the acquisition of coping skills, family therapy where appropriate, and relapse prevention. Spiritually based intervention is also recommended, given the longstanding success of 12-Step programs with substance use and the increasing use of spiritual principles in treating eating disorders.

References

1. Andersen A. Eating disorders in males: gender divergence and management. Currents 2001; 2:2.
2. Hudson JI, Hiripi E, Pope HG, et al. The prevalence and correlates of eating disorders in the National Comorbidity Survey Replication. J Biol Psychiatry 2007 Feb; 61:348-58.
3. National Institute of Mental Health. Eating Disorder Statistics, 2008. Available at https://www.gurze.com/client/client_pages/printable_pages/eatingdisorderstats.html.
4. Carlat DJ, Camargo CA, Herzog DB. Eating disorders in males: a report on 135 patients. Am J Psychiatry 1997; 154:1127-32.
5. Ross H, Ivis F. Binge eating and substance use among male and female adolescents. Int J Eat Disord 1999 Nov; 26:245-60.
6. American Psychiatric Association Work Group on Eating Disorders. Practice Guidelines for the Treatment of Patients With Eating Disorders, 2006. Available at https://www.psychiatryonline.com/pracGuide/loadGuidelinePdf.aspx?file=EatingDisorders3ePG_04-28-06.
7. Tanofsky MB, Wilfley DE, Spurrell EB, et al. Comparison of men and women with binge eating disorder. Int J Eat Disord 1997; 21:49-54.
8. Sharp CW, Clark SA, Dunan JR, et al. Clinical presentation of anorexia nervosa in males: 24 new cases. Int J Eat Disord 1994 Mar; 15:125-34.
9. Clements T. A healthy change of mind. Presented at Remuda Ranch, Wickenburg, Ariz., 2009.
10. Treasure J. Getting beneath the phenotype of anorexia nervosa: the search for viable endophenotypes and genotypes. Can J Psychiatry 2007 Apr; 52:212-9.
11. Christiano B, Mizes JS. Appraisal and coping deficits associated with eating disorders: implications for treatment. Cog Behav Prac 1997; 4:263-90.
12. Carlat DJ, Camargo CA. Review of bulimia nervosa in males. Am J Psychiatry 1991 Jul; 148:831-43.
13. Mahalik JR. Incorporating a gender role strain perspective in assessing and treating men's cognitive distortions. Prof Psychiatry Research Prac 1999; 30:333-40.
14. Miller AL, Rathus JH, Linehan MM. Dialectical Behavior Therapy With Suicidal Adolescents. New York City: The Guilford Press; 2007.

Sidebar

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