Eating Disorders in Males

Eating disorders have been traditionally thought of as female disorders, with males representing a rare and atypical minority of presentations. As a result, males with eating disorders have been uniquely stigmatized. However, contemporary evidence has illustrated an increasing prevalence of male eating disorders, although males continue to be underrepresented in treatment studies and often go undetected in clinical practice. This chapter provides an overview of the prevalence of eating disorders in males, highlights distinct differences in clinical presentations, and provides recommendations for tailoring clinical treatment approaches. It also describes useful clinical resources related to males and eating disorders, including useful assessment measures and website resources.

Atypical Eating Disorders and Specific Phobia of Vomiting

Some individuals with specific phobia of vomiting (SPOV) (emetophobia) may present with disordered eating, including food restriction and weight loss. Such cases may be misdiagnosed as anorexia nervosa (AN), thus complicating case conceptualization, formulation, and treatment. This chapter outlines the clinical features of SPOV, including those that overlap with AN and other disorders. Treatment approaches and their evidence base are discussed, and a clinical case example of an individual with SPOV and disordered eating is presented. More research is needed to address the overlap between eating disorders and SPOV in order to better distinguish overlaps in presentation and to develop treatments that effectively target the central fears in these cases.

Diabetes and Eating Disorders

Rates of eating disorders are higher in patients with type 1 and type 2 diabetes than in the general population. Types of eating disorders include anorexia; bulimia; binge-eating disorder; subclinical eating disorders; and an eating disorder unique to type 1 diabetes, intentionally restricting insulin doses as a calorie purge—often referred to by laypeople as “diabulimia.” Women with diabetes and eating disorders (including disordered eating behaviors) have significantly elevated blood glucose ranges, higher rates of hospitalization, higher rates of diabetes complications, and, in some cases, higher mortality rates. This chapter discusses risk factors, presentation, and identification of eating disorders within the diabetes population. Specific recommendations are given for this difficult-to-treat population, including the need for an expanded treatment team as well as the need to establish mutually agreed upon and incremental diabetes management goals.

Body Dysmorphic Disorder and Eating Disorders

This chapter addresses the comorbid presentation of body dysmorphic disorder (BDD) and disordered eating. BDD affects approximately 2% of the population and involves perceived defects of appearance along with obsessive preoccupation and repetitive, compulsive-like behaviors. The prevalence of comorbid BDD and eating disorders is high: Approximately one–third of those with BDD will have a comorbid eating disorder, and almost half of those with an eating disorder will have comorbid BDD. There are complicating diagnostic and treatment factors that arise when an individual experiences both. A core feature of these disorders is body image concern, which may be explained by both shared and unique aberrancies in visual and visuospatial processing that have neurobiological underpinnings. Understanding shared and unique pathophysiology may help inform and guide treatment, as well as open up lines of future research into their etiology.

Suicidality, Self-Injurious Behavior, and Eating Disorders

Regardless of specific diagnosis, individuals with eating disorders have strikingly high rates of self-injurious behavior and suicidal ideation. It is essential that clinicians working with individuals who have eating disorders conduct regular and thorough assessments of suicidality and self-harm in their patients and understand a variety of strategies for intervention with these problems. This chapter outlines evidence-based approaches to assessment and intervention with suicidality and self-harm. It discusses the literature on lethality assessment, no-suicide contracts, involving family, hospitalization, and means restriction. It also focuses on strategies from dialectical behavior therapy for managing both self-harm and suicide risk, such as contingency management, diary card self-monitoring, telephone coaching, and behavioral chain analysis.

The Complex Relationship Between Eating Disorders and Substance Use Disorders

Eating disorders (ED) and substance use disorders (SUD) frequently co-occur but are rarely treated in a comprehensive integrated manner. This chapter elucidates the complex relationship between ED and SUD to help the treating professional create an integrated treatment plan that addresses both disorders and any other co-occurring conditions. Evidence-based treatments for each disorder are discussed, and recommendations on how to take “best practices” from both fields to formulate a treatment plan that addresses the specific needs of the patient are presented. The chapter includes case examples that demonstrate the importance of understanding the adaptive function of both disorders when developing an effective intervention.

Food Selectivity in Autism Spectrum Disorder

Children with autism spectrum disorder (ASD) have a fivefold increased risk of developing a feeding problem compared to peers. Food selectivity is the most widely documented feeding concern in ASD. However, it does not frequently correspond with compromised gross anthropometric parameters (i.e., height, weight, and body mass index) likely to trigger attention in pediatric settings. Poor dietary diversity is associated with increased risk of vitamin and mineral deficiencies and diet-related diseases. This chapter reviews the current state of the science regarding the prevalence, topography, consequences, and remediation of feeding problems in ASD. Food selectivity is differentiated from other eating disorders, with a specific focus on exploring the possible link between ASD and anorexia nervosa. A framework to guide the assessment and treatment process is provided, and current treatment approaches are reviewed. The chapter concludes with recommendations to enhance the evidence base to promote development of best standards of care.

Eating Disorders and Borderline Personality Disorder

Individuals with eating disorders (EDs) tend to have elevated rates of comorbid borderline personality disorder (BPD). A number of studies have found that individuals with both ED and BPD present with a more complicated clinical picture compared to individuals with ED alone, both in terms of eating pathology and in terms of more severe problems with depression, anxiety, impulse control, and affect dysregulation. Therapists are often faced with clinical dilemmas with regard to limiting therapy-interfering behaviors and attending to health-threatening or self-destructive behaviors without reinforcing them while ensuring that these behaviors do not supersede the therapeutic focus on ED symptoms, potentially reinforcing self-destructive behaviors. This chapter offers guidelines for responding to therapy-interfering behaviors in this population from the perspective of dialectical behavior therapy, with a case example to illustrate these principles.

Treating Eating Disorder–Posttraumatic Stress Disorder Patients

Despite elevated prevalence rates of trauma and post-traumatic stress disorder (PTSD) in eating disorder (ED) individuals, there is a surprising lack of data on how to effectively treat this population. The most significant gaps in the literature include the “what” (which PTSD treatment to use) and “when” (sequential vs. concurrent treatment) of PTSD treatment. Clinicians are often fearful in working with this ED subgroup, particularly given that these patients often report high-risk behaviors such as suicidality and self-harm. This chapter presents a new approach to treating comorbid PTSD that seems to be very promising for ED–PTSD patients. Borrowed from dialectical behavior therapy (DBT), this approach (called DBT PE) outlines readiness criteria and a protocol for altering the treatment plan if concerning behaviors emerge during the course of PTSD treatment. ED clinicians are encouraged to use DBT PE principles and to disseminate their results.

Clinical Guidelines for the Treatment of Anxiety in Eating Disorders

Approximately two-thirds of individuals diagnosed with eating disorders have had one or more concurrent anxiety disorders in their lifetime. Anxiety symptoms most often predate the onset of an eating disorder and are associated with worse outcomes, implicating anxiety as a possible vulnerability factor in the onset and maintenance of an eating disorder. Individuals with eating disorders also tend to possess personality traits associated with anxiety. This significant comorbidity is likely a result of a shared underlying temperament profile that may predispose individuals to both an eating disorder and certain anxiety disorders. Given the negative impact of anxiety on recovery, eating disorder clinicians should be aware of these shared vulnerabilities and, ideally, be equipped to treat comorbid anxiety issues with a working knowledge of best practice treatment approaches. Furthermore, for patients with a dual diagnosis, clinicians must construct an integrative treatment approach taking into account impairments from both illnesses.