Written by Randall Flanery, PhD, Director of Webster Wellness Professionals
A trim young man sits in my office, brought to see me by his parents who aren’t sure if they should be concerned. He has noticeable muscle definition by virtue of a rigorous work-out regimen, and consumes a high protein, low fat diet of about 2800 calories a day. His conversation with me is pleasant and respectful, and seems older than a boy about to start high school. He does not see himself as fat nor likely to become fat. His biggest dissatisfaction is that despite his efforts, his biceps and shoulders are not bigger, and that his abdomen is not a “six pack”. His pediatrician indicates that his heart rate is 46 beats a minute and all laboratory tests are normal. He has had two episodes of dizziness which he attributes to not drinking enough water while working out in a hot gym. His parents describe him as a highly motivated, accomplished young man, a little perfectionistic and rule-driven, and somewhat stubborn about his eating and exercise. They ask, “Is there a problem here?”
It is a question that is asked frequently by parents and healthcare professionals about boys. The young man shows many admirable health behaviors and there are some areas of concern, specifically the low heart rate, fainting episodes, body dissatisfaction about not being muscular enough, and hints of rigidity. Is it an eating disorder, and if it is, which one? How serious is the situation?
Some would argue that it is not even a case of an eating disorder. His weight is not dangerously low, he is eating a seemingly adequate amount and has not lost weight. The medical issues are easily explained as a product of heavy exercising and inadvertent dehydration. The eating regimen is common for body builders, and is certainly not a weight loss diet, nor does he have a strong drive for thinness. It is a plausible argument and would require more extensive investigation to clarify the situation. Many parents and pediatricians would not see this as a serious problem as long as the behaviors do not become more extreme.
An eating disorder specialist might suspect the beginning stages of anorexia nervosa (AN); or if he or she has kept up with the literature, might consider muscle dysmorphia or orthorexia. Boys can be diagnosed with AN, and the likelihood seems to be increasing. (Madden et al., 2009). About half of low weight adolescent males meet all of the criteria for anorexia nervosa defined as calorie restriction resulting in low weight, fear of becoming fat, and body image distortion. This young man may be restricting relative to his energy expenditure, but he does not express a strong drive for thinness nor does he have a body image distortion in which he sees himself as fat when he is not.
The youth sees himself as behaving in a healthy fashion. Indeed, he is following public health recommendations to eat a low fat diet and exercise multiple times a week. Orthorexia (Bratman, 2001), defined as an obsession with healthy eating, might be a possibility. The dedication to healthly eating becomes a measure of self-worth. Any slips from healthy eating can cause intense fear which is alleviated only be becoming more vigilant and rigid about eating. While orthorexia can result in an emaciated individual with rigid rules for eating, the motivation is not so much to be thin as to be healthy.
This boy is primarily dissatisfied that he is not gaining muscle. Despite several months of regular workouts and faithful adherence to an eating regimen designed to produce muscle mass, in his own estimation he is still not big enough. His shoulders could be broader, his biceps bigger, and his abdomen bulging with well-defined muscle, and yet it hasn’t happened. The suspicion is that the exercise is excessive and that the low fat, high protein diet is rigid, exaggerated, neglectful of essential nutrients, i.e. unhealthy. I would suggest that this young man probably has muscle dysmorphia.
While considered an example of body dysmorphic disorder, it has many characteristics in common with AN, and is more usefully understood as an eating disorder (Pope et al., 2002). Individuals with muscle dysmorphia use unhealthy weight control methods to attain a biologically abnormal physical appearance that enhances self-esteem. Like in AN, he restricts his intake, exercises excessively, avoids dietary fat, has highly distorted body image, and judges his value based on physical appearance. The medical risks can be every bit as great as AN. Intensive treatment is indicated and should target reintroduction of foods that have been omitted, adequate hydration, and a positive energy balance.
Boys and girls who develop AN, are striving to make their bodies conform to a culturally-defined standard of attractiveness. Both will utilize health-threatening weight control practices to shape their bodies. For nearly all girls, the goal is to be thin; for some boys, it is also to be thin, but many muscularity, i.e. bigger. Recent research (Darcy et al., 2012) illustrates the challenge. Adolescent males are much less likely to endorse items on the Eating Disorders Examination indicating a desire to lose weight, a core feature of AN, and are not concerned about eating or weight but rather achieving a specific body shape. As such, they are less likely to meet diagnostic criteria for an eating disorder, the health risk is likely to be underestimated, and boys will not be urged to seek appropriate treatment. My recommendation would be, when in doubt regarding a male with a possible eating disorder, to schedule both a comprehensive psychological assessment as well as an in depth medical evaluation by healthcare professionals who are familiar with eating disorders.
- Bratman, S. (2001). Health Food Junkies. Broadway Books, New York.
- Darcy, A.M., Doyle, A.C., Lock, J., Peebles, R., Doyle, P., and LeGrange, D. (2012). The Eating Disorders Examination in Adolescent Males with Anorexia Nervosa: how does it compare to adolescent females. Int J of Eat Disorders, 45(1), 110-114.
- Madden, S, Morris, A, Zurnski, YA, Kohn, M, Elliot, EJ. Burden o eating disorders in 5-13 year-old children in Australia. Med J Australia, 2009; 190:410-414.
- Pope, H., Phillips, K., & Olivardia, R. (2002). The Adonis complex: How to identify, treat, and prevent body obsession in men and boys. New York, NY: Touchstone.
- Randall C. Flanery, Ph.D. – Director and Eating Disorder Treatment Specialist at Webster Wellness Professionals
Randall Flanery, PhD, earned his doctorate in Clinical Psychology at the University of Wisconsin in Madison in 1983. He is the Director of Webster Wellness Professionals, a St. Louis eating disorder treatment center.
Specific treatment interests of his are: evidence-based treatments of anorexia nervosa, bulimia nervosa, binge eating disorder, and other variants of eating disorders. He also is especially interested in tailoring treatment methods for males with eating disorders and weight control concerns.
He is an adjunct associate professor of Family Medicine at Saint Louis University School of Medicine. Dr. Flanery has more than 25 years of clinical experience treating eating disorders and obesity. He also has a broad background in the treatment of a variety of childhood and adolescent conditions. He uses evidenced-based methods to help individuals achieve lifetime healthy weight management and weight control. Besides authoring publications on the treatment of eating disorders and childhood health problems, he has served as Director of Eating Disorders Programs and Child/Adolescent services.
He is a member of the American Psychological Association, the International Association of Eating Disorders Professionals (IAEDP), Academy of Eating Disorders (AED), and the Society of Child Clinical Psychology. He is a past editor and reviewer of PsyCritiques, an online journal of reviews. Dr. Flanery is a frequent speaker to professional and public groups.