Tuesday, January 21, 2020

Emotion Regulation Challenges Among Teenage Girls Who Have Anorexia or Depression

Contributor: Staff at Timberline Knolls Residential Treatment Center

Given the physical, psychological, and social transformations that are characteristic of adolescence, it is not uncommon for a teen to experience temporary challenges related to healthy or appropriate emotion regulation strategies.
For teenage girls who have developed anorexia nervosa or a depressive disorder, the likelihood that they may engage in unhealthy emotion regulation strategies may be more pronounced. In turn, these dysfunctional or self-defeating strategies may exacerbate their struggles with anorexia and depression.

Healthy vs. Unhealthy Emotion Regulation

As defined by Abigail Rolston, B.A., and Elizabeth Lloyd-Richardson, Ph.D., in a document created for the Cornell Research Program on Self-Injury and Recovery, emotion regulation refers to “a person’s ability to manage and respond to an emotional experience effectively.”
Rolston and Lloyd-Richardson cited meditating, talking with friends, seeking therapy, and maintaining appropriate self-care as examples of healthy emotion regulation. Unhealthy emotion regulation strategies, they noted, include substance use, self-harm, aggression, and withdrawal.
Rolston and Lloyd-Richardson also observed that adolescence can be a “particularly precarious” time, with adolescent girls at elevated risk for interpersonal stress, which can prompt them to employ unhealthy emotion regulation strategies.
In a 2015 study that was published by the journal Frontiers in Psychology, lead author Ines Wolz of the University of Tübingen and her co-authors cite a relationship between emotion regulation, body image, and disordered eating. The authors also report that, in the absence of appropriate emotion regulation strategies, individuals may engage in unhealthy eating behaviors in an attempt to control or process their emotions, which can lead to the onset of an eating disorder.

Increased Risk Among Teenage Girls Who Have Anorexia or Depression

According to a 2019 study that was published by the Journal of Eating Disorders, both anorexia and depression can predispose adolescent girls to struggle with maladaptive emotion regulation strategies. The study was led by Anca Sfärlea and Sandra Dehning, both of whom are affiliated with the Department of Child and Adolescent Psychiatry, Psychosomatics, and Psychotherapy at University Hospital, Ludwig Maximilian University of Munich.
Sfärlea and Dehning’s study involved 86 girls ages 12-18. Twenty-five of the study’s subjects were experiencing anorexia nervosa, 26 had been diagnosed with major depression, and 35 had neither condition. The girls who had either anorexia or depression had received either inpatient or outpatient care at University Hospital Munich. The girls in the “healthy” group had been recruited either from previous studies or via local advertisements.
Sfärlea and Dehning determined that the girls who had anorexia or major depression were much more likely than those in the “healthy” group to struggle with maladaptive emotion regulation. For purposes of this study, the researchers identified acceptance, problem-solving, and reappraisal as examples of appropriate or adaptive emotion regulation strategies. They listed rumination, avoidance, and suppression as examples of maladaptive emotion regulation strategies.

Potential Impact of Emotion Regulation on Treatment

In Sfärlea and Dehning’s study, the girls in the anorexia nervosa and major depression groups also demonstrated an increased prevalence of alexithymia, which is an impaired ability to recognize or discuss one’s emotions.
The authors of a 2017 study by researchers at the University of California San Diego and Dartmouth College reported that difficulties related to alexithymia appear to have a greater impact on emotion dysregulation among patients who were treated for anorexia nervosa.
A 2019 study from the United Kingdom suggests that alexithymia may complicate the treatment process. “It has been frequently observed that people experiencing alexithymia may find it difficult to engage with and benefit from psychological therapy,” the authors of the UK study wrote.

The Value of Comprehensive Care

As the multiple studies cited in previous sections indicate, the risks associated with anorexia nervosa and depression are not limited to the symptoms that are directly linked to these disorders. Unhealthy emotion regulation strategies and alexithymia are two of the many potential effects that can further complicate the lives of individuals who develop anorexia or a depressive disorder.
Anorexia is more common among adolescents than among adults, and more prevalent among girls than among boys. In the abstract of a 2016 study in the journal European Child & Adolescent Psychiatry, the authors report that “symptomatic anorexia nervosa showed the earliest onset with a considerable proportion of cases emerging in childhood.” The authors also observed that “eating disorder symptomatology is common, particularly in female adolescents and young women.”
For teen girls who have developed anorexia, an elevated risk for concerns such as depression, emotion regulation difficulties, and alexithymia is among the many reasons why comprehensive treatment may be most valuable. Effective care that can identify and properly address the full scope of a teen girl’s physical, mental, and behavioral health needs can best prepare her to make sustained progress toward improved well-being.

Sources
Brown, T.A.; Avery, J.C.; Jones, M.D.; Anderson, L.K.; Wierenga, C.E.; and Kaye, W.H. The Impact of Alexithymia on Emotion Dysregulation in Anorexia Nervosa and Bulimia Nervosa over Time. Eur Eat Disord Rev. 2018 Mar;26(2):150-155. doi: 10.1002/erv.2574. Epub 2017 Dec 21. PubMed PMID: 29266572. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/29266572
Hemming, L.; Haddock, G.; Shaw, J.; and Pratt, D. (2019) Alexithymia and Its Associations with Depression, Suicidality, and Aggression: An Overview of the Literature. Front. Psychiatry 10:203. doi: 10.3389/fpsyt.2019.00203
Nagl, M.; Jacobi, C.; Paul, M.; Beesdo-Baum, K.; Höfler, M.; Lieb, R.; Wittchen, H.U. Prevalence, incidence, and natural course of anorexia and bulimia nervosa among adolescents and young adults. Eur Child Adolesc Psychiatry. 2016 Aug;25(8):903-18. doi: 10.1007/s00787-015-0808-z. Epub 2016 Jan 11. PubMed PMID: 26754944. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/26754944
Rolston, A. and Lloyd-Richardson, E. What is emotion regulation, and how do we do it? Cornell Research Program on Self-Injury and Recovery. Retrieved from http://selfinjury.bctr.cornell.edu/perch/resources/what-is-emotion-regulationsinfo-brief.pdf
Sfärlea, A.; Dehning, S.; Keller, L.K.; et al. Alexithymia predicts maladaptive but not adaptive emotion regulation strategies in adolescent girls with anorexia nervosa or depression. J Eat Disord 7, 41 (2019) doi:10.1186/s40337-019-0271-1
Wolz, I.; Agüera, Z.; Granero, R.; Jiménez-Murcia, S.; Gratz, K.L.; Menchón, J.M.; and Fernández-Aranda, F. (2015) Emotion regulation in disordered eating: Psychometric properties of the Difficulties in Emotion Regulation Scale among Spanish adults and its interrelations with personality and clinical severity. Front. Psychol. 6:907. doi: 10.3389/fpsyg.2015.00907


Masculinity, Males, and Muscles: Teaching our Young Men to Honor Their Bodies

I do a lot of writing for Eating Disorder Hope, something that I enjoy and take seriously. Often I write in the third-person and approach a topic with the attitude of a journalist objectively reporting on a topic. At times, I put more of my own experience as a therapist into an issue, hoping that this will benefit readers.
And sometimes, I’m presented with a topic that feels like it could land me in deep waters. Writing on the subject of masculinity is one of those moments.
In light of the recent #Metoo movement, I am particularly sensitive to how masculinity has harmed and degraded women. It is lamentable that we participate in a culture which objectifies and uses women as commodities.
I’m also aware that some would like to label all traditional ideas of masculinity as toxic.
So, it is with great humility that I offer my thoughts on helping raise boys to honor their bodies in the hope they do not develop self-contempt, body hatred, or body dysmorphic disorder.
Actually, rather than offering many thoughts on the topic, I bring one, what I hope is substantial, concept to the table; we need to honor people as people and celebrate the dignity of each individual.
Some men are physically and athletically gifted; others are rocket scientists. Some like the University of Nebraska’s assistant football coach Jovan Dewitt posses are both (before coaching, he was a rocket scientist for NASA). There are female athletes, politicians, mathematicians, and surgeons. Some are black, some white, some brown. Some African, some Asian, some Brazilian.
There are individuals, like my friend Daniel who has severe autism and can’t communicate in full sentences but lights up a room with songs and movie quotes. And there is a 16-year-old Asperger’s sufferer who is challenging world-leaders to treat climate change with urgency.
Among the nearly 7 billion people on planet earth, you can find both a black, female gymnast amazing the world with a triple-double tumbling pass and a young man with Down’s Syndrome starring in a movie about a Peanut Butter Falcon.
Personally, my worldview is one that honors the dignity of all people. And the body is a necessary, beautiful aspect of being human. Bodies do limit and shape us, such as in our career choices.
Because of my size and lack of speed, I won’t ever be a player in the National Football League. Meanwhile, the physical limitations of Stephen Hawking did not stand in the way of his reshaping how we understand space and time.
In other words, I see the body as an essential aspect of human identity. Yet, alone, it cannot sustain the burden of defining someone’s value or identity.
Being athletic may provide advantages and opportunities in our culture not afforded to those who can’t jump as high or throw as far. Yet these abilities do not measure the true impact one can make in the world around them.
In light of this, let’s teach young men to see their own bodies as worthy of care, but not as definitive statements on their masculinity or dignity. And let’s encourage them to do the same with each individual they meet, regardless of race, gender, ability, or appearance.

REFERENCES:
Heady, C. (2018, March 19). Huskers assistant Jovan Dewitt has teaching outside linebackers down to a science. Retrieved December 18, 2019, from https://www.omaha.com/sports/college/huskers/teams/football/huskers-assistant-jovan-dewitt-has-teaching-outside-linebackers-down-to/article_81d7a6df-714e-59d0-b5c5-090c1a9d6011.html.

About the Author:
Travis Stewart, LPC has been mentoring others since 1992 and became a Licensed Professional Counselor in 2005. His counseling approach is relational and creative, helping people understand their story while also building hope for the future. Travis has experience with a wide variety of issues which might lead people to seek out professional counseling help.
This includes a special interest in helping those with compulsive and addictive behaviors such as internet and screen addiction, eating disorders, anxiety, and perfectionism. Specifically, he has worked with eating disorders since 2003 and has learned from many of the field’s leading experts. He has worked with hundreds of individuals facing life-threatening eating disorders in all levels of treatment. His website is wtravisstewart.com

The opinions and views of our guest contributors are shared to provide a broad perspective on eating disorders. These are not necessarily the views of Eating Disorder Hope, but an effort to offer a discussion of various issues by different concerned individuals. 
We at Eating Disorder Hope understand that eating disorders result from a combination of environmental and genetic factors. If you or a loved one are suffering from an eating disorder, please know that there is hope for you, and seek immediate professional help.
Published January 3, 2020, on EatingDisorderHope.comReviewed & Approved on January 3, 2020, by Jacquelyn Ekern MS, LPC

Setting Reasonable Expectations for Eating Disorder Recovery in 2020

Our culture is constantly chasing the concept of instant gratification. In fact, this is one of the factors that make an individual vulnerable to developing disordered eating patterns as a “quick fix” to achieve a certain appearance or resolve personal or mental health challenges. But, eating disorder recovery is not a “quick fix”.
It is this same desire for instant gratification that can lead to disappointment in recovery. Once the brave decision to recover is made, we want it just to happen. The sad truth is that deciding to recover is only the first step of many.

Be Honest About Where You Are in Eating Disorder Recovery

The first step to setting any realistic goal is first to establish the truth about where you are at this very moment. If we aren’t being transparent about our current disordered thoughts and behaviors, we can’t even begin to consider what a realistic expectation is.
Precisely where you are in recovery is where you need to be to begin the process of moving forward.

Narrow Your Focus

The clear goal of eating disorder treatment and recovery is to become recovered. Before you click the “back” button because I just stated something incredibly obvious, consider that goal.
Doesn’t it bring about more questions than guidance and answers? What does eating disorder recovery look like? What does it look like for me? Who decides? Do I have to be recovered mind, body, and soul to achieve it?
When we set our sights on the umbrella goal of “being recovered,” it’s hard to know what that looks like. This not only makes it confusing on where to begin but can be disconcerting when we don’t allow ourselves to feel successful until we’ve risen to this giant and overwhelming challenge.
Narrow your focus to more attainable, smaller goals that lead up to ultimate eating disorder recovery.
Are you beginning with weight restoration, finding a treatment facility, engaging in therapy, looking for a dietitian, communicating with your loved ones, processing past trauma, changing your self-talk?
All of these may be necessary at some point in your journey, but based on where you are right now (see above), what needs to come first? Once you’ve determined that, break it down even smaller.
If you decided your goal is to recover from an eating disorder and get into eating disorder treatment in 2020, you will first need to find a treatment center and consult with your doctor. You should also ask your insurance company what will be covered, work through how you will get there, and consider how to arrange your job or school while you are in treatment.
All of this sounds incredibly overwhelming, and often, we set a goal, consider the steps it will take to achieve, feel overwhelmed, and throw in the towel. Instead, write out each step and place them in the order they need to be accomplished.
Start with the first one. That is your goal.

Give Yourself a Deadline

Alright, we have a smaller goal. Now, we need to consider a realistic timeline for achieving it.
Using the example above, your first goal might be to consult with your doctor. What is a reasonable time in which you can schedule and attend an appointment with your doctor?
This turns your goal into something less intangible and overwhelming and makes it manageable based on your capabilities. “I will schedule and attend an appointment with my doctor within the next month to ask about eating disorder recovery and referrals.”
In this way, you exactly know what your goal is, what it will look like once it is achieved, and exactly how much time you believe is reasonable to have completed it.
Going “small” in this way not only helps you to feel in control over your recovery process but gives you more opportunities to feel successful and pat yourself on the back.
If we only say “I will be recovered,” we don’t know what that looks like and won’t give ourselves credit for progress until we are fully and completely recovered, which takes time. This can break-down our momentum and feelings of self-worth in the meantime.
Making your goals specific, attainable, and timely helps you to make them more realistic, thus leading to eating disorder recovery!

About the Author:
Margot Rittenhouse, MS, PLPC, NCC is a therapist who is passionate about providing mental health support to all in need and has worked with clients with substance abuse issues, eating disorders, domestic violence victims, and offenders, and severely mentally ill youth. 
As a freelance writer for Eating Disorder Hope and Addiction Hope and a mentor with MentorConnect, Margot is a passionate eating disorder advocate, committed to de-stigmatizing these illnesses while showing support for those struggling through mentoring, writing, and volunteering. Margot has a Master’s of Science in Clinical Mental Health Counseling from Johns Hopkins University.

The opinions and views of our guest contributors are shared to provide a broad perspective on eating disorders. These are not necessarily the views of Eating Disorder Hope, but an effort to offer a discussion of various issues by different concerned individuals. 
We at Eating Disorder Hope understand that eating disorders result from a combination of environmental and genetic factors. If you or a loved one are suffering from an eating disorder, please know that there is hope for you, and seek immediate professional help.
Published January 8, 2020, on EatingDisorderHope.comReviewed & Approved on January 8, 2020, by Jacquelyn Ekern MS, LPC

Thursday, December 5, 2019

Binge Eating: How the Health at Every Size Approach Can Transform Treatm

Binge Eating: How the Health at Every Size Approach Can Transform Treatment

By Jennie J. Kramer, LCSW-R, Executive Director of Metro Behavioral Health Associates and Ashley Seruya, Social Work graduate intern and HAES Educator and Content Specialist
How can clinicians, clients experiencing eating disorders, and loved ones of those struggling all contribute to the changing culture of eating disorders? At our centers, we believe it starts with tackling the weight stigma that is so embedded within the diagnosis and treatment of BED and the entire eating disorder diagnostic category.
So let’s start with some simple definitions: what is a binge?
Compulsive Overeating is akin to what some call “grazing”. It is often eating all day, perhaps not too mindfully, almost by rote and certainly not in response to intuitive hunger cues. An example is someone who keeps a supply of a food in a desk drawer at work and eats from it rather frequently all day long. One is often not aware that she/he/they is doing it.
Emotional Eating is also not in response to intuitive hunger cues but much more episodic in nature. It is most often in response to or in anticipation of some emotions or events that cause anxiety, worry, upset or any other unpleasant feelings. There’s also usually a great awareness that it is happening but one feels helpless to do anything else in the moment in an attempt to self soothe.
These are not binges per se. Bingeing certainly has components of emotional and compulsive overeating but it is most often much more copious amounts of food in one sitting, stopped only by either physical discomfort, pain or falling asleep. It is most often alone and accompanied by a sense of great personal shame.
It is also important to note that all categories are quite fluid. Many who struggle actually utilize multiple behaviors across the spectrum, including bingeing, restricting, and purging. Though an individual may lean more heavily on one behavior or another, it is important to acknowledge that these categories are not as black and white as clinical procedure might suggest. With BED specifically, it is unusual to experience bingeing without also engaging in restrictive behavior of some kind, though this is not always acknowledged diagnostically.
There is inherent weight bias within the DSM-5 or Diagnostic Statistical Manual, the present standard for all psychiatric diagnoses, including those related to one’s relationship to food and body. For example, the diagnosis of Anorexia Nervosa (AN) requires an individual to be of low weight while those with BED are often assumed to be of higher weight. These general weight class assumptions are rooted in weight stigma. In truth, many individuals struggling with anorexia are in average-sized or larger bodies.
As a result, many individuals have a difficult time being properly diagnosed, especially those in higher-weight bodies exhibiting restrictive symptoms. Their experience may not be taken as seriously, despite existing research that indicates that how much weight is lost in short period of time is much more indicative of the severity of a restrictive eating disorder than weight itself. Someone who, for example, is of a higher weight and loses a large amount of weight in a short period of time via restriction but is still considered “overweight” or “obese” by the BMI scale will likely be misdiagnosed and their restrictive behaviors are likely to not be believed by providers because of the stereotypes surrounding eating disorders and the ways in which the DMS-5 perpetuates these stereotypes. Furthermore, insurance reimbursement often relies on DSM-5 diagnoses. Being diagnosed improperly can lead to improper treatment and an inability to pay for that treatment.
In terms of treatment, this means embracing a Health at Every Size (HAES) approach to recovery for all eating disorders. HAES, a body of work that began in the 60s and has been popularized by Dr. Linda Bacon, is an approach to health and wellbeing that is weight inclusive rather than weight centric. Instead of pathologizing larger bodies, HAES proposes that all people are deserving of respect and quality of care, no matter their size. HAES proponents believe all people in all bodies should be able to pursue health if that is something they desire and are committed to creating a world in which we divorce health status from weight.
Let’s say that again – divorcing health status from weight. Quite the task when we are all steeped in diet culture at every turn.
Here are some statistics to ponder:
  • Often referred to as the “obesity paradox,” people in the “overweight” and “obese” categories on the BMI scale have a lower morbidity rate than those in the “normal” and “underweight” BMI categories;
  • No current research can show sustained intentional weight loss on a long-term basis;
  • Health gains are maintained with or without maintaining weight loss when health behaviors are maintained;
  • Those who do engage in intentional weight loss are more likely to end up heavier than when they initially began attempting to lose weight;
  • Weight cycling, the most likely result of attempts at intentional weight loss, may be more metabolically dangerous than remaining at a stable higher weight.
With all of this information in mind, it becomes clear that what we think we know about weight isn’t quite as black and white as previously believed. For eating disorders, this becomes an important factor in diagnosing and treating those in higher-weight bodies. Too many well intended treatment models continue to pathologize larger bodies, not believing people when they report their experiences of restriction simply because they are not “underweight.” Many then get wrongly treated via weight loss clinics, highlighting the misunderstanding of how BED functions.
Instead, let’s start by acknowledging bingeing behavior as one of several coping mechanisms meant to self soothe. We also need to begin acknowledging the role that restriction plays in BED, and the role of internalized fat-phobia in all eating disorder development and maintenance. Understanding more about the society in which we live and how it continues to treat larger-bodied individuals as second-class citizens (hiring managers are less likely to hire someone who is “overweight;” it is legal to fire someone for being in a larger body in the majority of states; peer-to-peer bullying related to weight is a pervasive problem in our schools; stereotypes about larger people persist, including beliefs about laziness and poor personal hygiene), is essential to understanding how eating disorders function and some of the barriers individuals face when attempting to recover. How can we truly expect people to let go of their eating disorder behaviors when we live within a world that tells us that in order to be valuable, we must be thin? How can we expect people to even understand their behavior is disordered when we don’t recognize the restriction that takes place in bingeing-type eating disorders? These are important questions to be asking ourselves as professionals, sufferers and those who support loved ones who suffer.

The Power of What We See: An Examination of Weight Bias in Television Programming

The Power of What We See: An Examination of Weight Bias in Television Programming

By Kristine Vazzano, PhD
The human brain processes images 60,000 times faster than words.
This data is not only powerful, but pivotal in illustrating the many ways the media can impact how we see and feel about our bodies as well as those around us. Living in our culture, we are exposed to numerous images each day dictating how we “should” look. Inherent in these messages can be the notion that fat is bad and thin is good. Although these messages are prevalent in countless media streams, television continues to be a primary media outlet. When we look closely at how body shapes and sizes are characterized in television, several trends and patterns of weight stigma become apparent.
These trends include:
  • Reality shows focusing on weight loss, featuring weight loss as a game and something solely in someone’s control. These shows ignore the harmful consequences of dieting and reinforce the dangerous idea that becoming thinner means positive things for someone’s overall happiness, health, and appearance.
  • Mischaracterizing people based on their size. Television shows commonly depict certain characters in a negative light, appearing unintelligent, unhappy, or mean. In fact, in 40% of children’s movies, a character of a higher weight is disliked as a part of the story line.
  • Featuring characters in larger bodies as the sources of humor or someone to make fun of. These trends are particularly evident in children’s movies and video games.
  • Misrepresenting size diversity by showing more women that are underweight and fewer women in higher weight bodies.
What are the implications?
The messages in television programming misrepresenting size diversity and people in higher weight bodies contributes to harmful and inaccurate stereotypes. These patterns imply that a person’s character or personality is negatively linked to their body shape and size.  Laughing at individuals in higher weight bodies and casting them in a negative light reinforces weight bias that is already common in our culture. It perpetuates weight-based stigma, the harmful notion that it is acceptable to make fun of those in a larger body.
Furthermore, by stigmatizing individuals with a higher body weight in these ways, TV programming is reinforcing the thin ideal making it seem as though thinner bodies are something we must strive for in order to be happier, healthier, well liked, and successful.
Much of the programming is geared toward a younger audience, one particularly vulnerable to developing attitudes and beliefs about others and their own bodies as well.
What can we do?
  • Be aware and critical of what you see. Challenge messages reinforcing weight stigma. Educate yourself and those around you about the importance of treating all people with respect.
  • We have the power to choose some of what we consume. Turn off the shows that reinforce weight bias. Seek out shows, social media accounts and other media that challenges the thin ideal and provides healthier, flexible messages.
  • Speak out about weight bias. Stand up to the discriminatory messages you see and hear. Reinforce the message that size does not demonstrate someone’s worth, personality or health.

Network Analysis of Males and Eating Disorder Symptoms

Network Analysis of Males and Eating Disorder Symptoms

By Lauren Forrest, MA
When you think of the term “eating disorder”, what words come to mind? Perhaps you think of descriptors like girls, women, thin, body image, and lean. If you read a case description of someone with an eating disorder, how often would you guess the case description described a female vs. a male? It’s likely your mind would have a stronger association between eating disorder girls/women/female, as compared to eating disorder + boys/men/male. And it’s true: girls and women are more likely to be affected by eating disorders than boys and men. However, the gender gap of eating disorder prevalence is closer than you may think—males account for roughly 20–25% of affected individuals (Hudson et al., 2007; Mohler-Kuo et al., 2016; Udo & Grilo, 2018). Importantly, one reason why male eating disorders are lesser known than female eating disorders may be because of differences in core eating disorder symptoms (for a thorough review, see Murray et al., 2017). In collaboration with a team of excellent colleagues (Natalie Perkins, Jason Lavender, and April Smith), I led a study that identified core eating disorder symptoms among men, and I’m excited to tell you more about it.
This study used something called network analysis to identify core eating disorder symptoms. Network analysis is a statistical technique that identifies how individual symptoms interact with one another. Through empirical methods, network analysis specifically identifies the symptom(s) that have the strongest connections to other symptoms in the network, which is important because these highly-connected symptoms may be those that cause the development of several other symptoms in the network. For example, network analysis findings among women indicate that eating disorder symptoms like shape and weight overvaluation—where people feel like their shape or weight is extremely important to how they judge themselves as people—are highly related to several other symptoms, like fearing weight gain and dieting.
Even though network analysis shows promise to better understand core symptoms of eating disorders, males have been very under-represented in eating disorder network studies. Without including boys and men in our research studies, we can’t know whether the symptom-level interactions identified among women are operating similarly for boys and men. Our study identified specific eating disorder symptoms that may be the main drivers of eating disorders in men. To do this, our symptom network included items that are typically used to assess eating disorders, while also including items that capture experiences that seem to be important to men’s experiences, such as items related to male (vs. female) body ideals.
In western society, the male body ideal is muscular and lean. This is in contrast to the female body ideal, which is thin and marked by having a low weight. To achieve these different body ideals, males and females may engage in specific eating disorder behaviors. Dietary restriction and purging may be used to lose weight and achieve a thin body ideal, whereas eating large quantities of specific foods (e.g., those high in protein), lifting weights, and exercising intensely may be used to gain muscle mass and achieve a muscular body ideal. Most of the measures that are commonly used to assess eating disorders do an excellent job of assessing attitudes and behaviors associated with achieving a thin body ideal, but few incorporate items that assess attitudes and behaviors associated with achieving a muscular body ideal (please see the great work of Dr. Kelsie Forbush for an exception). In our study, we used a “both–and” approach, where we included items in the network that are commonly used in eating disorder research (but lack male/muscularity specificity) while also including items that capture muscularity-related body ideals, dissatisfaction, and behaviors.
The results of our study were quite interesting. We found the items with the greatest importance in the network—i.e., items that were most strongly associated with all other items—were shape overvaluation (believing a person’s body shape is one of their most important qualities), wanting to lose weight, fearing losing control over eating, feeling guilty for missing a weight training session, and using dietary supplements. The first three symptoms (shape overvaluation, wanting to lose weight, and fear of losing control over eating) were expected to be important, based on previous research. But the most interesting part of the results was that the last two symptoms (feeling guilty for missing weight training and using dietary supplements) came from measures assessing male/muscularity-specific eating disorder symptoms. This may mean that to most accurately diagnose, understand, and treat eating disorders among males, we need to be paying attention to some of the things we already pay attention to for female eating disorders (e.g., shape overvaluation, valuing weight loss) while also increasing the attention we pay to things like dissatisfaction about one’s body not being “muscular enough” or “lean enough” and the behaviors that may arise from this dissatisfaction (e.g., intense and strict weight lifting schedules, supplement use).
More broadly, one implication of these results is that as a field we may need to expand our theoretical models of eating disorders. Rather than our models specifying that pursuit of a thin body is the driver of all eating disorder symptoms (which is a belief ranging from implicit to explicit in current theoretical models of eating disorders), we may better conceptualize male and female symptoms by specifying that pursuit of any body ideal (thin, muscular, lean, etc.) could lead people to engage in specific eating and exercise behaviors to achieve that ideal. For some people, these experiences may result in clinically significant eating pathology. Such an expansion could bring necessary growth and diversity to our field, and ultimately help us impact more people through more accurately assessing, diagnosing, treating, and preventing eating disorders.
To my mind, one of the most problematic stereotypes about eating disorders is that they are “female diseases.” There is a kernel of truth to this stereotype, as eating disorders do affect more females than males. However, the fact that a sex difference exists doesn’t mean that males don’t develop eating disorders, and it also doesn’t mean that eating disorders present exactly the same in men and women. My hope is that by conducting research like what my colleagues and I did here, we can help the eating disorders field better recognize the similarities and differences between male and female eating disorders, so that we can make sure that we’re providing the most thorough and effective assessment and treatment for all affected individuals. 

Eating Disorders Coalition Celebrates Latest Federal Guidance on Implementation of Mental Health Parity to Promote Compliance and Enforce Eating Disorders Coverage


WASHINGTON, D.C. (October 28, 2019) – The US Department of Labor, US Department of Health and Humans Services, and the US Department of the Treasury released guidance last month entitled, “FAQs About Mental Health and Substance Use Disorder Parity Implementation and the 21st Century Cures Act Part 39,” providing additional direction to insurance plans, issuers, and outside stakeholders in an effort to promote compliance with the Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA). The Eating Disorders Coalition for Research, Policy & Action (EDC) applauds the Departments additional guidance, including new clarifications that will enhance insurance coverage for eating disorders as a result of the Anna Westin Act provisions included within the 21st Century Cures Act (P.L. 114-255). 

The EDC has worked tirelessly to educate federal agencies on the barriers to care for individuals and families with eating disorders. This work has included submission of public comments on previous federal guidance documents in September 2017 and June 2018; Congressional letters of support in 2017 (House/Senate) and 2018 (House/Senate); and participation in a July 2018 and a January 2019 federally hosted forums with stakeholders and federal agencies to discuss MHPAEA implementation. The most recent guidance from the Departments includes victories for our community regarding the following: 

  • Coverage of Sub-group Disorders: When a plan or issuer provides benefits for a mental health condition/substance use disorder, benefits for that condition or disorder must be provided in every classification in which medical/surgical benefits are provided. Insurance plans are in violation of MHPAEA if coverage for eating disorders does not extend to all sub-types including, anorexia nervosa, bulimia nervosa, binge eating disorder, avoidant/restrictive food intake disorder, and other specified feeding or eating disorders (OSFED). 

  • Shifting the Burden of Proof for Fail-First Policies to Payers: It is incumbent upon the insurance company, not the patient, to prove they’re in compliance with step therapy protocols and are able to demonstrate evidentiary standards were utilized comparably to develop step therapy requirements between mental health/substance use disorder benefits and medical/surgical benefits. 

  • Residential Care Classified as Inpatient, Covered Benefit: Residential eating disorders treatment is classified as a sub-category of inpatient care to ensure the patient receives their inpatient covered benefit just as skilled nursing facilities, nursing home care, and hospice are considered sub-categories of inpatient care. 

  • Rights to Receive Medical Necessity and Denial Information: Insurance plans must provide current/potential patients and contracted providers with free of charge information regarding claim denials and related documents on medical necessity requirements to file within 30 days of a participant’s request. 

“The recent guidance from the Departments provides further clarity to individuals and families with eating disorders, treatment providers, and insurance companies to fully comply with the Mental Health Parity and Addiction Equity Act as intended,” said EDC Board President Chase Bannister, MDIV, MSW, LCSW, CEDS. “Our coalition has worked diligently to fight for equitable treatment under the law. We will remain steadfast in our mission to continue having a seat at the table as we educate the Departments on MHPAEA violations and work together to drive change for those in need of treatment.” 

The EDC recognizes that parity enforcement and compliance both remain a work in progress, therefore we will continue to use our collective voice to provide expertise to the Departments as they release additional implementation guidance on a rolling basis. 

The Eating Disorders Coalition for Research, Policy & Action (EDC) is a Washington, DC-based, federal advocacy organization comprised of advocacy organizations, academics, treatment providers, family/loved ones of children with eating disorders and people experiencing eating disorders nationwide. The EDC advances the recognition of eating disorders as a public health priority throughout the United States. Additional resources can also be found at www.eatingdisorderscoalition.org.