Eating disorders refer to a group of conditions defined by abnormal eating habits that may involve either insufficient or excessive food intake to the detriment of an individual's physical and mental health. Bulimia nervosa, anorexia nervosa, and binge eating disorder are the most common specific forms in the United States.
Eating problems classified as EDNOS are far from atypical among the college student population.15 Approximately 6% of college women indicate eating patterns that meet criteria for anorexia and bulimia, whereas 25% to 40% of undergraduate women report subclinical disordered eating that falls under the rubric of EDNOS.16-19 Thus, most eating pathology seen on college campuses falls under the category of EDNOS, and many researchers have suggested that the EDNOS diagnosis is the most useful framework with which to understand the eating-related experiences of college women.20-22
Clinical observation has long suggested a link between personality and eating disorders. Research has consistently linked anorexia (particularly when the patient does not also have bulimic symptoms) to personality traits such as introversion, conformity, perfectionism, rigidity, and obsessive-compulsive features (1). The picture for bulimia is more mixed. Traits such as perfectionism, shyness, and compliance have consistently emerged in studies of individuals with bulimia or with anorexia, although research has often found bulimic patients to be extroverted, histrionic, and effectively unstable (2).
Patients with anorexia nervosa are malnourished and severely underweight, whereas patients with bulimia nervosa are generally not malnourished and not underweight. Clinically, the presence of being severely underweight may be difficult to detect without thorough clinical examination, because patients with anorexia have a tendency to deny their eating disorder and will try to hide their low weight by wearing loose clothes. However, patients with bulimia nervosa are typically not underweight and, therefore, are more likely to go unnoticed. Other eating disorders are a heterogeneous group because of their many different symptoms and causes.
In general, our data suggest that the characteristics of males with eating disorders are similar to those seen in females with eating disorders. The diagnostic distribution of our case series is similar to figures reported for females, among whom prevalence rates for bulimia are estimated to be five to 10 times greater than those for anorexia (8). However, 32% of our series met the criteria for an eating disorder not otherwise specified, a figure which is higher than the 10% reported by Mitchell et al. (9) in their series of 25 women, suggesting that atypical eating disorders may be a particular problem in males.
Several findings are of particular interest. First, the men with eating disorders had a higher rate of major mood disorders than did the comparison men. This finding resembles that reported by previous investigators for both men (13, 38, 47, 52) and women (69-74) with eating disorders. Major depression in our men with eating disorders cannot be explained as a reaction to their eating disorder, since nearly one-half of them developed depression more than a year before the onset of the eating disorder. Nor, conversely, can the eating disorder be explained as a reaction to depression, since nearly one-half of the subjects developed depression more than a year after the onset of the eating disorder.
Self-damaging behaviors are a common feature of mental disorders and they can take many different forms. Two examples are self-injurious behavior (e.g., self-cutting and self-burning), and certain eating disorder symptoms (e.g., extreme food restriction and purging). Despite the superficial differences between self-injurious behavior and eating disorder symptoms, they share some important phenomenological characteristics. For example, they both begin in adolescence or early adulthood and mostly occur in females (American Psychiatric Association, 1994; Suyemoto, 1998).
In the diagnostic and statistical manual of mental disorders fourth edition (DSM-IV),2 three broad categories are delineated: anorexia nervosa, bulimia nervosa, and eating disorder not otherwise specified. The international classification of diseases tenth revision (ICD-10) has three categories: anorexia nervosa, bulimia nervosa, and atypical eating disorder.3 Briefly, anorexia nervosa is characterised by extremely low bodyweight and a fear of its increase; bulimia nervosa comprises repeated binge eating, followed by behaviours to counteract it. The category of eating disorder not otherwise specified encompasses variants of these disorders, but with subthreshold symptoms (eg, menstruation still present despite clinically significant weight loss, purging without objective binging).
Men and boys with eating disorders have been the subject of occasional reports since Morton's 1694 report (1), which included both a male and a female patient. In the first half of the 20th century, males with eating disorders were considered rare because eating disorders were assumed to be female-gender-bound (2).
This latter issue spawned two critical areas of debate. One argument has been that because eating disorders are so rare in males, the nature of the illness must somehow be atypical in males (3, 4). The second line of discussion has suggested that there must be something different about males who develop an eating disorder. For example, it has been suggested that a higher proportion of males with eating disorders might be homosexual (5,6).
Lifetime prevalence of anorexia nervosa is estimated to be less than 1%, and lifetime prevalence of bulimia nervosa is estimated to be 1%-3%, among American women in the general population (1). However, prevalence of eating disorders seems to be higher in substance-abusing samples, although differences in sampling and measurements have resulted in a wide range of estimates of co-occurrence. A review of 51 reports on the comorbidity of eating and substance use disorders found a range of co-occurrence from none to 55% (median=17%) (2). The purging subtypes of bulimia are most commonly associated with co-occurring substance use and eating disorders. Alcohol is the substance most commonly associated with co-occurring disorders (3,4).
Eating disorders pose a considerable threat to young adult women's health and adjustment because they are associated with significant psychosocial impairment and adverse health outcomes, such as loss of bone mass, infertility, and high rates of suicide or death, resulting from complications of starvation (1). To date in the United States, epidemiological studies of anorexia nervosa and bulimia nervosa have focused on white women and girls, and information about the prevalence of eating disorders in ethnic minority groups is unknown (2).