Ideally, the amount of weight gain should be determined by a medical or dietary professional experienced with eating disorders. During the weight gain phase, patients should be strongly encouraged to significantly limit or refrain from excessive physical activity. Anxiety during weight gain should be redirected toward working on self-esteem and coping skills, as well as exploring antecedents of the eating disorder that often relate to body weight, such as teasing or bullying.
Males tend to overvalue muscularity in terms of body image and therefore are much more concerned about building muscle with weight gain and are fearful of body fat, whereas females are more fearful of any type of weight gain or increase in size. Males also tend to be more fearful of fats and carbohydrates in food compared with females who are more calorie-avoidant in general. It is also important to address dietary behaviors that are very rigid and limited in terms of food varieties because these typically are related to resistance to eating normally and decreased treatment effectiveness.
CBT. On the basis of clinical experience, CBT appears to be a very useful treatment for males with eating disorders. CBT gives patients a framework with which to work on eating disorder symptoms as well as on anxiety and affective disorders. In addition, CBT helps identify and challenge errors in thinking concerning food, weight, body image, and the drive to exercise, along with the many different triggers, thoughts, and feelings associated with eating disorder behaviors.
Males with eating disorders tend to externalize emotional distress and, in general, are less likely to be comfortable talking about their feelings, negative experiences, or life events. CBT provides an understandable and structured approach that both addresses externalizing tendencies and facilitates a positive exploration of thoughts and feelings.
For males, as for females, the average length of time between onset of illness and treatment is approximately 5 years.30 Patients often report feeling forced into treatment. Engaging the male patient in treatment can be facilitated using all-male treatment groups. In these groups, males see other males discussing eating disorder symptoms that typically have been viewed as “female” problems, and they experience appropriate emotional expression that is identified as strength rather than weakness.
Because of the increased likelihood of externalized coping skills and anger as a symptom of depression, a treatment team member’s ability to be comfortable with the male population can facilitate expression of thoughts and feelings as an alternative to less helpful coping skills. Family therapy is essential to allow for appropriate and productive emotional expression and healthy conflict for patients, rather than using eating disorder behaviors as the main mechanism for emotional regulation. Experiential therapy programs that include art therapy, movement, and recreation therapy are particularly useful for work on body image and healthy nonverbal expression, team building, problem solving, and exercise issues.
Approach to excessive exercise. As part of treatment, excessive exercise behaviors often need to be addressed. Ideally, therapy should be individualized for the patient on the basis of fitness beliefs and behav-iors. Obtaining collateral information from parents, former medical and behavioral health care providers, and coaches is recommended because patients typically minimize these behaviors and are often reluctant to identify exercise behaviors as dysfunctional.
For treatment of underweight persons, all but the most quiescent fitness activities are suspended until weight restoration is progressing satisfactorily. Once there is a positive response to nutritional and other components of treatment, fitness activities are introduced slowly and re-sponses are observed closely. This is difficult for many persons with eating disorders at this level of care, but particularly so for athletes or those who identify closely with athletics.