Treatment & Prevention

Treatment

Eating disorders and exercise related problems, including muscle dysmorphia require expert help. Due to the complex nature of the illness a therapist who is an expert in this field should be utilised. It is comforting to see that boys are becoming more open to getting treatment and seem less traumatized about having a ‘girl’s’ disease than they were in the past.

The first step in getting assistance with an eating disorder should be a visit to the family doctor, who would probably take some blood samples, administer an ECG and possibly a Dexa Scan to measure bone density. One indication of general fitness in men is the waist-to-hip ratio. Measuring the waist and dividing it by the measurement of the hips will give a ratio value; values of 0,90 to 0,95 are associated with better health.

The goal of treatment for eating disorders should be a multidisciplinary approach that incorporates medical management as an integral part of the overall care of the client.
It is suggested that a combination of cognitive-behavioural therapy and antidepressant medications is the most effective approach. However, as a cautionary note, people with anorexia don’t improve as often or as robustly with serotonin reuptake inhibitors (SRIs) as those with body dysmorphic disorder (BDD), yet bulimia patients seem to respond well to SRIs or a wider range of antidepressant medications. Sadly, the relationship between pharmacotherapy and psychotherapy in treating body image disturbance is largely unexplored, yet pharmacologic treatment is effective for both anorexia and bulimia patients to a greater and lesser degree.

In general, the eating disorder approaches used for girls work equally well in boys. The psychological therapy techniques that are options in the treatment of eating disorders:

·        Supportive psychotherapy

·        Cognitive-behavioural therapy

·        Family therapy

·        Interpersonal therapy

·        Dialectical behavioural therapy

·        Mindfulness-based cognitive therapy

·        Acceptance and commitment therapy

·        Schema therapy

All of which can be of value or in combinations, suited specifically to the need(s) of the client. It is worth noting that even with treatment, only half of patients with anorexia nervosa recover and that up to 25% of clients are disabled severely by chronic development of their disease. Death is more often a result of inanition, fluid and electrolyte imbalance, or suicide. A distressing number of bulimic sufferers also die, usually due to cardiac arrhythmias related to electrolyte disturbances. Most men with muscle dysmorphia resist getting treatment claiming that they are content the way they are, some admit they have a fear of becoming weak if they give up exercise and/or the drugs.

Treatment for muscle dysmorphia is still in its early stages since it has only been recognized as a specific condition in recent years. Specific antidepressants such as fluoxetine (Prozac) seem to be effective in controlling the obsessive-compulsive symptoms of the sufferer, and behavioural therapy is often used in combination with the drug therapy. One of the most common treatments is cognitive behavioural therapy, which examines and changes the individual’s underlying belief system. In addition, exposure therapy can also allow young men to face situations they have been avoiding in a controlled and ‘safe’ environment. The most promising method of treatment for the bigorexic is probably from a sports medicine physician in conjunction with a counsellor who works with athletes.

The core features of Body Dysmorphic Disorder (BDD), obsessional preoccupations and compulsive, repetitive behaviours are similar to those found in patients with Obsessive-Compulsive Disorder. OCD is treated effectively with a combination of serotonin-reuptake inhibitors (SRIs) and cognitive behavioural therapy. BDD is found to be similar to social phobia and depression as well, both of which are treated effectively with SRIs. Up to 82% of patients treated with drugs that block the reuptake of serotonin and exposure and response therapy, respond well. Counselling or psychotherapy usually is not very effective with BDD when used alone. The central problem in BDD, according to Veale, Willson & Clarke (2009) is the ‘preoccupation with a [deformed] feature, rather than the feature itself’ and as such BDD is better treated using CBT and/or medication’.

·        Medication

Anti-obsessional medication is not recommended for mild symptoms of BDD, but is a recommended option in treating moderate to severe BDD. A patient with BDD may well receive medication before the commencement of CBT. The SRIs are classified as antidepressants or anti-obsessionals and can relieve the symptoms of BDD sufficiently to allow the CBT to be effective. The first choice of medication for people with BDD should be SRIs as they enhance the normal activity of the brain and improve the ability to lessen anxiety and reduce the levels of preoccupation in the patient. If medication is administered the patient should begin to see some improvement in their symptoms within four to six weeks, with maximum benefit being seen in four to six months of taking medication.

·        Cognitive-Behavioural Therapy

Cognitive-Behavioural Therapy (CBT) focuses on how we think and how that relates to the way we feel and behave. The cognitive component of CBT focuses on the intrusive thoughts (cognitions) or beliefs of the patient. In ‘Understanding Body Dysmorphic Disorder’, Phillips explains that the goal here is to ‘identify, evaluate and change unrealistic and self-defeating ways of thinking’. The behavioural component of CBT focuses on the problematic behaviour, that of avoidance, checking, reassurance seeking behaviours, focusing on stopping these behaviours and changing or replacing them with better alternatives. The two components usually work together, to give us the cognitive-behavioural approach. Cognitive-behavioural therapy has been shown to be effective for adults and is endorsed by the National Institute for Health and Clinical Excellence (NICE). Cognitive restructuring helps the person with BDD to identify their negative thoughts and beliefs and highlight them as ‘erroneous’ thinking. Isolating the negative thoughts, the person can then create more affirming, helpful beliefs about themselves.

Exposure therapy is used to help sufferers deal with their fears in a controlled environment, encouraging them to face situations that they have feared. Ideally the person will gradually learn to stop avoiding these situations and slowly feel more comfortable in them. Response prevention aims at reducing and eventually stopping the destructive compulsive rituals of the BDD sufferer. Prevention begins by reducing the amount of easier rituals to reduce and then moving on to the more difficult rituals. Perceptual training teaches the person how to view his body in totality, as a whole, developing a less negative view of himself.

·        Cosmetic treatments

Many people suffering with BDD will become depressed as a result of both the intrusive thoughts of inadequacy and the compulsive behaviours. An approximated 80-90% of people with BDD have problems with depression. A growing number of men are having plastic surgery to change their appearance and cosmetic surgery is becoming even more common in men than women. It is suggested that up to one-third of all men seeking cosmetic surgery display the criteria for a diagnosis of BDD. A sobering thought, reported in Phillips (2009) unveils that up to 40% of children and adolescents with BDD receive cosmetic surgery. Ironically, most people who suffer from BDD are not usually satisfied with the outcome of their surgery.

·        Education

Unscrupulous practitioners and over-zealous coaches often prescribe or obtain prescriptions for steroids which are then administered. There may well be schools promoting and subsidizing the supplement use among its learners in an attempt to increase the ‘winning’ power of its sports teams. At present this is an invalidated statement but one worth pursuing in future research. Predominantly, the ‘black market’ is the illegal underground market that supplies underground drugs to male teens and adults, making acquisition of the drugs very easy. ‘Prevention is better than cure’, and as such, we need to address the potential evils at the root; we need to attack the problem among our youth during or prior to them beginning their use of mass building supplements, long before the user progresses to potentially life-threatening steroid use.

In Proctor (1998), research discovered that “providing high school athletes with information concerning only the harmful effects of anabolic steroids” (and they are numerous), the student’s “interest in trying steroids actually increased”. Interestingly, a balanced approach including information around both the benefits and risks of taking steroids, also failed to show changes in high schools students attitude towards the use of anabolic steroids. Anabolic steroid education may be most effective when it provides, in addition to “an in-depth knowledge base, alternative ways to improve appearance and performance and skills to effectively deal with [psychological] issues”. The anabolic steroid education programme should be multifaceted; it needs to be “effective not only in improving the knowledge base of the at-risk preadolescent but also changing their attitudes towards using anabolic steroids”.

·        Diet and exercise

Diet and exercise can be helpful in both the treatment and prevention of depression. It is no secret that foods high in sugar and beverages high in caffeine, have the potential to cause children’s’ moods to become unstable and irritable. Allergies to certain food can also result in mood swings. It is the responsibility of the parent to educate their child about what foods to eat and in what quantity to help with the stabilizing of their moods. Exercise is beneficial in improving the general health and mood of the child. Team or group sports would be of benefit for the child with depression. Endorphins are released into the brain during exercise; as such their mood improves almost immediately. It is difficult to get a depressed child to do anything, but setting the example for your child can encourage him to begin to get involved in organized or casual exercise.

The preceding section is deliberately scant with information pertaining specifically to treatment and potential medication use for adolescents with body image issues, eating disorders or depression. Disordered eating patterns stem from body image concerns; as such the focus with adolescents in particular should be preventative measures.

Prevention

The promotion of healthy behaviours should be an integral component of every child’s upbringing as a primary preventive measure for body image concerns, eating disorders and childhood obesity.

The National Eating Disorders Association (NEDA) outlines strategies for parents/spouses to help to improve male body image:

·        Recognize that males can and do develop eating disorders

·        Learn to identify the warning signs of eating disorders and increase your awareness of resources in your community that can assist.

·        Understand that professions and activities that necessitate weight restrictions put males at risk for developing eating disorders.

·        Talk to your son/male spouse about the ways in which cultural attitudes regarding ideal male body shape, masculinity, and sexuality are shaped by the media.

·        Encouraging male adolescents to explore caring, nurturing and cooperation as ‘masculine’ activities.

·        Demonstrate respect for gay men, and men who display personality traits or who are involved in professions that stretch the limits of traditional masculinity.

·        Never emphasize body size or shape as an indication of a young man’s worth or identity.

·        Confront others who tease men who do not meet traditional cultural expectations for masculinity.

·        Listen to your son’s thoughts and feelings, take his pain seriously, allowing him to become who he is.

·        Validate your son’s striving for independence and encourage him to develop all aspects of his personality, not only those that family and/or culture find acceptable.

·        Understand the crucial role of the father and other male influences in the prevention of eating disorders.

The parent plays an integral role in nurturing a positive body image in a child. It is imperative that a parent gain clear, informed understanding of their own body image attitude relating to body image. This primary step will ensure that they are physically active parents who enjoy and celebrate their own sense of style; eating healthily and avoiding dieting practices. The parent should take time on a regular basis to assist the child to critically evaluate the media messages that place a person’s value on their body shape or size. This will help the child to generate their own sense of style and nurture their own positive body image perceptions.

Parents are encouraged to educate themselves about the myths associated with male eating disorders; allowing for open, honest, non-judgemental discussion with their son. If your son presents with signs or symptoms of disordered eating habits it is important to remain calm and compassionate when confronting the issue. Show care and understanding, all the while encouraging him to acquire the assistance he may need to overcome his potentially dangerous eating habit.

Schools have an equally important role in addressing the potential for disordered eating among their students. It is imperative that schools begin to develop policies that encourage acceptance of diversity and zero tolerance approaches to harassment, creating an environment that fosters positive self-esteem and body image among its pupils, with the ultimate goal being a reduction in the incidence of disordered eating. The objectives of the school curriculum should include:

·        Enhancing feelings of self-acceptance/appreciation among pupils

·        Increasing body satisfaction

·        Increasing awareness among pupils to the normal body changes of puberty and adolescence

·        Empowering pupils to critically address media messages that perpetuate a poor body image

·        Improving pupils’ knowledge of healthy eating practices and lifestyle

·        Decreasing the risk of disordered eating among pupils

In order to reach these objectives, the school curriculum needs to include:

·        a positive attitude towards healthy eating and food in general

·        age appropriate knowledge on normal growth and development

·        a sensible physical education regime

·        activities focused on enhancing body image

·        educational workshops for staff

Staff should be encouraged to be informed role models of positive self-esteem and healthy lifestyle practices.

The school environment is often the environment where signs and symptoms of body image concerns and poor nutritional habits are identified. The NEDA conveniently place these signs/symptoms into three categories: emotional, physical and behavioural signals.

Emotional signals:

o   Change in attitude/performance

o   Expresses body image complaints/concerns

o   Talks about dieting

o   Is overweight but appears to eat very little

o   Appears sad/depressed/anxious/expresses feelings of worthlessness

o   Is target of body/weight bullying

o   Spends more time alone

o   Is obsessed with maintaining low weight for sports

o   Overvalues self-sufficiency

Physical signals include:

o   Sudden weight loss/gain or fluctuations in short time frame

o   Abdominal pain

o   Feeling full/bloated

o   Feeling faint/cold/tired

o   Dry hair, skin, dehydration, blue hands/feet

o   Lanugo hair

And behavioural signals:

o   Diets or chaotic food intake, pretends to eat, skips meals

o   Exercises for long periods of time, excessive

o   Constantly talks about food

o   Makes frequent trips to bathroom

o   Wears baggy clothes

§  To hide a very thin physique or weight gain

§  To hide ‘normal’ body because of shame, embarrassment

o   Is fatigued/dizzy

o   Avoids tuck-shop

o   Carries own food

o   Shows compulsive behaviour

o   Denies difficulty