1

Running head: BULIMIA NERVOSA IN MEN

Bulimia Nervosa in Men: A Review of the Literature

Elizabeth Holloway

Wake Forest University

Bulimia nervosa is characterized by the combination of a reoccurrence of binge eating,

compensatory behaviors to avoid weight gain, and self-evaluation heavily influenced by weight

and body shape. Cash and Deagle found that 73% of bulimia nervosa patients had a larger

perception of their body and that their body dissatisfaction exceeded 87% of control participants

(as cited by Erford et al., 2013). Although the prevalence of eating disorders is less than 5% in

the general population, studies have found higher rates in adolescent and adult females (Berg,

Peterson, & Frazier, 2012). In both genders, prevalence rates have increased in the recent

generations with the average age of diagnosis at 19.7 years and the average duration 8.3 years

(Erford et al, 2013). A 10:1 female-to-male ratio of diagnosis and an underrepresentation of men

in current studies, that has yet to be systematically explained, bulimia nervosa in men has yet to

be thoroughly examined in the profession (American Psychiatric Association, 2013). The

purpose of this literature review is to discuss the diagnosis of bulimia nervosa and the lack of

research in men. The methodology used to obtain the materials that support this review is

described first; followed by reviews of meta-analyses, peer-reviewed journals, and various

articles to expand on this diagnosis, specifically the comorbidity, treatment and frequency in

men; a focus on the male population diagnosed with bulimia nervosa is exemplified to influence

future research and conclude the review.

Bulimia Nervosa in Men: A Review of the Literature

Recurrent episodes of binge eating, atoning eating behaviors to avoid gaining weight, and

self-evaluation heavily influenced by body shape and weight are the characteristics that classify

bulimia nervosa in the DSM-V (American Psychiatric Association, 2013). Classified in the

“Feeding and Eating Disorders” section of the manual, bulimia nervosa is defined by the

occurrence of its characteristics at least once a week for 3 months. The severity of this disease is

exemplified by its prevalence: 2% of women during their lifetime (Keski-Rahkonen et al., 2009),

a 10: 1 ratio of women to men, and an elevated risk for mortality of 2% per decade (American

Psychiatric Association, 2013). The risk of mortality is paired with a low treatment percentage,

less than 45% of individuals with a diagnosed eating disorder seek treatment (Hackler, Vogel &

Wade, 2011).

The associated issues with bulimia nervosa include depression, hypokalemia, and

gastrointestinal issues (Polnay et al., 2013) as well as irregular menstruation, esophageal tears,

cardiac arrhythmias, and skeletal myopathies (American Psychiatric Association, 2013).

Increased suicide risk is also elevated with bulimia nervosa, as well as comorbidity with other

disorders such as major depressive disorder and mood disorders.

Although less common in men than in women, the male population diagnosed with

bulimia nervosa is one that is highly neglected in research studies. The reason for the numerical

difference in diagnoses between the two genders is that men perceive greater stigma with seeking

counseling because they are expected to be independent and in control by social standards

(Hackler, Vogel & Wade, 2011).

In order to obtain the most accurate peer reviewed journals that are relative to this

literature review, I used the databases of PsycINFO, PubMed, and ProQuest. To begin with a

broad view of this review, I searched the databases, specifically those linked to the ZSR library

online, for “bulimia nervosa” and was overwhelmed with results. The search for the name of the

disease only led to 178 results amongst multiple databases and topics ranged from meta-analyses

to comorbidity of the disorder with substance abuse and other DSM-V disorders. To prevent

using outdated research, I narrowed the search down to publication years of 2011 and later and

also discarded any journal or result that was not peer reviewed. To condense these results to

accommodate the specification of men and bulimia nervosa, I then searched for the combination

of words such as “bulimia nervosa” and “men” or “males.” These limits provided a less

extensive search and provided many examples of research written that deal with current works

involving men and bulimia nervosa. I also did not focus on results that dealt predominantly with

other eating disorders such as anorexia nervosa or binge-eating disorder. To greater expand on

the search involving men and bulimia, I also searched terms such as “eating disorder” to include

articles that discussed the greater scheme but only focused on information that specifically said

“bulimia nervosa.” In order to find articles that specifically focused on the reasons why it’s less

reported that men are diagnosed, I searched terms, in addition to the base search of “bulimia

nervosa” and “men” or “males”, such as “stigma.” The results in this search provided articles

that helped assess the particular social pressures unique to men that impact their coming forward

with eating disorders. Differences between genders diagnosed with bulimia nervosa was also

discussed thoroughly in these search results because the keywords searched caused gender and

sex differences to be a topic discussed.

Recurrent episodes of binge eating, atoning eating behaviors to avoid gaining weight, and

self-evaluation heavily influenced by body shape and weight are the characteristics that classify

bulimia nervosa in the DSM-V (American Psychiatric Association, 2013). Classified in the

“Feeding and Eating Disorders” section of the manual, bulimia nervosa is defined by the

occurrence of its characteristics at least once a week for 3 months, specifically:

1) Eating in a discrete amount of time, within a 2-hour period, an amount of food that is

greater than what most individuals would consume in that time period or a sense of

lack of control over eating during the episode

2) Recurrent compensatory behaviors in order to prevent weight gain. These include

self-induced vomiting, misuse of laxatives, diuretics, or other medications; fasting; or

excessive exercise

3) The binge-eating and compensatory behaviors both occur an average of at least once

a week for the duration of 3 months

4) Self-evaluation is unduly influenced by body shape and weight

5) The disturbance does not occur exclusively during episodes of anorexia nervosa

Comorbidity

Due to the prognostic factors of bulimia nervosa, such as low self-esteem, social anxiety

and depressive symptoms, comorbidity with the disorder is high (American Psychiatric

Association, 2013). As many as 95% of those diagnosed with bulimia nervosa met criteria for

another DSM-V disorder and reported role impairment (Sandberg & Erford, 2013). The most co-

occurring disorder related to eating disorders as a whole is major depressive disorder; this

diagnosis is highly associated with suicidal attempts (Lenz, Taylor, Fleming & Serman, 2013).
6
BULIMIA NERVOSA IN MEN
Fewer than half, 43.2%, of individuals with bulimia nervosa seek treatment and are more likely

to seek treatment for other conditions other than their eating disorder (Sandberg & Erford, 2013).

The risk of major depressive disorder that is associated with bulimia nervosa also influences the

suicide risk that is associated with the disorder. With a CMR, or crude morality rate, of 2% per

decade, bulimia nervosa is associated with both suicide and all-cause deaths. Per the DSM-V,

when treating a client with this diagnostic, a comprehensive evaluation of suicide-related

ideations and incidents of attempted suicide needs to be taken (American Psychiatric

Association, 2013).

Another comorbidity associated with bulimia nervosa is substance use and self-harm. The

DSM-V reports that 30% of diagnosed individuals have a lifetime prevalence of alcohol or

stimulant use. The use of stimulants often begins as a method to control weight and body shape,

such as the use of ipecac, laxatives, and diuretics (American Psychiatric Association, 2013).

Self-harm without intent to commit suicide is also common in individuals with bulimia nervosa.

Nonsuicidal self-injury often occurs in parts of the body that the individual particularly finds

problematic, such as thighs or stomach (Berg, Peterson & Frazier, 2012).

Treatment

Although the numbers are low for those that seek treatment for bulimia nervosa, 50% of

individuals are expected to recover. Cognitive behavioral therapy is one of the most common and

most recommended routes for treatment of bulimia nervosa; this could be because it’s applicable

to a wide range of diagnoses and for both genders (Fursland, Byrne, Watson, La Puma & Allen,

2011). With a focus on the present instead of the past, this therapy also provides the ability for

individualized and flexible treatment plans. The popularity of cognitive behavioral therapy,

especially in regards to bulimia nervosa, is supported by its reduction in bulimic symptoms,

2013). When comparing face-to-face and online group therapy in bulimia nervosa patients,

Stephanie Zerwas found that neither method was better than the other but that treatment, that

would otherwise not be available to some, benefited those that would not have access to care and

that both groups were free of binging and purging after 12 months (Bulimia, 2016). When

traditional therapies do not work, Federici suggests dialectical behavior therapy that was

originally meant for clients with borderline personality disorder, a comorbid diagnosis of bulimia

nervosa. Within the practice of DBT, they also integrate elements of cognitive behavior therapy,

include dieticians, and practice the DBT hierarchy. This practice finds reduction in suicidal

tendencies, substance abuse, and frequency of hospital visits (Federicia, Wisniewski & Ben-

Porath, 2012). Medication alone, without therapy, has been researched for treatment of bulimia

nervosa. While medication produced an initial positive result, it did not last and the clients

relapsed. The results were better and longer lasting when medication was accompanied with

therapy (Erford et al, 2013).

Men with Bulimia Nervosa

Within the DSM-V’s description of bulimia nervosa is the statement that “males are

especially underrepresented in treatment-seeking samples, for reasons that have not yet been

systematically explained” (American Psychiatric Association, 2013, pg. 348). Bulimia nervosa

has been called “a Western culture-bound syndrome” with an emphasis on female beauty

because of the assumption that women are only susceptible to societal pressure, especially that of

thinness (Nelson, Castonguay & Locke, 2011). With a diagnostic ratio of 10:1 female to male,

the diagnosis of bulimia nervosa for men has left the population less researched and less visible

in data. Traditionally thought of as a white, female disorder, research has predominantly focused
8
BULIMIA NERVOSA IN MEN
on this group in adolescence, the time when this disorder is most prevalent (American

Psychiatric Association, 2013). This belief leaves this group unresearched and causes delay and

prevention of professionals to make an accurate diagnosis; early detection and referral to

specialists is pivotal in this diagnosis (Räisänen, 2014). Burlew and Shurts (2013) found that

“men with bulimia also tend to wait longer before seeking treatment because of the shame of

having a ‘female’ disorder” (Burlew & Shurts, 2013). Societal pressures for men to be

independent and strong leave this group less likely to seek out help for mental disorders; women

are more likely than men to seek help for emotional issues and have more positive attitudes

towards counseling (Hackler, Vogel & Wade, 2011). Mclean et al. (2014) identified five

components of stigmatizing attitudes towards bulimia nervosa: advantages of bulimia nervosa,

minimization/ low seriousness, unreliability, social distance, and personal responsibility. The

same study also found that men considered anorexia and bulimia nervosa to be less serious than

women (Mclean et al., 2014).

Discussion

Burlew and Shurts (2013) found that preventative methods such as providing information on

eating disorders and comorbid issues such as mood disorders, focusing on the cultural influence

on body image, and distinguishing between unhealthy and healthy nutrition and eating practices

will help prevent the prevalence of eating disorders, such as bulimia nervosa, in men (Burlew &

Shurts, 2013). Their research also indicated that the prevalence of bulimia nervosa in men may

be correlated with sexual preferences; homosexual men are at a greater risk for eating disorders

than heterosexual men. Further research should also focus on the correlation between gender,

sexuality, and eating disorders; it’s believed that homosexual men are more likely to experience

a diagnosis than heterosexual men, but research is lacking in that subject, too. Gay men
9
BULIMIA NERVOSA IN MEN
experience body image disturbances at higher rates and are exacerbated by the difficulty of

navigating their sexuality; they also report a greater pressure to have a lean appearance per gay

culture (Bozard & Young, 2016). The lack of research in regards to men and bulimia nervosa can

be attributed to the belief that it’s a “female” disorder but this is a population that is affected and,

therefore, needs to be researched. The strength that can be found in research is the overall

research provided for bulimia nervosa and the acknowledgment that men are not included and

that social pressures are becoming more gender-specific and leading to eating disorders for both

sexes. A weakness on researching bulimia nervosa is that it’s often grouped into research on

eating disorders as a whole, including research specific to anorexia nervosa or binge-eating

disorder. The most cited number of men with bulimia nervosa, or eating disorders in general, is

10% of the population diagnosed; because of the lack of research, there is some disagreement

that this number could actually be as much as 25% of the population (Räisänen, 2014).
10
BULIMIA NERVOSA IN MEN
References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental

disorders (5th ed.). Washington, DC: Author.

Berg, K. C., Peterson, C. B., & Frazier, P. (2012). Assessment and diagnosis of eating disorders:

A guide for professional counselors.  Journal of Counseling and Development, 90(3),

262-269. doi:http://dx.doi.org.go.libproxy.wakehealth.edu/10.1002/j.1556-

6676.2012.00033.x

Bozard, R. L., & Young, J. S. (2016). The roles of family, friends, and Romantic/Sexual partners

in the body image of sexual minority men. Journal of Counseling and

Development, 94(2), 150-160.

doi:http://dx.doi.org.go.libproxy.wakehealth.edu/10.1002/jcad.12072

Bulimia; online group therapy may be effective treatment for bulimia nervosa. (2016, Dec

18). NewsRx Health & Science Retrieved from http://go.libproxy.wakehealth.edu/login?

url=https://search-proquest-com.go.libproxy.wakehealth.edu/docview/1846738875?

accountid=14868

Burlew, L. D., & Shurts, W. M. (2013). Men and body image: Current issues and counseling

implications. Journal of Counseling and Development, 91(4), 428-435. Retrieved from

http://go.libproxy.wakehealth.edu/login?url=https://search-proquest-

com.go.libproxy.wakehealth.edu/docview/1439531289?accountid=14868

Erford, B. T., Richards, T., Peacock, E., Voith, K., McGair, H., Muller, B., . . . Chang, C. Y.

(2013). Counseling and guided self-help outcomes for clients with bulimia nervosa: A

meta-analysis of clinical trials from 1980 to 2010. Journal of Counseling and

url=https://search-proquest-com.go.libproxy.wakehealth.edu/docview/1330852085?

accountid=14868

Fursland, A., Byrne, S., Watson, H., Puma, M. L., Allen, K., & Byrne, S. (2012). Enhanced

cognitive behavior therapy: A single treatment for all eating disorders. Journal of

Counseling and Development : JCD, 90(3), 319-329.

doi:http://dx.doi.org.go.libproxy.wakehealth.edu/10.1002/j.1556-6676.2012.00040.x

Hackler, A. H., Vogel, D. L., & Wade, N. G. (2010). Attitudes toward seeking professional help

for an eating disorder: The role of stigma and anticipated outcomes. Journal of

Counseling and Development, 88(4), 424-431.

doi:http://dx.doi.org.go.libproxy.wakehealth.edu/10.1002/j.1556-6678.2010.tb00042.x

Keski-Rahkonen, A., Hoek, H. W., Linna, M. S., Raevuori, A., Sihvola, E., Bulik, C. M., . . .

Kaprio, J. (2009). Incidence and outcomes of bulimia nervosa: A nationwide population-

based study. Psychological Medicine, 39(5), 823-31.

doi:http://dx.doi.org.go.libproxy.wakehealth.edu/10.1017/S0033291708003942

Lenz, A. S., Taylor, R., Fleming, M., & Serman, N. (2014). Effectiveness of dialectical behavior

therapy for treating eating disorders. Journal of Counseling and Development : JCD, 92(1),

26-35. doi:http://dx.doi.org.go.libproxy.wakehealth.edu/10.1002/j.1556-6676.2014.00127.x

McLean, S. A., (Hons), Paxton, S. J.,., Massey, R.,B. (Hons), Hay, Phillipa J,., Mond, J. M.,., &

Rodgers, B.,. (2014). Stigmatizing attitudes and beliefs about bulimia nervosa: Gender, age,

education and income variability in a community sample. International Journal of Eating

Disorders,  47(4), 353. Retrieved from http://go.libproxy.wakehealth.edu/login?

accountid=14868

Nelson, D. L., Castonguay, L. G., & Locke, B. D. (2011). Challenging stereotypes of eating and

body image concerns among college students: Implications for diagnosis and treatment of

diverse populations. Journal of College Counseling, 14(2), 158-172. Retrieved from

http://go.libproxy.wakehealth.edu/login?url=https://search-proquest-

com.go.libproxy.wakehealth.edu/docview/926454220?accountid=14868

Polnay, A., James, V. A. W., Hodges, L., Murray, G. D., Munro, C., & Lawrie, S. M. (2014).

Group therapy for people with bulimia nervosa: Systematic review and meta-

analysis. Psychological Medicine, 44(11), 2241-2254.

doi:http://dx.doi.org.go.libproxy.wakehealth.edu/10.1017/S0033291713002791

Räisänen, U., & Hunt, K. (2014). The role of gendered constructions of eating disorders in

delayed help-seeking in men: A qualitative interview study. BMJ Open, 4(4)

doi:http://dx.doi.org.go.libproxy.wakehealth.edu/10.1136/bmjopen-2013-004342

Sandberg, K., & Erford, B. T. (2013). Choosing assessment instruments for bulimia practice and

outcome research. Journal of Counseling and Development : JCD, 91(3), 367-379.

doi:http://dx.doi.org.go.libproxy.wakehealth.edu/10.1002/j.1556-6676.2013.00107.x