To examine whether self-stigma of seeking psychological help and being male would be associated with an increased likelihood of having an undiagnosed eating disorder. A multi-national sample of 360 individuals with diagnosed eating disorders and 125 individuals with undiagnosed eating disorders were recruited. Logistic regression was used to identify variables affecting the likelihood of having an undiagnosed eating disorder, including sex, self-stigma of seeking psychological help, and perceived stigma of having a mental illness, controlling for a broad range of covariates. Being male and reporting greater self-stigma of seeking psychological help were independently associated with an increased likelihood of being undiagnosed. Further, the association between self-stigma of seeking psychological help and increased likelihood of being undiagnosed was significantly stronger for males than for females. Perceived stigma associated with help-seeking may be a salient barrier to treatment for eating disorders – particularly among male sufferers.
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Self-stigma of Seeking Help and Being Male Predict an Increased Likelihood of Having an Undiagnosed Eating Disorder
1. Self-stigma of seeking
help and being male
predict an increased
likelihood of having an
undiagnosed eating
disorder
Griffiths, S., Mond., J. M., Li, Z., Gunatilake,
S., Murray, S. B., Sheffield, J., & Touyz, S.
(2015). International Journal of Eating
Disorders.
2. #1 Approximately 75% of eating disorders
are undiagnosed (Hart et al., 2011)
#2 Diagnosis is important because it
facilitates access to appropriate and
effective treatment (Striegel-Moore et al.,
2000)
Introduction
3. #3 Self-stigma of seeking psychological
help may contribute to undiagnosed eating
disorders (Griffiths et al., 2014)
#4 Males may suffer disproportionately
from self-stigma of seeking psychological
help due to masculinity (Griffiths et al.,
2015; Smiler, 2006)
Introduction
4. Methods - procedure
An online survey requested participants who:
a. were currently diagnosed with an eating disorder;
b. had recovered from an eating disorder; or
c. thought they might have an eating disorder
5. Q1 “Have you ever been diagnosed with
an eating disorder by a health
professional, such as a general
practitioner or psychologist?”
YES = Diagnosed group, NO = Question 2
Q2 “Do you think you might have an eating
disorder?
YES = Undiagnosed group, NO = Excluded
Methods - procedure
6. 485 persons with eating disorders
360 diagnosed
125 undiagnosed
~50% of diagnosed group in treatment
0% of undiagnosed group in treatment
Methods - participants
7. Comparison of EDE-Q global scores
0
1
2
3
4
5
6
Clinical norm
(Welch et al. 2011)
Community norm
(Mond et al. 2006)
Diagnosed
Undiagnosed
EDE-Q
Global score
8. Comparison of EDE-Q subscale scores
0
1
2
3
4
5
6
Clinical norms
(Welch et al. 2011)
Community norms
(Mond et al. 2006)
Dietary
Restraint
Eating
Concern
Shape
Concern
Weight
concern
Diagnosed
Undiagnosed
10. #1 Men were four times more likely to be
undiagnosed than women
OR = 4.04 (95% CI: 1.43, 11.43), p = .009
#2 Self-stigma of seeking psychological
help predicted a greater probability of
being undiagnosed
OR = 1.57 (95% CI: 1.07, 2.30), p = .022
Results
11. #3 Significant interaction between sex and
self-stigma of seeking psychological help
OR = 6.81 (95% CI: 1.39, 33.25), p = .018
Results
16. #1 Findings consistent with the view that
males with eating disorders are more
reluctant to seek treatment and more likely
to be undiagnosed
#2 Self-stigma of seeking psychological
help may be responsible, to some extent,
for this reluctance
Discussion
17. #3 Conflict between traditional masculine
gender roles and the act of reaching out
for help may explain why self-stigma of
seeking psychological help has a stronger
influence on males
#4 Addressing males’ negative beliefs
about seeking treatment is important for
early intervention initiatives
Discussion
18. #1 Cross-sectional design
#2 The experience of treatment may
reduce self-stigma about seeking
treatment
#3 Relatively few males recruited
Discussion - limitations
19. #4 Certain subgroups of sufferers may
have been underrepresented
#5 Factors likely to have influenced
diagnosis, such as access to services,
were not examined
#6 Eating disorders were self-reported and
not confirmed with interview assessments
Discussion - limitations
20. Investigate men with muscle dysmorphia
and men who use steroids
Muscle dysmorphia sufferers tend to be
more traditionally ‘masculine’ than men
with anorexia nervosa and ‘healthy’
control men (Kanayama et al., 2006;
Murray et al., 2013)
Discussion – future research
21. #1 Self-stigma of seeking psychological
help may be a salient barrier to eating
disorder diagnosis and treatment,
particularly for males
Conclusion
22. Griffiths, S., Mond, J. M., Murray, S. B., & Touyz, S. (2014). The prevalence and adverse associations of
stigmatization in people with eating disorders. International Journal of Eating Disorders.
http://doi.org/10.1002/eat.22353
Griffiths, S., Murray, S. B., & Touyz, S. (2015). Extending the masculinity hypothesis: An investigation of gender
role conformity, body dissatisfaction, and disordered eating in young heterosexual men. Psychology of Men
& Masculinity. http://doi.org/10.1037/a0035958
Hart, L. M., Granillo, M. T., Jorm, A. F., & Paxton, S. J. (2011). Unmet need for treatment in the eating disorders:
A systematic review of eating disorder specific treatment seeking among community cases. Clinical
Psychology Review, 31(5), 727–735. http://doi.org/10.1016/j.cpr.2011.03.004
Kanayama, G., Barry, S., Hudson, J. I., & Pope, H. G. (2006). Body Image and Attitudes Toward Male Roles in
Anabolic-Androgenic Steroid Users. American Journal of Psychiatry, 163(4), 697–703.
http://doi.org/10.1176/appi.ajp.163.4.697
Mond, J. M., Hay, P. J., Rodgers, B., & Owen, C. (2006). Eating Disorder Examination Questionnaire (EDE-Q):
Norms for young adult women. Behaviour Research and Therapy, 44, 53–62.
Murray, S. B., Rieger, E., Karlov, L., & Touyz, S. W. (2013). Masculinity and femininity in the divergence of male
body image concerns. The Journal of Eating Disorders, 1(11), 1–8. http://doi.org/10.1186/2050-2974-1-11
Striegel-Moore, R. H., Leslie, D., Petrill, S. A., Garvin, V., & Rosenheck, R. A. (2000). One-year use and cost of
inpatient and outpatient services among female and male patients with an eating disorder: evidence from a
national database of health insurance claims. International Journal of Eating Disorders, 27(4), 381–389.
Welch, E., Birgegård, A., Parling, T., & Ghaderi, A. (2011). Eating disorder examination questionnaire and clinical
impairment assessment questionnaire: General population and clinical norms for young adult women in
Sweden. Behaviour Research and Therapy, 49(2), 85–91. http://doi.org/10.1016/j.brat.2010.10.010
References
23. Griffiths, S., Mond., J. M., Li, Z.,
Gunatilake, S., Murray, S. B., Sheffield, J.,
& Touyz, S. (2015). Self-stigma of seeking
help and being male predict an increased
likelihood of having an undiagnosed
eating disorder. International Journal of
Eating Disorders.
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Editor's Notes
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A hierarchical binary logistic regression was conducted using SPSS version 21.
Box-Tidwell tests were conducted to examine whether the relationships between the continuous predictors and the log odds were linear by including interactions between the continuous predictors and their logs into the model.
Significant interaction terms were observed for duration of disorder and number of co-morbid conditions.
Scatterplots graphing the relationship between the predicted probability of membership in the undiagnosed group and the predictors were created in order to assess the likelihood that non-linear relationships existed. For both variables, clear quadratic relationships were observable. Thus, these predictors were squared and entered in addition to the non-squared term to represent linear, and quadratic relationships, respectively.
The predictors entered at Step 1 were sex, self-stigma of seeking psychological help, self-stigma of mental illness, the EDE-Q global score and the six variables representing various eating disorder behaviours, the duration (in years) of eating disorder symptoms, the number of currently diagnosed co-morbid conditions, and demographic variables including country of residence, employment status, relationship status and highest level of education. Age was not entered as a predictor because it exhibited a very high correlation with duration of eating disorder symptoms. Two additional predictors were added at Step 2, namely, the quadratic terms for self-stigma of seeking psychological help and number of co-morbid conditions. The addition of these terms was justified by the results of the Box-Tidwell tests and visual inspection of the scatterplots. Three additional predictors representing the hypothesised interactions between sex and self-stigma of seeking psychological help, sex and perceived stigma of mental illness, and self-stigma of seeking psychological help and perceived stigma of mental illness, were entered at the third and final step.
The logistic regression model at Step 1 was significant, (Nagelkerke R2 = .45, χ²(21, N = 485) = 176.41, p < .001). Further, the Hosmer and Lemeshow Test was non-significant, χ²(8, N = 485) = 3.65, p = .89, indicating acceptable model-fit.
The addition of the quadratic terms at Step 2 resulted in a significant increase in the explanatory power of the model, Nagelkerke R2 = .02, χ²(2, N = 485) = 9.85, p = .007, and the Hosmer and Lemeshow Test remained non-significant, χ²(8, N = 485) = 4.75, p = .78.
The addition of the interaction terms at Step 3 also resulted in a significant increase in the explanatory power of the model, Nagelkerke R2 = .02, χ²(3, N = 485) = 8.20 p = .042, and the Hosmer and Lemeshow Test remained non-significant, χ²(8, N = 485) = 3.16, p = .92 Thus, the model was retained at Step 3, which included both the quadratic terms and interaction terms, Nagelkerke R2 = .49, χ²(26, N = 485) = 194.46, p < .001.
The retained model correctly classified 82.9% of cases as either diagnosed or undiagnosed. Sensitivity was 55.2% and specificity was 92.5%. Positive predictive value was 71.9% and negative predictive value was 85.6%. That is, 71.9% of participants who self-reported being undiagnosed were correctly classified by the model as undiagnosed and 85.6% of participants who self-reported being diagnosed were correctly classified as diagnosed.
The model at Step 3 did not produce any Cook’s distance values above 1.0, suggesting that the results were not unduly influenced by data points with large residuals or high leverage.
Given the very high levels of eating disorder symptomatology in the undiagnosed group, the findings underscore the need to change males’ negative self-beliefs about seeking out psychological services for eating problems. Indeed, low uptake of mental health care among males may become increasingly problematic in the future. Researchers have shown that between 1995 and 2005 the prevalence of strict dieting, purging and binging among Australian males more than doubled (Hay et al., 2008). Further, between 1998 and 2008, the prevalence of extreme dieting and purging increased faster among Australian males than Australian females (Mitchinson et al., 2015).