Eric is a 24-year-old man seeing his primary care doctor, Dr. Frank, for evaluation of “fatigue.” During his initial evaluation, Eric—who is currently a full-time runner with hopes of qualifying for the 10-km competition in the next Olympic Games—explains that he has been sleeping poorly for the past 6–9 months, with difficulty falling asleep, early morning awakening, and feeling tired and “worn down all the time.” Eric, a successful collegiate runner, chose to pursue an elite running career after graduating college. He continued working with his college coach and was sharing a house with runner friends, while working part-time at a local running store. After some early disappointing races, Eric decided that he might perform better if he lost 5 lb to achieve the weight he had raced at in his junior year, which had been his most successful season. It was easy to lose this weight with a small reduction in calorie intake and an increase in his weekly mileage. Over the next 12 months, still unable to improve his performance to the level he thought was within his capacity, Eric became more focused on his diet and weight, gradually reducing his intake further and forgoing speed workouts and group runs with his teammates for long runs on his own to try to increase his mileage further. He felt his job at the running store was getting in the way of his running, and quit the job. He began considering switching to a new coach or relocating. He was spending less time with his housemates and more time in his bedroom, reading and stretching. He found himself worrying about his future and what would come of him if he did not achieve his professional running goals.

By the time he saw Dr. Frank, 18 months after graduation from college, he was 20 lb below his senior-year weight, with a BMI of 17.5. He felt cold all the time, tired and unfocused. He described a very restricted diet, in terms of range of food items and overall calories. He admitted that “on occasion” he got so hungry that he would eat much larger amounts in a short period of time; he would then reduce his intake the next day and add a few more miles to his run. He reported a low mood. He had difficulty falling and staying asleep, feeling constantly “on edge.” He hoped Dr. Frank could offer a medication to help him sleep better, so he might be able to train at a higher level.

Preferred diagnosis: The most appropriate diagnosis for Eric is anorexia nervosa (AN) [for more discussion of AN, see Chap. 1]. Eric has been restricting his calories with increasing preoccupation about maintaining a very low weight and fear about gaining weight. In addition, he has become more focused on his weight as a measure of his self-worth and identity, such that his weight on any given day has a substantial impact on how he feels about himself. His drive for thinness has surpassed its initial purpose; what developed in attempt to enhance performance has now seemed to have led to a decline in performance and impairment in several areas of functioning.

For many reasons, the diagnosis of AN might be missed or discounted in Eric’s case—most relevant here, Eric is male and an athlete. Eating disorders in general, and AN specifically, are significantly more prevalent in females, with a reported 10:1 female predominance in AN. This statistic, however, should highlight that AN is in fact not an exclusively female disorder, and clinicians should be mindful of the small but significant population of males with AN. Moreover, because the typical AN patient is female, it is important to note that a boy or man with AN may have clinical features that differ somewhat from the classic perception of the disorder. Whereas a female patient, due to various factors including pervasive cultural norms and social acceptability, might be more likely to explicitly link her maintenance of low weight to her body image, a male patient might not report body image as a motivating factor. He might, for example, be more likely to attribute his low weight and refusal to gain weight to an athletic performance goal. This will be particularly common in men who participate in sports that involve vertical motion where being at a very lean weight enhances performance, such as middle- and long-distance running, as well as those sports that involve weight classes, such as wrestling, where there is a potential advantage to being in the upper range of a weight class below one’s natural body type.

Males with eating disorders may be more likely than women to have a history of being overweight before the development of the eating disorder and to have more general psychiatric comorbidity; males with eating disorders may be diagnosed later in the course of illness than females, perhaps in part due to assumptions that eating disorders are largely exclusive to girls and women. Homosexual males appear to be at higher risk for developing eating disorders than heterosexual males.

As the case of Eric demonstrates, the diagnosis of an eating disorder in competitive athletes, male and female, may be more challenging to make and at risk of being missed. Elite and otherwise competitive athletes will manipulate their food intake and exercise to optimize their performance. As mentioned previously, some athletic endeavors, such as those requiring vertical motion like running and dancing, are typically better performed the leaner an athlete is (though excessive leanness to the detriment of essential stores of fat mass will ultimately begin to hamper performance). Other sports involve weight classes, where an athlete may actively manipulate his or her weight to be at the upper limit of a weight class at the time of the precompetition weigh-in. Weight control may include cutting calories, or limiting specific macronutrients (such as carbohydrates, in the case where water weight needs to be kept at a minimum—for example, before a wrestling match weigh-in). Athletes may add in extra calorie-burning exercise in order to expend more energy and bring weight down. Some additional compensatory behaviors, including wearing extra clothing in order to lose more fluid in sweat as a temporary measure before a weigh-in, are not uncommon practice. Among certain groups, behaviors that might be considered frankly disordered in the general population may be almost normative, with extreme dieting or purging of food subtly or not so subtly encouraged by teammates or even a coach.