Introduction
Eating disorders, especially anorexia nervosa, are rare in the general population, particularly among males. Lifetime prevalence estimates from the U.S. National Comorbidity Survey Replication suggest that anorexia nervosa only occurs in about 0.3% of men (Hudson et al. Reference Hudson, Hiripi, Pope and Kessler2007). In large, epidemiological studies of male active-duty service members and veterans, anorexia nervosa is estimated to be less common than in the general population, with reported point estimates of 0.01% and 0.00005%, respectively (Striegel-Moore et al. Reference Striegel-Moore, Garvin, Dohm and Rosenheck1999; Antczak & Brininger, Reference Antczak and Brininger2008). However, one study aimed at directly assessing eating pathology among active-duty male sailors revealed a much higher prevalence for anorexia nervosa of 2.5% (McNulty, Reference McNulty1997). Still other research has found comparable rates of eating disorder symptoms between military and civilian populations (Litwack et al. Reference Litwack, Mitchell, Sloan, Reardon and Miller2014). Thus, it remains unknown whether life in the military may increase the prevalence of eating pathology.
Previous research suggests that the stress of military life (e.g. combat deployment) and the strict weight and fitness requirements for service members may contribute to eating pathology (McNulty, Reference McNulty1997, Reference McNulty2001; Antczak & Brininger, Reference Antczak and Brininger2008). Specifically, these rules may promote an excess focus on weight and appearance and reinforce extreme dieting and exercise behaviour (Bodell et al. Reference Bodell, Forney, Keel, Gutierrez and Joiner2014). In support of this notion, one study found that the prevalence of disordered eating increased following deployment (Jacobson et al. Reference Jacobson, Smith, Smith, Keel, Amoroso, Wells, Bathalon, Boyko and Ryan2009), and others reported increased rates of eating disorder symptoms and purging behaviours during fitness testing periods (Carlton et al. Reference Carlton, Manos and Van Slyke2005). On the other hand, one longitudinal study following 139 soldiers through basic training concluded that military training tended to result in healthier eating habits and body weights (Williamson et al. Reference Williamson, Martin, Allen, Most, Alfonso, Thomas and Ryan2002). Due to these conflicting findings, further study is required to assess whether military service contributes to eating disorder symptoms among men.
One recent article reported a case of bulimia nervosa in an active-duty male sailor (Staten, 2013). It concluded that pre-deployment stress and an upcoming fitness evaluation contributed to the patient's bingeing and purging behaviours, lending credence to the idea that military life may exacerbate eating pathology. Furthermore, the author emphasized the challenges of diagnosing bulimia nervosa because it is ego-syntonic and often stigmatized, such that individuals with bulimia nervosa often seek treatment for other physical symptoms and not their eating pathology.
The current case report (details of the case have been altered to protect the patient's confidentiality) of a former Navy midshipman extends this previous work in two ways. First, it presents a case illustrating the relationship between military service and anorexia nervosa symptoms, which currently does not exist in the literature. It lends support to the conclusions of Staten (2013) and Bodell and colleagues (Reference Bodell, Forney, Keel, Gutierrez and Joiner2014), which suggest that the weight and fitness requirements in the military contribute to eating pathology. Second, this report discusses ways in which comorbid psychopathology symptoms complicate differential diagnosis of anorexia nervosa, extending the work of Staten (2013), which discussed the difficulty of diagnosing eating pathology in the face of other physical symptoms. This contribution is important, since many studies have documented psychiatric comorbidity among veterans with eating disorders (Davidson, Reference Davidson1976; Striegel-Moore et al. Reference Striegel-Moore, Garvin, Dohm and Rosenheck1999; Maguen et al. Reference Maguen, Cohen, Cohen, Madden, Bertenthal and Seal2012). Comorbid conditions may exacerbate eating disorder symptoms, in addition to causing difficulties with differential diagnosis and treatment (Hamlett & Curry, Reference Hamlett and Curry1990). The case specifically demonstrates the reciprocal relationship of obsessive compulsive disorder (OCD) with anorexia nervosa and the overlap between these two disorders.
Presenting problems
T.K. is a 31-year-old Caucasian male, who participated in a comprehensive intake assessment at a speciality clinic for obsessive compulsive and related disorders. His psychologist from the Veteran's Administration (VA) healthcare system referred him, recommending ‘more intensive treatment for his OCD’. He was accompanied by his mother during the evaluation. She stated that she attended because she wanted to be involved in T.K.'s care. He reportedly lived independently and was not reliant on his mother for immediate financial support.
T.K. reported that he suffered from ‘severe OCD’ since approximately 9 years ago, in addition to problems with anxiety and sleep. We asked T.K. to describe his current symptoms and history of presenting illness. At the time of the intake, T.K. reported that his entire day was strictly scheduled around ‘obsessing’ about eating and elaborate exercise ‘rituals.’ He stated that he ate the same very healthy, low-calorie meals (e.g. he described a typical meal as a lean protein, like chicken, a serving of vegetables, and little or no carbohydrates) at the same times each day and exercised at least twice a day for 2–3 hours at a time. He emphasized that this was a marked decrease in duration (and intensity) of his exercise compared to the recent past. T.K. noted that if his eating or exercise schedule was disturbed, he would become highly distressed for fear of weight gain. He also reported body image disturbances, feeling ‘fat, slow, and lethargic’. T.K. perceived himself as fat, despite being below his ideal body weight. At 172.72 cm and 55.3 kg, his body mass index (BMI) was 18.5 and he was 83.3% of his ideal weight (Robinson et al. Reference Robinson, Lupkiewicz, Palenik, Lopez and Ariet1983; note that in this case, BMI may be elevated because of muscle mass, relative to body size). Additionally, T.K. explained that he refused to eat any high-calorie foods and avoided situations in which he felt pressure to eat such foods (e.g. social gatherings at a restaurant). He stated that he could not ‘fathom’ how someone could eat a dessert spontaneously (e.g. on a date) and without compensatory behaviours (he specified extra exercise or reduction of caloric intake at prior meals). T.K. noted that he engaged in compensatory exercise when he consumed more calories than he has planned. T.K. also described extreme concern about his body image and expressed a longstanding desire for thinness. He noted that his ‘obsessions’ with exercise and fitness contributed to marked impairment in social relationships. For example, dating was ‘impossible’ because of his difficulty in eating at restaurants and remaining (relatively) sedentary for several hours. He described extreme anxiety when exercise rituals were delayed.
Assessments
T.K. was administered a battery of measures to assess anxiety, depression, OCD, and eating disorder severity. T.K.'s score on the Beck Anxiety Inventory (Beck & Steer, Reference Beck and Steer1993), a 21-item self-report measure of anxiety symptoms over the past week, was 24, suggesting moderate anxiety (T score = 71, 98th percentile). He endorsed being unable to relax and fearing the worst would happen, in addition to terror and nervousness. T.K. also completed the Beck Depression Inventory, 2nd edition (Beck et al. Reference Beck, Steer and Brown1993), a 21-item self-report measure of depression symptoms over the past week. His score of 39 suggested the presence of severe depression (T score = 86, >99th percentile). He fully endorsed items regarding feeling like crying but being unable to do so, agitation/restlessness, and loss of interest in sex. Next, on the Obsessive Compulsive Inventory – Revised (Foa et al. Reference Foa, Huppert, Leiberg, Langner, Kichic, Hajcak and Salkovskis2002), an 18-item self-report measure assessing OCD severity, T.K.'s responses produced a total score of 41. Scores above 21 suggest probable OCD. He fully endorsed several items regarding checking and counting behaviours, and difficulty controlling thoughts. Finally, T.K. completed a 28-item self-report measure of eating disorder symptoms experienced in the past 28 days, the Eating Disorders Examination Questionnaire (EDEQ; Fairburn & Beglin, Reference Fairburn and Beglin1994). On this measure his score was 4.00. In samples of men in the community, the EDEQ exhibits a mean of 0.44 (s.d. = 0.05); thus, T.K. was likely in the top 1% of men in terms of the number and severity of eating disorder symptoms being experienced. His scores were elevated on all subscales, suggesting excessive eating restraint, eating concerns, shape concerns, and weight concerns.
Case conceptualization
T.K.'s case was conceptualized on the basis of cognitive and behavioural theories of anorexia nervosa and OCD. Fairburn and colleagues (Reference Fairburn, Shafran and Cooper1999) formulated the most influential cognitive-behavioural theory of anorexia nervosa. Specifically, they argued that it resulted from and was maintained by an operantly reinforced sense of control. They asserted that individuals may experiment with controlling different aspects of their lives after feeling a sense of loss of control and find success in controlling their eating and exercise behaviours. The disorder is then maintained as a consequence of satisfying this need for control each time self-imposed restriction or exercise requirements are met, along with the relevant sociocultural reinforcement of meeting the thin/fit ideal.
Notably, the cognitive-behavioural model of anorexia nervosa has been adapted to a transdiagnostic perspective, which includes four additional mechanisms that influence several eating disorders (see e.g. Fairburn et al. Reference Fairburn, Cooper and Shafran2003). First, the interpersonal environment may be stressful and create a need for control that is manifested in restricted eating. Moreover, it may emphasize concerns over weight and shape. Second, a desire for perfectionism strengthens an individual's desire to strictly adhere to self-imposed rules regarding shape and weight. Third, an intolerance of negative mood states may make an individual susceptible to negative reinforcement of eating and exercise behaviours. For instance, if an individual is intolerant of feeling embarrassed and being thin reduces the sense of embarrassment, then behaviours to maintain thinness are strengthened. Finally, low esteem in individuals with eating disorders leads them to believe that they are incapable of success, placing them at greater risk for returning to eating behaviours over which they have greater control (and therefore a higher perceived likelihood of success).
T.K.'s mother reported that during his college years, T.K. experienced a break-up with his girlfriend, which resulted in poor mood and social isolation. T.K. reportedly turned to a strict daily exercise routine to help him cope and regain a sense of control. T.K. noted that he continued this exercise and began restricting his eating, as well as obtaining a sense of ‘relief’ from anxiety when completing his daily routine. In the military, he noted exercising above and beyond the normal fitness requirement and receiving commendation from his peers and superiors for doing so. Furthermore, T.K. described himself as a ‘perfectionist’, particularly with regard to his exercise routine. Finally, his mother noted that T.K. had difficulty interacting with others because of a lack of confidence, which prevented him from engaging in alternative reinforcing activities. Thus, T.K.'s case fits well with the theories of development and maintenance of anorexia nervosa put forth by Fairburn et al. (Reference Fairburn, Shafran and Cooper1999, Reference Fairburn, Cooper and Shafran2003).
It was clear from T.K.'s presentation and the assessment procedures that he also met criteria for OCD. There are several cognitive and behavioural theories of OCD. T.K.'s presentation fits best with the traditional behavioural theory of OCD, as outlined by Steketee (Reference Steketee1993) and Kozak & Foa (Reference Kozak and Foa1997). These authors put forward the idea that obsessions are thought to result from the repeated pairing of anxious thoughts with objects (e.g. fear of germs with bathrooms). Once paired, compulsions may be used to reduce anxiety associated with encountering a feared object (e.g. excessive hand washing, avoiding restrooms). Consequently, the conditioned relationship between the anxious thought and the object is maintained, and the compulsive behaviour is negatively reinforced.
T.K., for example, described several obsessional thoughts about his dog becoming sick. His dog walks reportedly became associated with these anxious thoughts about something bad happening to his dog. As a consequence, T.K. stated that he developed a compulsion to walk his dog on a certain route each day. This behaviour was reportedly reinforced by a reduction in anxiety about the health of his dog. Clearly, the development and maintenance of T.K.'s OCD symptoms conforms well with the cognitive-behavioural conception of OCD.
When describing his presenting problems, T.K. highlighted severe anxiety. He meets criteria for generalized anxiety disorder (GAD), including excessive worries that are difficult to control and corresponding restlessness, difficulty concentrating, irritability, and poor sleep (APA, 2013). T.K. and the therapist agreed that these anxieties were largely accounted for by obsessive compulsive symptoms. T.K. took this conclusion one step further, emphasizing that his ‘OCD’ symptoms were the driving force for his dangerous eating and exercise behaviours. T.K.'s mother reinforced this conceptualization of his presentation as primary OCD with eating-related symptoms. Indeed, he met all DSM-5 criteria for OCD (APA, 2013). T.K. reported intrusive thoughts, which he attempted to control or suppress, and repetitive behaviours aimed at reducing anxiety and obsessions. These symptoms caused him distress, as evidenced by him seeking out treatment, and reportedly consumed most of his daily routine.
In spite of the fact that T.K. met diagnostic criteria for OCD, his primary pathology appeared to be anorexia nervosa. Indeed, T.K. met all DSM-5 criteria for the disorder (APA, 2013). He endorsed calorie restriction, compensatory exercise, fear of gaining weight, and feeling fat, despite being objectively below his ideal body weight. The DSM-5 states, ‘OCD can be distinguished from AN in that in OCD the obsessions and compulsions are not limited to concerns about weight and food’ (APA, 2013, p. 241). And indeed, T.K.'s most pressing intrusive thoughts focus on eating, exercise, and weight gain, with other obsessions about safety and counting being ancillary. Furthermore, it has been noted in the literature that males with anorexia nervosa exhibit affective disturbances and obsessionality that may be a manifestation of eating pathology (i.e. starvation, overactivity, etc.; Hamlett & Curry, Reference Hamlett and Curry1990). In sum, T.K.'s presentation warranted a diagnosis of primary anorexia nervosa, with secondary OCD.
Feedback to the patient
The attending psychologist presented this case conceptualization to the patient and his mother at a follow-up session. T.K.'s mother was receptive to this alternative conceptualization. T.K., on the other hand, objected to this description of his symptoms. He insisted that his body image was not distorted, that his exercise was ‘reasonable’, and that ‘most people’ would make the ‘healthy decisions’ that he was making. He added that his appearance was healthy and that weight gain was unacceptable. Finally, he reasserted the importance of his OCD symptoms in explaining his condition, arguing that once his ‘OCD’ was ‘under control’ his eating and exercise habits would improve. It may have been difficult for T.K. to accept an eating disorder diagnosis, given the stigma attached to being a man with an eating disorder and internalization of the lean and muscular body ideal (McCabe & Ricciardelli, Reference McCabe and Ricciardelli2004; Ricciardelli et al. Reference Ricciardelli, McCabe, Williams and Thompson2007; Jones & Morgan, Reference Jones and Morgan2010).
It was the treatment team's impression that anorexia nervosa must be addressed prior to intensive OCD treatment (or addressed in the context of an eating disorders treatment programme). This recommendation was made in light of a previous hospitalization history during military service (his mother stated that military doctors told T.K. that ‘he would die’ if he continued his bout of severe restriction and intense exercise), his inability to maintain a healthy eating and exercise routine, despite being in outpatient therapy at a reputable VA hospital, and the clinical complexity of the case (i.e. comorbidity). The attending therapist presented outpatient and inpatient/residential options to T.K. and his mother. The clinician strongly recommended that the patient seek residential therapy for eating pathology, preferably with an option for concurrent or sequential OCD treatment.
Outcome
T.K. was unreceptive to this recommendation. He denied the need for residential treatment. T.K. stated that it would ‘take away’ his freedom, remove him from the things he loves (his family, his dog, exercise), and cause him to engage in a compensatory return to his routine upon release. T.K.'s history likely contributed to this impression, as he described ‘hating’ being hospitalized and feeling strong urges to return to his eating and exercise routine post-discharge. Furthermore, his military background, which emphasized self-reliance and heavy exercise, likely strengthened his aversion to a treatment programme featuring strict behavioural contingencies and reduced exercise. Despite two sessions with our team utilizing motivational interviewing, T.K. asserted that he did not need residential treatment and that a change of mindset through limited outpatient therapy was all that was necessary for him to improve. T.K.'s mother encouraged him to utilize residential treatment and agreed to look into referral sites for T.K. He cancelled or failed to attend all follow-up appointments with our service; notably, each of these appointments was scheduled by his mother. In a phone follow-up, T.K.'s mother indicated that he reluctantly agreed to visit a treatment programme to explore the possibility of enrolment.
Patients receiving difficult news tend to report that they wish to receive accurate diagnoses with honest information about potential options for treatment (Cleary et al. Reference Cleary, Hunt, Escott and Walter2010). In this case, the treatment team provided its assessment in an empathic manner, although T.K. disagreed with the therapists’ opinion. Because clinicians and patients often disagree about diagnoses, therapy processes, and therapy outcomes, the team chose to view the disagreement as a natural part of managing the therapeutic alliance and ensuring the best outcome for the patient (Safran & Muran, Reference Safran and Muran2002; Bachelor, Reference Bachelor2013). Consequently, a motivational interviewing approach was chosen in order to validate T.K.'s concerns with inpatient therapy, while encouraging a belief in the need for a more intensive treatment option (Miller & Rollnick, Reference Miller and Rollnick2012). This approach, along with the influence of T.K.'s concerned and helpful family members, may have contributed to his willingness to explore a residential treatment facility.
Discussion
There are a number of inconsistencies in the literature regarding the relationship between military service and eating pathology. The above case demonstrates some important ways in which military service may contribute to eating disorder symptoms, especially those of anorexia nervosa. It highlights the importance of the eating environment, as well as social reinforcers in the development of unsafe eating and exercise behaviour, dovetailing well with the cognitive-behavioural conceptualization of anorexia nervosa. Furthermore, this case illustrates lessons in differentially diagnosing anorexia nervosa from other disorders when complex presentations are observed.
T.K. stated that military life directly contributed to his symptoms. In his military units, T.K. was described as being known as the as the most fit among a group of young men and women who exercised regularly. T.K. explained that he exercised above and beyond typical military physical training to maintain this image and was commended for this behaviour by his peers and superiors. He described thriving on this identity and feared that making changes would result in negative judgements from himself and his peers. T.K. also reported that his eating schedule was very structured in the military. He typically could only eat at certain times of the day, usually following exercise. Consequently, he described associating eating with exercise, and beginning to feel compelled to engage in exercise to ‘work off’ calories consumed.
The small literature on anorexia nervosa among current and former servicemen suggests that the stress and fitness requirements of military life may be aetiological factors in the development of eating disorders (McNulty, Reference McNulty1997, Reference McNulty2001; Antzcak & Brininger, Reference Antczak and Brininger2008; Bodell et al. Reference Bodell, Forney, Keel, Gutierrez and Joiner2014; Staten, Reference Staten2013). This case study adds further evidence to this literature, as T.K.'s disordered eating and exercise habits were certainly exacerbated by reinforcement of excessive exercise by fellow service members. Furthermore, this case demonstrates how the scheduled exercise and eating regimen of the military can be a liability for aggravating eating pathology. Eating can become paired with heavy levels of exercise within a context emphasizing self-control (Smith et al. Reference Smith, Klosterbuer and Levine2009). These points fit well with Fairburn and colleagues’ (Reference Fairburn, Shafran and Cooper1999) cognitive-behavioural conceptualization of anorexia nervosa, as T.K. appeared to develop a conditioned relationship between self-control and eating/weight, which was reinforced by the social environment.
Extending this work, animal models of anorexia nervosa have been developed. For instance, rats will increase their level of activity when placed on a restricted feeding schedule and demonstrate the highest levels of activity in anticipation of food presentation (Gelegen et al. Reference Gelegen, Pjetri, Campbell, Collier, Oppelaar and Kas2010; Pérez-Padilla et al. Reference Pérez-Padilla, Magalhães and Pellón2010). Often in rats, this increased activity level leads to a further decrease in feeding (Lett et al. Reference Lett, Grant, Smith and Koh2001), evincing mutually reinforcing maladaptive eating and exercise habits. These findings are consistent with the case presentation outlined above, as well as the cognitive-behavioural theory of anorexia nervosa, which emphasizes functional behavioural relationships between activity, eating, and control over the environment. Thus, the strict eating and exercise routine in the military may contribute to the exacerbation and maintenance of anorexia nervosa symptoms, a possibility that could be examined in future research. Specifically, individuals in weight management groups might be fruitfully compared to military individuals undergoing fitness testing to examine whether the relation between exercise and eating is specific to military life or to diet and exercise programs more generally.
Eating disorders often present in conjunction with other forms of psychopathology (Davidson, Reference Davidson1976; Striegel-Moore et al. Reference Striegel-Moore, Garvin, Dohm and Rosenheck1999; Maguen et al. Reference Maguen, Cohen, Cohen, Madden, Bertenthal and Seal2012), making them difficult to diagnose and treat. T.K., for example, met criteria for anorexia nervosa, OCD, and GAD. In terms of differential diagnosis, we conceptualized his condition as primary anorexia nervosa because most of his obsessions and compulsions centred on eating and exercise and largely accounted for his anxiety (APA, 2013). Although this eating disorder has been shown to be distinct from OCD and GAD in terms of personality and clinical features (Jiménez-Murcia et al. Reference Jiménez-Murcia, Fernández-Aranda, Raich, Alonso, Krug, Jaurrieta, Alvarez-Moya, Labad, Menchon and Vallejo2007), there is considerable overlap of anorexia nervosa with these disorders (APA, 2013). Indeed, there is clear symptom overlap. Individuals with anorexia nervosa experience worry and obsessive thoughts about body image, followed by compensatory restriction, exercise, or purging. Additionally, there may be serotonergic dysfunction and limbic abnormality across anorexia nervosa, OCD, and GAD (Serpell et al. Reference Serpell, Livingstone, Neiderman and Lask2002; Lewin et al. Reference Lewin, Menzel, Strober, Storch and McKay2013), as well as genetic overlap between anorexia nervosa and the other disorders (Dellava et al. Reference Dellava, Kendler and Neale2011).
In the case of T.K., OCD and GAD symptoms clearly contributed to and overlapped with eating disorder symptoms. Indeed, exerting control over exercise and eating helped T.K. to reduce worries and relieve obsessive thoughts. Furthermore, his obsessions with timing and counting led to compulsions to count repetitions during exercise and strictly schedule his meals and workout sessions. However, it was clear that T.K. met all criteria for an eating disorder, including being well below his ideal body weight, having body image disturbances, and fearing weight gain. Further, T.K.'s obsessional thoughts and compulsive behaviours centred on eating and exercise, evincing a primary diagnosis of anorexia nervosa over OCD or GAD. Moreover, according to his reports, T.K.'s eating and exercise behaviours preceded the development of OCD symptoms. Starvation syndrome in individuals with anorexia nervosa may exacerbate OCD symptoms, with these symptoms tending to fade with restoration of healthy weight (Fairburn, Reference Fairburn2008). Consequently, addressing eating pathology was of primary concern in in this case.
Unfortunately, individuals who have an eating disorder and comorbid GAD or OCD typically have worse outcomes than those with an eating disorder only (Crane et al. Reference Crane, Roberts and Treasure2007; Thornton et al. Reference Thornton, Dellava, Root, Lichtenstein and Bulik2011). This consequence may partly be explained by increased perfectionism of those with OCD, resulting in a reduced willingness to make changes (Jiménez-Murcia et al. Reference Jiménez-Murcia, Fernández-Aranda, Raich, Alonso, Krug, Jaurrieta, Alvarez-Moya, Labad, Menchon and Vallejo2007). Similarly, fasting and exercise may reduce anxiety, creating negative reinforcement of anorexia nervosa symptoms in individuals with comorbid GAD (Serpell et al. Reference Serpell, Livingstone, Neiderman and Lask2002). Both of these factors were clearly influential in maintaining T.K.'s eating disorder, as he was perfectionistic with his eating and exercise and gained relief from anxiety symptoms through adherence to his routine.
Another possibility for worse outcomes in individuals with comorbid disorders suggested from this case study is reduced insight about eating disorder symptoms caused by a comorbid condition. Numerous studies suggest worse outcomes for OCD treatment in patients with poor insight (see e.g. Raffin et al. Reference Raffin, Fachel, Ferrão, de Souza and Cordioli2009). T.K. believed that his anorexia nervosa symptoms were the result of his OCD, and that all he needed was a ‘change in mindset’ to improve his body image and eating/exercise behaviours. This belief led him to deny the need for intensive treatment of his eating disorder. The possibility of reduced insight in individuals with comorbid eating and anxiety disorders could be examined in future research.
Summary
T.K.'s case illustrates the importance of a comprehensive case conceptualization, accurate differential diagnosis and prioritizing treatment recommendations to maximize treatment efficacy and patient safety. These factors are especially salient given the elevated mortality risk in those with anorexia nervosa, compared to healthy individuals and those with other eating disorders (Hudson et al. Reference Hudson, Hiripi, Pope and Kessler2007). This case also demonstrates a rare occurrence of anorexia nervosa in a male and a military veteran, and highlights important ways in which military life may contribute to the onset and maintenance of eating disorder symptoms. Finally, this case study illustrates the need for further research into the overlap and distinctions between anorexia nervosa and OCD, as well as the contributions that being a service member makes to each of these disorders.
Ethical standards
The authors followed APA ethical guidelines in completing this manuscript and related activities.
Declaration of Interest
None.
-
• Understand overlap between eating-related and anxiety-related pathologies.
-
• Enhance differential diagnosis of anorexia nervosa, generalized anxiety disorder, and obsessive compulsive disorder.
-
• Develop hypotheses about ways in which military service may contribute to eating pathology in men.
Comments
No Comments have been published for this article.