Unveiling Gender Differences in Psychological Well-being and Rational Beliefs Among Eating Disorder Patients

Eating disorders (EDs) are complex and difficult-to-treat psychiatric conditions. They are commonly characterized by high comorbidity rates with other psychiatric disorders, adverse outcomes including high treatment drop-out and relapse rates, as well as low rates of full remission (Wildes et al., 2011; Keski-Rahkonen & Mustelin, 2016; Cooper & Dalle Grave, 2017; Udo & Grilo, 2019; Tomba et al., 2019). The promotion of psychological well-being and adaptive thinking is a crucial aspect in the treatment of psychiatric illnesses and EDs in particular (de Vos et al., 2018; Tomba et al., 2014, 2017; Tecuta et al., 2023). Recovery is indeed achieved not only through alleviation of the negative aspects of the illness but also through an enhancement of the positive functional ones (Ryff & Singer, 2000), in line with the dual continua model according to which distress and positive mental well-being operate on distinct yet related continua (Keyes, 2002).

Lack of self-acceptance in particular is defined as holding a positive regard towards oneself (Ryff & Singer, 2008), a characteristic that is also associated with self-actualization (Maslow, 1968), optimal functioning (Rogers, 1961), and maturity (Allport, 1961). It is considered across the theoretical psychological literature as a fundamental nucleus of mental health (Jahoda, 1958) and has been hypothesized to play a central role in ED symptomatology. Empirically, the clinical relevance of self-acceptance is supported in the ED literature as an impaired aspect of the disorder (Tomba et al., 2014, 2017; Tecuta et al., 2023) and as a fundamental criterion for recovery from EDs (de Vos et al., 2018). Self-acceptance has indeed been considered a fundamental target for effective treatments for quite some time (Wilson, 1996), with Fairburn’s transdiagnostic ED model and enhanced cognitive-behavioral therapy (CBT-E; Fairburn et al., 2003; Fairburn, 2008) considering as central to the development and maintenance of EDs a core negative self view in the form of low self-esteem. Individuals with EDs indeed attempt to obtain a detrimental sense of self-worth through their ability to control their eating habits, shape and weight, thus activating a cycle of alternating dietary restriction and disinhibition. However, the associations between self-acceptance and the ED symptomatology so far have been examined only in female ED samples (Cooper & Proudfoot, 2013; Tomba et al., 2014; Atwood & Friedman, 2020), while gender differences remain unknown.

The available studies on ED gender differences have indeed followed the negatively-skewed historical trend of the medical and psychiatric model in focusing on dysfunctional aspects, such as ED-specific psychopathological differences. The available evidence supports a primarily lower illness severity in ED male patients compared to females (Dahlgren et al., 2017; Jennings & Phillips, 2017; Nevonen & Broberg, 2006; Stanford & Lemberg, 2012; Smith et al., 2017) and different associations with over-evaluation of weight and shape where females exhibit an internalization of the thin ideal while males pursue muscularity (Pope et al., 2000; Gorrell & Murray, 2019; Nagata et al., 2019). However, differences in self-acceptance understood as both a domain of positive functioning within Ryff’s (1989) model of psychological well-being and as an adaptive belief concerning the self (David et al., 2013), remain unknown.

Given the rising number of males affected by EDs (Mitchison et al., 2014; Mitchison & Mond, 2015; Gorrell & Murray, 2019) and the paucity of research on positive and adaptive psychological components in ED male patients, the current study’s aims are to compare male ED patients and healthy male controls and male and female ED patients in self-acceptance understood as both a domain of psychological well-being (PWB) in Ryff’s model (1989) and as a rational belief (Ellis, 1958; David et al., 2013). As PWB dimensions significantly correlate with each other (Ryff, 1989), and since adaptive rational beliefs also commonly overlap and correlate (DiGiuseppe et al., 2018), the groups will also be compared in PWB dimensions of positive relations with others, personal-growth, environmental mastery, purpose in life, and autonomy and in adaptive rational beliefs of frustration tolerance and realistic thinking (Ellis, 1958). Moreover, correlational analyses between rational beliefs and PWB dimensions will be conducted separately for male and female ED patients.

The present study was approved by the appropriate University Bioethics Committee and Department of Psychology Ethics Committee with protocol number 68,444 on May 10th 2018 of University of Bologna. All individual participants gave their informed consent to participate in the study.

Twenty-seven male participants from the general population matched for age constituted the control sample for male ED patients, with a mean age of 30.15 ± 11.11 years, which did not differ significantly from the male patient sample (t(41) = 1.92, p = 0.06). Most of the control participants were single (74.1%), had a degree (77.8%) and were currently students (55.6%). Control participants did not differ significantly in education (p = 0.06), occupation (p = 0.12) and marital status (p = 0.4) compared to the male patient sample.

Interest in the role of positive psychological functioning in the ED field is growing (Tomba et al., 2014, 2017; de Vos et al., 2018), together with the interest in understanding gender differences in the ED population to improve inclusiveness in their treatment (Smith et al., 2017; Gorrell & Murray, 2019; Nagata et al., 2019). Previous works underscored how a paucity of optimal and positive functioning is correlated with ED symptomatology independently of the severity of the disorder (Tomba et al., 2014). To the best of our knowledge, this is the first study investigating the differences between ED male patients and controls and between male and female ED patients in self-acceptance and correlated domains of positive functioning and adaptive beliefs. It is also the first study investigating the correlations between positive functioning in terms of adaptive beliefs and psychological well-being separately for male and female ED patients.

Coming to our hypotheses concerning self-acceptance specifically, when comparing male ED patients to male general population controls, the patient group showed lower levels of self-acceptance, even though this difference was not significant neither in terms of self-acceptance as a dimension of psychological well-being conceptualized by Ryff (1989) nor as a form of adaptive and rational thinking according to Ellis (1958).

Regarding overall psychological well-being, while data in the literature on male ED patients well-being is lacking, the current study’s results pertaining to controlled comparisons are in line with previous findings on other mixed-gender psychiatric populations in which impaired levels of psychological well-being dimensions compared to healthy controls emerged (Rafanelli et al., 2000; Fava et al., 2001). Indeed, significant impairments have been detected in the domains of PWB environmental mastery, personal growth, purpose in life, and self-acceptance in remitted patients with panic disorders (Fava et al., 2001) and in all PWB dimensions in patients with affective disorders (Rafanelli et al., 2000) compared to healthy controls.

Regarding the controlled comparisons in Ellis’s rational beliefs between male ED patients and male general population controls, previous studies in female samples had uncovered significant differences between ED patients and controls in positive core beliefs and self-schemas (Stein & Corte, 2007; Cooper & Proudfoot, 2013). Our study however, did not find significant differences in males. Nonetheless, mean scores of rational adaptive beliefs were lower in male ED patients, but the difference did not reach statistical significance, possibly due to the lack of statistical power as sample sizes for males were relatively small. Another possible reason for a lack of significant findings in males pertains to the use of the ABS-2 in which all measured cognitive constructs are confounded and highly correlated, with items that include wording about both the cognitive process and content reflecting IBs and RBs about achievement versus failure, approval versus rejection, and comfort versus discomfort. A measure of IBs and RBs specifically focused on self-accepting one’s body and eating patterns might have yielded more meaningful results.

In fact, considering correlational analyses, results in male patients showed that self-acceptance, understood as a rational belief of the ABS-2, was strongly and significantly associated with environmental mastery, a dimension which in ED male patients compared to controls was compromised, along with personal growth and positive relations dimensions. This result is particularly important, as a lack of environmental mastery, together with a sense of subjective incompetence, plays a central role in the ED symptomatology and treatment response (albeit in female patients) (Tecuta & Tomba, 2018). In other words, male ED patients in the current study reported greater difficulties in managing everyday affairs and in changing or improving the surrounding environment, as well as in developing new attitudes or behaviors in response to life challenges and in creating trusting relationships with others (Ryff & Singer, 1996) aspects that in turn correlated with self-acceptance in ED male patients.

Concerning gender differences in the patient sample, greater impairment in self-acceptance, dependent on symptomatology, was observed in female patients, in line with previous studies (Tomba et al., 2014, 2017). Self-acceptance as a rational belief was also significantly associated with all PWB-dimensions in female ED patients, in line with a previous study in which both PWB-self-acceptance and cognitive balance given by greater endorsement of rational beliefs, represented a central node in the network symptomatology of ED female patients (Tecuta et al., 2023). Significant gender differences within the ED group emerged also in in terms of other psychological well-being domains. In particular, male and female ED patients showed differentially compromised PWB dimensions, with males exhibiting more compromised levels of self-growth and positive relations with others and with females exhibiting more compromised levels of autonomy and self-acceptance, coherent with previous studies conducted in the general population (Ruini et al., 2003). However, when controlling for EDI-3 general psychological maladjustment, only the gender differences on self-growth and positive relations with others remained significant for males. Individuals with low levels of self-growth have a feeling of “personal stagnation” and generally feel bored and uninterested with life. Despite the lack of previous studies in ED clinical populations, this finding is in line with studies in the general population in which males scored lower than females in this PWB dimension (Ryff & Keyes, 1995; Matud et al., 2019), as well as with studies in which healthy men showed worse self-actualization, a psychological construct that has been assimilated to the one of personal growth (Ryff & Singer, 2008; Okech & Chambers, 2012). Individuals with lower scores in positive relations with others have few close ones and find it difficult to be warm and open, therefore finding themselves isolated and frustrated in interpersonal relationships (Ryff & Keyes, 1995). Our finding that male ED patients score lower than females in positive relations with others is in line with previous studies in the general population (Ryff & Singer, 1995; Ahrens & Ryff, 2006; Karasawa et al., 2011; Matud et al., 2019). The impairment showed by ED male patients in positive relations with others is also in line with findings from qualitative studies showing that psychological problems in male ED patients often manifest as self-isolation and that the enjoyment of social life is a relevant element in the recovery process (Räisänen & Hunt, 2014; Björk et al., 2012). Due to social and cultural expectations, male patients indeed exhibit greater difficulties in disclosing negative emotions and distress, leading to a lack of social support as found in other clinical populations dealing with anxiety, depression and psychosis, in which male patients also showed a greater impairment in social functioning compared to their female counterparts (Grossman et al., 2006; Køster et al., 2008; Scott & Collings, 2010; Derdikman-Eiron et al., 2011). Furthermore, the lower scores found in male ED patients in positive relations with others might be accentuated by the double stigma they experience deriving from having a psychiatric disorder which is additionally recognized as a female-specific disorder (Weltzin et al., 2005; Dearden & Mulgrew, 2013; Muise et al., 2003; Murray et al., 2016).

In terms of rational beliefs, male ED patients exhibited greater levels of self-acceptance and frustration tolerance, albeit dependent on ED-related psychopathology, as the findings lost significance once EDI-3 general psychological maladjustment was accounted for. Indeed, female ED patients exhibited more severe psychopathology compared to male ED patients, confirming previous findings on eating symptomatology in healthy individuals (Smith et al., 2017) and in patients (Dahlgren et al., 2017; Jennings & Phillips, 2017; Nevonen & Broberg, 2006; Stanford & Lemberg, 2012; Smith et al., 2017). Greater ED psychopathology is significantly associated with worse self-acceptance, as found in female ED patients (Tomba et al., 2014). Moreover, greater ED severity is generally associated with more severe emotion regulation difficulties (Anestis et al., 2007; Lavender et al., 2015; Monell et al., 2018), an aspect that might overlap conceptually with frustration intolerance, which is also defined as a difficulty in accepting and tolerating difficult emotions (Harrington, 2007).