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Muscle dysmorphia is a subtype of the obsessive mental disorder
body dysmorphic disorder Body dysmorphic disorder (BDD), also known in some contexts as dysmorphophobia, is a mental disorder defined by an overwhelming preoccupation with a perceived flaw in one's physical appearance. In BDD's delusional variant, the flaw is imagined ...
, but is often also grouped with
eating disorders An eating disorder is a mental disorder defined by abnormal eating behaviors that adversely affect a person's health, physical or mental health, mental health. These behaviors may include eating too much food or too little food. Types of eatin ...
.Lee F Monaghan & Michael Atkinson, ''Challenging Myths of Masculinity: Understanding Physical Cultures'' (Surrey:
Ashgate Publishing Ashgate Publishing was an academic book and journal publisher based in Farnham (Surrey, United Kingdom). It was established in 1967 and specialised in the social sciences, arts, humanities and professional practice. It had an American office in ...
, 2014)
p 86
In muscle dysmorphia, which is sometimes called "bigorexia", "megarexia", or "reverse anorexia", the delusional or exaggerated belief is that one's own body is too small, too skinny, insufficiently muscular, or insufficiently lean, although in most cases, the individual's build is normal or even exceptionally large and muscular already.Katharine A Phillips, ''Understanding Body Dysmorphic Disorder: An Essential Guide'' (New York:
Oxford University Press Oxford University Press (OUP) is the publishing house of the University of Oxford. It is the largest university press in the world. Its first book was printed in Oxford in 1478, with the Press officially granted the legal right to print books ...
, 2009), p
50–51
James E Leone, Edward J Sedory & Kimberly A Gray
"Recognition and treatment of muscle dysmorphia and related body image disorders"
''Journal of Athletic Training'', 2005 Oct–Dec;40(4):352–359.
Muscle dysmorphia affects mostly men, particularly those involved in sports where body size or weight are competitive factors, becoming rationales to gain muscle or become leaner. The quest to seemingly fix one's body consumes inordinate time, attention, and resources, as on exercise routines, dietary regimens, and nutritional supplementation, while use of
anabolic steroids Anabolic steroids, also known as anabolic-androgenic steroids (AAS), are a class of drugs that are structurally related to testosterone, the main male sex hormone, and produce effects by binding to the androgen receptor (AR). Anabolic steroids ...
is also common. Other body-dysmorphic preoccupations that are not muscle-dysmorphic are usually present as well. Although likened to
anorexia nervosa Anorexia nervosa (AN), often referred to simply as anorexia, is an eating disorder characterized by Calorie restriction, food restriction, body image disturbance, fear of gaining weight, and an overpowering desire to be thin. Individuals wit ...
, muscle dysmorphia is especially difficult to recognize, since awareness of it is scarce and persons experiencing muscle dysmorphia typically remain healthy looking. The distress and distraction of muscle dysmorphia may provoke absences from school, work, and social settings.Anonymous webpage author
"Muscle dysmorphia"
McCallum Place website, visited 21 May 2016.
Compared to other body dysmorphic disorders, rates of suicide attempts are especially high with muscle dysmorphia. Researchers believe that muscle dysmorphia's incidence is rising, partly due to the recent cultural emphasis on muscular male bodies.Harrison G Pope Jr, Katharine A Phillips & Roberto Olivardia, ''The Adonis Complex: The Secret Crisis of Male Body Obsession'' (New York:
Free Press Freedom of the press refers to legal protections for public communications media. Free Press may also refer to: Publications * ''Free Press'' (CPBF), the journal of the Campaign for Press and Broadcasting Freedom * ''Free Press'' (Malayalam magaz ...
, 2000) p
156
160,197.


Signs and symptoms

Although body dissatisfaction has been found in boys as young as age six, muscle dysmorphia's onset is estimated at usually between ages 18 and 20.McCabe MP & Ricciardelli LA (2004), "Body image dissatisfaction among males across the lifespan: A review of past literature", ''Journal of Psychosomatic Research'' 56(6):675–685. According to ''DSM-5'', muscle dysmorphia is indicated by the diagnostic criteria for body dysmorphic disorder via "the idea that his or her body is too small or insufficiently muscular", and this specifier holds even if the individual is preoccupied with other body areas, too, as is often the case. Further clinical features identified include excessive conduct of efforts to increase muscularity, activities such as dietary restriction,
overtraining Overtraining occurs when a person exceeds their body's ability to recover from strenuous exercise. Overtraining can be described as a point at which a person may have a decrease in performance or plateau as a result of failure to perform at a certa ...
, and injection of growth-enhancing drugs. Persons experiencing muscle dysmorphia generally spend over three hours daily pondering increased muscularity, and may feel unable to limit weightlifting. As in anorexia nervosa, the reverse quest in muscle dysmorphia can be insatiable. Those suffering from the disorder closely monitor their body and may wear multiple clothing layers to make it appear larger. Muscle dysmorphia involves severe distress at having one's body viewed by others. Occupational and social functioning are impaired, and dietary regimes may interfere with these. Patients often avoid activities, people, and places that threaten to reveal their perceived deficiency of size or muscularity. Roughly half of patients have poor or no insight that these perceptions are unrealistic.Cafri G, Olivardia R & Thompson JK (2008), "Symptom characteristics and psychiatric comorbidity among males with muscle dysmorphia", ''Comprehensive Psychiatry'' 49(4):374–379. Patient histories reveal elevated rates of diagnoses of other mental disorders, including eating disorders,
mood disorders A mood disorder, also known as an affective disorder, is any of a group of conditions of mental and behavioral disorder where the main underlying characteristic is a disturbance in the person's mood. The classification is in the ''Diagnostic ...
,
anxiety disorders Anxiety disorders are a group of mental disorders characterized by significant and uncontrollable feelings of anxiety and fear such that a person's social, occupational, and personal functions are significantly impaired. Anxiety may cause phys ...
, and
substance use disorder Substance use disorder (SUD) is the persistent use of drugs despite substantial harm and adverse consequences to self and others. Related terms include ''substance use problems'' and ''problematic drug or alcohol use''. Along with substance-ind ...
,Hitzeroth V, Wessels C, Zungu-Dirwayi N, Oosthuizen P, & Stein DJ (2001), "Muscle dysmorphia: A South African sample", ''Psychiatry and Clinical Neurosciences'' 55(5):521–523. as well as elevated rates of suicide attempts.


Risk factors

Although muscle dysmorphia's development is unclear, several risk factors have been identified.


Trauma and bullying

Versus the general population, persons manifesting muscle dysmorphia are more likely to have experienced or observed traumatic events like sexual assault or domestic violence, or to have sustained adolescent
bullying Bullying is the use of force, coercion, Suffering, hurtful teasing, comments, or threats, in order to abuse, aggression, aggressively wikt:domination, dominate, or intimidate one or more others. The behavior is often repeated and habitual. On ...
and ridicule for actual or perceived deficiencies such as smallness, weakness, poor athleticism, or intellectual inferiority.Edwards C, Molnar G & Tod D (2017)
"Searching for masculine capital: Experiences leading to high drive for muscularity in men"
''Psychology of Men & Masculinity'' 18(4)"361–371.'
Increased body mass may seem to reduce the threat of further mistreatment.Olivardia R (2001), "Mirror, mirror on the wall, who's the largest of them all? the features and phenomenology of muscle dysmorphia", ''Harvard Review of Psychiatry'' 9(5):254–259.


Sociopsychological traits

Low
self-esteem Self-esteem is confidence in one's own worth, abilities, or morals. Self-esteem encompasses beliefs about oneself (for example, "I am loved", "I am worthy") as well as emotional states, such as triumph, despair, pride, and shame. Smith and Macki ...
is associated with higher levels of body dissatisfaction and of muscle dysmorphia.Grieve FG (2007), "A conceptual model of factors contributing to the development of muscle dysmorphia", ''Eating Disorders: The Journal of Treatment & Prevention'' 15(1):63–80.
Vulnerable narcissism Narcissistic personality disorder (NPD) is a personality disorder characterized by a life-long pattern of exaggerated feelings of self-importance, an excessive need for admiration, and a diminished ability to empathize with other people's ...
has also been linked to heightened muscle dysmorphia risk. Increased body size or muscularity may seem to enhance the masculine identity.


Media exposure

As Western media emphasize physical attractiveness, some marketing campaigns now exploit male body-image insecurities.Cohane GH, & Pope HG Jr (2001), "Body image in boys: A review of the literature", ''International Journal of Eating Disorders'' 29(4):373–379.Mangweth B, Pope HGJ, Kemmler G, Ebenbichler C, Hausmann A, et al. (2001), "Body image and psychopathology in male bodybuilders", ''Psychotherapy and Psychosomatics'' 70(1):38–43.Pope HG Jr, Olivardia R, Borowiecki JJ 3rd & Cohane GH (2001)
"The growing commercial value of the male body: A longitudinal survey of advertising in women's magazines"
''Psychotherapy and Psychosomatics'' 70(4):189–192.
Leit RA, Pope HG Jr, & Gray JJ (2001), "Cultural expectations of muscularity in men: The evolution of playgirl centerfolds", ''International Journal of Eating Disorders'' 29(1):90–93. Since the 1980s, the number of fitness magazines and of partially undressed, muscular men in advertisements have increased. Such media provoke bodily comparisons and pressure individuals to conform, yet increase the gap between men's perceptions of their own muscularity versus their desired muscularity.Leit RA, Gray JJ, & Pope HG Jr (2002), "The media's representation of the ideal male body: A cause for muscle dysmorphia?", ''International Journal of Eating Disorders'' 31(3):334–338. In college-aged men, a strong predictor of a muscularity quest is internalization of the idealized male bodies depicted in media.Daniel S & Bridges SK (2010)m The drive for muscularity in men: Media influences and objectification theory, ''Body Image'' 7(1):32–38.Parent MC & Moradi B (2011), "His biceps become him: A test of objectification theory's application to drive for muscularity and propensity for steroid use in college men", ''Journal of Counseling Psychology'' 58(2):246–256.


Athletic participation

Athletes tend to share some psychological factors that may predispose to muscle dysmorphia, factors including high levels of competitiveness, need for control, and perfectionism, and athletes tend to be more critical of their own bodies and body weight.Davis C & Cowles M (1991), "Body image and exercise: A study of relationships and comparisons between physically active men and women", ''Sex Roles'' 25(1–2):33–44. Athletes who also fail to meet their sports performance goals may escalate efforts to modify their builds, efforts that overlap those of muscle dysmorphia. Involvement in sports where size, strength, or weight, whether higher or lower, imply competitive advantage associates with muscle dysmorphia.Chung B (2001)
"Muscle dysmorphia: A critical review of the proposed criteria"
''Perspect Biol Med'' 44(4):565–574.
Athletic ideals reinforce the social ideal of muscularity. Conversely, those already disposed to muscle dysmorphia may be more likely to participate in such sports.


Sexual orientation

It has been observed that
men who have sex with men Men who have sex with men (MSM) are men who engage in sexual activity with other men, regardless of their sexual orientation or sexual identity. The term was created by epidemiologists in the 1990s, to better study and communicate the spre ...
(MSM) have a unique relationship with the development of muscle dysmorphia symptoms. MSM are at increased risk for experiencing internalized
heterosexism Heterosexism is a system of attitudes, bias, and discrimination in favor of heterosexuality and heterosexual relationships. According to Elizabeth Cramer, it can include the belief that all people are or should be heterosexual and that hetero ...
, which can lead to dissatisfaction with one's body and the internalizing of standards for attractiveness. Men who conform to conventional ideals of masculinity often report increased stress from not meeting the imposed standard of a masculine and muscular body. In a sample of 2,733 MSM who reported body dissatisfaction, only one in every 10 reported feeling no dissatisfaction with their muscularity. Dissatisfaction with muscularity had a stronger relationship with quality of life impairment when compared to dissatisfaction with body fat, height, and penis size. Those who identify as a
sexual minority Sexual and gender minorities (SGM) comprise individuals whose sexual identity, sexual orientation, sexual behavior, or gender identity differ from the majority of the surrounding society. Sexual minorities include lesbians, gay men, bisexual peo ...
are at increased risk for victimization due to their identity. Having been a victim of homophobic bullying is associated with more symptoms of muscle dysmorphia. A possible cause for this relationship can be the increased feelings of paranoid ideation that a MSM individual can experience following homophobic bullying.


Diagnosis


Treatment

Treatment of muscle dysmorphia can be stymied by a patient's unawareness that the preoccupation is disordered or by avoidance of treatment. Scientific research on treatment of muscle dysmorphia is limited, the evidence largely in
case reports In medicine, a case report is a detailed report of the symptoms, signs, diagnosis, treatment, and follow-up of an individual patient. Case reports may contain a demographic profile of the patient, but usually describe an unusual or novel occurrence ...
and anecdotes, and no specific protocols have been validated. Still, evidence supports the efficacy of family-based therapy,
cognitive behavioural therapy Cognitive behavioral therapy (CBT) is a form of psychotherapy that aims to reduce symptoms of various mental health conditions, primarily depression, PTSD, and anxiety disorders. Cognitive behavioral therapy focuses on challenging and chang ...
, and pharmacotherapy with
selective serotonin reuptake inhibitor Selective serotonin reuptake inhibitors (SSRIs) are a class of drugs that are typically used as antidepressants in the treatment of major depressive disorder, anxiety disorders, and other psychological conditions. SSRIs primarily work by blo ...
s. Also limited is research on
prognosis Prognosis ( Greek: πρόγνωσις "fore-knowing, foreseeing"; : prognoses) is a medical term for predicting the likelihood or expected development of a disease, including whether the signs and symptoms will improve or worsen (and how quickly) ...
of the untreated.


Prevalence

Prevalence estimates for muscle dysmorphia have greatly varied, ranging from 1% to 54% of men in the studied samples. Samples of gym members, weightlifters, and bodybuilders show higher prevalence than do samples from the general population. Rates even higher have been found among users of anabolic steroids.Gruber AJ & Pope HG (1999), "Compulsive weight lifting and anabolic drug abuse among women rape victims", ''Comprehensive Psychiatry'' 40(4):273–277. The disorder is rare in women but does occur, and has been noted especially in female bodybuilders who have experienced sexual assault. Muscle dysmorphia has been identified in China, South Africa, and Latin America.Ung EK, Fones CS, & Ang AW (2000), Muscle dysmorphia in a young Chinese male, ''Annals of the Academy of Medicine'' (Singapore) 29(1):135–137.Soler PT, Fernandes HM, Damasceno VO, et al. (2013), "Vigorexy and levels of exercise dependence in gym goers and bodybuilders", ''Revista Brasileira de Medicina do Esporte'' 19(5):343–348.Rutsztein G, Casguet A, Leonardelli E, López P, Macchi M, Marola ME & Redondo G (2004), "Imagen corporal en hombres y su relación con la dismorfia muscular", ''Revista Argentina De Clínica Psicológica'' 13(2):119–131. Nonwestern populations less exposed to western media show lower rates of muscle dysmorphia.Yang CJ, Gray P, & Pope HG Jr, (2005), "Male body image in Taiwan versus the west: Yanggang Ahiqi meets the Adonis complex", ''The American Journal of Psychiatry'' 162(2):263–269.


History

Muscle dysmorphia was first conceptualized by healthcare professionals in the late 1990s.Pope HG, Katz DL & Hudson JI (1993), "Anorexia nervosa and 'reverse anorexia' among 108 male bodybuilders", ''Comprehensive Psychiatry'' 34(6):406–409.Pope HG Jr, Gruber AJ, Choi P, Olivardia R & Phillips KA (1997), "Muscle dysmorphia: An underrecognized form of body dysmorphic disorder", ''Psychosomatics: Journal of Consultation and Liaison Psychiatry'' 38(6):548–557.Tod D, Edwards C & Cranswick I (2016)
"Muscle dysmorphia: Current insights"
''Psychology Research and Behavior Management'' 9:179–188.
In 2016, 50% of peer-reviewed articles on it had been published in the prior five years. Although muscle dysmorphia was initially viewed as
anorexia nervosa Anorexia nervosa (AN), often referred to simply as anorexia, is an eating disorder characterized by Calorie restriction, food restriction, body image disturbance, fear of gaining weight, and an overpowering desire to be thin. Individuals wit ...
's inverse—questing to be large and muscular instead of small and thin—later researchers fit the subjective experience to
body dysmorphic disorder Body dysmorphic disorder (BDD), also known in some contexts as dysmorphophobia, is a mental disorder defined by an overwhelming preoccupation with a perceived flaw in one's physical appearance. In BDD's delusional variant, the flaw is imagined ...
. The
American Psychiatric Association The American Psychiatric Association (APA) is the main professional organization of psychiatrists and trainee psychiatrists in the United States, and the largest psychiatric organization in the world. It has more than 39,200 members who are in ...
recognized muscle dysmorphia with the fifth edition of the ''
Diagnostic and Statistical Manual of Mental Disorders The ''Diagnostic and Statistical Manual of Mental Disorders'' (''DSM''; latest edition: ''DSM-5-TR'', published in March 2022) is a publication by the American Psychiatric Association (APA) for the classification of mental disorders using a com ...
'', which classifies it under body dysmorphic disorder.American Psychiatric Association
"Body dysmorphic disorder"
''Diagnostic and Statistical Manual of Mental Disorders'', Fifth Edition (Arlington, VA: American Psychiatric Association, 2013).
Muscle dysmorphia is absent from the ''
International Statistical Classification of Diseases and Related Health Problems The International Classification of Diseases (ICD) is a globally used medical classification that is used in epidemiology, health management and clinical diagnostics, diagnosis. The ICD is maintained by the World Health Organization (WHO), which ...
present edition, the tenth, published in 1992.dos Santos Filho CA, Tirico PP, Stefano SC, Touyz SW & Claudino AM (2016), "Systematic review of the diagnostic category muscle dysmorphia", ''Australian and New Zealand Journal of Psychiatry'' 50(4):322–333.


Reclassifications

Muscle dysmorphia's classification has been widely debated, and alternative ''DSM'' classifications have been proposed. *Eating disorder: Many of muscle dysmorphia's traits overlap with those of eating disorders,Griffiths S, Mond JM, Murray SB & Touyz S (2015), "Positive beliefs about anorexia nervosa and muscle dysmorphia are associated with eating disorder symptomatology", ''Australian and New Zealand Journal of Psychiatry'' 49(9):812–820.Murray SB & Touyz SW (2013), "Muscle dysmorphia: Towards a diagnostic consensus", ''Australian and New Zealand Journal of Psychiatry'' 47(3):206–207. including focus on body weight, shape, and modification,Russell J (2013), Commentary on: "Muscle Dysmorphia: Towards a diagnostic consensus". ''Australian and New Zealand Journal of Psychiatry'' 47(3):284–285. whereas body dysmorphic disorder otherwise usually lacks such dietary and exercise components. Also, persons experiencing muscle dysmorphia tend to score high on the
Eating Attitudes Test The Eating Attitudes Test (EAT, EAT-26), created by David Garner, is a widely used 26-item, standardized self-reported questionnaire of symptoms and concerns characteristic of eating disorders. The EAT is useful in assessing "eating disorder ris ...
and
Eating Disorder Inventory The Eating Disorder Inventory (EDI) is a self-report questionnaire used to assess the presence of eating disorders, (a) anorexia nervosa both restricting and binge-eating/purging type; (b) bulimia nervosa; and (c) eating disorder not otherwise sp ...
,Nieuwoudt JE, Zhou S, Coutts RA & Booker R (2012), "Muscle dysmorphia: Current research and potential classification as a disorder", ''Psychology of Sport and Exercise'' 13(5):569–577.Behar R & Molinari D (2010), "Muscle dysmorphia, body image and eating behaviors in two male populations", ''
Revista Médica de Chile ''Revista Médica de Chile'' is a peer-reviewed scientific journal covering aspects of internal medicine. It is published by the Sociedad Médica de Santiago and the editor-in-chief is Dr. Luis Michea. The journal was established in 1872. Abstrac ...
'' 138(11):1386–1394.
while muscle dysmorphia and anorexia nervosa share diagnostic crossover.Murray SB, Rieger E, Touyz SW & De la GG (2010), "Muscle dysmorphia and the DSM-V conundrum: Where does it belong? A review paper", ''International Journal of Eating Disorders'' 43(6):483–491. Muscle dysmorphia and disordered eating correlate more to each other than either correlates to body dysmorphic disorder.Pope CG, Pope HG, Menard W, Fay C, Olivardia R, & Phillips KA (2005), "Clinical features of muscle dysmorphia among males with body dysmorphic disorder: ''Body Image'' 2(4):395–400.Foster AC, Shorter GW, & Griffiths MD (2015), "Muscle dysmorphia: Could it be classified as an addiction to body image?", ''J Behav Addict'' 4(1):1–5. Treatment for eating disorders may also be effective for muscle dysmorphia.Greenberg ST & Schoen EG (2008), "Males and eating disorders: Gender-based therapy for eating disorder recovery", ''Professional Psychology: Research and Practice'' 39(4):464–471. * Behavioral addiction: Some researchers seek muscle dysmorphia's reclassification as a
behavioral addiction Behavioral addiction, process addiction, or non-substance-related disorder is a form of addiction that involves a compulsive behavior, compulsion to engage in a rewarding non-Chemical substance, substance-related behavior – sometimes called a n ...
. Muscle dysmorphia's effort to maintain
body image Body image is a person's thoughts, feelings and perception of the aesthetics or sexual attractiveness of their own body. The concept of body image is used in several disciplines, including neuroscience, psychology, medicine, psychiatry, psycho ...
is enacted through activities such as exercise, diet, and related shopping, which may cause conflicts with others. Moreover, compulsive muscle building and dietary restriction can escalate these conflicts. Further, abstinence from these activities can provoke withdrawal symptoms, returning the individual to compulsive behavior.


See also

*
Anorexia athletica Anorexia athletica (sports anorexia), also referred to as hyper-gymnasia, is an eating disorder characterized by excessive and compulsive exercise. An athlete with sports anorexia tends to overexercise, to give themselves a sense of having control ...
*
Exercise bulimia Exercise bulimia is a subset of the psychological disorder called bulimia in which a person is compelled to exercise in an effort aimed at burning the calories of food energy and fat reserves to an excessive level that negatively affects their ...


Notes

{{reflist Bodybuilding Culture-bound syndromes Somatic symptom disorders Eating disorders