Muscle dysmorphia

Muscle dysmorphia is a subtype of the obsessive mental disorder body dysmorphic disorder, but is often also grouped with eating disorders.[1][2] 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.[1][3]

Muscle dysmorphia affects mostly males, particularly those involved in sports where body size or weight are competitive factors, becoming rationales to gain muscle or become leaner.[3] 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 is also common.[1][3] Other body-dysmorphic preoccupations that are not muscle-dysmorphic are usually present as well.[1]

Although likened to anorexia nervosa,[2][4] muscle dysmorphia is especially difficult to recognize, since awareness of it is scarce and persons experiencing muscle dysmorphia typically remain healthy looking.[3] The distress and distraction of muscle dysmorphia provoke absences from school, work, and social settings.[1][5] Compared to other body dysmorphic disorders, rates of suicide attempts are especially high with muscle dysmorphia.[1] Researchers believe that muscle dysmorphia's incidence is rising, partly due to the recent cultural emphasis on muscular male bodies.[3][6]

Signs and symptoms

Although body dissatisfaction has been found in males as young as age six, muscle dysmorphia's onset is estimated at usually between ages 18 and 20.[7][8] 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.[9]

Further clinical features identified include excessive conduct of efforts to increase muscularity, activities such as dietary restriction, over-exercise, and injection of growth-enhancing drugs.[10] Persons experiencing muscle dysmorphia generally spend over three hours daily pondering increased muscularity, and may feel unable to limit weightlifting.[7] As in anorexia nervosa, the reverse quest in muscle dysmorphia can be insatiable.[11] Those suffering from the disorder closely monitor their body and may wear multiple clothing layers to make it appear larger.[7]

Muscle dysmorphia involves severe distress at having one's body viewed by others.[10] Occupational and social functioning are impaired, and dietary regimes may interfere with these.[7] Patients often avoid activities, people, and places that threaten to reveal their perceived deficiency of size or muscularity.[7] Roughly half of patients have poor or no insight that these perceptions are unrealistic.[7][12] Patient histories reveal elevated rates of diagnoses of other mental disorders, including eating disorders, mood disorders, anxiety disorders, and substance use disorder,[12][13][14] as well as elevated rates of suicide attempts.[7]

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,[7][15] or to have sustained adolescent bullying and ridicule for perceived deficiencies such as smallness, weakness, poor athleticism, or intellectual inferiority.[7][16] Increased body mass may seem to reduce the threat of further mistreatment.[7][17]

Sociopsychological traits

Low self-esteem associates with higher levels of body dissatisfaction and of muscle dysmorphia.[18] Increased body size or muscularity may seem to enhance the masculine identity.[7]

Media exposure

As Western media emphasize physical attractiveness, some marketing campaigns now exploit male body-image insecurities.[19][20][21][22] Over the past 20 years, the number of fitness magazines and of partially undressed, muscular men in advertisements have increased.[18][17] Such media provoke bodily comparisons and pressure individuals to conform,[18] yet increase the gap between men's perceptions of their own muscularity versus their desired muscularity.[23] In college-aged men, a strong predictor of a muscularity quest is internalization of the idealized male bodies depicted in media.[24][25]

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,[18] and athletes tend to be more critical of their own bodies and body weight.[26] Athletes who also fail to their performance goals may escalate efforts to modify their builds, efforts that overlap those of muscle dysmorphia.[3] Involvement in sports where size, strength, or weight, whether higher or lower, imply competitive advantage associates with muscle dysmorphia.[19][10][27] Athletic ideals reinforce the social ideal of muscularity.[18] Conversely, those already disposed to muscle dysmorphia may be more likely to participate in such sports.[3]

Treatment

Treatment of muscle dysmorphia can be stymied by a patient's unawareness that the preoccupation is disordered or by avoidance of treatment.[3] Scientific research on treatment of muscle dysmorphia is limited, the evidence largely in case reports and anecdotes,[7] and no specific protocols have been validated.[3] Still, evidence supports the efficacy of family-based therapy, cognitive behavioural therapy, and pharmacotherapy with selective serotonin reuptake inhibitors.[7] Also limited is research on prognosis of the untreated.[7]

Prevalence

Prevalence estimates for muscle dysmorphia have greatly varied, ranging from 1% to 54% of men in the studied samples.[7] Samples of gym members, weightlifters, and bodybuilders show higher prevalence than do samples from the general population.[7] Rates even higher have been found among users of anabolic steroids.[15][28] The disorder is rare in women but does occur, and has been noted especially in female bodybuilders who have experienced sexual assault.[7][15] Crossing cultures, muscle dysmorphia has been identified in China, South Africa, and Latin America.[14][29][30][31][32] Nonwestern populations less exposed to western media show lower rates of muscle dysmorphia.[33]

History

Muscle dysmorphia was first conceptualized by healthcare professionals in the late 1990s.[34][10][7] In 2016, 50% of peer-reviewed articles on it had been published in the prior five years.[7]

Although muscle dysmorphia was initially viewed as anorexia nervosa's inverse—questing to be large and muscular instead of small and thin[34]—later researchers fit the subjective experience to body dysmorphic disorder.[10] (Some debate continues.)

The American Psychiatric Association recognized muscle dysmorphia with the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders. This DSM-5, published in 2013, classifies it under body dysmorphic disorder.[9] Muscle dysmorphia is absent from the International Statistical Classification of Diseases and Related Health Problems' present edition, the tenth, published in 1992.[28]

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,[7][35][36] including focus on body weight, shape, and modification,[37] whereas body dysmorphic disorder otherwise usually lacks such dietary and exercise components.[36] Also, persons experiencing muscle dysmorphia tend to score high on the Eating Attitudes Test and Eating Disorder Inventory,[38][32] while muscle dysmorphia and anorexia nervosa share diagnostic crossover.[39] Muscle dysmorphia and disordered eating correlate more to each other than either correlates to body dysmorphic disorder.[13][40] Treatment for eating disorders may also be effective for muscle dysmorphia.[41]
• Behavioral addiction: Some researchers seek muscle dysmorphia's reclassification as a behavioral addiction.[7][36][40][37] Muscle dysmorphia's effort to maintain body image is enacted through activities such as exercise, diet, and related shopping,[40] which may cause conflicts with others.[40] Moreover, compulsive muscle building and dietary restriction can escalate these conflicts.[40] Further, abstinence from these activities can provoke withdrawal symptoms, returning the individual to compulsive behavior.[35][40]

Notes

1. Katharine A Phillips, Understanding Body Dysmorphic Disorder: An Essential Guide (New York: Oxford University Press, 2009), pp 50–51.
2. Lee F Monaghan & Michael Atkinson, Challenging Myths of Masculinity: Understanding Physical Cultures (Surrey: Ashgate, 2014), p 86.
3. 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.
4. Anthony J Cortese, Provocateur: Images of Women and Minorities in Advertising, 4th edn (London: Rowman & Littlefield, 2016), p 94.
5. Anonymous webpage author, "Muscle dysmorphia", McCallum Place website, visited 21 May 2016.
6. Harrison G Pope Jr, Katharine A Phillips & Roberto Olivardia, The Adonis Complex: The Secret Crisis of Male Body Obsession (New York: Free Press, 2000) pp 156, 160,197.
7. Tod D, Edwards C & Cranswick I (2016), "Muscle dysmorphia: Current insights", Psychology Research and Behavior Management 9:179–188.
8. 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.
9. American Psychiatric Association, "Body dysmorphic disorder", Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (Arlington, VA: American Psychiatric Association, 2013).
10. 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.
11. Mosley PE (2009). "Bigorexia: Bodybuilding and muscle dysmorphia". European Eating Disorders Review. 17 (3): 191–198. doi:10.1002/erv.897. ISSN 1099-0968. PMID 18759381.
12. Cafri G, Olivardia R & Thompson JK (2008), "Symptom characteristics and psychiatric comorbidity among males with muscle dysmorphia", Comprehensive Psychiatry 49(4):374-379.
13. 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.
14. 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.
15. Gruber AJ & Pope HG (1999), "Compulsive weight lifting and anabolic drug abuse among women rape victims", Comprehensive Psychiatry 40(4):273-277.
16. 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.'
17. 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.
18. 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.
19. Cohane GH, & Pope HG Jr (2001), "Body image in boys: A review of the literature", International Journal of Eating Disorders 29(4):373-379.
20. 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.
21. 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.
22. 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.
23. 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.
24. Daniel S & Bridges SK (2010)m The drive for muscularity in men: Media influences and objectification theory, Body Image 7(1):32-38.
25. 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.
26. 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.
27. Chung B (2001), "Muscle dysmorphia: A critical review of the proposed criteria", Perspect Biol Med 44(4):565–574.
28. 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.
29. 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.
30. 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.
31. 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.
32. Behar R & Molinari D (2010), "Muscle dysmorphia, body image and eating behaviors in two male populations", Revista Médica de Chile 138(11):1386-1394.
33. 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.
34. Pope HG, Katz DL & Hudson JI (1993), "Anorexia nervosa and 'reverse anorexia' among 108 male bodybuilders", Comprehensive Psychiatry 34(6):406-409.
35. 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.
36. Murray SB & Touyz SW (2013), "Muscle dysmorphia: Towards a diagnostic consensus", Australian and New Zealand Journal of Psychiatry 47(3):206-207.
37. Russell J (2013), Commentary on: "Muscle Dysmorphia: Towards a diagnostic consensus". Australian and New Zealand Journal of Psychiatry 47(3):284-285.
38. 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.
39. 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.
40. 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.
41. 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.