Muscle dysmorphia

Muscle dysmorphia is a subtype of the obsessive mental disorder body dysmorphic disorder, but is often also grouped with eating disorders.Lee F Monaghan & Michael Atkinson, ''Challenging Myths of Masculinity: Understanding Physical Cultures'' (Surrey: Ashgate, 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, 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 is also common. Other body-dysmorphic preoccupations that are not muscle-dysmorphic are usually present as well.

Although likened to anorexia nervosa, 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, 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, over-exercise, 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, anxiety disorders, and substance use disorder,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 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 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. 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. Over the past 20 years, 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 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 (MSM) have a unique relationship with the development of muscle dysmorphia symptoms. MSM are at increased risk for experiencing internalized heterosexism, 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 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.

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 and anecdotes, and no specific protocols have been validated. Still, evidence supports the efficacy of family-based therapy, cognitive behavioural therapy, and pharmacotherapy with selective serotonin reuptake inhibitors. Also limited is research on prognosis 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. Crossing cultures, 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's inverse—questing to be large and muscular instead of small and thin—later researchers fit the subjective experience to body dysmorphic disorder.

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.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 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 and Eating Disorder Inventory,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'' 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. Muscle dysmorphia's effort to maintain body image 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.

Notes

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Bodybuilding
Culture-bound syndromes
Somatic symptom disorders
Eating disorders