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 Publishing, 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), pp 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,Anthony J Cortese, Provocateur: Image of Women and Minorities in Advertising, 4th edn (London: Rowman & Littlefield, 2016), p 94. 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) pp 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, 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. Vulnerable narcissism 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 (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.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. The disorder is rare in women but does occur, and has been noted especially in female bodybuilders who have experienced sexual assault.