by Roberto Olivardia, PhD; Aaron Blashill, PhD; & Jonathan Hoffman, PhD
Overview
Muscle Dysmorphia or MD is a form of Body Dysmorphic Disorder (BDD). MD is defined by:
- Being preoccupied by worries that one’s body is “too small” or “not muscular enough” despite having a normal build, or in many cases, an objectively extremely “buff” physique. In other words, how people with MD think about or perceive the size of their body and muscles is distorted, sometimes to the point of seeming delusional.
- Engaging in repeated behaviors or mental reviewing in response to their perceived physical “flaws” or “defects.” Examples include constantly checking the appearance of their muscles in mirrors or other reflective surfaces or engaging in mental rituals comparing how muscular they are to that of other people.
MD mainly affects males, with symptoms usually beginning in the late teens or early adulthood. The number of individuals affected by muscle dysmorphia is unknown; however, research indicates that between 1.7% and 2.4% of individuals meet criteria for body dysmorphic disorder. One study showed that about 22% of men with body dysmorphic disorder also met criteria for muscle dysmorphia. This would suggesting that about 0.5% of men in general may meet criteria for MD. It is also important to highlight that these numbers may be underestimates, and additional research is needed in this area.
There is no specific cause known for MD, although factors such as biology, being teased or bullied while growing up, and problematic ways of thinking about wanting to be highly muscular are possible factors. In addition, cultural and media influences that create unrealistic models of bodily perfection as both attainable and necessary, may play a role as well. And finally low-self esteem and feelings of social isolation and loneliness can go hand in hand with MD.
Sometimes also referred to as “bigorexia” or “reverse anorexia,” MD may have some overlap with eating disorders, but is not an eating disorder. While individuals with MD often follow very precise, time-consuming, and painstakingly picky diets, their eating habits are driven by an all-consuming concern with improving the mass and leanness of their muscules, as opposed to issues relating to their weight or body fat percentage, as seen in individuals with eating disorders. And although people with MD certainly can appear vain or self-absorbed, they are different from narcissists because, far from having an inflated self-image, they are often plagued by doubts, insecurities, shame, and low self-esteem. In addition, they are specifically focused on perfecting their muscles whereas true narcissists need to feel like they are better than anyone else in all respects. It’s easy to not take MD seriously, but individuals with MD can be at risk for suicidal behaviors when they lose hope that their muscles will ever look the way they “should.”
In their desperation to achieve ever-larger and leaner, and more “perfect” bodies, people with MD exercise excessively, spending many hours at the gym, often risking injuries, or making them worse by refusing to stop, even when in significant pain. Many with MD will wear baggy clothing to disguise “imperfections,” whereas others will spend a great deal of time selecting, or tailoring, attire to accentuate certain body parts, or “uphold” an arbitrary “standard” of appearance.
Individuals with severe MD are known to sacrifice relationships, their other interests, financial stability, and careers to “get big.” They will often make important life decisions based upon how it will impact their work out schedules. If confronted by well-meaning partners, friends or family members, they may deny, rationalize, become angry and defensive, or start isolating or avoiding them. In the worst cases, the rest of life ceases, only the obsession with their muscles remains.
Muscle dysmorphia is associated with a number of thoughts and beliefs about one’s self and others, including:
- Beliefs that one’s body is not sufficiently muscular and large enough
- Over valuing appearance
- Intrusive negative thoughts about one’s body that leads to distractibility and difficulty focusing attention
- Belief that other’s negatively evaluate their appearance
There are also a number of behavioral signs of muscle dysmorphia, including:
- Excessively working out/lifting weights (multiple hours per day)
- Repeatedly counting calories
- Avoiding eating out at restaurants due to perceived lack of control over food content
- Balancing carbohydrates, fats, proteins, and vitamins to achieve a “perfect” formula
- Eating multiple meals throughout the day at rigidly adhered to schedules
- Excessively checking mirrors, or other reflective surfaces
- Avoidance of mirrors, or other reflective surfaces
- Avoidance of social situations where bodies may be on display (e.g., the beach, or pool)
- Camouflaging one’s bodies by wearing multiple layers of clothing to appear “larger”
- Use of anabolic steroids or other appearance and performance enhancing drugs
Other features of MD:
- Gender: Muscle dysmorphia primarily affects men, although women can also suffer from the disorder.
- Age: The onset of muscle dysmorphia is typically in late adolescence, although it can also develop later in life.
- Race and Ethnicity: Although cultural studies are needed, patients with muscle dysmorphia represent various racial and ethnic groups. It is not exclusive to one group.
- Socioeconomic Status: Muscle dysmorphia seems to affect men and women from all socioeconomic levels.
- Sexual Orientation: Both heterosexual and homosexual men suffer from muscle dysmorphia.
- Education: Various levels of education are represented in individuals who struggle with muscle dysmorphia.
Disorders commonly seen along with Muscle Dysmorphia:
- Obsessive-Compulsive Disorder
- Substance abuse
- Eating Disorders (Restrictive eating, bulimia nervosa, binge eating disorder)
- Mood Disorders (Depression, Bipolar Disorder)
- Social Anxiety Disorder
- Attention Deficit Hyperactivity Disorder (ADHD)
How muscle dysmorphia is different healthy bodybuilding or fitness:
- Inaccurate body image and perception
- Self-esteem is almost entirely rested on muscle build, while other factors (intelligence, sense of humor, relationships etc) are discounted.
- Interference of MD behaviors with job, school, and relationships rather than being integrated in one’s life.
- Use of dangerous substances, such as anabolic steroids, that are clearly contraindicated for a healthy lifestyle.
Treatment
People with MD will often deny there is a problem and refuse to consider mental health treatment. In fact, they are often more likely to seek remedies like plastic surgery to “correct” their erroneously perceived “flaws” rather than psychological help.
For those who do consider psychological treatment, it can feel like a “catch-22” dilemma. Not seeking treatment means continued struggles with obsessive thinking and compulsive behavior; however, seeking treatment might include decreasing time at the gym and ceasing any steroid use, resulting in loss of muscle mass, which is scary for those with muscle dysmorphia. It is important that individuals with MD work with therapist who specializes in BDD, OCD or body image disorders. Education is important in helping to inform individuals with muscle dysmorphia about healthy body ideals, proper nutrition, and the dangers of over exercise. Cognitive behavior therapy or CBT can be helpful in addressing negative self-talk and unhelpful thinking patterns while at the same time targeting repetitive or compulsive behaviors and increasing healthy behaviors. Therapy can also be supplemented with attendance at support groups.
Yet another issue often plaguing those with MD pertains to the misuse and abuse of anabolic steroids, human growth hormones, and other substances that, in a sense, make false, almost magical promises that they are the solution to obstacles in creating perfectly ripped, v-shaped bodies. These substances are common in the body building culture and while they can undoubtedly “work” in terms of a short-term “fix,” they often feed into a vicious cycle of escalating anxiety, depression, even rage attacks. Ironically, these substances actually may detract from appearance and “masculinity” by creating eruptions of pimples and other dermatological problems as well as causing adverse affects on sexual organs and functioning. Ceasing steroid use is essential for physical and mental health, but should not be done abruptly and should occur under the care of a physician.
Suggested Readings:
The Adonis Complex (2000). Harrison G. Pope, Jr., Katharine Phillips, MD, & Roberto Olivardia, PhD.
Roberto Olivardia, PhD, is a Clinical Instructor of Psychology at Harvard Medical School. He maintains a private psychotherapy practice in Lexington, MA, where he specializes in the treatment of BDD, OCD, and attention deficit hyperactivity disorder (ADHD). He also specializes in the treatment of eating disorders in boys and men. He is co-author of The Adonis Complex, a book which details the various manifestations of body image problems in men.
Aaron J. Blashill, PhD, is a Staff Psychologist at Massachusetts General Hospital, and Instructor in Psychology at Harvard Medical School, Boston.
Jonathan Hoffman, PhD, ABPP, is Clinical Director of the NeuroBehavioral Institute in South Florida, and is a member of the IOCDF Scientific & Clinical Advisory Board.