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{{Short description|Subtype of the obsessive mental disorder body dysmorphic disorder}}
{{Use dmy dates|date=October 2020}}
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'''Muscle dysmorphia''' is a subtype of the obsessive mental disorder [[body dysmorphic disorder]], but is often also grouped with [[eating disorders]].<ref name="Phillips2009"/><ref name=Monaghan-Atkinson>Lee F Monaghan & Michael Atkinson, ''Challenging Myths of Masculinity: Understanding Physical Cultures'' (Surrey: [[Ashgate Publishing]], 2014), [https://books.google.com/books?id=Ys-pBAAAQBAJ&pg=PA86&dq=dysmorphia+megarexia p 86].</ref> 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.<ref name=Phillips2009>Katharine A Phillips, ''Understanding Body Dysmorphic Disorder: An Essential Guide'' (New York: [[Oxford University Press]], 2009), pp [https://books.google.com/books?id=uRTcOYgWj9cC&pg=PA50&dq=muscle+dysmorphia 50–51].</ref><ref name=Leone-etal>James E Leone, Edward J Sedory & Kimberly A Gray, [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1323298 "Recognition and treatment of muscle dysmorphia and related body image disorders"], ''Journal of Athletic Training'', 2005 Oct–Dec;'''40'''(4):352–359.</ref>

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.<ref name="Leone-etal"/> 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.<ref name="Phillips2009"/><ref name="Leone-etal"/> Other body-dysmorphic preoccupations that are not muscle-dysmorphic are usually present as well.<ref name="Phillips2009"/>

Although likened to [[anorexia nervosa]],<ref name="Monaghan-Atkinson"/><ref>Anthony J Cortese, ''Provocateur: Image of Women and Minorities in Advertising'', 4th edn (London: [[Rowman & Littlefield]], 2016), [https://books.google.com/books?id=TTaCCgAAQBAJ&pg=PA94 p 94].</ref> muscle dysmorphia is especially difficult to recognize, since awareness of it is scarce and persons experiencing muscle dysmorphia typically remain healthy looking.<ref name="Leone-etal"/> The distress and distraction of muscle dysmorphia may provoke absences from school, work, and social settings.<ref name="Phillips2009"/><ref name=McCallum>Anonymous webpage author, [https://www.mccallumplace.com/muscle-dysmorphia.html "Muscle dysmorphia"], McCallum Place website, visited 21 May 2016.</ref> Compared to other body dysmorphic disorders, rates of suicide attempts are especially high with muscle dysmorphia.<ref name="Phillips2009"/> Researchers believe that muscle dysmorphia's incidence is rising, partly due to the recent cultural emphasis on muscular male bodies.<ref name="Leone-etal"/><ref name=Pope-etal>Harrison G Pope Jr, Katharine A Phillips & Roberto Olivardia, ''The Adonis Complex: The Secret Crisis of Male Body Obsession'' (New York: [[Free Press (publisher)|Free Press]], 2000) pp [https://books.google.com/books?id=Jo-LHyyIy_kC&pg=PA156 156], 160,197.</ref>

==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.<ref name="Tod16"/><ref name="McCabe04">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.</ref> 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.<ref name="DSM"/>

Further clinical features identified include excessive conduct of efforts to increase muscularity, activities such as dietary restriction, [[overtraining]], and injection of growth-enhancing drugs.<ref name="Pope97"/> Persons experiencing muscle dysmorphia generally spend over three hours daily pondering increased muscularity, and may feel unable to limit weightlifting.<ref name="Tod16"/> As in anorexia nervosa, the reverse quest in muscle dysmorphia can be insatiable.<ref>{{Cite journal|author=Mosley PE|date=2009|title=Bigorexia: Bodybuilding and muscle dysmorphia|journal=European Eating Disorders Review|language=en|volume=17|issue=3|pages=191–198|doi=10.1002/erv.897|pmid=18759381|s2cid=20128770 |issn=1099-0968}}</ref> Those suffering from the disorder closely monitor their body and may wear multiple clothing layers to make it appear larger.<ref name="Tod16"/>

Muscle dysmorphia involves severe distress at having one's body viewed by others.<ref name="Pope97"/> Occupational and social functioning are impaired, and dietary regimes may interfere with these.<ref name="Tod16"/> Patients often avoid activities, people, and places that threaten to reveal their perceived deficiency of size or muscularity.<ref name="Tod16"/> Roughly half of patients have poor or no insight that these perceptions are unrealistic.<ref name="Tod16" /><ref name="Cafri08">Cafri G, Olivardia R & Thompson JK (2008), "Symptom characteristics and psychiatric comorbidity among males with muscle dysmorphia", ''Comprehensive Psychiatry'' '''49'''(4):374–379.</ref> Patient histories reveal elevated rates of diagnoses of other mental disorders, including eating disorders, [[mood disorders]], [[anxiety disorders]], and [[substance use disorder]],<ref name="Cafri08"/><ref name="Pope05"/><ref name="Hitzeroth11">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.</ref> as well as elevated rates of suicide attempts.<ref name="Tod16"/>

==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]],<ref name="Tod16"/><ref name="Gruber99"/> or to have sustained adolescent [[bullying]] and ridicule for actual or perceived deficiencies such as smallness, weakness, poor athleticism, or intellectual inferiority.<ref name="Tod16"/><ref name="Edwwards16">Edwards C, Molnar G & Tod D (2017), [https://dx.doi.org/10.1037/men0000072 "Searching for masculine capital: Experiences leading to high drive for muscularity in men"], ''Psychology of Men & Masculinity'' '''18'''(4)"361–371.'</ref> Increased body mass may seem to reduce the threat of further mistreatment.<ref name="Tod16"/><ref name="Olivardia01">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.</ref>

===Sociopsychological traits===
Low [[self-esteem]] is associated with higher levels of body dissatisfaction and of muscle dysmorphia.<ref name="Grieve07">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.</ref> [[Narcissistic personality disorder#Subtypes|Vulnerable narcissism]] has also been linked to heightened muscle dysmorphia risk.<ref>{{cite journal | last1=Boulter | first1=Matt W. | last2=Wooldridge | first2=Tom | last3=Bjelland | first3=Vegard E. | last4=Sandgren | first4=Sebastian S. | title=My father, myself, and my muscles: Associations between muscle dysmorphia, narcissism and relationship with father among exercising males | journal=Personality and Individual Differences | date=2023 | volume=207 | article-number=112173 | doi=10.1016/j.paid.2023.112173 | url=https://www.sciencedirect.com/science/article/pii/S019188692300096X | doi-access=free }}</ref> Increased body size or muscularity may seem to enhance the masculine identity.<ref name="Tod16"/>

===Media exposure===
As Western media emphasize physical attractiveness, some marketing campaigns now exploit male body-image insecurities.<ref name="Cohane01">Cohane GH, & Pope HG Jr (2001), "Body image in boys: A review of the literature", ''International Journal of Eating Disorders'' '''29'''(4):373–379.</ref><ref name="Mangweth01">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.</ref><ref name="Pope01">Pope HG Jr, Olivardia R, Borowiecki JJ 3rd & Cohane GH (2001), [https://www.ncbi.nlm.nih.gov/pubmed/11408837 "The growing commercial value of the male body: A longitudinal survey of advertising in women's magazines"], ''Psychotherapy and Psychosomatics'' '''70'''(4):189–192.</ref><ref name="Leit01">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.</ref> Since the 1980s, the number of fitness magazines and of partially undressed, muscular men in advertisements have increased.<ref name="Grieve07"/> Such media provoke bodily comparisons and pressure individuals to conform,<ref name="Grieve07"/> yet increase the gap between men's perceptions of their own muscularity versus their desired muscularity.<ref name="Leit02">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.</ref> In college-aged men, a strong predictor of a muscularity quest is internalization of the idealized male bodies depicted in media.<ref>Daniel S & Bridges SK (2010)m The drive for muscularity in men: Media influences and objectification theory, ''Body Image'' '''7'''(1):32–38.</ref><ref name="Parent11">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.</ref>

===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,<ref name="Grieve07"/> and athletes tend to be more critical of their own bodies and body weight.<ref name="Davis91">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.</ref> Athletes who also fail to meet their sports performance goals may escalate efforts to modify their builds, efforts that overlap those of muscle dysmorphia.<ref name="Leone-etal"/> Involvement in sports where size, strength, or weight, whether higher or lower, imply competitive advantage associates with muscle dysmorphia.<ref name="Cohane01"/><ref name="Pope97"/><ref name="Chung01">Chung B (2001), [https://www.ncbi.nlm.nih.gov/pubmed/11600802 "Muscle dysmorphia: A critical review of the proposed criteria"], ''Perspect Biol Med'' '''44'''(4):565–574.</ref> Athletic ideals reinforce the social ideal of muscularity.<ref name="Grieve07"/> Conversely, those already disposed to muscle dysmorphia may be more likely to participate in such sports.<ref name="Leone-etal"/>

===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.<ref name="Brewster17">{{cite journal |last1=Brewster |first1=ME |last2=Sandil |first2=R |last3=DeBlaere |first3=C |last4=Breslow |first4=A |last5=Eklund |first5=A |title="Do you even lift, bro?" objectification, minority stress, and body image concerns for sexual minority men |journal=Psychology of Men & Masculinity |date=2017 |volume=18 |issue=7 |pages=87–98 |doi=10.1037/men0000043|s2cid=34272538 }}</ref> Men who conform to conventional ideals of masculinity often report increased stress from not meeting the imposed standard of a masculine and muscular body.<ref name="Kimmel05">{{cite journal |last1=Kimmel |first1=SB |last2=Mahalik |first2=JR |title=Body image concerns of gay men: The roles of minority stress and conformity to masculine norms |journal=Journal of Consulting and Clinical Psychology |date=2005 |volume=73 |issue=6 |pages=1185–1190 |doi=10.1037/0022-006X.73.6.1185|pmid=16392992 }}</ref> 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.<ref name="Griffiths19">{{cite journal |last1=Griffiths |first1=S |last2=Murray |first2=SB |last3=Mitchison |first3=D |last4=Castle |first4=D |title=Relative strength of the associations of body fat, muscularity, height, and penis size dissatisfaction with psychological quality of life impairment among sexual minority men |journal=Psychology of Men & Masculinities |date=2019 |volume=20 |issue=1 |pages=55–60 |doi=10.1037/men0000149|s2cid=149433191 }}</ref>

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.<ref name="Fabris22">{{cite journal |last1=Fabris |first1=MA |last2=Badenes=Ribera |first2=L |last3=Longobardi |first3=C |last4=Demuru |first4=A |last5=Konrad |first5=SD |last6=Settanni |first6=M |title=Homophobic bullying victimization and muscle dysmorphic concerns in men having sex with men: The mediating role of paranoid ideation |journal=Current Psychology |date=2022 |volume=41 |issue=6 |pages=3577–3584 |doi=10.1007/s12144-020-00857-3|s2cid=255509015 }}</ref>

==Diagnosis==
{{Empty section|date=March 2023}}
==Treatment==

Treatment of muscle dysmorphia can be stymied by a patient's unawareness that the preoccupation is disordered or by avoidance of treatment.<ref name="Leone-etal"/> Scientific research on treatment of muscle dysmorphia is limited, the evidence largely in [[case reports]] and anecdotes,<ref name="Tod16"/> and no specific protocols have been validated.<ref name="Leone-etal"/> Still, evidence supports the efficacy of [[Family Therapy|family-based therapy]], [[Cognitive Behavioral Therapy|cognitive behavioural therapy]], and pharmacotherapy with [[selective serotonin reuptake inhibitor]]s.<ref name="Tod16"/> Also limited is research on [[prognosis]] of the untreated.<ref name="Tod16"/>

==Prevalence==

Prevalence estimates for muscle dysmorphia have greatly varied, ranging from 1% to 54% of men in the studied samples.<ref name="Tod16"/> Samples of gym members, weightlifters, and bodybuilders show higher prevalence than do samples from the general population.<ref name="Tod16"/> Rates even higher have been found among users of anabolic steroids.<ref name="Gruber99">Gruber AJ & Pope HG (1999), "Compulsive weight lifting and anabolic drug abuse among women rape victims", ''Comprehensive Psychiatry'' '''40'''(4):273–277.</ref><ref name="Filho16"/> The disorder is rare in women but does occur, and has been noted especially in female bodybuilders who have experienced sexual assault.<ref name="Tod16"/><ref name="Gruber99"/>

Muscle dysmorphia has been identified in China, South Africa, and Latin America.<ref name="Hitzeroth11"/><ref name="Ung00">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.</ref><ref name="Soler13">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.</ref><ref name="Rutsztein04">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.</ref><ref name="Behar10"/> Nonwestern populations less exposed to western media show lower rates of muscle dysmorphia.<ref name="Yang05">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.</ref>

==History==

Muscle dysmorphia was first conceptualized by healthcare professionals in the late 1990s.<ref name="Pope93">Pope HG, Katz DL & Hudson JI (1993), "Anorexia nervosa and 'reverse anorexia' among 108 male bodybuilders", ''Comprehensive Psychiatry'' '''34'''(6):406–409.</ref><ref name="Pope97">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.</ref><ref name="Tod16">Tod D, Edwards C & Cranswick I (2016), [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4977020 "Muscle dysmorphia: Current insights"], ''Psychology Research and Behavior Management'' '''9''':179–188.</ref> In 2016, 50% of peer-reviewed articles on it had been published in the prior five years.<ref name="Tod16"/>

Although muscle dysmorphia was initially viewed as [[anorexia nervosa]]'s inverse—questing to be large and muscular instead of small and thin<ref name="Pope93"/>—later researchers fit the subjective experience to [[body dysmorphic disorder]].<ref name="Pope97"/>

The [[American Psychiatric Association]] recognized muscle dysmorphia with the fifth edition of the ''[[DSM-5|Diagnostic and Statistical Manual of Mental Disorders]]'', which classifies it under body dysmorphic disorder.<ref name="DSM">American Psychiatric Association, [https://books.google.com/books?id=-JivBAAAQBAJ&q=muscle=dysmorphia "Body dysmorphic disorder"], ''Diagnostic and Statistical Manual of Mental Disorders'', Fifth Edition (Arlington, VA: American Psychiatric Association, 2013).</ref> Muscle dysmorphia is absent from the ''[[International Statistical Classification of Diseases and Related Health Problems]]''' present edition, the [[ICD-10|tenth]], published in 1992.<ref name="Filho16">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.</ref>

==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,<ref name="Tod16"/><ref name="Griffiths15">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.</ref><ref name="Murray13">Murray SB & Touyz SW (2013), "Muscle dysmorphia: Towards a diagnostic consensus", ''Australian and New Zealand Journal of Psychiatry'' '''47'''(3):206–207.</ref> including focus on body weight, shape, and modification,<ref name="Russell13">Russell J (2013), Commentary on: "Muscle Dysmorphia: Towards a diagnostic consensus". ''Australian and New Zealand Journal of Psychiatry'' '''47'''(3):284–285.</ref> whereas body dysmorphic disorder otherwise usually lacks such dietary and exercise components.<ref name="Murray13"/> Also, persons experiencing muscle dysmorphia tend to score high on the [[Eating Attitudes Test]] and [[Eating Disorder Inventory]],<ref name="Nieuwoudt12">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.</ref><ref name="Behar10">Behar R & Molinari D (2010), "Muscle dysmorphia, body image and eating behaviors in two male populations", ''[[Revista Médica de Chile]]'' '''138'''(11):1386–1394.</ref> while muscle dysmorphia and anorexia nervosa share diagnostic crossover.<ref name="Murray10">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.</ref> Muscle dysmorphia and disordered eating correlate more to each other than either correlates to body dysmorphic disorder.<ref name="Pope05">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.</ref><ref name="Foster15">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.</ref> Treatment for eating disorders may also be effective for muscle dysmorphia.<ref name="Greenberg08">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.</ref>
* Behavioral addiction: Some researchers seek muscle dysmorphia's reclassification as a [[behavioral addiction]].<ref name="Tod16"/><ref name="Murray13"/><ref name="Foster15"/><ref name="Russell13"/> Muscle dysmorphia's effort to maintain [[body image]] is enacted through activities such as exercise, diet, and related shopping,<ref name="Foster15"/> which may cause conflicts with others.<ref name="Foster15"/> Moreover, compulsive muscle building and dietary restriction can escalate these conflicts.<ref name="Foster15"/> Further, abstinence from these activities can provoke withdrawal symptoms, returning the individual to compulsive behavior.<ref name="Griffiths15"/><ref name="Foster15"/>

== See also ==
* [[Anorexia athletica]]
* [[Exercise bulimia]]

==Notes==
{{reflist}}

[[Category:Bodybuilding]]
[[Category:Culture-bound syndromes]]
[[Category:Somatic symptom disorders]]
[[Category:Eating disorders]]

Muscle dysmorphia - Revision history

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