Muscle dysmorphia

Muscle dysmorphia is the obsessive preoccupation with a delusional or exaggerated belief 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][2] Sometimes called "bigorexia", "megarexia", or "reverse anorexia", it is a subtype of body dysmorphic disorder, but is often also grouped with eating disorders.^[1][3]

Affecting mostly affects males, particularly those participating in athletics, muscle dysmorphia involves a disordered fixation on gaining body mass. This quest consumes inordinate time, attention, and resources, as on exercise routines, dietary regimens, and nutritional supplemention, while use of anabolic steroids is also common.^[1][2] Other body-dysmorphic preoccupations that are not muscle-dysmorphic are usually present as well.^[1]

Muscle dysmorphia is distressful and distracting, provoking absences from school, work, and socializing.^[1][4] Versus other body dysmorphic disorders, rates of suicide attempts are especially high with muscle dysmorphia.^[1] Although likened to anorexia nervosa,^[3][5] muscle dysmorphia is difficult to recognize, especially since those experiencing it typically look healthy to others.^[2] Muscle dysmorphia's incidence is rising, partly through recent popularization of extreme cultural ideals of men's bodies.^[2][6]

History

Muscle dysmorphia was first conceptualized as a health risk in the late 1990s.^[7][8][9] Initially, the symptom profile was considered to be a reverse form of anorexia nervosa.^[7] Instead of a person desiring to be small and thin, he or she desires to be large and muscular. Later research, however, indicated that the subjective experience of muscle dysmorphia was more closely related to that of body dysmorphic disorder.^[8] This is still subject to debate.

Research has increased in recent years. As of 2016, 50% of all peer-reviewed studies on the topic had been published in the past 5 years.^[9] The American Psychiatric Association first recognized muscle dysmorphia as a valid disorder in 2013 in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders. In the DSM-5, it is classified as a specifier for body dysmorphic disorder.^[10] Muscle dysmorphia still remains absent from the International Statistical Classification of Diseases and Related Health Problems, the tenth issue of which was published in 1992.^[11]

Alternative classifications

The classification of muscle dysmorphia has been widely debated and alternative DSM classifications have been proposed:

• Eating Disorder: Eating disorders and muscle dysmorphia share many characteristics.^[12] Many researchers have called for it to be reclassified as a type of eating disorder^[12][13][9] due to the fact that preoccupation with body weight and shape, and its modification, underpin both disorders.^[14] In general, body dysmorphic disorder does not typically include the food and exercise related psychopathology that characterize muscle dysmorphia and eating disorders.^[12] Studies have shown that people with muscle dysmorphia score higher on measures of eating disorders, such as the Eating Attitudes Test and Eating Disorder Inventory, than the general population.^[15][16] Also, individuals suffering from muscle dysmorphia and eating disorders typically experience high impairment while those suffering from body dysmorphia typically experience lower levels of impairment.^[17][18] There is even some evidence that treatment for eating disorders is effective for muscle dysmorphia as well.^[19] Muscle dysmorphia and anorexia nervosa share additional similarities such as diagnostic crossover with time and familial transmission.^[20] From a practical standpoint, it is possible that reclassifying muscle dysmorphia as an eating disorder would further reduce the size of the DSM's "Feeding and Eating Conditions Not Elsewhere Classified" section.^[21][18]

• Behavioral Addiction: Others have argued for muscle dysmorphia it to be reclassified as a behavioral addiction.^{[9][12][18][14]} It is argued that the addictive activity of muscle dysmorphia is the maintaining of body image through a number of different activities such as bodybuilding, exercise, eating and shopping for certain foods and food supplements, taking specific drugs, and purchasing and using physical exercise accessories.^[18] Although their activities may cause them harm, and may continue to cause them harm in the future, individuals with muscle dysmorphia continue to engage in them. This is similar to how people suffering from behavioral addictions still continue to engage in the harmful activities to which they are addicted.^[18] The typical behaviors that accompany muscle dysmorphia share many characteristics with behavioral addictions. For example, muscle building and dietary restriction in people who experience muscle dysmorphia hold high importance, can lead to mood modification, and can lead to interpersonal conflicts.^[18] People can build up tolerance to their muscle building and dietary restriction practices and may need to increase levels in order to achieve the desired physiological and/or psychological effects.^[18] They can also experience symptoms of withdrawal if they are unable to engage in the maintenance activities and even if they are able to stop these activities, they are susceptible to relapse.^[13][18]

Signs and symptoms

According to the DSM-5, muscle dysmorphia can be diagnosed if an individual meeting the diagnostic criteria for body dysmorphic disorder is "preoccupied with the idea that his or her body build is too small or insufficiently muscular." This specifier is still used even if the individual is preoccupied with other body areas, which is often the case.^[10]

Psychologists have expanded upon this basic framework and have found other clinical features often found in those with muscle dysmorphia. Individuals suffering from muscle dysmorphia are often consumed by activities aimed at increasing muscularity.^[8] This can often lead to participation in unhealthy behaviors (e.g. the use of physique-enhancing drugs, dietary restriction, and excessive exercise).^[8] People who suffer from muscle dysmorphia generally spend more than three hours per day thinking about becoming more muscular and believe that they have little control over their weightlifting activities.^[9] They engage in body monitoring and camouflaging behaviors, such as wearing multiple layers of clothing to appear larger.^[9]

These symptoms can be impairing. They experience severe distress regarding having their bodies viewed by others.^[8] They experience impaired occupational and social functioning and often report that their diet regimes interfere at least moderately with their lives.^[9] They often avoid activities, people, and places because of their embarrassment over their perceived lack of muscularity.^[9] Approximately 50% of patients have little or no insight into their condition and its severity.^[22][23]

They are also more likely to experience or have experienced a concurrent or past psychiatric diagnosis with eating disorders, mood disorders, anxiety disorders, and substance use disorder being the most common.^[22][17][24] They are more likely to have attempted suicide than members of the general population.^[9] Onset of muscle dysmorphia has been predicted to generally occur between 18 and 20 years of age.^[9]

Prevalence

Prevalence estimates for muscle dysmorphia have been highly variable, with estimates ranging anywhere from 1-54% of men being affected.^[9] Prevalence estimates are often found within more specific populations, with gym members, weightlifters, and bodybuilders showing higher prevalence rates than the general population.^[9] Even higher rates have been found among members of these groups who also use anabolic steroids.^[25][11] Onset of muscle dysmorphia has been predicted to generally occur between 18 and 20 years of age, but there may be significant prevalence rates in much younger populations since body dissatisfaction has been found in males as young as six years old.^[9][26] Muscle dysmorphia is far less common in women, but still possible, especially in women who are victims of sexual assault.^[9][25]

Cases cross cultural barriers, with clinical populations appearing in places such as China, South Africa, and Latin America.^{[24][27][28][29][16]} Prevalence in these countries may be mediated by exposure to western ideals of muscularity. One study found that college-aged men in Austria, France, and the United States report a similar gap between current perceived and ideal levels of muscularity.^[30] Meanwhile, populations that are less exposed to western ideals of muscularity tend to have lower prevalence rates.^[31]

Causes

The causes of muscle dysmorphia are unclear, but several significant risk factors and theories have been proposed:

• Muscle dysmorphia as a coping or defense mechanism: Many researchers have identified psychological predisposing factors associated with muscle dysmorphia. People suffering from muscle dysmorphia are more likely to have experienced or observed a traumatic event (e.g. sexual assault or domestic violence) than members of the general population.^[9][25][23] The drive to become muscular has been theorized to be a way for people to cope psychologically with past trauma.^[9] People suffering from muscle dysmorphia are also more likely to have been victimized, bullied, or ridiculed for perceived deficiencies (e.g. being small, weak, non-athletic, or intellectually inferior) as adolescents than the general population.^[9][32] It is theorized that many of these people are driven to become more muscular because it would not only help them cope with their unpleasant past, but it would also allow them to defend themselves in the future or at least stop the harassment.^[33][9]
• Muscle dysmorphia as a result of low self-esteem and insecurities: Low self-esteem can contribute to muscle dysmorphia, with lower levels being linked to higher body dissatisfaction and higher levels of muscle dysmorphia^[34] Individuals who develop beliefs that muscular appearance is important and have lower perceptions of themselves are at a heightened risk for developing muscle dysmorphia.^[9] For people whose self-esteem is contingent upon appearance, this association is even more dangerous as they tend to spend even more time on appearance-related behaviors, such as lifting weights.^[34][35] Muscle preoccupations may also develop as a way to address insecurities, such as insecurity about sexual capability.^[9] Research has found a link between muscularity and feelings of reproductive success and have postulated that for people suffering from Muscle Dysmorphia, muscles may become a secondary sex characteristic, which indicate virility and the ability to provide safety and resources for partners and offspring.^[36] Drive for muscularity is also correlated negatively with genital satisfaction, indicating that some men may develop muscularity preoccupations as a way to compensate for perceived deficiencies.^[37]
• The negative effects of media exposure and muscle dysmorphia: Other research has pointed towards the threat of popular culture and media exposure. Not only does media in western culture promote standards of attractiveness, but marketing campaigns have also begun to specifically target male body-image insecurities.^{[38][23][39][40][41]} This generates social comparison and pressure for individuals to take measures to conform to the ideal.^[34] Men exposed to muscular images show a significantly greater discrepancy between their own level muscularity and desired level of muscularity than men who are not exposed to muscular images.^[42] Unfortunately, the number of fitness magazines directed at men and the number of partially-clothed well-muscled men in magazine advertisements have increased over the past 20 years, increasing the potential for men to be exposed to these images.^[34][33] Studies have found that the strongest predictor of a drive for muscularity in college aged men is the extent to which they have internalized the ideal male body presented by the media.^[43][44]
• Participation in sports and Muscle Dysmorphia: A correlation has also been found between sports participation and muscle dysmorphia. The condition has been found to be positively correlated with involvement in sports such as football and wrestling – sports that emphasize size and strength and in which being large carries the notion of gaining an "edge" over the competition.^[38][8][45] Sports can help expose individuals to the social ideal of muscularity and reinforce the obtainment and maintenance of this ideal.^[34] In general, athletes are more critical of their bodies and body weight than those who do not regularly engage in planned exercise.^[46] Athletes who are both critical of their bodies and fail to achieve performance standards may resort to the extreme measures associated with muscle dysmorphia to achieve a body ideal.^[47] Athletes share many of the psychological factors that have been theorized to increase the likelihood of muscle dysmorphia such as high levels of competitiveness, high need for control, and perfectionist tendencies.^[34] It is unclear if the sports serve as a gateway to muscle dysmorphia or if those predisposed to the condition are more likely to participate in such sports.^[47]

Treatment

Treatment of muscle dysmorphia is complicated by the fact that many individuals who suffer from it do not recognize it or seek treatment.^[47] It becomes the responsibility of healthcare professionals to identify the problem and intervene at the correct time. The first step is convincing the individual that he or she needs help.^[47] Unfortunately, scientific research on the treatment of muscle dysmorphia is severely limited and largely based on anecdotes and case reports.^[9] No specific treatment programs have been developed, although several general approaches have been successful.^[47] Some research has supported the efficacy of family-based therapy, cognitive behavioural therapy, and the use of selective serotonin reuptake inhibitor (anti-depressant) medications in the treatment of muscle dysmorphia.^[9][48] Like research on treatment, research on prognosis has been severely limited.^[9]

Notes