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Body dysmorphic disorder (BDD) is a psychological disorder, recognised as a psychopathological condition in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV)¹ that is now affecting an increasing amount of both males and females.² In males, BDD is characterised by an individual developing obsessional preoccupations about specific areas of their body. These obsessional beliefs can be related to thoughts about their facial features being ugly, receding hairlines, and even small penis size.

Muscle dysmorphia is a form of Obsessive Compulsive Disorder (OCD), which is sub-catagorised as Body Dysmorphic Disorder (BDD). A more recent extension of BDD is the inclusion of a new sub-category termed muscle dysmorphia (MD).² MD has been shown to affect mainly males, and has been shown to be particularly prevalent in male weight-lifters and bodybuilders.³ Muscle dysmorphia has been termed by some researchers as the “Adonis Complex”,⁴ reverse anorexia, or bigorexia.³

An individual who experiences muscle dysmorphia develops a pathological preoccupation about their muscular appearance, specifically the desire to increase muscle mass, and reduce body fat, with a discrepancy between their perceived imagined and actual self.⁵

Why the increase in muscle dysmorphia?

It has been widely speculated in the popular press, and academic research, that the cultural idea of female thinness has been supported through the media and their representation of the female physique, and this has been a contributory factor in the rise of disorders such as anorexia nervosa.⁷ In a unique study to examine the change in societal pressure with regard to the male physique, Pope and his colleagues studied the changing anthropomorphic measurements of male action figures over a 25-year period. The findings of this study are truly astounding, and emphasise the increasing importance that the media has placed on the ideal male physique as being increasingly muscular.

Pope was able to extrapolate the body dimensions of the action figures to a height of 70 inches (5’ 10’’). The GI Joe (Action Man) figure of 1973, at 5’ 10’’ would have a 31-inch waist, 44-inch chest, and 12-inch biceps. The GI Joe version of 1998, at 5’ 10’’ would have a 36-inch waist, 54-inch chest, and 27-inch biceps.⁸

Diagnostic assessment of muscle dysmorphia

The DSM-IV list the following diagnostic criteria for the recognition of Muscle Dysmorphia:

1. The individual is obsessed with the belief that his/her body should be more lean and muscular. Significant amounts of time are devoted to weight-lifting, and fixation on one’s diet is common.
2. At least two of the following four criteria should be met:
   • The uncontrollable focus on pursing the usual training regime causes the person to miss out on career, social and other activities.
   • Circumstances involving body exposure are preferably avoided: if avoidance is not possible, significant unease and worry occur.
   • Performance on work and social arenas is affected by presumed body deficiencies.
   • The potentially detrimental effects of the training regime fail to discourage the individual from pursuing dangerous activities.

Unlike anorexia nervosa, in which the person is concerned about being overweight, or other types of body dysmorphic disorder, in which the concern is with other physical aspects, the individual with muscle dysmorphia believes that his or her body is insufficiently small or muscular.¹

In an attempt to specifically measure muscle dysmorphia, as opposed to the clinical diagnostic criteria of the DSM-IV, researchers have developed the Muscle Dysmorphia Inventory (MDI).⁸ The MDI assesses muscle dysmorphia from a multi-dimensional perspective using three diagnostic factors:

Desire for size (DFS)

Questions concern thoughts of being smaller, less muscular, and weaker than desired, or wishes to increase size and strength.

Appearance intolerance (AI)

Questions relate to negative beliefs about one’s body and resulting appearance anxiety or body exposure avoidance.

Functional impairment (FI)

Questions that relate to maintaining exercise routines, interference of negative emotions when not being able to train, and avoiding social situations because of negative feelings about one’s body.⁹

Questions the personal trainer can ask to determine whether muscle dysmorphia is present in their client

Below are a list of questions, and information, that you could attempt to discover from your client to make an assessment of muscle dysmorphia. It is usually most effective to ask your clients these types of questions informally. Your client’s responses to the questions, or your observations, will give you a potential insight into the level that muscle dysmorphic traits might impact on their lives.

Social avoidance

1. How often have your relationships with others been affected by your exercise and diet regimes?
2. Do your concerns about your appearance influence your school or career performance?
3. Do you miss out on opportunities because of being self-conscious?
4. Do you miss school/career/social activities because of your appearance concerns?
5. What measures do you take to avoid showing your body? Do you pass up the opportunity to participate in sports because you will have to change in front of others? Do you wear baggy clothes or hats to hide your body/face?
6. Do your concerns about your appearance affect your sex life?

Time

1. What portion of each day do you spend grooming yourself?
2. How much time is spent daily on exercisers with the specific intent of bettering your appearance, rather than improving sport performance?
3. How much do you actively worry about your appearance?
4. How frequently does your appearance make you feel distraught, depressed, or anxious?

Diets and other practices

1. How commonly do you diet, ingest certain foods (low-fat, low-carbohydrate, or high-protein foods), or take supplements with the explicit aim of enhancing your appearance?
2. What proportion of your income is devoted to items and practices (eg equipment, classes, grooming supplies, surgery, special foods, dietary aids) to better your physical appearance?
3. Have you ever taken any drug (legal or illegal) to either drop weight, or increase muscle mass?
4. Aside from drugs, have you pursued other methods of enhancing your appearance, such as overexercising, attempting your exercise regime despite being injured, fasting, purging or other detrimental nutritional activities, or unproven methods for increasing muscle mass?⁶

The key challenge for fitness professionals is to acknowledge that some of their clients might suffer from some form of muscle dysmorphia or experience related elements that impact on their lives. By understanding and being aware of this disorder, fitness professionals will gain a greater understanding of the behavioural, emotional, and cognitive processes that their clients will experience. This will allow the exercise professional to become more effective in helping the client cope more adaptively with this issue.

References

1. American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) (2000), 4th ed, American Psychiatric Association, Washington DC.
2. Pope HG, Gruber AJ, Choi P, Olivardia R and Phillips KA (1997), Muscle Dysmorphia. An underrecognised form of body dysmorphic disorder, Psychosomatics, 38, 548-557.
3. Pope HG, Katz DL and Hudson JI (1993), Anorexia nervosa and “reverse anorexia” among 108 male bodybuilders, Comprehensive Psychiatry, 34, 406-409.
4. Pope HG, Phillips KA and Olivardia R, (2000), The Adonis Complex: The secret crisis of male body obsession, Free Press, New York.
5. Dawes J and Mnakin T (2004), Muscle dysmorphia, Strength and Conditioning Journal, 26, 24-25.
6. Leone JE, Sedory EJ, Gray KA (2005), Recognition and treatment of muscle dysmorphia and related body image disorders, Journal of Athletic Training, 40, 352-359.
7. Cash TF and Pruzinsky T (1990), Body images: Developments, deviance, and change. Guildford, New York.
8. Pope HG, Olivardia R, Gruber A and Borowiecki J (1999), Evolving ideals of male body image as seen through action toys, International Journal of Eating Disorders, 26, 65-72.
9. Schlundt DG, Woodford H and Brownlee A (2000), Muscle dysmorphia in male weightlifters: Psychological characteristics and practices (unpublished manuscript).

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