Treating Muscle Dysmorphia

Muscle dysmorphia, sometimes referred to as “bigorexia”, is a type of body image disorder. While the public is generally more familiar with anorexia, which is characterized with an obsession with losing weight, “bigorexia” is essentially the opposite. Victims of muscle dysmorphia display an unhealthy obsession with gaining muscle mass, motivated by an irrational belief that their current body is not muscular enough. Although muscle dysmorphia is often considered a type of eating disorder alongside anorexia nervosa and bulimia nervosa, under the DSM-V it is actually classified as a subtype of dysmorphic disorder, which falls within the obsessive-compulsive spectrum unlike anorexia nervosa (APA, 2013). Unlike many other disorders related to body image, muscle dysmorphia disproportionately affects men, many of whom have normal, healthy bodyweights or are actually more muscular than average (Phillips, 2009).

Debate exists regarding whether or not muscle dysmorphia is truly a body dysmorphia. Based on research, some suggest that it is better classified as an eating disorder. One study found that victims of muscle dysmorphia, compared to healthy gym-goers, exhibited disordered eating habits more similar to people with eating disorders (Murray and Touyz, 2013). Another study analyzed men with body dysmorphia, comparing those who had muscle dysmorphia with others in the group who did not. The study found that the men with muscle dysmorphia experienced a lower quality of life, were more likely to have attempted suicide, and were more likely to exhibit substance use disorder (Pope et al, 2005). Victims of muscle dysmorphia display other traits similar to victims of eating disorders, like avoiding social activities due to perceived defects, altering clothing choices to hide their bodies, and reporting feelings of being unable to control their harmful behaviors (Tod et al, 2016).

Compared to other disorders, a victim of muscle dysmorphia can be difficult to identify. Unlike many victims of anorexia nervosa or bulimia nervosa, people with muscle dysmorphia often are physically unremarkable. They may even look healthier than most people (Leone et al 2005). Further complicating diagnosis, roughly half of victims have little to no insight into their body image disturbance, so it is unlikely that they will seek treatment or even agree that their behavior is abnormal or unhealthy (Tod et al, 2016). As the disorder is relatively new, having only been formally recognized by the American Psychological Association in 2013, it is less understood and is not as well known by the general public compared to other body image disorders.

As is the case with other disorders, it can sometimes be difficult to determine when a normal behavior crosses the threshold of pathological behavior and becomes a health concern. Difficulty differentiating between a fitness enthusiast and a person unhealthily obsessed with body image complicates diagnosis of muscle dysmorphia. The DSM-V addresses this by classifying a pattern of behavior as obsessive-compulsive when the victim performs repetitive behavior or mental acts (such as comparing himself to others), and when the victim’s preoccupation with an imagined defect causes “clinically significant distress” or when it causes “impairment in social, occupational, or other areas of functioning” (APA, 2013).

Under the DSM-V definition of obsessive-compulsive disorders, of which muscle dysmorphia is a subtype, a normal gym-goer or fitness enthusiast would not be classified as having muscle dysmorphia. Diagnosis would be based on whether the individual frequently compares himself to other people, avoids social activities out of embarrassment, or engages in unhealthy behavior (such as steroid abuse or unhealthy dieting) as a result of the distress caused by dysmorphia. Despite these difficulties in identifying those with muscle dysmorphia, the typical victim looks like the following:

• Usually male (Mosley, 2009)

• If female, is likely to have been a victim of sexual assault prior to exhibiting symptoms of muscle dysmorphia (Gruber and Pope, 1999)

• On average, spends more than three hours per day imagining being more muscular (Mosley, 2009)

• Approximately 50% deny that they have a problem (Tod et al, 2016)

• 20% use steroids to enhance muscularity (Phillips, 2009)

• Feels unable to resolve their concerns (Mosley, 2009)

• Exercise and diet regimens interfere with work and social life (Mosley, 2009)

Due to the short duration of time for which muscle dysmorphia has been recognized and studied, there is little evidence to support treatment methods for it. Research indicates that the prevalence of muscle dysmorphia is driven at least partially by exposure to western media that emphasizes muscularity in men (Yang et al, 2005). Based on this, it is possible that limiting exposure to depictions of idealized unattainable standards (fitness magazines, bodybuilding websites, etc.) could help victims become better aligned with reality and could help prevent the acquisition of muscle dysmorphia in the first place.

Anecdotal evidence and limited case studies have shown promising results from family- based treatment, but more data is needed to strongly support this as a treatment method (Tod et al, 2016). Since muscle dysmorphia is classified as a body dysmorphic disorder, some advocate the use of selective serotonin reuptake inhibitors since theses are a standard intervention for other body dysmorphic disorders. This, too, is not yet strongly supported by evidence, and debate exists regarding whether muscle dysmorphia should be classified as a dysmorphic disorder, or whether it would be more accurately described as an eating disorder (Murray and Touyz, 2013).

In conclusion, muscle dysmorphia remains a poorly understood disorder that causes a great deal of suffering to its victims. Due to a lack of public understanding, victims are unlikely to seek help and are not likely to feel included in body positivity movements that focus on combating beauty standards that idealize small women while disregarding beauty standards that idealize muscular men. More research is needed to help classify muscle dysmorphia as well as to fully understand its causes and develop effective treatments. As awareness improves and treatments are developed, western culture can continue moving toward standards that are healthy and attainable by all.

References

1. American Psychiatric Association, 'Body dysmorphic disorder', Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (Arlington, VA: American Psychiatric Association, 2013)
2. Katharine A Phillips, Understanding Body Dysmorphic Disorder: An Essential Guide (New York: Oxford University Press, 2009), pp 50–51
3. 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
4. Tod D, Edwards C & Cranswick I (2016), 'Muscle dysmorphia: Current insights', Psychology Research and Behavior Management 9:179–188.
5. Substance Abuse and Mental Health Services Administration. DSM-5 Changes: Implications for Child Serious Emotional Disturbance [Internet]. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 2016 Jun. Table 23, DSM-IV to DSM-5 Body Dysmorphic Disorder Comparison. Available from: https://www.ncbi.nlm.nih.gov/books/NBK519712/table/ch3.t19/
6. 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
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9. Mosley PE (2009). 'Bigorexia: Bodybuilding and muscle dysmorphia'. European Eating Disorders Review. 17 (3): 191–198.
10. Gruber AJ, Pope HG., Jr Compulsive weight lifting and anabolic drug abuse among women rape victims. Compr Psychiatry. 1999;40(4):273–277