Definition and symptoms of muscle dysmorphia

MD is a psychiatric condition, characterized by a pathological preoccupation with the overall muscularity and drive to gain weight without gaining fat. This kind of body image disorder was long considered as the reverse form of AN since those men with MD believe that they are weak and small but in reality they are unusually muscular (Pope et al., 1993). Contrary to AN where the body image disorder is in connection with the thin ideal, in the case of MD, the body image disorder relates to the athletic (“Schwarzenegger”) ideal. The abuse and/or dependence of anabolic androgenic steroids, the hiding behaviour, and the excessive exercise are very common among MD sufferers. Table 1 describes the similar dimensions and the major differences in the symptomatology of AN and MD (Túry & Gyenis, 1997). MD is considered as a special male body image disorder since it is mostly associated with the male bodybuilder population.

Table 1

Similarities and differences between anorexia nervosa and muscle dysmorphia (cited from Túry & Gyenis, 1997)

Anorexia nervosa Muscle dysmorphia

 typical disorder of women  typical disorder of men

 chronic weight loss, emaciation  significant weight gain, hypermuscular physique

 intense fear of gaining weight  intense fear of losing weight

 body image disorder relating to thin

ideal (believe that they are obese)  body image disorder relating to the athletic ideal (believe that they are thin)

 demonstrative behaviour  hiding behaviour

 abuse of laxatives and diet pills  abuse of anabolic-androgenic steroids

Thompson, Heinberg, Altabe, & Tantleff-Dunn (1999) conceptualized the symptoms of MD through the dimensions of body image disturbances:

a) Perceptual dimension

Individuals with MD tend to perceive themselves as thin and small while in reality they are extremely muscular. Relating to the perceptual distortion, one study showed that 42% of the men with MD could well recognize the inaccuracy in their perception of their own body sizes in contrast to those who could recognize poorly (50%) or could not recognize at all (8%) (Olivardia, Pope, & Hudson, 2000).

b) Cognitive dimension

MD is characterized by a preoccupation and obsession with the idea that one’s body is insufficiently big and muscular even though their well-defined physique (Pope et al., 2000). The body image distortion can lead to obsessive thoughts and intense anxiety about their appearance. Olivardia et al. (2000) found that men with MD reported thinking about their lack of muscularity for more than 5 hours per day. Since these thoughts are very intrusive and time consuming it can be even difficult to concentrate on a task for these men (Pope et al., 2000).

Specific cognitive distortions –like those in body dysmorphic disorder– are very common, such as “black and white thinking”, “filtering”, and “mind reading” (Pope et al., 2000). Individuals with MD have little control over these thoughts, which can cause

the feeling of helplessness. They often try to overcome these feelings and thoughts via compulsive behaviours, such as excessive bodybuilding.

c) Behavioural dimension

The most common behaviour associated with MD is excessive working out. Men with MD spend long hours with lifting weights in the gym and often give up important social, occupational, or recreational activities because of the compulsive need to maintain their workout and diet schedule (Pope et al., 1997). This compulsive workout is distinct from enthusiastic sport activities and should not be confused with them. MD sufferers have a compulsive need for working out which leads to a rigid workout schedule that they even sacrifice important events to adhere to their strict workout regimen. Moreover, men with MD have a special diet that they strictly try to follow.

The dietary schedule focuses on the “perfect” combination of proteins, carbohydrates, fats, and vitamins in order to develop and build their bodies (Olivardia, 2001).

Mirror checking is another prominent behavioural aspect of MD. Extreme mirror checking derives from the obsessive thought of being or getting too small which leads to an intense urge to check. Men with MD reports significantly more mirror checking (9.2 ± 7.5) per day than normal comparison bodybuilders did (3.4 ± 3.3 [Olivardia et al., 2000]).

Social avoidance or hiding behaviour is a common feature of individuals with MD as they feel very uncomfortable and anxious about their body and appearance (Pope et al., 1997). Therefore, they often cancel or avoid social events where their bodies would be exposed to others, wear bulky clothes even in hot weather because they feel ashamed of their “weak” bodies. This kind of negative body image can lead to impaired social and intimate relationships.

Men with MD commonly use anabolic-androgenic steroids to enhance their muscle mass. According to a study, 46% of men with MD reported steroid use, while only 7%

of the comparison weightlifters without MD (Olivardia et al., 2000). Men continue to

use these substances despite being aware of or experiencing the adverse physical or psychological consequences (Pope et al., 1997).

As the consequence of overtraining and excessive exercise, men with MD are at risk for several injuries, for instance, broken bones, damaged joints and ligaments (Pope et al., 1997). Because of the compulsive need for lifting weights and the intense fear of losing weight they often keep on training even when they are seriously injured.

d) Emotional dimension

The feelings of guilt when skipping a workout or neglecting the special diet are pervasive for those with MD who are so insisting on their workout and diet schedule.

They often feel depressed and anxious about their appearance and may experience intense cognitive distortions when they have to skip a workout.