Muscle dysmorphia and eating disorder related psychopathological

Results indicated that men with MD displayed more eating disorder related psychopathological characteristics, as they reported higher levels of drive for thinness and interoceptive awareness relative to the group of normal weightlifters, and had higher levels of perfectionism and interpersonal distrust comparing to the normal weightlifters and low risk MD group. These results correspond to previous study findings that emphasized the association between MD, disordered eating, and eating disorder related characteristics (McFarland & Kaminski, 2009; Mossley, 2009;

Olivardia et al., 2001; Pope at al., 1993; Pope et al., 1997; Pope & Katz, 1994). Of note, Olivardia et al. (2001) found similar results, as muscle dysmorphic men had elevated scores on the Eating Disorder Inventory (Garner et al., 1983), that is, they showed perfectionistic traits, maturity fears, feelings of ineffectiveness, and drive for thinness.

The etiology of MD may resemble to that of eating disorders, as some behavioral and psychological traits of AN and BN are similar in case of MD.

Significantly higher level of drive for thinness was associated with MD. However this result may be controversial, Olivardia (2001) also pointed out the relationship between MD and the drive for thinness, and he argued that the present subscale of the EDI also refers to the drive for leanness –which is also common in AN. Men with MD may be that obsessed with their percentage of their body fat like women with AN, which partially explains the relationship between MD and drive for thinness. Moreover, Kelley, Neufeld, and Musher-Eizenman (2010) confirmed this relationship as they suggested that both drive for thinness and drive for muscularity can be experienced simultaneously.

The high risk MD group also reported higher levels of interoceptive awareness. This eating disorder related psychopathological characteristic refers to “one's lack of confidence in recognizing and accurately identifying emotions and sensations of hunger

or satiety” (Garner et al., 1983). This eating disorder related characteristic may lead to the development of either binge eating or BN which is common in MD (McFarland &

Kaminski, 2009; Olivardia et al., 2001; Pope et al., 1997). Moreover, the strict dietary regimens, the use of ergogenics and food supplements may also distract their sensations of hunger and satiety. Furthermore, this kind of lack of confidence may also contribute to the development of body monitoring and body obsessions.

Perfectionism was also related to MD. Perfectionism is defined as the pursuit of unrealistic goals (Nugent, 2000, cited by Grieve, 2007). In the conceptual model of MD (Grieve, 2007) perfectionism influences the development of MD. Research evidence shows that eating disordered women have unattainable body shape goals and higher levels of perfectionism than women without eating disorders (Vohs et al., 2001). Men with MD also have unrealistic body shape goals, thus it is hypothesized that perfectionism may also influence the development of MD. Kuennen and Waldron (2007) supported this hypothesis as they found a direct relationship between perfectionism and MD. Our study results also confirm the association between MD and perfectionism, indicating that men with MD are prone to pursue a perfect and unattainable muscular body ideal. The results also support this hypothesis, as even though the high risk MD group had the highest BMI, they also reported the highest levels of desire toward weight gain comparing to the low risk MD group and normal weightlifters. Moreover, as it was mentioned before, those males who wanted to gain weight reported the highest level of importance of muscle mass gain.

MD was also associated with higher levels of interpersonal distrust. This association is possibly due to their impaired social and intimate relationships. Often, MD is socially and occupationally impairing and those who are affected usually avoid social activities and people (Cafri et al., 2008; Kovács & Túry, 2001; Olivardia, 2001; Pope et al., 1993;

Pope et al., 1997). This might be because of they believe that their bodies are not sufficiently lean and muscular, and being afraid of humiliations relating to their perceived body deficiencies. As a result of their imagined body flaws –which is also a characteristic of body dysmorphic disorder– they avoid those situations where their bodies are exposed to others. Thus, they hide their bodies and wear loose and heavy

clothes even in the summer. This characteristic of MD may lead to the elevated scores of interpersonal distrust.

Although we did not assess childhood victimization, some authors emphasized that childhood bullying experiences may also contribute to the development of MD. Some study results pointed out that those boys who suffered from childhood physical victimization by peers and parents –because of being physically weak– are more likely to engage in bodybuilding activity (Fussel, 1991; Klein, 1993). The assumption that childhood bullying experiences are strongly associated with the development of MD was supported by the study of Wolke and Sapouna (2008). Their study results showed that those weightlifters who were subjected to childhood bullying experiences displayed more MD symptoms. This kind of negative childhood experience may also contribute to the development of interpersonal distrust. Moreover, weightlifting is not a team sport that requires social interactions and can be performed even alone. Furthermore, Wolke and Sapouna (2008) also emphasized that MD and impaired psychosocial functioning are often related; thus, clinicians should be aware of this association.

To summarize, our results highlighted the association between eating disorder related psychopathological characteristics and MD. Several studies pointed out that males with MD are at increased risk for developing eating disorders (McFarland & Kaminski, 2009; Mossley, 2009; Olivardia et al., 2001; Pope at al., 1993; Pope et al., 1997; Pope &

Katz, 1994). The rigid adherence to a dietary regimen, the weight control behaviours, such as following a special diet, eating in every three hour even if not hungry, the use of food supplements, and the preoccupation with food contribute to the development of an eating disorder (Goldfield et al., 1998). These results showed that some underlying characteristics of men with MD are similar to that of patients with eating disorders, which may predispose them to the development of a full-blown eating disorder.

Besides the eating disorder related psychopathological characteristics, we also examined the relationship between MD and eating disorders. This association is well-established in the literature (McFarland & Kaminski, 2009; Olivardia et al., 2000; Pope et al., 1993;

Pope & Katz, 1994; Pope et al., 1997). Although, the prevalence of eating disorders in

the high risk MD group and low risk MD group was higher (10.9% and 9.5%, respectively) compared to the normal weightlifters (5.4%), we did not find significant association between MD and eating disorders. It can be that we did not apply the appropriate measure for the assessment of eating disorders, as we used the SCOFF questionnaire. This screening tool has been developed to raise the suspicion of a likely case of an eating disorder and has not been designed to be used as a diagnostic tool.

Therefore, the assessment of eating disorders should be planned due foresight. Further studies should consider the use of other scales to reveal the association between MD and eating disorders in Hungarian risk populations.