Body Dysmorphic Disorder, Reverse Anorexia and Muscle Dysmorphia – A Review

By – Nick Bailey BSc (Hons)

1.0 Theories relating to weight training and bodybuilding

The oldest sporting event that involves adjustable external resistance is weightlifting. Before any other competitive event involving a barbell existed, English-speaking nations adopted the term ‘Olympic weightlifting’ or ‘Olympic lifting‘. Weightlifting is now performed every four years in the Olympic Games. Weightlifting is not a generic term to be applied to all that use weights (Dougal 1987).

Bompa (1999) also states that a sub category of weightlifting evolved in the late 1930s and early 1940s, individuals began to compare their muscular development in a competitive arena. The activity became known as body building its governing body is known as the International Federation of Body Builders (IFBB).

Brittan (1989) defined bodybuilding as:

“A sport or activity in which the primary objective is to develop the size of the skeletal muscles. Bodybuilders focus on other areas as well, such as developing all of the muscles proportionally (symmetrically), minimizing body fat and increasing their strength. Because bodybuilders focus on muscular development, that is the main thing they achieve.”

1.1 Cultural trends of body ideals

Modern western culture puts great emphasis on portraying the ideal physique. Both genders pursue the creation of this ideal physique being portrayed in the popular media (Shaw & Waller 1995). People become motivated to achieve similar physiques of extreme subgroups (e.g., fashion models, athletes and entertainers) sometimes to the extent where by which this pursuit of the cultural ideal becomes unhealthy.

Higgins 1987 developed the Self Discrepancy Theory, which postulates that body dissatisfaction reflects the extent of the discrepancy between self perceived physical attributes and the internalised standards of physical realities, cultural expectations and health standards. Phillips et al (1993) used the self-discrepancy theory to evaluate physique ideals in both genders. Their findings were that the vast majority of women desired to be thinner and in contrast many men desired greater muscular development.

Olivardia, Pope & Hudson (2000) state that the mesomorphic male body type is viewed as being more socially desirable and possessing greater physical and athletic prowess then the ectomorphic body type. This cultural acceptance of the heavily muscled male ideal can be directly shown when observing the muscular evolution of children’s action figures over the last four decades. Pope, Phillips & Olivardia, (2000) have termed this ‘the evolution of G.I Joe’. The authors claim that over the last four decades there has been a significant increase in muscle tone and size of these action figures. As many children’s earliest messages regarding body image come from such toys it can be hypothesised these images do contribute to body image perceptions in young males.

The ‘ideal’ male body that the media portrays to women seems to have followed the same trend in terms of the increasingly muscular male body that is portrayed to boys and men. Pope et al (2000) carried out a study involving looking at dimensions of males in Playgirl magazine from 1973-98. The findings show that using the Free Fatty Mass Index (FFMI) formula the average centrefold male in Playgirl magazine has shed 12lbs of fat and gained 27lbs of muscle from 1973 to 1998. The conclusions made from this study were that society is preaching an increasingly muscular ideal; in doing so possibly causing an increase in cases of male body obsession.

1.2 Body Dysmorphic Disorder (BDD)

“BDD is an ever expanding line of research that looks at pathological attitudes and behaviours of males and females.”

(Lantz, Rhea, & Mayhew 2001)

Olivardia et al (2000) suggest many males experience specific body image concerns such as size of the nose, thinning of hair and also more general concerns such as the shape/size of the whole body. These body image issues are often considered annoying and can cause passing distress but for most do not interfere with daily living. However for many other men these perceived ailments become so consuming their daily lives are directly affected by these body image concerns. The researchers claim this can manifest itself in these individuals through symptoms such as depression and self-imposed social exclusion. This in some cases can then lead to a recognised psychiatric condition known as Body Dysmorphic Disorder or BDD (Phillips et al 1993). Men with BDD develop health-threatening worries that concern a preoccupation with an imagined or slight defect in appearance. In reality these appearance defects are minimal. A 1991 review of BDD indicated a trend towards equal instances in both genders, 1.0 male – 1.25 female ratio (Phillips 1991). The research also shows that women are more likely to be abnormally concerned with individual body parts where as males are more concerned with the shape and size of the whole body.

Pope, Gruber & Choi, (1997) have identified a subtype of BDD concerning an individual’s pathological preoccupation with their muscularity. This BDD subtype has been termed muscle dysmorphia.

1.3 Muscle Dysmorphia (MD)

Muscle Dysmorphia is a relatively new area of research in the area of sports psychology but has been recognised within the body building community as ‘the disease’ for many decades (Fussell 1991). Pope, Katz & Hudson (1993) first discovered MD when researching instances of steroid use and anorexia nervosa in 108 male body builders. MD at the time was termed reverse anorexia; in 1997 Pope et al renamed the disorder muscle dysmorphia as they believed the disorder to be a specific subtype of BDD.

1.4 Definitions of Muscle Dysmorphia

According to Olivardia et al (2000) people with MD view themselves as too thin and therefore feel pressure to gain muscle size/strength even when in reality their bodies are significantly more heavily muscled than the average male. MD sufferers’ lives revolve around weightlifting, dieting and other associated activities. In addition to this preoccupation with muscle size Pope et al (1997) identified MD sufferers to be obsessed with leanness. During detailed interviews with body builders suffering from MD the researchers found that when these bodybuilders examined their physiques in the mirror they expected to see large striated musculature. This lead Pope et al (1997) to conclude there may be a duel obsession with both gaining muscular size and strength while maintaining a low body fat percentage.

Choi, Pope & Olivardia (2002) looked at 54 weight trainers, 24 with MD and 30 without MD. The researchers found that the men with MD considered themselves to be less physically attractive and less healthy than their peers; a combination of beliefs previously found in women with BDD. Men with MD were also significantly more likely to be dissatisfied with their overall body appearance, muscle tone and weight than men in the comparison group, and were much more likely to be worried about their weight, buttocks, hips, thighs and legs.

“Those with MD, although often highly muscular, believe themselves to be of very small musculature. This belief leads them to become obsessed with exercising, particularly weightlifting, and at risk of misusing anabolic-androgenic steroids.”

Choi (2002)

People with MD were also found to avoid situations where they might be seen without clothing and often wore several layers of clothing, even in hot weather, to avoid their bodies being seen. The authors attempt to explain this behaviour as changing cultural ideals where mens’ bodies are becoming more visible alongside an increased acceptance of physical exercise as a desirable activity, MD in men may be one negative consequence of physical exercise, particularly weight training, being motivated primarily by physical appearance.

1.5 Possible Precipitating Factors of MD

Lantz et al (2001) suggests that self-esteem and body image distortion/dissatisfaction may be of relevance in the onset of MD. In terms of self-esteem, research focusing on the appeal of anaerobic activities such as weight lifting has implications that self-esteem is central to the need for self-improvement in some individuals. Lombardo (1992) states that in some cases self-esteem could be related to the perceived size, shape and attractiveness of one’s body. With cultural attitudes towards the ideal body image being so prevalent in today’s society the pursuit of these unrealistic ideals by certain individuals can culminate in obsessive exercise regimens and weight control techniques, which have both been linked to low levels of self-esteem.

However Chung (2001) states although MD may be related to low self-esteem, it is no more related than other body dysmorphic disorders or anorexia nervosa. Therefore it cannot be distinguished from these other disorders in terms of self-esteem discrepancies. Self-discrepancy theory (Higgins 1987 cited by Phillips et al 1993) suggests that individuals purse an ideal such as the mesomorphic body type. The theory indicates that the actual physical activity involved (i.e. weightlifting) this ideal is not in itself the problem, but the pathological pursuit of the ideal promotes problems with self-esteem. Smith, Hale & Collins (1998) found that when weight training is used to compensate for low self-esteem the individual can become obsessive about the activity; to the extent where social activates and meaningful occupations become neglected.

Pope et al (1997) believe that as one increases muscular size the individual views oneself more favourably. However this use of weight training to boost self-esteem can become the individual’s sole method used to feel good about themselves. For these individuals the time they spend weight training maybe the only time they feel a high degree of self-esteem.

In terms of body image concerns Lantz et al (2001) suggests body image has two components – distortion and dissatisfaction.

“Distortion relates to the internal perceptual image of ones body; dissatisfaction relating to the disturbance of the feelings that one has about ones body.”

Lantz et al (2001)

Blouin and Goldfield (1995) looked into the link between body image distortions in male body builders. They found that as body builders seek to build the ‘ideal’ mesomorphic body shape through weight lifting, one of the reasons they do so is to produce a perceived positive appearance. Due to today’s society endorsing and promoting such a physical appearance an increasing amount of males report body dissatisfaction as these ‘ideals’ are in most cases unattainable.

Chung (2001) links bodybuilding’s greatest athlete Arnold Schwarzenegger’s rise to fame as a catalyst to the proliferation of MD as a culture bound syndrome. The author believes Schwarzenegger redefined how males defined acceptable muscularity by appearing in high profile motion pictures such as Terminator combined with being appointed by then President Ronald Regan as Head of the US Fitness Council. This enabled an individual who had developed a level of muscularity the general population would previously consider freakish, was now the epitome of physical fitness and a figure head for the development of the nations fitness council. This lead to a new accepted level of muscularity within the Western world.

1.6 Behavioural factors related to MD

Many behaviours of the MD sufferer have been identified in research literature. The most prominent of which are body size/symmetry, dietary constraints, pharmacological aids, dietary supplements, exercise dependence and physique protection (Pope et al 1997).

Body Size/Symmetry

To adhere to the cultural ideal of body image a major factor is to achieve a similar body size and symmetry to the images the popular media portray. Pope et al (1997) suggest these masculine images portrayed have a similar effect on men as the feminine images on women. In a survey by Pope et al (2000) 89% of MD sufferers claimed muscular symmetry was integral to attaining their ideal physique. This may also be reinforced by the fact that bodybuilding competitions are judged on size and symmetry of ones physique.

Dietary Constraints

MD sufferers place high importance on dieting issues. The diet of a MD sufferer is primarily concerned with gaining muscle size and strength. The amount and type of calories are calculated to create ideal conditions within the body to promote muscle growth while reducing fat levels (Pope et al 2000). In extreme cases dietary habits can become so consuming that the MD suffer will eat up to 10 meals at pre determined time intervals during the day. These meals are carefully prepared prior, the emphasis is not taste or enjoyment but purely concerned with nutritional content. To exemplify this some extreme MD sufferers have been found to drink up to 30 raw egg whites per day with a total disregard for the possible health risk. Olivardia et al (2000) notes that about one third of men who suffer from MD also have an eating disorder such as binge eating or an idiosyncratic pattern such as a focus on extreme low-fat, high-protein diets.

Pharmacological Aids and Dietary Supplements

Pope et al (2000) also found that individuals with MD will often use nutritional supplements and in extreme cases pharmacological substances in an effort to attain their ideal physique. These substances range from over the counter protein and energy drinks to ergogenic aids such as creatine and in extreme cases anabolic steroids. Worblewska (1997) reported that as many as 75% of those participating in body building competitions used anabolic steroids. Olivardia et al (2000) claims that more than half of MD sufferers use steroids, and that the rest are tempted. He also adds that use of nutritional supplements is almost universal in this group. This suggests MD sufferers are willing to use possible life ending drugs in a bid to attain a physically attractive physique.

Exercise Dependence

Weinberg and Gould (1999) defined an individual who is exercise dependant as someone who exercises compulsively, maintains a rigid schedule of intense exercise, feels guilty when the exercise schedule is violated, exercises when ill, tried or injured. Pope et al (1997) states that previous research has suggested a link between BDD and Obsessive-Compulsive Disorder (OCD) there has been no direct research into whether MD will elicit similar tendencies as BDD.

Smith, Hale & Collins (1998) suggest there is strong evidence that exercise dependence can be psychologically, socially and physically debilitating. The researchers found that prolific exercisers suffered symptoms such as guilt and depression when unable to exercise as planned. They also state that the majority of research in the area has been focused on aerobic exercise. Kubistant (1998) found that weight training could enhance self-esteem (for theory behind this see 3.1). As self-esteem is improved this can become the focus of weight training as the individual feels good about one’s self. This time-spent training in the gymnasium can become the sole time the individual feels this enhanced level of self-esteem and therefore in some cases becomes compulsive about their training. The authors state that individuals most susceptible to exercise addiction are those whose self-worth is reliant upon their identification of themselves as athletes.

Pierce and Morris (1998) found that power lifters elicit a high level of exercise dependence when using a modified addiction scale for runners. They found that exercise addiction was largely a socially influenced within the body building community as it signifies high levels of dedication needed to gain a prominent role within the complex social community.

Pope et al (2000) also found that many MD sufferers employment was dictated by their need to train. Many would be employed, as personal trainers enabling exercise at will. Others employment would be selected with the sole objective if fitting into their work out regime.

Smith et al (1998) found a significant lack of quantitative measures of exercise dependence relating to anaerobic activities. The researchers therefore sought to devise and validate a measure of their own – the Bodybuilding Dependence Scale (BDS). This was a 9-item, Likert scale design designed to determine the degree to which bodybuilders suffer form exercise dependence. The BDS was found to have high levels of internal consistency and construct validity.

Physique Protection

Pope et al (2000) hypothesised that MD sufferers will also go to great lengths to hide perceived defects in their physiques by various intervention methods, such as avoiding busy times of training at the gymnasium as to reduce the risk of training with more muscular weight trainers, wearing baggy clothing to hide the size and shape of their physique and avoiding public situations where physique exposure is necessary.

1.7 Consequences of MD

In addition to compromising health, MD can also affect an individual’s quality of life (Pope et al, 2000). The obsessive behaviour can interfere with education, job and career opportunities. Olivardia et al (2000) add that MD can effect personal relationships with significant others as MD sufferers are obsessed with their selfs to the point where others needs pale into insignificance. Sufferers also have to endure side effects associated with related eating disorders, over training and steroid use. These side effects can manifest themselves in restlessness, slowed metabolism, mood swings, anxiety and depression (Olivardia et al 2000).

1.8 Remedial intervention methods

Many people with MD resist getting treatment stating that they are content with the way they are. Some admit they are afraid that if they give up the drugs and exercise, they will wither away to frailty. For those who enter treatment, cognitive-behavioural therapy combined with medication such as serotonin reuptake inhibitors (Pope et al 2000). Another strategy may be to help suffers realise that the current portrayal of male body image are unrealistic. If males are made aware to rise above the messages of contemporary society and the media, they can regain the harmony with their bodies that previous generations took for granted (Olivadia et al 2000).

Chung (2001) opposes the use of cognitive-behavioural therapy due to the fact the MD sufferer would be influenced by a therapist’s personal view of body ideals. As body ideals vary between individuals the author believes consistency of treatment would suffer. Therefore Chung (2001) proposes the focus of therapy should be around modifying one’s perception of the physical self and resultant behaviours to achieve a more realistic body ideal.

1.9 Critique of proposed MD criteria

Despite many authors claiming MD is a specific sub-type of BDD Chung (2001) questions the validity of this statement. The author believes many of the symptoms of MD can also be linked to OCD. Philips (1993) reported that BDD was relatively common in patients being treated for OCD. The researchers concluded that OCD was possibly a characteristic of BDD, whether OCD is a direct result of BDD is yet to be ascertained.

Chung (2001) also critiques his own claim of a link between OCD and BDD by stating that OCD characterised behaviours are prevalent in other sports yet are not considered indicative of obsession. For instance many elite athletes exhibit similar behaviours such as training intensely for hours a day and being concerned with weight and size. A judo player may be concerned with losing enough weight and a rugby player with gaining weight. These individuals may meet the diagnostic criteria for MD yet their behaviour is sanctioned by their athletic culture.

Chung (2001) also states that the main purpose of bodybuilding is to have greater muscularity and leanness than your competitors. The author questions whether it is possible to differentiate between a healthy level of dedication and MD and therefore questions MD’s warrant of being termed a subcategory of BDD.

Exercise is an excellent and low-cost way of getting back on track, or simply where you want to be. Train hard and you will keep healthy: and as was aforementioned, you will be able to achieve anything. I hope this helps at least one person. Thanks to those who’ve helped me.


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