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Muscle Dysmorphia and Body Dysmorphic Disorder

Posted Sep 22 2008 5:37pm

Former body builder, Christopher Bell, had a unique, insiders look at the use and abuse of anabolic steroids. You see, both of his brothers are also body builders, one is a champion, and the other became tried his luck on the pro-wrestling circuit.

For Bell, the use of steroids was not something that he could condone, but his brothers both felt otherwise. In an attempt to understand the reasoning behind his brothers' choice, Bell embarked on the task of making a documentary about the use of performance-enhancing drugs "and their effects on the American dream". The result: "Bigger, Stronger, Faster"; released in U.S. theaters on May 30, 2008 by Magnolia Pictures.

As the film's director, Bell attempts to explore some of the medical claims about the dangers of anabolic steroid use, the ultra-competitive world of professional sports, and the American culture's obsession with fit, muscular male images. Among other concerns, Bell includes a critical look at the role of male images in advertising, unveiling the methods of airbrushing and enhancement that can make any man look 30 pounds thinner and 40 pounds more muscular. However, Bell neglects a very important consideration and fails to in any way address an increasingly prevalent condition that may very well be at the heart of a majority of cases of abuse of performance-enhancing drugs: muscle dysmorphia (MD).

A sub-type of body dysmorphic disorder, muscle dysmorphia is the belief that one's body build is too small or inadequately muscular, even when one is very muscular and in peak physical shape (see Treatment Notes dated 8-29-08 for more about body dysmorphic disorder). You may have heard this condition described as "reverse anorexia", or even "bigorexia" (both are an unfortunate choice of words). More recently, specialists Harrison Pope, Katherine Phillips, and Roberto Olivardia have referred to the body image concerns and related symptoms that accompany MD as "The Adonis Complex".

The condition almost exclusively affects males and can lead to obsessions about body size and muscularity that can literally dominate a man's life. Pursuit of muscular strength and a "cut" body outweighs all other pursuits; self-esteem is built solely upon body shape and build. In contrast to weight-lifters without MD, MD sufferers demonstrate a wide range of pathology.

The DSM-IV-TR includes the following considerations for diagnosing muscle dysmorphia:

  • The individual is obsessed with the belief that his or her body should be more lean and muscular.
  • Significant amounts of time devoted to weight lifting and fixation on one’s diet are common.
  • Two of the following should be present: 1) The uncontrollable focus on pursuing the usual training regimen causes the person to miss out on career, social, and other activities, 2) Circumstances involving body exposure are preferably avoided; if avoidance is not possible, significant unease and worry occur, 3) Performance in the work and social arenas is affected by the presumed body deficiencies, 4) The potentially detrimental effects of the training regimen fail to discourage the individual from pursuing hazardous practices.
  • 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

Research indicates that people with MD perceive themselves as small in build, even when the opposite may in fact be true.In efforts to fix their perceived smallness, people with muscle dysmorphia lift weights, engage in resistance training, and exercise compulsively. They may take anabolic steroids or other muscle-building drugs to get bigger, a practice with potentially lethal consequences.

The persistent preoccupation, obsessions and compulsive exercise seen in MD may interfere with one's schooling, career, relationships, and general well-being.  Shame and embarrassment are frequently reported by males with MD. According to, "since the person is exceedingly self-conscious at all times, s/he cannot relax and enjoy life without worrying about how other people may be seeing, and criticizing, the perceived smallness." Those with MD, through compulsive and excessive exercise, may experience damage to their muscles, joints, and tendons. However, most will continue their intensive exercise despite injury. Males with MD are at increased risk for unhealthy weight control methods and eating disorders.

As is true with eating disorders, the biggest hurdle is convincing the person with MD that he or she needs help. Etiology and treatment of MD is similar to that which is efficacious for Body Dysmorphic Disorder (see Treatment Notes dated 8-29-08).

Sources: Olivardia, R. (2004). Body Dysmorphic Disorder. In Thompson, J.K. (Ed.) Handbook of eating disorders and obesity, pp.542-561. New Jersey: John Wiley & Sons.

Pope, H.G., Phillips, K.A., &Olivardia, R. (2000). The adonis complex: The secret crisis of male body obsession. Washington D.C.: Free Press.

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (DSM IV-TR). 4th ed. Washington, DC: American Psychiatric Association; 2000.

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