What is Muscle Dysmorphia (MD)?

Back in 2015, the BBC reported that as many as 1 in 10 men in the gym were believed to have muscle dysmorphia. That figure equated to about 0.7% of the UK’s population, or around about 427,000 British males. Since then, social media has fuelled the situation more, with men in particular being bombarded with “supermale” images on a daily basis on sites like Instagram.

The situation is serious. In 2021, suicide prevention charity CALM published data which showed that half of men under 40 have struggled with their mental health as a result of their body image. Indeed, half of the men with muscle dysmorphia had already attempted suicide.

What is muscle dysmorphia?

Muscle dysmorphia (MD) has also been colloquially called “bigorexia” and is much more common in men compared with women. Men’sHealth Magazine describes it as a “disorder of magnitude” where men are “pathologically preoccupied with their muscularity to the extent that they can think about getting bigger or leaner for over five hours a day”.

Essentially, it is characterised by a disturbance in how a person view’s their body including a drive for increased muscularity. A person suffering from MD perceives themselves as being too small and/or weak despite the person actually being muscular and large. Often prevalent in bodybuilders and weightlifters, MD affects the person psychologically, socially and behaviourally.

Psychologically, those with MD are preoccupied with their appearance, often hiding their muscular bodies as they feel too small. Often, showing their bodies results in embarrassment and shame. Behaviourally, a person with MD will exercise excessively and obsessively, spend hours in the gym, have disordered eating including protein muscle-building shakes, and sometimes steroid use. Socially, MD leads to an inability to function well at work as well as withdrawing from social life, preferring to spend more time working out.

There is still much debate about what kind of condition muscle dysmorphia is. MD has been considered a subtype of body dysmorphic disorder, but it is still debated whether this should be the case or whether it is more akin to obsessive-compulsive disorder or even an eating disorder. Regardless of its classification, MD has exercise psychopathology as a key symptom, so excessive exercising, negative moods when prevented from exercising and impaired social functioning as a result are all features.

What causes muscle dysmorphia?

It is not exactly clear what causes muscle dysmorphia. However, in a similar way to other psychological disturbances, it is likely the result of a combination of factors including a person’s genetic predisposition to developing psychiatric conditions as well as their present environment and past experiences.

Studies suggest that there is a trend towards an individual having experienced a traumatic experience (such as but not limited to physical assault, bullying or rape) and muscle dysmorphia. Research by Murray et al quoted one of its participants as having said: “When I get big, I reckon people just won’t mess with me.” This implies that excessive training leading to MD may have stemmed from a desire for safety and protection when faced with adversity in some individuals.

Research also suggests that some participants with MD in these studies could have made the leap to the condition as a result of their desire for reproductive success, given that muscularity is a secondary sex characteristic in males that suggests virility.

There’s also a third precursor that correlates negatively with the development of MD: genital satisfaction. Given that around 50% of males are reportedly unhappy with the size of their penis, developing a preoccupation with muscularity could be seen as a way of addressing this insecurity, whether consciously or not.

What are the signs and symptoms of muscle dysmorphia?

The signs and symptoms of muscle dysmorphia may include:

• Excessive weight training.
• Disordered eating including restricted diets, use of protein products such as shakes, or eating in a regimented way.
• Spending many hours exercising.
• Missing social activities and/or important events to exercise.
• Obsessively checking one’s appearance including looking in mirrors or taking photos/selfies.
• Avoiding looking in mirrors or being in photographs.
• Avoiding situations where the body may be visible such as going to the beach or swimming.
• Weighing oneself daily or more often.
• Taking supplements/drugs to reduce body fat or build up muscle mass.

What are the risk factors of muscle dysmorphia?

Muscle dysmorphia is much more prevalent in males than it is in females. This means that males are at an increased risk of developing the condition. It is also thought that those who already visit the gym may be at increased risk due to the perceived competition in the gym environment.

Weightlifters and bodybuilders are at increased risk of developing muscle dysmorphia, although it has to be noted that many of these people result in being bodybuilders because they develop MD. Non-competitive athletes are said to be at less risk than those who compete. A further risk factor is lifting weights in order to change body composition, focussing on appearance rather than improving performance.

The onset of MD tends to occur during late adolescence, so young males particularly are at risk at this time. This often coincides with them choosing career paths, which can also influence the development of the condition. A 2014 study also showed that those who study sports science and exercise are much more likely to have traits of MD than those studying other subjects such as dietetics and biology.

Despite being rare in women, women bodybuilders, especially those who have experienced a traumatic experience such as an assault or rape, are much more likely to develop muscle dysmorphia in comparison with non-bodybuilding women.

As mentioned, social media, photo editing apps and TV also have a lot to answer for when it comes to the onset and development of MD. If a person scrolls Instagram and follows weightlifting or bodybuilding accounts or hashtags, they are more likely to become preoccupied and obsessive about their own musculature comparatively.

Photo editing apps are also extremely harmful, not only because the photos you see of bodybuilders on social media are often highly edited or angled well, but also because editing apps can also allow people to edit their own photos to see what bigger muscles would look like on themselves, comparing their real body with a manipulated, edited version. This is what can then drive their desire to be bigger even further. Programmes like Love Island which seemingly only feature one body type – you’ve guessed it, the young, fit, muscly kind – only serve to make the bombardment of the superhuman image worse.

What disorders can be seen alongside muscle dysmorphia?

Given that muscle dysmorphia has psychological and environmental causes, it is often linked or concurrent with other disorders. These often include OCD, eating disorders such as anorexia and bulimia, depression and anxiety, and personality disorders like vulnerable narcissism.

Eating Disorders

Muscle dysmorphia is sometimes called “reverse anorexia” and there is certainly a cross-over between eating disorders and the condition. Restrictive eating, anorexia, bulimia nervosa and binge eating disorder are all commonly seen with muscle dysmorphia.

Obsessive-Compulsive Disorder

OCD is also common among those with MD. Indeed, excessive exercising in itself may be an obsession and a compulsion within this condition.

Mood Disorders

Conditions such as bipolar disorder, depression and anxiety also coincide with MD. Depression can be the result of the MD or it can be a part of its cause.

Other Conditions

Muscle dysmorphia also has other comorbidities such as attention deficit hyperactivity disorder (ADHD) and social anxiety disorder. Substance abuse (whether anabolic steroids or other substances) is also strongly correlated with muscle dysmorphia.

Living with muscle dysmorphia

Living with muscle dysmorphia is extremely difficult. Firstly, many people with MD will not admit their feelings nor will they accept that they have a condition. This is particularly an issue when it comes to men and their mental health.

It’s perhaps easier to understand what life is like for someone with MD by looking at someone with the condition. Craig Costa, an American bodybuilder, describes his life with MD in Men’sHealth magazine. He describes being triggered almost all the time, from the moment he wakes and looks in the mirror, to when he goes to the gym and when he scrolls Instagram.

Costa spends his time at the side of the wrestling ring comparing his physique to the other athletes, distracting him from his performance. When he does receive compliments, he deflects them and makes jokes. He disbelieves them as he knows it’s not true. The insight into Costa’s life shows the psychology behind the condition.

Living with the condition can be even more extreme. Sufferers often pick the most minuscule flecks of fat out of meat they’re eating, refuse to kiss people as it risks extra calories being ingested via the salvia, and even refrain from sex so that their energy can be used for training. For some, training is only considered successful if it’s made you vomit or faint.

Sufferers also miss important events because of their preoccupation with training and food. Wedding menus may not cater to their needed macros that day or they may miss a party because it’s leg day. The person’s self-esteem is so intertwined with their musculature that it dwarfs everything else into insignificance. Indeed, anecdotally, men with MD have reportedly given up their well-paid job so that they can become a personal trainer, fuelling their need to train all the time.

How is muscle dysmorphia diagnosed?

Muscle dysmorphia is assessed by using the Muscle Dysmorphic Disorder Inventory checklist (MDDI).

Questions in the checklist are scored from ‘never’ to ‘always’:

• I think my body is too skinny/slender.
• I wear loose clothing so that people can’t see my body.
• I hate my body.
• I wish I could be heavier.
• I find my chest too small.
• I think my legs are too thin.
• I feel like I have too much body fat.
• I wish my arms were stronger.
• I am embarrassed to let people see me without a shirt or t-shirt.
• I feel anxious when I miss one or more days of exercise.
• I cancel social activities with friends because of my workout/exercise schedule.
• I feel depressed when I miss one or more days of exercise.
• I miss opportunities to meet new people because of my workout schedule.

Each of these questions corresponds with a specific category of questions such as the drive for size (questions 1, 4, 5, 6, and 8), appearance intolerance (questions 2, 3, 7 and 9) and functional impairment (questions 10, 11, 12 and 13).

This shows that there are three areas that assessors look out for when diagnosing muscle dysmorphia:

• A desire to be bigger/stronger.
• The dissatisfaction with appearance.
• Impaired functioning.

Many people don’t recognise that they are living with MD until they’re diagnosed with something else such as depression as a result of a training injury or that their relationship has ended (often as a result of their MD). For others, they’re diagnosed once they learn that their use of steroids to build up muscle has destroyed their sperm count and they find they can’t conceive.

Treatment for MD is sought by a sufferer’s family as they’re the ones that recognise the signs long before the sufferer does. This was the case with Asa, whose story can be read among others on the MyoMinds website.

How is muscle dysmorphia treated?

Seeking treatment is often fraught with difficulty for those who suffer from MD. Many sufferers deny that they have the condition and many refuse to consider treatment especially if it is mental health related. Some individuals seek surgery to correct the flaws they perceive in their bodies rather than seek psychological help.

Muscle dysmorphia is often considered a difficult problem to treat given that its trigger and cause are often unknown. Many doctors choose to treat muscle dysmorphia in a similar way that they would treat other body dysmorphic conditions. These treatments would include cognitive behaviour therapy (CBT) and antidepressant medications such as SSRIs.

Treatment can be a dilemma. By not treating the condition, the person continues to struggle and be unhappy with their condition. But, seeking treatment will mean reduced exercise, reduced muscle mass and stopping any use of steroids that they may be using. For this reason, educating individuals as a part of their treatment process is essential.

Cognitive behaviour therapy can teach sufferers to put the brakes on their thinking and challenge their beliefs about themselves. It can also teach strategies such as limiting mirror time in the morning to just enough time to sort one’s appearance or increasing socialisation by doing something without having done a workout that morning. This kind of therapy is often supplemented with support groups, either in person or online.

Given that research into muscle dysmorphia is relatively small in comparison to other medical conditions, more research needs to be done to fully understand the condition and to discover treatments that are most beneficial for sufferers. What’s more, social media and TV companies need to step up and change the perceptions of viewers by being more inclusive on their platforms when it comes to representing bodies of all shapes and sizes. If not, the future is likely to be even bleaker in this regard when it comes to future generations.