In Australia, 3% of the total male population is estimated to have a DSM-5 diagnosed eating disorder (Hay, Girosi, & Mond, 2015). Recent studies show that over-exercising and an extreme pursuit for muscle growth are often perceived as healthy behaviours for males (Mitchison & Mond, 2015). However, such behaviours can lead to severe health issues, such as muscle dysmorphia.
What is Muscle Dysmorphia?
Muscle dysmorphia, also termed ‘bigorexia’ or ‘reverse anorexia’, is characterised by a preoccupation with the idea that one’s body is too small or insufficiently muscular, despite having an average to very muscular physique (American Psychiatric Association, 2013). Individuals with this disorder have an extreme distortion of body image. As a means of pursuing muscularity, individuals with muscle dysmorphia will often engage in meticulous dieting, excessive exercise (particularly excessive weight lifting) and in some cases substance use (such as anabolic-androgenic steroids) (American Psychiatric Association, 2013; Mitchison & Mond, 2015; Murray et al., 2012).
Due to muscle dysmorphia being a relatively new diagnosable disorder, there is a lack of consensus regarding diagnostic criteria and hence the population prevalence is still unclear (Mitchison & Mond, 2015). Mitchison and Mond (2015) suggest that body image concerns, particularly muscle dysmorphia, have a later onset in males than females. To assist with understanding the presentation of this disorder, recent studies have explored the links between muscle dysmorphia and eating disorders symptomatology.
Body dissatisfaction is becoming increasingly prevalent among the male population. In particular, muscularity has been recognised by males as a representation of masculinity (Franko et al., 2013; Murray et al., 2013). Pope, Phillips & Olivardia (2000) argue that gender role stereotypes may be contributing to this, as male preference for a muscular physique is consistent with the male body ideal frequently portrayed in contemporary Western media. A cohort study, involving 246 young heterosexual men completing an online survey, found that increased conformity to the aforementioned ‘masculine norms’ predicted greater muscle dissatisfaction and muscularity-orientated disordered eating (Griffiths, Murray & Touyz, 2015). According to Griffiths, Murray and Touyz (2013) muscularity-orientated disordered eating behaviours include very high levels of protein consumption, restriction of non-protein related food components, timed eating (every 2-3 hours), liquid calorie consumption, the use of appearance enhancing drugs (testosterone boosters, steroids) and supplement use. Similar to DSM-5 diagnosable eating disorders (Anorexia Nervosa, Bulimia Nervosa, Binge Eating Disorder and OSFED), such regimented behaviours indicate an unhealthy preoccupation with food to achieve a certain appearance or physique. As well as muscularity-orientated disordered eating and excessive exercise for muscle growth, muscle dysmorphia has been shown to be linked with several other compulsive body image behaviours such as; excessive body checking, body avoidance (deliberate covering or avoiding mirrors), self-comparison to others’ bodies and social avoidance (Mitchison & Mond, 2015; Veale, 2004). Over the past 10 years, research exploring the relationship between sexual orientation and body dissatisfaction has increased. A particular study conducted in the United States in 2016 found that gay men reported lower body satisfaction than heterosexual men and were nearly twice as likely to diet for weight loss as opposed to increased size or muscularity which has previously been identified as a reason for dieting among heterosexual men (Frederick & Essayli, 2016).
An additional Australian study found that adverse relationships between body dissatisfaction and mental health related quality of life and between body dissatisfaction and psychological distress were more pronounced in males than females (Griffiths et al., 2016a). Such findings highlight the external pressures and expectations placed on males to conform to ‘masculine norms’, which when internalised can potentially increase the risk of body image concerns, such as muscle dysmorphia, and disordered eating behaviours (Murray et al., 2013; Griffiths et al., 2015).
Sports and Fitness
In some sports, weight and physique are recognised as performance enhancing qualities. Research suggests that male athletes involved in sports stressing muscularity and aesthetics may be predisposed to developing muscle dysmorphia (Leone, Sedory & Gray, 2005). Increasingly, evidence is showing links between competitive bodybuilding and muscle dysmorphia (Mosley, 2009; Santarnecchi & Dettore, 2012; Leone et al., 2005). Competitive bodybuilding is the pursuit of a muscular physique through strenuous exercise and tailored dieting. Competitors pose on stage and are scored by a panel of judges based on size, symmetry and definition of musculature (Mosley, 2009). In order to achieve ‘ideal’ aesthetics, bodybuilders engage in regimented weight training and dieting, often guided by coaches (Mosley, 2009; Santarnecchi & Dettore, 2012). A study exploring bodybuilding attitudes and behaviours found that competing bodybuilders showed higher levels of appearance intolerance (correlated to body dissatisfaction and self-esteem) and supplement use, demonstrated a significant drive for size and engaged in less social interaction, when compared with non-competing bodybuilders and non-trainers (Santarnecchi & Dettore, 2012). The severity of muscle dysmorphia was also greater in competing bodybuilders. This reinforces previous research findings that involvement in aesthetic focused sports can increase a male’s risk of developing muscle dysmorphia and potentially an eating disorder. It is to be noted, however, that bodybuilding is not an exclusive sport impacting on muscle dysmorphia prevalence, but rather an example, and hence future research could focus on additional sports which encourage associated behaviours.
Extensive research shows that anabolic- androgenic steroid (AAS) use among males is becoming increasingly associated with a drive for muscularity and improved appearance, rather than enhanced performance (Griffiths et al., 2016b; Cohen et al., 2007). Additionally, body dissatisfaction has been reported as a common denominator between males with eating disorders and males using AAS (Bjork, Skarberg & Engstrom, 2013; Kanayama et al., 2006). A recent study investigated whether comorbid body image psychopathology varies as a function of motivation (appearance versus performance) for AAS use (Murray et al., 2016). It was found that males using AAS for appearance purposes reported greater dietary restraint and functional impairment. Overall, those using AAS primarily for performance showed greater eating disorder psychopathology and muscle dysmorphia psychopathology. From these findings, one might argue that the pursuit of muscularity among males may continue to increase non-medical use of AAS, and consequently result in a higher prevalence of muscle dysmorphia and/ or eating disorders. Griffiths et al. (2016b) claim that health professionals, researchers and policy makers should have an understanding of the science behind steroid efficacy. It is argued that such knowledge can provide insight into the allure of steroids and may better inform professionals in preventing and treating steroid use (Griffiths et al., 2016b).
Treatment and Future Diagnosis
To date, there is limited research on direct treatment approaches for muscle dysmorphia. This may be due to the lack of consensus around diagnostic criteria (Mitchison & Mond, 2015; Suffolk, Dovey & Goodwin, 2013). A particular case study conducted in 2015, explored the effectiveness of family-based treatment, commonly used for Anorexia Nervosa patients, on a 15 year old male with muscle dysmorphia (Murray & Griffiths, 2015). Treatment included 10 sessions over a period of 7 months and assessment was based on the Muscle Dysmorphia Disorder Inventory (MDDI) which measures drive for size, appearance intolerance and functional impairment. Post discharge, the male’s MDDI score reduced significantly from 59 to 10. In addition to this, the male’s parents reported no detection of disordered eating and a significant improvement in mood. This evidence may inform future treatment approaches for adolescents, however additional research is required.
As previously mentioned, there is recent debate around the diagnosis of muscle dysmorphia. This illness is currently classified in the DSM-5 as a subtype of body dysmorphic disorder in the Obsessive Compulsive and Related Disorders section (American Psychiatric Association, 2013, p.243). Eating disorders experts acknowledge the obsessive compulsive component of muscle dysmorphia, however argue that due to associated rigid eating behaviours, weight preoccupation and intensive training, muscle dysmorphia symptomology also aligns closely with eating disorders diagnosis (Nieuwodt et al., 2012; Murray et al., 2010). It is suggested that identifying coherent symptoms for muscle dysmorphia and acknowledging the illness as an eating disorder in the forthcoming DSM may assist health professionals in making an informed diagnosis and applying appropriate treatment approaches (Murray et al., 2010; Suffolk et al., 2013; Murray & Touyz, 2012). The classification and diagnosis of muscle dysmorphia requires further investigation and is a potential focus for future research.
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