TABLE OF CONTENTS
2. Bigorexics and their stories
3. Signs and symptoms of muscle dysmorphia
4. Psychobehavioural factors
5. The Media as a contributor
6. Co-occurring psychiatric disorders
7. Contributing factors
8. Obsessive-compulsive disorder and anxiety
9. Sexual orientation concerns
10. Intervention strategies and treatment
11. Advice for the family
12. Additional reading
13.1 Appendix A – Diagnostic Criteria for Muscle Dysmorphia (Pope et al.: 2000, p 248)
13.2 Appendix B – Do I Have Muscle Dysmorphia? (Paterson: 2008, pp 47-48)
13.3 Appendix C – Clues to the Adonis Complex in Boys (Pope et al.: 2000, pp 194-195)
13.4 Appendix D – Drugs Abused by Athletes as Compiled from Underground Guides
The term ‘bigorexia nervosa’, along with another synonym ‘reverse anorexia’, are nicknames for muscle dysmorphia. Muscle dysmorphia is deemed to be a sub-type of body dysmorphic disorder. It is seen primarily in men who usually perceive themselves as puny, or not muscular enough. The man or boy with muscle dysmorphia is bombarded with obsessive thoughts that their muscles aren’t big enough and feel small and weak, even though, in many cases, they may actually have large, strong muscles.
The Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) describes body dysmorphic disorder (BDD) as a preoccupation with a defect in appearance. The defect is either imagined or minor, but if a defect is present, the individual’s concern about the defect is markedly excessive in comparison with the severity of the defect (Claiborn & Pedrick: 2002). Sufferers of Muscle Dysmorphia, like others with BDD, see parts of their body as defective. This excessive preoccupation with body size and muscularity causes the sufferer to feel small when they’re actually big.
In Paterson (2008), muscle dysmorphia is defined as a syndrome seen in both men and boys who feel dissatisfied with their bodies; not believing they are muscular enough. Morgan (2008) explains that at the ‘root’ of muscle dysmorphia is a distortion of body image. Body dysmorphia occurs almost exclusively in males and is a condition that consists of believing that one cannot be big enough (Andersen et al: 2000). In the Psychology Today magazine of 1997, it was reported that 43% of men interviewed were dissatisfied with their overall appearance; this is a dramatic increase form 15% in 1972 and 34% in 1985; so much so that Claiborn & Pedrick (2002) suggest that male body image dissatisfaction is catching up with that of women. Andersen et al. (2000) purports that more men than ever are dissatisfied with their weight, but unlike women, half of them want to get heavier, almost always in the form of increased muscle. In Phillips (2009) we discover that approximately one-quarter of men with body dysmorphic disorder are preoccupied with their overall body build.
Morgan (2008) suggests that muscle dysmorphia exists at the end of a spectrum of behaviours designed to reshape the body. A strong parallel with body dysmorphic disorder is the ‘imagined’ status of the defect in appearance; the brain of the bigorexic sufferer sees a perfectly normal body shape, but the mind perceives a skinny nobody; even with good muscle mass they believe their muscles are inadequate.
There is an estimated prevalence of BDD in the general population at about 1-2%. Muscle dysmorphia, being a sub-type, accounts for around 10% of the BDD population, according to Pope et al. (2000) however if we were to add in all those males with less serious muscle obsessions, the percentage would probably be double or triple this figure.
The term ‘muscle dysmorphia’ was coined in 1997, yet we still know very little about the development of body image, particularly during the preschool and early elementary school years and very few have examined males’ body image perception in this age group (Drummond: 2006). We are aware however, that children as young as five experience feelings of body image dissatisfaction as they begin to reflect upon, compare and contrast their own bodies with others and the images around them. These perceptions of young boys are under reported and often not regarded as an issue of concern, yet with muscle dysmorphia affecting boys as young as 6 years of age and up to 7% of high school boys abusing anabolic steroids to build muscles, with the primary motivation being to improve physical appearance; a thorough understanding of the signs, symptoms and causal factors for the development of muscle dysmorphia is essential.
2. Bigorexics and their stories…
Meet Brian, Mark, Nick and Jack, four bigorexia sufferers. Here are their stories;
Brian, a high school freshman, dreads going to gym class each day. At 6’2” and 130 pounds, Brian feels that his muscle development is well below other boys his age. Spending each night feeling his arms and counting his ribs in front of the mirror, Brian refuses to go to the gym, too afraid that others will make fun of him, and instead overeats constantly in an attempt to gain weight. Today in physical education, the all-male class is playing “shirts and skins” basketball. Knowing that he will be on the “skins” team, Brian is trying to think of a way to get out of class. (Frame: 2004)
Mark, a muscular man in his 20s, believed his upper body was too thin and that he looked “dwarfed and wimpy”. To build himself up, he drank protein drinks every day and lifted weights for hours daily. At least 20 times a day he asked his father, “Do I look okay? Am I getting bigger?” Mark always wore long-sleeved shirts to hide his “skinny” arms and avoided going to the beach. When I (his therapist) met him, he was wearing five layers of T-shirts and sweatshirts to look bigger. (Phillips: 2009)
Nick, a 32-year-old former mechanic, carried weight lifting to an extreme, severely damaging his body. Nick had severe muscle dysmorphia. To increase his body size, he ate massive quantities of food, weight-gain powders and special vitamins. He also wore extra shirts and padded his clothes. “But the main thing I did,” he said, “was lift weights. I lifted for hours a day.” Lifting became the focus of Nick’s life. I stopped working because of it. I dropped out of life…I couldn’t concentrate on my work because all I was thinking about was lifting. I didn’t see my friends-I just stayed in my basement lifting. I lost a lot of them because of it. Once, I got so upset thinking I wasn’t big enough that I stayed in my basement for a month, lifting and lifting. I was so depressed, thinking I’d never be big enough, that I thought I’d rather be dead. I couldn’t let anyone see my body. (Phillips: 2009)
I [Jack] was a skinny kid, and very self-conscious about the way I looked. I particularly hated my knobbly knees and used to get teased at school about them. Things were fairly miserable at home in any case, so that was just one piece of the jigsaw…I didn’t want to be seen as nerdy anymore, and started to think more about the way I dressed and my haircut, I even got my ear pierced…I started working out in the university gym…I found I was really good at lifting weights, and I surprised myself that I could shift heavier weights than guys who looked bigger than me…I really began to bulk out, particularly my biceps and pecs…the bigger I got, the more I wanted to grow. I became a lot more self-conscious about myself in the changing room, comparing myself with the other guys, thinking that their glutes and pecs seemed bigger than mine…I wasn’t doing well academically and I started to work out at the same time as I was revising…I began to be obsessed with my diet, eating lots of raw eggs…some days I would skip lectures to fit my [gym] routine in…it made me feel in control…then I began to read bodybuilding magazines and sent away for some [commercially available protein supplements]…I soon realized that everyone at the new gym was taking steroids…I gave it a go…what I really didn’t like was the effect it had on my mind…I didn’t really mind the roid rage [but] I felt tired, tired, tired and just couldn’t get out of bed in the morning sometimes…it didn’t really bother me being chucked out of university, but I was really concerned that [now] I didn’t know where to workout…(Morgan: 2008)
As is blatantly obvious in the case of Nick and Jack, muscle dysmorphia has serious, long-reaching effects on the psychological and physiological makeup of the sufferer. We can identify some common symptoms or signs in males who may be developing or have developed muscle dysmorphia.
3. Signs and symptoms of muscle dysmorphia…
Brian feels extreme shame and embarrassment about his perceived ‘skinny’ body; Mark resorts to drinking protein shakes and lifts weights for hours in order to try to bulk up; Nick eats massive quantities of food and lifts weights excessively to try to look larger than he ‘thinks’ he is, and Jack eventually succumbs to the potential of supplement and steroid use to gain muscle mass. All four of the males show signs of muscle dysmorphia in their behaviour.
In Veale et al. (2009), we see that many men who have developed muscle dysmorphia spend hours lifting weights and pay great attention to nutrition, with some resorting to the use and abuse of steroids in their struggle to gain mass. The male with muscle dysmorphia is completely preoccupied with their body build and this leads them to try and work harder and harder to build muscles, leading to often dangerous patterns of over-exercising (Paterson: 2008).
Sufferers of bigorexia are likely to become very withdrawn and avoid social situations, they will often wear excessive amounts of shirts and jumpers to try to look bigger (more muscular) to others. They are unlikely to have a girlfriend as most of their time is taken up by their constant exercise regime, in addition the self-esteem of the sufferer is so low that they doubt very much whether any girl would be interested in them anyway due to their ‘small and puny’ physique.
In addition to the ‘self-hatred’ of their bodies they show extreme fanaticism in their diet choices and will often avoid complete food groups such as carbohydrates or fats. The excessive exercising leads to extreme hunger and can result in them ‘binging’ on the carbohydrates and fats that they attempt to eliminate from their diets.
In extreme cases financial difficulties can develop as massive amounts of money is pumped in to gym memberships, personal trainers, expensive home gym fitness equipment and dietary supplements. Paterson (2008) confirms that there is a strong link between muscle dysmorphia and compulsive overeating, which again can lead to financial hardship for the sufferer.
They will often experience exhaustion and low body temperature from over exercising, which can lead to hypothermia. High blood pressure and low testosterone levels can lead to a diminished sex drive in the bigorexic male. Restlessness and anxiety are juxtaposed with mood swings and a sluggish metabolism often leading to bouts of depression. The over-exercising of the bigorexic can also lead to physical injuries or over-developed legs, leading to chaffing or bleeding; their exercising goes beyond the bounds of health (Morgan: 2008). They obsess about their diets and apportion their food for the day, even avoiding restaurants in cases; they will habitually go on holiday where there is a gym, or they transport their weights with them, limiting sex to conserve their energy for workouts.
In the article Recognition and treatment of muscle dysmorphia, Leone et al, site the Self-Destructive Behaviours Associated with Muscle Dysmorphia, courtesy of Dawes and Mankin:
- Disordered eating patterns and/or an eating disorder
- Preoccupation with working out at expense of social commitments
- ‘stressful dieting’ (i.e., very high-protein or low-fat diets)
- Training despite the presence of injuries or illness
- Abuse of pharmacologic agents (i.e., anabolic steroids)
- Excessive use of dietary supplements (i.e., creatine)
- Disruption of body image satisfaction
- Obsessive-compulsive rituals
In research conducted by Phillips (2009) it was determined that 71% of men with muscle dysmorphia (MD) lifted weights excessively, 64% exercised excessively and 71% dieted, in addition 86% of the men had a problem with alcohol or drugs. In order for a diagnosis of muscle dysmorphia to be given to a sufferer the DSM-IV outlines the Diagnostic Criteria for Muscle Dysmorphia (see Appendix A), with the focus being on a preoccupation with the ‘idea’ that the body is not sufficiently lean and muscular. In Morgan (2008) we are presented with The Muscle Dysmorphia Questionnaire (MuD-Q), if five or more ‘yes’ responses are given to these questions it is highly probable that you are suffering from muscle dysmorphia, with a possibility occurring with at least three positive responses.
The Muscle Dysmorphia Questionnaire (MuD-Q)
1. Do you feel yourself to be scrawny when others tell you that you’re too muscular?
2. Do you feel that you have lost control over your exercise regime?
3. Do physical activities to enhance your appearance dominate your life?
4. Do you spend more than an hour a day in training to improve your body shape?
5. Do you spend more than 30 minutes a day in checking your physical appearance?
6. Do you currently take drugs (steroids, diet pills, muscle-building agents) to enhance your physical appearance?
7. Do you regularly prioritise your physical regime over your career or studies?
8. Do you regularly prioritize your physical regime over your friends, family or relationships?
9. Have you continued in your physical regime despite being injured or ill?
10. Do you avoid situations in which your body will be seen by others?
In addition to the MuD-Q, Paterson (2008) presents a system of questions to determine if you are suffering from muscle dysmorphia; a ‘yes’ response to a number of these questions would be indicative of a problem (see Appendix B).