The Classification of Muscle Dysmorphia

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For some time, society's emphasis on appearance has negatively affected women. Now we're finding increasing numbers of men who are also overly dissatisfied with their bodies. This trend has led to a new disorder, muscle dysmorphia (MD), which is characterized by a preoccupation with muscularity accompanied by perceptual, affective, and behavioral components that interfere with daily activities. Currently, MD is not included in the DSM-IV, although it is purported to be a kind of body dysmorphic disorder (BDD), which in turn is a somatoform disorder. This study investigated relationships among symptoms of MD and variables most relevant to a DSM classification of men who lift weights regularly. No relationship was found between MD and a measure of somatoform disorder. Instead, BDD, OCD (obsessive-compulsive disorder), body dissatisfaction, and hostility are the main predictors of MD. This suggests that MD is an OCD spectrum disorder, rather than a somatoform disorder.

Keywords: men weightlifters, muscle dysmorphia, body dissatisfaction, muscularity, DSM-IV, body dysmorphic disorder, obsessive compulsive disorder

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American men are experiencing increased concern about their appearance (Olivardia, Pope, Mangweth, & Hudson, 1995). One reason may be due to Western culture's growing emphasis on unrealistic, overly muscular images of men. These muscularly endowed physiques, unattainable for the average male, have been depicted in all forms of the media and even in toy action figures. One need only compare the early GI Joe action-figure body of 1964 with the "super-articulated" GI Joe body of today to glimpse the intrusion of society's devotion to muscularity into child culture. Not surprisingly, an increasing number of teenage boys and men are concerned that they are neither muscular enough nor lean enough. These concerns have been accompanied by a higher incidence of eating disorders in males (Olivardia et al., 1995). In fact, Andersen, Cohn, and Holbrook (2000) postulate that up to 25-30 percent of eating disordered individuals might be males.

MUSCLE DYSMORPHIA

With the advent of increased body dissatisfaction comes a fairly new, still under-researched disorder, muscle dysmorphia (MD). It has already reached public awareness through the publication of The Adonis Complex (Pope, Phillips, & Olivardia, 2000). Pope, Katz, & Hudson (1993) originally referred to this disorder in the medical literature as "Reverse Anorexia Nervosa" because of its similarities to certain aspects of anorexia nervosa (AN). Individuals suffering from these two disorders share common perceptual and affective characteristics. Both show a preoccupation with appearance and experience extreme distress and anxiety associated with these preoccupations. They hide their bodies in oversized clothing and participate in compulsive behaviors such as specific eating rituals with strictly monitored food intake (not to be confused with compulsive eating behaviors, in which a person overeats without regard to physical cues of hunger or satisfaction, or binges without purging) and excessive exercise. However, whereas anorexics view their emaciated bodies as too fat, individuals suffering from MD perceive their often extremely muscular physiques as too small and even puny. Moreover, people with MD may engage in harmful and even self-destructive behaviors such as continuing to lift weights even when they are injured and using anabolic steroids (Olivardia, Pope, & Hudson, 2000). A fundamental difference between AN and MD is that anorexics, being concerned with perceived body fat, engage in characteristic pathological eating behaviors with excessive exercise as a secondary characteristic, while those suffering from muscle dysmorphia, being concerned with underdeveloped musculature, engage in pathological exercise routines with restrictive eating as a secondary characteristic (Olivardia, 2001).

The identification of muscle dysmorphia emerged from three studies examining the use of anabolic steroids in weightlifters (Pope et al., 1993). The objective of these studies was not originally associated with muscle dysmorphia. Obviously, not all men who lift weights and participate in strict exercise and diet regimens fall into this pathological category. In fact, most men who exercise at gyms have healthy attitudes about fitness and realistic views about their bodies (Pope, Gruber, Choi, Olivardia, & Phillips, 1997). However, striking symptoms of obsession with muscularity emerged in these studies, thereby moving the authors to recommend that what had been previously referred to as "reverse anorexia nervosa" should be termed "muscle dysmorphia" and be considered a type of body dysmorphic disorder (BDD).

Whereas BDD is defined in the Diagnostic and Statistical Manual, 4th edition (American Psychiatric Association, 1994) as a preoccupation with an imagined defect in appearance causing clinically significant distress or impairment in social, occupational, or other important areas of functioning, not being the result of another mental disorder, Pope et al. (1997) defined muscle dysmorphia as a preoccupation with a misperception that muscles in general are small despite sufficient muscularity. This disorder affects both men and women but appears to be more prevalent in men. The mean age of onset is 19.4 years (SD = 3.6) (Olivardia, 2001; Olivardia et al., 2000; Pope et al., 1997).

An important outcome of the studies reviewed above is the suggestion that muscle dysmorphia is a valid diagnostic category. However, acknowledgment of its very existence depends upon where in the DSM system it should be classified.

MD and OCD Spectrum Disorders. Appearing to be a subtype of BDD, muscle dysmorphia would fall under the category of somatoform disorders. However, it has been suggested that BDD, and therefore MD, might be more appropriately conceptualized as an obsessive-compulsive (or OCD) spectrum disorder (1) because of its similarities to OCD characteristics. During the DSM-IV revision process, consideration was given to moving BDD to the anxiety disorders section because of these similarities. The change was not implemented because of a dearth of comparison data (Phillips & Hollander, 1996). Since that time, a wealth of research has documented substantial similarities such as intrusive, obsessional fears and compulsive rituals (Bienvenu, Samuels, Riddle, Hoehn-Saric, Kung-Yee, & Cullen, 2000; Phillips, 1998; Phillips, Dwight, & McElroy, 1998; Phillips, Gunderson, Mallya, McElroy, & Carter, 1998; Saxena, Winograd, Dunkin, Maidment, Rosen, Vapnik, et al., 2001; Simeon, Hollander, Stein, Cohen, & Aronowitz, 1995; Veale et al., 1996.) Additionally, BDD and OCD also exhibit similarities in age of onset, course of illness, and high comorbidity (Lydiard, Brady, & Austin, 1994; Phillips, Pope, & McElroy, 1994; Phillips, McElroy, & Hudson, 1995; Zimmerman & Mattia, 1998). Similarities in response to treatment have also been observed in the two disorders (Hollander & Benzaquen, 1997; Hollander, Allen, Kwon, Mosovich, Schmeidler, & Wong, 1999; Phillips et al., 1995, 1998; Rosen, Reitter, & Orosan, 1995; Saxena et al., 2001).

While there appear to be more similarities than differences between BDD and OCD, the differences are important, suggesting more of a spectrum relationship than an interchangeable label. For example, fewer individuals with BDD are married (Phillips et al., 1998), which is consistent with the theory that BDD is more highly correlated with social isolation and impairment than OCD. It was also found that insight is more generally impaired in BDD than in OCD so that subjects are convinced that their defects are real (Phillips et al., 1998; Simeon et al., 1995). Moreover, a substantial percentage of BDD but not OCD subjects have been found to be delusional (Phillips et al., 1994). What these differences in social impairment and insight (along with possible delusions) might suggest is that BDD (and thus MD) relates to OCD as a more socially phobic, depressed, and psychotic variant (Phillips, 2000; Phillips et al., 1998).

While the research literature now supports a recategorization of BDD, there is still a dearth of literature investigating the relationship of MD to either BDD or OCD. The few …