How to Stop the Suffering Caused by Muscle Dysmorphia / Bigorexia: Treatment Options and Bodybuilder Attempts to Manage Symptoms

(Muscle dysmorphia part 2)

Muscle dysmorphia, or bigorexia, causes a great deal of suffering. It consumes lives, it ruins lives, it can even end lives. In part 1 “What is muscle dysmorphia/bigorexia, and do you have it?” I discussed what muscle dysmorphia is and what might cause it. I compared current medical understandings of muscle dysmorphia (which are very limited) with what I have learnt from bodybuilders about muscle dysmorphia. I described how the medical world is only concerned with those individuals who are significantly impaired by muscle dysmorphia. They only consider the tip of the iceberg. However, bodybuilders can see muscle dysmorphia as an inevitable consequence of bodybuilding, and thus they are concerned with protecting all bodybuilders from the suffering of muscle dysmorphia. They are concerned with the whole iceberg, including the huge part under the water that medicine has failed to consider.

If we approach muscle dysmorphia as something that certain individuals develop because of their genetics, family, or experience of trauma (as medicine does) then there is really very little that can be done to prevent or reduce the suffering muscle dysmorphia causes, except for treating those particular individuals. Of course we could make general efforts to stop bullying or sexual assault, or to encourage healthy family relations, but we already do these things and yet people still suffer from muscle dysmorphia.

If we approach bodybuilding as a practice that places individuals at risk of being swept off by the tide of muscle dysmorphia, that is, if we approach muscle dysmorphia as a spectrum from healthy to disordered (as bodybuilders do), then there is a lot that can be done to prevent or reduce the harms of muscle dysmorphia. We can ensure that individual bodybuilders are able to keep to their feet and successfully manage the mental health risks of bodybuilding. We can help individuals to manage their muscle dysmorphia symptoms, helping to prevent them from getting out of hand. [We could, of course, ban bodybuilding but given that our culture is moving towards more and more muscular ideals I don’t think that could happen without a major cultural shift in what we value about bodies].

These two different approaches to preventing the suffering caused by muscle dysmorphia — (1) the medical treatment of muscle dysmorphia, and (2) bodybuilder strategies to manage muscle dysmorphia — are the focus of this paper. I am currently working with a clinical psychologist, Roberto Olivardia, to help me refine my ideas on muscle dysmorphia. In what follows I rely on his descriptions of how he treats individuals with muscle dysmorphia, and his thoughts on whether or not bodybuilder management strategies for managing muscle dysmorphia are likely to be effective.

The medical treatment of muscle dysmorphia

In order to prevent the suffering caused by muscle dysmorphia, medicine focusses on treating individual sufferers. However, there is not much evidence to inform the treatment of muscle dysmorphia. In fact, there are only three case reports of young males with muscle dysmorphia, and one study with a subclinical sample of four individuals at risk of muscle dysmorphia. The three case reports employed (1) an anti-depressant (Phillips et al 1997), (2) a family-based treatment used to intervene in eating disorders (Murray and Griffiths 2015), and (3) a combination of anti-depressant and cognitive behavioural therapy (CBT) approaches (Ung 2000). Outar and colleagues (2021) used a CBT approach on individuals at risk of muscle dysmorphia and propose it as a preventative measure.

Muscle dysmorphia treatment typically involves the reduction of bodybuilding practices and stopping enhancement drug use (Olivardia 2001). Specifically, treatment tends to consist of:

• Cognitive Therapy: Challenging cognitive distortions people with muscle dysmorphia have about themselves, their bodies and how other see them. For example, “When I walk into a room, the first thing people think is how small I am.” The goal is to challenge these negative thoughts and gather data/evidence for the thoughts to make them as accurate as possible, since the negative thoughts feed into compulsive or avoidant behaviours.
• Behavioural Therapy consisting of Exposure and Response Prevention (ERP) therapy i.e. exposing the person to any situation they are avoiding and preventing the response of their compulsion. It can include skipping a workout day and leaving the house that day, taking their shirt off at a beach, wearing a shirt that they feel is less flattering of their muscularity, decreasing mirror checking, etc.
• Psychotherapy: Addressing self-esteem (how does the person define themselves aside from their body image?), any trauma history, assertiveness skills.
• Addressing any comorbid diagnoses (such as mood or anxiety disorders) including through medication where appropriate.
• Ceasing AAS use.
• Nutritionist: For those patients with eating disorders, or who get too caught up in their eating, a nutritionist can be helpful.

Bodybuilder management of muscle dysmorphia

Most sufferers of muscle dysmorphia don’t seek treatment (Olivardia 2001). There may be several reasons for this:

1. A general feeling that outsiders don’t understand the bodybuilding lifestyle (because we often don’t!).

2. The general distrust many enhanced bodybuilders have of health professionals’ expertise when it comes to bodybuilding.

3. The fact that treatment tends to include stopping or reducing behaviours that are considered to be normal within bodybuilding, such as long hours of training and AAS use.

Because bodybuilding demands such discipline it is often much more than a hobby for practitioners. It is a lifestyle, and one many identify heavily with. Thus, bodybuilders may be reluctant to treat muscle dysmorphia as changes to their normal bodybuilding behaviours would entail losing a major part, if not the major part, of their identity.

"I don't think I'd want to seek treatment [for his muscle dysmorphia symptoms] because I think the solution to that would be being different than I'm trying to be. I enjoy what I'm doing, what I'm trying to be, I guess you could say. … Which is a total addict mentality, but yeah, that's the case" [Edward].

4. Bodybuilders may feel positively about muscle dysmorphia, and muscle dysmorphia symptoms may be considered normal within bodybuilding communities.

"To be honest, I like it [muscle dysmorphia symptoms]. I like working out, I like steroids, I like everything about it. So, I'm not too sure if I want to [seek treatment] … What I would think is problematic would be completely different to what a psychologist who doesn’t train would think. My version of problematic is probably like extreme" [Calum].

Bodybuilders are much more likely to discuss ways to manage muscle dysmorphia, than to suggest treatment. They tend to describe muscle dysmorphia as an inevitable consequence of bodybuilding, but state that it is possible to manage muscle dysmorphia (whilst continuing bodybuilding) so that it does not develop to the degree that it impairs the individual. They suggest several strategies to do so. I list these strategies along with some thoughts on whether they are likely to be successful at reducing muscle dysmorphia symptoms.

1. Know what you as an individual can realistically achieve.

Being realistic about what can be achieved surely can’t be a bad thing, but will it actually make much difference when it comes to body comparison? All bodybuilders will tell you that genetics is the key to bodybuilding. But how many are truly accepting of this? Does this knowledge really stop them from feeling shit if they are looking at someone more jacked than them?

2. Understand how Photoshop, lighting and contrast are all used to give the appearance of greater muscle and less fat.

"How you gonna look like Bob? Bob doesn’t even look like Bob!" [YouTube video].

This strategy is unlikely to work as research has demonstrated that even when people know about how images can be altered through apps like Photoshop, exposure to these images still has a negative impact on their body image.

3. Seek objective feedback about your body such as measurements, photographs, and the opinions of others.

This strategy is unlikely to work as compulsive measuring and photographing of the body, and reassurance seeking from others, are symptoms of muscle dysmorphia. Thus, suggesting doing these things in order to manage muscle dysmorphia doesn’t make much sense.

4. Shift focus from appearance to strength.

"I feel like my mentality improved when I switched from bodybuilding to powerlifting" .

"For those who are overly obsessed with aesthetics, just focus on the numbers [weights you are lifting] instead … you inevitably get the size anyway. So, become more strength focussed as opposed to aesthetics focussed, is what I am saying, while of course having the objective of being bigger over time in mind, because you still care about it. It’s something you still value. But you’re just changing your perspective, you’re changing the goals – you are making strength first, hypertrophy second" .

Shifting focus from hypertrophy to strength may help some with muscle dysmorphia, but, as bodybuilders acknowledged, the obsession may simply transfer from muscle to strength.

5. Understand that high levels of muscularity are temporary.

"… you can’t be this weight when you are 50, you can’t, your heart will not take it, 350 [lbs] you can’t. One day you’ll have to reduce everything and the weight will go down, you will have to face it" .

6. Learn to deal with changes to the body or diet.

These changes can be very unsettling. Bodybuilders describe being especially at risk of muscle dysmorphia immediately after a bodybuilding competition.

7. Separate your sense of self from your body.

"It takes a very self-aware and emotionally intelligent person to be able to separate that body that you are building for stage and to be competitive, and the real life you, it’s very hard to separate the two. … If you can separate yourself from your body and just realise that this is just my body, I can have fun with it, play with it, build it, I can shrink it, I can get it lean, then you’re going to be in a safer position" [podcast].

Some bodybuilders are forced into realising that their body does not define them. Because of injury, health problems, or incarceration, they lose their muscle and this forces a change in perspective.

"I have identified as this physical being for so long. … It took me to be laid out for all that time [after an injury], and to look like shit for a little bit … It was my open acceptance of the fact that I don’t have control, that it’s OK, and that I am so much more, and it sounds freaking cheesy, that I am so much more than a body, and actually really realising that, to take a little step forward. To say that I am completely better now is not the case. … It took me, having to deal with not looking the way I wanted to for a span of time and having zero control over it, and finding myself outside of my physical entity to really understand that" [podcast].

8. Know that there is more to you than your muscularity, and live like this.

"If you have everything in your life based on your biceps, then if you lose that you lose yourself. Whereas when people have multiple things going on in their lives they are not going to have as many issues" [Calum].

"Try to identify why you place so much emphasis on body image or this physical pursuit, and whether you can find aspects of yourself that you like or feel accomplished about that aren’t related to physical image. It’s very easy to get caught in the spiral of “I’m shit at everything but improving my physique makes me feel better and that makes me feel better but my physique is shit so I’m shit at everything so I feel shit” [Bjorn].

Some of the strategies that bodybuilders suggest for reducing muscle dysmorphia symptoms show promise, but others are unlikely to work. I don’t think anyone could argue against strategies 5-8. It would be great if we could help bodybuilders deal with bodily change including the loss of muscle. I have heard of a lot of suffering, especially after competitions. I know bodybuilders would have their own strategies for dealing with bodily change, and I am sure psychologists would have strategies for helping people deal with body changes too. Therefore, perhaps bodybuilding and medicine could collaborate and come up with some effective strategies to help bodybuilders deal with the ups and downs that is bodybuilding.

Knowing that you are more than your body is something that medicine and bodybuilding agree on is important when it comes to reducing the harms of muscle dysmorphia. It is something that I have had to learn as I age. What I think would be fucking fascinating would be to talk to bodybuilders who have stopped bodybuilding and lost their muscle. Both those who have handled this change well, and those who haven’t. The loss of muscle is something that is not often discussed in bodybuilding communities. Maybe in order to help people build muscle in a mentally healthy way, we need to work out how people lose muscle in a mentally healthy way.

Conclusion

There have been two separate discussions of muscle dysmorphia going on. One in the field of medicine, and one in the bodybuilding community. While some bodybuilders have engaged with the medical model, this model is very limited, and it offers only one solution to the problem of muscle dysmorphia: treatment. For various reasons, bodybuilders may not be ready or willing to engage with treatment services. If we are really serious about reducing the harms of muscle dysmorphia we need to do more than treat the few sufferers who present for treatment. We need to prevent the development of muscle dysmorphia, and failing that, help those who suffer from it to manage their disorder. We need to bring medical and bodybuilder perspectives together to come up with practical solutions so that individuals can build their bodies in ways that also build their sense of worth and well-being.

I would really like to hear about your experiences and what has helped you to reduce or prevent the suffering caused by muscle dysmorphia. Please message me or comment.

Photo credit: Photo by Jesper Aggergaard on Unsplash

References cited

MURRAY, S. B. & GRIFFITHS, S. 2015. Adolescent muscle dysmorphia and family-based treatment: A case report. Clinical Child Psychology and Psychiatry, 20, 324-330.

OLIVARDIA, R. 2001. Mirror, Mirror on the Wall, Who’s the Largest of Them All? The Features and Phenomenology of Muscle Dysmorphia. Harvard Review of Psychiatry, 9, 254-259.

OUTAR, L., TURNER, M. J., WOOD, A. G. & O’CONNOR, H. 2021. Muscularity rationality: An examination of the use of Rational Emotive Behaviour Therapy (REBT) upon exercisers at risk of muscle dysmorphia. Psychology of Sport and Exercise, 52.

PHILLIPS, K. A., O’SULLIVAN, R. L. & POPE JR, H. G. 1997. Muscle dysmorphia. The Journal of Clinical Psychiatry, 58, 361-361.