What is Muscle Dysmorphia/Bigorexia, and Do You Have It?

(Muscle Dysmorphia Part 1)

Bodybuilders have always known that there are some members of the bodybuilding community who get so obsessed with bodybuilding that it ruins their lives. These individuals can’t control their bodybuilding practice and it impairs their ability to function. Bodybuilders called this obsession with bodybuilding ‘bigorexia’. It wasn’t until the 1990s that medical scientists started talking about it, initially terming it ‘reverse anorexia’ (Pope et al., 1993), but later shifting to the term ‘muscle dysmorphia (MD)’ (Pope et al., 1997). I have chosen to go with the term ‘muscle dysmorphia’ because it is used by medical practitioners, scientists and (some) bodybuilders.

People who have muscle dysmorphia suffer greatly. Their self-esteem may rest entirely on how big they are (Pope, Phillips and Olivardia 2000). Many men with muscle dysmorphia train whilst injured (Pope, Phillips and Olivardia 2000). They may suffer relationship issues (Griffiths and Murray 2017), and many attempt suicide (e.g. 50% of a sample of 15; Pope et al., 2005).

So, what is muscle dysmorphia? The answer really depends on who you ask. Muscle dysmorphia is an illness, and there are many ways of understanding illnesses. Medical understandings tend to dominate, but alternative understandings exist. Arguably the most important understanding of any illness is the sufferer’s understanding, which may or may not build on medical understandings.

The group of people most likely to suffer from muscle dysmorphia are bodybuilders, or those who build muscle for aesthetic reasons (Murray et al 2016; Skemp et al., 2013). Despite the fact that muscle dysmorphia was ‘discovered’ by medical science amongst bodybuilders, and that muscle dysmorphia is most common amongst bodybuilders, no one has actually thought to ask bodybuilders about muscle dysmorphia … until now 😉

I am an anthropologist who has been working in online bodybuilding communities, particularly enhancement communities, for the last 4 years. In this paper, and the next, I want to tell you what I have learnt from bodybuilders about muscle dysmorphia, and compare that to how muscle dysmorphia is described in the medical literature. My aim is to increase understanding within both bodybuilding and scientific communities, but most importantly I want to build understanding between them.

Muscle dysmorphia from the medical perspective

What is muscle dysmorphia?

From a medical perspective muscle dysmorphia is a psychiatric disorder which was first discussed in the scientific literature in the 1990s, and which was first mentioned in the Diagnostic and Statistical Manual of Mental Disorders (DSM)¹, 5th edition, which was published in 2013. Thus, muscle dysmorphia is quite a ‘new’ illness, and knowledge about muscle dysmorphia is still in its infancy. What’s more, there are major problems with the science of muscle dysmorphia. The lack of clinical samples, the fact that measurements have not used validated cut-off scores, and problems with research design, mean that the majority of studies of MD are of the lowest level of methodological quality (Sandgren and Lavallee 2018).

Muscle dysmorphia – DO YOU HAVE IT?

If you answer ‘yes’ to the questions* in 1) and 2) you could be diagnosed as having muscle dysmorphia.

* I have based the questions on the most commonly used diagnostic criteria for muscle dysmorphia (as proposed by Pope and colleagues in 1997).

1. Are you preoccupied with not being lean and muscular enough? That is, do you spend ‘long hours’ in the gym and pay ‘excessive attention’ to your diet?
   • My thoughts – Could most dedicated bodybuilders fall into this category? As you may have noticed the terms ‘preoccupied’, ‘long hours’ and ‘excessive attention’ are subjective. That is, people differ in their opinion of what ‘long’ and excessive’ are. How an individual defines these terms depends on what they think of as ‘normal’. If I have learnt anything from bodybuilders over the years it is this:
     • What dedicated bodybuilders consider ‘normal’ in terms of training, and attention to diet and body composition would be considered ‘not normal’ by outsiders.

2. Does your training and diet impact your life in ways that really hurt you? For example:
   • Does it stop you being able to socialise and have relationships with other people?
   • Does it impact on your ability to work?
   • Do you give up important activities because you have to train or stick to your diet?

You must experience clinically significant distress to be diagnosed with muscle dysmorphia.

If you answer ‘yes’ to the questions in both 1) and 2) you could be diagnosed as having muscle dysmorphia. Whether or not the distress you experience is ‘clinically significant’ only a clinician can tell you (and I am not a clinician). If you are experiencing a lot of impairment as a result of your training and diet regime please consider seeking help straight away. I will describe medical treatment for muscle dysmorphia, as well as how bodybuilders attempt to manage muscle dysmorphia in part 2.

To be diagnosed as having muscle dysmorphia, it is not enough to be preoccupied with bodybuilding, that obsession has to have a significant negative impact on your life. The medical perspective on muscle dysmorphia is only concerned with those who are impaired by their preoccupation with bodybuilding (whereas bodybuilders tend to discuss muscle dysmorphia or bigorexia as a spectrum from positive to negative – see below).

There is debate about what type of psychiatric disorder muscle dysmorphia is. While some argue that muscle dysmorphia should be categorised as an eating disorder (Murray and Touyz 2013), and others a behavioural addiction (Foster et al., 2015), muscle dysmorphia is currently classified as a type of body dysmorphic disorder. Body dysmorphic disorders are a specific type of obsessive-compulsive disorder. People with body dysmorphic disorders suffer from a preoccupation with what they see as a problem with their appearance, but this ‘problem’ is hardly noticeable, or is actually invisible, to other people. Body dysmorphic disorders involve repetitive behaviours (e.g., mirror checking) or mental acts (e.g., comparing appearance with that of others) in response to the perceived problem with their appearance. In muscle dysmorphia sufferers perceive themselves as inadequately muscular despite the fact that they have significant muscle. As for mirror checking and body comparison, show me a bodybuilder who doesn’t engage in these activities repetitively! 🤣

Those with muscle dysmorphia are likely to suffer from other psychiatric disorders as well. These include mood and anxiety disorders (Cafri et al., 2008; Olivardia et al., 2000), eating disorders (Badenes-Ribera 2019) and ‘substance abuse’ (Pope et al, 1997), particularly of anabolic androgenic steroids (AAS)(Cooper et al, 2020).

What causes muscle dysmorphia?

As with other psychological disorders, there is unlikely to be a single pathway to muscle dysmorphia, and people may develop the condition in different ways (Tod, Edwards, & Cranswick, 2016).

• There may be a genetic cause.
  • A study found a potential familial transmission between muscle dysmorphia symptomology (undiagnosed) and anorexia nervosa in 3 sets of male twins (Raevouri 2009).
• Muscle dysmorphia may be caused by bullying and trauma.
  • There are studies correlating childhood experiences of being bullied with later development of muscle dysmorphia (Wolke and Sapouna, 2008; Edwards et al., 2017). Individuals with muscle dysmorphia are more likely to have had or observed a traumatic event (Tod, Edwards & Cranswick 2016), particularly experiences of physical or sexual assault (Gruber & Pope, 1999; Pope et al., 1993; Pope et al., 1997).
• Family factors may play a role in causing muscle dysmorphia.
  • Pace and colleagues (2020) found that boys showed higher level than girls in dependency-oriented and achievement-oriented parental psychological control and linked that to the development of muscle dysmorphia. Edwards et al (2017) noted that fathers were often the perpetrator of bullying for the men who were consumed with attaining a muscular body image.
• Social and cultural factors such as body ideals play an important role in the development of muscle dysmorphia.
  • Although sociocultural factors, such as increasingly muscular ideals, have been implicated in the development of muscle dysmorphia since the disorder was first identified by scientists (Pope et al., 1993; Pope et al., 1997; Pope, Phillips & Olivardia 2000), these factors have been rarely explored through research. However, some research is looking into connections between muscle dysmorphia and gender. For example, men with muscle dysmorphia have been found to be more traditional with regards their masculinity (Murray et al., 2013).

Muscle dysmorphia from the bodybuilder perspective

Perhaps the most important thing I found is that bodybuilders don’t often discuss muscle dysmorphia. There is much more discussion of training, nutrition and drug use in bodybuilding communities, than there is mental health. But bodybuilder discussions of muscle dysmorphia are getting more frequent, if the increasing number of YouTube videos and forum discussions on this topic are anything to go by.

The bodybuilder perspective on muscle dysmorphia overlaps with the medical perspective. There are some bodybuilders who use the medical model (described above) to discuss muscle dysmorphia. But most of the bodybuilders I talked to and observed, spoke about muscle dysmorphia in a different way. They spoke about muscle dysmorphia from an experiential perspective. That is, they spoke as people who suffered from, or were at risk of developing, muscle dysmorphia.

What is muscle dysmorphia/bigorexia?

Firstly, there are some similarities between the medical perspective and the bodybuilder perspective on muscle dysmorphia. Both discuss body image distortion (seeing your body differently from how others see it) and body dissatisfaction. Bodybuilders describe these things as common, constant and normal, as this well-known bodybuilding saying suggests:

“The day you start lifting is the day you become forever small.“

Many bodybuilders set goals for their physique but find that when they reach that goal, the ‘goal posts shift’ and they consequently never feel satisfied.

“If you had 21 inch arms you’re like ‘fuck that I want 22’, soon as you get to 22 you’re like ‘Arnold had 22 I want to be bigger than Arnold, I want to be 23’. It’s like a riptide man. You’re up to your knees in water and before you know it you’re out in the middle of the ocean, and you’re like holy shit where’s the shore? How’d I get out here?” [Luke].

There are some differences between how bodybuilders and medicos discuss muscle dysmorphia. When bodybuilders talk about a problematic preoccupation with bodybuilding they tend to use the terms ‘bigorexia, and ‘body dysmorphia’ rather than ‘muscle dysmorphia’.² Also from a medical perspective, only those who are significantly impaired by their bodybuilding practice are thought to have muscle dysmorphia, but a lot of bodybuilders talk about muscle dysmorphia as a spectrum that every bodybuilder is on.

“It’s not this dichotomous thing where you either have body dysmorphia or body image issues or you don’t, you fall on a continuum.” [YouTube video]

Being on this spectrum or continuum of muscle dysmorphia can be experienced as a positive or a negative. At one end of the spectrum, the body image distortion and constant dissatisfaction that characterises muscle dysmorphia is relatively mild and can be experienced as a welcome motivation. That is, you will train hard and stick to your diet if you feel smaller than you actually are, and are somewhat dissatisfied with your body. But at the other end of the spectrum the level of body image distortion and body dissatisfaction can become so extreme that it becomes crippling and ruins your life. Thus, bodybuilders aim to manage their muscle dysmorphia so they can stay at the motivational end and don’t find themselves slipping towards the crippling end (as I discuss in part 2).

What causes muscle dysmorphia?

Bodybuilders often describe muscle dysmorphia as a normal and inevitable consequence of bodybuilding. When you practice bodybuilding ‘a certain amount of body dysmorphia is to be expected” [YouTube video].

I have only seen one bodybuilder describe their muscle dysmorphia as beginning before they started bodybuilding: ‘it started with the He-man dolls when I was 6 years old’ [YouTube video]. Most bodybuilders describe muscle dysmorphia as resulting from bodybuilding. That is, they began bodybuilding because of an insecurity (such as with regards sexual attractiveness), but bodybuilding amplified their insecurity into a disorder.

“It’s a lifestyle that, if you have any kind of insecurities, if you are not mentally sound and you go into extreme bodybuilding it’s going to take whatever issues you have and it’s going to amplify them. It’s like you’re not just putting your body on steroids, you’re putting your issues on steroids, figuratively speaking” [podcast].

“Bodybuilding is not a great sport for mental health … The entire sport is about getting the self-perceived perfect body … You can have entire training phases devoted to developing weak points that the general population wouldn’t even think about” .

Bodybuilding can provide mental health benefits and social benefits, but it could also have a negative impact on body image. As a result, bodybuilding was sometimes described as a ‘double-edged sword’.

“It’s weird because I was a real skinny dude with ZERO confidence but, my insecurities then were not like my insecurities now, in that I never minded my body as much as I do now. … I don’t really remember giving overly much thought about my body then, like, I always wanted to be bigger but it was never something I’d hide myself away because of [he does this now sometimes], or compare myself to others over [he does this frequently now]. … I remember when I was 60-65kg, training and I felt pumped and genuinely thought I was massive but in a way that I’ve NEVER had since. … Whereas now, no matter how pumped I feel, I always see myself as one of the smallest in the gym. I know I’m currently 112kg, but even knowing that I just see myself very often as the same 65kg lad I used to be, moreso bothered now than when I actually WAS that size. But my confidence is waaaay better now because I do find people respond to me a lot more positively … and bodybuilding has given me a lot of awesome experiences and I fuckin love love love the lifestyle and friends I’ve met along the way. It’s my life after all, it’s what gives me purpose and drives me everyday to try and be better, bigger and stronger than the day before. I love everything about the lifestyle, and the negative side it brings to my life is a price I’m willing to pay for all the positivity it brings for me. Hence the double-edged sword. It’s made me outwardly confident and happy and loving the life I lead but inwardly a right fuckin mess of emotions and hating how my body looks because i feel skinny more than I don’t” [Dylan via message].

The practices of bodybuilding are described by some as causing symptoms of muscle dysmorphia. For instance, bodybuilders often state that they ‘feel fat’ when bulking, and ‘small’ when cutting. Furthermore, the ‘pump’, or temporary engorgement of the muscle being trained, is said to fuel dissatisfaction because, as is frequently stated, ‘you are never as big as your pump’. Some attribute muscle dysmorphia to the use of mirrors in bodybuilding.

“Anyone who makes progress in the gym and looks at their body in the mirror all the time is going to develop this disorder” .

But the practice that was most often described by bodybuilders as a cause of muscle dysmorphia was enhancement drug use:

“It’s very apparent that while users are using they’re never satisfied with their physique, and they only get satisfaction when they’ve finished that period of their lives” [Alan].

“Bodybuilders describe bodybuilding communities as places that put people at risk of developing muscle dysmorphia. For example, the bodybuilding community has been described as a ‘breeding ground for obsessive-compulsive behavior’ ” [social media comment].

“You get so engulfed in this [bodybuilding] world that crazy becomes normal. It would be like me having an eating disorder, but I’m just around other people with eating disorders and we’re just talking about it and it’s completely normal. You enter into this world in which craziness is normal, and it just amplifies all these problems in you, and it can cause some serious issues” [podcast].

“The world of bodybuilding, and following that world, it’s like living in a bar and trying not to become an alcoholic. You can definitely do it but you’re so surrounded by all these issues and it’s amplifying all your issues, that I really don’t recommend it to most people” [YouTube video].

Bodybuilding was described as encouraging people to identify with their body too much [podcast], and as encouraging people to compare themselves to other bodybuilders, thus warping their perception of what their body should look like, and how it compares to other people’s bodies. As bodybuilders tend to follow other bodybuilders on social media it means that they are ‘focusing on what confirms their idea that they are small’ .

Conclusion

What I have learnt about muscle dysmorphia from bodybuilders raises the age-old question of whether psychiatric disorders should be approached as something completely different from normality, or if we should approach psychiatric disorders as one end of a spectrum that runs from normal to disordered. Medical science is only concerned with those who are impaired, to clinically significant levels, by their preoccupation with bodybuilding. But bodybuilders recognise that normal, healthy bodybuilding can put an individual at risk of developing an obsession with bodybuilding. Therefore, bodybuilders are not only concerned about those who are already suffering, they are concerned about all bodybuilders.

The truth is we don’t know where the boundary between mentally healthy bodybuilding and disordered bodybuilding lies. This boundary has scarcely been discussed: not by scientists, nor by bodybuilders. We need to understand how feelings experienced initially as benefits in terms of bodybuilding motivation, can become impairments that cause distress. Only then can we prevent bodybuilders from being caught in the tide of muscle dysmorphia, and losing sight of the shore. To do this we really need to bring the medical and bodybuilder perspectives on muscle dysmorphia together. I hope my research helps to achieve this.

Next: Muscle dysmorphia (Part 2) – How to stop the suffering caused by muscle dysmorphia/bigorexia: Treatment options and how bodybuilders attempt to manage it.

I am always keen to hear your feedback. If you are a bodybuilder please feel free to tell me if you think my ideas are any good, or if you think I’m missing the mark. Message me or comment. As an anthropologist I am keen to represent the community I study as well as I can.

I protect the privacy and confidentiality of bodybuilders who share their stories online, or who have spoken to me directly, so all names included are pseudonyms.

1. The DSM is the handbook used by health care professionals (in the United States and much of the world) to diagnose mental disorders.
2. However, the term ‘muscle dysmorphia’ is being used by bodybuilders more frequently in recent years, particularly those bodybuilders who take a medical perspective on this issue.

Image by Schäferle from Pixabay

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