Most people would like to change something about their physical appearance, and this normative discontent is not usually indicative of a serious body image issue. However, some individuals may feel extreme preoccupation with an aspect of their appearance: they perceive to be flawed. Typically, this perception is inaccurate or exaggerated and indicative of body dysmorphia.
Body Dysmorphic Disorder
Characterized as a somatoform disorder in the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision (DSMIV-TR), body dysmorphic disorder is described as a preoccupation with an imagined defect in appearance, which causes severe distress and impairment in daily functioning. Body dysmorphic disorder tends to co-occur with other psychiatric conditions, such as obsessive-compulsive disorder, depression, substance abuse, and eating disorders. The disorder is prevalent in settings where a high importance is placed on physical appearance, such as sport and exercise contexts and in particular aesthetic sports.
Individuals with this disorder are overcome with constant preoccupations that aspects of their appearance are deformed, when in reality, the perceived flaw is minimal or non-existent. Individuals tend to focus on a few body areas and spend much of the day thinking about the perceived flaws. These individuals typically have low self-esteem and are prone to rejection, low self-worth, and shame. Individuals tend to exhibit delusions of reference, which involves thinking that other people focus on and mock one’s perceived flaws and defects. These individuals are highly motivated to examine, improve, seek assurance, and hide the perceived flaw and respond by engaging in obsessive-compulsive behaviors. In competitive sport settings, symptoms may manifest as withdrawal from teammates and constant need for reassurance from teammates and coaches. These coping behaviors may extend to excessive dieting, compulsive exercising, and seeking plastic surgery.
The etiology of body dysmorphic disorder is complex and multifactorial and includes genetic, neurobiological, sociocultural, and psychologycal influences. Particularly in competitive sport and exercise settings, sociocultural influences play a large role, including strong pressures from coaches, trainers, parents, and even media influences. For example, a genetically predisposed adolescent elite gymnast who presents with high tendencies for perfectionism may be heavily influenced by social pressures, and be at high risk for developing body dysmorphic disorder. Despite the probable influence of social and cultural factors, clinical features of body dysmorphic disorder are similar across different cultures, even though typically body image concerns are more prevalent in Western societies.
Symptoms of body dysmorphic disorder initially present themselves during adolescence; however, most individuals are not diagnosed for an extended period of time after initial onset because of shame and embarrassment associated with discussing the preoccupations. Aside from difficulties in diagnosis, treatment for body dysmorphic disorder is also challenging. Treatment options include pharmacotherapy, particularly the use of serotonin reuptake inhibitors, and cognitive behavioral therapy, focusing on exposure and systematic desensitization.
Body dysmorphic disorder is equally prevalent in males and females; however, a subset of the disorder, muscle dysmorphia, is reported more frequently among males. Muscle dysmorphia is a chronic preoccupation with insufficient muscularity and inadequate muscle mass. Individuals presenting with muscle dysmorphia perceive themselves as much thinner than they actually are, and experience pressure to increase muscle mass and strength, despite possessing a much higher muscle mass than the average male. This condition involves excessive attention to muscularity, distress over presenting the body to others, extreme weight training, and focus on diet. Impaired function in daily life is also an outcome of these compulsive behaviors, along with a high risk of abusing physique-enhancing supplements and drugs, particularly anabolic steroids.
Individuals with muscle dysmorphia experience heightened shame with their preoccupations and engage in physique protection by hiding perceived defects and avoiding situations of physique exposure. For example, individuals may avoid busy times of training at the fitness center to avoid being seen by muscular weight trainers or wear loose clothing to hide the shape and size of their physiques. Researchers have indicated that athletes who are body builders and weight lifters are particularly susceptible to muscle dysmorphia and are at significant risk of anabolic steroid abuse. In competitions where physique-altering drugs are prohibited, individuals are at an increased risk for developing eating disorders and manipulating resistance training programs to achieve higher muscle mass while maintaining leanness.
Various theoretical frameworks have been employed to understand the complexity of muscle dysmorphia. Psychological theories posit that individuals strive for high muscularity to compensate for feelings of inadequacy, low self-esteem, and issues with masculinity identity. Sociocultural theories suggest that individuals with muscle dysmorphia strive for muscular physiques to attain societal and media-driven ideals that equate masculinity with muscularity. Sociocultural theories may be useful to explain muscle dysmorphia in elite athletes and the prevalence of similar body-related disorders in sport culture. Athletes are more susceptible to muscle dysmorphia if they are involved in sports that predominantly require strength and power, such as weight lifting, or aesthetics involving muscularity (e.g., body building).
Significant stigma surrounds psychiatric disorders like body and muscle dysmorphia, especially among athletes. In sport and exercise settings especially, psychoeducation is important to increase awareness and diminish shame surrounding having these disorders. Informed coaches and trainers can play an important role in preventing, identifying, and aiding in treatment of body and muscle dysmorphia. Treatment options in sport settings are best dealt with using a biopsychosocial model, which uses pharmacological and psychological treatment, while respecting the importance of the social and cultural sport environment in which these disorders thrive.
- American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed., text revision). Washington, DC: Author.
- Phillips, K. A. (2001). Somatoform and factitious disorders. Washington, DC: American Psychiatric Publishing.
- Pope, H. G., Phillips, K. A., & Olivardia, R. (2000). The Adonis complex: The secret crisis of male body obsession. New York: Free Press.
- Tod, D., & Lavallee, D. (2010). Toward a conceptual understanding of muscle dysmorphia development and sustainment. International Review of Sport and Exercise Psychology, 3, 111–113.