Body Dysmorphic Disorder and Muscle Dysmorphia

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.

Muscle Dysmorphia

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.

References:

  1. American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed., text revision). Washington, DC: Author.
  2. Phillips, K. A. (2001). Somatoform and factitious disorders. Washington, DC: American Psychiatric Publishing.
  3. Pope, H. G., Phillips, K. A., & Olivardia, R. (2000). The Adonis complex: The secret crisis of male body obsession. New York: Free Press.
  4. 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.

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