Muscle dysmorphia/bigorexia/Adonis complex

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Muscle dysmorphia, also known as bigorexia or the Adonis complex, is a form of body dysmorphic disorder (BDD) where an individual is obsessively concerned about the muscularity of their body. As a trainer, you should recognize this in clients and then refer them to a psychiatrist. At least, according to recent research whose results will soon be published in the Journal of Strength and Conditioning Research (1).

Muscle dysmorphia

Just like with losing weight, some people can lose the balance between healthy dieting and exercising on one hand, and obsessive and excessive weight loss on the other, as is the case with anorexia nervosa. Similarly, in training and eating for muscle mass, this balance can often be hard to find. This can lead to various psychological, social, relational, and occupational problems.

In this article, I will discuss the term “muscle dysmorphia / the Adonis complex” and one of the related issues, namely the use of anabolic steroids.

Body dysmorphic disorder and Muscle dysmorphia

Body dysmorphic disorder (BDD) is “a distressing or impairing preoccupation with a nonexistent or slight defect in body appearance” (2 through 5). Think of people who constantly think about and are insecure about the size of their nose while it is objectively not unusual. We’re not talking about women who wonder if their butt is too big in those jeans they bought two sizes ago. Nor about men who only find their belly problematic when it prevents them from seeing the bottom part of the TV when the national team is playing.

Body dysmorphic disorder concerns individuals for whom this obsession with a certain body part prevents them from functioning optimally, socially or professionally. If the same woman, even in pants two sizes bigger, dares not cross the street for fear everyone is staring at her butt, then you can speak of Body dysmorphic disorder.

Muscle dysmorphia is a form of BDD where the preoccupation or obsession does not concern a specific body part, but the muscularity of the entire body.

Muscle dysmorphia: What?

According to recent research, instead of on the bench for the benchpress, I better take a seat on a psychiatrist’s couch. They had 146 men fill out a survey with questions about:

• the (degree of) desire to be muscular,
• “social anxiety” regarding physique,
• Ideal image regarding the muscularity of a man

Then they asked about characteristics of muscle dysmorphia. In the study, they speak of the following properties:

• exercise dependence
• diet manipulation
• concerns about size & symmetry
• physique protection behavior
• supplementation

The outcome of this survey should give trainers an indication when they should refer people for psychological guidance:

The results also highlight signals (e.g., anxiety about muscularity) that strength and conditioning coaches can use to identify at risk people who may benefit from being referred for psychological assistance.

Adam Thomas, Aberystwyth University

Muscle dysmorphia: “Bro, do you even lift?”

As you see, I’ve ticked all the properties mentioned in the study as they apply to me as well as many others. In fact, most of these properties (if not all) I see as positive. With only these points, you might wonder what’s wrong with that. Let’s take a closer look at them:

Exercise dependence: Freely translated as an addiction to training. This could be considered positive. After all, it’s much easier to go training regularly when it has become somewhat of an addiction. In this context, I have written about the development of motivation into addiction.

Motivation combined with discipline ensures that you go training. Subsequently, habituation ensures that less and less discipline is needed because it becomes a habit. Finally, the habit turns into an addiction, and you don’t know any better than that training belongs in your daily activities like eating and going to the toilet.

Diet manipulation: We try to encourage people to eat healthily. Dieting (which is any form of following a conscious nutrition schedule, not just for losing weight) is part of the “holy trinity” training-eating-rest. Following a good diet is something I can only encourage.

Concerns about size and symmetry: This is probably the reason most people enter the gym, less body fat or more muscle mass.

Physique protection behavior: Anyone who ever thinks: “Crap, I’m breaking down muscle mass because I haven’t eaten for more than three hours,” may tick this off.

Supplementation: That pot of protein shakes from BodyenFitshop standing behind you on the shelf indicates that you can also tick this off.

Looking at it this way, no personal trainer will tell their clients: “Sorry, please come back with a statement from the psychiatrist that you are not obsessive.” A dealer doesn’t refer a junkie to a rehab clinic either. Although this comparison seems skewed, it applies in several respects. Just like with drug and alcohol use, the harmfulness depends only partly on the product itself and the extent to which it is used. The harmfulness is largely determined by the extent to which someone is less able to function because of it.

Do you drink a beer for sociability, or do you brush your teeth in the morning with Johnny Walker?

…persons with muscle dysmorphia are pathologically preoccupied with the appearance of the body as a whole; they are concerned that they are not sufficiently large or muscular; their lives become consumed by weightlifting, dieting, and associated activities.

Harrison G. Pope, Mclean Hospital/Harvard Medical School (Pope).

This definition from the 1997 Pope study names the preoccupation with weightlifting and dieting as a feature of muscle dysmorphia and bigorexia. That your life revolves around weightlifting, nutrition, and other matters related to your muscle mass is something that is often promoted.

After all, we often say enough: “It’s a lifestyle!”

That others can’t understand this is also not news. Many declare you crazy when you say you train four to seven times a week, eat 8 or more meals a day, wake up and go to sleep with a shake, etc. “We,” the people who do make it a lifestyle, however, consider ourselves the superhumans. “We” can’t understand how you don’t pay attention to your body as “we” do. “We” can’t imagine that you’ve been complaining about your figure for years without doing anything about it.

The now popular saying: “Bro, do you even lift?” is indicative of how people seriously engaged in strength training feel superior over those who do not.

One resorts to comfort-feeding and stuffs themselves with everything fattening during a depressive episode caused precisely by being overweight. The other thinks: “I’ll do something about it,” then realizes this isn’t something you can do just once and thus makes it a lifestyle.

Who is the crazy one?

Below, I’ll return to many of these points, but from the situation where things have gone too far. All these points that can be considered positive can indeed have a disturbing effect on your social and professional life under different circumstances.

The Adonis complex or bigorexia

If you only look at it from the positive side, you might think that the whole term “muscle dysmorphia” was invented by people who have never trained themselves. People who have no affinity with strength training and find everyone crazy who does find it important.

The problem is that anorexia patients on pro-anorexia forums probably think exactly the same way (6). “Those people really don’t get it. Who would want to be as fat as they are? Look at that woman, you can even see she has buttocks!”

You are about to visit a so-called ‘pro ana’ site. ‘Pro ana’ stands for ‘pro anorexia nervosa’.
On this site, anorexia patients discuss what concerns them the most, such as tricks to become even thinner than they already are.

Visitors to this site may be shocked by the unhealthy and dangerous tricks these patients teach each other. But even more shocking is that they act as if it’s all very normal.
They deny being sick. For these patients, their anorexia is not a life-threatening psychiatric disease, but a ‘healthy’ way of living.

Part of the warning when opening the Pro-ana website, a website

From anorexia patients, often everyone except the patient themselves understands that there is a problem. The person themselves is no longer able to assess this (objectively). Reverse anorexia is therefore a term that might more clearly indicate what the problem is when we talk about muscle dysmorphia and the Adonis complex.

• The lack of ability to objectively appreciate the muscularity of one’s own body.
• No matter how much muscle mass you have managed to gain, never being satisfied with the result.
• No rational consideration between the risks of means to achieve your goal and the value of this goal itself.

In 1994, researchers placed ads in gyms in Boston and L.A (7). They asked, among other things, about self-image and use of anabolic steroids. A total of 156 men responded. Of these, 10% (16 men) felt physically small and weak while they were actually large and muscular (according to the objective standard of the researchers).

In a study of nine of these sixteen men, the term “reverse anorexia nervosa” was introduced (8). Interestingly, two of these nine men had a history of “normal anorexia nervosa”. Apparently, they had changed their preoccupation with being too fat into the compulsive thought that they were too small (4).

Asking a bodybuilder if they’ve lost weight is like asking an anorexia patient if they’ve gained weight. In that sense, I’m a bit of a sadist.

The dangers of Muscle dysmorphia: steroids

And with this last point, we come to one of the actual dangers of muscle dysmorphia. The quote above from researcher Pope was not yet complete:

Consequences include profound distress about having their bodies seen in public, impaired social and occupational functioning, and abuse of anabolic steroids and other drugs.

Harrison G. Pope, Mclean Hospital/Harvard Medical School (4).

Regarding the first mentioned consequences (psychological, social, and occupational), I will delve further into them below. Many people will understand to what problems muscle dysmorphia / bigorexia can lead on the last point. The use of anabolic steroids and other drugs.

All nine men who felt small and weak in the study mentioned above used steroids. Most said they used these as a “remedy” for feeling too small, while a couple indicated that they only got “reverse anorexia” after using them. In various studies, it has been shown that bodybuilders generally have a less positive self-image than other athletes (8 through 12).

The use of anabolic steroids to be more muscular and/or leaner will, for many people, by definition be a sign of the inability to objectively appreciate the muscularity of their own body or the inability to make a rational consideration between the means and the goal. I can’t blame them.

Is this where the line is drawn? Can you say that if you use steroids just to look more muscular, you can no longer make rational considerations? That you’re then ready for the couch? Personally, I find this too simplistic given the huge difference in the way various people use anabolic steroids. Paradoxically, it seems to me that it is precisely the people who do NOT have muscle dysmorphia who use anabolic steroids for the wrong reasons. These are usually people (especially boys/men) who have an on-and-off relationship with the gym.

Not training for months, but still wanting to be the man as soon as you’ve found the gym again. Not having the patience to start slowly, but immediately injecting steroids to achieve results quickly that you could also achieve if you trained more regularly and were more serious about nutrition. For someone who does not use anabolic steroids but finds it unimaginable not to train for weeks, let alone months, the term muscle dysmorphia seems more applicable to myself than to the users mentioned. Incidentally, finding it unimaginable not to train for more than, for example, two days is also one of the characteristics of muscle dysmorphia, but more on that later.

It’s different if you take someone who has the same continuous drive to keep training and pay attention to nutrition and also uses anabolic steroids. Here, I see steroid use just like the continuous drive for training and dieting simply as an additional indication of muscle dysmorphia / bigorexia.

Besides, steroid use doesn’t necessarily say anything about what you look like since it’s just one of the factors. Personally, I know several steroid users with a physique that I can’t exactly envy. The lack of talent combined with effort or knowledge ensures that their result remains behind despite using steroids. What if the roles were reversed? Would I still be natural, would I turn to steroids, or would I just realize that bodybuilding is not for me and start playing bridge?

Just insecure people?

Harvard has conducted several studies in this area. In one of them, a survey among 193 people showed that 18 of them (all men) “suffered” from muscle dysmorphia. Notably, all these 18 men also had concerns about other physical features:

They all had additional appearance concerns which focused on such body parts as penis, hair, skin, ears, and chin.

Harrison G. Pope, Mclean Hospital/Harvard Medical School (4)

And here, fortunately, I don’t recognize myself. Okay, my sisters teased me in the past that I have pointy ears like Dr. Spock, but that didn’t mean I wore a sweatband or anything else every day to hide my ears. I know I’m not Brad Pitt, but to say that I’m worried about my physical features other than muscle mass, no. When we talk about muscle dysmorphia, aren’t we just talking about insecure people who are insecure about so many things, of which muscle mass is just one? It’s not a strange thought if you see that cases of anorexia can turn into “reverse anorexia”.

Common associated behaviors included lifting weights, eating large amounts of food and special diets, mirror checking, constant comparison with others, reassurance-seeking behavior, camouflaging with clothing, and wearing extra layers of clothing to enhance their apparent size.

Harrison G. Pope, Mclean Hospital/Harvard Medical School (4)

The mentioned behaviors stemming from this insecurity I also don’t all recognize. The first ones like weightlifting, eating a lot, and dieting, of course, yes. “That’s part of the lifestyle,” as mentioned before.

“Mirror checking”? Sure, when no one’s watching. I can leave the house in the morning without glancing at my face and walking around with Brinta still stuck on my lip, but passing the bathroom mirror without taking a look at my body doesn’t happen often.

“Being muscular is relative”

“Constant comparison with others”. Constant comparison with others? Check. Of course, check. Being muscular is, after all, relative.

Just look at the first editions of the Mr. Universe competitions or bodybuilders in the 60s. They were quite a spectacle back then, while I would dare to step onto the stage next to them. However, looking at today’s bodybuilders, I would appear next to them like that guy in the top photo who seems to have gotten lost looking for a tanning bed and suddenly participates in a bodybuilding contest.

Whether you’re muscular depends as much on the muscularity of others as on your own. You can feel like a big man in your local gym, a big fish in a small pond. When you suddenly find yourself in the big sea, you turn out to be a small fish. I had to mentally prepare myself for expos like FIBO and Bodypower.

Prepare for the fact that I would at best be average in terms of muscularity there (and that’s only thanks to the ladies present). Even someone like me, who sometimes feels like a forty-year-old virgin as a natural bodybuilder, can feel the temptation of steroids (for a fraction of a second) when seeing men twice my size and the massive attention they get.

It’s natural to compare yourself with others, though not always healthy. We do it all the time: Looking for the standard. Often to adhere to the same standard, but sometimes just to distinguish yourself from it. Bodybuilders don’t simply want to be muscular; they want to be more muscular than others. The question is when this desire to distinguish oneself develops into harmful behavior.

Muscle dysmorphia / bigorexia, being obsessively concerned with the muscularity of the body, can lead to various psychological, social, and occupational problems. Below, I will delve further into these problems.

The Adonis Complex

Above, I indicated that the inability to determine one’s own muscularity objectively is a characteristic of muscle dysmorphia, also commonly known as the Adonis Complex or bigorexia. Here, you can make a distinction. On the one hand, between people who somewhere know that they are objectively muscular, but do not find subjective comfort in it, and on the other hand, those who, for example, genuinely think they are smaller than another while this is not the case.

In the latter case, it can be such a psychological burden that they make great efforts not to show their body in public (1).

Such individuals may go to great lengths to avoid having their bodies seen in public. They may wear baggy sweatpants and sweatshirts, or layers of clothes, even in summer, to hide their bodies. They avoid beaches, swimming pools, locker rooms, and other places where their bodies might be seen; if such exposure is unavoidable, they may experience great distress. The only exception to this pattern is in bodybuilding contests, where the individual may appear after weeks of rigorous preparation, and only when in peak condition.

Harrison G. Pope, Mclean Hospital Harvard Medical School

Just as people with overweight often want to hide their extra weight or are not eager to go to a swimming pool, you may want to hide your “too small” body. This can be very difficult and limiting. This is reflected in the examples of people with muscle dysmorphia. Personally, this is strange to me. I recognize the feeling of not feeling optimal if your training or nutrition has been less for a while. Subjectively, I can then be dissatisfied with myself, but objectively, I still know that I am more muscular than the average person. People with muscle dysmorphia really can’t see this objectively, keep comparing themselves to others who they think are bigger, but aren’t in reality. They also continually seek confirmation of their muscularity from others, as evident from “case 2” at the bottom of the article.

Example of muscle dysmorphia

I personally do not know the examples of many of the symptoms mentioned. At least not where those symptoms are so severe that they become dysfunctional. The case reports mentioned in the work of researcher Pope and colleagues offer more insight into the more severe cases and can serve as an example (of what not to do)(4). I discuss one of the four examples here, the other three can be found at the bottom of the article in the original text. Based on these examples, I will then discuss the social, relational, and occupational problems that can arise due to muscle dysmorphia / bigorexia.

“Case 3”: Female bodybuilder

A 29-year-old woman who has been strength training for 13 years and bodybuilding for 7 years. Between her 15th and 16th year, she struggled with anorexia and between her 17th and 22nd with bulimia. From her 16th year, she started with strength training and changed her ideal body type from “model thin” to muscular. At 22, she was physically attacked, which was the reason to start with “serious bodybuilding” to feel more resilient*. Her diet helped her get rid of bulimia. She started using various supplements, but also ephedrine (from the now-banned ‘stackers’), diuretics (diuretics to expel fluid), and eventually anabolic steroids. These latter led to more frequent problems such as amenorrhea (abnormally absent menstruation), acne, and a deeper voice.

As a result, she did achieve her ideal body type, which made her feel “euphoric and manic”. This feeling disappeared when she did not use steroids, causing her to become depressed and disappointed in her body. Interestingly, even when she was in optimal shape, she hid her figure under loose clothing.

She reports that even when in optimal shape, she wears baggy pants and sweatshirts to hide her body.

Harrison G. Pope, Mclean Hospital Harvard Medical School

Additionally, she became distressed and irritated when something interfered with a workout. When she ate something not on her diet plan, she no longer ran to the bathroom to vomit as before, but ran a few kilometers further to burn off the calories. Even if it was 4 a.m.!

When she was hospitalized with kidney failure, doctors attributed it to her steroid use combined with a high-protein diet and dehydration (she was preparing for a competition). A few months after being discharged from the hospital, she started a steroid cycle again, the same diet and training**.

She lives alone and says she is not interested in others because they would stand in the way of her training regime too much. This attitude also started simultaneously with the training and is therefore not caused by another psychological disorder. She works as a personal trainer so she can spend as much time in the gym as possible.

* Female users of anabolic steroids are relatively often (sexually) abused in the past, compared to men who use steroids and women who do not (Ip). Resilience is therefore often mentioned as a reason to start bodybuilding and use steroids.

** The question remains to what extent a protein-rich diet poses a higher burden on the kidneys. We have previously written an article answering the question: is too much protein bad for the kidneys?

(When researchers placed an ad asking for women who had participated in bodybuilding competitions, 38 women responded. A whopping 32 of them, 84%, reported “severe preoccupation with being muscular and lean”. This caused limited social or occupational functioning. 38% of these women used anabolic steroids.)

Social, relational, occupational, financial, and health problems due to muscle dysmorphia

Now it might be clearer how muscle dysmorphia can be limiting or even destructive to your functioning.

Relational: Consider, for example, people who have difficulty with intimacy because they are ashamed of their body. But mainly think about the time and attention that a “lifestyle” like bodybuilding requires. The saying “A couple that trains together, stays together” might come from the simple fact that it is incredibly difficult to fully commit to bodybuilding when your partner does not see it as a priority.

In the interview with Harold Kelley, a “wheelchair bodybuilder”, it emerged that his wife is his biggest support. She also competes and takes care of his diet (plan). This seems to make maintaining a relationship and simultaneously going all-in for a career as a bodybuilder much easier. If you have a relationship with someone who has no affinity with strength training, let alone the preoccupation with it as you do, then you are constantly explaining why you have to train again and why you can’t just eat whatever is on the table.

Of the 32 female bodybuilders, there were five who preferred to live alone so that no one could interfere with their training and diet.

many individuals with muscle dysmorphia adopt a consuming lifestyle revolving around their workout schedule and meticulous diet. Many spend so much time in the gymnasium that they forgo intimate relationships or occupational opportunities

Harrison G. Pope, Mclean Hospital Harvard Medical School

Occupationally, muscle dysmorphia can have a significant impact as well. Of those same 32 female bodybuilders, 17 worked in a gym, slightly more than half! You can read this in two ways: 1. Great, they made their passion their profession. Or: 2. They let more interesting occupational opportunities go to be in the gym and thus do not fully develop themselves.

“Case 4”, at the bottom, is another example of someone with muscle dysmorphia. She has a higher education degree but does not seek work in her field. Instead, she works in the gym to be able to train often enough.

Socially: Besides the aforementioned relational and occupational factors, there’s also the fear of missing workouts or deviating from the diet. If someone with muscle dysmorphia misses a day of training, they can become very distressed and agitated. Deviations from the diet plan are highly undesirable, so they often avoid eating with others. Activities that interfere with the usual routine are often avoided.

Financially: I recently wrote in the article, do I need supplements, about which supplements really work and which are at least questionable. This is to save you unnecessary costs on supplements. I recently spoke to someone in the gym who said he spends more than 200 euros a month on supplements. I still doubt this because I hardly ever see him train, and he doesn’t exactly look like someone who finds muscle mass so important that he would spend more than 200 euros a month on it. How much do you think you need besides protein, creatine, and maybe a pre-workout (which I advise you to mix yourself)? Don’t get me wrong, I also have more than ten jars of powders and pills at a certain moment, but they are not all purchased monthly.

You easily reach the hundreds of euros a month if you use steroids, especially in the case of expensive growth hormone. For some, this means they have to drastically lower their standard of living, especially if, instead of a job as a bank manager, for example, they choose a career as a personal trainer. Earning millions or having a normal income like the (male) top bodybuilders is reserved for very few. The documentary Generation Iron shows this well. We see bodybuilders from the top 10 in the world, where the number 1 literally bathes in luxury (Phil Heath), while another drives around uninsured (Victor Martinez). The ladies are nowadays a bit smarter in making money from their physique via social media like Paige Hathaway and Jenny Selter.

Health: Just like top sports in general, bodybuilding at a high level is also not exactly conducive to health. Having a lot of muscle mass and a low body fat percentage prevents many so-called diseases of affluence such as diabetes caused by overweight. However, extremely large muscle mass can cause some of the same complaints as overweight due to fat given the heavy load on the heart and joints. Then we haven’t even talked about the possible complications of steroid use. I once wrote that steroid use can theoretically be used safely under certain conditions. However, this requires a certain objective consideration of risks that people with muscle dysmorphia often cannot make.

How often does muscle dysmorphia occur?

Although it is difficult to estimate the prevalence of muscle dysmorphia, the disorder appears to affect a substantial number of individuals. We diagnosed reverse anorexia nervosa in 10% of our earlier unselected sample of 156 male bodybuilders. In the second ongoing study, we noted prominent features of muscle dysmorphia in 32 of 38 competitive female bodybuilders studied to date.

Harrison G. Pope, Mclean Hospital Harvard Medical School

That then again gives hope regarding the figures for men. The researchers themselves point out that the selection of the target group could distort the figures. Naturally, you will encounter more people with muscle dysmorphia among bodybuilders than among “normal people”. 10% then still seems to be manageable. The percentage among women turns out much higher. However, this has to do, among other things, with the fact that only competition bodybuilders were interviewed for this. As mentioned above, competition bodybuilding requires much more from you than “hobby building”. By definition, you have a greater chance of a dysfunctional preoccupation with being muscular when you compete.

In addition, it is difficult to get good figures because some people with muscle dysmorphia do not show up for the studies on this because they are ashamed of their figure.

Do I have muscle dysmorphia?

Throughout this article, as you heard the symptoms, you probably often mirrored your own situation to assess whether you are a healthy athlete or an obsessive case for the psychiatrist. I did, in any case. The researchers from Harvard have established the following criteria to assess whether someone suffers from muscle dysmorphia:

Criteria

1. The person has a preoccupation with the idea that one’s body is not sufficiently lean and muscular. Characteristic associated behaviors include long hours of lifting weights and excessive attention to diet.
2. The preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning, as demonstrated by at least two of the following four criteria:
   • 2a) the individual frequently gives up important social, occupational, or recreational activities because of a compulsive need to maintain his or her workout and diet schedule;
   • 2b) the individual avoids situations where his or her body is exposed to others, or endures such situations only with marked distress or intense anxiety;
   • 2c) the preoccupation about the inadequacy of body size or musculature causes clinically significant distress or impairment in social, occupational, or other important areas of functioning;
   • 2d) the individual continues to work out, diet, or use ergogenic (performance-enhancing) substances despite knowledge of adverse physical or psychological consequences.
3. The primary focus of the preoccupation and behaviors is on being too small or inadequately muscular, as distinguished from fear of being fat, as in anorexia nervosa, or a primary preoccupation only with other aspects of appearance, as in other forms of BDD.

As the researchers indicate, it is important not to confuse muscle dysmorphia with people who simply love bodybuilding:

Finally, it is important to note that muscle dysmorphia should not be confused with mere enthusiasm for bodybuilding. Many people may become so devoted to bodybuilding or other sports that they sometimes forgo other opportunities. However, ordinary dedication to sports is not associated with the profound body dissatisfaction, subjective distress, and impaired social and occupational functioning reported by individuals with frank muscle dysmorphia.

To distinguish between “normal bodybuilders” (who might feel addressed under point 1) and others, you should especially look at the points under 2). Essentially, it comes down to whether the preoccupation with being muscular makes you less happy and/or misses chances of happiness, if your psychological and physical health actually worsens, you should at least scratch your head.

Also read the other examples at the bottom. This gives a clear picture of the harmful effects of being (too) obsessively concerned with muscle mass. While at the beginning of going through the studies I somewhat doubted whether I should take a seat on the couch myself, it is now clear that this is far from the case. Just the fact that I was vain enough to use a photo of myself as the featured photo for this article (with the mirror) and that there are even two photos of myself in part I, clearly indicates that I am really not afraid to show my body (even when I look rather pitiful next to a pro bodybuilder).

Psychological cause

It is clear from the examples that people with muscle dysmorphia often have (had) more problems. The obsession with muscle mass in the form of muscle dysmorphia seems simply to be a very specific expression of these problems. As mentioned in part I, muscle dysmorpia is therefore a specific type of Body Dysmorphic Disorder (“a distressing or impairing preoccupation with a nonexistent or slight defect in body appearance”). Not surprisingly, it occurs relatively often that people who had anorexia nervosa in the past have “converted” this into reverse anorexia. The underlying dissatisfaction with the appearance that cannot be objectively assessed here is the cause.

In the studies, it also repeatedly comes back that addiction susceptibility is relatively high in people with muscle dysmorphia. This is expressed not only in the addiction to training but also in the use of anabolic steroids, which is often combined with other drug use.

Therefore, it is good to recognize the risk profile in yourself. This differs per person. Just as there are people who are addicted after one joint, you should think twice before using other drugs, while another can use it recreationally. Especially if you have struggled with a form of Body Dysmorphic Disorder in the past, or specifically anorexia nervosa or bulimia, be warned! I’m not saying you should avoid the gym like an ex-alcoholic (which apparently doesn’t exist) should avoid a bar. It is wise to immediately set objective (healthy and realistic) goals and continuously hold up a mirror to yourself. The latter, of course, I mean figuratively, because if you do that literally ten times a day, according to the criteria, you already have a problem!

When psychological guidance?

Part I of this article began with the assertion from recent research that trainers should recognize muscle dysmorphia in clients. If you have seen the examples and read about the occupational choices people with muscle dysmorphia often make, you have already noticed the problem with this assertion. People with muscle dysmorphia are often trainers/fitness instructors/personal trainers themselves! Even in cases where this is not so, you should not expect someone with muscle dysmorphia to take advice from an average fitness instructor in a gym. Someone with muscle dysmorphia looks at the average fitness instructor and thinks: “If your physique is a reflection of what you can teach me, then I know enough”. That’s not always fair, but understandable. I had the same experience when I wanted to get serious about bodybuilding and realized that it is a sub-specialism within strength training in which very few fitness instructors and/or personal trainers are sufficiently specialized. That was the reason for me to specialize myself.

Whom do they/we listen to, then? To people who have achieved what they/we want to achieve. This is especially evident in so-called contest prepping, the preparation for competitions. So much is involved that even someone who has been doing strength training for ten years might find it pleasant to be guided in this. Should this “competition coach” then be the one who recognizes muscle dysmorphia and refers you? First of all, we have the problem of the dealer who is unlikely to send his customer to a rehab clinic quickly. A difference here, of course, is that a dealer knows anyway that his actions are probably not beneficial to his customers’ health. From a competition coach, however, you still assume good intentions combined with commercial interests. The question is then which of these weighs more heavily for a coach.

Finally, the question is whether such a coach can recognize the problem at all. After all, this person usually has the same kind of lifestyle as his clients and a preoccupation with muscularity. Just as I describe symptoms in both parts of this article that I do not see as negative (the urge to train and eat certain foods), a coach will not look for problems behind them either. It is mainly the criteria under 2) that you should pay attention to, but these are typically matters from the personal sphere. As a coach, you will probably only find out about them by actively asking.

Conclusion: Finding the right balance

As with so many things in life, the most important thing is to find the right balance. Everyone will make different choices, but whatever you choose, force yourself to remain as objective as possible. Personally, I find my weight and body fat percentage much more interesting than what I see in the mirror because they are objective. I can also set an objective goal where I can say: “This is good”. However, if you stand on the scale five times a day, you have another typical symptom of muscle dysmorphia.

Occupationally, socially, and relationally, it is good to ask yourself which sacrifices are proportional. A bit of grumbling from your partner because you’re going to train again will be acceptable to many, but breaking up a relationship because of training might go too far. I say “might” because this is also relative. If you’ve been seriously training for ten years and you’ve had a new partner for a week who demands that you completely change this, then it’s perhaps not strange if you wonder what you find more important. If you’ve been married for ten years and have children together, then such a consideration should look very different (should).

The question I often ask myself in determining a budget for supplements is simple: “Are those few hundred grams to possibly a few kilos of extra muscle mass worth this?”. The same question can be asked for everything you invest in your body. Now let’s hope you can give yourself a good answer.

Other examples (1):

Case 1:

Mr. A. is a 27-year-old, single, white, heterosexual man. He is 66 inches tall and weighs 203 pounds. His body fat is measured at 17%-a figure that is average, or perhaps slightly leaner than average, for an American man of his age. By contrast, his FFMI is 28 kgl/m2-a figure indicating massive muscularity, well beyond what could normally be achieved without the use of anabolic steroids or other drugs. Despite his size, Mr. A. does not believe that he is muscular, but he feels very fat and unhappy with his body proportions. He was surprised to find that his body fat was 17%, believing that he was much fatter.

Mr. A. reports that, since the age of 19, all of his waking hours are consumed with preoccupations of getting bigger. He tries to resist these thoughts, but reports success only half of the time. He weighs himself 2-3 times daily and checks mirrors 10-12 times a day to monitor his physique. He wears baggy sweatshirts and long pants even in the heat of summer to disguise his perceived “smallness,” He has a friend the same height and weight as himself, but he sees his friend as “huge” by comparison with himself.

Mr. A. routinely gives up enjoyable activities because of this preoccupation. He declined an invitation from friends to go to a college reunion for fear that people would comment on his “small body,” He never eats in restaurants because he maintains a strict diet to enhance muscularity and minimize fat. He has sacrificed or compromised relationships with women, friends, and family because of this preoccupation. He reports that if he were forced to forgo weightlifting for a single day, he would become anxious and depressed.

On the SCID, Mr. A. reports a past history of major depression. He also reports past cannabis dependence, stimulant dependence, and hallucinogen dependence. He reports the use of anabolic steroids for much of the time since he was 18. He has been free of all drugs for 6 months but admits that he is constantly tempted to resume steroid use.
Case 2:

Mr. B. is a 22-year-old, single, white, homosexual, business-school student. He is 71.5 inches tall and weighs 252 pounds. His body fat is measured at 25%, and his FFMI is a very muscular 25.9 kgl/m2, suggesting possible anabolic steroid use, although he denies this. He feels very dissatisfied with the way his body is proportioned. Since the age of 18, Mr. B. has spent 6 days a week lifting weights and at least 4 hours a day being preoccupied with thoughts of becoming more muscular. He weighs himself 10 times weekly and checks mirrors almost every time he passes one. He wishes that he would not look in mirrors constantly but feels as if he has little control over this behavior.

His belief in his “small size” leads him to wear baggy sweatshirts, always with long sleeves, for fear that someone may comment on his lack of muscularity. Mr. B. reports that he has lost many friends and sexual partners because he feels compelled to go to the gym rather than spend time with them. When he is with friends, he frequently questions them about his appearance. He constantly compares himself to other men at the gym and wishes that he could look as big as he perceives the other men to look.

Lifting weights preempts all other activities in Mr. B.’s life. He reports feeling frustrated and anxious when he is not able to go to the gymnasium. He reports that he would feel “uncomfortable” if he could not exercise for a day and “extremely uncomfortable” if he could not work out for a week. He often forces himself to eat, even when he is clearly not hungry, for fear that not eating will result in a decrease in muscularity. On the SCID, Mr. B. reports a history of bipolar disorder with at least two prior manic episodes, neither of which was diagnosed at the time. Recently, he developed a mixed episode that was correctly diagnosed and successfully treated with lithium carbonate. He also currently has panic disorder and obsessive-compulsive disorder.
Case 4:

Ms. D., a 29-year-old, single, white woman with no past medical or psychiatric history, has been bodybuilding for 10 years. In her teens, she was a nationally recognized ballet dancer. Although she trained rigorously for dancing, she was of normal weight and showed no evidence of an eating disorder. She then began bodybuilding specifically to replace dancing.

When not competing, she maintains her body fat at an extremely low 8-9% through a scrupulous diet and rigorous workout schedule. She is 66 inches tall, her off-season weight is 140 pounds, and her most recent competition weight was 126 pounds at a body fat of 5%. She brought with her to the interview a handwritten log of her muscle circumferences, pounds of weight lifted, and body fat, measured repeatedly over the last several years.

To maintain her low body fat, she eats a regimented diet of precise amounts of specific foods year-round. Each morning, she prepares numerous plastic bags with food portions for the day: 1.75 ounces of tuna, one-quarter cup of rice, and precise quantities of various vegetables. She carries these with her and eats them at specific times. Although her physician has urged her to increase her body fat in the off-season (if only to permit menstruation), she refuses, claiming that his opinion is uninformed. In reality, she cannot tolerate her appearance with body fat over 9%. After her first bodybuilding contest, she “lost control” of her diet briefly and quickly perceived her body as unacceptable, although she had remained very muscular, lean, and fit. She felt extremely depressed and anxious until she regained her current maintenance level.

She describes bodybuilding as an all-consuming lifestyle that preempts all other commitments; she only rarely sees her boyfriend or family. Despite holding a professional degree, she works as a personal trainer in a gymnasium because this is the only job that allows her enough time for her own exercise regimen.

References

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6. http://www.pro-ana.be/
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9. Yates A: Compulsive Exercise and Eating Disorders: Toward an Integrative Theory. New York, Brunner/Mazel,1991
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13. Pope, HG, Jr., Gruber, AJ, Choi, P, Olivardia, R, and Phillips, KA. Muscle dysmorphia: An underrecognized form of body dysmorphic disorder. Psychosomatics 38: 548-557, 1997.
14. Ip EJ, Barnett MJ, Tenerowicz MJ, Kim JA, Wei H, Perry PJ. Women and anabolic steroids: an analysis of a dozen users.Clin J Sport Med. 2010 Nov;20(6):475-81. doi: 10.1097/JSM.0b013e3181fb5370.
15. Thomas, Adam; Tod, David A.; Edwards, Christian J.; McGuigan, Michael R. DRIVE FOR MUSCULARITY AND SOCIAL PHYSIQUE ANXIETY MEDIATE THE PERCEIVED IDEAL PHYSIQUE MUSCLE DYSMORPHIA RELATIONSHIP. Journal of Strength & Conditioning Research:POST ACCEPTANCE, 16 June 2014doi: 10.1519/JSC.0000000000000573