Diagnosis
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| Muscle dysmorphia |
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Muscle dysmorphia is a subtype of the obsessive mental disorder body dysmorphic disorder, but is often also grouped with eating disorders. [1] [2] In muscle dysmorphia, which is sometimes called "bigorexia", "megarexia", or "reverse anorexia", the delusional or exaggerated belief is that one's own body is too small, too skinny, insufficiently muscular, or insufficiently lean, although in most cases, the individual's build is normal or even exceptionally large and muscular already. [1] [3]
Muscle dysmorphia affects mostly men, particularly those involved in sports where body size or weight are competitive factors, becoming rationales to gain muscle or become leaner. [3] The quest to seemingly fix one's body consumes inordinate time, attention, and resources, as on exercise routines, dietary regimens, and nutritional supplementation, while use of anabolic steroids is also common. [1] [3] Other body-dysmorphic preoccupations that are not muscle-dysmorphic are usually present as well. [1]
Although likened to anorexia nervosa, [2] [4] muscle dysmorphia is especially difficult to recognize, since awareness of it is scarce and persons experiencing muscle dysmorphia typically remain healthy looking. [3] The distress and distraction of muscle dysmorphia may provoke absences from school, work, and social settings. [1] [5] Compared to other body dysmorphic disorders, rates of suicide attempts are especially high with muscle dysmorphia. [1] Researchers believe that muscle dysmorphia's incidence is rising, partly due to the recent cultural emphasis on muscular male bodies. [3] [6]
Although body dissatisfaction has been found in boys as young as age six, muscle dysmorphia's onset is estimated at usually between ages 18 and 20. [7] [8] According to DSM-5, muscle dysmorphia is indicated by the diagnostic criteria for body dysmorphic disorder via "the idea that his or her body is too small or insufficiently muscular", and this specifier holds even if the individual is preoccupied with other body areas, too, as is often the case. [9]
Further clinical features identified include excessive conduct of efforts to increase muscularity, activities such as dietary restriction, overtraining, and injection of growth-enhancing drugs. [10] Persons experiencing muscle dysmorphia generally spend over three hours daily pondering increased muscularity, and may feel unable to limit weightlifting. [7] As in anorexia nervosa, the reverse quest in muscle dysmorphia can be insatiable. [11] Those suffering from the disorder closely monitor their body and may wear multiple clothing layers to make it appear larger. [7]
Muscle dysmorphia involves severe distress at having one's body viewed by others. [10] Occupational and social functioning are impaired, and dietary regimes may interfere with these. [7] Patients often avoid activities, people, and places that threaten to reveal their perceived deficiency of size or muscularity. [7] Roughly half of patients have poor or no insight that these perceptions are unrealistic. [7] [12] Patient histories reveal elevated rates of diagnoses of other mental disorders, including eating disorders, mood disorders, anxiety disorders, and substance use disorder, [12] [13] [14] as well as elevated rates of suicide attempts. [7]
Although muscle dysmorphia's development is unclear, several risk factors have been identified.
Versus the general population, persons manifesting muscle dysmorphia are more likely to have experienced or observed traumatic events like sexual assault or domestic violence, [7] [15] or to have sustained adolescent bullying and ridicule for actual or perceived deficiencies such as smallness, weakness, poor athleticism, or intellectual inferiority. [7] [16] Increased body mass may seem to reduce the threat of further mistreatment. [7] [17]
Low self-esteem is associated with higher levels of body dissatisfaction and of muscle dysmorphia. [18] Vulnerable narcissism has also been linked to heightened muscle dysmorphia risk. [19] Increased body size or muscularity may seem to enhance the masculine identity. [7]
As Western media emphasize physical attractiveness, some marketing campaigns now exploit male body-image insecurities. [20] [21] [22] [23] Since the 1980s, the number of fitness magazines and of partially undressed, muscular men in advertisements have increased. [18] Such media provoke bodily comparisons and pressure individuals to conform, [18] yet increase the gap between men's perceptions of their own muscularity versus their desired muscularity. [24] In college-aged men, a strong predictor of a muscularity quest is internalization of the idealized male bodies depicted in media. [25] [26]
Athletes tend to share some psychological factors that may predispose to muscle dysmorphia, factors including high levels of competitiveness, need for control, and perfectionism, [18] and athletes tend to be more critical of their own bodies and body weight. [27] Athletes who also fail to their sports performance goals may escalate efforts to modify their builds, efforts that overlap those of muscle dysmorphia. [3] Involvement in sports where size, strength, or weight, whether higher or lower, imply competitive advantage associates with muscle dysmorphia. [20] [10] [28] Athletic ideals reinforce the social ideal of muscularity. [18] Conversely, those already disposed to muscle dysmorphia may be more likely to participate in such sports. [3]
It has been observed that men who have sex with men (MSM) have a unique relationship with the development of muscle dysmorphia symptoms. MSM are at increased risk for experiencing internalized heterosexism, which can lead to dissatisfaction with one's body and the internalizing of standards for attractiveness. [29] Men who conform to conventional ideals of masculinity often report increased stress from not meeting the imposed standard of a masculine and muscular body. [30] In a sample of 2,733 MSM who reported body dissatisfaction, only one in every 10 reported feeling no dissatisfaction with their muscularity. Dissatisfaction with muscularity had a stronger relationship with quality of life impairment when compared to dissatisfaction with body fat, height, and penis size. [31]
Those who identify as a sexual minority are at increased risk for victimization due to their identity. Having been a victim of homophobic bullying is associated with more symptoms of muscle dysmorphia. A possible cause for this relationship can be the increased feelings of paranoid ideation that a MSM individual can experience following homophobic bullying. [32]
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Treatment of muscle dysmorphia can be stymied by a patient's unawareness that the preoccupation is disordered or by avoidance of treatment. [3] Scientific research on treatment of muscle dysmorphia is limited, the evidence largely in case reports and anecdotes, [7] and no specific protocols have been validated. [3] Still, evidence supports the efficacy of family-based therapy, cognitive behavioural therapy, and pharmacotherapy with selective serotonin reuptake inhibitors. [7] Also limited is research on prognosis of the untreated. [7]
Prevalence estimates for muscle dysmorphia have greatly varied, ranging from 1% to 54% of men in the studied samples. [7] Samples of gym members, weightlifters, and bodybuilders show higher prevalence than do samples from the general population. [7] Rates even higher have been found among users of anabolic steroids. [15] [33] The disorder is rare in women but does occur, and has been noted especially in female bodybuilders who have experienced sexual assault. [7] [15]
Muscle dysmorphia has been identified in China, South Africa, and Latin America. [14] [34] [35] [36] [37] Nonwestern populations less exposed to western media show lower rates of muscle dysmorphia. [38]
Muscle dysmorphia was first conceptualized by healthcare professionals in the late 1990s. [39] [10] [7] In 2016, 50% of peer-reviewed articles on it had been published in the prior five years. [7]
Although muscle dysmorphia was initially viewed as anorexia nervosa's inverse—questing to be large and muscular instead of small and thin [39] —later researchers fit the subjective experience to body dysmorphic disorder. [10]
The American Psychiatric Association recognized muscle dysmorphia with the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders , which classifies it under body dysmorphic disorder. [9] Muscle dysmorphia is absent from the International Statistical Classification of Diseases and Related Health Problems' present edition, the tenth, published in 1992. [33]
Muscle dysmorphia's classification has been widely debated, and alternative DSM classifications have been proposed.
An eating disorder is a mental disorder defined by abnormal eating behaviors that adversely affect a person's physical or mental health. Types of eating disorders include binge eating disorder, where the patient eats a large amount in a short period of time; anorexia nervosa, where the person has an intense fear of gaining weight and restricts food or overexercises to manage this fear; bulimia nervosa, where individuals eat a large quantity (binging) then try to rid themselves of the food (purging); pica, where the patient eats non-food items; rumination syndrome, where the patient regurgitates undigested or minimally digested food; avoidant/restrictive food intake disorder (ARFID), where people have a reduced or selective food intake due to some psychological reasons; and a group of other specified feeding or eating disorders. Anxiety disorders, depression and substance abuse are common among people with eating disorders. These disorders do not include obesity. People often experience comorbidity between an eating disorder and OCD. It is estimated 20–60% of patients with an ED have a history of OCD.
Bulimia nervosa, also known as simply bulimia, is an eating disorder characterized by binge eating followed by purging or fasting, and excessive concern with body shape and weight. This activity aims to expel the body of calories eaten from the binging phase of the process. Binge eating refers to eating a large amount of food in a short amount of time. Purging refers to the attempts to get rid of the food consumed. This may be done by vomiting or taking laxatives.
Orthorexia nervosa is a proposed eating disorder characterized by an excessive preoccupation with eating healthy food. The term was introduced in 1997 by American physician Steven Bratman, M.D. He suggested that some people's dietary restrictions intended to promote health may paradoxically lead to unhealthy consequences, such as social isolation; anxiety; loss of ability to eat in a natural, intuitive manner; reduced interest in the full range of other healthy human activities; and, in rare cases, severe malnutrition or even death.
Appetite is the desire to eat food items, usually due to hunger. Appealing foods can stimulate appetite even when hunger is absent, although appetite can be greatly reduced by satiety. Appetite exists in all higher life-forms, and serves to regulate adequate energy intake to maintain metabolic needs. It is regulated by a close interplay between the digestive tract, adipose tissue and the brain. Appetite has a relationship with every individual's behavior. Appetitive behaviour also known as approach behaviour, and consummatory behaviour, are the only processes that involve energy intake, whereas all other behaviours affect the release of energy. When stressed, appetite levels may increase and result in an increase of food intake. Decreased desire to eat is termed anorexia, while polyphagia is increased eating. Dysregulation of appetite contributes to anorexia nervosa, bulimia nervosa, cachexia, overeating, and binge eating disorder.
Binge eating disorder (BED) is an eating disorder characterized by frequent and recurrent binge eating episodes with associated negative psychological and social problems, but without the compensatory behaviors common to bulimia nervosa, OSFED, or the binge-purge subtype of anorexia nervosa.
Binge eating is a pattern of disordered eating which consists of episodes of uncontrollable eating. It is a common symptom of eating disorders such as binge eating disorder and bulimia nervosa. During such binges, a person rapidly consumes an excessive quantity of food. A diagnosis of binge eating is associated with feelings of loss of control. Binge eating disorder is also linked with being overweight and obesity.
Body dysmorphic disorder (BDD), also known in some contexts as dysmorphophobia, is a mental disorder defined by an overwhelming preoccupation with a perceived flaw in one's physical appearance. In BDD's delusional variant, the flaw is imagined. When an actual visible difference exists, its importance is disproportionately magnified in the mind of the individual. Whether the physical issue is real or imagined, ruminations concerning this perceived defect become pervasive and intrusive, consuming substantial mental bandwidth for extended periods each day. This excessive preoccupation not only induces severe emotional distress but also disrupts daily functioning and activities. The DSM-5 places BDD within the obsessive–compulsive spectrum, distinguishing it from disorders such as anorexia nervosa.
Body image is a person's thoughts, feelings and perception of the aesthetics or sexual attractiveness of their own body. The concept of body image is used in several disciplines, including neuroscience, psychology, medicine, psychiatry, psychoanalysis, philosophy, cultural and feminist studies; the media also often uses the term. Across these disciplines, there is no single consensus definition, but broadly speaking, body image consists of the ways people view themselves; their memories, experiences, assumptions, and comparisons about their appearances; and their overall attitudes towards their respective heights, shapes, and weights—all of which are shaped by prevalent social and cultural ideals.
The affective spectrum is a spectrum of affective disorders. It is a grouping of related psychiatric and medical disorders which may accompany bipolar, unipolar, and schizoaffective disorders at statistically higher rates than would normally be expected. These disorders are identified by a common positive response to the same types of pharmacologic treatments. They also aggregate strongly in families and may therefore share common heritable underlying physiologic anomalies. Affective disorders are linked to higher rates of cardiovascular disease.
The obsessive–compulsive spectrum is a model of medical classification where various psychiatric, neurological and/or medical conditions are described as existing on a spectrum of conditions related to obsessive–compulsive disorder (OCD). "The disorders are thought to lie on a spectrum from impulsive to compulsive where impulsivity is said to persist due to deficits in the ability to inhibit repetitive behavior with known negative consequences, while compulsivity persists as a consequence of deficits in recognizing completion of tasks." OCD is a mental disorder characterized by obsessions and/or compulsions. An obsession is defined as "a recurring thought, image, or urge that the individual cannot control". Compulsion can be described as a "ritualistic behavior that the person feels compelled to perform". The model suggests that many conditions overlap with OCD in symptomatic profile, demographics, family history, neurobiology, comorbidity, clinical course and response to various pharmacotherapies. Conditions described as being on the spectrum are sometimes referred to as obsessive–compulsive spectrum disorders.
Harrison Graham "Skip" Pope, Jr., is an American professor and physician, currently Professor of Psychiatry at Harvard Medical School and an attending physician at McLean Hospital. He is also the Director, Biological Psychiatry Laboratory at McLean's. According to the ISI index, he is one of the most highly cited psychiatrists of the 20th century. Pope's research focus is on substance abuse, especially anabolic steroids, marijuana, hallucinogens, and MDMA. In his book the Adonis Complex, he argues that the media fuels body image disorders for not only women but men as well. He has also written extensively about repressed memory and recovered memory controversy, arguing that repressed memory does not exist. Pope has been a pioneer in designing the first randomized clinical trials of several currently accepted treatments for psychiatric disorders.
The Eating Disorder Inventory (EDI) is a self-report questionnaire used to assess the presence of eating disorders, (a) anorexia nervosa both restricting and binge-eating/purging type; (b) bulimia nervosa; and (c) eating disorder not otherwise specified including binge eating disorder. The original questionnaire consisted of 64 questions, divided into eight subscales. It was created in 1984 by David M. Garner and others. There have been two subsequent revisions by Garner: the Eating Disorder Inventory-2 (EDI-2) and the Eating Disorder Inventory-3 (EDI-3).
The figure rating scale (FRS), also known as the Stunkard scale, is a psychometric measurement originally developed in 1983 to communicate about the unknown weights of a research subject's absent relatives, and since adapted to assess body image.
Anorexia nervosa (AN), often referred to simply as anorexia, is an eating disorder characterized by food restriction, body image disturbance, fear of gaining weight, and an overpowering desire to be thin.
The differential diagnoses of anorexia nervosa (AN) includes various types of medical and psychological conditions, which may be misdiagnosed as AN. In some cases, these conditions may be comorbid with AN because the misdiagnosis of AN is not uncommon. For example, a case of achalasia was misdiagnosed as AN and the patient spent two months confined to a psychiatric hospital. A reason for the differential diagnoses that surround AN arise mainly because, like other disorders, it is primarily, albeit defensively and adaptive for, the individual concerned. Anorexia Nervosa is a psychological disorder characterized by extremely reduced intake of food. People with anorexia nervosa tend to have a low self-image and an inaccurate perception of their body.
Many memory impairments exist as a result from or cause of eating disorders. Eating disorders (EDs) are characterized by abnormal and disturbed eating patterns that affect the lives of the individuals who worry about their weight to the extreme. These abnormal eating patterns involve either inadequate or excessive food intake, affecting the individual's physical and mental health.
Chew and spit is a compensatory behavior associated with several eating disorders that involves chewing food and spitting it out before swallowing, often as an attempt to avoid ingesting unwanted or unnecessary calories. CS can be used as a way to taste food viewed as “forbidden” or unhealthy. Individuals who partake in CS typically have an increased desire for thinness, increased loss of control (LOC) and body dissatisfaction. CS can replace vomiting and/or binging behaviors, or serve as an additional behavior to many eating disorders.
Paul E. Garfinkel is a Canadian psychiatrist, researcher and an academic leader. He is a professor at the University of Toronto and a staff psychiatrist at Centre for Addiction and Mental Health (CAMH).
Body image disturbance (BID) is a common symptom in patients with eating disorders and is characterized by an altered perception of one's own body.
Body checking is a compulsive behaviour related but not exclusive to various forms of body dysmorphic disorders. It involves frequently collecting various information about one’s own body in terms of size, shape, appearance or weight. Frequent expressions of this form of behaviour entails for example mirror checking, trying to feel one’s own bones, pinching the abdomen, frequent body weight measurement and comparing your own body to that of others. Studies have shown that an increased rate of body checking correlates with an overall increased dissatisfaction with the own body.