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Muscle Dysmorphia: What Happens when Body Image Collides with Exercise, Nutrition, and Substance Abuse?


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Learn about the growing problem of Muscle Dysmorphic Disorder and how it relates to eating disorders. This presentation will focus on the male population who is in relentless pursuit of muscularity. For more information about the author David A. Wiss, MS, RDN, CPT visit his website at

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Muscle Dysmorphia: What Happens when Body Image Collides with Exercise, Nutrition, and Substance Abuse?

  2. 2. OBJECTIVES • Understand challenges males face with respect to ED recovery • Describe the obsessions and compulsions associated with muscle dysmorphia (MD) • Recognize the potential for substance abuse including anabolic androgenic steroids, workout supplements, and illicit drugs • Identify eating patterns common to the bodybuilding community • Describe potential treatment approaches
  3. 3. DISORDERED EATING IN MALES • More commonly in pursuit of a lean, muscular physique • Male athletes w/ weight classes • Body weight and composition • Distorted eating/exercise • Role of the fitness industry • Similar to the fashion industry • Unrealistic body types • Photoshop Body dissatisfaction
  4. 4. RISK FACTORS – MALES • Genetic vulnerability • Psychological factors • Socio-cultural influences • Harmful belief systems: • Males should have one body type • You are what you look like • Males need to be in control • Eating disorders and other mental illnesses are not masculine Perfectionism Bullying Dieting Trauma Childhood obesity
  5. 5. WARNING SIGNS – MALES • Preoccupation with bodybuilding, weight lifting, or muscle toning • Weight lifting when injured • Anxiety/stress over missing workouts • Using anabolic steroids or other substances • Conflict over gender identity or sexual orientation • Decreased interest in sex, or fears around sex • Lowered testosterone • Muscular weakness Socio-cultural influences mean that over-exercising and the extreme pursuit of muscle growth are frequently seen as healthy behaviors for males and even be actively encouraged Ego-syntonic: psychological term referring to behaviors, values, feelings that are in harmony with or acceptable to the needs and goals of the ego, or consistent with one’s ideal self-image
  6. 6. PSYCHOLOGICAL WARNING SIGNS • Preoccupation w/ eating, food, routine • Feeling anxious around meal times • Feeling “out of control” around food • Having a distorted body image • Obsessed w/ body shape, weight, appearance • Extreme black-and-white thinking • Changes in emotional and psychological state • Using food as a source of comfort • Using food as self punishment
  7. 7. BEHAVIORAL WARNING SIGNS • Extreme dieting behavior • Eating in private, avoiding social meals • Evidence of binge eating • Changes in clothing style • Compulsive exercising • Suddenly disliking foods they have liked previously • Extreme sensitivity to comments about body shape, weight, eating & exercise habits • Obsessive rituals around food prep. • Secretive behavior
  8. 8. TREATMENT BARRIERS – MALES • Limited treatment access • Less-specialized attention • Males report lower expectations of anticipated benefits from ED treatment1 • More difficulty admitting their disorder due to fear of negative reaction2 1.Hackler, A. H., Vogel, D. L., & Wade, N. G. (2010). Attitudes towards seeking professional help for an eating disorder: The role of stigma and anticipated outcomes. Journal of Counseling and Development, 88(4), 424-431. 2. Robinson, K. J., Mountford, V. A., & Sperlinger, D. J. (2013). Being men with eating disorders: Perspectives of male eating disorder service- users. Journal of Health Psychology, 18(2), 176-186.
  9. 9. OBSTACLES TO RECOVERY – MALES • Co-occurring disorders • Mood • Anxiety • Substance use disorders (SUD) • Compulsive exercise • Past adverse treatment experiences • History of trauma • Sexual abuse • Weight-based victimization 1. Weltzin, T. E., Cornella-Carlson, T., Fitzpatrick, M. E., Kennington, B., Bean, P., & Jeffries, C. (2012). Treatment issues and outcomes for males with eating disorders. Eating Disorders, 20, 444-459. 2. Woodside, D. B., Garfinkel, P. E., Lin, E., Goering, P., Kaplan, A. S., Goldbloom, D. S., & Kennedy, S. H. (2001). Comparisons of men with full or partial eating disorders, men without eating disorders, and women with eating disorders in the community. American Journal of Psychiatry, 158(4):570-574.
  10. 10. MUSCLE DYSMORPHIA (MD) • Obsessively preoccupied w/ the belief that one is insufficiently muscular • Shares characteristics with: • Eating disorders • Obsessive-compulsive disorder • Body dysmorphic disorder • Frequently associated w/ steroid abuse • Ego-syntonic
  11. 11. MUSCLE DYSMORPHIA • First described by Pope and Katz in 19941 • “Reverse anorexia” • Single-minded desire to gain (rather than lose) weight • “Bigorexia”2 • Observed almost exclusively in males (as noted in DSM-5) • Recent rise in women struggling with muscularity concerns 1. Pope, H. G., & Katz, D. L. (1994). Psychiatric and medical effects of anabolic-androgenic steroids: A controlled study of 160 male athletes. Archives of General Psychiatry, 51, 375- 382. 2. Mosley, P. E. (2008). Bigorexia: Bodybuilding and muscle dysmorphia. European Eating Disorders Review, 17, 191-198.
  12. 12. MUSCLE DYSMORPHIA • Concerns w/ individual body parts • Rigorous weight-lifting regimen • High-protein diet • Spread across 6 or more meals • Compulsive mirror-checking • Comparison with others • Convinced they look much smaller than others of comparable size • Delusional outlook
  13. 13. MD – PHYSICAL APPEARANCE CONCERNS • Dissatisfied • Preoccupied • Impairment/distress • Insecure • Seeking reassurance • Disturbed self-perception
  14. 14. FITNESS INDUSTRY • Aggressive marketing: • Magical products • Ergogenic nutrients • Gym memberships • Goal: achieving the ideal body • Similar to fashion industry’s controversial use of underweight models, fitness industry relies on unrealistic imagery to engender insecurity in customer base
  15. 15. BODYBUILDING CULTURE • Winners determined by panel of judges for presentation of their physique, not actual athletic performance • Pre-contest: go to any lengths to manipulate physique at the expense of performance • Dehydration • Restriction (CHO, sugar, salt) Present-day cultural standards of attractiveness
  16. 16. MD – DSM-5 • Muscle dysmorphia (MD) not in ED category • Obsessive-compulsive and related disorders • Body dysmorphic disorders • Compensatory behaviors for BN • Men less likely to engage in laxative abuse1 • No mention of muscle-building or thermogenic agents often abused by men 1. Nunez-Navarro, A., Aguero, Z., Krug, I., Jimenez-Murcia, S., Sanchez, I., Araguz, N., ...Fernandez-Aranda, F. (2012). Do men with eating disorders differ from women in clinics, psychopathology and personality? European Eating Disorders Review, 20, 23-31.
  17. 17. MD AS FORM OF OCD • Obsessional thoughts: • Muscularity • Compulsive behaviors: • Rigorous dietary rituals • Excessive exercise • Self-inspection • Reassurance-seeking • ICD-10 • BDD classified within the somatoform disorders category • Biomarkers don’t explain
  18. 18. MD & ED • 22% males w/ MD characteristics formerly met criteria for AN1 • “Replaced their earlier preoccupation with being too fat with being too small” • 13% formerly met criteria for BN1 • Bodybuilders & males with BN2 • Excessive weight/shape preoccupation • Extreme body modification practices • Binge eating 1.Pope, H. G. Jr, Gruber, A. J., Choi, P., Olivardia, R., Phillips, K. A. (1997). Muscle dysmorphia. An underrecognized form of body dysmorphic disorder. Psychosomatics, 38(6), 548- 557. 2. Goldfield, G. S., Blouin, A. G., & Woodside, D. B. (2006). Body image, binge eating, and bulimia nervosa in male bodybuilders. Canadian Journal of Psychiatry, 51(3), 160-168.
  19. 19. MD & ED Similarities: • Compulsive preoccupation w/ perceived physical inadequacies and abnormal habits • Compensatory behaviors w/ attempts to hide or cover defects and excessive exercise • Avoid activities involving eating and forgo personal relationships and occupational opportunities that interfere with time needed for exercise and food preparation • Body dissatisfaction, frequent body checking • Low self-esteem • Black-and-white thinking
  20. 20. BINGE EATING – MALES • Associated with exercise-related behavior1 • Regardless of desire to lose weight • Physical activity aimed at: • Caloric expenditure • Muscle development • Alterations of body composition • Some bodybuilding diets include a planned binge episode for muscle anabolism or stress relief 1. De Young, K. P., Lavender, J. M., & Anderson, D. A. (2010). Binge eating is not associated with elevated eating, weight, or shape concerns in the absence of the desire to lose weight in men. International Journal of Eating Disorders, 43, 732-736.
  21. 21. ED & SUD – MALES • Men w/ BED greater frequency of SUD1 • Many men uncover symptoms of EDs during addiction treatment2 (hiding out?) • SUD not limited to street drugs may include3 • Fat burners • Anabolic androgenic steroids • Performance-enhancing drugs 1. Barry, D. C., Grilo, C. M., & Masheb, R. M. (2002). Gender differences in patients with binge eating disorder. International Journal of Eating Disorders, 31, 63-70. 2. Stanford, S. C., & Lemberg, R. (2012). Measuring eating disorders in men: Development of the eating disorder assessment for men (EDAM). Eating Disorders: The Journal of Treatment and Prevention, 20(5), 427-436. 3. Eisenberg, M. E., Wall, M., & Neumark-Sztainer, D. (2012). Muscle-enhancing behaviors among adolescent girls and boys. Pediatrics, 130(6), 1019-1026.
  22. 22. MD – ADOLESCENT MALES • Highest prevalence observed in1 • Asian male high school students • Overweight/obese • Competitive athletes • Weight-class sports • Warning signs: • Highly methodical exercise • Excessive protein powder • Muscle-building agents • Steroids 1. Eisenberg, M. E., Wall, M., & Neumark-Sztainer, D. (2012). Muscle-enhancing behaviors among adolescent girls and boys. Pediatrics, 130(6), 1019- 1026.
  23. 23. STEROIDS • Schedule III controlled substances • Anabolic Steroid Control Acts of 1990 and 2004 • Appearance and performance- enhancing drugs (APED) • Increase fat-free mass • Reduce body fat • Increase strength • Increase endurance
  24. 24. STEROIDS • Often used in conjunction w/ • Thyroid hormones • Fertility medications • Pain medications • Sports supplements • Pre-workout stimulants • Creatine • Pro-hormones (legal and illegal) Little or no regulation by FDA 1. McCreary, D. R., Hildebrandt, T. B., Heinberg, L. J., Boroughs, M., & Thompson, J. K. (2007). A review of body image influence on men's fitness goals and supplement use. American Journal of Men's Health, 1(4). 2. Cafri, G., Thompson, J. K., Ricciardelli, L., McCabe, M., Smolak, L., & Yesalis, C. (2005). Pursuit of the muscular ideal: Physical and psychological consequences and risk factors. Clinical Psychology Review, 25, 215-239.
  25. 25. STEROIDS – MEDICAL USES • Dz states of muscle wasting • HIV-AIDS, cancer • Osteoporosis • Increase low testosterone secondary to hypogonadism
  26. 26. STEROIDS – ADVERSE EFFECTS • Acne, impaired reproductive function, gynecomastia1 • Increased risk for CVD 2°: • Atherosclerosis, thrombus formation, hypertension2 • Psychiatric complications1 • Mood dysregulation, anxiety, aggression • Withdrawal symptoms3 • Variable energy, reduced libido, depression 1. Casavant, M. J., Blake, K., Griffith, J., Yates, A., & Copley, L. M. (2007). Consequences of anabolic androgenic steroids. Pediatric Clinics of North America, 54, 677-690. 2. Kanayama, G., Hudson, J. I., & Pope Jr., H. G. (2008). Long-term psychiatric and medical consequences of anabolic- androgenic steroid abuse. Drug and Alcohol Dependence, 98(1-2), 1-12. 3. Rohman, L. (2009). The relationship between anabolic androgenic steroids and muscle dysmorphia: A review. Eating Disorders, 17, 187-199.
  27. 27. STEROIDS – ADVERSE EFFECTS • Suicidal ideation1 • Violence2 • Complications with3 • Anger • Trauma • Post-traumatic stress 1. Wong, S. S., Zhou, B., Goebert, D., & Hishinuma, E. S. (2013). The risk of adolescent suicide across patterns of drug use: A nationally representative study of high school students in the United States from 1999 to 2009. Social Psychiatry and Psychiatric Epidemiology. Advance online publication. 2. Beaver, K. M., Vaughn, M. G., DeLisi M., & Wright, J. P. (2008). Anabolic-androgenic steroid use and involvement in violent behavior in a nationally representative sample of young adult males in the United States. American Journal of Public Health, 98, 2185-2187. 3. Mitchell, K. S., Mazzeo, S. E., Schlesinger, M. R., Brewerton, T. D., & Smith, B. N. (2012). Comorbidity of partial and subthreshold PTSD among men and women with eating disorders in the national comorbidity survey-replication survey. International Journal of Eating Disorders, 45, 307-315.
  28. 28. STEROIDS & SUD • 35% of male steroid abusers met lifetime criteria for SUD1 • Dependence syndromes • Progression to other recreational drugs, including stimulants2 • Significant percentage of male heroin addicts living in a treatment facility used opioids to counteract associated depression and withdrawal following steroid abuse3 1.Kanayama, G., Hudson, J. I., & Pope Jr., H. G. (2008). Long-term psychiatric and medical consequences of anabolic- androgenic steroid abuse. Drug and Alcohol Dependence, 98(1-2), 1-12. 2. Hildebrandt, T., Langenbucher, J. W., Lai, J. K., Loeb, K. L., & Hollander, E. (2011). Development and validation of the appearance and performance enhancing drug schedule. Addictive Behavior, 36(10), 949-958. 3. Arvary, D. & Pope Jr., H. G. (2000). Anabolic-androgenic steroids as a gateway to opioid dependence. New England Journal of Medicine, 342(20), 1532.
  29. 29. EXERCISE DEPENDENCE • Describing the related phenomenon of compulsive physical activity1 • Originally did not involve muscle development, only aerobic • Now linked to drive for muscularity2 • May partially explain the phenomenon of steroid addiction 1. Veale, D. (1987). Exercise dependence. British Journal of Addiction, 82, 735-40. 2. Hale, B. D., Roth, A. D., DeLong, R. E., & Briggs, M. S. (2010). Exercise dependence and the drive for muscularity in male bodybuilders, power lifters, and fitness lifters. Body Image, 7, 234-239.
  30. 30. Terry, A., Szabo, A., & Griffith, M. (2004). The exercise addiction inventory: A new brief screening tool. Addiction Research and Theory, 12(5), 489-499.
  31. 31. Hildebrandt, T., Langenbucher, J., & Schlundt, D. G. (2004). Muscularity concerns among men: Development of attitudinal and perceptual measures. Body Image, 1(2), 169-181. Muscle Dysmorhpic Disorder Inventory (MDDI) 1-5 scale 1 never 5 always
  32. 32. RESTRICTIVE EATING • Nutritional guidance from: • Muscle magazines • Online bodybuilding forums • Personal trainers • Anecdote • Supplement industry • Careful timing of sugar intake • Eliminate dietary fruit • Eliminate dietary dairy • Whey has calcium
  33. 33. BODYBUILDER DIETING • Protein at 3-5 g/kg day • CHO restricted to 2 g/kg • “Contest prep” • Extreme: ketogenic diet • CHO cycling, alternating • Low intake (2 g/kg) • High intake (6 g/kg) • Prevents undesirable hormonal adaptations • Ghrelin, leptin • Effective!!!
  34. 34. BODYBUILDER DIETING • Other forms of cycling • Anabolic phase (“bulking”) • Catabolic phase (“cutting”) • Timed with “stacking” of steroid cycles • Two or more different types • Mixing oral and injectable types • Highly calculated macronutrient breakdowns synced with exercise and substance protocols
  35. 35. BODYBUILDER DIETING • Diet Analysis+ of a 3-day “weight cutting diet” from a popular online source • Cyclic pattern • 3 meal plans over 6 days • “No carbs other than post-workout” • “No carbs and no fat” • 7th day excessive low-fat processed CHO to refill glycogen • “Cheat day” (Binge day?) • Repeat cycle
  36. 36. BODYBUILDER DIETING • Primary protein: chicken breast • Primary CHO: brown rice • Both appear several times/day • Hypothetical athlete: • 22 y/o male, 5’11” 190 lbs. • Compared to DRI: • Calorie intake 78% • Protein intake 520% (over 4 g/kg) • Omega-3 33% • Omega-6 51% • Folate 24%
  37. 37. TREATMENT – NUTRITION • Always best assessed on an individual basis • Eating behavior • Physical activity • Lab tests, other indices of physiological status • Reduction/elimination of excessive supplements • Protein/amino acids • Creatine/preworkout formulas • Avoid diet-related extremes
  38. 38. TREATMENT – NUTRITION • Increased consumption of plant-based antioxidants • Gradual and progressive increase in fiber-rich foods • Decrease protein • EFAs • Fatty fish, flax seeds, walnuts, avocados, pine nuts, etc… • Folate • Lentils, chickpeas, spinach, asparagus, etc…
  39. 39. TREATMENT – PHYSICAL ACTIVITY • Shift focus away from extreme muscle mass and towards sustainable fitness • Normalize levels of body fat and muscle • Period of abstinence from exercise in early recovery • Added back slowly • Exercise beneficial in ED treatment1,2,3 1. Calogero, R. M. & Pedrotty, K. N. (2004). The practice and process of healthy exercise: An investigation of the treatment of exercise abuse in women with eating disorders. Eating Disorders: The Journal of Treatment and Prevention, 12(4), 273-291. 2. Hausenblas, H. A., Cook, B. J., & Chittester, N. I. (2008). Can exercise treat eating disorders? Exercise and Sport Sciences Review, 36(1), 43-47. 3. Thien, V., Thomas, A., Markin, D., & Birmingaham, C. L. (2000). Pilot study of a graded exercise program for the treatment of anorexia nervosa. International Journal of Eating Disorders, 28, 101-106.
  40. 40. TREATMENT – PSYCHIATRIC • No drugs are FDA-approved for treatment of BDD • SRIs medication of choice1 • Fluoxetine • Sertraline • Citalopram • Escitalopram • Fluvoxamine • Clomipramine • More research needed 1. Phillips, K. A., & Hollander, E. (2008). Treating body dysmorphic disorder with medication: Evidence, misconceptions, and a suggested approach. Body Image, 5(1), 13-27.
  41. 41. TREATMENT – THERAPY • Cognitive Behavioral Therapy • Identifying/challenging misconceptions in thinking: • Food, weight, body image, compulsion to exercise • Neutralize triggers • Address shame, depression, anxiety, social avoidance, body image concerns • More emphasis on personal qualities vs. appearance Group Therapy Alumni Base Cultural Pressures Gender Stereotypes Advertising Marketing Psychology-Of-Men
  42. 42. ASSESSMENT TOOLS • Critical objective is to distinguish healthy focus on athleticism from obsessive thoughts and compulsive behaviors • Eating Disorder Assessment for Men (EDAM)1 • Core diagnostic issues • Binge eating • Disordered intake behaviors • Body dissatisfaction • Muscularity concerns 1. Stanford, S. C., & Lemberg, R. (2012). Measuring eating disorders in men: Development of the eating disorder assessment for men (EDAM). Eating Disorders: The Journal of Treatment and Prevention, 20(5), 427-436.
  43. 43. ASSESSMENT TOOLS • Appearance and Performance Enhancing Drug Use Schedule (APEDUS)1 • Structured interview designed to generate information regarding steroid dependence • Accurate measures of steroid dependence • Core pathology associated with APED use • Drug and non-drug 1. Hildebrandt, T., Langenbucher, J. W., Lai, J. K., Loeb, K. L., & Hollander, E. (2011). Development and validation of the appearance and performance enhancing drug schedule. Addictive Behavior, 36(10), 949-958.
  44. 44. THE ROLE OF THE DIETITIAN • Dietary intake • Nutritional needs • Regular feeding patterns • Healthy weight goal • Food fears, restrictions, rules • Feelings/emotions around food • Medical nutrition therapy
  45. 45. CONCLUSIONS • Mental health professionals are more likely to see more men with disordered eating as the standard of attractiveness for the male body is increasingly centered on muscular physique • One benefit to early symptom detection is to reduce escalation to abuse of steroids and other substances • Many steroid users find it difficult to discontinue their use and often accelerate and progress to other substances, perpetuating the cycles of body dissatisfaction and drug addiction
  46. 46. CONCLUSIONS • MD has potential for disrupting social and occupational functioning. Sustainable recovery should be based on normalizing self-destructive thoughts, emotions, and behaviors • There is a need for dietitians specializing in behavioral health to carry effective nutrition messages to the MD population (“re-education”) • There will be a need for physical trainers with insight into MD who can monitor and evaluate the progress of re-introduced exercise for those in recovery (ex-body builders?)
  47. 47. FUTURE RESEARCH • Prevalence of MD in pop. and for each gender • Neurological, metabolic, psychosocial contributions to behavior associated with each gender • Prevalence of BED among bodybuilders, aggressive dieters, and those with MD • Long-term psychiatric/medical effects of steroid use • Anger, trauma, PTSD, depression, OCD, anxiety • Co-occurrence of ED and SUD in male population • Steroid use preceding use of other substances versus other substances preceding steroids
  48. 48. FUTURE RESEARCH • Interactions between food, supplement, and substance intake related to muscle-seeking • Long-term impact of stimulant-based pre-workout formulas and other muscle-enhancing supps • Misperception of body image in male population, impact of fitness mags, pornography, other media • Role of exercise dependence in relation to steroid dependence, impact of lifestyle interventions • Treatment and recovery of MD • Impact of male RDNs and gender of treatment team
  49. 49. QUESTIONS?