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 www.NutritionInRecovery.com

1. MUSCLE DYSMORPHIA:
WHAT HAPPENS WHEN BODY
IMAGE COLLIDES WITH
EXERCISE, NUTRITION, AND
SUBSTANCE ABUSE?

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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. MD – PHYSICAL APPEARANCE CONCERNS
• Dissatisfied
• Preoccupied
• Impairment/distress
• Insecure
• Seeking reassurance
• Disturbed self-perception

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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. STEROIDS – MEDICAL USES
• Dz states of muscle wasting
• HIV-AIDS, cancer
• Osteoporosis
• Increase low testosterone
secondary to hypogonadism

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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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

50. QUESTIONS?