Muscle Dysmorphia: An Overview of Clinical Features and Treatment Options

Differences in the impacts of muscle dysmorphia symptoms on distress between heterosexual women and homo/bisexual women

Muscle Dysmorphia (MD) and its psychological impacts on women, especially within sexual minorities, are still relatively understudied. The objective of this study was to compare the relationship of MD symptoms and psychological distress between heterosexual women and lesbian/bisexual women. Our sample consisted of 479 Brazilian cisgender women from the community, aged between 18 and 70 years (M = 32.78; SD = 10.45). Among them, 327 (68.27 %) identified as heterosexual, 134 (27.98 %) as bisexual, and 18 (3.76 %) as lesbian. To ensure there was no bias due to measurement error, the psychometric properties of the instruments in the sample were tested, and invariance between the groups was assessed. t-tests, structural equation modeling, and latent profile analyses were conducted to comprehend the differences between the groups. The results indicated significant differences and a greater severity of MD symptoms and distress for lesbian/bisexual women. The implications of these results are discussed, emphasizing the need for further exploration of MD studies within sexual minorities.

A conceptual framework on body representations and their relevance for mental disorders

Many mental disorders are accompanied by distortions in the way the own body is perceived and represented (e.g., eating disorders, body dysmorphic disorder including muscle dysmorphia, or body integrity dysphoria). We are interested in the way these distortions develop and aim at better understanding their role in mental health across the lifespan. For this purpose, we first propose a conceptual framework of body representation that defines this construct and integrates different perspectives (e.g., cognitive neuroscience, clinical psychology) on body representations. The framework consists of a structural and a process model of body representation emphasizing different goals: the structural model aims to support researchers from different disciplines to structure results from studies and help collectively accumulate knowledge about body representations and their role in mental disorders. The process model is reflecting the dynamics during the information processing of body-related stimuli. It aims to serve as a motor for (experimental) study development on how distorted body representations emerge and might be changed. Second, we use this framework to review the normative development of body representations as well as the development of mental disorders that relate to body representations with the aim to further clarify the potential transdiagnostic role of body representations.

At the Crossroads between Eating Disorders and Body Dysmorphic Disorders-The Case of Bigorexia Nervosa

Bigorexia nervosa (BN) is a controversial nosological entity, considered either a feeding/eating disorder (FED) or a subtype of body dysmorphic disorder (BDD). This rapid review aims to explore the characteristic features of BN and identify evidence-based therapeutic interventions for this condition. Three electronic databases (PubMed, Cochrane, and Google Scholar) were searched for relevant information about BN, and 26 reports were reviewed in detail. The results showed that bodybuilders, weightlifters, and other populations involved in athletic activities are the most vulnerable to the onset of this disorder. Patients with BN should also be screened for physical and psychiatric comorbidities and complications, such as anabolic steroid use disorder, physical exercise addiction, and depressive or anxiety disorders. The main differential diagnoses for BN are schizophrenia spectrum disorders, depressive disorders, anxiety disorders, bodily distress disorder, and obsessive-compulsive disorders. Using validated screening instruments is considered very important from a clinical perspective, with the aim of providing early identification of this disorder. Therapeutic interventions for patients with BN are still in the early phases of development, and no specific pharmacological treatment has yet been identified. Since it is similar to the obsessive-compulsive spectrum, cognitive behavioral therapy has been suggested as a useful intervention; however, it has not yet been validated in large-scale clinical trials. In conclusion, based on the reviewed data, clarifying the concept of BN is of practical importance for constructing adequate prevention strategies and validating proper therapeutic interventions.

Sex-dependent clinical presentation, body image, and endocrine status in long-term remitted anorexia nervosa

OBJECTIVE

Although anorexia nervosa (AN) in males has recently gained attention, knowledge of its psychological and physiological outcomes is still scarce. We explore sex-specific characteristics of long-term remitted AN with respect to residual eating disorder (ED) psychopathology, body image, and endocrinology.

METHOD

We recruited 33 patients with AN in remission for at least 18 months (24 women, 9 men) and 36 matched healthy controls (HCs). Eating disorder psychopathology and body image ideals were assessed via clinical interviews, questionnaires, and an interactive 3D body morphing tool. Plasma levels of leptin, free triiodothyronine, cortisol, and sex hormones were quantified. Univariate models controlled for age and weight were used to test for the effects of diagnosis and sex.

RESULTS

Both patient groups showed residual ED psychopathology but normal weight and hormone levels relative to HCs. Male remitted patients demonstrated significantly stronger muscularity-focused body image ideals, evident in interviews, self-reports, and behavioural data, than both female patients and HCs.

CONCLUSIONS

Sex-specific body image characteristics in patients with remitted AN point towards the need to adjust test instruments and diagnostic criteria to male-specific psychopathology. In the future, sufficiently powered studies should evaluate the risk of men with AN developing muscle dysmorphia in the long term.

The mediating effect of body appreciation between muscle dysmorphia and bulimia nervosa among Lebanese adolescents

BACKGROUND

Muscle dysmorphia (MD) is a common psychological disorder present in Lebanese adolescents. Several disorders can be present concomitantly with MD such as bulimia nervosa and exercise addiction. This study aims to explore the mediating effect of body appreciation between Muscle dysmorphia and bulimia nervosa, and to validate the exercise addiction inventory scale in Lebanese adolescents.

METHODS

This was a cross-sectional designed study, conducted between August-September 2022, and enrolling 403 adolescents currently residing in Lebanon (15 to 18 years old), from all Lebanese governorates (Beirut, Mount Lebanon, North, South, and Bekaa). Our sample was chosen using the snowball technique, a soft copy of the questionnaire was created using google forms software, and an online approach was conceived to proceed with the data collection.

RESULTS

The mean age of the participants was 16.63 ± 1.46 years with 57.3% females. The factor analysis for the Exercise Addiction Inventory suggested one factor, which explained 62.58% of the common variance. The confirmatory factor analysis revealed an adequate fit to the model with satisfactory Maximum Likelihood Chi-Square/Degrees of Freedom (χ²/df), SRMR, CFI, TLI, and AVE. The mediation analysis showed that the direct relation between bulimia and MD was not significant after eliminating the effect of body appreciation (r = .12, p < .001). However, body appreciation was significantly associated with bulimia nervosa (r=-1.06, p < .001) and MD (r=-.28, p < .001).

CONCLUSION

Body appreciation was found to be a mediator between muscle dysmorphia and bulimia nervosa and thus it is the main factor leading to both disorders. Therefore, body appreciation should be addressed in the evaluation and management of Muscle Dysmorphia.

Validation of the Arabic version of the Muscle Dysmorphic Disorder Inventory (Ar-MDDI) among Lebanese male university students

BACKGROUND

To date, the vast majority of research on disordered eating symptomatology and body image disturbances from the Arab world have been performed exclusively among women; and mainly used thinness-oriented measures that are not sensitive to detect muscularity-oriented symptoms, which are more evident in males. Therefore, the objective of our study was to validate the Arabic version of the Muscle Dysmorphic Disorder Inventory (Ar-MDDI), in order to make it accessible for Arabic-speaking populations.

METHODS

Using a snowball sampling technique, men university students (n = 396) from multiple universities in Lebanon filled the survey in this cross-sectional designed study (January-May 2022). A soft copy of the questionnaire was created using google forms software, and sent to participants through the different social media platforms such as Facebook, Instagram, and WhatsApp. We used the Muscle Dysmorphic Disorder Inventory to assess Muscle Dysmorphia, along with the Big Three Perfectionism Scale to assess perfectionism and Eating Attitude Test (EAT) to evaluate the inappropriate eating attitudes. To explore the factor structure of Ar-MDDI, we computed a principal-axis Exploratory Factor Analysis (EFA) with the first split-half subsample using the FACTOR software. We used data from the second split-half to conduct a Confirmatory Factor Analysis (CFA) using the SPSS AMOS v.29 software. Pearson correlation test was used to test the convergent and divergent validity of the Ar-MDDI scale with the other scores included in the study.

RESULTS

The results of the EFA revealed three factors, which explained 57.68% of the common variance: Factor 1 = Appearance intolerance, Factor 2 = Drive for size, and Factor 3 = Functional impairment. The CFA fit indices of the three-factor model of the Ar-MDDI scale showed good results. Moreover, 254 (64.1%) of the participants had inappropriate eating attitudes (EAT scores ≥ 20). Indices suggested that configural, metric, and scalar invariance was supported according to eating attitudes. No significant difference between participants with appropriate versus inappropriate eating attitudes in terms of functional impairment, drive for size and appearance intolerance. Perfectionism scores correlated positively with the Ar-MDDI, which suggests divergent validity.

CONCLUSION

Our findings revealed that the validation of the Arabic scale yielded excellent properties, preliminarily supporting its use for the assessment of muscle dysmorphia among Arabic-speaking university men. This would hopefully allow for its timely detection and management in Arab clinical settings and encourage cross-cultural research on this topic.

Exploration of height dissatisfaction, muscle dissatisfaction, body ideals, and eating disorder symptoms in men

Objective: Height is a significant, yet under-studied dimension of body dissatisfaction in men. The present study examined the relationship between height dissatisfaction, height, muscle and fat dissatisfaction, body ideals, and eating disorder symptoms in men. Participants and methods: Participants were a sample of male undergraduate Australian students (N = 224) who were administered self-report measures of height, muscle, and fat dissatisfaction, eating disorder symptoms, and muscle and body fat body-ideals, and reported their height. Results: Results showed that height, muscle dissatisfaction, and desired muscularity were important for explaining height dissatisfaction. Additionally, although eating disorder symptoms did not uniquely predict height dissatisfaction, there were small positive correlations between height dissatisfaction and eating disorder symptoms. Conclusions: This study highlights the importance of height in male body dissatisfaction and its association with muscular dissatisfaction and desired muscularity, as well as the potential significance of height in male eating disorders.

Does #beauty have a dark side? Testing mediating pathways between engagement with beauty content on social media and cosmetic surgery consideration

Beauty content on social media has grown exponentially, however research has yet to investigate its association with appearance concerns. This study drew on components of the tripartite influence model to test the associations between young women's engagement with beauty content on social media and cosmetic surgery consideration. A sample of 399 undergraduate women aged 17-25years (M_age = 19.36) completed measures of beauty social media engagement, upward appearance comparison, general attractiveness internalization, dysmorphic appearance concerns, and consideration of cosmetic surgery. Path analysis was used to test direct and indirect associations. In line with the tripartite influence model, results supported a serial mediation model that comprised significant paths from beauty social media engagement through in turn, upward appearance comparison, general attractiveness internalization, and dysmorphic appearance concerns, to cosmetic surgery consideration. However, neither general attractiveness internalization nor dysmorphic appearance concerns mediated the link between beauty social media engagement and consideration of cosmetic surgery. Findings provide new insights into the links between engagement with the growing beauty social media trend and cosmetic surgery consideration.

Association between muscle dysmorphia psychopathology and binge eating in a large at-risk cohort of men and women

BACKGROUND

Current research on muscle dysmorphia (MD) has focused on restrained eating behaviors and has adopted a primarily male perspective. Despite initial evidence, the role of possible binge eating associated with MD has only been scarcely investigated. To extend the transdiagnostic and cross-gender approaches and address the dearth in research related to MD, this study investigated the association between MD psychopathology and binge eating in men and women.

METHODS

This study investigated the association between MD psychopathology and binge eating in both men and women. Participants were a sample of 5905 men (n = 422) and women (n = 5483) social media users aged 18-72 years. They completed an online survey that included self-report measures assessing demographics, binge eating, MD psychopathology, and drive for thinness and leanness. Binge eating was assessed using the diagnostic questions of the validated German version of the Eating Disorder Examination-Questionnaire. The Muscle Dysmorphic Disorder Inventory (MDDI) was used to assess MD psychopathology. A total score of > 39 was set as a cutoff to define an "MD at-risk" state for both men and women. Hierarchical logistic regression analysis was used to analyze the association between MD psychopathology and binge eating.

RESULTS

MD psychopathology was significantly positively associated with binge eating in both men and women. Among the three MDDI subscales, only appearance intolerance was significantly associated with MD, and drive for size and functional impairment were not associated. MD at-risk status yielded a predicted probability of binge eating of 25% for men and 66.9% for women. The increased probability of binge eating associated with MD at-risk status was mainly accounted for by appearance intolerance in men and drive for thinness in women.

CONCLUSION

MD psychopathology is positively associated with binge eating in both men and women. Binge eating episodes should therefore form part of the clinical assessment of MD.

Psychometric evaluation of the muscle dysmorphic disorder inventory (MDDI) among gender-expansive people

PURPOSE

Muscle dysmorphia is generally classified as a specific form of body dysmorphic disorder characterized by a pathological drive for muscularity and the preoccupation that one is too small or not sufficiently muscular. The majority of research on the condition has been conducted in cisgender men with a paucity of literature on gender minority people, a population that is at risk for muscle dysmorphia. One of the most widely used measures of muscle dysmorphia symptoms, the Muscle Dysmorphic Disorder Inventory (MDDI), has not been psychometrically validated for use in gender minority samples, the aim of the present study.

METHODS

We evaluated the psychometric properties of the MDDI in a sample of 1031 gender-expansive individuals (gender minority people whose gender identity differs from that assumed for their sex assigned at birth and is not exclusively binary man or woman) aged 18-74 who were part of The PRIDE Study, a large-scale, U.S., longitudinal cohort study.

RESULTS

Using a two-step, split-sample exploratory and confirmatory factor analytic approach, we found support for the original three-factor structure of the measure. The subscales showed adequate internal consistency, and convergent validity was supported based on significant associations of the MDDI subscale scores with theoretically related scores on a widely used measure of disordered eating.

CONCLUSIONS

These findings provided novel support for adequate psychometric properties of the MDDI in a sample of gender-expansive individuals, facilitating the use of this measure in future research on muscle dysmorphia in this understudied and at-risk population.

Testosterone, identity and the body: Exploring cultural definitions of disorder

Medically-sanctioned testosterone administration has seen increasingly widespread application in the treatment of gender dysphoria (GD). Yet, by comparison, this approach is not medically accepted for those who are experiencing muscle dysmorphia (MD), a specifier of body dysmorphic disorder (BDD), despite both conditions reflecting incongruences between self-perception, identity and phenotype, and both currently being classified as mental health disorders. Rather, by stark contrast, those with MD are largely treated with psychological intervention to accept themselves as they physically are and the illicit use of testosterone for muscle-related body perception purposes is generally subject to criminal justice enforcement actions. In this commentary, we examine attempts to distinguish between the use of testosterone for gender-affirming hormone therapy in the case of GD and for aesthetic (muscle enhancement) use in the case of MD, as well as explore the implications of this disparity. Moreover, we consider how such disparity in policy and practice may be understood, in part, as an example of a bias reflecting the selective pathologizing of anabolic-androgenic steroid (AAS) use, socio-cultural evolutions in gender identity and expression and, more broadly, the manner in which culture defines disorder and its appropriate response.

'Big boys don't cry': Examining the indirect pathway of masculinity discrepancy stress and muscle dysmorphia symptomatology through dimensions of emotion dysregulation

Prevailing conceptualizations of muscle dysmorphia (MD) have highlighted the role of adherence to stereotypical ideals of masculinity. In addition, the endorsement of masculine norms has been associated with dysfunctional emotional regulation, itself a correlate of body image psychopathology. Building on this, the present study sought to investigate the indirect relationship between masculinity discrepancy stress (i.e., distress related to one's perceived discrepancy in masculinity) and MD symptomatology via different facets of emotion dysregulation among adult men. A sample of 391 university and community men aged 18-50 years completed an online survey measuring the aforementioned constructs. A test of parallel indirect pathways revealed that emotion dysregulation, as a unitary construct, accounted for a substantial proportion (29.3 %) of the total association between masculinity discrepancy stress and MD symptomatology. Further, a significant unique indirect pathway was found through the specific emotion dysregulation facet of lack of access to adaptive emotion regulation strategies. Together, these findings suggest that emotion dysregulation is a particularly important construct to consider in understanding the relationship between perceived discrepancies in masculinity and MD symptomatology.

Who's the 'bigger' man? Parsing the relationships between masculinity and men's muscularity dissatisfaction

Muscularity dissatisfaction is documented to be a pervasive phenomenon among men. While previous studies have examined theoretically relevant predictors of muscularity dissatisfaction, such as adherence to traditional masculine norms, to the best of our knowledge we are not aware of empirical research that has assessed how perceived discrepancies in one's level of masculinity may also be associated with these concerns. Therefore, the objective of this study was to determine whether perceived deficits in masculinity bear predictive utility over and above adherence to traditional masculine norms in the context of muscularity dissatisfaction. An online survey that included measures assessing the aforementioned constructs was completed by 390 university and community adult men. A hierarchical regression analysis showed that while adherence to masculine norms was associated with increased muscularity dissatisfaction, masculine role discrepancy (and attendant stress) were particularly strong predictors of muscularity dissatisfaction. Our findings make a novel contribution to the male body image literature by demonstrating the relative importance of perceived discrepancies in masculinity, and related stress, in the context of muscularity dissatisfaction. Pending replication in relevant clinical samples using prospective designs, this study provides preliminary evidence that masculine role discrepancies may be promising targets to help allay muscularity concerns among men.

An investigation of distress tolerance and difficulties in emotion regulation in the drive for muscularity among women

Despite the negative emotional experiences that often accompany the pursuit of an idealized appearance, we know little about emotion regulation in the context of female drive for muscularity. To address this knowledge gap, we examined whether distress tolerance and difficulties in emotion regulation were significantly associated with the drive for toned muscularity among women. In this study, 221 Australian university women completed an online survey assessing drive for muscularity, distress tolerance, and emotion regulation difficulties. Results revealed that low distress tolerance and emotion regulation difficulties were positively associated with drive for muscularity attitudes and behaviors, after controlling for body mass index and general negative affect. Our findings suggest that women with a range of distress tolerance and emotion regulation difficulties, particularly the urgent need to regulate, and non-acceptance of, distress may experience a higher drive for muscularity. This study provides preliminary evidence that specific aspects of distress tolerance and poor emotion regulation may be promising targets in prevention and treatment interventions aimed to address the excessive drive for muscularity among women.

Looking at the Figures: Visual Adaptation as a Mechanism for Body-Size and -Shape Misperception

Many individuals experience body-size and -shape misperception (BSSM). Body-size overestimation is associated with body dissatisfaction, anxiety, depression, and the development of eating disorders in individuals who desire to be thinner. Similar symptoms have been noted for those who underestimate their muscularity. Conversely, individuals with high body mass indices (BMI) who underestimate their adiposity may not recognize the risks of or seek help for obesity-related medical issues. Although social scientists have examined whether media representations of idealized bodies contribute to the overestimation of fat or underestimation of muscle, other scientists suggest that increases in the prevalence of obesity could explain body-fat underestimation as a form of renormalization. However, these disparate approaches have not advanced our understanding of the perceptual underpinnings of BSSM. Recently, a new unifying account of BSSM has emerged that is based on the long-established phenomenon of visual adaptation, employing psychophysical measurements of perceived size and shape following exposure to "extreme" body stimuli. By inducing BSSM in the laboratory as an aftereffect, this technique is rapidly advancing our understanding of the underlying mental representation of human bodies. This nascent approach provides insight into real-world BSSM and may inform the development of therapeutic and public-health interventions designed to address such perceptual errors.

Negative psychological correlates of the pursuit of muscularity among women

OBJECTIVE

There is increasing public and scientific focus on women's pursuit of a muscular and toned appearance. However, the psychological correlates of women's drive for muscularity are currently unclear. Therefore, we examined the associations of drive for muscularity with four important negative psychological indices among women: eating disorder (ED) symptoms, and symptoms of depression, anxiety, and stress.

METHOD

A sample of 221 university women completed an online survey that included measures assessing the aforementioned constructs.

RESULTS

Drive for muscularity evidenced positive associations with all negative psychological indices, except for anxiety. Muscularity-oriented attitudes, as opposed to behaviors, demonstrated the strongest associations with ED and depression symptoms.

DISCUSSION

Our findings make a novel contribution to the scant literature by demonstrating that women who endorse attitudes and/or behaviors geared toward attaining the female muscular ideal may be susceptible to experiencing ED symptoms and negative emotional states. This study provides preliminary evidence that muscularity-oriented attitudes, in particular, may be a promising target for the treatment of EDs and negative emotional states in women with a preoccupation toward muscularity.

Muscle Dysmorphic Disorder Inventory (MDDI): Validation of a German version with a focus on gender

Muscle dysmorphia (MD) is a condition that is characterized by body image disturbance, a drive for muscularity and excessive exercising. It leads to considerable functional impairment. Most previous studies focused on male samples. The study aimed to validate a German version of the Muscle Dysmorphic Disorder Inventory (MDDI) in order to make the instrument available in German speaking countries. We further aimed to explore for gender differences in the MDDI factors (measurement invariance) and to assess the relationship between MD and positive dimensions of body experience as well as exercise dependence. 394 participants (53% females, mean age 24.3 years) took part in an internet-based survey. The three-factor structure of the English version of the MDDI was replicated, independent of gender (multi group CFA; Base model TLI = .961; CFI = .970). Cronbach´s alpha was .81-.84 for the subscales and .75 for the MDDI total score. MD was associated with exercise dependence and negatively correlated with dimensions of positive body experience, which can be considered relevant for satisfying relationships and a positive sense of self: e.g. body contact and sexual fulfillment. Men and women showed differences in two subscales of the MDDI (appearance intolerance, drive for size). Testing for measurement invariance resulted in weak invariance: Equivalent factor structure for men and women, but significantly different loadings and coefficients. No statistically significant difference in the MDDI total score was found. The findings suggest good psychometric properties of the German version of the MDDI. Future studies should address the question of cut-off scores and norms for different samples as well as a possible overlap between MD and eating disorder psychopathology in women.