The Menacing Mirror: Understanding Muscle Dysmorphia

Mallory Becker, M.A., R.Psyc.

Mallory Becker

Registered Psychologist

The Menacing Mirror:  Understanding Muscle Dysmorphia


            We live in a world that is very focused on external appearance.  Although currently the social, relational and personal pressure that attracts the most attention is slimness.  However, there is also an opposite pressure, particularly for males, to be very muscular.  When this pressure becomes a personal obsession and individuals give up important social, occupational or recreational activities in order to maintain a strict workout schedule, avoid situations of exposing their bodies, experience extreme levels of distress over inadequate musculature when the inadequacy is not obvious, or continue to diet, lift weights, or use performance-enhancing substances despite knowledge of adverse physical or psychological consequences, muscle dysmorphia may be diagnosed (Pope, Phillips & Olivardia, 2000).  Muscle dysmorphia is a recently subcategory of body dysmorphic disorder and is most prevalent in men, particularly those who are active in weight lifting or body building (Grieve, 2007).  People with muscle dysmorphia are preoccupied with the personal perception that they are not lean and muscular enough, even though they are usually more muscular than average people (Grieve, 2007).  The previous concerns range in severity from minor annoyances to life-threatening obsessions (Phillips, 2005).  Additionally, muscle dysmorphia can have different courses from manageable dissatisfaction to a full-blown psychiatric body image disorder (Phillips, 2005).

            Many psychological and behavioral symptoms exist with muscle dysmorphia (Olivardia, 2003).  The criteria for muscle dysmorphia is not included as a specific diagnosis in DSM-VI-TR (2000) text revision, but it has additional references regarding body building and excessive weight lifting to in addition to the description of body dysmorphic disorder to accommodate muscle dysmorphia classification (Pope et al., 2000).  Pope et al., (2000) have drafted and published operational criteria for muscle dysmorphia using the same style as the DSM-IV-TR (2000) text revision.  In order to be diagnosed, an individual must have all three attributes in the list from “A” to “C” (Pope et al., 2000).  Pope et al., (2000) criteria for muscle dysmorphia is as follows: 

  1. Preoccupation with the idea that one’s body is not sufficiently lead and muscular.  Characteristic associated behaviors include long hours of lifting weights and excessive attention to diet.
  2. The preoccupation is manifested by at least two of the following four criteria:
      1. 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.
      2. The individual avoids situations where his or her body is exposed to hers, or endures such situations only with marked distress or intense anxiety.
      3. The preoccupation about the inadequacy of body size or musculature cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
      4. The individual continues to work out, diet, or use performance-enhancing substances despite knowledge of adverse physical or psychological consequences.
  1. 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 body dysmorphic disorder.

In addition to the previous diagnosable symptoms, other symptoms exist with muscle dysmorphia (Olivardia, 2003).  Excessive attention to diet such as counting calories and ensuring high levels of proteins are also characteristic of muscle dysmorphia (Olivardia, 2003).  Mirror-checking occurs much more often in individuals with muscle dysmorphia than normal individuals and often check themselves out in store windows, pocket mirrors or the back of spoons when mirrors are absent (Olivardia, 2003).  Men with muscle dysmorphia have reported that they checked themselves in mirrors an average of 9.2 times per day, and some reported checking themselves in the mirror more than 50 times a day (Pope et al., 2000).  Ordinary weightlifters report that they spend 40 minutes per day thinking about being too small, not being big enough or getting better while men with muscle dysmorphia averages 325 minutes a day with such preoccupations (Pope et al., 2000).  Additionally, individuals with muscle dysmorphia compare their physique with others as a means of social comparison, which often results in further body distortion and anxiety (Olivardia, 2003).  It has also been found that men with muscle dysmorphia report higher body dissatisfaction, more dysfunctional eating attitudes, a higher prevalence of anabolic steroid use, and a greater history of mood, anxiety and eating disorders when compared to other weight lifters without muscle dysmorphia (Olivardia, 2003).  In a survey, men with muscle dysmorphia, 47 percent of men said they were “totally dissatisfied” or “mostly dissatisfied” and 74 percent felt “somewhat,” “mostly,” or “extremely,” fat (Pope et al., 2000).  Although the overall prevalence rate of muscle dysmorphia is unknown, the estimated prevalence rate of muscle dysmorphia is 10% of weightlifters (Olivardia, 2003).

            Muscle dysmorphia also has detrimental social and relational effects (Pope et al., 2000).  Occupational difficulties occur in people with muscle dysmorphia if are fired from their jobs or voluntarily leave their professions because of a compulsive need to work out (Pope et al., 2000).  Travel plans are also interfered with because of the condition because if there is no gym in the place of destination, individuals with muscle dysmorphia often abandon travel plans or go to great lengths the bring equipment (Pope et al., 2000).  Additionally, the sex lives of individuals with muscle dysmorphia are affected such as absent/limited intercourse to avoid “unnecessary” physical labor to conserve energy, or because these individuals do not want to show their bodies that they are dissatisfied with (Pope et al., 2000).  In order to adhere to strict diets, it is not uncommon for people with muscle dysmorphia to avoid restaurants if the calorie count is not known (Olivardia, 2003).  The fear of getting smaller overrides concerns of failing jobs and relationships (Olivardia, 2003).  However, it is very important to note that many people with muscle dysmorphia suffer in silence, and do not let others know about the reasoning behind their obsessive behaviors (Pope et al., 2000).

            Anabolic steroid use is also another common symptom of muscle dysmorphia (Olivardia, 2003).  While taking steroids, some people develop serious mood changes, raging from mild irritability to severe aggressiveness, often accompanied by grossly impaired judgment and grandiose beliefs called “roid rage” (Pope et al., 2000).  In a study, 46 percent of male weightlifters with muscle dysmorphia reported a history of steroid use versus only 7% of those without muscle dysmorphia therefore, muscle dysmorphia appears to be a risk factor for steroid use (Olivardia, 2003).  Additional health implications involved with muscle dysmorphia include training when injuring, which can lead to further injuries such as hernias, breaking bones and ligaments from excessive exercise (Olivardia, 2003).

            Currently, there is little research specifically focusing on the causes of muscle dysmorphia however, a fair amounts of research and speculation have focused on the causes body dysmorphic disorder, which is the classification of a broader disorder that muscle dysmorphia is derived from (Olivardia, 2003).  The causes of body dysmorphic disorder are likely applicable to muscle dysmorphia because muscle dysmorphia is a form of body dysmorphic disorder.  Firstly, genetic/biological factors such as genetic predisposition, neurotransmitters (serotonin, dopamine, GABA), brain areas, evolutionary factors and temperament may possible pathways to the development of body dysmorphic disorder (Phillips, 2005).  It is also important to not that muscle dysmorphia is believed to run in families (Olivardia, 2003).  Serotonin and other neurotransmitter deregulation is an inherited tendency that may be responsible for altered mood, cognition, memory, sleep, appetite, anxiety, delusional thinking, eating behavior, sexual behavior and pain (Phillips, 2005).  It is also suggested that body dysmorphic disorder is a “complex” genetic disorder involving many different genes that interact in complex ways with each other and with multiple environmental factors to increase the risk (Phillips, 2005).  However, it is important to note that not all people with a “Body Dysmorphic Disorder Genes” will develop body dysmorphic disorder – it just increases the risk of developing the disorder (Phillips, 2005).  In small study found that individuals with body dysmorphic disorder had a total greater white matter in the brain when compared to healthy individuals (Phillips, 2005).  Additionally, this study found that the left caudate nucleus was larger than the right caudate nucleus which is involved in regulating voluntary movements, habits, cognitions and “pre-packaged” repetitive behaviors (Phillips, 2005).  These findings are only preliminary and more research must be conducted to ensure validity (Phillips, 2005).  Other researchers have suggested that the amygdale is overly active, which may be responsible for excessive anxiety and fear that may drive compulsive behaviors (Phillips, 2005).  According to the evolutionary viewpoint, it is possible for normal, adaptive, evolutionarily based behaviors and preferences such as desire for symmetry or grooming to become excessive and go into overdrive causing body dysmorphic disorder or muscle dysmorphia to develop (Phillips, 2005). 

            In additional to biological causes, psychological factors such as life events, personality traits, importance of appearance to self esteem may also be importation of causing body dysmorphic disorder or muscle dysmorphia (Phillips, 2005).  Life events such as being teased about appearance has been inked to greater body dissatisfaction and may increase the risk of developing body dysmorphic disorder (Phillips, 2005).  Certain personality traits such as perfectionalism, shyness, self-consciousness, hypersensitivity to rejection, anxious, depressed, and feelings of vulnerability may predispose, not cause people to body dysmorphic disorder (Phillips, 2005).  The importance of appearance, particularly the drive for muscularity as a means for compensating for a feeling of inadequacy about one’s masculinity may be a factor for developing muscle dysmorphia (Olivardia, 2003).  Achieving a body that is very muscular may be a symbolic expression of one’s manhood, with hopes to inspire respect, admiration and envy of men and women (Olivardia, 2003).  For some men, the rationale of being very muscular is to express strength and power causing others to feel intimidated and be fearful (Olivardia, 2003). 

            Cultural factors such as society’s emphasis on appearance and media pressure and may also be factors of body dysmorphic disorder and muscular dysmorphia (Phillips, 2005).  Sociocultural factors such as value of beauty may be a causal factor however, these factors may influence the form that body dysmorphic disorder takes (Phillips, 2005).  My personal speculative hypothesis is that muscle dysmorphia may be common in western countries because of the rise of female power in society.  Some men may feel overwhelmed and fear that their masculinity is being threatened due to the flood of females undertaking traditional male roles.  This fear may become excessive and take the form of muscle dysmorphia when one becomes obsessed about being muscular as a way of confirming one’s masculinity and power.  Additionally, media pressure about being masculine may be a causal factor as role models in movies and other celebrities are becoming more muscular over time (Pope et al., 2000).  For example, if the 1962 G.I. Joe was a man, he would be 5 feet 10 inches tall, have a 32 inch waist, a 44 inch chest, and a 12-inch bicep – which is similar to that of an ordinary man in reasonably good physical shape (Pope et al., 2000).  The 1991 G.I. Joe expanded to a man is 5 feet 10 inches tall, has a shrunken waist to 29 inches, 16.5 inch biceps (which approaches the limits of what a lean man might attain without steroids) (Pope et al., 2000).  Other action heroes such as batman, star wars figurines, and wrestling superstars have the same increasing muscularity trends (Pope et al., 2000).

            Finally, a triggering event such as a comment about appearance, stressful life event and feelings of rejection may be a factor in causation of body dysmorphic disorder and muscle dysmorphia (Phillips, 2005).  Eight percent of people with body dysmorphic disorder reported that a negative comment about their appearance triggered the onset of symptoms (Phillips, 2005).  Often, these stressors are related to psychological themes such as rejection and in order to cope with the situation, one may try to prevent it from happening in the future by becoming obsessive about a particular trait they are insecure about (Phillips, 2005). 

            With muscle dysmorphia, the biggest difficulty is persuading the individual to consider treatment (Pope et al., 2000).  These individuals are usually in good physical health because they pay compulsive attention to their bodies (Pope et al., 2000).  Some people may come to a doctor with other complaints due to muscle dysmorphia such as side effects of anabolic steroids, or developing a serious orthopedic injury due to practicing when injured but most individuals even with severe cases are too busy at the gym to even think of seeking medical help (Pope et al., 2000).  It isn’t known which treatment method is the best because muscle dysmorphia is a recent condition and scientific treatment studies have not been published (Pope et al., 2000).  Often, cognitive behavioral therapy is recommended which helps change the distorted view of their appearance, resist problematic behavior such as reassurance seeking, and stop avoid important obligations like social events (Pope et al., 2000).  A psychoeducational aspect is also a necessary part of treatment where clinicians asses the patient’s body-image ideals and how realistic they are (Olivardia, 2003).  Education should include proper nutrition, dangers of steroids, and the fact that media images are not an accurate representation of what people do or should look like (Olivardia, 2003).  It is also important to pay attention to the age that muscle dysmorphia emerged (Olivardia, 2003).  Psychotherapy can explore peer experiences, important events, gender and sexual identity that may have contributed to the onset of the condition (Olivardia, 2003).  Some patients are prescribed antidepressant medications that are known to be effective in treating obsessive-compulsive disorder, and often provide relief for men who uncontrollably obsess about their muscularity (Pope et al., 2000).  However, antidepressants can sometimes be easy and effective, but can also be complicated and have harmful side effects (Pope et al., 2000).

            Muscle dysmorphia is associated with a number of other psychiatric disorders such as bulimia nervosa (Olivardia, 2003).  A study found that 29 percent of men with muscle dysmorphia had a history of an eating disorder (Olivardia, 2003).  Furthermore, men with muscle dysmorphia had similar scores to those with eating disorders on all subscales of the Eating Disorder Inventory such as perfectionalism, maturity fears, feelings of ineffectiveness and a drive for thinness (Olivardia, 2003).  Anxiety and mood disorders also commonly co-occur with muscle dysmorphia (Olivardia, 2003).  In another study, 58 percent of men with muscle dysmorphia had a history of a mood disorder in comparison to 20 percent of normal controls (Olivardia, 2003).

            Muscle dysmorphia has detrimental effects to family and friends of the individual (Phillips, 2005).  It is very difficult to watch a loved one struggle with this disorder and can make observers feel frustrated and angry because one cannot do anything to get patients to stop obsessing about their looks (Phillips, 2005).  The first step is to recognize the symptoms of muscle dysmorphia, take them seriously and maintain open conversations (Phillips, 2005).  Next, one can encourage and support psychiatric treatment (Phillips, 2005).  If the individual with muscle dysmorphia refuses to get treatment, focus on the suffering and problems of functions due to the disorder (Phillips, 2005).  Do not discuss the “defect” or try to talk to the person with muscle dysmorphia out of their beliefs about their looks – rather create a supportive home environment (Phillips, 2005).  It is also important to limit involvement with muscle dysmorphic rituals and not to offer reassurance is these behaviors are not beneficial (Phillips, 2005).  Other interventions friends and family can do include encouraging better functioning but recognizing limitations, encourage participation in family events, praising small gains, looking at the big pictures, patience, limiting angry outbursts and get immediate help if the person with muscle dysmorphia is contemplating suicide (Phillips, 2005). 

            Muscle dysmorphia is a disorder where victims often suffer in silence (Pope et al., 2000).  Although diagnosis and treatments are currently being investigated, the ideal situation is to avoid the problem from becoming a disorder (Pope et al., 2000).  One can use protective factors such as not buying into media images, remembering that many super-muscular male bodies are products of drugs, realize that a vast industry profits from making one feel insecure about one’s body, knowing that masculinity is not defined by the way one looks, and that  it is okay to look okay (Pope et al., 2000).  In the future, it would be very beneficial to have increased public awareness about muscle dysmorphia so victims of the disorder do not suffer silently alone.



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Features and Phenomenology of Muscle Dysmorphia.  Harvard Rev Psychiatry, 9,

254 – 259.  Retrieved March 25th, 2007, from the PsycINFO database.


Phillips, K. A.  (2005).  The Broken Mirror: Understanding and Treating Body

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Pope. H. G., Phillips, K. A., & Olivardia, R.  (2000).  The Adonis Complex: the secret

crisis of male body obsession.  New York: The Free Press.


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