I have noticed recently that my wonderful son Luke, who is in the pre-teenage years, has become more ‘aware’ of his body and discusses things like ‘six-pack abs’ and the need to be strong and have big muscles, probably like most boys of his age. I remember an old colleague at the University of Free State mention to me that her son, who was starting his last year at school, and who was a naturally good sports-person, had started supplementing his sport with gym work as he perceived that ‘all boys his age were interested in having big muscles’, as my colleague described it. A few decades ago, my old colleague and friend Mike Lambert, exercise physiologist and scientist without peer, and I did some work researching the effect of anabolic steroid use on bodybuilders, and noted that there were not just physical but also psychological changes in some of the trial participants. I did a fair amount of time in the gym in my University days, and always wondered why some of the biggest folk in the gym seemed to do their workouts with long pants and tracksuit tops, sometimes with hoods up, even on hot days, and how in conversation with them I was often told that despite them being enormous (muscular rather than obese-wise), they felt that they were small compared to their fellow bodybuilders and weightlifters, and that they needed to work harder and longer in the gym than they were currently doing to get results. All of these got me thinking of the fascinating syndrome known as muscle dysmorphia, also known as the Adonis complex, ‘bigorexia’, or ‘reverse anorexia’ and what causes the syndrome / disorder in the folk that develop it.
Muscle dysmorphia is a disorder mostly affecting males (though females can also be affected) where there is a belief or delusion that one’s body is too small, thin, insufficiently muscular or lean, despite it often being normal or exceptionally large and muscular, and related to obsessional efforts to increase muscularity and muscle mass by weightlifting exercise routines, dietary regimens and supplements, and often anabolic steroid use. This perception of being not muscular enough becomes severely distressing for the folk suffering from the syndrome, and the desire to enhance their muscularity eventually impacts negatively on the sufferer’s daily life, work and social interactions. The symptoms usually begin in early adulthood, and are most prevalent in body-builders, weight-lifters, and strength-based sports participants (up to 50 percent in some bodybuilder population studies, for example). Worryingly, muscle dysmorphia is increasingly being diagnosed in younger / adolescent folks, and across the spectrum of sports participants, and even in young folk who begin lifting weights for aesthetic rather than sport-specific purposes, and who from the start perceive they need to go to gym to improve their ‘body beautiful’. Two old academic friends of mine, Dave Tod and David Lavallee, published an excellent article on muscle dysmorphia a few years ago, where they suggested that the diagnostic criteria for the disorder are that the sufferer needs to be pre-occupied with the notion that their bodies are insufficiently lean and muscular, and that the preoccupation needs to cause distress or impairment in social or occupational function, including at least two of the four following criteria: 1) they give up / excuse themselves from social, occupational or recreational activities because of the need to maintain workout and diet schedules; 2) they avoid situations where their bodies may be exposed to others, or ‘endure’ such situations with distress or anxiety; 3) their concerns about their body cause distress or impairment in social, occupational or other areas of their daily functioning; and 4) they continue to exercise and monitor their diet excessively, or use physique-enhancing supplements or drugs such as anabolic steroids, despite knowledge of potential adverse physical or psychological consequences of these activities. Folk with muscle dysmorphia spend a lot of their time agonizing over their ‘situation’, even if it is in their mind rather than reality, look at their physiques in the mirror often, and are always of the feeling that they are smaller or weaker than what they really are, so there is clearly some cognitive dissonance / body image problem occurring in them.
What causes muscle dysmorphia is still not completely known, but what is telling is that it was first observed as a disorder in the late 1980’s and early 1990’s, and was first defined as such by Harrison Pope, Katharine Phillips, Roberto Olivardia and colleagues in a seminal publication of their work on it in 1997. There are no known reports of this disorder from earlier times, and as suggested by these academics, it’s increasing development appears to be related a growing social obsession with ‘maleness’ and muscularity, that is evident in the media and marketing adverts of and for the ‘ideal’ male in the last few decades. While women have had relentless pressure on them from the concept of increasing ‘thinness’ as the ‘ideal body’ perspective for perhaps a century or longer from a social media perspective, with for example the body size of female models and advertised clothes sizes decreasing over the years (and it has been suggested that in part this is responsible for the increase in the prevalence in anorexia nervosa in females), it appears that males are now under the same marketing / media ‘spotlight’, but more from a muscularity rather than a ‘thinness’ perspective, with magazines, newspapers and social media often ‘punting’ this muscular ‘body ideal’ for males when selling male-targeted health and beauty products. Some interesting changes have occurred which appear to support this concept, for example the physique of GI-Joe toys for young boys changing completely in the last few decades, apparently being much more muscular in the last decade or two compared to their 1970 prototypes. Matching this change, in 1972 only 15-20 percent of young men disliked their body image, while in 2000 approximately 50% percent of young men disliked their body image. Contemporary young men (though older men may also be becoming increasingly ‘caught up’ in similar desire for muscularity as contemporary culture puts a price on the ‘body beautiful’ right through the life cycle) perceive that they would like to have 13 kg more muscle mass on average, and believe that women would prefer them to have 14 kg more muscle mass to be most desirable, though interestingly when women were asked about this, women were happy with the current mass of their partners, and many were indeed not attracted to heavily-muscled males. Therefore, it appears that social pressure may play a large part in creating an environment where men perceive their bodies in a negative light, and this may in turn lead to the development of a ‘full blown’ muscle dysmorphia syndrome in some folk.
While the concept that social pressure plays a big role in the development of muscle dysmorphia, other factors have also been suggested to play a part. Muscle dysmorphia is suggested to be associated with, or indeed a sub-type of, the more general body dysmorphic disorder (and anorexia nervosa, though of course anorexia nervosa is about weight loss, rather than weight gain), where folk develop a pathological dislike of one or several body parts or components of their appearance, and develop a preoccupation with hiding or attempting to fix their perceived body flaw, often with cosmetic surgery (and this apparently affects up to 3 percent of the population). It has been suggested that both muscle dysmorphia and body dysmorphic disorder may be caused by a problem of ‘somatoperception’ (knowing one’s own body), which may be related to organic lesions or processing issues in the right parietal lobe of the brain, which is suggested to be the important area of the brain for own-body perception and the sense of self. In folk that have lesions of the right parietal cortex, they perceive themselves to be ‘outside’ of their body (autoscopy), or that body parts are missing / there is a lack of awareness of the existence of parts of the body (asomatognosia). Non-organic / psychological factors have also been associated with muscle dysmorphia, apart from media and socio-cultural influences, including being a victim of childhood bullying, being teased about levels of muscularity when young, or being exposed to violence in their family environment. It has also been suggested that it is associated with appearance-based rejection sensitivity, which is defined as anxiety-causing expectations of social rejection based on physical appearance – in other words, for some reason, folk with muscle dysmorphia are anxious that they will be socially rejected due to their perceived lack of muscularity and associated appearance deficits. Whether this rejection sensitivity is due to prior negative social interactions, or episodes of childhood teasing or body shaming, has not been well elicited. Interestingly, while studies have reported inconclusive correlations with body mass index, body fat, height, weight, and pubertal development age, there have been strong correlations reported with mood disorders, anxiety disorders, perfectionism, substance abuse, and eating and exercise-dependence / addiction disorders, as well as with the clinical depression, anxiety, and obsessive-compulsive disorders. There does not appear to be a strong relationship to narcissism, which perhaps is surprising. Whether these are co-morbidities or they have a common pathophysiology at either a psychological or organic level is yet to be determined. It has been suggested that a combination of cognitive behavioural therapy and selective serotonin reuptake inhibitor prescription (a type of antidepressant) may improve the symptoms of muscle dysmorphia. While these treatment modalities would support a link between muscle dysmorphia and the psychological disorders described above, the efficacy of these treatment choices is still controversial, and there is unfortunately a high relapse rate. It is unfortunately a difficult disorder to ‘cure’, given that all folk need to eat regularly in order to live, and most folk incorporate exercise into their daily routines, which make managing ‘enough’ but not ‘excessive’ amounts of weightlifting and dietary regulation difficult to regulate in folk who have a disordered body image.
Muscle dysmorphia appears therefore to be a growing issue in contemporary society, which is increasing in tandem with the increased media-related marketing drive for the male ‘body beautiful’, which now appears to be operating at a similar level to the ‘drive for thinness’ media marketing which has blighted the female perception of body image for a long time, and has potentially led to an increased incidence of body image disorders such as anorexia nervosa and body dysmorphic syndrome. However none of these are gender specific, and it is not clear how much of a relationship these body image disorders have with either organic brain or clinical psychological disorders, as described above. It appears to be a problem mostly in young folk, with older folk being more accepting of their body abnormalities and imperfections, whether these are perceived or real, though sadly it appears that there is a growing incidence of muscle dysmorphia and other body image disorder in older age, as societies relationship and expectations of ‘old age’ changes. As I see my son become more ‘interested’ in his own physique and physical development, which must have obviously been caused by either discussions with his friends, or due to what he reads, or what the ‘actors’ in his computer games look like which he so enjoys playing, like all his friends, I hope he (and likewise my daughter) will always enjoy his sport but have a healthy self-image through the testing teenage and early adult period of time. I remember those bodybuilders my colleague Mike and I worked with all those years ago, and how some of them were comfortable with their large physiques, while with some it was clearly an ordeal to take off their shirts in order to be tested in the lab as part of the trials we did back then. The mind is very sensitive to suggestion, and it is fascinating to see that males now are being ‘barraged’ with advertising suggesting they are not good enough, and if they buy a certain product it will make them stronger, fitter, better, and thus more attractive, to perhaps the same level females have been subjected to for a long period of time. The mind is also sensitive to bullying, teasing and body shaming, as well as a host of other social issues which impinge on it particularly in its childhood and early adolescent development phases. It’s difficult to know where this issue will ‘end’, and whether governmental organizations will ‘crack down’ on such marketing and media hype which surely ‘target’ folks (usually perceived) physical inadequacies or desires, or if it is too late to do so and such media activity has become innate and part of the intrinsic fabric of our daily life and social experience. Perhaps education programs are the way to go at school level, though these are unfortunately often not successful.
There are so many daily challenges one has to deal with, it may seem almost bizarre that folk can spend time worrying about issues that are not even potentially ‘real’, but for the folk staring obsessively at themselves in the mirror, or struggling to stop the intrusive thoughts about their perceived physical shortcomings, these challenges are surely very real, and surely all-consuming and often overwhelming. In Greek mythology Adonis was a well-muscled half man, half god, whose was considered to be the ultimate in masculine beauty, and according to mythology his masculine beauty was so great that he won the love of Aphrodite, the queen of all the gods, because of it. Sadly for the folk with muscle dysmorphia, while they may be chasing this ideal, they are likely to be too busy working on creating their own perfect physique to have time to ‘woo’ their own Aphrodite, and indeed, contemporary Aphrodite’s don’t appear to even appreciate the level of muscularity they eventually obtain. The mirror on the wall, as it usually is, is a false siren, beckoning those weak enough to fall into its thrall – no matter how big, never to appear as the biggest or most beautiful of all.