Muscle dysmporphia as an addiction
Posted Feb 17, 2015
Muscle Dysmorphia (MD) describes a condition characterised by a misconstrued body image in individuals interpret their body size as both small and weak even though they may look normal or even be highly muscular. Those experiencing the condition typically strive for maximum fat loss and maximum muscular build. MD can have potentially negative effects on thought processes including depressive states, suicidal thoughts, and in extreme cases, suicide attempts.
MD was originally categorised in a 1993 issue of Comprehensive Psychiatry by Dr. H.G. Pope and colleagues as Reverse Anorexia Nervosa, due to characteristic symptoms in relation to body size. It has been considered to be part of the spectrum of Body Dysmorphic Disorders (BDDs) referring to a range of conditions that tap into issues surrounding body image and eating behaviors. Consequently, there is a lack of consensus amongst researchers whether MD is a form of BDD, Obsessive-Compulsive Disorder (OCD), or a type of eating disorder. However, I, and two of my colleagues (Andrew Foster and Dr. Gillian Shorter), have published a paper in the Journal of Behavioral Addictions arguing that MD could perhaps be classified as an addiction.
Our "Addiction to Body Image" (ABI) model attempts to provide an operational definition and to introduce a standard assessment across the research area. The ABI model uses my addiction components model as the framework in which to define muscle dysmorphia as an addiction. For the purposes of our paper, body image was defined as a person’s “perceptions, thoughts and feelings about his or her body” (taken from Grogan’s 2008 book Body image: Understanding body dissatisfaction in men, women, and children). The addictive activity is the maintaining of body image via a number of different activities such as bodybuilding, exercise, eating certain foods, taking specific drugs (e.g., anabolic steroids), shopping for certain foods, food supplements, and/or physical exercise accessories, etc.). Each of these components is described below in the context of MD symptomatology and behavioral maintenence.
Salience: A person with an ABI may: (i) have cognitive disturbances that lead to a total preoccupation with activities that maintain body image such as physical training and eating according to a strict dietary intake, (ii) be able to perform other tasks such as work and shopping (explained by reverse salience – see below) as these tasks will be designed and built around being able to engage in specific body image maintenance behaviors such as physical exercising and eating, and (iii) be able to manipulate their personal situation to ensure so that they can perform these maintenance tasks. The individual with ABI may even change or forego career opportunities and other daily activities as it may reduce their ability to train or control eating behavior during the day.
Reverse salience: If the person with ABI cannot engage in the maintenance behaviors such as training and/or eating when they want, their thought processes are likely to focus on being able to train and/or eat (i.e., carry out the desired behavior to maintain body image). This excessive preoccupation with the maintenance behaviors may occur when the person is in a position where they cannot engage in the behavior. This may even result in the manifestation of physical symptoms. More specifically, the cognitive disturbance creates a negative thought process that facilitates the manifestation of physical symptoms (e.g., shakes, sweating, nausea, etc.) as seen in other addictions. It is expected that due to some of the dietary restrictions that the person with ABI places upon their body, it may manifest physical symptoms (such as fainting and falling unconscious) because of low blood sugar levels.
Mood modification: For an individual with ABI, being able to engage in the maintenance behaviors brings a sense of reward to the person. As a consequence, training and food intake (either in restrictive or over-eating) should facilitate the release of endorphins into the bloodstream, which would increase positive mood. The physical act of engaging in physical exercise and training (whether cardio- or weight-based) will produce a physical state whereby the muscles are enriched with blood (which at their biggest is known as a ‘pump’). This pump brings a sense of euphoria and happiness to the person. The ABI model proposes that engaging in the maintenance behaviors—for example weight training—will create a chemical high created by the body though the release of chemicals such as endorphins. A person with ABI will desire these chemical changes and this may have the same effect (both physiologically and psychologically) as other psychoactive substances. Once their maintenance behaviors have been completed, the person’s mood will relax due to completion of the activity, and the person may also have a feeling of utopia, a sense of inner peace, or an exceptional high. This feeling has been linked to the use of AASs in gym training. The person with ABI will need to control their food intake (i.e., less or more protein and carbohydrates). The ABI model proposes this will become a secondary dependence due to the food intake being part of the process to maintain the primary dependence (i.e., the sculpting of the body). This will be due to the body adapting to the amount of calories it is being fed, but also due to requirement of being lighter or heavier—and for longer—which in turn will allow the person to obtain the desired body shape.
Tolerance: The person with ABI may need to increase the levels and intensity of the training or the food restriction (i.e., the maintenance behaviors) to achieve the desired physiological and/or psychological effects. This can be achieved through different training strategies or by the consumption of different foods. In some circumstances, this may be achieved through the use of psychoactive substances such as AASs or other food inhibiting drugs. Record keeping of training sessions and seeking out changes in activities may assist the individual in combatting the effects of tolerance.
Withdrawal: The person with ABI is expected to have negative physical and/or psychological effects if they are unable to engage in the maintenance activities. This would be likely to include one or more psychological and/or physical components such as intense moodiness and irritability, anxiety, depression, nausea, and stomach cramps. They will not be able to just stop the maintenance behaviors without experiencing one or more of these symptoms.
Conflict: The person with ABI becomes focused on their maintenance behaviors of training and/or eating. These behaviors can become all consuming, and the need to train, control diet, and exercise may conflict with their family, their work, the use of resources (e.g., money) and their life in general. In some cases of the addiction, the process is thought have healthy physical consequence and adds to life in the short-term, in the long-term, the addiction will detract from their overall quality of life.
Relapse: If the person with ABI manages to stop the maintenance behaviors for a period of time, they may be susceptible to triggers to re-engage in the behaviors again. CBT approaches for treatment of MD include aspects which address triggers or reinforcing behavior, and reducing stress around maintaining body image to prevent likelihood of relapse. When a person with ABI re-engages with behaviors again, they may go straight back into the destructive training and eating patterns they were engaged in prior.
The ABI model differs from other addiction models in relation to the primary and secondary dependencies. For instance, in exercise addiction, the individual has the primary goal of exercising, and the cognitive dysfunction in this condition is the act of exercising in, and of, itself. If the person loses weight or increases their body size through their exercise, this is seen as a secondary dependence as it is a natural consequence of the primary dependence and is not the primary goal. In MD, the primary dependence is maintenance in behaviors that facilitate body size change due to the cognitive dysfunction of negative perceptions of their body image. Exercise and/or dietary controls are the secondary dependence as they assist in achieving the primary goal of maintaining their desired body size and composition. In addition, exercise addiction tends to relate to compulsive aerobic exercise, with the endorphin rush from the physical exertion rather than a reward from physique change.
In the ABI model, the perception of the positive effects on the self-body image is accounted for as a critical aspect of the MD condition. The maintenance behaviors of those with ABI may include healthy changes to diet or increases in exercise. However, such behaviors can hide or mislead those with ABI away from the negative thought processes that are driving their addiction. It is in the cognitive dysfunction of MD where we believe there is a pathological issue, and why the field has encountered problems with the criteria for the condition. The attempt to explain MD in the same manner as other BDDs may not be adequate due to the cognitive dysfunction occurring in the context of the potentially positive physical effects via improvements in shape, tone, and/or health of the body.
Based on empirical evidence to date, we propose that Muscle Dysmorphia could be re-classed as an addiction due to the individual continuing to engage in maintenance behaviors that cause long-term psychological damage. More research is needed to explore the possibilities of MD as an addiction, and how this particular addiction is linked to substance use and/or other comorbid health conditions. Controversy about the conceptual measurement of the condition, has led to a number of different scales adapted from different criteria that may not fully measure the experience of MD.
However, a group of questions that might test the applicability of the ABI approach to measuring and conceptualising MD have not been asked. Questionnaires such as the Exercise Addiction Inventory and the Bergen Work Addiction Scale could be adapted to fit MD characteristics. Adequate conceptualisation is key to explore the clinically relevant condition. This new ABI approach may also have implications for diagnostic systems around similar conditions such as other BDDs or eating disorders.
Dr. Griffiths would like to than Andy Foster and Dr. Gillian Shorter for their input into this article
References and further reading
Andreassen, C.S., Griffiths, M. D., Hetland, J. & Pallesen, S. (2012). Development of a Work Addiction Scale. Scandinavian Journal of Psychology, 53, 265-272.
Berczik, K., Szabó, A., Griffiths, M. D., Kurimay, T., Kun, B., & Demetrovics, Z. (2012). Exercise addiction: symptoms, diagnosis, epidemiology, and etiology. Substance Use and Misuse, 47, 403-417.
Cafri, G., & Thompson, J. K. (2007). Measurement of the muscular ideal. In J. K. Thompson, & G. Cafri (Eds.), The muscular ideal: Psychological, social, and medical perspectives (pp. 107-120). Washington, DC: American Psychological Association.
Grieve, F.G., Truba, N., & Bowersox, S. (2009). Etiology, assessment, and treatment of Muscle Dysmorphia. Journal of Cognitive Psychotherapy, 23, 306-314.
Griffiths, M. D. (2005). A ‘components’ model of addiction within a biopsychosocial framework. Journal of Substance Use, 10, 191-197.
Grogan, S. (2008). Body image: Understanding body dissatisfaction in men, women, and children. London: Routledge.
Kuennen, M. R., & Waldron, J. J. (2007). Relationships between specific personality traits, fat free mass indices, and the muscle dysmorphia inventory. Journal of Sport Behavior, 30, 453-461.
Mangweth, B., Pope, H. G., Jr., Kemmler, G., Ebenbichler, C., Hausmann, A., De Col, C., Kreutner, B., Kinzl, J., & Biebl. W. (2001). Body image and psychopathology in male bodybuilders. Psychotherapy and Psychosomatics, 70, 38–43.
Maida, D. M., & Armstrong, S. L. (2005). The classification of muscle dysmorphia. International Journal of Men’s Health, 4, 73–91.
McFarland, M. B., & Karninski, P. L. (2008). Men, muscles, and mood: the relationship between self-concept, dysphoria, and body image disturbances. Eating Behaviours, 10, 68-70.
Mosley, P.E. (2009). Bigorexia: Bodybuilding and muscle dysmorphia. European Eating Disorders Review. 17, 191-198.
Murray, S. B., Rieger, E., Touyz, S. W., & De la Garza Garcia, Y. (2010). Muscle Dysmorphia and the DSM-V Conundrum: where does it belong? International Journal of Eating Disorders, 43, 483-491.
Nieuwoudt, J. E., Zhou, S., Coutts, R. A., & Booker, R. (2012). Muscle dysmorphia: Current research and potential classification as a disorder. Psychology of Sport and Exercise, 13, 569-577.
Olivardia, R., Pope, H. H., & Hudson, J. I. (2000). Dysmorphia in male weightlifters: A Case-control study. American Journal of Psychiatry, 157, 1291-1296.
Phillips, K. A. (1998). Body dysmorphic disorder: Clinical aspects and treatment strategies. Bulletin of the Menninger Clinic, 62, (4 Suppl A), A33–A48.
Pope, H. G., Jr., Gruber, A. J., Choi, P., Olivardia, R., & Phillips, K. A. (1997). Muscle dysmorphia. An underrecognised form of body dysmorphic disorder. Psychosomatics, 38, 548–557.
Pope, H. G., Jr., Katz, D. L., & Hudson, J. I. (1993). Anorexia nervosa and ‘‘reverse anorexia’’ among 108 male bodybuilders. Comprehensive Psychiatry, 34, 406–409.
Pope, C. G., Pope, H. G., Menard, W., Fay, C., Olivardia, R., & Phillips, K.A. (2005). Clinical features of muscle dysmorphia among males with body dysmorphic disorder. Body image, 2, 395-400.
Terry, A., Szabo, A. & Griffiths, M. D. (2004). The Exercise Addiction Inventory: A new brief screening tool. Addiction Research and Theory, 12, 489-499.
Veale, D. (2004) Body dysmorphic disorder. Postgraduate Medical Journal, 80, 67-71