Psychiatry and Clinical Neurosciences (2001), 55, 521–523
Original Article
Muscle dysmorphia:A South African sample VOLKER HITZEROTH, mbchb, mmed (psych), CHARMAINE WESSELS, ba (hons), NOMPUMELELO ZUNGU-DIRWAYI, ba (hons), PIET OOSTHUIZEN mbchb, mmed (psych) AND DAN J. STEIN, mbchb, frcpc Department of Psychiatry, University of Stellenbosch, Cape Town, South Africa
Abstract
It has recently been suggested that muscle dysmorphia, a pathological preoccupation with muscularity, is a subtype of body dysmorphic disorder (BDD). There are, however, few studies of the phenomenology of this putative entity. Twenty-eight amateur competitive body builders in the Western Cape, South Africa, were studied using a structured diagnostic interview that incorporated demographic data, body-building activities and clinical questions focusing on muscle dysmorphia and BDD. There was a high rate of muscle dysmorphia in the sample (53.6%). Those with muscle dysmorphia were significantly more likely to have comorbid BDD based on preoccupations other than muscularity (33%). Use of the proposed diagnostic criteria for muscle dysmorphia indicated that this is a common and relevant entity. Its conceptualization as a subtype of BDD seems valid. The disorder deserves additional attention from both clinicians and researchers.
Key words
body dysmorphic disorder, body building, muscle dysmorphia.
INTRODUCTION Body dysmorphic disorder (BDD) is characterized by pathological preoccupation with a nonexistent or slight defect in body appearance. Although described in the clinical literature for over 100 years, the disorder only recently gained entry into the official nomenclature.1,2 Since then, there has been a growing appreciation of the prevalence and morbidity of BDD, and a number of groups have undertaken valuable systematic studies of the clinical phenomenology and appropriate management of the disorder.3–6 Nevertheless, many questions about the nosological status of BDD remain unresolved.7 Recently, for example, Pope et al. introduced the term ‘muscle dysmorphia’ to describe a hypothesized subtype of BDD characterized by pathological preoccupation with muscularity.8 They suggest that this disorder may cause severe subjective distress, impaired social and occupational functioning, and abuse of anabolic steroids and other substances.
Correspondence address: Dan J. Stein, Department of Psychiatry, University of Stellenbosch, PO Box 19063, Tygerberg 7505, Cape Town, South Africa. Email:
[email protected] Received 13 February 2001; accepted 10 March 2001.
The present study aimed to gather preliminary data on the putative construct of muscle dysmorphia in the South African setting. Subjects participating in an amateur body-building competition were interviewed, and a comparison was undertaken of those who did and did not meet proposed criteria for muscle dysmorphia8 in terms of demographic data, body-building activities, nutritional and substance supplements, past medical and psychiatric history, and comorbid BDD on the basis of preoccupations other than muscularity.
METHOD Subjects participating in an amateur body-building competition (open to any member of a body-building club in the Western Cape) were asked to undergo a structured diagnostic interview. All subjects in the competition (24 males, four females; aged 26.39 ± 6.13 years, range 17–40) consented to the interview, which was undertaken by a psychiatry resident (VH) on the same day. The interview comprised demographic data, details about body-building activities (age at which body building began, number of years of body building, frequency and duration of training sessions, use of supplements/substances), prior medical and psychiatric consultations, the diagnostic module for BDD of
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the SCID-I,9 and questions addressing the research criteria for muscle dysmorphia proposed by Pope et al.8 The proposed research criteria for muscle dysmorphia were based on DSM-IV criteria for BDD.8 They are:
Data was analysed using the Statistical Package for the Social Sciences (SPSS), using t-tests, c2 or Fisher’s exact test, as appropriate.
1 The person has a preoccupation with the idea that one’s body is not sufficiently lean and muscular. Characteristic associated behavior includes long hours of lifting weights and excessive attention to diet. 2 The preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning, as demonstrated by at least two of the following four criteria: (i) 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; (ii) the individual avoids situations where his or her body is exposed to others, or endures such situations with marked distress or intense anxiety; (iii) the preoccupation with the inadequacy of body size or muscularity causes clinically significant distress or impairment in social, occupational, or other important areas of functioning; and (iv) the individual continues to work out, diet or use ergogenic (performance-enhancing) substances despite knowledge of adverse physical or psychological consequences. 3 The primary focus of the preoccupation and behavior is on being too small or inadequately muscular, as distinguished from fear of being fat, as in a norexia nervosa, or a primary preoccupation only with other aspects of appearance, as in other forms of BDD.
Of the 28 subjects, 15 (53.6%) met the proposed diagnostic criteria for muscle dysmorphia. By definition these subjects met criteria 1 and 3 for muscle dysmorphia, and they frequently also met criteria 2(i) (14/15), 2(ii) (2/15), 2(iii) (13/15), and 2(iv) (11/15). On comparison of subjects with and without muscle dysmorphia (Table 1), there were no significant differences in demographic data. There were no differences in body-building activities such as frequency and duration of training sessions. However, subjects with muscle dysmorphia had more frequently sought prior medical consultation, with a range of different complaints. One male subject with muscle dysmorphia gave a prior history of an eating disorder, but was unwilling to provide specific details about this. Subjects with muscle dysmorphia were also significantly more likely to meet diagnostic criteria for BDD on grounds other than muscle concerns (33% vs 0%). When muscle dysmorphia subjects were divided into groups with and without comorbid BDD, however, there were no significant differences in demographic data, in body-building activities, in use of nutritional or other substances, or in history of medical or psychiatric consultations.
Table 1.
RESULTS
DISCUSSION The present study found a high rate (53.6%) of muscle dysmorphia in a sample of amateur competitive body
Muscle dysmorphia versus non-dysmorphia
Muscle dysmorphia Age (SD) Sex Marital status Education Weight Height Previous medical consultation Previous psychiatric history Number of hours/week in gym Nutritional supplements Substance use BDD preoccupations other than muscularity
Present (n = 15)
Absent (n = 13)
P
25.47 ± 6.08 12 males, 3 females 11 singles, 4 married 9 secondary, 6 tertiary 74.4 ± 17.3 kg 173.9 ± 10.8 cm 5 yes, 10 no 1 yes, 14 no 12.2 ± 4.2 14 yes, 1 no 6 yes, 9 no 5 yes, 10 no
26.05 ± 4.70 12 males, 1 female 5 single, 8 married 10 secondary, 3 tertiary 70.1 ± 13.1 kg 166.7 ± 8.2 cm 0 yes, 13 no 1 yes, 12 no 13.11 ± 7.8 8 yes, 5 no 2 yes, 11 no 0 yes, 13 no
ns ns ns ns ns ns 0.04 ns ns 0.07 ns 0.04
Muscle dysmorphia in South Africa
builders in the Western Cape. We also showed that those with muscle dysmorphia were significantly more likely to have comorbid BDD based on preoccupations other than muscularity; 33% of the subjects with muscle dysmorphia had such comorbidity. According to the proposed definition of muscle dysmorphia, patients suffer from a preoccupation with muscularity that is associated with clinically significant distress or impairment in social, occupation or other important areas of functioning. Our data seem to support the seminal proposal of Pope et al.,8 that this is a relevant diagnostic entity. The sample size was too small to undertake detailed analyses of subtypes of subjects; however, given the nature of the sampling method, it not surprising that criteria 2(ii) (fear of public display) was not commonly met. Clearly, the fact that this was a sample of competitive body builders makes extrapolation of prevalence to other groups problematic. Nevertheless, competitions of the kind from which subjects were drawn are commonly held throughout the country, and a wide range of body builders participate in them. There may also be a bias against muscle dysmorphia in competitive subjects given that one proposed characteristic of the diagnosis is avoidance of public displays. Certainly, Pope et al.’s preliminary calculations suggest that muscle dysmorphia is highly prevalent, particularly in men.8 Similarly, the fact that this sample was made up of competitive body builders may have resulted in a ceiling effect with regard to body-building activities (e.g. number of hours per week in the gym), leading to a lack of differentiation on these variables between subjects with and without muscle dysmorphia. The relatively small size may have compounded this lack of differentiation. Nevertheless, there was evidence that subjects with muscle dysmorphia may use medical services more, and the use of nutritional and other supplements may be a clue to the diagnosis. Certainly, a number of studies have documented an association between ‘reverse anorexia nervosa’9 or muscle dysmorphia10 and steroid abuse. The finding that five of the 15 subjects with muscle dysmorphia suffered from comorbid BDD (in contrast to none of the 13 subjects without this entity) is consistent with an hypothesis that the two conditions are related. Similarly, Pope et al. describe a study in which 18/193 subjects with BDD had muscle dysmorphia.8 These findings would seem to support the validity of the conceptualization of muscle dysmorphia as a subtype of BDD. Further characterization (and comparison with BDD) of muscle dysmorphia’s demographic characteristics, comorbidity (e.g. with
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OCD, mood disorder, eating disorders, and ‘exercise dependence’11), course, and response to intervention would be useful to consolidate this hypothesis.
CONCLUSION Overall, the findings here are consistent with the proposal of Pope et al.8 that muscle dysmorphia is a relevant diagnostic entity. The data indicate that the condition deserves more attention from both clinicians and researchers. In addition, the present data raises a range of questions about the pathogenesis and management of pathological preoccupation with muscularity.
ACKNOWLEDGMENTS This study was supported by the MRC Research Unit on Anxiety and Stress Disorders (South Africa), and undertaken with the cooperation of the Western Province Body Building Organization (IFBB).
REFERENCES 1. Birtchnell SA. Dysmorphophobia – a century discussion. Br. J Psychiatry. 1988; 153 (Suppl. 2): 41–43. 2. Phillips KA. Body dysmorphic disorder: The distress of imagined ugliness. Am. J. Psychiatry 1991; 148: 1138–1149. 3. Phillips KA, McElroy SL, Keck PE et al. Body dysmorphic disorder: 30 cases of imagined ugliness. Am. J. Psychiatry 1993; 150: 302–308. 4. Hollander E. Treatment of obsessive-compulsive spectrum disorders with SSRIs. Br. J. Psychiatry 1998; 35S: 7–12. 5. Veale D, Boocock A, Gournay K et al. Body dysmorphic disorder. A survey of fifty cases. Br. J. Psychiatry 1996; 169: 196–201. 6. McKay D, Todaro J, Neziroglu F et al. Body dysmorphic disorder: A preliminary evaluation of treatment and maintenance using exposure with response prevention. Behav. Res. Ther. 1997; 35: 67–70. 7. Phillips KA, McElroy SL, Hudson JI et al. Body dysmorphic disorder. An obsessive-compulsive spectrum disorder, a form of affective spectrum disorder, or both? J. Clin. Psychiatry 1995; 56 (Suppl. 4): 41–51. 8. Pope HG Jr, Gruber AJ, Choi P et al. Muscle dysmorphia. Psychosomatics 1997; 38: 548–557. 9. Pope HG JR, Katz DL, Hudson JI. Anorexia nervosa and ‘reverse anorexia’ among 108 male bodybuilders. Compr. Psychiatry 1993; 34: 406–409. 10. Blouin AG, Goldfield GS. Body image and steroid use in male bodybuilders. Int. J. Eat. Disord. 1995; 18: 159–165. 11. de Coverley Veale DM. Exercise dependence. Br. J. Addict. 1987; 82: 735–740.
