Muscle dysmorphia: A systematic and meta-analytic review of the literature to assess diagnostic validity

Adaptation and validation of the muscle dysmorphic disorder inventory in a population of French athletes (MDDI-Fr)

INTRODUCTION

Muscle dysmorphia, a theme mainly investigated by Anglo-Saxon research, is a specific body dysmorphic disorder that characterizes individuals who think they are insufficiently muscular and lean. Understudied in francophone countries, tools translated and validated in French to measure the symptomatology of muscle dysmorphia remain rare.

OBJECTIVES

The aim of this study was the translation into French and the psychometric validation of a tool evaluating muscle dysmorphia, the Muscle Dysmorphic Disorder Inventory (MDDI-Fr), through 13 items divided into three dimensions: the "Drive For Size" (DFS), the "Appearance Intolerance" (AI) and the "Functional Impairment" (FI).

METHODOLOGY

A first translation step was conducted, followed by two cross-sectional studies conducted in France. In both of the latter studies, a sociodemographic questionnaire and the Muscle Dysmorphic Disorder Inventory - French version (MDDI-Fr) were administered. The first study included 342 university students (Mage=20.9; SDage=2.9), and 1822 athletes for the second study (Mage=23.9; SDage=5.9). Validation was performed using internal consistency measures and confirmatory factor analysis.

RESULTS

The correlation matrices showed good significant results between items and dimensions. The three dimensions appeared distinct from each other with significant intra-dimension correlations. The internal consistency of the tool and its three dimensions show valid Cronbach's alphas (study 1: DFS=0.79, AI=0.74, FI=0.75, MDDI=0.74; study 2: DFS=0.72, AI=0.75, FI=0.83, MDDI=0.75). In addition, the tri-factor analysis shows significant and promising scores for the tool in three dimensions and 13 items for study 1 (χ2/df=4.67, CFI=0.85, TLI=0.83, RMSEA=0.10, SRMR=0.00), as for study 2 (χ2/df=16.08, CFI=0.87, TLI=0.84, RMSEA=0.09, SRMR=.06). Gender analyses were conducted on study 2, which showed that the DFS subscale (items 1, 4, 5) and the AI subscale (items 6 and 9) presented the greatest differences in factor loadings between genders.

CONCLUSION

The translation, as well as the validation of the MDDI-Fr structured with 13 items and three dimensions, showed significantly satisfying results for its adaptation in French in a population of French men and women practicing weight training. However, the "Appearance Intolerance" dimension shows moderate links with the global tool, which should be investigated in future studies. Although the psychometric properties of the MDDI-Fr are promising, additional research is needed to gain a better understanding of gender differences in the results, especially for the DFS dimension.

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.

Going deeper into eating and body image pathology in males: Prevalence of muscle dysmorphia and eating disorders in a university representative sample

Disorders associated with body dissatisfaction such eating disorders (ED) and muscle dysmorphia (MD) in males are understudied and surrounded by controversy regarding their nosological aspects. The current study examined the prevalence rates of clinical cases of ED and MD through a two-phase study with gold standard clinical interview in a representative sample of 850 Spanish undergraduate men, of whom 141 were interviewed. Levels of body dissatisfaction, compulsive exercise, anxious-depressive symptoms and the amount of physical activity were also explored. A prevalence rate for ED of 1.4% and 1.3% for MD was found. No differences were observed between the clinical groups on scales related to body image, supporting the current perspective that MD as well as ED and Body Dysmorphic Disorder could be clustered in a new spectrum of body image disorders, where the behaviours performed to achieve body change could range from restriction or muscularity-oriented eating alterations to pathological exercise or cosmetic surgery. The usefulness of the cut-off points of the screening questionnaires in MD and ED in males are discussed.

New understandings meet old treatments: putting a contemporary face on established protocols

In the twenty years since the publication of the most widely used treatment manuals describing evidence-based therapies for eating disorders, there have been some substantial advances in the field. New methods of delivering treatments have been trialled and our perception of mental health has advanced; significant cultural changes have led to shifts in our societal landscape; and new technologies have allowed for more in-depth research to be conducted. As a result, our understanding of eating disorders and their treatment has broadened considerably. However, these new insights have not necessarily been translated into improved clinical practice. This paper highlights the changes we consider to have had the greatest impact on our work as experienced clinical psychologists in the field and suggests a list of new learnings that might be incorporated into clinical practice and research design.

Does the interpersonal theory of suicide explain relationships between muscle dysmorphia symptoms and suicidal ideation?

Muscle dysmorphia (MD) symptoms are robustly associated with suicidal thoughts/behaviors. Risk factors for suicidal ideation, such as perceived burdensomeness and thwarted belongingness, may help explain the relationship between MD symptoms and suicidal ideation. The current study extended past cross-sectional research by testing if perceived burdensomeness and/or thwarted belongingness mediated longitudinal relationships between MD symptoms and suicidal ideation. Two hundred and sixty-nine U.S. men recruited from Prolific completed self-report measures at three timepoints separated by one month each. Analyses used an adapted version of a longitudinal three-wave mediation model to test study hypotheses. Perceived burdensomeness mediated longitudinal relationships between MD symptoms and suicidal ideation. Thwarted belongingness did not show significant relationships with MD symptoms or suicidal ideation. Results extend past research by demonstrating that perceived burdensomeness may be a mechanism underlying longitudinal relationships between MD symptoms and suicidal ideation while establishing temporal ordering. Clinicians may consider targeting perceived burdensomeness in cases of comorbid MD/suicidality by using techniques that promote interpersonal effectiveness.

'The day you start lifting is the day you become forever small': Bodybuilders explain muscle dysmorphia

Muscle dysmorphia (MD) is a pathological preoccupation with muscularity characterised by negative body image, compulsive behaviours, and obsessive thoughts. Since its first identification academics have suggested that it is caused by sociocultural factors. Despite this there has been very little research exploring the role of sociocultural factors in the development and maintenance of MD, and no research that examines MD from within its cultural context. Instead the medical model of MD has dominated understanding. This model presents professionals as the experts on this disorder, and sufferers as pathological individuals in need of expert treatment. This renders cultural context largely irrelevant to understandings of MD. In this paper we present a different kind of expertise with regards MD. We describe the expertise of those most likely to suffer from MD, and upon whom medical descriptions of MD are based: bodybuilders. Specifically, we describe how bodybuilders explain MD (their definition, theory of aetiology and experience of MD, as well as their suggested management strategies), and compare these explanations to the dominant medical model. Through a consideration of the expertise of bodybuilders we break the tunnel vision of medicine, and suggest ways we can move beyond our current under-developed understanding of MD. This paper examines MD from within its cultural context, and in so doing it lays the foundation for a sociocultural explanatory model of MD. If we are to significantly reduce the harms of this disorder we cannot rely solely on treating the few individuals who present to clinicians. Rather we must develop ways to help sufferers to manage their disorder, and to prevent the development of this disorder among those at risk in the first place. To do this we must understand the sociocultural dimensions of MD, and collaborate with bodybuilding communities.

A descriptive analysis of scoring patterns on clinically relevant questionnaires in 26 adults with diagnosed muscle dysmorphia

OBJECTIVE

Few studies have recruited adults with a formal diagnosis of muscle dysmorphia (MD), a psychological illness defined by preoccupation that one lacks muscularity and/or leanness, combined with significant functional impairment. This study presented descriptive statistics for a range of clinically relevant questionnaires in one of the largest samples of adults with confirmed diagnoses of MD.

METHOD

We recruited 29 adults who met diagnostic criteria for MD as determined by semi-structured diagnostic interviews and administered a battery of questionnaires assessing MD symptomology, compulsive exercise, and disordered eating. Descriptive statistics were calculated for both total and subscale scores for each questionnaire. Raincloud plots are included to show the distribution of total scores.

RESULTS

Of the 29 participants, 26 completed all questionnaires. Mean scores were high across all questionnaires and broadly consistent with results in past studies that also recruited a clinical MD sample. Most participants scored above proposed clinical cut-off scores for questionnaires assessing compulsive exercise and disordered eating.

CONCLUSIONS

This study adds to the small body of published questionnaire data in clinical MD samples. We stress that questionnaire scores should not be used alone to infer the presence of MD, but could be considered as a useful adjunct to a comprehensive clinical interview.

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.

Conformity to masculine norms, interoceptive dysfunction, and changes in muscle dysmorphia symptoms

Muscle dysmorphia (MD) is a psychiatric illness characterized by preoccupation and compulsive behaviors to increase muscle size/definition. Despite its severity, few risk factors/mechanisms for MD have been identified. Conformity to masculine norms may be a MD risk factor. Furthermore, interoceptive dysfunction may facilitate MD. symptoms, as well as underlie relationships between conformity to masculine norms and MD symptoms. However, research has yet to test the mediating role of interoceptive dysfunction for said relationships. The current study tested if interoceptive dysfunction underlies relationships between conformity to masculine norms and MD symptoms among 269 US men who completed three surveys separated by one month that contained measures of focal constructs. Our sample was majority White, heterosexual, and non-Hispanic. A three-wave autoregressive mediation model was tested in which conformity to masculine norms predicted interoceptive dysfunction, which then predicted MD symptoms. Results indicated that conformity to specific masculine norms predicted both interoceptive dysfunction and MD symptoms over time. Furthermore, our hypothesized mediation pathways were not discovered. Conformity to masculine norms appears to be a risk factor for MD symptoms and interoceptive dysfunction. If clinicians can reduce rigid adherence to masculine stereotypes, this may increase connection with one's body and reduce subsequent MD symptoms.

A qualitative investigation of the phenomenology of muscle dysmorphia: Part 2

Muscle dysmorphia (MD) is a mental disorder characterised by preoccupation that one lacks muscularity and/or leanness, leading to substantial functional impairment. This article is the second of a two-part qualitative study examining the phenomenology of MD among 29 adults with diagnosed MD. We used reflexive thematic analysis to generate five themes which capture the role of exercise in the lives of people with MD. In summary, participants were highly motivated by a constant desire to progress their strength and appearance, and bad or missed workouts which threatened to derail their progress were associated with acute mental health impairment. Most participants scheduled rest days and modified workouts, both for muscle building-related goals and to reduce the risk of injuries, but often continued to exercise when sick. Alongside appearance-driven motivations, participants reported exercising for a variety of non-appearance-related reasons, including to structure their daily lives, boost self-esteem, regulate affect, and gain a sense of control from being able to manipulate their body composition. Exercise was often regarded as a core part of one's identity and overwhelmingly perceived as a net positive behaviour. Sample participant resistance training and cardio routines are described in detail within this article.

A qualitative investigation of the phenomenology of muscle dysmorphia: Part 1

Muscle dysmorphia (MD) is a psychological disorder defined by preoccupation with one's perceived lack of muscularity and/or leanness, causing significant functional impairment. Studies of individuals with diagnosed MD are rare and no large-scale qualitative studies of the disorder exist. We conducted a qualitative study exploring the lived experiences of 29 individuals with diagnosed MD. Using reflexive thematic analysis, we generated five themes capturing the core features of MD. We identified two distinct phenotypes of MD: a "muscular/lean phenotype" focused on both gaining muscle and remaining lean, and a "muscular phenotype" with a sole preoccupation of increasing muscle mass. Participants also described their physique goals as never-obtained "moving goalposts", differed in their desire for muscularity versus leanness, and experienced fluctuations in body dissatisfaction during "cutting" versus "bulking" phases, and pre- versus post-workout. Almost all participants reported avoiding public body exposure and compulsively mirror-checking. Most were rigorous dieters who meticulously tracked their caloric and macronutrient intake, and were obsessive about meeting protein targets. Disruptions to dieting and training were often minimised by compromising their social lives. Low self-esteem appeared a predisposing factor for MD, while social comparison, body image distortion, and integration of MD into one's self-identity may represent maintaining factors. Additional clinically valuable insights into MD's phenomenology are discussed in detail.

Management of eating disorders for people with higher weight: clinical practice guideline

INTRODUCTION

The prevalence of eating disorders is high in people with higher weight. However, despite this, eating disorders experienced by people with higher weight have been consistently under-recognised and under-treated, and there is little to guide clinicians in the management of eating disorders in this population.

AIM

The aim of this guideline is to synthesise the current best practice approaches to the management of eating disorders in people with higher weight and make evidence-based clinical practice recommendations.

METHODS

The National Eating Disorders Collaboration Steering Committee auspiced a Development Group for a Clinical Practice Guideline for the treatment of eating disorders for people with higher weight. The Development Group followed the 'Guidelines for Guidelines' process outlined by the National Health and Medical Research Council and aim to meet their Standards to be: 1. relevant and useful for decision making; 2. transparent; 3. overseen by a guideline development group; 4. identifying and managing conflicts of interest; 5. focused on health and related outcomes; 6. evidence informed; 7. making actionable recommendations; 8. up-to-date; and, 9. accessible. The development group included people with clinical and/or academic expertise and/or lived experience. The guideline has undergone extensive peer review and consultation over an 18-month period involving reviews by key stakeholders, including experts and organisations with clinical academic and/or lived experience.

RECOMMENDATIONS

Twenty-one clinical recommendations are made and graded according to the National Health and Medical Research Council evidence levels. Strong recommendations were supported for psychological treatment as a first-line treatment approach adults (with bulimia nervosa or binge-eating disorder), adolescents and children. Clinical considerations such as weight stigma, interprofessional collaborative practice and cultural considerations are also discussed.

CONCLUSIONS

This guideline will fill an important gap in the need to better understand and care for people experiencing eating disorders who also have higher weight. This guideline acknowledges deficits in knowledge and consequently the reliance on consensus and lower levels of evidence for many recommendations, and the need for research particularly evaluating weight-neutral and other more recent approaches in this field.

The association between social media addiction and eating disturbances is mediated by muscle dysmorphia-related symptoms: a cross-sectional study in a sample of young adults

PURPOSE

Although the association between problematic use of the internet and eating disorders (EDs) in young adults has been previously established, its underlying mechanisms have not been completely clarified. It has been suggested that exposure to idealized very thin and toned body images (e.g., "thinspiration" and "fitspiration" trends) on social media might lead to increased feelings of body dissatisfaction which, in turn, can represent a trigger for EDs. We have tested this hypothesis in a sample (N = 721) of young adults (504 females, mean age: 24.13 ± 3.70 years; range 18-34).

METHODS

Self-report measures investigating symptoms related to social media addiction (SMA), muscle dysmorphia (MD), and EDs were used. A mediational model analyzing the direct and indirect effects of SMA-related symptoms on ED-related symptoms through the mediating role of MD-related symptoms was performed controlling for confounding factors (e.g., socio-demographic variables, substances use, body mass index, psychopathological distress).

RESULTS

The model showed that the total effect of SMA-related symptoms on ED-related symptoms was significant (B = 0.213; p = 0.022) and that this association was mediated by MD-related symptoms (B = 0.083; p = 0.021).

DISCUSSION

Our findings support the possibility that MD-related symptoms play a relevant role in mediating the association between SMA severity and ED pathology.

LEVEL OF EVIDENCE

Level III, evidence obtained from well-designed cohort or case-control analytic studies.

Conformity to masculine norms, masculine discrepancy stress, and changes in muscle dysmorphia symptoms

Muscle dysmorphia (MD) is a severe psychiatric illness; however, little is known regarding risk factors for MD development. Conformity to masculine norms may represent a risk factor for MD, but research has yet to establish temporal ordering for these relationships. Masculine discrepancy stress (distress at not amounting to masculine stereotypes) could represent a mechanism underlying these relationships. Therefore, the current study examined longitudinal relationships between conformity to masculine norms, masculine discrepancy stress, and MD symptoms. Participants were 272 men displaying elevated MD symptoms who completed self-report questionnaires at three timepoints. An autoregressive cross-lagged mediation model was specified to examine relationships between conformity to masculine norms and MD symptoms and test if masculine discrepancy stress mediated these relationships. Masculine discrepancy stress did not mediate relationships between masculine norms and MD symptoms. However, MD symptoms predicted increased masculine discrepancy stress, and conformity to masculine norms was related to MD symptoms. MD symptoms were both a predictor and outcome of masculine norms, and signs for relationships differed on the masculine norm endorsed. Conformity to masculine norms may represent a risk factor and outcome for MD symptoms. If clinicians provide clients with tools to reduce rigid adherence to masculine identities, this may prevent MD symptom development.

Androgen Misuse and Abuse

Androgens are potent drugs requiring prescription for valid medical indications but are misused for invalid, unproven, or off-label reasons as well as being abused without prescription for illicit nonmedical application for performance or image enhancement. Following discovery and first clinical application of testosterone in the 1930s, commercialization of testosterone and synthetic androgens proliferated in the decades after World War II. It remains among the oldest marketed drugs in therapeutic use, yet after 8 decades of clinical use, the sole unequivocal indication for testosterone remains in replacement therapy for pathological hypogonadism, organic disorders of the male reproductive system. Nevertheless, wider claims assert unproven, unsafe, or implausible benefits for testosterone, mostly representing wishful thinking about rejuvenation. Over recent decades, this created an epidemic of testosterone misuse involving prescription as a revitalizing tonic for anti-aging, sexual dysfunction and/or obesity, where efficacy and safety remains unproven and doubtful. Androgen abuse originated during the Cold War as an epidemic of androgen doping among elite athletes for performance enhancement before the 1980s when it crossed over into the general community to become an endemic variant of drug abuse in sufficiently affluent communities that support an illicit drug industry geared to bodybuilding and aiming to create a hypermasculine body physique and image. This review focuses on the misuse of testosterone, defined as prescribing without valid clinical indications, and abuse of testosterone or synthetic androgens (androgen abuse), defined as the illicit use of androgens without prescription or valid indications, typically by athletes, bodybuilders and others for image-oriented, cosmetic, or occupational reasons.