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When to Suspect Muscle Dysmorphia

Bringing the 'Adonis Complex' to Light

'Why be Clark Kent when I can be Superman?'

Mental health professionals are noting a shift in why men build their muscles, from athletic performance to physical appearance. The trend, as alluded to in the above quote from one of their patients, is fueled by a changing view of the ideal male physique that has even prompted GI Joe toys to bulk up over the past two decades (1).

A recent survey (2) of Austrian, French, and American men identified the ideal men's body weight as about 28 lb more muscular than their own weight. (Ironically, an associated pilot study found that women preferred an ordinary male body.)

Working out with weights to build muscle produces health benefits and can build self-esteem. Physicians and mental health professionals, though, are noticing that more men are crossing the line into patterns that include body obsession, eating disorders, and steroid use.

Out in the Open

Concerns about the health effects of body-image misperception in men received national attention this spring on the talk show circuit and in the lay press when a book on the topic was published titled The Adonis Complex: The Secret Crisis of Male Body Obsession (3). The book's authors state that the Adonis complex refers to a wide range of body- image concerns, from hair loss to body fat. Muscle dysmorphia, however, is a more specific term that describes preoccupation with body size and muscularity.

"Exercise is a great thing, but there are extremes," says Roberto Olivardia, PhD, muscle dysmorphia researcher and coauthor of The Adonis Complex. "A few patients that I've worked with have hit rock bottom. They are housebound and suicidal because they believe they are too small." Olivardia is a clinical psychologist at McLean Hospital in Belmont, Massachusetts.

Pathologic Interrelationships

Pathologic body dissatisfaction in men was first referred to in the medical literature as "reverse anorexia nervosa," which the lay press labeled "bigorexia." Muscle dysmorphia, a term that surfaced in the medical literature in 1997 (4), is thought to be a form of body dysmorphic disorder. According to the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders, body dysmorphic disorder is intense dissatisfaction with imagined ugliness of a specific body part; however, Pope et al (4) have defined muscle dysmorphia as a preoccupation with the misperception that muscles are small despite sufficient muscularity.

Muscle dysmorphia and anorexia nervosa have some similarities: shame about body image, history of depression or anxiety, and self-destructive compulsive behaviors. In fact, Olivardia notes that about one third of men who have muscle dysmorphia also have an eating disorder such as bingeing or an idiosyncratic pattern such as a focus on extreme low-fat, high-protein diets.

Another major health concern cited as a hallmark of muscle dysmorphia is anabolic steroid use. Olivardia says that more than half of these patients use steroids, and that the rest are tempted. He also adds that use of nutritional supplements is almost universal in this group.

How to Recognize Muscle Dysmorphia

Olivardia, who presents grand rounds talks on muscle dysmorphia to physicians and other healthcare professionals, says that he is often asked what separates a normal desire to become more muscular from pathologic perceptions. "Doctors want to know how to recognize this," he says.

A recent controlled study (5) of muscle dysmorphia in weight lifters offers some guidance on how to recognize the condition in patients. The researchers used demographic, psychiatric, and physical measures to compare 24 men with muscle dysmorphia with 30 controls. They found that those with muscle dysmorphia were more likely to:

  • Respond that they were totally or mostly dissatisfied with their body,
  • Have higher rates of current or past major mood, anxiety, or eating disorders,
  • Spend more than 3 hours per day thinking about their muscularity,
  • Avoid activities and people because of their perceived body defect,
  • Report little or no control over compulsive weight lifting and dietary patterns, and
  • Relinquish activities that were formerly enjoyable.

Another feature that physicians may notice if they suspect that a patient may have body dysmorphia is obvious camouflaging of the body with layers of heavy clothes to hide perceived smallness, or clothes that are modified to accentuate muscularity (such as extra buttons to make a shirt sleeve tighter). Olivardia notes that a physiatrist at one of the grand rounds sessions voiced concern over musculoskeletal injuries from overtraining in patients who have muscle dysmorphia.

There are not yet diagnostic criteria for muscle dysmorphia, but Kirk Brower, MD, an addiction psychiatrist at the University of Michigan in Ann Arbor who has worked with steroid-using patients who have muscle dysmorphia, suggests a list of questions for physicians to use during the patient workup (table 1). He also notes that physicians should do a complete physical exam and pertinent laboratory testing on these patients, particularly to note symptoms such as testicular shrinkage and to flag abnormal liver function tests. "These things all become part of the physical feedback to enhance motivation for change," Brower says.

TABLE 1. Suggested History Questions to Ask Patients Who May Have Muscle Dysmorphia

Why do you lift weights, and how many hours per week do you lift? Do you lift weights to enhance your appearance?

Have you given up other activities to spend more time lifting weights?

Do you think of yourself as being small? Do you spend 30 minutes or more per day thinking about this? Do you avoid social situations because of these thoughts?

Do you use nutritional supplements or drugs to enhance your appearance? Have you ever used or thought about using anabolic steroids?

Have you felt sad or blue for more than 2 weeks in the past 6 months? Do you have problems with sleep or appetite? (brief screen for other psychiatric conditions)

How much do you want to weigh? (an unhealthy weight or a big difference from current weight is a red flag)

Treatment Steps

Olivardia says the first step in treating a patient who has muscle dysmorphia is to address concomitant psychiatric conditions that may be present—namely a mood, anxiety, or eating disorder. "Antidepressants, especially the ones that address obsessive-compulsiveness, have been wonderful," he says. "They don't eliminate the condition, but they enable the patient to engage in other parts of treatment."

Referral to a psychiatrist is often warranted, particularly if steroid use is involved or if the patient has other psychiatric problems. Olivardia suggests that physicians seek out therapists who specialize in treating patients who have eating disorders or body-image problems. "It should also be someone who is in tune with men's issues," he says.

Brower says it can be difficult to engage patients in therapy, particularly if the patient suspects that the physician will address steroid use immediately. "Often, patients with this disorder are sizing everyone else up, so there may be some competitiveness with the therapist," he says.

Though physicians may want to ease slowly into addressing steroid use with patients, the physician's honest view of the behavior must be aired, Brower says. "Anabolic steroids are part of the problem, and patients need to know that it's difficult to move on and meet life's goals while continuing to use." A detailed drug history can help physicians assess whether the patient has the motivation to change.

Progress during the body-image part of therapy will be difficult if the patient is still using steroids or other drugs, Brower says. Easing patients off steroids involves having them work through the pros and cons of using the drugs. "They usually see the down sides, but the 'drugs are bad for you' message doesn't work," he says.

Psychotherapy for muscle dysmorphia involves correcting the patient's body-image distortions by building the patient's capacity for social relationships and intimacy. "Through the eyes of trusted individuals and friends they become aware of true body perceptions," Brower says.

Beefed-Up Consciousness

Men who have muscle dysmorphia are extremely reluctant to seek help from physicians. "Some patients see this as an assault on their masculinity," says Olivardia, alluding to similarities to women's appearance concerns and eating disorders. "Physicians need to recognize this—like being aware of clues for eating disorders in men," he says.

The public spotlight that has come with the publication of The Adonis Complex seems to have created a cultural context for men to come forward and seek treatment for muscle dysmorphia, says Olivardia. "There's an incredible relief and validation in the letters I've gotten from people who've read the book, similar to what happened with men and depression years ago" he says.

Lisa Schnirring


  1. Pope HG Jr, Olivardia R, Gruber A, et al: Evolving ideals of male body image as seen through action toys. Int J Eat Disord 1999;26(1):65-72
  2. Pope HG Jr, Gruber AJ, Mangweth B, et al: Body image perception among men in three countries. Am J Psychiatry 2000;157(8):1297-1301
  3. Pope HG Jr, Phillips KA, Olivardia R: The Adonis Complex: The Secret Crisis of Male Body Obsession. New York City, The Free Press, 2000
  4. Pope HG Jr, Gruber AJ, Choi P, et al: Muscle dysmorphia: an underrecognized form of body dysmorphic disorder. Psychosomatics 1997;38(6):548-557
  5. Olivardia R, Pope HG Jr, Hudson JI: Muscle dysmorphia in male weightlifters: a case-control study. Am J Psychiatry 2000;157(8):1291-1296

Field Notes

Counting Fat Grams Is Passé
The American Heart Association (AHA), in new dietary guidelines published in the October 31 issue of Circulation, downplays the need to calculate fat gram totals and other nutrition components. Instead, the AHA encourages Americans to focus more on replacing high-fat foods with fruits, vegetables, grains, fat-free and low-fat dairy products, fish, poultry, and lean meat.

Ronald M. Krauss, MD, principal author of the guidelines and a senior scientist at the Lawrence Berkeley National Laboratory at the University of California at Berkeley, said in an AHA press release that Americans still need to limit saturated fats and cholesterol, which is easier with a positive message about what people should eat. "When people eat out, it's hard to think about what percentage of the dinner comes from saturated fat," he says. "It's much easier to think about the various food groups."

Other new components of the AHA guidelines, which are based on 205 referenced studies, are a focus on obesity prevention and the addition of two weekly servings of fish such as tuna or salmon that is high in omega-3 fatty acids. Unchanged are previous recommendations about salt and cholesterol intake.

The guidelines offer specific recommendations for patients who have hypertension, hypercholesterolemia, diabetes, insulin resistance, high triglycerides, congestive heart failure, kidney disease, or obesity. The scientific statement on the AHA nutrition guidelines is available online at A patient- oriented version of the guidelines is available online at

College Football's Norwalk-On Virus
A case report in the October 26 issue of The New England Journal of Medicine describes what appears to be the first known case of Norwalk-like virus in a sports setting.

The incident involved a Saturday evening college football game 2 years ago in which Duke University players developed vomiting and diarrhea during the game and continued to play. The team physician and coaches had noted that players had been retching on the sidelines and in the locker room, and that some players' uniforms were soiled with vomit and feces. By Sunday evening, some of their Florida State opponents (who won the game 62 to 13), developed similar gastrointestinal symptoms.

Serologic data suggested that the likely source was turkey sandwiches that were contaminated by an infected food handler. They also confirmed that the relatively rare genogroup 1 Norwalk-like virus was responsible for the illness; genogroup 2 strains are more frequently associated with outbreaks in the United States. RNA sequencing determined that the same virus infected the Florida State players.

Researchers recommend that players with acute gastroenteritis symptoms be held from competition to avoid disease transmission to other players, and that players and support staff should be educated about proper hygiene measures, such as hand washing.

Ideal Builds for Certain Sports?
In a historical and entertaining look at physiology research, Lincoln E. Ford, MD, a physiologist and cardiologist at the Indiana University School of Medicine in Indianapolis, observes that there are ideal body sizes for some sports. However, in his review of data from elite athletes, he found that training and other factors can overcome a size disadvantage.

Ford's observations were published in September in a book titled Muscle Physiology and Cardiac Function, which was released to coincide with the American Physiological Society meeting and the 2000 Olympic Games. He found that certain body types favored certain sports, for example:

  • Shorter stature: boxing, gymnastics, football running backs, sprinting, long-distance running.
  • Taller stature: middle-distance running, weight lifting, high jumping.

Soccer is one sport that doesn't seem to have a body-size advantage, Ford notes, which might make it attractive to anyone who wishes to participate.

Calcium Supplements: Get the Lead Out
The lead content of calcium supplements has been an issue since 1980 when a US Food and Drug Administration report aired concerns. University of Florida researchers, in an effort to see if manufacturers have made strides to reduce the lead content, found that many calcium supplements still contain lead.

The report, published in the September 20 issue of The Journal of the American Medical Association, found that of 21 nonprescription supplements tested, 8 had measurable lead content. Lead was found in natural (oyster shell) calcium supplements, as well as in those from refined sources. Some brand-name products had detectable lead, even those from refined sources. Two prescription formulations contained no lead. Two formulations advertised as tested for lead did not contain lead.

The authors note that lead in calcium supplements is an important concern because an estimated 5% of the US population consumes the supplements. They advise consumers to not assume that brand-name supplements have no lead content, and to seek out brands that have been labeled as having been tested for lead.