Recognizing and Treating “Bigorexia” in Clinical Practice

Body dysmorphic disorder (BDD) “consists of a distressing or impairing preoccupation with imagined or slight defects in appearance.”¹ Muscle dysmorphia (MD) is “a condition underpinned by people’s beliefs that they have insufficient muscularity.”² The condition has been increasing in both public and professional awareness, beginning with the late 1980s and early 1990s, when several studies and books drew attention not only to the disorder but to its potential deleterious impact on the health and lives of those who suffer from it.² In particular, the work of Pope et al has spurred research and placed the disorder on the map.^3,4  

MD (sometimes referred to as “reverse” or “big” anorexia, colloquially called “bigorexia”) is on the rise, according to Jason Nagata, MD, MSc, assistant professor of pediatrics in the division of Adolescent and Young Adult Medicine at the University of California, San Francisco. Dr Nagata is also the editor of the recently published book Eating Disorders in Boys and Men.

“During the COVID-19 pandemic, we’ve seen an explosion of eating disorders and body dysmorphia, with more awareness being brought to these issues,” Dr Nagata said.

An Australian study of 3618 adolescents (aged 11-19 years) found an MD prevalence of 2.2% in boys and 1.4% in girls.⁵ Boys with MD were more likely than girls with MD to report severe preoccupation with muscularity and engage in weight-lifting regiments that interfered with their lives, while girls were more likely to report discomfort with body exposure.⁵

According to a report by the British Broadcasting Corporation, as much as 10% of male gym members in the UK (roughly 427,000 individuals) may have MD.⁶ A study of 1320 service members in the military found a prevalence rate of BDD of 13% in males and 21.7% in females; however, the prevalence of MD was 12.7% in males and only 4.2% in females.⁷ And a study of close to 15,000 adolescents found that 22% reported engaging in muscle-enhancing behavior, such as excess exercise, taking supplements or steroids, and engaging in muscularity-disordered eating behaviors.⁸

The Story of “John”

“John W” is a 19-year-old college freshman. During his junior year of high school, his parents went through a divorce and his mother moved with him to a different city, where he felt insecure about how to get along with the kids in his new school. He regarded football as an “in” to making new friends, but even on the football team, there were “cliques” of teammates who had known each other since kindergarten. He felt like an “outsider” and never built up the sense of camaraderie he had with his teammates at his old school.

He was accepted into college on a football scholarship, but midway through senior year, the COVID-19 pandemic started, with the resulting lockdown. John spent the remainder of his senior year watching TikTok and YouTube videos of football players and doing at-home body-building exercises to keep himself in shape and “get more ripped.” When college began, there was a “hybrid” model with some online classes and some in-person activities, and then became fully in-person. Once he settled into full-time campus life, John’s life began to revolve around his football activities.

Since college has begun, John has become even more dedicated to improving not only his sport but also his appearance and musculature, believing that he is too puny to succeed in such a competitive athletic environment. There is no real basis to this perception, as John’s muscles are toned and well developed. But he has started to restrict his diet, consuming mostly proteins and curbing his fat and carbohydrate intake. His coach and teammates praise his dedication.

Increasingly driven, John begins to spend more time at the gym. Beyond football practice, he is working out 3 hours daily. He begins cutting classes and missing out on social activities. He avoids looking in mirrors because he doesn’t like his appearance. Beyond team practice, he has become socially isolated. His grades are falling but he doesn’t want to take the time to “just sit around” and do homework because it will detract from the time he “should” be exercising. He continually thinks about his appearance, what he will eat, what supplements he will take, and when he thinks about anything else, he feels guilty. On the advice of a friend on the football team, he begins taking performance-enhancing drugs.

What Drives MD?

MD is included in the Diagnostic and Statistical Manual of Mental Disorders fifth edition (DSM-5) as a variant of body dysmorphic disorder, under the obsessive-compulsive disorder (OCD) category.⁹ (Table 1) The patient’s preoccupation with not being sufficiently muscular can take several different forms. (Table 2)

Table 1

DSM-5 Diagnostic Criteria for Body Dysmorphic Disorder

Disorder Class: Obsessive-Compulsive and Related Disorders   · Preoccupation with 1 or more perceived defects or flaws in physical appearance that are not observable or appear slight to others. · At some point during the course of the disorder, the individual had performed repetitive behaviors or mental acts in response to the appearance concerns · The preoccupation causes clinically significant distress or impairment in social, occupational, or other areas of functioning · The appearance preoccupation is not better explained by concerns with body fat or weight in an individual whose symptoms meet the criteria for an eating disorder   Specify if: · With muscle dysmorphia: the individual is preoccupied with the idea that his or her body build is too small or insufficiently muscular. This specifier is used, even if the individual is preoccupied with other body areas (which is often the case) · Indicate the degree of insight regarding body dysmorphic disorder belief (eg, “I look ugly” or “I look deformed”) · With poor insight: the individual thinks that the body dysmorphia beliefs are probably true  · With absent insight/delusional beliefs: the individual is completely convinced that the body dysmorphic beliefs are true

Table 2

Behaviors Associated with MD

Type of Behavior	Examples
· “Fixing” — ie, behaviors designed to contribute to attaining the desired appearance	· Excessive weightlifting, muscle-building exercises    · Protein-loaded diet · Supplement use
· Camouflaging/avoidance	· Wearing baggy clothing
· Reassurance seeking	· “Do my arms look big?”
· Checking	· Mirror examinations · “Flexing” behaviors

During the past decade, even before the pandemic, “a lot of attention has been given to social media and how it affects girls and women, but studies have also shown impacts on boys and men,” Dr Nagata said. It is known that both Facebook and Instagram had conducted research¹⁰ and had data on how these platforms can affect teenagers, and initial findings show that these teenagers were feeling worse about their bodies and were even at higher risk for suicide.

Muscularity has become a “significant indicator of masculinity” for today’s males.¹¹ Several studies have shown that the pressure to become more muscular starts at increasingly younger ages, especially in boys. Children’s toy action figures have become more muscular,¹² sending a message to children that this is how the “ideal male” should look, according to Dr Nagata.

“With the rising use of social media, there are more opportunities for young men to become ‘influencers’ and get ‘likes’ by putting their bodies on display. Young men often compare themselves to influencers on social media and find themselves lacking,” Dr Nagata observed. And social media’s algorithms are responsible for sending ads for fitness-related products, such as protein supplements or bodybuilding equipment to people who have watched or “liked” fitness posts, which present a steady stream of messages about how young men “should” look and what they can do to make that happen.

The increased use of Zoom and similar platforms means that people are frequently looking at images of themselves, becoming increasingly self-critical of their appearance, and feeling driven to change it — a phenomenon that is sometimes called “Zoom dysmorphia.”^13,14  

“The pandemic, coupled with the increased use of social media, has created a set of circumstances that have increased the problem of body image issues in teenagers and young adults, but it has been less recognized in boys and young men,” Dr Nagata said.

Nagata’s research suggests that the use of protein powders and shakes as a way of building muscle often begins in adolescence.¹⁵ In fact, use of these products during teen years may lead to a 2- to 5-fold higher risk for new use of steroids and other muscle-building products in emerging adulthood.¹⁵

Although 20-21 years old was the age at which concerns about muscularity typically peak,¹⁶ “we are now seeking referrals of kids even before adolescence — children as young as 8 or 9 years old,” Dr Nagata reports.

Risk Factors and Comorbidities

Amy Gooding, PsyD, a clinical psychologist at the Eating Recovery Center, Baltimore in Hunt Valley, Maryland, specializes in treating athletes (typically of college age) within the program. She said that MD in males is “generally caused by a combination of factors.”

These include a genetic predisposition,^17,18 neurobiological factors (eg, white matter and structural connectivity abnormalities and disturbances in visual processes, such as visual perception and visuospatial information processing),¹⁷ and psychological factors, such as perfectionism.¹⁹ In addition, depression, anxiety, low self-esteem, negative early life experiences (like being bullied), and traumas (such as abuse) can raise the risk for BDD and MD.^8,20 “These are similar risk factors as for eating disorders,” Dr Gooding noted. Indeed, mood disorders, eating disorders, and nonmuscle BDD are common comorbidities.

A 2019 study looked at 149 young men (ages 11 to 18) and found that, among those with a healthy weight, almost a quarter (24.1%) were dissatisfied with the shape of their bodies. And almost a third (30%) of athletes were dissatisfied, compared with 21.6% of non-athletes.²¹ Another study of close to 400 male bodybuilders (aged ≥18 years) found that 5.7% were at risk for MD. The study found that participants <27 years of age and those who consumed protein powder were at greater risk for MD, based on their Muscle Dysmorphia Inventory (MDI) score.²²

There may also be racial and ethnic differences. Nagata and colleagues studied close to 16,000 high school students and found that 29.6% of the adolescent boys reported attempts to gain weight (including 39.6% who were normal weight, 12.85 who were overweight, and 10.6% who were obese, based on BMI). Black/African American and multiracial adolescent males had greater odds of weight gain attempts, compared with White adolescent males.^8,23 Being Black/African American was also associated with increased odds of muscularity-disordered eating behaviors.^8,23

Complications Associated with MD

“When a person is working out for many hours daily, even a ‘regular’ diet for a teenager can be insufficient, and there can be an energy deficit leading to malnutrition,” Dr Nagata said. “MD carries all the potential complications of an eating disorder and associated malnutrition because energy out is greater than energy in.” The patient’s heart rate and/or blood pressure can be “dangerously low” from malnutrition, and the patients often suffer from dehydration.

Dr Nagata said that the nature of the physical workup will depend on the symptoms and presentation. “We check their heart and usually do cardiac tests, such as electrocardiograms (ECGs). When the body goes into starvation, many organs can be affected, including the heart, liver, kidneys, and bones. There can be pubertal delays; and, depending on what drugs or supplements the patient is using, there can be harmful effects on the liver and kidneys, as well as other side effects. Dietary and muscle-building supplements, which are for the most part not FDA-regulated but purchased online or over-the-counter, are often mislabeled or tainted with illegal substances such as steroids.”

Dr Nagata noted that steroids also have an impact on mood, and can lead to aggression, irritability, and even violence. Patients may also be using anabolic-androgenic steroids, which are synthetic derivatives of testosterone demonstrated to build muscle tissue in human beings at a rate impossible to achieve with diet and exercise alone.²⁴

If MD Is Suspected

Clinicians of all specialties, as well as teachers, parents, and coaches should have muscle-building behaviors in children, adolescents, and emerging adults on their radar and be aware if a teen is starting to be preoccupied and worried about his appearance, weight, musculature, or engaging in concerning eating behaviors, Dr Nagata advised.

If any of these behaviors are present, a more formal workup and assessment should be conducted. To assess for the presence of MD, several questions might be useful. (Table 3)

Table 3

Questions to Ascertain if Muscle Dysmorphia May Be Present

Social avoidance	· How often have your relationships with others been affected by your exercise and diet regiment? · Do you have concerns about your appearance? If so, do they influence your school or career performance? · Do you miss out on opportunities to progress because of your self-consciousness? · Do you frequently miss school/work or avoid social activities because of your appearance concerns? · What measures do you take to avoid showing your body to others? · Do your concerns about your appearance affect your sex life?
Time	· What portion of each day do you spend grooming yourself? · How much time is spent daily on exercises with the specific intent of bettering your appearance rather than improving your performance in sport? · How much of your day is taken up with actively worrying about your appearance? · How frequently does your appearance make you feel distraught, depressed, or anxious?
Diet and other practices	· How commonly do you diet? · How commonly do you ingest certain foods (eg, low-fat, low-carb, or high-protein) or take supplements to enhance your appearance? · What portion of your salary or other income is devoted to items and practices to better your physical appearance? · Have you at any time taken a drug (lawful or not) to drop pounds or increase muscle mass? · Aside from drugs, have you pursued other methods of enhancing your appearance?

In addition, a number of scales have been developed. The Male Body Checking Questionnaire (MBCQ) is a male-specific questionnaire that particularly focuses on MD in males.²⁵ The Muscle Dysmorphia Disorder Inventory (MDDI) has been validated in men and women of various sexual orientations, including transgender men, and in a variety of populations and has been translated into several languages.^26,27 

Dr Gooding said that these patients can be treated in a variety of settings, both inpatient and outpatient, depending on their level of need — this might include a residential setting, a partial hospital day program, an intensive outpatient program, or a community-based setting.

Pharmacotherapy for MD

There is some limited evidence suggesting that antidepressant agents — particularly selective serotonin reuptake inhibitors (SSRIs) — may be beneficial in treating severe forms of MD, based on their success in treating other types of BDD. SSRIs might be able to reduce obsessional thinking and compulsive behaviors by increasing available concentrations of serotonin in the brain.²⁴ Antidepressants that have been investigated include citalopram, escitalopram, clomipramine, fluvoxamine, and fluoxetine.²⁴ SSRIs may be particularly helpful for patients whose impairment may be related to depressive symptoms derived from concerns about appearance.²⁴

If the patient has been using steroids, the patient might experience “postcycle blues” — a colloquial term for the hormonal fluctuation that can occur after steroid discontinuation.²⁴ Muscle mass may be quickly regained, and the patient may experience depression, anxiety, and lack of sex drive, even suicidality.²⁴ Symptoms of steroid cessation may last as long as a month but if they continue, an endocrinologist may need to be consulted.²⁴

Helpful Nonpharmacologic Interventions

Psychoeducation is the “number 1” intervention according to Dr Gooding. Psychoeducation and psychotherapy — particularly cognitive behavioral therapy (CBT) are the preferred treatment for MD/BDD, and psychoeducation is the first step in CBT.

There are several different types of CBT, including CBT for depression, CBT for anxiety, CBT-E for eating disorders, and CBT for OCD, Gooding said. Each is specialized for the disorder it is treating. In the case of MD, “we are treating an obsessive-compulsive disorder.” But “while MD is treated similar to how we treat OCDs, it is important to provide education on how to properly fuel the body, given that these patients have often restricted their eating in pursuit of the ‘ideal/perfect’ body.”

It is important to teach the patient about “signs of an unhealthy relationship with exercise,” similar to education about an unhealthy relationship with food. “We teach them how our thoughts are related to our behaviors, how they are automatic, and how they drive our behaviors. This helps them develop the understanding of how their disorder develops and maintains itself,” said Dr Gooding.

An important component of CBT for MD is “cognitive restructuring” of several “cognitive distortions” or unhelpful thinking patterns, Dr Gooding noted — in particular perceptions of masculinity (what the “perfect” or “ideal” man should look or act like); perfectionistic thinking (seeking a “perfect” or “ideal” body as a way of gaining importance and acceptance); and ego syntonic beliefs (eg, promuscularity and pro-exercise messages found online and in society at large).²⁴ 

Other core principles and techniques of CBT that are useful in treating MD include the technique of exposure and response prevention that “aims to help affected individuals practice tolerating distress without intervening with safety/ritual or escape behaviors” (ie, behaviors aimed to prevent a “feared catastrophe”) and aims to reduce “avoidance behaviors” (eg, only attending the gym late at night to avoid the shame of having other people see one’s body).⁴³

“In CBT, we address the maladaptive internal beliefs that are driving the unhealthy thoughts and behaviors, and we address the triggers to the person’s symptoms and teach them new ways to cope with those,” Dr Gooding said. “Triggers might be negative thoughts about themselves or others, intense emotions or previous trauma for those who have experienced it.”

Patients can learn how to block the obsessive behavior — in this case, the urge to exercise. “Patients can learn coping skills to block the urge to exercise. As an outpatient, the patient can learn how to identify their triggers, and cope with those. On higher levels of care, patients typically can’t exercise because there is no exercise equipment, and they learn how to ride out those urges, challenge their thoughts, and tolerate high levels of distress while they receive more intensive treatment,” Dr Gooding added.

Other therapies that might hold promise in treating MD include acceptance and commitment therapy (ACT) and dialectical behavior therapy (DBT).²⁴ Both have shown promise in people with EDs and some of the core principles that make them useful in that context may have applicability for MD as well.²⁴

Family-based treatment (FBT) is “one of the most widely advocated evidence-based treatments for adolescent anorexia nervosa” because it “centrally mobilizes parental resources to bring about nutritional rehabilitation in their child, ensuring complete cessation of all ecological and maintaining factor of the disorders, while siblings are encouraged to adopt a supportive stance.”²⁴ However, the feasibility of this approach in later adolescence or early adulthood, when individuals may no longer be living with family members, “needs to be further investigated.”²⁴

Establishing a New Relationship With Exercise

An important component of educating patients is teaching them to distinguish between healthy and unhealthy exercise, and allowing them to slowly return to healthy exercise, according to Dr Gooding. “You might compare this to a person with any other type of injury who wants to return to playing. “You don’t immediately return the person back to their sport because they might reinjure themselves.” You encourage a slow return and monitor their amount of exercise. A coach can be included in this protocol to watch the player and hopefully help him to return to an appropriate amount of exercise if possible.”

The Importance of Multidisciplinary Collaboration

“The general treatment approach consists of an interdisciplinary support team,” said Dr Nagata — a therapist for mental health, a medical provider to monitor medical complications, and a dietician or nutritionist to help with supporting the patient’s diet.

“Athletes presenting with excess exercise often don’t know that they can have huge energy deficits and experience a starvation state if they don’t keep up with nutrition,” he noted. They need help learning how to incorporate healthy eating patterns and balance them out with healthy exercise patterns.

It is also important to incorporate coaches and athletic trainers into the long-term plan, especially if the patient seeks to return to athletics, Dr Gooding added.

It might be helpful to refer families and youngsters to organizations for resources and support. While there are no organizations specifically devoted to MD, there are several organizations that might be helpful, including the National Eating Disorder Association (NEDA) and the Body Dysmorphic Disorder Foundation (BDDF).  

The Story of “John” (continued)

John collapsed during football practice and was brought to the student health service. The nurse practitioner found his heart rate and blood pressure to be “alarmingly low” and recommended that he go to the emergency department. Laboratory testing revealed abnormalities in kidney function as well. He was admitted to the hospital and, once medically stabilized, he was transferred to the adolescent eating disorders unit. John remained an inpatient for a week, receiving treatment with an SSRI as well as participating in individual and group psychoeducation and CBT-based psychotherapy. He then entered the partial hospital program and continued his pharmacologic and psychotherapeutic program. During this time, he took a temporary leave from college, but his goal was to return to college and rejoin the football team.

His therapist, in coordination with the coach, devised a plan that included an optimal amount of exercise that he could not exceed. He also worked with a nutritionist to develop a healthy eating plan. Eventually, he returned to college and was able to rejoin the team. He also began to expand his interests and horizons, making friends with students who were not on the team and developing a more varied social life.

Resources

Eating Disorders in Boys and Men

https://www.nationaleatingdisorders.org

https://bddfoundation.org

www.eatingrecoverycenter.com

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