‘Bigorexia’ is on the rise—How can physicians help?

Inside most gyms, amid the din of churning cardio equipment, clanging of weights, and smell of sweat, you’ll sense the undeniable positive energy that stems from people trying to better themselves. But for some—particularly young men—the gym also has a dark side.

Fueled by popular culture, the market economy, and social media, increasing numbers of young men are presenting with muscle dysmorphia, a body dysmorphic disorder known colloquially as “bigorexia.” The disorder has risen to such prominence that the New York Times highlighted the issue in a March 2022 article.

For young men with muscle dysmorphia, no amount of reps, personal records broken, or quantity of protein consumed is enough to abate feelings that they’re too weak, too small, or carry too much body fat. This disorder—and the societal implications that gave rise to it—present challenges for clinicians.

MDLinx interviewed a prominent researcher on this problem to discuss possible approaches for physicians.

Looking beneath the surface

Appearances can be deceiving, said Tom Hildebrandt, PsyD, a faculty member and professor at Mount Sinai whose research covers clinical interventions for adolescents and adults with eating and weight disorders.

An adolescent’s investment in diet and exercise could belie an unhealthy relationship with their body if their thoughts and behaviors on those subjects become intrusive and disruptive, Hildebrandt explained. One need look no further than an iron-pumping legend.

“When I look in the mirror, I throw up,” Arnold Schwarzenegger said in 2016. “I’d look in the mirror after I won one Mr. Olympia after another and think, ‘How did this pile of s— win? … I never saw perfection; there was always something lacking.”

This leaves young boys vulnerable, Hildebrandt said: “If you take that temperament and you apply it to tax law, you become a great tax lawyer. If you apply it to control of your shape, weight, or pursuing Mr. Olympia, it can have a much different kind of impact on your sense of self-worth.”

Understanding muscle dysmorphia

The DSM-5 classification defines muscle dysmorphia as a body dysmorphic disorder falling in the class of obsessive-compulsive and related disorders.^[]

“With muscle dysmorphia: The individual is preoccupied with the idea that his or her body build is too small or insufficiently muscular,” the classification report stated. “This specifier is used even if the individual is preoccupied with other body areas, which is often the case.”

According to Hildebrandt, people with muscle dysmorphia have a preoccupation with aspects of appearance, muscularity, symmetry, or body composition, causing distress. Research indicates this is common among young men.

In a 2019 study published in the California Journal of Health Promotion, researchers assessed a group of 149 young men between ages 11 and 18 for their attitudes toward eating and weight control practices as well as body weight and shape.^[] They also administered the Muscle Dysmorphia Inventory (MDI).

Among this group, 4% were classified underweight, 58.4% had a healthy weight, 15.4% were overweight, and 22.1% were obese. Among those with a healthy BMI, 24.1% were dissatisfied with the shape of their bodies. Nearly 30% of athletes in the group were dissatisfied with their weight, compared with 21.6% of non-athletes.

A 2021 Perspectives in Psychiatric Care article identified predictive factors of muscle dysmorphia.^[] The study involved 384 male bodybuilders, all 18 years or older. Researchers found that 5.7% were at risk for muscle dysmorphia.

Those aged 27 years or younger, and those who consumed protein powder, had higher MDI scores. Findings also established a positive link between muscle dysmorphia and social physique anxiety.

So why is muscle dysmorphia in young men apparently becoming more prominent?

Why this study matters

Hildebrandt cautioned that while there currently is no research on the number of young men with muscle dysmorphia, anecdotally there appears to be more young men presenting for care. Although the New York Times article highlights how social media is to blame, Hildebrandt said the explanation’s more nuanced.

According to Hildebrandt, gym culture, spurred by the Pumping Iron film and other elements, began to seep into the mainstream in the late ‘70s. Along with it, the market economy offered products to support muscle-building, as well as hyper-masculine images and ads.

By its nature, said Hildebrandt, social media could be harmful to those vulnerable to the disorder.

“Social media is a huge social-comparison engine,” he remarked. “It’s often very focused on specific things like something in gym culture, or appearance. And so that engine, if you’re vulnerable and you don’t have resilience against it, can really be problematic.”

What should physicians do?

Along with not taking traditional physical health markers at face value, Hildebrandt suggested that doctors suspecting muscle dysmorphia ask patients two questions:

• What motivates you to do this?

• Is it causing any distress?

If a physician suspects muscle dysmorphia based on the answers, Hildebrandt advises assessing the patient for the use of appearance- and performance-enhancing drugs. From there, specialty care such as cognitive behavioral therapy may be indicated.

Ultimately, though, it’s patient-provider trust that will direct patients with muscle dysmorphia toward help.

“I think it really takes an extra set of questions, and a feeling of trust that you’re not going to be judged, to open up about it," Hildebrandt added.