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Recognizing the Signs of Body Dysmorphic Disorder and Muscle Dysmorphia

Graves, B Sue Ed.D., FACSM; Welsh, Raymond L. Ph.D.


Learning Objective To gain a better understanding of body dysmorphic disorder and muscle dysmorphia as both relate to exercise behaviors.

Health/fitness professionals should be aware of BDD and MD and offer assistance to clients displaying the symptoms.

Sue Graves, Ed.D., FACSM, is an associate professor in the Department of Exercise Science and Health Promotion at Florida Atlantic University where her research focuses on professional preparation and exercise and the older adult.

Raymond L. Welsh, Ph.D., recently retired from the position of professor in the Department of Exercise Science and Health Promotion at Florida Atlantic University where his research was focused on future issues of the health/fitness profession.

Are some individuals exercising obsessively to achieve an “ideal” body? Do such individuals possess false images of their bodies? Can obsessive exercise behaviors be a symptom of an underlying mental disorder? Are health/fitness professionals encouraging excessive exercise behaviors? Unfortunately, the answer to all these questions may be yes.

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Body Dysmorphic Disorder

A growing concern within the mental health field is that many of today’s excessive exercisers could have body dysmorphic disorder (BDD). In 1997, the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) recognized body dysmorphic disorder as an unhealthy preoccupation with one’s physical appearance or body image. Individuals diagnosed with BDD have such an unrelenting preoccupation with body image that it disrupts work, social, and/or other areas of daily living (1). Many with BDD tend to be preoccupied with the face, hair, and skin, but any body part can become the focus of the disorder. Muscle, muscle mass, body symmetry, and stature are common preoccupations with some body dysmorphics. Incessant grooming, constant glances into the mirror, camouflaging use of clothes or makeup, along with other non-productive behaviors are symptomatic of BDD. Obsessive exercise is a common strategy used by BDD sufferers to ameliorate their real or imagined physical flaws. Research dealing with BDD suggests that obsessive-compulsive disorder, social anxiety, and depression are part of the clinical picture of BDD. Suicidal thinking is a not uncommon consequence of BDD (2).



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Muscle Dysmorphia

While not yet officially recognized within the mental health field, “Muscle Dysmorphia” (MD), a form of BDD that occurs almost exclusively in men, has been described as an unhealthy preoccupation with body size and muscularity (3). Individuals with MD obsess over their perceived underdevelopment, just the opposite of the anorexia nervosa sufferer. Compulsive weight lifting or resistance training, even in those with well-developed musculature, becomes the central focus of life for those suffering with MD. Exercising through injury and a tendency toward steroidal use is common in those with MD. Like BDD, those who suffer from MD have an unhealthy preoccupation with body image to the extent that relationships, work, school, and other activities of daily living are negatively affected (4). Psychotherapy and the use of psychopharmacological agents are the preferred treatments for BDD and MD sufferers (5).



The underlying cause(s) of MD and BDD remain unknown. Like many disorders, the cause(s) are likely multi-factorial. Perhaps there is a genetic component, but early life experiences, combined with the incessant idealization of the “perfect body” pictured daily in our electronic and print media, and unconsciously reinforced in many of our spas and fitness centers, could be part of the etiology of BDD and MD. A recent study reported the percentage of American men dissatisfied with their physical appearance was 43, a three-fold increase from 25 years ago (3,5). Discovering the reasons for this secular trend with respect to body image would be interesting. For more information on BDD and MD refer to the annotated bibliography in the appendices of this article.

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The Health/Fitness Professional and BDD and MD

Since BDD and MD sufferers tend to use exercise inappropriately to ameliorate their real or imagined physical defect, the likelihood of such individuals coming into contact with a health/fitness professional is high. As such, health/fitness professionals need to be aware of the existence of these diseases and offer assistance to clients when it seems appropriate.

For example, it has always been deemed appropriate to offer constructive advice to a client, if, in the best judgment of the health/fitness professional, the exercise program or regimen of a client is too strenuous or otherwise contraindicated. In like manner, advising clients about questionable diets and diet supplementation has become routine within the health/fitness profession. Thus, it is not too much of a stretch to ask the health/fitness professional to be aware and to be prepared to deal with the issue of obsessive exercise in clients who might suffer from BDD or MD. Suggestions to assist the professional in this task are:

  • Get to know your clients. A good place to begin is to obtain a personal statement about the client’s health/fitness goals and prior exercise history.
  • Maintain accurate logs of client exercise sessions.
  • Discuss progress toward achieving client fitness goals frequently.
  • Display reminders about constructive, health-enhancing exercise.
  • Counsel client when instances of excessive exercise are observed.
  • Place brochures about BDD and MD in convenient locations.
  • Maintain a list of licensed mental-health professional for purposes of referral.
  • Another helpful suggestion is to invite a local mental health expert to lecture from time to time at the spa, gymnasium, or other workout facility on the topic of BDD, MD, and obsessive exercise.
Table 1

Table 1

Beyond following the suggestions listed above, it is incumbent on the health/fitness professional to be a positive role model for health and the life enhancing aspects of exercise. It is important that the health/fitness professional exhibits the best of what exercise can offer–to demonstrate the joy and balance exercise can bring to an individual’s life. Over-selling the benefits of exercise, promoting unrealistic images of the human body, or under valuing those less fit, either consciously or unconsciously, exacerbates the incidences of BDD and MD in the vulnerable. Turning a blind eye to obsessive exercise behaviors also is not acceptable.

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Condensed Version and Bottom Line

Health and fitness professionals need to be aware of psychological disorders that may harm clients and fellow professionals. Two types are BDD and MD. BDD is a preoccupation with one’s physical appearance, while MD focuses on muscularity and symmetry. These behaviors are not the same as enthusiasm for bodybuilding. The professional can gain the knowledge necessary to provide proper guidance for diagnosis and/or treatment.

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1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: American Psychiatric Association Press, 1994.
2. Weinshenker, N.J. About body dysmorphic disorder. New York University Child Study Center: Accessed May 2, 2003.
3. Pope, HG, Phillips, KA, and Olivardia, R. The Adonis complex: the secret crisis of male body obsession. New York: Free Press, 2000.
4. Pope, HG, Gruber, AJ, Choi, P, Olivardia, R, and Phillips, KA. Muscle dysmorphia: an underrecognized form of body dysmorphia. Psychosomatics 38(6): 548-557, 1997.
5. Phillips, KA and Castle, DJ. Body dysmorphic disorder in men. British Medical Journal 323(7320):1015-1016, 2001.
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Reading Suggestions

Beckelman, L Body Blues. New York: Crestwood House, 1994. (Reading level, grades 9-12).
    Cantor, C, and B Fallon. Phantom Illness: Shattering the Myth of Hypochondria. Boston: Houghton-Mifflin, 1996.
      Phillips, K. The Broken Mirror: Understanding and Treating Body Dysmorphic. New York: Oxford University Press, 1996.
        Pope, H, K Phillips, and R Olivardia. The Adonis Complex: The Secret Crisis of Male Body Obsession. New York: The Free Press, 2000.
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          Recommended Web Sites

 Butler Hospital site has questions and other information regarding body dysmorphia.
   This Anorexia Nervosa and Related Disorders site discusses less well-known disorders, such as body dysmorphia and muscle dysmorphia.
     The National Eating Disorders Association and American Anorexia/Bulimia Association collectively cover eating disorders and image information.
       Council on Size and Weight Discrimination provides information for the larger individual. Has a section for body image and children.

                  Muscle Dysmorphia; Body Dysmorphia; Clients; Obsessive Exercise; Constructive Advice

                  © 2004 American College of Sports Medicine