Muscle dysmorphia refers to a condition in which individuals are preoccupied with the belief they are insufficiently large and muscular, and they may be obsessed with weightlifting, dieting, and other activities aimed at increasing size and definition (21). Case reports and research reveal that these individuals also experience anxiety about having their bodies viewed by others, experience impaired occupational and social functioning, and participate in risky health behaviors, such as physique-enhancing drugs (4). The investigations conducted so far have contributed to knowledge about the types of symptoms associated with the condition and what life is like for individuals experiencing muscle dysmorphia (10,15,29). To date, most research on muscle dysmorphia has treated the condition as a somewhat stable characteristic within a trait-like framework. There is an absence of research examining daily variation of muscle dysmorphia symptoms and the events and contexts that might influence the condition in susceptible individuals.
Within the broader area of body image, investigators have begun to examine intraindividual variability (17,25). For example, greater variation in body image states has been correlated with appearance investment, body image cognitive distortion, and higher self-presentation perfectionism (25). Given that muscle dysmorphia is a body-image disturbance (24), it is possible that symptoms associated with the condition may also have state-like properties that vary on a daily basis in response to intraindividual, interpersonal, and environmental changes. A weight training session is one such event that varies (e.g., people have training days and rest days) and may influence muscle dysmorphia symptoms.
The purpose of the current study was to examine the influence of a weight training session on muscle dysmorphia symptoms in individuals who might be susceptible to the condition. Previous research has indicated that young men with some degree of commitment to weight training may be one group of individuals susceptible to developing muscle dysmorphia. There is evidence, for example, that the onset of the condition may occur around the age of 20, and individuals often participate in weight lifting and other strength sports (19). When engaged in weight lifting activities, individuals are exposed to stereotypes about the muscular ideal male physique through mediums such as muscle-related magazines, supplementation advertising, posters of current sporting heroes, and interactions with other trainers. There is considerable evidence that exposure to the ideal muscular physique contributes to body image disturbance in men (3), and has been proposed as one contributing factor to muscle dysmorphia (13).
Muscle dysmorphia and other body-image disturbances are conditions that strength and conditioning specialists and athletic trainers come across in their professional lives (14). Research on the state-like properties of the condition and the events that lead to daily variation in the symptoms among susceptible individuals may contribute to helping strength and conditioning specialists and athletic trainers being able to identify at-risk individuals and assisting these people in locating suitable help. Also, to date, there have been few studies focused on possible treatments or the degree to which muscle dysmorphia might be influenced by prevention attempts. For example, there are no randomized controlled trials examining muscle dysmorphia intervention or prevention programs. These types of studies are typically expensive and time consuming. Research in which the state-like properties of the condition are examined and the degree to which muscle dysmorphia symptoms may be influenced by daily events could provide direction regarding the likelihood that prevention and intervention programs may be successful. Such research might contribute one strand of evidence toward the justification of randomized treatment trials for muscle dysmorphia. The specific aim of the current study was to examine the influence of a weight training session on muscle dysmorphia symptoms in young men who regularly participate in the activity. The specific symptoms assessed included the extent to which individuals (a) focused on becoming bigger and gaining muscle (drive for size), (b) were unhappy with their appearance (appearance intolerance), and (c) experienced negative emotions when deviating from workout and diet regimens, and the exclusion of social, occupational, and recreational activities because of adherence to training or diet regimens (functional impairment ). It was hypothesized that after a weight training session, individuals would report lower drive for size, appearance intolerance, and functional impairment compared with their reports on a rest day.
Experimental Approach to the Problem
The effects of a weight training session on muscle dysmorphia symptoms were examined using a within-subjects crossover repeated measures design. A rest day was used as the control condition. Testing involved subjects completing a muscle dysmorphia questionnaire on 2 occasions: once on a training day and once on a rest day. A crossover design was employed to avoid any training day-order effects that may have influenced subjects' responses on the questionnaire.
After the investigators had obtained approval from the institutional ethics committee, men (n = 30) signed informed consent forms before their participation in the study. Subjects had a mean age of 20.93 years (SD = 2.60), weight of 86.87 kg (SD = 10.59), and height of 1.76 m (SD = 0.01). They had been involved in weight training for 3.57 years (SD = 2.53) and trained 4.0 (SD = 1.0) times per week. Regarding competitive sports participation, 24 subjects played rugby union, 2 played soccer, 1 was a cyclist, 1 was a boxer, and 1 was a bodybuilder. The remaining subject did not participate in any competitive sport. Regarding supplementation, 97% were currently taking some form of dietary supplement, with protein being the most common (and was being taken by 79% of the sample). In addition, 13% admitted to using anabolic steroids.
Subjects completed the Muscle Dysmorphic Disorder Inventory (MDDI [9,10]) on 2 occasions. The MDDI is a self-report questionnaire, derived from published proposed muscle dysmorphia diagnostic criteria (21), that measures 3 subscales (drive for size, appearance intolerance, and functional impairment) along the cognitive, emotional, and behavioral body image disturbance dimensions (10). The drive for size subscale measures the frequency of thoughts and desires to be more muscular and represents the muscle dysmorphia criteria of preoccupation with muscularity. The appearance intolerance subscale measures negative beliefs and the anxiety associated with an individual's body and appearance, and is associated with the muscle dysmorphia distress and avoidance criteria. The functional impairment subscale measures the negative emotions associated with workout and diet regimen deviation, and the exclusion of social, occupational, and recreational activities because of adherence to training or diet regimens. The functional impairment subscale mirrors the muscle dysmorphia impairment criteria. In the current study, the phrase “right now” was added to the questionnaire instruction preceding the items to read: “For each question, select the option that most closely describes how the statement applies to you right now.” The change was designed to capture how each item applied to the subject at that moment in time and is in keeping with other state questionnaires used in sport and exercise contexts (e.g. ). Evidence exists for the validity and reliability of the MDDI (9,10). In the current study, Cronbach's alphas were calculated to assess the subscales' reliability. On the rest day, the alphas were 0.89 (drive for size), 0.78 (appearance intolerance), and 0.91 (functional impairment). On the training day, the alphas were 0.81 (drive for size), 0.70 (appearance intolerance), and 0.88 (functional impairment). The Cronbach's alphas attested to the questionnaire's internal reliability and were sufficiently high to allow data analyses to proceed (6).
When providing written informed consent, subjects also completed a demographic questionnaire designed to collect information regarding age, self-reported weight and height, supplementation use, training history, and current training practices. These data were used to help describe the sample.
Investigators invited subjects to participate on an individual basis after having explained the study's purpose, risks, and safeguards. Data collection occurred over 2 days, and subjects were randomly allocated to 1 of 2 groups. Each group consisted of 15 subjects. On day 1, the subjects from group 1 completed the MDDI immediately after a weight training session, and those in group 2 completed the questionnaire on a rest day at the approximate time that would correspond with the end of their normal training routine. A crossover design was used, and on day 2, the subjects in group 2 completed the MDDI immediately after training, and those in group 1 completed the questionnaire on a rest day at the approximate time that would correspond with the end of their normal training routine. A crossover design was employed to avoid any order effect that may have arisen from having the same order of days for each subject. At the completion of the study, subjects were debriefed.
Data checks and analyses were undertaken in accordance with Field (7). The data were found to be normally distributed, and no outliers were identified. In addition, the homogeneity of variance assumption had not been violated. The Cronbach's alphas were reported above and attested to each subscale's internal reliability (6). At the group level, paired t-tests were used for the main analyses (alpha was set at 0.05), and Cohen's effect sizes (d) for dependent means were calculated to help assess the magnitude of the intervention effects. At the individual level, difference scores were calculated for each questionnaire subscale for each subject. Difference scores were calculated by subtracting the rest day score from the training day score.
Table 1 presents the means and SDs for the subscales across the rest and training days. The mean drive for size score was significantly higher on a rest day than on a training day (t = 5.66, p = 0.001) and d = 1.03, indicating a large effect. The mean score for appearance intolerance was significantly higher on a rest day compared with on a training day (t = 3.80, p = 0.001) and d = 0.69, indicating a moderate to large effect. The mean score for functional impairment was significantly higher on a rest day than on a training day (t = 2.19, p = 0.037) and d = 0.40, indicating a small to moderate effect.
Figure 1 presents subjects' difference scores for each subscale between their total on a training day and a rest day. Regarding drive for size, 80% of subjects reported a decrease from the rest to training day, 10% reported no change, and 10% reported an increase. Regarding appearance intolerance, 57% of subjects reported a decrease from the rest to training day, 30% reported no change, and 13% reported an increase. Regarding functional impairment, 57% of subjects reported a decrease from the rest to training day, 23% reported no change, and 20% reported an increase.
Table 2 presents the averages and SDs across each subscale for those individuals who reported either a drop or an increase in subscale score from the rest day to training day. These results were not subjected to paired t-tests because such procedures would likely have been underpowered because of the small number of subjects reporting increases. The trend, however, was that subjects who experienced a drop in score from rest to training day typically reported higher symptom severity.
The aim of the current study was to examine the influence of a weight training session on muscle dysmorphia symptoms in young men. Results supported the hypothesis and indicated that drive for size, appearance intolerance, and functional impairment were significantly lower after a weight training session compared with on a rest day. Examining the magnitude of the effects, as measured by Cohen's d, it seemed that weight training had the greatest influence on drive for size, followed by appearance intolerance, and then functional impairment. Perhaps, the order may be understandable given the acute consequences of resistance training. Many strength trainers talk about “the pump” in which during training fluid enters the muscle and increases its size, and this adjustment lasts for a short period of time after a session. Potentially, drive for size had the greatest reduction because of the short-term increase in size after training when subjects completed the questionnaire. In addition, the short-term increase in size may have temporarily led to individuals having a body shape that more closely resembled the ideal physique and underpinned their drop in appearance intolerance. Finally, it might be expected that there would be a drop in functional impairment because just completing a training session may have lessened any concerns subjects had about their adherence to their weight training program.
The results on an individual basis corroborate the group analysis. For each subscale, the majority of subjects reported lower scores after a weight training session compared with a rest day. The drive for size subscale had the largest proportion of subjects with lower scores, followed by appearance intolerance and functional impairment. These results reveal individual variation in response to a similar stimuli, a feature associated with psychological research (1). One possible individual difference that could explain the results was symptom severity. Subjects who experienced a drop from rest to training day typically reported higher symptom severity compared with those who had an increase. Inferential statistics were not undertaken on these difference scores, because given the small number of people reporting an increase any tests would have likely been underpowered. The hypothesis that symptom severity was a relevant individual difference needs further testing. Another individual difference variable that investigators might consider examining is subjects' reasons or motives for weight training. Individuals, for example, who train for different reasons (e.g., appearance, health, or sport performance), might report different changes in their muscle dysmorphia symptom severity after training.
Regarding symptom severity, currently, cut-off scores do not exist on any muscle dysmorphia measure by which individuals may be classified as having muscle dysmorphia. Diagnosis is currently achieved through clinical judgment. In comparison with previous research (8-10), however, the current subjects reported high scores on each of the 3 subscales, particularly on the rest day, indicating greater than normal symptom severity. The current subjects were similar to groups Hildebrandt et al. (10) labeled as “muscle dysmorphic” and “muscularity concerned.” Comparing the current data with previous research provides evidence that the subjects in this study had substantial concerns about their muscularity levels. Based on existing research, it is from the type of individual examined in this study that people with full-blown muscle dysmorphia are likely to emerge, and these were the subjects on which we wanted to focus-those susceptible to the condition.
The weight training session consisted of the subjects' normal training programs. We wanted to find out if what subjects did as part of their normal training regimes influenced muscle dysmorphia symptoms. Having established that a weight training session can influence muscle dysmorphia symptoms, a potentially fruitful line of inquiry has opened up, and investigators have some justification for the process of identifying specific variables that mediate the influence of a weight training session on muscle dysmorphia symptoms. There are a large number of program design and social variables that might mediate the relationship observed in the current study. For example, given that previous research has shown that varying program design influences mood states (27), research could examine specific training variables such as total work done and rest periods. From a different perspective, there is a social component to muscle dysmorphia, and examples of specific variables investigators might examine include interactions with training partners and the presence of advertising posters containing pictures of highly muscular sports models.
The results from the current study provide a new perspective on the conceptualization of muscle dysmorphia and its symptoms. Previous research has framed the condition from a trait-like perspective and has treated it as a somewhat stable characteristic. The current results, however, indicate that muscle dysmorphia symptoms have state-like properties and may vary from day-to-day as a result of changes in the environment (e.g., having undertaken a weight training session). Understanding the variability of the condition and its symptoms, and the intrapersonal, interpersonal, and contextual influences, may provide knowledge about the experiences of individuals either with or susceptible to muscle dysmorphia, such as the young men in the current study. Although the current study provides an initial insight, additional research is needed to help develop a more complete understanding of the day-to-day variation and potential influences. Investigators could, for example, examine the effect of (a) other types of training, such as plyometrics; (b) contextual variables, such as the presence or absence of other muscular weight trainers; (c) intrapersonal characteristics, such as appearance investment; and (d) interpersonal factors, such as personal relationships.
As another contribution to knowledge, the results offer initial evidence supporting the use of the modified MDDI as a state measure of muscle dysmorphia symptoms in young men who regularly weight train. First, Cronbach's alphas generally supported the questionnaire's internal reliability. Second, the pattern of results was in keeping with the hypotheses, indicating some evidence for the inventory's construct validity. Although these signs are encouraging, more research is needed to fully establish the psychometrics of the modified MDDI as a state measure of muscle dysmorphia symptoms. For example, the current study might be replicated in women and with older men.
The current study compliments and extends existing research within the broader muscle dysmorphia knowledge base. For example, the results add to other studies that have found that training-related variables, such as exercise dependence (4,16,20,23,26), duration of lifting (11), and participation in strength and power sports (2,5,12,18) to be related to muscle dysmorphia. Also, as indicated above, these existing studies have used trait measures of muscle dysmorphia and the current results extend these investigations by associating intrapersonal symptom variation with the presence or absence of training. It is logical to expect that strength and power sport participation is associated with muscle dysmorphia. The defining feature of the condition is a perceived lack of muscularity, and involvement in strength and power sports provides opportunities for individuals to develop size and definition (2).
Research on muscle dysmorphia is still in its embryonic stages, and there is great scope for investigators to expand existing knowledge. The current study offers a new direction by indicating that the condition has state-like properties, and some specific research possibilities were identified above. More broadly, other research questions need to be addressed. For example, the prevalence of the condition is unknown. Large scale epidemiological studies on clearly specified populations using well-defined diagnostic criteria have yet to be undertaken. Along another line, available evidence regarding prevention and treatment options comes from anecdotes and brief case reports (22). Although providing initial evidence for treatment options, such as cognitive behavioral therapy, these possibilities await empirical verification. The finding that muscle dysmorphia symptoms have state-like properties and are influenced by environmental variables provides initial justification for prevention and treatment research. If the condition was not malleable to environmental variables then prevention and treatment options would likely be unsuccessful. As a third line of inquiry, it is recognized that strength and conditioning specialists and athletic trainers come across and interact with individuals with and at risk of developing muscle dysmorphia (14). Investigators will most likely add a great deal to knowledge by finding out the experiences strength and conditioning specialists and athletic trainers have had when interacting with individuals with muscle dysmorphia. Practitioners will also likely benefit from learning about the perceptions and experiences of their peers and gain insights that will help them when coming into contact with clients concerned about their muscularity.
Although muscle dysmorphia is associated with negative health and well-being consequences (4), concerns about muscularity levels are not necessarily negative. The desire to enhance muscle mass can motive individuals to train and obtain the health and performance benefits associated with weight training. It is only when such behavior begins to interfere with individuals' health, well-being, and functioning that the desire to increase muscularity may be considered detrimental. It is likely that the vast majority of people who weight train do not have detrimental muscularity issues that interfere with their well-being or lives.
The results indicate that muscle dysmorphia symptoms have state-like properties and may be influenced by situational variables. Strength and conditioning specialists, athletic trainers, and mental health professionals need to get to know their clients and consider environmental circumstances before making decisions about the presence or absence of the condition. Specific behaviors that strength and conditioning practitioners might observe include (a) excessive time spent weight training, (b) verbal statements highlighting negative perceptions of one's muscularity, (c) drug abuse, (d) admissions of strained relationships and impaired occupational functioning, and (e) anxiety and depression symptoms. If strength and conditioning specialists perceive clients to have severe muscularity concerns that are associated with detrimental physical and psychological consequences, then referral to qualified mental health professionals is the suitable course of action. As a second implication, the possibility that environmental variables may influence muscle dysmorphia symptoms provides initial evidence that prevention and treatment interventions may be effective.
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