Muscle dysmorphia (MD) is defined as a preoccupation with the idea that one's body is not sufficiently lean and muscular (2,5,10). Typically, individuals exhibiting MD-like behaviors most often perceive themselves as small and weak when in fact they are quite large and muscular (2). The literature in general supports that athletes involved in the sport of weightlifting are particularly vulnerable to the development of MD. However, despite consistent signs, symptoms, and defining characteristics of MD, there appears to be a discrepancy among the various subgroups within the weightlifting community as it relates to the development of MD risk factors. In other words, making generalizations about MD risks for all athletes who weight train does not appear to be justified; however, an understanding of the signs and symptoms of the disorder is paramount for those working with these athletes.
Predisposing factors for MD include issues that put an individual at a greater risk for developing MD. These factors may include low self-esteem, a negative body image (body image dissatisfaction), body image distortion, narcissism, depression (13,22), bipolar disorder, obsessive-compulsive disorder, and eating disorders (5,7). These predisposing factors are similar to those associated with the eating disorders of anorexia nervosa and bulimia nervosa, and as such, this disorder is commonly referred to as “reverse anorexia” (14,16,20). Davis et al. (3) examined the personality traits of young men with MD and found similar vulnerability traits as women obsessed with thinness. These traits included neuroticism, perfectionism, narcissism, and obsession with fitness. Their results concluded that all these traits, with the exception of narcissism, were significantly and simultaneously related to MD (3).
The behavioral characteristics of MD are slightly different from the predisposing factors for MD and include engaging in excessive amounts of exercise (such as weightlifting), drastic manipulation of diet to change one's physique, using supplements and pharmaceutical agents as a means of enhancing one's muscularity, wearing certain clothing to hide or accentuate body features, and exhibiting anxiety-like symptoms in situations where their body may be exposed. As such, social physique anxiety may become obvious as well as social and occupational impairment (8,11,22). Further, because MD is often associated with other comorbidities such as obsessive-compulsive disorder, other behaviors could include spending endless hours in the gymnasium, checking oneself in the mirror >10 times a day, spending countless amounts of money on supplements, deviant eating patterns, and substance abuse (5,10,17).
Hildebrandt et al. (7) looked at MD symptomology among male weightlifters. This study sought to determine if there exists a certain subgroup of weightlifters that is consistent with the diagnosis of MD. Data collected from 237 male weightlifters separated the participants into 5 subgroups, which were best defined by the type of body composition changes they desired: dysmorphic, muscle concerned, fat concerned, normal behavioral, and normal. They found that the Dysmorphic group desired to decrease body fat and increase muscle mass and had the highest scores across dimensions of body image disturbance, associated psychopathology, and appearance-controlling behaviors. The authors also concluded that their findings add supportive evidence that MD is a subtype of Body Dysmorphic Disorder and Obsessive-Compulsive Disorder (7). In a subsequent study, Hildebrandt et al. (6) explored the heterogeneity in body image disturbance among appearance- and performance-enhancing drug (APED) users. These authors note that the propensity to use APEDs, the choice of APEDs used, and the pattern of APED use may be influenced by the degree of body dissatisfaction and drive for muscularity, and the demands of one's athletic identity (e.g., bodybuilding). Appearance- and performance-enhancing drug use is among criteria used for MD diagnosis. The authors used the Muscle Dysmorphic Disorder Inventory to measure MD symptoms, which included 3 subscales consistent with proposed MD criteria: desire for size, appearance intolerance, and functional impairment. It was determined that not all appearance and performance-enhancing drug users suffered from significant body image disturbance and thus MD symptoms. The findings from this study indicated that there were subgroups within those who suffered from body image disturbance, ranging in pathology and even in severity within the subgroups. What they found to be the defining variable for the subgroup was a combination of training identity and the desired bodily changes (size vs. leanness). They found that those who scored the highest on the subscales (class 1) were bodybuilders and those who scored lower (class 3) were primarily comprised of power lifters. Although anabolic-androgenic steroid use and MD have also been studied, a review by Rohman (19) showed that persons with MD often used steroids and other performance-enhancing substances, but a clear relationship between the 2 has not been established. Thus, there remain questions about the degree, susceptibility, and severity of MD symptoms among those individuals who engage in weightlifting.
Although recognition and treatment of MD is improving (2), research on specific at-risk populations is lacking. Recent research suggests that competitive weight training athletes exhibit specific behavioral risk factors associated with MD, but the degree to which noncompetitive weight training athletes exhibit these same risk factors is not known. Further, it appears that the prevalence of MD may be dependent upon the focus or goal of the weight training activities, where individuals who engage in appearance-related weight training are at higher risk for MD than are individuals engaging in weight training to improve performance. It was therefore the purpose of this study to examine and compare MD between male and female, competitive and noncompetitive, and appearance-related and performance-related weightlifters.
Experimental Approach to the Problem
Very little research exists in regards to examining specific goals of the weightlifter, or essentially why it is that they weight train and the relationship between these goals and characteristics of MD. We hypothesized that the differences in why individuals weight train will highly influence the level of risk for development of MD. Thus, those who are focusing more on body shaping and building are at a greater risk of developing MD vs. those who may be weight training for building strength and power for their sport. We further hypothesized that individuals who do so competitively will exhibit the greatest risk. To assess whether the focus or goal of the weightlifter plays a role in risk development, our study used an online self-report questionnaire of a previously validated survey (Muscle Dysmorphia Inventory) (18). Although the culture of weight training itself clearly leads to certain behaviors, extreme behaviors may be more evident in subcultures of the weight training community, which may be defined by the goals and focus of the participants. Awareness of the goals and motivation behind the weightlifter may be beneficial for all coaches and fitness professionals so as to be able to identify who may be at greatest risk for this disorder.
A power analysis was conducted to determine optimal sample sizes per group based on a moderate effect size and a power of 0.8. The participants in this study included 85 competitive (55 men and 30 women) and 48 noncompetitive (24 men and 24 women) weight training athletes (mean age = 31 ± 12 years). Competitive athletes were identified as individuals who have competed or who intended to compete in state, regional, national, or international competitions within the 12 months of the time they took the MDI for this study. The participants that did not fit these criteria were put in the noncompetitive category. The participants were further separated by the focus of their weight training goals, which included appearance enhancement or performance enhancement. The participants were considered to be appearance-oriented if their weightlifting goals were chiefly to improve appearance (bodybuilding or body shaping). Conversely, the participants were considered performance oriented if their chief weightlifting goals were to develop strength and power. Descriptive characteristics of the sample are presented in Table 1. All the procedures were approved by the University of Wisconsin-La Crosse's Institutional Review Board for the protection of human subjects. The subjects were informed that they gave informed consent by submitting their electronic questionnaire data.
To determine body image perceptions and the extent of MD present among the groups, the Muscle Dysmorphia Inventory (MDI) was used (18). The creators of the MDI separated the most salient aspects of MD into 2 categories: nutritional aspects and physique concerns. Nutrition-related characteristics of MD include dietary behavior (maximizing macronutrients to achieve maximum size), supplement use (protein or carbohydrate powders, e.g., to enhance workout or aid in postworkout recovery), and pharmacological use (steroid or other drugs used to boost muscle size). The physique-concern category is made up of overall body size and symmetry, exercise dependence, and physique protection (hiding one's body). The MDI was found to be reliable and valid in previous research (9,18).
The MDI is a 27-item self-report instrument specifically designed for the assessment of behavioral and psychological characteristics associated with MD. The MDI contains 6 subscales (dietary behavior, supplement use, physique protection, exercise dependence, body size and symmetry, and pharmacological use) and each subscale uses a 6-point Likert scale ranging from “never” (=1) to “always” (=6). All the surveys were sent electronically and submitted to a secure online database. Along with MDI scores, height was self-reported to the nearest 0.25 in. and weight was self-reported to the nearest 0.25 lb.
Subscale scores were computed by summing item scores within each subscale category. A higher score per individual subscale was therefore associated with an increased MD risk. Between-group subscale score differences were examined with 2 × 2 × 2 Factorial analyses of variance (ANOVAs). Based on previous research, it is recommended that the subscales be totaled separately because each subscale is intended to measure a conceptually independent trait of MD (8,18). Summing across subscale scores, therefore, could lead to misinterpretation of results. The level of significance was set at 0.05.
The results of the Factorial ANOVAs are presented in Table 2. Men scored significantly higher on the supplement (p = 0.006), physique protection (p = 0.039), and body size and symmetry subscales (p < 0.001; Figure 1) and competitive weightlifters scored significantly higher than noncompetitive weightlifters on dietary behavior (p < 0.001), supplement (p < 0.001), exercise dependence (p < 0.001), and body size/symmetry subscales (p = 0.002; Figure 2). Finally, weightlifters with a primary focus on appearance enhancement scored significantly higher than those with a focus on performance enhancement on all 6 subscales (p < 0.01; Table 2, Figure 3). There was an interaction effect in the dietary behavior subscale between focus × status (p = 0.006), indicating that appearance-based athletes had a higher subscale score than performance-based athletes. Overall interaction effects were nonsignificant with the exception of gender × focus × status for the pharmacology subscale (p = 0.027) and the body size/symmetry subscale (p = 0.030). Although these interaction effects were statistically significant, examination of the means indicated that the mean differences were of no practical significance.
This study sought to assess and compare levels of MD among various groups of weightlifters. The results showed that men were at higher risk than women on the MD subscales of supplement, physique protection, and body size/symmetry. There is very little published research on women and MD. Much of the research on female populations looks at eating disorders and the drive to be thin. Although not as at-risk as men, this study showed that women share some commonalities with men in symptoms and psychological/predisposing factors related to MD and eating disorders and should therefore not be ignored where MD risk is concerned.
This study also found that competitive athletes had higher MD subscale scores than noncompetitive athletes in the areas of diet, supplement, exercise dependence, and body size/symmetry. This is similar to what has been seen in other studies; however, noncompetitive or recreational weight training athletes should not be overlooked as many of them possess body image and self-esteem factors associated with MD (4).
Finally, this study found that athletes with a primary focus on appearance (such as bodybuilders and body shapers) had higher MD scores than those with a focus on performance (such as power lifters) on every subscale. These findings are similar to those found in other related studies. Muller et al. (12) examined both the prevalence of predisposing factors and behavioral characteristics of MD among selected college athletes by using the Adult Self-Perception Profile Survey instead of the MDI, which was used in this study. Similar to this study, Muller found that bodybuilders consumed more nutritional supplements, had stricter dietary practices, checked their weight more often, and considered pharmacological use more than performance-related athletes. Muller did not, however, find any difference between bodybuilders and performance-related athletes on perfectionism, self-esteem, or narcissism.
Lantz et al. (8) compared MD characteristics between elite-level power lifters and elite-level bodybuilders. They defined power lifters as athletes who are interested in weight training to lift as much as possible in a single repetition (i.e., developing muscular strength), whereas bodybuilders were defined as athletes primarily interested in lifting weights to develop hypermesomorphic physiques, defined by muscular shape, striation and symmetry. Similar to the results from this study, their results showed that bodybuilders were significantly more likely to report body size-symmetry concerns, physique protection, dietary behavior, and pharmacological use than were power lifters.
Pickett et al. (15) examined competitive bodybuilders, weight trainers, and athletically active controls for patterns of MD. Among other things, the 3 groups were assessed on body image evaluation, investment and anxiety, eating attitudes, and social self-esteem. Competitive bodybuilders had a more positive global appearance evaluation but were more psychologically invested in their physical appearance. Competitive bodybuilders also reported a higher social self-esteem, but greater incidents of eating disturbances. Weightlifters and active controls reported greater dissatisfaction with their midsections and lower overall body satisfaction. Unlike this study, Picket et al. concluded that bodybuilders did not exhibit more MD and are more satisfied with themselves because they were able to achieve the mesomorphic body shape that most men want.
Baghurst and Lirgg (1) studied MD traits in male football, weight training, and competitive natural and nonnatural bodybuilding samples. The participants completed the MDI. As with this study, Baghurst and Lirgg's results showed that both bodybuilding populations scored higher on the inventory than the other groups did, especially in the dietary behavior and supplement use categories. The only difference between natural and nonnatural bodybuilding samples was in the use of pharmaceutical agents. A difference between the findings of this study and those of the Baghurst and Lirgg study was that the Baghurst and Lirgg study found no differences between groups on the size and symmetry subscale.
Many of the differences between the results of this study and those from previous studies may be attributed to differences in study populations and instrumentation; however, some study results may have also been influenced by time of year and by time of day. Thomas et al. (21) found that MD symptoms could be highly variable depending on an athlete's training season. Further, they found that a drive for increased size, appearance intolerance, and functional impairment were significantly lower after a weight training session compared with a rest day. Future studies should attempt to eliminate or control for these variations before MD comparisons are made between groups.
Many studies confirm that the underlying feature of MD is a perceived lack of muscularity. These studies conclude that individuals who participate in strength and power sports are more susceptible to MD, given the opportunity to increase size and strength in these types of sports. This study looked deeper into this phenomenon by examining MD differences between men and women, between competitive and noncompetitive athletes, and between weightlifters with appearance-related goals vs. performance-related goals. This differentiation between types of athletes adds to the existing MD research. Coaches, health, and fitness professionals, and mental health professionals should be aware of how gender, competition, and goals influence athletes' risks for MD and related disorders. Persons working with athletes are encouraged to pay attention to body image dissatisfaction, negative self-talk, and indications of impaired social and occupational functioning that is often associated with MD. Finally, given the evidence that symptoms and behaviors associated with MD can be variable, it is important to observe athletes over time so as to determine if their drive for performance enhancement or physique enhancement is simply related to the nature of their sport, or if it is a chronic pathological condition. If and when an athlete displays signs of MD or related disorders, strength and conditioning professionals and coaches must be prepared to refer the athlete to a trained mental health professional, dietician, and physician.
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Keywords:Copyright © 2013 by the National Strength & Conditioning Association.
eating disorders; body image; physique enhancement