Here's a test. Saunter into your local hardcore bodybuilding gym and ask the biggest guys in the place about "muscle dysmorphia."
Provided you're not wearing a CrossFit T-shirt and interrupting them mid-set, you'll likely get a few standard responses.
Most will say it's all media hullaballoo. Others will look at you like you asked them for directions to the nearest Vegan diner. A brave few might quietly admit that it can be a problem – just not with them, of course.
Muscle dysmorphia is categorized by being totally obsessed with the idea that you're not muscular enough. In mild form, it's a recreational gym-rat avoiding situations where other larger bodybuilders are present because he feels he's too small. In its extreme, it's a 300-pound ticking time-bomb desperately chasing another ten pounds of mass so he can finally feel "big enough."
However, isn't there a little muscle dysmorphia in every lifter? And can't it be argued that it can, in small doses, be a good thing?
Can we even call it a disease?
Good questions. For answers, we turn to Dr. Stu.
Dr. Stuart Murray is no ordinary couch psychologist. He started lifting weights at 15, back when hardcore meant hardcore – no chrome, no women, just wall-to-wall monsters. Dr. Stu was also starting his first psychology degree around that same time and soon found himself looking around the gym and wondering what it all meant.
Years later, while finishing off his second doctorate, he took some time out between papers to talk about being obsessed with muscularity, male body image, steroids, and why, as TNation readers, you're probably not mentally ill.
T NATION: So Dr. Stu, who the hell are you?
Dr. Stuart Murray: I'm an academic clinical psychologist. I have a Doctorate of Clinical Psychology, and I've just handed in my Ph.D., which is mostly a collection of my published work on the diagnosis and treatment of what we call Muscle Dysmorphia. Most of my everyday work is treating that, or other eating disorders. I've also just been invited to join the National Eating Disorder Collaboration as the expert on male body image.
T NATION: Let's start with the obvious. Muscle Dysmorphia, MD for short. What is it?
DSM: A total preoccupation with not appearing muscular enough. This includes behaviors that focus around building muscle but also getting lean, as leanness enhances the appearance of muscularity.
It's characterized by a few things, one of which is intense feelings of guilt and shame. MD guys define themselves purely by how they look, and since they intensely distort their own body image, it means they feel like they can never be big enough. It's a perfect storm for feelings of inadequacy.
We often see guys with MD repeatedly checking their reflection or asking people for reassurance whether they've gotten bigger, which is all aimed at reducing the shame they feel as a result of their preoccupation of being too small.
T NATION: How do we know if we have MD?
DSM: If you've got MD, you train compulsively. I mean, we all train a bit beaten up from time to time, but these guys will take it to extremes. One patient I treated was benching with a broken wrist and a torn rotator cuff. His anxiety at missing training was greater than the pain of benching. If you do miss a day of training, you worry that you're going to lose size in that day off and usually endure it with fairly intense anxiety.
Dietary regime is also excessively controlled. For example, one guy would weigh out 124 grams of rice, because that cooks to precisely to 100 g of carbs. Another would take Tupperware meals to weddings and formal functions; many others simply decline any invitations that might disrupt their diet plan. Another guy had a high-powered corporate job and kept a blender right on his office desk so he could eat every two hours like clockwork. He refused to put it away, and stuck to his guns so hard it eventually got him fired.
T NATION: Good for him! Obviously his skinny fat boss wasn't hardcore and would never get big. Wait, sorry about that. MD must be tough on relationships?
DSM: It can be devastating. Guys with MD will have family or friends who think they prioritize their training and diet over everything else. In extreme cases, guys can't have sex or get dressed with the lights on.
T NATION: When do these guys finally get help?
DSM: The pathway that usually brings these guys to treatment is depression. They feel horrible because none of their relationships are working, their work sucks, and their life just doesn't work. The reason for this is because they define themselves completely through their body.
They can never hit what they think is 'muscular enough' as the goalposts are always moving, so they're constantly left disappointed in themselves. Often there's so much shame involved that it takes a long time before they eventually admit that they're disgusted and ashamed by their own bodies.
T NATION: Okay bucko, stop it right there. Let me stand up on behalf of my bodybuilding brethren. You sir, are trying to demonize somewhat eccentric but perfectly normal behavior.
You are going after our subculture, calling it abnormal, and turning it into a movie-of-the-week disorder. You don't understand what we do, and you don't have the slightest idea what you're talking about.
As far as I'm concerned, sitting on your ass eating Cheetos while watching "Dancing with the Douchebags" is abnormal behaviour. What's the fancy government-funded acronym for that?
DSM: That's not what I'm doing. Hoisting big iron and eating clean is perfectly healthy. What makes something an "illness" is the amount of stress and impairment it causes to your life. Like anxiety for example – we've all got things we avoid in daily life, but when that avoidance starts to significantly impair everything that surrounds you, we call it a disorder. We're not trying to turn normal muscle-building behavior into a pathology because it's not.
I'm also not trying to enforce anything on anyone. The people that come to us seeking help define psychological disorders, and we put patterns to their behaviors to try to help them. We don't walk around trying to tell the world it's sick. How far would that get you as a therapist? You'd get told where to go rather quickly.
At the very least, if I were trying to do everything you said there, it would all make me a massive hypocrite. Finishing this Ph.D is taking up all my spare time, and I'm itching to get back into the gym.
T NATION: Fair enough. Let's use your typical committed TNation reader as an example. They watch their food carefully. They might count calories every now and then, especially when dieting. They cook everything they can for themselves and always try to have a protein snack handy.
Let's say they train every day, sometimes twice a day, following one of the kick-ass programs here at TNation. As a result, they aren't small. So now they're mentally ill?
DSM: Not in that respect, no.
What might make something like this a pathology is, a) a pervasive sense of shame that you're not big enough, and b) a significant impairment to the rest of your life, where you miss out on all the things you'd like to do because you can't not train.
T NATION: So it's a negative rather than a positive feedback loop?
DSM: Yeah, this isn't normal muscle building behavior. We all enjoy training, for the most part. We accept bad days, and persevere. When we get stronger or bigger, it makes us happy to handle more weight. That's positive feedback.
But training becoming like a job, where you don't enjoy it but you do it because the thought of not doing it scares the shit out of you, is negative feedback. For these lads, training fills a different kind of need. Exercising to avoid feeling bad, rather than exercising to feel or perform better.
One of the things we look for in diagnosis is evidence of reflexively and immediately going to the gym upon feeling bad. Fight with the girlfriend? Gym. Bad phone call from the power company? Gym. Jets lose to the Cowboys? Gym. It becomes an emotional crutch, in much the same way binging and purging is in eating disorders.
T NATION: So, are your patients always massive?
DSM: Not always. Some of them are unbelievably big, but many aren't. I think the key criterion is body distortion rather than any kind of size. Big or small, if you put them in front of a mirror, they'll all tell you the same thing: they're disgusting. So it's not all defined by your body size, it's your internal reaction to your body.
There are differences, of course. The big guys will pick holes in their own physique – abs, biceps, lats not big enough – and the less-big guys just think they're tiny everywhere. The condition is easier to diagnose when someone's average height, 240 pounds and 6% bodyfat, and all they can think about is how much their calves suck.
T NATION: Come on, now. I have flat shoulders, for example, and they piss me off greatly. Does that mean I should be fitted for a straight jacket?
DSM: There's a difference between you knowing you have rubbish shoulders and an unhealthy preoccupation with your rubbish shoulders. You don't wear baggy clothes so people can't see your flat shoulders. You don't analyze them in the mirror for hours upon end. You wouldn't go to the gym in the middle of the night so people can't see your shoulders.
Also, if you did a shoulder specialization program and brought them up, you wouldn't immediately acquire a similar and equally dire preoccupation with, say, your biceps. These guys continually and ceaselessly change goalposts. There's no sense of achievement with the individual steps in physique development. We call it self-oriented perfectionism.
T NATION: I suppose steroids (AAS) can play a nasty part in all this?
DSM: It's almost mandatory. And not just AAS, the whole pharmacopoeia, everything that's not nailed down. Some studies have found 100% of MD patients use anabolics and other performance enhancing drugs. I've found it to be less than 100%, but certainly very high.
But it's a fallacy to say all AAS users have muscle dysmorphia; rather the vast majority of MD patients use steroids. There's a big difference there. AAS use is in the psychological diagnostic criteria ('use of ergogenic substances'), but any responsible psychologist should be able to tell the difference between steroid use and MD with steroid use.
Some clinicians have said that steroid use causes muscle dysmorphia. That's bollocks, and I'll bet they've never been inside a gym in their lives, and if they have it was a Planet Fitness. Steroid use in some cases enhances self-esteem. If someone is using AAS, and they get closer to their ideal bodyweight or size, they usually walk around thinking, "I'm bigger, I know it, and this is okay by me so I'm happy." End of story. They go about their daily lives feeling better about themselves. If that fits the person reading this, he meets none of the MD diagnostic criteria.
There's also the obvious difference between performance and appearance-enhancing use. If you want to run faster, press more, throw further, etc., it's vastly different from just wanting to look more jacked.
T NATION: What role does the media, specifically the Internet, play in all this? It seems like a lot of guys are trying to live up to a body image being created by 21st century bodybuilders that's unattainable to 99.9% of the population?
DSM: Absolutely. To make matters worse, there are now all these bizarre sites where bodybuilding physiques are photoshopped into cartoon caricatures that would be 400-500 pound guys in real life. Most likely see this as fiction, but you have to be concerned about some of the more impressionable kids just starting out.
T NATION: What role does competitive bodybuilding have in all this?
DSM: MD patients can show their bodies off, but only after meticulous preparation, so bodybuilding is perfect for them. Think about it, if you have a core belief that you're not muscular enough, winning a bodybuilding contest can be very validating. But remember the goalposts. If you win, you'll want to win at the next level.
Also, remember that only one guy wins. The whole "everyone on stage is a champion" thing may make for a warm and fuzzy Faceboook status, but for the guys with MD, second place is really just first loser.
T NATION: What sort of response do you expect to get from this?
DSM: I expect some people will contact me anonymously asking questions. The Internet is good like that, and that's what I'm here for. Incidentally, anything I'm told is completely confidential, and you can ask me anything about it.
I also expect those questions to be drowned out in a shower of abuse. I've sent questionnaires out before that have come back with every question annotated with insults. "Why would you ask that?" "This doesn't make any sense!" "You've got no idea what you're talking about." I've left out the swear words.
People have even written to tell me that muscle dysmorphia is really good, that they like having it, and they don't want treatment. They'll justify the most extreme behavior they can come up with as a necessary sacrifice, and add that I'm an idiot for even calling it a disorder for good measure.
MD is experienced as a positive thing by most of the guys who have it, even though their lives are crumbling around them. They actually believe having MD is what keeps them driving towards a larger physique – which is of course part of the illness!
T NATION: And I suppose men are rarely good at asking for psychological help in the first place.
DSM: Yeah, there's also a bunch of masculinity issues involved with muscle dysmorphia. Guys who typically want to get bigger and bigger are often guys who also feel threatened in their masculinity, and so try to embody the ultimate masculine body. The clinical term is hyper-muscularity.
Keep in mind that parts of this illness are experienced as positive, plus the level of masculinity and reluctance to appear weak, which helps us appreciate why not many guys want to seek treatment until things are really bleak.
Interestingly, about 10% of MD patients are women. Typically, they score very strongly on questionnaires about masculine traits – I mean psychologically, not physically.
T NATION: 90% men to 10% women. That's almost the precise reverse of the figures on anorexia!
DSM: Very true. There's a strong parallel between them. These guys would be surprised how unbelievably similar they sound to anorexia patients. Believe me, this is equally as real, equally as significant.
T NATION: Okay, we're out of space. What about a conclusion?
DSM: I think everyone can agree that there's a level at which any behavior becomes unhealthy. We have a set of behaviors that we all do, and for some people they aren't healthy.
I don't think these guys get anything like the support they need from the community around them. These guys are our friends and brothers, and they need help. So awareness is a good start, and I'm glad some in the fitness media like TNation have the balls to address something this confrontational.
Anyone who wants to talk about this can contact me anonymously at email@example.com.
T NATION: Thanks for doing this today doc!
DSM: It was my pleasure.
Have comments about what you just read? Furious, frothing at the mouth, and dying to give this Dr. Stu character a swift kick to the gonads?
Or did he describe someone who sounds a lot like someone you know. A friend, a family member, or maybe even that big SOB you see every morning in the mirror?
Dr. Stuart Murray is a Psychologist who has clinical experience across a wide range of psychological difficulties. Currently completing his Ph.D and Doctoral training at the University of Sydney, Stuart has trained at Royal Prince Alfred Hospital in the Eating Disorders Unit, and is recognized internationally in the area of male body image disorders and Muscle Dysmorphia. He can be reached at firstname.lastname@example.org.