Bigorexia nervosa, also known as muscle dysmorphia or reverse anorexia, is an emerging psychiatric disorder characterized by an obsessive focus on becoming more muscular.
Individuals with bigorexia have a distorted self-image and see themselves as small and weak even if they have large, muscular physiques.
This excessive preoccupation leads to unhealthy behaviors like over-exercising, restrictive dieting, and abuse of anabolic steroids.
While bigorexia shares traits with both eating disorders and body dysmorphic disorder, it may warrant recognition as a distinct clinical entity.
Key Facts:
- Bigorexia nervosa manifests as obsessive thoughts about being too small and weak coupled with compulsive exercise routines and abnormal eating habits designed to become more muscular.
- Muscle dysmorphia was first described in male bodybuilders but does occur in women too. Prevalence is estimated between 5-15% in certain populations like bodybuilders and military personnel.
- Individuals with bigorexia often develop comorbid conditions like depression, anxiety disorders, anabolic steroid abuse, and exercise addiction. These require screening and treatment.
- While currently classified as a type of body dysmorphic disorder in DSM-5 and ICD-11, emerging evidence suggests bigorexia may be better conceptualized as a unique disorder at the intersection of eating disorders and body dysmorphic disorders.
- Cognitive behavioral therapy shows promise in treating bigorexia, but larger clinical trials are needed. Developing and validating assessment tools to screen high-risk populations is an important research goal.
Source: Brain Sci. 2023
Bigorexia Defined – Obsessions About Muscularity and Compulsions To Become Bigger
Bigorexia nervosa, also referred to as muscle dysmorphia or reverse anorexia, is a condition characterized by an intense preoccupation with the idea that one’s body is too small or insufficiently muscular.
This obsession manifests as constant rumination about not being big or muscular enough.
It is coupled with compulsive behaviors aimed at increasing muscularity like over-exercising, restrictive dieting, and abuse of bodybuilding supplements or anabolic steroids.
Though bigorexia is currently classified as a type of body dysmorphic disorder in DSM-5 and ICD-11 diagnostic systems, experts argue it may be better conceptualized as a distinct clinical entity.
This is because, in addition to the core feature of being excessively preoccupied with flaws in physical appearance seen in body dysmorphic disorder, bigorexia nervosa has cognitive and behavioral symptoms resembling those found in eating disorders like anorexia.
Origins and History – First Described in Male Bodybuilders in the 1980s
The condition now recognized as bigorexia nervosa was first described in the late 1980s in men involved in bodybuilding and weightlifting.
Researchers noticed that some male athletes displayed a disturbing obsession with becoming more muscular, along with a distorted self-perception of being too small and weak, even if they had very large, muscular physiques.
This phenomenon was referred to with terms like reverse anorexia, Adonis complex, and muscle dysmorphia in these early reports.
It was noted to be associated with unhealthy attempts to gain muscle mass and dysfunctional eating habits.
Initially considered an issue mostly affecting male bodybuilders, there is now evidence that bigorexia occurs in women too.
Prevalence and Populations at Risk – Bodybuilders and Military Personnel Most Affected
Estimates vary, but research suggests bigorexia nervosa affects between 5-15% of people involved in activities like bodybuilding, weightlifting, and certain sports.
Males in military populations also seem to have heightened vulnerability.
For example, up to 44% of male weightlifters may experience muscle dysmorphia during their lifetime.
Comparatively lower rates between 5-10% are reported in women involved in athletic activities like gymanstics and dance which emphasize leanness over muscularity.
But experts caution that bigorexia in women is likely underdiagnosed.
More research is required to firmly establish prevalence rates across gender and age groups.
But muscle dysmorphia appears most common among individuals involved in aesthetic sports or physical training programs that idealize extreme muscularity or low body fat percentage.
Comorbid Conditions – Steroid Abuse, Exercise Addiction, Mood Disorders
Individuals with bigorexia nervosa often develop other psychiatric problems that compound their dysfunction and distress.
These comorbidities require proper screening and management alongside treating the muscle dysmorphia itself.
Some common comorbidities include:
- Anabolic steroid abuse – Up to 30% of those with muscle dysmorphia misuse steroids and hormones to accelerate muscle growth. This is an addictive disorder requiring dedicated treatment.
- Exercise addiction – Compulsive over-exercising to gain muscle mass can cross into a genuine addiction, making it hard for a person to cut back despite severe negative consequences.
- Mood disorders – Bigorexia is associated with conditions like depression, anxiety, and body image shame. Poor self-esteem fuels the distorted self-perception central to muscle dysmorphia.
- Disordered eating – Abnormal eating behaviors like bingeing or restrictive dieting are common as individuals try to manipulate body composition. Some data indicate 20% of people with bigorexia have a history of an eating disorder like anorexia or bulimia.
Bigorexia at the Crossroads of Eating Disorders and Body Dysmorphia
Despite being currently classified as a body dysmorphic disorder in DSM-5 and ICD-11 diagnostic criteria, bigorexia nervosa has clinical characteristics resembling both body dysmorphic disorder and eating disorders like anorexia.
This has prompted debate on whether bigorexia may be better conceptualized as a unique clinical entity, rather than just a muscularity-focused subtype of body dysmorphic disorder.
Arguments in favor of making it a distinct disorder:
- Core feature of distorted self-image and perceived flaws in physical appearance is common to both body dysmorphic disorder and bigorexia. But content of the perceived flaws differs, relating to thinness in anorexia nervosa versus lack of muscularity in bigorexia.
- Individuals with bigorexia exhibit obsessive thoughts and compulsive behaviors aimed at altering body composition reminiscent of eating disorder pathology. This extends beyond just appearance concerns.
- Disordered eating patterns like restrictive diets and binge eating occur at significant rates in people with bigorexia, along with histories of clinical eating disorders. This eating pathology seems intrinsic to bigorexia rather than just secondary muscle gain efforts.
- Males with bigorexia tend to display more traditionally “feminine” psychological and behavioral traits, similar to males with eating disorders. This contrasts with most men who simply want to gain muscle mass through weight training.
In summary, bigorexia nervosa seems to clinically exist at the intersection between body dysmorphic disorders and eating disorders.
Further research may provide enough evidence to warrant designating it a unique diagnostic entity in future iterations of diagnostic classification manuals.
Assessment and Diagnosis – Screening Tools Needed to Detect Muscle Dysmorphia
There are currently no universally accepted, validated diagnostic criteria or assessment tools specifically for identifying bigorexia nervosa.
However, researchers have developed a few self-report questionnaires focused on screening for muscle dysmorphia in men engaged in bodybuilding and athletics.
Examples include the Drive for Muscularity Scale, the Male Body Checking Questionnaire, and the Muscle Dysmorphic Disorder Inventory.
These tools measure factors like preoccupation with lacking muscularity, maladaptive body image self-monitoring behaviors, and functional impairment caused by muscle dysmorphia.
While promising, more research is needed to develop sensitive, specific assessment instruments to screen both men and women from the general population for bigorexia nervosa.
This will improve clinical recognition and allow early intervention to prevent complications.
Ensuring healthcare providers are aware of bigorexia as a clinical entity distinct from simple desire to build muscle mass will also facilitate accurate diagnosis and treatment.
Treatment – CBT Shows Potential But More Research Needed
There are currently no evidence-based guidelines for effectively treating bigorexia nervosa.
However, some clinical studies provide preliminary support for using cognitive-behavioral therapy (CBT) and related psychotherapies.
CBT focuses on modifying dysfunctional thought patterns and behaviors that maintain muscle dysmorphia like rigid exercise regimens and disordered eating habits.
Group-based CBT interventions show promise for improving body satisfaction and reducing risk factors like oversupplementation and extreme dieting.
Anti-depressant medications like SSRIs may also provide some therapeutic benefits, similar to their use in body dysmorphic disorder, but no pharmacological treatments are formally approved yet.
Family therapy could help in cases involving adolescents or young adults still living at home.
Focusing treatment on the family environment may impact enabling behaviors that fuel bigorexia pathology.
While results so far are encouraging, more rigorous, large-scale studies are required to conclusively demonstrate efficacy and safety of different therapies for bigorexia nervosa.
Developing and validating treatment protocols is a key goal for future research.
The Path Ahead – Increasing Recognition and Prevention Through Education
While bigorexia nervosa remains poorly characterized compared to more established eating disorders like anorexia and bulimia, awareness and recognition of muscle dysmorphia as a bonafide clinical entity is gradually increasing in both the medical community and public sphere.
Key steps that will continue improving identification and proper management of bigorexia include:
- Educating physicians, psychologists, coaches, and athletic trainers to screen for muscle dysmorphia, especially in vulnerable populations like bodybuilders, weightlifters, and military personnel.
- Increasing public awareness about the risks of bigorexia through public health campaigns and media coverage. Reducing stigmatization facilitates earlier help-seeking behavior.
- Developing easy-to-use assessment instruments to identify at-risk individuals before bigorexia nervosa progresses to more entrenched stages.
- Research to better elucidate neurobiological and socio-cultural underpinnings of bigorexia. This can guide prevention strategies and lead to novel therapies.
While debate continues whether muscle dysmorphia warrants recognition as a distinct clinical disorder, building consensus around clear diagnostic criteria and treatment approaches remains a key goal on the road ahead for this emerging condition.
References
- Study: At the crossroads between eating disorders and body dysmorphic disorders – the case of bigorexia nervosa
- Authors: Octavian Vasiliu (2023)
