When Kenan was 16, he started going to the gym to get bigger. He had been bullied his entire life about his size, and once he started to see his body change in the mirror he couldn’t get enough.
“I got some results and then just ran with it,” Kenan, who is using his first name only for privacy reasons, told Salon in a phone interview. “It was like a dopamine loop from hell for the next 10 years.”
Kenan’s time at the gym began to eat up the rest of his life. He would skip hanging out with friends or going on trips if it meant that he couldn’t work out. He started counting every “macro” — or macronutrient of proteins, carbohydrates and fats — that went into his body, adding thousands of calories of canola oil to his smoothies so he could put on weight. He even brought his own prepackaged meals to his cousin’s wedding so he could be sure the food served there was not interfering with his regimen.
“Basically, if I did not have a great gym session where I got stronger or felt like I was improving, it ruined my entire day,” Kenan said. “It would feel like I was a failure, like I couldn’t do anything right.”
At one point, Kenan came across the term muscle dysmorphia in a bodybuilding forum and recognized his own experience. Also known as “reverse anorexia” or “bigorexia,” muscle dysmorphia is a pathologic preoccupation with muscularity. In the most recent version of the psychiatric manual used to classify mental illness, it is listed as a specific type of body dysmorphia rather than its own diagnosis, although it also shares some characteristics found in eating disorders.
“The goal of exercise and physical activity is to improve your life and make you feel happier and healthier,” said Dr. Jason Nagata, an adolescent medicine specialist at the University of California, San Francisco who has studied muscle dysmorphia. “But for these individuals, it becomes a burden and an obsession that they cannot stop thinking about.”
"For these individuals, it becomes a burden and an obsession that they cannot stop thinking about."
Muscle dysmorphia was first classified in 1997 as an "underrecognized" condition that likely afflicted “substantial numbers of Americans.” Although it has recently grown in awareness and some bodybuilders have spoken out about it, relatively little research has been conducted to better understand it since it was first introduced, said Dr. Kyle T. Ganson, a social work professor at the University of Toronto who also studies muscle dysmorphia.
That’s in part because there are no questions specific to muscle dysmorphia on national surveys that are typically used to estimate a condition’s prevalence in the population. And most of the studies examining muscle dysmorphia are small and limited.
Yet muscle dysmorphia has been shown to increase a person’s risk for depression, anxiety, and suicidality. People with muscle dysmorphia are more likely to have experienced a traumatic event than the general population. And people with muscle dysmorphia are also more likely to use supplements and steroids, which carry their own health risks.
Kenan experienced overuse injuries in his elbows, knees and back. One time, he nearly broke a rib on his lifting belt, but he kept going back to the gym, even though it hurt to breathe.
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“There was a running calendar my friends would keep about how long it would take me to get injured because I was pushing it too hard,” Kenan said.
In one study Ganson published earlier this year, he estimated that 2.8% of boys and men in the U.S. and Canada could meet criteria for muscle dysmorphia. It is more common in people identifying as men and in certain populations, like bodybuilders. However, these numbers are likely underestimated. For example, in another 2019 study Ganson conducted, 22% of males and 5% of females reported disordered eating behaviors related to muscularity.
“We need more research on clinical samples, how to treat these individuals, and what barriers there are to treatment,” Ganson told Salon in a phone interview. “I think a lot of that is still somewhat in its infancy.”
Eating disorders are themselves understudied within the mental health field, where conditions like anorexia have incorrectly been stereotyped as only affecting teenage girls. Efforts to understand how social media perpetuates unrealistic body standards that affect mental health have also largely been focused largely on girls. Yet the increasing prevalence of muscle dysmorphia suggests it is having an effect on everyone.
In our consumerist society, “more” is often conflated with better.
“Both muscle dysmorphia and anorexia can be viewed as disorders where an individual has internalized these messages about idealized masculinity or femininity in such an extreme way that it is causing distress and dysfunction to the other parts of their lives,” said Linda Lin, a psychologist at Emmanuel College who has studied muscle dysmorphia.
More recent research has demonstrated that one in three eating disorders occurs among boys, and gender diverse people experience them at even higher rates. Yet muscle dysmorphia falls in a unique position where exercise and strength training are considered healthy habits in society, and as such may not be seen as problematic — even when they are pushed to the extreme.
“In general, people with eating disorders like other mental health conditions face stigma, and people don’t want to out themselves for having a disorder,” Nagata told Salon in a phone interview. “I think for boys, there is sort of a double stigma.”
Society supports the idea that muscularity equals masculinity, and the media portrays certain standards for what the male body “should” look like. In addition to male bodies getting larger and larger in superhero movies, one 1999 study found that even the size and muscularity of toy action figures children play with growing up have been expanding over time. In our consumerist society, “more” is often conflated with better.
“When I went to the gym, my trainer used to ‘boo’ thin people,” said Giuseppe Magistrale, a psychologist who founded an online treatment program for eating disorders called Lilac. “In the gym, it is super normalized. There is a culture.”
With the proliferation of social media, these unrealistic expectations of body image have become even more prolific, adding to the pressures men face to conform to them. In one 2020 study, Instagram posts that represented bigger muscles got more likes. Another published in September in the journal Body Image found the use of filters was associated with muscle dysmorphia symptoms.
“Previous generations didn’t really have that, versus now if you look at movies and TV and all of these things, all of a sudden guys have this intense pressure to look a certain way,” Kenan said. “That pressure was really mounting.”
All of this ultimately delays the time that it takes people with muscle dysmorphia to seek treatment. Like with eating disorders, many people with muscle dysmorphia may end up originally seeking help for something else before the topic of dysmorphia arises. Kenan, for example, ultimately decided to seek help from a therapist after his relationship fell apart.
Treatments for people with muscle dysmorphia will vary based on the individual and provider, in part because there have been no randomized control trials to test which therapies work best. (One clinical trial testing cognitive behavioral therapy is currently underway in Turkey.) Some are pushing for muscle dysmorphia to be classified as its own disorder, so that it can be better measured and studied.
“The creation of a diagnosis is very important because it validates the problem,” Magistrale said. “In male culture and gym culture, it is still [seen as] a non-existent disorder, so at the cultural level, we have a lot of work to do.”
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Sometimes, treating muscle dysmorphia may involve an interdisciplinary team including a mental health, medical, and nutrition provider, Nagata said. Ultimately, treatment for muscle dysmorphia is about healing the relationship patients have with their body, exercise, and food, said Dr. Lindsey Landgrebe, a licensed sport psychologist who specializes in working with athletes in her private practice.
“I think it’s about first understanding their drive for being bigger and more muscular … and then working to build other ways of coping with whatever the underlying distress is,” Landgrebe told Salon in a phone call. “It’s also a matter of expanding how they see themselves so they can understand their value is more than just their appearance.”
Kenan was able to trace the origins of his muscle dysmorphia back to getting bullied as a child for his size.
“I figured there were two ways to deal with it: either own it, or change it,” he said. “I think that is what started it for me.”
These days, he is going to the gym less and doesn’t restrict his meals. He has been able to redirect the energy he was putting toward the gym into personal development, relationships and his career, he said.
“I took that tenacity I had at the gym and put it toward reading books and self-educating myself based on what my therapists have suggested,” Kenan said. “I kind of just replaced the hyperobsession I had at the gym with [other parts of] life and found balance.”
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