RESEARCH ARTICLE

Bigorexia: Bodybuilding and Muscle Dysmorphia

Philip E. Mosley*,y
Trafford General Hospital, Manchester, UK

Abstract
Muscle dysmorphia is an emerging condition that primarily affects male bodybuilders. Such individuals obsess about
being inadequately muscular. Compulsions include spending hours in the gym, squandering excessive amounts of
money on ineffectual sports supplements, abnormal eating patterns or even substance abuse. In this essay, I illustrate
the features of muscle dysmorphia by employing the first-person account of a male bodybuilder afflicted by this
condition. I briefly outline the history of bodybuilding and examine whether the growth of this sport is linked to a
growing concern with body image amongst males. I suggest that muscle dysmorphia may be a new expression of a
common pathology shared with the eating disorders. Copyright # 2008 John Wiley & Sons, Ltd and Eating
Disorders Association.

Keywords
bodybuilding; muscle dysmorphia; bigorexia; eating disorders; steroids

*Correspondence
Dr Philip E. Mosley, The Moorside Unit, Greater Manchester West Mental Health NHS Foundation Trust, Trafford General Hospital,
Urmston, Manchester M41 5SL, UK. Tel: 07812 463615. Fax: 0161 746 2672.
Email: [email protected]

Published online 1 September 2008 in Wiley InterScience (www.interscience.wiley.com) DOI: 10.1002/erv.897

quately muscular. Compulsions include spending hours

Introduction in the gym, squandering excessive amounts of money
It has long been recognised that many women suffer on ineffectual sports supplements, abnormal eating
from body image-related anxieties, ranging from simple patterns or even substance abuse.
unhappiness with shape and weight to a serious eating In this essay, I illustrate the features of muscle
disorder such as anorexia nervosa. dysmorphia by employing the first-person account of a
In comparison, little attention has been devoted to male bodybuilder afflicted by this condition. I briefly
the study of men who also display these concerns. In the outline the history of bodybuilding and examine
sport of bodybuilding, men pursue an idealised muscle- whether the growth of this sport is linked to a growing
bound body image as the primary goal of their training. concern with body image amongst males. I suggest that
Developing a healthy body through following an muscle dysmorphia may be a new expression of a
enjoyable exercise routine is undoubtedly a wholesome common pathology shared with the eating disorders.
endeavour; nevertheless, it seems that by focussing
overtly upon body image some bodybuilders are led to What is bodybuilding?
crave an unattainable figure. Muscle dysmorphia is an
Bodybuilding is the pursuit of a muscular physique
emerging condition that primarily affects male body-
through a regime of weight training and a tailored
builders. Such individuals obsess about being inade-
programme of nutrition. Although female bodybuilders
exist, it is primarily a male-dominated activity. In the
y
Foundation Year Doctor. sport of competitive bodybuilding individuals display

Eur. Eat. Disorders Rev. 17 (2009) 191–198 ß 2008 John Wiley & Sons, Ltd and Eating Disorders Association. 191
Bodybuilding and Muscle Dysmorphia P. E. Mosley

their physiques to a panel of judges, who score each

entrant on the basis of the size, symmetry and definition
What is muscle dysmorphia?
of his (or her) musculature. The aesthetic qualities of As the popularity of bodybuilding increases, evidence
bodybuilding differentiate it from the discipline of suggests that increasing numbers of young men are
powerlifting, where the goal is purely to lift the heaviest becoming dissatisfied with their appearance. The nature
weight possible; in fact powerlifters often carry excess of this dissatisfaction is not a desire for smaller and
fat in order to increase the quantity of muscle they can slimmer bodies, as is most often the case in women, but
pack onto their oversized frames. rather larger and more muscular ones (Pope et al.,
Perhaps the first ever bodybuilder was Eugen Sandow 2000a).
(1867–1925), a Prussian who began his career as a A pathological pre-occupation with overall muscu-
sideshow strongman but soon began displaying his larity and leanness appears to be a relatively new body
physique as a work of art. The sport grew slowly image disturbance that primarily affects men. The
throughout the twentieth century; by the late 1970s the condition first entered the literature in 1993 when Pope,
bodybuilding subculture remained small and largely Katz and Hudson described a condition they termed
overlooked, based primarily around its adopted home ‘reverse anorexia’ in a population of male bodybuilders.
in Southern California. These men, although they were highly muscular,
The world was exposed to bodybuilding in 1977 with believed that they appeared inadequately small and
the release of Arnold Schwarzenegger’s cult film weak. They declined social invitations, wore heavy
‘Pumping Iron’, a documentary showcasing the body- clothes even in the heat of summer and refused to be
building lifestyle as the ‘Austrian Oak’ prepared to take seen at the beach. The term reverse anorexia was based
his sixth Mr Olympia title, the highest accolade in upon the prevalence of past anorexia nervosa amongst
competitive bodybuilding. As the ebullient Schwarze- this sample and the similarity in body-related concerns
negger rose to stardom as a Hollywood actor, body- and behaviours to those suffering from eating disorders.
building became accepted into mainstream Western These men expressed a desire to gain greater
fitness culture. musculature whilst not gaining fat. (Choi, Pope, &
Today, many men across the United Kingdom lift Olivardia, 2002).
weights as part of their fitness regime. Whilst few may Pope and his colleagues have since dominated
aspire to the overblown bodies of modern Mr Olympia research into this entity, subsequently renaming the
competitors, the male fitness industry is booming. In a condition ‘muscle dysmorphia’, classifying it as a
quest for toned biceps and ‘six-pack’ abdominals, more subtype of body dysmorphic disorder and proposing
men than ever are joining gyms, reading fitness the operational diagnostic criteria presented in
magazines and experimenting with performance- Table 1 (Pope, Gruber, Choi, Olivardia, & Phillips,
enhancing supplements. 1997).

Table 1 Diagnostic criteria for muscle dysmorphia

Pre-occupation with the idea that one’s body is not sufficiently lean and muscular. Characteristic associated behaviours include long
hours of lifting weights and excessive attention to diet.
The pre-occupation is manifested by at least two of the following four criteria:

(1) The individual frequently gives up important social, occupational or recreational activities because of a compulsive need to maintain
his or her workout and diet schedule.
(2) The individual avoids situations where his or her body is exposed to others, or endures such situations only with marked distress
or intense anxiety.
(3) The pre-occupation about the inadequacy of body size or musculature causes clinically significant distress or impairment in
social, occupational or other important areas of functioning.
(4) The individual continues to work out, diet or use performance-enhancing substances despite knowledge of adverse physical
or psychological consequences.

The primary focus of the pre-occupation and behaviours is on being small or inadequately muscular, as distinguished from fear of
being fat as in anorexia nervosa, or a primary pre-occupation only with other aspects of appearance as in other forms of body
dysmorphic disorder.

192 Eur. Eat. Disorders Rev. 17 (2009) 191–198 ß 2008 John Wiley & Sons, Ltd and Eating Disorders Association.
P. E. Mosley Bodybuilding and Muscle Dysmorphia

Why is nuscle dysmorphia the ontological identity of bodybuilding and its

important? connection to muscle dysmorphia.
Muscle dysmorphia at its most severe is profoundly
distressing. Some men become so pre-occupied with Methods and background
muscle development that they will miss social events,
The bodybuilder in question became known to the
lose their job and even continue training through injury
author at a local gymnasium, where both undertake
rather than interrupt their fitness schedule. Unable to
their fitness regimes. Information was collected in
achieve an unrealistic body image, the afflicted body-
the gym through a series of informal interviews and the
builder may spend vast amounts of money on
subject gave his informed consent for the material to be
nutritional supplements and may eventually exper-
used in this study.
iment with anabolic steroids. These drugs produce
The subject of this study is a 27-year-old male with a
rapid increases in lean muscle mass with few immediate
past psychiatric history of depression and bulimia
side effects. However, prolonged use is associated with
nervosa. Both were diagnosed and treated by a
raised cholesterol, prostate enlargement, male-pattern
psychiatrist using a combination of fluoxetine and
baldness, acne, gynaecomastia and testicular atrophy.
cognitive behavioural therapy. The course of treatment
Withdrawal from a cycle of steroids can lead to
for bulimia nervosa ended over 4 years ago although he
depression and has been associated with suicide (Pope
still takes citalopram for his low mood; for this he
& Brower, 2000).
consults his general practitioner. He has not received a
formal diagnosis of muscle dysmorphia because he has
How many people does muscle not sought treatment, although he meets the criteria
dysmorphia affect? outlined by Pope in Table 1.
Pope and colleagues (Kouri, Pope, Katz, & Oliva,
The prevalence of muscle dysmorphia is difficult to 1995) have devised a mathematical formula to estimate
estimate. Pope claims that up to 10% of the body- a man’s muscularity. The ‘fat-free mass index’ (FFMI) is
builders he has studied exhibit prominent symptoms of calculated using the subject’s height, weight and
muscle dysmorphia and that the total number of males approximate percentage of body fat. The resulting
of all ages in the USA who have used anabolic steroids number correlates with the body type of the subject. A
may exceed 2 million (Pope, Phillips, & Olivardia, man with a FFMI of 16 would be frail or flabby; a FFMI
2000b). of 20 is of average build; one of 23 corresponds to a man
Amongst a population of bodybuilders, some may who is noticeably muscular. The authors believe that it
not meet the formal criteria for muscle dysmorphia but is impossible to achieve a FFMI of over 26 without the
may still be affected by body image concerns that cause assistance of anabolic steroids, which permit a user to
them significant levels of distress. Conversely, many break through the ‘biological ceiling’ of natural
bodybuilders displaying severely pathological beha- muscularity. The FFMI of this bodybuilder is 28.
viour, even those abusing anabolic steroids, may feel
that their activities are simply part of a healthy lifestyle
and will not present to health services.
On discovering bodybuilding:

. . .I guess I’ve always been fixated with my body shape.

Why is this study important? As a kid I was scrawny and I used to envy the popular
Although Pope and his colleagues have written athletic boys on the rugby team. I began lifting weights
extensively about the features of muscle dysmorphia when I was about 14, using this tiny multi-gym in the
little has been published on the phenomenology of school lunch hour. I discovered I was pretty strong for
the bodybuilding lifestyle. The introverted nature of the my size and quickly I began to see results. . . My mates
bodybuilding community means that outsiders have and I used to mess about on the back seat of the school
obtained only a glimpse of a significant underground bus, flexing our biceps to try and impress the girls;
subculture. Here I present selected excerpts from the pretty soon I found had the biggest arms, it made me
experiences of a male bodybuilder as a means to grasp feel good about myself. . .

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Bodybuilding and Muscle Dysmorphia P. E. Mosley

On past experiences of diet and of hours to keep my muscles topped up, even if I’m not
exercise: hungry. . . When I’m in a cutting phase I’ll restrict my
carb intake to almost nothing so as to lean up and make
. . .When I arrived at university I got into boxing in a my muscles stand out. I read about this carb-cycling diet
big way. My coach encouraged me to diet down from in Flex magazine, which some of the top pros use to help
70kg to 57kg in my first year so that I could fight as a them shred body fat. It does involve controlling every
featherweight. It was a ridiculous thing to be doing to gram of carbohydrate that you take in each day, which is
my body but that was the only way he would let me frankly almost impossible, but I try to follow it as best I
compete. Basically, I had to live on a diet of Slim-Fast can. . . I do prepare all my food in advance so I can be
milkshakes, whilst still keeping up this six day-a-week sure I’m getting clean calories and I never have to fall
training routine of running, sparring and weightlift- back on junk food from the cafeteria. It is really hard to
ing. I became fixated on food; after a hard training keep this kind of diet up and maintain any kind of
session I wanted to eat a big plate of pasta like other normal life, but I persevere because that’s what it takes
normal sportsmen, but I had to content myself with an to build the kind of body I want. . .
apple and protein shake! I checked on the Internet and
my new weight made me officially anorexic, which was
On steroid use:
something I was actually proud of at the time because
it proved how hard I’d had to work. . . . . .I’ve done three cycles of steroids in the past year. I
don’t see it as cheating, because everyone else in the gym
On current attitudes to weightlifting: is using them and besides, even on gear you still have to
. . .Each session I concentrate on a different body part; for put all the hours in at the gym and stick to the same diet,
example in a given week I might work chest on Monday, they’re not magic. . . I know steroids are bad for you in
back on Tuesday, legs on Wednesday etc. Splitting the the long run but frankly I’m not that bothered about
different muscle groups lets me really blast each one and how healthy I am in twenty years; I want to feel good
allows me to train more regularly without getting about myself now. And are steroids that much more
fatigued. For each muscle group, I have a repertoire of unhealthy than living off junk food like most other men
exercises that I’ve picked up over the years, just from my age? Those people are messing up their bodies too. . .
watching other bodybuilders and from reading maga- The medical profession are always very quick to
zines. I find which ones work for me and stick with them, highlight the dangers of steroids, but I reckon that’s
but I’m always looking to incorporate new techniques so motivated just as much by some puritanical desire to
as to shock the muscles into growth. I have a little control what people put in their bodies than by hard
notebook in which I chart all the exercises I do and the fact. My doctor knows no more about anabolic steroids
weights I lift, so that when I analyse my workouts I can than the average man on the street whereas I’ve read up
see if I’m getting stronger. . . I definitely think about how on all the different chemical structures of the various
the weights I’m lifting are going to affect my appearance. steroids, how they get metabolised in the body and all
For example, I might choose to train legs twice per week if the side effects, so I’ve educated myself and I feel I’ve
I feel my quads are lagging, or change the angle of a reduced the risk. . . Although when I came off my last
bench press so that it accentuates my upper chest. . . I’m cycle I got really depressed and even felt suicidal for a
very serious about my training; if I haven’t pushed few weeks, which really worried me. But I don’t want to
myself to the limit then I feel like I’ve wasted my time. If stop juicing now because I’ve seen the results and I don’t
the gym is crowded and I can’t complete all the exercises want to lose that edge. . .
in my program then I get really irritable...
On quality of life:
On current attitudes to diet:
. . .Bodybuilding is my life, so I make sacrifices
. . .When I’m bulking I always try to keep my muscles elsewhere. I’m always thinking about the nutritional
supplied with protein and carbs so they can grow. Each content of food and how it would affect the way I look,
day I’m aiming to eat 3 grams of protein for every so I can never eat out at restaurants or go to a friend’s
kilogram of my bodyweight, taking a meal every couple for dinner because it would mess up my diet. And I

194 Eur. Eat. Disorders Rev. 17 (2009) 191–198 ß 2008 John Wiley & Sons, Ltd and Eating Disorders Association.
P. E. Mosley Bodybuilding and Muscle Dysmorphia

spend so much money on stuff like protein-powders anorexic patient, the primary disturbance is one of
and fat-burning pills that I have no money left to go eating, to which may be added excessive exercise as a
out drinking; to be honest I don’t have that many secondary characteristic. The reverse applies to the
friends anyway. Not enough time for them. . . I often patient with muscle dysmorphia.
arrive to work late or leave early because I have to The overwhelming feature of the somatoform
train, and even when I am there my mind is always on disorders is the generation of medically unexplained
my next meal or gym session. I guess my ideal job physical symptoms (somatisation). This is not a
would to be a personal trainer, then I could just live in principal feature of either body dysmorphic disorder
the gym. . . or muscle dysmorphia. Some academics have already
suggested that body dysmorphic disorder might be
On muscle dysmorphia: more appropriately conceptualised as an obsessive-
compulsive spectrum disorder on the evidence of an
. . .Do I have a problem? I guess so. I sometimes wonder overlapping psychopathology—namely intrusive,
what the point of my life is. I work so hard at my body obsessional fears and compulsive rituals (Philips,
but underneath I still hate the way I look. In my mind I Gunderson, Mallya, McElroy, & Carter, 1998). Body-
know I am bigger than most of the guys on the street builders with muscle dysmorphia also report pre-
but I still feel inadequate. I don’t like undressing in occupations and obsessional thoughts about muscu-
front of my girlfriend and I don’t enjoy sex because I’m larity as well as compulsive exercise and checking of
too busy worrying about the way I look. Even just muscularity (Olivardia, 2001).
looking at my body in the mirror when I come out of A study by Maida and Armstrong (2005) used
the shower makes me feel horrible. . . validated questionnaires to assess committed male
weightlifters on measures of muscle dysmorphia,
tendency to somatise, features of obsessive-compulsive
Is muscle dysmorphia a type of disorder and characteristics of disordered eating,
eating disorder? amongst others. Not only did the researchers identify
Individuals with muscle dysmorphia demonstrate a that symptoms of muscle dysmorphia are strongly
specific maladaptive pattern of behaviour, namely an related to certain measures of eating disorder (body
obsessive drive to exercise and to restrict their diet. As dissatisfaction and perfectionism) and obsessive-
mentioned previously, Pope and his colleagues origin- compulsive disorder, but also that symptoms of muscle
ally labelled muscle dysmorphia ‘reverse anorexia’ dysmorphia were not at all related to somatisation.
based on the apparent links between the two conditions. The fact remains that the distinctive cognitions and
Nevertheless, Pope’s proposed diagnostic criteria for rigorous lifestyle of the obsessive bodybuilder in his
muscle dysmorphia categorise it instead as a subtype of pursuit of bigness parallel the phenomenology of the
body dysmorphic disorder, defined as a pre-occupation man with an eating disorder in his pursuit of thinness. I
with an imagined or exaggerated deficit in appearance suggest that if the core psychopathology in anorexia
that has the characteristics of an overvalued idea, is not nervosa is over-evaluation of eating, shape and weight; a
amenable to re-assurance and leads to significant similar over-evaluation occurs in muscle dysmorphia,
distress plus impairment of functioning. In the tenth but in a different direction. Both disorders value
version of the International Classification of Diseases leanness and demonise adiposity.
(ICD-10), body dysmorphic disorder is classified in Men with anorexia nervosa, bulimia nervosa and
section F45.2 as a hypochondriacal disorder, which thus binge eating disorder consistently show marked
groups it with a diverse range of presentations known as dissatisfaction with their body image (Olivardia, Pope,
‘somatoform’. Mangweth, & Hudson, 1995). Bodybuilders, although
This shift in nosology seems to be based upon the concerned with gaining muscle rather than losing fat,
profound distortion of body image present in those also display an increased pre-occupation with their
severely affected by the condition, coupled with the body image, food and exercise (Mangweth et al., 2001).
dominance of pathological exercise behaviour over An examination of the severe dieting practices prevalent
abnormal eating behaviour alone. Olivardia’s (2001) in the sport of competitive bodybuilding indicates that
phenomenological analysis contends that in the such men are at increased risk of developing a

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Bodybuilding and Muscle Dysmorphia P. E. Mosley

traditional eating disorder and many already practice bodybuilding, a hypermasculine and narcissistic enter-
abnormal body image modifying behaviour on a prise. Although women have always been attracted to
regular basis (Anderson, Barlett, Morgan, & Brownell, athletic males, most do not find an excessively muscular
1995). body desirable. Perhaps the bodybuilder seeks a good
Different types of eating disorder, namely anorexia body so that he can feel good about himself?
nervosa, bulimia nervosa and eating disorder not
otherwise specified (EDNOS), share a distinctive
psychopathology and are not stable over time, with
substantial migration of patients between diagnoses.
Does bodybuilding predispose
However, the overall concept of eating disorder does
to muscle dysmorphia?
show considerable stability and suggests that these Has the growth of the bodybuilding culture facilitated
disorders might best be considered as a single entity the appearance of muscle dysmorphia in men with body
(Milos, Spindler, Schnyder, & Fairburn, 2005). It is my image concerns? It is possible that some individuals
contention that a trans-diagnostic view of the eating with pre-existing psychopathology gravitate towards
disorders might therefore also include muscle dysmor- bodybuilding, eventually culminating in the develop-
phia. ment of frank muscle dysmorphia. Clinical case studies
suggest that muscle dysmorphia is almost always found
in individuals heavily involved in bodybuilding rather
than simple weightlifting. In a comparison of a
What causes muscle dysmorphia? population of bodybuilders (who lift weights to develop
If it seems likely that muscle dysmorphia represents a an attractive body) and powerlifters (who lift weights
novel manifestation of a universal pathology involving purely to increase strength) the bodybuilders were far
body image, eating and exercise, then one must wonder more likely to display features of muscle dysmorphia
what factors have shaped the emergence of this new (Lantz, Rhea, & Cornelius, 2002).
phenomenon. It is doubtful, however, that all bodybuilders are at
In his book ‘The Adonis Complex’ Pope considers risk of a pathological body image disturbance. One
the growing number of ordinary men who are might even expect that a rise in physicality would
dissatisfied with the muscularity of their bodies and parallel a rise in self-esteem, especially if coupled with
lays the blame for this trend at the door of positive feedback from others.
contemporary Western culture. The modern child is In this vein, Pickett, Lewis, and Cash (2005)
given action figurines that portray heroes with compared a group of competitive bodybuilders to a
implausibly muscled physiques (Pope, Olivardia, group of men who trained with weights and with a
Gruber, & Borowiecki, 1999). Men are now targeted group of athletically active men who did not use weights
by marketing campaigns that seek out their body image at all. Although competitive bodybuilders were more
insecurities, just as females have been for many years. likely to display disordered eating attitudes, the authors
And just as semi-naked females have long been used to assert that competitive bodybuilders were no more
sell everyday products, the stripped male torso is now a muscle dysmorphic in comparison with either group. In
frequent advertising tool (Pope, Olivardia, Borowiecki, fact, bodybuilders were more likely to have a favourable
& Cohane, 2001). self-evaluation of body image. Their finding contradicts
Worryingly, today’s society tells us that the steroid- those of Lantz et al., although the authors seem to
enhanced, lean, muscular physique embodies not only ignore this issue.
the healthy lifestyle to which we should all aspire, but However, a number of methodological flaws detract
also the minimum physical standard that all men are from the merit of this study (Smith, Wright, Bruce-
expected to attain. Low, & Hale, 2005). Most importantly, the authors
Why is it important for the 21st century man to have failed to use a validated, multidimensional measure of
muscles? As gender roles change and women outper- muscle dysmorphia that takes account of its many
form males in education and in the workplace, males facets, instead relying on measures that only partially
find their traditional status challenged. An insecure approach the muscle dysmorphia construct. A suitable
gender identity may partly explain the growth of tool might have been the muscle dysmorphia inventory

196 Eur. Eat. Disorders Rev. 17 (2009) 191–198 ß 2008 John Wiley & Sons, Ltd and Eating Disorders Association.
P. E. Mosley Bodybuilding and Muscle Dysmorphia

(MDI), developed by Rhea, Lantz, and Cornelius weights in the gym as an enjoyable and healthy pursuit.
(2004), which provides a global assessment of all of the However, if physical exercise behaviour in men is
behaviours associated with this entity. motivated primarily by physical appearance, as more
As the prime motivation of bodybuilding is to men take to the gym in order to increase their
become bigger and leaner, one must wonder if it is musculature more may be at risk of developing muscle
possible to distinguish between a healthy enthusiasm dysmorphia.
for bodybuilding and muscle dysmorphia given that the The literature on muscle dysmorphia is almost
underlying rationale for both is the same. It is difficult exclusively dominated by Pope and his colleagues. It is
to separate the two populations in a formal study important that other clinicians also examine this
without introducing a tautological selection bias, but phenomenon, in order to stimulate a constructive
one study claims that individuals with muscle debate.
dysmorphia differ from normal weight-lifting men
on the basis of measures such as body dissatisfaction,
eating attitudes, prevalence of anabolic steroid use and
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