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Give me strength: Muscle Dysmorphia as an addiction

Muscle Dysmorphia (MD) describes a condition characterised by a misconstrued body image in individuals interpret their body size as both small and weak even though they may look normal or even be highly muscular. Those experiencing the condition typically strive for maximum fat loss and maximum muscular build. MD can have potentially negative effects on thought processes including depressive states, suicidal thoughts, and in extreme cases, suicide attempts. These negative psychological states have also been linked with concurrent use of Appearance and Performance Enhancing Drugs (APED) including Anabolic Androgenic Steroids (AAS).

MD was originally categorised in 1993 by Dr. H.G. Pope and colleagues (in the journal Comprehensive Psychiatry) as Reverse Anorexia Nervosa, due to characteristic symptoms in relation to body size. It has been considered to be part of the spectrum of Body Dysmorphic Disorders (BDD) referring to a range of conditions that tap into issues surrounding body image and eating behaviours. Consequently, there is a lack of consensus amongst researchers whether MD is a form of BDD, Obsessive-Compulsive Disorder (OCD) or a type of eating disorder. Earlier this year, Andy Foster, Dr. Gillian Shorter and I published a paper in the Journal of Behavioral Addictions about the ‘Addiction to Body Image’ model, and arguing that MD could perhaps be conceptualized as an addiction.

Our ‘Addiction to Body Image’ (ABI) model attempts to provide an operational definition and to introduce a standard assessment across the research area. The ABI model uses my addiction components model (outlined is a previous blog) as the framework in which to define muscle dysmorphia as an addiction. For the purposes of our paper, body image was defined using Sarah Grogan’s definition (from her 2008 book Body image: Understanding body dissatisfaction in men, women, and children) who said it was a person’s “perceptions, thoughts and feelings about his or her body”. We argued that the addictive activity in MD is the maintaining of body image via a number of different activities such as bodybuilding, exercise, eating certain foods, taking specific drugs (e.g., anabolic steroids), shopping for certain foods, food supplements, and/or physical exercise accessories, etc.).

In the ABI model, the perception of the positive effects on the self-body image is accounted for as a critical aspect of the MD condition. The maintenance behaviours of those with ABI may include healthy changes to diet or increases in exercise. However, such behaviours can hide or mislead those with ABI away from the negative thought processes that are driving their addiction. It is in the cognitive dysfunction of MD where we believe there is a pathological issue, and why the field has encountered problems with the criteria for the condition. The attempt to explain MD in the same manner as other BDDs may not be adequate due to the cognitive dysfunction occurring in the context of the potentially positive physical effects via improvements in shape, tone, and/or health of the body.

We also argued that there is a difference in the cognitive dysfunction with a misconstrued self-body image compared to other BDDs. The cognitive dysfunction causes the individual with MD to have a misconstrued view of their own body image, and the person believes they are small and puny. This negative mindset has the potential to cause depression and other disorders, and may facilitate the addiction. Unlike other conceptualizations of MD in the BDD literature, we would argue that the agent of the addiction is the perceived body image that is maintained by engaging in secondary behaviours such as specific types of physical activity and food. The most important thing in the life of someone with MD is how their body looks (i.e., their body image). The behaviours that the person with MD engages in (such as excessive exercise or disordered eating) are merely the vehicles by which their addiction (i.e., their perceived body image) is maintained.

Based on empirical evidence to date, we proposed that Muscle Dysmorphia could be re-classed as an addiction due to the individual continuing to engage in maintenance behaviours that cause long-term psychological damage. More research is needed to explore the possibilities of MD as an addiction, and how this particular addiction is linked to substance use and/or other comorbid health conditions. Controversy about the conceptual measurement of the condition, has led to a number of different scales adapted from different criteria that may not fully measure the experience of MD.

However, a group of questions that might test the applicability of the ABI approach to measuring and conceptualising MD have not been asked. Questionnaires such as the Exercise Addiction Inventory and the Bergen Work Addiction Scale (two scales that I co-developed) could be adapted to fit MD characteristics. Adequate conceptualisation is key to explore the clinically relevant condition. This new ABI approach may also have implications for diagnostic systems around similar conditions such as other BDDs or eating disorders.

Dr Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Additional input: Andy Foster and Dr. Gillian Shorter

Further reading

Andreassen, C.S., Griffiths, M. D., Hetland, J. & Pallesen, S. (2012). Development of a Work Addiction Scale. Scandinavian Journal of Psychology, 53, 265-272.

Foster, A.C., Shorter, G.W.& Griffiths, M.D. (2014). Muscle Dysmorphia: Could it be classified as an Addiction to Body Image? Journal of Behavioral Addictions, in press.

Griffiths, M.D. (1997). Exercise addiction: A case study. Addiction Research, 5, 161-168.

Griffiths, M. D. (2005). A ‘components’ model of addiction within a biopsychosocial framework. Journal of Substance Use, 10, 191-197.

Griffiths, M. D., Szabo, A., & Terry, A. (2005). The Exercise Addiction Inventory: A quick and easy screening tool for health practitioners. British Journal of Sports Medicine, 39, 30-31.

Grogan, S. (2008). Body image: Understanding body dissatisfaction in men, women, and children. London: Routledge.

Mosley, P.E. (2009). Bigorexia: Bodybuilding and muscle dysmorphia. European Eating Disorders Review. 17, 191-198.

Murray, S. B., Rieger, E., Touyz, S. W., & De la Garza Garcia, Y. (2010). Muscle Dysmorphia and the DSM-V Conundrum: where does it belong? International Journal of Eating Disorders, 43, 483-491.

Nieuwoudt, J. E., Zhou, S., Coutts, R. A., & Booker, R. (2012). Muscle dysmorphia: Current research and potential classification as a disorder. Psychology of Sport and Exercise, 13, 569-577.

Olivardia, R. (2001). Mirror, mirror on the wall, who’s the largest of them all? The features and phenomenology of muscle dysmorphia. Harvard Review of Psychiatry, 9, 254–259.

Phillips, K. A. & Hollander, E. (1996). Body dysmorphic disorder.In T.A. Widige, A.J. Frances, H.A. Pincus, R. Ross, M.B. First, & W.W. Davis, Eds. DSM-IV Sourcebook, Volume 2. Washington DC: American Psychiatric Association.

Philips, K. A., Gunderson, C. G., Mallya, G., McElroy, S. L., & Carter, W. (1998). A comparison study of body dysmorphic disorder and obsessive-compulsive disorder. Journal of Clinical Psychiatry, 59, 568–575.

Pope, H. G., Jr., Gruber, A. J., Choi, P., Olivardia, R., & Phillips, K. A. (1997). Muscle dysmorphia. An underrecognised form of body dysmorphic disorder. Psychosomatics, 38, 548–557.

Pope, H. G., Jr., Katz, D. L., & Hudson, J. I. (1993). Anorexia nervosa and ‘‘reverse anorexia’’ among 108 male bodybuilders. Comprehensive Psychiatry, 34, 406–409.

Pope, C. G., Pope, H. G., Menard, W., Fay, C., Olivardia, R., & Phillips, K.A. (2005). Clinical features of muscle dysmorphia among males with body dysmorphic disorder. Body image, 2, 395-400.

Veale, D. (2004) Body dysmorphic disorder. Postgraduate Medical Journal. 80, 67-71.

Give me strength: Another brief look at muscle worship

In previous blogs I have examined sthenolagnia (a sexual paraphilia in which individuals derive sexual pleasure and sexual arousal from individuals displaying strength or muscles). Another related behaviour is cratolagnia where – according to Dr. Anil Aggrawal’s book Forensic and Medico-legal Aspects of Sexual Crimes and Unusual Sexual Practices – individuals derive sexual arousal and pleasure more generally from displays of strength (rather than muscles in and of themselves). Following that blog, I received a couple of emails from two males who suggested that I should write a blog on ‘muscle worship’ that although having a sexual aspect, is not the only aspect. According to the Wikipedia entry on muscle worship:

“Muscle worship is a social behaviour, usually with a sexual aspect (a form of body worship), in which a participant, the worshipper, touches the muscles of another participant, the dominator, in sexually arousing ways, which can include rubbing, massaging, kissing, licking, “lift and carry”, and various wrestling holds. The dominator is almost always either a bodybuilder, a fitness competitor, or wrestler, an individual with a large body size and a high degree of visible muscle mass. The worshipper is often, but not always, skinnier, smaller, and more out of shape”.

According to a couple of academic authors, muscle worshippers can be of either gender, and of any sexual orientation, although many authors appear to suggest it is more prevalent among gay men who view bodybuilders as little more than ‘sex objects’ and because bodybuilding is common among members of the gay community (see for instance: Benoit Denizet-Lewis’s 2009 book America Anonymous: Eight Addicts in Search of a Life, or John Edward Campbell’s 2004 book Getting it on Online: Cyberspace, Gay Male Sexuality, and Embodied Identity). A quick search online also suggests there is a large gay pornographic market for muscle worship along with numerous webcam muscle worship sites. Muscle worship appears to have crossovers with other sexually paraphilic behaviour such as sexual masochism. As the Wikipedia entry notes:

“The amount of forceful domination and pain used in muscle worship varies widely, depending on the desires of the participants. Sometimes, the dominator uses his or her size and strength to pin a smaller worshiper, forcing the worshipper to praise the dominator’s muscles, while in other cases, the worshiper simply feels and compliments the muscles of a flexing dominator. Male and female bodybuilders offer muscle worship sessions for a price in order to supplement their low or nonexistent income from bodybuilding competitions. Paid sessions sometimes involve sexual gratification, even when well-known competitors are involved, they offer fans the chance to meet in person and touch a highly muscular man or woman”.

A 2008 paper by Dr. Niall Richardson (2008) in the Journal of Gender Studies also made some interesting (and important) distinctions between muscle worship and two other erotic practices often associated with bodybuilding: ‘hustling’ and ‘sponsorship fantasies’. More specifically, Richardson wrote:

“Alan Klein describes ‘hustling’ as ‘the selling of implicit or explicit sex by a bodybuilder’ (1987, p. 132) and this can range from doing stripogram type work to engaging in full penetrative sex. Likewise muscle-worship is not to be confused with ‘sponsorship’ or ‘growth fantasies’. Katie Arnoldi’s superb first novel, Chemical Pink (a book which will probably become as revered a text for cultural critics of bodybuilding as Sam Fussell’s Muscle [1991]) describes, often in lurid detail, the horrors of female bodybuilding sponsorship. In Chemical Pink, Arnoldi depicts the ‘sponsorship’ agreement between female bodybuilder Aurora and her sponsor Charles. It soon becomes evident that Charles has a Pygmalion fantasy and gains supreme pleasure from his manipulation of Aurora’s body, feeding her endless protein-rich meals and hefty cycles of anabolic steroids and growth hormones (Arnoldi 2001, pp. 100–102, 111). While Henry Higgins delighted in shaping Eliza’s social graces, the muscle sponsor wants to build and shape his idealized female body and, as such, muscle-sponsorship can be compared to other sexual fantasies, such as ‘feederism’, in which the manipulation of the sexual partner’s weight is the sexual pleasure”.

What I found most interesting here is how various aspects of Muscle Worship are compared to both mainstream (i.e., prostitution) and not-so-mainstream (e.g., feederism) sexual behaviours. Another short article I read on muscle fetishism (outside of the gay community as it concerned female muscle growth) on the Sex and the University website suggested that there were also links with macrophilia (sexual arousal from giants) and breast expansion fetishes:

“Female muscle growth (FMG) is a fantasy genre involving muscular growth of a woman. Many who enjoy these fantasies are attracted to Female bodybuilding or other muscular women. This interest frequently centers on the biceps. FMG is related to the growth fantasies giantess and breast expansion fetishism. This fantasy is sometimes about an equalization or reversal of the stereotypical power relationship (that some people imagine/take for granted) in a heterosexual couple”.

As I noted in my previous blog on sthenolagnia, FMG devotees frequent places where female body builders are found (e.g., gyms, health clubs, bodybuilding tournaments, etc.). However, I also noted that some FMG devotion may be based in fantasy rather than actuality, particularly if it is related to aspects of macrophilia and transformation fetishes (both of which I covered in previous blogs). For instance, Marvel Comics character ‘She-Hulk’ is a popular representation of FMG fantasy and can be found on websites such as the Female Muscle Factory. Although there is little in the way of academic research on the topic, many devotees of Muscle Worship appear to be sexually aroused by an equalization (or reversal) of the stereotypical power relationship among heterosexual couples.

Dr Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Further reading

Aggrawal A. (2009). Forensic and Medico-legal Aspects of Sexual Crimes and Unusual Sexual Practices. Boca Raton: CRC Press.

Assael, S. (2007). Steroid Nation. New York: ESPN Books.

Burt, J. (2007). Top five freaky fetishes. The Sun, September 7. Located at: http://www.thesun.co.uk/sol/homepage/news/21158/Top-five-freaky-fetishes.html

Campbell, E. (2004). Getting it on Online: Cyberspace, Gay male Sexuality, and Embodied Identity. London: Routledge.

Carson, H.A. (2010). A Roaring Girl: An interview with the Thinking Man’s Hooker. Bloomington, Indiana: Author House.

Denizet-Lewis, B. (2009). America Anonymous: Eight Addicts in Search of a Life. New York: Simon and Schuster.

Klein, A.M. (1993). Little Big Men: Bodybuilding Subculture and Gender Construction. Albany: State University of New York Press.

Love, B. (2001). Encyclopedia of Unusual Sex Practices. London: Greenwich Editions.

Richardson, N. (2008): Flex-rated! Female bodybuilding: feminist resistance or erotic spectacle? Journal of Gender Studies, 17, 289-301

Sex and the University (2008). Sthenolagnia: Muscle fetishism. Located at: http://sexandtheuniversity.wordpress.com/2008/05/28/sthenolagnia-muscle-fetishism/

Steele, V. (1996). Fetish: Fashion, Sex and Power. Oxford: Oxford University Press.

Wikipedia (2012). Muscle worship. Located at: http://en.wikipedia.org/wiki/Muscle_worship