Blog Archives

Surprise, surprise: A brief overview of our recent papers on strange addictions and behaviours

Following my recent blogs where I outlined some of the papers that my colleagues and I have published on mindfulness, Internet addiction, gaming addiction, youth gambling, workaholism, exercise addiction, and sex addiction, here is a round-up of recent papers that my colleagues and I have published on strange and/or surprising addictions and behaviours.

Foster, A.C., Shorter, G.W. & Griffiths, M.D. (2015). Muscle Dysmorphia: Could it be classified as an Addiction to Body Image? Journal of Behavioral Addictions, 4, 1-5.

  • Background: Muscle dysmorphia (MD) describes a condition characterised by a misconstrued body image in which individuals who interpret their body size as both small or weak even though they may look normal or highly muscular. MD has been conceptualized as a type of body dysmorphic disorder, an eating disorder, and obsessive–compulsive disorder symptomatology. Method and aim: Through a review of the most salient literature on MD, this paper proposes an alternative classification of MD – the ‘Addiction to Body Image’ (ABI) model – using Griffiths (2005) addiction components model as the framework in which to define MD as an addiction. Results: It is argued 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 the use or purchase of physical exercise accessories). 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 (rather than addiction to exercise or certain types of eating disorder). Conclusions: Based on empirical evidence to date, it is proposed that MD could be re-classified as an addiction due to the individual continuing to engage in maintenance behaviours that may cause long-term harm.

Griffiths, M.D., Foster, A.C. & Shorter, G.W. (2015). Muscle dysmorphia as an addiction: A response to Nieuwoudt (2015) and Grant (2015). Journal of Behavioral Addictions, 4, 11-13.

  • Background: Following the publication of our paper ‘Muscle Dysmorphia: Could it be classified as an addiction to body image?’ in the Journal of Behavioral Addictions, two commentaries by Jon Grant and Johanna Nieuwoudt were published in response to our paper. Method: Using the ‘addiction components model’, our main contention is that muscle dysmorphia (MD) actually comprises a number of different actions and behaviors and that the actual addictive activity 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 purchase or use of physical exercise accessories. This paper briefly responds to these two commentaries. Results: While our hypothesized specifics relating to each addiction component sometimes lack empirical support (as noted explicitly by both Nieuwoudt and Grant), we still believe that our main thesis (that almost all the thoughts and behaviors of those with MD revolve around the maintenance of body image) is something that could be empirically tested in future research by those who already work in the area. Conclusions: We hope that the ‘Addiction to Body Image’ model we proposed provides a new framework for carrying out work in both empirical and clinical settings. The idea that MD could potentially be classed as an addiction cannot be negated on theoretical grounds as many people in the addiction field are turning their attention to research in new areas of behavioral addiction.

Maraz, A., Király, O., Urbán, R., Griffiths, M.D., Demetrovics, Z. (2015). Why do you dance? Development of the Dance Motivation Inventory (DMI). PLoS ONE, 10(3): e0122866. doi:10.1371/ journal.pone.0122866

  • Dancing is a popular form of physical exercise and studies have show that dancing can decrease anxiety, increase self-esteem, and improve psychological wellbeing. The aim of the current study was to explore the motivational basis of recreational social dancing and develop a new psychometric instrument to assess dancing motivation. The sample comprised 447 salsa and/or ballroom dancers (68% female; mean age 32.8 years) who completed an online survey. Eight motivational factors were identified via exploratory factor analysis and comprise a new Dance Motivation Inventory: Fitness, Mood Enhancement, Intimacy, Socialising, Trance, Mastery, Self-confidence and Escapism. Mood Enhancement was the strongest motivational factor for both males and females, although motives differed according to gender. Dancing intensity was predicted by three motivational factors: Mood Enhancement, Socialising, and Escapism. The eight dimensions identified cover possible motives for social recreational dancing, and the DMI proved to be a suitable measurement tool to assess these motives. The explored motives such as Mood Enhancement, Socialising and Escapism appear to be similar to those identified in other forms of behaviour such as drinking alcohol, exercise, gambling, and gaming.

Maraz, A., Urbán, R., Griffiths, M.D. & Demetrovics Z. (2015). An empirical investigation of dance addiction. PloS ONE, 10(5): e0125988. doi:10.1371/journal.pone.0125988.

  • Although recreational dancing is associated with increased physical and psychological well-being, little is known about the harmful effects of excessive dancing. The aim of the present study was to explore the psychopathological factors associated with dance addiction. The sample comprised 447 salsa and ballroom dancers (68% female, mean age: 32.8 years) who danced recreationally at least once a week. The Exercise Addiction Inventory (Terry, Szabo, & Griffiths, 2004) was adapted for dance (Dance Addiction Inventory, DAI). Motivation, general mental health (BSI-GSI, and Mental Health Continuum), borderline personality disorder, eating disorder symptoms, and dance motives were also assessed. Five latent classes were explored based on addiction symptoms with 11% of participants belonging to the most problematic class. DAI was positively associated with psychiatric distress, borderline personality and eating disorder symptoms. Hierarchical linear regression model indicated that Intensity (ß=0.22), borderline (ß=0.08), eating disorder (ß=0.11) symptoms, as well as Escapism (ß=0.47) and Mood Enhancement (ß=0.15) (as motivational factors) together explained 42% of DAI scores. Dance addiction as assessed with the Dance Addiction Inventory is associated with indicators of mild psychopathology and therefore warrants further research.

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Greenhill, R. & Griffiths, M.D. (2015). Compassion, dominance/submission, and curled lips: A thematic analysis of dacryphilic experience. International Journal of Sexual Health, 27, 337-350.

  • Objectives: Dacryphilia is a non-normative sexual interest that involves enjoyment or arousal from tears and crying, and to date has never been researched empirically. The present study set out to discover the different interests within dacryphilia and explore the range of dacryphilic experience. Methods: A set of online interviews were carried out with individuals with dacryphilic preferences and interests (six females and two males) from four countries. The data were analyzed for semantic and latent themes using thematic analysis. Results: The respondents’ statements focused attention on three distinct areas that may be relevant to the experience of dacryphilia: (i) compassion; (ii) dominance/submission; and (iii) curled-lips. The data provided detailed descriptions of features within all three interests, which are discussed in relation to previous quantitative and qualitative research within emotional crying and tears, and the general area of non-normative sexual interests. Conclusions: The study suggests new directions for potential research both within dacryphilia and with regard to other non-normative sexual interests.

Atroszko, P.A., Andreassen, C.S., Griffiths, M.D. & Pallesen, S. (2015). Study addiction – A new area of psychological study: Conceptualization, assessment, and preliminary empirical findings. Journal of Behavioral Addictions, 4, 75–84.

  • Aims: Recent research has suggested that for some individuals, educational studying may become compulsive and excessive and lead to ‘study addiction’. The present study conceptualized and assessed study addiction within the framework of workaholism, defining it as compulsive over-involvement in studying that interferes with functioning in other domains and that is detrimental for individuals and/or their environment. Methods: The Bergen Study Addiction Scale (BStAS) was tested — reflecting seven core addiction symptoms (salience, mood modification, tolerance, withdrawal, conflict, relapse, and problems) — related to studying. The scale was administered via a cross-sectional survey distributed to Norwegian (n = 218) and Polish (n = 993) students with additional questions concerning demographic variables, study-related variables, health, and personality. Results: A one-factor solution had acceptable fit with the data in both samples and the scale demonstrated good reliability. Scores on BStAS converged with scores on learning engagement. Study addiction (BStAS) was significantly related to specific aspects of studying (longer learning time, lower academic performance), personality traits (higher neuroticism and conscientiousness, lower extroversion), and negative health-related factors (impaired general health, decreased quality of life and sleep quality, higher perceived stress). Conclusions: It is concluded that BStAS has good psychometric properties, making it a promising tool in the assessment of study addiction. Study addiction is related in predictable ways to personality and health variables, as predicted from contemporary workaholism theory and research.

Atroszko, P.A., Andreassen, C.S., Griffiths, M.D. & Pallesen, S. (2016). Study addiction: A cross-cultural longitudinal study examining temporal stability and predictors of its changes. Journal of Behavioral Addictions, 5, 357–362.

  • Background and aims: ‘Study addiction’ has recently been conceptualized as a behavioral addiction and defined within the framework of work addiction.  Using a newly developed measure to assess this construct, the Bergen Study Addiction Scale (BStAS), the present study examined the one-year stability of study addiction and factors related to changes in this construct over time, and is the first longitudinal investigation of study addiction thus far. Methods: The BStAS and the Ten Item Personality Inventory (TIPI) were administered online together with questions concerning demographics and study-related variables in two waves. In Wave 1, a total of 2,559 students in Norway and 2,177 students in Poland participated. A year later, in Wave 2, 1,133 Norwegians and 794 Polish who were still students completed the survey. Results: The test-retest reliability coefficients for the BStAS revealed that the scores were relatively stable over time. In Norway scores on the BStAS were higher in Wave 2 than in Wave 1, while in Poland the reverse pattern was observed. Learning time outside classes at Wave 1 was positively related to escalation of study addiction symptoms over time in both samples. Being female and scoring higher on neuroticism were related to an increase in study addiction in the Norwegian sample only. Conclusion: Study addiction appears to be temporally stable, and the amount of learning time spent outside classes predicts changes in study addiction one year later.

Dr. Mark Griffiths, Professor of Behavioural Addiction, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Further reading

Greenhill, R. & Griffiths, M.D. (2014). The use of online asynchronous interviews in the study of paraphilias. SAGE Research Methods Cases. Located at: http://dx.doi.org/10.4135/978144627305013508526

Greenhill, R. & Griffiths, M.D. (2016). Sexual interest as performance, intellect and pathological dilemma: A critical discursive case study of dacryphilia. Psychology and Sexuality, 7, 265-278.

Griffiths, M.D. (1996). Behavioural addictions: An issue for everybody? Journal of Workplace Learning, 8(3), 19-25.

Griffiths, M.D. (1999). Dying for it: Autoerotic deaths. Bizarre, 24, 62-65.

Griffiths, M.D. (2001). Stumped! Amputee fetishes. Bizarre, 44, 70-74.

Griffiths, M.D. (2001). Heaven can wait: The psychology of near death experiences. Bizarre, December, 63-66.

Griffiths, M.D. (2012). The use of online methodologies in studying paraphilia: A review. Journal of Behavioral Addictions, 1, 143-150.

Griffiths, M.D. (2013). Bizarre sex. New Turn Magazine, 3, 49-51.

Griffiths, M.D. (2013). Eproctophilia in a young adult male: A case study. Archives of Sexual Behavior, 42, 1383-1386.

Prophet share: A case study of ‘addiction to fortune telling’

In the latest issue of the Journal of Behavioral Addictions, there are two papers that I co-authored on muscle dysmorphia as an addiction (see ‘Further reading’ below). The reason I mention this is because in the same issue there was a case study report by Dr. Marie Grall-Bronnec and her colleagues of a woman (Helen) that was ‘addicted’ to fortune tellers. As noted in their paper:

“Clairvoyance consulting, also known as fortune teller consulting, is a behavior that may seem harmless, but can also become excessive. Fortune telling is defined as the practice of predicting information about a person’s life, using for example…astrology, cartomancy or crystallomancy”.

As I have noted in a number of my previous blogs, I subscribe to the view that if there are clinical criteria for addiction and a behaviour fulfils the criteria, it should be classed as an addiction (irrespective of the behaviour). This has led to accusations of me “watering down the concept of addiction” because such criteria have been applied to behaviours as diverse as gardening and chewing gum. According to the authors of the ‘fortune telling addiction’ paper:

“Helen is a 45-year-old woman who declares early on suffering from ‘a clairvoyance addiction’…She has no particular medical history, except for two major depression episodes after romantic breakups, and does not take any medication. She regularly sees a psychiatrist for support psychotherapy because of negative life events (sexual abuse and death in her family). She is divorced and does not have any children. Her career as a manager seems to fully satisfy her. She decides to seek treatment on account of her excessive financial expenditures due to the consultation of fortune tellers. Another motivation that explains her decision is her age. Indeed, she says she is entering a new phase in her life, after renouncing to the idea of becoming a mother one day”.

According to the paper, Helen had been consulting fortune tellers since she was 19 years old. She started using such people for educational and career advice as she claimed that she was poor at reaching important decisions herself and thought the life choices she made would be wrong. The authors noted that her first meeting with a clairvoyant was an event that gave her a feeling of reassurance. In her mid-twenties, her visits to clairvoyants escalated significantly and ended up losing control of her use of fortune telling”. At that particular time, she was visiting clairvoyants to get relationship advice from them (e.g., “Does he really love me?” and “How long will our relationship last?”). Her current ‘addiction to clairvoyants’ dates back to her mid- to late-30s when she got divorced after the failure of her marriage:

“She repeatedly returned to fortune telling to reassure herself about the future of her relationship, and increasingly so as it deteriorated. The breakup worsened the disorder. Since her divorce, she consults fortune tellers – not always the same person – on the phone or online, in a compulsive way, more and more often (up to every day), for longer and longer periods of time (up to 8 hours a day) and spends each time more and more money (up to 200 euros per session). As she is never satisfied with the fortune tellers’ predictions, she will consult again very soon after the latest call or connection. Every choice she has to make, from the most trivial (going to the movies) to the most important (making relationship decisions), leads her to irrationally consult a fortune teller”

Before each consultation she said he got very excited at the prospect and that the experience relieved all of her psychological discomfort (at least in the short-term). However, not long after consultations she would feel incredibly guilty. The paper also reported that during consultations with the fortune tellers, she was totally convinced that they could see her future and that their predictions would come true. He authors went on to report:

“This excessive behavior gives her some kind of reassurance and allows her to make up for her lack of self-confidence. In that sense, the excessive behavior could be considered as an attempt at self-medication or as a way to cope with negative emotions. However, Helen knows that her belief in the fortune tellers’ ability to predict the future is completely irrational. This brings major adverse consequences, particularly in financial terms: despite a comfortable income, she is indebted. She also says having low self-esteem, due to her in- ability to resist her strong urge to consult fortune tellers, and due to her being isolated from the others because of the time spent consulting fortune tellers. Helen succeeds in limiting the consultation of fortune tellers during short periods of time, when her financial situation becomes too critical”.

The authors of the report also used different sets of addiction criteria to determine whether Helen was truly addicted to consulting clairvoyants. They also used my own six criteria (salience, mood modification, tolerance, withdrawal, conflict, and relapse). Here are the authors own description of the behaviour using my components model:

  • Salience: “Consulting fortune tellers becomes the most important activity in Helen’s life and dominates her thinking (preoccupation and cognitive distortions), feelings (cravings) and behavior (she has progressively quit all her leisure activities, particularly going out with friends)”.
  • Mood modification: “Helen says feeling excitement before each consultation, but also feels nervous tension and anxiety. This excessive behavior gives her some kind of reassurance and the excessive behavior could be considered as an attempt at self-medication or a way to cope with negative emotions”.
  • Tolerance: “Over time, Helen has been feeling a growing need to consult fortune tellers, and the consultations have to last longer to obtain the same effect of relief”.
  • Withdrawal: “When she attempts to resist the urge to consult or has to refrain from consulting fortune tellers (in the case of her financial situation being too critical, for example), she feels tense and nervous”.
  • Conflict: “Helen knows that her use of fortune telling is problematic, and that it brings very negative consequences. However, she cannot refrain from consulting fortune tellers, leading to an intra-psychic conflict and guilt”.
  • Relapse: “Over the years, Helen has made repeated efforts to reduce and stop this problematic behavior. Her clinical course is characterized by relapses and remissions”.

Based on the evidence presented, there is clear evidence that Helen’s behaviour was problematic. Whether it was genuinely addictive is debatable but the authors provided some evidence that (in this case at least) the behaviour appeared to include some addictive aspects. The authors conclude that in addition to individual risk factors, other situational and structural characteristics may have played a role in the development of problematic behaviour concerning Helen’s ‘addiction’:

Regarding the risk factors related to the object of addiction (i.e. fortune telling use), one might mention, inter alia, the possibility to consult online, which guarantees anonymity. Furthermore, the Internet increases both accessibility and availability. Finally, the money spent during fortune telling sessions seems virtual, which makes it all the more easy to spend. Increased risks related to the Internet have already been described on gambling (Griffiths, Wardle, Orford, Sproston & Erens, 2009). Regarding socio-environmental risk factors, today’s society encourages the need for control and does not give way to uncertainty. In Helen’s case, all the conditions were met for the fortune telling use to become excessive, and we are tempted to conclude that it is an addictive-like phenomenon”.

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

Further reading

Foster, A.C., Shorter, G.W. & Griffiths, M.D. (2015). Muscle Dysmorphia: Could it be classified as an Addiction to Body Image? Journal of Behavioral Addictions, 4, 1-5.

Grall-bronnec, M. Bulteau, S., Victorri-Vigneau, C., Bouju, G. & Sauvaget, A. (2015). Fortune telling addiction: Unfortunately a serious topic about a case report. Journal of Behavioral Addiction, 4, 27-31.

Griffiths, M.D. (1996). Behavioural addictions: An issue for everybody? Journal of Workplace Learning, 8(3), 19-25.

Griffiths, M. (2005). A “components” model of addiction within a biopsychosocial framework. Journal of Substance Use, 10, 191–197.

Griffiths, M.D., Foster, A.C. & Shorter, G.W. (2015). Muscle dysmorphia as an addiction: A response to Nieuwoudt (2015) and Grant (2015). Journal of Behavioral Addictions, 4, 11-13.

Griffiths, M., Wardle, H., Orford, J., Sproston, K. & Erens, B. (2009). Sociodemographic correlates of internet gambling: Findings from the 2007 British gambling prevalence survey. CyberPsychology and Behavior, 12, 199–202.

Hughes, M., Behanna, R. & Signorella, M. L. (2001). Perceived ac- curacy of fortune telling and belief in the paranormal. Journal of Social Psychology, 141(1), 159–160.

Shein, P. P., Li, Y. Y. & Huang, T. C. (2014). Relationship between scientific knowledge and fortune-telling. Public Understanding of Science, 23(7), 780–796.

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.