The Classification of Muscle Dysmorphia

Abstract

For some time, society’s emphasis on appearance has negatively affected women. Now we’re finding increasing numbers of men who are also overly dissatisfied with their bodies. This trend has led to a new disorder, muscle dysmorphia (MD), which is charac- terized by a preoccupation with muscularity accompanied by per- ceptual, affective, and behavioral components that interfere with daily activities. Currently, MD is not included in the DSM-IV, although it is purported to be a kind of body dysmorphic disorder (BDD), which in turn is a somatoform disorder. This study investi- gated relationships among symptoms of MD and variables most relevant to a DSM classification of men who lift weights regularly. No relationship was found between MD and a measure of somato- form disorder. Instead, BDD, OCD (obsessive-compulsive disor- der), body dissatisfaction, and hostility are the main predictors of MD. This suggests that MD is an OCD spectrum disorder, rather than a somatoform disorder.

Full text

The Classification of Muscle Dysmorphia
DENISE MARTELLO MAIDA and SHARON LEE ARMSTRONG
La Salle University
For some time, society’s emphasis on appearance has negatively
affected women. Now we’re finding increasing numbers of men
who are also overly dissatisfied with their bodies. This trend has
led to a new disorder, muscle dysmorphia (MD), which is charac-
terized by a preoccupation with muscularity accompanied by per-
ceptual, affective, and behavioral components that interfere with
daily activities. Currently, MD is not included in the DSM-IV,
although it is purported to be a kind of body dysmorphic disorder
(BDD), which in turn is a somatoform disorder. This study investi-
gated relationships among symptoms of MD and variables most
relevant to a DSM classification of men who lift weights regularly.
No relationship was found between MD and a measure of somato-
form disorder. Instead, BDD, OCD (obsessive-compulsive disor-
der), body dissatisfaction, and hostility are the main predictors of
MD. This suggests that MD is an OCD spectrum disorder, rather
than a somatoform disorder.
Keywords: men weightlifters, muscle dysmorphia, body dissatis-
faction, muscularity, DSM-IV, body dysmorphic disorder, obses-
sive compulsive disorder
American men are experiencing increased concern about their appearance (Olivar-
dia, Pope, Mangweth, & Hudson, 1995). One reason may be due to Western cul-
ture’s growing emphasis on unrealistic, overly muscular images of men. These mus-
cularly endowed physiques, unattainable for the average male, have been depicted in
all forms of the media and even in toy action figures. One need only compare the
73
Correspondence concerning this article should be sent to Denise Maida, Department of Psychology, La
Salle University, 1900 W. Olney Avenue, Philadelphia, PA 19131. Electronic mail: denisemaida@
comcast.net.
International Journal of Men’s Health, Vol. 4, No. 1, Spring 2005, 73-91.
© 2005 by the Men’s Studies Press, LLC. All rights reserved.

early GI Joe action-figure body of 1964 with the “super-articulated” GI Joe body of
today to glimpse the intrusion of society’s devotion to muscularity into child culture.
Not surprisingly, an increasing number of teenage boys and men are concerned that
they are neither muscular enough nor lean enough. These concerns have been
accompanied by a higher incidence of eating disorders in males (Olivardia et al.,
1995). In fact, Andersen, Cohn, and Holbrook (2000) postulate that up to 25-30 per-
cent of eating disordered individuals might be males.
MUSCLE DYSMORPHIA
With the advent of increased body dissatisfaction comes a fairly new, still under-
researched disorder, muscle dysmorphia (MD). It has already reached public aware-
ness through the publication of The Adonis Complex (Pope, Phillips, & Olivardia,
2000). Pope, Katz, & Hudson (1993) originally referred to this disorder in the med-
ical literature as “Reverse Anorexia Nervosa” because of its similarities to certain
aspects of anorexia nervosa (AN). Individuals suffering from these two disorders
share common perceptual and affective characteristics. Both show a preoccupation
with appearance and experience extreme distress and anxiety associated with these
preoccupations. They hide their bodies in oversized clothing and participate in com-
pulsive behaviors such as specific eating rituals with strictly monitored food intake
(not to be confused with compulsive eating behaviors, in which a person overeats
without regard to physical cues of hunger or satisfaction, or binges without purging)
and excessive exercise. However, whereas anorexics view their emaciated bodies as
too fat, individuals suffering from MD perceive their often extremely muscular
physiques as too small and even puny. Moreover, people with MD may engage in
harmful and even self-destructive behaviors such as continuing to lift weights even
when they are injured and using anabolic steroids (Olivardia, Pope, & Hudson,
2000). A fundamental difference between AN and MD is that anorexics, being con-
cerned with perceived body fat, engage in characteristic pathological eating behav-
iors with excessive exercise as a secondary characteristic, while those suffering from
muscle dysmorphia, being concerned with underdeveloped musculature, engage in
pathological exercise routines with restrictive eating as a secondary characteristic
(Olivardia, 2001).
The identification of muscle dysmorphia emerged from three studies examining
the use of anabolic steroids in weightlifters (Pope et al., 1993). The objective of these
studies was not originally associated with muscle dysmorphia. Obviously, not all
men who lift weights and participate in strict exercise and diet regimens fall into this
pathological category. In fact, most men who exercise at gyms have healthy attitudes
about fitness and realistic views about their bodies (Pope, Gruber, Choi, Olivardia, &
Phillips, 1997). However, striking symptoms of obsession with muscularity emerged
in these studies, thereby moving the authors to recommend that what had been previ-
ously referred to as “reverse anorexia nervosa” should be termed “muscle dysmor-
phia” and be considered a type of body dysmorphic disorder (BDD).
Whereas BDD is defined in the Diagnostic and Statistical Manual, 4th edition
(American Psychiatric Association, 1994) as a preoccupation with an imagined
defect in appearance causing clinically significant distress or impairment in social,
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MAIDA and ARMSTRONG

occupational, or other important areas of functioning, not being the result of another
mental disorder, Pope et al. (1997) defined muscle dysmorphia as a preoccupation
with a misperception that muscles in general are small despite sufficient muscular-
ity. This disorder affects both men and women but appears to be more prevalent in
men. The mean age of onset is 19.4 years (SD = 3.6) (Olivardia, 2001; Olivardia et
al., 2000; Pope et al., 1997).
An important outcome of the studies reviewed above is the suggestion that mus-
cle dysmorphia is a valid diagnostic category. However, acknowledgment of its very
existence depends upon where in the DSM system it should be classified.
MD and OCD Spectrum Disorders. Appearing to be a subtype of BDD, muscle dys-
morphia would fall under the category of somatoform disorders. However, it has
been suggested that BDD, and therefore MD, might be more appropriately conceptu-
alized as an obsessive-compulsive (or OCD) spectrum disorder1because of its simi-
larities to OCD characteristics. During the DSM-IV revision process, consideration
was given to moving BDD to the anxiety disorders section because of these similari-
ties. The change was not implemented because of a dearth of comparison data
(Phillips & Hollander, 1996). Since that time, a wealth of research has documented
substantial similarities such as intrusive, obsessional fears and compulsive rituals
(Bienvenu, Samuels, Riddle, Hoehn-Saric, Kung-Yee, & Cullen, 2000; Phillips,
1998; Phillips, Dwight, & McElroy, 1998; Phillips, Gunderson, Mallya, McElroy, &
Carter, 1998; Saxena, Winograd, Dunkin, Maidment, Rosen, Vapnik, et al., 2001;
Simeon, Hollander, Stein, Cohen, & Aronowitz, 1995; Veale et al., 1996.) Addition-
ally, BDD and OCD also exhibit similarities in age of onset, course of illness, and
high comorbidity (Lydiard, Brady, & Austin, 1994; Phillips, Pope, & McElroy,
1994; Phillips, McElroy, & Hudson, 1995; Zimmerman & Mattia, 1998). Similari-
ties in response to treatment have also been observed in the two disorders (Hollander
& Benzaquen, 1997; Hollander, Allen, Kwon, Mosovich, Schmeidler, & Wong,
1999; Phillips et al., 1995, 1998; Rosen, Reitter, & Orosan, 1995; Saxena et al.,
2001).
While there appear to be more similarities than differences between BDD and
OCD, the differences are important, suggesting more of a spectrum relationship than
an interchangeable label. For example, fewer individuals with BDD are married
(Phillips et al., 1998), which is consistent with the theory that BDD is more highly
correlated with social isolation and impairment than OCD. It was also found that
insight is more generally impaired in BDD than in OCD so that subjects are con-
vinced that their defects are real (Phillips et al., 1998; Simeon et al., 1995). More-
over, a substantial percentage of BDD but not OCD subjects have been found to be
delusional (Phillips et al., 1994). What these differences in social impairment and
insight (along with possible delusions) might suggest is that BDD (and thus MD)
relates to OCD as a more socially phobic, depressed, and psychotic variant (Phillips,
2000; Phillips et al., 1998).
While the research literature now supports a recategorization of BDD, there is
still a dearth of literature investigating the relationship of MD to either BDD or
OCD. The few existing studies were consistent, however, in finding that those suf-
fering from muscle dysmorphia experienced preoccupations and obsessional
75
THE CLASSIFICATION

thoughts about muscularity, usually accompanied by compulsive behaviors, such as
excessive exercise, checking and comparing their muscularity to others, and seeking
reassurance, thus providing support for a relationship between MD and OCD (Oli-
vardia, 2001; Olivardia et al., 2000; Pope et al., 1997).
MD and Mood Disorders. Olivardia et al. (2000) elucidated the increased co-mor-
bidity of muscle dysmorphia and mood disorders. Compared to the normal control
group, where 20 percent had a history of mood disorders, those with muscle dysmor-
phia had a 58 percent incidence of major depressive disorder and bipolar disorder.
MD and Anxiety Disorders. There was also an increased comorbidity of muscle dys-
morphia with anxiety disorders. Lifetime prevalence of anxiety disorders was found
in 29 percent of men with muscle dysmorphia compared to three percent of the com-
parison group (Olivardia et al., 2000).
MD and Eating Disorders. Phenomenologically, muscle dysmorphia and eating dis-
orders appear closely related. The case-control study by Olivardia et al. (2000) com-
pared men with muscle dysmorphia to normal weightlifters. Men with muscle dys-
morphia scored similarly on all Eating Disorder Inventory (EDI) subscales (Garner,
Olmstead, & Polivy, 1983) compared to people with eating disorders. Results indi-
cated that muscle dysmorphia and eating disorders share symptoms in the EDI sub-
scales “perfectionist traits,” “maturity fears,” “feelings of ineffectiveness,” and
“drive for thinness.” However, the drive for thinness manifests differently in men
with muscle dysmorphia, who are not preoccupied with being overweight per se but
are instead extremely concerned about leanness, that is, in attaining a low percentage
of body fat.
Hudson & Pope (1990) suggested that MD, OCD, bulimia, anorexia, and some
anxiety disorders may share a common physiological abnormality and thus MD
might be a member of this “family” of affective spectrum disorders. Sociocultural
influences that might predispose or cultivate this condition are also similar to mes-
sages from the media about the link between muscularity and masculinity. This link
is evidenced by the covers of magazines of men with rippled muscles and tight,
sculpted abs and the increase in muscularity of action figures such as GI Joe and
Star Wars characters (Hall, 2000; Pope, Olivardia, Gruber, & Borowiecki, 1999;
Spitzer, Henderson, & Zivian, 1999). Unfortunately, this idealized physique is not
attainable by the average male without the use of potentially harmful drugs.
Dissimilarities between muscle dysmorphia and eating disorders are found in
familial histories and childhood trauma. A history of family discord and childhood
abuse (physical, sexual, and/or emotional) are strong etiological factors in the devel-
opment of eating disorders (DeGroot, Kennedy, Rodin, & McVey, 1992; Everill &
Waller, 1994; Fallon, Sadik, Saoud, & Garfinkel, 1994) but not in cases of MD. It
should be noted that prominent features of muscle dysmorphia are shame and
embarrassment, thereby possibly affecting the reporting of childhood abuse(s).
MD and Exercise Disorders. Like muscle dysmorphia, exercise disorders have not
been recognized as separate disorders in the DSM-IV. What appear to be related con-
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MAIDA and ARMSTRONG

ditions—exercise addiction (Glasser, 1976), obligatory running (Coen & Ogles,
1993), and morbid exercising (Veale, 1987)—have been described in the DSM and
termed “exercise dependency.” Exercise dependency might appear to be related to
muscle dysmorphia in that the individuals commit exorbitant amounts of time to
working out. Exercise dependency has also attracted researchers’ interests (Blumen-
thal, O’Toole, & Chang, 1984; Brewerton, Stellefson, & Hibbs, 1995; Furst & Ger-
mone, 1993; Yates, 1991). The diagnostic criteria of exercise dependency include
biological symptoms such as tolerance and withdrawal symptoms as well as psy-
chosocial symptoms such as interference with functioning in other areas of one’s life.
To date, research has focused only on aerobic exercise dependency, which differs
from muscle dysmorphia in the desired end result. For example, compulsive aerobic
exercisers seem to desire the “runner’s high” endorphin rush (Blumenthal, O’Toole,
& Chang, 1984) rather than an enhanced, large muscular physique. In contrast, indi-
viduals suffering from muscle dysmorphia avoid aerobic exercise since this kind of
fitness routine tends to reduce lean muscle and body size (Pope et al., 1997).
SUMMARY
The literature reviewed above supports the contention that BDD is an OCD spec-
trum disorder rather than a somatoform disorder. Since MD is a form of BDD, it
would also then fall within the OCD spectrum disorders. MD is also related to eating
disorders and to mood and anxiety disorders. While Olivardia et al., (2000) have
already postulated MD to be a viable diagnostic category in its own right, direct
empirical support for the placement of MD is still lacking.
THE STUDY
Following previous studies, we sought a sample of men who lift weights and who
would manifest a broad range of attitudes about their bodies from those falling into
the mainstream to those whose preoccupations may be classified as pathological. In
this sample, we investigated the relationship between muscle dysmorphic attributes
with symptoms of obsessive-compulsive disorder and eating disorders as well as
depression and anxiety. Because we intended to differentiate among variables that
predicted MD from those that do not, we included some additional personality vari-
ables that we suspected were unrelated to MD to provide a contrast set.
Figure 1 illustrates the proposed model of the relationships among OCD, BDD,
eating disorders, and MD based on the previous research. Since it is assumed that
symptoms of depression and anxiety are pervasive throughout many of these disor-
ders, they are not individually depicted in the suggested model. This model now pro-
vides a framework from which to conduct the empirical study that is needed to
determine the placement of MD.
The hypotheses that guided this research were that symptoms of muscle dys-
morphia are:
1. positively related to variables measuring symptoms of BDD, OCD, eating disor-
ders, depression, and anxiety;
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THE CLASSIFICATION

2. less related to a variable measuring symptoms of somatoform disorder; and
3. unrelated to other variables measuring symptoms of personality and pathology,
specifically hostility, interpersonal sensitivity, paranoid ideation, and psychoti-
cism.
The reader should note that variable names mentioned in these hypotheses and
throughout this study refer to dimensions of symptoms rather than to clinically diag-
nosed groups.
METHOD
Subjects. The subjects were 106 male volunteers between the ages of 18 and 45 who
were involved in varying weight lifting and/or fitness routines. The sample came
from clients at private and university gyms in Pennsylvania and New York. Subjects
need not have been competitive athletes but were screened before being asked to
participate in the study and indicated they lifted weights four or more times weekly.
Materials. Five questionnaires were given to each subject. The first questionnaire,
an informational form, included six questions: age range, employment and/or stu-
dent status, highest level of education attained, marital status, involvement in orga-
nized sports, and months/years subject had been weight training.
The second questionnaire measured the dimension of muscle dysmorphia. The
two parts to this questionnaire consisted of the Drive for Muscularity Scale
(McCreary & Sasse, 2000) and the Muscle Dysmorphia Symptom Questionnaire
(MDSQ) (Olivardia et al., 2000).
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MAIDA and ARMSTRONG
Figure 1. Some proposed obsessive-compulsive spectrum disorders and their
possible relationship to OCD and one another.
Eating
Disorder
Symptoms
Body
Dysmorphic
Symptoms
Obsessive-
Compulsive
Symptoms
Muscle
Dysmorphia
Symptoms

The Drive for Muscularity Scale (DMS) is a 15-item, self-report questionnaire
designed to measure an individual’s perception that he or she is not muscular enough
and that bulk should be added to his or her frame (irrespective of the person’s per-
centage of muscle mass or body fat). Items are scored on a six-point scale. The scores
were normed on an adolescent population (M= 37.78, SD = 12.20). Reliability of the
DMS is more than adequate with Cronbach alpha reliability coefficients of .84
(males) and .78 (females). Measures of validity were also found to be adequate. In
studies of convergent validity, an ANOVA found that higher DMS scores were
related to subjects’ attempts to gain weight. The second method for examining con-
vergent validity was to assess the correlations between the DMS and the number of
times per week the participant typically engaged in weight training activities. The
frequency of weight training was positively but weakly related to DMS scores (r=
.24). In terms of discriminant validity, the DMS had no significant correlation with
the drive for thinness construct of the Eating Attitudes Test (r= -.05) and had a
slightly negative correlation with the Body Dissatisfaction Scale (r= -.15).
The second part of this questionnaire is an unpublished symptom inventory, the
Muscle Dysmorphia Symptom Questionnaire, developed by Olivardia & Pope
(2000), to assess the severity of muscle dysmorphia. Currently, there are neither reli-
ability nor validity data.
The third questionnaire, the Body Dysmorphic Disorder—Yale-Brown Obses-
sive-Compulsive Scale (Phillips, Hollander, Rasmussen, Aronowitz, DeCaria, &
Goodman, 1997) is a 12-item, semi-structured instrument designed to assess severity
of BDD on a four-point scale (maximum 48). Each item is rated as a composite of all
the subjects’ appearance-related obsessions and compulsive behaviors independent of
their context. The scale was normed on 125 subjects with BDD (63 men and 62
women). Interclass correlation coefficients demonstrated excellent interrater reliabil-
ity across four raters for the total score and individual item scores. Test-retest relia-
bility over an interval of one week was also acceptable (r= .88). Cronbach’s alpha
coefficient was .80, indicating adequate homogeneity of the scale. Total score on the
BDD–Y-BOCS was significantly correlated with measures of illness severity.
The Brief Symptom Inventory (Derogatis, 1984), the fourth questionnaire, is a
shortened form of the Symptom Checklist–90-R (SCL-90-R) and was used for our
purposes to measure tendencies of somatization (SOM), obsessive-compulsive dis-
order (OCD), depression (DEP), anxiety (ANX), as well as the unrelated disorders
hostility (HOS), interpersonal sensitivity (IS), paranoid ideation (PI), and psychoti-
cism (PSY), which in our study served to establish discriminant validity. The BSI
consists of 53 items scored on a five-point scale constituting eight subscales.2The
scores used for our comparison purposes were normed on a male nonpatient popula-
tion. The reliability, validity, and utility of the BSI instrument have been tested in
more than 400 research studies. The BSI was found to have adequate psychometric
properties with a satisfactory internal consistency ranging from a low of .77 for Psy-
choticism to a high of .90 for depression. Test-retest measures within a one-week
interval produced coefficients between .80 and .90 for somatization. Results of vali-
dation studies have proved adequate as well. A high degree of convergent validity
for the BSI was found with correlations ranging from .50 to .75 (Derogatis, 1984).
79
THE CLASSIFICATION

The Eating Disorders Inventory (EDI: Garner, Olmstead, & Polivy, 1983), the
fifth questionnaire used, measures the range of eating disorder characteristics. There
are eight subscales that reflect attitudinal, behavioral, and psychological correlates
of anorexia nervosa and bulimia nervosa: drive for thinness (DT), bulimia (BUL),
body dissatisfaction (BDIS), ineffectiveness (INEF), perfectionism (PER), interper-
sonal distrust (IDIS), interoceptive awareness (IA), and maturity fears (MF). The
scores used for comparison purposes were normed on a female non-patient popula-
tion. Psychometric properties for this test are acceptable. Measures of internal con-
sistency have been reported as high (Cronbach’s alpha = .93) while test-retest relia-
bilities were between 0.65 and 0.97 (Garner et al., 1983).
Procedure. Signs were posted in and around gym/fitness area entrances asking for
volunteers to complete questionnaires for a study looking at male fitness attitudes.
The researcher and associates also visited Philadelphia and New York area non-
commercial, small gyms to solicit volunteers and relied on gym managers to distrib-
ute questionnaires to clients. Each set of randomly ordered questionnaires was
placed in a postage-paid, self-addressed mailing envelope. The instructions advised
subjects of absolute anonymity and emphasized the importance of completing each
question on each questionnaire regardless of its personal relevance in order for data
to be included in the study.
RESULTS
Characteristics of the Sample. Of the 200 questionnaires distributed, 106 partici-
pants responded, consisting entirely of men who lifted weights regularly (at least
four times a week).
The majority (about 79%), were 18 to 32 years old, about 11% were 33 to 40
years old, and about 9% were in their early 40s. Of the 106 participants, about 74%
were employed, and 54% were college students. Concerning marital status, 56%
were single, 22% had a significant other, 17% were married, and nearly 5% were
divorced or separated. Fifteen percent of the subjects had not attended college,
almost 29% had completed at least four years of college, and 56% had attended col-
lege for one to three years. Of those who had attained a college degree, 3.8%
obtained an associate’s degree, 26.4% obtained a bachelor’s degree, 5.7% obtained a
master’s degree, 5.7% possessed a medical or law degree, and fewer than 1% pos-
sessed other doctorates.
Descriptive statistics for all psychological variables for both the normed sam-
ples and the study sample are reported in Table 1.
Incidence of Heightened Symptoms of Muscle Dysmorphia. We intentionally did not
study a sample of men who were diagnosed with muscle dysmorphia, and thus our
sample included a wider range of symptoms, which is an advantage for a correla-
tional analysis. Nevertheless, the extreme end of our sample is not unlike samples of
diagnosed cases featured in previous research (Olivardi et al., 2000). For a partici-
pant to be considered as having heightened symptoms of muscle dysmorphia, he
needed to demonstrate a high drive for muscularity (a score of over 31 on the Drive
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MAIDA and ARMSTRONG

for Muscularity Questionnaire, McCreary & Sasse, 2000) and to affirmatively answer
several questions related to being preoccupied with thoughts of his muscularity and
whether this preoccupation disrupted social functioning. As it turned out, our subjects
who met the last two criteria also exhibited scores of over 52 on the Drive for Muscu-
larity Questionnaire. About 25%, or 26 participants, fit into this category. Of this
25%, approximately 85% were between the ages of 18 and 32 years, 70% were
unmarried, 56% were unemployed, 35% had a college degree, 61% were currently
enrolled in or had previously attended college, 57% had been weightlifting for more
than five years, and 40% had been seriously weightlifting for more than three years.
Relationships Among Variables of Interest. See Table 2 for the correlation matrix for
all variables. As hypothesized, MD symptoms were found to be positively related to
variables measuring BDD, OCD, depression, anxiety, body dissatisfaction, and per-
fectionism (eating disorder scales). MD symptoms were found unrelated to symp-
toms of somatoform disorder. The remaining five eating disorder scales indicated no
relationship to MD. Other variables, as expected, showed little or no correlation with
MD, with the exception of hostility, which was found to have a moderately positive
relationship to MD.
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THE CLASSIFICATION
Table 1
Descriptive Statistics of All Normed Samples and of Variables of Study Sample
Normed Sample Study Sample Possible
Mean (SD) Mean (SD) Rangeb
Muscle Dysmorphia (DMS) 37.96 (12.20)a55.27 (16.01) 6-90
Body Dysmorphia (BDD) 11.29 (7.34) 29.30 (7.50) 0-48
Somatization (SOM) 0.32c(0.38c) 0.23 (0.32) 0-28
Obsessive-Compulsive (OCD) 1.81c(0.69c) 0.37 (0.041) 0-24
Depression (DEP) 1.02c(0.80c) 0.21 (0.33) 0-26
Anxiety (ANX) 0.65c(0.57c) 0.26 (0.31) 0-44
Hostility (HOS) 0.99c(0.83c) 0.03 (0.040) 0-20
Interpersonal Sensitivity (IS) 0.49c(0.59c) 0.24 (0.38) 0-16
Paranoid Ideation (PI) 0.74c(0.52c) 0.03 (0.041) 0-20
Psychoticism (PSY) 0.43c(0.48c) 0.15 (0.27) 0-20
Drive for Thinness (DT) 5.76 (1.91) 5.00 (1.60) 0-25
Bulimia (BUL) 0.92 (1.08) 2.00 (0.014) 0-30
Body Dissatisfaction (BDIS) 12.89 (3.76) 10.20 (0.032) 0-45
Ineffectiveness (INEF) 2.84 (1.77) 2.00 (0.015) 0-45
Perfectionism (PER) 9.94 (5.29) 5.20 (0.16) 0-35
Interpersonal Distrust (IDIS) 2.28 (1.86) 2.20 (0.012) 0-35
Interoceptive Awareness (IA) 2.72 (1.96) 2.90 (0.47) 0-65
Maturity Fears (MF) 0.99 (1.18) 2.50 (0.33) 0-40
Notes: aSample statistic; bA higher value indicates more severe symptoms; cOriginal score recalculated for
comparison purposes.

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MAIDA and ARMSTRONG
Table 2
Correlations of All Hypothesized Variables
BDD SOM OCD DEP ANX HOS IS PI PSY DT BUL BDIS INEF PER IDIS IA MF
MD .61** .16 .52** .36** .39** .45** .12 .11 .05 .15 .14 .48** .01 .41** .04 .03 .15
BDD .29** .43* .44** .38** .27* .39** .15 .13 .17 .03 .32** .09 .34** .01 .10 .12
SOM .23* .33* .48* .23* .12 .28* .21* .07 .03 .20* .06 .31** .12 .12 .02
OCD .34** .31** .30** .12 .11 .05 .13 .01 .29** .07 .37** .08 .01 .10
DEP .72** .26** .54** .48** .52** .13 .00 .31** .16 .38** .25** .15 .12
ANX .37** .52** .60** .52** .16 .06 .32** .15 .49** .32** .17 .04
HOS .08 .26** .08 .12 .09 .38** .01 .25** .18 .08 .07
IS .43** .58** .02 .13 .09 .03 .24* .17 .01 .09
PI .64** .06 .07 .14 .08 .12 .63** .12 .06
PSY .01 .01 .02 .08 .01 .44** .17 .05
DT .13 .16 .09 .10 .04 .25** .01
BUL .03 .13 .06 .03 .04 .05
BDIS .04 .31** .10 .05 .14
INEF .06 .03 .01 .11
PER .06 .06 .02
IDIS .10 .14
IA .26**
MF
Notes. *Correlation is significant at the .05 level (2-tailed). **Correlation is significant at the .01 level (2-tailed).

Predicting Muscle Dysmorphia. To better understand these relationships, a stepwise
multiple regression was performed on seven variables that had figured in our
research hypotheses (and also had a statistically significant relationship with MD).
The weaker correlated measures (depression, anxiety, and perfectionism) were not
found to contribute significantly to the prediction of MD. The regression indicated
that the four remaining variables (BDD, OCD, BDIS, and HOS) were significant
predictors of MD (F(4, 101) = 29.70, p= .000. The multiple correlation coefficient
was .74, indicating approximately 54% of the variance of the MD model can be
accounted for by the linear combination of these measures. Although BDD was
found to be the strongest predictor of MD (adjusted R squared = .36, p= .000),
OCD, HOS, and BDIS all added to the predictive strength (adjusted R squared =
.52, p= .000). A hierarchical multiple regression was also performed on these seven
variables, which produced the same four significant predictor variables.
Identifying Mediators. The four variables identified as predictors of MD (BDD,
OCD, BDIS, and HOS) were also found to correlate significantly, although mildly,
with one another, with the exception of OCD and BDD, where there was a stronger
relationship. Thus, it would appear that some of these variables are likely mediators
for others. Based on previous research reviewed above, it would seem that OCD is a
root variable for MD, mediated by BDD. This is just another way of expressing the
idea that MD is a form of BDD, which research suggests is an OCD spectrum disor-
der. While we were initially surprised that hostility symptoms significantly predicted
MD, further investigation of the research literature concerning the relationship of
hostility and eating disorders led us to consider that it should be included in our
model (see further discussion below). Also, since previous research has established a
strong connection between BDIS symptoms and OCD symptoms, BDIS was entered
as a mediator candidate.
To test for mediation, a four-step regression procedure introduced by Baron and
Kenny (1986) was conducted for each potential mediator. The mediators in the
model to be tested were BDD, HOS, and BDIS. OCD was the independent variable
(IV), and MD was the dependent variable (DV). The first step in each procedure was
to regress the dependent variable (DV) on the independent variable (IV). In Step 2,
the mediator was regressed on the independent variable. Next, the DV was regressed
THE CLASSIFICATION
Table 3
Four-Step Regression to Test Mediation of Variables on OCD
Standardized Coefficient
Variable (β‚ or Beta)
Step 1 Step 4
Hostility (HOS) .445 .305
Body Dissatisfaction (BDIS) .477 .313
Body Dysmorphic Disorder (BDD) .519 .316
83

on the IV. Finally, in Step 4 the DV was regressed on both IV and on the mediator.
To satisfy mediation, the IV must affect both the DV and the mediator in the pre-
dicted direction in Steps 1 and 2, the mediator must affect the DV in the predicted
direction in Step 3, and the effect of the IV must be less in Step 4 than in Step 1. All
the requirements for mediation were satisfied for each of the potential mediators.
The standardized coefficient (β) dropped in all cases from Step 4 to Step 1, as can be
seen in Table 3.
These analyses indicate that hostility, body dissatisfaction, and body dysmor-
phic symptoms are all mediators of obsessive-compulsive symptoms’ effect on mus-
cle dysmorphia symptoms. The model that has emerged that best captures these
results is depicted in Figure 2.
DISCUSSION
The sample obtained in this study was a reasonable pool to investigate the relation-
ships among the variables of interest here. As anticipated, there was a suitable inci-
dence of acute muscle dysmorphia symptoms. In this study, nearly 25% of the par-
ticipants (26 out of 106 men) met the previously delineated criteria for the diagnosis
of MD (Pope et al., 1997). Moreover, these 26 men shared common characteristics
with the MD sample from an earlier study (Olivardia et al., 2000). These characteris-
tics included preoccupation with a perceived inadequacy in their muscularity, which
was distinguished from fear of fat (as in anorexia nervosa) or a preoccupation only
with other aspects of appearance (as in other forms of body dysmorphic disorder).
84
MAIDA and ARMSTRONG
Figure 2. Model of relationship between MD and OCD, BDD, BDIS, and HOS
symptoms.
Obsessive-
Compulsive
Symptoms
r = .29
r = .30
r = .48
r = .61
r = .45
r = .43
Body
Dissatisfaction
Symptoms
Body
Dysmorphic
Symptoms
Muscle
Dysmorphia
Symptoms
Hostility
Symptoms

Additionally, this preoccupation caused these individuals to give up important
social, occupational, or recreational activities to engage in extensive weightlifting.
Finally, these men experienced discomfort with and even avoidance of activities
where their bodies might be exposed to others.
Characteristics of our entire sample compared as expected to those of the
groups that generated the normed results for the scales we used. Although our sam-
ple did have a higher mean MD score than that of the group used in the development
of the Drive for Muscularity Questionnaire (DMS), it should be noted that the norm-
ing group used in development of the DMS was an adolescent population. Research
has found that the age of onset of MD is 19.4 years (SD = 3.6) (Olivardia et al.,
2000), which might account for this difference in means.
There were also relatively unimportant differences between our sample and the
normed samples for most of the subscales of the BSI. Our sample produced slightly
higher means for depression, anxiety, and hostility, while somatization was lower
than the normed sample, which was also on the low side. Our sample, in general,
seemed to report few somatic symptoms. Finally, our sample mean was substantially
lower than the mean of the normed sample for the Y-BOCS-BDD. However this dif-
ference is undoubtedly due to the fact that the sample population used for that
scale’s development consisted of subjects currently diagnosed with body dysmor-
phic disorder.
We turn now to a discussion of each of the hypotheses that motivated our study.
It will be shown that the results of this study generally supported the stated hypothe-
ses but with one additional unexpected significant correlation.
Consistent with the hypothesis that symptoms of muscle dysmorphia (MD) are
related to variables measuring body dysmorphic disorder (BDD), a very strong posi-
tive correlation was found. In fact, BDD was found to be the strongest predictor of
MD. Also as expected, MD was found to have a strong positive relationship to
obsessive-compulsive disorder (OCD).
Muscle dysmorphia symptoms are strongly related to body dissatisfaction and
moderately related to perfectionism, which are two of the eight measures of eating
disorder characteristics (EDI). Consistent with previous research (Olivardia et al.,
2000), we found no relationship between MD and the remaining measures of the
EDI (bulimia, interpersonal distrust, and interoceptive awareness). Discussions with
our participants revealed that some of the questions on the EDI were perceived as
being more geared toward women’s issues (e.g., questions focusing on buttocks and
thigh/hip size) than toward men’s issues. It should be noted that the EDI was devel-
oped using primarily female anorexic patients and female norm controls (Garner et
al., 1983). Perhaps an eating disorder questionnaire that is more gender neutral or
one that employs different screening techniques for males would have produced
results for the remaining EDI subscales that are more indicative of potential eating
issues of men.
Also consistent with our hypotheses and the literature, muscle dysmorphia was
moderately related to various measures of affective spectrum disorders, particularly
depression and anxiety.
Of great importance to the issue of proper classification was the fact that symp-
toms of muscle dysmorphia were not related to somatization (a measure of somato-
85
THE CLASSIFICATION

form disorder). In fact, it was found that our sample reported fairly low somatic
symptoms in general. This is of practical value because mental health professionals
rely on accurate diagnostic tools to help them identify precisely the mental illnesses
their patients suffer, an essential step in deciding what treatment or combination of
treatments their patient needs. The Diagnostic and Statistical Manual (DSM) has
become a central part of this process. DSM-IV is based on many, many years of
research and input of thousands of psychiatric experts. It has evolved into a carefully
constructed, numerical index of mental illnesses grouped by categories and subcate-
gories. Each entry contains a general description of the disorder followed by a listing
of possible symptoms, which enables clinicians to identify their patients’ illnesses
with a high degree of accuracy and confidence. DSM-IV is organized according to
phenomenological principles (i.e., groups of like symptoms, which are commonly
associated with a specific illness). Its descriptions of illnesses and lists of symptoms
are meant to support the diagnostic process. Moreover, the DSM-IV’s mental disor-
ders coding helps in the process of research data collection and retrieval and also
helps as researchers compile information for statistical studies. Finally, proper clas-
sification is of integral importance since the DSM-IV’s codes are often required by
insurance companies when psychiatrists, physicians, and other mental health profes-
sionals file claims. The U.S. government’s Health Care Financing Administration
also requires mental healthcare professionals to use the codes for the purposes of
Medicare reimbursement.
As hypothesized, our study found no relationship between MD and other mea-
sures of personality and pathology such as interpersonal sensitivity, psychoticism,
and paranoid ideation. However, a fourth measure that was expected to be unrelated,
hostility, turned out to be strongly related to MD. In fact, along with BDD, OCD and
BDIS, hostility was found to be one of the four variables with the strongest predictor
qualities of MD. A further regression analysis indicated that hostility mediates OCD
as a powerful predictor of MD.
There are currently no reported studies citing the relationship between hostility
and muscle dysmorphia. Additionally, there is a dearth of research investigating hos-
tility as it relates to OCD and BDD. Based on our findings, specific research should
be conducted to look at hostility and its relationship to these variables and also to the
specific task conditions of this study. For example, a factor possibly related to hostil-
ity was the time at which the questionnaires were completed. Perhaps endorphins
released after strenuous exercise affected the participants’ level of hostility.
A look at the literature on hostility and eating disorders appears more promising
for providing clues to the underlying relationship between hostility and MD in men.
Although there have been no studies linking anorexia nervosa or any other eating dis-
order to overt hostility, there have been a number of studies suggesting that self-
directed hostility is a factor in anorexia nervosa and bulimia (Neuman & Halvorson,
1983). Numerous further studies were consistent in finding self-directed hostility to
be one of a number of factors (along with obsessiveness, dependency, unassertive-
ness, external locus of control, and low self-esteem) that contribute to the psychologi-
cal profile of women with eating disorders (Cachelin & Maher, 1998; Hall, Blakey,
& Hall, 1992; Rosen & Ramirez, 1998; Smolak & Levin, 1993; Tiller, Schmidt, Ali,
& Treasure, 1995; Williams, Chamove, & Millar, 1990; Williams, Power, Millar,
86
MAIDA and ARMSTRONG

Freeman, Yellowlees, Dowds, et al., 1994). Rogers & Petrie (1997, 2001), on the
other hand, suggest that self-directed hostility was a poor predictor of scores on The
Eating Attitudes Test (Garner & Garfinkel, 1979). Our study did find a moderate cor-
relation between hostility (directed towards others) and certain eating disorder traits
(body dissatisfaction and perfectionism), although further analyses would be required
to determine whether a mediating relationship exists. In any case, the relationship
between eating disorders and obsessive-compulsive symptoms and traits has been
well established (Jarry & Vaccarino, 1996), as have associated features such as body
dissatisfaction and poor body image (Alexander-Mott & Lumsden, 1994). Hence, it
might be postulated that hostility as a fourth factor (along with BDD, OCD, and
BDIS) might not only play a significant role in the development of MD but, if self-
directed, might be a factor in the development of eating disorders in men.
Regression analyses helped us to understand the relationships among the vari-
ables related to MD. It was found that BDD alone was not as powerful a predictor of
MD as the combination of BDD, obsessive-compulsive disorder (OCD), body dis-
satisfaction (BDIS), and hostility (HOS). Further, although related to MD, depres-
sion, anxiety, and perfectionism did not make independent contributions to the pre-
diction of MD. (The comorbidity of both depression and anxiety with a host of
symptom variables and disorders would suggest that they would not be statistically
independent factors.) Finally, BDD, BDIS, and HOS were found to be mediators of
OCD in its effects on MD.
In summary, a picture emerges of the characteristic symptoms of males who
suffer from muscle dysmorphia. In addition to the presenting symptoms described
above, he also exhibits symptoms of the researched variables BDD, OCD, BDIS,
and HOS as well as depression, anxiety, and perfectionism.
Figure 2 depicts our answer to the main question of this research project: Where
does MD belong in relation to the variables studied? It illustrates our causal specula-
tion that OCD is the root factor in MD and exerts its influence through the mediating
variables of BDD, BDIS, and HOS. Hence, its symptoms are more closely related to
symptoms of an OCD spectrum disorder than to those of a somatoform disorder.
MD also shares symptoms with eating disorders through BDIS.
The results of this study have important implications for where MD should be
classified diagnostically. MD symptoms were found to be related to symptoms of
OCD and BDD rather than to those of somatoform disorders, where it has been offi-
cially assigned. Other researchers have already suggested that BDD might better be
classified as an OCD spectrum disorder. MD’s inherent relationship to BDD, along
with its similarities to body dissatisfaction symptoms seen in eating disorders, sug-
gests that, along with BDD, MD should be considered as an OCD spectrum disorder.
To extend the empirical support for considering the appropriate categorization of MD,
a next step should be to replicate these findings with a clinically diagnosed population
of MD. To explore further the role of hostility in BDD and MD, a contrastive sample
of the clinically diagnosed eating disordered population should be studied as well.
Finally, and most important, these suggested further studies should be executed with
the goal of completing a theoretical analysis of why the diagnostic variables are
related, how they develop among males suffering from MD, what their sociocultural
interpretations might be, and what the implications are for treatment and social policy.
87
THE CLASSIFICATION

NOTES
1.
The term “spectrum disorder” indicates that the disorder in question has fea-
tures similar to the primary disorder in terms of phenomenology (descriptive charac-
teristics), age of onset, clinical chronic course, comorbidity, possible etiology, familial
concordance, and/or treatment response (Bienvenu, Samuels, Riddle, Hoehn-Saric,
Liang, Cullen, et al., 2000). It does not imply the disorders are identical.
2. The BSI includes a ninth scale, phobic anxiety, which was not reported in this
study.
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