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Journal of Loss and Trauma
International Perspectives on Stress & Coping
ISSN: (Print) (Online) Journal homepage: https://www.tandfonline.com/loi/upil20
Intervention Development for People with Muscle
Dysmorphia Symptoms: Best Practice and Future
Recommendations
Sebastian S. Sandgren & David Lavallee
To cite this article: Sebastian S. Sandgren & David Lavallee (2022): Intervention Development for
People with Muscle Dysmorphia Symptoms: Best Practice and Future Recommendations, Journal
of Loss and Trauma, DOI: 10.1080/15325024.2022.2119718
To link to this article: https://doi.org/10.1080/15325024.2022.2119718
© 2022 The Author(s). Published with
license by Taylor & Francis Group, LLC
Published online: 19 Sep 2022.
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Intervention Development for People with Muscle
Dysmorphia Symptoms: Best Practice and Future
Recommendations
Sebastian S. Sandgren
a
and David Lavallee
b
a
Department of Education and Sports Science, University of Stavanger, Stavanger, Norway;
b
School of Applied Sciences, Abertay University, Dundee, United Kingdom
ABSTRACT
Symptoms of muscle dysmorphia carry significant risks for peo-
ple’s health and wellbeing. A key priority is therefore to sup-
port this group in reducing their symptoms and distorted
behaviors to mitigate against the development of clinically
severe muscle dysmorphia. However, few interventions exist
and there is a need to develop new programs urgently. In this
article, we provide researchers and practitioners with evidence-
based recommendations on how to effectively achieve this.
Recommendations are based on the health intervention devel-
opment literature and the Intervention Mapping Protocol is
introduced as a valuable tool for systemizing the development
process. We encourage and now call on researchers and practi-
tioners to action this imminent and important task of develop-
ing interventions to address muscle dysmorphia symptoms.
ARTICLE HISTORY
Received 3 July 2022
Accepted 28 August 2022
KEYWORDS
Body dysmorphic disorder;
intervention; prevention
Muscle dysmorphia is characterized by a pathological belief that one is insuf-
ficiently muscular, and the disorder is currently classified in the Diagnostic
and Statistical Manual of Mental Disorders 5th Edition (DSM-5) as a speci-
fier for body dysmorphic disorder (American Psychiatric Association, 2013).
Literature has shown that symptoms common to the disorder include a dis-
torted body image, obsession with muscle mass, size and leanness, fixation
on body image, anxiety and stress (Sandgren & Lavallee, 2018), excessive and
compulsive exercise/weight-training (Martenstyn et al., 2022). Both men and
women experience these symptoms, yet males typically report higher levels
of symptomatology (e.g., Lechner et al., 2019). Some anecdotal reports sug-
gest clinicians are experiencing an increasing number of men presenting
with the disorder (Griffiths & Murray, 2018), and recent empirical research
suggests muscle dysmorphia is also increasingly common in adolescent boys
CONTACT Sebastian S. Sandgren sebastian.s.sandgren@uis.no Department of Education and Sports
Science, University of Stavanger, Stavanger, Norway.
ß2022 The Author(s). Published with license by Taylor & Francis Group, LLC
This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives
License (http://creativecommons.org/licenses/by-nc-nd/4.0/), which permits non-commercial re-use, distribution, and reproduction
in any medium, provided the original work is properly cited, and is not altered, transformed, or built upon in any way.
JOURNAL OF LOSS AND TRAUMA
https://doi.org/10.1080/15325024.2022.2119718
and girls (e.g., Mitchison et al., 2021). Importantly, exact prevalence numbers
are lacking due to methodological issues, such as the absence of clinical cut-
off scores on screening measures (Tod et al., 2016). Moreover, although
muscle dysmorphia has primarily been studied in Western countries (Tod
et al., 2016), there is now an increase in research reporting the prevalence of
muscle dysmorphia symptoms in Non-Western countries, such as China,
Pakistan and Indonesia (e.g., He et al., 2021; Sarfarz et al., 2020;Susanto
et al., 2020). This suggests muscle dysmorphia is a growing, global mental
health concern, and the research conducted to date provides a platform for
future epidemiological research designed to inform evidence-based and par-
ticipant-centered interventions.
The development of muscle dysmorphia symptoms is complex, and
further research is needed to confirm the causal risk factors for the dis-
order. Nevertheless, empirical research has identified several, potential
risk factors. For example, most recent research suggests that preexisting
perfectionistic attitudes (e.g., Dryer et al., 2016), vulnerable narcissism
(e.g., Boulter & Sandgren, 2022), conformity to specific masculine norms
(e.g., Grunewald et al., 2022), social media addiction and eating distur-
bances (e.g., Imperatori et al., 2022), parental control, authority and
resentment (e.g., Olave et al., 2021;Paceetal.,2020) and other relational
victimization such as the father-child object relation (e.g., Wooldridge,
2022) may all contribute to the development of muscle dysmorphia.
Importantly, it is evident from the literature that muscle dysmorphia
symptoms (e.g., excessive weight training, fixation on body image) carry
significant risks for people’s health and wellbeing (Sandgren & Lavallee,
2018). For example, functional impairment (e.g., feeling unable to carry
out certain functions in their daily lives), body dissatisfaction (e.g.,
strong discomfort with one’s appearance resulting in symptoms of anx-
iety and depression), and suicidal ideation (Ortiz et al., 2021). Muscle
dysmorphia is also linked with the development of behaviors associated
with other, serious psychological and physiological health consequences
(e.g., abusing anabolic-androgenic steroids; Harris et al., 2019). A key
priority should therefore be to support people with muscle dysmorphia
in reducing their symptoms. However, this area of research is still largely
underdeveloped and poorly understood. This calls for future research.
Although several interventions and treatment options are on offer for
people with body dysmorphic disorder (Krebs et al., 2017), it is unclear
whether these are effective for people with muscle dysmorphia, or if people
with muscle dysmorphia seek out current interventions and treatment
options for body dysmorphic disorder. This lack of clarity highlights the
need to further investigate the development and maintenance of muscle
dysmorphia, which in turn, should lead to new and improved interventions
2 S. S. SANDGREN AND D. LAVALLEE
(e.g., Krebs et al., 2017). Additionally, based on the extant literature, inter-
ventions that specifically target muscle dysmorphia are rarely developed
and evaluated (Leone et al., 2005; Tod et al., 2016). Additionally, compul-
sive exercise is one characteristic of muscle dysmorphia and a recent sys-
tematic review of studies treating compulsive exercise in eating disorders or
muscle dysmorphia found that none of the 18 included studies sampled
people with muscle dysmorphia (Martenstyn et al., 2022). Consequently,
there is a need to carefully develop and evaluate future interventions for
people with symptoms of muscle dysmorphia, and early intervention is par-
ticularly important to prevent symptoms from worsening. The purpose of
this article is to encourage future intervention development work in this
area and provide researchers and practitioners with evidence-based recom-
mendations on how to effectively achieve this. In this article, we focus on
the early stages of development where a lot of groundwork is typically
needed. We feel this is most appropriate given the current status on muscle
dysmorphia research.
Current interventions for muscle dysmorphia
From the available evidence-base, it appears that only two published, peer-
reviewed studies have delivered and evaluated an intervention with the pri-
mary aim of targeting muscle dysmorphia. However, details of development
are lacking. Outar et al. (2021) developed an intervention comprising of
rational emotive behavior therapy and cognitive behavioral therapy, and
results suggested that symptoms were reduced post-intervention. Although
positive, only two males and two females with high levels of self-reported
muscle dysmorphia symptoms were recruited to the study. Murray and
Griffiths (2015) also evaluated an eating disorder-focused, family-based
intervention with only one adolescent male meeting full diagnostic criteria
for muscle dysmorphia. Results suggested a decrease in symptoms. Indeed,
there is a high rate of diagnostic cross-over between eating disorders and
muscle dysmorphia (Badenes-Ribera et al., 2019), so it is plausible that
many of the therapeutic approaches and techniques adopted in eating dis-
order interventions (e.g., cognitive behavioral therapy) will also work well
in interventions targeting muscle dysmorphia. It is beyond the scope of this
article to argue for, or recommend, specific therapeutic and psychological
approaches or techniques to adopt in future muscle dysmorphia interven-
tions. Additional, different interventions testing various therapies and tech-
niques in larger, randomized controlled trials with the target group are first
needed to make such assumptions.
Of significant importance, there are other, more critical steps that should
be taken by future intervention developers prior to making decisions on the
JOURNAL OF LOSS AND TRAUMA 3
type of therapy to adopt and commencing larger-scale intervention testing.
These initial steps involve being clear about which principles inform the
entire intervention development process and attempting to make this process
as systematic and manageable as possible. This approach is vital because it
allows researchers to make early assumptions about expected acceptability
and potential efficacy. Drawing on the health intervention development lit-
erature, the potential usefulness in adopting an approach and following a
protocol/framework (in this case, the Intervention Mapping Protocol) to aid
the development of a future muscle dysmorphia intervention is intro-
duced below.
Adopting an approach
Interventions for muscle dysmorphia are health interventions by nature.
The World Health Organization’s(2020) International Classification of
Health Interventions defines an intervention as “an act performed for, with
or on behalf of a person or population whose purpose is to assess, improve,
maintain, promote or modify health, functioning or health conditions.”
These interventions are complex, and the process of development can be
challenging. Intervention development refers to the whole process of identi-
fying, collecting, developing, reviewing, refining, and optimizing interven-
tion materials and delivery mechanisms (Craig et al., 2008). Therefore, this
process should not be taken frivolously. In the health intervention domain,
developers often adopt an endorsed approach to intervention development
to assist with the process and help with recognizing key principles to be
considered throughout the development phase (e.g., evidence, participant
views; O’Cathain et al., 2019). Answering why an intervention for muscle
dysmorphia is needed now and reflecting on which values should inform
the intervention can help with deciding on which approach to adopt. We
list below some examples of why a participant-centered and evidence-based
approach may hold value when developing future muscle dysmorphia
interventions.
Because little is known about what type of intervention is preferred by,
or acceptable to, people with muscle dysmorphia symptoms (e.g., Outar
et al., 2021), it will be imperative to focus on considering the perspectives
and experiences of the target group (i.e., a participant-centered approach;
O’Cathain et al., 2019). Doing so will help to tailor the intervention to the
target populations’psychological and social context (Bartholomew et al.,
2011) and make sure the intervention matches participants’preferences for
intervention format and delivery. For example, should early intervention
initiatives be implemented in the environment that serves as a social frame-
work for muscularity-oriented behaviors and attitudes (i.e., gyms and
4 S. S. SANDGREN AND D. LAVALLEE
fitness centers)? Adopting a participant-centered approach will aid the
accumulation of data to help answer such questions and back up the deci-
sions made. Additionally, because few muscle dysmorphia interventions
have been developed and evaluated, and there is limited knowledge about
what type of treatment or therapeutic techniques are most effective with
this group of participants, there may be substantial value in grounding
future muscle dysmorphia intervention components in empirical evidence
(i.e., an evidence-based approach; O’Cathain et al., 2019). Evidence-based
decisions used in future muscle dysmorphia interventions could, for
example, be informed by those successfully used for treating body dys-
morphic disorders (e.g., cognitive behavioral therapy; Krebs et al., 2017)or
other mental health disorders closely related to muscle dysmorphia (e.g.,
eating disorders).
Furthermore, depending on the context and needs, approaches can also
be combined, and previous health interventions which have combined a
participant-centered and an evidence- and theory-based approach have
demonstrated successful behavior change in participants across a variety of
health settings (Bartholomew Eldridge et al., 2016). It is likely that by
adopting a similar, combined approach, this will help maximize both the
acceptability and potential efficacy of future muscle dysmorphia interven-
tions. Researchers and practitioners wishing to take on the important task
of developing interventions for people with muscle dysmorphia symptoms
are recommended to decide on an approach in advance of beginning their
development work. After deciding on an approach, researchers can decide
on, and follow, a protocol/framework that endorses the approach taken to
help make this process even more systematic and manageable.
Following protocols or frameworks
Within the health intervention development literature, protocols and frame-
works serve as guidance tools to help intervention developers with the deci-
sion-making process and to address questions directly related to the
context of their interventions. Some of the most frequently used for the
development of participant-centered and evidence- and theory-based health
interventions include Behavior Change Wheel (Michie et al., 2014),
Intervention Mapping Protocol (Bartholomew Eldridge et al., 2016), and
Theoretical Domains Framework (French et al., 2012). There are many
similarities between these, but they differ in their strengths and limitations
(O’Cathain et al., 2019). The six guiding questions outlined by O’Cathain
et al. (2019) can further help with deciding which protocol or framework is
the best fit for the development of a novel intervention to address muscle
dysmorphia symptoms: (1) What is the intention of the new intervention?
JOURNAL OF LOSS AND TRAUMA 5
(2) What is the context of the intervention? (3) What values inform the
development? (4) What skills and experience do the research team have?
(5) Which approaches have resulted in interventions shown to be effective?
and (6) What resources are available for the intervention development?
After choosing a protocol or framework to follow/consult, intervention
developers can commence their development work with clear guidance on
how and when to achieve different tasks related to their intervention, to
preserve progress during this demanding process.
The Intervention Mapping Protocol is rigorous, comprehensive, and has
been extensively used previously for the development of successful health
interventions (Bartholomew Eldridge et al., 2016), such as reducing eating
disorder symptoms in athletes (Sandgren, Haycraft, Arcelus, et al., 2022).
The protocol has yet to be adopted for the development of a muscle dys-
morphia intervention and we will now illustrate how the Intervention
Mapping Protocol, as an example, can serve as a useful guidance tool for
intervention development for people with muscle dysmorphia symptoms.
Intervention mapping
Intervention Mapping consists of six steps with several tasks for intervention
developers to undertake and evaluate (Bartholomew Eldridge et al., 2016):
(1) needs assessment and logic model of problem, (2) logic model of change,
(3) intervention design, (4) intervention production, (5) implementation
plan, and (6) evaluation plan. In the present article, we focus on the first two
steps of the protocol: conducting a needs assessment to inform the interven-
tion and creating logic models to identify targets and change methods.
Conducting a needs assessment to inform the intervention
The first step of Intervention Mapping is to conduct a needs assessment
where the research team (intervention development team) collect and review
existing evidence, as well as collect any new data where evidence is lacking
(i.e., what evidence is already known and what other evidence would be use-
ful to know to inform the intervention?). Researchers should begin by fully
analyzing muscle dysmorphia and its multiple causes. Importantly, literature
has highlighted potential challenges with recruiting people with muscle dys-
morphia to psychological interventions (e.g., Martenstyn et al., 2022; Outar
et al., 2021). One key, first step of a needs assessment should therefore be to
explore the causes for this and test different recruitment strategies to identify
the most appropriate and effective methods.
Additionally, due to the paucity of research around muscle dysmorphia
interventions, there is a need to explore the prerequisites and intervention
6 S. S. SANDGREN AND D. LAVALLEE
preferences of people with muscle dysmorphia symptoms. Similar to previ-
ous athlete eating disorder research (e.g., Kroshus et al., 2014; Sandgren,
Haycraft, Pearce, et al., 2022), there may also be value in gathering the views
of key stakeholders who are likely to encounter individuals with muscle dys-
morphia symptoms (e.g., personal trainers, psychologists, other health pro-
fessionals, parents and peers) as they may have some useful insight into the
best ways to support those at risk. Doing this, the needs assessment ensures
evidence is available to make decisions around the format, delivery and dos-
age of the intervention, which are informed by people with muscle dys-
morphia symptoms and any relevant key stakeholders. This should help to
increase acceptability and possibly also, adherence (Bartholomew Eldridge
et al., 2016). Conducting a needs assessment requires significant resources,
and the research team should therefore consider any resource or time con-
straints and plan their assessment(s) accordingly. Establishing a collaborative
working group with different responsibilities may help to overcome any
resource and time constraints.
Creating logic models to identify targets and change methods
The second step of Intervention Mapping involves creating one logic model
of the problem and one logic model of change based on evidence from the
literature and the needs assessment (Bartholomew Eldridge et al., 2016).
The logic model of the problem seeks to identify the causes of muscle dys-
morphia in individuals and is intended to help the researchers better
understand the nature of the disorder (i.e., identifying personal and envir-
onmental determinants for developing muscle dysmorphia symptoms,
maintenance factors, behavioral and environmental outcomes of the identi-
fied determinants, and the impact that the disorder can have on an individ-
ual’s quality of life). In turn, the model can help to identify targets for
intervention and behavioral change. To illustrate, the model can, for
example, identify that many individuals with muscle dysmorphia symptoms
have low motivation toward starting in-person therapy (personal determin-
ant) due to secrecy, being in denial and lack of openness (e.g., Pope et al.,
2005; Wooldridge, 2022). This could promote an avoidance of support-
seeking behaviors (behavioral factor) and may drive the continuation of
excessive and compulsive muscle-building behaviors and attitudes (health
problem). If left untreated, symptoms will ultimately affect the overall qual-
ity of life and health, such as experiences of functional impairment, body
dissatisfaction and suicidal ideation (Ortiz et al., 2021). The logic model of
problem should consider multiple personal and environmental determi-
nants in the analysis.
JOURNAL OF LOSS AND TRAUMA 7
After creating a logic model of the problem, the task is to propose solu-
tions to address the determinants (targets) identified. This logic model
focuses on identifying what will change and the methods for achieving this.
This, in turn, helps to ensure the intervention is suitably targeted and
equipped with appropriate change methods (Bartholomew Eldridge et al.,
2016). For example, to address concerns with existing support options for
muscle dysmorphia (e.g., in-person therapy), individuals are provided with
support that enables them to work independently or together with a profes-
sional to enhance knowledge, self-efficacy/esteem, and own decision-
making (performance objectives). This can be facilitated by presenting full
and honest descriptions of muscle dysmorphia symptoms and potential
consequences of the disorder, and by emphasizing the benefits of change
and the disadvantages of not making any changes (change objectives).
Accordingly, this may improve the individuals’level of openness and
motivation toward making change (behavioral outcome), and therefore
reduce symptoms. The logic model of change should identify appropriate
performance and change objectives for every personal and environmental
determinant identified in the logic model of problem.
Following on from conducting a needs assessment and creating logic
models, there are several, other important steps of Intervention Mapping
involved in the development process. For example, generating and develop-
ing intervention themes, components, scope and sequence, and pilot test-
ing, refining and producing intervention materials (Bartholomew Eldridge
et al., 2016). Findings from the needs assessment and logic models will
assist the research team in every step for the remainder of this process and
until the intervention is developed and ready for evaluation. In line with
health intervention guidelines, this initial evaluation should focus on assess-
ing the feasibility, acceptability and potential efficacy (e.g., can the
intervention work, and if so, how?; Tickle-Degnen, 2013). Only then, and
depending on initial findings, is it worthwhile to invest in larger, more
definitive trials.
Summary
There is an urgent need to develop interventions to support individuals
with symptoms of muscle dysmorphia. If delayed any further, many peo-
ple with these symptoms will not receive intervention early enough,
whichinturnislikelytocausesymptomstoworsen.Theprocessof
development is complex and should be treated as a longer-term initia-
tive; however, consulting available evidence and guidelines from the
health intervention development literature can help make this process
more manageable. We have highlighted best practices to intervention
8 S. S. SANDGREN AND D. LAVALLEE
development, drawing on established guidelines from the health inter-
vention development literature, and illustrated the potential usefulness
in adopting a participant-centered and evidence-based approach for the
development of a future muscle dysmorphia intervention. Following/
consulting an existing protocol or framework (e.g., Intervention
Mapping) should help make this process more achievable. Conducting a
thorough needs assessment and creating logic models will require sig-
nificant resources and research efforts, but in turn this work will hope-
fully leave researchers with a strong evidence base and infrastructure for
making appropriate, evidence-based decisions when developing interven-
tions. This should help maximize the interventions’acceptability and
effectiveness. Lastly, we hope that this article will spark further inquiry
on the topic and serve as meaningful guidance for researchers and prac-
titioners wishing to take on the pivotal task of developing muscle dys-
morphia interventions.
Acknowledgment
This research received no specific grant from any funding agency in the public, commer-
cial, or not-for-profit sectors. The authors would like to thank Dr Carolyn Plateau and
Professor Emma Haycraft at Loughborough University for their support in framing and
contextualizing the health intervention recommendations described in this article.
Author contributions
The authors contributed equally to the conceptualization and investigation of this work,
and writing, reviewing. and editing the manuscript. All authors have read and approved
the submitted manuscript.
Disclosure statement
No potential conflict of interest was reported by the author(s).
Notes on contributors
Sebastian S. Sandgren is an Associate Professor in the Department of Education and
Sports Science, University of Stavanger, Norway.
David Lavallee is Professor of Duty of Care in Sport in the School of Applied Sciences,
Division of Sport and Exercise Sciences, Abertay University, United Kingdom.
ORCID
Sebastian S. Sandgren http://orcid.org/0000-0002-8782-8454
David Lavallee http://orcid.org/0000-0002-3829-293X
JOURNAL OF LOSS AND TRAUMA 9
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