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In the earlier days of the television program "Saturday Night Live," comics performed a routine poking fun at bodybuilders in which fictional muscle men "Hans" and "Franz" flexed their muscles and promised to "pump you up."
But for some bodybuilders, body image is no laughing matter. No matter how large they become, they may see themselves as small. What seems to others nothing more than exaggerated physical vanity may be a manifestation of distorted body image, or dysmorphia, according to several ongoing studies of bodybuilders by psychiatrist Harrison G. Pope Jr., M.D., of McLean Hospital in Belmont, Mass., and colleagues. A report summarizing the studies was published in the November-December issue of Psychosomatics ("Muscle Dysmorphia: An Underrecognized Form of Body Dys-morphic Disorder").
The frequency of the disorder, which the authors of the study have tentatively named muscle dysmorphia, is unknown. But based on data analyzed so far, the authors speculate that it may afflict up to 10 percent of bodybuilders. Crude estimates suggest this might translate into 500,000 to 1 million individuals, the authors say.
Lead author Pope spoke with Psychiatric News about the study.
"What is interesting is that out of these dozens and dozens of interviews," all of the requests have come from Anglo-Saxon countries, but with the exception of the Sao Paolo article, no Latin American countries. He speculated that "body image and muscularity per se may not be as much of a preoccupation in Latin American society" as in Anglo-Saxon culture.
"Why is this preoccupation much more prominent in some countries than others?" Pope asked. This subject is worthy of anthropological examination, he said.
In contemplating the etiology of muscle dysmorphia, Pope suggested that it may be "one of several possible symptom clusters related to some common underlying predisposition." It may be that depression, obsessive-compulsive disorder (OCD), bulimia nervosa, and other anxiety and eating disorders share an underlying physiologic anomaly, and that muscle dysmorphia is a member of the family of "affective spectrum disorders," according to Pope.
How this physiologic abnormality manifests itself, if at all, is a function of culture and environment. "If you have OCD and you are raised in a society that has no running water, it is unlikely you will develop a hand-washing obsession," Pope observed.
Muscle dysmorphia is "just one form of body dysmorphic disorder (BDD) like any other, and we already have criteria for BDD as a whole," Pope commented. But because the disorder makes it difficult for people to recognize that they have a problem, identification and treatment are a challenge, he noted.
"The first step is to do what we have done - to delineate the syndrome and describe it so it will be recognizable to people who have it, to their families and friends, and especially to primary care physicians," Pope remarked. General practitioners "may be the first to notice it when someone comes in with an orthopedic injury" or some other primary physical problem, he noted.
Once it is recognizable and identified, "the odds are better - they are still not high - that an individual is going to be willing to consider the possibility of some kind of intervention."
Drug therapy is promising, although the data for drug efficacy in treating muscle dysmorphia are lacking, said Pope. Selective serotonin reuptake inhibitors, such as Prozac and Paxil, are likely candidates.
"Since they clearly work in other forms of BDD, they would be expected to work in this subtype as well," he noted.
The chief obstacle in ascertaining drug efficacy is that "so few of these people present for treatment" that it is very difficult to gather clinically significant data. He drew an analogy to anorexic women who come to the doctor and "protest that they do not need any psychiatric treatment; they only need to lose a couple of pounds." Unlike muscle dysmorphia, however, "anorexia nervosa is more often a life-threatening illness, and the patient is forced to accept treatment," Pope added.
Eric Hollander, M.D., is a professor of psychiatry and director of the compulsive, impulsive, and anxiety disorders program at Mt. Sinai School of Medicine in Manhattan.
"I think it’s a real entity," Hollander told Psychiatric News. "It appears to be a variant of BDD. We’re seeing it more commonly these days. In part there are social pressures for men to look strong and youthful. But there are many men who develop compulsive behavior around exercise."
Hollander estimates that about 1 percent of all Americans suffer from some form of BDD. He guessed that muscle dysmorphia afflicts a relatively small percentage of gym users.
"Taking steroids is the most serious medical issue in this disorder" due to possible irreparable cardiovascular harm, according to Hollander. Another medical problem, however, is that some people continue to exercise even with dislocated shoulders or other injuries, using analgesics to mask the pain.
Muscle dysmorphia may cause social problems. "People may do this as their exclusive social activity. . .and it may interfere with their careers," said Hollander. They may exercise to the exclusion of dating and sex, and may even alter their careers to spend more time at the gym.
For many people the behavior is "egosyntonic" in that those who have the disorder are comfortable with the symptoms, Hollander added. Often, however "we see people because in addition to muscle dysmorphia, they have other variants of BDD or other variants of OCD," he explained.
Somewhat in contrast to Pope, Hollander sees muscle dysmorphia as part of the "OCD spectrum" disorders, not the family of "affective disorders. We don’t think this is a mood disorder," he commented. But he noted that the OCD spectrum is "a subset of the affective spectrum."
Rather than affect, the disorder is defined mainly by "the obsessive thoughts about body size and shape, and the compulsive behavior regarding exercise and use of a variety of supplements and steroids in an attempt to bulk up," Hollander said.
There is a selective response to SSRI’s in OCD spectrum disorders, which Hollander said he has used successfully to treat people with muscle dysmorphia. Treatment response is "an important defining factor" in determining whether someone suffers from an OCD spectrum disorder, he added. While all SSRI’s have an anti-obsessional effect, the other classes of antidepressant drugs, including norepinephrine reuptake inhibitors, tricyclic and tetracyclic antidepressants, monoamine oxidase inhibitors, and electroconvulsive therapy - "which are all good treatment for affective disorders - are all ineffective for treating OCD spectrum disorders," Hollander observed.
Although muscle dysmorphia affects only a small percentage of the population, "it can be debilitating," said Hollander. "Here’s the other point. Many think that BDD and their variants are trivial illnesses. But they’re not. Many people can have their lives totally consumed by this. It can cause substantial impairment in social and occupational functioning, and there is a high rate of suicide in this population."
Although related to OCD, "the disorder is frequently complicated by depression and social phobia," Hollander added.
He said he has treated about 10 patients with the problem over the last four years. The people he has treated have improved meaningfully about 70 percent of the time - which is typical for treatment of OCD disorders, Hollander said.