Commentary on: ‘Muscle dysmorphia: Towards a diagnostic consensus’

Our collective preoccupation with body weight and shape and its modification would seem to underpin both eating disorders and body dysmorphia, so it is not unreasonable for Murray and Touyz (2013) to propose that the latter be categorized with the former. Where, then, would muscle dysmorphia fit and would this further reduce the size of the unacceptably large Eating Disorder Not Otherwise Specified (EDNOS) category in the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) (Fairburn and Cooper, 2011) or Feeding and Eating Conditions Not Elsewhere Classified as it has been most recently (as of 2 April 2012) relabelled in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5) (American Psychiatric Association, 2012)? Nosological issues aside, practical considerations around treatment implications and clinical utility of this proposal are important and need to be addressed.

The worth of diagnostic concepts is determined by their relevance to treatment and prognosis (Kendell, 1975) and the authors state, somewhat anecdotally, that eating disorder treatment is effective for muscle dysmorphia. They quote Pope et al., (2005) who remarked on the greater psychopathology and functional impairment in muscle dysmorphia than in body dysmorphic disorder, noting the frequent co-morbidity of muscle dysmorphia with substance abuse disorders including steroid misuse and other compulsive behaviours. Chung (2001) posited that muscle dysmorphia be classified with obsessive–compulsive disorders, and the similarity to eating disorders, particularly anorexia nervosa, has already been noted (Murray et al., 2010; Murray and Touyz, 2013). As stated by the authors, the various alternative terms for muscle dysmorphia, namely reverse anorexia, male anorexia, bigorexia or vigorexia do capture the experience of eating disorders for some, and possibly an increasing number of males in the context of contrasting societal expectations for male and female shape ideals, i.e. GI Joe versus catwalk emaciation. Umberto Eco’s term ‘hyperreality’ aptly describes this obsessive meme as applied to body image (Eco, 1986).

The authors also state the need for DSM-5 to accurately represent clinical reality and be useful to clinicians. This is where their assertions are less compelling. Muscle dysmorphia is occasionally seen in females (usually in association with other psychopathology) and is by no means the only form of eating disorder in males. In psychiatric practice, anorexia nervosa and bulimia nervosa are relatively uncommon in males but are nevertheless seen more often than muscle dysmorphia (although the perspective of some male clinical psychologists might be different). Binge eating disorder (BED; as in DSM-5) whether presenting to psychiatric practice or clinics specializing in endocrinology, diabetes, obesity or bariatric surgery, is reasonably prevalent and equally so in males and females (Smith et al., 1998). This eating disorder could hardly be more antonymic to the muscle dysmorphia described so well in Sam Fussell’s (1991) Muscle: Confessions of an Unlikely Bodybuilder. One might expect to encounter similar cases in any popular gym around town – and not exclusively in males.

Many, perhaps the majority, of patients with muscle dysmorphia, do not present to psychiatric or eating disorder services at all, but may be more likely to seek help initially for medical complications caused by their aberrant behaviours. Thus, categorizing muscle dysmorphia with somatoform disorders as a subcategory of body dysmorphic disorder, might still seem to have more to recommend it in practical terms. Prompt psychiatric and clinical psychology referral is in order and with this comes an obligation to educate our colleagues and be ready to offer treatment strategies to target (as with body dysmorphic disorder) the obsessive and delusional features, as well as the nutritional and medical issues. We might expect to be doing more of this in the future given the media driven obsession with body image and the extreme makeover.

See Viewpoint by Murray and Touyz, 2013, 47(3): 206–207.