Muscle Dysmorphia: 'Puniness' in the Mind

The Adonis Complex
by Harrison G. Pope, Jr., M.D., Katherine A. Phillips, M.D., Roberto Olivardia, Ph.D.

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The body image distortions of men with "muscle dysmorphia" are strikingly analogous to those of women (and some men) with anorexia nervosa. In fact, some people have colloquially referred to muscle dysmorphia as "bigorexia nervosa" or "reverse anorexia." People with anorexia nervosa see themselves as fat when they're actually too thin; people with muscle dysmorphia feel ashamed of looking too small when they're actually big. A recent study of ours illustrates these parallels. In this study, we compared interview and questionnaire responses from twenty-four young men with muscle dysmorphia, recruited from gymnasiums in the Boston area; thirty young men without muscle dysmorphia, recruited from the same gymnasiums; twenty-five college men with eating disorders such as anorexia nervosa and bulimia nervosa (binge eating and vomiting); and twenty-five ordinary college men without eating disorders. On question after question, the men with muscle dysmorphia showed levels of pathology similar to the college men with eating disorders. In particular, the men from these two groups shared a need to exercise every day, shame about their body image, feelings of being too fat, dislike of their bodies, and often, lifetime histories of anxiety and depression. By contrast, the group of weightlifters without muscle dysmorphia closely resembled the ordinary college men on all of these same indices. In other words, men with muscle dysmorphia report that they are suffering just as badly as men with anorexia nervosa.

Also like people with anorexia nervosa, men with muscle dysmorphia often risk physical self-destruction. Frequently, they persist in compulsive exercising despite pain and injuries, or continue on ultra low-fat, high-protein diets even when they are desperately hungry. Many take potentially dangerous anabolic steroids and other drugs to bulk up, all because they think they don't look good enough.

But these men's nagging worries are rarely relieved by increasing their bodybuilding. In psychological terms, we call such persistent worries "obsessions." And in response to these obsessions, people are driven to repetitive behaviors — in Scott's case, constant weightlifting — which, in turn, we call "compulsions." Though people may realize, on one level, that their obsessive beliefs are irrational and their compulsive behaviors futile, they still cannot "shut off" their endless and often self-destructive behaviors. Scott is a case in point. Although his feelings of self-criticism were utterly irrational, Scott was so convinced of his deficiencies that, at the end of the day, he chose catering to his muscle obsession over maintaining his relationship with Sarah.

The sources of Scott's muscle obsessions and weightlifting compulsions are not known with absolute certainty, but most likely are threefold. First, there's almost certainly a genetic, biologically based component. In other words, some people like Scott inherit a chemical predisposition to developing obsessive-compulsive symptoms. But genetics do not act alone. The second likely component is psychological — obsessive and compulsive behavior stems, in part at least, from one's experiences growing up, such as being teased. Scott still remembers being called "dorky" and "wimpy" in school, and these memories still fuel his muscle obsession and his compulsion to work out. And finally, we believe that society plays a powerful and increasing role, by constantly broadcasting messages that "real men" have big muscles — just like the bodybuilders in the pictures on the walls of the Olympic Gym. Men like Scott have been exposed to these images ever since they were small boys, thus laying the groundwork for muscle dysmorphia and other forms of the Adonis Complex in adulthood.

BODY-DISSATISFIED MEN: A SILENT EPIDEMIC

Cases as severe as Scott's may be uncommon. But for every man with severe muscle dysmorphia, dozens of others experience at least some distress about their muscularity. For example, a 1997 study found that an amazing 45 percent of American men were dissatisfied with their muscle tone — almost double the percentage found in the same survey in 1972. Thus, we can calculate that there are presently well over 50 million muscle-dissatisfied men in our country. And these millions of men are surrounded by many millions of very perplexed family members, friends, and loved ones, who probably can't quite understand what this anxiety about bigness and muscles is all about.

Why is muscle dissatisfaction, together with other body-appearance preoccupations, becoming so common among modern men? Our grandfathers didn't seem to worry about how muscular they looked. They didn't do bench presses or abdominal exercises three days a week, or go to the gym to work out on the StairMaster, or worry about their percentage of body fat. Why has the Adonis Complex infected so many men over the last thirty years or so?

One reason is that our grandfathers were rarely, if ever, exposed to the "supermale" images — aside from Charles Atlas on an occasional matchbox cover — that Scott and his friends see every day. In modern society, these images aren't confined to pictures in the gym — they're everywhere. Look at television over the last several decades. The hard-bodied lifeguards in Baywatch are viewed by over 1 billion viewers in 142 countries — figures unmatched by any previous television series. Or look at the movies. Hollywood's most masculine men of the 1930s, 1940s, and 1950s — John Wayne, Clark Gable, Gregory Peck — look like wimps in comparison to modern cinema's muscular action heroes — Arnold Schwarzenegger, Sylvester Stallone, or Jean-Claude van Damme. Today, while growing up, a young man is subjected to thousands and thousands of these supermale images. Each image links appearance to success — social, financial, and sexual. But these images have steadily grown leaner and more muscular, and thus more and more remote from what any ordinary man can actually attain. And so society and the media preach a disturbing double message: a man's self-esteem should be based heavily on his appearance, yet by the standards of modern supermale images, practically no man measures up.

It becomes understandable, then, that millions of modern American men are unhappy with how they look. And it isn't surprising that among these millions, we are seeing increasing numbers of serious casualties — men like Scott, whose lives have been damaged by these trends. Growing up in the 1970s and '80s, Scott steadily absorbed the stream of supermale images from the modern media. In fact, he described to us how he watched Rambo movies and Schwarzenegger action thrillers and, even as a child, fantasized that he would someday look like those heroes. Gradually, body appearance became the dominant basis — and ultimately the only basis — for his self-esteem. To lose even a little of that muscle, or to gain even a little body fat, brought him instant shame and humiliation. For Scott, a muscled body became more important, much more important, than being a successful businessman. It became so important that it brought him nearly complete social isolation and even cost him his relationship with the woman he loved.

BILL AND STACY: FALLOUT FROM FAT

Back at the Olympic Gym, another man is suffering from a very different form of the Adonis Complex. Bill is tall, thin, and in his early thirties. He's drenched with sweat after thirty-five minutes of running on the treadmill at seven minutes per mile. He's wondering, at this moment, whether he's run long enough or fast enough, whether he's burned off enough calories to compensate for the food he ate earlier in the day, and whether he still looks a little too fat. And he's already beginning to feel guilty about the eating binge that he knows will happen after he gets home tonight.

On his way home from the gym, Bill will purchase two large Italian submarine sandwiches, two large bags of Doritos, two cans of onion dip, and a quart of chocolate-chip cookie-dough ice cream. After shutting off the ringer on his phone, he'll begin to eat as fast as he can — sometimes even using both hands to feed himself, grabbing food with his left while eating from his right. Before he even has a chance to think about it, nothing will be left but a bunch of empty bags, containers, and wrappers.

Bill told us about his secret eating binges when he came to see us for one of our research studies of men with eating disorders. Even though he knew that we were familiar with this type of problem, it still took him a long while to let down his guard and tell us the full story.

"As soon as I've finished the last potato chip or the last gulp of ice cream," he said, "I feel totally guilty and disgusted with myself. I just can't believe that I've done it again, that I've lost control. When I was younger, I even tried to make myself vomit in the bathroom after the eating binges. But I wasn't very good at it. Now, I just try to diet in between the binges. Or I'll go and run some extra miles to try to burn off the food. Sometimes, I've even gone running at three o'clock in the morning. No one in the world knows that I do this. For years, I even kept it a secret from my wife. When I didn't show much interest in sex, she kept thinking I was having an affair. Actually, I was just too caught up in the binge eating and my weight. I hated the way I looked."

He grew visibly uncomfortable. "It probably sounds ridiculous, but my food problem ruined my marriage. Early on, we had a really close relationship — we'd been high school sweethearts and best friends. I really loved Stacy and felt I was the luckiest guy in the world to be married to her. But when my food problem started, I began to retreat. I retreated into this little world where food was really all that mattered, where I spent my entire day planning my meals and thinking about my weight. I gradually shut her out even though I really didn't want to. I just lost control."

Stacy eventually divorced Bill. She never found out that Bill's real problem was an eating disorder. In fact, she'd thought she was to blame — that something was wrong with her. Bill had tried to reassure her that it wasn't her problem, but he was still unable to reveal to her that the real problem was his chronic feeling of worthlessness. Despite all of the love he and Stacy shared, Bill felt he wasn't good at anything. He felt fat, mediocre, and unattractive.

Bill's self-hatred crept up on him insidiously. First, he began to withdraw from Stacy, his sex drive waning daily. Next he started going to the gym excessively in an attempt to convert his body into a mass of muscle. And then he became obsessed with food, so obsessed that it destroyed the most important relationship of his life.

"I loved Stacy so much. I still really love her. I wish I could have her back," he said plaintively. "She was my soul mate. I could tell her a lot of things — except this."

Bill's condition is called "binge-eating disorder." Only recently has this condition been recognized by professionals as an actual psychiatric problem. In fact, Bill told us that for many years he hadn't even known that his peculiar eating pattern had a name. And when he found out, at last, that he wasn't alone with his illness, he refused to see a therapist, or even tell his family doctor.

"I guess I never really wanted to admit that I had a serious eating problem," he said. "I was really ashamed, because I felt that it was a female thing to have eating problems like that. I'd never heard of a man with an eating disorder. I got more and more worried about being too fat. When I was younger, there was a time when it got to the point where I would weigh myself four or five times in a day. Sometimes if I gained even a pound, I would go to the gym or go running because I thought I was getting fatter. But then, half the time, I'd get hungry again, and then I'd go on another eating binge and be right back where I started. I mean, how many guys struggle with that?" Bill took a deep breath and sighed, "I feel I don't measure up."

"Where do you think those feelings come from?" we asked.

"I guess I've pretty much always felt like a failure," Bill explained. "I came from a family with five older sisters and no brothers at all. When I was born, my parents put all their hopes in me."

"That must have been pretty hard on you, being the only son with your parents' high expectations," we offered.

"Well, especially when you understand what my father was like. He was a well-meaning man, but he was very tough with me. He couldn't understand why I was scared to go to school as a child, and he would yell at me until I cried in the morning when I was forced to get on the school bus. I had a lot of little fears like that while I was growing up, and my father just couldn't figure out why I couldn't just instantly overcome them."

"It sounds as though your father put a lot of pressure on you."

"Yes. A lot of pressure — pressure to play sports, pressure to act tough, pressure to be masculine. But it was also about control. He had a pretty hard childhood himself — his father was a violent alcoholic who would get drunk and beat him — so for my father everything had to do with keeping a stiff upper lip and showing no fear."

"And what happened if you failed to meet his expectations?"

"He would just become a horrible person if you didn't do what he wanted or didn't live up to his expectations. He'd say: 'You're such a disappointment' or 'I'm ashamed to be the father of such a little cry baby' or 'You're a spoiled brat.'"

"How did you handle it back then?"

"I don't know. I just recall feeling totally helpless and hopeless. I felt like the world's biggest loser — shy, stupid, ugly, you name it. My mother was always afraid of my father, so she stood behind whatever he did. I felt like there was nowhere to turn."

"Well, it's little wonder that you don't feel completely good about yourself now, as an adult."

"I don't feel good about myself at all. I still feel like that little kid, terrified to get on the school bus with the other kids. Only now, to make matters worse, I also constantly feel as though I'm fat and overweight."

In fact, Bill wasn't fat at all. His body fat measured only 11 percent — making him far leaner than an average American man of his age.

"But you realize that, in reality, you're not fat all?" we asked.

"Yeah, I know, I know. Everybody says that," he admitted. "I look around at other guys and realize that I'm thinner than they are, but it still doesn't make the feelings go away.

"When I was a teenager, I went on this mission to improve my appearance. I started lifting weights and running every day after school. It made me feel good because I felt like I was proving myself to my father. Also, I figured that if I kept it up, I'd be more confident in social situations, because I'd be more muscular and athletic."

Bill went on to describe an episode of depression he experienced during his senior year of high school. He began to feel hopeless about what he would do after graduating. He started sleeping ten or eleven hours each night, he couldn't concentrate on anything, and he felt guilty and down on himself for no reason. "I felt like shit. I couldn't talk to anyone about it. And no one asked about what was going on even though they must have been able to see something was wrong."

Bill suffered through the blackness of the depression for another year, and gradually discovered that exercise made him feel better. But when he went to college, he injured his ankle while running and was forced to stop exercising for many weeks. The depression returned, more severely. About that time, Bill discovered that binge eating would temporarily alleviate his depression.

"It was a high. It kind of numbed me," he said. "All of those messages inside of my head about being too shy, being stupid, being ugly — for a moment those voices went quiet and I could feel at peace with myself."

At first, Bill binged only occasionally, but gradually he became drawn into a cycle of binge eating, dieting, working out, and binge eating again. This cycle seemed to keep the depression at bay, but increasingly, he became preoccupied that he was getting too fat. He began to weigh himself and look at himself in the mirror more and more often. Soon the thoughts of food, body weight, exercise, and fat came to consume virtually all of his day.

"But I still couldn't talk about it with anybody. I didn't think any of my friends would understand. In fact, I'm surprised I'm here right now. Guys aren't supposed to get all hung up about their appearance."

And so Bill's preoccupations remained secret for years. Despite all of his physical and emotional problems, despite having been severely depressed, Bill's visit to our research laboratory was the first time he'd ever seen a mental health professional — the first time he had ever reached out for help.

Copyright © 2000 by Harrison G. Pope, Jr., M.D., Katharine A. Phillips, M.D., and Roberto Olivardia, Ph.D.

About the Author

Harrison G. Pope, Jr., M.D., is a professor of psychiatry at Harvard Medical School and chief of the Biological Psychiatry Laboratory at McLean Hospital. He lives in Concord, Massachusetts.

Katherine A. Phillips, M.D., is an associate professor of psychiatry at Brown University School of Medicine, director of Butler Hospital's Body Dysmorphic Disorder and Body Image Program, and the author of The Broken Mirror: Understanding and Treating Body Dysmorphic Disorder. She lives in Providence, Rhode Island.

Roberto Olivardia, Ph.D., is a clinical research fellow at Harvard Medical School. He lives in Malden, Massachusetts.