Muscle Dysmorphia: The Belief of Being Too Small

Table of Contents

1. How It Was Named and Classified
2. How Common It Is in the Groups Studied
3. Symptoms and Measurement Scales
4. Anabolic Steroids and Other Substances
5. The Overlap With Eating Disorders
6. Depression, Anxiety and Suicidal Thoughts
7. Social Media Findings
8. Cognitive Behavioral Therapy Evidence
9. Medication Evidence
10. Limits of the Evidence
11. Key Research Papers
12. Connections
13. Featured Videos

How It Was Named and How the Diagnostic Manual Classes It

The first name was "reverse anorexia." In 1993, Pope and colleagues were interviewing 108 male bodybuilders, 55 who had used anabolic steroids and 53 who had not, for a study of the psychiatric effects of those drugs. Nine of the men believed they looked small and weak although they were large and muscular. They described turning down social invitations, refusing to be seen at the beach, and wearing heavy clothes in summer heat. All nine were steroid users, and four said these symptoms contributed to their decision to start.

In 1997 the same group wrote that they had met both men and women with this preoccupation, tentatively named it "muscle dysmorphia," classed it as a form of body dysmorphic disorder, and proposed diagnostic criteria for research. Later surveys, including the Australian and German ones below, still apply those criteria. The informal word "bigorexia" appears in later writing, including a 2023 rapid review that uses the term "bigorexia nervosa" and calls the condition a controversial category.

A case-control study in 2000 compared 24 men with muscle dysmorphia with 30 ordinary weightlifters from Boston-area gyms. The two groups differed on body dissatisfaction, eating attitudes, steroid use, and lifetime mood, anxiety and eating disorders, while the ordinary weightlifters showed little psychiatric illness. The authors concluded that the condition appeared to be a valid diagnosis.

A label inside another diagnosis

The Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5), does not list muscle dysmorphia as a disorder of its own. It appears as a specifier of body dysmorphic disorder, meaning a descriptive label added to that diagnosis when the preoccupation is with being too small or insufficiently muscular.

The classification is still disputed

• A 2016 systematic review kept 34 of 5,136 articles published through 2014. Most were cross-sectional with small, non-clinical samples, and all were graded at the lowest level of methodological quality. The authors wrote that the evidence did not secure the validity or classification of muscle dysmorphia as a new disorder.
• A 2020 systematic and meta-analytic review of 40 papers found preliminary support for it as a clinically valid presentation, with two symptom patterns (behavioral, and cognitive plus behavioral). It found insufficient evidence to say whether it belongs as a specifier of body dysmorphic disorder or as a separate condition. Symptoms, treatment response and family links resembled both body dysmorphic disorder and eating disorders.
• A 2012 comparison of 21 men with muscle dysmorphia, 24 men with anorexia nervosa and 15 gym-using controls found wide similarities and gave what the authors called moderate support for a kinship with anorexia nervosa.
• A 2024 Spanish interview study suggested a broader spectrum of body image disorders in which body-change behavior ranges from food restriction to pathological exercise or cosmetic surgery.
• A 2023 paper on bodybuilders' own explanations argued that the medical model has overlooked the cultural setting of the condition, and that bodybuilders hold expertise of their own about it.

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How Common It Is in the Groups Studied and How Weak Those Estimates Are

No single reliable figure exists. Published estimates run from about 1% to above 10%, and the spread reflects who was sampled and how a "case" was defined at least as much as any real difference between groups.

Three things stand out in these numbers.

• The case definition moves the answer. The German study used one set of answers and changed only the weighting and the cut-off. The estimate for men went from 11.0% to 3.5%. Its authors reported that the estimates depend strongly on those choices.
• Interviews are rare. The Spanish study confirmed cases by clinical interview and reached the lowest figure in the table. The Australian authors wrote that diagnostic interviews are needed to verify their own survey figures. Most other figures come from questionnaires, which measure symptoms rather than establish a diagnosis.
• Women are present but less studied. The Australian survey found no significant gender association, though symptoms differed: boys more often reported severe preoccupation and a weight-lifting routine that interfered with life, and girls more often reported discomfort with exposing their bodies. A Brazilian community sample of 479 women found more severe symptoms and distress among lesbian and bisexual women than among heterosexual women.

Comparing groups adds a further finding. A 2017 meta-analysis of 31 studies and 5,880 participants, 90% of them male, found higher symptom scores in bodybuilders than in other resistance trainers, and higher scores in competitive than in non-competitive bodybuilders. Study quality was rated generally poor to moderate. The authors could not say whether bodybuilding worsens these traits or whether people with them are drawn to bodybuilding. The North American survey found almost no demographic differences by age, gender, race or ethnicity, or sexual orientation, apart from a lower body mass index among those with probable muscle dysmorphia. The German study also found lower body mass index among its most consistent correlates, a reminder that the condition follows the belief rather than actual size.

For scale, a 2024 review puts body dysmorphic disorder as a whole at about 2% of adults.

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Symptoms and Measurement Scales

Studies describe a recurring cluster of features.

• The central belief: a conviction of being small or under-muscled, often alongside a strong concern about gaining fat. A 2002 comparison of male weightlifters reported poorer body image in those with the condition and concern about fat in addition to the wish for more muscle.
• Checking: repeatedly assessing muscle size. In a North American sample of 1,153 boys and men, body checking did not differ significantly between those with probable muscle dysmorphia and those with probable anorexia nervosa or atypical anorexia nervosa, and both groups scored higher than those with neither.
• Training that takes over: a 2008 study of 15 men with current muscle dysmorphia, 8 with past muscle dysmorphia and 28 controls found more thinking about muscularity, appearance checking, bodybuilding dependence and functional impairment in current cases.
• Social and work costs: men in the 2000 case-control study described shame, embarrassment and impaired social and working lives.
• Reassurance and withdrawal: a three-week daily survey of 50 people meeting criteria placed seeking reassurance, dieting, supplement use, body dissatisfaction and staying away from others because of appearance among the most central symptoms.

The questionnaires researchers use

• Muscle Appearance Satisfaction Scale (2002): 19 items across five areas, namely bodybuilding dependence, muscle checking, substance use, injury and muscle satisfaction. It was developed in 372 male weightlifters.
• Muscle Dysmorphia Inventory (2004): 27 items across six areas, namely size and symmetry, supplement use, exercise dependence, pharmacological use, dietary behavior and physique protection.
• Muscle Dysmorphic Disorder Inventory (2004): a 13-item questionnaire with three subscales, namely drive for size, appearance intolerance and functional impairment. It has since been tested in further groups, including 330 transgender men in the United States and 1,501 lesbian and bisexual women in Brazil.

These scales measure symptoms rather than establish a diagnosis, and the 2017 meta-analysis counted eight different tools across its 31 studies, which makes results hard to compare. Cut-offs vary too: one 2026 Italian student survey counted a score above 39 on the Muscle Dysmorphic Disorder Inventory as clinical risk, and the Spanish interview study discussed how useful such screening cut-offs are in men.

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Anabolic Steroids and Other Substances

The steroid link has been part of the condition since the 1993 interviews, and it is where the most serious physical harm sits. The association is well reported, while the direction is less clear.

What the association looks like

• A 2025 systematic review and meta-analysis of ten studies, five quantitative and five qualitative, found higher symptom scores in anabolic-androgenic steroid users than in non-users (standardized difference about 0.45). It also found a correlation of about 0.24 with obsessive-compulsive traits, on a scale where 0 is no link and 1 a perfect one.
• In Oslo, 153 men with current or past steroid use reported more severe symptoms than 88 weightlifting controls. When steroid dependence symptoms and muscle dysmorphia symptoms were analyzed together, however, no significant connections between the two symptom groups appeared.
• Among 1,515 boys and men who had never used these drugs, probable muscle dysmorphia was associated with stronger intentions to use them. Probable anorexia nervosa or bulimia nervosa showed the same pattern, with no significant difference between the three conditions.
• The word "substances" covers a wide range. In a study of 2,261 sexual-minority adults, lifetime use of appearance- and performance-enhancing drugs and supplements ran from 29% to 44% across groups, and protein and creatine were the most common. In the 2016 military survey, muscle dysmorphia was linked to using supplements to get more muscular (odds ratio 5.4).

The intention data and the 1993 reports fit the idea that the belief can come before the drug. Cross-sectional data cannot show this directly, and steroid use could also feed the preoccupation.

The reported harms of the drugs

• Heart disease: a Danish registry study followed 1,189 men sanctioned for steroid use in fitness centers against 59,450 matched controls for an average of 11 years. The adjusted hazard ratios were 3.00 for heart attack, 2.42 for venous clots, 2.26 for arrhythmias, 3.63 for heart failure and 8.90 for cardiomyopathy.
• Death: a 2026 meta-analysis of three cohorts found a risk ratio of 2.57 for death from any cause (95% confidence interval 1.98 to 3.33). Its authors note that confounding, differing follow-up and the small evidence base do not allow a conclusion about cause.
• Dependence: a 2009 review estimated that about 30% of users develop a dependence syndrome, with continued use despite physical, social or work harm.
• Hormones and stopping: these drugs suppress the body's own testosterone signaling. Reviews describe long-lasting low testosterone after use, with low mood or major depression during withdrawal that can push men back to the drugs.
• Other reported problems: a 2019 review lists psychiatric disorders, infertility, nerve toxicity, musculoskeletal injury, liver toxicity and needle-borne infections, and rates the underlying evidence low to moderate in quality.

Steroids are not the only risk. A 2024 case report describes a 21-year-old bodybuilder who died of multi-organ failure after months of using the chemical 2,4-dinitrophenol, with anabolic steroids also found in his hair. He had already been hospitalized for organ failure once. Muscle dysmorphia was only a suspected diagnosis, so this single case shows the danger of the substance more than it shows anything about the condition.

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The Overlap With Eating Disorders

The body goals point in opposite directions, yet the behavior looks similar. A 2019 meta-analysis of 39 articles found a positive correlation of 0.36 between muscle dysmorphia symptoms and eating disorder symptoms, with the size depending on the sample and on the questionnaires used.

The 2012 comparison of men with muscle dysmorphia and men with anorexia nervosa found shared disturbance in body image, eating and exercise, with the differences matching the opposite physiques each group was pursuing. A 2024 interview-based Spanish study found eating disorders in 1.4% of undergraduate men and muscle dysmorphia in 1.3%, with no differences between the clinical groups on body image scales.

A 2026 survey of 2,001 Italian university students reported that clinical-level symptoms were among the strongest predictors of eating disorder risk (odds ratio 2.94, 95% confidence interval 2.03 to 4.25). The detail is revealing. Appearance intolerance and functional impairment were linked with higher odds, while drive for size was linked with slightly lower odds (odds ratio 0.93). In that sample, the distress and disruption tracked with disordered eating, and the wish to be bigger alone did not. The study was a single cross-sectional survey, so it cannot show which came first.

More general background on these conditions is on the Eating Disorders and Anorexia Nervosa pages.

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Depression, Anxiety and Suicidal Thoughts as Reported

The early case-control studies found more lifetime mood and anxiety disorders in men with muscle dysmorphia than in ordinary weightlifters. The 2017 meta-analysis reported correlations with depression of 0.23 to 0.53, with anxiety of 0.32 to 0.42, and inverse correlations with self-esteem of 0.42 to 0.47. Correlations of this kind do not show which came first.

Suicidal thoughts and past attempts

Research here is limited. Body dysmorphic disorder as a whole carries considerable suicide risk according to a 2024 review, and the findings specific to muscle dysmorphia are these:

• Among 63 men with body dysmorphic disorder reviewed in 2005, the 14 with muscle dysmorphia were more likely to have attempted suicide, and had poorer quality of life and more substance use disorders, than the 49 without it.
• In a Canadian study of 912 adolescents and young adults, symptoms at the start, especially appearance intolerance, were associated with suicidal thoughts and planning a year later, in models before and after adjustment.
• In 269 men in the United States surveyed three times, one month apart, feeling like a burden to others carried the link between symptoms and later suicidal thoughts. A sense of not belonging did not. Two cross-sectional samples (273 and 261 people) also pointed to feeling like a burden.
• In the second of those samples, dysmorphia symptoms were not related to how often people had attempted suicide, a different result from the 2005 clinic review above.
• In 272 men surveyed three times over six weeks, the order was not simple. A rise in suicidal thoughts was followed by a rise in muscle dysmorphia symptoms at the next survey, and the authors proposed that some men may use muscle-building to cope. Rising eating disorder symptoms, by contrast, were followed by more suicidal thoughts.
• Among the 50 people in the three-week daily survey, feeling like a burden, feeling disgust and dwelling on the past were the most central suicide-related factors.

These studies measure thoughts, plans and past attempts in mostly non-clinical samples, and none of the abstracts reports deaths. In the US, the 988 Suicide & Crisis Lifeline (call or text 988) answers 24 hours a day.

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Social Media Findings

The link with social media is frequently asserted and only partly tested. What exists is mostly one-time surveys, so the findings are associations.

• The content matters: in 1,553 boys and men in Canada and the United States, more frequent viewing of muscular bodies, muscle-building supplements and muscle-building drugs online was each associated with probable muscle dysmorphia, independent of total time on social media. The authors state that the direction of the relationship remains to be worked out.
• The review evidence is thin: a systematic review published in 2026 found 22 studies, only 5 of them on muscle dysmorphia, and mostly cross-sectional in non-clinical samples. It called the evidence for muscle dysmorphia preliminary.
• Time and comparison: a German survey of 540 young athletes, recruited through a social media platform, found scores of 38 versus 35 on the Muscle Dysmorphic Disorder Inventory in those using social media 60 minutes or more daily versus less. A statistical model ranked daily time, comparison with fitness influencers and seeking "likes" as its leading predictors. The authors describe exposure as raising risk, though a one-time survey recruited that way cannot establish cause.
• Absorbing the ideal: in a weighted German adult survey, media and peer pressure did not directly predict muscle dysmorphia. Their effect ran through taking muscular ideals on as one's own.
• A statistical pathway: in 721 young adults, most of them women, muscle dysmorphia symptoms partly carried the association between social media addiction symptoms and eating disorder symptoms.
• An older experiment: in 2002, college men shown advertisements with muscular men then showed a wider gap between their own perceived muscularity and their ideal than men shown neutral advertisements. This experiment compared two exposures directly, but it measured a brief change in perception in students, not the condition itself.

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Cognitive Behavioral Therapy Evidence and How Thin It Is

A 2017 overview described the evidence to guide treatment as "sorely lacking." It discussed borrowing from body dysmorphic disorder and anorexia nervosa treatment, such as restructuring perfectionistic beliefs and skills for regulating emotion. A 2026 Lancet review of adolescents and young adults states that some approaches show promise and that outcome data in large, diverse clinical adolescent samples remain scarce. The direct evidence found for this page is the following handful of studies.

• One randomized trial (2025): 59 men with muscle dysmorphia and a history of steroid or similar drug use were assigned to 12 weekly online sessions of cognitive behavioral therapy (30 men) or a waiting list (29 men). Those treated had large falls in muscle dysmorphia symptoms (standardized change 1.12), depression (0.98), distress (0.93), disordered eating (0.74) and exercise addiction (1.07), sustained at three months. The control group did not change significantly. The trial was open-label, so participants knew which group they were in, and its comparison was a waiting list. Those features can inflate results on symptom scales. All participants had a drug-use history, so it does not speak to everyone with the condition. Its authors suggest a possible first-line role; no independent replication turned up in the searches for this page.
• A small pilot (2025): 10 adults in Australia completed eight weekly telehealth sessions with no drop-outs. Symptoms, compulsive exercise and disordered eating fell by large amounts (Hedges' g of 1.66, 1.15 and 1.28) and stayed lower at three months. With no control group, the authors themselves wrote that controlled trials with larger samples are needed.
• A qualitative case series (2024): 7 men aged 35 to 55 with steroid-use histories completed 12 weeks of therapy. They reported shifts in body image and reductions in compulsive behavior and steroid use. They also reported feelings of loss and anxiety as routines changed, and some relapsed under stress.
• One case report (2015): a 15-year-old boy went into remission with eating-disorder-focused, family-based treatment. A single case cannot show how often this would work.

Access is a further limit. In a 2026 survey of 259 licensed outpatient psychotherapists in Canada and the United States, self-reported knowledge and confidence in treating boys and men with eating disorders and muscle dysmorphia were low. The 2025 meta-analysis also noted limited engagement with health services among people with the condition, and the 2024 military review found no military-specific treatment studies.

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Medication Evidence

No trial of a medication specifically for muscle dysmorphia turned up in the searches for this page. A 2023 rapid review stated that no specific pharmacological treatment has been identified, and the 2026 Lancet review lists medication as a subject for future research. A 2005 narrative review stated that "therapy and medication do work" while calling treatment options limited, and its abstract names no trial behind that statement.

The medication case therefore comes by extension from body dysmorphic disorder in general, where a 2024 review lists selective serotonin reuptake inhibitors among the evidence-based treatments. Those trials report on the broad diagnosis, and their abstracts give no results for a muscle dysmorphia subgroup.

• In a 2016 relapse-prevention trial, 100 adults with body dysmorphic disorder received open-label escitalopram for 14 weeks, and 67.0% responded. The 58 responders were then randomized to continue the drug or switch to placebo for six months. Relapse was 18% on escitalopram and 40% on placebo.
• In a 12-week placebo-controlled fluoxetine study of 67 adults with body dysmorphic disorder, emergence of suicidal thoughts did not differ significantly between groups, and worsening of suicidal thoughts was less common on fluoxetine than on placebo. No attempts or deaths occurred.

A separate question is treating steroid dependence when the two conditions occur together. A 2010 review suggested three targets: the body image disorder, the low hormone state after stopping (for which it describes human chorionic gonadotropin or clomiphene), and the drug's rewarding effects. The last idea comes from an animal finding that naltrexone blocked steroid dependence, and the review extends it to people by inference only. A 2026 clinical review describes the same condition as an emerging use disorder calling for psychiatry, addiction medicine and endocrinology together. Neither is a trial in people with muscle dysmorphia. A separate page covers low testosterone and its treatment.

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Limits of the Evidence

• Mostly one-time surveys. Reviews from 2016 to 2026 keep finding cross-sectional, non-clinical samples, which cannot separate cause from consequence. This affects the steroid, eating disorder, depression and social media findings alike.
• "Probable" is not "diagnosed." Many figures use self-report algorithms rather than interviews, and the German study shows how far the choice of algorithm can move the estimate.
• Unsettled definition. With classification still debated and at least eight questionnaires in use, studies do not always measure the same thing.
• Skewed samples. Early work came from small groups of bodybuilders and gym users recruited at gyms or through advertisements. Online panels and social media recruitment bring their own bias. Participants in the 2017 meta-analysis were 90% male, and work in women is more recent.
• Very small treatment base. One open-label randomized trial, one pilot, one case series and one case report make up most of the direct evidence for psychological treatment. No randomized trial of a medication for this subtype turned up in the searched literature, and prevention work is limited. The 2026 Lancet review notes that eating disorder prevention programs show potential for reducing symptoms.
• Weak harm attribution. The strongest harm data concern steroids in general, not people with muscle dysmorphia specifically. The records read for this page include no long-term study of the course of muscle dysmorphia itself, including deaths.

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Key Research Papers

1. Pope HG, Katz DL, Hudson JI. Anorexia nervosa and "reverse anorexia" among 108 male bodybuilders. Compr Psychiatry. 1993;34(6):406-9. PubMed PMID: 8131385
2. Pope HG, Gruber AJ, Choi P, Olivardia R, Phillips KA. Muscle dysmorphia. An underrecognized form of body dysmorphic disorder. Psychosomatics. 1997;38(6):548-57. PubMed PMID: 9427852
3. Olivardia R, Pope HG, Hudson JI. Muscle dysmorphia in male weightlifters: a case-control study. Am J Psychiatry. 2000;157(8):1291-6. PubMed PMID: 10910793
4. Choi PY, Pope HG, Olivardia R. Muscle dysmorphia: a new syndrome in weightlifters. Br J Sports Med. 2002;36(5):375-6; discussion 377. PubMed PMID: 12351338
5. Pope CG, Pope HG, Menard W, Fay C, Olivardia R, Phillips KA. Clinical features of muscle dysmorphia among males with body dysmorphic disorder. Body Image. 2005;2(4):395-400. PubMed PMID: 17075613
6. Cafri G, Olivardia R, Thompson JK. Symptom characteristics and psychiatric comorbidity among males with muscle dysmorphia. Compr Psychiatry. 2008;49(4):374-9. PubMed PMID: 18555058
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1. PubMed: muscle dysmorphia
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Connections

• Body Dysmorphic Disorder — the main topic page
• Eating Disorders — the wider group this condition overlaps with
• Anorexia Nervosa — the condition first used as its mirror image
• Obsessive-Compulsive Disorder — the related preoccupation and ritual pattern
• Depression — a frequent reported companion
• Low Testosterone and Testosterone Replacement Therapy — the hormone state after steroid use
• Hidden Prescription Drugs in "Natural" Supplements — undeclared drugs found in supplements
• Testosterone: The Male Hormone Axis — an animation of the hormone system steroids suppress

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