Muscle dysmorphia: never feeling big enough

It usually looks like

• Being proud of progress, even on off days
• Eating out with friends without panic
• Resting when ill, injured or tired
• Skipping a session for a family event without much distress

It can look like

• Feeling small however much you grow
• Missing work, school or family events to train or eat on schedule
• Panic or low mood on rest days
• Training through injury

Some people feel worse on rest days than on training days, which suggests exercise is being used to cope with hard feelings.

Checking muscles in mirrors, or avoiding mirrors, is common. So is wearing baggy clothes or layers to look larger.

Some people count calories and nutrients to a “perfect” formula, eat many strictly timed meals and avoid restaurants.

Cycles of “bulking” and “cutting”, and “cheat meals” that feel out of control, can also be part of it.

Training with injuries and exercising more after eating “off plan” are described in research on muscle dysmorphia.

People often avoid places where bodies are on show, and sometimes people and places in general, because of muscle worries.

Intrusive thoughts about not being big enough can make it hard to focus, and people often believe others judge their body.

Sports where size or weight matters, plus perfectionism and competitiveness, may raise risk. Rates are much higher among competitive bodybuilders.

Research suggests sexual minority men may face extra pressure to match body ideals, and discrimination can add to it.

A review of military studies estimated muscle dysmorphia in about 15% of men and 5% of women in the samples studied. The military setting may keep it going, though it is not the root cause.

Teens are at a stage when attitudes about building muscle form. Daily muscle-building exercise is common among U.S. high school boys.

It is more often linked with men, but it also occurs in women, including women who lift or compete.

Being bullied, especially for being small or not sporty, and trauma such as assault or abuse may raise risk. For some, muscle feels like protection.

People with muscle dysmorphia often hold strongly to traditional masculine norms, like being tough and in control.

In one experiment with 300 young men, viewing shirtless, muscular images from Instagram influencers lowered body satisfaction compared with clothed or scenery images.

Reviews link more social media use, and muscle-building content in particular, with more muscle dysmorphia symptoms, though more research is needed on cause and effect.

Low self-esteem, anxiety, low mood and feeling that others expect perfection are linked with muscle dysmorphia.

Some people with muscle dysmorphia use risky substances to build muscle. These are linked with heart problems, liver damage, fertility problems and infections from shared needles.

Training without enough rest, or through pain, raises the risk of strains and overuse injuries.

Some people have lost jobs or relationships because training and diet came first.

Muscle dysmorphia is linked with more depression and anxiety, and with suicidal thoughts.

CBT helps you notice the thoughts and habits that keep muscle worries going, and slowly try new ways of training, eating and seeing yourself.

A small study of an 8-week online CBT programme for adults showed fewer symptoms, which lasted at 3 months.

In one case report, a teenager improved when parents helped limit restrictive eating and over-exercise, with a therapist guiding them.

A two-session group programme called “The Body Project: More than Muscles” reduced symptoms compared with a waitlist.

Search at iocdf.org/find-help. Ask whether the therapist has worked with muscle dysmorphia or BDD.

Free support and treatment referrals, plus free online support groups open to all genders.

988 Suicide & Crisis Lifeline: call or text 988, or chat at 988lifeline.org. Free, confidential, 24/7.

Crisis Text Line: text HOME to 741741, 24/7.

If someone is in immediate danger, call 911.