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Muscle Dysmorphia in Adolescent Boys: Causes and Outcomes

Neal Cotter

April 27th, 2011



While an 85-pound girl may be the stereotypical image of people with eating disorders, the true demographic affected by them goes far beyond this description.  The struggles of the male population with disordered eating and exercise habits are often ignored in the wake of better-known conditions like Anorexia Nervosa, but these issues often silently torment the men and the boys who suffer from them.  Muscle Dysmorphic Disorder, also known as “reverse anorexia,” is a subset of Body Dysmorphic Disorder in which a person begins to pursue muscularity to an excessive extent and suffers from obsessive thoughts that can lead to exercise dependence or even substance abuse (Cafri et. al 2006), and this condition is becoming more prevalent in a society which regards an increasingly muscular body as the ideal male physique.  Adolescent boys are particularly susceptible to acquiring a disordered pattern of thinking, since they are just beginning to develop physically and psychologically into adults. While no one cause or group of causes can be isolated as the root of all cases of Muscle Dysmorphic Disorder in adolescents, common themes among many instances of MDD include a strong interpersonal and media influence and several emotional patterns that leave boys particularly predisposed to developing a disorder.  MDD most commonly manifests itself in excessive amounts of exercise, but in many cases it can lead teens to experiment with performance-enhancing substances, the most common of which is anabolic steroids.  Overall, studies show that Muscle Dysmorphic Disorder is a far more serious pattern in today’s adolescent male population than it is commonly given credit for, and it is only by recognizing the risk factors and manifestations of this condition that understanding and treating it can become possible.

Causes of MDD

            Like any psychological disorder, MDD takes root in a myriad of different sources, both within the person suffering from the condition and throughout his environment.  For adolescent boys with Muscle Dysmorphia, the media’s influences are most easily identifiable since the images of the ideal male body presented to today’s youth reflect increasingly unrealistic physiques, but several interpersonal and internal factors are also greatly influence many cases of MDD.  While the common risk factors can be neatly divided into external and internal causes, it is vital to remember that both categories modify and intensify the other, and it is almost always a combination of these two that underlies the disorder.

External Causes

Media Influence


            Although MDD in adolescent boys is a highly under-researched phenomenon, a large proportion of the studies done on it include analyses of the influence of the images and role expectations presented by the media on boys with a high drive for muscularity.  In a detailed study of the anatomical dimensions of popular action figures, researchers measured the toys’ waist, chest, and biceps, and then used these values to generate measurements for a life-sized human of the same proportions (Pope et. al 1998).  An analysis of several versions of GI Joe over the course of 20 years reveals this popular icon’s transformation from a relatively average man with minimal muscular definition to an extraordinarily muscular figure with nearly impossibly large measurements.  In fact, the researchers claim that if the most recent GI Joe action figure was created at a normal male height of 70 inches, it would possess larger biceps than any bodybuilder in history, demonstrating the brand’s unrealistic portrayal of the male body.  Observations of other modern action figures present even more alarming results: Batman sports the same bicep size as GI with a larger chest and smaller waist, and Wolverine stands out as the largest of all figures, with a massive 62 inch chest.  Although the researchers behind this study did not directly measure the effects of these images of masculinity on growing boys, the recent transition from relatively ordinary physiques to ones with unattainable masculinity in toys that boys play with from an early age means that they will be bombarded with unrealistic ideals throughout their childhood, which leaves today’s youth more susceptible to developing skewed perceptions of the male body than ever before.


            A study by Leit et. al (2001) sought to analyze the effects of similar types on images on an older demographic: young men reaching the end of adolescence.  While the 82 undergraduate college students who made up the sample were not quite boys, the mean age was still only 19.8, so their experience was not far removed from that of males the midst of adolescence.  The sample was divided into a control group, which was shown 30 slides of neutral advertisements, and an experimental group, which viewed 10 neutral slides and 20 slides containing advertisements with muscular male bodies.  Participants’ body image perceptions following the advertisements were then assessed using the Somatomorphic Matrix, which required them to select images of the average, ideal, and most attractive male bodies, and then compare their own to these figures.  Researchers found that overall, the experimental group showed significantly greater discrepancies between their ideal and perceived body shapes than the control group, which led to the conclusion that the media’s representation of men’s bodies exacerbates males’ body dissatisfaction.   From these results, it is clear that as one of the most frequent recipients of the media’s advertising images, adolescent boys are particularly susceptible to developing the body dissatisfaction experienced by the men in this study, and at their earlier stage of emotional development, the effects may be even more dramatic.  As the researchers note, it is impossible to measure the lifelong effects of exposure to these images, but the noticeable results of even this short experience with them suggest that over the course of more than a decade of consistently viewing unrealistic representations of the male body, adolescents’ self-perceptions are likely to be even more drastically altered, which suggests these images’ role in driving males towards MDD.


            Other studies of several causes of MDD in adolescent boys include an analysis of the media’s influence as one of the many factors that predict the disorder.  In a survey of 269 teenage boys focused on their muscle-gaining habits and societal influences (Cafri et. al 2006), media-related perceptions of the ideal male body were found to be significant predictors of Muscle Dysmoprhia in adolescent males, which illustrates that the results of the two previously mentioned studies have been verified in real-world applications.  Another survey included media influence as a factor in psychological assessments of 587 boys in Australia (Ricciardelli et. al 2003), but in this study, the media was not found to be a significant direct influence.  This result stands in opposition to most other studies which point to media influence as one of the primary causes of MDD, but it is possible that the survey generated some data that was not extreme enough to be deemed  statistically significant.  Another possible interpretation of this result is based on cultural differences.  Since the other studies were conducted among American teens, this survey could indicate that Australia’s media representations of the male body are not as extreme or pressuring as those found in the United States.  More data would be needed, however, to verify this theory.  Overall, detailed analyses of the male body in the media show measurable increases in muscularity over time, and most studies show that adolescent males’ response to these ideals is one of dissatisfaction at the discrepancy between their real and ideal bodies.

Social/interpersonal factors

            While the images of muscularity that abound in the media are relatively standard across the population, individual boys experience vastly different levels of teasing and pressure from their families and peers, and those subject to unsupportive interpersonal interactions are often at a greater risk for developing MDD.  Although the Australian study of adolescent boys failed to prove the media’s influence on Muscle Dysmorphia, it did find peer and parent influence to be one of the three most significant predictors of an intense desire to change one’s muscle size (Ricciardelli and McCabe 2003).  Since the survey consisted in part of the following four Likert scales: Body Dissatisfaction, Body Image Importance, Body Change Strategies to Decrease Weight, Body Change Strategies to Increase Muscle, parent and peer influence were largely related to the first two categories because they contributed to the unsatisfactory self-perception that led boys to pursue muscle-building techniques.  In a different study done on steroid use among adolescents (Irving et. al 2002), researchers surveyed 4746 middle and high school students about various aspects related to usage and found that parents who display concerns about weight are more likely to raise children who take steroids to gain muscle, which suggests that being in an environment which places great importance on body image leads adolescents to more harshly evaluate their own physique.  Thus, although relatively limited data is available on the influence of interpersonal factors on the development of MDD in adolescent boys, it is clear that being in a home or school environment that highly values a specific body image increases the pressure for young males to conform to a more muscular appearance.

Internal Causes

            In addition to environmental influences, studies have found that many internal factors related to a boy’s self-esteem and body image assessment are significant risk factors for the onset of MDD.  Besides parent and peer influence, the two strongest predictors for an urge to develop a more muscular body in the study done by Ricciardelli and McCabe (2003) were negative affect and body image importance, which both reflect adolescent males’ internal emotional states and value systems.  These findings were produced using Marsh’s General Self Scale and the Negative Affect Scale in addition to the four previously mentioned Likert scales, and they provide evidence that depressive emotions can lead boys to alter themselves externally in order to compensate for the self-esteem issues that generate this negative affect.  The distinction of  body image importance as a separate predictive factor from negative affect illustrates that even boys with generally positive emotions are at risk to develop MDD if they ascribe a great deal of importance to their physical appearance, and in particular, their muscularity.  In most cases, however, there is largely a high degree of overlap between these two factors, since many adolescents who strive for the ideal male body develop negative affect as a result of the discrepancy between their real and ideal appearance.

            Another study seeking to analyze adolescent males’ desires to increase their muscularity (McCreary and Sasse 2000) also included measures of self-esteem and emotions in its survey of 96 adolescent boys and 101 teen girls, producing similar results to the previous study.   The drive for muscularity in boys was positively correlated with low self-esteem and higher depression levels, which matches the other study’s finding that a negative affect is often related to the development of MDD.  Interestingly, this result was unique to the boys surveyed in the study because the same factors showed no association with drive for muscularity in girls, suggesting that the internal risk factors for Muscle Dysmorphia in adolescent boys are unique to the male demographic.

            Finally, the study done by Cafri et. al (2006) also included measures of adolescent boys’ emotions, and confirmed negative affect as one of the principal predictors of Muscle Dysmorphia, thus reinforcing the concept of emotional state as a key influence in the development of MDD.

From Ricciardelli and McCabe (2003)

Manifestations of MDD

            While Muscle Dysmorphic Disorder is not an independent condition listed in the most recent version of the DSM, its proposed symptoms are modeled on the accepted criteria for Body Dysmorphic Disorder and apply these descriptions of a perceived physical defect to the topic of muscularity. Therefore, MDD is currently understood as a preoccupation with a perceived lack of muscularity that results in hours of muscle-building activity and meticulous regulation of one’s diet. In addition, a patient must be accurately described by two of the following: forgoes other social or occupational activities to maintain a workout schedule, feels of intense anxiety at exposing his body to others, experiences significant distress or impairment in other areas of life, and continues to workout despite adverse consequences.  Finally, clinicians make clear that the preoccupation is distinguished from anorexia nervosa and other disorders because it focuses specifically on the lack of sufficient muscularity (Murray et. al 2010).  In adolescent boys, many of these criteria are reflected in teens’ strong commitment to working out to gain muscle, as this exercise often becomes excessive and obsessive.  In some cases, adolescents also attempt to quell the anxiety by ingesting drugs like steroids to aid muscle growth.  Although MDD is still not a recognized psychological disorder in the DSM, boys who follow the general patterns of highly frequent exercise and substance use for muscle gain show signs of developing the symptoms associated with clinicians’ current definition of MDD.

Frequent Exercise


            As studies have proven, the desire to develop a muscular physique most often manifests itself in large amounts of exercise in adolescent boys.  In the previously mentioned study done by McCreary and Sasse (2000), the 96 male participants were surveyed on a series of factors relating to the drive for muscularity as determined by interviews with weightlifting enthusiasts, and a positive relationship was found between a high drive for muscularity and frequent exercise.  Boys who tested high on the drive for muscularity also displayed a significantly higher desire for weight gain, which is likely the end goal of their frequent exercise.  Since the adolescent males scored higher than the females on nine of the fifteen categories, it is evident that frequent exercise to fulfill one’s drive for muscularity is more strongly associated with teen boys than with teen girls.

            Another Australian study which analyzed the body change strategies of 40 boys in seventh and ninth grade (McCabe and Ricciardelli 2001) reconfirmed this idea of frequent exercise as the most typical body change strategy among adolescent males.  Surveys indicated that exercise was the most common method for weight alteration among the boys surveyed and that the use of diet change and supplements was far less prevalent.  The statistics compiled by the researchers reflect this trend, since of the 40 boys surveyed, 22 report exercising to change the size of their muscles, and 11 said they do so often.  Among the choices presented to them, exercising to gain muscle was the most popular reason for engaging in physical activity among the boys surveyed as opposed to exercising to change their weight or shape.  As a result, this study illustrates that muscle gain is the primary motivation of many adolescent males who engage in exercise, and although the boys surveyed were not diagnosed with MDD, their responses indicate the widespread use of exercise to satisfy the drive to build muscle among this demographic.  It is when this desire to become more muscular manifests itself in an intense anxiety about working out that MDD begins to develop.

From McCabe and Ricciardelli (2001)

Substance Use


While not quite as common as excessive exercise, the use of muscle-building substances (particularly anabolic steroids) is one of the most prominent ways in which adolescents with MDD seek to alleviate the discrepancy between their real and ideal bodies.  McCreary and Sasse (2000) did not take specific data on steroid usage in their study on adolescent males with high drives for muscularity, but noted in their discussion that the boys’ high frequency of exercise demonstrated a willingness to act on their desires for a more muscular body that put them at greater risk for turning to substances like steroids as a solution.  Another study on adolescents’ pursuit of muscularity (Cafri et. al 2006) included substance use in the survey questions and discovered that 9.8% of the teenage boys surveyed reported having used some type of muscle-enhancing drug.  Surprisingly, prohormone and ephedrine had higher statistics for lifetime and current usage than did anabolic steroids, demonstrating that even though steroids are probably the most widely known substance for building muscle, there are several other drugs that adolescents consume in their pursuit of muscularity.  Although researchers noted that many of the nearly 10% of boys who had used one or more of the substances had only done so experimentally, this relatively high proportion still demonstrates that the desire to improve one’s muscularity produces enough anxiety in adolescent males to motivate nearly one in ten of them to take drastic measures to achieve their ideal physique.


            A study focused exclusively on steroid use among adolescents surveyed 4746 middle and high school students of both genders (Irving et. al 2002) to determine both the prevalence of anabolic steroid usage and users’ opinions about the drug.  Unlike the previous study, the proportion of male steroid users found through this survey (5.4%) does not take into account the use of other muscle-enhancing drugs, making this statistic more singularly demonstrative of the widespread use of anabolic steroids.  Examining the boys’ opinions about substance use for muscle gain, researchers found that on average steroid users possessed less knowledge and concern about health and a greater willingness to experiment with unhealthy weight control behaviors, which illustrates that many adolescents satisfy the criterion of MDD that describes a continuation of muscle-seeking behavior despite adverse consequences (in this case, the negative health effects).  Researchers also noted that steroid users overall showed less satisfaction with their shoulders than non-users and about equal levels of satisfaction in other areas.  Thus, this study suggests that steroid usage only perpetuates negative perceptions of adolescents’ body image, and rather than alleviate the anxiety associated with MDD, it can actually worsen it.  The large sample size for the survey makes these results even more credible and suggests that this figure is likely to hold across a broader population as well, demonstrating that in general, steroid use is surprisingly prevalent among teenage boys despite its failure to ameliorate any dissatisfaction with their muscularity.


            While MDD among adolescent males still receives far less attention than better known disorders like Anorexia Nervosa and Bulimia Nervosa which more often affect girls, the results of these studies show that Muscle Dysmorphia is negatively influencing a large proportion of teenage boys and stems from many of the same sources associated with female eating disorders.  Just as the media, peers, and families communicate to girls the need to be thin, young males are bombarded with images portraying the ideal male body as unrealistically muscular and face a great pressure to conform to this model.  These forces interact with boys’ emotions and perceptions of the value of body image to produce behaviors typical of MDD such as excessive exercise and the use of muscle-enhancing substances.  Clearly, many adolescent males face a psychological struggle parallel to girls with Anorexia, and for this reason, greater efforts should be made to research Muscle Dysmorphia and educate young boys on the dangers of taking extreme measures to achieve a more muscular physique.  Much in the way Anorexia Nervosa among females has received growing attention in recent years, the same measures to promote awareness should be applied to this more subtle but equally agonizing condition.  Using these methods, health experts can instill young boys a balanced understanding of exercise that focuses more on personal wellbeing than achieving an ideal body image.  Only through greater clinical and laboratory research can researchers fully understand the myriad of forces behind Muscle Dysmorphic Disorder and begin to devise prevention strategies that will allow adolescent males to have healthier, more realistic exercise habits and self-perceptions.



Cafri, G., Van der Berg, P., and Thompson, J. K. (2006). Pursuit of Muscularity in Adolescent Boys: Relations Among Biopsychosocial Variables and Clinical Outcomes.  Journal of Clinical Child & Adolescent Psychology 35(2). 283-291.


Irving, L. M., Wall, M., Neumark-Sztainer, D., and Story, M. (2002). Steroid Use Among Adolescents: Findings from Project EAT. Journal of Adolescent Health 30(4). 243-252.


Leit, R. A., Gray, J. J., and Pope, H. G. (2001). The Media’s Representation of the Ideal Male Body: A Cause for Muscle Dysmorphia? International Journal of Eating Disorders 31(3). 334-338.


McCabe, M. P., and Ricciardelli, L. A. (2001). Body Image and Body Change Techniques Among Young Adolescent Boys. European Eating Disorders Review 9(5). 335-347


McCreary, D. R., and Sasse, D. K. (2000).  An Exploration of the Drive for Muscularity in Adolescent Boys and Girls. Journal of American College Health 48(6). 297-304.


Murray, S. B., Rieger, E., Touyz, S. W., and García, Y. D. (2010). Muscle Dysmorphia and the DSM-V Conundrum: Where Does It Belong? A Review Paper. International Journal of Eating Disorders 43(6). 483-491.


Pope, H. G., Olivarida, R., Gruber, A., and Borowiecki, J. (1998). Evolving Ideals of Male Body Image as Seen Through Action Toys. International Journal of Eating Disorders 26(1). 65-72


Ricciardellli, L. A., and McCabe, M. P. (2003). Sociocultural and Individual Influences on Muscle Gain and Weight Loss Strategies Among Adolescents. Psychology in the Schools 40(2). 209-224.







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