In the United States, males represent approximately one-third of those battling eating disorders. These disorders often emerge during adolescence, and estimates suggest that up to 14% of American men will experience an eating disorder by the age of 40, with a higher likelihood of mortality compared to women. Despite this, male eating disorder expert Jason Nagata believes that recognition of this mental health issue is lacking.
Muscle dysmorphia, which primarily affects males, exemplifies this under-recognition. The disorder is characterized by an obsession with muscle building and is classified under obsessive-compulsive and related disorders in the DSM, though it often includes extreme dieting.
Nagata, an associate professor in the Division of Adolescent and Young Adult Medicine at the University of California, San Francisco, and an eating disorders hospitalist at UCSF Benioff Children’s Hospital, suggests reclassifying muscle dysmorphia as an eating disorder in the forthcoming sixth edition of the DSM. He argues that this shift could enhance the identification of patients requiring support, improve referrals to specialists, and boost insurance coverage.Â
However, this suggestion is contentious, with some experts contending that the current classification is accurate and can be used alongside an eating disorder diagnosis when needed.
Nagata recently spoke with STAT about his efforts to highlight the needs of boys and men with muscle dysmorphia. This interview has been edited for length and clarity.
Can you explain the current muscle dysmorphia classification?
To be officially diagnosed with muscle dysmorphia, several criteria must be met: a fixation on muscularity or feeling insufficiently muscular, repetitive behaviors such as mirror or weight-checking, constant comparison to others’ muscularity, and significant distress or impairment in social, occupational, or other areas. Importantly, it cannot be better explained by an eating disorder or its symptoms. This last criterion makes the conditions mutually exclusive: meeting the criteria for an eating disorder in the DSM means muscle dysmorphia cannot also be diagnosed.Â
How do you perceive the relationship between muscle dysmorphia and eating disorders?
Muscle dysmorphia is the formal DSM term, but it’s often called “bigorexia” or “reverse anorexia.” Unlike anorexia nervosa, where individuals want to lose weight despite being thin, those with muscle dysmorphia might be muscular but perceive themselves as scrawny.
People aiming to build muscle often engage in various eating behaviors that might be seen as disordered, such as high-protein diets, cutting carbs and fats, and using strategies like “bulking and cutting” or intermittent fasting.
Why do you think this condition should be reclassified?
Medicine is always evolving, and the introduction of muscle dysmorphia into the DSM was a positive step. Thirteen years have passed since its classification, and there’s room for improvement.
The primary issue is mutual exclusivity. Exercise and nutrition are intertwined, and some individuals develop eating disorders or disordered eating from a desire to be muscular. The current DSM lacks an eating disorder diagnosis that addresses muscularity concerns. The language medical professionals use is crucial.
Beyond the DSM definitions, a spectrum exists. Many people experience a mix of muscularity concerns and disordered eating, but only a small fraction meet the complete muscle dysmorphia criteria.
Have you encountered this in your clinical practice?
I primarily work at an eating disorders treatment center. We’ve observed a growing number of boys and men over recent years. Without a muscularity-focused eating disorder in the DSM, the official diagnosis is “unspecified feeding and eating disorder” (UFED), which doesn’t specifically address muscularity and covers various conditions.
Many of our male patients express concerns about muscularity and use performance-enhancing drugs or supplements and engage in excessive exercise. Some meet all muscle dysmorphia criteria except for the exclusion of an eating disorder.
What is the current treatment process for muscle dysmorphia?
Treatment access is very limited due to the scarcity of studies. There are few muscle dysmorphia specialists globally, and I’m unaware of dedicated treatment centers. Individuals typically see general mental health providers, who may not specialize in muscle dysmorphia, or attend eating disorder treatment centers like ours.
Stigma is a barrier to care for anyone with an eating disorder or body image issue. Boys often experience a double stigma due to the feminized perception of these conditions. The lower recognition of these issues in boys and men compared to girls can delay diagnosis and treatment.
When diagnosed, these boys and men are often in treatment centers with patients primarily dealing with anorexia nervosa or focused on weight loss and thinness. This can be isolating, as they struggle to find relatable peers.
Is insurance a concern as well?
Healthcare providers must code for diagnoses, and under the DSM-5, they shouldn’t code for both muscle dysmorphia and an eating disorder. Some providers do code both when symptoms overlap, risking misdiagnosis scrutiny from insurance companies. Providers shouldn’t have to risk audits by deviating from the DSM just to secure patient treatment.
How could changing the DSM classification improve treatment?
While it’s uncertain, reclassification might ease access to care for boys and men through eating disorder programs, general programs, or new body dysmorphic disorder programs. This could lead to more personalized care.
Recognizing a muscularity-oriented disordered-eating diagnosis could spur more studies in the field. Currently, with cases coded as “unspecified,” studies and treatments are limited. Standardizing diagnostic criteria could enhance clinician training and national study surveillance, paving the way for specific treatment pathways. Without greater recognition, boys and men will continue to suffer silently.
What additional changes are you advocating for in regard to muscle dysmorphia?
I advocate for increased recognition of muscularity-oriented eating components in the eating disorder field. Screening questions traditionally focus on weight loss, but adding questions about supplement use, performance-enhancing drugs, and excessive exercise could improve early identification and diagnosis in both pediatric and adult primary care.
Overall, I seek better acknowledgment of eating disorder diversity across gender, race, ethnicity, and socioeconomic status, moving beyond the stereotypical white, thin, female portrayal. Although significant research advances have been made in the past two decades, more progress is needed.Â
STAT’s coverage of health challenges facing men and boys is supported by Rise Together, a donor-advised fund sponsored and administered by National Philanthropic Trust and established by Richard Reeves, founding president of the American Institute for Boys and Men; and by the Boston Foundation. Our financial supporters are not involved in any decisions about our journalism.
