In the Shadows

It’s rarely discussed and just starting to be researched, but body-image disorders among male athletes is a real—and growing—problem.

By R.J. Anderson

R.J. Anderson is an Assistant Editor at Training & Conditioning.

Training & Conditioning, 14.5, July/August 2004, http://www.momentummedia.com/articles/tc/tc1405/shadows.htm

Imagine being in the funhouse at a carnival. You look into one of those distorted mirrors and see a body that is different than your actual proportions. Your head is huge, your torso grossly elongated, and your legs bow like bananas. It’s kind of funny.

Imagine looking into your bathroom mirror and having similar results. After hours of working out at the gym, your chest is flat, your arms look like sticks, and your six-pack bulges out like a pitcher of Kool-Aid. Or at least that’s how it seems to you.

If you were a competitive athlete, in the best shape of your life, you wouldn’t be very amused. And for many men suffering from muscle dysmorphia, that is what happens every time they sneak a peak at their reflection.

Often referred to as reverse anorexia nervosa, muscle dysmorphia is a body image disorder primarily affecting males in which they become preoccupied with the misperception that their muscles are too small. Individuals with the condition are often driven to spend countless hours in the gym, to the detriment of their relationships, social lives, and physical well being. No matter how much or how hard they work out, men with muscle dysmorphia never feel muscular enough. But that doesn’t stop them from trying.

“Male athletes who have muscle dysmorphia tend to compulsively lift weights, ignoring signs of physical distress to their ligaments and joints,” says Roberto Olivardia, PhD, a clinical psychologist at McLean Hospital in Belmont, Mass., and muscle dysmorphia researcher, as well as co-author of The Adonis Complex: The Secret Crisis of Male Body Obsession. “Even when their bodies tell them to stop, they continue working out, thinking that more is better. They also tend to not pay attention to other physiological needs like hydration and food intake. And a number of them will use anabolic steroids.”

In a 2000 study, Olivardia found that 50 percent of men with muscle dysmorphia had used or were using steroids. Olivardia also notes that about one-third of men with muscle dysmorphia have a current eating disorder, a history of an eating disorder, or idiosyncratic eating patterns—such as placing an emphasis on extreme low-fat, high-protein diets.

Experts lay much of the blame on the media’s increased glorification of the male physique. “Women have been subjected to images of thin models for a long time and now men are subjected more and more to these hugely muscular icons and imagery,” says Olivardia. “Everything from World Wrestling Entertainment to music videos showing rappers with their shirts off revealing perfectly chiseled pecs and biceps. There’s definitely a pressure that boys today feel, which they didn’t feel as much 15 years ago, to look fit and toned.”

As the pressure mounts, so do the statistics. A recent study in Norway revealed that eight percent of elite male athletes in that country suffer from some type of eating disorder. The British Medical Journal found that the number of men who openly report dissatisfaction with their physical appearance has tripled in the last 20 years, and that therapists report seeing 50 percent more men for evaluation and treatment for eating disorders than they did in the 1990s. In the United States, however, the problem has not been researched much.

In this article we will take a look at muscle dysmorphia and how to recognize its symptoms in your student-athletes. We’ll also talk to a number of experts about how to approach an athlete they suspect may be in a phase of muscle dysmorphia or experiencing an eating disorder.

From the Gym to the Field
How prevalent is muscle dysmorphia in team-sport athletics? It’s hard to know since much of the earliest research has focused on body builders. But anecdotal information about other athletes is growing.

Heidi Skolnick, MS, CDN, a nutritionist for the New York Mets and the New York Giants, sees the problem at the professional level. “I have linemen who are very unhappy about their bodies and it doesn’t matter that they make a lot of money and can outrun most people—they’re not necessarily happy being that big,” says Skolnick. “It’s surprising to hear a lineman say, ‘I feel fat, I don’t fit in my clothes.’ Here’s a professional athlete who you assume would be proud of their largeness, but instead they are very sensitive to how their bodies look.”

Skolnick says that these athletes often focus their obsession on one particular body part. “They say, “I’m okay with my chest, but I hate my stomach or my legs are too big,’” she says. “And I think a lot of it comes from comparing themselves to other guys around the locker room or on the covers of magazines.”

At Ohio State University, Jennifer Carter, PhD, a psychologist at the school’s Sports Medicine Center, is working with varsity athletes to study the problem more systematically. She has surveyed Ohio State athletes for the past two years and will do so again, along with athletes from three other schools, this fall. (See “Survey Questions” below.)

In her 2002 study, results showed that one percent of the 882 athletes surveyed (of which 57 percent were male) showed possible signs of muscle dysmorphia. While that may not seem like an alarming statistic, Carter is quick to point out that the questionnaire was not anonymous. She explains that one of the biggest problems with studying muscle dysmorphia is that men are very reluctant to admit having any type of negative body image.

“The difficulty with this topic is that men do not voluntarily discuss this,” says Carter. “As time has gone on, more men have talked to me during individual counseling about being concerned that they are not muscular enough, but a lot of people don’t even know this problem is going on. I talk to our athletic trainers and occasionally an athletic trainer might refer an athlete to me who they suspect might have this problem, but I don’t think it is being recognized as a huge problem as of yet.”

Olivardia explains that, because body image disorders are largely viewed as only affecting women, most men are ashamed to admit they may be suffering from them. “The shame is enormous,” says Olivardia. “I’m often the first person, or the only person, that a lot of men disclose this problem to—and that’s because they know I’m an expert in the field and I’ve written about it. Some of these men are married and their wives don’t even know that they struggle with muscle dysmorphia or bulimia because they are so ashamed.”

A Definition
Muscle dysmorphia is a subtype of body dysmorphic disorder (BDD). BDD is the diagnosis people get when they are preoccupied with how their body looks—whether it’s their nose, hair, skin, or any part of their body. Muscle dysmorphia is a type of BDD in which the preoccupation happens to be on their muscularity and their physique. Because research within this particular branch of BDD is in its infancy, not much is known about the origins of the disorder, nor is there much information regarding how many people are affected.

“We do know that muscle dysmorphia is associated with either a mood or an anxiety disorder,” says Olivardia. “Most men with muscle dysmorphia tend to have an underlying depression, or underlying anxiety. But we don’t know what comes first.

“A lot of men I work with who have muscle dysmorphia say that working out is a way of taking control,” Olivardia continues. “It is similar to what you hear from women who have eating disorders, except women use food as a way of controlling their lives and managing their emotions, while men with muscle dysmorphia rely on exercise to take control. If they are at the gym for five hours a day and the only thing they have to focus on is their body, it can serve as a distraction away from other things in their life that might be completely falling apart.”

As with eating disorders, there is a wide range of severity. “Just like in the female population when we talk about eating disorders being a continuum, I’d say it’s the same thing for muscle dysmorphia,” says Skolnick. “There’s this range of eating patterns and body dissatisfaction that is occurring. It doesn’t have to be a full-blown dysmorphic phase, but many men are beginning to take on characteristics of the disorders that are definitely not healthy.”

Spotting a Suspect
Not every athlete who puts in extra time in the weight room is muscle dysmorphic, and just because an athlete is conscientious about his diet, he does not necessarily have an eating disorder. But where is the line that tells us an athlete is doing too much? How do you know when an athlete’s drive for health has become unhealthy?

“In general, coaches and athletic trainers should have a sense as to where the boundaries are that the person has in working out,” says Olivardia. “From there they will be able to notice how an athlete’s workout routine affects his general attitude about his body and if it is getting in the way of other things in his life—his relationships, his friendships, his eating habits, his studying.”

Excessive mirror-checking is one warning sign that may help tip off whether a person is having issues with body image. “Men with muscle dysmorphia often check mirrors as a way of reassuring,” says Olivardia. “It’s not that they’re vain and like the way they look. It’s actually for the opposite reason—they don’t like the way they look, and they want to find a way to improve it.”

If an athlete is noticeably weight-conscious or body-fat conscious, they might be taking things too far. “I see a lot of guys who get into restrictive eating in the name of eating clean and trying to be healthy,” says Skolnick. “I definitely don’t want to discourage guys from being thoughtful about what they eat, but they get to a point where they won’t eat something like a donut. They develop strict rules around what they can and cannot eat versus having guidelines for trying to eat better.”

Carter echoes the sentiment. Athletes she has worked with who have body image problems report thinking about food, diet, or working out 80 or 90 percent of their day. She adds that substance abuse often accompanies eating and body image disorders among college athletes.

Other signs include skipping meals with the team, preferring to eat alone, wearing baggy clothing to cloak perceived inadequacies, not wearing shorts or short-sleeved shirts, and refusing to take their shirt off at the beach. And of course, there is the matter of steroid abuse, the ultimate sign that an athlete is unhappy with his body.

“What’s ironic is that most of the men with muscle dysmorphia are in very good shape,” says Olivardia. “In some cases they are above average in terms of their muscularity. A lot of them have a very low body fat percentage, and to the average eye they would be deemed very muscular, but they don’t see it.”

Treatment & Therapy
When you or a member of your staff suspects that an athlete may have an unhealthy preoccupation with body image, how should you approach him? How can you find out what’s going on without causing him to feel ashamed and retreat into a defensive shell?

“The most important thing is to take a stance of concern and empathy for that person as opposed to saying, ‘What are you doing to yourself?’ or being sarcastic,” says Olivardia. “You might start by simply saying, ‘I think you’re overdoing it in your workouts.’

“If you come from a point of concern rather than putting them on the defensive, the denial is easier to break through,” Olivardia continues. “Share with them observable behaviors like, ‘I see that you are isolating yourself from the team,’ or ‘I noticed that you worked out four and a half hours today, when typically you’re supposed to work out an hour and a half,’ or ‘I see that you seem very sullen and very sad,’ as opposed to something like, ‘I think you might be depressed.’

“Sharing with them the concrete behaviors makes it harder for them to argue with you, compared to if you say, ‘I think that you have a body image problem.’ Because they can just say, ‘No, I don’t.’ Then the conversation is pretty much over.”

The idea is to engage the athlete in a preliminary conversation about their habits and fears to glean how serious the problem is. If the athlete’s focus on body image seems fairly minor, there are many ways to steer him back on course and away from full-blown muscle dysmorphia.

“Basically, just give a lot of positive reinforcement in terms of what he is accomplishing,” says Olivardia. “Definitely do not use critical language, because men with muscle dysmorphia are hyper-sensitive to criticism. Focus on their strengths and not their weaknesses.”

Olivardia says it’s also important for coaches to model balanced behavior themselves—especially strength and conditioning coaches. “If you’re a coach who eats, breathes, and sleeps working out, then the athlete will pick up on that,” says Olivardia. “As a coach, if you live a very balanced life yourself, an athlete can look upon you as a model of inspiration—somebody who eats well-balanced meals, who exercises appropriately, but also has relationships, has fun, is social, and is comfortable with himself.”

Strength coaches can also encourage athletes to seek out relaxation techniques or other activities that offer an alternative to working out when encountering stress. “Coaches should really reinforce self-care,” says Olivardia. “The idea is to make sure that not only are they eating well and working out, but that they are sleeping well, drinking enough water, and getting enough social stimulation.”

At Ohio State, Carter tells her coaches to be particularly careful when they talk to an athlete about losing or gaining weight. “We would like them to consult with the medical staff first to see if it’s advisable and if they think it will help the athlete’s performance,” says Carter. “And if so, we then refer the athlete to a dietitian to make sure they are doing it in a healthy way. Often, athletes are instructed to lose or gain weight and have no clue how to do that in a healthy way, which can lead to unhealthy behaviors.”

Outside Help
If an athlete’s behavior or habits reach a level of becoming obsessive or self-destructive, athletic trainers and strength coaches are encouraged to refer the athlete to a sports psychologist. When an athlete comes to her exhibiting symptoms of an eating or body image disorder, Carter uses a technique called cognitive behavioral therapy. The technique examines the underlying assumptions athletes have about themselves and how they feel the rest of world sees them.

Says Carter, “For example, when addressing the idea that, ‘People will accept me only if I am very muscular,’ we’ll ask, ‘What are some other aspects of your self that people might like? What are some strengths that you have? Are there muscular people you know who aren’t necessarily popular?’”

Olivardia, who also utilizes cognitive behavioral therapy, says the technique helps correct a lot of distortions these athletes have. “Their thoughts are typically very negative,” says Olivardia. “The behavioral part of cognitive behavioral therapy should address any of those behaviors that we either want to increase or reduce.”

To increase socialization, Olivardia often asks patients who have muscle dysmorphia to step outside of their comfort zone. If a patient feels uncomfortable in social situations, and tends not to wear short-sleeved shirts or shorts because they feel like their arms or legs are too small, Olivardia will have that patient establish a goal to overcome that fear. “I’ll say, ‘Okay, your goal this week is, if it’s 90 degrees outside, you have to wear shorts,’” says Olivardia. “I try to expose them to the very things that they are fearing or avoiding in some way.

“To limit mirror-checking, I ask patients to take a baseline of how many times they look in a mirror in a day,” continues Olivardia. “The goal is to reduce the number of times that they are checking the mirror each day.”

Olivardia also employs general psychotherapy when treating patients with eating or body image disorders. He talks to patients about their background, looking at some of the issues that might predispose them to the condition, including depression, anxiety, family history, child abuse, negative peer experiences, perfectionist tendencies, or low self-esteem.

What’s Next?
While muscle dysmorphia and eating disorders among males are not even close to approaching the levels of body image problems experienced by women, they are important to look out for. “I think athletes have an additional layer of risk because the models they are looking at are people who are specifically invested in muscular physique and toning up,” says Olivardia. “A lot of the products they might buy—protein shakes or fat-burning supplements—typically feature endorsements from men who probably got their body through using steroids. So athletes are measuring themselves up against what is an immeasurable body—one that is the product of drug use.

“Muscle dysmorphia is a body image disorder, but when you add the athletic world where there is a pressure to perform, it becomes even more pronounced,” he adds. “One of my patients had an athletic scholarship, so his base of viability at the university was dependent upon him doing well athletically. As a result, he thought taking steroids was a necessary thing, to both grow his body and enhance his performance.”

Part of the problem is that for a long time, the assumption was that these types of disorders didn’t affect men. But they do. It just happens that men are particularly good about hiding these problems, which Olivardia says makes the disorders even more dangerous.

“We think that this problem is going to get worse before it gets better,” says Olivardia. “The images that boys and men are bombarded with of muscular men is only increasing.”



Sidebar: Survey Questions
Jennifer Carter, PhD, a psychologist at The Ohio State University Sports Medicine Center, gives athletes the following survey to uncover any body image disorders. The questions originally appeared in the article “An Exploration of the Drive for Muscularity in Adolescent Boys and Girls,” published in the Journal of American College Health. Athletes are asked to answer each statement using a scale of one to six, one being never, and six being always.

—I wish that I were more muscular.
—I lift weights to build up muscle.
—I use protein or energy supplements.
—I drink weight-gain or protein shakes.
—I try to consume as many calories as I can in a day.
—I feel guilty if I miss a weight-training session.
—I think I would feel more confident if I had more muscle mass.
—Other people think I work out with weights too often.
—I think that I would look better if I gained 10 pounds in bulk.
—I think about taking anabolic steroids.
—I think that I would feel stronger if I gained a little more muscle mass.
—I think that my weight-training schedule interferes with other aspects of my life.
—I think my arms are not muscular enough.
—I think my chest is not muscular enough.
—I think my legs are not muscular enough.