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Eating Disorders: The Journal of


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A Conceptual Model of Factors


Contributing to the Development of
Muscle Dysmorphia
a
Frederick G. Grieve
a
Western Kentucky University , Bowling Green, Kentucky, USA
Published online: 18 Feb 2007.

To cite this article: Frederick G. Grieve (2007) A Conceptual Model of Factors Contributing to the
Development of Muscle Dysmorphia, Eating Disorders: The Journal of Treatment & Prevention, 15:1,
63-80, DOI: 10.1080/10640260601044535

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Eating Disorders, 15:63–80, 2007
Copyright © Taylor & Francis Group, LLC
ISSN: 1064-0266 print/1532-530X online
DOI: 10.1080/10640260601044535

A Conceptual Model of Factors Contributing to


1532-530X
1064-0266
UEDI
Eating Disorders,
Disorders Vol. 15, No. 1, October 2006: pp. 1–32

the Development of Muscle Dysmorphia

FREDERICK G. GRIEVE
Muscle
F. G. Grieve
Dysmorphia

Western Kentucky University, Bowling Green, Kentucky, USA


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Muscle dysmorphia is a recently described subcategory of Body


Dysmorphic Disorder. It is most prevalent in males and has a
number of cognitive, behavioral, socioenviornmental, emotional,
and psychological factors that influence its expression. An etiologi-
cal model describing these influences is presented for evaluation.
Nine variables (body mass, media influences, ideal body internal-
ization, low self-esteem, body dissatisfaction, health locus of
control, negative affect, perfectionism, and body distortion) were
identified through the use of extant literature on muscle
dysmorphia and through extrapolation from literature involving
women and eating disorders. The functional relationships among
these variables are described and implications of the model are
discussed.

For years, the focus of body image studies has been on women; however, it
appears that men are becoming more and more concerned with body
appearance. Muscle dysmorphia (MD) is a newly described subcategory of
body dysmorphic disorder, which is gaining attention (Pope, Gruber, Choi,
Olivardia, & Phillips, 1997). The disorder affects mostly men, particularly
those who engage in weight lifting or body building (Pope, Katz, & Hudson,
1993). MD is part of a larger, society-wide increased focus on male bodies
(c.f., Pope, Olivardia, Borowiecki, & Cohane, 2001) that Pope and his col-
leagues have termed the Adonis Complex (Pope, Phillips, & Olivardia,
2000). Some factors contributing to the development of MD have been

The author thanks Pitt Derryberry, Cheryl Grieve, Adrienne Helmick, Crystal Henson, Lindsay Jack-
son, Lesley Montgomery, Sheena Moyers, and Adrian Thomas for their assistance with the completion of
this manuscript.
Address correspondence to Frederick G. Grieve, Department of Psychology, Western
Kentucky University, 1906 College Heights Blvd., #21030, Bowling Green, KY 42101-1030.
E-mail: rick.grieve@wku.edu

63
64 F. G. Grieve

explicated (see Pope et al., 2000, for a review), but have not necessarily
been placed in a theoretical model. The goal of the present paper is to out-
line a conceptual model of the factors influencing the development of MD
in an attempt to guide both research and practice.

MUSCLE DYSMORPHIA

Muscle dysmorphia is a collection of attitudes and behaviors that are charac-


teristic of an extreme desire to gain body mass. Attitudes include a dislike of
one’s current body shape and a strong desire to change it through increased
muscle mass, and behaviors include excessive weight lifting, eating large
quantities of high-protein foods, use of weight gain supplements, and use of
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anabolic steroids. Diagnostic criteria for MD have been outlined (Pope


et al., 1997). Individuals with MD are preoccupied with the fact that they do
not perceive themselves to be lean and muscular enough, even though they
are often more muscular than average people. This preoccupation with
body shape is persistent and causes clinically significant impairment or dis-
tress in daily functioning. Individuals give up important social, occupa-
tional, or recreational activities due to the desire to maintain a strict workout
schedule; avoid situations in which their bodies are exposed to others;
experience extreme levels of distress over inadequate musculature when
such inadequacy is not apparent; and continue to lift weights, diet, or use
performance-enhancing substances despite knowledge of adverse physical
or psychological consequences (Olivardia, 2001).
There are a number of psychological and behavioral symptoms of MD.
In some cases, body image disturbance is noted; individuals with MD
believe that they are smaller than they actually appear (Olivardia, 2001).
Many times, individuals with MD hide their bodies when in public; arrange
their lives so that lifting weights and working out are not compromised;
spend many hours in the weight room, often to the point of impairing social
and intimate relationships; continue weight training even when injured; and
follow a meticulous diet, which usually includes the use of inappropriate or
illegal supplements. They actively avoid situations in which their bodies will
be exposed, such as beaches, and experience high levels of anxiety if
forced to endure such situations (Olivardia, 2001). Another behavior that is
prevalent is mirror-checking. Men with MD check their appearance much
more than normal individuals and much more than other weight lifters
(Olivardia, Pope, & Hudson, 2000). They also compare their physique with
that of others as a means of social comparison, which often leads to a
downward spiral in terms of body distortion and anxiety (Olivardia, 2001).
Men with MD differ from other weight lifters, as men with MD report
greater body dissatisfaction, more dysfunctional eating attitudes, a higher
prevalence of anabolic steroid use, and a greater history of mood, anxiety,
Muscle Dysmorphia 65

and eating disorders (Olivardia et al., 2000). The prevalence rate for MD has
been estimated to be 10% of weightlifters (Pope & Katz, 1994). However,
Goodale, Watkins, and Cardinal (2001) found that a number of college stu-
dents meet subclinical levels of muscle dysmorphia symptoms. Thus, the
true prevalence rate of MD is unknown.

MUSCLE DYSMORPHIA AND EATING DISORDERS

While MD has been classified as a subcategory of Body Dysmorphic Disor-


der (Pope & Katz, 1994), and as part of the obsessive-compulsive spectrum
of disorders (Maida & Armstrong, 2005; Olivardia, 2001), it appears to be a
disorder that straddles both anxiety and eating disorders. There are a num-
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ber of similarities between the diagnostic criteria for MD and both anorexia
nervosa (AN) and Bulimia Nervosa (BN). In fact, the original conceptualiza-
tion of MD was named reverse anorexia (Pope, Katz, & Hudson, 1993)
because of its perceived similarities with AN. Further, men with MD often
either have a history of eating disorders (Pope et al., 1993) or have concomitant
symptoms of eating disorders along with MD (Olivardia, Pope, Borowiecki, &
Cohane, 2004).
In both eating disorders and MD, the person’s self-opinion is strongly
influenced by his or her body shape and size. The closer the individual is to
the social ideal body shape, the higher his or her self-opinion. The farther
away from the social ideal, the lower the self-opinion. For men, the most
common social ideal is lean muscularity with low body fat; therefore, those
who develop MD aspire to attain the most muscular figures with as low per-
centage of body fat as possible. For women, the social ideal is thin; there-
fore, those who develop eating disorders, especially AN, aspire to attain thin
figures. In both cases, the desire to attain the social ideal leads to an
extreme body shape. MD is characterized by a chronic preoccupation with
body shape, which occurs in conjunction with changes in eating and exer-
cise practices that are similar to those seen in women with AN and BN.
There is perceived body distortion in both MD and AN. Men with MD
believe themselves to be smaller than they actually are (Olivardia, 2001)
while women with AN believe themselves to be larger than they actually are
(Fairburn & Brownell, 2002).
Behaviorally, men with MD exhibit abnormal eating patterns that are
driven by overvalued belief systems. Men with MD consume a large number
of calories with the goal of increasing muscle mass. This large intake in cal-
ories is analogous to binge eating, though whether men with MD feel out of
control while eating has not yet been evaluated. However, it is clear that the
eating patterns exhibited by men with MD are influenced by underlying dis-
torted cognitions, as are the eating patterns exhibited by women with AN
and BN. These similarities in symptom presentation imply that similar forces
66 F. G. Grieve

are operating on both men and women in the development of eating disor-
ders and MD. Therefore, it is probable that factors specific to the develop-
ment of eating disorders also influence the development of MD.

FACTORS INCLUDED IN THE MODEL

There are four different types of variables that can influence the develop-
ment of MD included within the model (see Figure 1). The categories repre-
sent the biopsychosocial model of psychopathology (Kiesler, 1999). The
categories represented in the model are socioenvironmental factors (media
influences, sport participation), emotional factors (negative affect), psycho-
logical factors (body dissatisfaction, ideal body internalization, self-esteem,
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body distortion, perfectionism), and physiological factors (body mass).


As with the development of any psychological disorder, there are a
number of factors that contribute to the etiology of MD. Most of these vari-
ables interact with each other in a complex manner. However, many of the
proposed relationships have not yet been empirically examined. The model
endorsed here is, perhaps, a bit simplistic, but it offers a starting point from

Muscle Dysmorphia

Perfectionism Body Distortion Negative Affect

Body Mass Body Dissatisfaction L o w Se l f -E s t ee m

S po r t Ideal Body
Participation Media Pressure Internalization

FIGURE 1 Contributing factors in the development of Muscle Dysmorphia.


Muscle Dysmorphia 67

which future research can begin to examine the relationships between the
indicated variables.

Body Dissatisfaction
Although there are a number of different definitions for body dissatisfaction,
for the present discussion it refers to the extent to which there is a discrep-
ancy between individuals’ perception of the perfect body and their actual
physical appearance (Keeton, Cash, & Brown, 1990). People use many dif-
ferent standards of comparison for body shape, and changes in social set-
ting may increase the salience of one standard over another (Higgins,
Strauman, & Klein, 1986). The current standard for women is thin, while the
current standard for men is athletic and muscular (see the discussion on
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Ideal Body Internalization).


Women in general tend to be dissatisfied with their bodies, mostly
because they view themselves as unacceptably overweight (Brownell &
Rodin, 1994). Men, on the other hand, have historically been perceived as
less dissatisfied with their bodies, although this could have reflected differ-
ential satisfaction. Men tend to focus on the whole body while women tend
to focus on specific body parts, such as thighs (Lantz, Rhea, & Mayhew,
2001). Ridgeway and Tylka asked men to describe the parts of their bodies
with which they were dissatisfied; most men in their sample reported dissat-
isfaction with their abdominal regions, arms, and chest. However, a large
number of men in the study reported dissatisfaction with other areas of their
bodies, such as shoulders, back, upper legs, buttocks, and calves.
It appears as though the number of men who report being dissatisfied
with their appearance is increasing (Olivardia et al., 2004). When asked, a
majority of college men identified at least one area of their bodies with
which they were dissatisfied (Ridgeway & Tylka, 2005). Further, dissatisfac-
tion appears to begin at a young age. Furnham and Calnan (1998) reported
that 69% of their sample of adolescent boys were dissatisfied with their bod-
ies because they felt that their present body shape deviated from their ideal
body shape. Using an adult sample, Pope, Gruber et al. (2000) found that
men from Austria, France, and the United States desired a body that was
approximately 28 pounds more muscular. McCreary and Sasse (2000) report
on a drive for muscularity, which includes men’s perceptions that they are
not as big or muscular as they really are, that negatively influences men’s
body image.
There appear to be two different types of men and boys who are dissatis-
fied with their bodies: those who are obese and want to lose weight and those
who are underweight and want to gain weight (Furnham & Calnan, 1998). Both
groups report that they want to appear more mesomorphic, and it is this desire
that fuels the body dissatisfaction. However, the two groups will use different
techniques to achieve their goals. Individuals who are obese will use weight loss
68 F. G. Grieve

techniques—and, perhaps, moderate muscle-building activities, which promote


weight gain (McCabe & Ricciardelli, 2001)—while individuals who are under-
weight will use mostly weight gain techniques. It is the individuals who are, or
believe themselves to be, underweight who are at the highest risk of developing
MD. In fact, the greatest body dissatisfaction appears to occur in thin males.
College age men who are underweight are as dissatisfied with their bodies as
college women who are overweight (Harmatz, Gronendyke, & Thomas, 1985).
Henson (2004) examined the relationship between body dissatisfaction
and level of MD symptoms. Results of the study indicated that dissatisfaction
with upper body strength significantly predicted MD symptoms.
Body dissatisfaction is an important mediator in the model. Most vari-
ables influence body dissatisfaction, which then influences MD through low
self-esteem and body distortion.
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Body Distortion
A key component to the development of eating disorders is a distortion of
how the woman views her body (American Psychiatric Association, 2000).
Usually this is a distortion of size. Women with AN believe that they are
larger than their actual appearance. The development of MD depends on a
similar distortion of body size. However, in this case, the distortion is that
men believe they are smaller than what they appear (Olivardia, 2001).
While women in general tend to believe they are overweight (Miller,
Coffman, & Linke, 1980), there is evidence that men believe they are thinner
than what they actually are. For example, Mintz and Betz (1986) found that
63% of slightly overweight men, as defined by the Metropolitan Life Insur-
ance desirable weight ranges, believed they were of normal weight, and
23% of normal weight men believed they were either slightly underweight
or underweight. Similarly, McCreary (2002) found that 43% of overweight
men perceived themselves to be normal weight, and Andersen (2002)
reported that men felt thin until their weight was as high as 105% of their
ideal body weight.
In the model, body distortion is influenced by and, in return, influ-
ences, body dissatisfaction. It is the conjunction of these two variables that
brings about the symptoms of MD.

Body Mass
Body mass is included in the model as this variable serves as the basis for
comparison. Body mass is one criterion by which a diagnosis of MD can be
made, much in the same way body weight is one of the diagnostic criteria
(American Psychiatric Association, 2000) for AN. For the development of
MD, both the perception of low body weight as well as a muscular body
shape appear to be necessary.
Muscle Dysmorphia 69

Although the clinical description of MD (see Olivardia, 2001, and Pope


et al., 1997) does not explicitly state that individuals suffering from the dis-
order have increased levels of muscularity, references to lifting weights and
being preoccupied with muscularity predominate. Therefore, while it is con-
ceivable that an individual with low levels of muscularity could develop
MD, the likelihood is that the disorder will only be diagnosed in those who
are muscular and mesomorphic, and those who are perhaps even bordering
on being (or actually are) hypermesomorphic.
Increasing body mass is very important for many men (McCreary &
Sasse, 2000). College men, in particular, report wanting to increase their
muscle mass (Lynch & Zellner, 1999). Lifting weights is a fairly popular
activity, with 22% of college men reporting that they currently lift weights
three times or more per week and 53% reporting that they have lifted at this
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rate at some point in their lives (Grieve, Wann, Henson, & Ford, in press).
Weight lifting activities begin in young children; approximately 25% of mid-
dle-school-age boys reported regularly lifting weights to gain muscle mass
(Smolak, Murnen, & Thompson, 2005).
Despite the importance that increased body mass has for men, the rela-
tionship between body mass index (BMI) and symptoms of MD has not
been established (see Cafri et al., 2005, for a review). Therefore, body mass,
while included in the present model, needs to be stringently evaluated for
continued acceptance in the model.

Media Influences
The muscular ideal is conveyed to the population via a number of social
influences, including family members, peers, schools, athletics, and health
care professionals, and mass media (Smolak et al., 2005; Stanford & McCabe,
2005). Mass media—the most influential of the social pressures—encom-
passes a number of technologies, from billboards to radio, but most studies
and theories on the etiology of eating disorders focus on visual media such
as television, movies, and magazines (Groesz, Levine, & Murnen, 2001). The
media widely and frequently serve to transmit increasingly impossible male
and female body standards as cultural ideals (Harrison & Cantor, 1997).
Individuals often perceive pressure from the media to conform to these
increasingly impossible body standards, and such media pressure can lead to
the development of eating disorders in women and MD in men.
For women, the prevalence rates of eating disorders have mirrored
changes in mass media representations of women through the same time
span. As the media ideal has become thinner, the prevalence rates of AN
and BN have increased (Harrison & Cantor, 1997). Historically, males have
been assumed to be protected against the effects of media pressure for a
certain body shape as males depicted in the visual media have reflected the
average male body type. However, over the past 20 years, the male models
70 F. G. Grieve

used in the media have become more muscular and have moved toward a
hypermesomorphic standard (Pope, Olivardia, et al., 2001). Such a move
underscores the value of a masculine body and has brought about an
increased pressure on ordinary males to obtain potentially unreachable
standards for body shape.
The media can influence men’s body image through the contrast effect.
Media advertisements generate social comparison (Richins, 1991). Although
social comparison can work in a positive manner, it generally does not do
so. As the number of male bodies in advertisements increases, the opportu-
nities for such a comparison increase. Social comparison can lead to a
decrease in satisfaction with current body shape (see the discussion on
Body Dissatisfaction).
In addition to changes in media presentations of the male body, there
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have been changes in other role models for male bodies. Playgirl center-
folds (Leit, Pope, & Gray, 2001; Spitzer, Henderson, & Zivian, 1999) and
action toys (Pope et al., 1999) have both become more muscular and
“dense” over the past 20 years. Action figures, in particular, have undergone
a transformation from being representations of normal-shaped men in the
1970s to having body shapes that are virtually unattainable by the majority
of the population in the 2000s (Pope et al., 1999). Now, male action figures
appear to be as poor a body model for boys as Barbie is for girls (Norton,
Olds, Olive, & Dank, 1996).
The number of fitness magazines directed at men and the number of
undressed men in advertisements in other magazines have increased over the
past 20 years, as well (Pope, Olivardia, et al., 2001). Therefore, the potential
is there for men to be as influenced by muscular body shapes as females are
by thin body shapes. For example, boys who experience body dissatisfaction
do so because of sociocultural pressures that endorse larger, more muscular
bodies than what the boys perceive they have (Pope et al., 1997). Further,
media pressure has been found to be a significant contributor to adolescent
boys’ muscle-building activities, such as lifting weights and using both legal
and illegal supplements (Smolak et al., 2005; Stanford & McCabe, 2005).
The ideal male form in media presentations is moving toward that of
the V-shaped masculine physique—tall, muscular, and mesomorphic. The
current sociocultural standard for attractiveness for men is a healthy,
extremely athletic appearance (Parks & Read, 1997). This preference
appears to develop at an early age, often between the ages of six and seven
(Wright & Bradbard, 1980), and increases with age until it peaks during
adolescence and early adulthood (Collins & Plahn, 1988).
There is evidence that men focus on the discrepancy between their
actual body shape and the ideal body shape (Wrobleska, 1997), which
increases the likelihood of the development of MD. Festinger’s social com-
parison theory has been used as a theoretical guide to understand the
impact of the media on self-evaluations for women with eating disorders
Muscle Dysmorphia 71

(Shaw & Waller, 1995). This theory suggests that people evaluate them-
selves based on a comparison with others. If the media portray men as mus-
cular and these muscular men become a point of comparison, then men will
be more likely to view their own bodies negatively.
Lorenzen, Grieve, and Thomas (2004) and Baird and Grieve (2006)
have both found that exposing men to pictures of muscular men leads to
body dissatisfaction. Lorenzen et al. exposed men to photographs of muscu-
lar and average men and found a decrease in body satisfaction post-expo-
sure only in the men exposed to photographs of muscular men. Baird and
Grieve (2006) found similar results exposing men to actual magazine adver-
tisements that had either male models in addition to products or solely
products; men exposed to advertisements with male models reported lower
body satisfaction post-exposure than those who were exposed to advertise-
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ments with only products.


In the proposed etiological model, media exposure directly
influences body dissatisfaction. It can do this through a number of mech-
anisms. One such mechanism is through influencing men’s perceptions of
physical attractiveness. Personal standards for physical attractiveness tend
to increase after exposure to an unusually high level of attractiveness;
such as can be found in the media. People who are exposed to high
levels of attractiveness may experience a contrast effect in that they will
experience their own bodies as less attractive when compared to media
ideals (Kenrick & Gutierres, 1980), which increases levels of body
dissatisfaction.
Another mechanism by which media exposure influences body dissatis-
faction is through increasing anxiety and self-consciousness about a prob-
lem (in this case not being mesomorphic enough) and providing a solution
to the problem (usually by purchasing and using the advertised product).
While this process appears to influence women more so than men (see
Gould, 1987), it is possible that men who are influenced by this type of
media process (and, hence, have higher levels of body dissatisfaction than
those less influenced) will be more likely to develop MD.

Ideal Body Internalization


Ideal body internalization involves the acceptance of the cultural ideal. For
men, this cultural ideal is a mesomorphic body shape. Current research sup-
ports that the internalization of a thin body ideal interacts with other vari-
ables to contribute to the development of eating disorders in women
(Thompson & Stice, 2001). For men, acquiring a certain body shape is one
of the primary factors influencing their desire to gain muscle (Ridgeway &
Tylka, 2005). Accordingly, it is hypothesized that the internalization of the
mesomorphic body ideal presented in the media will increase the likelihood
of the development of MD.
72 F. G. Grieve

According to self-discrepancy theory (Higgins, 1987), people have


a number of domains of self, which interact to bring about different
behaviors. The three types of self include the actual self, which repre-
sents the attributes people or significant others believe they actually
possess; the ideal self, which represents the attributes people or signifi-
cant others would really like to possess; and the ought self, which
represents attributes people or significant others believe they are
obliged to have. In this theory, the ideal and ought selves are self-
guides, or self-evaluative standards. When there are discrepancies
between the actual self and the self-guides, negative emotional-motiva-
tional states result, which, in turn, lead to emotional distress and
self-defeating behaviors. Self-guides can exert either a strong or weak
influence. Weak self-guides lead to problems with disobedience,
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aggressiveness, and lack of responsibility. Strong self-guides lead to


increased emotional intensity of self-evaluation and a desire to reduce
self-discrepancies. Although men typically develop weak self-guides,
there is evidence that they can develop strong self-guides (Strauman
Vookles, Berenstein, Chaiken, & Higgins, 1991). When this happens—
especially if men adopt the cultural ideal as their body image guide—
they are vulnerable to body dissatisfaction, maladaptive eating prac-
tices, and maladaptive exercise practices.
There is evidence that men are starting to be influenced by a muscu-
lar ideal body shape. When surveyed, men report the ideal body as tall,
muscular, and lean (Ridgeway & Tylka, 2005). The adoption of a muscular
ideal happens at a very early age. Six year old boys have demonstrated
a preference for a muscular body shape (Staffieri, 1967). These desires
represent an internalization of the current sociocultural standard of
attractiveness.
There is evidence to suggest that internalization of an ideal body shape
influences body satisfaction. Ogden and Mundray (1996) exposed men to
pictures of both thin and obese models. They found that men who were
exposed to the pictures of thin models had worse body image following the
exposure than men exposed to the pictures of fat models. Similarly, Lorenzen,
Grieve, and Thomas (2004) exposed men to pictures of both muscular and
non-muscular models. The results indicated that men’s self-rated body
image decreased following exposure to the muscular models but not fol-
lowing exposure to the non-muscular models. Further, Moyers (2005) exam-
ined ideal-actual body shape discrepancies in men and found that the
greater the ideal-actual discrepancy, the lower the person’s body satisfaction
and the more likely he endorsed symptoms of MD.
In addition, the muscular ideal is reinforced by significant or respected
others, such as family, peers, and media. These sources communicate
expectations about the benefits of muscle gain, and such expectations play
an important role in the promotion of the muscular ideal (Smolak et al.,
Muscle Dysmorphia 73

2005; Stanford & McCabe, 2005). As an example, men report that they want
to have more muscle mass than they actually do (Pope, Gruber et al., 2001).
Further, college men believe that college women find more muscular men
attractive than what college women actually report (Grieve, Newton, Kelley,
Miller, & Kerr, 2005). College men also believe that women desire men who
are taller and who have blue eyes and blond hair (Jacobi & Cash, 1994).
However, college women, while they do not find the mesomuscular figure
attractive, believe that everyone else—men and women alike—does find
such a body shape attractive (Lynch & Zellner, 1999). Finally, men have a
tendency to overestimate the amount of muscularity that women find attrac-
tive (Grieve et al., 2005).
In the model, ideal body internalization influences both body dissatis-
faction and low self-esteem. For body dissatisfaction, it is a positive relation-
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ship: the more ideal body internalization, the higher the level of body
dissatisfaction. For self-esteem it is a negative relationship: the more ideal
body internalization, the lower self-esteem.

Sport Participation
It has been established that participation in sports that focus on weight
(e.g., wrestling, track) increases the incidence rates of eating disorders
(Stoutjesdyk & Jevne, 1993). For MD, the stage may be set by participating
in sports that reward high muscle mass, such as football. Individuals who
participate in such sports are more likely to use/abuse anabolic steroids
than individuals who do not participate in such sports (c.f., Irving, Wall,
Neumark-Sztainer, & Story, 2002). Use of anabolic steroids influences the
body mass/adiposity of an individual, and, as seen previously, high density
body mass could be a precursor for MD. In addition, athletes share many of
the psychological factors that could increase the likelihood of MD. These
factors include a high level of competitiveness, a high need for control, and
perfectionistic tendencies. In addition, athletes are exposed to pressures
toward particular weights and body shapes that are unique to sport (Haase,
Prapavessis, & Owens, 2002).
Potentially, sport participation could play a similar role as dieting does
in the development of eating disorders. While dieting does not lead to the
development of an eating disorder in all cases, it does increase the risk for
development (Schmidt, 2002). Sport participation does not lead to the
development of MD in all cases, but it does increase the risk for developing
the disorder.
In the model, sport participation directly influences body mass/adipos-
ity and ideal body internalization. Sport participation exposes individuals to
the social ideal of muscularity. In addition, there is some reinforcement for
obtaining and maintaining the ideal body shape, as performance tends to
improve with muscularity.
74 F. G. Grieve

Low Self-Esteem
Psychological factors also play a role in the etiology of MD. Low self-esteem
provides one source of motivation for the behavioral symptoms of MD. For
example, people whose self-esteem is contingent upon appearance tend to
spend more time engaging in behaviors related to appearance, such as lift-
ing weights (Crocker, 2002).
Mintz and Betz (1986) reported a significant positive relationship
between self-esteem and body attitudes. Men and women who had more
positive attitudes about their bodies had higher levels of self-esteem. There
is a negative relationship between self-esteem and MD symptoms; men with
lower self-esteem report higher levels of MD (Olivardia et al., 2004).
In the model, low self-esteem is influenced by ideal body internaliza-
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tion, body dissatisfaction, and negative affect. In turn, low self-esteem


affects body dissatisfaction and negative affect. For both body dissatisfaction
and negative affect, the reciprocal relationship is negative in nature: the
lower the self-esteem, the higher the body dissatisfaction and the worse the
mood.

Perfectionism
Perfectionism has been defined as the pursuit of unrealistic goals (Nugent,
2000). Women with eating disorders are pursuing the unrealistic goal of
reaching an unattainable body shape. Not surprisingly, it has been found
that women with eating disorders have higher levels of perfectionism than
women who do not have eating disorders (Vohs et al., 2001). Since men
with MD also are struggling to reach an unattainable body shape, it is
hypothesized that perfectionism will influence the development of this dis-
order. In fact, Henson (2004) examined this relationship and found that
some aspects of perfectionism, most notably concern over mistakes, pre-
dicted the level of reported MD symptoms.
In the model, perfectionism influences the development of muscle dys-
morphia both directly and indirectly. The direct influence can be found in
the relentless pursuit of the “perfect body.” The indirect influence is through
body dissatisfaction. If the man’s body deviates from the perfect body, he
will be dissatisfied with his body shape. This increases the likelihood of the
development of MD.

Negative Affect
In this etiological model, negative affect provides the motivation for the
behavioral symptoms of MD. In addition, it provides a negative reinforce-
ment of these symptoms. In this way, the symptoms of MD can be seen as
ego-syntonic, much as the symptoms of AN are.
Muscle Dysmorphia 75

Negative affect is influenced by low self-esteem, body dissatisfaction,


and body distortion. In return, it influences low self-esteem, body distortion,
and symptoms of MD. Body dissatisfaction expresses its influence on the
symptoms of MD through negative affect.

DISCUSSION

Muscle dysmorphia is a newly-described disorder for men with some fea-


tures that parallel eating disorders in women. The key component to both
eating disorders and MD is body dissatisfaction. Women who differ from the
societal ideal of thinness and who endorse such an ideal perform behaviors
to move their bodies more toward the ideal. These behaviors take the form
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of the eating disorders AN and BN. Men whose bodies differ from the
societal ideal of muscularity and who endorse this ideal perform behaviors
to move their bodies toward that ideal. Many times, these behaviors result
in MD.
Because of the similarities in symptom presentation between MD and
eating disorders, many of the factors that influence the development of eat-
ing disorders, such as body dissatisfaction, ideal body internalization, and
perfectionism, also could influence the development of MD. There is a full
and expanding research literature related to the development of eating dis-
orders in women. These studies can be useful in creating research hypothe-
ses to use with men.
Much of the research cited in the etiological model has examined vari-
ables that are associated with subclinical levels of MD. The studies have
focused on body image disturbance, body shape satisfaction, and other vari-
ables within the normal population. On one level, the model needs to be
applied to those who actually have or are at risk for developing MD. On
another level, these findings parallel the experiences of women. Many
women without eating disorders have subclinical levels of eating disorder
symptoms. For example, some two-thirds of college women have partici-
pated in at least one session of binge eating (Harvard Medical School,
2002), and most women are so dissatisfied with their appearance that it has
been termed a normative dissatisfaction (Brownell & Rodin, 1994).
While historically men have been perceived to be immune from social
influences that endorse a certain body type, it appears that this is changing.
The pressures from media and peers are already influencing what men per-
ceive as a desirable physique. Men are beginning to report being dissatisfied
with their bodies. These attitudes represent subclinical levels of MD, and
suggest areas ripe for future study.
Other models to explain MD have been proposed. Olivardia (2001)
presented a brief biopsychosocial model for the development of MD that
included genetic contributions, a drive for muscularity, low self-esteem,
76 F. G. Grieve

appearance-related social pressures, and body-image consciousness. Lantz,


Rhea, and Mayhew (2001) proposed a model that included precipitating
variables (self-esteem and body dissatisfaction), psycho-behavioral charac-
teristics (body size/symmetry, dietary constraints, use of psychopharmaco-
logical aids, use of dietary supplements, exercise dependence, and
physique protection), and negative outcomes (alienation and narcissism). In
the model, the development of MD is directly influenced by body dissatis-
faction. In turn, there is a reciprocal relationship between MD and the psy-
cho-behavioral characteristics. The present model incorporates many of the
concepts from these two models and extends the model to include other
etiological contributions.
In addition to these two models, Cafri et al. (2005) recently reviewed
factors contributing to the development of risky health behaviors, such as
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steroid use, dieting to lose weight, and dieting to increase muscularity, and
presented a model that outlined the relationships among the factors. This
model includes biological factors (body composition/BMI, pubertal growth,
pubertal timing), societal factors (media influence, peer and parental pres-
sures, teasing, peer popularity), social body comparison, body image dissat-
isfaction (with muscularity and with body fat), psychological functioning
(negative affect, low self-esteem), and sport participation. This model is a
general model combining factors that contribute to a number of different
behavioral outcomes. The etiological model presented in the present work
is more specific to the development of MD. While it includes some of the
same factors as the Cafri et al. model, it also encompasses other variables
(such as ideal body internalization) that are not covered in that model. The
proposed relationships in both models are slightly different. These differ-
ences are to be expected, given the different purposes of the models.
The three most important variables in the model are ideal-body internal-
ization, body dissatisfaction, and body distortion. It is the combination of these
three factors that produces the underlying conditions necessary for the devel-
opment of MD. Variables that appear to have less of an influence (though are
still important variables to consider, both empirically and clinically) include
media pressure, perfectionism, low self-esteem, negative affect, sport participa-
tion, and body mass. These variables either influence the development of
ideal-body internalization, body dissatisfaction, or body distortion, or they
mediate the effects of those variables on the eventual development of MD.
The next research step is to empirically validate the associations in the
model via path analysis, or other similar statistical procedure. Currently, the
relationships are purely theoretical. A large-scale study examining all of the
variables in the model using participants from a number of different con-
texts will increase the validity and usefulness of the model. Further, it is
important to evaluate developmental aspects of the model. Do the variables
have equal influence across different ages or are there some variables that
are more important during one phase of life than others? For example, the
Muscle Dysmorphia 77

internalization of the muscular ideal appears to be very salient for college


men and adolescents. However, is it less important to older adults? Other
variables that could be mediated by age include body dissatisfaction, media
influences, sport participation, and perfectionism.
In conclusion, the model presented here is a preliminary model for the
etiology of MD. It incorporates a number of variables that are implicated in
the development of eating disorders as well as several unique variables.
This model has been proposed to begin the research process, not as the cul-
mination of research efforts.

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