Muscle Dysmorphic Disorder (MDD), or bigorexia, is defined by the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) as a body dysmorphic disorder that triggers a preoccupation with the idea that one’s body is too small or not muscular enough. It is considered to be one of the specifiers of body dysmorphic disorders [1]. People with body dysmorphic disorders typically present compulsory behaviors, which they sustain in the conviction that going through with them might help them achieve the body goal they desire [1]. These compulsions can be reflected by different actions, as it can range from spending hours in the gym, spending excessive amounts of money on ineffectual sports supplements, abnormal eating patterns or even sometimes by substance abuse [2].
The diagnosis of Body Dysmorphic Disorders (BDD) is based on many criteria which were addressed in the DSM-5. One of the main criteria that can help diagnose a patient with a body dysmorphic disorder is the preoccupation, with one or many perceived but minimal flaws in the person’s physique. Furthermore, performing repetitive behaviors like mirror checking, excessive grooming, reassurance- seeking or mental acts, like comparing his or her appearance with others, are also considered to be important aspects in the diagnosis of BDD. In addition to a continuous distress and impairment in social, occupational and other important areas of functioning, people with BDD should be screened for a concomitant eating disorder which should always be ruled out [1]. Muscle dysmorphia being a specifier of body dysmorphic disorders, another commonly found feature is the preoccupation of the individual with the idea that his body build is too small or insufficiently muscular [1]. Moreover, MDD can affect the lifestyle of individuals by triggering social isolation or by causing some impairment in social and occupational functioning owing to the extended hours spent exercising, the constant preoccupancy and focus on their diet, and the withdrawal from any other social, occupational, or recreational activities [3]. Some MD sufferers were reported to refuse social invitations or beach outings because of their fear of looking too small [3].
Sociodemographic characteristics of MDD
BDD seems to affect a significant number of university students of various specialties. A study done on young adults majoring in biology, sport sciences and dietetics showed a prevalence of muscle dysmorphia of 5.9% [4]. When it comes to gender, while the medical literature discusses vastly the disorders of body image in women, especially in eating disorders [5], a recent growing interest in male body image research has only lately emerged, going from the fact that males desire a more muscular body and a stronger physique [6, 7]. Many variables including body mass, media influences, ideal body internalization, low self-esteem, body dissatisfaction, negative affect, perfectionism, and body distortion were identified through the medical literature as variables implicated in muscle dysmorphic disorders in women [8]. Other studies targeting different age groups in males, suggest that a higher risk of MD was associated with younger ages [9], but found no significant difference between low-risk and high-risk groups of gym users regarding their marital status, level of education, or Body Mass Index (BMI) [10]. Moreover, a higher risk of developing muscle dysmorphia (MD) was correlated with a higher frequency of training and higher numbers of competitions but not with longer durations of training during the week [10]. A study conducted on 3618 Australian adolescents also showed the independence of the prevalence MD from socioeconomic status (SES) [11].
MDD and perfectionism
Perfectionism can be defined as a multidimensional measure, it is the tendency to claim of others or of oneself an extremely high or even flawless level of performance, more than what is needed by the situation [1]. Perfectionism is not considered a psychological disorder in itself; however, it is linked to anxiety and other mental health issues, such as obsessive–compulsive disorder (OCD) [12], depression, anxiety, and eating disorders [1]. Noting that there are 5 main styles of perfectionism: self-oriented perfectionism, socially prescribed perfectionism, other-oriented perfectionism, overt perfectionism, and covert perfectionism [13]. As previously mentioned, perfectionism constitute one of the variables affecting muscle dysmorphia in women [8]; hence, a similar correlation could also be questioned in men. Indeed, in a meta-analysis which was aimed at evaluating the association between perfectionism and MDD, and which included 5880 participants, both men and women, from 31 studies (21 of them targeting men, 1 targeting women, and the remaining targeting both), perfectionism was found to be positively correlated with muscle dysmorphia [14]. Moreover, perfectionism was associated with concurrent body dysmorphic disorder symptoms among adolescents [14]. This association remained significant even when controlling over other confounding factors such as anxiety and depression [14]. Other results suggest that susceptibility to Muscle Dysmorphia and Eating disorders depend on pre-existing perfectionistic attitudes, especially that of socially prescribed perfectionism [15].
MDD and disordered eating
Eating disorders are defined by the DSM-5 as a persistent disturbance of eating [1]. These behavioral conditions can be associated with distressing thoughts or emotions which can affect the individual’s physical, psychological, and social function [16]. These eating attitudes can be explained by inappropriate thoughts, feelings, beliefs, and relationship an individual might experience with food, which can then influence his nutritional choices, his behavioral and consequently his health status [17]. A significant positive relationship between Muscle Dysmorphic Disorder Inventory (MDDI) and Eating Attitudes Test (EAT-40) in both professional and recreational bodybuilders was recently found [18]. Muscle Dysmorphia in men seems to have parallel features to eating disorders in women, the mutual component between eating disorders (EDs) and muscle dysmorphia being body dissatisfaction [8]. Indeed, males with eating disorders appear to possess higher desires for a more muscular shape, and therefore tend to perform body weight-related sports [18].
Orthorexia Nervosa (ON) is described as a pathological fixation on healthy food intake in addition to an excessive worrying with disturbing thoughts concerning healthy dietary consumption [19, 20]. The healthy eating obsession is pursued by ON sufferers through a strict diet centered on food quality and not quantity, demonstrating unrealistic concern over food selection, preparation and eating [21]. In Lebanon, one of the eating disorders that seem to have an unexpected high prevalence among the population, is Orthorexia nervosa (ON). A large number of the Lebanese population therefore appears to be preoccupied with healthy behavior and nutrition [21]. A previous study, conducted among Italian university students, shed the light on the possible relationship between ON, MD and eating disorders. In fact, the conditions were overlapping in the co-presence of ON, MD and EDs traits [22]. But further research and understanding of the effect of orthorexia nervosa and eating attitudes on the symptomatology of muscle dysmorphia is still needed.
Perfectionism, eating attitudes, orthorexia nervosa and MDD
In terms of relationship with eating behaviors, a systematic study, reviewing 55 papers published between 1990 and 2005, highlighted the relation between perfectionism and the diagnosis of eating disorders, anxiety disorders, and mood disorders [23]. Self-oriented perfectionism, which is one of the types of perfectionism that were previously stated, was found to be more specific to eating disorders in particular, than it is to depressive or anxiety disorders [24]. On the other hand, inappropriate eating behaviors including orthorexia nervosa, anorexia nervosa, and bulimia nervosa, shares similarities with regards to perfectionism, body image attitudes, and attachment style [26]. Moreover, having a history of an eating disorder seems to highly predict orthorexia nervosa. Within the literature, there is a continuing debate about the classification of orthorexia nervosa as a separate disorder [25], an alternative of an already established eating disorder or obsessive compulsive disorder (OCD) [26]. Some researchers propose that it could be a precursor for, or a residual of an eating disorder [27]. The results of a cohort study suggested that ON may be a continuum of anorexia nervosa and bulimia nervosa, where a person switches from an obsession with the quantity to the quality of food [27]. Therefore, these disorders might be on the same spectrum of disordered eating [26]. However, a recent study showed that ON does not sufficiently predict OCD symptoms [28].
The association between orthorexia nervosa and perfectionism has been rarely studied. Adherence to perfect rules in life is a predictor of mental illness and eating disorders [29]. Higher perfectionism was associated with more orthorexia nervosa in two studies [30,31,32]. Recent findings showed that all dimensions of perfectionism were positively associated with following strict eating rules, and namely, ON [33]. Valente et al. demonstrated the same findings and concluded that since perfectionism is focused around the desire to control one’s life events, ON might be a trial to control one’s own nutrition in life [34].
Eating disorder and muscle dysmorphic share lots of similarities; obsession in increased muscle mass may lead to eating disorders [35]. One study found a negative association between MD and ON [36], while another one found a positive association between ON tendencies and perceived muscularity [37]. Other researchers determined that persons at risk of MD might also be at risk or ON, general disordered eating or both [38]. Of note, the literature previously highlighted the role of perfectionism as a mediator of the association between orthorexia nervosa and excessive exercising [27], yet no light was given for the mediating role of ON. Further investigation is still needed as for the mediating effect of orthorexia nervosa and other eating attitudes on the correlation between perfectionism and muscle dysmorphia.
The present study
The Lebanese fitness industry has been growing significantly. The industry witnessed a growth of 20%, between 2010 and 2015, which proves the interest of the Lebanese population in general and especially the young adults in fitness [39]. However, since 2019, the country witnessed significant economic crises with income losses, inflation, and weakening of the Lebanese currency that drove more than half of the citizens below the poverty line [40]. Thus, there have been limited studies assessing the impact of such events on the modification of sociodemographic characteristics including socioeconomic status, physical activity and financial burden that might be affecting MDD among the young Lebanese males. The literature highly concentrates on disorders related to body image among women but only minimally when it comes to the male population [5]; hence, in order to provide general practitioners, and primary care physicians in general, and psychiatrists in particular, with additional information concerning muscle dysmorphia among male university students in Lebanon, this study seemed essential, and was therefore conducted to (1) identify the prevalence of MDD, and (2) evaluate the indirect effect of eating attitudes in general and orthorexia nervosa in particular, in the association between perfectionism and MDD among a sample of male university students.
