Muscle dysmorphia symptomatology among a national sample of Canadian adolescents and young adults
Introduction
Muscle dysmorphia (MD) is characterized by the pathological pursuit of muscularity. The cardinal symptom of MD is the preoccupation of insufficient muscle size and definition, resulting in marked distress, as well as a significant drive for muscularity (American Psychiatric Association, 2013, Pope et al., 1997). Categorized as a specifier of Body Dysmorphic Disorder (American Psychiatric Association, 2013), core MD symptoms may include compulsive exercise and weight training, specific dieting to build and maintain muscularity, use of appearance- and performance-enhancing drugs and substances (APEDS), and overall functional impairment (Cafri et al., 2008, Pope et al., 2005, Pope et al., 1997). To date, much of the research on MD symptomatology has been limited to bodybuilders (Cafri et al., 2008, Mitchell et al., 2017, Olivardia et al., 2000, Pope et al., 2005) and data among large community samples is lacking, particularly in Canada. This presents an important gap to be filled with future research. Specifically, more research is needed to describe the sociodemographic characteristics of individuals who report greater MD symptomatology to improve assessment, prevention, and intervention efforts.
It has been well documented that individuals with MD and who engage in MD-related symptoms are overwhelmingly boys and men (Ganson et al., 2021, Ganson and Nagata, 2022, Glazer et al., 2021, Mitchison et al., 2021, Nagata et al., 2019, Nagata et al., 2020, Tod et al., 2016). Indeed, the ideal male body is one that emphasizes bulk muscularity and leanness (Murray et al., 2017, Nagata et al., 2020), likely explaining the disproportionate prevalence of MD symptomatology among males. However, girls and women can also experience MD and engage in MD-related symptoms (Gruber, 2007, Gruber and Pope, 1999, Mitchison et al., 2021), and recent research has documented that transgender adult men have similar, and at times greater, MD symptomatology in relation to cisgender men (Amodeo et al., 2022). This research underscores a need for more research on gender diverse samples to delineate differences in MD symptomatology across genders.
In addition, there is a dearth of literature on MD symptomatology across sexual identities and diverse racial and ethnic identities. However, research has documented that sexual minority individuals (i.e., those who identify as gay or lesbian, bisexual, queer, etc.), compared to their heterosexual peers, are often at greater risk of body dissatisfaction, including muscle dissatisfaction, eating disorder psychopathology, and use of APEDS (Blashill et al., 2017, Calzo et al., 2013, Calzo et al., 2015, Hazzard et al., 2020, Nagata et al., 2020). This may indicate that sexual minority individuals are at greater risk of MD symptomatology, given the centrality of body dissatisfaction in presentations of MD. Similarly, individuals across races and ethnicities experience body image concerns, and many boys and men who do not identify as White report high engagement in weight-gain and muscle-building behaviors (Ganson et al., 2021, Ganson et al., 2022, Nagata et al., 2020, Nagata et al., 2022, Ricciardelli et al., 2007). This prior research emphasizes that more investigations among diverse samples are needed to explore potential differences in MD presentations across sexual identities and races and ethnicities.
Another factor that may be crucially related to MD is body mass (Grieve, 2007). While body mass index (BMI) is unable to differentiate between fat mass and muscle mass (Ganson et al., 2019), a low BMI suggests a smaller body size. Within the context of MD symptomatology, those with a smaller body may have desire to increase their body size through building muscle (Cafri et al., 2005). Additionally, lower BMI has been shown to be associated with weight gain attempts and muscle-building behaviors (Ganson et al., 2021, Nagata et al., 2020, Nagata et al., 2022), which are common MD behaviors. Conversely, higher BMI is often associated with increased body dissatisfaction, as well as weight stigma, and thus, attempts to alter one’s body to fit the sociocultural ideal (Calzo et al., 2012, Spahlholz et al., 2016). Within this context, both low and high BMI may be relevant to MD symptomatology as individuals across the weight spectrum may be attempting to achieve the muscular body ideal.
As discussed, the literature on the sociodemographic correlates of MD symptomatology, while growing, remains relatively scant, particularly among community samples. There remains a need to delineate the sociodemographic characteristics of adolescents and young adults who experience MD symptomatology. This age group is particularly important as it is a key developmental time period where body dissatisfaction is high (Bucchianeri et al., 2013, Wang et al., 2019) and the onset of MD is common (i.e., the age of onset is typically roughly 19 years old; Tod et al., 2016). Additionally, there is an overall small percent of the general population who experience a clinical diagnosis of MD, while the individual attitudes and behaviors (i.e., symptoms) of MD are relatively common (Pope et al., 2017). For example, 2.2 % of Australian adolescents in a recent study met clinical criteria for MD (Mitchison et al., 2021), which is significantly lower than the prevalence of high engagement in weight training (Ganson, Rodgers, et al., 2022), APEDS use (Calzo et al., 2016, Ganson and Nagata, 2022, Nagata et al., 2020), weight gain attempts (Ganson et al., 2021, Nagata et al., 2019), as well as muscle dissatisfaction and drive for muscularity (Eik-Nes et al., 2018, Frederick et al., 2007), all of which characterize MD symptomatology. Additionally, investigating symptomatology on a spectrum is important given the psychosocial distress and impairment of MD symptoms (Tod et al., 2016). Therefore, it is important to determine the occurrence of MD symptomatology (i.e., as a continuous phenomenon) in the general population.
The Muscle Dysmorphic Disorder Inventory (MDDI) is a widely used measure of MD symptomatology (Hildebrandt et al., 2004). Specifically, the MDDI includes three subscales (Drive for Size, Appearance Intolerance, and Functional Impairment), as well as a total score, that capture attitudes and behaviors related to MD, with higher scores indicating greater MD symptomatology (Hildebrandt et al., 2004). Additionally, prior research has used a clinical MD cut-off score of ≥ 40 on the MDDI total score (Longobardi et al., 2017, Nagata et al., 2021, Varangis et al., 2012, Zeeck et al., 2018), which may afford healthcare professionals with a potential initial screening tool for MD. Therefore, the use of MDDI scores to capture MD symptomatology in relation to key sociodemographic correlates can inform intervention and prevention efforts among healthcare and public health professionals, as well as potentially new clinical cut-off points.
Therefore, the aims of this study were:
1. To describe the occurrence of MD symptomatology and clinical risk among a national sample of adolescents and young adults in Canada. It was hypothesized that men would report greater unadjusted MD symptomatology compared to women and transgender/gender non-conforming (TGNC) participants. Given the dearth of literature, there was no a priori hypothesis of how prevalent MD clinical risk would be among the sample.
2. To determine whether lifetime anabolic-androgenic steroid use (AAS) is more common among those with greater MD symptomatology. It was hypothesized that those who report any lifetime AAS use would have higher MDDI scores in both unadjusted and adjusted analyses.
3. To determine the sociodemographic characteristics of Canadian adolescents and young adults associated with MD symptomatology. It was hypothesized that those with lower BMIs and men would be more likely to report greater MD symptomatology in adjusted analyses. No other a priori hypothesis were established for aim three.
Section snippets
Methods
Participants included 2256 adolescents and young adults from the Canadian Study of Adolescent Health Behaviors, a wide-ranging survey investigating the social and behavioral health of young people who completed an online survey via Qualtrics. The sample was recruited via Instagram and Snapchat advertisements, without targeting specific populations, from November to December 2021. Advertisements invited participants to complete a survey related to eating, exercise, and health behaviors.
Results
The overall sample had a mean age of 22.9 (SD = 3.9) and mean BMI of 24.6 (SD = 5.1). More than half the sample were women (55.7 %), with 37.6 % men and 6.7 % identifying as TGNC. The majority of the sample identified as White (61.5 %) and heterosexual (59.6 %). Full sample sociodemographic characteristics can be reviewed in Table 1.
Results for aim one showed that participants had an average MDDI total score of 31.6 (SD = 8.0). For the subscales, the average scores were 10.8 (SD = 5.2) for
Discussion
This study is one of the few to investigate MD symptomatology among a community sample of adolescents and young adults. Findings for aim one showed that MD symptomatology, measured using the MDDI, was relatively common among the sample, with an average score of 31.6 among the overall sample, with men reporting greater total MD symptomatology compared to women and TGNC participants, which confirms our study hypothesis. Indeed, the mean MDDI scores across genders were highly variant. Men in our
Conclusion
Among a national sample of Canadian adolescents and young adults, MD symptomatology was relatively common, particularly among boys and men. MD symptomatology differed based on several sociodemographic characteristics, including lower BMI, those of South Asian and Middle Eastern descent, and sexual minority identities. Findings have important implications for professionals. More research is needed to understand the psychological and social factors associated with MD symptomatology among
Funding
This study was funded by the Connaught New Researcher Award (#41707) at the University of Toronto.
CRediT authorship contribution statement
KTG: Conceptualization; Data curation; Formal analysis; Funding acquisition; Investigation; Methodology; Project administration; Resources; Software; Supervision; Validation; Writing - original draft; Writing - review & editing. LH: Conceptualization; Visualization; Writing - original draft; Writing - review & editing. MLC: Conceptualization; Writing - review & editing. RFR: Conceptualization; Writing - review & editing. SBM: Conceptualization; Writing - review & editing. JMN:
Conflicts of interests
All authors report no conflicts of interest.
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