SYMPTOMS OF MUSCLE DYSMORPHIA, BODY
DYSMORPHIC DISORDER, AND EATING DISORDERS
IN A NONCLINICAL POPULATION OF ADULT MALE
WEIGHTLIFTERS IN AUSTRALIA
JOHANNA E. NIEUWOUDT, SHI ZHOU, ROSANNE A. COUTTS,
School of Health and Human Sciences, Southern Cross University, Lismore, Australia
ABSTRACT
Nieuwoudt, JE, Zhou, S, Coutts, RA, and Booker, R.
Symptoms of muscle dysmorphia, body dysmorphic disor-
der, and eating disorders in a nonclinical population of adult
male weightlifters in Australia. J Strength Cond Res 29(5):
1406–1414, 2015—The current study aimed to (a) deter-
mine the rates of symptoms of muscle dysmorphia (MD),
body dysmorphic disorder (BDD), and eating disorder; (b)
determine the relationships among symptoms of MD, BDD,
and eating disorders; and (c) provide a comprehensive com-
parison of symptoms of MD, BDD, and eating disorders in
a nonclinical population of adult male weightlifters in Aus-
tralia. The participants (N = 648, mean age = 29.5 years, SD
= 10.1) participated in an online survey, consisting of Mus-
cle Appearance Satisfaction Scale, the Body Dysmorphic
Disorder Questionnaire, and the Eating Attitude Test-26.
Results indicated that 110 participants (17%) were at risk
of having MD, 69 participants (10.6%) were at risk of having
BDD, and 219 participants (33.8%) were at risk of having an
eating disorder. Furthermore, 36 participants (5.6%) were
found at risk of having both MD and BDD, and 60 partici-
pants (9.3%) were at risk of having both MD and an eating
disorder. Significant correlations and associations were
found between symptoms of MD and BDD, and symptoms
of MD and eating disorders. Support was provided for the
comorbidity of, and symptomatic similarities between, symp-
toms of MD and BDD, and symptoms of MD and eating
disorders. This may reflect a shared pathogenesis between
symptoms of MD, BDD, and eating disorders. Strength and
conditioning professionals, exercise scientists, athletic train-
ers, and personal trainers should be aware that adult males
who are working out with weights (i.e., free weights or
Address correspondence to Johanna E. Nieuwoudt, johanna.
nieuwoudt@scu.edu.au.
29(5)/1406–1414
Journal of Strength and Conditioning Research
Ó 2015 National Strength and Conditioning Association
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AND RAY BOOKER
machines) may be at increased risk of having MD, BDD,
and eating disorders.
KEY WORDS muscularity, weightlifting, men, prevalence,
disordered eating
INTRODUCTION
M
ale body image research suggests that there has
been a dramatic increase in males who are dis-
satisfied with their bodies and want to become
more muscular. Research suggested that a drive
for muscularity underlies the behavioral symptoms of muscle
dysmorphia (MD; (29)). Muscle dysmorphia is observed as
a strong drive to increase muscularity and decrease body fat
(35) and seems to be based on perceived muscularity, regardless
of actual muscle size and definition (36). The prevalence of MD
is not yet known (30). Only a few researchers have published
the MD rates found in their studies (e.g., (18,35)), and such
rates have ranged from 10 to 53.6%.
It seems that MD may be a form of body dysmorphic
disorder (BDD), where the preoccupation is overall muscu-
larity, as opposed to a perceived physical defect (29). Indeed,
an MD specifier has been added to BDD in the fifth edition of
Diagnostic and Statistical Manual of Mental Disorders (DSM-5;
(1)). Body dysmorphic disorder is characterized by a preoccu-
pation with a perceived or imagined defect in physical appear-
ance causing marked impairment in functioning (1) and affects
0.7–2.4% of the general population (6,12,21). Research indi-
cated that men with BDD may also display symptoms of MD.
In their respective studies, C. G. Pope et al. (34) found that 14
of the 63 male participants with BDD also had MD, and H. G.
Pope et al. (35) found that 18 of the 193 participants with
BDD also had MD. Another study found that 5 of 15 (N =
28) participants with MD symptoms also displayed other clas-
sic BDD symptoms (18). In contrast, participants (n = 13)
without MD did not display these BDD symptoms (18).
Research has found that males with BDD who also displayed
MD symptoms were similar to those with BDD but without
MD symptoms on many variables, such as BDD severity and
delusionality, preoccupation with non-muscle–related body

parts, and non-MD–related BDD behaviors (34). Individuals
with BDD and MD had clinically significantly higher rates of
attempted suicide, a higher prevalence of anabolic androgenic
steroid use, more likely to weight train excessively, and have
a strict diet compared with individuals with BDD but without
MD symptoms (34). Body dysmorphic disorder symptomatol-
ogy was found to be positively correlated with compulsive exer-
cise, which reflects the relationship between compulsive
exercise and MD as a type of BDD (5).
Muscle dysmorphia was originally thought to be a form of
eating disorder (36), with symptoms of MD closely resembling
those exhibited by men with an eating disorder (29). Arguments
against the categorization of MD as a form of eating disorder
have been partly based on the assumption that disordered eat-
ing was only a secondary feature of the condition (28). Eating
disorders are characterized by persistent disturbances in eating
habits that lead to a change in food consumption and cause
clinically significant distress or impairment in important areas of
functioning (1). Research suggests that the rate of males diag-
nosed with an eating disorder is increasing, from 10% in pre-
vious years to about 25% in 2007 (19).
Researchers have argued that MD should be categorized
within an eating disorder spectrum because MD (drive for
weight gain) and anorexia nervosa (drive for weight loss) exists
on opposing ends of the same continuum of body image
psychopathology (27). Researchers concluded that there were
many similarities between MD and anorexia nervosa, such as
disordered eating practices, shared etiological factors, diagnostic
crossover with time, shared familial transmission, and response
to similar treatment approaches (27), with further research pro-
viding moderate support for symptomatic similarities between
MD and anorexia nervosa (25). It seems that eating practices
alone can exacerbate MD symptoms because MD is inclusive of
central eating- and exercise-related practices (26). Behar and
Molinari (3) found that a group of weightlifters with MD scored
higher in the 40-item Eating Attitudes Test and Eating Disor-
ders Inventory compared with a group of weightlifters without
MD. The weightlifting groups also scored higher in the 40-item
Eating Attitudes Test and Eating Disorders Inventory compared
with medical students who did not do weightlifting (3).
To advance the understanding of MD symptomatology,
further research is needed to explore the symptomatic relation-
ships among MD, BDD, and eating disorders. Furthermore, the
rates of MD symptoms, BDD symptoms, and eating disorder
symptoms in adult male weightlifters are largely unknown. To
address this, an online survey study was conducted in a non-
clinical population of adult male weightlifters in Australia that
aimed to (a) determine the rates of MD symptoms, BDD
symptoms, and eating disorder symptoms; (b) determine the
relationships among symptoms of MD, BDD, and eating
disorders; and (c) provide a comprehensive comparison of
symptoms of MD, BDD, and eating disorders. The outcomes
of this study would thus contribute toward enhancing the
understanding of these disorders. It will inform strength and
conditioning professionals of the rates of symptoms of MD,
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BDD, and eating disorders in adult males who are working out
with weights (i.e., free weights or machines) and increase their
awareness of these disorders in weightlifting/training popula-
tions. A better understanding of the symptoms of these
disorders may allow strength and conditioning professionals
to identify and refer at-risk individuals for help from mental
health practitioners.
METHODS
Experimental Approach to the Problem
This study used a cross-sectional design with an online
survey. Symptoms of MD were assessed with the Muscle
Appearance Satisfaction Scale (MASS), symptoms of BDD
were assessed with the Body Dysmorphic Disorder Ques-
tionnaire (BDDQ), and symptoms of eating disorders were
assessed with the 26-item Eating Attitude Test (EAT-26).
Subjects
Before conducting the study, ethics approval was obtained
from the Human Research Ethics Committee of Southern
Cross University (with approval number ECN-12-169). Partic-
ipants were invited to participate in an online survey about
weightlifting, diet, and male body image. The inclusion criteria
were (a) adult males at least 18 years of age, (b) individuals who
are working out with weights (i.e., free weights or machines) at
least 3 times per week, and (c) currently residing in Australia.
An information statement was provided at the start of the
questionnaire. Participant consent was implied by completing
the survey. Participation was voluntary, and participants could
withdraw at any time of the study.
A total of 648 adult males participated in the online
survey. The participants’ ages ranged from 18 to 65 years
(mean = 29.5 6 10.1 years). The majority of participants
(85.3%) were Caucasian, heterosexual (93.4%), and 40% of
the participants indicated that they were single. Partici-
pants were engaged in weightlifting at least 3 days or more
per week. Most participants (94.8%) had 1 weightlifting
session per day.
Procedure
Potential participants were recruited online: through e-mails,
participant friends, weightlifting and bodybuilding discussion
forums, and Facebook. A link (web address) to the survey was
provided. Facebook searches were initiated using the words
“gym” and the names of cities/suburbs of cities and towns in
Australia. Invitations to participate in the study were posted on
Facebook profile walls. Facebook users were asked to share the
post. Invitations to participate were posted on Australian body-
building and weightlifting forums, such as Aussie gym junkie
(www.aussiegymjunkies.com), Australian bodybuilding (www.
ausbb.com), and Size Matters (www.sizematters.com.au).
E-mails were sent by the University bulk e-mail system to all
students and staff.
The online survey was opened for 51 weeks, from August
8, 2012 to July 30, 2013. The online survey was supported
by Qualtrics research software. Participants were free to
VOLUME 29 | NUMBER 5 | MAY 2015 | 1407
 Symptoms of MD, BDD, and Eating Disorders
withdraw from the survey at any stage without explanation
and were able to skip any questions that they did not want
to answer. The survey could be saved and continued at
a later time.
Measures
The following self-report measures were used: the MASS,
the BDDQ, and the EAT-26.
Muscle Appearance Satisfaction Scale. The MASS (23) is a 19-
item self-report measure of MD symptomatology, in which
items are rated on a 7-point Likert scale, with responses
ranging from 1 (strongly disagree) to 7 (strongly agree).
Total scores range from 19 to 133. The MASS consists of
5 subscales: Bodybuilding Dependence, Muscle Checking,
Substance Use, Injury Risk, and Muscle Satisfaction. The
scores from each question under each subscale are added
up. The MASS provides a dimensional description, with
higher scores in the subscales indicating greater risk for
MD. There is no cut-off score with a clinical population
(S. B. Mayville, written personal communication, November 7,
2011). Although there is not a defined cut-off score, this
instrument provides a dimensional description, with higher
scores in the subscales indicating greater risk for MD.
Therefore, in the current study, quartiles (25th and 75th
percentiles) were identified for each subscale to determine
the degree of MD symptoms among the participants.
Participants whose scores were at and above the 75th
percentile on the subscales were considered as reporting
high symptoms, and individuals with scores at and below
the 25th percentile were regarded as reporting low symp-
toms. The participants whose scores were between the
25th and 75th percentiles were considered to possess mod-
erate symptoms. Participants who had high scores in 3 or
more subscales of the MASS were considered as being at
greater risk of MD in the current study.
In previous studies with male participants, the MASS
showed good internal consistency in the United States but
varied internal consistency in other countries. The MASS had
good test-retest reliability (r ranged from 0.76 to 0.89) and
showed construct validity between the MASS and measures
of body image disturbance (23). In the current study, the MASS
had good internal consistency (a = 0.89). The subscales of the
MASS had Cronbach’s alpha values ranging from 0.72 to 0.86.
Body Dysmorphic Disorder Questionnaire. The BDDQ (32) is
a self-report screening tool to assess the presence of BDD
symptoms. The BDDQ (32) consists of a series of “yes or no”
questions that ask the individual about appearance concerns
and the impact of these concerns on the individual’s life. If
the individual answers “yes” to a question, it leads to a ques-
tion asking to list or describe the concern or impact of the
concern. An individual is likely to have BDD if the individual
answers “yes” to both parts of question 1, “yes” to any of the
questions in question 3, and selects “b” or “c” for question 4.
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The BDDQ has had 100% sensitivity and 89% specificity in
a psychiatric outpatient setting (32).
Eating Attitudes Test—26 Items. The EAT-26 is a self-report
measure designed to assess eating disorder symptomatology
(13). The EAT-26 is used as a screening tool to identify indi-
viduals who are at increased risk for eating disorders (13). The
EAT-26 consists of 26 items, and the response to each item is
rated on a 6-point Likert-type scale from 1 (always) to 6
(never). Item scores for items 1 to 25 range from 3: always,
2: usually, 1: often, 0: sometimes, 0: rarely, to 0: never. Item 26
is reverse scored. Scores are calculated by simply summing the
values of the participant’s choices for the entire scale: scores
range from 0 to 75. A score of 20 or above indicates a high
level of concern about dieting, body weight, and problematic
eating behaviors (13). Behavioral questions are also included
in the questionnaire and determine the presence of extreme
weight-control behaviors and providing an estimate of their
frequency. In previous studies, the EAT-26 demonstrated good
internal consistency. In the present study, the EAT-26 had
good internal consistency (a = 0.820).
Statistical Analyses
Descriptive statistics were used to explore the study
population’s characteristics. Mean values of the measure-
ments with SD were reported. Cronbach’s alpha was used
to determine the reliability and internal consistency of the
MASS and the EAT-26. Crosstabulations were used to
examine frequencies of participants at risk of MD only,
BDD only, an eating disorder only, at risk of both MD
and BDD, at risk of both MD and an eating disorder, and
at risk of both BDD and an eating disorder. Log-linear
analysis was used to find associations between MD, BDD,
and eating disorder variables. Spearman rank order corre-
lation (rs) and point-biserial correlation (rpb) analyses were
undertaken to examine the associations between MD,
BDD, and eating disorder symptomatology. The level of
significance was set at p # 0.05.
Continuous variables were not normally distributed; non-
parametric tests were therefore used to compare continuous
variables across groups. Participants at risk of, and not at risk of,
MD, BDD, and eating disorders were compared on each of the
measures. Kruskal-Wallis tests were conducted to compare
continuous variables across groups of participants at risk of,
and not at risk of, MD, BDD, and eating disorders. Mann-
Whitney U-tests were undertaken to examine between-group
differences, and effect size (r) was calculated by z/square root
of N. Chi-square tests and Fisher’s exact tests were used to
explore the relationships between categorical variables across
groups of participants at risk of, and not at risk of, MD, BDD,
and eating disorders. Bonferroni corrections were made to con-
trol for possible type 1 error for contrast analyses, leading to
a corrected critical significant level of p , 0.002. Statistical anal-
yses were performed using IBM SPSS, Statistics 20 (IBM SPSS;
Chicago, Illinois).
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RESULTS
Muscle Dysmorphia, Eating Disorder, and Body Dysmorphic

*MD = muscle dysmorphia; BDD = body dysmorphic disorder; EAT = eating disorder; EAT-26 = Eating Attitudes Test—26 items; MASS = Muscle Appearance Satisfaction Scale.
MD and BDD and
EAT mean (6SD)
Disorder Symptomatology

98.09 (12.52)

24.86 (11.87)
26.67 (4.59)

18.95 (5.88)

20.52 (5.05)
15.38 (3.96)
16.57 (3.99)
The mean scores of the MASS and its subscales were
calculated for the total sample (MASS, 66.50 6 19.05; Body-
building Dependence subscale, 18.46 6 6.21; Muscle Check-
ing subscale, 11.62 6 5.47; Substance Use subscale, 12.43 6
5.55; Injury Risk subscale, 11.63 6 4.40; Muscle Satisfaction
subscale, 12.61 6 4.24). The survey results indicated that
a number of participants were at risk of having either MD,

BDD and EAT

68.80 (12.24)

19.60 (11.71)
mean (6SD)

19.85 (5.37)

12.45 (4.91)

10.95 (4.32)
11.05 (3.79)
14.50 (4.73)
BDD, or an eating disorder, or both MD and BDD, both
MD and an eating disorder, or both BDD and an eating
disorder, as seen in Table 1.
Log-linear analysis was used to find associations
between MD, BDD, and eating disorder variables. The

91.75 (12.75)
3-way log-linear analysis produced a final model that

MD and EAT
mean (6SD)
TABLE 2. Mean (6SD) scores on the MASS total score, the subscales of the MASS, and the EAT-26 total scores.*

23.12 (3.80)

17.87 (6.17)

19.12 (4.26)
16.25 (2.71)
15.37 (4.27)

15.12 (4.19)
retained the 2-way interactions between MD and BDD,
MD and eating disorders, and BDD and eating disorders.
The likelihood ratio of the highest order interactions
(MD by BDD by eating disorders) model was not
significant, x2(2.191) = 1, p = 0.139. The likelihood ratio

MD and BDD
of the 2-way interactions (MD by BDD; MD by eating

mean (6SD)

96.87 (6.49)

26 (2.87)

17.75 (2.12)

21.00 (2.78)
16.00 (1.07)
16.12 (3.68)

8.00 (4.14)
disorders; and BDD by eating disorders) model was signif-
icant, x 2(90.820) = 3, p , 0.001. To break down this effect,
separate x2 tests on the MD, BDD, and eating disorder
variables were performed. Significant associations were
found between MD and BDD, x2(67.885) = 1, p , 0.001;
72.17 (13.42) 66.77 (10.14)
mean (6SD)

17.61 (3.94)

12.27 (4.53)

11.04 (4.05)
11.08 (3.86)
14.77 (3.88)

12.38 (8.16)
and between MD and eating disorders, x2(25.494) = 1, p ,
Only EAT

0.001. The main effect of BDD was the most important

effect in the model (z = 12.192). The odds of having symp-
toms of MD and symptoms of BDD were 0.49. The odds of
having symptoms of MD and symptoms of eating disorders
mean (6SD)

20.08 (4.83)

14.67 (4.92)

13.00 (6.34)
10.83 (4.76)
13.58 (3.55)

11.92 (6.21)
were 1.2. The odds ratio of 0.41 indicated that the odds of
Only BDD

having symptoms of MD and symptoms of BDD were 0.41

times the odds of having symptoms of MD and symptoms
of eating disorders. In other words, the odds of having
symptoms of MD and symptoms of eating disorders were
mean (6SD)

87.75 (6.94)

24.25 (2.19)

12.37 (4.37)

18.50 (3.96)
16.00 (2.87)
16.62 (3.70)

9.37 (5.73)
Only MD

TABLE 1. Number and percentage of participants

who were at risk of having MD, BDD, or an
67.39 (12.49)
mean (6SD)
No disorder

eating disorder, or co-existence of disorders.*

19.24 (5.48)

11.54 (4.09)

12.00 (4.67)
10.70 (3.70)
13.91 (3.01)

5.42 (3.40)

Number Percentage

MD 110 17
BDD 69 10.6
Eating disorder 219 33.8
Substance use
dependence

MD and BDD 36 5.6

satisfaction
Bodybuilding

EAT-26 total
MASS total

MD and eating disorder 60 9.3

checking
Measures

Injury risk

BDD and eating disorder 43 6.6

score

score
Muscle

Muscle

*MD = muscle dysmorphia; BDD = body dysmorphic

disorder.

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 Symptoms of MD, BDD, and Eating Disorders

2.45 times the odds of having symptoms of BDD and
symptoms of MD.
Mean scores and SDs of groups of participants at risk of,
and not at risk of, MD, BDD, and eating disorders on the
subscales of the MASS, the total score of the MASS, and the
total score of the EAT-26 are shown in Table 2. Participants
at risk of MD, BDD, and eating disorders reported the high-
est mean score on the MASS total score, Bodybuilding
Dependence subscale, Muscle Checking subscale, and Sub-
stance Use subscale. Participants at risk of both MD and
eating disorders reported the highest mean score on the
Injury Risk subscale. On the Muscle Satisfaction subscale,
participants at risk of MD only reported the highest mean
score. Participants at risk of MD, BDD, and eating disorders
reported the highest mean score on the EAT-26 total score.
To meet the independence assumption of the Mann-
Whitney U-test, comparisons were calculated for groups of
participants at risk of (a) no disorder, (b) MD only, (c) BDD
only, (d) eating disorders only, (e) both MD and BDD, (f )
both MD and eating disorders, and (g) MD, BDD, and eat-
ing disorders. However, this study is limited to comparisons
of the following groups: (a) at risk of MD only and BDD
only and (b) at risk of MD only and eating disorders only.
Mann-Whitney U-tests revealed significant differences
between groups with MD only and BDD only on the Body-
building Dependence subscale (U = 81.500, z = 23.528,
p , 0.001, r = 0.50), the Injury Risk subscale (U = 77.000,
z = 23.634, p , 0.001, r = 0.51), and the MASS total score
(U = 47.000, z = 24.284, p , 0.001, r = 0.61).
Mann-Whitney U-tests revealed significant differences
between groups with MD only and eating disorders only
on the Bodybuilding Dependence subscale (U = 614.000,
z = 27.097, p , 0.001, r = 0.54), the Muscle Checking
subscale (U = 866.500, z = 26.148, p , 0.001, r = 0.47),
the Substance Use subscale (U = 845.500, z = 26.251, p ,
0.001, r = 0.47), Injury Risk subscale (U = 858.000, z =
26.237, p , 0.001, r = 0.47), Muscle Satisfaction subscale
(U = 1226.500, z = 24.859, p , 0.001, r = 0.37), and
the MASS total score (U = 98.000, z = 28.933, p ,
0.001, r = 0.68).
Mann-Whitney U-tests revealed no significant differences
between groups on the EAT-26 total score. Chi-square tests
and Fisher’s exact tests were used to explore the relation-
ships between categorical variables (from the BDDQ) across
groups of participants at risk of, and not at risk of, MD, BDD,
and eating disorders.

TABLE 3. Spearman rank order correlation and point-biserial correlations between the MASS, BDDQ, and the EAT-
26.*

MASS BD MC SU IR MS

EAT-26 (rs) 0.411 0.274 0.216 0.192

p ,0.001 0.002 0.014 0.030
Binge (rpb) 0.184
p 0.037
Vomit (rpb) 0.196
p 0.026
Laxatives, diuretics (rpb) 0.177
p 0.045
Exercise (rpb) 0.226
p 0.010
Lost $9 kg (rpb) 20.184
p 0.038
BDDQ (rpb) 0.324 0.315 0.299 0.218 0.178
p ,0.001 ,0.001 0.001 0.014 0.045
Has it upset you a lot (rpb) 20.211 20.186
p 0.017 0.035
Has it gotten in the way (rpb) 210.219
p 0.0.13
Are there things you avoid (rpb) 20.247
p 0.005
How much time do you think about it (rpb) 0.383 0.385 0.372 0.255
p ,0.001 ,0.001 ,0.001 0.005

*MASS = Muscle Appearance Satisfaction Scale total score; BD = Bodybuilding Dependence subscale; MC = Muscle Checking
subscale; SU = Substance Use subscale; IR = Injury Risk subscale; MS = Muscle Satisfaction subscale; EAT-26 = Eating Attitudes
Test—26 items; BDDQ = Body Dysmorphic Disorder Questionnaire; rpb = point-biserial correlation coefficient; rs = Spearman rank
order correlation coefficient.

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Chi-square tests revealed significant associations between
“being worried about how you look” and whether participants
were at risk of symptoms of MD or not, x2 (1, n = 642) =
25.815, p , 0.001, u = 20.201, whether participants were at risk
of BDD or not, x2 (1, n = 642) = 42.171, p , 0.001, u = 20.256,
and whether participants were at risk of eating disorders or not,
x2 (1, n = 642) = 16.140, p , 0.001, u = 20.159.
Chi-square tests revealed significant associations between
“thinking about your appearance problems a lot” and
whether participants were at risk of symptoms of MD or
not, x 2 (1, n = 412) = 19.894, p , 0.001, u = 20.220, and
whether participants were at risk of BDD or not, x2 (1, n =
412) = 118.285, p , 0.001, u = 20.536.
Chi-square tests revealed significant associations between “has
it often upset you a lot” and whether participants were at risk of
symptoms of MD or not, x2 (1, n = 164) = 14.039, p , 0.001,
u = 20.293, and whether participants were at risk of BDD or
not, x2 (1, n = 164) = 26.899, p , 0.001, u = 20.405.
Fisher’s exact tests revealed significant associations between
the “amount of time spent thinking about how you look” and
whether participants were at risk of symptoms of MD or not,
x2 (2, n = 162) = 24.902, p = 0.001, uc = 0.391, and whether
participants were at risk of BDD or not, x2 (2, n = 162) =
188.356, p , 0.001, uc = 0.964.
Correlational Analyses
Spearman rank order and point-biserial correlational analy-
ses were undertaken to examine the correlations between
MD, BDD, and eating disorder symptomatology. A number
of significant correlations were found, as seen in Table 3.
DISCUSSION
The present study found that 110 participants (17%) were at
risk of MD, as seen in Table 1. Previous studies have reported
10–53.6% of participants being at risk of MD (e.g., (18,35)).
Muscle dysmorphia rates vary significantly depending on the
sample population, the assessment methods, and sample
size. Muscle dysmorphia has been found to be associated
with bodybuilding activities (2,14,17,18,37), such as long
hours of weightlifting, as stipulated in the proposed MD
criteria (35). It would thus be expected that samples consist-
ing of bodybuilders and weightlifters would be at increased
risk of MD compared with samples of university students.
Because of the lack of standardized procedures for diagnos-
ing individuals with MD and the diversity of sample popu-
lations, the currently published rates of participants at risk of
MD might not be comparable.
The percentage of participants (10.6%, n = 69) who were
at risk of having BDD in the present study, as seen in Table
1, was much higher compared with the percentage (0.7–
2.4%) of individuals with BDD in the general population
(6,12,21) but was comparable with prevalence rates reported
in student populations, which have ranged from 5% (7) to
13% (4). It could be speculated that the high rate of BDD
symptoms might be because of the nature of the sample we
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Journal of Strength and Conditioning Research | www.nsca.com
studied because BDD prevalence rates vary significantly de-
pending on the sample population, the assessment methods,
and sample size (6). Alternatively, the high rate of BDD
symptoms might be because the BDDQ, a self-report screen-
ing tool, was used in the present study. It is possible that
participants may be more willing to disclose their specific
BDD concerns in a survey (6) compared with in-person
interviews that are usually conducted for making a clinical
diagnosis of BDD. Body dysmorphic disorder may also be
difficult to diagnose and is often underdiagnosed (31). Indi-
viduals with BDD might be reluctant to discuss their appear-
ance concerns because they may be ashamed of their BDD
symptoms (6). It should be noted that the BDDQ can be
used to assess the presence of BDD symptoms (32) but not
for making a clinical diagnosis of BDD.
The relationship between MD and BDD has received
limited investigation in previous research. The current study
found that 36 of the 648 participants (5.6%) were at risk of
having both MD and BDD (Table 1), with the odds being 0.49
of having symptoms of both MD and BDD. Previous studies
that have found that 9.3% of 193 male participants and 22.2%
of 63 male participants with BDD also had MD (34,35).
Another study found that 5 of 15 participants with MD
(33.3%) also displayed other classic BDD symptoms (18).
Results from this study indicated that MD symptoms were
significantly associated with symptoms of BDD, as x2(67.885)
= 1, p , 0.001. Symptoms of BDD were found to be the most
important effect (z = 12.192) in MD with BDD, MD with
eating disorders, and BDD with eating disorder interactions.
Significant associations were revealed between BDD
symptomatology (in particular between “being worried
about how you look,” “thinking about your appearance
problems a lot,” “being upset about it a lot,” and the “amount
of time spent thinking about how you look”) and whether
participants were at risk of MD only or not. Also, significant
correlations were found between MD symptoms and BDD
symptoms (Table 3). These findings provide support for
research indicating similarities between MD symptoms and
BDD symptoms (18,29,34,35).
Despite the generally comparable findings between
participants at risk of MD only and at risk of BDD only,
the distinguishing features for these 2 disorders were the
weightlifting activities and unsafe weightlifting behaviors.
Significant differences were found in MD symptomatology
between participants at risk of MD only and participants at
risk of BDD only on the Bodybuilding Dependence sub-
scale, the Injury Risk subscale, and the MASS total score.
This may be because the BDDQ does not assess specific
MD symptoms, in particular excessive weightlifting habits,
and symptoms of overtraining and attitudes toward unsafe
weightlifting behavior. Participants at risk of BDD only had
slightly higher mean scores than participants at risk of
MD only on the Muscle Checking subscale of the MASS
(Table 2). A predominant symptom of BDD is the presence
of compulsive behaviors designed to examine a perceived
VOLUME 29 | NUMBER 5 | MAY 2015 | 1411
 Symptoms of MD, BDD, and Eating Disorders
defect (9), thus explaining higher scores on the Muscle
Checking subscale.
In eating disorder symptomatology, no significant difference
was found between participants at risk of MD only and
participants at risk of BDD only. Participants at risk of BDD
only had slightly higher mean scores than participants at risk of
MD only on the total score of the EAT-26, as seen in Table 2.
Eating disorders and BDD can be comorbid (33). Previous
research found that 30.1% of participants with BDD were
excessively preoccupied with their weight (10) and 29% of
participants with BDD had excessive weight concerns (20).
Results of the current study indicated that 219 participants
(33.8%) were at risk of having an eating disorder, as seen in
Table 1. It could be speculated that the high rate of eating
disorder symptoms might be because of the nature of the sam-
ple we studied. Research has indicated that serious recreational
and competitive bodybuilding may increase the risk of eating
disorders (16). Although strict dieting and eating-related distur-
bances are common among male bodybuilders, little research
has examined eating disturbances in this population (16).
Muscularity-oriented disordered eating behaviors include very
high levels of protein consumption, severe restriction of non-
protein–related dietary components (e.g., carbohydrates and
fats), interrupting important activities to accommodate frequent
eating (eating every 2–3 hours), continued food consumption
despite feeling full, consuming a large proportion of calories in
liquid (blended) form, and the use of appearance-enhancing
drugs, such as supplements, “testosterone boosters,” and ste-
roids (25). Goldfield et al. (15) stated that it was not possible
for a bodybuilder to meet criteria for anorexia nervosa, but it
was possible to meet criteria for bulimia nervosa. Research
indicated a high prevalence of bulimia nervosa in recreational
male bodybuilders, with no differences found between males
with bulimia nervosa and male bodybuilders in the lifetime
prevalence of using diuretics, vigorous exercise, or strict dieting
to lose fat or weight (15).
It should be taken into consideration that the high rate of
eating disorder symptoms might be because the EAT-26, a self-
report screening tool, was used in the present study to assess
the presence of eating disorder symptoms. It was used to assess
individuals who might be at risk of having eating disorders but
not for making a clinical diagnosis of an eating disorder.
Few studies have examined the relationship between MD
and eating disorders. The present study found that 60 of the
648 participants (9.3%) were at risk of having both MD and
an eating disorder, as seen in Table 1. The odds of having
symptoms of MD and symptoms of eating disorders were
1.2. Results from the current study indicated that MD
symptoms were significantly associated with symptoms of
eating disorders, as x 2(25.494) = 1, p , 0.001. A previous
study found that a group of weightlifters with MD scored
higher in the 40-item Eating Attitudes Test and Eating
Disorders Inventory compared with a group of weightlifters
without MD (3). Murray et al. (26) found that eating prac-
tices alone could exacerbate MD symptoms because MD
the TM
1412 Journal of Strength and Conditioning Research
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was inclusive of central eating- and exercise-related
practices.
No significant differences were identified in eating disorder
symptomatology between participants at risk of MD only and
participants at risk of eating disorders only. In addition, the
correlational data suggested a relationship between the
symptoms of MD and eating disorders, as identified through
the MASS total score and the EAT-26 total score, as seen in
Table 3. Small but significant correlations were found between
the Substance Use subscale of the MASS and the laxatives,
diuretics behavioral question of the EAT-26, between the
Injury Risk subscale of the MASS and the vomit and exercise
behavioral questions of the EAT-26, and between the Muscle
Satisfaction subscale and the binge eating and the lost $9 kg
behavioral questions of the EAT-26 (Table 3). The results are
perhaps not unexpected because the proposed MD diagnostic
criteria repeatedly refer to disordered eating (35). These
findings concur with previous research reporting similarities
between MD symptoms and eating disorder symptoms
(22,29), especially symptoms of anorexia nervosa (25,27).
McFarland and Kaminski (24) found that males with increased
symptoms of MD were more likely than other males to use diet
pills, to vomit, and to diet to manage their weight. A systematic
literature review indicated that the majority of physically active
individuals with MD follow specific eating schedules to
increase muscle mass and decrease body fat—with such régimes
consisting of high protein and low fat foods, with nutritional
and performance-enhancing supplements (8).
Significant differences were found between participants at
risk of MD only and participants at risk of eating disorders
only on all 5 subscales of the MASS, and the MASS total
score. This finding is not entirely surprising because the
MASS assesses weightlifting activity, muscle checking
behaviors, muscle-enhancing supplement use, unsafe weightlift-
ing behavior, and muscle satisfaction. In contrast, the EAT-26
assesses disordered eating pertaining to a drive for thinness and
not a drive for muscularity.
The BDDQ and EAT-26 are screening tools and can
provide only a probable diagnosis of BDD or an eating
disorder. Body dysmorphic disorder and eating disorders
should ideally be diagnosed through a clinical interview.
Therefore, the rates reported in this study were based on the
presence of symptoms of BDD and eating disorders and not
on clinical diagnoses. Also, the EAT-26 may not be sensitive
to muscularity-oriented disordered eating and body image
concerns. Although the current findings suggested similar-
ities between MD and BDD, and between MD and eating
disorders, nosological associations could not be inferred.
The current research consisted of an online survey,
therefore the possibility existed that participants might have
interpreted the meanings of questions or statements differ-
ently to those intended or might have perceived some of the
statements or questions as vague (11). The sample was also
limited to those individuals who had access to a survey over
the Internet (11) and to those who had access to the Web sites

and were aware of the survey. Self-selection bias is a limitation
of Internet surveys. Self-selection bias also occur in traditional
surveys, thus is not unique to Internet survey research. Also,
the data were exclusively based on self-report, which can have
tendencies toward social desirability bias.
The findings from the current study provided support for
the comorbidity of symptoms of MD and BDD, and
symptoms of MD and eating disorders, and a number of
similarities were found between MD symptoms and eating
disorder symptoms, and between MD symptoms and BDD
symptoms. It may reflect a shared pathogenesis between MD,
BDD, and eating disorders. Results indicated that MD
symptoms were significantly associated with BDD and eating
disorder symptoms, with the odds of having symptoms of MD
and symptoms of eating disorders being greater than the odds
of having symptoms of MD and symptoms of BDD.
PRACTICAL APPLICATIONS
The present results do not suggest that working out with
weights (i.e., free weights or machines) is not a healthy
activity. Weightlifting and training do not cause MD, and
only a minority of men who weight train might develop MD.
A strict eating and training program is relatively important
for individuals who want to increase their muscularity, and it
only becomes problematic when the drive for muscularity
becomes an obsession, as in MD. Muscle dysmorphia has
harmful health consequences, thus strength and condition-
ing professionals should be aware that adult males who are
working out with weights (i.e., free weights or machines)
may be at increased risk of having MD. Individuals who
work out with weights may also be at risk of BDD and eating
disorders, and the symptoms of these disorders may be
comorbid. A better understanding and awareness of the rates
and symptoms of MD, BDD, and eating disorders may help
strength and conditioning professionals to identify and refer
at risk individuals for help from mental health professionals.
ACKNOWLEDGMENTS
Ray Booker is retired.
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