Journal of Strength and Conditioning Research, 2002, 16(4), 649–655
q 2002 National Strength & Conditioning Association
Muscle Dysmorphia in Elite-Level Power Lifters
and Bodybuilders: A Test of Differences Within a
Conceptual Model
CHRISTOPHER D. LANTZ,1 DEBORAH J. RHEA,2
ALLEN E. CORNELIUS3
1
Health and Exercise Science, Truman State University, Kirksville, Missouri 63501; 2Kinesiology Department,
Texas Christian University, Fort Worth, Texas 76109; 3Department of Psychology, Springfield College,
Springfield, Massachusetts 01109.
ABSTRACT
The purpose of this study was to determine if associated
characteristics of muscle dysmorphia (MD) were different
between elite-level competitive bodybuilders and power lift-
ers. Elite-level competitive bodybuilders (n 5 100) and pow-
er lifters (n 5 68) completed the muscle dysmorphia inven-
tory (MDI) at the time of or immediately before competition.
A 2 3 6 (group 3 MDI subscales) multivariate analysis of
variance indicated that bodybuilders were significantly more
likely to report body size–symmetry concerns (F(1, 167) 5
10.31, p , 0.001), physique protection (F(1, 167) 5 10.27, p
, 0.001), dietary behavior (F(1, 167) 5 28.38, p , 0.001), and
pharmacological use (F(1, 167) 5 19.64, p , 0.001) than were
power lifters. These results suggest that elite-level body-
builders are significantly more likely to engage in character-
istics associated with MD than are elite-level power lifters.
Key Words: exercise dependence, steroids, diet, body
image
Reference Data: Lantz, C.D., D.J. Rhea, and A.E. Cor-
nelius. Muscle dysmorphia in elite-level power lifters
and bodybuilders: A test of differences within a con-
ceptual model. J. Strength Cond. Res. 16(4):649–655.
2002.
Introduction
L antz and Rhea (14, 24) have proposed a 6-factor
psychobehavioral model of muscle dysmorphia
(MD) (see Figure 1). Their research indicates that peo-
ple with MD exhibit specific behavioral and psycho-
logical characteristics that can be divided into 2 cate-
gories: nutrition and physique concerns. Nutrition
comprises behaviors concerned with pharmacological
use, supplement use, and dietary behavior. Pharma-
cological use involves the use of steroids and other
illegal synthetic hormones to increase muscle size and
definition. Supplement use is associated with the use
AND
of legal substances designed to enhance the quality of
a workout (e.g., energy drinks) or to aid in postwork-
out recuperation (e.g., creatine monohydrate). Dietary
behavior involves the close monitoring of proteins, car-
bohydrates, and fats to achieve maximum muscle size
and striation. The common thread among these 3 be-
haviors is that the individual ingests specific foods and
supplements to enhance muscle size and definition.
The conceptual model suggests that muscle dysmor-
phic weightlifters are more likely to engage in these
nutritional behaviors in pursuit of an enhanced, well-
defined muscular physique than are nondysmorphic
weightlifters. A recent study by Olivardia et al. (19)
provided partial support for this component of the
model. Their study compared a small sample of dys-
morphic ‘‘weightlifters,’’ who were defined as persons
who could bench-press their own body weight 10
times or more and had concerns about looking small,
with a normal group of ‘‘weightlifters,’’ defined as
those who had lifted for at least 2 years and could
bench-press their own body weight 10 times or more.
These authors reported that dysmorphic weight lifters
were significantly different from nondysmorphic
weight lifters in a number of areas, including eating
attitudes and anabolic steroid use.
The second category associated with the psycho-
behavioral model of MD, physique concerns, is char-
acterized by concerns regarding body size–symmetry,
physique protection, and exercise dependence. Body
size–symmetry focuses on the degree of satisfaction
one has with muscle size, shape, and definition. Phy-
sique protection includes behaviors designed to avoid
having the body viewed by others. According to Klein
(11), these behaviors can include wearing baggy or
bulky clothing, altering workout times to avoid scru-
tiny by other weight lifters, and avoiding situations
where the physique may be exposed (e.g., going to the
649
650 Lantz, Rhea, and Cornelius
Figure 1. Psychobehavioral model of muscle dysmorphia.
beach). Exercise dependence involves being preoccu-
pied with exercise, maintaining a rigid schedule of in-
tense exercise, resisting the temptation to quit exercis-
ing, feeling guilty when the exercise schedule is vio-
lated, and exercising even when ill, tired, or injured.
The conceptual model argues that muscle dysmorphic
persons are more likely to experience dissatisfaction
with their physique, use bulky clothing, alter training
times to hide their physique, and exercise compulsive-
ly to develop a hypermesomorphic physique. This
component of the model is partially supported by the
research of Olivardia et al. (19), who found that dys-
morphic weight lifters expressed significantly greater
body dissatisfaction than did nondysmorphic weight
lifters.
A growing concern in the MD literature is the iden-
tification of persons who are most susceptible to de-
veloping MD. Clinical studies of MD (19, 21, 22) sug-
gest that this proposed disorder is most likely found
in persons who are dissatisfied with their body and
are heavily involved in weightlifting and other muscle
development activities. However, to date, empirical
data on the incidence of MD in weight lifters is insuf-
ficient. A major limitation of the existing research on
MD is the use of the term ‘‘weightlifter’’ to describe
the samples under investigation. In using this generic
term, researchers have failed to make a crucial dis-
tinction between those individuals who are motivated
primarily by developing muscle size and definition
(bodybuilders) and those who pursue primarily mus-
cle strength (power lifters and Olympic weightlifters)
(6, 11). Power lifters and Olympic weightlifters train
to lift as much weight as possible in a single repetition
in 3 distinct lifts (squat, bench press, and deadlift) or,
in the case of the Olympic lifter, 2 lifts (clean and jerk,
and snatch). Rarely are these persons concerned with
muscle development or body size–symmetry, except as
it relates to body weight restrictions that may force
them to participate in a higher weight class (28). Con-
versely, competitive bodybuilders are rarely concerned
with 1 repetition maximums but rather use weight
training to develop a hypermesomorphic physique
that shows tremendous muscular shape, striation, and
symmetry. Given the divergent goals of power lifters
and bodybuilders, it may be erroneous to classify them
into a single group assuming that they both manifest
similar characteristics associated with MD. In light of
the emphasis MD research has placed on weightlifters,
it is important for researchers to determine if MD-re-
lated differences exist between specific groups of
weightlifters, such as bodybuilders and power lifters.
Previous research on MD has provided limited in-
sight into the disorder because it was based on a sub-
jective clinical framework and failed to consider the
divergent motivations of persons who train with
weights. Therefore, the purpose of this study was to
determine if differences existed between bodybuilders
and power lifters with regard to manifested charac-
teristics identified in the psychobehavioral model of
MD advocated in the line of research by Rhea and
Lantz. On the basis of previous research (11, 14, 24,
25), we hypothesized that bodybuilders would report
higher scores on each of the muscle dysmorphia in-
ventory (MDI) subscales than would power lifters.
Methods
Subjects
Participants in the current study included elite-level
power lifters (n 5 68) and elite-level bodybuilders (n
5 100). Power lifters (63 men, 5 women) were com-
petitors in a national championship meet and repre-
sented all weight classes. They averaged 31.68 (SD 5
6.62) years of age and reported an average of 15.53
(SD 5 7.74) years of active training for competition.
Fifty-seven (84%) power lifters identified themselves as
white, whereas the remaining 11 (16%) identified
themselves as African American or Asian. Bodybuild-
ers (79 men, 21 women) were competing at a national
qualifying meet or currently training for regional or
national competition at 1 of 3 training facilities. They
averaged 30.99 (SD 5 7.22) years of age and reported
an average of 12.75 (SD 5 4.49) years of active training
for competition. Seventy-one bodybuilders identified
themselves as white, whereas the remaining 29 iden-
tified themselves as African American or Asian. Be-
cause of the low representation of females, each group
was combined as a total number of bodybuilders and
a total number of power lifters for all analyses. This
study was approved by the Institutional Review Board
for the Protection of Human Subjects.

Instrumentation
The MDI (23–25) is a 40-item self-report measure de-
signed for the assessment of behavioral and psycho-
logical characteristics associated with MD. The MDI is
based on the conceptual model identified by Lantz and
Rhea (14, 25) and contains 6 subscales: body size–sym-
metry (e.g., I feel satisfied with the shape of my body);
physique protection (e.g., I wear bulky clothing to hide
my physique from others); exercise dependence (e.g., I
maintain a strict workout schedule); supplement use
(e.g., before a workout I consume energy drinks); di-
etary behavior (I regulate my caloric intake to maxi-
mize muscle development); and pharmacological use
(I use steroids to increase my size and definition). Of
the 6 subscales, 5 use a 6-point Likert scale of ‘‘al-
ways,’’ ‘‘usually,’’ ‘‘often,’’ ‘‘sometimes,’’ ‘‘rarely,’’ or
‘‘never.’’ Pharmacological use is the subscale omitted
from this scoring system. Responses for each item of
the 5 subscales are scored from 1 to 6, with a score of
6 assigned to the responses farthest in the ‘‘symptom-
atic’’ direction (‘‘always’’ or ‘‘never,’’ depending on
whether the item is keyed in the positive or negative
direction, respectively) and a score of 1 for the re-
sponses farthest in the ‘‘asymptomatic’’ direction.
Thus, positively scored items are scored as follows:
‘‘always’’ 5 6, ‘‘usually’’ 5 5, ‘‘often’’ 5 4, ‘‘some-
times’’ 5 3, ‘‘rarely’’ 5 2, and ‘‘never’’ 5 1. Item scores
contribute to only 1 subscale score. Subscale scores are
computed by summing all the item scores for that par-
ticular subscale. A higher score per subscale translates
into a higher risk of the characteristics associated with
MD. The pharmacological use subscale requires re-
spondents to indicate how often they use various phar-
macological aids (2 or more times daily 5 6, once daily
5 5, 2–6 times weekly 5 4, 1–3 times monthly 5 3,
less than once a month 5 2, never 5 1). This subscale
can be separated into individual items for measuring
which aid is used most often to enhance body size. On
the basis of Garner’s (7) work with the eating disorder
inventory, it is recommended that these 6 subscales be
totaled separately, not collectively, because each MDI
subscale is intended to measure a conceptually inde-
pendent trait. Calculating a total score can pose seri-
ous problems of interpretation.
While the MDI was still in the developmental stag-
es, Rhea et al. (25) provided initial psychometric sup-
port for it. Exploratory principal components analysis
of noncompetitive, recreational weight trainers’ (n 5
156) responses to MDI items revealed a 6-factor model
accounting for 47% of the known variance. Internal con-
sistencies (Cronbach’s alpha) for the respective sub-
scales were body size–symmetry (0.73), dietary behav-
ior (0.88), exercise dependence (0.72), physique protec-
tion (0.71), supplement use (0.75), and pharmacological
use (0.53). In the present study, Cronbach’s alphas for
the power-lifter sample were as follows: body size
Muscle Dysmorphia 651
(0.73), dietary behavior (0.84), exercise dependence
(0.51), physique protection (0.55), supplement use
(0.91), and pharmacological use (0.35). For the body-
builder sample, Cronbach’s alphas were as follows:
body size (0.70), dietary behavior (0.87), exercise de-
pendence (0.72), physique protection (0.56), supple-
ment use (0.80), and pharmacological use (0.57). Note
that the internal consistency of the physique protection
and pharmacological use subscales was considerably
lower than for the other MDI subscales. This is likely
related to the substantially restricted range of respons-
es of the nonclinical populations used in this study. A
copy of the MDI is available from the first author.
Procedures
Power lifters were sampled during their national
championship meet. Permission was obtained from the
national organization and meet coordinator before
data collection. Participants were approached imme-
diately after their participation in a competition, and
willing participants completed the MDI. For the body-
builder sample, permission was obtained from com-
petition coordinators before a national qualifying com-
petition and from gym owners before data collection.
Participants were approached immediately after their
participation in a competition or after a workout to
complete the questionnaire. At least 1 of the authors
was present at each site to answer any questions the
power lifters or bodybuilders may have had.
Results
Table 1 presents the means and standard deviations
for age, years of training for competition, and each of
the MDI subscales for the total group and its 2 parts,
power lifters and bodybuilders. Independent analyses
of variance demonstrated that the 2 groups were of
similar ages, F(1, 167) 5 0.53, p . 0.05, but the power
lifters had been training for competition significantly
longer, F(1, 167) 5 7.44, p 5 0.001.
To determine if MD characteristic differences exist-
ed between competitive bodybuilders and power lift-
ers, a 2 3 6 (group 3 MDI subscales) multivariate
analysis of variance was conducted. This analysis re-
vealed a significant difference between bodybuilders
and power lifters (Wilks’ Lambda 5 0.703; F(6, 161) 5
11.31, p , 0.05). Follow-up univariate analyses of var-
iance revealed that bodybuilders were significantly
more likely to report body size–symmetry (F(1, 167)
5 10.31, p , 0.001), physique protection (F(1, 167) 5
10.27, p , 0.001), dietary behavior (F(1, 167) 5 28.38,
p , 0.001), and pharmacological use (F(1, 167) 5 19.64,
p , 0.001) than were power lifters (see Table 1).
Because of the significant subscale differences
found between bodybuilders and power lifters, the
number and percentage of individuals scoring above
a cutoff score for each of the subscales were computed.
This approach is similar to the approach used in the
652 Lantz, Rhea, and Cornelius

Table 1. Means (X) and standard deviations (SDs) of age, years of training, and muscle dysmorphia inventory (MDI)
subscales by power lifters, bodybuilders, and total group.

Power lifters (n 5 68) Bodybuilders (n 5 100) Total group (N 5 168)

Subscales X SD X SD X SD

Age (y) 31.68 6.62 30.99 7.22 31.33 6.92

Years of training* 15.53 7.74 12.75 4.49 14.14 6.12
Nutrition factors
Diet* 26.16 7.89 32.90 8.15 29.53 8.02
Supplementation 15.14 6.62 15.59 5.15 15.36 5.89
Pharmacology* 9.89 3.34 12.76 4.56 11.33 3.95
Physique development factors
Exercise dependence 20.78 4.17 20.90 3.44 20.84 3.81
Body size* 16.24 5.44 18.90 5.17 17.57 5.31
Physique protection* 6.46 2.63 7.88 2.95 7.17 2.79

* Statistically significant differences at the 0.05 level.

Table 2. Number and percentage of bodybuilders, power of individuals using at least 1 of the pharmacological
lifters, and total group above a lower-limit cutoff score aids. Approximately 14% of the study participants had
an extreme concern with size and symmetry: of these,
No. of 9% were bodybuilders, and 5% were power lifters. The
Body- Power Total
sub- Lower cutoff scores also reflected that 21% of the bodybuild-
builders lifters group
scale limit
ers were highly concerned with dietary manipulation,
Factor items cutoff n % n % N %
although the majority of bodybuilders (71%) and pow-
Diet 8 40 21 21 1 1 22 13 er lifters (65%) used nutritional supplements to en-
Size 5 25 9 9 5 7 14 8 hance performance.
Exercise de-
pendence 5 25 6 6 6 9 12 7 Discussion
Physique pro-
tection 4 20 0 0 0 0 0 0 The results of the current study indicate that elite-level
Supplement competitive bodybuilders may engage in more behav-
use 4 20 71 71 44 65 112 68 iors characteristic of MD than do elite-level competi-
Pharmacolo- tive power lifters. Specifically, bodybuilders reported
gical use 5 17 17 3 4 20 12 greater dissatisfaction with their physique, greater en-
gagement in physique protection, greater dietary ma-
nipulation, and greater likelihood of using pharma-
eating disorder literature with the eating disorder in- cological aids to improve physique development than
ventory (7, 8, 26, 30). The cutoff scores were calculated did power lifters.
to identify who might be at a higher risk of symptoms One of the major issues commonly associated with
related to MD (see Table 2). These cutoff scores were MD is body size–symmetry. In fact, MD has often
based on individuals who scored at least a 5 out of 6 been defined as the pathological pursuit of a hyper-
on all the items within a subscale. A minimum cutoff mesomorphic physique, with muscle dysmorphic in-
score was decided by identifying how many items dividuals perceiving themselves as thin and weak
composed a subscale and then multiplying that num- when, in reality, they are often quite large and mus-
ber by 5 (lowest concerned score). For example, body cular. The results of the current study showed that
size–symmetry had 5 items, so someone had to score bodybuilders were significantly more likely to report
at least 5 on all 5 items. This would calculate to a cutoff concerns regarding the size and shape of their phy-
score of 25. Cutoff scores were not calculated for the sique than were power lifters. This finding supports
pharmacological subscale because an individual might previous studies that showed a link between body im-
use only 1 pharmacological substance, such as ste- age dissatisfaction and male bodybuilders (3, 18, 20).
roids, to enhance performance or size. Therefore, the These individuals pursue an ideal body through in-
number of individuals scoring at least a 4, 5, or 6 on creased body size and development of a mesomorphic
each item (i.e., a score of 4 represents use of the sup- body shape. Bodybuilding places its primary empha-
plement at least once daily) was calculated, and then sis on the size and definition of the muscular physique,
those numbers were summed to obtain a total number which may promote pathological concerns regarding

these qualities. In contrast, a power lifter’s sole focus
is on the amount of weight moved in a single repeti-
tion, and physique concerns are associated only with
maintaining a weight that will qualify the individual
for a particular weight class (27).
Related to the differences in body size–symmetry
is the finding that bodybuilders were more concerned
with protecting their physique from public evaluation
than were power lifters. Given the emphasis placed on
physique development by the bodybuilding commu-
nity (6, 11) and the relative lack of concern expressed
by power lifters regarding their physique develop-
ment, it seems reasonable that bodybuilders would
show more concern for their bodies and make more of
an effort to conceal their bodies than would power
lifters. A plausible explanation for bodybuilders’ need
to protect their physique may be found in the self-
presentation–impression management work of Leary
(15–17). Self-presentation refers to the processes by
which individuals attempt to control the impressions
others form of them (17). According to James and Col-
lins (10), persons use self-presentation to help manage
self-esteem and to facilitate identity development. It
may be that bodybuilders engage in physique protec-
tion in order to be identified with the behaviors com-
mon to the bodybuilding subculture. It may also be
that bodybuilders feel a need to protect their self-es-
teem (body dissatisfaction has been shown to be re-
lated to low self-esteem) by prohibiting others from
evaluating their body negatively and do so by engag-
ing in self-presentation management behaviors. Al-
though self-presentation theory provides some inter-
esting possibilities, empirical research is needed to es-
tablish the link between physique protection behaviors
and self-presentational concerns. Ultimately, however,
this finding should be viewed with caution because the
internal consistencies for the physique protection sub-
scale were below the acceptable standard (i.e., 0.70) for
both the power lifting (0.55) and bodybuilding (0.56)
samples. Although the scale has demonstrated accept-
able psychometric qualities in previous studies (22),
further investigation is necessary to confidently estab-
lish the psychometric properties of this subscale.
The finding that bodybuilders engaged in a greater
degree of dietary manipulation than did power lifters
supports previous research indicating that persons ob-
sessed with gaining muscle size and definition impose
considerable dietary constraints on themselves. These
persons often sacrifice what would be considered a
normal or healthy diet in an effort to maintain a strict
schedule of fats, proteins, and carbohydrates (2, 5, 9,
12, 13). For example, Kleiner et al. (12, 13) found that
the bodybuilders’ diet was repetitive and monotonous,
resulting in, among other things, hypohydration,
amenorrhea in females, and low levels of important
nutrients such as zinc and calcium. Although research
has compared the nutritional behaviors of bodybuild-
Muscle Dysmorphia 653
ers (2) and weightlifters (21) with those of other
groups (i.e., obligatory exercisers, sedentary persons),
there has been a surprising lack of research directly
comparing the dietary behaviors of bodybuilders with
those of power lifters.
This study also showed significant distinction be-
tween power lifters and bodybuilders with regard to
use of pharmacological aids. On the surface, the re-
sults of the current study suggest that bodybuilders
are more likely to use these potentially harmful sub-
stances than are power lifters. This study supported
previous findings that many serious bodybuilders use
pharmacological aids, such as steroids and other ille-
gal synthetic hormones, to increase muscle size and
definition (4, 12, 13). The percentage of competitive
bodybuilders who identified themselves as using
pharmacological aids in this study (17%) was at the
lower end of the range (15–40%) reported by Kleiner
et al. (13)—nowhere near the 75% identified by Wrob-
lewska (31). This discrepancy may be explained by the
respondents’ interpretation of what is considered a
pharmacological substance vs. a nutritional supple-
ment. The bodybuilders and the power lifters reported
a significantly higher use of nutritional supplements
such as creatine monohydrate and androstendione.
Androstendione is currently banned by several orga-
nizations because of its purported performance en-
hancement qualities (29); however, it remains available
to consumers because it has not been officially classi-
fied as a steroid. This may have allowed individuals
to respond that they were using nutritional supple-
ments without confirming the actual use of pharma-
cological aids. It is likely that the usage rates of phar-
macological substances would have changed depend-
ing on how the respondents classified the substances
they were currently using. Moreover, this interpreta-
tion may provide some insight into the low internal
consistency of the pharmacological subscale. If the re-
spondents had viewed the various substances identi-
fied in this subscale differently, their usage patterns
would also likely have differed. This would result in
low internal consistency of the subscale items. Al-
though use of pharmacological aids alone should not
be considered indicative of a disorder, the continued
use of these substances to enhance physique develop-
ment is certainly a cause for concern.
One of the debated issues identified in the Intro-
duction concerned the degree to which a person must
possess specific characteristics associated with MD to
be diagnosed as muscle dysmorphic. A preliminary
step taken in this study to address this issue was the
calculation of cutoff scores for each of the subscales.
The idea behind cutoff scores was to identify individ-
uals who expressed extreme concerns with each of the
identified characteristics proposed by Lantz and Rhea.
Although these cutoff scores cannot diagnose individ-
uals with MD, they do represent an initial attempt to
654 Lantz, Rhea, and Cornelius
identify individuals with at-risk levels associated with
MD. Although we believe that identifying someone ex-
hibiting concerns with only 1 of the factors is not suf-
ficient to diagnose a muscle dysmorphic individual,
we believe that using cutoff scores gives us a closer
look into the seriousness of these initial characteristics
associated with MD. On the basis of the cutoff scores
of this study, 13% of the study participants demon-
strated extreme concerns with dietary behavior, 8%
with size, and 7% with exercise dependence. These
percentages give us an initial insight into the disorder,
although much more research is needed to determine
the severity of these concerns and the number of fac-
tors needed to identify someone as muscle dysmor-
phic.
Overall, the results of this investigation indicate
that elite-level bodybuilders report behaviors that are
characteristic of MD to a greater extent than do elite-
level power lifters. This suggests that it is inaccurate
to classify these 2 groups in the same category and
that some members of the bodybuilding community
may be at greater risk of developing MD than are
those involved in power lifting. However, caution
should be exercised in using any 1 of these subscales
individually to explain MD. Individual subscales were
explained in this study to show why these variables
might be considered important, although the overall
message is that 4 of the 6 subscales identified strong
characteristics associated with MD. It should be noted
that the MDI is not intended to serve as a diagnostic
instrument; however, it does provide valuable infor-
mation regarding symptomatology and psychological
themes that may be relevant in some sport subcul-
tures.
An important next step is for research to further
establish the psychometric development of the MDI
and determine the relationship between the MDI sub-
scales and other related constructs such as self-presen-
tational concerns and social physique anxiety. Also, re-
search should determine what levels of these behaviors
actually constitute a disorder as opposed to levels that
are simply characteristic of athletes at high competi-
tion levels. Finally, some of these data were collected
immediately after competition, and it is possible that
subject responses were influenced by their perfor-
mance in competition. Future research may wish to
consider how competitive participation and outcome
might influence the perception of factors associated
with MD.
Practical Applications
MD research suggests the bodybuilding community
may be at greater risk of developing these disorders
when compared with the power-lifting community.
This is valuable information, which may assist coaches,
personal trainers, and other persons working with ath-
letes to identify the early signs of pathological behav-
iors. Early identification of behaviors associated with
this disorder may help prevent serious problems with
pharmacological abuse, poor nutrition, and exercise
dependence.
References
1. AMERICAN PSYCHIATRIC ASSOCIATION. Diagnostic and Statistical
Manual of Mental Disorders—Text Revision (4th ed.). Washington,
DC: American Psychiatric Press, 2000.
2. ANDERSON, S., K. ZAGER, R. HETZLER, M. NAHIKIAN-NELMS,
AND G. SYLER. Comparison of eating disorder inventory (EDI-
2) scores of male body builders to the male college student
subgroup. Int. J. Sport Nutr. 6:255–262. 1996.
3. BLOUIN, A., AND G. GOLDFIELD. Body image and steroid use in
male body builders. Int. J. Eat. Disord. 18:159–165. 1995.
4. BRILL, J., AND M. KEAN. Supplementation patterns of compet-
itive male and female body builders. Int. J. Sport Nutr. 4:398–
412. 1994.
5. BROWNELL, K. Dieting and the search for the perfect body:
Where physiology and culture collide. Behav. Ther. 22:1–12.
1991.
6. FUSSELL, S. Muscle: Confessions of an Unlikely Bodybuilder. New
York: Avon Books, 1991.
7. GARNER, D. Eating Disorders Inventory—2, Professional Manual.
Odessa, FL: Psychological Assessment Resources, 1991.
8. GARNER, D., M. OLMSTED, AND J. POLIVY. Development and
validation of a multidimensional eating disorder inventory for
anorexia nervosa and bulimia. Int. J. Eat. Disord. 2:15–34. 1983.
9. HICKSON, J., T. JOHNSON, W. LEE, AND R. SIDOR. Nutrition and
the precontest preparations of a male bodybuilder. J. Am. Diet.
Assoc. 90:264–267. 1990.
10. JAMES, B., AND D. COLLINS. Self-presentational sources of com-
petitive stress during performance. J. Sport Exerc. Psychol. 19:
17–35. 1997.
11. KLEIN, A. Little Big Men. Albany, NY: State University of New
York Press, 1993.
12. KLEINER, S., T. BAZZARRE, AND B. AINSWORTH. Nutritional sta-
tus of nationally ranked elite body builders. Int. J. Sport Nutr.
4:54–69. 1994.
13. KLEINER, S., T. BAZZARRE, AND M. LITCHFORD. Metabolic pro-
files, diet, and health practices of championship male and fe-
male body builders. J. Am. Diet. Assoc. 90:962–967. 1990.
14. LANTZ, C., D. RHEA, AND J. MAYHEW. The drive for size: Char-
acteristics and consequences of muscle dysmorphia. Int. Sport
J. 5:71–85. 2001.
15. LEARY, M. Self-presentation processes in exercise and sport. J.
Sport Exerc. Psychol. 14:339–351. 1992.
16. LEARY, M. Self-Presentation: Impression Management and Interper-
sonal Behavior. Dubuque, IA: Brown and Benchmark, 1995.
17. LEARY, M., AND R. KOWALSKI. Impression management: A lit-
erature review and two-component model. Psychol. Bull. 107:
34–47. 1990.
18. LOOSEMORE, D., AND D. MORIARTY. Body dissatisfaction and
body image distortion in selected groups of males. Can. Alli-
ance Health, Phys. Educ. Recreation J. 56:11–15. 1990.
19. OLIVARDIA, R., H. POPE, AND J. HUDSON. Muscle dysmorphia
in male weightlifters: A case-control study. Am. J. Psychiatry
157:1291–1296. 2000.
20. PASMAN, L., AND J. THOMPSON. Body image and eating distur-
bance in obligatory runners, obligatory weight lifters, and sed-
entary individuals. Int. J. Eat. Disord. 7:759–769. 1988.
21. POPE, H., A. GRUBER, P. CHOI, R. OLIVARDIA, AND K. PHILLIPS.
Muscle dysmorphia: An underrecognized form of body dys-
morphic disorder. Psychosomatics 38:548–557. 1997.
22. POPE, H., D. KATZ, AND J. HUDSON. Anorexia nervosa and ‘‘re-

verse anorexia’’ among 108 body builders. Compr. Psychiatry 34:
406–409. 1993.
23. RHEA, D., AND C. LANTZ. Development of the muscle dysmor-
phia inventory. In: Annual Meeting of the Association for the Ad-
vancement of Applied Sport Psychology. Nashville, TN, 2000.
24. RHEA, D., AND C. LANTZ. Muscle dysmorphia: A confirmatory
test of a new model. In: Annual Meeting of the American Alliance
for Health, Physical Education, Recreation and Dance. Orlando, FL,
2000.
25. RHEA, D., C. LANTZ, AND G. TRAIL. Conceptualization and mea-
surement of muscle dysmorphia. In: Annual Meeting of the As-
sociation for the Advancement of Applied Sport Psychology. Banff,
Alberta, Canada, 1999.
26. SHORE, R., AND J. PORTER. Normative and reliability data for
11–18 year olds on the eating disorder inventory. Int. J. Eat.
Disord. 9:201–207. 1990.
27. SMITH, D., B. HALE, AND D. COLLINS. Measurement of exercise
Muscle Dysmorphia 655
dependence in body builders. J. Sports Med. Phys. Fitness 38:66–
74. 1998.
28. VEALE, D., K. GOURNAY, W. DRYDEN, A. BOOCOCK, F. SHAH, R.
WILLSON, AND J. WALBURN. Body dysmorphic disorder: A cog-
nitive behavioral model and pilot randomized controlled trial.
Behav. Res. Ther. 34:717–729. 1996.
29. VOLEK, J., N. DUNCAN, S. MAZZETTI, R. STARON, M. PUTUKIAN,
A. GOMEZ, D. PEARSON, W. FINK, AND W. KRAEMER. Perfor-
mance and muscle fiber adaptations to creatine supplementa-
tion and heavy resistance training. Med. Sci. Sports Exerc. 18:
1147–1156. 1999.
30. WEAR, R., AND O. PRATZ. Test-retest reliability for the eating
disorder inventory. Int. J. Eat. Disord. 6:767–769.
31. WROBLEWSKA, A. Androgenic-anabolic steroids and body dys-
morphia in young men. J. Psychosom. Res. 42:225–234. 1997.
Address correspondence to Dr. Christopher D. Lantz,
clantz@truman.edu.