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Are anxiety and obsessive-compulsive symptoms related to muscle dysmorphia?

The present study examines how muscle dysmorphia (MD), a clinically significant preoccupation that one's body is inadequately muscular, relates to trait anxiety and obsessive-compulsive symptoms. 97 college-age men completed the MD Inventory, the Drive for Muscularity Scale, the Male Body Attitudes Scale, the Social Physique Anxiety Scale, the trait scale of the Speilberger State-Trait Anxiety Inventory, and an abbreviated version of the Yale Brown Obsessive-Compulsive Scale. Bivariate correlation analyses revealed that trait anxiety and obsessive-compulsive symptoms demonstrated strong relationships with both social physique anxiety and overall MD symptomology. Path analysis indicated that anxiety-related variables accounted for 77 percent of the variance in MD symptoms. The findings lend support to the assertion that MD should be placed within the obsessive-compulsive spectrum of disorders.

Keywords: muscle dysmorphia, anxiety, obsessive-compulsive symptoms, men


Although not officially listed in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (American Psychiatric Association, 2000) (DSM-IV-TR), muscle dysmorphia (MD) is recognized by many researchers as a legitimate psychological disorder. Olivardia (2001) provides thorough diagnostic criteria for MD. First, one must be preoccupied with the idea that his or her body is not sufficiently lean or muscular. Second, the preoccupation must cause clinically significant distress or impairment in social, occupational or other important areas of functioning as demonstrated by (a) giving up participating in important activities in these areas because of a compulsive need to maintain diet and workout schedules, (b) avoiding situations in which one's body is exposed to others, (c) exhibiting clinically significant distress in these areas of functioning, (d) continuing exercising, dieting, and using performance enhancing substances despite negative physical or psychological consequences, and (e) being preoccupied with being too small or inadequately muscular rather than on being overweight.

Grieve (2007) discusses factors that influence the development of MD. These include socio-environmental (media presentation of ideal images and sports participation), emotional (negative affect and body image dissatisfaction), psychological (idealized body image and low self-esteem), and cognitive (perfectionism) influences (Grieve). Of most interest to the present study are the emotional influences, especially negative affect.

Maida and Armstrong (2005) noted positive correlations between symptoms of MD and variables such as anxiety and obsessive-compulsive symptoms. They examined a model in which obsessive-compulsive symptoms were related to symptoms of eating disorders, body dysmorphic disorder, and MD. Obsessive-compulsive symptoms were also directly related to symptoms of MD. These findings indicate strong positive relationships between obsessive-compulsive symptoms, anxiety, symptoms of body dysmorphic disorder, and symptoms of MD, with the strongest relationship being between obsessive-compulsive symptoms and symptoms of MD. However, since Maida and Armstrong measured anxiety using the Brief Symptom Inventory (BSI; Derogatis, 1984), which is a screening instrument for psychiatric disorders, replication of these findings with a more comprehensive evaluation of anxiety is in order. Moreover, Maida and Armstrong did not directly evaluate symptoms of MD. They used a combination of measures to suggest symptoms of MD. Thus, replication with a measure designed to evaluate symptoms of MD is warranted.

Another variable of interest in terms of negative affect is social physique anxiety, a body-related anxiety that stems from the fear of others evaluating one's appearance (Hart, Leary, & Rejeski, 1989). Conceptually, symptoms of MD include concern over body shape and hiding of the body (Olivardia, 2001). Further, prior research has demonstrated a link between MD and social physique anxiety. Grieve, Jackson, Recce, Marklin, and Delaney (in press) found that men who reported higher levels of social physique anxiety also reported higher levels of MD symptoms.

Two other variables--drive for muscularity and body focus--are notable in the development of MD (Grieve, 2007). A drive for muscularity underlies the behavioral symptoms of MD in that people with the disorder want to be larger and more muscular than what they actually are (Olivardia, 2001). There is a large body of research that ties a drive for muscularity to MD (Thompson & Cafri, 2007). A second factor important in the development of MD is body focus. Individuals high in MD exhibit a number of body checking behaviors such as looking at their bodies in mirrors (Olivardia, 2001).

The present study was designed to expand upon the work of Maida and Armstrong, and evaluate the relationship that anxiety symptoms have with MD. The model proposed for the study includes obsessive-compulsive symptoms, trait anxiety, social physique anxiety, drive for muscularity and media influences as factors that are related to MD. The general model under study was taken from Grieve (2007), and was modified to include the anxiety symptoms of interest to the present research.

Levels of anxiety are presumed to be motivational factors that will influence both drive for muscularity and body locus. If individuals are anxious about their appearance or display obsessive ideas about appearance, it is likely that they will experience a higher level of body focus. Because the social ideal for the male body is a hypermesomorphic one (Grieve, Newton, Kelly, Miller, & Kerr, 2005; Parks & Read, 1997; Ridgeway & Tylka, 2005), an acceptable way to decrease body-related anxiety is to develop a drive for muscularity.

The study was designed to address two limitations noted in the research by Maida and Armstrong: use of a screening instrument for anxiety and not directly measuring the symptoms of MD. For the present study, the trait section of the Speilberger State-Trait Anxiety Inventory (Speilberger, Gorsuch, & Lushene, 1983) was used to evaluate anxiety, and the Muscle Dysmorphia Inventory (Short, 2005) was used to evaluate symptoms of MD.

The specific hypotheses under study are:

1. Higher levels of anxiety, measured as obsessive-compulsive symptoms, levels of trait anxiety, and level of social physique anxiety, will be associated with higher levels of MD symptoms.

2. Higher levels of anxiety will be associated with a higher body locus and a higher drive for muscularity.

3. Higher levels of body focus and drive for muscularity will be associated with higher levels of MD symptoms.



Participants in the study were 97 male volunteers recruited from a mid-sized university in the mid-South. The mean age of the participants was 21.75 years (SD = 4.52); the average height was 70.86 inches (SD = 2.71); and the mean weight was 184.11 pounds (SD = 44.12). Participants had a mean body mass index of 26.29 (SD = 5.38). In all, 74 (85.1%) participants were Caucasian, 5 (5.7%) were African American, 4 (4.6%) were Asian, 1 (1.1%) was Hispanic, 1 (1.1%) was Pacific Islander, and 2 (2.3%) were bi-racial.

Thirty-two participants (36.8%) acknowledged using some form of supplement while working out. Creatine, protein shakes, and vitamins were the supplements mentioned most often. Forty-four (50.6%) reported having an active gym membership; 64 (73.6%) said they participated in cardiovascular exercise; 6 (6.9%) said they used topical analgesics before working out and 12 (13.8%) reported using them afterwards; and 12 (13.8%) participants said they used pain medication before a workout while 21 (24.1%) reported using them afterwards.


Demographics. Participants completed a 22-item demographics survey assessing age, weight, height, and ethnicity. They were also asked about active gym membership, frequency of working out, and use of supplements to gain body mass.

Anxiety. The Speilberger State-Trait Anxiety Inventory (STAI; Speilbergcr, Gorsuch, & Lushene, 1983) was used to assess for state and trait-based levels of anxiety. The STAI is a 40-item self report measure that assesses both how a person feels at the moment (state anxiety) and how he or she generally feels (trait anxiety). The STAI includes such statements as "I feel calm" and "I make decisions easily." These items are rated on a four-point Likert-type scale from 1 (not at all) to 4 (very much so). Because the focus of this study is on the overall personality and long-term characteristics of the participants, only the scores on trait anxiety were used in the analysis. Higher scores indicate higher levels of trait anxiety. Sansoni, Vellone, and Piras (2004) report a Cronbach's Alpha of .95 for the trait version of the STAI. In the present study, the Cronbach's alpha for the STAI was .95.

The Social Physique Anxiety Scale (SPAS; Hart, Leary, & Rejeski, 1989) was administered to evaluate body anxiety. The SPAS consists of 12 items that participants rate on a five-point Likert-type scale from 1 (not at all) to 5 (extremely). Higher scores on the SPAS indicate higher levels of social physique anxiety. Hart et al. (1989) found that the SPAS demonstrates good internal consistency (r = .90) and test-retest reliability (r = .82). In the present study, Cronbach's alpha was .92.

An abbreviated version of the Yale Brown Obsessive-Compulsive Scale (YBOCS; Goodman, Price, Rasmussen, & Mazure, 1989) was administered to assess symptoms of obsessive-compulsive disorder. This version of the YBOCS consists of 10 self-report items on which participants rank, on a scale of 0 to 4, how much control they perceive themselves as having over their obsessions or compulsions. Higher scores indicate higher levels of obsessive-compulsive features. Frost, Steketee, Krause, & Trepanier (1995) reported Cronbach's alphas for the total score as .88. The Cronbach's alpha for the total score present study was .92.

Muscle Dysmorphia. To assess for symptoms of MD, the Muscle Dysmorphia Inventory (MDI; Short, 2005) was used. The MDI is a 25-item questionnaire that assesses eight components of MD: Inadequacy, Preoccupation, Muscularity Drive, Increased Muscularity, Compulsivity, Body Anxiety, Social Sacrifice, and Persistence. Included in the MDI are such items as "I feel badly when I do not get to work out." Participants rank these items on a six-point Likert-type scale, from 1 (strongly disagree) to 6 (strongly agree). Higher scores indicate a greater endorsement of MD symptomatology. In previous research, the MDI has an overall Cronbach's alpha of .87 (Short, 2005). For the present study, the Cronbach's alpha was .82.

Drive for Muscularity. To assess a participant's drive for muscularity, the Drive for Muscularity Scale (DMS; McCreary & Sasse, 2004) was administered. The DMS is a 15-item questionnaire with statements such as "I wish I were more muscular" and "Other people think I work out with weights too much." Participants rank these items on a six-point Likert-type scale, from 1 (always) to 6 (never). The DMS is reverse scored so that high scores indicate higher levels of drive for muscularity (McCreary, 2007). McCreary and Sasse (2004) found that the DMS had a Cronbach's alpha of .87 among male participants. For the present study, the Cronbach's alpha was .92.

Body Focus. To assess attitude about body image, participants were given the Male Body Attitudes Scale (MBAS; Tylka, Bergeron, & Schwartz, 2005). This 29-item measure allows participants to answer on a seven-point Likert-type scale from 0 (never) to 6 (always). Lower scores indicate higher levels of body focus and negative body opinion. The MBAS assesses body focus on four dimensions, including Muscularity, Body Fat, Height, and Overall Body. The MBAS has adequate total scale reliability (r = .88) for test-retest procedures (Tylka et al., 2005). In the present study, Cronbach's alpha was .92.

Descriptive statistics for all measures are presented in Table 1.

Participants completed the demographics survey followed by the MDI, DMS, MBAS, SPAS, YBOCS, and STAI. The entire process took about 20 minutes for each participant.


Before addressing the conducted analyses, it is important to note that there were ten participants who had missing data. This data was replaced using mean substitution, and the participants were included in the analyses.

Path analysis via a series of regressions (Pedhazur, 1997) was used to examine relationships in the specified recursive model. As illustrated in Figure 1, considered predictors of MD comprise three exogenous variables, including Social Physique Anxiety, Obsessive Compulsive Features, and Trait Anxiety, and two endogenous variables, including Drive for Muscularity and Body Attitude. The path analysis is the culmination of 12 regressions. Specifically, two regressions were conducted assessing the contribution from each exogenous variable to each endogenous variable. Then one regression was conducted from each exogenous variable to MD, and one regression was conducted from each endogenous variable to MD while accounting for the contributions from the upstream exogenous variables. Path coefficients specified in Figure 2 are therefore the standardized beta weights from each regression. The model also accounts for correlations between Social Physique Anxiety and Trait Anxiety, Social Physique Anxiety and Obsessive Compulsive Features, and Trait Anxiety and Obsessive Compulsive Features.


Figure 2 illustrates the path coefficients from the exogenous and endogenous variables included in the model and also the correlations among the exogenous variables. Most of the specified pathways had statistically significant relationships. There were only two pathways that did not achieve statistical significance. These were from trait anxiety to drive for muscularity and from obsessive-compulsive features to drive for muscularity. Overall, the total model [R.sup.2] denotes that the predictors accounted for 73 percent of the variance in the symptoms of MD. Given this large [R.sup.2], it is apparent that the model possess acceptable goodness of fit.



The results of the study support all of the hypotheses under study. There were several strong relationships between trait anxiety, social physique anxiety, obsessive-compulsive features, and MD symptoms. Trait anxiety was found to be highly predictive of social physique anxiety. A similar pattern of association was reported in women with disturbed eating patterns (Bas, Asci, Karabudak, & Kiziltan, 2004). Trait anxiety was also significantly negatively associated with body attitude; that is, a higher level of trait anxiety was a reliable predictor of low body attitude. This finding is consistent with past research completed with women who have eating disorders.

Kashima, Tatsuhisa, Okamoto, Nogoshi, Wada, Tadai, et al. (2003) found that higher scores on the Body Attitude Test (BAT) correlated with higher scores on both the STAI and Self-Rating Depression Scale, suggesting that those who suffer from eating disorders also experience negative appreciation of body size, unfamiliarity with their bodies, and general body dissatisfaction, and, therefore, have high trait anxiety. Finally, trait anxiety also had a strong, predictive relationship with overall MD symptoms, as illustrated by the relationship between the STAI and MDI. The results suggest that trait anxiety integrates well into existing models of MD. Because MD involves high levels of exercise to obtain and maintain a certain body shape, the findings also support research indicating that people who exercise excessively have higher levels of obsessive-compulsive symptoms (Gulker, Laskis, & Kuba, 2001).

Similar to trait anxiety, obsessive-compulsive features are strongly related to and were predictive of several factors of MD. In the present study, a strong predictive relationship was found between obsessive-compulsive features and body focus. This relationship could indicate unhealthy obsessions in each of these three areas for men who have high levels of MD symptoms. Individuals may, for example, be able to find relief from their intrusive, obsessive thoughts about their bodies by working out excessively or consuming a high protein diet or supplements.

Obsessive-compulsive features were also strongly correlated with and highly predictive of social physique anxiety and overall MD symptoms. This finding suggests that a man's underlying obsession with his own body magnifies the concerns he has regarding evaluation. This could also be a sign of underlying obsessive-compulsive features. Body focus could, therefore, be the primary focus of obsessional thinking or compulsive behaviors.

Obsessive-compulsive features and overall MD symptoms were also strongly related in this study. It could be that a predisposition towards obsessive thinking and compulsive behaviors, when paired with other factors linked to MD, lead to the expression of those obsessions and compulsions through bodily preoccupation. For example, an individual who suffers from obsessive thinking and is exposed to media images of muscular men may manifest his or her compulsions by working out in an effort to obtain an idealized body shape.

Social physique anxiety was also strongly positively correlated with MD symptoms. These findings support past research of Grieve el al. (in press), who found that men with higher levels of social physique anxiety also had higher levels of MD symptoms. Conceptually, a relationship between social physique anxiety and MD is understandable. Even though they have very muscular body shapes, people with MD are worried about how their bodies look and do not believe they measure up to their standards. This discrepancy can lead to the development of social physique anxiety.

Taken together, the findings support and extend the findings Maida and Armstrong (2005). Similar relationships were noted for both studies between obsessive-compulsive features, levels of anxiety, and drive for muscularity. The present study also found a relationship between anxiety, obsessive-compulsive symptoms, social physique anxiety, and symptoms of Muscle Dysmorphia.

In general, the findings of the present study lend support to Maida and Armstrong's (2005) assertion that MD should he placed within the obsessive-compulsive spectrum of disorders. There is presently a lack of consensus about the classification of MD. In addition to being classified in the obsessive-compulsive spectrum of disorders, it has also been classified as a Body Dysmorphic Disorder (Pope, Katz, & Hudson, 1993), as an Eating Disorder (Goodale, Watkins, & Cardinal, 2001), and as part of the Obsessive Compulsive spectrum of disorders (Maida & Armstrong, 2005). That obsessive-compulsive features were found to be strong predictors for MD symptomatology, body attitude, and social physique anxiety lends support to Maida and Armstrong's placement of MD under the obsessive-compulsive spectrum.

The classification of MD is not simply a philosophical debate. Correct classification has important implications for diagnosis and, especially, for treatment. Placing the disorder within an appropriate spectrum allows clinicians to devise appropriate treatments for the disorder. Inappropriate placement may lead to the development of potentially ineffective treatments and possible client endangerment. On the treatment of MD, see Olivardia (2007).

Interestingly, this study found a relationship between aspects of negative affect and MD, whereas previous research (Henson, 2004; Jonda, 2007) did not. The current study found both trait anxiety and obsessive-compulsive features to be predictive of MD symptomatology. Jonda's model of MD symptomatology noted a weak standardized beta-weight (.101) between negative affect and MD symptomatology. This difference may be the result of how each study measured negative mood stales. Whereas the current study used specific assessment tools to assess trait anxiety and obsessive-compulsive features, the study by Jonda used the Positive and Negative Affect Scales (PANAS; Watson, Clark, & Tellegen, 1988), an instrument designed to measure normal mood fluctuations. Thus, it may be that negative emotional states need to be of clinical significance before they substantively influence MD symptoms.

Because the current study found that both obsessive-compulsive features and trait anxiety were predictive of MD, future research may wish explore how other psychological mood states relate to MD symptomatology. Future research could expand the current study's findings by incorporating, for example, clinical measures of depression and anger.

The present study also has some limitations worth addressing. The most obvious improvement would be a larger sample size. While the overall reliability and the overall goodness of fit of the model specified in the model of the study was strong, more participants would improve statistical power and give opportunity to find greater numbers of participants with clinical levels of MD. This study also lacked a measure for media influence. As the existing literature has shown how important media influence is in people with MD, future studies should incorporate such a measure.

Another possibility to consider would be that MD may not fit into any existing spectrum of disorders. While the literature attempts to classify MD under a particular heading, it may also be possible that MD presents us with a unique symptomatology and etiology that warrants its own classification in a manner analogous to eating disorders.

Perhaps the most effective way to treat patients with MD is to treat it as its own disorder rather than trying to classify it within the body of existing disorders. In fact, it may be fruitful to consider the diagnostic history of eating disorders which only attained the status of a separate diagnostic category in the DSM-IV (Williamson, Zucker, Martin, & Smeets, 2004). Such diagnostic clarification has led both to a greater specificity of the subtypes within the eating disorders (the binging-eating/purging and the restricting subtypes of anorexia nervosa) and to the genesis of diagnosis specific treatments of choice (interpersonal or cognitive-behavioral therapies for anorexia nervosa). So, too, we can imagine the improved ability to identify at-risk individuals, render accurate diagnoses, and advance the treatment of individuals with MD, all as a consequence of finding a diagnostically apt placement for the disorder outside of existing groupings.

Finally, one limitation of the study is that it evaluates symptoms of anxiety and MD within a normal college population. Participants who met diagnostic criteria for MD were not recruited for participation; therefore, the findings may only be generalizable to sub-clinical populations. However, the range of scores on the MDI in this study (27 to 126) indicates that there were some participants who reported high levels of MD symptoms. Further, college-age men are at a higher risk for developing MD than other age groups of men or of women. While women can meet diagnostic criteria for MD, the disorder is much more prevalent in men than women. Therefore, college-age men are the population to which these findings should be generalized.

In conclusion, while this study does not make any definitive statement regarding the classification of MD, it does reveal that anxiety and obsessive-compulsive symptoms are strongly related to high levels of MD symptoms, lending support to Maida and Armstrong's (2005) assertion that MD should be classified under the obsessive-compulsive spectrum of disorders. This study brings researchers one step closer to being able to classify MD appropriately based upon its etiology and psychological comorbidity.


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Western Kentucky University

Christopher G. Chandler, Frederick G. Grieve, W. Pitt Derryberry, and Phillip O. Pegg, Western Kentucky University.

Correspondence concerning this article should be addressed to Frederick G. Grieve, Department of Psychology, 1906 College Heights Boulevard #21030, Bowling Green, KY 42101-1030. Email:
Table 1
Descriptive Statistics for the Measures

Measure     Sample     Mean      SD       Range of
           Size (N)                        Scores

YBOCS         95       7.76     6.82      0.00-27.00
DMS           97      39.70    15.21     16.00-75.00
MBAS          96      97.28    21.43     50.00-141.00
MDI           93      66.26    19.61     27.00-126.00
SPAS          97      16.75     6.39      7.00-35.00
STAI          94      72.68    22.36     40.00-139.00

Note: YBOCS = Yale Brown Obsessive-Compulsive Scale; DMS = Drive for
Muscularity Scale,; MBAS = Male Body Attitudes Scale; MDI = MD
Inventory; SPAS = Social Physique Anxiety Scale; STAI = Spielberg
State-Trait Anxiety Inventory.
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Author:Chandler, Christopher G.; Grieve, Frederick G.; Derryberry, W. Pitt; Pegg, Phillip O.
Publication:International Journal of Men's Health
Article Type:Report
Geographic Code:1USA
Date:Jun 22, 2009
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