For Some, No Amount of Pumping Iron Is Enough
What drives some bodybuilders is a form of mental illness that can be treated with drugs, a researcher says.
These people have a type of body dysmorphic disorder, a condition which is characterized by a preoccupation with an imagined or slight defect in appearance, said Dr. Eric Hollander of Mount Sinai School of Medicine in New York.
“Body dysmorphic disorder affects probably 1-to-2% of the U.S. population, but among men in particular there is a sort of subclassification called ‘bigorexia,’ which is sort of the opposite of anorexia,” Hollander said. Anorexics think they are too fat no matter how thin they are--and bigorexics think themselves too small no matter how big they are, he said.
Bigorexia, more properly termed muscle dysmorphia, is not yet formally recognized as a psychiatric condition, Hollander said. But the coming revision of the American Psychiatric Assn.’s Diagnostic and Statistical Manual will describe the condition, he said.
Bodybuilding can be a healthy competition, but these people take muscle development to the point at which it interferes with ordinary living, including holding a job or staying healthy, Hollander said. “They will continue to exercise even after they have dislocated a shoulder,” he said.
As an expression of body dysmorphic disorder, muscle dysmorphia is an obsessive-compulsive spectrum disorder, Hollander said. People with OCD are driven to do things such as repeatedly check their appearance in mirrors and perform ritualistic movements.
“An exaggerated sense that something doesn’t look right” seems to have origins in brain chemistry, Hollander said. He and his colleagues reported in Archives of General Psychiatry on the effects of the drug clomipramine on the brain chemical serotonin.
One of serotonin’s normal roles seems to be in turning off brain processes that signal when “things don’t fit our conceived notions,” Hollander said. If serotonin levels are abnormally low, however, it can’t turn off the mental alarm bell that rings when things don’t seem right, and the bell keeps on ringing even when things are right, he said. Clomipramine helps the brain raise serotonin levels by interfering with the body’s ability to destroy the chemical, he said.
Hollander and his colleagues wanted to be sure clomipramine was producing improvements in the behavior of people with body dysmorphic disorder, and that the patients were not improving simply because they knew they were getting treatment and therefore expected themselves to improve. So the researchers compared clomipramine with another drug, desipramine, which had similar side effects but does not affect serotonin.
Clomipramine treatment was significantly better in reducing patients’ repetitive movements and obsessive preoccupation with perceived flaws, the study found. But it is not a cure, Hollander said. “Don’t think about symptoms going down to zero,” he said. “They were 25-to-35% improved.” There was, however, a significant improvement in their ability to go back to school or function at work, and a significant drop in their thoughts of suicide, he said.
Although this study did not focus on muscle dysmorphia, treatment for body dysmorphia has been shown to work on muscle dysmorphia, Hollander said. And a clinician who was not involved in the study said she found the drug to work, especially in combination with psychological therapy.
“I don’t feel behavior therapy is sufficient, and certainly medications are not efficacious alone either,” said Fugen Neziroglu, senior clinical director of the Bio-Behavioral Institute in Great Neck, N.Y.
Neziroglu has treated a number of people with muscle dysmorphia. “I had one who just left, an attractive, nice, 44-year-old man, he’s telling me he has flab on his sides,” she said. “You look at him and you know he has no flab.”
Medications help to stabilize patients with muscle dysmorphia, but therapy is needed to retrain habits and thought patterns needed to make the improvements last, Neziroglu said. Clomipramine is one of the better drugs, she said.
And therapy alone may be adequate treatment, said James Rosen, a clinical psychologist and professor at the University of Vermont. The cognitive-behavioral approach teaches patients to realize when their thoughts are unrealistic, recast their self-image into more neutral terms, and adapt to situations that could set off the compulsion, he said.
For muscle dysmorphia, this could include easing away from the idea that the exercisers would lose control of themselves if they skip a workout, Rosen said.
However, one bodybuilding promoter said he couldn’t tell whether bodybuilders have this condition. High-level bodybuilders are like other athletes in paying extremely close attention to what they eat, how much they exercise and where they fall short of their own goals, said James Lorimer of the Arnold Schwarzenegger Fitness Weekend, Feb. 22-27 in Columbus, Ohio.
“I can’t say I place these particular athletes outside the normal range of people who are trying to be the best they can be in whatever sport they are in,” Lorimer said. “You can say it’s excessive, it’s unusual, but [I] can’t say whether it is disordered or not.”
