Muscle Dysmorphia

Muscle dysmorphia is a real, treatable mental health condition — not vanity, not “discipline,” and not “just being into fitness.” If you found your way here because the gym, your reflection, or your supplement shelf has taken over more of your life than you ever planned, you are in the right place. There is a clinical name for what you are living with, there is a serious body of research behind it, and there is care that works.

We are Inland Psychiatric Medical Group (IPMG), serving patients across San Bernardino and Riverside counties. This essay is for the person who suspects something is wrong, for the partner or parent watching it happen, and for the lifter who has been quietly worried about themselves for a long time.

What Muscle Dysmorphia Really Is

Muscle dysmorphia is a clinically recognized form of body dysmorphic disorder (BDD). The American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR, 2022) lists BDD in the chapter on Obsessive-Compulsive and Related Disorders. When the preoccupation centers on the idea that one’s body is too small or not muscular enough, clinicians apply the “with muscle dysmorphia” specifier.

In plain language, the DSM-5-TR criteria for BDD are:

A preoccupation with one or more perceived defects or flaws in physical appearance that are not observable, or appear only slight, to others.
Repetitive behaviors (mirror checking, excessive grooming, comparing yourself to others, seeking reassurance) or mental acts performed in response to the appearance concerns.
Clinically significant distress or impairment in social, work, school, or other important areas of life.
The preoccupation is not better explained by concerns about body fat or weight in the context of an eating disorder — though the two can overlap.

In muscle dysmorphia specifically, the preoccupation is with not being muscular or lean enough. The DSM-5-TR explicitly notes that the specifier still applies even if other body areas are also a focus, which is common.

You may have heard the word “bigorexia.” That is patient and media slang, popularized by social media coverage. It is not the clinical term. The clinical term is body dysmorphic disorder with muscle dysmorphia. We use the clinical term in this essay because the slang, while useful for recognition, can make a serious condition sound like a punchline.

What the Pattern Often Looks Like

We are going to describe patterns, not give you a checklist to diagnose yourself. Self-diagnosis is not the point. The point is to recognize whether an evaluation might help you.

People with muscle dysmorphia often experience some combination of the following:

Preoccupation with muscularity, leanness, or a specific body area — chest, arms, shoulders, abdomen, back.
Frequent mirror checking, or the opposite, active avoidance of mirrors and reflective surfaces.
Constant comparison to other people in person, on social media, or in images.
A rigid training schedule that overrides work, school, sleep, family time, intimacy, medical appointments, or injury recovery.
Significant distress, anxiety, or low mood when training is missed or interrupted.
Restrictive or rule-bound eating organized around macros, “clean eating,” or repeated cycles of “bulking” and “cutting.”
Heavy supplement use; use of performance-enhancing substances including anabolic-androgenic steroids (AAS), selective androgen receptor modulators (SARMs), peptides, or growth hormone.
Body checking through clothing fit, photographs, or repeated weighing.
Avoidance of situations where the body is visible — beaches, locker rooms, intimacy — or the opposite, compulsive exposure and posting.
Hiding the true extent of training, eating rules, or substance use from family, partners, or clinicians.
An internal experience of feeling small, weak, or “soft” no matter what the mirror, the scale, or other people actually say.

That last point matters. Muscle dysmorphia occurs in people of every body size and every level of muscularity, including people who are objectively very muscular. The pain is in the perception, not in the proportions.

Healthy Fitness vs. Muscle Dysmorphia

Many readers come to this question first: Do I just take fitness seriously, or do I have a clinical problem? The honest answer is that the two can look identical from the outside, and the difference is usually in how the activity functions in your life.

Healthy training serves your life. Muscle dysmorphia training overrides your life.
Healthy goals are flexible and respond to feedback from your body, your doctor, and the people who love you. Muscle dysmorphia goalposts keep moving — you reach them and they move again.
Healthy lifters can take a rest day without distress. With muscle dysmorphia, rest feels unsafe.
Healthy people can eat outside their plan at a wedding, a holiday, or a hard day, without crisis. With muscle dysmorphia, deviation feels catastrophic.
Healthy people listen to medical advice, including about injury recovery. With muscle dysmorphia, that advice gets overridden.
Healthy people can be honest with the people they love about how they train, eat, and use substances. With muscle dysmorphia, that information often gets hidden.

If you read that list and felt a private flinch of recognition, that is information. It is not a verdict. It is a reason to talk to a clinician.

Who Develops Muscle Dysmorphia

Muscle dysmorphia is most often diagnosed in men and adolescent boys, but it occurs in women, transgender, and nonbinary people as well. Onset is typically in adolescence or early adulthood, frequently in the months or years after someone starts serious weight training.

Recent research gives a clearer picture of how common this is:

In a 2025 study of 1,488 boys and men ages 15–35 in the United States and Canada, Ganson and colleagues found a prevalence of probable muscle dysmorphia of 2.8% (95% confidence interval 2.0–3.7%).¹
In a 2021 Australian study of 3,618 adolescents (the EveryBODY study), Mitchison and colleagues estimated point prevalence at 2.2% in boys and 1.4% in girls ages 11–19.²
A 2025/2026 review in The Lancet Child & Adolescent Health by Nagata and colleagues concluded that “in the past 30 years, muscle dysmorphia has gained heightened relevance for young males as rates of conceptually related conditions, such as eating disorders, have increased in adolescent boys and muscle-building behaviours … have become more common in adolescence.”³

Risk is concentrated in environments that put pressure on the body: gym and bodybuilding culture, social media fitness content, certain sports (bodybuilding, wrestling, mixed martial arts, gymnastics, competitive cheer), and some military settings. Muscle dysmorphia also commonly co-occurs with depression, anxiety, obsessive-compulsive disorder (OCD), eating disorders, social anxiety, perfectionism, ADHD, and substance use disorders — particularly involving anabolic-androgenic steroids.

For most of the last hundred years, the body-pressure media environment that we now associate with eating disorders was overwhelmingly aimed at girls and women. That has changed. Adolescent boys and young men now scroll through algorithmic feeds saturated with idealized male physiques, “looksmaxxing” content, steroid talk, and a relentless ranking of bodies.

Researchers are starting to name this directly. The Nagata 2025/2026 Lancet review explicitly links frequent exposure to muscularity-oriented social media content to elevated rates of probable muscle dysmorphia. A 2025 academic preprint by Sánchez and colleagues introduced the term “pro-bigorexia content” to describe algorithmically amplified material — body-check videos, supplement endorsements, extreme training, steroid normalization — that current platform moderation does not catch the way it (sometimes) catches pro-anorexia content.⁴

This is not a story about blaming individuals for what they see. It is a story about an environment. Naming the environment matters because it explains why this condition is rising and why it can feel like everyone is in on something you are missing. They are not. You are watching a feed.

Anabolic-Androgenic Steroids, SARMs, and Other Performance Drugs

Use of anabolic-androgenic steroids (AAS) — and related compounds including SARMs, peptides, growth hormone, and trenbolone — is common in people with muscle dysmorphia. Harrison Pope, Gen Kanayama, and colleagues at McLean Hospital and Harvard have spent decades documenting this relationship, including findings that men with muscle dysmorphia have markedly higher rates of AAS use and that, for many users, body image distress is a primary motivator.⁵

We are not going to describe how these substances are used. We do want to be honest about the medical reality of what they do.

At a high level, long-term AAS use has been associated with:

Cardiovascular complications, including left ventricular hypertrophy, dilated cardiomyopathy, reduced ejection fraction, premature coronary artery disease, hypertension, dyslipidemia, arrhythmias, and sudden cardiac death. A 2025 narrative review in Biomedicines by Iliakis and colleagues, and a 2025 systematic review of AAS-induced cardiomyopathy cases in Clinical Case Reports, both document these patterns and note that some cardiac changes may not fully reverse even after stopping.⁶
Hormonal effects, especially suppression of the body’s natural testosterone production through the hypothalamic-pituitary-gonadal axis. In Kanayama and colleagues’ 2015 Addiction study of former long-term AAS users, more than a quarter (29%) experienced major depressive episodes during AAS withdrawal, and a meaningful subset failed to recover normal sexual function even with testosterone replacement.⁷
Liver injury and abnormal lipid panels.
Mental health effects, including mood swings, irritability and aggression during use, and major depression during withdrawal — with a meaningful risk of suicide in the withdrawal period.⁸

For people with a significant AAS history, stopping safely is not a one-step decision. It benefits from coordinated medical care: an endocrinologist or knowledgeable primary care clinician for hormonal recovery; cardiology evaluation when indicated; and a mental health clinician to support you through the withdrawal period, when depression and suicidal thinking can spike. Antidepressant medication is sometimes part of that support.

Most importantly: if you have been using these substances, you deserve full medical and mental health care, without shame. Many people with significant AAS histories started using in part because of body image distress, performance pressure, or undiagnosed muscle dysmorphia. Treating the underlying illness — not just the substance — is what changes the long-term picture.

The Medical Stakes

Muscle dysmorphia is not a minor problem. Across the research, it is associated with:

Elevated suicide risk. Body dysmorphic disorder as a whole carries some of the highest rates of suicidality in psychiatry. According to Katharine Phillips’s summary in Primary Psychiatry (2007), “approximately 80% of individuals with BDD experience lifetime suicidal ideation and 24% to 28% have attempted suicide.”⁹ Phillips and Menard’s 2006 prospective study in the American Journal of Psychiatry estimated a standardized mortality ratio for completed suicide of approximately 45 — that is, roughly 45 times the rate in the general population, higher than the comparable figures for eating disorders, major depression, or bipolar disorder.¹⁰ People with the muscle dysmorphia specifier have shown even higher rates of suicidality and substance use disorders than people with BDD without the specifier.¹¹
Substance use disorders, particularly AAS and stimulants.
Co-occurring eating disorders, including restrictive patterns during “cutting” phases and binge episodes during “bulks.”
Overtraining injuries and long-term joint, tendon, and back damage from training through pain.
Cardiovascular disease in those with AAS history.

This is why we treat muscle dysmorphia as a serious clinical condition. Not because we want to scare anyone. Because the stakes deserve respect.

If You Are Thinking About Suicide

If you are having thoughts of suicide or self-harm, please reach out right now. Call or text 988. It is free, confidential, and staffed 24/7. You can also call IPMG, go to your nearest emergency department, or use any of the resources at the bottom of this page. You are not a burden. Reaching out is the move.

What Treatment Actually Looks Like

The good news, and we mean this, is that there is real, evidence-based treatment for muscle dysmorphia. The current 2024–2026 standard of care looks like this:

Cognitive Behavioral Therapy for BDD (CBT-BDD). This is the most studied psychotherapy for body dysmorphic disorder. The treatment manual developed by Sabine Wilhelm, Katharine A. Phillips, and Gail Steketee (Guilford Press, 2013) is widely used. CBT-BDD typically combines cognitive work (examining and shifting the thoughts driving the preoccupation) with behavioral work (changing the rituals and avoidances that maintain it). A 2024 meta-analysis in the Journal of Affective Disorders by Zhao and colleagues, pooling 11 randomized controlled trials, reported significant reductions in BDD symptoms, depression, and anxiety, along with improvements in functioning and quality of life.¹²

Exposure and Response Prevention (ERP). A specific behavioral approach, often woven into CBT-BDD, that gradually reduces compulsions like mirror checking, photo checking, body comparison, and reassurance seeking. ERP is the same family of intervention used for OCD.

Medication. Selective serotonin reuptake inhibitors (SSRIs) — particularly fluoxetine — are considered first-line medication treatment for BDD. Clomipramine, an older serotonin reuptake inhibitor, also has evidence and is sometimes used. No medication is FDA-approved specifically for BDD or muscle dysmorphia as of 2026; SSRIs and clomipramine are used off-label, on the basis of strong clinical evidence. The International OCD Foundation’s expert opinion, authored by Jamie Feusner, MD, and Katharine A. Phillips, MD, states plainly: “There are no medications that currently have FDA approval for treating BDD; however, research and clinical experience suggests that these medications are safe and effective for a majority of people with BDD.”¹³ Clinical experience and published work indicate that BDD often requires higher SSRI doses than those typically used for depression — in a range closer to what is used for OCD. Your prescribing clinician will determine what is right for you, on the basis of your full history.

Treatment of co-occurring conditions. Depression, OCD, eating disorders, substance use disorders (including AAS), and anxiety disorders are common and are treated alongside the core BDD work, not after it.

Medical care for patients with AAS history. Medically supervised cessation, endocrine evaluation, cardiac evaluation when indicated, and mental health support through the withdrawal period.

Family or partner inclusion. Especially helpful for adolescents and young adults. Family members are not “the problem,” and they are not the cure — but their involvement, done thoughtfully, helps.

Access in the Inland Empire

We will be honest. BDD-specialty clinicians are limited everywhere in the country, including here. The good news is that CBT and ERP for OCD and related conditions are available across the Inland Empire through individual licensed therapists, group practices, and several specialty clinics. The International OCD Foundation maintains a free, searchable directory of BDD and OCD specialists — including by state, insurance, and provider credentials — at bdd.iocdf.org.

California’s SB 855 (the state’s mental health parity law, in force since January 1, 2021, with final enforcement regulations adopted by Insurance Commissioner Ricardo Lara in 2025) requires commercial health plans to cover medically necessary treatment for all mental health and substance use disorders listed in the DSM, including BDD with muscle dysmorphia, on the same terms as physical health conditions.¹⁴ In practice, this means your commercial insurance is required to cover this care.

If you are unsure where to start, we can help you triage. IPMG sees patients across San Bernardino and Riverside counties and can guide you toward the right level of care.

What to Expect From Treatment

Recovery from muscle dysmorphia is real, and it is also a process. Honest expectations help.

Many people do one to two years of weekly or twice-weekly outpatient work, sometimes with intensive phases. Some need less. Some need more.
Symptom improvement is usually gradual, not sudden. Small changes — fewer mirror checks, a missed gym day that did not become a crisis, a meal eaten without panic — add up.
For people with AAS history, recovery has physical and mental health components, and the hormonal and cardiac side of things has its own timeline.
Relapse is part of many recovery paths. A return of symptoms during a stressful period, an injury, a breakup, or a transition does not erase the work you have already done. It is information about what supports you need.

Supporting Someone With Muscle Dysmorphia

If you are a parent, partner, sibling, or friend reading this because of someone else, a few things matter more than the rest.

Do not comment on their body, training, food, or appearance — even with intended compliments. “You look great” and “you look huge” can both reinforce the illness. So can “you look thinner” or “you look better than before.” Body-focused comments, even kind ones, feed the system you are trying to help shrink.
Express concern about their wellbeing, not their behavior. “I am worried about how stressed you seem about training” lands very differently than “you train too much.”
Watch for safety concerns: significant substance use including AAS, severe food restriction, deep depression, withdrawal from people, and talk of self-harm. Take these seriously.
Encourage evaluation. Do not police, lecture, search the bathroom, or count supplements. None of that helps long-term, and most of it makes things worse.
Take care of yourself. Supporting someone through this is hard. You are allowed to have your own therapist, your own support, and your own limits.

A Short Word to Close

If you have seen yourself in any part of this essay, the next step is an evaluation. Not a self-diagnosis. Not another research deep dive. A conversation with a clinician who knows this territory.

You deserve full care — including if you have been using anabolic steroids, including if you have been hiding this from the people who love you, including if you are not sure whether what you are living with is “serious enough.” It is serious enough. Reach out.

IPMG: (909) 707-6261. We serve patients across San Bernardino and Riverside counties.

Frequently Asked Questions

“Am I sick, or do I just take fitness seriously?” The honest test is not how hard you train. It is whether training serves your life or runs it; whether you can take a rest day without distress; whether you can eat outside your plan without crisis; whether you are honest with the people you love about what you are doing; and whether your goals are flexible or whether the goalposts keep moving. If those questions made you uncomfortable, talk to a clinician. An evaluation is not a verdict.

“Can women get muscle dysmorphia?” Yes. Muscle dysmorphia is diagnosed predominantly in men and adolescent boys, but it occurs in women, transgender, and nonbinary people as well. Symptom patterns can look somewhat different across groups, but the underlying preoccupation and impairment are the same.

“I’ve been using steroids. Can I just stop?” Sometimes, but please do not try alone. Anabolic-androgenic steroid use suppresses the body’s own testosterone production, and stopping can be followed by months — sometimes longer — of low hormone levels, low mood, low libido, fatigue, and meaningfully elevated suicide risk during withdrawal. Cardiac and lipid changes also need attention. Stopping safely is much easier with a clinician who knows this territory — typically a combination of medical care (endocrinology or knowledgeable primary care, and sometimes cardiology) and mental health support. You will not be judged. Bring everything to the table.

“Is muscle dysmorphia the same as an eating disorder?” No, but they overlap. Muscle dysmorphia is a form of body dysmorphic disorder, classified in the obsessive-compulsive-related family in DSM-5-TR. Eating disorders are their own diagnostic category. Many people with muscle dysmorphia have restrictive eating patterns, binge episodes, or rigid food rules that meet criteria for an eating disorder as well, and both conditions can be treated together.

“What if I’m scared treatment will make me ‘lose my gains’?” This fear is very common and very understandable. Treatment is not about taking away the gym or your strength. It is about changing the relationship between training and the rest of your life — so that you can train because you choose to, not because missing a day feels like a crisis. Many people find that as the compulsion eases, training actually gets more sustainable, not less.

“How do I help a son, brother, partner, or friend without making it worse?” Do not comment on their body, food, training, or appearance — even with compliments. Express concern about their wellbeing, not their behavior. Watch for substance use, depression, and self-harm. Encourage evaluation. Do not police. Take care of yourself.

“Can someone fully recover?” Yes. Many people achieve substantial, durable improvement with evidence-based treatment, and many no longer meet criteria for the disorder after treatment. Recovery is rarely linear, but it is real, and it is worth the work.

If you or someone you love is in crisis, help is available 24/7.

BDD-specialty care:

International OCD Foundation BDD Resources — free finder for BDD-specialty therapists, support groups, and treatment programs: bdd.iocdf.org

Eating disorder overlap:

National Alliance for Eating Disorders Helpline — 1-866-662-1235

24/7 crisis support:

988 Suicide & Crisis Lifeline — call or text 988

988 en Español — call 988, press 2

Veterans Crisis Line — call 988 and press 1, or text 838255

The Trevor Project (LGBTQ+ youth) — 1-866-488-7386, or text START to 678-678

Crisis Text Line — text HOME to 741741

California Peer-Run Warm Line — 1-855-845-7415

Inland Empire local resources:

San Bernardino County DBH ACCESS Line (24/7): 888-743-1478

San Bernardino County Mobile Crisis Response: call 800-398-0018 / text 909-420-0560

San Bernardino County SARC (substance use access, including AAS): 800-968-2636

Riverside University Health System (RUHS) CARES Line (24/7): 800-499-3008

Inland SoCal Crisis Helpline: 951-686-HELP (4357)

ARMC Adolescent Psychiatric ER (ages 13–17): 909-580-1000

Loma Linda University Children’s Hospital ER (under 13): 909-651-6233

For any life-threatening emergency, call 911 or go to your nearest emergency department.

Sources

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR). American Psychiatric Publishing; 2022.

dos Santos Filho CA, Tirico PP, Stefano SC, Touyz SW, Claudino AM. Systematic review of the diagnostic category muscle dysmorphia. Australian & New Zealand Journal of Psychiatry. 2016;50(4):322–333.

Tod D, Edwards C, Cranswick I. Muscle dysmorphia: current insights. Psychology Research and Behavior Management. 2016;9:179–188.

Ganson KT, Mitchison D, Rodgers RF, Murray SB, Testa A, Nagata JM. Prevalence and correlates of muscle dysmorphia in a sample of boys and men in Canada and the United States. Journal of Eating Disorders. 2025;13(1):47. doi:10.1186/s40337-025-01233-x. ↩
Mitchison D, Mond J, Griffiths S, Hay P, Nagata JM, Bussey K, Trompeter N, Lonergan A, Murray SB. Prevalence of muscle dysmorphia in adolescents: findings from the EveryBODY study. Psychological Medicine. 2022;52(14):3142–3149. doi:10.1017/S0033291720005206. ↩
Nagata JM, Hur JO, Murakami K, Ganson KT, He J, Murray SB, Lavender JM. Muscle dysmorphia in adolescents and young adults. The Lancet Child & Adolescent Health. 2025/2026. doi:10.1016/S2352-4642(25)00283-4. ↩
BigTokDetect: A Clinically-Informed Vision-Language Modeling Framework for Detecting Pro-Bigorexia Videos on TikTok. arXiv:2508.06515 (2025). ↩
Pope HG Jr, Kanayama G, Hudson JI. Risk factors for illicit anabolic-androgenic steroid use in male weightlifters: a cross-sectional cohort study. Biological Psychiatry. 2012;71(3):254–261. Kanayama G, Pope HG Jr, Hudson JI. Associations of anabolic-androgenic steroid use with other behavioral disorders: an analysis using directed acyclic graphs. Psychological Medicine. 2018;48(15):2601–2608. ↩
Iliakis P, Stamou E, Kasiakogias A, et al. Anabolic–Androgenic Steroids Induced Cardiomyopathy: A Narrative Review of the Literature. Biomedicines. 2025;13(9):2190. doi:10.3390/biomedicines13092190. Steroid-Induced Cardiomyopathy: Insights From a Systematic Literature Review and a Case Report. Clinical Case Reports. 2025. PMC11865342. ↩
Kanayama G, Hudson JI, DeLuca J, Isaacs S, Baggish A, Weiner R, Bhasin S, Pope HG Jr. Prolonged hypogonadism in males following withdrawal from anabolic-androgenic steroids: an under-recognized problem. Addiction. 2015;110(5):823–831. doi:10.1111/add.12850. ↩
Thiblin I, Runeson B, Rajs J. Anabolic androgenic steroids and suicide. Annals of Clinical Psychiatry. 1999;11(4):223–231. Kanayama G, Brower KJ, Wood RI, Hudson JI, Pope HG Jr. Treatment of anabolic-androgenic steroid dependence: emerging evidence and its implications. Drug and Alcohol Dependence. 2010;109(1–3):6–13. ↩
Phillips KA. Suicidality in body dysmorphic disorder. Primary Psychiatry. 2007;14(12):58–66. PMC2361388. ↩
Phillips KA, Menard W. Suicidality in body dysmorphic disorder: a prospective study. American Journal of Psychiatry. 2006;163(7):1280–1282. PMC1899233. ↩
Pope CG, Pope HG, Menard W, Fay C, Olivardia R, Phillips KA. Clinical features of muscle dysmorphia among males with body dysmorphic disorder. Body Image. 2005;2(4):395–400. International OCD Foundation. Diagnosing BDD. bdd.iocdf.org/professionals/diagnosis/. ↩
Zhao et al. Is cognitive behavioral therapy an efficacious treatment for psychological interventions in body dysmorphic disorders? A meta-analysis based on current evidence from randomized controlled trials. Journal of Affective Disorders. 2024;352:237–249. doi:10.1016/j.jad.2024.02.115. Wilhelm S, Phillips KA, Steketee G. Cognitive-Behavioral Therapy for Body Dysmorphic Disorder: A Treatment Manual. Guilford Press; 2013. ↩
Feusner J, Phillips KA. Medication Treatment for BDD: FAQ. International OCD Foundation. bdd.iocdf.org/expert-opinions/medication-faq/. Phillips KA. Treating body dysmorphic disorder with medication: evidence, misconceptions, and a suggested approach. Body Image. 2008;5(1):13–27. PMC2705931. ↩
California Senate Bill 855 (Wiener, 2020). California Department of Insurance. “Commissioner Lara expands mental health access with final landmark rulemaking to enforce California Mental Health Parity Act.” Press release 050-2025. ↩