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In this video, Harrison "Skip" Pope Jr., MD, MPH, of Harvard Medical School in Boston, and Katharine Phillips, MD, of NewYork-Presbyterian/Weill Cornell Medical Center in New York City, discuss symptoms, treatments, and social propagation of muscle dysmorphia, a type of body dysmorphic disorder focused around gaining more muscle.

The following is a transcript of their remarks:

Pope: My name is Dr. Harrison Pope, better known as Skip Pope. I'm a professor of psychiatry here at Harvard Medical School. It was in 1997 that Kathy Phillips and I, and a couple of other co-authors, actually wrote a paper noting that there were many men who had so-called "muscle dysmorphia" -- a term that we actually coined in that paper -- and who had a preoccupation that they were just never big enough or muscular enough.

Phillips: And I'm Dr. Katharine Phillips. I'm a professor of psychiatry at New York Presbyterian and Weill Cornell Medicine in NYC, and I have been studying body dysmorphic disorder (BDD), like Skip, for about the past 30 years -- muscle dysmorphia being one form of BDD. We also co-authored a book, , about body image concerns in boys and men, including muscle dysmorphia.

Muscle dysmorphia, sometimes called "bigorexia," is a preoccupation with the belief that one's body isn't large or muscular enough, so it's usually men and boys who have these beliefs that they look too puny or too small, when in reality they look normal or even in some cases very muscular. In addition, these concerns with body size and muscularity involve excessive preoccupation, worrying about this, and these concerns cause clinically significant distress or impairment in day-to-day functioning.

Typically, you know, people with muscle dysmorphia and other forms of body dysmorphic disorder are depressed. Many have thoughts about suicide even; body dysmorphic disorders is associated with a very high rate of suicidal thoughts and suicidal behavior, and probably actual suicide.

And then there can be, you know, impairment in terms of day-to-day functioning. People may have difficulties with relationships or with jobs because they're so obsessed with how they look and are often spending a lot of time checking mirrors and comparing themselves with others and doing other repetitive behaviors. They're often just very ashamed of how they look, even though they look normal, and they may avoid being around other people and social activities.

Pope: Yeah, for example, a common type of complaint that I hear from guys who have muscle dysmorphia said: "Well, I got a bad shot of myself in the mirror, and so I canceled my date to go out that evening." Or they declined an invitation to go out to dinner because the particular restaurant where everybody was getting together for dinner did not offer sufficient high-protein, low-fat dishes to satisfy their needs. Or they would get into trouble with their boss because they had to get up and mix a protein shake for themselves in the local kitchen exactly every 2 hours, and all manner of ritualistic behaviors of this nature can obviously seriously undermine both your social life and your occupational functioning.

Muscle dysmorphia not only causes psychiatric problems -- impairment of social and occupational functioning and distress -- but it also can lead to medical problems. Perhaps number one on that list is using anabolic steroids. Many boys and men who develop muscle dysmorphia become preoccupied that they're not big enough. And then they discover that with anabolic steroids, they can gain huge amounts of muscle. As a result, they'll start taking steroids and will often develop a dependence syndrome on steroids where they continue to take them year in and year out with almost no breaks.

And then in addition to that problem, there is also the fact that they may train even though they have an injury; they're afraid to stop lifting weights at the gym even when they should be doing so because they can't tolerate the possibility that they might lose an ounce of muscle mass if they fail to work out.

Steroids also have long-term medical dangers, especially on the heart, which is not surprising if you think about it, steroids act on muscles and the heart is a muscle. It is, in fact, the strongest muscle in the body, and it's the only muscle that never rests. In long-term steroid users, we've shown in our studies that there is an increase of so-called cardiomyopathy, when the heart starts to pump inefficiently, and also an increase in hardening of the arteries -- atherosclerotic disease -- so that these guys are at greater risk for having a heart attack and sometimes will have heart attacks or strokes even in their 30s or 40s as a result of these effects of steroids. So there are a lot of health threats for individuals with muscle dysmorphia who can't gain control of their symptoms.

Neither Kathy nor I have talked about the issue of the prevalence of muscle dysmorphia. And that's a tough question. And the reason is that people with muscle dysmorphia don't just come forward to be counted, and so a lot of it is somewhat speculative as to how many silent cases there are out there, that pass under the radar and never actually end up in a clinic or in the hands of a doctor.

I think both of us suspect that the number is much greater than the number who are actually visible, because both with muscle dysmorphia and other forms of BDD, people are characteristically very reluctant to disclose their preoccupations and will do their best to hide them, or will sometimes even deny that they have a problem at all and say that: "This is normal, that one should want to be big and muscular. What's wrong with me? I have no problem with that."

Phillips: Many of the patients I see with BDD and the muscle dysmorphia form are brought by somebody else, a family member often, who recognizes that they have this problem. Many people with BDD and muscle dysmorphia are very depressed so sometimes they come for the treatment of depression.

I think, you know, there are some clues as to whether someone may have muscle dysmorphia. One is that if they are using anabolic steroids, which many do, their upper body is going to be disproportionately muscular. Their shoulders and neck area and upper body is going to be more muscular than is typically attainable by most men.

There may also be social avoidance; discomfort being around others. Skip mentioned a patient who canceled plans at the last minute to go out because he "got a bad look at himself in the mirror."

Some men with muscle dysmorphia try to hide their body, and this is true with people with BDD more generally, they hide what they don't like. So they may be wearing multiple layers of clothes, big baggy sweatshirts. Now, not everyone who wears those clothes has BDD, but that's a possible clue.

I remember, Skip, 20 or 30 years ago when we were seeing some of the first people with BDD and muscle dysmorphia, I remember seeing a young man who I noticed had six T-shirts on. I could see at the top the layers of different T-shirts. That was a clue, right? I asked him, I said, "You know, it looks like you're wearing a lot of T-shirts," and it turned out he was trying to make himself look bigger. So sometimes they're trying to hide with clothes, sometimes they're trying to look bigger.

Frequent eating -- a patient of mine referred to it as "force-feeding" -- these frequent high-protein, low-fat meals and excessive use of dietary supplements -- like protein supplements in creatine to try to build muscle and shed fat -- excessive working out.

I've seen patients who so severely damaged their bodies -- probably permanently -- from really very excessive working out, not only in the gym, but at their own home, sometimes even lifting furniture and lifting big stacks of dishes at work because they feel so badly about how they look. And they have very strong urges to try to build up their bodies, so they'll kind of lift – some of them will lift anything in sight. So these are some of the clues that a person might have muscle dysmorphia.

Pope: Kathy, to my knowledge, there have still not been any formal studies of muscle dysmorphia per se from a treatment perspective...virtually everything that we can say about treatment is just from what we know about treatment of other forms of BDD.

Phillips: Right.

Pope: And those comprise certain medications, the so-called selective serotonin reuptake inhibitors (SSRIs), drugs in the Prozac family, and a couple of related families. And then so-called cognitive behavioral therapy (CBT), which is a verbal type of therapy directed specifically at the misperceptions that Kathy has just talked about that are characteristic of this problem.

Phillips: The CBT helps people cut back on all the repetitive, excessive behaviors, like mirror checking and excessive weight lifting, and helps people feel more comfortable going out into social situations that they might have been avoiding. These are both excellent treatments. I just want to mention that medications like Prozac and Zoloft and Lexapro are usually very well tolerated and not habit-forming; there are a lot of myths out there online about these medications, but they usually help, and you often need higher doses than you would typically use for other other conditions like depression or anxiety. So CBT and the serotonin reuptake inhibitors are usually helpful, and can even be life-saving.

Pope: This is a cognitive distortion that is common in Western, industrialized countries and is fueled, I think, by corporate advertising that we all see every day. We see all of these muscular bodies in advertisements and TV, dramas, cartoons, and magazines. Partly because there's money to be made in making men feel insecure about their bodies and to get them to purchase equipment and supplements and all manner of other things, much in the same way that the corporate world has preyed upon the insecurities of women for the last century or two.

One of the trends that I think has just been an index of this societal preoccupation with male muscularity has been the evolution of action toys, the little figures that little boys play with. And the most famous action toy is probably , who's been around for 50 years. And in the early eighties, they came out with the miniature G.I. Joes.

This is the 1982 "G.I. Joe Grunt," which as you can see, is a perfectly ordinary looking soldier. [This is] his 1997 counterpart, who as you can see has gotten quite a bit more muscular than his 1982 predecessor. In fact, his biceps are practically as big as his waist.

And we can see the same trend in other characters. Here, for example, is Han Solo from the original release of "Star Wars". So this is from back around 1980, but then when "Star Wars" was re-released in the mid-90s, we see that Han has gotten considerably more muscular. Looks like he's been given a few courses of anabolic steroids.

So these changes, I think, are a testimonial to this increased preoccupation with male muscularity that has helped to breed an increase in cases of muscle dysmorphia.

Phillips: Yeah, it may have contributed to the rise of this form of BDD, combined with the media images, and now the social media platforms. We're not saying this is the only cause, because BDD is about 40% to 50% heritable, so, [it is] genetically determined, although we don't know the specific genes. But these kinds of influences that we've been talking about, the social influences, the G.I. Joes, may have contributed to this kind of relatively new form of BDD, muscle dysmorphia. We didn't see muscle dysmorphia. I mean, it wasn't described a hundred years ago when other forms of BDD were described, so we think this is a relatively new version of BDD.

Pope: This is not something that is likely to go away anytime soon. People say, "Well, what should society do?" or, you know, "What can be done on a cultural basis to prevent this problem?" And the answer is: not much. There is no obvious way that you're going to turn the tide, unless there's an entire groundswell of opposition. It seems likely that we're gonna be with this for a long time to come.

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