Muscle Dysmorphia in Strength and Physique Athletes: Clinical Recognition and Psychiatric Comorbidity - a narrative review

Abstract

Background. Muscle dysmorphia (MD) is a specifier of body dysmorphic disorder characterised by persistent preoccupation with being insufficiently muscular or lean, coupled with compulsive training, rigid dietary control, and frequent use of appearance- and performance-enhancing drugs. Strength and physique athletes, particularly bodybuilders, are considered disproportionately at risk, yet the condition remains under-recognised and its nosological status is debated.

Aim. To synthesise, from a clinical perspective, the definition, prevalence, clinical presentation, psychiatric comorbidity, and diagnostic challenges of MD in strength and physique athletes, with attention to anabolic-androgenic steroid use and its medical consequences.

Materials and Methods. Narrative review of peer-reviewed studies, including systematic reviews, meta-analyses, cross-sectional and case-control studies, network analyses, qualitative studies, case reports, and clinical/epidemiological surveys addressing MD, related eating and body-image pathology, and steroid use in athletic and non-athletic populations.

Results. MD is consistently more prevalent among bodybuilders than other resistance-trained populations, with substantial comorbidity involving eating disorder symptoms, obsessive-compulsive traits, exercise addiction, depression, anxiety, and steroid dependence. Diagnostic criteria are inconsistently applied, screening tools lack validated cut-offs, and classification within body dysmorphic, eating, or addictive-disorder frameworks remains contested.

Conclusions. MD is a clinically significant, likely under-detected condition among strength and physique athletes, demanding improved clinician awareness, standardised assessment, and integrated psychiatric and medical management, particularly given its entanglement with anabolic-androgenic steroid use disorder.