Muscle dysmorphia in adolescents and young adults

Summary

Body image concerns among adolescent boys and young men are increasingly recognised as societal ideals shift towards a lean, muscular physique. In severe cases, these pressures can lead to muscle dysmorphia, a specifier of body dysmorphic disorder marked by preoccupation with being too small or insufficiently muscular. Adolescents and young adults are developmentally vulnerable and might be at higher risk for a variety of eating-related and body image-related concerns, including muscle dysmorphia. This narrative Review synthesises current evidence on the epidemiology, assessment, and treatment of muscle dysmorphia in adolescents and young adults to guide clinicians. Although some treatment approaches show promise, outcome data in large, diverse, clinical adolescent samples remain scarce. Muscle dysmorphia-specific preventive strategies are few, although eating disorder prevention programmes show potential for reducing muscle dysmorphia symptoms. Future research should investigate pharmacotherapy and prevention programmes, validate assessment tools across populations, and examine cultural influences internationally. Advancing understanding of muscle dysmorphia will better equip clinicians to identify and address symptoms in adolescents and young adults.

Introduction

Once assumed to predominantly affect females, the pervasiveness of body dissatisfaction among adolescent (ages 10–18 years) and young adult (ages 19–25 years) males is now more widely recognised as one consequence of increasingly muscular and lean male body ideals. Young males are bombarded with media representations of highly idealised male bodies, from action figures to social media fitness influencers, shaping unrealistic standards of physicality from as young as age 6 years.1, 2 In severe cases, muscularity-oriented concerns and symptoms can reach severity levels consistent with muscle dysmorphia, a specifier of body dysmorphic disorder defined by a pathological preoccupation with being insufficiently muscular.³ 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 boys⁴ and muscle-building behaviours (eg, anabolic steroid use, energy and workout supplement use, and compulsive weightlifting) have become more common in adolescence.⁵ Despite having substantial psychosocial, medical, and functional consequences, muscle dysmorphia symptoms often go unrecognised due to little clinical awareness and the paucity of validated assessment tools, particularly for younger populations.

Adolescence and young adulthood are crucial times during which body dissatisfaction, pathological exercise patterns, and disordered eating commonly develop or are exacerbated, thus highlighting these developmental periods as essential targets for identification and early intervention to prevent long-term morbidity.⁶ Yet, there remain unresolved questions around the classification of muscle dysmorphia (eg, whether it is best understood as a form of body dysmorphic disorder or an eating disorder), underscoring the need for diagnostic clarity. With preparations already underway for future diagnostic frameworks, such as the Diagnostic and Statistical Manual of Mental Disorders (DSM)-6, now is a crucial moment to consolidate evidence on muscle dysmorphia in adolescents and young adults. Identifying gaps in the literature will provide a foundation for future research that will improve our understanding of how muscle dysmorphia should be classified, guiding treatment development and informing public health strategies aimed at reducing its burden. Moreover, consolidating the existing knowledge base to clarify what is known and debated regarding muscle dysmorphia terminology, assessment, and interventions will better equip clinicians to recognise symptoms, including in adolescent and young adult males who could be particularly at risk.

Key messages

• Although muscle dysmorphia is currently classified as a specifier under body dysmorphic disorder, there is debate over whether its classification as an eating disorder would improve diagnostic clarity to inform better assessment and treatment in adolescents

• Muscle dysmorphia in adolescents and young adults likely arises from complex interactions between genetic, physiological, psychological, and socioenvironmental risk factors

• Disordered eating, excessive exercise, anabolic-androgenic steroid use, and mood and anxiety disorders commonly co-occur with muscle dysmorphia, resulting in possible treatment complications

• The Muscle Dysmorphic Disorder Inventory (MDDI), Drive for Muscularity Scale, Muscularity Oriented Eating Test, and Male Body Attitudes Scale are commonly used as assessment tools in adolescents and young adults, with a score of at least 40 on the MDDI indicating clinically significant muscle dysmorphia symptoms

• Cognitive behavioural therapy is the primary treatment modality; however, evidence also supports family-based treatment and cognitive dissonance-based interventions

• Muscle dysmorphia prevention programmes adapted from school-based eating disorder programmes and dissonance-based and cognitive behavioural therapy prevention programmes have also shown a reduction in muscle dysmorphia symptomology in adolescents and young adults

• Future research should investigate refined or reimagined diagnostic criteria that will help inform the research and development of developmentally appropriate assessment tools, treatments, and prevention programmes for adolescents and young adults diagnosed with and at-risk of muscle dysmorphia

Definition and debate over classification

A brief history of muscle dysmorphia and related terminology is shown in the panel. Despite the status of muscle dysmorphia as a specifier for body dysmorphic disorder within the current DSM, 5th edn, text revision (DSM-5-TR) framework (and within the ICD-11 framework¹¹), debate persists about whether muscle dysmorphia might be more accurately classified as an eating disorder. Body dysmorphic disorder is centrally characterised by preoccupation with a perceived appearance defect, most commonly skin or hair concerns, that is inconsistent with or slighter than objective observation and results in functional impairment.¹² However, individuals with muscle dysmorphia report substantially higher muscularity-oriented behaviours, poorer quality of life, greater psychosocial impairment, higher likelihood of substance use, and greater suicidality than those with body dysmorphic disorder.^{13, 14, 15} Moreover, muscle dysmorphia predominantly affects males, which is not the case for body dysmorphic disorder or other obsessive-compulsive spectrum disorders.¹⁴

Panel: History of muscle dysmorphia

Diagnostic criteria from the Diagnostic and Statistical Manual of Mental Disorders, 5th edn, text revision (DSM-5-TR) and clinical manifestations are shown in figure 1.

Figure 1.

DSM-5-TR criteria for body dysmorphic disorder and anorexia nervosa and potential criteria for muscle dysmorphia

1993: Pope and colleagues⁷ identify a group of male bodybuilders (aged 19–41 years) who, despite having large and muscular physiques, were preoccupied with the belief that they were insufficiently muscular and engaged in dysfunctional behaviours, such as excessive weightlifting, adherence to rigid protein-focused diets, and anabolic-androgenic steroid use.⁸ Their condition was initially termed reverse anorexia nervosa due to its cognitive and behavioural parallels with anorexia nervosa, albeit with an inverse focus on muscularity rather than thinness.

1997: Pope and colleagues⁹ redefine this condition as muscle dysmorphia, conceptualising it as a variant of body dysmorphic disorder rather than as an eating disorder, reasoning that eating pathology was secondary to body image disturbance.

2000: The Adonis Complex¹⁰ is published by Pope, Phillips, and Olivardia and outlines male body image concerns, describes muscle dysmorphia’s presentation and diagnostic criteria, and gives treatment recommendations.

2013: Muscle dysmorphia is included in DSM-5 as a body dysmorphic disorder specifier within the obsessive-compulsive and related disorders category.

Some researchers have posited that muscle dysmorphia could instead be a more male-oriented manifestation of anorexia nervosa, meriting its reclassification as an eating disorder.¹⁴ Individuals with muscle dysmorphia report high levels of eating disturbance and body weight or shape-control behaviours, often in the form of compensatory exercise following deviation from dietary regimens.¹⁴ Similarities between male anorexia nervosa and muscle dysmorphia clinical profiles, such as symptom presentation, age of onset, psychological traits, and treatment responses, have been empirically supported.^{13, 14} Moreover, clinical observations suggest that specific adolescent males with thinness-oriented eating disorders (ie, anorexia nervosa) might be at risk for transitioning to more muscularity-oriented symptoms, indicating potentially similar underlying risk and maintenance factors.¹⁶ Given that eating disorder diagnostic criteria were developed largely based on experiences and presentations most common among females, more research into male eating and body image concerns is needed to better understand muscle dysmorphia in relation to eating disorders and body dysmorphic disorder.¹⁴

The debate over muscle dysmorphia classification highlights broader concerns about the subjectivity and limitations of current diagnostic criteria.¹³ Accurate categorisation, especially in adolescents and young adults, is essential to shape treatment approaches and research priorities, reduce barriers to care, and avoid both the under-recognition of male body image disturbances and the overpathologising of normative behaviours.^{13, 14} As research continues, a refined nosological framework will be crucial to improve understanding of and care for this complex disorder.

Epidemiology

Evidence suggests that muscle dysmorphia often emerges during mid-to-late adolescence, with a mean age of onset around 18–20 years.^{13, 14} This timing reflects developmental transitions, such as puberty, increased body awareness, and shifting social identities that can lead to body dissatisfaction and muscularity concerns.^{17, 18} Compared with eating disorders, which often peak earlier in adolescence (approximate age 12–15 years),¹⁹ muscle dysmorphia symptoms can intensify in early adulthood as individuals gain greater autonomy and easier access to resources, such as gym memberships and appearance and performance-enhancing drugs (APEDs).²⁰

Given the paucity of muscle dysmorphia epidemiological research and the variability of diagnostic criteria and assessment tools, reported rates vary widely across studies and prevalence in adolescents and young adults remains unclear. 14, 21 Much of the early literature was based on samples of male weightlifters and bodybuilders, for whom prevalence is likely higher, restricting generalisability to broader populations.²² However, some research has also examined muscle dysmorphia symptomatology in larger community-based and population-based samples of adolescents and young adults. For example, based on criteria outlined by Pope and colleagues,⁹ muscle dysmorphia prevalence was 1·8% in a sample of 3618 Australian adolescents,²⁰ whereas 17·2% of a community sample of 2256 Canadian adolescents and young adults²³ were at clinical risk of muscle dysmorphia based on the Muscle Dysmorphic Disorder Inventory (MDDI).¹⁷ In a sample of 472 Argentine college students, approximately 7% met criteria for muscle dysmorphia and 42·4% were defined as at risk using the Drive for Muscularity Scale.²¹ Yet another study of 2000 Australian adolescents found that 44·1% of males reported concerns indicative of muscle dysmorphia.²⁴ Despite exact rates varying, substantial proportions of adolescents and young adults report muscularity-oriented concerns.

In industrialised nations, adolescent males report higher muscle dysmorphia symptom severity and functional impairment than adolescent females, including anabolic-androgenic steroids (AAS) use and preoccupation with muscularity,²⁰ but muscle dysmorphia is not exclusive to males.^{14, 17} Although the prevalence of clinical muscle dysmorphia tends to be marginally higher in males than females, a study published in 2022 did not find this difference to be statistically significant.²⁰ This finding could reflect changes in female body ideals, which have also shifted towards increased tone and muscularity.^{20, 25}

Differences in body ideals shaped by culture, race, and ethnicity might further affect the manifestation and prevalence of muscle dysmorphia in adolescents and young adults.²² For example, in some countries in sub-Saharan Africa, larger body size is viewed as a symbol of wealth and beauty, leading adolescents to endorse greater drive for muscularity, but not leanness.²² In lower-income and middle-income countries, poverty might decrease the drive for leanness while increasing the drive for muscularity as a symbol of masculinity and social capital.²² However, increasing exposure to media and body ideals could lead to increased muscle dysmorphia symptomatology in these regions.²² Ultimately, the current paucity of data underscores the need for large-scale epidemiological studies that account for gender, sexuality, race, and culture to better understand the global burden and expression of muscle dysmorphia.

Risk factors

It is likely that muscle dysmorphia symptomatology in adolescents and young adults arises from a complex interplay of genetic, physiological, psychological, and socioenvironmental factors (figure 2).²⁶

Figure 2.

Overview of risk factors implicated in the development of muscle dysmorphia in adolescents and young adults

Genetic and physiological risk factors

Although scarce, emerging evidence suggests a genetic component to muscle dysmorphia. Twin studies have found potential familial transmission between muscle dysmorphia and anorexia nervosa in male populations, indicating shared causal pathways.¹³ Muscle dissatisfaction and use of muscle-enhancing substances also appear to be influenced by both genetic and unique individual-level factors (ie, personal choices and individual exposures).¹³ Body size, as measured in previous research using BMI, might also play a role. Lower BMI is associated with higher scores on drive for size and functional impairment components of muscle dysmorphia, whereas higher BMI is linked with greater appearance intolerance and weight dissatisfaction.¹⁷

Psychological risk factors

Several cognitive and affective factors might be implicated in muscle dysmorphia, including distorted self-perception regarding inadequate muscularity²⁷ even among individuals at or above their ideal body weight, with 23% of men with normal weight (estimated using the Metropolitan Life Insurance desirable weight ranges) believing they are underweight.²⁶ Drive for muscularity, which can evolve from non-pathological appearance interests to maladaptive behaviours, is also considered a risk factor for muscle dysmorphia.²² Several more general psychological risk factors have been proposed that are particularly salient to adolescents and young adults given the socioemotional changes that characterise these developmental periods. For example, negative affect, including symptoms of anxiety and depression (which commonly onset during adolescence or young adulthood), is consistently associated with muscle dysmorphia symptomatology and is potentially related to increased body dissatisfaction or impairment associated with symptoms.^{1, 28} Similarly, low self-esteem might underlie muscle dysmorphia’s behavioural symptoms.^{1, 29} Self-esteem also appears to both mediate and exacerbate vulnerability to sociocultural appearance ideals.¹

Personality and temperament traits, such as neuroticism and perfectionism, have also been identified as potential risk factors that, especially when combined with physiological or socioenvironmental factors, could increase risk of muscle dysmorphia.^{28, 29} Socially prescribed perfectionism, defined by the belief that others expect one to pursue and embody unrealistic ideals, has been shown to mediate the associations of media, peers, and teasing with muscle dysmorphia symptoms.^{29, 30}

Socioenvironmental and interpersonal risk factors

Gender role stress and traditional masculinity norms³¹ might contribute to muscle dysmorphia risk in adolescents and young adults. In particular, identification with male societal expectations emphasising muscularity, strength, and dominance could lead to stress that contributes to pathological body control behaviours.²⁵ The shift towards hypermuscular male imagery in media over the past 30 years has contributed to the widespread internalisation of unattainable body ideals.^{1, 22} Adolescents and young adults are particularly vulnerable to media influences due to identity formation and heightened peer comparison during this developmental stage.³² Media exposure in adolescent males has been strongly associated with drive for muscularity.²² Of particular relevance to adolescents and young adults, social media use has specifically been associated with muscularity-oriented body concerns and behaviours;³³ this could be due to increased exposure to unrealistic and often filtered body ideals on image-based platforms, which is further exacerbated by algorithms that can continuously feed users muscle-related content.^{34, 35} Content related to muscular bodies, muscle-building dietary supplements, and APEDs is particularly associated with probable muscle dysmorphia, even when controlling for overall time spent on social media.³⁵ Boys and young men have also reported using social media to learn about diets, weight training routines, and supplements, potentially implicating it as an aggravating factor in the development of muscle dysmorphia.³³

Interpersonal relationship patterns might also confer risk for muscle dysmorphia. For example, having an insecure avoidant attachment style has been linked with higher muscle dysmorphia symptom scores in a sample of Italian male bodybuilders.³⁶ Childhood trauma, such as bullying victimisation, might also increase risk of muscle dysmorphia in adolescents and young adults.³⁷ Among females, trauma—such as sexual violence—has been linked with compulsive weightlifting and muscularity-focused behaviours.^{22, 38, 39} The pursuit of increased muscularity and strength might function as a means of coping with feelings of insecurity or fear, potentially driving pathological behaviour and muscle dysmorphia symptoms.⁴⁰

Socioeconomic and structural factors can also contribute to the development of muscle dysmorphia. For example, food insecurity has been associated with muscle dysmorphia symptomatology in adolescents and young adults, with one study finding that nearly 20% of food-insecure participants scored above the clinical threshold for muscle dysmorphia.⁴¹ Individuals with restricted access to nutrient-rich foods might become dissatisfied with their ability to achieve a muscular physique, fuelling compensatory behaviours and increasing muscle dysmorphia risk.⁴¹

Understanding muscle dysmorphia’s multifactorial risk landscape is essential for early identification and prevention, particularly in vulnerable adolescent and young adult populations. Screening could incorporate questions about social media use, trauma history, body dissatisfaction, and appearance-related distress in female and male patients to facilitate timely intervention.

Subpopulations

Transgender boys and men

In the past 5 years, research has highlighted differences in muscle dysmorphia symptomatology among gender minorities. Although transgender boys, cisgender boys, and cisgender men report similar drives for size, transgender men exhibit greater appearance-related anxiety and engage more frequently in avoidance behaviours.⁴² Additionally, compared with gender-expansive individuals and transgender women, transgender men report greater overall muscle dysmorphia symptoms and a higher drive for size associated with functional impairment.⁴³ For gender minority populations, passing in society as one’s gender identity could increase the desire to be more muscular.¹⁷ Lifetime use of APEDs is also notably prevalent across gender minority groups (45·2% of transgender men, 30·7% of gender-expansive individuals, and 14·9% of transgender women) and is associated with elevated symptoms of both eating disorders and muscle dysmorphia.⁴⁴ Importantly, gender minority populations are highly diverse and not all individuals strive to achieve a traditionally binary body ideal.⁴⁵

Sexual minorities

Muscle dysmorphia appears to disproportionately affect sexual minority populations. For example, an Italian study reported an 8·8% prevalence in men who have sex with men, who also showed a greater risk at younger ages (18–34 years) than older ages (≥35 years).⁴⁶ Additionally, research has shown that lesbian and bisexual women have greater muscle dysmorphia symptom severity and associated distress compared with heterosexual women.⁴⁷ Similar results have been reported among Canadian gay and lesbian adolescents and young adults.¹⁷ Discrimination based on sexual and gender identity can heighten stress and reinforce pressure to conform to specific body ideals.¹⁷ Furthermore, misuse of APEDs was notable among cisgender sexual minorities, with 30·6% reporting lifetime use.⁴⁸

Racial and ethnic minorities

Emerging research highlights important cultural and ethnic differences in muscle dysmorphia symptomatology and related behaviours. For example, among men at US universities, higher levels of muscle dysmorphia pathology were found among Asian and Hispanic or Latino participants versus European and African American participants, with the strongest association between drive for muscularity and body checking observed in Asian participants.⁴⁹ Hispanic or Latino sexual minorities also exhibit high rates of body dysmorphic disorder, APED misuse, and drive for muscularity.⁴⁸ Similarly, a Canadian study found that adolescents and young adults identifying as south Asian or Middle Eastern reported greater muscle dysmorphia symptomatology than their White peers, potentially due to acculturation stress from adapting to different cultural body ideals promoting exacerbated symptoms.¹⁷ Notably, cultural norms and contextual factors, such as food insecurity, can shape body ideals differently across settings. For instance, a study in Burkina Faso found that only 8·7% of individuals who desired increased muscularity also wanted lower body fat, contrasting with the stereotypically Western male body ideal of lean muscularity.²²

Athletes

Adolescents and young adults involved in athletics could have elevated risk of muscle dysmorphia symptoms. In particular, sports that accentuate or reward physique, weight, or strength—such as bodybuilding, wrestling, powerlifting, or American football—might confer greater risk through their associations with increased rates of body dissatisfaction, AAS use, and disordered eating patterns.^{2, 50, 51} In a sample of Italians aged 16–19 years, greater engagement in sports and physical activity was associated with greater muscle dysmorphia symptom-related functional impairment.⁵² Moreover, athletes often share psychological traits that can exacerbate muscle dysmorphia risk, including perfectionism, competitiveness, and control, which are further compounded by sport-specific pressures to meet performance or aesthetic ideals.² Sports can also reinforce the maintenance of body ideals because performance tends to improve with increased muscularity.² Finally, muscle dysmorphia and related eating disorder symptoms can vary by sport or training goals. For example, endurance athletes might exhibit an increased drive for leanness, whereas those participating in weight-based sports might engage in compensatory behaviours to remain in their weight class.⁵³ Muscle dysmorphia symptoms are particularly prevalent in competitive bodybuilders, with studies reporting rates as high as 53·6% and symptom severity increasing with the level of competition.^{29, 54} Crucially, these behaviours can go unrecognised in adolescent and young adult athletes due to norms that value discipline and appearance, thereby delaying diagnosis and care. Clinicians should consider sport participation and training motives as key components of muscle dysmorphia risk assessment.

Assessment

There are several questionnaires that assess muscularity-oriented attitudes and behaviours (table 1). It could also be useful to assess eating disorder symptoms in parallel when evaluating for muscle dysmorphia, because disordered eating behaviours commonly co-occur and can inform treatment planning.^{55, 56, 57, 58, 59, 60}

Table 1.

Summary of available questionnaires assessing muscularity-oriented attitudes and behaviours

	Description	Rating scale	Validated populations	Clinical interpretation
Muscle Dysmorphic Disorder Inventory	13-item self-report assessing diagnostic criteria for muscle dysmorphia, such as drive for size, appearance intolerance, and functional impairment	5-point Likert-type scale (1=never to 5=always)	Studies in adults aged 18–30 years conducted in non-clinical Lebanese, Chinese, and Spanish male university students, and in French male and female university athletes1, 2, 3, 4	Score of at least 40 indicates clinically significant muscle dysmorphia symptoms
Drive for Muscularity Scale	15-item self-report assessing muscularity-related attitudes, behaviours, and dissatisfaction	6-point Likert-type scale (0=never to 5=always)	Studies in adults aged 17–35 years conducted in non-clinical French male athletes and Chinese and Argentinian male university students;3, 5, 6 a study conducted in non-clinical Spanish adolescent males (aged 12–17 years)11	Elevated scores suggest a higher severity of muscle dysmorphia
Muscularity Oriented Eating Test	15-item self-report measure assessing eating behaviours and attitudes aimed at increasing muscularity	5-point Likert-type scale (1=never to 5=always)	Studies in adults aged 17–30 years conducted in non-clinical American, Turkish, and Argentinian male university students12, 13, 14	Elevated scores suggest a higher severity of muscle dysmorphia
Male Body Attitudes Scale	24-item self-report specifically developed to assess male body image, with subscales assessing dissatisfaction with body fat, muscularity, and height	6-point Likert-type scale (0=never to 5=always)	Studies in adults aged 17–30 years conducted in non-clinical American and Argentinian male university students6, 15	Elevated scores, particularly on the muscularity subscale, were associated with higher scores on the Muscle Dysmorphic Disorder Inventory, suggesting higher severity of muscle dysmorphia

Most measures do not have established clinical cutoff scores and might only have norms drawn from specific populations, which are typically cisgender, heterosexual, White adult males. Validation studies have not consistently included adolescents or diverse groups, such as racial, ethnic, sexual, and gender minorities. As a result, their reliability and validity in younger and more diverse clinical populations remain unclear and caution is advised when using these questionnaires outside of their original research contexts. Of the muscle dysmorphia screening questionnaires, the MDDI has received the most extensive psychometric validation across several populations.^{61, 62, 63, 64} Further challenges include stigma and hesitancy to seek psychological evaluation or care. Findings from the past year have shown that individuals with possible muscle dysmorphia report significantly higher self-stigma around seeking help and are less likely to be engaged in mental health treatment compared with individuals without possible muscle dysmorphia.⁶⁵ Taken together, screening those with known risk factors or those within vulnerable populations could be a pragmatic approach to early identification of at-risk adolescents and young adults.

Comorbidities and complications

Disordered eating

Because muscle dysmorphia is characterised by a drive for increased muscularity and size, changes (often maladaptive or unhealthy) to eating patterns and food intake are common. In particular, greater muscle dysmorphia symptom severity is associated with higher eating disorder symptomatology.⁵⁵ For example, in a study of Italian undergraduate students, those with muscle dysmorphia had a prevalence of eating disorder risk 10 times higher than those without (odds ratio 10·23; p≤0·001).⁵⁶ Moreover, in Turkish male bodybuilders, overall eating disorder symptoms were positively associated with total muscle dysmorphia symptoms, fat dissatisfaction, and muscle dissatisfaction.⁵⁷ Another study found that muscle dysmorphia symptomatology was positively associated with binge eating behaviour in German adult men and women.⁵⁸ Moreover, consuming so-called cheat meals, a behaviour characterised by intentionally straying temporarily from more restrictive eating habits to consume a large quantity of food, was associated with greater eating disorder psychopathology (particularly binge eating) in Canadian adolescents and young adults.⁵⁹ Similarly, engaging in bulking and cutting—an intentional oscillation between periods of caloric surplus to increase muscle mass and caloric deficit to reduce body fat—was associated with eating disorder psychopathology, drive for muscularity, and muscle dysmorphia symptomatology.⁶⁶ Importantly, among men at risk for muscle dysmorphia, the probability of engaging in binge eating behaviours was 25%,⁵⁸ suggesting that binge eating could even be a behavioural marker of muscle dysmorphia symptomatology. ^{58, 60} Given the potentially severe psychosocial and medical consequences (eg, cardiovascular, endocrine, neurological, and gastrointestinal) associated with eating pathology, these findings underscore the importance of evaluating for disordered eating symptoms when muscle dysmorphia symptoms are present or suspected. Notably, as adolescence and young adulthood are crucial developmental periods during which both muscle dysmorphia and eating disorder symptoms often emerge or escalate, early recognition and intervention in this age group are particularly important to prevent progression to entrenched pathology and long-term health consequences.

Excessive exercise

In 2019, nearly one in five US adolescent boys in high school reported daily muscle-building exercise, which exceeds the recommended 2–3 days per week for physical health.⁶⁷ Among young adults with muscle dysmorphia, high resistance training volume is common: in China in 2018, 27·6% of students trained more than six days a week and 56·3% of students trained for more than 1 h per session;⁶⁸ in Peru in 2015, 52·5% of students with the highest levels of muscle dysmorphia symptoms exercised more than 5 h a week.⁶⁹ This pattern of excessive exercise is not without consequence. In a study of Australian adolescent boys with muscle dysmorphia, 43·2% reported that their weightlifting regimen interfered with daily life and 60·5% had substantial psychosocial impairments.²⁰ More time spent weightlifting has also been independently associated with a higher risk of injury, including musculoskeletal strains and overuse injuries.⁷⁰ Interestingly, exercise might also serve as short-term coping or emotion regulatory functions in muscle dysmorphia, as drive for size, appearance intolerance, and functional impairment were found to be significantly elevated on rest days versus training days.⁷¹ Such reinforcement could further promote a harmful cycle of compulsive training.

AAS use

AAS use for muscle building is a concern among adolescent boys and young adult men.⁷² For example, high co-occurrence between muscle dysmorphia and the use of ergogenic substances has been found in both Spanish (50%⁷³) and Colombian (60–90%⁷⁴) samples of young adults. Moreover, the lifetime use of AAS was 16·2% in Australian adolescent boys with an muscle dysmorphia diagnosis²⁰ and other research in a sample of US adolescents found that muscle dysmorphia and sports participation predicted muscle-enhancing substance use.⁵¹ This finding is particularly concerning as AAS use has been linked to a range of adverse effects, including cardiovascular and mental health disorders, AAS-withdrawal hypogonadism, neurotoxicity, musculoskeletal injuries, infertility, liver toxicity, and needle-borne infections.⁷⁵ Because adolescence is a key developmental window during which attitudes towards muscle building and decisions to initiate AAS use often solidify, 76, 77 early prevention and intervention efforts in this age group are essential to reduce the risk of AAS-related harms. Given the strong association between muscle dysmorphia and AAS use, alongside the increasing ease of obtaining AAS and related substances (eg, selective androgen receptor modulators) without a prescription and through unregulated online markets, muscle dysmorphia should be recognised as a significant risk factor for use of these substances, warranting attention to the potential adverse health consequences.

Other mental health concerns

Individuals with a history of muscle dysmorphia exhibit higher rates of mood and anxiety disorders than those without.⁷⁸ This finding could be a result of distress related to body appearance, including frequent preoccupation with muscularity, dissatisfaction with appearance, excessive appearance checking, dependence on bodybuilding, and functional impairment.⁷⁸ Moreover, muscle dysmorphia was associated with increased rates of suicidal ideation and suicide planning over a 12-month period among Canadian adolescents and young adults.⁷⁹ Research has also found that adolescent boys who engage in muscle-building exercise 6–7 days per week were more likely to participate in high-risk behaviours (ie, physical fighting, weapon and gun carrying, binge drinking, and concurrent use of cigarettes, e-cigarettes, and cannabis) than adolescent boys who do not engage in muscle-building exercise.⁸⁰ Such findings suggest that high involvement in muscle-building behaviours in adolescence and young adulthood, although socially accepted, might co-occur with other risky behaviours and potentially reflect broader sociocultural narratives linking muscularity to masculinity.^{80, 81, 82, 83, 84, 85, 86, 87, 88, 89}

Interventions

Although research on interventions in adolescence and young adulthood remains scarce, current approaches have largely adapted strategies from eating disorder treatment models. Cognitive behavioural therapy (CBT) is the primary modality because of its efficacy in treating body dysmorphic disorder,⁹⁰ despite insufficient muscle dysmorphia-specific protocols. Other interventions similarly draw from eating disorder frameworks instead of being developed specifically for muscle dysmorphia. For pharmacotherapy, selective serotonin reuptake inhibitors and serotonin reuptake inhibitors have shown utility in the treatment of body dysmorphic disorder generally, but muscle dysmorphia-specific studies are few.⁹¹

CBT

An Australian pilot study evaluated an 8-week telehealth CBT programme for adults (aged 18–49 years) diagnosed with muscle dysmorphia.⁹² The intervention adapted the CBT-enhanced framework (a transdiagnostic treatment approach for eating disorders) to target specific muscle dysmorphia maintenance factors, including promoting flexible eating patterns, reducing compulsive exercise, improving emotion regulation, broadening life values beyond appearance, addressing compulsive body checking and avoidance, and minimising body comparison and harmful social media use. Participants had significant reductions before and after treatment across all muscle dysmorphia and eating disorder outcome measures. Notably, these improvements were maintained at the 3-month follow-up, providing preliminary support for the programme’s sustained effects.⁹²

Family-based treatment

In a case study examining the efficacy of family-based therapy for muscle dysmorphia, a boy aged 15 years participated in a ten-session programme over 7 months.⁹³ Treatment focused on parental control of eating and exercise, reducing parental anxiety, and shifting family attention away from weight and appearance. The parents intervened to halt disordered eating habits, such as intake restrictions to high-protein and low-calorie foods, adding protein powder to meals, and feeling distress when unable to eat every few hours. The parents also imposed clear limits on excessive exercise routines (eg, daily cardiovascular workouts, extended weightlifting, and exercising while injured), with flexibility introduced only as the adolescent’s anxiety decreased. By discharge, the patient had ceased disordered behaviours, improved regulation of eating and exercise, and showed reduced preoccupation with muscularity.⁹³

Cognitive dissonance-based interventions

Cognitive dissonance-based interventions have also shown promise in reducing muscle dysmorphia symptoms among young adults with body dissatisfaction. In one study, a two-session programme called The Body Project: More than Muscles, targeted internalisation of the idealised muscular physique.⁹⁴ Session one involved examining the origins and societal reinforcement of this ideal and challenging it through group discussion and homework assignments (eg, mirror exposure, email writing, and behavioural challenges). Session two reinforced learning through review, role playing resistance strategies, and promoting body activism. Compared with control individuals placed on a waitlist, participants showed significant reductions in muscle dysmorphia symptomatology immediately after the intervention and at a 4-week follow-up.⁹⁴

Prevention

Although there is little on prevention programmes tailored specifically to muscle dysmorphia, insights can be drawn from the more established and extensively studied prevention efforts for eating disorders in adolescents and young adults (table 2). Such prevention programmes often address variables highly relevant to muscle dysmorphia, such as body image, body satisfaction, attitudes towards AAS use, body ideal internalisation, drive for muscularity, and media literacy, suggesting that they can offer valuable components or frameworks to adapt to muscle dysmorphia-focused prevention.

Table 2.

Examples of prevention programmes for eating disorders with potential use for muscle dysmorphia

	Reference	Country	Number of sessions	Age (SD*), years	N	Programme type	Results pertaining to muscle dysmorphia
Healthy Body Image: Teaching Kids to Eat and Love Their Bodies Too!	Kater et al (2000)95	USA	Ten	4th and 6th grade†	222	School-based	Improvements in responses regarding individual body development; attitudes about body size; factors influencing body size and shape; attitudes towards dieting and body image; and critical thinking regarding media images
Body Image Prevention Programme	Stanford and McCabe (2005)96	Australia	Two	12–13	121	School-based	Improvements in muscle satisfaction and self-esteem; no differences in overall body satisfaction, body image importance, use of AASs or supplements, excessive exercise, or eating pathology
Media Smart	Wilksch and Wade (2009)97	Australia	Eight	8th grade‡	540	School-based	Boys had greater reductions in dieting, body dissatisfaction, and weight or shape concerns after the programme and at a 6-month follow-up compared with boys not in the programme
Happy Being Me	Bird et al (2013)98	UK	Three	10–11	88	School-based	Improvements in ideal body internalisation and appearance comparison; no significant effect at 3-month follow-up
POPS Program	Warschburger and Zitzmann (2018)99	Germany	Nine	10–16	568	School-based	Greater improvements compared with control individuals in body dissatisfaction, perceived media pressures, obligatory exercise, social comparison, and perfectionism at 3-month follow-up
ATLAS	Goldberg et al (1996)100	USA	Seven	15	1506	School-based	Reduction in intent to use AAS, greater knowledge of AASs and their effects; more negative attitudes about AAS use, improved feelings of athletic abilities, higher self-esteem, more competent drug refusal skills, less belief in media messages, and improved nutrition and exercise behaviours through 9–12-month follow-ups; no change in body image
Body Project 4 All	Kilpela et al (2016)101	USA	Two, each 120 min	19·9 (1·2)	185	Dissonance-based	Improved body satisfaction after the programme and at the 2-month and 6-month follow-up; improved muscularity dissatisfaction after the programme and at 2-month follow-up, but not at 6-month follow-up
Body Project: More than Muscles	Brown et al (2017)94	USA	Two, each 120 min	20·4 (2·4)	93	Dissonance-based	Decrease in ideal body internalisation, dietary restraint, muscle dysmorphia symptoms, and drive for muscularity after the programme and at 1-month follow-up; improvements in muscularity dissatisfaction at follow-up
Body Project M	Jankowski et al (2017)102	UK	Two, each 90 min	20·8 (4·5)	108	Dissonance-based	Decrease in ideal body internalisation and muscularity dissatisfaction after the programme but not at 3-month follow-up
Pride Body Project	Brown and Keel (2015)103	USA	Two, each 120 min	21·5 (2·5)	87	Dissonance-based	Decreases in body dissatisfaction, drive for muscularity, and dietary restraint after the programme and at 1-month follow-up; ideal body internalisation was lower after the programme but not at follow-up

AAS=anabolic-androgenic steroids.

^*SD given if available.

^†In the USA, 4th grade typically includes children aged 9 and 10 years. 6th grade typically includes children aged 11 and 12 years.

^‡In Australia, 8th grade typically involves children aged 13 and 14 years.

School-based prevention programmes could be important in reducing body dissatisfaction and, by extension, the risk of muscle dysmorphia among adolescents.^{95, 96, 97, 98, 99, 100} These programmes can function as universal prevention programmes, efficiently reaching large groups through brief (two to ten sessions) formats and addressing multiple contributing factors simultaneously.^{95, 96, 97, 98, 99, 100} Programmes that integrate media literacy alongside education on the risks of AAS use could be particularly impactful and provide a comprehensive approach that targets sociocultural pressures, behavioural risk factors, and awareness of the medical and psychosocial complications associated with muscle dysmorphia.^{95, 96, 99, 100} Media literacy components addressing the pervasive use of filters, photograph editing apps, and artificial intelligence-generated idealised body images could help adolescents and young adults critically evaluate unrealistic appearance standards.^{95, 99, 100} Although dissonance-based interventions have shown efficacy in improving body satisfaction, most studies have been conducted in young adult populations, thereby limiting understanding of their effectiveness in younger adolescents.^{94, 101, 102} If adapted successfully for this age group, these interventions could serve as selective prevention programmes for groups at elevated risk, requiring as few as two sessions.^{94, 96, 101, 102} For example, the PRIDE Body Project showed that dissonance-based interventions can be effective among young gay men, suggesting potential use for sexual minority adolescents at risk of muscle dysmorphia.¹⁰³ Future prevention efforts could also explore parental interventions or target individuals with emerging body dissatisfaction or disordered eating behaviours to prevent progression to muscle dysmorphia. However, implementation strategies will need to balance targeted outreach with the practical and ethical considerations of avoiding the stigmatisation of specific youth populations within school environments.

Conclusions and future directions

Muscle dysmorphia is a complex and under-recognised psychiatric condition that likely affects a substantial number of adolescents and young adults, particularly boys, young men, and gender-diverse individuals. Despite growing clinical concerns, numerous questions about muscle dysmorphia remain due to insufficiencies in nosological clarity, standardised diagnostic criteria, culturally and developmentally appropriate assessment tools, and validated treatments (figure 3). These gaps leave adolescents and young adults at risk for severe psychosocial and physiological consequences from muscle dysmorphia that could have substantial and long-term effects into adulthood.

Figure 3.

linical challenges, research priorities, short-term goals, and long-term goals to improve care of muscle dysmorphia in adolescents and young adults

APED=appearance and performance enhancing drug.

An important first step in future work is to consider establishing more formalised and distinct criteria for muscle dysmorphia that are independent of its current status in the DSM-5-TR and ICD-11 as a body dysmorphic disorder specifier. Figure 1 presents a modified set of proposed diagnostic criteria that draws from existing body dysmorphic disorder and eating disorder criteria, as well as conceptual and empirical insights into muscle dysmorphia symptomatology. Specifically, these proposed criteria highlight the central cognitive-affective (eg, preoccupation with or fear of insufficient muscularity and self-evaluative and perceptual disturbances related to muscularity) and behavioural (eg, persistent maladaptive physical activity and eating-related behavioural patterns) symptoms of the syndrome that distinguish it from body dysmorphic disorder more generally and from eating disorders (such as anorexia nervosa). If future research applying these alternative criteria supports the further consideration of muscle dysmorphia as a type of eating disorder, a modification to its name could also be warranted. For example, following the precedents established with the initial inclusion of binge-eating disorder in DSM-IV and purging disorder in DSM-5, future iterations of the DSM might consider including muscularity-oriented eating disorder as a type of other specified feeding or eating disorder, facilitating more research and clinical attention to this condition, particularly within the eating disorder field. Research on muscle dysmorphia that applies independent diagnostic criteria, such as those proposed above (versus using existing criteria that tie muscle dysmorphia to body dysmorphic disorder), will be important for addressing whether muscle dysmorphia is best classified with eating disorders or obsessive-compulsive and related disorders.

If muscle dysmorphia were to be reclassified as an eating disorder, it could be renamed as muscularity-oriented eating disorder and be initially included in a future iteration of the DSM as an identified type of other specified feeding or eating disorder to facilitate further research. DSM-5-TR=Diagnostic and Statistical Manual of Mental Disorders, 5th edn, text revision.

Future research should also prioritise large-scale, diverse, and inclusive epidemiological studies to better define the prevalence, developmental course, and sociodemographic correlates of muscle dysmorphia in adolescence and young adulthood. Although psychological interventions for muscularity-oriented concerns that are adapted from existing eating disorder treatments (eg, CBT and dissonance-based programmes) show promise, further investigation of interventions more specifically developed for or targeting muscle dysmorphia in adolescence and young adulthood is needed. For example, although pharmacological data in muscle dysmorphia are scarce, findings from body dysmorphic disorder suggest potential benefits of selective serotonin reuptake inhibitors and serotonin reuptake inhibitors, indicating a need for direct evaluation of pharmacological treatments in adolescents and young adults with muscle dysmorphia.⁹¹ Adolescents in particular require focused investigation as they navigate puberty, identity formation, and increased exposure to appearance-focused media. Sexual, gender, racial, and ethnic minority adolescents and young adults might further have unique body ideals, stressors, and symptom presentations. Clinicians who work with adolescents and young adults are therefore uniquely positioned to advocate for these research advances and to promote early intervention for muscle dysmorphia symptoms.

Search strategy and selection criteria

References for this narrative review were identified through searches of PubMed for articles published from Jan 1, 1993, to July 1, 2025, with the search terms “adolescent”, “young adult”, and “muscle dysmorphia”, with no language restrictions. Articles were also identified through searches of the authors’ own files. The final reference list was compiled based on originality and relevance to the broad scope of this review, emphasising international studies and inclusion of marginalised groups.