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Graduate Student Journal of  Psychology 
2018, Vol. 17

Copyright 2018 by the Department of  Counseling and Clinical Psychology 
Teachers College, Columbia University

Objective Measurement and Insight Assessment of  
Muscle Dysmorphia

Austin B. Lowe, M.A., Frederick G. Grieve, Ph.D., and Amy Brausch, Ph.D.
Western Kentucky University

Muscle dysmorphia is a relatively new psychological disorder primarily affecting men. The main diagnostic 
criterion is an obsession with the idea that the body is not sufficiently lean or muscular when compared to 
others. As a muscular physique is so important to their self-worth, individuals with muscle dysmorphia may 
have little insight into how their behaviors are affecting their lives and may be less likely to seek psychological 
treatment. The purpose of  this study was to measure factors related to exercise and muscle dysmorphia and 
examine their relationship to insight and recognition of  criteria for muscle dysmorphia. Participants (N = 85) 
completed a series of  questionnaires to assess the independent variables and were then administered two 
questionnaires designed to assess insight to any criteria of  muscle dysmorphia participants might be experi-
encing as well as their recognition of  criteria in a case vignette. A series of  multiple regression analyses were 
conducted using feeling of  obligatory exercise, exercise motivation, reasons for exercise, athletic identity, 
and symptoms of  muscle dysmorphia as predictor variables for awareness of  diagnostic criteria of  muscle 
dysmorphia and self-reported symptoms of  muscle dysmorphia. Results indicated that participants with higher 
athletic identity and greater symptoms of  muscle dysmorphia had a higher insight into their own dysmorphia 
than participants with low athletic identity and fewer symptoms of  muscle dysmorphia. At the same time, 
individuals with more symptoms of  muscle dysmorphia had a lower recognition of  muscle dysmorphia in 
others than those with fewer symptoms.

Historically, psychological research addressing body 
image concerns has focused predominately on women, 
as dissatisfaction with the body was primarily seen in 
women (Brownell & Rodin, 1994). The rationale behind 
this was that their bodies were seen as the major form 
of  social capital for women (Crandall, 1994). However, 
more recent research (Grieve, Wann, Henson, & Ford, 
2006) indicates that men, too, have begun to be dissatis-
fied with their bodies. While women generally want to 
lose weight and be thinner (Thompson & Stice, 2001), 
men desire to either lose weight or gain weight, with 
a focus on increased muscularity rather than adipos-
ity (Ridgeway & Tylka, 2005). The focus on increasing 
muscularity can lead to pathological behaviors; the 
syndrome that results from these pathological behaviors 
has been termed muscle dysmorphia (Pope, Gruber, Choi, 
Olivardia, & Phillips, 1997).

In the most recent version of  the Diagnostic and 
Statistical Manual of  Mental Disorders (DSM5; American 

Psychological Association, 2013), muscle dysmorphia is 
listed as a subtype of  body dysmorphic disorder. The 
key symptom of  muscle dysmorphia is that an individual 
believes that his or her body is not as muscular as he or 
she wishes it would be, even though the individual is 
usually more muscular than the majority of  the popu-
lation (Olivardia, 2001). Obsessions with muscularity 
lead individuals to frequently miss social or occupa-
tional functions because they are overly committed to 
their exercise routines. Whereas a woman with an eating 
disorder will generally be seen compulsively exercising 
to improve her lower body, a man with muscle dysmor-
phia may exercise just as frequently, but focus on his 
upper body muscles instead (Thompson & Stice, 2001; 
Ridgeway & Tylka, 2005).

Despite obsessive commitments to exercise, indi-
viduals with muscle dysmorphia have varying degrees 
of  insight into their preoccupation with their body 
size. A study by Olivardia, Pope, and Hudson (2000), 
revealed that of  the 24 male weightlifters that met three 
of  the specific criteria for muscle dysmorphia, 10 (42%) 
participants reported “excellent” or “good” insight into 
recognizing that their impressions of  their body size 

Override (Hidden running head text):
Lowe, Grieve, Brausch
Muscle Dysmorphia

Keywords: Muscle dysmorphia; motivation; athletic identity; insight; 
awareness

Please address correspondence regarding this article to: 
rohgcnslr1219@outlook.com



100

LOWE, GRIEVE, BRAUSCH

was mistaken; 12 (50%) of  participants reported “fair” 
or “poor” insight. The remaining two participants (8%) 
lacked any insight and refused to accept that they were 
not “small” (Olivardia, Pope, & Hudson, 2000).

Additionally, individuals with muscle dysmorphia 
feel intense anxiety when their bodies are exposed in 
public and go to extreme lengths to avoid such situations 
(APA, 2013). Even though they are distressed by others 
seeing their bodies, individuals with muscle dysmor-
phia frequently check their appearance in the mirror to 
look for any changes in physique. Finally, individuals 
with muscle dysmorphia have strict diets comprised of  
high protein and low amounts of  carbohydrates and 
fats. They often use performance-enhancing substances, 
such as anabolic-androgenic steroids, despite the risk 
to their health (Olivardia, 2001; Grieve, Truba, & 
Bowersox, 2009).

One of  the greatest concerns regarding muscle 
dysmorphia is that even though individuals may be 
concerned about the effects their behavior has on their 
lives, the fear of  becoming less muscular is greater 
(Olivardia, 2001). Even when individuals do seek out 
treatment, it is often for depression, anxiety, eating or 
steroid abuse, rather than issues surrounding muscle 
dysmorphia. In the previously mentioned study by 
Olivardia, Pope, and Hudson (2000), a clinical interview 
revealed that of  the 24 participants, 29% had a history 
of  an eating disorder, 58% reported a history of  a mood 
disorder, and 29% had a lifelong history of  an anxiety 
disorder (Olivardia et al., 2000).

Despite these findings, little research has been 
done to assess what factors contribute to an individual 
seeking treatment other than receiving encouragement 
from others. There are some barriers to therapy for 
individuals with muscle dysmorphia (Grieve et al., 2009). 
Individuals with muscle dysmorphia find the symp-
toms ego-syntonic: that is, the symptoms do not cause 
distress. In fact, working out and dieting to increase 
muscle mass decreases the anxiety that they experience 
because they believe they are too small. Individuals with 
muscle dysmorphia do not consider therapy necessary 
for improving their lives, and they skip sessions with 
their therapists because the sessions conflict with their 
scheduled gym times, using this as a form of  self-medi-
cation (Olivardia et al., 2000).

Currently, the only information regarding prevalence 
of  muscle dysmorphia is limited to specific populations 

(Olivardia, 2001). Studies have proposed that 5% to 
10% of  weightlifters and 9% of  men diagnosed with 
body dysmorphic disorder have muscle dysmorphia 
(Cafri et al., 2005; Olivardia, 2001). This is most likely 
an underestimate of  the true prevalence rate as it is 
difficult to provide an estimate of  the population. Many 
men do not see the symptoms of  muscle dysmorphia as 
indicating a problem—in fact, they view the symptoms 
as eliminating a problem (see Olivardia, 2001)—so they 
do not present for treatment. The mean age of  onset for 
symptoms is 19.4 years (Olivardia et al., 2000), which 
means that it generally begins in college as young men 
begin to adopt the social ideal body image. As muscle 
dysmorphia is associated with anabolic steroid use 
(Olivardia, 2001), it is important to note that the rate of  
anabolic steroid use in young men is similar to the rate 
of  bulimia nervosa in young women (Schooler & Ward, 
2006); that is, approximately 2 million males of  all ages 
in the United States have used anabolic steroids at some 
point in their lives (Pope, Phillips, & Olivardia, 2000).

Grieve (2007) proposed a conceptual model for 
the etiology of  muscle dysmorphia that included four 
categories of  variables, each with contributing factors: 
socioenvironmental, emotional, psychological, and 
physiological. While limited research has been done in 
all of  these areas (see Grieve, 2007), socioenvironmen-
tal factors have been shown to be the most influential 
in individuals who develop muscle dysmorphia. These 
factors convey muscular ideals through an individual’s 
social environment, such as family, peers, athletics, and 
mass media. Mass media has been regarded as the most 
influential of  all pressures (Grieve, 2007). Mass media, 
predominately in Western societies, promotes indi-
viduals with physiques that are generally impossible to 
attain without the use of  anabolic steroids (Baghurst & 
Kissinger, 2009). The Western social ideal male body 
includes a muscular build, with a broad chest and thin 
waist; this is often considered a “V” shape (Ridgeway 
& Tylka, 2005).

Studies have shown that media presentations of  
the male body (i.e., magazine models, action toys, and 
celebrities) influence body image ideals through contrast 
effects (Grieve, 2007). Even though social comparison 
theory has been shown to help others by increasing self-
esteem through contrasting with others considered to 
be of  lower status (Dijkstra, Gibbons, & Buunk, 2010), 
the opposite effect has been shown to result from 



101

MUSCLE DYSMORPHIA

contrasting with individuals with a perceived higher 
status. In the case of  muscle dysmorphia, comparing 
oneself  to overly muscular individuals can decrease 
self-esteem. Exposure to muscular male models in the 
media has been associated with lower levels of  body 
satisfaction and self-esteem (Leit, Gray, & Pope, 2002). 
As these messages have previously led females to adopt 
exercise and dietary strategies to attain thinness, it is 
reasonable to guess that they can equally lead males to 
engage in similar strategies to gain and improve muscu-
lar physiques (Cafri et al., 2005).

Men with body image concerns can overutilize 
exercise; in fact, this excessive exercise can become 

“addictive” and sometimes is referred to as anorexia 
athleticism (Strother, Lemberg, Stanford, & Turberville, 
2012). In addition to exercising in order to improve 
muscularity, several other motivations have been identi-
fied as factors in determining why individuals complete 
exercise, how often they exercise, and how long they 
exercise. Self-Determination Theory (SDT; Deci & 
Ryan, 1985) has been suggested as a means of  exploring 
motivations in order to gain a greater understanding of  
the motives underlying exercising (Duncan, Hall, Wilson, 
& Jenny, 2010). SDT proposes that motivations for exer-
cising can be broken down into two categories: intrinsic 
motivations and extrinsic motivations. Intrinsic motiva-
tions are focused on personal interests, with specific 
motivations being enjoyment, improving abilities, or 
social affiliation. On the other hand, extrinsic motiva-
tions are concerned with achievement or recognition, 
and include weight loss or appearance (Markland & 
Ingledew, 1997).

Further research into motivations for exercise has 
found that there are differences in motivation based 
on gender. In a study conducted by Kilpatrick, Hebert, 
and Bartholomew (2005), male and female college 
students were administered the Exercise Motivations 
Inventory-2 (EMI-2; Markland & Ingledew, 1997) to 
distinguish differences in extrinsic and intrinsic moti-
vations between genders; the EMI-2 is comprised of  
various subscales, each reflecting a different motiva-
tion regarding why people think they should exercise. 
An analysis of  the results revealed that men rated the 
motives of  competition, challenge, social recogni-
tion, and strength and endurance higher than women; 
weight management was the only motive that women 
rated higher than men. Given that the motivations 

rated highest by men are frequently seen in individuals 
exhibiting criteria of  muscle dysmorphia, as well as the 
sample being comprised of  college students that have 
been primarily used in previous studies, there is a greater 
need for understanding of  exercise and individual moti-
vations (Kilpatrick et al., 2005).

Exercising should be distinguished from sport 
and athletic participation. Although both are classified 
as forms of  physical activity, there are benefits and 
motivations related to athletic involvement beyond 
the physiological aspects of  just exercising (Kilpatrick, 
Bartholomew, & Riemer, 2003). Exercise has normally 
been defined as participating in physical activity to gain 
or maintain fitness; on the other hand, sport is defined 
as engaging in physical activity for recreational purposes. 
Individuals participating in sport derive benefits such 
as higher self-esteem, more positive body image, 
greater social development, and greater social status 
than non-participating individuals (Cafri et al., 2005). 
Furthermore, individuals participating in athletics often 
develop skills that carry over into their personal lives, 
such as abstaining from alcohol and illicit drugs, accept-
ing and overcoming failures and difficult situations, as 
well as having a wider range of  educational and career 
opportunities.

Kilpatrick, Hebert, and Bartholomew (2005) exam-
ined the differences in exercise behaviors and motivation 
for exercise between engaging in exercise and engaging 
in sports. Results indicated that participants engaged in 
exercise more frequently and at a higher intensity than 
they engaged in sports, but there were no significant 
differences in ratings of  duration or adherence to activ-
ity. Additionally, analyses revealed a mix of  intrinsic and 
extrinsic motivations for each form of  physical activity; 
participants rated appearance, strength and endurance, 
stress management, health pressures, ill-health avoid-
ance, and positive health motives higher when they 
engaged in exercise, but rated affiliation, challenge, 
competition, enjoyment, and social recognition moti-
vations higher when participating in sport (Kilpatrick 
et al., 2005).

Sport participation also carries associated risks. The 
most salient set of  risks for the present study involve 
body image issues. Athletes participating in sports such 
as bodybuilding and football, where greater muscle 
mass and body size are valued are at risk for develop-
ing steroid abuse or muscle dysmorphia (Grieve, 2007). 



102

LOWE, GRIEVE, BRAUSCH

On the contrary, sports with weight restrictions, such 
as wrestling, boxing, swimming, or gymnastics, inspire 
participants to avoid gaining weight in an effort to stay 
lean; as a result, these individuals have a high risk of  
developing eating disorders or abuse of  diuretics and 
laxatives (Cafri et al., 2005; Murray, Rieger, Karlov, & 
Touyz, 2013).

Athletic identity is defined as the degree to which 
an individual considers him- or herself  an athlete 
(Chen, Snyder, & Magner, 2010). Athletic identity has 
been found to correlate with: athletic appearance; the 
importance of  exercise, sport, and physical activity; 
perceptions of  competence; and encouragement from 
others to be an athlete. Benefits associated with higher 
levels of  athletic identity include an improved sense of  
self, perceived improved social life, and higher levels of  
confidence. A strong athletic identity can also improve 
athletic performance by providing an individual with a 
more focused approach to training. Finally, individuals 
who strongly identify themselves as athletes exercise 
more frequently and engage in more exercise behaviors 
than those with lower athletic identities.

In a study by Chen, Snyder and Magner (2010), 
athletic identity, commitment to sports, and sports 
participation were examined in relation to possible 
benefits on personal and social life. A sample comprised 
of  163 student-athletes and 112 non-athlete students 
were administered a series of  questionnaires to assess 
the previously mentioned factors. An analysis of  the 
results showed that student athletes reported that their 
athletic involvement had improved their overall health, 
development, and meeting new friends. Interestingly, 
the researchers noted that athletes who were involved 
in team sports (i.e., football, basketball, volleyball, etc.), 
rated personal role, personal attributes, core benefits, 
social relationship, and special behaviors higher than 
athletes involved with more individual sports (i.e., 
track and field, tennis, etc.); the athletes involved with 
the individualized sports reported placing a greater 
importance of  sports in their lives and expectations of  
others higher than team sport athletes (Chen, Snyder, 
& Magner, 2010).

However, there are also costs that arise with the 
adoption of  a stronger athletic identity. Individuals 
with a strong athletic identity run the risk of  neglecting 
areas of  their life unrelated to athletics, such as work or 
friendships outside of  sport. Also, because they often 

lack other sources of  self-worth, individuals with a 
high sense of  athletic identity are more vulnerable to 
depression when faced with role-disrupting life events 
(Brewer, 1993). For example, after sustaining an injury, 
individuals with a high degree of  athletic identity are 
likely to interpret it as inhibiting their ability to exercise or 
participate in competitions; this in turn decreases mood 
and self-esteem (Brewer, Van Raalte, & Linder, 1993).

Present Study

The purpose of  the current study was to examine 
patterns of  and motivations for participants’ exercising 
and their awareness for any personal evidence of  muscle 
dysmorphia. We predicted that participants score on 
the exercise and MD questionnaires will be negatively 
related to personal insight of  diagnostic criteria for 
muscle dysmorphia in themselves. We also predicted 
that participants score on the exercise and MD ques-
tionnaires will be positively related to identification of  
diagnostic criteria via a case vignette. The independent 
variables were chosen to assess the degree of  factors 
related to exercise, importance of  exercise, and typical 
behaviors of  muscle dysmorphia in participants. These 
variables were considered important to assess in relation 
to muscle dysmorphia because the majority of  studies 
have not examined frequency of  exercise in participants, 
considered alternative motivations for exercise aside 
from improving musculature, or have used samples 
comprised of  professional athletes without assessing 
the importance that their participation in athletics is to 
their self-concept.

Method

Participants
Participants were 85 men all over the age of  18 

who were recruited via two methods. Approximately 
one-third (27 participants; 31.8%) were students attend-
ing university; participants were recruited through the 
Department of  Psychology’s online participant pool and 
were awarded course credit for their participation. The 
remainder of  the participants (58, 68.2%) were recruited 
through the Amazon Mechanical Turk website and were 
awarded a monetary payment upon completion; these 
participants were awarded either $0.20 (initially) or $0.50 
(later) for their participation.



103

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The average age of  participants was 32.73 
(SD = 13.42), with ages ranging from 18 to 65. 
Participants were comprised of  8 (9.3%) high school 
graduates, 13 (15.1%) freshmen in college, 9 (10.5%) 
sophomores, 6 (7.0%) juniors, 19 (22.1%) seniors, 
13 (15.1%) graduate students, and 17 (19.8%) college 
graduates. Participants included 58 (68.2%) Caucasians, 
17 (20.0%) Asians, 5 (5.9%) African Americans, 2 (2.4%) 
American Indian/Alaskan Natives, 2 (2.4%) participants 
who did not indicate their race/ethnicity, and 1 (1.2%) 
Hispanic (see Table 1).

Body mass index (BMI) was calculated for partici-
pants by using their reported height and weight. 
The mean height of  participants was 70.24 inches 
(SD = 3.51), with heights ranging from 60 to 76 inches. 
The mean weight of  participants was 184.47 pounds 
(SD = 45.26), ranging from 70 to 310 pounds. The mean 
BMI of  participants was 26.17 (SD = 5.73), ranging 
from 11.30 to 44.09; this average falls outside the range 
of  what is considered a healthy BMI (18.5 to 24.9) into 
the overweight range (25 to 29.9).

Of  the 85 participants, 39 reported currently partici-
pating in one or more sports. At least one participant 
reported engaging in the following sports: baseball, 
basketball, bowling, boxing, cheerleading, chess, cricket, 
cross fit, cycling, dance, dodge ball, fishing, football, 
Frisbee, golf, hiking, hockey, powerlifting, racing, 
soccer, softball, table tennis, skipping rope, swimming, 
tae kwon do, tennis/badminton, track/running, volley-
ball, weightlifting.

Materials and Procedure
Demographics. Participants completed a demo-

graphic questionnaire that included questions regarding 
age, race/ethnicity, education level, current sport partici-
pation, height, and weight. The response option to the 
question regarding sport participation was an open 
response to allow participants to define sport partici-
pation in their own manner.

Obligatory Exercise Questionnaire. This 
measure was used to assess fixation, frequency, and 
commitment to exercising (OEQ; Pasman & Thompson, 
1988). The OEQ is composed of  20 questions designed 
to gather information on individual attitudes and habits 
in exercise; responses are on a four-point Likert-type 
scale, from 1 (Never) to 4 (Always). An example ques-
tion on the OEQ is “If  I miss a planned workout, I 

attempt to make up for it the next day.” The OEQ is 
scored by summing the responses for each question 
(reverse scoring two questions). Higher scores indicate 
a greater sense of  obligation to exercise. The OEQ 
has excellent internal consistency (Cronbach’s α = .96; 
Pasman & Thompson, 1988).

Exercise Motivations Inventory – 2. This measure 
(EMI-2; Markland & Ingledew, 1997) was used to deter-
mine overall motivation behind exercise participation. 
The EMI-2 contains a total of  51 questions that are 
designed to assess fitness and health-related reasons for 
exercising among exercisers and non-exercisers; for this 
study, participants responded to each reason on a scale 
from 1 (Not at all true for me) to 5 (Very true for me). 

Table 1
Demographics of Participants

Characteristic n %
Gender

Male 85 100
Age

11–20 14 16.4

21–30 33 38.9
31–40 14 16.6
41–50 7 8.4
51–60 10 11.9
61–70 4 4.8
N/A 3 3.5

Ethnicity
Caucasian 58 68.2
Asian 17 20.0
African American 5 5.9
American Indian/Alaskan Native 2 2.4
Other 2 2.4
Hispanic 1 1.2

Education
High School Graduate 8 9.3
College Freshmen 13 15.1
College Sophomore 9 0.5
College Junior 6 7.0
College Senior 19 22.1
College Graduate 17 19.8
Graduate Student 13 15.1



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A sample motivation for exercising question is “To stay 
slim.” The EMI-2 total score was obtained by summing 
the scores of  all items. In addition, scores for each 
of  the subscales (Stress Management, Revitalisation, 
Enjoyment, Challenge, Social Recognition, Affiliation, 
Competition, Health Pressures, Ill-Health Avoidance, 
Positive Health, Weight Management, Appearance, 
Strength & Endurance, and Nimbleness) was obtained 
by summing the items associated with each. The EMI-2 
is applicable to exercisers and non-exercisers, and has 
acceptable internal consistency across subscales, with 
Cronbach’s alpha ranging from .69 to .92 (Markland & 
Ingledew, 1997).

Reasons for Exercise Inventory. This measure 
(REI; Silberstein, Striegel-Moore, Timko & Rodin, 1988) 
assessed how important specific reasons for exercise 
were for participants. The REI contains a total of  24 
reasons for exercising and asks participants to rate how 
important each reason is, with responses ranging from 
1 (Not at All Important) to 7 (Extremely Important). An 
example reason for exercising on the questionnaire is 

“To cope with stress, anxiety.” The REI has six subscales: 
Weight Control, Attractiveness, Mood, Fitness, Health 
Concerns, Enjoyment, and Tone. Each subscale score 
consisted of  the sum of  the items associated with 
the subscale. The REI assesses participants’ reasons 
for exercising in contrast to reasons why they believe 
they should exercise. Furthermore, the subscales have 
reported good internal consistency, averaging between 
.70 and .81 (Crawford & Eklund, 1994).

Athletic Identity Measurement Scale. This 
measure (AIMS; Brewer & Cornelius, 2001) was used 
to measure participants’ athletic identity. It is made 
up of  three factors: Exclusivity, Social Identity, and 
Negative Affectivity (Groff  & Zabriskie, 2006). The 
AIMS consists of  seven questions with responses rang-
ing from 1 (Strongly Disagree) to 7 (Strongly Agree). 
The AIMS is scored by summing the scores for each of  
the subscales. The AIMS has high internal consistency 
(coefficient alpha = .81; Brewer & Cornelius, 2001) and 
test-retest reliability (r = .89, p < .01; Brewer, 1993).

Muscle Dysmorphia Questionnaire. This 
measure (MDQ; Grieve et al., 2014) was used to measure 
symptoms of  muscle dysmorphia. The MDQ is made up 
of  34 questions with responses ranging from 1 (Strongly 
Disagree) to 6 (Strongly Agree). A sample question from 
this inventory is “I am inclined to continue to work out 

when I am sick.” The MDQ is scored by summing the 
scores (reverse scoring three items). The MDQ has a 
high internal consistency (Cronbach’s α = .86; Grieve 
et al., 2014).

Symptom Insight Assessment. The SIA was 
designed by the experimenter by using the criteria for 
muscle dysmorphia (Olivardia, 2001) as a guideline. 
Participants were instructed to rate to what degree they 
believed they exhibited each of  the criteria for muscle 
dysmorphia. Participants rated each criterion on a scale 
from 1 (Not at all true for me) to 6 (Very true for me). 
This measure was used to assess participant knowledge 
and awareness of  any personal symptoms of  muscle 
dysmorphia.

Criteria Awareness Assessment. Participants 
read a vignette describing an individual who exhibited 
each of  the criteria of  muscle dysmorphia; they were 
then asked to rate how much they believed the patient 
described met the criteria for muscle dysmorphia on 
a scale from 1 (Not at all true for Jim) to 6 (Very true 
for Jim). Both this measure and the vignette were 
designed by the experimenter by using the criteria for 
muscle dysmorphia (Olivardia, 2001) and a case history 
reported in a previous study (Mosley, 2009) as a guide. 
This measure was used to assess identification of  the 
symptoms of  muscle dysmorphia.

Procedure
Prior to study commencement, Institutional Review 

Board approval was obtained. In-person participants 
were given an informed consent document that indi-
cated that completing the survey implied consent; 
on-line participants were given the same document with 
a link that indicated consent and took participants to the 
actual survey. After agreeing to participate, participants 
completed the demographics questionnaire. Participants 
then completed the OEQ, the EMI-2, the REI, the 
AIMS, and the MDQ in this order.

After completing the above questionnaires, partici-
pants were asked to rate themselves on each of  the 
diagnostic criteria for muscle dysmorphia. Participants 
read the vignette and indicated to what extent they 
believed the individual in the vignette met each of  
the diagnostic criteria for muscle dysmorphia. Upon 
completing the study, participants were debriefed about 
the aim of  the study, the purpose of  each question-
naire, the hypotheses, and contact information for any 



105

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questions regarding their participation; participants were 
then guided to the final page and instructed to close 
the browser window. Amazon Mechanical Turk partici-
pants were provided a code at the end of  the survey 
and were paid when they used that code in the recruit-
ment website. The mean amount of  time that it took 
participants to complete the study was 23.87 minutes 
(SD = 28.09), with times ranging from 7 to 172 minutes.

In order to ensure that participants from Amazon 
Mechanical Turk were paying attention to item content, 
five manipulation check questions were spread through-
out the survey to ensure that participants were reading 
the items. Although participants were excluded from 
the data set if  they missed even one manipulation check 
question, the Amazon Mechanical Turk participants 
were only denied payment if  they missed more than 
three manipulation check questions.

Results

Preliminary Analyses
The items from each of  the questionnaires were 

summed to create a total score for each scale (see 
Table 2 for means and standard deviation). Cronbach’s 
alpha was calculated for each of  the scales to deter-
mine internal consistency; each scale was shown to 
have high internal consistency, with coefficients ranging 
from .81 to .96. Pearson product-moment correlation 
coefficients were conducted to assess the relationship 
between each of  the variables; results were varied with 
the two strongest correlations between the EMI-2 and 

the REI (r = .84, p < .001) and between the MDQ and 
SIA (r = .870, p < .001) (see Table 3 for full results).

Hypothesis Testing
A multiple regression analysis was conducted to 

predict scores on the symptom insight and criteria aware-
ness from scores on the OEQ, EMI-2, REI, AIMS, and 
MDQ. Hypothesis 1 proposed that high scores on the 
OEQ, EMI-2, REI, AIMS, and MDQ would be asso-
ciated with low scores on the SIA. The overall model 
was significant, F (5, 79) = 57.19, p < .005, R2 = .78; 
however, only the AIMS (t = 3.064, p = .003) and MDQ 
(t = 13.864, p = .000) were statistically significant predic-
tors of  symptom identification in participants.

Hypothesis 2 proposed that high scores on the 
OEQ, EMI-2, REI, AIMS, and MDQ would be asso-
ciated with high scores on the CAA. The overall model 
was significant F (5, 79) = 3.88, p < .005, R2 = .20, but 
in this analysis, only the MDQ was a significant predic-
tor of  criteria awareness for muscle dysmorphia in 
the presented case vignette (t = -2.280, p = .025). See 
Table 4 for the full results.

To determine if  sports participation was a factor in 
participants’ responses, a second, separate set of  regres-
sion analyses were run where participants were split into 
one of  two groups based on whether they answered 
‘Yes’ or ‘No’ to participating in sports; 39 participants 
reported that they currently participated in sports, 
while 46 participants denied current sports participa-
tion. Results were similar to the total sample analysis 
for the SIA for both groups; overall, the independent 

Table 2
Descriptive Statistics for Each of the Measures Used in the Study

Variable M SD Range Alpha (α)
OEQ 45.95 10.52 26–76 .89
EMI-2 159.74 37.06 69–242 .96
REI 112.54 25.55 39–168 .92
AIMS 20.73 12.10 7–49 .94
MDQ 94.13 26.77 47–147 .92
SIA 14.44 6.64 6–30 .83
CAA 30.40 5.27 15–36 .81

Note. The above statistics were obtained for the following measures: Obligatory Exercise Questionnaire (OEQ); 
Exercise Motivations Inventory – 2nd edition (EMI-2); Reasons for Exercise Inventory (REI); Athletic Identity 
Measurement Scale (AIMS); Muscle Dysmorphic Questionnaire (MDQ); Symptom Insight Assessment (SIA); 
Criteria Awareness Assessment (CAA).



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variables statistically significantly predicted scores, but 
only the AIMS and MDQ were statistically significant 
predictors; sport participation group: F (5, 33) = 19.25, 
p < .005, R2 = .75; no sports participation group: F (5, 
40) = 33.68, p < .005, R2 = .81. However, neither groups’ 
scores on the independent variables were statistically 
significant in predicting CAA scores; sport participa-
tion group: F (5, 33) = 1.90, p > .05, R2 = .22; no sport 
group: F (5, 40) = 1.36, p > .05, R2 = .15. See Tables 5 
and 6 for full results.

Discussion

Muscle dysmorphia is a fairly new clinical diagnosis 
that is primarily shown in adolescent and adult males. 
The primary symptom is that an individual believes 
that he or she is not sufficiently lean or muscular, even 

though the individual may already be overly muscular 
(Pope et al., 1997). These symptoms and beliefs are 
often derived from individuals comparing themselves 
to others they encounter or a desire to conform to 
specific body types promoted by mass media (Baghurst 
& Kissinger, 2009; Grieve, 2007). To compensate, indi-
viduals engage in behaviors to increase muscularity that 
include frequent weightlifting and strict eating behaviors, 
often taking away time from social or occupational activ-
ities (American Psychiatric Association, 2013; Olivardia, 
2001). As the compulsion to attain a certain body shape 
becomes central to their self-concept, individuals with 
muscle dysmorphia may be unwilling to admit that their 
behaviors are negatively affecting their lives and may be 
unwilling to seek treatment because it would take away 
from their time exercising (Grieve, Truba, & Bowersox, 
2009; Olivardia, Pope, & Hudson, 2000).

Table 3
Correlations Among Variables

Variable OEQ EMI REI AIMS MDQ SIA CAA
Pearson Correlation 1 .663** .547** .610** .542** .452** -.272*

OEQ Sig. (2-tailed) .000 .000 .000 .000 .000 .012
N 85 85 85 85 85 85 85
Pearson Correlation .663** 1 .840** .680** .443** .375** -.199

EMI-2 Sig. (2-tailed) .000 .000 .000 .000 .000 .068
N 85 85 85 85 85 85 85
Pearson Correlation .547** .840** 1 .502** .405** .330** -.055

REI Sig. (2-tailed) .000 .000 .000 .000 .002 .618
N 85 85 85 85 85 85 85
Pearson Correlation .610** .680** .502** 1 .397** .450** -.317**

AIMS Sig. (2-tailed) .000 .000 .000 .000 .000 .003
N 85 85 85 85 85 85 85
Pearson Correlation .542** .443** .405** .397** 1 .870** -.335**

MDQ Sig. (2-tailed) .000 .000 .000 .000 .000 .002
N 85 85 85 85 85 85 85
Pearson Correlation .452** .375** .330** .450** .870** 1 -.325**

SIA Sig. (2-tailed) .000 .000 .002 .000 .000 .002
N 85 85 85 85 85 85 85
Pearson Correlation -.272* -.199 -.055 -.317** -.335** -.325** 1

CAA Sig. (2-tailed) .012 .068 .618 .003 .002 .002
N 85 85 85 85 85 85 85**

*Correlation is significant at the 0.05 level (2-tailed); **Correlation is significant at the 0.01 level (2-tailed).



107

MUSCLE DYSMORPHIA

The purpose of  the current study was to assess 
participant insight to the diagnostic criteria that they 
might have and to determine whether they recognize 
diagnostic criteria in a case vignette. The predic-
tor variables used were obligation to exercise (OEQ), 
motivations and reasons for exercise (EMI-2 and REI, 
respectively), athletic identity (AIMS), and symptoms of  
muscle dysmorphia (MDQ). It was hypothesized that 
individuals with high scores for each of  the predictor 
variables would have a low insight score, but would have 
a high score on recognizing symptoms in the vignette.

The first hypothesis was that individuals with high 
obligation, motivation, and reason for exercise, athletic 
identity, and muscle dysmorphia behavior would report 
low symptom insight and recognition. An analysis of  
the results indicated a statistically significant increase 
in symptom insight as athletic identity and muscle 

dysmorphia behavior increased. Of  the six criteria listed, 
the ones that participants rated the highest were: (1) You 
are hung-up on the idea that your body is not sufficiently 
lean or muscular; (2) You avoid situations where your 
body is exposed to others, or endure such situations 
with distress or anxiety; and (3) You have feelings about 
the inadequacy about your body size and musculature 
that causes distress and impairment in your social, occu-
pational, or other important areas of  functioning.

These results are somewhat similar to Olivardia, 
Pope, and Hudson (2000). Of  the 24 men with muscle 
dysmorphia interviewed, less than half  had accurate 
insight that their body perception was distorted. This 
lack of  insight could be due to the nature of  muscle 
dysmorphia symptoms. The symptoms are ego-
syntonic; that is, excessive weight lifting relieves anxiety 
that people have about their bodies so the symptoms 

Table 4
Regression Examining Predictor Variables for Symptom Insight Assessment and Criteria Awareness Assessment, Overall

SIA CAA
Variable B SE B β p B SE B β p

OEQ -.059 .049 -.093 .237 -.028 .075 -.055 .713
EMI-2 -.020 .021 -.111 .356 -.026 .033 -.186 .421
REI .000 .026 .002 .987 .074 .039 .358 .062
AIMS .128 .042 .232 .003 -.098 .064 -.226 .126
MDQ .217 .016 .876 .000 -.055 .024 -.277 .025

Note. The above statistics were obtained for the following measures: Obligatory Exercise Questionnaire (OEQ); Exercise Motivations 
Inventory – 2nd edition (EMI-2); Reasons for Exercise Inventory (REI); Athletic Identity Measurement Scale (AIMS); Muscle Dysmorphia 
Questionnaire (MDQ); Symptom Insight Assessment (SIA); Criteria Awareness Assessment (CAA).

Table 5
Regression Examining Predictor Variables for Symptom Insight Assessment and Criteria Awareness Assessment, 
Sport Participants (n = 39)

SIA CAA
Variable B SE B β p B SE B β p

OEQ -.136 .084 -.230 .116 -.087 .122 -.177 .481
EMI-2 -.003 .045 -.013 .946 -.099 .065 -.506 .137
REI -.035 .053 -.105 .513 .125 .076 .455 .110
AIMS .177 .085 .269 .045 .051 .123 .093 .681
MDQ .227 .026 .919 .000 -.046 .038 -.222 .243

Note. The above statistics were obtained for the following measures: Obligatory Exercise Questionnaire (OEQ); Exercise Motivations 
Inventory – 2nd edition (EMI-2); Reasons for Exercise Inventory (REI); Athletic Identity Measurement Scale (AIMS); Muscle Dysmorphia 
Questionnaire (MDQ); Symptom Insight Assessment (SIA); Criteria Awareness Assessment (CAA).



108

LOWE, GRIEVE, BRAUSCH

are seen in a positive light (Grieve, 2007; Grieve et al., 
2009). Therefore, many times people who exhibit the 
symptoms do not see them as problematic.

The second hypothesis proposed that, after reading 
the vignette of  an individual exhibiting symptoms of  
muscle dysmorphia, participants with high obligatory 
exercise, motivation and reason to exercise, athletic iden-
tity, and muscle dysmorphia behavior would have high 
recognition of  symptoms in the described individual. 
Analyses showed a significant decrease in recognizing 
symptoms in the vignette as participants’ behaviors of  
muscle dysmorphia (MDQ) increased.

These results show some relation to the concept of  
identification in social comparison theory. As noted by 
Dijkstra et al. (2010), when an individual identifies with 
a comparison target, those who view the target as doing 
worse off  themselves, make downward comparisons 
between themselves and the target, provoking feelings 
of  anxiety or fear (Dijkstra et al., 2010). In this study, 
it is likely that participants saw something of  them-
selves in the description in the vignette and reported 
low symptomology as a means of  defending their own 
self-image.

In addition, the relationship between insight and 
athletic identity can be attributed to the behaviors 
associated with athletic involvement. Participation in 
athletics already requires a significant time commitment. 
Athletes generally obtain and maintain a particular body 
shape through exercise and diet as part of  this participa-
tion (Brewer, Van Raalte, & Linder, 1993). Therefore, it 
is possible that individuals with high levels of  athletic 

identity recognize the criteria for muscle dysmorphia 
because of  the experience of  being an athlete rather 
than because of  experiencing mental illness.

These results also hold clinical implications. The 
results suggest that the MDQ and SIA may be beneficial 
in a treatment setting to measure the specific behaviors 
of  muscle dysmorphia and patient insight about the 
preoccupation with improving body image. Taking this 
one further step, a readiness to change survey could also 
be administered to patients to determine how willing 
they are to change their behavior, what therapy might be 
most effective, and possible treatment outcome. Thus, 
insight into problem behaviors can be used as a moti-
vational tool, such as within motivational interviewing 
(Miller & Rollnick, 2013).

There are several limitations to the results of  this 
study. First, even though the SIA and CAA are based 
on the established criteria for muscle dysmorphia 
(American Psychiatric Association, 2013; Olivardia, 
2001), they were specifically designed for this study, and 
therefore may have questionable validity. Additionally, 
the vignette was also written for this study and was 
not tested in advance; therefore, it is possible that the 
vignette does not sufficiently or accurately describe 
the criteria for muscle dysmorphia. Second, there is 
the possibility that because participants were allowed 
to complete the survey outside of  a research environ-
ment for their own convenience, some participants may 
have misunderstood the questions. Third, the SIA and 
CAA were administered at the end of  the study; even 
though there is a decreased likelihood of  this affecting 

Table 6
Regression Examining Predictor Variables for Symptom Insight Assessment and Criteria Awareness Assessment, 
No Sport Group (n = 46)

SIA CAA
Variable B SE B β p B SE B β p

OEQ .042 .069 .052 .543 .127 .104 .219 .229
EMI-2 -.035 .023 -.211 .130 .009 .035 .072 .803
REI .018 .028 .081 .524 .030 .042 .190 .478
AIMS .120 .057 .169 .042 -.052 .087 -.103 .549
MDQ .208 .020 .855 .000 -.054 .030 -.309 .079

Note. The above statistics were obtained for the following measures: Obligatory Exercise Questionnaire (OEQ); Exercise Motivations 
Inventory – 2nd edition (EMI-2); Reasons for Exercise Inventory (REI); Athletic Identity Measurement Scale (AIMS); Muscle Dysmorphia 
Questionnaire (MDQ); Symptom Insight Assessment (SIA); Criteria Awareness Assessment (CAA).



109

MUSCLE DYSMORPHIA

the CAA, administering the SIA at the beginning of  the 
study could have made it less likely to be influenced by 
response bias.

Future research should focus on assessing differ-
ences in muscle dysmorphia symptoms and behaviors 
based on ethnicity, sport, and gender. Including 
measures of  self-esteem, depression, or anxiety could 
also be useful in a treatment setting to determine patient 
overall mood state and gain a greater understanding 
of  psychological well-being for individuals with muscle 
dysmorphia.

In conclusion, individuals have difficulty recognizing 
symptoms of  muscle dysmorphia in others. However, 
those with a strong athletic identity or high rates of  
behaviors appear to have greater insight to any possible 
symptoms that they themselves might be experiencing, 
which may be useful in treatment.

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