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Muscle Dysmorphia in Different Degrees of Bodybuilding Activities: Validation Of Body Image 9 (2012) 396–403 Contents lists available at SciVerse ScienceDirect Body Image jou rnal homepage: www.elsevier.com/locate/bodyimage Muscle dysmorphia in different degrees of bodybuilding activities: Validation of the Italian version of Muscle Dysmorphia Disorder Inventory and Bodybuilder Image Grid a,∗ b Emiliano Santarnecchi , Davide Dèttore a Department of Neurological and Sensorial Sciences, University of Siena, Siena, Italy b Department of Psychology, University of Florence, Florence, Italy a r t i c l e i n f o a b s t r a c t Article history: The purpose of the study was to validate two measures of muscle dysmorphia (MD) into the Italian Received 17 April 2011 language. The sample included three participant groups: (1) competing bodybuilders, (2) non-competing Received in revised form 16 March 2012 bodybuilders, and (3) non-bodybuilding controls. In general the Italian versions of the scales showed Accepted 18 March 2012 psychometric utility that is consistent with the original instruments. The severity of MD was greater for competing bodybuilders than non-competing bodybuilders and controls. Keywords: © 2012 Elsevier Ltd. All rights reserved. Body image Muscle dysmorphia Bodybuilding Body dysmorphic disorder Introduction In the early 1990s, Pope et al. (1993) described an extreme form of body image disturbance called ‘reverse anorexia’, now known as Body dysmorphic disorder (BDD) is characterized by the exces- muscle dysmorphia (MD) (Pope, Gruber, Choi, Olivardia, & Phillips, sive concern and preoccupation of an imaginary body defect or 1997; Vandereycken, 2011). Pope et al. (1993) described a patho- a slight physical anomaly (Pope, Katz, & Hudson, 1993). BDD has logical desire to become more lean and muscular in both men and been included for the first time in nosography in the DSM-III and women. When MD was first included in the DSM-III it was described ICD-10 (Phillips, McElroy, Keck, Pope, & Hudson, 1993). In the last as a subtype of body dysmorphic disorder (BDD), as the two con- 20 years, several authors have reported evidence of body image ditions had several aspects in common. Three main criteria define disturbance in males and male weightlifters (Andersen, Bartlett, the MD subtype: a preoccupation with being lean and muscular; a Morgan, & Brownell, 1995; Drewnowski, Kurth, & Krahn, 1995; negative belief about one’s own body and subsequent body avoid- Schwerin et al., 1996). Several studies have investigated the preoc- ance or anxiety; and the interference of these two aspects in social cupation with muscularity, in terms of its prevalence and correlates and/or occupational areas of functioning. (Frederick, Fessler, & Haselton, 2005; McCreary & Sasse, 2000), Recently many studies have been conducted with the purpose suggesting that body image disturbance in men relates to two fac- of enlarging knowledge about muscle dysmorphia along with the tors: desire for increased muscularity and reduced body fat. Pope, necessity of a review of BDD in the DSM-5 (Phillips, Wilhelm, Koran, Olivardia, Gruber, and Borowiecki (1999) found that men idealized Didie, Fallon, & Feusner, 2010). A recent contribution (Murray, a body size on average 28 pounds more muscular than their cur- Rieger, Touyz, & De la Garza Garcia Lic, 2010) supported the neces- rent weight, suggesting that obtaining lean muscle mass is the most sity of a reassignment of muscle dysmorphia from BDD to the eating desired form of weight change in men. This is most probably due disorders field, due to the analogies between their symptomatol- to the modification in cultural ideals, reflected in the increasingly ogy: the pathological search of weight loss (anorexia nervosa) and lean and muscular action figures of movie, magazine and television weight gain (muscle dysmorphia), along with the focus on qual- stars (Frederick et al., 2005). ity and amount of food consumed. They also cited evidence from research that demonstrated the similar epidemiological charac- teristics of the two disorders, such as diagnostic crossover time and the finding that 29% of men with MD had previously suf- ∗ fered from an eating disorder (Olivardia, Pope, & Hudson, 2000); Corresponding author at: Policlinico “Le Scotte”, Viale Bracci, 2, Siena, 53100, common etiological factors such as similar responses to psycho- Italy. Tel.: +39 3382149984; fax: +39 0577270260. E-mail address: [email protected] (E. Santarnecchi). logical or pharmacological therapies (Lamanna, Grieve, Derryberry, 1740-1445/$ – see front matter © 2012 Elsevier Ltd. All rights reserved. doi:10.1016/j.bodyim.2012.03.006 E. Santarnecchi, D. Dèttore / Body Image 9 (2012) 396–403 397 Fig. 1. The Bodybuilder Image Grid (BIG). Figure grid is composed by individual figures that represent a distance of 6.5% body fat from figure to figure, and a progressive increase from left to right starting with 3.5% and ending with 36% across the columns. The muscularity dimension includes figures that have a degree of muscularity and body fat percentage that is unattainable without the use of ergogenic drugs such as steroids. Derived from the original paper by Hildebrandt et al. (2004). Hakman, & McClure, 2010); and familial disturbance transmission Italian versions of these assessments are provided in the online supported by studies on twin siblings (Raevuori, Keski-Rahkonen, supplementary materials linked to this article. Hoek, Sihvola, Rissanen, & Kaprio, 2008). However there is also evidence to suggest that obsessive–compulsive disorder, anorexia Test–Retest Reliability of the MDDI and BIG-S (Study 1) and MD could constitute alternative manifestations of obsessive thoughts (focus about the germs, thinness and muscle size) and A 3-week test–retest correlational study was conducted to test compulsive behavior (washing, reduction of the weight, exercis- the reliability of MDDI and BIG-S both in competing and non- ing). When considering all these possible similarities between MD competing bodybuilders. and various DSM-IV disorders, we think that a simple inclusion of MD in a pre-existing disorder classification could be an over- Participants simplification and also premature. It would be more useful to conceptualize muscle dysmorphia as an independent disorder and Ten male competing bodybuilders (Mage = 31 SDage = 10; thus concentrate on developing measures that adequately capture rangeage 26–35; BMI = 29.35; range 28–32), and 25 non- its uniqueness and allow a more efficient differential diagnosis pro- BMI cess. competing males (Mage = 33 SDage = 5; rangeage 24–37; BMI = 24.09; range 22–26) with at least 1 year of continuous weightlifting Several instruments for the assessment of MD and other BMI experience were participants in the study. Body mass index related disorders have been validated and proposed in the last (BMI) evaluation was performed through a direct height/weight ten years, such as the Muscle Dysmorphia Inventory (Rhea, Lantz, 2 measurement, following the canonical formula weight/(height) . & Cornelius, 2004), the Muscle Appearance Satisfaction Scale (Mayville, Williamson, White, Netemeyer, & Drab, 2002) and the Body Building Dependence Scale (Smith & Hale, 2004). However Assessments there is currently a lack of validated instruments in the Italian language that prevents study of this disorder in both clinical and The Muscle Dysmorphia Disorder Inventory (MDDI) is a measure research fields. of muscle dysmorphia derived from the Schlundt Muscle Dys- This current study aims to provide an Italian validation of two morphia Inventory (MDI) [unpublished manuscript] that originally specific instruments for muscle dysmorphia: the Muscle Dysmor- consisted of 16 self-report items based on MD research criteria. phia Disorder Inventory (MDDI) and the Bodybuilding Image Grid Hildebrandt et al. (2004) revised the original MDI for the purpose (BIG), both published by (Hildebrandt, Langenbucher, & Schlundt, of integrating the instrument with questions about the Functional 2004). We believe these instruments could help clinicians to better Impairment characteristic of MD. The final version of MDDI items identify muscle dysmorphia or similar conditions, since a spe- includes seven questions assessing the three diagnostic factors cific tool for aiding differential diagnosis is lacking in Italy. The associated with MD: desire for size, appearance anxiety/avoidance, 398 E. Santarnecchi, D. Dèttore / Body Image 9 (2012) 396–403 and Functional Impairment. Participants rate all questions on a 5- non-training groups received a discount to buy supplements or point Likert-type scale from “never” (“1”) to “always” (“5”). fitness clothing online in exchange for their participation. The factorial analysis conducted by Hildebrandt et al. (2004) reveals a consistent three-factor structure, regarding cognitions, Data Analysis emotions, and behaviors related to body image. The first subscale, Desire For Size (DFS), consists of questions concerning thoughts of To establish test–retest reliability, participants completed the being smaller, less muscular, and weaker than desired, or a wish to MDDI and BIG-S at a 3-week interval. Both the first and the sec- increase size and strength. The thinking style represented by this ond copy of the tests were completed at the gym and immediately subscale is consistent with the preoccupation about inadequate size reported to the test administrator. Pearson’s product–moment cor- in MD as described by Pope et al. (1997). The second factor, Appear- relations were calculated for each subscale and the total score of ance
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