What Is Bigorexia?
Craig Golias is huge on Instagram—literally, huge. The 39-year-old wants to be the largest and most muscular man on social media. Weighing more than 330 pounds, he's one of the largest bodybuilders in the world.
But he feels small.
"I feel like I'm addicted to getting big," Golias said in the 2020 documentary "Bigorexia," which explored muscle dysmorphia through the perspective of five people in the bodybuilding industry. "When you want to be the biggest, you just keep on getting bigger until you are the biggest. And even when you are the biggest, you still want to get bigger. I would definitely say I have bigorexia, because I'm never satisfied."
Golias was reluctant to be filmed for the documentary because he was concerned he'd be perceived as small. When taking a picture of himself, he made sure it was taken from an angle where he looked as big as possible.
Muscle dysmorphia, also known as bigorexia, is a subtype of body dysmorphic disorder (BDD). This condition, which mostly affects males, although women may also have it, is marked by a preoccupation with muscle mass.
'Even when you are the biggest, you still want to get bigger.'
"It's associated with a lot of obsessive thinking around size, how other people might be perceiving them, constantly thinking about getting bigger or shrinking and getting smaller, coupled with a lot of typically compulsive or avoidant behaviors," said Roberto Olivardia, Ph.D., a clinical instructor of psychology at Harvard Medical School and an expert on muscle dysmorphia.
Compulsive behaviors may include lifting weights constantly, frequent mirror checking and obsessively choosing clothes that best accentuate muscularity. Men with bigorexia may ask their friends if they look big today or if they look smaller than they did yesterday. An avoidant behavior would be avoiding social situations for fear of being seen as small.
"These are not individuals who are sort of arrogantly thinking they look great," Olivardia explained. "If anything, they're worried that they don't. These individuals may not leave their house sometimes if they feel that they don't look muscular or fit enough."
Anabolic steroid use is common among men with bigorexia. Some inject synthol, an oil-based compound, to make their muscles appear larger. Both steroids and synthol carry major health risks. Opiate addiction is also common because many of these men overtrain, experience pain and then develop a dependence on painkillers, Olivardia added.
Reinforced through culture
Many people with muscle dysmorphia don't know it's an actual condition or fail to realize they have a problem, according to Aaron Flores, a registered dietitian nutritionist in Los Angeles who works with men afflicted with eating disorders and body image issues.
"Because it's reinforced through culture in so many ways, people will think it's OK to stand in front of the mirror at the gym and spend a lot of time scrutinizing one muscle group," he explained. "For a lot of folks, they don't even know there's something that's problematic with that."
Men with muscle dysmorphia come into Flores' office knowing they have a preoccupation "but not quite understanding how deep the rabbit hole goes," he added. "It gets normalized so much in our culture. It's like this focus on, 'I can never be muscular enough. I always need to be working really diligently.'"
Olivardia, likewise, said most men don't come into his office thinking they have muscle dysmorphia. The majority of his clients don't identify bigorexia as an issue until a life-changing event happens or they have a medical issue from steroid use.
"They are coming in because maybe they've gotten an injury, they can't work out and they're incredibly depressed or suicidal," he said. "Or their second wife has divorced them because they said, 'You're obsessed with the gym and it's like your addiction.' Or they got fired from a job."
The muscular ideal that Instagram, YouTube and other forms of social media promote is becoming more prevalent, according to Meghan Gillen, Ph.D., an associate professor of psychology at Penn State Abington.
"There's a pressure for men to have this ideal body size," Gillen said. "I think some people are just more psychologically vulnerable to these kinds of pressures than others, whether it's family pressures, traumatic experiences or social pressures."
At what point does it become a problem?
Generally, it's healthy to lift weights and build muscle. While there may be a fine line between healthy and unhealthy behavior, Gillen explained that weightlifting generally becomes a problem when it takes over your life.
"I'd say it becomes a problem when it disrupts your life and your ability to function," Gillen said. "For example, it becomes a problem when you're not able to work because you're going to the gym so often. You can't maintain your relationships with family or friends because you're so focused on weightlifting and that's all you want to talk about."
Having body image distortions is typically a red flag for muscle dysmorphia, Olivardia noted.
"How accurate is the person in perceiving their body?" he said. If the individual is not seeing what other people are seeing, they run a higher risk of developing unhealthy behaviors, he added.
"How much of their self-esteem rests upon their body and body image?" Olivardia continued. "Certainly, to have some part of your sense of confidence and self-esteem [rest on] your body image is normative for most people, but if all of it is rested on your body, then you're going to be in trouble."
Olivardia pointed out that many of his clients with muscle dysmorphia are creative, intelligent and funny.
"They have a lot of wonderful traits that they discount very easily if their bodies are not what they feel they need them to be," he said.
How therapy can help
Therapy is the best available treatment option for bigorexia, Gillen said.
"The therapist can diagnose and provide an appropriate course of treatment for whatever that person's individual case might be," she said.
Therapy involves psychoeducation about the condition and general information on why certain behaviors, including eating habits, are unhealthy, Olivardia explained, adding that one-third of men with bigorexia have an eating disorder, too.
"A lot of their eating habits are idiosyncratic," he said. "What's healthy eating? What is a healthy regulation of exercise? Because working out for six hours is really not benefiting you."
Cognitive behavioral therapy (CBT) is one of the most common approaches to targeting the behaviors associated with bigorexia. CBT is a form of talk therapy that helps individuals learn how to identify and change negative thought patterns.
"What are the behaviors they're doing that we want them to decrease? What are the behaviors they're not doing that we want them to increase? The cognitive part really catches up after the behaviors start changing," Olivardia said. "What are the thoughts that they have when they walk in a room and they think, 'Everyone thinks I'm too small'? Well, let's examine that."
Muscle dysmorphia is often a symptom of something else, such as trauma, an eating disorder, anxiety or depressive disorders, or even being bullied as a child.
"It can be dealing with some feeling of inadequacy that comes in many forms," Olivardia said. "We can deal with the muscle dysmorphia symptoms, but if we're not dealing with some of those underlying issues, they might present themselves in other ways."
Olivardia often teaches assertiveness skills to clients whose muscles are a compensating factor.
"Sometimes these men struggle with social anxiety, so they think, 'if I look perfect,' it makes up for the lack of skills they have internally," he said.
It's not an 'easy fix'
Flores said it's critical for people who think they may have bigorexia to work with a professional who has experience with body dysmorphia.
"If someone doesn't quite have the understanding from a clinician's standpoint how deep this rabbit hole goes or how hard it is, the intervention provided might not be very helpful," he said.
Flores emphasized that overcoming bigorexia requires hard work for most people and may take years.
"It's not an easy fix," he said. "It is not like you're just going to work with me for six sessions and then it's all done. For a lot of folks, this is a lot of really deep work connected to a lot of other parts of their lives."
For people struggling with bigorexia, Flores has this important message: You're not alone.
"This is more common than folks realize," he said. "It's OK to get help. It's OK to find a therapist or a dietitian or both who can support you with this."