Psyche & Addiction

What muscle dysmorphia means

Muscle dysmorphia is examined in research as a clinically relevant symptom presentation. A systematic review and meta-analysis of 40 publications found preliminary support for this. A cluster analysis differentiated between a behavioral and a cognitive or cognitive-behavioral presentation.

It remains unclear whether this symptom presentation is best classified as a specifier of body dysmorphic disorder (BDD) or as an independent psychiatric disorder. An increased symptom score is therefore not automatically a clinical diagnosis. The literature also does not provide a reliable prevalence for the entire bodybuilding population.

What body image findings are present in bodybuilders

A systematic review and meta-analysis of 31 predominantly observational studies with a total of 5,880 participants, around 90% of whom were men, found higher levels of muscle dysmorphia symptoms in bodybuilders than in non-competitive strength athletes. Competitive bodybuilders also outperformed non-competitive bodybuilders. Pooled effect sizes on various muscle dysmorphia subscales ranged from 0.53 to 1.12; for the comparison by competition status, an effect size of 1.21 with a 95% confidence interval of 0.82 to 1.60 was reported.

In the subsamples, muscle dysmorphia symptoms were associated with anxiety, social body image anxiety, depression, neuroticism, and perfectionism. The reported correlations were for anxiety r = 0.32 to 0.42, with social body image anxiety r = 0.26 to 0.75, for depression r = 0.23 to 0.53, for neuroticism r = 0.38 and perfectionism r = 0.35. Self-concept and self-esteem were negatively associated with r = −0.32 to −0.36 respectively r = −0.42 to −0.47. These are connections, not evidence of cause or direction.

The study quality was predominantly poor to moderate; eight different survey instruments were used. The overview neither clarifies the causal direction nor a reliable prevalence for all bodybuilders. The high proportion of men also limits transferability to other populations.

What controlled studies of anabolic-androgenic steroids (AAS) show about aggression

A systematic review and meta-analysis of 12 randomized trials involving 562 healthy men found a small increase in self-reported aggression after excluding one outlier. The effect was Hedges g = 0.171 with a 95% confidence interval of 0.029 to 0.312 k = 11. In the analysis of an acute administration was g at 0.291 with a 95% confidence interval of 0.014 to 0.524.

The finding relates to a psychometric self-report in experimental situations. It is not proof that AAS trigger violence or extreme aggression in all users. The effect was not replicated in external assessments or in subanalyses with doses above 500 mg and longer administration. Studies included acute exposures and periods ranging from 3 days to 14 weeks; The transferability to real multiple cycles and vulnerable people is therefore limited.

What can happen when weaning

A systematic review of clinical studies on men with non-medically indicated AAS use and attempts to discontinue reported the following complaints, among others:

• Fatigue, muscle pain, restlessness and insomnia
• depressed mood, loss of libido and loss of appetite
• Suicidal thoughts, body image dissatisfaction and steroid cravings

The studies are heterogeneous and do not provide uniform prevalence or causal evidence for individual symptoms. The covert and illicit nature of use also makes robust characterization of the withdrawal syndrome in a single study difficult.

A clinical review describes chronic AAS discontinuation as being associated with a withdrawal syndrome of anxiety and depression. The suppression of the hypothalamus-pituitary-testes axis, or HPT axis for short, is described as a harmful effect. For men with less than a year of use, typical HPT axis recovery is reported to be within one year. This is a typical, not a universal, prognosis, and does not prove a direct causal chain from hormonal decline to depression.

The available literature therefore does not allow the statement that a universally most dangerous phase exists immediately after discontinuation for all users. Suicidal ideation has been reported, but a prospective time course or causal relationship has not been robustly examined.

What can be deduced about AAS dependency

Steroid cravings have been documented in connection with discontinuation. The clinical overview also describes that stressful withdrawal symptoms can promote a relapse into consumption. However, steroid cravings alone are not evidence of addiction in a particular person.

The clinical reviews do not provide a uniform syndrome definition and a representative prevalence of AAS dependence. There is no reliable test in the available clinical literature for tolerance and continued use despite harm as general characteristics across real user populations. An individual risk of addiction cannot therefore be calculated from bodybuilder status, training volume or a single symptom.

When medical or psychological evaluation makes sense

If you have low mood, anxiety, insomnia, loss of libido, severe body image distress, craving for steroids or suicidal thoughts in connection with discontinuation, a medical and psychological evaluation is a well-founded safety decision. Such complaints are not automatically a diagnosis.

General safety information: If you have acute suicidal thoughts, medical help should be sought immediately.

The evidence for safe and effective treatment of AAS discontinuation and withdrawal is weak. This does not result in a standardized promise of success or a general recommendation for a specific medication or a self-administered discontinuation regimen.

Limits and open questions

The core body image literature is predominantly observational and heterogeneous. It shows connections, but no longitudinal causal chain, from muscle dysmorphia to functional impairment to AAS consumption.

A direct human causal chain from the drop in the HPT axis to depression or relapse has not been proven. Likewise, direct human evidence that changes in GABA or serotonin cause mood or AAS dependence is not reported in the clinical reviews evaluated.

Representative prevalence data for the entire bodybuilding population as well as reliable data for women and other genders are lacking. Moderators such as pre-existing psychopathology, specific AAS combinations, route of administration, dose, duration of use, age and gender have also been insufficiently investigated in real user populations.

There is no reliable evidence on the frequency of combining AAS with ephedrine, fat burners or pre-workouts as well as on AAS-specific randomized studies on psychotherapy, pharmacotherapy, relapse prevention and safe withdrawal.

The robust conclusion therefore remains limited: higher levels of muscle dysmorphia symptoms and psychological associations have been observed in bodybuilders, controlled AAS studies have found a small self-reported aggression effect, and withdrawal symptoms have been clinically described. This does not result in a general diagnosis or an individual prognosis, a universally dangerous withdrawal phase or a blanket statement about aggression.

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