Some bodybuilders just don't know when to stop. Some get so obsessed with building muscles and sculpting their bodies that they develop a disorder similar to anorexia, called bigorexia or muscle dysmorphia.
Despite their bulging muscles, a small subset of bodybuilders remain convinced they're still scrawny, and that distorted view can make pumping iron their life's focus, to the exclusion of family and work.
Now, a new study suggests that men with bigorexia show eating and behavior patterns as dangerous as those associated with anorexia and bulimia.
Instead of trying to look thin, like someone with an eating disorder, people with bigorexia become desperate to gain muscle, says researcher Barbara Mangweth, a psychologist at the University Clinics of Innsbruck, Austria.
"Bodybuilders act in the reverse way [from anorexics and bulimics]," Mangweth says. Those in the study "tried to eat as often as possible," she says. "Bodybuilders who were participating in competitions were always carrying their doggy bag with them because they needed to eat a certain amount of calories a day, between 4,000 and 5,000 calories a day." People with muscle dysmorphia often avoid restaurant food, she says, because it threatens their strict, high-protein diets.
"Sometimes they change their jobs because they need to do bodybuilding, [and] they leave their families because their women are not able to deal with the situation that their husband is only putting energy into bodybuilding, not other family issues," Mangweth says.
"He gets isolated more and more, and is not able to see how muscular he is or he becomes," she says. "He still feels that he is slim and lean."
Men with the disorder often wear baggy clothes to hide what they think is a small physique. "That's the distortion," she says.
The distortion can lead to extreme attempts to enlarge muscles, she says, with victims sometimes turning to steroids and other dangerous bodybuilding drugs and continuing to pump iron through pain and injury.
Not all bodybuilders suffer from this disorder, Mangweth stresses. "Bodybuilders [who participated in the study] were psychologically very healthy," she says. "It would be a misunderstanding to say that bodybuilders are psychopathologically a new group."
The difference lies in the 1 to 2 percent of bodybuilders who develop muscle dysmorphia disorder.
"This is a group of men who start bodybuilding not just because of a cosmetic reason," she says. "They suffer from depression, obsessive-compulsive disorder or anxiety. The bodybuilding is just one area where they act out their distress."
Treatments include drug therapy and cognitive-behavioral counseling, which teaches men that their thoughts are unrealistic and that they need to reshape their body image more than their muscles, Mangweth says. Results of her study appear in the journal Psychotherapy and Psychosomatics.
But Sharlene Hesse-Biber, a sociology professor at Boston College, says society needs to change its approach to really conquer the problem.
"We're living in a very weight-obsessed culture," Hesse-Biber says, and making it an individual's problem is like blaming the victim.
"We have to look wider than the individual," she says. "We have to look at this as a socio-cultural trouble."

DO YOU SUFFER FROM BIGOREXIA?
Men who have this condition will usually say yes to two or three of the following:
· Do you worry that your body isn't sufficiently lean or muscular?
· Have you eaten special high protein or low fat diets or use food supplements to improve your muscularity?
· Do you sometimes wear heavy clothes to cover your body as you feel you are not big enough?
· Do you continue to work out when you have an injury because you were afraid you would lose muscle mass?
· Do you compare yourself to other men worrying that they are bigger than you?
· Do you feel envious if you see someone bigger than you and do you think about it for sometime afterwards?
· Have you turned down social events, taken time off work or had broken relationships because of the need to work out?
· Do you avoid situations were your body might be seen such as the swimming baths because you don't think you are muscular enough?