Revista Adolescência e Saúde

Revista Oficial do Núcleo de Estudos da Saúde do Adolescente / UERJ

NESA Publicação oficial
ISSN: 2177-5281 (Online)

Vol. 14 nº 1 - Jan/Mar - 2017

Case Report Imprimir 

Páginas 97 a 101


Bigorexia - a self-diagnose case

Vigorexia - un caso de autodiagnóstico

Vigorexia - um caso de autodiagnóstico

Autores: Cláudia Patrícia Simões Mendes Arriaga1; Sílvia Neto2; Rita Moinho3; Graça Milheiro4; Alexandra Luz5; Pascoal Moleiro6

1. Pediatrics Intern, Pediatrics Unit, Leiria Hospital Center, Leiria, AC, Portugal
2. Pediatrics Intern, Pediatrics Unit, Leiria Hospital Center, Leiria, AC, Portugal
3. Pediatrics Assistant, Pediatrics Unit, Coimbra Pediatric Hospital, Coimbra Hospital Center and University. Coimbra, AC, Portugal
4. Pediatric Psychiatry Assistant, Pediatrics Unit, Leiria Hospital Center,Leiria, AC, Portugal
5. Pediatrics Assistant, Pediatrics Unit, Leiria Hospital Center, Leiria, AC, Portugal
6. Pediatrics Assistant, Pediatrics Unit, Leiria Hospital Center, Leiria, AC, Portugal

Cláudia Patrícia Simões Mendes Arriaga
Largo do Pinheiro Manso Nº1
Carapinheira, Portugal. CEP: 3140-073
arriaga_c@hotmail.com

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Keywords: Body image, male, adolescent behavior, muscle development, adolescent medicine.
Palabra Clave: Imagen corporal, masculina, comportamiento del adolescente, desarrollo muscular, medicina del adolescente.
Descritores: Imagem corporal, masculino, comportamento do adolescente, desenvolvimento muscular, medicina do adolescente.

Abstract:
OBJECTIVE: Raise awareness among healthcare professionals to a less common conduct disturbance, the bigorexia, characterized by an excessive concern with muscularity and body image.
CASE DESCRIPTION: A 17 years old adolescent was referred to an Outpatient Adolescent Medicine Clinic due to muscular pain, predominantly at the shoulders, with one year of evolution. He was a weightlifting practitioner and he had stopped this activity two months before with no relief. During the interview, he presented a high concern with his body shape, namely referring thin arms, loss of muscular mass, flaccid abdomen and an increase of body fat. He denied the consumption of dietary supplements and anabolic drugs. Analytical and imaging auxiliary tests were performed which excluded organic disease. Follow-up consultations with family involvement, revealed an adolescent with low self-esteem, an obsession with body shaping, tendency to social isolation and long periods of time spent at the gym. The diagnosis of bigorexia was evoked by the adolescent and confirmed by the pediatrician. Improvement was achieved with intervention of a multidisciplinary team (pediatrician, dietitian and child psychiatrist), modulation of his social skills, promoting self-esteem and supervised return to physical activity.
COMMENTS: Bigorexia differential diagnosis includes other behavioral disorders, namely those that shows changes in body image perception. Healthcare professionals should know its signs and symptoms leading to a timely identification of the disorder, crucial for an adequate approach and treatment.

Resumen:
OBJETIVO: Alertar a los profesionales de salud para un trastorno de la conducta poco conocido, la vigorexia, que se caracteriza por una excesiva preocupación con la imagen corporal y con la musculatura.
DESCRIPCIÓN DEL CASO: Adolescente de 17 años del sexo masculino indicando en la consulta de Medicina del Adolescente dolor muscular, predominantemente en los hombros, con un año de evolución. Era practicante habitual de halterofilia, habiendo suspendido lapráctica de esta modalidad dos meses antes sin mejoría. Durante la consulta, reveló gran preocupación con la forma corporal, específicamente brazos finos, pérdida de masa muscular, abdomen flácido y aumento de grasa corporal. Negaba consumo de suplementos dietéticos y productos anabolizantes. Fue realizada averiguación complementaria, analítica y de imagen, con exclusión de patología orgánica. El cuidado posterior con envolvimiento familiar reveló un adolescente con baja autoestima, obsesión por la imagen corporal, inclinación al aislamiento social y largos períodos de tiempo anterior en el gimnasio. El diagnóstico de vigorexia fue revelado por el propio adolescente y confirmado por el pediatra. La recuperación pasó por intervención de un equipo multidisciplinario (pediatra, dietista y pedopsiquiatra), con modulación de las capacidades sociales, promoción de la autoestima y retorno controlado a la actividad física.
COMENTARIOS: El diagnóstico diferencial de vigorexia incluye disturbios de conducta, especialmente los que cursan con alteración de percepción de imagen corporal. Los profesionales de salud deben conocer las señales y síntomas que la caracterizan llevando a una identificación precoz del disturbio, siendo esta fundamental para un óptimo abordaje y prestación de atenciones.

Resumo:
OBJETIVO: Alertar os profissionais de saúde para um transtorno da conduta pouco conhecido, a vigorexia, que se caracteriza por uma excessiva preocupação com a imagem corporal e com a musculatura.
DESCRIÇÃO DO CASO: Adolescente de 17 anos do sexo masculino referenciado à consulta de Medicina do Adolescente por dor muscular, predominantemente nos ombros, com um ano de evolução. Era praticante habitual de halterofilismo, tendo suspendido a prática desta modalidade dois meses antes sem melhoria. Durante a consulta, revelou grande preocupação com a forma corporal, nomeadamente referindo braços finos, perda de massa muscular, abdómen flácido e aumento de gordura corporal. Negava consumo de suplementos dietéticos e produtos anabolizantes. Foi realizada investigação complementar, analítica e de imagem, com exclusão de patologia orgânica. O seguimento posterior com envolvimento familiar, revelou um adolescente com baixa autoestima, obsessão pela imagem corporal, tendência ao isolamento social e longos períodos de tempo passados no ginásio. O diagnóstico de vigorexia foi evocado pelo próprio adolescente e confirmado pelo pediatra. A recuperação passou pela intervenção de uma equipa multidisciplinar (pediatra, dietista e pedopsiquiatra), com modulação das competências sociais, promoção da auto-estima e retorno controlado à atividade física.
COMENTÁRIOS: O diagnóstico diferencial de vigorexia se faz inclui distúrbios da conduta, nomeadamente os que cursam com alteração da percepção da imagem corporal. Os profissionais de saúde devem conhecer os sinais e sintomas que a caracterizam levando a uma identificação precoce do distúrbio sendo esta fulcral para uma ótima abordagem e prestação de cuidados.

INTRODUCTION

Over time, social evolution has been based on models, many of them headlined by the media1. The body has become a key element in personal identity, with a trend towards the uniformization of human diversity. Social media showcase an image of perfection centered on a lean body as a symbol of health and well-being1. Dietary constraints and diets, together with exercise, appear as ways of reshaping the body and consequently attaining perfection2,3. The quest for beauty and the cult of the perfect body has fostered the appearance of psychiatric pathologies 3.

During the past few years, new non-drug addictions have been appearing2, consisting of apparently harmless repetitive activities that trigger feelings of satisfaction, pleasure and control, in pursuit of a specific target2. They have appeared in several fields, particularly physical activity, where bigorexia is an example. This syndrome is still a matter of much dispute among authors3-5, due to difficulties in its classification. It is characterized by the presence of repetitive thoughts about the need to exercise in order to pump up muscle mass, as these people see themselves as thinner than they really are3.

Despite earlier references to exercise as an addiction, it was during the 1990s that an entity appeared where exercise became an obsession6,7. Described by Pope in 19936, he called this reverse anorexia due to its similarity to eating disorders. Subsequently, other names have also been used: Adonis complex or muscle dysmorphia2,5,8.

Today, this diagnosis is distinguished from eating disorders9, particularly during phases of clear dissatisfaction with self-image, seeking to alter the body through diet and physical activities, necessarily recalling that these disorders also occur among males10. The differences appear when weight is relativized, with no fear of "being fat", but with concern focused rather on body shape3,11. Concern and conduct focused on a body viewed as under-muscled differs from dissatisfaction with specific parts of the body, as occurs with body dysmorphic disorder. Diagnostic criteria based on the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) shown in Table 112.




Although studies indicate different prevalence rates, it is estimated that 6% to 10% of people going to gym regularly suffer from bigorexia2,6, mainly young men between 18 and 25 years of age2,6.

The authors intend to issue a warning about a pathology that will be under-diagnosed, which interferes significantly with the overall functioning of teenage boys.


CASE DESCRIPTION

This case study addresses an adolescent Caucasian male, 17 years of age, referred for an appointment with the Adolescent Medicine Unit for widespread muscle pain, more specifically around the shoulders, extending back for about a year, and with increasing intensity. The patient denied injury or any other trigger event and had not presented any similar complaints previously, nor any obvious constraints on mobility, joint impairment or stiffness. The pain did not appear at any specific time of day, growing worse with movement and effort and easing when at rest, not relieved by analgesics and curtailing daily activities. There was no reference to any signs of local inflammation, and fever was denied. The adolescent said that he felt fatigued, with alterations in his sleep patterns and weight loss (6 kg in a year), with changed eating habits, selecting "healthy" foods and limiting others that "are fattening". He described himself as a youngster who always ate well, without thinking about nutrients or calories, which is something he now feels is vital for "a healthy body". Always physically active, more than a year and a half ago he signed up with a gym, going there sporadically at first and then every day for two to three hours, preferably lifting weights. Encouraged by his buddies, he took protein supplements for two months, until his parents discovered this and forbade him to do so. He denied taking anabolic steroids, although knowing people who do so. Ordered by his physician, he stopped lifting weights two months previously, although with no indication of relief in the complaints and increasingly strong feelings of personal dissatisfaction, sadness and even guilt. He did not like the way he looked to himself, describing himself as having skinny arms, narrow shoulders and lean thighs, with no muscles, a flaccid stomach and fatty build-ups.

This youngster lived with his parents and a teenage sister, all healthy, engaged in conflictive relationships, particularly with his parents. He had performed well in the classroom up to the 12th grade, a year ago. He denied any consumption of alcohol, tobacco or illegal drugs, and was rarely invited to go out by his classmates. He denied any recent romantic relationship or any wish for a girlfriend, or close friends. According to his parents, he has always tended towards low self-esteem, comparing himself unfavorably to his peers, with rising personal dissatisfaction.

Medical observation noted sad expressions, cooperative speech in a monotone, well-nourished and well hydrated, with adequate muscle mass and a Body Mass Index (BMI) of 22.12kg/m2 putting him in the 50-75 percentile (CDC growth charts). He mentioned pain when moving and palpating his arms, shoulders, thighs and popliteal region, although with no joint pain or palpable adenopathies. Cardiac and pulmonary auscultation and abdominal palpation showed no alterations, reaching puberty stage 5 on the Tanner scale. The mental examination noted sad moods and unhappiness with the situation, low self-esteem and obsessive discourse focused on his body image.

A chest and shoulders X-ray, with abdominal and shoulder echographs showed no alterations. An analytical assessment produced no evidence of anemia, no alterations in the hemogram, plate count and liver and kidney functions; negative inflammation parameters, including sedimentation speeds; summary urine analysis with no alterations and negative toxicology search.

A diagnostic hypothesis of bigorexia was reached, with follow-up during subsequent appointments focused on buttressing self-appreciation mechanisms, reiterating self-concepts and encouraging the identification of elements disrupting his inner balance and triggering anxiety, unhappiness and frustration with himself. After supplementary investigations, he returned to physical activities, gradually improving and with a weight gain associated with muscle hypertrophy, and a well-controlled low-fat protein-rich diet. He put on 12.7kg during a year of monitoring, reaching a BMI of 26.25kg/m2, and happily displaying the muscle hypertrophy of his body and limbs, with no complaints. However, he stated that he wanted even better outcomes and that he felt "hooked" on gym, with daily motivation that was almost obsessive, wondering whether he might have bigorexia.

Once a diagnosis of bigorexia was evoked, the pediatrician and the pediatric psychiatrist confirmed it. Follow-up focused on identifying his malaise, monitoring complaints and respective constraints, allowing him to return to daily activities with rising levels of social involvement and physical activity, without adversely affecting other areas. Follow-up continued for fourteen months, initially with monthly appointments and then every two months, at the Adolescent Medicine and Pediatric Psychiatry Unit. Treatment with an anxiolytic was proposed, which he followed (SOS) responding better to anxiogenic situations. Analytical and imagiological control at six months overlapped.

Regular monitoring, intervention and orientation, all multidisciplinary and tailored to the patient´s needs constituted his treatment plan.


REMARKS

This case study addresses an adolescent boy with feelings of personal dissatisfaction that are very characteristic of this phase. Like other youngsters, the quest for his own identity and an image endowing him with acceptance and advantages in his peer group and for society in general, leads to a level of dysfunction that meets pathological criteria. Social pressures prompt many youngsters to seek changes, associated with feelings of authority over their own bodies and their acts that make them feel they can everything themselves. While the desired shape for adolescent girls is slimness and the most usual method for achieving this is diet control and manipulation, the ideal of heavily muscled bodies is more prevalent among boys, with exercise the way of achieving this. Thus, similar to eating disorders among girls, these disorders currently appearing among boys also belong to the dysmorphic disorders12. Their identification is important, as this may be associated with complex dysfunctions in many areas for these youngsters, meaning that awareness is crucial for intervention12,13.

The presence of self-criticism, acknowledging the obsessive and dysfunctional nature of their ideas, is a key factor for a good prognosis, self-criticism is a key element paving the way to intervention and consequently resulting in minimal levels of drug therapy.

Among these adolescents, similar to the described case, initially symptoms fall within the sphere of obsession and also eating behavior, evoking other pathologies that are hard to diagnose and require early intervention. There are warning signs for which clinicians must be alert: obsession with going to gym and / or compulsive physical exercise; dissatisfaction with the body; eating disorders and consumption of anabolic and other steroids 3,12.

Once this nosological condition has been identified, treatment involves joint psychological and pharmacological approaches14. In addition to early identification, clinicians play a key role in prevention. The intervention of a pediatric psychiatrist is vital in order to supplement the follow-up, helping ensure a better clinical and functional prognosis.

Diagnosing, advising and above all warning about the risks inherent to this disorder is a goal for any healthcare practitioner working with adolescents.


REFERENCES

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2. Molina JMR. Vigorexia: adicción, obsesión o dismorfia; un intento de aproximación. Salud y drogas, 2007; 7: 2007: 289-308.

3. Ribeiro PCP, Oliveira PBR. Culto ao Corpo: Beleza ou doença? AdolescSaude 2011; 8(3): 63-69.

4. Eisenberg ME, Wall M, Neumark-Sztainer D. Muscle-enhancing Behaviors Among Adolescent Girls and Boys. Pediatrics, 2012; 130:1019-1026.

5. Viadel MH, Mirallesa JLG, Viadel JVH. Dismorfia muscular, vigorexia o complejo de Adonis: a propósito de un caso. PsiqBiol 2005; 12: 133-5.

6. Pope HG, Katz DL, Hudson JI. Anorexia nervosa and "reverse anorexia" among 108 male bodybuilders. ComprPsychiatry1993; 34: 406-409.

7. Pope HG, Gruber AJ, Mangweth B, Bureau B, Col C, Jouvent R, Hudson JI. Body image perception among men in three countries. Am J Psychiatry2000; 157:1297-1301.

8. Choi PY, Pope HG, Olivardia R. Muscle dysmorphia: a new syndrome in weightlifters. Br J Sports Med 2003; 37:280-1.

9. Sánchez RM, Moreno AM. Ortorexia y vigorexia: nuevostrastornos de laconducta alimentaria? Trastornos de la Conducta Alimentaria 2007;5:457-482.

10. Moinho R, Dias I, Luz A, Moleiro P. Perturbações do comportamento alimentar em rapazes: que diferenças? Acta PediatrPort 2014; 45: 124-129.

11. Chung B. Muscle dysmorphia: a critical review of the proposed criteria. PerspectBiol Med. 2001; 44: 565-74.

12. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed, Washington DC, 2013.

13. Contesini N, Adami F, Blake MT, Montero CBM, Abreu LC, Valentini VE et al. Nutritional strategies of physically active subjects with muscle dysmorphia. Int Arch Med 2013; 1:6-25.

14. Leone JE, Sedory EJ, Gray KA. Recognition and Treatment of Muscle Dysmorphia and Related Body Image Disorders. J Athl Train 2005; 40(4): 352-359.
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