In western countries, it’s common that girls and women strive to be slim. Studies show that their weight dissatisfaction can already be seen in the low-to-normal weight range [1, 2]. Boys and men, in turn, are only dissatisfied when they are clearly overweight . Young men are particularly dissatisfied with low weight and the fact that they don’t have enough muscle mass [4, 5]. Thus, being dissatisfied with muscle size, shape and distinctness is fairly common for teen-aged boys and young men [4, 6] and are the milder forms of muscle dissatisfaction. The ultimate misconception is the seriously disturbed conception of muscles i.e. muscle dysmorphia, which is assumed to be rare .
Being dissatisfied with muscles tends to increase substance use which increase muscle mass.
Both muscle dissatisfaction and muscular dysmorphism is associated with using supplements for increasing muscles. When the dissatisfaction is great, i.e. the closer one is to muscle dysmorphia, it is more likely that anabolic hormones will be used.
In a Finnish population survey , 12% of 22 to 24 year-old men had used some muscle-building products on a regular basis for at least three months. The survey was based on a sample of more than 1,200 people. The survey also found a dose-response relationship  between muscle dissatisfaction and substance use: the more the dissatisfaction increased, the more the likelihood of using mass-increasing substances. The survey did not distinguish between supplements and anabolic hormones.
The statistical relation between muscle dissatisfaction and using muscle-enhancing substances should not be interpreted to mean that all men who develop their muscles with the various methods are dissatisfied with their muscles. As good example is body-builders who, on the contrary, have been shown in the majority to be satisfied with their body , although among them, there are nonetheless more people who have symptoms of muscle dysmorphia and the problems it causes [9,10].
Personality features predispose to body image disturbances
In addition to having symptoms of being dissatisfied regarding one’s body, weight and muscles, dysmorphic body image disturbances and eating disorders which meet the criteria of full psychiatric disease classification, are common in young adults in Western countries [11,12,13,14]. They are psychiatric disorders whose key symptom is body image or eating disorders. In young people, real skinniness (boys) or being overweight (boys and girls) will significantly increase body dissatisfaction and risk of body image and eating disorders [3,5] but, on the other hand, none of those disorders are necessarily related to actual appearance or weight in any way .
Instead, psychological characteristics and personal traits are essential for their pathogenesis . Typical predisposed personality traits for body image disorder, eating disorders and their symptoms are impulsivity, lack of flexibility, low self-esteem, emotional instability and the drive for perfection, which may also occur with unacceptable level of fear of making mistakes.
For the symptoms to develop, various degrees of obsessive thoughts and actions are a most likely prerequisite. This is apparent by repeated mirroring, weighing or measuring of the body, compulsive physical exercise, strong need for symmetry and order as well as harsh rules regarding eating and other aspects in daily life.
In both disorder types there are also unbalanced eating habits , where either a person will not eat regularly or substitute meals, follow strict diets or switch between starvation and over-eating. In addition, depression and anxiety disorders (such as various phobias and panic disorder), as well as body image disturbances are common for both types.
Body image disturbance means that the person sees their own body in an unrealistic manner – either thinking it is too big, too ugly or some other negative characteristic. Concretely this is seen by a person suffering from muscular dysmorphism and who is an extremely musclar person, sees themselves as small and spindly or a person suffering from anorexia seeing themselves as being too fat despite serious malnutrition.
In areas where western culture is dominant, appearance and body dissatisfactions are common, but elsewhere this is rare. The strongest scientific evidence regarding our culture’s provocative effect on body dissatisfaction and eating disorders are from among the indigenous populations of the Pacific Islands. Here, the fairly recent invasion of western media and “values” (Westernization) has rapidly led to becoming a part of everyday life where body dissatisfaction is rampant and there is an increased pursuit of gaining more muscles and being slimmer [17, 18, 19].
Prior to the start of Westernization, obesity-related body dissatisfaction and the glorification of thinness or extreme muscularity were unknown phenomena in these indigenous cultures. This shows that, although genetic susceptibility has a clear influence to the emergence of body dissatisfaction in women  as well as in men , this feature will not appear without a cultural environment which triggers it.
MD, postdoctoral researcher
Department of Public health, University of Helsinki