RESEARCH ARTICLE The Emotional Regulatory Features of Bulimic Episodes and Compulsive Exercise in Muscle Dysmorphia: A Case Report Stuart B. Murray 1 * , Sarah Maguire 2 , Janice Russell 3 & Stephen W. Touyz 1 1 School of Psychology, University of Sydney, Sydney, NSW, Australia 2 Centre for Eating and Dieting Disorders, University of Sydney, Sydney, NSW, Australia 3 School of Medicine, University of Sydney, Sydney, NSW, 2006, Australia Abstract Muscle dysmorphia is a recently identified psychiatric condition, whose relationship to the eating disorders remains unclear. This case describes an adolescent male who met diagnostic criteria for both an eating disorder not otherwise specified and muscle dysmorphia, allowing the first examination of read muscle dysmorphia presentations. This case suggests that muscle dysmorphia may present inclusive of episodes of binge eating and purging in addition to compulsive exercise, which may serve an emotional regulation function. We suggest that the assessment of muscle dysmorphia include a comprehensive assessment of all eating disorder features including bulimic symptoms, and that treatment address these features. Clinical implications for the conceptualization of muscle dysmorphia are discussed. Copyright # 2011 John Wiley & Sons, Ltd and Eating Disorders Association. Keywords muscle dysmorphia; male eating disorder; male body image; emotion regulation *Correspondence Stuart B. Murray, School of Psychology, University of Sydney, Sydney, NSW 2006, Australia. Tel: þ61 420 838734. Fax: þ61 2 9036 5223. Email: stuartm@psych.usyd.edu.au Published online 27 January 2011 in Wiley Online Library (wileyonlinelibrary.com) DOI: 10.1002/erv.1088 Empirical research investigating body image concerns in males has consistently concluded that males are becoming equally as body dissatisfied as their female counterparts (Garner, 1997). This body dissatisfaction however, rather than presenting as a desire to lose weight, as is commonly observed in females, presents as a desire to gain weight and enhance the visible appearance of lean muscularity (McCreary & Sasse, 2000). Muscle dysmorphia is a recently identified psycho- logical disorder, defined by a pathological desire to increase muscle mass, and most commonly occurs in males (Olivardia, 2001). Although relatively recently identified, this disorder was initially conceptualized and hypothesized to be a reverse form of anorexia nervosa, due to their striking similarities, and an elevated prevalence or previous features of anorexia nervosa (Pope, Katz, & Hudson, 1993). A characteristic distortion of one’s body size was identified, which in the case of muscle dysmorphia leads one to under- estimate one’s current level of muscularity, causing significant distress (Pope, Gruber, Choi, Olivardia, & Phillips, 1997). A similar, inverted mechanism is well understood in anorexia nervosa, and leads those afflicted to overestimate their body mass, also causing significant distress (Mangweth et al., 2003) along with a complex array of behavioural and cognitive com- pensatory features, including dietary modification and exercise-related practices. Muscle dysmorphia also includes a complex array of behavioural and cognitive features, including diet and exercise regimens, and avoidant behaviours which reinforce beliefs about being too small (Olivardia, 68 Eur. Eat. Disorders Rev. 20 (2012) 68–73 ß 2011 John Wiley & Sons, Ltd and Eating Disorders Association.