3.3.1. Turkey

Five studies identified the mechanism of MD on the associations between disordered eating attitudes, social physique anxiety, frustrated basic needs, body image perception and physical activity in Turkey (Arslan et al., 2022; Devrim et al., 2018; Duran & Oz, 2022; Duran et al., 2020; Selvi & Bozo, 2020). All studies applied validated scales to determine MD symptoms. Three of the studies determined the MD symptoms using the MDDI form (Devrim et al., 2018; Duran & Oz, 2022; Duran et al., 2020), whereas the others applied MASS to evaluate MD presence and muscle dissatisfaction (Arslan et al., 2022; Selvi & Bozo, 2020). Studies using the MDDI form have shown a high prevalence of MD symptoms in bodybuilders between 5.7% in recreational bodybuilders (Duran & Oz, 2022), 58.3% in professional bodybuilders (Devrim et al., 2018), and 11.2% in university students (Duran et al., 2020). In good agreement with these findings, research applying the MASS revealed that drive for muscularity positively predicted each facet of MD in male bodybuilders (Selvi & Bozo, 2020), and MD symptoms and bodybuilding dependence were commonly linked to male students (Arslan et al., 2022).

3.3.2. Iran

Two studies were conducted in Iran on male recreational bodybuilders to evaluate muscle-oriented patterns and related psychopathological and sociodemographic conditions (Angoorani & Halabchi, 2015; Nonahal et al., 2014). One of the studies indicated a positive weak relationship between the role of media (determined using SATAQ-3) and MD (determined using MDDI) (r = 0.26), and positive moderate interaction between MD and perfectionism (determined using MPS) (r = 0.308) and difficulties in emotional regulation (r = 0.47) (Nonahal et al., 2014). The regression analysis also showed that the role of media, perfectionism and the difficulties in emotional regulation predict 26.9% of the variance in MD symptoms in male recreational bodybuilders.

3.3.3. Lebanon

Only one study has been conducted in Lebanon evaluating MD and associated psychological indicators. Investigating the MD symptoms and their interaction with eating attitudes, orthorexia nervosa (ON), and perfectionism in male university students, the study findings revealed that 6.6% of the participants had MD symptoms (determined via MDDI) (Merhy et al., 2023). Rigid perfectionism and self-critical perfectionism were found to be negatively linked to eating attitudes (r = −0.56 and −0.47, respectively). In addition, ON was suggested to be a main mediator of all subdivisions of perfectionism, revealing that perfectionism may result in healthy eating attitudes by the fear of imperfection.

3.3.4. Kuwait

In Kuwait, one study was performed to determine the prevalence of disordered eating and body dissatisfaction based on current body composition among male university students (Ebrahim et al., 2019). The findings showed that a higher percentage of participants had disordered eating attitudes (46.2%) determined using EAT-26, and most participants (67.3%) were dissatisfied with their current muscle mass and 57.5% wanted to increase their muscle mass, evaluated using BIG.

3.3.5. North Cyprus

Harmancı and Okray (2021) conducted a cross-sectional study in North Cyprus (Turkish Republic of Northern Cyprus) aiming to evaluate MD symptoms, narcissistic personality traits and body image perception in male recreational bodybuilders compared to sedentary individuals (Harmancı & Okray, 2021). Results showed that a narcissistic tendency was positively associated with functional impairment and narcissistic tendency, MD symptoms, and body dissatisfaction was higher in bodybuilders compared to sedentary individuals.

4.1.1. Turkey

Studies conducted in Turkey presented a high rates of MD symptoms in both professional and recreational bodybuilders and university students (58.3, 5.7 and 11.2%, respectively). International Obsessive-Compulsive Disorder Foundation indicates that 0.5% of men may meet MD criteria (Olivardia et al., 2023). However, literature on MD research reported a higher prevalence of MD symptoms in bodybuilders such as 3.4% in Southern Italy (Cella et al., 2012), 25% in Northern Italy (Longobardi et al., 2017), and 58.6% in South Africa (Hitzeroth et al., 2001). In line with the literature (Cella et al., 2012; Hitzeroth et al., 2001; Longobardi et al., 2017), the current findings indicated a high level of MD symptoms in Turkey. These results reveal that the preoccupation with being more muscular could be a serious psychopathological problem, especially among professional bodybuilders. Researchers and health professionals should work together to develop measures and/or validate clinical cut-off scores on existing measures to detect MD symptoms and the severity of symptoms, as it is well known that MD symptoms can trigger many psychopathological problems (Murray et al., 2019).

In contrast to existing literature (Thomas et al., 2014; Zheng et al., 2021), one study showed a positive but weak correlation between social physique anxiety and MD in male bodybuilders and stated that bodybuilders had low levels of MDDI scores (Duran & Oz, 2022). However, they included bodybuilders who participated in bodybuilding sports for at least one month and one month may not be enough to develop MD symptoms and social physique anxiety related to MD.

Literature on MD provided a stronger relationship between MD and ED psychopathology (Badenes-Ribera et al., 2019; Mitchell et al., 2017), indicating that people with MD symptoms may develop disordered eating attitudes to achieve more muscle mass. Disordered eating attitudes include behaviours such as having more protein in their diets than recommended, constantly thinking about what to eat throughout the day and preferring to eat alone (Devrim et al., 2018). In line with the literature (Badenes-Ribera et al., 2019; Mitchell et al., 2017), one study included in the review indicated that disordered eating attitudes are positively associated with MD symptoms in male bodybuilders (r = 0.614, p < 0.001) (Devrim et al., 2018). In addition, bodybuilders with ED had higher body image and muscle mass dissatisfaction. An interesting finding showed that bodybuilders with MD symptoms pay more attention to their own opinions, even if their partners don’t like their body image (Devrim et al., 2018). This may be related to childhood secure attachment problems and their perspectives on emotional relationships. One study noted a significant interaction between MD and insecure-avoidant attachment style in early childhood (Fabris et al., 2018). It shows that individuals with an insecure-avoidant attachment in childhood also avoid attachment to their partners in adulthood (Fabris et al., 2018; Mohd Hasim et al., 2018).

Studies have mainly been conducted on young adults in Turkey. With the sociocultural changes, migration problems and economic crisis experienced in Turkey in recent years, many young adults cannot find the opportunity to meet their basic psychological needs. This may lead them to preoccupy their body to become more muscular and develop MD and associated psychopathologic problems in the long term.

4.1.2. Iran

Two studies in Iran on male recreational bodybuilders to evaluate muscle-oriented patterns and related psychopathological and sociodemographic conditions (Angoorani & Halabchi, 2015; Nonahal et al., 2014). Studies on MD and media noted that media triggers the desire to be thinner in women and a more muscular body type in men (Calogero et al., 2004; Imperatori et al., 2022). In addition, one study presented a significant link between social media addiction, MD, and EA (Imperatori et al., 2022). The role of media on the ideal body internalization may enhance body image-related concerns and disordered eating attitudes, causing undesirable psychologic consequences in Iran.

Another study investigated the prevalence of anabolic androgenic steroid use and its interaction with psycho-socioeconomic factors and body image perception; however, researchers did not evaluate MD symptoms since there is no validated questionnaire to determine MD symptoms in Iran (Angoorani & Halabchi, 2015). Therefore, further studies are needed to make a reliable prediction about MD and associated determinants in Iran.

Investigating the prevalence of AAS use and its interaction with psycho-socioeconomic factors and body image perception, Angoorani and Halabchi (2015) showed that 16.6% of bodybuilders used AAS, and AAS use in bodybuilders was higher in those with low family income and younger age groups. Researchers explained these results as difficulties in reaching healthy foods may trigger the use of AAS in order to achieve the desired body shape and size, and experienced athletes may not report all supplements administered correctly due to doping/ethical concerns (Angoorani & Halabchi, 2015). Research on MD has highlighted that bodybuilders with MD tend to use more AAS to achieve desired body shape, and muscle dissatisfaction may be a triggering factor in using AAS to achieve the ideal body image (Nogueira et al., 2014; Rohman, 2009). In contrast to these claims, no association was detected between body image perception and AAS use among male recreational bodybuilders in the study (Angoorani & Halabchi, 2015). However, although they included high numbers of participants, they did not add bodybuilding experience as an inclusion criterion. Therefore, it is hard to predict how long participants participated in bodybuilding sports. As we know that MD is a type of condition that worsens along with time and experience (Cafri et al., 2005; Grieve et al., 2009), we could not generalize these results to all male recreational bodybuilders in Iran.

4.1.3. Lebanon

The only study about MD in Lebanese male university students showed that disordered eating attitudes can mediate MD symptoms and body dissatisfaction in rigid individuals and self-perfectionists with a predominant sense of dissatisfaction (Merhy et al., 2023). Along with the findings, although perfectionism may trigger more healthy eating, the preoccupation with the perfect eating model may worsen MD psychopathology. These findings are in accordance with the current literature (Arji et al., 2016; Dryer et al., 2016; Dunkley & Blankstein, 2000; Perkins, 2019), suggesting that perfectionism may be an important contributor to the development of MD symptoms and associated psychological problems including anxiety disorders, and depression. Since MD and related psychological problems may be severe in individuals who are chronically concerned about disapproval and rejection from others and constantly making self-criticism (Dunkley & Blankstein, 2000), experts may primarily focus on the underlying perfectionism problem prior to treating MD symptoms.

4.1.4. Kuwait

The only study on body dissatisfaction and disordered eating in Kuwaiti male university students showed high levels of disordered eating attitudes (46.2%) and body dissatisfaction (67.3%) (Ebrahim et al., 2019). Researchers highlighted that one of the main reasons for body dissatisfaction and disordered eating attitudes is due to the high rates of being overweight (33%) and obese (17.8%) (Ebrahim et al., 2019). Although researchers did not determine MD symptoms, higher rates of disordered eating attitudes, body dissatisfaction, personality characteristics and desiring a more muscular body shape may contribute to the development MD (Boulter & Sandgren, 2022; Devrim et al., 2018; Suffolk et al., 2013). To our knowledge, no study determined the MD symptoms in either clinical or non-clinical samples and no validated questionnaires were present in Kuwait. Therefore, the MDDI is the most widely used measure of MD symptoms (Sandgren & Lavallee, 2018) and this should first be validated in Kuwait. There is a need for future studies in which self-esteem, mental health and body dissatisfaction and MD symptoms are determined together in Kuwaiti individuals.

As the researchers highlight, Kuwaiti young adults may have cultural adjustments compared to Western countries, and collectivism as the prevailing cultural framework in Kuwait can lead to lower self-esteem and mental health problems such as anxiety, depression, and pessimism (Ebrahim et al., 2019). In accordance with this prediction, a meta-analysis on body dysmorphic disorder and self-esteem showed a stronger link between low self-esteem and body dysmorphic disorders (Kuck et al., 2021). this meta-analysis underlined the importance of treating basic psychological needs in improving self-esteem, as these can trigger co-occurring psychological problems such as severe depression.

4.1.5. North cyprus

The only study on MD symptoms of bodybuilders in North Cyprus presented that a narcissistic tendency was positively associated with functional impairment and narcissistic tendency, MD symptoms, and body dissatisfaction was higher in bodybuilders compared to sedentary individuals. The existing literature on MD and narcissism provided controversial results (Christopher et al., 2018; Collis et al., 2016; Littrell et al., 2020). Some researchers suggested a positive link between MD and narcissistic tendency (Christopher et al., 2018; Littrell et al., 2020), while others showed no correlation (Collis et al., 2016). One study that well illustrates the reason for these controversial results determined the relationship between narcissism and MD by identifying both dimensions of narcissism (vulnerable and grandiose) (Boulter & Sandgren, 2022). Results showed that vulnerable narcissism, reflecting being insecure, and hypersensitive to rejection, was linked to MD, while no association was found between grandiose narcissism and MD. These findings suggest that vulnerable narcissism and MD psychopathology shared the same facets of negative emotionality. Therefore, health professionals should consider vulnerable narcissism as a risk factor for MD symptoms in North Cyprus.

4.2.1. Bodybuilders

Six studies included in the systematic review were conducted on bodybuilders (n = 1958) (Angoorani & Halabchi, 2015; Devrim et al., 2018; Duran & Oz, 2022; Harmancı & Okray, 2021; Nonahal et al., 2014; Selvi & Bozo, 2020), and only the male gender was included. Two of four studies determining MD symptoms presented a high level of MD symptoms in bodybuilders, 5.7% in recreational (Duran & Oz, 2022) and 58.3% in professional bodybuilders (Devrim et al., 2018). On the other hand, although other studies did not define the exact percentage of bodybuilders with MD symptoms, they showed the mediator role of media, difficulties in emotion regulation, narcissistic tendency and body dissatisfaction on MD symptoms (Harmancı & Okray, 2021; Nonahal et al., 2014; Selvi & Bozo, 2020), inconsistent with literature (Christopher et al., 2018; Dryer et al., 2016; Grieve, 2007; Littrell et al., 2020). Only one study involved both professional and recreational bodybuilders (Devrim et al., 2018); however, it compared MD symptoms by the presence of an EA rather than comparing them within groups. These findings indicated that MD is an emerging problem common among bodybuilders in the Middle East and is influenced by many psychological and sociocultural factors. In addition, one study determining MD symptoms in accordance with the Basic Psychological Needs showed that MD symptoms may worsen when individuals’ basic psychological needs are not met (Selvi & Bozo, 2020). As previously known, the main issue in MD is to diagnose the individual rather than treatment (Leone et al., 2005; Soler et al., 2018). Therefore, health professionals should use the cause/mediation factors found to be associated with MD in bodybuilders in the Middle East.

Only one study determined the potential interaction between EA and MD disorders, indicating that MD disorders were highly associated with disordered eating attitudes in both professional and recreational male bodybuilders (r = 0.614, p = 0.001) (Devrim et al., 2018). This data is consistent with the literature showing a stronger link between ED and MD psychopathology, indicating that bodybuilders’ efforts to become more muscular can cause them to follow restrictive diets and disrupt their eating behavior (Babusa & Túry, 2012; Badenes-Ribera et al., 2019; Dryer et al., 2016; Mitchell et al., 2017). Thus, paying attention to eating attitudes could provide a significant clue in detecting MD symptoms in bodybuilders. In addition, since both ED and MD problems are very difficult to diagnose (Leone et al., 2005; Murray et al., 2019; Soler et al., 2018; Strother et al., 2012), it is recommended that when one is diagnosed, the other should be evaluated at the same time.

Although the potential interaction between AAS use and MDD is commonly discussed in MD literature (Babusa & Túry, 2012; Rohman, 2009), it is not known exactly whether AAS use may trigger MD symptoms or vice versa. One study determining the relationship between AAS use and body image perception found no association between AAS use and body dissatisfaction in bodybuilders in Iran (Angoorani & Halabchi, 2015). However, they did not evaluate MD symptoms. Since AAS use may be a life-threatening factor beyond being unethical, AAS use, MD and body image disorder should be determined together in studies to be conducted in the Middle East. In addition, clinical studies should be conducted to ascertain the exact rate of AAS use, as bodybuilders tend not to mention current AAS use due to doping and ethical concerns.

4.2.2. University students

MD research on university students in the Middle East was mainly focused on MD symptoms and its interaction with EA, in particular, disordered eating attitude and orthorexia, body image disturbance, perfectionism, self-confidence, and body and muscle dissatisfaction (Arslan et al., 2022; Duran et al., 2020; Ebrahim et al., 2019; Merhy et al., 2023). Although they use different scales to evaluate muscle dysmorphic disorder and body image, all articles showed that MD symptoms, muscle dissatisfaction and body image disturbance were common among male university students. The prevalence of MD is found to be higher in university students (6.6 to 11.2%), similar to university students in Argentina (6.9%) (Compte et al., 2015), and Italy (5.9%) (Gorrasi et al., 2020). One reason may be that most young male adults dream of having big arms, broad shoulders, developed chest muscles, and V-shape. In order to achieve this image, they do intense bodybuilding exercises and regulate their nutrition. Although it does not cause a problem in the beginning, it can be triggered by socio-cultural pressure such as the media and environment over time, and this situation can trigger the development of MD and associated psychological problems including anxiety, depression, compulsive behaviours like staring at their muscles on the mirror for hours (Begin et al., 2019; Grossbard et al., 2011; Zheng et al., 2021). Thus, health professionals should be aware of the common mediators observed in individuals with MD and determine potential co-existing psychological problems including self-esteem, perfectionism, and body image perception to provide appropriate treatment.

Only one study included the female gender (n = 722) and showed that muscle dissatisfaction, bodybuilding dependence and obesity anxiety are higher in males compared to females, implying that males are more prone to muscle-oriented preoccupation and MD symptoms (Arslan et al., 2022). This is consistent with the literature suggesting that norms are heavily gender-dependent, such as men wishing to have more muscle mass while women idealize a thinner body image (Grossbard et al., 2011). In addition, all studies examined EA symptoms. Results showed either a high level of disordered eating attitudes (46.2 to 64.1%) (Arslan et al., 2022; Ebrahim et al., 2019; Merhy et al., 2023) or participants with health eating obsession presented more MD symptoms (Duran et al., 2020). Previous research on ON, an EA, and MD revealed contradictory results. Some studies found a meaningful interaction between ON tendency and MD symptoms (Cerea et al., 2018; Gorrasi et al., 2020), while others stated that the relationship between ON and MD in university students was unclear (Bo et al., 2014). Individuals with MD may tend to eat more planned and healthier foods compared to their counterparts, and this may evolve as a preoccupation with healthy eating eventually. In addition, one should be noted that some research presented healthy eating obsession as a potential risk factor for eating disorders (Parra-Fernandez et al., 2018). Studies on orthorexia have also reported that when orthorexia overlaps with perfectionism this may trigger the psychopathology of MD (Merhy et al., 2023). Therefore, it may be helpful for health professionals to determine ON tendency in individuals with MD or ED potential.

Surprisingly, in a cross-sectional study on university students presented a positive weak correlation between MD and physical activity (Arslan et al., 2022). However, this result may not represent real conditions, as they collected the data during the COVID-19 outbreak.

4.3.1. Muscle dysmorphia

As suggested in the literature (Badenes-Ribera et al., 2019), studies included in the systematic review applied the MDDI (Hildebrandt et al., 2004), and the MASS (Mayville et al. 2002) to detect MD symptoms. Six of the ten studies applied the MDDI (Devrim et al., 2018; Duran & Oz, 2022; Duran et al., 2020; Harmancı & Okray, 2021; Merhy et al., 2023; Nonahal et al., 2014). Of the studies, four of them defined the cut-off value of MDDI and indicated a high level of MD symptoms in both professional and recreational bodybuilders (5.7 and 58.3%) (Devrim et al., 2018; Duran & Oz, 2022), and male university students (6.6 and 11.2%) (Duran et al., 2020; Merhy et al., 2023). Other two studies showed that perfectionism, media, emotional dysregulation in recreational bodybuilders (Nonahal et al., 2014), and body dissatisfaction and functional impairment in recreational bodybuilders may be the main mediators of MD symptoms (Harmancı & Okray, 2021). Studies applying MASS have also revealed the implicit interaction between the drive for muscularity and MD symptoms in recreational bodybuilders (Selvi & Bozo, 2020) and between muscle dissatisfaction and bodybuilding addiction in male university students (Arslan et al., 2022). Only two studies (conducted in Iran and Kuwait) did not include any questionnaires to determine MD symptoms due to the lack of valid measurement tools in their country (Angoorani & Halabchi, 2015; Ebrahim et al., 2019). As most of the studies applied the highly-recommended tools in detecting MD symptomatology (Badenes-Ribera et al., 2019), we can interpret these results as both bodybuilders and male university athletes in the Middle East presented a noticeable level of MD symptoms.

4.3.2. Appearance and image

Research on MD has noted body image perception as one of the main mediators in MD research (Dryer et al., 2016; Hildebrandt et al., 2004; Suffolk et al., 2013), as a possible first step in MD development may be body and muscle dissatisfaction. Therefore, most studies include measurement tools to detect body appearance and image perception to determine its predicted effect on MD symptoms (Hildebrandt et al., 2004; Santarnecchi & Dettore, 2012). The BIG (both original and scaled forms) (Hildebrandt et al., 2004), BIS, DOS (McCreary et al., 2004), SPAS (Hart et al., 1989), MBSRQ (Cash, 1990), and the SATAQ-3 (Thompson et al., 2004) were used to detect body image concerns and satisfaction in studies included in this systematic review. Seven studies including the measurement tools on body appearance and image perception provided conflicted results (Angoorani & Halabchi, 2015; Devrim et al., 2018; Duran & Oz, 2022; Ebrahim et al., 2019; Harmancı & Okray, 2021; Nonahal et al., 2014; Selvi & Bozo, 2020). Four of the seven studies (57.1%) showed high muscle dissatisfaction with the current body and a desire for a more muscular body shape (Devrim et al., 2018; Ebrahim et al., 2019; Harmancı & Okray, 2021; Selvi & Bozo, 2020). In addition, drive for muscularity and body dissatisfaction were found to be positively associated with MD psychopathology (Selvi & Bozo, 2020).

All studies found meaningful interaction between MD and body image perception administered validated measurement tools and two of the studies conducted on bodybuilders set inclusion criteria as doing bodybuilding for at least one year (Devrim et al., 2018; Harmancı & Okray, 2021; Selvi & Bozo, 2020). Other three studies found weak or no correlation between body image dissatisfaction and MD symptoms (Angoorani & Halabchi, 2015; Duran & Oz, 2022; Nonahal et al., 2014). However, one of them included participants doing bodybuilding for at least one month (Duran & Oz, 2022). Therefore, considering the study methodologies, body image dissatisfaction and the desire of being more muscular may trigger MD symptoms in male university students and both professional and recreational bodybuilders living in the Middle East. These findings are consistent with the literature (Begin et al., 2019; Cafri et al., 2005); individuals try to achieve an ideal body image such as being more muscular by exercising more and restricting their diets because they are not satisfied with their current body, thus this goal may trigger MD. It seems that MD and body image disorder have a bidirectional interaction, MD can be triggered when the person is not satisfied with their current body shape, and body image perception may deteriorate further as MD develops. Therefore, determining both MD and body image perception together can help in determining the severity of MD in individuals, which can be decisive when determining the treatment approach.

4.3.3. Eating disorders

As studies suggested EA as a potential mediator for MD symptoms (Badenes-Ribera et al., 2019; Dryer et al., 2016), five studies (one in bodybuilders (Devrim et al., 2018) and four in male university students (Arslan et al., 2022; Duran et al., 2020; Ebrahim et al., 2019; Merhy et al., 2023) administered questionnaires related to eating behaviours. To determine eating attitudes associated MD symptoms, studies used the EAT (both the long (EAT-40) and short form (EAT-26)) (Garner & Garfinkel, 1979), ORTO-11 (Donini et al., 2004) and DOS (Barthels et al., 2015). Four (80%) of the studies showed that disordered eating attitudes or healthy eating obsession may trigger MD psychopathology and body dissatisfaction in both bodybuilders and male university students (Devrim et al., 2018; Duran et al., 2020; Ebrahim et al., 2019; Merhy et al., 2023), in consistent with the studies on MD and ED (Badenes-Ribera et al., 2019; Dryer et al., 2016; Mitchell et al., 2017). A systematic review on bodybuilders showed that bodybuilders consumed a high-protein (1.9–4.3 g/kg/day), low-carb diet (<6 g/day, <30 of total energy) (Spendlove et al., 2015). In addition, studies have indicated that bodybuilders do not pay attention to micronutrient intake when accounting for macronutrients in their diets (Amanda et al., 2018; Ismaeel et al., 2017; Spendlove et al., 2015). Bodybuilders should be informed about the long-term consequences of consuming more protein than recommended to increase muscle hypertrophy, the importance of carbohydrates for recovery after resistance exercises, and the importance of micronutrients for energy metabolism and muscle physiology.

In a meta-analysis on determining ED and MD psychopathology suggested the Eating Disorder Examination Questionnaire (EDE-Q) modified form is the more sensitive measurement tool in determining eating attitudes in studies on MD as the form comprises muscularity-related questions (Badenes-Ribera et al., 2019). In addition, Since the MOET consisted of questions about muscle-oriented disordered eating, it has been considered a good measurement tool for assessing MD symptoms (Murray et al., 2019). However, none of the studies conducted in the Middle East applied these questionnaires. One reason might be that these tools are not validated in their country. Therefore, since EA are so difficult to diagnose (Strother et al., 2012) and can be extremely problematic in every aspect of well-being, validating more appropriate tools for MD research could be a great addition to future research.

4.3.4. Personal characteristics

The BPNSFS (Chen et al., 2014), MPS (Frost et al., 1990), BTPS (Smith et al., 2016), SCS (Akin, 2007), and NPI (Raskin & Hall, 1979) were the measurements tools in defining personal characteristics in the MD studies. All studies on personal characteristics and MD symptomatology indicated that perfectionism, narcissistic tendency and low self-confidence may be one of the indicators triggering or worsening MD psychopathology (Duran et al., 2020; Harmancı & Okray, 2021; Merhy et al., 2023; Nonahal et al., 2014; Selvi & Bozo, 2020). In addition,Selvi & Bozo, 2020 determined MD psychopathology within the scope of the Basic Psychological Theory in bodybuilders. Researchers presented a new perspective, revealing that MD symptoms may develop or worsen if one’s basic psychological needs are not met. It has been emphasized that basic psychological needs such as autonomy, competence, and relatedness are the main predictors of psychological health and well-being. The frustration of any of those needs may have negative consequences on psychopathology that cause body image-related concerns and associated psychopathologic problems. In the study, findings showed that both frustrated relatedness and need frustration had indirect links to all aspects of MD and positively predicted drive for muscularity (Selvi & Bozo, 2020). To be more precise, bodybuilders may develop muscle dissatisfaction due to their inability to achieve their desired goals in life, their inability to decide freely, and their lack of belonging in relationships, which may lead to creating a preoccupation to have more muscle mass to compensate for their frustration needs.

4.3.5. Health and fitness

The GHQ 28 (Goldberg & Hillier, 1979) and IPAQ (Craig et al., 2003) were applied to determine the general health and physical activity levels of participants in the studies. One study on bodybuilders revealed that low family income and younger age may cause more AAS use in recreational bodybuilders (Angoorani & Halabchi, 2015). However, they applied a self-administered questionnaire, therefore, all bodybuilders may not inform about their AAS use frankly. Another study on male university found a weak association between physical activity and MD symptoms (r = 0.249, p < 0.001) (Arslan et al., 2022). As the data collected during the COVID-19 pandemic, results may not present the actual condition.