Jason Nagata Pushes DSM Reclassification For Muscle Dysmorphia, Expanding Eating Disorder Access

Jason Nagata, an associate professor of pediatrics in the Division of Adolescent and Young Adult Medicine at the University of California, San Francisco and an eating disorders hospitalist at UCSF Benioff Children’s Hospital, is making a policy argument with direct clinical consequences: muscle dysmorphia should be reclassified as an eating disorder in the upcoming sixth edition of the DSM.

His case, laid out in an interview with STAT, is that the current diagnostic structure misses how many boys and men actually present. Rather than a narrow dispute over psychiatric taxonomy, the proposal speaks to who gets recognized, where they get referred, and whether insurance coverage follows.

Why the classification matters

Muscle dysmorphia overwhelmingly affects males and is characterized by a hyperfixation on building muscles. It is currently categorized under obsessive-compulsive and related disorders in the DSM, even though it frequently also involves extreme dieting.

Nagata said a formal diagnosis requires several criteria: a preoccupation with muscularity or being insufficiently muscular, repetitive behaviors such as mirror-checking, weight-checking, and constant comparisons to others’ muscularity, and clinically significant distress or impairment in social, occupational, or other areas of functioning. The final criterion, he said, is the sticking point: the condition cannot be better explained by an eating disorder or eating disorder symptoms.

That makes the diagnoses mutually exclusive. As Nagata described it, if a patient meets criteria for an eating disorder under the current DSM, that patient cannot also have muscle dysmorphia.

The treatment gap

Nagata argues that this structure breaks from how exercise, nutrition, and body-image pathology overlap in real life. He said many people trying to become muscular engage in behaviors that can look like disordered eating, including high-protein diets, cutting carbohydrates, cutting fats, bulking and cutting, and intermittent fasting.

In his eating disorders treatment center, Nagata said there has been an increasing number of boys and men in recent years. But because there is no muscularity-oriented eating disorder in the DSM, their formal diagnosis is often “unspecified feeding and eating disorder,” or UFED. He said that label is not specific to muscularity and instead functions as a catchall category.

Many of those patients, he said, also report muscularity concerns, performance-enhancing drug or supplement use, and excessive exercise. Some would meet all the muscle dysmorphia criteria except for the final rule that excludes people who already have an eating disorder.

Nagata’s argument is that reclassification could make doctors more likely to identify these patients correctly, refer them to specialists, and improve insurance coverage. That is especially relevant because he described treatment access as very limited: only a handful of studies exist, there are very few muscle dysmorphia specialists in the world, and he is not aware of muscle dysmorphia treatment centers. In practice, he said, patients usually end up with a general mental health provider or in eating disorder treatment centers like his.

Why boys and men are still missed

STAT reported that males make up about a third of the population struggling with eating disorders in the United States. By some estimates, as many as 14% of American men experience an eating disorder by age 40, and they may be more likely to die from it than women.

Nagata said stigma remains a major barrier. Anyone with an eating disorder or body image issue can face stigma in seeking care, but boys often experience what he described as a double stigma because they may not want to be identified with a condition that has a feminized association.

That creates a policy signal beyond this diagnosis alone. When a disorder that overwhelmingly affects males sits outside the category where most treatment infrastructure exists, recognition and access can lag even if clinicians understand the symptoms. Nagata’s push to move muscle dysmorphia in DSM-6 is therefore also a push to align diagnostic labels with the care settings patients are already using.

The field is not settled on that solution. STAT noted that some experts argue muscle dysmorphia should remain under its current classification because that classification is accurate and can be combined with an eating disorder diagnosis when needed. But Nagata’s critique targets the cases that do not fit neatly under the current rules, especially patients whose muscularity concerns and disordered eating arrive together.