Jason Nagata, a pediatrician and eating disorders specialist at the University of California, San Francisco, is campaigning for a change that sounds academic and is anything but. He wants muscle dysmorphia, the obsessive drive for muscularity often called bigorexia, moved out of the obsessive-compulsive disorders section of the next edition of psychiatry's diagnostic manual and reclassified as an eating disorder. The proposal has drawn a real debate within the field, and the disagreement is the most useful thing about it, because the fight is not over the science of where the condition belongs. It is over what a diagnostic category does.
A diagnosis is not a neutral description of a patient. It is a ticket: to insurance coverage, to a treatment program's admission criteria, to a screening question, to a national surveillance statistic, to a line of research funding. The box a condition sits in decides who gets treated for it, who gets counted, and who gets studied. Nagata's argument, stated plainly, is that muscle dysmorphia sits in a box that produces no treatment, no coverage, and no data for the boys and men who have it.
The current box was built to exclude
Muscle dysmorphia entered the DSM in 2013 as a specifier of body dysmorphic disorder, housed in the obsessive-compulsive and related disorders category. The diagnosis describes a preoccupation with being insufficiently muscular, paired with repetitive behaviors such as mirror-checking and rigid eating routines, causing clinically significant distress. The current criteria close with a quiet exclusion: the diagnosis does not apply if the symptoms are better explained by an eating disorder.
That exclusion is the crux of Nagata's case. In his eating disorders clinic, boys and men with muscularity concerns rarely arrive as textbook muscle dysmorphia cases, because most also have eating disturbances that trigger the exclusion. They get coded instead as unspecified feeding and eating disorder, a catch-all that captures almost nothing and opens almost nothing. As Nagata puts it, "you can't really separate exercise and nutrition." The behaviors travel together: the training, the tracking, the eating, the supplement use. A classification that treats them as mutually exclusive describes a patient that barely exists.
The exclusion has consequences that are not theoretical. A clinician who codes both muscle dysmorphia and an eating disorder has produced a contradiction in the manual's own terms, and providers report that doing so invites insurance scrutiny or audits. The practical result is that the muscularity problem gets dropped from the record. What is not coded is not billed, not referred, and not counted.
The patients are not rare; the care is
The epidemiology makes the gap in care harder to dismiss. Males make up about a third of Americans with eating disorders, and studies suggest as many as 14 percent of American men experience an eating disorder by age 40. Men with eating disorders may be more likely to die from them than women, in part because the conditions are identified late, if at all. Community studies put probable muscle dysmorphia at roughly 2 to 3 percent of men, and screening studies of adolescent boys find far larger fractions at clinical risk. Men diagnosed with muscle dysmorphia are nearly three times as likely to have attempted suicide as men with related body image conditions.
Against those numbers, the treatment infrastructure is nearly absent. There are few studies of treatment for muscle dysmorphia, few specialists anywhere, and no dedicated treatment centers. Boys and men face a double stigma: the stigma of having an eating disorder at all, and the stigma of having the one that has been feminized in the public mind, which delays identification and care. A boy with muscularity obsessions does not see himself in the standard image of the eating disorder patient, and neither, often, does his doctor.
Reclassification is an infrastructure argument wearing a nosology costume
What Nagata is really asking for becomes clear in his list of expected benefits: access to eating disorder treatment programs, more studies, standardized criteria, clinician training, and national surveillance. Not one of those is a scientific claim about the nature of the condition. Every one of them is a claim about what the diagnostic box can buy. The scientific question, whether muscle dysmorphia is better understood as an eating disorder or an obsessive-compulsive spectrum condition, is contested, and reasonable experts answer it differently. The covariance evidence is mixed; comorbidity with OCD runs high, though similar comorbidity exists between anorexia and OCD. The manual's placement was a judgment call in 2013, and a different committee might reasonably have decided otherwise.
But the infrastructure question has a more definite answer. An eating disorder diagnosis routes a patient toward a field with screening tools, treatment programs, and billing codes. An OCD-spectrum placement routes the same patient toward nothing comparable, because the muscularity presentation does not fit the typical OCD treatment pathways either. The current arrangement is the worst of both: the condition sits with the obsessive-compulsive disorders while its treatment-relevant features, the eating, the training, the pursuit of size, sit with the eating disorders, and the exclusion rule forbids anyone from treating both at once.
The counterarguments deserve respect. Some experts say the current classification is accurate and that the two diagnoses can already be combined when needed. There is a case that the DSM's problem here is the exclusion rule itself rather than the placement, and that removing the mutual exclusivity would solve the coding problem without a category move that could destabilize treatment of the OCD presentation. And a reclassification is not free: it would take effect over years, and patients would not gain access on the day the new manual ships. But the status quo is not costless either, and it falls hardest on the patients the field has spent the least time looking at.
The parts that need no committee
The DSM-6 is years away, and the debate over muscle dysmorphia will not be settled before it arrives. The useful question is what changes in the meantime, and the answer is that most of the practical changes require no manual at all. The screening questions Nagata wants, about supplement use, performance-enhancing drug use, and compulsive exercise, can be asked tomorrow in any pediatric or primary care visit, and they would surface cases that currently hide. The Canadian screening data suggest why that matters: among adolescent boys and young men, more than a quarter scored above the threshold for clinical risk on screening tools, a figure far above any diagnostic prevalence and a measure of how much distress never becomes a diagnosis.
The training gap is the same problem from the provider side. Eating disorder curricula have been built around the presentation the field historically saw, and a clinician trained to look for restriction and thinness will not recognize a patient whose disorder is measured in plates of chicken and hours at the gym. The double stigma works on both sides of the exam room: the patient does not bring it up because the condition has been feminized in the public mind, and the clinician does not ask because the training never said to. Both failures are fixable without waiting for a committee, which is why Nagata frames reclassification as the capstone of the work rather than its beginning.
The research gap is the hardest to close without the category move, and it is the strongest argument in the reclassification's favor. Treatment studies for muscle dysmorphia are scarce, funding follows diagnostic codes, and surveillance counts what the manual names. A condition without a recognized category is a condition without a research pipeline, and the patients lose twice: once to the illness and once to the field's inability to study it. The manual cannot cure anyone. It can decide whether anyone tries.
The box is the care
The DSM reads like a dictionary and functions like a gate. What the next edition does with muscle dysmorphia will decide whether thousands of boys and men keep receiving catch-all codes that buy nothing, or get screened, counted, referred, and studied. Nagata also wants the screening questions that would make that real: routine questions about supplement use, performance-enhancing drug use, and compulsive exercise, and a recognition that eating disorders do not look like the stereotypical white, thin, female presentation the field was built around. Whatever the manual decides about the category, that broadening of the lens is the part that requires no committee approval, only clinicians willing to ask. If you or someone you know is struggling with an eating disorder, the National Alliance for Eating Disorders helpline offers free support.
Primary sources
- Ashleigh DeLuca's STAT article of August 20, 2026, for Jason Nagata's proposal and reasoning, the DSM exclusion criterion and its insurance consequences, the unspecified feeding and eating disorder coding pattern, the double stigma account, the expected benefits of reclassification, and the counterarguments from experts who defend the current classification.
- Published epidemiology reviews for the estimates that males make up about a third of Americans with eating disorders, that as many as 14 percent of men experience an eating disorder by age 40, the community prevalence of probable muscle dysmorphia around 2 to 3 percent, and the finding that men with muscle dysmorphia are nearly three times as likely to have attempted suicide.
- Analyses of the classification debate for the comorbidity evidence with obsessive-compulsive disorder and the unresolved covariance findings.