In recent decades, there has been a noticeable surge in public interest surrounding male physiques (Cafri et al., 2005; Maier et al., 2019). Many individuals are driven by the pursuit of the “perfect” physique with minimal effort and a strong desire for social acceptance (Jackson, 2002). This growing preoccupation with male physique is significant in light of the prevalence of anabolic-androgenic steroid (AAS) misuse in Iran, which surpasses global statistics and poses serious health risks. Specifically, the overall prevalence rate of AAS misuse in the Iranian athletic population is a staggering 36.2%, with bodybuilding athletes exhibiting a higher prevalence rate of AAS misuse compared to other athlete categories (Selk-Ghaffari et al., 2021). The majority of men influenced by this trend strive to improve their physical fitness through the adoption of low-fat, high-protein diets and unconventional weight training routines. Frequently, they complement these efforts with the use of adjuncts such as AAS or other performance-enhancing substances (González-Martí et al., 2018; Pope et al., 2017). AAS, originating from metabolic processes, not only enhances muscle volume and strength but also accelerates posttraining recovery, thereby optimizing sports performance and facilitating muscle growth (Griffiths, Hay, et al., 2016; Pysny et al., 2019). Considering the significant prevalence of AAS abuse in men (Anawalt, 2019) and also given the consequences and serious risks of its abuse for physical and mental health, including damage to liver function, damage to the vascular system and brain, mood swings, and increased aggression, it is necessary to identify and evaluate the psychological factors related to the tendency to use AAS (Morrison et al., 2015; Pope, Kanayama, et al., 2014; Zahnow et al., 2018).
Among other influential psychological variables in an individual’s life, schemas are of great importance. Young (1999) believes that each psychopathological symptom is related to one or more early schemas (Delattre et al., 2004). Early maladaptive schemas (EMSs) are deeply ingrained, dysfunctional, and pervasive patterns of cognitions, emotions, bodily sensations, and memories that develop during early childhood (Young et al., 2003). EMSs continue to develop throughout life (Gong & Chan, 2018) and are activated with high levels of destructive effects in certain (Nordahl et al., 2005). Some individuals may use AAS to cope with emotional pain caused by the activation of the primary maladaptive schema (Grest et al., 2021; Khosravani et al., 2017; Pauwels et al., 2014; Quinn et al., 2019; Shin et al., 2018; Soyaslan & Özcan, 2019; Zamirinejad et al., 2018).
Building upon the understanding of EMSs and their profound influence on behavior, emotions, and cognition, it becomes evident that the activation of maladaptive thoughts linked to muscle and the inclination to enhance muscle development through the use of AAS can be attributed to EMSs (Farmer & Kashdan, 2012). Furthermore, the fusion of these maladaptive thoughts with reality serves to amplify the inclination toward AAS use. In our research, we specifically examine the phenomenon of AAS use through the lens of body image-related cognitive fusion, which means getting trapped in thoughts related to bodily muscular shape and appearance. This confusion can become so profound that, after a while, these thoughts are perceived as genuine experiences rather than mere interpretations of physical reality (Ferreira et al., 2014; Trindade & Ferreira, 2014). In this way, the individual considers his current body based on distorted perceptions, bodily sensations, and thoughts related to his physical appearance (Cooper et al., 2020). A person who becomes entangled in thoughts of body dissatisfaction may opt for intense bodybuilding exercises over social engagements with friends, demonstrating how a focus on one’s body can disrupt social interactions. Additionally, they may turn to AAS to address perceived flaws, illustrating the various behaviors that individuals may exhibit due to this preoccupation (Griffiths & Murray, 2018).
While there exists a significant association between EMSs and the cognitive fusion related to body image concerns, it is important to note that not all individuals with EMS necessarily resort to using steroids. Besides, not all people with body image-related cognitive fusion tend to use steroids. It seems that the missing link in these relationships is the mediating variable of muscle dysmorphia (MD). People with MD have a constant mental preoccupation with having a muscular body and, as a result, do excessive bodybuilding exercises. MD, defined as obsessive–compulsive disorder and related disorders, is a subcategory of body dysmorphic disorder, in which the defect in the perception of the body image of these people is focused on the muscle, for example, I’m not stout enough (American Psychiatric Association, 2013). People suffering from this disorder have a body with a normal appearance and are even very muscular, but their unrealistic perception makes them consider themselves thin and not muscular (Glashouwer et al., 2018; Mitchell et al., 2017). This disorder has a high prevalence in gymgoers (Baghurst & Kissinger, 2009; Griffiths, Murray, & Mond, 2016; Mitchison & Mond, 2015; Tod et al., 2016; Zemestani & Jalalvand, 2019) and is known to be an early risk sign for AAS use (Greenway & Price, 2018; Zarghami & Nazari, 2018). Unfortunately, the level of dissatisfaction with muscle in people with this disorder does not improve even with the increase in muscle mass caused by AAS consumption (Kanayama et al., 2020).
Studies consider misbehavior and neglect of experiences in childhood as the cause of pathological preoccupation with muscularity in people with MD (Didie et al., 2006; Tingaz, 2020). This form of inattention and neglect of the experiences that are applied in childhood controls the behavior, emotion, and thoughts related to muscles in the form of EMS and causes dissatisfaction of the muscles and suffering from MD (Cafri et al., 2008; Gruber & Pope, 1999). Moreover, the more a person suffers from body image-related cognitive fusion, the more likely they are to be affected by MD (Dastghir & Karimi, 2019). The reason is that many people with MD have an unrealistic perception of their body image, which may be cognitively fused with it (Goldfield, 2009).
Despite growing research aimed at understanding the predictors, correlates, and outcomes of performance-enhancing substance use, there are several gaps in the knowledge base regarding the relationship between the psychological component and the tendency to use AAS. Among the gaps in the research literature related to AAS, one can mention the lack of attention to the variable of EMSs. The studies conducted often focus on childhood experiences as a key variable (Choi et al., 2017; Ganson et al., 2021). Among other gaps in the field of AAS, one can refer to the lack of investigation of cognitive flexibility in the tendency to use AAS. To remove this research gap, the present study has used cognitive fusion as one of the components of psychological flexibility, and by simultaneously examining EMSs, it has created a deeper understanding of the reason for the tendency to use AAS in the form of a structural equation with the mediation of MD. The emphasis of this research on the tendency to use AAS instead of emphasizing its abuse reduces the emotional load related to the prohibition of consumption and increases the probability of accuracy of response (Cohen et al., 2007; Gwizdek et al., 2017). The research population was changed from the scope of professional bodybuilders to the general population interested in muscle building to provide a broader view of AAS-related problems.
Methods
Participants
The research statistical population comprised all male athletes referring to Isfahan bodybuilding clubs. From this statistical population, 474 people were selected by multistage random cluster sampling method. The inclusion criteria were as follows: informed consent to participate in the research, age 18 years and above, and a history of sports training for at least 3 months. The participants who did their exercises as part of the treatment process for specific diseases and the people who submitted incomplete questionnaires were excluded from the study. It should be noted that this study was reviewed and approved by the ethics committee of the Ministry of Sports and Youth.
The average age of the participants was 27.85 years, and the standard deviation was 7.21. According to demographic information, 278 people (58.6%) had a history of sports for 1 year or more, 106 people (22.4%) had a history of 6 months to 1 year, and 90 people (19%) had a history of 3–6 months. In terms of body mass index, 272 (57.4%) were considered normal weight, 106 (22.4%) were classified as overweight, 68 (14.3%) were categorized as thin, and 28 (5.9%) fell into the obese category.
Measures
Muscle Dysmorphic Disorder Inventory is a 13-item scale developed by Hildebrandt et al. (2004), and the questions are scored on a 5-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree) with a total score of 13 to 65. The subscales of this questionnaire are (a) Drive for Size, (b) Appearance Intolerance, and (c) Functional Impairment. High scores show symptoms of MD (Murray et al., 2012). The reliability coefficient of this questionnaire in the study by Hildebrandt et al. (2004) was reported to be 0.77–0.85 using Cronbach’s alpha method, and the test–retest reliability coefficient was estimated to be 0.81–0.87. To validate this questionnaire in Iran, we asked a native English speaker to accurately translate the Muscle Dysmorphic Disorder Inventory into Persian and then gave the results to another translator for retranslation. In this study, this questionnaire was validated using the Yale–Brown Obsessive–Compulsive Scale Modified for Body Dysmorphic Disorder, and a significant correlation was observed between the two scales of MD and body deformity (p < .05). The direction of the relationship between the two scales was positive, and the intensity of correlation was equal to 0.62, which indicated a strong correlation between the two scales of MD and body deformity.
Cognitive Fusion Questionnaire—Body Image was developed by Ferreira et al. (2014) to measure body image-related cognitive fusion. It consists of 10 questions which are rated on a 7-point Likert scale ranging from 1 (never true) to 7 (always true) with a total score of 10–70. Higher scores on the Cognitive Fusion Questionnaire—Body Image indicate higher levels of cognitive fusion or entanglement with unwanted thoughts about one’s body image. This scale provides a unidimensional structure and shows good psychometric properties in the original study (α = .97). Additionally, in Iran, this questionnaire has been validated and its Cronbach’s alpha is equal to .93 (Dastghir & Karimi 2019).
Young Schema Questionnaire—Short Form, originally developed by Young in 1999, was translated into an Iranian version for our study. Its shorter version consists of 90 questions, evaluating 18 schemas related to five domains of disconnection and rejection, impaired autonomy and performance, other-directedness, overvigilance/inhibition, and impaired limits. Participants respond to this questionnaire using a 6-point Likert scale, ranging from 1 (completely false) to 6 (completely true), with higher scores indicating unhealthier core beliefs. Additionally, Rodrigues et al. (2019) determined Cronbach’s alpha for each of the 18 schemas to be between .53 and .90, indicating moderate to good internal consistency.
Prototype Willingness Model Questionnaire contains 26 questions and six subscales: (a) positive attitude toward AAS use, (b) subjective norms, (c) prototype of use, (d) behavioral intention to use AAS, (e) behavioral tendency to use AAS, and (f) behavior of using AAS. Manoochehri et al. (2021) conducted a preliminary study on 32 athletes in Iran to investigate the reliability and validity of this questionnaire and reported a reliability coefficient of 0.70–0.90 using Cronbach’s alpha method. The total score of this questionnaire is such that a higher score indicates a tendency to use anabolic steroids.
Procedures
The sampling method was as follows: First, Isfahan City was divided into different regions using a multistage random cluster sampling method, and three regions were randomly selected. From among the clubs in the target regions, four clubs were selected, and after checking the inclusion and exclusion criteria, the link to answer the questionnaire was sent to the members of the club, and also informed consent was obtained from the participants.
Data analysis of this research was done at two levels descriptive and inferential findings. At the level of inferential findings, the relationship between the variables was examined with the Pearson correlation test, and the research model was tested with the structural equation modeling technique. The maximum level of alpha error to test hypotheses was .05 (p ≤ .05), and data analysis was performed using SPSS (version 27) and AMOS (version 24).
Results
As shown in Appendix A, initially, the relationship between all 18 schemas with the mediating variable of MD and the dependent variable of the tendency to use steroids was tested. This test was performed with the purpose of screening to identify significant relationships with a correlation higher than .1 and to include in the model only the variables that have a relationship with at least one of the two mediating or dependent variables, to provide a simpler model with a better fit. Accordingly, only three schemas of emotional deprivation (ED), defectiveness/shame (DS), and failure (FA) had a significant relationship with the mediating and dependent variables, and the intensity of correlations was more than .10.
Fornell–Larcker criterion was used to check the correlation between the variables, the results of which are displayed in Table 1.
Correlation Matrix Between the Research Variables and Multicollinearity
| Variables | Emotional deprivation | Defectiveness/shame | Failure | Cognitive fusion | Muscle dysmorphia | Tendency to use AAS | VIF |
|---|---|---|---|---|---|---|---|
| Emotional deprivation | 1 | 1.69 | |||||
| Defectiveness/shame | .58*** | 1 | 2.93 | ||||
| Failure | .42*** | .64*** | 1 | 2.32 | |||
| Cognitive fusion | .44*** | .54*** | .48*** | 1 | 1.81 | ||
| Muscle dysmorphia | .47*** | .37*** | .38*** | .56*** | 1 | 1.64 | |
| Tendency to use AAS | .31*** | .35*** | .26*** | .45*** | .52*** | 1 | — |
Note. AAS = anabolic-androgenic steroids; VIF = variance inflation factor.
***p ≤ .001.
The assumption of nonmulticollinearity between the variables affecting the tendency to use AAS was checked with the variance inflation factor, and because all the values were <5, strong collinearity was not observed between the variables affecting the tendency to use AAS.
The research conceptual model was tested using the structural equation modeling technique in AMOS software. According to the structural modeling in AMOS software, all the obvious variables of the model had a factor load >0.40 and had acceptable validity. Figure 1 displays the simplified experimental model in the mode of standardized coefficients.
—The final results of the structural model (nonsignificant paths are not drawn). ED = emotional deprivation; DS = defectiveness/shame; FA = failure.
Citation: Journal of Clinical Sport Psychology 18, 3; 10.1123/jcsp.2023-0042
According to Figure 1, the strongest effect in the model was related to the effect of body image-related cognitive fusion on the tendency to use AAS with a coefficient of 0.53 and the effect of body image-related cognitive fusion on MD with an impact factor of 0.47.
As shown in Appendix B, reliability was evaluated by using two methods of composite reliability and Cronbach’s alpha, and all values were >0.70, indicating that all questionnaires had acceptable reliability based on two methods of composite reliability and Cronbach’s alpha. It should be noted that due to the small number of questions in each schema, values higher than 0.60 were also accepted in Cronbach’s alpha.
The fit indices generally suggested an almost acceptable fit of the data with the model, and overall, the fit of the model can be relatively confirmed. Table 2 shows the fit indices of the model.
Fit Indices of the Model
| Fit index | R2 | AGFI | IFI | NFI | CFI | GFI | RMSEA | Chi-square/df |
|---|---|---|---|---|---|---|---|---|
| Criterion | .33 < | .70 < | .90 < | .90 < | .90 < | .90 < | .08 > | 1< x <5 |
| Result | .49 | .75 | .89 | .91 | .92 | .88 | .85 | 4.14 |
Note. AGFI = adjusted goodness-of-fit index; CFI = comparative-fit index; IFI = incremental fit index; NFI = normed fit index; GFI = goodness of fit index; RMSEA = root mean square error of approximation.
Examining the direct effects (Table 3) demonstrated that the direct effect of FA schema on the tendency to use AAS was rejected (p > .05). The findings revealed that eight direct effects, out of a total of nine effects, were confirmed.
The Results of Testing the Structural Relationships in the Model (Direct Effects)
| Relationship | Standardized coefficient | Unstandardized coefficient | Standard error | t | p |
|---|---|---|---|---|---|
| ED → MD | 0.17 | 0.26 | 0.105 | 2.48 | .014 |
| DS → MD | 0.25 | 0.38 | 0.093 | 4.09 | <.001 |
| FA → MD | 0.26 | 0.23 | 0.079 | 2.91 | .004 |
| BIRCF → MD | 0.47 | 0.36 | 0.033 | 10.91 | <.001 |
| ED → MFAAS | 0.27 | 0.25 | 0.124 | 2.01 | .045 |
| DS → MFAAS | 0.21 | 0.19 | 0.074 | 2.57 | .011 |
| FA → MFAAS | 0.01 | 0.01 | 0.212 | .05 | .962 |
| BIRCF → MFAAS | 0.53 | 0.42 | 0.041 | 10.24 | <.001 |
| MD → MFAAS | 0.3 | 0.47 | 0.096 | 4.89 | <.001 |
Note. MD = muscle dysmorphia; ED = emotional deprivation; DS = defectiveness/shame; FA = failure; BIRCF = body image-related cognitive fusion; MFAAS = motivation for anabolic androgenic steroids.
Table 4 shows the results of testing the mediation role. The role of the mediator was analyzed with the help of bootstrapping method in AMOS software, and the resulting standard error was also examined.
The Results of Testing the Mediation Relationship of MD
| Relationship | Indirect effect | Standard error | t | p |
|---|---|---|---|---|
| ED → MD→ MFAAS | 0.051 | 0.027 | 1.89 | .059 |
| DS → MD→ MFAAS | 0.075 | 0.029 | 2.59 | .01 |
| FA → MD→ MFAAS | 0.078 | 0.032 | 2.44 | .015 |
| BIRCF → MD→ MFAAS | 0.141 | 0.041 | 3.44 | <.001 |
Note. MD = muscle dysmorphia; ED = emotional deprivation; DS = defectiveness/shame; FA = failure; BIRCF = body image-related cognitive fusion; MFAAS = motivation for anabolic androgenic steroids.
The results of Table 4 indicated that the mediating variable of MD statistically had a significant mediating role in the relationship between the three variables of DS, FA, and body image-related cognitive fusion with the dependent variable of the tendency to use AAS (p < .05). Accordingly, it can be concluded that the FA schema was only indirectly effective (mediated by MD) in the tendency to use AAS and the ED schema was only directly effective in the tendency to use AAS, and the two variables of DS schema and body image-related cognitive fusion, directly and indirectly, affected the tendency to use AAS (p < .05).
Discussion
The increasing tendency to use performance-enhancing substances such as AAS in young people (Nagata et al., 2020), especially in gymgoers, is worrying. To reduce the problems caused by the tendency to use AAS, health experts investigated its underlying factors. The present study was designed to help understand the psychological factors related to the tendency to use AAS in gymgoers. The findings of this research indicated a high level of the tendency to use AAS in people who had maladaptive schemas (ED, DS, and FA) and experienced high levels of cognitive fusion, and in fact, the effect of these variables on the tendency to use AAS is from the path of MD as a mediating variable.
Based on the results of the present study, it was found that MD can potentially mediate the tendency to use AAS. As a result, it can be stated that those participants who tend to use AAS also suffer from MD. The findings of this study demonstrate that there is a significant positive relationship between MD and the tendency to use AAS. This finding is in line with Pope, Wood, et al. (2014) study, which considers the increase in MD symptoms to be one of the main factors predicting the use of AAS. Moreover, research has shown that about 90% of men with MD use AAS (Murray et al., 2012). The present study revealed that the MD factor can have the potential to identify people who tend to use steroids. On the other hand, some studies showed high levels of MD symptoms in AAS users, and according to the findings of the present study, which was conducted on the tendency to use AAS, and other studies concerning people who had a history of AAS use, it can be said that there is a two-way relationship between MD and AAS use, and AAS use may be a symptom of MD rather than a causal factor (Greenway & Price, 2018). In explaining this finding, it can be mentioned that MD is a multidimensional construct and the tendency to use anabolic steroids is its most consistent predictor (Fritts, 2016). Although the tendency to use AAS is one of the most consistent predictors of MD (Khorramabady, 2017), Longobardi et al. (2017) by examining 145 Italian male bodybuilders, found that the tendency to use AAS is not related to the risk of MD.
The first years of life play an important role in creating a realistic body image (Ganson et al., 2021; Zemestani & Jalalvand, 2019). The findings of the present study suggest that the cognitive, emotional, and physical manifestation of adverse childhood experiences in the form of EMSs can affect people’s tendency to use AAS. In explaining these results, it can be said that people during development, in the process of identification and stabilization of behaviors to protect against interpersonal harm caused by negative consequences related to these schemas, develop different behaviors. The behaviors used are generally maladaptive like increasing muscle to exaggerate physical strength (Frederick et al., 2017) which is mentioned in the theory of precarious masculinity (Vandello et al., 2008) or avoiding drug use problems (Shorey et al., 2014; Zamirinejad et al., 2018). The analysis of the participant’s responses in this research indicates that there is a significant relationship between the schemas of ED, DS, and FA with the tendency to use AAS. Unlike ED and DS, which are both directly and indirectly related to AAS (with the mediating role of MD), the relationship between FA and AAS can be explained only indirectly and with the effect of MD.
Lack of body confidence and lack of social acceptance are important factors in the tendency to use AAS (Greenway & Price, 2018). It seems that bodybuilders with ED schema tend to use AAS in adulthood due to nonsatisfaction with the need for guidance, love, and empathy from the source of attachment so that they can avoid the interpersonal traumas caused by nonsatisfaction of psychological needs (Ganson et al., 2021). Further, in explaining the mediating role of MD in the relationship between the tendency to use AAS and ED, the role of childhood experiences in the formation of MD can be mentioned. This finding is consistent with the study by Tingaz (2020) and Didie et al. (2006). In his research, Tingaz (2020) confirms that MD is significantly related to childhood neglect. It seems that people who are not loved and cared for in childhood learn not to value themselves as adults. Therefore, people with MD neglect themselves with excessive physical exercises. This neglect can also be manifested by not paying attention to the contraindications of AAS (Kanayama et al., 2020).
In explaining the relationship between DS and the tendency to use AAS, which was confirmed both directly and indirectly (with the mediating role of MD), it can be stated that people with DS schema in childhood have a sense of inner inferiority and worthlessness due to being in an environment where they have been constantly blamed and humiliated. It seems that these people want to remove their inner humiliation by AAS because if individuals consider themselves less muscular than other men, they have a sense of worthlessness and inner humiliation, which turns into MD (Greenway & Price, 2018; Murray et al., 2016).
It seems that failure to meet the need for independence and self-efficacy in childhood from the source of attachment creates the mental–emotional experience of “I can’t” in the individual, which disrupts his performance in the form of FA schema. The findings of this research demonstrated that there is a positive relationship between FA schema and the tendency to use AAS with the mediation of MD. The belief in failure in these people makes them turn to muscle building through the tendency to use AAS to gain a sense of self-efficacy by an overcompensation mechanism. The results of this research are consistent with the results obtained by Cohen et al. (2007). If we consider depression as a kind of internal conflict with a sense of failure, our findings are inconsistent with the findings of Boyda and Shevlin (2011).
Another variable discussed in this research is body image-related cognitive fusion. Unrealistic body image-related fusion and mental preoccupation with being muscular often lead to AAS abuse. The findings of this research acknowledge the existence of a significant positive relationship between the tendency to use AAS and body image-related cognitive fusion mediated by MD. Body image-related cognitive fusion is one of the important predictive factors in the diagnosis of MD disorder, which is in line with the findings of Ferreira et al. (2014) and Trindade and Ferreira (2014). In explaining this finding, it can be mentioned that bodybuilders with MD disorder engage in continuous bodybuilding exercises to get rid of the feeling of insufficient muscle mass, or they somehow reduce the anxiety caused by these thoughts through avoidance behaviors such as experiential avoidance, control of adverse internal experiences, or modification. Nevertheless, avoidance strategies tend to intensify internal pain and suffering and prevent adaptive behaviors (Hayes et al., 2006); here, maladaptive behaviors mean the tendency to use AAS.
Clinical Implications
The findings of this study shed light on crucial clinical implications in understanding and addressing the increasing tendency to use AAS among individuals, particularly in the context of bodybuilding and muscle development. The high prevalence of AAS misuse in the Iranian athletic population, especially among bodybuilding athletes, underscores the need for targeted interventions and preventive measures within this demographic group.
EMSs, deeply ingrained patterns that develop during early childhood and persist throughout life, have been identified as significant psychological factors associated with the tendency to use AAS. Recognizing the role of EMSs in influencing behaviors related to body image concerns and AAS use can inform clinical assessments and interventions. Mental health professionals working with individuals involved in bodybuilding and fitness can incorporate assessments of EMSs to identify potential risk factors for AAS use and develop targeted therapeutic strategies. Building on this understanding, the study also underscores the importance of considering childhood experiences, particularly adverse experiences manifested through EMSs, in understanding the motivations behind AAS use. Mental health professionals should explore and address the impact of ED, DS, and FA schemas in their therapeutic interventions. Tailoring interventions to address underlying emotional and psychological needs related to these schemas may contribute to preventing the reliance on AAS as a coping mechanism.
The study emphasizes the mediating role of MD in the relationship between EMSs and the tendency to use AAS. Clinicians should be attentive to signs of MD in individuals with body image concerns, as it serves as a potential marker for the inclination toward AAS use. Interventions addressing MD, such as cognitive–behavioral therapy or psychoeducation, may prove beneficial in reducing the risk of AAS misuse among individuals struggling with distorted perceptions of their muscularity. In the Iranian context, understanding the cultural and societal factors influencing body image perceptions and AAS use is paramount. Mental health professionals in Iran should consider the unique sociocultural landscape when tailoring interventions and preventive measures. Addressing cultural attitudes toward body image, promoting open dialogue, and collaborating with local communities can enhance the effectiveness of interventions.
Furthermore, recognizing the role of body image-related cognitive fusion in the context of AAS use highlights the significance of integrating cognitive strategies in therapeutic approaches. Addressing unrealistic body image-related thoughts and promoting cognitive flexibility can be crucial in reducing the likelihood of individuals resorting to AAS as a means of coping with body dissatisfaction. Therapeutic interventions should aim to enhance individuals’ acceptance of their bodies and foster healthier coping mechanisms for managing body image concerns.
In summary, the clinical implications drawn from this research emphasize the importance of comprehensive assessments, targeted interventions, and a multidimensional approach in addressing the complex interplay of psychological factors associated with the tendency to use AAS. By integrating these insights into clinical practice, health care professionals can contribute to more effective prevention and intervention strategies for individuals at risk of AAS misuse in the pursuit of an idealized physique.
Conclusions
Although we know that psychological factors do not have a 100% effect on the tendency to use AAS, it seems that a distinction must be made between the causes of the tendency to use AAS among individuals. Meanwhile, noncompetitive bodybuilders are a group of people whose goal is not to participate in bodybuilding competitions, and their tendency to increase muscle mass is probably for social acceptance and covering up the problems that can originate from childhood (Jones & Crawford, 2006; Mcvey et al., 2005). The findings of the present study suggested that in addition to maladaptive schemas being able to increase the desire to use AAS, MD is a very important factor in this regard.
Paying special attention to the psychological factors of the tendency to use AAS, and not its consumption, in explaining the desire to use it and examining these factors in the form of a structural model alongside MD among noncompetitive bodybuilders show the innovation of this study. However, this research had specific limitations. The self-report nature of the present study introduces the possibility of bias in the results. Furthermore, because the study exclusively involved male participants, generalizing the findings to the female population becomes challenging. Additionally, in future studies, it would be beneficial to explore anorexia nervosa disorder as a variable influenced by EMSs in both competitive and noncompetitive bodybuilders, alongside MD disorder.
Acknowledgments
Clinical sport psychology in Iran has seen gradual recognition, moving from focusing on the physical aspects of sports to integrating psychology into athletic training. Education and training programs are in the early stages, and the field is emerging as athletes and organizations seek psychological support for enhanced performance and well-being. Cultural and social factors play a role, emphasizing the need for understanding Iran’s sports culture. While challenges exist, opportunities for growth involve potential collaboration with international experts.
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Appendix A
Pearson’s correlation test between all schemas with the mediating variable of muscle dysmorphia and the dependent variable of the tendency to use steroid.
| Variables | Muscle dysmorphia | Tendency to use steroids | ||
|---|---|---|---|---|
| r | p | r | p | |
| Abandonment | .07 | .146 | .08 | .089 |
| Mistrust | .01 | .929 | .04 | .335 |
| Social isolation | .05 | .267 | .05 | .33 |
| Dependence | .04 | .376 | .08 | .084 |
| Vulnerability | .02 | .74 | .06 | .18 |
| Enmeshment | .01 | .875 | .01 | .767 |
| Entitlement | .04 | .401 | .01 | .834 |
| Self-control | .07 | .142 | .04 | .359 |
| Subjugation | .08 | .092 | .08 | .081 |
| Self-sacrifice | .09 | .047 | .03 | .575 |
| Approval-seeking | .04 | .348 | .09 | .041 |
| Emotional inhibition | .01 | .808 | .08 | .091 |
| Unrelenting standards | .04 | .334 | .07 | .121 |
| Pessimism | .08 | .093 | .01 | .833 |
| Punitiveness | .07 | .146 | .08 | .08 |
| Emotional deprivation | .47 | 0 | .31 | 0 |
| Defectiveness/shame | .37 | 0 | .35 | 0 |
| Failure | .38 | 0 | .36 | 0 |
Appendix B
Validity and reliability indicators.
| Variables | Validity and reliability indicators | |
|---|---|---|
| Composite reliability | Cronbach’s alpha | |
| Abandonment | – | .74 |
| Mistrust | – | .75 |
| Social isolation | – | .79 |
| Dependence | – | .76 |
| Vulnerability | – | .8 |
| Enmeshment | – | .62 |
| Entitlement | – | .7 |
| Self-control | – | .69 |
| Subjugation | – | .77 |
| Self-sacrifice | – | .67 |
| Approval-seeking | – | .7 |
| Emotional deprivation | – | .73 |
| Unrelenting standards | – | .73 |
| Pessimism | – | .76 |
| Punitiveness | – | .75 |
| Emotional deprivation | 0.85 | .81 |
| Defectiveness/shame | 0.86 | .81 |
| Failure | 0.82 | .83 |
| Body image-related cognitive fusion | 0.96 | .94 |
| Muscle dysmorphia | 0.77 | .75 |
| Motivation for anabolic androgenic steroids | 0.9 | .85 |
