May is Mental Health Awareness Month. For too long, men have been silent about mental health and are literally killing us. We can change that. Our Healthy Mind series, Healthy Body sheds light on mental health issues that everyone should be talking about.

Chris Marvin had a secret ritual in the mornings he practiced in college. Sunlight filtered through the curtains, rose from the bed around 7 a.m. After making sure his door was locked, he rummaged in the drawers and in the depths of his mini-refrigerator. Then, on a white marble desk that would have been beautiful if it were not for the prints of Thrasher and Mayhem, I would align everything I needed to spend the day.

First, I took a caffeine pill to feel alive; then a couple of painkillers: a preemptive strike against the routine of training two hours a day, seven days a week. (“There is no resting muscle,” he told himself.) A blow from his bong would help soothe his racing heart. Instead of water, he poured a glass of whiskey for his pre-workout supplements. Then it would be injected into your glutes or deltoids with anabolic steroids from the black market. After putting his supplies back in their hiding places, he would ride his bicycle half a mile from the house outside the campus he shared with the fraternity brothers in Northern California, where he studied exercise science.

“A kinesiology specialist doing all that crap, I was a walking oxymoron,” says Marvin, now 32 years old. Nothing could keep him out of the gym, not even the injuries that would eventually require surgery. “It would make my training partner keep my shoulder in place to be able to do uprisings, in my mind, it was indestructible.”

By the time he was 25 and working at home in San Diego, Marvin weighed 95 kilos and his back was rippling like Hulk’s. When he finally disconnected from the steroids and increased his use of synthetic marijuana, ecstasy, sleeping pills and Valium, in addition to drinking and painkillers, he dropped to 64 and fell into a deep depression. After a difficult time, he spent more than a week locked in a psychiatric ward.

“I had used so many drugs that I did not sleep for eight days,” he says. “From there, I went to a cognitive behavioral therapy program, and that’s where they pointed out that I had muscle dysmorphia, I’ve never heard of that before, I was like, ‘What the hell is that?’

If you look closely, you may see a little of yourself in Marvin. From an early age, men are taught to be bigger, stronger and faster, and to fight against pain. Anger? Do you hate yourself? Anxiety? Who needs a therapist when you have the gym? And who among us has not tried to fix our internal insecurities through our outward appearance?

Unlike Marvin, you probably do not have a mental disorder, much less a substance abuse problem that you have developed to cope with it. Muscle dysmorphia, or MD, is a little-known psychological condition that was first described in the scientific literature in the late 1990s. Because formal diagnostic criteria define MD as a subset of a larger group, body dysmorphic disorder, it is impossible to know how many people are affected.

But the current diagnostic parameters can be applied to millions of people who simply are not satisfied with their physique. Those who suffer from the so-called “bigorexia” become obsessed with their appearance, perceiving themselves as insufficiently muscular even though they really are. “People congratulate me,” says Marvin, “but in my head I would say, ‘This part sucks.'” He was very insecure even though he seemed better than most people, I worked hard thinking about my body. ”

The difference between someone with muscle dysmorphia and someone healthy is the grade. Early research in the American Journal of Psychiatry reveals that a typical bodybuilder spends about 40 minutes a day thinking about improving his physique. People with muscle dysmorphia spend about 325 minutes and are examined in a mirror an average of 9.2 times a day. The condition usually originates in late adolescence or early adulthood, and most men who exhibit the hallmark of MD have been intimidated or embarrassed by their strength or appearance.

Marvin’s case was extraordinary. In high school, he was 1.80 and weighed around 68 kilos. Uncoordinated and not athletic, he warmed up the bench of the basketball team and became the target of jokes in the weight room. “They laughed at me for being the weakest guy there, he says.” He was much smaller than everyone. I was mocked for a long time. ”

Research shows that children up to 6 years old express their desire to be muscular, and that men are more likely to pursue that type of physique if they make fun of them or receive encouragement from their parents or partners to do so. And beyond their inner circle, men face constant pressure to see themselves in a certain way.

We see it in the movies. We see it on television: fat people always play the fool. We see it in quick advertising, how is a model of underwear? We see it in magazines: even in Men’s Health, we sell it on our covers. We see it in dating applications: how are you framing your Tinder profile? We see it on social networks. We see it in video games: research shows that men have lower self-esteem over their bodies after using very muscular avatars. We see it in toys: at the end of the 1990s.

“When we see images of muscular bodies that bombard us, we feel less satisfied with ours,” says Stuart Murray, Ph.D., clinical psychologist at UC San Francisco. “The established norm is not realistic in many ways, many of the idealized images we see are retouched and, by definition, impossible to reproduce, and the models often do extreme diets for a photo shoot.”

The ideal male body in pop culture has a V-shaped torso, large arms, broad shoulders, a flat belly and a small waist. In one study, nine out of 10 men of college age expressed a desire for more musculature. In yet another, more than 90 percent of adolescent males reported exercising to appear more muscular; two-thirds altered their diet to increase their size or muscle tone; and almost 6 percent admitted using steroids, which are now also considered aspect enhancers instead of simple performance enhancers.

A few months before Marvin began in the state of Sonoma in 2008, he had a vision not so much of what he wanted to be but what he wanted to become. “I had these fantasies like all men, I wanted to be big, muscular, ride a motorcycle, have women, be athletic,” he says. “It was not any of those things.” So he started training, but he did not know what to do in the gym or how long he was supposed to get results. A few months later, she bought steroids from an acquaintance and learned how to inject them thanks to the mother of a classmate, a nurse who gave her syringes that she took from her hospital.

“I was 21 and a half years old, my testosterone was as high as ever, I decided it was not good enough,” she says. “I wanted that quick fix and, of course, I gained 13 kilos and I said, ‘Shit, this is amazing.'” The feelings of power and confidence were quite incredible, drugs allowed me to be what I was not, I felt smarter, Safer, sexier, I felt at ease. ”

But steroids did not address the underlying pathology of muscle dysmorphia, which led Marvin to focus obsessively on his perceived defects. “I would not take my damn shirt off because I was so ashamed of my chest,” she says. “Instead of saying: ‘Friend, take a look, my arms grow, my legs grow, my back is growing’, I would concentrate on my chest and say: ‘My God, I’m pathetic.’ I just focused on my inadequacies.” .

Marvin marked almost all the boxes in search of symptoms and associated behaviors of muscular dysmorphia. Humor changes? “If you interrupt me in traffic, I would get angry because I assumed you did it on purpose.” Depression and anxiety? He lived in a state of “general discomfort just below panic,” especially among muscular types. “I did a routine of bending in the mirror every day and focused on my weaknesses.” Deteriorated social functioning? “I was unable to be around people without at least being drugged with marijuana, I needed that shock absorber to feel good about myself.” Some of its symptoms were associated MD complications: substance abuse? “In the inpatient program, they told me he was the most advanced drug user they had ever met.” Suicidal thoughts? After a bad break, he says: “I considered driving my car off the road every day for about two years.”

When he stopped taking steroids in 2013, he faced a new problem: his body no longer produced testosterone naturally, a condition known as anabolic hypogonadism induced by steroids, or ASIH. Now use a prescribed androgen cream every morning, rotating between the sites on your forearms and upper torso. (His girlfriend can not touch the active site for hours to protect her hormonal balance – even a hug could harm her.) Due to the damage of the ligaments and tendons of her insane exercise regimen and steroid use, she wakes up with pains in almost every the joints.

“I fucked my body for the rest of my life,” he laments. “Part of my therapy was to realize that my exterior does not define my interior, I would assign my morality based on how my body looked, how my training went and what I ate that day.”

Eating disorders are another hallmark of muscle dysmorphia. Weight gain requires a high-calorie diet, but even with anabolic steroids, it is extremely difficult for an experienced and genetically maximized lifter to make a “clean” volume, a term for building muscle without adding fat. The quest to get bigger while you destroy leads to strange diet choices, with extremely inadequate levels of vitamins and minerals.

“Men can look incredibly healthy, like Greek statues, and yet they are very medically compromised,” says Murray, who is also co-director of the National Association of Men with Eating Disorders. “It can end with a dangerously low heart rate and electrolyte imbalances.”

Doctors identify three main types of eating disorders. Anorexia is a caloric restriction; bulimia is purging calories by expelling food, using laxatives or diuretics, or by exercising to cancel the intake (or a combination of these); and binge eating is losing control, eating when you’re not hungry or consuming excessive amounts at the same time.

Although eating disorders and muscular dysmorphia are listed separately in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, current research sees them as a constellation of related behaviors. Both are the direct result of the overvaluation of an idealized body type, which fuels a lean of leanness, an impetus for muscle mass, or both. These body image disorders can lead to disordered eating behaviors, a topic that is rarely discussed in the lives of men.

“There is a double stigma in men,” says psychiatrist Brad Smith, M.D., medical director of eating disorders services at Rogers Behavioral Health, a treatment center with branches across the country. “There is the stigma of having a psychological or psychiatric problem, it is difficult to get men to seek treatment even for depression, in addition to that, this is typically characterized as a woman’s disease.”

“Society has taught us that we are strong, masculine figures who do not really think about that kind of thing,” says Dan Stein, 35, a strong, masculine figure who almost dies because of that sort of thing.

Two weeks before he left home for the University of Minnesota in 2001, Stein weighed 97 kilos, thanks to years of McDonald’s racing, sugary soft drinks and junk food. “My parents called me husky,” he says. “Dad, that’s probably the most accurate description of where I was.” Determined to get in shape, he started running 6 miles a day, five days a week, and occasionally lifted weights in the school gym. When he returned home for the winter holidays, he already weighed 83 and, he says, “everyone told me how good he looked at me, it was an ego boost.” By the end of his second semester, he weighed 75. But he was skinny, had no muscles or a lot of definition. ”

A turning point came early, in its second year. Without a shirt, Stein was playing soccer with some friends in a field near his apartment. The members of the school football team, also shirtless, passed by. “Some very attractive girls came over and we started talking to them,” says Stein. “In my head I was like, ‘I’ve been working like crazy, what can I do to look like these guys and get attention?'”

Stein thought the problem should be his diet. In truth, he was eating very little to gain muscle. Without knowing how the body works, Stein’s diet became so restrictive that breakfast consisted of a handful of special K protein or honey in oat bunches. For lunch, I would eat a small tin of tuna and half a melon. The dinner consisted of a bag of popcorn or a protein bar. Meanwhile, he ran up to 50 miles per week and lifted weights three times a day for 90 minutes per session. He often woke up at 2 a.m., 45 minutes ago in the machine to climb stairs in his building, and then went back to sleep. He was consuming about 1,000 calories a day and spending around 4,000, and says he “began to weaken in the gym.”

Stein missed so many classes to go to the gym that he did not finish school. He returned to live with his parents in Wisconsin and began serving tables at a local restaurant. Each night, he brought home the same dinner, pasta with marinara, and locked himself in his room so that no one would see him swallow the marinara sauce and spit the noodles in the trash. Only one real meal was allowed per year, Thanksgiving dinner, but only after running an individual half marathon in the morning. His exercise was so compulsive that he once ran in a climate of minus 10 degrees. He was so obsessed with the shape of his body that he would spend up to 15 minutes in anguish over the bottle of diet soda to drink: one that had five calories or another that had 10.

“I was one of those ignorant people who thought that the only way to burn calories is by exercising,” he recalls. “I did not know that eating food is burning calories, that breathing, every function of our body, burns calories.”

At its lightest point, Stein weighed only 60 kilos. His eyes were sunken, his cheeks were emaciated, and his fingers were cold. The summer before his last year of college (he finally got his qualifications in a technical school and finished at the University of Wisconsin-Milwaukee), he visited his older brother in Georgia. Although he was at 32 degrees, Stein was wearing a shirt, a sweatshirt and two pairs of pants. His nails were blue and his lips were purple. For lunch, he asked his brother’s fiancee to increase the temperature. “He looked at me like I was crazy,” says Stein. “His hands were cold.” I started thinking that I had something physically wrong with me. Had cancer?

A doctor in Wisconsin told him he had 20 signs of starvation. “That’s when I realized I was anorexic,” he says. “My family always knew I had a problem, but they dodged it, and I put it aside, my body was in decay, and I really realized that if I did not change something soon, I could die.”

Eating disorders affect men of all ages, races, ethnicities and sexual orientations. It is estimated that 10 million men in the United States will be affected at some point in their lives by eating disorders, which have the highest mortality rate of any mental disorder.

“We need to educate people about what to look for and how to talk to our children,” says psychotherapist Andrew Walen, L.C.S.W.-C, founder of the Body image Therapy Center in Maryland and president of the National Association of Men with Eating Disorders. “It’s not about beauty, it’s about what makes you special: your humanity, your empathy, your kindness, these are the messages we must convey to our young people, instead of ‘Are you the best? Are you the strongest? Are you the fittest? We have to tell you that your body is your home, it’s not an advertisement. ”

Multiple eating disorders can overlap in people, and men with muscle dysmorphia often go through the behavioral symptoms of all three; Even a cheat meal can be considered binge if it causes mental anguish. The first warning signs that your body might be affected include dehydration, slower heart rate, low blood pressure and reduced body temperature. To aggravate the problem: doctors do not always know what to look for in men.

An example: Walen remembers being contacted by the parents of a 14-year-old boy who had lost more than 20 percent of his body weight in three months. He had become obsessed with running, riding a bicycle and lifting weights, and had also become emotionally disconnected. “This is a classic case of a young adolescent with an eating disorder,” Walen told parents. “We’re going to take lab tests to make sure he’s not medically compromised.” But the adolescent’s primary care doctor did not believe it. He patted his patient on the belly and said, “It looks good, I wish I had abs like that.” When the blood test returned, he showed kidney failure and problems with liver enzymes.

Walen, 45, could understand male eating disorders better than anyone else. He was a patient before becoming a therapist. In 1997, an MRI revealed that compulsive functioning had reduced his left hip to bone. Fearing that he would need a hip replacement surgery before age 30, he started lifting weights. If he could not be as thin as he wanted to be, he thought he would become as muscular as possible. He got up so obsessively that he tore the rotators in both shoulders. “This is an absolutely masculine experience of eating disorders, muscle dysmorphia and disorders in body image,” he says.

Hoping to find support, Walen attended a conference on eating disorders, but felt out of place when she realized that the other men in the room were parents of girls with feeding problems. The only book that related it, Making Weight, focused on anorexia: fighters, boxers, MMA fighters, distance runners and gymnasts are especially at risk, and did not address the spectrum of their experiences, especially binge eating and compulsive lifting . Then, in 2014, he wrote and self-published Man Up to Eating Disorders, to “normalize the experience and create a recovery tribe”.

It is a vital job. By the time a man admits that he has a problem and overcomes his reluctance to seek help, the damage often progresses dangerously. One study found that between 1999 and 2009, the number of men requiring hospitalization for an eating disorder increased by 53 percent, more than double the increase in women. “There is a mistaken belief that this is rare and that men who suffer from these are atypical, emasculated or strange,” says Murray. “We have to change that gym culture.”

Dan Stein calls it a “fascinating miracle” that he did not die or suffered long-term complications due to his battle against anorexia, which lasted almost five years. His recovery included some sessions with a therapist, but it was largely a self-guided education. “I learned everything I could about the human body,” he says. “How it survives, how it works, the physical form, nutrition, health, literally everything I could get my hands on.”

Stein now lives on the outskirts of Los Angeles and works for a social networking company a few blocks from Muscle Beach. Five days a week, for no more than 75 minutes, you exercise at Gold’s Gym Original. “I’m surrounded by some of the most fit and attractive human beings on the planet,” he says. “There are times when you think: ‘My God, I’d like to be like that guy.’ But I reject those thoughts and do not derail myself.”

He limits his cardiovascular exercise to 30 minutes a week, he says, “because I do not want to lose weight anymore and I associate cardiovascular exercise with weight loss.”

Maintains his 81 kilos and 9 percent body fat by eating six meals a day, including lean proteins (chicken, egg white, fish), complex carbohydrates (potatoes, quinoa, whole wheat pasta), fruits (blueberries, apples), vegetables (asparagus, broccoli) and healthy fats (coconut oil, almond butter, olive oil). It even has a slice of cheesecake.

“I thought that genetically he had received a bad hand,” he says of his old mentality. “When I began to understand that my body does not act differently than 99 percent of the public, I realized that it was not physical, it was mental, now I know that I bring much more than just how I see myself.”

Chris Marvin has experienced a similar transformation. The man who once obtained 68 Percocets in less than 72 hours now attends 12 therapy sessions at least three times a week. “My brain got me into the mess I was in, so I should not try to solve this alone,” he says. “I express things on the air.”

Marvin has been clean and sober since completing an intensive behavior modification program three months ago five years ago. Her new morning routine includes drinking a cup of coffee and saying a prayer she wrote after finishing the program. Include this line: “Relieve my fear and insecurity, and replace it with self-esteem and acceptance”.

Marvin named his personal training business One Rep at a Time, a nod to overcoming addiction one day at a time and building genuine muscle for months and years. Some of his clients are also recovering, and Marvin openly shares his battles with them. “I feel like I finally found my vocation,” he says.

To put himself in the right mindset in the gym, Marvin listens to an epic and intense battle music that “makes me feel like I’m saving the world.” He no longer curses himself, and will often restore his body and mental focus with deep breathing exercises. “I used to think that everyone who was addicted to exercise had high blood pressure because they were so angry,” he says. “My old trainings were a way to punish myself, I do this now as a way to improve myself.”

But Marvin knows what lurks in the background, waiting for the opportunity to consume his life once more. Every time you post a photo without a shirt on Instagram, a proven and true marketing strategy for personal trainers, but risky for someone recovering from muscle dysmorphia, worries about unleashing insecurities or introducing new ones to their clients and followers. “My recovery is fluid,” he says. “It will always be an act of balance.”

Do you have any eating disorder?

Consider these statements from a 50-item eating disorder assessment designed specifically for men. Choose one of the six answers: never, rarely, sometimes, often, usually or always, as it applies to the following statements. Answering “always” to these and other statements suggests that you may have a problem.

1. I weigh several times a day

2. I take laxatives to control my weight

3. Others are worried about my eating habits

4. When I compare my body with advertising (ads, magazines, television, etc …) I feel maladjusted

5. I check my body several times a day.

6. My day is planned around the burning of calories