Had a friend with pretty bad case...
He was also obsessive-compulsive. Totally natural, huge looking round muscle bellies, year round 6%-7% or less bf. About 5'8 200lbs but looked absolutely big and ripped. Constantly looking in the mirror, clean diet 365 days a year. EXTREMELY easy to screw with i.e. "Did you hurt your shoulders and have not been able to train them?" etc.
This would result in another of his insane routines of 8 exercises per bodypart with 6 sets per exercise with 12-15 reps for shoulders, even if it was on leg day...even if he was in the middle of squats. I'm talking 3 hour workouts all natural. He genetics must have been freaky off the charts.
Miss one workout, he thinks he is "fat", will wear jackets, sweaters etc. He told me one day that his girlfriend thought he might have a problem. I told him I would like to confirm it for him.
This guy trains like an animal, rips his quad off the bone at the knee doing squats. He has no family here, and has a few friends from work. Can't really move the first week or so after surgery so friends from work brought him "food" to the house. I'm talking cakes, pies, candy, fudge, pizzas, etc. It was a total reverse Atkins diet. When I finally visited with some fish, chicken, lean meats,protein , etc, he hadn't eaten in two days. I thought he was going to cry. To screw with the obsessive/compulsive part of his behavior when I would exit his him downstairs (he was trapped upstairs) I would move a picture, or vase about a quarter inch. When he finally makes it downstairs he know "something is not quiet right" but can't really place it.
He is out of the gym for 3 months, joins another one to "pre-workout" for a month before coming back to ours so as not to "look small". He trains like a banshee for six months and guess what? He rips the quad off his other knee!
For a guy with dysmorphia not being able to work out was the most brutal thing that could occur. He came back from this one as well.
It always amazed me how much he admired my physiqe and my workout partners. We were "big" 6'2 270 or so, but our body fat percentages usually hovered around "gravy". Dude was not being humble, he really thought he looked a lot worse than us, when we couldn't been in his condition on stage that he carried in everyday life.
It is somehow different from low self esteem but must be related in some aspect. I probably should not have joked around with him but basically I was the only one in the gym he would really speak with, just focused as could be straight ahead. In my opinion this is worse but less dangerous than the anorexia because he struggling to both get big and not be fat at the same time. Quite a challenge. I have not worked out in seven months and have not even walked into the gym. I bet when and if I get to go back, he will still be envious of my soft muscle bellies, increasing paunch, and disappearing lat syndrom lats.
Pekkerwood