An instrument for the evaluation of muscle dysmorphia: The Italian validation of the adonis complex questionnaire

Abstract Background and aims Muscle dysmorphia (MDM), or bigorexia, is a subcategory of body dysmorphic disorder (BDD), also known as “Adonis Complex” in nonscientific contexts. One of the most used tools to investigate MDM is the Adonis Complex Questionnaire (ACQ). The ACQ is a 13‐item US questionnaire, designed for male subjects only, related to the dissatisfaction and concerns about physical appearance. The aim of the current study was to evaluate the validity of the Italian version of the ACQ. Methods The instrument was administered to a sample of 322 male adults, recruited from the general population. We used the maximum‐likelihood confirmatory factorial analysis (CFA), analyzing the covariance matrices with AMOS 24.0, to evaluate the different factorial models proposed in the literature. Results The evaluation of the factorial structure of the Italian version of the ACQ demonstrates the greater stability and internal consistency of the two‐factor model, compared to the original three‐factor model. The factors have no correlation with the demographic characteristics of the sample. Conclusions The present study confirms the validity and the reliability of the Italian two‐factor version of the ACQ and highlights the general tendency, among Italian males, to have concerns about their own physical appearance with recurring thoughts and eating behaviors finalized to improve it. Our study represents an advance in the use of adequate and reliable instruments to assess concerns about physical appearance in the Italian male population.

O'Sullivan, , was described as a pathologic preoccupation with muscularity and leanness; subjects affected consider themselves small and frail and perceive their bodies to be significantly leaner and less muscular than they actually are. Other characteristic features are that subjects with MDM typically exercise compulsively, present deviant eating patterns, stare in the mirrors excessively, and many chronically use anabolic-androgenic steroids and other substances in order to get bigger (Baghurst & Lirgg, 2009;Griffiths, Foster, Foster, & Shorter, 2015;Griffiths, Murray, Murray, & Touyz, 2013;Klimek & Hildebrandt, 2018); they also avoid places where their bodies will be seen, such as beaches and swimming pools. These symptoms cause clinically significant distress or impairment in the social and occupational functioning.
In Italy, both for the lack of information about MDM and for reasons of taboos, as elsewhere, this syndrome's topic has only recently been discussed; a recent estimate suggests that Italians affected by muscle dysmorphia are around 60.000 (Longobardi, Prino, Prino, Fabris, & Settanni, 2017). This syndrome is more prevalent in males than in females. Recent researches estimated the prevalence of MDM in the university student population between 5.9% and 6.99% (Bo et al., 2014;Compte, Sepulveda, Sepulveda, & Torrente, 2015).
Subjects with muscle dysmorphia rarely reach clinician's attention, because the MDM it is an ego-syntonic disorder. Furthermore, MDM it is coherent with the cultural standards and because of that it can be allowed, or even encouraged, by the environment. In fact, these subjects could appear fit, tonic, and successful to others (Leone, Sedory, Sedory, & Gray, 2005), but secretly have concerns and obsessions about their own physical appearance. These factors contribute to make muscle dysmorphia very difficult to study and to treat (Strother, Lemberg, Lemberg, Stanford, & Turberville, 2012).
The tripartite influence model of body dissatisfaction states that social pressure from family, peers, and media leads to the development of body dissatisfaction through the internalization of a societal body ideal and the encouragement of social comparison (Cafri et al., 2005). Tylka (2011) adapted this model to the male population demonstrating that mesomorphic internalization, muscularity, and body fat dissatisfaction play a mediational role in the association between social pressure and disordered eating behaviors. Muscularity and thinness oriented internalization can be considered a potential risk factor for eating disorders in the male population. Longitudinal and cross-sectional studies, in the adult and adolescent male population, also demonstrated the role of muscularity and eating disorders symptoms in the association between internalization of appearance ideals and body dissatisfaction (Brown, Forney, Forney, Pinner, & Keel, 2017;Cahill & Mussap, 2007;Edwards, Tod, Tod, Molnar, & Markland, 2016). A recent study (Klimek, Murray, Murray, Brown, Gonzales Iv, & Blashill, 2018) pointed out that body ideal internalization in men may be best conceptualized as interactions between muscularity and thinness internalization in association with various disordered eating cognitions and behaviors, such as MDM.
One of the most used tools to assess MDM is the Adonis Complex Questionnaire (ACQ); the ACQ is 13-item US questionnaire, designed for male subjects only, related to the dissatisfaction and concerns about physical appearance. It was introduced by Pope, Phillips and Olivardia (2000). The questionnaire evaluates the concerns about physical appearance and related behaviors, but does not provide a detailed information about symptoms severity levels. The score ranges from 0 to 39, where 0 is the total absence of concerns about physical image and 39 suggests a serious pathological condition (Latorre-Román, Garrido-Ruiz, Garrido-Ruiz, & Garcia-Pinillos, 2014).
The aim of the current study was to evaluate the validity of the Italian version of the ACQ.

| Participants
The sample consists of 322 adult males (Tables 1 and 2) aged between 18 and 55, recruited from the general population. An online version of the questionnaire has been distributed to a nonbodybuilder population and in closed thematic groups on social networks to subjects who practice bodybuilding and fitness. No exclusions criteria were applied, except all subjects declared that they do not consider themselves professional bodybuilders.

| Procedure
The questionnaire has been translated into Italian, with the permission of the author, by two psychiatrists and then translated back to English to verify the reliability of the translation. All the subjects completed the Italian version of the ACQ between June and October 2017. The ACQ consists of 13 items, and the subjects are asked to choose between three possible answers the most representative of their own condition.
The answers indicate in increasing order the presence and severity-from normal to pathological-of the concerns about physical appearance, as well as how this affects life and behavior in personal, social, relational, sexual, nutritional, and sportive life. In particular, values of 0-9 indicate minor concern for body image, 10-19 indicate mild to moderate, 20-29 indicate a serious concern for body image, and, lastly, 30-39 are indicative of severe forms of body image dissatisfaction and MDM (Leone et al., 2005).

| Statistical analysis
The factorial analysis of the items, introduced by Latorre-Román et al. (2014), highlighted three dimensions obtained from three subscale scores, corresponding to 3 internal factors such as: factor 1, psychosocial impact of physical appearance; factor 2, control of physical appearance; and factor 3, concern for physical appearance.
We used the maximum-likelihood confirmatory factorial analysis (CFA), analyzing the covariance matrices with AMOS 24.0, to evaluate the different factorial models proposed in the literature.
We performed the three-factor model (3F), primarily introduced by Latorre-Román et al. (2014), with the 13 items: the first factor consists of items that evaluate the psychosocial impact of physical appearance; the second factor consists of items that investigate the control of physical appearance; and the third factor evaluates the concern for physical appearance.
Moreover, the unidimensional nature of the questionnaire has been evaluated with a one-factor model for all the 13 items (1F) and with a two-factor model (2F); the first factor consists of items 2, 3, 8, 9, 10, 11 and the second factor includes items 1, 4, 5, 6, 7,

12, 13.
A confirmatory factor analyses (CFA) were conducted to assess the underlying factor structure of the ACQ. The model fit was assessed using root mean square error of approximation (RMSEA), and values <0.06 were considered a good fit. The validation analysis of the models was evaluated through the two indices method.
The chi-square and the comparative fit index (CFI) were used to compare the accuracy of the models.
We conducted an exploratory factor analysis, in order to explore the factorial structure of the ACQ in the sample, using the principal

| Ethics
This research was conducted in accordance with the Declaration of Helsinki and was approved by the ethical Committee of the University of L'Aquila. All the procedures were carried out with the adequate understanding of the subjects, who read and signed an informed consent form before participating in this research project.
All the authors declare that no financial support was received for this study.

| RE SULTS
The 322 subjects have a mean age of 38.1 years (SD = 11.28). As regards of the educational level, the majority of the participants,  Table 4).
The CFA has shown that the one-factor model (1F) is not suitable, while both the two (2F)-and three-factor (3F) models can be accepted ( Table 5). The suitability of the data for the factor analy- The first factor consists of seven items, related to the psychosocial effect of physical appearance, and explains 24.77% of the variance.
The second factor consists of 6 items, related to control of physical appearance, and explains 23.01% of the variance ( Table 6). The reliability of the ACQ and the homogeneity of factors were satisfactory for both the factors (Table 7). The correlation analysis between the ACQ factors and the demographic variables did not show significant relations.

| D ISCUSS I ON
The Adonis Complex concept (Pope et al., 2000) -Román et al. (2014). In this case, the first factor consists of items that evaluate the psychosocial effect of physical appearance, and the second both the concern for the physical appearance and the control of physical appearance, highly interrelated. Both the factors show a good internal consistency.
The concern and the control of physical appearance factors are closely related to each other, and this finding would support the literature that considers body dysmorphic disorder (BDD) as belonging to the obsessive-compulsive spectrum.  (Phillips, Gunderson, Gunderson, Mallya, McElroy, & Carter, 1998;Phillips, McElroy, Hudson, & Pope, 1995). In this way, in a mixed population (not exclusively sportsmen and/or bodybuilders) dietary behavior is considered the most used method to control the physical appearance, searching for physical fitness probably through food restrictions (Murray et al., 2012). This can be the reason why, in the DSM-5, muscle dysmorphia and body dysmorphic disorder (BDD) are considered a bridge between the obsessive-compulsive spectrum disorders and the eating behavior disorders; this finding can have some major clinical implications.
The findings of the current research confirm that the features of the two disorders are present also among the general Italian male population. It would be interesting, in further studies, to carry out a comparative research administering the questionnaire to a population of bodybuilders and sportsmen in order to highlight any significant differences. and Eating Attitudes Test (EAT-26), could be administered to evaluate concurrent validity.

| Study limitations
Another limitation is that the ACQ was administered only to a male population, and it would be interesting, in future researches, to analyze the psychometric properties of the Italian version of the ACQ also in a female sample.

| CON CLUS ION
The current study confirms the validity and the reliability of the Italian two-factor version of the ACQ and highlights the general tendency, among Italian males, to have concerns about their own physical appearance with recurring thoughts and eating behaviors finalized to improve it.
Our study represents an advance in the use of adequate and reliable instruments to assess concerns about physical appearance in the Italian male population.

ACK N OWLED G M ENT
This study was supported by funding from the University of L'Aquila.

CO N FLI C T O F I NTE R E S T
The authors declare no potential conflict of interest.

AUTH O R CO NTR I B UTI O N S
GR has been involved in the study concept and design, in the review of the literature, in the data analysis and interpretation, and in the drafting and revision of the manuscript. AP has been involved in the study supervision, in the supervision of the methodology, and in the review and editing of the manuscript. CI has been involved in the data curation, and in the review and editing of the manuscript.
GC has been involved in the in the data collection and in the review of the literature. GP has been involved in drafting and reviewing the manuscript. SP has been involved in drafting and reviewing the manuscript. AI has been involved in the study supervision, in the supervision of the methodology, and in the review and editing. FP has been involved in the conception and design of the study, in the data analysis and interpretation, and in the drafting and revision of the manuscript. Moreover, she supervised all of the steps of the study (review of literature, data analysis, interpretation data, drafting/revision of the manuscript). All of the authors agreed on the order in which their names have been listed and gave the final approval of the version to be published.

DATA AVA I L A B I L I T Y S TAT E M E N T
The data that support the findings of this study are available from the corresponding author upon reasonable request.