Exercise addiction is an obsessive or compulsive desire to exercise

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We might assume a person that goes to the gym every day is “addicted” to exercise. But in reality, exercise addiction is a complicated condition that researchers still don’t fully understand.

Exercise addiction is different from going to the gym or for a run everyday. Rather, the condition is characterised by an obsessive or compulsive need to exercise, to the detriment of quality of life. For example, a person with the condition might skip a friend’s wedding because they “need” to train.

Exercise addicts also experience strong withdrawal symptoms and train through injury, rather than following medical advice. One example of this is the case of Hope Virgo, who exercised so much and ate so little that she had a calcium deficiency, causing her to break bones while exercising.

Key symptoms of exercise addiction generally include:

  • Feeling a compulsion to do more and more exercise, or feeling that you’re not doing enough
  • Training through injury
  • Feeling strong withdrawal symptoms if exercise is stopped
  • Missing important social events because you “have to” exercise.

Exercise addiction is not currently recognised by either the World Health Organization or the American Psychiatric Association due to a lack of research on the condition. However there’s a growing body of research exploring exercise addiction.

How common the issue is seems to vary significantly between different types of exercise. It’s estimated that between 0.3-0.5% of the total population (including people who don’t exercise) are at risk of exercise addiction. In people who exercise regularly, between 3-7% of people are at risk of developing exercise addiction. However, we can’t be sure how accurate these numbers are as there’s currently no universally accepted diagnostic criteria for exercise addiction.

Complicated diagnosis
As such, current tools to diagnose exercise addiction assess a person’s risk by using an educated guess of what to measure. Some tools are based on medical diagnostic criteria for substance abuse, while others compare symptoms against the experiences of self-defined “exercise addicts”. This means that different methods of measuring exercise addiction are reporting on different things, which makes it pretty hard to say how common it really is.

Complicating matters further is the athlete paradox. Professional athletes train a lot – typically more than the average gym enthusiast. They definitely have to make sacrifices, often impacting their quality of life because of it – for example, they probably miss social events for training at times.

But if you ask them to analyse their own behaviour, they will often tell you they are just following their training schedule, that they have no choice. Athletes would therefore score highly on standard exercise addiction questionnaires.

Exercise addiction has also been shown to be linked to eating disorders, with a recent study showing that people with eating disorders are 3.7 times more likely to have exercise addiction. In fact, “excessive exercise” is part of the diagnostic criteria for both bulimia and anorexia. This is because people with eating disorders look to find ways to lose weight, and exercise is one way to burn calories.

Linkshave also been found between body dysmorphic disorder (also known as body dysmorphia) and exercise addiction. Body dysmorphic disorder is an anxiety disorder in which a person might obsess over one or more perceived flaws in their appearance. This link suggests that negative body image might be intrinsically linked to exercise addiction.

There are also links between exercise addiction, eating disorders and obsessive-compulsive disorder (OCD). People with OCD demonstrate many of the same traits that are present in both exercise addiction and eating disorders such as a lack of control over a compulsion, such as exercise. This shows that exercise addiction could simply be another form of OCD.

Some researchers have argued that exercise addiction does not exist if another disorder isn’t present. Yet the majority of research on exercise addiction doesn’t screen for primary conditions like eating disorders or body dysmorphic disorder – instead they only looks for signs of exercise addiction.

This means that we just don’t know whether or not exercise addiction is an independent condition or simply a symptom of something else. Future research should try focusing on screening for other disorders when looking at exercise addiction to see whether or not this condition exists if other conditions – like eating disorders – aren’t present.

Current treatments for potential exercise addiction can include cognitive behavioural therapy, although its efficacy is questionable as limited studies have been conducted. When it comes to treatment, it’s important to determine if exercise addiction is the primary condition, or whether it is a symptom of something else. If it’s a symptom of another condition, treating the primary condition should be the priority.


Exercise Addiction, Exercise Dependence, Abusive Exercise, and Other Forms of Problematic and Unhealthy Exercise
Exercise addiction (EA) describes a condition of excessive or abusive exercising behavior in which moderate to intense physical activity becomes a compulsive behavior (i.e., preoccupation with exercise routines, over-exercising, and inability to control the exercising behavior).

The individual is driven or compelled to continuing exercise for longer and more regular periods, i.e., excessive amounts of exercise, to the detriment of his or her personal, social, and professional life and regardless of harmful health consequences, while even ignoring clinical advice or training while exhausted, injured or ill; in addition, when abstaining from training, the individual shows the typical withdrawal symptoms that characterize behavioral addictions (Adams, 2009; Adams & Kirkby, 1998; Lichtenstein et al., 2017; Marques et al., 2019; Trott et al., 2020; Veale, 1987; Yates et al., 1983).

EA has been defined as a craving or rigid and extreme urge for physical activity that leads to highly intense exercise and generates physiological and psychological adverse manifestations and symptoms (Meyer et al., 2011; Petit & Lejoyeux, 2013), including overtraining and chronic fatigue, bodily pain, injuries, doping, stress, depression, sleep dysfunction, and disordered eating, as well as performance impairments.

Thus, it is a “morbid pattern of behavior in which the habitually exercising individual loses control over his or her exercise habits and acts compulsively, exhibits dependence and experiences negative consequences to health as well as in his or her social and professional life” (Szabo et al., 2015, p. 303).

More specifically, EA refers to a multidimensional maladaptive pattern of exercise that is associated with significant distress and impairment and characterized by the following (Hausenblas & Symons Downs, 2002a):

(1) tolerance to increased exercise amounts,

(2) withdrawal effects when exercise is not undertaken,

(3) intention effects resulting in recurrent and longer involvement,

(4) lack of control in engaging or reducing behavior,

(5) excessive time spent in exercising or related behaviors,

(6) reductions in other activities because of exercise, and

(7) the continuance of exercise despite recurrent physical or psychological problems.

Hausenblas and Symons Downs (2002a) proposed that the presence of at least three of the previous symptoms evidenced exercise dependence.

Accompanying this diversity of definitions, a plethora of terms has been used to define this maladaptive engagement in physical activity (e.g., exercise addiction, exercise dependence, obligatory/excessive/abusive/compulsive exercise, exercise misuse/abuse), making the interpretation of the literature challenging; since each term has specific features and connotations (e.g., implication of pathology and problematic categorizing of individuals from a pathology-based definition), it has been proposed that the term EA encompasses all, as it might gather all the meanings (e.g., Berczik et al., 2012; Cook et al., 2014; Freimuth et al., 2011; Hausenblas & Symons Downs, 2002a; Lichtenstein et al., 2017; Petit & Lejoyeux, 2013; Szabo, 2009; Szabo et al., 2015, 2018; Weinstein & Weinstein, 2014). This proposal also coincides with the most frequent characterization of excessive behaviors: 75% of the studies focusing on excessive exercise adopted the frame of addiction conceptualization (e.g., Mudry et al., 2011), yet others have found that “exercise dependence” is more frequently used to refer excessive exercise (e.g., Gonçalves et al., 2019).

Usually—but not uniquely—expressed as a continuum instead of a discrete entity, EA begins with a search for pleasure or performance goals in physical effort (i.e., recreational exercise, athletic training), which then gives way to an obsession for exercise resulting in a need to practice it more and more frequently and intensely (i.e., problematic, at-risk exercise leading to addiction) (Elbourne & Chen, 2007; Freimuth et al., 2011; Gapin & Petruzzello, 2011; Meyer & Taranis, 2011; Petit & Lejoyeux, 2013; Weinstein & Weinstein, 2014). Thus, it seems there is a developmental pathway that leads from exercising for fun (“want to”) to an increasing commitment to exercise (“have to”) and finally to a psychophysiological dependence on exercise (“must to”) that is no longer linked to enjoyment or performance goals (Gapin & Petruzzello, 2011; Zeeck et al., 2017). Supporting this continuum, Cook et al. (2013) and Magee et al. (2016) found in athletes several subgroups graded by type and severity of symptoms by using both cut-off points and clustering techniques for within-subject profiles. Some other empirical findings support the conceptualization of EA as a continuum by finding different results for different ranges of EA (e.g., Gorrell & Anderson, 2018). Moreover, qualitative research on the self-narratives of problematic exercise also supports the continuum (e.g., Johnston et al., 2011). Thus, it seems there is not only the chance to categorize individuals as being either dependent/nondependent but also as having a variety of levels of risk and EA manifestations.

Despite the negative health effects that can be associated with excessive exercise, including increased physical and mental illness, injury, and particularly disordered eating and eating disorders, evidence has shown that individuals with EA show unremarkable levels of psychological morbidity and do not report sufficient psychological distress to warrant classifying EA as a pathology or including EA in nosological classifications such as the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5), or the International Classification of Diseases, 11th Edition (ICD-11), as a separate disorder with its own entity, although the lack of sustained and methodologically rigorous evidence may profoundly contribute to this insufficiency (Marques et al., 2019; Szabo et al., 2015). The more recent DSM-5R still incorporates EA among nonsubstance-related behavioral addictions, which are included alongside substance use disorders. Dependence on exercise can be considered an addictive behavior because it presents signs that are typical of other addictive behaviors, such as loss of control over the behavior, mood disturbances, and tolerance and abstinence syndrome, and dedicating too much time to the behavior, with interferences in life and relapses (Cook et al., 2014; Marques et al., 2019).

As an addiction, exercise dependence can be primary, i.e., exercising is an end in itself, such that the behavior is intrinsically rewarding and gratifying, and individuals are motivated for the psychological gratification resulting from the compulsive exercise behavior itself, or it can be secondary, such that the individual is driven to exercise to accomplish a separate outcome, as occurs when he or she exercises to facilitate an eating or a body image dysfunction, i.e., a symptom of an eating disorder (Veale, 1987). In its form of secondary to psychopathology, exercise is used as a compensatory behavior in an attempt to lose weight, balance calories, control body composition, and enhance one’s physical appearance such that it exacerbates symptoms and consequences related to eating-related disturbances. Since the very early studies that focused on the sports arena, primary and secondary exercise dependence have been proven to be distinct and independent conditions (e.g., Blaydon et al., 2002, 2004; Cook & Luke, 2017; Cook et al., 2013; Cunningham et al., 2016). However, the existence of EA as a secondary dependence has been debated (see Cook et al., 2014; Szabo et al., 2015). In contrast, other scholars have stated that EA and eating disorders cannot exist independently from one another at all, meaning that EA is always secondary (see Adams, 2009; Elbourne & Chen, 2007; Lichtenstein et al., 2017). As recent reviews have showed (e.g., Godoy-Izquierdo et al., 2021, in this Issue; Gonçalves et al., 2019), there exists a commitment to excessive exercise that is clearly related to weight and shape preoccupation, weight control, dietary attitudes and behaviors, and body image issues.

Research on EA started in the 1970s, grew in the 1980s to the 2000s, and exploded until recently; it is currently a well-recognized although poorly understood and controversial phenomenon for which investigation is still inconsistent (e.g., Adams, 2009; Adams & Kirkby, 1998; Allegre et al., 2006; Berczik et al., 2012; Cook et al., 2014; Davis, 2000; Freimuth et al., 2011; Gonçalves et al., 2019; Hausenblas & Symons Downs, 2002a; Kerr et al., 2007; Lichtenstein et al., 2017; Petit & Lejoyeux, 2013; Szabo et al., 2018; Veale, 1987; Weinstein & Weinstein, 2014). However, knowledge has been based on a lack of well‐controlled empirical evidence (Gonçalves et al., 2019; Hausenblas & Symons Downs, 2002a; Szabo, 2009; Szabo et al., 2015) and, more importantly, the absence of a consensus on the nomination, definition, operationalization, identification, and measurement of EA manifestations and etiological and outcome correlates, along with issues on evidence-guided diagnosis and clinical practice. In addition, there is a neglect of the multiple and varied subjective experiences of those suffering from EA. Moreover, EA has been mainly approached in contexts outside the sports arena, such as regular exercisers and fitness center users, clinical samples of patients with eating disorders or the general population, mostly including university students (see Cook et al., 2013; Gonçalves et al., 2019). Nevertheless, sports-specific risk factors have been proposed from the beginning, such as involvement in endurance sports (e.g., Di Lodovico et al., 2019; Kerr et al., 2007; Nogueira et al., 2018). As athletes are a high-risk subgroup for EA due to the amount of practice and the demands of the competitive context, a focus will be given to this condition in the athletic population.

EA: Who Is Affected and How? Prevalence and Sporting Features
An inconsistency has also been observed in reporting the prevalence of EA. Among regular exercisers and community samples, EA affects 2–43% of individuals (see Cook et al., 2014; Cook & Luke, 2017; Di Lodovico et al., 2019; Simón-Grima et al., 2019; Szabo et al., 2015; Zeeck et al., 2017). The most incredible figures indicate prevalence rates that can reach 80% of the general population and leisure exercisers (Egorov & Szabo, 2013; Petit & Lejoyeux, 2013; Trott et al., 2020). Moreover, Szabo et al. (2019) found a non-significantly different prevalence rate of 11.5% using the EAI (with the scoring rating scale changed from original) and 9% with the EDS-R in a sample of exercisers, and only a 88% of concordance between both tools for identifying the individuals who were at risk, symptomatic and asymptomatic; such discrepancies have been also previously found (e.g., Mónok et al., 2012). All these findings support that the measurements being used are probably assessing related but not totally identical psychological constructs.

Among athletes of diverse sports and performance levels, rates have been reported to range from 3 to 41% (see Magee et al., 2016; Szabo et al., 2015). Research on the prevalence of EA has focused mostly on individual sports; specifically, among endurance athletes such as runners and triathletes, estimates range from 3 to 77% (see Cook et al., 2013; Cook & Luke, 2017; Di Lodovico et al., 2019; Gapin & Petruzzello, 2011; Nogueira et al., 2018). In team and ball sports, for instance, 7–18% incidence rates in football have been found (Costa et al., 2015; Di Lodovico et al., 2019; Lichtenstein et al., 2014), but others report up to 28% prevalence (Modolo et al., 2011). Godoy-Izquierdo et al. (2021, in this Issue) found prevalence estimates between 1 and 59% for a wide range of sports types and levels of competition; the figures are 1–51% for runners, 30% for triathletes, 8–9% for ironman and cycling athletes, and 15–30% for athletes in a nondisaggregated variety of sports. Two studies disaggregated prevalence rates by gender; in both running and a variety of sports, women were between 55 and 67% more likely to report EA. Moreover, one study specifically distinguished between lean (40%) and nonlean (26%) sports for calculating the prevalence of EA among female athletes.

Recent meta-analytic research estimates that 13% of the active population—including but not uniquely athletes—may suffer from EA (Simón-Grima et al., 2019), with a range between 1 and 52% (Gonçalves et al., 2019). Another meta-analysis (Marques et al., 2019) reported a prevalence of 3–7% among regular exercisers and of 6–9% in the athlete population, yet estimates ranged from 1.4 to 17% for the latter, suggesting a slightly higher risk among the athlete population compared to the general population. Marques et al. (2019) also found that EA had been examined in just 11 studies among the athletic population, with only one study reporting findings for primary and secondary risk for EA: primary EA was found in 8% of athletes, while secondary EA was observed in 1%.

However, in a recent review, Godoy-Izquierdo et al. (2021, in this Issue) found more studies exploring the prevalence of secondary EA, with overall prevalence rates ranging from 1 to 80%. Differentiating by sports, rates are 31–80% for runners, 22% for triathletes, 1% for cyclers, and 13–57% for athletes in a nondisaggregated variety of sports. None of the studies disaggregated prevalence rates by gender or lean vs. nonlean types of sports. Comparatively, two studies showed a nearly 30% points higher prevalence of EA co-occurring with eating pathology compared to pure EA, whereas another study found similar rates for both conditions, and only one found a difference of 8% points favoring the prevalence of pure EA.

The discrepancies in the prevalence figures could reflect differences in a number of contextual, sports or athletes’ individual risk factors as well as methodological problems (e.g., measures used to assess EA, classification algorithms or decisions on diagnostic criteria) (e.g., Berczik et al., 2012; Cook et al., 2014; Gonçalves et al., 2019; Lease & Bond, 2013; Magee et al., 2016; Szabo et al., 2015; Trott et al., 2020). Simply stated, the varying sample characteristics and assessment tools may be limiting our understanding of EA (Cook et al., 2013). Indeed, in a sample of ironman athletes (Magee et al., 2016), it was found that 9% could be considered at risk for EA, 79% could be considered as nondependent but symptomatic, and only 12% could be considered as nondependent and asymptomatic based on scoring criteria and cut-off points; however, when using profile analytic techniques, while the majority of athletes appeared to have a healthy involvement with sports and may derive positive health and well-being outcomes from their training and participation in competition, approximately 30% belonged to the at-risk and symptomatic profiles, which could reflect maladaptive patterns of exercise.

Moreover, these figures are based on self-report measures as screening instruments, which inform on the risk of having EA, but only a small percentage of these “at-risk” individuals would fulfill the criteria based on the diagnostic symptoms for addiction or dependence in a clinical interview (Zeeck et al., 2017). In addition, voluntary participation in research on EA probably introduces sample bias, as individuals with unhealthy behaviors are less likely to collaborate (Magee et al., 2016). Consequently, prevalence rates may be both overestimated and underestimated.

Additionally, there is an increasing number of individuals in the general population exercising as athletes. Competitions in many sports, such as running disciplines, ball or racquet sports, and weightlifting, have attracted recreational athletes who participate for a variety of reasons but for whom there was no planned athletic career or supervision by professionals. With increases in their participation in athletic events with true athletes, it is plausible that a greater number of individuals among this recreational population may increasingly identify with the athletic model and potentially make an effort to control their performance. Consequently, given the prevalence rates of EA, a potentially large number of recreational athletes could be increasingly engaged in compulsive exercise to control performance, as well as to decrease or suppress negative affectivity such as anxiety or guilt when not able to exercise, or to manage eating and bodily dimensions. Given that these recreational athletes do not have the formation, monitoring, counseling, and control that professional athletes have, they can be at a particular risk. Thus, there is a distinct need for increased clinical screening, prevention, and management of factors that may precipitate or exacerbate vulnerability for EA in this population (Gorrell & Anderson, 2018). Improved understanding of this reality may help to identify for whom the relation between exercise—and eating—pathology may be most problematic and to inform screening and clinical interventions.

reference link: https://link.springer.com/article/10.1007/s11469-021-00641-9


Source: The Conversation

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