September 2016 Issue

Focus on Fitness: Exercise Addiction
By Jennifer Van Pelt, MA
Today's Dietitian
Vol. 18 No. 9 P. 62

Exercise is good for you—so the more exercise, the better, right? The answer is, "no." Too much exercise can be just as unhealthful as no exercise. First reported in 1970, exercise addiction has been researched since then, but it's still not fully understood or as well defined as other addictions.1,2 Currently, exercise addiction is categorized as a behavioral addiction. The Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) by the American Psychiatric Association defines a behavioral addiction as a compulsive psychological and physiological urge for one or more specific behaviors. However, exercise addiction is not included in the DSM-5, making exact clinical diagnosis and treatment difficult.2

In this article, I'll discuss what research has revealed about exercise addiction, including symptoms that may help you identify clients at high risk of exercise addiction. Two types of exercise addiction—primary and secondary—are currently recognized. In primary exercise addiction, physical activity is the sole gratifying behavior performed for some kind of psychological release or relief. Secondary exercise addiction is a symptom of an eating disorder, in which physical activity is performed as a means of calorie control and weight loss. One-third to one-half of those with anorexia may have secondary exercise addiction.2,3 This article will cover only primary exercise addiction.

Addicted or Just Dedicated?
Diagnosing exercise addiction is tricky. Daily amount of exercise isn't a reliable sole indicator of addiction; motivations for exercise and associated behaviors must also be considered. And, as we view exercising regularly as part of a healthful lifestyle, exercise addiction often hides behind what is seen as normal behavior. Though secondary exercise addiction is quite common, primary exercise addiction is rare; prevalence in the general population is estimated at only 3%. However, prevalence and risk have been found to be higher in certain groups, such as ultramarathon runners, "extreme" athletes, and bodybuilders.2,3

Consider the following individuals:

• Steve is a college-aged runner with competitive race times approaching Olympic level. His coach has encouraged him to increase training to qualify for the Olympic trials, and potentially, Olympic competition. Steve decides to stop participating in an extracurricular theater group and forgo pledging a fraternity to spend more time training—adding new activities like weight training and plyometrics to boost performance. He tries to maintain friendships with his theater group despite his busy schedule. One day, Steve sprains his ankle while training. He continues to train for Olympic running events, but moves his daily workouts to the pool, where he does deep-water running to stay in shape while his ankle heals.

• Laura, 35, is a divorced accountant. She joins a gym after her divorce to meet new people and get in shape. She loves the classes and the equipment there. During the week, she gets up at 5 AM every day to take a spinning or CrossFit class; sometimes she's late for work because she stays at the gym on the treadmill after class. Three days per week, after work, she also has a session with a personal trainer and then takes a hot yoga class. On weekends, she attends a Zumba class. When her personal trainer is sick and has to cancel two sessions in one week, Laura is very irritable and anxious. She does some weight training, but hurts her back and shoulders lifting too much weight. She decides to push through the back and shoulder pain and take the hot yoga class anyway.

Would you consider one or both of these individuals to be an exercise addict? To decide, let's look at the following key behaviors associated with exercise addiction:

• Withdrawal symptoms: When unable to exercise, the individual experiences negative feelings, such as anxiety, restlessness, sleep issues, and/or irritability.
• Time: Preparing for, participating in, and recovering from exercise takes up a substantial amount of the individual's life.
• Control: The individual is unable to successfully reduce exercise amount or stop exercising.
• Reduction in activities/social isolation: The individual stops social, occupational, or recreational activities in favor of exercise.
• Continuance: The individual continues to exercise despite physical or other problems, even while knowing that exercise is the cause.
• Intention: The individual is unable to maintain his or her nonexercise schedule due to consistently exceeding the amount of time allotted for exercise.2-4

Based on the above symptoms, Laura is likely to be an exercise addict. While exercise does interfere with other aspects of Steve's life and takes up a large amount of his time, Steve isn't an exercise addict, just a dedicated athlete in training for the Olympics.

A red flag for exercise addiction is when a client uses exercise as a coping or escape mechanism, and exercise becomes what researchers call "their life's main organizing principle" to the extent of causing negative consequences or making life unmanageable.3 Exercise addicts are at high risk for physical injuries, including overuse and acute injuries, chronic pain, decreased immunity, impaired ability to recover from exercise, unhealthful weight loss, exhaustion, cardiovascular problems, and depression.1

The symptoms of exercise addiction are similar to other behavioral addictions and substance dependency. Research has shown that exercise addicts may be more susceptible to other addictive behaviors. One review found that 25% of exercise addicts showed signs of other behavioral addictions, such as shopping, sex, gambling, nicotine, and alcohol/drugs.5 And, those recovering from other addictions may be more at risk of exercise addiction.3 For example, a recovering alcoholic or gambling addict may be counseled to exercise to fight urges and feel better; exercise then may become the new addiction.

Certain personality types also may be at greater risk of exercise addiction, based on the emotional link between exercise and coping. Individuals with obsessive-compulsive, neurotic, and anxious personalities may use excessive exercise to deal with compulsion, anxiety, and neuroses. Also at higher risk are high-energy, extroverted individuals; perfectionists; and narcissists/egocentrics, who may use exercise to manage energy or fuel needs to attain their desired physique.4

Research on the treatment of exercise addiction is currently limited.2,3 As with other behavioral addictions, cognitive-behavioral therapy is generally recommended.3 Exercise addiction is unique in that the behavior itself is viewed positively; with other addictions (eg, gambling and alcohol), the behaviors are viewed negatively. Judging whether one's exercise routine is excessive enough to diagnose addiction is challenging, as is getting the addicted individual to recognize the negative consequences of a behavior viewed as healthful.

For a comprehensive look at exercise addiction, including history, research, personal accounts, and resources, check out The Truth About Exercise Addiction: Understanding the Dark Side of Thinspiration by Schreiber and Hausenblas.

— Jennifer Van Pelt, MA, is a certified group fitness instructor and health care researcher in the Reading, Pennsylvania, area.

References
1. Jee YS. Exercise addiction and rehabilitation. J Exerc Rehabil. 2016;12(2):67-68.

2. Egorov AY, Szabo A. The exercise paradox: an interactional model for a clearer conceptualization of exercise addiction. J Behav Addict. 2013;2(4):199-208.

3. Freimuth M, Moniz S, Kim SR. Clarifying exercise addiction: differential diagnosis, co-occurring disorders, and phases of addiction. Int J Environ Res Public Health. 2011;8(10):4069-4081.

4. Schreiber K, Hausenblas HA. The Truth About Exercise Addiction: Understanding the Dark Side of Thinspiration. Lanham, MD: Rowman & Littlefield; 2015.

5. Sussman S, Lisha N, Griffiths M. Prevalence of the addictions: a problem of the majority or the minority? Eval Health Prof. 2011;34(1):3-56.