Exercise Dependence

Many people become physically active to improve their health and to look and feel better. But physical activity may become addictive for a small proportion  (3%–5%)  of  the  population.  It  is  important to emphasize that while exercise may represent an addictive  behavior  for  some  people  who  engage in  it  to  an  extreme  and  unhealthy  level,  habitual exercise  itself  is  not  inherently  abusive  and  people  should  be  active  to  meet  guidelines  (e.g.,  150 minutes of moderate-intensity physical activity per week) to experience its numerous health benefits.

Exercise Dependence Defined

When  the  desire  to  exercise  becomes  an  obsession and it negatively impacts a person’s physical and psychological health, it is considered a serious problem  known  as  exercise  dependence.  Simply stated, exercise dependence is a craving for leisure-time physical activity that results in uncontrollable and  excessive  exercise  behavior  that  manifests  in physiological  (e.g.,  tolerance)  or  psychological (e.g., withdrawal) symptoms. Other general terms for exercise dependence include exercise addiction, overexercising,  obligatory  exercise,  compulsive exercise,  and  exercise  fanaticism.  Common  characteristics of exercise dependence are continuing to exercise despite having an injury or illness; giving up social, occupational, and family obligations for exercise; and experiencing withdrawal effects, such as anxiety and tension when not able to exercise.

The  growing  consensus  in  recent  years  is  that exercise  dependence  is  similar  to  other  substance dependence   disorders   and   should   be   defined within a cluster of cognitive, behavioral, and physiological symptoms. Researchers have thus defined exercise  dependence  as  a  maladaptive  pattern  of exercise,  leading  to  clinically  significant  impairment or distress, as manifested by three (or more) of  the  criteria  listed  in  Table  1,  occurring  at  any time in the same 12-month period.

Exercise  dependence  may  also  play  a  pivotal role in explaining the function of exercise behavior in the development and maintenance of eating disorders.  To  this  end,  it  is  necessary  to  distinguish the etiology of the exercise dependence symptoms. Understanding  the  psychological  antecedents  of exercise may help clarify the relationship between eating disorders and excessive exercise by offering insight into the distinction between primary versus secondary  exercise  dependence.  Primary  exercise dependence  occurs  when  the  individual  meets criteria  for  exercise  dependence  and  continually exercises solely for the psychological gratification resulting from the exercise behavior—for example, a  runner  who  continually  increases  distance  and speed  to  facilitate  the  enjoyment  that  is  experienced from the running itself.  Secondary exercise dependence  occurs  when  an  exercise-dependent individual  uses  increased  amounts  of  exercise  to accomplish some other end, such as weight management  or  body  composition  manipulation—for example,  a  runner  who  continually  increases distance  and  speed  to  burn  calories  and  facilitate weight loss. Because exercise can be used as a compensatory  behavior  to  either  prevent  or  reverse weight gain, secondary exercise dependence in the context of eating disorders occurs when an individual meets the criteria for exercise dependence and continually  exercises  to  manipulate  and  control one’s own body; thus, exercise dependence is secondary to an eating disorder. Recently, researchers have  found  that  exercise  dependence  symptoms, not  exercise  behavior,  mediate  the  relationship between  exercise  and  eating  pathology.  That  is, psychological  factors,  rather  than  the  amount  of exercise itself, may better explain why the exercise dependence–eating disorder relationship exists.

Prevalence and Societal Importance of Exercise Dependence


Table 1    Exercise Dependence Criteria

Despite  the  worldwide  increase  in  obesity  over the  past  several  decades,  there  is  nevertheless  a growing  rate  of  excessive  behavioral  addictions, such  as  gambling;  Internet  use;  and  exercise dependence  that  can  result  in  poor  psychological  and  physiological  health  outcomes,  including increased  risk  for  illness,  stress,  depression,  and injury.  Recent  evidence  suggests  the  estimated prevalence  of  exercise  dependence  in  the  general adult population is 3% to 5%. Among particular subgroups of adult exercisers, for example marathoners and sport science students, the prevalence of exercise dependence is even higher. In general, men  present  higher  rates  of  exercise  dependence symptoms,  which  parallels  the  higher  rates  of physical  activity  participation  among  men  than women. The prevalence rate is about 10% for at risk for exercise dependence among regular adult exercisers.  Even  more  concerning  is  the  recent evidence that youth may also be at risk for exercise dependence symptoms. One study found that 6%  of  youth  ages  14  to  16  years  were  classified as  at  risk  for  exercise  dependence  and  an  additional  65%  were  classified  as  nondependent  but with some symptoms. Compared to the girls, the boys reported more overall exercise behavior and exercise  dependence  symptoms.  While  it  has  historically  been  thought  that  men  develop  exercise dependence symptoms in early adulthood as they hit  their  peak  fitness  level,  this  recent  evidence suggests that boys may be more at risk for developing exercise dependence symptoms at an earlier age  in  the  developmental  timeline—possibly  due to  their  greater  involvement  in  leisure-time  play, youth sports, and the types of vigorous activities like  running  and  weight  lifting  that  can  perpetuate overexercising. This is problematic because it increases the chances for long-term chronic health problems (injury, illness).

There is also a growing body of research beginning  to  quantify  the  exact  aspects  of  health  that are  affected  by  exercise  dependence.  Specifically, compared  with  nondependent  controls,  individuals  with  exercise  dependence  often  experience  an increased amount of overuse injuries like tendinitis and  muscle  injuries,  negative  affect  (particularly during exercise cessation), anxiety about the shape of  one’s  body,  neuroticism,  hypochondria,  and compulsive  shopping  or  buying.  Unfortunately, exercise   dependence   tends   to   be   overlooked because  it  represents  a  socially  acceptable  (or socially  tolerated)  addiction  that  appears  to  be  a reasonable form of dependence.

Measurement of Exercise Dependence

Measurement of exercise dependence relies primarily on self-report assessments due to the manifestation of psychological, behavioral, and cognitive symptoms.  Assessing  the  frequency,  duration, and  intensity  of  physical  activity  alone  does  not provide  an  accurate  estimate  of  the  underlying psychological factors that drive the symptomatology.  Although  there  are  several  unidimensional measures  of  excessive  exercise  (e.g.,  Negative Addiction  Scale,  Commitment  to  Running  Scale, and  Obligatory  Exercise  Questionnaire),  these measures have been criticized for not providing a complete  assessment  of  the  construct  of  exercise dependence.

The growing consensus among researchers and practitioners is that exercise dependence is better conceptualized  as  a  multidimensional  construct that parallels behavioral addiction, and therefore, is  more  appropriately  measured  by  multidimensional assessments that take into account the theoretical  underpinnings  of  addiction.  Researchers have  posited  that  behavioral  addictions  manifest when  a  behavior  can  provide  either  pleasure or  relief  from  internal  discomfort  of  anxiety  or stress,  and  the  behavior  is  characterized  by  feelings  of  powerlessness  or  loss  of  control,  and  is maintained despite serious physical or psychological  consequences.  It  is  now  accepted  that  addictions are a part of a biopsychosocial process that share  a  set  of  common  symptoms,  such  as  tolerance,  withdrawal,  mood  modification,  conflict, and relapse.

One  validated  self-report  measure  that  falls within  this  categorization  of  addiction  is  the Exercise  Addiction  Inventory  (EAI)  developed  by Annabel  Terry,  Attila  Szabo,  and  Mark  Griffiths. The  EAI  assesses  six  components  of  exercise addiction:  salience,  mood  modification,  tolerance,  withdrawal,  conflict,  and  relapse.  Another psychometrically   validated   measure   to   assess exercise  dependence  is  the  Exercise  Dependence Scale-Revised   (EDS-R)   developed   by   Heather Hausenblas  and  Danielle  Symons  Downs  and  is based  on  the  Diagnostic  and  Statistical  Manual of  Mental  Disorders,  4th  Edition,  Text  Revision (DSM-IV) criteria for substance dependence. This 21-item  measure  assesses  symptoms  across  seven criteria  (tolerance,  withdrawal,  intention  effects, loss of control, time, reduction in other activities, and  continuance).  The  EAI  and  EDS-R  are  easy to administer and offer researchers and practitioners useful tools for assessing exercise dependence symptoms.

Exercise Dependence Diagnosis and Treatment

Currently  there  are  no  formal  diagnostic  criteria for  exercise  dependence.  However,  the  DSM-IV now  includes  behavioral  addictions  (although gambling is the only designated behavioral addiction  in  this  category).  A  key  factor  in  identifying  a  person  with  exercise  dependence  symptoms is  distinguishing  between  the  excessive  exercise behavior  and  eating  pathology.  As  noted  above, primary exercise dependence occurs in the absence of  an  eating  disorder,  whereas  secondary  exercise  dependence  co-occurs  with  eating  pathology. Thus,  a  diagnostic  hierarchy  is  required  whereby a  person  should  be  first  evaluated  for  an  eating disorder such as anorexia nervosa or bulimia nervosa.  If  the  exercise  behavior  is  secondary  to  the eating  pathology,  then  referral  and  treatment  for an eating disorder should be the priority. If eating pathology is ruled out, the individual may meet the criteria for primary exercise dependence. However, focusing only on the excessive exercise behavior in terms  of  frequency  and  intensity  of  exercise  patterns fails to take into account the criteria that are unique  to  substance  dependence,  such  as  tolerance and withdrawal. Thus, determining if a person meets the aforementioned criteria for exercise dependence  may  provide  insight  to  the  excessive exercise. Both the EAI and EDS-R are reliable and useful  tools  that  may  assist  clinicians  in  assessing  exercise  dependence.  Also  considering  other coexisting  addictions,  such  as  alcohol  or  drugs or behavioral addictions like gambling, spending, or Internet use, can provide additional context to whether  the  person  has  an  addictive  personality disorder. Identifying individuals who are at risk for exercise  dependence  is  a  major  challenge  because exercise  is  considered  a  positive  health  behavior. Thus,  excessive  exercise  often  goes  unnoticed  as a negative health behavior until it has reached an extreme  form.  A  key  warning  sign  to  distinguish between  healthy  and  dependent  exercise  is  that healthy  exercisers  organize  their  exercise  around their lives, whereas dependents organize their lives around their exercise.


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