Despite some incredibly compelling research findings observing the significant connection between compulsive exercise and eating disorders, including research that found that of 100 patients (AN, BN, EDNOS), 38 percent of those with anorexia nervosa engaged in compulsive exercise, this compulsion is not currently recognized by the American Psychological Association as a separate diagnosis. (1) And while gambling and internet addictions were included in the fifth edition of the Diagnostic and Statistical Manual (DSM), which was released earlier this year, the consensus was that more research about compulsive exercise is needed to validate a formal diagnostic category, even though exercise compulsion is a very real problem for many individuals struggling with eating and body-related disorders.
Below, Jennifer Lombardi, MFT, Executive Director of Eating Recovery Center of California (formerly known as Summit Eating Disorders and Outreach Program), answers common questions about exercise compulsion and outlines practical strategies to help patients and families identify and address this issue. In recovery from anorexia for nearly 20 years and herself a fitness instructor in addition to being a widely recognized eating disorder treatment expert, Lombardi has unique insight into this common behavior that is often intertwined with food, eating and body-image issues.
What is exercise compulsion?
Lombardi: Compulsive exercise, excessive exercise and obligatory exercise are used interchangeably -- there is no universal terminology. Exercise compulsion is generally defined as being "characterized by a significant amount of physical activity combined with a compulsive need to do the activity." (2) In other words, the exercise is obligatory in nature and it doesn't have to be a certain type of exercise or performed for a minimum duration. It's important to look at the intention behind the movement -- if there is a sense of urgency or agitation when individuals can't engage in the exercise behavior, there is likely an issue.
How do cultural perceptions about exercise complicate the identification and treatment of exercise compulsion?
Lombardi: In recent years, there has been a major cultural shift around the idea that exercise is going to help you -- not only in supporting general health and maintenance of a healthy weight during an obesity "epidemic," but also as a tool to manage anxiety and stave off depression. Exercise also makes us "feel good," and interestingly, compulsive over-exercisers often present with higher self-esteem despite having lower body-esteem. This paradox makes total sense if you consider the temperament of those suffering from an eating disorder -- they are high achievers, tend to have low reward dependence and novelty seeking traits, and they live in a rigid, "black and white" world. Exercise is concrete, measurable and accepted. The reward from exercise can be intrinsic in nature -- individuals with low reward dependence can do it well and push themselves privately. There is also a lot of cultural reinforcement around exercise, and our patients feel good about themselves because they are excelling at something considered by most to be a 'healthy' behavior.
But exercise is one of those behaviors that means something different to eating disordered patients when considering their temperament and brain chemistry. It's actually quite similar to cultural narratives around wine -- abundant research has found that a glass of red wine each day is "heart healthy," but clinicians with an understanding of addiction would never tell an alcoholic that one glass of wine per day is healthy.
What role do families play in the issue of exercise compulsion?
Lombardi: The family unit is where we often see this exercise compulsion dynamic play out with young patients. Parents have rallied around their son or daughter's activity or sport participation, and their objections to stopping the exercise behavior is often "When they're playing their sport, they feel the best and most confident about themselves." When the clinician tries to explain the self-esteem paradox and that exercise means something different to their loved one than other kids, parents will often cite the positive cultural notions around exercise as a healthy tool to help us overcome obesity and anxiety/depression. These ideas can challenge identification and treatment of compulsive exercise, occurring alone or alongside an eating disorder. When an issue is identified and treatment is sought, it is important to get buy-in around a patient's movement issues from their support system prior to them leaving the structured treatment environment. Again, because exercise has the general impression of being healthy and part of a balanced lifestyle, it is critical that families are educated about the slippery slope that exercise represents for individuals struggling with and recovering from an eating disorder.
Can compulsive exercise occur among competitive athletes?
Lombardi: In general, there tends to be confusion around the concepts of overtraining and overreaching. Overtraining is defined as excessive training characterized by long lasting fatigue and worsening performance, and it should not be confused with overreaching, the principle of training that encourages the athlete to push beyond the body's current ability. (3) While overreaching is a common method of competitive athletes, overtraining involves excessive intensity/duration, inadequate recovery time, unhealthy psychological state and malnutrition. The difference between the two principles is usually the nutritional component -- athletes that are overreaching are usually taking in sufficient nutrients and "fuel" to support their activities. We have to help athletes to understand and become aware that they are not training to improve stamina and performance for competition, but they are actually exercising "just because," and their athleticism no longer falls into a healthy range due to the compulsion and improper nutrition.
In addition to assessment from an eating disorders treatment professional including therapists, dietitians and psychiatrists, a thorough medical evaluation is also a critical component of assessment, as exercise relates very directly to physical health and medical status. To this end, it is important to identify a physician with eating disorders experience. Our societal norms around exercise and physical activity and accepted frequencies -- 30 minutes, five days per week, play for 60 minutes each day, take 10,000 steps per day, etc. -- can challenge the identification of dangerous patterns and/or normalize compulsive exercise, even among seasoned medical professionals.
If you're struggling with an eating disorder, call the National Eating Disorder Association hotline at 1-800-931-2237.
References:
1. Brewerton TD, Stellefson EJ, Hibbs N, Hodges EL, Cochrane CE. "Comparison of eating disorder patients with and without compulsive exercising." International Journal of Eating Disorders. 1995 May;17(4):413-6.
2. Bewell-Weiss CV, Carter JC. "Predictors of excessive exercise in anorexia nervosa." Comprehensive Psychiatry. 2010 Nov-Dec;51(6):566-71.