Reprinted from Eating Disorders Review
July/August Volume 25, Number 4
July/August Volume 25, Number 4
It’s a dilemma. Your patient is an elite athlete, and regularly exercises at a higher-than-normal pace. However, you are concerned that the level of daily exercise may actually be harmful. What is the difference between exercise as a healthy lifestyle choice and exercise as an addiction? As Dr. Kim Dennis explained in her recent International Association of Eating Disorders Professionals webinar presentation on exercise addiction (“Exercise: Addiction or Healthy Lifestyle Choice?”), there are definite differences and steps that help make the distinction.
While the prevalence of exercise addiction in the general population is only about 3%, rates are higher among some groups, such as ultra-marathon runners and sports science students. One of the highest rates is among people with eating disorders. Dr. Dennis, who is Medical Director of Timberline Knolls Residential Treatment Center, Lemont, IL, notes that from 39% to 48% of people with eating disorders also have exercise addiction (also termed secondary exercise addiction).1
Exercise addiction appears to cluster with food disorders, overuse of caffeine, work addiction, and shopping addiction as well.1 When exercise addiction and eating disorders co-occur, the danger is that only one disorder will be treated. The eating disorder, where symptoms are better known, usually is the focus of treatment, and the secondary disorder, exercise addiction, remains hidden and thus untreated, said Dr. Dennis. And, because of this, despite an improved relationship with food, patients will not gain weight because they are controlling their weight and/or shape by increasing their exercise regimens.1
Is the Exercise Level Healthy or Not?
The healthy lifestyle model of exercise involves exercise linked to improved health and cognition, or prevention of osteoporosis and greater overall satisfaction with life. It is regular and has positive effects on mental and physical well-being. This is true for all ages. Healthy exercise often involves a social activity versus solitary or secretive exercise. It promotes fun and relationships, not an ideal body shape or a targeted weight.
Exercise becomes problematic when the individual begins to plan his or her day around their exercise regimen. The regimen may become more and more rigid, and exercise becomes a means to alter mood; it also becomes a primary organizing principle. That is, where the increased activity originally helped an individual cope, now it makes life unmanageable. Daily functioning is impaired, and often the person can no longer meet his or her usual obligations at home and at work.
Exercise’s Effect on Mood
There is ample evidence that exercise has mood-altering effects. Exercise serves to increase positive affect, such as increasing self-esteem and decreasing the negative affect associated with depression and anxiety.2 At least three possible biological mechanisms connect improved mood and exercise. The first, the thermogenic hypothesis, holds that exercise increases body temperature, and thus reduces somatic anxiety. Decreased anxiety is related to increased temperature in certain regions of the brain.3 The second hypothesis states that exercise releases catecholamines, which are strongly implicated in control of mood, attention, and movement, as well as endocrine and cardiovascular responses linked to stress. The third hypothesis involves endorphins. Exercise releases endorphins, which are naturally occurring opiates. This can have unplanned consequences because with regular intense exercise, the brain counteracts by down-regulating endorphin production. Because of this, an individual will need to continue increasing exercise to maintain the natural balance of endorphins in the brain.4
Just as with other addictions, exercise addiction has a reward pathway. Some of the primary brain structures that participate in this pathway include the ventral tegmental area (VTA), the nucleus accumbens, and the prefrontal cortex. A new area of research involves a transcription factor, the protein, ΔfosB. This protein accumulates in the nucleus accumbens and dorsal striatum (brain regions important for reward and addiction) after chronic exposure to all drugs of abuse, but importantly also after chronic consumption of so-called natural rewards, including high levels of activity.5 The protein has long-lasting effects, and one hypothesis is that lasting brain changes are related to relapse potential in substance addiction, behavioral addictions, and eating disorders as well.
Who Is At Greatest Risk?
Patients who may be at greater-than-normal risk include those with low self-esteem, those who have undergone traumatic life events, those who have co-occurring disorders, including eating disorders and substance abuse, and those with depression and anxiety disorders. One group at particularly high risk includes gymnasts, figure skaters, cross-country runners, rowing crew members, and cheerleaders. A family culture of excessive exercise is also a risk factor and, according to Dr. Dennis, there may be a genetic component as well. Living with parents who abuse substances can also increase the risk.
Table 1. Some Physiologic Effects of Exercise Addiction
Decreased anabolic (testosterone) response
Loss of emotional vigor
Autonomic sympathetic insufficiency
Decreased maximum oxygen uptake
Decreased levels of blood lactate
Increased cortisol response (muscle wasting)
Some of the physiologic repercussions of exercise addiction can be seen in Table 1. These side effects include decreased anabolic (testosterone) response, loss of emotional vigor, immunosuppression, decreased maximum oxygen uptake, decreased blood lactate, and increased cortisol response (muscle wasting). Over time the patient needs increased amounts or increased intensity of exercise to get the same effect. When he or she withdraws from exercise, depression can set in. The exercise addict may describe feeling like “jumping out of his skin” when exercise is taken away.
First, Assess Medical and Nutritional Status
The first step in intervening, according to Dr. Dennis, is a thorough assessment of the patient’s medical and nutritional status. Then, it is helpful to carefully look at the individual’s relationship to exercise, food, and his or her body. Is the individual restricting or purging, in addition to over-exercising? At this point it may also be helpful to determine whether the patient is exercising to promote health or to interfere with good health. A number of standardized scales can be used to screen and monitor these patients. One is the Exercise Dependence Scale-21, an instrument that uses a 6-point scale to measure possible dependence on exercise.6 The scale, scored on a Likert-like scale from 1 (never) to 6 (always) includes such items as “I would rather exercise than spend time with family/friends” and” I am unable to reduce how intensely I exercise.”
Once the diagnosis of exercise addiction is established, a treatment team can be assembled; the team often includes an internal medicine specialist, psychiatrist, therapist, exercise specialist, nutritionist, and support groups of family members and coaches. Next, it is important to assess the patient for co-occurring disorders such as substance use disorders, depression or anxiety. According to Dr. Dennis, another key to successful therapy is avoiding anorexogenic agents, wellbutrin if the patient has a history of anorexia nervosa or bulimia nervosa, as well as benzodiazepines.7
Guidelines for Reintroducing Exercise
At some point, when the patient is medically and psychologically stable, it will be appropriate to reintroduce healthy exercise. Initially, all exercise should be planned for a group setting or monitored closely; a good initial schedule includes 20 to 30 minutes of exercise up to 3 times a week. Dr. Dennis stressed that ongoing monitoring and support are critical, and if the patient’s physical or psychological status worsens, exercise should be discontinued until the patient is more stable.
It is also important to define goals of healthy exercise. An often overlooked maxim is that rest can be potent medicine. [Note: Some inpatient and residential programs use benzodiazepines to help the patient settle and rest. This isn’t in the Practice Guidelines, but is more of a clinical approach.] Some therapists have had success with "mindfulness/meditation, emotion management skills, and interpersonal effectiveness training (dialectical behavior therapy). Finally, having access to support groups in group therapy or 12-step support will help patients maintain the advances they have made.