Intended for healthcare professionals

Practice Practice Pointer

Addiction to exercise

BMJ 2017; 357 doi: https://doi.org/10.1136/bmj.j1745 (Published 26 April 2017) Cite this as: BMJ 2017;357:j1745
  1. Heather A Hausenblas, professor of kinesiology1,
  2. Katherine Schreiber, patient with 10 years’ experience of living with exercise addiction2,
  3. James M Smoliga, associate professor of physiology3
  1. 1Department of Kinesiology, School of Applied Health Sciences, Brooks Rehabilitation College of Healthcare Sciences, Jacksonville University, Jacksonville, FL 32211, USA
  2. 2New York, USA
  3. 3Department of Physical Therapy, High Point University, High Point, NC 27268, USA
  1. Correspondence to: H A Hausenblas hhausen{at}ju.edu

What you need to know

  • Addiction to exercise might form part of a broader eating disorder or may occur in isolation

  • Inability to stop or reduce exercising, for example in response to an injury, may indicate addiction

  • Treatment broadly follows the principles of treating other addictions, for example cognitive behavioural therapy and exercise reprogramming

Author’s story

By the time KS entered college, her world revolved around the gym. No sooner would she finish a lecture than she would dash to the campus fitness centre. She would feel anxious if she missed a workout and would go no matter how tired or busy she was. Travelling was very difficult because of her obsessiveness about her exercise routines. She lost many friendships and career opportunities because she was barely available outside her exercise schedule. By the time she was 26 years old, KS had weathered two herniated discs and a stress fracture and had persistent exhaustion.

Exercise has numerous health benefits and is generally viewed as a positive behaviour,1 so patients and clinicians may overlook the dangers of excessive exercise and addiction. This article explores how healthcare professionals can recognise and understand the risks of primary exercise addiction.

Details of literature search

We searched PubMed and PsychINFO using the terms “exercise addiction,” “exercise dependence,” and “excessive exercise” for systematic reviews and experimental, cross-sectional, and case studies. The overall quality of the evidence for this area is modest with a reliance on descriptive and observational studies. Few controlled trials and experimental designs exist.

What is exercise addiction?

People with exercise addiction experience loss of control such that exercise becomes an obligation and excessive.23 Although exercise addiction is not officially classified as a mental health disorder, it is characterised by similar negative effects on emotional and social health as other addictions. Primary exercise addiction differs from excessive exercise seen in people with eating disorders (also known as secondary exercise addiction), in which exercise represents a means to control weight.4

How common is it?

Estimates of prevalence in the general population are lacking. Because of the lack of sustained and methodologically rigorous research, diagnostic criteria are not well defined or validated. Some observational studies show that symptoms of exercise addiction range from 0.3% to 0.5% in the general population, while among regular exercisers it ranges between 1.9% and 3.2%.25

What are the risk factors?

Questionnaire based studies identify several risk factors for exercise addiction. A positive relationship with other behavioural addictions such as shopping and internet addiction has been observed.67 People who strongly identify themselves as an exerciser and have low self esteem are more at risk.8 Individuals with tendencies for anxiety, impulsiveness, and extroversion have a higher risk for exercise addiction.9

Men and women are equally at risk, but in men it is more often primary exercise addiction and in women it is more often secondary exercise addiction.810 Convenient sample studies reveal that risk for exercise addiction varies by physical activity,511 with reported incidence as high as 25% in runners12 and 30% in triathletes.13

How do patients present?

Individuals engaging in high volumes of exercise may report overuse injury (such as stress fracture and tendinopathy),14 anaemia, amenorrhoea, or other symptoms of endocrine, metabolic, or immune dysfunction.151617 Indicators of overtraining—such as unexplained decreases in performance, persistent fatigue, and sleep disturbance—may be reported.

Patients may continue to exercise despite injury or illness and give up social, occupational, and family obligations to exercise. Patients may report withdrawal effects when their exercise schedule is disrupted—such as inability to sleep and concentrate, restlessness, anxiety, sadness, or irritability.18 Symptoms may be exacerbated when patients are requested to limit or refrain from exercise (such as during recovery from an injury).

Exercise addiction should not be confused with a high level of commitment to a physical activity or a healthy habit.3 Overuse injuries and overtraining regularly occur in ambitious but non-addicted athletes. Exercise addicts are distinguished from other high volume exercisers, whose intrinsic desire to exercise is under control and does not regularly result in emotional, social, or occupational disruptions.

How is it diagnosed?

Diagnosis is based on clinical judgment. To help, clinicians can screen patients to understand motivating factors behind their training regimen, their emotional connection to exercise, and how it influences other aspects of their life. Box 1 presents related questions you could use during the consultation.

Box 1: Sample questions to ask a patient to assess whether he or she should be further evaluated for exercise addiction

These questions can be included in a patient interview to provide a practitioner with a more complete idea of the patient’s relationship with exercise. Clinical judgment is necessary in assessing whether the patient’s exercise behaviours are healthy, so that an appropriate action plan can be developed

Determine if the patient seems to be engaging in excessive exercise
  • How often do you exercise?

  • How long is your typical workout?

Explore the patient’s motivation for exercise behaviours
  • Why do you exercise?

  • What are your goals that you hope to achieve through your exercise routine? How did you decide on the exercise routine your currently perform?

Determine if patient is responsive to physical cues to reduce exercise when necessary
  • How do you know when you have exercised too much or reached your personal limits?

  • If you feel you have done too much, what do you do to ensure that you recover properly?

  • How do you know when you are ready to resume your normal exercise routine?

  • When you have been ill or injured, do you continue to exercise? If so, how do you modify your training to accommodate the illness or injury?

Determine if exercise behaviours are interfering with other important aspects of life
  • Does your exercise schedule frequently conflict with your work, school, family, or social obligations or interests?

  • If so, what do you feel are the consequences of these conflicts?

Establish the patient’s emotional connection to exercise
  • How do you feel when you are unable to exercise or have to modify your exercise routine?

Determine if the patient balances exercise with other leisurely activities
  • Do you engage in any other activities in your free time?

If the patient expresses a reluctance to take time off of exercise, demonstrates frustration and irritability when advised to reduce exercise, and reports exercise getting in the way of work and personal relationships, or if the patient discloses having tried to cut back on exercise but repeatedly failed, exercise addiction is likely.

Validated tools are available to determine risk of exercise addiction and severity of symptoms. However, these scales are for screening rather than diagnostic tools. For example, the Exercise Addiction Inventory is a brief, six-item screening tool that assesses salience, mood modification, tolerance, withdrawal symptoms, conflict, and relapse (see box 2).519 A person scoring above the cut-off score of 24 is classified as at risk of exercise addiction and should be referred to the appropriate mental healthcare provider for further evaluation. Other screening tools, such as the Exercise Dependence Scale 2120 and Compulsive Exercise Test21 (see tables A and B in online data supplement), cover fairly similar ground but in greater detail.

Box 2: Exercise Addiction Inventory as a screening tool19

This was developed to be a quick and easy screening tool for healthcare providers.

Questions
  1. “Exercise is the most important thing in my life” (salience)

  2. “Conflicts have arisen between me and my family and/or my partner about the amount of exercise I do” (conflict)

  3. “I use exercise as a way of changing my mood” (mood modification)

  4. “Over time I have increased the amount of exercise I do in a day” (tolerance)

  5. “If I have to miss an exercise session I feel moody and irritable” (withdrawal symptoms)

  6. “If I cut down the amount of exercise I do, and then start again, I always end up exercising as often as I did before” (relapse)

Scoring
  • 1 = strongly disagree; 2 = disagree; 3 = neither agree nor disagree; 4 = agree; 5 = strongly agree

  • A total score ≥24 (out of 30) indicates a person at risk for exercise addiction who should be referred to an appropriate specialist

  • A score of 13-23 indicates a potentially symptomatic person

  • A score of 0-12 indicates an asymptomatic individual

How is it treated?

There is scant literature on treatment of exercise addiction. As with most behavioural addictions, cognitive behavioural therapy and dialectical behaviour therapy are recommended to restructure maladaptive beliefs about exercise and manage mood disturbances.22 The goal of therapy is not to prevent the patient from working out, but to help them recognise the addictive behaviour and reduce exercise routine rigidity. Early identification can enable prompt management before compulsive exercise leads to an eating disorder23 or physical pathologies associated with excessive exercise such as injuries (fig 1), dysrhythmias, and myocardial fibrosis,2425 or osteoporosis.26

Figure1

Fig 1 Coronal (left) and axial (right) T1-weighted magnetic resonance images of a femoral stress fracture in a competitive distance runner. Yellow demarcations and arrow show subtle linear area of abnormal signal and enhancement of the posterior medial medullary canal with adjacent mild periosteal reaction centred 13 cm below the greater trochanter. The patient’s chief complaint was general pain in the thigh, which was initially misdiagnosed as a quadriceps strain. Individuals presenting with musculoskeletal overuse injuries such as this should be screened to determine whether exercise addiction is a contributor to high training volumes

In addition to informing the patient about these risks, discuss the appropriate amount of exercise for health benefits, based on guidelines set forth by the American College of Sports Medicine1 and the Centers for Disease Control and Prevention.27

You can work with the patient to develop “SMART” goals (specific, measurable, achievable, results-focused, and timely) for daily exercise.28 Although goal setting in exercise addiction has been little studied, SMART goals may work as part of a personalised plan with collaboration between the healthcare provider and patient with follow-up visits to monitor progress towards these goals.29 Additionally, patients may find it beneficial to work with fitness professionals and psychotherapists to design an appropriate training regimen and to re-learn how to use internal sensations, such as pain and fatigue, to differentiate between appropriate versus excessive training and healthy versus unhealthy motivators, such as comparison with others.30

For competitive athletes, acknowledge the physical demands and high training volumes required for success in the sport, but explain how fatigue from excessive exercise leads to decreased performance. They may discuss the situation with their coach and allied staff (such as athletic trainers and physiotherapists) so that these people can play an active role supporting athletes to regulate their exercise regimen.

Further investigations and referral to orthopaedics may be warranted if a patient presents with injury from excessive exercise. Involve a dietician if the patient is concerned about his or her weight. Consider referral to a psychologist, psychiatrist, or social worker trained in managing patients with behavioural addictions if emotional and interpersonal disturbances are noted.

Education into practice

  • Does this article give you ideas on how better to identify patients with addiction to exercise?

  • Think about a patient who presented with a primary complaint which may have been related to excessive exercise. Did you explore the possibility of excessive exercise? Does this article give you ideas on how you might do so next time?

  • If a patient responds unfavourably (such as “You just wouldn’t understand” or “This is normal for me”), how might you continue to engage with him or her in a supportive manner?

How patients were involved in creating this article

KS was diagnosed with exercise addiction. She has contributed to all aspects of the creation of this article by reviewing research, writing, and editing. She emphasised current treatments available for exercise addiction as well as questions physicians can ask their patients.

Footnotes

  • Contributors: JMS developed the idea for this article, contributed to writing this article, and edited the article. KS performed literature searches, drafted the article, and edited the article. HAH performed secondary literature searches, contributed to writing this article, and edited article. HAH is the guarantor of the article.

  • Competing interests: We have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.

  • Patient consent obtained

  • Provenance and peer review: Commissioned; externally peer reviewed

References

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