Running on empty: Can excessive exercise really be an addiction?

Back in 1997, I published my first academic paper on exercise addiction – a case study of a young women addicted to martial arts – at least according to the definition of exercise I was using. However, at present, exercise addiction is not officially recognised in any medical or psychological diagnostic frameworks such as the American Psychiatric Association’s Diagnostic and Statistical Manual (DSM) or the World Health Association’s International Classification of Diseases. However, there has been a lot of research into whether exercise can be classed as a bona fide addiction.

In spite of the widespread usage of the term ‘exercise addiction’ there are many different terminologies that describe excessive exercise syndrome. Such terms include (i) exercise dependence, (ii) obligatory exercising, (iii) exercise abuse, and (iv) compulsive exercise. In a recent review that I co-wrote with Dr Zsolt Demetrovics and colleagues at Eotvos Lorand University (Budapest), we believe the term ‘addiction’ is the most appropriate because it incorporates both dependence and compulsion. Based on research carried out internationally, we believe that exercise addiction should be classified within the category of behavioural addictions. The resemblance is evidenced not only in several common symptoms, but also in demographic characteristics, the prognosis of the disorder, co-morbidity, response to treatment, prevalence in the family, and etiology.

But how is exercise addiction assessed? Several instruments have been developed and adopted for the assessment of exercise addiction. Two relatively early scales, the ‘Commitment to Running Scale’ and the ‘Negative Addiction Scale’ are no longer used because of theoretical and methodological shortcomings. Among the psychometrically tested instruments, the ‘Obligatory Exercise Questionnaire’ (OEQ), the ‘Exercise Dependence Scale’ (EDS), and the ‘Exercise Dependence Questionnaire’ (EDQ) have proved to be both psychometrically valid and reliable instruments for assessing the symptoms and the extent of exercise addiction.

The OEQ is a 20-item self-report questionnaire that assesses the urge for undertaking exercise. The questionnaire has three subscales comprising (i) the emotional element of exercise, (ii) exercise frequency and intensity, and (iii) exercise preoccupation. The EDS conceptualizes compulsive exercise on the basis of the DSM criteria for substance abuse or addiction, and empirical research shows that it is able to differentiate between at-risk, dependent and non-dependent athletes, and also between physiological and non-physiological addiction. The EDS comprises seven subscales including (i) tolerance, (ii) withdrawal, (iii) intention effect, (iv) lack of control, (v) time, (vi) reduction of other activities, and (vii) continuance. In contrast to the EDS, the EDQ is aimed to measure compulsive exercise behaviour as a multidimensional construct. Furthermore, it can be used in assessing compulsion in many different forms of physical activities.

To generate a quick and easily administrable tool for surface screening of exercise addiction, I, and my colleagues (Annabel Terry and Attila Szabo), developed the ‘Exercise Addiction Inventory’ (EAI), a short 6-item instrument aimed at identifying the risk of exercise addiction. The EAI assesses the six common symptoms of addictive behaviours, namely (i) salience, (ii) mood modification, (iii) tolerance, (iv) withdrawal symptoms, (v) social conflict, and (vi) relapse. The EAI has been psychometrically investigated and has relatively high internal consistency and convergent validity with the EDS.

There are several other instruments available for assessing exercise addiction. However, they are either rarely adopted in research or are aimed at a specific form of physical activity such as body building (such as the ‘Bodybuilding Dependency Scale’). A more general but seldom adopted instrument is the ‘Exercise Beliefs Questionnaire’ (EBQ) that assesses individual thoughts and beliefs about exercise and it is based on four factors comprising (i) social desirability, (ii) physical appearance, (iii) mental and emotional functioning, and (iv) vulnerability to disease and aging. Empirical testing shows the instrument to have acceptable psychometric properties. There is also the ‘Exercise Dependence Interview’ (EXDI) that not only assesses compulsive exercising, but also eating disorders. However, one of the major limitations of this measure is that no psychometric properties have been reported.

Another scale is the ‘Commitment to Exercise Scale’ (CES) that examines the pathological aspects of exercising (e.g., continued training despite injuries) and compulsory activities (e.g., feeling guilty when exercise is not fulfilled). The CES has a satisfactory level of reliability. Finally the ‘Exercise Orientation Questionnaire’ (EOQ) measures attitudes towards exercise and related behaviours. The EOQ comprises six factors including (i) self-control, (ii) orientation to exercise, (iii) self-loathing, (iv) weight reduction, (v) competition, and (vi) identity.

Of these instruments outlined, the most popular currently are the EDS and the EAI (due to its brevity and easy scoring). Research has shown that when employed together, these two instruments yield comparable results. Despite the development of all these different scales and screening tools, their existence does not guarantee that exercise addiction will ever be officially recognised by the medical and/or psychiatric community.

Dr Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Further reading

Allegre, B., Souville, M., Therme, P. & Griffiths, M.D. (2006). Definitions and measures of exercise dependence, Addiction Research and Theory, 14, 631-646.

Berczik, K., Szabó, A., Griffiths, M.D., Kurimay, T., Kun, B. & Demetrovics, Z. (2011). Exercise addiction: symptoms, diagnosis, epidemiology, and etiology. Substance Use and Misuse, DOI: 10.3109/10826084.2011.639120

Downs, D. S., Hausenblas, H. A., & Nigg, C. R. (2004). Factorial Validity and Psychometric Examination of the Exercise Dependence Scale-Revised. Measurement in Physical Education and Exercise Science, 8(4), 183-201.

Downs, D. S., Hausenblas, H. A., & Nigg, C. R. (2004). Factorial Validity and Psychometric Examination of the Exercise Dependence Scale-Revised. Measurement in Physical Education and Exercise Science, 8(4), 183-201.

Freimuth M., Moniz S., & Kim S.R. (2011). Clarifying exercise addiction: Differential diagnosis, co-occurring disorders, and phases of addiction. International Journal of Environmental Research and Public Health, 8, 4069-4081.

Griffiths, M. D. (1997). Exercise addiction: A case study. Addiction Research, 5, 161-168.

Griffiths, M. D., Szabo, A., & Terry, A. (2005). The exercise addiction inventory: a quick and easy screening tool for health practitioners. British Journal of Sports Medicine, 39(6), e30.

Ogden, J., Veale, D. M., & Summers, Z. (1997). The development and validation of the Exercise Dependence Questionnaire. Addiction Research, 5(4), 343-355.

Pasman, L. N., & Thompson, J. K. (1988). Body image and eating disturbance in obligatory runners, obligatory weightlifters, and sedentary individuals. International Journal of Eating Disorders, 7(6), 759-769.

Terry, A., Szabo, A., & Griffiths, M. D. (2004). The exercise addiction inventory: A new brief screening tool. Addiction Research and Theory, 12(5), 489-499.

Yates, A., Edman, J. D., Crago, M., & Crowell, D. (2001). Using an exercise-based instrument to detect signs of an eating disorder. Psychiatry Research, 105(3), 231-241.