Eat to the beat: What is the relationship between exercise addiction and eating disorders?

In previous blogs I briefly examined both exercise addiction and eating addiction. However, there is some research that these two disorders sometimes co-occur. In some of the papers I have co-written we have reviewed the evidence as to whether exaggerated exercise behaviour is a primary problem in the affected person’s life or whether it emerges as a secondary problem in consequence of another psychological dysfunction. In the former case, the dysfunction is usually classified as primary exercise addiction because it manifests itself as a form of behavioural addiction. In the latter case, it is usually termed as secondary exercise addiction because it co-occurs with another dysfunction, typically with eating disorders, such as anorexia nervosa or bulimia nervosa.

In primary exercise addiction, the motive for over-exercising is typically geared toward avoiding something negative, although the affected individual may be totally unaware of their motivation. It is a form of escape response to a source of disturbing, persistent, and uncontrollable stress. However, in the case of a secondary exercise addiction, the excessive exercise is used as a means of weight loss (in addition to very strict dieting). Thus, secondary exercise addiction has a different etiology than primary exercise addiction. Nevertheless, it should be highlighted that many symptoms and consequences of exercise addiction are similar whether it is a primary or a secondary exercise addiction. The distinguishing feature between the two is that in primary exercise addiction, the exercise is the main objective, whereas in secondary exercise addiction, weight loss is the main objective, while exaggerated exercise is one of the primary means in achieving the objective.

In a qualitative study published by Dr Diane Bamber (University of Cambridge), she and her team interviewed 56 regularly exercising adult women. On the basis of the analysis of the results, the authors identified three factors in the diagnostic criteria of secondary exercise addiction. Among these factors, only the presence of eating disorder symptoms differentiated secondary from primary exercise addiction. The other two factors (i.e., dysfunctional psychological, physical, or social behaviour, and the presence of withdrawal symptoms) were nonspecific to secondary exercise addiction.

However, Dr Michelle Blaydon (formerly of the University of Hong Kong) and colleagues attempted to further sub-classify secondary exercise addiction based on the primary source of the problem, which in their view was related to either a form of eating disorder or to an exaggerated preoccupation with body image. Although this appears to have face validity, to date, there is no empirical evidence for such speculation. Furthermore, a different research study by Dr Diane Bamber found no evidence for primary exercise addiction. In fact, they believe that all problematic exercise behaviours are linked to eating disorders. However, this view remains critically challenged in the literature and there are documented case studies – including one that I published myself back in 1997 where no eating disorders were present at all.

In addition to several studies that have reported disordered eating behaviour often (if not always) accompanied by exaggerated levels of physical exercise, the reverse relationship has also been established. Individuals affected by exercise addiction often (but not always) show an excessive concern about their body image, weight, and control over their diet. This co-morbidity makes it difficult to establish which is the primary disorder. This dilemma has been investigated using trait and personality-oriented investigations. In an early but widely cited controversial study led by Dr Alayne Yates (University of Hawaii) concluded that addicted male long-distance runners resembled anorexic patients on a number of personality dispositions (e.g., introversion, inhibition of anger, high expectations, depression, and excessive use of denial) and labelled the similarity as the “anorexia analogue” hypothesis.

To further test the hypothesis, Yates and colleagues examined the personality characteristics of 60 male obligatory exercisers and then compared their profiles with those of clinical patients diagnosed with anorexia nervosa. While the study did not lend support to the hypothesis, the authors claimed that running and extreme dieting were both dangerous attempts to establish an identity, as either addicted to exercise or anorexic. The study has been criticized for a number of shortcomings, including the lack of supporting data, poor methodology, lack of relevance to the average runner, over-reliance on extreme cases or individuals, and exaggerating the similarities between the groups.

Indeed, later investigations also failed to reveal similarities between the personality characteristics of people affected by exercise addiction and those suffering from eating disorders. Therefore, the anorexia analogue hypothesis has failed to secure empirical support. Numerous studies have further examined the relationship between exercise addiction and eating disorders but no consensus has emerged. One reason for the inconsistent findings may be attributed to the fact that the extent of co-morbidity could vary from case to case depending on personality predispositions, the underlying psychological problem that has led to exercise addiction, and/or the interaction of the two, as well as the form and severity of the eating disorder.

A French study led by Professor Michel Lejoyeaux (Bichat and Maison Blanche Hospital) on 125 Parisian male and female current exercise addicts reported that 70% of their sample were bulimic. In another US study by Dr Patricia Estok and Dr Ellen Rudy among 265 young American adult women runners and non-runners, 25% of those who ran more than 30 miles per week showed a high risk for anorexia nervosa. In studies of people with eating disorders, a study by Peter Lewinsohn (Oregon Research Institute, US) found excessive exercise activity among males with binge eating disorders, but not females. However, the percentage overlap was not reported. Finally, in a review by Marilyn Freimuth (Fielding Graduate University, US), she and her colleagues reported that among people with eating disorders, 39% to 48% also experienced an exercise addiction.

Basically, the major weakness of the literature is the complete lack of large-scale studies. In a recent review of the addiction co-morbidity literature that I did with Dr Steve Sussman and Nadra Lisha (University of Southern California), we didn’t locate a single study on the co-occurrence of exercise addiction with other disorders with a sample size of more than 500 participants.

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

Further reading

Bamber, D.J., Cockerill, I.M., Rodgers, S., & Carroll, D. (2003). Diagnostic criteria for exercise dependence in women. British Journal of Sports Medicine, 37(5), 393–400.

Berczik, K., Szabó, A., Griffiths, M.D., Kurimay, T., Kun, B. & Demetrovics, Z. (2012). Exercise addiction: symptoms, diagnosis, epidemiology, and etiology. Substance Use and Misuse, DOI: 10.3109/10826084.2011.639120.

Blaydon, M.J., & Lindner, K. J. (2002). Eating disorders and exercise dependence in triathletes. Eating Disorders, 10(1), 49-60.

Blaydon, M.J., Lindner, K. J., & Kerr, J. H. (2004). Metamotivational characteristics of exercise dependence and eating disorders in highly active amateur sport participants. Personality and Individual Differences, 36(6), 1419-1432.

Estok, P.J., & Rudy, E.B. (1996). The relationship between eating disorders and running in women. Research in Nursing & Health, 19, 377-387.

Freimuth, M., Waddell, M., Stannard, J., Kelley, S., Kipper, A., Richardson, A., & Szuromi, I. (2008). Expanding the scope of dual diagnosis and co-addictions: Behavioral addictions. Journal of Groups in Addiction & Recovery, 3, 137-160.

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

Lejoyeux, M., Avril, M., Richoux, C., Embouazza, H., & Nivoli, F. (2008). Prevalence of exercise dependence and other behavioral addictions among clients of a Parisian fitness room. Comprehensive Psychiatry, 49, 353-358.

Lewinsohn, P.M., Seeley, J.R., Moerk, K.C., & Striegel-Moore, R.H. (2002). Gender differences in eating disorder symptoms in young adults. International Journal of Eating Disorders, 32, 426-440.

Sussman, S., Lisha, N. & Griffiths, M.D. (2011). Prevalence of the addictions: A problem of the majority or the minority? Evaluation and the Health Professions, 34, 3-56.

Szabo, A. (2010). Addiction to exercise: A symptom or a disorder? New York, NY: Nova Science Publishers.

Yates, A., Leehey, K., & Shisslak, C. M. (1983). Running – an analogue of anorexia? New England Journal of Medicine, 308(5), 251-255.

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.