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Let’s get physical: Exercise addiction (revisited)
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 ‘exercise dependence’, ‘obligatory exercising’, ‘exercise abuse’, and ‘compulsive exercise’. Exercise addiction has been conceptualised as a behavioural addiction. The symptoms and consequences of exercise addiction have often been characterised by six common components of addiction: salience, mood modification, tolerance, withdrawal symptoms, personal conflict, and relapse.
For some people, exercise addiction is a primary problem in the person’s life whereas in others it can be a secondary problem as a consequence of other psychological dysfunctions (like eating disorders such as anorexia nervosa). In the former case, the dysfunction is considered as primary exercise addiction, while in the latter case it is termed as secondary exercise addiction because it co-occurs with another dysfunction. The differentiating feature between the two is that in primary exercise addiction the objective is the exercise itself, whereas in secondary exercise addiction the objective is weight loss, where excessive exercise is one of the primary means in achieving the desired objective.
The incentive or motive for fulfilling planned exercise is an important distinguishing characteristic between addicted and nonaddicted exercisers. The reason people exercise is often for an intangible reward such as feeling in shape, looking good, being with friends, staying healthy, building muscles, losing weight, etc. The personal experience of the anticipated reward reinforces and strengthens the exercise behaviour. Committed exercisers maintain their exercise for benefiting or gaining from their activity and thus, their behaviour is motivated via positive reinforcement. However, empirical research has demonstrated that addicted exercisers have to exercise in order to avoid negative feelings or withdrawal. The individual’s exercise may become a chore that has to be fulfilled, or otherwise an unwanted event would occur (such as the inability to cope with stress, or gaining weight, becoming moody, etc.). Every time a person undertakes behaviour to avoid something negative, bad, and/or unpleasant, the motive behind that behaviour acts as a negative reinforcement. In these situations, the person feels they have to do it rather than wanting to do it.
Mood modification is a key factor among the symptoms of exercise addiction and suggests there is a self-medication aspect of exercise that facilitates the distinction between normal and abnormal exercise. Addicts do not simply exercise to experience the joy of it, but rather to escape negative, unpleasant feelings and everyday difficulties.
The Exercise Addiction Inventory is one of the most recent and most widely used screening tools in the research area of exercise addiction, primarily because of its brevity and excellent psychometric properties (i.e., reliability and validity). The EAI comprises only six statements, each corresponding to one of the symptoms in the ’components’ model of addiction. Each statement is rated on a 5-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree). The EAI cut-off score for individuals considered at-risk of exercise addiction is 24 out of 30. To date, the only nationally representative study examining exercise addiction is a study that I co-authored with some Hungarian colleagues. We surveyed over 2,700 Hungarian adults aged 18–64 years and assessed exercise addiction using the EAI. Results showed that the proportion of the people at risk for exercise addiction was 0.5%.
There are numerous theories that deal with both the causes of exercise addiction and the process and mechanisms of its development and maintenance. A significant number of psychological theories are based on learning theory or the cognitive psychology approach. According to the theory of functioning, both positive reinforcers (e.g., a feeling of euphoria following exercise or muscle growth from exercise) and negative reinforcers (e.g. an end to unpleasant feelings through exercise or avoidance of the presumed negative effect of missed exercise) may lie behind the development and maintenance of exercise addiction which, according to the fundamental principles of learning theory, may contribute to the establishment of compulsive and addictive exercise that may be viewed as maladaptive.
One of my research colleagues, Dr. Attila Szabo stresses the role of cognitive appraisal mechanisms in the development of the vicious cycle that leads to excessive exercise. The process starts when the habitual exerciser uses exercise as a means of coping with stress, and the affected individual learns to depend on exercise at times of stress. The addicted exerciser is then trapped in a vicious cycle of needing increased amounts of exercise to deal with the consistently increasing life stress, part of which is caused by exercise itself.
It also appears that the issue of self-assessment represents a further significant factor among the psychological factors in the sense that during exercise, the physical strength experienced through exercise in a person dissatisfied with his or her body or body image contributes to the formation of a more positive self-image and self-assessment. It has also been shown that exercise activities (such as weightlifting) have a positive effect on body image and self-esteem both in men and in women. Perfectionism, obsessive-compulsive functioning, and heightened anxiety have also been claimed to be determining factors in exercise addiction.
The public promotion of healthy and appropriate exercise patterns may reduce the incidence of exercise addiction. It is important in public health programs and campaigns to (i) stress the healthy nature of regular exercise and (ii) communicate the message that exercise when taken to excess can be potentially harmful. It is important to raise awareness of potential harm within the population of regular exercisers. Some psychologists claim that individuals with exercise addiction have a poor understanding of the negative health consequences of excessive exercising, of the mechanism of exercise adaptation, and the need for rest between exercise sessions. The use of education may be an effective step in the prevention and treatment of exercise addiction.
As with other addictive disorders, the environment of regular exercisers also plays a significant role in recognising this condition early. In more severe cases psychotherapeutic interventions may be needed. When treating exercise addiction, abstinence from exercise may not be a required and/or realistic goal, because exercise has many benefits for health and no one would advocate doing no exercise. Therefore, the typical treatment goal would more likely be be to return to moderate and controlled exercise. In some cases, a different form of exercise may be recommended.
CASE STUDY
Joanna is a 25-year old student, well-educated female, from a stable family background, who realized that she had a problem surrounding exercise, and more specifically the martial art Jiu-Jitsu. Here, Joanna’s behavior is described in terms of the main components of addiction:
- Salience: Jiu-Jitsu is the most important activity in Joanna’s life. Even when not actually engaged in the activity, she is thinking about the next training session or competition. She estimates that she spends approximately six hours a day (and sometimes much more) involved in training (e.g., weight training, jogging, general exercise, etc.).
- Tolerance: Joanna started Jiu-Jitsu at an evening class once a week during her teenage years and built up slowly over a period of about five years. She now exercises every single day, and the lengths of the sessions have become longer and longer (suggesting tolerance).
- Withdrawal: Joanna claims she becomes highly agitated and irritable if she is unable to exercise. She claims she also gets headaches and feels nauseous if she goes for more than a day without training or has to miss a scheduled session.
- Mood modification: Joanna experiences mood changes in a number of ways. She feels very high and ‘buzzed up’ if she has done well in a Jiu-Jitsu competition (especially so if she wins). She also feels high if she has trained hard and for a long time.
- Conflict: Joanna’s relationship with her long-term partner ended as a result of her exercise. She claimed she never spent much time with him and was not even bothered about their break-up. Her university work suffered because of the lack of time and concentration.
- Loss of control: Joanna claims she cannot stop herself engaging in exercise when she “gets the urge”. Once she has started, she has to do a minimum of a few hours of exercise.
- Relapse: Joanna has continually tried to stop and/or cut down but claims she cannot. She becomes highly anxious if she is unable to engage in exercise and then has to go out and train to make herself feel better. She is well aware that exercise has taken over her life but feels powerless to stop it.
- Negative consequences: Joanna spends money beyond her means to maintain her exercising habit (e.g., on entrance fees for weight training, swimming, entrance fees enter Jiu-Jitsu tournaments across the country, etc.). She has resorted to socially unacceptable means (e.g., stealing) in order to get money to fund herself
In short, exercise is the most important thing in Joana’s life, and the number of hours engaged in physical activity per week has increased substantially over a five-year period. She displays withdrawal symptoms when she does not exercise, and experiences euphoric experiences related to various aspects of her exercising (e.g., training hard, winning competitions, etc.). She experiences conflict over exercise in many areas of her life and acknowledges she has a problem. Furthermore, she has lost friends, her relationship has broken down, her academic work has suffered, and she has considerable debt.
Note: An expanded version of this article was first published by Rehabs.com
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.
Allegre, B., Therme, P., & Griffiths, M. D. (2007). Individual factors and the context of physical activity in exercise dependence: A prospective study of ‘ultra-marathoners’. International Journal of Mental Health and Addiction, 5, 233-243.
Berczik, K., Szabó, A., Griffiths, M. D., Kurimay, T., Kun, B., Urbán, R., & Demetrovics, Z. (2012). Exercise addiction: symptoms, diagnosis, epidemiology, and etiology. Substance Use and Misuse, 47, 403-417.
Downs, D. S., Hausenblas, H. A., & Nigg, C. R. (2004). Factorial validity and psychomaetric examination of the Exercise Dependence Scale-Revised. Measurement in Phisical Education and Exercise Science, 8, 183-201.
Griffiths, M. (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, e30-31.
Hausenblas H. A., & Downs, S. D. (2002a) Exercise dependence: a systematic review. Psychology of Sport Exercise, 3, 89-123.
Hausenblas, H. A., & Downs, S. D. (2002). How much is too much? The development and validation of the exercise dependence scale. Psychology and Health, 17, 387-404.
Mónok, K., Berczik, K., Urbán, R., Szabó, A., Griffiths, M.D., Farkas, J., Magi, A., Eisinger, A., Kurimay, T., Kökönyei, G., Kun, B., Paksi, B. & Demetrovics, Z. (2012). Psychometric properties and concurrent validity of two exercise addiction measures: A population wide study in Hungary. Psychology of Sport and Exercise, 13, 739-746.
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. (2000). Physical activity as a source of psychological dysfunction. In S. J. Biddle, K. R. Fox & S. H. Boutcher (Eds.), Physical Activity and Psychological Well-Being (pp. 130-153). London: Routledge.
Szabo, A., & Griffiths, M. D. (2007). Exercise addiction in British sport science students. International Journal of Mental Health and Addiction, 5, 25-28.
Terry, A., Szabo, A., & Griffiths, M. (2004). The exercise addiction inventory: a new brief screening tool. Addiction Research and Theory, 12, 489-499.
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.
