In July last year, a group of doctors from the Ludwig Maximillian University of Munich (LMU) and the Schoen Clinic, Roseneck, submitted an article to the journal of eating disorders. The article suggests a draft transdiagnostic definition and clinical assessment for inclusion in the DSM-5* for what they refer to as compulsive exercise. Compulsive exercise is not recognized today under the DSM-5. However, the use of exercise as a purging tool is a recognized symptom across the other eating disorder diagnosis.
I was curious to understand more about compulsive exercise, or what I have seen referred to as ‘exercise addiction’ in the media. What it is and whether it exists as a primary addiction for people. Is it prevalent enough to be classified and treated in a different way to the current DSM-5 classifications such as anorexia nervosa, bulimia nervosa or binge eating disorder? And what can be done about this worrying phenomenon.
So, in January this year, I reached out to Clinical Psychotherapist, Certified Eating Disorder Specialist (CEDS) and Registered Dietitian, Gabrielle Tuscher, to get some answers. In her work, Gabrielle has come across this phenomenon and was very happy to shed some light on this problem, which is not talked about enough in our fitness-obsessed society.
*The Diagnostic and Statistical Manual of Mental Disorders (DSM–5) is a journal which defines and classifies mental disorders in order to improve diagnoses, treatment, and research. It was compiled by and used by International experts in mental health.
Is exercise addiction (or compulsive exercising) an ‘eating disorder’?
Gabrielle: Exercise addiction is not a separate DSM-5 diagnosed disorder. It is currently only recognized as a purging tool within other classifications of eating disorders. However, exercise addiction is rampant, especially amongst athletes or dancers, and non-professional athletes. Hopefully, soon, exercise as a stand-alone addiction will have its own diagnostic classification.
It is important to understand that exercise alone is not the issue. More often than not, some form of disordered eating comes with it, such as the need for structure in eating ‘clean’ or ‘healthy’ or in a manner that is overly restrictive in itself, which develops into an obsession. When exercise starts to become a problem, it begins affecting other aspects of an individual’s life and everything begins to revolve around how, where, what and when one exercises.
The problem is, to a bystander, it is not evident that it has become an unhealthy release versus what we have come to understand exercise for – its benefits on health. For example, if someone shares they exercise 7 days a week for 3 hours, the typical response to this may be “you are so disciplined. I wish I had that drive and dedication….good for you!”.
Pam: So, is compulsive exercising the act of exercising every day?
Gabrielle: No, not at all. It is the compulsive nature behind it; not necessarily the quantity or the ‘what’. It is when somebody NEEDS to do something; where there is a driving fear around cutting it out or not doing it the way it ‘has to be’ dependent on that persons individual rules behind it. Or if there is a perceived consequence to not doing it, or changing how you perform it. Then it becomes a problem. Please keep in mind it is fantastic to exercise and take care of your body, but if you are injured for example, and you still NEED to exercise, then this is a red flag that something is wrong.
Pam: I can see why it may be hard to recognize. I guess we don’t know what is going on in someone’s head.
Gabrielle: Yes, but there are certain red flags that indicate that someone is exercising for the wrong reasons. Such as:
- preoccupation with an exercise routine or intrusive thoughts about exercise that interfere with your ability to concentrate or focus
- finding time at any cost to exercise, like cutting school or taking time off from work
- exercise is your social life — you turn down social activities so as not to miss your scheduled workout
- feeling overly anxious, guilty or angry if unable to exercise and you can’t tolerate changes or interruptions of your exercise routine
- exercising alone to avoid having your routine disturbed
- exercising is driven primarily by a desire to control your weight, shape and/or body composition
- food choices are based solely on exercise (you exercise as punishment for eating “bad” foods, to purge calories or you overly restrict what you eat if you can’t exercise)
- lying about exercise or you always exercise alone
- you can’t take rest days or time off from exercise — even if you’re injured or ill.
- persistent desire and/or unsuccessful attempts to control or reduce exercise (e.g., can’t take a day off during the week or time off periodically throughout the year)
- engaging in non-purposeful or excessive exercise beyond a sensible fitness or training program
- how you feel about yourself on a daily basis is based on how much exercise you perform or how hard you work out
- exercise isn’t fun or pleasurable or you’re never satisfied with your physical achievements
- amenorrhea (loss of three consecutive menses or failure to begin menstruating by age sixteen) and/or stress fractures
What are the consequences of over-exercising?
Gabrielle: If you are over-taxing and under-fueling the body then the body starts breaking itself down. The easiest source of fuel is your muscle tissue and your organs. There is a misconception that the exercise itself is building muscle or strength when it is under starvation mode. If you are not fueling the body properly; then what you are really doing, is wasting muscle tissue – the body literally starts to east itself to try to stay alive and/or will store energy as fat. The person progressively weakens, which results in serious physical consequences.
Lots of things can occur:
- Bone Breaks and stress fractures
- Heart failure
- Kidney failure
- Electrolyte imbalances
- Low blood pressure
- Amenorrhea (loss of menstruation for women).
Pam: So, how do people end up in treatment? Do they notice the signs and seek help or come to you after they have suffered some consequences?
Gabrielle: Even with these signs, most people don’t realize that they have a problem with exercise. And when confronted with it, they think you are an absolute lunatic for suggesting they are doing anything unhealthy. Treatment involves helping them to understand when something healthy has become extremely damaging and dangerous, that it is important to reevaluate its role in your life and confront the drive behind your need to use it as a coping tool.
Most often, patients who come to me, present with a co-occurring eating disorder or other mental health disorder. The most common I have seen include:
- Other eating disorders
- Post-traumatic stress disorder (PTSD)
- Anxiety and depression or other mood disorders
- Alcohol addictions or other addictions
- Obsessive-compulsive disorder (OCD)
If I recognize that there is a dependency on exercise in conjunction with one of these (or other illnesses) then we need to confront them. How dependent the person is will determine how the treatment flows. During the treatment, the person begins to understand how to use exercise for the right reasons instead of what their rules dictate.
Is the solution to cut out exercise?
Pam: So, how does treatment work? Does the person need to cut out all exercise?
Gabrielle: If exercise is used as a purging tool, I will advise my client to cut it down or change it up for a period of time. If they cannot, and continually abuse it, then I will ask them to cut it out completely until we have addressed the underlying issues driving their need to use it. At that point, it can be quite terrifying for the client to give up what is often their only self harm outlet.
If one was admitted inpatient into a residential treatment facility, and exercise is part of your illness, then exercise will not be permitted. Often gentle yoga is allowed to those whom have moved to a level that allows them to exercise in some capacity.
Some clients have jobs that revolve around exercising, such as athletes or dancers. In this case, because it is their job, they cannot simply cut it out completely – that is not realistic.
Regardless, the treatment objective is to understand what drives the illness and to help the client develop a healthier relationship with exercise and themselves. I work to understand why the person needs it, what drives them to do it, what they believe the consequences are if they don’t do it and how they feel about that. It is about challenging the thought process and challenging the routine.
Of course, if the persons’ physical health is in danger; continuation of exercise is not an option. If they are at risk of heart failure or have an injury, for example, that is a different story.
Pam: How do you deal with pushback from clients about needing exercise to remain happy and healthy?
Gabrielle: A lot of people I see who are extreme, have done damage to their bodies already, though they may still argue that they are helping their body by continuing to exercise. In this case it takes a lot of work to challenge their beliefs even if they are suffering a facture or worse, bradycardia. We emphasize that continuation could result in heart failure, and even death.
This is very different from when exercise is managed properly and the aspects that surround it. If you are hydrating and fueling your body and using exercise moderately then you will feel good when you do it. Treatment helps them understand this. We work together to understand what drives the dependency. It is about challenging the thought process and challenging the routine.
Full recovery is possible
Gabrielle: What is quite interesting, is that when someone does cut out exercise after being dependent; there is always a sense of relief. It is so terrifying for the person, as it is with an eating disorder when you remove the behavior that has been relied upon to cope. But I often see that, within two weeks, the client starts to feel relief.
Stopping the exercise is a relief because they no longer have to push themselves to the point of self-punishment. Usually, when you are in that position, you are not physically or medically capable of doing it, the only thing driving you is your head.
Some people have to cut it out for years, others months. And some people just get to the point where they no longer NEED to do it and genuinely want to do it to feel good. If their relationship with exercise has changed, they may have a situation where they have some exercise planned but will think to themselves ‘I am just not up to it today’; and so they will leave it without any guilt or anxiety kicking in. Full recovery is possible.
So, how can we prevent exercise addiction?
Gabrielle: This is tough because our society normalizes the problem. I come across people in my everyday life who have a really bad relationship with exercise. I met a man through friends who had run up and down his buildings stairwell three times before coming for lunch. He was introduced as someone who does marathons and triathlons and who was obsessed with exercise. But everyone was cheering him on. Everybody was joking about what he won’t eat and how he needs to push himself to extremes to ‘function’.
And most people are getting the wrong information from unqualified people. There are a lot of issues with personal trainers these days.
Some trainers tell people what to do with their diet when they are not qualified dietitians so are not allowed to do so. Even suggesting supplements etc. That shouldn’t be happening unless they are properly licensed.
And many trainers will base what they suggest on what they do themselves. People follow this expecting the same results. But they don’t look at the fact that this person is likely exercising many hours a day and it is part of their job and their needs do not apply to your needs.
Then there are gyms who are happy to watch people come in and exercise for hours on end without saying anything, despite seeing emaciated appearance. They don’t intervene, even though they will be liable if someone has a heart attack in their gym. There are some exceptions. In the US and UK, some of the better gyms track client’s usage of services. And if it is excessive, they will raise it with the client and caution them and give them a warning. Then they are monitored and if they don’t abide to the pull back their membership is revoked. This is great because it means they will actually help people when they cannot help themselves.
Gabrielle is a leading voice in the eating disorder treatment community in Asia. Amongst the small group of certified specialists in the region, Gabrielle has dedicated her career to treating those living with eating disorders and campaigning for better education and regulation on those treating this fatal illness.
To read more of Gabrielle’s expert advice, check back here regularly for future articles. Gabrielle has kindly offered her experience on a number of interesting topics. You may also like to check out the article she wrote last year for sassymamahk which offers additional tips for recognizing eating disorders in children and adolescents.
You may connect with Gabrielle via the details listed on our Friends of Recovery page.
I wish to offer my sincere appreciation to Gabrielle for her time and for sharing the benefit of her experience.
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