Motivation and emotion/Book/2020/Exercise addiction

Overview
Exercise addiction, also known as exercise dependence, compulsive exercise and obligatory exercise is where an individual develops an unhealthy fixation and compulsion to exercise. In today’s world exercise has become an important in health, socialising, body appearance, outlet for stress and a therapy for mental illness. Given that exercise is an integral component of a healthy lifestyle, individuals who suffer from exercise addiction seem to rarely seek help as it can be justified and deluded as a 'dedication' rather than addiction. This in turn can lead to physical injury, social difficulties, relationship strain, poor mental health and in extreme cases even death (Landolfi, 2012).

Focus questions:
 * What is exercise addiction?
 * What causes of exercise addiction?
 * How is exercise addiction diagnosed?
 * How is exercise addiction treated?

What is exercise addiction?
Exercise addiction is an unhealthy obsession with exercise and physical fitness (Hausenblas & Symons Downs, 2002). A person who is addicted to exercise will often demonstrate traits similar to other addicts. These traits include obsessing over the behaviour, continuing to engage with the behaviour even when it is causing physical harm, engaging in the behaviour despite wanting to stop, engaging in the behaviour in secret and even when it adversely impacts other areas of life such as relationships, work and other activities (Landolfi, 2012).It is estimated that 3% of the general population have an exercise addiction. However, among some groups such as sport science students and ultra-marathon runners the prevalence is even higher and in some niche areas including gyms/fitness clubs up to 42% of participants have been found to meet the criteria for exercise addiction (Freimuth, Moniz & Kim, 2011).

Exercise addiction belongs to a group known as behavioural addictions, where a person gets addicted to the benefits and rewards of their own activity (Lichtenstein & Jensen, 2016). Exercise addicts are more likely to exercise for intrinsic rewards and experience disturbing feelings of deprivation and withdrawal when they are unable to exercise (Lichtenstein & Jensen, 2016). Exercise causes the release of certain chemicals in the nervous system. These chemicals create a sense of pleasure or reward. Exercise addiction in some cases is likely to be a dependence on this pleasure response (Landolfi, 2012).

An essential factor in determining the boundary between a healthy ‘commitment’ and an 'addiction' is the deep feeling of withdrawal amongst addicted exercisers (Freimuth, Moniz & Kim, 2011). For example, a person addicted to exercise continues to push themselves further even when they have met their stated goal i.e. weight loss or successfully finishing a 10km run. This is not dissimilar to the behaviour of an alcoholic who continues to consume even after the ‘desired stress relief’ from alcohol has been achieved. The behaviour often not only has devastating effects in all areas of an individual's life but often leads to physical and psychological problems. Fortunately, there is treatment available for those who suffer from this addiction (Landolfi).

Symptoms and different forms of exercise addiction
"Exercise addiction is the result of a ‘multidimensional maladaptive pattern of exercise’, which leads to significant clinical distress or impairment (Lichtenstein & Jensen, 2016). A common trend with exercise addicts is the need to maintain or pursue what they believe to be an ideal body image (Landolfi, 2012). For these people, exercise assists with maintaining structure in their lives and is often described as ‘welcomed stability’ which they lack in other areas of life (reference?) . Self-worth and sense of identity often become directly linked to the amount of exercise the individual completes and the results they see (Landolfi, 2012). A study by Katz et al. (1986)(improper use of APA) showed that exercise addicted long-distance runners depend on excessive exercise to try to deal with their poor self-concept, depression, and bulimia (Landolfi, 2012). It is not surprising that people most predisposed to developing an exercise addiction are ones who lack a strong sense of self-identity and end up using their exercise addition as a ‘coping mechanism’ for their emotional distress (Landolfi, 2012)."Research has also shown that athletes who undertake serious cross-fit exercises are significantly more at risk of developing an exercise addiction than others, as they tend to experience harmful adverse attitudes and beliefs directly related to their exercise activity (Lichtenstein & Jensen, 2016). Therefore, this group was found to experience more distress, and are at risk of negative consequences related to their exercise addiction such as injuries, illness, and loss of social relations. Exercise addiction is often a co-occurring disorder and is often associated with another mental disorder, eating disorders and other addictive activities (Lichtenstein & Jensen, 2016).

The regularity and intensity of the exercise continues until the behaviour becomes the main factor in a person’s life and everything else is organised around their exercise. (Freimuth, Moniz & Kim, 2011). The exercise addict not only feels a sense of gratification and physical rush, however, continues to push themselves further by for example lifting more weights, running longer or going to more exercise classes. True to the nature of addiction, a behaviour that first began as a way to make life more enjoyable ends up making life unmanageable. As the life of the addicted person revolves entirely around exercise, the pleasure of the behaviour declines as the driving motivation shifts into avoiding symptoms of withdrawal (Freimuth, Moniz & Kim, 2011).

What causes exercise addiction?
Great debate has centred around what causes an exercise addiction – is it a primary or secondary addiction? An example of this is extreme weight loss and health decline could result from exercise addiction, however the reverse can also be true as exercise addiction can also be the result of one of body image and/or eating disorders.

Furthermore, evidence suggests that exercise can relieve withdrawal symptoms associated with other addictions such as a chemical dependency on cocaine, but exercising primarily for this purpose may in itself open the gateway for an exercise addiction (Freimuth, Moniz & Kim, 2011). In behavioural addictions, as the primary addictive behaviour decreases in frequency, it is possible that moderate exercise becomes problematic, as this behaviour replaces the mood-altering functions of the initial addiction (Freimuth, Moniz & Kim, 2011). Also, the need to be attentive to signs of exercise addiction is not limited to those who treat addictions. Some psychotherapy patients will use exercise as a primary form of mood regulation. The challenges of psychotherapy can lead to an increase in this behaviour. Being aware of the phases of exercise addiction will assist clinicians identify if recreational or at-risk exercise is becoming problematic or in fact is already an exercise addiction (Freimuth, Moniz & Kim, 2011).

An eating disorder, such as anorexia or bulimia, can lead to an unhealthy obsession with exercise. A body image disorder can also be the cause of exercise addiction. This is known as a secondary addiction (Stubblefield, 2020). A primary exercise addiction occurs in the absence of an eating disorder or any other physical or psychological condition. Any weight loss is secondary to calories burned or if there is dieting, it only occurs for the purpose of enhancing performance. However, for some people the primary motivation for exercise is weight loss that occurs in the extreme. This kind of primary exercise addiction is known as ‘anorexia athletica’. With secondary exercise addiction, exercise is paired with a co-occurring eating disorder. Exercise along with for example vomiting and taking laxatives, serve to alleviate the consequences of calorie consumption (Freimuth, Moniz & Kim, 2011).

An inherent danger, for secondary forms of exercise addiction, arises when exercise is no longer possible, for example as a result of illness or injury, as psychiatric disorders which may have been masked by exercise can resurface. A study conducted by Little concluded that when athletic ‘neurotics’ were unable to continue working out, their pre-existing mental health complications re-emerged needing attention (Little, 1969). Efforts to cope with emotional or mental strain by identifying too strongly with a particular physical activity may cause exercise addicts to lose control. As a result, exercising excessively has not been found to be an ideal solution for dealing with life stressors (Landolfi, 2012).

Western cultures place great emphasis on how we look with our bodies becoming more and more objectified and perceived as ‘machines’ that can be changed and altered at will (Corazza et al., 2019). This mechanical view of the human body and its functions is reflective of a ‘dualistic’ way of thinking, where there is none or very little meaningful correlation between the body and mind. With chaotic lifestyles, daily routines, fast transportation and communication, it is no wonder individuals feel increasingly disconnected from the environment around them, and instead find themselves chasing the ‘perfect’ body (Corazza et al., 2019). Sadly, this thinking is intertwined with the notion that we all have the power to choose how we look, a message that is continuously reiterated through media and other social platforms. This phenomenon is being increasingly linked with appearance anxiety and other psychopathological features and resulted in a study conducted across gyms in Europe finding a correlation between exercise addiction and the previously unexplored association with appearance anxiety, low self-esteem and the use of a range of fitness supplements consumes without any medical consultation. (Corazza et al., 2019)



Diagnosing exercise addiction
Exercise addiction in itself is not easy to clinically diagnose, this is mainly due to the fact that it is not considered as a distinctive illness (Landolfi, 2012). Hence, there is no specific or agreed diagnostic criteria for clinicians to use in order to diagnose exercise addiction. However, tools for assessing exercise addiction include the Exercise Addiction Inventory, Commitment to Exercise Scale, Exercise Dependence Scale and Obligatory Exercise Questionnaire. However, these tools lack clinical validation. Given this void, assessment techniques to date include a range of both quantitative and qualitative resources, for example – interviews, case studies as well as self-report questionnaires developed to explore exercise attitudes, behaviours and cognitions (Landolfi, 2012).

It is not surprising many clinicians look at exercise addiction as a part of the cluster of behavioural, cognitive and physiological matters, similar to those of people with a drug and/or alcohol addiction (Stubblefield, 2020). Furthermore, in order to diagnose exercise addiction, professionals need to be skilled and experienced at asking questions as well as hold a comprehensive knowledge and understanding of the individual’s previous health and wellbeing history (Stubblefield, 2020).

A further complication to diagnosing exercise addiction is that individuals are more likely to continue to exercise and not seek medical advice/attention even at times of illness or injury, often due to fear of experiencing withdrawal. This can be mistaken for a strong commitment to maintaining physical fitness rather than an addiction (Landolfi, 2012).

Measuring exercise addiction
As noted previously, some of the most widely used questionnaires for exercise addiction are the Exercise Dependence Scale (EDS), the Obligatory Exercise Questionnaire (OEQ), the Commitment to Exercise Scale (CES) and the Exercise Addiction Inventory (Landolfi, 2012). These tools differ in their theoretical frameworks and focus areas. For example, the EDS strongly reflects the Diagnostic and Statistical Manual (DSM) criteria for chemical dependence, while the others do not, and there are particular tools which are more designed to suit particular groups (Zeeck et al., 2017). On the one hand the Compulsive Exercise Test (CET) assesses pathological exercising in individuals with an eating disorder, while on the other, the Exercise Dependence Scale (EDS) was designed to be used when working with athletes (Zeeck et al., 2017). Three of the most popular scales used will be discussed below.

Exercise dependence scale (EDS)
EDS is founded on the DSM-IV (APA, 1994) criteria for chemical dependence. It is a multi-faceted theoretical based measure for symptoms of exercise dependence that identifies individuals who are at-risk, have some symptoms, or have no symptoms for exercise addiction (DSM-IV; APA, 1994; Veale, 1995). People undertaking the EDS are asked to identify how each of the items reflects their exercise behaviours and beliefs over the past three months on a 5-point Likert scale ranging from 1 being ‘never’ and 5 being ‘always’ (Landolfi, 2012).The EDS explores a ‘multidimensional maladaptive pattern of exercise’, which leads to significant clinical distress and/or impairment. Where three or more of the following symptomatic factors are present at the same time, there is cause for concern (Hausenblas & Symons Downs, 2002): (Reference for table?)Case Study

“Joanna” (not her real name) is 25 years old does not identify herself to be addicted to exercise, and instead believes she had a problem surrounding exercise. Joanna has ‘0’and ‘A’level qualifications and is from a stable background. She eats very well and describes herself as being in excellent physical condition except for a recent injury sustained to her arm during a Jiu-Jitsu session. Jiu- Jitsu is her main hobby which began in her late teens and she describes herself as a very good amateur. She does not use (and has never used) anabolic steroids...

After Joanna provided further background information about her life and exercise, it was reviled she had symptomatic factors:


 * Salience - Jiu-Jitsu is the most important activity in Joanna’s life above everything else.
 * Tolerance - exercises every single day and the lengths of the sessions are getting longer and
 * Withdrawal - Joanna she claims she gets highly agitated and irritable if she is unable to exercise
 * Relapse - Joanna can only go a few days of no exercise before her day to day living becomes absolutely unbearable
 * Conflict - Joanna’s relationship with her long term partner has finished as a result of her exercise and she spends money beyond her means to maintain her exercising habit.
 * Despite Joanna not believing she was addicted to exercise, it seemed that exercise has turned her life upside down and she was indeed suffering from the consequences of exercise addiction.

(Griffiths, 1997)

The Obligatory exercise questionnaire (OEQ)
The OEQ is one of a number of tools used to measure excessive exercise activity, particularly in relation to eating disorders (Steffen & Brehm, 1999). It is a four-point Likert type of tool with 20 items, measuring people’s attitudes and activities in relation to their individual exercise routines. The higher the score, the stronger sense of obligation to exercise the individual is shown to have (Terry, Szabo & Griffiths, 2004).

The OEQ is often used and the psychometric properties of the questionnaire have been well established (Terry, Szabo & Griffiths, 2004). It encompasses a vast range of activities, including from weightlifting to running, and can be used by exercisers as well as control groups. Interestingly, the OEQ also looks at secondary dependence (Terry, Szabo & Griffiths, 2004), such as the relationship between exercise behaviour, eating disorders and body image. Addicted runners are often known for having an increased need for perfection, hence it is not surprising they have a great desire to exert control over their lives as well as their bodies (Terry, Szabo & Griffiths, 2004). Pasman and Thompson (1988) found by using the OEQ, for example that runners had greater eating disorders than the control groups, and that this was increased for females over males (Terry, Szabo & Griffiths, 2004).

Exercise addiction inventory (EAI)
EAI was developed with the aim of being a quick and simple way of carrying out a short form inventory and was actioned using components of behavioural addiction (Griffiths, 1996). Similarly to the EDS, the EAI is also a theoretically based screening tool of exercise addiction that can differentiate between individuals who are at-risk, have some symptoms, or have no symptoms of exercise dependence (Terry, Szabo & Griffiths, 2004).

The EAI relies on a self-report measure made up of six items. It reflects beliefs and attitudes about exercise behaviour, based on the perceived importance of exercise, the subjective experience reported as a consequence of exercise, and the frequency of exercise needed to achieve the desired benefits. It also explores the individual’s motivation to continue exercising due to the fear of experiencing withdrawal symptoms, perceived conflicts between the individual and their relationships as a result from their exercising, and the ease of relapse and return back to the problematic pattern of exercise behaviour (Terry, Szabo & Griffiths, 2004).

The EAI has some significant advantages as it can be quickly and anonymously administered and is known to show the same results as some of the more lengthier tools. It can be conducted by non-clinical professionals who are often well based to carry out the EAI due to being the first point of contact of the exercise addicted person as a result of injury (Terry, Szabo & Griffiths, 2004). As these professionals are not experts in ‘psycho-metric assessment’, the ease of doing the EAI as well as identifying results, can be valuable especially with deciding whether the person would benefit from being referred for further consultation to prevent more harm (Terry, Szabo & Griffiths, 2004).

Treating exercise addiction
Education is a major component in the treatment of exercise addiction. Berczik et al., posit the importance of teaching individual’s 'moderation’ and ‘self-control', lessons which should be delivered in the first instance parents and teachers. However, some exercise addicts may only take note of these facts if they are portrayed by a professional such as a GP. Given this, professionals working with someone who is addicted to exercise cannot for example make the assumption the person understands the need for appropriate recovery following physical activity, and the necessity of structured rest periods as a valuable component of a good exercise program. On top of this, exercise addicts do not have an articulated goal in relation to their to exercise activity, but rather focus on only increasing the amount of exercise they undertake. It is crucial that individuals are provided with information about the harmful effects of extreme exercising (Landolfi, 2012).

People are encouraged to exercise in a way that allows them to maintain physical, psychological and social well-being. Part of the education process for physical health involves mentoring individuals on recovery periods, the need for compulsory rest days, as well as the need for the body to regenerate in order to support good performance. However, a clinician must also remember that many exercise addiction related symptoms have much deeper roots as exercise is typically only part of the problem (ie primary and secondary addiction). If a GP thinks they are unable to treat the underpinning condition effectively, referral to a psychologist may be necessary (Landolfi, 2012).

Treatment typically focuses on some type of cognitive-behaviour intervention (such as behaviour modification counselling). A primary objective involves helping people to change their attitudes toward physical activity. A therapist might for example address the behaviours and attitudes which have led the person to engage in addictive exercise, as well as their emotions concerning expectations for successful behavioural change. As noted in previous sections, exercise addiction often comes with low self-esteem, distorted body image and perfectionist tendencies that are commonly observed in secondary exercise addiction. Developing self-esteem entails allowing a person to build a self-concept that is not connected to their appearance or social approval. Therapy may involve having the person explain matters such as why the exercise is rewarding in terms of self-esteem, and allowing the individual themselves to come up with alternative activities to gain similar types of rewards. Early sessions typically require the person to talk about their exercise history, focusing on the amount of 'time' as well as level of 'intensity' they exercise. Following an initial assessment, diagnoses such as for eating disorders, depression and nutritional deficiencies may also be discovered (Landolfi, 2012).

Self help programs Since 1935, Alcoholics Anonymous (AA), a community-based self help program, has been assisting alcoholics to get and remain abstinent. It has been found to be effective for significant numbers of people around the world. Due to its success the 12-step model has been adapted and applied to many other types of addiction treatment. There are 12-step-inspired programs for every kind of addiction, including for exercise addiction. If a person is struggling with an addiction, it is not uncommon to discover a lot of other people are as well, and chances are good that a 12-step program can assist (Stubblefield, 2020).

Conclusion
Exercise is a great tool to combat mental illness, relieve stress, remain physically healthy and enjoy life (Landolfi, 2012). As with other addictions, once an individual becomes obsessed and is unable to stop despite negative consequences exercise addiction becomes a dangerous, strenuous and a life consuming addiction. Exercise addiction often comes with low self-esteem, distorted body image and perfectionist tendencies (Landolfi, 2012). Unhealthy exercise can include factors such as obsessing over the behaviour, continuing to engage with the behaviour even when it is causing physical harm, engaging in the behaviour despite wanting to stop and engaging in the behaviour in secret and even when it adversely impacts in other areas of life such as  with relationships, work and other activities. Often exercise addiction can be difficult to diagnose as it can present itself as a primary addiction or it can occur as a secondary addiction, for example eating disorders often have exercise addiction as secondary illness and vice versa (Freimuth, Moniz & Kim, 2011).

Many different scales have been used for measuring exercise addiction including the Exercise Dependence scale, the Obligatory Exercise Questionnaire and the Exercise Addiction Inventory, however there is no specific or agreed upon diagnostic criteria for clinicians to use in order to diagnose exercise addiction (Landolfi, 2012). Treatment of exercise addiction can involve educating people on what unhealthy exercise is, cognitive-behaviour intervention, addressing the behaviours and attitudes which have led the person to engage in addictive exercise (Landolfi, 2012) and self-help programs (Stubblefield, 2020).