Recognising and Treating Exercise Addiction
Welcome to Issue 296 of Institute Inbrief
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Issue 296 // Institute Inbrief
Dear Reader,

Welcome to Edition 296 of Institute Inbrief! In this edition we look at exercise addiction - its characteristics, symptoms, diagnosis, and what counsellors and mental health workers can do to support clients afflicted by it. 
 
Also in this edition:
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  2. Building Shame Resilience in Clients
  3. Treating Anxiety with CBT: The Evidence
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Recognising And Treating Exercise Addiction
Anyone who feels pressure to stay in shape, overweight people who begin an extreme weight loss program, and those with other addictions could develop an exercise addiction. As counsellors, how can we help?  

He’s up at 5:00 a.m. every morning, slipping into jogging shorts despite the single-digit temperatures, cold winds, and darkness. He pounds the pavement faithfully for 90 minutes a day, at least five days a week. He is also chronically tired and complains of frequent joint pain. He has recently been feeling like, “Why bother? Life is just a treadmill of ‘have-to-dos’”. And he may turn up in your rooms asking for help for an unclear malaise. Will you recognise it as possible exercise addiction?

Defining exercise addiction: The symptoms and the diagnosis

Exercise in our health-conscious western cultures is deemed to be a good thing, so it can be hard to say where we draw the line, deciding, “More than this is not good.” We can define exercise addiction, also called “overtraining”, as an unhealthy obsession with physical fitness and exercise. It often, but not always, results from body image and eating disorders. While excessive exercise is not currently recognised as a disorder by the American Psychiatric Association (and thus not included in the DSM), increasing evidence shows that it is a real and serious condition. It’s not easy to “diagnose” because most exercise addicts don’t see anything wrong with their behaviour, so neither they nor loved ones report it. Its symptoms, however, are similar to those of other addictions:

Loss of control

The person feels an inability to control the urge to exercise or to stop exercising for a significant period of time, even when there is an injury requiring time to heal.

Continuance

The individual continues to exercise even in the presence of injuries, physical problems, interpersonal issues, or psychological problems.

Intention effects

The exerciser goes beyond the original intended duration, frequency, or intensity of exercise without meaning to do so.

Time

The person spends much time engaging in, planning for, thinking about, or recovering from exercise.

Less time with other activities

The individual spends less time in social, occupational, or other situations as a direct result of exercise.

Tolerance

The person needs more exercise, more often, or at a higher intensity, to feel the original desired effect.

Withdrawal

The exerciser has feelings of irritability, restlessness, or anxiety when not exercising for a period (Stubblefield, 2016; Cornell, n.d.; Freimuth, Moniz, & Kim, 2011).

Who is at risk?

The short answer is that anyone who feels pressure to stay in shape, overweight people who begin an extreme weight loss program, and those with other addictions could all develop an exercise addiction. About 15% of “obligatory athletes” are also addicted to cigarettes, alcohol or illicit drugs, and about 25% of those who overdo exercise may have other addictions or compulsions, such as sex addiction or shopping compulsion (Stubblefield, 2016).

Primary or secondary?

Those who overtrain physically but do not have other psychological or behavioural conditions are deemed to have a primary exercise addiction, wherein preoccupation with exercise is the main problem. It tends to occur more in men, and often develops in response to having gotten the pleasurable effects of endorphins released during exercise.

Conversely, a secondary exercise addiction co-occurs with other conditions, typically eating disorders such as anorexia nervosa and bulimia. It is more common in women and usually develops as a result of body image issues (Cornell, n.d.).

The health consequences of too much exercise

Here comes the scary part. Overtraining is not just about joint inflammation, loss of muscle mass, sprained ligaments and torn muscle tendons (Cornell, n.d.), though these injuries are inconvenient enough. To fully appreciate the destructive nature of exercise addiction, let’s go through the repercussions at each major level of being.

Physical

Gut issues leading to disease

New research from the Australian sport journal Alimentary Pharmacology and Therapeutics shows that, when people exercise two or more hours per day, the physiological stress on the body can trigger Leaky Gut Syndrome, which can lead on to diseases such as Multiple Sclerosis and Chronic Fatigue. It also plays a role in a number of other diseases (Hodges, 2017).

Cardiovascular symptoms and the risk of dying

Overtraining taxes the cardiovascular system, so obligatory athletes may have an elevated heart rate during routine exercises, or even while in a resting state, that they would normally handle (Perna, 2017). Beyond that, long sessions on the treadmill or doing other endurance sports can cause permanent structural changes to the heart muscles which are described as “cardiotoxic”. These changes predispose athletes to abnormal heart rhythms, making them more susceptible to sudden cardiac death.

Studies released by the 
European Heart Journal in 2013 point to fat-burning workouts as being contributors to poor cardiac health, especially for those with a family history of arrhythmias (Hodges, 2017). Finally, a report by Danish researchers published in the Journal of the American College of Cardiology claimed that those who overdo exercise undo the benefits of it. Study participants who ran at a fast pace more than four hours a week for more than three days a week had about the same risk of dying during the study’s 12-year follow up as those who were sedentary, hardly exercising at all.

Weakened bones

Excessive exercise produces cortisol, a hormone emitted by the adrenal gland during periods of physical stress. At continued high levels it has immunosuppressive effects, putting overtrainers at risk of falling ill. And they are twice as likely to end up with osteoporosis or arthritis from the weakened bones that result from excess cortisol circulating in the bloodstream (Hodges, 2017).

Social and psychological

Because exercise addiction requires so much time and energy, obligatory athletes typically have dysfunctional relationships. Friends and family feel left out, and only end up creating conflict when they approach the exercise addict with their concerns. Some people cut classes, take time off work (often unpaid), and skip social functions so that they can exercise. It is not a social function for such individuals to exercise, so they don’t compensate for missed social events by exercising with friends or family; they prefer to exercise by themselves so that they can rigidly stick to routines, controlling the intensity, duration, and timing of the exercise session (Cornell, n.d.).

Overtraining Syndrome

Those who overtrain portray the same biochemical markers as those with clinical depression. Put another way, those who have Overtraining Syndrome have altered emission of serotonin and tryptophan (“feel good” hormones), just as depressed people do. Both the clinically depressed and the “overtrained” show lowered motivation, insomnia, and irritability. The Technical University of Munich recently found that young athletes with insufficient time to recover from stress and injury are 20% more likely to suffer from depression (Hodges, 2017).

Profile of an exercise addict

If you are wondering whether the person sitting in front of you in session could be an exercise addict, you would, of course, enquire about the symptoms we identified at the start of this post. There are also a few personality characteristics which you can look to in order to check out the possibility. Regardless of which particular constellation of symptoms a client may have, the common factor is their repetition of a behaviour – even a “healthy” one – past the point where it is health-inducing.

Extreme need for control

Healthy exercisers organise their exercise around their lives, but exercise addicts organise their lives around their exercise. Extreme exercisers often have an equally extreme need for control in their lives.

Perfectionist

Often concurrent with high needs for control, exercise addicts can display strong perfectionism as they go for that perfect “Mr Universe” body or “magical” weight. Listen for sounds of self- or other-criticism as you hear the client’s story; there will always be that “just a bit more” that they felt they could have achieved.

High achievers

Psychiatrist Alayna Yates, professor emeritus at the University of Hawaii, describes about 100 men and women she describes as “obligatory runners”. These high-performing, intelligent human beings have an average of 18 years of education (Allen, n.d.).

Treatment for exercise addiction

As with any addiction, the first step is to get the individual to acknowledge that they have a problem and that change is necessary. Obviously, this is trickier with exercise addiction than a dependence on, say, alcohol or other substances, because exercise is basically a healthy habit that we should be doing most if not all days. Once the obligatory athlete is on board, there are both mental/emotional level treatments and physically-based ones.

Four phases of exercise and assessment tools

In an attempt to clarify exercise addiction, Freimuth et al (2011) used the four phases of addiction to examine the attributes of exercise that define it as a healthy habit distinct from an addiction. As occurs with other addictions, they identified: Phase 1, Recreational, in which exercise is engaged because it is pleasurable and rewarding; Phase 2, At-Risk, in which mood-altering effects and possible altered chemical functioning of the brain are seen; Phase 3, Problematic Exercise, where the exerciser becomes more rigid in maintaining intense exercise patterns and there begin to be adverse effects in the person’s life; and Phase 4, Exercise Addiction, in which the behaviour becomes life’s organising principle. Consistent with the paradoxical nature of addiction, a behaviour that began as a way to make life more bearable by facilitating coping ultimately makes life unmanageable.

Freimuth et al (2011) identify the Exercise Dependence Scale (EDS–R: Downs, Hausenblas, & Nigg, 2004) and the Exercise Addiction Inventory (EAI: Terry, Szabo, & Griffiths, 2004) to assess which stage the exerciser is at. You could use either with your client; the EAI is briefer, at six questions, as compared to the EDS-R’s 21 items.

Recognising dysfunctional thought patterns

As you begin to hear the “musts” and “shoulds” of the client, you can call attention to them. These could include, for example: “I must exercise at least two hours a day” or “I should get my BMI (Body Mass Index) to 18 (indicating extreme thinness) or I’m no good”. Therapies that can challenge irrational or disordered thinking include CBT (cognitive behavioural therapy), motivational interviewing, and IPT (interpersonal therapy). Mindfulness practice can help people to refrain from engaging with unhelpful thoughts, though it doesn’t ask practitioners to challenge them.

Treat the primary problem first

If your client’s exercise addiction is primary (meaning that the person does not have other psychological or behavioural addictions), then you are free to work directly with the exercise addiction. If, however, the addiction is secondary – for example, as exercise addiction is for many women with eating disorders – you need to treat the primary problem first, and may need to circle back to the excessive exercise habit later.

Work on self-esteem and coping skills

Typically, men with muscle dysmorphia think that they are too small and scrawny, so their excessive exercise is for the purpose of building themselves up. Women with body image issues and eating disorders typically want to go the other way, becoming thinner. But either way, the individual has begun to train excessively because of an underlying deficit of self-esteem. Especially if the client is habitually forgoing social events and time with family and friends in order to exercise, they may be using exercise as a crutch:  a way of coping with perceived or actual deficits in interpersonal skills. Or the extra exercise could be a way of coping with other difficult life situations that the person is trying to avoid (such as an unhappy marriage, bad job, or other problem).

In such cases, part of your brief can be to help the person toward greater self-acceptance, supplemented by the teaching of coping skills tailored to their need.  While the therapies named above can play a definite role in this, re-building a sense of self is treated in a profound way with psychodynamic therapies, such as object relations, Jungian, or transpersonal modalities like Psychosynthesis. These are able to help the client look to relations in early life for the likely origins of issues of self-esteem and basic sense of “okay-ness”.

Re-wiring the brain: Getting past the need for “runner’s high”

Some individuals, particularly those who are prone to depression and/or anxiety, may be loath to reduce an intense exercise schedule because they crave the release of endorphins they receive from high-intensity activities, such as running. But the “runner’s high” feelings of elation caused by the release of these hormones – however powerful – are actually coming at a cost:  the gradual burnout of the adrenal glands. At some stage, the person is likely to crash, so the idea is to help the person climb down from the excesses before major damage is done.

Time off, re-start slowly

This intervention is probably the one most dreaded by over-trainers: that they should take some time off training, and then re-start slowly. As a mental health professional, it may be your job to suggest that the body needs its time to heal, and recurring injuries, chronic fatigue, irritability, and other symptoms of exercise addiction need to abate. When exercise is resumed, it should be at a pace, frequency, and level of intensity that will help the client to regain a balanced lifestyle.  How can you know about that, you ask? You probably need to refer.

Refer for specialised help

An exercise physiologist can help the client to come up with a healthy workout schedule when he or she resumes exercising. A medical professional, such as the person’s G.P., may be able to prescribe medications to help with the anxiety and/or depression that can result from exercise withdrawal, and of course, can help the client to get onto medications to help with any physical injuries caused by excessive exercise.

Conclusion

Although exercise addiction is not included in DSM-5, it is imperative that as mental health professionals we become familiar with its attributes. The physician may see repetitive injuries and not recognise this as a sign that the compulsion to exercise prevents an injury from full healing. For mental health professionals, the client committed to exercise may develop an addiction during the course of therapy if exercise is the primary means to manage the emotional demands of change.

Addiction specialists also must remain attuned to the signs and symptoms of exercise addiction given its co-occurrence with substance use disorders and other behavioural addictions such as sex, work, and shopping (Freimuth et al, 2011). If an exercise addict makes their way to you, you don’t have to be the whole treatment team, but you can help immensely by recognising the addiction for what it is and getting the helping ball rolling.

 



References

Allen, A. (n.d.). Exercise addiction in men. WebMD. Retrieved on 5 July, 2018, from: Hyperlink.

Cornell, R. (n.d.). Exercise addiction. Project Know. Retrieved on 5 July, 2018, from: 
Hyperlink.

Downs D.S., Hausenblas H.A., Nigg, C.R. (2004). Factorial validity and psychometric examination of the Exercise Dependence Scale-Revised. Meas. Phys. Educ. Journal of Exercise Science, 8, 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. Retrieved on 8 July, 2018, from: 
Hyperlink.

Hodges, R. (2017). Too much exercise is bad for your gut – and the other dangers of over training. The Telegraph. Retrieved on 5 July, 2018, from: 
Hyperlink.

Perna, E. (2017).  The side effects of excessive exercise. Livestrong. Retrieved on 5 July, 2018, from: 
Hyperlink.

Stubblefield, H. (2016). Exercise addiction. Healthline. Retrieved on 5 July, 2018, from: 
Hyperlink.

Terry, A., Szabo, A., & Griffiths, M. (2004). The exercise addiction inventory: A new brief screening tool.Addiction Research Theory, 12, 489–499.
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Jungian analysts have called it the “swampland of the soul”. Other psychotherapy writers have observed how it originally served to keep us safe; the tendency to shame has been a universal one in which our desire to hide our flaws from others has saved us from being kicked out of the group (the society), which evolutionarily would have meant death (Sholl, 2013). So which is it? Is shame totally pathological, or is it ever helpful to us? And how shall we deal with it in the therapy session, especially when we are faced with a highly self-critical or otherwise shame-prone client?

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Treating Anxiety with CBT: The Evidence
Generally considered a short-term therapy, Cognitive Behavioural Therapy (CBT) often consists of about 8 to 12 sessions in which client and therapist work collaboratively to identify problem thoughts and behaviours. CBT is considered the gold standard in the psychotherapeutic treatment of anxiety disorders and several meta-analyses (i.e., studies reviewing the results of multiple studies) have been published in recent years regarding the efficacy and effectiveness of CBT for anxiety. In this article, we briefly explore the evidence for treating anxiety with CBT.

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As the population ages in nations such as Australia and the United States, increasing numbers of offspring wonder how to help their retired, now lonely, and often depressed parent. Some of these may ask you for advice on how to help their beloved mum or dad. Of course, health problems must be tended to, but when the senior is relatively healthy yet unhappy, you might suggest that the adult child encourage their parent to begin volunteering. There are enormous benefits to both the volunteers and their communities. 


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