by Karin Kratina, PhD, RDN, LDN, SEP
(This article has been published in several journals.)
You may know her. She works out harder than most people you know, and doesn't feel ready to face the day unless she knows she will get her workout in, rain or shine. She will turn down social engagements to make sure she gets her workout. If, for any reason, she isn't able to get her full workout, she will be concerned and try to get in a little more exercise later, or possibly the next day.
From the outside, she appears to be a motivated, fit and happy person. Actually, she's too exhausted to go out with her friends and is increasingly alone and lonely. She continues to work out even when her doctor tells her an injury means she should stop. Her doctor is confused by her refusal to slow down; she's usually a very compliant patient. At one point, her doctor forced her to stop exercising for a week. Her depression and anxiety were so overwhelming that she was virtually immobilized until she could get back to exercising.
Men and women such as this are presenting to counseling in increasing numbers--not because they want to slow down their exercise, but because something is interfering with it. If these exercisers were willing to take a look at what they are doing, they would find that their activity is not about performance or reshaping their bodies, but about dealing with life. They would find exercise is essential to them to provide a feeling of mental well-being, to release their tension and anger, and even relieve anxiety and depression. They also would find they have few other strategies to cope with these feelings.
Diagnostic Criteria for Exercise Dependence
While there are many terms in the literature used interchangeably with compulsive exercise, "exercise dependence" is the preferred term. In 1987, de Coverly Veale proposed diagnostic criteria for exercise dependence using the core features of a dependence syndrome (4):
- A narrowing of repartee, leading to a stereotyped pattern of exercise with a regular schedule, once or more daily;
- Salience with the individual; giving increased priority over other activities to maintain the pattern of exercise, obviously giving up other things in life so that they can maintain their exercise;
- Increased tolerance to the amount of exercise performed over the years;
- Withdrawal symptoms related to a disorder of mood, following a cessation of the exercise schedule;
- Relief or avoidance of withdrawal symptoms by further exercise;
- Subjective awareness of a compulsion to exercise;
- Rapid reinstatement of the previous pattern of exercise and withdrawal after a period of abstinence.
- Either the individual continues to exercise despite a serious physical disorder known to be caused, aggravated, or prolonged by exercise and is advised as such by a health professional;
- The individual has argumentive difficulties with his partner, family, friends or occupation;
- The self-inflicted loss of weight by dieting is as a means towards improving performance.
According to de Coverly Veale, "primary exercise dependence" occurs when an individual meets all of the proposed criteria and anorexia nervosa and bulimia nervosa are ruled out. Pure exercise dependence is found most often in middle-aged men in their 40's and 50's. Weight loss by dieting is seen in primary exercise dependence as a means to improve performance; however, if weight loss is too drastic, performance would be impaired, so typically weight is not allowed to drop too low.
Excessive exercise directed towards weight loss or balancing caloric intake is regarded as"secondary exercise dependence". Most often, this kind of activity involves individuals who have a primary diagnoses of an eating disorder.
The prevalence of exercise dependence is not known. Some researchers believe a relatively small percent of menand women have a severe dependence; others feel that as many as 7% of committed exercisers are dependent on exercise. Possibly 50% of anorexics and bulimics deal with some form of exercise dependence.
A core feature of any dependency is the experience of negative affect when the object of dependence is removed. Glasser described the negative effect that runners experience when they are forced to forego running. Symptoms he found were: depressed mood, irritability, fatigue, anxiety, impaired concentration, sleep disturbance, guilt, tension, vague sense of discomfort. These symptoms were relieved when running was resumed. (5)
There are no conclusive studies as to why these affective withdrawal symptoms occur. Some believe these exercisers are addicted to endorphins, the morphine-like hormones secreted by the body under stress, and that withdrawal from endorphins creates the symptoms. It is the endorphin release that is thought to cause what is commonly referred to as "runner's high".
Used as a Way to Cope
Another theory regarding exercise dependence is that exercise has become a means of coping. A person may exercise to deal with feelings (tension, stress, anger, guilt, anxiety, loneliness, etc.). Often unaware of the feelings, the dependent person simply acknowledges the drive to exercise which pushes down these feelings. Without exercise, the thoughts and feelings which have been avoided and denied flood back.
Essentially, the dependent exercisers have been working out their bodies rather than their problems. Without effective coping mechanisms, they become overwhelmed and are compelled to exercise again to control unwanted feelings. What began as the pursuit of pleasure had become the avoidance of pain.
Treating Exercise Dependency
Typically, compulsive activities are a source of shame and embarrassment. Not so with exercise dependence. This is not a shame-based activity. The exercisers like what they are doing. Exercise dependent clients typically present to treatment because they no longer are able to continue the exercise. Possibly their doctor requirestherapy due to injury, or their partner or spouse threatens to leave if therapy is not initiated. These clients tend to be extremely resistant to exploring issues around their exercise.
If the purpose of exercise dependence is to avoid and deny the underlying feelings, anxiety and/or depression, the recovery involves identifying and dealing effectively with these feelings. Without effective coping skills, it is difficult to endure the uncomfortable feelings that arise when exercise is curtailed. An understanding friend, skilled dietitian or exercise physiologist, or therapist may aid in the process.
Changing Up the Exercise
Some may be ready to make changes in their exercise patterns, others may need to stay at their current level of exercise while therapy is initiated. Their relationship with exercise will need to be challenged, for instance, make changes in their exercise program. I asked one client to wear sandals rather than walking shoes when she power walked. She returned with a very different perspective of her walking and thereafter used her ability to 'chose sandals for her walk' as an indication of the intensity of her feelings. The possibilities are endless, especially one who understands that most dependent exercisers have repetitive exercise patterns. For example:
- Go the opposite direction. Run clockwise instead of counter-clockwise.
- Change the order of the activities. Do weights first rather than last.
- Switch activities. Swim instead of run, use a free weight for biceps rather than a machine.
- Take a different aerobics class.
- Wear different gear. Run in torn gym shorts rather than sleek running shorts.
- Quit counting. How do they know when to stop?
- Express feelings during exercise. Instead of pushing a feeling down, stay present to it while exercising. Move in such a way that the feeling is expressed, for instance, a form of aerobic dance, NIA: Non-Impact Aerobics, uses feelings expression.
Cut Back on Exercise
Frequently, the intensity, frequency or duration of exercise must be reduced. This reduction can occur over time, or can be "cold turkey". Since withdrawal symptoms are usually most intense 36 to 48 hours after ceasing exercise, I challenge clients to omit exercise for three days. I explain what they most likely will experience and help them set up a support system. This break from activity can allow a compulsive exerciser to see the impact exercise has on their lives and create an opening to make changes.
Challenge Belief Systems
Exercise dependent individuals will need to examine their belief system around exercise, health, and fitness in order to unravel cognitive distortions. The client will need to understand and accept that training daily is counterproductive, that a low percent of body fat does not necessarily make them healthier, that they will not get out of shape if they take off a day or two, that muscles need days without exercise to recover and refuel, that calories eaten will replace depleted glycogen stores which will help them perform better, or even that minimal movement can contribute to health andbe considered exercise.
For instance, in a group I facilitated, a client, "Debbie," wasexpressing difficulty getting in touch with her feelings. A group member challenged her saying, "Well, you exercise all thetime, anyway" (inferring that it is difficult to get in touch with feeling when exercising frequently). Debbie disagreed with her stating she exercised "20 minutes a day." I said, "I'm confused because youcome to my aerobics class, and that's a 45 minute class. Do you leave before we're finished?" "No," she said "twenty minutes. The other stuff, the sit-ups, push-ups and other stuff is notreally exercise." I asked her "what is exercise." She said, "Exercise is when you get your heart rate up." Someone else said, "But you walk all the time, you walk to the store andeverywhere." Debbie said, "That's not really exercise, because I don't get my heart rate up." We explored her beliefs, but she steadfastly maintained that she exercised only 20 minutes a day. Later, she talked about another resident who "exercised all the time." I said, "Why is walking for her exercise, but not for you?" She laughed at this inconsistency in her thinking and was willing to discuss it. Thereafter she began to open up and explore her own relationship with exercise.
Develop Other Coping Tools
Alternative coping methods must be strengthened. Clients will need to explore a variety of coping strategies to find those with which he or she is comfortable. A consultation with an exercise physiologist familiar with exercise dependence may be helpful to outline a sound exercise program. Relaxation tapes and journaling can help with feelings and anxiety that may arise. Help them to learn to truly enjoy movement.
As exercise is decreased, a client will have more time on their hands. Plan activities that can take the place of goal directed exercise that are nurturing and relaxing...movies or dinner with a friend, adopt and train a pet, maintain an aquarium, garden, take a slow walk on the beach, sit and watch the sunset, read a good book.
Recovery involves learning to trust relationships, to vent feelings, to be assertive, to take risks, and to meet personal needs. Underlying conflict, previously avoided and denied, will need to be confronted and worked through. Self-image and self-esteem will need to be built in areas other than exercise. Ultimately, clients will need to learn to trust and depend on other people in their lives in order to move beyond exercise dependence.