Deborah Brauser

July 07, 2014

LONDON ― Excessive exercising, or so-called "exercise addiction," is a real problem and often occurs within the context of eating disorders (EDs) ― although not always, according to a presentation here at the International Congress of the Royal College of Psychiatrists (RCPsych) 2014.

Dr. Caroline Meyer

During the presentation, investigators discussed past problems with trying to "conceptualize and define" this disorder and presented preliminary data that examined whether compulsive exercise (CE) could be successfully measured.

That study, which included 712 patients and is currently in preparation, showed that those with an ED had significantly higher scores in weight control exercise, lack of enjoyment, exercise rigidity, and avoidance behaviors than those without an ED.

In addition, the investigators reported that they "are coming to the end" of a 4-year randomized control trial (RCT) that assessed the effectiveness of the Loughborough Eating Disorders Activity Therapy Program (LEAP), an intervention that uses cognitive-behavioral therapy (CBT) to counteract CE.

"We have encouraging pilot data for LEAP, which is currently being used in workshops around the world," lead author Caroline Meyer, PhD, director of the Center for Research into Eating Disorders and professor of psychology at Loughborough University in Leicestershire, United Kingdom, told meeting attendees.

With CE overall, "patients don't want to exercise this much. They know they're going to die or do themselves serious damage if they continue, and they're often doing it while injured. But they just can't stop," said Dr. Meyer.

Problematic Symptom

According to past research, "excessive exercisers across diagnoses" require longer stays of hospitalization compared with those who do not exercise to excess. CE is also predictive of earlier time to relapse and poor long-term outcome.

In addition, CE usually occurs before the development of an ED, but is often one of the last symptoms of an ED to subside with treatment.

"When speaking to clinicians in this area, this was always the symptom they really struggled to shift. They could stop patients from bingeing and could get people's weight up, but getting people to stop this rigid exercise was really problematic," said Dr. Meyer.

She reported that approximately half of patients with bulimia and more than half of those with anorexia nervosa have this repetitive, compulsive urge to be physically active.

"Addiction to exercise clearly doesn't just occur within eating disorders. Lots of our work has been with athletes or with community samples. But there is a lot we can learn from the [ED] field that we can extrapolate to various other domains," she added.

Dr. Meyer said that there is a "vast inconsistency" in the literature when it comes to defining CE, and numerous terms have been used to describe it.

"What's clear, however, is that people try to define this either in terms of a quantitative dimension (how much people are doing, or the so-called 'excessive' description) or a qualitative dimension (the 'compulsive' description)," she explained.

Past studies that have tried to define the disorder through quantitative measures have suggested that it occurs when an individual exercises for more than 3 hours a day or for at least 5 to 6 times a week for 1 hour a day and has followed this regimen without stopping during the previous 3 to 12 months.

"The list goes on and on and varies so much. It really is ridiculous in terms of trying to quantify this problematic engagement with exercise," said Dr. Meyer, adding that what might be perfectly acceptable for a healthy individual is not for others who have certain health conditions.

"So it's very hard to quantify 'what is too much?' Instead, we're interested in the qualitative definition and what drives [CE]," she said.

Behavioral Addiction?

Most literature agrees that this type of exercise is compulsive. It moves from an enjoyable and voluntary behavior to a state in which it becomes ritualized and a patient feels out of control and simply cannot stop, even if they want to.

"If we think of this in terms of a kind of behavioral addiction, and look at the compulsive direction of it, then there are lots of data suggesting that it is related to eating psychology ― but there's also much more to it than that," said Dr. Meyer.

To understand CE better, the investigators conducted a large, systematic literature review in 2011 and then used the information to build their own so-called "maintenance model."

They then sought to test whether this multidimensional model, which they named the Compulsive Exercise Test (CET), was robust and useful in 5 studies to date, including 1 with 376 young women, 1 with 1012 adolescents, 1 with 490 athletes, and 1 with 356 patients with an ED.

"We wanted to see if this would enable us to measure whether the interventions we have for this type of behavior are meaningful and successful," said Dr. Meyer.

A recently completed study assessed 356 patients diagnosed with an ED vs 356 "healthy controls." Preliminary results showed that the groups differed significantly in CET scores on global measures (71.0 vs 11.4, respectively), avoidance (2.75 vs 1.74), weight control exercise (3.47 vs 2.59), lack of enjoyment (2.21 vs 1.48), and exercise rigidity (2.90 vs 2.37) (for all, P < .001).

There were no between-group differences in mood improvement. "This appears to be one area that we don't need to be that concerned about. It's one area that doesn't necessarily distinguish someone with pathology," said Dr. Meyer.

In an effort to turn this information into a useful intervention, the investigators created the LEAP program, a semistructured intervention with a CBT approach, to be used adjunctively with standard ED treatment.

LEAP concentrates on working with, not against, patients; discusses healthy and unhealthy exercise; and promotes gaining control over CE in a group or individual format within 8 1-hour cumulative sessions. Its 4 core themes are education, guided discovery, skills training, and relapse prevention.

The researchers' 4-year RCT, plus 1-year follow-up, is currently coming to an end. It assessed LEAP in outpatients with CE and EDs and "is quite encouraging."

"The feedback from the trial and from discussing with those who have gone through the workshops seems to be that patients are quite accepting of LEAP, and therapists/clinicians like it because they've really not had the resources before to focus on this behavior," said Dr. Meyer, reporting that a program manual is currently available to download free of charge.

"Just bear in mind that at the moment, it's not evidence-based. We don't have efficacy data for it. But I think it's quite useful," she said.

In a comment to Medscape Medical News, Dr. Meyer added that, overall, it is important for clinicians to think about CE in terms of what is driving the compulsion. "We find that people get stuck with this behavior. Once we can shift some of their other problematic behaviors, the exercise is something that is really difficult for them to give up."

However, she admitted that there is a mixed message here.

"We're always saying that exercise is good, but then suddenly we're telling them there's a problem. I think that rather than trying to get them to stop, unless they're very medically unwell, work with them to maintain some exercise, but also work on their relationship with it and their beliefs about it and try to get them more in control by giving them specific strategies."

New Insight

Session moderator Alan Currie, FRCPsych, consultant psychiatrist with Northumberland, Tyne and Wear NHS Foundation Trust in Newcastle, United Kingdom, told Medscape Medical News that he would prefer to move away from "quantitatively describing this as exercise addiction."

Dr. Alan Currie

"What we're interested in is the qualitative aspects of it. What's different? And what makes it something that you can't stop even when it's destructive? A model that picks out what the motivations are that drive this behavior is something we learned a lot about this morning," said Dr. Currie, who was not involved with the research.

He noted that there are undoubtedly some people who have eating disorders in which excessive exercise is a component.

"But what we're starting to understand now is that there are actually many people who are using exercise in a way that is not that helpful to them, and might even be destructive, and don't have an eating disorder," he said.

"So we have to start to think about troubled people who are doing harm to themselves but might be on the fringe of a diagnosis or a condition. And it's important for clinicians to know what questions to ask, to pick out if the exercise a person is doing is actually part of the psychopathology or is a hobby or an interest that may be helpful for them."

The study authors have reported no relevant financial relationships.

International Congress of the Royal College of Psychiatrists (RCPsych) 2014. Session S40. Presented June 27, 2014.

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