By Rebecca Gawler

DYSFUNCTIONAL EXERCISE

What is dysfunctional exercise?

 Dysfunctional exercise describes a large spectrum of behaviours, ranging from lack or avoidance of physical activity to excessive or compulsive behaviours(1). Dysfunctional exercise is an umbrella term, incorporating various phrases such as exercise abuse, compulsive exercise, exercise dependence, obligatory exercise, excessive exercise and exercise addiction(2). Typically, dysfunctional exercise can be grouped into the following domains(3): 

1. Excessive

  • Exercise characterized by excessive frequency, duration and intensity(3)

  • Usually exceed physical activity guidelines and in quantities that others would regard as abnormal(4) 

2. Compulsive

  • Exercise to reduce or prevent feelings of distress(3,5,6)

  • Often strongly resembles the pattern of addiction, involving compulsive urges and strong withdrawal effects(4,5) 

3. Compensatory

  • Exercise to compensate for the effects of food intake on weight or shape(3,4)

  • Usually related to "burning off" calories or exercising to gain permission to eat(3)

 These 3 components may be inter-related for patients or may be experienced independently of each other(3). Therefore, it is important to note that an individual may have dysfunctional exercise patterns without exercising more than is typically considered normal. The quantity of exercise does not account for the thought patterns driving the behaviour or the physical, psychological and social harm that results(22)

Dysfunctional exercise is not a recognised clinical diagnosis in the DSM-5, but has been described as a symptom of eating disorders(3). However, throughout the literature it is recognised that dysfunctional exercise can also exist independently of other diagnoses(7) 

Signs and symptoms

Physical

  • Overuse injuries(8)

  • Stress fractures(8)

  • Chronic bone and joint pain(8)

  • Persistent fatigue and sluggishness(8)

  • Symptoms associated with malnutrition may occur when exercise levels exceed nutritional intake(9), including low bone density, disrupted menstruation, fluctuations in weight, sleep disturbance, dizziness, increases in cold sensitivity, muscle weakness, gastro-intestinal complaints and difficulties concentrating(8,9,10)

Behavioural and emotional

  • Intense feelings of anxiety, depression, irritability, guilt and/or distress if unable to exercise or if exercise is postponed(5,8)

  • Avoiding or cancelling important activities and social commitments in order to exercise(8,11)

  • Exercising at inappropriate times or in inappropriate settings(8)

  • Secretive or hidden exercise(8)

  • Exercising despite injury, illness or fatigue(12)

  • Exercising regardless of weather(8)

  • Rigid exercise regimen(12)

  • Discomfort or distress with rest or inactivity(8)

  • Exercising as permission to eat or to "burn off" food intake(3,8)

  • Strong desire to push oneself and work very hard when exercising(8)

  • Exercising with the purpose of influencing weight or shape(3,5)

  • Turning daily activities into an opportunity to exercise(13). For example, standing when watching television, jogging rather than walking, taking the stairs rather than the elevator

  • Number counting associated with movement e.g., calories burnt, steps, distance, speed(12)

  • Pacing, which involves fast, persistent walking without the intention of reaching a destination(4)

  • Leg jiggling/shaking while sitting, usually rhythmic and unilateral(4) 

Consequences

Physical

  • Overuse injuries(8)

  • Stress fractures(8)

  • Chronic bone and joint pain(8)

  • Persistent fatigue and sluggishness(8)

  • RED-S(8)

  • Physical health consequences associated with malnutrition, when physical activity levels exceed nutritional intake e.g. low bone density, loss of menstrual cycle(8,9)

  • Sleep disturbances(1)

Emotional/psychological

  • Intense feelings of anxiety, depression, irritability, guilt and/or distress if unable to exercise(8)

  • Anxiety(7)

  • Depression(7)

Social

  • Negative effects on interpersonal relationships(14)

  • Lack of time for other activities(11)

  • Marital strain(11)

  • Interference with work(11)

Who it affects

Dysfunctional exercise can occur as a standalone concern(7), however is likely to exist as a co-morbidity or symptom of the following conditions:

Eating disorders(3,5,7)

The relations between exercise, coping and eating pathology is complex(6), however it is clear from the research that dysfunctional exercise has a significant role in the development and maintenance of eating disorders(3,5). 

In eating disorders, dysfunctional exercise:

  • Often precedes the onset of an eating disorder(15)

  • Is one of the last symptoms to subside(16)

  • Is associated with a higher risk of relapse(17)

  • Is associated with a poor long term outcome(3)

  • Is associated with a higher rate of hospitalisation(18)

In hospitalised eating disorder patients(18):

  • 78% engaged in dysfunctional exercise

  • 60% were competitive athletes prior to onset of disorder

  • 60% reported that sport or exercise began prior to dieting

  • 75% reported that physical activity levels increased when food intake and weight decreased the most

Muscle dysmorphia

Muscle dysmorphia is characterised by beliefs of insufficient leanness or muscularity, usually accompanied by excessive muscle-building activities such as weightlifting and use of other methods including dietary changes and anabolic steroids(7). This extreme focus on achieving fitness and body image goals shares many similarities with dysfunctional exercise and therefore frequently occur together(7).

Obsessive-compulsive disorder (OCD)

OCD is a disorder characterised by recurring unwanted thoughts, ideas or sensations (obsessions) that frequently lead to repetitive behaviours (compulsions) and interfere with an individual's daily activities or social interactions(19). Studies have shown that it is common for individuals who engage in dysfunctional exercise to also score highly on OCD tests, due to the compulsive nature of both(7).

Addictions

Approximately a third of individuals with dysfunctional exercise also exhibit another addiction(20). These commonly include nicotine, alcohol, illicit drugs, work, internet, gambling, sex and compulsive buying(20,21)

Gender

Dysfunctional exercise can affect both genders, however there are differences in prevalence of certain presentations:

  • Women are more likely to engage in exercise to compensate for food intake than males(3)

  • Men are more likely to report excessive exercise(3)

  • Both men and women are equally as likely to engage in compulsive exercise(3) 

What drives it?

The underlying causes and contributors to dysfunctional exercise are not fully understood and are often complex and vastly differ between individuals(6). The following are some of the most commonly researched and observed:  


Affect/mood regulation

There is a large amount of research supporting the positive effects of exercise on mental wellbeing22. However, exercising to improve mood is significantly different than exercising to avoid negative emotions such as anxiety, depression, guilt and distress(4,6). Both are types of mood/affect regulation, yet there are significant differences between the 2 approaches as outlined in the below table(6): 

Those with eating disorders often experience high levels of anxiety and therefore will frequently engage in exercise as an affect regulation strategy(4). However, this can rapidly lead to a pattern of exercise dependence, with individuals experiencing withdrawal effects such as heightened anxiety or distress when unable to exercise(4). 

 The biological effects of malnutrition

The state of starvation seems incompatible with high levels of physical activity. However, in patients with eating disorders, the coexistence of excessive exercise and calorie restriction is common(18).

Malnutrition (occurring from calorie restriction and/or excessive exercise) frequently causes serotonin dysregulation(18). These changes to serotonin have been associated with the development of compulsive behaviours, as seen in conditions such as OCD(23). Consequently, various behaviours including exercise can become ritualistic, compulsive and excessive(24).

It has been observed that as patients are re-fed and move out of a malnourished state, the obsessive need for exercise tends to diminish(24,25). Therefore, in order to address dysfunctional exercise effectively, patients must be receiving dietetic and psychological assistance to re-nourish the body and consequently improve serotonin regulation.

Desire to control shape and weight

A desire to control shape and weight can cause significant distress for many individuals with eating disorders(26). There are a number of ways that exercise is used in a dysfunctional way to control weight and shape:

  • Exercising to counteract food choices(3,5)

  • Exercise to build muscle in conditions such as muscle dysmorphia(7)

  • Exercising to change body shape in an attempt improve self-esteem. For many people, the desire to control weight and shape comes from the assumption that the way a person looks can mirror the way a person is(7). Therefore, addressing perceived "flaws" in their body can act as a way to address perceived "flaws" or dissatisfaction about their personality and life. 

References

  1. Taranis L, Meyer C. Associations between specific components of compulsive exercise and eating-disordered cognitions and behaviors among young women. International Journal of Eating Disorders. 2011;44(5):452-458. doi:10.1002/eat.20838

  2. Dobinson A, Cooper M, Quesnel, D. Safe Exercise at Every Stage (SEES): A Guideline for Managing Exercise in Eating Disorder Treatment. Safe Exercise at Every Stage website. https://www.safeexerciseateverystage.com/access-sees-guidelines. Published 2019. Accessed 20th November, 2020.

  3. Holland L, Brown T, Keel P. Defining features of unhealthy exercise associated with disordered eating and eating disorder diagnoses. Psychol Sport Exerc. 2014;15(1):116-123. doi:10.1016/j.psychsport.2013.10.005

  4. Davies R. The treatment of compulsive physical activity in anorexia nervosa lacks a conceptual base. Advances in Eating Disorders: Theory, Research and Practice. 2015;3(1):103-112. doi:10.1080/21662630.2014.892835

  5. Mond J, Hay P, Rodgers B, Owen C. An update on the definition of "excessive exercise" in eating disorders research. International Journal of Eating Disorders. 2006;39(2):147-153. doi:10.1002/eat.20214

  6. Thome, J. and Espelage, D., 2004. Relations among exercise, coping, disordered eating, and psychological health among college students. Eating Behaviours, 5, pp.337-351.

  7. Lichtenstein M, Hinze C, Emborg B, Thomsen F, Hemmingsen S. Compulsive exercise: links, risks and challenges faced. Psychol Res Behav Manag. 2017;10:85-95. doi:10.2147/prbm.s113093

  8. National Eating Disorders Association. Compulsive Exercise. National Eating Disorders Association website. https://www.nationaleatingdisorders.org/learn/general-information/compulsive-exercise. Updated 2018. Accessed November 20th, 2020.

  9. Brown K. Physiotherapy In Eating Disorders. 1st ed. The Physiotherapy Eating Disorders Professional Network Group; 2018:1-5. https://cpmh.csp.org.uk/content/physiotherapy-eating-disorders. Accessed November 18, 2020.

  10. National Eating Disorders Association. Warning Signs and Symptoms. National Eating Disorders Association website. https://www.nationaleatingdisorders.org/warning-signs-and-symptoms. Published 2018. Accessed November 20, 2020.

  11. Landolfi E. Exercise Addiction. Sports Medicine. 2013;43(2):111-119.

  12. Reel J. J. The Right 'Dose' of Activity: Health Educators Should Promote Mindful and Intuitive Exercise. J Community Med Health Educ. 2012;2(9). doi:10.4172/2161-0711.1000e111

  13. Kolnes L. Embodying the body in anorexia nervosa - a physiotherapeutic approach. J Bodyw Mov Ther. 2012;16(3):281-288. doi:10.1016/j.jbmt.2011.12.005

  14. Furst D, Germone K. Negative Addiction in Male and Female Runners and Exercisers. Percept Mot Skills. 1993;77(1):192-194. doi:10.2466/pms.1993.77.1.192

  15. Davis C, Blackmore E, Katzman D, Fox J. Female adolescents with anorexia nervosa and their parents: a case-control study of exercise attitudes and behaviours. Psychol Med. 2005;35:377-386. doi:10.1017/S0033291704003447

  16. Kron L, Katz JL, Gorzynski G, Weiner H. Hyperactivity in anorexia nervosa: A fundamental clinical feature. Compr Psychiatry. 1978;19(5):433-440. doi:10.1016/0010-440X(78)90072-X

  17. Carter J, Blackmore E, Sutandar-pinnock K, Woodside D. Relapse in anorexia nervosa: a survival analysis. Psychol Med. 2004;34(4):671-679. doi:10.1017/s0033291703001168 

  18. Davis, C., Kennedy, S., Ravelski, E. and Dionne, M., 1994. The role of physical activity in the development and maintenance of eating disorders. Psychological Medicine, 24(4), pp.957-967.

  19. Gorrindo T, Parekh R. What is Obsessive-Compulsive Disorder?. American Psychiatric Association. https://www.psychiatry.org/patients-families/ocd/what-is-obsessive-compulsive-disorder. Published 2017. Accessed November 20, 2020.

  20. Sussman S, Lisha N, Griffiths M. Prevalence of the Addictions: A Problem of the Majority or the Minority?. Eval Health Prof. 2011;34(1):3-56. doi:10.1177/0163278710380124

  21. Freimuth M, Moniz S, Kim S. Clarifying Exercise Addiction: Differential Diagnosis, Co-occurring Disorders, and Phases of Addiction. International Journal of Environmental Research and Public Health. 2011;8:4069-4081. doi:10.3390/ijerph8104069

  22. Warburton D, Nicole C, Bredin S. Health benefits of physical activity: the evidence. Can Med Assoc J. 2006;174(6):801-809. doi: 10.1503/cmaj.051351

  23. Barr, L., Goodman, W., Price, L. and Mcdougle, C., 1992. The serotonin hypothesis ofobsessive compulsive disorder: Implications of pharmacologic challenge studies. Clinical Psychology, 53(4), pp.17-28.

  24. Davis C, Kaptein S. Anorexia nervosa with excessive exercise: A phenotype with close links to obsessive-compulsive disorder. Psychiatry Res. 2006;142:209-217.

  25. Crisp, A., 1967. The possible significance of some behavioural correlates of weight and carbohydrate intake. Journal of Psychosomatic Research, 11(1), pp.117-131.

  26. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Washington D.C.: American Psychiatric Association Publishing; 2013. 

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