Considering its benefits, both mentally and physically, regular exercise can be viewed as beneficial and even therapeutic. However, when practiced obsessively, rewarding behaviors such as exercise can trigger severe negative consequences. Exercise addiction has been associated with eating disorder traits such as concern for weight and perfectionism. In fact, eating disorders are the most common disorder to co-occur with exercise addiction, although exercise addiction can also be comorbid with other addiction disorders such as substance and alcohol abuse. While the DSM-V lists only gambling under behavioral addictions, researchers have modified the DSM-IV TR criteria for substance dependence to identify exercise addiction.
Tolerance: in order to feel the desired effect (a “buzz” or sense of accomplishment), the amount of exercise increases
Withdrawal: negative effects such as anxiety, irritability, restlessness, and sleep problems occur in the absence of exercise
Lack of control: attempts to cease exercising for a period of time or to reduce exercise level are unsuccessful
Intention effects: consistently exercising beyond the intended amount or exceeding the intended routine
Time: a great deal of time is spent recovering from, preparing for, and/or engaging in exercise
Reduction in other activities: occupational, recreational, and/or social activities occur less often or stop altogether as a direct result of exercise
Continuance: continuing to exercise despite the behavior creating or exacerbating psychological, interpersonal and/or physical problems
To understand how exercise can become an addiction, clinicians can refer to the “Four Phase” model. In the first phase, exercise is recreational and occurs primarily because it is rewarding and pleasurable. In the second phase, the exercise has become an at-risk behavior, with the exercise becoming more intense and/or lasting for longer periods of time than intended. By the third phase, exercise has become problematic. The person’s day is organized around the increasingly rigid exercise regime, and exercise that was once done socially is now performed alone. The person also experiences withdrawal symptoms when exercise stops. Additionally, the exercise has become indiscriminant; if the preferred form of exercise is unavailable, then other types will be performed. The fourth and final phase is exercise addiction. At this point the behavior has become life’s main organizing principle, and the primary motivation becomes avoiding withdrawal symptoms. The person now experiences impairments in functioning and is unable to meet role obligations due to the exercise.
These four phases are useful for early identification of exercise addiction as well as defining treatment goals and helping patients distinguish between recreational and addictive exercise. Assessment and treatment of exercise addiction should take into account its stages of development and its comorbidity with other psychiatric disorders. The goal of treatment may not be abstinence from exercise, but instead a return to moderate exercise. This can be achieved through the identification and correction of automatic thoughts such as those related to the need to control the body and the idea that exercise is always good, even if done in a driven or obsessive manner. Clinicians may also employ behavioral strategies, such as contingency management, rewarding maintenance of lower exercise levels or abstinence from a specific type of exercise.
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