Causes, Diagnosis & Treatment Options of Excessive Exercise
Contributed Article by Theodore E. Weltzin, MD – Medical Director of Eating Disorder Services, Rogers Memorial Hospital
Excessive exercising is an often overlooked component of eating disorders. For both males and females, participation in athletics and attempts at improving athletic performance can initiate an eating disorder. There are some characteristic symptoms associated with excessive exercise; with the appropriate questioning, these symptoms can be identified and then incorporated into a comprehensive eating disorder treatment.
Identifying Excessive Exercising in Eating Disorder Patients
While most eating disorder patients describe periods of exercising as a way of either counteracting the effects of eating or attempts at weight loss, excessive exercising has a number of characteristics which set it apart from typical exercise seen in this population. Excessive exercise is frequently a daily activity in which the person reports intense anxiety if they are unable to engage in the exercise activity. Those engaging in excessive exercise may plan out their day prominently focusing on exercise, scheduling other activities around their exercise goals. Those engaged in excessive exercise may reduce their social, school and work activities in order to exercise. Patients who engage excessive exercise often have significant problems with interpersonal, occupational, and academic functioning.
For those engaged in excessive exercise, the act of exercising can increase anxiety and stress. Excessive exercisers report that they often feel like they are not good enough, not fast enough or not pushing themselves hard enough during a period of exercise. They report feeling an intense pressure to increase the duration, intensity or difficulty of their exercise routine.
Even in the face of detrimental effects, excessive exercisers will continue to exercise. Excessive exercisers may miss out on promotions at work or lose jobs, or damage their relationships as the result of their excessive exercise. Strikingly, excessive exercisers will sometimes exercise in the face of physical damage, even recent bone fractures. In extreme cases, excessive exercisers will remove casts from their ankles or feet in order to continue to exercise.
Causes of Excessive Exercise in Eating Disorder Patients
For eating disorder patients, the relationship between exercise and abnormalities may be more complex than simply purging calories. There are likely both psychological and biological causes to excessive exercise in eating disorder patients.
Restrictive eating increases activity in both humans and animals. Recent research has shown that this increase may relate to serotonin or leptin mediated effects on anxiety and appetite (Holtkamp et al., 2004). In eating disorder patients, excessive exercise and perfection also predict dietary restraint (McLaren L, Fauvin K, White D. 2001)
It is not unreasonable to link excessive exercise with self-induced purging. Psychologically, excessive exercise, like self-induced purging, has been shown a response to uncomfortable internal states like high levels of depression or anxiety. Studies suggest that eating disorder patients who engage in excessive exercise are, in general, more likely to be depressed. In anorexics, excessive exercisers often have prominent anxiety symptoms. (Penas-Lledo E et al., 2002).
The treatment of purging by vomiting requires abstinence from purging. Likewise, abstinence from exercise and abstinence from restricting helps to identify mechanisms that may contribute to the compulsive nature of this symptom.
Evaluating Someone for Excessive Exercise
The evaluation of an excessive exerciser involves taking a detailed history of an individual’s exercise activities, much like taking a nutritional history for someone with an eating disorder.
Taking an exercise history includes evaluating when a person first began to exercise, creating a record of athletics and types of athletics that the person has participated in, and understanding how that participation has progressed over time. Frequently, excessive exercisers begin with very appropriate levels of athletics and activities. As an individual degenerates into their eating disorder, they will begin to use exercise as a way of burning calories and dealing with body image related issues. Next, the urge to exercise becomes out of control.
Sometimes the urge to exercise becomes so extreme that an excessive exerciser will quit organized activities where the amount of activity a person can participate in may be monitored or regulated. Patients at Rogers Memorial Hospital have reported quitting organized activities like track or cross country running because they feel that they are not allowed to exercise enough. People will go to extremes. An extremely excessive exerciser may bicycle up to 400 miles every week, run 10 to 15 miles every day, or work out three to five times daily in the gym.
Once the frequency, duration, and type of exercise have been characterized, it is important to identify an individual’s emotional and cognitive distortions associated with exercise. An excessive exerciser may report that if they do not exercise they will gain weight. An excessive exerciser may report intense feelings of shame and guilt associated with not exercising or not exercising as intensely or for as long a period of time as they feel like they should.
An excessive exerciser may report an escalating pattern of exercise. Excessive exercisers may sometimes engage in isometric type exercises even during eating disorder treatment. Frequently, people who engage in excessive exercise will minimize their behaviors or the psychological impact or destructive nature of these activities on their life.
Treatment of Excessive Exercising
The treatment of excessive exercising is very similar to the treatment of eating disorders in general.
For severely underweight patients, strictly limiting activity (including exercise) is medically necessary and will lead to severe increases in anxiety at some times to the point of panic. Commonly, patients will engage in secretive exercise, continually pace or be in constant movement in order to reduce anxiety. In these cases, physically restricting a patient is unrealistic and completely inhibiting exercise is impossible. Instead, treatment needs to focus on providing adequate nutrition to avoid further weight loss or to increase weight.
In these cases, a patient can either eat more or exercise less. The more energy is expended; the more calories need to be consumed. This becomes a motivation for the patient early in treatment. Giving a patient a choice can sometimes lead to a voluntary reduction in exercise.
It is very important, in our experience, to have people abstain from any exercise at all for some period of time. This will increase the excessive exerciser’s anxiety, but allows them to identify the psychological underpinnings associated with excessive exercise.
After a period of abstinence from exercise, the next phase of treatment is to identify and challenge errors in thinking and cognitive distortions around exercise. Once the patient has been identified as someone who exercises excessively, having them complete and present a history or “exercise autobiography” can help to underscore the dysfunctional characteristics of their exercise.
This technique is a way for the patient to attempt to re-label the exercise as destructive and really not exercise at all. Frequently, patients can identify exercise as a way of purging calories or emotions. Once they realize this, they often can see the need to change.
Being able to comprehensively list preoccupations and repetitive behavior around exercise is essential prior to re-instituting exercise. This technique is very similar to the behavioral therapy used for treating obsessive compulsive disorder.
Once an excessive exerciser has been able to work through, identify and begin to successfully challenge these symptoms, then it is time to re-institute exercise “Cardio” or “calorie burning” activities typically present the most anxiety, therefore excessive exercisers are initially reintroduced to low activity (walking) and non-cardio exercise (typically weight training). With a therapist present, the patient processes thoughts feelings and urges to go faster or for a longer duration or to increase their heart rate. Excessive exercisers will often wish to stay away from non-cardio related activities. Activities like weightlifting often stimulates a patient’s fears in terms of “bulking up” or increasing body size.
Reintroducing exercise in a controlled way is often times very helpful. Excessive exercisers at Rogers Memorial often start out by engaging in group walking in a socialized atmosphere. On these walks, the patient is able to monitor and discuss attempts at increasing the pace of the walk. This can help them to begin to normalize a casual, socialized exercise behavior.
Reintroducing cardiovascular exercises in terms of running, swimming, and cycling is then done under the guidance of a certified exercise physiologist. During these activities, excessive exercisers are asked to identify and resist their urges to increase the intensity of their workout. This also allows the patient to get a sense of accomplishment if they can resist urges in the setting that they have in the past engaged in compulsive behaviors.
When an excessive exerciser is able to start to take control their activities, they develop an exercise plan, similar to a meal plan that might be used nutritionally. The patient is asked to create a weekly exercise plan in terms of types of activities, duration, where the exercises occur and under whose supervision. This plan is very important and should be carried through even after leaving a residential treatment center for eating disorders.
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Published Date: June 10, 2008
Last Reviewed By: Jacquelyn Ekern, MS, LPC on June 12, 2012
Page last updated: September 17, 2012
Article Contributed by our Sponsor~ Rogers Memorial Hospital
Published on EatingDisorderHope.com, Eating Disorders Resources