Exercise addiction: causes, symptoms, diagnosis and treatment

By Cristiano Antonino On May 30, 2023

Exercise addiction, although not yet included in the Diagnostic and Statistical Manual of Mental Disorders (DSM 5), has been defined as a behavioural addiction (Demetrovics and Griffiths, 2005) as it manifests itself with distinctive features of this problem (prominence, changes in mood, tolerance, withdrawal, personal conflict and relapse)

The study on exercise addiction

The authors who have studied this phenomenon have distinguished two forms in which it can occur: in the case where exercise addiction manifests itself in the absence of other psychological problems, we speak of primary exercise addiction; in the (more frequent) case where it manifests itself as a consequence of other psychological dysfunctions (typically eating disorder – DCA), we speak of secondary addiction.

The reason that drives the person addicted to exercise to overtraining, in the case of a primary form, is generally to avoid the perception of ‘negative’ emotions, feelings or thoughts (Szabo, 2010), although the addicted person is hardly aware of this process.

Addiction thus takes the form of an ‘escape’ from a stressful condition, which causes discomfort in a persistent manner and which the person feels he or she cannot cope with otherwise.

In cases where excessive exercise is instead associated with an eating disorder (in a secondary addiction framework), the underlying motivation will rather be weight loss (usually in conjunction with a strict diet or dietary restrictions).

It is therefore evident that primary and secondary addiction have a different aetiology, although they manifest themselves with similar symptoms and consequences.

To date, there is much debate in the literature concerning the clinical legitimacy of the diagnosis of primary addiction, although there are documented cases (Griffiths, 1997) in which eating disorders are completely absent.

In addition to the differential diagnosis just described, in order to establish the clinical existence of a primary exercise dependency, it is also necessary to carefully examine the characteristics, frequency and intensity of withdrawal symptoms, as negative psychological feelings are reported by all those who exercise regularly when they are unable to do so for some reason (Szabo et al., 1996).

The intensity of withdrawal symptoms is a crucial factor in distinguishing those who exercise regularly from those who are addicted to exercise.

Comorbidity in exercise addiction

There is a close association between exercise addiction and eating disorders (Sussman et al., 2001).

Depressive and anxiety disorders are also often observed in comorbidity with this phenomenon.

While several studies have shown that pathological eating behaviour often (if not always) accompanies excessive levels of physical activity, it is also true that individuals with exercise addiction may present excessive preoccupation with their body image, weight and diet control (Blaydon and Lindner, 2002).

This coexistence of pathologies often makes it difficult to determine which is the primary disorder.

Causes of exercise addiction

Physiological hypotheses

According to the ‘runner’s high’ hypothesis, as a result of intensive running training, runners do not experience fatigue or feel exhausted but rather experience an intense sense of euphoria described as a ‘feeling of flying’ or being able to ‘make effortless movements’.

This feeling has been attributed to the brain activity of beta-endorphins that are activated during a running session.

According to another hypothesis, based on research carried out by Thompson and Blanton (1987), the effect of training is accompanied by a reduction in the activity of the sympathetic system at rest and thus a general decrease in alertness (subjectively felt as drowsiness and asthenia).

The reduction in alertness is coped with by athletes through exercise, but as the effects of this are only temporary, further training sessions are systematically required.

According to a third hypothesis, the pleasant psychological condition characterised by the relaxing and anxiolytic effects of exercise prompts people to resume exercising as soon as they begin to feel anxious again.

Increased anxiety may lead to a greater need to exercise and thus to more frequent and intense training sessions.

In stressful situations, the frequency, duration and intensity of exercise may gradually increase as an antidote to stress and anxiety (i.e. a condition called ‘tolerance’ develops).

Psychological hypotheses

The affective regulation hypothesis with regard to exercise addiction suggests that exercise has a dual effect on mood (Hamer and Karageorghis, 2007): it increases positive emotions and contributes to the improvement of mood (understood as a psychological state that lasts for many hours or days) and reduces the impact of unpleasant emotions.

However, the regulation of affectivity through training induces only temporary effects: following periods of abstention from exercise, severe feelings of deprivation or actual withdrawal symptoms may develop that only find relief with the resumption of exercise.

Typically, between training sessions, one begins to reduce rest periods to prevent the onset of withdrawal symptoms.

People who exercise regularly may be motivated by the negative reinforcement just described (avoidance of withdrawal symptoms) or by positive reinforcement (the ‘runner’s high’).

Exercise motivated by negative reinforcement is typical for people with addictions: in these cases, the person feels that they ‘must’ do it, not that they ‘want to’.

Psychotherapy of exercise addiction

Two psychotherapeutic interventions have proven effective in the treatment of various types of behavioural and substance addictions: motivational interviewing (Miller and Rollnick, 2002) and Cognitive Behavioural Psychotherapy.

There are currently no clinical trials that have evaluated their usefulness in exercise addiction, but these approaches may also be effective with respect to this type of addiction (Rosemberg & Feder, 2014).

In exercise addiction, as in other conditions, accurate diagnosis and differential diagnosis are the cornerstones of an effective treatment plan: concomitant disorders must be considered and all co-existing conditions must be treated.

The presence of other associated disorders can in fact establish a vicious circle that worsens the patient’s condition. Furthermore, it is important to ascertain that a personality disorder is not present as, in such cases, a targeted therapy for the personality disorder can be decisive for the exercise addiction.

It is important that the treatment clarifies what caused the onset of the addiction and what factors and situations lead to the persistence of the disorder.

Furthermore, it is necessary to work with the patient so that he or she develops more appropriate alternative behaviour and effective strategies to replace excessive exercise.

A typical goal of psychotherapeutic treatment may be a return to moderate or controlled exercise.

In some cases, the implementation of different forms of exercise may be recommended.

Finally, the use of psycho-educational programmes can also be an effective component of the treatment of exercise addiction, as there is often insufficient knowledge of the negative effects of extreme exercise on health, the body’s adaptation mechanism to exercise and the need to rest between exercise sessions.