Title: Exercise dependence and associated disorders: A review.
Subject(s): EXERCISE addiction
Source: Counselling Psychology Quarterly, Jun96, Vol. 9 Issue 2, p119, 11p
Author(s): Cockerill, Ian M.; Riddington, Megan E.
Abstract: Focuses on exercise addiction. Description and definition of exercise dependence; Conceptual generality of dependence; Research evidence for the existence of exercise dependence; Exercise dependence-eating disorder relationship.
AN: 9608223732
ISSN: 0951-5070
Note: This title is held by UNCG Library
Database: Academic Search Elite
Section: THEORY AND PRACTICE
ABSTRACT While the term exercise addiction has been largely rejected in favour of, for example, exercise dependence, the association of exercise with addiction stems from Glasser (1976) who differentiated between positive and negative addiction to running, being analogous to commitment and dependence, respectively. There are a number of possible explanations for exercise dependence, the more popular being based upon endorphin production and on personality. A key issue for research is to determine the threshold between commitment and dependence; that is, how much exercise is necessary to benefit mental health, and how much is too much? In addition, a holistic approach incorporating biological, social and situation-specific, as well as psychological factors, is supported in order to explain further the reasons for an exercisedependent lifestyle. While "compulsive athleticism" (Yates et al., 1994) presents a cause for concern, and although it is not yet possible to identify unequivocally the antecedents of this behaviour, it is proposed that a counselling approach to the problem of exercise dependence and associated negative self-perception may be timely.
Exercise is recognized as an important way of maintaining both physical and psychological well being, although some of the claims made by the 'exercise industry' for its importance are often tenuous and frequently extend beyond evidence available from published research. There has been a considerable interest by the media in what they tend to refer to as 'exercise addiction', perhaps because of its sinister overtones, and while it is known that some individuals do exercise excessively, which creates both physical and mental distress, there is little conclusive evidence to substantiate its widespread existence. This paper will attempt to clarify what is known about the phenomenon and

then suggest some directions and procedures for further research. The discussion focuses upon the following issues:
• description and definitions of exercise dependence;
• the conceptual generality of dependence;
• research evidence for the existence of exercise dependence;
• the exercise dependence-eating disorder relationship;
• the measurement of exercise dependence.
Description and definitions of exercise dependence
Any form of behaviour engaged in to excess is usually perceived as being abnormal and, therefore, merits treatment of some kind, especially if it is likely to have an adverse effect upon the lives of both the participant and those with whom that person lives and works.
The term used most frequently to describe these various activities is addiction and while it may be an appropriate term to describe some behavioural states, it does not lie easily alongside others. Those who are considered to be addicted to exercise, for example, will usually derive considerable benefit from it, while the lives of some exercisers may be affected negatively by this so-called addictive behaviour, illustrating the paradox that while exercise is generally beneficial, it can also have negative consequences.
The notion of spending many hours of each week, and even perhaps each day, exercising is not new and such behaviour may have its roots in asceticism, or the searching after an ideal. Endeavouring to control the body through exercise, dieting, or taking cold baths is not a recent phenomenon; indeed, both Lawrence of Arabia and Franz Kafka were believed to have been devotees of such a lifestyle, but it is only when the sought-after benefits of the activities cease to be available that such practices become questionable, and even pathological. It is possible to differentiate between those who indulge in or abstain from an activity for a purpose, such as the religious ascetics of the middle ages and the marathon runners of today, from those whose principal focus is self-actualisation through enhanced self-esteem.
A leading authority in the field of what she refers to as obligatory exercise is Yates
(1991), especially in respect of the relationship between obligatory exercise and the eating disorders. It is not mere coincidence that both sets of behaviour are synonymous with those societies where individuals are encouraged to achieve more, to 'become someone', and to develop their self-worth. For those who experience extreme pressures from such coercion, intensive exercise and eating-disordered behaviour are frequently the means adopted for taking greater control of their lives by setting specific goals, such as miles run or weight lost, and seeking to achieve them. Although it was Glasser's (1976) differentiation between positive addiction to running, promoting enhanced psychological well-being alongside physiological benefits, and negative addiction, producing considerable introspection and a state where exercise controls one's life, Little (1969) had earlier drawn attention to the negative features of exercise in identifying athlete's neurosis as a condition typically afflicting middle-aged men who persist in running despite being

injured or ill. He suggested that such individuals use exercise to offset the effects of ageing, as far as it is possible.
Addiction is probably not the best word to describe such an intense commitment to exercise, because of its negative connotations and since, in Glasser's view, one can be positively addicted to exercise also, and Dishman (1988) referred to Peele's (1981) proposed adoption of the term dependence preferred by the World Health Organization's
Committee on Addiction-Producing Drugs. Exercise-dependent persons, then, are those who are likely to organize their life round their exercise, while highly-committed, but non-dependent, individuals will organize their exercise round their lives.
Yates et al. (1983, 1994) have referred to obligatory runners to describe exercise dependent people, and to compulsive athleticism to identify the concept. Compulsion meaning that compulsive individuals do not derive any benefit from, say, running, but they are driven to do it. If they are unable to have structure in their lives, which can be rigorously controlled through exercise, they believe that their world might fall apart.
Indeed, physical activity is perceived by compulsive exercisers to be a vehicle for selfstrengthening and Yates (1991) has suggested that activity is frequently used by perfectly healthy individuals as a means of self-regulation and self-definition.
There is evidence from case studies that the majority of compulsive exercisers are high achievers in other walks of life. Each is likely to be strongly independent, enjoys being active, has a high need for achievement and a high internal locus of control.
Paradoxically, this individual tends to set goals which are then readjusted upwards and, therefore, they never actually attain them. While these characteristics can be identified fairly readily among obligatory exercisers, Sachs (1981) argued that it is difficult to attribute specific personality traits to such a person, the highly-committed runner.
The conceptual generality of dependence
It is by no means straightforward to draw a direct parallel between those who are positively addicted to, or dependent upon, exercise and individuals addicted to other activities. For example, Brown (1988) has suggested that addiction presupposes the possession of several core components, namely: salience, euphoria, tolerance, withdrawal symptoms, conflict, and relapse. At this juncture it is important to note that a fundamental difference between so-called addiction. to exercise and addiction to other behaviours is that long periods of relatively-intensive exercise require considerable physical and mental effort, whereas gambling, fruit-machine playing, and drug and alcohol addiction do not require similar degree of effort to become involved. In addition, exercise is more readily available than other potentially addictive behaviours, yet the effort required for it to become obligatory is great.
While Griffiths (1995) has suggested that these components are applicable to technological addictions, not all six have relevance for exercise. It is true that salience takes effect when the activity occupies the greater portion of a person's waking hours and, even when they are not actually exercising, those people are thinking about their next run,

weight-training session, or what to eat, and when. Euphoria has a key role to play both during and after exercise, just as it has while playing a one-arm bandit and it probably incorporates physiological markers that support the endorphin hypothesis. At the opposite end of the continuum lie withdrawal symptoms, which are likely to be common to most addictive behaviours. Stress tolerance has obvious implications for exercise, with increasing time and effort having to be invested in the activity in order to attain a similar perceived psychological benefit to that obtained earlier with less investment. Conflict among addicted exercisers and alcoholics is comparable inasmuch as both forms of behaviour can have profound negative effects upon family and work. Finally, relapse as a general component of addiction is not applicable to exercise, principally because of the effort demanded to participate. Hence it is unlikely that anyone will slip back quickly into excessive exercise behaviour.
Yates (1991) and her colleagues have suggested that obligatory runners with an eating disorder do not pursue the activity to attain a specific athletic goal, they run and do not eat as ends in themselves. Their purpose for running and not eating is to maintain a homeostasis, not only in respect of appearance, but in life generally. She has described five functions which are derived from these behaviours. Self regulation, or self control, is the primary function of obligatory exercisers and is the means by which these people are revitalized and able to stabilize and organize their lives. Self definition is said to reflect the exerciser's pursuit of an ideal self, the supreme achiever in business or the fashion industry's super model. Defence against receptive pleasure suggests that obligatory exercisers and dieters resist anything which provides gratification; they are unable to enjoy doing things, or even doing nothing, for their own sake. A spartan existence provides strength and the belief that they can be in control. Separation maintenance is the means whereby the exerciser will be able to maintain a discrete distance from others through physical activity. While using the currently-popular expression 'needing my own space' is acknowledged, the runner and the dieter become obsessed by the need for separation from others. Self hurt is yet another procedure for proving inner strength and control. The injured runner should stop, but is determined to win the battle with pain, often by working even harder.
Although the prime motive for all obligatory exercisers is self regulation and control--of athletic performance, physical appearance, or both--it has been pointed out that the difference between the committed and the compulsive exerciser is that the former is invigorated and strengthened by exercise, while the latter has begun to see exercise as work and no longer enjoys the pleasure that it once provided. What, then, is the symptomatology of the obligatory runner, dependent exerciser, compulsive exerciser, fitness fanatic, or exercise addict, whichever terminology one chooses to use? Although it has not been possible to identify unequivocally a personality typology for this individual, there are certain characteristics that each seems to possess. Most have already been reported, but it may be useful to list them in suggesting that compulsive exercisers:
• are dissatisfied with their body and/or themselves;
• will exercise to have control, but become controlled by the activity;
• do not enjoy having free time;

• become dependent on the euphoric and calming benefits of exercise;
• are avid goal-setters;
• become socially withdrawn.
It is worth pointing out, however, that Lazarus (1966) has referred to the idiosyncratic nature of stress reactions and the same may be true of individual responses to regular and intensive training. In fact, the greater majority of those who run every day, even though they may never test their fitness in races, have been shown to be healthy and psychologically well-balanced individuals.
Research evidence for the existence of exercise dependence
It is well known that a limitation to studying the effects of obligatory exercise on participants is that it is often necessary to require them to withdraw from their activity for a prescribed period of time. In an unpublished study of obligatory exercisers who attended aerobics classes (Varvel, 1992), an initial cohort of more than 200 men and women was reduced to just 22 when they were informed that the study would mean voluntary withdrawal from exercise for three days. Crossman, Jamieson & Henderson
(1987) examined the effects of training layoff by competitive runners and swimmers upon state anxiety and mood. Interestingly, there was no evidence of withdrawal symptoms when the layoff was planned, although other studies have been inclined to reveal the opposite finding. All the participants were self-reported 'addicts' of either running or swimming, yet the planned day of rest was perceived as a relief rather than a punishment. It is proposed that only when exercise is self-imposed and where training is not prescribed and supervised by a coach, that withdrawal symptoms are likely to occur.
Should exercise be missed because of an injury or having to be somewhere when training would normally take place, then symptoms of tension, depression, and possibly anger will be evident. Thus, a continuum extending from being substituted during a match, through suffering an injury to taking planned rest will produce variable withdrawal effects.
Cockerill (1995) has recently drawn attention to the importance of the so-called 'feelgood factor' associated with exercise and referred to an instrument developed by Rejeski,
Best, Griffith & Kenney (1987) for the evaluation of positive affect during exercise as reflected by mood change. However, while the effects of both moderate and vigorous exercise have usually been found to be beneficial, a number of questions remain largely unanswered which are of direct relevance to counselling for exercise prescription. First, it needs to be recognized that while some people find exercise intrinsically enjoyable, others do not, and adherence to an exercise programme that might be advocated as part of treatment for mild depression can be difficult for some individuals. Second, the form of exercise recommended needs to be considered carefully. It is likely that an aerobic activity such as swimming or running will be suggested. Some will inevitably prefer the former as it tends to make the exerciser less conspicuous than does the lone runner, who stands out doing something that others in the vicinity are not. Third, it is necessary for those prescribing exercise to recognize that the positive feelings of well being

experienced soon after exercise may remain longer for some than for others, while it is also true that one's mood can fluctuate at different stages of an exercise session.
With running perhaps being the most popular form of activity for the regular exerciser, it is natural that much of the exercise psychology research has focused upon this area. The
Profile of Mood States (POMS) questionnaire (McNair, Lorr & Droppleman, 1971) being the most-used psychometric instrument and it has been used successfully to identify mood profiles which differentiate regular and committed runners from compulsive runners. For example, Wormington, Cockerill & Nevill (1992) have shown that the
POMS is sensitive to changes in psychological well being that can occur when training load increases beyond a psychologically desirable level. Both Gondola & Tuckman
(1983) and Cockerill, Nevill & Byrne (1992) have suggested that there may be optimal levels of exercise for optimal mood. In the case of the recreational, or occasionally competitive, runner this has been shown to be around 50 km per week. Rushall (1990) developed an instrument to measure stress tolerance in athletes which is intended to offset the possibility of staleness, followed by overtraining and, ultimately, burnout. He made reference to Selye's (1950) early assertion that stress tolerance is finite, therefore once one's individual threshold is reached the benefits of exercise will become deficits.
Morris, Steinberg, Sykes & Salmon (1990) have shown that there is a phenomenon that may be termed exercise addiction, inasmuch as withdrawal from activity induces both cognitive and somatic anxiety, insomnia and perceived strain. Their explanation of the symptomatology is interesting, with one reason being that the runners--each of whom was paid 50 to stop running for two weeks--had reverted to their non-running state, which possibly involved performing activities that were uninteresting, depressing, and anxietyprovoking.
It has been suggested recently by Veale (1995) that primary exercise dependence reflects someone who does not have an associated eating disorder, who adapts their life to accommodate their exercise, and who is only unable to function effectively when prevented from exercise through injury or illness. One notable recent development has been the self-report Exercise Dependence Questionnaire of Ogden, Veale & Summers
(1996) to examine relationships between exercise behaviour and eating attitudes, the latter being evaluated using the Gamer & Garfinkel (1979) Eating Attitudes Test.
Veale (1995) has also considered recently whether there is a difference between exercise dependence and overtraining, yet another area of some confusion in the meaning of various descriptive terms. For example, Silva (1990) drew attention to differences between staleness, overtraining and burnout, which are stages of training-stress intensity.
He quite rightly pointed out that overtraining should not be confused with training overload, a recognized training principle designed to induce what is known as a training effect. There is probably a clear distinction between primary exercise dependence and overtraining, with the former fulfilling Veale's (1995) description of it as a psychological preoccupation with the need to exercise, whereas over-training occurs when 'there is repeated failure of the body's adaptive mechanisms to cope with chronic training stress,'
(Silva, 1990), with a concomitant change in mental state. Hence the latter has more of a somatic than a cognitive focus.

The exercise dependence-eating disorder relationship
An important study by Yates, Leehey & Shisslak (1983) showed that there is a positive association between obligatory runners and disordered eating to suggest that some runners tend to behave in a way that is similar to women with an eating disorder. More recently, Yates and her colleagues (Yates, Shisslak, Crago & Allender, 1994) have shown that the various studies of the running-eating relationship may be placed chronologically into three discrete categories. For example, early investigations did not tend to differentiate between level of commitment to running and showed little in common between runners and anorexic patients. Subsequent research took account of the number of miles run per week, obligatory runners were defined, and it was demonstrated that while eating was not a preoccupation among this criterion group, they were similar to anorexics in having a high need for perfection. A third generation of studies placed greater emphasis upon the psychology of the obligatory runner and began to reveal some psychological similarities between obligatory runners and those with certain forms of eating disorder. For example, there is a tendency for such runners to follow a so-called
'healthy' diet which means restricting the amount, as well as the nature, of food consumed. A further similarity is that the groups either run further or eat less, as in the case of anorexics, to exert a greater sense of control over their bodies and their lives. The need for control is also a recurring theme in studies of dependence and in a study of slotmachine gambling by Carroll & Huxley (1994), using Rotter's (1966) locus of control scale, adolescents classified as dependent gamblers scored higher on the scale than nondependent participants and even believed that they were able to control the machines.
Running is an activity that can be carried out alone and the need for independence and control evidenced in many runners tends to be mirrored in other individual sports such as gymnastics, where Cockerill & Quinton (1995) have pointed out that there is a high percentage of eating disorders by comparison with team-oriented sport participants.
However, in most respects obligatory exercisers are enthusiastic, industrious and successful people who, according to Yates et al. (1994), become caught up in a reciprocal feedback loop where hard work brings reward, which generates more effort for more success and this, in turn, interacts with their persistent and perfectionist characteristics to work or exercise even harder.
Yates (1994) and her colleagues have also drawn attention to a possible important hormonal link between exercise dependence and eating disorder. Vasopressin is an antidiuretic hormone (ADH) whose presence increases in compulsive exercisers and eating-disordered persons. It has been reported that animals injected with the hormone continued to practice well-learned behaviours, with a comparison drawn between their behaviour and obsessive-compulsive disorder. Of particular relevance to the obligatory exercise-eating disorders relationship is the fact that vasopressin is elevated in both anorexics and bulimics. This work is likely to provide useful collaborative opportunities for sport psychologists and biochemists and the early work of Van Ree, Hijman, Jolles &
DeWied (1985) could provide a basis for applied work in sport science.
The measurement of exercise dependence

It has been emphasized throughout this paper that concern for the potentially harmful effects of exercise dependence may be premature. Indeed, the majority of those who exercise daily through swimming, running, cycling, exercise-to-music classes and other forms of aerobic exercise, invariably benefit from their activity. In a carefullyconstructed 12-item Commitment to Running Scale, Carmack & Martens (1979) identified the four most frequent reasons for running under the categories: feelings when a run is missed, reasons for beginning running, present reasons for running, and benefits derived from running. They also found that those who are committed experience a euphoric, meditative state which they termed 'spinning free', a condition which Bannister
(1973), the world's first four-minute miler, referred to as 'being one with the seashore'.
Cudahy (1989), an ultra-distance runner, has expressed a similar mental state while running with these words: "There are changes in mental and physical states which are somehow related to the act of continuous movement allied to minimal rest and sleep. For instance, time loses its exactitude, hours pass like moments, but a moment may expand and hang outside any time constraint." He continues: "Of course it is hard, the physical demands are enormous, the concentration and commitment needed leave no place to hide, no reserves to harbour--but in that giving of everything I find release into peace and a great joy."
McCready & Long (1985) were aware of the importance of control among exercisers and produced their Exercise Objectives Locus of Control Scales, a 15-item inventory that evaluates three separate components, namely internal locus of control, chance, and powerful others. The value of the instrument is that it highlights the key area for identifying exercise-dependent individuals, although its use may be limited some 10 years after publication, since a high internal locus of control is now well established as an important characteristic of exercise dependence.
Corbin et al. (1987) modified the Commitment to Running Scale to include other forms of exercise. Their Commitment to Physical Activity Scale was designed principally to measure commitment across a wide range of activities at a moderate level and not to evaluate intensity of commitment by using statements such as "physical activity is the most important thing in my life". However, among the 12 statements there are several which are capable of revealing a high commitment to physical activity when answered maximally, for example, "Physical activity is vitally important to me".
If exercise dependence per se is to be measured, then a questionnaire such as that of
Ogden, Veale and Summers (1996) may be what is required. Their multidimensional scale includes self-report measures of the social effects of exercise as well as motivational factors and affective states. The importance of an eclectic approach was reinforced by Kagan & Squires (1985) who adopted an even broader focus in their attempt to discover whether obligatory exercisers possessed an 'addictive' personality.
They employed six self-report personality tests to assess dependence, compulsiveness,
Type-A personality, rigidity, need for social approval, and hostility, finding support for the notion that "in terms of personality characteristics, results were consistent with the theory that individuals can become addicted to regular exercise" (Kagan & Squires,
1985).

Throughout this review it has been shown that there is evidence to indicate that compulsive exercisers are very likely to score towards the extreme end of a scale on psychological measures such as eating control, body satisfaction, self-esteem, and selfefficacy. Ogden and her colleagues (Ogden, Veale & Summers, 1994), and especially
Kagan & Squires (1985), have led the way in this respect and reinforce the statement by
Yates et al. (1994) that "no single factor could determine an over-commitment to exercise, fitness, or diet". First, Yates and her co-workers argued that the most appropriate research model will incorporate biological, sociocultural, situational, and psychological factors. Second, research that incorporates a risk-factor model is likely to identify those at risk from over-commitment to exercise, eating control, and body image-especially thinness--if they are shown to be high achievers and perfectionists with a tendency for obsessional control.
To this end a measure of self-perception, the Self-Perception Inventory (SPI), is being developed by the first author and its psychometric properties are currently being evaluated. As well as a global measure of self-perception, the inventory incorporates six cluster-scale scores; these are exercise dependence, eating control, obsessional control, body satisfaction, self-esteem and self-efficacy, together with a social-desirability scale.
The purpose of the instrument is to address some of the issues resulting from the need for a multidimensional approach to research into compulsive overcommitment to exercise, eating control, and body shape, as well as to examine a possible association between the above behavioural factors and the cognitive components of self-esteem and self-efficacy.
In addition, with ample evidence available that over-commitment of this kind can occur among British children well before adolescence, the SPI will be used to examine the incidence of such behaviour in a series of cross-cultural studies. In the first instance, comparisons are being made between British and Greek adolescents to determine whether negative self-perception is culture-specific or an international phenomenon.
In conclusion, it is re-emphasized that while much is known about the benefits of regular exercise as a concomitant to physical and psychological well being, the criteria presently used to determine 'How much is too much' remain to be established more precisely. The distinction between those who are dependent on exercise because it helps them to function efficiently in whatever they do, and those who exercise excessively from a compulsive-obsessional standpoint, needs to be more sharply focused. Finally, because exercise, diet and health are current preoccupations of very large numbers of people in many countries, it is timely to consider the role of counselling to encourage involvement in, and adherence to, exercise. However, counselling is likely to prove especially useful for those who are perceived to be at risk from an unduly negative self-perception associated with excessive exercise and its associated disorders.
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~~~~~~~~
By IAN M. COCKERILL & MEGAN E. RIDDINGTON
School of Sport and Exercise Sciences, University of Birmingham, U
Correspondence to: Dr Ian M. Cockerill, MEd, PhD, C. Psychol., AFBPsS, School of
Sport and Exercise Sciences, University of Birmingham, Edgbaston, Birmingham B 15
2TT, UK.
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Source: Counselling Psychology Quarterly, Jun96, Vol. 9 Issue 2, p119, 11p.
Item Number: 9608223732