Understanding the Role of Compulsive Exercise in Anorexia Nervosa:
A Grounded Theory Study
Summary of Study Findings
Rationale for the study
Exercise is a highly prevalent feature of Anorexia Nervosa (AN) (Davis et al., 1997), and is
associated with increased severity of the eating disorder and a poorer prognosis (Strober
et al., 1997; Shroff et al., 2006). It is therefore important that the role of exercise within AN
is understood. Exercise in AN has been traditionally viewed using frequency-based criteria
and termed ‘excessive exercise’ (Davis et al., 1997). Recent research, however,
recognises the importance of compulsive aspects of exercise, and has found compulsive
exercise to be the type of exercise most strongly associated with eating disorder
symptomology (Meyer et al., 2011; Boyd et al., 2007). Compulsive exercise is a type of
exercise associated with concerns about body weight and shape. It also involves
continuing to exercise to cope with difficult feelings that occur when not exercising, or
continuing to exercise to avoid possible negative consequences of stopping exercising
(Meyer et al., 2011).
Existing research and psychological theory suggests compulsive exercise in AN is likely to
have a number of functions, including management of body weight and shape, emotional
regulation, management of beliefs relating to feared consequences of altering exercise,
and even regulation of negative self-beliefs (e.g. Meyer et al., 2011; Cooper, 2012). This
research does not, however, provide a full account of the role of compulsive exercise in
AN. Due to this, and because no qualitative research in the area has been undertaken, a
qualitative study which aimed to investigate the role of compulsive exercise in AN was
undertaken.
Method
The study used modified grounded theory methodology (Charmaz, 2006). Ten women,
who were exercising compulsively, were recruited from three NHS eating disorder
services. Seven women met diagnostic criteria for AN (restricting subtype), and three met
the study criteria for AN-type Eating Disorder Not Otherwise Specified (EDNOS-AN).
The women were interviewed about their experiences of exercise in the past and present,
and their expectations for the future. The study data was analysed according to grounded
theory, and a theoretical model was developed based on what participants had said about
their experiences.
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Results
The model developed will now be explained, and displayed in pictorial form in Figure 1
below. The model explains the process by which compulsive exercise seems to become
integrated into AN.
Participants identified that exercise was not valued during their early history, and taking
part in sports or exercise was generally limited. Consequently, it seems participants’
motivation for exercising came from a desire for fitness or body change, which was
encouraged by family, friends and wider society. Alongside this, participants recalled
experiences of exercising for recreation, where they engaged in some sporting activities
for social reasons. Such experiences may have allowed participants to develop an
awareness of the features of enjoyable exercise, but primarily promoted an understanding
of exercise as important for fitness and body change.
It seemed that later on participants made a conscious decision to lose weight or improve
their fitness, and chose exercise for achieving this. This led them to enter into a process of
their exercise becoming engrained, changing in its purpose, characteristics and intensity,
and becoming associated with dietary restriction. Thus exercise seemed to join with
dietary restriction to facilitate an episode of AN developing.
Participants described their exercise feeling inescapable. This involved it being an
essential activity, which was non-negotiable and beyond control, target-driven, inflexible,
and private and shameful in its nature. As exercise was inescapable in this manner, it
became central in participants’ AN. This involved exercise being a driving force in their
eating disorder, exercise having a complex reciprocal relationship with eating, and
managing body weight and shape being the core role for exercise. Over time, participants
discovered other roles for exercise, including exercising to manage their emotions, to
improve their view of themselves, and feel in control of life. These other functions of
exercise became equally important as managing weight and shape, and a vicious cycle
seemed to form where aspects of exercise served to reinforce one another, meaning that
exercise continued to feel inescapable.
Exercise being central in their daily lives led participants to spend time taking stock of their
exercise, evaluating its helpfulness and identifying that it limited their lives. This led some
to work towards change, whereas others attempted exercising differently following an
enforced change in circumstances, such as a hospital admission. Regardless of how
participants began working towards change, the experience led them to reflect on their
exercise further. When attempting change, participants were looking to exercise in a
manner which resembled their previous experiences of exercising for recreation. This often
occurred while attempting changes in eating, and thus recovery from AN. Participants
identified negative consequences of exercising differently, such as fearing weight gain
when exercising differently, feeling distressed or anxious when prevented from exercising,
and viewing themselves negatively when prevented from exercising. These negative
consequences related to the roles for exercise participants identified, and resulted in their
efforts to change being blocked, and exercise continuing to feel inescapable.
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Early and contextual factors
Exercise becoming engrained
Exercise becoming associated
with dietary restriction and body
change
Exercise not being valued
during early history
Exercise becoming target-driven
and embedded
Sociocultural encouragement to
exercise for fitness or body change
Exceptions: Exercising for recreation
Exercise becomes central in AN
Exercise is a driving force in AN
Exercise is inescapable
Negotiating change
Negative
consequences
of exercising
differently
essential
target-driven
inflexible
private and shameful
Exercise and eating are reciprocal
Exercising to manage body
weight and shape
Later roles for exercise
Exercising to regulate emotional
experience
Working towards
change
Exercising to improve view of self
Exercising to feel in control of life
Taking stock of exercise
Evaluating exercise
Exercise limits life
Figure 1: A theoretical model illustrating how compulsive exercise becomes integrated into AN
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Conclusion
In summary, the model developed explains a process whereby individuals vulnerable to
compulsive exercise move through a time-period when exercise becomes engrained,
leading to exercise feeling inescapable in the context of AN, and developing a central role
in the eating disorder. The initial role for compulsive exercise seems to be managing body
weight and shape, and later roles including managing emotions, improving one’s self-view,
and feeling in control are discovered over time and become equally important.
Parallels can be drawn between the model developed and existing psychological
explanations of compulsive exercise (e.g. Meyer et al., 2011). This study makes a unique
contribution as it offers a developmental explanation of compulsive exercise in AN, and
provides information about the experience of compulsive exercise, and the complex
relationship between exercise and dietary restriction. The findings identify a need for
compulsive exercise to be addressed as a central aspect of AN in clinical practice, where
clinicians should help patients understand the relationship between exercise and other
aspects of their eating disorder, and support them in making changes. Future research
should investigate whether lack of early exercise experiences leads individuals to be
vulnerable to developing AN with a compulsive exercise component, and explore the
processes by which exercise and disordered eating interact to facilitate the development of
AN.
References
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Charmaz, K. (2006). Constructing grounded theory: A practical guide through qualitative
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Strober, M., Freeman, R., & Morrell, W. (1997). The long-term course of severe anorexia
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Lead Researcher: Sally Clarke (Trainee Clinical Psychologist)
sally.clarke@hmc.ox.ac.uk
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