OVER EXCERCISING, OVER ACTIVITY
Is there such a thing as too much exercise?
By Carolyn Costin, MA, M.Ed., MFCC

What is it?
Signs & Symptoms
Approaching Someone in Need
Risk Factors
Treatment

What is Over-Exercise and Over-Activity?
Accompanying with the steady increase in the number of people with eating disorders has been a rise in the number of people with exercise disorders: people who are controlling their bodies, altering their moods, and defining themselves through their over involvement in exercise activity, to the point where instead of choosing to participate in their activity, they have become "addicted" to it, continuing to engage in it despite adverse consequences. If dieting taken to the extreme becomes an eating disorder, exercise activity taken to the same extreme may be viewed as an activity disorder, a term used by Alayne Yates in her book Compulsive Exercise and the Eating Disorders (1991).

In our society, exercise is increasingly being sought, less for the pursuit of fitness or pleasure and more for the means to a thinner body or sense of control and accomplishment. Female exercisers are particularly vulnerable to problems arising when restriction of food intake is combined with intense physical activity. A female who loses too much weight or body fat will stop menstruating and ovulating and will become increasingly susceptible to stress fractures and osteoporosis. Yet, similar to individuals with eating disorders, those with an activity disorder are not deterred from their behaviors by medical complications and consequences.

People who continue to overexercise in spite of medical and/or other consequences feel as if they can't stop and that participating in their activity is no longer an option. These people have been referred to as obligatory or compulsive exercisers because they seem unable to "not exercise," even when injured, exhausted, and begged or threatened by others to stop.

The terms pathogenic exercise and exercise addiction have been used to describe individuals who are consumed by the need for physical activity to the exclusion of everything else and to the point of damage or danger to their lives. The term anorexia athletica has been used to describe a subclinical eating disorder for athletes who engage in at least one unhealthy method of weight control, including fasting, vomiting, diet pills, laxatives, or diuretics. For the rest of this chapter, the term activity disorder will be used to describe the overexercising syndrome as this term seems most appropriate for comparison with the more traditional eating disorders.

Signs and Symptoms of Activity Disorder
The signs and symptoms of activity disorder often, but not always, include those seen in anorexia nervosa and bulimia nervosa. Obsessive concerns about being fat, body dissatisfaction, binge eating, and a whole variety of dieting and purging behaviors are often present in activity disordered individuals. Furthermore, it is well established that obsessive exercise is a common feature seen in anorexics and bulimics; in fact, some studies have reported that as many as 75 percent use excessive exercise as a method of purging and/or reducing anxiety. Therefore, activity disorder can be found as a component of anorexia nervosa or bulimia nervosa or, although there is yet no DSM diagnosis for it, as a separate disorder altogether.

There are many individuals with the salient features of an activity disorder who do not meet the diagnostic criteria for anorexia nervosa or bulimia nervosa. The overriding feature of an activity disorder is the presence of excessive, purposeless, physical activity that goes beyond any usual training regimen and ends up being a detriment rather than an asset to the individual's health and well-being. In her book, Compulsive Exercise and the Eating Disorders, Alayne Yates lists the proposed features of an activity disorder, a summary of which is listed below.

Features of an Activity Disorder

  • The person maintains a high level of activity and is uncomfortable with states of rest or relaxation.
  • The individual depends on the activity for self-definition and mood stabilization.
  • There is an intense, driven quality to the activity that becomes self-perpetuating and resistant to change, compelling the person to continue while feeling the lack of ability to control or stop the behavior.
  • Only the overuse of the body can produce the physiologic effects of deprivation (secondary to exposure to the elements, extreme exertion, and rigid dietary restriction) that are an important component perpetuating the disorder.
  • Although activity disordered individuals may have coexisting personality disorders, there is no particular personality profile or disorder that underlies an activity disorder. These persons are apt to be physically healthy, high-functioning individuals.
  • Activity disordered persons will use rationalizations and other defense mechanisms to protect their involvement in the activity. This may represent a preexisting personality disorder and/or be secondary to the physical deprivation.
  • Although there is no particular personality profile or disorder, the activity disordered person's achievement orientation, independence, self-control, perfectionism, persistence, and well- developed mental strategies can foster significant academic and vocational accomplishments in such a way that they appear as healthy, high-functioning individuals.
Activity disorders, like eating disorders, are expressions of and defenses against feelings and emotions and are used to soothe, organize, and maintain self-esteem. Individuals with the eating disorders (anorexia nervosa and bulimia nervosa) and those with activity disorders are similar to one another in many respects. Both groups attempt to control the body through exercise and/or diet and are overly conscious of input versus output equations. They are extremely committed individuals and pride themselves on putting mind over matter, valuing self-discipline, self-sacrifice, and the ability to persevere.

They are generally hard-working, task-oriented, high-achieving individuals who have a tendency to be dissatisfied with themselves as if nothing is ever good enough. The emotional investment these individuals place on exercise and/or diet becomes more intense and significant than work, family, relationships, and, ironically, even health. Those with activity disorders lose control over exercise just as those with an eating disorder lose control over eating and dieting, and both experience withdrawal when prevented from engaging in their behaviors.
Individuals with anorexia nervosa and bulimia nervosa and those with activity disorders usually score high on the EDI subscales of perfectionism and asceticism and have similar distortions in their cognitive (thinking) styles. The following list includes examples of the thinking patterns of people with activity disorders that are similar to the mental distortions in those with eating disorders.

Cognitive Distortions in Activity Disorder
Dichotomous, Black and White Thinking

  • If i don't run, I can't eat.
  • I either run an hour or it's not worth it to run at all.
  • Overgeneralization

    • Like my mom, people who don't exercise are fat.
    • I either run an hour or it's not worth it to run at all.
    Magnification
    • If I can't exercise, my life will be over.
    • If I don't work out today, I'll gain weight.
    Selective Abstraction
    • If I can go to the gym, I am happy.
    • I feel great when I exercise, so if I exercise I'll never be depressed.
    Superstitious Thinking
    • I must run every morning or something bad will happen.
    • I must do 205 sit-ups every night.
    • I can't stop at 1 hour and 59 minutes, it has to be exactly 2 hours, so when the fire alarm went off I couldn't get off the Stairmaster, I had to keep going, even if the gym was burning down.
    Personalization
    • People are looking at me because I'm out of shape.
    • People admire runners.
    • I am a runner, it's who I am, I could never give it up.
    Arbitrary Inference
    • People who exercise get better jobs, relationships, and so on.
    • People who exercise don't get sick as much.
    Discounting
    • My doctor tells me not to run, but she is flabby so I don't listen to her.
    • No pain, no gain.
    • Nobody really knows the effects of not having a period anyway, so why should I worry?

    Physical Symptoms of Activity Disorder
    A key in determining if a person is developing an activity disorder is if she has the symptoms of overtraining (listed below) yet persists with exercise anyway. Overtraining syndrome is a state of exhaustion in which individuals will continue to exercise while their performance and health diminish. Overtraining syndrome is caused by a prolonged period of energy output that depletes energy stores without sufficient replenishment.

    Symptoms of Over-Training
    • Fatigue
    • Reduction in performance
    • Decreased concentration
    • Inhibited lactic acid response
    • Loss of emotional vigor
    • Increased compulsivity
    • Soreness, stiffness
    • Decreased maximum oxygen uptake
    • Decreased blood lactate
    • Adrenal exhaustion
    • Decreased heart rate response to exercise
    • Hypothalamic dysfunction
    • Decreased anabolic (testosterone) response
    • Increased catabolic (cortisol) response (muscle wasting)
    The only cure for the above symptoms is complete rest, which may take a few weeks to a few months. To a person with activity disorder, resting is like giving up or giving in. This is similar to an anorexic who feels like eating is "giving in." When giving up their exercise behaviors, those with activity disorder will go through psychological and physical withdrawal, often crying, yelling, and making statements like
    • I can't stand not exercising, it's driving me crazy, I'd rather die.
    • I don't care about the consequences, I have to work out or I'll turn into a fat blob, hate myself, and fall apart.
    • This is worse torture than any effects of the exercise, I feel like I'm dying inside.
    • I can't even stand being in my own skin, I hate myself and everyone else.

    It is important to note that these feelings diminish over time but need to be carefully attended to.

    Approaching an Individual with an Activity Disorder
    In January 1986, the Physician and Sports Medicine Journal discussed the subject of pathogenic (negative) exercise in athletes and listed recommendations for approaching athletes practicing one or more pathogenic weight control techniques. The recommendations can be reformulated and extended for use when approaching individuals with activity disorders who are not necessarily considered athletes.

    Guidelines for Approaching the Activity Disordered Individual

    • A person who has good rapport with the individual, such as a coach, should arrange a private meeting to discuss the problem in a supportive style.
    • Without judgment, specific examples should be given regarding the behaviors that have been observed that arouse concern.
    • It is important to let the individual respond but do not argue with him or her.
    • Reassure the individual that the point is not to take away exercise forever but that participation in exercise will ultimately be curtailed through an injury or by necessity if evidence shows that the problem has compromised the individual's health.
    • Try to determine if the person feels that he or she is beyond the point of being able to voluntarily abstain from the problem behavior.
    • Do not stop at one meeting; these individuals will be resistant to admitting that they have a problem, and it may take repeated attempts to get them to admit a problem and/or seek help.
    • If the individual continues to refuse to admit that a problem exists in the face of compelling evidence, consult a clinician with expertise in treating these disorders and/or find others who may be able to help. Remember that these individuals are very independent and success oriented. Admitting they have a problem they are unable to control will be very difficult for them.
    • Be sensitive to the factors that may have played a part in the development of this problem. Activity disordered individuals are often unduly influenced by significant others and/or coaches who suggest that they lose weight or who unwittingly praise them for excessive activity.

    Risk Factors
    One outstanding difference between the eating disorders and activity disorders seems to be that there are more males who develop activity disorders and more females who develop eating disorders. Exploring the reason for this may provide a better understanding of both. What are the causes that contribute to the development of an activity disorder? Why do only some individuals with eating disorders have this syndrome and others who have this syndrome don't have eating disorders at all? What we do know is that the risk factors for developing an activity disorder are varied, including sociocultural, family, individual, and biological factors, and are not necessarily the same ones that cause the disorder to persist.

    Sociocultural
    In a society that places a high value on independence and achievement combined with being fit and thin, involvement in exercise provides a perfect means for fitting in or gaining approval. Exercise serves to enhance self-worth, when that self-worth is based on appearance, endurance, strength, and capability.

    Family
    Child-rearing practices and family values contribute to an individual choosing exercise as a means of self-development and recognition. If parents or other caregivers endorse these sociocultural values and they themselves diet or exercise obsessively, children will adopt these values and expectations at an early age. Children who learn not only from society but also from their parents that to be acceptable is to be fit and thin may be left with a narrow focus for self-development and self-esteem. A child reared with phrases such as "no pain, no gain," may endorse this attitude wholeheartedly without the proper maturity or common sense to balance this notion with proper self- nurturing and self-care.


    Individual
    Certain individuals seem predisposed to need a high level of activity. Individuals who are perfectionists, achievement oriented, and have the capacity for self-deprivation will be more likely to seek out exercise and become addicted to the feelings or other perceived benefits the exercise provides. Additionally, individuals who develop activity disorder seem outwardly independent, unstable in their view of themselves, and lacking in their ability to have fully satisfying relationships with others.


    Biological
    Just as with eating disorders, researchers are exploring what biological factors may contribute to activity disorders. We know that certain individuals have a biologically based predisposition to obsessive thoughts, compulsive behaviors, and, in women, amenorrhea. We know that in animals the combination of food restriction and stress causes an increase in activity level and, furthermore, that food restriction with increased activity can cause the activity to become senseless and driven.

    Furthermore, parallel changes have been detected in the brain chemicals and hormones of eating disordered females and long-distance runners that may explain how the anorexic tolerates starvation and the runner tolerates pain and exhaustion. In general, activity disordered men and women seem to be different biochemically than nondisordered individuals and are more easily led and trapped into a cycle of activity that is resistant to intervention.

    Treatment for an Activity Disorder
    The principles of treatment for individuals with activity disorders are similar to those with eating disorders. Medical issues must be handled, and residential or inpatient treatment may be necessary to curtail the exercise and to deal with depression or suicidality, but most cases should be able to be treated on an outpatient basis unless the activity disorder and an eating disorder coexist. This combination can present a serious situation rather quickly. When lack of nutrition is combined with hours of exercise, the body gets broken down at a rapid pace, and residential or inpatient treatment is often required.
    Sometimes hospitalization is encouraged to patients as a way to relieve the vicious cycle of nutrient deprivation combined with exercise before a breakdown occurs. Activity disordered individuals often recognize that they need help to stop and know that they cannot do it with outpatient treatment alone. Eating disorder treatment programs are probably the best choice for hospitalizing those with activity disorder. An eating disorder facility that has a special program for athletes or compulsive exercisers would be ideal. (See the description of The Monte Nido Residential Treatment Facility on pages 251–274).

    Therapy for an Activity Disorder
    It is important to keep in mind that activity disordered people tend to be highly intelligent, internally driven, independent individuals. They will most likely resist any kind of vulnerability such as going for treatment unless they become injured or face some kind of ultimatum. Excessive activity protects these individuals against desiring to get close, to take in something from another, or to depend on anyone.

    Therapists will have to maintain a calm, caring stance with the goal of helping the individual define what he or she needs, rather than focusing on taking things away. Another therapeutic task is to help the individual receive and internalize the soothing functions the therapist can provide, thus promoting relationships over activity.

    THERAPEUTIC ISSUES TO DISCUSS IN THE TREATMENT OF ACTIVITY DISORDER

    • Overactivity of mind or body
    • Body image
    • Overcontrol of the body
    • Disconnection from the body
    • Body care and self-care
    • Black-and-white thinking
    • Unrealistic expectations
    • Tension tolerance
    • Communicating feelings
    • Ruminations
    • The meaning of rest
    • Intimacy and separateness