Over-exercising, 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 overinvolvement 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 u and se 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 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.

Medical Reference from "The Eating Disorders Sourcebook"

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.
• Not exercising means you are lazy.

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

The following section discusses a problem that is the polar opposite of too much activity exercise resistance. "Exercise resistance" is a fairly new term used to describe an intense reluctance to exercise, particularly seen in women.

Eating Disorders: Exercise Resistance in Women

by Francie White, M.S., R.D.

Just as binge eating disorder lies at the opposite end of the disordered eating spectrum from anorexia nervosa, exercise resistance is an activity disorder at the opposite end of the spectrum from addictive or compulsive exercise. As a dietitian specializing in eating disorders, I have noticed a common phenomenon in women with emotional overeating patterns, many of whom qualify as having binge eating disorder.

These women often suffer from entrenched inactivity patterns that are resistant to intervention or treatment. Many professionals assume that inactivity is due to factors such as a harried lifestyle, industrialization, laziness, and, in overweight individuals, the discouraging factor of physical difficulty or discomfort in moving. Behavior modification counseling programs, use of specialized personal trainers, and other types of motivational strategies to encourage a physically active lifestyle seem to be ineffective.

Over a three-year period, beginning in 1993, I began exploring what I call "exercise resistance" in a binge eating disordered population of six groups of ten to twenty women each. The following information is what emerged from studying these groups.

For many women with a history of body image problems, moderate to severe overeating histories, and/or a history of repeated attempts at weight loss, exercise resistance is a common syndrome that requires specialized treatment. Remaining inactive or physically passive appears to be an important aspect of the psychological defense system within the eating disorder itself, providing a balance of sorts from the psychological discomfort that accompanies exercising. This psychological discomfort varies from moderate to severe anxiety and is related to a profound sense of physical and emotional vulnerability.

Underactivity or physical passivity appears to offer a sense of control over body and feelings, just as disordered eating and over-exercise do. Exercise resistance may simply be another component in the menu of options from which men and women find themselves suffering in this time of epidemic eating and body image problems. If we are to begin to look at exercise resistance as a separate syndrome worthy of specialized understanding and treatment, here are some factors to consider.

WHAT DIFFERENTIATES THE EXERCISE RESISTANT INDIVIDUAL FROM SOMEONE WITH SIMPLE LOW MOTIVATION OR POOR EXERCISE HABITS?

• The individual strongly resists any suggestion to become more physically active (barring any physical impairments and given several workable options).
• The individual reacts with anger, resentment, or anxiety to any suggestion to become more physically active.
• The individual describes experiencing moderate to severe anxiety during physical activity.

RISK FACTORS FOR DEVELOPING EXERCISE RESISTANCE

• A history of sexual abuse of any kind at any age.
• A history of three or more weight loss diets.
• Exercise used as a component of a weight loss regimen.
• A larger body size as a boundary or defense against unwanted sexual attention or sexual intimacy (be it conscious or unconscious).
• Parents who forced or overencouraged exercise, especially if the exercise was to compensate for perceived, or actual, overweight in the child.
• Early puberty or development of large breasts and/or early significant weight gain.

THE MEANING OF EXERCISE RESISTANCE

To better understand exercise resistance, we can borrow from our understanding of how weight loss diets have affected eating behavior. We know that weight loss diets are a key aspect in the historical mistreatment of overweight individuals, in many cases actually contributing to binge eating, which increases over time. Responses from the women surveyed support the view that exercise resistance may be an unexpected, unconscious backlash against the current cultural emphasis on slimness and the overfocus on the symptom; for example, the weight, instead of the inner psychodynamic issues.

QUESTIONS TO ASK THE INDIVIDUAL WITH EXERCISE RESISTANCE

• What feelings and associations emerge for you at hearing the term exercise? Why?
• When did being physically active change for you from "playing" as a child to "exercise"? When did it shift from something natural, an activity you did spontaneously (for example, from an internal drive), to something you felt you should do?
• Has physical activity ever been something that you did to control your weight? If so, how was that for you, and how has it affected your motivation to exercise?
• How did your exercise attitudes change during and after puberty?
• Does being physically active relate in any way to your sexuality? If so, how?

A theme ran through the comments of the women studied that echoes the information in chapter 4, "Sociocultural Influences on Eating, Weight, and Shape." Most of the women expressed that they felt extremely degraded and vulnerable by their direct experiences of being encouraged to exercise as a means to achieve an acceptable body. Instead of being encouraged to exercise for fun, exercise for these women was connected to body image, or the pursuit of an acceptable body.

Many of the women's stories included experiences of deep humiliation, public or otherwise, at being overweight and unable to achieve this illusive standard. Other women actually acquired a lean, thinner body and experienced unwanted sexual objectification by peers and adults. In a significant number of the women, rapes and other sexual abuse occurred after weight loss, and, for many, sexual abuse was connected to the onset of exercise resistance and binge eating.

Many women are confused as they experience the desire to be thinner while at the same time feeling anger and resentment at what they have been told they have to do to achieve it, for example, exercise. For some, exercise resistance and weight gain may be symbolic boundaries, expressing a rebellious refusal to patronize a system in which the playing field for women is not about sports, or even achievement, but about sexual attractiveness to men"We'll play, you pose." This system is one in which women and men equally participate and perpetuate. Women objectify one another and themselves right along with men.

The above discussion of exercise resistance by Francie White was written specifically for inclusion in this book. It is important to understand this area as another disorder on the continuum of those being discussed. The understanding and treatment of exercise resistance are similar to that of eating disorders in that the therapist must impart an empathy for the need for the behaviors instead of trying to take them away.

When working with an exercise resistant individual, one must explore and resolve the source of the resistance, such as underlying anxiety, resentment, or anger. The goal of treatment is that the individual will be able to become physically active by choice, not coercion. It is important to begin by validating the resistance and even in some cases prescribing it, making statements such as:

• It is important that you can choose to not exercise.
• Resisting exercise serves a valuable function for you.
• Continuing not to exercise is one way for you to keep saying "no."

By making these comments, the therapist helps validate the need for the resistance and eliminates the obvious conflict.

It is important to clarify that the issue of addressing exercise resistance is to help individuals who are compelled to "not exercise" just as we try to help others who are compelled to do so, both of which leave the behavior out of the realm of choice. Little attention has been paid to exercise resistance, but it is clear that those who have it, like those with exercise obsession or disordered eating, appear to be in a love-hate relationship with their bodies; derive inner psychological or adaptive functions from their behavior; and are involved in a struggle not just with food or exercise but with the self.

For an examination of the struggle with self and other dynamics that result in eating disorders, the next three chapters will deal with the main areas in which the causes of eating disorders are understood, with a chapter devoted to each of the following:

SOCIOCULTURAL

A look at the cultural preference for thinness, and the current epidemic of body dissatisfaction and dieting, with an emphasis not only on weight loss but also on the ability to control one's body as a means of gaining approval, acceptance, and self-esteem.

PSYCHOLOGICAL

The exploration of underlying psychological problems, developmental deficits, and traumatic experiences such as sexual abuse, which contribute to the development of disordered eating or exercise behaviors as coping mechanisms or adaptive functions.

BIOLOGICAL

A review of the current information available on whether or not there is a genetic predisposition or biological status that is at least partly responsible for the development of an eating or activity disorder.

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