When Exercise Becomes Too Much of a Good Thing

Exercise offers numerous benefits both to the mind and body, and it is one of the best things we can do to improve our overall health. Beyond the obvious physical benefits, it boosts the mood, provides a means for socializing with others, and offers a structure and routine that many people crave. 

But too much exercise can lead to health problems, causing physical and psychological harm. Over time, overuse injuries may crop up, and if working out becomes a compulsion it can put a strain on work, relationships, and daily commitments.

We spoke to Melissa Ertl, PhD, psychologist and postdoctoral research fellow at the New York State Psychiatric Institute and Columbia University Irving Medical Center, who has studied exercise addiction to better understand its clinical presentation and its correlates—and to identify when your Peloton habit may be cause for concern.

What is exercise addiction and how closely related is it to psychiatric conditions like anorexia and bulimia?

Although there is no formal clinical diagnosis, exercise addiction is often defined as the craving of physical activity that results in extreme exercise that significantly interferes with important activities, occurs at inappropriate times or in inappropriate settings, or occurs despite injury or other medical complications. Research has found exercise addiction to be closely related to disorders like anorexia, bulimia, and body dysmorphia. Some people who have an exercise addiction may also have eating behaviors linked with anorexia and bulimia.

In our research, we found two groups of young adults with a relatively high percentage of individuals at clinical risk for exercise addiction: One group also tended to engage in other disordered eating behaviors at high rates—including diet pill and laxative use, binge eating, purging, and exercising for more than 60 minutes per session to lose weight, as well as heavy alcohol use—and the second group did not engage in the other risk behaviors at high rates, despite reporting high severity of symptoms of exercise addiction. Interestingly, studies suggest that individuals with a diagnosed eating disorder are 3.5 times as likely to demonstrate exercise addiction than individuals without an eating disorder.

Is there any debate around adding exercise addiction to the DSM-V?

Although exercise addiction is noted in the category of substance-related and other addictive disorders as a type of repetitive behavior or potential behavioral addiction that merits further investigation, the DSM-5 notes that there is insufficient peer-reviewed evidence to establish the diagnostic criteria, etiology, and course descriptions needed to identify exercise addiction behaviors as constituting a distinct and specific mental disorder. In DSM-5, exercise addiction behaviors are considered symptoms of other recognized behavioral disorders. In addition to eating disorders, some people with nicotine, alcohol, or other drug use disorders can commonly experience exercise addiction, as can people who engage in compulsive sex or spending. Researchers have also theorized that exercise addiction has some obsessive-compulsive dimension, given the compulsion to engage in exercise even if contraindicated or harmful.

What kind of treatments have proven to be helpful for those struggling with exercise addiction?

There has been little study of specific treatments for exercise addiction. However, psychotherapy and interventions informed by the strong empirically-supported traditions of theories of behavior change would be a good starting point. Some good rules of thumb I would recommend to anyone are to avoid exercise if you are injured or feeling unwell and to have a discussion with your medical provider if you are concerned about how much you should be exercising. If you notice that exercise has an outsized or unhealthy importance in your life, psychotherapy with a trusted mental health professional may help you understand the role of exercise in your life and explore how to find a healthier balance that supports your well-being.

In a recent article in the journal Substance Use and Misuse, you draw the connection between exercise addiction and behaviors such as alcohol misuse. Can the behaviors be treated similarly? 

Similar to some other addictive behaviors, exercise activates the dopamine reward system and can contribute to stress-reduction and a rush of endorphins and cannabinoids that produce a natural “runner’s high,” or a euphoric feeling post-exercise. In our recent study, around 6% of college students clustered into a group with some of the highest levels of reported impulsivity, disordered eating, alcohol use, and exercise addiction compared to the other groups. Because of the co-occurrence of these behaviors, therapy might focus on underlying problems that link the behaviors, like the personality trait of impulsivity, which has been established as a contributing factor to a range of health risk behaviors. In this case, therapy focused on addressing a client’s impulsive behaviors and what gives rise to them may be a helpful place to start.

Does exercise addiction have a peak and does it wane as people get older?

Research has leaned toward focusing on triathletes and elite athletes, who tend to have high levels of exercise addiction. As for age groups, a recent review found that young adults also have high rates of exercise addiction, perhaps due to the importance young people may attribute to body image. To date, there is no known peak for exercise addiction. There is so much we don’t know, given that exercise addiction is an emerging health concern that has only been named and studied in the last few decades. Rates of exercise addiction vary, but the review estimated 3-7% prevalence among regular exercisers with higher rates among elite athletes.

While the current “body positive” movement has improved messaging around different shapes and sizes, do you think it has had an impact on a personal level? What does recovery look like?

Thanks to body positive movements, there is an increasingly mainstream understanding of the hugely detrimental mental health impacts of sizeism and fatphobia. Poor body image continues to be a factor that is linked with exercise addiction and disordered eating behaviors. Engaging with communities and media that are size-inclusive and affirming is immensely valuable for people in coming to understand their body not through a specific societal lens of what is an “ideal body” based on social and cultural conventions for attractiveness, youth, or thinness, among other qualities—but through a more liberated sense of self and view of the body as something to be appreciated, cared for, and worthy of esteem. Body image concerns are something that psychotherapy can directly address, and on the other side of restriction, guilt, and shame is the possibility of self-acceptance, empowerment, and body peace.