Better Defining ‘Excessive Exercise’

According to the 4th edition of the Diagnostic and Statistical Manual (DSM-IV), exercise becomes “excessive” when it significantly interferes with important activities, or occurs at inappropriate times or in inappropriate settings, or when the athlete keeps exercising in spite of injury or other medical complications.

Jonathan Mond and other researchers at the Neuropsychiatric Research Institute, Fargo, ND, recently hypothesized that people who exercise only for weight or shape reasons might have levels of eating disorder psychopathology rivaling those of people with eating disorders (Int J Eat Disord 2006;39:147). Their research was conducted as part of the Health and Well-Being of Female ACT Residents Study, a large-scale Australian epidemiologic study of disability associated with bulimic-type eating disorders among young adult women in the community.

Study Format

First, self-report questionnaires were given to 10,000 women 18 to 42 years of age. The questionnaires included measures of eating disorder psychopathology, health-related quality of life, questions about general psychological distress, and exercise behavior, as well as other social and demographic information.

The final study group included 3,472 women who had exercised at least once a week over the past 4 weeks. The women were asked to indicate how often they exercised mildly, moderately, and rigorously. Next, they completed the Eating Disorder Examination Questionnaire (EDE-Q), and the Medical Outcomes Study Short-Form Disability Scale (SF-12), a 12-item measure of perceived impairment in everyday functioning. Finally, they filled out the Commitment to Exercise Scale (CES), an 8-item measure designed to address obligatory exercise.

Two Variables were Identified

As predicted, the degree of guilt experienced when exercise was postponed and the extent to which an individual exercised to lose weight or change body shape were the two variables most strongly associated with higher levels of eating disorder psychopathology and reduced quality of life. There was also a link between frequency of rigorous exercise and the women’s perception of their physical health.

About 9% (322) of the women in the study group reported exercising only to lose weight or to improve their shape, and 3.9% (136) reported intense guilt after postponing exercise. One hundred and nineteen (3.3%) of the women reported experiencing both of these behaviors.

The best predictor of eating disorder psychopathology was found in the CES item, “I feel guilty after missing an exercise session.” Results of an earlier study by Ackard et al (Eat Disord 2002; 10:31) found that emotional attachment to exercise, particularly negative emotion associated with missing an exercise session, correlated most highly with subscales of the Eating Disorders Inventory.

Notably, the items of the CES that corresponded most closely to the definition of excessive excise given in the DSM-IV (“Do you exercise even when you have sustained an exercise-related injury?” and “Are there times when you turn down an invitation to an interesting social event because it interferes with your exercise schedule?”) were not associated with higher levels of eating disorder psychopathology.

Thus, the portion of the DSM-IV that specifies symptoms of excessive exercise may need to be revisited and modified in the next revision, the DSM-V.