Addressing Compulsive Exercise in Treatment

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Compulsive exercise often presents itself in patients with eating disorders. As summarized in this paper, estimates range (depending on the sample and method of assessment) from 31%-81% in adolescents and adults seeking treatment for anorexia nervosa, and 20%-57% of those with bulimia nervosa.

Signs of problematic exercise vary across individuals but common features of it include:

  • Doing physical activity despite being at a low weight for one’s body (i.e., in a state of starvation)
  • Exercising to compensate for eating behavior
  • Exercising to the point of or through injury
  • Difficulty taking days off or varying the type or intensity of physical activity
  • Not meeting social, school, or work responsibilities due to exercise
  • Doing physical activity in a manner that interferes with weight restoration or maintenance.

Compulsive exercise can be a pathway to eating disorders relapse, and can be a tricky aspect of these disorders to address; what we think of as “healthy” for one person may not apply to the next.

Structured treatment programs range in how and in what ways compulsive exercise is addressed. Recently, investigators in Germany decided to systematically study the helpfulness of adding a therapy group that discusses compulsive exercise (and its implications on thoughts, behaviors, and overall health) to their inpatient program. Because they were developing a new intervention, the aim of their research at this early stage was to test if their group was deemed potentially helpful by participants.

Results from this study were published the Journal of Eating Disorders.

Study Specifics

Data were collected from 32 adolescent and adult inpatients at a behavioral medicine hospital in Germany. Study participants were all female and, on average, approximately 22 years old. The majority of the sample (approximately 81%) had a diagnosis of anorexia nervosa, with the remainder of individuals meeting criteria for bulimia nervosa (BN) (6.25%), or an other specified feeding and eating disorder (such as atypical anorexia nervosa) (12.5%). Patients were also included based on their endorsement of engaging in compulsive exercise and, on average, exercised approximately 4 hours daily.

In this study, compulsive exercise was defined as:

  • Repetitive exercise that the person feels driven to perform in response to an obsession or according to rules that must be applied rigidly
  • Exercise aimed at preventing or reducing distress or at preventing some dreaded event or situation

Patients who agreed to be in this study participated in the intervention group – healthy exercise behavior (HEB) – twice weekly for four weeks in addition to their standard treatment. The group was led by a clinical psychologist and sports therapist.

Following an introduction to the purpose and goals of the group, several topics were addressed:

  • Recognizing situations that might elicit urges for compulsive exercise
  • Learning to discern between healthy (i.e., reasonable, appropriate) and compulsive exercise behavior
  • Distinguishing exercise myths from facts
  • Identifying and practicing alternative coping strategies for stress

The researchers interviewed patients at the beginning and end of the study and asked everyone to complete questionnaires many aspects of compulsive exercise. After the intervention, the patients were also asked to rate how helpful they found the group to be.

Study Results

Group participants’ scores on measures of compulsive exercise including the Commitment to Exercise Scale and Compulsive Exercise Test decreased from baseline to post-intervention. Reductions in these scores suggest that patients formed a healthier relationship with exercise, and their drive to engage in it, by the end of the intervention. Forty percent of the patients rated HEB as “very helpful,” 45% found it “pretty helpful,” and 15% reported it to be “partially helpful.” One hundred percent of group participants said they would either “fully” or “strongly” recommend the group to other patients.

What does it all mean?

Compulsive exercise is a common feature of eating disorders like anorexia nervosa, bulimia nervosa, and atypical anorexia nervosa. Patients receiving treatment in a structured setting described a group targeting compulsive exercise to be an acceptable and somewhat helpful addition to treatment. They also reported a reduction in commitment to exercise and exercise rigidity, though this may have been confounded by the structure and supervision provided at the program.

Though limited by a fairly young, entirely female sample, this study provides support for further evaluation of interventions to specifically target compulsive exercise. As the investigators acknowledge, a larger, randomized trial with a control group is necessary (and in fact, already underway!) to tease apart specific effects of the study intervention from treatment as usual.

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