E

xercise bulimia is perhaps a lesser-known eating disorder than anorexia nervosa (AN) or bulimia nervosa (BN), but it can be just as dangerous. Engaging in excessive exercise can be harmful to a person’s physical and mental health and often requires professional treatment to overcome.

What is Exercise Bulimia?

Exercise bulimia is characterized by excessive and pathological exercise. It is similar to bulimia nervosa in that instead of “purging” by self-induced vomiting or diarrhea, a person exercises excessively to burn calories in order to compensate for food consumption.

Exercise bulimia is not a formal diagnosis in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), a diagnostic tool published by the American Psychiatric Association (APA). However, excessive exercise as a compensatory behavior is listed as a symptom of bulimia nervosa. (1) 

As such, exercise bulimia may exist on its own, as a symptom of bulimia nervosa, or in conjunction with co-occurring anorexia nervosa. Since exercise bulimia isn’t a formal clinical term, you may hear it called many other things, such as “exercise addiction,” “compulsive exercise,” or “excessive exercise.”

Symptoms of Exercise Bulimia

While movement is healthy for our minds and bodies, too much exercise can indicate a problem. Countless people make exercise a part of their daily routine, but the problem comes in when that exercise becomes compulsive or pathological. Compulsive exercise may include the following criterion: (2)

  • Exercising with the goal of compensating after overeating (for example, having a binge on food and then going to the gym for multiple hours afterward to compensate)
  • Exercising according to rigid self-imposed rules and in response to an obsession
  • Exercising is time-consuming, interferes with the person’s life and responsibilities, and is continued regardless of negative consequences

Symptoms of exercise bulimia may include: (3,4)

  • Experiencing a preoccupation with exercise and weight management
  • Missing important events or neglecting hobbies in order to exercise
  • Feeling ashamed or guilty if you miss a workout
  • Excessively tracking how many calories you burn during a workout
  • Becoming defensive if someone points out how much you exercise
  • Having distorted body image
  • Exercising for multiple hours a day, way longer than the average work out of a half hour to an hour at a time
  • Continuing to work out even if you are sick or injured
  • Deriving little to no joy from exercise, even activities that were once fun
  • Experiencing cravings to work out
  • Stopping menstruation (in those who menstruate)

People with exercise bulimia are typically very rigid with their workout routines, so much so that they are unable to skip a workout or cut one short without feeling guilty. This can occur in people who are attempting to lose weight via exercise as well as attempting to gain muscle via excessive weightlifting. 

Much like other eating disorders, exercise bulimia is accompanied by a sense of shame, which can only perpetuate the cycle of compulsive exercise.

Traits Linked to Compulsive Exercise

A review of literature revealed that compulsive exercise is associated with the following: (4)

  • Eating disorder pathology and symptoms
  • Neuroticism: A tendency toward negative affect or emotional state, including irritability, anger, depression, anxiety, and emotional instability
  • Perfectionism: Desiring flawlessness, setting extremely high standards, and being overly critical of oneself
  • Narcissism: A sense of entitlement and inflated sense of self-importance 
  • Obsessive compulsive traits: Obsessive thoughts and repetitive, uncontrollable behaviors

Complications of Exercise Bulimia

Exercise bulimia and excessive exercise can lead to many different psychological and medical complications, including: (3,5,6)

  • Increased risk of arrhythmias (abnormal heart rhythm)
  • Extreme fatigue
  • Weakened immune system leading to more frequent illnesses
  • Overuse injuries, such as stress fractures or osteoarthritis
  • Mood swings or irritability
  • Depression and anxiety
  • Sleep disturbances
  • Extreme soreness
  • Dangerous weight loss
  • Increased suicidality

Over-exercising can also lead to rhabdomyolysis, a serious and potentially life-threatening condition in which an individual’s muscles break down, releasing proteins and muscle enzymes into the bloodstream, which can lead to kidney failure. (7) 

Treatment for Exercise Bulimia

Treatment for exercise bulimia will depend upon your individual needs, symptomatology, and co-occurring conditions like other eating disorders or mental health conditions.

A Biopsychosocial Approach

A quality eating disorder treatment program will use a biopsychosocial approach to care—this model understands and aims to address the various biological, psychological, and social factors that influence a person’s body image, exercise, disordered eating, and mental health. When you first enter a program, a treatment provider will perform a biopsychosocial assessment, which evaluates:

  • The patient’s perception of their exercise bulimia and how it’s affected them and those around them
  • Description of exercise bulimia and any other disordered eating symptoms and triggers
  • The duration of their exercise bulimia
  • Current patterns of exercise and eating
  • Body image dissatisfaction and distortion
  • Family history of mental health conditions or eating disorders
  • History of trauma
  • Effects of exercise bulimia on their life
  • Occupational and educational history
  • Living situation
  • Community relationships
  • A sensitive physical assessment of weight, pulse, blood pressure, etc.
  • Motivation for change

Treatment Modalities

Research has indicated that some people with exercise bulimia or compulsive exercise may need motivational interviewing, a short-term therapeutic modality aimed at resolving ambivalence related to change and entering treatment. (4)

Once someone is ready to enter treatment and heal their relationship with exercise, their individualized treatment plan may include several therapies, such as:

  • Cognitive Behavioral Therapy (CBT): Examines the connection between your thoughts, feelings, and behaviors so you can understand how the three influence one another, aiming to change behaviors, emotions, and thought patterns. Also examines and challenges core beliefs that aren’t helpful and influence compulsive exercise.
  • Acceptance and Commitment Therapy (ACT): Aims to increase psychological flexibility and encourages you to make choices that align with your values.
  • Dialectical Behavior Therapy (DBT): Focuses on mindfulness, emotional regulation, distress tolerance, and communication with others. 
  • Exposure therapy: Exposes you to your fear, which over time can habituate the stimulus and lead to reduced anxiety. For someone with exercise bulimia, the exposure may include stopping exercise or movement.
  • Group therapy: Allows patients to share honestly while still being accepted by others, which can be very validating. Different groups may focus on different modalities, such as CBT groups or DBT groups.
  • Nutritional counseling: Debunks myths related to food and your food beliefs. May also involve meal support and planning.

One of the main goals of treatment for exercise bulimia is to restore a healthy relationship with exercise and movement. This may involve movement groups in which you learn to enjoy movement again, focusing on physical activity that brings you joy as opposed to choosing exercise based on how many calories it can burn or how much muscle it can build. Mindful movement can help strengthen your mind-body connection and help you appreciate and care for your body.

Posted 
May 25, 2022
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Resources

  1. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). 
  2. Dittmer, N., Jacobi, C. & Voderholzer, U. (2018). Compulsive exercise in eating disorders: proposal for a definition and a clinical assessment. Journal of Eating Disorders 6(42)
  3. National Library of Medicine. (2022). Are you getting too much exercise?
  4. Lichtenstein, M. B., Hinze, C. J., Emborg, B., Thomsen, F., & Hemmingsen, S. D. (2017). Compulsive exercise: links, risks and challenges faced. Psychology research and behavior management, 10, 85–95.
  5. O’Keefe, J., Patil, H., Lavie, C., et al. (2012, June). Potential adverse cardiovascular effects from excessive endurance exercise. Mayo Clinic Proceedings, 87(6), 587-595
  6. Smith, A. R., Fink, E. L., Anestis, M. D., Ribeiro, J. D., Gordon, K. H., Davis, H., Keel, P. K., Bardone-Cone, A. M., Peterson, C. B., Klein, M. H., Crow, S., Mitchell, J. E., Crosby, R. D., Wonderlich, S. A., le Grange, D., & Joiner, T. E., Jr (2013). Exercise caution: over-exercise is associated with suicidality among individuals with disordered eating. Psychiatry research, 206(2-3), 246–255.
  7. Sunder, A., Mohanty, B., Singh, A., & Yadav, P. (2019). Rhabdomyolysis - Exercise induced nightmare. Journal of family medicine and primary care, 8(1), 305–307.

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