Excessive exercise played a big role in my eating disorder and, predictably, I am drawn to studies that look at the role excessive exercise plays in eating disorder symptomatology, course and outcome. This topic has captured the interest of many eating disorder researchers, with studies revealing that up to 80% of individuals with anorexia nervosa may exercise excessively (Davis et al., 1997), though others suggest more modest statistics, around 39% (Shroff et al., 2006; Tetyana wrote a post about this article here).
Scholars have also noted the potentially obsessive and compulsive nature of exercise among some individuals with eating disorders and have made the natural transition toward examining whether links exist between excessive exercise and obsessive-compulsive disorder (OCD) and/or obsessive-compulsive personality disorder (OCPD) traits (If you are confused about the difference between OCD and OCPD, click here). Young, Rhode, Touyz & Hay (2013) conducted a rigorous systematic review to synthesize and draw conclusions from the results of such studies.
The authors aimed to clarify the links between both OCPD traits and OCD and excessive exercise among individuals with AN. They performed literature searches and identified 10 studies that met their stringent criteria for content and quality. Among the studies chosen, participants were engaged in various forms of treatment (both inpatient and outpatient) for AN in the US, Canada, Germany, Spain, Slovenia, and the UK. Six studies used a cross-sectional design, two were retrospective, one was prospective and one was quasi-experimental.
Studies used a number of different self-report questionnaires and clinical interviews to obtain their results. Of course, trying to compare studies using various instruments and different definitions of what counts for excessive exercise, for example, can be difficult and can be bit of a methodological minefield. However, while the authors acknowledged the potential pitfalls of their method, they still came to some interesting conclusions based on the studies they analyzed.
WHAT COUNTS AS EXCESSIVE EXERCISE?
The first hurdle faced when comparing a number of studies looking at the relationship between OCDP, OCD, and excessive exercise is determining what qualifies as “excessive.” Different scales measuring this construct use different definitions, usually relying on a combination of:
- The frequency and duration of the exercise
- The conditions surrounding the exercise (e.g. “at inappropriate times,” in lieu of other activities, or while ill or injured)
- Mood state/feelings surrounding exercise (e.g. guilt if one does not exercise, lack of enjoyment of exercise)
OCDP vs. OCD
There are a number of differences between OCPD traits and OCD that warrant mentioning in order to interpret this article’s findings. OCPD traits were measured using clinical interviews or trait inventories. These instruments identify individuals with an “obsessional personality type,” which incorporates traits such as perfectionism, drive for order and symmetry, as well as excessive doubt. OCD, measured in these studies using self-report questionnaires, is assessed based on symptoms (e.g. washing, obsessing, ordering, etc.) and the distress associated with these symptoms.
This paper included studies that looked at OCPD, OCD, or both, in relation to excessive exercise. They found that the relationship between OCD and excessive exercise does not appear to be the same as between OCPD and excessive exercise.
THE RELATIONSHIP BETWEEN EXCESSIVE EXERCISE AND OCD
Several of the studies found links between these two constructs:
- Regardless of dietary status, patients who engaged in excessive exercise had significantly higher numbers of obsessive-compulsive symptoms (Davis & Kaptein, 2006)
- Stronger feelings of obligation and pathological attitudes were related to exercise among individuals with AN presenting with excessive exercise (Davis et al., 1995)
- Positive correlation between activity level and “obsessive-compulsiveness” (Davis et al., 1995)
- Links between obsessive beliefs, behaviours, exercise behaviour and eating disorder psychopathology (Naylor et al., 2011)
- Positive relationship between excessive exercise and rituals/preoccupations and obsessions/compulsions (Shroff et al., 2006)
Importantly, some studies found no differences in OCD between individuals who exercised excessively and those who didn’t (Anderluh et al., 2009; Holtkamp et al., 2004). Others actually found negative correlations, suggesting that those with OCD may be less inclined to exercise excessively (Penas-Lledo et al., 2002).
From these mixed results, the relationship between excessive exercise and OCD remains unclear. The authors attribute these different findings to differences in measurement; those studies finding negative correlations used a more comprehensive model, adding in more potential confounding variables into the mix in an attempt to clarify relationships.
THE RELATIONSHIP BETWEEN EXCESSIVE EXERCISE AND OCPD
The link between OCPD and excessive exercise appears to be stronger. Several of the studies in this review found that individuals who presented with excessive exercise had a higher lifetime prevalence of OCPD traits, particularly self-oriented perfectionism (Davis et al., 1995).
Being more rule-bound and cautious as a child, though not necessarily during the eating disorder, was also related to excessive exercise (Anderluh et al., 2009).
MUTUALLY REINFORCING?
The relationship between OCD, OCPD traits, and excessive exercise in individuals with AN is complex. One model seeking to explain the relationship between OCPD traits and excessive exercise in particular suggests that excessive exercise combined with obsessive-compulsive traits and reduced dietary intake may contribute to the development and maintenance of anorexia nervosa (Davis et al., 1995).
According to this model, excessive exercise and reduced dietary intake would increase obsessive-compulsiveness, which could in turn lead to a higher level of exercise and further decreases in dietary intake with the increasing obsessions.
COMPLEXITY AND INDIVIDUALITY
The reasons why individuals exercise excessively are as varied as individuals themselves. Obsessionality seems to be one potential driving force, as studies in this review indicate that exercise may be used in an attempt to reduce anxiety and/or to numb obsessional thoughts. This finding in particular spoke to me because exercise, for me, was certainly a way of stopping thoughts entirely, including various anxieties and obsessions.
This review looked only at OCD/OCPD traits/excessive exercise links among individuals with AN. I would be curious to see what results would be found when looking at these links among individuals with BN and/or EDNOS.
Certainly, the lack of clarity in defining constructs, especially “excessive exercise” limits the extent to which we can be sure of the results. As interesting as systematic reviews can be for giving us a great deal of information from a number of different studies, there is always the risk of comparing apples to oranges, particularly when there are large differences in the way the studies were conducted.
Nonetheless, this review is a useful start to clarifying the links between OCD and OCPD traits and excessive exercise among individuals with AN, and may spark further interest in conducting more studies in this vein… such as, perhaps, a qualitative investigation asking patients about their experiences with (and understanding of) obsessive-compulsive traits and excessive exercise?
References
Young, S, Rhodes, P, Touyz, S, & Hay, P (2013). The relationship between obsessive-compulsive personality disorder traits, obsessive-compulsive disorder and excessive exercise in patients with anorexia nervosa: A systematic review. Journal of Eating Disorders, 1, 16-29 DOI: 10.1186/2050-2974-1-16
Great post! I’ve been interested in this topic as well. Something I haven’t seen a lot of work on is the use of a “healthy level” of excercise as part of recovery. I mean, exercise has been shown to reduce anxiety and OCD symptoms. For me, it has helped in the past to STOP thinking about food and shift my focus to more healthy patterns of thought. Of course we don’t want to justify excessive exercise, but the conversation around engaging in a healthy level of physical activity seems largely absent, in my opinion.
Thanks Liz. Interesting point; I think there needs to be more of a discussion of this topic for sure. As it stands, I find that exercise tends to be a bit taboo in some treatment programs; I totally and completely agree with programs that limit and even completely stop exercise during treatment, as I feel that radical break is necessary in order to separate food from exercise, particularly among people who have experienced excessive exercise as a major symptom of their disorder. However, I think there needs to be more of a focus on re-introduction of exercise in a moderate and balanced way. Without this, it can be hard to navigate the tension of including exercise as a healthy part of one’s life (including it’s potential mental and physical health benefits) without letting it become excessive. Of course, exercise doesn’t always become excessive in individuals with eating disorders, which is another thing I find really interesting about it, so the way it is approached likely needs to be very individualized- then again, which parts of an eating disorder don’t need to be approached on a case-by-case basis? Ah complexity…
This has been one of the trickiest parts of being recovered, for me. Physical activity is required to be healthy, right? So what do you do if you can’t seem to approach it in a healthy way? Working out does wonders for my baseline anxiety level, which decreases OCD symptoms, but then sometimes just thinking about going for a run is enough to change my eating habits. What gives?
Absolutely, I have had similar difficulties (though I have not suffered from/been diagnosed with OCD/OCPD, I have struggled with anxiety). I think for me the main trouble was that yes, exercising helps with my anxiety but it got to a point where it (and other ED symptoms) was the ONLY way I could deal with my anxiety- and all other emotions for that matter. It has been quite tricky to find the balance where I can engage in activity in a “healthful” (which I would define as balanced and not taking over other parts of my life) way. As I mentioned in other comments, I think it is something we don’t talk about enough in research and treatment contexts.
I can’t really envision that happening on a treatment-wide scale. Try justifying different caloric intakes or exercise regimes in an IP setting or something.
I never had an issue with exercise, even though I exercised a lot and continue to be quite active. There was a brief time period where I was very particular about exercising and when I did it, but I did very little compared to even now. But I don’t exercise excessively at all.
I’m sure during treatment they told me to stop exercising or something. But they told me lots of things I didn’t listen to. Hah.
Like Andrea said, I think it is a huge taboo.
Some people can’t comprehend that I can exercise a lot but still have a totally healthy attitude toward it. I haven’t done cardio in ages because I walk more. That’s fine with me. I’ve never had an exercise related injury because I always listened to my body and took extra days off if I felt like it. All that kinda stuff. But you know, a lot of people seem to think treatment/recovery “should” be this or “shouldn’t” be that.
Formal treatment isn’t really made to be individually-tailored, I feel.
I think it is absent because if you allow one person to exercise because they legit don’t have a problem, everyone who does will be going, “BUT HOW COME SHE CAN.”
Ahh, good point. I didn’t think about how exercise may be perceived amongst peers in a treatment program. I guess the potential costs to the group as a whole outweigh the benefits for a few.
I once had someone tell me that if you start viewing exercise as a “currency” for food intake, that’s when to take a step back. Although, for some, I wonder if the hunger induced from exercising may help an individual eat more when they need to and kickstart a healthier eating pattern. Yet again, something to be addressed with an individual practitioner.
I never had anyone treat exercise as a taboo during my recovery, but I only saw a private practitioner. Have others had a different experience in the outpatient setting?
Good point- just from a practical standpoint individualizing inpatient/group treatment isn’t really feasible; however, I still think there is room for more discussion about the re-introduction of exercise if appropriate in individual sessions within the broader treatment protocol, especially for those with a history of excessive exercise. I did this with a dietician following treatment, and we even talked about how any talk about how to navigate the tricky world of activity/exercise post-treament wasn’t explored in the program. Totally agree about the potential for comparison being a complicating factor in terms of having this discussion in treatment programs.
Just realized my comment seems to contradict itself a bit… overtired at the moment, hopefully it made some kind of sense…
Also! Liz: I’ve heard the same re: the point at which exercise becomes currency for food intake is a point for reassessment.
“Others actually found negative correlations, suggesting that those with OCD may be less inclined to exercise excessively”
IMO, this should not be so surprising, given the variation in obsessions that people with OCD have. I imagine some people with OCD exercise less for OCD reasons. A lot of OCD sufferers will avoid any triggers for compulsions, such as driving the long way around hospitals that may have contaminants so they won’t have to wash. Some people feel required to count and thus avoid numbered environments (hello treadmill!), and some people have obsessions about somatic experiences (heart rate, breath, movement patterns) which could also be a problem with exercise. I’m sure there are as many people with exercise-related compulsions they are avoiding as there are people who use exercise as a compulsion to satisfy some other obsession.
You’re right, it isn’t all that surprising. Like most things, I would imagine it is quite individual in terms of the ways in which people’s OCD and ED symptoms manifest. I think the article’s findings echo this ambiguity; while some studies suggest a positive correlation, those that found a neutral or negative relationship highlight the multiplicity of OCD and ED manifestations. This also underscores the difficulty researchers have had in trying to draw out the links between the 2, I think; it may be impractical to assume that there is an easily explained relationship.