Exercise I: As a Way to Restrict? You Bet.

Recap of Anorexia Athletica in Research and Literature

I’ve mentioned in other posts that the eating disorder spectrum includes: anorexia nervosa, restriction/reactive eating cycles, bulimia nervosa, orthorexia and anorexia athletica. Let's look at anorexia athletica in more detail....

Greg Betza: Flickr.com

Greg Betza: Flickr.com

While the DSM-IV currently identifies anorexia nervosa and bulimia nervosa as two distinct mental illnesses, they are neural conditions with the same biological underpinnings. b Almost two-thirds (62%) of patients who initially develop anorexia nervosa will have shifted to bulimia by an eight-year follow-up point from the onset of the disorder. 2

All the other restrictive facets I list above, for the purpose of psychiatric diagnosis using the DSMI-IV are either defined as various sub-types of anorexia nervosa or bulimia nervosa, or are lumped into the catchall of ED-NOS (eating disorder not otherwise specified). Nonetheless most patients on this disorder spectrum will slide from one facet to another and/or express multiple facets at once.

Anorexia athletica is also closely tied to the Female Athlete Triad. The Female Athlete Triad is: inadequate and/or ill-timed energy intake; amenorrhea (lack of a regular menstrual cycle); and bone density loss.

Female athlete triad has got a new interpretation: the concomitant occurrence of eating disorder and the consequent menstruation dysfunction is significant.” 3

Klado and colleagues conducted an epidemiological study to more clearly define and narrow the prevalence of eating disorders within the athletic communities, it appears to be between 20-25%.

However, the prevalence of eating disorders within particular sports is more severe:

The prevalence of EDs is higher in athletes than in controls, higher in female athletes than in male athletes, and more common among those competing in leanness-dependent and weight-dependent sports than in other sports.” 4

There is exercising to restrict, restricting to compete and exercising for addictive reasons. These can overlap or not.

Exercising “Normally”

Whether an amateur or elite athlete (and everything in between), the markers of normal exercise involve two critical behaviors: 

  1. Adequate rest. Additional rest when injured to achieve full recovery.
  2. Taking in adequate energy in correctly timed intervals to stay strong and at peak performance at all times. Any accidental undernourishment is quickly rectified. 

The Exercise Addict

Exercising too much or too long is of course subjective. Obviously top competitive athletes are exercising enormous portions of the day every day and their calorie intakes must necessarily keep up with it all.

Exercise addiction and anorexia athletica overlap in behaviors and outcomes but not in neurochemical origin.

I have what we could call a sub-clinical addictive personality, although it’s not really a personality trait, it’s a variation in neurotransmitter set points and resting states when compared to a norm. As a result, I am an adrenaline (epinephrine) junkie. There are various kinds of adrenaline junkies at various severity levels and mine is mild.

However, I get runner’s high and not everyone does. What is happening is that my stress response is triggered by exercise (in a good way) and it floods my system with epinephrine. The epinephrine triggers my brain to produce endocannabinoids. The endocannabinoids are the natural sedative, anxiety-reducer and create a sense of wellbeing. However, when these naturally dissipate after the run, my system actually drops a bit below the zero point rather than to just zero as it should. This can create a need to push more the next time to create the same level of a natural high. 5

I am competitive with myself. I push the speed or the distance or both every time. So when is this behavior an addiction? It is a matter of degree. Just like everyone has gone back home to check the iron isn’t still on, obsessive-compulsive disorder is about the degree to which the “check again" behavior monopolizes the person’s life.

Here are the six facets that are used to determine whether anything has become an addiction (including exercise): 

  1. Salience: does the activity become the most important one in a person’s life? Do they think about it more than anything else? Do they crave it or feel they are suffering without it? As soon as they are not doing the activity are they planning when they can next do the activity? Do they forego other previously pleasant activities in their lives so they can do the activity in question?
  2. Mood modification: That’s the subjective feeling of the “high”. The feeling of “in the zone” or “meditative” or “calming”, “neutralizing other stresses”.
  3. Tolerance: Needing to increase the amount and time dedicated to the activity to get the same levels of mood modification.
  4. Withdrawal Symptoms: Irritability, short-tempered, jumpiness, anxiety when unable to do the activity in question.
  5. Conflict: Interpersonal issues arising with loved ones and friends as a result of the activity. Family and friends expressing their anxiety, concern or irritation with the person’s focus on the activity. Intrapersonal conflict where the person experiences guilt or anxiety that she is harming herself and others with her focus on the activity.
  6. Relapse: Attempts to avoid or moderate the involvement in the activity are punctuated with repeated returns to the activity at a quickly restored or even heightened level than before. 6

Here you will find the Exercise Addiction Inventory (EAI) developed by Annabel Terry, Attila Szabo and Mark Griffiths.

The EAI cut-off score for individuals considered to have exercise addiction is 24. Out of interest, I score a 17 – sub-clinical but certainly not something to ignore either.

What is missing in the above facets, and found in all kinds of addictions, is perseverance of the behavior despite negative consequences in your life. While interpersonal conflict can be a facet of negative consequences, it is not the only example.

For exercise addiction, the primary negative consequence would be continuing to exercise despite an injury or health concern that is worsened by exercise.

Endurance and Distance Sports Increase Exercise Addiction

“Results indicate that approximately 20% of triathletes are at risk for exercise addiction, 79% are committed exercisers who exhibit some symptoms of exercise addiction, and 1% are asymptomatic. Results also demonstrate that female triathletes are at greater risk for exercise addiction than male triathletes. Training for longer distance races (e.g., Olympic-, Half-Ironman-, and Ironman-) put triathletes at greater risk for exercise addiction than training for shorter races.” 7

Distance running, from a training perspective, is usually defined as follows: more than 20 miles per week and 6 or more miles per run. At and above that threshold, the chance for developing exercise addiction begins to increase markedly.

And while the Female Athlete Triad prevalence is 20-25% for women who run around 20 miles a week, it jumps to 43% for women who run 60 miles a week. 8

Anorexia Athletica

Those on the eating disorder spectrum exercise to burn energy. They may experience the facets listed in the EAI (above) but with some subtle differences.

While presumably it must be feasible to have both the neural conditions for active eating disorders as well as the predisposition to have the endocannabinoids progressively drop with each “high”, generally those excessively exercising due to anorexia athletica express calmness while exercising, perhaps not so much a “high”.

The calmness for the eating disorder spectrum occurs whenever the patient is successfully restricting. All restrictive behaviors are avoidant behaviors developed to try to lower the anxieties triggered by thoughts of weight gain, body image and food intake.


As with any other facet of the eating disorder spectrum, recovery is achieved by replacing restrictive behaviors with non-restrictive behaviors. Cognitive behavioral therapy is suitable for all facets of theeating disorder spectrum, including anorexia athletica. Other psycheducational frameworks might be more appropriate for some patients: exposure response prevention, motivational interviewing and/or dialectical behavior therapy (to name just a few).

As anorexia athletica is not just over-exercise, but is undernourishment in relation to exercise levels. It is still fundamentally a harmful eating behavior, and not just harmful exercise levels in isolation of calorie restriction.

Usually your recovery effort will necessitate both re-feeding and complete rest from exercise.

The Phases of Recovery from an Eating Disorder blog post will help orient you on what to expect during a recovery effort.

1. Stober, M., R. Freeman, C. Lampert, J. Diamond, and W. Kaye. "Controlled family study of anorexia nervosa and bulimia nervosa: evidence of shared liability and transmission of particular syndromes." Am J Psych 157, no. 3 (2000): 393-401.

 2. Eddy, Kamryn T., Pamela K. Keel, David J. Dorer, Sherrie S. Delinsky, Debra L. Franko, and David B. Herzog. "Longitudinal comparison of anorexia nervosa subtypes." International Journal of Eating Disorders 31, no. 2 (2002): 191-201.

3. Resch, Maria. "Eating disorders in sport–Sport in eating disorders." Hungarian Medical Journal 1, no. 4 (2007): 449-454.

4. Sundgot-Borgen, Jorunn, and Monica Klungland Torstveit. "Prevalence of eating disorders in elite athletes is higher than in the general population." Clinical Journal of Sport Medicine 14, no. 1 (2004): 25-32.

5. Sapolsky, Robert M. Why zebras don't get ulcers: The acclaimed guide to stress, stress-related diseases, and coping-now revised and updated. Macmillan, 2004.

6.  Allegre, Benjamin, Marc Souville, Pierre Therme, and Mark Griffiths. "Definitions and measures of exercise dependence." Addiction Research & Theory 14, no. 6 (2006): 631-646.

7. Youngman, Jason D. "Risk for Exercise Addiction: A Comparison of Triathletes Training for Sprint-, Olympic-, Half-Ironman-, and Ironman-distance Triathlons." (2007).

8. Golden, Neville H. "A review of the female athlete triad (amenorrhea, osteoporosis and disordered eating)." International journal of adolescent medicine and health 14, no. 1 (2002): 9-18.