**2. Motivation for exercise in BN**

The motives for being physically active can vary over time and from person to person. The motives are influenced by factors such as age, BMI, mood, personality, knowledge and attitudes (Dishman, Sallis, & Orenstein, 1985). The motives can be extrinsic, intrinsic or a combination of these. In females from both the general population and from eating disordered populations, weight control and/or regulation are perceived as very important reasons for physical activity and exercise (Furnham, Badmin, & Sneade, 2002; Mond & Calogero, 2009). Other motives and reasons for physical activity and exercise are physical fitness, health, well-being, regulation of mood and affects, and socializing (Cash, Novy, & Grant, 1994; Plonczynski, 2000).

Bratland-Sanda et al. (2010a) found no differences in importance of exercise as a weight regulator between patients with eating disorders and age-matched non-clinical controls.

Physical Activity and Exercise in Bulimia Nervosa: The Two-Edged Sword 171

exercise becomes excessive when it makes a significant negative impact on other aspects of life, e.g. work, social life and/or family, when it is performed within inappropriate timing and/or setting, and/or the exercise is continued despite injuries, illness or severe complications (APA,1994). Compulsive or obligatory exercise refers to an individual's feeling of being forced to exercise when the motive is no longer performance enhancement, but rather avoidance of the negative feelings that occur with exercise deprivation (Draeger, Yates, & Crowell, 2005). Exercise dependence is defined as the drive to perform leisure-time exercise, and that this drive results in uncontrolled excessive exercise behavior with physiological and/or psychological symptoms of exercise deprivation. The physical withdrawal symptoms are key features of this behavior, and these symptoms did not occur before the exercise behavior pattern started (Hamer & Karageorghis, 2007; Hausenblas & Symons Downs, 2002). The reason why there are several different terms used on what seems to be the same issue, is that destructive and unhealthy exercising has been examined using different disorders and concepts from the field of psychiatry. Mechanisms of substance dependence have been used to explain exercise dependence, and obsessive-compulsiveness

To make the concepts of excessive exercise, compulsive exercise and exercise dependence

Dimension Main issue Example

be compulsive.

amount

Compulsive motives and behavior, and expression of a need to follow rituals. The behavior does not have to be excessive in

Avoid withdrawal symptoms.

Table 1. Differences between the concepts of excessive exercise, compulsive exercise and

Too much exercise, but the motives for the exercise can vary. The motives do not have to BN patients who perform a high amount exercise, but the motive can be to enhance performance in a certain type

BN patients who have to perform 200 sit ups before getting out of bed in the morning. If interrupted, he/she needs to do the whole procedure from the start.

A BN patient who constantly but unintentionally increases amount of exercise because of increased tolerance, lacks control of the exercise behavior, experiences withdrawal symptoms with exercise deprivation, exercise despite injury and/or illness and that the exercise interfere with other aspects of life.

of sport.

has been used to explain compulsive exercising.

clearer, the differences are pointed out in Table 1.

Quantitative only (i.e. duration, intensity and frequency)

Qualitative only (i.e. motivation and attitudes)

Quantitative + qualitative

Excessive exercise

Compulsive exercise

Exercise dependence

BN: bulimia nervosa.

exercise dependence.

Fig. 1. Frequency of reported aerobic (e.g. running, walking, swimming, cycling) and nonaerobic (e.g. strength training, yoga, pilates) physical activities among a sample of adult female inpatients with bulimia nervosa.

Interestingly, differences did occur in importance of exercise to enhance fitness and health (perceived as less important among the patients) and importance of exercise to regulate negative affects (perceived as more important among the patients). The use of physical activity and exercise as an affect regulator did only occur for regulation of negative affects, no differences in perceived importance of exercise to regulate positive affects was found between patients and controls. One possible explanation for this finding is the high levels of negative affects such as anxiety, depression, shame, guilt etc. among the patients, and therefore the main focus is to down regulate these affects rather than to improve positive affects and well-being. It is important to note that our study was carried out on patients with longstanding eating disorders, and that motives for physical activity and exercise might change during different phases of the disorder. It can be hypothesized that body weight and shape are more important reasons for exercise among patients with short duration of the eating disorders compared to the longstanding eating disorder patients. Future studies need to address this.

### **3. Excessive exercise and exercise abuse in BN**

#### **3.1 When there is too much of a good thing: definition of excessive exercise and exercise dependence**

There is no consensus on how to define excessive exercise and exercise dependence. And often these terms, in addition to compulsive exercise, are used interchangeably. In the DSM-IV, excessive exercise is defined under the diagnosis of BN. According to this definition,

Fig. 1. Frequency of reported aerobic (e.g. running, walking, swimming, cycling) and nonaerobic (e.g. strength training, yoga, pilates) physical activities among a sample of adult

Interestingly, differences did occur in importance of exercise to enhance fitness and health (perceived as less important among the patients) and importance of exercise to regulate negative affects (perceived as more important among the patients). The use of physical activity and exercise as an affect regulator did only occur for regulation of negative affects, no differences in perceived importance of exercise to regulate positive affects was found between patients and controls. One possible explanation for this finding is the high levels of negative affects such as anxiety, depression, shame, guilt etc. among the patients, and therefore the main focus is to down regulate these affects rather than to improve positive affects and well-being. It is important to note that our study was carried out on patients with longstanding eating disorders, and that motives for physical activity and exercise might change during different phases of the disorder. It can be hypothesized that body weight and shape are more important reasons for exercise among patients with short duration of the eating disorders compared to the longstanding eating disorder patients. Future studies need

**3.1 When there is too much of a good thing: definition of excessive exercise and** 

There is no consensus on how to define excessive exercise and exercise dependence. And often these terms, in addition to compulsive exercise, are used interchangeably. In the DSM-IV, excessive exercise is defined under the diagnosis of BN. According to this definition,

female inpatients with bulimia nervosa.

**3. Excessive exercise and exercise abuse in BN** 

to address this.

**exercise dependence** 

exercise becomes excessive when it makes a significant negative impact on other aspects of life, e.g. work, social life and/or family, when it is performed within inappropriate timing and/or setting, and/or the exercise is continued despite injuries, illness or severe complications (APA,1994). Compulsive or obligatory exercise refers to an individual's feeling of being forced to exercise when the motive is no longer performance enhancement, but rather avoidance of the negative feelings that occur with exercise deprivation (Draeger, Yates, & Crowell, 2005). Exercise dependence is defined as the drive to perform leisure-time exercise, and that this drive results in uncontrolled excessive exercise behavior with physiological and/or psychological symptoms of exercise deprivation. The physical withdrawal symptoms are key features of this behavior, and these symptoms did not occur before the exercise behavior pattern started (Hamer & Karageorghis, 2007; Hausenblas & Symons Downs, 2002). The reason why there are several different terms used on what seems to be the same issue, is that destructive and unhealthy exercising has been examined using different disorders and concepts from the field of psychiatry. Mechanisms of substance dependence have been used to explain exercise dependence, and obsessive-compulsiveness has been used to explain compulsive exercising.

To make the concepts of excessive exercise, compulsive exercise and exercise dependence clearer, the differences are pointed out in Table 1.


BN: bulimia nervosa.

Table 1. Differences between the concepts of excessive exercise, compulsive exercise and exercise dependence.

Physical Activity and Exercise in Bulimia Nervosa: The Two-Edged Sword 173

**Davis et al. (1994)** AN, BN (n=45) 24.6 (4.8) AN: 78%

**Davis et al.(1997)** AN, BN (n=127) 27.7 (7.8) AN: 81%

(n=1857) 26.3 (7.7)

(n=165) 26.0 (7.8)

AN: anorexia nervosa. BN: bulimia nervosa. EDNOS: eating disorders not otherwise specified.

excessive, and/or the behavior is compulsive, then this strategy turns maladaptive.

Table 2. Selected studies examining prevalence of excessive exercise, compulsive exercise

of negative affects into a certain level. When the amounts of physical activity or exercise get

Vigorous intensity physical activity is also a typical sign of exercise dependence. When a female inpatient with EDNOS was asked about her vigorous intensity physical activity, she said: *"I can't walk away from the anxiety; I have to run from it."* This quote is in my opinion a valuable illustration of the use of physical activity to reduce negative affects, and that sometimes the physical activity has to be of certain intensity for the individual to achieve the intended effect. Therefore, it is a paradox that vigorous intensity physical activity performed in excessive amounts actually can worsen mood (Lind, Ekkekakis, & Vazou, 2008). Why the exercise dependent individuals prefer vigorous intensity physical activity is still not explored adequately. It can however be hypothesized that the vigorous intensity physical activity results in an acute suppression of the negative affects, and that this effect is only temporary. In that way, the level of negative affects can in fact end up being worse after the

As of today, there is no consensus on how to manage and treat exercise dependence. Beumont et al. (1994) and Calogero & Pedrotty (2004) found promising results when using

(n) Age Prevalence

BN: 23%

BN: 57%

AN: 54% BN: 39% EDNOS: 46%

BN: 46%

AN: 44% BN: 21% EDNOS: 21%

R-AN: 80% B-AN: 43% BN: 39% EDNOS: 32%

AN: 50% BN: 6% EDNOS: 47%

17%

BN (n=71) N/A AN: 39%

20.8 (7.2)

BN (n=61) 18.8 (5.9) AN: 46%

30.1 (8.5)

(n=212) Range: 16-40 AN, BN, EDNOS:

Study Patient population

AN (n=18)

AN (n=115) BN (n=38) EDNOS (n=56)

AN (n=63)

AN, BN, EDNOS

AN, BN, EDNOS

AN (n=4) BN (n=17) EDNOS (n=17)

and/or exercise dependence among patients with bulimia nervosa.

**Abraham et al. (2006)** AN, BN, EDNOS

physical activity session than it was before.

**3.4 Management of exercise dependence** 

**Brewerton et al.** 

**Solenberger (2001)**

**Penas-Lledo et al.** 

**Shroff et al. (Shroff et** 

**DalleGrave et al.** 

**Bratland-Sanda** 

N/A: not available.

**(1995)**

**(2002)**

**al., 2006)**

**(2008)**

**(2010b)** 

Especially the term exercise dependence has been discussed to be both positive and negative. Some argue that exercise dependence is a positive type of dependence (Morgan, 1979), whereas others believe that the development of a dependency is in itself negative. Cockerill & Riddington (1996) divided between healthy commitment to exercise and a negative dependence to exercise. According to these definitions, the individuals with a healthy commitment to exercise schedule the exercise routines to the more important aspects of life (e.g. work and family life), whereas the individuals with a negative dependency to exercise schedule the rest of their lives around the exercise routines (Cockerill & Riddington, 1996).

A study from 2005 examined whether compulsive exercise would be a better term than excessive exercise for the exercise performed as weight compensatory behavior (Adkins & Keel, 2005). Using a sample of 265 female and male undergraduate students, they found that compulsive exercise score positively predicted disordered eating, whereas quantity of exercise was a negative predictor of disordered eating. They therefore argue that compulsive exercise better describe exercise as a symptom of BN. Unfortunately, this study included a non-clinical sample, and there is a possibility that findings could have been otherwise with a clinical sample of patients with BN.

## **3.2 Prevalence of exercise dependence among patients with BN**

Studies which have examined prevalence of exercise dependence in patients with BN are listed in Table 2. As the table shows, prevalence of exercise dependence in BN ranges from 17% to 57%. This large range can be explained by different definitions of the term exercise dependence, different assessment methods, age of the patient and duration of illness. It is believed that prevalence of exercise dependence is higher among patients in the acute phase of the disorder, and therefore a higher frequency of patients with shorter duration of the illness is classified as exercise dependent (Davis et al., 1997).

#### **3.3 Characteristics of exercise dependence: high intensity activity and affect regulation**

Exercise dependent patients show more severe eating disorders psychopathology, more symptoms of anxiety and depression, longer duration of treatment, poorer prognosis for recovery, and higher risk of relapse compared to non-dependent patients (Bratland-Sanda et al., 2010b; Brewerton, et al., 1995; Calogero & Pedrotty, 2004; DalleGrave, et al., 2008; Penas-Lledo, et al., 2002; Shroff, et al., 2006; Strober, Freeman, & Morrell, 1997). Bratland-Sanda et al. (2011) examined explanatory factors for exercise dependence among patients with eating disorders and non-clinical controls. In this study, weekly amount of vigorous intensity physical activity and importance of exercising for regulation of negative affects explained 78% of the variance in exercise dependence score among the patients. Among the nonclinical controls, these two variables explained 53% of the variance.

Affect regulation is the process with the aim of decreasing negative affects and increasing positive affects (Larsen, Prizmic, Baumeister, & Vohs, 2004). Negative affect regulation can both indicate down-regulation of negative affects such as depression and anxiety, and maladaptive affect regulation strategies (Fonagy, Gergely, Jurist, & Target, 2002). Eating disorder can in itself be viewed as a maladaptive affect regulation strategy, because eating disorders symptoms such as bingeing, purging and/or starvation can function as a way to suppress and/or avoid difficult emotions and affects (Harrison, Sullivan, Tchanturia, & Treasure, 2009). Physical activity is an example of a strategy that can be positive for regulation

Especially the term exercise dependence has been discussed to be both positive and negative. Some argue that exercise dependence is a positive type of dependence (Morgan, 1979), whereas others believe that the development of a dependency is in itself negative. Cockerill & Riddington (1996) divided between healthy commitment to exercise and a negative dependence to exercise. According to these definitions, the individuals with a healthy commitment to exercise schedule the exercise routines to the more important aspects of life (e.g. work and family life), whereas the individuals with a negative dependency to exercise schedule the rest of their lives around the exercise routines

A study from 2005 examined whether compulsive exercise would be a better term than excessive exercise for the exercise performed as weight compensatory behavior (Adkins & Keel, 2005). Using a sample of 265 female and male undergraduate students, they found that compulsive exercise score positively predicted disordered eating, whereas quantity of exercise was a negative predictor of disordered eating. They therefore argue that compulsive exercise better describe exercise as a symptom of BN. Unfortunately, this study included a non-clinical sample, and there is a possibility that findings could have been

Studies which have examined prevalence of exercise dependence in patients with BN are listed in Table 2. As the table shows, prevalence of exercise dependence in BN ranges from 17% to 57%. This large range can be explained by different definitions of the term exercise dependence, different assessment methods, age of the patient and duration of illness. It is believed that prevalence of exercise dependence is higher among patients in the acute phase of the disorder, and therefore a higher frequency of patients with shorter duration of the

Exercise dependent patients show more severe eating disorders psychopathology, more symptoms of anxiety and depression, longer duration of treatment, poorer prognosis for recovery, and higher risk of relapse compared to non-dependent patients (Bratland-Sanda et al., 2010b; Brewerton, et al., 1995; Calogero & Pedrotty, 2004; DalleGrave, et al., 2008; Penas-Lledo, et al., 2002; Shroff, et al., 2006; Strober, Freeman, & Morrell, 1997). Bratland-Sanda et al. (2011) examined explanatory factors for exercise dependence among patients with eating disorders and non-clinical controls. In this study, weekly amount of vigorous intensity physical activity and importance of exercising for regulation of negative affects explained 78% of the variance in exercise dependence score among the patients. Among the non-

Affect regulation is the process with the aim of decreasing negative affects and increasing positive affects (Larsen, Prizmic, Baumeister, & Vohs, 2004). Negative affect regulation can both indicate down-regulation of negative affects such as depression and anxiety, and maladaptive affect regulation strategies (Fonagy, Gergely, Jurist, & Target, 2002). Eating disorder can in itself be viewed as a maladaptive affect regulation strategy, because eating disorders symptoms such as bingeing, purging and/or starvation can function as a way to suppress and/or avoid difficult emotions and affects (Harrison, Sullivan, Tchanturia, & Treasure, 2009). Physical activity is an example of a strategy that can be positive for regulation

**3.3 Characteristics of exercise dependence: high intensity activity and affect** 

(Cockerill & Riddington, 1996).

**regulation** 

otherwise with a clinical sample of patients with BN.

**3.2 Prevalence of exercise dependence among patients with BN** 

illness is classified as exercise dependent (Davis et al., 1997).

clinical controls, these two variables explained 53% of the variance.


AN: anorexia nervosa. BN: bulimia nervosa. EDNOS: eating disorders not otherwise specified. N/A: not available.

Table 2. Selected studies examining prevalence of excessive exercise, compulsive exercise and/or exercise dependence among patients with bulimia nervosa.

of negative affects into a certain level. When the amounts of physical activity or exercise get excessive, and/or the behavior is compulsive, then this strategy turns maladaptive.

Vigorous intensity physical activity is also a typical sign of exercise dependence. When a female inpatient with EDNOS was asked about her vigorous intensity physical activity, she said: *"I can't walk away from the anxiety; I have to run from it."* This quote is in my opinion a valuable illustration of the use of physical activity to reduce negative affects, and that sometimes the physical activity has to be of certain intensity for the individual to achieve the intended effect. Therefore, it is a paradox that vigorous intensity physical activity performed in excessive amounts actually can worsen mood (Lind, Ekkekakis, & Vazou, 2008). Why the exercise dependent individuals prefer vigorous intensity physical activity is still not explored adequately. It can however be hypothesized that the vigorous intensity physical activity results in an acute suppression of the negative affects, and that this effect is only temporary. In that way, the level of negative affects can in fact end up being worse after the physical activity session than it was before.

#### **3.4 Management of exercise dependence**

As of today, there is no consensus on how to manage and treat exercise dependence. Beumont et al. (1994) and Calogero & Pedrotty (2004) found promising results when using

Physical Activity and Exercise in Bulimia Nervosa: The Two-Edged Sword 175

Future studies need to examine the mechanisms behind exercise dependence, and different treatment options for exercise dependence. Effects of different types of physical activities in treatment of BN among both male and female patient populations need to be addressed.

Physical activity has a number of physiological and psychological effects, and it has been shown effective as a preventive and therapeutic variable in diseases such as type 2 diabetes, cardiovascular disease, osteoporosis, depression, anxiety and certain types of cancer. Among patients with BN, the physical activity is a two-edged sword. On one hand, up to about 50% of patients with BN are classified as exercise dependent, and these patients do need to reduce the amounts of weekly physical activity. On the other hand, a randomized controlled trial found an exercise program superior to nutritional counselling and cognitive behavior therapy among young adult females with BN. Future studies need to further address the possible preventive and therapeutic effects of physical activity in this patient

Abraham, S. F., Pettigrew, B., Boyd, C., & Russell, J. (2006). Predictors of functional and

ACSM. (2009). American College of Sports Medicine position stand. Progression models in

Adkins, E. C., & Keel, P. K. (2005). Does "excessive" or "compulsive" best describe exercise as

American Psychiatric, A. (1994). *Diagnostic and Statistical Manual of Mental Disorders (DSM-*

Bahr, R. (2009). *Aktivitetsh†ndboken: fysisk aktivitet i forebygging og behandling*. Oslo:

Beumont, P. J., Arthur, B., Russell, J. D., & Touyz, S. W. (1994). Excessive physical activity in

Bouchard, C., Blair, S. N., & Haskell, W. L. (2007). *Physical activity and health*. Champaign, Il.:

Bratland-Sanda, S. (2010). *Physical activity in female inpatients with longstanding eating* 

Bratland-Sanda, S., Martinsen, E. W., Rosenvinge, J. H., Ro, O., Hoffart, A., & Sundgot-

dieting disorder patients: proposals for a supervised exercise program. *Int.J* 

Borgen, J. (2011). Exercise dependence score in patients with longstanding eating disorders and controls: the importance of affect regulation and physical activity

a symptom of bulimia nervosa? *Int.J Eat.Disord., 38*(1), 24-29.

*disorders.* PhD, Norwegian school of sport sciences, Oslo.

exercise amenorrhoea among eating and exercise disordered patients. *Hum.Reprod.,* 

resistance training for healthy adults. *Med Sci Sports Exerc, 41*(3), 687-708. doi:

**5. Future research** 

**6. Conclusion** 

population.

**7. References** 

*21*(1), 257-261.

10.1249/MSS.0b013e3181915670

*IV)*. Washington DC: APA.

Helsedirektoratet.

Human Kinetics.

*Eat.Disord, 15*(1), 21-36.

intensity. *Eur Eat Disord Rev, in press*.

supervised and health related physical activity in treatment of excessive amounts of exercise and exercise dependence. Other strategies used are motivational interview, cognitive behavioral therapy and psycho-education (Long & Hollin, 1995; Mavissakalian, 1982; Stunkard, 1960).
