Monte Nido® Eating Disorder Treatment Center
"All that we are is the result of what we have thought."

Buddha

books and articles by Carolyn
Excercise Addiction: Fit or Fanatic

"Alice never could quite make out, in thinking it over afterward, how it was that they began; all she remembers is that they were running hand in hand, and the Queen went so fast that it was all she could do to keep up with her; and still the Queen kept crying, "Faster! Faster!" but Alice felt she could not go faster, though she had no breath left to say so. ...

"...Are we nearly there?" Alice managed to pant out at last.

"Nearly there?" the Queen repeated. "Why, we passed it ten minutes ago! Faster!" And they ran on for a time in silence, with the wind whistling in Alice's ears, and almost blowing her hair off her head, she fancied.

"Now" Now!" cried the Queen "Faster! Faster!" And they went so fast that at last they seemed to skim through the air, hardly touching the ground with their feet till, suddenly, just as Alice was getting quite exhausted, they stopped, and she found herself sitting on the ground, breathless and giddy.

The Queen propped her up against a tree, and said kindly, "You may rest a little now." Alice looked round her in great surprise. "Why, I do believe we've been under this tree the whole time! Everything's just as it was!"

"Of course it is," said the Queen. "What would you have it?"

Carroll Lewis, Through The Looking Glass


Along with the steady increase in the number of people with eating disorders has been a rise in the number of people over involved in exercise activity, to the point where instead of choosing to participate in their activity they have become "addicted" to it continuing to engage in it despite adverse consequences. If dieting taken to the extreme becomes an eating disorder, exercise activity taken to the same extreme may be viewed as an "Activity Disorder," a term used by Alayne Yate's in her book, "Compulsive Exercise and The Eating Disorders."

In our society exercise is increasingly being sought, less for the pursuit of fitness or pleasure and more for the means to a thinner body or sense of control and accomplishment. In the climate of thinness mania, female exercisers are particularly vulnerable to problems arising when restriction of food intake is combined with intense physical activity. A female who loses too much body fat will stop menstruating and ovulating and will become increasingly susceptible to stress fractures and osteoporosis. Yet, similar to individuals with eating disorders, those with an activity disorder are not deterred from their behaviors by medical complications and consequences. People who continue to over exercise in spite of medical and/or other consequences feel as if they can't stop and that participating in their activity is no longer an option. These people have been referred to as obligatory or compulsive exercisers because they seem unable to "not exercise," even when injured, exhausted or begged by others to stop. The terms pathogenic exercise and exercise addiction have also been used when describing these individuals who are consumed by the need for physical activity to the exclusion of everything else and to the point of damage or danger to their lives.


Individuals with eating disorders and those with activity disorder are similar to one another in many respects. Both groups attempt to control the body through exercise and/or diet and are overly conscious of input vs. output equations. They are extremely committed individuals and pride themselves at putting mind over matter, valuing self discipline, self sacrifice and the ability to persevere. They are generally hard working, task oriented, high achieving individuals who have a tendency to be dissatisfied with themselves. The emotional investment these individuals place on exercise and/or diet becomes more intense and significant than work, family, relationships and ironically even health. Those with activity disorder lose control over exercise just as those with eating disorders lose control over dieting and both experience withdrawl when prevented from engaging in their behaviors.

One outstanding difference between the eating disorders and activity disorders seems to be that there are more males who develop activity disorders and more females who develop eating disorders. Exploring the reason for this may provide a better understanding of both. What are the causes that contribute to the development of an activity disorder? Why do only some individuals with eating disorders have this syndrome and others who have this syndrome don't have eating disorders at all? What we do know is that the risk factors for developing an activity disorder are varied including sociocultural, family, individual and biological factors, and are not necessarily the same factors which cause the disorder to persist.

Physical Symptoms of Activity Disorder

A key in determining if a person is developing an activity disorder is if they have symptoms of over training yet persist with exercise anyway.

Symptoms of Over training
Fatigue Reduction in performance
Decreased concentration Inhibited lactic acid response
Loss of emotional vigor Increased compulsivity
Soreness, Stiffness Decreased maximum oxygen uptake
Decreased blood lactate Hypothalamic dysfunction
Autonomic sympathetic insufficiency Adrenal exhaustion
Immunosuppression "acute phase" response
Decreased catechtamine sensitivity ( heart rate response to exercise)
Increased central serotonin & GABA
Decreased anabolic (testosterone) response
Increased catabolic (cortisol) response (muscle wasting)

In many cases the only cure for the above symptoms is complete rest which may take a few months. To a person with activity disorder resting is like giving up or giving in. This is similar to an anorexic who feels like eating is, "giving in". When giving up their exercise behaviors those with activity disorder will go through psychological and physical withdrawal which improves over time.

We have all been told that exercise is a good thing, but as always, too much of a good thing turns bad. There are people who exercise for fun or because they just want to be healthy, but according to the clients in my practice, the number of individuals working out in destructive and obsessive ways, is steadily increasing.

Bedraggled, pale, exhausted, protein starved individuals show up in my office every day who feel they must; exercise their skinny, frail body in order to "not get fat," or who boast of attending two, or even three, aerobics classes in one day, or running yet another 10 K. Exercising, for many of these people, has become merely a means to achieve a number on a scale, or some other external measurable goal. These poor clients of mine are far from the radiant glow of health.

Our cultural fixation on the ideal female figure and appearance, especially thinness, has infiltrated and damaged women's sports and taken female athletes into an arena where what they look like can mean as much as how they perform. Here we find the extreme of the "fit or fanatic" spectrum, but we mustn't forget that the extreme indicates the direction or goal in which all are encouraged to aspire to. Ballerinas, skaters, and gymnasts are the most obvious examples. Consider the following scenario. The female gymnasts in the 1992 Olympics whose average age was 16, average height was 4' 9" and average weight was 83 pounds, were a year younger, 61/2 inches shorter and 23 pounds lighter than the female gymnasts seen in 1976.

In women's gymnastics and figure skating, we no longer expect to see women. We have come to expect little girls. And we expect these girls not only to be very talented, but in order to win, or even be in the running, they must also be very thin, very young, and very pretty. In figure skating, even costumes, which can cost as much as $5000, affect their scores.

In, "Little Girls in Pretty Boxes", Joan Ryan exposes the truth behind the scenes of these elite female athletes. Ryan quotes gymnastics trainer, Jack Rockwell, "I remember a top American official saying to Mary Lou Retton a year after the (1984) Olympics, 'You know, if I could, I'd take half a point off just because of that fat hanging off of your butt.'" These girls must not let their bodies grow up and develop female curves, menarche and post pubescent body fat. In other words, in these sports, to become a woman means your elite career is over. "Because they excel at such a young age, girls in these sports are unlike other elite athletes. They are world champions before they can drive."

Strenuous exercise combined with poor eating can have severe and often unforeseen consequences, for example, delaying puberty. All females who exercise are susceptible. Close to 2/3rds of female college athletes have irregular or non existent periods, a condition known as amenorrhea. With amenorrhea, the rate of bone loss can be alarming. An absence of menstruation means an absence of estrogen,which means bones can't develop properly. This can have a profound effect on a girl's skeletal development since 48 to 70% of bone mass and 15 % of height are achieved during adolescence. A 23 year old bulimic patient of mine was recently tested for bone density and discovered that it was indicative of a 65 year old woman. A 21 year old amenorrheic anorexic runner I am currently treating, tested with a bone density of an eighty year old!

Heather, an anorexic college student I was treating, was up to running at least 10 miles or more per day on a diet of lettuce and mushrooms. "I really don't feel like I need food," Heather told me, "I know it's crazy but running is my food." Heather had previously been hospitalized and there were no available funds left for inpatient treatment so I was struggling to manage this case on an outpatient basis, knowing her life was at risk. I , of course, kept asking her to stop running and she kept "trying." Meanwhile, her weight kept plummeting. "I don't have a choice" she told me, "There is a voice in my head that says I must run, faster and farther, even though I know it's not getting me anywhere I want to go." I read Heather the above quote from, Through The Looking Glass, and we discussed how, inside her head she was both Alice and the Queen.

Luckily before Heather died from cardiac arrest or before I had to step in and require another hospitalization at her parents expense, Heather tore her Achilles tendon and although she even tried to keep running on it, she was forced to stop. This was the beginning of her recovery. Heather now thanks her injury for saving her life but knows that her journey to recovery is not yet over. She still has a part of herself that thinks like Alice's crazy queen.

The Alice In Wonderland Queen mentality is all to common in young girls today. Exercise or, "working out," is too often approached with an oppressive, compulsive, nonsensical and even dangerous attitude by females who engage in it. For females, the craze in fitness, gym memberships, health spas and resorts has more to do with the pur-suit of thinness, than the pursuit of fitness. In her book, Compulsive Exercise and The Eating Disorders, Alayne Yates discusses this issue and refers to the Glamour magazine study of 33,000 women readers, revealing that 95% of the respondents exercised to control their weight, not improve their health. Therefore, overweight females are made to feel, as the phrase implies, that, " to work out" has nothing to do with play or fun, but is another form of oppression or torture imposed on them in order that they conform to the ideal standard of beauty.

As a society we need to change "working out" back into, "having physical fun, " or "using our bodies in play." We need to add back into our lives dancing, walks in the park, trips to the beach, hikes on the weekend or bike rides. Playing physical games like tennis or softball can be fun as well. However, even games can be turned into another way to perform, or be measured, if not carefully thought about. Too often the competitiveness of the game and the desire to score highly or to win ruins the whole idea of "play" or "fun." For most of the participants who do not "excel" at the skill of a particular activity, it may not be fun, and for others, winning becomes the goal instead of simply playing, being active and having a good time. Our culture is good at promoting competitive sports and the desire to win and it needs no help in promoting exercise for weight loss. But we have failed at promoting activity and fitness in a healthy, and enjoyable way that is motivating for young people to engage in and continue. The current poor physical fitness of our youth and adult population testifies to this. Instead of a means to some end goal, exercise or physical activity that adds joy, fun and fitness, to our lives needs to be the goal.

One of the newest examples of goal oriented thinking and behavior gone awry is the current craze in body composition or body fat testing. For example, a local gym in my area conducts routine body fat testing for all members. They recently awarded a "First Place" ribbon to sixteen year old Catie, an anorexic patient of mine, for having the lowest body fat of all female gym members. Catie had nine percent body fat. Catie also had heart problem, she was not menstruating, and had just recently been discharged from an inpatient eating disorder program. Upon discharge from the hospital, Catie signed up at the gym where no screening procedures take place. She was exercising against the advice of her doctor and yet she won a fitness award! The paradox here is an outrage and a sad commentary on our society as a whole. And, this is not an isolated occurrence. I have several female clients with similar stories. All of this increases resistance to treatment. As Catie's statement to me poignantly describes, "You say I'm not healthy, you say I'm at risk, yet I win the award in my gym for fitness, it's making me crazy. Who can I believe?" I understood Catie's confusion. Everyone should become more pro active in trying to stop this kind of nonsense. In Catie's case, I contacted the gym and let them know the dangers of their policies and procedures. I urge anyone who comes across this kind of situation to take my lead and speak up. I informed the gym owner that a body fat of 9% was not healthy for a female and in fact, anything below 15% can interfere with menstruation, ovulation and bone density. I followed up calls by sending literature in the mail and I let gym owners, coaches, dance teachers, and even doctors know that they may be liable if anything happens to young girls, like Catie, who are using their facilities, or are under their care or supervision.

If You Think Someone you Care About Has A Problem With Exercise, Ask Yourself These Questions:
  1. Do you see evidence of aimless and/or excessive physical activity that goes beyond normal exercise or the usual training regimen of others ?
  2. Do you see evidence of depressed mood and self-deprecating thoughts or behaviors if she can't exercise?(e.g restricting her eating, crying or calling herself fat )
  3. Does she avoid situations in which she may be observed while eating (e.g., refusing to eat with friends or her teammates on road trips, making excuses such as having to eat
  4. before or after the team meal)?
  5. Does she appear preoccupied with the eating and exercise behavior of other people such as friends, relatives, or teammates?
  6. Do you see any changes in her physical appearance and/or performance that suggesst she is run down, weak, and sickly?
  7. Is she is able to voluntarily abstain from exercise?
  8. Does she exercise even when hurting or injured?
  9. Does she miss or avoid social or family activities because she has to exercise?
  10. Has her time spent exercising steadily been increasing?
  11. Is she defensive about any suggestion to curb her exercise?

If you can answer yes to even one of the above questions you should approach your friend with your concern and consult a health professional with expertise in eating disorders because they are the most likely professionals prepared to treat exercise disorders. Your friend is probably oriented toward success and accomplishment and will feel embarrassed about being diagnosed with a disorder. He or she will very likely resist any offer of help. Your friend probably will think and say that he or she either doesn't have a problem or can handle any problem on his or her own. Let your friend know that outside help is almost always necessary and should not be regarded as a failure or lack of effort. Most importantly, don't give up at the first try. See the side bar on this topic for helpful tips.

APPROACHING AN INDIVIDUAL WITH AN ACTIVITY DISORDER
In January 1986, The Physician and Sports Medicine journal discussed the subject of pathogenic exercise in athletes and listed recommendations for approaching athletes practicing one or more pathogenic weight-control techniques. The recommendations can be reformulated and extended for use when approaching individuals with activity disorders who are avid exercisers but not necessarily considered athletes.

Guidelines for approaching the activity disordered individual:
  1. A coach or person who has good rapport with the individual should arrange a private meeting with him or her to discuss their in a supportive style.
  2. Without judgment, specific examples should be given regarding observations that arouse concern.
  3. It is important to let the individual respond but do not argue with him or her.
  4. Reassure the individual that the point is not to take away exercise if an admission that an eating (or exercise) problem exists. Do however, state that participation in exercise or on a team will ultimately be curtailed if evidence shows that the problem has compromised the individual's health in a way that could lead to injury.
  5. Try to determine if the person feels that he or she is beyond the point of being able to voluntarily abstain from the problem behavior.
  6. Do not stop at one meeting, these individuals will be resistant to admitting they have a problem and it may take repeated attempts to get them to admit a problem and or seek help.
  7. If the individual continues to refuses to admit that a problem exists in the face of compelling evidence, consult a clinician with expertise in treating these disorders and/ or find others who may be able to help. Remember that these individuals are very independent and success oriented. Admitting they have a problem that they are unable to control will be very difficult for them.
  8. Be sensitive to the factors that may have played a part in the development of this problem. Activity disordered individuals are often unduly influenced by significant others and/or coaches who either suggest they lose weight, or who unwittingly praise them for excessive activity.


TREATMENT FOR ACTIVITY DISORDER
The principles of treatment for individuals with activity disorder are similar to those for eating disorders. Medical issues must be handled and inpatient treatment may be necessary for depression or suicidality, but most cases should be able to get treatment on an outpatient basis unless the activity disorder and an eating disorder co exist. This combination can present a serious situation rather quickly. When lack of nutrition is combined with hours of exercise, the body gets broken down at a rapid pace and inpatient treatment may be required. Sometimes hospitalization is offered to patients as a way to relieve their vicious cycle before a breakdown occurs. Activity disordered individuals often recognize they need help to stop and know that they cannot do it with outpatient alone. Eating disorder treatment programs are probably the best choice for hospitalizing those with activity disorder. An eating disorder facility that had a special program for athletes or compulsive exercisers like the program at The Monte Nido Treatment Center in Malibu, California, would be ideal. If you would like more information on assessment or treatment please feel free to contact Carolyn Costin or Monte Nido at 310-457-9958.