Dr Jennifer Jordan Senior Lecturer University of Otago Christchurch

15:05 - 15:15 and Extreme Sports Anton Krupicka Exercise & Extreme Sports Addiction

Jennifer Jordan PhD National Addiction Centre Department of Psychological Medicine University of Otago, Christchurch https://blondeau.wordpress.com/2013/12/12/ultramarathon-running-as-spiritual-practice/ “I became a f…. hamster. Seventeen miles a day on a treadmill. I would get up in the morning, and before I went to the studio, I would run eight-and-a-half miles in about an hour. Then I’d come home and run another eight and a half. I started getting OCD about the calories, making sure I burned 2,000 every day. In the end, I got down to about 149 pounds. I ran to the point where I started to get injured. All the constant pounding from the running began to tear up my hip flexors.”

https://www.theguardian.com/music/2015/aug/04/eminem-became-addicted-to-exercise-following-drug-rehabilitation What is meant by exercise addiction?

• “Exercise addiction is a condition when a regularly exercising person loses control over her or his exercise behaviour, while acting compulsively and exhibiting dependence, resulting in negative consequences in their day to day health and /or life” (Szarbo et al, 2016)

• Other Terms for EA • Compulsive, obsessive driven, obligatory, excessive, intense, at risk

• Not (yet) in DSM-5 or ICD

• So, is exercise addiction a real thing? EA is multifactorial - it’s not just the amount of exercise

AMOUNT + COMMITMENT + MOTIVATION

Positively reinforcing exercise motivations • Runner’s high • Achievement /mastery/ testing /overcoming limits • Health • • Improves positive affect • Spiritual Avid exerciser: High amount + high commitment + positive motivation • Negatively reinforcing (escape) exercise motivations Addiction.com • Reduces negative affect (stress and ) • Compensatory behaviour in eating disorders (avoid weight gain) Exercise addiction: High amount + high commitment + escape motivation AMOUNT + COMMITMENT + MOTIVATION + HARMS

• Mild injuries become worse • Over training syndrome • Cardiac problems • Leaky gut • Immune system • Poor sleep

• Low mood • Reduced quality of life • Impacts on life role functioning/ relationships/ work or education • Distress at loss of control /powerlessness Addiction model applied to exercise Salience Exercise dominates life Mood Positive buzz or relief from negative emotion modification Tolerance Increasing the amount of exercise in order to feel the desired effect Withdrawal Intensity of symptoms is key symptoms Guilt, irritability, , anxiety/stress, feel fat / sluggish, restlessness, sleep problems Personal conflict Continuation despite interpersonal and roles impacts - Internal ambivalence Relapse Unsuccessful attempt to moderate exercise levels or stop, relapse Co-existing problems

• Psychiatric comorbidity • Eating disorders • Body dysmorphia • Orthorexia • Mood disorders • Anxiety disorders • Other substance related or behavioural addiction

• Personality traits • Novelty seeking / excitement / impulsivity

• Persistence • Perfectionism (negative aspects) • Obsessive compulsive personality drive • Low self-esteem • Harm avoidance • Low agreeableness/ cooperativeness How prevalent? General adult population - Hungary Monok et al 2012 < .5% University students ~ 3% Sports science students 6.9% Higher in at risk groups 80% 55% Gym attendees 10% - 42%

Triathletes 30.4% primary 21.6% secondary Amateur endurance cyclists 17% Ultra marathoners Allegre et al 2007- only one study 3.2% Extreme sports addiction

Europagymnasium Baumgartenberg Rock climbers experience withdrawal symptoms (: craving, and negative affect) if they can’t climb (Heirene et al, 2016) “Adrenaline junkies”

Risk of serious injury and death is inherent in the activity Differences vs. “daily” exercise addiction • Activities may be less frequent than “daily” EA • Extreme experiences trigger the Biggest Waves Ever Surfed - Nazare • More intense dopamine high due to deficiency of dopamine-inhibiting receptors • Strong positive motivations • Passion, peak experiences, pushing limits • Unlikely to identify behaviour as a problem Overlap with “daily” exercise addiction • Similar sensation seeking, impulsive personality traits seen in SUD • Overuse injuries • Tolerance / withdrawal discomfort How to assess in general practice? • Presentation likely to be for an injury, not for exercise addiction

• Consider if: • Physical signs and symptoms • Injuries related to high levels of training (stress fractures etc) • Over training syndrome • Extreme leanness / change in body weight /Amenorrhea • Significant distress at inability to exercise • High risk groups • Eating disorders • Body building, endurance exercisers • History of other addiction issues and now exercising • Useful screener • Exercise Addiction Inventory- 6 questions (Terry et al, 2004) Treatment

• Surprisingly little specifically about EA - no RCTs • Brief intervention • Advice about the risks of excessive exercise, recommended levels, rest days • Treat comorbid or underlying mental health conditions • • Cognitive behavioural therapy, motivational interviewing etc • Existing addiction treatment models likely to be applicable Conclusions

• Exercise addiction is an emerging category • affects few but has serious physical and psychological impacts and warrants attention

• High levels of exercise are not in themselves pathological

Take home message: It is the harm, not the amount