Journal of Behavioral 2(4), pp. 199–208 (2013) DOI: 10.1556/JBA.2.2013.4.2 The paradox: An interactional model for a clearer conceptualization of exercise

ALEXEI Y. EGOROV1,2,3 and ATTILA SZABO4,5*

1Department of Psychiatry and Addictions, Faculty of Medicine, St. Petersburg State University, St. Petersburg, Russia 2Department of Psychiatry and Addictions, Mechnikov North-West Medical University, St. Petersburg, Russia 3Laboratory of Behaviour Neurophysiology, and Pathology, Sechenov Institute of Evolutionary Physiology and Biochemistry, St. Petersburg, Russia 4Institute for Health Promotion and Sport Sciences, Eötvös Loránd University, Budapest, Hungary 5Institutional Group on Addiction Research, Institute for Psychology, Eötvös Loránd University, Budapest, Hungary

(Received: May 22, 2013; revised manuscript received: September 12, 2013; accepted: October 13, 2013)

Background and aims: Exercise addiction receives substantial attention in the field of behavioral addictions. It is a unique form of addiction because in contrast to other addictive disorders it is carried out with major physical-effort and high energy expenditure. Methods: A critical literature review was performed. Results: The literature evaluation shows that most published accounts report the levels of risk for exercise addiction rather than actual cases or morbidi- ties. The inconsistent prevalence of exercise addiction, ranging from 0.3% to 77.0%, reported in the literature may be ascribed to incomplete conceptual models for the morbidity. Current explanations of exercise addiction may suggest that the disorder is progressive from healthy to unhealthy exercise pattern. This approach drives research into the wrong direction. Discussion: An interactional model is offered accounting for the adoption, maintenance, and trans- formation of exercise behavior. The here proposed model has an idiosyncratic black-box containing the antecedents and characteristics that are unique to the individual, which cannot be researched via the nomothetic approach. Sub- jective aspects in the black-box interact with stressful life events that force the person to cope. The range of coping may be wide. Escape into exercise depends on personal (subjective) and situational (objective) factors, but the sub- jective components are inaccessible for a priori scholastic scrutiny. It is our view that currently only this dual interactional model may account for the fact that exercise addiction emerges suddenly and only in a few individuals from among those at high risk, estimated to be around 3.0% of the exercising population.

Keywords: dependence, exercise abuse, research, review, theory, transformation

INTRODUCTION dividuals spend too much time at work (workaholism – Scottl, Moore & Miceli, 1997), or online (Internet addiction Exercise addiction within behavioral addictions – Young, 1998). Some are too fond of shopping (shopping addiction – Krueger, 1988), watching television (addiction Currently three types of addictions are known in the scholas- to television – Kubey & Csikszentmihalyi, 2002), overin- tic literature: 1) substance or chemical addictions, 2) behav- dulging in porn or sexual activity ( – ioral (non-chemical or non-pharmacological) addictions, Carnes, 1983), or physical activity (exercise addiction – and 3) food addictions (Egorov, 2013). Behavioral addic- Szabo, 2010), or even tango dancing (dance addiction – tions are compulsive psychological and physiological urges Targhetta, Nalpas & Perney, 2013). While to date relatively for one or more specific behaviors. There is increased atten- little attention has been devoted to the understanding and tion devoted to this group of morbidities by researchers in treatment of these “imprisoning” behaviors, they should no the field. A category of “” is included longer be ignored. As pointed out by Martin and Petry into the new DSM-V (American Psychiatric Association, (2005), non-chemical addictions may not only resemble, but 2013). While there are many forms of behavioral addictions they also share a common neurobiological mechanism with with wide range of consequences, the DSM-V category of or drug addictions. Thus behavioral addictions are behavioral addictions only includes gambling addiction. not only possible, but they are preponderant in the daily hu- Internet addiction was also considered for inclusion into this man life (Holden, 2001) – regardless of the recognition category, but there was no consensus in the working group. and/or consensus of the DSM-V working group – and may Therefore, Internet addiction is only included in the man- be more common than expected, because it is difficult to de- ual’s appendix to encourage further research. Exercise ad- tect them as they very often blend into the normal spectrum diction, after over four decades of scholastic interest and re- search on the topic, is still left out from the DSM-V. * Corresponding author: Attila Szabo, PhD, Associate Professor It is becoming increasingly more evident that people and Deputy Director; Institute for Health Promotion and Sports could become addicted to various behaviors. In addition to Sciences, Faculty of Education and Psychology, Eötvös Loránd behavioral addiction to gambling recognized in the DSM-V University, Bogdánfy u. 10, H-1117 Budapest, Hungary. Phone: (Parke & Griffiths, 2004), new forms of addictive behaviors +36-70-243-712 or +36-1-209-0619; E-mails: drattilaszabo@ have surfaced in the medical literature. Indeed, numerous in- yahoo.com or [email protected]

ISSN 2062-5871 © 2013 Akadémiai Kiadó, Budapest Egorov and Szabo

Table 1. Working classification of non-chemical forms of addictive behavior (Egorov, 2007, 2013)

Gambling addiction Erotic addiction Positive (or socially accepted) Technological addictions Food addictions addictions (Glasser, 1976) Gambling and betting Love addiction Workaholism or work addiction Internet addiction1 Overeating addiction addictions Sexual addiction Exercise addiction2 Mobile phone addiction Starvation-diet related addiction Mixed love-sex, partner Shopping addiction (compulsive Television addiction addiction buying) Religious addiction Relationship addiction 1Internet addiction includes: Internet-gamblers, Internet-gamers, Internet-workaholics, Internet-sexaholics, Internet-erotaholics, Internet-shopaholics, Internet relationship and social networking addicts. 2Exercise addiction does not include excessive exercise observed as symptom in eating disorders. of the daily human activities. Indeed, behavioral addictions 1970). The author of the study faced great difficulties in re- are often as serious in their consequences as alcohol or drug cruiting highly committed athletes (exercising 5–6 days a addictions (Martin & Petry, 2005). A majority of non-phar- week), who would be willing to give up their training for one macological addictions are usually encountered within a month. In fact, eligible potential participants have refused to family context and often seem to be fostered by family pro- participate in the experiment even when they were offered cesses (J.Y. Yen, C.F. Yen, C.C. Chen, S.H. Chen & Ko, cash reward. Baekeland was only able to recruit athletes who 2007). Therefore, family therapy is usually a first option in trained only 3–4 times a week. During the month of the de- treating the variety of non-pharmacological addictions at in- privation, these participants reported negative psychological dividual-clinical (idiosyncratic cases), rather than group-re- well-being, which surfaced as high level of , frequent search level. night awakenings, and sexual tension. There are several new attempts to classify behavioral ad- Later the concept of addiction to exercise was first intro- dictions. Egorov (2007, 2013) offered a working classifica- duced by Sachs and Pargman (1984). The authors have used tion of non-chemical forms of addictive behavior (Table 1). the term running addiction to describe the source of a set of In this classification Glasser’s (1976, 2012) concept of posi- withdrawal symptoms that surface during periods of running tive addiction has been incorporated in a context of mundane deprivation: anxiety, tension, irritability, muscle twitching, humane behaviors that under ordinary circumstances may etc. However, earlier, Morgan (1979) also provided exam- make the individual stronger and happier. These behaviors, ples in which runners continued to run, despite the adverse however, turn into negative addictions or psychopathology circumstances (for example, various injuries), which should once they start to be abused to the point where they result in reduce or interrupt training. Diagnosed clinical cases of ex- harm to both the affected individual and her/his social sur- ercise addiction in all kinds of sports – martial arts, weight roundings. lifting, and body building – were only reported later Physical exercise is one of the behaviors that benefits (Griffiths, 1997; Hurst, Hale, Smith & Collins, 2000; people both physically and mentally and, therefore, its regu- Murphy, 1994). These clinical cases of exercise addiction lar practice may be beneficial and viewed by Glasser (2012) are characterized by loss of control over the exercise behav- – and perhaps many others – as therapeutic. Recently, Glas- ior, which is performed as “obligation” rather than for en- ser highlighted that in certain cases self-improving behav- joyment, and also have negative physical and psychosocial iors like exercise or meditation could become addictive and consequences for the individual. Symptoms include all com- this form of addiction builds strength in the person and pro- ponents of addictive disorders: salience, withdrawal, mood motes a happier and healthier living. This is a view that in modification, conflict, tolerance, and relapse (Szabo, 2010). conjunction with the clinically diagnosed cases of exercise In light of this definition pathogenic exercisers could be dis- addiction (Griffiths, 1997) confers a paradoxical role for ex- tinguished from the other high-volume exercisers, like ath- ercise behavior. Indeed, habitual or committed forms of ex- letes, who maintain control over their training, have a fixed ercise may be therapeutic, while loss of control renders the schedule of training to also meet other life-obligations, and behavior pathogenic. In this analytical account the current encounter no harmful or negative consequences as a result of models forwarded for exercise addiction are reconsidered. their intensive training. Then in an attempt to segregate risk assessment (nomothetic To avoid a conceptual confound, it should be mentioned approach via questionnaire-screening) and clinical diagno- that De Coverley Veale (1987) differentiated between pri- sis of exercise addiction, an alternative interactional model mary and secondary exercise addiction. In this article only is proposed for the better understanding of the exercise para- primary exercise addiction is considered because secondary dox. exercise addiction is a symptom in a number of eating disor- ders including and (De Coverley Veale, 1987). In these disorders, excessive exer- EXERCISE ADDICTION cise is a means for caloric control and weight loss rather than for escape from a psychological hardship. Secondary exer- In the past decades several publications dealing with exer- cise addiction as a symptom in eating disorders occurs in dif- cise addiction have emerged. Research into highly accus- ferent “doses” in people affected by eating disorders. It was tomed exercise started with a work that investigated the ef- estimated that one third of anorectics may be affected (Crisp, fects of exercise deprivation on sleep patterns (Baekeland, Hsu, Harding & Hartshorn, 1980).

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ESTIMATED PREVALENCE THEORETICAL MODELS OF EXERCISE ADDICTION FOR EXERCISE ADDICTION

Mass screening for exercise addiction takes place by using The apparent lack of understanding of the exercise paradox, psychometrically validated questionnaires. Two instruments begs for sound theory-driven research. In his 2010 mono- that prove to be similar in sensitivity and reliability (Mónok graph, Szabo presented two specific models for exercise ad- et al., 2012) are the Exercise Dependence Scale (EDS, 21 diction and several models that try to explain the psycholog- items; Hausenblas & Downs, 2002) and the Exercise Addic- ical beneficence of exercise, which in turn could be indi- tion Inventory (EAI, 6 items; Terry, Szabo & Griffiths, rectly linked to exercise addiction. In the current paper only 2004). These scales do not convey exact – or accurate – in- the specific models are dealt with. The Sympathetic Arousal formation about the actual prevalence of exercise addictions Hypothesis (Thompson & Blanton, 1987) is physiological since they are screening- rather than diagnosis-tools. Indeed, model suggesting how adaptation of the organisms to habit- the estimates based on these questionnaires should be inter- ual exercise may lead to addiction. Briefly, adaptation to ex- preted as symptomatic or at risk for exercise addiction as ercise lowers the body’s sympathetic activity. Lower sym- also noted be the developers of the tools (Hausenblas & pathetic activity at rest means lower level of arousal. This Downs, 2002; Terry et al., 2004). new baseline or resting level of arousal may not be adequate A number of inquiries were conducted on convenience for various daily activities. It may be experienced as a lethar- samples of university students. Hausenblas and Downs gic or energy-lacking state. This feeling prompts the person (2002) reported that between 3.4% and 13.4% of their sam- to do something about it, or to increase her/his arousal. One ples were at high risk for exercise addiction. The lower fig- means to do that is exercise. However, the effects of exercise ure was also confirmed by Griffiths, Szabo and Terry (2005) in increasing arousal are only temporary and, therefore, who reported that 3.0% of university students could be more and more bouts of exercise may be needed to trigger an at-risk of exercise addiction. Later Szabo and Griffiths optimal state of arousal (Figure 1). Further, not only the fre- (2007) confirmed that the prevalence of risk for exercise ad- quency but also the volume of exercise may need to be in- diction is about 3.6% in the general exercising population, creased due to training effect. Such an increase accounts for while the figure is nearly double (6.9%) in British Sport the tolerance in the addiction process. The main dilemma Science undergraduates. The study by Hausenblas and with this model is that sympathetic adaptation to exercise is Downs (2002) was conducting by using the EDS, whereas universal, so it occurs in everyone, but only about 3% of the the other two by using the EAI. Nevertheless, the two instru- regular may become addicted to the behavior ments yielded comparable results in American and British (Sussman et al., 2011a). samples. Recently, in a Hungarian population-wide study The second model presented by Szabo (2010) was the (Mónok et al., 2012) the proportion of exercisers at-risk Cognitive Appraisal Hypothesis (Szabo, 1995). This model for addiction was 1.9% among exercisers and 0.3% in takes in consideration life-stress – that requires challenge the general population as gauged with the EDS. However, beyond one’s perceived resources – in the addiction model. the EAI yielded slightly higher figures, 3.2% in habitual Some (but it is unknown who) exercisers may try to escape exercisers and 0.5% in the general population. Mónok from an ongoing or a sudden stress by resorting to exercise et al. (2012) attributed the discrepancy to a lack of an as the means of coping with stress. Once exercise is the cop- empirically established cut-off point for the EAI. In spite of ing method with stress, the person depends on it to function the slight discrepancy between the EDS and EAI they well. She/he believes that exercise is a healthy means of cop- appear to project a “close estimation” of the prevalence of ing with stress based on information from scholastic and risk for exercise addiction in committed exercisers public information sources. Therefore, the person is using (Sussman, Lisha & Griffiths, 2011a). Several investigations that used other instruments than the EDS and EAI in the scrutiny of the risk for exercise addiction have found exag- Regular exercise gerated or unlikely figures for the morbidity, as summarized in Table 2. Although researchers have stressed that actual cases of exercise addiction are rare (Szabo, 2000; Veale, 1995) espe- Decreased sympathetic arousal at rest cially when compared to other addictions (Sussman et al., 2011b), figures of above 40% prevalence, published in the past five years, suggest that the psychopathology is not well Physical: feeling lethargic, tired, lazy understood among scholars. The diversity in instruments used, samples, and methods of inquiry – as well as some pos- sible cross-cultural issues that were not addressed to date – Psychological: feeling down, bad, negative may all contribute to the inconsistencies seen in Table 2. Further, as noted earlier, the questionnaire-based studies could only estimate the preponderance of the “at-risk” exer- cisers rather than actual clinical cases. Consequently, the lat- Urge to increase arousal ter may be even lower than the estimates based on the popu- lation-wide results reported recently (Mónok et al., 2012). Exercise workout

Figure 1. The Sympathetic Arousal Hypothesis Based on: Thompson & Blanton (1987).

Journal of Behavioral Addictions 2(4), pp. 199–208 (2013) | 201 Egorov and Szabo

Table 2. Prevalence of exercise addiction according to extant reports in the scholastic literature Year Author(s) Sample studied Measure(s) used Prevalence (%) 1995 Thornton & Scott Runners Commitment to Running Scale (CRS – 77% Carmack & Martens, 1979) 1998 Slay et al. Runners Obligatory Running Questionnaire 26.2% of male runners, (Blumenthal, O’Toole & Chang, 1985) 25% of female runners 2000 Bamber, Cockerill & Carroll Mixed exercisers and Exercise Dependence Questionnaire 14.8% and 9% also university students (EDQ – Ogden, Veale & Summers, 1997) suffering of eating disorders 2002 Ackard, Brehm & Steffen Female university exercisers Obligatory Exercise Questionnaire 8.0% (Pasman & Thompson, 1988) 2002 Blaydon & Lindner Triathletes EDQ 30.4% primary and 20.6% secondary exercise addiction 2002 Hausenblas & Downs University students Exercise Dependence Scale (EDS – 3.4% and 13.4% in two Hausenblas & Downs, 2002) studies 2004 Downs, Hausenblas & Nigg University students EDS-Revised (EDS-R – Downs et al., 3.6% and 5.0% in two 2004) studies 2005 Griffiths et al. University students Exercise Addiction Inventory (EAI – 3.0% Terry et al., 2004) 2007 Allegre, Therme & Griffiths Ultra-marathoners EDS-R (French) 3.2% 2007 Szabo & Griffiths Habitual exercisers and Exercise Addiction Inventory (EAI – 3.6% in habitual exercisers, Sport Science students Terry et al., 2004) 6.9% in Sport Science undergraduates 2007 Youngman Triathletes EAI 19.9% 2008 Lejoyeux, Avril, Richoux, Fitness centre attendees Interview and own questionnaire 42% Embouazza & Nivoli 2009 Modolo et al. (cf. Modolo Various amateur athletes Negative addiction Scale (NAS – 32% et al., 2011) Hailey & Bailey, 1982) 2010 Smith, Wright & Winrow Competitive runners EDS and Running Addiction Scale 50% (RAS – Chapman & De Castro, 1990) 2011 Grandi, Clementi, Guidi, Habitual exercisers EDQ (Italian) 40.5% Benassi & Tossani 2011 Villella et al. High school students EAI (Italian) 8.5% 2012 Costa, Cuzzocrea, Hausenblas, Fitness centre attendees EDS-R (Italian) 6.6% Larcan & Oliva 2012 Lejoyeux, Guillot, Chalvin, Fitness centre attendees EAI (French) and own questionnaire 29.6% Petit & Lequen 2012 McNamara & McCabe Elite athletes The Exercise Dependence and Elite 34.8% Athletes Scale (EDEAS – McNamara & McCabe, 2013) 2012 Mónok et al. Population-wide study EDS and EAI (Hungarian) 0.3% on EDS and 0.5% on EAI in general population; 1.9% on EDS and 3.2% on EAI in regular exercisers 2013 Lichtenstein, Christiansen, Exercisers and soccer EAI (Danish) 5.8% Bilenberg & Støving players 2013 Menczel et al. Fitness centre attendees EDS & EAI (Hungarian) 1.8% + 1.8% who exhibited both exercise addiction and eating disorders rationalization to explain the exaggerated amount of exer- A “Four Phase” model for exercise addiction was pro- cise that progressively takes a tool on other obligations and posed by Freimuth, Moniz and Kim (2011). The first phase daily activities. However, when interference of exercise is characterized by pleasurable activity while the behavior is with other life-obligations forces the individual to reduce the under control. There are no major negative consequences in amount of exercise, psychological hardship emerges in form general, but muscles soreness or minor strains may occur. In of withdrawal symptoms. Loss of exercise also means the phase two, the psychological beneficence of exercise is real- loss of the coping mechanism. Consequently, the exerciser ized and the mood-modifying effects may be adopted for loses control, which generates greater vulnerability to stress coping with hardship. Addiction is most likely to occur by further amplifying the negative feelings associated when exercise becomes the primary or the sole means of with the lack of exercise. The problem could be resolved coping with stress. This part of the model may address the only through resuming the previous pattern of exercise often onset of exercise addiction, but it does not specify two key at the expense of the other obligations in the daily life (Fig- issues: 1) a distress must exist, whether progressively ure 2). While this model depicts exercise addiction as coping mounting or suddenly appearing, and 2) under what condi- or escape, it only accounts for maintenance of addiction, but tions or influences will exercise be adopted for coping with not its onset. stress? The third phase is characterized by the rigid organi-

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Exercise is the means of coping A “Biopsychosocial” model for exercise addiction in with unbearable stress elite athletes was also proposed recently (McNamara & McCabe, 2012). It is our view that overtraining and over commitment in elite athletes does not parallel the psychiatric Lack or exercise means loss of the coping mechanism cases of exercise addiction. In our opinion this model is questionable for at least two reasons: 1) Timing and avail- ability; If behavioral addictions are means of escape from Loss of control over the stressful unbearable stress (Korolenko, 1991), the escape needs to situation happen when the pain dictates or the urge arises. Elite ath- letes have a training regimen that is scheduled for them, in group settings, and at directed intensity. These are not char- Increased actual or perceived vulnerability to stress acteristics of exercise or any other behavioral or chemical addiction, because the compulsive urges that dominate the person’s behavior – after she/he has lost control over the ad- Psychological hardship (withdrawal dictive behavior(s) – trigger craving for instant fulfillment. symptoms) 2) The model has a biologically determined onset, like body mass index (BMI), given as example by the authors (McNamara & McCabe, 2012). If we consider deeply that Strong urge for exercise most addictions are forms of escape from painful reality (Korolenko, 1991), then while biological factors affect Figure 2. The Cognitive Appraisal Hypothesis psychology, the route of addiction(s) may be – most likely – Based on: Szabo (1995). of psychological origin. The “Biopsychosocial” model (Fig- ure 4) states that exercise addiction has a biological factor zation of daily obligations around exercise, negative conse- (e.g. BMI) at its route of origin in the elite athletes. Social quences due to exaggerated exercise, and several forms of and psychological processes may interact to determine exercise either for replacing or complementing the habitual whether exercise addiction will occur or not. Freimuth et al. mode of exercise. Further, exercise is performed individu- (2011) warned that intensive training, for long hours, and ally, rather than with friends, in a team, or during scheduled ambitious strivings to become the best of the best that char- fitness classes. The fourth or the last stage encompasses the acterizes successful elite athletes, should not be confused typical symptoms of fully manifested addiction like sa- with symptoms of addiction in spite of the fact that there is lience, tolerance, conflict, need for mood modification and overlap in the latter. This point of Freimuth et al. is fully en- the avoidance of withdrawal symptoms and relapse. While dorsed for the two principal reasons discussed above. the model is appealing indeed, it does not account for the choice of coping mechanism, or who and why from among the exercise population will turn to this form of time and Biological factors i.e. Body mass index major energy requiring means of coping with adversity (Fig- (BMI) ure 3).

Phase One: Recreational Exercise Pleasurable activity, the behavior is under Social forces Psychological control, no or rare negative consequences apart Coach, teammate, processes from sore muscles or minor strains. parental or peer pressure, Self-esteem, training beliefs, socio-cultural pressure, etc. etc.

Phase Two: At-Risk Exercise The mood-modifying effects of exercise are dis- covered and used for coping with hardship. Ad- diction is most likely to occur when exercise be- Exercise addiction comes the primary or the sole means of coping with stress. Figure 4. The “Biopsychosocial” model for exercise addiction in elite athletes

Phase Three: Problematic Exercise Based on: McNamara & McCabe (2012). Daily obligations are rigidly organized around exercise, negative consequences emerge, ex- ercise is performed individually, several forms A theoretical model accentuating the possible role of of exercises are undertaken. interleukin six (IL-6) in exercise addiction has been pro- posed by Hamer and Karageorghis (2007). According to the model, an unidentified trigger causes IL-6 levels to rise and Phase Four: Exercise Addiction generate cytokine-induced sickness behavior that is linked Control over exercise is lost, salience and toler- to negative affect. In individuals affected by psychological ance appears, daily obligations are relaxed, avoidance of withdrawal symptoms becomes a hardship an elevated level of IL-6 could yield even more primary objective. negative mental state. However, the IL-6 hypothesis may not account for the possibility that some individuals will re- Figure 3. The “Four Phase” model for exercise addiction sort to exercise while others may reach for chemical means Based on: Freimuth, Moniz & Kim (2011). of escape. The low prevalence of exercise addiction is as-

Journal of Behavioral Addictions 2(4), pp. 199–208 (2013) | 203 Egorov and Szabo cribed to possible adaptations to exercise, whereas the lack AN EXPANDED INTERACTIONAL MODEL of it may increase vulnerability to exercise addiction (Fig- FOR EXERCISE ADDICTION ure 5). A missing aspect of the existing models for exercise addic- tion is the determinant(s) of the choice of exercise as a means of escape from hardship. Here it is strongly stressed, that an interaction between personal values, social image, past exercise experience, and life situation jointly determine whether one will use exercise for coping or resort to other means of dealing with stress. The possible number of inter- actions between personal and situational factors is so large the each case is idiographic in a mindset resembling a secret “black-box”. The box could only be opened after diagnosis with the help of mental health professionals. Indeed, exer- cise addiction, unlike other chemical and/or behavioral ad- dictions, has a unique characteristic not present in other ad- dictions, which is the physical challenge or work. It was pro- posed, based on preliminary laboratory evidence, that exer- cise acts as cathartic-buffer for stress (Tsang & Szabo, 2003). Habitual exercisers when experiencing stress – knowing the mood improving effects of exercise from past experience (Freimuth et al., 2011) – may resort to exercise to cope with the challenge. However, not all exercisers will try to reduce the pain of a novel emotional hardship with exer- cise, but instead may resort to passive forms of escape be- haviors or addiction(s). Therefore, a model taking into ac- Figure 5. The IL-6 Model for exercise addiction count the personal aspects interacting with social-environ- mental factors may be necessary for the better understanding Based on: Hamer & Karageorghis (2007). of the genesis of exercise addiction in the affected individu- Note: The dotted line reflects that inability to cope with exercise load als. Indeed, a positive relationship was established between my further increase IL-6 levels. exercise addiction risk-scores and trait anxiety (Coen & Ogles, 1993), perfectionism (Cook, 1996), and obsessive The review of the extant models that were specifically compulsiveness (Spano, 2001). Further, it was reported that forwarded for the explanation of exercise addiction clearly neuroticism, extraversion, and agreeableness could predict reveals that there is inconsistency in the research perspec- symptoms of exercise addiction (Hausenblas & Giacobbi, tives from which this behavioral addiction is examined. 2004). Finally, gender (Cook, Hausenblas & Rossi, 2013) Simply and perhaps crudely summarized, according to the and sex role orientation (Rejeski, Best, Griffith & Kenney, Sympathetic Arousal Hypothesis most habitual exercisers 1987) may also have mediating roles. The large combination may be affected by exercise addiction, a fact that is unlikely of subjective psychological factors interacting with situa- with a mean estimate of 3% (Sussman et al., 2011a); the tional variables may renders difficult if not impossible the Cognitive Appraisal Hypothesis accounts for exercise ad- scrutiny of exercise addiction from a nomothetic perspec- diction only after the behavior has been adopted for coping tive. with adversity, and cannot explain who/why chooses exer- The model presented in Figure 6 is an interactional cise as a means of coping; the “Four Phase” model is a hier- model for exercise addiction. It is in line with the proposed archical/developmental model, but again it does not address PACE (Pragmatics, Attraction, Communication, Expecta- when and who would rely on the mood-moderating effects tion) model for addictions in general (Sussman et al., of exercise for coping and with specific (?) adversities or 2011b). In the current model (Figure 6) a complex set of per- stress. The way the model may be interpreted is that all exer- sonal factors interact with a number of environmental – cisers who discover the mood improving and other positive and/or situational – factors to determine the primary motive psychological results of exercise may become addicted for exercise behavior. These motives diverge in two direc- while coping with stress; The “Biopsychosocial” model that tions (Robbins & Joseph, 1985). A health (mental or physi- was developed for elite athletes has unconvincing theoreti- cal) motivated individual, for example, may run for better or cal background in context of the freedom of choice to satisfy improved health (gain health) and/or to prevent ill health craving and urges inherent in addictions. Finally the IL-6 consequences like gaining weight, being lethargic, etc. Both model may be an intermediary in the etiology of exercise ad- incentives are therapeutic in nature. However, health mo- diction, but it cannot account neither for the trigger in raising tives could also have a mastery-orientation, like becoming IL-6 levels nor in exercise-related consequences, since ac- stronger and lifting more weight (performance orientations), cording to the model some exercisers may be affected while or concentrating better and being more productive at work. others (with adaptation) may not. Therefore, a model ac- If better concentration would be the aim, a therapeutic-ori- counting for the adaption, maintenance, and transformation entation would be established, but if the expected conse- of the behavior – and therefore addressing the exercise para- quence of the better concentration (productivity) is the ob- dox – is needed for a consistent conceptualization and re- jective, then the mastery orientation is the driving force. search framework in the understanding of exercise addiction The most important component of the here proposed as a clinical morbidity. model is the consideration of a suddenly emerging reaction,

204 | Journal of Behavioral Addictions 2(4), pp. 199–208 (2013) Exercise addiction revisited

Figure 7. The PACE Model for addictions Based on: Sussman et al. (2011b).

model is in harmony with the PACE model, it is specific to exercise and highlights how orientation, experience and per- sonal-situational interactions could all play mediating roles in the manifestation of exercise addiction. Past research long ago has revealed that addiction risk is higher in those who exercise for escaping the stress or changing their emotions, Figure 6. An interactional model for the better understanding or physical appearance to improve self-esteem as compared of the exercise paradox to those who exercise for mastery reasons (Thornton & Scott, 1995). Indeed, Baker, Piper, McCarthy, Majeskie and determined by a set of idiographic (i.e., personal and situa- Fiore (2004) proposed a model for drug addiction in which tional) interactions in the black-box to an ongoing and no addictive behavior is sustained through negative reinforce- longer bearable – or suddenly appearing – life stressor that ment in an effort to avoid negative affect. Szabo (2010) also causes psychological pain over which the individual has no argued that exercise addiction is motivated by negative rein- control. This component accounts for the surmise that exer- forcement. However, initial therapeutic orientation, like los- cise addiction is not evolutionary, or slowly progressing, but ing weight and/or gaining muscles, may – following fulfill- rather revolutionary, or suddenly surfacing (Szabo, 2010). ment of the goal – turn into mastery orientation and be main- At the moment when the situation gets out of control, a per- tained within the spectrum of healthy exercise pattern. Then, son will “gravitate” towards a means of available coping in as the bi-directional arrow (refer to Figure 6) indicates be- accord with the “Pragmatics” phase of the PACE model tween the therapeutic-orientation and major life-stress (Sussman et al., 2011b – see Figure 7). The choice is deter- (black), it is possible that through therapeutic exercising – mined by conscious and subconscious interactions (in the without addiction – one could master the situation and re-es- black-box) between individual aspects, situational factors, tablish a healthy pattern of exercise whilst coping with ad- and antecedents of exercise behavior, in accord with the “At- versity in a healthy way. traction” component of the PACE model, in a similar way as A broken arrow (Figure 6) from mastery orientation to the motivation for exercise is initially determined. Accord- exercise addiction accounts for the unlikely and possibly ingly, even mastery-oriented exercisers may now shift focus rare occurrences when an athlete would jeopardize her/his to the therapeutic aspects of exercise and get more involved health to stretch the personal limits. It must be stressed that in it to get rid of the painful stress. This attentional cognition the key reason beyond overtraining – which eventually will is also in line with the “Communication” factor in the PACE be unsuccessful due to strain, injury and staleness – could be model in that experience, inter- and intrapersonal thought, traced to mental or psychological origins: 1) the athlete is beliefs and convictions will influence the escape path or the unable to accept and to realize rationally a personal limit; 2) choice of the individual. For example, the lack of experience the athlete strives to beat own or past (other’s) record at any with alcohol, tobacco, or leisure drugs in conjunction with cost or otherwise all the athletic career was meaningless, 3) long exercise history and positive beliefs about exercise pressure from a past failure, or an unpleasant experience, (media, social, health values) all interact with unique per- generates a psychological need to “prove” oneself at what- sonal factors during the effort of coping. An already “thera- ever cost. While these motivations could fuel exaggerated peutic” exerciser in the model is more likely to chose exer- exercise behaviors, the route and path leading to the mani- cise for coping. Then, also in agreement with the PACE festations of the behavior is different from that of exercise model, the greater the expectation from exercise, the more addiction. In fact, the broken arrow may reflect instances of unlikely that the exerciser will turn to other forms of addic- exaggerated training whilst chasing of dream (or illusion) tions. Being a “positive addiction” it is much easier to hide that an athlete cannot give up. As such, it may be more behind exercise whilst maintaining one’s reputation in the closely defined as obsessive- rather social environment, in contrast to other forms of addictions than addiction. It should be noted that addiction involves bearing a social stigma. compulsion and dependence (Berczik et al., 2012) and the The PACE model was proposed for behavioral addic- later may be absent in mastery situations, and therefore tions in general (Sussman et al., 2011b). While the current marked with a broken arrow. Journal of Behavioral Addictions 2(4), pp. 199–208 (2013) | 205 Egorov and Szabo

CONCLUSION Blaydon, M. J. & Lindner, K. J. (2002). Eating disorders and exer- cise dependence in triathletes. Eating Disorders, 10, 49–60. Blumenthal, J. A., O’Toole, L. C. & Chang, J. L. (1985). Is running Approaching half-century of research, exercise addiction is an analogue of anorexia nervosa? An empirical study of obliga- still not well understood. The spectrum of the reported pre- tory running and anorexia nervosa. Obstetrical & Gyne- ponderance ranging from 0.3% to 77% shows that there are cological Survey, 40(2), 94–95. theoretical and methodological barriers to research in this Carmack, M. A. & Martens, R. (1979). Measuring commitment to area. Indeed, nomothetic research could yield results about running: A survey of runner’s attitudes and mental states. Jour- proneness or risk while actual clinical cases can only be ex- nal of Sport Psychology, 1, 21–42. amined through idiographic research. The existing models Carnes, P. (1983). The sexual addiction. Minneapolis, MN: for exercise addiction are incomplete. A new more compre- CompCare Publications. hensive interactional model, complementing the extant Chapman, C. L. & De Castro, J. M. (1990). Running addiction: models, is offered with a view to the more homogeneous Measurement and associated psychological characteristics. conceptualization of exercise addiction. Nevertheless, this The Journal of Sports Medicine and Physical Fitness, 30, dual interactional model has a subjective or idiosyncratic 283–290. component, that interacts with objective situational ele- Coen, S. P. & Ogles, B. M. (1993). Psychological characteristics of ments, for which the nomothetic perspective and scholastic the obligatory runner: A critical examination of the anorexia research may not account for. Therefore, the message of this analogue hypothesis. Journal of Sport & Exercise Psychology, paper is that researchers should clearly distinguish between 15, 338–354. risk for exercise addiction that may or may not end up in Cook, B., Hausenblas, H. A. & Rossi, J. (2013). The moderating ef- morbidity and actual clinical or psychiatric cases of exercise fect of gender on ideal-weight goals and exercise dependence addiction. The scope of the model presented in here is to symptoms. Journal of Behavioral Addictions, 2 (1), 50–55. draw a line between risk and morbidity. The exercise addic- Cook, C. A. (1996). The psychological correlates of exercise de- tion literature, apart from a few case studies, deals with esti- pendence in aerobics instructors. Unpublished master’s thesis, mates of risk that may never turn into actual morbidity. University of Alberta, Alberta, Canada. (cf. Hausenblas & Giacobbi, 2004). Costa, S., Cuzzocrea, F., Hausenblas, H. A., Larcan, R. & Oliva, P. (2012). Psychometric examination and factorial validity of the Funding sources: No financial support was received for this Exercise Dependence Scale-Revised in Italian exercisers. study. Journal of Behavioral Addictions, 1(4), 186–190. Crisp, A. H., Hsu, L. K. G., Harding, B. & Hartshorn, J. (1980). Authors’ contribution: AYE recognized the need for the re- Clinical features of anorexia nervosa: A study of a consecutive view and wrote up the draft paper; ASz reviewed the extant series of 102 female patients. Journal of Psychosomatic Re- models in the literature and devised the newly presented search, 24, 179–191. model. De Coverley Veale, D. M. W. (1987). Exercise dependence. British Journal of Addiction, 82, 735–740. Conflict of interest: The authors declare no conflict of inter- Downs, D. S., Hausenblas, H. A. & Nigg, C. R. (2004). Factorial est. validity and psychometric examination of the exercise depend- ence scale-revised. Measurement in Physical Education and Exercise Science, 8, 183–201. Egorov, A Y. Neximiheskie zavisimosti [Non-chemical ad- REFERENCES dictions]. Sankt Petersburg, Izdatelstvo “Rech”. (in Russian) Egorov, A. Y. (2013). New classification and psychopathology of Ackard, D. M., Brehm, B. J. & Steffen, J. J. (2002). Exercise and nonchemical addictions. Journal of Behavioral Addictions, 2 eating disorders in college-aged women: Profiling excessive (Suppl. 1), 14. Abs. exercisers. Eating Disorders, 10(1), 31–47. Freimuth, M., Moniz, S. & Kim, S. R. (2011). Clarifying exercise Allegre, B., Therme, P. & Griffiths, M. (2007). Individual factors addiction: Differential diagnosis, co-occurring disorders, and and the context of physical activity in exercise dependence: A phases of addiction. International Journal of Environmental prospective study of “ultra-marathoners”. International Jour- Research and Public Health, 8(10), 4069–4081. nal of Mental Health and Addiction, 5(3), 233–243. Glasser, W. (1976). Positive addiction. New York: Harper and American Psychiatric Association (2013). Diagnostic and statisti- Row. cal manual of mental health disorders: DSM-5 (5th ed.). Wash- Glasser, W. (2012). Promoting client strength through positive ad- ington, DC: American Psychiatric Publishing. diction. Canadian Journal of Counselling and Psychother- Baekeland, F. (1970). Exercise deprivation: Sleep and psychologi- apy/Revue Canadienne de Counseling et de Psychothérapie, cal reactions. Archives of General Psychiatry, 22(4), 365–369. 11(4), 173–175. Baker, T. B., Piper, M. E., McCarthy, D. E., Majeskie, M. R. & Grandi, S., Clementi, C., Guidi, J., Benassi, M. & Tossani, E. Fiore, M. C. (2004). Addiction motivation reformulated: An (2011). Personality characteristics and psychological distress affective processing model of negative . Psycho- associated with primary exercise dependence: An exploratory logical Review, 111(1), 33–51. doi:10.1037/0033-295X.111. study. Psychiatry Research, 189(2), 270–275. 1.33 Griffiths, M. D. (1997). Exercise addiction: A case study. Addic- Bamber, D., Cockerill, I. M. & Carroll, D. (2000). The pathological tion Research & Theory, 5(2), 161–168. status of exercise dependence. British Journal of Sports Medi- Griffiths, M. D., Szabo, A. & Terry, A. (2005). The exercise addic- cine, 34(2), 125–132. tion inventory: A quick and easy screening tool for health prac- Berczik, K., Szabo, A., Griffiths, M. D., Kurimay, T., Kun, B., titioners. British Journal of Sports Medicine, 39(6), e30. Urbán, R. & Demetrovics, Z. (2012). Exercise addiction: Hailey, B. J. & Bailey, L. A. (1982). Negative addiction in runners: Symptoms, diagnosis, epidemiology, and etiology. Substance A quantitative approach. Journal of Sport Behavior, 5, Use & Misuse, 47(4), 403–417. 150–153.

206 | Journal of Behavioral Addictions 2(4), pp. 199–208 (2013) Exercise addiction revisited

Hamer, M. & Karageorghis, C. I. (2007). Psychobiological mecha- Murphy, M. H. (1994). Sport and drugs and runner’s high nisms of exercise dependence. Sports Medicine, 37(6), 477–484. (Psychophysiology). Psychology in Sport. London: Taylor and Hausenblas, H. A. & Downs, S. D. (2002). How much is too much? Francis. The development and validation of the exercise dependence Ogden, J., Veale, D. & Summers, Z. (1997). The development and scale. Psychology and Health, 17, 387–404. validation of the Exercise Dependence Questionnaire. Addic- Hausenblas, H. A. & Giacobbi, P. R., Jr. (2004). Relationship be- tion Research & Theory, 5(4), 343–355. tween exercise dependence symptoms and personality. Per- Parke, J. & Griffiths, M. D. (2004). Gambling addiction and the sonality and Individual Differences, 36(6), 1265–1273. evolution of the “near miss”. Addiction Research & Theory, Holden, C. (2001). ‘Behavioral addictions’: Do they exist? Sci- 12(5), 407–411. ence, 294(5544), 980–982. Pasman, L. & Thompson, J. K. (1988). and eating dis- Hurst, R., Hale, B., Smith, D. & Collins, D. (2000). Exercise de- turbance in obligatory runners, obligatory weightlifters, and pendence, social physique anxiety, and social support in expe- sedentary individuals. International Journal of Eating Disor- rienced and inexperienced bodybuilders and weightlifters. ders, 7, 759–777. British Journal of Sports Medicine, 34(6), 431–435. Rejeski, W. J., Best, D. L., Griffith, P. & Kenney, E. (1987). Korolenko Ts. P. (1991). Addiktivnoe povedenie& Ob]aq xarakte- Sex-role orientation and the responses of men to exercise ristika i zakonomernosti razvitiq [Addictive behavior. Gen- stress. Research Quarterly for Exercise and Sport, 58(3), eral characteristics and patterns of development.] Review of 260–264. Psychiatry and Medical Psychology, 1, 8–15. (in Russian) Robbins, J. M. & Joseph, P. (1985). Experiencing exercise with- Krueger, D. W. (1988). On compulsive shopping and spending: A drawal: Possible consequences of therapeutic and mastery run- psychodynamic inquiry. American Journal of , ning. Journal of Sport Psychology, 7, 23–39. 42(4), 574–584. Sachs, M. L. & Pargman, D. (1984). Running addiction. In M. L. Kubey, R. & Csikszentmihalyi, M. (2002). Television addiction. Sachs & G. W. Buffone (Eds.), Running as therapy: An inte- Scientific American, 286(2), 74–81. grated approach (pp. 231–252), Lincoln, NE: University of Lejoyeux, M., Avril, M., Richoux, C., Embouazza, H. & Nivoli, F. Nebraska Press. (2008). Prevalence of exercise dependence and other behav- Scottl, K. S., Moore, K. S. & Miceli, M. P. (1997). An exploration ioral addictions among clients of a Parisian fitness room. Com- of the meaning and consequences of workaholism. Human Re- prehensive Psychiatry, 49(4), 353–359. lations, 50(3), 287–314. Lejoyeux, M., Guillot, C., Chalvin, F., Petit, A. & Lequen, V. Slay, H. A., Hayaki, J., Napolitano, M. A. & Brownell, K. D. (2012). Exercise dependence among customers from a Parisian (1998). Motivations for running and eating attitudes in obliga- sport shop. Journal of Behavioral Addictions, 1(1), 28–34. tory versus nonobligatory runners. International Journal of Lichtenstein, M. B., Christiansen, E., Bilenberg, N. & Støving, R. Eating Disorders, 23(3), 267–275. K. (2013). Validation of the exercise addiction inventory in a Smith, D., Wright, C. & Winrow, D. (2010). Exercise dependence Danish sport context. Scandinavian Journal of Medicine & Sci- and social physique anxiety in competitive and non-competi- ence in Sports. (in press – Early online, retrieved 08 May, 2013 tive runners.InternationalJournalofSportandExercisePsy- from: doi:10.1111/j.1600-0838. 2012. 01515. x) chology, 8(1), 61–69. Martin, P. R. & Petry, N. M. (2005). Are non-substance-related ad- Spano, L. (2001). The relationship between exercise and anxiety, dictions really addictions? The American Journal on Addic- obsessive-compulsiveness, and narcissism. Personality and In- tions, 14(1), 1–7. dividual Differences, 30(1), 87–93. McNamara, J. & McCabe, M. P. (2012). Striving for success or ad- Sussman, S., Lisha, N. & Griffiths, M. D. (2011a). Prevalence of diction? Exercise dependence among elite Australian athletes. the addictions: A problem of the majority or the minority? Journal of Sports Sciences, 30(8), 755–766. Evaluation & the Health Professions, 34(1), 3–56. McNamara, J. & McCabe, M. P. (2013). Development and valida- Sussman, S., Leventhal, A., Bluthenthal, R. N., Freimuth, M., tion of the Exercise Dependence and Elite Athletes Scale. Per- Forster, M. & Ames, S. L. (2011b). A framework for the speci- formance Enhancement & Health. (in press – Early online, re- ficity of addictions. International Journal of Environmental trieved 21 May, 2013 from: http://dx.doi.org/10.1016/j.peh. Research and Public Health, 8, 3399–3415. 2012.11.001) Szabo, A. (1995). The impact of exercise deprivation on well-being Menczel, Z., Kovacs, E., Farkas, J., Magi, A. Eisinger, A., Kun, B. of habitual exercisers. The Australian Journal of Science and & Demetrovics, Zs. (2013). Prevalence of exercise dependence Medicine in Sport, 27, 68–75. and eating disorders among clients of fitness centres in Buda- Szabo, A. (2000). Physical activity as a source of psychological pest. Journal of Behavioral Addictions, 2(Suppl. 1), 23–24 dysfunction. In S. J. H. Biddle, K. R. Fox & S. H. Boutcher Abs. (Eds.). Physical activity and psychological well-being (Chap- Modolo, V. B., Antunes, H. K., Gimenez, P. R., Santiago, M. L., ter 7, pp. 130–195). London: Routledge. Tufik, S. & Mello, M. T. D. (2011). Negative addiction to exer- Szabo, A. (2010). Exercise addiction: A symptom or a disorder? cise: Are there differences between genders. Clinics (Sao New York: Nova Science Publishers Inc. Paulo), 66(2), 255–260. Szabo, A. & Griffiths, M. D. (2007). Exercise addiction in British Mónok, K., Berczik, K., Urbán, R., Szabó, A., Griffiths, M. D., sport science students. International Journal of Mental Health Farkas, J., Magi, A., Eisinger, A., Kurimay, T., Kökönyei, G., and Addiction, 5(1), 25–28. Kun, B., Paksi, B. & Demetrovics, Z. (2012). Psychometric Targhetta, R., Nalpas, B. & Perney, P. (2013). Argentine tango: properties and concurrent validity of two exercise addiction Another behavioral addiction? Journal of Behavioral Addic- measures: A population wide study in Hungary. Psychology of tions, 2(3), 179–186. Sport and Exercise, 13, 739–746. Terry, A., Szabo, A. & Griffiths, M. D. (2004). The exercise addic- Morgan, W. P. (1979). Negative addiction in runners. The Physi- tion inventory: A new brief screening tool. Addiction Research cian and Sports Medicine, 7, 57–77. and Theory, 12, 489–499.

Journal of Behavioral Addictions 2(4), pp. 199–208 (2013) | 207 Egorov and Szabo

Thompson, J. K. & Blanton, P. (1987). Energy conservation and L. & Conte, G. (2011). Behavioral addictions in adolescents exercise dependence: A sympathetic arousal hypothesis. Medi- and young adults: Results from a prevalence study. Journal of cine and Science in Sports and Exercise, 19, 91–97. Gambling Studies, 27(2), 203–214. Thornton, E. W. & Scott, S. E. (1995). Motivation in the committed Yen, J. Y., Yen, C. F., Chen, C. C., Chen, S. H. & Ko, C. H. (2007). runner: Correlations between self-report scales and behavior. Family factors of internet addiction and substance use experi- Health Promotion International, 10(3), 177–184. ence in Taiwanese adolescents. CyberPsychology & Behavior, Tsang, T. C. E. & Szabo, A. (2003). Motivation for increased 10(3), 323–329. self-selected exercise intensity following psychological dis- Young, K. S. (1998). Internet addiction: The emergence of a new tress: Laboratory based evidence for catharsis. Journal of Psy- clinical disorder. CyberPsychology & Behavior, 1(3), 237– chosomatic Research, 55(2), 133. 244. Veale, D. (1995). Does primary exercise dependence really exist? Youngman, J. D. (2007). Risk for exercise addiction: A compa- In J. Annett, B. Cripps & H. Steinberg (Eds.), Exercise addic- rison of triathletes training for sprint-, olympic-, half- tion: Motivation for participation in sport and exercise (pp. ironman-, and ironman-distance triathlons. Open Access Dis- 1–5). Leicester: The British Psychological Society. sertations. Paper 12. Retrieved May 17, 2013 from Villella, C., Martinotti, G., Di Nicola, M., Cassano, M., La Torre, http://scholarlyrepository.miami.edu/cgi/viewcontent.cgi?article G., Gliubizzi, M. D., Messeri, I., Petruccelli, F., Bria, P., Janiri, =1011&context=oa_dissertations

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