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Exercise is usually a healthy activity, except when it's a condition called hypergymnasia. Here is what you need to know about this secretive form of bulimia and how to help friends and family members who live with it.

Hypergymnasia. Anorexia athletica. Exercise bulimia. Compulsive exercise. Or sometimes just "excessive exercise." These are five terms for an "eating disorder" that isn't all about eating.

What could possibly be wrong with excessive exercise?

Exercise is usually beneficial for health. When you exercise, your brain releases endorphins. These are the feel-good chemicals that activate reward systems in the brain. Endorphins can potentially help people who live with eating disorders control their eating, and they do, most of the time.

In the case of "excessive" exercise, however, the results of physical activity tend to be counterproductive. Some people who are overweight, or who see themselves as overweight, have unrealistic expectations about how their bodies should look. These ideas are independent of what they see in the mirror. No amount of physical exercise and dieting could ever be enough, and any attempt to use physical exercise as a boost to wellbeing is doomed to failure. People who suffer the conditions referred to as hypergymnasia or exercise bulimia are compelled to exercise to try to feel better about themselves. But the exercise they do always makes them feel worse.

Excessive exercise is not a common condition, but it is not a rare condition, either. One study estimated the frequency of the condition to be about one in 200 people. However, another study found characteristics of exercise obsession in 42 percent of long-distance runners.

How "excessive" is excessive exercise?

Hypergymnasia, anorexia athletica, exercise bulimia, compulsive exercise, and excessive exercise aren't terms your doctor can find in the DSM-5. Maybe this diagnosis will be included in the DSM-6, but for now, doctors think of excessive exercise in the same way that they think of obsessive-compulsive disorder.

To have be considered to have this condition, a patient must:

  • Feel compelled to do a rigid, preset, fixed program of exercises or to participate in predetermined exercise activities,
  • So much that the compulsion interferes with the patient's daily activities (more than an hour a day).

People who suffer hypergymnasia feel that they just have to get exercise. Worrying about exercise ruins their lives. However, there is something very important left out of this definition. There is no requirement that people who have hypergymnasia actually get exercise. They just need to feel that they absolutely, positively must exercise and feel bad whether they do it or not. Some people who suffer an actual compulsive exercise disorder are sedentary. Some actually do go out and get a lot of exercise. And others are fidgety but otherwise inactive. They may tap their feet or drum their fingers or squirm and wiggle all day long, but avoid taking on any kind of exercise challenge.

This doesn't mean that hypergymnasia isn't a "real" disease. Part of the criteria for diagnosing it is that the compulsion to exercise, no matter how it is acted out or whether it is acted on or not, is disruptive to daily activities of living. Someone who has this psychological issue can be ill or disabled but obsessed with the idea of exercise. Sitting around paralyzed by the thought "I really have to get out and exercise!" would also qualify as a symptom. The presence of a compulsion to exercise without the actual performance of exercise in this condition is known as the exercise paradox.

The previous edition of the Diagnostic and Statistical Manual, the DSM-IV, had a definition for exercise dependence: "a multidimensional, maladaptive pattern of exercise, leading to clinically significant impairment, or distress."

What is the treatment for hypergymnasia?

Hypergymnasia is usually treated as if it were obsessive-compulsive disorder, also known as OCD. But treatment of this condition begins with limiting its complications. People who are compelled to exercise and actually perform it miss out on some kinds of social relationships. They are more prone to exercise-related injuries. One of the goals of therapy is to make sure people living with a compulsion to exercise are able to maintain intimate, family, social, and work relationships. Another goal is simply making sure they don't hurt themselves as they exercise.

Psychotherapy attempts to address some frequent features of hypergymnasia:

  • Perfectionism, the inability to accept the results of frequent exercise.
  • Narcissism, particularly when a focus on self leads to a lack of attention to family and job.
  • High extraversion which is expressed not as a need to interact with people but as a need to burn energy.
  • Low agreeableness, an inability to compromise on the requirements of perfectionism.
  • Neuroticism, a lack of emotional stability, which can lead to a self-centered focus in working through life issues.

And the doctor frequently has to address other forms of addiction that occur with hypergymnasia, including those to alcohol, drugs, sex, and, ironically, food.

As therapy progresses, people who live with an exercise addiction gradually learn to recognize and control their triggers for excessive activity, and their triggers for unproductive worry. Overcoming hypergymnasia takes a long time, but the eventual result is a richer, happier, more stable life without the need to exercise hours every day.

  • Adkins EC, Keel PK. Does “excessive” or “compulsive” best describe exercise as a symptom of bulimia nervosa? IntJ EatDisord. 2005. 38:24–29.
  • Bratland-Sanda S, Mathisen TF, Sundgot-Borgen J, Rosenvinge JH. Defining compulsive exercise in eating disorders: acknowledging the exercise paradox and exercise obsessions J Eat Disord. 2019 Apr 4. 7:8. doi: 10.1186/s40337-019-0238-2. eCollection 2019. PMID: 30988952.
  • Mathisen TF, Bratland-Sanda S, Rosenvinge JH, Friborg O, Pettersen G, Vrabel KA, Sundgot-Borgen J. Treatment effects on compulsive exercise and physical activity in eating disorders. J Eat Disord. 201.
  • 6:43. doi: 10.1186/s40337-018-0215-1.
  • Photo courtesy of SteadyHealth

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