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The Obligatory Exerciser

Assessing an Overcommitment to Exercise

John Draeger, MD; Alayne Yates, MD; Douglas Crowell, MS

THE PHYSICIAN AND SPORTSMEDICINE - VOL 33 - NO. 6 - JUNE 2021

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In Brief: A small group of patients are overly committed to their exercise routines, possibly to the detriment of their physical and psychological well-being. The concept of obligatory exercise is difficult to define, and its prevalence has not been extensively studied. Clinicians who are aware of behavioral and personality descriptors for obligatory exercisers can identify the problem and suggest treatment options. Treatment may follow guidelines similar to those for overtraining, addiction, compulsion, and eating disorders. Preventive measures lie in understanding exercisers' attitudes and beliefs about exercise and their bodies.

The benefits of exercise have been well documented over the past few decades,1-3 but a growing body of evidence suggests that some individuals are obligatory exercisers. These are people who will not interrupt their exercise schedule, even when they are injured or when they know that continuing to exercise could cause physiologic or psychological changes that could harm their lives.4-7 Our focus will be to describe the phenomenon of the obligatory exerciser, provide guidelines to identify individuals who may be at risk, and suggest treatment options.

A Typical Example

A 38-year-old physician who is also a marathon runner arrives at a sports medicine clinic with reports of persistent fatigue, muscle soreness, and lack of energy. The man is concerned that his marathon and 10K running times have become progressively slower over the past few months. He has recently chosen to focus on the 10K race, because he believes that he does not have the time to prepare adequately for the marathon. He has a busy medical practice and a large family. The patient reports that his wife says he is becoming increasingly irritable, and he has been awakening in the middle of the night worrying about his training routine and recent performance.

The patient has rarely missed a day of running in years, and on weekdays he gets up at 5:30 am for an early 5- to 7-mile run before work. On weekends, he does a long 10- to 12-mile run one day and speed trials on the other—a reduction from his previous training volume. He worries that if he reduces his training any more he will lose his training base and will not be able to improve his times further. The patient states that running used to be a way of reducing stress and giving him time to think, but now he has to force himself to run, and he no longer enjoys it as much as he used to.

Historical Perspective

In 1969, Little8 examined the concept of the obligatory exerciser, although he used the term "athlete's neurosis" to describe a group of middle-aged men who continued to run despite injuries.

In 1970, Baekeland9 was interested in the effect on sleep when exercisers interrupted their training. He noted that it was difficult to recruit regularly exercising subjects who were willing to stop running for a month, and that many of the runners would not stop exercising "for any amount of money."

Over the next three decades, considerable research identified chronic exercisers in a variety of sports and activities as obligatory exercisers when their commitment to their routines became excessive. Among athletes, this phenomenon has been observed in runners,10,11 gymnasts,12,13 bodybuilders,14 weight lifters,15 wrestlers,16 and dancers.17 Obligatory exercise traits have also been seen in recreational exercisers18-20 and individuals with eating disorders.21 Exercise addiction has been the subject of books22-24 and articles in this journal.6,25,26 An estimated 10% of runners are obligatory exercisers.27

Many terms have been used to describe this phenomenon in an effort to further understand and characterize it (table 1). We use the term "obligatory exerciser" to describe any person who feels obligated or compelled to continue exercising despite the risk of adverse physiologic (eg, overtraining and injury) or psychological (eg, social isolation) outcomes.

TABLE 1. Terms Used to Describe an Overcommitment to Exercise

Activity disorder
Compulsive athleticism
Excessive exercise
Exercise addiction
Exercise dependence
Obligatory exercise
Obligatory running
Running addiction

Obligatory exercisers develop specific goals for their exercise and performance. However, when confronted with a decrease in performance, they will push their bodies harder to succeed. As in the clinical case example above, an otherwise capable professional may begin running as a way to relieve stress, but then cannot keep from running, even when it becomes a source of stress and begins to cause problems. The resulting symptoms may resemble overtraining and eventually interfere with the ability to exercise at all.

Theoretical Views

Even skilled sports medicine clinicians may not always recognize the characteristics of the obligatory exerciser, partly because no clear-cut definition of the condition is known. The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV)28 describes "excessive exercise" as a criterion for bulimia nervosa, but no explanation of how much exercise is "excessive" is given.

Wichstrom29 used a quantitative criterion of eight exercise sessions per week to define excessive exercise in his study. Seigel and Hetta30 defined high-level exercise as at least 1 hour six times each week. Other studies have used various quantitative measures to delineate when exercise is excessive.31-34 Using the quantity of exercise to help describe the obligatory exerciser may be useful, but many athletes and coaches believe that sustaining high levels of training are critical to remaining competitive.

Although high levels of exercise increase the risk of injury,1 many people will continue to exercise despite the risks.13,25,26 Yates et al11 designated runners as obligatory if they continued to run despite clear contraindications, such as stress fractures. All but 3 of the 27 obligatory runners scored in the healthy range on a series of psychological tests, yet they continued their training routines even when injured.11 This drive to maintain exercise levels has been studied using various models.

Many exercisers have described a "high" that they get from exercising.30,35 This high is central to their thinking and behavior, and exercisers may feel driven to achieve it, just like drug addicts. The obligatory exerciser has sometimes been described as "addicted" to exercise.22,24,26,27,36,37

De Coverly Veale7 proposed that the diagnostic criteria for "exercise dependence" be based on the core features of a dependence syndrome or addiction. He suggested that addicted exercisers experience symptoms of withdrawal if they cannot maintain their current volume of exercise. This suggests that, to experience the "high" and avoid withdrawal symptoms, addicted exercisers continue to exercise despite the risk of serious injury.

Other exercisers have described exercise as a driven and painful "compulsion" that had to be performed regardless of the discomfort or the risks.23,26 Some authors have used the terms "addiction" and "compulsion" interchangeably36-39 in regard to exercise. However, the "driven" quality of the exercise "addict" is sometimes confused with the "compulsion" to exercise. The difference may be that, in the addiction view, obligatory exercisers just want to experience the high regardless of the pain, while, in the compulsion view, obligatory exercisers have to continue to exercise until it "feels right," regardless of the pain, to avoid anxiety when they are unable to exercise.

Researchers have used a variety of instruments to assess the obligatory exerciser's addiction, attitudes, and commitment to exercise.15,19,31,40-43 Others have used standardized measures to identify the personality traits of the obligatory exerciser11,44-46 but produced various findings. Table 2 summarizes some of the behavioral and personality descriptors that have been used to characterize the obligatory exerciser.

TABLE 2. Common Descriptors of the Obligatory Exerciser


Behavioral
Becomes angry or anxious or feels guilty when an exercise session is missed
Continues to exercise, despite an injury or physical illness
Does not reduce training volume on clinical advice
Focuses on reducing body weight and changing body shape
Increases exercise volume following several days of not exercising
Keeps extensive logs and records
Maintains a rigid diet
Maintains a strict routine of training with little variation
Structures social activities around the exercise routine

Personality
Achievement oriented
Addictive
Compulsive
Independent
Narcissistic
Neurotic
Obsessive
Perfectionistic
Persistent

One study47 suggested that excessive exercise is not an expression of dysfunctional personality, while another48 suggested that it may be, depending on the severity of specific traits. Thus, the term "obligatory" may be a better general term to describe this phenomenon, because it has no clear connection to any disorder.

"Obligatory" does not suggest an addiction or a compulsion. The term implies that patients may feel obliged to exercise when the motive is no longer to improve performance, but to reduce or avoid any emotional problem that will arise if they are unable to exercise. In any event, additional research will be necessary to assist the clinician in addressing several very basic questions, such as:

• Who is the obligatory exerciser?
• Who is at risk to become one?
• In the absence of injury or illness, should the clinician treat the patient who is an obligatory exerciser?
• How does the clinician address the patient's need to maintain a high level of exercise despite the risks?
• What treatment approaches are indicated for the obligatory exerciser who has already developed symptoms, such as the 38-year-old physician in the case study cited earlier?

Diagnostic Considerations

De Coverly Veale7 suggested that the importance of making a diagnosis lies in the prevention of serious injuries, including death. In a later paper,39 he stated that the criteria for exercise dependence are difficult to define, but that overtraining and obligatory exercise appear to share similar characteristics. The markers that are seen in overtraining may be useful in identifying and diagnosing the obligatory exerciser.

Overtraining syndrome is a serious concern marked by decreased performance, increased fatigue, persistent muscle soreness, and mood disturbances.4 The physical and psychological effects of overtraining have been extensively investigated,4,48-51 but comparable studies of obligatory exercisers are lacking. To our knowledge, no direct comparison of overtrained athletes with obligatory exercisers has been made. Nevertheless, it may be realistic to suggest that, because of the high levels of investment in exercise, obligatory exercisers may report some of the same symptoms that occur with overtraining (table 3).

TABLE 3. Symptoms Indicative of Overtraining


Anxiety
Apathy
Changes in values and beliefs
Chronic fatigue
Decreased appetite
Decreased self-confidence
Depression
Emotional isolation
Hostility
Impaired concentration
Mental exhaustion
Mood changes
Muscle soreness
Sleep disturbance
Substance abuse

History and physical exam. Clinical assessment, of course, begins with a physical examination and a comprehensive health and exercise history (table 4). The patient's training volume and injury rate are important to note. Because evidence suggests that psychological signs and symptoms are among the most sensitive indicators for excessive exercise,4,52 the clinician should also carefully note the athlete's subjective rating of mood, fatigue, stress, and soreness.

TABLE 4. Important Factors in the Health and Exercise History for Possible Obligatory Exercisers


Diet and nutritional status
Exercise history
Intensity and volume of current exercise program
Injuries
Menstrual history
Past and present health status
Performance history
Social and psychological stressors

One tool that could be particularly useful is the Profile of Mood States (POMS).53 The POMS is a self-report inventory that is both easy to administer and interpret. The results describe changes in total mood disturbance, anxiety, tension, depression, and loss of vigor. Changes in total mood disturbance; increases in anxiety, tension, and depression; and loss of vigor have been reported to occur with chronic increases54 and decreases in exercise training.55

The clinician's level of concern should increase if the patient describes at-risk behaviors (see table 2); however, obligatory exercisers may not readily admit to any of these behaviors because of their need to appear healthy and normal.11,56 Particularly because of some characteristic personality traits, patients may not want to be seen as sick, weak, inadequate, or needing help from anyone. They may also fear criticism from friends, family, coaches, or other athletes. A series of questions (table 5) will help assess the patient's commitment to exercise, but the clinician must decide on the best way to present these questions.

TABLE 5. Questions for the Assessment of Commitment to Exercise


Are you preoccupied with challenging or changing your body?
Do you become anxious or angry if you miss a planned workout?
Do you consider exercise the most important event of the day?
Do you constantly think about exercising?
Do you continue to exercise despite injuries?
Has your pattern of exercise caused problems in your relationships?
Have your family or friends made comments about your exercise routines?
Is it difficult to take days off from your training routine?

Differential diagnosis. Physical disorders that must be ruled out before establishing a diagnosis include Addison's disease, hyperthyroidism, hypothyroidism, nutritional deficiencies, muscle diseases, and anemia. Mental disorders to consider include eating disorders, depression, anxiety disorders, and chronic fatigue syndrome.

Prevention and Treatment Strategies

Although standards for the diagnosis and treatment of obligatory exercisers have not been established, physicians should be able to identify the problem and begin some form of prevention or treatment before additional harm occurs. The American College of Sports Medicine1 has developed standards for the amount of exercise that is needed to improve health, but not for the amount of exercise that will adversely affect quality of life.

Bamber et al48 recommend establishing appropriate exercise and training routines as essential to prevent overtraining, and this approach may be helpful for the obligatory exerciser as well. Periodization (ie, cycles of training with set recovery periods) can be introduced to those patients who feel obliged to maintain high levels of training. As a preventive strategy, periodization emphasizes the importance of balance in training to achieving optimal performance goals. Patients should be educated about how recovery periods, mandatory days of rest, and the body's need to regenerate contribute to peak performance.

Prevention must also include an understanding of the patient's attitudes and beliefs in three areas that can negatively reinforce each other: exercise, eating, and body weight. An overcommitment to exercise is a strong predictor of dietary concerns and restraint.57 Exercise and dietary control together are effective for weight management, but in susceptible individuals this combination may contribute to the development of an eating disorder.58,59

Davis et al60,61 found that some of the women in their studies developed obsessional concerns about weight after they began to exercise. This progressed to dissatisfaction with their bodies and an unrealistic ideal body image.62 Practitioners, educational programs, parents, coaches, and fitness facilities alike should routinely address the dangers of using excessive exercise and dieting to pursue an idealized body image or performance level.

Yates et al63 developed the Exercise Orientation Questionnaire (EOQ) to assess the attitudes of exercisers toward exercise, their bodies, and themselves. A Self Loathing Sub Scale (SLSS), included in the EOQ, can be used as a screening tool (table 6).63,64 A score higher than 16 on the SLSS is related to high ratings of exercise investment, exercise frequency, and duration of exercise sessions and may also indicate other obligatory behaviors, such as an eating disorder.64

TABLE 6. Self Loathing Sub Scale (SLSS) Questionnaire
The following statements may or may not describe your feelings about exercise. Read each statement and then circle the appropriate number to indicate how well the statement describes how you feel most of the time. There are no right or wrong answers.
Strongly agree (5); Agree (4); Uncertain (3); Disagree (2); Strongly disagree (1)

1. I disliked my body before I began to exercise.
54321
2. I am an active person.
54321
3. I am dissatisfied with my performance.
54321
4. I feel better after I exercise.
54321
5. I hate my body when it won't do what I want.
54321
6. My best friends are athletes.
54321
7. If I don't reach my goals, I feel like a failure.
54321
8. I am a good athlete.
54321
Total score ______

Only the odd-numbered questions are scored. The maximum possible score is 20. A score higher than 16 represents high risk for obligatory behavior.

Treatment usually takes place after the obligatory exerciser has developed a problem, such as an injury or total exhaustion. The injury can be treated, and the clinician may choose to address the underlying factors that contributed to the injury. The clinician may choose to treat the problem as an overtraining issue and suggest decreasing training and adding rest days.

Uusitalo4 has suggested tapering the exercise routine with combinations of rest, good nutrition, and sleep to support the body's recovery process. If tapering is not successful in reversing the homeostatic imbalance, the best treatment becomes complete rest, avoiding exercise for 2 weeks.4 However, if the obligatory exerciser's drive to continue to exercise prevents the implementation of this strategy, personality and behavioral assessment may be necessary. Referral to a psychiatrist or psychologist may be indicated at that time.

If the patient chooses to decrease or discontinue exercising, the clinician needs to monitor for compliance and the evolution of any possible signs and symptoms. Obligatory exercisers usually experience anxiety when they cannot maintain high exercise levels or have to stop exercising altogether. Relaxation techniques, gated breathing, self-hypnosis, meditation, or massage may be helpful in managing the anxiety. If the obligatory exerciser needs to have activity as a part of successful treatment, tai chi or yoga, in addition to movement or dance therapy, may be useful options.65

Other approaches may include cognitive-behavioral therapy, group therapy, family therapy, and pharmacology. A recent study showed that cognitive-behavioral therapy was useful in improving body image in female obligatory exercisers.66 The selection of any treatment approach will draw on the individual's choices and commitment to change, the clinician's training and orientation, and accessible community resources.

Case Study Treatment Considerations

In our example case study, the physician came to the clinic with fatigue, muscle soreness, lack of energy, irritability, and sleep disturbed by worries about his training and performance. Initially he wanted to focus on improving his performance using traditional sports medicine treatment (eg, training tips, nutritional support). He expressed frustration that his body would not do what he wanted it to do.

Our patient was able to schedule a reduction in training, and within 2 weeks his physical symptoms disappeared, and his mood improved. We suggested to him that his self-imposed obligation to maintain his exercise routine was putting him at risk for overtraining. With encouragement, he began to look into his overcommitment to training and to learn relaxation exercises, and he agreed to massage therapy twice weekly. He also began seeing a therapist regularly to develop rational alternatives to his driven thoughts about training.

Commitment to Awareness

Many Americans do not participate in nearly enough physical activity; however, a small group of people exercise excessively for various reasons and may be unable to interrupt their routines, even if they are injured. Clinicians who can identify these individuals will facilitate prevention, early intervention, and effective treatment. A broader awareness of the problem and attention to early signs of overtraining may help prevent others from becoming overcommitted. Successful treatment requires sensitive support, education, guidance, and therapeutic approaches that are appropriate for the underlying traits and values of the individual obligatory exerciser.

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Dr Draeger is an assistant clinical professor and Dr Yates is a professor in the department of psychiatry at the University of Hawaii in Honolulu. Mr Crowell is the coordinator of exercise and sport science at Kapiolani Community College in Honolulu. Address correspondence to Alayne Yates, MD, Dept of Psychiatry, University of Hawaii, University Tower 4th floor, 1356 Lusitana St, Honolulu, HI 96813; e-mail to [email protected].

Disclosure information: Drs Draeger and Yates and Mr Crowell disclose no significant relationship with any manufacturer of any commercial product mentioned in this article. No drug is mentioned in this article for an unlabeled use.


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