Compulsive exercise in eating disorders: proposal for a definition and a clinical assessment

BACKGROUND: Compulsive exercise has been recognized as a highly prevalent symptom in eating disorders (ED) for over 100 years and is associated with poor short-term and long-term treatment outcome. Progress in understanding and treatment of compulsive exercise will remain limited as long as no consensus framework for definition and assessment of compulsive exercise exists, as results cannot be compared across clinical studies. Based on existing literature, it was our aim to propose a transdiagnostic definition and a clinical assessment for compulsive exercise, that can be applied to adolescent and adult patients with ED. METHOD: During a series of meetings of experienced clinicians at a highly specialized hospital for eating disorders, we elaborated a transdiagnostic definition of compulsive exercise in ED. Additionally, we derived a clinical interview for the assessment of compulsive exercise and its different subtypes. RESULTS: The core criterion when defining and assessing compulsive exercise is a pathologically increased exercise pattern characterized by 1) excessive exercise that a patient feels driven to perform in response to an obsession or according to rules that must be applied rigidly, and 2) exercise that is aimed at preventing or reducing distress or at preventing some dreaded consequence. A second necessary criterion is the physical or psychological burden caused by compulsive exercise, i.e., that it is time-consuming, significantly interferes with the patient’s daily routine, occupational functioning or social relationships or is continued despite medical injury, illness, or lack of enjoyment. Insight that compulsive exercise is excessive or unreasonable was added as an optional criterion. Compulsive exercise manifests itself in three different subtypes: 1) vigorous exercise, 2) marked increase in daily movement, or 3) motor restlessness. The above criteria must be met during the past 6 months, together with one of the three subtypes of compulsive exercise. CONCLUSIONS: The proposed criteria aim to foster the discussion around definition and assessment of compulsive exercise with the goal of reaching an international consensus in the near future. Providing a consistent framework for researchers and clinicians would considerably advance understanding and treatment of compulsive exercise in ED patients.