Vulnerability to exercise addiction, socio-demographic, behavioral and psychological characteristics of runners at risk for eating disorders

The use and misuse of the SCOFF screening measure over two decades: a systematic literature review

PURPOSE

The SCOFF questionnaire was designed as a simple, memorable screening tool to raise suspicion that a person might have an eating disorder. It is over 20 years since the creation of the SCOFF, during which time it has been widely used. Considering this, we wish to review the use of the SCOFF in peer-reviewed scientific journals, and to assess whether it is being used appropriately in the manner in which it was originally devised and tested.

METHODS

The Preferred Reporting Items for a Systematic Review and Meta-analysis (PRISMA) guidelines were followed, and all search strategies and methods were determined before the onset of the study. PubMed and Wiley Online Library were searched using the terms SCOFF and eating. Two reviewers were involved in the reviewing process. Criteria for appropriate use of the SCOFF were formalised with the tool's original authors.

RESULTS

180 articles were included in the final review. 48 articles had used the SCOFF appropriately, 117 articles inappropriately and 15 articles had been mixed in the appropriateness of their use.

CONCLUSION

This systematic review highlights the inappropriate use of the SCOFF in diverse languages and settings. When used correctly the SCOFF has made a significant contribution to the understanding of eating disorders and its simplicity has been applauded and led to widespread use. However in over two-thirds of studies, the use of the SCOFF was inappropriate and the paper highlights how and in what way it was misused, Guidelines for the appropriate use of the SCOFF are stated. Future validation and avenues of research are suggested.

LEVEL OF EVIDENCE

Level I.

Ready, set, …and difficultly slowing down: What role does alexithymia, emotional regulation and interoceptive awareness play in exercise dependence?

Alexithymia is associated with a diverse range of addictive behaviours including exercise addiction symptoms. In addition, emerging research indicates that emotional regulation and interoceptive processes may help explain this relationship. Thus, the current study tested the ability of emotion regulation to mediate the relationship between alexithymia and exercise addiction symptoms and whether interoceptive awareness moderates these relationships. A total of 404 physically active adults (86.8 % female) completed measures of alexithymia, exercise dependence symptoms, difficulties with emotion regulation and interoceptive awareness (Mage = 43.72, SD = 14.09). Alexithymia, emotion regulation, interoceptive awareness and exercise dependence symptoms were all significantly correlated. Further analysis revealed that emotional regulation mediated the relationship between alexithymia and exercise dependence, although the mediation model did not vary as a function of interoceptive awareness. These findings underscore the importance of considering emotion-focused processes in treatment planning and other initiatives designed to help individuals who display exercise dependence symptoms.

The Expanded Exercise Addiction Inventory (EAI-3): Towards Reliable and International Screening of Exercise-Related Dysfunction

Exercise addiction (EA) refers to excessive exercise, lack of control, and health risks. The Exercise Addiction Inventory (EAI) is one of the most widely used tools in its assessment. However, the cross-cultural psychometric properties of the EAI could be improved because it misses three pathological patterns, including guilt, exercise despite injury, and experienced harm. Therefore, the present study tested the psychometric properties of the expanded EAI (EAI-3) in a large international sample. The EAI-3 was administered to 1931 physically active adult exercisers speaking five languages (Chinese, German, Italian, Japanese, and Turkish) and other measures for obsessive-compulsive behavior, eating disorders, and personality traits. The assessment structure and reliability of the EAI-3 were tested with factorial analyses and through measurement invariance across languages and sex. Finally, a cutoff point for dysfunction-proneness was calculated. The EAI-3 comprised two factors, reflecting the positive and pathological sides of exercise. The structure had excellent reliability and goodness-of-fit indices and configural and metric invariances of the scale were supported. However, three items caused violations in scalar invariance. The results of partial measurement invariance testing suggested an adequate fit for the data. Following sensitivity and specificity analysis, the EAI-3's cutoff score was 34 out of a maximum score of 48. This preliminary study suggests that the EAI-3 is a promising tool for screening EA in an international sample, with a robust and reliable structure comparable across languages and sex. In addition, the proposed cutoff could pave the way toward a consensus on a threshold to screen for EA.

Why do we climb mountains? An exploration of features of behavioural addiction in mountaineering and the association with stress-related psychiatric disorders

Common knowledge implies that individuals engaging in outdoor sports and especially in regular and extreme mountaineering are exceptionally healthy and hardened. Physical activity in outdoor environments has a positive effect on physical and mental health. However, regular and/or extreme mountaineering might share similarities with behavioural addictions and could thus also have a negative impact on health. In this cross-sectional web-based questionnaire study, we collected data on exercise and mountaineering addiction (Exercise Addiction Inventory; original and adapted version for mountaineering; Exercise Dependence Scale adapted version for mountaineering). Further surveyed parameters included mountaineering habits, Risk-Taking Inventory, Sensation-Seeking/Emotion Regulation/Agency Scale (SEAS), resilience, self-perceived stress, physical activity in metabolic units and mental health. Comparisons were performed between individuals with symptoms of addiction to mountaineering (MA) and individuals without symptoms of addiction to mountaineering or sports in general (CO) using non-parametric analyses. We analysed data from 335 participants, n = 88 thereof with addiction to mountaineering (MA) and n = 247 control participants (CO). The MA group scored significantly higher with regards to self-perceived stress (p < 0.001) and included a significantly higher number of individuals affected by symptoms of depression (p < 0.001), symptoms of anxiety (p < 0.001), symptoms of eating disorders (p < 0.001), alcohol abuse or dependence (p < 0.001), illicit drug abuse (p = 0.050), or current and history of psychiatric disorders (p < 0.001). Individuals with MA showed higher values in all SEAS subscales as well as increased risk-taking (p < 0.001). Regular and extreme mountaineering can display features of a behavioural addiction and is associated with psychiatric disorders. Behavioural addiction in mountaineering is associated with higher levels of sensation-seeking, emotion regulation, and agency, as well as increased risk-taking.

Exercise dependence and orthorexia nervosa in Crossfit: exploring the role of perfectionism

Physical exercise and healthy diet have a positive effect on health. However, the pathological dimension of both behaviors, namely exercise dependence and orthorexia nervosa, can lead to negative results. So far, literature on these behaviors in the context of high-intensity sports is limited. The present study aims for investigating exercise dependence and orthorexia nervosa in a sample of Crossfit athletes, as well as examining the mediating role of perfectionism in their manifestation.The sample consisted of 110 people who attended Crossfit programs and 131 active gym members. The Exercise Dependence Scale was used to assess exercise dependence, the ORTO-15 to assess orthorexic behavior and the Almost Perfect Scale to evaluate perfectionism.19.8% of crossfitters and 3.8% of gym members were at risk for exercise dependence. 11.7% of participants in the Crossfit group and 10% of participants in the control group had orthorexic symptoms. An association was found between the scores on the two behaviors. In addition, the dimension of perfectionism high standards predicted obligatory exercise and orthorexia nervosa, while the dimension of discrepancy predicted only exercise dependence.The study suggests that exercise dependence is more evident in Crossfit compared to gym athletes and may be accompanied by orthorexic symptoms. Orthorexia nervosa is a noticeable phenomenon in the population of active exercisers. Perfectionism is a risk factor for obligatory exercise and orthorexia. A more demanding selection of target populations is encouraged in order to better understand exercise dependence, orthorexia nervosa and their personality background.

Alexithymia, reward sensitivity and excessive exercise in non-binge-eaters versus severe binge eaters: Implications for primary and secondary exercise dependence

A distinction has been made between primary and secondary exercise dependence, with the latter defined as excessive exercise secondary to disordered eating and weight concerns. Based on theoretical considerations from research on the roles of trait factors in addictions, the present study used validated scales to assess alexithymia, sensitivity to reward and punishment, emotion regulation and interoception in relation to exercise dependence symptoms in Australian male and female non-binge eaters (n = 228) and severe binge eaters (n = 126) aged 18-30 yr. In both groups, exercise dependence symptoms were significantly positively associated with reward sensitivity and interoceptive awareness, with the latter two variables predicting exercise dependence symptoms in hierarchical regression models; punishment sensitivity was significantly negatively related to such symptoms. Alexithymia was significantly associated with exercise dependence symptoms only in non-binge eaters; in severe binge eaters, alexithymia explained 0% of unique variance. Male sex was associated with more exercise dependence symptoms in severe binge eaters only. Participants in the severe binge group scored significantly higher on measures of exercise dependence, alexithymia, risky alcohol use, and sensitivity to reward and punishment, and significantly lower on emotion regulation, compared to those in the non-binge group. Hierarchical regression models explained 25% of variance in exercise dependence symptoms in non-binge-eaters and 43% in severe binge eaters. Findings are discussed in terms of the distinction between primary and secondary exercise dependence, the role of alexithymia, study limitations including data collection during the COVID-19 pandemic in Australia, and suggestions for future research.

Compulsive exercise among college students: 5-year time trends in prevalence and demographic, substance use, and mental health correlates

PURPOSE

To provide 5-year time trends in prevalence and demographic, substance use, and mental health correlates of compulsive exercise among a national sample of college men and women.

METHODS

We analyzed 4 academic survey years (2016-2020; N = 8251) of the national (USA) Healthy Minds Study. Compulsive exercise was measured by self-report of any occurrence of "compulsive" exercise in the past 4 weeks. Unadjusted prevalence of compulsive exercise in the past 4 weeks was estimated across the 4 survey years by sex. Multiple logistic regression analyses were conducted among the pooled sample and stratified by sex to estimate the associations between compulsive exercise in the past 4 weeks and demographic, substance use, and mental health correlates.

RESULTS

Among the pooled sample, 11% (95% confidence interval [CI] 9.60-12.42%) of men and 17% (95% CI 15.86-18.24%) of women reported compulsive exercise in the past 4 weeks. Prevalence across the 4 survey years remained stable among men and women. Higher body mass index was associated with greater odds of any compulsive exercise in the past 4 weeks among men, while any sports participation was associated with greater odds of any compulsive exercise in the past 4 weeks among women. Compulsive exercise in the past 4 weeks was associated with greater odds of all mental health symptoms and illicit drug use among men and women, and higher odds of alcohol use among women.

CONCLUSION

Compulsive exercise is relatively common among college men and women and is associated with substance use behaviors and poor mental health symptoms.

LEVEL OF EVIDENCE

V, cross-sectional descriptive study.

Esporte e Competências de Vida: Uma Análise sob a Ótica da TSC

Resumo Este trabalho propõe uma discussão teórica sobre o desenvolvimento positivo por meio do esporte, com foco na aprendizagem de “competências de vida”, que recebem uma atenção crescente na educação do século XXI, e pretende discutir e integrar diferentes modelos existentes com base na teoria social cognitiva (TSC) de Albert Bandura. Para isso, foi descrito o modelo heurístico de Gould e Carson, traçando comparativos com modelos teóricos posteriores. São apresentados aspectos da TSC que possibilitam a percepção de uma unidade teórica entre os diversos modelos, o que pode facilitar e aprofundar a compreensão do fenômeno. Conclui-se que os benefícios do esporte ao desenvolvimento humano não são automáticos e dependem de múltiplos fatores, especialmente dos aspectos cognitivos e relacionais associados a essas práticas. Esses fatores devem ser o foco das intervenções para que as vivências esportivas sejam, de fato, promotoras de um desenvolvimento positivo. A TSC permite integrar os diferentes modelos e pode servir de base para o planejamento de intervenções e pesquisas que promovam a aprendizagem de competências de vida nos esportes.

The Role of Sports Physiotherapist in Confronting Exercise Addiction

Everyday physical activity plays an important part in health maintenance and disease prevention. Excess exercise, however, can cause detrimental effects on both physical and mental health. It can also hamper the quality of life to an extent that individual is unable to regulate this behavior. ‘Addicted’ exercisers are more likely to work out for intrinsic rewards and experience troubling feelings of deprivation. In comparison, ‘committed’ exercisers participate in physical activity for extrinsic benefits and, when they cannot exercise, do not experience extreme withdrawal symptoms. Sportspersons indulge themselves in long hours of training as a response of their quest to improve endurance and performance in the face of common setbacks. Recognizing the addiction to exercise is also a contentious idea and the aim of this article is to draw an attention towards the same. Exercise Addiction diagnosis needs employment of questionnaires such as Exercise Dependence Scale, Obligatory Exercise Questionnaire, and Exercise Addiction Inventory. They need to be employed in the pre-participation evaluation of an individual participating in any sports event. Physiotherapists are often the first to meet an individual with exercise addiction. Physiotherapists play an important role in diagnosis of exercise addiction as well as in prevention as they are aware of challenges of treating exercise addicted patients and develop specific approaches to deal with their issues. As if it goes unnoticed, the prognosis can even be fatal.

Examining the Relationship between Exercise Dependence, Disordered Eating, and Low Energy Availability

Both dietary and exercise behaviors need to be considered when examining underlying causes of low energy availability (LEA). The study assessed if exercise dependence is independently related to the risk of LEA with consideration of disordered eating and athlete calibre. Via survey response, female (n = 642) and male (n = 257) athletes were categorized by risk of: disordered eating, exercise dependence, disordered eating and exercise dependence, or if not presenting with disordered eating or exercise dependence as controls. Compared to female controls, the likelihood of being at risk of LEA was 2.5 times for female athletes with disordered eating and >5.5 times with combined disordered eating and exercise dependence. Male athletes with disordered eating, with or without exercise dependence, were more likely to report signs and symptoms compared to male controls-including suppression of morning erections (OR = 3.4; p < 0.0001), increased gas and bloating (OR = 4.0-5.2; p < 0.002) and were more likely to report a previous bone stress fracture (OR = 2.4; p = 0.01) and ≥22 missed training days due to overload injuries (OR = 5.7; p = 0.02). For both males and females, in the absence of disordered eating, athletes with exercise dependence were not at an increased risk of LEA or associated health outcomes. Compared to recreational athletes, female and male international caliber and male national calibre athletes were less likely to be classified with disordered eating.

Narcissism and Exercise Addiction: The Mediating Roles of Exercise-Related Motives

The present research examined whether the associations that narcissistic personality features had with exercise addiction were mediated by particular motives for engaging in exercise in a large Israeli community sample (N = 2629). The results revealed that each aspect of narcissism was positively associated with exercise addiction. Narcissistic admiration and narcissistic rivalry had similar positive indirect associations with exercise addiction through the interpersonal motive for exercise. However, these aspects of narcissism diverged in their indirect associations with exercise addiction through psychological motives, body-related motives, and fitness motives for exercise such that these indirect associations were positive for narcissistic admiration but negative for narcissistic rivalry. Narcissistic vulnerability had positive indirect associations with exercise addiction through body-related motives and fitness motives that were similar to those observed for narcissistic admiration. These results suggest that exercise-related motives may play important roles in the associations that narcissistic personality features have with exercise addiction. The discussion will focus on the implications of these results for understanding the complex connections between narcissism and exercise addiction.

A comparative meta-analysis of the prevalence of exercise addiction in adults with and without indicated eating disorders

BACKGROUND

Exercise addiction is associated with multiple adverse outcomes and can be classified as co-occurring with an eating disorder, or a primary condition with no indication of eating disorders. We conducted a meta-analysis exploring the prevalence of exercise addiction in adults with and without indicated eating disorders.

METHODS

A systematic review of major databases and grey literature was undertaken from inception to 30/04/2019. Studies reporting prevalence of exercise addiction with and without indicated eating disorders in adults were identified. A random effect meta-analysis was undertaken, calculating odds ratios for exercise addiction with versus without indicated eating disorders.

RESULTS

Nine studies with a total sample of 2140 participants (mean age = 25.06; 70.6% female) were included. Within these, 1732 participants did not show indicated eating disorders (mean age = 26.4; 63.0% female) and 408 had indicated eating disorders (mean age = 23.46; 79.2% female). The odds ratio for exercise addiction in populations with versus without indicated eating disorders was 3.71 (95% CI 2.00-6.89; I² = 81; p  ≤ 0.001). Exercise addiction prevalence in both populations differed according to the measurement instrument used.

DISCUSSION

Exercise addiction occurs more than three and a half times as often as a comorbidity to an eating disorder than in people without an indicated eating disorder. The creation of a measurement tool able to identify exercise addiction risk in both populations would benefit researchers and practitioners by easily classifying samples.

Morbid exercise behaviour and eating disorders: A meta-analysis

BACKGROUND AND AIMS

This study examined the relationship between self-reported symptoms of morbid exercise behaviour (MEB) and eating disorders (ED) using meta-analytic techniques.

METHODS

We systematically searched MEDLINE, PsycINFO, Web of Science, SciELO and Scopus. Random effects models were used to compute pooled effect sizes estimates (r). The robustness of the summarized estimates was examined through sensitivity analyses by removing studies one at a time.

RESULTS

Sixty-six studies comprising 135 effect-sizes (N = 21,816) were included. The results revealed: (a) small-sized relationship in the case of bulimic symptoms (r = 0.19), (b) small- (r = 0.28) to medium-sized relationships (r = 0.41) in the case of body/eating concerns, and (c) medium-sized relationships in the case of overall ED symptoms (r = 0.35) and dietary restraint (r = 0.42). Larger effect sizes were observed in the case of overall ED symptoms in clinical, younger, and thinner populations, as well as when employing a continuously-scored instrument for assessing ED or the Compulsive Exercise Test for assessing MEB. Larger effect sizes were also found in female samples when the ED outcome was dietary restraint.

CONCLUSIONS

The identified gaps in the literature suggest that future research on the topic may benefit from: (a) considering a range of clinical (in terms of diagnosed ED) and non-clinical populations from diverse exercise modalities, (b) addressing a wide range of ED symptomatology, and (c) employing longitudinal designs that clarify the temporal direction of the relationship under consideration.

Association between personality traits and suicidality by age groups in a nationally representative Korean sample

Suicide is a leading health issue, which substantially contributes to the causes of death worldwide. Personality traits are some of the major risk factors for suicidality. We sought to identify the relationships between personality traits and suicidality by age group.The Big-Five Inventory-10 traits were measured in community-dwelling individuals in a nationally representative sample in the Republic of Korea. Because personality traits are long-standing patterns throughout one's lifetime, suicidality was measured based on lifetime history, rather than in a recent period. To comprehensively examine independent influences of personality traits on suicidality, psychiatric comorbidity and sociodemographic data were adjusted for.A total of 6022 subjects (3714 females and 2308 males) were included. Agreeableness (odds ratio (OR) [95% confidential intervals (CI)] = 0.79 [0.64-0.98]) was negatively associated with suicidal ideation, whereas neuroticism (1.27 [1.05-1.54]) and openness (1.36 [1.11-1.67]) were positively associated with suicidal ideation among young adults. Openness (1.25 [1.10-1.43]) had a positive association, and conscientiousness (0.86 [0.75-0.98]) had a negative association with suicidal ideation among the middle-aged group. Neuroticism is the only influencing factor for suicidal attempts among the young adult (1.88 [1.24-2.86]) and older (1.65 [1.24-2.20]) groups.Given the differential associations between personality traits and suicidality by age groups, future studies are needed to comprehensively identify possible roles of personality in suicide by age.

The relationship between moderate to vigorous physical activity and cognitive rigidity in anorexia nervosa

A drive for physical activity despite underweight is a core feature of anorexia nervosa. This pilot study detects which aspect of physical activity, if any, could be related to cognitive rigidity in anorexia nervosa. Twenty-eight outpatients with anorexia nervosa and 24 healthy participants were assessed for cognitive flexibility with the Trail Making Test (TMT) and for multiple dimensions of physical activity by subjective and objective assessments. Correlation analysis was conducted to disentangle the relationship between cognitive rigidity and the different aspects of physical activity, then, the moderating effect of anorexia nervosa on this relationship was assessed. A principal component analysis was performed to incorporate all variables of physical activity in (a) global factor(s) reflecting the multidimensional nature of this construct. Cognitive rigidity (TMT b - a score) was significantly correlated to the amount of objectively assessed physical activity estimated, only in the sample of patients with anorexia nervosa. The principal component analysis confirms the correlation between a single construct of "physical activity" and cognitive rigidity in anorexia nervosa only. This pilot study suggests a relationship between cognitive rigidity and physical activity that could help explain the persistence of the latter despite ongoing malnutrition in patients with anorexia nervosa.

Is problematic exercise really problematic? A dimensional approach

OBJECTIVE

Though moderate exercise has numerous health benefits, some individuals may become excessively preoccupied with exercise, endorsing features akin to "addiction." The aim of this study was to evaluate the relationships between problematic exercise (viewed dimensionally), quality of life, and psychological measures.

METHODS

Young adults were recruited from an established population-based cohort in the United Kingdom and completed an online survey. The factor structure of the Exercise Addiction Inventory (EAI) was characterized. Relationships between dimensional EAI factor scores and other variables (impulsivity, compulsivity, emotional dysregulation) were elicited.

RESULTS

Six hundred and forty-two individuals took part in the study (mean age 23.4 years, 64.7% female). The EAI yielded two factors - a "general factor" and a "relationship conflict factor." Both EAI factor scores were associated with disordered eating, impulsivity (UPPS), and compulsivity (CHI-T). Only the relationship conflict factor score was significantly associated with impaired quality of life (all domains) and with maladaptive personality traits (emotional dysregulation and obsessive-compulsive personality disorder traits). Few participants met conventional threshold for full exercise addiction (1.1%).

CONCLUSION

Higher problematic exercise scores, in a sample largely free from exercise addiction, were associated with impulsive and compulsive personality features, emotional dysregulation, and disordered eating. Further research is needed to examine whether these results generalize to other populations (such as gym attendees) and are evident using more rigorous in-person clinical assessment rather than online assessment. Longitudinal research is needed to examine both positive and negative impacts of exercise, since moderate exercise may, in fact, be useful for those with impulsive/compulsive tendencies, by dampening negative emotional states or substituting for other more damaging types of repetitive habit.

Compulsive exercise and weight suppression: Associations with eating pathology in distance runners

Some athletes, particularly those who participate in activities that emphasize leanness such as competitive running, are at greater risk for eating disorder (ED) pathology. Compulsive exercise (CE) is linked with ED pathology among female athletes, with evidence that CE for weight control is most strongly correlated with ED thoughts and behaviors. Weight suppression (WS), the discrepancy between highest adult weight and current weight, is also linked with ED symptoms. Taken together, runners with greater WS may be more likely to engage in CE to influence their weight or shape and may subsequently report other associated ED symptoms. As such, the current study investigated associations between CE and ED pathology in a mixed-gender sample of adult distance runners (N = 277, 51% female), and tested the impact of WS on this association. Results indicated that females reported greater CE and ED pathology, whereas males reported greater WS. A significant interaction effect for CE x WS, (p < .05) indicated that the relation between CE and ED scores was stronger among male runners who reported higher WS. In contrast, WS did not impact the association between CE and ED pathology for female runners. Results from the current study have important implications for the assessment and treatment of ED in athletes, specifically runners, and suggest that WS is an important factor to consider when working with male athletes.

Which sports are more at risk of physical exercise addiction: A systematic review

INTRODUCTION

Excessive physical exercise may evolve into physical exercise addiction, a recently identified entity with many yet unclear aspects, such as global prevalence and variability according to different types of physical exercise.

METHODS

We systematically reviewed the current literature up to June 2018 to collect all studies screening exercise addiction with two of the most frequently used screening scales: the Exercise Addiction Inventory (EAI) and the Exercise Dependence Scale (EDS).

RESULTS

We detected forty-eight studies (20 using the EAI, 26 the EDS, and 2 both scales) reporting variable point prevalence of exercise addiction risk, depending on the target population and the investigated sport. The EAI identifies a higher proportion of people at risk for physical exercise addiction among endurance athletes (14,2%) followed by ball games (10,4%), fitness centre attendees (8,2%) and power disciplines (6,4%), while a frequency of 3,0% was reported in the general population. Studies using the EDS found discrepant results.

DISCUSSION

This systematic review suggests that sport disciplines are associated with different vulnerability for physical exercise addiction. Besides the different addictive potential of each sport, the heterogeneity of results may be also due to socio-demographic and cultural characteristics of the target populations. The EAI and the EDS identify different proportions of individuals at risk for exercise addiction both in general population and in specific sport categories. As the EAI screens a higher proportion of subjects at risk, especially in endurance disciplines, it could be more appropriate for early detection of at-risk subjects and/or disciplines.

CONCLUSION

Tailored prevention strategies for each discipline could help better preserving benefits of sports. More precision in research methods and the use of the most appropriate scale are required to allow a better comparability of prevalence among physical exercise disciplines and in general population.