105
Journal of Exercise Physiologyonline
Official Research Journal of
Editor-in-Chief
Tommy
the American
Boone, PhD,
Society
MBA of
Exercise
Review Physiologists
Board
Todd Astorino, PhD
Julien Baker,
ISSN 1097-9751
PhD
Steve Brock, PhD
Lance Dalleck, PhD
Eric Goulet, PhD
Robert Gotshall, PhD
Alexander Hutchison, PhD
M. Knight-Maloney, PhD
Len Kravitz, PhD
James Laskin, PhD
Yit Aun Lim, PhD
Lonnie Lowery, PhD
Derek Marks, PhD
Cristine Mermier, PhD
Robert Robergs, PhD
Chantal Vella, PhD
Dale Wagner, PhD
Frank Wyatt, PhD
Ben Zhou, PhD
Official Research Journal
of the American Society of
Exercise Physiologists
ISSN 1097-9751
October 2019
Volume 22 Number 5
JEPonline
Exercise Dependence: An Updated Systematic Review
Juliana Gonçalves Baptista1, Paulo Nunes Costa Filho1, Marcelo
Faria Porretti2, Giannina do Espírito-Santo3, Monique Assis2,
Alexandre Palma1
1
Universidade Federal do Rio de Janeiro, School of Physical
Education and Sports, Rio de Janeiro, Brazil; 2Universidade do
Estado do Rio de Janeiro, Physical Education and Sports Institute,
Rio de Janeiro, Brazil; 3Comissão Nacional de Ética em Pesquisas
com Seres Humanos, Brasília, Brazil
ABSTRACT
Baptista JG, Costa Filho PN, Porretti MF, Espírito-Santo G do,
Assis, M, Palma A. Exercise Dependence: An Updated Systematic
Review. JEPonline 2019;22(5):105-125. In 2002, Hausenblas and
Downs (39) published an important review about exercise
dependence. More than 15 yrs later, our study aims to conduct an
updated systematic review of the research examining exercise
dependence. The updated systematic review included searching the
ERIC, Medline/PubMed, Scopus, and Sportdiscus databases using
the following key words: exercise dependence, negative addiction,
exercise addiction, compulsive exercise, obligatory exercise, and
exercise commitment from which 136 English language articles
published between 2000 to 2019 met the inclusion criteria and were
analyzed regarding exercise dependence in nonclinical populations.
The Exercise Dependence Scale (39) was the most frequently used
self-report questionnaire. Exercise dependence symptoms differed
greatly among the samples investigated and the use of various
instruments made the comparisons among the studies very difficult.
Consistent with the seminal systematic review by Hausenblas and
Downs, the exercise dependence literature remains inconsistent.
Hence, the findings highlight the need for a consensus regarding the
measurement, criteria, and terminology for exercise dependence.
Key Words: Addiction, Dependence, Exercise, Physical Activity
 106

INTRODUCTION

In 2002, Hausenblas and Downs (39) published a comprehensive and systematic review of
88 exercise dependence and deprivation research articles published between 1970 and
1999. This review was designed to bring definitional clarity to the concept of exercise
dependence, basing it on the substance dependence criteria from the Diagnostic and
Statistical Manual of Mental Disorders (3rd Edition) (39). However, clinicians and researchers
have continued to use a plethora of synonymous terms to describe the phenomenon of
exercise as a behavioral addiction illustrating that the research in this area is still evolving.

Applying the DSM as a guide, Hausenblas and Downs (39) proposed that at least 3 of the
following 7 criteria or symptoms must be met for the diagnosis of exercise dependence: (i)
tolerance is the need for increasing the duration, frequency, and intensity of exercise to
obtain the desired effect or by experiencing less effect with extended use of the same amount
of the exercise; (ii) withdrawal is exhibited when the person stops the exercise and
experiences disagreeable symptoms (e.g., anxiety, fatigue) or when by use the exercise as a
way to either relieve or prevent withdrawal symptoms; (iii) intention effects is when the
exercise behavior is greater than was originally intended; (iv) loss of control is the inability
to reduce the amount of exercise, despite the desire to do so; (v) time represents a relatively
large amount of time spent in performing or preparing for the exercise; (vi) reductions in
other activities is a reduction in social, occupational, or recreational activities because of
physical activity; and (vii) continuity reflects that exercising persists despite recurring
physical or psychological effects (39).

Exercise addicts are distinguished from other high-volume exercisers, in particular athletes,
whose intrinsic motive to exercise is typically under their control and it does not manifest in
psychological, social, or occupational issues (78). Also, of importance is the distinction
between primary versus secondary exercise addiction. Primary exercise addiction is different
from excessive exercise addiction that characterized by eating disorders (also known as
secondary exercise addiction), in which the exercise represents a means to control weight. In
regards to the eating disorders, Egorov and Szabo (23) stated that “excessive exercise is a
means for caloric control and weight loss rather than for escape from a psychological
hardship” (p. 200). In this sense, Cunningham, Pearman, and Brewerton (15) affirm that the
primary exercise addiction is more addictive in nature and that the secondary exercise
addiction is more compulsive. Thus, individuals suspected of exercise addiction should
undergo further evaluation to determine if it is primary or secondary to ensure that the
underlying symptoms are properly addressed. The focus on this review is on primary exercise
dependence.

In their review, Hausenblas and Downs (39) highlighted that many of the studies they
reviewed did not include a control group, had various exercise dependence/addiction
measures that were largely unidimensional, lacked a well-defined criterion for the cutoff point
for exercise dependence, and used inappropriate or invalid diagnosis criteria (e.g., exercise
frequency, duration, and/or intensity). They concluded that an understanding of exercise
dependence has been inconclusive due, in part, to a “lack of experimental research,
inconsistent or nonexistent control groups, failure to control for participant biases, discrepant
operational criteria for exercise dependence, and/or invalidated or inappropriate measures for
exercise dependence” (p. 114). As a result, Hausenblas and Downs (39) recommended that
 107

future researchers adopt multidimensional instruments, use a control group, apply theoretical
models to guide the purpose of the study, use objective measures of exercise and health,
examine various types of physical activities, and use varied research designs (e.g.,
longitudinal, qualitative, experimental, and ecological). They also noted a need to examine
the prevalence of exercise dependence and the personality profiles of exercise addicts.
Therefore, it is important to examine if these recommendations were adopted to determine
the current state and scope of the exercise dependence research area and to guide future
research.

Furthermore, the current circumstance of society should also be highlighted since exercise
prevents and treats many diseases. In effect, exercise has become a synonym for health
(54). Individuals who yearn to be healthy may also see physical activity as a way to achieve
socially valued ideals. In an attempt to reach this goal, people may adopt certain practices,
such as uncontrollable and excessive exercise.

Because of the increased interest in exercise dependence in both the research and the
mainstream literature, an updated review is warranted to determine, in part, which of the
research recommendations from Hausenblas and Downs (39) have been examined and/or
implemented. Therefore, the purpose of this study was to review the primary exercise
dependence research from 2000 to 2019 in populations that were not under clinical treatment
(e.g., eating disorders) to determine whether the recommendations suggested by Hausenblas
and Downs (39) were considered.

METHODS

Selection Criteria and Coding

This study consisted of a computer-based search in ERIC, Medline/PubMed, Scopus, and
Sportdiscus using the following key words: exercise dependence, negative addiction,
exercise addiction, compulsive exercise, obligatory exercise, and exercise commitment, in
view of the greater appearance of these terms in the literature. Inclusion criteria were
English-language studies published between January 2000 to January 2019 that assessed
primary exercise dependence and/or addiction. As pointed out by Hausenblas and Downs
(39), primary exercise dependence “can be differentiated from an eating disorder by clarifying
the ultimate objective of the exerciser, the physical activity is an end in itself. In contrast,
Hausenblas and Downs (39) state that for secondary exercise dependence, “the compelling
motivation for physical activity is the control and manipulation of body composition” (p. 113).
In order to classify primary and secondary dependence, it was decided to exclude studies
with clinical samples for eating and body disorders. A total of 1,292 articles were identified.
The cutoff date was defined by taking into consideration that Hausenblas and Downs (39)
conducted a systematic review on articles on this topic up to 1999. Since the present study
used inclusion and exclusion criteria and databases that were similar to those of the earlier
review, it was decided to use the year 2000 as the starting date for inclusion. Therefore, from
the two stages of screening articles (see Figure 1), a total of 136 articles remained to be fully
read and analyzed. Consistent with the review by Hausenblas and Downs (39), the following
information was assessed from the included studies: (a) study design; (b) terminology; (c)
measure; (d) participant characteristics; (e) main themes; and (a) prevalence of exercise
dependence. Two authors independently reviewed and categorized the study information.
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Figure 1. Article Selection Process

RESULTS

Study Design
Regarding the study design, 130 were quantitative, 4 were qualitative, and 2 were both a
quantitative-qualitative (Quanti-Quali). Most of the quantitative studies used only self-report
assessments of exercise dependence. Only 11 of the studies used both objective and self-
report assessments. For the qualitative studies, 3 used a semi-structured interviewed and 1
study used open-ended questions. Regarding data-gathering methods in the Quanti-Quali
approach, the articles used a self-report questionnaire and semi-structured interview.
 109

Terminology
Eleven different terms were used to describe exercise dependence with exercise
dependence being the most common term used (n = 60 studies). This was followed by
exercise addiction (n = 28), compulsive exercise (n = 17), obligatory exercise or obligation to
exercise (n = 16), excessive exercise (n = 4), exercise commitment (n = 3), bodybuilding
dependence (n = 3), negative addiction (n = 2), commitment to running (n = 1), dance
addiction (n = 1), and obsessive-compulsive disorder (n = 1).

Exercise Dependence Measures

Sixteen different exercise dependent measures were used in the studies reviewed. One study
was identified that used a measurement that was not specific to exercise dependence (i.e.,
Consumptive Habits Questionnaire), and 4 articles used an author-developed measure.
Some studies used more than 1 questionnaire to measure dependence. The most frequently
used measure was the Exercise Dependence Scale (Table 1).

Table 1. Exercise Dependence Measures

Scale References Number of

Studies

Exercise Dependence Scale (40) 38

Exercise Addiction Inventory (82) 26
Obligatory Exercise Questionnaire (70) 19
Compulsive Exercise Test (81) 14
Exercise Dependence Questionnaire (69) 13
Commitment to Exercise Scale (16) 6
Bodybuilding Dependence Scale (76) 4
Running Addiction Scale (10) 4
Exercise Commitment Scale (87) 3
Negative Addiction Scale (35) 3
Exercise Dependence Scale (61) 2
Running Addiction Scale (74) 2
Exercise Dependence Criteria (44) 1
Exercise Dependence and Elite Athletes Scale (63) 1
Obsessive-Compulsive Scale (28) 1
Compulsive Exercise Scale (83) 1

Participant Characteristics
Regarding gender, 105 studies included both men and women, 15 studies examined women
only, and 14 studies included men only. Two studies, in addition to male and female, also
included people who did not qualify for binary gender distinction. With regard to participant
characteristics, most of the studies sampled university students (n = 40 studies) followed by
people engaging in nonspecific or multiple activities (n = 26), members of gym or fitness
centers (n = 19), runners (n = 16), practitioners in general (n = 11), triathletes (n = 6),
bodybuilders (n = 4), teenagers (n = 4), physical education teachers or students (n = 4).
dancers (n = 3), and elite surfers (n = 1).
 109

Terminology
Eleven different terms were used to describe exercise dependence with exercise
dependence being the most common term used (n = 60 studies). This was followed by
exercise addiction (n = 28), compulsive exercise (n = 17), obligatory exercise or obligation to
exercise (n = 16), excessive exercise (n = 4), exercise commitment (n = 3), bodybuilding
dependence (n = 3), negative addiction (n = 2), commitment to running (n = 1), dance
addiction (n = 1), and obsessive-compulsive disorder (n = 1).

Exercise Dependence Measures

Sixteen different exercise dependent measures were used in the studies reviewed. One study
was identified that used a measurement that was not specific to exercise dependence (i.e.,
Consumptive Habits Questionnaire), and 4 articles used an author-developed measure.
Some studies used more than 1 questionnaire to measure dependence. The most frequently
used measure was the Exercise Dependence Scale (Table 1).

Table 1. Exercise Dependence Measures

Scale References Number of

Studies

Exercise Dependence Scale (40) 38

Exercise Addiction Inventory (82) 26
Obligatory Exercise Questionnaire (70) 19
Compulsive Exercise Test (81) 14
Exercise Dependence Questionnaire (69) 13
Commitment to Exercise Scale (16) 6
Bodybuilding Dependence Scale (76) 4
Running Addiction Scale (10) 4
Exercise Commitment Scale (87) 3
Negative Addiction Scale (35) 3
Exercise Dependence Scale (61) 2
Running Addiction Scale (74) 2
Exercise Dependence Criteria (44) 1
Exercise Dependence and Elite Athletes Scale (63) 1
Obsessive-Compulsive Scale (28) 1
Compulsive Exercise Scale (83) 1

Participant Characteristics
Regarding gender, 105 studies included both men and women, 15 studies examined women
only, and 14 studies included men only. Two studies, in addition to male and female, also
included people who did not qualify for binary gender distinction. With regard to participant
characteristics, most of the studies sampled university students (n = 40 studies) followed by
people engaging in nonspecific or multiple activities (n = 26), members of gym or fitness
centers (n = 19), runners (n = 16), practitioners in general (n = 11), triathletes (n = 6),
bodybuilders (n = 4), teenagers (n = 4), physical education teachers or students (n = 4).
dancers (n = 3), and elite surfers (n = 1).
 111

Biological Factors Cardiovascular response, hormones, anthropometric 10

measurements, sleep level, electroencephalogram, and
occurrences of injuries.

Other Addictions Co-occurrence of other types of addictions (e.g., 8

alcohol, buying, video gaming, sexual or muscle
dysmorphia).

Quality of Life Quality of life level in relation to exercise dependence 7

level.

Physical-Social It is related to the “degree to which the people become 5

Anxiety anxious when others observe or evaluate their
physiques”.

Instrument The differences between measurement instruments for 2

Comparison exercise dependence were evaluated.

Exercise Effects of deprivation/cessation of exercise. 2

Deprivation

Prevalence of Exercise Dependence Symptoms

Table 3 presents the prevalence of exercise dependence symptoms reported in the 46
articles that evaluated this outcome. The prevalence of exercise dependence ranged from
1.44% to 51.7%.

Table 3. Occurrence Levels in Articles with Quantitative Approaches.

Ref. Participants Exercise Dependence Occurrence Level

Measurement

(2) 95 ultra-marathon Exercise Dependence 3.2% at risk of exercise

runners, both sexes Scale dependence
(3) 241 male students of Exercise Dependence Exercise Dependence Scale: 8.3%
the Physical Scale and Compulsive exercise dependent
Education and Sports Exercise Test Compulsive Exercise Test: 13.4%
exercise compulsive
(4) 120 exercisers, both Exercise Dependence 17.5% of exercise addiction
sexes Scale
(6) 171 triathletes, both Exercise Dependence 30.4% primary exercise-dependent
sexes Questionnaire
(8) 120 regular gym Exercise Addiction 42.5% high risk exercise addiction
individuals, both Inventory level
sexes
(11) 2,660 long-distance Exercise Dependence 1.44% at risk of exercise
runners, both sexes Scale dependence
 112

(13) 169 individuals who Exercise Dependence 9% at risk of exercise dependence

exercised regularly, Scale
both sexes
(14) 262 young (17-25 Exercise Dependence 18.3% at risk of exercise
years) athletes, both Scale dependence
sexes
(18) 155 runners, both Exercise Addiction 17.36% of exercise addiction
sexes Inventory
(19) 996 high school Exercise Addiction 6.2% for maladaptive physical
students Inventory exercise
(21) 805 students at a Exercise Dependence 6% at risk of exercise dependence
school, both sexes Scale
(22) 351 physically active Exercise Dependence 3.4% at risk of exercise
participants, both Scale dependence
sexes
(25) 101 men regular Bodybuilding 17.8% dependent
weight trainers Dependence Scale
(27) 257 university Commitment to Exercise 21.8% dependent
students, both sexes Scale
(32) 107 gym Exercise Dependence 29.9% primary exercise dependent
practitioners, both Questionnaire
sexes
(33) 569 university Consumptive Habits 18.1% compulsive exercisers
students, both sexes Questionnaire
(nonspecific)
(34) 305 students of the Exercise Dependence Men: 13.2% of exercise addiction
Physical Education Scale Women: 15.8% of exercise
and Sports, both addiction
sexes
(36) 146 men weight lifters Exercise Dependence 15.1% at risk of exercise
(bodybuilders, weight Scale dependence
lifters, fitness)
(38) 188 amateur Running Addiction Scale 11% high level of exercise
endurance athletes, dependence
both sexes
(43) 248 gym users, both Exercise Dependence 9.5% at risk of exercise
sexes Scale dependence
(47) 300 gym Questionnaire 42% exercise dependent
practitioners, both developed by the
sexes. authors
(48) 1601 undergraduate Exercise Addiction 11.3% exercise dependent
students, both sexes Inventory
(50) 274 exercisers, men Exercise Addiction 7.1% prevalence of exercise
Inventory addiction in the football group and
9.7% in fitness group.
(51) 603 regular Exercise Addiction 5% of exercise addiction
Crossfitters, both Inventory
 113

sexes
(52) 577 fitness Exercise Addiction 6.8% of exercise addiction
exercisers, both Inventory
sexes
(53) 1083 exercisers, both Exercise Addiction Injured exercisers: 7.7% of
sexes Inventory exercise addiction
Non-injured exercisers: 6.7% of
exercise addiction
(55) 292 university Exercise Dependence 14% at risk of exercise
students, both sexes Questionnaire dependence
(56) 345 Ironman Exercise Dependence 29.6% exercise dependent
participants, both Scale
sexes
(58) 859 amateur Exercise Addiction Men: 17% of exercise addiction
endurance cyclists, Inventory Women: 16% of exercise addiction
both sexes
(62) 234 elite athletes of Exercise Dependence 34.84% at risk of exercise
different sports, both and Elite Athletes Scale dependence
sexes
(64) 1439 fitness center Exercise Dependence Exercise Dependence Scale: 2.2%
users, both sexes Scale and Exercise exercise dependent.
Addiction Inventory Exercise Addiction Inventory: 7%
exercise dependent.
(65) 517 university Exercise Dependency 3.3% at risk of exercise
students, both sexes Scale dependence
(66) 300 individual and Negative Addiction 28% female and 38% male
groups sport athletes, Scale exercise dependent
both sexes
(67) 128 individuals of Exercise Dependence 7.8% at risk of exercise
fitness centers, both Scale dependence
sexes
(68) 396 university Exercise Dependence Sport science students: 5.3% at
students (sport Scale risk of exercise dependence.
science students; Non-sport science students: 7.2%
non-sport science at risk of exercise dependence.
students), both sexes
(71) 204 women university Compulsive Exercise 51.7% exercise compulsive
students Test
(72) 147 university Exercise Addiction 23% of exercise addiction
students, both sexes Inventory
(73) 1,008 fitness Exercise Addiction 10.4% of exercise addiction
exercisers, both Inventory
sexes
(75) 726 participants, Commitment to Exercise 4.1% performed obligatory
women Scale exercises
(77) 176 men (gym Exercise Dependence 5.1% at risk of exercise
practitioners or Scale dependence
 112

(13) 169 individuals who Exercise Dependence 9% at risk of exercise dependence

exercised regularly, Scale
both sexes
(14) 262 young (17-25 Exercise Dependence 18.3% at risk of exercise
years) athletes, both Scale dependence
sexes
(18) 155 runners, both Exercise Addiction 17.36% of exercise addiction
sexes Inventory
(19) 996 high school Exercise Addiction 6.2% for maladaptive physical
students Inventory exercise
(21) 805 students at a Exercise Dependence 6% at risk of exercise dependence
school, both sexes Scale
(22) 351 physically active Exercise Dependence 3.4% at risk of exercise
participants, both Scale dependence
sexes
(25) 101 men regular Bodybuilding 17.8% dependent
weight trainers Dependence Scale
(27) 257 university Commitment to Exercise 21.8% dependent
students, both sexes Scale
(32) 107 gym Exercise Dependence 29.9% primary exercise dependent
practitioners, both Questionnaire
sexes
(33) 569 university Consumptive Habits 18.1% compulsive exercisers
students, both sexes Questionnaire
(nonspecific)
(34) 305 students of the Exercise Dependence Men: 13.2% of exercise addiction
Physical Education Scale Women: 15.8% of exercise
and Sports, both addiction
sexes
(36) 146 men weight lifters Exercise Dependence 15.1% at risk of exercise
(bodybuilders, weight Scale dependence
lifters, fitness)
(38) 188 amateur Running Addiction Scale 11% high level of exercise
endurance athletes, dependence
both sexes
(43) 248 gym users, both Exercise Dependence 9.5% at risk of exercise
sexes Scale dependence
(47) 300 gym Questionnaire 42% exercise dependent
practitioners, both developed by the
sexes. authors
(48) 1601 undergraduate Exercise Addiction 11.3% exercise dependent
students, both sexes Inventory
(50) 274 exercisers, men Exercise Addiction 7.1% prevalence of exercise
Inventory addiction in the football group and
9.7% in fitness group.
(51) 603 regular Exercise Addiction 5% of exercise addiction
Crossfitters, both Inventory
 115

addictions (5,84). Thus, there has been great use of the diagnosis criteria proposed by Veale
(84) and by Hausenblas and Downs (40), both based on the Diagnostic and Statistical
Manual of Mental Disorders. Although debate has occurred regarding the terminology of
exercise dependence, with dependence and addiction emerging as the most popular terms,
clarity and consistency is needed.

More specifically, we found that the research literature is confused by several terms such as
compulsion, addiction, and dependence, given that these terms may refer to similar, if not the
same, pathological patterns of problematic exercise. Although Hausenblas and Downs (39)
recommended definitional clarity of the myriad of terms used to guide the next generation of
research in this area, we found a variety of terms are still used to explain the same or similar
phenomenon. That is, in the studies we reviewed, 11 different terms were observed that
hampers the literature searches on this subject. Cook, Hausenblas, and Freimuth (12) stated
that “addiction terminology represents all forms of problematic exercise, while compulsive
terminology is a preferable term for problematic exercise that is secondary to an eating
disorder. The reported that definitional clarity, both in nomenclature and in measurement that
quantify aspects of addiction or compulsion, is needed to further our understanding of the
antecedents and consequences of excessive exercise” (12, p. 140).

Consistent with the review by Hausenblas and Downs (39), many different measures were
used to assess exercise dependence of which the multidimensional Exercise Dependence
Scale was the most frequently used questionnaire. The Exercise Dependence Scale is a
multidimensional instrument that consists of measuring and operating 7 exercise dependence
criteria (i.e., tolerance, abstinence, intention effect, lack of control, time spent, decrease in
other activities, and continuation) (20). Unfortunately, despite specific recommendations for
consistency in the measurement of exercise dependence, very little has changed over the
past decade. Presently, there is still a diversity of instruments and diagnostic criteria used to
assess the level of exercise dependency. As well, according to Egorov and Szabo (23) “the
current exercise dependence measures do not convey information about the actual
prevalence of exercise addiction since they are screening- rather than diagnosis-tools.
Indeed, the estimates based on these questionnaires should be interpreted as symptomatic
or at risk for exercise addiction” (23, p. 201). This point further highlights the need for
definitional, terminology, and measurement consistency for exercise dependence. It is also
important to indicate that the measurement questionnaires used in these studies cannot
establish a cause and effect relationship, given that they can only evaluate the level of
exercise dependence symptoms and do not provide a definitive diagnosis because the
instruments “measure susceptibility”, with regard to the “presence and intensity of the
symptoms” (5, p. 408).

Regarding the participants’ characteristics, we found that university students were most
frequently studied, especially students linked to the fields of psychology and physical activity.
Unfortunately, university students often represent a convenient sample that limits
generalizability to other populations. With regard to gender, most studies examined both
sexes. Because a gender difference appears for exercise dependence symptoms (79), future
researchers are encouraged to examine the moderating effect of gender and exercise
dependence symptoms and their correlates.
 116

Within the main themes, the most recurrent category was “other psychological or mental
factors”. Within this category, studies on personality characteristics emerged, thus meeting
one of the recommendations from Hausenblas and Downs (39). More specifically, higher
levels of extraversion, perfectionism, and neuroticism and lower levels of agreeableness were
evidenced in groups reporting more exercise dependence symptoms (39,41). Some papers
found positive relationships among anxiety, narcissism, and depression levels with exercise
dependence symptoms. Future studies are encouraged to move beyond quantitative
approaches based on psychobiological theories to an analysis that is also of a qualitative
nature with sociocultural assumptions to provide further depth into the antecedents and
consequences of exercise dependence because the personalities construction are also due
to sociocultural relationships (45).

In the “dietary behavior” group, studies on eating disorders predominate through the use of
questionnaires such as the Eating Disorder Inventory. This research typically found a greater
occurrence of exercise dependence symptoms related to drive for thinness, body
dissatisfaction, and bulimia even in nonclinical samples. As expected, in the context of the
“exercise behavior”, physical activity level and frequency were positively related to exercise
dependence symptoms. Thereby, weight and shape preoccupation could lead to obligatory
exercise (24). Further research is needed to examine the relationship between diet and
excessive exercise.

Regarding the “psychological characteristics related to exercise”, studies on motivation

towards exercise are emphasized. The self-perception of the importance of exercise in a
person’s life was something important in people with exercise dependence symptoms. Also,
some papers indicated that the motivation towards exercise related to body shape reasons,
introject regulation motivation, personal challenge, mood control, health, and pleasure.

Regarding the “social factors”, the main results consisted of greater appearance pressure
from the media, family, and female friends (9,29), especially regarding body image that leads
to a greater body dissatisfaction (29) and internalization of western attitudes regarding
appearance (9). In addition, there is the media pressure for slimness among women (9,29)
and men (29), internalization of western attitudes regarding female appearance (9), influence
and pursuit of greater musculature among males (30), pressure from men’s spouses (9),
pressure from coaches and teammates and high beliefs in exercise (62); all were predictors
of high appearance of exercise dependence symptoms. Although in two studies (21,85) there
was a higher percentage of exercise dependence symptoms among men, and in other ones
the women showed higher exercise dependence symptoms (14,31), Modolo et al. (66) did not
find any significant differences between men and women regarding exercise dependence
symptoms. This context may be related to the social panorama that is experienced.
According to Bourdieu (7), in current society, there is male symbolic dominance in such a
way that women (as the dominated party) are subjected to pressure to adapt to certain
“standards” regarding habits and conduct (such as submissiveness, fragility or dullness),
which would therefore be reflected in their desires and practices that are also related to the
body. On the other hand, it cannot be ignored that men also suffer social pressures, which
consequently reflect on their desires, ideals, and practices (such as the search for more
imposing and robust bodies).
 117

Studies on the “behavior and body image” category showed that individuals placed great
importance on body image, especially women (46,59,60). This confirms the findings in the
categories of “dietary behavior” and “social factors”. Given the large amount of cases in
published studies, it seems that women are more susceptible to being dissatisfied with their
bodies, developing disorders (either food or body-related), and/or suffering greater social
pressures to adopt certain behaviors in search of socially valued standards. Moreover, these
data explain the number of studies that chose to select only one sex, generally women.

In the context of biological characteristics, 5 main psychobiological hypotheses for

comprehending exercise dependence were found (5,37). The first hypothesis relates to
altered regulation of exercise (i.e., changes to physiological variables when not exercising)
such as what would be evidenced in exercise deprivation studies. Negative outcomes may be
increased when individuals are requested to limit or refrain from exercise (i.e., during
recovery from an injury), and may be accompanied by other symptoms of anxiety or
depression. Experimental exercise deprivation studies reveal that these negative emotional
consequences interfere with the normal daily functioning of the individual (1).

The second hypothesis suggests that exercise dependence is similar to anorexia, through
research on animals, in which the drastic reduction of food consumption induce the excessive
exercise level, because the association between the hypothalamus-pituitary-adrenal axis and
drastic the reduction in caloric intake would increase physical exercise with mediation of
lower body fat percentages (37) and lower leptin levels (49). In this manner, a vicious circle
would be created through the reward mechanism (37). Lichtenstein et al. (49), in their studies
with men, analyzed the association between leptin levels and exercise dependence
symptoms. Their data showed that excessive training in exercise addiction is associated with
low levels of body fat-adjusted leptin levels.

The third hypothesis relates to catecholamines, considering that with a regular training
program, the catecholamine level (adrenalin and noradrenaline) of the sympathetic nervous
system tends to decrease due to adaptation towards efficiency of energy use. A decrease in
this system would produce lethargy, fatigue, and diminished excitation, consequently causing
an effect of increased exercise levels to reach satisfaction (37).

The fourth hypothesis relates to endorphins. Through their release during exercise, the
practitioner has a pleasant feeling in his body. Similarly, “with regular intense exercise, the
increased endorphin production results in brain down-regulation” (26, p. 4074), derived from
the need to continue or increase the exercise levels in order to reach the satisfaction and
balance brain (26,37).

There is the hypothesis of cytokines, in which signs of cytokines would promote changes to
neural activity. Interleukin-6 (IL-6) is the first cytokine in circulation and is initially triggered
through incapacity to deal with high loads, acute psychological stress, acute infection, and
decreased muscle glycogen concentration during exercise (37). These would give rise to
increased IL-6 and would also result in high production of cortisol (37). However, in the
“biological factors” category, Heaney, Ginty, Carroll, and Phillips (42) found a lower level of
saliva cortisol in the group with exercise dependence symptoms, in relation to those without
symptoms.
 115

addictions (5,84). Thus, there has been great use of the diagnosis criteria proposed by Veale
(84) and by Hausenblas and Downs (40), both based on the Diagnostic and Statistical
Manual of Mental Disorders. Although debate has occurred regarding the terminology of
exercise dependence, with dependence and addiction emerging as the most popular terms,
clarity and consistency is needed.

More specifically, we found that the research literature is confused by several terms such as
compulsion, addiction, and dependence, given that these terms may refer to similar, if not the
same, pathological patterns of problematic exercise. Although Hausenblas and Downs (39)
recommended definitional clarity of the myriad of terms used to guide the next generation of
research in this area, we found a variety of terms are still used to explain the same or similar
phenomenon. That is, in the studies we reviewed, 11 different terms were observed that
hampers the literature searches on this subject. Cook, Hausenblas, and Freimuth (12) stated
that “addiction terminology represents all forms of problematic exercise, while compulsive
terminology is a preferable term for problematic exercise that is secondary to an eating
disorder. The reported that definitional clarity, both in nomenclature and in measurement that
quantify aspects of addiction or compulsion, is needed to further our understanding of the
antecedents and consequences of excessive exercise” (12, p. 140).

Consistent with the review by Hausenblas and Downs (39), many different measures were
used to assess exercise dependence of which the multidimensional Exercise Dependence
Scale was the most frequently used questionnaire. The Exercise Dependence Scale is a
multidimensional instrument that consists of measuring and operating 7 exercise dependence
criteria (i.e., tolerance, abstinence, intention effect, lack of control, time spent, decrease in
other activities, and continuation) (20). Unfortunately, despite specific recommendations for
consistency in the measurement of exercise dependence, very little has changed over the
past decade. Presently, there is still a diversity of instruments and diagnostic criteria used to
assess the level of exercise dependency. As well, according to Egorov and Szabo (23) “the
current exercise dependence measures do not convey information about the actual
prevalence of exercise addiction since they are screening- rather than diagnosis-tools.
Indeed, the estimates based on these questionnaires should be interpreted as symptomatic
or at risk for exercise addiction” (23, p. 201). This point further highlights the need for
definitional, terminology, and measurement consistency for exercise dependence. It is also
important to indicate that the measurement questionnaires used in these studies cannot
establish a cause and effect relationship, given that they can only evaluate the level of
exercise dependence symptoms and do not provide a definitive diagnosis because the
instruments “measure susceptibility”, with regard to the “presence and intensity of the
symptoms” (5, p. 408).

Regarding the participants’ characteristics, we found that university students were most
frequently studied, especially students linked to the fields of psychology and physical activity.
Unfortunately, university students often represent a convenient sample that limits
generalizability to other populations. With regard to gender, most studies examined both
sexes. Because a gender difference appears for exercise dependence symptoms (79), future
researchers are encouraged to examine the moderating effect of gender and exercise
dependence symptoms and their correlates.
 119

in 2013, a new dimension was added as a diagnostic criterion: craving. In which it is

understood that craving "is manifested by an intense desire or urge for the drug that may
occur at any time but is more likely when in an environment where the drug was previously
obtained or used" (p. 483). Although exercise dependence is still not included in this DSM-V,
it may be interesting that future studies consider this dimension in its analysis, since the
substance diagnostic criteria of DSM are currently used to measure the symptoms of
exercise dependence.

ACKNOWLEDGMENTS
We thank all the friends and colleagues with whom we had joyful and enriching conversations
and discussions on the matters treated in this article.

Address for correspondence: Alexandre Palma, PhD, School of Physical Education and
Sports, Rio de Janeiro Federal University, Av. Carlos Chagas Filho, 540 – Cidade
Universitária – 21941-599, Rio de Janeiro, RJ, Brazil. Email: palma_alexandre@yahoo.
com.br

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We also found an increase in the number of studies that used theoretical models to predict
dependence (e.g., self-determination theory) (17). Among studies on co-occurrence of other
types of addictive behavior, studies on alcohol appeared most frequently revealing a positive
relationship between exercise dependence symptoms and alcohol drinking (9,47,57).

Finally, regarding the levels of prevalence of exercise dependence symptoms, although only
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that prevalence estimates appeared to be influenced by the characteristics of study samples
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declared, and differences between the types of subject, by itself, have given rise to difficulty
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In relation to the main themes, psychological characteristics relating to exercise and dietary
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expanding. Moreover, the analyses are mostly based on medical and biological discourse
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Finally, out of the 136 articles, 46 analyzed the occurrence rate of exercise dependence
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to a consensus regarding the extent of its occurrence. Thus, it is necessary to continue this
research to better understand the scope of the problem, especially in regards to the
physiological and psychological factors that bring about exercise dependence.

CONCLUSIONS

Our review revealed that the literature remains inconsistent, given that the use of various
types of measurement instruments, measurement criteria for the levels of exercise
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consensus difficult. Standardization of terminology and measurement is needed to provide
consistent advancement for this behavioral addiction. Consistent terminology would improve
database searches. In addition, standard criteria for symptom classification, such as cutoff
points could be adopted. This last point intersects with the numerous types of measurement
instruments: perhaps this diversity is a reflection of the difficulty in comprehending and
understanding exercise dependence. Moreover, considering that, from the DSM-V, published
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