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Working out the pain

section identifier imagethe front cover of a crosscurrents magazine- the main image is a vase with bold coloured flowers

Treating eating disorders and unhealthy exercise poses double challenge

By Abigail Pugh

Spring 2004, Vol 7 No 3


Sara* readily speaks now about experiences that for years she kept private: “Puberty found me gaining 30 pounds in a short period of time,” she recalls. “Despite my mother warning me that it would be temporary and difficult, this period was devastating. As an extremely athletic child, I valued a hip-less, masculine body type that was conducive to athletic performance, so I became obsessed with the bodies of female gymnasts. The extra weight I carried all went to my stomach. It really depressed me to look down at my stomach, so I had to be very thin elsewhere to achieve the flat stomach, which I never achieved at that stage.”

Like Sara, some women and men exercise their bodies to excess, usually in conjunction with problem eating behaviour, putting both body and mind at risk. In fact, researchers estimate that approximately 12 per cent of gym-goers in the United States have a problematic relationship to exercise. The problem may relate directly to weight loss or calorie control and can complicate an existing eating disorder.

Sara’s disorder didn’t end when she left her teens behind: In her 20s, she taught aerobics for a living, which compounded her problems with food. She had a powerful investment in staying slender, and exercise was a reliable method of controlling her weight, as well as “counteracting” and “compensating for” her smoking addiction. Now in her mid-30s, she is able to speak openly and clearly about her painful struggle with an eating disorder, because at last she has the objectivity and peace of mind that only hindsight can bring.

“I would feel tremendous anxiety when missing a workout, to the point that it interfered with my ability to enjoy my day,” she recalls. “I’d deal with it by planning a bigger, harder session the next day, and with repeated assurances to myself that I would make the missed workout up. I remember setting off to the gym as a teen quite full from a binge; yet on the way out the door, grabbing two more pieces of bread just to make sure I felt really full and out of control” (to motivate herself to work out harder).

The anxiety and ritualistic enactment of punishing daily exercise sessions is typical of a syndrome that some researchers call “exercise bulimia” or “anorexia athletica.” Anorexia athletica is not as widely recognized a diagnosis as are anorexia nervosa (compulsive restriction of food intake), bulimia (overeating followed by vomiting, exercise or laxative/diuretic abuse) and binge eating disorder (overeating without use of compensatory measures). But by itself and, more commonly, when accompanied by an eating disorder, it can lead to considerable injury. Exercisers with the disorder often adhere to punishing regimens or three or four hours a day, risking fatigue and low blood sugar. The drive to work out no matter what can lead to exercisers ignoring injury or muscle strain, leading to dehydration, exhaustion, sprains, tears, fractures and heart failure. It can also result in skipping work, social obligations and other activities and can lead to or compound depression. Some researchers suggest that excessive exercise can suppress the sense of hunger, thus maintaining or worsening an already-existing eating disorder.

Therapies for compulsive exercise encompass a wide range of traditions. Christine Courbasson, a specialist in eating disorders at the Centre for Addiction and Mental Health in Toronto, uses a mixture of cognitive/behavioural and dialectical behaviour therapy approaches and principles of Zen, aimed at helping clients fully accept the self and tolerate ambiguity and imperfection. “This means working on the whole individual, as opposed to just the problematic behaviour,” says Courbasson. She feels that excessive exercise functions as an outlet for many women who are unhappy with life and are told that exercise will fix their problems. Between 90 and 95 per cent of her clients are women, between ages 18 and 50. Courbasson believes that re-introducing moderate exercise is possible and desirable: “It’s good to portray exercise as an important part of life.”

Ann Kerr is program director at Sheena’s Place, a support centre in Toronto for people with eating disorders. Her program follows a non-medical model: no assessment is made of incoming clients, and no records are kept. Sheena’s Place offers approximately 65 different therapy groups, divided into generic support groups, those dealing with body image issues, skill building groups and expressive sessions including yoga, pilates, art and mindfulness meditation. What are the reasons for disordered exercise? “Most often”, says Kerr, “the woman feels she has no choice: it doesn’t feel self-destructive. Most do it to maintain some sort of internal equilibrium; to calm anxiety that’s not necessarily weight-related.” Often, flesh and weight gain assume an obsessional or phobic significance to the individual: “The most feared thing is to become fat, but the experience has nothing to do with actual weight,” says Kerr. “There’s a heaviness, a deadness, an anxiety in how this person experiences her own body.”

Kerr’s client population, similar to Courbasson’s, is between 90 and 95 per cent female, with about 60 per cent between age of 20 and 40. In Kerr’s experience, younger clients have a stronger tendency to use exercise in a disordered manner than women in their 30s and 40s. A 2002 study published in Eating and Weight Disorders found that structured exercise in the form of resistance training is a useful therapeutic tool for hospitalized clients with anorexia: the regimen strengthens body composition and psychological well-being. However, Kerr says that exercising in a “normal” way after having struggled with a disordered pattern can be very challenging: “Traditional hospital-based programs used to stop patients exercising altogether,” she says. “It’s hard to get many people to start again, and they become very sedentary. The challenge is how to get people moving again.” Some clients are able to find a way to exercise and keep a normal weight, ” but some can’t risk triggering a relapse,” says Kerr. “They have to be abstinent.” This is a particularly great loss for professional athletes, such as dancers or gymnasts, who are more prone to eating disorders than the general population, and who often must let go of their profession (see sidebar, p. 15).

Caroline Davis, a psychology professor at York University in Toronto, argues that a “harm reduction” model similar to that used increasingly in the addictions field might prove effective in some cases, where total behavioural change is too much to expect. She gives the example of a client who weighs perhaps 15 pounds less than her ideal weight, but who says, “If weighing 130 pounds is what it means to get better, then I don’t want to get better!” For this client, being underweight and continuing to exercise may be a more realistic and healthy goal than complete abstinence.


Athletes and eating disorders – no obvious connection

While many studies demonstrate an increased vulnerability to problematic exercise among professional athletes compared with the general population, other studies show that athletes are less likely to develop compulsive or addictive patterns. Caroline Davis, a psychology professor at York University, says that both can be proven, and that results depend on how “athlete” is defined. Her 1994 study, published in Psychological Medicine, showed that more than half of the eating disordered paticipants were competitive athletes or dancers. However, using a more conservative definition of “athlete” – only those who were competitive at the national or international levels (or who were professional dancers) – Davis’ 2001 study in Sport and Exercise Psychology found that around 25 per cent of hospitalized individuals were athletes. Davis says that very possibly, according to much looser definitions of “athlete,” rates of eating disorders may actually be lower than among the general population, which are estimated to be around three per cent.


Approximately 12 per cent of gym-goers have a problematic relationship to exercise. The problem may relate directly to weight loss or calorie control and can complicate an existing eating disorder.


When does a “healthy” habit turn into a problem?

According to Christine Courbasson, an eating disorders specialist at the Centre for Addiction and Mental Health, there is a fine line between being obsessed with body shape and having an eating or exercise disorder. Symptoms that an interest in fitness has become anorexia athletica include:

  • exercising over and above the requirements for good health

  • exercising despite physical illness or injury

  • linking exercise achievements with calories burned

  • exercising as a direct response to calories consumed

  • defining self-worth solely in terms of performance

  • repetitive, obsessional thoughts about weight and diet

  • compromising work, school, and relationships to find extra time for workouts

  • forgetting that physical activity can be fun

  • feeling compelled to push on to the next challenge

  • justifying excessive behaviour by insisting that the exercise is necessary or healthy


“The most feared thing is to become fat, but the experience has nothing to do with actual weight. There’s a heaviness, a deadness, an anxiety in how this person experiences her own body.”