ORIGINAL RESEARCH

published: 09 December 2021

doi: 10.3389/fpsyt.2021.751550

Mental Disorders in Individuals With

Exercise Addiction—A
Cross-Sectional Study
Maximilian Meyer 1*, Isabel Sattler 2 , Hanna Schilling 2 , Undine E. Lang 1 , André Schmidt 1 ,
Flora Colledge 2† and Marc Walter 1†
1
University Psychiatric Clinics, University of Basel, Basel, Switzerland, 2 Department of Sport, Exercise and Health, University
of Basel, Basel, Switzerland

Background and Aims: Exercise addiction has not yet been designated as an addictive
disorder in the DSM-5 due to a lack of detailed research. In particular, associations with
other psychiatric diagnoses have received little attention. In this study, individuals with
a possible exercise addiction are clinically assessed, in order to establish a profile of
co-occurring psychiatric disorders in individuals with exercise addiction.
Edited by:
Carlos Roncero, Methods: One hundred and fifty-six individuals who reported exercising more than
University of Salamanca, Spain
10 h a week, and continued to do so despite illness or injury, were recruited for the
Reviewed by:
Mary Jo Larson,
study. Those who met the cut-off of the Exercise Dependence Scale (n = 32) were
Brandeis University, United States invited to participate in a screening with the Structured Clinical Interview for DSM-5
Domenico De Berardis, (SCID-5-CV) and personality disorders (SCID-5-PD). Additionally, an interview based
Azienda Usl Teramo, Italy
on the DSM-5 criteria of non-substance-related addictive disorders was conducted to
*Correspondence:
Maximilian Meyer explore the severity of exercise addiction symptoms.
[email protected]
Results: 75% of participants fulfilled the criteria for at least one psychiatric disorder.
† These authors have contributed Depressive disorders (56.3%), personality disorders (46.9%) and obsessive-compulsive
equally to this work and share last
disorders (31.3%) were the most common disorders. Moreover, there was a significant
authorship
positive correlation between the number of psychiatric disorders and the severity of
Specialty section: exercise addiction (r = 0.549, p = 0.002).
This article was submitted to
Addictive Disorders, Discussion: The results showed a variety of mental disorders in individuals with
a section of the journal exercise addiction and a correlation between the co-occurrence of mental disorders
Frontiers in Psychiatry
and the severity of exercise addiction. Exercise addiction differs from other addictive
Received: 01 August 2021
und substance use disorders, as obsessive-compulsive (Cluster C), rather than impulsive
Accepted: 12 November 2021
Published: 09 December 2021 (Cluster B) personality traits were most commonly identified.
Citation: Conclusions: Our results underscore the importance of clinical diagnostics, and
Meyer M, Sattler I, Schilling H,
Lang UE, Schmidt A, Colledge F and
indicate that treatment options for individuals with exercise addiction are required.
Walter M (2021) Mental Disorders in However, the natural history and specific challenges of exercise addiction must be
Individuals With Exercise Addiction—A
studied in more detail.
Cross-Sectional Study.
Front. Psychiatry 12:751550. Keywords: exercise addiction, SCID-5, exercise dependence, excessive exercising, behavioural addiction,
doi: 10.3389/fpsyt.2021.751550 diagnostic screening

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Meyer et al. Mental Disorders in Exercise Addiction

INTRODUCTION TABLE 1 | Criteria developed for rating the severity of exercise addiction based on
symptoms that have been reported to occur in individuals who exercise
The term exercise addiction can be found in scientific literature excessively (24).

dating back to the late 1970s (1). It is used to refer to 1 Exercise volume has increased over time in order to avoid
individuals who lose control over their exercising habits and negative feelings of guilt or laziness
continue their regimen despite negative physical, psychological, 2 Negative affective response when exercise is reduced or
and social consequences (2). Other terms like obligatory exercise, sessions are missed/stopped
exercise dependence and compulsive exercise have emerged since 3 Attempts to reduce exercise volume are feared and/or
(3, 4). Although the symptoms of exercise addiction have unsuccessful
been described in the literature for over five decades, robust 4 Is often preoccupied with exercise (e.g., having persistent
evidence for the classification as a behavioural disorder is still thoughts of when and where next session will take place,
planning training, thinking of ways to exercise during other
lacking (5, 6). The literature consists mostly of qualitative activities)
data and case reports listing self-reported symptoms of the 5 Exercise is used as a way to cope with negative life
phenomenon (7–9) while consistent and methodologically solid experiences or stressors
studies are scarce (2, 10). To assess unhealthy exercising 6 Exercise is continued in spite of illness, injury or severe pain,
behaviour, scholars have developed questionnaires based on at levels beyond rehabilitative training
the self-reported symptoms of their study subjects (11). Those 7 Lies about or minimises time and intensity of exercise
questionnaires also highlight that a uniform understanding of 8 Has jeopardised or lost a significant relationship, job, or
the phenomenon is lacking: the Exercise Dependence Scale educational or career opportunity because of exercise
(EDS) (12) identifies individuals at risk of exercise dependence 9 Despite rational understanding of the negative physical and/or
and the Obligatory Exercise Questionnaire (OEQ) (13) rates psychological burden of exercise habits, habits are continued
whether problems with obligatory exercise can be observed. 10 Feeling of guilt when exercise is missed or reduced
Colledge et al. (14) have pointed out that in a review of 79
questionnaire-based studies addressing exercise addiction, five
different questionnaires are employed, each of which is based on
a distinct conceptual framework. United States also suffered from alcohol use disorder (73.2%),
With the introduction of pathological gambling in the personality disorders (60.8%), affective disorders (49.6%), anxiety
fifth edition of the Diagnostic and Statistical Manual of disorders (41.3%), and 38.1% had a substance use disorder
Mental Disorders, “gambling disorder” is still the sole addictive (excluding alcohol). This is in line with the findings of Kessler et
disorder that is found in the category of “non-substance- al. (23), who reported that 96.3% of those with gambling disorder
related disorders.” Other behaviours with possible pathological also meet the criteria for another mental disorder in their lifetime.
characteristics have been discussed but not been added due In a recent meta-review Colledge et al. (24) studied the range
to insufficient peer-reviewed evidence (10). Behaviours that of symptoms reported in the literature, and proposed criteria
show addictive or pathological traits and are therefore being for exercise addiction based on the DSM-5 criteria for gambling
investigated are internet-related behaviours like gaming (15), disorder (Table 1). These criteria are designed to serve as the
as well as sex, shopping, and exercise (5). Notably, there is an basis for a clinical screening of symptoms which may indicate
ongoing general discussion about the extent to which excessive exercise addiction. Since these criteria were used in this study
behaviours can be compared to substance-related addictive to rate the severity of the observed symptoms, the term exercise
disorders (16, 17). A main point of criticism is that criteria addiction is used concordantly.
for substance-related addictions are often adapted and used In case of exercise addiction, the prevalence and range of co-
for identifying behavioural addictions without it being clear occurring mental disorders has not yet been clinically examined.
whether those criteria are suitable for pathological behaviours Eating disorders are frequently discussed within the context of
(18). It also bears noting that the guidelines which might excessive exercising habits (25) and indeed it seems intuitive
constitute a mental disorder are subject of debate (19). The that exercise might be practised simply for the purpose of
DSM-5 characterises mental disorders as syndromes affecting weight control. Furthermore, some of the highest prevalence
the individual’s cognition, emotion regulation, or behaviour. It rates of exercise addiction (between 38 and 45%) are reported
further states that significant distress is usually associated with in individuals with diagnosed eating disorders (26). Exercising
the underlying condition (20). Therefore, the demonstration of behaviour would therefore have to be considered a symptom of
psychological distress caused by excessive behaviours is necessary the underlying disorder rather than its own entity. In respect
to strengthen the argument for the addition of further non- to this, the differentiation between primary and secondary
substance-related disorders. Nonetheless, excessive behaviours exercise dependence has been proposed, with primary meaning
show apparent similarities to substance-related addictions: dual- that exercising habits are not a secondary feature of anorexia
diagnoses are commonly made in individuals suffering from nervosa or bulimia nervosa (27). This distinction has been
gambling disorder, particularly impulse-control disorders, mood broadly adopted by scholars and the implication has been made
disorders, anxiety disorders and other addictive (substance that exercise dependence without co-occurring eating disorders
related) disorders (21). Petry et al. (22) reported that individuals is a rare phenomenon (28–30). However, Grandi et al. (31)
with gambling addiction from a large national sample of the have explicitly excluded those with eating disorders in their

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Meyer et al. Mental Disorders in Exercise Addiction

studies, and still found symptoms of exercise addiction, providing between 2019 and 2021. The advertisements invited applicants
evidence that the phenomenon exists apart from eating disorders. between 18 and 70 years of age, exercising more than 10 h a
The theory that exercise addiction might be a maladaptive week, and continuing their exercise despite illness or injuries to
coping-strategy to escape from psychological hardship has also participate. These criteria were selected as they were judged to
been discussed (4, 32). This is supported by robust evidence be indicative of a possible addictive disorder in line with DSM-
that exists for positive effects of physical exercise in individuals 5 criteria, yet also simple and clear enough to be communicated
with major depression (33, 34). Indeed, it seems plausible that clearly on an advertising flyer or poster. CHF 40 were given for
exercise might resemble a self-medicating coping pattern and participation in the first examination and an additional 150 CHF
is being used for affect-regulation and stress relief. It is also were given for further participation in the study.
possible that exercise addiction might be related to emotional
dysregulation (35) and higher levels of alexithymia (36) which Measures
are also commonly found in substance use disorders. However, During the initial screening, the Exercise Dependence Scale-21
to date, no studies with a longitudinal design examine the (EDS-21) was used to identify individuals with possible exercise
chronological relationship between exercise addiction and co- addiction. The EDS-21 is a validated 21-item questionnaire
occurring mental disorders to test this theory. whose development was based on the DSM-IV criteria
In summary, doubts about the existence of primary exercise for substance use disorders (12). Each criterion (tolerance,
addiction and whether it should be regarded as a behavioural withdrawal, intention effect, lack of control, time, reduction in
addiction are warranted. Although symptoms of exercise other activities and continuance) is represented by a subscale,
addiction are consistently reported in the literature, no clinical consisting of 3 items. Items are rated on a 6-point Likert-scale.
studies that examine the prevalence of a variety of mental Participants who score in the dependent range (i.e., 4 or 5 on
disorders in individuals with exercise addiction are available. the Likert-scale) on at least three criteria are rated “symptomatic,
It is therefore unclear whether those with exercise addiction at-risk for exercise dependence” (12). Individuals who met this
suffer from mental disorders more commonly than the general cut-off were invited to a second examination.
population, and whether they show the same pattern of co- In the second examination, the Structured Assessment of
occurring disorders that has been observed in other behavioural Personality Abbreviated Scale (SAPAS) was conducted. The
disorders like gambling disorder. It is also unclear whether the SAPAS is a brief screening tool for personality disorders that
severity of exercise addiction symptoms affect and influence co- consists of 8 items and showed good sensitivity (0.94) and
occurring disorders, and whether those disorders originate from acceptable specificity (0.85), with the cut-off being set at 3
the excessive exercising habits or vice versa. fulfilled items or more (37). Next, the Structured Clinical
Thorough clinical diagnostic screening is needed in Interview for DSM-5 (SCID-5) was conducted to screen for
individuals with exercise addiction to gather data on the mental disorders. The SCID-5-CV was used in every participant
prevalence of co-occurring disorders. This would make it to screen for lifetime prevalence of depressive disorders and
possible to investigate whether co-occurring disorders are in fact currently prevalent Axis I disorders. In addition, the SCID-5-PD
limited to eating disorders or whether their range matches that was conducted on participants that met the cut-off of the SAPAS
of substance use disorders and pathological gambling. If exercise score. Third, participants were interviewed about their exercising
addiction occurs with a varying range of other diagnoses, this habits and the extent of their exercise addiction.
could be further evidence that it is a distinct mental disorder. Severity of exercise addiction symptomatology was assessed
We are the first group worldwide to systematically identify a using the 10 item symptom checklist suggested by Colledge et
population of individuals with exercise addiction and conduct al. (24) and shown in Table 1. These criteria were derived from
gold-standard clinical diagnostic interviews; this study paves the available literature on the phenomenon of exercise addiction and
way for a detailed, clinical description of the to-date insufficiently used to further describe and assess the severity of symptoms. The
defined phenomenon of exercise addiction. degree of severity was rated severe if 9 or 10 criteria were fulfilled,
moderate for 7 or 8, mild for 5 or 6 or subclinical if the participant
Aim fulfilled 4 criteria or less.
The present study investigates the co-occurrence of mental
disorders in individuals with exercise addiction. We hypothesise Procedure
that the range of co-occurring disorders matches those of The EDS-21 was provided in paper-pencil form. Interviews were
other substance-related disorders, such as depressive disorders, held face-to-face. Following the outbreak of COVID-19, the
personality disorders, and anxiety disorders, and is therefore not EDS-21 was provided online and interviews were held via the
limited to eating disorders. conferencing platform Zoom.

MATERIALS AND METHODS Statistical Analysis

Data analysis was conducted using SPSS version 27. A one-way
Participants ANOVA was conducted to find out whether there was a difference
Individuals were recruited by advertisements in fitness studios, between exercise addiction severity groups (subclinical, mild,
a local newspaper and via Unimarkt Basel, an online market moderate, and severe) and mean number of mental disorders
platform run by the University of Basel. Recruitment took place in each group. A post-hoc Tukey test was used to identify

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Meyer et al. Mental Disorders in Exercise Addiction

which groups differ from each other. Level of significance was addiction (M = 0.17, SD = 0.41), to mild exercise addiction
set at p < 0.05. (M = 2.63, SD = 2.72), to moderate exercise addiction (M =
Pearson’s r correlation coefficient was calculated to find 3.50, SD = 2.89), to severe exercise addiction (M = 3.50, SD =
out whether the number of fulfilled exercise addiction criteria 2.40) (see Figure 1). A post-hoc Tukey test showed that only the
correlated with total number of mental disorders. Two-sided level subclinical group and the moderate group differed significantly
of significance was set at p < 0.05. at p < 0.05 (p = 0.021).
An independent t-test was conducted to find out whether The total number of disorders showed a strong positive
the number of fulfilled exercise addiction criteria differed in correlation to the severity of exercise addiction (r = 0.506, p =
individuals who participated in athletic competitions. Two-sided 0.004) and is demonstrated in Figure 2.
level of significance was set at p < 0.05. Table 3 compares found disorders according to their DSM-
Outliers exceeding two standard deviations in number of 5 chapter in competing and non-competing participants. There
disorders were excluded for the calculation of Pearson’s r and was no statistically significant difference in the number of
one-way ANOVA (n = 2). fulfilled exercise addiction criteria [t(30) = −0.20, p = 0.369]
of participants who competed (M = 6.40, SD = 2.72), when
RESULTS compared to the rest of the sample (M = 6.24, SD = 2.05).

Sample Description
One hundred and fifty-six individuals were recruited for DISCUSSION
screening, of which 32 met the cut-off of the EDS-21 and
were invited to the second examination. Mean age of our This is the first study to systematically identify individuals
sample was 27.9 years (SD = 12.5), comprising 16 men and with exercise addiction and conduct a gold-standard psychiatric
16 women. Exercise hours per week ranged from 5 to 55 (M diagnostic screening. Only individuals that met the cut-off of the
= 17.2, SD = 10.3). Although a minimum of 10 h exercise per EDS-21 (12) were invited for diagnostic screening. We found a
week was an explicit inclusion criterion, it emerged that one high prevalence of mental disorders in individuals with exercise
participant reduced their exercise activity between recruitment addiction, with 75% suffering from at least one disorder listed in
and completion of the interview, accounting for this discrepancy. the DSM-5. Additionally, the spectrum of disorders we found was
46.9% (n = 15) reported participation in competitions. The broad: 32 different disorders were diagnosed in a sample of 32
level of competition ranged from local leagues to national and participants (see Table 2).
world championship participation. None of our participants was The most common comorbidities in gambling disorder
a full-time professional athlete. Most participants reported doing have been found to be alcohol use disorder, personality
multiple different sports. Fitness (strength training) was most disorders, affective disorders, and anxiety disorders (22). Cluster
common (n = 23), followed by running (n = 14) and cycling B personality disorders are found the most in gambling
(n = 12). Other disciplines varied greatly and included handball, addiction, followed by Cluster C and Cluster A disorders
CrossFit, tennis, hiking, martial arts, yoga, basketball, hammer (38). In our sample, depressive disorders (56.3%), personality
throw, swimming and climbing, among others. disorders (46.9%) and obsessive-compulsive disorders (31.3%)
were the most common (Table 2). Cluster C personality disorders
Descriptive Statistics were particularly common with 40.6% of participants suffering
Exercise addiction severity ranged from subclinical (0–4 criteria) from either obsessive-compulsive personality disorder (25%) or
to severe (9–10 criteria). A total of 8 (25%) participants fulfilled 4 avoidant personality disorder (15.6%). This finding suggests that
criteria or fewer. Mild exercise addiction (5–6 criteria) was found impulsive personality traits might be less prevalent in individuals
in 25% (n = 8), moderate exercise addiction (7–8 criteria) was with exercise addiction who rather seem to be located at the
found in 37.5% (n = 12) and severe exercise addiction (9–10 compulsive pole of the diagnostic spectrum. Notably, scholars
criteria) was found in 12.5% (n = 4). have previously discussed two different dimensions of “unhealthy
Participants were diagnosed with 32 different mental disorders exercise”: a quantitative dimension (“excessive”) that takes
as defined by the DSM-5, with a total of 100 diagnoses. Major duration, frequency and intensity of exercise into account and
depressive disorder was the most common and was found in a qualitative dimension (“compulsive”), which is characterised
46.9% (n = 15), followed by obsessive-compulsive personality by rigid exercise schedules, prioritisation of exercise over other
disorder (n = 8, 25%) and insomnia (n = 8, 25%). The complete activities and feeling of guilt and anxiety when exercise sessions
range of disorders is listed in Table 2. No mental disorder was are missed (39). As addiction is defined in the DSM-5 in terms
found in 25% (n = 8). One participant with moderate exercise of cognitive, physical, and behavioural characteristics, and not
addiction was found to have no mental disorders. All participants in quantitative terms, the “compulsive” dimension appears to be
with more than seven fulfilled exercise addiction criteria also met more relevant in the identification of exercise addiction.
the diagnostic criteria for at least one mental disorder. The total number of mental disorders in our sample increased
There was a statistically significant difference between exercise with exercise addiction severity. Additionally, there was only one
addiction severity groups on total number of mental disorders participant without a mental disorder who fulfilled seven or more
as determined by one-way ANOVA [F (3,26) = 3.54, p = 0.028]. exercise addiction criteria. While our statistical analysis does
The total number of disorders increased from subclinical exercise not account for the clinical severity of the respective conditions,

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Meyer et al. Mental Disorders in Exercise Addiction

TABLE 2 | DSM-5 chapters and their according disorders currently prevalent in our sample (n = 32).

DSM-5 chapter Disorder

N1 % in sample N2 % in sample

Depressive disorders 18 56.3 Major depressive disorder 15 46.9

Premenstrual dysphoric disorder 7 21.9
Personality disorders 15 46.9 Obsessive-compulsive personality disorder 8 25
Avoidant personality disorder 5 15.6
Narcissistic personality disorder 3 9.4
Schizoid personality disorder 2 6.3
Antisocial personality disorder 1 3.1
Borderline personality disorder 1 3.1
Histrionic personality disorder 1 3.1
Obsessive-compulsive and related disorders 10 31.3 Body dysmorphic disorder 5 15.6
Hoarding disorder 4 12.5
Excoriation disorder 4 12.5
Obsessive-compulsive disorder 1 3.1
Trichotillomania 1 3.1
Anxiety disorders 9 28.1 Social anxiety disorder 6 18.8
Generalised anxiety disorder 2 6.3
Specific phobia (Animal type) 2 6.3
Panic disorder 1 3.1
Sleep-wake disorders 9 28.1 Insomnia disorder 8 25
Hypersomnolence disorder 2 6.3
Neurodevelopmental disorders 6 18.8 Attention-deficit/hyperactivity disorder 6 18.8
Substance-related and addictive disorders 5 15.6 Alcohol use disorder 3 9.4
Gambling disorder 1 3.1
Stimulant use disorder 1 3.1
Cannabis use disorder 1 3.1
Other (Anabolic Steroids) substance–related disorders 1 3.1
Feeding and eating disorders 5 15.6 Anorexia nervosa 3 9.4
Bulimia nervosa 1 3.1
Avoidant/restrictive food intake disorder 1 3.1
Disruptive, impulse-control, and conduct disorders 1 3.1 Intermittent explosive disorder 1 3.1
(Antisocial personality disorder) (1) (3.1)
Trauma- and stressor-related disorders 1 3.1 Posttraumatic stress disorder 1 3.1
Bipolar and related disorders 1 3.1 Bipolar I disorder 1 3.1
Total 100

Lifetime prevalence is given for Major Depressive Disorder, including recurrent and single episode. Antisocial personality disorder is found in two chapters in the DSM-5 which was
accounted for in our total number of diagnosed disorders. N1 = number of subjects who fulfilled the criteria for one or more disorders from the respective DSM chapter. N2 = number
of subjects who fulfilled the criteria for the specific disorder.

this finding implies that with an increasing number of exercise obsessive-compulsive disorders. Scholars have previously
addiction criteria the occurrence of a mental disorder is also reported on primary exercise addiction to show traditional
more likely. This indicates that exercise addiction is found in addictive traits, whereas secondary exercise addiction was found
individuals who are more likely to require psychiatric treatment. to be more compulsive in nature (30). No strong link between
Most interestingly, only five participants in our sample exercise addiction and eating disorders was observed in our
suffered from an eating disorder. This contradicts previous sample. However, this is not the case for obsessive-compulsive
studies which reported a strong link between exercise addiction disorders and obsessive-compulsive personality disorders.
and eating disorders (28–30). The variety of sport disciplines Therefore, we are not able to rule out that exercise addiction
practised in our sample supports the findings of Lichtenstein et symptoms might be secondary to this part of the diagnostic
al. (40), who found no difference in the prevalence of exercise spectrum. Literature also indicates an association between
addiction between team sports and endurance sports. body dysmorphic disorder and exercise addiction symptoms
Besides eating disorders, exercise addiction might (41). However, our data suggests that these symptoms are not
be secondary to other mental disorders such as limited to body dysmorphic disorder or obsessive-compulsive

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Meyer et al. Mental Disorders in Exercise Addiction

FIGURE 1 | Mean number of mental disorders by severity of exercise addiction (n = 30). Outliers exceeding two standard variations in number of disorders (n = 2)
were excluded.

FIGURE 2 | Scatterplot of our sample (n = 30) demonstrating the correlation between number of fulfilled exercise addiction criteria and number of disorders. Outliers
exceeding two standard variations in number of disorders (n = 2) were excluded.

disorder alone, as we found that only five and one participant(s) difference between competing and non-competing participants
respectively met the diagnostic criteria for each specific disorder. in number of fulfilled exercise addiction criteria.
It might also be possible that our sample included multiple More than half of our sample suffered from a depressive
heterogenous groups of aspiring athletes, individuals suffering disorder (56.3%) in their lifetime, with major depressive disorder
from eating disorders and individuals with body dysmorphic being the most common (46.9%). Since exercise has been found
disorder, all of which would require a more careful interpretation to have positive effects on depression (33, 34), the theory that
of the respective role of exercise addiction symptoms. However, excessive exercise is used as self-medicating coping-pattern seems
we do not think that this was the case regarding participation plausible. Further studies are needed to investigate the natural
in athletic competitions. Even though we did not conduct history of exercise addiction and its connexion to the emergence
statistical inference, the descriptive comparison of disorders by of depression longitudinally.
competing and non-competing participants (Table 3) did not The importance of clinical distress caused by conditions that
differ noticeably. We also did not find a statistically significant qualify as mental disorders is emphasised by the DSM-5 and

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Meyer et al. Mental Disorders in Exercise Addiction

TABLE 3 | Comparison of mental disorders by DSM-5 chapter between that the observed exercising behaviour resembles a coping-
competing and non-competing participants. strategy to deal with other psychological conditions or current
Competing sample Non-competing
life circumstances not detected in our interview. To deal
(n = 15) sample (n = 17)
with this limitation, exercise addiction symptoms need the be
observed over longer periods of time to gather longitudinal
1 1
DSM-5 chapter N % in sample N % in sample data and to investigate the requirement of psychiatric and
psychotherapeutic treatment.
Depressive disorders 9 60.0 9 52.9
Personality disorders 6 40.0 9 52.9
Obsessive-compulsive and 7 46.7 3 17.6
LIMITATIONS
related disorders
Anxiety disorders 4 26.7 5 29.4
Our study has several limitations. First, our sample size was
Sleep-wake disorders 5 33.3 4 23.5
small, which does not allow us to study the potential secondary
Neurodevelopmental 4 26.7 2 11.8
nature of exercise addiction in different subgroups in more detail.
disorders Second, we used a cross-sectional design and are therefore not
Substance-related and 2 13.3 3 17.6 able to draw conclusions about the stability of symptoms over
addictive disorders time. Third, we did not sample a matched control group (e.g.,
Feeding and eating 2 13.3 3 17.6 individuals who exercise more than 10 h a week but did not
disorders meet the EDS-21 cut-off) and are therefore not able to establish,
Disruptive, impulse-control, 1 6.7 - - whether the total number of mental disorders we found is in
and conduct disorders fact excessive among the population we studied. Finally, we used
Trauma- and - - 1 5.9 exercise addiction criteria as proposed in literature to assess
stressor-related disorders
exercise addiction severity. However, this scale is not a validated
Bipolar and related - - 1 5.9
instrument, and its psychometric properties are unknown.
disorders

N1 = number of subjects who fulfilled the criteria for one or more disorders from the DATA AVAILABILITY STATEMENT
respective DSM chapter.

The raw data supporting the conclusions of this article will be

made available by the authors, without undue reservation.
in scientific literature (19). It bears noting, that we did not
assess clinical distress or disability in detail or by the means ETHICS STATEMENT
of validated instruments specifically developed for this purpose.
The 10 criteria for exercise addiction (Table 1) as well the fact The study procedures were carried out in accordance with
that all participants scored above the threshold of the EDS-21 the Declaration of Helsinki. The study was approved by the
served as our measure for the presence of significant distress, Ethikkommission Nordwest- und Zentralschweiz (EKNZ) on May
as both instruments formulate items based on the experience of 10th, 2019. All subjects were informed about the study and all
discomfort, distress, and impairment. provided informed consent.
Finally, it is important to note that despite meeting and
exceeding the EDS-21 cut-off for exercise dependence, we found AUTHOR CONTRIBUTIONS
that in 25% of our sample <5 exercise addiction criteria applied.
This is a further indication that self-report questionnaires MM wrote the first draft, conducted clinical interviews,
addressing exercise addiction may need to be redesigned, as performed statistical analysis, and takes responsibility for the
numerous (2, 42, 43) studies now suggest that they are not integrity of the data and the accuracy of the data analysis.
adequate in differentiating between sportspeople and individuals IS conducted clinical interviews. HS recruited participants
with an addictive disorder. and conducted initial screening. FC obtained funding. MW
supervised the study. FC and MW designed the study and wrote
the protocol. UL and AS revised the manuscript and provided
CONCLUSION substantial intellectual input. MM, IS, and FC had full access to all
data in the study. All authors contributed to and have approved
Depression, Cluster-C personality disorders and other obsessive- the final manuscript.
compulsive disorders appear to be particularly common in
subjects with exercise addiction. Our data therefore provides an FUNDING
indicator that the phenomenon of exercise addiction does co-
occur with a variety of mental disorders. Our study shows that Funding for this study was provided by the Gertrud Thalmann
the phenomenon of exercise addiction occurs independently of Fonds of the University Psychiatric Clinics (UPK) Basel.
eating disorders and body dysmorphic disorders. Since this is The funding source was not involved in the study design,
a cross-sectional study, it remains unclear whether symptoms collection, analysis or interpretation of the data, writing
of exercise addiction remain stable over time (and in relation the manuscript, or the decision to submit the paper
to the respective mental disorders). It is also entirely possible for publication.

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Meyer et al. Mental Disorders in Exercise Addiction

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Meyer et al. Mental Disorders in Exercise Addiction

prevalences and validation of the exercise addiction inventory. Conflict of Interest: The authors declare that the research was conducted in the
Addict Res Theory. (2014) 22:431–7. doi: 10.3109/16066359.2013. absence of any commercial or financial relationships that could be construed as a
875537 potential conflict of interest.
41. Corazza O, Simonato P, Demetrovics Z, Mooney R, van de
Ven K, Roman-Urrestarazu A, et al. The emergence of Exercise Publisher’s Note: All claims expressed in this article are solely those of the authors
Addiction, Body Dysmorphic Disorder, And Other Image-Related and do not necessarily represent those of their affiliated organizations, or those of
Psychopathological Correlates In Fitness Settings: A Cross Sectional the publisher, the editors and the reviewers. Any product that may be evaluated in
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42. de la Vega R, Parastatidou IS, Ruíz-Barquín R, Szabo A. Exercise
addiction in athletes and leisure exercisers: the moderating role of
passion. J Behav Addict. (2016) 5:325–31. doi: 10.1556/2006.5.2016. Copyright © 2021 Meyer, Sattler, Schilling, Lang, Schmidt, Colledge and Walter.
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Theoretical conceptualisations of problematic exercise in is permitted, provided the original author(s) and the copyright owner(s) are credited
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