The dangers of “healthy” addictions

Addiction takes many forms. Although there is hardly a clear consensus on how to define addiction – and the term itself has been met with some resistance – it is generally agreed that it involves a compulsive need for, and subsequent inability to function without, the presence of the addictive substance or behavior in spite of negative consequences associated with use. There have been hundreds of different types of addictions recognized or identified, from physical addictions (such as to alcohol, tobacco, or other substances of abuse) to behavioral addictions (such as to gambling, work, or sex).

The line at which a habit or behavior reaches the level of addiction is sometimes difficult to recognize. (At what point is one an alcoholic instead of an oenophile?) While significant attention has been paid to the development of precise diagnostic criteria to address this question in the context of physical addictions, behavioral addictions are only just beginning to earn formal recognition – addictions to gambling and other behaviors were added to the Diagnostic and Statistical Manual of Mental Disorders (DSM) in just the last year, whereas physical addictions had been included in previous editions going back several decades. This relative lack of attention is one reason why behavioral addictions are often more difficult to recognize and treat.

Can a healthy behavior become a problem?

Perhaps the greatest difficulty of all, however, comes in recognizing addictions to behaviors which, under normal circumstances, would be considered healthy or necessary. Consider, for instance, the example of exercise. In addition to reducing risk of metabolic dysregulation, cardiovascular disease, cancer, and neurodegeneration, exercise also has benefits for emotional and mental well-being, including treatment and prevention of depression and anxiety. Physical activity is acutely rewarding, triggering release of endorphins and cannabinoids which act on the brain to induce the sense of euphoria commonly referred to as “runner’s high,” and according to a 2013 Stress in America survey by the American Psychological Association, many adults report positive effects on mood and stress following workouts.

But anything that brings about acute feelings of joy and relief – whether exercise, gambling, alcohol, or heroin – has the potential to develop into addiction in certain individuals. In an essay for the New York Times, author Emi Nietfeld relates her personal struggle with exercise addiction, using the healthy habit of fitness to experience the same sensations she’d previously achieved through self-harm with a razor blade. While cutting had earned the horror of those around her, she describes how the intensity and frequency of her workouts had earned her accolades and praise, even as the addiction began to take a toll on her physical and mental health. But was it just a matter of doing “too much” that made the habit pathological?

More than counting training hours

As I discussed on a recent “Ask Me Anything” episode of The Drive, the health benefits of exercise increase proportionally with one’s level of commitment and seemingly have no upper bounds. In essence, evidence indicates that there is no such thing as “too much” exercise. And Nietfeld, who was working as a full-time software engineer through much of the time she recounts in her essay, likely wouldn’t have had the time to match or exceed the typical training hours of an elite professional athlete. So what differentiates a healthy athletic lifestyle from exercise addiction? And how can one have virtually infinite benefits to physical and mental health while the other threatens serious physical and mental harm? 

In 2010, Hausenblas and Downs used a modified version of the DSM criteria for substance dependence to propose a series of criteria for distinguishing exercise addiction from healthy engagement in physical activity. While devoting a great deal of time to exercise was one factor on their list, it was only considered a sign of addiction when at least two other defining features were also present. Many of these other features align with more classical signs of addiction, such as withdrawal (experiencing negative physical and psychological effects such as anxiety and difficulty sleeping when exercise is ceased) and the development of tolerance (requiring an ever-increasing amount of exercise to experience the same positive sensations). Other important hallmarks include a reduction in other social, professional, or recreational activities and a lack of ability to control or limit one’s exercise level, as well as continuing to engage in exercise even after recognizing that it is “creating or exacerbating physical, psychological, and/or interpersonal problems.”

Understanding and recognizing the difference

From some of these criteria, we can begin to understand the apparent paradox of unlimited benefits from exercise and the dangers of exercise addiction. Even professional athletes must balance training with other elements of a healthy life, including cultivating social relationships, engaging in other interests, and being attentive to mental health needs. An elite athlete’s training program is meticulously planned out and controlled to maximize benefit while keeping injury risk as low as possible, generally including days off for recovery. And when injuries do arise, no athletes in their right minds are going to take any chances – better to rest or switch to low-impact exercises than risk worsening the issue and potentially ending one’s career.

Contrast this with Ms. Nietfeld’s experience. She hints at isolating herself emotionally from her peers and routinely exceeding the workout plans outlined by her coaches. She describes pushing on with workouts despite injuries, ultimately accelerating and exacerbating spinal damage, and she relates how attempts to cut back on workouts for recovery purposes left her with panic attacks and an inability to sleep. Indeed, far from setting a goal of maximizing benefit and minimizing injury risk, Nietfeld reveals that she “wanted pain,” framing exercise as yet another form of willful self-harm, though less obvious and destructive than cutting or abusing drugs. Her drive to exercise did not come from a desire to reach a fitness goal or even out of any apparent love for engaging in sports or physical activity. As she describes it, her drive came instead from a place of trauma and a desire to punish herself – an important distinction between her experience and that of elite athletes who wouldn’t classify as “addicted.”

But as Nietfeld explains, the very fact that exercise isn’t typically destructive only enhances the danger when one has an unhealthy attitude towards it. When we’re praised for our fitness and discipline, it’s easier to ignore warning signs of addiction and rationalize the continuation of a harmful mindset, whereas more reprehensible coping strategies such as drugs or alcohol might lead to faster recognition of a problem. This irony is perhaps what makes Nietfeld’s story so poignant and underscores the importance of understanding and recognizing the defining features of addiction, even for otherwise healthy behaviors.

Exercise: a vehicle for health, or a goal of its own?

It’s intuitive that substance use disorders or gambling addictions would be maladaptive and pose health risks. But even behaviors with enormous physical and mental health benefits have the potential for harm when they reach the level of addiction, and exercise is no exception.

While there may be no such thing as “too much exercise” when it comes to the goal of maximizing payoffs for overall health, the calculation shifts when the goal instead becomes the pursuit of fleeting post-workout euphoria or the sense of physical punishment. In these latter cases, exercise is no longer a vehicle for promoting health but instead becomes a goal in itself – one which, in certain individuals under certain circumstances, can take priority over one’s own health and develop into addiction. For most people who work out regularly, this pathological progression will never take place, but understanding the problem and knowing the warning signs are crucial for recognizing when you or someone close to you may be in need of help.