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{{short description|Compulsive engagement of excessive physical exercise despite negative consequences}}
{{short description|Compulsive engagement of excessive physical exercise despite negative consequences}}
{{addiction glossary}}
{{addiction glossary}}
'''Exercise addiction''' is a state characterized by a compulsive engagement in any form of physical exercise, despite negative consequences. While regular exercise is generally a healthy activity, exercise addiction generally involves performing excessive amounts of exercise to the detriment of physical health, spending too much time exercising to the detriment of personal and professional life, and exercising regardless of physical injury.<ref name="Exercise addiction review">{{cite journal | vauthors = Landolfi E | title = Exercise addiction | journal = Sports Med | volume = 43 | issue = 2 | pages = 111–9 | year = 2013 | pmid = 23329605 | doi = 10.1007/s40279-012-0013-x | s2cid = 35726964 }}</ref><ref name=Demetrovics/><ref name=Sussman>{{cite journal |vauthors=Sussman S, Lisha N, Griffiths M |title=Prevalence of the addictions: a problem of the majority or the minority? |journal=Eval Health Prof |volume=34 |issue=1 |pages=3–56 |date=March 2011 |pmid=20876085 |pmc=3134413 |doi=10.1177/0163278710380124}}</ref> It may also involve a state of [[substance dependence|dependence]] upon regular exercise which involves the occurrence of severe withdrawal symptoms when the individual is unable to exercise.<ref name="Exercise addiction review" /> Differentiating between addictive and healthy exercise behaviors is difficult but there are key factors in determining which category a person may fall into.<ref name=Krivoschekov>{{cite journal |vauthors=Krivoshchekov SG, Lushnikov ON |title=[Psychophysiology of sports addiction (exercises addiction)] |language=ru |journal=Fiziol Cheloveka |volume=37 |issue=4 |pages=135–40 |year=2011 |pmid=21950095 |doi=10.1134/S0362119711030030|s2cid=20543670 }}</ref> Exercise addiction shows a high comorbidity with eating disorders.<ref name=Demetrovics>{{cite journal |vauthors=Demetrovics Z, Kurimay T |title=[Exercise addiction: a literature review] |language=hu |journal=Psychiatr Hung |volume=23 |issue=2 |pages=129–41 |year=2008 |pmid=18956613 }}</ref>
'''Exercise addiction''' is a state characterized by a compulsive engagement in any form of physical exercise, despite negative consequences. While [https://thehelpingposts.blogspot.com/ exercise is very important for a healthy body], exercise addiction generally involves performing excessive amounts of exercise to the detriment of physical health, spending too much time exercising to the detriment of personal and professional life, and exercising regardless of physical injury.<ref name="Exercise addiction review">{{cite journal | vauthors = Landolfi E | title = Exercise addiction | journal = Sports Med | volume = 43 | issue = 2 | pages = 111–9 | year = 2013 | pmid = 23329605 | doi = 10.1007/s40279-012-0013-x | s2cid = 35726964 }}</ref><ref name=Demetrovics/><ref name=Sussman>{{cite journal |vauthors=Sussman S, Lisha N, Griffiths M |title=Prevalence of the addictions: a problem of the majority or the minority? |journal=Eval Health Prof |volume=34 |issue=1 |pages=3–56 |date=March 2011 |pmid=20876085 |pmc=3134413 |doi=10.1177/0163278710380124}}</ref> It may also involve a state of [[substance dependence|dependence]] upon regular exercise which involves the occurrence of severe withdrawal symptoms when the individual is unable to exercise.<ref name="Exercise addiction review" /> Differentiating between addictive and healthy exercise behaviors is difficult but there are key factors in determining which category a person may fall into.<ref name=Krivoschekov>{{cite journal |vauthors=Krivoshchekov SG, Lushnikov ON |title=[Psychophysiology of sports addiction (exercises addiction)] |language=ru |journal=Fiziol Cheloveka |volume=37 |issue=4 |pages=135–40 |year=2011 |pmid=21950095 |doi=10.1134/S0362119711030030|s2cid=20543670 }}</ref> Exercise addiction shows a high comorbidity with eating disorders.<ref name=Demetrovics>{{cite journal |vauthors=Demetrovics Z, Kurimay T |title=[Exercise addiction: a literature review] |language=hu |journal=Psychiatr Hung |volume=23 |issue=2 |pages=129–41 |year=2008 |pmid=18956613 }}</ref>


Exercise addiction is not listed as a disorder in the fourth revision of the ''[[Diagnostic and Statistical Manual of Mental Disorders]]'' (DSM-IV). This type of [[addiction]] can be classified under a [[behavioral addiction]] in which a person's behavior becomes obsessive, compulsive, and/or causes dysfunction in a person's life.<ref name=Villella>{{MEDRS|date=November 2011}}<!--this is a primary study, used incorrectly in this article-->{{cite journal |vauthors=Villella C, Martinotti G, Di Nicola M |title=Behavioural addictions in adolescents and young adults: results from a prevalence study |journal=J Gambl Stud |volume=27 |issue=2 |pages=203–14 |date=June 2011 |pmid=20559694 |doi=10.1007/s10899-010-9206-0|s2cid=19239770 |display-authors=etal}}</ref> The next revision of the DSM ([[DSM-5]]) will include an addictions and related disorders section; [[gambling]] is the only non-substance addiction that is likely to be included. Other non-substance addictions, such as exercise addiction, are being researched but their inclusion is undetermined.<ref name="O'Brien">{{cite journal|last=O'Brien|first=Charles|title=Addiction and dependence in DSM-V|journal=Addiction|date=1 May 2011|volume=106|issue=5|pages=866–867|doi=10.1111/j.1360-0443.2010.03144.x|pmid=21477226|pmc=3812919}}</ref>
Exercise addiction is not listed as a disorder in the fourth revision of the ''[[Diagnostic and Statistical Manual of Mental Disorders]]'' (DSM-IV). This type of [[addiction]] can be classified under a [[behavioral addiction]] in which a person's behavior becomes obsessive, compulsive, and/or causes dysfunction in a person's life.<ref name=Villella>{{MEDRS|date=November 2011}}<!--this is a primary study, used incorrectly in this article-->{{cite journal |vauthors=Villella C, Martinotti G, Di Nicola M |title=Behavioural addictions in adolescents and young adults: results from a prevalence study |journal=J Gambl Stud |volume=27 |issue=2 |pages=203–14 |date=June 2011 |pmid=20559694 |doi=10.1007/s10899-010-9206-0|s2cid=19239770 |display-authors=etal}}</ref> The next revision of the DSM ([[DSM-5]]) will include an addictions and related disorders section; [[gambling]] is the only non-substance addiction that is likely to be included. Other non-substance addictions, such as exercise addiction, are being researched but their inclusion is undetermined.<ref name="O'Brien">{{cite journal|last=O'Brien|first=Charles|title=Addiction and dependence in DSM-V|journal=Addiction|date=1 May 2011|volume=106|issue=5|pages=866–867|doi=10.1111/j.1360-0443.2010.03144.x|pmid=21477226|pmc=3812919}}</ref>

Revision as of 16:23, 5 March 2023

Addiction and dependence glossary[1][2][3]
  • addiction – a biopsychosocial disorder characterized by persistent use of drugs (including alcohol) despite substantial harm and adverse consequences
  • addictive drug – psychoactive substances that with repeated use are associated with significantly higher rates of substance use disorders, due in large part to the drug's effect on brain reward systems
  • dependence – an adaptive state associated with a withdrawal syndrome upon cessation of repeated exposure to a stimulus (e.g., drug intake)
  • drug sensitization or reverse tolerance – the escalating effect of a drug resulting from repeated administration at a given dose
  • drug withdrawal – symptoms that occur upon cessation of repeated drug use
  • physical dependence – dependence that involves persistent physical–somatic withdrawal symptoms (e.g., fatigue and delirium tremens)
  • psychological dependence – dependence socially seen as being extremely mild compared to physical dependence (e.g., with enough willpower it could be overcome)
  • reinforcing stimuli – stimuli that increase the probability of repeating behaviors paired with them
  • rewarding stimuli – stimuli that the brain interprets as intrinsically positive and desirable or as something to approach
  • sensitization – an amplified response to a stimulus resulting from repeated exposure to it
  • substance use disorder – a condition in which the use of substances leads to clinically and functionally significant impairment or distress
  • tolerance – the diminishing effect of a drug resulting from repeated administration at a given dose

Exercise addiction is a state characterized by a compulsive engagement in any form of physical exercise, despite negative consequences. While exercise is very important for a healthy body, exercise addiction generally involves performing excessive amounts of exercise to the detriment of physical health, spending too much time exercising to the detriment of personal and professional life, and exercising regardless of physical injury.[4][5][6] It may also involve a state of dependence upon regular exercise which involves the occurrence of severe withdrawal symptoms when the individual is unable to exercise.[4] Differentiating between addictive and healthy exercise behaviors is difficult but there are key factors in determining which category a person may fall into.[7] Exercise addiction shows a high comorbidity with eating disorders.[5]

Exercise addiction is not listed as a disorder in the fourth revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). This type of addiction can be classified under a behavioral addiction in which a person's behavior becomes obsessive, compulsive, and/or causes dysfunction in a person's life.[8] The next revision of the DSM (DSM-5) will include an addictions and related disorders section; gambling is the only non-substance addiction that is likely to be included. Other non-substance addictions, such as exercise addiction, are being researched but their inclusion is undetermined.[9]

Classification

A concrete classification of exercise addiction has proven to be difficult due to the lack of a specific and widely accepted diagnostic model.[10] Most interpretations of addiction have traditionally been limited to drugs and alcohol, which makes it even more difficult to identify addictive tendencies in exercise.[11] While excessive exercise is the overarching theme with exercise addiction, the term also includes a variety of symptoms like withdrawal, "exercise buzz", and impaired physical function.[12] Excessive exercise has been classified in different ways; sometimes as an addiction and sometimes as a more general compulsive behavior. Psychiatric case studies have shown that exaggerated exercise could lead to negligence of work and family life. With an addiction, individuals become "hooked" to the feeling of euphoria and pleasure that exercise provides. This pleasure keeps the individual from stopping and leads to excessive exercise. With a compulsion people often do not necessarily enjoy repeating certain tasks, as they may feel like performing it will fulfill a duty that is required of them.[13] There are many opinions on whether concrete diagnostic criteria should be created for this type of addiction. Some say preoccupation with exercise that causes significant impairment in a person's life, not due to another disorder, may be enough criteria to label this disorder.[12] Others say there is not enough information about exercise addiction to develop diagnostic criteria. As of 2007, the term "excessive exercise" continues to be used while the "exercise addiction" model continues to be debated.[14]

Three main types of disorders are associated with excessive exercise:[15]

  1. Anorexia athletica (obligatory exercise) - When an individual feels compelled to exercise beyond the point of benefitting one's body. Individuals will participate in athletic activities regardless of pain, injury, illness, etc., and will try to arrange their lives in order to maximize workout time.
  2. Exercise bulimia - When an individual has binge eating sessions that are followed by periods of high-intensity exercise.
  3. Body dysmorphic disorder - When an individual is obsessed with parts of their body and perceive them to be different or odd. These individuals will create highly regimented routines in order to improve their perception of the "flawed" body part.

Signs and symptoms

Five indicators of exercise addiction are:[7]

  1. An increase in exercise that may be labeled as detrimental, or becomes harmful.
  2. A desire to experience euphoria; exercise may be increased as tolerance of the euphoric state increases.
  3. Not participating in physical activity will cause dysfunction in one's daily life.
  4. Severe withdrawal symptoms following exercise deprivation including anxiety, restlessness, depression, guilt, tension, discomfort, loss of appetite, sleeplessness, and headaches.
  5. Exercising through trauma and despite physical injuries.

Key differences between healthy and addictive levels of exercise include the presence of withdrawal symptoms when exercise is stopped as well as the addictive properties exercise may have leading to a dependence on exercise.[13]

Those who succumb to exercise addiction may experience overtraining, which is best defined as a “condition of poor adaptation to a chronic period of excessive stress caused by a physical exertion, resulting in the development of the syndrome, compromising the health and sports performance”.[16]

Overtraining includes one or more of the following:[17]

  • Persistent muscle soreness
  • Elevated resting heart rate
  • Increased susceptibility to infections
  • Increased incidence of injuries
  • Insomnia
  • Decreased appetite
  • Weight loss
  • Impaired performance
  • Decreased motor coordination and force production

Exercise addiction may also lead to mood disturbances. Those who undergo rigorous training without adequate rest are more likely to experience depression, anger, fatigue and confusion.[18]

In addition, excessive training may cause exhaustion of the autonomic nervous system. Some symptoms include decreased total testosterone level, an imbalance between testosterone and cortisol, decreased sympathetic tone, and decreased exercise-induced lactate.[17] These chemical balances can lead to premature osteoporosis, where the lack of testosterone accelerates bone loss, and elevated levels of cortisol alters calcium and bone metabolism by “increasing bone reabsorption and decreasing bone formation or intestinal absorption of calcium”.[19] Calcium undernutrition may eventually occur, accelerating premature osteoporosis.

Mechanisms

As of 2016, the mechanisms involved in the development of an exercise addiction, associated with the transition from healthy committed exercise to compulsive exercise, are unknown.

Exercise addiction, however, has long been known to begin with a desire for physical fitness. An eating disorder, such as anorexia nervosa or bulimia supports an unhealthy obsession with exercise, as such. A body image disorder can likely cause exercise addiction as well.[20] One of the prevailing mechanisms for this addiction lies within these activities that expose individuals to the mood-altering effects of this behavior, and can many times deposit dopamine directly into the blood flow.

The chemical functioning of the brain may also play an integral role in potential mood changes based on exercise. Griffiths [21] reported a lengthy case study of exercise addiction and laid out three viable prospects of biological mechanisms that pair an improved satisfactory mood with exercise:

  • The Thermogenic Hypothesis: Exercise is said to increase body temperature, thereby diminishing somatic anxiety. This decrease in anxiety can be related to a higher temperature in certain regions of the brain.[22]
  • The Catecholamine Hypothesis: Exercise releases catecholamines, a group of substances in bloodstream (usually in response to emotional/physical stress) which regulate our mood, attention, and movement as well as endocrine and cardiovascular responses that are linked to stress levels in our body.[23]
  • The Endorphin Hypothesis: Exercise releases endorphins, which are opiates that occur naturally in the body, however, sometimes an enjoyable experience as such, has indirect consequences resulting in irregularity where the increased endorphin production over time entices the individual to continue performing regular intense aerobic exercise. Such high levels of endorphin production means the brain will have to down-regulate endorphin production, essentially “manipulating” the individual to believe that the exercise must be performed daily in order to maintain the new natural balance in the brain.[24]

Griffiths' findings suggest that once exercise occurs at high frequencies, it must be maintained in a similar manner and is very difficult to break the pattern.[20] Similarly,  it can be argued [24] that with reduced voluptuary pleasure from other activities, it is likely that a person may have to maintain such levels of intense exercise in order to optimize and activate certain reward systems within the mesolimbic dopamine system in the brain. If they are not activated, the person will continue feeling the original level of distress prior to exercise.

Assessment

Different assessment tools can be used to determine if an individual is addicted to exercise.[25] Most tools used to determine risk for exercise addiction are modified tools that have been used for assessing other behavioral addictions. Tools for determining eating disorders can also show a high risk for exercise addiction.[26]

The Obligatory Exercise Questionnaire was created by Thompson and Pasman in 1991, consisting of 20 questions on exercise habits and attitudes toward exercise and body image. Patients respond to statements on a scale of 1 (never) to 4 (always).[27] This questionnaire aided in the development of another assessment tool, the Exercise Addiction Inventory.[25]

The Exercise Addiction Inventory was developed by Terry et al in 2004. This inventory was developed as a self-report to examine an individual's beliefs toward exercise. The inventory is made up of six statements in relation to the perception of exercise, concerning: the importance of exercise to the individual, relationship conflicts due to exercise, how mood changes with exercise, the amount of time spent exercising, the outcome of missing a workout, and the effects of decreasing physical activity. Individuals are asked to rate each statement from 1 (strongly disagree) to 5 (strongly agree). If an individual scores above 24 they are said to be at-risk for exercise addiction.[25]

When Exercise Addiction and Personality Disorders Coexist

Common co-occurring disorders are prominent in that they can mask exercise addiction and/or complicate treatments for many patients. Eating disorders and Impulse Control Disorder, like many other anxiety disorders, can oftentimes be disguised as exercise addiction and are maintained primarily by negative reinforcement through anxiety reduction.[citation needed] Addictive behavior, more commonly described as impulsivity,[28] consists of jerky, rapid and unplanned responses to external or internal stimuli. Impulsive behavior can result in many negative consequences and is intuitively driven by a desired end-goal of a positive reward,[29] similar to the one received after a good workout.

Eating disorders are the most common co-occurring disorder with exercise addiction, with 39–48% of people suffering from both. For some, the primary motivation for exercise is extreme weight, which has been given a special name: anorexia athletica. When exercise addiction and eating disorders co-occur for many trying to bulk up, only one problem will be treated which raises an alarming concern. Often the eating disorder, which is also the more-known and apparent disorder, is the primary focus of treatment and the secondary exercise addiction is disguised and often tossed aside .[30] Despite a healthier, now improved relationship to food and one’s appetite, the individual will still not gain any additional weight, and thus leads to a repetitive cycle that is managed through a more potent exercise regimen.

Treatment

Behavioral addiction and substance abuse disorders are treated similarly; treatment options include exposure and response prevention. No medications have been approved for the treatment of behavioral addictions. Studies have shown promise in the use of glutamatergic altering drugs to treat addictions other than exercise.[31] Exercise addictions comorbid in patients with an eating disorder may be treated through psychotherapy involving education, behavioral interventions, and a strengthened family support structure. In treating the eating disorder, obsessions and compulsions produced by obscured body image ideals will also be treated, this includes exercise addiction.[32]

Epidemiology

Most research has focused on adult population or on college students, but little is known about epidemiology of behavioral addictions in adolescence.[8] A study conducted by Villella et al looked at a group of students and the prevalence of various addictions. His results showed exercise addiction was the second most prevalent, after compulsive buying.[8] High risk groups that appear to be addicted to exercise include athletes in sports encouraging thinness or appearance standards, young and middle-age women, and young men.[8]

Prognosis

Individuals with exercise addiction may put exercise above family and friends, work, injuries, and other social activities.[7] If not identified and treated, an exercise addiction may lead to a significant decline in one's health.[7]

Comorbidity

An addiction, by definition, includes repeated compulsive behaviors that negatively affect daily living.[6] There are two ways to classify addictive behaviors: substance addiction and process addiction. An exercise addiction is a type of process addiction, in which an individual's mood toward a certain event becomes dependent on addictive behaviors.[6] Many educational, occupational, and social activities are stopped due to excessive exercising. Depression may develop if exercise is neglected or may result from reoccurring physical injuries that limit exercise.[6] Exercise addiction is often related to obsessive-compulsive disorder as exercise addicts may have obsessions or compulsions toward physical activity. Exercise addiction is also commonly associated with eating disorders as a secondary symptom of bulimia or anorexia nervosa.[13] Approximately 39-48% of people that have an eating disorder are also addicted to exercise.[33] When diagnosing bulimia, exercise addiction is referred to as a compensatory behavior and indicator of the underlying disorder. Research also shows exercise addiction influences not only the development of eating disorders but also their maintenance.[13]

Animal models

As with many human diseases and disorders, animal models are sometimes used to study addiction. For example, voluntary wheel running by rodents, viewed as a model of human voluntary exercise, has been used to study withdrawal symptoms, such as changes in blood pressure, when wheel access is removed from mice.[34]

See also

References

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  2. ^ Nestler EJ (December 2013). "Cellular basis of memory for addiction". Dialogues in Clinical Neuroscience. 15 (4): 431–443. PMC 3898681. PMID 24459410. Despite the importance of numerous psychosocial factors, at its core, drug addiction involves a biological process: the ability of repeated exposure to a drug of abuse to induce changes in a vulnerable brain that drive the compulsive seeking and taking of drugs, and loss of control over drug use, that define a state of addiction. ... A large body of literature has demonstrated that such ΔFosB induction in D1-type [nucleus accumbens] neurons increases an animal's sensitivity to drug as well as natural rewards and promotes drug self-administration, presumably through a process of positive reinforcement ... Another ΔFosB target is cFos: as ΔFosB accumulates with repeated drug exposure it represses c-Fos and contributes to the molecular switch whereby ΔFosB is selectively induced in the chronic drug-treated state.41. ... Moreover, there is increasing evidence that, despite a range of genetic risks for addiction across the population, exposure to sufficiently high doses of a drug for long periods of time can transform someone who has relatively lower genetic loading into an addict.
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    Addiction: A term used to indicate the most severe, chronic stage of substance-use disorder, in which there is a substantial loss of self-control, as indicated by compulsive drug taking despite the desire to stop taking the drug. In the DSM-5, the term addiction is synonymous with the classification of severe substance-use disorder.
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  6. ^ a b c d Sussman S, Lisha N, Griffiths M (March 2011). "Prevalence of the addictions: a problem of the majority or the minority?". Eval Health Prof. 34 (1): 3–56. doi:10.1177/0163278710380124. PMC 3134413. PMID 20876085.
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  8. ^ a b c d [unreliable medical source?]Villella C, Martinotti G, Di Nicola M, et al. (June 2011). "Behavioural addictions in adolescents and young adults: results from a prevalence study". J Gambl Stud. 27 (2): 203–14. doi:10.1007/s10899-010-9206-0. PMID 20559694. S2CID 19239770.
  9. ^ O'Brien, Charles (1 May 2011). "Addiction and dependence in DSM-V". Addiction. 106 (5): 866–867. doi:10.1111/j.1360-0443.2010.03144.x. PMC 3812919. PMID 21477226.
  10. ^ Johnston, Olwyn (2011). "Excessive Exercise: From Quantitative Categorisation to a Qualitative Continuum Approach". Eur. Eating Disorders Rev. 19 (3): 237–248. doi:10.1002/erv.970. PMID 21584916.
  11. ^ Landolfi, Emilio (2012-12-21). "Exercise Addiction". Sports Medicine. 43 (2): 111–119. doi:10.1007/s40279-012-0013-x. ISSN 0112-1642. PMID 23329605. S2CID 35726964.
  12. ^ a b Veale (1995). "Does primary exercise dependence really exist?". The British Psychological Society.
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  16. ^ Guimaraes Teixeria, Thiago; Terra, Rodrigo; Lourenco Dutra, Patricia Maria (2017). "Chronic Effects of Exhausting Exercise and Overtraining on the Immune Response: Th1 and Th2 Profile". Motricidade. 13 (3): 69–78. doi:10.6063/motricidade.10049.
  17. ^ a b Lee, David Jonathan (2010). "Adrenal Fatigue Syndrome, Part 2: Adrenal Function and Overtraining". Athletic Therapy Today. 15 (2): 28–31. doi:10.1123/att.15.2.28.
  18. ^ Tobar, David A. (2012). "Trait Anxiety and Mood State Responses to Overtraining in Men and Women College Swimmers". International Journal of Sport and Exercise Psychology. 10 (2): 135–148. doi:10.1080/1612197X.2012.666399. S2CID 144623355.
  19. ^ Delimaris, Ioannis (2014). "Potential Adverse Biological Effects of Excessive Exercise and Overtraining Among Healthy Individuals". Acia Medicia Martiniana. 14 (3): 5–12. doi:10.1515/acm-2015-0001. S2CID 62811234.
  20. ^ a b Freimuth, Marilyn; Moniz, Sandy; Kim, Shari R. (October 2011). "Clarifying Exercise Addiction: Differential Diagnosis, Co-occurring Disorders, and Phases of Addiction". International Journal of Environmental Research and Public Health. 8 (10): 4069–4081. doi:10.3390/ijerph8104069. PMC 3210598. PMID 22073029.
  21. ^ Griffiths, Mark (January 1997). "Exercise Addiction: A Case Study". Addiction Research. 5 (2): 161–168. doi:10.3109/16066359709005257. ISSN 1058-6989.
  22. ^ Craft, Lynette L.; Perna, Frank M. (2004-06-01). "The Benefits of Exercise for the Clinically Depressed". The Primary Care Companion to the Journal of Clinical Psychiatry. 06 (3): 104–111. doi:10.4088/pcc.v06n0301. ISSN 1523-5998. PMC 474733. PMID 15361924.
  23. ^ GRUENBERG, ALAN M. (2009-01-05). "Stahl's Essential Psychopharmacology Neuroscientific Basis and Practical Application, Third Edition. By S. M. Stahl. (Pp. 1096; $85.00; ISBN 978-0-521-6736-1 pb.) Cambridge University Press: New York. 2008". Psychological Medicine. 39 (3): 520–521. doi:10.1017/s0033291708005060. ISSN 0033-2917. S2CID 145124966.
  24. ^ a b Adams, Jeremy (2009-05-08). "Understanding Exercise Dependence". Journal of Contemporary Psychotherapy. 39 (4): 231–240. doi:10.1007/s10879-009-9117-5. ISSN 0022-0116. S2CID 27779648.
  25. ^ a b c Terry, Annabel; Szabo, Attila; Griffiths, Mark (2004). "The exercise addiction inventory: a new brief screening tool". Addiction Research and Theory. 12 (5): 489–499. CiteSeerX 10.1.1.547.1889. doi:10.1080/16066350310001637363. S2CID 145615216.
  26. ^ Johnston, Olwyn (2011). "Excessive Exercise: From Quantitative Categorisation to a Qualitative Continuum Approach". Eur. Eat. Disorders Rev. 19 (3): 237–248. doi:10.1002/erv.970. PMID 21584916.
  27. ^ J.K. Thompson; L. Pasman. "The Obligatory Exercise Questionnaire". Retrieved 22 November 2011.
  28. ^ Brewer, Judson A.; Potenza, Marc N. (January 2008). "The neurobiology and genetics of impulse control disorders: Relationships to drug addictions". Biochemical Pharmacology. 75 (1): 63–75. doi:10.1016/j.bcp.2007.06.043. ISSN 0006-2952. PMC 2222549. PMID 17719013.
  29. ^ Grant, Jon E.; Potenza, Marc N. (June 2006). "Compulsive Aspects of Impulse-Control Disorders". Psychiatric Clinics of North America. 29 (2): 539–551. doi:10.1016/j.psc.2006.02.002. ISSN 0193-953X. PMC 1812126. PMID 16650722.
  30. ^ Freimuth, Marilyn (2008). Addicted? Recognizing Destructive Behaviors Before It's Too Late. Maryland: Rowman & Littlefield Publishers. p. 1.
  31. ^ Grant JE, Potenza MN, Weinstein A, Gorelick DA (September 2010). "Introduction to behavioral addictions". Am J Drug Alcohol Abuse. 36 (5): 233–41. doi:10.3109/00952990.2010.491884. PMC 3164585. PMID 20560821.
  32. ^ Comer, Ronald J. (2010). Abnormal psychology (7th ed.). New York: Worth Publishers. pp. 363–65. ISBN 978-1-4292-1631-9.
  33. ^ Freimuth, Marilyn; Moniz, Sandy; Kim, Shari R. (2011-10-21). "Clarifying Exercise Addiction: Differential Diagnosis, Co-occurring Disorders, and Phases of Addiction". International Journal of Environmental Research and Public Health. 8 (10): 4069–4081. doi:10.3390/ijerph8104069. PMC 3210598. PMID 22073029.
  34. ^ Kolb, E. M., S. A. Kelly, and T. Garland, Jr. 2013. Mice from lines selectively bred for high voluntary wheel running exhibit lower blood pressure during withdrawal from wheel access. Physiology & Behavior 112-113:49–55.
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