BackgroundCompulsive exercise has been recognized as a highly prevalent symptom in eating disorders (ED) for over 100 years and is associated with poor short-term and long-term treatment outcome. Progress in understanding and treatment of compulsive exercise will remain limited as long as no consensus framework for definition and assessment of compulsive exercise exists, as results cannot be compared across clinical studies.Based on existing literature, it was our aim to propose a transdiagnostic definition and a clinical assessment for compulsive exercise, that can be applied to adolescent and adult patients with ED.MethodDuring a series of meetings of experienced clinicians at a highly specialized hospital for eating disorders, we elaborated a transdiagnostic definition of compulsive exercise in ED. Additionally, we derived a clinical interview for the assessment of compulsive exercise and its different subtypes.ResultsThe core criterion when defining and assessing compulsive exercise is a pathologically increased exercise pattern characterized by 1) excessive exercise that a patient feels driven to perform in response to an obsession or according to rules that must be applied rigidly, and 2) exercise that is aimed at preventing or reducing distress or at preventing some dreaded consequence. A second necessary criterion is the physical or psychological burden caused by compulsive exercise, i.e., that it is time-consuming, significantly interferes with the patient’s daily routine, occupational functioning or social relationships or is continued despite medical injury, illness, or lack of enjoyment. Insight that compulsive exercise is excessive or unreasonable was added as an optional criterion.Compulsive exercise manifests itself in three different subtypes: 1) vigorous exercise, 2) marked increase in daily movement, or 3) motor restlessness.The above criteria must be met during the past 6 months, together with one of the three subtypes of compulsive exercise.ConclusionsThe proposed criteria aim to foster the discussion around definition and assessment of compulsive exercise with the goal of reaching an international consensus in the near future.Providing a consistent framework for researchers and clinicians would considerably advance understanding and treatment of compulsive exercise in ED patients.

Introduction: Treatment of compulsive exercise is recognized as a key unmet challenge in the treatment of anorexia nervosa (AN). To address this challenge, we developed the manualized group intervention "healthy exercise behavior" (HEB). This study evaluates the efficacy of HEB for the reduction of compulsive exercise as add-on to routine inpatient treatment (treatment as usual [TAU]) in a randomized controlled trial. Methods: Two hundred and seven adolescent and adult female inpatients with (atypical) AN were randomly allocated to TAU or to additional participation in HEB (TAU + HEB). HEB integrates elements of exercise-based therapy into a cognitive-behavioral approach. Assessments took place at admission, pre-intervention, post-intervention, discharge, and 6 months follow-up. Primary outcome was the severity of compulsive exercise assessed by the Commitment to Exercise Scale between pre-and post-intervention; secondary outcomes were additional aspects of compulsive exercise, assessed by the Compulsive Exercise Test, weight gain, eating disorder and general psychopathology, and emotion regulation. Results: In intention-to-treat analysis for the primary outcome, the TAU + HEB group showed significantly stronger reductions in the severity of compulsive exercise compared to the TAU group (z = -2.81; p = 0.005; effect size [ES] = -0.3). We also found significantly stronger reductions from admission to discharge (z = 2.62; p = 0.009; ES = -0.43), and from admission to follow-up (z = 2.1; p = 0.035; ES = -0.39). Regarding secondary outcomes, we found significant group differences between pre-and post-intervention in additional aspects of compulsive exercise (z = -2.55; p = 0.011; ES = -0.27). We did not find significant differences regarding weight gain, eating disorder and general psychopathology, and emotion regulation. Conclusions: Our intervention proved efficacious in reducing compulsive exercise in inpatients with (atypical) AN.

BackgroundPatients with eating disorders (ED) often suffer from compulsive exercise behavior, which is associated with lower short-term response to treatment and poorer long-term outcome. Evidence-based interventions specifically targeting compulsive exercise behavior have been scarce so far. We developed a manualized group therapeutic approach integrating cognitive-behavioral therapy, exercise therapy and exposure with response management to promote healthy exercise behavior. Our objective was to examine the feasibility and acceptance of this new approach as add-on to regular inpatient treatment in a pilot study. Additionally, we wanted to estimate preliminary effect sizes.MethodsThirty-two female, adolescent and adult eating disordered inpatients were recruited. According to the 4th ed. of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), twenty-six patients met criteria for Anorexia nervosa (AN), two for Bulimia nervosa and four for eating disorder not otherwise specified. Semi-structured interviews were conducted for qualitative evaluation of feasibility and acceptance of the new intervention. Patients completed the Commitment to Exercise Scale (CES) and the Compulsive Exercise Test (CET) for assessment of compulsive exercise, the Eating Disorder Inventory-2 for assessment of eating disorder pathology, the Beck Depression Inventory-II and Brief Symptom Inventory for assessment of depressive and general psychopathology and the Emotion Regulation Skills Questionnaire for assessment of emotion regulation before the beginning and at the end of the group intervention. Additionally, weight gain was monitored.ResultsFeasibility of our approach was confirmed. All patients reported a high satisfaction with both structure and content of the group. Between pre- and post-intervention, patients showed significant reductions in compulsive exercise (effect size CES: 1.44; effect size CET total: 0.93), drive for thinness (effect size: 0.48), depressive symptoms (effect size: 0.36), general psychopathology (effect size: 0.29) and acceptance of emotions (effect size: − 0.62). Patients with AN also showed significant mean weight gain during the intervention (effect size: − 0.44).ConclusionsResults of our pilot study indicate that our integrative approach to compulsive exercise in ED patients might represent a promising new therapeutic option. Feasibility and acceptance of the intervention were confirmed. Preliminary effect sizes on most outcomes were promising. As improvements in Body-mass-index, eating disorder and general psychopathology are also to be expected by routine inpatient treatment, a large randomized trial is currently underway to evaluate the efficacy of this new intervention.

The objective of the study was to investigate whether cognitive fatigue in patients with multiple sclerosis (MS) is a spontaneous phenomenon or whether it can be provoked or exacerbated through cognitive effort and motor exercise. Thirty two patients with definite MS and cognitive fatigue according to the Fatigue Scale for Motor and Cognitive Functions (FSMC ≥ 22) performed attention tests (alertness, selective, and divided attention subtests from the TAP test battery for attention performance) twice during rest (baseline), and before and after treadmill training and cognitive load (a standardised battery of neuropsychological tests lasting 2.5 hours). Subjective exhaustion was assessed with a 10-point rating scale. Tonic alertness turned out to be the most sensitive test and showed significantly increased reaction times after treadmill training and after cognitive load. Patients' subjective assessment of exhaustion (10-point rating scale) and the objective test results were discrepant. In contrast, healthy control subjects (N = 20) did not show any decline of performance in the subtest alertness after cognitive or physical load. Data favour the concept that fatigue is induced by physical and mental load. Discrepancies between subjective and objective assessment offer therapeutic options. The common notion of a purely "subjective" lack of physical and/or mental energy should be reconsidered.