Theoretical conceptualisations of problematic exercise in psychometric assessment instruments: A systematic review

Perfectionism and compulsive exercise: a systematic review and preliminary meta-analysis

PURPOSE

There is a consistent link between perfectionism and compulsive exercise, and both are implicated in the maintenance of eating disorders, however no meta-analysis to date has quantified this relationship. We hypothesised that there would be significant, small-moderate pooled correlations between perfectionism dimensions and compulsive exercise.

METHODS

Published, peer-reviewed articles with standardised measures of perfectionism and the Compulsive Exercise Test were included. There were 7 studies included (N = 3117 participants, M age = 21.78 years, 49% female).

RESULTS

Total perfectionism (r = 0.37), perfectionistic strivings (r = 0.33), and perfectionistic concerns (r = 0.32) had significant pooled positive associations with compulsive exercise. Most studies (67%) were rated as fair or good quality as an indication of risk of bias. Limitations included the low number of available studies, the inclusion of only one clinical sample, and predominately cross-sectional studies which precluded causal inference.

CONCLUSION

Higher perfectionism was associated with higher compulsive exercise. More research is needed on compulsive exercise to determine the best intervention approach given its relationship to perfectionism and relevance in the context of eating disorders.

LEVEL OF EVIDENCE

Level I: Evidence obtained from a systematic review and meta-analysis.

The Arabic Version of Compulsive Exercise Test among Saudi Population; Translation and Validation

Compulsive exercise is a condition characterized by uncontrollable exercise behaviour that may lead to severe and harmful physical and psychological consequences. Indeed, compulsive exercise is among the early symptoms of eating disorders that may affect different age groups. Globally and among Arab countries, compulsive exercise is common, while the screening methods used to assess compulsive exercise are limited. Thus, the Compulsive Exercise Test (CET) has emerged as a tool to assess cognitive, behavioural, and emotional factors related to compulsive exercise. The CET is a self-report, Likert-type scale comprising five distinct subscales. The increase in the CET scores is more likely associated with worsened pathology. Since the Arab countries lack such an assessment tool, we aimed to translate the CET into Arabic, validate the translated version, confirm the factor structures, and assess the internal consistency of the different subscales. Herein, we used the forward-backward translation method as recommended by the World Health Organization (WHO). The overall validity index of the translated version showed a score higher than 0.78, while the scale-level content validity index based on the average calculating method (S-CVI/Ave) and the agreement method (S-CVI/UA) were 0.91 and 0.58, respectively. Moreover, we recruited 399 Arabs living in Saudi to measure the internal consistency, and the value of the substantive internal consistency with Cronbach's α was 0.81. Subsequently, four of the Arabic-CET subscales had substantive internal consistency with Cronbach's α values higher than or equal to 0.70. Furthermore, the exploratory factor analysis results supported the substantial use of the five-subscale model. Taken together, our study supports using the Arabic-CET version to measure exercise compulsiveness among Arabs.

Validation and measurement invariance of the Compulsive Exercise Test among Brazilian and American young adults

PURPOSE

To evaluate compulsive exercise, researchers often rely on the widely used Compulsive Exercise Test (CET). However, the measure has shown unstable factor structure in several validation studies and is not available in Portuguese for use in Brazil. We aimed to describe the translation and cultural adaptation of the CET to Brazilian Portuguese, to test several factor structures among Brazilian and US samples of men and women, to test measurement invariance across countries, and to evaluate its internal consistency. Furthermore, we sought to evaluate convergent validity, correlating the CET with a measure of eating disorder symptoms, and to compare compulsive exercise symptoms between countries.

METHODS

Four models of the latent structure of the CET were tested using confirmatory factor analyses (CFAs), three-factor structure with 15 items, three-factor structure with 18 items, four-factor structure with 21 items, and the original five-factor structure with 24 items, in a sample of 1,531 young adults (601 Brazilians and 930 Americans), aged 18-35 years.

RESULTS

A series of CFAs demonstrated that the three-factor structure with 15 items showed a better fit to the data. This model demonstrated good convergent validity and internal consistency. Results from the CET multigroup CFA showed evidence for the invariance at the configural, metric, and scalar levels across Brazilians and Americans. Furthermore, significant differences were found between Brazilians and Americans, with Brazilians demonstrating higher scores on the Avoidance and rule-driven behavior and Mood improvement subscales, whereas US participants scored higher on the Weight control exercise subscale.

CONCLUSIONS

Results support the three-factor structure with 15 items to be used as a measure of compulsive exercise among Brazilians and Americans, allowing cross-cultural comparisons between these countries.

LEVEL OF EVIDENCE

Level V, Cross-sectional, Psychometric study.

The Expanded Exercise Addiction Inventory (EAI-3): Towards Reliable and International Screening of Exercise-Related Dysfunction

Exercise addiction (EA) refers to excessive exercise, lack of control, and health risks. The Exercise Addiction Inventory (EAI) is one of the most widely used tools in its assessment. However, the cross-cultural psychometric properties of the EAI could be improved because it misses three pathological patterns, including guilt, exercise despite injury, and experienced harm. Therefore, the present study tested the psychometric properties of the expanded EAI (EAI-3) in a large international sample. The EAI-3 was administered to 1931 physically active adult exercisers speaking five languages (Chinese, German, Italian, Japanese, and Turkish) and other measures for obsessive-compulsive behavior, eating disorders, and personality traits. The assessment structure and reliability of the EAI-3 were tested with factorial analyses and through measurement invariance across languages and sex. Finally, a cutoff point for dysfunction-proneness was calculated. The EAI-3 comprised two factors, reflecting the positive and pathological sides of exercise. The structure had excellent reliability and goodness-of-fit indices and configural and metric invariances of the scale were supported. However, three items caused violations in scalar invariance. The results of partial measurement invariance testing suggested an adequate fit for the data. Following sensitivity and specificity analysis, the EAI-3's cutoff score was 34 out of a maximum score of 48. This preliminary study suggests that the EAI-3 is a promising tool for screening EA in an international sample, with a robust and reliable structure comparable across languages and sex. In addition, the proposed cutoff could pave the way toward a consensus on a threshold to screen for EA.

Does Exercise Addiction Exist Among Individuals Engaged in Team-Based Exercise? A Position Paper

Exercise addiction is a term used to describe dysfunctional exercise behavior characterized by the classic symptoms of addictions, which eventually result in physical, psychological, or social harm to the affected individual. While well over 1000 peer-reviewed papers on problematic exercise have been published, very few studies have explored the conceptual differences between team-based and individual-based exercise, and no previous study has critically addressed this issue. The rationale for this distinction is that team-based exercise is typically organized and scheduled by others with little or no control over its timing by the individual team member. On the contrary, individual-based exercise can be self-scheduled. Consequently, more (total) control over its timing facilitates the satisfaction of craving-induced urges characterized by an addiction. It is posited that exercise addicts, in general, are “lone wolves” in the context of their addiction. Therefore, being addicted to exercise in team sports is only possible if the individual resorts to additional individually-controlled exercise above and beyond team-based training. To support this position, the present paper briefly reviews the few studies conducted in this area and examines how their results match the diagnostic interpretation of “addiction.” The present position paper highlights that “control” over the addictive behavior, in this case, exercise, is an important marker in the potential for the risk of exercise addiction. Therefore, future studies should consider that team-based exercise assigns little control to the individual. However, the extent to which additional individual-based exercise occurs and poses a risk of addiction within team exercises merits further research attention.

Exercise addiction: A narrative overview of research issues

This narrative overview summarises the work on exercise addiction (EA) over the past 12 years and exposes critical conceptual and methodological issues. More than 1000 articles exist on EA, conceptualised as uncontrolled training harming the individual. Still, EA has no clinical diagnosis criteria at this time. Research is increasing continuously, but it is stale in advancing knowledge. Scalar measurement and lack of differentiation between addictive and instrumental exercise could be reasons for insufficient progress. Exercise addiction fits in the framework of behavioural addictions, but excessive exercise patterns also co-occur with other morbidities, including eating or body-image disorders. In these cases, exercise is instrumental; it functions to achieve a non-exercise-related goal. Therefore, it is essential to separate primary from secondary EA. Based on the interactional model, significant stress and capacity-exceeding ambitions fuel primary EA, while chief motives behind secondary EA embed body image dissatisfaction and eating disorders. Few reports exist on EA's brain mechanisms, which could delay its classification as a distinct psychiatric dysfunction. Treatment of EA involves cognitive-behavioural approaches, but we know little about their effectiveness. Conceptually focussed psychophysiological research and in-depth interviews, complementing scalar data, could answer several open questions in this widely studied but relatively stagnant scholastic field.

Disorders due to addictive behaviors: Further issues, debates, and controversies •

Two recent papers in the Journal of Behavioral Addictions by Brand et al. (2022), and Sassover and Weinstein (2022) both make interesting additions to the place of behavioral addictions in the more general addictive behaviors field. This commentary discusses some of the further nuances in the debates surrounding whether problematic engagement in social networking, pornography, and buying/shopping should be considered as possible 'disorders due to addictive behaviors' in the ICD-11. Particular emphasis in this commentary is placed on social network use disorder and its delineation. While there is growing evidence that addictions to sex, pornography, social network sites, exercise, work, and buying/shopping may be genuine disorders among a minority of individuals, none of these behaviors is likely to be included in formal psychiatric manuals in the near future until there is more high-quality data on all research fronts (e.g., epidemiological, neurobiological, psychological, and clinical).

Examining the reliability of the scores of self-report instruments assessing problematic exercise: A systematic review and meta-analysis

Background and aims

Problematic exercise (PE) has mainly been assessed with self-report instruments. However, summarized evidence on the reliability of the scores derived from such instruments has yet to be provided. The present study reports a reliability generalization meta-analysis of six well-known self-report measures of PE (Commitment to Exercise Scale, Compulsive Exercise Test, Exercise Addiction Inventory, Exercise Dependence Questionnaire, Exercise Dependence Scale, and Obligatory Exercise Questionnaire).

Methods

Pooled effect sizes were computed using a random-effect model employing a restricted maximum likelihood estimation method. Univariable and multivariable meta-regressions analyses were employed for testing moderator variables.

Results

Data retrieved from 255 studies (741 independent samples, N = 254,174) identified three main groups of findings: (i) pooled alpha values that, ranging from 0.768 to 0.930 for global scores and from 0.615 to 0.907 for subscale scores, were found to be sensitive to sociodemographic and methodological characteristics; (ii) reliability induction rates of 47.58%; and (iii) the virtually non-existent testing of the assumptions required for the proper applicability of alpha. Data unavailability prevented the provision of summarized reliability estimates in terms of temporal stability.

Discussion

These findings highlight the need to improve reliability reporting of the scores of self-reported instruments of PE in primary studies. This implies providing both prior justification for the appropriateness of the index employed and reliability data for all the subpopulation of interest. The values presented could be used as a reference both for comparisons with those obtained in future primary studies and for correcting measurement-related artefacts in quantitative meta-analytic research concerning PE.

A Review of the Components of Problematic Exercise in Psychometric Assessment Instruments

Backgrounds

The range of theoretical conceptualizations of problematic exercise in psychometric assessment instruments makes it difficult to identify the components that define this phenomenon. A better understanding of the underlying components of problematic exercise may contribute to progress toward providing scientific evidence that allows for deciding whether problematic exercise should be considered a substantive mental health disorder. The objective of the present review was to examine and compare, through a content analysis of their items, the components of problematic exercise in psychometric assessment instruments identified in a recent systematic review.

Methods

A total of 33 components of problematic exercise were identified in the 17 assessment instruments included in the present review.

Results

The results show that, despite the lack of consensus in the operational definition of their factors and the variety of ways of wording their items, the instruments reflect some common components that might indicate core criteria (i.e., salience, withdrawal, and mood modification) or candidate components (i.e., conflict, and continuance despite problems) of problematic exercise. However, other components of different nature were shown to be specific to some of the problematic exercise conceptualizations on which the assessment instruments are based.

Conclusion

In the interest of reaching a consensus that allows to advance in this research field, further studies are needed to resolve which components are inherently problematic.

Physical Appearance Perfectionism: Psychometric Properties and Factor Structure of an Assessment Instrument in a Representative Sample of Males

Perfectionism is a multidimensional construct with both positive and negative aspects. Recently, the concept of appearance-oriented perfectionism has been introduced, which is associated with body image dissatisfaction and weight and shape control behaviors. The Physical Appearance Perfectionism Scale (PAPS) is a 12-item two-factor instrument developed to assess this new dimension of perfectionism. The aim of the study is to validate the Spanish version of PAPS among a representative sample of 850 male university students in Spain (M = 20 years old; SD = 2.7). Exploratory and confirmatory factorial structure, internal consistency, convergent and concurrent validity, and associated predictor variables analyses have been carried out. Results showed that the Spanish version of the PAPS maintains the original factor structure with all items and proves to be a reliable instrument. Physical appearance-oriented perfectionism is associated with general perfectionism, higher body dissatisfaction, Eating Disorders and Muscle Dysmorphia symptomatology, and compulsive exercise, particularly in the Worry about Imperfection subscale. These variables also act as predictors of physical appearance perfectionism. The use of the PAPS-S and the analysis of its subscales is recommended in the context of body image-related pathologies such as Eating Disorders and Muscle Dysmorphia.

Mental Disorders in Individuals With Exercise Addiction-A Cross-Sectional Study

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. Methods: One hundred and fifty-six individuals who reported exercising more than 10 h a week, and continued to do so despite illness or injury, were recruited for the study. Those who met the cut-off of the Exercise Dependence Scale (n = 32) were invited to participate in a screening with the Structured Clinical Interview for DSM-5 (SCID-5-CV) and personality disorders (SCID-5-PD). Additionally, an interview based on the DSM-5 criteria of non-substance-related addictive disorders was conducted to explore the severity of exercise addiction symptoms. Results: 75% of participants fulfilled the criteria for at least one psychiatric disorder. Depressive disorders (56.3%), personality disorders (46.9%) and obsessive-compulsive disorders (31.3%) were the most common disorders. Moreover, there was a significant positive correlation between the number of psychiatric disorders and the severity of exercise addiction (r = 0.549, p = 0.002). Discussion: The results showed a variety of mental disorders in individuals with exercise addiction and a correlation between the co-occurrence of mental disorders and the severity of exercise addiction. Exercise addiction differs from other addictive und substance use disorders, as obsessive-compulsive (Cluster C), rather than impulsive (Cluster B) personality traits were most commonly identified. Conclusions: Our results underscore the importance of clinical diagnostics, and indicate that treatment options for individuals with exercise addiction are required. However, the natural history and specific challenges of exercise addiction must be studied in more detail.