Skip to main content Accessibility help
Hostname: page-component-99c86f546-7c2ld Total loading time: 0.641 Render date: 2021-11-29T00:55:50.762Z Has data issue: true Feature Flags: { "shouldUseShareProductTool": true, "shouldUseHypothesis": true, "isUnsiloEnabled": true, "metricsAbstractViews": false, "figures": true, "newCiteModal": false, "newCitedByModal": true, "newEcommerce": true, "newUsageEvents": true }

Chapter 2 - Athletics: Energy Levels, Exercise Addiction and Disordered Eating

Published online by Cambridge University Press:  29 July 2020

Amit D. Mistry
Barnet, Enfield and Haringey Mental Health NHS Trust
Thomas McCabe
NHS Greater Glasgow and Clyde
Alan Currie
Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust
Get access


BR presented as a 22-year-old single, university student and an endurance runner. She had competed successfully at middle and long distance events since the age of 14. Since transitioning to university, B had increased her training load considerably with the hope of competing at national level and eventual selection for international competition. However, over the past year she had suffered two stress fractures that had not been given appropriate time to heal. Initially, she had presented to her primary health care physician (GP) several times including for ongoing pain management which she was attempting to treat herself by way of over-the-counter medications. During one of these GP consultations, she revealed how stressed and anxious she was and the effect this had on her athletic performance. She was then referred to a sports psychiatrist, based on the perceived longevity of untreated mental health symptoms and her wish to return to competitive sport as soon as possible. The report from this consultation and assessment is below.

Publisher: Cambridge University Press
Print publication year: 2020

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)


Mountjoy, M, Sundgot-Borgen, J, Burke, L, Carter, S, Constantini, N, Lebrun, C, et al. The IOC consensus statement: Beyond the Female Athlete Triad-Relative Energy Deficiency in Sport (RED-S). Br J Sports Med. 2014;48(7):491–7. Available from: Scholar
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (DSM-5). 5th edition. Washington, DC: American Psychiatric Publishing; 2013 [refd 2018 Jun 29]. 1947. Available from:®%29Google Scholar
Frisch, RE. Body fat, puberty and fertility. Biol Rev Camb Philos Soc. 1984;59(2):161–88.CrossRefGoogle ScholarPubMed
Loucks, AB. Energy balance and body composition in sports and exercise. In: Journal of Sports Sciences. 2004. 114.CrossRefGoogle Scholar
Mountjoy, M, Sundgot-Borgen, JK, Burke, LM, Ackerman, KE, Blauwet, C, Constantini, N, et al. IOC consensus statement on relative energy deficiency in sport (RED-S): 2018 update. Br J Sports Med. 2018;52(11):687–97.CrossRefGoogle Scholar
Gordon, CM, Ackerman, KE, Berga, SL, Kaplan, JR, Mastorakos, G, Misra, M, et al. Functional hypothalamic amenorrhea: An endocrine society clinical practice guideline. J Clin Endocrinol Metab. 2017;102(5):1413–39.CrossRefGoogle Scholar
Joy, E, Kussman, A, Nattiv, A. Update on eating disorders in athletes: A comprehensive narrative review with a focus on clinical assessment and management. Br J Sports Med. 2016;50(3):154–62. Available from:–095735CrossRefGoogle ScholarPubMed
Fahrenholtz, IL, Sjödin, A, Benardot, D, Tornberg, B, Skouby, S, Faber, J, et al. Within-day energy deficiency and reproductive function in female endurance athletes. Scand J Med Sci Sport. 2018;28(3):1139–46.CrossRefGoogle ScholarPubMed
Melin, A, Tornberg, B, Skouby, S, Møller, SS, Sundgot-Borgen, J, Faber, J, et al. Energy availability and the female athlete triad in elite endurance athletes. Scand J Med Sci Sport. 2015;25(5):610–22.CrossRefGoogle ScholarPubMed
Abbate-Daga, F, Delsedime, N, De-Bacco, C, Fassino, SGA. Resistance to treatment and change in anorexia nervosa [corrected]: a clinical overview.[Erratum appears in BMC Psychiatry. 2014; 14:62]. BMC Psychiatry. 2013 [refd 2019 Dec 7];13:294. Available from:; http://dc8qa4cy3–2004&rft_val_fmt=info:ofi/fmt:kev:mtx:journal&rfr_id=info:sid/Ovid:prem&rft.genre=article&rft_id=info:doi/Google Scholar
Haase, AM, Prapavessis, H, Glynn Owens, R. Perfectionism, social physique anxiety and disordered eating: A comparison of male and female elite athletes. Psychol Sport Exerc. 2002;3(3):209–22.CrossRefGoogle Scholar
WHO. International Statistical Classification of Diseases and Related Health Problems: 10th revision. World Health Organization. 2011.Google Scholar
Madigan, DJ, Stoeber, J, Passfield, L. Perfectionism and training distress in junior athletes: A longitudinal investigation. J Sports Sci. 2017;35(5):470–5.CrossRefGoogle ScholarPubMed
Forsberg, S, Lock, J. The relationship between perfectionism, eating disorders and athletes: A review. Minerva Pediatr. 2006;58(6):525–36.Google ScholarPubMed
Downs, DS, Hausenblas, HA, Nigg, CR. Factorial validity and psychometric examination of the exercise dependence scale-revised. Meas Phys Educ Exerc Sci. 2004;8(4):183201.CrossRefGoogle Scholar
Arends, JC, Cheung, M-YC, Barrack, MT, Nattiv, A. Restoration of menses with nonpharmacologic therapy in college athletes With menstrual disturbances: A 5-year retrospective study. Int J Sport Nutr Exerc Metab. 2012 [refd 2019 Dec 7];22(2):98108. Available from: ScholarPubMed
Berga, SL, Marcus, MD, Loucks, TL, Hlastala, S, Ringham, R, Krohn, MA. Recovery of ovarian activity in women with functional hypothalamic amenorrhea who were treated with cognitive behavior therapy. Fertil Steril. 2003 [refd 2019 Dec 7];80(4):976–81. Available from: ScholarPubMed
Michopoulos, V, Mancini, F, Loucks, TL, Berga, SL. Neuroendocrine recovery initiated by cognitive behavioral therapy in women with functional hypothalamic amenorrhea: A randomized, controlled trial. Fertil Steril. 2013;99(7).CrossRefGoogle ScholarPubMed
Arthur-Cameselle, JN, Quatromoni, PA. Eating disorders in collegiate female athletes: Factors that assist recovery. Eat Disord. 2014;22(1):5061.CrossRefGoogle ScholarPubMed
Papathomas, A, Lavallee, D. Self-starvation and the performance narrative in competitive sport. Psychol Sport Exerc. 2014;15(6):688–95. Available from: Scholar
Miller, WR, Rollnick, S. Motivational interviewing: Preparing people to change addictive behavior. Miller, WR, Rollnick, S, eds. Journal of Community and Applied Social Psychology. 1st edition. New York, NY: Guilford Press; 1991 [refd 2019 Dec 7]. Available from: Scholar
Woolsey, CL, Mannion, J, Williams, RD, Steffen, W, Aruguete, MS, Evans, MW, et al. Understanding emotional and binge eating: From sports training to tailgating. The Sport Journal. 2013 [refd 2019 Dec 7]. Available from: Scholar
Hausenblas, HA, Schreiber, K, Smoliga, JM. Addiction to exercise. BMJ. 2017; 26 (357):1745.CrossRefGoogle Scholar
Griffiths, MD, Szabo, A, Terry, A. The exercise addiction inventory: A quick and easy screening tool for health practitioners. Br J Sports Med. 2005;39(6).CrossRefGoogle ScholarPubMed
Freimuth, M, Moniz, S, Kim, SR. Clarifying exercise addiction: Differential diagnosis, co-occurring disorders, and phases of addiction. Int J Environ Res Public Health. 2011;8(10):4069–81.CrossRefGoogle Scholar
Thornton, EW, Scott, SE. Motivation in the committed runner: Correlations between self-report scales and behaviour. Health Promot Int. 1995 [refd 2019 Dec 7];10(3):177–84. Available from: Scholar
Scully, D, Kremer, J, Meade, M, Graham, R, Dudgeon, K. Physical exercise and psychological well being: A critical review. Br J Sports Med. 1998;32(2):111–20.CrossRefGoogle ScholarPubMed
De Souza, MJ, Nattiv, A, Joy, E, Misra, M, Williams, NI, Mallinson, RJ, et al. Female athlete triad coalition consensus statement on treatment and return to play of the female athlete triad: 1st international conference held in San Francisco, California, May 2012 and 2nd international conference held in Indianapolis, Indiana, M. Br J Sports Med. 2014;48(4):289.CrossRefGoogle Scholar

Send book to Kindle

To send this book to your Kindle, first ensure is added to your Approved Personal Document E-mail List under your Personal Document Settings on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part of your Kindle email address below. Find out more about sending to your Kindle.

Note you can select to send to either the or variations. ‘’ emails are free but can only be sent to your device when it is connected to wi-fi. ‘’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.

Find out more about the Kindle Personal Document Service.

Available formats

Send book to Dropbox

To send content items to your account, please confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account. Find out more about sending content to Dropbox.

Available formats

Send book to Google Drive

To send content items to your account, please confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account. Find out more about sending content to Google Drive.

Available formats