Integrating Screening and Clinical Interviews: Advancing the Assessment of Exercise Addiction in Athletes

Background and aimsQuestionnaire-based tools such as the Exercise Dependence Scale (EDS) are widely used to identify athletes exhibiting dependence-like features, but it remains unclear how these classifications relate to clinically relevant addictive exercise behaviour. This study combined quantitative screening with structured clinical interviews to (1) examine the proportion of athletes showing high EDS scores who meet ICD-11 criteria for a disorder due to addictive behaviour (6C5Y), (2) characterize psychological and motivational differences between athletes classified as exercise addicted versus non-addicted based on ICD-11 (6C5Y), and (3) identify the most discriminative predictors of this classification. MethodsA total of 342 endurance athletes (159 female, 183 male) completed an online survey including the EDS, life satisfaction, and motivational factors. Athletes exceeding the EDS cut-off (>77; n = 63) and consenting to re-contact were invited to structured diagnostic interviews based on ICD-11 criteria for disorders due to addictive behaviors and additionally completed the SCL-90-R; 34 athletes participated in the interview phase (attrition rate: 46.0%). ResultsOf the 34 interviewed athletes, 24 (70.6 %, 95 % CI: 53.6-83.9 %) were classified as exercise addicted according to ICD-11, while 10 (29.4 %, 95 % CI: 16.1-46.4 %) were not classified as addicted. Compared to non-addicted athletes, those classified as addicted reported greater withdrawal-related symptoms, more comorbidities, lower life satisfaction, and higher weight-related exercise motivation, while training volume did not differ. In an exploratively LASSO model, withdrawal symptoms, past comorbidities, and interview-based anamnesis emerged as the strongest predictors of ICD-11 classification (AUC = 0.97). ConclusionsHigh EDS scores often reflect exercise dependence features that may be normative in endurance athletes, whereas only a subset meet ICD-11 criteria for clinically relevant addictive exercise behaviour. These findings highlight the importance of withdrawal-related symptoms and comorbidities for differential assessment and support a multi-method approach to distinguish high involvement or dependence from true pathological addiction.