Exercise addiction: a serious disorder biting comments.

Imagine that you’re in a gym. When you arrive, there’s a good-looking woman vigorously working… Imagine that you’re in a gym. When you arrive, there’s a good-looking woman vigorously working out. When you’re done with your own workout, she’s still there, plugging away.

You might admire her discipline or envy her figure.

But she might have a secret — the exercise is compulsive, part of an eating disorder that may, literally, be killing her.

Sometimes called “exercise bulimia,” compulsive exercise can happen in women with either bulimia or anorexia. But because bulimics usually have normal weight, the disorder isn’t as obvious as it would be in a stick-thin anorectic.

In fact, they may even be praised for it.

“When you’re sticking your head in the toilet, you don’t get much kudos from society,” said Dr. Jim Harris, a psychologist in the eating disorder program at Presbyterian Hospital of Dallas. “When you’re exercising, boy, everybody gives you kudos.”

One of the cornerstones of the syndrome is the excessive, punishing nature of the workouts.

“I’ve had patients who may get up at 3 in the morning, work out for three hours, go to work, and then come home and do another three-hour workout,” he said. “Even Olympic athletes don’t train like that.”

Eventually, the workouts can interfere with social life, leading the patient to keep a veil of secrecy.

Some people even belong to more than one health club, so that the staff can’t tell how much they’re working out.

“Paradoxically, they say they can spot each other at the gym,” Harris said. “There’s a dead look in the eyes. Exercise should be fun.”

Harris said he had one patient who restricted all fat and meat from her diet, used laxatives and worked out for four hours a day. Her heart had a leaky valve, and there was fluid around her heart.

“It was killing her, and she couldn’t stop the exercise,” he said. She was an intelligent woman, but the compulsion was too strong, he said.

Dr. Urszula Kelley, clinical director of Presbyterian Hospital’s eating disorders program, said victims can become very creative in hiding their exercise.

“We’ve had some people who set the alarm for 1:30 a.m., sneak out of the house when everyone is asleep, run for 15 miles, then sneak back in, shower, put their nightclothes on and go back to bed,” she said.

Others exercise in the bathroom with the shower running, so the noise of the water will hide what they’re doing.

About 4.5 percent of adolescent and young women have bulimia, Harris said. “It’s really epidemic proportions. They’ve overused everything, even their heart, beyond all reason.”

Bulimia usually involves a variety of symptoms — eating excessive amounts of food in a binge, then getting rid of the calories by vomiting, misuse of laxatives, excessive exercise or other methods.

Like an alcoholic, a bulimic can literally be addicted to the behaviors, Harris said.

“These are often bright young women,” he said. “They know what the cardiologist has told them, and they believe her, but they just can’t stop it. … You may hate yourself for it, but you just can’t stop.”

There’s some evidence that serotonin, a brain chemical that’s involved in addiction and depression, may play a role in bulimia, he said.

Treatment usually involves a combination of psychotherapy, family therapy, nutritional treatment and antidepressants.

“It’s a gradual process, but it’s possible,” Kelley said.

During therapy, patients generally learn how to identify their feelings and learn new behaviors to cope with them, said Dr. Stephanie Setliff, medical director of the intensive outpatient program for eating disorders at Children’s Medical Center of Dallas.

For instance, when a teen-age girl with bulimia has a fight with her mother, her impulse may be to go on a 5,000- to 10,000-calorie binge, followed by a purge.

Instead, through therapy, she can learn to identify that she’s feeling upset and angry, and learn new behaviors — finding someone to talk to, for instance.

“It’s real directed,” Setliff said of the therapy. “It’s not someone sitting around pondering the meaning of life or their childhood.”

There can also be family therapy, because very often there are stresses in the family that aren’t being talked about. There may be another child with an illness, or marital stress between the parents, for instance.

Dr. Nicole Caldwell, a pediatric psychologist at Children’s, said she saw one family that had such bad communication that “no one really talked about what was going on with each other. It was ‘Hi, how was your day?’ ‘Fine.’ Even when something bad happened, no one would talk about it, even though they all knew about it. It’s not going to go away just because you decide not to discuss it.”

The most important change in the family is to talk about feelings, Caldwell said, and not have the parents be the ones to keep track of how much the child is eating or exercising.

“We’re the professionals, so if the patient gets mad at us, that’s OK,” she said. “But we don’t want this antagonistic power struggle going on about the eating disorder.”