27 May 2013

Running use disorder - is ultramarathon running an addiction?

The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) was published earlier in May at the American Psychiatric Association (APA) meeting in San Francisco. The criteria in DSM is widely used for diagnosis of mental disorders in both the US and other countries and recognized both by health authorities, insurance companies and industry. Obviously, there is a large debate about the criteria, in particular as there tends to be a lot of varying opinions regarding these disorders. This debate tends of course to be louder just when the criteria are updated.

One of the new diagnoses in DSM-5 is “substance use disorder”, replacing former “substance dependence” in the previous DSM-IVTR classification. I entertained myself this morning with trying to diagnose myself whether I had a “running use disorder” according to the new criteria. DSM-5 specifies the severity of the diagnosis “use disorder” depending on how many of 11 symptoms that are fulfilled; 2-3 symptoms mean a mild disorder, 4-5 a moderate and over 6 a severe disorder. I fulfilled 9/11 criteria for having a “running use disorder”. I cannot reveal the criteria here due to copyright issues, but I can definitively say that I have cravings for running, experience withdrawal when not running and have developed a tolerance for running. I also spend a great deal of time running, I sometimes run in physically hazardous situations and I continue to run despite having physical pain and I am always on the borderline to develop use injuries due to my running.

It was running despite the risk to develop injuries that made me think about the analogue between running and substance abuse. Last season I suffered periodically of Achilles tendinopathy of in particular my right ankle. The symptoms did not prevent me from racing as planned and to gather my points for the UTMB, but they made it necessary to adjust my training periodically and avoid very long training runs. Yesterday I was out for a 14 mile (23 km) run with the last 7 miles on a relatively flat and hard surface and last night I felt pain in my Achilles tendon again. It went fine running to work this morning, but I will now have to be more vigilant on my symptoms and not to run to fast in particular during these longer runs.

There was recently a study published by Nielsen and colleagues discussing the classification of running-related injuries based on volume or pace errors (Nielsen et al. Int J Sports Phys Ther 2013; 8:172-9).

From Nielsen et al. 2013 based on Taunton et al. Br J Sports Med 2002; 36:95-101.
 The authors review the evidence that a change in running pace may be associated with the development of achilles tendinopathy. From my personal experience I think it is much truth in this, however, there are certainly other risk factors involved for myself despite a too high pace; for instance sex (male), age (early 40’s), shoes (yesterday I used light trail shoes without much stability) etc. A recent review about the risk factors can be found in Munteanu & Barton J Foot Ankle Res 2011; 4: 15. Both the incidence and prevalence of Achilles tendinopathy among ultramarathon runners appears to be around 10% in several studies so I am certainly not the only one struggling with this. And I am certainly not the only one being classified with a “running use disorder”.

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