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A psychiatrist's perspective: running, how much is too much?

The request to write an article on the psychiatric aspects of running came at a time when I had injured my calf muscle and was unable to run for a few days. Therefore, I pen this as a rather frustrated casual runner who is out of his daily routine due to injury. This allowed me to have a slightly different perspective on the importance of this activity in my life. Having run almost every day for over 15 years, running has become part of my routine and the perfect start to my day. Wake up, do the ablutions and then pull on my runners and away I go. Its where I become fully alert, plan my day, work away my anxieties, soothe my concerns, ruminate about my future and that of my family, problem solve issues and fantasize of many a thing. My running has changed over the years just as I have. I now run on a treadmill as opposed to the streets or cross country due to an ankle injury which required surgery. Although stiff and arthritic, it still allows me to run on the softer treadmill. I am grateful for that. I also do weights and other exercises to have a ‘complete’ work out. However the lack of running is affecting my enjoyment and sense of wellbeing and I am itching to return as soon as I can do so safely.

As a casual runner, if the impact this activity has on me is so profound, I wonder about its relevance on an elite athlete or a person who is committed to much longer and strenuous running than me. I must admit that the article is not designed for an elite athlete and rather focused on the ‘casual athlete’ if I may use that term. Much has been written about the benefits of running and other exercises for the body and the mind. However there is a growing number of articles which allude to the cons of running and other endurance activities. Most of these focus on ‘overtraining syndrome’ or ‘under recovery syndrome’ as well as some limited arguments related to cardiac difficulties including accelerated plaque formation as well as general injuries of musculoskeletal nature and chronic pain. Is there a downside in psychological terms to running? If so what, when, how, who and so on!

Let us consider a slightly different argument. Millions of human beings run regularly for a variety of reasons. General fitness, training for a specific running event, training for a specific sport, competitive running, rehabilitation from certain injuries, weight loss, social running and so on. The psychological make up of these widely diverse runners cannot be the same. This could explain why there are such discrepant results and outcomes when they are studied as a cohort. This leads to the question, what are the psychological traits of runners who engage in strenuous running or endurance type long distance running?

The first thought that comes to my mind, having seen and treated multiple middle and long distance athletes is obsessionality. These athletes engage in a tough sport and achieve incredible results. However the commonality appears to be a significant amount of internal ‘driven-ness’, very narrow focus, incredible self motivation and sacrifice and oodles of obsessional thinking. Their basic functions such as sleep, diet, general activity, employment, family and other social commitments, self esteem, confidence, self value, physical health and so on seem to be positioned carefully around ‘the run’. Many of them manage this exceedingly well but a few fall short. Usually this is when an injury prevents them from engaging in this activity or other life events intervene into this activity. The same is also applicable to the ‘casual runner’ who is engaged at a very high level in this activity but does not have the support team around them to monitor and manage them unlike the elite athlete.

When this occurs there is a psychological reaction to this which is akin to grief and results in strong emotional change and on occasion changes to mood and/or anxiety. In fact the most common domains of emotional disturbance I have seen is dysphoria (a state of unease or generalised dissatisfaction with life) and irritability/ anger. This is also frequently accompanied by maladaptive coping strategies like substance abuse which result in dysfunction which is usually most characterised in interpersonal relationships at work or home which leads to further stressors and over time a vicious cycle is established. If their injury, or the initial stressor that led to the cessation in activity resolves, then more often than not they return to normal functioning. However a percentage, and we do not have statistics for this, remain caught in this vicious cycle leading to significant dysfunction, distress and disorder.

Are runners more prone to this than other athletes? Well, there are no clear studies comparing this therefore the science is rather lacking. However, I am of the opinion that it doesn’t matter so much. If we take runners as their own control, there is a substantial change in their mental wellbeing as a result of the stressor affecting the activity. Well, too much of it or the absence of the same. It has to be accepted that running is a fundamentally good activity which when done as part of a balanced routine is highly protective and promotes good mental and physical health.

The above narrative was a lead in to my main point which is the psychological or psychiatric effect, if any, that running has on runners. Running offers many psychological benefits with an increase in positivity, self confidence, general bonhomie, physical health, better mood, cognitive improvements, better sleep and some effect in reducing anxiety. Running

excessively may reverse all of the above and could reduce mental health and likely brings about physical damage due to injury and recovery difficulties in some athletes. It is important to remember that many ultra marathon runners and other groups who run long distances socially appear to manage this without any ensuing difficulties. The book Born to Run by Christopher McDougall is a great example of this. We are yet to understand why some can and some run into difficulties. Pun unintended.

As a psychiatrist, I have seen firsthand the impact of mental illness on athletes. Athletes are not immune from becoming affected by mental illness. The current evidence points to a possible increased incidence of mental disorders like depression and anxiety amongst athletes when compared to general population. It is suspected that, this is due to a unique combination of intrinsic personality aspects such as obsessionality, the pressure and stress of performance in a highly scrutinised environment, the unpredictable nature of competitive sports and possibly other similar specific stressors which remain unclear.

There is also the difficulty in identifying clinical depression in athletes. It presents differently according to many studies with less emphasis on emotional symptoms such as feeling sad or guilty and rather more focussed on cognitive symptoms such as poor attention and concentration and loss of interest in training and engagement in their sport. Some start hating their chosen sport and become avoidant or develop injuries which then allow them to not engage in training or game time. It remains a rather complex area with ongoing scientific research being done to understand this better.

Overall, we still remain in the dark over how to answer the question above. How much is too much? I suspect that this is a highly variable threshold which differs from runner to runner and the best we can do is to encourage a harmonious balance between this activity and other life activities. Curbing obsessionality, allowing adequate time for rest and recovery, good dietary intake, monitoring for symptoms of clinical depression or anxiety and avoiding poor coping strategies like substance abuse will all lead to positive health and longer enjoyment of this much loved activity. Now, if only my calf would settle down so I can get back into it! Happy running.

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