ORIGINAL RESEARCH published: 18 June 2021 doi: 10.3389/fpsyg.2021.681808 Exercise Addiction and Muscle Dysmorphia: The Role of Emotional Dependence and Attachment Leticia Olave 1 , Ana Estévez 2 , Janire Momeñe 2 , Roger Muñoz-Navarro 3 , María José Gómez-Romero 4,5 , María Jesús Boticario 1 and Itziar Iruarrizaga 1,6* 1 Department of Experimental Psychology, Cognitive Processes and Speech Therapy, Complutense University of Madrid, Madrid, Spain, 2 Department of Personality, Evaluation and Psychological Treatment. University of Deusto, Bilbao, Spain, 3 Department of Psychology and Sociology, University of Zaragoza, Zaragoza, Spain, 4 Stress and Health Research Group, School of Psychology, Autonomous University of Barcelona, Barcelona, Spain, 5 Egarsat, Terrassa, Spain, 6 Cognition, Emotion and Health, Research Group, Madrid, Spain Background: Both exercise addiction (EA) and muscle dysmorphia (MD) primarily involve the compulsive practice of physical exercise and are classified as behavioral addictions in different lines of research. These types of addictions are frequently comorbid with other addictive pathologies, such as emotional dependence (ED), which is closely related to childhoodattachment.ThisstudyispresentedtoaddressthescarcityofresearchrelatingEA and MD with other behavioral addictions. The aims are to analyze the sex differences found Edited by: in emotional dependence, attachment dimensions, EA and MD; to analyze the association Ryan Thomas Philips, National Institute of Mental Health, between EA and MD and other behavioral addictions, such as emotional dependence and National Institutes of Health (NIH), attachment dimensions; and to analyze the possible role that childhood attachment plays United States in mediating the interaction between emotional dependence and EA and MD. Reviewed by: Ornella Corazza, Method: The sample comprised 366 participants (54.6% women) aged 17–31 University of Hertfordshire, (M = 23.53; SD = 6.48). United Kingdom Results: There are sex differences, with men scoring higher in EA, MD, and ED. Francesco Fischetti, University of Bari Aldo Moro, Italy The positive relationship between EA and ED (values between 0.16 and 0.28), MD *Correspondence: (presentingvaluesbetween0.42and0.70),andattachmentstylesbasedonpreoccupation, Itziar Iruarrizaga interference,permissiveness,andvalueofparentalauthority(valuesbetween0.11and0.14) iciariru@psi.ucm.es is highlighted. On the other hand, MD was positively related to ED (values ranging from 0.24 Specialty section: to 0.36) and attachment styles based on the value of parental authority, self-sufficiency, This article was submitted to and resentment toward parents (between 0.17 and 0.18), and negatively related to secure Psychopathology, a section of the journal attachment (values between −0.13 and −0.18). Likewise, the predictive role of ED and Frontiers in Psychology attachment styles in EA and MD was tested. And it was observed how attachment styles Received: 17 March 2021 mediated the relationship between EA and ED, as well as the relationship between MD and Accepted: 24 May 2021 ED. Thus, it has been shown that people with EA and MD present attachment styles that may Published: 18 June 2021 influence negatively the decision-making process when choosing inappropriate strategies Citation: Olave L, Estévez A, Momeñe J, to achieve adequate emotional regulation, even selecting inappropriate goals for physical Muñoz-Navarro R, exercise with negative consequences. Gómez-Romero MJ, Boticario MJ and Iruarrizaga I (2021) Exercise Addiction Conclusions: The dissemination of the findings among mental health and sports science and Muscle Dysmorphia: The Role of professionals is necessary to develop prevention and intervention strategies for people Emotional Dependence and Attachment. affected by EA and MD. Front. Psychol. 12:681808. Keywords: emotional dependence, behavioral addictions, excessive exercising, attachment dimensions, muscle doi: 10.3389/fpsyg.2021.681808 dysmorphia Frontiers in Psychology | www.frontiersin.org 1 June 2021 | Volume 12 | Article 681808 Olave et al. Exercise Addiction, Emotional Dependence and Attachment INTRODUCTION Some studies show that there is an association between EA and MD. For example, Cafri et al. (2008) found that people with Exercise addiction (EA) is a type of behavioral addiction MD showed higher muscle dissatisfaction, appearance checking, and is characterized by a loss of behavioral control resulting and more bodybuilding dependence. Meanwhile, Babusa et al. in compulsive exercising (Hausenblas and Downs, 2002a; (2015) confirmed that people with MD showed the highest levels Scharmer et al., 2020). Initially, this conduct is driven by of EA, exercising longer and more frequently in comparison with positive reinforcement, and, later, it persists due to negative people without MD or with moderate risk factors. Olave et al. reinforcement (Echeburúa et al., 2009). According to Griffiths (2019) found that when MD increased, there was greater risk of (1997) and Terry et al. (2004), EA is related to the concepts EA, which favored muscle dissatisfaction and the exacerbation of abstinence, tolerance, relevance (importance that is conferred of MD. to the behavior), euphoria, conflicts (with the self or others), Emotional dependence is also considered to be a behavioral time spent on the behavior, and relapse. Hausenblas and addiction and is defined as the intense need for affection from Downs (2002a) conceptualize EA as a multidimensional one’s partner (Castelló, 2005), even though it is not included maladaptive pattern that generates a clinically significant within the various international classifications of mental and emotional disturbance. Meanwhile, the DSM IV (American personality disorders. Some of the main characteristics are the Psychiatric Association, 1994) identified EA based on the criteria idealization of one’s partner, fear of loneliness and breakup, of tolerance, withdrawal, intention effects, lack of control, time, obsession with one’s partner, low self-esteem, and submission reduction in other activities, and continuance. Currently, exercise (Castelló, 2005). Some studies refer to love addiction when addiction does not appear in international classifications of talking about emotional dependence, and they compare it with mental disorders, although the DSM 5 (American Psychiatric classical substance addictions, because it involves craving to have Association, 2013) considers some addiction disorders unrelated a partner, deep worry when he or she is not with his or her to substances, and it includes gambling addiction; in the chapter partner, and intense suffering in the case of a breakup (Timmreck, of disorders that require further study, it includes addiction 1990; Schaeffer, 1998). to online gambling. For this reason, in the present study, Emotionally dependent individuals share certain we alternate the concepts of exercise addiction and excessive characteristics with addictive pathologies, and they show exercising as synonyms. difficulties with impulse control (Castelló, 2005; Villegas and Muscle dysmorphia (MD) was initially described as “reverse Sánchez, 2013). Impulsivity, although it is not the main focus in anorexia” (Pope et al., 1997), given that the main symptoms are this study, is a very important element that underlies addictive the belief of being too thin and not being muscular enough. The disorders and acts as a precursor of behavioral addictions (De three criteria around which MD was supposed to be structured Sola-Gutiérrez et al., 2013). Emotional dependence is also suggested that the individuals were (a) worried about the idea correlated with other behavioral addictions, such as sex addiction that their body did not have sufficient muscle, (b) generating or compulsive sexual behavior (Sánchez Zaldívar and Iruarrizaga significant clinical malaise, (c) and that their primary concern Díez, 2009; Iruarrizaga et al., 2019), Internet addiction, or cell as well as their behavior could revolve around the idea of not phone addiction (Estévez et al., 2017). being muscular enough. Unlike EA, MD is listed in the DSM 5 The acquisition of dysfunctional childhood attachment is (American Psychiatric Association, 2013) as a specifier of body especially relevant in the etiology of emotional dependence. The dysmorphic disorder (BDD), within the group of obsessive- development of childhood attachment (Ainsworth et al., 1978), compulsive disorder and related disorders. According to the where the socioemotional needs of children are not satisfied, is American Psychiatric Association (2013), MD is defined as an related to emotional dependence in adulthood, where affective individual’s belief that his or her muscles are not big enough, deficiency lingers (Castelló, 2005), and romantic relationships and it can be delirious, depending on the level of seriousness are pursued as a means to meet emotional needs (Lemos and and the lack of introspection. Some authors consider MD as Londoño, 2006; Skvortsova and Shumskiy, 2014). a type of EA (Pace et al., 2020) within the framework of Estévez et al. (2018) point out that the relation between behavioral addictions, and they suggest that it should be included childhood attachment and impulsive behavior is mediated by in the addiction model, in which an individual continues to attachment styles, and that certain attachment styles can be follow a compulsive pattern of physical exercise and strict eating predictors of emotional dependence and can favor the continuity habits even though they have clear negative consequences, both of abusive romantic relationships (Momeñe and Estévez, 2018). psychological and physical, with the objective to maintain an The style of parental socialization is also significantly related ideal body (Foster et al., 2014; Griffiths et al., 2015). Specifically, to teenagers’ addictions. In a sample of young Spanish people, the internalization of the ideal body image appears to be one of Martínez et al. (2013) found that lenient parenting acted as a the strongest predictors of muscle dysmorphia (Schneider et al., protection factor against substance consumption in contrast to 2016). Nevertheless, other authors believe that more research the authoritative style. Nevertheless, these results do not agree is needed before including MD within a model of body image with research done in the United States, where authoritative addiction (Grant, 2015; Nieuwoudt, 2015). In this context, it parenting is presented as a protective factor and lenient parenting is important to highlight the relationship between MD and as a risk factor (Darling and Cumsille, 2003). Besides all this, BDD, where it has been found important correlations between attachment style is related to decision-making in such a way appearance anxiety, BDD, and EA (Corazza et al., 2019). that insecure or anxious style is related to worse capacity in Frontiers in Psychology | www.frontiersin.org 2 June 2021 | Volume 12 | Article 681808 Olave et al. Exercise Addiction, Emotional Dependence and Attachment the executive process (Deniz, 2011), even emotional intelligence TABLE 1 | Sociodemographic data of the participants. has been shown to mediate the relationship between secure Variable % attachment and decision-making (Phang et al., 2020). This provides information about the fact that people with maladaptive Physical exercise in gym 54% attachment styles may have reduced decision-making capacity, Spanish nationality 96% including those related to emotional regulation and opting University student 100% for the compulsive practice of physical exercise as a strategy Single 91.3% (Chamberlain and Grant, 2020). Heterosexual 72.4% Sex differences have been found, indicating that more men are affected by EA and MD (González-Cutre and Sicilia, 2012; Barrientos-Martínez et al., 2014). Although these problems are more prevalent among males, they are also found in women emotional, and behavioral aspects of muscle dysmorphia. It is (Hale et al., 2013; Zeeck et al., 2018). In regard to emotional formed by 19 items and 5 scales: (a) bodybuilding dependence, dependence, there are no clear differences between sex. Some (b) muscle checking, (c) substance use, (d) injury, and (e) muscle studies do not find significant differences (Pradas and Perles, satisfaction. Responses are collected on a five-point Likert scale 2012; Momeñe et al., 2017; Urbiola et al., 2019), while others (1 = I completely disagree; 5 = I totally agree). In this study, suggest that, in some emotional dependence subscales (Urbiola the adaptation conducted by González-Martí et al. (2012) was et al., 2017; Estévez et al., 2018), or even in total emotional used, showing good psychometric properties with values for dependence (Rodríguez-Pérez et al., 2019), males score higher. Cronbach’s alpha between 0.86 and 0.95. In light of the lack of research relating EA and MD with Emotional dependence survey (Lemos and Londoño, 2006). other behavioral addictions, such as emotional dependence This tool has been designed to evaluate emotional dependence and its association with childhood attachment, the following in the Spanish-speaking population. It consists of 23 items objectives are set: (1) to analyze the sex differences found and 6 factors: (a) separation anxiety, (b) partner’s affective in emotional dependence, attachment dimensions, EA, and expression, (c) changing of plans, (d) fear of loneliness, (e) MD, (2) to analyze the association between EA and MD and borderline expression, and (f) attention-seeking. Responses are other behavioral addictions, such as emotional dependence and reported on a six-point Likert scale (1 = completely false attachment dimensions, and (3) to analyze the possible role that about me; 6 = this describes me perfectly). It contains adequate childhood attachment plays in mediating the interaction between psychometric properties, showing a Cronbach’s alpha of 0.92 in emotional dependence and EA and MD. the present study. CaMir-R (Pierrehumbert et al., 1996). This is a self- MATERIALS AND METHODS reported measure that evaluates representations of attachment and conceptions of family functioning. It has 32 items and This is a cross-sectional, correlational, non-experimental study. 7 dimensions: (a) security, (b) preoccupation with family, (c) The incidental sample was obtained from students of the parental interference, (d) regard for authority, (e) parental Complutense University of Madrid and snowball sampling was permissiveness, (f) self-sufficiency and resentment toward used to recruit the participants. Information was gathered parents, and (g) childhood trauma. Responses are reported on a through pencil and paper surveys in the university classrooms. five-point Likert scale (1 = strongly agree; 5 = strongly disagree). All the participants gave informed consent at the beginning of We have used the Spanish adaptation developed by Balluerka the study. The study has been carried out following the criteria of et al. (2011), which shows, in the present study, a Cronbach’s the Declaration of Helsinki (World Medical Association, 2013). alpha, which ranges between 0.60 and 0.85. Participants Procedure The sample consisted of 366 participants (54.6% of women) Students filled out the questionnaires in the classroom during between 17 and 31 years old (M = 23.53; SD = 6.48). Following teaching hours. They were informed that participation was are the most relevant sociodemographic data (see Table 1). voluntary, and that if they did not want to participate, they could give back a blank questionnaire without any penalty. Likewise, Measures they were told that their data were confidential and anonymous Exercise addiction inventory (Terry et al., 2004). The Spanish and that they would only be used for statistical purposes. The adaptation conducted by Sicilia et al. (2013). It is a six-item students did not receive any kind of compensation. They were self-reported survey with a five-point Likert-type scale response given between 15 and 20 min to fill out the questionnaires. format (1 = I completely disagree; 5 = I totally agree). It establishes cutoff points to create classifications with respect to Data Analysis the risk of presenting exercise addiction or excessive exercise. The analysis of the data was carried out with the IBM SPSS In the present study, the level of internal consistency, measured statistics software V25.0. Descriptive and correlational analyses through Cronbach’s alpha, was 0.70. were carried out between emotional dependence, attachment Muscle appearance satisfaction scale (Mayville et al., 2002). dimensions, exercise addiction, and muscle dysmorphia, It is a self-reported instrument that informs about the cognitive, although Pearson’s r. Secondly, a stepwise multiple regression Frontiers in Psychology | www.frontiersin.org 3 June 2021 | Volume 12 | Article 681808 Olave et al. Exercise Addiction, Emotional Dependence and Attachment was carried out in order to analyze the predictive role of for authority,” “self-sufficiency and resentment toward parents,” emotional dependence and attachment dimensions in exercise and “childhood trauma,” with values ranging between 0.11 addiction and muscle dysmorphia. Next, a mediation analysis and 0.35. was carried out through regression analysis to check the role of attachment dimensions in mediating the relation between The Predictive Role of Emotional exercise addiction and emotional dependence. In addition, a Dependence and the Attachment second mediation analysis was carried out to study the role of Dimensions Over EA and MD attachment dimensions in mediating muscle dysmorphia and In the third place, we analyzed the predictive role of emotional emotional dependence. Finally, the difference of means relative dependence and the attachment dimensions over EA and MD to sex was analyzed in emotional dependence, attachment (see Table 4). dimensions, exercise addiction, and muscle dysmorphia through Attention-seeking and the attachment dimensions the Student’s t-test. This way, the size of the difference of means “preoccupation with family” and “parental permissiveness” was obtained through Cohen’s d (1992), who pointed out that predicted EA, explaining 36% of its variance. Likewise, values under 0.20 would be considered small, around 0.50 would borderline expression and regard for authority predicted MD, be considered medium, and, over 0.80, large. explaining 46% of its variance. Furthermore, affective expression toward the partner and the attachment dimensions “parental RESULTS permissiveness,” and “self-sufficiency and resentment toward parents” predicted the 31% of variance in muscle satisfaction. Sex Differences In addition, borderline expression, attention-seeking and the In the first place, we analyzed the differences between emotional attachment dimensions “security,” “preoccupation with family,” dependence, attachment dimensions, EA, and MD based on sex and “parental permissiveness” predicted exercise dependence. (see Table 2). Borderline expression, attention-seeking, and the attachment Significant differences were observed between men and dimensions “security,” “parental interference,” and “value to women, with males reporting higher scores in the subscales parental authority” predicted muscle checking, explaining 42% of emotional dependence, changing of plans, and borderline of its variance. Moreover, borderline expression, attention- expression as well as in EA and MD, together with their five seeking, and the attachment dimensions “security” and “parental subscales. The effect sizes were small for borderline expression, interference” predicted 38% of the variance in substance use. EA, and muscle satisfaction, and moderate for the rest. Finally, the obtained results reflected that borderline expression, attention-seeking, and the attachment dimensions “security” Correlation Analyses Between Emotional and “parental permissiveness,” together, predicted 40% of the variance in injuries. Dependence, Attachment Dimensions, Exercise Addiction, and MD The Role of Attachment Dimensions in Secondly, we analyzed Pearson’s correlation between emotional Mediating the Association Between EA and dependence, attachment dimensions, exercise addiction, and MD (see Table 3). It was observed that EA showed a statistically Emotional Dependence significant positive correlation with emotional dependence and In the fourth place, we analyzed the role of attachment its six subscales (separation anxiety, partner’s affective expression, dimensions in mediating the association between EA and changing of plans, fear of loneliness, borderline expression, and emotional dependence (see Table 5). attention-seeking) with values between 0.16 and 0.28; and with We found that 20.45% of the association between EA MD and its subscales (substance use, muscle checking, injuries, and emotional dependence was explained by the attachment and exercise dependence), presenting values between 0.42 and dimensions. Likewise, 21.21% of the association between EA and 0.70. Finally, with the attachment dimensions of preoccupation separation anxiety was explained by the attachment dimensions. with family, parental interference, regard for authority and About 33.33% of the association between EA and borderline permissiveness, the correlation showed low values between expression was explained by the attachment dimensions. Ten 0.11 and 0.14. This showed that greater exercise addiction percent of the association between EA and changing of plans was indicative of higher levels of emotional dependence, MD, was explained by the attachment dimensions. About 22.22% concern, interference and parental permissiveness, regard for of the association between EA and fear of loneliness was authority, and self-sufficiency and resentment toward parents. explained by the attachment dimensions. Finally, 9.09% of the Muscle dysmorphia is significantly and positively correlated association between EA and attention-seeking was explained by with emotional dependence and its six subscales, with values the attachment dimensions. ranging from 0.24 to 0.36; and with the attachment dimensions “regard for authority,” and “self-sufficiency and resentment The Role of the Attachment Dimensions in toward parents.” It is negatively correlated with secure Mediating the Association Between MD attachment, with values between −0.13 and −0.18. Emotional and Emotional Dependence dependence showed statistically significant positive associations Last, we analyzed the role of the attachment dimensions with the attachment dimensions “parental interference,” “regard in mediating the association between MD and emotional Frontiers in Psychology | www.frontiersin.org 4 June 2021 | Volume 12 | Article 681808 Olave et al. Exercise Addiction, Emotional Dependence and Attachment TABLE 2 | Differences according to sex in emotional dependence, attachment, exercise addiction, and muscular dysmorphia. Variables Women (n = 200) Men (n = 166) t Effect size (d) M DT M DT Emotional dependence Changing of plans 6.58 3.08 8.23 3.69 4.61** 0.25 Borderline expression 3.90 1.67 4.25 1.90 1.86* 0.10 Exercise addiction Exercise addiction 12.55 5.03 14.59 5.99 3.48* 0.19 Muscle dysmorphia Muscle dysmorphia 31.63 7.65 37.07 13.43 4.63** 0.28 Substance use 4.66 1.47 5.73 2.94 4.31** 0.27 Exercise dependence 7.22 2.54 9.09 4.24 5.00** 0.30 Muscle satisfaction 8.30 2.92 8.98 2.58 2.39* 0.12 Muscle checking 5.87 2.35 7.43 4.10 4.36** 0.26 Injury 4.19 1.96 5.80 3.11 5.78** 0.33 *p < 0.05; **p < 0.001. dependence (see Table 6). This was carried out through a linear 14.28% of the association between injuries and attention-seeking regression analysis. were explained by the attachment dimensions. About 21.67% of the association between MD and emotional dependence, 27.27% of the association between MD and DISCUSSION separation anxiety, 25% of the association between MD and affective expression toward the partner, 25% of the association Significant differences occur based on sex. Males score higher in between MD and changing of plans, 28% of the association the subscales of emotional dependence, changing of plans, and between MD and fear of loneliness, and 14.28% of the association borderline expression. These results match with previous results, between MD and attention-seeking was explained by the where men showed higher emotional dependence than women attachment dimensions. Furthermore, 36.67% of the association (Urbiola and Estévez, 2015; Urbiola et al., 2017). This means between muscle satisfaction and affective expression toward the that men are more likely to quit other activities and stop seeing partner was explained by the attachment dimensions. Likewise, people to be with their partners and spend as much time as the results showed that 22.05% of the association between muscle possible with them and that they will exhibit borderline behaviors checking and emotional dependence, 24.98% of the association when expressing their emotions toward their partners. Significant between muscle checking and separation anxiety, 25.64% of the differences are also found in favor of men in EA and MD, together association between muscle checking and affective expression with their five subscales. These results also coincide with the toward the partner, 20% of the association between muscle data shown in other studies (Hausenblas and Downs, 2002b; checking and changing of plans, 21.73% of the association González-Cutre and Sicilia, 2012; Compte and Sepúlveda, 2014). between muscle checking and fear of loneliness, 12.50% of the This study manifests the statistically significant association association between muscle checking and borderline expression, between EA or excessive exercising and MD. The results coincide and 22.72% of the association between muscle checking and with those encountered in other studies where both constructs attention-seeking were explained by the attachment dimensions. appear related. Hale et al. (2013) found that people that practice In addition, 19.75% of the association between substance use bodybuilding show MD and EA more often than those who are and emotional dependence, 21.05% of the association between lifting weights recreationally. In a sample of athletes, Latorre substance use and separation anxiety, 21.73% of the association Román et al. (2016) found that EA was significantly associated between substance use and changing of plans, 4.73% of the with body dissatisfaction, a relevant aspect of MD. Even though association between substance use and borderline expression, causal relationships cannot be established, it seems coherent to and 17.39% of the association between substance use and think that a person with MD develops comorbidity with EA, attention-seeking were explained by the attachment dimensions. given that they build their muscles through physical exercise. Finally, 19.61% of the association between injuries and emotional What is not as clear is that a person with EA will necessarily dependence, 20.83% of the association between injuries and develop MD. However, as pointed out in Olave et al. (2019), separation anxiety, 27.02% of the association between injuries a higher risk of EA is associated with an increase in muscle and affective expression toward the partner, 17.24% of the dissatisfaction, and, as a consequence, an increase in MD. association between injuries and changing of plans, 19.04% of Corazza et al. (2019) also found an important relation between the association between injuries and fear of loneliness, 11.76% of MD and EA, and also BDD and appearance anxiety in people who the association between injuries and borderline expression, and exercise in the gym. Frontiers in Psychology | www.frontiersin.org 5 June 2021 | Volume 12 | Article 681808 Frontiers in Psychology | www.frontiersin.org Olave et al. TABLE 3 | Correlations between emotional dependence, exercise addiction, muscle dysmorphia, and attachment. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 Emotional dependence – Separation anxiety 0.92** – Partner’s affective 0.88** 0.73** – expression Changing of plans 0.77** 0.67** 0.58** – Fear of loneliness 0.68** 0.52** 0.58** 0.36** – Borderline expression 0.66** 0.55** 0.52** 0.48** 0.44** – Attention seeking 0.77** 0.65** 0.69** 0.57** 0.46** 0.42** – Exercise addiction 0.26** 0.24** 0.22** 0.18** 0.16** 0.20** 0.28** – Muscle dysmorphia 0.35** 0.32** 0.28** 0.24** 0.24** 0.34** 0.34** 0.63** – Muscle satisfaction −0.15** −0.14** −0.18** −0.04 −0.14** −0.13* −0.08 −0.04 −0.29** – Substance use 0.20** 0.18** 0.13* 0.15** 0.10 0.28** 0.23** 0.42** 0.81** −0.03 – Muscle checking 0.35** 0.31** 0.29** 0.24** 0.25** 0.30** 0.32** 0.51** 0.87** −0.06 0.66** – Injury 0.29** 0.26** 0.22** 0.22** 0.19** 0.26** 0.33** 0.62** 0.83** −0.00 0.65** 0.69** – 6 Exercise dependence 0.30** 0.26** 0.22** 0.22** 0.21** 0.30** 0.29** 0.70** 0.89** −0.03 0.72** 0.75** 0.75** – Security −0.05 −0.07 −0.01 0.01 −0.08 −0.11* 0.01 −0.03 −0.13* 0.04 −0.09 −0.09 −0.09 −0.14** – Preoccupation with 0.02 0.04 0.07 −0.02 0.00 −0.11* −0.01 0.13* 0.05 −0.07 −0.03 0.05 0.03 0.06 0.17** – family Parental Interference 0.28** 0.27** 0.30** 0.14** 0.25** 0.16** 0.15** 0.11* 0.04 −0.15** −0.07 0.04 0.01 0.02 0.05 0.24** – Regard of authority 0.23** 0.25** 0.26** 0.13* 0.11* 0.09 0.17** 0.13* 0.17** −0.13* 0.10 0.18** 0.11* 0.12* 0.20** 0.28** 0.34** – Parental 0.09 0.04 0.11* 0.08 0.09 0.04 0.14* 0.14** 0.07 0.13* 0.09 0.07 0.14** 0.10 0.22** −0.02 0.03 0.02 – Exercise Addiction, Emotional Dependence and Attachment permissiveness Self-sufficiency and 0.39** 0.36** 0.38** 0.29** 0.24** 0.27** 0.29** 0.09 0.18** −0.21** 0.09 0.17** 0.11* 0.09 0.06 0.17** 0.45** 0.42** −0.03 – resentment toward parents Childhood trauma 0.21** 0.20** 0.22** 0.09 0.18** 0.03 0.20** 0.07 0.08 −0.02 0.03 0.13* 0.05 0.06 0.26** 0.25** 0.22** 0.32** 0.15** 0.31** – June 2021 | Volume 12 | Article 681808 *p < 0.05; **p < 0.001. Olave et al. Exercise Addiction, Emotional Dependence and Attachment TABLE 4 | The predictive role of emotional dependence and attachment dimensions in exercise addiction and muscle dysmorphia. Predictor variable B β T Sig. Criterion variable EMOTIONAL DEPENDENCE EXERCISE ADDICTION Attention seeking 0.56 0.23 3.06 0.00** Exercise addiction ATTACHMENT Preoccupation with family 0.30 0.15 2.72 0.01* Exercise addiction Parental permissiveness 0.37 0.13 2.52 0.01* Exercise addiction (R = 0.36; R² = 0.13; R²Corrected = 0.10) EMOTIONAL DEPENDENCE MUSCLE DYSMORPHIA Borderline expression 1.42 0.23 3.81 0.00** Muscle dysmorphia Attention seeking 1.06 0.22 3.12 0.00** Muscle dysmorphia ATTACHMENT Security −0.55 −0.15 −2.91 0.00** Muscle dysmorphia Parental interference −0.44 −0.12 −2.09 0.04* Muscle dysmorphia Regard for authority 0.66 0.13 2.29 0.02* Muscle dysmorphia (R = 0.46; R² = 0.21; R²Corrected = 0.18) EMOTIONAL DEPENDENCE Muscle satisfaction Partner’s affective expression −0.11 −0.18 −2.02 0.04* Muscle satisfaction ATTACHMENT Parental permissiveness 0.17 0.12 2.34 0.02* Muscle satisfaction Self-sufficiency and resentment toward −0.12 −0.14 −2.16 0.03* Muscle satisfaction parents (R = 0.31; R² = 0.10; R²Corrected = 0.06) EMOTIONAL DEPENDENCE Muscle dependence Borderline expression 0.44 0.22 3.60 0.00** Muscle dependence Attention seeking 0.34 0.22 3.04 0.00** Muscle dependence ATTACHMENT Security −0.21 −0.18 −3.34 0.00** Muscle dependence Preoccupation with family 0.16 0.12 2.33 0.02* Muscle dependence Parental permissiveness 0.18 0.10 2.02 0.04* Muscle dependence (R = 0.42; R² = 0.18; R²Corrected = 0.15) EMOTIONAL DEPENDENCE Muscle checking Borderline expression 0.32 0.17 2.74 0.01* Muscle checking Attention seeking 0.23 0.15 2.14 0.03* Muscle checking ATTACHMENT Security −0.14 −0.12 −2.32 0.02* Muscle checking Parental interference −0.14 −0.12 −2.14 0.03* Muscle checking Regard for authority 0.20 0.13 2.18 0.03* Muscle checking (R = 0.42; R² = 0.18; R²Corrected = 0.15) EMOTIONAL DEPENDENCE Substance use Borderline expression 0.35 0.28 4.37 0.00** Substance use Attention seeking 0.21 0.21 2.86 0.00** Substance use ATTACHMENT Security −0.08 −0.11 −2.07 0.04* Substance use Parental interference −0.13 −0.17 −2.93 0.00** Substance use (R = 0.38; R² = 0.15; R²Corrected = 0.12) EMOTIONAL DEPENDENCE Injury Borderline expression 0.23 0.15 2.47 0.01* Injury Attention seeking 0.33 0.28 3.87 0.00** Injury ATTACHMENT Security −0.11 −0.13 −2.37 0.02* Injury Parental permissiveness 0.18 0.13 2.62 0.01* Injury (R = 0.40; R² = 0.16; R²Corrected = 0.13) *p < 0.05; **p < 0.001. Frontiers in Psychology | www.frontiersin.org 7 June 2021 | Volume 12 | Article 681808 Olave et al. Exercise Addiction, Emotional Dependence and Attachment TABLE 5 | Mediation of attachment dimensions in the relationship between exercise addiction and emotional dependence. Independent variable Dependent variable Total effect Direct effect Bootstrap 95% CI Exercise addiction Emotional dependence 0.88** 0.70** 0.36 1.05 Exercise addiction Separation anxiety 0.33** 0.26** 0.12 0.39 Exercise addiction Partner’s affective expression 0.18** 0.12** 0.04 0.21 Exercise addiction Changing of plans 0.10** 0.09** 0.02 0.16 Exercise addiction Fear of loneliness 0.09** 0.07* 0.01 0.12 Exercise addiction Attention seeking 0.11** 0.10** 0.06 0.14 *p < 0.05; **p < 0.001. TABLE 6 | Mediation of attachment styles in the relationship between muscle dysmorphia and emotional dependence. Independent variable Dependent variable Total effect Direct effect Bootstrap 95% CI Muscle dysmorphia Emotional dependence 0.60** 0.47** 0.30 0.64 Muscle dysmorphia Separation anxiety 0.22** 0.16** 0.09 0.24 Muscle dysmorphia Partner’s affective expression 0.12** 0.09** 0.05 0.13 Muscle dysmorphia Changing of plans 0.08** 0.06** 0.03 0.09 Muscle dysmorphia Fear of loneliness 0.07** 0.05** 0.03 0.08 Muscle dysmorphia Attention seeking 0.07** 0.06** 0.03 0.08 Muscle satisfaction Emotional dependence −1.03** −0.53 −1.17 0.14 Muscle satisfaction Separation anxiety −0.38* −0.16 −0.44 0.10 Muscle satisfaction Partner’s affective expression −0.30** −0.19* −0.36 −0.03 Muscle satisfaction Fear of loneliness −0.16* −0.11 −0.22 −0.00 Muscle satisfaction Borderline expression −0.08* −0.05 −0.11 0.01 Muscle checking Emotional dependence 1.95** 1.52** 0.93 2.07 Muscle checking Separation anxiety 0.70** 0.53** 0.29 0.74 Muscle checking Partner’s affective expression 0.39** 0.29** 0.18 0.41 Muscle checking Changing of plans 0.25** 0.20** 0.09 0.30 Muscle checking Fear of loneliness 0.23** 0.18** 0.09 0.28 Muscle checking Borderline expression 0.16** 0.14** 0.09 0.19 Muscle checking Attention seeking 0.22** 0.17** 0.10 0.24 Substance use Emotional dependence 1.62** 1.30** 0.45 2.21 Substance use Separation anxiety 0.57** 0.45** 0.14 0.77 Substance use Partner’s affective expression 0.25* 0.17 0.02 0.35 Substance use Changing of plans 0.23** 0.18* 0.04 0.32 Substance use Borderline expression 0.21** 0.20** 0.12 0.29 Substance use Attention seeking 0.23** 0.19** 0.08 0.30 Injury Emotional dependence 2.04** 1.64** 0.90 2.34 Injury Separation anxiety 0.72** 0.57** 0.26 0.86 Injury Partner’s affective expression 0.37** 0.27** 0.11 0.43 Injury Changing of plans 0.29** 0.24** 0.11 0.38 Injury Fear of loneliness 0.21** 0.17** 0.05 0.29 *p < 0.05; **p < 0.001. EA also appears to be associated with emotional dependence. be that the person with emotional dependence, in his or her These results are relevant because they increase the evidence pursuit not to lose the beloved person, might exercise his or that behavioral addictions are interrelated. In previous studies, her body to achieve a desired body figure and feel attractive, EA was related to shopping addiction and food addiction which could lead to compulsive physical exercise. In respect (Lejoyeux et al., 2008), but not found to be related to emotional of its relationship with the attachment dimensions, EA has dependence. In this sense, the role of impulsiveness is probably been related to family concern, parental interference, regard fundamental, given that it underlies addictive pathologies (De for authority, and permissiveness. These attachment dimensions Sola-Gutiérrez et al., 2013). An explanatory hypothesis could are insecure, and, except for permissiveness, they are marked Frontiers in Psychology | www.frontiersin.org 8 June 2021 | Volume 12 | Article 681808 Olave et al. Exercise Addiction, Emotional Dependence and Attachment by an anxiogenic component. These results contradict the ones will be more likely to develop EA and/or MD. The same happens found by Lichtenstein et al. (2014), who did not find significant with insecure attachment styles. However, secure attachment results in the attachment style in a sample of people with style also predicts some of the scales of MD, which suggests EA, although they did find a certain tendency to the insecure that even people with secure attachment can experience exercise attachment dimension. dependence, constantly check their muscles in front of the Muscle dysmorphia is significantly associated with EA and mirror, use substances to increase their muscles, and persist with emotional dependence. It is not surprising that individuals their physical exercise despite the occurrence of injuries. with emotional dependence also show MD, given that both problems are closely related to low self-esteem and a negative Practical Implications evaluation of oneself, which would lead to body dissatisfaction These results bring evidence of the existing connections and compulsive physical exercise. Furthermore, MD has been between EA, emotional dependence, MD, and some insecure found to be associated with maladaptive attachment dimensions, attachment styles in people that exercise in and out of the which means that as MD increases so do emotional dependence gym. The dissemination of these findings is necessary so that and the attachment dimensions “regard for authority” and professionals in the field of mental health and sport science “self-sufficiency” and “resentment toward parents,” while secure can conduct prevention and be better prepared to intervene attachment decreases. These findings are consistent with Fabris with individuals with EA and MD. It has been proved that et al. (2018), who found a significant association between having excessive physical exercise can increase the likelihood of addictive an insecure attachment type (avoidant) and the risk of developing behaviors and health problems (Nogueira et al., 2018). The MD. It is also necessary to point out the importance of substance current treatments for EA are oriented toward a cognitive- use, part of DM, and its relationship with full MD and EA. behavioral intervention (Márquez and Vega, 2015), and for Mooney et al. (2017) found in a sample of gym and fitness MD pharmacologist treatment, cognitive behavioral therapy, club users a risk of EA, appearance anxiety, and low self-esteem, and metacognitive therapy (Nicewicz and Boutrouille, 2020). In as well as an inclination to use products to supplement their addition to this, it will be necessary to explore and work on physical exercise protein (41%), caffeine (30%), nitric oxide attachment style, interpersonal connections, and comorbidity (13%), and anabolic steroids (7%). In this same line, Dores with other addictive pathologies, such as emotional dependence. et al. (2021) found in a large sample, including the participants On the other hand, these dependencies could be partly reduced from Spain (15.7%), during the lockdown because the COVID- by improving emotional regulation skills, since this would reduce 19, strong relations between physical exercise and use of image impulsive conduct, worries; improve coping skills, decision- and performance-enhancing drugs, and, as in other studies, making, and the aversiveness of the situations (Gómez-Romero anxiety about appearance also increased the probability of using et al. 2020); and could cultivate secure attachment. these drugs. Furthermore, incorporating elements of emotional regulation The connection between emotional dependence and in the practice of sport and physical exercise, as well as in attachment dimension has also become evident. Thus, the education field, favored the decrease of these addictions. In with greater emotional dependence, there would be greater this sense, adolescence would be a critical stage, where physical parental interference, regard for authority, self-sufficiency, and changes occur as well as the first social and sexual relationships. resentment toward parents, and childhood trauma. These results Programs designed to prevent these addictions could be very coincide with the results of other studies (Estévez et al., 2018), beneficial for adult relationships and for the acceptance of where it was found that parental permissiveness, self-sufficiency, one’s body. resentment toward parents, and childhood trauma predicted emotional dependence. This suggests that individuals with Limitations emotional dependence are more likely to show an insecure The present study has some limitations. It is cross-sectional, attachment style in their interpersonal relationships. which means that causality connections cannot be established We must highlight the mediatory role of attachment, given and conclusions are limited. In future investigations, longitudinal that it explains part of the connection between EA and MD and studies should be carried out in order to validate the predictive emotional dependence, especially borderline expression. This role of the analyzed variables and include other psychological component of emotional dependence refers to the expression variables, such as emotional regulation or impulsivity, which of emotions in an uncontrolled way, as though they had can intervene in the connection between these variables. Other borderline personality disorder (BPD). Contrasting evidence limitations are found in the evaluation tools, given that they exists that individuals with BPD are more likely to have an are self-reported measures, and they are screening tools with insecure attachment style (Gunderson, 1996; Nickell et al., 2002; no diagnostic validity (Sicilia et al., 2015). Also, in this Bakermans-Kranenburga and van Ijzendoorna, 2009; Mosquera study, statistical analyses have been carried out in the general and González, 2013). This result coincides with those of Estévez population, which is why the next research objective is to study et al. (2018), who examined the mediatory role of attachment in these variables in a population with EA and DM and observe if connection with emotional dependence and impulsive behaviors. there are differences with control participants. Another challenge The predictive role of emotional dependence in EA and MD for the future is to include the variable of BDD, since it is closely has been confirmed. People who show the need to attract their related to DM and EA (Corazza et al., 2019), and observe if it partners’ attention and borderline expression of their emotions interacts with the variables studied. Finally, because the sample Frontiers in Psychology | www.frontiersin.org 9 June 2021 | Volume 12 | Article 681808 Olave et al. Exercise Addiction, Emotional Dependence and Attachment consists of university students, the generalization of the results to AUTHOR CONTRIBUTIONS the general population is limited. LO has carried out the data collection and has written DATA AVAILABILITY STATEMENT the manuscript. II has directed the project and has written the manuscript. AE, JM, and RM-N have performed the The raw data supporting the conclusions of this article will be data analysis. MG-R and MB have done the translation made available by the authors, without undue reservation. into English. All authors assisted with the preparation of the manuscript. ETHICS STATEMENT FUNDING This work is part of the research for the doctoral thesis, and has been approved by the doctoral committee of the Faculty Funding for this manuscript has been provided by the of Psychology of the Complutense University of Madrid. The Department of Experimental Psychology, Cognitive Processes patients/participants provided their written informed consent to and Speech Therapy, Complutense University of Madrid; participate in this study. This study has been approved by the Department of Personality, Evaluation and Psychological deontological commission of the Faculty of Psychology of the Treatment, University of Deusto; and School of Psychology, Complutense University of Madrid. Autonomous University of Barcelona. REFERENCES Darling, N., and Cumsille, P. (2003). Theory, measurement, and methods in the study of family influences on adolescent smoking. Addiction 98, 21–36. Ainsworth, M. D. S., Blehar, M. C., Waters, E., and Wall, S. (1978). 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Available online at: https://www.aesed.com/ doi: 10.1556/JBA.3.2014.020 upload/files/v44n1_art1.pdf Frontiers in Psychology | www.frontiersin.org 11 June 2021 | Volume 12 | Article 681808 Olave et al. Exercise Addiction, Emotional Dependence and Attachment Urbiola, I., and Estévez, A. (2015). Dependencia emocional y esquemas Conflict of Interest: The authors declare that the research was conducted in the desadaptativos tempranos en el noviazgo de adolescentes y jóvenes. Behav. absence of any commercial or financial relationships that could be construed as a Psychol. Psicol. Conductual 23, 571–587. potential conflict of interest. Villegas, M. J., and Sánchez, N. (2013). Dependencia emocional en un grupo de mujeres denunciantes de maltrato de pareja. Textos Sentidos 7, 10–29. Copyright © 2021 Olave, Estévez, Momeñe, Muñoz-Navarro, Gómez-Romero, World Medical Association (2013). World Medical Association Declaration of Boticario and Iruarrizaga. This is an open-access article distributed under the Helsinki: ethical principles for medical research involving human subjects. terms of the Creative Commons Attribution License (CC BY). The use, distribution JAMA 310:21. doi: 10.1001/jama.2013.281053 or reproduction in other forums is permitted, provided the original author(s) Zeeck, A., Welter, V., Alatas, H., Hildebrandt, T., Lahmann, C., and Hartmann, and the copyright owner(s) are credited and that the original publication in A. (2018). Muscle Dysmorphic Disorder Inventory (MDDI): validation this journal is cited, in accordance with accepted academic practice. No use, of a German version with a focus on gender. PLoS ONE 13:e0207535. distribution or reproduction is permitted which does not comply with these doi: 10.1371/journal.pone.0207535 terms. Frontiers in Psychology | www.frontiersin.org 12 June 2021 | Volume 12 | Article 681808