Integrating screening and clinical interviews to assess clinically relevant addictive exercise behaviour in athletes.

Background and aims: Questionnaire-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 semi-structured, study-specific 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 meeting versus not meeting ICD-11-based criteria for clinically relevant addictive exercise behaviour, and (3) identify the most discriminative candidate features of this classification. Methods: A 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 semi-structured, study-specific clinical 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%). Results: Among the 34 EDS-positive athletes who completed the clinical interview, 24 (70.6 %, 95 % CI: 52.5-84.9 %) met ICD-11-based criteria for clinically relevant addictive exercise behaviour. Compared to athletes not meeting these criteria, those meeting ICD-11-based criteria reported greater withdrawal-related symptoms, more comorbidities, lower life satisfaction, and higher weight-related exercise motivation, while training volume did not differ. In an exploratory LASSO model, withdrawal symptoms and past comorbidities emerged as preliminary candidate discriminative features of ICD-11-based classification status. Conclusions: High EDS scores may reflect elevated exercise dependence features in endurance athletes, whereas not all 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 clinically relevant addictive exercise behaviour. However, findings from the interview phase should be interpreted cautiously given the small sample size and exploratory nature of the analyses.