Having been in both the eating disorder and addiction medicine fields for many years, I have been fascinated with the high correlation and differences between patients with substance use disorders (SUDs) and eating disorders. The most obvious difference is that women are significantly more likely to have an eating disorder than men. Men are about twice as likely as women to have a SUD. Up to 35 percent of alcohol or illicit drug abusers have an eating disorder compared to 3 to 6 percent of the general population (CASA, 2003). Up to 50 percent of individuals with an eating disorder abuse alcohol or illicit drugs, compared with 9 percent in the general population. Research indicates that people who begin abstaining from nicotine, alcohol or other drugs following treatment often engage in unhealthy eating, particularly with regard to high sugar foods or take up a process addiction (CASA, 2003).
Is there a correlation with dopamine, drugs, and food? Obesity for example is very complicated, taking in account an individual’s genetics, personality characteristics, life experiences, and the properties of the drug/food. I believe talking about food addiction will bridge the two disease sets. They have clearly been treated differently, with eating disorders in general focusing on the individual’s thoughts and feelings about food, body image, and size versus an addiction to food/drugs. With SUDs abstinence is a primary goal, whereas with eating disorders abstinence of behaviors is the goal along with medical stability, but not abstinence of food or eating. No wonder they are approached differently. This article will point out that some of the eating disorders, specifically binge eating disorder and bulimia nervosa, fit an addiction construct. In my experience, anorexia nervosa does not fit the addiction model as well.
Obesity and Food Addiction
There is a rising obesity epidemic that has had researchers’ investigating the idea that food addiction is a real possibility for some individuals in the same way drinking alcohol for some is a social thing and others with SUDs should completely abstain or it could lead to a relapse. Certainly, many patients of size have faced stigma, shame, and difficulty managing their health like many patients with SUDs.
Obesity is defined as a medical condition that involves a weight measure versus height. A body mass index (BMI) score of 30.0 or higher is considered obesity. A BMI of 25.0 to 29.9 is considered overweight. For children and adolescents under age twenty, one looks at the ninety-fifth percentile of the CDC BMI—age growth charts show that obesity and being overweight are defined as a BMI between the eighty-fifth and ninety-fifth percentiles. It is estimated that more than one third of adults (35.7 percent) are obese, a percentage that is about the same in men and women (NIDDK, 2012a).
According to CASA (2016), nearly one hundred genes have been implicated in the determination of body weight and twenty-two of them consistently are linked to obesity (Rankinen et al., 2006). More than one hundred chemicals in the brain and body—including dopamine, GABA, norepinephrine, and serotonin—play critical roles in regulating energy balance, appetite, food intake, and weight (Schwartz, Woods, Porte, Seeley, & Baskin, 2000).
We must screen all of our patients for eating disorders, SUDs, and now food addiction. Having a psychiatric diagnosis of an eating disorder would put you in a group to have the highest mortality rate of any mental illness at 6 to 7 percent (Dennis, Pryor, & Brewerton, 2014). Additionally, the mortality rate associated with eating disorders is twelve times higher than the death rate of all causes of death for females ages fifteen to twenty-four, and the third most chronic illness among adolescents. Five to ten percent of anorexics die within ten years of onset, 18 to 20 percent die within twenty years of onset, and only 50 percent report ever being cured (South Carolina Department of Mental Health, 2006). One third of the adult population is obese and one-fifth of the adolescent population in the United States is obese. Smoking is the leading cause of preventable disease and death and obesity is the second (CASA, 2016).
According to the National Center on Addiction and Substance Abuse at Columbia University, “Obesity is a complex medical condition driven by many factors (e.g., biological predispositions to gain weight, high caloric intake, availability of and accessibility to highly processed foods, large portion sizes, relatively higher cost and inconvenience of obtaining healthy versus unhealthy food, [and] low physical activity” (2016). The concern about obesity are the health risks, and according to the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), the major diseases include: type 2 diabetes, heart disease, hypertension, fatty liver, certain types of cancer (breast, colon, endometrial, and kidney) and stroke (NIDDK, 2012a).
I am going to introduce an evidence-based rating scale called the Yale Food Addiction Scale (YFAS). The YFAS is the most widely used tool for looking at symptoms of food addiction (University of Michigan, 2016; Gearhardt, Corbin, & Brownell, 2009).
This can be used by anyone and should be part of a screen for individuals you suspect may have food addiction and certainly in those with a SUD/ED issues. It is a scale with twenty-five items, and if individuals endorse three or more symptoms on the scale and demonstrate clinical significant impairment or distress in the past month, they would meet the criteria for food addiction (CASA, 2016). The YFAS is based on the criterion for SUD—key symptoms listed below are very familiar to the substance addiction criterion and were based on the addiction criteria in DSM-IV:
- Food is eaten in larger amount and for longer periods than intended.
- There is persistent desire or repeated unsuccessful attempts to quit (dieting).
- There is much time/activity to obtain (food).
- Important social, occupational or recreational activities are given up or reduced.
- Use continues despite knowledge of adverse consequences (e.g., failure to fulfill role obligations, use in physically hazardous situations).
- Tolerance, meaning a need for more food before one stops eating
- Withdrawal, which may be seen with exercise and from sugar in some animal models (Avena, Bocarsly, Rada, Kim, & Hoebel, 2008).
When looking at the YFAS screening tool, the majority of patients with eating disorders would not meet criteria for a food addiction. It appears that only around 20 to 27 percent of individuals with bulimia nervosa and binge eating disorder (BED) would also have meet YFAS criteria. Thirty-six to forty-two percent of people with BED are obese, who are more likely to demonstrate cravings for sweet food than obese individuals without the disorder. Withdrawal symptoms from food are not seen in the same way as chemical addictions. Yet, in animal studies it may be seen with sugar and exercise. In addition, for those misusing laxatives, diuretics, and diet pills, there are significant withdrawal symptoms. I frequently tell patients I can detox someone from heroin in a few days, where it may take three to six weeks to “detox” someone from laxatives. In a sample of obese patients, of the 42 to 57 percent that met YFAS criteria for food addiction, some had BED. About half of obese individuals who meet criteria for food addiction also meet criteria for BED (CASA, 2016).
The rates of food addiction among obese individuals with BED are higher than among those obese individuals without BED. In addition, about half of obese individuals who meet criteria for food addiction also meet criteria for BED.
Another phenomenon seen in patients with obesity is that they have a very low rate of substance addiction. Much of this is thought to be due to dopamine being stimulated with highly processed food.
Eating Disorders in the DSM-5
There are three main classes of eating disorders according to the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5; 2013).
Anorexia nervosa is characterized by restriction of food intake relative to energy requirements leading to a low body weight—often significantly under 85 percent of ideal body weight—fear of gaining weight or getting fat, even though significantly underweight and distortion in body image (i.e., how one evaluates their shape or weight or lack of recognition of the seriousness consequences due to low weight). Body image and fear of getting overweight are the main criteria that are challenging. It clearly is not over eating in this case, but the intense fear of what the food will do to the body. Approximately 0.5 percent of adults have anorexia nervosa (CASA, 2003).
Bulimia nervosa is characterized by binge eating, meaning eating an amount of food larger than what most people eat and a sense of lack of control when eating. In addition there are recurrent compensatory behaviors (purging) to prevent weight gain such as self-induced vomiting, excessive exercise or misuse of laxatives, diet pills, amphetamines, and stimulants. These binge/purge behaviors occur from once a week to sometimes over ten episodes a day. While the majority of patients with bulimia nervosa are in their normal weight range, there are still significant body image issues that interfere with recovery. Approximately 1 percent of adults have bulimia nervosa (CASA, 2003).
Binge Eating Disorder
Finally, there is binge eating disorder. This diagnosis recently became official in 2013, when published criteria were placed in the DSM-5. BED is in some ways similar to bulimia nervosa in that there are recurrent episodes of binge eating and a sense of lack of control. In addition, the individual must have three of the following:
- Eating much more rapidly than normal
- Eating until feeling uncomfortably full
- Eating large amounts of food when not hungry
- Eating alone because of feeling embarrassed by how much one is eating and feeling disgusted with oneself, depressed or guilty afterwards
This should occur on average once a week for at least three months to make a diagnosis. It is estimated that 2.6 of the adult population has BED (CASA, 2016).
Eating Disorders, Food, and Addiction
As with classic drug and alcohol addiction, eating disorders begin with experimentation, such as dieting and self-induced vomiting for weight management, yet only a small percentage loses control. Similarly with alcohol, the majority of adults have experimented, but only a relatively small percentage loses control. In addition, eating disorders lead to a chronic compromised nutritional and medical state, have a chronic relapsing course and potentially tragic outcomes.
Eating disorders have the three C’s seen in addiction: compulsive craving, loss of control, and continued use/behaviors despite negative consequences. Often there is cognitive impairment; negative impact on all organ systems; issues with self-esteem; mood and anxiety disorders; and a history of trauma.
And sadly, like classic drug and alcohol addiction, these patients are very resistant to treatment, have frequent relapses, have long-term illness and as mentioned previously, the illness is potentially life threatening from not only medical compromise but have the highest risk for suicide of any psychiatric illness.
In 2011 the American Society of Addiction Medicine (ASAM) updated their definition of addiction to fit both substance use and process addictions. According to ASAM, addiction is characterized by:
- An inability to consistently abstain
- Impaired behavioral control
- Craving or increased hunger for drugs or rewarding experiences (process or behavioral addictions)
- A diminished recognition of problems with one’s behaviors and interpersonal relationships
- A dysfunctional emotional response
Addictive behaviors are motivated through substances or behaviors to increase positive affect and/or good feelings. A behavior that allows one to escape negative affect while bringing relief, pleasure or a high characterizes a potential addiction in early stages of development. When an individual discovers that the behavior has a benefit, which is often not obtainable through other means, the behavior continues with increased frequency. Bulimia nervosa behaviors are examples of this; bingeing may bring relief, anxiety reduction, and/or pleasure and then purging prevents the weight loss. This way an individual can, in general, eat whatever they want and not gain weight (NIDDK, 2012b). So, is bulimia nervosa a way to manage the food addiction, albeit a potentially lethal way? I already stated that 20 to 27 percent of patients with bulimia nervosa have food addiction, but that is significantly less than half of patients with the disorder.
So once again, this then begs the question: Is food addicting?
I do not generally think of food as an addictive drug, and yet there are addictive qualities of some ingredients found in the most highly palatable and caloric-dense foods—sugar, fat, and salt. According to CASA, “These psychoactive substances: (1) stimulate the reward and motivation-oriented regions of the brain during consumption or in the presence of related environmental cues, (2) promote craving, (3) reinforce continued consumption/use and tolerance, and (4) elicit withdrawal symptoms when consumption/use is cut back or eliminated” (2016).
Furthermore, CASA states, “Often what makes something addictive is that a concentrated dose or high potency and a rapid rate of absorption. We see this in fat or refined carbohydrates that have a high glycemic load. Highly processed and palatable food ingredients produce a powerful sense of pleasure I the brain and reinforce behaviors to ensure their repeated ingestion” (2016). There is also the fact that eating food is biologically necessary for survival and food is a natural reward, which makes it challenging to stop food addiction.
The Environmental Factor
Both substance use and eating disorders have a genetic basis that leads to a primary, chronic brain disease that is influenced by the environment. It has been said that genetics load the gun and the environment pulls the trigger, meaning that if someone wasn’t exposed to alcohol, drugs, dieting, laxatives, diuretics, and refined and highly processed food, they could not become dependent on them. The majority of adults in the US have drank alcohol, dieted, overeaten, and eaten highly processed foods, yet only a small percentage become alcoholic or develop an eating disorder. Genetics account for about 50 to 60 percent of having a substance use problem (Enoch & Goldman, 2001). Males are twice as likely as females to have alcohol or drug addiction. Women are five to eight times more likely to have an eating disorder than men. A study published in the Journal of Studies on Alcohol and Drugs showed that if you have a gene for alcoholism or alcohol dependence, you are 38 to 53 percent at risk for developing bulimia—specifically binge eating and purging with vomiting, laxatives, and diuretics (Munn-Chernoff et al., 2013). Genetics account for about 40 to 60 percent of this contribution. There is no gene for eating disorders that has been discovered at this time, however, there are genes for low self-esteem, perfectionism, anxiety, family history, and being female—all traits that are pervasive in individuals with an eating disorder (Munn-Chernoff et al., 2013).
Environmental concerns include: family beliefs and attitudes toward drugs; food, exercise, and body image; exposure to parental SUDs; peer groups that encourage drug use or being weight focused; recreational use of laxatives and diuretics; diet pills; and self-induced vomiting. In addition, adverse childhood events including trauma, mental health, physical health, and household dysfunction can be contributing factors. For SUDs, the earlier the age of onset of use, the more likely one is to become a substance abuser—40 percent if onset is at fourteen years old or younger and 10 percent if onset is at twenty years old and older. The same holds true for eating disorders; the earlier people begin to diet, the more likely they are to develop an eating disorder. Naturally, exposure to highly palatable food can happen very young.
Another environmental factor is the influence of media. This is especially relevant in print magazines and television. For women, the cultural norm today is still that “thin is in.” Anorexia nervosa and being thin appears to be the only mental illness that appears to be culturally acceptable and to have positively reinforced behaviors, such as dieting and weight loss, rather than condemned.
Men have cultural goals of achieving six-pack abs. One would think that in athletics there would be a healthy balance of diet and exercise, yet many sports are very body and weight focused. Ballet, crew, wrestling, and dance often focus on size with the generalized thought that smaller is better. A phenomenon that is often seen is when a patient with a SUD stops using chemicals, but takes up a process addiction and/or eating disorder. So in knowing that if someone may take up another addiction when giving up substances, what would treatment look like for that individual?
Specialized treatment for individuals with a SUD and often a co-occurring eating disorder and/or food addiction is a must. This should be integrated treatment with a team of treatment professionals. As previously noted, integrated treatment would include comprehensive screening for eating disorders, food addiction, SUDs, and other co-occurring disorders and medical conditions. This would be with diagnostic screening tools such as SCOFF (Morgan, Reid, & Lacey, 2000), the Michigan Alcoholism Screening Test (MAST10; Selzer, 1971), DSM-5 criteria (APA, 2013), lab, drug screens, and x-ray studies.
The treatment plan should be integrated and comprehensive enough to include SUDs, food addiction, and eating disorders. It should also have individualized therapists, dietitians, and treatment teams trained to treat all disorders. Ideally, this is when services are provided in the same location by the same treatment clinicians. If only one level of care is available in a particular facility, then a plan should be established at the onset for patients to go through the continuum of care from detox down to inpatient, residential, partial hospitalization, intensive outpatient, and finally outpatient care (Dennis, Pryor, & Brewerton, 2014).
For patients with SUDs, food addiction or eating disorders, clinicians should treat the life-threatening issues first. Medical detoxification is critical for most drugs of abuse and then medical stabilization, including weight stabilization and reduction of eating disorder behaviors. The team of professionals should include a physician who is American Board of Addiction Medicine-certified or has added qualifications in addiction medicine from the American Psychiatric Association, as well as trained in eating disorder treatment.
Additionally, these individuals may be therapists, clinicians, and dietitians who are certified by the International Academy of Eating Disorder Professionals for eating disorder expertise. Therapists can be licensed to become a certified addiction counselor with a level III CAC passing a certification examination. In addition, the national certified addiction counselor and master addiction counselor licenses are available through the National Association of Addiction Treatment Providers as well as other agencies (Dennis et al., 2014).
There is an eating disorder treatment focus on increased restraint versus moderating control. Recovery focuses on abstinence of eating disorder behaviors versus normalization of eating behaviors. Finally, there are significant differences in the eating disorder field with psychotherapy, dialectical behavioral therapy (DBT), exposure response prevention (ERP), medications, interventions, and self-help.
In summary, because of the large overlap in patients having SUDs, food addiction, and eating disorders, there needs to be screening for all of these conditions in patients who present with one condition. Eating disorders have the highest mortality of any psychiatric illness and to treat the patients competently, treatment facilities must use an integrated treatment team with trained staff in both areas.
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