One question we did not address in Chapter 6 is whether binge eating is an addiction. If you have ever experienced the sense of loss of control and urge to eat associated with binge eating, this question might well have crossed your mind. Or you might have read about binge eating being an addiction. Widely used terms such as compulsive overeating and food addiction certainly suggest that this is the case. In fact this view has such a strong following in the United States that it is the basis for certain prominent treatment programs.
For these reasons, it is important to consider whether binge eating should be viewed as a form of addiction. If it is not, then treatment programs based on this premise may well not be appropriate. This chapter focuses on three main questions:
1. Is it right to view binge eating as an addiction?
2. Is there any relationship between the known addictions, such as alcohol and drug abuse, and binge eating?
3. Are there implications of this view for the treatment of binge eating problems?
THE THEORY OF BINGE EATING AS AN ADDICTION
OA believes that compulsive overeating is a threefold disease: physical, emotional and spiritual. We regard it as an addiction which, like alcoholism and drug abuse, can be arrested but not cured.
—Overeaters Anonymous leaflet
According to the theory that binge eating is a form of addiction—the so-called “addiction model” of binge eating—binge eating is the result of an underlying physiological process equivalent to that responsible for alcoholism. People who binge are biologically vulnerable to certain foods (typically sugar and starches) and as a result become “addicted” to them. These foods are “toxic” to these people who, as a result, are unable to control their intake so their consumption progressively rises. Since this vulnerability is biologically based, they can never be cured of the problem (or “illness”): rather, they have to learn to accept it and adjust their lives accordingly.
Is the addiction model valid? As Terence Wilson of Rutgers University has stressed, nowadays “the concept of addiction has been debased by promiscuous and imprecise usage to describe virtually any form of repetitive behavior.” Some of us, we are told, are “sex addicts,” others are “TV addicts” or “shopaholics.” The result is that it is no longer clear what it means to have an addiction. When the word is used in this loose, all-embracing way, most of us could be said to be “addicted’’ to something or other.
Nevertheless, there are some similarities between binge eating and the classic addictions involving alcohol and drug abuse, and many people focus on these similarities to support the addiction model of binge eating. They point out that whether the behavior is alcohol/drug abuse or binge eating, the person
• Has cravings or urges to engage in the behavior.
• Feels a loss of control over the behavior.
• Is preoccupied with thoughts about the behavior.
• Might use the behavior to relieve tension and negative feelings.
• Denies the severity of the problem.
• Attempts to keep the problem secret.
• Persists in the behavior despite its adverse effects.
• Often makes repeated unsuccessful attempts to stop.
These similarities are, however, partial. They are interesting, and some are relevant to treatment—for example, the use of the behavior to deal with tension—but the fact that things are similar or have properties in common does not make them the same. Moreover, focusing exclusively on the similarities, as is often done, neglects important differences between these forms of behavior, differences that are both central to the understanding of them and central to their successful treatment.
There are three main differences between binge eating and substance abuse, all of which are important:
1. Binge eating does not involve the consumption of a particular class of foods. Elsewhere Terence Wilson has pointed out that if bulimia nervosa were an addiction, patients should preferentially consume specific “addictive” foods. This is not the case in bulimia nervosa, and the same is true in binge eating disorder. The key eating abnormality in binge eating is the amount of food consumed, not what foods are eaten (as we discussed in Chapter 1).
2. Those who binge eat have a drive to avoid the behavior. People with binge eating problems, other than those with binge eating disorder, are continually trying to restrict their food intake, that is, they are attempting to diet. What distresses them about their binge eating is that it represents a failure to control their eating and carries the risk of weight gain. There is no phenomenon equivalent to dieting in alcohol (or drug) abuse. Those who abuse alcohol have no inherent drive to avoid alcohol against the background of which their excessive drinking takes place. In fact a major goal of addiction treatment programs is to instill in the addict the determination not to engage in the addictive behavior. In most binge eating problems, in contrast, this determination already exists in the form of the strong desire to control food intake. Indeed, the drive to control eating is a problem in its own right as it perpetuates the binge eating (as we discussed in Chapter 4).
3. Those who binge eat fear engaging in the behavior. In most binge eating problems, accompanying the drive to diet is a set of attitudes toward shape and weight characterized by the overevaluation of shape and weight (see Chapter 4). Self-worth is judged almost exclusively in terms of appearance and weight, and (as we discussed in Chapter 6) these attitudes play an important role in perpetuating the disorder through encouraging persistent and strict dieting. Once again, there is no equivalent phenomenon in alcohol or drug abuse. In other words, the desire to restrict eating encourages those with binge eating problems to binge. In contrast, those addicted to alcohol or drugs are not vulnerable to abuse of these substances as a result of their wish to avoid them.
As can be seen, there are markedly different mechanisms involved in binge eating and substance abuse and these point to two diametrically opposed approaches to their treatment. In the case of most binge eating problems, treatment needs to focus on moderating self-restraint. In contrast, treatments for addiction need to focus on strengthening it.
On the other hand, binge eating does occur among some people who do not diet particularly intensely, specifically many of those with binge eating disorder. The binge eating of these people is not driven by dieting, or at least to a far lesser degree. Difficulties coping with stress seem to be much more important. So, potentially, there is more of an overlap between the mechanisms driving their binge eating and those driving alcohol or drug abuse.
THE RELATIONSHIP BETWEEN BINGE EATING AND SUBSTANCE ABUSE
Even if binge eating is not itself an addiction, are the similarities between binge eating and substance abuse indicative of an association between the two? Could both problems be caused by a single underlying abnormality? To answer these questions, studies have been carried out to determine how often and under what circumstances the two problems appear in the same person or the same family.
Substance Abuse among People with Binge Eating Problems
While proponents of the addiction model of binge eating often state that the rates of alcohol and drug abuse are disproportionately high among those with binge eating problems, this is not the case. While research findings indicate that the rates are indeed raised, they are no higher than those among people with other psychiatric disorders.
Binge Eating Problems among Those with Substance Abuse
If there is a specific association between binge eating and substance abuse, those with alcohol and drug addiction should have a raised rate of binge eating problems. This does indeed appear to be the case, but once again it seems that is a nonspecific association in that there is an elevated rate of eating problems among people with other psychiatric disorders, for example, anxiety disorders and depression.
Family Studies
Several studies have reported a raised rate of substance abuse among the relatives of people with bulimia nervosa. This finding is interesting but, like the others already mentioned, difficult to interpret. The rates seem to be no higher than those among the relatives of people with other psychiatric disorders. This is not what would be expected if binge eating problems and substance abuse were the result of a common underlying process.
The Relationship between the Disorders over Time
To understand the relationship between two disorders, it is also important to know whether one tends to lead to the other or vice versa. Studies of those people with alcohol problems who also have an eating problem suggest that the latter develops first. This finding is not surprising, however, since eating problems typically begin at an earlier age than alcohol problems.
The Effects of Treatment
If a single abnormality underlies both binge eating problems and substance abuse, then the successful treatment of one of these problems might be expected to lead to the emergence of the other (unless the underlying abnormality had also been corrected). This phenomenon is sometimes referred to as symptom substitution. There is no evidence that it occurs in this context: indeed, there is evidence that it does not, at least among people with binge eating problems (see Box 12).
Box 12. Changes in alcohol intake in those treated for an eating disorder.
It is commonly assumed that people who have both a binge eating problem and a high alcohol intake do less well in treatment. Sometimes voiced is the related concern that elimination of the binge eating problem might worsen the accompanying alcohol problem.
Data from a study of “enhanced cognitive behavior therapy” (CBT-E) were used to investigate these relationships. One hundred and forty-nine patients with an eating disorder were divided into two groups, a high-intake group whose weekly alcohol intake exceeded healthy guidelines and a low-intake group whose intake was within healthy limits. Both the low- and the high-intake groups suffered from an eating disorder of equivalent severity.
There were two main findings. First, the low and high alcohol intake groups responded in an almost identical way to CBT-E, thus refuting the assumption that those with a high alcohol intake would respond less well. Second, during treatment the alcohol intake of most patients in the high intake group fell to within healthy limits despite it not being a focus of CBT-E. The alcohol intake of a small minority did increase, but these people made limited progress in all respects so it does not appear that improvement in their eating problem was encouraging them to drink. In other words it seems that there was no symptom substitution.
Source: Karacic, M., Wales, J. A., Arcelus, J., Palmer, R. L., Cooper, Z., & Fairburn, C. G. (2011). Changes in alcohol intake in response to transdiagnostic cognitive behaviour therapy for eating disorders. Behaviour Research and Therapy, 49, 573–577.
THE IMPLICATIONS OF THE ADDICTION MODEL FOR TREATMENT
Our goal is to abstain from compulsive overeating one day at a time. We do this through daily personal contact, meetings and by following the twelve-step program of Alcoholics Anonymous, changing only the words “alcohol” and “alcoholic” to “food” and “compulsive overeater.”
—Overeaters Anonymous leaflet
Given that there are no grounds for claiming that binge eating is the result of an addictive process, is it appropriate to treat it as one? The straight answer is “No.” The principles underlying addiction-oriented treatment are at total odds with the treatment approach that has proved most effective for binge eating problems.
Treatment, according to the addiction model, should be based on the approach used by Alcoholics Anonymous (and other related groups) for helping those with alcohol problems. This is the so-called “12-step” approach. Four features distinguish this approach from the most successful form of treatment for binge eating problems, a psychological treatment termed cognitive behavior therapy or CBT (described in Chapter 8):
1. Twelve-step approach: The disorder is an illness for which there is no cure. A book of daily readings for members of Overeaters Anonymous states, “It is the experience of recovering compulsive overeaters that the illness is progressive. The disease does not get better; it gets worse. Even while we abstain, the illness progresses.”
CBT approach: Recovery is well within the reach of most people. Long-term follow-up studies of bulimia nervosa and binge eating disorder indicate that full recovery is possible and not uncommon, and that with appropriate treatment the great majority of people improve substantially (see Chapter 8).
2. Twelve-step approach: Immediate abstinence is paramount. The focus of the 12-step approach is on stopping binge eating as rapidly as possible, and group pressure may be applied to serve this end. In some treatment meetings, abstinent participants are identified and praised, whereas those who have not been abstinent are given little or no opportunity to speak: indeed, they may be asked to leave.
CBT approach: Emphasis on the immediate cessation of binge eating is neither reasonable nor realistic. The abstinence stance is heartless and unreasonable. While with good advice and support many people can stop binge eating fairly rapidly, many others cannot. It may take them weeks or months to get to this point. The CBT approach places no emphasis on the immediate cessation of binge eating.
3. Twelve-step approach: A major strategy for achieving abstinence from binge eating is an additional form of abstinence: the total lifelong avoidance of the (“toxic”) foods that trigger binge eating.
CBT approach: Food avoidance should be eliminated, not encouraged. As discussed earlier, the view that certain foods are toxic and somehow cause people to binge has no basis in fact. Clinical and experimental evidence indicate that it is the very attempts to avoid these foods that make many people vulnerable to binge (see Chapter 4). It is for this reason CBT focuses on eliminating food avoidance rather than encouraging it. The addiction model would predict that this would promote further binge eating. The research indicates that the exact opposite is the case.
4. Twelve-step approach: One is either in control or out of control; foods are safe or toxic; one is abstinent or not. Underpinning the abstinence approach is an all-or-nothing way of thinking.
CBT approach: Black-and-white thinking is a problem that needs to be addressed. To take one example, an all-or-nothing view of progress after treatment encourages people to regard any setback as a “relapse” rather than a “lapse.” This way of thinking leads people to give up in the face of slips when there is no need for them to do so. All-or-nothing thinking is common among people who binge, and it seems to contribute to it, as we discussed in Chapter 4. So, rather than reinforcing this way of thinking, as in the abstinence approach, it is important to help people recognize and counter it.
There is, of course, more to addiction-based treatments than I have presented. Their greatest strength is the high level of long-term support and fellowship that many provide. This, combined with the simplicity of their message, makes them attractive to some people. However, the “bottom line” must be effectiveness. The 12-step approach to binge eating problems has never been evaluated properly, whereas a great deal is known about the effectiveness of other forms of treatment. These are the subject of the final chapter in this section of the book.