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![Can Compulsive Overeating, Binge Eating Disorder, and
Bulimia really be an Addiction?
The “Naysayers” –
Drug addiction, alcohol dependency, and process addictions
[e.g. compulsive gambling] are substances and behaviors that
are not necessary for life. Food is.
The “Believers” –
But so is water and air – However, people do not consume
water & air beyond their biological needs or in ways that
threaten their survival. So perhaps the problem is semantics
drug addiction… not all drugs are addictive
food addiction… not all foods are addictive](https://image.slidesharecdn.com/pwptwpls2016-160802120226/85/EATING-DISORDERS-ADDICTIVE-PERSPECTIVE-4-320.jpg)
![“A Rose is a Rose”
Given the interaction between the biology of a person and their
behavior with food…
“Addictive Eating” may be considered by some as synonymous with:
* Compulsive Overeating [non binge eating]
• Binge Eating Disorder
• Bulimia
• Some forms of Anorexia*
• “Food Addiction”](https://image.slidesharecdn.com/pwptwpls2016-160802120226/85/EATING-DISORDERS-ADDICTIVE-PERSPECTIVE-6-320.jpg)
![EMOTIONAL OR BIOLOGICAL
DETERMINANTS?
Much more often than not, disordered eating is approached
as a psychological problem involving poor impulse control
and “emotional eating.”
Not recognizing, and treating, the biological drivers of food
cravings and overeating often leads to a poor outcome of
treatment. Likewise for restricting types of eating disorders.
Treatment of an eating disorder demands attention to the
nature of the substance [properties of the foods consumed],
the nature of the person [psychological contributors] and the
biology of the individual.](https://image.slidesharecdn.com/pwptwpls2016-160802120226/85/EATING-DISORDERS-ADDICTIVE-PERSPECTIVE-7-320.jpg)
![Dynamics of Pathological Eating
Genetics? Appetite Gene, ED Gene(s)?
Reward Circuits? – Dopamine/ Opioid Receptors
Role of Serotonin and effect on Mood
Classical Conditioning/Associative Learning?
External food [salient] cues “trumping” internal cues
Hormonal – ghrelin, leptin, insulin controlled?
Emotional Eating
Processed foods, “junk food environment”
Plasticity and Cross Addiction?
Switching forms of eating disorders
Stress > Cortisol > Increased [or decreased] Appetite](https://image.slidesharecdn.com/pwptwpls2016-160802120226/85/EATING-DISORDERS-ADDICTIVE-PERSPECTIVE-8-320.jpg)
![Anorexia, Restricting Type
“If anorexic individuals experience
endogenous DA release as anxiogenic
rather than hedonic, this may explain
their pursuit of starvation, because food
refusal may be an effective means of
diminishing the anxious feelings
associated with the disorder.” [negative
reinforcement]](https://image.slidesharecdn.com/pwptwpls2016-160802120226/85/EATING-DISORDERS-ADDICTIVE-PERSPECTIVE-15-320.jpg)
![Sensitization, Cross-Addiction, and Relapse -
Neuroplasticity
Opposite of tolerance – repeated abuse of a substance
will create a significant “sensitivity” or dopamine release
with related substances [cross addiction].
Binge eaters, in particular with sugar, will be more
“sensitive to the effects of alcohol and cocaine than
non-binge eaters
Although tolerance is reversible it appears sensitization
remains for extended periods and even a small amount
of the offending substance [or behavior] will result in a
heightened response. [See prior slide]
Supports “gateway” substances.
Summary of this research and theory appears in Nicole Avena’s text – Hedonic Eating, Oxford Press, Chapter 10, 2015](https://image.slidesharecdn.com/pwptwpls2016-160802120226/85/EATING-DISORDERS-ADDICTIVE-PERSPECTIVE-22-320.jpg)
![Neuroplasticity, Chronicity, and
Relapse
There appears to be plasticity associated with the addiction
phenomenon in general as well as changes produced by
addiction to specific addicting drugs. These findings also
provide the basis for the current understanding of addiction as
a chronic, relapsing disease of the brain with changes that
persist long after the last use of the drug. Hence. the
neuroplasticity in brain circuits and cell function induced by
addictive substances [and behaviors] that are thought to
underlie the compulsions to resume addictive behavior
warrant further exploration. These investigations have
significant implications for future therapies and treatments.](https://image.slidesharecdn.com/pwptwpls2016-160802120226/85/EATING-DISORDERS-ADDICTIVE-PERSPECTIVE-26-320.jpg)
![Tenets of Recovery
Need to identify and abstain from the addictive food
substances [abstinence]-cross addiction
Need to address mood / psychological issues
contributing to maintenance of addictive eating
[addressing depression if present and initiating better
coping skills
Need to address the physical issues associated with food
addiction [exercise, stress, diabetes]
Eliminating isolation, participation with community
based support groups, and cultivating a functional
spiritual relationship with an entity other than oneself.](https://image.slidesharecdn.com/pwptwpls2016-160802120226/85/EATING-DISORDERS-ADDICTIVE-PERSPECTIVE-34-320.jpg)
![Components of a Blended Treatment Model
Structured Food Plan – eliminates “trigger” foods
CBT + DBT = Harm Reduction
Constructive Living Model – Transcending Feelings for “Right Action” [see
“Guide to Eating Disorder Recovery”]
Concurrent Treatment of Related Diagnoses
Real World Setting– In Vivo experiences
Use of Community based support groups
Medication when needed
Evidence Based Treatments
Daily Living Skills [meal preparation, food shopping, etc.]
Individualized Family Therapy](https://image.slidesharecdn.com/pwptwpls2016-160802120226/85/EATING-DISORDERS-ADDICTIVE-PERSPECTIVE-35-320.jpg)
![LEVELS OF CARE
“One Size Does Not Fit All”
Inpatient (Hospital Based)
Residential (Non-Hospital Based)
Partial Hospital (Day Treatment)
Intensive Outpatient (Half-Day Treatment)
Outpatient (Therapist, Dietitian, etc.)
…Support Groups [OA, FAA, SR, ABA, etc.]](https://image.slidesharecdn.com/pwptwpls2016-160802120226/85/EATING-DISORDERS-ADDICTIVE-PERSPECTIVE-39-320.jpg)
More Related Content
Similar to EATING DISORDERS - ADDICTIVE PERSPECTIVE
EATING DISORDERS - ADDICTIVE PERSPECTIVE
- 1. FOOD AND ADDICTION EatingDisorders – Process Addiction, Substance Use Disorder, or Psychiatric Illness? PREPARED FOR WPLS- JULY 22, 2016 MILESTONES EATING DISORDERS PROGRAM
- 2. PART ONE –THE PROBLEM…
- 3. Basic Assumptions Addictionin general is a complex combination of interactions between the biology of the “addict”, the nature of the substance abused, and the environment these take place. In other words, there is the nature of the person and the nature of the substance. The availability of the offending substances is the spark that starts the process. Food addiction / Eating Disorders are no exception.
- 4. Can Compulsive Overeating,Binge Eating Disorder, and Bulimia really be an Addiction? The “Naysayers” – Drug addiction, alcohol dependency, and process addictions [e.g. compulsive gambling] are substances and behaviors that are not necessary for life. Food is. The “Believers” – But so is water and air – However, people do not consume water & air beyond their biological needs or in ways that threaten their survival. So perhaps the problem is semantics drug addiction… not all drugs are addictive food addiction… not all foods are addictive
- 5. : Tolerance WithdrawalSymptoms More For Longer Periods Than Intended Unsuccessful Effort To Cut Back Or Control Significant Time To Obtain Or Recover From Effects Giving up social, occupational, recreational, activities because of substance use Continuation Despite Consequences * LEVEL OF DEPENDENCY: MILD 2-3 MODERATE 4-5 SEVERE 6+ SUBSTANCE USE DISORDERS AMERICAN PSYCHIATRIC ASSOCIATION 2016
- 6. “A Rose isa Rose” Given the interaction between the biology of a person and their behavior with food… “Addictive Eating” may be considered by some as synonymous with: * Compulsive Overeating [non binge eating] • Binge Eating Disorder • Bulimia • Some forms of Anorexia* • “Food Addiction”
- 7. EMOTIONAL OR BIOLOGICAL DETERMINANTS? Muchmore often than not, disordered eating is approached as a psychological problem involving poor impulse control and “emotional eating.” Not recognizing, and treating, the biological drivers of food cravings and overeating often leads to a poor outcome of treatment. Likewise for restricting types of eating disorders. Treatment of an eating disorder demands attention to the nature of the substance [properties of the foods consumed], the nature of the person [psychological contributors] and the biology of the individual.
- 8. Dynamics of PathologicalEating Genetics? Appetite Gene, ED Gene(s)? Reward Circuits? – Dopamine/ Opioid Receptors Role of Serotonin and effect on Mood Classical Conditioning/Associative Learning? External food [salient] cues “trumping” internal cues Hormonal – ghrelin, leptin, insulin controlled? Emotional Eating Processed foods, “junk food environment” Plasticity and Cross Addiction? Switching forms of eating disorders Stress > Cortisol > Increased [or decreased] Appetite
- 9. THE CASE FORADDICTIVE EATING
- 10. So…What Have WeLearned and Who Have We Studied?
- 11. A Couple of“Volunteers”
- 13. Food Addiction Is… “Foodaddiction is a disease causing loss of control over the ability to stop eating certain foods. Scientifically, food addiction is a cluster of chemical dependencies on specific foods or food in general; after the ingestion of highly palatable foods such as sugar, excess fat and/or salt the brains of some people develop a physical craving for these foods. Over time, the progressive eating of these foods distorts a person’s thinking and leads to negative consequences they do not want but cannot stop.” From: Food Addiction Institute Website http://foodaddictioninstitute.org/what-is-food-addiction/
- 14. Dopamine – TheReward /Feel Good Neurotransmitter The greater the expectation and experience of the substance, the “stronger” the dopamine signal. Drugs such as cocaine, amphetamines, alcohol, opiates stimulate increased levels of dopamine. Dopamine deficiencies will develop in response to repeated abuse of substances. The down regulation of D2 receptors creates tolerance. Dopamine deficiencies are thought to motivate drug seeking behavior / craving in an attempt to avoid withdrawal or experience the prior pleasant feelings. “Chasing the original high”
- 15. Anorexia, Restricting Type “Ifanorexic individuals experience endogenous DA release as anxiogenic rather than hedonic, this may explain their pursuit of starvation, because food refusal may be an effective means of diminishing the anxious feelings associated with the disorder.” [negative reinforcement]
- 16. Anorexia: Addictive Elements “Many people with AN exercise compulsively and find little in life rewarding aside from the pursuit of weight loss. Like other traits, these too persist, in a more modest form, after recovery. These particular traits all involve the neurotransmitter dopamine, which contributes to altered reward and affect, decision-making, and executive control. There is considerable evidence that altered function of dopamine occurs in AN possibly contributing to over-exercise and decreased food intake.” Eating Disorders Center for Treatment and Research, University of California School of Medicine Kaye W, Fudge J, Paulus M. New insight into symptoms and neurocircuit function of anorexia nervosa. Nat Rev Neurosci. 2009;10(8):573-84.
- 17. HEDONIC EATING Research hasshown that the brain begins responding to fatty and sugary foods even before they enter our mouth. Merely seeing a desirable item excites the reward circuit. As soon as such a dish touches the tongue, taste buds send signals to various regions of the brain, which in turn responds by spewing the neurochemical dopamine. The result is an intense feeling of pleasure. * Nicole Avena,PhD., Hedonic Eating: How the Pleasure of Foods Affects our Brains and Behavior, Oxford University Press, 2015
- 18. Control versus bingeeater “sight of food cue” and dopamine reaction CONTROL BED
- 19. USE > ABUSE> DEPENDENCY “Frequently overeating highly palatable foods saturates the brain with so much dopamine that it eventually adapts by desensitizing itself, reducing the number of cellular receptors that recognize and respond to the neurochemical.” “Consequently, the brains of overeaters demand a lot more sugar and fat to reach the same threshold of pleasure as they once experienced with smaller amounts of the foods. These people may, in fact, continue to overeat as a way of recapturing or even maintaining a sense of well-being.” * Robert H. Lustig, M.D., et al. “The Toxic Truth About Sugar,” Nature 487 (2012)
- 20. Down Regulation ofD2 Receptors
- 21. MRI Study withComparison of Available Dopamine Without Addictive Stimuli
- 22. Sensitization, Cross-Addiction, andRelapse - Neuroplasticity Opposite of tolerance – repeated abuse of a substance will create a significant “sensitivity” or dopamine release with related substances [cross addiction]. Binge eaters, in particular with sugar, will be more “sensitive to the effects of alcohol and cocaine than non-binge eaters Although tolerance is reversible it appears sensitization remains for extended periods and even a small amount of the offending substance [or behavior] will result in a heightened response. [See prior slide] Supports “gateway” substances. Summary of this research and theory appears in Nicole Avena’s text – Hedonic Eating, Oxford Press, Chapter 10, 2015
- 23. fMRI AFTER DRINKINGA MILKSHAKE *Scan on left – Subject given Milkshake after more than a year of abstinence from sugar + high palatable foods. Concept of “sensitivity” and plasticity…
- 24. SUGAR ADDICTION >USE > ABUSE "The brain's pleasure center, called the nucleus accumbens, is essential for our survival as a species... Turn off pleasure, and you turn off the will to live... But long-term stimulation of the pleasure center drives the process of addiction... When you consume any substance of abuse, including sugar, the nucleus accumbens receives a dopamine signal, from which you experience pleasure. And so you consume more.
- 25. SUGAR ADDICTION -TOLERANCE The problem is that with prolonged exposure, the signal attenuates gets weaker. So you have to consume more to get the same effect -- tolerance. And if you pull back on the substance, you go into withdrawal. Tolerance and withdrawal constitute addiction. And make no mistake, sugar is addictive." Dr. Robert Lustig, Professor of Pediatrics in the Division of Endocrinology at the University of California
- 26. Neuroplasticity, Chronicity, and Relapse Thereappears to be plasticity associated with the addiction phenomenon in general as well as changes produced by addiction to specific addicting drugs. These findings also provide the basis for the current understanding of addiction as a chronic, relapsing disease of the brain with changes that persist long after the last use of the drug. Hence. the neuroplasticity in brain circuits and cell function induced by addictive substances [and behaviors] that are thought to underlie the compulsions to resume addictive behavior warrant further exploration. These investigations have significant implications for future therapies and treatments.
- 27. American Society ofAddiction Medicine Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. This is reflected in the individual pursuing reward and/or relief by substance use and other behaviors. The addiction is characterized by impairment in behavioral control, craving, inability to consistently abstain, and diminished recognition of significant problems with one’s behaviors and interpersonal relationships. Like other chronic diseases, addiction involves cycles of relapse and remission. Without treatment or engagement in recovery activities, addiction is progressive and can result in disability or premature death.
- 28. Coke Spends Lavishlyon Pediatricians and Dietitians Coke beneficiaries include the Academy of Pediatrics, as well as a number of respected medical and health groups, including $3.1 million to the American College of Cardiology, more than $3.5 million to the American Academy of Family Physicians, $2 million to the American Cancer Society and roughly $1.7 million to the country’s largest organization of dietitians, the Academy of Nutrition and Dietetics. McDonalds has done the same as well as other fast and junk food manufacturers. N.Y. Times September 28, 2015
- 29. “See Any Parallelsto the Tobacco Industry?”
- 30. Food for Thought “Alltruth passes through three stages… First, it is ridiculed. Second, it is violently opposed. Third, it is accepted as being self-evident.” Arthur Schopenhauer German philosopher (1788 – 1860)
- 31. FOOD AND ADDICTON… PARTTWO: THE SOLUTION
- 32.
- 33.
- 34. Tenets of Recovery Need to identify and abstain from the addictive food substances [abstinence]-cross addiction Need to address mood / psychological issues contributing to maintenance of addictive eating [addressing depression if present and initiating better coping skills Need to address the physical issues associated with food addiction [exercise, stress, diabetes] Eliminating isolation, participation with community based support groups, and cultivating a functional spiritual relationship with an entity other than oneself.
- 35. Components of aBlended Treatment Model Structured Food Plan – eliminates “trigger” foods CBT + DBT = Harm Reduction Constructive Living Model – Transcending Feelings for “Right Action” [see “Guide to Eating Disorder Recovery”] Concurrent Treatment of Related Diagnoses Real World Setting– In Vivo experiences Use of Community based support groups Medication when needed Evidence Based Treatments Daily Living Skills [meal preparation, food shopping, etc.] Individualized Family Therapy
- 36. Elements of aFood Plan Prescribed by a registered dietitian familiar with food addiction model Often involves weighing, measuring food Consistent schedule of eating 3 to 5 times daily Identifies and eliminates trigger foods Focus on a food plan not a “diet” or weight loss Discourages focus on weight but rather restoration of health and end addictive eating Accountability Recognizes nutritional / caloric needs are a dynamic process with period adjustments needed
- 37. S.E.R.F. “A Formula forlong term recovery” SPIRITUALITY EXERCISE REST FOOD PLAN See text “A Guide to ED Recovery” pages 95-106
- 38. 1. FEELINGS AREUNCONTROLLABLE DIRECTLY BY SELF WILL 2. FEELINGS MUST BE RECOGNIZED AND ACCEPTED “AS IS” 3. EVERY FEELING, NO MATTER HOW UNPLEASANT, HAS A PURPOSE 4. FEELINGS CHANGE OVER TIME UNLESS RE-STIMULATED 5. FEELINGS / THOUGHTS CAN BE INDIRECTLY INFLUENCED BY BEHAVIOR 6. WE‘RE RESPONSIBLE FOR WHAT WE DO NO MATTER HOW WE FEEL * David Reynolds, PhD., Constructive Living, 1984 Principles of “Constructive Living”
- 39. LEVELS OF CARE “OneSize Does Not Fit All” Inpatient (Hospital Based) Residential (Non-Hospital Based) Partial Hospital (Day Treatment) Intensive Outpatient (Half-Day Treatment) Outpatient (Therapist, Dietitian, etc.) …Support Groups [OA, FAA, SR, ABA, etc.]
- 40.
- 41.
- 42. CONTACT INFORMATION Marty Lerner,PhD. Milestones Eating Disorders Program 2525 Embassy Drive Hollywood, Florida 33026 Email: Mlerner@MilestonesProgram.Org 800-347-2364 http://www.milestonesprogram.org/ *References to topics available upon request
Editor's Notes
- #4 Addiction > Tolerance and Withdrawal + Substance seeking and craving Dependency > Tolerance and Withdrawal [physical adaptation to repeated exposure] but not with craving and substance seeking behavior.
- #6 Although DSMV delineates between difference substances of abuse, it does acknowledge a general category for those substances not specifically listed and assigned a set of criteria. In most instances, however, the criteria are similar across substances. It would appear the current description of FA would meet the criteria for a substance use disorder. An additional criterion for addiction is proposed that it causes distress and impairment.
- #11 Most of the research regarding the regulation of appetite has been performed with laboratory animals and obese subjects. Only recently have we begun to identify and study individuals [regardless of weight classification] who manifest an addictive relationship with certain foods and/or food consumption.
- #12 In a series of replicated studies, laboratory rats worked harder and longer for a sucrose [sucrose water] reward than for a dose of cocaine.
- #14 Ashley Gherhardt, et al, published a series of studies with subjects meeting criteria for Binge Eating Disorder and estimates 40-60% of these subjects met [YFAS] criteria for food addiction. Phil Werdell reports a yet unpublished epidemiological study suggesting an estimated 50% of the obese, 30% of the overweight and 20% of the normal weight population harbor significant traits commensurate with food addiction [per the suggested definition above].
- #16 TYPE I = EXPERIENCE OF EATING NOT REWARDING BUT PROVOKES ANXIETY TYPE II = RESTRICTING / PURGING WILL STIMULATE REWARD VIA DOPAMINE MECHANISM: TOLERANCE EQUALS MORE RESTRICTING
- #20 BEGINNING = LOVE FOOD, REWARDING, NO CONSEQUENCES MIDDLE = BEGINNING OF CONSEQUENCES, NOT AS REWARDING BUT STILL SOMEWHAT REWARDING END STAGE = VERY LITTLE IF ANY REWARD, NEG REINFORCEMENT, CONTINUING IN ORDER TO AVOID WITHDRAWAL OR EFFECTS OF NOT DOING IT.
- #21 DOWN REGULATION OF DOPAMINE AND DOPAMINE RECEPTORS.
- #22 Availability of Dopamine – Control Subject, Obese Subject, Cocaine Abuser, Alcoholic. *Current research is suggesting D1 receptors play more of a role in mediating reward circuitry with alcohol while D2 receptors are more influential with reward circuitry for food and some drugs such as cocaine. Opiate receptors have also been identified as having a role with the reward circuitry with food in animal studies – lab mice preferring [work harder] sugar water over morphine with a similar result comparing preference for sugar versus cocaine.
- #25 Dynamics of tolerance and withdrawal Tolerance and withdrawal = dependency Tolerance, Withdrawal, Craving [substance seeking] = addiction
- #27 Neuropsychopharmacology (2008) 33, 166–180; doi:10.1038/sj.npp.1301564; published online 5 September 2008. We tend to “remember” [plasticity-wise] events and behaviors we either have an emotional [positive or negative] experience with or have practice with [e.g. muscle memory, trauma, reward experiences, sensory experiences, etc. Operant conditioning via persistent reward reinforcement and re-structure of neural pathways. Recovery may “build” competing pathways [via new repeated behaviors and experiences] but the addictive pathways [memory] remain. MRI imaging demonstrates how re-introduction of an addictive substance can result in an initial surge of dopamine and “awaken” the seemingly dormant addictive pathways].
- #29 Primary ingredient used in Coca Cola and most soft drinks is….HFCS. Primary “trio” of ingredients in a typical McDonalds value meal….Sugar, Fat, Flour, Salt = Hamburger, French Fries, Soft Drink [super sized]. ABOVE = "BLISS POINT"
- #30 Any parallels between the food processing industry and lessons learned from the cigarette manufacturers?
- #31 Nature of the person interacting with the nature of the substance. Biological interaction with psychological elements of the individual.
- #36 COGNITIVE BEHAVIOR THERAPY + DIALECTICAL BEHAVIOR THERAPY [MARSHA LINEHAN] AND TAILORED FOR FA POPULATION BY MOLLY CARMEL, LCSW AT THE BEACON PROGRAMS
- #38 RECOVERY CHECK LIST – PERSONAL / INDIVIDUAL CONCEPT OF SPIRITUALITY, MODERATE [PRESCRIBED] EXERCISE, BALANCE BETWEEN WORK AND PLAY, ABSTINENT [PRESCRIBED] FOOD PLAN. May utilize SMART RECOVERY groups instead of or in addition to 12-Step groups.
- #39 FROM CONSTRUCTIVE LIVING TEXT – 1984 DAVID REYNOLDS, PhD AND A GUIDE TO ED RECOVERY, MARTY LERNER, PhD 2015 PGS 67-76