In individuals with obesity and binge eating disorder (BED), eating patterns can show addictive qualities, with similarities to substance use disorders on behavioural and neurobiological levels. Bulimia nervosa (BN) has received less attention in this regard, despite their regular binge eating symptoms. The Yale Food Addiction Scale (YFAS) was developed according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, diagnostic criteria for substance use disorders, and food addiction can be diagnosed when at least three addiction symptoms are endorsed and a clinically significant impairment or distress is present. Although the prevalence of food addiction diagnoses is increased in individuals with obesity and BED, recent studies which used the YFAS showed that there are also individuals with normal weight who can be classified as being ‘food addicted’.
Results provide support for the notion that BN can be described as addiction-like eating behaviour and suggest that food addiction most likely improves when BN symptoms remit.
Food Addiction and Bulimia Nervosa
Adrian Meule, Vittoria von Rezori, Jens Blechert
This study was reviewed and approved by the ethical committee of the University of Salzburg, Austria. Women with a current diagnosis or a history of BN were recruited via outpatient clinics and counselling centres specialised on eating disorders in southern Germany. Participants signed written informed consent.
Women who reported to have a current diagnosis of BN (n = 34) were excluded if they were currently underweight (BMI< 17.5 kg/m2 ), scored below the cut-off of the Eating Disorder Examination Questionnaire (EDE-Q) of 2.3 (Mond, Hay, Rodgers, Owen, & Beumont, 2004)1 or reported less than eight binge or less than eight purging episodes within the past 28 days on the EDE-Q. As a result, eight participants were excluded, leaving a final sample size of n = 26 for the current BN group.
Based on self-reported eating disorder symptoms, women with current (n = 26) or remitted (n = 20) BN, and a control group of women matched for age and body mass index (n = 63) completed the YFAS and other measures. Results revealed that all patients with current BN received a food addiction diagnosis according to the YFAS while only six (30%) women with remitted BN did. None of the women in the control group received a food addiction diagnosis.
The current study aimed to investigate the concept of food addiction and its correlates in women with bulimic symptomatology. All participants currently exhibiting bulimic behaviours and 30% of those with a history of BN could be classified as ‘food addicted’ according to the YFAS while none of the women in the control group received such a diagnosis. This finding is in line with the study by Speranza et al. (2012) as it clearly demonstrates that eating behaviour in individuals with BN is highly comparable with substance use in SUDs and that bulimic behaviour may itself be described as an addicted behaviour. These findings based on self reported behaviour are complemented by recent examinations of neurobiological processes that show similarities between BN and substance dependence as well (Hadad & Knackstedt, 2014).
One potential clinical implication of the present finding of addiction-like characteristics in individuals with BN would be to adapt SUD interventions for BN. This might include psychoeducational modules on addiction or stimulus control procedures that reduce exposure to ‘addictive’ foods (in contrast to current practice in BN psychotherapy). For example, case reports exist, which showed that providing an addiction framework motivated change in patients with BN and their families (Slive & Young, 1986). Some self-help groups encourage to avoid certain ‘addictive’ foods (e.g. Russel-Mayhew, von Ranson, & Masson, 2010), which is usually considered contraindicated in the treatment of BN (Wilson, 2010). Techniques such as motivational interviewing or acceptance-oriented imagery to cope with urges may be adapted from SUD treatments to enhance motivation to change and dealing with food cravings (Davis & Carter, 2014). Finally, pharmacotherapy targeting opioid and dopaminergic neurotransmitter systems have been shown to be effective in SUD treatments and may also be helpful in reducing binge eating (Davis & Carter, 2014; Hadad & Knackstedt, 2014). For example, a recent animal study showed that an aldehyde dehydrogenase inhibitor,
which has been shown to reduce alcohol and cocaine intake in rats, selectively attenuated binge eating of palatable foods and dopamine release in sugar-bingeing rats (Bocarsly et al., 2014).
food addiction; Yale Food Addiction Scale; bulimia nervosa; binge eating; substance dependence
Meule, A., von Rezori, V., & Blechert, J. (2014). Food Addiction and Bulimia Nervosa. European Eating Disorders Review, 22(5), 331–337. doi:10.1002/erv.2306