BED and Addictive Behaviors

While addictive behaviors and binge eating disorder (BED) do not mirror one another, some characteristics of addictive behaviors can be helpful in screening and treating people with BED. Though it is tempting to categorize the two as similar, a recent study by Alexandra Paul and colleagues at Johns Hopkins University School of Nursing in Philadelphia showed distinct differences between BED and addictive behaviors (Substance Abuse and Rehabilitation. 2023. 14:P77).

BED involves recurring episodes of binge eating and consuming a large amount of food in a short period while feeling a loss of control over eating. BED is classified as: mild (1 to 3 episodes a week; moderate (4-7 episodes per week); severe (8-13 episodes per week), and extreme (14 or more episodes per week).

Food Addiction

Addiction to food, which is assessed with the Yale Food Addiction Scale (YFAS), affects around 20% of adults (Eur Eat Disord Rev. 2022. 30:85), and is not yet a formal diagnosis recognized by the DSM-5. As the authors note, there is often a phenotypic overlap of food addiction with BED. BED and addictive behaviors are similar in that they both feature a loss of control, consuming food or other substances in larger than intended amounts, and continued behaviors in spite of adverse consequence and greater clinical distress. The neurobiological profiles are also similar, according to the authors.

The authors note that both BED and addictive behaviors are underrecognized and underdiagnosed in spite of available and effective treatments for both. Despite the fact that the lifetime prevalence of BED is estimated to be 1.9%, it is often underdiagnosed, and thus may go untreated. In one survey, 93% of general healthcare providers and 89% of psychiatrists could not correctly identify the diagnostic criteria for BED (J Nurse Scholarsh. 2019. 51:399). Additional barriers to screening of addictions as well as BED include time and workflow constraints.

Current pharmacological treatment also often falls short. At this time, the only FDA-approved medication for treating BED is lisdexamfetamine (Vyvanase™), which is usually prescribed at a dose of 30 mg, then increased by 20 mg weekly, to reach a recommended dosage of 50 to 70 mg per day. Use of lisdexamfetamine has reduced binge eating rates by 32% to 40% (JAMA Psychiatry. 2015.72:235).

Lisdexamfetamine also includes a warning about abuse and dependence. Other medications, such as selective serotonin reuptake inhibitors (SSRIs), have also been useful in BED cases. Only the antiepileptic agent topiramate decreases both binge eating and weight gain–either alone or when combined with cognitive behavioral therapy (CBT). In the few trials published, pharmacotherapy appears to be less effective than psychological treatment for BED (Biol Psychiatry.2005.57:301).

Would abstinence work?

Treatment goals for BED are aimed at reducing binge eating episodes, and ultimately are designed to enable patients to abstain from binge eating. In contrast, the treatment goal for substance-related disorders is total abstinence. Behavioral and psychological therapies most often used for addictions include CBT and 12-Step programs (J Consult Clin Psychol.2019. 87:109389). According to the authors, when an “addictive approach” is used in BED treatment, it merely makes it more challenging for vulnerable individuals to moderate their intake. And, with this approach, foods may not be viewed as “forbidden,” but may actually have chemical properties that give them a greater propensity to cause binge eating. Programs such as Overeaters Anonymous and 12-Step programs encourage abstinence from certain foods. These programs have not been tested among BED patients, and further research is needed, according to the authors.

Chronicity

Addictions are often seen as chronic relapsing brain disorders because permanent neurobiological changes take place that cannot be completely cured even with remission (N Engl J Med.2016.374:363). The few available long-term studies of BED show that about half of individuals make a full recovery after receiving a single treatment, without need for continued monitoring. Paul and her colleagues concluded that despite the similarities between BED and addictive behaviors, there are notable differences.