PHOTO: Hadis Safari
Text: Anna Nagygyörgy, Viktória Farkas y Alejandra Misiolek
When talking about addictions, people usually have something in their mind about certain substances, like alcohol or tobacco, but there are other types of addictions, for example, behavioral ones. In this post we are going to clarify what falls within the “category’ of addictions, what they are like, and what happens when apart from addiction, an eating disorder is present as well.
What are addictions?
For most of history, a person suffering from a substance use disorder has been viewed as someone with a character flaw or a moral deficiency and stigmatized with labels such as “addict” or worse. Research has expanded our understanding of the brain changes responsible for this condition and now we can recognize substance use disorder as a progressive, chronic and relapsing disorder that can be handled by treatment and recovery.
Types of addictions: physical and behavioral addictions
The physical addictions include the use of substances. The DSM-5 (1) specifically lists nine types of substance addictions within the category of substance use disorders: alcohol; caffeine (yes, even caffeine is on the list); cannabis; hallucinogens; inhalants; opioids; sedatives, hypnotics, and anxiolytics; stimulants; and tobacco. The symptoms of substance use disorders fall into the following 4 categories:
- Impaired control: using more of a substance or more often than the person intended; wanting to cut down on using but not being able to. An example of that could be someone who begins their night out by saying they will only have one drink but ends up drinking 6 beverages instead.
- Social problems: neglecting responsibilities and relationships; giving up activities because of substance use; being unable to complete tasks at home, school or work. An example of that could be a college student neglecting their studies and skipping classes because of drinking or being hungover.
- Risky use: using the substance in risky settings (for example drinking alcohol before driving a car), continued use despite known problems.
- Physical dependence: needing more of the substance to get the same effect also known as tolerance; having withdrawal symptoms (for instance hand tremors in the case of alcohol) when a substance isn’t used.
A person can be addicted to behaviors just as seriously as one can be addicted to substances. Behavioral addiction is defined as any time when one loses control of their actions to engage in behaviors that result in brief feelings of happiness. Common types of behavioral addictions include addictions to sex, the internet, pornography, using cell phones, video games, work, gambling, exercise, and shopping.
In the beginning, the person becomes dependent on the pleasurable feelings that come as a result of these behaviors and begins to act compulsory on that behavior. But later on, these good feelings change and the addiction causes more harm than pleasure to the person affected and their environment as well. Despite the severe consequences, the addicted person continues the behavior in question.
The vicious circle of substance use and withdrawal syndrome
The general mechanism of substance addictions is that over time, it becomes a repetitive cycle of being intoxicated, which is followed by withdrawal and then the craving of the substance. When not intoxicated, the individual experiences negative feelings such as depression, anxiety, irritability and anhedonia.
The reason behind this cycle is the reward network in our brains (2). In this network, the dopamine neurons are responsible for the feeling of pleasure. This network can help us strive, focus and find things interesting. These dopamine neurons are engaged when someone is intoxicated, and during withdrawal, they have decreased functioning. This whole process contributes to the loss of motivation and reduced sensitivity to other types of rewards in everyday life. An example of that could be a person who now avoids meeting friends – which previously brought them joy – and drinks or uses drugs alone instead.
Moreover, in the addicted state, there is a reduced sensitivity to the drug’s rewarding properties, which means that a much higher dose is needed to produce the desired effect. In other words, they become more tolerant of the substance. Over time, this leads to seeking the drug not for its pleasurable effects, but instead to escape the negative feelings that come with withdrawal.
Bulimia and alcoholism
Is there a relationship between eating disorders and addictions?
Throughout the last few decades, studies have found a strong association between addictions and eating disorders, especially in bulimia, binge eating disorder and anorexia purgative type. This means that people experiencing an eating disorder are more likely to have a substance use disorder compared to the ones not having an eating disorder.
For example, in a recent study in the United States (3) it has been found that students experiencing eating disorders had a much higher risk of using a substance regularly than their peers. Researchers found that they would misuse cigarettes, alcohol, marijuana, cocaine, hallucinogens and MDMA more frequently. There is another important issue related to the vicious cycle of addiction in eating disorders when one influences the other: the use of more substances at the same time further impacts mental, emotional, and physical health and aggravates negative outcomes that are associated with an eating disorder. In other words, the use of the substances harms people´s emotions and becomes a trigger for more ED (Eating Disorder) cycles, thus, we can observe important comorbidities between alcohol and bulimia or alcohol and purgative anorexia
The risk of substance use in people struggling with Eating Disorders
If we look at other findings (4), we can see differences in the types of eating disorders and their relationships to addiction. In the case of bulimia, individuals may turn to substances to dampen bulimic urges. So when they are on the verge of having a binge eating episode or vomiting they rather smoke a cigarette or drink alcohol instead. In the case of anorexia, women may use substances to lose weight. So instead of eating, they might turn to drinking or taking drugs (most frequently stimulants like cocaine or amphetamine).
It remains unclear why eating disorders and addictions frequently coexist. These associations are complex and likely have several biological and psychosocial influences. For example, when women begin to recover from eating disorders, they may substitute substances (for instance alcohol) for the eating disorder symptoms (like binge eating) or vice versa. Another hypothesis is that the associations between eating disorders and substance use result from shared traits of impulsivity and difficulties with emotional regulation. Having a binge-eating episode or using a substance often occurs when there are difficult emotions a person has to face. Food or any substance (for example tobacco, alcohol or caffeine) intake is often the answer for these people to regulate their negative emotions.
How to prevent drug use and eating disorders?
Having seen the studies cited above and from clinical experience, it is clear that prevention is crucial when it comes to substance use and eating disorders as well. It is especially important in younger age groups as important behavioral changes occur during this stage of development and also because there is greater exposure to substances and peer pressure. The goal of prevention is to avoid substance use to encourage healthy development and ensure that young people can realize their potential and interact positively with their families, schools and communities. Additionally, the sooner we begin interventions focused primarily on helping these people with emotional regulation, the less likely the vicious cycles created by EDs and addictions will become chronic.
- American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596
- Volkow, N.D. and Blanco, C. (2023), Substance use disorders: a comprehensive update of classification, epidemiology, neurobiology, clinical aspects, treatment and prevention. World Psychiatry, 22: 203-229. https://doi.org/10.1002/wps.21073
- Qeadan, F., English, K., Luke, A., & Egbert, J. (2023). Eating disorders and substance use: Examining associations among US college students. International Journal of Eating Disorders, 56(5), 956–968. https://doi.org/10.1002/eat.23892
- Baker, J.H., Mitchell, K.S., Neale, M.C. and Kendler, K.S. (2010), Eating disorder symptomatology and substance use disorders: Prevalence and shared risk in a population-based twin sample. Int. J. Eat. Disord., 43: 648-658. https://doi.org/10.1002/eat.20856