Food Addiction & Self-Harm: Maladaptive Coping

Introduction

Biological Basis

Genetic predisposition accounts for 40-60% of the vulnerability to addiction, highlighting its nature as a medical condition.

Environmental Influence

Factors like early exposure, trauma, and socioeconomic conditions play critical roles in the development of SUD.

Some behaviors that appear harmful may serve important regulatory functions for individuals struggling with emotional distress. This module examines food addiction—a controversial concept with significant research support—and non-suicidal self-injury, both of which can be understood as maladaptive attempts to cope with overwhelming emotions. Understanding the function of these behaviors is essential for compassionate, effective treatment.

Learning Objectives

By the end of this module, you will be able to:

Explain the evidence for and against food addiction as a concept
Describe the role of highly palatable foods in reward circuitry
Understand non-suicidal self-injury and its functions
Explain the role of endogenous opioids in both conditions
Apply appropriate assessment and treatment approaches

Food Addiction: The Concept

How we speak about addiction affects patient care and recovery. Use person-first language to reduce bias.

Instead of

Addict or Substance

Clean/Dirty Tests

Use This

"Person with Substance Use Disorder"

"Positive/Negative Results"

Definition

Food addiction proposes that certain foods (particularly highly palatable, processed foods) can trigger addiction-like responses in vulnerable individuals, characterized by:

Loss of control over eating
Continued consumption despite negative consequences
Tolerance (needing more to achieve same effect)
Withdrawal-like symptoms when reducing intake
Craving

Controversy

Arguments FOR Food Addiction:

Neuroimaging shows similar brain activation to drug addiction
Animal models demonstrate addiction-like behaviors with sugar
Clinical phenomenology resembles substance addiction
Provides framework for understanding and treatment
Yale Food Addiction Scale validated

Arguments AGAINST:

Natural behavior (eating) vs. drug use
No single addictive substance identified
Risk of stigmatization
May oversimplify complex eating behaviors
Industry may exploit concept (blame individual, not food)

Current Status

NOT in DSM-5 or ICD-11 as formal diagnosis
Research criteria exist (Yale Food Addiction Scale)
Active area of scientific debate
Clinical utility acknowledged by many

Neuroscience of Highly Palatable Foods

The Reward System Hijack

The brain's reward system evolved to reinforce survival behaviors. Addictive substances create a dopamine surge that far exceeds natural stimuli:

Opioids

2-10x Normal Release

Cocaine

Blocks Reuptake

Alcohol

GABA/Glutamate Shift

Nicotine

Acetylcholine Trigger

Reward Circuitry Activation

Highly palatable foods (high sugar, fat, salt combinations) activate reward pathways:

| Finding | Implication | |---------|-------------| | Dopamine release in NAc | Same reward pathway as drugs | | Opioid system activation | Pleasure response | | Tolerance-like effects | May need more for same satisfaction | | Withdrawal-like symptoms | Irritability, craving when restricted |

The "Bliss Point"

Food scientists engineer processed foods to maximize palatability:

Optimal sugar/fat/salt ratio
Texture engineering
Flavor enhancement
Designed to "override" natural satiety signals

Note: This doesn't mean these foods are "addictive substances" in the same way as drugs, but they may exploit similar neural mechanisms.

Which Foods?

Research suggests certain food characteristics are associated with addiction-like eating:

High glycemic index (rapid blood sugar spike)
Combination of fat + refined carbohydrates (rare in nature)
High caloric density
Processing that removes fiber, water, protein

Examples: Chocolate, ice cream, pizza, chips, cookies, cake

Rarely implicated: Vegetables, fruits, plain meats, whole grains

Yale Food Addiction Scale

Overview

The Yale Food Addiction Scale (YFAS) is a 25-item self-report measure assessing addiction-like eating using DSM criteria for substance use disorders adapted for food.

Criteria Assessed

Eaten more than intended
Unable to cut down despite wanting to
Great deal of time spent obtaining, eating, recovering
Craving
Failure to fulfill major role obligations
Continued eating despite social/interpersonal problems
Important activities given up
Eating in physically hazardous situations (while driving)
Continued eating despite physical/psychological problems
Tolerance
Withdrawal

Prevalence Using YFAS

| Population | Prevalence | |------------|------------| | General population | 5-10% | | Overweight/obese | 15-25% | | Bariatric surgery candidates | 30-50% | | Binge Eating Disorder | 50-70% |

Binge Eating Disorder

DSM-5 Criteria

Recurrent episodes of binge eating characterized by:

Eating, in a discrete period, more than most people would eat
Sense of lack of control during episode

Episodes associated with 3+ of:

Eating more rapidly than normal
Eating until uncomfortably full
Eating large amounts when not hungry
Eating alone due to embarrassment
Feeling disgusted, depressed, or guilty afterward

Frequency: At least once weekly for 3 months Distress: Marked distress about binge eating No compensatory behaviors (distinguishes from bulimia)

Relationship to Food Addiction

Significant overlap but not identical:

Many with BED meet food addiction criteria
Not all with food addiction meet BED criteria
Food addiction may identify specific subtype
Treatment implications may differ

Treatment Approaches for Problematic Eating

Cognitive Behavioral Therapy (CBT)

Gold standard for BED and problematic eating:

Establish regular eating patterns
Identify triggers for binge/overeating
Develop alternative coping strategies
Address cognitive distortions about food, body, control
Exposure and response prevention

Dialectical Behavior Therapy (DBT)

Addresses emotional regulation:

Mindfulness skills
Distress tolerance
Emotion regulation
Interpersonal effectiveness
Particularly useful when eating is emotion-driven

Pharmacotherapy

FDA-approved for BED:

Lisdexamfetamine (Vyvanse)—reduces binge frequency

Off-label:

SSRIs (reduce binge frequency, treat comorbid depression)
Topiramate (reduces binge eating, promotes weight loss)
Naltrexone (opioid antagonist—may reduce food reward)

Nutritional Approaches

Regular, balanced meals
Avoid severe restriction (triggers bingeing)
Minimize highly palatable "trigger foods" (individualized)
Work with dietitian experienced in eating disorders

Non-Suicidal Self-Injury (NSSI)

Definition

Non-suicidal self-injury is the deliberate, self-inflicted destruction of body tissue without suicidal intent and for purposes not socially sanctioned.

Common Methods:

Cutting (most common)
Burning
Hitting self
Scratching
Skin picking
Interfering with wound healing

Prevalence

| Population | Lifetime Prevalence | |------------|---------------------| | Adolescents | 15-20% | | Young adults | 10-15% | | Adults | 5-6% | | Clinical populations | 40-80% |

Functions of NSSI

Understanding WHY someone self-injures is crucial for treatment:

Emotion Regulation (most common):

Reduces overwhelming negative emotions
Provides relief from numbness
Interrupts dissociation
"Resets" emotional state

Self-Punishment:

Expressing anger at self
Punishing perceived failures
Addressing guilt/shame

Communication/Influence:

Expressing distress to others
Seeking help
Influencing others' behavior

Anti-Dissociation:

"Feeling real" or "feeling alive"
Grounding when dissociated
Confirming existence

Anti-Suicide (paradoxically):

Release pressure to prevent suicide attempt
Alternative to suicide

Endogenous Opioids and NSSI

The Opioid Hypothesis

Self-injury may work through the endogenous opioid system:

Mechanism:

Tissue damage triggers endorphin release
Endorphins bind to opioid receptors
Pain relief and mood elevation occur
Behavior is reinforced

Evidence:

Naltrexone (opioid antagonist) reduces NSSI in some studies
People who self-injure often report reduced pain sensitivity
Endorphin levels may be abnormal in those who self-injure

Connection to Other Behaviors

This mechanism may also explain:

Exercise addiction (runner's high)
Some aspects of eating pathology (sugar/fat trigger opioid release)
Compulsive behaviors that provide relief

Assessment of NSSI

Key Areas to Assess

Method, Frequency, Severity:

What methods used?
How often?
Medical severity of injuries?
Escalation over time?

Function:

What purpose does it serve?
What triggers episodes?
What emotions precede/follow?

Suicidality:

NSSI increases suicide risk
Always assess suicidal ideation/intent
Distinguish NSSI from suicide attempts

Comorbidities:

Depression, anxiety
PTSD, trauma history
Borderline personality disorder
Eating disorders
Substance use

Screening Questions

"Some people hurt themselves on purpose when they're upset. Has this ever happened to you?"
"Have you ever cut, burned, or hurt yourself on purpose?"
If yes: "What led up to it? How did you feel before/after?"

Treatment of NSSI

Psychotherapy

Dialectical Behavior Therapy (DBT):

Developed for borderline personality disorder
Strong evidence for NSSI reduction
Teaches alternative coping skills
Distress tolerance, emotion regulation

Cognitive Behavioral Therapy:

Identify triggers and patterns
Develop alternative responses
Address underlying cognitions

Mentalization-Based Therapy:

Understanding mental states of self and others
Improves emotional processing

Safety Planning

Identify triggers and warning signs
Alternative coping strategies
Delay and distraction techniques
Means reduction
Emergency contacts

Harm Reduction

Non-judgmental approach
Minimize damage if stopping immediately not possible
Wound care education
Gradual reduction in frequency/severity

Pharmacotherapy

No medications specifically approved for NSSI

Treat underlying conditions (depression, anxiety)
Naltrexone (limited evidence)
Consider psychiatric comorbidities

Connecting Themes: Maladaptive Coping

How we speak about addiction affects patient care and recovery. Use person-first language to reduce bias.

Instead of

Addict or Substance

Clean/Dirty Tests

Use This

"Person with Substance Use Disorder"

"Positive/Negative Results"

Common Features

Both food addiction/binge eating and NSSI share:

Attempt to regulate overwhelming emotions
Short-term relief, long-term consequences
Often linked to trauma history
May involve endogenous opioid systems
Stigmatized and misunderstood
Respond to similar treatment approaches (DBT)

Trauma-Informed Understanding

Many of these behaviors develop in context of:

Childhood trauma
Invalidating environments
Lack of healthy coping models
Emotional neglect

Key Message: These behaviors often make sense as survival strategies in context, even when they become harmful.

Case Study: Multiple Coping Behaviors

Shreya, 19, presents with her mother who is concerned about cuts on Shreya's arms and recent weight gain. Shreya admits to cutting herself when "things get too overwhelming" and eating "until I feel numb" several times weekly. She has history of childhood sexual abuse. She says cutting and eating are "the only things that help."

Discussion Questions:

4What functions might both behaviors be serving?
5How would you assess suicidality?
6What is the role of the trauma history?
7What treatment approach would you recommend?
8How would you engage her mother as a support?

Key Takeaways

Food addiction is a controversial but research-supported concept with neurobiological evidence
Highly palatable foods activate reward circuitry similarly to drugs of abuse
The Yale Food Addiction Scale provides research criteria for assessment
Non-suicidal self-injury serves functions, most commonly emotion regulation
Endogenous opioids may mediate the "relief" from both binge eating and self-injury
Both conditions often have roots in trauma and inadequate coping development
DBT is effective for both, addressing underlying emotional dysregulation
Compassionate, non-judgmental assessment is essential

Part 3 Complete! Next: Part 4: Resolution & Future, beginning with Module 14: Treatment & Recovery →

Introduction

Biological Basis

Environmental Influence

Learning Objectives

Food Addiction: The Concept

Definition

Controversy

Current Status

Neuroscience of Highly Palatable Foods

The Reward System Hijack

Reward Circuitry Activation

The "Bliss Point"

Which Foods?

Yale Food Addiction Scale

Overview

Criteria Assessed

Prevalence Using YFAS

Binge Eating Disorder

DSM-5 Criteria

Relationship to Food Addiction

Treatment Approaches for Problematic Eating

Cognitive Behavioral Therapy (CBT)

Dialectical Behavior Therapy (DBT)

Pharmacotherapy

Nutritional Approaches

Non-Suicidal Self-Injury (NSSI)

Definition

Prevalence

Functions of NSSI

Endogenous Opioids and NSSI

The Opioid Hypothesis

Connection to Other Behaviors

Assessment of NSSI

Key Areas to Assess

Screening Questions

Treatment of NSSI

Psychotherapy

Safety Planning

Harm Reduction

Pharmacotherapy

Connecting Themes: Maladaptive Coping

Common Features

Trauma-Informed Understanding

Case Study: Multiple Coping Behaviors

Key Takeaways

Module Quiz

Learning Resources

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