Food Addiction & Self-Harm: Maladaptive Coping

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

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

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

1. Eaten more than intended
2. Unable to cut down despite wanting to
3. Great deal of time spent obtaining, eating, recovering
4. Craving
5. Failure to fulfill major role obligations
6. Continued eating despite social/interpersonal problems
7. Important activities given up
8. Eating in physically hazardous situations (while driving)
9. Continued eating despite physical/psychological problems
10. Tolerance
11. Withdrawal

Prevalence Using YFAS

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

DSM-5 Criteria

Recurrent episodes of binge eating characterized by:

1. Eating, in a discrete period, more than most people would eat
2. 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

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

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

The Opioid Hypothesis

Self-injury may work through the endogenous opioid system:

Mechanism:

1. Tissue damage triggers endorphin release
2. Endorphins bind to opioid receptors
3. Pain relief and mood elevation occur
4. 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

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?"

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

• 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 →