Food Addiction: Eating Disorder or Substance Use Disorder?

Are certain eating disorders basically food addictions comparable to substance use disorders (SUDs) such as alcoholism or heroin abuse? That is the question discussed by Marty Lerner, Ph.D., in his presentation as part of the Williamsburg Place Lecture Series. Lerner is a licensed and board-certified clinical psychologist who specializes in the treatment of eating disorders. He is the CEO of Milestones In Recovery in Florida.

Feeding and eating disorders certainly appear in a different section than substance use disorders in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), the manual widely used by researchers and clinicians as the principal authority for psychiatric diagnoses.

“The majority of people who treat eating disorders do not regard them as addictions,” Lerner said. “They treat them more as a traditional psychiatric issue.” For Lerner, however, there are strong similarities. His basic assumption is that addiction is a “complex combination of interactions between the biology of the ‘addict,’ the nature of the substance abused, and the environment these take place.” The availability of the substance is the spark that sets off the process.

“Addiction is about ‘fixing’ feelings,” Lerner explained. “Recovery is about doing the next right thing, despite feelings.”

The nature of the person and nature of the substance are major factors in certain types of eating disorders that Lerner considers food addictions. Throughout his lecture, Dr. Lerner compared the reaction of individuals with a predisposition to addiction to people who don’t have it (nature of the person).

One hospitalized patient on a morphine pump might experience discontinuation syndrome (physical withdrawal symptoms) but not addiction when the morphine is stopped while another person with an addictive nature will continue to crave the drug. “The addict will want more, the non-addict will want no part of it,” said Lerner.

So what about compulsive overeating? Lerner presented a definition of the Food Addiction Institute: “Food addiction is a disease causing loss of control over the ability to stop eating certain foods.” Lerner believes these patients develop a “chemical dependency on specific foods” (nature of the substance).   

Disordered eating is frequently approached as a psychological problem involving poor impulse control and “emotional eating.” But “not recognizing, and treating, the biological drivers of food cravings and overeating often leads to a poor outcome of treatment. According to Lerner, we are dealing with a mixture of both emotional and biological aspects. “Treatment of an eating disorder demands attention to the nature of the substance, the nature of the person or behaviors, and the biology of the individual.”

In his experience most people with eating disorders are “sensitive to high glycemic foods,” mainly highly processed food, sugar, and products containing white flour. The human body regulates appetite and satiety mostly through two hormones, leptin and ghrelin. Leptin acts as a brake on hunger, and ghrelin is the “gas pedal.” Unfortunately, some “20 percent of humans are born with faulty brakes,” said Lerner.

The dynamics for eating disorders and SUDs are almost identical and come in three chapters. In the first chapter, the addictive substances work terrifically for the individual with the right biological disposition and a need to self-medicate emotional pain. In the second chapter, that person is mostly chasing the euphoria of the first. In third chapter, the solution becomes the problem: “you no longer like how you feel with the substance or behavior and you can’t stand how you feel without it,” explained Lerner. “You’re constantly trying to avoid withdrawal.”

Lerner’s three chapters of recovery are the mirror image of the above sequence. First, it is really hard and uncomfortable; Lerner calls this initial phase “legitimate suffering.” In the second chapter, it gets slowly easier and in the third “you’re much more comfortable in recovery than you were when using.”

Major drivers behind substance use and eating disorders are underlying mental health issues such as depression, anxiety, and unprocessed trauma. This is what both the binge eater and the heroin user are trying to suppress, or at least control. “For overeaters eating becomes an antidepressant, for people suffering from anorexia not eating becomes an antidepressant, and both are headed for a train wreck because eventually it doesn’t work anymore,” Lerner said. “All addictions have that in common.”

Since addictions, including food addiction, are based on a “complex combination of interactions,” they require a comprehensive approach to treatment. Dr. Lerner’s comprehensive therapy can be summarized with the acronym SMERF. It stands for spirituality, meditation, exercise, rest, and food—for him the five main ingredients to overcoming 90 percent of what ails us humans, but particularly addiction.

Spirituality is powerful but purposely ambiguous because it is personal—the belief in something other than your ego, a Higher Power, or God of your understanding. Meditation means taking a period of time, getting quiet, becoming aware of how many times the mind “leaves the station” and bringing it back—as physical training is exercise for the body, meditation is exercise for the mind. Exercise accordingly: do for your body what’s healthy. Rest: find the right balance between work, play, and recuperation. And finally, eat nutritious food according to individual needs—a food plan means putting boundaries around your food, abstain from unhealthy eating, unhealthy food, eliminating highly processed foods, sugars, white flour, and keep an eye on volume.

Recovery from a binge-eating disorder “is not about losing weight, it’s about changing everything,” said Lerner. “If all you’re doing is abstention—not drinking or overeating—you’re just buying some time and you will probably relapse. The secret is hard work—gastric surgery and antidepressants will only get you so far—if you’re not willing to put in the work to get from chapter one to chapter three, it’s all an illusion.”