DSM-V Acknowledges Food Addiction

DSM-5 CoverThis past May, The American Psychiatric Association unveiled its updated Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V). The inclusion of Binge Eating Disorder as a diagnostic category bodes well for the eventual recognition of food addiction as a substance use disorder in future editions of the manual.

The following is an excerpt:

“Binge Eating Disorder:

A. Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following:

a. recurrent episodes of binge eating, in which binge eating is defined as eating in a discrete period of time, (e.g. within a 2-hour period) an amount of food that is definitely larger than what most people would eat in a similar period of time under similar circumstances, and

b. a sense of lack of control over eating during the episode (e.g. a feeling that one cannot stop eating or control what or how much one is eating.).

B. Three of the following:

a. Eating much more than normal.

b. Eating until feeling uncomfortably full.

c. Eating large amounts of food when not physically hungry.

d. Eating alone because of feeling embarrassed by how much one is eating.

e. Feeling disgusted with oneself, depressed or very guilty afterwards.

C. Marked distress regarding binge eating.

D. The bingeing occurs as least once a week for 3 months.

E. The binge eating is not associated with the recurrent use of inappropriate compensatory behavior as in bulimia nervosa and does not occur exclusively during the course of bulimia nervosa or anorexia nervosa…..

Specify current severity:

The minimum level of severity is based on the frequency of episodes of binge eating (see below). The level of severity may be increased to reflect other symptoms and the degree of functional disability.

  • Mild: 1-3 binge-eating episodes per week.
  • Moderate: 4-7 binge-eating episodes per week.
  • Severe: 8-13 binge-eating episodes per week.
  • Extreme: 14 or more binge-eating episodes per week.”1

Health professionals familiar with food addiction, as well as self-assessed food addicts, will immediately notice that many, possibly a large majority, of cases of food addiction fulfill all the characteristics of Binge Eating Disorder and that most late- and final-stage food addicts display severity equivalent to “severe” or “extreme” Binge Eating Disorder. In the introduction to the Feeding and Eating Disorder section of the DSM-5, this is acknowledged:

“Some individuals with disorders described in this chapter report eating-related symptoms resembling those typically endorsed by individuals with substance-use disorders, such as strong craving and patterns of compulsive use. The resemblance may reflect the involvement of the same neural systems, including those implicated in regulatory self-control and reward in both groups of disorders. However, the relative contributions of shared and distinct factors in the development and perpetuation of eating and substance use disorder remain insufficiently understood.” (DSM-5, p 329)

This recognition of food as a substance-use disorder in the diagnostic manual is of extreme importance. It gives clinicians encouragement to look for a psycho-socially caused eating disorder, a biochemically caused food addiction, or both. It also means that in the treating of Binge Eating Disorder, both the traditional treatment for eating disorder (i.e. therapy, mindfulness training, and medication) and traditional addictive-,model treatments (i.e., abstinence, education about chemical dependency and preparation for 12-Step-type aftercare) should be covered by health insurance reimbursement as appropriate to the clinician’s diagnosis. This principle obviously applies equally where binge-eating co-occurs with anorexia and/or bulimia. Here too, the binge eating may have psychodynamic roots, be caused by biochemical addiction or both.

These conclusions align completely with the observations of Dr. Charles O’Brien, chairman of the Substance Use Work Group of the DSM-5. As we reported earlier, in his letter to the Food Addiction Institute, Dr. O’Brien wrote:

“We share your interest in understanding how eating behaviors can take on characteristics that strongly resemble the behavior of individuals who abuse substances such as cocaine. It is likely that this resemblance reflects the fact that neurobiological systems involved in processing of reward are disturbed in both disorders. The problem is that, at present, the precise nature of these disturbances and how the neurobiology of eating disorders resembles and differs from the neurobiology of substance-use disorders is unknown. We, and the members of our Work group, wholeheartedly endorse research to understand this important overlap.” (foodaddictioninstitute.org. July 2012)

We replied that The Food Addiction Institute favors introducing food as a Substance Use Disorder on an experimental basis – as Binge Eating disorder was published in the DSM-IV-TR – to encourage clinical and scientific experimentation. Meanwhile, we encourage clinicians to look not only for psycho-social, trauma-based eating disorders but also for biochemical cravings that may be caused by consumption of a specific food or foods. Each needs to be treated differently, and the most complex cases often satisfy criteria for both psycho-social eating disorders and food addiction.

  1. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, pp. 350-352. Arlington, VA, American Psychiatric Association, 2013. []