The Difference Between Dependence and Compulsion (and why it’s important)

Addiction is a layman’s term. Often it’s used to describe substance dependence. It’s also sometimes used when referring to compulsive behaviors such as gambling, shopping or sex.

The DSM-IV, the book of diagnostic criteria for all manner of disorders, uses two terms with regard to what you probably think of when you hear the word addiction. Those terms are abuse and dependence.

Let’s use alcohol as an example.

When I was a substance abuse counselor I evaluated many, many people who were court ordered to my office following a DUI or some other legal trouble that arose from something they did while or after they’d been drinking. Many of these people were diagnosed with alcohol abuse, which requires that someone in a 12-month period have a recurring problem with the law, failure to fulfill a major life role (work, family, etc.), putting themselves or others into dangerous positions (driving while intoxicated, getting into fights, becoming violent after drinking, etc.) or continued use even after a problem has occurred as a result of their use.

So, someone who only drinks occasionally, but drives while intoxicated, becomes violent, or calls in sick to work the next day when they do–and continues to drink even after being arrested, having their spouse move out or being warned at their job, is someone who would probably be diagnosed with alcohol abuse.

Dependence is different. Someone who is diagnosed with alcohol dependence exhibits signs of having built up a tolerance, suffers withdrawal when they don’t drink, must drink more and more to achieve the same level of intoxication, may have failed to successfully cut down or quit drinking, spends a lot of their time on alcohol (thinking about it, planning to drink, obtaining alcohol, etc.), has given up parts of their lives (social, work, family, etc.) in favor of alcohol and continues to drink even knowing that it is a major problem for them (after being arrested or losing their families, for instance.)

Diagnosis of dependence requires presence of three of these. So someone who must drink to avoid withdrawal, wants to quit but can’t and has continued to drink even knowing the consequence of doing so is losing their marriage is clinically dependent on alcohol. This is the person that most people would consider an addict.

Now, knowing all of that, it makes sense that some people believe that they are addicted to food. I mean, if you quit eating you get physically ill. Almost everyone in Western culture has tried to cut back on food, but eventually failed. And even if you are threatened with a loss of a job or the end of your marriage, you continue to eat.

It’s harder to make a case for food abuse, actually, since it’s not yet illegal to eat. Not even for fat people. I suppose you might be able to claim food abuse if you repeatedly forget to pick your kids up from school or miss work because you’re too busy eating to attend to your life. And you might stretch the hazard criteria to include food if you believe that someone who continues to eat even though they are fat is putting their lives at risk.

But here’s the thing. I don’t think you can diagnose food dependence or abuse. You can’t be dependent on food anymore than you can be on breathing or sleeping. Suggesting so is dangerous, in my opinion, because it suggests that food is something that can be abstained from like alcohol or drugs. And it obviously isn’t.

Does that mean that it’s impossible to have an unhealthy relationship with food? There are millions of people who suffer from disordered eating, which suggests the answer to that question is no. Can eating become a compulsion? Sure. But I think it’s important to understand that dependence and compulsion are not the same thing, even though they both are often called addiction.

The DSM defines a compulsion as a repetitive behavioral or mental act that a person feels driven to perform and requires that the act be directed at avoiding distress or a tragic event.

Refusing to maintain a sufficient body weight or making yourself throw up are food-related compulsions that are undertaken as a way to avoid the tragic event of becoming fat.

Eating enough to sustain yourself at your current weight is not a mental illness. It is not a compulsion or a dependence.

One reason people use alcohol or drugs in the first place is because they stimulate a flood of feel good chemicals. They aren’t using because it sucks, right? They use because it feels good, even when the consequences are negative.

Food stimulates the same chemicals. Know why we have those chemicals? We have them because they help insure our survival as a species. When we eat something with a lot of carbs or fat, our bodies reward us because those are the things that would keep us alive should we ever find ourselves in a famine.

The mere fact that eating feels good does not make food an addictive substance. Eating is something that can be done in a disordered way, but the fact that it is necessary to human life precludes it from being an addictive behavior.

Eating disorders and substance dependence can come from the same place. They might start as a way to find some sense of control or to cope with some bad something that’s happening in a person’s life. But they are not the same. They are not diagnosed the same way, they are not in the same section of the DSM. As a licensed drug and alcohol counselor, I can’t treat eating disorders or fat people with ‘food addiction.’

Some people want food addiction to be included in the next edition of the DSM. They want us to think of the poor fat kids who really need their daily sustenance to be stigmatized.

Think about this: alcohol is separated from other drugs in the DSM and in treatment settings. There is a level of drinking (1 drink per day for women, 2 for men) that is considered safe and unlikely to lead to abuse or dependence. Why? Because alcohol is a food. It has nutritive value.

In fact, while most other drugs result in weight loss, alcohol often results in weight gain. Because it has calories.

So even though in excess it causes severe problems and is one of the only substances that can cause death on withdrawal, it is given a pass as long as its not used in a compulsive way.

So why shouldn’t food be treated in the same way? After all, if you eat too much of it, you get the fat and then the diabetes or heart disease or just drop dead, right? In moderate amounts, okay, but eat too much of it and it’s the end of the line for you.

Alcohol is food (grains, grapes, potatoes, etc.) that has been manipulated into a fermented liquid that causes intoxication is toxic if taken in large amounts.

Food poisoning is something else, right? It doesn’t come from eating so much that you die.

Alcohol floods your brain with chemicals to the point that the natural amount that you make doesn’t have an affect anymore. This is why depression is common with recovery. Without the flood, for a while nothing feels good anymore.

Food does exactly what it’s supposed to do. It stimulates your brain to offer you a reward for eating it. Grapes give you a little happy feeling, wine intoxicates you.

Alcohol is a drug.

Food is not.

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Filed under body, mind, spirit

4 responses to “The Difference Between Dependence and Compulsion (and why it’s important)

  1. Mulberry

    This is interesting! Can you get Pattie Thomas to write something about it in her column in Psychology Today? It’s something more people should know, and Psychology Today is just the place to talk about it.
    How do some people get addicted to starving themselves? What’s in it for them, brain chemical-wise?

    • That’s the thing, Mulberry. Anorexia is not an addiction, it’s a compulsion. What’s in it for them is a sense of control and also a reduction of stress/anxiety. By controlling what they eat, they ease their anxiety about getting fat or being fat if they feel like they are.

    • Also, it would be awesome if Pattie Thomas talked about this to a wider audience. She’s so amazing.

  2. Thank you for this. Very informative and I finally understand the difference!

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