What Causes Habits and Addictions?

Copyright © 2014 by David D. Burns, MD

Why do we overeat? Why do we use drugs or drink too much?

Many experts believe that people overeat because of emotional problems, such as depression, low self-esteem, anxiety, boredom, loneliness, irritability, or stress. According to this theory, people who binge on food are trying to comfort themselves with food. This is called “emotional eating.”

Other experts use the term, “emotional dysregulation.” This is a big and impressive term that simply means that some individuals have trouble regulating, or controlling, their emotions, so they turn to food, drugs, or alcohol to comfort themselves when they feel upset, or to escape from the problems in their lives.

It turns out that that these theories may not be correct—recent research suggests that the real cause of addictions may be something much simpler and far more obvious.

Recently I had a chance to test these theories in a research study involving 160 newly admitted patients at the Stanford University Hospital. The main focus of the study was a validation of my EASY Diagnostic System, along with a new scale I created to assess the importance of motivation in recovery from depression. This is the reference for the study:

Burns, D. Westra, H., Trockel, M., & Fisher, A. (2012) Motivation and Changes in Depression. Cognitive Therapy and Research DOI 10.1007/s10608-012-9458-3 Published online 22 April 2012

After completing the analyses for our research paper, I also did a number of secondary analyses to test the role of different kinds of negative emotions in individuals with habits and addictions, such as overeating and binge eating, as well as drug and alcohol abuse.

The results were not what I expected. The first surprising finding was that emotional problems and relationship problems did not seem to play an important role in overeating or binge eating. In fact, the correlation between overeating and depression was negative. This meant that people who were more depressed actually ate less, on average, than people who were not feeling depressed. This suggested that depression and low self-esteem might not be major causes of overeating, and may actually cause people to eat less. For the most part, other kinds of negative emotions, such as anxiety and anger, as well as a wide variety of psychiatric disorders, did not seem to be meaningfully linked with overeating, gambling, or drug or alcohol abuse.

I don’t want to promote these results as written in stone, but they were intriguing. If independent studies can confirm these findings, it would mean that the cause of habits and addictions may be quite different from what lots of people think.

There were some additional findings about drug and alcohol abuse that seemed promising. A new scale I created, called the “Urges to Use Scale,” was massively correlated with alcohol abuse and drug abuse. This scale assesses fantasies and temptations to get high that people have been struggling with. Once patients’ scores on this scale were taken into account in our statistical models, nothing else seemed to have any direct effects at all on drug or alcohol abuse.

So what do these findings mean? Before we go too far interpreting any research findings, I want to emphasize that all studies, including my own, are flawed in various ways. So I only share these preliminary and unpublished findings with a certain amount of caution. They are certainly worth some thoughtful reflection, but it would be important to see if these findings can be replicated in independent samples before we get too excited about them. But if the findings do hold up, they suggest that most habits and addictions might not be emotional problems at all, but rather disorders of motivation and desire.

So why do people eat too much and gain weight? Why do we have the current epidemic of obesity in America when we didn’t have these problems 100 years ago? And why do so many people get hooked on alcohol and drugs? Perhaps the answer is far simpler than we thought. Maybe we overeat because we want to eat all that tasty, delicious food. And maybe we drink and use drugs simply because it’s very tempting and extremely rewarding to get high.

If you do a little inward reflection, I think you might see right away that what I’m saying rings true. For example, let’s say that you have a problem with overeating, and you walk past the Cinnabon stand in the local airport or mall. You smell the sweet delicious smell and you tell yourself things like this:

  1. Oh, those Cinnabons smell SO GOOD.
  2. I’ve had a hard week, I deserve it.
  3. I’ll just have a bite or two, that can’t hurt.
  4. I’ll have a salad for dinner to make up for it.
  5. Mmmm. It would taste wonderful!

And then you succumb, trying one of their Carmel Pecanbons, not noticing that you’ve just devoured more than 1,000 calories.

Now, if Cinnabons are not your thing, you can simply substitute chocolate cake, or chips, or a Martini, or whatever your favorite addiction might be, and I’m certain you’ll identify a similar flow of tempting, seductive thoughts.

Then why do we have the current epidemic of obesity? What explains the massive and alarming increase in recent decades? My hunch is that the real cause of overeating is the availability of an abundance of tasty, high food in our society. We are constantly tempted by television ads for seductive, high calorie foods, by fast food joints, and all the tempting foods in our refrigerators and kitchen cabinets as well. It’s no huge surprise that so many of us succumb to these temptations.

One hundred years ago we did not have an epidemic of obesity because we didn’t have so much tempting food or the means to obtain it. During the past century, our genes have not changed, but the food supply has changed dramatically. However, things have not changed so much in third-world countries—because people don’t have the means to buy fattening foods, so they don’t have the same problems with obesity.

And by the same line of thinking, the real cause of alcohol and drug abuse may be the widespread availability of these substances, and the intense temptations to use them, such as enticing and incredibly clever television ads for ice cold beer during the superbowl, as well as documentaries on pot and other drugs.

If overeating, and drug and alcohol abuse are primarily motivational problems, “disorders of desire,” so to speak, this might explain why current treatment programs are not especially effective. I’m sure you are also aware that most, if not all, diets and weight loss programs have poor success rates in the short term and in the long run as well. The same is true of most, if not all, of the current addiction treatment programs. Maybe part of the reason the outcomes are so disappointing is because we are not targeting the true causes of these problems.

For example, some experts believe that overeating is a behavioral problem. They point out that many people who binge will starve themselves by skipping meals, and then they binge at dinner, or they eat massive snacks between meals. So these experts forcefully encourage patients to stop skipping meals and binging, and to start eating three balanced meals per day, using behavior modification techniques.

How well does this work? I’ve seen some of the data from research on programs who are testing behavioral therapies for binging and overeating. At the start, the patients are massively overweight and binging many times a week. By the end of the program, their binging has been reduced or eliminated completely, and they are eating three healthy meals per day. So you’d natural conclude that the treatment is effective. But the only problem is that most of these patients haven’t lost weight. In fact, in the data I saw, many of them gained tremendous amounts of weight.

To me, the conclusion seemed pretty obvious. Overeating is probably not caused by disordered eating patterns, and behavioral modification of these disordered eating habits is not going to be particularly effective for most overweight individuals.

I don’t mean to target that approach to overeating, and apologize if I sound overly critical—I simply want to emphasize that none of the current treatments are hitting home runs, and that something seems to be missing from our understanding and treatment methods for habits and addictions.

Perhaps, treatment programs would benefit by taking motivation and desires into account. That might mean developing new treatment strategies to target and attack the tempting thoughts that trigger the powerful and nearly irresistible urges to eat all that tasty and delicious food, or to use drugs and alcohol.

So why do we abuse food, drugs, and alcohol? Here’s my answer: We overeat because high-calorie food is delicious. And we love to get high because its fun and it feels good!

Along with my colleagues, I am designing studies to see if we can confirm my preliminary findings in the Stanford inpatient study, and I am also designing some new treatment tools that target motivation and desires.