RESEARCH ARTICLE

An Investigation of Goodman’s Addictive Disorder Criteria inEating DisordersMario Speranza1,2*, Anne Revah‐Levy2,3, Ludovic Giquel4, Gwenolé Loas5, Jean‐Luc Venisse6,Philippe Jeammet2,4 & Maurice Corcos2,4

1Centre Hospitalier de Versailles, Service de Pédopsychiatrie, Le Chesnay, France2INSERM U669, Université Paris‐Sud and Université Paris Descartes, Paris, France3Centre de Soins Psychothérapeutiques de Transition pour Adolescents, Hôpital d’Argenteuil, Argenteuil, France4Institut Mutualiste Montsouris, Département de Psychiatrie de l’Adolescent et du Jeune Adulte, Paris, France5Service universitaire de psychiatrie, hôpital Pinel, CHU d’Amiens, Amiens cedex 01, France6Hopital Saint‐Jacqus, Unité d’Addiction, Amiens, France

Abstract

The aim of this study was to examine how far Goodman’s addictive disorder criteria were met by individuals with eating disordersaccording to subtypes. The study provided a cross‐sectional comparison among three samples of eating disorders [restricting anorexianervosa (R‐AN), N= 68; purging anorexia nervosa (P‐AN), N= 42; and bulimia nervosa (BN), N= 66], a sample of substance‐relateddisorders (SRDs, N= 48) and a sample of matched controls (N= 201). Diagnosis of addictive disorder was made following Goodman’scriteria. Addictive personality traits were assessed with the Addiction Potential Scale of theMinnesotaMultiphasic Personality Inventory—2 and with the Zuckerman’s Sensation Seeking Scale. Results showed that individuals with BNmet Goodman’s addictive disorder criteria inthe same proportion as drug‐addicted individuals (65% vs 60%, p=NS). They both showed higher rates than R‐AN individuals (35%;R‐AN versus BN: F= 11.9, p< 0.001 and R‐AN versus SRD: F= 7.16, p< 0.01). Although BN and SRD showed higher rates of addictivedisorders compared with P‐AN, differences were not significant. Scores on the Sensation Seeking and on the Addictive Potential scalesparalleled the distribution of addictive disorders, with individuals with BN and with P‐AN showing higher levels than individuals with R‐AN.Results showed that a subgroup of individuals with an eating disorder experiences their disorder as an addiction and may deserve specifictherapeutic attention. Copyright © 2011 John Wiley & Sons, Ltd and Eating Disorders Association.

Keywords

anorexia nervosa; bulimia nervosa; eating disorders; substance‐related disorders; Goodman’s addictive disorder criteria; Minnesota Multiphasic Personality Inventory

addiction potential; sensation seeking

*Correspondence

Mario Speranza, MD, PhD, Centre Hospitalier de Versailles, Service de Pédopsychiatrie, 177 rue de Versailles, 78157 Le Chesnay, France. Tel: +33(1).39.63.97.53;

Fax: +33(1).39.63.93.45.

Email: msperanza@ch‐versailles.fr

Published online 10 August 2011 in Wiley Online Library (wileyonlinelibrary.com) DOI: 10.1002/erv.1140

Introduction

There is a growing trend in contemporary psychiatry whichconsists in extending the term of addiction, classically related tosubstance dependencies, to describe a wide range of behavioursthat share several common features, such as craving or compul-sion, loss of control and persistence despite accruing adversebiological, psychological and social consequences (Goodman,1990; Shaffer, 1997). Alcohol and drug use disorders have beenincluded in a construct of this type and also habits such as com-pulsive buying (Lejoyeux, Mc Loughlin, & Ades, 2000) or patho-logical gambling (Dickerson & Baron, 2000) and more recently,disorders of eating behaviour such as anorexia nervosa (AN) orbulimia nervosa (BN) (Davis & Claridge, 1998). Although not allthese conditions present a physiological withdrawal syndrome

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(which specifically defines dependence), it has been suggestedthat any behaviour which has the ability to influence psycholog-ical states can be potentially addictive in vulnerable individuals(Goodman, 2008). Neuroadaptation (tolerance and withdrawal),in fact, can result from addictive behaviours that do not requireingestion of psychoactive substances. Indeed, addiction seems tobe not simply a property of a drug, it results from an ‘intemperaterelationship between a person and the object of his or heraddiction’ (Fenichel, 1945). This is not simply a quantitative shiftin experience; it is a qualitative change in behavioural patternswhich may have reorganising effects on the entire personality(Shaffer, 1997).

In an interesting effort to give theoretical coherence to theseclinical observations, Goodman (1990) proposed the term of‘addictive disorder’ to define a new nosographical entity. This

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M. Speranza et al. Addictive Eating Disorders

refers to a process whereby a behaviour, which can functionboth to produce pleasure and to provide escape from internaldiscomfort, is employed in a pattern characterized by (1)recurrent failure to control the behaviour (powerlessness) and(2) continuation of the behaviour despite significant negativeconsequences (unmanageability). According to Goodman, twosets of factors shape the development of an addictive disorder asfollows: those that concern an underlying addictive process andthose that relate to the selection of a particular substance orbehaviour as the one that is preferred for addictive use. Thus,addictive disorders as a group is not a collection of distinctdisorders, but an underlying process that can be expressed in oneor more of various behavioural manifestations. To operationalizethis entity, Goodman (1990) specified the diagnostic criteria in aformat similar to that of the Diagnostic and Statistical Manual ofMental Disorders, making it applicable to both psychoactivesubstances and behavioural addictions (see Table 1 for the listingof the diagnostic criteria). According to him, only thesimultaneous presence of all the major criteria signs an addictivedisorder. Since Goodman’s proposal, a certain number ofarguments and data have been advanced to support the inclusionof eating disorders (EDs) in the addictive spectrum as follows:from a clinical perspective, the two main features, powerlessnessand unmanageability of behaviours, are specific defining featuresof EDs, especially of BN (Davis & Claridge, 1998; Wilson, 1991);epidemiological studies have shown a greater‐than‐chanceassociation between EDs and substance‐related disorders (SRDs)in cross‐sectional as well in longitudinal studies, with purging

Table 1 Addictive disorder criteria according to Goodman (1990)

A. Recurrent failure to resist impulses to engage in a specified behaviour.

B. Increasing sense of tension immediately prior the initiation of behaviour.

C. Pleasure or relief at the time of engaging in the behaviour.

D. A feeling of a lack of control while engaging in the behaviour.

E. At least five of the following:

1. Frequent preoccupation with the behaviour or preparatory activities

2. Frequent engaging in the behaviour to a greater extent or over a longer period

than intended

3. Repeated efforts to reduce, control or stop the behaviour

4. A great deal of time spent in activities necessary for the behaviour, engaging in

the behaviour or recovering from its effects

5. Frequent engaging in the behaviour when expected to fulfil occupational,

academic, domestic or social obligations

6. Important social, occupational or recreational activities given up or reduced

because of the behaviour

7. Continuation of the behaviour despite knowledge of having a persistent or

recurrent social, financial, psychological or physical problem that is caused or

exacerbated by the behaviour

8. Tolerance: need to increase the intensity or frequency of the behaviour in order

to achieve the desired effect or diminished effect with continued behaviour of

the same intensity

9. Restlessness or irritability if unable to engage in the behaviour

F. Some symptoms of the disturbance have persisted for at least 1month or have

occurred repeatedly over a longer period of time.

Note: To reach the categorical diagnosis of addictive disorder according to

Goodman (1990), criteria A–D plus criterion E (five among nine symptoms) must

be met for at least 1month.

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anorexia nervosa (P‐AN) and BN subjects showing higher ratesthan restricting anorexia nervosa (R‐AN) subjects (Bulik et al.,2004; Corcos et al., 2008; Fernandez‐Aranda et al., 2008); andpersonality studies have suggested that EDs and SRDs sharecertain sets of psychobiological dimensions such as impulsivity/compulsivity (Hatsukami, Owen, Pyle, & Mitchell, 1982; Leon,Kolotkin, & Korgeski, 1979) or sensation seeking/anhedonia(Davis & Claridge, 1998; De Silva & Eysenck, 1987; Zuckerman,1990). Finally, biological research on reward mechanisms andmesencephalic dopamine circuits has brought support to thisaddictive model of EDs. For example, abnormally low levels ofdopamine D2 receptors have been reported in individuals withdrug addiction and compulsive overeating, leading to thehypothesis of pathological eating being a means to compensatefor reduced activation of dopamine‐modulated reward circuits(Blumenthal & Gold, 2010; Wang et al., 2001).

In spite of this growing interest in the addictive spectrum, theintegration of EDs into this heuristic entity is still under inquiry.In the literature, only one study was found exploring the conceptof EDs as addictive disorder according to Goodman’s criteria, in asample of binge eaters (Cassin & von Ranson, 2007). Moregenerally, few studies have directly investigated personality traitsby directly comparing samples of subjects with EDs and subjectswith SRDs (Hatsukami et al., 1982; Leon et al., 1979). Thesestudies did not always take account of the known cross‐comorbidity between these disorders, thus running the risk ofoverestimating the commonalties. Samples were not matched forage and duration of the illness, which are major parameters in theclinical presentation of these disorders. Finally, these studies weremostly conducted without differentiating AN and BN subtypes.

The aim of this study was threefold. The first aim was toexamine how far the addictive disorder criteria of Goodman(1990) were met by individuals with EDs according to subtypes.The second aim was to explore addictive personality traits in EDsubtypes. Finally, the third aim was to investigate which clinicalvariables were specifically associated with addictive EDs (i.e. thosefulfilling Goodman’s criteria). To avoid the risk of overestimatingaddictive features in EDs, we planned a cross‐sectional compar-ison between noncomorbid matched sample of subjects with EDsor SRDs. We made the hypothesis that individuals with P‐AN andwith BN would more often meet the criteria for an addictivedisorder and would show more addictive personality traitscompared with individuals with R‐AN.

Methods

Participants

Subjects in this study were selected from a larger samplerecruited in a European collaborative multicentre study onaddictive behaviours (INSERM Dependence Network 1994–2000no. 494013) (Corcos et al., 2008). The recruitment centres wereacademic psychiatric hospitals specialized in adolescents andyoung adults with addictive disorders in France and Switzerland.During the period from January to December 2001, allinpatients and outpatients aged between 18 and 45 years fulfillinga diagnosis of an SRD (alcohol or illicit substance abuse ordependence) or/and an ED (R‐AN or P‐AN or BN) of the

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Addictive Eating Disorders M. Speranza et al.

Diagnostic and Statistical Manual of Mental Disorders, FourthEdition (DSM‐IV) were referred to the research team for furtherassessment. A sample of healthy participants was recruited byadvertising in nursing schools and medical facilities. Controlparticipants were screened to eliminate current and lifetime SRDsand EDs. Overall, 374 individuals with an ED or an SRD and513 normal controls were included in the European researchnetwork. For the present study, four samples of noncomorbidindividuals with an ED (R‐AN or P‐AN or BN) or an SRD anda sample of matched controls were selected from the entiresample of the network. To ensure good comparability betweengroups, the sample of substance‐addicted participants wasselected and matched to the overall sample of eating‐disorderedindividuals according to age, gender (women only) and durationand severity of illness. Matching criteria were age of 22 years(±5 years) and duration of illness of 5 years (±2 years). Patientswere matched with the control participants for age, gender andprofessional status.

Instruments

The research protocol consisted of a structured diagnosticevaluation completed by a self‐administered questionnaire (Corcoset al., 2008). Diagnoses of EDs and SRDs were established using theMini International Neuropsychiatric Interview (MINI‐4.1, lifetimeversion). The MINI is a structured, validated diagnostic instru-ment, jointly designed by French and American teams to explore ina standardized fashion each criterion necessary for the establish-ment of current and lifetime DSM‐IV Axis I main diagnoses(Sheehan et al., 1997). The MINI has shown good reliability withthe Composite International Diagnostic Interview and also showngood inter‐rater reliability (Sheehan et al., 1998).

The diagnosis of addictive disorder was established byfollowing the criteria of Goodman (1990). According toGoodman, at least four essential criteria and five among nineadditional criteria must be met to reach the categorical diagnosisof addictive disorder (see Table 1). Symptoms must havepersisted for at least 1month or have occurred repeatedly over alonger period of time. Following the method suggested byCassin and von Ranson (2007), we developed a structuredinterview to assess current symptoms of a behavioural addictionby translating into questions each of the Goodman’s criteria.

Addictive personality traits were investigated using thefollowing two self‐report measures: the Addiction Potential Scale(APS) (Weed, Butcher, McKenna, & Ben‐Porath, 1992) and theZuckerman Sensation Seeking Scale (SSS) (Zuckerman, Kolin,Price, & Zoob, 1964). The APS is an additional subscale of therevised version of the Minnesota Multiphasic PersonalityInventory—2 (Hathaway & McKinley, 1996). It was developedwith the aim of identifying personality characteristics and lifestylepatterns associated with substance abuse but without any directcontent to substance use (Weed et al., 1992). Factor analyses ofthe APS have shown that this scale contains, besides the typicalimpulsive factors such as acting out, surgency and risk‐taking,other factors such as dissatisfaction and lack of self‐efficacy, moredirectly focusing on the psychological distress of the subjects(Clements & Heintz, 2002; Sawrie et al., 1996). The APS hasshown acceptable test–retest reliability (0.73 for APS) (Greene,Weed, Butcher, Arredondo, & Davis, 1992; Weed et al., 1992).

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The Zuckerman SSS (Form V) (Zuckerman et al., 1964) is oneof a handful of ‘core traits’ that can be used to describe humanpersonality. The SSS is a forced‐choice questionnaire yielding foursubscale scores and a total score as follows: thrill and adventureseeking, experience seeking, disinhibition and boredom suscep-tibility. Although it is not a direct measure of impulsivity, theconstruct of sensation seeking has been linked to impulsivity inseveral studies (Hur & Bouchard, 1997; Nower, Derevensky, &Gupta, 2004; Zuckerman, Ballenger, & Post, 1984). The SSS hasbeen translated and validated in French language (Carton,Jouvent, & Widlöcher, 1992; Loas et al., 2001). To simplify thereading of the text, in the present study we report the data only ofthe SSS total score, the correlations between the four subscalesand the total score being very high (between 0.65 and 0.74).

Depression severity was measured with the French translation ofthe abridged version of the Beck Depression Inventory (BDI‐13).The BDI is a self‐report inventory measuring characteristicattitudes and symptoms of depression (Beck, Ward, Mendelson,Mock, & Erbaugh, 1961). An abridged version with 13 itemsselected within all the items showing a high correlation (≥0.90)with the total score of the BDI‐21 has been developed as a specifictool for epidemiological studies including clinical and nonclinicalsubjects (Beck & Beck, 1972). The 21‐item and the 13‐item formshave shown correlations ranging from 0.89 to 0.97 and a similarfactor structure indicating that the short form is an acceptablesubstitute for the long form (Beck, Rial, & Rickels, 1974). Both theoriginal versions of the BDI‐13 and the French translation havehigh internal consistency and substantial test–retest reliability(Beck, Steer, & Garbin, 1988; Bobon, Sanchez‐Blanque, & VonFranckell, 1981).

Binge‐eating and purging behaviours were assessed withquestions issued from the MINI diagnostic interview (Sheehanet al., 1998). Binge‐eating behaviours (defined as the consump-tion of large amounts of food in a short period of time associatedwith a sense of lack of control during the episode) and purgingbehaviours (vomiting, laxatives and diuretics) were consideredpresent if they were currently used independently of theirfrequency.

At the end of the assessment procedure, the clinician rated theseverity of the illness with the Clinical Global Impression scale(CGI) (Guy, 1976). The CGI requires the clinician to rate on aseven‐point scale (1 = normal to 7 = extremely ill) the severity ofthe patient’s illness at the time of assessment, relative to theclinician’s past experience and training with patients with thesame diagnosis. In the present study, the CGI reflects the overallseverity of the patient’s illness including EDs or SRDs and othercomorbid disorders. Considering that it is difficult to directlycompare the severity of EDs presenting with different clinicalfeatures, CGI was mainly used in the comparisons between EDswith and without an addictive disorder of Goodman (1990).

Procedure

Diagnostic interviews were conducted by a research team ofmaster’s level clinicians (psychologists or psychiatrists) familiarwith DSM‐IV Axis I/II disorders and experienced in assessmentand/or treatment of psychiatric adolescents. To reach highlevels of reliability, the research evaluation team participated inseveral training sessions, including commented scoring of

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M. Speranza et al. Addictive Eating Disorders

videotaped interviews. Final research diagnoses were establishedby the best‐estimate method on the basis of the interviews andany additional relevant data from the clinical record according tothe longitudinal, expert, all data standard (Pilkonis, Heape,Ruddy, & Serrao, 1991).

The protocol was approved by the local ethics committee (Paris‐Cochin Hospital). After full information had been provided, allsubjects gavewrittenconsent toparticipate in the study.

Statistical analyses

Comparison between groups for personality traits were performedusing a one‐way analysis of variance followed by a Bonferronicorrection for multiple analyses. We secondarily added depressionscores as covariate of the analysis of variance analyses after theobservation of a difference in depression severity between EDsubgroups and SRD. This adjustment was proposed to avoid thebias of attributing differences in the personality variables betweengroups to depression and not to the variables themselves.Compliance with the addictive disorder criteria of Goodman(1990) was examined using a χ2‐test. Pearson’s correlations werecomputed to evaluate the relationships between variables. Finally,to explore which clinical variables were specifically associated withaddictive EDs (i.e. those fulfilling Goodman’s criteria), weperformed a logistic regression analysis (participants fulfillingGoodman’s criteria or not) with the following variables aspredicting measures (method stepwise): body mass index,duration of the illness, inpatient status, CGI, presence of bingeingand/or purging behaviours, BDI, APS and SSS total score. Results

Table 2 Comparison of eating disorders and substance‐related disorders on perso

R‐AN

(N= 68)

P‐AN

(N= 42)

Sociodemographics

Age (M±SD) 22.8 (5.9) 22.9 (4.5)

Education (bachelor’s degree) (N, %) 63 (94%)1 42 (100%)2

Living in couple (N, %) 6 (9%) 9 (21%)

Unemployed (N, %) 8 (12%) 3 (7%)

Clinical characteristics

BMI (M±SD) 14.6 (1.9)1 15.8 (2.2)2

Inpatient (N, %) 52 (76%) 23 (56%)

Onset of illness (M± SD) 19.2 (6.7) 18.4 (5.7)

Duration of illness (M± SD) 4.8 (5.5) 4.9 (4.6)

Binge‐eating behaviours (N, %) 3 (4.5)1,2 30 (71.4)1,3

Purging behaviours (N, %) 2 (3.1)1,2 33 (78.6)1,3

Clinical Global Impression (M± SD) 5.1 (0.9)1 5.2 (1.0)2

Beck Depression Inventory (M± SD) 13.0 (7.1)1,2 15.2 (6.4)3,4,5

Personality measures

MMPI Addiction Potential Scale (M± SD) 55,6 (8.5)1,2 56,1 (8.0)3,4

Sensation Seeking Scale (M± SD) 16,0 (5.9)1,2,3 20,0 (5.7)1,4

Goodman’s addictive disorder (N, %) 24 (35%)1,3 20 (48%)

T‐scores above 65 are considered pathological. Results of the comparisons for Addict

Inventory scores. Significant differences between groups are indicated by the same sup

R‐AN, restricting anorexia nervosa; P‐AN, purging anorexia nervosa; BN, bulimia nerv

MMPI, Minnesota Multiphasic Personality Inventory.†χ2 or analysis of variance with Bonferroni correction.

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are presented as means ± standard deviation. Statistical analyseswere performed on SPSS (SPSS Inc., Chicago, IL, USA), version16.0. Significance was set at 0.05.

Results

Sociodemographic characteristics of the sample

According to the inclusion criteria, 176 ED and 48 SRD womenwithout a concurrent cross‐comorbidity were included in thefinal research sample. The clinical sample was matched with acontrol sample of 201 participants of similar age, gender andprofessional status. ED subtypes were represented as follows: 68individuals with R‐AN, 42 individuals with P‐AN and 66individuals with BN. The mean age of the sample was 23.4 ± 5.1.The majority of the participants (92%) had a bachelor’s degree;22% of the participants had a stable partner. Only a smallminority (9%) was unemployed (and not in training). Therewere no significant differences between subgroups in socio-demographic variables with the exception of the substance‐related participants who were less educated than the othergroups. Participants had a severe disorder with a mean durationof the illness of more than 5 years. Participants with AN weremore often recruited as inpatients. The SRD participants werealmost all (87%) dependent on opiates and cocaine andcurrently on substitution with methadone. Subjects withincomplete data were discarded (N= 31). The clinical character-istics of the sample are presented in Table 2.

nality measures and Goodman’s addictive disorder criteria

BN (N= 66) SRD (N= 48) Controls

(N= 201)

Statistics†

F (p)

24.1 (4.7) 25.1 (4.9) 23.0 (4.9) 2.22 (NS)

61 (96%)3 32 (73%)1,2,3,4 195 (97%)4 55.3 (<0.001)

18 (28%) 13 (29%) 50 (25%) 8.3 (NS)

2 (3%) 7 (16%) 13 (6%) 7.2 (NS)

21.5 (3.9)1,2 21.0 (3.2)1,2 21.4 (2.8)1,2 96.4 (<0.001)

11 (17%) 18 (41%) – 48.39 (<0.001)

20.0 (6.5) 22.0 (8.3) – 2.32 (NS)

5.8 (4.9) 5.9 (3.4) – 0.69 (NS)

66 (100)2,3 – – 125 (<0.001)

66 (100)2,3 – – 134 (<0.001)

4.3 (1.1)1,2 4.7 (1.1) – 8.79 (<0.01)

11.4 (6.3)3,6 8.6 (5.3)1,4,7 3.1 (3.8)2,5,6,7 83.7 (<0.001)

57,4 (9.9)5, 62,4 (10.0)1,3,6 50,4 (9.2)2,4,5,6 20.0 (<0.001)

20,2 (6.3)2,5 25,3 (4.9)3,4,5,6 18,0 (6.3)6 16.3 (<0.001)

43 (65%)1 29 (60%)3 – 13.9 (0.003)

ion Potential Scale and Sensation Seeking Scale are adjusted on Beck Depression

erscripted numbers. MMPI scores are presented as T‐scores.

osa; SRDs, substance‐related disorders; NS, not significant; BMI, body mass index;

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Goodman’s addictive disorder criteria

Individuals with BN met the addictive disorder criteria ofGoodman (1990) in the same proportion as drug‐addictedindividuals (65% vs 60%, p=NS). They both showed higher ratesfor this diagnosis compared with R‐AN subjects (35%; R‐ANversus BN: F= 11.9, p< 0.001 and R‐AN versus SRD: F= 7.16,p< 0.01). Although BN and SRD showed higher rates of addictivedisorders compared with P‐AN, differences were not significant.Individual analysis showed some differences in the frequency ofdistribution of Goodman’s criteria between diagnostic groups.Overall, a large proportion of participants (between 59% and98%) met the majority of the essential criteria (A–E) and theduration of disturbances criterion (F). However, individualpatients exhibited differential patterns of criteria required tomeet the diagnosis of addictive disorders. Significant differenceswere observed mainly between the R‐AN group and the othergroups who fulfilled the essential criteria at similar high rates(Table 3). Among the essential criteria, only two were lessfrequently rated as positive from drug‐addicted individuals asfollows: criterion B (‘Increasing sense of tension immediatelyprior the initiation of behaviour’) and criterion D (‘A feeling of alack of control while engaging in the behaviour’). Concerning thecomplementary criteria, the tolerance criterion (‘Need to increasethe intensity or frequency of the behaviour in order to achieve thedesired effect or diminished effect with continued behaviour ofthe same intensity’) was significantly more often subscribed bySRD participants compared with ED participants. R‐AN partici-pants more frequently reported giving up important social,occupational or recreational activities because of the behaviour(Table 3).

Addictive personality traits

Drug‐addicted participants had significantly higher scores than allthe other groups on both the APS (with the only exception of theBN group who showed similar scores than SRD) and the SSS. Allthe ED groups scored higher than the controls on the APS withdecreasing scores going from BN individuals, to R‐AN and P‐ANindividuals. ED patients could not be differentiated on the SSSwhen compared with the controls, although the scores followedthe same decreasing profile of the APS, with R‐AN showing thelowest scores (even lower than control subjects). Adjusting ondepression severity did not significantly modify the intensity anddirections of these effects.

Association between clinical variables andaddictive eating disorders

Concerning the relationships between the clinical variables of thestudy in the ED participants, we observed a significant correlationonly between the SSS and the binge‐eating (0.31, p< 0.001) orpurging behaviours (0.31, p< 0.001) but not for the APS (0.09, NSand 0.06, NS respectively). APS and SSS were uncorrelated (0.05,NS). The logistic regression analysis performed on the entiresample of EDs showed that participants could be significantlydiscriminated according to the presence or the absence of anaddictive ED (Model likelihood ratio= 183.7, p= 0.003). Theoverall model explained only a small part of the variance(Nagelkerke R2 = 0.08). The only significant positive association

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concerned the presence of binge‐eating behaviours (p= 0.008;Wald Z= 8.60, p= 0.003, OR 2.8, CI 1.4–5.7). Neither impulsivity(as measured with the SSS) nor the APS was significantlycorrelated with an addictive ED.

Discussion

The present study is, to our knowledge, the first to exploresimultaneously the positive ratings on the addictive disordercriteria of Goodman (1990) and the presence of addictivepersonality traits in individuals with different types of EDs. It isalso the first to directly compare EDs and SRDs with a specificmatching for sociodemographic and clinical variables to avoidsample‐related bias. Results from our study showed that asubgroup of individuals with an ED experiences their disorderas an addiction. In fact, almost half of the ED patients fulfilled thecriteria for an addictive disorder according to Goodman’sproposal. Individuals with BN showed the highest rates, followedby individuals with P‐AN and finally by individuals with R‐AN.

During the last two decades, a large body of research hasindicated that substance‐use problems are common amongwomen with EDs (Bulik et al., 2004; Fernandez‐Aranda et al.,2008). This association is strong in women with BN and bingeing/P‐AN and weak in R‐AN (Baker, Mitchell, Neale, & Kendler,2010; Calero‐Elvira et al., 2009). Our study shows that thepresence of an ED with addictive qualities follows the samedistribution as those of SRDs. This result is even more interestingif one considers that in our sample, EDs were selected on the basisof their noncomorbidity with SRDs. Direct comparisons of ourresults with other studies are limited. The only other study usingthe criteria of Goodman (1990) in a sample of patients with bingeEDs (Cassin & von Ranson, 2007) found smaller rates (40.5%) ofaddictive disorders. Such differences could be attributed tovariations in the assessment methodology. For example, Cassinand von Ranson used phone interviews with patients recruited inthe community, whereas our study was conducted using face‐to‐face interviews with severe EDs. In our sample, rates of addictivedisorders in individuals with BN were similar to those observedamong individuals with SRDs. One possible reason to explain therelatively low proportion of addictive disorders in SRD partici-pants of our study is the nature of the dependence. The greatmajority of our SRD participants were dependent on opiates andcocaine, but they were almost all currently on substitution withmethadone. The therapeutic use of methadone as a substituteproduct may have reduced the relevance of criterion B(‘Increasing sense of tension immediately prior the initiation ofbehaviour’) and of criterion D (‘a feeling of a lack of control whileengaging in the behaviour’), which may explain the less than100% overlap between addictive disorders and SRDs. Beside thispotential bias, these results support the conclusions reached byerv1140-bib-0011Cassin and von Ranson concerning the validityof the definition of addictive disorders. Unlike DSM‐IV diagnosesof substance dependence which require only a subset of criteria tobe met, Goodman’s criteria must all be simultaneously endorsedto meet the diagnosis, which seems more restrictive and less opento the criticism that is all‐inclusive and risk ‘overpathologizing’.These restrictive criteria may thus identify a subgroup of disorderssharing an underlying addictive process that expresses itself in one

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Table 3 Percentage of individuals meeting Goodman’s addictive disorder criteria according to eating disorder subtypes

Criteria R‐AN

(N= 68)

P‐AN

(N= 42)

BN

(N= 66)

SRD

(N= 48)

Statistics† Group differences *

χ2

N (%) N (%) N (%) N (%) F (p <)

A. Recurrent failure to resist impulses to engage in a specified behaviour. 56 (82%) 41 (98%) 62 (94%) 41 (85%) 8.71 (0.03) R‐AN<P‐AN

B. Increasing sense of tension immediately prior the initiation of behaviour. 47 (69%) 38 (90%) 59 (89%) 35 (73%) 10.8 (0.02) R‐AN<P‐AN/BN

C. Pleasure or relief at the time of engaging in the behaviour. 50 (73%) 29 (69%) 55 (83%) 42 (87%) 6.45 (0.09) –

D. A feeling of a lack of control while engaging in the behaviour. 40 (59%) 37 (88%) 64 (97%) 37 (77%) 32.1 (0.001) R‐AN<P‐AN/BN/SRD

E. At least five of the following: 56 (82%) 37 (88%) 53 (80%) 41 (85%) 1.32 (0.72) –

1. Frequent preoccupation with the behaviour or preparatory activities 53 (78%) 39 (93%) 49 (74%) 36 (75%) 3.75 (0.18) –

2. Frequent engaging in the behaviour to a greater extent or over a longer period

than intended

48 (71%) 32 (76%) 44 (67%) 35 (73%) 1.24 (0.74) –

3. Repeated efforts to reduce, control or stop the behaviour 48 (71%) 35 (83%) 55 (83%) 36 (75%) 4.16 (0.24) –

4. A great deal of time spent in activities necessary for the behaviour,

engaging in the behaviour or recovering from its effects

48 (71%) 29 (69%) 42 (64%) 31 (65%) 0.94 (0.81) –

5. Frequent engaging in the behaviour when expected to fulfil occupational,

academic, domestic or social obligations

40 (59%) 25 (59%) 41 (62%) 21 (44%) 4.33 (0.23) –

6. Important social, occupational or recreational activities given up or reduced

because of the behaviour

57 (84%) 31 (72%) 41 (62%) 37 (77%) 8.51 (0.04) R‐AN>BN

7. Continuation of the behaviour despite knowledge of having a persistent or

recurrent social, financial, psychological or physical problem that is caused or

exacerbated by the behaviour

62 (91%) 36 (86%) 53 (80%) 40 (83%) 3.33 (0.34) –

8. Tolerance: need to increase the intensity or frequency of the behaviour in order

to achieve the desired effect or diminished effect with continued behaviour of the

same intensity.

34 (50%) 19 (45%) 32 (48%) 40 (93%) 19.0 (0.00) R‐AN/P‐AN/BN> SRD

9. Restlessness or irritability if unable to engage in the behaviour 59 (87%) 34 (81%) 56 (85%) 44 (92%) 6.98 (0.07) –

F. Some symptoms of the disturbance have persisted for at least 1month or have

occurred repeatedly over a longer period of time.

63 (93%) 42 (100%) 65 (98%) 42 (87%) 6.41 (0.09) –

Diagnosis of addictive disorder 24 (35%) 20 (48%) 43 (65%) 29 (60%) 13.9 (0.003) R‐AN<BN/SRD

R‐AN, restricting anorexia nervosa; P‐AN, purging anorexia nervosa; BN, bulimia nervosa; SRDs, substance‐related disorders.†χ2‐test followed by Fisher’s exact test between groups.

*p< 0.05.

M. Speranza et al. Addictive Eating Disorders

or more of various behavioural manifestations. As stated byKrueger (1999), the co‐occurrence of different psychiatricdisorders in proportions greater than chance suggests that thedisorders are indicators of latent factors or hypothetical corepsychopathological processes that underlie putatively separateconditions. Previous studies exploring addictive features in eatingand other disorders, however, have produced mixed findings, tothe point that Heubner (1993) has argued that the concept of an‘addictive personality’ across behavioural disorders could benothing more than chronically depressed mood with an inabilityto maintain internal equilibrium. Results from our study providesome new data to discuss this critical viewpoint. In fact, thedecreasing profile in the rates of addictive disorders observedbetween ED subtypes was paralleled by the results of thepersonality traits. Although not systematically significant, theSensation Seeking and Addictive Potential scales showed higherscores in individuals with BN and P‐AN compared withindividuals with R‐AN. Both Sensation Seeking and AddictivePotential have been linked to impulsivity (Clements & Heintz,2002; Nower et al., 2004) which has been largely explored in EDsand associated with severity of ED symptoms (Lacey & Evans,1986; Newton, Freeman, & Munro, 1993), greater comorbidity(Bulik et al., 2004) and poorer treatment outcome (Fassino et al.,

Eur. Eat. Disorders Rev. 20 (2012) 182–189 © 2011 John Wiley & Sons, Ltd and Eating Disorde

2005). If impulsivity seems to be a key personality factor in EDs,however, it does not directly explain the addictive quality of ED inour study. In fact, results from the regression analysis performedto identify the clinical variables specifically associated with anaddictive ED revealed that the presence of binge‐eating behaviourswas the only variable significantly associated with this diagnosis.Thus, impulsivity could play an indirect role in the development ofthe addictive process in EDs by favouring the use of self‐maintaining behaviours such as binge‐eating behaviours (Kemps& Wilsdon, 2010).

Some limitations must be taken into consideration ininterpreting the findings of this study. First, participants in thestudy were only a subgroup of the overall sample which waslimited to young women without crossed comorbidity. Caution isrequired in generalizing the results to other samples. Second, theresults on the addictive disorders of Goodman (1990) must beconsidered as exploratory because the criteria have not beenformally validated. Although we developed a structured interviewto assess each of the Goodman’s criteria and we aimed at reachinghigh levels of diagnostic reliability by a formal training of theinvestigators, this is not equivalent to a validation study which isstill needed before considering Goodman’s addictive disorder as areliable diagnostic category (Holden, 2010). Finally, concerning

187rs Association.

Addictive Eating Disorders M. Speranza et al.

the exploration of the addictive features associated with EDs, wechoose a personality approach using the APS and the Zukerman’sSSS. If the SSS is a well‐known personality measure, someconcerns can be raised about whether the APS really measurespersonality traits or psychopathological features related tosubstance abuse. Moreover, we could have used a moretemperament‐based approach closer to the biology and thegenetics of the addictive process. Further studies should look atthe interaction between temperament and personality, especiallywithin the functional systems implicated in the addictive processsuch as motivation–reward, affect regulation and behaviouralinhibition systems (Goodman, 2008).

Notwithstanding these limitations, the results of our studysuggest that a subgroup of individuals with EDs experience theirdisorder as an addiction. Among these subjects, individuals withBN and P‐AN show the highest rates of addictive disorders andpresent some personality features that can place them at high riskfor developing SRDs. Further studies using a longitudinalapproach should explore the joint dynamics of powerlessnessand unmanageability of behaviours to better understand how, ininteraction with other constitutional and environmental factors,they can induce an addictive process in individuals with EDs.

188 Eur. Eat. Disorders

Acknowledgements

This work was conducted within the clinical research project‘Dependence Network 1994–2000’. All the following centresparticipating in the project should be acknowledged: Departmentof Adolescent and Young Adult Psychiatry, Institut MutualisteMontsouris, Paris, France; Department of Psychiatry, HôpitalPinel, Amiens, France; Department of Psychiatry, Hôpital Saint‐Jacques, Nantes, France; Department of Psychiatry HôpitalUniversitaire, Besançon, France; and Department of Child andAdolescent Psychiatry, SUPEA, Lausanne, Switzerland.

Funding for this study was provided by the National Institutefor Medical Health Research (INSERM no. 494013) and by theFondation de France. The promoter of the project is the InstitutMutualiste Montsouris.

Conflict of interest

The authors have declared that there is no conflict of interest.

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