Impulsive Behavior in Eating Disorders

Like all people, eating disordered individuals have various personality traits. We might describe a person as calm, excitable, extroverted, introverted, cooperative, or antagonistic. All of these traits help to describe the personality that an individual possesses. Frequently,the term impulsive is also used.

Impulsive behavior seems to be particularly characteristic of individuals with bulimia nervosa or the binge-purge type of anorexia nervosa. That is, these individuals may look for excitement, fail to think about the negative consequences, and engage in behaviors that is potentially self-damaging.

These impulsive tendencies may lead to a variety of potentially harmful behaviors including excessive alcohol or drug use, rage outbursts, violence, self-destructive behaviors, sexual promiscuity, shoplifting, or other forms of social irresponsibility. When an eating disordered individual displays these behaviors, it may significantly complicate their life, and if they are receiving treatment, it may pose further difficulties for their recovery.

What Causes Impulsivity?

Impulsive traits and behaviors are undoubtedly a product of a wide variety of factors, including genetics, biological factors, family environment, stressful situations, and social and peer influences. The complexity of the causes of impulsive behavior is seen in recent studies, which have attempted to clarify the origins of impulsivity. Several of these studies suggest that individuals with eating disorders, particularly bulimia nervosa, may carry a gene that has been linked to impulsive behavior. Furthermore, this gene is thought to regulate the production of serotonin, a neurotransmitter in the brain.

In one study, it was demonstrated that bulimic individuals who carried this particular gene were not only more impulsive, but also had lower levels of serotonin in their bloodstream, possibly indicating that the genetic predisposition influences both serotonin production and impulsivity.

On the other hand, there is evidence that some impulsive bulimic individuals have been victims of stressful or abusive environments in childhood. For example, children who have been sexually abused are more likely to engage in a variety of impulsive behaviors, including bingeing and purging, than nonabused children. One study suggested that these patterns emerge by the time the child is 15 years old, suggesting that early adversity may be a significant factor in the development of impulsive behaviors.

These are only two factors that may influence impulsivity, and it is important to realize that the origin of this trait is extremely complex and is unlikely to be the product of any single event in a person’s life. Furthermore, impulsive behaviors may change over time, depending on the quality of the person’s life, the status of their eating disorder, and whether or not they are receiving treatment.

Clinical Manifestations

Extremely impulsive individuals who have eating disorders may often receive a diagnosis of borderline personality disorder. This is a psychiatric condition characterized by impulsive behaviors, extreme moodiness (especially anger), interpersonal instability, a variety of self-damaging or suicidal behaviors, and confusion about identity. In Europe, this is sometimes referred to as having multi-impulsive bulimia (MIB). MIB is a condition in which a bulimic individual displays at least three of the following: 1) extreme alcohol abuse or dependence, 2) other drug abuse or dependence, 3) stealing or shoplifting, 4) self-mutilation (such as cutting or burning), and 5)suicide gestures.

It is likely that the ideas of borderline personality disorder and MIB are highly related. Importantly, however, eating disordered individuals who display either illness may show other concerning behaviors: extreme anxiety and depression, substance use disorders, high levels of family and interpersonal conflict, frequent hospitalizations, and heavy utilization of behavioral medications.

In comparison to less impulsive eating disordered individuals, borderline or MIB patients seem to respond poorly to traditional eating disorder treatments and have a more negative long-term course. In one study of 112 bulimic patients, 20 fully met criteria for MIB. Twenty years after they were diagnosed, only 3 of these patients were recovered or doing well and nearly half of them had significant alcohol or drug abuse problems—25 percent had died. Thus, it is clear that highly impulsive behavior can become a significant, damaging, and even life-threatening feature of eating disorders and should be taken seriously.

How Does Impulsivity Affect Treatment?

It appears as though high levels of impulsivity render eating disorder treatment less effective, although this has not been consistently shown in the scientific literature. Highly impulsive patients are less likely to fully engage in the process and more likely to drop out. Impulsivity may also limit the effectiveness of drug therapy because the patient may erratically take their medication, or if they are purging, perhaps fail to receive an adequate dose of the medication. Impulsive individuals who engage in self-destructive behaviors may frequently be hospitalized because of the risk of significant self-harm. All of these behaviors complicate treatment efforts.

Currently, clinicians and researchers are attempting to identify ways to help highly impulsive individuals. Therapies focusing on emotion regulation and delaying gratification may ultimately be helpful. At this point in time, however, impulsive behaviors are a significant threat to effective eating disorder treatment and may result in high levels of treatment dropout or treatment ineffectiveness

What Can the Family Do?

Eating disordered individuals who engage in impulsive and problematic behaviors are likely to have family members who are extremely concerned, upset, and distraught about their loved one’s lifestyle and choices. Not only do these families have to deal with bulimia nervosa or anorexia nervosa, but also substance use, possible criminal activity, suicide risks, and a variety of impulsive behaviors that can be upsetting.

In some cases, families may benefit from consultations with the legal systems or social services to assist them in trying to manage their loved one’s behavior. In extreme cases, this may include seeking legal commitment to treatment. Although treatment is likely to be tough and unpredictable, involvement in the patient’s overall treatment plan is critical and may enhance the stability and effectiveness of the care.

Stephen Wonderlich, PhD, is Professor and Associate Chairperson in the Department of Neuroscience, University of North Dakota School of Medicine & Health Sciences. He is also Co-Director of the Eating Disorders Institute and Director of Clinical Research for the Neuropsychiatric Research Institute.