Impulsivity in Patients with Eating Disorders

Impulsivity plays a significant role in the development and maintenance of eating disorders like bulimia nervosa and binge eating disorder. Individuals with high levels of impulsivity may struggle with regulating their eating behaviors, often engaging in binge eating or purging without considering the consequences. Addressing impulsivity in treatment, such as through temperament-based therapy with supports (TBT-S), can help individuals develop healthier coping strategies.

Impulsivity & Eating Disorders

Impulsivity is a personality trait that describes the tendency to act without thinking or with little regard for the consequences. Patients with eating disorders, especially those with bulimia nervosa, anorexia nervosa binge eating and purging subtype (AN-BP) or binge eating disorder (BED), show higher levels of impulsivity than their peers.¹

Other common personality traits common to people with eating disorders are:

• Perfectionism
• Negative affect
• Harm avoidance
• Obsessive-compulsivity
• Detachment

Traits of Impulsivity

Impulsivity is recognized as a complex construct with at least five distinct facets that encompass a variety of behaviors:²

• Negative urgency
• Positive urgency 
• Lack of planning
• Sensation-seeking
• Lack of perseverance

Negative urgency

Those with eating disorders are more likely to experience negative urgency, the tendency to act impulsively when experiencing intense negative emotions. Research indicates that among the five facets of impulsivity, negative urgency is the most strongly connected to eating disorder symptoms.³

Negative urgency varies by diagnosis and is more common in those who binge and/or purge, like those with bulimia nervosa, binge eating disorder (BED) and AN-BP.⁴

Individuals with bulimia tend to score higher in negative urgency than those with anorexia nervosa, and those with AN-BP score higher than those with anorexia nervosa restricting subtype (AN-R), with those who binge often presenting with other impulse control disorders and experiencing increased difficulties with emotional regulation.⁴

Binge eating or purging in response to feelings of depression, anxiety or guilt is a common way people with eating disorders exhibit negative urgency. Negative urgency can also express itself in other ways, like:

• Yelling something hurtful during an argument
• Engaging in risky sexual behavior after rejection
• Harming oneself when feeling depressed or lonely

Positive urgency

Positive urgency is also elevated in people with eating disorders but is less researched, probably due to higher levels of negative emotionality in these patients. Positive urgency refers to the tendency to act impulsively when feeling strong positive emotions.

There is only one study that has examined positive urgency in individuals with eating disorders, showing that positive urgency was higher in AN-BP, bulimia nervosa and other specified feeding and eating disorder (OSFED) compared to AN-R and healthy controls.⁴ An everyday example of positive urgency in eating disorder patients is binge eating after a major achievement or special event. Other examples of positive urgency include:

• Irresponsibly gambling large sums of money after receiving a raise
• Drinking excessively after a major achievement
• Making a large purchase after having a great day

Lack of planning

Lack of planning – the inability to consider the consequences of one's behavior – is common in patients with eating disorders. Those with bulimia nervosa tend to score higher in lack of planning compared to those with anorexia nervosa, and those with AN-BP score higher than those with AN-R, supporting the relationship between impulsivity, binge eating and purging.⁴

However, when using measures that assess cognitive aspects of planning, rather than behavior, there are no significant differences between those with eating disorders and those without.⁴

Some common examples of lack of planning are:

• Quitting a job before securing a new one
• Making and then breaking large commitments
• Changing plans without informing others

Sensation-seeking

Sensation seeking is higher in individuals with eating disorders. It refers to the tendency to seek thrills and excitement. For those with these disorders, sensation seeking may lead to risky behavior outside their condition or show up within their eating disorder as a disregard for the dangers of overexercise, malnutrition or purging. Levels of sensation seeking differ by diagnosis.

People with anorexia nervosa tend to score lower, while those with bulimia nervosa score higher and individuals with BED score similarly to controls.⁴

Everyday examples of sensation seeking include:

• Thrill-seeking behavior
• Excessive alcohol consumption or drug use

However, sensation seeking does not always involve risky activities. It can be a positive trait. Seeking new experiences, like traveling or starting a new hobby, are two ways someone can show healthy sensation-seeking.

Lack of persistence

Lack of persistence is also more common in individuals with eating disorders. Lack of persistence refers to the difficulty in continuing a task when it is boring, challenging or exhausting. Similar to sensation seeking, lack of persistence also varies depending on the diagnosis.

Those with anorexia nervosa report greater persistence, while those with bulimia nervosa score similar to controls.⁴ This may be partially explained by increased rigidity found in those with anorexia nervosa, particularly AN-R.

Some examples of lack of persistence include:

• Quickly becoming discouraged when a task is difficult
• Procrastinating until the last possible moment
• Abandoning projects when there are setbacks

Impulsivity & Dual Diagnosis

Eating disorders often occur alongside other conditions like alcohol use disorder, borderline personality disorder, attention deficit hyperactivity disorder (ADHD) and bipolar disorder, leading to a dual diagnosis that can make treatment more difficult.

Alcohol use disorder

Alcohol use disorder and binge eating and purging disorders like bulimia nervosa, AN-BP, and BED are all connected to impulsivity.^5-9

Alcohol use offers a quick way to escape negative feelings related to disordered eating – such as guilt after a binge or shame after purging – which can reinforce the behavior over time.

Borderline personality disorder

Impulsivity in at least two potentially harmful areas is a common sign of borderline personality disorder (BPD). Some characteristics of BPD are also seen in disordered eating behaviors like binge eating and purging.

Attention deficit hyperactivity disorder

Impulsivity and inattention are common features of both bulimia nervosa and ADHD; individuals with ADHD often show poor impulse control and emotional regulation, which are also observed in those with bulimia nervosa and BED.

Bipolar disorder

Bipolar disorder, BED, and bulimia nervosa all involve impulsivity.¹⁰ During manic or hypomanic episodes, individuals with bipolar disorder who binge and/or purge may become impulsive, struggle with self-control and find it difficult to listen to their body’s hunger cues.

Psychotherapy for Impulsivity: Temperament-based Therapy with Supports

Temperament-based therapy with supports (TBT-S) is a neurobiologically based treatment that targets the underlying factors influencing the development of an eating disorder, including biology, brain function, genetics and personality traits.

The main feature of TBT-S is modifying existing personality traits, which are difficult to change, to support an individual’s recovery rather than their eating disorder. People with anorexia nervosa and bulimia nervosa have shown notable reductions in eating disorder symptoms through TBT-S.

Getting Help for a Severe Eating Disorder

Impulsivity is a common challenge for people living with both an eating disorder and dual diagnosis, often making everyday decisions feel more difficult. While it can be frustrating, support is available to help manage these behaviors.

References

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2. Lavender, J. M., & Mitchell, J. E. (2015). Eating disorders and their relationship to impulsivity. Current Treatment Options in Psychiatry, 2(4), 394–401. https://doi.org/10.1007/s40501-015-0061-6
3. Fischer, S., Smith, G. T., & Cyders, M. A. (2008). Another look at impulsivity: A meta-analytic review comparing specific dispositions to rash action in their relationship to bulimic symptoms☆. Clinical Psychology Review, 28(8), 1413–1425. https://doi.org/10.1016/j.cpr.2008.09.001
4. Farstad, S. M., McGeown, L. M., & Von Ranson, K. M. (2016). Eating disorders and personality, 2004–2016: A systematic review and meta-analysis. Clinical Psychology Review, 46, 91–105. https://doi.org/10.1016/j.cpr.2016.04.005
5. Rosval, L., Steiger, H., Bruce, K., Israël, M., Richardson, J., & Aubut, M. (2006). Impulsivity in women with eating disorders: Problem of response inhibition, planning, or attention? International Journal of Eating Disorders, 39(7), 590–593. https://doi.org/10.1002/eat.20296
6. Lee, R. S. C., Hoppenbrouwers, S., & Franken, I. (2019). A Systematic Meta-Review of Impulsivity and Compulsivity in Addictive Behaviors. Neuropsychology Review, 29(1), 14–26. https://doi.org/10.1007/s11065-019-09402-x
7. Doumas, D. M., Miller, R., & Esp, S. (2016). Impulsive sensation seeking, binge drinking, and alcohol-related consequences: Do protective behavioral strategies help high risk adolescents? Addictive Behaviors, 64, 6–12. https://doi.org/10.1016/j.addbeh.2016.08.003
8. Hirvelä, L., Sipilä, P. N., & Keski-Rahkonen, A. (2021). Relationship between sensation seeking, alcohol problems and bulimic symptoms: a community-based, longitudinal study. Eating and Weight Disorders - Studies on Anorexia Bulimia and Obesity, 27(2), 589–595. https://doi.org/10.1007/s40519-021-01193-6
9. Bø, R., Billieux, J., & Landrø, N. I. (2016). Which facets of impulsivity predict binge drinking? Addictive Behaviors Reports, 3, 43–47. https://doi.org/10.1016/j.abrep.2016.03.001
10. McElroy, S. L., Kotwal, R., Keck, P. E., & Akiskal, H. S. (2005). Comorbidity of bipolar and eating disorders: distinct or related disorders with shared dysregulations? Journal of Affective Disorders, 86(2–3), 107–127. https://doi.org/10.1016/j.jad.2004.11.008