14.7 — Addiction, Eating Disorders and Self-Harm

Three things that look different and share a mechanism: a behaviour that reliably produces relief from an unbearable internal state, at a cost that arrives later.

Understanding that shared shape is what makes the responses make sense — and it is why "just stop" fails in all three.

Addiction

Covered mechanically in 8.4. The clinical essentials.

What defines it: compulsive use despite clear harm, loss of control over amount or timing, craving, and — in many cases — tolerance and withdrawal.

The mechanism (8.1): the wanting system becomes sensitised while the liking system fades. Which produces the state outsiders cannot understand — intense pursuit of something no longer enjoyed.

And the control systems that would intervene are impaired, both by the substance and by the chronic state.

Withdrawal safety, repeated because it matters: alcohol and benzodiazepine withdrawal can be life-threatening. Do not stop either abruptly if you are physically dependent — get medical advice. Opioid withdrawal is extremely unpleasant and not usually dangerous, and the overdose risk after a break in use is very high because tolerance falls.

What works: medication where it exists — opioid substitution treatment substantially reduces mortality, and effective medications exist for alcohol and nicotine. Structured psychological treatment. Peer support. Combinations beat single approaches.

Relapse is expected, at rates comparable to other chronic conditions requiring behaviour change. Treating it as total failure predicts a worse outcome (4.8).

Eating disorders

Serious illnesses, not lifestyle choices or vanity, and anorexia nervosa has one of the highest mortality rates of any mental illness — from physical complications and from suicide.

Anorexia nervosa. Restriction of intake leading to significantly low weight, intense fear of gaining weight, and a disturbance in how body weight or shape is experienced. The person frequently does not see themselves as underweight, which is a feature of the illness rather than denial.

Bulimia nervosa. Recurrent binge eating with a sense of loss of control, followed by compensatory behaviour — vomiting, laxatives, fasting, excessive exercise. Weight is frequently in the normal range, which is why it is missed.

Binge eating disorder. Recurrent binges with loss of control and marked distress, without compensatory behaviour. The most common of the three and the least recognised.

And ARFID — avoidant/restrictive food intake disorder — restriction driven by sensory aversion, fear of choking or lack of interest, without body image concerns. Recognised relatively recently and frequently missed, particularly in autistic people.

What they are actually about: rarely food. Control, in a life where little feels controllable, is the most common theme. Also perfectionism, anxiety, and — with binge eating — emotional regulation.

Warning signs: preoccupation with food, calories or body; eating alone or avoiding meals with others; rituals around food; going to the bathroom after meals; excessive exercise; weight change; withdrawal; and in physical terms, cold intolerance, hair loss, dizziness, and menstrual changes.

What helps: specialist eating disorder treatment, which is a distinct expertise. Family-based treatment has the best evidence for adolescents with anorexia. Cognitive behavioural therapy adapted for eating disorders has good evidence for bulimia and binge eating. Medical monitoring alongside, because the physical risks are real.

And early treatment matters substantially for outcome.

If somebody you know may have one: do not comment on their weight or appearance in either direction, do not police their eating, and do raise it once, privately, focused on your concern about them rather than about food. Then help them get to a professional.

Self-harm

Most self-harm is not a suicide attempt. This is the most important thing on this section and it is widely misunderstood.

What it usually is: a way of managing an unbearable internal state — providing relief from emotional pain, ending a dissociated numbness, or expressing something that cannot be said. It works, in the short term, which is why it recurs.

And it is common, particularly in adolescence.

But it is also a risk factor. People who self-harm have substantially elevated risk of eventually dying by suicide, so it should never be dismissed as attention-seeking — a phrase that has done a great deal of harm and that misdescribes what is happening.

What helps.

Replace the function, not just the behaviour. Ask what it does — relief, feeling something, self-punishment, communication — because each has different substitutes.

Distress tolerance skills (15.5): cold water, intense sensation, physical exertion, and riding the urge (8.4). Urges to self-harm peak and pass, and getting through one without acting makes the next easier.

Reduce access to means where possible.

And treat the underlying condition, which is usually depression, trauma or emotional dysregulation. DBT has the best evidence for repeated self-harm.

If somebody tells you: stay calm, do not express horror, do not demand they stop, do not inspect wounds. Ask what it does for them, and ask whether they want to die — the second question is separate and it must be asked (14.8).

The shared response

All three: address the function before the behaviour.

Ask what state it is relieving. Then work on the state and on alternative routes to relief.

And in all three, shame is the accelerant (4.8). Every one of these is hidden, every one is judged, and hiding is what delays help by years.

The single most useful thing you can offer somebody in any of these situations is to be unshocked.

What to do

If it is you: tell one person, and get an assessment. All three have specialist treatments and general counselling is not the same thing.

Reduce access, in whatever form applies.

Learn one distress tolerance skill (15.5) and use it once before you need it.

And in India: Tele-MANAS on 14416 is free and 24 hours, and a psychiatrist or clinical psychologist for the specific treatments. For alcohol dependence, see a doctor before stopping.

Next: 14.8 is the page to read before you need it.