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Behavioral Addictions: What’s Real & What Isn’t?

There is a lot of misinformation about behavioral addictions.
Currently, only one behavioral addiction is recognized as an official mental health disorder by the American Psychiatric Association: gambling addiction. Other behaviors can certainly be addictive, though they may not be official psychological conditions.

Defining Addiction

The word addiction is actually not a clinical term or diagnosis, and the term has been a subject of controversy for many years. The concept of addiction is difficult to define. In terms of the diagnostic utility of the term, many argue that it has little.
Instead, the American Psychiatric Association (APA) now uses the term substance use disorder instead of addiction or dependence. APA believes this term is more descriptive of the actual disorder involved when people demonstrate addictive behaviors associated with the use of drugs or alcohol. 

Nonetheless, the term addiction remains prevalent in literature and even in conversations between clinicians.

Behavioral Addictions

Likewise, so-called behavioral addictions or process addictions (interchangeable terms) are also very difficult to quantify and measure.
The general definition for a behavioral addiction is that it is a disorder that affects the neural circuitry of the reward system in the brain. It is characterized by repetitive and compulsive involvement in a rewarding non-substance-related behavior despite experiencing adverse consequences from the behavior.
In other words, behavioral addictions are addictive behaviors in relation to activities that are not alcohol or drug use. The conceptualization of different types of behavioral addictions has been just as problematic as trying to define the term addiction as it relates to substance abuse.

What Are Some Commonly Proposed Behavioral Addictions?

One of the major issues associated with the conceptualization of behavioral addiction is that examples can be made to define nearly any activity as potentially addictive. The line between addictive behavior (which is dysfunctional), choice, compulsion, and commitment becomes very thin and subjective.
The following activities have been singled out as potential behavioral addictions:

  • Gambling
  • Playing games on the internet
  • Playing video games
  • Food and eating
  • Sex, including viewing pornography
  • Shopping
  • Exercise
  • Watching television

What Behavioral Addictions Are Legitimate?

Currently, there is only one behavioral addiction that is considered to be a true mental health disorder by APA: gambling disorder. The decision to include gambling disorder in the DSM-5, released in 2013, was based on research findings that found the disorder met the criteria established by the APA to designate some type of behavior as representing a formal mental health disorder.
APA lists diagnostic criteria for gambling disorder, and an individual must meet four of the symptoms over a 12-month period in addition to experiencing significant impairment in functioning or significant distress associated with gambling to meet the diagnostic criteria. Only a trained clinician can make a formal diagnosis.

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Gaming Disorder & Internet Addiction

In 2018, the World Health Organization (WHO) recognized gaming disorder as a legitimate behavioral or process addiction, though it is still not a disorder according to the APA. WHO endorsed diagnostic criteria for gaming disorder that is included in the latest revision of the International Classification of Diseases (ICD-11).
The disorder was accepted based on clinical research suggesting that this is a legitimate form of addictive behavior. It represents a pattern of gaming behavior, such as video gaming or digital gaming, that is characterized by impairments in control with playing games, such that the person’s gaming activities take precedence over important daily activities and escalate. This results in negative consequences for the person.
APA lists internet gaming disorder in its section on conditions requiring further study. It does not yet consider video games/gaming as a form of behavioral addiction.
One condition reviewed by the committee that helped organize the DSM-5 was internet addiction disorder. At the time, it was decided there was not enough empirical evidence to justify the inclusion of the disorder in the current manual.

What About the Others?

Aside from WHO declaring gaming disorder a legitimate disorder and gambling disorder being listed in the DSM-5, there are currently no other recognized, diagnosable behavioral addictions. That being said, clinicians often attempt to diagnose people with food addictions, sex addictions, and other forms of addictions.

In some cases, such as sex addiction, some clinicians have developed provisional diagnostic criteria; however, these are not formally recognized by APA, WHO, and other formal bodies.

Research evidence for many of these conditions regarding their legitimacy as mental health disorders is lacking. In many cases, more research needs to be done to identify the actual symptoms of the disorder and how they relate to the conceptualization of addictive behavior.

For instance, hypersexuality or sex addiction has been reviewed several times for inclusion in the DSM. The research has never been able to fully satisfy the reviewers that such a disorder actually exists.

Compulsion vs. Addiction

Part of the problem is that many researchers find that so-called behavioral addictions are actually more similar to compulsions than to addictive behavior.
Addiction is a broad term that describes the process of how people become dependent on a substance or behavior to cope with everyday living, and they continue to use the substance use or engage in the behavior even when it is causing them harm or dysfunction. Compulsion represents a narrow term that describes an intense urge to perform an act.

The urge can sometimes lead to a behavior, but it does not always.

Often, compulsive behaviors do not include the sensation of pleasure, whereas addictive behaviors do.

Compulsive behaviors typically relieve dysphoric feelings, like anxiety, whereas engaging in addictive behavior typically induces pleasure.
People who have compulsions often recognize their compulsive behaviors are not realistic.

They are often very disturbed by their behavior.

People with addictions often believe they are engaging in proactive behavior, and they deny the fact that their behavior has adverse consequences for them.

These differences are obviously not set in stone, but research findings have not been able to verify that many of the behavioral addictions actually fulfill the evidence-based criteria needed to define a behavior as addictive.

Changes in the Conceptualization of Addiction

In 2011, ASAM (American Society of Addiction Medicine) altered its definition of addiction, which led to the notion that the neurological process of addiction was different than previously conceived. 

Specifically, elimination of the importance of physical dependence as a defining feature of all addictions (tolerance and withdrawal symptoms) helped to legitimize the notion that certain types of other non-substance-related behaviors can also be addictions.

Currently, addiction is conceptualized as a brain disease that involves more areas of the brain than the reward pathway. It may include dysfunction in areas of the brain that are associated with impulse control. It may also involve areas of the brain that are important in motivation and acquiring and maintaining new behaviors.

This reconceptualization of addiction has led to the identification of certain behaviors that may be addictive. In the future, it will most likely lead to the identification of other behavioral addictions that could include food addiction, sex addiction, and shopping addiction. 

At the current time, these are not considered legitimate diagnoses by organizations that research and define the standards for mental illnesses or addictive behaviors. 

Sources

(2013) Diagnostic and statistical manual of mental disorders (5th Edition). American Psychiatric Association from

(August 2010) Introduction to behavioral addictions. The American Journal of Drug and Alcohol Abuse Retrieved August 2019 from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3164585/?_escaped_fragment_=po=8.33333

(August 2018) What is gambling disorder? American Psychiatric Association. Retrieved August 2019 from https://www.psychiatry.org/patients-families/gambling-disorder/what-is-gambling-disorder

(September 2018) Gaming disorder. World Health Organization. Retrieved August 2019 from https://www.who.int/features/qa/gaming-disorder/en/

(August 2013) Addiction: Choice or compulsion? Frontiers in Psychiatry. Retrieved August 2019 from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3736117/

(December 2011) Public policy statement: Definition of addiction. American Society of Addiction Medicine. Retrieved August 2019 from https://www.asam.org/resources/publications/magazine/public-policy-statements/2011/12/15/the-definition-of-addiction

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