Almost everyone is familiar with and understands to some degree what addiction is in terms of substance abuse (things like alcohol, nicotine, illicit drugs, and prescription medications). Frankly, most of us have by now encountered at least one or two alcoholics or drug addicts in school or at work, in our personal lives, or at least in the media. These individuals are people driven by a “need” to escape life’s challenges by getting high in one form or another. In other words, substance addicts are not using drugs or alcohol simply to party and have a good time (though their addiction probably started out that way). Instead, they abuse substances as a way to “maintain a feeling of control” and to “make it through the day, get through life, etc.” Many of these individuals, despite their substance abuse, are reasonably functional, managing to keep an intact personal and professional life while hiding their addiction. Others demonstrate problems that are clearly evident to even the most casual of observers (DUI, job loss, destroyed relationships, etc.) Regardless of whether an addict’s substance abuse is covert or overt, there is little confusion or debate among either lay people or therapy professionals regarding the nature and cycle of drug and alcohol addiction.
A more challenging concept for most people, including many members of the therapy community, is the notion of behavioral addictions (also called process addictions). Gambling, spending, eating, video gaming, relationships, and sex are among the numerous pleasurable life activities that can be hijacked by an addictive disorder, as the brain of the addicted person adapts itself to the endless variety, intensity, and excitement that those experiences naturally produce in all of us. Much of this confusion stems from the fact that behavioral addictions sometimes involve what are, for most people, healthy and life-affirming activities. Eating and sex, for example – two of the more common behavioral addictions – fall squarely into this category, as these behaviors contribute to survival of both the individual and the species. In fact, these activities are so inherently necessary to human existence that our brains are pre-programmed to experience them as pleasurable, thereby encouraging us to engage in them.
Unfortunately, some vulnerable individuals, most often those who struggle with underlying emotional challenges like depression, anxiety, low self-esteem, attachment deficit disorders, and unresolved trauma, learn over time to abuse the brain’s inherent pleasure response to these life-affirming experiences as a way to distract from emotional turmoil, life stressors, and the occasional unpleasantness of day-to-day life. In other words, they abuse these pleasurable activities not to enjoy, but to escape. This is the exact same reason that alcoholics drink and drug addicts use. The unconscious goal is to gain a sense of control over challenging emotional states and uncomfortable interactions by doing something like eating, perusing porn, or gaming – some activity which literally makes the person feel excited, distracted, fulfilled, etc. Over time, these behavioral patterns can become a person’s default response to just about everything that feels emotionally challenging – good and bad. When these repetitive patterns involve abuse of alcohol or drugs, the individual has developed a Substance Use Disorder (SUD in the DSM-5). When the repetitive pattern involves self-soothing and escape with a pleasure seeking behavior, that individual has developed a process addiction.
Is “Behavioral Addiction” Another Term for OCD?
Behavioral addictions and Obsessive Compulsive Disorder (OCD) are not the same thing, though the disorders may seem similar at first glance. The main difference is that behavioral addictions begin with the brain’s pleasure response. In other words, behavioral addictions involve potentially pleasurable activities, while OCD does not. Both disorders seek to address similar emotional challenges (anxiety, fear, loss, etc.), but OCD is characterized by repetitive actions that are not in and of themselves pleasurable. Typical OCD anxiety-reducing behaviors include excessive washing and cleaning, repeated checking (of the oven, the lights, the iron, etc.), hoarding, aversions to particular numbers, counting (ceiling tiles, stripes on the road, etc.), and a wide variety of other idiosyncratic rituals. Not so fun. Another difference between behavioral addictions and OCD is that people with OCD generally recognize that their compulsive behavior is irrational and detrimental, whereas active behavioral addicts are quite often deeply in denial about the depth, breadth, and even the existence of their problem.
The Gamut of Behavioral Addictions…
Process addictions involve the repetitive abuse of potentially pleasurable behaviors as a way to gain control over emotional pain. Again, this is the same basic reason that substance abusers engage in their addictions. Not surprisingly, the core elements of substance addictions are also seen in behavioral addictions. These include:
- Preoccupation and obsession about using/doing the substance/behavior
- Tolerance and escalation
- Loss of control (failed attempts to curtail or quit the substance/behavior)
- Continuation despite negative consequences (“He had to quit a national political position due to sexual scandal, but continued the behavior for quite some time thereafter.”)
- Cravings and other symptoms of withdrawal
Among the more common behavioral addictions are:
- Compulsive Gambling: an uncontrollable urge to gamble – casinos, online gambling, stock market, dog tracks, horses, etc.
- Compulsive Spending: out-of-control shopping – buying things one doesn’t want or need, hiding purchases, shopping in secret to conceal one’s spending, etc.
- Food Addiction: compulsive eating that continues despite repeated attempts to cut down, and despite adverse consequences to health and other aspects of the addict’s life
- Love Addiction: compulsively pursing the “rush” of new romance – failed affairs that begin with intense passion but end relatively quickly and badly, multiple relationships simultaneously, etc.
- Sexual Addiction: compulsive sexual behavior – porn, masturbation, escorts, sensual massage, affairs, casual sex, anonymous sex, exhibitionism, voyeurism, etc.
- Video Game Addiction: compulsive video gaming to the point where the player loses track of time, food, sleep, hygiene, friends, family, and other aspects of healthy living
It should be noted that digital technology drives many process addictions. Essentially, the ease of access, the anonymity, and the affordability of the Internet makes engaging in many pleasurable, potentially addictive behaviors much, much easier. Gamblers, spenders, porn users, and video gamers, for instance, can instantly and effortlessly engage in their addictions online in the privacy of their own homes, keeping their problematic activity a complete secret from friends, family, and employers – until their addiction’s escalating consequences cause their outward lives to crumble, that is.
Fat Lazy Perverts?
Sadly, many in our culture still view behavioral addictions as moral failings rather than chronic, progressive, and treatable illnesses. Food addicts are labeled “fat and lazy,” sex addicts are labeled “perverts,” etc., much as society used to call alcoholics “bums” and drug addicts “degenerate fiends.” This occurs primarily because our culture, as a whole, has a limited understanding of behavioral addictions, typically viewing them as “less serious” than real (i.e., substance) addictions. However, despite the common perception, those of us working in the addiction treatment field see every day that process addictions are every bit as real and destructive as chemical addictions, with out-of-control compulsive behaviors wreaking the same types and degree of havoc on families, careers, and lives as unrestrained substance abuse.
Addressing this, in 2011 the American Society of Addiction Medicine (ASAM) adopted a revised definition of addiction that encompasses both substance abuse and behavioral compulsions. However, behavioral addictions remain largely undefined elsewhere, most notably in the ever-behind-the-curve DSM. Using the recently released DSM-5 therapists can specifically diagnose compulsive gambling and eating disorders, but little else. Beyond that, clinicians tied to the DSM-5 (as many are) must rely on the nebulous “Impulse Control Disorders Not Elsewhere Defined” language that the manual provides. Needless to say, this clinical misalignment has led to a great deal of uncertainty surrounding the diagnosis and treatment of behavioral addictions.
With or without an official DSM-5 diagnosis, the journey toward recovery (a life free of behavioral addiction) is a complex, long-term process that requires professional, addiction-focused counseling coupled with ongoing social support – usually in the form of 12-step recovery groups. As is the case with all forms of addiction, reducing shame and stigma are an essential part of the process. Given the fact that most behavioral addictions are still looked at as moral failings rather than treatable illnesses, we have a long way to go in this regard.