Who is the Addict?

Behavioral Addictions: A Basic Understanding

Devon is 22 years old. He started drinking alcohol and smoking pot in his early teens. At first this was a way to socialize, but soon he was isolating in his bedroom with the door locked – getting high, listening to music, and playing video games. His grades dropped, he fell away from his friends, and he lost interest in sports, girls, and other activities. Now he has no money, his family is no longer willing to support his drug habit, and the only people he hangs out with are also heavy drug users.

Jane is 51 years old and married. She first went to a casino while in Las Vegas on her second honeymoon at the age of 49. There, she sat with her new husband Jon at the blackjack table placing $2 bets with him, laughing and joking whether they won or lost. After the honeymoon Jane and Jon returned to the East Coast and he went back to his demanding job, leaving her alone at home during the day. To pass the time she started playing online poker. Before she knew it, she was gambling all the time, ignoring both the household and Jon. Recently, Jon learned that she had depleted their retirement accounts and run up $100,000 in credit card bills. Now he’s threatening to leave her.

Interestingly, Devon’s family knows exactly what to do with him. They want to send him to rehab for substance abuse treatment. Whether Devon is willing to go, and to participate in recovery once there, is another story entirely, and one that is outside the scope of this blog. The point is that it’s clear to everyone (including Devon) that he is an addict and needs outside assistance if he’s ever going to get his life on track. On the other hand, Jane’s husband Jon is completely at a loss. He just can’t understand what has happened to the bright, funny, smart, and sensible woman he married. The best plan he can come up with is to tell her, “If you don’t stop wasting money, I’m leaving you.”

Jane is an Addict, Too!

In 2012 the American Society of Addiction Medicine smartly set forth a definition of addiction that encompasses both substance abuse and certain compulsive behaviors. Using ASAM’s definition it is easy to see and understand that Jane is every bit the addict that Devon is, and that she needs (and deserves) treatment, too.

In most ways, substance and behavioral addictions are incredibly similar. Essentially, substance addicts are people who’ve lost control over their use of alcohol, prescription drugs, and/or illegal drugs such as methamphetamine, heroin, and cocaine. And let’s not forget nicotine. If you want to see the power of a substance addiction, just watch a smoker trying to quit! Behavioral addictions (also called “process addictions”) involve the same basic loss of control. The only real difference is that with behavioral addictions the loss of control involves not substances but potentially pleasurable activities such as gambling, working, eating, spending, sex, and the like.

Sadly, a whole lot of people mistakenly view behavioral addictions as “moral flaws” that are “less serious” than “real” addictions. However, those of us who treat these concerns on a regular basis continually witness the ways in which out-of-control impulsive, compulsive, and addictive behaviors wreak as much havoc on families, careers, and lives as addictions to alcohol, prescription medications, and illegal drugs. Furthermore, we see the ways in which behavioral addictions often pair with substance abuse. For instance, many sex addicts are also addicted to stimulant drugs such as cocaine or methamphetamine. Usually, if such an addict is to find lasting sobriety he or she must be treated for both addictions simultaneously. Otherwise, whichever addiction it is that hasn’t been treated can easily lead to relapse with the other.

The Process of Process Addictions

Part of the confusion around behavioral addictions stems from the fact most addictive behaviors are – for most people, most of the time – healthy, perhaps even essential activities. Things like eating and being sexual, for instance, contribute to survival of the individual and the species. Without these activities the human race would quickly die out. Because of this, our brains are programmed to encourage these behaviors. And for people who become addicts, this is where the problem starts. Simply put, eating and being sexual trigger, among other things, the release of dopamine in the rewards center of the brain, resulting in feelings of pleasure. (Addictive drugs trigger a similar neural response.) Not surprisingly, this biochemical pleasure process is a key element in the development and maintenance of addictions. Essentially, the brain remembers that eating or being sexual (or gambling, in Jane’s case) causes feelings of pleasure. In other words, the brain recognizes that an easy way to feel better is to engage in the pleasurable (and therefore potentially addictive) activity.

Unfortunately, people who struggle with underlying emotional or psychological issues such as depression, anxiety, low self-esteem, attachment deficit disorders, unresolved childhood trauma, and the like sometimes learn to abuse the brain’s dopamine response as a means of coping with stress and masking emotional pain. Eventually, the pleasurable activity is engaged in not to feel better, but to feel less. In time it becomes the person’s go-to coping mechanism for just about everything, resulting in addiction.

To further understand the similarities between substance addictions and behavioral addictions, it may help to consider the drug addict who, cash in hand, has found a source for the drugs he so desperately wants. He leaves work early without informing his boss, hops in the car, and speeds to the dealer’s house. Isn’t he “high” already? After all, his thinking is impaired (he’s making bad decisions), his heart is racing, and he feels compelled to purchase and use the drugs no matter the consequences, And the closer he gets to using, the harder his heart pounds, the more clammy his hands get, and the more tunnel-visioned and misinformed his thinking becomes. Yes, indeed, he is high. Yet at this point there are no actual drugs in his system!

Behavioral addictions operate on the same “anticipatory high” principle. For instance, sex addicts find as much (if not more) pleasure and relief (from stress and emotional pain) in the fantasy and pursuit of sex as in the sex act itself. They sometimes refer to this elevated, fantasy-driven state of neurochemical excitement as “the bubble” or “the trance.” They simply lose touch with reality for hours or even days at a time – high on the idea of sex – with little or no actual physical contact. Thus we see that for both substance addicts and behavioral addicts the fantasies and actions that lead up to actually using/acting out (the ritualized process of the addiction) are every bit as compelling and desirable as the actual drug or behavior.

Identifying Behavioral Addictions

Behavioral addictions are often initially identified during substance abuse treatment or soon thereafter. Usually they pop up as either a cross-addiction or a co-occurring addiction. (Cross-addictions are when the addict uses one addiction to replace another; co-occurring addictions are when two disorders are present at the same time.)

  • Cross-Addiction: While in residential treatment for alcohol addiction, Sydney gains 20 pounds, replacing her drinking with compulsive eating. Later, when she eventually decides to go on a diet, she suddenly finds herself drinking again.
  • Co-Occurring Addiction: Jack leaves treatment for cocaine abuse, thinking he is cured. Once home, he calls up his favorite prostitute, thinking he’ll “treat” himself because he’s been sober for 30-plus days. Within minutes of her arrival, he’s doing lines of cocaine, little realizing that his cocaine use and his sexual behaviors are directly linked.

As is the case with substance abuse recovery, the journey toward sobriety from behavioral addictions is a long-term process that typically requires professional counseling with a clinician or team of clinicians experienced in addressing the specific addiction, along with any cross- or co-occurring disorders that may be present. Happily, such treatment is now available at facilities like The Ranch, Promises, and the Sexual Recovery Institute. One significant treatment difference between substance and behavioral addictions lies in the definition of sobriety. Whereas complete abstinence is typically expected in drug and alcohol treatment, those addicted to things like food and sex learn must carefully identify the behaviors that do and don’t compromise the values and relationships they hold most dear. Then they contract to not engage in the problematic activities and to limit their engagement in the non-problematic activities to moderate and appropriate levels. Otherwise, the treatment and recovery process is incredibly similar for both substance and behavioral addictions.