When hearing the word “addiction,” most of us tend to think of alcoholism and substance abuse, as opposed to addictive behaviors like eating, spending, gambling, video gaming and being sexual. Nevertheless, people can and do become addicted to highly pleasurable, self-soothing and dissociative behaviors just as they can become addicted to pleasurable, self-soothing and dissociative substances –with similarly problematic results. In fact, the core symptomology of substance addiction (referred to as “substance use disorder” in the DSM-5) and process/behavioral addictions are almost exactly the same, as outlined below:
- Preoccupation to the point of obsession with the substance or activity
- Loss of control over use of the substance or activity, typically evidenced by failed attempts to quit or cut back
- Directly related negative consequences – relationship trouble, issues at work or in school, declining physical and/or emotional health (depression, anxiety, loss of self-esteem, etc.), isolation, financial woes, loss of interest in previously enjoyable activities, legal trouble and more
Though the American Psychiatric Association is not overly accepting of behavioral addictions, excluding them (except for gambling addiction) from the DSM-5, other professional organizations, most notably the American Society of Addiction Medicine, are much more accepting. In fact, ASAM’s definition of addiction, adopted in 2011, opens with the following language:
Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors [emphasis added].
Thanks in large part to the APA’s behind-the-times stance, there is a good deal of clinical confusion about how to understand and label a behavioral addiction. Somewhat amazingly, this sad state of affairs is largely unnecessary if/when one understands the etiology of addiction. Put simply, addictions of all types form and manifest in the same basic ways. For starters, the risk factors for substance and behavioral addictions are the same – most often a combination of genetic and environmental factors. In other words, people are at-risk when there is a history of addiction (any type) or mental illness in the family, and/or they have unresolved (most often early-life) trauma. A lot of the time these at-risk individuals turn to alcohol, prescription medications or illicit substances as a way to self-medicate stress and/or emotional discomfort, but they may also turn to an intensely pleasurable pattern of behavior.
The simple truth is that addictive substances and addictive behaviors trigger the same basic neurochemical response – primarily the release of dopamine (along with serotonin, oxytocin, and a few other mood-related neurochemicals), resulting in feelings of pleasure, anticipation and distraction. This intense neurochemical response to addictive substances and/or behaviors provides temporary escape and relief. Over time, some individuals learn that the easiest way to avoid feelings of stress and emotional discomfort is to ingest an addictive substance or engage in a highly pleasurable (and therefore potentially addictive) behavior. Eventually they start to use these substances and/or behaviors not to feel better, but to feel less (i.e., to control what they feel). This is a sure sign of addiction. So the only significant difference between substance and behavioral addictions is that substance addicts ingest alcohol or drugs to create an escapist neurochemical reaction, while behavioral addicts rely on an intensely pleasurable fantasy or activity – no substance necessary.
Part of the confusion around process addictions arises because certain addictive behaviors are (for most people, most of the time) healthy and essential to life. For instance, eating and being sexual contribute to survival of both the individual and the species. (This is why our brains are programmed to experience pleasure when we engage in these activities.) Unfortunately, for vulnerable people (people at-risk for addiction), this pleasure response can become a go-to coping mechanism, turned to time and time again until the individual loses control over it.
To further understand the link between substance and behavioral addictions, consider a cocaine addict on payday. After receiving his check, he runs to the bank to exchange it for cash, perhaps leaving work early to do so. Then he dashes off to his dealer’s house to spend money that he really ought to set aside for food, rent, childcare and the like. As he approaches his dealer’s house, his heart races, he’s sweating, and he is so obsessed and preoccupied with his addiction that he doesn’t even notice the police car parked a block away. He is so completely focused on cocaine that the day-to-day world, with all of its problems and obligations, has temporarily receded. In most respects this individual is high already: He has “escaped” from his life, his decision-making is distorted, and he has lost touch with reality. It doesn’t matter that there are no actual drugs in his system, because his brain is pumping out dopamine (based on euphoric recall and anticipatory fantasy) as if there are. This neurobiological state of escape and dissociation, no matter how it is induced, is the goal of all addictions.
Put simply, addiction is about the manipulation of one’s own neurochemistry, and this can happen with or without an addictive substance. Sex addicts in particular “get high” based more on thoughts and fantasies than anything else. In fact, sex addicts typically experience more pleasure and escape through anticipating and chasing sex than from sex itself. They even have a name for this condition, referring to it as either “the bubble” or “the trance.” Essentially, they recognize that their addiction is not about sex, it’s about losing touch with reality for an extended period of time. For them, engaging in sex and reaching orgasm actually ends the high and throws them back into the real world, where they must once again face life and all its problems.
Even though behavioral addictions are in most respects similar to substance abuse issues, they are often more difficult to identify. After all, they’re easier to hide, they’re (usually) more socially acceptable, and outside observers (even some therapists) don’t always recognize the behaviors as potentially addictive. Much of the time behavioral addicts must experience serious directly related consequences before anyone is willing to confront them and help them to admit they have a problem. Other times behavioral addictions are only uncovered during treatment for a substance use disorder or some other psychiatric condition. For instance, a woman in treatment for depression and alcohol abuse may find herself acting out sexually with other patients or even staff, leading to an evaluation for sex and love addiction, or a man attending Alcoholics Anonymous may find himself continually relapsing at the local casino, leading to a realization that he has an intertwined alcohol and gambling addiction.
Another major obstacle in the identification and treatment of behavioral addictions is that many clinicians are not trained to properly assess for them, along with the fact that most people tend to view them as being less serious than “real” addictions. In actuality nothing could be further from the truth. Put simply, behavioral addictions wreak the same types and degree of havoc as substance use disorders – relationship trouble, issues at work or in school, declining physical and/or emotional health (depression, anxiety, loss of self-esteem, etc.), isolation, financial woes, loss of interest in previously enjoyable activities, legal trouble and more. Furthermore, substance and behavioral addictions are often inextricably linked, meaning addicts must deal with both problems simultaneously or they may not recover from either.
As is true with the substance addictions, healing from a behavioral addiction is a long-term process that is best accomplished utilizing a combination of professional counseling with an addiction treatment specialist – including addiction-focused group therapy – and 12-step or other addiction-focused support groups. My personal website provides resource listings for both addicts and treatment specialists.
Robert Weiss LCSW, CSAT-S is Senior Vice President of Clinical Development with Elements Behavioral Health. He has developed clinical programs for The Ranch in Nunnelly, Tennessee, Promises Treatment Centers in Malibu, and The Sexual Recovery Institute in Los Angeles, among others. He is author of Cruise Control: Understanding Sex Addiction in Gay Men and Sex Addiction 101: A Basic Guide to Healing from Sex, Porn, and Love Addiction, and co-author with Dr. Jennifer Schneider of both Untangling the Web: Sex, Porn, and Fantasy Obsession in the Internet Age and Closer Together, Further Apart: The Effect of Technology and the Internet on Parenting, Work, and Relationships. For more information you can visit his website, www.robertweissmsw.com.