Conceptualizing addiction has been a matter of great debate for decades. For many people, the concept of addiction involves the taking of drugs. Therefore it is perhaps unsurprising that most official definitions concentrate on drug ingestion. Despite such definitions, there is now a growing movement that views a number of behaviors as potentially addictive, including those that do not involve the ingestion of a drug. These include behaviors as diverse as gambling, eating, sex, exercise, videogame playing, love, shopping, Internet use, social networking and work. I have argued in many of my papers that all addictions – irrespective of whether they are chemical or behavioral – comprise six components (i.e., salience, mood modification, tolerance, withdrawal, conflict and relapse). More specifically:
- Salience – This occurs when the activity becomes the single most important activity in the person’s life and dominates their thinking (preoccupations and cognitive distortions), feelings (cravings) and behavior (deterioration of socialized behavior). For instance, even if the person is not actually engaged in the activity they will be constantly thinking about the next time that they will be (i.e., a total preoccupation with the activity).
- Mood modification – This refers to the subjective experiences that people report as a consequence of engaging in the activity and can be seen as a coping strategy (i.e., they experience an arousing “buzz” or a “high” or, paradoxically, a tranquilizing feel of “escape” or “numbing”).
- Tolerance – This is the process whereby increasing amounts of the activity are required to achieve the former mood-modifying effects. This basically means that for someone engaged in the activity, they gradually build up the amount of the time they spend engaging in the activity every day.
- Withdrawal symptoms – These are the unpleasant feeling states and/or physical effects (e.g., the shakes, moodiness, irritability, etc.) that occur when the person is unable to engage in the activity.
- Conflict – This refers to the conflicts between the person and those around them (interpersonal conflict), conflicts with other activities (e.g., work, social life, hobbies and interests) or from within the individual (e.g., intra-psychic conflict and/or subjective feelings of loss of control) that are concerned with spending too much time engaging in the activity.
- Relapse – This is the tendency for repeated reversions to earlier patterns of excessive engagement in the activity to recur, and for even the most extreme patterns typical of the height of excessive engagement in the activity to be quickly restored after periods of control.
In May 2013, the new criteria for problem gambling (now called Gambling Disorder) were published in the fifth edition of the Diagnostic and Statistical Manual for Mental Disorders (DSM-5), and, for the very first time, problem gambling was included in the section “Substance-related and Addiction Disorders” rather than in the section on impulse control disorders, as had been the case since 1980, when it was first included in the DSM-III. Although most of us in the field had been conceptualizing extreme problem gambling as an addiction for many years, this was arguably the first time that an established medical body had described it as such.
There had also been debates about whether or not “Internet Addiction Disorder” should have been included in the DSM-5. As a result of these debates, the Substance Use Disorder Work Group recommended that the DSM-5 include “Internet Gaming Disorder” (IGD) in Section III (“Emerging Measures and Models”) as an area that required further research before possible inclusion in future editions of the DSM.
To be included in its own right in the next edition, research will have to establish the defining features of IGD, obtain cross-cultural data on reliability and validity of specific diagnostic criteria, determine prevalence rates in representative epidemiological samples in countries around the world and examine its associated biological features. Other than gambling and gaming, no other behavior (e.g., sex, work, exercise, etc.) has yet to be classified as a genuine addiction by established medical and/or psychiatric organizations.
In one of the most comprehensive reviews of chemical and behavioral addictions, Dr. Steve Sussman, Nadra Lisha and myself examined all the prevalence literature relating to 11 different potentially addictive behaviors. We reported overall prevalence rates of addictions to cigarette smoking (15%), drinking alcohol (10%), illicit drug-taking (5%), eating (2%), gambling (2%), Internet use (2%), love (3%), sex (3%), exercise (3%), work (10%) and shopping (6%). However, most of the prevalence data relating to behavioral addictions (with the exception of gambling) did not have prevalence data from nationally representative samples and therefore relied on small and/or self-selected samples.
Addiction is an incredibly complex behavior and always results from an interaction and interplay between many factors, including the person’s biological and/or genetic predisposition, their psychological constitution (personality factors, unconscious motivations, attitudes, expectations, beliefs, etc.), their social environment (i.e. situational characteristics such as accessibility and availability of the activity, the advertising of the activity) and the nature of the activity itself (i.e., structural characteristics such as the size of the stake or jackpot in gambling). This global view of addiction highlights the interconnected processes and integration between individual differences (i.e., personal vulnerability factors), situational characteristics and structural characteristics and the resulting addictive behavior.
There are many individual (personal vulnerability) factors that may be involved in the acquisition, development and maintenance of behavioral addictions (e.g. personality traits, biological and genetic predispositions, unconscious motivations, learning and conditioning effects, thoughts, beliefs and attitudes), although some factors are more personal (e.g., financial motivation and economic pressures in the case of gambling addiction). However, there are also some key risk factors that are highly associated with developing almost any (chemical or behavioral) addiction, such as having a family history of addiction, having co-morbid psychological problems and having a lack of family involvement and supervision. Psychosocial factors such as low self-esteem, loneliness, depression, high anxiety and stress all appear to be common among those with behavioral addictions.
This article briefly demonstrates that behavioral addictions are a part of a biopsychosocial process and not just restricted to drug-ingested (chemical) behaviors. Evidence is growing that excessive behaviors of all types do seem to have many commonalities and this may reflect a common etiology of addictive behavior. Such commonalities may have implications not only for treatment of such behaviors but also for how the general public perceives such behaviors.