A central controversy in the field of addiction is whether the so-called “behavioral” addictions—addictions to activities such as eating, exercising, sex, video game playing, and gambling—are real addictions. But concepts of addiction have changed over the years, and experts vary in their understanding of what an addiction is, so until a consensus is reached, the controversy is likely to continue to some extent. However, much has been learned since the last update to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) was published.
Current Status
While a strong movement of addictions professionals and public opinion supports the recognition of addiction to behaviors such as sex, shopping, video game playing, the internet, eating, and exercise, the American Psychiatric Association (APA), who develop, write and publish the diagnostic and statistical manual (DSM), has only included gambling disorder in its most recent edition (DSM-5). There are advocates—as well as naysayers—for the inclusion of each of the behavioral addictions as “real” addictions, but with a few notable exceptions, such as Professor Jim Orford, a clinical psychologist and author of “Excessive Appetites,” who has long argued for the recognition of a range of addictive behaviors, they tend to focus on one behavior rather than the full range. However, each of the major addictive behaviors mentioned here has had attempts made to formulate diagnostic criteria based on the experiences of those affected, which bear a close resemblance to existing criteria for alcohol and drug dependence and compulsive gambling. Outside of the world of professional psychiatry and psychology, the media has taken on and embraced the concepts of behavioral addictions. “Oprah,” the most successful, highest-rated talk show in global television history, routinely addressed topics related to a range of addictions. These topics include well-established addictions, such as illicit and prescription drug abuse, behavioral addictions, such as sex addiction and shopping addiction, and other activities that are not usually included in the discussion about addiction, such as self-cutting (often discussed in relation to Borderline Personality Disorder) and plastic surgery. The portrayal of these activities as addictions resonates with both sufferers and the viewing public, and clearly, these shows are in touch with contemporary issues.
History
The history of the addiction concept is grounded in work with people addicted to alcohol and other drugs. As alcohol and other drugs physically alter people’s brain chemistry, causing a cycle of tolerance and withdrawal that can keep people wanting more and more of the drug, the whole basis of addiction theory rests on the idea of chemical dependence. The toxic effects of alcohol and other drugs on the brain and the rest of the body reinforce the concept of addiction as a disease — people who drink a lot and take a large number of drugs for extended periods of time tend to eventually get very ill. But in fact, the disease model of addiction, which focuses on the physiological actions of drugs, was initially intended to reduce the moral judgment of addicts by portraying them as “sick” rather than “evil.” And the medical community as a whole is moving towards greater recognition of the role of stress and psychological health in all areas health and wellness. With preventative medicine and patient empowerment being embraced by both professionals and the public as legitimate approaches to addressing healthcare issues, the disease model of addiction is becoming obsolete. So if gambling is an addiction, why not other activities that provide certain individuals with the thrill and letdown that characterizes addictive behaviors? Mainly because there has not been the research, driven by associated funding, to adequately support the existence of other addictive behaviors. And the research that does exist is fragmented across many disciplines and areas of interest. And is there a risk associated with the inclusion of otherwise non-problematic behaviors alongside alcohol and drug dependence? There are important arguments on both sides of this debate.
Case For
The patterns of development of each addiction, the thought process involved, the reward cycle that maintains addictive behaviors, the social and relationship consequences, and the process of recovery have a great deal in common across addictive behaviors. Understanding, for example, that it is not gambling per se that is causing the gambling addict to lose everything, but a process of avoiding the reality of his situation, allows a therapist to work with him in facing up to, accepting, and improving his life. In the same way, understanding that a drug user, binge eater, excessive exerciser, or obsessive bargain hunter are all using these behaviors to try and avoid the stress of their lives, and in the process, are making things worse, allows therapy to focus on resolving this, rather than fixating exclusively on the behavior itself. An inclusive model of addiction also allows us to adequately prepare people for the risk that they will not only relapse to their previous addictive behavior but that they also risk developing another addiction. This common problem is a result of not learning effective coping skills to deal with life stresses, and, with the focus on the previous addictive behavior, to develop the same addictive pattern with another behavior. Treatment approaches, such as the stages of change model and motivational interviewing, are successful in treating addictions of all kinds. Recognition of the addictive process as the primary driving force behind all addictive behaviors, whether they are focused on a substance or an activity, allows many more people to be helped in integrated addictions services. Some of these services already exist, and the inclusion of different addictions in group therapy is highly advantageous to the therapeutic process, as people disengage from the specific behavior and recognize instead what it is doing for them, and how to meet this need in a healthier way. Another positive aspect of the recognition of behavioral addictions as real addictions is that it de-emphasizes the inadequate disease model of addiction, which has run its course and no longer serves its original purpose.
Case Against
An important argument against the inclusion of a range of behaviors in a concept of addiction is that they may not be addictions. While the patterns might be the same, it is possible that addiction to substances is a completely different process from compulsive behaviors. As Dr. Christopher Fairburn stated: “The fact that things are similar or have properties in common does not make them the same. And focussing exclusively on these similarities… distracts from the difference between these behaviors.” Another argument against including non-substance behaviors in a theory of addiction is that the physical consequences of alcohol and drug use are so severe that including less harmful activities dilutes the importance of “genuine” addictions, and makes them more socially acceptable. This trivializes the severity of alcohol and drug dependence, making these substances seem as harmless as spending too much at the mall or overindulging in chocolate cake. Also, some people think that including non-substance activities as addictions means that the term is used so loosely that it could be applied to any behavior, and everyone could be seen to be addicted to something. Jim Orford quotes another psychologist, Hans Eysenck, as saying, “I like playing tennis and writing books on psychology; does that mean that I am addicted to tennis and book writing?”
Where It Stands
The media continues to use the addiction label to describe excessive behavior, and it is used in everyday language as people seek help for their own excessive behavior, and that of their loved ones. In response to critics of the inclusive addiction approach: Individual and special aspects of each addictive behavior can be addressed while people work on the psychological aspects of their addiction and can be integrated with medical approaches. The facetious argument that addiction could be applied to anything anyone enjoys is missing the point. It is not enjoying an activity that makes it an addiction, it is engaging in it so excessively that other areas of life suffer. If Hans Eysenck was playing so much tennis that his health and relationships were suffering, absolutely, he could be addicted to tennis playing. The same goes for his book writing.
