What is Behavioural Addiction?

Introduction

Behavioural addiction is a form of addiction that involves a compulsion to engage in a rewarding non-substance-related behaviour – sometimes called a natural reward – despite any negative consequences to the person’s physical, mental, social or financial well-being. Addiction canonically refers to substance abuse; however, the term’s connotation has been expanded to include behaviours that may lead to a reward (e.g. gambling, eating, or shopping) since the 1990s. A gene transcription factor known as ΔFosB has been identified as a necessary common factor involved in both behavioural and drug addictions, which are associated with the same set of neural adaptations in the reward system.

Psychiatric and Medical Classifications

Diagnostic models do not currently include the criteria necessary to identify behaviours as addictions in a clinical setting. Behavioural addictions have been proposed as a new class in DSM-5, but the only category included is gambling addiction. Internet gaming addiction is included in the appendix as a condition for further study.

Behavioural addictions, which are sometimes referred to as impulse control disorders, are increasingly recognised as treatable forms of addiction. The type of excessive behaviours identified as being addictive include gambling, eating, having sexual intercourses, using pornography, computers, video games, internet and digital media, physical exercise, and shopping.

In August 2011, the American Society of Addiction Medicine (ASAM) issued a public statement defining all addiction in terms of brain changes. “Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry.”

The following excerpts are taken from the organisation’s FAQs:

The new ASAM definition makes a departure from equating addiction with just substance dependence, by describing how addiction is also related to behaviors that are rewarding. This is the first time that ASAM has taken an official position that addiction is not solely “substance dependence.” This definition says that addiction is about functioning and brain circuitry and how the structure and function of the brains of persons with addiction differ from the structure and function of the brains of persons who do not have addiction. It talks about reward circuitry in the brain and related circuitry, but the emphasis is not on the external rewards that act on the reward system. Food and sexual behaviors and gambling behaviors can be associated with the “pathological pursuit of rewards” described in this new definition of addiction.

We all have the brain reward circuitry that makes food and sex rewarding. In fact, this is a survival mechanism. In a healthy brain, these rewards have feedback mechanisms for satiety or ‘enough.’ In someone with addiction, the circuitry becomes dysfunctional such that the message to the individual becomes ‘more’, which leads to the pathological pursuit of rewards and/or relief through the use of substances and behaviors. So, anyone who has addiction is vulnerable to food and sex addiction.

Meanwhile, DSM-5 has deprecated the term “addiction”.

Treatment

Behavioural addiction is a treatable condition. Treatment options include psychotherapy and psychopharmacotherapy (i.e. medications) or a combination of both. Cognitive behavioural therapy (CBT) is the most common form of psychotherapy used in treating behavioural addictions; it focuses on identifying patterns that trigger compulsive behaviour and making lifestyle changes to promote healthier behaviours. Because cognitive behavioural therapy is considered a short term therapy, the number of sessions for treatment normally ranges from five to twenty. During the session, therapists will lead patients through the topics of identifying the issue, becoming aware of one’s thoughts surrounding the issue, identifying any negative or false thinking, and reshaping said negative and false thinking. While CBT does not cure behavioural addiction, it does help with coping with the condition in a healthy way. Currently, there are no medications approved for treatment of behavioural addictions in general, but some medications used for treatment of drug addiction may also be beneficial with specific behavioural addictions. Any unrelated psychiatric disorders should be kept under control, and differentiated from the contributing factors that cause the addiction.

Research

A recent narrative review in 2017 examined the existing literature for studies reporting associations between behavioural addictions (pathological gambling, problematic internet use, problematic online gaming, compulsive sexual behaviour disorder, compulsive buying and exercise addiction) and psychiatric disorders. Overall, there is solid evidence for associations between behavioural addictions and mood disorder, anxiety disorder as well as substance use disorders. Associations between ADHD may be specific to problematic internet use and problematic online gaming. The authors also conclude that most of current research on the association between behavioural addictions and psychiatric disorders has several limitations: they are mostly cross-sectional, are not from representative samples, and are often based on small samples, among others. Especially more longitudinal studies are needed to establish the direction of causation, i.e. whether behavioural addictions are a cause or a consequence of psychiatric disorders.

Biomolecular Mechanisms

ΔFosB, a gene transcription factor, has been identified as playing a critical role in the development of addictive states in both behavioural addictions and drug addictions. Overexpression of ΔFosB in the nucleus accumbens is necessary and sufficient for many of the neural adaptations seen in drug addiction; it has been implicated in addictions to alcohol, cannabinoids, cocaine, nicotine, phenylcyclidine, and substituted amphetamines as well as addictions to natural rewards such as sex, exercise, and food. A recent study also demonstrated a cross-sensitization between drug reward (amphetamine) and a natural reward (sex) that was mediated by ΔFosB.

Besides increased ΔFosB expression in the nucleus accumbens, there are many other correlations in the neurobiology of behavioural addictions with drug addictions.

One of the most important discoveries of addictions has been the drug based reinforcement and, even more important, reward based learning processes. Several structures of the brain are important in the conditioning process of behavioural addiction; these subcortical structures form the brain regions known as the reward system. One of the major areas of study is the amygdala, a brain structure which involves emotional significance and associated learning. Research shows that dopaminergic projections from the ventral tegmental area facilitate a motivational or learned association to a specific behaviour. Dopamine neurons take a role in the learning and sustaining of many acquired behaviours. Research specific to Parkinson’s disease has led to identifying the intracellular signalling pathways that underlie the immediate actions of dopamine. The most common mechanism of dopamine is to create addictive properties along with certain behaviours. There are three stages to the dopamine reward system: bursts of dopamine, triggering of behaviour, and further impact to the behaviour. Once electronically signalled, possibly through the behaviour, dopamine neurons let out a ‘burst-fire’ of elements to stimulate areas along fast transmitting pathways. The behaviour response then perpetuates the striated neurons to further send stimuli. The fast firing of dopamine neurons can be monitored over time by evaluating the amount of extracellular concentrations of dopamine through micro dialysis and brain imaging. This monitoring can lead to a model in which one can see the multiplicity of triggering over a period of time. Once the behaviour is triggered, it is hard to work away from the dopamine reward system.

Behaviours like gambling have been linked to the newfound idea of the brain’s capacity to anticipate rewards. The reward system can be triggered by early detectors of the behaviour, and trigger dopamine neurons to begin stimulating behaviours. But in some cases, it can lead to many issues due to error, or reward-prediction errors. These errors can act as teaching signals to create a complex behaviour task over time.

What is Impulse-Control Disorder?

Introduction

Impulse-control disorder (ICD) is a class of psychiatric disorders characterised by impulsivity – failure to resist a temptation, an urge, or an impulse; or having the inability to not speak on a thought.

Many psychiatric disorders feature impulsivity, including substance-related disorders, behavioural addictions, attention deficit hyperactivity disorder, foetal alcohol spectrum disorders, antisocial personality disorder, borderline personality disorder, conduct disorder and some mood disorders.

The fifth edition of the American Psychiatric Association’s Diagnostic and statistical manual of mental disorders (DSM-5) that was published in 2013 includes a new chapter (not in DSM-IV-TR) on disruptive, impulse-control, and conduct disorders covering disorders “characterized by problems in emotional and behavioral self-control”. Five behavioural stages characterise impulsivity:

  • An impulse;
  • Growing tension;
  • Pleasure on acting;
  • Relief from the urge; and
  • Finally guilt (which may or may not arise).

Types

Disorders characterised by impulsivity that were not categorised elsewhere in the DSM-IV-TR were also included in the category “Impulse-control disorders not elsewhere classified”. Trichotillomania (hair-pulling) and skin-picking were moved in DSM-5 to the obsessive-compulsive chapter. Additionally, other disorders not specifically listed in this category are often classed as impulsivity disorders. Terminology was changed in the DSM-V from “Not Otherwise Classified” to “Not Elsewhere Classified”.

Sexual Compulsion

Sexual compulsion includes an increased urge in sexual behaviour and thoughts. This compulsion may also lead to several consequences in the individual’s life, including risky partner selection, increased chance for STIs and depression, as well as unwanted pregnancy. There has not yet been a determined estimate of its prevalence due to the secretiveness of the disorder. However, research conducted in the early 1990s in the United States gave prevalence estimates between 5-6% in the US population, with male cases being higher than female.

Internet Addiction

The disorder of Internet addiction has only recently been taken into consideration and has been added as a form of ICD. It is characterised by excessive and damaging usage of Internet with increased amount of time spent chatting, web surfing, gambling, shopping or consuming pornography. Excessive and problematic Internet use has been reported across all age, social, economic, and educational ranges. Although initially thought to occur mostly in males, increasing rates have been also observed in females. However, no epidemiological study has been conducted yet to understand its prevalence.

Compulsive Shopping

Compulsive shopping or buying is characterised by a frequent irresistible urge to shop even if the purchases are not needed or cannot be afforded. The prevalence of compulsive buying in the US has been estimated to be 2-8% of the general adult population, with 80-95% of these cases being females. The onset is believed to occur in late teens or early twenties and the disorder is considered to be generally chronic.

Pyromania

Pyromania is characterised by impulsive and repetitive urges to deliberately start fires. Because of its nature, the number of studies performed for fire-setting are understandably very few. However, studies done on children and adolescents suffering from pyromania have reported its prevalence to be between 2.4 and 3.5% in the United States. It has also been observed that the incidence of fire-setting is more common in juvenile and teenage boys than girls of the same age.

Intermittent Explosive Disorder

Intermittent explosive disorder or IED is a clinical condition of experiencing recurrent aggressive episodes that are out of proportion of any given stressor. Earlier studies reported a prevalence rate between 1-2% in a clinical setting, however a study done by Coccaro and colleagues in 2004 had reported about 11.1% lifetime prevalence and 3.2% one month prevalence in a sample of a moderate number of individuals (n=253). Based on the study, Coccaro and colleagues estimated the prevalence of IED in 1.4 million individuals in the US and 10 million with lifetime IED.

Kleptomania

Kleptomania is characterised by an impulsive urge to steal purely for the sake of gratification. In the US the presence of kleptomania is unknown but has been estimated at 6 per 1000 individuals. Kleptomania is also thought to be the cause of 5% of annual shoplifting in the US If true, 100,000 arrests are made in the US annually due to kleptomaniac behaviour.

Signs and Symptoms

The signs and symptoms of impulse-control disorders vary based on the age of the persons suffering from them, the actual type of impulse-control that they are struggling with, the environment in which they are living, and whether they are male or female.

Co-Morbidity

Complications of late Parkinson’s disease may include a range of impulse-control disorders, including eating, buying, compulsive gambling, sexual behaviour, and related behaviours (punding, hobbyism and walkabout). Prevalence studies suggest that ICDs occur in 13.6-36.0% of Parkinson’s patients exhibited at least one form of ICD. There is a significant co-occurrence of pathological gambling and personality disorder, and is suggested to be caused partly by their common “genetic vulnerability”. The degree of heritability to ICD is similar to other psychiatric disorders including substance use disorder. There has also been found a genetic factor to the development of ICD just as there is for substance use disorder. The risk for subclinical PG in a population is accounted for by the risk of alcohol dependence by about 12-20% genetic and 3-8% environmental factors. There is a high rate of co-morbidity between ADHD and other impulse-control disorders.

Mechanism

Dysfunction of the striatum may prove to be the link between OCD, ICD and SUD. According to research, the ‘impulsiveness’ that occurs in the later stages of OCD is caused by progressive dysfunction of the ventral striatal circuit. Whereas in case of ICD and SUD, the increased dysfunction of dorsal striatal circuit increases the “ICD and SUD behaviours that are driven by the compulsive processes”. OCD and ICD have traditionally been viewed as two very different disorders, the former one is generally driven by the desire to avoid harm whereas the latter one driven “by reward-seeking behaviour”. Still, there are certain behaviours similar in both, for example the compulsive actions of ICD patients and the behaviour of reward-seeking (for example hoarding) in OCD patients.

Treatment

Impulse-control disorders have two treatment options: psychosocial and pharmacological. Treatment methodology is informed by the presence of comorbid conditions.

Medication

In the case of pathological gambling, along with fluvoxamine, clomipramine has been shown effective in the treatment, with reducing the problems of pathological gambling in a subject by up to 90%. Whereas in trichotillomania, the use of clomipramine has again been found to be effective, fluoxetine has not produced consistent positive results. Fluoxetine, however, has produced positive results in the treatment of pathological skin picking disorder, although more research is needed to conclude this information. Fluoxetine has also been evaluated in treating IED and demonstrated significant improvement in reducing frequency and severity of impulsive aggression and irritability in a sample of 100 subjects who were randomised into a 14-week, double-blind study. Despite a large decrease in impulsive aggression behaviour from baseline, only 44% of fluoxetine responders and 29% of all fluoxetine subjects were considered to be in full remission at the end of the study. Paroxetine has shown to be somewhat effective although the results are inconsistent. Another medication, escitalopram, has shown to improve the condition of the subjects of pathological gambling with anxiety symptoms. The results suggest that although SSRIs have shown positive results in the treatment of pathological gambling, inconsistent results with the use of SSRIs have been obtained which might suggest a neurological heterogeneity in the ICD spectrum.

Psychosocial

The psychosocial approach to the treatment of ICDs includes cognitive behavioural therapy (CBT) which has been reported to have positive results in the case of treatment of pathological gambling and sexual addiction. There is general consensus that cognitive-behavioural therapies offer an effective intervention model.

TypeDescription
Pathological GamblingSystematic desensitisation, aversive therapy, covert sensitisation, imaginal desensitisation, and stimulus control have been proven to be successful in the treatments to the problems of pathological gambling. Also, “cognitive techniques such as psychoeducation, cognitive-restructuring, and relapse prevention” have proven to be effective in the treatments of such cases.
PyromaniaPyromania is harder to control in adults due to lack of co-operation; however, CBT is effective in treating child pyromaniacs.
Intermittent Explosive DisorderAlong with several other methods of treatments, cognitive behavioural therapy has also shown to be effective in the case of Intermittent explosive disorder as well. Cognitive Relaxation and Coping Skills Therapy (CRCST), which consists of 12 sessions starting first with the relaxation training followed by cognitive restructuring, then exposure therapy is taken. Later, the focus is on resisting aggressive impulses and taking other preventative measures.
KleptomaniaIn the case of kleptomania, the cognitive behaviour techniques used in these cases consists of covert sensitisation, imaginal desensitisation, systematic desensitisation, aversion therapy, relaxation training, and “alternative sources of satisfaction”.
Compulsive BuyingAlthough compulsive buying falls under the category of Impulse-control disorder – Not Otherwise Specified in the DSM-IV-TR, some researchers have suggested that it consists of core features that represent impulse-control disorders which includes preceding tension, difficult to resist urges and relief or pleasure after action. The efficiency of cognitive behaviour therapy for compulsive buying is not truly determined yet; however, common techniques for the treatment include exposure and response prevention, relapse prevention, cognitive restructuring, covert sensitization, and stimulus control.

Book: The Addiction Treatment Planner: Includes DSM-5 Updates

Book Title:

The Addiction Treatment Planner: Includes DSM-5 Updates.

Author(s): Robert R. Perkinson, Arthur E. Jongsma, and Timothy J. Bruce.

Year: 2014.

Edition: Fifth (5th).

Publisher: Wiley.

Type(s): Paperback and Kindle.

Synopsis:

The Addiction Treatment Planner, Fifth Edition provides all the elements necessary to quickly and easily develop formal treatment plans that satisfy the demands of HMOs, managed care companies, third-party payors, and state and federal agencies.

  • New edition features empirically supported, evidence-based treatment interventions.
  • Organised around 43 behaviourally based presenting problems, including substance use, eating disorders, schizoid traits, and others.
  • Over 1,000 prewritten treatment goals, objectives, and interventions – plus space to record your own treatment plan options.
  • Easy-to-use reference format helps locate treatment plan components by behavioural problem.
  • Includes a sample treatment plan that conforms to the requirements of most third-party payors and accrediting agencies including CARF, The Joint Commission (TJC), COA, and the NCQA.

Book: Clean – Overcoming Addiction And Ending America’s Greatest Tragedy

Book Title:

Clean – Overcoming Addiction And Ending America’s Greatest Tragedy.

Author(s): David Sheff.

Year: 2014.

Edition: First (1st).

Publisher: Houghton Mifflin Harcourt.

Type(s): hardcover, Paperback, and Audiobook.

Synopsis:

Addiction is a preventable, treatable disease, not a moral failing.

As with other illnesses, the approaches most likely to work are based on science – not on faith, tradition, contrition, or wishful thinking. These facts are the foundation of Clean.

The existing addiction treatments, including Twelve Step programmes and rehabs, have helped some, but they have failed to help many more.

To discover why, David Sheff spent time with scores of scientists, doctors, counsellors, and addicts and their families, and explored the latest research in psychology, neuroscience, and medicine.

In Clean, he reveals how addiction really works, and how we can combat it.

Research: Treatments for Internet Gaming Disorder and Internet Addiction: A Systematic Review

Research Paper Title:

Treatments for Internet Gaming Disorder and Internet Addiction: A Systematic Review.

Author(s): Kristyn Zajac, Meredith K. Ginley, Rocio Chang, and Nancy Petry.

Year: 2017.

Journal: Psychology of Addictive Behaviours, 31(8).

DOI: 10.1037/adb0000315.

Abstract:

Problems related to excessive use of the Internet and video games have recently captured the interests of both researchers and clinicians.

The goals of this review are to summarise the literature on treatment effectiveness for these problems and to determine whether any treatments meet the minimum requirement of an evidence-based treatment as defined by Chambless et al. (1998).

Studies of treatments for Internet gaming disorder (IGD) and Internet addiction were examined separately, as past studies have linked IGD to more severe outcomes. The systematic review identified 26 studies meeting predefined criteria; 13 focused on treatments for IGD and 13 on Internet addiction.

The results highlighted a paucity of well-designed treatment outcome studies and limited evidence for the effectiveness of any treatment modality. Studies were limited by methodological flaws, including small sample sizes, lack of control groups, and little information on treatment adherence, among other problems. In addition, the field is beset by a lack of consistent definitions of and established instruments to measure IGD and Internet addiction.

The results of this review highlight the need for additional work in the area of treatment development and evaluation for IGD and Internet addiction. Attention to methodological concerns identified within this review should improve subsequent research related to treating these conditions, and ultimately outcomes of patients suffering from them.

You can download a copy of the full paper here.

Research: Relationship between Internet Addiction and Academic Performance among Foreign Undergraduate Students

Research Paper Title:

Relationship between Internet Addiction and Academic Performance among Foreign Undergraduate Students.

Author(s): Najmi Hayati, Masoumeh Alavi, and Syed Mohamed Shafeq.

Year: 2014.

Journal: Procedia – Social and Behavioural Sciences, 114 (Conference: 4th World Conference on Psychology, Counseling and Guidance).

DOI: 10.1016/j.sbspro.2013.12.795.

Abstract:

The purpose of this study is to identify the relationship between Internet Addiction (IA) and academic performance among foreign undergraduate students in Universiti Teknologi Malaysia (UTM).

This study also identified the differences in internet addiction in terms of gender and country of original.

Four countries were selected through simple random sampling; there were China, Yemen, Somalia and Indonesia. Then, a total of 120 students were selected randomly from those countries. In order to measure IA, Internet Addiction Test (IAT) based on Young’s (1998) survey which modified by Pee and Shafeq (2009), was used.

The data collected was analysed using SPSS. The statistical techniques frequency and percentage were used to identify the patterns of using the Internet; t-test and one-way ANOVA were used to examine the differences in IA in terms of demographic factors. Pearson correlation technique was also used to determine the relationship between IA and academic performance.

The results of the study showed that there were no significant differences in IA in terms of gender, country of origin. The results also indicated that there were no significant differences in IA in terms of CGPA. This suggests that future research needs to work on large-scale using multiple-campus technology assessments.

You can download a copy of the full paper here.

Research: Risk Factors of Internet Addiction and the Health Effect of Internet Addiction on Adolescents

Research Paper Title:

Risk Factors of Internet Addiction and the Health Effect of Internet Addiction on Adolescents: A Systematic Review of Longitudinal and Prospective Studies.

Author(s): Lawrence T. Lam.

Year: 2014.

Journal: Current Psychiatry Reports, 16(11), pp.1-9.

DOI: 10.1007/s11920-014-0508-2.

Abstract:

Internet gaming addiction was included in the latest version of the DSM-V as a possible disorder recently, while debate is still on-going as to whether the condition called “Internet Addiction” (IA) could be fully recognised as an established disorder.

The major contention is how well IA could fulfil the validation criteria as a psychiatric disorder as in other well-established behavioural addictions. In addition to various proposed validation criteria, evidence of risk and protective factors as well as development of outcomes from longitudinal and prospective studies are suggested as important.

A systematic review of available longitudinal and prospective studies was conducted to gather epidemiological evidence on risk and protective factors of IA and the health effect of IA on adolescents. Nine articles were identified after an extensive search of the literature in accordance to the PRISMA guidelines. Of these, eight provided data on risk or protective factors of IA and one focused solely on the effects of IA on mental health.

Information was extracted and analysed systematically from each study and tabulated. Many exposure variables were studied and could be broadly classified into three main categories:

  • Psychopathologies of the participants, family and parenting factors; and
  • Others such as Internet usage, motivation, and academic performance.

Some were found to be potential risk or protective factors of IA. It was also found that exposure to IA had a detrimental effect on the mental health of young people. These results were discussed in light of their implications to the fulfilment of the validation criteria.

You can download a copy of the full paper here.

Book: Internet Addiction in Children and Adolescents

Book Title:

Internet Addiction in Children and Adolescents: Risk Factors, Assessment, and Treatment.

Author(s): Kimberly S. Young and Cristiano Nabuco de Abreu (Editors).

Year: 2017.

Edition: First (1st).

Publisher: Springer Publishing Co Inc.

Type(s): Paperback and Kindle.

Synopsis:

This is the first book to thoroughly examine how early and easy access to the Internet and digital technologies impacts children and adolescents. Experts in the field examine the research that shows the social, cognitive, developmental, and academic problems that can result when children spend excessive time in front of screens. As a whole, the book provides an invaluable resource for those who need to assess, treat, and prevent Internet addiction in children and adolescents.

Internet Addiction in Children and Adolescents:

  • Provides tools that help predict a child’s level of risk for media-related problems.
  • Examines how to diagnose and differentiate Internet addiction from other psychiatric conditions.
  • Explores evidence-based treatment approaches and how to distinguish pathology from normal development.
  • Shows how to create inpatient treatment programs and therapies to address media addiction.
  • Highlights the psychological, social, and family conditions for those most at risk.
  • Evaluates the effects of the excessive use of electronic games and the Internet on brain development.
  • Explores the physical risks that result from excessive media use and strategies for combating the problem.
  • Examines school-based initiatives that employ policies and procedures designed to increase awareness of excessive media use and help educators identify students who misuse technology, and that provide strategies of intervention and communication with parents.
  • Identifies signs of problem Internet behavior such as aggressive behavior, lying about screen use, and a preference for screen time over social interactions.
  • Outlines the risk factors for developing Internet addiction.
  • Provides strategies for treatment and prevention in family, school, and community settings.

Practitioners and researchers in psychology, social work, school counseling, child and family therapy, and nursing will appreciate this book’s thorough review of Internet addiction among children and adolescents. The book also serves as an engaging supplement in courses on media psychology, addiction counseling, abnormal psychology, school counseling, social issues, and more.

Book: Internet Addiction

Book Title:

Internet Addiction: Prevalence, Risk Factors and Health Effects.

Author(s): Margaret Adams (Editor).

Year: 2016.

Edition: First (1st).

Publisher: Nova Science Publishers.

Type(s): Hardcover and Kindle.

Synopsis:

According to the World Health Organisation, pathological addiction is the psychic, and sometimes even physical, condition arising from the interaction between a living organism and an exogenous substance, characterised by behavioural responses and other reactions that always include a compulsive need to take the substance continuously or periodically, in order to get its psychic effects and/or to avoid the distress related to its withdrawal.

This book presents a review on Internet addiction, which is considered an emergent problem especially amongst adolescents, and examines the risk factors and health effects of this addiction.