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Behavioral Addiction: An Overview

Dr. Manoj Kumar Sharma, Associate Professor

& Sarah Khan, Junior Research Fellow

Department of Clinical Psychology

NIMHANS, Bangalore

 

“Every form of addiction is bad, no matter whether the narcotic be alcohol or morphine or idealism” – Carl Jung

Newly emerging knowledge relating to the Human brain suggests that a reward is a reward – no matter where it comes from, be it chemical or an experience.  Associated with it (reward) is the possibility and threat of getting ambushed in an addiction. Taking from where Carl Jung left, I emphasize the intensity and severity of the problem, adding that the classification of addiction could be varied and currently includes a host of new addictions, namely, Problem gambling or ludomania (an urge to gamble despite harmful negative consequences or a desire to stop), Internet addiction (a maladaptive pattern of Internet use, characterized by psychological dependence, withdrawal symptoms when off-line for prolonged periods, loss of control, compulsive behavior and clinically significant impairment of normal social interactions or distress), Shopping addiction/ Compulsive buying (an “excessive spending” disorder which is poorly controlled, markedly distressful, time-consuming and which results in familial, social, vocational and/or financial difficulties, Compulsive sex (engaging in persistent and escalating patterns of sexual behavior acted out despite increasing negative consequences to self and others), Video game addiction (excessive or compulsive use of computer and video games that interferes with daily life and hampers social functioning) and Exercising or obligatory exercise or  anorexia athletica (a compulsion for exercise, with guilt and anxiety if he or she doesn’t work out). Even though these activities are practiced by almost everyone on a daily basis, they become addictions when they come in the way of healthy living. These together are termed as Behavior or Process addictions.

The World Health Organization defines addiction as “a state of periodic and/or chronic intoxication produced by the repeated consumption of a natural or synthetic drug. This state of intoxication is manifested by an overpowering want, need or compulsion with the presence of a tendency to increase the dose and evidence of phenomena of tolerance, abstinence and withdrawal, where there is always psychic and physical dependence on the effects of the drug” (Gossop and Grant, 1990). In line with it, Behavioral addiction (also called process addiction or “non-substance-related addiction”) is a recurring compulsion by an individual to engage in some specific activity, despite harmful consequences, as deemed by the user himself to his individual health, mental state, or social life. For example, while shopping sometimes is acceptable, but when shopping becomes such an integral part of one’s life, to the point of bankrupcy; then it would be shelved as an addiction. The rationale for the existence of this category is that compulsive behaviors follow the same clinical pattern and may even derive from the same neural network as compulsive substance use.

The main difference between process addictions and compulsions is the experience of pleasure. While people who have addictions suffer all manner of discomforts, the desire to use the substance or engage in the behavior is based on the expectation that it will be pleasurable. On the other hand, it is not necessary that someone suffering from obsessive compulsive disorder might get any pleasure from the behavior that he engages in. However, the action will most probably derive a feeling of relief in the patient. Another major distinction between an addiction and a compulsion has to do with the individual’s awareness of reality. When people have obsessive-compulsive disorder, they are usually aware that their obsession is not real. They are often disturbed by feeling the need to carry out a behavior that defies logic, yet they do it anyway to relieve their anxiety. In contrast, people with addictions are often quite detached from the senselessness of their actions, feeling that they are just having a good time, and that other concerns aren’t that important.

Some of the symptoms common to all behavior addictions includes mood swings, gaining feeling of euphoria from the activity, compulsive need to act out the behavior, obsessive thinking about and planning the behavior and allowing the behavior to take precedence over work, health, and family. These symptoms can be observed with similar frequency in both men and women in case of Internet addiction disorder (Akman & Mishra, 2010; Korgaonkar & Wolin, 1999; Teo & Lim, 2000). Male youth are overrepresented in a lot of the behavioral addictions, particularly problem gambling (Vitaro et al, 2001). Most of the older problem gamblers are females (McCormack et al., 2003) or those who have disabilities, or too much idle time (McNeilly & Burke, 2000; Southwell et al., 2008). However, they are less likely to encounter practical difficulties as a result of their gambling-arrests, indebtedness, family problems, etc. (Petry, 2002).

Apart from studies on gender differences, studies on statistics/ prevalence of these disorders are rapidly surfacing. 4.8% adolescents report significant pathological or problem patterns of gambling, while 10-15% remain at risk for the development of severe problems (Hardoon and Derevensky, 2002), 3.9% teen in the age range 15-17 years are affected by problem gambling (White et al., 2007) and 2.8 %  in the grade 7-12 have a gambling problem (CAMH, 2010). 2.1% older adults have a moderate or severe gambling problem (Wiebe et al., 2004). Average worker spends 21 hours per week online in the workplace compared to only 9.5 hours at home (Davis, 2001). 31% Canadians between ages 16-94 are addicted to their work (Keowan, 2007). 3-6% of adults in the U.S.A. are affected with sex addiction disorder (Kaplan & Krueger, 2010). 10.3% of the students aged between 7-12 years are affected by video game addiction (CAMH, 2010).

In India, other than lottery, legal gambling is limited to betting on horse racing. Even though the exact statistics are not known there is potential for newer behavioral addiction. As of 2010, there were 52 million active users of internet: the usage has gone up from 9.3 hours/week to 15.7 hours/week and around 4% browse through mobiles (Sinha, 2010).

CO-MORBIDITY

Process addictions do present with various psychiatric illnesses like anxiety disorders, unipolar and bipolar depression, schizophrenia, borderline and other personality disorders. One of the strongest correlates of problem gambling, and of other process addictions like sex addiction, is substance abuse (Bourget et al., 2003). People who abuse substances (especially those who use heroin, methadone or cocaine) are four to 10 times more likely than the general population to have a gambling problem (Ledgerwood & Downey, 2002; Spunt et al., 1998). Most commonly the substance abuse predates the process addiction, but sometimes the process addiction begins first, or both concerns arise simultaneously (Kausch, 2003). Some theorists believe that tolerance for one kind of behavioral addiction breeds increased tolerance for other kinds (cross-tolerance) (Carnes et al., 2005). Problem gambling, for example, frequently occurs in concert with other process addictions, particularly an involvement with risky sexual practices. Grossly pathological incidents or ongoing conditions in childhood are linked to commensurately negative outcomes later in life, including problem gambling (Moore & Jadlos, 2002).

CAUSES/ PSYCHOSOCIAL FACTORS OF BEHAVIORAL ADDICTION:

Genetic factors play an important role by causing susceptibility to addictive behaviors. Apart from that, family influences on the development of addictions can be very powerful. A child who watches his parents or other adult relatives using substances or engaging in other addictive behaviors gets the message that this is acceptable. It is typical childhood behavior to want to emulate significant adults in one’s life. The child is often looking for adult approval when she copies the adult’s behavior. In families where addictions are openly practiced, young people may be purposely introduced to and included in the addiction. This may be seen as an acceptable custom common to the family culture. In families where physical, verbal, emotional, and sexual abuse may be present, it is not uncommon for a person to begin using addictive substances at an early age to escape the emotional pain. Once a person discovers that he can numb the emotional pain with addictive substances or behaviors, he typically continues this practice on into adulthood. Psychological factors like one’s personality, vulnerability to stress, past traumatic life events, motivation and desire also contribute to addiction. Apart from genetic and psychological factors, social and economic conditions also have an impact on a person’s risk of developing behavioral addictions.

Moore, T. & Jadlos, T. (2002). The etiology of pathological gambling: A study to enhance understanding of causal pathways as a step towards improving prevention and treatment. Wilsonville, OR: Oregon Gambling Addiction Treatment Foundation.

THEORY

Social learning theory (Bandura, 1992): It is based on observations of social situations and how a person learns behavior from it.

There are four stages in social learning theory that explain a potential addict’s behavior. The first stage involves attention. The potential addict makes a conscious choice to watch others engaging in addictive behaviors. Memory is the second stage, with the individual recalling what he has observed. The third stage is imitation. In this stage, the individual repeats the behaviors that he has observed. Motivation is the fourth stage. If the addictive behavior is to be imitated and carried out, there must be some internal motivation for the individual to do so. So how does this learning theory apply to the development of addictions? The addictive behavior of a friend, family member, peer or other admired individual gets one’s attention. An addict may remember watching addictive behaviors in those people he looked up to or admired. At some point, he may have made a choice to try the addictive behavior that he observed. The internal motivation he may have felt to continue using the addictive behavior may have been the approval of the person being imitated or the numbing of emotional pain or the stimulation of the pleasure pathway in his brain. All of this may have happened at either a conscious or an unconscious level.

Negative reinforcement theory (Skinner, 1953): It involves the removal of an unpleasant stimulus when a desired behavior occurs. Negative reinforcement also causes a behavior to be repeated, but in this case, the action causes a bad feeling or situation to go away. For example, some people repeatedly self-medicate with prescription drugs, alcohol or other substances because it removes unpleasant feelings of stress or anxiety. For people with substance abuse problems, the perceived rewards of drug abuse were probably learned long ago: taking a drug or consuming alcohol brings a feeling of pleasure or euphoria, however brief. The same principle can be applied to behavioral addictions. When the good feelings wear off, the user is likely to keep repeating the behavior because it brings relief from bad feelings – such as stress, anxiety or withdrawal. Unfortunately, this can create a difficult pattern of negative reinforcement and cause a patient to continue their behavioral addictions for longer periods of time. Also, sometimes negative reinforcements cause a person to remain stuck even when the consequences aren’t likely to take place, which can open the door to compulsive behaviors.

Bio-psycho-social theories (Blaszczynski & Nower, 2002): It says that number of personal and social factors increase the probability of syndromes like problem gambling and other process addictions.

ASSESSMENT

The best predictor for a client having a given process addiction is evidence for their already having another process addiction. Such addictions overlap, conceal and substitute for one another and may sabotage treatment for one addiction if any others are not identified and addressed. Clients may not necessarily view all of their process addictions as problems, or may fail to mention them for other reasons. Sometimes it isn’t clear what the addiction even is (e.g., Griffiths, 2008, asks, is an Internet gambler addicted to the Internet, gambling or both?). The Addictive Behaviors Questionnaire (Malat et al., 2010) can quickly flag a broad range of problematic behaviors. Rather than a proper diagnostic tool, it is essentially an early-warning system that a client may be experiencing difficulties in certain areas. The clinician may then probe for further information about the client’s involvement in those areas, either with specific screens or interview questions.

According to Littman and Sharp ( 2004), a complete assessment for someone with behavioral addictions should includes: Precipitating factors, Current level of functioning, Relationships and work situation, legal situation, physical and mental health (history and current problems), past treatment, crisis issues, treatment goals & motivation levels. The other scale for assessment of behavioral addiction are Readiness to Change Questionnaire( Rollinck 1992). Internet Addiction Test: It is a 20 item questionnaire based on 5-point likert scale to assess addiction to internet (Young, 1995; Widyanto, McMurran, 2004).The Lie-Bet Tool: It is two items questions tool, used to rule pathological gambling behaviors (Johnson et al 1988).Sex Addiction Screening Test: It is designed to assist in the development of sexually compulsive behavior which may indicate the presence of sex addiction (Carnes, 1992). Eating Addiction Test: The EAT-26 can be used in a non-clinical as well as a clinical setting not specifically focused on eating disorders (Garner et. al., 1982). Work Addiction Test: It is a 25 item self report questionnaire based on work habit description. It measure five functional indicators of work addiction: compulsive tendencies, control, impaired communication, inability to delegate and self worth. It is rated on 4-point likert scale (Robinson, 1999).

TREATMENT

The treatment of this cluster of disorders is motivated by the debate of whether “addiction” is best understood as a brain disease or a moral condition. If addiction is indeed considered as a brain disease then, the root cause of the problem cannot be a moral/ social flaw/ defect or a failure in character.

It has been seen that treating non-chemical addictions is similar to treating chemical addictions: assess, diagnose, plan treatment, intervene and evaluate the effectiveness of method.

Currently, the treatment of behavioral or process addictions begins with the launch of insight in a person. Psycho-education, motivation enhancement therapy (it is important to motivate the person to accept these behaviors as problems & use adaptive coping behaviors), supportive therapy, cognitive behavioral therapy, individual therapy are some of the therapies used to learn new coping skills, and beat the isolation and shame that comes with these disorders. Being a newly studied disorder, no particularly conclusive or substantial efficacy studies have attested the superiority of one therapy over the other. However, three treatment modalities in particular Moore, T. & Jadlos, T. (2002). The etiology of pathological gambling: A study to enhance understanding of causal pathways as a step towards improving prevention and treatment. Wilsonville, OR: Oregon Gambling Addiction Treatment Foundation.

show some promise: cognitive behavioral therapy, a 12-step addiction program and expressive arts therapy (Yang, 2000).

On the other hand, even if treatment succeeds in reducing or eliminating a process addiction, there is a risk of “replacement” process addictions arising after therapy if the broad range of potential and actual problem behaviors has not been addressed (Freimuth, 2005). There is still debate among researchers about how “chronic” process addictions really are. Some would say that the client may “recover” but never be truly “cured.” Someone who has been addicted is at far greater risk than the average person of returning to the problem behavior and relapse at some time or another probably happens to the majority of clients. Follow-up and aftercare can spot early indications of such substitutions and intervene to prevent a new process addiction from taking over. It is probably best to proceed to treatment with whatever level of motivation or stage of readiness the client can manage, settling for harm reduction if the client is not prepared to attempt a full eradication of the problem(s).

IMPLICATIONS

Bearing in mind the co-morbidity of the disorder with a variety of others, it would not be completely unscientific to speak of the disorder as a serious dislocation if not corrected/ put right on time. These/ the above arguments serve as a ground for discussing the implications of behavior addictions, in the world over and specifically India.  The implications not only hold true at the individual level, but also at the societal level; reconfirming that the actions of the adults shadow the one’s of those younger. With already a few known cases of video game addiction, internet addiction and gambling, the numbers are on an all time rise.

There is a need to understand the prevalence/ pattern/ longitudinal work to address the development of these addictions in Indian context & related burden associated with it. It will also help to standardize tool to assess these addictions, help in developing the intervention module for them, develop prognostic factors and family intervention program for them.

References:

Akman, I., & Mishra, A. (2010). Gender, age and income differences in Internet usage among employees in organizations. Computers in Human Behavior, 26, 482-490.

Blaszczynski, A. & Nower, N. (2002). A pathways model of problem and pathological gambling. Addiction, 97, 487–499.

Bourget, D., Ward, H. & Gagne, P. (2003). Characteristics of 75 gambling-related suicides in Quebec. Psychiatry and the Law (CPA Bulletin), December, 17–21.

Carnes, PJ (1992). Don’t call it love: When the diagnosis is sexual addiction. New York, NY: Bantam Books.

Carnes, P., Murray, R. & Charpentier, L. (2005). Bargains with chaos: Sex addicts and addiction interaction disorder. Sexual Addiction & Compulsivity, 12, 79–120.

Centre for Addiction and Mental Health. (2010, June). Highlights from the 2009 OSDUHS mental health and well-being report. CAMH Population Studies eBulletin, 11(2).

Freimuth, M. (2005). Hidden Addictions. New York: Jason Aronson.

Garner,DM,Olmstd,MP,Bohr,Y &  Garfinkel, PE (1982)The eating Attitude Test and clinical Correlates. Psychological medicine, 12, 871-78

Griffiths, M. (2009). Re: process addictions. Email communication with author. April 29, 2009.

Johnson,EE,Hamer,R,Nora,RM,Tan,B,Eistenstein,N & Englehart,C(1988)The Lie/bet questionnaire for screening pathological gamblers. Psychological Reports, 80, 83-88

Hardoon, K. & Derevensky, J. (2001). Social influences involved in children’s gambling behavior. Journal of Gambling Studies, 17, 191–215.

Kaplan, M.S. & Krueger, R.B. (2010). Diagnosis, Assessment and Treatment of Hypersexuality. Journal of Sex Research, 47(2-3), 181-198.

Kausch, O. (2003). Patterns of substance abuse among treatment-seeking pathological gamblers. Journal of Substance Abuse Treatment, 25, 263–270.

Keowan, L.A. (2007). Time escapes me: Workaholics and time perception. Canadian Social Trends, Statistics Canada. Catalogue No. 11-008.

Ledgerwood, D. & Downey, K. (2002). Relationship between problem gambling and substance use in a methadone maintenance population. Addictive Behaviors, 27, 483–491.

Littman-Sharp, N. (2004). Introduction to the treatment of problem gambling. In S. Harrison & V. Carver (Eds.), Alcohol and Drug Problems: A Practical Guide for Counsellors (pp. 675–707). Toronto: Centre for Addiction and Mental Health.

Malat, J., Collins, J., Dhayanandhan, B., Carullo, F. & Turner, N. (2010). Addictive behaviors in comorbid addiction and mental illness: Preliminary results from a self-report questionnaire. Journal of Addiction Medicine 4(1), 38-46.

McNeilly, D. & Burke, W. (2000). Late life gambling: The attitudes and behaviors of older adults. Journal of Gambling Studies, 16, 393–415.
Moore, T. & Jadlos, T. (2002). The etiology of pathological gambling: A study to enhance understanding of causal pathways as a step towards improving prevention and treatment. Wilsonville, OR: Oregon Gambling Addiction Treatment Foundation.

Petry, N. (2002). A comparison of young, middle-aged, and older adult treatment-seeking pathological gamblers. The Gerontologist, 42, 92–99.

Sinha(2010) Internet in India, assessed on Ist August2011: http://www.pluggd.in/internet-usage-in-india-market-statistics-297

Skinner, B.F. (1953). Science and Human Behavior. New York: Macmillan.

Southwell, J., Boreham, P. & Laffan, W. (2008). Problem gambling and the circumstances facing older people: A study of gaming machine players aged 60+ in licensed clubs. Journal of Gambling Studies, 24, 151–174.

Spunt, B., Dupont, I., Lesieur, H., Liberty, H.J. & Hunt, D. (1998). Pathological gambling and substance misuse: A review of the literature. Substance Use & Misuse, 33 (13), 2535–2560.

Teo, T. S. H., & Lim, V. K. G. (2000). Gender differences in Internet usage and task preferences. Behaviour & Information Technology, 19(4), 283-295.

Vitaro, F., Brendgen, M., Ladouceur, R. & Tremblay, R. (2001). Gambling, delinquency, and drug use during adolescence: Mutual influences and common risk factors. Journal of Gambling Studies, 17, 171–190.

White, M.A., Mun, P., Kauffman, N., Whelan, C. & Regan, M. (2007, January). Teen gambling in Ontario: Behaviours and perceptions among 15 to 17 year olds. Toronto: Responsible Gambling Council.

Wiebe, J., Single, E., Falkowski-Ham, A. & Mun, P. (2004, November). Gambling and problem gambling among older adults in Ontario. Responsible Gambling Council and Canadian Centre on Substance Abuse.

Yang, D. J. (2000). Craving your next web fix: Internet addiction is no laughing matter. U.S. News and Worm Report, 128, 41.

Young, KS( 1999). Evaluation and treatment of Internet Addiction. Innovations in clinical Practice. L.

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