Behavioral addiction
Behavioral addiction, process addiction, or non-substance-related disorder is a form of addiction that involves a compulsion to engage in a rewarding non-substance-related behavior – sometimes called a natural reward – despite any negative consequences to the person's physical, mental, social or financial well-being. In the brain's reward system, a gene transcription factor known as ΔFosB has been identified as a necessary common factor involved in both behavioral and drug addictions, which are associated with the same set of neural adaptations.
Addiction canonically refers to substance abuse; however, the term's connotation has been expanded to include behaviors that may lead to a reward since the 1990s. Still, the framework to diagnose and categorize behavioral addiction is a controversial topic in the psychopathology field.
Psychiatric and medical classifications
Diagnostic and Statistical Manual of Mental Disorders recognized behavioral addictions for the first time in DSM-5 with gambling disorder, formerly pathological gambling, as the only non-substance-related disorder classified under the chapter of "Substance-Related and Addictive Disorders". Internet gaming addiction was included in the appendix as a condition for further study. Although "addiction" is commonly used to describe repetitive harmful behavior in nonmedical settings, DSM-5 recommended the neutral term "disorder" instead of "addiction" under the clinical settings to avoid uncertain definition and potentially negative connotation.Similar to the changes in DSM-5, the eleventh revision of the International Classification of Diseases introduced the category "Disorders due to substance use or addictive behaviours", based on the diagnostic framework of impaired control, repetitive harmful behavior, and continuation or escalation despite negative consequences. The new sub-category "Disorders due to addictive behaviours" included gambling disorder, gaming disorder, and two residual categories to raise attention among clinicians and the public and to facilitate further research.
In 2019, the American Society of Addiction Medicine revised its definition of addiction including substance use and compulsive behaviors, stating: "addiction is a treatable, chronic medical disease involving complex interactions among brain circuits, genetics, the environment, and an individual's life experiences."
Other addictive behaviors which have received research attention but with insufficient or inconclusive evidence include pornography use disorder, compulsive buying disorder, social network use disorder, work addiction, exercise addiction, compulsive sexual behavior disorder, and food addiction.
Types
Exercise addiction
Exercise addiction is a state characterized by a compulsive engagement in any form of physical exercise, despite negative consequences. While regular exercise is generally a healthy activity, exercise addiction generally involves performing excessive amounts of exercise to the detriment of physical health, spending too much time exercising to the detriment of personal and professional life, and exercising regardless of physical injury. It may also involve a state of dependence upon regular exercise which involves the occurrence of severe withdrawal symptoms when the individual is unable to exercise. Differentiating between addictive and healthy exercise behaviors is difficult but there are key factors in determining which category a person may fall into. Exercise addiction shows a high comorbidity with eating disorders.Exercise addiction is not listed as a disorder in the fourth revision of the Diagnostic and Statistical Manual of Mental Disorders. This type of addiction can be classified under a behavioral addiction in which a person's behavior becomes obsessive, compulsive, or causes dysfunction in a person's life.
Gambling addiction
Problem gambling, ludopathy or ludomania is repetitive gambling behavior despite harm and negative consequences. Problem gambling may be diagnosed as a mental disorder according to DSM-5 if certain diagnostic criteria are met. Pathological gambling is a common disorder associated with social and family costs. Estimates suggest the affected global population is between 0.1% and 6%.The DSM-5 has re-classified the condition as an addictive disorder, with those affected exhibiting many similarities to those with substance addictions. The term gambling addiction has long been used in the recovery movement. Pathological gambling was long considered by the American Psychiatric Association to be an impulse-control disorder rather than an addiction. However, data suggests a closer relationship between pathological gambling and substance use disorders than exists between PG and obsessive–compulsive disorder, mainly because the behaviors in problem gambling and most primary substance use disorders seek to activate the brain's reward mechanisms, while the behaviors characterizing obsessive-compulsive disorder are prompted by overactive and misplaced signals from the brain's fear mechanisms.
Problem gambling is an addictive behavior with a high comorbidity with alcohol problems. A common tendency shared by people who have a gambling addiction is impulsivity.
Internet addiction
Pornography addiction
Sexual addiction
Shopping addiction
Video game addiction
Internet gaming disorder affects an estimated 5% of the global population.Work addiction
Treatment
Behavioral addiction is a treatable condition. Treatment options include psychotherapy and psychopharmacotherapy or a combination of both. Cognitive behavioral therapy is the most common form of psychotherapy used in treating behavioral addictions; it focuses on identifying patterns that trigger compulsive behavior and making lifestyle changes to promote healthier behaviors. Because cognitive behavioral 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 behavioral addiction, it does help with coping with the condition in a healthy way. Currently, there are no medications approved for treatment of behavioral addictions in general, but some medications used for treatment of drug addiction may also be beneficial with specific behavioral addictions.Another form of treatment is recreational therapy. A Certified Therapeutic Recreation Specialist uses leisure and recreation to help individuals recover from their injuries, ailments, or addictions. Therapeutic recreation can help an individual struggling with addiction to improve their self-esteem, confidence, motivation, resiliency, autonomy, enjoyment, and overall emotional state.
Research
The classification and diagnostic framework of behavioral addictions under DSM-5 and ICD-11 has been a controversial subject among the clinical research field. For example, this 2020 narrative review considered ICD-11's guidelines to be adequate to include more behavioral addictions based on clinical relevance and empirical evidence, while this 2015 journal article questioned the atheoretical and confirmatory research approaches on the accuracy of qualitative factors and criticized the lack of consideration of social elements and psychological processes.A recent narrative review in 2017 examined the existing literature for studies reporting associations between behavioral addictions and psychiatric disorders. Overall, there is solid evidence for associations between behavioral addictions and mood disorders, anxiety disorders, 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 behavioral 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 behavioral addictions are a cause or a consequence of psychiatric disorders.
A systematic review in 2021 investigating the correlation between autism and behavioral addiction found inconclusive evidence for a general correlation. However found evidence of correlation when comorbid mental health conditions were present. Another systematic review in 2022 estimating the prevalence of behavioural addiction during the COVID-19 pandemic found the prevalence to be 11.1%.
Behavioral addiction and the brain
Several recently published studies have investigated potential brain abnormalities associated with behavioral addiction. A 2024 meta-analysis of neuroimaging studies related to specific types of behavioral addiction aimed to distinguish whether subtypes of behavioral addiction share a common neural basis. It found that research subjects affected by various behavioral addictions demonstrate similarities in the role of the frontostriatal circuits. Findings confirmed previous studies, highlighting the role of hyperactivation in the bilateral caudate nucleus, a part of the basal ganglia. Likewise, hyperactivation of the right inferior frontal gyrus and left middle frontal gyrus, both located in the brain's frontal lobe, was observed.A similar 2024 meta-analysis likewise identified abnormalities in cortical thickness among subjects affected by differing behavioral addictions. These subjects were noted to have a thinner cerebral cortex than individuals without behavioral addiction. Areas of the cerebral cortex affected were specifically the precuneus, postcentral gyrus, orbital-frontal cortex, and dorsolateral prefrontal cortex. An association between these areas and specific genes thought to be involved in dopamine metabolism and behavioral regulation was identified, the most significant of which was the dopamine D2 receptor. Additionally, researchers found that increased severity of behavioral addiction was linked to increased thinning of the cerebral cortex within the precuneus and postcentral gyrus.
Likewise, a 2023 meta-analysis found that subjects affected by differing behavioral addictions demonstrated similarities in gray matter volume, specifically a marked loss of gray matter volume in the anterior cingulate cortex, middle cingulate cortex, and superior frontal gyrus. This decrease in gray matter volume is associated with a decrease in brain connectivity. The meta-analysis suggests that this lack of gray matter could be associated with behavioral aspects of behavioral addiction, such as inhibition.