Behavioral Addictions _ _______________________________________________________________________
impulse control and self-regulation, which led to repetitive engagement of the behavior despite negative consequences [1; 2]. The concept of an obsessive-compulsive spectrum of disorders was proposed in 1993; disorders that featured an inability to control or delay repetitive behaviors were thought to fall on a spectrum from impulsivity to compulsivity [3]. Numerous psychiatric and neurologic disorders were included in this spectrum [4]. Further research suggested that impulsivity and compulsivity appeared in substance and behavioral addictions at different stages, and the “impulsive-compulsive disorder” model was proposed. In this model, impulsivity was dominant in earlier- stage addiction, when behavior is motivated and reinforced by reward, and compulsivity was dominant in later stages, when behavior is motivated and reinforced by avoidance of negative emotional states [5]. Expansion of Core Features An influential 2006 study broadened the definition and core features of addiction as 1) a state of craving or urge that imme- diately precedes the behavior, 2) impaired ability to control the behavior, and 3) the behavior continues despite negative consequences [6]. Criterion 3 suggested addiction was no longer tethered to substance use. This was cemented in 2011, when the American Society of Addiction Medicine (ASAM) released their definition of addiction. The core features of this definition are [7]: • The inability to consistently abstain • Impairment in behavioral control • Craving • Diminished recognition of significant problems with one’s behaviors and interpersonal relationships • A dysfunctional emotional response Numerous repetitive problematic behaviors became suggested as behavioral addictions, but criticism that excessive normal behaviors were becoming overpathologized ensued [4; 8; 9]. Concerns were raised that such persons could become stig- matized, based in part on study results suggesting that “brain disease” explanations of drug addiction had unforeseen con- sequences on clinician and public attitudes—the inability of persons with addiction to control behavior being hard-wired into their brains was perceived to make them more danger- ous [10]. This concern along with recognition of the roles of prevention and harm reduction in the spectrum of addiction recovery led the ASAM in 2019 to adopt a revised definition of addiction as “a treatable, chronic medical disease involv- ing complex interactions among brain circuits, genetics, the environment, and an individual’s life experiences. People with addiction use substances or engage in behaviors that become compulsive and often continue despite harmful circumstances. Prevention efforts and treatment approaches for addiction are generally as successful as those for other chronic diseases” [7].
INTRODUCTION The term “addiction” is traditionally used to describe the pathologic behavioral patterns a subset of persons exhibit from exposure to substances with central nervous system (CNS) activity (e.g., heroin, cocaine, alcohol). However, addiction is not a unitary construct; it incorporates common features that include repetitive engagement in rewarding (at least initially) behaviors, loss of control (spiraling engagement over time), persistence despite consequences, aversive states when inges- tion is halted or substantially cut back, and an appetitive urge or craving state prior to engaging in the behavior. Many of these pathologic behaviors have long been classified as impulse control disorders, including pathologic gambling, intermittent explosive disorder, kleptomania, pyromania, and trichotillo- mania. Research suggests that several of these impulse control disorders more accurately represent behavioral addictions. As a distinct area of study, behavioral addiction is recent, and extensive knowledge advances have been made since 2010. Growing evidence suggests that behavioral and substance addic- tions overlap in clinical expression (e.g., craving, tolerance, withdrawal symptoms), comorbidity, neurobiologic profile, heritability, and treatment. Behavioral and substance addic- tions also share similar features in natural history, phenomenol- ogy, and adverse consequences. This course will address the most common non-substance behavioral addictions, including pathologic gambling, compulsive sexual behavior, compulsive buying, and compulsive video gaming. BEHAVIORAL ADDICTION: EVOLUTION AND CONCEPTS In some behavioral addictions, the published research is vast but confusing. Prominent investigators in this field view behavioral addictions through differing paradigms, which has interfered with expert consensus and efforts to advance the field. Disagreement on diagnostic criteria has prevented standardized measurement of treatment outcomes. Debate has also focused on whether behavioral addictions qualify as addictions or are better explained as disorders of impulse control or compulsivity, and whether “Internet addiction” as a unified construct is valid. EVOLUTION IN THE CONCEPT OF BEHAVIORAL ADDICTION Early Characterizations The concept of addiction involving non-substance behaviors as repeated urges to engage in counter-productive activities was introduced in 1990. At the time, behavioral addictions were proposed to encompass obsessive-compulsive disorder (OCD), “compulsive spending” (including gambling), “over- eating” (binge eating), “hypersexuality,” and kleptomania. It was thought these behaviors were linked to addiction by poor
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