________________________________________________________________________ Behavioral Addictions
The DSM-5 and Classification Issues A major step forward in the recognition of behavioral addic- tions as addictive disorders came in 2013 with the American Psychiatric Association (APA) publication of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) [11]. In the DSM-5, pathologic gambling was renamed gambling disorder, becoming the first recognized behavioral addiction. This followed decades of research and data dem- onstrating similarities to substance addictions [8]. Internet gaming disorder and its proposed diagnostic criteria were placed in Section III (Emerging Measures and Models); the body of evidence was extensive, but standardized diagnostic criteria remain absent [12]. Decisions in the DSM-5 concerning behavioral addiction were based on evidence published before 2013 in an emerging and quickly evolving field. While some criticism reflected the premature state of some evidence and lack of consensus, other criticism was directed at decisions to omit behavioral addic- tions that were viewed as subjective and biased [4]. INTERNET-MEDIATED BEHAVIORAL ADDICTION Internet addiction is the concept of addiction to Internet use itself, as opposed to the concept that some addictions are medi- ated by Internet use. The description and diagnostic criteria of Internet addiction disorder first appeared in 1996. Internet addiction disorder was considered an impulse control disorder, based on an inability to control Internet use and resulting in impaired functioning. An Internet addiction disorder typology was proposed, consisting of [13]: • Cybersex addiction • Cyber-relationship addiction
• Anonymity, which can encourage behaviors inhibited offline by stigma and fear of detection and increase perceived control over the content, tone, and nature of online experience. Anonymity can increase the comfort level of users with fears of social rejection by removing the ability to look for and detect disapproval or judg- ment in facial expressions or body language. • Convenience of use in familiar, comfortable environ- ments, reducing perceptions of risk • Escapism. Online gaming, gambling, buying, or sex is reinforced by a subjectively experienced “high,” with habitual pursuit a core feature of addiction. Relief from negative emotions and distress related to real-world problems further reinforces the behavior. • Immersion can facilitate a dissociation-like state in which the user loses track of time, feels like someone else, blacks out, or experiences a trance-like state, a reinforcing effect for some. • Disinhibition. The core reward for some. Users tend to lower their defenses and emotionally reveal themselves faster online than offline. Socially inhibited users can find the disinhibiting environment and perceived con- nection to others powerfully reinforcing. Other contributors to online impulsivity include invisibility and the absence of authorities (e.g., police, parents, teachers) that communicate power and hierarchy offline and constrain behavior [21]. Freed of inhibitions that maintain offline behav- ior within the boundaries of civility, social acceptability, and legality, users may act on impulses online they would otherwise attempt to resist [22]. COGNITIVE AND BEHAVIORAL ASPECTS OF BEHAVIORAL ADDICTION As with substance addiction, behavioral addictions are defined by the presence of cognitive, affective, and behavioral abnor- malities that reflect maladaptive alteration of underlying neural structures—the core pathology. Functional magnetic resonance imaging (fMRI) and other brain imaging methods can identify these core pathologic features and their similarity to those of substance addiction. Addiction research is moving toward classifying psychopathology on dimensions of behavior and neurobiology and away from DSM-type symptom checklists. This is expected to improve assessment and diagnostic validity and treatment efficacy [23]. Impulsivity The ability to delay, withhold, or interrupt a behavioral response is a key aspect of executive function. Suppressing an inappropriate immediate response allows time for other processes (and predicting consequences of possible actions) to promote appropriate behavioral choices. Effective inhibitory control is required for adaptive functioning, such as restraining impulses for spiteful, peculiar, and/or inappropriate expres- sion [11; 24].
• Internet compulsions • Information overload • Computer addiction
This work in a newly evolving, unexplored area could not foresee the current reality of Internet centrality in daily life. Many aspects of Internet use deemed pathologic in 1996 have become normative [14]. The Internet is now considered the medium of choice in many gambling, gaming, sex, and other addictions, but not itself the object of addiction, and the con- cept of Internet addiction has been abandoned [15]. The DSM-5 contributed to this confusion in the introductory text for Internet gaming disorder by stating that it was also commonly referred to as Internet use disorder or Internet addiction [11]. This message was unclear, but some features unique to the Internet may promote excessive or addictive behaviors, including [16; 17; 18; 19; 20; 21]: • Accessibility through high-speed broadband connec- tions • Affordability, as the Internet lacks previous cost restraints
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