The recent issue of Scientific American has an article by Carl Erik Fisher, a psychiatrist and bioethics professor at Columbia University, in which he explores whether behavioral addictions are mental illnesses or just bad habits. His article, “Food, sex, gambling, the internet: When is it addiction?” is available by subscription.
Fisher defines behavioral addictions as “an overwhelming, repetitive and harmful pattern of behaviors apart from drug or alcohol abuse.” Behavioral addictions are things like an addiction to gambling or shopping or video games or sex. The DSM-5, the encyclopedia of mental disorders, has a category for gambling addiction, and “internet gaming disorder” was added to the appendix as needing further study.
I wrote about the nature of addiction for Salvo Magazine in “Dying to Feel Good.” It specifically addressed prescription pain medicine addiction, or opiate drug addiction. Opiate drug addiction is a little easier to recognize as an addiction because of its physical effects. However, as Dr. Fisher points out, he gets more people calling him for behavior addictions than for cocaine and heroin combined. These people are overwhelmed with harmful repetitive behaviors that are ruining their lives, but they are unable to stop doing them.
The first difficulty with behavior addictions is pinpointing what exactly they are. They tend to manifest very much like an obsessive compulsive disorder but neurologically look more like addictive behavior. Some people do suffer withdrawal symptoms when they abstain from the behavior, such as anxiety and depression as well as nausea and headaches. But, different people have different withdrawal symptoms and some suffer from withdrawal to a greater or lesser degree.
I was giving a lecture on worldviews in video games, and in passing I mentioned video game addiction. I had just watched the Frontline documentary on internet gaming addiction that followed several teens in South Korea who had to go to a video game recovery camp to unplug. One person in the audience did not believe people could be addicted to video games citing the fact that they do not convulse or get sick when they do not get their game playing in.
This is an important distinction. What the audience member was talking about is called physical withdrawal symptoms, which is not the same thing as addiction. Some people link the two because often one is a sign of the other, but many experts on addiction contend that while people will often seek out their drug to avoid the painful withdrawal symptoms, addiction isn’t just about physical dependency.
One example cited in the literature was caffeine. Some people get headaches and fatigue if they do not have their daily cup of coffee. They will often say they are addicted to coffee when what they really mean is that they have a chemical dependency. Just looking at what is going on at a purely physiological level, coffee isn’t giving the same dopamine response (in most people) that heroin, compulsive gambling, or other entrapping substances and behaviors do. There is something more going on in compulsive gambler or the heroin addict at the neurological level than mere chemical dependency.
One book that I found incredibly helpful on this topic was Addiction and Virtue: Beyond the Models of Disease and Choice by Kent Dunnington. He draws from Aristotle and Aquinas to help us understand the connection between the physical and the mental. The pre-moderns did not separate body and mind the way us moderns do. It is one of the best books on addiction that I have read and came to me by a recommendation from a palliative care nurse.
Addiction is hard to address because many people will focus only on the neurological without considering the behavioral. Others think it is only a behavior issue in which the addict should “just stop.” Dunnington’s book is helpful because he draws from Aristotle and Aquinas’s discussions on why people will sometimes feel powerless to choose what is in their best interest. In other words, he looks at why individuals will do what is bad even though they know, and even desire to do, what is good (i.e., the Aristotelian idea of incontinence). This seems to come closer to addressing the complexity of addiction.
Let’s go back to coffee as an example. The non-physical, but equally important difference between behavior (or substance) addiction and coffee is that one is entrapping while the other is just enjoyable (coffee IS enjoyable!). In fact, the problem with both substance and behavior addictions is that the substance or the behavior ceases to be enjoyable so you have to consume or do more and more to get the same enjoyment out of them.
This is not the case with caffeine or many other things that people enjoy and would rather not give up, even if they know they should. Typically with food items like coffee or chocolate or pizza, the first bite is still the most enjoyable and then the law of diminishing returns sets in.* People who have one cup of coffee in the morning tend to keep having one cup of coffee each morning out of habit. They (typically) don’t continue to escalate their coffee consumption until all they are thinking about is the next cup of coffee, and they do not eventually become so consumed with getting more and more coffee that they orient their entire lives around getting their next hit of coffee at the expense of neglecting their family, job, or well-being.
Dr. Fischer suggests that behavior addiction, like many other mental health issues, is a spectrum of disorders. Often people with behavior addiction display other mental health issues. He points to studies that show there may be three (or more) different types of gambling addiction, each requiring a different type of treatment:
…behaviorally conditioned gamblers who get in the habit of chasing wins and losses, emotionally vulnerable gamblers who are responding to anxiety or depression, and antisocial gamblers who are dysfunctionally impulsive across the board.
Internet gaming addiction could easily fall into these three categories as well. By looking at behavior addictions as falling into different categories, people can get treatment for the underlying causes, such as anxiety or thrill-seeking, rather than trying to merely curb the behavior.
Finally, rather than assuming that we have all of the answers, Dr. Fisher takes a more humble approach that maintains the dignity of the individual by not reducing him or her to neurochemistry and recognizes that patients are unique individuals:
We have to assume we do not have all the answers. People cannot simply be reduced to their ‘hijacked’ reward systems, and there is no single, unassailably correct diagnosis of or treatment for addiction. Someday a new wave of research findings may help make finer distinctions more precisely. For now, though, we do the best we can by trying to learn as much about our patients as possible.
*One could argue that this is how to distinguish between someone who has bad eating habits and a true food addiction. People with “food addiction” actually display similar neurological signals as someone who takes cocaine when they are eating. They do not experience diminishing returns.