David Fawcett PhD, LCSW
Nearly everyone is familiar with and understands to some degree the concept of substance addiction—the abuse of and dependency on ingested chemicals such as nicotine, alcohol, illicit drugs, and even prescription medications. More difficult to comprehend is the concept of process (behavioral) addictions—compulsively engaging in a behavior despite obvious negative consequences.
In the most recent edition of its Diagnostic and Statistical Manual of Mental Disorders (the DSM-5), the American Psychiatric Association states that Substance Use Disorder (aka, Substance Addiction) occurs when an individual continues using a substance despite significant substance-related problems.[i] For diagnostic purposes, the APA lists 11 possible benchmarks, any two of which are enough to indicate addiction.[ii] However, clinicians who treat substance addiction tend to look for the following criteria:
- Preoccupation to the point of obsession with the substance(s) of choice.
- Loss of control over use, generally evidenced by multiple failed attempts to quit or cut back.
- Negative consequences causally related to use of the substance(s) of choice.
Somewhat inexplicably, the American Psychiatric Association almost completely avoids discussion of process addictions, excluding them—except for gambling addiction, which they call Gambling Disorder—from the DSM-5.[iii] The World Health Organization, the American Psychological Association, and the American Society for Addiction Medicine (and many other psychiatric and medical professional organizations) are more forward-thinking in this regard. For example, the American Society for Addiction Medicine has issued the following statement:
Addiction is a primary, chronic disease of brain reward, motivation, memory, and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social, and spiritual manifestations. This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors [emphasis added].[iv]
Despite the American Psychiatric Association’s strange oversight in the DSM-5, there is no doubt that process addictions exist, and that they are every bit as devastating and destructive as substance addictions to both addicts and the people who love and care for them.
The most common process addictions are:
- Sex Addiction
- Porn Addiction
- Love/Relationship Addiction
- Compulsive Eating
- Gambling Addiction
- Shopping/Spending Addiction
- Video Game Addiction
- Social Media/Internet Addiction
If you’re wondering how a behavior can be addictive, let me state that the behaviors listed above all trigger the same neurochemical response as addictive substances—the release of dopamine, adrenaline, and a variety of other pleasure-related neurochemicals (oxytocin, serotonin, and various endorphins). Still, the idea of a behavior being addictive can be a head-scratcher. Mostly because many potentially addictive behaviors are generally thought of as healthy, even essential activities. For example, eating, searching for romance, and being sexual, three of the most common process addictions, contribute directly to individual and species survival. If we do not engage in these behaviors, we die, and eventually our species will also die.
Recognizing this fact, our brains are evolutionarily programmed to experience pleasure when we engage in these (and other) life-sustaining activities. And, as described above, that encouragement comes in the form of dopamine, adrenaline, etc.
Unfortunately for individuals who struggle with underlying emotional and/or psychological issues (depression, anxiety, low self-esteem, unresolved trauma, and the like), this life-sustaining pleasure response can morph into a go-to coping mechanism that is used to deal with any and all forms of emotional and/or psychological discomfort. This coping mechanism is then turned to time and time again until the individual loses control over it. That is a sure sign of addiction. Whether it’s a substance or a behavior, addicts use not to feel good, but to feel less.
At the end of the day, the primary difference between substance and behavioral addictions is that substance addicts ingest alcohol or drugs to create an emotionally escapist neurochemical reaction, while behavioral addicts rely on an intensely pleasurable fantasy or activity.
To further understand the link between substance and behavioral addictions, consider a cocaine addict on payday. After receiving his check, he skips out of work early and drives to the bank to swap it for cash. Then heads to his dealer’s house to buy cocaine with money that he really should spend on food and rent. As he approaches his dealer’s house, his heart races, he’s sweating, and he is so obsessed and preoccupied with using that he doesn’t even notice that there’s a police car parked a block away.
At this point, this individual is so completely focused on cocaine that his day-to-day world, with all of its problems and obligations, has temporarily disappeared. In anticipation of using cocaine, his brain is pumping out dopamine and adrenaline, effectively distracting him from his various life difficulties. He has escaped from stress, depression, anxiety, and the like. His decision-making is distorted and he has lost touch with reality. In short, he is high. It doesn’t matter that there are no actual drugs in his system because his brain is pumping out dopamine and other pleasure-related neurochemicals as if there are.
This neurobiological state of distraction and emotional escape, no matter how it is induced, is the goal with all addictions. Stated simply, addiction is about the manipulation of neurochemistry, and this can occur with or without an addictive substance.
Sex addicts in particular experience an anticipatory high based more on fantasies and ritualistic preparations than anything else. In fact, sex addicts experience more pleasure and escape through anticipating, chasing, and preparing for sex than from the sex act itself. They even have a name for this condition, referring to it as the bubble or the trance. Gambling addicts describe a similar state of emotional and psychological dissociation.
Addictions are not about ingesting a substance or engaging in a behavior, they’re about losing touch with reality for an extended period. With behavioral addictions, it is the process that leads to being in the bubble/trance—i.e., to the ‘anticipatory high’ that creates emotional relief. That is why behavioral addictions are officially referred to as process addictions.
If you need more evidence that process addictions are real, consider the fact that fMRI brain scans of gambling addicts, porn addicts, and other behavioral addicts, when they are exposed to addictive stimuli, will mirror the brain scans of people who are actively using a substance, such as cocaine. In fact, the brains of sex/porn addicts and cocaine addicts are almost indistinguishable.
Sadly, our culture has a limited understanding of and little compassion for process addictions, typically viewing them either as moral failings or less serious than ‘real’ addictions (substance addictions). Neither stance is accurate. Process addictions are not character flaws; they are, like all addictions, maladaptive behaviors used for emotional regulation. More importantly, process addictions are every bit as destructive as substance addictions, wreaking the same types and degrees of havoc on addicts, families, careers, and lives.
[i] American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders: DSM-5, p 481. Washington, D.C.: American Psychiatric Association.
[ii] American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders: DSM-5, p 490-91. Washington, D.C.: American Psychiatric Association.
[iii] American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders: DSM-5, p 481. Washington, D.C.: American Psychiatric Association.
[iv] “Definition of Addiction,” American Society of Addiction Medicine, accessed Dec 31, 2014, asam.org/for-the-public/definition-of-addiction.