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 (Alcoholism and Drug Addiction) can be identified by 11 criteria, any two of which are enough for a diagnosis.[i] That said, most addiction therapists make addiction diagnoses based on three primary signs:
- Preoccupation to the point of obsession with the substance (or behavior) 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 (or behavior) of choice.
The next most common signs of addiction are tolerance and escalation.
- Tolerance: Tolerance occurs when the body requires increasingly larger or more potent doses to get the same effect from an addictive substance or a behavior.
- Escalation: Escalation occurs when a person indulges his or her tolerance to an addictive substance or behavior with larger or more potent doses and/or behaviors that result in higher intensity.
Almost every addict, regardless of the nature of his or her addiction, will experience some degree of tolerance and escalation.
What Do Tolerance and Escalation Look Like?
With substance addictions, tolerance and escalation cause the addict to take more of a substance or a stronger substance in an attempt to achieve and maintain the desired high. With process (behavioral) addictions, tolerance and escalation will cause the addict to spend increasing amounts of time in the addiction or to increase the intensity of his or her addictive behaviors. Over time, thanks to tolerance and escalation, addicts often find themselves using substances and engaging in behaviors they never expected or wanted.
For an illustrative example, consider heroin addiction. Nobody, and I do mean nobody, shoots heroin right out of the gate. They start out with alcohol or marijuana or, perhaps, a prescription medication. As time passes, tolerance builds, and, in response, usage escalates. Maybe they start drinking or smoking pot the moment they wake up, or they start crushing and snorting the pills they’ve been abusing for faster effect, etc. Eventually, even those behaviors don’t produce the desired high, so they ‘discover’ harder drugs and more impactful ways to ingest those drugs. Before they know it, and often without ever making a conscious decision to do so, they find themselves with a needle in their arm.
Behavioral addictions escalate in similar fashion. Let’s use porn addiction as an example. Occasionally viewing and masturbating to ‘vanilla’ porn is, for many people, the psychological equivalent of drinking a few beers or smoking a little pot. As usage continues, however, tolerance sets in and the porn user must look at more porn or more intense porn to create the desired high. Before long, the user is looking at porn that, when he or she started, would have been a turn-off. A porn addict might also escalate to other online behaviors (webcams, sexting, apps, etc.) and even real-world behaviors (strip clubs, casual sex, anonymous sex, prostitution, affairs, and the like).
For both substance and process addicts, escalation might also involve a cross or co-occurring addiction.
- Cross-Addiction: Occurs when an addict switches from one addictive substance or behavior to another.
- Co-Occurring Addiction: Occurs when an addict engages with multiple addictive substance or behaviors at the same time.
With sexualized drug use (paired/fused substance/sex behaviors), we tend to see both cross and co-occurring behaviors. For instance, the addict may use meth or cocaine while seeking sex and being sexual (co-occurring addiction), and then switch to alcohol or opiates to ‘come down’ and self-medicate shame about sexual behaviors (cross-addiction).
[i] American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders: DSM-5, p 490-91. Washington, D.C.: American Psychiatric Association.