It’s the time of year when people tend to behave in excessive ways. Parties are ramping up, and multiple helpings of chocolate cake with extra cream and a glass of dessert wine seems like a good idea. Who can resist?
But what if you continued these bad habits throughout the year? Would you consider yourself an addict? Tiger Woods reportedly attended a sex-addict clinic this year because of his repeated infidelities. Would you consider him an addict?
Most people would answer no to these questions. Perceptions change, however. These days, we accept that people can get addicted to drugs and alcohol, yet until the end of the 18th century, repeated heavy alcohol consumption was not considered an addiction – even among the medical profession.
The idea of behavioural addictions is on the rise, and not just in the tabloid media. When the next edition of the Diagnostic and Statistical Manual of Mental Disorders comes out in 2011, there is likely to be a new category for addiction and related disorders. This will reference gambling and leave the way open for other behavioural disorders such as overeating, and addiction to the internet, shopping and sex. In order to be diagnosed as addicted, one would have to be engaging in compulsive, out-of-control behaviour, with negative consequences for a person’s life.
In a paper published last year in the journal Addiction, Professor Doug Sellman of the National Addictions Centre in Christchurch found that the general public does not have much tolerance or compassion for those with addictions, viewing these disorders as self-inflicted. Why, then, are some experts now suggesting that certain behaviours are as addictive as drugs?
BIOLOGY OF COMPULSION
There are some striking similarities between compulsive drug-taking behaviour and other forms of compulsive behaviour. This was observed early on by the 12-step movement, a term used to describe Alcoholics Anonymous and its offshoots.
In the 12-step programs, alcohol addiction is seen in biological terms (i.e., people who are genetically susceptible become alcoholics), but it manifests in compulsive behaviour: drinking. This model, where addiction is a problem specific to a susceptible person, leading to compulsive problematic behaviour, was popular in the 19th and 20th centuries and remains so, especially in the US. Any problematic compulsive behaviour could be viewed as being caused by the disease process of addiction. Indeed, the 12-step model has been applied to drugs (Narcotics Anonymous); overeating (Overeaters Anonymous); sex addicts (Sex Addicts Anonymous) and gambling (Gamblers Anonymous), and there may be other behaviours this model could be relevant to.
The popular concept of the addictive personality is born from this model, suggesting that people are at the mercy of their personalities.
The biology of drug addiction and behavioural compulsion also appear similar. People find it easier to understand how someone can be addicted to alcohol or drugs (which are specific external agents) than be dependent on a particular behaviour. However, there is increasing evidence that addiction to compulsive behaviours involves similar brain mechanisms to drugs and alcohol, known as the dopamine reward pathway.
We know from previous studies that pleasurable behaviours trigger the release of dopamine, a feel-good neurotransmitter in the brain. This chemical reward increases the likelihood of the behaviour being repeated, and eventually becoming a habit. The dopamine reward pathway has been implicated in those who overeat. A study in the March 2010 edition of Nature Neuroscience added to the evidence when the authors found differences in rats’ brains after the rodents were given unlimited access to high-sugar food and quickly developed compulsive binge-eating patterns.
The results of this study also suggest that environmental factors, such as increased or unlimited access to high- fat food options, can contribute to the problem of overeating and obesity. Firing of the dopamine pathway is also seen in gamblers, according to a study published in Neuron in 2001. Future studies will no doubt examine whether other problematic behaviours also trigger this chemical.
Another way drug addiction and compulsive behaviours are similar is from a reinforcement standpoint. Anyone who engages in behaviour they view as compulsive but ultimately unhelpful will probably acknowledge that when they first started engaging in the behaviour, it felt good so they continued it. For example, think about the first taste of a favourite chocolate bar waiting in the fridge as an after-work snack. Or the buzz you feel when you have just bought a great new outfit.
The behaviour also may have distracted from pain or negative emotion (for example, a hard and tiring day with the boss). If it is continued, at some point the behaviour results in problems in many areas of the individual’s life (relationships, work, family, hobbies), which are often neglected in favour of the addictive behavior. Similarly, if other people engage in the behaviour regularly, it becomes socially reinforcing and normative. The idea of retail therapy, i.e., go out and buy something to make yourself feel better, is one example.
ADDICTION AS AN EXCUSE
One of the questions directed at psychologists and psychiatrists about behavioural addictions is whether, in calling something an addiction, we are excusing it. The concern seems to be one of subjects shirking responsibility.
Let’s take Tiger Woods as an example. If we label his behaviour as sex addiction, are we condoning it? While Woods’ behaviour was the topic of many dinner party conversations over the past year, it was my experience that he was always spoken of as fully responsible. So, diagnosing these conditions may be appropriate if it means people begin to attempt to understand their own behaviour, and get appropriate treatment. However, if the diagnosis becomes an excuse that engenders a sense of helplessness, we are not solving the problem.
Unfortunately, the notion of helplessness in the face of addiction is reinforced by some sectors of society. Consider a recent case in Honolulu where a federal judge ruled that a man who claims he’s psychologically dependent on and addicted to an online video game may proceed with a lawsuit against the game’s South Korean manufacturer. The man in question says he’s spent more than 20,000 hours playing the game since 2004 and the game’s producers never warned him about the danger of game addiction.
Although addiction experts acknowledge around 50 per cent of addiction is genetic, this does not mean that people are powerless to do anything about it. The labels may be changing, but clinical psychologists and other professionals have been treating compulsive behaviours since the birth of the profession. The therapies most commonly associated with addiction include motivational interviewing, 12-step approaches and cognitive behaviour therapy. Even though these methods are quite disparate in their approaches, it is increasingly being shown that the style of therapy doesn’t matter as much as how engaged you are in the process.
Sellman’s Addiction paper outlined the most important things known about alcohol addiction (although its findings may be true for other addictions also). Among them were that most people with addictions who present for help have other psychiatric problems as well (most commonly social phobia, depression and post-traumatic stress disorder). This makes overcoming the problem through force of will more problematic. Also salient was that addiction, in Sellman’s view, is a long-term problem in which the majority of people who present for help commonly relapse multiple times. The simplistic notion of a one-time magic fix is unrealistic. Change in behaviour takes time, as people have to learn new behaviours and practise them.
WHAT TO DO
If you can relate to the idea of compulsive behaviour, try these tips that are usually part of addiction therapy.
List all the good things about the behaviour. For overeating it might be: tastes good, relaxes me, fills in time, etc. Now, list all the less good things about the behaviour. For overeating, the list might be: getting heavier, harder to exercise, feel worse about myself, feel like I can’t change, etc. What do you notice about the two lists? Often having the advantages and disadvantages of the behaviour in black and white can generate a different way of thinking about it.
Think about the last time the behaviour occurred. What led up to the behaviour? When did the thought to engage in the behaviour first enter your mind? Is this a common trigger? One of the most powerful predictors of drug and alcohol use is negative emotion a few hours beforehand. Do you notice that a specific emotion/thought makes you want to engage in the behaviour more than other emotions/thoughts? By identifying the possible triggers, you can start to think about what alternative behaviours would be more useful to you.
What happened as a consequence of the behaviour? Did you feel relief or happiness? What happened next? Did you feel embarrassment or shame? What were others’ reactions to the behaviour? If you can learn to fast-forward to the probable consequences, you have less reason to engage in the behaviour.
Learn to deal with cravings by learning to ‘surf the urge’. Urge surfing is a term coined by Professor Alan Marlatt, director of the Addictive Behaviors Research Center at the University of Washington, as part of a program of relapse prevention. People are taught that urges are episodic and not constant; they come and go. They may fluctuate in intensity during an episode and do not by themselves predict relapse. Urges gradually decrease over time if people do not give in to them.
Think about situations that you might engineer that are seemingly innocuous but in fact are high risk, because they set you up to fail. An example for overeating might be finding yourself driving past the supermarket instead of taking another way home, and convincing yourself to buy high-sugar foods, just in case people pop in and you have to entertain them.
So if you find you are reaching for the third or fourth helping of dessert regularly, you may have an addiction – but the take-home message is, it is possible to do something about it.