Process addictions, or behavioral addictions, represent addictive behaviors that occur as a result of activities that do not directly involve drugs or alcohol. The essential features of behavioral addictions include the following:
- The individual fails to resist a particular temptation or impulse to perform an act that may be potentially harmful to the person or others.
- Each process addiction has a specific essential feature that characterizes it.
- Repetitively engaging in the behavioral addiction interferes with the functioning of the individual or causes them significant distress.
Thus, the major features of behavioral addictions are similar to the features of substance use disorders. The onset of behavioral addictions often occurs in adolescence and results in feelings of tension before the act is committed and feelings of gratification or pleasure during the act. The behavior is often considered to be ego-syntonic by the person initially (acceptable to one’s values and ways of thinking) until the behavior begins to become problematic and uncontrollable. As the behavioral addiction progresses, the behavior may become ego-dystonic (less acceptable with one’s values and ways of thinking) over time, as the individual attempts to control the behavior and get involved in treatment. This notion of behavioral addictions being initially ego-syntonic separates them from obsessive and compulsive disorders, which are considered by clinicians to be ego-dystonic. This results in the features of process addictions being more similar to substance use disorders.
Other similarities between substance use disorders and process addictions include:
- Cravings or urges to perform the behavior
- Feelings of anxiety, stress, and dysphoria when the behavior cannot be engaged in
- The tendency of people with both disorders to score similarly on measures of impulsivity and the ability to delay gratification (often scoring low on their ability to delay impulsive behaviors)
Despite recognition by the American Psychiatric Association (APA) that process addictions do exist (currently these are diagnosed under unspecified or unknown substance-induced disorders as non-substance-related disorders), there is insufficient research to formally classify many of the commonly conceived process addictions as actual psychiatric disorders. In fact, at the time of this writing, only one process addiction is identified formally by APA. When one looks at the literature, it appears that almost any type of behavior can somehow become a process addiction.
As mentioned, APA lists diagnostic criteria for only one formal behavioral addiction or process addiction: gambling disorder. Gambling disorder presents with specific symptoms, such as:
- A persistent and recurrent problem with gambling that leads to significant impairment or distress
- Gambling away increasing amounts of money in order to generate excitement
- Becoming restless or irritable when attempting to cut down or stop gambling
- Making repeated unsuccessful efforts to either control or stop gambling
- Frequent preoccupation with gambling
- Gambling when feeling under duress
- Returning to gambling very quickly after losing money in an effort to win back losses
- Frequently lying in order toin order to hide gambling behavior
- Jeopardizing one’s status at work, a significant relationship, one’s standing at school, or other important activities or relationships as a result of gambling
- Frequently relying on friends and relatives to help financially due to gambling behavior
The gambling behavior demonstrated by the individual cannot be better explained by some other mental disorder (e.g., bipolar disorder) and is not due to the effects of some medical condition. A formal diagnosis of gambling disorder occurs when an individual presents with four or more of the above symptoms within a 12-month period. Gambling disorder can be rated as mild (4-5 symptoms), moderate (6-7 symptoms), or severe (more than 7 symptoms).
The prevalence of gambling disorder is estimated to be 0.2-0.3 percent in the general population. The lifetime prevalence of gambling disorder is estimated to be higher in African Americans than in other ethnic groups. According to APA, individuals who are diagnosed with gambling disorder have more health issues than other individuals. There are high rates of co-occurring substance abuse (particularly tobacco abuse and alcohol abuse), anxiety disorders, major depressive disorder, and personality disorders.
Gambling disorder is treated by using a combination of psychotherapy (most often, some form of Cognitive Behavioral Therapy) and support group participation (e.g., Gamblers Anonymous). Individuals often feel irritable and nervous when they stop gambling, but there is no formal withdrawal protocol. Medications may be used for individuals who have other co-occurring issues. Individuals with co-occurring gambling disorder and a substance use disorder would require specific treatment for the substance use disorder in addition to treatment for the gambling disorder.
Sex addictions are considered to be disorders of intimacy that are most often characterized by an individual having repetitive and compulsive thoughts about having sex, engaging in sex with multiple sexual partners, or compulsively engaging in masturbation, the use of sexual devices, pornography, or illegal activities, such as child pornography or exhibitionism. Their sexual behavior has a negative impact that leads to significant distress or issues with functioning. As they increase their sexual activity, they find they need to engage in more and more sexual activity to receive the level of satisfaction they once got at lower levels of sexual activity.
The literature on sexual addiction notes that individuals who are sex addicts do not necessarily become sex offenders. The causes of sexual addictions are not understood, but like other addictive behaviors, they are considered to be an interaction of heredity, environmental experiences, and social factors. Some research suggests that some medications can be useful in treating symptoms, such as antidepressant medications or dopamine antagonist medications.
In spite of the above information, the current edition of the APA’s Diagnostic and Statistical Manual of Mental Disorders, DSM-5, does not list sexual addiction in any category. The previous edition (DSM-IV and DSM IV-TR) listed sexual addictions in a category known as sexual disorders not otherwise specified. This previous listing has placed some of the behaviors associated with sexual addictions in a category of sexual disorders, psychological disorders that involve issues with sexual functioning, and not in the category of substance use disorders.
Sexual addictions were excluded from the DSM-5 because the committees reviewing the research for the relevancy and validity of these disorders found no significant research findings that indicated such a disorder existed. Proponents of the disorder had hoped that the name would be changed from sex addiction to hypersexual disorder; however, the research committees could not find significant evidence to warrant this. In fact, the majority of research has failed to demonstrate the presence of sexual addiction in individuals who are purported to have sexual addictions, and in fact, these people did not demonstrate any significant behavioral alternations from individuals without so-called sexual addictions. It should be noted that certain behaviors that are often associated as being indicative of sexual addictions, such as exhibitionism, frotteurism, and pedophilia, are considered to be forms of sexual disorders and not forms of addictive behaviors; these sexual disorders are currently categorized as paraphilic disorders by APA.
Individuals who experience distress as a result of what they believe to be excessive sexual behavior or who believe they are obsessed with sexual activity should receive treatment. Treatment often consists of participation in support groups and psychotherapy.
Estimates of the prevalence of sexual addictions vary quite substantially. There are no reliable estimates of sexual addiction prevalence, as there are no formal diagnostic criteria for a disorder that is not yet formally recognized. Any prevalence estimates for such a disorder would be unreliable.
More than two-thirds of American adults are considered to be overweight or obese. This leads to the idea that so-called food addictions are actual disorders. Unfortunately, the organizations that research, identify, and develop diagnostic criteria for addictive behaviors disagree on this subject.
In fact, it could be relatively safe to conclude that since food is a necessity for life, all animals are addicted to food in some sense. Moreover, it would be clumsy at best to state that over two-thirds of the American population has a mental disorder (addiction to food), as disordered behaviors by definition must depart from normality. When over two-thirds of the population behaves in some manner, this behavior cannot be considered to be a departure from normality.
The addictive ability of food has been debated in research circles, and proponents of the notion that individuals can have an addictive relationship with food report that an estimated 5-10 percent of the general population expresses behaviors that are consistent with having an addictive relationship with food. On the other hand, the majority of researchers believe that the term food addiction is problematic because it is not descriptive of disordered eating behavior and therefore is not valid.
As with sex addiction, there is no diagnostic category in the DSM-5 for food addiction. There is a category describing certain eating disorders. A recent review in the journal Neuroscience & Biobehavioral Reviews put forth the case that there is not enough evidence to conclude that food has addictive potential the same way that certain drugs and even gambling have addictive potentials. Thus, the term food addiction represents a misnomer, and the authors of the article propose that the term eating addiction may be more appropriate.
Eating disorders represent a separate category from substance use disorders, and they are characterized by a disturbance of eating-related behaviors that results in an altered consumption or absorption of food and can lead to significant impairment in health or overall functioning. This includes disorders, such as binge eating disorder, anorexia, bulimia, etc. Eating disorders are often comorbid (co-occur) with other mental health disorders, such as obsessive-compulsive disorders, depression, personality disorders, etc. In some cases, an individual with an eating disorder may have a comorbid substance use disorder.
The treatment of eating disorders and obesity is complicated and often consists of using a combination of medications and psychotherapy. Support group participation can be of assistance to individuals with eating disorders. Individuals who are overweight and need assistance controlling their urges to eat should consult with a physician and a trained therapist who specializes in these disorders.
Like most of the other behavioral process addictions, Internet addiction is not formally recognized as a type of addictive behavior by organizations that produce the diagnostic criteria for these disorders. APA does list Internet gambling disorder as a potential disorder in their section Conditions for Further Study in the DSM-5.
Like other process addictions, an Internet disorder/addiction would also have to present with a standardized set of reliable symptoms. As in the cases of food addiction and sex addiction, these standardized reliable symptoms are not apparent in the literature, and the research evidence has not produced standardized reliable diagnostic criteria for them. At the time of this writing, there are no formally standardized and empirically validated symptoms for Internet addiction. Nonetheless, some sources suggest that the symptoms of internet addiction include:
- Feelings of euphoria during computer use
- Inability to prioritize time as a result of Internet use
- Issues with dishonesty regarding revealing how much time one spends on the Internet
- Psychological symptoms associated with discontinuing the use of the Internet, such as anxiety, depression, irritability, insomnia, etc.
- Defensiveness when accused of spending too much time online
- Boredom with routine tasks
- Issues with one’s occupational, social, or educational functioning as a result of internet use
Other symptoms associated with Internet use disorders are relatively vague and general, such as backache, avoidance of work, mood swings, loneliness, etc., and lack any type of diagnostic validity.
Individuals who engage in the compulsive or problematic use of technology and, as a result of their Internet use, fail to maintain important personal obligations certainly do have a problem; however, at the current time, diagnosing this is a formal form of addictive behavior is questionable due to a lack of standardized empirical evidence that Internet addiction disorder exists.
Nonetheless, treatment associated with other process addictions, such as the use of psychotherapy, support group participation, social support from family and friends, and psychoeducation, can be useful in helping these individuals to curb their use of the Internet. It is unclear at this time if treatment for problematic Internet use should include total abstinence from use of the Internet or other technology. In fact, in this day and age, forcing individuals to remain totally abstinent from the Internet or technology appears unrealistic. Instead, individuals can learn control and temperance in Internet use in the same way that individuals who are overweight can learn to change their eating habits.
Outside of gambling disorder, at the time of this writing, there are no formal diagnostic criteria in place for other forms of process addictions. Because there are no formal standardized diagnostic criteria, these disorders cannot be listed as formal addictions. One cannot have an actual disorder without diagnostic criteria for it. In the future, this may change as new research helps to clarify these issues.
On the other hand, individuals can have problematic behaviors associated with almost any type of action. One need not have a formal addiction to have a problem with eating, online use, sexual activity, etc. Therapists utilizing cognitive-behavioral techniques can use the same general approach that is used for the treatment of substance use disorders. Individuals who believe that their behavior is causing them distress or problems with functioning and opt to seek professional help should do so whether or not these behaviors are formally listed as mental health disorders.
Peer Support Groups for Behavioral Issues
If individuals wish to become active in support group participation for certain types of behavioral issues, there are a number of 12-Step groups that may suit their needs.
- Clutterers Anonymous
- CoSex and Love Addicts Anonymous
- Food Addicts in Recovery Anonymous
- Food Addicts Anonymous
- Gamblers Anonymous
- Overeaters Anonymous
- Online Gamers Anonymous
- Sexaholics Anonymous
- Sex Addicts Anonymous
- Sexual Compulsives Anonymous
- Sexual Recovery Anonymous
- Underearners Anonymous
- Workaholics Anonymous