In 2006 and 2007, I was part of a team invited to present the rationale for adopting billing codes for SBIRT (screening, brief intervention, referral to treatment) at the American Medical Association CPT® (current procedural terminology) Editorial Panel. For various, sound reasons, our request was initially greeted with skepticism: what are the boundaries of addiction? Wherein lies the responsibility of the physician for behavioral problems? Do physicians need to address all behaviors designated as addictions—Internet use? Excessive exercise? Sexual obsession? Chocolate lovers? Gambling? Work?
If our request for billing codes to formalize substance use screening was extended to other compulsive behavioral problems, we knew our focused mission would falter. It would compromise the validity of the evidence-based case we had developed, because definitions and scientific evidence of other compulsive behaviors were less developed than those for alcohol and other drugs. The concept of behavioral addictions was controversial. With the exception of eating disorders, obsessive behavioral compulsions had limited evidence for their impact on physical health. We asserted that compulsive use of alcohol and other drugs uniquely can result in, or exacerbate, diseases of the brain and body, medical diseases that reside at the heart of the practice of medicine.
Our petition was approved, and SBIRT procedures were mainstreamed into healthcare settings.
“Addictions to Substances” and “Behavioral Compulsions”
Yet recently, both addiction specialists and the public have increasingly acknowledged that certain behaviors—sex, jogging, shopping, gambling, Internet use—do have some traits in common with addictions to psychoactive substances. As evidence has accumulated that compulsive behaviors can be validated scientifically, a new category of addictive disorders has been inserted into the Diagnostic and Statistical Manual of Mental Disorders (DSM-V), the diagnostic guide that catalogs diagnostic categories and criteria for psychiatric disorders. Thus far, only one form of intense preoccupation with a behavior—“disordered gambling”—has reached the high bar required for insertion in the manual as a diagnostic entity. For the others, research data falls short of the stringent requirements for inclusion. Intriguingly, there is some overlap between substance use disorders and disorders of compulsive behaviors: they typically begin in adolescence or young adulthood, their natural histories are patterned as chronic and relapsing, recovery without intervention or treatment is possible in some, both are manifest with a disregard of, or loss of interest in, feeling pleasure in critical functions of living, both can generate detrimental economic, employment, legal, educational, social, or other consequences, both can escalate in time spent thinking or engaging in these activities, both manifest loss of control, craving, tolerance, and inability to quit. Stopping drug use or a behavioral compulsion can result in psychological withdrawal, manifest as irritability, anxiety, depression, or sleep disorders. In addition to overlap in symptoms, some other traits of compulsive substance use or compulsive behaviors appear to intersect: personality types, co-occurring psychiatric diseases, heritability, biological targets, and treatment. Relapse rates following cessation of both categories of compulsive behavior are high.
Notwithstanding these coinciding features, there are also significant distinctions between the two broad categories of compulsive behaviors. Compulsive substance use achieves rewarding sensations by altering brain chemistry and eventually leading to a host of brain changes in circuitry, metabolism, and biochemistry. Compulsive behaviors alter mood by engaging in activities that may affect reward mechanisms but their composite effects on brain chemistry, circuitry and organization are less clear. To avoid the overuse of the term “addiction” for behavioral activities that do not yet fulfill rigorous scientific criteria, the rest of the article resorts to a designation of “behavioral compulsions.”
What Is Current State of Scientific Evidence of Behavioral Compulsions?
Recent reviews of the literature (Sussman, Lisha, & Griffiths, 2011; Yau & Potenza, 2015) highlight the prevalence of compulsive behaviors among American populations and are excellent sources of information. An estimated 47% of the population shows signs of addictive behaviors; this 47% prevalence rate calls into question the validity of a diagnostic category. Can it be a natural state of our species? Two examples of “workaholics” demonstrate the controversial nature of this diagnostic category. If a 24-year-old unmarried man works 19 hours a day, 6 days a week, and is rewarded financially and with promotions, would his behavior be categorized as pathological? If a 42-year-old married father of three children works 19 hours each day, and on weekends, returning home to a sullen wife and detached children, can this same “workaholic” pattern now be designated pathological? Personal values, reward priorities, long-term strategic financial goals, or pathology—the interpretation is uncertain.
Individuals can achieve pleasure but also can become dependent on excessive engagement in behaviors, such as gambling, Internet use, sex, exercise, eating, compulsive spending, or work. In each case, initiation of these activities is motivated by a desire to elevate mood, improve self-esteem, and dampen inner negative feelings. Impulsivity, sensation seeking, and diminished harm avoidance are other personality factors found in some studies of people with behavioral and substance addictions. Yet, unique environmental and biological factors are likely to play a major role in individual behaviors, as ready access to an array of temptations does not translate to a high prevalence of compulsive behaviors. An estimated minority of the adult population engages in these “compulsive behaviors” (all possibly underestimated): eating, 2%; gambling, 2%; Internet, 2%; sex, 3%; exercise, 3%; shopping, 6%; with excess work schedules garnering a higher prevalence.
Many who fall into the category of a compulsive behavioral disorder also have co-occurring behavioral compulsions or substance use disorders, estimated in the range of 50%. A recent sampling revealed two to four co-occurring compulsive behaviors. Among these, only shopping and excess work hours appear to fall within the prevalence range of substance use disorders.
Is There an Underlying Biology of Compulsive Behaviors?
As with substance use disorders, dopamine systems in the reward circuits of the brain are implicated in compulsive behavior. D3 dopamine receptors in one brain region correlate with problem—e.g., gambling severity and impulsivity. Recently, several intriguing reports have highlighted severe impulse control disorders involving pathological gambling, hypersexuality, and compulsive shopping, with the use of dopamine receptor agonist drugs (Moore et al., 2014). These agents are used to treat Parkinson’s disease, restless leg syndrome, and a hormonal imbalance called hyperprolactinemia. Pramipexole and ropinirole were dopamine receptor agonist drugs that had the strongest association with impulse control disorders. These drugs have a particular affinity for a dopamine target in the brain designated the D3 dopamine receptor. The evidence that dopamine receptor agonist drugs can trigger impulse control disorders suggest that specific biological processes may reside at the very core of compulsive behaviors, whether normal or abnormal. Other factors, such as age of onset of Parkinson’s, geographic location, also contribute to behavioral compulsions in Parkinson’s disease. At the very least, these FDA-approved drugs should be used cautiously by vulnerable populations.
Treatment for compulsive behaviors and substance use disorders are similar. Treatment is initiated by withdrawal and alleviation of withdrawal symptoms, and can be helped with medications.
Following this difficult period, the objectives are to motivate the person to resist repeating the behaviors, to cope with cravings, and replace rewarding compulsions with alternatives. Cognitive-behavioral therapy (CBT) is useful to challenge irrational beliefs that may maintain compulsive behaviors. Together with self-help programs, CBT has proven to be effective. Relapse prevention and sustaining long-term abstinence is the ultimate goal. Medication assistance with opioid antagonists for a gambling disorder has yielded promising results. As with risky or problematic substance use, brief interventions (15 minutes) may be effective or, in some cases, more effective than more lengthy approaches. Yet no single approach is completely effective and combined approaches are more beneficial.
With ready access to the Internet, to gambling casinos, to shelves overloaded with chocolate or clothing, to erotica, society has eased the path to compulsive behaviors. Vulnerable people in appropriate milieu engage in compulsive behaviors to elevate mood, improve self-esteem, and dampen inner, negative feelings—the same reasons underlying substance use. Depending on the presence, or severity of adverse consequences or loss of control, these behaviors may be designated pathological or within the spectrum of the normal human condition. Those engaged in compulsive behaviors require detailed evaluation of whether use has progressed into the risky, problematical, or pathological range. The effective prevention, intervention and treatment services (SBIRT) developed for substance use disorders may be adaptable for compulsive behavioral disorders. Evidence-based screening and interventions will enable providers to address the full range of detrimental behaviors that can devastate lives.
Moore, T. J., Glenmullen, J., & Mattison, D. R. (2014). Reports of pathological gambling, hypersexuality, and compulsive shopping associated with dopamine receptor agonist drugs. JAMA Internal Medicine, 174(12), 1930-1933. doi:10.1001/jamainternmed.2014.5262
Sussman, S., Lisha, N., & Griffiths, M. (2011, March). Prevalence of the addictions: a problem of the majority or the minority? Evaluation & the Health Professions, 34(1), 3-56. doi: 10.1177/0163278710380124
Yau, Y. H. C., & Potenza, M. N. (2015, March/April). Gambling disorder and other behavioral addictions: Recognition and treatment. Harvard Review of Psychiatry, 23(2), 134-146.