Of all the different addictions, process addictions may be the least understood by both the medical community and those who suffer from these problems. The term ‘process addictions’ encompasses addictive behaviors that do not include substances like alcohol or drugs, and the most recognized process addictions involve gambling, with those relating to Internet use, sexual behavior and food also under consideration.
Multiple terms have been used to describe these non-substance addictions, including behavioral addictions. Because these addictions can be different from substance abuse, people have debated whether to consider them addictions. Some medical professionals have argued that the term should be confined to substance-use disorders like alcohol and drugs, while others say addiction might include a broader range of behaviors. There is a growing acceptance that gambling, sex, food and other problematic behaviors may fit the bill for addiction because they meet the generally agreed upon core elements of what constitutes an addiction: continued engagement in a behavior despite adverse consequences, compulsive engagement, diminished control over engagement and a competitive urge or craving state immediately prior to engagement. Those elements are found in many individuals who gamble excessively, use pornography or the Internet to excess or who have unhealthy eating habits such as bingeing. Other behaviors that might result in a process addiction are compulsive buying and playing video games.
Like all addictions, the behavior is usually one that the individual enjoys and continues to engage in despite adverse consequences such as financial losses, legal problems and health concerns. The person’s level of enjoyment may change over time, with some behaviors eventually becoming dissociated from being pleasurable and instead becoming habitual or compulsive.
Precise risk factors for process addictions are not well understood. Certain factors appear linked, such as in gambling addiction, where a person’s chance of addiction is higher if he or she started gambling at an early age or has a family history of gambling addiction. Some research indicates that genetic factors can make a person more likely to have a process addiction. Research also suggests that gambling, binge eating and compulsive sex are associated with neurobiological features in the brain similar to those found in association with substance-use disorders. For more on process addictions, see https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3164585/.
DSM-5 and Treatment
The uncertainty over whether some process behaviors truly are addictions can lead to difficulty for patients seeking treatment. The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) from the American Psychiatric Association, which is used to describe the features of disorders and may be used to justify billing for treatment, recognizes gambling disorder as an addiction. Additionally, binge eating disorder is included with eating disorders. That inclusion makes it possible for more addiction professionals to offer treatment.
Some forms of excessive Internet use, including Internet gaming, are now included in the DSM-5 as areas requiring more research, suggesting that they may be included later as addiction. Sexual addictions are not yet in the DSM-5, which may pose a barrier to those needing help. When the behavior is not recognized by the DSM-5 as a legitimate addiction, some people may be discouraged from recognizing that their behavior is a treatable condition. The medical community’s reluctance to state that problematic sexual behaviors can be addictions might lead the person to minimize the situation. The person suffering from this process addiction also may be more likely to think the behavior can be overcome with willpower alone and, when that fails, the urge to engage in the behavior may be strong.
Not being in the DSM-5 also can discourage treatment professionals from offering care for sexual addictions because they may not be reimbursed.
For those experiencing addictive behavior with gambling, food, Internet, gaming or sex, it is important to take these problems seriously and find practitioners who have expertise with behavioral addictions. For gambling, a good first step often is to call a gambling help line. The national help line offered by the National Council on Problem Gambling (www.ncpgambling.org) is a popular choice. These helplines can serve as useful resources for questions about treatment and care providers. As research continues on these problems, treatment options continue to grow. Gambling has been studied more than the other process addictions, with multiple studies investigating the efficacy and tolerability of treatments. Those studies indicate that cognitive behavioral therapy shows good results, but no pharmaceutical treatment has an indication from the U.S. Food and Drug Administration for gambling disorder.
Some states, such as Connecticut, have active, state-supported treatment programs for gambling addiction. When people call the state’s gambling help line, they are directed to the statewide gambling treatment program, which has options for both group and individual therapy. Psychiatric evaluation also is available. Programs may prescribe medication for the gambling disorder and/or co-occurring problems with mood, anxiety and substance abuse.
These programs have helped thousands of people overcome their process addictions and lead happy, productive lives. Many people come into a gambling addiction program feeling very depressed and with serious financial problems, but the right treatment program can yield positive results.
Abstinence vs. Moderation
A treatment plan for process addiction typically will focus on behavioral therapy, with the therapist helping the patient understand the reasons behind the addiction, what triggers it and what may have helped control it in the past. It is also important to help patients learn coping skills to manage not gambling, including maintaining abstinence without relapsing.
The length of treatment for process addictions can vary on a case-by-case basis. As with substance addictions, lifelong abstinence often is the goal, and people sometimes commit to a lifelong treatment plan like a 12-step program. Some treatment professionals, however, say that certain patients can be successful with a harm-reduction approach for gambling disorders not eliminating the behavior altogether but keeping it at a manageable level. While there is no clear answer yet on which approach is more successful in the long run, many individuals who have tried to control their gambling ultimately encounter more substantial problems, so abstinence appears the most prudent course of action.
Some process behaviors like gambling and pornography use may have a priming effect on the patient, meaning that even a little exposure is enough to set off a craving and need for more. For that reason, it is common for a process addiction treatment professional to encourage the patient to abstain entirely from gambling or other problem behaviors forever, but that does not necessarily mean that the patient has to remain in treatment.
Food addictions pose a particular challenge for long-term success because, unlike gambling or pornography, the use of food cannot be eliminated. In this case, a solution often is to target problematic comfort foods that can lead to binge eating. Those foods can be managed or replaced with alternatives. Some research also suggests that success is more likely when the patient focuses on reducing types of eating, like binges, rather than eliminating a type of food.
There is a lot we do not understand yet about process addictions. Gambling is the most well studied process addiction, and even there the treatment community is still seeking answers on the best course of treatment and the likelihood of recovery. We have even further to go with food, Internet use and sex addictions. Internet addiction is an area that needs immediate attention because the online world is a rapidly changing environment. In particular, attention must be paid to how different age groups are affected by Internet use and possibly drawn into addictive behavior, especially since we are introducing the Internet to increasingly younger children.