Behavioral addiction

Behavioral addiction, process addiction,

Addiction canonically refers to substance abuse; however, the term's connotation has been expanded to include behaviors that may lead to a reward (such as gambling, eating, or shopping)[7] since the 1990s. Still, the framework to diagnose and categorize behavioral addiction is a controversial topic in the psychopathology field.^[8][9]

Diagnostic and Statistical Manual of Mental Disorders (DSM) recognized behavioral addictions for the first time in DSM-5 with gambling disorder, formerly pathological gambling, as the only non-substance-related disorder classified under the chapter of "Substance-Related and Addictive Disorders".^[10] Internet gaming addiction was included in the appendix as a condition for further study.^[11] Although "addiction" is commonly used to describe repetitive harmful behavior in nonmedical settings,^[12] DSM-5 recommended the neutral term "disorder" instead of "addiction" under the clinical settings to avoid uncertain definition and potentially negative connotation.^[13]

Similar to the changes in DSM-5, the eleventh revision of the International Classification of Diseases (ICD-11) introduced the category "Disorders due to substance use or addictive behaviours," based on the diagnostic framework of impaired control, repetitive harmful behavior, and continuation or escalation despite negative consequences.^[14] The new sub-category "Disorders due to addictive behaviours" included gambling disorder (formerly under the habit and impulse disorders), gaming disorder (a new diagnosis), and two residual categories (other specified and unspecified) to raise attention among clinicians and the public and to facilitate further research.^[14][15]

In 2019, the American Society of Addiction Medicine (ASAM) revised its definition of addiction including substance use and compulsive behaviors, stating: "addiction is a treatable, chronic medical disease involving complex interactions among brain circuits, genetics, the environment, and an individual’s life experiences."^[16]

Other addictive behaviors which have received research attention but with insufficient or inconclusive evidence include pornography use disorder, compulsive buying disorder, social network use disorder, work addiction, exercise addiction, compulsive sexual behavior disorder, and food addiction.^{[13][17][18][19]}

Exercise addiction is a state characterized by a compulsive engagement in any form of physical exercise, despite negative consequences. While regular exercise is generally a healthy activity, exercise addiction generally involves performing excessive amounts of exercise to the detriment of physical health, spending too much time exercising to the detriment of personal and professional life, and exercising regardless of physical injury.^[20][21][22] It may also involve a state of dependence upon regular exercise which involves the occurrence of severe withdrawal symptoms when the individual is unable to exercise.^[20] Differentiating between addictive and healthy exercise behaviors is difficult but there are key factors in determining which category a person may fall into.^[23] Exercise addiction shows a high comorbidity with eating disorders.^[21]

Exercise addiction is not listed as a disorder in the fourth revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). This type of addiction can be classified under a behavioral addiction in which a person's behavior becomes obsessive, compulsive, and/or causes dysfunction in a person's life.^[24]

Behavioral addiction
Other names	Ludopathy, ludomania, degenerate gambling, gambling addiction, compulsive gambling, gambling disorder
Symptoms	Spending a lot of money and time in casino/sports betting, Video game addiction[25]

Problem gambling, ludopathy^[26] or ludomania is repetitive gambling behavior despite harm and negative consequences. Problem gambling may be diagnosed as a mental disorder according to DSM-5 if certain diagnostic criteria are met. Pathological gambling is a common disorder associated with social and family costs.

The DSM-5 has re-classified the condition as an addictive disorder, with those affected exhibiting many similarities to those with substance addictions. The term gambling addiction has long been used in the recovery movement.^[27] Pathological gambling was long considered by the American Psychiatric Association to be an impulse-control disorder rather than an addiction.^[28] However, data suggests a closer relationship between pathological gambling and substance use disorders than exists between PG and obsessive–compulsive disorder, mainly because the behaviors in problem gambling and most primary substance use disorders (i.e., those not resulting from a desire to "self-medicate" for another condition such as depression) seek to activate the brain's reward mechanisms, while the behaviors characterizing obsessive-compulsive disorder are prompted by overactive and misplaced signals from the brain's fear mechanisms.^[29]

Problem gambling is an addictive behavior with a high comorbidity with alcohol problems.^[30] A common tendency shared by people who have a gambling addiction is impulsivity.

This section is an excerpt from Internet addiction disorder.[edit]

Internet addiction disorder (IAD), also known as problematic internet use, or pathological internet use, is a problematic compulsive use of the internet, particularly on social media, that impairs an individual's function over a prolonged period of time. Young people are at particular risk of developing internet addiction disorder,^[31] with case studies highlighting students whose academic performance declines as they spend more time online.^[32] Some experience health consequences from loss of sleep^[33] as they stay up to continue scrolling, chatting, and gaming.^[34]

Excessive Internet use is not recognized as a disorder by the

gaming disorder appears in the ICD-11.^[36]

Controversy around the diagnosis includes whether the disorder is a separate clinical entity, or a manifestation of underlying psychiatric disorders. Definitions are not standardized or agreed upon, complicating the development of evidence-based recommendations.

Many different theoretical models have been developed and employed for many years in order to better explain predisposing factors to this disorder. Models such as the cognitive-behavioral model of pathological Internet have been used to explain IAD for more than 20 years. Newer models, such as the Interaction of Person-Affect-Cognition-Execution model, have been developed more recently and are starting to be applied in more clinical studies.[37]

In 2011 the term "Facebook addiction disorder" (FAD) emerged.^[38] FAD is characterized by compulsive use of Facebook. A 2017 study investigated a correlation between excessive use and narcissism, reporting "FAD was significantly positively related to the personality trait narcissism and to negative mental health variables (depression, anxiety, and stress symptoms)".^[39][40]

In 2020, the documentary The Social Dilemma, reported concerns of mental health experts and former employees of social media companies over social media's pursuit of addictive use. For example, when a user has not visited Facebook for some time, the platform varies its notifications, attempting to lure them back. It also raises concerns about the correlation between social media use and child and teen suicidality.^[41]

Additionally in 2020, studies have shown that there has been an increase in the prevalence of IAD since the COVID-19 pandemic.^[42] Studies highlighting the possible relationship between COVID-19 and IAD have looked at how forced isolation and its associated stress may have led to higher usage levels of the Internet.^[42]

Turning off social media notifications may help reduce social media use.^[43] For some users, changes in web browsing can be helpful in compensating for self-regulatory problems. For instance, a study involving 157 online learners on massive open online courses examined the impact of such an intervention. The study reported that providing support in self-regulation was associated with a reduction in time spent online, particularly on entertainment.^[44]

Behavioral addiction is a treatable condition.^[71] Treatment options include psychotherapy and psychopharmacotherapy (i.e., medications) or a combination of both. Cognitive behavioral therapy (CBT) is the most common form of psychotherapy used in treating behavioral addictions; it focuses on identifying patterns that trigger compulsive behavior and making lifestyle changes to promote healthier behaviors. Because cognitive behavioral therapy is considered a short-term therapy, the number of sessions for treatment normally ranges from five to twenty.^[72] During the session, therapists will lead patients through the topics of identifying the issue, becoming aware of one's thoughts surrounding the issue, identifying any negative or false thinking, and reshaping said negative and false thinking. While CBT does not cure behavioral addiction, it does help with coping with the condition in a healthy way. Currently, there are no medications approved for treatment of behavioral addictions in general, but some medications used for treatment of drug addiction may also be beneficial with specific behavioral addictions.^[73][74]

Another form of treatment is recreational therapy. A Certified Therapeutic Recreation Specialist (CTRS) uses leisure and recreation to help individuals recover from their injuries, ailments, or addictions. Therapeutic recreation can help an individual struggling with addiction to improve their self-esteem, confidence, motivation, resiliency, autonomy, enjoyment, and overall emotional state.^[75][76]

The classification and diagnostic framework of behavioral addictions under DSM-5 and ICD-11 has been a controversial subject among the clinical research field.^[18] For example, this 2020 narrative review^[17] considered ICD-11's guidelines to be adequate to include more behavioral addictions based on clinical relevance and empirical evidence, while this 2015 journal article questioned^[77] the atheoretical and confirmatory research approaches on the accuracy of qualitative factors and criticized the lack of consideration of social elements and psychological processes.

A recent narrative review

A systematic review in 2021 investigating the correlation between autism and behavioural addiction^[79] found inconclusive evidence for a general correlation. However found evidence of correlation when comorbid mental health conditions were present. Another systematic review in 2022 estimating the prevalence of behavioural addiction during the COVID-19 pandemic^[80] found the prevalence to be 11.1%.

One of the major areas of study is the amygdala, a brain structure which involves emotional significance and associated learning. Research shows that dopaminergic projections from the ventral tegmental area facilitate a motivational or learned association to a specific behavior.^[85] Dopamine neurons take a role in the learning and sustaining of many acquired behaviors. Research specific to Parkinson's disease has led to identifying the intracellular signaling pathways that underlie the immediate actions of dopamine. The most common mechanism of dopamine is to create addictive properties along with certain behaviors.^[86] There are three stages to the dopamine reward system: bursts of dopamine, triggering of behavior, and further impact to the behavior. Once electronically signaled, possibly through the behavior, dopamine neurons let out a 'burst-fire' of elements to stimulate areas along fast transmitting pathways. The behavior response then perpetuates the striated neurons to further send stimuli. The fast firing of dopamine neurons can be monitored over time by evaluating the amount of extracellular concentrations of dopamine through micro dialysis and brain imaging. This monitoring can lead to a model in which one can see the multiplicity of triggering over a period of time.^[87] Once the behavior is triggered, it is hard to work away from the dopamine reward system.

Behaviors like gambling have been linked to the newfound idea of the brain's capacity to anticipate rewards. The reward system can be triggered by early detectors of the behavior, and trigger dopamine neurons to begin stimulating behaviors. But in some cases, it can lead to many issues due to error, or reward-prediction errors. These errors can act as teaching signals to create a complex behavior task over time.^[87]

• Addictive behavior
• Addictive personality
• ANKK1 § Addictive behaviors
• Habit