Guest Blog – Increasing Acceptance of Behavioral Addictions as Real

Repetitive, out-of-control behaviors entrap some people. I contend these behaviors qualify as addictions, whether for food, online sports gambling, constant internet use, or excessive sexual behaviors.

Technology has hijacked reward systems for many, challenging some people’s ability to control behavior. One example is internet gaming disorder (IGD), or persistently overusing video games, leading to significant impairment or distress, whether played alone or with others. Another is online shopping addiction (OSA), compulsive shopping on the internet causing economic, social, and emotional consequences. Social media addiction (SMA) is a preoccupation with social media sites, evidenced by irresistible urges to log on and increasing time using online platforms, resulting in impairment or distress.

Let’s briefly review food addiction, gambling addiction, gaming addiction, and sex addiction.

A major milestone in increasing acceptance of such so-called “process” addictions was publication of The Behavioral Addictions by Michael Ascher and Petros Levounis in 2014 (full disclosure: it included my chapter on food). It was the first American Psychiatric Association (APA) book covering diagnosis and treatment of patients with behavioral addictions.

Another milestone was the addition of gambling addiction to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), published by the American Psychiatric Association (APA) in 2014. So far, gambling is the only behavioral addiction in this publication.

In contrast, the World Health Organization’s ICD-11 diagnostic manual recognizes “gaming disorder” as a condition characterized by recurrent gaming behavior, online or offline. DSM-5 describes internet gaming disorder (IGD) as a behavioral addiction pending further study. IGD does not include general problems with internet use, online gambling, or overuse of social media or smartphones.

To be diagnosed with IGD, a person is preoccupied with gaming, and experiences withdrawal symptoms when stopping gaming. In addition, the person spends increasing amounts of time or money gaming, and the behavior causes significant impairment or distress. While the ICD-11 and DSM-5 both recognize behavioral addictions, they differ in scope and approach.

Petros Levounis, M.D., immediate past president of the American Psychiatric Association, is a prominent voice advocating for stigma reduction in technology-enabled gambling, sexual compulsivity, and other behavioral addictions. In May 2024, Dr. Levounis discussed technology addictions, internet gaming, cybersex, and social media addiction. He pointed out that technology-enabled addictions are similar to all addictions, with tolerance and withdrawal, internal concerns, and external consequences. Some patients cannot cut back on their behaviors despite their desire and repeated efforts to do so. ​​.

Dr. Levounis also highlighted that behavioral addictions can accelerate loss of control. However, many patients with behavioral addictions respond to treatments commonly used for substance use disorders, such as cognitive behavioral therapy. Dr. Levounis also noted that a significant portion of individuals with technology addictions suffer from other psychiatric and addictive disorders, necessitating a comprehensive approach to evaluation and treatment

U.S.-wide gambling was $93-billion industry in 2022, with mobile betting accounting for a significant portion. In New Jersey and Pennsylvania, cell phone betting represents over 80% of total sports betting. The ease of placing bets and rewards, users report, leads some individuals to develop a behavioral addiction to online gambling.

For over 20 years, Marc Potenza, M.D.. Ph.D., has led Yale’s department of psychiatry research to better understand gambling addiction and develop more effective treatments. His research suggests that lottery tickets and playing games with gambling elements on mobile devices can activate neural pathways in the brain similar to those involved in other addictions.

College student gamblers often face significant financial challenges, including accumulating debt and spending money on betting intended for tuition or living expenses. There is a strong correlation between gambling and mental health issues among college students. Those who engage in gambling are more likely to experience anxiety, depression, and substance abuse.

Gambling disorder is currently classified in DSM-5 as a behavioral addiction. This inclusion reflects a growing body of research demonstrating similarities between gambling disorders and substance use disorders, such as craving, tolerance, and withdrawal. Neuroimaging studies have demonstrated that gambling activates the brain’s reward system similarly to drugs of abuse. People with gambling disorder often exhibit an inability to stop despite negative consequences and preoccupation with gambling, much like individuals addicted to drugs or alcohol are preoccupied with those substances.

Gambling disorder leads to significant personal, social, and financial problems. Individuals with gambling disorder may experience severe distress, relationship problems, job loss, and financial ruin. By recognizing gambling disorder as an addiction, the DSM-5 improves diagnosis and treatment, reducing shame and stigma and helping those affected receive appropriate care and support. For these and other reasons, scientists have been amassing evidence for the DSM committee to consider inclusion of other behavioral addictions.

Similar neurobiological features are reported among individuals addicted to gambling, substance use, and food, sex, and internet gaming. Like drugs of abuse, potato chips dare you to eat just one, as eating one stimulates the desire and interest to eat another. They stimulate their own taking. Also, much evidence in neuroscience suggests drugs of abuse hijack the food-related reward/motivation systems.

Several celebrities have openly described struggles with sex addiction. Their stories have inspired many people to seek help. For example, David Duchovny, the actor known for his roles in The X-Files and Californication, sought treatment for sex addiction in 2008.

Tiger Woods publicly acknowledged his struggles with sex addiction in 2010 after his extramarital affairs became public, shocking the sports world when he checked into a residential treatment facility.

Jada Pinkett Smith revealed that her grandmother taught her how to “self-pleasure” when she was 9 and that she went through a period when she was masturbating five times a day. Pinkett Smith did not discuss how she dealt with her addiction, but did say she is adamant about identifying a root cause. Many others have privately sought help for sex addiction without making their struggles public.

Cybersex, online sexual activity, may become a behavioral addiction resulting from overutilization of modern technologies, like smartphones and computers. Clinically referred to as compulsive sexual behavior disorder, sex addiction shares similarities with other forms of addiction. At its core, addiction involves dysregulation of the brain circuits associated with reward, motivation, and self-control. There is an ongoing debate about what constitutes “normal” versus “compulsive” sexual behavior, complicating the development of clear diagnostic criteria. Concerns about pathologizing normal variations in sexual behavior also play a role.

Stefanie Carnes, Ph.D., president of the International Institute for Trauma and Addiction Professionals, is an internationally recognized therapist in this field. She works with clients struggling with sexuality and intimacy issues, such as compulsive and addictive sexual behaviors, infidelity, sexual trauma, and sexual assault.

Dr. Carnes says that children are often inappropriately exposed to pornography when young. “Today’s kids are often raised with a digital device from infancy. Within a few clicks, they can access very hard-core images. This has become a major source of sex education for our children, which can influence their developing sexuality. Young people need an education that not everything they see onscreen is healthy sex.”

However, Carnes says, “We must be cautious about over-pathologizing teen use of pornography since it is very normal for adolescents to be very curious about sex. As a result, clinicians should be careful about providing a sex addiction diagnosis to a minor. Additionally, parents should be careful not to shame teenage children for viewing pornography, as it is normative for this generation.”

Gambling disorder is an accepted behavioral addiction by the American Psychiatric Association’s DSM5. Gaming will likely follow in the next edition, and other disorders, such as food addiction and sex addiction, may become accepted in the near future.