Behavioral addictive disorders: How they develop and how they are treated

What is a behavioral addiction?

Everyone comes into contact with potentially addictive substances such as alcohol, online games or medications in everyday life. It is no wonder that addictive disorders have now become one of the biggest risk factors for morbidity and mortality worldwide, according to the German Medical Journal. Nevertheless, not everyone develops an addiction who regularly deals with potentially addictive substances, and the type of addictive substance and the strength of the addiction can also vary depending on the individual case. For example, there is alcohol addiction, shopping addiction, or sex addiction. People can therefore be addicted not only to substances such as cigarettes, but also to a certain behavior. In these cases, the term behavioral addiction is used. In contrast to substance-related addiction, those affected repeat a behavior that is part of everyday life for most people to a healthy extent. In their case, however, this behavior takes place excessively, i.e. addictively. This can make it difficult to recognize a behavioral addiction at an early stage and to distinguish between normal and addictive behavior.

Behavioral addictions are also known as behavioral, non-substance or non-substance addictions. As the name suggests, it is everyday behaviors that people develop an addiction to. Working, eating or playing can become a problem. Things that are normal for other people and are also practiced by them. The difference is that in addicts this behavior takes place excessively as well as uncontrollably until it leads to mental, financial, social or even physical consequences. Officially, however, such behavioral addictions do not belong to the category of addictions, but are included in the international classification system of disorders: Abnormal Habit and Impulse Control Disorder.

What is the difference to substance-related addiction?

Addictions that are recognized and classified as such are the so-called substance-related addictions. In this case, there is a mental and, above all, physical dependence on certain substances. This applies, for example, to alcohol, drugs or medication. This physical dependence does not exist in behavioral addictions and is therefore the most important distinguishing feature. People with a substance addiction therefore also experience physical withdrawal symptoms when they are unable to access their addictive substance. Psychological withdrawal symptoms such as strong cravings, on the other hand, occur equally in both substance and non-substance addictions.

How is this different from obsessive-compulsive disorder?

Distinguishing a behavioral addiction from an obsessive-compulsive disorder is not always easy. There is a great similarity between these disorders, which is why behavioral addictions are classified in the group of so-called compulsive spectrum disorders. Nevertheless, it is important to distinguish them from each other in order to make the correct diagnosis in individual cases and to initiate effective therapy. This diagnosis must be made by a specialist who is familiar with the disorders in detail. In principle, however, it can be said that in an obsessive-compulsive disorder, an action is repeated compulsively to relieve anxiety or discomfort, whereas in a behavioral addictive disorder, the behavior has other motivations. They often experience it as pleasurable, a reward, so to speak - but have difficulty controlling it. The most important distinguishing feature between behavioral addictions and compulsive behaviors is thus the underlying motivation.

Development of a non-substance-related addiction

As with substance-related addiction, behavioral addiction also develops gradually and is therefore often difficult to recognize for those affected and their social environment. In retrospect, it is usually difficult to say when normal behavior turned into addictive behavior. How this process takes place, at what speed and for what reasons, is highly individual. For a non-substance-related addiction to occur, however, several factors are always involved. Depending on the individual case, these can interact in different numbers and combinations. These include, for example:

• Negative reinforcement, i.e., a behavior ends a state perceived as unpleasant or reduces negative feelings such as fear, boredom or sadness. Therefore, they are highly likely to repeat that behavior.
• Psychological factors rooted in personality. Certain character traits such as impulsivity, a low resistance to stress or a lack of self-esteem can therefore favor the development of addictive disorders.
• Self-medication, i.e. the person actually suffers from a depression or anxiety disorder, which is, however, suppressed by the behavioral addiction. In this way, those affected treat themselves, so to speak.
• Genetics, because there is now evidence that a genetic predisposition can also play a role in the development of addictions of all kinds. This also applies to behavioral addictions, which occur more frequently in some families.
• Coping strategy often acquired in childhood, for example, to relieve frustration because basic emotional needs are not being met. The behavior then serves as a kind of "self-stimulant" or "self-soother."
• Social factors such as peer pressure or an environment in which the problematic behavior is accepted (for too long), perhaps even encouraged, are another risk factor for the development of behavioral addictions.
• Childish modes, meaning the person did not learn in childhood to set longer-term goals and pursue them in a disciplined manner. There is some lack of impulse control. This is a common consequence of an overly hedonistic parenting style.
• Neurobiological factors that appeal to the reward system in the brain when the particular behavior is performed. As a result, it is perceived as satisfying and the brain strives to repeat it. Sometimes this is the result of dysregulation of the reward system.

After a behavioral addiction has been diagnosed, the question of the individual causes should therefore always be in the foreground. Then the problem can be tackled at the root, so to speak, and treated optimally, increasing the chances of recovery. The only question that remains is when and how a behavioral addiction is diagnosed. As mentioned before, it often develops insidiously from a once normal behavior, so that it is usually only recognized when it is already strongly pronounced and has possibly already caused greater damage, for example in financial terms.

How can a behavioral addiction be diagnosed?

The only question that remains is how a diagnosis is made in such cases. After all, it is the basic prerequisite for effective therapy. If a behavioral addiction is suspected, it is important to turn to an expert in the field of psychiatry and psychology. Such psychiatrists, psychotherapists & co can make the diagnosis based on the following criteria:

• Diagnostic criteria, based on the Diagnostic and Statistical Manual of Mental Disorders or other guidelines recognized for diagnosis. These help identify addictive disorders and determine their nature. For example, for gambling addiction, at least four of nine criteria must be met.
• Clinical assessment, beginning with a medical history in which patients are asked about their circumstances, symptoms, as well as behaviors, to get a general idea, based on experience as a behavioral addiction specialist.
• Exclude other causes to prevent hasty or erroneous conclusions. Accordingly, for example, other potential mental disorders, substance abuse, or medical problems must be ruled out, using tests and examinations as appropriate.
• Establishing the time course, such as the duration and course, in which the addictive behavior occurs. This helps in assessing whether the behavior is already addictive and how pronounced the behavioral addiction is.
• Functional impairment, i.e. it is examined whether the addictive behavior has already led to consequences in the life of the person concerned, for example at work, in social life or also in physical health.
• Self-reports, i.e. those affected report independently on how they experience their behavior and how they explain it to themselves. This also provides information about whether they are aware of the problems associated with their addiction and where the potential causes lie.
• Psychosocial consequences, i.e. it is determined whether psychosocial problems have already arisen as a result of the addiction or have contributed to it, such as relationship, legal or financial problems.

Making an expert diagnosis is therefore a complex and sometimes lengthy process. Therefore, it is not possible for relatives or affected persons themselves to make a diagnosis on their own. However, they can act as initiators so that addicts seek professional help. Sometimes, there must first be an understanding on the part of the addict in order to even be able to initiate successful therapy. So usually by this time they have already reached a high level of suffering with major effects on various areas of their lives. More on this later.

Which addictive disorders are behavioral?

In principle, people can become addicted to any behavior. As mentioned above, it is about actions that are part of normal everyday life, as long as they are practiced to a healthy degree. In principle, however, it is primarily behavior that is perceived as a reward and triggers the corresponding areas in the brain that becomes addictive - or that serves as a distraction from fears, anger or other negative emotions. Typical examples are:

1. Gamblingaddiction, for example, to gambling or online games that are played over a long period of time or lead to outbursts of anger, a debt, and other negative consequences.
2. Sports addiction, since happiness hormones are released during sports, but recognition for the beautiful body or other obsessive goals can also be in the foreground.
3. Sex addiction, on the one hand as a distraction and on the other hand because of the happiness hormones. This can involve sexual activities of various kinds.
4. Media addiction, be it to television, streaming, social media or the Internet. The pursuit of recognition, for example through followers, can also take on addiction-like structures.
5. Shopping addiction, in which excessive purchases are made, for example online. It does not matter whether those affected actually need what they have bought and can afford it at all.
6. Work addiction, either as a distraction or for recognition, appreciation or other positive results.
7. Bingeeating, which can be reflected in so-called "binge eating," with no control over the type or amount of food consumed.
8. Cell phone addiction that goes beyond normal everyday use - and even this is excessive for many people. In a tangible addiction, however, individuals have lost control over their cell phone use and react violently when denied access.
9. Nail biting, which can also take on addictive forms. The same applies to so-called trichotillomania, in which a person pulls out their own hair. In such forms of behavioral addictions, the boundaries to obsessive-compulsive disorder become particularly blurred.

This is by no means the end of the list. In addition, the effects of the addiction can be just as individual as its type and severity.

What are the effects of behavioral addictions?

An addiction always has negative consequences. This is the only reason why it is perceived as an addiction, and it is this pressure of suffering that sooner or later forces many of those affected into the realization that they need professional help. In the case of substance-related addictions, these consequences are often of a physical nature, because, for example, the abuse of alcohol, drugs or medication has health consequences. But there are a variety of other consequences that can also occur with behavioral addictions:

• Psychological consequences, such as depression or anxiety. These can be both a cause and a consequence of the (non) substance-related addiction. For example, excessive gambling can lead to sleep deprivation, stress, and anxiety.
• Physical consequences that can also result from lack of sleep and stress. But injuries from a sports addiction or other health problems are also possible - and can be fatal in the worst case.
• Occupational consequences, because sooner or later many of those affected can no longer perform satisfactorily on the job, perhaps staying away from work altogether or pursuing their addiction during working hours, threatening a job loss.
• Social consequences, such as a social withdrawal, the neglect of friends as well as family or constant quarrels, because the environment has already noticed the addiction - but it has not yet come to any understanding.
• Legal problems that can arise from illegal behavior such as gambling crimes or the use of child pornography, to name just two of many examples.
• Financial problems, as addictive behavior can lead to debt, for example in the case of an addiction to shopping or gambling. These financial problems can also result in legal conflicts.

At worst, addictions can even threaten lives, whether through suicide due to depression, eating disorders, associating with the wrong people or other causes. That's why it's important for relatives as well as those affected not to take the subject lightly and to keep a close eye on when normal behavior turns into addictive behavior. If necessary, it is worth consulting an expert.

Prevention and therapy measures

At best, then, critical behavior is noticed early and prevented so that addiction does not develop in the first place. Prevention is therefore an important topic whenever behavioral addictions are involved. If, on the other hand, these are detected too late, professional therapy is necessary to change the behavior as quickly as possible and in the long term. There are also various options available for prevention as well as therapy, depending on individual factors: What type of addiction is it? How does it manifest itself? How severe is it? How long has it existed? What consequences has it already had? What are the underlying causes? These and many other questions must be answered by the treating physicians in order to develop an individual and successful therapy concept.

What are the options for prevention?

Because behavioral addiction can have so many different causes and manifestations, it is difficult to take general measures for prevention. Instead, it is important to develop and implement individual measures for each type of addiction. This applies to public measures as well as individual measures that each person can and should take when they discover a potential addiction. In recent years, for example, more and more precautions have been taken to counteract a gambling addiction before it becomes a mass problem due to increasing online (gambling). These include, for example, the player protection measures set out in the State Gambling Treaty, but also voluntary self-limitation strategies. Many providers protect minors, for example, by denying them access to their offerings, or they take further measures to identify and prevent problem gambling. They also help players in this regard by integrating features such as personal limits.

However, such measures are not possible for every type of addiction, and even if there are, the greatest responsibility lies with everyone themselves. After all, whether someone shops normally or addictively, gambles normally or addictively, has sex normally or addictively - all this can often only be assessed by oneself or as an extremely close person. Many addicts are true masters at hiding their disease from their social environment. Prevention is therefore primarily a question of personal responsibility, i.e. each person should observe, reflect and objectively evaluate his or her own behavior. In practice, however, this is difficult, because very few of those affected want to admit their problem. Often, therefore, it is only recognized when therapy is already necessary to treat it.

Therapy options for behavioral addictive disorders.

Whether therapy is necessary and what the best form it should take must be decided by a knowledgeable person such as a psychiatrist, neurologist or psychotherapist. In principle, however, there are many options available to counteract behavioral addiction. For quick as well as long-lasting success, this often requires a combination of several measures. Here are some examples:

1. Behavioral therapy to change harmful behavior patterns.
2. Drug therapy, but mostly used for concomitant diseases.
3. Self-help groups, for exchange and mutual support.
4. Inpatient treatment, which is recommended in particularly severe cases, for example for temporary abstinence.
5. Family therapy, if the family is also heavily burdened or is one of the main causes.
6. Cognitive behavioral therapy, to change dysfunctional thinking patterns and behaviors.
7. Biofeedback or neurofeedback to better understand physical responses to addiction.
8. Online addiction therapy, which can be used individually or as a companion to traditional therapy.
9. Relapse prevention to ensure therapy success over the long term.
10. Relaxation techniques to reduce potential triggers such as anxiety.

Social support is also an important factor for successful therapy in behavioral addiction disorders. It therefore makes sense to involve the social environment in order to minimize the risk of relapse, to manage the consequences of addiction together and to help those affected to combat their problem with motivation. With the right selection as well as implementation of therapy measures, the chances of successful treatment are then quite high. In particularly severe cases, however, therapy sometimes has to take place over the long term or be repeated several times. This also applies if the person concerned does not yet have (sufficient) insight into their behavioral addiction.