Behavioral addiction,process addiction,[1] ornon-substance-related disorder[2] is a form ofaddiction that involves acompulsion to engage in a rewarding non-substance-related behavior – sometimes called anatural reward[3][4] – despite any negative consequences to the person's physical, mental, social or financial well-being.[5] In the brain'sreward system, agene transcription factor known asΔFosB has been identified as a necessary common factor involved in both behavioral and drug addictions, which are associated with the same set of neural adaptations.[3][4][6]
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 thepsychopathology field.[8][9]
Diagnostic and Statistical Manual of Mental Disorders (DSM) recognized behavioral addictions for the first time inDSM-5 withgambling 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 theInternational 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, theAmerican Society of Addiction Medicine (ASAM) revised its definition of addiction includingsubstance use andcompulsive 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 includepornography use disorder,compulsive buying disorder,social network use disorder,work addiction,exercise addiction,compulsive sexual behavior disorder, andfood 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 ofdependence 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 theDiagnostic and Statistical Manual of Mental Disorders (DSM-IV). This type ofaddiction can be classified under a behavioral addiction in which a person's behavior becomes obsessive, compulsive, or causes dysfunction in a person's life.[24]
Problem gambling, ludopathy[25] or ludomania is repetitivegambling behavior despite harm and negative consequences. Problem gambling may be diagnosed as a mental disorder according toDSM-5 if certain diagnostic criteria are met. Pathological gambling is a common disorder associated with social and family costs. Estimates suggest the affected global population is between 0.1% and 6%.[26]
The DSM-5 has re-classified the condition as an addictive disorder, with those affected exhibiting many similarities to those with substance addictions. The termgambling addiction has long been used in the recovery movement.[27] Pathological gambling was long considered by theAmerican Psychiatric Association to be animpulse-control disorder rather than anaddiction.[28] However, data suggests a closer relationship between pathological gambling and substance use disorders than exists between PG andobsessive–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 highcomorbidity with alcohol problems.[30] A common tendency shared by people who have a gambling addiction isimpulsivity.
Internet addiction disorder (IAD) is characterized by excessive or poorly controlled preoccupations, urges, or behaviors regarding computer use and Internet access that lead to impairment or distress.[31] Young people are at particular risk of developing internet addiction disorder,[32] with case studies highlighting students whose academic performance declines as they spend more time online.[33] Some experience health consequences from loss of sleep[34] as they stay up to continuescrolling, chatting, and gaming.[35]
Excessive Internet use is not recognized as a disorder by theAmerican Psychiatric Association'sDSM-5 or theWorld Health Organization'sICD-11.[36] However,gaming disorder appears in the ICD-11.[37] 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.[38]
In 2011 the term "Facebook addiction disorder" (FAD) emerged.[39] FAD is characterized by compulsive use ofFacebook. A 2017 study investigated a correlation between excessive use andnarcissism, reporting "FAD was significantly positively related to the personality trait narcissism and to negative mental health variables (depression,anxiety, andstress symptoms)".[40][41]
In 2020, the documentaryThe 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.[42]
Additionally in 2020, studies have shown that there has been an increase in the prevalence of IAD since theCOVID-19 pandemic.[43] 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.[43]
Turning off social media notifications may help reduce social media use.[44] For some users, changes in web browsing can be helpful in compensating for self-regulatory problems. For instance, a study involving 157 online learners onmassive 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.[45]
Pornography addiction is the scientifically controversial[46] application of anaddiction model to the use ofpornography.[47] Pornography can be considered part of acompulsive behavior, with negative consequences for one's physical, mental, social, or financial well-being. While theWorld Health Organization'sICD-11 (2022) has recognizedcompulsive sexual behavior disorder (CSBD) as animpulse-control disorder,[48] CSBD is not anaddiction,[49][50] and theAmerican Psychiatric Association'sDSM-5 and theDSM-5-TR do not classify compulsive pornography consumption as amental disorder or a behavioral addiction.[49][51][52]
Problematic Internet pornography viewing, also known as problematic pornography use (PPU), is the viewing ofInternet pornography that is problematic for an individual due to personal or social reasons, including the excessive time spent viewing pornography instead of interacting with others and the facilitation ofprocrastination. Individuals may reportdepression,social isolation, career loss, decreased productivity, or financial consequences as a result of their excessive Internet pornography viewing impeding their social lives.[53]
Sexual addiction is a state characterized bycompulsive participation or engagement insexual activity, particularlysexual intercourse, despite negative consequences.[54] The concept is contentious;[55][56][57] as of 2023,[update] sexual addiction is not a clinical diagnosis in either theDSM orICD medical classifications of diseases and medical disorders, the latter of which instead classifying such behaviors as a part ofcompulsive sexual behavior disorder (CSBD).
There is considerable debate amongpsychiatrists,psychologists,sexologists, and other specialists whether compulsive sexual behavior constitutes anaddiction – in this instance a behavioral addiction – and therefore its classification and possible diagnosis.Animal research has established that compulsive sexual behavior arises from the sametranscriptional andepigenetic mechanisms that mediatedrug addiction in laboratory animals. Some argue that applying such concepts to normal behaviors such as sex can be problematic, and suggest that applying medical models such as addiction to human sexuality can serve to pathologise normal behavior and cause harm.[58]
Shopping addiction is characterized by an eagerness to purchase unnecessary or superfluous things and a lack ofimpulse control when it comes to shopping. It is a concept similar tocompulsive buying disorder (oniomania), but usually has a morepsychosocial perspective,[59] or is viewed as a drug-free addiction likeaddiction to gambling,Internet, orvideo games.[60] However, there is "still debate on whether other less recognized forms of impulsive behaviors, such as compulsive buying [...] can be conceptualized as addictions."[61]
Video game addiction (VGA), also known as gaming disorder or internet gaming disorder, is generally defined as abehavioural addiction involving problematic, compulsive use ofvideo games that results in significant impairment to an individual's ability to function in various life domains over a prolonged period of time. This and associated concepts have been the subject of considerable research, debate, and discussion among experts in several disciplines and has generated controversy within the medical, scientific, and gaming communities. Such disorders can be diagnosed when an individual engages in gaming activities at the cost of fulfilling daily responsibilities or pursuing other interests without regard for the negative consequences. As defined by theICD-11, the main criterion for this disorder is a lack of self control over gaming.
TheWorld Health Organization (WHO) included gaming disorder in the 11th revision of itsInternational Classification of Diseases (ICD). The American psychiatric association, while stating that there is insufficient evidence for the inclusion of Internet gaming disorder as an officially recognized disorder in the fifth edition (DSM-5) of theDiagnostic and Statistical Manual of Mental Disorders published in 2013, considered it worthy of further study, thus including it in its chapter onConditions for Further Study.
Controversy around the diagnosis includes whether the disorder is a separate clinical entity or a manifestation of underlying psychiatric disorders. Research has approached the question from a variety of viewpoints, with no universally standardized or agreed definitions, leading to difficulties in developing evidence-based recommendations.
Internet gaming disorder (IGD) affects an estimated 5% of the global population.[26]
Aworkaholic is a person who workscompulsively. A workaholic experiences an inability to limit the amount of time they spend on work despite negative consequences such as damage to their relationships or health.[62]
There is no generally accepted medical definition of this condition, although some forms ofstress,impulse control disorder,obsessive-compulsive personality disorder, andobsessive-compulsive disorder can be work-related; ergomania is defined as "excessive devotion to work especially as a symptom of mental illness".[63][64]
The phenomenon ofhustle culture, while disregarding healthywork–life balance, may exacerbate workaholism.[65][66]
Behavioral addiction is a treatable condition.[67] Treatment options includepsychotherapy andpsychopharmacotherapy (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 triggercompulsive 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.[68] 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.[69][70]
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.[71][72]
The classification and diagnostic framework of behavioral addictions underDSM-5 andICD-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[73] 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[74] in 2017 examined the existing literature for studies reporting associations between behavioral addictions (e.g.,pathological gambling,problematic internet use,problematic online gaming,compulsive sexual behavior disorder,compulsive buying, andexercise addiction) and psychiatric disorders. Overall, there is solid evidence for associations between behavioral addictions andmood disorders,anxiety disorders, as well assubstance use disorders. Associations betweenADHD may be specific to problematic internet use and problematic online gaming. The authors also conclude that most of current research on the association between behavioral addictions and psychiatric disorders has several limitations: they are mostly cross-sectional, are not from representative samples, and are often based on small samples, among others. Especially more longitudinal studies are needed to establish the direction of causation, i.e. whether behavioral addictions are a cause or a consequence of psychiatric disorders.
A systematic review in 2021 investigating the correlation betweenautism and behavioral addiction[75] 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 theCOVID-19 pandemic[76] found the prevalence to be 11.1%.
Several recently published studies have investigated potential brain abnormalities associated with behavioral addiction. A 2024 meta-analysis of neuroimaging studies related to specific types of behavioral addiction aimed to distinguish whether subtypes of behavioral addiction share a common neural basis. It found that research subjects affected by various behavioral addictions demonstrate similarities in the role of thefrontostriatal circuits. Findings confirmed previous studies, highlighting the role of hyperactivation in the bilateralcaudate nucleus, a part of thebasal ganglia. Likewise, hyperactivation of the right inferiorfrontal gyrus (IFG) and left middle frontal gyrus (MFG), both located in the brain'sfrontal lobe, was observed.[77]
A similar 2024 meta-analysis likewise identified abnormalities in cortical thickness among subjects affected by differing behavioral addictions. These subjects were noted to have a thinnercerebral cortex than individuals without behavioral addiction. Areas of the cerebral cortex affected were specifically theprecuneus, postcentral gyrus,orbital-frontal cortex, anddorsolateral prefrontal cortex. An association between these areas and specific genes thought to be involved in dopamine metabolism and behavioral regulation was identified, the most significant of which was thedopamine D2 receptor. Additionally, researchers found that increased severity of behavioral addiction was linked to increased thinning of the cerebral cortex within the precuneus and postcentral gyrus.[78]
Likewise, a 2023 meta-analysis found that subjects affected by differing behavioral addictions demonstrated similarities ingray matter volume, specifically a marked loss of gray matter volume in the anteriorcingulate cortex, middle cingulate cortex, and superior frontal gyrus. This decrease in gray matter volume is associated with a decrease in brain connectivity. The meta-analysis suggests that this lack of gray matter could be associated with behavioral aspects of behavioral addiction, such as inhibition.[79]
ΔFosB, agene transcription factor, has been identified as playing a critical role in the development of addictive states in both behavioral addictions and drug addictions.[3][4][6] Overexpression of ΔFosB in thenucleus accumbens isnecessary and sufficient for many of theneural adaptations seen in drug addiction;[3] it has been implicated in addictions toalcohol,cannabinoids,cocaine,nicotine,phenylcyclidine, andsubstituted amphetamines[3][80][81][82] as well as addictions to natural rewards such as sex, exercise, and food.[4][6] A recent study also demonstrated across-sensitization between drug reward (amphetamine) and a natural reward (sex) that was mediated by ΔFosB.[83]
One of the major areas of study is theamygdala, a brain structure which involves emotional significance and associated learning. Research shows that dopaminergic projections from theventral tegmental area facilitate a motivational or learned association to a specific behavior.[84] 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.[85] 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.[86] 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.[86]
ΔFosB has been linked directly to several substance-related behaviors ... Importantly, genetic or viral overexpression of ΔJunD, a dominant negative mutant of JunD which antagonizes ΔFosB- and other AP-1-mediated transcriptional activity, in the NAc or OFC blocks these key effects of drug exposure14,22–24. This indicates that ΔFosB is both necessary and sufficient for many of the changes wrought in the brain by chronic drug exposure. ΔFosB is also induced in D1-type NAc MSNs by chronic consumption of several natural rewards, including sucrose, high fat food, sex, wheel running, where it promotes that consumption14,26–30. This implicates ΔFosB in the regulation of natural rewards under normal conditions and perhaps during pathological addictive-like states.
It has been found that deltaFosB gene in the NAc is critical for reinforcing effects of sexual reward. Pitchers and colleagues (2010) reported that sexual experience was shown to cause DeltaFosB accumulation in several limbic brain regions including the NAc, medial pre-frontal cortex, VTA, caudate, and putamen, but not the medial preoptic nucleus. Next, the induction of c-Fos, a downstream (repressed) target of DeltaFosB, was measured in sexually experienced and naive animals. The number of mating-induced c-Fos-IR cells was significantly decreased in sexually experienced animals compared to sexually naive controls. Finally, DeltaFosB levels and its activity in the NAc were manipulated using viral-mediated gene transfer to study its potential role in mediating sexual experience and experience-induced facilitation of sexual performance. Animals with DeltaFosB overexpression displayed enhanced facilitation of sexual performance with sexual experience relative to controls. In contrast, the expression of DeltaJunD, a dominant-negative binding partner of DeltaFosB, attenuated sexual experience-induced facilitation of sexual performance, and stunted long-term maintenance of facilitation compared to DeltaFosB overexpressing group. Together, these findings support a critical role for DeltaFosB expression in the NAc in the reinforcing effects of sexual behavior and sexual experience-induced facilitation of sexual performance. ... both drug addiction and sexual addiction represent pathological forms of neuroplasticity along with the emergence of aberrant behaviors involving a cascade of neurochemical changes mainly in the brain's rewarding circuitry.
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'Sex addiction' is also referred to as a diagnosis or presenting problem. Sex addiction is not a diagnosis in the DSM-5-TR and identified as Compulsive Sexual Behavior in the ICD-11 rather than an issue of addiction.
Proposals for two constructs related to compulsive sexual behaviors, sexual addiction and hypersexual disorder, have been repeatedly rejected from inclusion in recent editions of theDiagnostic and Statistical Manual of Mental Disorders (DSM) for lack of empirical support and lack of consensus as to definition. [...] (CSBD), has been included in the International Classification of Diseases, 11th edition (ICD-11), under impulse control disorders rather than as an addiction disorder. CSBD has significant differences from substance use disorders (SUD) [...] Though the concept of a general sexual addiction or hypersexual disorder has a long history, it has not been supported by rigorous or replicated studies and has not so far produced evidence-based treatments.
Given that we do not yet have definitive information on whether the processes involved in the onset and maintenance of the disorder are equivalent to substance abuse disorders, gambling, and gaming (Kraus et al. 2016), CSBD is not included in the grouping of disorders due to substance and addictive behaviors, but rather in that of impulse control disorders (Kraus et al. 2018).
... materials in ICD-11 make very clear that CSBD is not intended to be interchangeable with sex addiction, but rather is a substantially different diagnostic framework
The defining feature of addiction is compulsive, out-of-control drug use, despite negative consequences. ...
compulsive eating, shopping, gambling, and sex–so-called "natural addictions"– ... Indeed, addiction to both drugs and behavioral rewards may arise from similar dysregulation of the mesolimbic dopamine system.
Naltrexone, a mu-opioid receptor antagonist approved by the US Food and Drug Administration for the treatment of alcoholism and opioid dependence, has shown efficacy in controlled clinical trials for the treatment of pathological gambling and kleptomania (76–79), and promise in uncontrolled studies of compulsive buying (80), compulsive sexual behavior (81), internet addiction (82), and pathologic skin picking (83). ... Topiramate, an anti-convulsant which blocks the AMPA subtype of glutamate receptor (among other actions), has shown promise in open-label studies of pathological gambling, compulsive buying, and compulsive skin picking (85), as well as efficacy in reducing alcohol (86), cigarette (87), and cocaine (88) use. N-acetyl cysteine, an amino acid that restores extracellular glutamate concentration in the nucleus accumbens, reduced gambling urges and behavior in one study of pathological gamblers (89), and reduces cocaine craving (90) and cocaine use (91) in cocaine addicts. These studies suggest that glutamatergic modulation of dopaminergic tone in the nucleus accumbens may be a mechanism common to behavioral addiction and substance use disorders (92).
Together, these findings demonstrate that drugs of abuse and natural reward behaviors act on common molecular and cellular mechanisms of plasticity that control vulnerability to drug addiction, and that this increased vulnerability is mediated by ΔFosB and its downstream transcriptional targets.
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