A process addiction, also known as behavioral addiction, is the repetitive occurrence of impulsive behaviors regardless of the negative consequences the behaviors may trigger.
Process or behavioral addiction became a focus of study in the 1980s and 1990s. Researchers hypothesized that changes wrought in the brain’s reward system by certain substances (e.g., cocaine ) and leading to substance use problems or addiction may also underlie the exercise of dysfunctional, directed behaviors that have negative consequences. In other words, the addictions may differ in nature (a process like gambling versus taking a substance like cocaine), but the end result in the brain/body is the same. To paraphrase one researcher, the brain does not care whether or not the reward comes from a chemical stimulus or from an experience.
Many of the behaviors listed in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (also known as the DSM-IV-TR) as “Impulsive-Compulsive, Not Elsewhere Classified,” may fall under the umbrella of process addiction. An essential feature of an impulse disorder is the inability
to resist engaging in an act that can harm the individual or others. For most, if not all, of these disorders, the act or behavior is preceded by a feeling of tension or anticipation. The behavior itself brings on a feeling of pleasure, gratification, or relief, and following the behavior, the person may or not feel regret or self-reproach.
In addition to the impulsive nature of the behaviors, there is also a pattern of behavioral addiction. The features of this group of disorders include the urge to engage in a behavioral sequence that has negative consequences or is counterproductive; a feeling of increasing tension as the execution of the behavior approaches; a resurgence of the urge after a lapse of hours, days, or weeks; and the presence of external cues for the behavior that vary and are specific to a particular behavioral addiction. These patterns are similar to those manifested in substance addiction (see below), and these behaviors can be classified as addictions because they have the same components as substance/chemical addictions, including mood modification, tolerance, withdrawal, and relapse .
Among this group of impulsive-compulsive behaviors that may also be classified as behavioral addictions are pathological gambling, kleptomania, pyromania, trichotillomania (recurrent pulling out of one’s own hair), compulsive buying, and compulsive sexual behavior. The suite of disorders may also include compulsive Internet/computer use. Of these disorders, pathological gambling has received the most attention and study. These disorders may ultimately be included in a new category in the DSM-V, called “Substance and Behavioral Addictions.” This category could include pathological gambling, kleptomania, pyromania, and disorders currently listed under “Impulsive-Compulsive Behaviors Not Otherwise Specified,” such as compulsive buying and impulsive-compulsive sex behavior.
Adolescence is a period of critical vulnerability in the development of addiction, for both cultural and neurobiological reasons. Age at onset for kleptomania is not known, but it is usually before adulthood, and two-thirds of people with kleptomania are female. Pyromania is both extremely rare and understudied, and no one has established the range of age at onset. The best-studied process addiction is pathological gambling, and its demographics can vary based on environmental factors, including proximity to a gambling location and exposure to gambling. It is more prevalent among males, and rates can be as high as 8% among adolescents and college-age students. The little research done thus far on Internet addiction suggests that it can affect any age or socioeconomic group.
Environmental and developmental
Being the child of a person who has an impulsive disorder such as pathological gambling may be a risk factor. Early onset of alcohol or drug use can exacerbate the severity of process addiction, and this pattern also holds true at least for pathological gambling. As mentioned above, adolescence is a critically vulnerable time, primarily because the brain areas affected as addiction develops are immature and susceptible. The immaturity may lead to a greater level of impulsive behaviors.
There have been some genetic links indicated in studies of pathological gambling and compulsive buying, but given the lack of information.
The mechanism underlying addiction involves disruptions in serotonin and dopamine signaling and monamine oxidase (MAO) activity. The MAO gene lies on the X chromosome, which can result in the observed sex differences in some behavioral addiction disorders. Males, who have only one X chromosome, express only the gene their single X chromosome carries; females have two X chromosomes, and having one normal version of MAO on one X chromosome can compensate for having a mutant version on the other chromosome.
Dopamine is a neurotransmitter involved in reward pathways in the brain and in the development or reinforcement of behaviors. This molecule and its associated proteins have been strongly implicated in substance abuse and behavioral addiction. People with process addiction may share many symptoms with people who have substance use disorders, including depression, loneliness, social impairment, and distraction.
Some symptoms are specific to a given behavior. For example, in impulsive-compulsive sex behavior, the person may have frequent, intrusive thoughts about sex and engage repeatedly in sex behaviors that may spiral out of their control.
Some criteria have been proposed for considering a behavior an addiction. These include the level of significance certain cues have for the person, the manifestation of withdrawal symptoms, tolerance (i.e., the need to engage in the behavior more or longer for the
These behaviors, although listed as different disorders in the DSM-IV-TR, share a suite of similar diagnostic features. These features include failure to resist the associated impulse (e.g., gambling or stealing), feelings of tension before engaging in the behavior, and a feeling of pleasure or relief when the behavior is being performed.
The specific behavioral or process addiction of pathological gambling has been associated with high rates of psychiatric comorbidity and mortality, one of many similarities between substance and process addictions. There is a frequent co-occurrence of some behavioral addictions with depression, suicide attempts, and anxiety .
Association with substance abuse
There are substantial similarities between a disorder like pathological gambling and substance use disorder, from the comorbidities to personality features, behavioral measures, and neurobiological observations; substance use disorder and behavioral or process addiction often occur together. For example, low serotonin levels have been identified in people with pathological gambling disorder and in people with alcohol dependency. There is the phenomenon of “cross priming,” in which the development of an addiction to a substance primes an individual’s neural circuitry for susceptibility to a process addiction; for example, amphetamine use might prime a person biochemically for developing a gambling problem. Studies in pathological gamblers bear out this link: among this group, as many as 70% people addicted to gambling are addicted to nicotine, 50–70% have alcohol problems, and up to 40% have problems with abuse of other drugs.!
The converse is that people who have substance use disorders can be up to 10 times more likely also to have a pathological gambling problem, and there are similar relationships between substance use disorder and kleptomania or compulsive buying. Compulsive sexual behavior and substance use disorder occur together in 25% and 71% of cases, respectively.
As with substance abuse, denial can be a key characteristic of the behavior in process addiction, and any treatment begins with recognition and acknowledgment of the problem.
The medical establishment is still in the early stages of developing and applying pharmacological treatment for process addiction. Selective serotonin reuptake inhibitors (SSRIs ) have proven beneficial in some studies, but not in others. More effective, at least for pathological gambling and kleptomania, are opioid antagonists like naltrexone and nalmafene. The efficacy of these drugs may result from the interaction of the opioid system with dopamine signaling pathways.
Pharmacological treatments can be based on comorbidities. For example, if obsessive-compulsive disorder, depression, or anxiety are present, SSRIs may be effective. Mood stabilizers might be efficacious if bipolar disorder is present, and if attention deficit/hyperactivity disorder (ADHD) is a comorbidity, stimulants or inhibitors of dopamine or noradrenaline reuptake (MAO-B inhibitors) may be beneficial.
Benzodiazepines can actually reduce inhibitions even more and are not recommended except in emergency situations to ameliorate acute agitation.
The 12-step programs (e.g., Gamblers Anonymous) are enormously popular and well recognized, but their dropout rates are high and few studies have established their level of effectiveness. Other therapeutic approaches can involve cognitive behavioral therapy, motivational interviewing, or relapse prevention, all based on approaches used for substance use disorders. The therapeutic approach may also need to be disorder specific; for example, for impulsive-compulsive sexual behavior, couples therapy may be warranted.
These disorders are considered to be chronic, and relapses in those that have been reasonably well studied, such as pathological gambling, are common. However, at least in the case of pathological gambling, appropriate treatment can help in management of the disorder.
Dopamine —A neurotransmitter involved in the reward pathways in the brain.
MAO-B inhibitors —Inhibitors of dopamine or nor-adrenaline reuptake by monoamine oxidase.
Process addiction, also known as behavioral addiction —The repetitive occurrence of impulsive behaviors regardless of the negative consequences the behaviors may trigger.
SSRI —Selective serotonin reuptake inhibitor
Trichotillomania —Recurrent pulling out of one’s own hair.
Prevention is based on decreased exposure to targets of process addiction; for example, little or no exposure to gambling can be helpful to people at risk. Early intervention may also be preventative.
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Emily Jane Willingham, Ph.D.
Prolixin see Fluphenazine