© 2015 Scientific American

FOOD
GAMES
TO: GAMBLING
ADDICTED

SEX
Are “behavioral addictions” really
mental illnesses or just bad habits?
A look at the latest evidence
By Carl Erik Fisher

INTERNET…
Illustrations by VIKTOR KOEN

SCIENTIFIC AMERICAN MIND 43

© 2015 Scientific American
T heo did not seem like the type to become addict-
ed to gambling. He was a literary star who had
published his first novel at age 24 to great success.
While traveling through Europe, he began visiting
elegant casinos, at first dabbling in table games
like roulette. With time, though, this pleasant di-
version became a compulsion, and he lost nearly
all his money in just a few years. He continued to produce critically ac-
claimed books—at one point churning out a new novel in less than a
month to settle urgent debts—but he struggled to stay afloat, and his
wife soon had to sell her jewelry. Remarkably, aside from the gambling,
his life seemed fine. His writing was respected, and his family life was
satisfying. He was simply hooked.
tional thought process or behavior that
causes harm. In my view, some behavior-
al addictions clearly meet that descrip-
tion—there is a reason we have had this
intuition since the time of Dostoyevsky.
Yet many people rush to diagnose
themselves with behavioral addictions,
not recognizing the underlying depres-
sion or anxiety driving their problems.
Treatment for them may have different
considerations, and research is just
starting to offer clues about how to help
these different types of addictions. After
all, that is the goal of all the questions
and debates — how can we best help peo-
“Theo” is actually Fyodor Dos- into the casinos of Romantic-era Eu- ple who are suffering?
toyevsky, the prototypical gambling ad- rope, addictions to sex, eating, video As I set out to understand this phe-
dict. Despite profound insight into the games and other behaviors are getting nomenon, I found that even the experts
human condition, Dostoyevsky struggled serious recognition in some quarters of within the field are divided— and that in-
with gambling for many years and was medicine and among the public. Casual- cludes those who support the idea of be-
almost financially ruined several times. ties of behavioral addictions are appear- havioral addiction. But along the way
His semiautobiographical novel The ing in the news: not just gamblers throw- I also caught glimpses of paths toward
Gambler —written to cover his debts, ing their life savings away but also porn a resolution.
published in 1867— described compulsive addicts masturbating to iPhones on the
gambling so well that 20th-century psy- freeway and even babies left to die by Disordered Desires
chiatrists studied it as a model for the parents engrossed in video games. People were making unhealthy
concept of gambling addiction. Doubters, however, argue that slapping choices about sex, eating and money
Well over a century ago people al- the addiction label on these habits inap- well before Dostoyevsky. Saint Augus-
ready realized that an individual could propriately excuses bad behavior. tine’s Confessions, written sometime
have what is today called a behavioral Are these behaviors mental disor- around the year 400, intricately ex-
addiction: an overwhelming, repetitive ders? Many people are striving to limit plores loss of control over sexual impuls-
and harmful pattern of behaviors apart their screen time or watch their diets, es. The root of the word “addiction” it-
from drug or alcohol abuse. Now, 150 but does that mean that Internet and self is thought to come from the Latin
years after Dostoyevsky first walked food addiction epidemics are upon us? term for “dedication,” and prior to the
Proponents argue, neuroscience evi- 19th century the word was often used to
dence in hand, that behavioral addic- describe behaviors in a positive light,
FAST FACTS tions are brain disorders, but critics such as being dedicated to public service
OUT OF CONTROL question those interpretations and pro- or “addicted to books.” But a darker
nn
Many people struggle with habitual test that we are unnecessarily medicaliz- view of addiction soon began to emerge.
behaviors that cause them distress and ing everyday suffering. In the 20th century the temperance
disrupt their life, such as too much This leaves psychiatrists like me in a movement, the development of psychia-
gambling, eating, sex or Internet use.
difficult position. In my practice in New try and the growth of Alcoholics Anon-
on
Genetic evidence, brain-imaging studies
and pharmaceutical treatments suggest York City, I received more inquiries in the ymous all shaped the disease model of
these behavioral addictions are similar to past year from people seeking help for In- addiction: loss of control over drugs and
drug and alcohol addictions. ternet addiction than for cocaine and her- alcohol is a chronic, relapsing, lifelong
pn
Despite the recent scientific advances, the oin addiction combined. It is hard to deny disorder. As early as 1957, offshoot 12-
notion that there are different subtypes of
that for some of them, behavioral addic- step programs such as Gamblers Anon-
behavioral addictions remains
controversial, leaving open the question of tions are real—these individuals are tru- ymous and Overeaters Anonymous ap-
whether there are different root causes of ly overwhelmed by repetitive, harmful plied the addiction model to problems
these addictions in different individuals. behaviors. Their schooling, marriage or that did not involve drugs or alcohol.
n
Regardless of other co-occurring mental job is in danger because of their uncon- In 1980 “pathological gambling”
disorders or suspicions about underlying
trolled actions. They sincerely want to was added to the Diagnostic and Statis-
issues, individual treatment plans that
address all psychological problems at stop, but they feel powerless. A mental tical Manual (DSM), the American Psy-
once work best. disorder is defined simply as a dysfunc- chiatric Association’s official categori-

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 Gambling Gets Its Due
IMAGING STUDIES grapple with obesity, a food-addiction
model is increasingly used to explain Researchers have increasingly used
SHOW THAT THE some people’s uncontrolled eating.
At the same time, however, the aca-
the tools of neuroscience to argue that be-
havioral addictions are brain-based dis-
BRAIN ACTIVITY demic understanding of addiction is a
conceptual minefield. Organized psychi-
orders. For example, as recently as the
early 2000s clinicians were not sure how
OF PROBLEM atry has long shied away from even to categorize pathological gambling.
using the word “addiction.” The DSM Some thought it looked more like obses-
GAMBLERS LOOKS formerly called it “dependence,” a sive-compulsive disorder than drug or al-
stand-in term that emphasized the idea cohol addiction. From their perspective,
SIMILAR TO THAT of addiction as a chronic, relapsing dis- pumping quarters into slot machines or

OF DRUG AND ease that is markedly different from oth-

er unhealthy drug and alcohol use.
repetitively washing one’s hands ap-
peared almost the same—irrational, com-
ALCOHOL That distinction, between “true” ad-
diction and other harmful patterns of
pulsive and almost automatic.
Marc N. Potenza, a gambling re-
ADDICTS. drug abuse, has been struck from the lat-
est edition, the DSM-5, published in
searcher at Yale University, published an
enlightening study in 2003. Using func-
2013. The update radically altered the tional MRI, a method for assessing blood
zation of mental disorders, as a condi- definition of addiction, collapsing both flow in the brain, his team measured the
tion deserving further study. In 1990 “dependence” and milder forms of “sub- cerebral activity of people with gambling
Isaac Marks, a psychiatric researcher in stance abuse” into one condition, “sub- problems as they watched provocative
London, penned a widely cited editorial stance use disorder,” with no clear divi- videos in the scanner: the thrill of an un-
in the British Journal of Addiction de- sion between mild and extreme cases. expected windfall, the clatter of new
scribing “non-chemical” addictions, That decision was based on data from chips, the flutter of cards. The imaging re-
and since then the idea has received in- more than 200,000 research partici- vealed decreased activity in the ventrome-
creasing attention from mainstream re- pants, which showed an even continuum dial prefrontal cortex (vmPFC), an area in
searchers and clinicians. from the worst cases down to less severe the middle of the frontal lobes associated
In popular culture, behavioral addic- substance-use problems. with regulating impulses. People with
tions are also getting much more recogni- This changing understanding of ad- OCD show the opposite result: they have
tion. Movies such as Shame and Don Jon diction makes it even more difficult to increased vmPFC activation during obses-
vividly portray sex and pornography ad- know how to define behavioral addic- sions, indicating excessive thoughts and
dictions. For better or for worse, sex ad- tions. Is gambling addiction like drug ad- preoccupations. These and subsequent
diction is the go-to excuse for unfaithful diction, or is it something else? The evi- imaging findings show that the brain ac-
celebrities. Residential rehabilitation cen- dence base for most behavioral addic- tivity of problem gamblers looks similar
ters for Internet addiction are booming in tions is far less robust than for substance to that of drug and alcohol addicts.
China and even starting to appear in the addictions, but research is beginning to In 2005 a group of researchers in
U.S. Additionally, as developed countries fill in the gaps. Hamburg, Germany, used fMRI to dis-

G AMBL ING
OFFICIAL STATUS: The oldest recognized behavioral addiction,
gambling disorder, has been listed under various names since
1980 in the DSM-III and the DSM-IV and is currently fully
accepted in the DSM-5.
PREVALENCE: Although more than 85 percent of the U.S.
population will try gambling at some point in their lives, experts
estimate that around 1 percent or less of all adults will develop
this disorder.
DID YOU KNOW?: Several celebrities have been reported to have
gambling disorder, including Charlie Sheen, Ben Affleck and
GE T T Y IMAGES

Tiger Woods, but such stories may be complicated by other issues,

possibly including substance use or mental health problems.

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 SE X
OFFICIAL STATUS: Hypersexual disorder was proposed for
the DSM-5, but after criticism it was not even included in
the appendix.
PREVALENCE: The numbers depend on the definition used, but
larger studies of hypersexual disorder (previously studied as
“compulsive sexual behavior”) have found rates around 1.5 to
2 percent of the population, with a significant gender difference
(greater than 3 percent for men; 1 percent or less for women).
DID YOU KNOW?: Studying the prevalence rates of hypersexual
disorder is difficult; many people are likely to underreport their
problems because of stigma. For this reason, cross-cultural stud-
ies of addictive sexual behaviors are particularly challenging.

cover further similarities between behav- how society should treat people who one, a drug that blocks opioid receptors
ioral and substance addictions. They suffer from these afflictions. in the brain, has successfully treated al-
measured responses in the ventral stria- There has been a plethora of fMRI cohol and opioid dependence since the
tum, a deep-brain structure rich in dopa- studies since Potenza’s influential gam- 1990s. More recent evidence shows that
mine and associated with sensitivity to bling studies. His initial findings have it can help with gambling addiction, and
rewards. Drug and alcohol addicts have been replicated several times, and the some smaller trials hint that it might
been shown to have both reduced activi- brain areas implicated are relatively con- ease sex addiction.
ty in the ventral striatum and altered do- sistent. Preliminary brain-imaging stud- These confluences suggest that be-
pamine levels. This lowered activity is ies have found some similar results in havioral and substance addictions might
consistent with the idea of a reward defi- food, sex and Internet addiction, al- have the same underlying causes — as
ciency: people with addictions have though the results are not always consis- does the fact that large population sur-
blunted responses to rewards, driving tent. Overall the findings are not as well veys show that the two types of addic-
them to compensate by seeking even aligned with findings from traditional tion tend to occur together. Such find-
more gratification. Sure enough, the substance-use disorder research. ings are often comforting to people who
gamblers in this study showed less activ- Investigation of the neurochemistry wonder why they cannot overcome a re-
ity in the ventral striatum. of these disorders is also preliminary, petitive behavior— framing it as a “real”
Such findings supported the formal but some researchers have found altered addiction can mitigate shame and speed
addition of “gambling disorder” to the neurotransmitter receptor function in recovery. For me and other clinicians,
DSM-5. The only other behavioral ad- people with food and Internet addic- the similarities between behavioral ad-
diction to be added was “Internet gam- tions. Studies using positron-emission dictions and drug addictions help us

C H A R L E S G U L L U N G G e t t y I m a g e s ; F O R I L L U S T R AT I O N P U R P O S E S O N LY
ing disorder,” but only in the appendix tomography have shown, for example, choose and be confident in our therapeu-
as a condition for further study. Debates lower levels of activity in dopamine-pro- tic strategies.
were fierce, however, about behavioral ducing regions of the ventral striatum at Yet just as with substance addicts,
addictions in general, and scientific com- rest in both obese people and people people who show signs of behavioral
monalities between behavioral and sub- with Internet addiction. PET studies of problems often have other mental dis-
stance addictions were the crux of the compulsive gamblers, however, have orders that may be complicating the
proponents’ argument. shown conflicting results. In food addic- diagnostic picture. To give them the best
tion, a growing body of evidence from
A Lot Like Drugs rodents shows changes in neurotrans-
Much scientific research on behav- mitters such as dopamine. So although THE AUTHOR
ioral addictions has focused on compar- there are interesting clues from neuro-
ing and contrasting them with substance chemistry, the jury is still out. CARL ERIK FISHER is assistant pro-
dependence. Aside from bolstering their Another clue that behavioral addic- fessor of clinical psychiatry at Colum-
status as disorders, doing so can offer tion may be quite similar to substance bia University. He works in the Division
clues as to whether similar treatments addiction is the fact that some pharma- of Law, Ethics, and Psychiatry and
might work, if such interventions should ceutical treatments appear to work for teaches in the university’s Masters
be covered by insurance companies, and both conditions. For example, naltrex- in Bioethics program.

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 treatment, sometimes it is important to fMRI studies of brain activation down to
look more closely at what underlies ABOUT HALF THE the intricate functions of neurotransmit-
their behaviors.
RISK OF DEVELOP- ters, the issue of causality is a big sticking
point for the interpretation of this re-
Why Me?
Patients with behavioral addictions
ING A COMPULSIVE search. The basics are clear: the brain has
circuits that respond to the feeling of plea-
often ask me whether they are fated to be INTERNET HABIT sure and the anticipation of reward. In
addicts—whether their battles for control some vulnerable individuals, these cir-
are an intrinsic part of their character. APPEARS TO BE cuits adapt in response to extreme repeti-
We have known for many years that ge- tions of pleasurable activities. Yet this
netic factors explain up to 50 percent of GENETIC, ABOUT process speaks only to how, not why;
the risk for developing addictions, includ- what ultimately drives the behavior re-
ing problem gambling. Just recently, ge- THE SAME AS FOR mains unexplained.
netic studies of other behavioral addic-
tions have found similar results. A 2014
ALCOHOLISM. An unexpected illustration of this
mystery comes from the treatment of
study of more than 800 Chinese twins Parkinson’s disease. The illness is treat-
and a 2015 study of more than 5,000 ed with drugs that act directly on dopa-
Dutch twins both found that, statistical- host of other environmental factors prob- mine receptors, and because the drugs
ly, genetic factors explained approxi- ably play a role in steering a person to- disrupt the reward system, some people
mately half the risk of compulsive Inter- ward an addiction — the reality is that with Parkinson’s develop compulsive be-
net use. The exact genetic contributions, only a small percentage of people who en- haviors. For some, eating, sex or gam-
however, are too complicated to make in- gage with potentially addictive sub- bling becomes addictive. Others abuse
terpretations based on an individual’s ge- stances or behaviors end up hooked, and the drugs themselves, taking more than
netic makeup. scientists know very little about why. Un- prescribed and doctor shopping for extra
Other factors can be set in motion be- fortunately, brain-imaging studies can- doses. But plenty of people do not devel-
fore a person’s birth, as illustrated by ro- not answer that question. If you could go op any compulsive behaviors, even
dent research of food addiction. In one back in time and put Dostoyevsky in a though they experience the same under-
2010 study, mouse mothers on a high-cal- scanner, he would almost definitely show lying influence—an introduction of pow-
orie, high-fat diet transmitted an exagger- altered activation in his brain’s reward erful dopamine-acting drugs.
ated preference for fat to their offspring, centers, but that would not necessarily Reducing the anatomy of addiction to
as compared with control mice on a nor- tell you that gambling was his fundamen- the “reward system,” therefore, is too
mal diet. This preference appeared to be tal problem. Maybe he was instead driv- simple. Yet discussions of the reward sys-
passed down through epigenetic altera- en by existential angst, or the trauma of tem dominate the scientific discourse
tions that effect the expression of the his Siberian exile, or even his document- about addictions, in part because it is
genes responsible for dopamine-manag- ed case of temporal lobe epilepsy. challenging to integrate all the other di-
ing proteins in the brain. Explaining the mechanism is not the mensions that matter—social, psycholog-
Life experience, early exposure and a same as revealing the cause. From the ical, even philosophical concerns.

F OOD
OFFICIAL STATUS: Food addiction is not officially recognized,
although some eating-disorder experts argue that certain
binge-eating cases may be caused by addictions.
PREVALENCE: Using the Yale Food Addiction Scale, a recently
created 25-item survey, and studying relatively small
populations, researchers have found food-addiction rates
of approximately 5 percent.
DID YOU KNOW?: Food addiction appears to show a significant
sex difference, with rates of more than 6 percent in women and
just 3 percent in men. It is also closely linked to weight status;
GE T T Y IMAGES

in obese populations, rates have been found to range from

7 percent to more than 37 percent.

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Societal Costs
When hypersexual disorder was pro- WHEN HYPER- goal— to help the people who are suffer-
ing from these plights.
posed as a new diagnosis, critics in the
psychiatric community expressed con-
SEXUAL DISORDER The Way Forward
cern about the social and legal ramifica-
tions. Would the disorder be misused in
WAS PROPOSED, A paradigm shift is happening in psy-
chiatry, and many researchers now say
court cases involving sex offenders? CRITICS WORRIED that no mental illness fits into a neat diag-
Would residential treatment centers pop nostic category. In fact, the National In-
up to unfairly profit from fad diagnoses, IT WOULD BE- stitute of Mental Health is completely re-
or would the disorder be used as an ex- vamping its research program to focus
cuse for sexual predation? COME AN EXCUSE less on lumping together symptoms and
Beyond the concrete risks, there is a
popular notion that medicalizing behav- FOR PREDATORY more on exploring the specific genetic and
neurobiological elements of mental disor-
iors such as compulsive sex and shop-
ping might cast people in an undeserved
BEHAVIOR. ders. In this way, behavioral addictions
are a case study in one of the trickiest
sick role. There is some value, the argu- problems in psychiatry: how to character-
ment goes, in preserving the opprobrium ize disorders that have no definitive brain
that society usually levels at philander- This issue of harm, however, is some- scan, no blood test and no gold standard.
ers and spendthrifts. Negative public times missed by researchers, which leads With time, and with more research into
perception might actually help keep to some odd proposals. For example, the underlying causes of such behaviors,
some people in check, whereas a new di- French researchers recently suggested we may be better able to help those who
agnosis might inappropriately absolve “tango addiction.” They claimed to have feel helpless and out of control.
them of responsibility. found that one third of recreational danc- One promising area of research sug-
If more behavioral addictions are ers had symptoms of craving and that 20 gests that any given type of behavioral
classified as mental disorders — as they percent had physical withdrawal symp- addiction— say, Internet gaming disor-
almost surely will be, with proponents toms related to the (admittedly captivat- der— might not be one neat disorder but
continuing to muster neuroscientific ing) Argentine dance. The problem, as rather an assortment of different under-
evidence — there will be societal conse- even those researchers admit, is they lying problems that happen to manifest
quences. Insurance coverage, disability could not find any good evidence of tan- the same way. This idea of subtypes was
determinations, or the public’s under- go causing real problems in people’s lives. first articulated in 2000 by Alex Blaszc-
standing of “mad versus bad”— the The gray area between clear disor- zynski, a psychology professor who
stakes are high. On the other hand, re- ders and unhealthy habits is rightfully studies gambling at the University of
stricting the recognition of behavioral controversial. Sometimes when people Sydney. He and his colleague Lia Now-
addictions could curtail identification of ask if they should call themselves ad- er, a professor of social work at Rutgers
and treatment for people who are truly in dicts, I have to reply that I don’t know. University, proposed three subgroups of
pain. As long as a behavioral addiction is We are in the midst of clarifying and gambling addiction: behaviorally condi-
causing significant harm in a person’s even redefining what addiction means, tioned gamblers who get in the habit of
life, I believe it needs to be recognized. with our eye constantly on the end chasing wins and losses, emotionally

ONL INE G A MING

OFFICIAL STATUS: Internet gaming disorder was included
in the DSM-5 as a condition deserving of further study.
PREVALENCE: Classifications of online gaming are extremely
variable. Depending on the criteria used and population studied,
estimates range from less than 0.1 percent to more than
50 percent of gamers.
DID YOU KNOW?: Treatment clinics for online gaming exist
in the U.S. and other countries. The South Korean government
A L E X S T O K E S A l a my

was so concerned about online gaming addiction in children

that it enacted a curfew, banning youths from playing games
online between midnight and 8 A.M.

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 IN T ERNE T
OFFICIAL STATUS: Not recognized in the DSM-5. The Internet can be
a gateway to potentially addictive material such as porn and games,
making “Internet addiction” a confusing and ill-defined diagnosis.
PREVALENCE: Broadly inclusive studies have found large numbers,
and findings depend on the culture (for example, 3.7 to 13 percent in
the U.S., 10.7 percent in South Korea, but only 1 to 5.2 percent in
Norway). More conservative estimates suggest that 1 percent of Inter-
net users have symptoms significant enough to warrant a diagnosis.
DID YOU KNOW?: The governments of South Korea and China are
particularly concerned about Internet addiction. A recent documenta-
ry, Web Junkie, estimates that there are more than 400 Chinese
Internet-addiction rehab “boot camps.”

vulnerable gamblers who are responding features of addicts and look at their un- sults by treating all issues simultaneously.
to anxiety or depression, and antisocial derlying genetics and neurochemistry. My own approach is to aim for this in-
gamblers who are dysfunctionally im- For example, in the substance-addiction clusive mind-set. We have to assume we do
pulsive across the board. field, researchers have recently shown not have all the answers. People cannot
Nower and Blaszczynski recently that variations in genes for specific neu- simply be reduced to their “hijacked” re-
studied data from more than 500 problem rotransmitter receptors can predict ad- ward systems, and there is no single, unas-
gamblers, drawn from an addiction study dicts’ responses to medications such as sailably correct diagnosis of or treatment
of more than 43,000 people, and found naltrexone. Considering how new this for addiction. Someday a new wave of re-
three distinct groups that matched their work is, the behavioral-addiction field search findings may help make finer dis-
model: one group with milder symptoms, may need time to catch up. tinctions more precisely. For now, though,
one with more co-occurring psychiatric In the meantime, a flexible and holis- we do the best we can by trying to learn as
disorders, and one with severe impulsivity tic approach to treatment is best. People much about our patients as possible.
across many areas of life. Also, in studies who consider themselves Internet addicts There are no easy answers. As the ex-
of online gaming, investigators have found or sex addicts, whose problems are com- amples of Dostoyevsky and Saint Augus-
distinct motivations similar to Blaszczyn- plicated by social anxiety or depression or tine show us, we humans have been en-
ski and Nower’s model: a preoccupation other issues, need more attention to the deavoring for ages to understand why we
with mastery (behavioral conditioning), a emotional component of their behavior, as get stuck in patterns of harmful behav-
compensation for real-life problems, or a opposed to those who fit the traditional iors and why for some the consequences
response to social anxiety (reactions to model of addiction and feel stuck in an au- from losing control are truly severe. As
emotional problems). Although the evi- tomatic cycle of stimulus and response. we begin to focus on this problem with
dence is still pending, some researchers be- Research has shown that when people real scientific rigor, the right question
lieve the subgroup model can also be ap- have both substance-use problems and might not be “Is this real?” but rather
plied to hypersexual behavior. other emotional issues, we get the best re- “How can we help?” M
The point of all these diagnostic re-
finements, of course, is to help the suffer-
ers of addiction. Unfortunately, studies
MORE TO EXPLORE
of treatments tailored to those subtypes
■ Do We All Have Behavioral Addictions? Allen Frances in Huffington Post; March 28, 2012.
have not yet shown any added benefit.
■ A Targeted Review of the Neurobiology and Genetics of Behavioural Addictions: An Emerging
Indeed, researchers in the field of sub-
Area of Research. Robert F. Leeman and Marc N. Potenza in Canadian Journal of Psychiatry/
stance-use disorder have argued over Revue Canadienne de Psychiatrie, Vol. 58, No. 5, pages 260–273; May 2013.
possible “typologies” of drug and alco- ■ Controversies about Hypersexual Disorder and the DSM-5. Rory C. Reid and Martin P. Kafka
BILL HINTON Get t y Images

hol addiction for decades, and there is in Current Sexual Health Reports, Vol. 6, No. 4, pages 259–264; December 2014.
still no clear consensus emerging. Per- ■ Disordered Gambling: The Evolving Concept of Behavioral Addiction. Luke Clark in Annals
of the New York Academy of Sciences, Vol. 1327, pages 46–61; 2014.
haps the current models, which are based
■ Are We Overpathologizing Everyday Life? A Tenable Blueprint for Behavioral Addiction
only on outwardly observable features of
Research. Joel Billieux, Adriano Schimmenti, Yasser Khazaal, Pierre Maurage and Alexandre
addictions, are incomplete. Diagnosis Heeren in Journal of Behavioral Addictions, Vol. 4, No. 3, pages 119–123. Published online
may have to go beyond the psychological May 27, 2015.

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