Behavioral Addiction

Abstract

Behavioral addiction is reflected in an individual pathologically pursuing reward and/or relief by a behavior that leads to dysfunction in characteristic biological, psychological, social, and spiritual manifestations. This behavior is generally a repetitive maladaptive behavior that has been postulated as being similar to substance use disorders in how it affects many different levels of function and has similar biological correlates. Behavioral addiction is driven by repetitive urges for this involuntary inclination, a diminished ability to control the behavior, the building up of tolerance, and a greater intensity to obtain the desired gratification. There are adverse psychological consequences, such as depression or anxiety, when the behavior is avoided. The most recent version of the American Psychological Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-V) lists only one behavioral addiction (gambling disorder), three behavioral compulsions (hoarding disorder, trichotillomania, and excoriation), and one impulse-control disorder (kleptomania). Based on the conceptual and existing criteria on the DSM-V, other behavioral addictions have been proposed, including compulsive buying, sexual addiction, eating, video game playing, and Internet addiction. This chapter reviews the most common behavioral addictions, their epidemiology, genetics, phenomenology, comorbidity, psychosocial, and pharmacological treatment.

Review Questions

• 1. A 19-year-old college student has been acting “odd” for several months according to her parents. She takes too many “diet pills” at home. Her mother wants to know “if something is wrong with her brain.” Which structure of the brain has been linked to positive reinforcement in behavioral addictions?

  • A. Nucleus accumbens

  • B. Striatum

  • C. Globus pallidus

  • D. Basal nucleus of Meynert

  • E. Hypothalamus

  Correct answer: A. Nucleus accumbens

  Explanation: The nucleus accumbens is involved in behaviors elicited by incentive stimuli. These behaviors include natural rewards like feeding, drinking, sexual behavior, and exploratory locomotion. A rewarding event follows an essential rule of positive reinforcement. Moreover, dopaminergic, GABA, NMDA, and other gene and neurotransmitter-related gene polymorphisms affect both hedonic and anhedonia behavioral outcomes [30, 31].

• 2. You are seeing a 55-year-old married female presenting for physical examination. She says that she has tried to decrease her buying of lottery tickets during the past two months. “I think it is better than being a slot machine addict like my husband.” From what we know about gambling, which of the following statements is most likely true in this case?

  • A. She has higher rates of use or dependence on illicit drugs.

  • B. She is at a higher risk than her husband of dying from suicide.

  • C. She is twice as likely as her husband to meet the criteria for drug addiction in her lifetime.

  • D. Her participation in gambling can escalate to addiction more quickly.

  Correct answer: D. Her participation in gambling, as a female, can escalate to addiction more quickly

  Explanation: Although more men have substance use problems, women tend to use or suffer from a behavior addiction at lower levels than men do, but they advance to a disorder more quickly. This phenomenon is called telescoping. Evidence exists of “telescoping” events (starting with smaller intensity or frequency with more rapid escalation) in some cases of gambling disorder. Women had a higher mean age at gambling initiation compared with that of men. According to the National Institute on Alcohol Abuse and Alcoholism, men are twice as likely as women to meet the criteria for drug addiction in their lifetime [8].

• 3. A 61-year-old man with a 19-year history of gambling disorder and worsening anxiety disorder is presenting to his monthly appointments; his doctor routinely asks him about his gambling behaviors. His reply is always the same: “I’m not giving up my gambling; my brother does it every day of his life and has no issues with it.” Which one of the following stages of change best describes this individual’s motivational level?

  • A. Action

  • B. Contemplation

  • C. Precontemplation

  • D. Maintenance

  • E. Preparation

  Correct answer: C. Precontemplation

  Explanation: According to Prochaska and DiClemente’s Stages of Change, precontemplation is characterized by either denial of the problem or an unwillingness to change.

• 4. A 21-year-old girl is concerned because her mother is spending too much time out “playing the horses.” She also wants to know your thoughts about medication treatments. Which one of the following pharmacotherapies should be considered a first-line treatment for pathologic gambling?

  • A. Naltrexone

  • B. Lithium

  • C. Topiramate

  • D. Bupropion

  • E. Amphetamine

  Correct answer: A. Naltrexone

  Explanation: Naltrexone should be considered a first-line treatment for pathologic gambling, but there is currently no FDA-approved medication [2]. No significant difference has been shown between bupropion or mood stabilizers such as lithium and carbamazepine and placebo for pathological gambling.

• 5. A 16-year-old male presented to the emergency department complaining of agitation, aggressiveness, and disorganized behavior, which developed within a day after discontinuation of playing his favorite Internet video game. In American youth 8–18 years of age, what is the prevalence of video game addiction?

  • A. 0.3%

  • B. 8.5%

  • C. 18%

  • D. 31%

  Correct answer: B. 8.5%

  Explanation: Nationally representative American samples show an Internet gaming disorder prevalence of 8.5% among those 8–18 years of age [22].

• 6. Peter is a 57-year-old male who has been treated for depression successfully with fluoxetine for ten years, struggles with daily worries that affect his sleep and functioning, and goes to Alcoholics Anonymous every week to maintain recovery from alcohol use disorder. His partner Matthew has threatened to end their relationship if he does not stop going to the casino, spending more time at the casino than he plans, and “bailing on” important family functions to gamble instead. Which of the following disorders has the highest comorbidity with gambling disorder?

  • A. Mood disorders

  • B. Anxiety disorders

  • C. Substance use disorders

  • D. Schizophrenia

  Correct answer: C. Substance use disorders

  Explanation: Gambling disorder is highly comorbid with other mental health disorders, particularly substance use disorders, and shows a heritability rate of 50–60% [9].