Bill’s wife, Pat, is concerned about him. She complains that Bill “smokes like a chimney.”
Josh’s mom continually asks him to get off the computer. She is certain that he spends too much time playing online games.
It really disturbs her that he has no other interests and seems to spend every waking hour playing online. Gina is angry with herself because she can’t pay her bills. And she admits that she can’t pay her bills because she has gambled away all of her income and savings.
Andrea’s sister, Marie, is worried about her. Whenever Marie visits Andrea she notices that there are empty vodka bottles in the trash.
What do Bill, Gina, Andrea, and Josh have in common? Most would recognize that all four are actively engaged in addictive behaviors, and a growing number of addiction researchers would agree. Still, there has long been disagreement over how to answer the question “What is an addiction?” In the past, many might have argued that Gina and Josh did not have an addiction because their gambling and online gaming didn’t involve the ingestion of a chemical substance. However, today, the growing scientific literature suggests that addictions are not exclusive to substances, but that we can become addicted to certain behaviors as well.
Evidence from biology and psychology suggests that addictions can be both chemical and behavioral. Functional Magnetic Resonance Imaging techniques (fMRI) can show us what is going on in people’s brains. These machines take pictures of people’s brains, and when part of a person’s brain is active, that portion stands out on the fMRI’s picture. fMRI studies show us that many types of addiction stimulate the same pathway, the brain’s reward system. When you experience something that you like or enjoy, a chemical in your brain (a neurotransmitter) called dopamine sends a message from one part of your brain (the ventral tegmental area) to another part of the brain (the nucleus accumbens), resulting in a feeling of pleasure. In fMRI studies, addicted brains “light up” similarly when looking at whatever they are addicted to. So, if we put Josh in an fMRI machine and show him pictures of World of Warcraft, and then put Bill in the machine and show him pictures of cigarettes, the pictures of their brains would look very alike.
Interestingly, research suggests that people at high risk for substance use disorders are also more likely to develop behavioral addictions. In 2000, a study conducted by Wendy Slutske and her colleagues at the University of Missouri found that men likely to develop problems with alcohol were also likely to develop problems with compulsive gambling. Another interesting research finding is that people who struggle with addictive behaviors often transition between addictive behaviors. Some people would label this behavior “symptom substitution.” Bill, for example, might start compulsively playing Internet games while he tries to quit smoking.
An exciting concept that has emerged in the fields of behavioral and chemical addictions is the “addiction syndrome,” a term coined by Harvard psychologist, Howard Shaffer. He views addiction as a group of related symptoms that develop together over time. But what exactly is a syndrome? AIDS is a good example. The same group of symptoms marks AIDS: HIV infection, a damaged immune system, and death by rare infections. Even though the infection that ultimately kills someone with AIDS differs from patient to patient, the underlying cause of death is the same. Addiction, Shaffer argues, is similar. Just like AIDS, it can reveal itself in different, but similar ways. A person with an addiction may have problems with gambling, cocaine, or alcohol, but the root causes of the addiction will be similar. Shaffer calls these the distal and proximal causes of addiction. Distal causes of addiction can be thought of as risks of developing an addiction, while proximal causes can be thought of as more immediate causes. To help think about the addiction WHAT EXACTLY ARE “ADDICTIVE BEHAVIORS”? By Bruce S. Liese and Carina Fowler syndrome, let’s return to our friend Andrea from above. Andrea had a genetic risk for developing alcohol problems. At 22, she began drinking to help deal with her father’s death. For Andrea, her genetic risk is a “distal” cause because it made her vulnerable to alcohol problems. Her father’s passing was a “proximal” cause because it was the event that actually triggered her to start drinking.
While Shaffer thinks about addiction as a syndrome, experts also look at addiction in terms of the behaviors that make it up. English psychologist Mark Griffiths says that an addictive behavior has six components—salience, mood modification, tolerance, withdrawal, conflict, and relapse. To understand Griffiths’ model, let’s look more in depth at Gina, our gambler. Gina goes to the casino four or five nights per week. For Gina, gambling is the only activity she engages in outside of work, and it dominates her thinking. Even at work, Gina finds herself constantly working out strategies for how to win more money playing cards and working the slot machines. In other words, gambling is highly salient, meaning that the activity is the most important thing in her life. Gina says that going to the casino makes her feel excited, but also oddly calm—as if she knows that the casino is where she is supposed to be. Gambling modifies her mood. Gina says she used to gamble only once a month or so, but now she must go more regularly in order to feel the same “rush” from winning. Over time, she has built up a tolerance to gambling. When she cannot go to the casino during her occasional business trips, Gina becomes extremely irritable, showing signs of withdrawal. Gina’s gambling is also producing conflict in her life. Her behavior deeply concerns her husband, who wants her to consult a psychologist or a physician, but when he has mentioned it before, they have had a big fight.
So, then, what is an addiction? Well, it depends on whom you ask. While some physicians and researchers hold fast to the idea that addiction can only be chemical, a growing body of research in neuroscience and psychology shows us that addictions can be behavioral as well as chemical due to shared pathways in the brain, underlying causes, and behaviors.
Bruce Liese, PhD, ABPP is a Professor of Family Medicine and Psychiatry and Courtesy Professor of Psychology at the University of Kansas. Dr. Liese is a scholar, teacher, clinician, and clinical supervisor who has lectured and presented workshops nationally and internationally. He has more than 50 publications and has co- authored two texts on addictive behaviors with Dr. Aaron T. Beck. Dr. Liese was also Editor of The Addictions Newsletter for ten years, an official publication of APA’s Division 50 (Addictions). For this work he received the Division 50 President’s Citation.
Carina Fowler, BA, is a 2013 graduate of Washington University in St. Louis. She was the recipient of Washington University’s 2013 Arnold J. Lien Prize for Outstanding Graduate in Political Science. She plans to apply to graduate programs this fall.