Most of us can easily grasp the concept of substance addictions. If we have not run headfirst into our own challenges with cigarettes, alcohol, prescription medications, illicit drugs, and the like, then we probably know someone who has. At the very least, we’ve seen alcoholism and drug addiction depicted on television, in movies, and elsewhere. Behavioral addictions, also referred to as process addictions, are usually more difficult to fathom. Nevertheless, people can and do become addicted to highly pleasurable, self-soothing, dissociative behaviors just as often and just as easily as they become addicted to highly pleasurable, self-soothing, dissociative substances – and they do this with similarly problematic results.
Sadly, the American Psychiatric Association has been slow to recognize behavioral addictions, excluding them, except for gambling addiction, from the latest edition of its Diagnostic and Statistical Manual of Mental Disorders. (The APA lists internet gaming addiction as a condition worthy of further study, but it’s not yet an official diagnosis.) Most other psychotherapeutic professional organizations are at least a little (and usually a lot) more forward-thinking. For example, the American Society of Addiction Medicine addresses behavioral addictions clearly and directly in their most recent statement defining addiction:
Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors [emphasis added].
The more we know about addictions, the more sense this makes. For starters, addictions are not about feeling good, they’re about feeling less. Addicts turn to addictive substances and behaviors not because they want to have a good time, but to self-medicate and self-regulate their emotions. Their goal is to escape from life and to not feel stress, anxiety, loneliness, depression, and other forms of emotional discomfort.
And this works, too. Addictive substances and behaviors trigger a neurochemical pleasure response – primarily the release of dopamine (pleasure), along with adrenaline (excitement), oxytocin (love and connection), serotonin (emotional well-being), and a variety of endorphins (euphoria) – resulting in feelings of pleasure, excitement, control, and, most importantly, distraction and emotional escape. Over time, some people learn that the easiest way to avoid uncomfortable feelings is to ingest an addictive substance or engage in a highly pleasurable (and therefore potentially addictive) behavior. Eventually, these individuals begin to use substances and behaviors not to feel better, but to feel less (to control what they feel). That is a sure sign of addiction.
Really, the only significant difference between substance and behavioral addictions is that substance addicts ingest alcohol or drugs to create an emotionally escapist neurochemical reaction, while behavioral addicts rely on an intensely pleasurable activity. Interestingly, even fantasies of a pleasurable substance or activity are enough to trigger the desired neurochemical response. This is referred to as an “anticipatory high.”
To further understand anticipatory highs, as well as the link between substance and behavioral addictions, consider a cocaine addict on payday. After receiving his check, he runs to the bank to exchange it for cash, perhaps skipping out of work early to do so. Then he dashes off to his dealer’s house to spend money that he ought to set aside for food, rent, childcare, and the like. As he approaches his dealer’s house, his heart races, he’s sweating, and he is so obsessed and preoccupied with the idea of using that he doesn’t even notice the police car parked a block away. He is so completely focused on cocaine that the day-to-day world, with its problems and obligations, has temporarily receded.