Behavioural health disorders rather than behavioural addictions

Starcevic’s (2016) article is a timely caution against using the term ‘behavioural addiction’ to include all repetitive behaviours involving poor impulse control, particularly in the light of a burgeoning number of new potential disorders for inclusion.

He identifies a wide range of behaviours and disorders as potential ‘behavioural addictions’ on a continuum from compulsivity to impulsivity, including gambling, spending, buying, sex, Internet use, exercise, food, work, social networking, dancing, fortune-telling and so on ‘ad infinitum’, and obsessive-compulsive disorder (OCD), kleptomania, pyromania, body dysmorphic disorder, repetitive self-injurious behaviours, personality disorders, autistic disorders, chronic tics, stereotypic movement disorders, trichotillomania, skin-pricking disorder and so on.

Diagnoses are useful simplifications of reality when they are clinically informative. Utility is likely to be diluted by including every disorder which involves a degree of compulsivity or impulsivity under one umbrella diagnostic category such as ‘behavioural addiction’.

‘Behavioural addiction’ is more likely to be useful clinically when reserved for a set of compulsive disorders which have strong aetiological, treatment and prognostic similarities to the substance addictions. Repetitive problematic behaviours primarily motivated by hedonic desire to consume or interact with something compelling may be a useful starting point for delineation. This set of disorders could then potentially cover a range of modern products that can induce a compelling pleasure in certain vulnerable people, and which over time with repetitive, heavy, use lead to a similar de-humanized state of compulsive consumption and craving for the product as in substance addiction.

It makes sense to include OCD alongside alcoholism, pathological gambling and sex addiction in a broad grouping of disorders from the point of view of similarities in the unconsciously learned nature of the compulsive habit (Lewis, 2015) and the known neural pathways associated with this learning, such as the involvement of dopaminergic pathways and neuroplastic changes in the striatum (Everitt et al., 2008). However, phenomenologically, this is mixing compulsive disorders primarily motivated by the avoidance of anxiety (OCD) with those primarily motivated by hedonic desire (alcoholism and others). There is a world of difference between fear and hunger, between anxiety management and hedonic control. A similar argument could be used for other disorders which include compulsivity or impulsivity in their phenomenology but do not involve the consumption or interaction with a ‘moreish’ object.

Starcevic outlines three main problems with validating new candidate behavioural addictions. First, he suggests the specific withdrawal patterns of substance addictions are entirely different from a general negative state of deprivation experienced by people afflicted with, for instance, a buying or pornography compulsion. However, anecdotal reports from people with a combination of a substance and behavioural addiction (narrowly defined as above) suggest the experience of hunger (craving) for the addictive object is very similar for both. It is noteworthy that the status of a specific withdrawal syndrome as a sign of an established addiction has recently been down-graded in Diagnostic and Statistical Manual of Mental Disorders–Fifth Edition (DSM-5; American Psychiatric Association [APA], 2013).

Second, Starcevic suggests that because many of the new behavioural addictions extend on a continuum into normality, this differentiates them from substance addictions. This is a false distinction. Substances have been used by Homo sapiens for over 100,000 years and almost undoubtedly have contributed to the species’ success. Drug use is just as much a normal human activity as is sexual activity, gambling and engaging in the Internet (in the modern world). All of these activities are intensely rewarding for some people and can lead to the development of compulsive habits (addictions). Changes in the nature of food and eating over the past half century, away from nutritious whole food and ‘eating to live’ to a range of hyper-palatable recreational food products and the marketing of ‘living to eat’, is emphasized in food addiction (Popkin, 2012).

Finally, Starcevic argues that abstinence is unreasonable when considering new potential behavioural addictions (which extend into normality) such as food and sex. Addiction interruption through abstinence is an effective strategy in drug addiction including alcohol, and is easily applied to, for instance, certain types of food products or certain types of sexual activity, rather than the absurdity of advocating abstinence from all food or all sexual activity.

The most important aspect of Starcevic’s paper may be the highlighting of a range of disorders involving impulsivity/compulsivity, which involve the development of deeply embedded habits that become increasingly inaccessible to frontal lobe influence over time. These externalizing disorders have attracted less attention in psychiatry to date than the traditional internalizing disorders, such as mood, anxiety and psychotic disorders.

Rather than try and herd all externalizing disorders into one diagnostic category such as behavioural addiction, as Starcevic has rightly cautioned against, it might nevertheless be useful and timely to name a new psychiatric domain, such as behavioural health disorders, to sit alongside the mental health disorders within psychiatry. The substance and behavioural addictions would be one of a number of diagnostic categories in this new domain.

See Viewpoint by Starcevic 50(8): 721–725.