Physical dependence is not the same as addiction but the terms are often conflated in treatment and recovery circles. Physical dependence is a process that occurs when the brain adapts to the effects of a drug and develops the phenomenon of tolerance. In other words, an individual will require more and more of the particular drug to achieve the initial positive effect. The user will begin to rely on the continued use of the drug to prevent painful and uncomfortable withdrawal symptoms.
Drug dependence, therefore, is typically defined as what causes tolerance and withdrawal (physical effects), while addiction is generally characterised by having a primarily mental component. Essentially, dependence is a physical thing whereas addiction is largely neurological. They are independent of each other but are often conflated in treatment and recovery circles.
This distinction becomes more blurred in the controversy about what determines ‘behavioural addiction’. Gambling and gaming are two non-substance behaviours that are classified as potential disorders (pathological gambling disorder in ICD10 and gambling disorder in DSM-5 and ICD11 and gaming disorder in ICD11). Note the word ‘disorder’, as addiction is not actually used in the descriptions. However, some argue for the inclusion of other non substance behaviours such as problematical sexual behaviour, internet, mobile phones, physical exercise, shopping and even plastic surgery.
With sex, multiple terms have been used interchangeably for many years: sex addiction, sexual compulsivity, hypersexuality, compulsive sexual behavior, however, the term ‘sex addiction’ appears to be losing credibility. The World Health Organisation (WHO) recognises Compulsive Sexual Behaviour Disorder (CSBD) and is characterised by “a persistent pattern of failure to control intense, repetitive sexual impulses or urges resulting in repetitive sexual behaviour,” according to diagnostic description in the ICD-11, which can include both the act of sex and sexual fantasies. It has been estimated to affect between 3 per cent and 6 per cent of the population. But it said the scientific debate was still ongoing as to “whether or not the compulsive sexual behaviour disorder constitutes the manifestation of a behavioural addiction”. The American Psychiatric Association (APA) rejected the proposed addition of “hypersexual disorder” to the fifth iteration of the DSM (Diagnostic and Statistical Manual of Mental Disorders) in 2013. Controversy contiunes to surround the sex addiction disorder, mainly due to the number of co-occurring mental health issues, such as anxiety and depression, which might suggest that the behaviours are an extension or manifestation of another illness.
Understanding diagnosis
So-called behavioural addictions tend to involve an increasing sense of arousal or tension immediately before the activity with an accompanying association with pleasure, gratification, or a discharge of tension at the point of engaging in the activity. This differs to OCD whereby acts in themselves are not pleasurable. Psychiatrists define these behaviours as impulse-control disorders (ICDs).
So, how do we define problem behaviour as dependence or addiction? The dependence syndrome has been used as a guide in treatment circles and can have its uses but might also be limiting in its effectiveness as a diagnostic tool.
The dependence syndrome is a clinical syndrome and has been used traditionally to classify the features of substance dependence and to determine what might be seen as problem behaviour (specifically around alcohol and drugs). Initially described by Edwards and Gross as a provisional description of alcohol dependence, the dependence syndrome has also been used to describe drug dependence and has a number of features:
Primacy of drug-seeking behaviour/Increased salience of the need for substances over competing needs and responsibilities
This is when the substance becomes the single most important thing in an individual’s life. This can involve a spectrum of severity and the effects can be quite subtle from one end of the spectrum the neglect of hobbies and relationships to the neglect of jobs and family commitments to a diminishing moral sense, leading to criminal behaviour.
Similar behaviour could be observed with individuals with respect to gambling and other so-called addictions such as food, shopping and plastic surgery. The aforementioned activities can witness preoccupation, increased ritualisation and obsessional thinking. But with mobile phones and the internet people will switch their attention to other activities more quickly.
Narrowing of the drinking/drug taking repertoire
This typically occurs when an individual increasingly relies on one drug or drink in preference to all others.
In behavioural terms this could be when an individual might concentrate on one type of gambling or one type of sexual activity or one type of food.
An acquired tolerance to alcohol/drugs
This is simply where a user requires more of the same drug in order to achieve the same effects.
In problem behaviour this is when an individual might need to engage in more of the activity to achieve the same level of satisfaction. It is when someone needs more funds for gambling in order to achieve the same effect, and it could be when someone with a food addiction requires more and more to achieve satisfaction or when someone needs greater stimulation in sex and porn to achieve the same result.
Loss of control
An inability to restrict further usage once the drug is taken or alcohol consumed.
With behavioural problems, particularly gambling, this is when losses spiral out of control, there is an abandonment of preset boundaries and stop controls. It could also be when shopping suddenly escalates with reckless abandon and the spending becomes out of control or even when someone misses out sleep or food due to preoccupation with online activities.
Signs of withdrawal symptoms when abstinence is attempted
A withdrawal syndrome may develop. Withdrawal symptoms from opiates may include anxiety, sweating, vomiting, and diarrhea. Alcohol withdrawal symptoms can include irritability, fatigue, shaking, sweating, and nausea.
People with food, sex and gambling problems have reported similar withdrawals when they try to enter a period of abstinence. Being addicted to something means that not having it causes withdrawal symptoms, or what might be a “come down”. Due to this being unpleasant, it’s easier to carry on having or doing what you crave, and so the cycle continues.
Relief or avoidance of withdrawal symptoms by further drinking/drug taking
The individual learns to anticipate and seeks to avoid the effects of withdrawal. This can involve a user having the drug available upon waking.
Individuals with problem behaviours will also report similar actions such as someone who is fixated on visiting sex workers gradually switching to porn and vice versa. It might also see a user ensuring mobile telephony is available when other equipment is unavailable (in the event of internet preoccupation).
Continued drinking/drug use despite negative consequences
A user will continue to use in spite of marital breakdown, relationship break-up, job loss, increasing debts and so on. Addictions have one of the highest remission rates. Most people do stop when negative consequences start to occur. The ones with a real problem will continue to use in spite of escalating negative events.
With behavioural issues users may incur increasing levels of financial debt, see more reckless activities in their lives and suffer further relationship breakdowns yet the behaviour continues.
Subjective awareness of compulsion to drink?
An individual will begin to realise that they do indeed have a problem.
With behavioural problems users may begin to realise that their sexual behaviour is problematical, or gambling is no longer fun, or association with food is obsessional or that spending has indeed become a problem.
Rapid reinstatement after abstinence
In an instance of relapse the user returns to the dependent pattern in a much shorter period than the time taken to initially arrive at the problem.
This may be similar to the individual who is caught up with behaviours returning to the same level of intensity of behaviour after a period of abstinence.
So, how do we define problem behaviour versus what might be seen as lifestyle choices when assessing behaviours that might be considered addictive? It may be easier to identify with the list of issues from the dependence syndrome when thinking of alcohol and drugs, since it may be more obvious to spot these signs. However, with non substance addictions there is perhaps less clarity about the negative effects. Take shopping, for example, there might be an accumulation of financial debts but, otherwise, the behaviour could be controlled and there might not be the same degree of loss of control that can be more evident in drink and drug taking. There might be shopping binges but less of the negative consequences in other parts of someone’s life. With porn, there might be some increasing preoccupation at times but less of the escalation associated with loss of control. That said, some porn addiction could potentially lead to more intense preoccupation and increasing obsessions, which in turn could lead to the need for greater degrees of stimulation leading potentially to illegal activity.
Seeking help with addictions
Some individuals lead alternative lifestyles such as swinging and having open relationships and it should not be the role of a therapist to pathologise such behaviours. The basic rule of thumb applies that behaviours are not a problem if there is no adverse consequences in your life. Where a therapist can help is when increasingly obsessional behaviour is undertaken in order to cope with difficult feelings, low mood, sadness or when such behaviours are causing negative consequences in other parts of your life. Being able to manage stress and difficult feelings is a barometer of good emotional regulation. With addiction, difficult feelings are not processed in a healthy manner, emotional intimacy is often avoided in relationships and self soothing behaviours are sought in an attempt to heal emotional pain. To be ‘affect dysregulated’ is to essentially lack a healthy emotional response to stress.
Therapy can help to uncover the source of the difficult feelings. Perhaps there was early abandonment, abuse, trauma, or emotional wounding, which could be restricting your ability to trust and to stay present in your relationships. Addictions, after all, are invariably a pointer that something in the psyche is distorted or out of place or that something in your unconscious is hidden. Uncovering hidden or denied roles can help to identify what needs healing so that you may manifest positive qualities that can lead to a path of transformation and a better capacity to cope with difficult feelings.
Noel Bell is a UKCP accredited psychotherapist based in London. Call him on 07852407140 to arrange an appointment.
