Behavioral Addictions: Helping Patients to Engage in Treatment
While traditionally the term “addiction” was confined to substance use disorders, extreme behaviors are now being recognized as “behavioral addictions” and attracting attention for their relevant social impact. This group includes sex, love, gambling, food, work, Internet use, and compulsive buying. Unlike with other behavioral addictions where research remains in its infancy, research in pathological gambling and substance use disorders suggests a strong neurobiological link based on biochemical, functional, neuroimaging, and genetic studies. A research work group of the DSM reclassified gambling disorder, making it the first (and only) behavioral addiction in DSM. “Internet gaming disorder” is a “condition for further study” and listed in Section 3 of DSM-5.
Like substance use disorders, the addiction model can be helpful in understanding behaviors that can hijack the pleasure-reward circuitry in the brain, resulting in compulsive engagement, loss of control, cravings, withdrawal, tolerance, and negative consequences (financial, interpersonal, legal, and so on) for the individual. Additionally, many of our patients may present with subclinical behavior that can be both personally and professionally damaging.
Behavioral addictions can have calamitous effects on both the individual and families. Patients who suffer from behavioral addictions can experience myriad emotions including shame, guilt, fear, irritability, sadness, and anxiety. To complicate matters, when patients present for treatment for a behavioral addiction, the only outcome for which they are often initially hoping is a decrease in negative consequences associated with the behavior, and not extinction or modification of the behavior itself.
It can be difficult for clinicians to discern and assess when excessive behavioral patterns require psychiatric intervention or whether presenting problems fall within the realm of normative behavior. Moreover, behavioral addictions can present in a wide range of subtle and complex patterns, and individuals are likely to fluctuate between the line of pathology and habit. Tracking and monitoring symptoms over time is critical for establishing patterns of use and documenting ongoing consequences.
Unfortunately, inquiring about many of these behaviors is not part of the standard psychiatric assessment, and most individuals do not normally seek treatment for behavioral addictions. The importance of asking the right questions and creating a space of nonjudgment is crucial. Without an investment in building the therapeutic alliance, clinicians can fail to gather all the pieces necessary to understand the full clinical picture of their patients.
It can help to build the therapeutic alliance by exploring the concept of ambivalence with our patients. After eliciting the behavior, clinicians should explicitly tell the patient that ambivalence is a normal part of the motivation and change process.
While medications can help to alleviate some symptoms associated with behavioral addictions and other co-occurring disorders, psychotherapy (both individual and group) often provides the best outcome. Psychiatrists are therefore in the position to provide psychoeducation to patients about the benefits of establishing a relationship with their therapist to explore more fully the problem and the function of the behavior. Explaining to patients that the behavior does not define them but is a symptom of an unmet need or underlying issue can be helpful in decreasing shame. Maintaining an empathic but hopeful stance that they can live a happier and more meaningful life if they engage in treatment can increase the likelihood that they will gather the intrinsic resolve to address the problem through treatment, which may include medications, therapy, or 12-step facilitations. The importance of maintaining an open, curious, flexible approach is paramount to building the therapeutic alliance and leading to improved treatment outcomes. ■
