| Symptom | DSM Alcohol | DSM Gambling | ICD Alcohol | ICD Gambling | |
|---|---|---|---|---|---|
| Social/ occupational problems | ✓ | ✓ | ✓ | ✓ | |
| Impaired control | ✓ | ✓ | ✓ | ✓ | |
| Tolerance | ✓ | ✓ | ✓ | ✓ | |
| Physical/ psychological problems | ✓ | ✓ | ✓ | ||
| Cravings/ urges | ✓ | ✓ | ✓ | ||
| Prioritising activity over others | ✓ | ✓ | ✓ | ||
| Withdrawal | ✓ | ✓ | ✓ | ||
| Self-medication (when distressed) | ✓ | ✓ | |||
| Chasing losses | ✓ | ✓ | |||
| Conceals (extent of) behaviour | ✓ | ✓ | |||
| Used more than planned | ✓ | ✓ | |||
| Substantial time obtaining & using | ✓ | ||||
| Hazardous use | ✓ | ||||
| Neglect of major roles | ✓ | ||||
| Preoccupation | ✓ | ||||
| Financial problems | ✓ | ||||
Tanning, Instagram, flying: Where do we draw the line?
An increasing number of new (and often bizarre) forms of addiction have been proposed in recent years, including addictions to video gaming, dancing, tanning, exercise, extreme sports (based largely on work by myself and colleagues), shopping, Instagram, Tinder, flying (yes, travelling in a plane), fortune telling, and even yourself.
Naturally, this has led to fears that we may be “over pathologizing” everyday behaviours and that the term addiction may lose meaning if it continues to be applied so liberally (Billieux et al., 2015). However, what the defining features of an addiction actually are is a surprisingly contentious subject. Both addiction experts and those with lived experience of addiction disagree within and between their groups about what it means to be “addicted” (Walters & Gilbert, 2000).
In this two-part post, I summarise some of the key ways in which addiction has been defined. I try to provide some clarity on what it means to be addicted and how it differs from simply doing a lot of something.
Diagnostic manuals
An obvious starting point is the manuals used by clinicians to diagnose psychological disorders, including addictions. These include the World Health Organisation’s International Classification of Diseases (ICD-11) and the American Psychiatric Association’s Diagnostic Statistical Manual (DSM-5). The DSM and ICD outline key criteria or symptoms that, when present simultaneously in sufficient numbers, characterise an addictive disorder. To illustrate this approach, I have included the core signs and symptoms for two addictive disorders according to these manuals in the below table. Alcohol dependence and gambling disorder were selected as the archetypal substance and behavioural (i.e., non-drug) addictions, respectively, though there are some minor differences in the criteria presented for other addictive disorders.
Looking at the table above, it’s clear that some criteria overlap addictive disorders and diagnostic manuals. Two stand out:
Continuation despite social and/or occupational problems associated with the activity (e.g., relationship breakdown/ absenteeism)
Impaired control, or repeated but unsuccessful attempts to control or quit the behaviour (i.e., difficulty stopping)
A strong case could be made that these two are the defining symptoms of addiction, and I doubt too many would disagree with this.
Tolerance is also seen across both disorders and diagnostic manuals, but I think it’s less central. Its absence would not preclude diagnosis—an individual who gambles with less money or less frequently now, but experiences equally or greater harms than when they first started gambling should not be excluded from diagnosis on this basis. Perhaps for this reason, tolerance is not an essential criteria for the diagnosis of gambling disorder in the ICD-11 and is listed among the “additional clinical features”.
Expand for more on diagnostic manuals
Specific diagnostic terms used
Alcohol: The DSM-5 uses the label “Alcohol use disorder” and the ICD-11 uses “Alcohol dependence”
Gambling: Both the DSM-5 and the ICD-11 use the term “Gambling disorder”.
Presentation & number of symptoms required for diagnosis
The ICD-11 doesn’t list symptoms in the same way as the DSM-5, but rather provides a descriptive definition of disorders, some “essential features”. For Alcohol Dependence, essential features include:
Recurrent or episodic use
Impaired control over use
Increasing prioritisation of use
Continued use despite harms
Physiological indicators of adaptions to use, including tolerance and/or withdrawal.
For Gambling Disorder, the ICD’s essential features include:
Persistent gambling behaviour
Impaired control over the behaviour
Increasing prioritisation of gambling
Continued gambling despite harms, including significant distress or impairment in important areas of function (family, social, educational etc.)
The DSM-5 requires a certain number of symptoms to be present to diagnose an individual with alcohol use disorder for gambling disorder and, depending on the number of symptoms, somebody can be classified as having a “mild”, “moderate”, or “severe” disorder (see the table below for more details).
| DSM-5 Alcohol use disorder | ICD-11 Alcohol dependence | DSM-5 Gambling disorder | ICD-11 Gambling disorder | |
| No. of criteria required for diagnosis: | Mild: 2-3 criteria. Moderate: 4-5. Severe: ≥6. | Essential criteria must be displayed for at least 12-months (or daily or almost daily for at least 3 months) | Mild: 4-5 criteria. Moderate: 6-7. Severe: 8-9 | Essential criteria must be displayed for at least 12-months (shorter duration possible if symptoms are severe) |
If you really want to know more about these manuals and how I coded each symptom, I’ve taken the liberty (thank me later!) of including the exact wording used for all the addiction symptoms they include for each diagnosis. Expand the section below to see the details:
Sources
The information found in the table and this expandable section was sourced from:
The Components Model (Griffiths, 2005)
Closely aligned with the ICD/DSM approach is Professor Mark Griffiths’ Components Model of addiction (Griffiths, 2005). Griffiths is a prolific publisher in the behavioural addictions field, (co-)authoring many studies of the aforementioned bizarre addictions. According to his Components Model, a person is addicted only if they meet six core signs or “components” of addiction:
Salience: The increasing importance and dominance of the activity (e.g., drug use, gambling) in thought (preoccupation), feelings (cravings), and behaviour (declining socialisation). Based on Griffith’s operational definition of salience, I would say this covers several of the symptoms proposed by the diagnostic manuals in the table: preoccupation, cravings, neglect of major roles, substantial time spent using/ doing & obtaining, and social/ occupational problems.
Mood modification: The emotional and subjective experiences associated with engaging with the activity (e.g., a high or euphoria) which can be defined in terms of a change from pre-engagement state (e.g., a reduction in anxiety, as in “self-medicating”). Similar to the symptom engages in behaviour when distressed in the table.
Tolerance: The need for increasingly more of the substance or more frequent or intense engagement with the behaviour (e.g., increasing bet size) to achieve the same subjective experiences formerly achieved at lower levels (also termed “habituation” in the addictions literature).
Withdrawal: The unpleasant physical and psychological states experienced when not engaging with the activity (i.e., during abstinence), including sweating, insomnia, restlessness, anxiety, and irritability.
Conflict: Internal and interpersonal conflict arising from excessive engagement with the behaviour, such as deteriorating relationships, work performance and participation with social activities. Covers (continuation despite) social/ occupational problems and perhaps reliance on others to solve financial problems from the table.
Relapse: Re-using the substance or re-engaging with the behaviour after a period of abstinence. I would lump this under impaired control.
With this model, Griffiths emphasises the commonalities between addictions and argues that if there are no core criteria for addictive disorders then there is little use in the term addiction (Griffiths, 2019). That is, what value is there in saying that excessive tanning or video gaming is a form of behavioural addiction if addiction does not refer to some commonly understood phenomenon? If tanning or video gaming “addictions” are distinct from established addictions (alcohol, gambling, opioids etc.), then new terms should be used.
I see the value in a confirmatory approach (with some caveats1) towards conceptualising addiction—that is, seeing whether people excessively engaging in an activity display the core features of recognised addictions. However, this could increase the chances of falsely claiming something resembles an addiction without giving full consideration to the unique features of the behaviour. This is the subject of much debate within the behavioural addictions field and not all agree that a confirmatory method is best, which leads us nicely onto considering the next approach to defining addiction.
The operational definition of behavioural addictions (Kardefelt-Winther et al., 2017)
Kardefelt-Winther et al. (2017) have claimed that:
“considerable resources are being diverted to conduct research on excessive behaviours that lack indications of functional impairment, psychological distress or a clear separation from normative behaviour in context… [and] if this expansion does not end, both the relevance and credibility of this field might be questioned.”
This, they argue, is the consequence of using a confirmatory approach to determine whether a pattern of behaviour—say, excessive tanning—represents a behavioural addiction based on the features of the Components Model (which they say are substance addiction symptoms). In their paper, the authors contend that certain features of the Components Model, namely tolerance and withdrawal, are difficult to apply and measure in relation to behaviours other than substances.
Kardefelt-Winther et al. also point out that preoccupations or cravings may be relatively innocuous in the context of behaviours like video gaming, but can be problematic in substance users. Finally, they warn that by simply seeing whether someone who engages excessively in a behaviour displays the symptoms of substance addictions (i.e. the six components), researchers are failing to explore the potentially unique features and boundaries of the behavioural pattern2.
Griffiths has hit back at this argument, asserting that the Components Model does not deny the idiosyncrasies of each addictive disorder (e.g., chasing losses in Gambling disorder) or proscribe the types of exploratory research required to uncover them (Griffiths, 2019).
Kardefelt-Winther and colleagues’ concerns with the Components Model of Addiction and the allied confirmatory approach led them to develop a new, operational definition of a behavioural addiction:
“A repeated behaviour leading to significant harm or distress. The behaviour is not reduced by the person and persists over a significant period of time. The harm or distress is of a functional nature”
This differs considerably from the previous definitions, most notably by omitting any explicit mention of impaired control3. The “significant harm or distress” referred to, however, is easily compared with the features of addiction as outlined in the previous two approaches (i.e., the diagnostic manual symptom: “continuation despite negative consequences” & the component: “conflict”).
As well as their operational definition, the authors provide exclusion criteria for behavioural addictions. That is, features that, if present, indicate that a pattern of behaviour is not a behavioural addiction:
The behaviour is better explained by an underlying disorder (e.g., a depressive disorder or impulse control disorder).
The functional impairment results from an activity that, although potentially harmful, is the consequence of a wilful choice (e.g., high level sports).
The behaviour can be characterised as a period of prolonged intensive involvement that detracts time and focus from other aspects of life, but does not lead to significant functional impairment or distress for the individual.
The behaviour is the result of a coping strategy.
These exclusion criteria are useful for differentiating high involvement with an activity, say sports or hobbies, from a behavioural addiction. Yet, as Griffiths (2017, 2019) has argued, these criteria could exclude many (if not all) cases of behavioural and substance addiction!
The first and fourth exclusion criteria may be problematic as addictions, including to substances and gambling, typically co-occur with other psychological disorders such as depression and/or anxiety (Lorains et al., 2011; Zambon et al., 2017), and thus the substance use or gambling can often be viewed as a form of coping strategy and yet still meet the criteria for addiction. Further, when individuals begin to engage with a behaviour, be it alcohol use or gambling, this is invariably of wilful choice (Griffiths, 2017), questioning the value of exclusion criterion 2. I would argue only the third criterion should be retained if we think behavioural addictions actually exist and are worth recognising.
Sussman and Sussman’s (2011) Five Common Elements
Many other academic articles contain discussions on the definition of addiction and Sussman and Sussman have attempted to systematically summarise these views (up to April 2011). Although it’s not quite clear how or what they extracted from the 52 studies identified in their review (their methodology section is pretty lacking in detail), they arrived at the conclusion that all forms of addiction share five common elements:
Appetitive effects—the behaviour is engaged in so as to achieve some form of appetitive effect (e.g., reduction in pain, enjoyment, arousal, fantasy)
Preoccupation with the behaviour, including cravings and (strangely) tolerance and withdrawal symptoms
Temporary satiation—the sense of gratification, relief or balance achieved from engaging in the behaviour that follows a period of subjective discomfort (withdrawal), resulting in a temporary state of satiation or reduction in appetite for the behaviour
Loss of control
Negative consequences associated with the behaviour
Interestingly, these features are similar (with some minor discrepancies) to Griffiths’ components model…
Thoughts so far
The definitions discussed so far mostly highlight the importance of a few distinguishing features of addiction. Most notably, impaired control and negative consequences associated with the behaviour pattern.
Kardefelt-Winther et al.’s definition of behavioural addictions diverges from the others by stressing the uniqueness of addictive disorders and differentiating drug and non-drug addictions. Their exclusion criteria are too strict, but they do raise some important concerns with the current zeitgeist of the field wherein someone is said to have a behavioural addiction if they display features roughly comparable to those of the Components Model.
Clearly, there is a fine line to be tread between recognising “new” behavioural addictions from which people are genuinely suffering (thereby stimulating research on the topic and promoting proper allocation of resources and services to those in need) and pathologizing and stigmatising normal behaviours (low-level gaming, mobile phone use etc.) and unduly wasting time and resources4.
In Part 2 of this post, I cover Shaffer et al.’s (2004) Syndrome Model of Addiction, how addiction might be defined according to Network theory, and how people who actually experience addiction define it. I also chime in on the debate as to where we draw the line between high involvement with an activity and addiction, before coming to an eclectic definition of addiction based on the many different approaches covered.
Last updated: 01/07/2023
References
Footnotes
I find the components model to be a useful blueprint when considering the core principles of addiction, but I would argue that all six components do not need to be present for someone to be classified as having an addiction (relapse and conflict and/or salience are key). Similar to the argument made by Kardefelt-Winther et al. (2017), some of these symptoms (especially, tolerance and withdrawal) may be less relevant to some behavioural addictions and may therefore not be necessary for classification, though I would diverge from Kardefelt-Winther and colleagues by arguing that the greater the number of “components” an individual displays (including tolerance & withdrawal) the stronger the case for declaring that they are addicted. On the removal of tolerance and withdrawal from the core criteria of addiction, Griffiths (2017) remarked: “Ironically, removing these from core addiction criteria may actually increase the prevalence of everyday leisure activities being labelled as an addiction.”↩︎
Kardefelt-Winther et al. (2017) make several more criticisms of the Components Model and the confirmatory approach to studying behavioural addictions, but the three I cover here are (I believe) the core arguments. See their article for more detail.↩︎
That said, their exclusion criteria listed below this point (i.e., “The functional impairment results from an activity that, although potentially harmful, is the consequence of a wilful choice”) could be said to introduce impaired control into their operational definition↩︎
Some may accuse me of “over pathologizing” normal behaviour, given my research on the parallels between extreme sports athletes and those with drug and behavioural addictions. However, I don’t think we ever argued that extreme sports athletes are addicted in the exact same way as those who suffer drug or non-drug addictions (and we certainly didn’t aim to pathologize extreme sports athletes); rather, we pointed out that there are qualitative similarities in the experiences between these groups. That said, I would perhaps be slightly more circumspect when making such comparisons and using addiction terminology if I were writing those papers today↩︎
Citation
BibTeX citation:
@online{heirene2020,
author = {Heirene, Rob},
title = {What Does It Mean to Be “Addicted?” {(Part} 1)},
date = {2020-04-14},
url = {https://robheirene.netlify.app/posts/2020-what-is-an-addiction-pt1},
langid = {en}
}
For attribution, please cite this work as:
Heirene, Rob. 2020. “What Does It Mean to Be
‘Addicted?’ (Part 1).” April 14, 2020. https://robheirene.netlify.app/posts/2020-what-is-an-addiction-pt1.
Social/ occupational problems
This would be better phrased as “continuation despite social and/or occupational problems/ harms”
Exact wording of symptom in the DSM-5:
ALCOHOL: “Alcohol use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by alcohol”
GAMBLING: “Has jeopardized or lost a significant relationship, job, or educational or career opportunity because of gambling”
Exact wording of symptom in the ICD-11:
ALCOHOL: “Increasing precedence of alcohol use over other aspects of life, including maintenance of health, and daily activities and responsibilities, such that alcohol use continues or escalates despite the occurrence of harm or negative consequences (e.g., repeated relationship disruption, occupational or scholastic consequences, negative impact on health)“
GAMBLING: “Continuation or escalation of gambling behaviour despite negative consequences (e.g., marital conflict due to gambling behaviour, repeated and substantial financial losses, negative impact on health)“