Behavioral addictions: You don’t need drugs or booze to be an addict

Hi from Hungary. I’m at a conference on behavioral addictions. Two days of talks by experts — psychologists, neuroscientists, psychiatrists, clinical researchers, etc. — who want to understand behavioral addictions. These include compulsive gambling, eating disorders, hypersexuality or sex addiction, and internet or gaming addiction.  And I am really high on the flood of information, insight, commitment and good intentions, knowledge, creativity, blah blah blah, not to mention that I happen to be in Budapest, which looks like a magical kingdom from some angles and a Communist-bloc relic from others.

I knew so little about Hungary, I actually forgot the name of my destination when checking in for my flight in Amsterdam. I was standing at one of those automatic check-in terminals, had entered my passport information, and then when the prompt asked me for the first three letters of my destination, I blanked out. I asked the guy next to me, which was kind of embarrassing as he was deep in a conversation with someone else: What’s the capital of Hungary? He thought about it for awhile and then said “Bucarest”. I typed in BUC, and then realized that’s where my wife, Isabel, was born — and she’s Romanian, not Hungarian. It finally came:



Coming in from the airport by cab, we crossed into another dimension. Mile after mile of hulking, dilapidated rectangular buildings, looking like they were last used 70 years ago to make bomb parts for the war. There was this stale ghost of leftover Communism everywhere. Everything looked shut down, grey slabs of concrete under a grey sky. This was Budapest?

My first surprise came when the driver demanded 5,450 for the ride. What? This could be trouble. But it turned out that 5,450 whatevers translated to 20 euros. Whew.  My next surprise was how beautiful the inner city turned out to be. At some invisible line the Communist-era shabbiness rolled back to reveal a land of Oz: Enormous but gorgeous monuments to a thousand years of changing architecture — churches, castles, museums, fountains — with elaborate arches and elegant turrets, tapering to slender needles pointed at the sky. All connected by wide avenues, full of shoppers, and bridges that appeared to be held up by steel lace. History oozing out of every stone in every facade.

gamblingThe third surprise was that the talks were so riveting I was hardly tempted by the marvels just outside the door. In two days I learned so much, met so many amazing people, discovered new research strategies, new devices, new recovery tools. For example, today I chatted for an hour with a man named Robert Pretlow, who spent two years — full-time — developingBob_app a cell-phone app, and a couple of decades studying child and adult eating disorders. This app (displayed on the right — so far only available for research) lets you chat with other recovering individuals, warns you about addictive triggers, reminds you about your own effective coping strategies, records your progress day by day. It’s like having a treatment centre in your pocket. Dr. Pretlow is using it to study eating disorders, but it seems that it could be applied to many other addictive problems as well. Bob agrees, but there is a lot of work to be done.

I learned about the hidden dangers in sex and gambling. This was not one of those conferences where you have to douse yourself with coffee to keep awake. I learned about the diversity of eating disorders — from binging, which looks a lot like sexaholicsubstance addiction, according to Marc N. Potenza at Yale  — to anorexia — which looks more like over-control. A lot of talks focused on OCD, obsessive-compulsive disorder, and quite a few speakers connected the compulsive nature of OCD with that of addiction. People talked about stages in the development of addiction (not far from the stages I listed the last couple of posts), and compared them with stages in the development of OCD. One guy showed how the addictive progression of stages coverged with the OCD progression — starting out in different places but ending up almost completely overlapping.

And these people weren’t just talking about behavior. There were neuroscience data in half the talks. The striatum was the overwhelming star of the show — the ventral striatum and its role in craving, and the dorsal videogamestriatum responsible for compulsion. It appears that OCD sufferers talk about their compulsions a lot like addicts talk about their addictions. I don’t want to stop it. I know it’s bad for me, but it makes me feel better. And their brains light up in almost all the same places! In fact, their brains show changes in synaptic density (some areas getting more connected, other areas getting less connected) that look exactly like what you see in addicts, over the same time frame, as they get worse — or better.

In just two days I learned so much, met with so many experts, exchanged email addresses, got books and papers handed to me…enough to keep me busy for quite a while.

And to keep you busy! In the next few posts I’m going to try to synthesize what I’m learning about behavioral addictions — gambling, sex, eating-disorderfood, and internet — how they develop, how they stabilize, and most of all how the same or at least overlapping brain changes underlie them all.  And here’s the clincher: I’m going to show you, as I continue to digest it myself, how similar ALL addictions are. When it comes to substance addictions versus behavioural addictions, there’s just not much difference in what the brain is doing.

So, it might seem counterintuitive, but heroin addicts, codependent partners, gaming addicts, and sex addicts are very, very much alike. In other words, you don’t have to be a heroin addict or an alcoholic to wreck your life. You can wreck it just as well by spending 18 hours a day on the internet, while the bills pile up, the unemployment cheques fizzle out (and you didn’t notice), and your wife starts packing, not only her stuff but the kids’ stuff too. You might reply: yeah, sure, but substance addiction can kill you! Behavioral addiction? That’s pretty wimpy in comparison. If you believe that, as I did until yesterday, I’ve got news for you. According to the stats, obesity (a result of food addiction) causes 4 – 5 times more “preventable deaths” in the U.S. than the number caused by alcohol.

The conference just ended. I’m going to go out and check on Budapest now — gaze at statues and absorb some culture. But stay tuned for a deeper look at the core processes underlying  behavioral and substance addictions — in other words all addictions. Coming up next.


20 thoughts on “Behavioral addictions: You don’t need drugs or booze to be an addict

  1. Shaun Shelly March 13, 2013 at 4:47 am #

    Jealous Marc – in good way. This is where I am in strong agreement with Stanton Peele’s writings and with Shaffer’s syndromal model: Addiction is an underlying disorder with many possible manifestations. I also explained it in my sex addiction article I have previously referred to.

    I look forward to hearing more!

    • Marc March 17, 2013 at 5:27 am #

      Coming up!

  2. Carolyn Kay March 13, 2013 at 6:14 am #

    Yes, yes, yes! The sooner we start treating obesity, in particular, as being due to addiction, the better chance we have of living longer, healthier, happier lives.

    I’m 26 years alcohol free and 15 years nicotine free, but I’m still struggling with what I’m sure is my primary addiction–food, especially sugary food.

    • Marc March 17, 2013 at 5:27 am #

      Hi Carolyn. Apparently policy makers in the U.S., in synch with the medical community, still see obesity as a result of poor eating habits underpinned by issues of availability, education, etc. Dr. Pretlow, whom I mention in the post, is one pioneer who strongly resists this view. I agree with him, and with you, that obesity is often the result of an addiction, and the proof is in the pudding, no pun intended. If there is a period of craving that leads up to the overeating, and if the eating itself takes on a compulsive quality — it is no longer in service of satisfaction, but rather an attempt to relieve the anxiety of resisting the impulse — then it’s clearly an addictive behaviour.

      Good luck with (what sounds like) one last mountain to climb!

      By the way, Elizabeth (see below) talks about food addiction in much the same way, and she has examined enough of the neuroscience literature to make a good case for it.

  3. Richard Henry March 13, 2013 at 7:11 am #

    This is where I feel like I suffer from R.D.S (Reward Deficiency Syndrome) I’m for ever seeking out satisfaction and wholeness in rewards. Some how I feel that the wiring up of my brain early on in my childhood did not connect enough for me to feel whole, and I am in constant search of outside influences to enlighten these feelings. I have gone through being a full blown alcoholic, cocaine addict, marijuana for 6 years and now, am getting those rewards through things like Pepsi, chocolate, ice-cream. I have gain a lot of weight, but am excited to finally get the rewards from, what I thought was a healthier way. It’s the little things in life today that I get rewards from. For me to get excited about a big glass of cold Pepsi is amazing to thing I get the same rewards as if I just done one of my past choice drugs. However I am aware today of the negative consequence of becoming obese and must always be aware of over doing anything in my life. For so long my brain was fogged up with chemicals, today it’s as if my brain was starving for knowledge and I have become the information fanatic, I’m just wonder what negative consequences are going to come of all the information? hahahaha…
    Thanks Marc

    • Marc March 17, 2013 at 5:42 am #

      It’s hard to study the effects of knowledge addiction, since most of those studying it also suffer from it! Seriously, though, I met the guy who “invented” Reward deficiency syndrome — at the conference. His name is Kenneth Blum. We had a long debate about the role of dopamine vs. other chemicals in the “cascade” of addiction. And yes, he calls it a cascade too.

      In a nutshell, there are several dopamine receptors that are different in different members of the population. The gene for one of the dopamine receptors differs in different individuals, and one of the versions of this gene does indeed predict a tendency toward addiction. I should stress that there is no single gene that predicts addiction. This gene is part of a cluster of genes that together may predict risk. Anyway, if you have the “wrong” variant of this gene, among others, then you may have a harder time feeling pleasure or attraction to “normal” rewards and thus be more drawn to special rewards.

      I don’t emphasize this perspective, because I think environmental factors still make up the biggest vulnerability. But, RDS is real, and you may indeed be stuck with it!

      • Shaun Shelly March 17, 2013 at 10:06 am #

        This, I would presume, is the DRD2 receptor? I believe the “availability” of these receptors is also significantly altered by environmental conditions, as demonstrated in the animal studies we have discussed previously.

        As you say, we should take cognisance, but not forget the other factors. We see silos of research and whole theories develop around these without taking the wider picture into account, hence my desire, as I believe it is yours, to develop an integrated theory of addiction. Mine is called a “cumulative” theory because all these factors add up until the tipping point is reached.

        But, just as certain predispositions will tip the scales in one direction, protective factors can help even things out. Environment and “effort” can certainly overcome many genetic predispositions – some of us are living proof of that!

        • Marc March 17, 2013 at 5:54 pm #

          Hi Shaun. Yes, it’s the DRD2 receptor. Blum says that low dopamine uptake by the “risk” allele of this receptor is responsible for Reward Deficiency Syndrome. He also calls it a hypodopaminergic response……not enough dopamine to feel the rewardingness of “normal” sources of pleasure and satisfaction.

          Yet, as you say, there are powerful interactions with environmental factors. Blum himself talks about the role of stress. Also, he seems to have several different hypotheses as to what’s going on. He talks about increased sensitivity to dopamine in the presence of the addictive stimulus or event — which sounds a lot like Berridge’s incentive sensitization. He talks about a lack of sensitivity to normal rewards, and he even talks about the challenge to self-control resulting from DA deficiency. In other words, it’s sort of a theoretical grab-bag, and indeed he lumps together a huge number of disorders, including ADHD and aggressive behavior problems, as outcomes of the deficieny.

          I’m going to talk in more detail about Blum’s model in an upcoming post, so let’s leave it at that for now.

          Meanwhile, take a look at

          ““Liking” and “Wanting” Linked to Reward Deficiency Syndrome (RDS): Hypothesizing Differential Responsivity in Brain Reward Circuitry — Kenneth Blum,*, Eliot Gardner, Marlene Oscar-Berman and Mark Gold….a 2011 paper in Current Pharmaceutical Design — which sounds like he had a hard time publishing it. It’s interesting to see how Blum tries to square his model with that of Berridge, and I don’t think he’s quite successful at it.

          • Shaun Shelly March 18, 2013 at 8:49 am #

            Will take a look, sounds really interesting.

            By the way, I read your book yesterday – WOW! It certainly had me gripped. I will e-mail you my complete impressions, but if there is anybody out there who has not read it I would strongly suggest reading it.

            What a fantastic way of linking the “science” with “reality”. It makes it all so clear and practical. I will certainly be recommending it to my students.

            • MB March 18, 2013 at 12:27 pm #

              Marc –

              Don’t want to get off-topic, but I’d like to add to Shaun’s praise for your book. I also want to apologize in advance for not purchasing it. I just picked it up at my public library yesterday and am taken by the way you balance the science with terrific description and a friendly, conversational tone.

              You’re a decade older than I. I started to make yearly trips to Berkeley, where my husband was raised, in the early 80s. While the full-blown hippie movement had passed by that time, there was and still is enough of a counter-culture feel to make your descriptions of Berkeley spot on. It adds an enhanced dimension to my reading.

              Your description is so vivid that I well understand your blog response to me ~ a few weeks ago that some recovering addicts have told you they are unable to finish your book because it is too evocative. I probably will NOT share this read with my recovering son. Quite honestly, I’m AFRAID of your acid trips. Can you read with your eyes closed?

  4. Elizabeth March 13, 2013 at 8:37 am #

    Excellent! This conference sounds fantastic!

    As another aside, the “behavioral addiction” of anorexia nervosa is actually the most deadly of all; even moreso than drug abuse! So, yes, you are indeed correct to highlight that ALL addictions take away from, or even take, our lives.

    Interestingly, approximately 90% of anorexics also develop binge eating behaviors. It’s like the opponent-process thing all over again. Instead of going through drug use/withdrawal, there’s binge eat/restrict. I guess the difference is the restriction part is just as rewarding as the binge, albeit in different ways.

    Walter Kaye at UCSD has some great stuff about how the act of food restriction in OCD patients may actually serve to relieve some of their obsessive tendencies, but then the restriction looses control:

    • Marc March 17, 2013 at 5:59 pm #

      Fascinating, as always. The eating disorders seem to take the prize as the most complex addiction, or cluster of addictions, on the map. I can’t imagine a substance addict getting much of a kick from restricting his or her intake. My personal (untutored) impression is that anorexia has some elements of masochism, so that suffering or at least deprivation is DIRECTLY rewarding — in the present tense. That would bring it in line with other addictions, whose appeal has to be so powerful in the here-and-now that it trumps all the consequences that unfold subsequently….in the future. More on that soon….

      • Elizabeth March 17, 2013 at 6:56 pm #

        Indeed, the “masochism” is sort of rewarding, and potentially due to an endophenotype associated with OCD. There is the thought that food deprivation reduces serotonin levels. The serotonin is associated with impulse control and inhibiting responding. OCD individuals may have an upregulation of a certain type of serotonin receptor that is associated with impulse control. Upon food restriction, some of that excessive control is released and it induces a sort of “euphoric” state in the individual. However, the rigid, rule-focused behaviors are still there and the food restriction goes out of control. This may be a contributing factor to resistance in treatment. It’s a bit speculative, but incredibly interesting. Kaye has a nice review about it.

  5. Kiffin March 13, 2013 at 10:51 am #

    The brain pathway is what determines the process of addiction and the target substance is more often than not irrelevant. The urge to get more and more of whatever is the defining activity rather than the actual getting part. The effect of the high is short-lived, while the urge for the high is never-ending. Isn’t that also the purpose of life, to survive no matter what? The survival instinct seems to get messed up, re-wired, tied up in knots, the natural pathway erased by addiction in another context, missing the mark in a wild attempt to achieve wrong goals.

  6. Suzanne Swan March 13, 2013 at 11:18 am #

    I am so glad you are exploring the concept of eating, sex, gambling, internet etc. as being behavioural addictions, and not related to just substance abuse and addiction. I am not a scientist or doctor, just interested and concerned with these issues. Perhaps you could incorporate in some posts some clues as to when mere ‘habit’ morphs into full-blown addiction.

    It is my personal, unprofessional, opinion that bullying is an addiction. It does not seem to fall into the addiction category by most accounts but bullies feel good when they humiliate others. There is a triumphant pleasure principle/reward scenario at work in tormenting someone else, beating them up and intimidating them. So, hey there, this feels so good and gives me power (even though I am a coward at heart); so let’s do it again.

    I would like to see bullying treated as an addiction rather than an unpleasant social evil or, in violent cases, as a crime.

  7. Spike March 13, 2013 at 6:45 pm #

    Great post Marc,

    As a sex addict it’s great to see it come to the fore what I have realised many years ago, that all addictions are pretty much the same.
    My definition of an addiction is any behaviour that is repeated compulsively to the destruction of you and the people around you. In other words it has a negative impact on your life.
    Having said that, there are also addictions that don’t seem to have a negative impact on your life. You might be addicted to classical music or rock climbing.

    Cheers Spike

  8. Janet March 14, 2013 at 8:44 am #


  9. Jaliya March 18, 2013 at 8:42 pm #

    Craving but no appetite(s) = Addiction in a nutshell?

    I’ve noticed over the years, with any addicted person I’ve known, that the instinctive appetites for what sustains us — food, water, air, rest, sleep, movement, communication, relation — fall into life-threatening disarray … a deranged regulatory/moderating process (?) … All natural appetites seem to devolve into a perennial one-pointed craving …

    Someone I’ve loved all my life recently died…a heart attack. A quick death, and my cherished one wasn’t alone. The decades-long consequences of unstoppable alcohol addiction felled him in an instant. I say this with all heart and no blame; as a witness.

    Towards the end of his life, he lived with me for several months. He tried … oh, how he tried. And then he just couldn’t try any more. He was so utterly lost, so devastated of relation. He was the sweetest and most hilarious soul I ever met; he was a joy to so many people, dogs, and cats. He was a brilliant thinker and he could riff like Robin Williams. He loved nothing more than to host a sudden party, to fire up the BBQ, gather friends in the garden, and feast away the night. For a few years, he had it all, according to his standards. All of his appetites were being met…and the craving was, for the first time in his life, quelled … He was the most beautiful sight in my world on the day of his wedding …

    His life broke ten years ago…and by the time he died, every person who had ever loved him was broken from direct relation with him. We could not reach him any more. He himself couldn’t, wouldn’t be reached…and if he reached for anything, ultimately, it was alcohol. His death was a horrific shock…and not a surprise.

    Marc, I keep recalling your experience of arriving at boarding school. You knew in your bones you didn’t belong there. All of your essential relational rhythms were thrown completely out of whack. You had absolutely no relational stability — no one familiar nearby, and you were in an utterly new and foreign place. How old were you? About nine?…and suddenly far away from hearth, home, and habitat; from friends and favourite trees and hangouts. All of your familiars, your protectors, your kin, are gone.

    What a shredding experience. In the face of so much loss (which is so rarely recognized as such), and needing immediately to adapt to all the new, what do we do with the shock of not belonging, of having no place, no people? We go within … to memory, for comfort … but memory’s stuffed with all that we can’t have right now (and for all we know, forevermore) …

    We end up craving the one thing that sustains us; what we can no longer have: that fundamental warmth: all that we have known as love. There’s no one to hold on to; nothing that we know by touch. We are bereft of relation and the stabilizing *feeling of love: the visceral pulse and heat — the sense — of being in relation…a rudimental mammalian need.

    Perhaps it’s a ‘perfect storm’ of relational losses, in combination with all the other factors, that tend a person toward addiction.

  10. Laura September 9, 2014 at 2:21 pm #

    I definitely agree with you, addictive personalities are what essentially gets us into trouble. Anything in moderation is okay, and no extreme is good. That is what I tell myself every day when I try to stay focused and active in my recovery. Thank you for your words of inspiration!


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