Definitions of Addiction

THE term addiction is difficult to define precisely in the current social/political context. The notion of addiction is generally understood negatively, implying uncontrollable behavior and a disease-model. As will be described, even the traditional term drug addiction is controversial, and behavioral scientists generally prefer the term substance-use disorder. The matter becomes more complex when one moves from the fairly well-defined phenomena of chemical tolerance and dependence (characterized by withdrawal-symptoms) to the more hazy realm of so-called behavioral (or process) addictions.

A GOOD place to begin is with an attempt on the part of modern psychologists to formulate a definition of addiction that includes both drugs and behaviors.

THE following attempt at a definition is taken from Treatment Strategies for Substance and Process Addictions, edited by Robert L. Smith, (American Counseling Association, Alexandria VA, 2015), pp. 3-4:

The term addiction is derived from the Latin addīcō meaning “enslaved by” or “bound to,” […]. The term addiction is frequently attached to a substance and viewed as dependence. Opium and morphine were two of the first addictive substances identified because of misuse of prescriptions. Society today often also characterizes individuals who participate in repetitive behaviors as being addicted. Thus, the term addiction currently applies to the misuse of alcohol, other drugs, and substances and to a large number of behavior patterns. […]

Scientifically speaking, individuals are considered addicted when they[:]

[1] relentlessly pursue a sensation or activity, whether it is a substance such as alcohol or a behavior like gambling,

[2] despite consequences to their health or well-being
(W. R. Miller, Forcehimes, & Zweben, 2011)

Similarly, addiction has been defined as the condition of being habitually or compulsively occupied with or involved in something. W. R. Miller et al. (2011) identified three kinds of actions that define an addiction:

(a) an action that is habitual, done regularly, and repeated;

(b) an action that appears to be compulsive in nature and at least partially outside of one’s conscious control; and

Dr. Smith, the author of this introduction, is concerned to find an understanding of addiction that encompasses both drugs and behaviors, or process-addictions. He believes that both drug addiction and process addictions are forms of brain diseases :

According to the DSM-5, all drugs taken in excess have in common the direct activation of the brain reward system, which is involved in:

the reinforcement of behaviors and

the production of memories,

producing a pleasure referred to as a high (APA, 2013, p. 481).

Moreover, gambling behaviors activate reward systems similar to the effects of a drug. The implication is that behavioral (process) addictions, such as addictions to[:]

sex,

the Internet,

shopping,

exercise, and

work

operate within the brain in a manner similar to addictions to alcohol and other drugs. Indeed, findings have shown that these repetitive behaviors produce similar chemical changes in the brain to those associated with the use of drugs.

And like a drug, the continued use of a behavior can get out of control, and attempts to stop can result in withdrawal symptoms, including

anxiety,

worry, and

irritation.

Supporting the idea that substance and process addictions are brain diseases are findings that changes in brain circuits are induced by thoughts and behavior patterns long before a behavior or drug becomes addictive. However, further research is needed before experts can validate the notion of process addictions as a brain disease. (Smith,Treatment Strategies. p.5)

The essential feature of a substance use disorder is a cluster of cognitive, behavioral, and physiological symptoms indicating that the individual continues using the substance despite significant substance-related problems. As seen in Table 1, the diagnosis of a substance use disorder can be applied to all 10 classes included in this chapter except caffeine. For certain classes some symptoms are less salient, and in a few instances not all symptoms apply (e.g., withdrawal symptoms are not specified for phencyclidine use disorder, other hallucinogen use disorder, or inhalant use disorder).

An important characteristic of substance use disorders is an underlying change in brain circuits that may persist beyond detoxification, particularly in individuals with severe disorders. The behavioral effects of these brain changes may be exhibited in the repeated relapses and intense drug craving when the individuals are exposed to drug-related stimuli. These persistent drug effects may benefit from long-term approaches to treatment.

Overall, the diagnosis of a substance use disorder is based on a pathological pattern of behaviors related to use of the substance. To assist with organization, Criterion A criteria can be considered to fit within overall groupings of[:]

[1] impaired control

[2] social impairment,

[3] risky use, and

[4] pharmacological criteria [tolerance and withdrawal].

Impaired control over substance use is the first criteria grouping (Criteria 1-4).

[1] The individual may take the substance in larger amounts or over a longer period than was originally intended (Criterion 1).

[2] The individual may express a persistent desire to cut down or regulate substance use and may report multiple unsuccessful efforts to decrease or discontinue use (Criterion 2).

[3] The individual may spend a great deal of time obtaining the substance, using the substance, or recovering from its effects (Criterion 3) In some instances of more severe substance use disorders, virtually all of the individual’s daily activities revolve around the substance.

[4] Craving (Criterion 4) is manifested by an intense desire or urge for the drug that may occur at any time but is more likely when in an environment where the drug previously was obtained or used. Craving has also been shown to involve classical conditioning and is associated with activation of specific reward structures in the brain. Craving is queried by asking if there has ever been a time when they had such strong urges to take the drug that they could not think of anything else. Current craving is often used as a treatment outcome measure because it may be a signal of impending relapse.

Social impairment is the second grouping of criteria (Criteria 5-7).

[5] Recurrent substance use may result in a failure to fulfill major role obligations at work, school, or home (Criterion 5).

[6] The individual may continue substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance (Criterion 6).

[7] Important social, occupational, or recreational activities may be given up or reduced because of substance use (Criterion 7). The individual may withdraw from family activities and hobbies in order to use the substance.

Risky use of the substance is the third grouping of criteria (Criteria 8-9).

[8] This may take the form of recurrent substance use in situations in which it is physically hazardous (Criterion 8).

[9] The individual may continue substance use despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance (Criterion 9). The key issue in evaluating this criterion is not the existence of the problem, but rather the individual’s failure to abstain from using the substance despite the difficulty it is causing.

The degree to which tolerance develops varies greatly across different individuals as well as across substances and may involve a variety of central nervous system effects. For example, tolerance to respiratory depression and tolerance to sedating and motor coordination may develop at different rates, depending on the substance. Tolerance may be difficult to determine by history alone, and laboratory tests may be helpful (e.g., high blood levels of the substance coupled with little evidence of intoxication suggest that tolerance is likely). Tolerance must also be distinguished from individual variability in the initial sensitivity to the effects of particular substances. For example, some first-time alcohol drinkers show very little evidence of intoxication with three or four drinks, whereas others of similar weight and drinking histories have slurred speech and incoordination.

Withdrawal symptoms vary greatly across the classes of substances, and separate criteria sets for withdrawal are provided for the drug classes. Marked and generally easily measured physiological signs of withdrawal are common with alcohol, opioids, and sedatives, hypnotics, and anxiolytics. Withdrawal signs and symptoms with stimulants (amphetamines and cocaine), as well as tobacco and cannabis, are often present but may be less apparent. Significant withdrawal has not been documented in humans after repeated use of phencyclidine, other hallucinogens, and inhalants; therefore, this criterion is not included for these substances. Neither tolerance nor withdrawal is necessary for a diagnosis of a substance use disorder. However, for most classes of substances, a past history of withdrawal is associated with a more severe clinical course (i.e., an earlier onset of a substance use disorder, higher levels of substance intake, and a greater number of substance-related problems).

Symptoms of tolerance and withdrawal occurring during appropriate medical treatment with prescribed medications (e.g., opioid analgesics, sedatives, stimulants) are specifically not counted when diagnosing a substance use disorder. The appearance of normal, expected pharmacological tolerance and withdrawal during the course of medical treatment has been known to lead to an erroneous diagnosis of “addiction” even when these were the only symptoms present. Individuals whose only symptoms are those that occur as a result of medical treatment (i.e., tolerance and withdrawal as part of medical care when the medications are taken as prescribed) should not receive a diagnosis solely on the basis of these symptoms. However, prescription medications can be used inappropriately, and a substance use disorder can be correctly diagnosed when there are other symptoms of compulsive, drug-seeking behavior.

Substance use disorders occur in a broad range of severity, from mild to severe, with severity based on the number of symptom criteria endorsed. As a general estimate of severity, a mild substance use disorder is suggested by the presence of two to three symptoms, moderate by four to five symptoms, and severe by six or more symptoms. Changing severity across time is also reflected by reductions or increases in the frequency and/or dose of substance use, as assessed by the individual’s own report, report of knowledgeable others, clinician’s observations, and biological testing. The following course specifiers and descriptive features specifiers are also available for substance use disorders: “in early remission,” “in sustained remission,” “on maintenance therapy,” and “in a controlled environment.” Definitions of each are provided within respective criteria sets.[...]

Individuals ages 18-24 years have relatively high prevalence rates for the use of virtually every substance. Intoxication is usually the initial substance-related disorder and often begins in the teens. Withdrawal can occur at any age as long as the relevant drug has been taken in sufficient doses over an extended period of time.

A. Persistent and recurrent problematic gambling behavior leading to clinically significant impairment or distress, as indicated by the individual exhibiting four (or more) of the following in a 12-month period:

1. Needs to gamble with increasing amounts of money in order to achieve the desired excitement.

2. Is restless or irritable when attempting to cut down or stop gambling.

3. Has made repeated unsuccessful efforts to control, cut back, or stop gambling.

4. Is often preoccupied with gambling (e.g., having persistent thoughts of reliving past gambling experiences, handicapping or planning the next venture, thinking of ways to get money with which to gamble).

5. Often gambles when feeling distressed (e.g., helpless, guilty, anxious, depressed).

6. After losing money gambling, often returns another day to get even (“chasing” one’s losses).

7. Lies to conceal the extent of involvement with gambling.

8. Has jeopardized or lost a significant relationship, job, or educational or career opportunity because of gambling.

9. Relies on others to provide money to relieve desperate financial situations caused by gambling.

Severity is based on the number of criteria endorsed. Individuals with mild gambling disorder may exhibit only 4-5 of the criteria, with the most frequently endorsed criteria usually related to preoccupation with gambling and “chasing” losses. Individuals with moderately severe gambling disorder exhibit more of the criteria (i.e., 6-7). Individuals with the most severe form will exhibit all or most of the nine criteria (i.e., 8-9). Jeopardizing relationships or career opportunities due to gambling and relying on others to provide money for gambling losses are typically the least often endorsed criteria and most often occur among those with more severe gambling disorder. Furthermore, individuals presenting for treatment of gambling disorder typically have moderate to severe forms of the disorder.

Gambling involves risking something of value in the hopes of obtaining something of greater value. In many cultures, individuals gamble on games and events, and most do so without experiencing problems. However, some individuals develop substantial impairment related to their gambling behaviors. The essential feature of gambling disorder is persistent and recurrent maladaptive gambling behavior that disrupts personal, family, and/or vocational pursuits (Criterion A). Gambling disorder is defined as a cluster of four or more of the symptoms listed in Criterion A occurring at any time in the same 12-month period.

A pattern of “chasing one’s losses” may develop, with an urgent need to keep gambling (often with the placing of larger bets or the taking of greater risks) to undo a loss or series of losses. The individual may abandon his or her gambling strategy and try to win back losses all at once. Although many gamblers may “chase” for short periods of time, it is the frequent, and often long-term, “chase” that is characteristic of gambling disorder (Criterion A6). Individuals may lie to family members, therapists, or others to conceal the extent of involvement with gambling; these instances of deceit may also include, but are not limited to, covering up illegal behaviors such as forgery, fraud, theft, or embezzlement to obtain money with which to gamble (Criterion A7). Individuals may also engage in “bailout” behavior, turning to family or others for help with a desperate financial situation that was caused by gambling (Criterion A9).

Distortions in thinking (e.g., denial, superstitions, a sense of power and control over the outcome of chance events, overconfidence) may be present in individuals with gambling disorder. Many individuals with gambling disorder believe that money is both the cause of and the solution to their problems. Some individuals with gambling disorder are impulsive, competitive, energetic, restless, and easily bored; they may be overly concerned with the approval of others and may be generous to the point of extravagance when winning. Other individuals with gambling disorder are depressed and lonely, and they may gamble when feeling helpless, guilty, or depressed. Up to half of individuals in treatment for gambling disorder have suicidal ideation, and about 17% have attempted suicide.

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