The Differences Between Behavioural and Substance Addictions
What is addiction? The answer to that question is not as simple as you might think. Indeed, the concept of addiction is quite a hard one to pin down.
One understanding of addiction is that it involves using a substance, or engaging in a behaviour, too much or too often. On this simplistic understanding, someone who drinks too much alcohol, and does so on a daily basis, would qualify as addicted.
There are problems with this definition. For instance, how much is too much? And how often is too often? Who gets to decide?
There is another, more complex definition of addiction. It is the definition used by the Diagnostic and Statistical Manual of Mental Disorders, 5th edition, an authoritative book which deals with a spectrum of addictions and disorders. 
The DSM-5 looks at many different factors in its assessment of addictions. It argues that addictions are associated with certain behaviours and certain responses when access to a substance or activity is denied. Those behaviours might include ignoring the need to eat or drink or getting insufficient sleep. Responses might include anger or frustration when unable to use a substance or perform an activity.
Other signs of addiction which the DSM-5 includes:
- The notion of dependence, which means relying on a substance or behaviour
- The fact that someone will engage in a behaviour or take a substance despite persistent negative consequences
- Neurological changes to the reward system pathway in the brain
In this article, we use the definition that addictions, or addictive disorders, are patterns of behaviour that an individual engages in despite negative consequences.
What is a behavioural addiction?
Much like substance addiction, a behavioural addiction affects the brain’s neural pathways. Behavioural addictions involve repeatedly engaging in an activity that is pleasurable, despite the negative consequences that it incurs.
Common examples of behavioural addictions include gambling addiction, sex addiction, porn addiction, love addiction, internet gaming addiction, internet addiction, shopping addiction, plastic surgery addiction, risky behaviour addiction, exercise addiction and food addiction.
In a behavioural disorder, the person with the disorder obsesses over a certain behaviour to the point where they struggle to think about anything else. They find it difficult not to engage in the behaviour, and have intense cravings when they are unable to perform the behaviour.
They even use behaviour as a means of coping with difficult emotions. Finally, they are unlikely to realise the extent of the problems caused by their addictive behaviour.
The DSM-5 has a section entitled ‘Substance-Related and Addictive Disorders’. In a note justifying the inclusion of gambling disorder in this section, it says:
‘This chapter also includes gambling disorder, reflecting evidence that gambling behaviours activate reward systems similar to those activated by drugs of abuse and produce some behavioural symptoms that appear comparable to those produced by the substance use disorders.
Other excessive behavioural patterns, such as Internet gaming, have also been described, but the research on these and other behavioural syndromes is less clear.’ 
As the DSM-5 points out, gambling disorder has a lot in common with substance use disorders (SUDs). This is a fascinating point, and one we will discuss in more detail later in the article.
What is a substance use disorder?
We’ve talked about behavioural addictions and some of their characteristics. So what about substance use disorders? What are their characteristics? What symptoms do they cause?
The DSM-5 argues that there are cognitive, behavioural and physiological symptoms of SUDs. It states that SUDs have an effect on brain circuits that lasts even beyond the point of detoxification. This manifests itself in cravings and relapses.
It goes on to say that, in order to diagnose a SUD, there are several criteria to look for. These criteria fall under the brackets of ‘impaired control, social impairment, risky use, and pharmacological criteria’. 
Symptoms relating to impaired control include the following:
- The individual takes the substance more often and in greater quantities than planned
- They have often tried and failed to stop using the substance
- The individual spends a considerable amount of time purchasing or acquiring the substance, as well as taking the substance
- Many of the individual’s activities revolve around the substance
- The individual experiences intense cravings for the substance
Social impairment-related symptoms include:
- The individual finds it harder to fulfil duties at work or at home
- They also experience social problems, such as losing friends or becoming more isolated
- They may forgo social activities they used to enjoy in order to use the substance
Risky use symptoms involve:
- Using the substance in situations where it is dangerous for the individual
- Using the substance even when the individual knows that they have a mental or physical health problem which is made worse by using the substance
Pharmacological symptoms include:
- Tolerance refers to needing a larger dose of a substance to achieve the same effect as before. Someone who has been using cannabis for a long time, for instance, will tell you that they need more of the drug in order to achieve the same high
- Most (but not all) drugs lead to withdrawal when the user stops taking them. Hallucinogenics (such as LSD, magic mushrooms) tend not to cause withdrawal symptoms, so this category does not apply to them
Similarities between behavioural and substance use disorders
We’ve spoken about the characteristics of behavioural addictions and SUDs. We’ve also touched upon the idea that some behavioural addictions, such as gambling addiction, are similar to SUDs in a number of ways. So, broadly speaking, what are the similarities between behavioural addictions and substance addictions? And what can this tell us about both forms of addiction?
On a basic level, behavioural addictions involve failing to resist a behaviour which one knows to be harmful. This ends up causing a lot of damage.
Even at this level, we can see the similarities between behavioural and substance addictions. Whether it is gambling, kleptomania, or alcohol addiction, all of these disorders involve a failure to resist impulses.
There are many more similarities between behavioural and substance use disorders. Both tend to kick in at a young age, either during adolescence or in early adulthood.  Both tend to follow a pattern where people quit, and then relapse, and in both cases, people sometimes get better without treatment. 
The phenomenology of engaging in addictive behaviour and using a substance is also similar. Before the act, people report feeling excitement or arousal; during the act, they feel pleasure or relief; after, they may feel shame or regret.
Perhaps surprisingly, behavioural addictions also exhibit similar features to tolerance and withdrawal, characteristics that we might associate with SUDs. In behavioural addictions, studies have found that people need to increase the intensity of behaviour to get the same ‘high’. 
What’s more, abstaining from the addictive behaviour for a long period can cause feelings of emptiness or depression, which corresponds to withdrawal.  There is no physiological side to this withdrawal, so in that regard, it differs from SUD withdrawal. However, it is still significant that those with behavioural addictions suffer a version of withdrawal without having used any substances.
Finally, financial problems and problems with relationships are common with both behavioural addictions (especially gambling addiction) and SUDs. Those with behavioural addictions are likely to break the law in order to fund their addiction, something which is also common among those with SUDs.
More similarities between behavioural and substance addictions: neural imaging
There is some evidence that what happens in the brain during substance use addictions corresponds to what happens in the brain during behavioural addictions. Neuroimaging suggests that the neural circuity of these addictions is the same: in other words, the same pathway is involved in both SUDs and behavioural addictions such as pathological gambling.
In both gambling and SUDs we see the release of dopamine after an instance of either gambling or drug-taking. However, ‘further research is warranted to clarify the precise role of dopamine in pathological gambling and other behavioural addictions.’ 
Are there any differences between behavioural addictions and substance use disorders?
We’ve talked a lot about the similarities between behavioural addictions and SUDs. However, there are some key differences. It’s important to bear these in mind so that we don’t completely elide these two different kinds of addiction.
Perhaps the main difference between behavioural addictions and SUDs is that behavioural addictions are unlikely to lead directly to long-term health problems since they do not involve the regular misuse of a dangerous substance.
Now, it is important to distinguish between direct and indirect health effects of addictive behaviours. For example, gambling addiction can lead indirectly to health consequences such as malnutrition, if the person involved neglects their need to eat and drink.
However, this is not a direct consequence of gambling. Substance use disorders produce direct, adverse health effects for the simple reason that substances are harmful to your body.
There are some exceptions to this rule. Skin-picking disorder, if classed as a behavioural addiction, could be said to lead directly to health effects, such as infections. Similarly, cutting and self-harm, if classed as an addiction, very clearly leads to adverse health effects.
That being said, the majority of addictive behaviours under consideration by the DSM-5 (such as internet addiction, internet gaming addiction, kleptomania and so on) do not lead to direct health consequences on anywhere near the same scale as substance use.
Why is this important? Perhaps only to remind ourselves that there is more damage to the body involved with SUDs, at least on a direct level.
This of course comes with the caveats given above, namely, that there are a few behavioural addictions that are directly harmful to the body, and that indirect harm exists and can be extensive in some cases.
Gambling disorder: a case study of a behavioural addiction
As gambling disorder is the only behavioural addiction listed under ‘substance-related and addictive disorders’ in the DSM-5, it may be interesting to take a closer look at this behavioural addiction and what makes it similar to substance use disorders.
According to the DSM-5, a gambling problem qualifies as a disorder or addiction if a person exhibits four of the following symptoms over the course of 12 months:
- Erratic behaviour, such as lying to conceal gambling involvement
- Impairments noted in terms of interpersonal relationships, functioning at work, or performance in school
- Is reliant on others financially as the result of gambling
- Is restless or excessively irritable when attempting to control or abstain from gambling
- Need to use increasing amounts of money in order to achieve the desired level of excitement
- Regularly attempts to ‘get even’ by returning to gamble after losing large quantities of money
- Regularly preoccupied with gambling
- Repeated unsuccessful attempts made to control, reduce, or abstain from gambling
- Seeks out gambling in order to cope with feelings of distress 
According to the DSM-5, the severity of the disorder can be measured by how many of these symptoms are shown. For example, someone who shows 7 or 8 of these symptoms has a severe gambling disorder, whereas someone who only shows 4 has a relatively mild gambling disorder.
The DSM-5 adds that a common feature of gambling disorder is the pattern of ‘chasing one’s losses’ . This involves gambling more in order to make up for money lost during previous sessions. Lying to family members about the extent of one’s gambling problem is also a common feature.
Gambling is also associated with certain mental distortions. Those suffering from gambling disorders may exhibit superstitions, denial, overconfidence and more.
They may also suffer from suicidal thoughts. Up to 50% of gambling addicts in treatment report having suicidal ideation. 17% have attempted suicide.
Gambling disorder often comes about during the teenage years or as a young adult. It can begin with something as small as a scratch card. It develops over a long period, although this tends to be shorter in females.
Some gamble regularly, others tend to have gambling episodes. Gambling problems often go away for long periods. Some people with gambling disorder mistake these periods of remission for having been cured of their problem completely.
They may begin engaging in small amounts of gambling, thinking that they can do so without becoming addicted. This is often how gambling disorder returns.
Generally speaking, gambling disorders are more common in males. It is also more common among younger and middle-aged people than older people.
Finally, gambling is often accompanied by poor physical health. This includes general ill-health and specific conditions such as tachycardia, which are more common in the gambling population. Mental health conditions such as depression and anxiety are also common.
Another issue with behavioural and substance use disorders is the high rates of comorbidity. Comorbidity refers to the presence of more than one disorder, for example, gambling disorder and alcohol use disorder. High rates of comorbidity have been found between gambling and substance use disorders. 
Substance use and behavioural disorders often go hand-in-hand. Someone with an alcohol use disorder is more likely to engage in risky behaviour, such as gambling; someone with a gambling disorder might be more likely to drink to excess, if, for example, they have a major win or a major loss.
Comorbidity is one of the challenges of treating behavioural disorders. The combination of a behavioural disorder and a substance use disorder adds an added layer of complexity which often needs to be unravelled in rehab.
Treatment for behavioural addictions
Treatment for behavioural addictions typically involves cognitive behavioural therapy, motivational enhancement and 12-step programmes. These three forms of treatment have been successful in treating behavioural disorders such as pathological gambling, skin picking, compulsive buying and kleptomania.  
Other forms of treatment for behavioural disorders include psychosocial approaches. This involves preventing relapses by planning for high-risk situations, encouraging sobriety and making lifestyle changes. Due to the frequent comorbidity between behavioural and substance addictions, getting sober is often a key component of treatment for behavioural addictions.
No medications have been approved for the treatment of behavioural addictions yet, but a few have shown promise. The most common is naltrexone, an opioid antagonist used to treat a variety of substance use disorders. Several studies have shown that naltrexone has a positive effect on a range of behavioural disorders.  
Behavioural addictions have yet to be fully understood. Research has shown that they bear a lot of similarities to substance use disorders, but there is still progress to be made if we are to treat these addictions as effectively as SUDs.
 American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://dsm.psychiatryonline.org/doi/book/10.1176/appi.books.9780890425596
About the author:
Jon writes for ADT Healthcare and a number of other websites. Jon graduated with a degree in psychology in 1992. Jon has been in recovery for 19 years.