Understanding Addiction and Compulsive Disorders: An Overview of the American College of Addictionology and Compulsive Disorders
Addiction is a complex, multifaceted disease encompassing psychosocial, genetic, spiritual, and metabolic components. It is estimated that up to 20% of the nation's population suffers from this disease, which is a leading cause of death and crime due to an error of omission. The American College of Addictionology and Compulsive Disorders (ACACD) offers comprehensive programs to train professionals in addiction intervention, treatment, and recovery management. This article provides an overview of addiction and compulsive disorders, drawing on current research and clinical insights to inform the discussion on the relationship between psychoactive substance use and behavioral addictions.
The Spectrum of Addictive Behaviors
Several behaviors, besides psychoactive substance ingestion, produce short-term reward that may engender persistent behavior despite knowledge of adverse consequences, i.e., diminished control over the behavior. Diminished control is a core defining concept of psychoactive substance dependence or addiction. These disorders have historically been conceptualized in several ways. One view posits these disorders as lying along an impulsive-compulsive spectrum, with some classified as impulse control disorders. The current Diagnostic and Statistical Manual, 4th Edition (DSM-IV-TR) has designated formal diagnostic criteria for several of these disorders (e.g., pathological gambling, kleptomania), classifying them as impulse control disorders, a separate category from substance use disorders.
This similarity has given rise to the concept of non-substance or “behavioral” addictions, i.e., syndromes analogous to substance addiction, but with a behavioral focus other than ingestion of a psychoactive substance. The concept of behavioral addictions has some scientific and clinical heuristic value, but remains controversial. Several behavioral addictions have been hypothesized as having similarities to substance addictions. Other behaviors (or impulse control disorders) have been considered for inclusion in the forthcoming DSM - compulsive buying, pathologic skin picking, sexual addiction (non-paraphilic hypersexuality), excessive tanning, computer/video game playing, and internet addiction. Which behaviors to include as behavioral addictions is still open for debate. Not all impulse control disorders, or disorders characterized by impulsivity, should be considered behavioral addictions. Although many of the impulse control disorders (e.g., pathological gambling, kleptomania) appear to share core features with substance addictions, others, such as intermittent explosive disorder, may not.
Behavioral Addictions: A Closer Look
The essential feature of behavioral addictions is the failure to resist an impulse, drive, or temptation to perform an act that is harmful to the person or to others. Each behavioral addiction is characterized by a recurrent pattern of behavior that has this essential feature within a specific domain. The repetitive engagement in these behaviors ultimately interferes with functioning in other domains. In this respect, the behavioral addictions resemble substance use disorders.
Behavioral addictions are often preceded by feelings of “tension or arousal before committing the act” and “pleasure, gratification or relief at the time of committing the act”. The ego-syntonic nature of these behaviors is experientially similar to the experience of substance use behaviors. This contrasts with the ego-dystonic nature of obsessive-compulsive disorder.
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Many people with behavioral addictions report an urge or craving state prior to initiating the behavior, as do individuals with substance use disorders prior to substance use. Additionally, these behaviors often decrease anxiety and result in a positive mood state or “high”, similar to substance intoxication. Emotional dysregulation may contribute to cravings in both behavioral and substance use disorders. Many people with pathological gambling, kleptomania, compulsive sexual behavior, and compulsive buying report a decrease in these positive mood effects with repeated behaviors or a need to increase the intensity of behavior to achieve the same mood effect, analogous to tolerance. Many people with these behavioral addictions also report a dysphoric state while abstaining from the behaviors, analogous to withdrawal.
Parallels Between Behavioral and Substance Addictions
Growing evidence suggests that behavioral addictions resemble substance addictions in many domains, including natural history, phenomenology, tolerance, comorbidity, overlapping genetic contribution, neurobiological mechanisms, and response to treatment, supporting the DSM-V Task Force proposed new category of Addiction and Related Disorders encompassing both substance use disorders and non-substance addictions. Current data suggest that this combined category may be appropriate for pathological gambling and a few other better studied behavioral addictions, e.g., Internet addiction.
Behavioral and substance addictions have many similarities in natural history, phenomenology, and adverse consequences. Both have onset in adolescence and young adulthood and higher rates in these age groups than among older adults.
As in substance use disorders, financial and marital problems are common in behavioral addictions. Individuals with behavioral addictions and those with substance use disorders both score high on self-report measures of impulsivity and sensation-seeking and generally low on measures of harm avoidance. However, individuals with some behavioral addictions, such as internet addiction or pathological gambling, may also report high levels of harm avoidance. Other research has suggested that aspects of psychoticism, interpersonal conflict, and self-directedness may all play a role in internet addiction . In contrast, individuals with obsessive compulsive disorder generally score high on measures of harm avoidance and low on impulsivity. Individuals with behavioral addictions also score high on measures of compulsivity, but these may be limited to impaired control over mental activities and worries about losing control over motor behaviors.
Comorbidity and Overlapping Vulnerabilities
Although most nationally representative studies have not included assessment of behavioral addictions, existing epidemiological data support a relationship between pathological gambling and substance use disorders, with high rates of co-occurrence in each direction. The St. Louis Epidemiologic Catchment Area (ECA) study found high rates of co-occurrence for substance use disorders (including nicotine dependence) and pathological gambling, with the highest odds ratios generally observed between gambling, alcohol use disorders, and antisocial personality disorder. A Canadian epidemiological survey estimated that the relative risk for an alcohol use disorder increased 3.8-fold when disordered gambling was present. Among individuals with substance dependence, the risk of moderate to high severity gambling was 2.9 times higher. Clinical samples of other behavioral addictions suggest that co-occurrence with substance use disorders is common.
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However, data about substance use comorbidity must be interpreted cautiously because any causal associations may manifest on a behavioral level (for example, alcohol use disinhibits a range of inappropriate behaviors, including those identified as addictive) or on a syndromal level (for example, a behavioral addiction starts after alcoholism treatment, possibly as a substitute for drinking). Problem gamblers with frequent alcohol use have greater gambling severity and more psychosocial problems resulting from gambling than those without alcohol use histories , and adolescents who are moderate to high frequency drinkers are more likely to gamble frequently than those who are not, suggesting a behavioral interaction between alcohol and gambling. In contrast, a similar finding regarding nicotine use suggests a syndromal interaction, as does the fact that adults with pathological gambling who are current or prior smokers had significantly stronger urges to gamble.
Other psychiatric disorders, such as major depressive disorder, bipolar disorder, obsessive compulsive disorder, and attention deficit hyperactivity disorder, are also commonly reported in association with behavioral addictions. However, many of these comorbidity studies were based on clinical samples.
Behavioral addictions and substance use disorders may have common cognitive features. Both pathological gamblers and individuals with substance use disorders typically discount rewards rapidly and perform disadvantageously on decision-making tasks such as the Iowa Gambling Task, a paradigm that assesses risk-reward decision making . In contrast, a study of individuals with internet addiction demonstrated no such deficits in decision-making on the Iowa Gambling Task.
Neurobiological Mechanisms
A growing body of literature implicates multiple neurotransmitter systems (e.g., serotonergic, dopaminergic, noradrenergic, opioidergic) in the pathophysiology of behavioral addictions and substance use disorders. Evidence for serotonergic involvement in behavioral addictions and substance use disorders comes in part from studies of platelet monoamine oxidase B (MAO-B) activity, which correlates with cerebrospinal fluid (CSF) levels of 5-hydroxyindole acetic acid (5-HIAA, a metabolite of 5-HT) and is considered a peripheral marker of 5-HT function. Low CSF 5-HIAA levels correlate with high levels of impulsivity and sensation-seeking and have been found in pathological gambling and substance use disorders.
The repetitive use of substances or engagement in a behavioral addiction following an urge may reflect a unitary process. Preclinical and clinical studies suggest that an underlying biological mechanism for urge-driven disorders may involve the processing of incoming reward input by the ventral tegmental area/nucleus accumbens/orbital frontal cortex circuit. The ventral tegmental area contains neurons that release dopamine to the nucleus accumbens and orbital frontal cortex. Limited evidence from neuroimaging studies supports a shared neurocircuitry of behavioral addictions and substance use disorders. Diminished activity of the ventral medial prefrontal cortex (vmPFC) has been associated with impulsive decision making in risk-reward assessments and with decreased response to gambling cues in pathological gamblers. Similarly abnormal vmPFC functioning has been found in people with substance use disorders.
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Brain imaging research suggests that the dopaminergic mesolimbic pathway from the ventral tegmental area to the nucleus accumbens may be involved in both substance use disorders and pathological gambling. Subjects with pathological gambling demonstrated less ventral striatal neuronal activity with fMRI while performing simulated gambling than did control subjects, similar to observations in alcohol-dependent subjects when processing monetary rewards. Diminished ventral striatal activation has also been implicated in the cravings associated with substance and behavioral addictions.
Dopamine involvement in behavioral addictions is also suggested by studies of medicated PD patients. Two studies of patients with PD found that more than 6% experienced a new onset behavioral addiction or impulse control disorder (e.g., pathological gambling, sexual addiction), with substantially higher rates among those taking dopamine agonist medication. A higher levo-dopa dose equivalence was associated with greater likelihood of having a behavioral addiction. Contrary to what might be expected from dopamine involvement, antagonists at dopamine D2/D3 receptors enhance gambling-related motivations and behaviors in non-PD individuals with pathological gambling and have no efficacy in the treatment of pathological gambling.
Genetic Factors
Relatively few family history/genetics studies of behavioral addiction have been designed with appropriate control groups. Small family studies of probands with pathological gambling , kleptomania, or compulsive buying each found that first-degree relatives of the probands had significantly higher lifetime rates of alcohol and other substance use disorders, and of depression and other psychiatric disorders, than did control subjects.
The genetic versus environmental contributions to specific behaviors and disorders can be estimated by comparing their concordance in identical (monozygotic) and fraternal (dizygotic) twin pairs. In a study of male twins using the Vietnam Era Twin Registry, 12% to 20% of the genetic variation in risk for pathological gambling and 3% to 8% of the nonshared environmental variation in risk for pathological gambling was accounted for by risk for alcohol use disorders. Two-thirds (64%) of the co-occurrence between pathological gambling and alcohol use disorders was attributable to genes that influence both disorders, suggesting overlap in the genetically transmitted underpinnings of both conditions.
There are very few molecular genetic studies of behavioral addictions. The D2A1 allele of the D2 dopamine receptor gene (DRD2) increases in frequency from individuals with non-problematic gambling to pathological gambling and co-occurring pathological gambling and substance use disorders. Several DRD2 gene single nucleotide polymorphisms (SNPs) have been associated with personality measures of impulsivity and experimental measures of behavioral inhibition in healthy volunteers , but these have not been evaluated in people with behavioral addictions.
Treatment Approaches
Behavioral addictions and substance use disorders often respond positively to the same treatments, both psychosocial and pharmacological. The 12-step self-help approaches, motivational enhancement, and cognitive behavioral therapies commonly used to treat substance use disorders have been successfully used to treat.
The American College of Addictionology and Compulsive Disorders (ACACD)
The American College of Addictionology and Compulsive Disorders stands ready to prepare and train individuals with the knowledge and skill-both academically and clinically-to properly meet the needs of this most devastating epidemic. The "C.Ad." Certified Addictionologist credential is granted upon successful completion of the 150-hour, 10-module program and examination, and the "DACACD" Diplomate (Board Certification) is granted in the 300-hour, 20-module program. These programs equip participants with the skills required to become primary intervention resources in addiction and compulsive disorders intervention, treatment, and recovery management.
The ACACD is committed to supporting a diversified and comprehensive, broadly based program utilizing both the didactic method and the applied clinical approach in teaching. This will allow both the "C.Ad." and "DACACD" designees a more enjoyable classroom experience, leading to successful opportunities to function in hospitals, residential treatment centers, outpatient programs, federal, state and county criminal justice programs, as well as in their private practice setting. The ACACD program is approved/certified by many states, including the Florida Certification Board (FCB), the Israel, India, Dominica and Japan Certification Boards, and many other State Boards, which are Member Boards of International Certification & Reciprocity Consortium (ICRC).
Addressing Substance Use Disorders: Resources and Training
The Drug Enforcement Administration (DEA) requires a one-time attestation of training on the management of substance use disorders (SUDs) prior to the renewal of a DEA registration. This requirement, which began on June 27, 2023, mandates the completion of eight hours of training on the treatment and management of patients with opioid or other SUDs.
The American College of Physicians (ACP), as an ACCME-accredited CME provider, offers various activities that count toward meeting this new DEA attestation requirement. These include interactive training modules, AI-powered simulation tools for practicing brief interventions, video bundles covering strategies for treating SUD, and podcasts discussing topics such as high-concentration cannabinoids and kratom.
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