“Addiction is a monster; it lives inside, and feeds off of you, takes from you, controls you, and destroys you. It is a beast that tears you apart, rips out your soul, and laughs at your weakness. It is a stone wall that stands to keep you in and the rest out. It is a shadow that always lurks behind you, waiting to strike. Addiction lives in everyone’s mind ... sitting, staring, waiting.” — Anonymous

This is the third of a three part series of articles on “What We Are Talking About When We Talk About Addiction.” In the first article I talked about the four primary ways we use the term today. In the second article I talked about behavioral addictions — and why they are not listed as diagnosable conditions in the DSM-5 (the manual used by therapists in the US to diagnose and treat pathologies, and insurance companies to pay for these treatments).

In this article we’ll be talking more about the current confusion about behavioral addictions … and why we really need to take them seriously, even if the DSM-5 (for the most part) ignores them.

Two Things Have Happened at the Same Time:

First, advances in neurobiology (especially brain scans) have revealed that behavioral addictions function in the brain — and therefore in the lives of people — just like substance addictions. 

As recently as 30 years ago, clinicians and researchers alike treated “addiction” as something that only happens with substances that have unique “addictive” components.

Now we’re able to actually “see inside the brain” (via brain imaging) of addicts craving and using various substances. And then we can compare this to brain imaging of other addicts craving and engaging in various addictive behaviors. What do we find?

The same thing is happening, whether the addictive agent is a substance or a process/behavior.

If you doubt this, feel free to do some searching online about “brain scan comparisons between behavioral and substance addiction” or something similar. Get ready to go down a rabbit hole. It’s no longer debatable.

The “Cambridge Handbook of Substance and Behavioral Addictions” contains a chapter titled, “Neurobiological Foundations of Behavioral Addictions.” In their summary, the authors write:

“Behavioral addictions have been found to have similar neurobiological correlates with each other and with substance use disorders on multiple levels of analysis such as alterations in availability of receptors in mesolimbic pathways, the amplitudes of cue-induced late potentials, and frontostriatal activity during reward-based tasks. The implicated neuropathological features support the inclusion of nonsubstance behaviors as addictive behaviors.”

The more we learn about the brain, and about how addiction functions, the more obvious it is that behavioral addictions work the same way — and therefore can be just as damaging — as substance addictions.

Why aren’t they being recognized as such for clinical work?

This brings us to the second thing that has happened: 

SECOND, addiction counseling — and therapy in general — has been taken over by insurance companies. 

I have worked closely with therapists for 18 years (serving as director of training for a group of therapists for 5 of these years, running addiction workshops). I’m currently back in my role as a pastor, and do addiction training and coaching as a side venture. At the same time, my wife is a therapist, and has worked in multiple states, for several different agencies.

I have both an insider’s view and an outsider’s perspective on the “therapy world,” and this is what I see:

Almost all therapy and addiction treatment is paid for by insurance companies — or at least run through them, even if the client pays most of it out of pocket — and consequently is controlled by them in many ways.

There are rare exceptions to this, where therapists are so well-known, and/or deal with rich clients, so they are able to have patients pay in cash for their services, and thus dispense with insurance companies and the limitations they place on care.

But for the vast majority of therapists here in the US, everything they do is dictated by the guidelines established by insurance companies. The first thing a therapist must do with a client, is to establish a clinical diagnosis — to label the specific problem a person is having, using the categories established by the DSM (The Diagnostic and Statistical Manual of Mental Disorders, now in its fifth edition, known as DSM-5).

Once this is done, insurance companies often impose limits on the number of sessions available to the client for treatment. They can, and sometimes do, request an audit of the records a therapist keeps, to ensure that the treatment — which they are paying for — falls within the guidelines of the diagnosis that has been established.

It’s hard to overstate how absolutely inter-twined the work of therapists are with insurance companies. Even small counseling centers usually have at least one full or part time staff person who’s only job is to interface between counselors, clients, and insurance companies: ensuring compliance with standards, accuracy on all forms, and (frequently) resolving conflicts when insurance companies refuse to pay for certain treatments.

As I pointed out in the previous article in this series, Federal law in the US requires that insurance companies pay for treatments for mental health disorders, just as they would pay for other physical ailments.

Now we get to the point I was making in the previous article. This is my own personal view, and you are free to disagree. But I am convinced that:

As long as insurance companies have any say in these discussions, behavioral addictions like food, sex, Internet, and gaming addictions will never find their way into the DSM as diagnosable conditions, because this would require them to pay for treatments of — arguably — the majority of the US adult population.

When I say that, I’m guessing your first reaction is, “Really? The majority of the US population? Are you sure?” I’ve been doing workshops, and speaking to various audiences around the world about these issues, and this is what I have come to believe.

Let me show you why.

Ask yourself: How many Americans are overweight or obese? (Right now it's nearly half, and the percentage is growing every year.) How many of these are struggling, even after trying diet after diet, because they are unable to control their behavior, despite its negative consequences in their lives? 

How many Americans are compulsive users of pornography, struggling to limit or stop its use? How many people are compulsive users of video games? Social media? Whenever I do the math on these questions, it adds up fast.

But don’t believe me, or worry about making sweeping generalizations of other people. Just take an honest look at your own life.

A Thought Experiment: 

Try Applying the Same Criteria the DSM-5 Lists for “Substance Use Disorder” to Behavioral Addictions Like Food and Sex

If the DSM-5 has established a set of criteria to diagnose “substance use disorder” — which is has — doesn’t it make sense that we should use those same criteria to diagnose other forms of addiction?

Interesting thought. What happens if we do this?

Take a look at the list below. These are the criteria used in the DSM-5 to diagnose “substance use disorder.” The way the DSM works with any diagnosis is as follows: it will list a certain number of criteria related to that disorder, and then a clinician will help the client to determine how many of the criteria they meet. 

If you do a self-assessment, it’s simply a matter of noting how many of the criteria you say “YES” to. In this case, there are 11 criteria, and the diagnostic assessment essentially boils down to: “How many of these 11 criteria are true of you?”

Here’s the experiment: As you read through the list, substitute “ultra-processed food” or “junk food” for “substance.” Take the test, based on how these ultra-processed junk foods are affecting your life.

(Alternative: try going through the list, and substitute “sex” or “pornography” for “substance.” Of if your concern is video gaming or social media use, substitute that for “substance.”)

Don’t just mentally go over the list … WRITE DOWN “YES” or “NO” to each question — either on paper or your computer — and keep track of your answers. Then tally the final score. How many answers of “yes this is true of me” did you get?

Here are the questions:

1. Using more of a substance than intended or using it for longer than you’re meant to.
2. Trying to cut down or stop using the substance but being unable to.
3. Experiencing intense cravings or urges to use the substance.
4. Needing more of the substance to get the desired effect — also called tolerance.
5. Developing withdrawal symptoms when not using the substance.
6. Spending more time getting and using the substance and/or recovering from substance use.
7. Neglecting responsibilities at home, work or school because of substance use.
8. Continuing to use even when it causes relationship problems.
9. Giving up important or desirable social and recreational activities due to substance use.
10. Using substances in risky settings that put you in danger.
11. Continuing to use despite the substance causing problems to your physical and mental health.

What score did you come up with? How many of these criteria are met in your life with your use of food, or sex, or pornography?

Here is how the DSM uses these criteria to determine a diagnosis:

• If you meet 2–3 criteria — you have a “mild” Substance Use Disorder (SUD)
• If you meet 4–5 criteria — you have a “moderate” disorder
• If you meet 6 or more — you have a “severe” disorder, which signals addiction to that substance. In other words, if you said “yes” to more than half the questions, you should be diagnosed with “severe (fill-in-the-blank) use disorder.”

I have gone through this thought experiment in talks to audiences in a variety of settings. People get visibly uncomfortable as they realize how many of these characteristics apply to certain behaviors in their own life.

I have no doubt that if we implemented just two categories of behavioral addiction — food and sex — and simply used the same criteria as with substance use, at least half of the US population would qualify for treatment for one or both of these disorders. If we added computer gaming and social media use, the numbers would go even higher.

Let’s go back to the question: are “behavioral addictions” really “addictions?” Do they function in a similar way, and damage a person’s well-being and relationships? My experience and observation is: absolutely yes. 

If you don’t believe this, talk to someone who’s battled obesity their entire life, or someone who’s lost jobs and relationships because of out-of-control sex addiction.

So let’s ask the question one more time: If this is so, why are they NOT defined and diagnosable as such in the DSM — the manual for therapists? I made this point in the previous article, but it bears repeating:

Because if they were, our whole system of therapy, treatment, and health insurance would be overwhelmed and collapse. Therapists would be inundated, and insurance companies would go out of business. This is especially true now that expensive GLP-1 medications have emerged as the best treatment for food addiction.

The Liability Issue

Not only that, but there’s also concerns about liability. If sex addiction is listed as a diagnosable mental health disorder, then it might be used as a defense in sexual assault cases. Would pornography companies then be liable for the consequences in peoples’ lives?

Or what about food? Could food companies be held liable for making people addicted, by engineering their products to spike dopamine?

These are just theoretical questions now, but if food and sex addiction were to get recognized as official diagnosis, it would open the door to a flood of litigation.

And so … now you know why (I believe) they’ll never be listed as addictions. Even if they are addictions. Even if they are damaging peoples’ lives, relationships, and health.

So What Does This Mean For US … Right Now?

As I’ve indicated several times in these articles, I speak about these issues in a variety of settings, and I’ve thought a lot about this. Here are the three things I try to emphasize in every talk I give ... because these are things every person needs to know:

1. We need to get beyond any antiquated notions of “addiction” being exclusively a problem related to chemical substances we ingest. Behavioral addictions are just as real, significantly more prevalent, and can be extremely damaging. Stop listening to people who try to downplay the validity of behavioral addictions, just because they’re not listed as diagnosable disorders. As I hope I’ve shown in this article, they don’t know what they’re talking about.

2. While #1 is true, it’s also the case that addictive agents vary widely in how destructive they are. We can argue all day about whether video games are as addictive as methamphetamines … but I’m sure that we will still agree that meth is much more dangerous and life-threatening. We could probably arrange a scale of how damaging each addiction is to a person’s life, and how likely it is to kill them.

But don’t let this exercise cause you to dismiss the damage of whatever addiction you’re dealing with. They’re all time-, energy-, money-, relationship-, and joy-killers. Left unchecked, they will all wreck your relationships, your self-esteem and respect, and ultimately kill you. Every single one.

3. If you struggle with behavioral addictions, take it seriously and get the help you need. This is the bottom line. This is what everything I’ve written in these three articles comes down to:

Is the problem in your life deeper than just a simple bad habit … is it a behavioral addiction?

What did you find when you took the self-assessment above, based on the 11 criteria? Be honest with yourself: Is this damaging your life? Are you willing to keep living like this? What if things get worse?

Just so you know, current research and the experience of millions of people demonstrates that, however bad it is right now for you, if you don’t make changes, it WILL get worse.

By definition, if something is an addiction then it is something you can’t “just stop” by deciding to. You have to take deliberate — some might even say “extreme” — measures. You have to keep at it. You have to get help, because it’s extremely rare for people to overcome addictions without getting help and support from others.

If you’d like to talk about the ways that programs I run might help you, feel free to reach out to me. If not, there are lots of other programs and people who are capable of providing help to you. I hope you’ll reach out and get the help you need.

Don’t wait for the therapy world to come around on this issue. Take charge and get the help you need right now.