Misdiagnosis of a Behavioral Addiction

Many people with behavioral addictions have been told that they have a form of obsessive-compulsive disorder (OCD). OCD is a mental disorder in which people experience repetitive intrusive thoughts (obsessions) and/or repetitive compulsive mental acts or physical rituals (compulsions). For example, individuals with OCD might experience intrusive obsessional thoughts that they have contaminated their hands with germs and, in response, will repeatedly wash their hands for hours on end in order to neutralize these thoughts.

Viewing behavioral addictions as forms of OCD is based on the common features of repetitive thoughts and behaviors. Certain clinical aspects, such as ritualistic behaviors, are shared between OCD and addictive behaviors (for example, gamblers often do things in a specific order to bring luck; many compulsive buyers excessively collect the things they purchase; kleptomaniacs may collect the things they steal). What’s different between people with behavioral addictions and people with OCD are personality features and biological features. Personality features of individuals with behavioral addictions include being impulsive and seeking rewards and sensations, while people with OCD are typically harm avoidant. In terms of biological differences, increased activity in cortico-basal ganglionic-thalamic circuitry has been described in studies of OCD when symptoms are provoked, but relatively decreased activity has been observed in these brain regions in symptom provocation studies in gambling. Other than in people with trichotillomania (hair pulling) and excoriation (skin-picking) disorder, family studies have not demonstrated an association between most of the behavioral addictions and OCD. Thus, except perhaps with hair-pulling and skin-picking disorders, there is simply less evidence linking these behaviors to OCD than to substance addictions.

Many people report doing their addictive behavior when they are feeling down or stressed, so some researchers and physicians have wondered whether these behaviors are merely symptoms of depression or anxiety. People can engage in either rewarding behaviors or in behaviors that help them “zone out” when they are feeling depressed or anxious. Many people with behavioral addictions report that the pleasurable yet problematic behaviors alleviate negative emotional states. The elevated rates of co-occurrence between these behaviors and depression and anxiety could support a relationship between behavioral addictions and depression or anxiety, at least in some people. This may be why some people who have behavioral addictions respond to treatment with antidepressant medications.

Just as with substance addictions, however, depression in these behaviors may be distinct from primary or uncomplicated depression. For example, depression in behavioral addictions may be a response to shame and embarrassment arising from the specific behaviors of the behavioral addiction, such as stealing. In addition, the repetitive behavior of a behavioral addiction usually continues well after the person’s depression or anxiety has cleared. This suggests that the behaviors are independent from anxiety and depression for most people, though they often coexist.

Many clinicians have little if any familiarity with these behaviors, even though they are very common. Because many health care providers are not familiar with behavioral addictions, they may incorrectly diagnose patients and prescribe treatment that is not useful or possibly even counterproductive. Therefore, patients and their families may have to educate their providers about these disorders. Individuals may be misdiagnosed as having depression instead of a behavioral addiction. Many people engage in all sorts of unhealthy behaviors to relieve, or “self-medicate,” their depression, including, sometimes, sex, gambling, shopping, or unhealthy eating. If the behaviors exist when the person is not depressed, or if the behaviors possibly contribute to the depression, a behavioral addiction may be the primary problem.

Many clinicians misdiagnose the person with a behavioral addiction as having bipolar disorder. When people are manic, they feel euphoric, don’t sleep, and act impulsively, and they may engage in activities that are pleasurable but have negative consequences. They do so because they are not able to judge the negative outcomes appropriately. Excessive gambling, sexual activity, and spending recklessly may all occur during a manic episode (assuming that other symptoms of mania also exist). If the problematic behavior also occurs when the person’s mood is stable, the individual may have a behavioral addiction in addition to bipolar disorder. If this behavior (gambling, sexual activity, spending) is the only problematic one that the person exhibits and there are no other symptoms of mania, then the diagnosis of bipolar disorder is less appropriate than a diagnosis of behavioral addiction.

People are often told that the behavior is simply a symptom of anxiety. It’s true that people who are worried and cannot stop thinking about possible catastrophic outcomes can find relief in distraction or in doing things that help them zone out and forget other problems. Hair pulling, skin picking, Internet use, gambling, sex, eating, and shopping can all provide this sort of transient relief from anxiety. When the behaviors occur or continue to occur even in moments of calm, when no anxiety is present, then they are likely to be independent problems that should be addressed as behavioral addictions.

Finally, because behavioral addictions often co-occur with substance addiction, some clinicians ignore the behavioral addiction and focus on the drug or alcohol problem only. Some people exhibit reckless, impulsive behaviors when intoxicated by alcohol or high on drugs. These individuals may gamble, have reckless sex, spend too much money, pick at their skin, pull their hair, or eat excessively. Alcohol intoxication is often disinhibiting, and people who are intoxicated or high may do things they would not ordinarily do. Stimulants, both prescribed and illicit (cocaine, methamphetamine), can also make people hypersexual and impulsive and can cause picking and pulling behaviors. Cannabis use may result in eating that is out of control. If these symptoms do not decrease or stop when the person is free from drugs and alcohol, then a diagnosis of behavioral addiction would be indicated.

Jon E. Grant, JD, MD, MPH, Brian L. Odlaug, PhD, MPH, and Samuel R. Chamberlain, MD, PhD are the co-authors of "Why Can't I Stop?: Reclaiming Your Life from a Behavioral Addiction"