Day # 171: Other Addictive Disorders

Today we will discuss "other" addictive disorders beyond substance use, commonly referred to as behavioral addictions or non-substance-related addictive disorders.

Today's Content Level: Intermediate to Advanced

Introduction 1, 2

• Addiction is traditionally conceptualized within the context of substance use. However, the core features of addiction are not inherently substance-specific (e.g., impaired control, craving, continued engagement despite harm, and functional impairment).

• Over time, there has been increasing interest in whether certain behaviors may represent non-substance (behavioral) addictions. The challenge is determining where to draw the line between normal behavior, maladaptive coping, compulsivity, and true addiction.

• This post takes a different approach than most in this series. Instead of going deep on one disorder, we will review the current landscape of behavioral addictions, with an emphasis on what is formally recognized, what remains under investigation, and what is commonly encountered in clinical practice.

Gambling Disorder 3, 4

• Gambling Disorder is the only non-substance-related disorder formally classified as an addiction in the DSM.

• It was previously categorized as an impulse control disorder but was reclassified due to substantial overlap with substance use disorders, including:

  • Activation of mesolimbic reward pathways

  • Tolerance-like phenomena (increasing monetary risk)

  • Withdrawal-like symptoms (irritability, restlessness)

  • Persistent engagement despite significant consequences

• Diagnostic features parallel substance use disorders:

  • Loss of control over behavior

  • Repeated unsuccessful attempts to cut back

  • Continued behavior despite harm (financial, occupational, or relational)

  • Preoccupation and “chasing losses”

• Gambling Disorder serves as the model behavioral addiction, and other proposed conditions are often evaluated against it.

Internet Gaming Disorder (IGD) 4, 5

• Internet Gaming Disorder (IGD) is included in the DSM as a condition for further study, reflecting growing but not yet definitive evidence.

• Proposed criteria closely mirror those of substance use disorders:

  • Preoccupation with gaming

  • Withdrawal symptoms when unable to play

  • Tolerance (increasing time spent gaming)

  • Loss of control

  • Continued use despite negative consequences

• Gaming is a normative behavior, especially in adolescents and young adults. The vast majority of gamers don’t have a disorder. The primary diagnostic challenge is distinguishing high engagement from pathological use, particularly given the normative nature of gaming in many populations.

• Clinical indicators that suggest disorder include:

  • Functional impairment (academic or occupational decline)

  • Social withdrawal

  • Sleep disruption

  • Failed attempts to reduce use

• IGD remains one of the most likely candidates for future inclusion as a formal behavioral addiction.

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Internet / Social Media Use 6

• Problematic internet and social media use are increasingly common presenting concerns. Patients frequently describe compulsive patterns characterized by:

  • Excessive time spent online

  • Difficulty disengaging

  • Craving or urge-driven use

  • Interference with sleep, attention, and relationships

• These platforms are expertly designed to reinforce engagement through:

  • Variable reward schedules

  • Continuous content delivery ("infinite scroll")

  • Social reinforcement mechanisms

• Despite these parallels to addiction models, internet and social media use are not DSM diagnoses at this point in time (in 2026).

• Current limitations include:

  • Lack of standardized diagnostic criteria

  • Difficulty distinguishing normative from pathological use

  • Insufficient longitudinal and neurobiological data

• Clinically, it may still be useful to conceptualize severe cases through an addiction framework, particularly when there is clear functional impairment.

  • Identify triggers

  • Replace with alternative behaviors

  • Address underlying anxiety, boredom, or loneliness

  • Build "friction" into use

    • Add delays (apps can introduce a forced mandatory waiting period before opening)

    • Remove social media apps and only access them through a browser

    • Disable all non-essential notifications

    • Replace phone-based applications with physical ones to decrease reliance on phones (e.g., alarm clock, journal, planner, calendar)

    • Use grayscale mode, making the interface less stimulating and appealing

    • Remove password saving, forcing you to type login credential each time

Pornography & Sex Addiction

Pornography 7

• Problematic pornography use is a common but diagnostically ambiguous clinical presentation.

• Patients may report:

  • Escalation in frequency or intensity of use

  • Subjective craving or urge states

  • Difficulty controlling behavior

  • Continued use despite negative consequences. Examples could include:

    • Relationship dysfunction → decreased intimacy, emotional alienation, feelings of betrayal, unrealistic sexual expectations, partner dissatisfaction.

    • Mental health → multiple cross-sectional studies show associations between higher/problematic pornography use and increased depressive symptoms, higher anxiety, lower self-esteem, increased apathy, and social isolation. Directionality of this association is unclear and an important confounding factor is distress related to moral incongruence when behavior conflicts with personal or religious values.

    • Pornography-Induced Erectile Dysfunction (PIED) → proposed phenomenon where individuals report difficulty achieving or maintaining erections with partners but have preserved erectile function with pornography.

• While these features resemble addiction, pornography use is not recognized as a DSM disorder.

• A key clinical challenge is differentiating:

  • High baseline libido

  • Moral or value-based distress

  • Compulsive behavior vs addiction-like patterns

• Not all distress associated with pornography use reflects a psychiatric disorder. However, in cases with clear loss of control and functional impairment, an addiction-based conceptualization may be clinically useful.

Sex Addiction 8

• “Sex addiction” is a widely used term but is not a DSM diagnosis. This construct remains controversial, in part due to concerns about over-pathologizing normative sexual behavior and the lack of consistent diagnostic criteria.

• The term is typically used to conceptualize problematic sexual behavior through an addiction framework, emphasizing features such as craving, loss of control, tolerance-like escalation, and continued engagement despite harm or negative consequences.

• A related condition, Compulsive Sexual Behavior Disorder (CSBD), is included in ICD-11, where it is classified as an impulse control disorder.

• CSBD is characterized by:

  • Persistent patterns of failure to control intense sexual impulses or urges

  • Repetitive sexual behavior despite adverse consequences

  • Significant distress or impairment

• The classification reflects ongoing uncertainty regarding whether problematic sexual behavior is best understood as:

  • An addictive disorder

  • An impulse control disorder

  • A compulsive (OCD-spectrum) condition

• Clinically, patients often exhibit features spanning all three domains.

  • Urges (impulsivity)

  • Repetitive behavior despite consequences (addiction-like)

  • Difficulty stopping despite lack of pleasure (compulsivity)

• As such, management is typically guided by:

  • Degree of impairment

  • Loss of control

  • Underlying psychiatric comorbidities (e.g., mood, anxiety, trauma-related disorders)

Other Potential Areas for Study

• Several additional behaviors have been proposed as potential behavioral addictions but are not currently included in formal diagnostic systems.

• Shopping (Compulsive Buying)

  • Recurrent, excessive purchasing

  • Temporary relief followed by guilt or regret

  • Financial and interpersonal consequences

• Exercise

  • Rigid, compulsive exercise patterns

  • Persistence despite injury

  • Distress when unable to engage

• Food Addiction

  • Loss of control over intake

  • Craving highly palatable foods

  • Overlap with established eating disorders (e.g., binge eating disorder)

• Workaholism

  • Excessive work involvement

  • Difficulty disengaging

  • Impairment in relationships and health

• These behaviors may become maladaptive and impairing. However, it remains unclear whether they represent:

  • Distinct addictive disorders

  • Maladaptive coping strategies

  • Manifestations of other psychiatric conditions

• At present, the DSM maintains a conservative approach, requiring robust evidence before expanding the addiction category.

Conclusion

• The concept of behavioral addiction continues to evolve. While the neurobiological overlap with substance use disorders is increasingly recognized, the threshold for formal diagnostic inclusion remains high.

• Current classification can be summarized as follows:

  • Established: Gambling Disorder

  • Emerging: Internet Gaming Disorder

  • Under debate: Pornography, sexual behavior, social media use

  • Exploratory: Shopping, exercise, food, work

• From a clinical standpoint, the focus should remain on:

  • Loss of control

  • Functional impairment

  • Persistence despite harm

• Regardless of diagnostic classification, behaviors meeting these criteria warrant clinical attention and intervention.

Resources for today's post include:

• First Aid for Psychiatry

• DSM-5-TR

• Articles referenced above

See our full list of book recommendations for the most up-to-date editions.

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