Kleptomania, gambling, sex, physical exercise, work among addictions explored in new book
Can someone actually get addicted to their indoor tanning salon?
When the American Academy of Dermatology made that connection in 2005, no one reacted more viscerally than Petros Levounis, who chairs the Department of Psychiatry at Rutgers New Jersey Medical School.
"I got very upset and went on national television and said, 'This is a disgrace'," he recalled. "We are trivializing the struggles of people who have to combat alcoholism, heroin abuse and cocaine addiction and the like."
Fast forward 10 years. Levounis and fellow lead author, Michael S. Ascher, a clinical associate in psychiatry at the University of Pennsylvania, have just released The Behavioral Addictions, a compilation of case studies of addictions unrelated to drugs or alcohol, which states on Page 187: "Tanning Addiction: When Orange Is The New Bronze."
Why the change of heart?
"I have had a change of heart, or more correctly, a change of mind because the data are such that they really point in the direction that these behavioral addictions run along very similar channels as substance use disorders," Levounis said. "That's both on clinical grounds, in terms of what we see in the presentation of our patients, and also on the basis of the neurobiology of the disorder, the science of how we understand addiction in 2015."
Additional chapters of The Behavioral Addictions address kleptomania, gambling, sex, Internet surfing, physical exercise, work and five other behaviors that make up the authors' dirty dozen behavioral addictions. Levounis and Ascher gathered contributions from 31 co-authors in assembling the case studies, then went a step further by recruiting students at NJMS to produce and act in videos portraying encounters between a "patient" and their clinician exploring a behavioral addiction. The book and videos were designed to work in tandem.
Levounis said his work with crystal methamphetamine addiction among gay men led him into the field of behavioral addiction. Many of the addicts also suffered sexual compulsions, he explained, so that in order to treat their drug addiction effectively, his group had to become expert in sex addiction.
The understanding and treatment of behavioral addictions are still at a rudimentary stage, according to Levounis. In fact, only gambling among the behavioral addictions is currently recognized as a medical disorder, gaining entry in 2013 to the Diagnostic Statistical Manual (DSM-5) published by the American Psychiatric Association. Recognition in the DSM-5 is essential for treatment to qualify for insurance reimbursement.
"Other disorders have less literature and less scientific investigation behind them, but it is more that the overall underlying machinery of these behavioral addictions does seem to be pretty well accepted as part of the more classical addictions like alcohol, heroin, and cocaine," Levounis said.
From a neurological standpoint, the journeys for both substance and behavioral addiction end up in the same reward-pleasure lanes in the brain. Whereas the on-ramps for drugs and alcohol are becoming better understood, Levounis explained, the corresponding entry points, or receptor targets, for behavioral addictions are not.
Apart from a medication approved earlier this year by the U.S. Food and Drug Administration to treat binge-eating disorder, treatment now relies exclusively on individual and group psychotherapy, motivational interviewing, and mutual help groups. Whereas drug and alcohol addiction can be treated through abstinence, he noted, that is not an option for a number of behavioral addictions, such as food.
"With the substance use disorders, as hard as it may be, the task is to lock the tiger in the cage and throw away the key," said Levounis. "With food disorders and eating addiction, you have to walk the tiger three times a day. Walking the tiger three times a day is radically different from locking the tiger in the cage."
Erin Zerbo, an assistant professor in NJMS' Department of Psychiatry, co-authored the chapter on kleptomania with Emily Deringer of the New York University School of Medicine.
The key to kleptomania is when people start to have recurrent episodes, often to relieve a particular emotional state, such as depression, Zerbo said. Kleptomania often is comorbid with other conditions, such as depression, alcoholism or interpersonal issues.
"They find themselves craving, thinking about it, going through stores, stealing things that they don't even need, throwing them away after, so it kind of takes on a life of its own," she explained.
Kleptomania has nothing to do with economic need, Zerbo explained. "It's much more about the act of stealing itself, the thrill and the rush that someone gets and they become addicted to that. They get a jolt of energy and they feel less depressed, but only temporarily."
Levounis said that accepting behavioral addictions, such as work, heavy exercise and indoor tanning as medical disorders is still difficult for many.
"There's a stigma of mental illness and that's what we are fighting for," Levounis said. "We're fighting for our patients and fighting for the legitimacy of a number of these disorders so they can be properly diagnosed and treated."