Addiction is a neuropsychological disorder characterized by a persistent and intense urge to use a drug or engage in a behavior that produces natural reward, despite substantial harm and other negative consequences. Repetitive drug use can alter brain function in synapses similar to natural rewards like food or falling in love[1] in ways that perpetuate craving and weakens self-control for people with pre-existing vulnerabilities.[2] This phenomenon – drugs reshaping brain function – has led to an understanding of addiction as a brain disorder with a complex variety of psychosocial as well as neurobiological factors that are implicated in the development of addiction.[3][4][5] While mice given cocaine showed the compulsive and involuntary nature of addiction,[a] for humans this is more complex, related to behavior[6] or personality traits.[7]
Classic signs of addiction include compulsive engagement in rewarding stimuli, preoccupation with substances or behavior, and continued use despite negative consequences. Habits and patterns associated with addiction are typically characterized by immediate gratification (short-term reward),[8][9] coupled with delayed deleterious effects (long-term costs).[4][10]
Examples of substance addiction include alcoholism, cannabis addiction, amphetamine addiction, cocaine addiction, nicotine addiction, opioid addiction, and eating or food addiction. Behavioral addictions may include gambling addiction, shopping addiction, stalking, internet addiction, social media addiction, video game addiction, and sexual addiction. The DSM-5 and ICD-10 only recognize gambling addictions as behavioral addictions, but the ICD-11 also recognizes gaming addictions.[11]
Signs and symptoms
Signs and symptoms of drug addiction can vary depending on the type of addiction. Symptoms may include:
Continuation of drug use despite the knowledge of consequences[12]
Disregarding financial status when it comes to drug purchases
Ensuring a stable supply of the drug
Needing more of the drug over time to achieve similar effects[12]
Social and work life impacted due to drug use[12]
Unsuccessful attempts to stop drug use[12]
Urge to use drug regularly
Other signs and symptoms can be categorized across relevant dimensions:
Behavioral Changes Physical Changes Social Changes
Angry and irritable
Changes to eating or sleeping habits
Changes to personality and attitude
Decreased attendance and performance in workplace or school setting[12]
Fearful, paranoid and anxious without probable cause[13]
Frequently engaging in conflicts (fights, illegal activity)
Frequent or sudden changes in mood and temperament
Hiding or in denial of certain behaviors
Lack of motivation
Periodic hyperactivity
Using substances in inappropriate settings
Abnormal pupil size
Bloodshot eyes
Body odor
Impaired motor coordination[13]
Periodic tremors
Poor physical appearance
Slurred speech
Sudden changes in weight
Changes in hobbies
Changes to financial status (unexplained need for money)
Legal problems related to substance abuse
Sudden changes in friends and associates
Use of substance despite consequences to personal relationships[13]
Definitions
The word "addiction" derives from the Latin "addico", meaning "giving over" with both positive connotations (devotion, dedication) and negative ones (being enslaved to a creditor in Roman law). This dual meaning persisted in traditional English dictionaries, encompassing both legal surrender and personal devotion to habits. Later, 19th century temperance movements narrowed the definition of addiction to just drug-related disease, ignoring behavioral addictions and the possibility of positive or neutral addictions. This restrictive view opposes the current understanding of addiction.[14]
"Addiction" and "addictive behaviour" are polysemes denoting a category of mental disorders, of neuropsychological symptoms, or of merely maladaptive/harmful habits and lifestyles.[15] A common use of "addiction" in medicine is for neuropsychological symptoms denoting pervasive/excessive and intense urges to engage in a category of behavioral compulsions or impulses towards sensory rewards (e.g., alcohol, betel quid, drugs, sex, gambling, video gaming).[16][17][18][19][20] Addictive disorders or addiction disorders are mental disorders involving high intensities of addictions (as neuropsychological symptoms) that induce functional disabilities (i.e., limit subjects' social/family and occupational activities); the two categories of such disorders are substance-use addictions and behavioral addictions.[21][15][19][20]
The DSM-5 classifies addiction the most severe stage of substance use disorder, due to significant loss of control and the presence of compulsive behaviours despite the desire to stop.[22] It is a definition that many scientific papers and reports use.[23][24][25]
"Dependence" is also a polyseme denoting either neuropsychological symptoms or mental disorders. In the DSM-5, dependences differ from addictions and can even normally happen without addictions;[26] besides, substance-use dependences are severe stages of substance-use addictions (i.e. mental disorders) involving withdrawal issues.[27] In the ICD-11, "substance-use dependence" is a synonym of "substance-use addiction" (i.e. neuropsychological symptoms) that can but do not necessarily involve withdrawal issues.[28]
Substance addiction
Main article: Substance use disorder
Further information: Substance abuse and Substance-related disorder
Addiction and dependence glossary[3][29][30]
addiction – a biopsychosocial disorder characterized by persistent use of drugs (including alcohol) despite substantial harm and adverse consequences
addictive drug – psychoactive substances that with repeated use are associated with significantly higher rates of substance use disorders, due in large part to the drug's effect on brain reward systems
dependence – an adaptive state associated with a withdrawal syndrome upon cessation of repeated exposure to a stimulus (e.g., drug intake)
drug sensitization or reverse tolerance – the escalating effect of a drug resulting from repeated administration at a given dose
drug withdrawal – symptoms that occur upon cessation of repeated drug use
physical dependence – dependence that involves persistent physical–somatic withdrawal symptoms (e.g., fatigue and delirium tremens)
psychological dependence – dependence socially seen as being extremely mild compared to physical dependence (e.g., with enough willpower it could be overcome)
reinforcing stimuli – stimuli that increase the probability of repeating behaviors paired with them
rewarding stimuli – stimuli that the brain interprets as intrinsically positive and desirable or as something to approach
sensitization – an amplified response to a stimulus resulting from repeated exposure to it
substance use disorder – a condition in which the use of substances leads to clinically and functionally significant impairment or distress
tolerance – the diminishing effect of a drug resulting from repeated administration at a given dose
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Drug addiction
Drug addiction, which belongs to the class of substance-related disorders, is a chronic and relapsing brain disorder that features drug seeking and drug abuse, despite their harmful effects.[31] This form of addiction changes brain circuitry such that the brain's reward system is compromised,[32] causing functional consequences for stress management and self-control.[31] Damage to the functions of the organs involved can persist throughout a lifetime and cause death if untreated.[31] Substances involved with drug addiction include alcohol, nicotine, marijuana, opioids, cocaine, amphetamines, and even foods with high fat and sugar content.[33] Addictions can begin experimentally in social contexts[34] and can arise from the use of prescribed medications or a variety of other measures.[35]
Drug addiction has been shown to work in phenomenological, conditioning (operant and classical), cognitive models, and the cue reactivity model. However, no one model completely illustrates substance abuse.[36]
Risk factors for addiction include:
Aggressive behavior (particularly in childhood)
Availability of substance[34]
Community economic status
Experimentation[34]
Epigenetics
Impulsivity (attentional, motor, or non-planning)[37]
Lack of parental supervision[34]
Lack of peer refusal skills[34]
Mental disorders[34]
Method substance is taken[31]
Usage of substance in youth[34]
Food addiction
Main article: Food addiction
The diagnostic criteria for food or eating addiction has not been categorized or defined in references such as the Diagnostic and Statistical Manual of Mental Disorders (DSM or DSM-5) and is based on subjective experiences similar to substance use disorders.[12][37] Food addiction may be found in those with eating disorders, though not all people with eating disorders have food addiction and not all of those with food addiction have a diagnosed eating disorder.[12] Long-term frequent and excessive consumption of foods high in fat, salt, or sugar, such as chocolate, can produce an addiction[38][39] similar to drugs since they trigger the brain's reward system, such that the individual may desire the same foods to an increasing degree over time.[40][12][37] The signals sent when consuming highly palatable foods have the ability to counteract the body's signals for fullness and persistent cravings will result.[40] Those who show signs of food addiction may develop food tolerances, in which they eat more, despite the food becoming less satisfactory.[40]
Chocolate's sweet flavor and pharmacological ingredients are known to create a strong craving or feel 'addictive' by the consumer.[41] A person who has a strong liking for chocolate may refer to themselves as a chocoholic.
Risk factors for developing food addiction include excessive overeating and impulsivity.[37]
The Yale Food Addiction Scale (YFAS), version 2.0, is the current standard measure for assessing whether an individual exhibits signs and symptoms of food addiction.[42][12][37] It was developed in 2009 at Yale University on the hypothesis that foods high in fat, sugar, and salt have addictive-like effects which contribute to problematic eating habits.[43][40] The YFAS is designed to address 11 substance-related and addictive disorders (SRADs) using a 25-item self-report questionnaire, based on the diagnostic criteria for SRADs as per DSM-5.[44][12] A potential food addiction diagnosis is predicted by the presence of at least two out of 11 SRADs and a significant impairment to daily activities.[45]
The Barratt Impulsiveness Scale, specifically the BIS-11 scale, and the UPPS-P Impulsive Behavior subscales of Negative Urgency and Lack of Perseverance have been shown to have relation to food addiction.[37]
Behavioral addiction
Main article: Behavioral addiction
The term behavioral addiction refers to a compulsion to engage in a natural reward – which is a behavior that is inherently rewarding (i.e., desirable or appealing) – despite adverse consequences.[9][38][39] Preclinical evidence has demonstrated that marked increases in the expression of ΔFosB through repetitive and excessive exposure to a natural reward induces the same behavioral effects and neuroplasticity as occurs in a drug addiction.[38][46][47][48]
Addiction can exist without psychotropic drugs, an idea that was popularized by psychologist Stanton Peele.[49] These are termed behavioral addictions. Such addictions may be passive or active, but they commonly contain reinforcing features, which are found in most addictions.[49] Sexual behavior, eating, gambling, playing video games, and shopping are all associated with compulsive behaviors in humans and have been shown to activate the mesolimbic pathway and other parts of the reward system.[38] Based on this evidence, sexual addiction, gambling addiction, video game addiction, and shopping addiction are classified accordingly.[38]
Sexual
This section is an excerpt from Sexual addiction.[edit]
Sexual addiction is a state characterized by compulsive participation or engagement in sexual activity, particularly sexual intercourse, despite negative consequences.[50] The concept is contentious;[51][52][53] as of 2023, sexual addiction is not a clinical diagnosis in either the DSM or ICD medical classifications of diseases and medical disorders, which instead categorize such behaviors under labels such as compulsive sexual behavior.
There is considerable debate among psychiatrists, psychologists, sexologists, and other specialists whether compulsive sexual behavior constitutes an addiction – in this instance a behavioral addiction – and therefore its classification and possible diagnosis. Animal research has established that compulsive sexual behavior arises from the same transcriptional and epigenetic mechanisms that mediate drug addiction in laboratory animals. Some argue that applying such concepts to normal behaviors such as sex can be problematic, and suggest that applying medical models such as addiction to human sexuality can serve to pathologise normal behavior and cause harm.[54]
Gambling
Main articles: Gambling and Problem gambling
Gambling provides a natural reward that is associated with compulsive behavior.[38] Functional neuroimaging evidence shows that gambling activates the reward system and the mesolimbic pathway in particular.[38] It is known that dopamine is involved in learning, motivation, as well as the reward system.[55][32] The exact role of dopamine in gambling addiction has been debated.[55] Suggested roles for D2, D3, and D4 dopamine receptors, as well as D3 receptors in the substantia nigra have been found in rat and human models, showing a correlation with the severity of the gambling behavior.[55] This in turn was linked with greater dopamine release in the dorsal striatum.[55]
Gambling addictions are linked with comorbidities such as mental health disorders, substance abuse, alcohol use disorder, and personality disorders.[56]
Risk factors for gambling addictions include antisocial behavior, impulsive personality,[37] male sex, sensation seeking,[57] substance use, and young age.
Gambling addiction has been associated with some personality traits, including: harm avoidance, low self direction, decision making and planning insufficiencies, impulsivity, as well as sensation seeking individuals.[57] Although some personality traits can be linked with gambling addiction, there is no general description of individuals addicted to gambling.[57]
Internet
Main article: Internet addiction disorder
Internet addiction does not have any standardized definition, yet there is widespread agreement that this problem exists.[58] Debate over the classification of problematic internet use considers whether it should be thought of as a behavioral addiction, an impulse control disorder, or an obsessive-compulsive disorder.[59][60] Others argue that internet addiction should be considered a symptom of an underlying mental health condition and not a disorder in itself.[61] Internet addiction has been described as "a psychological dependence on the Internet, regardless of the type of activity once logged on."[58] Problematic internet use may include a preoccupation with the internet and/or digital media, excessive time spent using the internet despite resultant distress in the individual, increase in the amount of internet use required to achieve the same desired emotional response, loss of control over one's internet use habits, withdrawal symptoms, and continued problematic internet use despite negative consequences to one's work, social, academic, or personal life.[62]
Studies conducted in India, United States, Asia, and Europe have identified Internet addiction prevalence rates ranging in value from 1% to 19%, with the adolescent population having high rates compared to other age groups.[63][64] Prevalence rates have been difficult to establish due to a lack of universally accepted diagnostic criteria, a lack of diagnostic instruments demonstrating cross-cultural validity and reliability, and existing controversy surrounding the validity of labeling problematic internet use as an addictive disorder.[65][64] The most common scale used to measure addiction is the Internet Addiction Test developed by Kimberly Young.[64]
People with internet addiction are likely to have a comorbid psychiatric disorder. Comorbid diagnoses identified alongside internet addiction include affective mood disorders, anxiety disorders, substance use disorders, and attention deficit hyperactivity disorder.[65]
Video games
Main article: Video game addiction
Video game addiction is characterized by the World Health Organization (WHO) as excessive gaming behavior, potentially prioritized over other interests, despite the negative consequences that may arise, for a period of at least 12 months.[66] In May 2019, the WHO introduced gaming disorder in the 11th edition of the International Classification of Diseases.[67] Video game addiction has been shown to be more prevalent in males than females, higher by 2.9 times.[68] It has been suggested that people of younger ages are more prone to become addicted to video games.[68] People with certain personalities may be more susceptible to gaming addictions.[68][69]
Risk factors for video game addiction include:
Male,
Psychopathologies (e.g. ADHD or MDD), and
Social anxiety.[70]
Shopping
Main articles: Shopping addiction and Compulsive buying disorder
Shopping addiction, or compulsive buying disorder (CBD), is the excessive urge to shop or spend, potentially resulting in unwanted consequences.[71] These consequences can have serious impacts, such as increased consumer debt, negatively affected relationships, increased risk of illegal behavior, and suicide attempts.[71] Shopping addiction occurs worldwide and has shown a 5.8% prevalence in the United States.[72] Similar to other behavioral addictions, CBD can be linked to mood disorders, substance use disorders, eating disorders, and other disorders involving a lack of control.[72]
Screening and assessment
Addictions Neuroclinical Assessment
The Addictions Neuroclinical Assessment is used to diagnose addiction disorders. This tool measures three different domains: executive function, incentive salience, and negative emotionality.[73][74] Executive functioning consists of processes that would be disrupted in addiction.[74] In the context of addiction, incentive salience determines how one perceives the addictive substance.[74] Increased negative emotional responses have been found with individuals with addictions.[74]
Tobacco, Alcohol, Prescription Medication, and Other Substance Use (TAPS)
This is a screening and assessment tool in one, assessing commonly used substances. This tool allows for a simple diagnosis, eliminating the need for several screening and assessment tools, as it includes both TAPS-1 and TAPS-2, screening and assessment tools respectively. The screening component asks about the frequency of use of the specific substance (tobacco, alcohol, prescription medication, and other).[75] If an individual screens positive, the second component will begin. This dictates the risk level of the substance.[75]
CRAFFT
The CRAFFT (Car-Relax-Alone-Forget-Family and Friends-Trouble) is a screening tool that is used in medical centers. The CRAFFT is in version 2.1 and has a version for nicotine and tobacco use called the CRAFFT 2.1+N.[76] This tool is used to identify substance use, substance related driving risk, and addictions among adolescents. This tool uses a set of questions for different scenarios.[77] In the case of a specific combination of answers, different question sets can be used to yield a more accurate answer. After the questions, the DSM-5 criteria are used to identify the likelihood of the person having substance use disorder.[77] After these tests are done, the clinician is to give the "5 RS" of brief counseling.
The five Rs of brief counseling includes:
REVIEW screening results
RECOMMEND to not use
RIDING/DRIVING risk counseling
RESPONSE: elicit self-motivational statements
REINFORCE self-efficacy[77]
Drug Abuse Screening Test (DAST-10)
The Drug Abuse Screening Test (DAST) is a self-reporting tool that measures problematic substance use.[78] Responses to this test are recorded as yes or no answers, and scored as a number between zero and 28. Drug abuse or dependence, are indicated by a cut off score of 6.[78] Three versions of this screening tool are in use: DAST-28, DAST-20, and DAST-10. Each of these instruments are copyrighted by Dr. Harvey A. Skinner.[78]
Alcohol, Smoking, and Substance Involvement Test (ASSIST)
The Alcohol, Smoking, and Substance Involvement Test (ASSIST) is an interview-based questionnaire consisting of eight questions developed by the WHO.[79] The questions ask about lifetime use; frequency of use; urge to use; frequency of health, financial, social, or legal problems related to use; failure to perform duties; if anyone has raised concerns over use; attempts to limit or moderate use; and use by injection.[80]
Causes
Personality theories
Main article: Personality theories of addiction
Personality theories of addiction are psychological models that associate personality traits or modes of thinking (i.e., affective states) with an individual's proclivity for developing an addiction. Data analysis demonstrates that psychological profiles of drug users and non-users have significant differences and the psychological predisposition to using different drugs may be different.[81] Models of addiction risk that have been proposed in psychology literature include: an affect dysregulation model of positive and negative psychological affects, the reinforcement sensitivity theory of impulsiveness and behavioral inhibition, and an impulsivity model of reward sensitization and impulsiveness.[82][83][84][85][86]
Neuropsychology
The transtheoretical model of change (TTM) can point to how someone may be conceptualizing their addiction and the thoughts around it, including not being aware of their addiction.[87]
Cognitive control and stimulus control, which is associated with operant and classical conditioning, represent opposite processes (i.e., internal vs external or environmental, respectively) that compete over the control of an individual's elicited behaviors.[88] Cognitive control, and particularly inhibitory control over behavior, is impaired in both addiction and attention deficit hyperactivity disorder.[89][90] Stimulus-driven behavioral responses (i.e., stimulus control) that are associated with a particular rewarding stimulus tend to dominate one's behavior in an addiction.[90]
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