Addiction was once viewed as an unsavoury fringe disease, tethered to substances with killer withdrawal symptoms, such as alcohol and opium. But now the scope of what humans can be addicted to seems to have snowballed, from sugar to shopping to social media. The UK’s first NHS internet-addiction clinic is opening this year; the World Health Organization (WHO) has included gaming disorder in its official addictions diagnosis guidelines.
The first glimmer of this shift was in 1992, when tabloids reported that Michael Douglas – Hollywood royalty, fresh from starring in the erotic thriller Basic Instinct – was holed up in an Arizonan rehab facility with sex addiction. No matter that, to this day, Douglas stringently denies ever suffering from the condition – the way we perceive addiction had begun to unfurl.
Back then, the broadening of the term was often viewed in medical circles as lazy appropriation; however, neuroscience has now largely accepted that it is the same brain chemical, dopamine, driving these irrepressible cravings. What’s more, our 21st-century world is so heavily baited with cues and stimuli – from stealthy marketing to junk food, not to mention the nagging lure of online life – that it appears to be rigging our dopamine systems to become “hypersensitised”.
“The range of what people are getting addicted to has increased,” confirms Michael Lynskey, a professor of addiction at King’s College London. “For my parents’ generation, the only options were tobacco and alcohol. Now there are more drugs, including synthetics, along with commercialisation and ways – especially online – of encouraging prolonged use of different things.”
Many of these emerging conditions are seen as behavioural rather than physical, substance-related addictions – but the consequences can be as grave. Gambling is the longest established behavioural addiction, having been medically recognised since 2013. Suicide rates, along with the likelihood of substance addiction, are higher among compulsive gamblers. “I see gambling students who drop out of university because they can’t stop,” says Henrietta Bowden-Jones, the consultant psychiatrist behind the forthcoming NHS internet-addiction clinic. “I see people with shopping compulsions who are in so much debt because they couldn’t stop themselves from buying three dresses in different sizes, that in the end their businesses and families suffer.”
Sometimes, she says, compulsions flit between different vices – for example, a young man seeking refuge from family problems might toggle between gaming and porn. “I saw [a gaming disorder patient] yesterday,” she adds, “who then went on to spending money on objects and clothes. You can somehow shift the behaviour but it’s an illness we don’t yet know enough about.”
It is hard to overlook, however, the fact that many of these thrills are available at the touch of a screen. When the addiction charity Addaction commissioned a YouGov survey in October 2018, it found that parents are twice as worried about their teenage children being addicted to social media as they are about drugs, and a similar ratio when comparing worries about gaming and drugs. Also in October, the EU announced it would fund the European Problematic Use of the Internet Research Network to investigate the public health implications.
Not everyone agrees with defining these new disorders as addictions – after all, you can’t overdose on them. Gambling and gaming are the only ones to have made it on to the WHO list of addictions. However, a paradigm shift in understanding addiction is in motion.
Take sex addiction. Seeking treatment for this controversial condition has, in cases such as that of the golfer Tiger Woods, been criticised as a cynical shortcut to redemption for philanderers. On the other hand, neuroscientists who have been able to study the brains of people with debilitatingly compulsive obsessions with sex witness similar responses to those they have observed in drug addiction cases.
Most of the standard criteria for addiction diagnosis do apply to these disorders, says Lynskey: “Tolerance, neglect of responsibilities, inability to stop, withdrawal.” Withdrawal is the obvious sticking point, although sugar withdrawal symptoms have been induced in lab rats – sweats, shakes, changes in body temperature, anxiety, the whole kaboodle. “If a teenager becomes irritable when a gaming session is cut short, there’s some discussion as to whether that’s a sort of mild withdrawal,” says Lynskey.
Terry Robinson, an esteemed professor of psychology and neuroscience at the University of Michigan – together with his colleague, Kent Berridge – identified dopamine as the neurochemical responsible for craving. He thinks debating the semantics of addiction is unhelpful. “Whether it’s drugs, sex, gambling or whatever, you’re looking at impulse-control disorders where people have difficulty refraining from maladaptive use. There are certainly similarities in terms of the psychological and neurobiological mechanisms involved.”
Once Robinson and Berridge had identified dopamine as “wanting” and pleasurable brain opiates as “liking” – two distinct phenomena – they discovered that you don’t have to like something in order to want it: a key finding about addiction. In addicts’ brains, the craving is unbearable even when they no longer like the object of their desire. Berridge once told me that the “massive”, “robust” wanting systems in the brain can be turned on with or without pleasure, whereas pleasure “has a much smaller and more fragile brain basis … That’s why life’s intense pleasures are less frequent and less sustained than life’s intense desires”. It also explains, perhaps, why humans are so easily herded into wanting new stuff and instant gratification, even when these things don’t make us happy.
“What’s happening in these addictions,” says Robinson, “is that the dopamine system is becoming hypersensitised, leading to these pathological motivational states.” He has identified three factors that could help explain why “there seems to be a wider variety of problematic things [to get addicted to]”. (He does caution, however, that “getting into social factors is very difficult in terms of proving cause and effect”.)
The first factor is that our modern environment is stuffed with craving-inducing stimuli. “People don’t appreciate the power of cues that have been associated with rewards, be it a drug or sex or food, in generating motivational states.” In fact, addicts can start liking the cues more than the end goal, such as the rigmarole of scoring drugs and so on. “The amount of cues associated with highly palatable foods are everywhere now,” he says. “Drugs, sex and gambling as well, and that has changed quite a bit over the years and could be leading to more problematic use.”
Lynskey agrees, adding “some of the marketing and design of gambling machines is a step ahead of all of us academics in devising ways to attract users and boost dopamine and retain them”. The “like” button, quantifying approval and igniting a compulsion to check social media, is a similar example. Introducing a report into the effects of social media on young people in early 2018, the UK’s children’s commissioner Anne Longfield wrote that “some children are becoming almost addicted to ‘likes’ as a form of social validation”.
Robinson’s second consideration is dosage. Our liking of sweet tastes suited us when we were hunter-gatherers, helping us choose ripe energy sources. Now, we have high-fructose corn syrup, which blows our minds with unnatural levels of glucose. Similarly with drugs, he points out: “Chewing coca leaves in the Andes is not the same as smoking crack cocaine. The pharmacology is different and this can also increase propensity to addiction.”
His final factor is simply access. “Food, sex, gambling and drugs – availability these days is much greater than it was in the past.” (Sex addiction can include consuming porn, sexting, compulsive masturbation, exhibitionism and chemsex.)
All these factors, Robinson continues, “combine in complex ways – and I’m sure we don’t understand them all – to increase the probability of problematic use in a variety of things”. Does this mean that more people are at risk in this era of throbbing dopamine excitation? Major risk factors for addiction, such as deprivation and childhood trauma, are still important predictors for how easily your dopamine system can be hijacked, says Robinson – “but you have laden on top of that ubiquitous cues, more potent formulations and increased availability”.
Another theory about what is driving the diversification of addictive behaviours stems from a series of experiments conducted in Canada in the late 1970s known as Rat Park. The psychologist Bruce Alexander found that lab rats, while isolated in empty cages with the option of drinking either plain or drugged water, easily became addicted to heroin; if you put rats in a vast, toy-filled enclosure with other male and female rats for company, the heroin couldn’t compete. The context was driving addiction, rather than the drug itself. The resulting study made minimal waves when it was published – yet today, Alexander is being flown all over the world to share his take on addiction, which he calls the dislocation theory.
“The modern world breaks down all kinds of community, all kinds of tradition and religions and stuff that has made life integral and full for people in the past,” he says. “You can’t just say: ‘OK, now I’m going to give you back what modernity took away.’ We have to reinvent society, as we perpetually do, with an eye on making sure there are enough connections for human beings with each other in a traditional way, so that people can grow up and be content enough so they don’t need to find substitutes in addiction for life.”
Organisations such as Addaction in the UK, he says, “are finding ways to get [addicts] together into groups and planting these groups in communities and getting the community to support people in these groups, not to give up their addictions but to have a meaningful life”. Steve Moffatt, policy manager at Addaction, says that like all such services, “we’re just starting to try to understand the level of issues that are out there. For this generation coming through, social media is a big thing and online activities generally, but we still don’t know the extent.”
Despite the increase in the range of addictions, says Lynskey, there are still probably fewer addicted people than there were 30 years ago because the level of nicotine dependency – the most deadly one – has dropped from 50% to less than 20% in the UK. However, updates to diagnosis guidelines mean that people who sit lower on the addictive spectrum can now be seen as having problematic dependencies. The influential American Psychiatric Association, he says, “used to distinguish between ‘abuse’ and ‘dependence’, whereas now they are in a single category of drug-use disorders. Perhaps as many as one in four males would meet the criteria for alcohol dependency, and a lower, but still substantial, number of females.” And yet these people are at no risk of seizures or death if they go into withdrawal. “There is a spectrum,” he says, “whether it’s alcohol or drug dependence or shopping addiction and people have become a bit happier with placing the point at which behaviour becomes problematic at a lower level of use.”
Bowden-Jones says the best evidence for treating behavioural addictions is using cognitive behavioural therapy (CBT) to help avoid cues (for example, taking a different route home so you don’t pass the bookmaker), rewarding good behaviour and reaffirming what people have to lose with constant reminders, such as on wristbands.
Assistance can also come in the form of stimulus-control tools. “There are fantastic blocks to put in place that can stop you from watching porn, gambling and indeed anything to do with the behaviour you have an issue with, except for gaming,” says Bowden-Jones. “We need to get to a position where, in the cold reality of your day, you can say: ‘I don’t need to spend more than two hours a day doing this, so I will block myself after two hours [of play].’” This responsibility, she says, lies with the gaming industry.
Mindfulness meditation has also helped to reduce substance abuse. In fact, it was found to be more effective than the Alcoholics Anonymous 12-step programme and CBT in 2014 research led by Sarah Bowden, an assistant professor of clinical psychology at Pacific University in Portland, Oregon; the previous year, Bowden, Berridge and other neuroscientific luminaries met to discuss addiction with the Dalai Lama. After all, Buddhists caught on to this craving problem thousands of years ago, using meditation to overcome the very urges that they identified as the linchpin of human suffering, long before these dopamine-fuelled times.
A modern challenge is the ubiquity, and the necessity: gone are the days when recovering behavioural addicts can be told to avoid the ever-necessary internet, for example. “Younger generations will be socially cut off,” says Bowden-Jones, “and what our patients say is when they feel they’re missing out, it pushes them more toward the virtual life that they already have a problem with rather than engaging properly in their face-to-face lives.” As Moffat says, “that’s where they get their validation”.
Many of us would plot our internet habits on the lower end of this spectrum: slaves to our phones, wasting hours that we will never get back stuck down internet rabbit holes, compulsively checking for likes. “There’s a great distinction,” says Bowden-Jones “between functional use and use that is not necessary. It’s like eating too much cake, which makes you feel bad. People who are on social media too much, it’s not a positive experience, although it may have started off as such.” There goes the dopamine without the pleasure, again.
