In trying to understand the scope of addiction, the Diagnostic and Statistical Manual of Mental Health Disorders (DSM-5) divides them into two categories: substance addictions and behavioral addictions.

Substance addictions involve the compulsive use of mind-altering substances such as nicotine, alcohol, amphetamines, and opiates. Behavioral addictions involve compulsive use of repetitive behaviors such as hair-pulling, skin-picking, bulimia, anorexia, cutting, and other self-harming behaviors. 

What if underneath, however, they are two sides of the same coin? A good example of how behavioral and substance addictions are the same thing is eating addiction. Many researchers want to call compulsive eating “food addiction,” placing blame on the ultra-processed “addictive” foods, such as refined sugar. This would put compulsive eating in the substance addiction category.

However, eating disorders are considered behavioral addictions. Shouldn’t compulsive eating be regarded as a behavioral disorder? Compulsive eating is a problem even when the available foods are not highly processed junk food. Also, very few people who eat ultra-processed junk food develop an addiction to it. Calling an eating disorder “food addiction” appears to be a terribly inappropriate label, an attempt to blame the substance rather than the behavior.

Let’s take a look at some of the substance disorders and see whether or not they might all be classified as behavioral disorders.

Nicotine Use Disorder. In order to smoke cigarettes, a person has to overcome the instinctual dislike of inhaling smoke in favor of the dopamine boost provided by nicotine. A similar process is involved with vaping. When not smoking or vaping, the user becomes increasingly nervous and agitated. This is relieved by smoking or vaping. It is considered an addiction when use is damaging to the health of the user, the user knows this, and the user wants to quit but struggles. All those elements must be present to qualify as nicotine addiction.

Many nicotine users say that stress and anxiety drive them to compulsive use, but it is the withdrawal symptoms that become the major source of stress and anxiety. Getting through a period of intense anxiety and stress is required to give up nicotine products until the user reaches a level where the cravings are bearable. Nicotine use is also associated with weight loss, and withdrawal is associated with weight gain. Technically, if the nicotine user does not want to quit, it is a habit, not an addiction.

Alcohol Use Disorder. The line between substance addiction and behavioral addiction is even murkier when it comes to alcohol use disorder (AUD). Millions of people drink products containing alcohol every day, yet only 10% of them are considered to have an AUD, according to a study by the Centers for Disease Control using data compiled by the Substance Abuse and Mental Health Services Administration. What about the others? The survey says:

Most excessive drinkers (90%) did not meet the criteria for alcohol dependence.

For a small percentage of people, the habitual use of alcohol becomes compulsive, the cravings become intolerable, and the need to consume alcohol eclipses all other goals and priorities. So why is it considered a substance use disorder when such a small fraction of the daily users are considered addicts? Why is it not seen as a behavioral disorder related to poor stress management, delay discounting, and impulsivity?

Opioid Use Disorder. Opioids have a reputation for being the most addictive of drugs. People get hooked quickly and, once addicted, find it impossible to quit. This is simply not true. Nicotine may be “more addictive” than heroin or cocaine or fentanyl or meth. A study of Vietnam veterans returning from the war as heroin addicts found that very few remained addicts once back in the United States. Researchers studying the attraction of substances found chocolate to cause more craving than nicotine or alcohol.

Whether substance or behavior, researchers have found a “general tendency to become addicted.” The sample of 573 college students and their parents is not large, but the findings are clear. The researchers found a correlation between addiction and cravings, lack of control and withdrawal. However, the ability to diagnose future addiction from surveys was small:

The results suggest, at best, a weak tendency to become addicted, across a wide range of substances or activities.

Another small study involving 216 addicted individuals and 78 control subjects found “notable personality distinctions” across behavioral and substance use disorders. For example, it found that people with AUD scored low on extraversion and that sex addicts and drug addicts had similar personality profiles. But the biggest finding was, across all addictive behaviors and substances, impulsivity and neuroticism were abnormally high compared to control subjects.

This once again suggests the unity of all addictions and the possible misclassification of behavioral disorders as substance use disorders.

Written by Steve O’Keefe. First published December 31, 2024.

Sources:

“Expanding the Definition of Addiction,” CNS Spectrums, May 2016.

“Addiction: What It Is, Causes, Symptoms, Types & Treatment,” Mayo Clinic, March 16, 2023.

“Mechanisms of Nicotine Addiction,” Cold Springs Harbor Perspectives in Medicine, April 27, 2020.

“Behavioral and cognitive effects of smoking: Relationship to nicotine addiction,” Nicotine & Tobacco Research, September 1999.

“Prevalence of Alcohol Dependence Among US Adult Drinkers, 2009–2011,” Centers for Disease Control, November 20, 2014.

“Heavy drinkers aren’t necessarily alcoholics, but may be ‘almost’ alcoholics,” Harvard Health Blog, November 14, 2014.

“Vietnam veterans’ rapid recovery from heroin addiction: a fluke or normal expectation?” Addiction, August 1993.

“Is there a general tendency to become addicted?” Addictive Behaviors, January-February 1993.

“Personality profiles of substance and behavioral addictions,” Addictive Behaviors, July 2018.

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