Substance and behavioral addictions may share a similar underlying process of dysregulation (2017)

Addiction. 2017 Apr 21. doi: 10.1111/add.13825.

Sussman S1, Rozgonjuk D2, van den Eijnden RJJM3.

Using inclusion–exclusion criteria to define ‘addiction’ may not be that helpful. A truly theoretical perspective of addiction can help us understand what we are really grappling with. Addiction is probably a process of dysregulation of an appetitive motivation system. Such dysregulation can occur regarding several behaviors, and vary in severity.

In an attempt to clarify what should be considered a behavioral addiction, and to prevent overpathologizing common behaviors, Kardefelt-Winter et al. [1] proposed to define it as ‘repeated behavior leading to significant harm or distress of a functional impairing nature, which is not reduced by the person and persists over a significant period of time’. The authors neglect to mention that the debate on the definition of behavioral addictions is not new, and holds for substance addictions as well. For example, a harm–dysfunction model has been proposed to distinguish ‘real’ alcoholism from a more transient, excessive drinking pattern [2]. Also, identifying exactly when substance misuse is eliciting ‘significant’ impairment, unfortunately tends to be a function of subjective self-judgements, may be context-driven and involves making qualitative decisions regarding quantitative phenomena [1, 3]. Kardefelt-Winter et al. also propose to exclude harmful behaviors that result from a willful choice as a behavioral addiction. Choice, or lack of choice, however, is also an ongoing issue in the substance addictions debate that may or may not distinguish ‘real’ alcoholism, for example, from excessive drinking [4]. In the midst of an addiction, it may certainly be a willful choice to drink excessively, based on a steep delayed discounting curve, or moment-by-moment thinking, or due to a lack of immediate negative consequences (yet) [3-5]. That, however, does not mean it is not an addiction. Also, Kardefelt-Winter and colleagues propose to exclude impairment-related behaviors that result from a coping strategy. If this exclusion criterion would be used for diagnosing alcohol dependence, its prevalence rates would drop enormously. In fact, a coping strategy model of substance and behavioral addiction exists, which would argue for coping serving as an inclusion criterion [3].

These things considered, the proposed definition of behavioral addiction and suggested exclusion criteria are harsh, and many substance addiction diagnoses would not survive this definition. Later in the paper, the authors seem to conclude that mobile phone addiction and social media addiction do not exist because there would be no indications of significant functional impairments. The literature on these topics, however, is very young due to relatively recent emergence of these technologies in mainstream use. The evidence concerning functional impairments of these behaviors is building [6, 7], and much work still has to be done.

Discussion about the nature of behavioral addictions such as in Kardefelt-Winter et al. is very welcome. However, we view it as most probable that addiction is a problem of life-style and associational memory, which interface with neurobiological processes associated with obtaining appetitive effects. That is, addiction probably reflects an appetitive motivation neurobiological system gone awry; may be recurrent or periodic; may be severe or not; may appear normative or deviant; and is likely to be very distressful only at some point [3].

Declaration of interests



1Kardefelt-Winther D., Heeren A., Schimmenti A., van Rooij A., Maurage P., Carras M. et al. How can we conceptualize behavioural addiction without pathologizing common behaviors? Addiction 2017;

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2Wakefield J. C., Schmitz M. F. How many people have alcohol use disorders? Using the harmful dysfunction analysis to reconcile prevalence estimates in two community surveys. Front Psychol 2014; 5: 22. pp. [Corrigendum: 2014; 5, Article 144, 3 pp.] Article 10.

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3Sussman S. Substance and Behavioral Addictions: Concepts, Causes, and Cures. Cambridge, UK: Cambridge University Press; 2017.


4Yaffe G. Lowering the bar for addicts. In: Poland J., Graham G., editors. Addiction and Responsibility. Cambridge, MA: MIT Press; 2011, pp. 113–139.

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5Bickel W. K., Mueller E. T., Jarmolowicz D. P. What is addiction? In: McCrady B. S., Epstein E. E., editors. Addictions: A Comprehensive Guidebook, 2nd edn. Oxford, UK: Oxford University Press; 2013, pp. 3–16.

6Lin Y. H., Chiang C. L., Lin P. H., Chang L. R., Ko C. H., Lee Y. H. et al. Proposed diagnostic criteria for smartphone addiction. PLOS ONE 2016; 11: e0163010.

7van den Eijnden R. J., Lemmens J. S., Valkenburg P. M. The social media disorder scale. Comput Hum Behav 2016; 61: 478–487.