If it were my choice, I would re-title this excellent little volume on Behavioral Addictions as "Behavioral Addictions and their Co-Morbidities." For this book reminds us that the so-called and often-contested "behavioral addictions" are much more common in persons with other "standard" substance addictions. In addition, these behaviors require careful differential diagnosis. Teasing out confounding factors is as important as treating problematic behaviors, especially since many treatments are still experimental.
For instance, Ascher's chapter on "work addictions" begins with a case study and reminds us that the man who works 72-hrs non-stop, without sleep, might also be in a manic state, which is hallmarked by decreased need for sleep and increased goal-oriented behavior. Several sections on "love addiction" or "romantic relationship addiction" or "sex addiction" give ample attention to co-morbid personality disorders and to persistent separation anxiety that also result in unstable relationships, fear of abandonment, or impulsive acts. The intriguing section on "Internet addiction" or "gaming addiction" addresses the overlap with ADHD, but skirts around studies on ASD and "IA". The hypothetical diagnosis of food addiction is compared to binge eating disorder and bulimia (but not to medical conditions that increase appetite, such as hyperthyroidism or Cushing's disease or even manic states).
Each chapter is short and simple to read, and one cannot fault authors who are constrained by word count for not including all possibilities. In contrast, we can praise the multiple authors and the editors for avoiding polemics about addiction or for prosetylzing about the correctness of these controversial diagnoses. After having endured so much public debate about DSM-5, and even more acrimony after the book went to press, and after hearing polarized arguments about which behavioral "addictions" met criteria for inclusion in DSM-5 and which did not, I half-expected this book to continue that approach. Fortunately, none of the chapters sound like partisan filibusters delivered on the Senate floor.
An early chapter on forensic aspects of "behavioral addictions" explores some of the reasons why those diagnoses of specific "behavioral addictions" (such as kleptomania or pyromania or pedophilic sex addiction) ignited such ire and carry such important implications. This chapter focuses on philosophical questions such as free will, without emphasizing the neurochemical aspects of addiction that intrigue clinicians and diagnosticians. In several cases, the chapters present hypothetical treatments for specific conditions, while admitting that such recommended approaches are either untested or incompletely tested. These caveats are essential, especially when some readers may skim the chapters before zeroing in on the "addiction" that interests them most or that concerns a particular patient whom they treat.
The authors are intellectually honest when they admit that much information is lacking and that a consensus is absent in many instances. Often times, complete or credible population-based studies are not yet available, so many chapters revolve around single case histories that are presented engagingly. In some cases, such as gambling, virtually everyone agrees that this is problematic behavior, but it took time to concur that gambling is closer to addictive behavior than to OCD or impulse control disorders.
Considering that many people are already involved in various 12-step groups for behavioral addictions, even before beginning psychiatric treatment, it is essential that practitioners familiarize themselves with the terminology used by these 12-steppers. It is useful to know about the wide array of self-help or support groups available, each with its own acronym. This book helps, and the short accessible chapters on specific addictions make for quick reading when a cram course on a specific "addiction" is needed.
By skimming chapters on the less obvious or less-discussed "addictions," such as gaming addiction or sex addiction, treaters can consider the possibility that such secretive behavior exists in patients whose symptoms do not respond to standard treatments. After reading this book, many practitioners may want to add direct questions about such behaviors in their intakes. We already use that approach when considering the contribution of drugs and alcohol, which can be concealed quite often.
I must confess: after reading the book in its entirety and completing the chapter on love addiction, I found myself harboring a heretical thought. This chapter explains the attachment phase (as opposed to the attraction phase), and links the fear of abandonment and inability to tolerate being alone to such "addictions. I wondered: could there be such a thing as "therapy addiction," where positive transference and a "healing relationship" (and fear of abandonment) result in perpetual but unproductive treatment?
While practicing psychiatry, we inevitably encounter persons who spent years in therapy with a particular therapist but readily admit to making no progress. Yet they are reluctant to stop but often cannot articulate why, apart from an inability to end such a longstanding relationship. Many such persons do not know which type of therapy they receive (which is important, considering that some therapeutic modalities have proven more effective for certain clinical presentations than others). This book makes me wonder if a behavioral addiction underlies these inexplicable choices. I wonder if that chapter will appear in the next edition.
© 2015 Sharon Packer
Sharon Packer, MD is a psychiatrist who is in private practice in Soho (NYC) and Woodstock, NY. She is an Asst. Clinical Professor of Psychiatry and Behavioral Sciences at Albert Einstein College of Medicine. Her books includeDreams in Myth, Medicine and Movies (Praeger, 2002), Movies and the Modern Psyche (Praeger, 2007) and Superheroes and Superegos: The Minds behind the Masks (Praeger/ABC-Clio, 2010). In press or in production are Sinister Psychiatrists in Cinema (McFarland, 2012) and Evil in American Pop Culture (ABC-Clio, 2013, co-edited with J. Pennington, PhD.) She can be contacted at firstname.lastname@example.org .