Pathological addictions: definition, prevalence and treatment

By Cristiano Antonino On Apr 7, 2023

The World Health Organisation (WHO) describes pathological dependence as a ‘psychic condition, sometimes also physical, resulting from the interaction between an organism and a substance, characterised by behavioural and other responses that include a compulsive need to take the substance continuously or periodically, in order to experience its psychic effects and sometimes to avoid the discomfort of its deprivation’

Despite the fact that the Diagnostic and Statistical Manual of Mental Disorders DSM-5 continues to propose a notion of ‘addiction’ referring mainly to the intake of psychotropic substances, this is also increasingly being used in the framing of particular syndromic entities arising from the development of addictive behaviour in the absence of any substance.

Pathological addictions, an overview

The new neurological sciences are proposing a unified theory of addiction, whereby behavioural addictions and substance addictions are considered as a whole.

Many authors are beginning to consider ‘substance addictions’ (e.g. to alcohol) and ‘behavioural addictions’ (e.g. pathological gambling) as clinical manifestations.

pathological gambling) as clinical manifestations with different similarities and treatable according to similar approaches. This is why it is preferred to speak of ‘pathological addiction’.

The ‘new addictions’, or ‘addictions without substance’, refer to a wide range of abnormal behaviours: these include pathological gambling, compulsive shopping, ‘new technologies addiction’ (addiction to TV, internet, social networks, video games, etc.), workaholism, sex-addiction and addiction to emotional relationships, and certain deviances in eating behaviour such as orthorexia or in sports training such as overtraining syndrome.

Pathological addictions: both classic substance addictions and behavioural addictions have several elements in common

They are initially sought out for the pleasure and relief they bring: this is the ‘honeymoon’ phase, during which denial of the problem is also almost always present;
The substance (or behaviour) constantly dominates the thought: there is an inability to resist the urge to take it (or to perform the behaviour), experienced in a compulsive manner;
Presence of craving: increasing desire or state of tension that precedes taking the substance (or performing the behaviour);
Presence of mood instability: initially preceding the taking of the substance (or the behaviour), later increasingly generalised;
Presence of tolerance, i.e. progressive need to increase the amount of substance (or time spent on the behaviour) in order to obtain the pleasurable effect;
Presence of an increasing feeling of loss of control over taking the substance (or performing the behaviour);
Presence of deep psychological and physical discomfort when stopping or reducing the intake of the substance (or the time devoted to the behaviour);
Use of the substance (or performance of the behaviour) continues despite the progressive and increasingly severe effects on personal and interpersonal functioning (work, emotional, friendship, personal…);
Frequent tendency to return to the substance (or behaviour) after a period of interruption (relapse phenomenon);
High frequency of taking more than one substance (or performing more than one behaviour), as well as of switching from one addiction to another;
The similarity of the main risk factors: impulsivity, sensation-seeking, inharmonious metacognitive skills, inadequate parental environment.
Cognitive-behavioural therapy (CBT) is the most suitable treatment in behavioural addictions, being evidence-based, and is also useful in substance addictions.

The key to its effectiveness lies in its focus on the development of the patient’s sense of self-efficacy with respect to his or her disease, the use of supportive psychopharmacological therapy, the enhancement of coping skills (i.e. stress coping skills) that progressively reduce the patient’s positive expectations of the addictive behaviour, and the collaboration between patient and therapist in solving the problem.

Research shows that the most important results for TCC are in the prevention of relapse, as its effects are long-lasting and improvements are seen even after treatment has ended (Epstein et al., 2003; Rawson et al., 2006).

Studies have shown that, at the end of treatment, the most lasting results are to be attributed to Cognitive-Behavioural interventions (which therefore also intervene on the person’s system of ideas and beliefs about himself, others, his disorder…), rather than to programmes that focus exclusively on the behavioural factor related to substance use, such as Contingency Management (CM) (Epstein et al., 2003; Rawson et al., 2002).

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