Commentary on: Are we overpathologizing everyday life? A tenable blueprint for behavioral addiction research

Abstract

Background and Aims

This commentary is written in response to a paper by Billieux, Schimmenti, Khazaal, Maurage and Hereen (2015) published in the Journal of Behavioral Addictions.

Methods

It supports and extends the arguments by Billieux, Schimmenti et al. (2015): that the study of behavioral addictions too often rests on atheoretical and confirmatory research approaches. This tends to lead to theories that lack specificity and a neglect of the underlying processes that might explain why repetitive problem behaviors occur.

Results

In this commentary I extend the arguments by Billieux, Schimmenti et al. (2015) and argue that such research approaches might take us further away from conceptualizing psychiatric diagnoses that can be properly validated, which is already a problem in the field. Furthermore, I discuss whether the empirical support for conceptualizing repetitive problem behaviors as addictions might rest on research practices that have been methodologically biased to produce a result congruent with the proposal that substance addictions and behavioral addictions share similar traits.

Conclusions

I conclude by presenting a number of ways of going forward, chief of which is the proposal that we might wish to go beyond a priori assumptions of addiction in favor of identifying the essential problem manifestations for each new potential behavioral addiction.

Introduction

In a recent paper in Journal of Behavioral Addictions, Billieux, Schimmenti, Khazaal, Maurage and Hereen (2015) provide a critical account of research developments in the field of behavioral addictions. They discuss how the use of atheoretical and confirmatory research approaches might contribute to overpathologizing daily life activities, which in the long run could prompt a dismissive appraisal of behavioral addiction research. As Billieux, Schimmenti et al. (2015) aptly state, the study of new behavioral addictions are often based on anecdotal observations where the target behavior is a priori considered an addictive behavior, which is a fundamentally atheoretical approach, followed by the development of screening tools according to traditional substance addiction criteria. These tools are then used to conduct research on whether risk factors or symptoms known to also play a role in substance addictions are associated with the newly proposed behavioral addiction, in order to confirm that the target behavior may be conceptualized as an addiction. This approach has been used most notably perhaps in recent attempts to validate Internet Gaming Disorder (IGD) as a behavioral addiction, which resulted in its inclusion in the DSM-5 research appendix (American Psychiatric Association, 2013).

I agree with Billieux, Schimmenti et al. (2015) in their assessment that such an atheoretical and confirmatory approach might lead researchers to overpathologize daily life activities and that it yields theoretical models that lack specificity. Furthermore, I argue that the atheoretical approach also takes us one step further away from conceptualizing psychiatric disorders that can be properly validated. Additionally, using both an atheoretical and a confirmatory approach together becomes methodologically problematic and might bias the results of empirical work. I will discuss these two issues further in this commentary.

Problems of Validity Following an Atheoretical Approach

It is first important to consider the justifications for approaching repetitive problem behaviors through a framework originally developed for research on substance addiction. Curiously, the justification seems to revolve primarily around the claim that there is an overlap between behavioral and substance addictions in terms of their manifestations. One of the first mentions of this overlap was Marks (1990), who observed that repetitive problem behaviors seem to share some core syndromes with substance addiction. Based on this observation he argued that “it is useful heuristically to regard a wide range of repetitive behaviors as addictive syndromes, whatever their external triggers” (p. 1394). I argue that in a research context such an approach might come with enough drawbacks to outweigh the benefits.

Approaching repetitive problem behaviors through a framework of addiction should only be done if it is somehow useful to equate disordered behaviors on the basis of shared traits. For example, Marks (1990) suggested that doing so might yield some therapeutic and preventive ideas for the new problem behavior and it is indeed possible that his suggestion has some utility, in particular for clinical practice. However, both for purposes of research and for the sake of diagnostic validity it is problematic to equate two disordered behaviors based on shared traits. According to Kendell and Jablensky (2003), validation of a proposed disorder hinges on whether one disorder can reliably be distinguished from another. In other words, demonstrable differences must exist between the defining characteristics of a disorder and those of other conditions with similar symptoms (p. 6). This suggested practice goes contrary to the tendency in behavioral addiction research, which is to equate repetitive behavior with addiction and construct diagnostic criteria based first and foremost on similarities with other addictions while not accounting for the differences. The problems that result from focusing only on similarities is evident in Internet addiction research where there is currently a lack of consensus on whether Internet addiction is a unique disorder or whether there are multiple addictive disorders related to specific Internet activities like online gaming or online gambling (e.g., Király et al., 2014). Criteria for Internet addiction and online gaming addiction are practically identical, which makes it conceptually difficult to distinguish the two proposed disorders from each other. Furthermore, some researchers suggest that a number of online addictions are only an extension of offline addictions, but this suggestion is difficult to verify in practice as online and offline addictions share the same criteria and thus cannot easily be separated. In both instances the only unique identifier is the medium through which a person engages in the activity; one might argue that online gaming addiction is easily distinguished from Internet addiction because games constitute a specific activity, or that the online gambler is different from the offline gambler because he gambles through the Internet. However, using the medium as the only distinguishing factor is not nearly as helpful when it comes to elucidating etiological processes as it would be to propose distinguishing factors based on the actual behavior and problem manifestations. This would make it easier to understand why some people might turn to online gambling rather than offline gambling, or experience problems only with the former but not the latter.

A second issue with ignoring potential differences is that it causes problems in assessment. This is the case for IGD for example, where the proposed criteria are conceptually identical to those for substance addiction even though some criteria, like tolerance, arguably lack contextual relevance or at the very least adequate phrasing (Kardefelt-Winther, 2014c, 2014e). This illustrates the difficulty of preserving validity of measurements when translating criteria from one disorder to another. Establishing construct and face validity presents a great challenge for researchers involved in IGD precisely because of questionable contextual relevance for a number of criteria which seem to be included as residuals from the substance addiction diagnosis. The a priori definition of addiction also impacts the content validity, as assessing content validity requires a detailed description of the content domain which, arguably, an operationalization constrained to traditional substance addiction criteria might not accommodate. However, IGD is not the only proposed behavioral addiction where this might be problematic; as Billieux, Schimmenti et al. (2015) point out, hyper-sexuality, compulsive buying, binge eating, excessive work involvement, excessive physical exercise and even excessive dancing are all framed as behavioral addictions and might be subjected to similar problems with validity and lack of contextual relevance for the proposed criteria. This is linked to the atheoretical approach described by Billieux, Schimmenti et al. (2015) because as they argue, such approaches leave us with concepts and theory that lack domain specificity. In other words, we lack theoretically sound models that can illustrate in detail the unique factors and processes involved in a particular problem behavior. This is something I also highlight in my own work (Kardefelt-Winther, 2014a, 2014d). It might be more useful for purposes of research to identify the unique symptomatology and phenomenology of each problem behavior, rather than approaching a problem behavior with the a priori assumption that addiction symptoms and experiences accurately represent its manifestation.

How did We Confirm That Repetitive Problem Behaviors are Addictions?

Beyond problems with validity and theory as reflected above, we might also ask how the atheoretical and confirmatory approach outlined by Billieux, Schimmenti et al. (2015) have impacted the fundamental proposal that repetitive problem behaviors can be conceived of as addictions. It is worth asking whether behavioral and substance addictions share symptoms and risk factors only because we use the same theoretical basis to operationalize the behaviors. Billieux, Schimmenti et al. (2015) allude to this possibility in their paper. If the criteria for a target behavior are based on a substance addiction framework – which is an atheoretical approach – it is more likely that a number of related risk factors for substance addiction will be found also in relation to the target behavior, at least on a correlational level, since the behaviors share similar surface characteristics such as persistence over time and problematic consequences. Together with a confirmatory approach to empirical work, which rarely fails to identify core symptoms of addiction in a small part of the target population, such results might seem to justify the claim that a new repetitive problem behavior is an addiction. However, this might also be seen as a self-fulfilling prophecy which reflects the theoretical and methodological choices made by the researcher rather than provides an accurate conceptualization of the problem behavior. This questions some of the empirical evidence underlying the construct of behavioral addictions. If the occurrence of shared risk-factors and syndromes constitutes the foundation for the claim that repetitive behaviors may usefully be regarded as addictions (e.g., Marks, 1990), then we might argue that the construct of behavioral addictions is also a self-fulfilling prophecy: a prophecy based on anecdotal accounts of repetitive problem behaviors, evidenced as addictions via atheoretical and confirmatory research practices which might have biased the studies to produce a result congruent with the proposal that substance addictions and behavioral addictions share similar traits.

Importantly, the point here is not to suggest that the construct of behavioral addictions is not useful, but just like the field of addiction study might benefit from a broader conceptualization of the phenomenon (Shaffer et al., 2004), so too might the study of behavioral addictions benefit from not exclusively adhering to an addiction framework in the theorization and empirical exploration of new repetitive problem behaviors. It is worth considering the extent to which alternative but relevant criteria might be ignored when the problem behavior is a priori defined as an addiction. As Howard Shaffer suggests, adopting a perspective of addiction can blind proponents to alternative explanations that may be equally or more useful (1986).

Conclusions

While this commentary has further problematized research on behavioral addictions in line with Billieux, Schimmenti et al. (2015) this does not imply skepticism towards research on repetitive problem behaviors. Although there seems to be an increase in the medicalization of repetitive problem behaviors, it is at the same time clear that some of these problem behaviors constitute real problems that have a detrimental impact on people’s lives. The crucial point raised by Billieux, Schimmenti et al. (2015) is that the approach typically taken in research on repetitive problem behaviors is at times problematic, as a priori assumptions of addiction can hinder rather than facilitate an open-minded scientific inquiry. This is not to say that such research is not valuable, but it raises the question of what other explanations we might find for repetitive problem behaviors if the addiction framework is not always used to define the boundary for the inquiry.

To truly determine whether addiction offers a valid and useful interpretation of certain repetitive problem behaviors we might explore qualitatively why people persist in certain behaviors despite experiencing problematic outcomes, but without theoretical preconceptions of addiction. If such reports repeatedly found that the traditional components of, for example, a substance addiction framework are expressed in relation to a certain repetitive behavior an argument could be made that the behavior may be likened to an addiction and usefully explored as such. However, such an argument must rely on an in-depth understanding of the content domain which is not facilitated by confirmatory surveys of risk factors or addiction symptoms, which tend to dominate the field, but rather through interviews and dialogue with those who exhibit problem behaviors. This approach has been taken recently by researchers studying problem gambling. However, in these studies researchers found explanations for repeated problem gambling that had little to do with addiction and uncontrollable use. Rather, problem gambling was framed as a consequence of attempts to escape from real life frustrations or a desire to fulfill unmet real life needs, such as a lack of progress or achievement (e.g., Blaszczynski, Wilson & McConaghy, 1986; Lesieur, 1979; Ricketts & Macaskill, 2003, 2004; Wood & Griffiths, 2007). Some of these studies used a grounded theory approach (e.g., Lesieur, 1979; Rickets & Macaskill, 2003, 2004; Wood & Griffiths, 2007) without any preconceptions of why problem gambling occurs and yielded promising results that suggested a process driven by needs for mood-management and coping rather than addiction. Although only a few studies exist as of yet, similar findings have been reported in regards to problematic online gaming (Kardefelt-Winther, 2014b; Snodgrass et al., 2014).

Another useful approach has been proposed and empirically tested by Billieux, Thorens et al. (2015) in an earlier paper. They showed the utility of identifying unique categories of problematic gamers, where each category was theorized as having a different set of antecedents for the problem behavior. Their assumption was empirically supported and has important implications for interventions as it highlights the need for personalized, custom-made interventions that target specific psychological mechanisms. The approach of considering each category of problematic gamer as unique might be applicable in the wider research area of behavioral addictions, where each problem behavior might be conceptualized as a distinct category with its own antecedents and etiological processes, but not necessarily constrained to a certain interpretation like addiction. While the addiction framework may offer a reasonable first interpretation, its continued application in research seems to lead to a point where unique factors and processes are excluded to the detriment of diagnostic validity, construct validity, face validity and content validity, in addition to the lack of theoretical specificity mentioned by Billieux, Schimmenti et al. (2015). Therefore, we might conclude that while plenty of attention has been given to the similarities between substance addictions and behavioral addictions, a shift in focus to that which sets repetitive problem behaviors apart might be a useful way to proceed (e.g., Kardefelt-Winther, 2014a, 2014e).

I agree with Billieux, Schimmenti et al. (2015) when they state that exclusively remaining within an explanatory framework of substance addiction might lead to a neglect of the key psychological processes that sustain a dysfunctional involvement in other problem behaviors. I will even take it one step further and suggest that going beyond a framework of addiction entirely might in some cases yield more useful results. This is a statement upon which my own research rests. Going forward, this begs the question of what other explanations for repetitive problem behaviors we might find when such behaviors are not only viewed through the lens of addiction.

Conflict of interest:

No competing financial interests exist.

Funding Statement

No financial support was received for this study.