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I I I I I I I I I I I I I I I I British ,foumal of Addicriorc (1990) 85, 1389-1394 EDITORIAL Behavioural (non-chemical) addictions Abstnet `Addiuiorr' deaous repeatioe sourines that aim to obtain chemicals and, less often, rourtnes taethout thct aim TA.e lmres an behaosok ral addiuions. ?ltey inclYds obsesseoe-contprlrioe disorder (OCD), wmpulsive spmdiq (mt,idixg tasnbtissg), overearisrg (bilurtia), Rypenesvaliry (maifJu or devim), and trkpromaseia. Common acToss dependenu syridsoMtes ia: a sepeaud aV to eaqaje in behaviour kstowc to be counterprodu=tw; niowttiV rercrion tattrl u is compleud; rapid urtporary smvcJtiq of of tlu temsioR by compkttqt1u behaviour, padual nrurr~ of the wqe; ryRdronte-speafic esterROl andperAaps internal dus for the Yr=e; secondary cortditioreiq of the uVe to external and internal Mr mmla strau:ies for relapse preventron by cue esposure and stiriwlus coruroL 77u urYe to complete a behaviour and diuontforr ifprevenud from this resembJc the aamg and the wishdsa:oal (WD) symtprones of nbssmrce abusers. Sonte WD ry"qronts are common ro seweral addictsoe syxdrohta while others Njay be more specific. AddictioR Cft11) and concpatsiox (pwh) overlap and can oresn sarquentialiy or rancurrertsly. Dif Jaext addiaiorrs occvs with oaryin,` amounts of plearure ac oariour srcaes. Psolorrded esposm can exdaroqty ndyce the vrje and disco+rcfort in OCD, and may help some other addictions. Conditioned c>ses are irportasu and for lastixg efficacy a rheraprsr may need to /enow their details for each syndaorne. Then may be soxe sircilariaes rn rJu early manogemeru and preveritson of relapse of behaviotcral and chereical addiaioRs. Normal `addictiona' Life u a seties of addictions and without tbem we die. They have varying time-scales. Every few moments we inhale air. If deprived of it, within seconds we strive to bteatbe, with immeau relief whea we succeed. More prolonged deprivation causes escaLtia= teasioa, severe witbdrawal symp- toms of asphyxiation and death within miaam Oa a longer time scale, eating, driakiag, defaeestioo, micturatioa aad aez also ia.ol.e tiacg desire: to perform an act; the att:wiubes off the daire, which nturns within bouts or days. Such tmrmal biological cycles are 10te cbemial addictions in their mounting tttSe to do something that stops the urge, which increases a8sin as time goes on. Whether they are to obtain cbemicals (ozygea, food and driak) or do something else, the behavioural cycles involve iabuiit bomeo- natic mechaaisms but are partly modifiable by e:perieace. We are also programmed to be able to learn otber normal behavioural routines which begin, are maintamed and modified by intermediate outeomes, end on achie.iaj the goal and restart whea appropriate. The routines are reiaed in by competing tepertoita that att ptioritized according to current needs aad dimly understood processes of habituation and boce~edom. Inability to engage in rewarding routines-being with family and fsieads, Ioaia4, pmblia`, prdeaia;-btia8s on witbdrawal symptoms calied grief, bomesickaess, nostalgia or other aeaae of miait~ old pleasures. We may then seek to regain our lost routine. Itepetiti.e routines are not called addictions until tbeir flreqtency/mteasity leads to handiup, and then usually only whea they aim at obuiaini cbemical:. Less often the addictioa label is also given to behavioural eseesaes that have no external subetaace as a foal. They can be called behavioural (non-chemial) addictioss. Similarity of beha.ionral and cbemieal addictioau Syndromes of behavioural addiction share features with tltoae of substance abuse which may point to overlapping patlioph7tiolopes (Table 1). The :yadrotaes are disorders of lmpulse control and self-regulation. They include obsessive-compulsive 1389 I

M~. M OMM M~= Mam ~M MA M ! = ~%M Table I. Sinrilaraut and dortnca acrott syndrornet of addiction Addiction syndrome Behavtoural Addiction feature• Cbemical OCD SPE BUL SEX KLE TRI TIC Tl)U 1. Ur`e to engage in a counterproductive behavioural sequence ( a cravirsj) + f I t h i t I 1 2. Mounting tension uaka the sequence is completed + h t i t ) ± 3. Completing the sequence rapidly switches off the tension temporarily (=quick fix) t t I f f ? _r 4. Rettrrn of the urge and terrsion over houn, days or weeks (=suirAdraw+wl syntrtorns) 1 f f f f ) f 1 1 S. External cues for ,he urge uniqsse to a given addictive syndrome f t i f F + i 1 t 6. Secondary conditioaiaB of the urge to external cues .nd to internal cues (dyWlsocu. boredom) t i + t t f 1 ! 1 7. Hedonic tone in early uaBe of addictan (p- pkasant, a=aversive, 0=neuual) # a p ? p 0 1 0 0 •. Habituatiar of craving and witbdr.wal by cue exposure 1 I J f ? ? ) 1 ? 9. Multiple addictiona (C-ssnny chetucals; N=tics and OCD) C ? T p • f - present, --absent. tOCD-obseuive-compulsive disorder; SPE=compulsive spending; BUL=bulnnia; SEX=hypersexualrty, voyeurism, exhibnionism, panlvphdia, letushism TRI- tncbotiBounnia (bair-pulliaB); KLE=kleptotnania (compulsive shophftin6); TIC=1ics; TOU - Tourctte syndrome; (=0 far benzodiazepmex w g I 04,00MV09

I I Editorial 1391 I I I I I I I I I I I I I disorder (OCD), compulsive spending (including gambling), overeating (_ bulimic binges), hyper- seruality [whether straight (see Orford, 1978- compulsive promiscuity) or deviant (e.g. exhibi- tionum, paedophilia, fetishism)], kleptomania, and perhaps trichotillomania, tics and the Tourette syndrome, in which features (5) and (6) below may be lackiag. The common aspects feature in the WHO definition of a dependence syndrome (Edwards, 1986 ): (1) repeated urges to engage in a particular behav- ioural sequence that is counterproductive, (2) mounting tension until the sequence is com- pleted, (3) rapid but temporary switching off of the tension by completing the sequence (a 'quick fls'), (4) gradual return of the urge over hours, days of (5) weeks, external cues for the urge unique to the particular addictive syndrome, (6) secondary conditioning of the urge to both environmental and internal cues, (7) similu strategies for relapse prevention: (a) training in impulse control by prolonged cue exposure in order to habituate cue-evoked craving and withdrawal and (b) stimulus con- trol (environmental manapmetit). The ur=e of behavioural addicts to engage in their behavioural routine, and the discomfort ensuing if prevented from completing it, respectively resemble the craving and the withdrawal symptoms of sttb- stance abusers. Some withdrawal hmptoms (e{* those of ansuty) are identical across certain bebav- ioural and chemical addicts, while others (e* runny nose, goose&sh) may be utbatance-sped5c (J. Powell, personal communication). Both the urge and the discomfort habitntte to prolonged exposure in the behavioural addiction of OCD; there is little data about this for other syndromes apart from a few attadia of bnlimia which found some response decrement to prolonged exposure. It is ttnclar if there at major differeoca m the habituation of ttcfa drivea by qpetite t-6er than by relief of discomfort, even wbere two such types of utga can be clearly distia;uiahed. Addircioa .crsns compulsioo Behavioural addictions are often called compul- sions to denote coercion from a dis<omfoet that has to be allayed, whereas addiction more implies attisction towards something. Craving suggests both pull and pusb-desire so urgent that if it is not soon met discomfort will follow. Pull involves a search for a:ood feeling. Push comes from unmet stroag desire and/or a quest for relief from withdrawal symptoms. Pull and push can occur sequentially. We are irresistibly drawn to our beloved, and have panis of pain when separated, people enjoy tobacco or cocaine and are distressed by its absence. Pull and push can also be concur- rent. Alcoholics, smokers and sexual deviants can simultaneously like and dislike what they are doing. We have no universally accepted use of terms like addiction, craving and compulsion [see the critique by Rozlowaki & Wilkinson (1987) and comments on it]. Some addictions may give pleasure at an early stage though not necessarily at the very start (alcohol, nicotine, opiates, cocaine, amphetamiae, temazepam, gambling). In various argots and epochs this euphoria is a rush, buzz, gouching out, etc. In some addicts the good feeling may only be intermit- tent. In others it may disappear Later, the behaviour continuing to avoid the distress of withdrawal symptoms, though only 28% of street opiate addicts noted conditioned withdrawal sickness (McAuliffe, 1982). Except for tension relief, pleasure is not a mapr fature of addictions such as OCD, or of repetitive behaviours such as trscbotillomania, re- peated scab-pickia;, tics or Tourette's syndrome. Is hedonic tone important? We surmise that it is harder to pve up a pleasurable than a neutral or unplasant activity, but this is speculative. arais, Mechanisnals Desire and discomfort often coexist, though the brain has diadainishable systems for reward and for panishmeat (Gray, 1987). Still unclear is bow much aeparata the mrch•^+=**• driving avetaion relief versus reward, and driving non-reward versus puaiahmeat. Other substrates, too, might be in- vwed. Some brain mechaaisms may be common to the establishmeat and maintenance of all addictmns, be they cbemical or behavioural, while other mecha- nisms may differ from one addiction to another. We expect some ditYerences in the patbophysiologies of heroin versus cocaine versus amphetamine versus benzodiazepine addiction, and some differences are likely in pathophysiologies across various behav- ioural addictions. To speculate, is there more involvement of compulsive gambling with mecha- nisms for intermittent reiafotremeat, and of com- pulsive rituals with comparator systems (in the I

1392 Editonal I 1 I I I septohippocampal system-Gray, 1987) that com- pute when an acvvtty's goal has been reachFd (Wiiliam James's 'flat'). Such questions must be answered before we can chart detailed brain maps of the various substrates involved in parucular addic- tive routines. A few tantalizing clues lead us on. In animals, acute heroin and cocaine administration appear to cause dopamine release in the nucleus accumbens, whereas benzodiazepines do not (Imperato, Mulas & DiChiara, 1986). Is this distinction also true for chronic adminutntion? Conditioned passive avoid- ance bears some resemblance to compulsive rituals; does its extinction by exposure iJxrapy release dopami.ne in the nucleus accumbens? Questions abound. TDe internal cues that condition to addiction seem similar across the various syndromes. Dyspho- rta is the chuf one. Addicts of most kinds are more Likely to indulge when they feel muerabie or bored (see the references above). Conditioned cues are so important that to be enduringly effective a therapist has to know about their detailed minutiae as well as about prescriptions and withdrawal schedules. To attain a lastingly successful outcome a clinician must appreciate the multifarious cues that prompt addicuve routines in order to teach sufferers how to develop approprtate long-term therapeutic strategies for stimulus and impulse control. I I I I I I I I I Conditioning of addicta Substance abusers usually become both behavioural and chemical addicta. They condition to cues connected with their drug takini, becoming turned on not only by smokin;, drinking or iaMcna8 the substance itself, but also by the routine of preparing and administerin8 it, and by other external cues concerning people, places and thiap associated with it. This conditioning can become so stroa.* that the context in which the drug is taken alters the lethal doae in aaimals (Sie=el, 1989). Strong conditionin; to e:teraal cues also occurs in behavioural addic- tions. Both chemical and behavioural addictions may also come to be prompted by internal cues of boredom or depression (Bradley et al.,1989; Carnes, 1989, 1989; Marks, 1987; Heather & Stallard 1989; Powell, 1990; Rootb & Marks, 1973) and even by feelings of well-bein8 (J. Strans, peraoaal communi- cstioc). Eaernal cna for the varioui behavioural and cbemical addictions differ accordin j to syndrome. They vary according to the context of each addic- aa CompuWve ritualizers have an urge to wash on aeeiai 'dirc' or to check on kavint their home. Gamblets ase lured when in the .iaaity of a betting shop. Balimia binge an s+eeinf oc sanellin= food. Fslubitionisa exhibit on seeia8 a femak on her own. Smokets reach for a cigarette when aittias in a wai~n8 room, when coffee is aerv ®d after a meal or aa they ponder what to write at tiseir desk. A beroia amoker wanted to uae on aeeing a biscuit foil wrapper at a friend'r a beroia iaiecta wanted to use on aaeiat an anti-AIDS poater depicting a close-up pirooo of aomeone iajectin8 (S. Dawe, peraooal oommt;aiation). Relapse prevention in lonf-term management Both behavioural and chemical addictions are easy enough to stop for a while. The real test is maintaining control for years until it becomes second nature. Clients have to identify triggers, higtt-risk environmenu and feelings, learn to resist these, carry out 'fire-drill' to tup slips (set-backs) in the bud, and to nuture new social bonds and activities to replace destructuve ones. As control is acquired clients carefully enter progressively more difficult (tempting) situations in order to strengthen control. In this extended process the patient is the player while the therapist acts as coach and cheer- leader. Relapse preveation has also been likened to a car joataey on which the driver must plan ahead carefully, anticipate rough roads, dangerous curves, critical intersections and alternative routes, know the limitations of liis/her skills and of the velucle, and obtain help from an instrucor, guide or esperi- enced taveller (Cammin8s, Gordon & Marlatt, 1980). Deuiled suggestions for sexual addicts appear in C.araes (1989) and for anxiety disorders ia Marks (1980, 1987). Despite their o.erhp each of the various bebav- iourai aod cbemipl addictive syndromes has its own particular patteras to be reckoned with. Wben upset esbibitioaiatu need to learn alternative comforting activities to exhibiting. Compulsive ritnalixers may have to start new useful pursuits to Sll the vacuum left on abandonini day-long washing and checking. Teenage smokers abould acquire the skill of sayini bo' wit6ow giving offence or losing status; role rehearsal ran help. Heroia sddicts are required to cultivate new frwndshipa to replace former oaa with drug uaess.

I I I I I I I I I I I I I I I I Acute phase of therapy There may also be similarities in the early manage- ment of behavioural and chemical addictions. A maior advance in the treatment of anxiety disorders came when it was realized that panic is switched off only temporarily by the quick fix of escape, avoidance, reassurance, rituals or dissociation. That fix actually raises the chance of panic recurring soon after and must be prevented to break the cycle permanently. The client learns to deliberately confront feared situations which induce discomfort, and to allow this discomfort to continue without hurriedly switching off. S/he discovers that if panic is allowed to go on long enough without being turned off by escape, rituals or dissociating, then it will subside eventually anyway within an hour or longer without any rituals having been carried out. This exposure exercise breaks the addictive cycle. As the exercise is repeated time and time again, permanent habituation to the triggering cues sets in. Exposure therapy is voluntary, carried out by the patient without coercion. Does exposure therapy relate to the acute treat- ment of chemical addicts? Some withdrawal symp- toms may be partly a product of conditioning and of expectation. Detoxification programs try to switch off such symptoms by a quick fix of medication cover, e.g. methadone, clonidine or benzodiazepines. Perhaps outcome would improve if such escape were discouraged and addicts were instead persu- aded to ride through withdrawal symptoms without medication cover, just as panic patients can learn to master their panic without tunning away from it, unaided by pills, and thus achieve long-term habituation. Some substance abusers might agree to undergo withdrawal while deliberately bringing on withdrawal symptoms without atppresamg them, learning to endure them until they snbaide, which could take days. Thereafter if they slip, use their substance for a while, and then have furthet withdrawal symptoms, these migfit be easier to accept without yet more using. Patieats' prior agreement to exposure is vint; forcing it on them would be unethical and could make them worx, as is true too in anziety disorders. Thus some chemical as well as behavioural addicts might benefit not only from cue exposure to control and eztinguish craving responses ia long- term management, but also from learning to control and habituate to withdrawal symptoms in the acute Phase. Many addicts have tried such cold-mrkey treatment on their own, failing when it is not done suf&iently systematically. Anxiety disorder pa- Editorial 1393 tients fail too if exposure attempts are half-hearted, and only succeed permanently when the exposure is done in a proper detailed program. A prvgram for opiate addicts migbt include repeated precipitation of withdrawal symptoms for a few hours by means of naltresone. Some will argue that few chemical addicts accept unmedicated withdrawal. Agreement might come more readily, however, if the expectations of addicts and clinicians change as they have in anxiety disorders. Thirty years ago few patients were asked to have deliberate cold-turkey encounters with panic, yet today this is part of routine self-ezposure therapy that most anxiety disorder patients accept and benefit from. As clinicians get used to proce- dure, so do tbeir patients. Another obtection is that withdrawal symptoms may persist for days, whereas panic usually abates within hours of exposure. However, in a few sufferers anxiety persists during 1-3 days of expo- sure before subsiding, yet they continue exposure and improve. Moreover, current expectations and medication cover during detoxification could, by promoting avoidance, acually prolong withdrawal symptoms that might otherwise decrease more rapidly without such cover. Another argument against inducing habituation to withdrawal symptoms might be that fear of such symptoms can deter relapse. However, impulse control may be superior without than with fear. Differeacea betw.ea bchavioural ausd claemical .ddicts Behavioural addicts try to alter their mental state mainly by a behavioural routine such as washing, checking or gambling, without taking any particular chemical. In anuety disorder cliaics fairly few obaessive-compttlsives, agonphobics or social pho- bcs become dependent on alcohol or drugs (though a sizeable number of alcholics in alcohol cliaics also have social phobia -z agoraphobia). Although multiple drug addictions are usual, with concurrent and/or sequential abuse of alcohol, tobacco, cannabis, haoin, cocaiae and amphet- amine, multiple behavioural addictions are less common. One rarely sea compulsive gambling plus bulimia plus exhibitionism. Multiple sexual deviancws can coexist, and Tourette's patients have tics and compulsive rituals, but few obses- rive-compulsives have Tourette's syndrome or tics.

1394 Eduorfel I I ~ I I I I 1, - Unlike most other addicts, OCD patients often have comples beliefs relited to their compulsive acts aLd/or thoughts. The addiction label is most quesuotuble in tricbotillomania, tics aad Tourertes syndrome, which have the simplest bebavtoural sequences aad ieast mounting tensuon that is switched off by an addictive act. The motivation to seek, accept and complete treatment may be Reater in some bebavioural than chemical addicts-a crucial issue for therapeutic success. Cosda.ion It is useful beuristically to regard a wide raase of repetitive bebaviotus as addictive syndromes, what- ever their external trMgers. Tbese syndromes share many similanues and have some important differ- ences. Some thertpetuic and preventive ideas follow from such a perspecnve. Acknowled=emesa Valuable comments on the manttscrtpt were made by Sharon Dawe, Jeffrey Gray, Jane Powell, Dave Rschards and John Straa;. IWAC MA>ti<S IarnrYU of Psychsairy, _ Ik Cmpq"y Park, Lo*don SES &!F, UK Refe!'taCa BtwatsY, E. P., Ptmtas, G., Gam, L. & Gassor, M. (1989) Carcumsuacrs surroandm8 the tnaual lapse to opute use followtn8 deton5cauoa, Brtash Jeerrol oj Psycksany, 154, pp. 354-359. CMtNfs, 0. (1989) Com'rary to l.oce,• helpsnt the sezLa1 add= (Mannapoi4s, Compcue Pubiisbers). CvxaltNos, C., GoatDoN, J!c MNt>aTr. A. (1980) Relapse prevention aad predtcuoa, in: W. Mtt.tEn ( Ed ) Addicnoe Beharnors, pp. 306-307 (New York, Perga- mon). EDwNRDs, G. (1986) The alcohol dependence syndrome: a concept as sumulus to enquiry, Bnruh Jourrai of Addscrso+t, 81, pp. 175-186. GRAY, J. A. (1987) The Prycholo& of Fear and Stre:r (Cambrsd8e Cambridge University Press). HuTHM N. & STetwtD, A. (1989) Does the Mulatt modei underesumate the amporunce of condiuoned cravtng in the relapse process?, in: M. GossoP (Ed.) Relapx arE Addurnx Behao:ourr, Chapter 10 (London, Routkdie). Ixrauro, A., Wz-es, A. & DiCtaam, G. (1986) Nicotine preferentially sumulates dopamme release in the hmbtc system of freely moving rats, EuropeaR Jossmal ojPhanRaco/oV, 132, pp. 337-338. KoaOwsu, L. T. & Wu.luNSON, D. A. (1987) C se and misuse of the concept of cravtn8 by alcobol,cobacco, aad dru8 tssearcbers, Bntsrk Jmtrsal of AddtcnoR, 82, pp. 31-36. MAIu, I. M. (1980) Lronq With Fear (New York, McGraw-Hill). IKNtsts, 1.M. (1987) Fears, Pho6sm ard RitYais (New Yoet, Ostord Uosversuty Press). MeAG'LaTE, W. E. (1982) A test of W,kler's tbeory of relapse: the frequency of relapse due to conditioned withdrawal sxkaess,luernarsoNal Journal ojAddutso+e, 17, pp, 19-33. Mu,i.t7t, W. R. (1981) Tlte Addurroe Behaoso+s (New York, Pesgamoa). OfttoRD, J. (1978) Hypersesuality: impLcauons for a tbeot7 of dependence, &sash Josrrwal of Addurto+r, 73, pp. 299-310. RooTN, G. & MARJis, I. M. (1973) Persistent eshibiuon- um: short term response to averuon, self-regulauon and relaxation tratments, Archtves of Se:ual Behsviour,3, pp. 227- 248. StaGii, S. (1989) Condiuonan8 mechanisms in drug dependence. Paper to Maudsley Conkreace on Drug Dependence, Loodoa, Jaly. I