Supervised by: Ellen Froustis MA, MSc. Ellen Froustis is a DPhil. Education candidate at the University of Oxford. She has a Master’s of Education-Special Emphasis School Counselling and a Master’s in Clinical Psychology. As the founder and director of EIMAI, and regional director of Peace Jam Greece, Ellen provides youth leadership development programs, bringing together youth with Nobel Peace Laureates and university students to create positive change in themselves and their communities. Ellen has served as General Secretary of the Greek Adlerian Psychological Association (2012-2016) and Vice President of Habitat for Humanity, Greater Athens (2006-2010). Ellen’s work with youth and schools has been awarded by the Near East Council of Overseas Schools, The Loukoumi Make A Difference Foundation, The Nobel Peace Laureate’s Billion Acts of Peace and Character.Org for best practices in character education.
Abstract
Habits form a part of our daily life. Up to 45% of decisions made daily are shaped by habits (Neal et al., 2006). There are biological, cognitive, socioemotional, and psychological factors involved in creating or changing habits. OSA Psychology Interns explored the most challenging habits to change—compulsions and addictions. They explored the research question: “What is the role of habit formation and treatment of compulsive disorders and addictions?” The review of literature found that compulsions and addictions share certain qualities but are different as well. Key findings suggest that compulsive habits generated from psychiatric disorders (e.g. OCD) or trauma (e.g. PTSD skin-picking) are controlled by internal mechanisms that urge a specific behaviour to alleviate distress from the environment. Addictions, on the other hand, begin as behaviours in search of pleasure. If they become frequent habits and surpass the threshold of pleasure, this behaviour continues to alleviate distress from withdrawal symptoms. At this point, it shares a similar objective as compulsions—to manage distress. Other behavioural addictions, such as gaming or internet addiction, are more difficult to diagnose and often viewed as impulse control disorders. Gambling involves risk and reward, and workaholism is the most difficult to diagnose. Like substance addictions, they need treatment if the behaviours interfere with daily functioning. Psychological treatments, such as CBT, AA, and GA, are more effective than medications, such as SSRIs. However, a combination of psychological treatments and medication can be more effective in more complex cases. Overall, prevention requires keen awareness of the impact of a habit on people’s lives so that changes can be made before the addiction stage or before they limit daily functioning. Commitment and persistence to break old habits and create healthier habits are possible by creating new cues and associations to more positive habits!
Introduction
Habits are incredibly powerful and essential in life. In fact, up to 45% of daily decisions (Neal et al., 2006). According to neuroscientists at MIT (Trafton, 2012; Martiros et al., 2018), habits are so strong that once they develop, a ‘habit loop’ is formed and encoded directly into the neural pathways of the brain, freeing up energy for the brain to focus on other things. This can have positive and negative implications for individuals developing habits, depending on the nature of the habit. Habit loops can make a laborious but very beneficial action automatic, which may help individuals achieve long-term goals. On the other hand, habit loops can also prevent the individual from consciously questioning disadvantageous behaviours (Gillebaart, 2020). Highly specific habits, even if initially beneficial, may become a hindrance when individuals fail to recognize situations in which a different behaviour is more suitable (Ramirez-Vizcaya & Froese, 2019). For example, cracking a joke upon hearing sombre news may sometimes lighten the mood, but it can elevate tensions at other times. From a psychological perspective, research has shown that the consistent repetition of a single action in familiar contexts can act as a ‘trigger’ for habits to form. This is mainly through associative learning, which is the procedure of performing your habitual action upon exposure to familiar cues. Thus, once you develop the cycle of performing your actions in familiar contexts, your dependence on conscious action or motivational processes reduces, leading to the habit being formed (Gardner et al., 2012). Our understanding of how habits are formed through decades of research evolved into the Habit Theory, which was confirmed by neuroscience.
Neurobiologically, habit formation is quite complex and not yet completely understood. Then how are habits built? There is strong evidence that suggests that the majority of habit building happens in the basal ganglia in the dorsolateral striatum (DLS) and dorsomedial striatum (DMS) (Amaya & Smith, 2018). The DLS and DMS exist as parallel and competing circuits for habits and goal-directed actions, respectively. There are multiple systems and processes for habit formation within the brain, but specifically within the DLS, there are two major methods of communication by medium spiny neurons (MSNs). These neurons develop differently based on different dopamine auto-receptors, which play a major part in shaping dopamine uptake and reward system, directly impacting habit formation (Amaya & Smith, 2018). Positive habits that form from these dopamine releases can lead to a successful career and a fulfilling lifestyle (Covey, 1998).
However, the brain can also seek excessive dopamine releases that can result in addictions and compulsions. Compulsivity stems from excessive repetition and habits that can feed into disorders like OCD and skin picking disorder. An individual struggling with compulsive behaviours has internal struggles while dealing with these unwanted habits: they are unable to stop themselves from repeating the act, they experience a loss of control and they feel like they must perform the act (Luigjes et al., 2019). The treatment of these disorders can be addressed both pharmacologically and psychologically through different types of therapies and medication.
Addictions, on the other hand, involve dynamic adaptations occurring at multiple levels influenced by a variety of contexts including (but not limited to) treatment environments. There are three stages of addiction: compulsion to seek and take the drug, loss of control of intake, and emergence of a negative emotional state during abstinence. Addictive behaviours can occur within a social context as they interact dynamically and lawfully with their environment because individuals and their social context influence each other. For example, when considering substance abuse as an addictive behaviour, it involves learned responses to a drug and to the environments in which drug taking is experienced. These learning histories are encoded by the brain as neuroplastic adaptations. Descriptions of addiction often use terms such as “out of control” to describe the persistence of addiction, yet behaviour that seems “out of control” to those observing is actually an individual’s response to their environment and perceived options at the time. (Gifford & Humphreys, 2007).
To manage behaviours that negatively affect mental health, people often seek treatment. Some people take medication, with reportedly 8.5% (22.5 million) of people in the U.S. above the age of 12 needing treatment for substance misuse (CBSHQ, 2015). However, the most common type of treatment is counselling (NIDA, 2019). Statistically, the most successful form of treatment is rehabilitation. For example, rehab used for drugs and alcohol helped 80% of patients overcome their addictions (Kelly et al. 2013).
Compulsions and addictions can be difficult to manage because of biological, cognitive, social and psychological influences on habit formation. This research paper will explore the research question: “What is the role of habit formation and treatment of compulsive disorders and addictions?”.
Literature Review
This literature review will explore habit formation in relation to compulsive and addictive behaviours and their treatments. The aim is to identify how habits are formed in psychiatric disorders that cause compulsions in comparison to habit formation in addictions, how each is treated and the degree to which treatments are effective in improving desired behaviours.
Compulsive Disorders
One of the most commonly known psychological disorders that results in compulsive behaviour is obsessive compulsive disorder (OCD). OCD is a condition that manifests in compulsive urges and behaviours. Compulsions are composed of patterns and repetitions that are distinguished through a feeling or need to perform a certain act. Compulsivity has also been seen as an imbalance between the brain’s goal and habit learning systems (Gillan & Robbins, 2016). Behaviours can become excessive when there is interference with daily routine and when they cause emotional distress. The methods of treatment can be either pharmacological or psychological, or a combination of both.
Pharmacological treatment of OCD involves Selective Serotonin Reuptake Inhibitors (SSRIs). SSRIs help reduce remuneration and anxiety symptoms for patients with OCD. SSRIs indirectly improve the symptoms of OCD by helping to manage obsessive behaviours. These medications target different neurotransmitters to reduce negative compulsive actions and urges, but they have side effects. A meta-analysis of pharmacological treatments for OCD (Fineberg et al., 2013), found that (SSRIs are the most effective in treating obsessive and compulsive behaviours. When discontinued, patients often relapse, indicating that long-term use is recommended. For patients that don’t respond well to this medication, antipsychotic medication is often prescribed (Fineberg et al., 2013).
A psychological treatment for OCD is Cognitive Behavioural Therapy (CBT) with Exposure and Ritual Prevention (ERP). The ERP treatment is a psychological treatment that is part of CBT. ERP is a therapy that exposes people to certain situations that can trigger obsessive behaviour and help them work through this behaviour in a safe environment by recognizing and modifying maladaptive thought patterns.
In a clinical study, Foa et al. (2005) used a combination of ERP with clomipramine, a medication, to treat OCD in comparison to a second group of individuals with OCD who were treated only with medication. Results showed that the combination of the drug with ERP led to better results than the drug alone. Furthermore, in a second study by Tundo (2006), a group of OCD patients who showed no improvement after SSRI treatment were placed in a trial to test the effects of CBT. The trial consisted of 36 patients and 21 patients who completed CBT showed improvement statistically. The clinical study resulted in an overall improvement of symptoms, which was generally rated as “much improved” or “very much improved.” These clinical studies are among many others that show that CBT with ERP is successful in the treatment of compulsions often experienced by individuals diagnosed with OCD. Medication can support CBT therapy but is not always helpful for all individuals when used alone.
A compulsion that is not exclusively associated with OCD is skin picking disorder, otherwise known as excoriation disorder or dermatillomania. It is a disruptive mental health issue characterised by compulsive skin picking behaviour. Skin picking disorder indicates an underlying dysfunction of motor inhibitory control processes (Grant et al., 2012). Skin picking is generally triggered by anxiety, stress or boredom; however, it can also be an indicator of an underlying issue such as depression or PTSD. It can shift over time from an automatic, trance-like state of picking to a more aware, focused state of picking, incorporating the use of tweezers, pins, etc., often leading to self-injurious behaviour (Schumer et al., 2017). Skin picking disorder can lead to serious harm to the skin tissue and, if not treated early on, may leave permanent physical damage.
A study by Schumer et al. (2017) compared the effectiveness of behavioural treatments and pharmacological treatments for skin picking disorder. The behavioural treatments consisted of CBT, Habit Reversal Therapy (HRT) and other various self-help methods. Behavioural therapy interventions involved three stages: the first stage assessed awareness of skin picking behaviours plus psychoeducation; the second stage consisted of learning strategies to reduce the frequency of skin picking behaviours (i.e. competing response exercises such as clenching one’s fist until the urge to pick has passed); the final stage focused on relapse prevention. The pharmacological treatments consisted of SSRIs and lamotrigine. The results indicated that overall, behavioural treatments were more effective than pharmacological treatments. However, interestingly, people who were given placebos or were waitlisted for therapy were also observed to get better (Schumer et al., 2017). This may indicate that changing habits is a matter of being aware, deciding to act, and consciously working on eliminating the behaviour; treatments exist for support.
A second case study of a young Turkish woman reported by İbiloğlu et al. (2016), found that fluctuating moods caused by other underlying mental issues and/or trauma can be a trigger for the disorder. The patient was reported to have gone through physical and mental abuse in her household, and later she was diagnosed with BPD (borderline personality disorder). Skin picking was a coping mechanism for her stressful upbringing and fluctuating moods. The patient said that she occasionally tried to stop skin picking but couldn’t because while she experienced guilt and shame because of her compulsive skin picking, she also experienced a sense of relief. The patient started treatment with an SSRI called fluoxetine and received HRT and CBT. The patient was also told to try to resist the urges to pick as much as possible. With time, the patient reported having less anxiety and weakening urges consequently. Eventually, she was able to overcome her compulsive habit of skin picking (İbiloğlu et al., 2016).
Compulsions, therefore, are a result of obsessions or intrusive thoughts in psychiatric disorders such as OCD and a coping mechanism for distress in the case of psychological disorders. Behaviour is automatic, and the purpose is to relieve psychological or emotional distress triggered by environmental factors. This differs from many everyday habits that are goal-oriented with the aim of pleasure, benefit, or achievement, in contrast to compulsions that aim to provide relief.
Addictions
In contrast to psychiatric compulsions that begin with internal cues (i.e. distress), behaviours that begin with the aim of pleasure are more conscious and have an external cue. In this case, choices available in the environment are selected to appease boredom, have fun, and achieve a goal. These choices can be playing video games or a friendly poker game, scrolling through the internet, having a glass of wine with friends, deciding to exercise or lose weight, for example. When these activities become frequent, they can turn into habits. When the threshold of benefits is surpassed, if they are not consciously stopped, they can become compulsive behaviours in the form of an addiction, which then become “bad habits”.
Bad habits interfere with people’s well-being and overall functioning. Therefore, what starts as an external goal (i.e. having a drink for pleasure and socialising), can result in an internal goal (i.e. needing a drink to avoid withdrawals). At this stage of addiction, the aim shifts from an externally controlled behaviour to achieve pleasure to an internally motivated, uncontrolled/automatic behaviour (i.e. urge) to manage the distress of withdrawal. This urge or need to feed the addiction shares common characteristics with psychiatric compulsions because both are internally motivated to manage distress (Heather, 2017). Many common everyday behaviours can become addictions such as substance misuse, internet addiction, gambling, or gaming disorder.
Substance Misuse
Alcohol Addiction
Alcoholism is an addiction to alcohol, and when diagnosed, it is called an alcohol use disorder (AUD). It is a chronic relapsing disorder associated with compulsive alcohol drinking, the loss of control over intake, and the emergence of a negative emotional state when no more alcohol is available (Koob & Volkow, 2010). AUD is a condition characterised by an impaired ability to stop or control alcohol use despite health consequences. It can be mild, moderate, or severe.
AUDs may be associated with several psychological and affective disorders (Ross et al., 1988). Several studies demonstrated that AUDs facilitate impulsive (Dom et al., 2006) and aggressive behaviours (Giancola, 2002). Subjects with a history of alcohol abuse and/or alcohol dependence may develop affective disorders that mimic a depressive episode (Mayfield & Coleman, 1968) or an anxious mood (Stockwell & Bolderston, 1987).
The aim of a study by Ferrulli et al. (2010), was to perform multiple psychometric assessments in alcohol-dependent patients, without other psychiatric diagnoses, both before and after 12 weeks of total alcohol abstinence. The study showed that several disorders, such as affective disorders, psychiatric symptoms, thinking disorders, negative symptoms, suspiciousness, hostility, aggressiveness, and social, familiar, and employment disability were present in active drinking alcohol-dependent patients. Many of them had a significant improvement after a 12 week period of total alcohol abstinence. To the best of our knowledge, all these psychometric assessments were investigated in alcohol-dependent patients before and after a period of abstinence for the first time.
Nosological, neuroscience, and psychoanalytic approaches to addiction have diverged over the last century. Identifying these psychological and affective disorders in alcoholic patients is crucial because they may have clinical and prognostic implications, such as psychosocial problems, non-compliance to pharmacological treatments, and risk of alcohol relapse (Johnson, 2011).
A case report by Johnson (2011) classified alcohol abuse as a purely psychological addiction after identifying that transference interpretation was the fundamental key to recovery. Transference interpretation is classically defined as making something conscious to the patient that was previously unconscious. Alcoholic drinking functioned to prevent this man from remembering overwhelming childhood events, events that were also lived out in his current relationships. Murders that occurred when he was a child were hidden in a screen memory. The patient had an obsessional style of relating where almost all feeling was left out of his associations. After he stopped drinking compulsively, he continued to work compulsively. The maternal transference had to be enacted and then interpreted in order for overwhelming memories to be allowed into conscious thought. After psychoanalysis, the patient resumed drinking and worked a normal schedule that allowed more fulfilling relationships. He had no further symptoms of distress from drinking at a 9-year follow-up. This case illustrates that alcohol abuse can be a purely psychological illness. Combining epidemiological, neurobiological, longitudinal, and psychoanalytic observations would allow multiple sources of information to be used in creating diagnostic categories for more accurate diagnosis and treatment of people struggling with alcohol dependency (Johnson, 2011).
Nicotine Addiction
Nicotine is a highly addictive and hazardous chemical found in tobacco plants. In America, roughly 50 million people are addicted to tobacco products such as cigarettes, cigars, chewing tobacco, and snuff (Addiction Center, 2022). Nicotine dependency (also known as tobacco addiction) involves physical and psychological factors that make quitting nicotine difficult, even if the person wants to. Like other addictive chemicals, nicotine releases a chemical called dopamine (a neurotransmitter that is part of the brain’s reward system and produces feelings of pleasure and reward). Furthermore, as nicotine enters the body, it releases endorphins, chemicals that help relieve stress and pain while also improving mood (Sissons, 2022). It creates mood-altering changes in the neurochemical state of the brain that make the person temporarily feel good. Inhaled smoke delivers nicotine to the brain in less than 20 seconds, making it highly addictive, and the “rush” is an integral part of the addictive process. Nicotine levels in the brain decrease when a person quits consuming tobacco. This change triggers processes that contribute to the addictive cycle of cravings and impulses. Long-term changes in the brain created by continued nicotine exposure result in nicotine dependency, and attempts to quit cause withdrawal symptoms that are relieved by resuming tobacco use (NIDA, 2021).
One treatment method for nicotine addiction is CBT. CBT teaches patients relapse-prevention skills (such as relaxation techniques) (Jhanjee, 2014) and efficient coping mechanisms to resist smoking in stressful circumstances and triggers (e.g. people, places, and things) that cause the behaviour. CBT assists patients in identifying these factors that trigger the behaviour. CBT and fundamental health education reduced nicotine dependency, according to a study comparing the two approaches (Raja et al., 2014). However, a different study discovered that patients who underwent intense group CBT for six weeks had higher percentages of success in quitting smoking than those who underwent only general health education for the same number of sessions (Webb et al., 2010).
Mindfulness is another behavioural treatment used for breaking nicotine addiction. In mindfulness-based smoking cessation treatments, patients are taught to become more conscious of and detached from the sensations, ideas, and cravings that can trigger a relapse. With the help of cognitive reprogramming, patients in this therapy deliberately pay attention to the thoughts that set off cravings and desires for cigarettes and reconsider them as expected and bearable. Patients learn coping mechanisms that enable them to deal with unpleasant feelings, such as stress and cravings, without resorting to tobacco smoking or other hazardous habits (Witkiewitzet al., 2014). The last ten years have seen a rise in interest in mindfulness-based therapies, which have been shown to improve overall mental health and reduce the risk of smoking relapse (de Souza et al., 2015). However, more well-controlled clinical trials are needed to build evidence and understand the mechanisms of change.
Nicotine Replacement Therapy (NRT) is another form of therapy that helps nicotine addicts break their habit while reducing the difficult withdrawal symptoms that come with quitting. The most common reason smokers do not quit is the unpleasant withdrawal symptoms and cravings, which can be reduced with NRT. Most people who try to quit tobacco do not succeed on their first attempt, however many others can do so without using NRT. In fact, it often takes several attempts for someone who wants to stop smoking to succeed. Most people who attempt to quit smoking on their own revert to it within the first month of doing so, often due to withdrawal symptoms. There are many over-the-counter NRT formulations that are equally effective for quitting, including transdermal patches, sprays, gums, and lozenges. NRTs boost the nicotine-targeted brain receptors, easing withdrawal symptoms and cravings that cause relapse. Many people use NRT to get through the withdrawal symptoms in the beginning, and those with more severe nicotine addiction may benefit from long-term treatment. Some of the withdrawal symptoms include anger, frustration, irritability, difficulty concentrating, insomnia, restlessness, anxiety, depression, and hunger/increased appetite (Wyant, 2021). In order to reduce withdrawal symptoms and cravings, it has been discovered that a combination of continuous nicotine administration via the transdermal patch plus one additional form of nicotine taken as needed (eg. lozenges, gum, nasal spray, or inhaler) is more efficient than a single type of NRT. According to research, NRT raises quitting rates by 50% to 70%, indicating it can be an effective form of therapy (Stead et al., 2012).
While addiction to substances involves a chemical and psychological addiction and is considered a “medical brain disorder”, behavioural addictions function differently (NIDA, 2018).
Internet Gaming Disorder
Internet Gaming Disorder (IGD) is a behavioural addiction involving a persistent habit of playing video games to the point where it negatively affects daily work and educational activities. IGD can develop similarly to drug addictions, in that they start out as a pastime and become a habit whenever an individual seeks pleasure or an escape from the outside world (Hu et al., 2017). People who develop this disorder lose control over the amount of time they spend playing the game even when there are clear negative consequences such as anger. People with Internet Gaming Disorder often feel low self-esteem, neglect, anxiety, aggression, depression, pessimism, loneliness, lack of empathy, and isolation (von der Heiden et al., 2019).
While there are not many formal treatments for this disorder, two studies found that bupropion, a drug used for treating depression, was more effective than no medication (Patel et al., 2016) and more effective than a placebo (Han & Renshaw, 2012) in reducing symptoms of IGD, particularly in young males. The no medication control group had the young adults do whatever they pleased to serve as a neutral comparison and see what medications can worsen or improve the participants’ IGDs. Separate studies have also found that methylphenidate (Han, 2009) and atomoxetine (Park, 2016) reduce video game playing time for pre-teen to adolescent children. Since methylphenidate and atomoxetine are used to treat ADHD, these two studies suggest impulsivity has a significant role in video game addiction and IGD.
In general, the most effective treatments for IGD have targeted an individual’s reasons behind playing video games instead of targeting their urge to play. Taking this into account, Deng (2017), conducted a study that tested the immediate and long-term effectiveness of different therapies that each addressed specific reasons for playing video games (ie. pleasure, escapism, impulsivity). The individuals taking part in the study, all of whom were male college students, displayed more substantial responses to depression and psychological needs therapy than impulsiveness therapy (Deng et al., 2017). There may not be many sure treatments for Internet Gaming Disorder because it is recognized by the American Psychiatric Association (APA) as a temporary disorder in the latest revision of the DSM-5.
It would be beneficial for more experiments to be done in the near future in order to learn more about this disorder and how to relieve its symptoms. Approximately 1.96% of the global population has shown symptoms of this disorder via stratified random sampling. However, due to the inconsistency of the current definition of IGD, other studies have reported percentages as high as 8-10% (Zajac, 2017). The prevalence of this disorder is higher than that of problem gambling and comparable to that of obsessive compulsive disorder, with a male-to-female ratio of 2.5:1 (NIH, 2020).
While only an estimated 0.3 to 1.0 percent of the general population might have internet gaming disorder, Markey et al. (2017), suggested that it is important to distinguish between “passionate engagement” and pathology (i.e. addiction). The level of distress experienced while playing may be a defining point to help identify an addiction over a passion for playing. While this disorder is currently being studied for treatments, there are effective ways of preventing children from becoming addicted to playing video games. Research has shown that video game addiction can be prevented by limiting screen time, or embedding alternate social activities, as doing so has a positive effect on children’s physical, social, and behavioural wellbeing (Lee, 2021).
Similar to gaming, IAD, or internet addiction disorder, is a disorder in which there is a compulsive need to spend a great deal of time on the Internet leading to mental, social, and professional difficulties in one’s life (Hoeg, 2022). IAD is a new age disorder, being a relatively recent find by science. So, while this addiction is becoming a larger problem as technology continues to develop and people spend more time on it for school, work and social purposes, medical professionals are still split on the authenticity of IAD, and whether internet addiction exists as a mental disorder in its own right. Those who do recognize IAD tend to classify it as a facet of an obsessive compulsive disorder or an impulse control disorder (Bennett, 2020). A compulsion is defined as a repetitive act that is completed to reduce anxiety or distress, which, in this case, originates from separation from the internet (Colon-Rivera & Howland, 2020). As of now, there is no official definition for internet addictions, but IAD mainly covers actions related to technology that become a hindrance to more important aspects of life, such as relationships, work, and school.
A study by Dai et al. (2022) examined the effectiveness of electroacupuncture (EA) and psychotherapy (PT) in patients suffering from internet addiction disorder. The study aimed to evaluate the impact of the different treatment methods on IAD patients and their Monoamine oxidase type A (MAOA) mRNA levels. To test this, researchers placed sixty Chinese college students in two different groups (EA and PT) to test the two different treatment methods. First, researchers measured the severity of internet addiction through tests that measured symptoms of IAD at the start and at the 40-day mark of the experiment. These were the Young’s Internet Addiction Test (IAT), Yale-Brown Obsessive-Compulsive Scale (Y-BOCS), Self-Rating Anxiety Scale (SAS), Self-Rating Depression Scale (SDS), Barratt Impulse Scale (BIS-11), and the Pittsburgh Sleep Quality Index (PSQI). MAOA mRNA data were also collected at the start and at the 40-day mark of the study.
The procedure for the PT group involved group psychotherapy mixed with individual psychotherapy for unique patient interventions. This treatment was received every four days for a total of ten sessions by the end of the experiment. In the EA group, acupuncture was applied at the wrists, midpoint of the second metacarpal radial side, lower calves, ankles, and four points on the top of the head. Participants received treatment every other day for a total of twenty sessions.
Results showed that EA and PT effectively reduced all test scores of IAD patients. MAOA expression of the PT group was increased, but there was no significant change in the EA group. However, this study had several limitations. For instance, participants were only brought in from a college, and the sample size was too small to generalise results. Also, IAD can be divided into many categories, but the experiment failed to classify participants into such groups. With that in mind, researchers concluded that electroacupuncture and psychological intervention could improve the severity of internet addiction and its symptoms in IAD patients. They also concluded that neurobiological changes may be the main cause of psychotherapeutic success for internet addiction.
Gambling Addiction
Pathological gambling (PG) is classified as an addictive disorder in the DSM-5 (Petry, 2005) and characterised by persistent and recurrent problems of gambling behaviour leading to significant impairment and distress. By definition, gambling is considered to be placing something of value at risk in the hopes of gaining something of greater value. It involves decision-making based on the assessment of relative risk and reward (William & Potenza, 2010).
There are not relatively many studies conducted on treatments for gambling using self-directed interventions. However, an early study by Oei & Gordon (2008) examined the effectiveness of Gamblers Anonymous (GA) involvement in abstinence from gambling. The sample included 75 participants with at least 21 months of GA involvement (Oei & Gordon, 2008). The results were that participants who had social support and followed the 12-step process after attending sessions of GA had a higher mean attendance and participation than relapsers. However, other psychologists have alternately explained that abstinence leads to greater GA involvement or that an extraneous variable (e.g. motivation) is the main factor that leads to abstinence for gambling and greater treatment involvement.
Another study on GA effectiveness by Petry (2003) compared gambling abstinence rates 2 months after initiating professional gambling treatment in a sample of 342 pathological gamblers with and without a history of attending GA. Of GA-experienced individuals, 48% achieved abstinence post-treatment compared to 36% of those without a history of GA attendance (Petry, 2003). Individuals with prior GA experience were also more likely to attend GA meetings after initiating professional treatment. However, although these results are encouraging based on the statistical evidence from the study, about half the sample did not attend GA when recommended to do so as a complement to their professional treatment. This reduces the reliability of the experiment.
Work Addiction
While other behavioural addictions can be identified because they take time away from one’s core responsibilities, such as school and work, what happens when work is the addiction? Work addiction occurs when a person is so preoccupied with their job that it begins to consume all of their time and attention. The “compulsion or the irrepressible drive to work nonstop” has been referred to as workaholism (Atroszko et al., 2019). Work addiction has also been shown to harm a person’s health, happiness, interpersonal connections, and capacity for social interaction, much like drinking (and other behavioural addictions).
Work addiction is often associated with internet addiction disorder because technology is intertwined with modern-day office jobs and socialising in modern society (Pereira et al., 2021). A person with a work addiction illness could exhibit certain behaviours, such as working long hours, constantly checking their phone and emails, bringing work home with them, skipping family functions, and feeling a sense of pleasure in activities because they are working. Individuals who have a relationship with workaholics may note that their loved one makes planned commitments, tries to reduce work time but cannot do so, and starts to feel extremely depressed, anxious, or angry while not working. Work addiction is not yet recognized as a formal mental illness (Atroszko et al., 2019). As a result, there is no predetermined threshold for the presence of a job addiction. Even just one or two of these signs and symptoms may indicate that an individual might have a problem with work addiction.
In behavioural addictions, withdrawal symptoms are often understudied. Most frequently, they are explained in terms of irritation and restlessness after the activity has ended (Atroszko et al., 2019). There are many significant indications that there may be some physical withdrawal in the case of work addiction. One area of study is the so-called “leisure illness,” for instance. It has been noted that some people experience illness and symptom development when away from work, especially on weekends and during holidays. The addiction to one’s work does not stop at leisure Illness from the withdrawal from working.
There is also a cross-cultural work-related phenomenon that often results in death from overwork. There are both environmental and psychological factors contributing to this. For instance, Polish physicians have died while working in hospitals after more than 24 hours of continuous duty (Atroszko et al., 2019), indicating environmental factors such as unfavourable medical work policies, workplace stressors, and a shortage of physicians contribute. The phenomenon of “death from overwork” is known as ‘karoshi’ in Japan or ‘gwarosa’ in South Korea, where a strong work ethic becomes an addiction with detrimental outcomes (Schaef & Fassel, 1988). However, psychological reasons have also been found in western contexts.
In performance-oriented societies, workaholism can function as a stimulant or to escape or avoid personal frustrations (Kang, 2021). Workaholism is believed to function as a way not to feel or mask emotions such as emptiness, fear of failure or worthlessness (Urban et al., 2019). When work addiction becomes pathological, there are three distinct characteristics: 1) a compulsive dependency resulting from work pressures or the need to build a positive identity to mask low self-esteem (Schaufeli et al., 2009.); 2) obsessive, perfectionist tendencies seeking social approval (Griffiths, 2011); and 3) suffering withdrawal symptoms when not working such as feeling guilty, anxious, depressed, dull, or irritable (Snir & Zohar, 2008).
While the study of work addiction is less extensive than that of formally recognized mental illnesses, work addiction can be a dangerous pathology that masquerades as a constructive and healthy enthusiasm for work. Current psychological tools that can differentiate between healthy and unhealthy work habits include the WART (WorkAddiction Risk Test) by Robinson (1989), which measures compulsive tendencies, control, and impaired communication, and the Work–BAT by Spence and Robbins (1992) that measures work involvement (WI), work drive (D), and work enjoyment (WE). The WART can identify obsessive compulsive traits that result in self-imposed demands, an inability to regulate work habits, and an overindulgence in work while matching Type A behaviour patterns with anxiety (Robinson, 1989). The Work-BAT shows that workaholics tend to score high on work involvement and work drive, but low on work enjoyment. Both tests have certain validity issues and aren’t perfect as most characteristics measured are also common to non-addictive work enthusiasts (Kang, 2021). A more recent test by Aziz et al. (2013), appears to be more comprehensive by measuring work-life conflict (WLC), work perfectionism (WP), work addiction (WA), unpleasantness (UP), and withdrawal symptoms (WD). While all psychometric tests have strengths and limitations, psychological therapy can help individuals identify the reasons they overindulge in work.
Psychologists recommend therapies such as counselling and support groups to help to reduce symptoms. Positive psychology, motivational interviewing, and cognitive behavioural therapy are all effective methods to address change in behaviour and maintenance of the recovery process from a job addiction. It is understandable how a job can affect a person’s well-being. When other parts of their life suffer because of too many work hours, it is beneficial to be open and honest about the risks of work addiction. To achieve a happier balance that leaves time for work and leisure, it is important to seek expert help when needed. Workaholism, like all behavioural addictions, have root causes in psychological issues that need to be addressed before physical and mental health declines.
Discussion
Understanding the role of habit formation in sustaining compulsions and addictions was helpful in answering the research question: “What is the role of habit formation and treatment of compulsive disorders and addictions?”.
Compulsive disorders and addictions are not commonly studied together, so it was necessary to explore the similarities and differences between the two before examining the treatments for these disorders. Both addictions and compulsions generally begin as a coping mechanism for one’s hardships or negative emotions such as childhood trauma, anxiety, and depression. The coping mechanisms turn into habits when they are done too frequently, and these habits can then become compulsions or addictions as the individual loses control over the behaviour. While genetics and neurobiological functioning can be involved in the presence of compulsive disorders in individuals, there are no genes that directly manifest as addictions, according to various debates that have evolved over time.
A key difference between the two pathologies is that psychiatric compulsions are intrinsic and intentional with a purpose of providing relief from psychological distress, while substance misuse and behavioural addictions originate as extrinsic cues for the purpose of pleasure; when regular use becomes a habit and it has more negative than positive outcomes, it ceases to be pleasurable and is sustained to avoid the distress of withdrawals. Both compulsions and addictions are hard-wired in the brain and can impact the quality and functioning of one’s life and make treatment difficult.
A wide variety of treatment options has been observed for addictions and compulsions. All treatments are either therapy-based or medication-based, with the former showing consistently positive results across nearly every addiction and compulsion examined in the literature review. In particular, cognitive behavioural therapy (CBT) was successful in treating multiple compulsions and addictions. Medication-based treatments were more successful when attempting to treat addictions than when attempting to treat compulsions. Habit reversal therapy (HRT) only helped individuals with compulsions due to the closer association with habits to compulsions. Aversion therapy was ineffective in the long term for addictions because, similar to classical conditioning, the associations with negative stimuli can diminish over time.
No matter how long an individual is given treatment and observed, the monitoring must end at some point. Relapses are very common for people with compulsions and addictions, and there is no guarantee that the observed effects of the treatments during studies will continue long-term. It is commendable that some studies have monitored their subjects for some time after their treatment, but more longitudinal studies are needed to confirm the effectiveness and reliability of the various therapies mentioned. Persistence and mental toughness of the subjects are both also important – but often less considered – factors that can affect the success of the treatments. Even treatments shown to be effective, like CBT, can fail if the patients are disengaged. These intangible factors can significantly impact the treatment of compulsions and addictions, which further emphasises the need for more studies to be conducted.
Conclusion
Positive and negative habits are inevitably seen in human and animal behaviours. Positive habits are supportive of us in our daily lives. Negative habits can hold us back from experiencing the level of progress that we wish to see in certain areas of our lives. Numerous findings from basic neuroscience research on habits have broadened our knowledge of how habits arise from changes in our lifestyle and neural activity of the brain.
The dynamics of activity observed in key habit-promoting brain regions suggest that many reward-seeking habits and negative habits involve multiple signalling mechanisms in the brain. An example is the role of the basal ganglia and dopamine, which makes individuals struggle to successfully eliminate their habits.
At present, the available findings suggest that the majority of compulsive habits and addictions can be combated by psychological therapies and medications – interventions discussed throughout this article. Important frameworks, such as Habit Theory, have suggested that further research and studies could provide more convincing evidence to finally enable individuals to successfully eliminate habits and reduce the problem of adherence issues and high dropout rates. In summary, changing habits starts with awareness and then requires commitment and focus on achieving the greater goal.
References
Addiction Center, n.a. (2022).Nicotine addiction and abuse. Addiction Center. https://www.addictioncenter.com/nicotine/
Amaya, K. A., & Smith, K. S. (2018). Neurobiology of habit formation. Current Opinion in Behavioral Sciences, 20, 145–152.
Aziz, S., Adkins, C. T., Walker, A. G., & Wuensch, K. L. (2010). Workaholism and work-life imbalance: Does cultural origin influence the relationship? International Journal of Psychology, 45, 72-79.
Atroszko, P. A., Demetrovics, Z., & Griffiths, M. D. (2019). Beyond the myths about work addiction: Toward a consensus on definition and trajectories for future studies on problematic overworking. Journal Of Behavioural Addictions. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7044606/
Bennett, T. (2020). Internet addiction: Definition, symptoms, causes, treatment, and more. Thriveworks. Blog. https://thriveworks.com/blog/internet-addiction/
Brazeau, W. & Hodgins, D. (2022). In Asmundson, G.J.G (Eds.), Comprehensive Clinical Psychology (Second Edition), 8:16. https://www.sciencedirect.com/referencework/9780128222324/comprehensive-clinical-psychology#book-info
CAMH.(n.d.). Nicotine Dependence. :https://www.camh.ca/en/health-info/mental-illness-and-addiction-index/nicotine-dependence
Center for Behavioral Health Statistics and Quality (CBSHQ, 2015). 2014 National Survey on Drug Use and Health: Detailed Tables. Rockville, MD: Substance Abuse and Mental Health Services Administration.
Chou, I., & Narasimhan, K. (2005). Neurobiology of addiction. Nature Neuroscience, 8(11), 1427–1427. https://doi.org/10.1038/nn1105-1427
Colon-Rivera, H., & Howland, M. (Eds.). (2020). What is obsessive-compulsive disorder? Psychiatry.Org. Blog. https://psychiatry.org/patients-/obsessive-compulsive-disorder/what-is-obsessive-compulsive-disorder
Covey, S. R. (1998). The 7 Habits of Highly Effective People. Franklin Covey.
Dai, Y., Zhang, C., Zhang, L., Wen, C., & Zhu, T. (2022). The modulation of mRNA levels of MAOA by electroacupuncture and psychotherapy in patients with pathological internet use. Frontiers in Psychiatry. 13:918729. doi: 10.3389/fpsyt.2022.918729.
de Souza, I. C., de Barros, V. V., Gomide, H. P., Miranda, T. C., Menezes, V., Kozasa, E. H., Ferrulli, A., Leggio, L., Cardone, S., D’Angelo, C., Mirijello, A., Vonghia, L., Miceli, A., Gasbarrini, G. & Addolorato, G. (2010). Psychosocial findings in alcohol-dependent patients before and after three months of total alcohol abstinence. Frontiers in Psychiatry 1:17.
Deng, L.Y., Liu, L., Xia, C.C., Lan, J., Zhang, J.T., & Fang, X.Y. (2017) Craving Behavior Intervention in Ameliorating College Students’ Internet Game Disorder: A Longitudinal Study. Frontiers in Psychology. 8, 526.
Dom, G., Hulstijn, W., & Sabbe, B. (2006). Differences in impulsivity and sensation seeking between early- and late-onset alcoholics. Addictive behaviours, 31(2), 298–308.
Fineberg, N.A., Reghunandanan, S., Brown A., Pampaloni, I. (2013). Pharmacotherapy of obsessive-compulsive disorder: evidence-based treatment and beyond. Australian and New Zealand Journal of Psychiatry, 47:121–141.
Foa, E.B., Liebowitz, M.R., Kozak, M.J., et al. (2005). Randomised, Placebo-Controlled Trial of Exposure and Ritual Prevention, Clomipramine, and Their Combination in the Treatment of Obsessive-Compulsive Disorder. American Journal of Psychiatry, 162(1): 151-161.
Gardner, B., Lally, P., & Wardle, J. (2012) Making health habitual: the psychology of ‘habit-formation’ and general practice. British Journal of General Practice, 62, 664-666.
Giancola, P. R. (2002). Alcohol-related aggression during the college years: Theories, risk factors, and policy implications. Journal of Studies on Alcohol, Suppl14, 129–139.
Gifford, E., & Humphreys, K. (2007). The psychological science of addiction. Addiction, 102(3), 352–361.
Gillan, C.M., Robbins TW, Sahakian BJ, van den Heuvel OA, van Wingen G. (2016). The role of habit in compulsivity. European Journal of Neuropsychopharmacology, 26(5):828-40.
Gillebaart, M., Benjamins, J., van der Weiden, A., Ybema, J. F., & De Ridder, D. (2020). Practice makes perfect: Repeatedly dealing with response conflict facilitates its identification and speed of resolution. Journal of Research in Personality, 86, Article 103955.
Grant, J. E., Odlaug, B. L., Chamberlain, S. R., Keuthen, N. J., Lochner, C., & Stein, D1. (2012). Skin picking disorder. The American Journal Of Psychiatry, 169(11), 1143–1149.
Han, D. H., Lee, Y. S., Na, C., Ahn, J. Y., Chung, U. S., Daniels, M. A., Haws, C. A., & Renshaw, P. F. (2009). The effect of methylphenidate on Internet video game play in children with attention-deficit/hyperactivity disorder. Comprehensive psychiatry, 50(3), 251–256.
Heather N. (2017). Is the concept of compulsion useful in the explanation or description of addictive behaviour and experience? Addict Behav Rep, 6:15-38.
Hoeg, N. (2022). Internet addiction. Addiction Center. Blog. https://www.addictioncenter.com/drugs/internet-addiction/
Hu, J., Zhen, S., Yu, C., Zhang, Q., & Zhang, W. (2017). Sensation Seeking and Online Gaming Addiction in Adolescents: A Moderated Mediation Model of Positive Affective Associations and Impulsivity. Frontiers in Psychology. 8, 699.
Ibiloğlu, O.A., Atli, A., Kaya, M. C., Demir, S., Bulut, M., & Sir, A. (2016). A Case of Skin Picking Disorder of a Patient with a History of Childhood Abuse. Noro psikiyatri arsivi, 53(2), 181–183.
Jhanjee S. (2014). Evidence based psychosocial interventions in substance use. Indian Journal of Psychological Medicine, 36(2), 112–118.
Johnson, B. (2011). Psychoanalytic treatment of psychological addiction to alcohol (alcohol abuse). Frontiers in Psychology 2:362.
Kang, S. (2020). Workaholism in Korea: Prevalence and socio-demographic differences. Frontiers in Psychology, 11: 569744.
Kelly, J. F., Stout, R. L., & Slaymaker, V. (2013). Emerging adults’ treatment outcomes in relation to 12-step mutual-help attendance and active involvement. Drug And Alcohol Dependence, 129(1-2), 151–157.
Koob, G., & Volkow, N. (2010). Neurocircuitry of Addiction. Neuropsychopharmacology 35, 217–238 (2010).
Luigjes, J., Lorenzetti, V., de Haan, S., Youssef, G. J., Murawski, C., Sjoerds, Z., van den Brink, W., Denys, D., Fontenelle, L. F., & Yücel, M. (2019). Defining Compulsive Behaviour. Neuropsychology review, 29(1), 4–13.
Martiros, N., Burgess, A. A., & Graybiel, A. M. (2018). Inversely active striatal projection neurons and interneurons selectively delimit useful behavioural sequences. Current Biology, 28(4), 560–573.
Mayfield, D. G., & Coleman, L. L. (1968). Alcohol use and affective disorder. Diseases of the Nervous System, 29(7), 467–474.
Neal, D. T., Wood, W., & Quinn, J. M. (2006). Habits—A Repeat Performance. Current Directions in Psychological Science, 15(4), 198–202.
NIDA (2019). Treatment Approaches for Drug Addiction Drug Facts. National Institute on Drug Abuse. Blog. https://nida.nih.gov/publications/drugfacts/treatment-approaches-drug-addiction
NIDA (2021). Is nicotine addictive? National Institute on Drug Abuse. https://nida.nih.gov/publications/research-reports/tobacco-nicotine-e-cigarettes/nicotine-addictive
NIDA (2018). What Does It Mean When We Call Addiction a Brain Disorder? National Institute on Drug Awareness. Blog. https://nida.nih.gov/about-nida/noras-blog/2018/03/what-does-it- mean-when-we-call-addiction-brain-disorder
Noto, A. R. (2015). Mindfulness-based interventions for the treatment of smoking: a systematic literature review. Journal Of Alternative And Complementary Medicine. 21(3), 129–140.
Oei, T.P., & Gordon, L.M. (2008). Psychosocial factors related to gambling abstinence and relapse in members of gamblers anonymous. Journal of Gambling Studies, 24(1) 91–105.
Park, J. H., Lee, Y. S., Sohn, J. H., & Han, D. H. (2016). Effectiveness of atomoxetine and methylphenidate for problematic online gaming in adolescents with attention deficit hyperactivity disorder. Human Psychopharmacology, 31(6), 427–432.
Patel, K., Allen, S., Haque, M. N., Angelescu, I., Baumeister, D., & Tracy, D. K. (2016). Bupropion: a systematic review and meta-analysis of effectiveness as an antidepressant. Therapeutic Advances in Psychopharmacology, 6(2), 99–144.
Petry, N. M. (2003). Patterns and correlates of Gamblers Anonymous attendance in pathological gamblers seeking professional treatment. Addictive Behaviours, 28(6), 1049–1062.
Petry, N. M., Steinberg, K. L., & Women’s Problem Gambling Research Center (2005). Childhood maltreatment in male and female treatment-seeking pathological gamblers. Psychology of Addictive Behaviours: Journal of the Society of Psychologists in Addictive Behaviors, 19(2), 226–229.
Pereira, H., Fehér, G., Tibold, A., Esgalhado, G., Costa, V., & Monteiro, S. (2021). The impact of internet addiction and job satisfaction on mental health symptoms among a sample of Portuguese workers. International Journal Of Environmental Research And Public Health. 18(13). 6943.
Raja, M., Saha, S., Mohd, S., Narang, R., Reddy, L. V., & Kumari, M. (2014). Cognitive Behavioural Therapy versus Basic Health Education for Tobacco Cessation among Tobacco Users: A Randomised Clinical Trial. Journal of Clinical and Diagnostic Research : JCDR, 8(4), ZC47–ZC49.
Ramírez-Vizcaya, S., & Froese, T. (2019). The enactive approach to habits: New concepts for the cognitive science of bad habits and addiction. Frontiers in Psychology, 10. 301.
Robinson, B.E. (1988). The Work Addiction Risk Test: development of a tentative measure of workaholism. Percept Mot Skills. (1) 199–210.
Ross, R. R., Fabiano, E. A., & Ewles, C. D. (1988). Reasoning and rehabilitation. International Journal of Offender Therapy and Comparative Criminology, 32, 29-35.
Schaufeli, W. B., Shimazu, A., & Taris, T.W. (2009). Being driven to work excessively hard: The evaluation of a two–factor measure of workaholism in the Netherlands and Japan. Cross–Cultural Research, 43(4), 320–348.
Schumer, M. C., Bartley, C. A., & Bloch, M. H. (2016). Systematic Review of Pharmacological and Behavioural Treatments for Skin Picking Disorder. Journal of Clinical Psychopharmacology, 36(2), 147–152.
Sissons, B. (2022). Everything You Need To Know About Nicotine. Medical News Today. Blog. https://www.medicalnewstoday.com/articles/240820#smoking
Snir, R., & Zohar, D. (2008). Workaholism as discretionary time investment at work: An experience–sampling study. Applied Psychology, 57(1), 109–127.
Spence, J. T., & Robbins, A. S. (1992). Workaholism: Definition, measurement, and preliminary results. Journal of Personality Assessment, 58(1), 160–178.
Stead, L. F., Perera, R., Bullen, C., Mant, D., Hartmann-Boyce, J., Cahill, K., & Lancaster, T. (2012). Nicotine Replacement Therapy For Smoking Cessation. The Cochrane Database Of Systematic Reviews, 11:CD000146.
Stockwell, T., & Bolderston, H. (1987). Alcohol and phobias. British Journal of Addiction, 82(9), 971–979.
Sussman, S., &Sussman, A.N. (2011). Considering the definition of addiction. International Journal of Environmental Research on Public Health, 8(10):4025-4038.
Torres-Rodríguez, A., Griffiths, M. D., Carbonell, X., & Oberst, U. (2018). Internet gaming disorder in adolescence: Psychological characteristics of a clinical sample. Journal of Behavioural Addictions, 7(3), 707–718.
Trafton, A. (2012). How the brain controls our habits. MIT News | Massachusetts Institute of Technology. Blog. https://news.mit.edu/2012/understanding-how-brains-control-our-habits-1029
Tundo, A., Salvati, L., Busto, G., Di Spigno, D., & Falcini, R. (2007). Addition of cognitive-behavioural therapy for nonresponders to medication for obsessive-compulsive disorder: a naturalistic study. The Journal of Clinical Psychiatry, 68(10), 1552–1556.
Urban, R., Kun, B., Mozes, T., Soltesz, P., Paksi, B., Farkas, J., Kokonyei, G., Orosz, G., Maraz, A., Felvinczi, K., Griffiths, M.D. & Demetrovics, Z. (2019). A four–factor model of work addiction: The development of the work addiction risk test revised. European Addiction Research, 25(3), 145–160.
Urban, N. B., Kegeles, L. S., Slifstein, M., Xu X., Martinez, D., Sakr, E., Castillo, F., Moadel, T., O’Malley, S. S., Krysta,l J. H., & Abi-Dargham, A. (2010). Sex differences in striatal dopamine release in young adults after oral alcohol challenge: a positron emission tomography imaging study with [11C] raclopride. Biological. Psychiatry 68, 689–696.
von der Heiden, J. M., Braun, B., Müller, K. W., & Egloff, B. (2019). The Association Between Video Gaming and Psychological Functioning. Frontiers in Psychology, 10, 1731.
Webb, M. S., de Ybarra, D. R., Baker, E. A., Reis, I. M., & Carey, M. P. (2010). Cognitive-behavioural therapy to promote smoking cessation among African American smokers: a randomised clinical trial. Journal of Consulting and Clinical Psychology, 78(1), 24–33.
Williams, W. A., & Potenza, M. N. (2008). Neurobiologia dos transtornos do controle dos impulsos [The neurobiology of impulse control disorders]. Revista brasileira de psiquiatria. 30 Suppl 1(0 1), S24–S30.
Witkiewitz, K., Bowen, S., Harrop, E. N., Douglas, H., Enkema, M., & Sedgwick, C. (2014). Mindfulness-based treatment to prevent addictive behaviour relapse: theoretical models and hypothesised mechanisms of change. Substance Use & Misuse, 49(5), 513–524.
Zajac, K., Ginley, M. K., Chang, R., & Petry, N. M. (2017). Treatments for Internet gaming disorder and Internet addiction: A systematic review. Psychology of Addictive Behaviours : Journal of the Society of Psychologists in Addictive Behaviours, 31(8), 979–994.
