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Behavioral Addiction in Women – The Neglected Cousin of Alcohol and Drug Addiction

Behavioral Addiction in Women – The Neglected Cousin of Alcohol and Drug Addiction

by Hope Rehab Team

Topic at a glance:

Behavioral Addiction in Women Not Taken Seriously Enough

The topic is perhaps one of the most controversial in contemporary addictions research, and the jury is still out: are compulsive behaviors similar to substance dependencies in cause, course and impact, or are they problematic misconduct at best?

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With the exception of compulsive gambling, none of the so called addictive behaviors managed to claim its place as an equal next to other recognized Substance Use Disorders in the most recent edition of the DSM (Diagnostical Statistical Manual V), the widely used mental health bible issued by the American Psychiatric Association (APA). Perhaps due to this lack of clinical recognition, behavioral addictions are often overlooked or not taken seriously enough. This notwithstanding, the impact on individuals afflicted by such compulsive behaviors and their loved ones can be grave.

Unlike alcohol and illegal drug use that affects men disproportionately among the genders, women are actually the front runners in compulsive behavior problems such as food addiction, compulsive shopping or plastic surgery. Contrary to popular belief, women are also not far behind their male counterparts when it comes to hypersexuality, or problematic internet use or gambling.

Apples or Oranges: Compulsive Behaviors versus Chemical Dependencies

Behavioral addiction describes problematic behaviors over which an individual has no longer control. Similar to individuals addicted to substances, such persons are mentally consumed with the problematic activity; if they are not engaging in it, they are thinking about it, or crave it. Extensive amount of time is spent to pursue, engage in or recovering from the addictive behavior, often at the expense of daily familial or work-related duties. Those afflicted report a feeling of tension or anticipatory excitement in preparation of the activity and pleasure or relief of tension as result of engaging in the acitivity. Also similar to alcohol and drug addicts, they are unable to stop themselves despite growing negative consequences, thus reflecting a severe loss of control.

Somewhat surprising perhaps is the fact that behavioral addiction also results into tolerance and withdrawal. Individuals have to increase or somehow intensify the behavior in order to continue achieving the desired effect, just as drug addicts have to increase their dosage, or change the mix of drugs they are taking to get high over time. Although withdrawal symptoms are less physical compared to those experienced following the cessation of alcohol and many of the illegal drugs, marked irritability, anger, anxiety, problems with cognitive functioning and sleep have been observed.

Women are actually the front runners in compulsive behavior problems such as food addiction, compulsive shopping or plastic surgery. 

In short, while much more research is necessary, including those leading to clear diagnostic criterias, existing studies have shown significant similarities between substance use disorders and behavioral addictions. Interestingly, and although impulsivity control problems are part of the picture for both substance use disorders and behavioral addictions, researchers distinguish these from pure impulse control disorders such as kleptomania, pathological skin picking or firesetting. The latter are in fact seen as more similar to conduct disorders rather than addictive disorders.

Gender differences: general trends

Telescoping, the fact that addiction to alcohol and drugs tends to develop quicker in women as compared to men, also appears to be true for behavioral addictions. Apart from this, research as to how behavioral addiction affects women differently from men is still in its infancy. What is known is that women show higher rates in compulsive shopping and food binging, while men are more prone to fall victim to compulsive exercising, gambling and hypersexuality. Some of these behaviors also appear to show differences in patterns of activities. For example, for compulsive gambling, men are more likely to get involved with internet gambling, betting, casino tables or poker. Female compulsive gamblers on the other hand show more affinity to “ scratch and win“ games. Although pathological gambling appears to affect much more men than women, those women are affected by it tend to show higher rates of suicidality.

Women are also more prone to develop problematic eating patterns, including higher levels of addiction to chocolate (yes, sorry, it does exist!). Hormonal fluctuations may play a role here, as cravings for sweets and chocolates are reportedly highest among women during premenstrual phases. Although men are typically more prone to hypersexual behaviors than women, one study found that approximately 7% of interviewed women in the US report sexual fantasies, urges, or behaviors they considered out of control. While young males are most likely to engage in excessive video game or other computer activities, young women have been found to be more vulnerable to spending extensive time on social media. Small to no gender differences are found in compulsive exercising.

Areas of Female Dominance: A Closer Look

Women account disproportionally for those affected by problematic eating patterns, plastic surgery and compulsive shopping. Two of these are particularly controversial as it relates to comparisons to substance use disorders:

Plastic Surgery

Let’s start with the least well understood and perhaps most surprising among compulsive behaviors: plastic surgery. Research findings suggest that women almost exclusively account for those repeatedly, voluntarily, excessively and without sound medical rationale undergoing surgical procedures. Among the 1.8 million surgical procedures done in the US in 2017, the top five are those commonly sought after by women: breast augmentation, liposuction, nose corrections, tummy tucks and eyelid lid surgery. Called minimally invasive procedures, things like botox injections, soft tissue fillers and laser hair removals are also mostly done by women. $16.4 billion US dollars worth, 92% of patients are Caucasian women in their forties and fifties.

Such cosmetic and medically unfounded procedures may not constitute a problem behavior per se, but can become problematic if resulting into negative consequences for the patient, or her loved ones. Studies suggest that patient expectations play a significant role as to whether surgical procedures will enhance or diminish life. Unrealistic expectations, such as hoping that younger looks will save a relationship, or solve some other identified problem in a patient’s life, are likely to result into grave disappointment, or even depression. A recent study has found a disturbing link between breast augmentation surgery and increased suicide rates among patients who voluntarily submitted to this procedure. Allergic reactions, infections, nerve damage, financial problems, or botched facial or bodily features followed by social alienation are other potential negative consequences women may experience.

Research findings suggest that women almost exclusively account for those repeatedly, voluntarily, excessively and without sound medical rationale undergoing surgical procedures.

Research into this rather puzzling compulsive behaviour among women has also found a strong link to mental health problems. Depression, substance use disorders, social anxiety, eating disorders, obsessive compulsive disorders and personality disorders are all found in women repeatedly undergoing the knife to change some perceived imperfection. Not surprisingly, Body Dismorphic Disorder (a firmly held and distorted belief about one’s perceived body image) is also implicated, making it likely that whatever the result, it will never suffice. Like a drug addict always wanting more and different but never having enough, these women find some part of their body that in their mind does not measure up.

Gender Stereotypes and Plastic Surgery

Quite obviously, gender stereotypes play a role in this. Women who are neither slim nor young are treated differently than those who fit the culturally prescribed ideal, affecting especially younger women’s self esteem negatively. Problems with relationships may be particularly attributed to looks, translating into aforementioned unrealistic expectations, and false hopes. Root causes may go deeper still.

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Clinicians and researchers in the field of trauma suggest trauma may play a role. Navajits, for example, posits that behaviors such as compulsive cosmetic surgery, excessive tanning or tattoing may all be similar to self-injurious behaviors such as cutting. Often accompanied by anticipatory excitement and temporary relief of tension while engaging in these activities, these behaviors may pose trauma reenactment. Trauma survivors may engage in behaviors that evoke similar emotional states as the original emotional trauma in order to gain control over this devastating experience.

This theory seems supported by the fact that female teens who undergo cosmetic surgery are more likely to show a history of self injurious behaviors, such as cutting or burning themselves. They also tend to suffer from anxiety and depression, which is often aggravated rather than alleviated as a consequence oft he chosen procedure. Interesting, this theory has also been implicated in the cause of hypersexual behaviors in women, as female survivors of child sexual abuse, specifically those exposed to pornography early in life, are said to be particularly at risk for developing this type of behavior.

Compulsive Overeating Or Binge Eating

Compulsive overeating, binge eating, food addiction and disordered eating are terms that are often used interchangeably, and medical professionals appear to differ as to whether or not these different terms do or do not constitute the same thing. Fact is, the American Psychiatric Association (APA) has included Binge Eating Disorder (BED) for the first time in the last edition of the Diagnostic Statistical Manual (DSM V), thus suggesting it to be equal to, yet different from other recognized eating disorders such as Bulimia Nervosa or Anorexia.

Although it remains highly controversial to compare eating disorders with addictive disorders, commonalities exist in some aspects. For example, BED sufferers report a loss of control over their behavior despite of increasing negative consequences, the most visible one being obesity. Following initial short-lived relief of tension or anxiety, shame, guilt and disgust with self after gorging large amounts of foods are also part of sufferers’ common experience. Eating alone in an attempt to hide or lie about how much they are actually consuming is common, the same way that hiding and lying about substance or alcohol use is part of addictions.

Women and Problematic Eating

Two thirds of individuals suffering from this type of problematic eating are women, and many are obese. There are no attempts to counter the massive caloric intake by purging or through laxatives as common in Bulimia. Health consequences can be severe, and include:

Although BED affects women across race and age, in the US, African American women have been particularly implicated. Poverty is a suspect in exploring external risk factors, taking into consideration that food with low nutritious content, thus processed food high in sugar, salt and fat, is typically cheaper. Marketing of low nutritious foods and beverages occurs to a much greater rate in low socioeconomic neighborhoods compared to White areas, also accounting for increased purchasing of such foods by those living in poverty.

Binge Eating as an Addiction

These unhealthy foods are said to have increased addictive qualities, affecting dopamine regulated brain reward pathways, resulting into increasing cravings for more of the same. Research has shown that those suffering from BED in fact show the same reaction to food cues as alcoholics show to cues involving drinking cues.  These common neurobiological underpinnings may be account for the fact that severe binging has been linked to increased alcohol consumption. Research also showed similarities in personality traits, such a need for control, between individuals suffering from eating disorders, and those struggling with alcohol and drug addiction, disregarding what subtype of eating disorder is involved.

Often cited as a potential precursor to BED, emotional overeating may initially start a response to stressful or overwhelming feelings. Dissatisfaction with body image and anxiety related to ones’ appearance in general have also all been linked to overeating. Women with BED also tend to show elevated rates of depression, substance use and personality disorders compared to women not engaging in disordered eating.

Although BED affects women across race and age, in the US, African American women have been particularly implicated. Poverty is a suspect in exploring external risk factors, taking into consideration that food with low nutritious content, thus processed food high in sugar, salt and fat, is typically cheaper. Marketing of low nutritious foods and beverages occurs to a much greater rate in low socioeconomic neighborhoods compared to White areas, also accounting for increased purchasing of such foods by those living in poverty.

From Passion to Compulsion: Tell-Tale Signs You’ve Crossed the Line

As with alcohol or drug addiction, there are clear signs to indicate a behavior has become more than just passion or pastime.

For some addictive behaviors, such as compulsive eating or hypersexuality, physical signs may be present. For example, weight gain or obesity may be evidence of binge eating behaviors. If binging is accompanied by purging, the afflicted person may show dental problems or signs of nutritional deficiencies, perhaps seeking professional help around these issues. Hypersexuality puts women at risk for STDs and violence, and signs can include anything from repeated doctor or pharmacy visits, to unexplained injuries. Using the internet in secrecy may also be a sign of cybersex or gambling activities.

If You Can’t Stop, You Have a Problem

As with any form of addiction, a clear indicator as to whether or not something constitutes a problem is repeated unsuccessful attempts to curtail time spent engaging in the activity. Just as alcohol or drug addicted individuals, those struggling with behavioral addiction are typically unable to shorten the time engaging in the problematic behavior. Moreover, attempts to do so may provoke withdrawal symptoms such as strong irritability, increased anxiety, mood swings or aggressive behaviors towards those getting in the way of pursuing renewed engagement with the problematic activity.

Clinically, in order to be considered problematic or compulsive in nature, individuals must show some degree of inability to function at home or at work as a result of their behavior.

Help & Support: What Loved Ones Can Do

Research findings indicate that persons with behavioral addictions do not tend to reach out for help, or for professional treatment. They do however sometimes reach out for help in dealing with the consequences of their addiction. For example, obese individuals may approach their doctors in getting help with their weight problem, and compulsive shoppers or gamblers may approach their family members for financial help. Women engaging in hypersexual behavior may seek medical attention for STD’s. Affected individuals may be asked to seek EAP (Employee Assistance Programs) services following decline in workplace productivity. Although regulations binding professionals to confidentiality, family member can offer rather than seeking information to professionals involved with their loved one. This will provide context and background to a patient’s presentation, and subsequent appointments may potentially fruitful conversation as to what is really going on.

Compulsive gamblers, shoppers, overeaters are not likely to share loved ones’ concerns. For them, the activity is one that provides relief and is thus more a solution, however temporary, rather than a problem. As such, nagging, complaining and pleading are not likely to produce desired behavior changes. The following suggestions may prove more helpful:

Professional Treatment Options

Although some studies suggest that behavioral addiction diminish and perhaps resolve themselves over time and on its own, waiting for this to happen may prove costly, damaging and perhaps even fatal in some cases.

For example, adolescents who spend their lives behind computer screens, thus foregoing studies, work and social relationships alike, may become increasingly depressed and socially inapt and anxious. Binge eaters run the risk of becoming severely obese, and with that likely to develop serious and potentially fatal health problems. Compulsive shoppers or gamblers may ruin entire families financially for years to come, and those engaging in compulsive plastic surgery are likely to end disappointed, disillusioned and potentially suicidal. In all of these cases, seeking professional help can kick-start increased health and healing.

Individualized Treatment for Behavior Addiction in Women

Ideally, treatment starts with a thorough assessment, and is tailored to the individual woman. Therapy can be accessed on an outpatient or inpatient/residential program and include group and individual sessions. Informed by the specific circumstances and contexts in which her addictive behavior started, continued or re-emerged, treatment will need to address factors contributing and/or underlying the addiction.

For example, mental health issues tend to play a significant role in women’s compulsive behaviors. Depression, anxiety and trauma ought to be screened for, and treated if present. Treatment may or may not include medication, depending on type and severity of the psychiatric problem, and a woman’s preference. For trauma survivors, gender specific groups or trauma specific programming may prove important for healing. Interpersonal Therapy (IPT) and Cognitive Behavioral Therapy (CBT) are research supported therapies in the treatment of depression. As relationships are key to women’s wellbeing and identity, IPT may prove particularly helpful in that it seeks to improve existing relationships and support networks.

Cognitive Behavioral Therapy for Behavior Addiction

Cognitive behavioral therapy (CBT) can be used to challenge and change negative self-talk related to shame and guilt often prevalent in female substance users. Furthermore, CBT facilitates behavior change by teaching participants to set smart goals in line with a healthy lifestyle, thus goals that are specific, measurable, achievable, realistic and time limited. Motivational enhancement, contingency management and relapse prevention programs that identify patterns of use, and teach coping skills to deal with cravings or high risk situations have been found beneficial in the treatment of substance use disorders and behavioral addiction alike. Since addictive behaviors may also surface as an undesired byproduct of withdrawal and abstinence from alcohol or illegal substances, psycho-education regarding cross addiction may be indicated.

Mindfulness Therapy for Behavior Addiction

Equally important, as women tend to engage both in substance use and addictive behaviors to ease difficult emotional states, or to reduce tension and stress, therapeutic modalities increasing coping skills in these domains are crucial treatment components. Mindfulness may prove helpful increasing women’s capacity to stay with all range of emotions, rather than seeking some sort of quick fix from any and all emotional discomfort. Mindfulness based stress reduction (MBSR), Mindfulness Enhanced Cognitive Therapy and Mindfulness Based Relapse Prevention (MBRP) are examples of mindfulness-based approaches that have shown promising results in the treatment of addictions

Mind-Body Therapies

Internalized oppressive stereotypes of female body images seem to play a role in compulsive eating and plastic surgery. Allowing women to explore such external factors may translate into healthier body image, and improved relationships with their own body. Mind body therapies such as yoga can foster healthy reconnection with their bodies. This in turn may decrease the likelihood of self-abuse (as in the form of compulsive cosmetic surgery, binge eating and hypersexuality).

Financial Support/Advice

Supporting women to become financially self-sufficient, for example by collaborating with employers, employment programs, or educational institutions may prove helpful in reducing poverty and addressing financial debt accumulated as a consequence of a behavioral addiction.

Help Overcoming the Barriers to Treatment for Women

Assisting women in addressing barriers to treatment, or barriers to maintaining a healthy and sober lifestyle following discharge translate into long-term positive outcomes. This may involve helping women identify affodable child or elder care arrangments so they can attend therapy sessions, or assist in dealings with health insurance providers to make therapy affordable and accessible.

Inpatient or Outpatient

Whether inpatient or outpatient treatment is preferred, and whether women may benefit more from one over another type of therapy is secondary. What really matters is that help is available. While the American Psychiatric Association may still await further research supporting the inclusion of behavioral addictions into the DSM, addictions professionals and family members alike have long recognized that compulsive behaviors are no laughing stock and by no means the poorer cousin of the real thing.

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