We all have bad habits we wish we could stop, like cracking knuckles, biting fingernails, or checking our smartphones 800 times a day. For the most part, these behaviors are still harmless, but some can become just as addictive and damaging as alcohol or drug use.
In a new book called Why Can’t I Stop?, Jon Grant, JD, MD, MPH, professor of psychiatry at the University of Chicago, explores seven of the most common and dangerous behavioral addictions: gambling, sex, stealing, internet use, shopping, hair pulling or skin picking, and food. Grant and his co-authors, Brian Odlaug from the University of Copenhagen and Samuel Chamberlain from the University of Cambridge, draw on research to describe these addictions, the complicated issues that might cause them, and what patients and family members can do to help.
Some research estimates that 10 to 15 percent of the population experiences one or more of these addictions in a given year, up to 48 million people in the United States alone. We spoke to Grant recently about their surprising prevalence, why they may be under-diagnosed, and why sometimes these issues hit close to home.
UChicagoMed: The number of people dealing with these issues is surprisingly big.
Jon Grant: Yes, but for some of these issues there are no large national studies of hundreds of thousands of people, except in the case of gambling. It always has to be a little bit cautiously interpreted.
Having said that, we do know that for a lot of these behaviors, there wouldn’t be a market for things unless people felt that people loved to engage in them. The fact that there is an internet porn market that is huge beyond all scope of knowledge does suggest that out of the gazillions of people looking at it, it isn’t surprising that a small percentage get hooked on it. Shopping is the same way. So I think that the unnerving factor of that is often that when we think, “Wow this is pretty common,” it makes us think how close to home it is.
Speaking of hitting a little too close to home, do you see a lot of patients with internet addiction? Has it been increasing? Because the internet is different now than it was even 5 years ago.
I think ease of access and constant internet connectivity is changing things. I just read in the Chicago Tribune about this problem with pedestrians—people are not watching when they cross the street and they’re getting hit. This speaks to something going on doesn’t it? Even though we had books before, people didn’t get hit while reading a book crossing the street. So they’re constantly getting stimulation all the time. So is it increasing? One could argue maybe it will, but what we do know is that awareness of the problem is increasing.
The problem with the internet, and I would analogize it to drinking in college, is that when everybody does it it’s often hard for people to have an awareness that they have a problem. So they only are aware when it’s at its most severe, catastrophic form, when they’re actually getting fired from a job because they can’t get off their cell phones or stop whatever games they’re playing. So sometimes it’s the secondary repercussions that are the eye-opening event, and that’s usually job issues.
Has that come from the smartphone era? Was it different when you had to sit down at a computer and dial up on a modem to get on the internet?
The smartphone has completely changed the game, because as you said, people go to bed with the phone right next to them. It’s causing insomnia; people wake up in the middle of the night and check their phones. It’s infiltrated the society in a way that we tell ourselves that we need it. I would argue that I’m not always so sure we need it as much as we think we do, especially if you’re spending hours playing Candy Crush or something. Whether we should call that a need is a very different issue.
It’s worth sitting and pondering what you’re not doing. What in life has been given up due to your smartphone? Is that a tradeoff that you’re okay with, or not? I don’t mind people wanting to work on their smartphones 24 hours a day, but the question is again if you’re really making that choice or if you’re feeling a compulsive need to do it.
Sometimes when we’re on the fence about whether you really have a problem with the internet, we’ll ask a patient to see what it’s like not being on the internet for a week, other than essential aspects of work, to see how much control they have. I’m amazed how much it terrifies people. Not that it was slightly uncomfortable, but that it was almost withdrawal-level of uncomfortable, that they’re almost fetal, rocking in a corner, because they can’t deal with it. At the very least, even if it doesn’t cause a lot of dysfunction in your life, that’s probably a good thing to know how much control you’ve given up to it.
Are these behaviors under diagnosed because of the shame element? Are people afraid to speak to their doctors about them?
I think there is shame, and also, for lack of a better word, a lack of information or ignorance about it. People will often think this is just a bad habit I have or I can’t control myself. They wonder why they would tell their primary doctor about it. There haven’t been a lot of 60 Minutes episodes about it. At least alcoholism is in every movie possible.
Primary care doctors are the people who should be on the front lines, but their first job is asking if the patient’s heart is okay, are their lungs okay, and maybe asking if they have a drug problem or are depressed. They can’t screen for every possible behavior, so these issues really fall through the cracks. Time and time again, when I screen people for it, they say they would never have told anybody if I had not asked explicitly.
It seems like many of these behaviors could be easily trivialized, or not taken seriously.
And they are trivialized. Unfortunately I think a lot of substance addictions can be trivialized too, although we have better education so people know better than to say it. But behavioral addictions are often trivialized. Family members say, “You don’t have a problem with that. It’s not possible because you’re not taking a drug into your body. It’s not a real addiction so quit looking for attention,” or, “You’re doing it just to hurt your family.”
Why is that hard for people to accept?
I don’t know why necessarily people have such visceral responses, except I do think sometimes when we know relatively little about something, if I’m not so sure why you have this problem, then I might start getting nervous that I might have the problem too. If I tell you just stop it, maybe if you can do that I can rest easy because I know if I ever develop the problem I’m not going to fall apart. So we have our own vested interest in hoping that somebody can be smacked into shape, if you will.
Obviously these are all very different behaviors, but what are some of the more effective treatments? Is there a common theme?
There is a common theme. Across the board the most common treatment would be individual therapy, particularly of a type called cognitive behavior therapy. It essentially is a therapy to help the way people think about a behavior so, for example, they don’t think the only way they can relax at night is to spend six hours on the internet. That’s a distortion—there are other ways of relaxing, people knew how to relax before the internet. But we tell ourselves things that are perhaps distortions, and that keeps the behavior going. So part of the therapy addresses that. And then we try to replace it with healthier behaviors. Learn what the behavior is doing for you. Is it relaxing? Fine, what other behavior can help you relax? Is it distracting? Then what other behavior can help distract you? So that has been the common type of therapy that has been used. There are nuanced differences between different behaviors, but that’s been probably the best single approach.
The 12 step programs exist for some of them, again not sure how helpful, and then medication has shown variable results in some behaviors but not all. So we have for any individual behavior five or six individual approaches.