The term “addiction” has traditionally been associated with dependence on mind-altering substances like alcohol or drugs. However, more and more people are engaging in certain behaviors—such as gambling, computer use, or internet browsing—in an excessive way.
This type of addiction, known as a “non-substance-related addiction” or “behavioral addiction,” is characterized by a compulsive repetition of specific behaviors. Affected individuals experience a strong urge to engage in the behavior, which dominates their thoughts and significantly limits their ability to make decisions or act freely. In the end, they feel unable to resist the urge.
Recent research supports classifying pathological gambling and excessive use of computers or the internet as genuine addiction disorders. The American diagnostic manual DSM-5 has already included pathological gambling under the category of behavioral addictions. Similar recognition is also recommended for internet gaming disorder.
In certain cases, compulsive shopping, excessive sexual behavior, and some forms of obesity may take on addiction-like traits. However, current research is not yet sufficient to officially classify them as behavioral addictions.
Classification of Behavioral Addictions
In the world’s most widely used diagnostic system for mental disorders—the International Classification of Diseases, 10th Revision (ICD-10, WHO 1992)—only pathological gambling is currently listed as a behavioral disorder. However, it is not classified under addictions but rather under impulse control disorders.
In contrast, the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5, APA 2014) introduces a new category for behavioral addictions, with pathological gambling as the only officially recognized condition. Internet addiction is listed only as a condition for further study in the appendix, as current research is still too limited to support a clear classification.
The reclassification of so-called non-substance-related addictions—from impulse control disorders to recognized addiction disorders in DSM-5—is based on growing scientific evidence. Strong parallels have been identified between substance-based and behavioral addictions in several key areas:
- Course of illness: Both tend to follow a chronic, recurring pattern, with higher prevalence in adolescents and young adults.
- Symptoms: Shared features include intense craving, loss of control, tolerance, and withdrawal symptoms.
- Comorbid conditions: Behavioral addictions are often found alongside depression, anxiety disorders, and ADHD.
- Treatment response: Treatment approaches and outcomes show similarities between the two groups.
- Biological basis: Research points to similar genetic predispositions and neurobiological mechanisms, especially involving neurotransmitters like glutamate, opioids, serotonin, and the dopamine/endorphin-regulated mesocorticolimbic reward system.
So far, most available data comes from studies on gambling and problematic internet use. For other behaviors that can become excessive and harmful—such as compulsive shopping, eating, or sexual behavior—the scientific evidence is still too limited to support a formal classification as behavioral addictions.
Pathological Gambling
Pathological gambling is marked by behaviors such as chasing losses, obsessive thoughts about gambling, and the inability to control gambling impulses. These behaviors are often impulsive—poorly thought out, risky, and linked to long-term negative consequences. Globally, the prevalence is relatively stable, averaging around 1.0%.
Compared to non-gamblers, individuals with pathological gambling have a six times higher lifetime risk of being diagnosed with alcohol abuse and a four times higher risk of current substance use or dependence. The classification of pathological gambling as a behavioral addiction is strongly supported by scientific evidence.
Research suggests that pathological gambling involves dysfunctions in the brain’s reward system, particularly involving dopamine and other neurotransmitters. These disruptions resemble those seen in substance addictions and contribute to cravings, loss of control, and compulsive behavior.
Treatment Options for Pathological Gamblig
A meta-analysis published by the Cochrane Collaboration examined the effectiveness of psychotherapeutic treatments for pathological and problematic gambling. The results showed that cognitive-behavioral therapy (CBT) was more effective than other approaches such as motivational interviewing or combined treatment formats. However, the evidence for alternative therapies was too limited to draw firm conclusions.
In Germany, treatment is available in both outpatient and inpatient settings. Key components of gambling therapy include:
- Psychoeducation (providing disorder-specific knowledge)
- Developing a personalized model of the disorder
- Cognitive restructuring, especially correcting distorted beliefs related to gambling
- Money management skills
- Stress management training
In most therapeutic approaches, the primary goal is complete abstinence from gambling.
Pharmacological treatment focuses primarily on µ-opioid receptor antagonists and glutamate-modulating medications. Medications like Naltrexone and Nalmefene, which are also used in alcohol addiction, have shown early promise in reducing gambling cravings in initial studies.
Prevention Strategies in Pathological Gambling
One of the core challenges in preventing gambling addiction—especially among young people—is the widespread and easily accessible nature of modern gambling options. New digital technologies have made gambling more available, more visually appealing, and more addictive than ever before (Hayer, 2012). Young people are particularly vulnerable to developing a gambling problem, making this a critical issue.
As a result, effective prevention of gambling addiction focuses more on structural (environmental) measures rather than simply encouraging individuals to change their behavior. Although there is a lack of systematic, controlled studies, useful insights can be drawn from prevention strategies in other countries:
- In Switzerland, commercial slot machines have been successfully banned from restaurants and bars.
- In Norway, slot machines were heavily scaled back—machines were slowed down and the maximum and average losses per hour were reduced.
- In the United States, strong legal action was taken against illegal online gambling operators, resulting in a market collapse and the bankruptcy of several companies (referred to as “Black Friday”).
In Germany, however, there has been little enforcement against illegal operators, and no significant reduction in the number of gambling machines.
Experts recommend implementing the following preventive measures:
- Limiting bets, maximum winnings (jackpots), and losses
- Reducing the frequency of “near wins”, which falsely encourage continued play
- Improving exclusion and self-limitation systems—these should not be run by gambling companies themselves, but by an independent third party
- Gambling addicts should be able to self-exclude from all gambling activities (except for lotteries, which have a low addiction risk and too many sales points to control efficiently)
There is also discussion about banning gambling advertisements at sporting events, including ads on jerseys and billboards. Such ads expose children and teenagers to gambling at a young age, lowering the barrier to entry and increasing the likelihood of addiction.
Computer and Internet Addiction
Interactive screen-based media are now widespread, and for some users, this leads to a pathological pattern of use that shows clear similarities to substance-related addictions. However, problematic internet use varies depending on how it manifests. The most thoroughly studied form of this addiction is compulsive video gaming. Other forms include excessive and compulsive use of:
- Online social networking or relationship platforms
- Online pornography
- Online gambling and shopping
- Endless web surfing and researching
It remains unclear whether the findings from gaming addiction can be applied to these other internet-based behaviors. A major limitation in past research has been the lack of consistent classification criteria, which makes comparing results difficult.
The DSM-5 proposes a research diagnosis for what it calls Internet Gaming Disorder, based on nine criteria. For now, this diagnosis applies specifically to gaming, the most studied area. Despite its frequent overlap with other mental health disorders, current research supports the idea that excessive gaming or internet use can be an independent clinical condition.
Because of inconsistent diagnostic criteria, prevalence studies are hard to compare. However, in Germany, representative surveys show that internet addiction affects between 1% and 2.3% of the general population. Among younger age groups, the numbers are significantly higher. For gaming addiction in adolescents, estimated prevalence ranges from 0.9% to 1.7%.
Neurobiology of Computer and Internet Addiction
The neurobiological research on computer and internet addiction is not as extensive as that on pathological gambling. However, existing studies—mostly focused on excessive gaming—suggest strong similarities between the two disorders in terms of brain function and behavioral changes.
Patients diagnosed with pathological gambling or internet/gaming addiction tend to:
- Show reduced sensitivity to monetary losses
- Exhibit heightened reactivity to gaming-related cues (known as cue reactivity)
- Act more impulsively
- Show altered patterns in reward-based learning
Unlike in some other disorders, cognitive flexibility (the ability to adapt thinking and behavior) appears to be unaffected in both conditions. Still, the number of neuroimaging studies is relatively small, and some suffer from significant methodological issues.
Psychological Consequences of Behavioural Addictions
Behavioural addictions have detrimental effects on the individual and their families, resulting in negative emotions such as shame, guilt, fear, irritability, sadness, and anxiety. At times there are also catastrophic financial consequences, e.g. gambling and shopping addictions. In other cases, when behavioral addictions consume an inordinate amount of time, people will neglect their daily responsibilities, such as homework or parenting. Frequently, patients seek treatment to reduce negative consequences rather than modifying or stopping the behaviour altogether. Clinicians can assess when excessive behavioral patterns require intervention with psychiatric and psychological care. Ideally, the patient has insight and wants to end the suffering imposed by the behavioral addiction. Otherwise, caring friends, family members, or colleagues will have to nudge the addict along to reach out for professional treatment. As is the case in chemical addictions (alcohol or drugs), denial is what stops people from getting needed treatment.
Prevention Strategies for Harmful Use of Media
Given the widespread presence of the internet and social media, a key goal from a general health-promotion perspective is to prevent harmful effects of media use. To be effective, prevention strategies must build on findings from epidemiological research on gaming and internet addiction. Importantly, media use should be recognized as a potential health risk—even before it crosses the line into clearly pathological behavior.
Although there is not yet a comprehensive overview of existing prevention programs and their effectiveness, there are signs that many current initiatives fall short of this goal. Most prevention efforts have not been developed based on health psychology principles. Instead, they tend to focus narrowly on teaching media skills—mainly about technical protections and providing information—rather than addressing psychological health risks.
Moreover, most of these programs have not been evaluated through randomized controlled trials, making it difficult to assess their true effectiveness. There is a clear need for more evidence-based prevention approaches.
Certain areas stand out as especially important for targeted prevention:
- Structural prevention (policy-level measures): For example, youth media protection could include age restrictions for games that carry a risk of addiction. Currently, games only receive higher age ratings if they contain violence or other content considered harmful to development—not if they pose a risk of addiction.
- Behavioral prevention: This also applies to other online content that may endanger young people, such as pornographic material and gambling platforms. Efforts in this area should focus on helping young people develop healthier media habits and better self-regulation.
Treatment for Behavioural Addictions
The therapeutic alliance is critical in addressing behavioural addictions. Building a relationship with the patient is key to understanding the full clinical picture. Patients must understand that the behaviour is not defining but rather a symptom of an underlying issue.
Exploring destructive patterns of behaviour and psychoeducation helps patients engaging in treatment. Empathy, hopefulness, and a flexible approach can lead to improved treatment outcomes. Psychotherapy, both individual and group, provides the best results. The 12-step program used in the treatment of substance abuse, also turned out to be effective treatment of behavioural addictions. However, the behavioural addictions are frequently comorbid with depression and anxiety. In such cases psychiatrists can provide supportive treatment with medication targeting the comorbidities.
Treatment Options for Behavioural Addictions
A review that analyzed eight treatment studies found two key issues: first, internet addiction is diagnosed in very different ways across studies; and second, only one of the studies used a controlled and randomized design. Most of the studies did not provide a detailed description of the therapeutic methods used.
However, a more recent meta-analysis identified 16 studies showing positive effects for both psychological and pharmacological interventions.
When it comes to medication, two published studies suggest that Bupropion (a dopamine and norepinephrine reuptake inhibitor) and Methylphenidate can help reduce problematic internet use in adolescents with comorbid ADHD symptoms.
In summary, based on current clinical experience and research, cognitive-behavioral therapy (CBT) appears to be particularly effective. Key elements of treatment include:
- Encouraging intrinsic motivation for change
- Reintroducing healthy alternative behaviors
- Helping individuals regain control over their digital use
Rebuilding real-life social connections and teaching social skills are also considered essential parts of therapy. Group therapy settings have proven especially helpful in supporting the development of these social skills.
Developing and Implementing Targeted Prevention Measures
Gambling is one of the oldest forms of human entertainment and is enjoyed without issue by the majority of people. However, the number of people who develop problematic or addictive gambling behaviors largely depends on how gambling is offered and how effectively it is regulated. There has been positive experience with structural prevention strategies, such as cross-platform self-exclusion and self-limit systems, and enforcing bans on activities like online poker.
New media—used for work, information, and leisure—are now an essential part of modern information society. Prevention efforts should aim to promote responsible and informed use of digital media in schools and training environments. This starts with providing clear education and practical tips for maintaining a healthy relationship with technology.
The same approach applies to raising awareness about emerging behavioral addictions. When practiced excessively, these behaviors can lead to dependence and cause harm. Prevention, therefore, also involves educating the public about these risks.
Limits of the Addiction Concept
The English word “addiction” comes from the Latin addictus, which originally meant “devoted like a slave.” This idea of a loss of free will is central to how addiction is understood and is reflected in the diagnostic criteria of the ICD-10. A core feature is loss of control—meaning the affected person struggles to regulate when they start or stop the behavior, and how much they engage in it.
People with addiction often neglect responsibilities, activities, hobbies, or interests as the craving for the substance (or behavior) becomes the center of their life. Use continues despite knowing the harmful consequences. Many report a strong, sometimes overwhelming urge to consume the substance—known as craving. Withdrawal symptoms and increasing tolerance are part of physical dependence.
Traditionally, the term “addiction” has referred to dependence on psychoactive substances like alcohol, nicotine, or other drugs. But in recent years, various behaviors—such as gambling, eating, sex, viewing pornography, computer or internet use, video gaming, compulsive spiritual practices (as opposed to healthy religious devotion), and shopping—have been considered as potential behavioral addictions.
This term refers to normal, pleasurable activities that become excessive, repetitive, and poorly controlled. The person feels compelled to engage in them—driven by an urge, craving, or impulse that they find difficult to resist—even when the behavior causes harm to themselves or others.
Behavioral addiction is now understood as a chronic condition, with a persistent risk of relapse even after long periods of abstinence. Like substance addictions, behavioral addictions can involve withdrawal symptoms and tolerance effects.
A key diagnostic question today is whether behavioral addictions resemble substance dependence more closely or whether they should be classified under impulse control disorders or obsessive-compulsive disorders.
Preventing Over-Pathologization
Not every passion or intense interest is a sign of addiction. That’s why key criteria in diagnosing addiction should include factors such as personal distress, loss of control over one’s actions, and a narrowing of behavioral options to addiction-related activities—despite harmful consequences.
It’s important to avoid labeling individual behaviors as pathological simply because they are socially “undesirable.” On one hand, new disorders must be evaluated based on solid scientific evidence to prevent the addiction concept from being overused or diluted. On the other hand, society must continually reflect on its own norms and values, which influence whether a particular behavior is seen as normal or as a disorder.
Behavioural Addictions. Summary
In recent years, the term “addiction” has expanded to include extreme behaviours beyond substance use disorders. These behavioural addictions such as gambling, sex, food, Internet addiction and compulsive buying have gained recognition for their negative impact on people’s lives. Research suggests a strong neurobiological link between pathological gambling and substance use disorders. Currently DSM 5 reclassified only gambling disorder as the first and only behavioral addiction. Other behavioral addictions are still in the research stage, but their “diagnostic upgrade” will follow soon.
Excessive engagement in these behaviors activates the same reward centers in the brain and leads to symptoms similar to those seen in substance-based addictions, such as alcohol, tobacco, or drug dependence. These symptoms include compulsive repetition, loss of control, increased tolerance, and in some cases, withdrawal symptoms (though usually milder).
Like other forms of addiction, behavioral addictions can consume so much of a person’s life that they interfere with work and social relationships. This often leads to problems in personal life and at the workplace, and may result in social withdrawal, mental health issues, and, in extreme cases, risk of suicide or neglect.
The potential for addiction, health risks, and serious social and professional consequences of behavioral addictions are comparable to those of substance addictions. For example, gambling addiction is often linked to massive debt, a significantly increased risk of suicide, criminal behavior to obtain money, and the threat of social isolation. From a public health and economic standpoint, it is considered one of the most costly mental health disorders.
The addiction model provides a solid foundation for effective and long-lasting prevention and treatment of behavioral addictions. This includes developing both behavior-based and structural prevention strategies, as well as applying cognitive-behavioral therapy methods.
Similar to how the German Interstate Gambling Treaty established a nationwide, qualified system of counseling and treatment—while also driving significant innovation in research and practice—there is now a need for increased professional focus on other behavioral addictions. This should involve improving their classification, diagnosis, and treatment, all supported by public funding.
Currently, there is not enough scientific evidence to officially classify compulsive shopping, excessive sexual behavior, or binge eating as behavioral addictions.