Can't Just Stop CHAPTER ONE What Is a Compulsion? A GENERATION OR SO AGO, it became trendy to describe all sorts of excessive behaviors as addictions, meaning an intense appetite for an activity, as in "I'm addicted to shopping" . . . or to weaving, yoga, jogging, work, meditating, making money (as a 1980 book called Wealth Addiction argued) or even to playing Rubik's Cube (a 1981 story in the New York Times deemed it "an addictive invention"). Once neurobiologists discovered that the same brain circuitry underlying addictions to nicotine, opiates, and other substances is also involved in, for instance, a chocoholic's craving for Teuscher truffles, pop sociologists were off to the races. Suddenly, we were all addicted to email and working and Angry Birds playing and Facebook posting and . . . well, everything that some people do in excess became an addiction. The only significant scientific barrier to this trend--psychiatry did not recognize any behavior as addictive in the formal sense of the term--fell in 2013. That spring, the American Psychiatric Association published the latest edition of its Diagnostic and Statistical Manual of Mental Disorders, widely regarded as the bible of the field, and for the first time it recognized a behavioral addiction: gambling. Gambling made the cut because it met the three criteria that, for decades, have been the defining characteristics of an addiction. First, the behavior (or substance) is intensely pleasurable, at least initially, and sinks its claws into soon-to-be addicts the first time they experience it. Second, engaging in the addictive behavior produces tolerance, in which an addict needs more and more of something to derive the same hedonic hit. And, finally, ceasing to engage in the addictive behavior triggers agonizing withdrawal symptoms on a par with those that torture the addict who is trying to kick a heroin habit. By these criteria, "addictions" to the electronic crack of the twenty-first century don't look like addictions, and they don't feel like it either, most crucially because they lack the defining hedonic quality. For me, at least, compulsively checking for emails feels more like what people with obsessive-compulsive disorder experience right before the urge to wash their hands or straighten a picture or step on the magical fourth sidewalk crack (because if they don't their mother will die). It feels like something you have to do, not something you want to do; something that alleviates anxiety (Is an elusive source finally getting back to me, but about to try a competitor unless I reply in the next five seconds?), rarely something that brings pleasure. They are compulsions, not addictions. What's the difference? The two terms are often used interchangeably in casual conversation ("compulsive shopping" vs. a "shopping addiction") with a mention of "impulsive" often thrown in for good measure. But since this is a book about compulsions and not addictions, let me explain how experts understand the differences. To wit: surprisingly, alarmingly, disappointingly, exasperatingly poorly. A Taxonomic Odyssey Without ratting out people who were kind enough to sit still for my persistent questioning, I'll simply note that they did not fill me with confidence about the solidity of the scientific foundation underpinning the understanding of compulsive behaviors. "Well, a behavioral addiction is governed by things like neurons and hormones," one tentatively began. "But a compulsive behavior is psychological, but is governed by physical mechanisms." Huh? The muddle was captured nicely, if inadvertently, by a 2008 paper in which the authors invent something they name "impulsive-compulsive sexual behavior" and define it as "one type of addictive behavior." Trifecta: a behavior that's impulsive, compulsive, and addictive. The lines dividing a compulsive behavior from an addictive one from an impulsive one seem to shift like tastes in fashion, and the confusion between and among them was practically codified by the many iterations of the American Psychiatric Association and its Diagnostic and Statistical Manual. Over the decades, the editions of the mega-selling DSM have rotated addiction, compulsion, and impulse through the definitions of syndromes, including eating disorders and anxiety disorders, as if the three were interchangeable. The DSM hasn't even managed to draw clear boundaries around OCD, which you'd think would be firmly ensconced as a compulsive disorder by virtue of its name, if nothing else. But no: early editions of the DSM described obsessive-compulsive disorder as marked by recurrent and persistent impulses to do this or that. When the APA's experts began working on what would become the DSM-5, their working names for pathological Internet use and pathological shopping were "C-I Internet usage" and "C-I shopping"--where the C stood for compulsive and the I for impulsive. The idea was that the excessive behaviors have features of both: impulsivity is the proximate cause, but a compulsive drive makes the behavior persist. To get a sense of how muddled the taxonomy was, consider trichotillomania, which afflicted Amy, whom you met in the Introduction. In 1987 it entered that year's DSM (edition III-R) as an impulse-control disorder, along with kleptomania, pyromania, and intermittent explosive disorder, among others. That reflected the common meaning of impulsivity as "rapid, unplanned behavior with little foresight of or regard for the negative consequences," as Yale University psychiatrist Marc Potenza defined it one day when I visited his office in downtown New Haven, Connecticut. But the 1994 edition, DSM-IV, added two criteria for diagnosing trichotillomania: "an increasing sense of tension immediately before pulling out the hair or when attempting to resist the behavior," and "pleasure, gratification, or relief when pulling out the hair." Both of these are exactly what defines a compulsion. Yet trichotillomania sat among the impulse-control disorders until 2013, when the DSM-5 (it switched that year from Roman numerals to Arabic) plucked it out of the impulse-control disorders and stuck it at the end of the chapter on OCD as a "related disorder." Oh, and the DSM-5 eliminated the criteria that hair pulling be preceded by tension and lead to relief--and yet there it sits, in the OCD chapter, a chapter for a disorder whose defining characteristic is the anxiety that spurs an action that relieves said anxiety. Tric's wanderings in the psychiatric wilderness are nothing compared to those of pathological gambling. The 1994 DSM had put compulsive gambling (my emphasis) in a grab-bag category called "impulse-control disorders not elsewhere classified," along with kleptomania, pyromania, and others. Again, that reflected the thinking that someone might impulsively decide to play the ponies and then, through some poorly understood mechanism, segue into doing so compulsively. In 2013, gambling also pulled off the trifecta: having previously been called compulsive and classified as impulsive, it became the first behavioral disorder to be formally categorized as an addiction. At least the new classification made sense, in that it hewed to the traditional three-part understanding of addiction (initial hedonic hit leading to intense desire for the substance or, now, the experience; tolerance; withdrawal) in the context of drugs. For starters, pathological gamblers experience cravings as powerful as a junkie's. While it's obviously tricky to quantify a subjective experience like craving, there is some empirical evidence that the brain mechanisms underlying an addiction to gambling overlap with those in an addiction to alcohol, nicotine, pain pills, or illegal drugs: when pathological gamblers watch videos of people playing craps or roulette or another casino game, the regions of their brains' frontal cortex and limbic system that spike with activity are nearly identical to the regions that go haywire in cocaine addicts who watch videos of people doing lines. In addition, pathological gamblers build up tolerance to gambling just as alcoholics do to booze or junkies to heroin: to get the same pleasurable rush from gambling, they have to make larger and larger bets. And finally, pathological gamblers experience psychological withdrawal when they try to quit or even taper off, again akin to what substance abusers suffer. Cravings, tolerance, withdrawal: pathological gambling qualifies as an addiction. In part, addiction and compulsion get mixed up because both words are used in ordinary language as well as clinical terminology, said Tom Stafford, a cognitive scientist at England's University of Sheffield who studies compulsive video-gaming. "Many people are cavalier about saying they're addicted to sports, or to shopping, or to their iPhone," he told me. "There isn't a clear line between an addiction like alcohol and a behavior they are very compelled to do, but I'd rather use the term compulsion for these behaviors." It isn't just casual use of the terms that causes confusion. "It's a real scientific controversy, how and in what ways addictions are or are not like compulsive behaviors," James Hansell, a professor and clinical psychologist at George Washington University and coauthor of a popular textbook on abnormal psychology, told me. Hansell paused, as if trying to find properly diplomatic language: "There is a primitive quality to this, trying to define what is a compulsion and what's an addiction." I Indeed, many researchers feel that the understanding, not just the nomenclature, of excessive behavior "has been shifting under our feet," as psychologist Carolyn Rodriguez of Columbia University said when I visited her office at Columbia University Medical Center. "Terms we had been using--like addiction, compulsion, and impulse control--are being looked at in a new light." Is there any hedonic hit from executing a compulsion? Rodriguez flipped through her mental Rolodex of patients. "In talking to them, I wouldn't say it feels good," she answered. "It just relieves anxiety." That relief might feel good, but it's a different kind of good than the pleasure that giving in to an addiction brings. Executing a compulsion brings an ebbing of the tide of angst, a lifting of the cap from a shaken soda bottle about to explode. People who feel compelled have a mental itch they need to scratch, like a poison ivy of the mind. One of Rodriguez's patients, she told me, "has intrusive thoughts about the name James. It makes him so anxious that if he ever sees it--like in the newspaper--he has to write Edward to cancel it out, and use Visine to wash away the sense that 'James' has contaminated his eyes." Rodriguez paused. "These people really suffer." Fortunately, a growing number of experts have begun to grapple with the failure to clearly distinguish addictions from compulsions from poor impulse control, and not merely to classify behaviors correctly for the sake of tidiness. There is a practical motivation, too: if therapists aren't sure whether the behavior that has hijacked your life is a compulsion, an addiction, or a manifestation of lousy impulse control, they're not likely to identify the most effective therapy. The treatment for a behavioral addiction is very different from that for a compulsive behavior, which in turn is different from the treatment for an impulse-control disorder. "You do need to get it right to determine effective treatment," Yale's Potenza said. What finally emerged is this three-part taxonomy: An addiction begins with a flash of pleasure overlaid by an itch for danger; it's fun to gamble or to drink, and it also puts you at risk (for losing your rent money, for acting like an idiot). You like how you feel when you win or when you get a buzz on. The addict-to-be takes a drag on a cigarette and finds that the nicotine hit makes him feel energized or mentally sharper. But eventually the substance or behavior ceases to bring pleasure, not only at the original levels of use but even at the extreme levels that typically characterize an addiction. Smokers lament that the forty-third cigarette of the day just isn't as pleasurable as the third smoke used to be. What once brought the high no longer does, necessitating ever-increasing doses, in substance abuse and in a gambler's greater bets. Despite the diminishing hedonic return on investment, so to speak, to cease engaging in the addictive behavior causes abject misery and, often, physical withdrawal pains like the shakes, irritability, or moodiness. Pleasure, tolerance, withdrawal: the Big Three of addiction. Impulsive behaviors involve acting without planning or even thought, driven by pleasure seeking and an urge for immediate gratification. They have an element of risk seeking--Hey, I bet it would be a blast to swan dive off this cliff!--where the risk is expected to lead to a feeling of reward. Pyromania and kleptomania are classic impulsive behaviors because they're all about seeking pleasure and excitement. As a result, impulsivity can be the first step toward a behavioral or substance addiction. Something (a stimulus) triggers a response, and the pathway from the stimulus to response does not pass through the cognitive or even the emotional brain, at least not consciously. Instead, an urge zips from your most primitive brain center to your motor cortex--Claim that wonderful sofa someone left at the curb; grab that luscious-looking cherry cheesecake from the dessert cart--without so much as a pit stop in regions that control higher-order cognitive functions (Where the heck would you put another couch? You know you'll feel guilty if you eat that). You do it reflexively. Like addictions, impulsive behaviors "have a hedonic quality," Jeff Szymanski, executive director of the International OCD Foundation (IOCDF), told me when we met in his hotel suite during the Foundation's 2013 annual meeting. " 'I stole and got away with it,' 'I lit this fire and got all these cool fire trucks to show up'--very much like, 'I gambled and won.' It's not about reducing anxiety." We give in to impulses because we expect to be rewarded with a feeling of pleasure or gratification or excitement. Impulses make us grab the 500-calorie muffin when we were sure when we entered the store that all we wanted was a skinny latte. Like addictive behaviors, impulsive ones offer the allure of something pleasurable. Impulsive behaviors become impulse-control disorders when you repeatedly give in to your urges and suffer detrimental consequences. Compulsions, in contrast to addictive and impulsive behaviors, are all about avoiding unpleasant outcomes. They are born in anxiety and remain strangers to joy. They are repetitive behaviors we engage in over and over and over again to alleviate the angst brought on by the possibility of negative consequences. But the actual behavior is often unpleasant--or at least not particularly rewarding, especially after umpteen rounds of it. At its simplest, the anxiety takes the form of the thought If I don't do this, something terrible will happen. If I don't check my BlackBerry constantly, I'll miss seeing emails the millisecond they land, and will therefore not reply in time to an urgent invitation or demand from my boss, or will just feel like I don't know what is going on. If I do not check my fiancé's Web history, I will not know whether he is cheating. If I do not religiously organize my closets, my home will be engulfed in chaos. If I don't shop, it will be proof that I can't afford nice things and am headed for homelessness. If I don't hang on to each precious object and instead bow to my family's wishes that I shovel out the clutter, I will feel exposed and vulnerable, like my most treasured memories have been buried in a landfill. Underlying every compulsion is the need to avoid what causes you pain or angst. "A compulsive behavior is one that's done with the intent of decreasing an overwhelming sense of anxiety," said Szymanski, who before becoming executive director of the foundation in 2008 treated patients at McLean Hospital's Obsessive Compulsive Disorder Institute. Unlike addictions with their frisson of risk taking, he said, "a compulsive behavior is risk averse," driven by the need to avoid harm and executed with the goal of reducing the anxiety triggered by the thought of that harm. I must do this to quell my fear and anxiety. The roots of compulsion lie in the brain circuit in charge of detecting threats. This circuit, receiving a message from the visual cortex that a stranger is lurking in the dark doorway up ahead on the deserted street where you're walking alone, screams, danger, danger! "That's anxiety," said Szymanski. "It's the feeling that something is not quite right and that you may be in some sort of danger. You have a crushing emotion that you would do anything to get rid of." Soon after interviewing Szymanski, I trekked up to the Bronx to meet Simon Rego, a psychologist at Montefiore Medical Center who specializes in OCD. "As long as the function is to relieve distress or anxiety or prevent a catastrophe that you firmly believe will otherwise happen, it's a compulsion," he said. "People will do a compulsion until 'it feels right.' Compulsions come from a sense that if I can't do this, I'm terrified about what will happen. The relief from distress can be pleasurable, if you think that calling a halt to smacking your head against a stone wall is pleasurable, but not in the same way that an addictive behavior is pleasurable." Thus, a compulsive behavior is one that you engage in to squelch anxiety. That's clearest in OCD, where a compulsion is paired with and preceded by a specific obsession, an anxiety-provoking thought that you can't shake. You are obsessed with the thought that your hands are dirty and so you compulsively wash; you are obsessed with the thought that you left the stove on and so you keep returning home to check; you are obsessed with the belief that stepping on a sidewalk crack will bring a world of tragedy down upon your family and so you meticulously pick your way across the concrete. The examples of the self-destructive rituals that OCD sufferers resort to in order to alleviate anxiety are legion. David, whom I visited in his Brooklyn apartment, apologized that he had not showered before I arrived. The reason, he said, was that when he showers he feels so compelled to scrub every square millimeter of his skin, and so certain he has missed a spot, that he will spend hours and hours under the pounding water, which would have made him late for our appointment. Others with a similar shower compulsion have it even worse: they use up the building's hot water and put them at risk for hypothermia when they can't leave the stall despite the freezing-cold water pouring onto them. By the end of my taxonomic odyssey, I had settled on this: A compulsion differs from an addiction because the initial impetus is alleviating anxiety, not finding pleasure, and because how much you need to engage in the compulsive behavior in order to do that does not escalate, as it does with an addiction. A compulsion is a driven behavior where the emotion behind the wheel is a psychic itch, a sense of distress, even a sense of foreboding which grows worse and worse if you do not give in. "Compulsive behavior is a form of self-medication," as James Hansell put it. "There are painful emotions being numbed or soothed or avoided by means of the compulsive behavior. There is anxiety underneath it." The compulsive behavior keeps pain at bay. It's a form of self-reassurance--Everything's okay now that I've checked the BlackBerry in the elevator leaving my office all of fifteen seconds after I checked the email on my desktop, but boy, I feel much better. Oh, wait, maybe a new one has arrived . . . Compulsions become habit-forming because they work so well: my worries about being out of the loop by failing to read a text the instant it lands melt away when I check compulsively. So I'll just keep doing it. Complications Ensue Just when I thought I had it all sorted out, Scott Caplan, a psychologist at the University of Delaware who studies excessive online gaming and Internet use, warned me, "Remember, 'addiction' and 'compulsion' are just words that people came up with. They may not track nature perfectly." Among the imperfections: an addiction can become a compulsion in the sense I'm using it. Over time, a behavioral addiction that began with thrill and pleasure seeking, driven by an overpowering desire for risk and reward, can segue into being all about assuaging the anxiety, agitation, and overall misery that come from tolerance and withdrawal. The addict uses the substance or engages in the behavior compulsively even though the reward waiting at the end of the rainbow is pleasurable only in the sense that when you stop hitting yourself over the head with a hammer it feels pleasurable. Deep into an addiction, said psychologist Nicole Prause of the University of California, Los Angeles, "a reward state changes into an aversive, craving state, and you begin to take a substance or engage in a behavior to decrease negative affect. You don't want to do it, but you have to in order to get yourself back to baseline, emotionally and psychologically." What had been an addiction morphs into a compulsion. Another wrench thrown into this neat taxonomy is that the same behavior can be a compulsion for one person, an impulse-control disorder for another, and a behavioral addiction for a third. One over-shopper hits the mall because of a failure of impulse control: she can't keep herself from steering into the parking lot while driving home, can't keep from "just checking to see if there's anything good on sale," and can't keep from buying. Again. But for other over-shoppers the behavior is a compulsion: if they are not engaging in it, their anxiety rises to an intolerable level, and engaging in it assuages that anxiety. Compulsive exercising illustrates the difficulty of trying to fit complicated, messy human behaviors into neat pigeon holes. When research on excessive exercise took off in the 1970s, about the time the jogging craze spread across the United States, scientists struggled to define what, exactly, they were studying. To some, the phenomenon of exercising to excess was "exercise addiction." To others it was "obligatory exercise," "compulsive exercise," or even a noble-sounding "commitment" to exercising arising from a competitive drive, a devotion to fitness, or the love of a challenge. II The terminological mishmash underlined the fact that scientists did not know whether they were dealing with an addiction (motivated by pleasure) or a compulsion (driven by an anxiety that only exercising could quell) or something else. A 2002 review of eighty-eight studies on excessive exercise, published over the previous twenty-nine years, found that the research had been hampered by "inconsistent or nonexistent control groups, discrepant operational criteria for exercise dependence, and/or invalidated or inappropriate measures of exercise dependence," as researchers at the University of Florida concluded in Psychology of Sport and Exercise. In other words, attempts to study extreme exercising were so lacking in methodological rigor they were practically junk science. But the problematic studies, in asking people to articulate why they exercised, did offer at least a glimmer of an empirically based taxonomy. People may punish their body through exercise for all sorts of complicated psychological reasons, research has shown. Some are motivated by the need to feel they are in control of at least part of their destiny, namely, their fitness and physiology. Others are driven by a need to demonstrate they can rise above common physical needs ("rest is for the weak") or that willpower can vanquish baser desires (to self-indulgently laze around). Still others, who take up exercise to improve their fitness, are driven to ever-longer and more frequent bouts of running or using a treadmill because it brings them pleasure--the hedonic-hit model of addiction. Others exercise for extrinsic rewards such as medals and the admiration of others. In none of these cases, however, do the extreme exercisers feel like their brain is about to explode if they can't exercise. In contrast, compulsive exercisers tend to exercise for intrinsic, mood-altering or -stabilizing reasons. They view exercise as the focus of their lives. It is the only way to relieve unbearable anxiety, and they suffer that anxiety if unable to exercise. They might have once been motivated by the pull of fitness, but eventually they do not so much enjoy exercise as find it the only way to quell the angst they feel when they are not exercising. "We know people have various motives for starting to exercise," said Danielle Symons Downs, a kinesiologist at Pennsylvania State University who developed an exercise dependence scale so therapists and individuals can assess whether the exercise is excessive. "And there are multiple reasons" why people do it to excess; "doing it to avoid intolerable anxiety is plausible." These are our compulsives, people like Carrie Arnold. Granted, the boundaries between addiction and compulsion can be fuzzy, since being deprived of an activity you deeply enjoy and want can trigger anxiety, too. But an addiction is born in joy and pleasure, a compulsion in anxiety. Compulsive exercisers experience "higher levels of anxiety when not running compared to non-obligatory runners," as the 2002 review put it. They feel antsy or worse if they miss a workout. The purpose, as is definitionally true of any compulsion, is "alleviating negative emotions," researchers led by Caroline Meyer of England's Loughborough University wrote in a 2011 study in the International Journal of Eating Disorders. "A key feature of compulsive exercise is a negative mood, such as experiencing feelings of anxiety, depression, and guilt when deprived of exercising." Where does that come from? The psychological and personality traits that put someone at risk of "developing a compulsivity towards exercise," as Meyer put it, include perfectionism and other elements of obsessive-compulsive personality disorder. In particular, compulsive exercisers tend to express much greater concerns over mistakes than other people do, have sky-high personal standards of achievement and morality, and feel chronic doubts about their actions--all reminiscent of the extreme conscientiousness that characterize mild compulsions. III "Perfectionism was among the best predictors of compulsive exercise," Meyer reported. The inevitable falling short of perfection provokes anxiety, which only exercise can quiet--and the result is a compulsion to work out to a self-destructive extreme. * * * To a man with a hammer, everything looks like a nail; to a reporter immersed in the science and phenomenology of compulsions, everything we do seems driven by anxiety, and every quirky extreme of behavior seems compulsive. In reporting the prevalences of the various forms of compulsion, I used the most credible numbers I could find, usually from a source such as the National Institute of Mental Health. But the recent surge in diagnoses of mental illness might not be what it seems. For one thing, psychiatrists and others have been relentless in spreading the message that we have a vast, underdiagnosed epidemic of mental illness. As a result, millions of people have taken it to heart, convinced they have a mental disorder and seeking professional confirmation of that. A loosening of diagnostic criteria is likely also fueling the reported rise in the incidence of mental disorders: over the years psychiatrists have decreed that you have to feel a certain way or experience certain symptoms for only three months instead of six, or have six symptoms rather than nine, to qualify for a formal diagnosis. The "epidemics" that the mental health industry cites reflect "changing diagnostic fashions," psychiatrist Allen Frances, who chaired the DSM-IV task force, told me. "It's not that more people are mentally ill, but that what counts as a mental illness changes." Remember, too, that there are no brain scans, blood tests, or other objective biomarkers for mental disorders. Rather, to make a diagnosis, psychiatry and psychology rely almost entirely on patients' self-report of how they are feeling. It isn't hard to meet criteria for one or another DSM diagnosis, especially because the experts who devise the criteria worry more about missing cases than about diagnosing as "mentally ill" people who are not. To a certain extent, it seems, we're as mentally ill as we think we are. In speaking to people in the grip of extreme compulsions, I often felt as if I was looking into suns so bright they overwhelmed the planets and the stars. Even after I understood that compulsive behaviors so extreme as to derail lives, loves, and careers stemmed from a desperate need to keep anxiety at bay, it was hard to see that these were just the hypertrophied versions of ordinary, everyday quirks; they were too jarring, too off-putting. But just as the dimmer celestial denizens invisibly populate the daytime sky as well as the night's, so less extreme versions of compulsive behaviors are all around us . . . and, if we look carefully enough, within us. So much of what we do, for good or ill, arises from the same spring as compulsions. By seeing our and others' behaviors through that prism, what had seemed inexplicable becomes understandable. And what I came to understand above all is that compulsive behavior is not necessarily a mental disorder. Some forms of it can be, and people in its clutches deserve to be diagnosed and helped. But many, many compulsions are expressions of psychological needs as common within humankind as to feel at peace and in control, to feel connected and to matter. And if those are mental illnesses, then we're all crazy. I . Soon after we spoke, Hansell died suddenly in 2013 at age fifty-seven. II . By whatever name, excessive exercising is not as prevalent as one might think from the gyms full of people taking spin classes or sweating on ellipticals. Even among the physically active, the population from whom studies typically seek volunteers, the prevalence of excessive exercise is around 3 percent. III . Mild compulsions are typical of obsessive-compulsive personality disorder, which itself is often driven by perfectionism, as I describe in Chapter 2. Excerpted from Can't Just Stop: An Investigation of Compulsions by Sharon Begley All rights reserved by the original copyright owners. Excerpts are provided for display purposes only and may not be reproduced, reprinted or distributed without the written permission of the publisher.
