You may also know people like Amy, who was a graduate student in neuroscience and the organizer of a compulsive-behavior support group when we met at a cafe. As I neared the restaurant I didn’t look twice at the woman standing at the corner of 73rd Street. Having glanced at her gorgeous brunette mane, I figured she couldn’t be the person who had agreed to tell me about her compulsion to rip out her hair.
Yet that’s who hesitantly introduced herself.
“Sharon?”
“Amy?”
Over the course of a meal, Amy explained that the hair pulling started when she was twelve. “It became a way to regulate the anxiety,” she said, such as from the pressure to excel academically and win acceptance to one of New York City’s stellar science high schools. She wore hats to cover her bald spots. For ten years she gave up swimming because she didn’t confine the pulling to her head—her legs and arms were also fair game—and eventually had no more body hair than a snake. Despite the ridicule she suffered from her trichotillomania—a syndrome marked by pulling one’s hair out so excessively that sufferers can become bald—it worked for her, relieving her omnipresent anxiety. “I’m wired for anxiety,” she said. “It builds up, and then I pull and it’s extremely rewarding. You feel normal again, like going back to your baseline instead of being at this heightened level of stress.”
One member of Amy’s trichotillomania support group is a cop who used to love playing golf but had to stop. “Every time he looked at his hands holding the club he had to pull out the hair on his wrists and the back of his hands,” Amy said. Another member, a rabbi, is consumed with guilt—not over the hair pulling itself but over the fact that he was doing work (hair pulling counts as work) on Shabbat, the day of rest when observant Jews will not so much as turn on a light.
While it is always fascinating to tour the fringes of human behavior (if only for the there but for the grace of God go I factor), these stories of severe compulsions brought a realization: that I was seeing shadows of myself, family, friends, and colleagues in them. We might not live at the extremes, but they illuminate the broad middle of the spectrum of human behavior where most of us do live. Over the years of research and reporting for this book, I came to see how much of what we do, although falling short of pathological and diagnosable, is driven not by the need for joy and not by curiosity, not by a sense of duty or even ego, but by a drive to quell anxiety. Maybe it’s keeping old books and papers because not having them around makes you feel as tense as if your bedroom walls had vaporized. Maybe it’s throwing yourself headlong into a project because it allays corrosive anxiety about the many dangers that could happen—to you, to your family, to the world—if you don’t. Maybe it’s shopping for groceries with military precision, or demanding that towels be hung just so, or expecting that household chores be executed according to a choreography that would make Balanchine roll his eyes.
Are We All at Least a Little Crazy?
The danger in immersing yourself in any subject is that you tend to see the world through a prism it creates and thus see examples of it everywhere. Behavior that once seemed ordinary acquires an aura of pathology. By the time I finished the reporting for Can’t Just Stop, every time I saw my colleagues furiously BlackBerry-ing in the elevator, unable to travel the few seconds from the nineteenth-floor newsroom to the sixteenth-floor cafeteria without checking for texts and emails, I thought, compulsion. I looked back on my decision to hitchhike to work after Hurricane Sandy in October 2012 (when the public transit system was down) as more than a bit compulsive, too. I couldn’t look at my husband’s book collection without seeing hoarding, especially when my idea of a good time on a Saturday afternoon is “Let’s give away some of these old books!” (Maybe that 1966 page-turner, Ecology and Field Biology, which he hadn’t looked at in decades?) Anxiety (about missing something, like a message about one’s job), anxiety (about the consequences of missing work), and anxiety (about losing part of one’s past) again.
In other words, much of what we do, for good or ill, grows from the same roots as pathological compulsions. By seeing our and others’ behaviors through that lens, what had seemed inexplicable, frustrating, self-destructive, or just plain idiotic (Why is she making a federal case over how I load the dishwasher? Why can’t she start working until she rearranges her desk? Why can’t he resist scrounging the red bows on the Christmas wreaths that the neighbors leave at the curb every January?) becomes understandable. And what I came to understand above all is that compulsive behavior, per se, is not a mental disorder. Some forms of it can be, and people in the clutches of true compulsions suffer terribly and need to be diagnosed and helped. But many, many “compulsions” are the expressions of psychological traits as commonplace as the drive to be loved and connected, to matter and to make a difference.
Most of us have probably told ourselves we could break free of our compulsions if we wanted to, that we could turn off the smartphone for most of our waking hours, resist the box of Thin Mints, or stroll past the “Huge Savings” sign in the window of our favorite store without a single muscle twitch propelling us toward the entrance. But a little voice asks, “Are you sure?” Venturing inside the heads and the worlds of people who behave compulsively not only shatters the smug superiority many of us feel when confronted with others’ extreme behavior. It also reveals elements of our shared humanity.
* * *
I. All of the people described in this book are real individuals, not composites or fictionalized. Where I give first and last names, those are their actual names; where I give only a first name (real or pseudonymous), it is at the request of the person interviewed.
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 addi
ction, 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.
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