Sharon Begley is an award-winning journalist who regularly covers health and science topics in her role as a senior science writer at Stat, the life sciences publication of The Boston Globe. Additionally, she has written and co-authored multiple books, including the New York Times bestselling The Plastic Mind. Her most recent book, Can’t Just Stop: An Investigation of Compulsions, considers what we misunderstand about compulsions and provides some answers about where they come from. Sharon recently joined Heleo’s Assistant Editor Mandy Godwin for a conversation on what compulsions are good for and why they can’t be tamed by saying, “just stop.”
This conversation has been edited and condensed.
Mandy: What’s the difference among an impulse, an addiction, and a compulsion? Why is there so much misunderstanding around these three categories?
Sharon: I was not expecting this to be so hard to figure out. When I started the book, I kept coming across examples where the same behavior was called addictive or impulsive or compulsive. I thought, before I go any further I better figure out what the heck I’m going to include, since I had to draw the line somewhere—keeping compulsions in and addictions out, for instance.
Unfortunately, even experts don’t have a clear idea of the differences. I’ll give you a couple of examples. One 2008 paper invented something called “impulsive-compulsive sexual behavior” and said it was “one type of addictive behavior.” Three in one! And the many editions of the American Psychiatric Association’s Diagnostic and Statistical Manual rotated addiction, compulsion, and impulse through the definitions of eating disorders and anxiety disorders, among others, as if the three were interchangeable.
This is what I finally figured out: an addiction begins with a hedonic hit. It feels good. The “it” can be a substance, like nicotine, but it can also be a behavior, like gambling. It brings a flash of pleasure. You feel the need to keep giving yourself that hedonic hit. An impulsive behavior, in contrast, happens without planning or even thought, driven by an urge for immediate gratification.
The crucial one to figure out, of course, was compulsive behavior. The scientific consensus boils down to this: rather than having their origins in joy or pleasure, like addictions, and rather than almost bypassing thinking and feeling, as impulses do, compulsions have their roots in anxiety.
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They’re 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 iPhone 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 religiously organize my closets, my home will be engulfed in chaos. As one psychiatrist put it to me, “A compulsive behavior is one that’s done with the intent of decreasing an overwhelming sense of anxiety.”
Mandy: Why does it never really work to tell someone who’s engaging in a compulsive action to “just stop”?
“Telling someone to just stop is like telling someone who’s desperately trying to save her child from rising waters to, you know, just calm down.”
Sharon: Because that totally and unfairly assumes that all it takes to shed a compulsion is willpower. And that ignores the root of a compulsion—the anxiety, the angst, the distress. Telling someone to just stop is like telling someone who’s desperately trying to save her child from rising waters to, you know, just calm down. One woman felt compelled to count the syllables in anything someone said to her. Another had to keep checking to be sure her cat Fred wasn’t in the refrigerator. I could practically see the waves of anxiety rolling off them as they talked about trying not to count or not to check. We’re wired to feel anxious in some circumstances, and some of us are wired to feel that in more circumstances than other people are.
Mandy: How are changes in technology changing what compulsion looks like?
Sharon: Technology is a new source of anxiety and therefore a new driver of compulsive behavior. But just because you engage in a compulsive behavior (or two) doesn’t mean your brain is broken and doesn’t mean you have a mental disorder. This is another area where psychiatry has been quick to label some common behaviors as pathological. So some of the hand-wringing in the early days of the Internet that spending “too much” time online was a sign of psychiatric illness now, in retrospect, looks ridiculous. When the APA last updated its diagnostic manual, “problematic Internet use” didn’t make the cut. There’s just no reliable way to assess it, and little scientific evidence that it’s itself a disorder rather than a symptom of something else, like depression.
But while compulsions aren’t necessarily mental disorders, especially when they’re mild, they still arise from anxiety. That’s what’s happening with technology. If we’re online, or texting, or checking and posting to social media to an extreme extent, it’s because of feelings and thoughts very much like those behind classic OCD. As one researcher told me, the underlying motivation to use a mobile phone is often not pleasure, but a response to stress and anxiety. We feel anxious if we’re not making use of every tiny slice of time, like if we’re waiting in a line. We feel anxious if we’re alone with only our thoughts. (In a 2014 study that let volunteers either do “nothing” for fifteen minutes or submit to a small electric shock, two-thirds of the men and one-quarter of the women chose to be zapped.) That anxiety makes us whip out our phones. This phenomenon is what led to the idea of FOMO, fear of missing out.
The web has another characteristic that can breed compulsive behavior: its reward structure is what psychologists call intermittent and variable. That means you can’t predict when you’ll come across something really fascinating or useful, and the reward you get from texts, web finds, and other things varies. Most of my Twitter feed and Facebook updates is digital dross. (“Barbara changed her Facebook picture!”) Payoff: zero. But every so often, you find a gem. Hopping from one site to another, or scrolling through social media, occasionally brings you to something important, entertaining, or even life-changing. Our brains want more, and our thumbs oblige.
Mandy: Why is there such a voyeuristic culture surrounding compulsion? For example, there’s a number of shows on TLC that relate to hoarding, and several of the behaviors in My Strange Addiction could probably better be described as compulsive. Why are we so interested in watching?
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Sharon: I think it’s two things. One is a “there but for the grace of god” reaction: you might be a bit of a pack rat, but people on hoarding shows are much worse. The other reason is that extremes can sometimes illuminate the less-extreme. By seeing or reading about people who are worse than we are, it can shed light on the origins of our own behavior and, maybe, trigger enough self-insight that we can change it if we want.
Mandy: Can any action be considered compulsive if it’s motivated by anxiety?
Sharon: It has to be repetitive—your go-to behavior whenever you feel a particular anxiety. If it’s acute, one-time-only anxiety, there’s probably not a compulsive behavior.
Mandy: What surprised you the most about investigating and talking with people who experience severe forms of compulsion?
Sharon: The main surprise was how generous they were to talk to me and share their stories. They really wanted people to understand why they behave as they do, in the hope that readers would gain an understanding of their own compulsions and those of people in their lives.
Another surprise was that it wasn’t that hard to understand what anxiety was driving them. I felt like I was playing therapist. I asked what they felt just before they needed to execute the compulsion, what they felt like after, when they first had to do it, and things like that—and in so many cases people eventually had amazing self-insight into what drove them.
Mandy: Would you say that we’re all “a little compulsive?” Do people react badly to imagining their regular anxieties as smaller forms of a medical condition?
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Sharon: It’s a rare person who doesn’t have some compulsion, who isn’t driven to some behaviors by anxiety. I include myself. Once I understood the role of anxiety in driving compulsions, I began to look at some of the things I do—for instance, often wanting to de-clutter and feeling anxious when my husband isn’t quite as enthusiastic—through this lens and, I hope, got a better understanding of what’s going on. Obviously there’s a difference between mild compulsions, which in many cases are little more than minor eccentricities, and severe, debilitating ones.
“Mild compulsions aren’t mental disorders. They’re adaptive, useful, normal.”
As for how people react to the idea that their ordinary, pretty mild behavior is on a spectrum with extreme compulsions, I don’t know. On the one hand, I hope I made it clear that mild compulsions aren’t mental disorders. They’re adaptive, useful, normal. There’s no stigma. On the other hand, some people want to qualify for a mental diagnosis—sort of I can’t help it, I have a disorder. I’m not sure what someone like this will think about the idea that it’s not a disorder.
Mandy: Are there certain kinds of compulsions that people often overlook?
Sharon: I’m not sure about “overlook,” but I don’t think most people recognize that anxiety-driven compulsions can motivate behaviors that are good for us or for society. In the political climate of 2017, the level of anxiety is off the charts. I bet we all know people who can’t sleep or work or concentrate. The anxiety of “I could be doing something to help” and/or “bad things are happening and I need to get off my backside and try to stop them”—is behind the decision of at least some people to go out and march, to protest, to try to do something. I hope that by putting this front and center some people might turn their anxiety into a behavior that feels compulsive but also makes a difference.
Mandy: Since we “can’t just stop” compulsive behavior, how can it be controlled? Is it possible? Should we attempt to address the underlying anxiety instead? Should we even try to control it?
Sharon: I don’t think everyone needs to have the goal of eliminating their compulsive behavior. If it’s working for you, embrace it. If it’s causing problems—as full-blown OCD and some compulsive shopping and most hoarding does—then it’s not a bad idea to seek treatment. But that’s not easy. Even for a well-known disorder like OCD it’s really hard to find a competent therapist. If you’re in that situation, or if your compulsion is one for which the scientific basis for treatment is really slim, as it is for most compulsive behaviors, then it might help to at least ask yourself what anxiety might be driving you. Sometimes answering that can help.