Episode 8 – What Is Misdiagnosis?
Dr. Ashish Bhatt ❘
Receiving the wrong diagnosis can impact the trajectory of someone’s life, but misdiagnosis still occurs. Dr. Bhatt explains why.
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Hayley: Hi, everyone. This is Straight Talk With The Doc, a podcast where you get expert insight on all things mental health, addiction, and treatment related. My name’s Hayley and I’m here with addiction medicine specialist Dr. Bhatt.
Dr. Bhatt: Hey Hayley, how are you?
Hayley: I’m doing great. In recent years, behavioral addictions have been getting more recognition with gambling disorder being added to the DSM and even disorders like internet gaming disorder being recognized. From my understanding, although terms like internet addiction, or more specifically, social media addiction are not listed in the DSM. There’s been more research to suggest that these disorders can have serious and negative effects on people’s lives. I think something that’s been gaining more attention and that we see getting reported on in the media now is people falling into dangerous social media use that leads them to find conspiracy theories or lose touch with reality in other ways. I want to get into all of that today. But first, I wanted to define what behavioral addictions are. Dr. Bhatt, can you help define that term?
Dr. Bhatt: First of all, I want to disclaim behavioral addiction is a term that’s not officially in the DSM-5. And the DSM-5 for those who are listening that don’t know what it is, its really basically the American Psychiatric Association’s diagnostic manual and how we diagnose mental health conditions and addictive disorders. A behavioral addiction spins off from the understanding of addictive behaviors that happen more traditionally or commonly with substance use disorders. Repetitive, maladaptive, just unhealthy relationships with using drugs or alcohol. Similarly, we use the word addiction when we saw that happening with a certain activity that people engaged in. And as you mentioned in the introduction, there are many activities that people are starting to do and starting to engage in that are resulting in them having impairment in their life as a whole. They start to neglect themselves, they start to have social and familial, school or work dysfunction. And it really happens when somebody engages in an activity or behavior to the point where it’s basically consuming them, their thoughts, their urges, and without the activity or with the activity often causes a lot of distress. Ultimately, the engagement in that activity causes a negative consequence for them or others in their lives. It’s becoming a big problem.
Hayley: Behavioral addictions and substance use disorders, it’s sounds like they have a lot of similarities with the negative effects. Is that correct?
Dr. Bhatt: Yeah and I think when we start getting to the point where some, either the behavior, regardless if it’s using a substance or being on the internet, where that behavior is to a degree where it’s negatively effecting you or those around you, or those who rely upon you physically, emotionally, socially- definitely. It’s not a positive thing. I think we relate it together because the initial relationship often is because we’re pursuing a reward. And that reward becomes so powerful, that it either is the motivating factor to continue behaving a certain way, or using a drug or alcohol, but often that reward becomes less over time. That’s tolerance and we have to continue doing more and more of it just becomes a vicious cycle. There’s a lot of commonality.
Hayley: Why aren’t behavioral addictions as recognized?
Dr. Bhatt: Like anything, when things aren’t formalized, they often aren’t recognized. Being that the scientific literature didn’t put it down on paper, often it’s not accepted in the scientific or medical community. But that doesn’t mean it doesn’t exist. Like anything, when we start to discover things, it’s a process or research and experimentation and discovery before it becomes official. With behavioral addictions, we have started that process already by identifying one: a gambling disorder. And that is an official behavioral addiction that has been identified. I believe over time you are going to see more official diagnosis of various behavioral addictions be solidified and recognized in the medical community.
Hayley: During my research on this topic, I kept coming across the world “compulsion.” I wanted to ask you about that. Is there a difference between a compulsion and an addiction? What is the difference?
Dr. Bhatt: I think addiction becomes the global disorder, the global disease. Where compulsion is just a component that we see within it. We often hear that term compulsion, often related with obsessions. Obsessions are basically an intense intrusive, repetitive thought. And a compulsion is the activity or the undoing of those thoughts. Compulsions would make up often behaviors that are incorporated within an addiction, but in itself it not an addiction.
Hayley: Getting into internet addiction and I’m using air quotes around the word addiction because I believe I’m correct in saying it’s not actually recognized. But how would you define that? What would characteristics or internet addiction be?
Dr. Bhatt: Let’s split it apart. Addiction being a chronic brain disease disorder of reward, motivation, related brain circuitry, memory, and when you’re using in a manner, either using a substance or behavior, to a degree that it ultimately has negative consequences in your life. These are often hallmarked by the inability to stop doing something that affects your behavior negatively. That you crave it or have urges. That you don’t recognize that these things are bad for you and it causes a lot of emotional ups and downs in your life. If you transition that or switch it to apply to any behavior activity, that’s really where they become applicable. When you’re talking about internet addiction, if somebody’s use of the internet is so destructive or so detrimental that they can’t function healthily in other aspects of their lives. Well then, with that definition that I just mentioned applies while using the internet, then we would say that they have an internet addiction.
Hayley: And for somebody in your field, is this common? Is this something that is seen or people talk about and experience, having detrimental effects from internet use?
Dr. Bhatt: I think what we see is that intertwined with the other behaviors that they’re using the internet for. Often, we will see people who have a gambling addiction, but they’re accessing that gambling site through the internet, or pornography addiction, and they’re accessing it through the internet. Various things that they’re using the internet for and social media. Social media is a big one that we see people being so consumed with. And it’s an unrealistic thing. Again, I have to put this in context, and when we’re talking about unrealistic and detrimental. We’re not talking about the casual user of internet or social media, or someone who makes one simple sports bet using the internet. No, we’re talking about people who are using this in a constant battle with themselves, with others, with isolation, with negative consequences to their mental health. And it becomes a serious problem. Even though we’re speaking about it, we’re talking about things that are causing extreme consequences as a result of extreme behaviors.
Hayley: When I was doing research on this, I saw that social media interactions actually generate dopamine in the brain.
Dr. Bhatt: It’s interesting that you bring that up, because I think we hear the word dopamine, which is a neurochemical that is thrown out a lot when we talk about addiction. But dopamine is really just a chemical associated with us feeling good. When we do something that makes us feel happy, it’s often because dopamine has been activated and it’s going up. And often it feels rewarding when we get pleasure from something. If something, an activity or a drug, increases dopamine and creates a certain pleasurable effect, it’s rewarding for us and it motivates us to do it again. And that’s where we can see that cycle starts to develop. A lot of people who have engaged in really negative relationships with any of these things that we mentioned before, are using the internet as a vehicle. While the internet often becomes that tool to continue that unfortunate destructive behavior. You mentioned social media. I don’t want to knock social media but being that so many people are attached to their phones and their computers. And we’re no longer separated, it does become a problem when we don’t have any sort of barrier between us and everybody. And on those that are impressionable or those that might have risk factors, having access to constant stimulation of other people’s perceived achievements or successes, it can cause a lot of problem. I don’t want to get off solely on social media, but I think people can hear that I see it as a problem for those vulnerable individuals.
Hayley: That’s something I want to talk about too. I feel like those vulnerable individuals could be young people. When we were growing up, I didn’t constantly have social media in my face. But a lot of really young kids, they have that now. How do you think that could affect their brains in the long-term?
Dr. Bhatt: Studies and research has shown that if we are inundated with certain things at a certain age, nature and nurture, and our genetics and epigenetics have this environmental influence on our internal construct that can basically unmask certain mental health conditions. We talk about young people, and you mentioned this, they’re going through a period of emotional, physical, psychological change. Hormones are flowing and changing, and it’s a very vulnerable time if they’re exposed to certain insults. And when I use the term insult, I’m talking about anything that can cause undue stress or duress. How social media comes into play here is that with the access of cell phones and smart phones and having internet at the touch of our fingertip. And people having access to Facebook and twitter and Instagram and Tik Tok, these are forms of entertainment. But when it gets to this competitive, one-upmanship of “look at me”, it’s basically trying to portray a certain sense of identity that often becomes unrealistic. And let’s just be honest, when you are a person who’s going through biological, neurobiological, and physical changes, the amount of receptor alteration in your brain can be affected, because our brains are built on feedback mechanisms. The amount of exposure to certain things creates a response. If you do anything that excess that disrupts your brains balance, it actually will alter the way it was supposed to evolve. When something becomes so addictive that they engage in it in a way that is unhealthy, it can unmask, unfortunately, illnesses that might not have been there. Or it can create certain types of illnesses due to just unrealistic expectation or a perception that they are perceiving. I don’t want to make this too long-winded, but at the end of the day, people often want to mimic what they see. And on a young impressionable mind, so many things are happening there at that time and trying to keep up with the other person, especially because they’re not seeing that that might be an artificial reality, it can start to create distorted, idealized things that they can’t keep up with, and it causes a lot of stress and anxiety and depression. And we’re seeing that quite a bit in the child and adolescent population.
Hayley: Exactly. I was going to say that something we’ve seen in recent years is that young girls who use social media have a higher risk for suicide.
Dr. Bhatt: We’re seeing that a lot, because social media becomes a vehicle for, like I said before, “look at me”, and people want to show off. People spend so much time focused on themselves. And social media is a platform to just talk about you, and that in itself is very addictive. And people gain a lot of pleasure in hearing about themselves and talking about themselves. It’s a very interesting phenomenon. But it’s just young people, they’re not able to critically analyze things the way that mature adults can. That’s where they are most vulnerable because they don’t know and they’re not able to tease out as well what’s right and what’s wrong or put much analysis into it. When somebody might be taking a picture of themselves and puts a little subtitle that says, “Oh, look at me in the morning”, yet they don’t know that they might’ve spent 5 hours trying to take that picture in multiple different ways and changed their outfit 50 different times. Again, it sets up unrealistic expectations. And then these people try to achieve these things and it causes really an unrealistic amount of stress. It’s also a vehicle for people bullying one another, and that leads to what you had mentioned about suicidal ideation. With trying to keep up with other people, peer pressure, social idealism, and people often are bullied through these things. And they’re constantly checking, constantly looking for affirmation through social media and the internet. And it’s becoming devastating. We’ve seen many people actually in psychiatric emergency rooms, adolescents, who have acted out in self-harm due to something that they saw, read, or we’re told by the internet or social media. It’s very sad.
Hayley: And also, like you said earlier, they’re trying to live up to something and be something that isn’t real. It’s really not possible. And I’ve experienced that as well as a woman looking at Instagram. Everybody looks perfect. You have to remind yourself that’s not real. It makes you lose touch with reality, like I mentioned at the beginning of this episode.
Dr. Bhatt: We say that and somebody could ask, “Dr. Bhatt and Hayley what are you guys talking about?” We’re all around it. It’s around us all the time. Even a magazine is edited and a billboard is not just posted up there without obviously a lot of marketing and a lot of thought going into it. Similarly, when somebody’s putting stuff out there on social media, they’re not going to want to do it in a way that shows them in a bad light. But the fact that we’re walking around with phones, the accessibility is a constant flooding. And the fact that initially it might be rewarding and creates that dopaminergic flood. The fact that it causes you to feel good for a period of time. It just becomes so much more reinforcing that you continue to do it over and over again in this addictive way. The compulsions lead to this addictive type of behavior that you’re not only using it to feel good, but you almost don’t know when to stop. And then not only do you not know when to stop, but you start to neglect certain aspects of your life. When you continue to do it you’re not only doing it to feel good anymore, you’re using it to escape bad feelings. There’s this other side of it. If I’m depressed or I’m anxious or I’m upset, now I go to the internet or I go social media or I’m looking for a like. I’m looking for somebody to comment on something that I’ve posted. And what if it’s not there? How do you feel? If you’re already depressed, sad, and anxious and you’re looking for something and you don’t get it, it just adds fuel to the fire. It’s just really this vicious cycle that develops or continues.
Hayley: Definitely, it’s that need for validation. For people who are struggling with that who can’t really control their internet or social media use, can they actually experience withdrawal symptoms?
Dr. Bhatt: I think that’s something that we don’t talk about or that people don’t even recognize. But we even see it in people who might not even suffer from addiction. We just become so habitualized to doing certain things that when we stop doing them, we feel this sense of foreignness. Like, “Wait a minute. What’s going on?” You might not recognize it as withdrawal, but you could feel a certain amount of apathy, a certain amount of anxiety. You could feel like you’re missing out on something or missing something. And you might not be able to put your finger on it, but this can happen to people who are conditioned to any reasonable activity that they’re not doing it in an addictive way. So, yes, when somebody’s having a behavioral addiction, or a substance use addiction, when they stop, there’s withdrawals in many different ways. And it usually happens from an emotional and psychological side.
Hayley: Earlier you mentioned that this internet or social media use might trigger or bring out a mental health disorder that was underlying that may have not necessarily been brought out. I wanted to ask: could social media addiction just be a symptom of anxiety or depression?
Dr. Bhatt: Yeah, I think I mentioned it when we were talking about often we will go to seek out something that’s pleasurable. If it’s the flip side of the addiction, it’s the negative reinforcement. Meaning, “I’m feeling bad”, “I’m feeling anxious”, and now I’m going to use something that’s going to make me feel better. If it’s a behavioral thing, how many times have we heard, “Oh I’m going shopping, I’m feeling sad so I’m going to go buy something”. And that’s an example, in a small way. But imagine if that’s a continuous thing. If we use the internet and the behaviors by the internet or social media to make us feel better, that’s just an example of negative reinforcement of social media or internet to continue. It’s used to continue. If I have an underlying anxiety or depression and I’m using this to levitate myself or remove myself from that feeling, it’s only going to be embedded in my memory that this got me out of it. And when I’m not using it again, it will lead me to attempt to explore using it in the future. That’s how habits develop. And we see that played out more commonly with substance use disorders. Many people who have depression or anxiety as an underlying thing, it’s exacerbated because we use an artificial means to feel better. And we use it through illicit substances or alcohol. You can do that similarly with a behavior that you can’t keep up with, or an action, or an activity that you can’t keep up with. And if it’s done through social media or the internet and you don’t address the underlying problem in itself, it’s just setting you up to be unsustainable. It can unmask. It can mask. But ultimately if you’re not addressing the underlying problem, it’s only going to make it worse.
Hayley: And also, like you said, it makes it worse. It can encourage bad behaviors. I saw that higher Instagram use has been associated with a greater tendency towards eating disorders. And this is something that I read about a while back, there’s almost like a group of people and they encourage each other in really negative ways. Do you also think that social media perpetrates the glamorization of drug use and alcohol use: a party lifestyle?
Dr. Bhatt: For those people that do it, yeah. Like I said in the beginning, I want to repeat it now, is that we’re not trying to say that all social media or the internet is negative. We want to make that clear. But for those that are engaging in it or using it in a negative way, of course, these things can have undue consequences. And there are groups and people who aggregate together. And unfortunately, it’s like-mindedness. People tend to be more attracted to people who are similar to them, or have similar beliefs, or similar hobbies, or similar tendencies. When you see people who might engage in bad activities or unhealthy activities and the group clusters together, you’re only increasing that surface area when you have a media that can incorporate their message getting out to hundreds and thousands and millions of people. It’s a very powerful tool. And if used negatively, unfortunately, not everyone has a good filter or is understanding how to receive those messages. If you get a group of people who unfortunately, are sending out a collective, negative message, you just have more power. And unfortunately, if perceived by a vulnerable and impressionable person, you’re just capturing one more person to increase that power. And that’s why we watch out for the younger population here. This is where we need to set limits. If I was a parent out there who’s listening to this, you definitely want to have the discussion with your teenage or adolescent child, because without limits to any sort of behaviors this stuff can become dangerous.
Hayley: Absolutely, that’s a good point. And like you said, it depends on how you use it. Some people use social media to connect with others who have the same interests and hobbies. They can make friends. I also know for people in the recovery community, that’s a really strong place where they connect with each other and they encourage each other in a healthy and positive way. But for those who have a bad effect from it, what can they do if social media is causing issues in their life? Is there a way for them to seek out help?
Dr. Bhatt: Many private organizations, they do have treatments specifically targeted for behavioral addictions, often called process addictions. I didn’t mention that on the outset, but there are treatment programs and rehabilitation facilities that actually can treat both a substance use disorder and a behavioral addiction together. And again, even though we haven’t really formalized these classifications in any major textbook, the research and the inclination to do so is there. But being that they all fall under the umbrella of addiction and that whole process of doing an activity or using a certain drug which increases a certain chemical that provides a reward, that whole cycle tends to mimic one another. They’re often treated with the same modality. You see that treatment often present where addiction and mental health treatment is provided. That is a positive; that is there. Another thing that I wanted to mention that you said prior to that, we’re not trying to paint the internet and social media in a negative way. With COVID and the pandemic, without it the world wouldn’t have been able to survive. In that sense, it’s so positive of how many beneficial things have happened as the result of the internet and our ability to communicate that way. Obviously, we’re trying to show the harm that can result when it’s not used in a healthy way and just to be able to recognize it. If we see or somebody sees people who continuously are consumed with being on the computer, looking for that affirmation, spending lots of money, constantly thinking about getting some sort of response who are starting to neglect their social family, school, or employment and behavior starts to change, mood starts to alter, these are signs and symptoms an internet or a behavioral addiction is there with the internet being that vehicle. I just wanted to mention that again, as we come to the end of this podcast episode.
Hayley: Definitely. It’s so important, too, to talk about it. Especially for those high-risk groups, those young girls who might be at risk, honestly. Thank you for going over that. We have resources on addictioncenter.com that talk about behavioral addictions and risky social media use if you want to check those out and learn more. There’s more episodes of Straight Talk With The Doc on Addiction Center, SoundCloud, Spotify, and Apple Podcasts, Make sure to check those out. Thank you for tuning in and we hope to have you next time for another episode.
Dr. Ashish Bhatt
Addiction Center’s Medical Content Director, Dr. Ashish Bhatt, MD, MRO is an accomplished physician, addiction medicine specialist, and psychiatrist with over 20 years of medical and administrative leadership.