Behavioral addictions

Question 1

Core features of behavioral and drug addictions

Answer 1

Similarities between behavioral addictions and substance use disorders

• repetitive or compulsive engagement in a behavior despite adverse consequences
• diminished control over the problematic behavior
• an appetitive urge or craving state prior to engagement in the problematic behavior
• hedonic quality during the performance of the problematic behavior

Question 2

Behavioral addiction

Answer 2

• gambling diroders
• sexual addiction
• eating disorder
• impulse control disorder
• compulsive buying
• internet addiction
• exercise addiction
• online gaming disorder
• compulsive hoarding

Question 3

Gambling disorder

Answer 3

excessive/problematic/pathological gambling

• GD costs an estimated 6 billion $/ year.

Individually:

• average debt of male gamblers: 55-90.000 dollars
• Average debt of female gamblers: 15 dollars

Question 4

Gambling disorders (DSM-5 diagnostic criteria)

Answer 4

A. Persistent and recurrent problematic gambling behavior leading to clinically significant impairment or distress, as individuated by the individual exhibiting four of the following in a 12-month period:
1. need to gamble with increasing amount of money in order to achieve the desired excitement
2- restless or irritable when attempting to cut down or stop gambling
3. making repeated unsuccessful effort to control, but back, or stop gambling
4. often preoccupied with gambling
5. often gambling when feeling distressed
6. after loosing money gambling, often returning another day to get even
7. Lies to conceal the extent of involvement with gambling
8. jeopardizin or losing a significant relationship, job or educational or career opportunity because of gambling
9. relying on others to provide money to relieve desperate financial situations caused by gambling

B. The gambling behavior is not better explained by a manic episode

Question 5

Stages of GD

Answer 5

1. Winning (3-5 years - tolerance, losing control, feeling of victory and omnipotence)
2. loosing (longer than 5 years - major setback, narcissistic crisis, borrowing money, lies and deception)
3. desperation (out of control lying, gambling to cover pain, anger and blame, financial difficulties, illegal activities, loosing partner/family)
4. hopelessness (completely losing all hope, giving up, depression, suicide, jail - last stage for many gamblers)
5. Recovery

Question 6

Structural and situational factors

Answer 6

• physical availability
• availability in time
• rapidity of feedback
• possibility to bet again
• rapidity of getting the money
• illusion of control
• visual and auditory effects
• atmosphere of the venue
• anonymity

Question 7

Prevalence of GD in the USA

Answer 7

Gambling diroder (GD)

• adults: 1.6 - 3.9%
• adolescents: 3.2-8.4%

Problem gambling
- adults: 3.5-5%

Question 8

Risk factors of GD

Answer 8

• younger age
• male (woman start later but have more rapid course)
• race: hispanic, African Americans, native Americans have more problems than caucasians
• lower level of education
• lower level of income
• staff of casiones (closeness to any casino)
• prisoners

Question 9

Comorbidity

Answer 9

people suffered in any mental disorder: 6-12%

people suffered in substance use disorder: 9.33%

Among GD people: 
- Alcohol, drug problem: 35-73%
 Mood disorders: 33-78%
 ADHD: 20%
 OCD: 1-20%
 Personality disorders: 25-87%
 Impulse control disorders: 18-43% 
 Suicide: 13-20%

Question 10

Negative consequences

Answer 10

• somatic complaints (gastrointestinal problems, high blood pressure)
• psychological problems (anxiety, depressive mood)
• family issues (problems in communication, intimacy, confidence; divorce, physical abuse)
• at work (lower efficacy, absence, job loss)
• legal issues
• financial consequences

Question 11

Etiology of GD (biological factors)

Answer 11

• comorbid psychiatric disorder
• family aggregation (GD in family)
• Twin studies: GD, alcoholism and antisocial personality disorder

Question 12

Reward deficiency syndrome

Answer 12

Blum et al, 2000

Abnormalities in the dopaminergic system: lower level functioning of the midbrain dopaminergic system, lack of D2 dopamin receptors -> reward deficiency syndrome
- impulsive, risk taking behavior

Question 13

Neuro-cognitive approach (GD)

Answer 13

• deficit in self-regulation processes
• deficit in high level cognitive processes
• behavioral inhibition
• cognitive flexibility
• time perception
• planning processes
• -> dysfunction in prefrontal cortex

Question 14

Psychological factors (GD)

Answer 14

• trauma
• low self-worth and feeling unwanted, unneeded or rjected
• psychoanalytical approach (repression of aggression)
• behavioral approach: learnt maladaptive behavior, money and excitement are positive reinforcements
• cognitive approach: distorted cognitive processes: illusion of control, explanations why cannot win.

Question 15

Therapy (GD)

Answer 15

Pharmacotherapy

• SSRI
• opiate antagnosist (naltrexone)
• mood stabilizers (lithium)
• dependent on the comorbid disorder
  > anxiety disorder: SSRI
  > impulsive control disorder: naltrexone
  > mood disorders: ms

Question 16

Psychotherapy (GD)

Answer 16

• psychoanalytic approach: correction of low level of self-worth and narcissistic problems
• cognitive behavioral therapy: correction of unrealistic and dysfunctional beliefs, developing problem solving behaviors, developing social skills, relapse prevention

family therapy

Question 17

Internet addiction

Answer 17

1995: Goldberg > symptom list for internet addiction disorder

First definition in 1998: Young - Internet addiction - similar to pathological gambling (impulse control disordeR)

Question 18

Symptoms of internet addiction (Young)

Answer 18

1. preoccupation with the Internet (thoughts about previous online activity or anticipation of the next online session)
2. Use of the internet in increasing amounts of time in order to achieve satisfaction
3. Repeated, unsuccessful effort to control, cut back or stop Internet use
4. Feelings of restlessness, moodiness, depression or irritability when attempting to cut down use of the internet
5. Online longer than originally intendended
6. Jeopardized or risked loss of significant relationships, job, educational or career opportunities because of internet use
7. Lies to family members, therapists or others to conceal the extent of involvement with the internet
8. Use of the internet is a way to escape from problems or to relieve a dysphoric mood

Question 19

Some characteristics of addictive internet users

Answer 19

• loneliness, lack of social interactions
• problems in adaption to social conventions
• dominance of abstract thinking
• avoidance of face to face communications
• need for change in self identity

Question 20

Etiology - personality (internet addiction)

Answer 20

• depression
• loneliness
• anxiety
• impulsivity
• low self control
• low self esteem

problematic family relations (dysfunctional relationship, divorce, neglect)

Question 21

Etiology - motivations (internet addiction)

Answer 21

• escape (from reality and problems)
• coping (stress, aggression)
• fantasy (new identities, new experiences)
• skill development (coordination, concentration etc.)
• competition (with others, being successful in something)
• recreation
• social factors

Question 22

Etiology - biology (internet addiction)

Answer 22

Internet use may also lead specifically to dopamine release in one of the reward structures of the brain.

dysfunction in dopaminergic system as in other addictive disorders.

same structures of the brain involved as in other chemical or behavioral addictions and impulse control disorders.

Question 23

Exercise addiction

Answer 23

Regular physical exercise contributed to the maintenance of health.

is it just a positive addiction? physical injury and negligence of everyday responsibilities (work and family life)

Question 24

Griffiths 6 component model of exercise addiction (EA)

Answer 24

1. salience: exercise is the most important activity in life and dominates thinking, feeling, behavior
2. Mood modification: exercise as a coping strategy
3. Tolerance: increasing amount of exercise are required to achieve the former effects
4. Withdrawal symptoms: unpleasant feeling states/physical effects when exercised is discontinued or reduced
5. Conflict: interpersonal conflict, conflicts with other activities, intrapsychic conflict
6. Relapse

Question 25

Primary vs. secondary EA

Answer 25

Primary EA - a form of behavioral addiction - exaggerated exercise is a primary problem - motivation for overexercising: avoiding something negative (escape from stress) - the exercise is the objective Secondary EA - co-occurs with another psychological dysfunction, typically with eating disorders (anorexia nervosa or bulimia nervosa) - excessive exercise is used for weight loss (objective)

Question 26

EA similarities with anorexia

Answer 26

- importance of eating is overrated - perfectionism - denial of exhaustion - good tolerance of unpleasant bodily sensation and pain - inhibition of anger - depressive tendencies

Question 27

Etiology - physiology (EA)

Answer 27

oldest and most popular: "runners high hypothesis" - intense feeling of euphoria after intensive running - increased peripheral beta-endorphin activity - but other activities (listening to music) cause similar euphoric states... "arousal regulation hypothesis" - regular exercise --> lower basal heart rate and lower sympathetic activity at rest - and, in parallel, lowers levels of arousal. - experienced as lethargic or energy-lacking states --> obvious way to increase the arousal level is via exercise

Question 28

"arousal regulation hypothesis"

Answer 28

- regular exercise --> lower basal heart rate and lower sympathetic activity at rest - and, in parallel, lowers levels of arousal. - experienced as lethargic or energy-lacking states --> obvious way to increase the arousal level is via exercise

Question 29

"runners high hypothesis"

Answer 29

- intense feeling of euphoria after intensive running - increased peripheral beta-endorphin activity - but other activities (listening to music) cause similar euphoric states...

Question 30

"thermogenic regulation hypothesis"

Answer 30

- intense physical activity increases body temperature --> trigger a relaxing state, reduces anxiety - positive reinforcers or motivational incentives exercise --> turn to exercise whenever they experience anxiety

Question 31

"catecholamine hypothesis"

Answer 31

- brain catecholaminergic activity is altered through exercise - central catecholamine levels -> regulating mood and affect - unclear: the peripheral changes in catecholamine levels have an effect on brain catecholamine levels or vice versa

Question 32

Etiology - psychology (EA)

Answer 32

AFFECT REGULATION HYPOTHESIS - exercise has dual effect on mood: increases positive affect and decreases negative affect (guilt, irritability, anxiety) associated with missed exercise - the longer the interval between two exercise session, the experience of negative affect becomes more likely -> tolerance COGNITIVE APPRAISAL HYPOTHESIS - using exercise as a means of coping with stress -> learning to depend on exercise at times of stress - person uses rationalization to explain the exaggerated amount of exercise. Low self-esteem, perfectionism, anxiety, OCD.