Behavioral/Process Addictions: Transforming our Understanding of Clients with Addictions VSIAS, 2016 DR. MARY CROZIER

2 What do you think might be similarities between substance and behavioral/process addictions? Criteria for Substance Use Disorder (SUD) Pathological Gambling Internet Gaming Disorder Hypersexuality Disorder Binge Eating Disorder (BED) Tolerance Withdrawal Problem Quantity and/or Frequency Preoccupation Compulsion Compromise of values Efforts to control

Objectives: Discuss the prevalence of behavioral/process addiction in clinical populations Differentiate behavioral/process addiction from substance addiction and describe the manifestations of behavioral/process addictions Summarize the literature that supports the similarities between behavioral/process and substance addictions Apply addiction treatment strategies to clients who have behavioral/process addictions List specific ways of incorporating this new information into future practice with clients who have behavioral/process addictions 3

What do we know about addictions? Cultural -vs- scientific perceptions Historical definitions & terms Substance abuse research 12 Step Model DSM-V criteria (APA, 2013) Bio-psycho-social-spiritual model Syndrome Model (Schaffer et al., 2004) 4

Control Drive 5 Non-Addicted BrainAddicted Brain (Volkow, 2007) Drive Memory Control Memory Drive Reward

PATHOLOGICAL GAMBLING 6

Criteria for Pathological Gambling Gambling with increasing amounts of money to achieved desired excitement Restless or irritable when attempting to cut down Unsuccessful efforts to control, cut back, or stop Preoccupation Way to escape problems Chases one’s losses Lies to conceal extent of involvement Jeopardizing or loss of relationships, jobs, etc. Relies on others for money (APA, 2013) 7

Manifestations of Pathological Gambling Behavioral and/or lifestyle changes to accommodate gambling events/venues Rush of anticipation/high when discussing or planning gambling events Hiding debts, borrowing money and/or fluctuations in financial gain Withdrawal/depression followed by “the chase” Use of defense mechanisms such denial or lying 8

Prevalence of Pathological Gambling ● Pathological Gambling – 1 to 2 % of population (Sims et al., 2012) ● Less than 1.0% ( %) of the U.S. population have experienced gambling disorder in their lifetimes (Kessler et al. & Petry et al.) ● Lifetime rates for problem gambling range from 0.9 to 2.3% (Kessler et al. & Petry et al.) 9

INTERNET GAMING DISORDER 10

Possible Criteria for Internet Gaming Disorder Preoccupation with Internet gaming Withdrawal symptoms when gaming is taken away Increased tolerance Unsuccessful attempts to control participation Loss of interest in previous activities/interests Continuing gaming despite knowledge of problems Deceiving others regarding amount of gaming Using gaming to escape or relieve mood Jeopardizing relationships, job, etc. (APA, 2013) 11

Manifestations of Internet Gaming Disorder Eye and back strain Carpal tunnel syndrome Changes in sleep patterns Problems with time management Decreased productivity Social withdrawal when off- line Missed appointments Compromised values Auditory hallucinations Enuresis/Encopresis Hand-arm vibration syndrome Peripheral neuropathy Blisters & calluses Deficient visual-spatial ability (Weinstein, 2010) 12

Prevalence of Internet Gaming Disorder 8-9% of adolescents show signs of problem use (Sims et al., 2012) 5 to 10% of Internet users (1 in 8) show signs of problem use (Karim & Chaudhri, 2012) Based on a telephone survey of 2500 adults, 69% were regular users, 6% felt relationships suffered due to excessive Internet use, 8% attempted to conceal non-essential use, 4% felt preoccupied by the Internet when offline 14% found it hard to stay away from the Internet for several days, 8% used it to escape & 12% stayed online longer than intended (Shaw & Black, 2008) Poll of youth 8-18 found 8.5% of computer gamers were pathological players (Harris Interactive, 2007) 13

HYPERSEXUALITY DISORDER Snow ball toss in summer Video 14

Etiology for Hypersexuality Disorder: Negative mood stages & PTSD Repeated, environmental exposure Social, familial, & cultural influences Internet access (anonymous, available, accessible, affordable & perceived as safe/risk-free) Neurobiology/ABC Model of Impulse Control: Amygdala leads to affective dysregulation Behavioral reward is controlled by the nucleus accumbens and ventral striatal circuits Cognitive control is impaired in the prefrontal cortex (Samenow, 2010) 15

Characteristics for Hypersexuality Disorder Recurrent failure to resist impulse Increased tension before initiation Pleasure/relief enacting the behavior Persistence of symptomatology for at least 1 month with at least 5 additional conditions, such as preoccupation, repeated attempts to control/stop, spending excessive amounts of time in the behavior, etc. (Goodman, 1993) 16

Manifestations of Hypersexuality Disorder Changes in sleep patterns Emotional rollercoaster including anticipation-anxiety-high- release Unplanned and/or unhealthy sexual encounters Lack of personal boundaries Compulsive masturbation/touching Insensitive jokes and remarks Unmanageability of sexual behavior Compromising of espoused values Engaging in cybersex 17

Proposed DSM V Diagnosis: Hypersexual Disorder A. Over a period of at least six months, recurrent & intense sexual fantasies, sexual urges, and sexual behavior in association with four or more of the following criteria: Excessive time is consumed by sexual fantasies and urges, and by planning for and engaging in sexual behavior. Repetitively engaging in these sexual fantasies, urges, and behaviors in response to dysphoric mood states (e.g. anxiety, depression, boredom, irritability). Repetitively engaging in sexual fantasies, urges, and behavior in response to stressful life events. Repetitive but unsuccessful efforts to control or significantly reduce these sexual fantasies, urges, and behavior. Repetitively engaging in sexual behavior while disregarding the risk for physical or emotional harm to self or others. (APA, 2013) 18

Proposed DSM V Diagnosis: Hypersexual Disorder (con’t.) B. There is clinically significant personal distress or impairment in social, occupational, or other important areas of functioning (Kafka, 2009a) associated with the frequency and intensity of these sexual fantasies, urges, and behavior. C. These sexual fantasies, urges, and behavior are not due to direct physiological effects of exogenous substances (e.g. drugs of abuse or medications) or to Manic Episodes. D. The person is at least 18 years of age. (APA, 2013) 19

Prevalence of Hypersexuality Disorder Compulsive cybersex, 6 to 9% of men using internet, use more than 11 hours/week (Garcia & Thibaut, 2010) Sex addiction is seen in approx. 3 to 6% of the general population, with a gender ratio of 5 men to 1 female. Higher rates have been suggested in specific populations such as sexual offenders and HIV patients (Garcia & Thibaut, 2010) Comorbidities with psychiatric disorders include: mood disorders (72%), anxiety disorders (38%), & substance abuse (40%) (Garcia & Thibaut, 2010) Between 3 to 6% of the population have hypersexuality disorder (Karim & Chaudhri, 2012) 20

BINGE EATING DISORDER 21

Criteria for BED Recurrent episodes of binge eating Eating in discrete periods of time Lack of control Binge eating episodes associated with 3 of following Eating more rapidly than normal Feeling uncomfortably full after eating Eating when not hungry Embarrassed by amount of food consumed Feelings of disgust, depression, or guilt Distress regarding eating Occurs at least 1x/week for 3 months (APA, 2013) 22

Neurobiology of BED Both food and drug intake are regulated by the same neurobiological pathways Inversely correlated by competing for same reward sites in brain Stimulation of one can inhibit the other Sugar has psychoactive effects A dopamine D2 receptor deficit has been identified in both high BMI and drug-addicted subjects Serotonin is low in those with BED and high in those with AN

Manifestation of Eating Disorders Talk of dieting with detailed knowledge of calories/fat grams Excessive compensatory behavior Evidence of binge eating or purging behavior Hiding food or eating privately Denial of risks and appearance 24

Prevalence of Eating Disorders 30 million Americans will experience an eating disorder during their lifetimes 1/3 of Americans w/an eating disorder are men 13% of women aged 50 & over have symptoms of an eating disorder 40-60% of girls 6-12 years old worry about weight Life time prevalence of BED is 3.6% in women and 2.1% in men. The 12-month prevalence is 1.7% for women and 0.8% for men (Hudson, Hiripi, Pope, & Kessler, 2010) 25

Other behavioral/process addictions… Exercise Debting Work Electronics ??? 26

DUAL ADDICTIONS & CO-OCCURRING DISORDERS 27

PolyDrug Abuse Replacement Multiple Drug Use Cycling Stacking Mixing Sequentialing Morphing (Inaba & Cohen, 2011) 28

Addiction Interaction Dimensions Cross tolerance Withdrawal mediation Replacement Alternating addiction cycles Masking Ritualizing Intensification Numbing Disinhibiting Combining Inhibiting (Carnes, Murray, & Charpentier, 2004) 29

Cycling Acting Out Bingeing Substance Abuse Spending/Debting Gambling Workaholism Sex and romance Acting In Diet Substance Avoidance Saving/Hoarding Risk Aversion Compulsive Athleticism Sex anorexia (Carnes et al., 2004) 30

31 Possible Linkages and Similarities Criteria for Substance Use Disorder (SUD) Pathological Gambling Internet Gaming Disorder Hypersexuality Disorder Binge Eating Disorder Tolerance XXXX Withdrawal XXXX Problem XXXX Quantity and/or Frequency XXXX Preoccupation XXXX Compulsion XXXX Compromise of values XXXX Efforts to control XXXX

Ripple Effect 32 SubstanceNeurotransmitter (s)Bodily Systems Effected Stimulants Epinephrine, Norepinephrine Nervous, Muscular, Digestive, Cardiovascular, Excretory, Respiratory, Integumental Depressants Dopamine, GABA, Endorphins, Acetylcholine, Serotonin Respiratory, Nervous, Cardiovascular, Excretory Alcohol GABA, Serotonin, Dopamine, Met-enkephalin, Glutamate, Endorphins Anandamides Nervous, Cardiovascular, Excretory, Reproductive, Muscular, Hallucinogens Dopamine, GABA, Norepinephrine Epinephrine, Endorphins, Acetylcholine, Serotonin Nervous Cannabis Norepinephrine, Dopamine, Acetylcholine, Opioid Peptides Nervous, Reproductive, Cardiovascular, Respiratory

Ripple Effect 33 DisorderNeurotransmitter (s)Bodily Systems Effected Depression Dopamine, GABA, Acetylcholine, & Serotonin, Norepinephrine Nervous Anxiety GABA, Norepinephrine, Dopamine, SerotoninNervous, Muscular PTSD Norepinephrine, Epinephrine, Serotonin Nervous, Cardiovascular, Respiratory, Endocrine, Digestive

Ripple Effect 34 BehaviorNeurotransmitter (s)Bodily Systems Effected Pathological Gambling Epinephrine, NorepinephrineNervous Internet Gaming Disorder Epinephrine Nervous HyperSexuality Disorder EpinephrineNervous Binge Eating Disorder Dopamine, SerotoninDigestive, Nervous, Skeletal, Excretory

Co-Morbidity between Process/Behavioral Addictions, SUD, & Mental Health Disorders 35

Pathological Gambling and Co-Morbidity high co-occurrence with SUD, ADHD, suicidal ideations, Cluster B personality disorder, and mood disorder (Ashley & Boehlke, 2012) A 2006 national study found mood disorder in 20% of general population and 50% in problem gamblers (Shaffer & Martin, 2012) More than 40% of problem gamblers have an impulse control disorder (Shaffer & Martin, 2012) Approximately 13% of general population has alcohol use disorder however 25% of pathological gamblers are alcohol abusers and 50% are alcohol dependent (Shaffer & Martin, 2012) 36

Pathological Gambling & Substance Use Disorders (Petry, Stinson, & Grant, 2005)

Pathological Gambling & Mental Health Disorders (Petry, Stinson, & Grant, 2005)

Internet Gaming Disorder and Co-Morbidity 30% of problem internet users meet criteria for a co- occurring mental health disorder, such as mood disorders, Bipolar 1, and depression (Ashley & Boehlke, 2012) 10% of individual with a SUD also have an internet addiction (Sussman, Lisha, and Griffiths, 2011) two clinical studies found these individuals to frequently meet criteria for SUD and mood, anxiety, and impulse control disorders (Shaw & Black, 2008) 39

Hypersexuality Disorder and Co-Morbidity high comorbidity with mood disorders (72%), anxiety disorders (38%), and substance use disorders (40% ) (Garcia & Thibaut, 2010) approximately 40% of people with SUD also have sex addiction (Sussman, Lisha, and Griffiths, 2011) 40

BED and Co-Morbidity 65.1% had anxiety, 46.4% had a mood disorder, 43.3% had an impulse control disorder, and 23.3% had a SUD; of those with BED, 48.9% had 3 or more co-occurring disorders (Hudson, Hiripi, Pope, & Kessler, 2007) 25% also have SUD (Sussman, Lisha, and Griffiths, 2011) 41

SCREENING TOOLS 42

Cage: Screening for Behavioral Addictions 1. Have you ever felt the need to Cut down on your ____? 2. Have you ever felt Annoyed by someone criticizing your ____? 3. Have you ever felt bad or Guilty about your ____? 4. Have you ever ___ as an Eye-Opener soon after waking? (Ewing, 1984) 43

CAGED: Screening for Internet Gaming Disorder 1.Have you felt the need to Cut down on your use of the Internet? 2.Are others Annoyed or do you feel irritated by others’ criticism of your Internet use? 3.Do you feel Guilty or anxious about your Internet use or try to cover it up? 4.Do you feel Empty or miss being online when you’re not? 5.Is the Internet Disrupting your life or are you neglecting parts of your life because of the Internet? (Origin unknown) 44

The 4 C’s: Screening for Behavioral Addictions Compulsion 1. Do you ever ___ more than you intended? 2. Have you ever neglected a responsibility because you were ___, or so you could ___? Control 1. Have you ever felt the need to control how much you ___ but were unable to do so easily? 2. Have you ever promised that you would quit ___ then engaged in that behavior the same day? Cutting down (and withdrawal symptoms) 1. Have you ever tried to quit ___? How many times? For how long? 2. Have you ever had any symptoms when you tried to quit ___? If so, did the symptom go away after you engaged in that behavior? Consequences 1. How long have you known that ___was hurting you? 45

Important Considerations for Screening Uniqueness of each client’s story Engage client in screening Screen each client Understand “continuum of use” Use does not equal dependence Be aware of your own projections (Johnson, 2004) 46

47 Time for Role Plays

Strategies Targeting Behavioral Addictions PreventionInterventionTreatment 48

Prevention for Behavior/Process Addiction Social skill building (universally available) Balance/wellness (work, school, avocation, recreation, health, social & family life, spiritual fulfillment, financial-political-environmental stability) Services for children & family members of those with addictions Technological advances (websites with timers, point of sale interventions, non- addictive products,…) Public Policy (restrict availability, age limits, fair pricing, insurance coverage for treating all addictions/conditions, honest labeling, transparency,…) Other strategies??? 49

Treatment Modalities Abstinence 50

Treatment Modalities Abstinence 12 step support groups (with birth year) Alcoholics Anonymous, 1935 Narcotics Anonymous, 1950’s Gamblers Anonymous, 1957 Overeaters Anonymous, 1960 Debtors Anonymous, 1968 Sex Addicts Anonymous, 1979 Nicotine Anonymous, 1982 Cocaine Anonymous, 1982 Workaholics Anonymous, 1983 Marijuana Anonymous, 1989 Double Trouble,

Treatment Modalities Abstinence 12 step Pharmacotherapy Individual, family, & group counseling Use of Motivational Interviewing Address the specific behavior, co-occurring disorders, dual addictions, and any underlying issues 52

Treatment Modalities Abstinence 12 step Pharmacotherapy Consult with other professionals like law/policy makers, internists, family counselors, nutritionists, dentists, financial consultants, store/casino owners, etc. 53

What Can You Do? Work to prevent behavioral/process addictions Address public misunderstanding of addictions Conduct behavioral/process addiction screenings on all clients initially and intermittently Adopt a public health perspective toward behavioral/process addictions Seek ongoing training & educational opportunities For ex. Harvard’s free BASIS Use the Strategic Prevention Framework to plan comprehensive, evidence- based services Refer clients to trained professionals and self-help groups Other??? 54

References American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5 th ed.); American Psychiatric Association, Washington, DC. Ashley, L. & Boehlke, K. (2012). Pathological gambling: A general overview. Journal of Psychoactive Drugs, 44(1), doi: / Carnes, Murray, & Charpentier. (2004). Addiction interaction disorder. In R. Coombs (Ed.), Handbook of addictive disorders: A practical guide to diagnosis and treatment, (pp.31-59). Wiley and Sons. Ewing, J. (1984). Detecting alcoholism: The CAGE questionnaire. Journal of the American Medical Association, 252 (14), Garcia, F. & Thibaut, F. (2010). Sexual addiction. The American Journal of Drug and Alcohol Abuse, 36, doi: / Goodman, A. (1998). Sexual addiction: An integrated approach. International Universities Press, Inc. Madison. Grant, J. E., Potenza, M. N., Weinstein, A., & Gorelick, D. A. (2010). Introduction to behavioral addictions. The American Journal of Drug and Alcohol Abuse, 36, doi: / Greenberg, Lewis, & Dodd (1999). Overlapping addictions and self-esteem among college men and women, Addictive Behaviors, 24(4),

References Harvard Health Publications (2010). Pathological gambling. The Harvard Mental Health Letter, Retrieved from ?accountid=10639 Hester, R. & Miller, W. (2003). Handbook of Alcoholism Treatment Approaches: Effective alternatives. Allyn and Bacon, Boston. Hudson, J. I, Hiripi, E., Pope Jr., H. G., & Kessler, R. C. (2007). The prevalence and correlates of eating disorders in the national comorbidity survey replication. Biological Psychiatry, 61(3), doi: /j.biopsych Inaba, D. S., & Cohen, W. E. (2011). Uppers, downers, and all arounders: Physical and mental effects of psychoactive drugs (7th edition). Medford, OR: CNS Publications. Internet Society (2012). Retrieved March 2012 from Johnson, J. L. (2004). Fundamentals of Substance Abuse Practice. Brooks/Cole, Belmont, CA. Karim, R. & Chaudhri, P. (2012). Behavioral addictions: An overview. Journal of Psychoactive Drugs, 44:1, Kessler RC, Hwang I, LaBrie RA, et al. DSM-IV pathological gambling in the National Comorbidity Survey Replication. Psychological Medicine 2008;38(9): Miller, W. & Rollnick, S. (2013). Motivational interviewing: Helping people change (3 rd ). The Guilford Press, NY. Petry, Stinson, & Grant. (2005). Comorbidity of DSM-IV pathological gambling and other psychiatric disorders: Results from the national epidemiological survey on alcohol and related conditions. Journal of Clinical Psychiatry, 66(5)

References Samenow, C. (2010). Classifying problem sexual behavior-It’s all in the name. Sexual Addiction and Compulsivity, 17, 3-6. Shaffer, H., LaPlante, D., LaBrie, R., Kidman, R., Donato, A., & Stanton, M. (2004). Toward a syndrome model of addiction: Multiple expressions, common etiology. Harvard Review of Psychiatry, 12, doi: / Shaffer, H., Martin, R., Kleschinsky, J., & Neporent, L. (2012). Change your gambling: Change your life. Jossey- Bass, San Francisco. Shaw & Black (2008). Internet addiction: Definition, assessment, epidemiological, and clinical management. CNS Drugs, 22(5), Sim, T., Gentile, D., Bricolo, F., Serpelloni, G., & Gulamoydee, F. (2012). A conceptual review of research on pathological use of computers, video games, and the internet. The International Journal of Mental Health and Addiction, 10(5), doi: /s Sussman, S., Lisha, N., & Griffiths, M. (2011). Prevalence of the addictions: A problem of the majority or the minority? Evaluation & the Health Professions, 34(1), 3–56. doi: / Volkow, N (2007). Retrieved from Weinstein, A. & Lejoyeau, M. (2010). Internet addiction or excessive internet use? The American Journal of Drug & Alcohol Abuse, 36: Wieland, D. M. (2015). Behavioral addictions. Journal of Psychosocial Nursing and Mental Health Services, 53(10),