Lecture 10 - Non-Drug Addiction

Sex Addiction

  • Many activities, not involving drug taking, are considered addictions:
    • Gambling addiction
    • Internet addiction
    • Sex addiction
    • Exercise addiction

How to Define Sex Addiction?

  • Uncontrollable sexual behaviour
  • Considerable consequences caused by sexual behaviour
  • Inability to stop despite these consequences
  • Persistently pursuing self-damaging or risky behaviour
  • Continuous wish or attempt to limit sexual behaviour
  • Sexual obsession and fantasizing as a primary survival strategy
  • A need to practice sexual behaviours more and/or more often (development of tolerance)
  • Spending abnormal amounts of time to get or have sex or to recuperate from sexual experiences
  • Neglect of important activities in work, relations, home front, and daily pastime because of sex
  • Negative consequences at the expense of other behaviours
  • These symptoms mirror the general addiction model, such as substance abuse, but with sexual behaviours.

What Constitutes "Sex" in This Context?

  • Sex with a partner?
  • Masturbation?
  • Pornography?
  • Sexting?
  • Seeking out sexual encounters through apps?

ICD-11 Classification

  • Framed as an impulse control disorder, not an addiction.
  • ICD-11 for Mortality and Morbidity Statistics (Version: 09/2020) includes:
    • 6C72 Compulsive sexual behaviour disorder
    • Under Impulse control disorders
  • Description:
    • Characterized by a persistent pattern of failure to control intense, repetitive sexual impulses or urges resulting in repetitive sexual behaviour.
    • Symptoms include repetitive sexual activities becoming a central focus, neglecting health, personal care, interests, activities, and responsibilities.
    • Numerous unsuccessful attempts to reduce repetitive sexual behaviour.
    • Continued repetitive sexual behaviour despite adverse consequences or deriving little or no satisfaction.
    • The pattern is manifested over an extended period (e.g., 6 months or more) and causes marked distress or significant impairment.
  • Exclusions:
    • Paraphilic disorders (6D30-6D3Z)

Key Points

  • Limited good quality data available.
  • Australian study (2009, N=20194N = 20194):
    • 4.4% of men saw themselves as addicted.
    • 1.2% of women saw themselves as addicted.
  • Predictors for problematic sexual behaviour and pornography:
    • Being male, young age, religiousness, frequent internet use, negative mood states, prone to sexual boredom, novelty seeking.
  • Wide variety of behaviours.
  • Comorbidity of hypersexual behaviour:
    • Anxiety disorder, mood disorder, substance use disorder, sexual dysfunction.
  • For pornography:
    • Smoking, drinking alcohol or coffee, substance abuse, and problematic video-game use.
  • Dopamine is involved, with evidence for activation of prefrontal cortex, ventral striatum, and amygdala.
  • People are often hesitant to report due to privacy concerns.

Internet Use

Definitions of Internet Addiction

  • When internet use is at the expense of physical and social functioning.
  • Feeling that true contacts and recognition only exist online.
  • Multiple people indicating problematic use, yet the individual cannot stop.
  • A loss of control over internet use leading to problems in daily life, as determined by a professional.
  • Problematic internet use resembles addictive behaviour.

Symptoms

  • Preoccupation: Thinking about past or future internet use.
  • Tolerance: Feeling the need to use the internet more to get the same satisfaction.
  • Withdrawal: Feeling restless, depressed, or irritated when limiting internet use.
  • Loss of Control: Staying online longer than intended.
  • Sacrifices: Risking an important relationship due to internet use.
  • Deception: Lying to others about internet use.
  • Escape: Using the internet as a way to escape problems.

Smartphone Use - Same Questions

  • The same question framework applies to smartphone use.

Research Findings

  • Norway, 2007 (N=2953N = 2953):
    • Addicted internet users reported high rates of preoccupation (97.5%), tolerance (72.4%), unsuccessful attempts to control use (66.1%), and using the internet to escape problems (92.7%).
  • Problematic internet use is associated with:
    • Being male, young age, having university education, unsatisfactory financial situation.

Prevalence

  • NL - 2014 (Kisjes et al.):
    • Normal use: 95%
    • Problematic use: 1 to 5% (adolescents 3.7%, adults 0.9%)
    • Internet addiction: < 1%
  • Addiction is often related to a specific application.

Online Gaming

  • Spending too much time on the internet could be due to gaming addiction rather than smartphone addiction.
  • Problematic gaming estimated to occur in 2-4% of pupils in secondary school, mostly boys.

Effects of Internet Addiction

  • Addicts:
    • Negative effect on school performance, daily routine, health, and relationship with parents and teachers.
  • Non-addicts:
    • Internet has an overall positive effect on various factors.

Internet Addiction and Personality

  • Lower self-esteem and higher depression symptoms in addicted group compared to non-addicts.
  • Pattern similar to results found in other studies.

Brain Activation

  • Cue presentation of video games elicits brain activation similar to drug addiction.
  • Study:
    • 19 adults, 10 days of game play with First Person Shooter “War Rock”.
    • fMRI comparing video game footage to neutral footage.
    • Areas activated: prefrontal cortex, thalamus, hippocampus.
    • Desire to play positively correlated with rmFrontal Lobe and rParahippocampal gyrus activity.

Social Networking Addiction (Kuss & Griffiths, 2017)

  • Social networking and social media use are not the same.
  • Social networking: Aim to connect with others.
  • 2021: Over 3 billion social network users worldwide.
  • 2019: Daily social media usage of global internet users amounted to 145 minutes per day.
  • Not every social media application is used to connect to others.
  • Compulsive need to connect to others > social networking addiction.

Key Considerations

  • Social networking is eclectic with many different forms of social media (e.g., permanent vs. quick deletion of posts, instant messages, blogging, microblogging, gaming, online dating).
  • Facebook is only one example of social media addiction.
  • It's a way of being; normal to be engaged in online networking, may meet a basic need of social support and self-expression.
  • Social networking may become addictive.
  • Different forms may be caused by different reasons.

Different Types – Different Reasons?

  • Study:
    • N=920N = 920 (36.6% male) secondary school pupils.
    • 27.6% played video or internet games, 42.4% logged in at social networking sites more than once a day.
  • Factors:
    • Internet: sex, conscientiousness, neuroticism
    • Gaming: sex, conscientiousness, openness
    • Social networking: extraversion, neuroticism

Fear of Missing Out (FOMO) (Wegmann et al., 2017)

  • "A pervasive apprehension that others might be having rewarding experiences from which one is absent (…)" (Przybylski et al., 2013, p. 1842).
  • Measured at trait or state level.
  • State-FoMo is important: need to have online experiences and fear of missing out of things that happen online is important.

Study Result

  • N=270N = 270 participants: students from Germany and Spain
  • Trait-FoMo was not included in the final model, is a broader construct.
  • Avoidance expectancies: distraction from problems.
  • Interpersonal sensitivity: ability to read and respond other people’s feelings and state.
  • Gaming 1: loss of control/time management, gaming 2: craving/social problems.

Additional Points

  • Addiction is to activities, not to the machine.
  • NoMophobia: No mobile phone phobia – related to the fear of not being able to engage in social networking.
  • For social networking addiction:
    • Unclear about gender differences.
    • More prevalent in younger population.
    • Difference in raters (self vs. other).
    • Internet landscape and tech evolve quickly, so research often lags reality.

Gambling

  • Every bet, for oneself or for others, for money or not, is gambling as soon as the outcome is uncertain or dependent on chance or ‘skill’.
  • Problem gambling:
    • Risky gambling behaviour that has negative consequences for an individual’s well-being: relations, family, finances, social situation and sought goals.
  • Compulsive (pathological) gambling:
    • Progressive disorder characterized by a continuous or periodical loss of control over gambling; preoccupation with gambling and getting money to gamble; irrational thinking; continuation of behaviour despite negative consequences.

DSM-5

  • Gambling disorder has been reclassified from impulse control disorders to the substance-related and addictive disorders class.
  • This change reflects the increasing and consistent evidence that some behaviors, such as gambling, activate the brain reward system with effects similar to those of drugs of abuse.
  • Other changes from DSM-IV:
    • A decrease in the number of criteria required to meet the diagnostic threshold from five or more under DSM-IV to four or more under DSM-5.
    • The addition of a 12-month window for clustering of symptoms.
    • The addition of a clinically significant distress or impairment criterion.
    • The removal of a legal criterion.

Gambling in the Netherlands

  • October 2021: Online gambling was legalized in NL.
  • Share of online betting has increased significantly.

Gambling Addiction in Netherlands

  • AGOG report: 2005 - 40,000 addicts and 76,000 at risk.
  • Jellinek: 2016 estimates - 79,000 are problem players and probably addicted, In addition, 95,700 are at risk.
  • Mostly middle-aged males who seek help.
  • 55% who sought help: gambling was the only problem they were being treated for, 45% sought help for other mental health problems too.

Risk Factors

  • Risk is increased if:
    • You have more money to bet and have more occasions to bet.
    • You can play alone and anonymously.
    • You play in a pleasant environment.
    • You believe you can control the outcome.
  • Online gambling is probably extra addictive: the games go faster, there is always access and you can play multiple games at the same time.

Components of Gambling Addiction

  • Phases identified:
    • Winning – more winning than losing
    • Losing – trying to win back the loss
    • Desperation – loss of control over gambling, clinical depression and suicide

Types of Gamblers

  • Action – especially skill games
  • Escape – especially chance games
  • Reasons stated: relaxation, getting rich quickly, adventure, flight, crisis in life, bored, lonely, relation problems
  • Blaszczynski & Nower – Pathways model identifies 3 types of problem gamblers:
    • Behaviorally conditioned: minimal levels of psychopathology
    • Emotionally vulnerable: comorbid anxiety and/or depression and poor coping skills
    • Antisocial impulsivist: high impulsivity, high levels of antisocial personality and AD disorders

Biological Factors

  • Gambling addiction often seen as an impulse-control disorder but now classified under DSMV as addiction.
  • Heritable (Eisen et al ’98) 46%, Lobo & Kennedy 50-60%, (in Vietnam veterans twins)
  • Norepinephrine increased
  • Serotonin decreased
  • Dopamine receptor dysfunction
  • Cloninger’s biopsychosocial model of personality:
    • Novelty seeking – Dopamine (low baseline)
    • Harm avoidance – Serotonin (high)
    • Reward dependence – Norepinephrine (low baseline)

Influencing Gambling Behaviour in Healthy Individuals (Campbell-Meiklejohn et al. 2011)

  • Experiments: drug vs. placebo
  • Tryptophan= serotonin precursor – absence from diet leads to serotonin depletion
  • Pramipexole = D2/D3 receptor agonist
  • Propanolol = beta-adrenoblocker
  • Examine effect of drug on ‘loss chasing’

Neurotransmitter Effects

  • Serotonergic activity is related to loss chasing decisions (more serotonin MORE loss chasing)
  • D2/D3 receptor activity is related to changes in the value judged as worth to chase (more dopamine - increased value of losses chased and decreased value of losses surrendered)

Brain Areas

  • Similar areas activated as in drug-related addictions, involved in decision making and reward pathway
  • VTA to nucleus accumbens
  • Basal ganglia, incl. amygdala
  • Striatum
  • Frontal cortical: prefrontal cortex

Cue Reactivity in Problem Gamblers

  • Study:
    • 17 problem gamblers seeking treatment
    • 18 non-gambling heavy smokers
    • 17 non-gambling non-smoking controls
  • MRI while watching neutral, gambling-related and smoking-related pictures
  • Results:
    • In problem gamblers: more activity in occipital lobe (visual processing), temporal lobe (incl amygdala) and prefrontal cortex
    • For gamblers, the pictures elicited a craving for the behaviour

Co-occurrence

  • Comorbidity occurs often in addiction – either between addictions or between addiction and other forms of psychopathology.
  • More depression in internet addiction.
  • Often found: Problematic gambling co-occurs with drug addiction