Transcript VSIAS-2016-crozier-finalx - Virginia Summer Institute for

Behavioral/Process Addictions:
Transforming our Understanding
of Clients with Addictions
VSIAS, 2016
DR. MARY CROZIER
[email protected]
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
2
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
Non-Addicted Brain
Addicted Brain
Control
Control
Control
Drive
Reward
Drive
Memory
Reward
Drive
Memory
(Volkow, 2007)
5
PATHOLOGICAL GAMBLING
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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)
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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
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Prevalence of Pathological Gambling
●Pathological Gambling – 1 to 2 % of population (Sims et al.,
2012)
●Less than 1.0% (0.4-0.6%) 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.)
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INTERNET GAMING DISORDER
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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)
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Manifestations of Internet Gaming Disorder
• Eye and back strain
• Carpal tunnel syndrome
• Auditory hallucinations
• Changes in sleep patterns
• Hand-arm vibration
• Problems with time
management
• Decreased productivity
• Social withdrawal when offline
• Missed appointments
• Compromised values
• Enuresis/Encopresis
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)
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HYPERSEXUALITY DISORDER
• Snow ball toss in summer
• Video
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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)
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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)
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Manifestations of Hypersexuality Disorder
• Changes in sleep patterns
• Emotional rollercoaster including anticipation-anxiety-highrelease
• 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
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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)
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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)
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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)
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BINGE EATING DISORDER
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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)
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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
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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)
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Other behavioral/process addictions…
• Exercise
• Debting
• Work
• Electronics
• ???
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DUAL ADDICTIONS
& CO-OCCURRING DISORDERS
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PolyDrug Abuse
• Replacement
• Multiple Drug Use
• Cycling
• Stacking
• Mixing
• Sequentialing
• Morphing
(Inaba & Cohen, 2011)
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Addiction Interaction Dimensions
• Cross tolerance
• Ritualizing
• Withdrawal mediation
• Intensification
• Replacement
• Numbing
• Alternating addiction
cycles
• Disinhibiting
• Masking
• Combining
• Inhibiting
(Carnes, Murray, & Charpentier, 2004)
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Cycling
Acting Out
Acting In
• Bingeing
• Diet
• Substance Abuse
• Substance Avoidance
• Spending/Debting
• Saving/Hoarding
• Gambling
• Risk Aversion
• Workaholism
• Compulsive Athleticism
• Sex and romance
• Sex anorexia
(Carnes et al., 2004)
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Possible Linkages and Similarities
Criteria for
Substance Use
Disorder (SUD)
Pathological
Gambling
Internet
Gaming
Disorder
Hypersexuality
Disorder
Tolerance
X
X
X
X
Withdrawal
X
X
X
X
Problem
X
X
X
X
Quantity and/or
Frequency
X
X
X
X
Preoccupation
X
X
X
X
Compulsion
X
X
X
X
Compromise
of values
X
X
X
X
X
X
X
X
Efforts to control
Binge Eating
Disorder
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Ripple Effect
Substance
Stimulants
Depressants
Alcohol
Hallucinogens
Cannabis
Neurotransmitter (s)
Bodily Systems Effected
Epinephrine, Norepinephrine
Nervous, Muscular, Digestive, Cardiovascular,
Excretory, Respiratory, Integumental
Dopamine, GABA, Endorphins, Acetylcholine,
Serotonin
Respiratory, Nervous, Cardiovascular, Excretory
GABA, Serotonin, Dopamine, Met-enkephalin,
Glutamate, Endorphins Anandamides
Nervous, Cardiovascular, Excretory,
Reproductive, Muscular,
Dopamine, GABA, Norepinephrine
Epinephrine, Endorphins, Acetylcholine,
Serotonin
Nervous
Norepinephrine, Dopamine, Acetylcholine ,
Opioid Peptides
Nervous, Reproductive, Cardiovascular,
Respiratory
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Ripple Effect
Disorder
Neurotransmitter (s)
Bodily Systems Effected
Depression
Dopamine, GABA, Acetylcholine, & Serotonin,
Norepinephrine
Nervous
Anxiety
GABA, Norepinephrine, Dopamine, Serotonin
Nervous, Muscular
PTSD
Norepinephrine, Epinephrine, Serotonin
Nervous, Cardiovascular, Respiratory,
Endocrine, Digestive
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Ripple Effect
Behavior
Neurotransmitter (s)
Bodily Systems Effected
Pathological Gambling
Epinephrine, Norepinephrine
Nervous
Internet Gaming
Disorder
Epinephrine
Nervous
HyperSexuality
Disorder
Epinephrine
Nervous
Binge Eating Disorder
Dopamine, Serotonin
Digestive, Nervous, Skeletal, Excretory
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Co-Morbidity between Process/Behavioral
Addictions, SUD, & Mental Health Disorders
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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)
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Pathological Gambling & Substance Use
Disorders (Petry, Stinson, & Grant, 2005)
Pathological Gambling & Mental Health
Disorders
(Petry, Stinson, & Grant, 2005)
70.0%
60.8%
60.0%
49.6%
50.0%
41.3%
40.0%
General adult population
30.0%
20.0%
Disordered gamblers
16.0%
17.2%
7.5%
10.0%
0.0%
Any mood disorder
Any anxiety disorder
Any personality disorder
Internet Gaming Disorder and Co-Morbidity
• 30% of problem internet users meet criteria for a cooccurring 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)
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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)
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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)
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SCREENING TOOLS
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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)
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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)
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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?
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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)
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Time for Role Plays
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Strategies Targeting Behavioral Addictions
Prevention
Treatment
Intervention
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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, nonaddictive products,…)
• Public Policy (restrict availability, age limits, fair pricing, insurance coverage for
treating all addictions/conditions, honest labeling, transparency,…)
• Other strategies???
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Treatment Modalities
• Abstinence
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Treatment Modalities
• Abstinence
• 12 step support groups (with birth year)
Alcoholics Anonymous, 1935
Nicotine Anonymous, 1982
Narcotics Anonymous, 1950’s
Cocaine Anonymous, 1982
Gamblers Anonymous, 1957
Workaholics Anonymous, 1983
Overeaters Anonymous, 1960
Marijuana Anonymous, 1989
Debtors Anonymous, 1968
Double Trouble, 1997
Sex Addicts Anonymous, 1979
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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.
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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 e-newsletter @ http://www.basisonline.org/
• Use the Strategic Prevention Framework to plan comprehensive, evidencebased services http://www.nrepp.samhsa.gov/
• Refer clients to trained professionals and self-help groups
• Other???
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References
• American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.);
American Psychiatric Association, Washington, DC.
• Ashley, L. & Boehlke, K. (2012). Pathological gambling: A general overview. Journal of Psychoactive Drugs,
44(1), 27-37. doi: 10.1080/02791072.2012.662078
• 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), 1905-1907.
• Garcia, F. & Thibaut, F. (2010). Sexual addiction. The American Journal of Drug and Alcohol Abuse, 36,
254-260. doi: 10.3109/00952990.2010.503823
• Goodman, A. (1998). Sexual addiction: An integrated approach. International Universities Press, Inc.
Madison.
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The American Journal of Drug and Alcohol Abuse, 36, 233-241. doi: 10.3109/00952990.
• Greenberg, Lewis, & Dodd (1999). Overlapping addictions and self-esteem among college men and women,
Addictive Behaviors, 24(4), 565-571.
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References
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and Bacon, Boston.
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10.1016/j.biopsych.2006.03.040
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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
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• Shaffer, H., Martin, R., Kleschinsky, J., & Neporent, L. (2012). Change your gambling: Change your life. JosseyBass, San Francisco.
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