Behavioral Addictions. Criteria, Evidence, and Treatment

394 Pages·2014·5.19 MB·English

by  Kenneth Paul Rosenberg and Laura Curtiss Feder (Eds.)

BEHAVIORAL
ADDICTIONS
Criteria, Evidence, and
Treatment
Edited by
KENNETH PAUL ROSENBERG, M.D.
Cornell University Medical Center, Psychiatry Department,
New York, NY, USA and UpperEastHealth.com
LAURA CURTISS FEDER, Psy.D.
Wellesley, MA, USA, www.drlaurafeder.com
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DEDICATION
For Claire and Alexander, Jonathan and Lilah
FOREWORD
In DSM-5 for the first time, the American Psychiatric Association added a
non-substance addiction to the category of addictive disorders. In May 2013,
Gambling Disorder was grouped in the section on Substance Use Disorders.
Gambling appears in prior versions of the DSM as “Pathological Gambling”
grouped with the impulse control disorders. Thus, the main effect of the
2013 revision was to change the name and the grouping. The criteria were
modified slightly by the symptom threshold to four or more symptoms.
Recent research on gambling has revealed a clinical course similar to
that of addictions, and recent brain imaging findings show that cues associ-
ated with gambling activate reward structures in the brain much the way
addicting drugs do. The committee took the position that addiction is a
disease of the reward system, and gambling activates brain reward structures
that reinforce compulsive gambling behaviors. Thus, a behavior that acti-
vates the reward system can have the same effect as a drug.
The work group considered other behaviors as potential candidates for
inclusion in DSM but maintained the consistent policy of requiring data in
the peer-reviewed literature showing evidence for inclusion. Another
behavior disorder, excessive Internet gaming, was seriously considered for
inclusion because there are over 200 publications on “Internet Addiction.”
The papers, however, lack consistent diagnostic criteria. Most of the cases
have been reported in Asian populations such as China, South Korea, and
Japan. The group finally decided to add “Internet gaming disorder” in sec-
tion 3 (Appendix) with a description of what future studies would be
required to have this disorder later added to the main group. It is hoped that
adding Internet gaming disorder to the Appendix of DSM-5 will stimulate
more research and perhaps result in its inclusion in the main body of the
classification in a future revision.
Other behavior disorders were considered. They include sex addiction,
food addiction, exercise addiction, and shopping addiction. The group
adhered to the policy of not including any disorder that was not supported
by multiple studies in peer-reviewed literature, although Behavioral Addic-
tions: Criteria, Evidence, and Treatment addresses many of these disorders in
great detail.
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Thus, this volume on behavioral addictions is timely and should serve as
a stimulus for more research. Data on prevalence in different populations,
for example, would be helpful. Is there a gender effect? If so, what is the
male:female ratio? Is there evidence of hereditary influence? What is the
peak age of onset and range of age of those afflicted? What are the results of
treatment? Do some patients simply outgrow the disorder?
For the clinician reading this book, it is my hope that Rosenberg and
Feder’s text will inform clinicians about the concepts of behavioral addic-
tion and help clinicians assess and treat these patients with improved under-
standing of the behavioral principles involved.
Charles P. O’Brien, M.D., Ph.D.
Chair, DSM American Psychiatric Association
Task Force on Substance Abuse Disorders
Kenneth Appel Professor
Department of Psychiatry
University of Pennsylvania
PREFACE
In mental health and addiction treatment, the true pioneers have not been
the medical experts or the providers, but the advocates and patients them-
selves. These men and women who came together in back rooms and
12-step meetings to declare that their behaviors constituted a medical illness
that required treatment. In the 1930s, the pioneering movement was
Alcoholics Anonymous. In the latter part of the 20th century, drug addicts
and “pathological gamblers” (as they were then called) found a similar degree
of solace, support, and healing from their peers, and founded groups such as
Narcotics Anonymous and Gamblers Anonymous. Most recently, sex, love,
shopping, food, and Internet “addicts” and advocates have also banded
together and founded groups such as Overeaters Anonymous, Sex and Love
Addicts Anonymous, and Debtors Anonymous. Much of the work here had
been developed and inspired by these advocates in the community, and this
book draws on and crystallizes their work in the first major text on the col-
lective topic of behavioral addiction. Our aim is to move the body of litera-
ture forward by synthesizing existing opinions and research on the topic.
This book works to elevate the discussion about behavioral addictions
into the medical and mental health lexicon with the science and theory that
support it so patients can be taken more seriously and be less stigmatized as
those with character flaws, personal weaknesses, or a lack of willpower and,
rather, get the actual help and support they need in the form of docu-
mented and evidence-based treatment. Our text offers clinicians and
researchers a basis for having informed discussions that will propel our field
forward.
As an addiction psychiatrist and a clinical psychologist working together
to edit this book (and formerly practicing together at Upper East Health, a
multidisciplinary addiction treatment practice in Manhattan), we advocate
and abide by a multidisciplinary and integrative treatment philosophy that
is grounded in both research and theory. This book is an effort to bring
together experts from various backgrounds and disciplines to address the
topic of behavioral addiction, with an emphasis on treatment.
This book benefits from authors who are renowned clinicians and pre-
eminent thinkers in their specialties. Most of our authors are trained in the
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xvi Preface
basic sciences and are accomplished researchers. A few of the authors offer
a perspective that could only belong to a trained outsider and observer. One
author is an anthropologist. Another is an attorney trained in mental health
law. One of our authors is an Indian spiritual leader with tens of millions of
followers, co-writing the chapter with one of the book’s editors.
We hope our readership includes clinicians (such as psychiatrists, psy-
chologists, social workers, and mental health counselors) as well as nurses,
physician assistants, doctors, clergy, and others in various helping and heal-
ing professions who work with those struggling with behavioral addiction.
We also anticipate that some patients and their family members will peruse
these pages. Some attorneys might find some of the information useful, as
may those studying anthropology and sociology.
Each chapter works to provide the current research and data about how
a particular behavioral addiction is defined and understood, including the
clinical criteria, epidemiology, common comorbidities, and differential
diagnoses and treatment recommendations. Clinical vignettes are then used
to further illustrate the disorder.
Our text begins with introductory remarks about the inclusion of
behavioral addictions into the psychiatric lexicon in the American Psychi-
atric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fifth
Edition (DSM-5). We then present our own overview of the nature, phe-
nomenology, and potential etiology of behavioral addictions. Given that
some of the current behavioral addictions were originally classified as
impulsive disorders or variants of obsessive-compulsive disorder, our next
chapter explores the distinction and intersections between impulsive, com-
pulsive, and addictive disorders. Gambling disorder, the most universally
accepted behavioral addiction, is the first diagnostic category presented in
the book. What follows are the chapters on particular behavioral addictions,
roughly presented in order of popular acceptance. Certain behavioral addic-
tions warrant more than one chapter. Abuses of the Internet are spelled out
in three chapters: one on Internet addiction disorder, one on Internet gam-
ing, and one on addictive social networking. Food addiction is explored in
two chapters: one exploring the topic generally with a case example focus-
ing on psychotherapy and one chapter on developments in the pharmacol-
ogy of weight loss and food addiction, with a case example about medication
choices. Sexual addiction is explored in two chapters: one on the overall
disorder and a second on the delicate family issues that arise when one’s
partner or parent is revealed as a sex addict. More controversial diagnoses
such as shopping, exercise, and love addiction are explored in scholarly and
Preface xvii
thorough chapters. Toward the end of the book, we include a chapter on
meditation, mindfulness, spirituality, and yoga—Eastern techniques gaining
popularity for treating addiction that are not addressed elsewhere in the
book. In the final chapter, a mental health lawyer discusses what all this may
mean in a court of law and gives suggestions for clinicians testifying as
expert witnesses. We have chosen to focus on the addictions that currently
have the most research support, and we have not included behaviors such as
“workaholism” and excessive, unnecessary plastic surgery, which may be
seen by some as addictions and which may be addressed in future editions.
We have also not included chapters on disorders that fall more into the
obsessive-compulsive and impulsive realm, such as trichotillomania and
intermittent explosive disorder, but our authors do address the overlaps
between obsessive, impulsive, and addictive disorders in Chapter 2 and
elsewhere.
Our eclectic group of authors may hail from a range of disciplines and
from around the globe, but all share an appreciation of the biopsychosocial
addiction model. Hence, each chapter explains how biological, psychologi-
cal, and sociocultural factors influence the development of the given disor-
der, and how they may inform treatment. Many chapters also address the
overlapping factors of impulsivity and compulsivity, and among our authors,
there is some debate about whether an orthogonal model of understanding
these traits is more suitable than considering them to fall along a single
spectrum.
Given where the field stands currently, we have edited a book that lives
on the frontiers of science and clinical care. A book that is a collection of
ideas and works to take the pulse of state-of-the-art behavioral addiction
research, diagnosis, and treatment. Tentative concepts, speculative neurosci-
ence, measured advocacy, healthy cynicism, and a commitment to clinical
care are evident in every chapter. Consensus is not reached, as it does not
currently exist, but the varying points of view—along with the data pre-
sented and the clinical vignettes presented throughout—provide a nuanced
understanding of behavioral addictions as they are understood today.
We extend our gratitude to our publisher Nikki Levy at Elsevier Press
for giving us the idea to write the book, and to our senior editorial project
manager Barbara Makinster for her patience and trust in us. We also thank
all of our authors who worked tirelessly. We thank those whose work
informs these pages, but did not contribute, instead providing mentorship,
support, and/or direction in the effort to solicit appropriate authors for
these chapters: April Benson, Ph.D.; Donald Black, M.D.; Hilarie Cash,
xviii Preface
Ph.D.; Robert Filewich; Allen Frances, M.D.; Richard Frances, M.D.; Mar-
tin Kafka, M.D.; Lorrin Koran, M.D.; Jean Petrucelli, Ph.D.; David Preven,
M.D., Ph.D.; Bruce Roseman, M.D.; Todd Sacktor, M.D.; and Gail Zitin,
M.Ed. Additionally, we thank the many researchers and developers who
allowed reproduction of their behavioral addiction assessment scales in the
appendices of our chapters. And most of all, we thank our patients, who
continue to be generous with their life stories that are revealed in these
pages, and who teach and inspire us with their dedication and determina-
tion to improve their lives.
Kenneth Paul Rosenberg, M.D. and Laura Curtiss Feder, Psy.D.
BIOGRAPHY
CO-EDITORS OF BEHAVIORAL ADDICTIONS: CRITERIA,
EVIDENCE, AND TREATMENT
Kenneth Paul Rosenberg, MD, is a board-certified Addiction Psychia-
trist and a Clinical Associate Professor in Psychiatry at the New York
Presbyterian Hospital–Weill Cornell Medical College. He is Consulting
Editor for the Journal of Sex and Marital Therapy, a Distinguished Fellow of
the American Psychiatric Association, and has been recognized on the lists
of U.S. World & News Report Best Doctors and New York Magazine’s Top
Addiction Psychiatrists. Dr. Rosenberg is Founder and Director of Upper
East Health Behavioral Medicine in Manhattan, a psychiatric practice that
provides treatment for individuals and families recovering from chemical
and behavioral addictions. He has discussed addiction on national broad-
casts of HBO, PBS, ABC, CNBC, and CNN and in the New York Times,
Washington Post, Huffington Post, Time Magazine, and People Magazine.
Dr. Rosenberg has produced educational films on mental health and addic-
tion for HBO and PBS, and is a recipient of a George Foster Peabody
Award.
Laura Curtiss Feder, PsyD, is a licensed clinical psychologist and mental
health consultant in private practice in New York and Massachusetts. Her areas
of specialty include treating addiction and compulsive behaviors, as well as
program evaluation and college counseling. She has engaged in many years of
clinical and research work in the fields of substance abuse and behavioral
addiction. She has contributed to scholarly publications on the assessment and
treatment of substance abuse and written for popular audiences on the emo-
tional aspects of skin picking and acne on Birchbox’s blog and in
100 Acne Tips & Solutions: The Clear Clinic Guide to Perfect Skin. Dr. Feder holds
her doctorate in clinical psychology from Rutgers, The State University of
New Jersey, and completed postdoctoral fellowships at the William Alanson
White Institute, including receiving a certificate in the treatment of eating
disorders, compulsions, and addictions. To learn more about Dr. Feder, her
research, consulting and clinical practice please see www.drlaurafeder.com.
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