THE BEHAVIORAL ADDICTIONS Petros Levounis, MD, MA Chair Department of Psychiatry Rutgers – New Jersey Medical School

Rutgers – New Jersey Medical School Fundamentals of Addiction Medicine Summer Series Newark, NJ – August 21, 2013

Outline 1. 2. 3. 4. 5. 6.

Spectrum of Behavioral Addictions Gambling Disorder Gambling Cognitive Distortions Body Dysmorphic Disorder Pharmacological Treatments Conclusions 2

1 Spectrum of Behavioral Addictions 3

Why did it take us that long?  Impulse Control Disorders, Substance Use Disorders, Somatoform Disorders, and Behavioral Addictions  The tobacco companies, the lawsuits, and organized medical professional organizations.  The DSM-5 4

Essential Features Failure to resist an  impulse,  drive, or  temptation to perform an act that is harmful to the person or others.

5

Impulsivity vs. Compulsivity  Both show inability to refrain from repetitive behaviors.  Impulsivity is driven by an effort to obtain arousal and gratification.  Compulsivity is driven by an effort to reduce anxiety.

6

Dimensional Approach

7

Adapted from: Hollander E, Clinical Manual of Impulse-Control Disorders, 2006.

COMPULSIVE END – OCD              

Body Dysmorphic Disorder Anorexia Nervosa Depersonalization Disorder Hypochondriasis Tourette’s Syndrome Trichotillomania Autism Binge Eating Compulsive Buying Kleptomania Pathological Gambling Self-Injurious Behaviors Sexual Compulsions Borderline Personality Disorder

IMPULSIVE END – Antisocial PD

8

Gender Differences MEN Body Dysmorphic Sexual Compulsion Pyromania Gambling Internet Addiction

WOMEN Anorexia Binge Eating Kleptomania Compulsive Buying Trichotillomania

9

Liu T, CNS Spectrum, 2007.

2 Gambling Disorder 10

Clinical Presentation DSM-5 Addiction Criteria, plus  “Chases” one’s losses  Lies to conceal the extent of her or his gambling  Relies on others for money

Phases    

Winning Phase Loss Phase Desperation Phase Hopelessness Phase 11

Blanco C, Cohen O, Luján JJ, et al: Pathological gambling and substance use disorders, in Substance Dependence and Co-Occurring Psychiatric Disorders: Best Practices for Diagnosis and Treatment. Edited by Nunes EV, Selzer J, Levounis P, Davies CA. New York, Civic Research Institute, 2010.

Epidemiology US Gambling Statistics:  $ 36 billion/year casino revenue (2011 data).  82% of US residents gamble.  1% - 3% meet criteria for PG.

Pathological Gamblers:  $ 40,000 average individual debt.  25 hours/week average time spent. 12

www.americangaming.org, accessed on February 13, 2013. Dickson-Gillespie L, Rugle L, Rosenthal R, Fong T: Preventing the incidence and harm of gambling problems. J Prim Prev 29:37-55, 2008. Fong TW: The biopsychosocial consequences of pathological gambling. Psychiatry 2(3):22-30, 2005.

2002-2011 Commercial Casinos US Consumer Spending

13

www.americangaming.org, accessed on February 13, 2013.

Screening Tools  The Lie/Bet Test  Have you ever felt the need to bet more and more money?  Have you ever had to lie to people important to you about how much you gambled?  .99 sensitivity, .91 specificity. 14

Johnson EE, Hamer R, Nora RM, et al: The lie/bet questionnaire for screening pathological gamblers. Psychological Reports 80:83-88, 1997.

3 Gambling Cognitive Distortions 15

The Shell Game

PRACTICE

16

The Shell Game

PLAY

17

What would you do? 1. Switch. 2. Stick to my original choice. 3. It doesn’t matter; either way my chance of winning is 50%. 4. You’ve lost me. I have no idea. 18

The Shell Game CARD #1

CARD #2

CARD #3

King/Chosen King

IF YOU SWITCH:

Win

Lose

Lose

Win

Lose

Win

King

Lose

Win

King/Chosen

Win

Lose

Chosen

Lose

Win

King

Lose

Win

King

Lose

Win

King/Chosen

Win

Lose

33%

66%

Chosen

King Chosen

IF YOU STAY:

Chosen

King Chosen Chosen

CHANCE OF WINNING:

19

Interpretative Biases  Attributing wins to skill, losses to flukes  Wrongly believing that a series of losses increases the chance of subsequent win  The “Sunk-Cost” effect  Near misses

20

Interpretative Biases Near Misses: Of Mice and Men  “Why Mice are Smarter than Men?”  “But I was only one number away from winning the lottery!”  Free dinner on my birthday. 21

Superstitious Beliefs

Believing in:  good luck objects (like animal parts),  behaviors,  routines.

22

Gaboury A, Ladouceur R: Erroneous perceptions and gambling. Journal of Social Behaviors and Personality 4:411-420, 1989.

Selective Memory

 Remembering wins while ignoring losses.  Totaling wins without correcting for amounts lost.

23

Telescoping  Temporal: Expecting that naturally occurring—that is, probabilistically expected—wins will happen sooner rather than later.

 Reference: Expecting that naturally occurring—that is, probabilistically expected—wins will happen to oneself rather than others. 24

4 Body Dysmorphic Disorder 25

26

DSM-5 Criteria 1. Preoccupation with one or more perceived defects or flaws that are not observable or appear slight to others. 2. At some point during the course of the disorder, the person has performed repetitive behaviors or mental acts in response to the appearance concerns. 27

American Psychiatric Association, DSM-5, 2013.

DSM-5 New Specifiers Specify if: Muscle dysmorphia form of BDD (i.e., the belief that one’s body build is too small or is insufficiently muscular). Indicate:  Good or fair insight  Poor insight  Absent insight (i.e., delusional beliefs) 28

American Psychiatric Association, www.DSM5.org, 2012.

Associated Features         

Excessive mirror checking Mirror avoidance Excessive exercising (primarily weight lifting) Camouflage (hats, beards, stuffed pants) Ideas of reference Frank delusions Social isolation (night crawlers) Suicidality The relentless pursuit of dermatological and surgical treatments 29

30 30

The Big Three

Skin 73 % Hair 56 % Nose 37 % 31

Phillips KA, The Broken Mirror: Understanding and Treating Body Dysmorphic Disorder, 2005.

Affected Body Parts            

Nose Eyes Eyelids Eyebrows Ears Mouth Lips Teeth Jaw Chin Cheeks Head

          

Genitals Breasts Buttocks Abdomen Arms Hands Feet Legs Hips Shoulders Spine

 Larger Body Regions  Overall Body Size  Body Built  Muscularity

32

33 33

Differential Diagnosis  Normal concerns about appearance  Healthy exercising  Eating Disorders  Gender Identity Disorder  Major Depressive Episode  Social Phobia  Trichotillomania  Koro 34

The Feusner Experiments 1

35

Feusner JD, Arch Gen Psychiatry, 2010.

The Feusner Experiments 2

36

Feusner JD, Psychological Medicine, 2011.

Global v. Local Processing

37

Feusner JD, Psychological Medicine, 2011.

Face Recognition Experiments

38

Bindemann M, Experimental Psychology, 2007.

Face Recognition in BDD

39

Jefferies K, J Obsessive Compuls Relat Disord, 2012.

5 Pharmacological Treatments 40

Pathological Gambling

41

Adapted from: Hollander E, Clinical Manual of Impulse-Control Disorders, 2006.

PG as an Impulsive Disorder  Opioid Antagonists  Naltrexone and Nalmefene.  Block opioid receptors, decrease dopamine function, and reduce “Reward Cravings.”  Best with family history of alcoholism. 42

Grant JE, Kim SW, Hollander E, et al: Predicting treatment response to opiate antagonists and placebo in the treatment of pathological gambling. Psychopharmacol 200:521-527, 2008. Grant JE, Potenza MN: Pathological Gambling: A Clinical Guide to Treatment. Washington, DC, American Psychiatric Publishing, 2004.

PG as an Compulsive Disorder  Selective Serotonin Reuptake Inhibitors  Fluvoxamine, Paroxetine, Escitalopram.  Block serotonin reuptake, increase serotonin function, and reduce “SelfMedication.”  Best with co-occurring depression or anxiety. 43

Hollander E, Sood E, Pallanti S, et al: Pharmacological treatments of pathological gambling. Journal of Gambling Studies 21:101-110, 2005.

Body Dysmorphic Disorder

44

Adapted from: Hollander E, Clinical Manual of Impulse-Control Disorders, 2006.

Fluoxetine for BDD  BDD-symptom response rates during a 12-week treatment trial with fluoxetine ~80 mg QD.

60% 50% 40% 30% 20% 10% 0% Delusional (n=27) Placebo

Non-Del. (n=37) Fluoxetine

 Fluoxetine helped both delusional and nondelusional subjects; however, no delusional patients responded to placebo. 45

Phillips KA, Arch Gen Psychiatry, 2002.

6 Conclusions

46

1. Behavioral addictions fall within an impulsivitycompulsivity spectrum of illness. 2. Gambling Disorder is now one of the “SubstanceRelated and Addictive Disorders.” 3. Body Dysmorphic Disorder falls under the DSM-5 “Obsessive-Compulsive and Related Disorders” chapter. 4. Antidepressants have shown efficacy for BDD, but not for Gambling Disorder. 47

Thank you

48