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Ornella Corazza, PhD.Reader in Substance Addictions and BehavioursDept. of Clinical and Pharmaceutical SciencesUniversity of Hertfordshire

E-mail: o.corazza@herts.ac.uk

The Dark Side of Appearance: Body Image Disorders, Exercise Addiction and the Use of Enhancement Drugs

Hertfordshire County Council, Public Health & the University of Hertfordshire

A globalised network world

�I think therefore I am��I am seen therefore I am�

THE ABSENT BODY

BEHAVIOURAL ADDICTIONS

ADDICTION IS A TERM DERIVED FROM THE LATIN ADDICERE

«TO ENSLAVE»«TO ASSIGN TO»For the Romans an addictus was a person who, having debt, was assigned to a creditor as a slave

BEHAVIOURAL ADDICTIONS

ADDICTION IS A TERM DERIVED FROM THE LATIN ADDICERE

«TO ENSLAVE»«TO ASSIGN TO»For the Romans an addictus was a person who, having debt, was assigned to a creditor as a slave

BEHAVIOURAL ADDICTIONS:A CONTROVERSIAL TOPIC

The concept of behavioral addictions has

scientific and clinical value, but remains

controversial.

Issues around behavioral addictions have

been long debated in the different

editions of the Diagnostic and Statistical

Manual of Mental Disorders (DSM) and

the International Classification of

Diseases (ICD), where the

notion of ‘‘addiction’’ referred almost

exclusively to the intake of substances

with psychotropic activity.

Why now?

COMMONFEATURES OFBEHAVIORALADDICTIONS

• Immediate pleasure and relief (NOT long-lasting!)

• Dominance: The substance (or behavior) constantly dominates the thinking (main ideation)

• Craving: There is a feeling and the increasing sense of tension before taking the substance

• Mood Instability: This is initially limited to the beginning of substance intake (or behavioral implementation), then increasingly generalized and extended to all aspects of existence

• Psychosocial impairment: narrowing of interests, neglect of other areas of life

• Tolerance: The need to increase the amount of substance (or the time dedicated to behavior) to get the ‘‘positive’’ effect

• Loss of control: The need to increase the amount of time dedicated to behavior to get the ‘‘positive’’ effect.

EUROPEAN NETWORK FOR PROBLEMATIC USE OF THE INTERNET (EU-PUI)Visit us at http://www.internetandme.eu/

• Multidisciplinary expertise (animal and human neuroscience, genetics, clinicians, bio & information-technology industry, service planners, patients & carers)

• Advance understanding of the psycho-biological basis of different forms of PUI and the societal cost and burden

• Development of innovative forms of treatment and prevention programmes

39 countries 146 members

HIKIKOMORI: the "modern-day hermits"

"I started to blame myself and my parents also blamed me for not going to school. The pressure started to build". "Then, gradually, I became afraid to go out and fearful of meeting people. And then I couldn't get out of my house."

"pulling inward, being confined"

“Acute social withdrawal” “Often seeking extreme degrees of isolation and confinement”

Age: 19-27 years oldMale prevalence (90%)2,000,000 cases in Japan

SELFITIES

Borderline - Taking selfies at least three times a day, but NOT posting them on social media

Acute - Taking selfies at least three times a day and posting every one of them on social media

Chronic - Take and post the selfies on social media more than six times per day

Do you take more thanthree selfies per day?

Exercise Addic+on (EXA)

• Considering its benefits in preserving or improving both physical and mental health, including the treatment of certain addictions, it might appear paradoxical that exercise can also develop into a serious dependence itself.

• EXA found between 0.3% and 0.5% among the general adult popula+on (Mónok et al., 2012), and between 3.0% and 12.0% among athletes or regular exercisers (Szabo et al., 2016; Corazza et al 2019). Nonetheless, this prevalence rate may reach over 20% in elite endurance athletes, such those parIcipaIng in triathlon and/or ironman races (Blaydon & Lindner, 2002; Youngman & Simpson, 2014). Studies suggest that men generally show higher scores in EA than women.

• EXA has a high comorbidity and a significant correlation with eating disorders and body image disorders (De Luca et al., 2017; Levallius et al., 2017; Rocks et al., 2017). It has been estimated that more than 40% of people suffering from eating disorder is also affected by EXA (Klein et al., 2004).

• The challenge in treating this addiction is due to the fact that the habit cannot cease completely, as physical activity plays a central role in gaining and maintaining a healthy lifestyle.

This represents a fertile ground not only for the

development of addictions but also for the

development of image related

psychopathologies

BODY DYSMORPHIC DISORDER (BDD)

BDD is severe disorder characterized by distressing preoccupation with perceived imperfections in one’sphysical appearance and time-consuming rituals (e.g., excessive mirrorchecking,cosmetic surgery seeking) aimed at checking, hiding, or fixing “flaws.”

MUSCLEDYSMORPHIA(MD)

MD is a condition in which the principal symptom

is a marked preoccupation with one’s body being

insufficiently muscular.

In the DSM-5, it is classified as a subtype of BDD

Image and Performance Enhancing Drugs (IPEDs), or simply “life-style drugs», as umbrella term used to describe a wide rage of products, which have the apparent potential to improve mental and physical functions, including:

• Anabolic drugs to enhance structure and function of muscles• Drugs taken for weight loss• Image-enhancing drugs taken to modify the ageing process, beauty andcosmetic appearance• “Sex drugs” and aphrodisiacs• Cognitive enhancers• Drugs taken to improve mood/social behaviours

AIM

To investigate whether there is a potential link between image perception, exercise addiction and the use of PIEDS

• Online survey, targeting people who regularly engage in fitness. Recruitment was supported via a dedicated project website (https://humanenhancementdrugs.com) and adverts on fitness blogs and other social media platforms

• Measures being used investigated – Demographics– PIEDS use and knowledge– Exercise Addiction (Exercise Addiction Inventory; EAI)– Body Image Perception (Anxiety Appearance Index; AAI) – Self-Esteem (Rosenberg’s Self Esteem Scale; RSE)

• The study was approved by the Ethics Committee Ethical at University of Hertfordshire prior to data collection (HSK/SF/UH/00104).

METHODS

Sample 1711

UK (377)Netherlands (189)Italy (494)Hungary (651)

Sex 66.3 % F33.7% M

Mean Age 30.17 ± 10.26

Occupation 63.6% Employed29% Student 5.3% Unemployed1.3% Retired

Type of activity

Walking 53.3%

Running 79.2%

Bodyweight 28.7%

Lift weights 27.2%

Swimming 19.6%

Hiking 12.8%

Gymnastics 11.3%

Football 8.9%

Yoga 8.7%

EA & BDD

• EA was detected in 11.7% of the overall sample, considering the cut-offscore of 24 points in the EAI. This was higher amongst male (15%),indicating a greater exposure to physical injuries and withdrawalsymptoms, like depression, anxiety and mood swings.

• Participants were also very concerned about their physical appearancewith 38.5% at risk of BDD, considering a cut-off score of 19 in the AAI.This mainly affected the mainly female (47.2%). This result was muchhigher not only than the scores reported among the general population(where BBD prevalence ranges from 0.7% to 2.3%), but also of thosefound among at risk populations (6.7% among general dermatologypatients, 14.0% among cosmetic dermatology patients, 10% in themaxillofacial setting, and 21% in patients seeking rhinoplasty (Bouman etal., 2017, Brito et al., 2016, Locatelli et al., 2017).

EAI and AAI in the four countries

DISCLOSING THE USE OF PRODUCTS TO INCREASE FITNESS PERFORMANCE

No, 60.20%

Yes, 39.80%

(n=1711)

Proteins63.3%

Nitric Oxide 8.2%

(17% UK Pilot)

Caffeine29.8%

Sibutramine1.1.%

(6% UK pilot)

Amphetamine 2.3%

(14% UK pilot)

Thyroid Hormone

3% (9% UK pilot)

Anabolic Steroid

5.9% (9% UK pilot)

Vitamins52.5%

Amino acid

39.1%

Laxatives2.3%

Fish Oil 27.9%

Herbal products

9.4%

Mineral Salt

13.1%

Guarana’7%

Antioxidants8.2%

Diuretics4.9%

Ginseng7.9%

GHB1.8%

VARIETY OF PRODUCTS BEING USED

- No previous medical advise- 8% of the sample reported side-effects from taking products, including:

Heart Palpita=ons

Diarrhea

Depression

Difficulties Sleeping

Mood SwingsHeadaches

Hair Loss

High BP

Acne

Side effects

HOW DID YOU FIND OUT ABOUT THESE PRODUCTS?

WHERE DID YOU PURCHASE THE PRODUCTS FROM?

Friends Family Personal Trainer

Medical Prof.

Magazine

Online Other

18.9% 3.7% 14.6% 4.5% 10.5% 41.4% 6.3%

Pharmacy Food Store Fitness Shop Online Other

8.3% 3.8% 48.6% 31.3% 8.0%

• Respondents who declared the use of fitness supplements scored significantly higher (p<0.001) in both the Appearance Anxiety Inventory and the Exercise Addiction Inventory with an average score of m=19.62 in the Exercise Addiction Inventory, m=18.91 in the Appearance Anxiety Inventory scale and m=12.27 in the Rosenberg Self-Esteem scale.

• However, no significant difference was recorded in the Rosenberg Self-Esteemscale

Users vs Non Users

BDD, EA and PIEDs use

Three different logistic models were created according to the gender of participants

1. Across the whole sample, EA emerged as a strong predictor of the consumption of fitness supplements. This risk appeared to be over three times higher in those reporting Exercise Addiction Inventory scores over the cut-off (p<0.001, OR = 3.03 with a CI ranging from 2.15 to 4.28.

2. The risk of using supplements was much higher in the male sample reporting Exercise Addiction Inventory score over the clinical cut-off (OR = 3.25, CI 1.81-5.86). In those cases where EA was identified, the risk of using sport supplements was over five times higher, making EA the strongest predictor for this group.

3. Other psychopathological factors were the major predictors of supplement use among female: Appearance Anxiety (OR = 1.5; CI 1.20-2.12) and low self-esteem as measured by the Rosenberg Self-Esteem scale (OR = 1.08; CI 1.02-1.15).

Highlights from the study

• The study revealed for the first time an association between the consumption of fitness supplements and the level of EA across sample, suggesting a predictability of use .

• Although preliminary, these findings indicate that intake of fitness enhancing products could be motivated by such underlying psychopathological and image-disturbance features.

• The statistical significance of EA was particularly high for males, where the risk of fitness supplements intake was from 1.8 to 5.8 times higher than that reported among females (Table 6).

• Conversely, the substance intake by the female group was more influenced by appearance anxiety and self-esteem.

• Need to develop more suitable and up to date rating scales.

KEEP FIT STUDYr

UK Italy Hungary NetherlandsOrnella Corazza (PI)Roisin MooneyKeith Sullivan Liam Blackwell David WellstedAndres Roman-Urrestarazu

Pierluigi SimonatoGiovanni MartinottiEduardo CinosiRita SantacroceGiulia PiazzonFabiola Sarchione

Lili RácmolnárRenáta BagiMáté KapitányZsolt DemetrovicsBalázs Varga

Katinka van de VenKyle MulrooneyAlvin Westmaas

…. We cannot forget….

Find out more about our partnership working on the Public Health Connect websitewww.hertsphconnect.org

Showcasing our renowned approach to addressing public health in Hertfordshire and the East of England using collaborative work to provide benefits for local populations

See how you can get involved and make a difference to the public health landscape!

#hertsphconnect@hertsphconnect