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

THE BEHAVIORAL ADDICTIONS

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1. Spectrum of Behavioral Addictions 2. Gambling Disorder 3. Gambling Cognitive Distortions 4. Body Dysmorphic Disorder 5. Pharmacological Treatments 6. Conclusions

Outline

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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.

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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.

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Dimensional Approach

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

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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

Liu T, CNS Spectrum, 2007.

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2 Gambling Disorder

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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

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.

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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.

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.

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2002-2011 Commercial Casinos US Consumer Spending

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

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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.

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

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3 Gambling

Cognitive Distortions 15

The Shell Game

PRACTICE

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The Shell Game

PLAY

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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.

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The Shell Game

CARD # 1

CARD # 2

CARD # 3

IF YOU STAY:

IF YOU SWITCH:

King/Chosen Win Lose King Chosen Lose Win King Chosen Lose Win Chosen King Lose Win

King/Chosen Win Lose King Chosen Lose Win

Chosen King Lose Win Chosen King Lose Win

King/Chosen Win Lose

CHANCE OF WINNING: 33% 66%

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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

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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.

Interpretative Biases

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Superstitious Beliefs

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

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

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Selective Memory

Remembering wins while ignoring losses.

Totaling wins without correcting for amounts lost.

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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.

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4 Body Dysmorphic

Disorder 25

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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.

DSM-5 Criteria

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American Psychiatric Association, DSM-5, 2013.

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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)

DSM-5 New Specifiers

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

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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

Associated Features

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30 30

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Skin 73 % Hair 56 % Nose 37 %

The Big Three

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

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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

Affected Body Parts

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33 33

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Normal concerns about appearance Healthy exercising

Eating Disorders Gender Identity Disorder Major Depressive Episode Social Phobia Trichotillomania

Koro

Differential Diagnosis

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The Feusner Experiments 1

Feusner JD, Arch Gen Psychiatry, 2010.

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The Feusner Experiments 2

Feusner JD, Psychological Medicine, 2011.

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Global v. Local Processing

Feusner JD, Psychological Medicine, 2011.

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Face Recognition Experiments

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Bindemann M, Experimental Psychology, 2007.

Face Recognition in BDD

Jefferies K, J Obsessive Compuls Relat Disord, 2012.

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5 Pharmacological

Treatments 40

Pathological Gambling

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

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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.

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.

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Selective Serotonin Reuptake Inhibitors Fluvoxamine, Paroxetine, Escitalopram. Block serotonin reuptake, increase

serotonin function, and reduce “Self-Medication.”

Best with co-occurring depression or anxiety.

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

PG as an Compulsive Disorder

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Body Dysmorphic Disorder

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

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0%

10%

20%

30%

40%

50%

60%

Delusional (n=27)

Non-Del. (n=37)

Placebo Fluoxetine

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

Fluoxetine helped both delusional and non-delusional subjects; however, no delusional patients responded to placebo.

Fluoxetine for BDD

Phillips KA, Arch Gen Psychiatry, 2002.

6 Conclusions

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1. Behavioral addictions fall within an impulsivity-compulsivity spectrum of illness.

2. Gambling Disorder is now one of the “Substance-Related 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.

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Thank you

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