Category Archives: Psychiatry

I drink, therefore I am: A brief look at alcohol dependence in Great Britain

Alcohol dependence is often viewed as a cluster of behavioural, cognitive, and physiological phenomena that in most affected people includes a strong desire to consume alcohol, and have difficulties in controlling their drinking. According to a 2013 report by Alcoholics Anonymous, alcoholism kills more people in the UK than any other drug apart from nicotine. Based on Government statistics, they claim one adult in every 13 is alcohol-dependent (although this is much higher than data collected from the most methodologically robust studies – see below). The General Household Survey (GHS) and the General Lifestyle Survey (GLF) have been measuring drinking behaviour for over 30 years. In relation to alcohol use, the latest 2013 Office for National Statistics (ONS) report notes that:

“The Department of Health estimates that the harmful use of alcohol costs the National Health Service around £2.7bn a year and 7% of all hospital admissions are alcohol related. Drinking can lead to over 40 medical conditions, including cancer, stroke, hypertension, liver disease and heart disease. Reducing the harm caused by alcohol is therefore a priority for the Government and the devolved administrations. Excessive consumption of alcohol is a major preventable cause of premature mortality with alcohol-related deaths accounting for almost 1.5% of all deaths in England and Wales in 2011”.

The ONS notes that obtaining reliable data on drinking behaviour is difficult. Compared to national alcohol sales, surveys carried out by social scientists consistently record lower levels of how much alcohol they consume because participants may consciously and/or unconsciously be underestimating alcohol consumption (e.g., alcohol use in the home may be based on the number of glasses of wine drunk with the amount poured into the glass being much greater than a standard unit of alcohol). In the most recent 2013 report (based on data collected in 2011), participants were asked two questions about their alcohol consumption. These were (i) maximum amount of alcohol drunk on any one day in the previous seven days, and (ii) average weekly alcohol consumption. The survey also obtained three measures of maximum daily alcohol consumption.

  • Exceeding the recommended daily alcohol limit. This measure assessed the proportion of men and women exceeding the recommended units of alcohol on their heaviest drinking day (i.e. 4 units for men, 3 units for women).
  • Engaging in binge drinking (i.e., intoxication). This measure assessed the proportion of men and women who exceeded the number of daily units considered as intoxicating (i.e., 8 units for men, 6 units for women).
  • Engaging in heavy drinking. This measure assessed the proportion of men and women who drank more than three times the recommended daily units of alcohol (i.e., more than 12 units for men and more than 9 units for women).

The results indicated that:

  • Over half of all adults (59%) reported that they had consumed alcohol in the week prior to the survey.
  • Men (66%) were more likely than women (54%) to have had an alcoholic drink in the week before the survey
  • More men (16%) drank on at least five out of seven days than women (9%) in the week prior to the survey.
  • Almost one in ten men (9%) drank alcohol every day in the week prior to the survey compared to only one in twenty women (5%).
  • More men (34%) exceeded the daily recommended units of alcohol than women (28%).
  • More men (18%) were binge alcohol drinkers than women (12%)
  • More men (9%) were heavy drinkers than women (6%)
  • Heavy drinking was most prevalent in those aged 16 to 44 years
  • Drinking alcohol was also associated with smoking nicotine with smokers being more likely to be binge drinkers and heavy drinkers.

Another major report on alcohol use in England was recently published by the Lifestyle Statistics, Health and Social Care Information Centre (in 2013). Their analyses were mainly obtained from the Health and Social Care Information Centre (HSCIC), Hospital Episodes Statistics (HES), and prescribing data. They reported that:

  • 61% of men and 72% of women had either drunk no alcohol in the last week, or had drunk within the recommended levels on the day they drank the most alcohol.
  • 64% of men drank no more than 21 units weekly, and 63% of women drank no more than 14 units weekly.
  • 12% of school pupils had drunk alcohol in the last week. This continues a decline from 26% in 2001, and is at a similar level to 2010, when 13% of pupils reported drinking in the last week.
  • In 2011/12, there were 200,900 admissions to English hospitals where the primary diagnosis was attributable to alcohol consumption (a 1% increase on the previous year).
  • In 2011/12, there were an estimated 1,220,300 admissions to English hospitals related to alcohol consumption where an alcohol-related disease, injury or condition was the primary reason for hospital admission or a secondary diagnosis (an increase of 4% on the previous year).
  • In 2012, there were 178,247 prescription items prescribed for the treatment of alcohol dependence in primary care settings or NHS hospitals and dispensed in the community (an increase of 6% on the previous year).

Arguably the most robust data on alcohol dependence in the UK comes from the 2009 Adult Psychiatric Morbidity Survey (APMS) carried out by the National Centre for Social Research and University of Leicester. Alcohol problems (including alcohol dependence) were measured using the AUDIT (Alcohol Use Disorders Identification Test) and the SADQ-C (Severity of Alcohol Dependence Questionnaire, community version). An AUDIT score of eight or more indicated hazardous drinking, and 16 or more indicated harmful drinking. SADQ-C scores of 4-19 indicated mild dependence; 20-34, moderate dependence; 35 or more, severe dependence.

Using the AUDIT, the prevalence of hazardous drinking was 24.2% (33.2% males, 15.7% females). A total of 3.8% of adults (5.8% males, 1.9% females) drank alcohol at harmful levels, i.e., around 1 in 25 adults. Among males, the highest prevalence of both hazardous and harmful drinking was in 25-34 year olds, whereas in females it was in 16 -24 year olds. Using the SADQ-C, the prevalence of alcohol dependence was 5.9% (8.7% males, 3.3% females), i.e., around 1 in 16 adults. For males, the highest levels of dependence were identified in those between the ages of 25-34 years (16.8%), whereas for females it was between the ages of 16-24 years (9.8%). Most of the recorded dependence levels were mild (5.4%), with relatively few adults showing symptoms of moderate or severe dependence (0.4% and 0.1% respectively). Compared to the previous APMS survey in 2000, the prevalence of alcohol dependence was lower for males in 2007, whereas it remained at a similar level for females.

Dr Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Further reading

Lifestyle Statistics, Health and Social Care Information Centre (2013). Statistics on Alcohol: England, 2013. Located at:

National Centre for Social Research/University of Leicester (2009). Adult Psychiatric Morbidity in England, 2007: Results of a Household Survey. London: NHS Information Centre

Office for National Statistics (2012). The 2010 General Lifestyle Survey. London: Office for National Statistics.

Office for National Statistics (2013). The 2011 General Lifestyle Survey. London: Office for National Statistics.

Sussman, S., Lisha, N. & Griffiths, M.D. (2011). Prevalence of the addictions: A problem of the majority or the minority? Evaluation and the Health Professions, 34, 3-56.

Below the waste: A brief look at the extreme world of bodily fluid art

As regular readers of my blog will know, I have a long-standing psychological interest in any extreme human behaviour. This also encompasses the world of popular culture and includes individuals that engage in extreme art (such as surrealists like Salvador Dali), extreme fashion (such as those that wear extreme lingerie, extreme body art (including both extreme tattooing and extreme body modification), and/or fetishistic body costumes), and extreme music (such as bands like Throbbing Gristle and the Velvet Underground).

Back in 1997 I was one of the many people that visited the controversial art exhibition Sensation at the Royal Academy of Art that featured a wide range of work by the ‘Young British Artists’ (and all owned by Charles Saatchi) such as the ‘shock art’ by Damien Hirst (‘The Physical Impossibility of Death in the Mind of Someone Living’), Tracy Emin (‘Everyone I Have Ever Slept With 1963–1995’), Jake and Dinos Chapman (‘Great Deeds Against the Dead, 1994’), Marcus Harvey (‘Myra’), and Ron Mueck (‘Dead Dad’). One of the pieces that I was particularly struck by was ‘Self’ a sculpture by Marc Quinn that was a cast of the artist’s own head made from approximately nine pints of his own frozen blood. As the Wikipedia entry on Quinn notes:

In interview in 2000, reflecting on the iconic artwork, [Quinn] remarked, ‘Well, I think it’s a great sculpture. I’m really happy with it. I think it is inevitable that you have one piece people focus in on. But that’s really good because it gets people into the work’. Described by Quinn as a ‘frozen moment on life support’, the work is carefully maintained in a refrigeration unit, reminding the viewer of the fragility of existence. The artist makes a new version of ‘Self’ every five years, each of which documents Quinn’s own physical transformation and deterioration”.

In interviews about his body of work (no pun intended), Quinn has said that he has gravitated towards the use of unconventional materials that address his “preoccupation with the mutability of the body and the dualisms that define human life”. In a short (but interesting) interview with The Huffington Post, he was asked how the metaphorical immortality in his work given that his work literally contained a part of him. He replied that:

In a funny way I think ‘Self’, the frozen head series, is about the impossibility of immortality. This is an artwork on life support. If you unplug it, it turns to a pool of blood. It can only exist in a culture where looking after art is a priority. It’s unlikely to survive revolutions, wars and social upheaval, I also think that the total self portrait-ness of using my blood and my body has an ironic factor as well, in that even though the sculpture is my form and made from the material from my body, to me if just emphasises the difference between a truly living person and the materials which make that person up. The sort of literalist point that has been missed by the cryogenicists who freeze themselves for supposed future regeneration”.

I was reminded of Quinn’s extreme art more recently when I was interviewed about the art of 36-year old Australian-based artist Dr Rev Mayers for the Discovery television series Forbidden (a program on which I am the resident psychologist. You can see Dr. Rev and my appearance on this programme here). As the documentary’s production notes made clear:

“Dr. Rev loves to paint. Like most artists he tries to put something of himself in to all his creations. But Dr Rev takes this concept to a whole other level. His paintings are created using his own blood, pumped fresh from his own veins and sprayed direct on to the canvas…He’s a natural born showman, lapping up the attention he gets while performing his death defying blood art stunts in front of live audiences. He’s survived his last feat – a live show painting with the blood being pumped directly from his arm – though he’s vowed never to try it again. ‘It’s a dangerous process if the airbrush had have blocked up, blood could have been pushed back into my body. I could have suffered a heart attack and died’…Mayers has just quit the tattoo business and blood painting is now his fulltime job. He’s been doing it for 6 years ever since he convinced his nurse to let him take home a vial of his own blood”.

Mayers describes himself as borderline bipolar, a showman and a talker. The motivation behind his art appears a lot less intellectual than that of Quinn with a seemingly simple rationale for doing what he does – contradiction and shock value. As he noted in the television program: “I don’t mean to sell myself but I’m certainly not boring and if it’s shocking that you guys want then you’ll get shocking!” Mayers also claimed that he likes the idea of contradicting the stigma that surrounds blood: “It’s not scary. It’s what gives us life” 

Quinn and Mayers’ artworks might be considered less extreme than examples of other ‘bodily fluid’ art that I came across during my research for this article. Many of you reading this may be familiar with the art of English Turner Prize winner Chris Ofili who often incorporates elephant dung into his paintings. However, the late Italian artist Piero Manzoni (who died in 1961 at the age of 29 years) filled ninety 30-gram tin cans with his own faeces (labeled ‘Merda d’artista’ that translates as ‘The Artist’s Shit’). Each in was valued as its weight in gold and the most recently sold can went for about £100,000. It is thought that none of the 90 cans has ever been opened so no-one is entirely sure whether they really contain Manzoni’s excrement or not. In an online essay about Manzoni by Stefano Cappeli, the author briefly made reference to the more psychological (in this case psychodynamic) elements of the faecal artwork:

“Manzoni’s cans of Artist’s Shit have some forerunners in the twentieth-century art, like Marcel Duchamp’s urinal (‘Fontaine’, 1917) or the Surrealists’ coprolalic wits. Salvador Dalì, Georges Bataille and first of all Alfred Jarry’s ‘Ubu Roi’ (1896) had given artistic and literal dignity to the word ‘merde’. The link between anality and art, as the equation of excrements with gold, is a leitmotiv of the psychoanalytic movement (and Carl G. Jung could have been a point of reference for Manzoni).
 Manzoni’s main innovation to this topic is a reflection on the role of the artist’s body in contemporary art”

Another controversial piece of art containing the artist’s own bodily fluid was American Andres Serrano’s 1987 photograph Piss Christ. The photograph depicts Jesus on a small plastic crucifix drowning in a glass of yellow liquid (i.e., Serrano’s own urine). His artworks also include other iconic statuettes in liquids such as blood and milk. Unsurprisingly, accusations of “cheaping Christianity” have been made towards the artist. But Serrano has consistently stated that Piss Christ is itself “a commentary on the cheapening and commercialization of Christian icons in the modern age”.

Other artists that have incorporated bodily fluids into their artworks include those that have used human sweat (e.g., ‘Waste to Work: Everyman’s Source’ by Daniela Kostova and Olivia Robinson that explores the relationship between work, sweat, pay, and unemployment), vomit (e.g., ‘Nexus Vomitus’ by Millie Brown, a half-hour operatic vomit performance), and menstrual blood (e.g., Ingrid Berthon-Moine’s portrait photographs such as ‘Forbidden Red’ and ‘Rouge Pur’ where lipstick is always replaced by menstrual blood).

The psychological motivations and eccentricities of artists such as Leonardo da Vinci, Van Gogh, Andy Warhol, and Salvador Dali have long been the discussion of both academics and non-academics alike. Abnormal psychology specialist Professor Gordon Claridge noted that many psychological studies have examined the minds of artists. This research has often showed a pattern of unhappy and/or lonely childhoods, and that artists are often highly sensitive individuals that may have experienced trauma (pushing them into art as a form of escapism, self-expression and/or therapy).

A study of 291 world famous men by Dr. Felix Post in a 1994 issue of the British Journal of Psychiatry found that over two-thirds (69%) had a mental disorder of some kind. More specifically, scientists were the least affected by mental health problems, while artists and writers had increased diagnoses of psychosis (i.e., mental conditions that involve losing touch with reality and may in extreme cases result in various types of hallucination). In her 1996 book Touched With Fire: Manic Depressive Illness And The Artistic Temperament, the psychiatrist Dr. Kay Redfield Jamison concluded that, among eminent artists, the rate of depressive illnesses (particularly bipolar disorder) was 20 times more common than in the general population. For instance, Picasso, Gauguin, Michelangelo and Jackson Pollock are all thought to have suffered from bipolar disorder, and Andy Warhol appeared to demonstrate all the signs of Asperger’s syndrome (i.e., a type of autism). Whether those engaged in extreme art activities are any more psychologically prone to mental disorders than ‘normal’ artists remains to be seen.

Dr Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Further reading

Capelli, S. (undated). Artist’s shit: Consumption of dynamic art by the art devouring public magic bases – Living sculptures. Located at:

Frank, P. (2011). Marc Quinn discusses self-portraits made of his own blood. The Huffington Post, June 8. Located at:

Jamison, K.R. (1996). Touched With Fire: Manic Depressive Illness And The Artistic Temperament. New York: The Free Press.

Jones, J. (2011). Andres Serrano’s Piss Christ is the original shock art. The Guardian, April 18. Located at:

May, G. (2013). 10 crazy pieces of art made from bodily fluids. Listverse, July 27. Located at:

Post, F. (1994). Creativity and psychopathology. British Journal of Psychiatry, 165, 22-34

Smith, S. (2011). When blood runs cold. Big Tattoo Planet, June 22. Located at:

Spooky (2012). Dr. Rev’s creepy artworks are painted in blood. Oddity Central, May 8. Located at:

Hot flat mate: The unusual case of co-existent pyrophilia and crush fetishism

Over the Christmas period, I was at a family wedding in the Cotswolds when by chance I came across Dr. Raj Persaud’s 2003 book From The Edge of the Couch (subtitled ‘Bizarre psychiatric cases and what they teach us about ourselves’) for sale in a charity shop in nearby Moreton-in-Marsh. As it was selling really cheaply I decided to buy it (even though this was the book where a number of the cases Dr. Persaud recounted were plagiarized from other people’s work).

One of the more interesting case studies in the book concerned a 1998 case study published by Dr. R.S. Shiwach and Dr. J. Prosser in the Journal of Sex and Marital Therapy. The paper concerned the treatment of an “unusual case of masochism (where the individual gained sexual arousal and pleasure from being burnt (i.e., pyrophilia) and crushed (i.e., ‘crush fetishism’) that often meant he was in dangerous and potentially life threatening situations. As the authors summarized:

“Masochistic sexual activity is potentially dangerous, rarely reported voluntarily, and hard to treat. [Our paper] describes a masochist patient who received sexual gratification from being burnt or crushed. Anti-androgen medication [leuprolide acetate], serotonin uptake inhibitor [fluoxetine], and psychodynamic psychotherapy along with sexual education and social-skills training and aversive behavior therapy [covert sensitization and olfactory aversion] were all tried over a period of 9 months. The response was measured by effects of treatments on the frequency of erotic fantasies and masturbation”.

The male masochist was a single 38-year-old man that turned up at a hospital burns unit for treatment to extensive burns on his lower body (around 20% of his total body area) before being referred to the psychiatric unit. His pyrophilic urges and interest in being crushed were long-standing and dated back to mid-adolescence. The incident that led to the hospital admission had involved one of the man’s regular ways of gaining sexual arousal which was to set fire to refuse collecting trucks (i.e., ‘dumpsters’) while he was inside of them and simultaneously masturbating. Dr. Persaud’s reported that:

‘[The man] would then masturbate before getting out [of the dumpster]. His burns had occurred when a plastic dumpster melted and turned over. His first sexual experience at age 15 [years] had occurred when he curled himself up in an oven and ejaculated – an adventure that had been prompted by having been threatened as a child with being roasted ‘like a pig’ as a punishment. A social isolate, he enjoyed watching videos and reading about people being burned at the stake or crushed. He had also attempted autoerotic asphyxia, but relinquished this as ‘too dangerous’”.

The recollection of ejaculating while inside an oven appears to be a critical event in the acquisition and development of the man’s unusual sexual preferences. As Dr. Persaud noted:

“[The man remembered] entering a big unlit oven out of curiosity and liking the warmth and sense of suffocation but did not realize he had ejaculated until the third such instance. He remained a socially isolated virgin and gave a history of sexual disinterest in males or females and of ignorance of sexuality in general…Twice he came close to self-immolation after pouring gasoline on himself…he denied getting any pleasure out of seeing other people suffer…he worked in places where he could have easy access to large waste disposers, ovens, and box compactors”.

Consequently, Dr. Persaud thought (as I do) that learning theory best explained this man’s etiology and that psychoanalytic factors like guilt and punishment may have also been important. This particular case was also reported in a 2006 paper by Dr. D.J. Williams (i.e., ‘Different [painful) strokes for different folks) in the journal Sexual Addiction and Compulsivity. Williams noted that the man had been arrested on a number of different occasions for climbing into refuse collecting dumpsters and had also broken his pelvis as a consequence of being crushed by a box compactor. Williams noted that: “clearly, most experts would agree that acting out fantasies in these dangerous situations posed a significant risk of severe physical harm and death, not to mention being illegal”. Dr. Persaud’s account also more specifically reported that:

‘[The man] would climb into refuse collecting trucks and ejaculate at the sensation of being crushed, only escaping at the last possible minute. He admitted masturbating almost daily to deviant sexual fantasies or to pictures of fire, people being burned or crushed, and even just the sight of chimneys. Recently he had been climbing into a large dumpster, pouring alcohol on the refuse and setting it on fire. He managed to masturbate and get out of the refuse bin with minor burns twice, but the plastic dumpster eventually melted and overturned, causing the injuries he now had”.

Despite the many different pharmacological and psychological interventions, none appeared to have any long-lasting effect. The first intervention was pharmacological and involved being injected weekly with an anti-androgen. This treatment resulted in a decrease of his fetishistic sexual fantasies and an overall decrease in his sex drive. However, the man didn’t like the fact that his sex drive has been significantly inhibited and asked to be taken off the medication. He also took anti-depressants over an 18-week period and then had aversive behaviour therapy (olfaction aversion) and psychodynamic therapy, social skills training, and sexual education. He was discharged after 34 weeks of treatment but on follow-up had resumed his fetishistic behaviour. Drs. Shewach and Prosser concluded that: Anti-androgens and aversive behavior therapies may be the most effective treatments for such cases, at least in the short-term, although the underlying social deficits and the need to reshape the sexual behavior ought to be addressed in the long-term”.

One of the observations that Dr. Persaud made about this case was that the masochism in this case did not involve psychological humiliation or any interaction with other people in the man’s life. I would also add that most of the focus and commentary in this particular case has been on the pyrophilic aspects rather than the crush fetishism aspects. This may be because there has been far less in the medical and clinical literature on crush fetishism than pyrophilia. However, this is not the only case where crush fetishism has been associated with another sexual paraphilia. At the end of last year, my case study of eproctophilia (i.e., sexual arousal from flatulence) in the Archives of Sexual Behavior involved an eproctophile that was also a crush fetishist.

Dr Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK 

Further reading

Balachandra, K. & Swaminath, S. (2002). Fire fetishism in a female Aasonist? Canadian Journal of Psychiatry, 47, 487-488.

Bourget, D. & Bradford, J.M.W (1987). Fire fetishism, diagnostic and clinical implications: A review of two cases. Canadian Journal of Psychiatry 32, 459-462.

Griffiths, M.D. (2013). Eproctophilia in a young adult male: A case study. Archives of Sexual Behavior, 42, 1383-1386.

Litman, L.C.  (1999). A case of pyrophilia. Canadian Psychological Association Bulletin, February, 18-20.

Persaud. R. (2003). From The Edge Of The Couch. London: Bantam Press.

Quinsey, V.L., Chaplin, T.C. & Upfold, D. (1989). Arsonists and sexual arousal to fire setting: Correlation unsupported, Canadian Journal of Behavior Therapy and Experimental Psychiatry, 20, 203-209.

Shiwach, R. S., & Prosser, J. (1998). Treatment of an unusual case of masochism. Journal of Sex and Marital Therapy, 24, 303-307.

Williams, D. J. (2006). Different (painful) strokes for different folks: A general overview of sexual sadomasochism (SM) and its diversity. Sexual Addiction and Compulsivity, 13, 333-346.

Carry on screening: A brief look at Internet Gaming Disorder

In this month’s issue of the Neuropsychiatry journal, I – and my research colleagues (Dr. Daniel King and Dr. Zsolt Demetrovics) – published a paper arguing that Internet Gaming Disorder needs a unified approach to assessment. Over the last 15 years, research into various online addictions has greatly increased. Prior to the publication of the fifth edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-5) in 2013, there had been some debate as to whether ‘internet addiction’ should be introduced into the text as a separate disorder. Alongside this, there has also been debate as to whether those researching in the online addiction field should be researching generalized internet use and/or the potentially addictive activities that can be engaged on the internet (e.g., gambling, video gaming, sex, shopping, etc.)

Following these debates, the Substance Use Disorder Work Group (SUDWG) recommended that the DSM-5 include a sub-type of problematic internet use (i.e., internet gaming disorder [IGD]) in Section 3 (‘Emerging Measures and Models’) as an area that needed future research before being included in future editions of the DSM. According to Dr. Nancy Petry and Dr. Charles O’Brien writing in a 2013 issue of Addiction, IGD will not be included as a separate mental disorder until the (i) defining features of IGD have been identified, (ii) reliability and validity of specific IGD criteria have been obtained cross-culturally, (iii) prevalence rates have been determined in representative epidemiological samples across the world, and (iv) etiology and associated biological features have been evaluated.

Although there is now a rapidly growing literature on pathological video gaming, one of the key reasons that IGD was not included in the main text of the DSM-5 was that the SUDWG concluded that no standard diagnostic criteria were used to assess gaming addiction across these many studies. A 2013 overview of instruments assessing problematic gaming by my colleagues and I in Clinical Psychology Review reported that 18 different screening instruments had been developed, and that these had been used in 63 quantitative studies comprising 58,415 participants. This comprehensive review identified both strengths and weaknesses of these instruments.

The main strengths of the instrumentation included the: (i) the brevity and ease of scoring, (ii) excellent psychometric properties such as convergent validity and internal consistency, and (iii) robust data that will aid the development of standardized norms for adolescent populations. However, the main weaknesses identified in the instrumentation included: (i) core addiction indicators being inconsistent across studies, (iii) a general lack of any temporal dimension, (iii) inconsistent cut-off scores relating to clinical status, (iv) poor and/or inadequate inter-rater reliability and predictive validity, and (v) inconsistent and/or dimensionality. It has also been noted by a number of authors that the criteria for IGD assessment tools are theoretically based on a variety of different potentially problematic activities including substance use disorders, pathological gambling, and/or other behavioral addiction criteria. There are also issues surrounding the settings in which diagnostic screens are used as those used in clinical practice settings may require a different emphasis that those used in epidemiological, experimental and neurobiological research settings.

Video gaming that is problematic, pathological and/or addictive (i.e., IGD) lacks a widely accepted definition. In a recent book chapter (in the 2014 book Behavioral Addictions: Criteria, Evidence and Treatment edited by Dr. Ken Rosenberg and Dr. Laura Feder), I and some of my Hungarian colleagues argued that some researchers consider video games as the starting point for examining the characteristics of this specific disorder, while others consider the internet as the main platform that unites different addictive internet activities, including online games. Recent studies have made an effort to integrate both approaches Consequently, IGD can either be viewed as a specific type of video game addiction, or as a variant of internet addiction, or as an independent diagnosis.

As I argued in one of my previous blogs, although all addictions have particular and idiosyncratic characteristics, they share more commonalities than differences (i.e., salience, mood modification, tolerance, withdrawal symptoms, conflict, and relapse), and this likely reflects a common etiology of addictive behavior. Consequently, online game addiction may be viewed as a specific type of video game addiction. Similarly, Dr. G. Porter and colleagues in a 2010 issue of the Australian and New Zealand Journal of Psychiatry, do not differentiate between problematic video game use and problematic online game use. They conceptualized problematic video game use as excessive use of one or more video games resulting in a preoccupation with and a loss of control over playing video games, and various negative psychosocial and/or physical consequences. However, unlike my conceptualization of gaming addiction, their criteria for problematic video game use does not include other features usually associated with dependence or addiction, (e.g., tolerance, physical symptoms of withdrawal), as they say there is no clear evidence that problematic gaming is associated with such phenomena. Researchers such as Dr. Kimberley Young view online gaming addiction as a sub-type of internet addiction and that the internet itself provides situation-specific characteristics that facilitate gaming becoming problematic and/or addictive.

In a 2010 issue of Computers in Human Behavior, Dr. M.G. Kim and Dr. J. Kim’s [11] proposed a Problematic Online Game Use (POGU) model that takes a more integrative approach and claims that neither of the approaches outlined above adequately capture the unique features of online games such as Massively Multiplayer Online Role Playing Games (MMORPGs). They argue that the internet is just one channel where people may access the content they want (e.g., gambling, shopping, sex, etc.) and that such users may become addicted to the particular content rather than the channel itself. This is analogous to the argument that I made over 15 years ago in a number of different papers that there is a fundamental difference between addiction to the internet, and addictions on the internet. However, MMORPGs differ from traditional stand-alone video games as there are social and/or role-playing dimension that allow interaction with other gamers.

The POGU model resulted in five underlying dimensions of addictive gameplay (i.e., euphoria, health problems, conflict, failure of self-control, and preference of virtual relationship). I also support the integrative approach and stress the need to include all types of online games in addiction models in order to make comparisons between genres and gamer populations possible (such as those who play online Real-Time Strategy (RTS) games and online First Person Shooter (FPS) games in addition to the widely researched MMORPG players). The POGU model comprises six dimensions (i.e., preoccupation, overuse, immersion, social isolation, interpersonal conflicts, and withdrawal).

Irrespective of approach or model, the components and dimensions that comprise online gaming addiction outlined above are very similar to the IGD criteria in Section 3 of the DSM-5. For instance, my six addiction components directly map onto the nine proposed criteria for IGD (of which five or more need to be endorsed and resulting in clinically significant impairment). More specifically: (1) preoccupation with internet games [salience]; (2) withdrawal symptoms when internet gaming is taken away [withdrawal]; (3) the need to spend increasing amounts of time engaged in internet gaming [tolerance], (4) unsuccessful attempts to control participation in internet gaming [relapse/loss of control]; (5) loss of interest in hobbies and entertainment as a result of, and with the exception of, internet gaming [conflict]; (6) continued excessive use of internet games despite knowledge of psychosocial problems [conflict]; (7) deception of family members, therapists, or others regarding the amount of internet gaming [conflict]; (8) use of the internet gaming to escape or relieve a negative mood [mood modification];  and (9) loss of a significant relationship, job, or educational or career opportunity because of participation in internet games [conflict].

The fact that IGD was included in Section 3 of the DSM-5 appears to have been well received by researchers and clinicians in the gaming addiction field (and by those individuals that have sought treatment for such disorders and had their experiences psychiatrically validated and feel less stigmatized). However, for IGD to be included in the section on ‘Substance-Related and Addictive Disorders’ along with ‘Gambling Disorder’, the gaming addiction field must unite and start using the same assessment measures so that comparisons can be made across different demographic groups and different cultures.

For epidemiological purposes, Dr. B. Koronczai and colleagues in a 2011 issue of Cyberpsychology, Behavior and Social Networking, asserted that the most appropriate measures in assessing problematic online use (including internet gaming) should meet six requirements. Such an instrument should have: (i) brevity (to make surveys as short as possible and help overcome question fatigue); (ii) comprehensiveness (to examine all core aspects of IGD as possible); (iii) reliability and validity across age groups (e.g., adolescents vs. adults); (iv) reliability and validity across data collection methods (e.g., online, face-to-face interview, paper-and-pencil); (v) cross-cultural reliability and validity; and (vi) clinical validation. It was also noted that an ideal assessment instrument should serve as the basis for defining adequate cut-off scores in terms of both specificity and sensitivity. To fulfill all these requirements, future research should adjust the currently used assessment tools to the newly accepted DSM-5 criteria and take much more efforts to reach and study clinical samples, which is an unequivocal shortcoming of both internet and gaming research.

In addition to further epidemiological and clinical research, further research is also needed on the neurobiology of IGD. A systematic review of 18 neuroimaging studies examining internet addiction and IGD by Dr. Daria Kuss and Griffiths in a 2012 issue of Brain Sciences noted that:

“These studies provide compelling evidence for the similarities between different types of addictions, notably substance-related addictions and Internet and gaming addiction, on a variety of levels. On the molecular level, Internet addiction is characterized by an overall reward deficiency that entails decreased dopaminergic activity. On the level of neural circuitry, Internet and gaming addiction lead to neuroadaptation and structural changes that occur as a consequence of prolonged increased activity in brain areas associated with addiction. On a behavioral level, Internet and gaming addicts appear to be constricted with regards to their cognitive functioning in various domains” (p.347).

The good news is that research in the gaming addiction field does appear to be reaching an emerging consensus. We noted in our 2013 Clinical Psychology Review paper that across many different studies, IGD is commonly defined by (a) withdrawal, (b) loss of control, and (c) conflict. However, it is critical that a unified approach to assessment of IGD is urgently needed as this is the only way that there will be a strong empirical basis for IGD to be included in the next DSM.

Dr Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Further reading

American Psychiatric Association (2013) Diagnostic and Statistical Manual of Mental Disorders – Text Revision (Fifth Edition). Washington, D.C.: Author.

Demetrovics, Z., Urbán, R., Nagygyörgy, K., Farkas, J., Griffiths, M. D., Pápay, O., . . . Oláh, A. (2012). The development of the Problematic Online Gaming Questionnaire (POGQ). PLoS ONE, 7(5), e36417.

Griffiths, M.D. (2000). Internet addiction – Time to be taken seriously? Addiction Research, 8, 413-418.

Griffiths, M. D. (2005). A ‘components’ model of addiction within a biopsychosocial framework. Journal of Substance Use, 10(4), 191-197.

Griffiths, M.D., King, D.L. & Demetrovics, Z. (2014). DSM-5 Internet Gaming Disorder needs a unified approach to assessment. Neuropsychiatry, under review.

Griffiths, M.D., Kuss, D.J. & King, D.L. (2012). Video game addiction: Past, present and future. Current Psychiatry Reviews, 8, 308-318.

Kim, M. G., & Kim, J. (2010). Cross-validation of reliability, convergent and discriminant validity for the problematic online game use scale. Computers in Human Behavior, 26(3), 389-398.

King, D. L., Delfabbro, P. H., Griffiths, M. D., & Gradisar, M. (2011). Assessing clinical trials of Internet addiction treatment: A systematic review and CONSORT evaluation. Clinical Psychology Review, 31, 1110-1116.

King, D. L., Delfabbro, P. H., & Griffiths, M. D. (2012). Cognitive-behavioral approaches to outpatient treatment of Internet addiction in children and adolescents. Journal of Clinical Psychology, 68, 1185-1195.

King, D.L., Haagsma, M.C.,Delfabbro, P.H.,Gradisar, M.S., Griffiths, M.D. (2013). Toward a consensus definition of pathological video-gaming: A systematic review of psychometric assessment tools. Clinical Psychology Review, 33, 331-342.

Koronczai, B., Urban, R., Kokonyei, G., Paksi, B., Papp, K., Kun, B., . . . Demetrovics, Z. (2011). Confirmation of the three-factor model of problematic internet use on off-line adolescent and adult samples. Cyberpsychology, Behavior and Social Networking, 14, 657–664.

Kuss, D.J. & Griffiths, M.D. (2012). Internet and gaming addiction: A systematic literature review of neuroimaging studies. Brain Sciences, 2, 347-374.

Kuss, D.J., Griffiths, M.D., Karila, L. & Billieux, J. (2013).  Internet addiction: A systematic review of epidemiological research for the last decade. Current Pharmaceutical Design, in press.

Pápay, O., Nagygyörgy, K., Griffiths, M.D. & Demetrovics, Z. (2014). Problematic online gaming. In K. Rosenberg & L. Feder (Eds.), Behavioral Addictions: Criteria, Evidence and Treatment. New York: Elsevier.

Petry, N.M., & O’Brien, C.P. (2013). Internet gaming disorder and the DSM-5. Addiction, 108, 1186–1187.

Porter, G., Starcevic, V., Berle, D., & Fenech, P. (2010). Recognizing problem video game use. The Australian and New Zealand Journal of Psychiatry, 44, 120-128.

Young, K. S. (1998). Internet addiction: The emergence of a new clinical disorder. Cyberpsychology and Behavior, 1, 237-244.

Self-expression of interest: A brief look at extreme body modification

One of the more noticeable ‘extreme’ trends is that of body modification. Arguably the most common (and socially acceptable) forms of body modification are ear piercing and tattoos, followed by various other types of piercings (e.g., nipple piercings) and various types of plastic surgery (e.g., rhinoplasty [nose jobs] and breast augmentation [boob jobs]). More extreme types include foot binding, extreme corseting, branding, amputation, and genital cutting. Such types of actions are known as ‘acquired characteristics’ as they cannot be genetically passed on to the individuals’ children. As the body modification section of the Wikipedia entry on acquired characteristics notes:

“Body modification is the deliberate altering of the human body for any non-medical reason, such as aesthetics, sexual enhancement, a rite of passage, religious reasons, to display group membership or affiliation, to create body art, shock value, or self-expression. The frequency of occurrence depends on the location, extent, and number of modifications, and, perhaps most importantly, on the mind of each individual being asked to accept the modifications on another”.

In a recent issue of the Archives of Sexual Behavior, Dr. David Veale and Dr. Joe Daniels added that:

“Body modification is a term used to describe the deliberate altering of the human body for non-medical reasons (e.g., self-expression). It is invariably done either by the individual concerned or by a lay practitioner, usually because the individual cannot afford the fee or because it would transgress the ethical boundaries of a cosmetic surgeon. It appears to be a lifestyle choice and, in some instances, is part of a subculture of sadomasochism. It has existed in many different forms across different cultures and age”.

These definitions of body modification would also appear to include such practices as circumcision (although this may of course be done for legitimate medical reasons as well as cultural and/or religious rites of passage). Other ‘extreme’ forms of body modification include:

  • Earlobe stretching: This refers to the gradual stretching of the earlobe through the gradual increase in size of piercing rings. This is typically carried out for aesthetic reasons, self-expression and/or group membership.
  • Branding: This refers to the deliberate burning of the skin to produce an irreversible symbol, sign, ornament and/or pattern on human skin. This is typically carried out for group membership reasons (but can also be carried out for aesthetics and/or self-expression).
  • Subdermal Implants (pocketing): This refers to a type of body jewelry placed underneath the skin and often used in conjunction with other forms of body modification. The body then ‘heals’ over the implant leading to a raised (sometimes 3-D) design. This is almost always done for aesthetic reasons and/or shock value.
  • Extraocular implants: This refers to the placing of small pieces of jewelry in the eye by cutting the surface layer of the eye following a surgical incision. Again, this is almost always done for aesthetic reasons and/or shock value.
  • Corneal tattooing: This is the practice of injecting a colour pigment into the eye. As with the previous two examples, this is almost always done for aesthetic reasons and/or shock value.
  • Tongue splitting: This refers to the splitting of the tongue so that the tongue looks like (for instance) a serpent’s tongue.
  • Tooth filing: This refers to the practice of filing teeth (often into the shape of sharp pointed fangs). This may be done for a variety of reasons including group membership, aesthetics and/or self-expression.
  • Tightlacing (waist training, corset training): This refers to the use of incredibly tight fitting corsets (typically by women) to produce an archetypal ‘hourglass’ figure. This is typically carried out for aesthetic reasons.
  • Pearling (genital beading): This refers to the permanent insertion of small beads beneath the skin of the genitals (such as the labia in women or the foreskin in men). Most of those who engage in pearling do it for aesthetic and/or sexual enhancement reasons (e.g., to increase sexual stimulation during vaginal or anal intercourse).
  • Anal stretching: This refers to the gradual stretching of the anus with the use of specialized built for purpose ‘butt plugs’ (typically carried out for sexual enhancement and stimulation).
  • Penis splitting (penile bisection): This is the cutting and splitting of a person’s penis from the glans towards the penis base (and which I covered at length – no pun intended – in a previous blog). This is typically done for reasons of sexual stimulation and fetishistic enhancement for either the self and/or sexual partner (although it has also been done for both religious and/or aesthetic reasons).

A really great 2007 review paper by Dr. Silke Wohlrab and colleagues in the journal Body Image examined all the known motivations for body modification (including tattoos and piercings) based on scientific studies and concluded almost all motivations fell into one or more of the following ten categories:

  • Beauty, art, and fashion (i.e., body modification as a way of embellishing the body, achieving a fashion accessory and/or as a work of art).
  • Individuality (i.e., body modification as a way of being special and distinctive, and creating and maintaining self-identity).
  • Personal narratives (i.e., body modification as a form of personal catharsis, and/or self-expression. For instance, it was claimed that some abused women “create a new understanding of the injured part of the body and reclaim possession through the deliberate, painful procedure of body modification and the permanent marking”).
  • Physical endurance (i.e., body modification as a way of testing a person’s own threshold for pain endurance, overcoming personal limits, etc.).
  • Group affiliations and commitment (i.e., body modification as part of sub-cultural membership or the belonging to a certain social circle).
  • Resistance (body modification as a protest against parents or society).
  • Spirituality and cultural tradition (i.e., body modification as part of a spiritual or cultural movement).
  • Addiction (i.e., body modification as a physical and/or psychological addiction due to (i) the release of endorphins associated with the pain of undergoing the practice, and/or (ii) the association with memories, experiences, values or spirituality).
  • Sexual motivations (i.e., body modification as a way of enhancing sexual stimulation).
  • No specific reason (i.e., body modification as an impulsive act without forethought or planning).

The review paper was incredibly thorough and these ten motivations cover everything they came across in the academic study of body modification. Unsurprisingly, the most frequently mentioned motivation was the expression of individuality and the embellishment of the own body. Hopefully I’ll cover some of the more specific body modifications in future blogs.

Dr Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Further reading

Aggrawal A. (2009). Forensic and Medico-legal Aspects of Sexual Crimes and Unusual Sexual Practices. Boca Raton: CRC Press.

Lemma, A. (2010). Under the skin: A psychoanalytic study of body modification. London: Routledge.

Love, B. (2001). Encyclopedia of Unusual Sex Practices. London: Greenwich Editions.

Rowanchilde, R. (1996). Male genital modification. Human Nature, 7, 189-215.

Veale, D. & Daniels, J. (2012). Cosmetic clitoridectomy in a 33-year-old woman. Archives of Sex Behavior, 41, 725-730.

Wikipedia (2012). Acquired characteristic. Located at:

Wikipedia (2012). Body modification. Located at:

Wikipedia (2012). Penile subincision. Located at:

Wohlrab, S., Stahl, J., & Kappeler, P. M. (2007). Modifying the body: Motivations for getting tattooed and pierced. Body image, 4, 87-95.

Fake’s progress: A beginner’s guide to Münchausen syndrome

One of the most interesting psychological disorders is Münchausen Syndrome (MS) and is sometimes referred to more colloquially as ‘hospital addiction syndrome’, ‘hospital hopper syndrome’ and ‘thick chart syndrome’. MS is currently classified in the most recent International Classification of Diseases under ‘other disorders of adult personality’. The primary characteristic of people suffering from MS is that they deliberately pretend to be ill in the absence of external incentives (such as criminal prosecution or financial gain). MS has been called a factitious disorder because sufferers feign illness, pretend to have a disease, and/or fake psychological trauma typically to gain attention and/or sympathy from other people. Doctors often nickname such people as ‘frequent flyers’. The name of the syndrome was coined in 1951 by Dr. Richard Asher (in a paper he published in The Lancet about people who fabricated illnesses) and derives from German Karl Friedrich Hieronymus Freiherr von Münchhausen (aka Baron Münchausen), a renowned eighteenth century nobleman, who was reported as telling many fantastical and impossible stories about himself.

A related condition is Münchausen Syndrome by Proxy refers to the abuse of someone else (quite often a child son or daughter), also as a way of seeking attention and/or sympathy for the sufferer. Some members of the medical community believe that this related MS condition should simply be re-named ‘medical abuse’). There are also some specific sub-types of MS. For instance, a 2011 paper in the Journal of Electrocardiology, by Dr. Joseph Vaglio reported a female case of Arrhythmogenic Münchausen Syndrome who intentionally simulated and stimulated irregular cardiac activity to gain medical attention by drinking (and overdosing) on caffeine.

According to Dr. A.J. Giannini and Dr. H.R. Black in the Psychiatric, Psychogenic and Somatopsychic Disorders Handbook, one of the most common signs among MS sufferers is that they may have multiple scars on their abdomen because of repeated exploratory or emergency operations. Other ‘warning signs’ listed on the Web MD website of MS include: (i) dramatic but inconsistent medical history, (ii) predictable relapses following improvement in the condition, (iii) detailed knowledge of hospitals and/or medical terminology, (iv) appearance of new or additional symptoms following negative test results, (v) willingness or eagerness to have medical procedures, (vi) history of seeking treatment at numerous hospitals, clinics, and doctors offices, possibly even in different cities, and (vii) problems with identity and self-esteem.

There has been a debate about whether MS should have been re-classified in the fifth edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders. For instance, in a 2008 issue of the journal Psychosomatics, Dr. Lois Krahn and her colleagues argued that MS should be classed as a somatoform disorder because MS sufferers may not be conscious that they are drawing attention to themselves. [According to Wikipedia, a somatoform disorder “is a mental disorder characterized by symptoms that suggest physical illness or injury – symptoms that cannot be explained fully by a general medical condition or by the direct effect of a substance, and are not attributable to another mental disorder”]. More specifically, Krahn and her colleagues noted:

Factitious and somatoform-disorder patients are alike in that they both organize their lives around seeking medical services in spite of having primarily a psychiatric condition. In DSM–IV, the key difference is that factitious-disorder patients feign illness, and somatoform disorder patients actually believe they are ill. Although patients may not be conscious of their motivation or even their behaviors, deliberately embellishing history or inducing symptoms exemplifies behaviors designed to enhance a self-concept of being ill. For DSM–V, we propose reclassifying factitious disorder as a subtype within the somatoform-spectrum disorders or the proposed physical-symptom disorder, premised on our belief that deliberate deceptions serve primarily to portray to treaters the sense of being ill”.

This appears to be part of the same debate that says MS is distinct from hypochondriasis in that MS patients are said to be aware that they are exaggerating their illness or disease, whereas hypochondriasis sufferers actually believe they have an illness or disease. Another way of looking at it is that MS sufferers want to be a patient whereas those with hypochondriasis don’t. One of the more unusual consequences of MS is that the affected individual will often undergo unnecessary medical procedures, treatments and/or exploratory operations to prolong hospital stay and gain sympathy and attention from those around them including the medical and nursing staff. It is also known that some MS patients have very good medical knowledge and use this as a way of creating and/or producing symptoms of known medical conditions.

Some of the reported risk factors for individuals that develop MS include (i) a history of childhood traumas and (ii) emotional deprivation (e.g., having parents or guardians that were emotionally unavailable due to illness and/or emotional problems while the individual was a child). In relation to treatment and prognosis, the Wikipedia entry on MS asserts:

“Providers need to acknowledge that there is uncertainty in treating suspected Münchausen patients so that real diseases are not under-treated. Then they should take a careful patient history and seek medical records, to look for early deprivation, childhood abuse, or mental illness. If a patient is at risk to himself or herself, inpatient psychiatric hospitalization should be initiated…Therapeutic and medical treatment should center on the underlying psychiatric disorder: a mood disorder, an anxiety disorder, or borderline personality disorder. The patient’s prognosis depends upon the category under which the underlying disorder falls; depression and anxiety, for example, generally respond well to medication and/or cognitive-behavioral therapy, whereas borderline personality disorder, like all personality disorders is presumed to be pervasive and more stable over time, thus offers the worst or best prognosis”.

Unfortunately there are no reliable statistics regarding the number of people who suffer from MS. Research suggests that both males and females are affected in roughly equal numbers and that the mean age of presentation is 36-years old. This is certainly one behaviour that we could do with more empirical research.

Dr Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Further reading

Asher, R. (1951). Munchausen’s syndrome. The Lancet, 1, 339–341.

Bhugra D. (1988). Psychiatric Munchausen’s syndrome. Literature review with case reports. Acta Psychiatrica Scandinavica, 77, 497–503.

Feldman, M.D., Hamilton, J.C & Deemer, H.N. (2001). Factitious Disorder. In K.A. Phillips (Eds.), Somatoform and Factitious Disorders. Washington D.C.: American Psychiatric Association.

Giannini A.J. & HR Black, H.R. (1978). Psychiatric, Psychogenic and Somatopsychic Disorders Handbook (pp.194-195). New Hyde Park, NY. Medical Examination Publishing.

Krahn, L.E., Bostwick, J.M. & Stonnington, C.M. (2008). Looking toward DSM-V: Should factitious disorder become a subtype of somatoform disorder? Psychosomatics, 49, 277–282.

Vaglio, J. C., Schoenhard, J. A., Saavedra, P. J., Williams, S. R., & Raj, S. R. (2011). Arrhythmogenic Munchausen syndrome culminating in caffeine-induced ventricular tachycardia. Journal of Electrocardiology, 44, 229-231.

Wikipedia (2013). Münchausen syndrome. Located at:ünchausen_syndrome

Within you, without you: Where does addiction reside?

In 1984, Dr. Milton Burglass and Dr. Howard Shaffer published a paper in the journal Addictive Behaviors and claimed that arguably the important questions in the addiction field are ‘why do people become addicted to some things and not others?’ and ‘why some people become addicted and not others?’ Answers to these questions have been hindered by two common misconceptions about addiction, which to some extent have underpinned the ‘hard core’ disease concept of addiction. These are that addiction somehow resides within: (i) particular types of people or (ii) particular substances, and/or particular kinds of activity. That is, either some people are already ‘diseased,’ or else some substances/ activities cause this disease, or both.

There is a belief that some people are destined to become addicted. Typically this is explained in one (or both) of two ways. That some people (i.e., ‘addicts’) have an addictive personality, and that there is a genetic basis for addiction. The evidence for ‘addictive personality’ rests to a certain extent upon one’s faith in the validity of psychometric testing. Setting aside this major hurdle, the evidence in this area (as I argued with my colleagues Dr. Michael Larkin and Dr. Richard Wood in a 2006 issue of Addiction Research and Theory [ART]) is still inconclusive and contradictory.

First, psychologists have yet to determine which particular personality traits are linked to addiction. Studies have claimed that ‘the addictive personality’ may be characterized by a wide range of factors (e.g., sensation-seeking, novelty-seeking, extroversion, locus-of-control preferences, major traumatic life events, learned behaviours, etc.). The extent of this range stretches not only the notion of an ‘addictive personality’ but also the concept of ‘personality’ itself. Inevitably, much of this work relies on correlation analysis, and so the interpretation of results is not easily framed in terms of cause and effect. The approach is overly simplistic and is underpinned by a simple proposition that if we can divide people up into the right groups, then the explanation will emerge. However, addiction is far more complex than this. Of course, the relationship between individual bodies, minds, contexts, and life histories is complex and important – but it requires that we approach the matter from a more sophisticated and integrative position.

The search for a genetic basis for addiction rests upon the notion that some types of individuals are somehow ‘biologically wired’ to become addicts. In our 2006 ART paper, we argued that we must set aside any doubts about the limited conceptualization of ‘the environment’ that often typifies this kind of research, and its combination with epidemiological designs that are largely descriptive. Meta-analytic reviews have concluded that the heritability of addictive behaviour is likely to be controlled by many genes each contributing a small fraction of the overall risk. Furthermore, some of these same genes appear to be risk factors for other problems, some of them conceptually unrelated to addiction. We argued that the main point here is that while these findings do contribute something to our understanding of ‘why some people and not others,’ they do not adequately or independently explain the range of variation. Therefore the most we can say is that some people are more likely to develop problems under certain conditions, and that given the right conditions most people could probably develop an addiction. Emphasis needs to be placed on identifying those ‘conditions,’ rather than on searching for the narrowest of reductionist explanations.

We also argued in our 2006 ART paper that substances and activities cannot be described as intrinsically addictive in themselves (unless one chooses to define ‘addictive’ in terms of a substance or behaviour’s ability to produce tolerance and/or withdrawal, and to ignore the range of human experience that is excluded by this). Biologists may be able to tell us very valuable things about the psychopharmacological nature of the rewards that particular substances and behaviours provide, and the different kinds of neuroadaptation that they may or may not produce in order to effect tolerance and/or withdrawal. But we argue that this on its own, is not an adequate explanation for addiction. In 1975, Dr. Lee Robins’ classic study (in the Archives of General Psychiatry) of heroin-users returning from the Vietnam war is one example of the evidence that refutes this oversimplification. This study clearly highlighted the importance of context (i.e., that in a war zone environment individuals were addicted to heroin but on return to civilian life the addiction ceased to exist), and the framework provided by such contexts for making sense of addiction. In a hostile and threatening environment, opiates clearly provided something not usually required by most people; and given a cultural environment in which opiate use is a commonplace, and opiates are available, then opiate use ‘makes sense’. This study provides support for the assertion that some people are more likely to become addicted under some conditions, and that given the right conditions perhaps many people could understand what it means to be an addict.

So, with regard to the question, ‘why some individuals/addictions and not others?’ the rewards associated with various activities may be qualitatively very different, and may not necessarily be inherent or unique to a particular activity or substance, either. Many rewarding activities are rewarding because they present individuals with opportunities to ‘shift’ their own subjective experience of themselves (for example, see the research on Ecstasy use and bungee jumping that I published with Dr. Michael Larkin in a 2004 issue of the Journal of Community and Applied Social Psychology).

Frequently, a range of such opportunities is offered to the experienced user. Dr. Howard Shaffer (in a 1996 paper in the Journal of Gambling Studies) has pointed out that those activities that can be most relied upon to shift self-experience in a robust manner are likely to be the most popular – and (as a consequence) to be the most frequent basis of problems. So, obviously, our understanding of the available resources for mood modification must play a major part in understanding addiction. However, we must make a careful distinction between describing some substances as being more ‘robust shifters of experience’ than others (as we advocated in our 2006 ART paper) and describing some substances as ‘more addictive’ than others (which we argued against).

Dr Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Further reading

Burglass, M.E. & Shaffer, H.J. (1984). Diagnosis in the addictions I: Conceptual problems. Addictive Behaviors, 3, 19-34.

Griffiths, M.D.  (2005). A ‘components’ model of addiction within a biopsychosocial framework. Journal of Substance Use, 10, 191-197.

Griffiths, M.D. (2011). Behavioural addiction: The case for a biopsychosocial approach. Transgressive Culture, 1(1), 7-28.

Griffiths, M.D. & Larkin, M. (2004). Conceptualizing addiction: The case for a ‘complex systems’ account. Addiction Research and Theory, 12, 99-102.

Larkin, M., Wood, R.T.A. & Griffiths, M.D. (2006). Towards addiction as relationship. Addiction Research and Theory, 14, 207-215.

Orford, J. (2001). Excessive Appetites: A Psychological View of the Addictions (Second Edition). Chichester: Wiley.

Robins, L.N, Helzer, J.E, & Davis, D.H (1975) Narcotic use in Southeast Asia and afterward. Archives of General Psychiatry, 32, 955-961.

Shaffer, H. J. (1996). Understanding the means and objects of addiction: Technology, the Internet, and gambling. Journal of Gambling Studies, 12, 461–469.

Tyndale, R.F. (2003). Genetics of alcohol use and tobacco use in humans. Annals of Medicine, 35(2), 94–121.

Walters, G. D. (2002). The heritability of alcohol use and dependence: A meta-analysis of behavior genetic research. American Journal of Drug and Alcohol Abuse, 28, 557–584.

Stats entertainment (Part 2): A 2013 review of my personal blog

My last blog of 2013 was not written by me but was prepared by the stats helper. I thought a few of you might be interested in the kind of person that reads my blogs. I also wanted to wish all my readers a happy new year and thank you for taking the time to read my posts.

Here’s an excerpt:

The Louvre Museum has 8.5 million visitors per year. This blog was viewed about 860,000 times in 2013. If it were an exhibit at the Louvre Museum, it would take about 37 days for that many people to see it.

Click here to see the complete report.

My fiction ‘addiction’: The psychology of Hannibal Lecter

If I ever went on the BBC television show Mastermind, one of my potential specialist subjects would be the fictional serial killing psychiatrist Hannibal ‘The Cannibal’ Lecter (in print and on screen). I have devoured all four of Thomas Harris’ original books and all the DVDs (all five films and the TV series). In short, I am an obsessive Lecterite. While I was at university in the 1980s doing my undergraduate psychology degree, I was also the Entertainment Editor of the University of Bradford’s newspaper (Fleece). One of the perks of my part-time (unpaid) job was that I got to watch all the latest cinema releases for free and review them for Fleece. In 1986, one of the films that I watched (and loved) was Manhunter directed by Michael Mann. At the time, I didn’t realize that the film was based on Thomas Harris’ second book Red Dragon (first published in 1981 following his 1975 non-Lecter novel Black Sunday). However, I do remember the great (and understated) performance by Scottish actor Brian Cox playing the serial killing psychiatrist (spelled ‘Lecktor’ rather than Lecter in that particular film).

It was in 1991 that my real fascination with Lecter began after seeing The Silence of the Lambs directed by Jonathan Demme (and starring Anthony Hopkins as Lecter). I went to see it in the first week it was out as I was a big fan of Demme’s work particularly his musical documentary of Talking Heads in Stop Making Sense (1984), and films such as Melvin and Howard (1980), Swing Shift (1984), and Something Wild (1986). I came out of the cinema and within the space of a few weeks I had seen the film three times (and I was delighted when the film won all five of the main Oscar categories in 1992 – only the third film ever to have done so). At the time, I was a psychology lecturer at the University of Plymouth, and was teaching a weekly criminal psychology module to police inspectors on the university’s BA in Social and Organizational Studies. I was enthralled by the film’s use of behavioural profiling of criminals and the fact that the star of the film was a strange and bizarre paradox – a highly intelligent and highly cultured psychiatrist that also happened to be a serial killing cannibal.

It was at this point that I bought the two Thomas Harris novels that featured Lecter (i.e., Red Dragon and the 1988 sequel The Silence of the Lambs). I was gripped. Harris had clearly done his psychological and criminological research well (and I found the two books even better than the films). From then on I sought out anything Lecter-related and bought Harris’ further sequel (Hannibal, 1999) and prequel (Hannibal Rising, 2006), and watched and bought the big-budget Hollywood films Hannibal (2001, directed by Ridley Scott), Red Dragon (2002, directed by Brett Ratner) and Hannibal Rising (2007, directed by Peter Webber and starring Gaspard Ulliel as the young Hannibal), and most recently the US television series Hannibal (2013, starring Mads Mikkelsen as Lecter). My good friends also started buying me Lecter-related gifts (such as Daniel O’Brien’s excellent 2001 book The Hannibal Files).

So why am I – and millions of others worldwide – so fascinated, and – for want of a better word – ‘hooked’ on Hannibal the Cannibal’s fictional exploits? In 2005, the American Film Institute voted Hannibal Lecter the No.1 villain of all time (and who would argue against?). I suppose one of the scariest things about Lecter is that he’s the composite of real serial killers. People like Lecter actually exist and Harris clearly did his homework in writing his novels. In July 2013, Harris gave a rare interview and claimed that his inspiration for Lecter was a real-life Mexican murdering doctor (that he gave a pseudonym ‘Dr. Salazar’) and that he met in the 1960s while he was a newspaper crime reporter. Harris claimed that ‘Salazar’ had a “certain elegance”. It has also been noted that Harris attended the trial of Pietro Pacciani, a suspected serial killer nicknamed the ‘Monster of Florence’. The Wikipedia entry on Lecter claims that Pacciani’s serial killing modus operandi was used in his Hannibal novel. The Wikipedia entry also went on to say:

“According to David Sexton, author of The Strange World of Thomas Harris: Inside the Mind of the Creator of Hannibal Lecter, Harris once told a librarian in Cleveland, Mississippi, that Lecter was inspired by William Coyne, a local murderer who had escaped from prison in 1934 and gone on a rampage that included acts of murder and cannibalism. In her book Evil Serial Killers, Charlotte Greig asserts that the serial killer Albert Fish was the inspiration, at least in part, for Lecter. Greig also states that to explain Lecter’s pathology, Harris borrowed the story of serial killer and cannibal Andrei Chikatilo’s brother Stepan being kidnapped and eaten by starving neighbours (though she states that it is unclear whether the story was true or whether Stepan Chikatilo even existed)”.

I was surprised to find that there are dozens of academic papers written from many perspectives including psychology, psychiatry, criminology, media/film studies, and literary criticism (and I may well come back and write further blogs on Lecter using some of these). However, the rest of today’s blog concentrates on a really interesting trilogy of papers about Lecter written by Professor James Oleson in the Journal of Criminal Justice and Popular Culture (during 2005-2006). Oleson did a thorough review of various academic literatures and noted (in his 2005 paper) the following in relation to (i) the appeal of serial killers, and (ii) the appeal of Lecter more specifically:

“Apter (1992) suggests that serial killers transfix people because dangerous things – like serial killers – tend to create a state of invigorating psychological arousal. To neutralize the feelings of anxiety that accompany dangerous threats – like serial killers – we use protective frames such as narrative explanations or criminological theories. In explaining the serial killer’s behavior, we allow ourselves to succumb to the exciting magnetism of evil (Kloer, 2002) and can thereby ‘experience the excitement of arousal without being overwhelmed by anxiety’ (Ramsland, 2005)…Why do we love Lecter? Perhaps because he is the ‘perfect gothic hero’ (Dunant, 1999) or because he is the perfect gothic antihero (Dery, 1999). Perhaps it is because the heroic and the villainous co-exist within him. Because he is Obi Wan Kenobi and Darth Vader rolled into one (Hawker, 2001), because he is Darth Vader and Superman rolled into one (Cagle, 2002), or because he is Sherlock Holmes and Professor Moriarty rolled into one (Sexton, 2001)”.

Professor Oleson spends a lot of the first paper examining whether Lecter fits any of the serial killer typologies that various criminologists have formulated over the last three or four decades. According to Oleson, various researchers have identified two key precursors that have a high association with serial homicide – a pathological fantasy life and childhood trauma. Oleson argues that Lecter fits “this basic etiological model” because “he enjoys a rich and detailed fantasy life” and “he suffered serious childhood trauma”. Oleson also recounted the FBI’s research into ‘organized’ and ‘disorganized’ serial killers, and argued that there was evidence across all Harris’ books that Lecter displayed all 14 profile characteristics of an organized serial killer: (i) average to above-average intelligence, (ii) socially competent, (iii) skilled work preferred, (iv) sexually competent, (v) high birth order status, (vi) father’s work stable, (vii) inconsistent childhood discipline, (viii) controlled mood during crime, (ix) use of alcohol with crime, (x) precipitating situational stress, (xi) living with partner, (xii) mobility with car in good condition, (xiii) follows crime in news media, and (xiv) may change jobs or leave town.

Oleson also notes there are some models of serial killing that Lecter does not fit at all. For instance, the ‘addiction model’ of killing argues that some serial killers have a compulsion to kill and that they become addicted to killing (as put forward in the 1988 book Serial Killers by Dr. Joel Norris, and the 1996 book The Psychopathology of Serial Murder by Dr. Stephen Giannangelo). Another psychological model associated with serial killers is the concept of ‘sociopathy’ and ‘psychopathy’ (now termed ‘antisocial personality disorder’). Throughout Harris’ novels there are various references to Lecter being a sociopath and in the films he is described as being a psychopath (most notably by the psychiatrist Dr. Frederick Chilton, Director of the Baltimore State Hospital for the Criminally Insane, where Lecter was sent after being caught by his former profiling partner at the FBI (Will Graham). Oleson uses Dr. Robert Hare’s commonly used Psychopathy Checklist (first published in a 1980 issue of the journal Personality and Individual Differences) and convincingly shows that there is little evidence that Lecter is a psychopath.

Another model that Lecter does not fit is the “homicidal triad” of warning-sign behaviours (i.e., bed-wetting, animal cruelty, and fire starting) outlined in the many books of the FBI’s Dr. John Douglas and Mark Olshaker. This FBI research asserts that these three warning behaviours (particularly when they co-occur in adolescence) signal an elevated risk of subsequent serial homicide. However, Oleson shows that Lecter does not fit this profile at all. In his second (2006) paper, Oleson also assesses to what extent Lecter is insane. According to the M’Naughten test for insanity:

“It must be clearly proved that, at the time of committing the act, the party accused was laboring under such a defect of reason, from disease of the mind, as not to know the nature and quality of the act he was doing, or that [if] he did know it, that he did not know he was doing what was wrong (Finkel, 1988)”.

Oleson argues that Lecter “flunks the M’Naughten test on all counts”. In fact he goes on to say that:

“[Lecter] does not suffer from a defect of reason – if anything, as a genius with an infinitely rare IQ score, he may suffer from a superhuman perfection of the reason… Similarly, Lecter knows perfectly well the nature and quality of the crimes he commits, and he knows that they are denounced as wrong by society…The character of Hannibal Lecter would be deemed sane under more recently developed tests for insanity, as well. Lecter, in perfect command of his will, does not commit his crimes because he is compelled. Accordingly, he would not be insane under any formulation of the irresistible impulse test (Finkel, 1988). Nor would he be found insane under the American Law Institute test. ‘A person is not responsible for criminal conduct if at the time of such conduct as a result of mental disease or defect he lacks substantial capacity either to appreciate the criminality of his conduct or to conform his conduct to the requirements of law’ (Finkel, 1988). Lecter possesses both near-infallible cognitive ability and an iron will. He in no way fits the categories of insanity articulated under prevailing rules”.

Oleson’s papers also examine the idea that Lecter may be a non-human monster, a vampire, a superhuman, and/or the Devil. He also speculates that his crimes may be the product of his superhuman intellect (as Lecter’s IQ is so high that it cannot be assessed by any instruments that are currently used). As Oleson concludes in the second of his three papers:

“It has been suggested that the character of Hannibal Lecter is so memorable because he emerges from paradox…It could simply be the case, however, that Lecter is such a successful villain because we love monster stories…because we need monsters…and because the Lecter novels skillfully combine the police procedural with particularly resonant elements of the supernatural horror story”.

I (for one) love the paradox of Lecter’s personality and character. Both (super)man and monster. I admire some of his character traits but (of course) despise others. He is a highly flawed criminal genius and polymath. A serial killer and a cannibal. Victim and villain. In his third paper on Lecter, Oleson asserts something that I agree (and will leave you) with:

“By asking why Hannibal Lecter commits his crimes, criminologists may be able to use the Lecter novels and movies as a catalyst for the study of the etiology of serial homicide. The character of Hannibal Lecter is, after all, based on real life serial killers, and provides readers and viewers with an intimate (if hyperbolic) case study of an organized serial killer. Characters drawn from novels can serve as valuable heuristic devices…teaching us a great deal about the nature of crime and evil”.

Dr Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Further reading

American Film Institute. (2005). Heroes and villains. Located at:

Finkel, N. J. (1988). Insanity on Trial. New York: Plenum Press.

Hare, R.D. (1980). A research scale for the assessment of psychopathy in criminal populations. Personality and Individual Differences, 1, 111-119.

Hare, R.D. (1996). Psychopathy: A clinical construct whose time has come. Criminal Justice and Behavior, 23, 25-54.

Hare, R. D. (2003). Manual for the Revised Psychopathy Checklist (2nd ed.). Toronto, ON, Canada: Multi-Health Systems.

Hickey, E. W. (1991). Serial Murderers and Their Victims. Pacific Grove, CA: Brooks/Cole.

Oleson, J. C. (2003). The celebrity of infamy: A review essay of five autobiographies by three criminal geniuses. Crime, Law, and Social Change, 40, 409-16.

Oleson, J. C. (2005). King of killers: The criminological theories of Hannibal Lecter, part one. Journal of Criminal Justice and Popular Culture, 12, 186-210.

Oleson, J. C. (2006). Contemporary demonology: The criminological theories of Hannibal Lecter, part two. Journal of Criminal Justice and Popular Culture, 13, 29-49.

Oleson, J. C. (2006). The devil made me do it: the criminological theories of Hannibal Lecter, part three. Journal of Criminal Justice and Popular Culture, 13, 117-133.

Raine, A. (1993). The Psychopathology of Crime. New York: Academic Press.

Sexton, D. (2001). The Strange Mind of Thomas Harris. London: Faber and Faber.

Wikipedia (2013). Hannibal Lecter. Located at:

French connections: A beginner’s guide to Paris Syndrome

While researching a previous blog on Stendhal Syndrome, I came across various references to a number of “city syndromes”. According to an interesting book chapter by Nadia Halim, city syndromes are “acute, (usually) short-lived disorders that have in common a similar set of symptoms and pattern of onset and recovery”. Each of the city syndromes that have been identified in the psychological literature is associated with a specific tourist destination (e.g., Jerusalem, Paris, Florence) and identified by medical practitioners (usually psychiatrists) when sufferers access mental health services. In essence, the condition is a type of ‘culture shock’ where an individual becomes psychologically disorientated when they experience new environments that feel alien to them.

One such city syndromes is ‘Paris Syndrome’, a psychological condition that appears to affect Japanese tourists only, suggesting that it is some kind of culture bound syndrome. According to an article in the BBC News, Paris Syndrome was first identified in 1986 by Professor Hiroaki Ota (a Japanese psychiatrist who was working in France at the time). The condition is said to cause mental breakdown when visiting the city. The incidence of the disorder is very small as reports estimate that only 10-20 people a year suffer out of millions of tourists. However, the only ‘cure’ is for the affected individuals to return back to Japan.

As far as I am aware, there are only a couple of academic papers that have been published on Paris Syndrome. The first one was a case study published in a 1998 issue of the Journal of the Nissei Hospital by Dr. Katada Tamami. This was a report of a male manic-depressive who shortly after visiting Paris presented with symptoms of insomnia, fluctuation of mood, aggression, irritation and increase in sex drive. Tamami noted that being separated from his family, and living alone in Paris, the man had an identity crisis as in Paris he was no longer a father or professor. His fantasy and idealization of Paris played a large part in his abnormal behaviour.

The second paper was by a group of French psychiatrists in a 2004 issue in the French psychiatry journal Nervure. The authors reported that between 1988 and 2003, a total of 63 Japanese patients had been hospitalized because of the condition (with a slight bias towards females in their 30s). Although the number of affected patients was relatively low, the Japanese Embassy arranged for a Japanese psychiatrist to work in the authors’ hospital (i.e., St. Anne’s Hospital). In fact, the Japanese Embassy has a 24-hour telephone hotline for Japanese tourists suffering from severe culture shock. The paper claimed that for affected individuals, the city of Paris held a  “quasi-magical” attraction and that it was characteristically “symbolic of all the aspects of European culture that are admired in Japan”. A Wikipedia article on Paris Syndrome claims that: “the susceptibility of Japanese people may be linked to the popularity of Paris in Japanese culture”. The same article also noted that:

“Mario Renoux, the president of the Franco-Japanese Medical Association, states in Liberation’s article ‘Des Japonais entre mal du pays et mal de Paris” (December 13, 2004) that Japanese magazines are primarily responsible for creating this syndrome. Renoux indicates that Japanese media, magazines in particular, often depict Paris as a place where most people on the street look like fashion models and most women dress in high-fashion brands”.

The symptoms of Paris Syndrome are typically transient and include anxiety attacks, violent and aggressive outbursts, feelings of persecution, acute psychotic delusions (of paranoia, megalomania, erotomania and/or mysticism), dissociative and/or disoriented feelings, depersonalization, derealization, psychomotor abnormalities (e.g., dizziness, sweating, tachycardia), and – in some cases – thoughts of suicide. Interviews with the affected individuals revealed that the Japanese arrive in the city with highly romanticized expectations and that many had spent years dreaming of coming to Paris before doing it in actuality.

The authors of the paper published in Nervure identified two fundamentally different types of the syndrome based on previous psychiatric problems and when the symptoms occurred:

  • Type 1 [Classic]: These individuals typically have a problematic psychiatric history and may travel to Paris for idiosyncratic “strange” or delusional reasons. However, the onset of the symptoms is immediate upon arrival in Paris (and may even begin in the airport).
  • Type 2 [Delayed Expression]: These individuals do not usually have a personal and/or familial psychiatric history. The reasons for visiting Paris are typically for ‘normal’ travelling reasons but the onset of the symptoms is much later than the ‘classic’ type (i.e., three months or longer after arriving in Paris).

As an example of the first type of sufferer, the paper described the case of a 39-year-old Japanese woman with a history of schizophrenia that was hospitalized following a psychotic breakdown on her immediate arrival in Paris. She had come to Paris following an advertizing campaign that had the tagline: “France is waiting for you”. She took it to mean it was her personal destiny to go there and claimed she was going to become the queen of one of the Scandinavian countries (“Sweden, Finland or Denmark”). As an example of the second type of sufferer, the paper described the case of a 30-year-old Japanese man with no previous psychiatric history who came to France for educational reasons. The onset of the symptoms was five months after arriving in France and started when he moved into a Paris hotel (after initially studying in Reims). He was hospitalized after experiencing severe anxiety, insomnia, anorexia, and auditory hallucinations (i.e., voices threatening to kill him and his family).

One of the factors that appear to be common among sufferers is that they appear to be highly unprepared for the reality of day-to-day life in the city (e.g., the marked cultural differences, the great difference in language, the difference in public manners and behaviours, etc.). It is these differences that appear to act as a trigger for the onset of the behaviour. The most salient trigger for Paris Syndrome is thought to be the language barrier. Another factor appears to be intense exhaustion caused by trying to cram in as much as possible in the short time available for sightseeing alongside the effects of jetlag. Such factors are said to contribute to the psychological destabilization of some Japanese visitors. Another French physician (Youcef Mahmoudia) working at the hospital Hotel-Dieu de Paris claimed that Paris Syndrome was “a manifestation of psychopathology related to the voyage, rather than a syndrome of the traveller” and hypothesized that it was the excitement resulting from visiting Paris that caused the psychosomatic symptoms (e.g., increased heart rates, dizziness, etc.).

Dr Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Further reading

Angelique, C. (2006). Paris syndrome hits Japanese. The Guardian, October 25. Located:

Fastovsky N, Teitelbaum A, Zislin J, et al (2000). The Jerusalem syndrome. Psychiatric Services, 5, 1052.

Halim, N. (2009). Mad tourists: The “vectors” and meanings of city-syndromes. In K. White (Ed.), Configuring Madness. Oxford: Inter-Disciplinary Press.

Monden, C. (2005). Development of psychopathology in international tourists. In van Tilburg, M. & Vingerhoets, A. (Eds.), Psychological Aspects of Geographical Moves: Homesickness and Acculturation Stress (pp. 213-226). Amsterdam: Amsterdam Academic Archive.

Tamami, K. (1998). Reflexions on a case of Paris syndrome. Journal of the Nissei Hospital, 26, 127-132.

Viala, A., Ota, H., Vacheron, M.N., Martin, P., & Caroli, F. (2004). Les Japonais en voyage pathologique à Paris: Un modèle original de prise en charge transculturelle. Nervure (supplement), 17(5), 31-34.

Wikipedia (2012). Paris Syndrome. Located at:

Wyatt, C. (December 20, 2006). Paris Syndrome strikes Japanese. BBC News, December 20/ Located at:


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