Monthly Archives: January 2012
The stranglers’ greatest hit: A brief overview of autoerotic asphyxiation
Hypoxyphilia (more commonly known as ‘autoerotic asphyxiation’ and less commonly known as ‘asphyxophilia’) is a rare and potentially life threatening paraphilia where a person seeks to reduce supply of oxygen to the brain during a heightened state of sexual arousal. Restricting the oxygen flow causes a build of carbon dioxide. This increase in carbon dioxide brings about feelings of giddiness and pleasure which when accompanied by masturbation can heighten the sexual sensations. Typically, this is achieved by chain, leather belt, rope noose or plastic bag either alone or with a partner and often results in death. Deaths occur due to the loss of consciousness caused by partial asphyxia. High profile deaths (by hanging) have included the Australian INXS singer Michael Hutchence, the US actor David Carradine, and the English MP and television reporter Stephen Milligan.
Although asphyxia from hanging has been described most frequently, a review of autoerotic asphyxiate deaths by Dr Roger Byard (Adelaide Women and Children’s Hospital, Australia) concluded that a wide variety of other lethal situations have been reported. Other hypoxyphilia variants that have been reported include: the use of plastic bags, chemical substance, food, electrocution, water submersion, and power hydraulics, etc.
There is some disagreement as to how common such deaths are. The American Psychiatric Association estimates that one in a million deaths are caused this way. The American FBI estimates there to be a mortality rate of 1000 deaths per year in the States. In a review of the literature, Dr Jane Uva (Wright State University, USA) estimated the mortality rate as being anywhere between 250 and 1000 deaths per year in the United States. Most hypoxyphiliacs are male with one Canadian study published in the British Journal of Psychiatry reporting only one of 117 accidental hypoxyphilic deaths as involving a female. In general, hypoxyphiliacs are white middle-aged males, although there are cases in literature of women or men up to 87 years of age.
There is limited data available but the goal seems to be to increase orgasm intensity. This bears some relationship with those who use amyl nitrate (which reduces brain oxygenation). It has been said that this type of behaviour may be a dangerous variant or manifestation of sexual masochism with its ritualised bondage themes. The person often keeps diaries and may watch themselves in mirrors or video record themselves. A German study of 40 accidental autoerotic deaths published in the journal Forensic Science International, reported that the bodies of hypoxyphiliacs are typically discovered naked and/or with genitalia in hand. Pornographic and/or other paraphilic material and/or sex toys are often present. Furthermore, the individuals will have ejaculated shortly before their death. The literature also shows that hypoxyphilia has also been associated with other paraphilias including masochism, transvestitism, bondage, and fetishism.
In one of the few studies of hypoxyphiliacs that are still alive, Dr Stephen Hucker (University of Toronto, Canada) surveyed over 100 participants via the Internet. He reported that 71% engaged in various masochistic activities, and 31% also took sadistic roles. Furthermore, 66% reported using bondage, 44% used clamps on themselves, 14% used electrical stimulation, and 37% self-flagellated. With regards to the act itself, the highest level of arousal was reported to be to obstruction of breathing. However, loss of control and loss of consciousness were also important in increasing sexual arousal. The lowest sexual arousal ratings were for pain and humiliation.
Finally, a recent review – again written by Hucker – in relation to the new DSM-V paraphilia classification, he surveyed over 100 practitioners who have expertise in treating paraphilic activity. Hucker recommended that the term ‘hypoxyphilia’ should be abandoned in favour of the term ‘asphyiophilia’ as there is little empirical evidence to indicate that the effects of oxygen deprivation per se are the primary motive for the paraphiliiac’s behavior. He argued that the behaviour is sexual arousal to restriction of breathing.
Dr Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK
Further reading
Behrendt, N., Buhl, N. & Seidl, S. (2002). The lethal paraphilic syndrome: Accidental autoerotic deaths in four women and a review of the literature. International Journal of Legal Medicine, 116, 148-152
Blanchard, R. & Hucker, S.J. (1991). Age, transvestism, bondage, and concurrent paraphilic activities in 117 fatal cases of autoerotic asphyxia. British Journal of Psychiatry, 159, 371-377.
Bogliolo, L.R., Taff, M.L., Stephens, P.J., & Money, J. (1991). A case of autoerotic asphyxia associated with multiplex paraphilia. American Journal of Forensic Medicine and Pathology, 12, 64-73
Burgess, A.W. & Hazelwood, R.R. (1983). Autoerotic deaths and social network response. American Journal of Orthopsychiatry, 53, 166-170
Byard, R. (1994). Autoerotic death — characteristic features and diagnostic difficulties. Journal of Clinical Forensic Medicine, 1, 71-78.
Cooper, A. J. (1996). Auto-erotic asphyxiation: Three case reports. Journal of Sex and Marital Therapy, 22, 47–53.
Hucker, S.J. (2008). Sexual masochism: Psychopathology and theory. In Laws, D.R. & O’Donohue, W.T. (Eds.), Sexual Deviance: Theory, Assessment and Treatment. pp.25-263. New York: Guildford Press.
Hucker, S.J. (2011). Hypoxyphilia. Archives of Sexual Behavior, 40, 1323-1326.
Janssen, W., Koops, E., Anders, S., Kuhn, S. & Püschel, K. (2005). Forensic aspects of 40 accidental autoerotic death in Northern Germany. Forensic Science International, 147S, S61–S64.
Martz, D. (2003). “Behavioral treatment for a female engaging in autoerotic asphyxiation”. Clinical Case Studies, 2, 236–242.
Tough, S., Butt, J. & Sanders, G. (1994). Autoerotic sexual asphyxial deaths: Analysis of nineteen fatalities. Canadian Journal of Psychiatry, 39, 157-160.
Uva, J.L. (1995). Review: Autoerotic asphyxiation in the United States. Journal of Forensic Sciences, 40, 574–581.
Tanorexia: Can excessive tanning be an addiction?
Back in June 1997, I appeared as the obligatory “addiction expert” on the BBC television programme ‘Esther’ talking about people who said they were addicted to tanning (and was dubbed by the researchers on the programme as ‘tanorexia’ – a term that – at the time – I had not come across and is still considered slang even by academics researching in the area). I have to admit that none of the case studies on the programme appeared to be addicted to tanning (at least based on my own addiction criteria) but it did at least alert me to the fact that some people at least claimed to be addicted to tanning.
There certainly appeared to be some similarities between the people interviewed and nicotine addiction in the sense that the ‘tanorexics’ knew they were significantly increasing their chances of getting skin cancer as a direct result of their risky behaviour but felt they were unable to stop doing it (similar to nicotine addicts who know they are increasing the probability of various cancers but also feel unable to stop despite knowing the health risks).
Since my appearance on the programme, tanning addiction – typically involving the repeated daily use of sun beds by women – appears to have become a topic for scientific investigation. If memory serves me correctly, most of the people who appeared on the show appeared to be using tanning as a way of raising their self-esteem and to feel better about themselves. Given that when we are exposed to ultraviolet rays from the sun or tanning bed, our bodies produce it’s own mood-inducing morphine-like substances (i.e., endorphins), the idea that someone could become addicted to tanning is not as far-fetched as it could be.
In fact, in a 2006 study published in the Journal of the American Academy of Dermatology by researchers at Wake Forest University Baptist Medical Center (USA) reported that frequent tanners (those who tanned 8-15 times a month; n=8) who took an endorphin blocker (naltrexone) similar to what a person undergoing alcohol or drug withdrawal suffers), whereas infrequent tanners (n=8) experienced no withdrawal symptoms under identical conditions. However, with only 16 participants in total, the results must be treated with some caution.
Symptoms and consequences of tanorexia are alleged to include (i) intense anxiety if sun bed sessions are missed by the tanorexic, (ii) competition among other tanorexics to see who can get the darkest tan, (iii) chronic frustration by the tanorexic that their skin colour is too light, and (iv), the belief by tanoexics that their skin colour is lighter than it actually is (similar to anorexics believing that they are much heavier than they actually are). Some academics claim that tanorexia is not actually the same as tanning addiction, and argue that tanorexics primary motivation is to get a deep coloured tan. However, there is little empirical research to show whether these tanning behaviours are different or part of the same syndrome.
A 2005 study conducted by researchers at the University of Texas (USA) and published in the US journal Archives of Dermatology claimed that more than half of beach lovers could be considered tanning addicts. They then went on to further claim that just over a quarter of the sample (26%) of “sun worshippers” would qualify as having a substance-related disorder if UV light was classed as the substance they crave. Their paper also reported that frequent tanners experienced a “loss of control” over their tanning schedule, and displayed a pattern of addiction similar to smokers and alcoholics.
Another study carried out in 2008 on 400 students and published in the American Journal of Health Behavior reported that 27% of the students were classified as “tanning dependent”. The authors claimed that those classed as being tanning dependent had a number of similarities to substance use, including (i) higher prevalence among youth, (ii) an initial perception that the behavior is image enhancing, (iii) high health risks and disregard for warnings about those risks, and (iv) the activity being mood enhancing. Independent predictors of tanning dependence included ethnicity (i.e., Caucasians more likely than African Americans to be tanning dependent), lack of skin protective behaviours (i.e., those sunbathing without sun cream and experiencing sunburn more likely to be tanning dependent), smoking (smokers more likely to be tanning dependent), and body mass index (obese people less likely to be tanning dependent).
There is also some interesting empirical evidence that in extreme cases, excessive tanning may be an indication of body dysmorphic disorder (BDD), a mental psychological condition where people are obsessively critical of their physique or self-image. A short article published in the Journal of the American Academy of Dermatology reported the case of 11 patients with BDD who used tanning in an attempt to conceal or improve the appearance of a perceived physical defect.
Overall, the evidence as to whether tanorexia and/or tanning addiction exists is limited with the vast majority of empirical data collected by dermatologists rather than psychologists and biologists. As I noted in a previous blog, I am not convinced – yet – that tanorexics experience a real dependence and/or addiction based on the published empirical evidence. However, at least there are research teams (particularly in the US) empirically investigating its existence.
Dr Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK
Further reading
Heckman, C.J., Egleston, B.L., Wilson, D.B. & Ingersoll, K.S. (2008). A preliminary investigation of the predictors of tanning dependence. American Journal of Health Behavior, 32, 451-464.
Hunter-Yates J., Dufresne, R.G. & Phillips, K.A. (2007). Tanning in body dysmorphic disorder. Journal of the American Academy of Dermatology, 56(5 Supplement), S107-S109.
Kaur, M., Liguori, A., Lang, W., Rapp, S., Fleischer, A., Feldman, S. (2006). Induction of withdrawal-like symptoms in a small randomized, controlled trial of opioid blockade in frequent tanners. Journal of the American Academy of Dermatology, 54, 709-711.
Warthan, M., Uchida, T. & Wagner, R. (2005). UV light tanning as a type of substance-related disorder. Archives of Dermatology, 141, 963-966.
Animal passions: The strange world of zoophilia
Of all the sexual paraphilias, arguably the two most repelling are necrophilia (covered in a previous blog) and zoophilia. Zoophilia (also more commonly know as bestiality) is typically defined as relating to recurrent intense sexual fantasies, urges and sexual activities with non-human animals.
The Kinsey Reports (of 1948 and 1953) arguably shocked its readers when it reported that 8% of males and 4% females had at least one sexual experience with an animal. As with necrophiliacs who are often employed in jobs that provide regular contact with dead people, the Kinsey Reports provided much higher prevalence for zoophilic acts among those who worked on farms (for instance, 17% males had experienced an orgasmic episode involving animals). The most frequent sexual acts engaged in with animals comprised calves, sheep, donkeys, large fowl (ducks, geese), dogs and cats. Males were most likely to engage in penile-vaginal intercourse or to have their genitals orally stimulated by the animals. Female zoophilia was most likely to involve household pets licking genitals. Less commonly, women have trained dogs to mount them and engage in intercourse. The sexologist Professor John Money asserted that zoophilic behaviours were usually transitory occurring when there is no other sexual outlet available.
The most recent studies of zoophilia since 2000 have typically collected their data online from non-clinical samples. This has included studies by Dr Andrea Beetz (University of Erlangen, Germany; 32 zoophiles), Dr Colin Williams and Dr Martin Weinberg (of Indiana University, USA; 114 zoophiles), and Dr Hani Miletski (Institute for Advanced Study of Human Sexuality, San Francisco, USA; 93 zoophiles). For instance, Hani Miletski used the internet to find zoophiles, and recruited them via advertisements in a zoophile magazine (i.e., Wild Animal Review). These studies all reported that both male and female self-identified zoophiles were attracted to animals out of either a desire for affection, a sexual attraction toward, and/or a love for animals. Many of the zoophiles in these three studies had a preference for sex with non-human animals.
Miletski’s study comprised 82 male and 11 female zoophiles. The most reported sexual fantasies of the sample were having sex with animals (76 % males and 45% females) and watching other humans have sex with animals (35% males and 40% females). The reasons that men said they engaged in sex with animals was sexual attraction to the animal (91%), love and affection for the animal (74%), the animals being accepting and easy to please (67%). Only 12% said it was because no human partners were available, and only 7% said it was because they were too shy to have sex with humans. For the females, the main reasons for having sex with animals was because they were sexually attracted to the animal (100%), love and affection for the animal (67%) and because they said the animal wanted it (67%). Most of the sample preferred sex with dogs (87% males; 100% females) and/or horses (81% males; 73% females). Only 8% of males wanted to stop having sex with animals and none of the females.
Hani Miletski went as far as to claim that zoophilia could perhaps be considered as an alternative sexual orientation. Interestingly, Miletski’s study – which I should add has never been published in a peer reviewed academic journal – noted that her participants differentiated themselves from the bestialists who used animals as sex objects without emotional attachment.
Andrea Beetz’ study comprised 32 male zoophiles. Sex had occurred with dogs (78%), horses (53%), cats (13%) and farm animals (19%). Over half (56%) had never been in therapy. Many of the zoophiles had a very close emotional attachment to their animals and reported that they love their animal partner as others love their human partner (and are devastated when their animal partner dies). They also claimed they cared about the sexual pleasure of their animal partner as well as their own. Beetz also examined how the interest in zoophilia began. She reported:
“Some have always been interested in their preferred animal and only later developed sexual fantasies about them, some read in books/magazines about zoophilia (e.g. the Sex Atlas), some found it very exciting to watch animal matings on TV (especially on the Discovery Channel in the US) and fantasized about that. Others started to touch the genitals of their pet-dog out of curiosity, in some cases the dog came up and licked the person`s genitals. Others did not remember when their fantasies started, but the behavior often started with nonsexual cuddling with the animal and then became sexual. So we see that there are a lot of ways that can lead up to the first sexual experience with an animal”
In all three studies, the most commonly preferred animals were either dogs or horses. However, it must be noted that these three studies, while extensive compared to the case reports published since Alfred Kinsey’s pioneering studies, collected data from non-clinical samples. Therefore, and unlike case study reports, the participants did not appear to be suffering any significant clinical significant distress or impairment as a consequence of their behaviour.
There may, of course, be other more idiosyncratic explanations for zoophilic behaviour. There are several medical conditions accounting for zoophilic behaviour (e.g., cerebral tumors located in the frontal lobe or in the lymbic system or hypothalamus). A very recent case reported in the journal Romanian Neurosurgery described the late onset of zoophilia in a 42-year old man who suddenly started engaging in zoophilic behaviour following an aneurysm in the posterior cerebral artery. More specifically, he developed a sexual interest towards the hens in his garden, and his wife found him several times having sex with the hens. Unfortunately, the man died a few weeks later following a rupture of the aneurysm. Another report published in the Annals of Pharmacotherapy highlighted the case of a 74-year old man who developed zoophilic tendencies five days after the start of his dopaminergic therapy for his Parkinson’s Disease.
Finally, it’s worth noting that there have also been papers and editorials published in the Veterinary Journal (VJ) about the violent sexual abuse of female calves. Vets – who often have to deal with the animals that have been sexually abused by humans – do not like the term ‘zoophilia’ as it tends to focus on the human perpetrator, with no attention being paid to the harm that might result for the animal. A 2006 editorial in the VJ claimed that the sexual abuse of animals is almost a last taboo – even to the veterinary profession. As Piers Beirne (University of Sothern Maine, USA) argues, the sexual abuse of an animal should be understood as sexual assault because: (i) human–animal sexual relations almost always involve coercion; (ii) such practices often cause pain and even death to the animal; and (iii) animals are unable either to communicate consent to us in a form that we can readily understand, or to speak out about their cause.
Dr Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK
Further reading
Beetz, A.M. (2000, June). Human sexual contact with animals: New insights from current research. Paper presented at the 5th Congress of the European Federation of Sexology, Berlin.
Beirne, P., 1997. Rethinking bestiality: towards a concept of interspecies sexual assault. Theoretical Criminology, 1, 317–340.
Ene, S., A. Sasaran, A. (2011). Zoophilic behavior in a patient with posterior cerebral arterial aneurysm. Romanian Neurosurgery, 18, 349-355.
Hvozdık, A., Bugarsky, A., Kottferova, J., Vargova, M., Ondrasovicova, O., Ondrasovic, M., & Sasakova , N. (2006). Ethological, psychological and legal aspects of animal sexual abuse. The Veterinary Journal, 172, 374-376.
Jimenez-Jimenez F.J., Sayed Y., Garcia-Soldevilla M.A. & Barcenilla B. (2002). Possible zoophilia associated with dopaminergic therapy in Parkinson disease. Annals of Pharmacotherapy, 36, 1178-1179.
Kafka, M.P. (2010). The DSM Diagnostic Criteria for Paraphilia Not Otherwise Specified. Archives of Sexual Behavior, 39, 373-376.
Kinsey, A. C., Pomeroy, W. B., Martin, C.E., Gebhard, P.H. (1953). Sexual Behavior in the Human Female. Philadelphia, PA: W.B. Saunders Company.
Kinsey, A. C., Pomeroy, W. B., Martin, C.E., (1948). Sexual Behavior in the Human Male. Philadelphia, PA: W.B. Saunders Company.
Miletski, H. (2000). Bestiality and zoophilia: An exploratory study. Scandinavian Journal of Sexology, 3, 149–150.
Miletski, H. (2001). Zoophilia – implications for therapy. Journal of Sex Education and Therapy, 26, 85–89.
Miletski, H. (2002). Understanding bestiality and zoophilia. Germantown, MD: Ima Tek Inc.
Munro, H.M.C. (2006). Animal sexual abuse: A veterinary taboo? The Veterinary Journal, 172, 195-197.
Williams, C. J., & Weinberg, M. S. (2003). Zoophilia in men: A study of sexual interest in animals. Archives of Sexual Behavior, 32, 523–535.
Playing the name game in the development of gambling problems
There has never been a shortage of adjectives to describe the small sub-sample of the population who develop gambling problems and come to the attention of psychologists, psychiatrists, and/or self-help agencies. Over the last 70 years, problem gambling has been described as ‘neurotic’, ‘compulsive’, ‘addictive’, ‘dependent’, impulsive’ and/or ‘pathological’ in a wide variety of scholarly outlets.
At present, the most commonly used terms by practitioners and treatment agencies are arguably ‘pathological’ and ‘compulsive’. The term ‘compulsive’ arose largely from Sigmund Freud’s 1928 description of the Russian novelist Dostoyevsky based on his semi-autobiographical book, The Gambler. Some gamblers clearly display compulsive behaviour and is currently the preferred terminology of Gamblers Anonymous. However, if compulsions are defined as being the behavioural component of the obsessional state in which the individual finds the abnormal behaviour alien and attempts to resist it, then clearly some gamblers cannot be described as compulsive as there is no element of resistance (i.e., they actually enjoy gambling), and their behaviour is not alien to them. In addition, some gamblers may be oblivious to the fact that they have a problem at all.
Influenced by the American Psychiatric Association’s Diagnostic and Statistical Manual, there seems to be an increased preference amongst professionals for the term ‘pathological gambling’ to describe individuals with severe gambling problems. Arguably, this owes much to the pioneering work of the psychiatrist Dr Emmanuel Moran who in the late 1960s and early 1970s argued in a series of seminal papers that the phrase ‘pathological gambling’ is descriptive as opposed to terms like ‘compulsive’ or ‘addictive’ which might suggest specific and homogenous etiologies. Estimates for the numbers of people who have a gambling problem are therefore a direct function of the particular criteria used in defining the problem in the first place. Others in the gambling studies field have agreed that the pathological gambling problem of impulse control is dissimilar to other obsessive and compulsive disorders.
Moran also pointed out in his many papers that it was highly unlikely that problem gamblers were a homogenous group of individuals, and that therefore ‘compulsive gambling’ to describe this diverse group was an unsatisfactory term. Professor Mark Dickerson (formerly of the University of Western Sydney before his retirement) also rejected the ‘compulsive’ typology. He said the label was merely functional, and the term ‘compulsive gambling’ acted as a legitimate way for individuals to seek the help of psychologists and psychiatrists. He also argued that the compulsive gamblers may just be a subset of regular gamblers except that they seek treatment for their behaviour.
The problem is therefore how to differentiate between those who gamble a lot but do not seek help, and those gamblers who end up seeking help at agencies such as Gamblers Anonymous. What difference is there? Is it cognitive? Is it genetic and/or physiological? Is it behavioural? All of the above? Due to the heterogeneous nature of gambling, there is probably no parsimonious answer but it would be useful for research and practitioner communities to choose an appropriate name that clearly distinguishes between those who need help with their gambling problem from those who do not.
Clearly there is more than one type of problem gambler as evidenced by the early classification of different problem gamblers by Moran (i.e., subcultural, psychopathic, neurotic, symptomatic and impulsive) through to the more recent ‘pathways’ model of Professor Alex Blaszczynski and Dr Lia Nower who assert there are three fundamentally different types of problem gambler (behaviourally conditioned, emotionally vulnerable, and antisocial impulsivist). I will return to these typologies in a subsequent blog. The real point I would make is that these typologies have good face validity but it is unlikely that all these types of problem gambler are pathological gamblers – particularly if pathological gambling implies the gambling abnormality comes from within the individual. Can problematic gambling that is due to a situational disposition (e.g., subcultural gambling where people gamble excessively because others do) really be defined as pathological?
What is needed is a unambiguous term that not only differentiates gamblers who seek treatment from those who do not, but that also incorporates the different sub-types of problem gambler. Terms such as ‘habitual’, ‘high frequency’, ‘heavy’ and ‘persistent’ would accurately describe the most regular gamblers but would not include the small minority who gamble only in short binges. Perhaps the most useful terms (and to some extent the most obvious) are those such as ‘excessive’ and/or ‘problematic’. However, both ‘excessive’ and ‘problematic’ are to some extent personal and subjective judgments where the gamblers (or those around them) perceive an imbalance of negative outcomes over the positive outcomes resulting in what is felt to be problematic behaviour. Evidently, these debates are not unique to gambling and can be found across the whole addiction studies field. However, whether the gambling studies field will ever reach consensus remains to be seen.
Dr Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK
Further reading
Blaszczynski, A. & Nower, L. (2002). A pathways model of pathological gambling. Addiction, 97, 487-500.
Dickerson, M.G. (1989). Gambling: A dependence without a drug. International Review of Psychiatry, 1, 157-172.
Griffiths, M.D. (2006). An overview of pathological gambling. In T. Plante (Ed.), Mental Disorders of the New Millennium. Vol. I: Behavioral Issues. pp. 73-98. New York: Greenwood.
Moran, E. (1970). Varieties of pathological gambling. British Journal of Psychiatry, 116, 593–597.
A glutton for reward (rather than punishment)? A brief psychological overview of excessive and addictive eating
In a previous article in this blog on shopping addictions, it was highlighted that the form of excessive or addictive behaviour someone develops may depend upon gender. As I noted in that article, men are more likely to be addicted to drugs, gambling and sex whereas women are more likely to suffer from ‘mall disorders’ such as eating and shopping. Food is – of course – a primary reward as it is necessary for our survival. However, it is this reward that gives highly palatable food (such as sugar) its addictive potential, leading to excessive eating as an addictive behaviour. Possible reasons behind such excessive eating in today’s society are many, including the increasing availability of food, a more inactive lifestyle, and financial considerations. Furthermore, as a means of mood enhancement, food is highly rewarding, easily available, low-cost and most of all it is legal!
Such justifications demonstrate some degree of explanatory power, contributing to research into the topic of excessive eating as an area of increasing interest. However, no such explanations address the critical question of why certain people seem to overeat, despite repeated efforts not to. The majority of obese cases tend to result from an over-consumption of energy, independent from a lack of physical activity. Therefore it may be people, rather than food, that need to be of focus here.
Prevalence rates for excessive and addictive eating are highly variable. Past year prevalence rates of eating disorders (particularly binge eating disorder, among older teens and adults typically varies between 1 to 2% but much higher figures have been reported in a variety of studies in a number of different countries (between 6% and 15% depending upon the sample). Based on these many studies that included samples of at least 500 participants, Professor Steve Sussman, Nadra Lisha (both at the University of Southern California) and myself estimated a past year prevalence rate of 2% for eating addiction among general population U.S. adults.
Reward sensitivity is a personality construct of Jeffrey Gray’s Reinforcement Sensitivity Theory, and is thought to control approach behaviour, by means of the dopamine reward centre. Individuals that are highly sensitive to reward are more prone to detect signals of reward in their environment (such as food) resulting in approaching these rewards more frequently, along with responding quicker and more strongly. Research demonstrates associations between reward sensitivity and increased food cravings, body weight, binge eating, and a preference for high fat food. Such findings offer a possible explanation for why only some individuals eat excessively when reward, particularly that produced by food, is a process available to all.
An excessive appetite for food has long been linked to emotional eating with research demonstrating that refined food addicts specifically report eating when they feel anxious. For instance, this is demonstrated in the eating habits of overweight Americans, revealing that women tend to binge eat when they feel lonely or depressed, while men overeat in positive social situations. Research dating back to the early 1990s found that women being treated for eating disorders described feeling less anxious as an episode of binge eating went on. Such research suggests that highly anxious people are more likely to turn to food for comfort, leading to excessive eating, yet in turn cause themselves more anxiety when this comfort is unavailable. For instance, this is demonstrated in the eating habits of overweight Americans, revealing that women tend to binge eat when they feel lonely or depressed, while men overeat in positive social situations.
Research has shown that obese people score higher on impulsiveness personality scales. Impulsivity is a tendency to ‘act on the spur of the moment’, often associated with a failure to learn from negative experience, wherein individuals know the appropriate way to behave but fail to act accordingly. Refined food addicts eat for a ‘pick-me-up’, although they are aware that they are not hungry, suggesting a correlation between reward sensitivity and impulsive reactions to such reward cues. Impulsive individuals have a tendency to react to stress and anxiety, with a craving for immediate satisfaction as a form of relief. Although eating may deliver this reward or relief, it may then condition impulsive individuals to react quickly, with this inapt response, to such feelings in the future; such as with feelings of hunger when feeling anxious. This could explain why repeated attempts to restrict food intake and lose weight, so often results in relapse in obese people.
Associations have also been observed between self-esteem and a variety of excessive eating behaviour populations, such as restrained eaters, bulimic patients, and binge eaters. One explanation for this suggests that individuals with low self-esteem have lower expectations for personal performance, resulting in less effort being made to resist challenges and temptations to their diets. This offers another explanation that individuals with low self-esteem depend more on external cues to control eating, such as how food looks, rather than internal cues, such as hunger, indicating reward sensitivity and resulting in dieters with low self-esteem overeating. Here, low self-esteem combined with reward sensitivity and its further correlations to impulsivity and anxiety, seem to demonstrate a destructive model of influence on behaviour, one trait further amplifying the next leading to continuous eating to excess.
In relation to low self-esteem, low social desirability has been seen to correlate significantly with restrained eating in obese people. High social desirability is most commonly associated with a desire for thinness. Therefore, although an association with eating behaviour exists, high social desirability is more likely to correlate with anorexic behaviours as opposed to excessive eating. Low social desirability, combined with low self-esteem as a cause or effect, could contribute to explaining excessive eating in some individuals, which in turn could be reasoned by contributions of all traits previously mentioned.
Finally, Professor Elizabeth Hirschman at Rutgers University has proposed a general model of addictive consumption that interrelates excessive and compulsive consumption behaviour. This model suggests similar characteristics people exhibit, along with common causes, patterns of development, and the similar functions such behaviours serve for individuals. Many of these have been previously associated with excessive eating in particular, further suggesting a general consumption personality principle.
Dr Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK
Further reading
Davenport, K., Houston, J. & Griffiths, M.D. (2012). Excessive eating and compulsive buying behaviours in women: An empirical pilot study examining reward sensitivity, anxiety, impulsivity, self-esteem and social desirability. International Journal of Mental Health and Addiction, DOI 10.1007/s11469-011-9332-7.
Davis, C., Levitan, R. D., Smith, M., Tweed, S. & Curtis, C. (2006) Associations among overeating, overweight, and attention deficit/hyperactivity disorder: A structural equation modelling approach. Eating Behaviors, 7, 266–274.
Hirschman, E.C. (1991) Recovering from drug addiction: A phenomenological account. In Sherry, J.F and Sternthal, B (Eds.), Advances in Consumer Research. Association for Consumer Research, 18, 541-549.
Hodgson R.J., Budd R. & Griffiths M. (2001). Compulsive behaviours (Chapter 15). In H. Helmchen, F.A. Henn, H. Lauter & N. Sartorious (Eds) Contemporary Psychiatry. Vol. 3 (Specific Psychiatric Disorders). pp.240-250. London: Springer.
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.
Trinko, R., Sears, R. M., Guarnieri, D. J. & DiLeone, R. J. (2007) Neural mechanisms underlying obesity and drug addiction. Physiology & Behavior, 91, 499–505.
The gender agenda and the feminization of gambling
The deregulation of the gambling industry both in the UK and elsewhere may not only pose a pose a problem to some of the general population but also to specific ‘at-risk’ groups such as women. Women may be equally as susceptible to developing problem gambling as men. Research has indicated that although they tend to acquire the disorder later in life, progression is often much faster.
Given the increase in gambling-related research, it is surprising that the gambling literature tends to focus on male populations to the neglect of women gamblers. This male bias in the literature is problematic and it often leads professionals to wrongly assume that what is true for male gamblers similarly holds true for their female counterparts. Non gender-specific research into gambling may yield findings which are irrelevant to female gamblers that consequently ignore how, why, when and where women gamble.
Findings from studies that have examined men and women concurrently have highlighted the importance of studying both intra- and inter-gender variations in gambling behaviour. For example, men have been repeatedly found to prefer strategic forms of gambling which necessitate a higher element of risk-taking and skill such as casino gambling or sports betting. This is in contrast to women who favour gambling activities that involve less monetary risk, such as slot machines and bingo – although there are cultural differences. Such differences in gambling behaviour between the genders may in part reflect differences in motivations to gamble.
Research has documented that male gamblers find the thrill of gambling, ego enhancement, communing, competitive risk-taking, and asserting their masculinity to be important motivations for gambling. Women on the other hand may be more motivated to gamble to escape from boredom and gain time out from family responsibilities. Furthermore, social interaction, environmental factors, and the perceived male dominance of some gambling environments may also positively or negatively contribute to the attractiveness of gambling for women. However, newer forms of gambling make it possible for females to swap gender (as is the case in online poker) without other players knowing they have done so.
Others have used gender theory to explain differences in men and women’s motivations to gamble in casinos. For example a 2005 study published in the journal Leisure Science by Professor Gordon Walker and colleagues (University of Alberta, Canada) concluded that differences might be attributed to males and females trying to either prove or negotiate their traditional gender roles. Men have been commonly been stereotyped as being more adventurous, assertive, aggressive, independent and task orientated, whilst women are viewed as being sensitive, gentle, dependent, emotional and people orientated. These images of men and women are ubiquitous and have been found to be relatively consistent across cultures. Walker and colleagues’ study found them to effect motivations to gamble such that risk taking/gambling as a rush, learning, and emotional stoicism (not displaying their emotions) were more important for males. Social interaction and being able to display their emotions were important for women. Thus, gender differences in motivations to gamble in casinos reflected traditionally held images of men and women. It was proposed that for some men, casinos provide an ideal place to prove their masculinity. This has also been noted in my own research among adolescent gamblers in British amusement arcades. On the other hand they provide a good setting for women to escape and cope with their everyday problems associated with traditional female gender roles.
The social acceptance of different types of gambling for males and females may also be influential for their gambling preferences. Therefore, differences in men and women’s motivations to gamble, gender roles, and the social acceptability of forms of gambling for men and women may explain why casino gambling remains more popular amongst males than females. Essentially men are greater risk takers, enjoy games of skill, have a necessity to prove their masculinity, and wager greater sums of money. These are all factors that are accommodated for by engaging in casino gambling.
Apart from gambling on bingo and lotteries, gambling has traditionally been a male domain. However, the newer (technological) forms of gambling are gender-neutral and what we seem to be witnessing more and more is the feminisation of gambling. An early (2001) national prevalence study on internet gambling that I published highlighted that female participants said they would prefer to gamble online rather than in a betting shop or casino because they perceived the internet to be a safer place to gamble, less intimidating, less stigmatising, and more anonymous.
As a consequence, gaming operators appear to now be targeting women in a way that just didn’t happen five years ago. The most obvious example is online bingo where online gaming companies have targeted females to get online, socialise, and gamble. Additionally, there are many operators around the world (including those in the lottery sector and television companies looking for other revenue streams) that are targeting women via its online instant game sites. Although males still heavily outnumber females in both online and offline gambling (as reported in the most recent British Gambling Prevalence Survey), it is likely that the prevalence of female gambling participation (and as a consequence problem gambling) will increase over the next decade.
This brief overview of gender and gambling highlights the general paucity of work that has been conducted in the field and indicates the need to examine female gambling more systematically and in greater detail. Motivations to gamble and gambling behaviour appear to vary as a function of gender and very few studies have examined this in any depth.
Dr Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK
Further reading
Casey, E. (2003). Gambling and consumption: Working-class women and UK National Lottery play. Journal of Consumer Culture, 3, 245-263.
Dixley, R. (1987). It’s a great feeling when you win: Women and bingo. Leisure Studies, 6, 199-214.
Grant, J.E. & Kim, S.W. (2002). Gender differences in pathological gamblers seeking medication treatment. Comprehensive Psychiatry, 43, 56-62.
Griffiths, M.D. (2001). Internet gambling: Preliminary results of the first UK prevalence study, Journal of Gambling Issues, 5. Available at: http://www.camh.net/egambling/issue5/research/griffiths_article.html.
Griffiths, M.D. (2003). Fruit machine addiction in females: A case Study. Journal of Gambling Issues, 8. Available at: http://www.camh.net/egambling/issue8/clinic/griffiths/index.html.
Griffiths, M.D. & Bingham, C. (2002). Bingo playing in the UK: The influence of demographic factors on play. International Gambling Studies, 2, 51-60.
Hing, N., & Breen, H., (2001). Profiling Lady Luck: An empirical study of gambling and problem gambling amongst female club members. Journal of Gambling Studies, 17, 47-69.
Mark, M.E. & Lesieur, H.R. (1992). A feminist critique of problem gambling research. British Journal of Addiction, 87, 549-565.
Potenza, M.N., Steinberg, M.A., Mclaughlin, S.D., Wu, R., Rounsaville, B.J. & O’Malley, S.S. (2001). Gender-related differences in the characteristics of problem gamblers using a gambling helpline. American Journal of Psychiatry, 158, 1500-1505.
Tavares, H., Zilberman, M.L., Beites, F. & Gentil, V., (2001). Gender differences in gambling progression. Journal of Gambling Studies, 17, 151-159.
Walker, G.J., Hinch, T.D. & Weighill, A.J. (2005). Inter and intra gender similarities and differences in motivations for casino gambling. Leisure Science, 27, 111-130.
Wardle, H., Moody. A., Spence, S., Orford, J., Volberg, R., Jotangia, D., Griffiths, M.D., Hussey, D. & Dobbie, F. (2011). British Gambling Prevalence Survey 2010. London: The Stationery Office.
Wood, R.T.A., Griffiths, M.D. & Parke, J. (2007). The acquisition, development, and maintenance of online poker playing in a student sample. CyberPsychology and Behavior, 10, 354-361.
Dead strange: A brief psychological overview of necrophilia
In a previous blog, I briefly examined paraphilias. One of the rarest of known paraphilias is necrophilia in which a person obtains sexual gratification by viewing or having intercourse with a corpse. Given the rarity of necrophilia, there is a lack of systematicaly reported empirical data with almost all knowledge emanating from published case studies.
Based on the case study data, necrophilia almost exclusively involves males who are driven to remove freshly buried bodies or seek employment in funeral parlours or morgues (in fact, in the biggest study of necrophilic behaviour found that 57% of necrophiliacs were employed in a profession that gave then access to dead bodies). However, rare cases of female necrophilia have been documented including the high profile case of Karen Greenlee.
Arguably, the most comprehensive study in the area was published in 1989 by Dr Jonathan Rosman and Dr Phillip Resnick (psychiatrists who were working at Cleveland Metropolitan General Hospital, USA). Their review examined 122 cases (comprising 88 from the world literature and 34 unpublished cases of their own). The motivation for engaging in necrophilic behaviour was examined and the results showed that two-thirds of the necrophiliacs reported the desire to possess an unresisting and unrejecting partner (68%). Other lesser motivations reported included wanting to be reunited with their dead romantic partner (21%), being sexually attracted to corpses (15%), comfort or overcoming feelings of isolation (15%), and/or seeking self-esteem by expressing power over a homicide victim (12%). They also classified the behaviour into three sub-types: (i) necrophilic homicide, (ii) “regular” necrophilia, and (iii) necrophilic fantasy. Some British research has also suggested that some necrophiles may opt for a non-living mate through a consistent failure to create normal romantic attachments with people that are alive.
Rosman and Resnick also theorized about the situational antecedents leading to necrophilic behaviour. Their theory was that necrophiliacs develop poor self-esteem that may be due to a significant loss. Furthermore, they suggested that necrophiliacs may be fearful of rejection by others and that they desire a sexual partner who is incapable of rejecting them. Here, necrophiliacs may be socially and/or sexually inept and may hate and/or fear the opposite sex. This causes them to seek out non-threatening, subjugated sexual partners (i.e. non-living people). Alternatively, they also suggested that necrophiliacs may be fearful of dead people, and that they transform their fear into a sexual desire. Perhaps unsurprisingly, necrophiliacs almost always manifest severe emotional disorders.
Dr Martin Kafka (McLean Hospital in Belmont, USA), one of the world’s leading paraphilia experts, argues that necrophilia could technically be considered as a fetish variant because the sexualized object of desire is ‘‘nonliving’’ although there are insufficient data to empirically support the argument. Necrophilia can be accompanied by ‘‘sadistic acts’’ and sexually motivated murder, certainly not behaviors associated with fetishism (as currently defined).
The sadistic side of necrophilia has certainly been reported in some of the more extreme case studies. For instance, Edwin Ehrlich and colleagues (at the Freie Universität Berlin, Germany) presented the case of a young man twice convicted on charges of defiling female corpses and who had undergone a long course of psychiatric treatment. All his necrophilic acts were committed over a 15-year period. In three cases, the necrophiliac skinned the trunk of the dead victims, placed the skin on his naked body and then stimulated himself sexually. In several cases, he kept mementos from the victims at his home (e.g., used burial clothes that he had removed from the coffins).
According to Professor Anil Aggrawal (Maulana Azad Medical College in New Delhi), cases like the one above indicate that necrophilia exists in many variations. Aggrawal argued that because so many related necrophilic behaviours are used differently by different people, a new classification was needed. Based on case studies in the literature, Aggrawal argued there were ten different types of necrophiliac. These comprised (i) role players, (ii) romantic necrophiles, (iii) necrophilic fantasizers (people having a necrophilic fantasy), (iv) tactile necrophiles, (v) fetishistic necrophiles (i.e., people having a sexual fetish for the dead), (vi) necromutilomaniacs (i.e., people having a necromutilomania), (vii) opportunistic necrophiles, (viii) regular necrophiles, (ix) homicidal necrophiles, and (x) exclusive necrophiles.
Homicidal necrophilia certainly seems to be a distinct sub-category of necrophilia. A recently published study by Michelle Stein (John Jay College of Criminal Justice, New York, USA) and colleagues reviewed 211 sexual homicides. Nearly 8% involved necrophilia (i.e., 16 cases). Their findings suggested that the most common explanation for necrophilia (i.e., the offender’s desire to have an unresisting partner) may not always be applicable in cases where necrophilia is connected to sexual murder.
Dr Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK
Further reading
Aggrawal, A. (2009). A new classification of necrophilia. Journal of Forensic and Legal Medicine, 16, 316-320.
Burg, B.R. (1982). The sick and the dead: The development of psychological theory on necrophilia from Krafft-Ebing to the present. Journal of the History of the Behavioral Sciences, 18, 242-254.
Ehrlich, E., Rothschild, M.A., Pluisch, F. & Schneider, V. (2000). An extreme case of necrophilia. Legal Medicine, 2, 224-226.
Kafka, M.P. (2010). The DSM Diagnostic Criteria for Paraphilia Not Otherwise Specified. Archives of Sexual Behavior, 39, 373-376.
Rosman, J.P. & Resnick, P.J. (1989). Sexual attraction to corpses: A psychiatric review of necrophilia. Bulletin of the American Academy of Psychiatry and the Law, 17, 153-163.
Stein, M.L., Schlesinger, L.B. & Pinizzotto, A.J. (2010). Necrophilia and sexual homicide. Journal of Forensic Science, 55, 443-446.
What do gambling prevalence studies really tell us?
Prevalence studies are frequently used in the field of gambling studies and are often seen as the pinnacle of good practice within the field. There are a number of good reasons why prevalence studies are important. In an article I co-wrote with Dr. Richard Wood (GamRes Ltd, Canada) we said that some of the benefits of prevalence studies are that they:
- Provide indicative data on the broad extent of clinical need for the overall population and sub-populations, general population risk factors, and some correlates of a particular disorder. This is useful information for many different stakeholders including those who have responsibility for programmes concerning intervention, treatment and social responsibility.
- Identify groups of people (for example, 18-24 year olds) where apparent needs do not match up with treatment service use. If we just surveyed treatment populations and/or those who attend Gamblers Anonymous, we would almost inevitably conclude that most problem gamblers are primarily white middle-aged men who typically have problems gambling on horse racing and/or casino games because females, various ethnic groups, and youth are disproportionately represented in treatment. It can also provide new research questions such as why such groups are not accessing treatment services.
- Allow comparison of different regions (within country or across counties) in terms of prevalence and their association with game availability, treatment availability, economic prosperity, crime rates, etc.
- Provide a snapshot of the life of a ‘normal’ gambler at a time of our choosing, rather than theirs. In contrast, clinical samples are consistent with people in crisis. We cannot always learn about the “normal” state of gambling, and how individuals can stay that way, from clinical samples.
- Provide attitudes and beliefs and behaviours in the general public (i.e., non-affected people) rather than non- representative groups (like problem gamblers).
However, they have very little explanatory power for understanding the development of problem gambling. This is the case for several reasons. Dr. Wood and I have argued that:
- Problem gambling is non-normally distributed across populations: Prevalence surveys select a sample that is representative of the entire adult population. However, problem gamblers are not equally distributed amongst that population and are therefore under- represented in general population surveys. For example, problem gambling in the UK is usually more prevalent amongst males, 18-24 age groups, those on lower incomes, for instance. Consequently, the actual prevalence of problem gambling may be higher.
- Problem gambling is a ‘sensitive’ issue for participants: Given that gambling is a behaviour that most problem gamblers do not want to talk about, they are much more likely than non-problem gamblers to refuse to agree to participate in any survey. (Conversely, those who do not gamble at all may also be under-represented in gambling surveys as they may feel that the issue is no concern of theirs).
- Non-response from problem gamblers: If problem gamblers happen to be in a household that is surveyed, they are much less likely to return the form than non-problem gamblers. If they happen to be in a household surveyed, they are less likely to return the call or form. Many may make themselves unavailable to answer survey questions if appointments are made to interview them. Furthermore, problem gamblers who agree to be surveyed are more likely to lie about the amount of time and money they spend on gambling, and about the frequency of their gambling – especially if they have not told their family that they have a problem and their family are not aware of the extent of their gambling. They are even more likely to lie during a survey if another family member is at home when they are answering the survey takers questions. No matter what the interview technique, households are not always places that encourage disclosure of information. Furthermore, household telephone interviews may also facilitate non-response as it is harder for problem gamblers to be honest when compared to self-completion methods. PGs are often in denial until they reach a point where they either get discovered or ask for help.
- Small numbers of problem gamblers: One of the real disadvantages of prevalence surveys is that they do not tell us very much about problem gambling. Although prevalence surveys can highlight slight fluctuations in problem gambling rates in comparison with other prevalence surveys, they do not tell us very much about problem gambling itself. The two recent British Gambling Prevalence Surveys (BGPSs) had approximately 55 to 70 people were identified as problem gamblers. Many qualitative studies (including treatment) studies have bigger samples of problem gamblers than that but are classed as unrepresentative.
- Gambling data from diverse groups may be unrepresentative: Some have argued that gambling prevalence surveys rarely capture responses from Culturally and Linguistically Diverse (CALD) groups. Some studies have found that gaming environments such as casinos comprise a disproportionate number of individuals from CALD groups.
- Problem gambling is not uniformly distributed in the population: Given that many prevalence surveys such as the BGPSs are household surveys, it should be noted that problem gamblers are more likely to be homeless and/or to be institutionalized (in prison, in mental hospitals), and therefore not even accessed to survey about their gambling behaviour in the first place.
- Unknown effect of false positives and false negatives on problem gambling estimates: One of the most highlighted problems is that when it comes to the screening instruments used to identify problem gambling, we do not know what effect false positives and false negatives have on the data. Typical survey samples worldwide are rather small (1,000 to 10,000 depending on population size). Therefore, the actual numbers of problem gamblers on which conclusions (and policy decisions) are made are very small (e.g., just over 50 problem gamblers in the case of the latest BGPS). To overcome the problem of small numbers and their analysis, the researchers often collapse sub-clinical and clinically significant cases of interest together. This analysis usually fails to consider the impact of false positive (in the sub-clinical group) on the validity of the conclusions drawn.
- Response rates to national surveys are decreasing: The response rates for national gambling surveys have been decreasing internationally. This may decrease the prevalence of problem gambling as problem gamblers are more likely to be in the group of non-responders.
- Survey response may differ as a function of media exposure to problem gambling: Australian researchers have argued that any given moment in time, the number of people surveyed who will admit to having a gambling problem is dependent on how much media attention has been given to concerns about gambling losses, and the level of problem gambling in the community. Shame and guilt (and therefore lying about gambling involvement) are apt to increase as public concern about gambling and gambling losses increases and as media reports become more prevalent and shocking.
- Random samples are still self-selecting samples: Even though most national gambling prevalence surveys are random it could still be argued that those who are approached still ultimately decide whether or not to participate and in that sense the sample is still self- selecting.
- Self-report methods can be problematic: The use of anonymous self-report methods may allow people to be economical with the truth and/or exaggerate and lie about certain issues. This is coupled with the fact that they may be asked things on which they have to rely on long-term memory (which may not be the most reliable). Furthermore, it is easy for a respondent to exaggerate or lie when they know that they are relatively anonymous and that nobody will question the validity of their answers.
- Actual problematic gambling behaviour is rarely considered in large-scale surveys: In order to overcome question fatigue and to increase participation rates, very few questions in large prevalence surveys actually focus on gambling problems beyond the screen questions used to identify people with problems. This leaves correlational factors only that are often basic demographics (e.g., age, location, etc.) or frequency questions (how often they play, etc.), that by themselves they do not provide much information as to why problems develop.
- Lack of theory-driven and/or model-driven research: In almost all gambling prevalence surveys there is a great emphasis on closed (forced) question responses rather than allowing respondents to explain what the issues are for their specific gambling behaviour (i.e., the studies are more about ‘data trawling’ rather than ‘theory building’). This also means that we are just measuring fluctuations rather than developing and testing theories that help us understand the fundamental issues.
- Understanding severity: There appears to be an assumption that endorsing one or two items on a problem gambling screen indicates a problem at a low level when there is little evidence to support this. Whilst endorsing the specified number of criteria on a diagnostic screen may be a good indicator of a gambling problem, the scores for endorsing one or two items may not have been validated as an indicator of a lesser problem. Answering in this way to one or two items may in fact indicate the extent of ‘normal’ risk inherent in gambling activities.
By highlighting some of the problems of prevalence surveys, Dr. Wood and I are not saying that these should not be carried out (as they clearly have a use as outlined at the start). However, there are lots of other methodologies for examining and understanding problem gambling. We need to look at the lives of the problem gamblers in far more detail than the data collected from prevalence surveys. Future prevalence surveys should be complemented with other more ‘in-depth’ methodologies including interviews, focus groups, Q-sorts and online discussions
Dr Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK
Further reading
Griffiths, M.D., Wardle, J., Orford, J., Sproston, K. & Erens, B. (2010). Gambling, alcohol consumption, cigarette smoking and health: findings from the 2007 British Gambling Prevalence Survey. Addiction Research and Theory, 18, 208-223.
Griffiths, M.D., Wardle, J., Orford, J., Sproston, K. & Erens, B. (2011). Internet gambling, health. Smoking and alcohol use: Findings from the 2007 British Gambling Prevalence Survey. International Journal of Mental Health and Addiction, 9, 1-11.
Griffiths, M.D. & Wood, R.T.A. (2009). Prevalence studies: What do they really tell us? Casino and Gaming International, 5(4), 102-104.
Orford, J., Griffiths, M.D., Wardle, J., Sproston, K. & Erens, B. (2009). Negative public attitudes towards gambling: findings from the 2006/07 British Gambling Prevalence Survey using a new attitude scale. International Gambling Studies, 9, 39-54.
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.
Wardle, H., Moody. A., Spence, S., Orford, J., Volberg, R., Jotangia, D., Griffiths, M.D., Hussey, D. & Dobbie, F. (2011). British Gambling Prevalence Survey 2010. London: The Stationery Office.
Wardle, H., Sproston, K., Orford, J., Erens, B., Griffiths, M.D., Constantine, R. & Pigott, S. (2007). The British Gambling Prevalence Survey 2007. London: The Stationery Office
Is excessive gambling compulsive, impulsive and/or addictive?
In 1980, pathological gambling was for the first time recognized as a mental disorder in the third edition of the Diagnostic and Statistical Manual (DSM-III) by the American Psychiatric Association, under the section “Disorders of Impulse Control” along with other illnesses such as kleptomania and pyromania. Adopting a medical model of pathological gambling in this way displaced the old image that the gambler was a sinner or a criminal.
In diagnosing the pathological gambler, the DSM-III stated that the individual was chronically and progressively unable to resist impulses to gamble and that gambling compromised, disrupted or damaged family, personal, and vocational pursuits. The behaviour increased under times of stress and associated features included lying to obtain money, committing crimes (e.g. forgery, embezzlement, fraud, etc.), and concealment from others of the extent of the individual’s gambling activities. In addition the DSM-III stated that to be a pathological gambler, the gambling must not be due to Antisocial Personality Disorder.
These criteria were later criticized for (i) a middle class bias (i.e. the criminal offences like embezzlement, income tax evasion were typically ‘middle class’ offences), (ii) lack of recognition that many compulsive gamblers are self-employed, and (iii) exclusion of individuals with Antisocial Personality Disorder. It was argued that the same custom be followed for pathological gamblers as for substance abusers and alcoholics in the past (i.e., allow for simultaneous diagnosis with no exclusions). Consequently, the revised criteria (DSM-III-R) that appeared in 1987 were subsequently changed and took on board these criticisms. More importantly, the criteria were modelled extensively on substance abuse disorders due to the growing acceptance of gambling as a bona fide addictive behaviour.
Research carried out among treatment professionals the end of the 1980s highlighted some dissatisfaction with the DSM-III-R criteria and that there was some preference for a compromise between the DSM-III and the DSM-III-R. As a consequence, the criteria were changed for DSM-IV. The DSM-IV criteria represented a combination of DSM-III and DSM-III-R with the addition of “escape” which was added on the basis of empirical research.
Although many researchers have recognized that there appear to be different types of problem gambler, it was arguably Dr Moran’s typology based upon male gamblers receiving psychiatric help for their gambling problems that proved most influential. The typology comprised the following types of problem gambler:
Subcultural – Gambles excessively due to others in their social environment gambling heavily. This type lacks independence and conforms to the social group.
Neurotic variety – Gambles excessively as a means of relief to stress and emotional difficulties.
Impulsive variety – Gambles excessively due to a “loss of control”. Money is gambled until it runs out and ‘symptoms of craving’ appear. This variety of pathology is the most serious and produces an economic and social functioning disturbance.
Psychopathic variety – Gambles excessively as part of general global disturbance (i.e. the psychopathic state. Criminality usually occurs but is on the whole unrelated to gambling).
Symptomatic variety – Gambles excessively because of an associated mental illness (e.g., depression) in which the illness is primary and the gambling a secondary symptomatic manifestation.
As with most other typologies, Moran’s classification may be clinically useful but the distinctions between each group were not clear and many patients may have had characteristics of more than one sub-type. More recently, Professor Alex Blaszczynski and Dr Lia Nower postulated a pathway model of the determinants of problem gambling based upon a series of clinical observations with problem gamblers and through integration with the literature. In some ways, this model was very similar to that formulated by Moran.
They argue that there are common influences that affect all problem gamblers, such as availability and access, classical and operant conditioning reinforcements, arousal effects, and biased cognitive schemas. However, they suggested that there are three distinct pathways into problem gambling, representing three primary motivating forces that drive different problem gamblers to gamble. The first of these, behaviourally conditioned problem gamblers, are not pathologically disturbed, but instead gamble excessively as a result of poor decision-making strategies and bad judgments. Any features such as preoccupation with gambling, chasing, depression, anxiety and related substance abuse are seen as the consequence, not the cause of their excessive gambling. These gamblers are usually motivated to seek and attend treatment, and re-establish controlled levels of gambling post-treatment.
The second group, emotionally vulnerable problem gamblers, are characterized by a predisposition to be emotionally susceptible. This group use gambling as a means of modifying mood states and/or to meet specific psychological needs. These gamblers display higher levels of pre-morbid psychopathology including depression, anxiety, substance dependence and deficits in coping or managing stress. They tend to engage in avoidant or passive aggressive behaviour, and use gambling as a means of emotional relief through dissociation and mood modification. The psychological dysfunction in these gamblers makes them more resistant to treatment and not suitable to permit controlled gambling. Treatment must focus the underlying vulnerabilities as well as the gambling behaviour.
The third group, ‘antisocial impulsivist’ problem gamblers, have biological dysfunctions, either neurological or neurochemical. They also possess similar psychosocial vulnerabilities as the pathway two gamblers. However, they are characterized by antisocial personality disorder and impulsivity and/or attention-deficit disorders. It is argued that these gamblers have a propensity to seek out rewarding activities (such as gambling) in order to receive stimulation. They tend to be clinically impulsive and display a broad range of problems independent of their gambling. These problems include substance abuse, low tolerance for boredom, sensation seeking, criminal acts, poor relationship skills, family history of antisocial behaviour and alcoholism. Gambling usually begins at an early age, has a rapid onset and occurs in binges. These gamblers are less motivated to seek treatment, have poor compliance rates and respond poorly to all interventions. All three subgroups are affected by environmental variables, conditioning effects and cognitive processes. However, in terms of treatment intervention each subgroup will have specific needs.
Dr Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK
Further reading
American Psychiatric Association. (1987). Diagnostic and Statistical Manual of Mental Disorders (DSM-III) (Vol. III). Washington, D.C.: American Psychiatric Association.
American Psychiatric Association. (2000). Diagnostic and Statistical Manual of Mental Disorders – Text Revision. Washington, D.C.: American Psychiatric Association.
Blaszczynski, A. & Nower, L. (2002). A pathways model of pathological gambling. Addiction, 97, 487-500.
Griffiths, M.D. (2006). An overview of pathological gambling. In T. Plante (Ed.), Mental Disorders of the New Millennium. Vol. I: Behavioral Issues. pp. 73-98. New York: Greenwood.
Moran, E. (1970). Varieties of pathological gambling. British Journal of Psychiatry, 116, 593–597.
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