Monthly Archives: June 2014

Give me strength: Muscle Dysmorphia as an addiction

Muscle Dysmorphia (MD) describes a condition characterised by a misconstrued body image in individuals interpret their body size as both small and weak even though they may look normal or even be highly muscular. Those experiencing the condition typically strive for maximum fat loss and maximum muscular build. MD can have potentially negative effects on thought processes including depressive states, suicidal thoughts, and in extreme cases, suicide attempts. These negative psychological states have also been linked with concurrent use of Appearance and Performance Enhancing Drugs (APED) including Anabolic Androgenic Steroids (AAS).

MD was originally categorised in 1993 by Dr. H.G. Pope and colleagues (in the journal Comprehensive Psychiatry) as Reverse Anorexia Nervosa, due to characteristic symptoms in relation to body size. It has been considered to be part of the spectrum of Body Dysmorphic Disorders (BDD) referring to a range of conditions that tap into issues surrounding body image and eating behaviours. Consequently, there is a lack of consensus amongst researchers whether MD is a form of BDD, Obsessive-Compulsive Disorder (OCD) or a type of eating disorder. Earlier this year, Andy Foster, Dr. Gillian Shorter and I published a paper in the Journal of Behavioral Addictions about the ‘Addiction to Body Image’ model, and arguing that MD could perhaps be conceptualized as an addiction.

Our ‘Addiction to Body Image’ (ABI) model attempts to provide an operational definition and to introduce a standard assessment across the research area. The ABI model uses my addiction components model (outlined is a previous blog) as the framework in which to define muscle dysmorphia as an addiction. For the purposes of our paper, body image was defined using Sarah Grogan’s definition (from her 2008 book Body image: Understanding body dissatisfaction in men, women, and children) who said it was a person’s “perceptions, thoughts and feelings about his or her body”. We argued that the addictive activity in MD is the maintaining of body image via a number of different activities such as bodybuilding, exercise, eating certain foods, taking specific drugs (e.g., anabolic steroids), shopping for certain foods, food supplements, and/or physical exercise accessories, etc.).

In the ABI model, the perception of the positive effects on the self-body image is accounted for as a critical aspect of the MD condition. The maintenance behaviours of those with ABI may include healthy changes to diet or increases in exercise. However, such behaviours can hide or mislead those with ABI away from the negative thought processes that are driving their addiction. It is in the cognitive dysfunction of MD where we believe there is a pathological issue, and why the field has encountered problems with the criteria for the condition. The attempt to explain MD in the same manner as other BDDs may not be adequate due to the cognitive dysfunction occurring in the context of the potentially positive physical effects via improvements in shape, tone, and/or health of the body.

We also argued that there is a difference in the cognitive dysfunction with a misconstrued self-body image compared to other BDDs. The cognitive dysfunction causes the individual with MD to have a misconstrued view of their own body image, and the person believes they are small and puny. This negative mindset has the potential to cause depression and other disorders, and may facilitate the addiction. Unlike other conceptualizations of MD in the BDD literature, we would argue that the agent of the addiction is the perceived body image that is maintained by engaging in secondary behaviours such as specific types of physical activity and food. The most important thing in the life of someone with MD is how their body looks (i.e., their body image). The behaviours that the person with MD engages in (such as excessive exercise or disordered eating) are merely the vehicles by which their addiction (i.e., their perceived body image) is maintained.

Based on empirical evidence to date, we proposed that Muscle Dysmorphia could be re-classed as an addiction due to the individual continuing to engage in maintenance behaviours that cause long-term psychological damage. More research is needed to explore the possibilities of MD as an addiction, and how this particular addiction is linked to substance use and/or other comorbid health conditions. Controversy about the conceptual measurement of the condition, has led to a number of different scales adapted from different criteria that may not fully measure the experience of MD.

However, a group of questions that might test the applicability of the ABI approach to measuring and conceptualising MD have not been asked. Questionnaires such as the Exercise Addiction Inventory and the Bergen Work Addiction Scale (two scales that I co-developed) could be adapted to fit MD characteristics. Adequate conceptualisation is key to explore the clinically relevant condition. This new ABI approach may also have implications for diagnostic systems around similar conditions such as other BDDs or eating disorders.

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

Additional input: Andy Foster and Dr. Gillian Shorter

Further reading

Andreassen, C.S., Griffiths, M. D., Hetland, J. & Pallesen, S. (2012). Development of a Work Addiction Scale. Scandinavian Journal of Psychology, 53, 265-272.

Foster, A.C., Shorter, G.W.& Griffiths, M.D. (2014). Muscle Dysmorphia: Could it be classified as an Addiction to Body Image? Journal of Behavioral Addictions, in press.

Griffiths, M.D. (1997). Exercise addiction: A case study. Addiction Research, 5, 161-168.

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

Griffiths, M. D., Szabo, A., & Terry, A. (2005). The Exercise Addiction Inventory: A quick and easy screening tool for health practitioners. British Journal of Sports Medicine, 39, 30-31.

Grogan, S. (2008). Body image: Understanding body dissatisfaction in men, women, and children. London: Routledge.

Mosley, P.E. (2009). Bigorexia: Bodybuilding and muscle dysmorphia. European Eating Disorders Review. 17, 191-198.

Murray, S. B., Rieger, E., Touyz, S. W., & De la Garza Garcia, Y. (2010). Muscle Dysmorphia and the DSM-V Conundrum: where does it belong? International Journal of Eating Disorders, 43, 483-491.

Nieuwoudt, J. E., Zhou, S., Coutts, R. A., & Booker, R. (2012). Muscle dysmorphia: Current research and potential classification as a disorder. Psychology of Sport and Exercise, 13, 569-577.

Olivardia, R. (2001). Mirror, mirror on the wall, who’s the largest of them all? The features and phenomenology of muscle dysmorphia. Harvard Review of Psychiatry, 9, 254–259.

Phillips, K. A. & Hollander, E. (1996). Body dysmorphic disorder.In T.A. Widige, A.J. Frances, H.A. Pincus, R. Ross, M.B. First, & W.W. Davis, Eds. DSM-IV Sourcebook, Volume 2. Washington DC: American Psychiatric Association.

Philips, K. A., Gunderson, C. G., Mallya, G., McElroy, S. L., & Carter, W. (1998). A comparison study of body dysmorphic disorder and obsessive-compulsive disorder. Journal of Clinical Psychiatry, 59, 568–575.

Pope, H. G., Jr., Gruber, A. J., Choi, P., Olivardia, R., & Phillips, K. A. (1997). Muscle dysmorphia. An underrecognised form of body dysmorphic disorder. Psychosomatics, 38, 548–557.

Pope, H. G., Jr., Katz, D. L., & Hudson, J. I. (1993). Anorexia nervosa and ‘‘reverse anorexia’’ among 108 male bodybuilders. Comprehensive Psychiatry, 34, 406–409.

Pope, C. G., Pope, H. G., Menard, W., Fay, C., Olivardia, R., & Phillips, K.A. (2005). Clinical features of muscle dysmorphia among males with body dysmorphic disorder. Body image, 2, 395-400.

Veale, D. (2004) Body dysmorphic disorder. Postgraduate Medical Journal. 80, 67-71.

The joy of mastication: Can chewing gum be addictive?

“Every time I go to the store I have to buy a [chewing gum called] ‘Big Red’. I chew three packs every day. I love the taste, and it’s sweet. I started chewing gum excessively when she couldn’t find a job after graduation. I became depressed because I thought that with my qualifications I would find a job immediately but I did not. Since I’ve been chewing gum I have had to make visits to the dentist more than once due to tooth pain” (Tamika Wilbourn, 22-year old US college graduate).

“I used to have an addiction problem. No, I was not addicted to drugs, alcohol, gambling, video games or any other typical vice that you can think of. I was addicted to chewing gum. A lot of you are probably thinking, ‘I have the same problem!’ or ‘I chew a lot of gum too!’  but I’ve yet to meet someone who chews as much gum as I once did. Some might argue that using the word ‘addiction’ in this context is going a little too far; I beg to differ. I used to NEED gum. I would chew so much gum that even when my jaw started to hurt, I kept chewing. I chewed in the morning, I chewed at night, I chewed when I was bored, stressed and nervous. I needed gum more than coffee; I was a chain chewer for about 7 whole years…I always carried at least 2 packs of gum with me at all times, and made it a point to stop and buy some if I was running low. I often went through 1-2 packs per day, maybe more. I would chew a piece for 5 minutes, spit it out and chew another. No matter what I did, I could convince myself that chewing just one piece of gum was enough…After a while I didn’t even like the taste anymore. Sure I liked the initial burst of minty sweetness, but what I really craved was the chewing motion. After a while the chain chewing did not feel good anymore, it felt necessary” (Stellina Saia, US business graduate).

A few months ago, I was contacted by a researcher from an American television production company. I was told that the company was planning to make a documentary film on people that were allegedly addicted to chewing gum. They had come across my blog and wanted to know if I thought chewing gum could be addictive. I had never come across a study that had examined the chewing of gum as an addiction but added that I thought it was theoretically possible. As an occasional gum chewer myself, I answered all the questions from a personal and anecdotal perspective but was unable to respond to any of the questions from an empirical standpoint (i.e., I had no data to support a single thing that I said. Everything I said was pure speculation).

I remember being asked about why people chew gum and I said there were multiple reasons. I know that I only ever chew gum after I have eaten – using it as a way to clean my teeth and remove food that may have stuck to my teeth. Occasionally I will chew mint gum to help freshen my breath or because I like the taste of a particular gum. I also made reference to English soccer managers (most notably Alex Ferguson and Sam Allardyce) that appear to chew gum as a stress relieving activity. In fact, there appear to appear to be many cognitive benefits to mastication (i.e., chewing). A recent (2013) review by Dr. Kin-ya Kubo and colleagues in the book Senescence and Senescence-Related Disorders noted that chewing helps improve learning and memory, may help people suffering from dementia, and provide stress relief:

“Although mastication is primarily involved in food intake and digestion, it also promotes and preserves general health, including cognitive function. Functional magnetic resonance imaging (fMRI) and positron emission topography studies recently revealed that mastication leads to increases in cortical blood flow and activates the somatosensory, supplementary motor, and insular cortices, as well as the striatum, thalamus, and cerebellum. Masticating immediately before performing a cognitive task increases blood oxygen levels in the prefrontal cortex and hippocampus, important structures involved in learning and memory, thereby improving task performance. Thus, mastication may be a drug-free and simple method of attenuating the development of senile dementia and stress-related disorders that are often associated with cognitive dysfunction. Previous epidemiologic studies demonstrated that a decreased number of residual teeth, decreased denture use, and a small maximal biting force are directly related to the development of dementia, further supporting the notion that mastication contributes to maintain cognitive function”.

A study by Dr. Yoshiyuki Hirano and colleagues in a 2013 issue of Brain and Cognition showed that chewing boosts thinking and alertness and that reaction times among chewers were 10% faster than non-chewers. The research team also reported that up to eight areas of the brain are affected by chewing (most notably the areas concerning attention and movement). It has been claimed that chewing increases arousal levels and that this increased arousal causes increased temporary blood flow to the brain. Commenting on these findings to the Daily Mail, Professor Andy Smith of Cardiff University, said that: “The effects of chewing on reaction time are profound. Perhaps football managers arrived at the idea of chewing gum by accident, but they seem to be on the right track”.

There are dozens and dozens of academic papers all showing the many benefits of mastication but I didn’t come across a single one that looked at whether chewing gum can be addictive. (If you type in ‘chewing gum’ and ‘addiction’ into any academic database you simply get loads of papers about the effectiveness of chewing nicotine gum in helping smoking cessation). However, as the opening quote highlights, there are online self-confessions of ‘chewing gum addiction’. Although the benefits of chewing gum appear to greatly outweigh the disadvantages, there are a number of online articles that take great pride in pointing out the negatives.

In a 2011 article on the Organic Authority website, Jill Ettinger provided a list of reasons of why people should give up chewing gum including jaw aches (accompanied by headaches), intestinal pressure for irritable bowel syndrome sufferers, over-production of saliva, and her assertion that most of the sugar-free chewing gum on the market is sweetened with aspartame, which has been linked to cancer, diabetes, neurological disorders, tinnitus and birth defects”. For those people that don’t chew sugar-free gum, she added that “the rest of the gum out there is typically sweetened with high fructose corn syrup, which in addition to a number of health issues (obesity, diabetes, cancer), is also one of the main causes of tooth decay”. An article in The Delphian by Valgina Cooper also claims chewing gum can be hazardous to your health (and partly based on her own chewing gum experiences). She reported:

“Did you know you could get addicted to gum? Jaws hurt. Teeth hurt because you have been popping gum all day. Millions of people chew gun but could it be an addiction? A person can be addicted to just about anything. People may buy 20 packs of gum a day because chewing gum can calm your nerves…But the taste can get you. Once you pop you can’t stop. Gum addiction can happen to you if you don’t know how to control yourself. First, you start chewing gum because you like the taste. Then you realize that you’re chewing gum when nervous or bored. It can be used to pacify you so it seems like you have something to concentrate on. Therefore the amount of gum chewed within a day increases. After this stage your body comes to a point where it needs gum all the time to feel comfortable…While many people chew gum, few realize that it can become an addiction that can leave you with serious health risks. How do you know you’ve become addicted to gum chewing? When you feel like you have to chew gum to function through the day – as I learned through my own experience”.

From what I have read on the topic, there is little in the empirical literature to suggest chewing gum can be an addiction. There is loads of anecdotal evidence that a minority of individuals chew gum excessively but little evidence among these individuals that it could be classed as an addiction. While I don’t rule out the theoretical possibility of becoming addicted to chewing gum, I have yet to see or read about a case that would fulfil my own criteria for addiction.

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

Further reading

Brook, C. (2013). Chewing over a problem? Chomping on gum can boost alertness by 10%. Daily Mail, February 4. Located at: http://www.dailymail.co.uk/news/article-2272800/Chewing-gum-GOOD-brain-boost-alertness-10.html

Cooper, V. (2003). Warning! Chewing gum can be hazardous to your health. The Delphian, December 10. Located at: http://students.adelphi.edu/delphian/2003.12.10/articles/q.shtml

Ettinger, J. (2011). Hate to burst your bubble but…9 reasons to stop chewing gum. Organic Authority, September 16. Located at: http://www.organicauthority.com/health/bubble-gums-reasons-to-stop-chewing-gum-health.html

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

Hirano, Y., Obata, T., Takahashi, H., Tachibana, A., Kuroiwa, D., Takahashi, T., … & Onozuka, M. (2013). Effects of chewing on cognitive processing speed. Brain and Cognition, 81(3), 376-381.

Kubo, K. Y., Chen, H., & Onozuka, M. (2013). The relationship between mastication and cognition. In Wang, Z. & Inuzuka (Eds.), Senescence and Senescence-Related Disorders. InTech. Located at: http://www.intechopen.com/books/senescence-and-senescence-related-disorders

Saia S. (2013). How I stopped chewing gum. My Yoghurt Addiction, February 25. Located at: http://myyogurtaddiction.com/2013/02/25/how-i-stopped-chewing-gum/

Trends reunited: How has gambling changed? (Part 2)

Most of the changes outlined in my previous blog were things that I predicted would happen in various papers that I wrote in the 1990s. However, there are many things that I did not predict would be areas of growing interest and change. The most interesting (to me at least) include (i) the rise of online poker and betting exchanges, (ii) gender swapping online and the rise of female Internet gambling, (iii) emergence of new type(s) of problem gambling, (iv) increase in use of behavioural tracking data, and (v) technological help for problem gamblers.

Online poker and betting exchanges: Two of the fastest growing forms of online gambling are in the areas of online poker and online betting exchanges. I have speculated there are three main reasons for the growth in these two particular sectors. Firstly, they provide excellent financial value for the gambler. There is no casino house edge or bookmakers’ mark-up on odds. Secondly, gamblers have the potential to win because there is an element of skill in making their bets. Thirdly, gamblers are able to compete directly with and against other gamblers instead of gambling on a pre-programmed slot machine or making a bet on a roulette wheel with fixed odds. However, one of the potential downsides to increased competition is recent research highlighting that problem gamblers are significantly more likely to be competitive when compared to non-problem gamblers. My research unit has also speculated other factors that have aided the popularity of online poker. These include (i) social acceptability of this type of gambling, (ii) promotion through televised tournaments often with celebrity players, (iii) 24/7 availability, (iv) the relative inexpensiveness of playing, and (v) the belief that this is predominantly a game of skill that can be mastered.

Gender swapping and the rise in female Internet gambling: One study by my research unitreported the phenomenon of gender swapping in online poker players. More female players (20%) in our study reported swapping gender when playing compared to males (12%). Typical reasons that female participants gave as to why they did this were that they believed other males would not take them so seriously if they knew they were playing against a woman. It also gave them a greater sense of security as a lone woman in a predominantly male arena. Males and females clearly had different motivations for gender swapping. For males it was a tactical move to give them a strategic advantage. For females it was more about acceptance or privacy in what they perceived to be a male dominated environment. Similar findings have been reported in relation to online computer game playing. In more general terms, the apparent rise in female Internet gambling is most likely because the Internet is a gender-neutral environment. The Internet is seen as less alienating and stigmatising medium when compared to male-dominated environments such as casinos and betting shops. The most obvious example is online bingo where online gaming companies have targeted females to get online, socialise, and gamble.

Emergence of new type(s) of problem gambling: The emergence of new technologies has brought with it new media in which to gamble. As noted above, the rise of online poker has been one of the success stories for the online gaming industry. This rise has also led to more research in this area including some that suggests a different way of viewing problem gambling. For instance, research has suggested that online poker may be producing a new type of problem gambler where the main negative consequence is loss of time (rather than loss of money). This research has identified a group of problem gamblers who (on the whole) win more money than they lose. However, they may be spending excessive amounts of time (e.g., 12 to 14 hours a day) to do this. This could have implications for problem gambling criteria in the future (i.e., there may be more criteria relating to the consequences of time conflicts as opposed to financial consequences).

Increase in use of behavioural tracking data: Over the past few years, innovative social responsibility tools that track player behaviour with the aim of preventing problem gambling have been developed including (e.g., mentor, PlayScan). These new tools are providing insights about problematic gambling behaviour that in turn may lead to new avenues for future research in the area. The companies who have developed these tools claim that they can detect problematic gambling behaviour through analysis of behavioural tracking data. If problem gambling can be detected online via observational tracking data, it suggests that there are identifiable behaviours associated with online problem gambling. Given that almost all of the current validated problem gambling screens diagnose problem gambling based on many of the consequences of problem gambling (e.g., compromising job, education, hobbies and/or relationship because of gambling; committing criminal acts to fund gambling behaviour; lying to family and friends about the extent of gambling, etc.), behavioural tracking data appears to suggest that problem gambling can be identified without the need to assess the negative psychosocial consequences of problem gambling.

Technological help for problem gamblers: Much of this article has discussed the potential downside of technological innovation. However, one area that was not predicted a decade ago is the use of technology in the prevention, intervention, and treatment of problem gambling. For instance, technology is now being used for health promotion using the Web, video games, and/or CD-ROMs. Internet gambling sites are beginning to feature links to relevant gambling awareness sites. For those sites that analyze their online behavioural tracking data, it may be the case that such data could be used to identify problem gamblers and help them rather than exploit them. Finally, help in the form of online therapy (such as online counselling) may be an option for some problem gamblers. For instance, an evaluation that we carried out of an online advice service for problem gamblers showed that clients were very positive about the service and that Internet gamblers were more likely to access the service than non- Internet gamblers.

Obviously the changes I have listed here are the ones that have been most important to me personally and have formed the backbone of my research. In writing these blogs, part of me finds it hard to believe that I am still actively researching in the gambling studies field and that there is always something new to learn and discover.

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

Further reading

Auer, M. & Griffiths, M.D. (2013).Limit setting and player choice in most intense online gamblers: An empirical study of online gambling behaviour. Journal of Gambling Studies, in press.

Griffiths, M.D. (1999). Gambling technologies: Prospects for problem gambling. Journal of Gambling Studies, 15, 265-283.

Griffiths, M.D. (2003). Internet gambling: Issues, concerns and recommendations. CyberPsychology and Behavior, 6, 557-568.

Griffiths, M.D. (2005). Online betting exchanges: A brief overview. Youth Gambling International, 5(2), 1-2.

Griffiths, M.D. (2006). Impact of gambling technologies in a multi-media world. Casino and Gaming International, 2(2), 15-18.

Griffiths, M.D. (2007). Interactive television quizzes as gambling: A cause for concern? Journal of Gambling Issues, 20, 269-276.

Griffiths, M.D. (2009). Internet gambling in the workplace. Journal of Workplace Learning, 21, 658-670.

Griffiths, M.D. (2011). Technological trends and the psychosocial impact on gambling. Casino and Gaming International, 7(1), 77-80.

Griffiths, M.D. (2013). Social gambling via Facebook: Further observations and concerns. Gaming Law Review and Economics, 17, 104-106.

Griffiths, M.D. & Cooper, G. (2003). Online therapy: Implications for problem gamblers and clinicians. British Journal of Guidance and Counselling, 13, 113-135.

Griffiths, M.D. & Whitty, M.W. (2010). Online behavioural tracking in Internet gambling research: Ethical and methodological issues. International Journal of Internet Research Ethics, 3, 104-117.

Griffiths, M.D., Wood, R.T.A. & Parke, J. (2009). Social responsibility tools in online gambling: A survey of attitudes and behaviour among Internet gamblers. CyberPsychology and Behavior, 12, 413-421.

Meyer, G., Hayer, T. & Griffiths, M.D. (2009). Problem Gaming in Europe: Challenges, Prevention, and Interventions. New York: Springer.

Wardle, H., Moody, A., Griffiths, M.D., Orford, J. & and Volberg, R. (2011). Defining the online gambler and patterns of behaviour integration: Evidence from the British Gambling Prevalence Survey 2010. International Gambling Studies, 11, 339-356.

Wood, R.T.A. & Griffiths, M.D. (2007). Online guidance, advice, and support for problem gamblers and concerned relatives and friends: An evaluation of the Gam-Aid pilot service. British Journal of Guidance and Counselling, 35, 373-389.

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.