Monthly Archives: October 2015

Step toe and fun: Another look at trampling fetishism

“I’m a guy and I LOVE being walked on by women wearing high heels. It doesn’t hurt. Is this normal to have women step on my guy parts with high heels?” (Question posted on a Yahoo! website).

In a previous blog I briefly looked at ‘trampling fetishism’. According to a relatively new Wikipedia entry on the behaviour:

“Trampling refers to the sexual activity that involves being trampled underfoot by another person or persons. Trampling is common enough to support a sub-genre of trampling pornography. Because trampling can be used to produce pain, the trampling fetish for some adherents is closely linked to sadomasochistic fetishism. A similar fetish is to imagine themselves as being tiny under another’s feet, or being normal size, but being trampled by a giant person. This is known as ‘giant/giantess fetishism’ or macrophilia. It is not the same as trampling. The most common form of trampling is done by a male or female walking on a male or female submissive and is usually done barefooted, in socks, nylons, or shoes. The trampler will predominantly walk, jump and stomp on the person’s back, chest, stomach, genitalia, face and in some rare instances, the neck”.

If you type ‘trampling fetish’ into Google, lots of YouTube video clips appear instantly. Video clips of trampling have been present on the internet since 1997 courtesy of an number of infamous American tramples such as ‘Daddo’ ‘Kingfish’ and ‘LAF’. If you’re not into the visual side, you can read various forms of trampling fan fiction such as the stories at the Trample and Crushing website.

Since writing my previous blog on this topic, I filmed an interview about a trampling fetishist as part of the television program Forbidden (on which I was the resident psychologist). The television program that I participated in followed the story of a man called Frank O’Brien. Frank recalls his fetish developing during early to mid- adolescence. As a 15-year old teenager, he would trick the girls he knew into stepping on him by inventing games that resulted in him being trampled upon. As the show’s production notes reported:

“[Frank would] invent games to race girls to the door of his cubby house and have them wrestle or sit on him in the process. In the backyard pool he’d encourage them to step on him underwater. Ever since he can remember Frank has wanted to get under a girl’s foot…You could say Frank gets a ‘kick’ out of it. And among friends Frank is known simply as ‘Step on Me.’ For Frank, there’s nothing finer than having a woman walk all over him”.

By his early thirties Frank’s trampling fetish began to take up more and more of his time. In his social life he started attending as many sadomasochistic shows that he could and he longed and desired dominant mistresses that would help cater for his trampling fetish. The back-story I received about Frank noted that:

“The mistresses he saw early in life largely turned Frank away from the idea of trampling. They were more prostitutes than professional mistresses with an idea of what he really wanted. Back in those days there was no training for mistresses in trampling and this really has only taken off in Australia since the early 2000s. Now there are mistresses who train specifically in trampling”.

According to Frank, Melbourne is the centre of Australia’s BDSM culture and he introduced the Forbidden film crew to the niche trampling community that exists there. Frank’s favourite club is ‘Provocation’ that hosts a monthly fetish social event.

“But his idea of getting down on the dance floor is a little different to most. When Frank gets down, he literally gets down. He has a special mat that he lies on to make the experience slightly more bearable but comfort is not exactly what Frank is looking for. He’ll bring with him a platform that he’ll set up beside his mat; written across it are the words ‘step up here – girls only’. And that’s exactly what Frank wants. He’ll lie there for hours in the club, enjoying the feeling of women trampling him. Some wear stilettos, some are in platform shoes and others go barefooted – he doesn’t discriminate about what kind of footwear is permitted, but generally sharper and more pointy shoes offer greater satisfaction for [him]”.

Frank describes himself naturally submissive and he now has weekly trampling sessions with ‘Mistress Spanklet’ who is Frank’s long-term friend and a Dom-sub ‘play partner’. Frank describes these weekly sessions as his “drug fix” and something he “couldn’t live without”. Despite having some of his bowel removed (and it being dangerous for him for someone to trample on his stomach), he cannot stop it. He now tries to avoid ‘tummy trampling’ but notes that:

“Trampling can be on any part of the body, including the more sensitive regions of the face, throat and genitalia. [He] enjoys cock and ball trampling on a weekly basis with Spanklet. His face, arms and legs are also prime trampling ground in private and in public”.

In fact, Frank claims that he was responsible for the first ever penis trampling photograph on the internet. In 1999, Frank claimed he took the full weight of a woman in sharp red stilettos twisting as hard as she could on his penis. Frank claims the photograph (taken by the woman’s sexual partner) kick-started “the worldwide cock trampling trend”.

There appears to be little academic research on the topic but anecdotal evidence suggests there is (unsurprisingly) an overlap between trampling fetishes and foot fetishes (podophilia) – on which there is quote a lot of academic research given it appears to be the most prevalent type of fetishism. Obviously Frank’s case is extreme and is heavily interwoven into his life. While there appear to be addictive elements to his behaviour, I don’t believe that Frank’s trampling fetish is an addiction. Bizarre and extreme – yes. Addictive – no. But I’m happy to be proved wrong.

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

Further reading

Semple, K. (2009). Bartender, make it a stiletto. New York Times, June 10. Located at:

Sexy Tofu (2012). National Fetish Day: Interview with a trampler. January 20. Located at:

Wikipedia (2012). Talk: Crush fetish. Located at:

Wikipedia (2012). Trampling. Located at:

Penned in: How to become an excessive (and productive) writer

Many people that I know would probably describe me as a ‘writaholic’ based on the number of articles and papers that I have had published. When it comes to addictions in academia, ‘writing addiction’ is just about the best one you can have. I don’t believe I have an addiction to writing but it is a very salient activity in my life and I am a habitual writer and I write every day. In previous blogs I examined diary writing and psychological wellbeing as well as an article on graphomania (obsessive writing). Today’s blog briefly examines some of the things that make people more productive writers (and by definition a more excessive writer). During my career I’ve published many articles on the writing process (see ‘Further reading’ below) and today’s blog looks at some of my beliefs and practices.

Before outlining some general advice, it’s also worth exploring many of the false beliefs that many of us have about writing – beliefs which may explain why many of us don’t like writing. For instance:

  • Writing is inherently difficult: Like speaking, writing doesn’t need to be perfect to be effective and satisfying.
  • Good writing must be original: Little, if any, of what we write is truly original. What makes our ideas worthwhile communicating is the way we present them.
  • Good writing must be perfect preferably in a single draft: In general, the more successful writers are more likely to revise manuscripts.
  • Good writing must be spontaneous: There appears to be a belief that writing should await inspiration. However, the most productive and satisfying way to write is habitually, regardless of mood or inspiration. Writers who overvalue spontaneity tend to postpone writing, and if they write at all, they write in binges that they associate with fatigue.
  • Good writing must proceed quickly: Procrastination goes hand in hand with impatience. Those writers who often delay writing suppose that writing must proceed quickly and effortlessly. However, good writing can often proceed at a slow pace over a lengthy period of time.
  • Good writing is delayed until the right mood with big blocks of undisrupted time available: Good writing can take place in any mood at any time. It is better to write habitually in short periods every day rather than in binges.
  • Good writers are born not made: Good writing is a process that can be learned like any other behaviour.
  • Good writers do not share their writing until it is finished and perfect: Although some writers are independent, many writers share their ideas and plans at an early stage and then get colleagues to read over their early drafts for comments and ideas.

Even when these false beliefs about writing are dispelled, many of us can still have problems putting pen to paper or finger to keypad. Insights about writing only slowly translate into actions. For most professionals, writing is only done out of necessity (i.e., a report that they have to hand in). This produces a feeling of ‘having to write’ rather than ‘wanting to write’ and can lead to boredom and/or anxiety. Furthermore, most people appear to view writing as a private act in which their problems are unique and embarrassing. Strategies for overcoming this include getting colleagues to criticize their own work before going ‘public’, sharing initial plans and ideas with others, and practising reviewing other people’s work.

It is generally acknowledged that there is no one proven effective method above all others for teaching people to become better writers. It is also a process that can be learned and can aid learning (i.e., a skill learned through opportunities to write and from instructional feedback). Although there are no ‘quick fixes’ to becoming a better writer, here are some general tips on how to make your writing more productive. I would advise you to:

  • Establish a regular place where all serious writing is done
  • Remove distracting temptations from the writing site (e.g., magazines, television)
  • Leave other activities (e.g., washing up, making the dinner) until after writing
  • Limit potential interruptions (e.g., put a “Do not disturb” sign on the door, unplug the telephone)
  • Make the writing site as comfortable as possible
  • Make recurrent activities (e.g., telephone calls, coffee making) dependent upon minimum periods of writing first
  • Write while ‘feeling fresh’ and leave mentally untaxing activities until later in the day
  • Plan beyond daily goals and be realistic about what can be written in the time available
  • Plan and schedule writing tasks into manageable units
  • Complete one section of writing at a time if the writing is in sections
  • Use a word processor to make drafting easier
  • Revise and redraft at least twice
  • Write daily rather than ‘bingeing’ all in one go
  • Share writing with peers as people are more helpful, judgmental and critical on ‘unfinished’ drafts

Obviously, the problem with such a prescriptive list such as this is that not every suggestion will work for everyone. Many of us know our own limitations and create the right conditions to help get the creative juices going. Some people can’t write in silence or with others in the room. By reading this short blog I cannot make you become a more productive and excessive writer overnight. However, it has hopefully equipped my blog readers with some tips and discussion points that may help in facilitating better writing amongst yourselves and colleagues.

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

Further reading

Griffiths, M.D. (1994). Productive writing in the education system. The Psychologist: Bulletin of the British Psychological Society, 7, 460-462.

Griffiths, M.D. (2001). How to…get students to write with confidence. Times Higher Education Supplement, June 8, p.24.

Griffiths, M.D. (2004). Tips on…Report writing. British Medical Journal (Careers), 328, 28.

Griffiths, M.D. (1998). Writing for non-refereed outlets (Part 1 – Professional journals and newsletters). Psy-PAG Quarterly, 29, 41-42.

Griffiths, M.D. (1999). Writing for non-refereed outlets (Part 2 – Newspapers and magazines). Psy-PAG Quarterly, 30, 5-6.

Griffiths, M.D. (2000). Writing and getting published – My top 10 tips. Psy-PAG Quarterly, 34, 2-4.

Griffiths, M.D. (2005). Addiction, fiction and media depiction: A light-hearted look at scientific writing and the media. Null Hypothesis: The Journal of Unlikely Science, 2(2), 16-17.

Griffiths, M.D. (2010). Top tips on…Writing with confidence. Psy-PAG Quarterly, 76, 33-34.

Griffiths, M.D. (2013). How writing blogs can help your academic career. Psy-PAG Quarterly, 87, 39-40.

Griffiths, M.D. (2014). Top tips on…Writing blogs. Psy-PAG Quarterly, 90, 13-14.

Making an online killing: A brief look at “suicide fetishes” and “addiction” to suicide websites

Back in March 2011, a then 46-year old American ex-nurse William Melchart-Dinkel from Minnesota was convicted of persuading two people he met online to commit suicide. Melchart-Dinkel was accused of having a “suicide fetish” because he got his kicks from frequenting online suicide chat rooms. Posing as a female nurse, he would chat online and feign compassion to depressed individuals and encourage them to commit suicide.

More specifically, a US court found him guilty of aiding the suicides of 18-year old Canadian student Nadia Kajouli (who jumped into a river and drowned), and 32-year old British IT technician Mark Drybrough (who hanged himself). During the trial, Nadia’s mother shared extracts of the online chats that took place between her daughter and Melchart-Dinkel (who was using various aliases including ‘Cami’, ‘Falcon Girl’ and ‘Li Dao’). A Minnesotan Internet crimes task force forensically examined Melchert-Dinkel’s computer and located online chats that he had with the Canadian teenager. The online conversation demonstrated that Melchart-Dinkel had urged Nadia to hang herself (rather than kill herself by drowning) and provided detailed instructions on how to kill themselves:

“If you wanted to do hanging we could have done it together online so it would not have been so scary for you…Most important is the placement of the noose on the neck…knot behind the left ear and rope across the carotid is very important for instant unconsciousness and death…I’m just trying to help you do what is best for you not me”.

Melchart-Dinkel even urged Nadia to kill herself while they were chatting online. A few hours after chatting with Melchart-Dinkel, Nadia emailed her roommate and told her she was going to “brave the weather and go ice skating” (in an effort to make it look like an accident). Nadia jumped into a frozen river (but her body was not found until 11 days after she had jumped in). In Mark’s case, Melchert-Dinkel replied to a question posted online by Mark about how he could hang himself if he didn’t have a high ceiling. Following a long email conversation, Melchert-Dinkel instructed him on what to do and convinced Mark that ‘she’ was suicidal too. Melchert-Dinkel wrote:

“I keep holding on to the hope that things might change. Caught between being suicidal and considering it. Same old story!…I don’t want to waste anyone’s time. If you want someone who’s suicidal, I’m just not there yet…Sorry. I admire your courage. I wish I had it”. 

Mark killed himself a few days later. Mark’s mother Elaine called Melchert-Dinkel her son’s “executioner”. She also told the Daily Mail in the UK:

“Mark had had a nervous breakdown and he was depressed and incredibly susceptible. [Melchert-Dinkel ]was there whispering in his ear every time he logged on. In the last email, [he] claimed to be a nurse, saying he had medical training, and proposed a suicide pact”

With the help of Celia Blay (a youth worker from Wiltshire in the UK), Mark’s mother managed to track Melchert-Dinkel. It was during their own investigation they discovered dozens of people had received similar emails to Mark’s:

“We found out everything about him on Google, including where he lived in Minnesota. He befriended them using a female identity, was very loving and sympathetic, but never suggested an alternative to death, even when they were only teenagers. He’d tell them that he intended to kill himself too, and said they should set up a web camera and he would do the same thing so they could watch each other die over the internet”.

During his testimony, Melchert-Dinkel admitted that he had asked between 15 and 20 people to commit suicide on camera while he watched (although when he was first caught, he said the online chatting must have been his teenage daughters). One report on Melchert-Dinkel’s case noted:

“While he never actually witnessed a suicide, he did believe that at least five of the people he had talked to were successful in taking their own lives. He also entered into around 10 ‘suicide pacts’ where he promised to kill himself simultaneously with the person he had been chatting with…Melchert-Dinkel was admitted to a hospital where he told doctors he had a ‘suicide fetish’ and an addiction to suicide websites”.

Before the trial, the Associated Press had interviewed Professor Jonathan Turley (George Washington University Law School), an expert on doctor-assisted suicide. It was reported that:

“[Professor Turley has] never heard of anyone being prosecuted for encouraging a suicide over the Internet. Typically, people are prosecuted only if they physically help someone end it all – for example, by giving the victim a gun, a noose or drugs. Last month, a Florida man was charged in his wife’s suicide after allegedly tossing several loaded guns onto their bed. Turley said if prosecutors file charges against Melchert-Dinkel, convicting him will be difficult – especially if the defense claims freedom of speech. The law professor said efforts to make it illegal to shout ‘Jump!’ to someone on a bridge have not survived constitutional challenges. ‘What’s the difference between calling for someone to jump off a bridge and e-mailing the same exhortation?’ he said”.

This line of defence was used by Melchert-Dinkel’s legal team. His behaviour was described as “abhorrent” by his own lawyer (Terry Watkins) but argued in court that his client’s actions were protected by the freedom of speech. Watkins said in court that:

“Freedom means you have to allow things to happen that some would find disgusting and completely unacceptable from a community or moral standpoint”.

However, the presiding judge (Thomas Neuville) said that the accused had “imminently incited the victims to commit suicide” and described Melchart-Dinkel’s online written comments as “unprotected speech”. He was sentenced to almost a year in prison (360 days) but was delayed until a ruling from the Supreme Court (SC). Earlier this year, the SC in Minnesota overturned Melchert-Dinkel’s conviction, and ruled that Minnesota’s law prohibiting the “encouraging” of suicide was unconstitutional and (as Professor Turley claimed) violated a person’s freedom of speech. However, the case (as far as I am aware) is still continuing because the original state prosecutors are trying to argue that Melchert-Dinkel “assisted” (rather than “encouraged”) people’s suicides.

My own take on this case is that Melchart-Dinkel committed a criminal act and that his claim to medics that he was addictedto encouraging people to commit suicide was made as a way of absolving responsibility for what he did. There was nothing about his online behaviour to suggest it was in any way addicted (at least not by my own criteria). Also, his own use of the word fetish is inappropriate in this instance. Although he did appear to get some kind of kick from his activity, there was nothing sexual in it. Again, his use of the word ‘fetish’ to describe his behaviour also appears to be another linguistic device to distance himself from taking the blame for his actions.

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

Further reading

Associated Press (2011). Nurse William Melchart-Dinkel had ‘suicide fetish’, went online to provoke two people’s deaths: cops. New York Daily News, October 17. Located at:

Caulfield, P. (2011). ‘Suicide fetish’ nurse found guilty of provoking people he found online to kill themselves. Daily News, March 16. Located at:

Firth, N. (2010). Revealed: The suicide voyeur nurse who ‘encouraged people to kill themselves online’. Daily Mail, March 20. Located at:

Guariglia, M. (2014). William Melchert-Dinkel: 5 Fast facts you need to know. Heavy News, March 19. Located at:

Murray, Rheana. (2008). A search for death: How the internet is used as a suicide cookbook. Chrestomathy, 7, 142-156.

Yount, K. (2014). Minnesota Supreme Court turns its back on mentally ill. (i)Pinion, March 27. Located at:

Meet markets: The psychology of school reunions

I was recently interviewed for a feature in The Observer newspaper about the psychology of school reunions. The journalist that interviewed me wanted to know the different types of people that go to them and why people would go to them in the first place. I have to admit that I’ve never come across any academic research on the topic and I’ve never ever gone to one myself so I had to rely on pure speculation.

Around the time of the interview I also got an email via LinkedIn from someone I was at junior school with and then spent the next week catching up on what she had been up to in the 35 years since I last saw her. The reason I mention this is that the psychology of why someone would correspond with someone else from their junior or secondary school after years of no communication whatsoever is probably similar (or the same) as the reasons for attending school reunions. So here are the reasons I came up with as to why someone might want to attend a school reunion (or catch up with an old class colleague on social media)

To catch up with old friends: Perhaps the most obvious reason for attending school reunions is simply to catch up, talk and socialise with old friends. This may also involve seeing what your old classmates have been up to and/or the see how their lives progressed (or in a minority of cases ended). I think we can all think of cases where we say to ourselves “I wonder what ever happened to [XXX]?” School reunions are perfect for finding some of the answers as none of us knew when we were in junior school what we would end up being later in our lives. Fundamentally, reunions are about reconnecting with others and connection is what many people want and need. As one of the few online articles on the psychology of reunions noted:

“A connection to school was a safe haven for many. Some could submerge themselves in academic life; others could forget about their cares in the reverie of an infatuation. Adolescent friendship may have been the guardian of your self-esteem, or the absence of connection, even if you were in a crowd, may have resulted in loneliness”.

To re-live good times and memories: It’s often said that school days were the best days of our lives and that school was a safe haven (even if it didn’t feel that way at the time). Some people will want to talk with old friends about the japes and pranks they used to get up to and have a laugh. Basically, people may attend school reunions for primarily nostalgic reasons.

To see how people have physically changed: Some people attending school reunions might want to see how people have changed and/or aged. Have your friends gone grey? Do they even still have hair? Have they turned from an ‘ugly duckling’ into a beautiful swan?

To change perceptions of how people remembered you: Another possible reason for attending a school reunion might be to change people’s perceptions of how your classmates remembered you. Maybe you were the class joker, the class bad boy, the class nerd, or the class wallflower. The school reunion might provide the perfect situation to correct people’s views and prejudices. 

To settle scores: For a small minority of individuals, the class reunion may be a way of getting revenge or settling scores. Similarly, it might be about getting closure on events that happened decades ago.

To compare and/or show off: Some people might want to attend school reunions simply as an opportunity to show off (or attempt to show off) how well they’ve done for themselves since leaving school and to engage in a little bit of ‘one-upmanship’ (defined by various dictionaries as “the technique or practice of gaining an advantage or feeling of superiority over another person” or a situation in which someone does or says something in order to prove that they are better than someone else). There may also be an element of ‘keeping up with the Joneses’ (i.e., “referring to the comparison to one’s neighbor as a benchmark for social class or the accumulation of material goods”) combined with social comparison theory (SCT). “[SCT], initially proposed by social psychologist Leon Festinger in 1954 centers on the belief that there is a drive within individuals to gain accurate self-evaluations. The theory explains how individuals evaluate their own opinions and abilities by comparing themselves to others in order to reduce uncertainty in these domains, and learn how to define the self” (Wikipedia entry on SCT).

In one of the few online articles I located on the psychology of school reunions noted:

“The problem with school reunions is that there is inevitable anxiety about how your life will compare to others. For some people this this may be about physical appearance; for others educational achievement or maybe financial status. It seems to be one of those things humans can’t resist doing. We need to compare ourselves to others to try to judge how we’re doing. This kind of behaviour is seen across many species as it’s crucial in judging whether you can beat a rival without putting yourself at risk…Simply put we look at those less successful than us and focus on how we are different from them. We then look at those more successful and focus on how we are similar to them”

The article also went on to say that:

“It’s common for high school reunions to trigger anxiety about appearance and status. Most of us want to forget our teenage self-conscious emotions that resulted from hormonal changes and social pressures. But years later, at a class reunion, those old insecurities get triggered. They rear their ugly head in the imagined judgment of peers: What will they think? Will I be successful enough? Will I look good to them? Resurfacing of emotional memories, it’s important to recognize that reunions are not at all about comparisons and judgments”.

I have to concur with much of this speculation as I’ve often had similar thoughts when meeting up with people I’ve not seen for years. Given that school reunion events are commonplace in many parts of the world, the biggest mystery is why there is little in the psychological literature on such social practices.

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

Further reading

Festinger, L. (1954). A theory of social comparison processes. Human Relations, 7(2), 117-140.

Russ (2013). The psychology of school reunions. Virtually Free, June 25. Located at:

Good buy to love: Introducing the Bergen Shopping Addiction Scale

(Please note that the following article was co-written using material provided by my research colleague Dr. Cecilie Schou Andreassen and our fellow researchers).

In two of my previous blogs I took a brief look at the area of shopping addiction (that you can read here and here). Since writing those blogs I’ve co-written a few papers on compulsive buying and shopping addiction (see ‘Further reading’ below), the latest of which was published in the journal Frontiers in Psychology (FiP) and led by my friend and research colleague Dr. Cecilie Schou Andreassen at the University of Bergen in Norway. In the FiP paper we reported on the development of a newly created instrument to assess this disorder called the Bergen Shopping Addiction Scale (BSAS).

Whether compulsive and excessive shopping represents an impulse-control, obsessive-compulsive or addictive disorder has been debated for several years This fact is reflected in the many names that have been given to this disorder including ‘oniomania’, ‘shopaholism’, ‘compulsive shopping’, ‘compulsive consumption’, ‘impulsive buying’, “compulsive buying’ and ‘compulsive spending’. In a review by Dr. Andreasson in the Journal of Norwegian Psychological Association, she argued that shopping disorder is best understood from an addiction perspective, and defined it as “being overly concerned about shopping, driven by an uncontrollable shopping motivation, and to investing so much time and effort into shopping that it impairs other important life areas”. Several authors (including myself) share this view as a growing body of research shows that those with problematic shopping behaviour report specific addiction symptoms such as craving, withdrawal, loss of control, and tolerance.

Research also suggests that the typical shopping addict is young, female, and of lower educational background. Some personality factors have also been shown to be associated with shopping addiction including extroversion and neuroticism. It has been suggested that neurotic individuals (typically being anxious, depressive, and self-conscious) may use shopping as means of reducing their negative emotional feelings. Other personality factors may actually protect individuals from developing shopping addictions (e.g., conscientiousness). Empirical research (including some research I carried out with Kate Davenport and James Houston published in a 2012 issue of the International Journal of Mental Health and Addiction) has consistently reported significantly lower levels of self-esteem among shopping addicts. Such findings suggest that irrational beliefs such as “buying a product will make life better” and “shopping this item will enhance my self-image” may trigger excessive shopping behaviour in people with low self-esteem. However, this may be related to depression, which has been shown to be highly comorbid with problematic shopping.

Other factors, such as anxiety have also often been associated with shopping, and it has also been suggested that self-critical people shop in order to escape, or cope with, negative feelings. In addition, shopping addiction has also been explained (by such people as Dr. Marc Potenza and Dr. Eric Hollander) as a way of regulating neurochemical (e.g., serotonergic, dopaminergic, opioid) abnormalities and has been successfully treated with pharmacological agents, including selective serotonin reuptake inhibitors (SSRIs) and opioid antagonists.

One of the key problems that we outlined in our new FiP paper is that in prior research there is a lack of a common understanding about how problematic shopping should be defined, conceptualized, and measured. Consequently, there are huge disparities and unreliable prevalence estimates of shopping addiction ranging from 1% to 20% and beyond (depending upon the criteria used to assess the disorder). Although several scales for assessing shopping addiction have been developed (mainly in the late 1980s and early 1990s) many of them have poor theoretical anchoring and/or are primarily rooted within the impulse-control paradigm. We also argued that several items of existing scales are outdated with regards to modern consumer patterns (such as people using cheques or no reference to online shopping). Newer scales that have been developed don’t view problematic shopping behaviour as an addiction in terms of core addiction criteria (i.e., salience, mood modification, tolerance, withdrawal, conflict, relapse and resulting problems).

This is why we decided to develop a new shopping addiction scale (i.e., the BSAS) containing a small number of items that reflect the core elements of addiction (and if you want to take the test yourself, it’s at the end of this article). We examined the psychometric properties of the new scale among a large sample of Norwegian individuals (n=23,537), and the testing phase began with 28 items (four statements for each of the seven components of addiction outlined above). The BSAS was constructed simply by taking the highest scoring item from each of seven 4-item clusters. We found that scores on the BSAS were significantly higher among females, as well as being inversely related to age (and therefore in line with previous research). We also found that scores on the BSAS were positively associated with extroversion and neuroticism.

The association of shopping addiction with extroversion may reflect that, in general, extroverts need more stimulation than non-extroverted individuals, a notion that is in line with studies showing that extroversion is associated with addictions more generally. It may also reflect the notion that extroverts purchase specific types of products excessively as a means to express their individuality, enhance personal attractiveness, or as a way to belong to a certain privileged group a (e.g., the buying of high end luxury goods). The association of shopping addiction with neuroticism may be because neuroticism is a general vulnerability factor for the development of psychopathology and that people scoring high on neuroticism engage excessively in different behaviours in order to escape from dysphoric feelings.

We also found that shopping addiction was inversely related to self-esteem. This is also in line with the findings of previous studies and implies that some individuals shop excessively in order to obtain higher self-esteem (e.g., associated “rub-off” effects from high status items such as popularity, compliments, in-group ‘likes’, omnipotent feelings while buying items, attention during the shopping process from helping retail personnel), to escape from feelings of low self-esteem, or that shopping addiction lowers self-esteem. Obviously our new scale needs to be further evaluated in future studies (as it has only been investigated in this one study) and it also requires validation in other cultures.

Overall, we concluded that the BSAS has good psychometrics – basically the scale is quick to administer, reliable and valid. With the advent of new technology and modern consumer patterns we may be witnessing an increase in problematic shopping behaviour. It is likely that new Internet-related technologies can greatly facilitate the emergence of problematic shopping behaviour because of factors such as accessibility, affordability, anonymity, convenience, and disinhibition. Therefore, we encourage other researchers to consider using the BSAS in epidemiological studies and treatment settings.

Want to take the test?  

Answer each of the following questions with one of the following five responses: ‘completely disagree’, ‘disagree’, ‘neither disagree nor agree’, ‘agree’, and ‘completely agree’.

  • You think about shopping/buying things all the time
  • You shop/buy things in order to change your mood
  • You shop/buy so much that it negatively affects your daily obligations (e.g., school and work)
  • You feel you have to shop/buy more and more to obtain the same satisfaction as before.
  • You have decided to shop/buy less, but have not been able to do so
  • You feel bad if you for some reason are prevented from shopping/buying things
  • You shop/buy so much that it has impaired your well-being

If you answer “agree” or “completely agree” on at least four of the seven items, you may be a shopping addict.

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

Further reading

Aboujaoude, E. (2014). Compulsive buying disorder: A review and update. Current Pharmaceutical Design, 20, 4021-4025.

Andreassen, C. S. (2014). Shopping addiction: An overview. Journal of Norwegian Psychological Association, 51, 194–209.

Andreassen, C.S., Griffiths, M.D., Pallesen, S., Bilder, R.M., Torsheim, T. Aboujaoude, E.N. (2015). The Bergen Shopping Addiction Scale: Reliability and validity of a brief screening test. Frontiers in Psychology, 6:1374. doi: 10.3389/fpsyg.2015.01374.

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, 10, 474-489.

Maraz, A., Eisinger, A., Hende, Urbán, R., Paksi, B., Kun, B., Kökönyei, G., Griffiths, M.D. & Demetrovics, Z. (2015). Measuring compulsive buying behaviour: Psychometric validity of three different scales and prevalence in the general population and in shopping centres. Psychiatry Research, 225, 326–334.

McQueen, P., Moulding, R., & Kyrios, M. (2014). Experimental evidence for the influence of cognitions on compulsive buying. Journal of Behavior Therapy and Experimental Psychiatry, 45, 496–501.

Workman, L., & Paper, D. (2010). Compulsive buying: A theoretical framework. Journal of Business Inquiry, 9, 89–126.

Choking aside: Another look at self-asphyxial risk-taking behaviour in adolescence

In a previous blog I examined the ‘choking game’ (also known by dozens of names including the ‘fainting game’ and ‘suffocation roulette’). This was a game that I played a couple of times as an adolescent (although we called it ‘Headrush’). This was a game where I would have my breathing temporarily stopped by someone holding onto my chest after a deep expiration and hyperventilation (so that I could not breathe). It induced feelings of light-headedness and dizziness followed by temporary unconsciousness (usually lasting 10 to 15 seconds).

This activity that I engaged in as a teenager is an example of self-asphyxial risk-taking behaviour (SARTB). It also appears that what I did when I was an adolescent was a form of ‘self-induced hypocapnia’ (i.e., a state of reduced carbon dioxide in the blood). It has also been reported that these ‘games’ can be played alone and typically involve self-strangulation, or sometimes with others, and where like my own experiences, the cutting off of the oxygen supply was carried out by somebody else.

Reports of SARTB date back to the early 1950s in the medical literature (for instance, Dr. P. Howard and his colleagues reported a case in a 1951 issue of the British Medical Journal). SARTB has been defined by R.L. Toblin and colleagues in a 2008 issue of the Journal of Safety Research as self-strangulation or strangulation by another person with the hands or a noose to achieve a brief euphoric state caused by cerebral hypoxia. As with autoerotic asphyxiation (i.e., suffocation as a way of enhancing sexual arousal), the aim of SARTB is to intentionally cut off the oxygen supply to the brain to experience a feeling of euphoria (the only difference being that in children’s games, it is not done for a sexual reason).

How prevalent the activity is debatable as most of the academically published studies are case reports (usually when a problem – and in some cases, death – has occurred). However, a comprehensive systematic review of SARTB was recently published by Busse et al (2015). They attempted to assess the prevalence of engagement in SARTB and associated morbidity and mortality in children and adolescents (and up to early adulthood). Busse and colleagues examined every survey and case study that had been published on SARTB, and more specifically examining the behaviour among those aged 
0–20 years (excluding any study where the motive was autoerotic, suicidal or self-harm). They reported that 36 studies had examined child and adolescent SARTB in 10 different countries (North America and France being the most common, but also reports in the UK).

Risk factors for SARTB were hard to assess because most of the studies examining such risks did not control for other confounding variables. However, five of the studies reported an association between SARTB and a number of other risky behaviours including substance misuse, risky sexual behaviours, poor mental health, poor dietary behaviours, and engagement in risky sports. The review also reported that there did not seem to be any association between SARTB and engagement in physical activity, and experiencing accidents, and/or hospital admissions. It was also noted that a number of other behaviours increased the likelihood of engaging in SARTB including experiences of violence, being more impulsive, having a thrill-seeking personality, and having lower school achievement. However, only six of the 36 studies they reviewed reported the potential for SARTB to be associated with other risky behaviours. No consistent findings were found between SARTB and gender, age and other demographic factors (such as socio-economic status).

Examining the studies as a whole, Busse and colleagues reported that awareness of SARTB ranged from 36% to 91%, and that the median lifetime prevalence of engagement in SARTB was 7.4% (however, these were studies that used convenience sampling, therefore none of the studies were necessarily representative). In the SARTB literature, a total of 99 fatal cases were reported (and of the 24 detailed case reports, most of the deaths occurred when individuals were engaged in SARTB alone and used some type of ligature).

In a different analysis in the Journal of Safety Research, Dr. R.L. Toblin and colleagues used US news media reports to estimate the incidence of deaths from SARTB. Their report identified 82 probable SARTB deaths among youths aged 6-19 years during 1995 and 2007. Of these 82 cases, 71 (86.6%) were male, and the mean age of death was just over 13 years of age. The study also noted that deaths were recorded in 31 US states and were not clustered by location, season or day of week. Busse and colleagues assert the importance of education and prevention and more specifically note:

“As it has been suggested that knowledge and identification of symptoms and signs of engagement in [SARTB] could have possibly enabled early identification and possible prevention of fatal cases, we believe that clinicians, paediatricians, health professionals and teachers should receive education on the symptoms and signs of [SARTB]. The need to educate health professionals has been highlighted as awareness of [SARTB] will enable these individuals to identify symptoms and signs and to act as educators to young people and their parents…We further recommend that more research is carried out together with young people to develop appropriate education material. In line with recommendations from others, we further recommend removing existing videos about [SARTB] from the internet and ensuring that preventative website rather than promotional websites appear first on internet searches” (p.8).

This brief examination of the literature suggests that a significant minority of adolescents have engaged in SARTB and that in extreme cases it may lead to death. Despite being known about for over 60 years, the data concerning SARTB are still limited and relatively little is known about the associated risk factors. However, SARTB certainly appears to be an activity that parents and teachers should be made more aware of even if the prevalence of such activity among children and adolescents is low.

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

Further reading

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

Busse, H., Harrop, T., Gunnell, D. & Kipping, R. (2015). Prevalence and associated harm of engagement in self-asphyxial behaviours (‘choking game’)
in young people: A systematic review. Archives of Disease in Childhood, doi:10.1136/archdischild-2015-308187.

Drake, J.A., Price, J.H., Kolm-Valdivia, N. & Wielinski, M. (2010). Association of adolescent choking game activity with selected risk behaviors. Academic Pediatrics, 10, 410-416.

Egge, M.K., Berkowitz, C.D., Toms, C. & Sathyavagiswaran, L. (2010). The choking game: A cause of unintentional strangulation. Pediatric Emergency Care, 26, 206-208.

Griffiths, M.D. (2015). A brief review of self-asphyxial risk-taking behaviour in adolescents. Education and Health, 33, 59-61.

Howard, P., Leathart, G. L., Dornhorst, A.C., & Sharpey-Schafer, E.P. (1951). The mess trick and the fainting lark. British Medical Journal, 2, 382-384.

MacNab, A.J., Deevska, M., Gagnon, F., Cannon, W.G. & Andrew, T (2009). Asphyxial games or “the choking game”: A potentially fatal risk behavior. Injury Prevention, 14, 45-49.

Shlamovitz, G.Z., Assia, A., Ben-Sira, L. & Rachmel, A. (2003). “Suffocation roulette”: A case of recurrent syncope in an adolescent boy. Annals of Emergency Medicine, 41, 223-226.

Toblin, R.L., Paulozzi, L.J., Gilchrist, J. & Russell, P.J. (2008). Unintentional strangulation deaths from the “choking game” among youths aged 6-19 years -United States, 1995-2007. Journal of Safety Research, 39, 445-448.

Urkin, J. & Merrick, J. (2006). The choking game or suffocation roulette in adolescence (editorial). International Journal of Adolescent Medicine and Health, 18, 207-208.

Hoovers and shakers: Another look at vacuum cleaner sex

In a previous blog I briefly looked at the medical literature relating to penile injuries arising from autoerotic interactions from vacuum cleaners. While researching that blog I also came across other literature that had examined vacuum cleaners being used for sexual purposes that I thought I would make another interesting blog. A number of references in the psychological literature make reference to particular types of people using vacuum cleaners as a source of sexual stimulation for masturbatory purposes. For instance, in a 2005 chapter by Lynne Moxon about sexuality and Asperger Syndrome (i.e., an autism spectrum disorder typically characterized by major difficulties in social interaction and non-verbal communication) noted that among Asperger’s sufferers:

“Lack of awareness of the use of the imagination for sexual fantasy can lead to the use of more physical forms of stimulation, such as the vibration of washing machines or public transport, or the use of vacuum cleaner pipes, holes in chair backs, socks, bottles and more unusual items, such as TV remote controls and golf clubs. Females unaware of the use of sex toys have used deodorant cans, scissors, keys and candles”.

In a 2013 study by Dr. Remigiusz Kijak published in the journal Sexuality and Disability, 133 people (mainly older age teenagers with ages ranging from 17 to 25 years) with mild intellectual disability were surveyed about their sexuality and sexual practices. Dr. Kijak reported that:

“During the studies it has also been determined that 7 % of the studied teenagers stimulate themselves in an untypical manner. The teenagers studied admitted to masturbating with tools, certain objects or to masturbating in a way other than a natural one. The study subjects masturbate using grease, food, furniture and even vacuum cleaners. Such masturbation can be determined as dangerous, mainly due to the fact that it fixes a certain, repeatable chain of strange rituals, often impossible to use in a partner relationship, and may result in a pleasure decrease”. 

As noted in my previous blog on the use of vacuum cleaners as a masturbatory aid, most writings on the topic concern penile injuries that have come to the attention of medics when things go wrong. However, there are a couple of case studies in the forensic literature that have featured vacuum cleaners in autoerotic deaths. In 1988, Dr. R.H. Imami and Dr. M. Kemal published a paper in the American Journal of Forensic Medicine and Pathology about a 57-year old white American male with a history of heart disease and chronic pancreatitis. The man was found naked slumped over his vacuum cleaner after a neighbour wondered why the vacuum cleaner had been on continuously for a long time. The man was found leaning against the dining table with his testicles, buttocks and thighs tightly bound with women’s tights. Near the table was a jar of urine, jars of lubricant and a wooden table leg covered in faecal excrement. The man was covered in burns from the vacuum cleaner. No defect was found in the vacuum cleaner. The autopsy revealed that the man had a heart attack while engaged in the autoerotic activity. The wooden table leg had been used in an attempt to stimulate orgasm via anal penetration. His wife had caught him masturbating with the vacuum cleaner before (and they hadn’t had sex for five years). The death was classes as natural rather than accidental.

In 1994, Dr. Clive Cooke, Dr. Gerard Cadden and Dr. Karin Margolius published a paper concerning four “unusual fatalities where death occurred during autoerotic practice”. Three of the four accidental deaths (electrocution, hanging, and courgette inhalation) involved young to middle-aged men. However, it is the fourth case that is of interest here. This involved an elderly man that (like the previous case) had heart disease. The authors reported that:

“The naked body of this 77[-year] old widower was found in the bathroom of his home…Adjacent to the body, and switched on and working, were a vacuum cleaner and a hair dryer. A pair of men’s underpants was impacted in the hose of the vacuum cleaner. Autopsy examination showed the body of an elderly man of normal build. There was no evident injury; in particular there were no apparent marks of electrical injury. Internal examination showed enlargement of the heart with extensive ischemic fibrous scarring of the thickened left ventricular myocardium. Extensive calcified coronary arteriosclerosis was present, with no thrombosis. There was no significant valvular disease. The lungs were mildly congested and there was benign hypertensive nephrosclerosis. Toxicological analysis was unremarkable. The vacuum cleaner and hair dryer, together with the electric circuitry of the house, were assessed by an electrical inspector and cleared of malfunction. The cause of death was therefore believed to be combined arteriosclerotic and hypertensive heart disease. The scene examination suggested the likelihood that the electrical appliances were being used autoerotically”.

In their discussion of this particular case, Cooke and colleagues noted that sudden autoerotic deaths due to a natural disease process (e.g., heart disease) have seldom been reported in the forensic literature. To their knowledge, only two previous case reports had been published prior to their own study – both males who after autopsy:

“…showed significant arteriosclerotic cardiovascular disease. One was the case of a 61 [-year] old man who died whilst bound with chain restraints; a vibrator was nearby [Hazelwood, Dietz & Burgess, 1981]. The second case was of a 57 [-year] old man whose body was found naked alongside a running vacuum cleaner; the testicles, thighs and buttocks were tightly bound with pantyhose [Imami & Kemal, 1988]. Such deaths are probably less frequent than sudden natural death associated with heterosexual or homosexual activity, particularly if with a novel partner [Malik, 1979]”.

Finally, the only other vacuum cleaner-related autoerotic death I located in the forensic literature was a 2005 case study report by Dr. Andrew Hitchcock and Dr. Roger Start in the Journal of Clinical Forensic Medicine. This was actually a case of hypoxyphilia where the device built to cut off the oxygen supply involved a vacuum cleaner. More specifically, the paper reported:

“A case is reported of a 36-year-old man who died following occlusive entrapment within a device for the purpose of hypoxyphilic gratification. The device was constructed in his own home using instructions found on his home computer down-loaded from the Internet. The device comprised a tough plastic cocoon large enough to accommodate an adult human and incorporating a system of plastic piping connected to a household vacuum cleaner for the evacuation of air within the cocoon. The mechanism of death was thought to be traumatic asphyxia after examination of the deceased and re-construction of the apparatus with the body in situ”.

The prevalence of autoerotic acts involving the use of vacuum cleaners is unknown as only those cases that result in serious genital injury and/or death come to the attention of medics and/or forensic scientists. As noted in my previous blog, the number of cases that are being reported is on the decrease but this may be because the topic is less novel than it used to be and may not be seen by journal editors as worthy of publication.

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

Further reading

Benson, R. (1985). Vacuum cleaner injury to penis: A common urologic problem? Urology, 25(1), 41-44.

Citron, N.D., & Wade, P.J. (1980). Penile injuries from vacuum cleaners. British Medical Journal, 281(6232), 26.

Cooke, C.T., Cadden, G.A., & Margolius, K.A. (1994). Autoerotic deaths: Four cases. Pathology, 26(3), 276-280.

Hazelwood, R.R., Dietz, P. E., & Burgess, A.W. (1981). The investigation of autoerotic fatalities. Journal of Police Science & Administration, 9, 404-411.

Hitchcock, A., & Start, R.D. (2005). Fatal traumatic asphyxia in a middle-aged man in association with entrapment associated hypoxyphilia. Journal of Clinical Forensic Medicine, 12, 320-325.

Imami, R. H., & Kemal, M. (1988). Vacuum cleaner use in autoerotic death. American Journal of Forensic Medicine and Pathology, 9, 246-248.

Kijak, R. (2013). The sexuality of adults with intellectual disability in Poland. Sexuality and Disability, 31(2), 109-123.

Klintschar, M., Grabuschnigg, P., & Beham, A. (1998). Death from electrocution during autoerotic practice: Case report and review of the literature. American Journal of Forensic Medicine and Pathology, 19, 190-193.

Malik, M. O. (1979). Sudden coronary deaths associated with sexual activity. Journal of Forensic Sciences, 24, 216-220.

Moxon, L. (2005). Diagnosis, disclosure and self-confidence in sexuality and relationships. In D. Murray (Ed.), Coming out Asperger: Diagnosis, Disclosure and Self-Confidence (pp. 214-229). London: Jessica Kingsley Publishers.

Rossi, M., Cascini, F., & Torcigliani, S. (1991). [Penile injuries caused by masturbation with a vacuum cleaner. Description of a case and review of the literature]. Minerva Urologica e Nefrologica, 44(1), 43-45.

Term warfare: Internet Gaming Disorder and Internet Addiction Disorder are not the same

Over the last 15 years, research into various online addictions has greatly increased. Alongside this, there have been scholarly debates about whether internet addiction really exists. Some may argue that because internet use does not involve the ingestion of a psychoactive substance, then it should not be considered a genuine addictive behaviour. However, the latest (fifth) edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) re-classified ‘Gambling Disorder’ as a behavioural addiction rather than as a disorder of impulse control. The implications of this reclassification are potentially far-reaching. The most significant implication is that if an activity that does not involve the consumption of drugs (i.e., gambling) can be a genuine addiction accepted by the psychiatric and medical community, there is no theoretical reason why other problematic and habitual behaviours (e.g., shopping, work, exercise, sex, video gaming, etc.) cannot be classed as a bone fide addiction.

There have also been debates among scholars that consider excessive problematic internet use to be a genuine addiction as to whether the those in the field should study generalized internet addiction (the totality of all online activities) and/or specific addictions on the internet such as internet gambling, internet gaming and internet sex. Since the late 1990s, I have constantly argued that there is a fundamental difference between addictions on the internet, and addictions to the internet. I argued that the overwhelming majority of individuals that were allegedly addicted to the internet were not internet addicts but were individuals that used the medium of the internet as a vehicle for other addictions. More specifically, I argued that internet gambling addicts and internet gaming addicts were not internet addicts but were gambling and gaming addicts using the convenience and ubiquity of the internet to gamble or play video games.

Prior to the publication of the latest DSM-5, there had also been debates as to whether ‘internet addiction’ should be introduced into the text as a separate disorder. Following these debates, the Substance Use Disorder Work Group (SUDWG) recommended that the DSM-5 include a sub-type of problematic internet use (i.e., internet gaming disorder [IGD]) in Section 3 (‘Emerging Measures and Models’) as an area that needed future research before being included in future editions of the DSM. However, far from clarifying the debates surrounding generalized versus specific internet use disorders, the section of the DSM-5 discussing IGD noted that:

“There are no well-researched subtypes for Internet gaming disorder to date. Internet gaming disorder most often involves specific Internet games, but it could involve non-Internet computerized games as well, although these have been less researched. It is likely that preferred games will vary over time as new games are developed and popularized, and it is unclear if behaviors and consequence associated with Internet gaming disorder vary by game type…Internet gaming disorder has significant public health importance, and additional research may eventually lead to evidence that Internet gaming disorder (also commonly referred to as Internet use disorder, Internet addiction, or gaming addiction) has merit as an independent disorder” (p.796).

In light of what has been already highlighted in previous research, two immediate problematic issues arise from these assertions. Firstly, IGD is clearly seen as synonymous with internet addiction as the text claims that internet addiction and internet use disorder are simply other names for IGD. Secondly – and somewhat confusingly – it is asserted that IGD (which is by definition internet-based) can also include offline gaming disorders.

With regards to the first assertion, internet addiction and online gaming addiction are not the same. A number of recent studies (including ones I’ve co-authored) clearly shows that to be the case. The second assertion that IGD can include offline video gaming is both baffling and confusing. Some researchers consider video games as the starting point for examining the characteristics of gaming disorder, while others consider the internet as the main platform that unites different addictive internet activities, including online games. For instance, I have argued that although all addictions have particular and idiosyncratic characteristics, they share more commonalities than differences (i.e., salience, mood modification, tolerance, withdrawal symptoms, conflict, and relapse), and likely reflects a common etiology of addictive behaviour. For me, IGD is clearly a sub-type of video game addiction. For people like Dr. Kimberley Young, ‘cyber-relationship addictions’, ‘cyber-sexual addictions’, ‘net compulsions’ (gambling, day trading) and ‘information overload’ are all internet addictions. However, many would argue that these – if they are addictions – are addictions on the internet, not to it. The internet is a medium and it is a situational characteristic. The fact that the medium might enhance addictiveness or problematic behaviour does not necessarily make it a sub-type of internet addiction.

However, recent studies have made an effort to integrate both approaches. For instance, some researchers claim that neither the first nor the second approach adequately captures the unique features of Massively Multiplayer Online Role-Playing Games (MMORPGs), and argue an integrated approach is a necessity. A common observation is that “Internet users are no more addicted to the Internet than alcoholics are addicted to bottles”. The internet is just a channel through which individuals may access whatever content they want (e.g., gambling, shopping, chatting, sex). On the other hand, online games differ from traditional standalone games, such as offline video games, in important aspects such as the social dimension or the role-playing dimension that allow interaction with other real players. Consequently, it could be argued that IGD can either be viewed as a specific type of video game addiction, or as a variant of internet addiction, or as an independent diagnosis. However, the idea that IGD can include offline gaming disorders does little for clarity or conceptualization.

Finally, it is also worth mentioning that there are some problematic online behaviours that could be called internet addictions as they can only take place online. The most obvious activity that fulfills this criterion is social networking as it is a ‘pure’ online activity and does not and cannot take place offline. Other activities such as gambling, gaming, and shopping can still be engaged in offline (as gamblers can go to a gambling venue, gamers can play a standalone console game, shoppers can go to a retail outlet). However, those engaged in social networking would not (if unable to access the internet) walk into a big room of people and start chatting to them all. However, even if social networking addiction is a genuine internet addiction, social networking itself is still a specific online application and could still be considered an addiction on the internet, rather than to it.

Based on recent empirical evidence, IGD (or any of the alternate names used to describe problematic gaming) is not the same as Internet Addiction Disorder. The gaming studies field needs conceptual clarity but as demonstrated, the DSM-5 itself is both misleading and misguided when it comes to the issue of IGD.

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

Further reading

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

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

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

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

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

Griffiths, M.D. & Pontes, H.M. (2014). Internet addiction disorder and internet gaming disorder are not the same. Journal of Addiction Research and Therapy, 5: e124. doi:10.4172/2155-6105.1000e124.

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

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

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

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

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

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

Kuss, D.J., Griffiths, M.D., Karila, L. & Billieux, J. (2014).  Internet addiction: A systematic review of epidemiological research for the last decade. Current Pharmaceutical Design, 20, 4026-4052.

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

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

Pontes, H. & Griffiths, M.D. (2014). The assessment of internet gaming disorder in clinical research. Clinical Research and Regulatory Affairs, 31(2-4), 35-48.

Pontes, H. & Griffiths, M.D. (2015). Measuring DSM-5 Internet Gaming Disorder: Development and validation of a short psychometric scale. Computers in Human Behavior, 45, 137-143.

Pontes, H., Király, O. Demetrovics, Z. & Griffiths, M.D. (2014). The conceptualisation and measurement of DSM-5 Internet Gaming Disorder: The development of the IGD-20 Test. PLoS ONE, 9(10): e110137. doi:10.1371/journal.pone.0110137.

Pontes, H., Kuss, D. & Griffiths, M.D. (2015). The clinical psychology of Internet addiction: A review of its conceptualization, prevalence, neuronal processes, and implications for treatment. Neuroscience and Neuroeconomics, 4, 11-23.

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

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

Slow pain coming: A brief look at benign masturbatory cephalalgia

In a previous blog, I examined the medical research on individuals that suffer severe headaches as a result of having sex (known in the clinical and medical literature as ‘coital cephalalgia’ and ‘benign coital headache’). In such circumstances, the headache typically occurs at the brink of orgasm. While researching that particular blog, I also came across a number of papers (mainly case studies) that reported that these types of headache could also occur during masturbation (known as ‘benign masturbatory cephalalgia’ (BMC). (Here, the term ‘benign’ defines a primary headache syndrome not caused by any intracranial disorder).

The first paper that I read on BMC was a case account by Dr. Frederick Vincent in a 1982 issue the Archives of Neurology. Although benign orgasmic cephalgia had already been well described in the medical literature (particularly among males), Dr. Vincent reported the case of a 28-year old woman with orgasmic cephalalgia that developed during masturbation. This was reported by Dr. Vincent as the first ever case of BMC. The young woman “suffered a sudden throbbing occipital headache as she became orgasmic by masturbation”. The headache lasted an hour accompanied by mild nausea, but no other neurologic symptoms. As a result of this case, Dr. Vincent argued that the term ‘coital cephalagia’ should be dropped and simply called ‘orgasmic cephalagia’ irrespective of whether the headache was self-induced (i.e., masturbatory) or caused by having sexual intercourse.

Following the publication of Vincent’s case study, Dr. James Lance immediately responded in the same journal saying that he had reported the cases of three of his patients whose headaches were brought on by masturbation. Lance also agreed that the term coital cephalalgia was too restrictive, but then argued that:

“Orgasmic cephalalgia ignores the premonitory headache that may build up as sexual excitement mounts before orgasm. Benign sex headache (using ‘sex’ in the popular sense) is an all-embracing, albeit unpoetic, term and is comparable with benign cough headache. It is worth emphasizing that neither condition is always benign”.

A 2004 case study published by Dr. Marcelo Valenca and colleagues in the journal Headache: The Journal of Head and Face Pain noted that only five cases of patients with thunderclap headache precipitated by sexual activity had been identified in the medical literature. In their paper, they reported the case of a 44-year-old woman that suffered both coital and masturbatory headaches during orgasm. After carrying out a number of medical tests they concluded that the women had experienced cerebral arterial narrowing shortly after her orgasmic headache attacks and that this “supported the hypothesis that segmental vasospasm may exert a role in the pathogenesis of this uncommon type of headache”.

A number of papers on orgasmic cephalagia have been published by Dr. Achim Frese and his colleagues. In a 2004 issue of the journal Neurology, Frese led a study examining the demography, clinical features, and comorbidity of headache associated with sexual activity (HSA) in interviews of 51 participants. They reported that HSA was not dependent on specific sexual habits and most often occurred during sexual activity with the usual partner (94%) and during masturbation (35%).

A 1998 paper by Dr. Daniel Jacome in Headache: The Journal of Head and Face Pain reported something slightly different but related to BMC. More specifically, Dr. Jacome reported the cases of two single men described as having masturbatory-orgasmic extracephalic pain (i.e., an ice-pick like pain that occurred in the neck of one of the men, and in the groin and genitalia of the other). Both men had pre-existing medical conditions (i.e., compressive spondylitic cervical myelopathy in the first case, and a tethered cord and intraspinal lipoma in the second case). These two unusual cases represent examples of extracephalic ice picklike pain triggered by sexual activity, in the absence of orgasmic cephalgia.

A more recent 2012 paper by Dr. Amy Gelfand and Dr. Peter Goadsby in the journal Pediatrics examined primary sexual headaches in two male adolescents. One of the two cases (a 16-year-old boy) developed headaches at the moment of orgasm, building up in intensity over 5 to 10 seconds, and then continuing for between 10 seconds to 2 minutes before stopping. The authors also reported that headaches occurred irrespective of whether orgasm was achieved through intercourse or masturbation. He was not formally treated because after several months, the patient no longer experienced the headaches with orgasm.

Finally, a 2006 paper by Dr. Ambar Chakravarty in the journal Cephalalgia examined data from 24 Indian patients (18 males and 6 females) over a 20-year period (1985–2004) that suffered preorgasmic headaches. Dr. Ambar reported that three of the youngest male patients (aged 19–23 years) had experienced masturbatory headache. One of the female patients (aged 30 years) only experienced orgasmic headache during masturbation (i.e., she never experienced headaches during sexual intercourse).

Summarizing the medical literature on orgasmic cephalagia as a whole (i.e., on coital and masturbatory cephalagia), the 2012 paper by Gelfand and Goadsby concluded that:

“The orgasmic subtype of primary sex headache is more common than the gradual onset pre-orgasm type and has received more attention in the medical literature…In the orgasmic subtype, headache onset is explosive and severe. Orgasms achieved through either sexual intercourse or masturbation can trigger the headache. The headache location is variable, although most often bilateral. The quality is typically pounding or throbbing. Duration of headache ranges from minutes to several hours. Age at onset is classically in the late thirties or early forties, and there is a male predominance. The natural history of the disorder is that after several months it typically remits, although some patients will have a chronic course lasting over a year, and recurrences are possible”.

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

Further reading

Chakravarty, A. (2006). Primary headaches associated with sexual activity—some observations in Indian patients. Cephalalgia, 26(2), 202-207.

Frese, A., Eikermann, A., Frese, K., Schwaag, S., Husstedt, I. W., & Evers, S. (2003). Headache associated with sexual activity: Demography, clinical features, and comorbidity. Neurology, 61(6), 796-800.

Gelfand, A.A., & Goadsby, P.J. (2012). Primary sex headache in adolescents. Pediatrics, 130(2), e439-e441.

Jacome, D.E. (1998). Masturbatory-orgasmic extracephalic pain. Headache: Journal of Head and Face Pain, 38(2), 138-141.

Lance, J. W. (1976). Headaches related to sexual activity. Journal of Neurology, Neurosurgery & Psychiatry, 39(12), 1226-1230.

Lance, J. W. (1983). Benign masturbatory cephalalgia. Archives of Neurology, 40(6), 393.

Østergaard, J. R., & Kraft, M. (1992). Benign coital headache. Cephalalgia, 12(6), 353-355.

Redelman, M. (2010). What if the ‘sexual headache’ is not a joke. British Journal of Medical Practitioners, 3(1), 40-44.

Valenca, M. M., Valenca, L. P., Bordini, C. A., Da Silva, W. F., Leite, J. P., Antunes‐Rodrigues, J., & Speciali, J. G. (2004). Cerebral vasospasm and headache during sexual intercourse and masturbatory orgasms. Headache: The Journal of Head and Face Pain, 44(3), 244-248.

Vincent, F. M. (1982). Benign masturbatory cephalalgia. Archives of Neurology, 39(10), 673.