Tub zero: A brief look at bath-related illnesses and fatalities

Regular readers of my blog will know that I have an interest in all things bizarre and out of the ordinary. In previous blogs I have examined coital cephalagia (people that get headaches from having sex) and masturbatory cephalagia (people that get headaches from masturbation). It was while researching those articles that I came across a 2005 paper on ‘bath-related headaches’ (BRHs) by Dr. Mak and colleagues in the journal Cephalagia.

BRH is rare headache syndrome. They reported 13 case studies (six from their own case files collected over a seven-year period and seven from other reports in the medical literature). They reported that all the cases involved “Oriental women” aged 32 to 67 years (with an average age of 51 years). The cases were reported in females from Hong Kong (n=6), Taiwan (n=4) and Japan (n=3). All of the women reported severe headaches (lasting from 30 minutes to 30 hours) that were triggered by bathing or other activities involving contact with water. Typically, the onset of the headaches were “hyperacute” and were like ‘thunderclap’ headaches (a severe headache that takes seconds to minutes to reach maximum intensity). The paper reported that no underlying secondary causes were identified and that drug treatment was generally unsatisfactory (although use of the drug Nimodipine was reported to shorten the length of the headache in some cases). Unfortunately, the only way that such headaches could be prevented was to avoid bathing.

After reading this paper I looked for other papers relating to bath-related illnesses. A 2000 paper by Dr. S. Cerovac and Dr. A. Roberts reported on 57 cases of burns sustained by hot bath and shower water (in the journal Burns) over an eight-year period. None of the 57 cases died as a result of the burns. The authors worked at Stoke Mandeville Hospital (in the UK) and they divided the cases into child (below the age of 16 years) and adult groups. Most of the children (n=39) were under the age of three years (83%), with two-fifths having superficial burns (41%). Most of these cases occurred due to what the authors described as “inadequate supervision” by the child’s parents (85%). Among the adult group, 83% of the adults were over 60 years of age with around 65% of them having “some form of psycho-motor disorder that predisposed to an accident which should have been anticipated”. The adult group had more extensive burns which resulted in eight deaths (out of 18 cases; 44%). They reported that the number of cases had been declining over the eight-year period but the study highlighted that fatal incidents could be caused by something as simple as bathing.

A 1995 study by Dr. J. Lavelle in the Annals of Emergency Medicine evaluated the risk factors associated with bathtub submersion injury and their relationship to child abuse and neglect over a 10-year period (1982-1992). They reported that there had been 21 patients treated for bathtub near-drownings (nine of which had subsequently died). Of these, two-thirds of the children (67%) had “historic and/or physical findings suspicious for abuse or neglect, including incompatible history for the injury, other physical injuries, previous child abuse reports, psychiatric history of the caretaker, and/or psychosocial concerns noted in the chart”. The mortality rate of 42% was significant. However, findings showed that no demographic characteristics identified at-risk children.

Perhaps the most common form of bathtub deaths are infant drownings. A paper by Dr. John Pearn and Dr. James Nixon examined the socio-demographic factors surrounding drowning accidents among children aged 0-15 years in a 1978 issue of Social Science & Medicine. Obviously this paper examined all drownings but did note that those that involved bathtub drownings occur “almost exclusively in lower social class homes” In a follow-up study specifically on bathtub drownings, Dr. Pearn and his colleagues reported the cases of seven bathtub drownings in the journal Pediatrics. All of the seven cases were infants in the US state of Hawaii. As with the previous paper, the authors reported that the families of the infant were typically of lower socioeconomic status but also added that the deaths had occurred when the father “had immediate care of the infant at the time of the accident”. In five of the cases, the drowned infant was being looked after by older sibling.

In 1985, Dr. Lawrence Budnick and Dr. D. Ross published a study on bathtub-related drownings in the USA in the American Journal of Public Health. They analysed information (1979-1981) on such deaths using data from the (i) National Center for Health Statistics and (ii) Consumer Product Safety Commission data. They reported 710 individuals had drowned in the bath during this period with an estimated mortality rate of 1.6 per million individuals per year. They reported an excess of deaths in the spring but this was not statistically significant. However, they did note that individuals “at the extremes of age were at greatest risk of death, with mortality rates of 5-6 per million per year”. Unsurprisingly, there was a frequent history of children below the age of five years being left unattended by parents. Amongst young to middle-aged adults, there was a frequent history of seizures or history of alcohol or drug use. Among more elderly individuals there was frequent evidence of having fallen in the bath.

Similarly, in 2006, Dr. G. Somers and colleagues carried out a 20-year review of bathtub drownings published in the American Journal of Forensic Medicine and Pathology. The authors retrospectively retrospective reviewed US autopsy records over a 20-year period (1984–2003). They identified 18 cases of bathtub drownings (8 boys and 10 girls) aged 6 months to 70 months (average of 17 months) almost three-quarters aged under one year (72%). The factors leading to the death were reported as inadequate adult supervision (89%), cobathing (39%), the use of infant bath seats (17%), and coexistent medical disorders predisposing the child to the drowning episode (17%).

A paper by Dr. R. Rauchschwalbe and colleagues in a 1997 issue of Pediatrics examined the role of bathtub seats and rings as a primary cause of death in US infant drowning deaths (1983-1995). The paper reported 32 deaths by drowning involving bath seats/rings with the victims’ ages at the time of the death ranging from 5 to 15 months (average 8 months old). Nine in ten deaths was due to a “reported lapse in adult supervision”. The authors concluded that infant drownings associated with bath seats/rings are increasing in the US and that very young children “should never be left in the bathtub unsupervised, even for brief moments”.

A more recent 2004 study by Dr. R. Byard and Dr. T. Donald in the Journal of Paediatrics and Child Health examined the possible role of infant bathtub seats in drowning and near-drowning (1998-2003). The authors used files from the Forensic Science Centre and Child Protection Unit, Women’s and Children’s Hospital in Adelaide (Australia). In the six-year period, there were six cases of drowning in children aged under two years. They noted:

“One of these cases, a 7-month-old boy, had been left unattended for some time in an adult bath in a bathtub seat. He was found drowned, having submerged after slipping down and becoming trapped in the seat. Three near-drowning episodes occurred in children under the age of 2 years, including two boys aged 7 and 8 months, both of whom had been left for some time in adult baths in bath seats. Both were successfully resuscitated and treated in hospital…These cases demonstrate the vulnerability of infants to immersion incidents when left unattended in bathtubs”.

In a 1984 paper in the Journal of the American Medical Association, Dr. Lawrence Budnick examined bathtub-related electrocutions in the USA (1979 to 1982). He reported that at least 95 Americans had been electrocuted in the bath and that the use of hair dryers in the bathroom had caused 60% of the deaths. It was also noted that two-thirds of the deaths had occurred during spring and winter, and that those under five years of age had the highest mortality rate.

A 2003 paper by Dr. N. Yoshioka and his colleagues in the journal Legal Medicine examined bathtub deaths in Japan. The authors claimed that approximately 100–120 cases of “sudden death in bathroom” are reported there every year and accounts for around “8–10% of the total number of what is considered unnatural deaths”. Most of the deaths occur in winter and 80% of cases involve the elderly and the authors described the deaths as “baffling” as the autopsies rarely locate the exact cause of death. By testing physiological changes 54 volunteers in both winter and summer, the authors reported that many heart conditions occurred during the winter months in their volunteers (e.g., cardiac arrhythmia including ventricular tachycardia, ventricular extrasystole, supraventricular extrasystole, and bradycardia) and that these conditions might lead to an increased risk for cardiac arrest while bathing.

Another possible reason for bathtub-related drownings is epileptic seizures while bathing. A paper by Dr. C. Ryan and Dr. G. examined drowning deaths among epileptics in a 1993 issue of the Canadian Medical Association Journal. The authors retrospectively reviewed deaths from drowning in Alberta (Canada) from 1981 to 1990. Of these drownings in Alberta (n=482), 5% (n=25) were directly related to epileptic seizures of which 60% (n=15) occurred while the individual was taking an unsupervised bath. The authors advised that all people with epilepsy should take showers (while sitting) instead of baths.

While most of these bath-related health issues and fatalities are rare, they do highlight the issue that accidents can happen anywhere and that in the bath can be a vulnerable location for infants left unattended or those with medical conditions that cause immobility.

Dr. Mark Griffiths, Professor of Behavioural Addiction, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Further reading

Budnick, L.D. (1984). Bathtub-related electrocutions in the United States, 1979 to 1982. JAMA, 252(7), 918-920.

Budnick, L.D., & Ross, D.A. (1985). Bathtub-related drownings in the United States, 1979-81. American Journal of Public Health, 75(6), 630-633.

Byard, R. W., & Donald, T. (2004). Infant bath seats, drowning and near‐drowning. Journal of Paediatrics and Child Health, 40(5‐6), 305-307.

Cerovac, S., & Roberts, A.H. (2000). Burns sustained by hot bath and shower water. Burns, 26(3), 251-259.

Lavelle, J. M., Shaw, K. N., Seidl, T., & Ludwig, S. (1995). Ten-year review of pediatric bathtub near-drownings: evaluation for child abuse and neglect. Annals of Emergency Medicine, 25(3), 344-348.

Mak, W., Tsang, K.L., Tsoi, T.H., Au Yeung, K.M., Chan, K.H., Cheng, T. S., … & Ho, S.L. (2005). Bath‐related headache. Cephalalgia, 25(3), 191-198.

Pearn, J. H., Brown, J., Wong, R., & Bart, R. (1979). Bathtub drownings: Report of seven cases. Pediatrics, 64(1), 68-70.

Nixon, J., & Pearn, J. (1978). An investigation of socio-demographic factors surrounding childhood drowning accidents. Social Science & Medicine. Part A: Medical Psychology & Medical Sociology, 12, 387-390.

Rauchschwalbe, R., Brenner, R.A., & Smith, G.S. (1997). The role of bathtub seats and rings in infant drowning deaths. Pediatrics, 100(4), e1.

Ryan, C. A., & Dowling, G. (1993). Drowning deaths in people with epilepsy. CMAJ: Canadian Medical Association Journal, 148(5), 781-784.

Somers, G. R., Chiasson, D. A., & Smith, C. R. (2006). Pediatric drowning: A 20-year review of autopsied cases: III. Bathtub drownings. American Journal of Forensic Medicine and Pathology, 27(2), 113-116.

Yoshioka, N., Chiba, T., Yamauchi, M., Monma, T., & Yoshizaki, K. (2003). Forensic consideration of death in the bathtub. Legal Medicine, 5, S375-S381.

Tubular hells: A brief look at ‘addiction’ to watching YouTube videos

 

A few days ago, I unexpectedly found my research on internet addiction being cited in a news article by Paula Gaita on compulsive viewing of YouTube videos (‘Does compulsive YouTube viewing qualify as addiction?‘). The article was actually reporting a case study from a different news article published by PBS NewsHour by science correspondent Lesley McClurg (‘After compulsively watching YouTube, teenage girl lands in rehab for digital addiction’). As Gaita reported:

“The story profiles a middle school student whose obsessive viewing of YouTube content led to extreme behavior changes and eventually, depression and a suicide attempt. The student finds support through therapy at an addiction recovery center…The student in question is a young girl named Olivia who felt at odds with the ‘popular’ kids at her Oakland area school. She began watching YouTube videos after hearing that it was a socially acceptable thing to do… Her viewing habits soon took the place of sleep, which impacted her energy and mood. Her grades began to falter, and external problems within her house – arguments between her parents and the death of her grandmother – led to depression and an admission of wanting to hang herself. Her parents took her to a psychiatric hospital, where she stayed for a week under suicide watch, but her self-harming compulsion continued after her release. She began viewing videos about how to commit suicide, which led to an attempt to overdose on Tylenol” [Note: The name of the woman – Olivia – was a pseudonym].

McClurg interviewed Olivia’s mother for the PBS article and it was reported that Olivia went from being a “bubbly daughter…hanging out with a few close friends after school” to “isolating in her room for hours at a time”. Olivia’s mother also claimed that her daughter had “always been kind of a nerd, a straight. A student who sang in a competitive choir. But she desperately wanted to be popular, and the cool kids talked a lot about their latest YouTube favorites”. According to news reports, all Olivia would do was to watch video after video for hours and hours on end and developed sleeping problems. Over time, the videos being watched focused on fighting girls and other videos featuring violence.

The news story claimed that Olivia was “diagnosed with depression that led to compulsive internet use”. When Olivia went back home she was still feeling suicidal and then spent hours watching YouTube videos on how to commit suicide (and it’s where she got the idea for overdosing on Tylenol tablets).

After a couple of spells in hospital, Olivia’s parents took her to a Californian centre specialising in addiction recovery (called ‘Paradigm’ in San Rafael). The psychologist running the Paradigm clinic (Jeff Nalin) claimed Olivia’s problem was “not uncommon” among clients attending the clinic. Nalin believes (as I do and have pointed out in my own writings) that treating online addictions is not about abstinence but about getting the behaviour under control but developing skills to deal with the problematic behaviour. He was quoted as saying:

“I describe a lot of the kids that we see as having just stuck a cork in the volcano. Underneath there’s this rumbling going on, but it just rumbles and rumbles until it blows. And it blows with the emergence of a depression or it emerges with a suicide attempt…The best analogy is when you have something like an eating disorder. You cannot be clean and sober from food. So, you have to learn the skills to deal with it”.

The story by Gaita asked the question of whether compulsive use of watching YouTube could be called a genuine addiction (and that’s where my views based on my own research were used). I noted that addiction to the internet may be a symptom of another addiction, rather than an addiction unto itself. For instance, people addicted to online gambling are gambling addicts, not internet addicts. An individual addicted to online gaming or online shopping are addicted to gaming or shopping not to the internet.

An individual may be addicted to the activities one can do online and is not unlike saying that an alcoholic is not addicted to a bottle, but to what’s in it. I have gone on record many times saying that I believe anything can be addictive as long there are continuous rewards in place (i.e., constant reinforcement). Therefore, it’s not impossible for someone to become addicted to watching YouTube videos but the number of genuine cases of addiction are likely to be few and far between. Watching video after video is conceptually no different from binge watching specific television series or television addiction itself (topics that I have examined in previous blogs).

I ought to end by saying that some of my own research studies on internet addiction (particularly those co-written with Dr. Attila Szabo and Dr. Halley Pontes and published in the Journal of Behavioral Addictions and Addictive Behaviors Reports – see ‘Further reading’ below) have examined the preferred applications by those addicted to the internet, and that the watching of videos online is one of the activities that has a high association with internet addiction (along with such activities such as social networking and online gaming). Although we never asked participants to specify which channel they watched the videos, it’s fair to assume that many of our participants will have watched them on YouTube), and (as the Camelot lottery advert once said) maybe, just maybe, a few of those participants may have had an addiction to watching YouTube videos.

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

Further reading

Gaita, P. (2017). Does compulsive YouTube viewing qualify as addiction? The Fix, May 19. Located at: https://www.thefix.com/does-compulsive-youtube-viewing-qualify-addiction

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

Griffiths, M.D., Kuss, D.J., Billieux J. & Pontes, H.M. (2016). The evolution of internet addiction: A global perspective. Addictive Behaviors, 53, 193–195.

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.

Griffiths M.D. & Szabo, A. (2014). Is excessive online usage a function of medium or activity? An empirical pilot study. Journal of Behavioral Addictions, 3, 74-77.

Kuss, D.J. & Griffiths, M.D. (2015). Internet Addiction in Psychotherapy. Basingstoke: Palgrave Macmillan.

Kuss, D.J., Griffiths, M.D. & Binder, J. (2013). Internet addiction in students: Prevalence and risk factors. Computers in Human Behavior, 29, 959-966.

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.

Kuss, D.J., van Rooij, A.J., Shorter, G.W., Griffiths, M.D. & van de Mheen, D. (2013). Internet addiction in adolescents: Prevalence and risk factors. Computers in Human Behavior, 29, 1987-1996.

McClurg, L. (2017). After compulsively watching YouTube, teenage girl lands in rehab for ‘digital addiction’. PBS Newshour, May 16. Located at: http://www.pbs.org/newshour/rundown/compulsively-watching-youtube-teenage-girl-lands-rehab-digital-addiction/

Pontes, H.M., Kuss, D.J. & 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.

Pontes, H.M., Szabo, A. & Griffiths, M.D. (2015). The impact of Internet-based specific activities on the perceptions of Internet Addiction, Quality of Life, and excessive usage: A cross-sectional study. Addictive Behaviors Reports, 1, 19-25.

Widyanto, L. & Griffiths, M.D. (2006). Internet addiction: A critical review. International Journal of Mental Health and Addiction, 4, 31-51.

Doctor, doctor: What can British GPs do about problem gambling?

A study published in the British Journal of General Practice in March 2017 reported that of 1,058 individuals surveyed in GP waiting rooms in Bristol (UK), 0.9% were problem gamblers and that a further 4.3% reported gambling problems that “were low to medium severity”. This is in line with other British studies carried out over the last decade which have reported problem gambling prevalence rates of between 0.5% and 0.9%.

I have long argued that problem gambling is a health issue and that GPs should routinely screen for gambling problems. Back in 2004, I published an article in the British Medical Journal about why problem gambling is a health issue. I argued that the social and health costs of problem gambling were (and still are) large at both individual and societal levels.

Personal costs can include irritability, extreme moodiness, problems with personal relationships (including divorce), absenteeism from work, neglect of family, and bankruptcy. Adverse health consequences for problem gamblers and their partners include depression, insomnia, intestinal disorders, migraine, and other stress related disorders. In my BMJ article I also noted that analysis of calls to the GamCare national gambling helpline indicated that a small minority of callers reported health-related consequences as a result of their problematic gambling. These included depression, anxiety, stomach problems, and suicidal ideation. Obviously many of these medical problems arise through the stress of financial problems but that doesn’t make it any less of a health issue for those suffering from severe gambling problems.

Research published in the American Journal of Addictions has also shown that health-related problems can occur as a result of withdrawal effects. For instance, one study by Dr. Richard Rosenthal and Dr. Henry Lesieur found that at least 65% of pathological gamblers reported at least one physical side effect during withdrawal, including insomnia, headaches, loss of appetite, physical weakness, heart racing, muscle aches, breathing difficulty, and chills.

Based on these findings, problem gambling is very much a health issue that needs to be taken seriously by all in the medical profession. GPs routinely ask patients about smoking cigarettes and drinking, but gambling is something that is not generally discussed. Problem gambling may be perceived as a grey area in the field of health, and it is therefore very easy for those in the medical profession not to have the issue on their wellbeing radar. If the main aim of GPs is to ensure the health of their patients, then an awareness of gambling and the issues surrounding it should be an important part of basic knowledge and should be taught in the curriculum while prospective doctors are at medical school. One of the reasons that GPs don’t routinely screen for problem gambling is because they are not taught about it during their medical training and therefore do not even think about screening for it in the first place. As I recommended in a report commissioned by the British Medical Association, the need for education and training in the diagnosis, appropriate referral and effective treatment of gambling problems must be addressed within GP training. More specifically, GPs should be aware of the types of gambling and problem gambling, demographic and cultural differences, and the problems and common co-morbidities associated with problem gambling. GPs should also understand the importance of screening patients perceived to be at increased risk of gambling addiction, and should be aware of the referral and support services available locally.

I also recommended that treatment for problem gambling should be provided under the NHS (either as standalone services or alongside drug and alcohol addiction services) and funded by gambling-derived profit revenue.

Back in 2011, Dr. Jane Rigbye and myself published a study using Freedom of Information requests to ask NHS trusts if they had ever treated pathological gamblers. Only 3% of the trusts had ever treated a problem gambler and only one trust said they offered dedicated help and support. I’m sure if we repeated the study today, little will have changed.

It is evident that problem gambling is not, as yet, on the public health agenda in the UK. NHS services – including GP surgeries – need to be encouraged to see gambling problems as a primary reason for referral and a valid treatment option. Information about gambling addiction services, in particular services in the local area, should be readily available to gamblers and GP surgeries are a good outlet to advertise such services. Although some gambling services (such as GamCare, the gambling charity I co-founded) provide information to problem gamblers about local services, such information is provided to problem gamblers who have already been proactive in seeking gambling help and/or information. Given that very few GPs could probably treat a problem gambler, what they must have is the knowledge of who they can refer their patients to.

Dr. Mark Griffiths, Professor of Behavioural Addiction, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Further reading

Calado, F. & Griffiths, M.D. (2016). Problem gambling worldwide: An update of empirical research (2000-2015). Journal of Behavioral Addictions, 5, 592–613.

Cowlishaw, S., Gale, L., Gregory, A., McCambridge, J., & Kessler, D. (2017). Gambling problems among patients in primary care: a cross-sectional study of general practices. British Journal of General Practice, doi: bjgp17X689905

Griffiths, M.D. (2001). Gambling – An emerging area of concern for health psychologists. Journal of Health Psychology, 6, 477-479.

Griffiths, M.D. (2004). Betting your life on it: Problem gambling has clear health related consequences. British Medical Journal, 329, 1055-1056.

Griffiths, M.D. (2007). Gambling Addiction and its Treatment Within the NHS. London: British Medical Association (ISBN 1-905545-11-8).

Griffiths, M.D. & Smeaton, M. (2002). Withdrawal in pathological gamblers: A small qualitative study. Social Psychology Review, 4, 4-13.

Rigbye, J. & Griffiths, M.D. (2011). Problem gambling treatment within the British National Health Service. International Journal of Mental Health and Addiction, 9, 276-281.

Rosenthal, R., & Lesieur, H. (1992). Self-reported withdrawal symptoms and pathological gambling. American Journal of the Addictions, 1, 150–154.

Wardle, H., Moody. A., Spence, S., Orford, J., Volberg, R., Jotangia, D., Griffiths, M.D., Hussey, D. & Dobbie, F. (2011).  British Gambling Prevalence Survey 2010. London: The Stationery Office.

Wardle, H., Sproston, K., Orford, J., Erens, B., Griffiths, M.D., Constantine, R. & Pigott, S. (2007). The British Gambling Prevalence Survey. London: The Stationery Office.

Dispensing wisdom: ATMs on the gaming floor

The gambling industry has long been trying to perfect techniques that keep players on their premises and gambling on their games longer. In short, their aim is to introduce facilities that maximize their bottom line profits. In super-casinos around the world, restaurants are often positioned in the centre so that customers have to pass the gaming areas before and after they have eaten. Live entertainment areas for music or sporting events (e.g., boxing matches) are also positioned similarly.

This strategy is often combined with the deliberate use of circuitous paths to keep customers in the casino longer, the psychology being that if the patrons are in the casino longer they will spend more money. Large US casinos have got this down to a fine art. A number of years ago I remember going to a live music concert at the MGM Grand in Las Vegas and on entering the casino it took me a 20- to 25-minute walk past thousands of slot machines and gaming tables before I even arrived at the auditorium! Although I didn’t gamble during the 45 minutes I was exposed to the slot machines to and from the casino entrance, I did wonder how many of the thousands in the audience had succumbed at some point.

UK gambling venues are now increasingly offering other non-gambling services (such as snack facilities and live entertainment) in a bid to either attract new customers or to keep those already in the venue as long as possible. The 2005 Gambling Act allowed even more of this diversification. It is also worth noting that some forms of gambling (such as slot machines) are far more profitable than other forms (such as table games). What’s more, slot machines don’t need a croupier to deal or spin the roulette ball. This means that most casinos worldwide are now dominated by slot machines in preference to other forms of gambling (although there are places like Macao where table games are preferred over slot machines).

Two of the biggest changes that have occurred in casinos worldwide over the last 20 years that appear to aid such a ‘maximisation’ strategy are the introduction of cash machines onto the gaming floors and the introduction of note acceptors to electronic gaming machines. At a very simplistic level, facilities like these create and enhance convenience gambling.

Note acceptors are very popular in countries like US, Canada and Australia. The gaming industry argues that note acceptors are popular with customers and enhance the playing experience in that they make life a little bit easier for the punter when standing in front of a slot machine not to have to keep going to the cashier for change. However, there is a very fine line between customer enhancement and customer exploitation. Note acceptors have the capacity to increase spending in a number of direct and indirect ways. Firstly, note acceptors increase privacy for the punter. More specifically for the punter, it avoids the potential embarrassment of letting gaming staff, friends, family or even other customers know how much they are spending. Secondly, note acceptors can aid in suspending judgment whereby more cash is transferred to credit in one go. Thirdly, note acceptors minimise breaks as players do not need to leave the machine to get change. Not taking breaks minimises ‘time out’ periods where punters can think more rationally about the money they have spent. A study carried out in Canadian casinos showed that the amount initially put into a slot machine by punters was twice as high on machines that had note acceptors. Although this is only one study, it does seem to suggest that gamblers spend more when a note acceptor is present. 

Like note acceptors, the introduction of automated cash dispensers onto the casino floor also increases privacy for the punter. Although studies have found that only a relatively small proportion of casino patrons seldom use cash dispensers at gambling venues, a significantly high proportion of problem gamblers do so. One study in New Zealand carried out by Professor Max Abbott found that only 2% of all adults interviewed in a national survey considered that greater access to these facilities led to an increase in their gambling. Among problem gamblers, this figure was over eight times as high at 17%.

In Australia, a study led by Professor Jan McMillen also found much greater cash dispenser usage at gambling venues by problem gamblers when compared to non-problem gamblers. They also found that problem gamblers withdrew larger amounts.  Money accessed in this way was most often for the purchase of both alcohol and gambling. They concluded that convenient access to cash dispenders in gambling venues contributed to greater expenditure and was a contributory factor in the development and persistence of gambling problems.

A number of other studies have reported similar findings. Problem gamblers frequently mention that adjacent access to cash dispensers is one of the most frequently mentioned reasons for gambler’s exceeding their planned spending limit. Research has also shown that both problem and non-problem gamblers would prefer cash dispensers to be located away from gambling venues. It would seem that the only people who want cash dispensers on gambling premises are the operators themselves, mainly because they know it increases revenue.

Dr Mark Griffiths, Professor of Behavioural Addictions, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Further reading

Abbott, M.W.  (2007). Situational factors that affect gambling behavior. In G. Smith, D. Hodgins & R. Williams (Eds.), Research and Measurement Issues in Gambling Studies. pp.251-278. New York: Elsevier.

Friedman, B. (2000). Designing Casinos to Dominate the Competition. Reno, NV: Institute for the Study of Gambling and Commercial Gaming, University of Nevada.

Griffiths, M.D. (2009). Casino design: Understanding gaming floor influences on player behaviour. Casino and Gaming International, 5(1), 21-26.

Griffiths, M.D. & Parke, J. (2003). The environmental psychology of gambling. In G. Reith (Ed.), Gambling: Who wins? Who Loses? pp. 277-292. New York: Prometheus Books.

Lam, L.W., Chan, K.W., Fong, D. & Lo, F. (2011). Does the look matter? The impact of casino servicescape on gaming customer satisfaction, intention to revisit, and desire to stay. International Journal of Hospitality Management, 30, 558-567.

McCormack, A. & Griffiths, M.D. (2013). A scoping study of the structural and situational characteristics of internet gambling. International Journal of Cyber Behavior, Psychology and Learning, 3(1), 29-49.

McMillen, J., Marshall, D., and Murphy, L. (2004). The Use of ATMs in ACT Gaming Venues: An Empirical Study. ANU Centre for Gambling Research, Canberra.

Parke, J. & Griffiths, M.D. (2007). The role of structural characteristics in gambling.  In G. Smith, D. Hodgins & R. Williams (Eds.), Research and Measurement Issues in Gambling Studies (pp.211-243). New York: Elsevier.

Wood, R.T.A., Shorter, G.W. & Griffiths, M.D. (2014). Rating the suitability of responsible gambling features for specific game types: A resource for optimizing responsible gambling strategy. International Journal of Mental Health and Addiction, 12, 94–112.

Search of the poisoned mind? A brief look at ‘internet search dependence’

Despite being a controversial topic, research into a wide variety of online addictions has grown substantially over the last decade. My own research into online addictions has been wide ranging and has included online social networking, online sex addiction, online gaming addiction, online shopping addiction, and online gambling addiction. As early as the late 1990s/early 2000s, I constantly argued that when it came to online addictions, most of those displaying problematic behaviour had addictions on the internet rather than addictions to the internet (i.e., they were not addicted to the medium of the internet but addicted to applications and activities that could be engaged in via the internet).

A recent 2016 paper by Dr. Yifan Wang and colleagues in the journal Frontiers in Public Health described the development of the Questionnaire of Internet Search Dependence (QISD), a tool developed to assess individuals who may be displaying a dependence on using online search engines (such as Google and Baidu). The notion of individuals being addicted to using search engines is not new and was one of five types of internet addiction outlined in a 1999 typology in a paper in the Student British Medical Journal by Dr. Kimberley Young (and what she termed ‘information overload’ and referred to compulsive database searching). Although I criticized the typology on the grounds that most of the types of online addict were not actually internet addicts but were individuals using the medium of the internet to fuel other addictive behaviours (e.g., gambling, gaming, day trading, etc.), I did implicitly acknowledge that activities such as internet database searching could theoretically exist, even if I did not think it was a type of internet addiction.

As far as I am aware, the new scale developed by Wang et al. (2016) is the first to create and psychometrically evaluate an instrument to assess ‘internet search dependence’. As noted by the authors:

“Subsequently, we compiled 16 items to represent psychological characteristics associated with Internet search dependence, based on the literature review and a follow-up interview with 50 randomly selected university students…We adopted the six criteria for behavioral addiction formulated by Griffiths (i.e., salience, mood modification, tolerance, withdrawal, conflict, and relapse) [Griffiths, 1999b]”.

Given the authors claimed they used an early version of my addiction components model (i.e., one from 1999 rather than my most recent 2005 formulation) to help inform item construction, I was obviously interested to see the scale’s formulated items. I have to admit that I had a lot of misgivings about the paper so I wrote a commentary on it that has just been published in the same journal (Frontiers in Public Health). More specifically, I noted in my paper that if an individual was genuinely addicted to searching online databases I would have expected to see all of my six criteria applied as follows:

• Salience – This occurs when searching internet databases becomes the single most important activity in the person’s life and dominates their thinking (preoccupations and cognitive distortions), feelings (cravings) and behaviour (deterioration of socialized behaviour). For instance, even if the person is not actually searching the internet they will be constantly thinking about the next time that they will be (i.e., a total preoccupation with internet database searching).
• Mood modification – This refers to the subjective experiences that people report as a consequence of internet database searching and can be seen as a coping strategy (i.e., they experience an arousing ‘buzz’ or a ‘high’ or paradoxically a tranquilizing feel of ‘escape’ or ‘numbing’ when searching internet databases).
• Tolerance – This is the process whereby increasing amounts of time searching internet databases are required to achieve the former mood modifying effects. This basically means that for someone engaged in internet database searching, they gradually build up the amount of the time they spend searching internet databases every day.
• Withdrawal symptoms – These are the unpleasant feeling states and/or physical effects (e.g., the shakes, moodiness, irritability, etc.), that occur when an individual is unable to search internet databases because they are ill, the internet is unavailable, or there is no Wi-Fi on holiday, etc.
• Conflict – This refers to the conflicts between the person and those around them (interpersonal conflict), conflicts with other activities (social life, hobbies and interests) or from within the individual themselves (intra-psychic conflict and/or subjective feelings of loss of control) that are concerned with spending too much time searching internet databases.
• Relapse – This is the tendency for repeated reversions to earlier patterns of excessive internet database searching to recur and for even the most extreme patterns typical of the height of excessive internet database searching to be quickly restored after periods of control.

Of the 12 QISD items constructed in the new scale, very few appeared to have anything to do with addiction and/or dependence but this is most likely due to the fact that the authors also used data collected from 50 participants to inform their items and not just the criteria in the addiction components model. However, relying heavily on input from their participants resulted in a number of key features in addiction/dependence not even being assessed (i.e., no assessment of salience, mood modification, conflict, relapse or tolerance). A couple of items may peripherally assess withdrawal symptoms (e.g., ‘I will be upset if I cannot find an answer to a complex question through Internet search’) but not in any way that is directly associated with addiction or dependence. This may be because the authors’ conceptualization of ‘dependence’ was more akin to ‘over-reliance’ rather than traditional definitions of dependence.

While the QISD may be psychometrically robust I argued that it appears to have little face validity and does not appear to assess problematic engagement in internet database searching (irrespective of how addiction or dependence is defined). Based on the addiction components model, I concluded my paper by creating my own scale to assess internet search dependence based directly on the addiction components model and which I argued would have much greater face validity than any item currently found in the QISD:

• Internet database searching is the most important thing in my life.
• Conflicts have arisen between me and my family and/or my partner about the amount of time I spend searching internet databases.
• I engage in internet database searching as a way of changing my mood.
• Over time I have increased the amount of internet database searching I do in a day.
• If I am unable to engage in internet database searching I feel moody and irritable.
• If I cut down the amount of internet database searching I do, and then start again, I always end up searching internet databases as often as I did before.

Dr. Mark Griffiths, Professor of Behavioural Addiction, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Further reading

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.

Andreassen, C.S., Pallesen, S., Griffiths, M.D. (2017). The relationship between excessive online social networking, narcissism, and self-esteem: Findings from a large national survey. Addictive Behaviors, 64, 287-293.

Canale, N., Griffiths, M.D., Vieno, A., Siciliano, V. & Molinaro, S. (2016). Impact of internet gambling on problem gambling among adolescents in Italy: Findings from a large-scale nationally representative survey. Computers in Human Behavior, 57, 99-106.

Griffiths, M.D. (1998). Internet addiction: Does it really exist? In J. Gackenbach (Ed.), Psychology and the Internet: Intrapersonal, Interpersonal and Transpersonal Applications (pp. 61-75). New York: Academic Press.

Griffiths, M.D. (1999a). Internet addiction: Internet fuels other addictions. Student British Medical Journal, 7, 428-429.

Griffiths, M.D. (1999b). Internet addiction: Fact or fiction? The Psychologist: Bulletin of the British Psychological Society, 12, 246-250.

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, 191-197.

Griffiths, M.D. (2012). Internet sex addiction: A review of empirical research. Addiction Research and Theory, 20, 111-124.

Griffiths, M.D. (2017). Commentary: Development and validation of a self-reported Questionnaire for Measuring Internet Search Dependence. Frontiers in Public Health, in press.

Griffiths, M.D., Kuss, D.J., Billieux J. & Pontes, H.M. (2016). The evolution of internet addiction: A global perspective. Addictive Behaviors, 53, 193–195.

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.

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.

Wang, Y., Wu, L., Zhou, H., Xu, J. & Dong, G. (2016). Development and validation of a self-reported Questionnaire for Measuring Internet Search Dependence. Frontiers in Public Health, 4, 274. doi: 10.3389/fpubh.2016.00274

Young, K. S. (1999). Internet addiction: evaluation and treatment. Student British Medical Journal, 7, 351-352.