Category Archives: Psychiatry
In a previous blog on animal hoarding I made a passing reference to Diogenes Syndrome (DS) that is sometimes referred to as ‘senile squalor syndrome’ (as it typically occurs in elderly individuals – although it has occasionally been reported in young adults). According to a paper by Alberto Pertusa and colleagues in a 2010 issue of Clinical Psychology Review:
“Squalor has been defined in various ways including, ‘social breakdown of the elderly’, ‘Diogenes syndrome’ and ‘severe domestic squalor’…These definitions have usually encompassed both domestic neglect and a lack of personal hygiene…The majority of case observations and studies on squalor have focused on elderly populations recruited from nursing or disability services…These studies initially suggested that those living in squalor were likely to be over the age of 60, primarily female, living alone and unmarried…Hypotheses on the etiology of squalor have moved from the phenomenon possibly being uni-dimensional to having heterogeneous causes such as physical disabilities, brain damage, psychiatric conditions, and personality disorders…A study on squalor reported the prevalence to be 0.005% in the United Kingdom”.
Hoarding is often a consequence of having DS but is associated with self-neglect and much of the items excessively hoarded are typically items of trash with little or no value. Like animal hoarders, those with DS often live on their own in severe domestic squalor and unsanitary conditions. As I noted in my previous blog, DS is characterized by extreme self-neglect, apathy, domestic squalor, social withdrawal, compulsive hoarding of rubbish, and lack of shame. Most sufferers refuse help of others and the onset of DS may sometimes be initiated by a stressful event in their lives (such as death of a loved one). According to a 2013 paper on DS by Dr. Projna Biswas and colleagues in the journal Case Reports in Dermatological Medicine:
“DS is named after the Greek Philosopher “Diogenes of Sinope” (4th century BC) who taught about cynicism philosophy. He kept his need for clothing and food to a minimum by begging. He used to follow some ideas like ‘life according to nature’, ‘self-sufficiency’, ‘freedom from emotion’, ‘lack of shame’, ‘outspokenness’, and ‘contempt for social organization’…The approximate annual incidence of Diogenes is 0.05% in people over the age of 60 [years]. Affected individuals come from any socioeconomic status, but are usually of average or above-average intelligence…It is often associated with other mental illnesses, such as schizophrenia, mania, and frontotemporal dementia…While no clear etiology exists, it is hypothesized that it may be due to a stress reaction in people with certain pre-morbid personality traits, such as being aloof, or certain personality disorders, such as schizotypal or obsessive compulsive personality disorder. There are suggestions that an orbitofrontal brain lesion may lead to such behaviours…while others state that chronic mania symptoms, such as poor insight, can lead to such a condition”.
DS was not included separately in the latest (fifth) edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) although hoarding (syllogomania) is included as a genuine psychiatric diagnosis. Because of deliberate self-isolation, physical neglect and poor eating, DS mortality rates are high with close to half of sufferers dying within five years of DS onset. Biswas and colleagues also note:
“Diogenes syndrome is also known as dermatitis passivata. The term Diogenes syndrome was coined in 1975 by [Clark and colleagues]…DS has been classified as primary or pure which is not associated with mental illness and secondary or symptomatic. Secondary DS is related to mental illness like schizophrenia, depression, and dementia…Alcohol abuse has been identified as a cofactor…Multiple deficiency states have been associated with DS including iron, folate, vitamin B12, vitamin C, calcium and vitamin D, serum proteins and albumin, water, and potassium…Skin lesions are mainly due to uncleanliness which may result in various infestations and infections. These are ignored by the patient. Dirt, dust, bacterial, fungal, and parasitic debris conglomerate to form thick crusts and scales over various parts of the body”.
The paper by Biswas and colleagues’ asserted that four symptoms have been reported as being in almost all DS sufferers. These are that they: (i) never ask for any help despite possessing nothing; (ii) are unusually fond of certain objects (including rubbish); (iii) display unusual behavior with other people (misanthropy) and (iv) display extreme self-neglect. Although hoarding is often present in those with DS, there have been some cases reported where no hoarding was present. In their 2010 review paper, Dr. Pertusa and colleagues noted:
“Research on hoarding has rarely included assessments of severe domestic squalor. Winsberg et al. (1999) noted that clutter inhibited normal activities of daily living – including personal hygiene. A few studies have provided more direct indications of squalor in hoarding. [one study in 2000] surveyed health department officers in Massachusetts who reported that 38% of their hoarding cases were ‘heavily cluttered with filthy environment, overwhelming’. [Another study] focused on cleanliness ratings of the personal appearance and the homes of 62 elderly hoarding individuals. In their sample, 17% of individuals were described as ‘extremely filthy’ and 33% of residences were rated as ‘extremely filthy and dirty’. For 32% of the residences, there was an overpowering odor from rotten food or animal or human feces. Many subjects could not use their refrigerator (45%), kitchen sink (42%), bathtub (42%), or toilet (10%). Lack of standardized instruments to measure squalor have prevented researchers from understanding squalor in compulsive hoarding”.
Dr. Pertusa and his colleagues claim the data on DS is scarce and that the clinical picture between hoarding and DS needs more clinical research. They do conclude that hoarding within a DS diagnosis is clinically different from other types of hoarding (for instance, compulsive hoarders do not display the same core features as those with DS such as squalor and self-neglect). Like many other clinical conditions, Pertusa’s team assert that longitudinal studies will best help uncovering the natural history and link (if any) between both DS and compulsive hoarding.
Dr Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK
Biswas, P., Ganguly, A., Bala, S., Nag, F., Choudhary, N., & Sen, S. (2013). Diogenes syndrome: a case report. Case reports in dermatological medicine, http://dx.doi.org/10.1155/2013/595192
Clark, A. N., Mankikar, G. D., & Gray, I. (1975). Diogenes syndrome. A clinical study of gross neglect in old age. Lancet, 1(7903), 366−368.
Drummond, L.M., Turner, J., Reid, S. (1996). Diogenes’ syndrome – a load of old rubbish? Irish Journal of Psychiatric Medicine, 14(3), 99–102.
Greve, K.W., Curtis, K.L., & Bianchini, K.J. (2004). Personality disorder masquerading as dementia: A case of apparent Diogenes syndrome. International Journal of Geriatric Psychiatry, 19, 703–705
Irvine, J. D., & Nwachukwu, K. (2014). Recognizing Diogenes syndrome: a case report. BMC Research Notes, 7(1), 276.
Pertusa, A., Frost, R.O., Fullana, M.A., Samuels, J., Steketee, G., Tolin, D., Saxena, S., Leckman, J.F., Mataix-Cols, D. (2010). Refining the diagnostic boundaries of compulsive hoarding: A critical review. Clinical Psychology Review, 30, 371-386.
Rosenthal, M., Stelian, J., & Wagner, J. (1999). Diogenes syndrome and hoarding in the elderly: Case reports. Israel Journal of Psychiatry and Related Sciences, 36, 29–34.
Regular readers of my blog will know that when it comes to certain films and television shows (and their accompanying DVD box sets) I can be somewhat obsessive and fanatical (for instance see, my blog on my love of all things concerning Hannibal Lecter). I’m one of those individuals that will watch some films again and again looking for further insight and deeper meanings (such as Memento, The Usual Suspects, Donnie Darko, Inception, Shutter Island, Seven, and The Shining). One of the films I have watched many times is Cameron Crowe’s psychological thriller Vanilla Sky (starring Tom Cruise, Kurt Russell, Cameron Diaz and Penélope Cruz), a remake of the Spanish film Abre los Ojos (Open Your Eyes).
One of the reason I like the film is that it prominently features the concept of lucid dreaming. I’d never heard of lucid dreaming until 1988. I was doing my PhD at the University of Exeter at the time and one of my best friends (Robert Rooksby) was doing his PhD on lucid dreaming. As the Wikipedia entry on lucid dreaming notes:
“A lucid dream is any dream in which one is aware that one is dreaming. In relation to this phenomenon, Greek philosopher Aristotle observed: ‘often when one is asleep, there is something in consciousness which declares that what then presents itself is but a dream’…The person most widely acknowledged as having coined the term is Dutch psychiatrist and writer Frederik (Willem) van Eeden…In a lucid dream, the dreamer has greater chances to exert some degree of control over their participation within the dream or be able to manipulate their imaginary experiences in the dream environment…Lucid dreams can be realistic and vivid. It is shown that there are higher amounts of beta-1 frequency band (13–19 Hz) brain wave activity experienced by lucid dreamers, hence there is an increased amount of activity in the parietal lobes making lucid dreaming a conscious process”.
Much like the films of David Lynch (one of my favourite film directors), Vanilla Sky is a film forces you to think about what is going on and is one of those films that you can come to your own conclusions as to what it all means. As a psychologist, I love films that play with the mind and Vanilla Sky is one of those films, particularly as psychology in the form of dreams, subjective reality, and the unconscious lie at the heart of the film. The director Cameron Crowe added many obscure clues and hidden references throughout the film to help viewers further explain the film and to add more layers. There are dozens of dedicated websites that have compiled lists of theories, messages and/or hidden clues. In the film’s production notes, Crowe later admitted: “We constructed the movie, visually and story-wise, to reveal more and more the closer you look at it. As deep as you want to go with it, my desire was for the movie to meet you there”. That alone is enough of a hook to get me watching repeatedly.
Another aspect of the film that I love is the perfect use of music. Almost every lyric of every song used throughout the movie interweaves seamlessly between the actors, the in-scene narrative, and the developing story line. The songs are expertly chosen. This is no surprise given that Crowe was formerly a music journalist and a contributing editor at Rolling Stone magazine. Like me, Crowe is a huge fan of The Beatles, and referred to the “clues” in Vanilla Sky as his own version of the ‘Paul McCartney is Dead’ rumour that swept the world in 1969 (i.e., the notorious Beatles hoax when fans worldwide became convinced through song lyrics, sonic tricks, and album art that Paul McCartney had died and was replaced by a look-alike). As Crowe commented: “Divorcing it from whether Paul was really dead or not, that was a really great parlour game: searching for clues, the excitement of different layers, some of them chilling, some of them really funny. It was a great model for us [on Vanilla Sky]”. One of the homages to The Beatles in the film concerns their song Revolution 9. The film contains countless references to the number (or time) 9:09 (on Aames’ wristwatch, a child’s shirt, the prison chalkboard, and multiple references to cats who, has myth has it, have nine lives).
I’m assuming that anyone that has read this far has seen the film (but if you haven’t – spoiler alert – some of what I’m about to write will likely reduce the enjoyment of watching the film for the first time). The thrust of the plot is as follows:
“From a prison cell where he has been charged for murder, David Aames (Tom Cruise, in a prosthetic mask, tells his life story to court psychologist Dr. Curtis McCabe (Kurt Russell). In flashback, David [who is acrophobic with an irrational fear of heights] is shown to be the wealthy owner of a large publishing firm in New York City which he inherited from his father, leaving its regular duties to his father’s trusted associates. As David enjoys the bachelor lifestyle, he is introduced to Sofia Serrano (Penélope Cruz) by his best friend and author Brian Shelby [who is writing a book on Aames] at a party. David and Sofia spend a night together talking, and fall in love. When David’s former lover, Julianna “Julie” Gianni (Cameron Diaz) hears of Sofia, she attempts to kill herself and David in a car crash. Julie dies but David survives, his face grotesquely disfigured, leading him to wear a mask to hide the injuries. With no hope to use plastic surgery to repair the damage, David cannot come to grips with the idea of wearing the mask for the rest of his life. One night on a night out with Sofia…David gets hopelessly drunk, and [is left by Sophia] to wallow in the street outside” (Wikipedia entry on Vanilla Sky)
It is generally accepted that everything from this point in the film is a dream (although others say the whole film is a dream). Rather than live out the rest of his life in a disfigured state, Aames has his body cryogenically frozen by a company called Life Extension after attempting suicide. He lives the rest of his life as a lucid dream from the moment he was found on the pavement after his drunken night out (“under the ‘vanilla sky’ from a Monet painting”). However, during cryogenic sleep, the lucid dream goes horribly wrong and starts to incorporate elements from his subconscious. After 150 years in suspended sleep, the company that placed Aames into cryogenic suspension calls in ‘Tech Support’ and Aames is offered a choice to either be reinserted into a corrected lucid dream, or to wake up by taking a leap of faith – literally – from the top of a high roof (that forces him to challenge his fear of heights).
“Conquering his final fear, David jumps off the building, his life flashing before his eyes, and whites out immediately before hitting the ground. A female voice commands him to ‘open your eyes’ (a recurring theme in the movie), and the film ends with David opening his eyes” (Wikipedia entry on Vanilla Sky).
Many different websites examining the film claim there are five interpretations of the film’s ending (and this is supported by Crowe himself). The five interpretations (taken verbatim from the Wikipedia entry on the film) are:
- “Tech support is telling the truth: 150 years have passed since Aames killed himself and subsequent events form a lucid dream.
- The entire film is a dream, evidenced by the sticker on Aames’ car that reads “2/30/01″ (February 30 does not occur in the Gregorian Calendar).
- The events following the crash form a dream that occurs while Aames is in a coma.
- The entire film is the plot of the book that Brian [Shelby, his best friend] is writing.
- The entire film after the crash is a hallucination caused by the drugs that were administered during Aames’ reconstructive surgery”.
(I’m most persuaded by the first interpretation). What I also love about the film is that Crowe added lots of little details that take a few viewings of the film before they are usually spotted. All of these help in both trying to interpret the film, as well as becoming a game where repeated watching becomes more rewarding. For instance:
- In the first scene in which Julianna appears, the tune ringing on her cell phone is Row Row Row Your Boat that features the lyric “life is but a dream”.
- At his birthday party, Aames is asked how it’s going to which he responds “Livin’ the dream, baby…livin’ the dream”.
- At the same party, Aames’ best friend Brian Shelby comes into the second apartment wears a t-shirt with the words “fantasy” in sparkly sequins.
- In one of the prison scenes, the word ‘DREAM’ is spelt out backwards on a chalkboard.
- In the prison cell, the book, Memories, Dreams, and Reflections (by Carl Jung) is on the table while Aames is talking to his psychiatrist Dr. McCabe. The book concerns Jung’s personal dreams and how they helped uncover his “shadow” and removed his persona (his ‘mask’). In fact one critique of the film by Carlo Cavagna described the whole film as “overtly Jungian”. More specifically, he asserted that Vanilla Sky is “fundamentally about the relationship between the ego and the unconscious, and practically a primer on the most fundamental concepts found in any Jungian glossary…For Jung, the unconscious includes desires repressed by our education and socialization, but there is more ‘psychic material that lies below the threshold of consciousness’. The unconscious is the foundation on which the conscious mind is based”.
- On Aames’ prison uniform the name tag says “Frozen Guy”.
- His patient number on his Life Extension cryogenic tank says “PL515NT 4R51MS” (which if the numbers are replaced with their corresponding letters of the alphabet, it almost spells “Pleasant Dreams”).
- As Aames is getting his prison photograph taken, the slate spells ‘When did the dream become a nightmare?’ (in simple code).
- Sofia calls Aames a “pleasure delayer” twice in the film (but says it so subtly that it’s hard to hear properly).
- When Aames and Sophia are lying in bed after making love, Sophia asks “Is this is a dream?” and Aames replied “absolutely”.
- At one point in the film, Dr. McCabe tells Aames that he’d had a nightmare the day before. Aames replies that “It’s all a nightmare”.
I said earlier in the article that I thought the songs were perfectly chosen. Many fans of the film have noted that the lyrics repeatedly appear to match the emotion of the scene where it is played. As the Uncool website notes:
“For example, the song that plays over David leaving Sophia’s in the morning is Jeff Buckley’s, ‘Last Goodbye’…that morning was there last one true goodbye. Yes, they see each other after this, but after the car wreck when both of their lives are forever changed. ‘Last Goodbye’ also contains the lyrics: ‘Kiss me, please kiss me, but kiss me out of desire, babe not consolation’ which follows David’s plight rather well (as the next time he sees her is after the accident and he wants her affections but not sympathy for his disfigurement)…Bruce Springsteen’s ‘The River’ album (featured in the closing montage) also has some lyrical significance. One of the best lines from the song ‘The River’ is: “Is a dream a lie if it don’t come true, or is it something worse?” Also, two R.E.M. songs are featured. Don’t forget what R.E.M. stands for. Rapid eye movement. As in a state of sleep. It’s when you dream”.
It doesn’t take a psychologist to work out that I simply love the level of detail that went into making the film. I am not a great fan of psychodynamic (psychoanalytic) interpretation, but in Vanilla Sky, the mask that Aames wore became his ‘persona’ and the term was used by Carl Jung to describe the face that we as individuals present to society and (in some cases) to ourselves. Carlo Cavagna argues that:
“[Aames] attraction to [Sophie] is irresistible because she is his anima, his archetypal dream lover, the personification of the feminine nature in his own unconscious. Jung posited that all men carry an ideal image of woman in their heads and unconsciously project that image onto “the person of the beloved…David’s disfigured face, which he sometimes hides with his mask, represents his shadow. For Jung, the shadow is the inferior part of the personality, the sum of all personal and collective psychic elements that, because of their incompatibility with the chosen conscious attitude, are denied expression in life and therefore coalesce into a relatively autonomous “splinter personality” in the unconscious. Despite the negative connotations of the word ‘shadow’, Jung meant it to encompass all those qualities that are suppressed, both positive and negative. ‘The shadow personifies everything that the subject refuses to acknowledge about himself and yet is always thrusting itself upon him directly or indirectly’… [Aames] reality is subjective, and his shadow is breaking through into consciousness. This is the source of the film’s main conflict. In discussing dream therapy and the difficulty of processing and assimilating the unconscious, Jung wrote that several negative outcomes are possible – eccentricity, infantilism, paranoia, schizophrenia, or regression (the restoration of the persona). The revelation and assimilation of David’s unconscious is essentially the story of Vanilla Sky”.
Although there are many critics who hated the film, I love it on many different levels (including the underlying psychology).
Dr Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK
Cavagna, C. (2001, December). Vanilla Sky. Located at: http://www.aboutfilm.com/movies/v/vanillasky.htm
Jung, C.G. (1961). Memories, Dreams, Reflections. New York: Vantage.
Kummer, R. (2010). “What is happiness to you?” Vanilla Sky (2001) Film Analysis. Located at: http://rkummer.hubpages.com/hub/What-is-happiness-to-you-Vanilla-Sky-2001-Film-Analysis
Rooksby, R. and Terwee, Sybe J.S. (1990). Freud, van Eeden and lucid dreaming. Lucidity Letter, 9(2), 18–28. Located at: http://www.sawka.com/spiritwatch/freudvan.htm
Turner, R. (2014). Vanilla Sky movie review: Beyond lucid dreams. Located at: http://www.world-of-lucid-dreaming.com/vanilla-sky-review.html
The Uncool (2015). Vanilla Sky secrets. Located at: http://www.theuncool.com/films/vanilla-sky/vanilla-sky-secrets
Wikipedia (2015). Vanilla Sky. Located at: https://en.wikipedia.org/?title=Vanilla_Sky
Mindfulness is a form of meditation that derives from Buddhist practice and is one of the fastest growing areas of psychological research. We have defined mindfulness as the process of engaging a full, direct, and active awareness of experienced phenomena that is spiritual in aspect and that is maintained from one moment to the next. As part of the practice of mindfulness, a ‘meditative anchor’, such as observing the breath, is typically used to aid concentration and to help maintain an open-awareness of present moment sensory and cognitive-affective experience.
Throughout the last two decades, Buddhist principles have increasingly been employed in the treatment of a wide range of psychological disorders including mood and anxiety disorders, substance use disorders, bipolar disorder, and schizophrenia-spectrum disorders. The emerging role of Buddhism in clinical settings appears to mirror a growth in research examining the potential effects of Buddhist meditation on brain neurophysiology. Such research forms part of a wider dialogue concerned with the evidence-based applications of specific forms of spiritual practice for improved psychological health.
Within mental health and addiction treatment settings, mindfulness-based interventions (MBIs) are generally delivered in a secular eight-week format and often comprise the following: (i) weekly sessions of 90-180 minutes duration, (ii) a taught psycho-education component, (iii) guided mindfulness exercises, (iv) a CD of guided meditation to facilitate daily self-practice, and (v) varying degrees of one-to-one discussion-based therapy with the program instructor. Examples of MBIs used in behavioural addiction treatment studies include Mindfulness-Based Cognitive Therapy, Mindfulness-Enhanced Cognitive Behaviour Therapy, Mindfulness-Based Relapse Prevention, Mindfulness-Based Stress Reduction, and Meditation Awareness Training.
Studies investigating the role of mindfulness in the treatment of behavioural addictions have – to date – primarily focused on problem and/or pathological gambling. These studies have shown that levels of dispositional mindfulness in problem gamblers are inversely associated with gambling severity, thought suppression, and psychological distress. Recent clinical case studies have demonstrated that weekly mindfulness therapy sessions can lead to clinically significant change in problem gambling individuals. Published case studies include: (i) a male in his sixties addicted to offline roulette playing, (ii) a 61-year old female (with comorbid anxiety and depression) addicted to slot machine gambling (treated with a modified version of Mindfulness-Based Cognitive Therapy), and (iii) a 32-year old female (with co-occurring schizophrenia) addicted to online slot-machine playing (treated with a modified version of Meditation Awareness Training). Also, a recent study showed that problem gamblers that received Mindfulness-Enhanced Cognitive Behaviour Therapy demonstrated significant improvements compared to a control group in levels of gambling severity, gambling urges, and emotional distress.
Outside of gambling addiction, case studies have investigated the applications of mindfulness for treating addiction to work (i.e., workaholism) and sex. In the case of the workaholic, a director of a blue-chip technology company in his late thirties was successfully treated for his workaholism utilizing Meditation Awareness Training. Significant pre-post improvements were also observed for sleep quality, psychological distress, work duration, work involvement during non-work hours, and employer-rated job performance. However, as with any case study, the single-participant nature of the study significantly restricts the generalizability of such findings.
Key treatment mechanisms that have been identified and/or proposed in this respect (several of which overlap with mechanisms identified as part of the mindfulness-based treatment of chemical addictions) include:
- A perceptual shift in the mode of responding and relating to sensory and cognitive-affective stimuli that permits individuals to objectify their cognitive processes and to apprehend them as passing phenomena.
- Reductions in relapse and withdrawal symptoms via substituting maladaptive addictive behaviours with a ‘positive addiction’ to mindfulness/meditation (particularly the ‘blissful’ and/or tranquil states associated with certain meditative practices).
- Transferring the locus of control for stress from external conditions to internal metacognitive and attentional resources.
- The modulation of dysphoric mood states and addiction-related shameful and self-disparaging schemas via the cultivation of compassion and self-compassion.
- Reductions in salience and myopic focus on reward (i.e., by undermining the intrinsic value and ‘authenticity’ that individuals assign to the object of addiction) due to a better understanding of the ‘impermanent’ nature of existence (e.g., all that is won must ultimately be lost, an attractive body will age and wither, a senior/lucrative occupational role must one day be relinquished, etc.).
- Growth in spiritual awareness that broadens perspective and induces a re-evaluation of life priorities.
- ‘Urge surfing’ (the meditative process of adopting an observatory, non-judgemental, and non-reactive attentional-set towards mental urges) that aids in the regulation of habitual compulsive responses.
- Reduced autonomic and psychological arousal via conscious-breathing-induced increases in prefrontal functioning and vagal nerve output (breath awareness is a central feature of mindfulness practice).
- Increased capacity to defer gratitude due to improvements in levels of patience.
- A greater ability to label and therefore modulate mental urges and faulty thinking patterns.
Although preliminary findings indicate that there are applications for MBIs in the treatment of behavioural addictions, further empirical and clinical research utilizing larger-sample controlled study designs is clearly needed. Despite this, both the classical Buddhist meditation literature and recent scientific findings appear to agree that when correctly practised and administered, mindfulness meditation is a safe, non-invasive, and cost-effective tool for treating behavioural addictions and for improving psychological health more generally.
Dr Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK
Griffiths, M.D., Shonin, E.S., & Van Gordon, W. (2015). Mindfulness as a treatment for gambling disorder. Journal of Gambling and Commercial Gaming Research, in press.
Shonin, E.S., Van Gordon, W. & Griffiths, M.D. (2013). Mindfulness-based interventions: Towards mindful clinical integration. Frontiers in Psychology, 4, 194, doi: 10.3389/fpsyg.2013.00194.
Shonin, E.S., Van Gordon, W. & Griffiths, M.D. (2013). Buddhist philosophy for the treatment of problem gambling. Journal of Behavioral Addictions, 2, 63-71.
Shonin, E., Van Gordon W., & Griffiths, M.D. (2014). Mindfulness as a treatment for behavioural addiction. Journal of Addiction Research and Therapy, 5: e122. doi: 10.4172/2155-6105.1000e122.
Shonin, E., Van Gordon W., & Griffiths, M.D. (2014). Current trends in mindfulness and mental health. International Journal of Mental Health and Addiction, 12, 113-115.
Shonin, E., Van Gordon, W., & Griffiths M.D. (2014). Cognitive Behavioral Therapy (CBT) and Meditation Awareness Training (MAT) for the treatment of co-occurring schizophrenia with pathological gambling: A case study. International Journal of Mental Health and Addiction, 12, 181-196.
Shonin, E., Van Gordon W., & Griffiths M.D. (2014). The emerging role of Buddhism in clinical psychology: Towards effective integration. Psychology of Religion and Spirituality, 6, 123-137.
Shonin, E., Van Gordon, W., & Griffiths M.D. (2014). The treatment of workaholism with Meditation Awareness Training: A case study. Explore: Journal of Science and Healing, 10, 193-195.
Shonin, E.S., Van Gordon, W. & Griffiths, M.D. (2014). Practical tips for using mindfulness in general practice. British Journal of General Practice, 624 368-369.
Shonin, E.S., Van Gordon, W. & Griffiths, M.D. (2015). Mindfulness in psychology: A breath of fresh air? The Psychologist: Bulletin of the British Psychological Society, 28, 28-31.
Shonin, E., Van Gordon W., Griffiths M.D. & Singh, N. (2015). There is only one mindfulness: Why science and Buddhism need to work together. Mindfulness, 6, 49-56.
“A body of an adult female of about 25 years old was found dead in a naked condition in a reserved forest area in South Delhi in June, 2006 by police. There was information to [the] police via public call as 2-3 people had killed one lady after [having] sex [with her] and [then running] away. Further enquiry, revealed that they all had consumed alcohol along with the lady. They also had sexual intercourse with her using condom…Following the quarrel they killed her by hitting her head with a heavy stone. After killing her, they also tried to destroy her identity by burning her face with wooden stick and twigs and her clothes. One of them also introduced a wine bottle inside [her] vagina. There were multiple postmortem injuries in particular pattern over left side lower part of chest, abdomen and inguinal regions including upper part of left thigh. All [the] accused were subsequently arrested by the police”.
This shocking account of a brutal murder was the opening paragraph in a paper by Dr. B.L. Chaudhary and his colleagues in a 2007 issue of the Journal of Indian Academy of Forensic Medicine (JIAFM). Although an increasingly common theme in television and film homicides, post-mortem mutilation of a dead person’s body by perpetrators is arguably much rarer than the incidence in fictionalized drama. The JIAFM paper noted that the majority of such cases typically involve body “dismemberment for the purpose of disposing or hiding a body or of preventing identification”.
A national study carried out in Sweden by Dr. Jovan Rajs and colleagues in the Journal of Forensic Sciences found that only 22 deaths over a 30-year period (1961-1990) had been criminally mutilated and/or dismembered. These were then classified into one of three types: (i) defensive, (ii) offensive (i.e., lust murder) and (iii) necromanic mutilation. They reported that the perpetrators of the defensive and aggressive post-mortem mutilation were typically “disorganized” (i.e., alcoholics, drug abusers, mentally disordered) whereas the lust murderers were typically “organized” with a long history of violent crimes. The JIAFM paper summarized the findings of Raus and colleagues:
“The characteristics of the mutilations were diverse. In cases of murder committed in association with sexual deviation, wounding is usually limited to the breasts and sexual organs. Corpse mutilation can also be of a symbolic nature as in cases of mafia murders (revenge punishment) and then it is associated with torturing the victim and with the motive of destruction of identify of victim”.
In the case of the female victim reported by Chaudhary and colleagues, they reported that it was the victim’s head, face, and chest that were burned, destroyed, and mutilated post-mortem. They speculated that this was done to either (i) to prevent identification of the victim, (ii) to make it difficult to determine the cause of death, or (iii) as an act of depersonalization as it is often seen “when the murder is disorganized and has a close relation to his victim or offensive mutilation as general act of frustration”. Why the men had inserted a foreign object into the woman’s vagina was less clear. The authors speculated that it may have been because of (i) frustration of a non-performing sexual partner because of heavy intoxication, (ii) an extortion demand by victim, (iii) blackmail by the victim, or (iv) psychopathic tendencies of the perpetrators can carried out for sadistic pleasure. However, they also added that:
“In this case as there was alleged history of consensual sexual activity which could be or could not be as body had injuries so it could be non-consensual activity also. Apparently there was no smell in the [gastric] contents but samples were sent for alcohol screening/concentration estimation. In [the medical] literature, various materials and objects like chilly powder, corrosives, metal or wooden sticks are introduced into genitalia as a part of punishment for unfaithfulness or infidelity. Males suffering from depression due to erectile dysfunctions, premature ejaculation and impotency may indulge in extreme frustration cases. In this psychological profiling of the accused can also be helpful in knowing for such abnormal instincts. At times, provocative words by female partner about their malehood could trigger such impulsive murder and mutilation”
Post-mortem mutilation while extreme can sometimes border on the almost unbelievable. For instance, Dr. J. Kunz and Dr. A. Gross published a paper in a 2001 issue of the American Journal of Forensic and Medical Pathology which as Ronseal would claim “does exactly what it says on the tin” as it was entitled “Victim’s scalp on the killer’s head: An unusual case of criminal postmortem mutilation”. The paper reported that:
“After killing his father, the son decapitated his body and dissected the scalp free, forming a mask of the father’s head and neck. The young man wore the scalp-mask over his own head to imitate the father. The motive of the murder was revenge, and the postmortem mutilation was the realization of the perpetrator’s fantasies, symbolically representing a penalty for the reprehensible past life of his father”.
Another extreme case of postmortem mutilation following murder was reported by Dr. Tomasz Konopka and his colleagues in a 2006 issue of the Journal of Forensic Medicine and Pathology. In this instance, a Polish man cut up the corpse and dismembered the body into 850 fragments. He “employed various tools to divide the body into fragments and subsequently boiled the pieces to reduce their volume”. This reduced the body volume by 30kg. The murderer then placed all the body fragments into two large pots in a space under his stairwell and then plastered over the wall to hide the body. Another paper by Dr. Konopka and colleagues in a 2007 issue of Legal Medicine examined 23 cases of dismembered bodies in the 1968-2005 period at the Cracow Department of Forensic Medicine. Of these, 17 were cases of defensive mutilation, three were offensive mutilation and two were dismemberment (decapitation, and direct cause of death). One case remained unclassified where the murderer dissected free skin from the whole torso. They concluded that:
“Apart from rare cases of necrophilia, the victim of dismemberment is always a victim of homicide. Homicides ending with corpse dismemberment are most commonly committed by a person close to, or at least acquainted with the victim and they are performed at the site of homicide, generally in the place inhabited by the victim, the perpetrator or shared by both. Such instances are generally not planned by the perpetrator and rarely serial in character”.
Finally, I came across an interesting 2009 paper by a Finnish team led by Dr. Häkkänen-Nyholm in the Journal of Forensic Sciences. The authors noted that research relating to mutilation of bodies by murderers was “sparse”. They estimated the rate of mutilation of the victim’s body in Finnish homicides. To do this they examined all crime and forensic reports of homicide offenders from 1995–2004 (n = 676). Only 13 murders (2.2%) involved postmortem mutilation. They concluded that:
“Educational and mental health problems in childhood, inpatient mental health contacts, self-destructiveness, and schizophrenia were significantly more frequent in offenders guilty of mutilation. Mutilation bore no significant association with psychopathy or substance abuse. The higher than usual prevalence of developmental difficulties and mental disorder of this subsample of offenders needs to be recognized”.
Chaudhary, B.L., Murty, O.P. & Singh, D. (2007). Foreign objects in genitalia: Homicide with destruction of identity – A case report. Journal of Indian Academy of Forensic Medicine, 29(4), 135-137.
Häkkänen-Nyholm, H., Weizmann‐Henelius, G., Salenius, S., Lindberg, N., & Repo-Tiihonen, E. (2009). Homicides with mutilation of the victim’s body. Journal of Forensic Sciences, 54(4), 933-937.
Hladík, J., Štefan, J., Srch, M., & Pilin, A. (2000). A rare case of evisceration. International Journal of Legal Medicine, 113(2), 107-109.
Konopka, T., Bolechala, F., & Strona, M. (2006). An unusual case of corpse dismemberment. The American Journal of Forensic Medicine and Pathology, 27(2), 163-165.
Konopka, T., Strona, M., Bolechała, F., & Kunz, J. (2007). Corpse dismemberment in the material collected by the Department of Forensic Medicine, Cracow, Poland. Legal Medicine, 9(1), 1-13.
Kunz, J. & Gross, A. (2001). Victim’s scalp on the killer’s head: An unusual case of criminal postmortem mutilation. American Journal of Forensic and Medical Pathology, 22(3), 327-31.
Rajs, J., Lundstrom, M., Broberg, M., Lidberg, L., & Lindquist, O. (1998). Criminal mutilation of the human body in Sweden: A thirty year medico-legal and forensic psychiatric study. Journal of Forensic Sciences, 43(3), 563-80.
Simonsen, J. (1989). A sadistic homicide. The American Journal of Forensic Medicine and Pathology, 10(2), 159-163.
Türk, E. E., Püschel, K., & Tsokos, M. (2004). Features characteristic of homicide in cases of complete decapitation. The American Journal of Forensic Medicine and Pathology, 25(1), 83-86.
Over the weekend I went to the cinema with my oldest son to watch Mad Max: Fury Road. The reason I mention this is because King Immortan Joe in the film (who live in a world where water is a scarce commodity) tells his thirsty subjects “Do not become addicted to water, it will take hold of you”. As soon as I got home after the film, I was straight onto Google and Google Scholar to see whether there had been anything written on ‘water addiction’. Unsurprisingly, there were lots of newspaper reports of individuals being ‘addicted’ to water but little in the academic literature. For instance, one American online article told the story of Sasha Kennedy:
“[Sasha] is addicted to water, drinking 25 liters of the stuff a day, far exceeding the USDA Recommended Daily Water Intake of 2.7 liters…What surprised me most was that the condition had a name: Psychogenic polydipsia. It is ‘an uncommon clinical disorder characterized by excessive water-drinking in the absence of a physiologic stimulus to drink’ and is typically found among mental patients on phenothiazine medications. Kennedy appears to be completely sane, although she does experience the dry mouth sensation characteristic of the condition…You’d think drinking so much water would do something to her health, but medical experts confirmed that there is nothing wrong with her. She doesn’t even have hypoatremia, where cells swell due to too much water in the blood. She’s perfectly healthy and her blood isn’t diluted. Then again, her habit started when she was two years old, so maybe her body acclimatized. Her lifestyle, however, is drastically affected by her addiction. She has to go to the toilet 40 times a day and can only get about an hour of sleep every night before having to wake up to drink some water or go to the loo. She carries large bottles of water with her everywhere she goes, and once quit her job because the tap water quality wasn’t up to par”.
Another case was reported by the UK’s Daily Mail who recounted the story of 22-year old “aquaholic” Sarah Schapira who (at the time the article was written) drank seven litres of water every day, and like Sasha above spent a lot of time in the toilet. Schapira stated:
“My argument has always been that water is good for you and helps you to detox. We’ve all been told about the benefits of water, so I drink lots and lots of it, from the minute I wake up to the minute I go to bed. If I don’t have my bottle of water I feel paranoid. And if I try not to drink for an hour, I start to feel dehydrated and I get throbbing headaches. But it has got to the stage where I don’t know how to give it up. It used to make me feel really good and healthy but not any more. I know I ought to cut down but I’m not sure how I can”.
Polydipsia (which in practical terms means drinking more than three litres of water a day) often goes hand-in-hand with hyponatraemia (i.e., low sodium concentration in the blood) and in extreme cases can lead to excessive water drinkers slipping into a coma. The low levels of sodium causes the brain to swell which in turn constricts the blood supply to the brain when the brain compresses against the skull’s inner surface. Another person interviewed for the Daily Mail story was 26-year-old Rachel Bennett, a marketing agent from North London who drank also drank seven litres of water a day which led to headaches and dizziness. She said:
“My friends used to tease me about the amount I drank, but I dismissed their fears because I always thought it was so good for me. It got to the stage where I felt I couldn’t function without it. If I woke without a bottle of water by my bed, I would feel really paranoid. I couldn’t drink tap water – that tasted awful – instead I drank Evian by the gallon. It’s expensive, too – I could spend over £30 a week on water – but I had got to the stage where I got a huge buzz from drinking so much”.
In researching this article, I was surprised to find dozens and dozens of academic papers on psychogenic polydipsia (PPD). For instance, a paper by Dr. Brian Dundas and colleagues in a 2007 issue of Current Psychiatry Reports noted that PPD is a clinical syndrome characterized by polyuria (constantly going to the toilet) and polydipsia (constantly drinking too much water), and is common among individuals with psychiatric disorders. They also noted that:
“The underlying pathophysiology of this syndrome is unclear, and multiple factors have been implicated, including a hypothalamic defect and adverse medication effects. Hyponatremia in PPD can progress to water intoxication and is characterized by symptoms of confusion, lethargy, and psychosis, and seizures or death. Evaluation of psychiatric patients with polydipsia warrants a comprehensive evaluation for other medical causes of polydipsia, polyuria, hyponatremia”.
A 2000 study in European Psychiatry by Dr. E. Mercier-Guidez and Dr. G. Loas examined water intoxication in 353 French psychiatric inpatients. They reported that water intoxication can lead to irreversible brain damage and that around one-fifth of deaths among schizophrenics below the age of 53 years are caused this way. The study reported that 38 of the psychiatric patients (11%) suffered from polydipsia with one-third of them at risk of water intoxication. They also reported that being polydipsic was significantly associated with being male, a cigarette smoker and celibate. Those with polydipsia were highly prevalent among those with schizophrenia, mental retardation, pervasive developmental disorders and somatic disorders.
A comprehensive review by Dr. Victor Vieweg and Dr. Robert Leadbetter in the journal CNS Drugs examined the polydipsia-hyponatraemia syndrome (PHS). They reported that PHS occurs in approximately 5%-10% of institutionalised, chronically psychotic patients, of which four-fifths have schizophrenia. Major clinical features are polydipsia and dilutional hyponatraemia. Patents with PHS can experience delirium, generalised seizures, coma and death. The main ways to treat such individuals are fluid restriction, daily bodyweight monitoring, behavioural approaches, and supplemental oral sodium chloride administration. However, these interventions can be expensive as they require experienced and dedicated multidisciplinary staff. They also report that:
“A number of pharmacological treatments have been assessed for PHS including the combination of lithium and phenytoin, demeclocycline, propranolol, ACE inhibitors, selective serotonin (5-hydroxytryptamine; 5-HT) reuptake inhibitors, typical antipsychotic drugs, clozapine and risperidone. Of these agents, the most promising are the combination of lithium and phenytoin, and clozapine…Long term strategies include behavioural interventions and the combination of lithium and phenytoin, and clozapine”.
Unsurprisingly, I found almost nothing on being addicted to water. A 2010 review article on PPD by Dr. D. Hutcheon and Dr. M. Bevilacqua in the Annals of the American Psychotherapy Association claimed:
“One way to assess a patient’s ability to limit polydipsia is to examine their objective reasons why polydipsia is so important in their lives. This can be initiated during psychosocial rehabilitation group meetings held semi-weekly (e.g., two 15-minute sessions per week). In these meetings, many patients have described a euphoric quality associated with polydipsia, although others have admitted to increased irritability. Most patients have noted a desire for stimulation, similar to other substances of abuse such as alcohol or street drugs. Developing an understanding of what influences a patient to develop an addiction for polydipsia can improve management of this dysregulation of fluid intake…During the treatment period in a structured inpatient setting, many patients diagnosed with psychogenic polydipsia, whether falling in the range of mild, moderate, or severe addiction, are unable to sustain a comfortable discharge to an open ward…psychogenic polydipsia can become an addiction with no demonstrable cure if left untreated… Due to the nature of the addiction and potential for self-injurious behavior, treatment requires a milieu that balances maximizing the patients’ dignity with their safety, which demands close scrutiny by the multidisciplinary team”.
I also found an old case study from a 1973 issue of the British Journal of Addiction on ‘water dependence’. This paper reported that the excessive drinking of water can dilute electrolytes in an individual’s brain and cause intoxication. A couple of papers by Dr. Bennett Foddy and Dr. Julian Savulescu have cited this case study in their own writings on addiction. In a 2010 issue of Philosophy, Psychiatry and Psychology, they noted:
“Of course, it can be claimed that a person who is addicted to sugar or water is diseased, and that their brain has changed in such a way as to make their sugar- or water-seeking behavior involuntary. Yet we know how sugar interacts with the brain to form a sensitization effect, and it is identical to how drugs – and sugar – interact with the brain of a non-addicted person. If addictions are formed through a pharmacological process, it is the exact same process that forms a person’s likes and dislikes of any pleasurable stimulus. Terms like ‘addiction’ and ‘dependence’ can reasonably be employed when a person’s likes become particularly strong, but it should be understood that these terms denote a difference in degree, not a difference in kind…The only relevant difference between drugs and sugar is that drugs produce a higher level of brain reward relative to the volume of the dose. It is easier to get addicted to heroin than to sugar, because you can do it by taking a quarter gram at a time. It is very hard to get addicted to water, because you must force down liters of it every day”.
This interesting extract argues that it is theoretically possible for someone to become addicted to water and that there is no real difference to drug addictions in terms of conceptualization and mechanism – just that the sheer amount of water that needs to be drunk to have a negative effect is large and highly unlikely.
Dr. Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK
Daily Mail (2005). Aquaholics: Addicted to drinking water. May 16. Located at: http://www.dailymail.co.uk/health/article-348917/Aquaholics-Addicted-drinking-water.html
de Leon, J., Verghese, C., Tracy, J. I., Josiassen, R. C., & Simpson, G. M. (1994). Polydipsia and water intoxication in psychiatric patients: a review of the epidemiological literature. Biological Psychiatry, 35(6), 408-419.
Dundas, B., Harris, M., & Narasimhan, M. (2007). Psychogenic polydipsia review: etiology, differential, and treatment. Current Psychiatry Reports, 9(3), 236-241.
Edelstein, E.L. (1973). A case of water dependence. British Journal of Addiction to Alcohol and Other Drugs, 68, 365–367.
Foddy, B., & Savulescu, J. (2007). Addiction is not an affliction: Addictive desires are merely pleasure-oriented desires. American Journal of Bioethics, 7(1), 29-32
Foddy, B., & Savulescu, J. (2010). A liberal account of addiction. Philosophy, Psychiatry, and Psychology, 17(1), 1-22.
Hutcheon, D., & Bevilacqua, M. (2010). Psychogenic polydipsia: A review of past and current interventions for treating psychiatric inpatients diagnosed with psychogenic polydipsia (PPD). Annals of the American Psychotherapy Association, 13(1). Located at: http://www.biomedsearch.com/article/Psychogenic-polydipsia-review-past-current/222558218.html
Teoh, S.Y. (2012). Woman addicted to water drinks 100 glasses a day. The Mary Sue, July 12. Located at: http://www.themarysue.com/woman-addicted-to-water/#geekosystem
Vieweg, W.V.R., & Leadbetter, R.A. (1997). Polydipsia-Hyponatraemia Syndrome. CNS Drugs, 7(2), 121-138.
Verghese, C., de Leon, J., & Josiassen, R. C. (1996). Problems and progress in the diagnosis and treatment of polydipsia and hyponatremia. Schizophrenia Bulletin, 22(3), 455-464.
In the summer of 2014 I was commissioned to review problem gambling in Great Britain (the fall out of which I wrote about in detail in a previous blog). Earlier last year, a detailed report by Heather Wardle and her colleagues examined gambling behaviour in England and Scotland by combining the 2012 data from the Health Survey for England (HSE; n=8,291 aged 16 years and over) and the 2012 Scottish Health Survey (SHeS; n=4,815). To be included in the final data analysis, participants had to have completed at least one of the gambling participation questions. This resulted in a total sample of 11,774 participants. So what did the research find? Here is a brief summary of the main results:
- Two-thirds of the sample (65%) had gambled in the past year, with men (68%) gambling more than women (62%). As with the British Gambling Prevalence Survey (BGPS), past year participation was greatly influenced by the playing of the bi-weekly National Lottery (lotto) game. Removal of those individuals that only played the National Lottery meant that 43% had gambled during the past year (46% males and 40% females).
- Gambling was more likely to be carried out by younger people (50% among those aged 16-24 years and 52% among those aged 25-34 years).
- The findings were similar to the previous BGPS reports and showed that the most popular forms of gambling were playing the National Lottery (52%; 56% males and 49% females), scratchcards (19%; 19% males and 20% females), other lottery games (14%; 14% both males and females), horse race betting (10%; 12% males and 8% females), machines in a bookmaker (3%; 5% males and 1% females), slot machines (7%; 10% males and 4% females), online betting with a bookmaker (5%; 8% males and 2% females), offline sports betting (5%; 8% males and 1% females), private betting (5%; 8% males and 2% females), casino table games (3%; 5% males and 1% females), offline dog race betting (3%; 4% males and 2% females), online casino, slots and/or bing (3%; 4% males and 2% females), betting exchanges (1%; males 2% and females 0%), poker in pubs and clubs (1%; 2% males and 0% females), spread betting (1%; 1% males and 0% females).
- The only form of gambling (excluding lottery games) where females were more likely to gamble was playing bingo (5%; 7% females and 3% males).
- Most participants gambled on one or two different activities a year (1.7 mean average across the total sample).
- Problem gambling assessed using the Problem Gambling Severity (PGSI) criteria was reported to be 0.4%, with males (0.7%) being significantly more likely to be problem gamblers than females (0.1%). This equates to approximately 180,200 British adults aged 16 years and over.
- Problem gambling assessed using the criteria of the fourth Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) was reported to be 0.5%, with males (0.8%) being significantly more likely to be problem gamblers than females (0.1%). This equates to approximately 224,100 British adults aged 16 years and over.
- Using the PGSI screen, problem gambling rates were highest among young men aged 16-24 years (1.7%) and lowest among men aged 65-74 years (0.4%). Using the DSM-IV screen, problem gambling rates were highest among young men aged 16-24 years (2.1%) and lowest among men aged over 74 years (0.4%).
- Problem gambling rates were also examined by type of gambling activity. Results showed that among past year gamblers, problem gambling was highest among spread betting (20.9%), played poker in pubs or clubs (13.2%), bet on other events with a bookmaker (12.9%), bet with a betting exchange (10.6%) and played machines in bookmakers (7.2%).
- The activities with the lowest rates of problem gambling were playing the National Lottery (0.9%) and scratchcards (1.7%).
- Problem gambling rates were highest among individuals that had participated in seven or more activities in the past year (8.6%) and lowest among those that had participated in a single activity (0.1%).
The authors also carried out a latent class analysis and identified seven different types of gambler among both males and females. The male groups comprised:
- Cluster A: non-gamblers (33%)
- Cluster B: National Lottery only gamblers (22%)
- Cluster C: National Lottery and scratchcard gamblers only (20%)
- Cluster D: Minimal, no National Lottery [gambling on 1-2 activities] (9%)
- Cluster E: Moderate [gambling on 3-6 activities] (12%)
- Cluster F: Multiple [gambling on 6-10 activities] (3%)
- Cluster G: multiple, high [gambling on at least 11 activities] (1%).
The female groups comprised:
- Cluster A: non-gamblers (40%)
- Cluster B: National Lottery only gamblers (21%)
- Cluster C: National Lottery and scratchcard gamblers only (7%)
- Cluster D: Minimal, no National Lottery (8%)
- Cluster E: moderate, less varied [2-3 gambling activities, mainly lottery-related] (8%)
- Cluster F: moderate, more varied [2-3 gambling activities but wider range of activities] (6%)
- Cluster G: multiple [gambling on at least four activities] (6%)
Using these groupings, the prevalence of male problem gambling was highest among those in Cluster G: multiple high group (25.0%) followed by Cluster F: multiple group (3.3%) and Cluster E: moderate group (2.6%). The prevalence of problem gambling was lowest among those in the Cluster B; National Lottery Draw only group (0.1%) followed by Cluster C: minimal – lotteries and scratchcards group (0.7%). The prevalence of female problem gambling was highest among those in the Cluster G: multiple group (1.8%) followed by those in Cluster F: moderate – more varied group (0.6%). The number of female gamblers was too low to carry out any further analysis. The report also examined problem gambling (either DSM-IV or PGSI) by gambling activity type.
- The prevalence of problem gambling was highest among spread-bettors (20.9%), poker players in pubs or clubs (13.2%), bettors on events other than sports or horse/dog races (12.9%), betting exchange users (10.6%) and those that played machines in bookmakers (7.2%).
- The lowest problem gambling prevalence rates were among those that played the National Lottery (0.9%) and scratchcards (1.7%).
- These figures are very similar to those found in the 2010 BGPS study although problem gambling among those that played machines in bookmakers was lower (7.2%) than in the 2010 BGPS study (8.8%).
- As with the BGPS 2010 study, the prevalence of problem gambling was highest among those who had participated in seven or more activities in the past year (8.6%) and lowest among those who had taken part in just one activity (0.1%). Furthermore, problem gamblers participated in an average 6.6 activities in the past year.
Given that the same instruments were used to assess problem gambling, the results of the most recent surveys using data combined from the Health Survey for England (HSE) and Scottish Health Survey (SHeS) compared with the most recent British Gambling Prevalence Survey (BGPS) do seem to suggest that problem gambling in Great Britain has decreased over the last few years (from 0.9% to 0.5%). However, Seabury and Wardle again urged caution and noted:
“Comparisons of the combined HSE/SHeS data with the BGPS estimates should be made with caution. While the methods and questions used in each survey were the same, the survey vehicle was not. HSE and SHeS are general population health surveys, whereas the BGPS series was specifically designed to understand gambling behaviour and attitudes to gambling in greater detail. It is widely acknowledged that different survey vehicles can generate different estimates using the same measures because they can appeal to different types of people, with varying patterns of behaviour…Overall, problem gambling rates in Britain appear to be relatively stable, though we caution readers against viewing the combined health survey results as a continuation of the BGPS time series”.
There are other important caveats to take into account including the differences between the two screen tools used in the BGPS, HSE and SHeS studies. Although highly correlated, evidence from all the British surveys suggests that the PGSI and DSM-IV screens capture slightly different groups of problem gamblers. For instance, a 2010 study that I co-authored with Jim Orford, Heather Wardle, and others (in the journal International Gambling Studies) using data from the 2007 BGPS showed that the PGSI may under-estimate certain forms of gambling-related harm (particularly by women) that are more likely to be picked up by some of the DSM-IV items. Our analysis also suggested that the DSM-IV appears to measure two different factors (i.e., gambling-related harm and gambling dependence) rather than a single one. Another important distinction is that the two screens were developed for very different purposes (even though they are attempting to assess the same construct). The PGSI was specifically developed for use in population surveys whereas the DSM-IV was developed with clinical populations in mind. Given these differences, it is therefore unsurprising that national surveys that utilize the screens end up with slightly different results comprising slightly different groups of people.
It also needs stressing (as noted by the authors of most of the national gambling surveys in Great Britain) that the absolute number of problem gamblers identified in any of the surveys published to date has equated to approximately 60 people. To detect any significant differences statistically between any of the studies carried out to date requires very large sample sizes. Given the very low numbers of problem gamblers and the tiny number of pathological gamblers, it is hard to assess with complete accuracy whether there have been any significant changes in problem and pathological gambling between all the published studies over time. Wardle and her colleagues concluded that:
“Overall, based on this evidence, it appears that problem gambling rates in England and Scotland are broadly stable. Whilst problem gambling rates according to either the DSM-IV or the PGSI were higher in 2010, the estimate between 2007 and the health surveys data were similar. Likewise, problem gambling rates according to the DSM-IV and the PGSI individually did not vary statistically between surveys, meaning that they were relatively similar” (p.130).
Dr. Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK
Griffiths, M.D. (2014). Problem gambling in Great Britain: A brief review. London: Association of British Bookmakers.
Orford, J., Wardle, H., Griffiths, M.D., Sproston, K. & Erens, B. (2010). PGSI and DSM-IV in the 2007 British Gambling Prevalence Survey: Reliability, item response, factor structure and inter-scale agreement. International Gambling Studies, 10, 31-44.
Seabury, C. & Wardle, H. (2014). Gambling behaviour in England and Scotland. Birmingham: Gambling Commission.
Wardle, H. (2013). Gambling Behaviour. In Rutherford, L., Hinchliffe S., Sharp, C. (Eds.), The Scottish Health Survey: Vol 1: Main report. Edinburgh.
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., & Seabury, C. (2013). Gambling Behaviour. In Craig, R., Mindell, J. (Eds.) Health Survey for England 2012 [Vol 1]. Health, social care and lifestyles. Leeds: Health and Social Care Information Centre.
Wardle, H., Seabury, C., Ahmed, H., Payne, C., Byron, C., Corbett, J. & Sutton, R. (2014). Gambling behaviour in England and Scotland: Findings from the Health Survey for England 2012 and Scottish Health Survey 2012. London: NatCen.
Wardle, H., Sproston, K., Orford, J., Erens, B., Griffiths, M. D., Constantine, R., & Pigott, S. (2007). The British Gambling Prevalence Survey 2007. London: National Centre for Social Research.
Wardle, H., Sutton, R., Philo, D., Hussey, D. & Nass, L. (2013). Examining Machine Gambling in the British Gambling Prevalence Survey. Report by NatCen to the Gambling Commission, Birmingham.
Note: A shortened version of this article was first published in The Independent.
Last month, Denmark passed a law making bestiality a criminal offence from July 1st in a move to tackle animal-sex tourism. Bestiality (also known as zoophilia) is typically defined as relating to recurrent intense sexual fantasies, urges, and sexual activities with non-human animals. At present, there are still a number of countries where zoophilia is legal including Brazil, Mexico, Thailand, Finland, Hungary, and Romania. In the US there is no federal law against zoophilia although most states class it as a felony and/or misdemeanour although in some states it is technically legal (for example, Texas, Kentucky, Nevada, New Jersey, New Hampshire, Wyoming, West Virginia, and New Mexico).
Over the last few years I have written articles on the psychology of many different types of zoophilia including those who have engaged in sexual activities with dogs (cynophilia), cats (aelurophilia), horses (equinophilia), pigs (porcinophilia), birds (ornithophilia), dolphins (delphinophilia), lizards (herpetophilia), worms (vermiphilia), and insects (formicophilia). Dr. Alfred Kinsey shocked the US back in the 1950s when his infamous ‘Kinsey Reports’ claimed that 8% of males and 4% females had at least one sexual experience with an animal. Perhaps unsurprisingly, there was a much higher prevalence for zoophilic acts among people that who worked on farms (for instance, 17% males had experienced an orgasmic episode involving animals). According to Kinsey, the most frequent sexual acts that humans engaged in with animals comprised calves, sheep, donkeys, large fowl (ducks, geese), dogs and cats.
In the 1970s, world renowned sexologist Professor John Money claimed that zoophilic behaviours were usually transitory occurring when there is no other sexual outlet available. However, research carried out in the 2000s shows this not be the case. Up until the advent of the internet, almost every scientific or clinical study reported on zoophilia were case reports of individuals that has sought treatment for their unusual sexual preference. However, the internet brought many like-minded people together and there are dozens of websites where zoophiles chat to each other online and share their videos including the Beast Forum, the largest online zoophile community in the world with tens of thousands of members.
Almost all of the recently published studies have collected their data online from non-clinical samples. All of these studies report that the overwhelming majority of self-identified male and female zoophiles do not have sex with animals because there is no other sexual outlet but do so because it is their sexual preference. The most common reasons for engaging in zoophilic relationships were attraction to animals out of either a desire for affection, and a sexual attraction toward and/or a love for animals.
For instance, a study by Dr. Hani Miletski surveyed 93 zoophiles (82 males and 11 females). Only 12% of her sample said they engaged in sex with animals because there were no human partners available, and only 7% said it was because they were too shy to have sex with humans. For the females, the main reasons for having sex with animals was because they were sexually attracted to the animal (100%), had love and affection for the animal (67%) and/or because they said the animal wanted sex with them (67%). Most of Miletski’s sample preferred sex with dogs (87% males; 100% females) and/or horses (81% males; 73% females). Only 8% of males wanted to stop having sex with animals and none of the females. Unlike case study reports of zoophilia published prior to 2000, the studies published over the last 15 years using non-clinical samples report the vast majority of zoophiles do not appear to be suffering any significant clinical significant distress or impairment as a consequence of their behaviour.
In 2011, Dr Anil Aggrawal published a comprehensive typology of zoophilia in the Journal of Forensic and Legal Medicine. Dr. Aggrawal’s claimed there were ten different types of zoophile based on both the scientific and clinical literature, as well as some theoretical speculation. For instance:
- Human–animal role-players – those who never have sex with animals but become sexually aroused through wanting to have sex with humans who pretend to be animals.
- Romantic zoophiles – those who keeps animals as pets as a way to get psychosexually stimulated without actually having any kind of sexual contact with them.
- Zoophilic fantasizers – those who fantasize about having sexual intercourse with animals but never actually do.
- Tactile zoophiles – those who get sexual excitement from touching, stroking or fondling animals or their genitals but do not actually have sexual intercourse with animals.
- Fetishistic zoophiles – those who keep various animal parts (especially fur) that are used as erotic stimuli as a crucial part of their sexual activity (typically masturbation). (See my previous blog on the use of an animal part as a masturbatory aid)
- Sadistic bestials – those who derive sexual arousal from the torturing of animals (known as zoosadismhttps://drmarkgriffiths.wordpress.com/2012/08/06/stuff-love-a-beginners-guide-to-plushophilia/) but does not involve sexual intercourse with the animal.
- Opportunistic zoosexuals – those who have normal sexual encounters but would have sexual intercourse with animals if the opportunity arose.
- Regular zoosexuals – those who prefer sex with animals than sex with humans (but are capable of having sex with both). Such zoophiles will engage in a wide range of sexual activities with animals and love animals on an emotional level.
- Homicidal bestials – those who need to kill animals in order to have sex with them. Although capable of having sex with living animals, there is an insatiable desire to have sex with dead animals.
- Exclusive zoosexuals – those who only have sex with animals to the exclusion of human sexual partners.
Personally, I don’t view human-animal role players as zoophiles as this would include those in the Furry Fandom (individuals that dress up and interact socially as animals). There is no official definition of what a ‘furry’ actually is although most furries would agree that they share an interest in fictional anthromorphic animal characters that have human characteristics and personalities and/or mythological or imaginary creatures that possess human and/or superhuman capabilities. The furry fandom has also developed its own vocabulary including words such as ‘fursona’ (furry persona), ‘plushie’ (person who has sex with cuddly toys), and ‘yiff’ (furry pornography). A study by David J. Rust of 360 members of the furry community suggested less than 1% were plushophiles and that 2% were zoophiles.
Many zoophiles believe that in years to come, their sexual preference will be seen as no different to being gay or straight. This is not a view I adhere to especially because animals cannot give consent (although many zoophiles claim the animals they have sexual relationships with do give ‘consent’). The one thing we do know is that the internet has revolutionised the way we carry out our research and get access to ‘hard to reach’ groups. Thanks to online research, zoophilia is just one of many sexually atypical behaviours that we now know more about both behaviourally and psychologically.
Dr. Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK
Aggrawal, A. (2011). A new classification of zoophilia. Journal of Forensic and Legal Medicine, 18, 73-78.
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R.J. Maratea (2011). Screwing the pooch: Legitimizing accounts in a zoophilia on-line community. Deviant Behavior, 32, 918-943.
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Please note: A shorter and slightly different version of this blog first appeared on addiction.com
Sex addiction appears to be a highly controversial area among both the general public and those who work in the addiction field. Some psychologists adhere to the position that unless the behaviour involves the ingestion of a psychoactive substance (e.g., alcohol, nicotine, cocaine heroin), then it can’t really be considered an addiction. But I’m not one of them. If it were up to me, I would have given serious consideration to including sex addiction in the latest (fifth) edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Given that ‘gambling disorder’ was reclassified from a disorder of impulse control to a behavioural addiction in the DSM-5, there is now no theoretical reason why other behavioural addictions can’t be added in the years to come. So why wasn’t sex addiction included in the latest DSM-5? Here are some possible reasons.
Some researchers think that sex addiction just doesn’t exist (for moral and theoretical reasons): Many scholars have attacked the whole concept of sex addiction saying it is a complete myth. It’s not hard to see why, as many of the claims appear to have good face validity. Many sociologists would argue that ‘sex addiction’ is little more than a label for sexual behaviour that significantly deviates from society’s norms. The most conventional attack on sex addiction is a variation on the position outlined in my introduction (i.e., that ‘addiction’ is a physiological condition caused by ingestion of physiological substances, and must therefore be defined physiologically). There are also attacks on more moral grounds with people saying that if excessive sexual behaviour is classed as an addiction it undermines individuals’ responsibility for their behaviour (although this argument could be said of almost any addiction).
The word ‘addiction’ has become meaningless: There are also those researchers within the social sciences who claim that the every day use of the word ‘addiction’ has rendered the term meaningless (such as people saying that their favorite television show is ‘addictive viewing’ or that certain books are ‘addictive reading’). Related to this is that those that work in the field don’t agree on what the disorder (e.g. ‘sex addiction’, ‘sexual addiction’, ‘hypersexuality disorder’, ‘compulsive sexual behaviour’, ‘pornography addiction’, etc.) should be called and whether it is a syndrome (i.e., a group of symptoms that consistently occur together, or a condition characterized by a set of associated symptoms) or whether there are many different sub-types (pathological promiscuity, compulsive masturbation, etc.).
There is a lack of empirical evidence about sex addiction: One of the main reasons that sex addiction is not yet included in the DSM-5 is that the empirical research in the area is relatively weak. Although there has been a lot of research, there has never been any nationally representative prevalence surveys of sex addiction using validated addiction criteria, and a lot of research studies are based upon those people who turn up for treatment. Like Internet Gaming Disorder (which is now in the appendix of the DSM-5), sex addiction (or more likely ‘Hypersexual Disorder’) will not be included as a separate mental disorder until the (i) defining features of sex addiction have been identified, (ii) reliability and validity of specific sex addiction criteria have been obtained cross-culturally, (iii) prevalence rates of sex addiction have been determined in representative epidemiological samples across the world, and (iv) etiology and associated biological features of sex addiction have been evaluated.
The term ‘sex addiction’ is used an excuse to justify infidelity: One of the reasons why sex addiction may not be taken seriously is that the term is often used by high profile celebrities as an excuse by those individuals who have been sexually unfaithful to their partners (e.g., Tiger Woods, Michael Douglas, David Duchovny, Russell Brand). In some of these cases, sex addiction is used to justify the individual’s serial infidelity. This is what social psychologists refer to as a ‘functional attribution’. For instance, the golfer Tiger Woods claimed an addiction to sex after his wife found out that he had many sexual relationships during their marriage. If his wife had never found out, I doubt whether Woods would have claimed he was addicted to sex. I would argue that many celebrities are in a position where they were bombarded with sexual advances from other individuals and succumbed. But how many people wouldn’t do the same thing if they had the opportunity? It becomes a problem only when you’re discovered, when it’s in danger of harming the celebrity’s brand image.
The evidence for sex addiction is inflated by those with a vested interest: One of the real issues in the field of sex addiction is that we really have no idea of how many people genuinely experience sex addiction. Sex addiction specialists like Patrick Carnes claims that up to 6% of all adults are addicted to sex. If this was really the case I would expect there to be sex addiction clinics and self-help support groups in every major city across the world – but that isn’t the case. However, that doesn’t mean sex addiction doesn’t exist, only that the size of the problem isn’t on the scale that Carnes suggests. Coupled with this is that those therapists that treat sex addiction have a vested interest. Out simply, there are many therapists worldwide who make a living out of treating the disorder. Getting the disorder recognized by leading psychological and psychiatric organizations (e.g., American Psychiatric Association, World Health Organization) legitimizes the work of sex addiction counselors and therapists so it is not surprising when such individuals claim how widespread the disorder is.
There may of course be other reasons why sex addiction is not considered a genuine disorder. Compared to behavioural addictions like gambling disorder, the empirical evidence base is weak. There is little in the way of neurobiological research (increasingly seen as ‘gold standard’ research when it comes to legitimizing addictions as genuine). But carrying out research on those who claim to have sex addiction can face ethical problems. For instance, is it ethical to show hardcore pornography to a self-admitted pornography addict while participating in a brain neuroimaging experiment? Is the viewing of such material likely to stimulate and enhance the individual’s sexual urges and result in a relapse following the experiment? There are also issues surrounding cultural norms. The normality and abnormality of sexual behaviour lies on a continuum but what is considered normal and appropriate in one culture may not be viewed similarly in another (what is often referred to by sociologists as ‘normative ambiguity’). Personally, I believe that sex addiction is a reality but that it affects a small minority of individuals. However, many sex therapists claim it is on the increase, particularly because the Internet has made sexual material so easy to access. Maybe if sex addiction does eventually make it into future editions of the DSM, it will be one of the sub-categories of Internet Addiction Disorder rather than a standalone category.
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