Category Archives: Psychiatry
Generally speaking, Internet addiction (IA) has been characterized by excessive or poorly controlled preoccupation, urges, and/or behaviours regarding Internet use that lead to impairment or distress in several life domains. However, according to Dr. Kimberly Young, IA is a problematic behaviour akin to pathological gambling that can be operationally defined as an impulse-control disorder not involving the ingestion of psychoactive intoxicants.
Following the conceptual framework developed by Young and her colleagues to understand IA, five specific types of distinct online addictive behaviours were identified: (i) ‘cyber-sexual addiction’, (ii) ‘cyber-relationship addiction’, (iii) ‘net compulsions (i.e., obsessive online gambling, shopping, or trading), (iv) ‘information overload’, and (v) ‘computer addiction’ (i.e., obsessive computer game playing).
However, I have argued in many of my papers over the last 15 years that the Internet may simply be the means or ‘place’ where the most commonly reported addictive behaviours occur. In short, the Internet may be just a medium to fuel other addictions. Interestingly, new evidence pointing towards the need to make this distinction has been provided from the online gaming field where new studies (including some I have carried out with my Hungarian colleagues) have demonstrated that IA is not the same as other more specific addictive behaviours carried out online (i.e., gaming addiction), further magnifying the meaningfulness to differentiate between what may be called ‘generalized’ and ‘specific’ forms of online addictive behaviours, and also between IA and gaming addiction as these behaviours are conceptually different.
Additionally, the lack of formal diagnostic criteria to assess IA holds another methodological problem since researchers are systematically adopting modified criteria from other addictions to investigate IA. Although IA may share some commonalities with other substance-based addictions, it is unclear to what extent such criteria are useful and suitable to evaluate IA. Notwithstanding the existing difficulties in understanding and comparing IA with behaviours such as pathological gambling, recent research provided useful insights on this topic.
A recent study by Dr. Federico Tonioni (published in a 2014 issue of the journal Addictive Behaviors) involving two clinical (i.e., 31 IA patients and 11 pathological gamblers) and a control group (i.e., 38 healthy individuals) investigated whether IA patients presented different psychological symptoms, temperamental traits, coping strategies, and relational patterns in comparison to pathological gamblers, concluded that Internet-addicts presented higher mental and behavioural disengagement associated with significant more interpersonal impairment. Moreover, temperamental patterns, coping strategies, and social impairments appeared to be different across both disorders. Nonetheless, the similarities between IA and pathological gambling were essentially in terms of psychopathological symptoms such as depression, anxiety, and global functioning. Although, individuals with IA and pathological gambling appear to share similar psychological profiles, previous research has found little overlap between these two populations, therefore, both phenomena are separate disorders.
Despite the fact that initial conceptualizations of IA helped advance the current knowledge and understanding of IA in different aspects and contexts, it has become evident that the field has greatly evolved since then in several ways. As a result of these ongoing changes, behavioural addictions (more specifically Gambling Disorder and Internet Gaming Disorder) have now recently received official recognition in the latest (fifth) edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Moreover, IA can also be characterized as a form of technological addiction, which I have operationally defined as a non-chemical (behavioural) addiction involving excessive human-machine interaction. In this theoretical framework, technological addictions such as IA represent a subset of behavioural addictions featuring six core components: (i) salience, (ii) mood modification, (iii) tolerance, (iv) withdrawal, (v) conflict, and (vi) relapse. The components model of addiction appears to be a more updated framework for understanding IA as a behavioural addiction not only conceptually but also empirically. Moreover, this theoretical framework has recently received empirical support from several studies, further evidencing its suitability and applicability to the understanding of IA.
For many in the IA field, problematic Internet use is considered to be a serious issue – albeit not yet officially recognised as a disorder – and has been described across the literature as being associated with a wide range of co-occurring psychiatric comorbidities alongside an array of dysfunctional behavioural patterns. For instance, IA has been recently associated with low life satisfaction, low academic performance, less motivation to study, poorer physical health, social anxiety, attention deficit/hyperactivity disorder and depression, poorer emotional wellbeing and substance use, higher impulsivity, cognitive distortion, deficient self-regulation, poorer family environment, higher mental distress, loneliness, among other negative psychological, biological, and neuronal aspects.
In a recent systematic literature review conducted by Dr. Wen Li and colleagues (and published in the journal Computers and Human Behavior), the authors reviewed a total of 42 empirical studies that assessed the family correlates of IA in adolescents and young adults. According to the authors, virtually all studies reported greater family dysfunction amongst IA families in comparison to non-IA families. More specifically, individuals with IA exhibited more often (i) greater global dissatisfaction with their families, (ii) less organized, cohesive, and adaptable families, (iii) greater inter-parental and parent-child conflict, and (iv) perceptions of their parents as more punitive, less supportive, warm, and involved. Furthermore, families were significantly more likely to have divorced parents or to be a single parent family.
Another recent systematic literature review conducted by Dr. Lawrence Lam published in the journal Current Psychiatry Reports examined the possible links between IA and sleep problems. After reviewing seven studies (that met strict inclusion criteria), it was concluded that on the whole, IA was associated with sleep problems that encompassed subjective insomnia, short sleep duration, and poor sleep quality. The findings also suggested that participants with insomnia were 1.5 times more likely to be addicted to the Internet in comparison to those without sleep problems. Despite the strong evidence found supporting the links between IA and sleep problems, the author noted that due to the cross-sectional nature of most studies reviewed, the generalizability of the findings was somewhat limited.
IA is a relatively recent phenomenon that clearly warrants further investigation, and empirical studies suggest it needs to be taken seriously by psychologists, psychiatrists, and neuroscientists. Although uncertainties still remain regarding its diagnostic and clinical characterization, it is likely that these extant difficulties will eventually be tackled and the field will evolve to a point where IA may merit full recognition as a behavioural addiction from official medical bodies (ie, American Psychiatric Association) similar to other more established behavioural addictions such as ‘Gambling Disorder’ and ‘Internet Gaming Disorder’. However, in order to achieve official status, researchers will have to adopt a more commonly agreed upon definition as to what IA is, and how it can be conceptualized and operationalized both qualitatively and quantitatively (as well as in clinically diagnostic terms).
Dr. Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK
Please note: This article was co-written with Halley Pontes and Daria Kuss.
Griffiths, M.D. (2000). Internet addiction – Time to be taken seriously? Addiction Research, 8, 413-418.
Griffiths, M.D. (2010). Internet abuse and internet addiction in the workplace. Journal of Workplace Learning, 7, 463-472.
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.
Király, O., Griffiths, M.D., Urbán, R., Farkas, J., Kökönyei, G. Elekes, Z., Domokos Tamás, D. & Demetrovics, Z. (2014). Problematic internet use and problematic online gaming are not the same: Findings from a large nationally representative adolescent sample. Cyberpsychology, Behavior and Social Networking, 17, 749-754.
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., Shorter, G.W., van Rooij, A.J., Griffiths, M.D., & Schoenmakers, T.M. (2014). Assessing Internet addiction using the parsimonious Internet addiction components model – A preliminary study. International Journal of Mental Health and Addiction, 12, 351-366.
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.
Lam, L.T. (2014). Internet Gaming Addiction, Problematic use of the Internet, and sleep problems: A systematic review. Current Psychiatry Reports, 16(4), 1-9.
Li, W., Garland, E.L., & Howard, M.O. (2014). Family factors in Internet addiction among Chinese youth: A review of English-and Chinese-language studies. Computers in Human. Behavior, 31, 393-411.
Pontes, H. & Griffiths, M.D. (2015). Measuring DSM-5 Internet Gaming Disorder: Development and validation of a short psychometric scale. Computers in Human Behavior, 45, 137-143.
Pontes, H.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.
Tonioni, F., Mazza, M., Autullo, G., Cappelluti, R., Catalano, V., Marano, G., … & Lai, C. (2014). Is Internet addiction a psychopathological condition distinct from pathological gambling?. Addictive Behaviors, 39(6), 1052-1056.
Widyanto, L. & Griffiths, M.D. (2006). Internet addiction: A critical review. International Journal of Mental Health and Addiction, 4, 31-51.
Young, K. (1998). Caught in the net. New York: John Wiley
Young K. (1999). Internet addiction: Evaluation and treatment. Student British Medical Journal, 7, 351-352.
In 2014, I was the resident psychologist on 12-episode television series called Forbidden made for the Discovery Channel. One of the strangest stories that the series reported on was ‘cane therapy’ for the ‘Twisted Treatments’ episode. Before I was interviewed for the story, I had to research the story and was also given some production notes as background material. According to the material I was provided with:
“Caning treatment was pioneered in Siberia by Dr Sergei Speransky a biologist from the Novosibirsk Institute of Medicine who together with Dr Marina Chuhrova released a research report in 2005 on whipping as a therapy. Dr Speransky and Dr Chukhrova developed the medical theory behind caning. Importantly Dr Chukhrova notes that, ‘It is not some warped sado-masochistic activity,’ but has a clear medical purpose. Apparently, there are some sound scientific principles behind these beatings. Namely the theory that pain activates the body’s immune system, causing it to perform much more effectively than under ‘normal circumstances.’ Dr Chukhrova taught [Dr. German Pilipenko] the theory as a student at university and controversially he has taken her theory and put it into practice, combining it with his own unique psychology treatment. 50-year old German Pilipenko has been caning people for nine years. In his spare time German enjoys the blissful serenity of mountain skiing in his local town. But in his professional life German has to bear the yelps, tears and groans of his patients – German canes and whips people for a living. German started to practice cane therapy in a medical clinic in 2004. Though the clinic no longer exists he’s continued the controversial practice as a private psychologist in a rented 14 square meter room in Novosibirsk’s Business Centre”.
Dr. Pilipenko is a psychotherapist and a hypnotist and claims that cane therapy can cure addictions (both chemical addictions such as alcohol and other drug addictions, and behavioural addictions such as sex addiction and work addiction), depression, phobias and neuroses. Along with Dr. Chukhrova, they have successfully treated over 1000 individuals (aged between 17 and 70 years) of their problems. The therapy appears to be arguably similar to primal therapy (which I briefly examined in a previous blog) and according to Pilipenko “can be used as a kind of anti-stress injection”. Via intense caning sessions Pilipenko not only draws physical pain from his clients but also their emotional reactions. It is the release of these emotions (as with primal therapy) is what he believes cures his patients of their addictions, stresses, depression, and anxieties. (If you are a journalist or an artist he offers the therapy free as a way of promoting his therapeutic practice). For the television programme, one of Dr. Pilipenko’s female clients (Anzhelika Alexeyev, a 22-year old, fifth-year medical student) was interviewed. The production notes I was given noted:
“Anzhelika is only at the beginning of her life, but she’s already experienced hardship and emotional difficulties. Receiving a beating from Dr Pilipenko has been her solution. She’s already visited him once but German believes there is more work to be done. [The programme will] follow Anzhelika through pain and tears as she returns for more caning. She also introduces her father to the treatment and we see her bring him for a session…Her first caning experience was at the start of [the] year…Anzhelika had been suffering stress after miraculously surviving a car crash. German’s advice was that ‘she really needed a lashing.’ She agreed. Initially at the start of the session Anzhelika wanted to leave. She suffered through the first beating in tears, though she persisted, knowing the pain was temporary. She believes the treatment has been successful in curing her trauma and stress related to the accident. In fact she is a big supporter of German’s caning and believes it helps to get rid of emotions that are deeply hidden, unacknowledged and out of control”.
Many newspaper reports have covered the ‘therapy’ over the last few years but nothing has been published on it in peer-reviewed scientific journals. According to one report on the Alternet news site:
“Practitioners Dr. German Pilipenko and Professor Marina Chukhrova say that their treatment is grounded in science: ‘We cane the patients on the buttocks with a clear and definite medical purpose’…The pair say that addicts suffer from a lack of endorphins, and that pain can stimulate the brain to release the feel-good chemicals, ‘making patients feel happier in their own skins.’ Mainstream doctors dismiss the practice, saying that exercise, acupuncture, massage, chocolate or sex are all better at stimulating endorphin secretion. Dr. Pilipenko admits, ‘we get a lot of skepticism…but so do all pioneers.’ The Siberian Times reports that ‘the reaction of most people is predictable: to snigger, scoff or make jokes loaded with sexual innuendo.’ And one recipient of the treatment, 41-year-old recovering alcoholic Yuri, says his girlfriend accused him of simply visiting a dominatrix. But he adds that although ‘the first strike was sickening…Somehow I got through all 30 lashes. The next day I got up with a stinging backside but no desire at all to touch the vodka in the fridge. The bottle has stayed there now for a year’.”
The Alternet story also interviewed another patient (Natasha, a 22-year-old recovering heroin addict with several months clean) who had been paying $100 for a two-hour session and claimed:
“I am the proof that this controversial treatment works, and I recommend it to anyone suffering from an addiction or depression. It hurts like crazy – but it’s given me back my life…With each lash, I scream and grip tight to the end of the surgical table. It’s a stinging pain, real agony, and my whole body jolts…I’m not a masochist. My parents never beat me or even slapped me, so this was my first real physical pain and it was truly shocking. If people think there’s anything sexual about it, then it’s nonsense.”
The article reported that Natasha had received 60 strokes of the cane per session (noting that drug addicts get double the number of lashes than alcoholics). Professor Chukhrova was then quoted as saying that extreme care is taken to ensure patient safety, and that:
“The beating is really the end of the treatment. We do a lot of psychological counseling first, and also use detox. It is only after all the counseling, and heart and pain resistance checks, that we start with the beating. [We use willow branches because they] are flexible and can’t be broken nor cause bleeding…If any patients get sexual pleasure from the beatings, we stop immediately…This is not what our treatment is about. If they’re looking for that, there are plenty of other places to go.”
According to Dr Pilipenko, the unusual combination of psychology and corporal-style punishment is designed to train patients in endurance, tolerance and resistance as ways of coping with stress. Pilipenko believes he provides his clients with the tools to deal with stress and problems in their lives. More specifically he claims that:
“Psychological stimulation is aimed to convince a patient that aggression, idleness and depression will cause problems in life…Usually a patient is prescribed three separate visits, before they can be cured but it might be necessary for anything up to 10 sessions, depending on the severity of the individual case”.
Dr. Pilipenko also claims that cane therapy that was practiced by monks in the Middle Ages. However, I also noted that following each caning, his clients receive both psychotherapy and hypnotherapy. This begs the question as to whether it is these additional forms of intervention that are key to therapeutic success rather than the caning in and of itself.
Dr. Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK
Alternet (2013). Weird science: Siberian psychologists caning patients “on the buttocks” in new addiction treatment. January 7. Located at: http://www.alternet.org/weird-science-siberian-psychologists-caning-patients-buttocks-new-addiction-treatment
Daily News (2014). Russian patients pay therapists to cane them in bizarre treatment. October 2. Located at: http://www.nydailynews.com/life-style/russian-patients-pay-therapists-cane-article-1.1960979
Siberian Times (2013). Beating the addiction out of you – literally. January 7. Located at: http://siberiantimes.com/other/others/features/beating-addiction-out-of-you-literally/
Stewart, W. (2013). How to beat your demons, literally: Siberian psychologists thrash patients with sticks to help them kick their addictions. Daily Mail, January 7. Located at: http://www.dailymail.co.uk/news/article-2258395/How-beat-addictions-literally-Siberian-psychologists-thrash-patients-sticks-help-kick-habits.html
“I’m a guy and I LOVE being walked on by women wearing high heels. It doesn’t hurt. Is this normal to have women step on my guy parts with high heels?” (Question posted on a Yahoo! website).
In a previous blog I briefly looked at ‘trampling fetishism’. According to a relatively new Wikipedia entry on the behaviour:
“Trampling refers to the sexual activity that involves being trampled underfoot by another person or persons. Trampling is common enough to support a sub-genre of trampling pornography. Because trampling can be used to produce pain, the trampling fetish for some adherents is closely linked to sadomasochistic fetishism. A similar fetish is to imagine themselves as being tiny under another’s feet, or being normal size, but being trampled by a giant person. This is known as ‘giant/giantess fetishism’ or macrophilia. It is not the same as trampling. The most common form of trampling is done by a male or female walking on a male or female submissive and is usually done barefooted, in socks, nylons, or shoes. The trampler will predominantly walk, jump and stomp on the person’s back, chest, stomach, genitalia, face and in some rare instances, the neck”.
If you type ‘trampling fetish’ into Google, lots of YouTube video clips appear instantly. Video clips of trampling have been present on the internet since 1997 courtesy of an number of infamous American tramples such as ‘Daddo’ ‘Kingfish’ and ‘LAF’. If you’re not into the visual side, you can read various forms of trampling fan fiction such as the stories at the Trample and Crushing website.
Since writing my previous blog on this topic, I filmed an interview about a trampling fetishist as part of the television program Forbidden (on which I was the resident psychologist). The television program that I participated in followed the story of a man called Frank O’Brien. Frank recalls his fetish developing during early to mid- adolescence. As a 15-year old teenager, he would trick the girls he knew into stepping on him by inventing games that resulted in him being trampled upon. As the show’s production notes reported:
“[Frank would] invent games to race girls to the door of his cubby house and have them wrestle or sit on him in the process. In the backyard pool he’d encourage them to step on him underwater. Ever since he can remember Frank has wanted to get under a girl’s foot…You could say Frank gets a ‘kick’ out of it. And among friends Frank is known simply as ‘Step on Me.’ For Frank, there’s nothing finer than having a woman walk all over him”.
By his early thirties Frank’s trampling fetish began to take up more and more of his time. In his social life he started attending as many sadomasochistic shows that he could and he longed and desired dominant mistresses that would help cater for his trampling fetish. The back-story I received about Frank noted that:
“The mistresses he saw early in life largely turned Frank away from the idea of trampling. They were more prostitutes than professional mistresses with an idea of what he really wanted. Back in those days there was no training for mistresses in trampling and this really has only taken off in Australia since the early 2000s. Now there are mistresses who train specifically in trampling”.
According to Frank, Melbourne is the centre of Australia’s BDSM culture and he introduced the Forbidden film crew to the niche trampling community that exists there. Frank’s favourite club is ‘Provocation’ that hosts a monthly fetish social event.
“But his idea of getting down on the dance floor is a little different to most. When Frank gets down, he literally gets down. He has a special mat that he lies on to make the experience slightly more bearable but comfort is not exactly what Frank is looking for. He’ll bring with him a platform that he’ll set up beside his mat; written across it are the words ‘step up here – girls only’. And that’s exactly what Frank wants. He’ll lie there for hours in the club, enjoying the feeling of women trampling him. Some wear stilettos, some are in platform shoes and others go barefooted – he doesn’t discriminate about what kind of footwear is permitted, but generally sharper and more pointy shoes offer greater satisfaction for [him]”.
Frank describes himself naturally submissive and he now has weekly trampling sessions with ‘Mistress Spanklet’ who is Frank’s long-term friend and a Dom-sub ‘play partner’. Frank describes these weekly sessions as his “drug fix” and something he “couldn’t live without”. Despite having some of his bowel removed (and it being dangerous for him for someone to trample on his stomach), he cannot stop it. He now tries to avoid ‘tummy trampling’ but notes that:
“Trampling can be on any part of the body, including the more sensitive regions of the face, throat and genitalia. [He] enjoys cock and ball trampling on a weekly basis with Spanklet. His face, arms and legs are also prime trampling ground in private and in public”.
In fact, Frank claims that he was responsible for the first ever penis trampling photograph on the internet. In 1999, Frank claimed he took the full weight of a woman in sharp red stilettos twisting as hard as she could on his penis. Frank claims the photograph (taken by the woman’s sexual partner) kick-started “the worldwide cock trampling trend”.
There appears to be little academic research on the topic but anecdotal evidence suggests there is (unsurprisingly) an overlap between trampling fetishes and foot fetishes (podophilia) – on which there is quote a lot of academic research given it appears to be the most prevalent type of fetishism. Obviously Frank’s case is extreme and is heavily interwoven into his life. While there appear to be addictive elements to his behaviour, I don’t believe that Frank’s trampling fetish is an addiction. Bizarre and extreme – yes. Addictive – no. But I’m happy to be proved wrong.
Dr Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK
Semple, K. (2009). Bartender, make it a stiletto. New York Times, June 10. Located at:
Sexy Tofu (2012). National Fetish Day: Interview with a trampler. January 20. Located at: http://sexytofu.com/tag/trampling/
Wikipedia (2012). Talk: Crush fetish. Located at: http://en.wikipedia.org/wiki/Talk%3ACrush_fetish
Wikipedia (2012). Trampling. Located at: http://en.wikipedia.org/wiki/Trampling
Addiction is a highly prevalent problem within today’s society and there is a lot of time and many spent in trying to prevent and treat the behaviour. There has also been a move towards getting addicts motivated to want to change their behaviour. The most influential model worldwide is probably the ‘stages of change’ model by Dr. James Prochaska and Dr, Carlo Di Clemente that identifies an individual’s ‘readiness for change’ and tries to get a person to a position where they are highly motivated to change their behaviour. The individual stages of this model are:
- Precontemplation – This is where the person unaware of the consequences of his or her own behaviour and no change in behaviour is foreseeable.
- Contemplation – This is where the person aware problem exists and is contemplating change.
- Preparation – This is where the person has decided to change in the near future (e.g., New Year resolution).
- Action – This is where the person effects change (e.g., gets rid of all association items related to the behaviour).
- Maintenance – This is where the person consolidates behaviour change over time.
- Relapse – This where the person reverts to a former behaviour pattern (e.g., contemplation, preparation).
People can stay in one stage for a long time and it is also possible for unassisted change such “maturing out” or “spontaneous remission”. Various techniques can be used to help people prepare for readiness include motivational techniques, behavioural self-training, skills training, stress management training, anger management training, relaxation training, aerobic exercise, relapse prevention, and lifestyle modification. The goal of treatment can be either abstinence or simply to cut down.
The intervention and treatment options for the treatment of addiction include, but are not limited to counselling/psychotherapies, behavioural therapies, cognitive-behavioural therapies, self-help therapies, pharmacotherapies, residential therapies, minimal interventions and combinations of these (i.e., multi-modal treatment packages). The most important of these are outlined below.
Pharmacotherapy: Pharmacological interventions basically consist of addicts being given a drug to help overcome their addiction. These are mainly given to those people with chemical addictions (e.g., nicotine, alcohol, heroin, etc.) but are increasingly being used for those with behavioural addictions (e.g., gambling, sex, work, exercise, etc.). For instance, some drugs produce an unpleasant reaction when used in combination with the drug of dependence, replacing the positive effects of the drug of dependence with a negative reaction. For instance, alcoholics are sometimes prescribed disulfiram (more commonly known as Antabuse), that when combined with alcohol may produce nausea and vomiting. Other common therapies include methadone and the use of opioid antagonists (such as nalaxone or naltrexene) for heroin addiction. The methadone prevents withdrawal symptoms, block the effects of heroin use, and decreases craving. The main criticism of all these treatments is that although the symptoms may be being treated, the underlying reasons for the addictions may be being ignored. On a more pragmatic level, what happens when the drug is taken away? Often, the addicts return to their addiction if this is the only method of treatment used.
Behavioural therapy: Behavioural therapies are based on the view that addiction is a learned maladaptive behaviour and can therefore be ‘unlearned’. These have mainly been based on the classical conditioning paradigm and include aversion therapy, in vivo desensitisation, imaginal desensitisation, systematic desensitisation, relaxation therapy, covert sensitisation, and satiation therapy. All of these therapies focus on cue exposure, and relapse triggers (like the sight and smell of alcohol/drugs, walking through a neighbourhood where casinos are abundant, pay day, arguments, pressure, etc.). The theory is that through repeated exposure to ‘relapse triggers’ in the absence of the addiction, the addict learns to stay addiction free in high-risk situations. It could be argued that if the addiction is caused by some underlying psychological problem, (rather than a learned maladaptive behaviour), then behavioural therapy would at best only eliminate the behaviour but not the problem. This therefore means that the addictive behaviour may well have been curtailed but the problem is still there so the person will perhaps engage in a different addictive behaviour instead.
Cognitive-behavioural therapy: A more recent development in the treatment of addictive behaviours is the use of cognitive-behavioural therapies (CBT). There are many different CBT approaches that have been used in the treatment of addictive behaviours including rational emotive therapy, motivational interviewing, and relapse prevention. The techniques assume that addiction is a means of coping with difficult situations, dysphoric mood, and peer pressure. Treatment aims to help addicts recognise high-risk situations and either avoid or cope with them without use of the addictive behaviour. In relapse prevention, the therapist helps to identify situations that present a risk for relapse (both intrapersonal and interpersonal). Relapse prevention provides the addict with techniques to learn how to cope with temptation (positive self statements, decision review, and distraction activities), coupled with the use of covert modelling (i.e., practicing coping skills in one’s imagination). It also provides skills for coping with lapses (by redefining what is happening), and utilizes graded practice (a desensitization technique where addicts encounter real life situations slowly). Overall, CBT approaches are better researched than the other psychological methods in addiction but are probably no more effective (Luty, 2003).
Psychotherapy: Psychotherapy can include everything from Freudian psychoanalysis and transactional analysis, to more recent innovations like drama therapy, family therapy and minimalist intervention strategies. The therapy can take place as an individual, as a couple, as a family, as a group and is basically viewed as a ‘talking cure’ consisting of regular sessions with a psychotherapist over a period of time. Most psychotherapies view maladaptive behaviour as the symptom of other underlying problems. Psychotherapy often is very eclectic by trying to meet the needs of the individual and helping the addict develop coping strategies. If the problem is resolved, the addiction should disappear. In some ways, this is the therapeutic opposite of pharmacotherapy and behavioural therapy (which treats the symptoms rather than the underlying cause). There has been little evaluation of its effectiveness although most addicts go through at least some form of counselling during the treatment process.
Self-help therapy: The most popular self-help therapy worldwide is the Minnesota Model 12-Step Programme (e.g., Alcoholics Anonymous, Gamblers Anonymous, Narcotics Anonymous, Overeaters Anonymous, Sexaholics Anonymous, etc.). This treatment programme uses a group therapy technique and uses only ex-addicts as helpers. Addicts attending 12-Step groups involves them accepting personal responsibility and views the behaviour as an addiction that cannot be cured but merely arrested. To some it becomes a way of life both spiritually and socially and compared with almost all other treatments it is especially cost-effective (even if other treatments have greater success rates) as the organization makes no financial demands on members or the community. For the therapy to work, the 12-Step Programme asserts that the addict must come to them voluntarily and must really want to stop engaging in their addictive behaviour. Further to this, they are only allowed to join once they have reached “rock bottom”. To date there has been little systematic study of 12-Step groups but drop out rates are very high (typically 80-90%). There are a number of problems preventing evaluation, particularly anonymity, sample bias, and what the criterion for success is. The empirical evidence suggests that self-help support groups’ complement formal treatment options and can support standardized psychosocial interventions.
When examining all the literature on the treatment of addiction, there are a number of key conclusions that can be drawn. These include that: (i) treatment must be readily available, (ii) no single treatment is appropriate for all individuals., (iii) it is better for an addict to be treated than not to be treated, (iv) it does not seem to matter which treatment an addict engages in as no single treatment has been shown to be demonstrably better than any other, (v) a variety of treatments simultaneously appear to be beneficial to the addict, (vi) individual needs of the addict have to be met (i.e., the treatment should be fitted to the addict including being gender-specific and culture-specific), (vi) clients with co-existing addiction disorders should receive services that are integrated, (vii) remaining in treatment for an adequate period of time is critical for treatment effectiveness, (viii) medications are an important element of treatment for many patients, especially when combined with counselling and other behavioural therapies, (ix) recovery from addiction can be a long-term process and frequently requires multiple episodes of treatment, (x) there is a direct association between the length of time spent in treatment and positive outcomes, and (xi) the duration of treatment interventions is determined by individual needs, and there are no pre-set limits to the duration of treatment.
Dr. Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK
Griffiths, M.D. (1996). Pathological gambling and its treatment. British Journal of Clinical Psychology, 35, 477-479.
Griffiths, M.D. & Dhuffar, M. (2014). Treatment of sexual addiction within the British National Health Service. International Journal of Mental Health and Addiction, 12, 561-571.
Griffiths, M.D. & H.F. MacDonald (1999). Counselling in the treatment of pathological gambling: An overview. British Journal of Guidance and Counselling, 27, 179-190.
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Last week, I was contacted by the journalist Abigail Moss about a previous blog that I wrote on Alice in Wonderland Syndrome (AIWS). AIWS is a non-contagious disorientation disorder and refers to when a person’s sense of body image, vision, hearing, touch, space, and/or time are distorted. AIWS sufferers typically experience micropsia (a neurological condition that affects human visual perception in which objects are perceived to be smaller than they actually are and make people feel bigger than they are) or macropsia (a neurological condition that affects human visual perception in which objects are perceived to be larger than they actually are and makes people feel smaller than they actually are).
Moss suffers from AIWS herself and has described her experiences both on camera (for instance in a short YouTube news piece and in numerous news articles such as one in the Daily Mail). Moss also sent me a first-person account of AIWS that she published in the online magazine Planet Ivy. Here are some of the things she recounted:
Extract 1: “When I was about five years old, I started to experience strange visual and sensory hallucinations. My hands and legs would seem too big for my body and the room around me would start to shrink inwards. All movements and sounds would seem extremely fast and hugely exaggerated, giving everything an odd feeling of urgency. This would last about 20 minutes and slowly fade away, and happened about four or five times a week…Luckily, my dad knew exactly what I was describing…He’d experienced the same thing as a kid. I haven’t outgrown it…but it doesn’t happen as often – maybe only five times a year”.
The first doctor suggested she might have a form of epilepsy but after that proved negative she was never diagnosed with anything official. Since then, other medics have suggested that she may have a sleep disorder or some kind of schizophrenia. It wasn’t until she was in her early twenties that she came across something that fitted her symptoms:
Extract 2: “Last year a tiny 50-word inset in a newspaper supplement caught my eye. ‘Alice in Wonderland Syndrome’ the heading read, and underneath it, a perfect description of my experience…I joined a Yahoo forum for ‘AIWS sufferers’…Countless fellow sufferers got in contact, all describing the same thing. Their descriptions were remarkably unvaried and it was immediately obvious this was the same thing I experience: ‘My body felt minuscule’, ‘Sounds were amplified’, ‘Everything was bigger and smaller at the same time’.”
The article outlined the many psychiatrists and psychologists Moss had visited about her condition with all the experts she saw claiming that they had never heard of AIWS. While the condition is rare, the condition has been well documented in the medical and clinical literature (see ‘Further reading’ below) so I was quite surprised that the experts she visited couldn’t have at least spent some time reading up on the syndrome. She then went on to say:
Extract 3: “My brain does something extremely weird, and nobody – not even the world’s leading bodies in the study of brains – can tell me what this is or why it happens. For me, this isn’t a problem, I don’t want to get rid of my episodes – they’re an interesting talking point and everyone knows writers are basically quite boring people. The experience, when it does pop up, doesn’t actually bother me or affect my day-to-day life”.
Moss wanted to ask me a few questions about my understanding of AIWS and how much is now known about it. She knew this wasn’t my primary area of expertise, but said that any opinions I might be able to offer would be invaluable to the article she was writing. I told her that my article on AIWS was written in a journalistic capacity rather from any position of expertise but she still wanted me to answer a few questions. Moss asked me three questions and I thought I would use this blog to share my full answers with my readers.
Question 1: “In my research I’ve found it almost impossible to find solid answers about what causes AIWS. Can you offer a view on what makes this condition so difficult to pin down?”
AIWS has been reported in the psychiatric and psychological literature since the early 1950s. However, since the first papers in the topic less than 20 papers have ever been published and all of them are case reports. Finding ‘solid answers’ based on so few cases is therefore inevitable. The literature is also biased because it is (a) based on those sufferers who seek out medical assistance, and (b) based on those doctors or clinicians that have written the cases for publication. If people don’t seek help and/or there cases remain unwritten, there is little chance if finding ‘solid answers’.
Secondly, the symptoms are not always identical which is why it is referred to as syndrome (that is, a group of symptoms that together are characteristic of a specific disorder or disease, or a predictable, characteristic condition or pattern of behavior that tends to occur under certain circumstances). Syndromes typically have many different causes which again means it is difficult to find ‘solid answers’.
Finally, given that the experiences (like your own) are often short-lived, it is very rare to be able to monitor people neurologically. The few published cases are based on chronic sufferers (who may not be representative of the vast majority of AIWS sufferers). Several neurologists have done M.R.I.s on patients with the condition, though once the bout has passed, there’s usually no sign of unusual brain activity. I read that Dr. Sheena Aurora was the first to scan the brain of someone — a 12-year-old girl — in the middle of an episode. According to Dr. Aurora, electrical activity caused abnormal blood flow in the parts of the brain that control vision and process texture, shape and size.
The case studies that I have read have provided lots of possible reasons for AIWS but there is no consensus and they could all be true (as having the same symptoms doesn’t mean there has to be the same cause). Some research appears to indicate that AIWS can be due to abnormal amounts of electrical activity that causes blood to flow abnormally in the brain areas that process texture and visual perception. AIWS has been associated with migraines, severe depression, and (in extreme cases) brain tumours. Case study research has indicated that AIWS manifestations are due to disturbed function of either medial temporal, hippocampal, tempro-occipital or tempro-parieto-occipital regions of the brain. Unfortunately, chronic AIWS is untreatable and time is the only healer. However, sharing experiences with other sufferers is also thought to be therapeutically beneficial
Question 2: “Is academic disagreement just part and parcel of all psychological conditions or does AIWS seems particularly open to discussion?”
I don’t think there is ‘disagreement’ as no two clinicians or psychiatrists have ever published papers examining the same individuals. They have all published papers based on the AIWS sufferers that they themselves saw and that who came in seeking help. All of the explanations could be correct as syndromes have multiple causes. This is not disagreement. It’s simply a case of multiple possible causes.
Question 3: “I have spoken to a large number of people who also say they also experience AIWS – how useful or valid do you think it would be to think of AIWS as more of a mental phenomenon than a syndrome, comparable with something like déjà vu, for example?”
The word ‘large’ is what we psychologists call a ‘fuzzy quantifier’ as ‘large’ to one individual is small to another. If you have spoken to 100 other sufferers worldwide I would say this is very very small. The condition appears to be rare although in one of my other areas of research, we have demonstrated that a small proportion of video gamers experience disorienting visual effects (that we call game transfer phenomena) like AIWS so such phenomena may be multi-faceted and may arise from specific activities (such as excessive and immersive game playing).
AIWS should not be compared with déjà vu as most scientific evidence suggests that déjà vu is an anomaly of memory and totally different from AIWS on a neurological level (but I’m not an expert on déjà vu and am only basing my opinion on what I have read in the psychological literature). However, there may be some conditions (such as schizophrenia and temporal lobe epilepsy) where individuals may experience both AIWS and déjà vu but these are symptoms of a specific medical disorder. Most individuals that have experienced déjà vu (as many as two-thirds of the population in some studies) and AIWS (very rare) do not have any underlying serious medical conditions.
I don’t know if any of my responses to Moss were of help either in relation to her own experiences or in writing her article but I was pleased with the observations I had made.
Dr Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK
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“Now there’s a really good book…[by French economist] Jacques Attali wrote in the late [1970s] called ‘Noise: The Political Economy of Music’…and the main tenet of that book is that…music is the best form of prophecy that we have…so that working with music or sound is our best way of divining a future, and being able to show to ourselves what’s round the corner in that psychological, or even psychic sense” (writer and graphic designer Jon Wozencroft being interviewed for the 2007 film Joy Division)
As a poverty stricken teenager in the early 1980s, all of my minimal disposable income was spent on buying records, cassettes, and music magazines (and to be honest, 35 years later nothing much has changed except I now buy far too many CDs instead of cassettes). Unlike most of my friends at the time I refused to be pigeon holed as a new romantic, a punk, a mod, or a goth because I liked music from all those genres. In the early 1980s was as equally as likely to buy a record by Adam and the Ants and Bauhaus as I was to buy records by Secret Affair and The Clash. I was also into city music scenes with my favourites being the ‘Liverpool scene’ (Echo and the Bunnymen, Teardrop Explodes, Wah! etc.), the ‘Sheffield scene’ (Human League, Heaven 17, Cabaret Voltaire, etc.), and the ‘Manchester scene’ (Magazine, Buzzcocks, Joy Division, The Smiths, The Passage, etc.).
The Manchester music scene was incredibly buoyant although often portrayed by the music press at the time as psychologically and emotionally ‘miserablist’. My parents could never understand what I saw in the “depressing and alienating music” (as they saw it) of bands like Joy Division and The Smiths. But it was through these bands that I developed an interest in psychology and what could be described as ‘psychgeography of post-punk’. In the case of Joy Division, their geographical location in Manchester and its surrounding area (Salford, Macclesfield) was integral to their music. In fact, a number of commentators (such as Liz Naylor, the co-editor of City Fun fanzine) have asserted that Joy Division “relayed the aura of Manchester” in the late 1970s and early 1980s.
All of my information about Joy Division came from reading the NME, listening to the John Peel Show on Radio 1, and listening to their two studio LPs (Unknown Pleasures and Closer) and assorted singles (that I mainly taped off the radio as most of them were not widely available). I was too young to go to gigs and they rarely appeared on television. Of the four members of Joy Division – Ian Curtis (vocals), Peter Hook (bass guitar), Bernard ‘Barney’ Sumner (guitar), and Stephen Morris (drums) – it was Curtis that captivated my adolescent attention. It was through Curtis’ documented medical conditions that helped develop my interest in psychology. Curtis suffered from epilepsy (like one of musical heroes Jim Morrison of The Doors) and clinical depression. It has also been alleged that he suffered from bipolar disorder (i.e., what used to be called ‘manic depression’) although this was never formally diagnosed (and many of those close to Curtis claim that such a claim is speculative at best).
Descriptions of Curtis’ behaviour on first sight look like bipolar disorder given the reports by his wife and others of his severe mood swings (where on one day he could have feelings of happiness and elation but on the next day could have feelings of intense depression and despair). However, other members of the band claimed that the mood swings were caused by the epilepsy medication Curtis was taking. However, bipolar disorder is not uncommon among musicians given many other high profile rock and pop stars have suffered from it including Brian Wilson (Beach Boys), Syd Barrett (Pink Floyd), Kurt Cobain (Nirvana), Ray Davies (The Kinks), Sinéad O’Connor, Poly Styrene (X-Ray Spex), and Adam Ant (to name just a few). Curtis was never afraid to write about psychological and medical conditions and the song ‘She’s Lost Control’ is arguably the most insightful song ever written about epilepsy (based not on his own experiences, but his observations of a female epileptic client who died while he was an Assistant Disablement Resettlement Officer based at the Job Centre in Macclesfield).
As any Joy Division fan knows, as a result of his severe depression, Curtis committed suicide by hanging himself on May 18, 1980 (a date I always remember because it was my favourite gran’s birthday), just two days before Joy Division were due to go on their first US tour. Even as a 14-year old teenager, I remember going to my local library in Loughborough not long after his death to learn more about depression, epilepsy, suicide, and attempted suicide (as he had two previous attempts to commit suicide earlier that year). I’m not saying that this alone was responsible for my career choice but it certainly facilitated my growing interest in psychology and mental health issues.
It was also through Joy Division that I started to read history books (and still do) on various psychological and non-psychological aspects of Nazism (and is evidenced by my previous blogs on the personality of Adolf Hitler and Nazi fetishism). Back in the late 1970s and early 1980s, Joy Division were often accused of having Nazi tendencies. It didn’t help that their name came from the 1955 novella House of Dolls by Jewish writer and Holocaust survivor Yehiel De-Nu (writing under his pen name Ka-tzetnik 135633). The ‘Joy Division’ was the name given to a group of Jewish women in World War II concentration camps whose only purpose was to provide sexual pleasure to Nazi soldiers. I have to admit I’ve never read any of De-Nu’s books. According to an online article by David Mikies (‘Holocaust Pulp Fiction’), De-Nu’s writings were “often lurid novel-memoirs, works that shock the reader with grotesque scenes of torture, perverse sexuality, and cannibalism“. In the 2006 book Joy Division and the Making of Unknown Pleasures, Jake Kennedy asserted that “Curtis’ fascination with extremes would hint to anyone willing to look beyond the headlines that the choice of name was probably an old fashioned punk exercise, matter of old habits dying hard”.
One of the bands earliest songs ‘Warsaw’ (which was also their band name prior to becoming Joy Division) is arguably a lyrical biography of Hitler’s deputy Führer Rudolf Hess. The song even begins with the lyric “3 5 0 1 2 5 Go!” (Hess’ prisoner of war serial number after he was captured after flying to the UK in 1941). Another of their early songs ‘No Love Lost’ features a spoken word section with a complete paragraph from The House of Dolls. A 2008 article by music writer Jon Savage in The Guardian newspaper noted that Curtis’ songs “such as ‘Novelty’, ‘Leaders of Men’ and ‘Warsaw’ were barely digested regurgitations of their sources: lumpy screeds of frustration, failure, and anger with militaristic and totalitarian overtones”.
Deborah Curtis (Ian’s wife) also remembered that her husband had a book by John Heartfield that included photomontages of the Nazi Period and that graphically documented the spread of Hitler’s ideals. The cover artwork of the band’s first record, the ‘An Ideal For Living’ EP, also featured a boy member the Hitler Youth drawn by guitarist Barney Sumner banging on a drum. Much of the flirtation with Nazi symbolism was arguably juvenile fascination and playful naivety. It’s also been noted that Joy Division’s early music concentrated on the nihilistic provocations of industrial music’s pioneers Throbbing Gristle (whose music I also examined at length in a previous blog). An interesting 2010 article by Mateo on the A View From The Annex website defended Joy Division’s use of Nazi imagery and lyrics:
“The Labour government´s betrayal of the working class during the 1970s and the rise of Thatcherism at the end of the 1970s heralded a future of mass unemployment, government repression and decaying industry. The perspective taken by Ian Curtis, the band´s sole lyricist, towards this growing authoritarianism and despair is crucial to understand if one is to place the references to fascism found in the band´s album art in the context intended by the artist, that is, a despairing anti-Nazism…Punk at that time was a unique music scene in which battles between anti-racists and neo-nazis were being thrashed out at concerts as the skinheads tried to appropriate the punk aesthetic and hijack the following of alienated, disillusioned working class youth who gravitated towards such a sub-culture in places like Manchester at the beginning of the 1980s…The lyrics of Ian Curtis made it clear that this was a presence suffered and feared as opposed to tolerated or toyed with by the band…Joy Division feared fascism, they did not flirt with it and the artwork and lyrics in ‘An Ideal for Living’ serves as a warning of growing fascistic tendencies in British society…For this, Curtis and his bandmates should be lauded for tackling such a controversial issue and expressing such a well-grounded fear and hostility towards such a veritable enemy of the working class during a swift turn to the right in Britain”.
By all accounts, Curtis was a voracious reader and read books by William Burroughs, Fyodor Dostoyevsky, Franz Kafka, Friedrich Nietzsche, Nikolai Gogol, Jean-Paul Sartre, Hermann Hesse and J.G. Ballard, many of which made their way into various Joy Division songs (an obvious example being their song ‘Interzone’ taken directly from a collection of short stories by William Burroughs). As Jon Savage noted:
“Curtis’s great lyrical achievement was to capture the underlying reality of a society in turmoil, and to make it both universal and personal. Distilled emotion is the essence of pop music and, just as Joy Division are perfectly poised between white light and dark despair, so Curtis’s lyrics oscillate between hopelessness and the possibility, if not need, for human connection. At bottom is the fear of losing the ability to feel”.
J.G. Ballard was a particular inspiration to Curtis (particularly the books High Rise and Crash, the latter of which was about the suffering of car accident victims and sexual arousal, and which I wrote about in a previous blog on symphorophilia). One of Joy Division’s best known songs (the opening ‘Atrocity Exhibition’ from their second LP Closer) took its’ name from Ballard’s collection of ‘condensed novels’ (and given its focus on mental asylums is of great psychological interest). So distinct is Ballard’s work that it gave rise to a new adjective (‘Ballardian’) and defined by the Collins English Dictionary as “resembling or suggestive of the conditions described in J.G. Ballard’s novels and stories, especially dystopian modernity, man-made landscapes and the psychological effects of technological, social or environmental developments”. Given this definition, many of Joy Division’s songs are clearly Ballardian as they examine the emotional and psychological effects of everything around them (including personal relationships on songs such as their most well known and most covered song, and only British hit ‘Love Will tear Us Apart’).
The overriding psychology and underlying philosophy of both Ian Curtis and Joy Division are both contradictory and complex but ultimately the band members were a product of the environment they were brought up in and the sum of their musical and literary influences. At the age of 24 years, Curtis’ suicide was undoubtedly tragic and like many other literary and musical ‘artists’, his death has been somewhat romanticized by the mass media. Although he didn’t quite make it into the infamous ‘27 Club’ of ‘rock martyr’ musicians that died when they were 27 years (e.g., Dave Alexander [The Stooges], Chris Bell [Big Star], Kurt Cobain [Nirvana], Richey Edwards [Manic Street Preachers], Pete Ham [Badfinger], Jimi Hendrix, Robert Johnson, Brian Jones [Rolling Sones], Janis Joplin, Jim Morrison [The Doors], Amy Winehouse) he is surely a candidate for being a prime honorary member (along with Jeff Buckley). Retrospectively looking at his lyrics (“In the shadowplay, acting out your own death, knowing no more” from ‘Shadowplay’, you can’t help but wonder (given that many of them were autobiographical) whether Curtis’ death could have been prevented by those closest to him.
Dr Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK
Curtis, D. (1995). Touching From A Distance. London: Faber and Faber.
Curtis, I., Savage, J. & Curtis, D. (2015). So This Is Permanence: Joy Division Lyrics and Notebooks. London: Faber and Faber.
Gleason. P. (2015). This Is the Way: “So This Is Permanence” by Ian Curtis. Located at: http://stereoembersmagazine.com/way-permanence-ian-curtis/
Hook, P. (2013). Unknown Pleasures: Inside Joy Division. London: Simon and Schuster.
Kennedy, J. (2006). Joy Division and the Making of Unknown Pleasures. London: Omnibus.
Mikies, D. (2012). Holocaust pulp fiction. The Tablet, April 19. Located at: http://www.tabletmag.com/jewish-arts-and-culture/books/97160/ka-tzetnik?all=1
Morley, P. (2007). Joy Division: Piece by Piece: Writing About Joy Division 1977-2007. London: Plexus Publishing.
Reynolds, S. (2006). Rip It Up and Start Again: Postpunk, 1978–1984. New York: Penguin.
Savage, J. (2008). Controlled chaos. The Guardian, May 10. Located at: http://www.theguardian.com/books/2008/may/10/popandrock.joydivision
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.
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).
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