Category Archives: Psychiatry
A few weeks ago, three independent things happened that has led me to writing this article. Firstly, I received an email from one of my blog readers who wrote:
“I’m a recovering addict. I still find that hard to admit even after time in therapy and the support of my loved ones, but to say it out loud can sometimes be a help. One part of my therapy, which really did strike a chord was something called ‘Chaos Addiction’. It was suggested to me that my addictive behaviors were fueled by a need to constantly have things in my life that were ‘in flux’ – to experience the ‘predictably unpredictable’. Looking back over my life, it hit home…I’d love it if you might think about sharing this with your site’s readership”.
Secondly, a couple of days later I was given a CD-R by one of my friends that included the song ‘Addicted to Chaos’ by the group Megadeth (from their 1994 album Youthanasia). Thirdly, a couple of days after that I was watching the film Chasing Lanes where the lead character in the film Doyle Gipson (played by Samuel L Jackson) is told by his Alcoholics Anonymous sponsor (played by William Hurt) that he was ‘addicted to chaos’ rather than alcohol.
I have never come across the term ‘chaos addiction’ prior to the email I was sent. As far as I am aware, there has never been any empirical research on the topic although Dr. Keith Lee did write a 2007 book (Addicted to chaos: The journey from extreme to serene) of his own experiences on the topic. Using case studies, the book examines individuals that have become “addicted to intensity out of the chaos and toward mind/body harmony, higher consciousness, and a deeply spiritual transformation”. More specifically:
“In a culture where the ‘extreme theme’ has become the norm, people are increasingly seduced into believing that intensity equals being alive. When that happens, the mind becomes wired for drama and the soul is starved of meaningful purpose. This type of life may produce heart-pounding excitement, but the absence of this addictive energy can bring about withdrawal, fear, and restlessness that is unbearable”.
In researching this article I came across a number of online articles dealing with ‘addiction to chaos’. The term has been applied to the actress Lindsay Lohan following a television interview with Oprah Winfrey (and the many articles that followed that honed in on her ‘addiction to chaos).
A short piece in Business Week by Clate Mask claimed that it is entrepreneurs that are frequently addicted to chaos (based on his “experiences and observations working with thousands and thousands of entrepreneurs over the years” along with his top three signs he sees as being addicted to chaos: (i) their business life revolves around the in-box, (ii) they can’t step away from the business, (ii) they are strangely proud they have so little free time. Clate then goes on to claim that:
“If you find yourself experiencing these symptoms, you are probably addicted to chaos. Get help. Business ownership should bring you more time, money, and control. If you’re not getting that, make some changes to your mindset and your business systems so you can find the freedom you were looking for when you started your business in the first place”.
An online article by Silvia Mordini discussed about her personal experiences and how she now uses yoga to provide grounding and stability in her life. (In fact, there are quite a few papers on treating addictions with yoga including a recent systematic review of randomized control trials by Paul Posadski and his colleagues in the journal Focus on Alternative and Complementary Therapies – see ‘Further reading’ below). As Mordini confessed:
“My past addiction to chaos simply hurt me too much. I got sick of the constant mental tug-o-war with myself. I’m not interested in feeling impatient with one thought and having to pull or push at the next one. Impatience promotes chaos and doesn’t feel good. The antidote to this is patience. Patience feels good. It feels like a return to mental stability no matter the chaos around us or what other people are thinking or doing…[The grounding that yoga brings] serves us as a simplifying force in order to stabilize our minds. When grounded, we plug back into our best selves and become fully present and balanced. Our energy stabilizes. Once centered, we are able to clearly see the circumstances of our lives. We no longer over-respond or over-worry because the static noise of chaos doesn’t pull us apart”.
She then goes on to provide her readers with five practical ways to promote stability and overcome addiction to chaos: (i) practice yoga, (ii) meditate, (iii) use a mantra (she suggests “I will let go of the need to be needed/I will let go of the need to be accepted/I will let go of the need to be accomplished), unplug from technology, and (v) get your hands and feet dirty (do some gardening, go for a walk on the beach, etc.). Obviously there is no clinical research confirming that these strategies would help overcome ‘chaos addiction’ but engaging in them certainly won’t do anyone any harm.
Another online article (‘Addicted to Chaos’) by addiction counselor Rita Barsky notes that many addicts grew up within dysfunctional families and noted:
“We never felt safe in our family of origin and the only thing we knew for sure was that nothing was for sure. Life was totally unpredictable and we became conditioned to living in chaos. When I talk about chaos in our lives, it was often not the kind that can be seen. In fact, many alcoholic/addict mothers were also super controllers and on the surface, our lives appeared to be perfect. The unsafe and chaotic living conditions of our lives were not visible or obvious to the outside world. Despite the appearance of everything being under control, we experienced continued chaos, developed a tolerance for chaos and I believe became addicted to chaos. I think it is important to say I have never done a scientific experiment to investigate this theory. It is based on observation of numerous alcoholic/addicts and their behavior”.
This was clearly written from experience and appears to have some face validity. Interestingly, Barsky then goes on to say:
“During the recovery process life becomes more manageable and less chaotic. The alcoholic/addict begins to feel a sense of autonomy and safety. A feeling of calm settles over their life. The paradox for the alcoholic/addict is that feeling calm is so unfamiliar it induces anxiety. There is a sense of waiting for the other shoe to drop. When there is a crisis, whether real or perceived, we actually experience a physical exhilaration and it feels remarkably like being active. From there it can be a very short distance to a relapse. Even if we don’t pick up we are not in a sober frame of mind. Addiction to chaos can be very damaging. Once engaged in someone else’s crisis we abandon ourselves and often develop resentments, especially if it is someone we love or are close to. Family chaos is the ‘best’ because it’s so familiar and we can really get off on it. When there is a crisis with family or friends we feel compelled to listen to every sordid detail and/or take action. We are unable to let go, we need to be in the mix even though it is painful and upsetting. It requires tremendous effort to detach and not jump in with both feet to the detriment to our well being”.
I find this account compelling because it’s written by someone that appears to have gone through this herself, and has now applied her therapeutic expertise retrospectively to understand the underlying psychology of what was occurring at the height of the addiction. Another compelling account is at Molly Field’s Yoga Blog.
“My object of desire is Chaos. My therapist told me at the end of my first session ever that I have a Chaos addiction…I’m not kidding: this stuff’s insidious. If it weren’t for my awareness of my ability to lose my temper over little-seeming things (aka scars from my past), I’d never know about the Addiction to Chaos. It’s because I grew up with it, was surrounded by it and trained by some of the world’s finest Chaos foments that I became one myself…My relationship with Chaos had become so much a part of my fabric of being that if I didn’t sense it, I would make it”.
Finally, I’ll leave you with the only tool that I have come across that claims to provide a diagnostic indication of whether someone is addicted to chaos. I need to point out that this came from the website of former psychologist Phil McGraw, the US television host of Dr. Phil. I have reproduced everything below verbatim (so when it says that “you are addicted to chaos” if you endorsed five or more of the ten items, that is the view of Dr. Phil – whenever I have co-developed a scale, I at least add the words “You may have a problem” rather than “You have got a problem”).
“While most people try to avoid drama, research shows that others have figured out how to trigger the body’s stress response, just for the rush. Take the test and find out if you’re creating chaos in your everyday life!
Directions: Answer the following questions ‘True’ or ‘False’
- Do you usually yell and scream to make your point?
- Do you ramp things up to win every argument?
- If you get sick, do you feel that EVERYONE should know about it?
- When you argue, do you ever break things or knock them over?
- Does being calm or bored sound like the worst thing to you?
- Do you ever yell at strangers if you feel that they are in your way?
- Do you hate it when you are not the center of attention?
- Is there usually a crisis to solve in your life?
- Do you break up or threaten a break up with a mate often?
- Are you usually the one who starts fights?
Results: If you answered ‘True’ to five or more of the questions above, you are addicted to chaos”
Dr Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK
Barsky, R. (2007). Addicted to Chaos. A Sober Mind, December 2. Located at: http://asobermind.blogspot.co.uk/2007/12/addicted-to-chaos.html
Field, M. (2012). Recovering from an addiction to chaos. The Yoga Blog, April 7. Located at: http://www.theyogablog.com/recovering-from-addiction/
Griffiths, M.D. (2005). Workaholism is still a useful construct Addiction Research and Theory, 13, 97-100.
Griffiths, M.D. (2011). Workaholism: A 21st century addiction. The Psychologist: Bulletin of the British Psychological Society, 24, 740-744.
Griffiths, M.D. & Karanika-Murray, M. (2012). Contextualising over-engagement in work: Towards a more global understanding of workaholism as an addiction. Journal of Behavioral Addictions, 1(3), 87-95.
Jakub, L. Addicted to chaos: Oprah’s interview with Lindsay Lohan. Hello Giggles, August 19. Located at: http://hellogiggles.com/addicted-to-chaos-oprahs-interview-with-lindsay-lohan
Kramer, L. (2015). Are you addicted to chaos? Recovery.org, January, 15. Located at: http://www.recovery.org/pro/articles/are-you-addicted-to-chaos/
Lee, J.K. (2007). Addicted to chaos: The journey from extreme to serene. Transformational Life Coaching and Consultancy.
Mask, C. (2011). Three signs you’re addicted to chaos. Business Week, March 18. Located at: http://www.businessweek.com/smallbiz/tips/archives/2011/03/three_signs_you_are_addicted_to_chaos.html
Posadzki, P., Choi, J., Lee, M. S., & Ernst, E. (2014). Yoga for addictions: a systematic review of randomised clinical trials. Focus on Alternative and Complementary Therapies, 19(1), 1-8.
Mordini, S. (2013). Are you addicted to chaos and drama? Mind Body Green, January 15. Located at: http://www.mindbodygreen.com/0-7395/are-you-addicted-to-chaos-and-drama.html
Haematophagia usually refers to the practice of animals feeding on the blood of another species. However, the term has also been applied to humans that consume blood (something that I have referred to in previous blogs on clinical vampirism and menophilia). Most writings on human haematophagia usually refer to the practice in some sexual and/or vampiric capacity (e.g., some individuals in China and Vietnam believe certain types of snake blood are aphrodisiacs and are drunk with rice wine) but haematophagia can also occur for other reasons.
While I working was in Spain, I was taken to one of the best Castilian restaurants, and as part of the starter I was served morcilla sausage. Morcilla sausage is basically a Spanish version of black pudding (aka ‘blood pudding’) and made from pig’s blood. I absolutely loved it. It did make me wonder what other ‘blood’ foods I might enjoy. I did a bit of research into the making of blood sausages and found out that variations of this dish exist in cultures all over the world (e.g., Europe, Asia, and the Americas), and that all kinds of different animals’ blood can be used (including pigs, sheep, cattle, goats, and ducks). According to the Wikipedia entry on human haematophagia:
“Drinking blood and manufacturing foodstuffs and delicacies with animal blood is also a feeding behavior in many societies. Cow blood mixed with milk, for example, is a mainstay food of the African Massai. Some sources say that Mongols would drink blood from one of their horses if it became a necessity. Black pudding is eaten in many places around the world. Some societies, such as the Moche, had ritual hematophagy, as well as the Scythians, a nomadic people of Russia, who had the habit of drinking the blood of the first enemy they would kill in battle…Psychiatric cases of patients performing hematophagy also exist. Sucking or licking one’s own blood from a wound is also a behavior commonly seen in humans, and in small enough quantities is not considered taboo. Finally, human vampirism has been a persistent object of literary and cultural attention”
There a numerous YouTube videos of the African Massai (in Tanzania) drinking blood directly from the necks of live cattle (such as here and here). Cattle blood drinking typically occurs after special celebrations (such as births, ritual circumcisions, etc.), but the special occasions are not compulsory for blood drinking to occur. The cattle are never killed and the cuts made to drink blood from appear to heal quickly. One report on the Environmental Graffiti website described the practice:
“Half a dozen Maasai warriors wrestle with the struggling cow. Another waits with his bow drawn, arrow at the ready. Finally, they have the straining animal in position. The warrior with the weapon shoots straight for the bovine’s jugular. Warm blood gushes into a waiting bucket, pumped out by the animal’s still-beating heart. The blood keeps flowing, almost filling the container, before the cow is released – its punctured neck sealed with a dab of cow dung. It will live to see another day. Its’ blood-donating job is done, at least for another month. The Maasai men who perform this blood-draining ritual do not intend to kill, or even harm, the animal. They merely want some of its nourishing crimson fluid to drink”.
Another Wikipedia entry focusing on blood as food notes that in addition to blood sausages, animal blood has also been used to thicken, colour, and/or flavour sauces and gravies, and for various types of blood soup (such as ‘czernina’ in Poland, ‘papas de sarrabulho’ in Portugal, and ‘svartsoppa’ made with goose blood in Sweden). Although blood is a taboo food in some cultures, in others it is perfectly acceptable – particularly in times when food has been scarce. Other cultures have other blood foods including blood pancakes (in Scandinavian and Baltic countries), blood tofu (China, Thailand, Vietnam), blood cake (Taiwan), blood potato dumplings (‘blodpalt’ made with reindeer blood in Sweden) and blood bread (‘paltbrod’ in Sweden). Additionally, Wikipedia noted that:
“Blood can also be used as a solid ingredient, either by allowing it to congeal before use, or by cooking it to accelerate the process. In Hungary when a pig is slaughtered in the morning the blood is fried with onions and is served for breakfast. In China, ‘blood tofu’ is most often made with pig’s or duck’s blood, although chicken’s or cow’s blood may also be used. The blood is allowed to congeal and simply cut into rectangular pieces and cooked. This dish is also known in Java as saren, made with chicken’s or pig’s blood. Blood tofu is found in curry mee as well as the Sichuan dish, maoxuewang. In Tibet, congealed yak’s blood is a traditional food”.
The Tanzanian Massai people are not the only culture to consume uncooked animal blood products. For instance, Inuits living in the Arctic Circle consume seal blood and believe it to have health and social benefits. According to a paper on consuming seal blood in a 1991 issue of Medical Anthropology Quarterly, seal blood is “seen as fortifying human blood by replacing depleted nutrients and rejuvenating the blood supply, [and] is considered a necessary part of the Inuit diet”. Another academic paper by Dr. Edmund Searles in a 2002 issue of the journal Food and Foodways reported that in relation to the drinking of seal blood: “Inuit food generates a strong flow of blood, a condition considered to be healthy and indicative of a strong body”. Historically, there are accounts of Irish people bleeding cattle as a preventative measure against cattle diseases. The Wikipedia entry on blood as food claims that the Irish mixed the drawn blood with “butter, herbs, oats or meal” to provide a “nutritious emergency food”.
During my research I also came across a story in The Atheist Times (with photographic evidence) of Hindus engaged in the practice of decapitating and drinking goat blood directly from its body (a blood sacrifice). The report claimed the practice was widely prevalent throughout India and Malaysia. These Hindus believe that the Hindu goddess Kali descends upon those drinking the goat’s blood.
Staying on the religious theme, there are (of course) many (arguably ‘mainstream’) simulated acts of haemotphagia – most notably in various religious ceremonies and rituals. The most obvious is in the transubstantiation of wine as the blood of Jesus Christ during Christian Eucharist (where religious followers believe they are drinking the blood of Christ). Various religions engage in such pseudo-haemotophagic practices including the Catholic Church, Eastern Orthodox, Oriental Orthodox, some Anglican, and Lutheran churches. (Other religions are the exact opposite and consider the drinking of blood taboo such as Jewish and Muslim cultures).
As this brief review demonstrates, non-sexual and non-vampiric human haematophagia and pseudo-haematophagia appear to be common and widespread in many cultures and countries. Academic research on the topic appears to be limited although it certainly warrants further investigation.
Dr Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK
Borré, K. (1991). Seal blood, Inuit blood, and diet: A biocultural model of physiology and cultural identity. Medical Anthropology Quarterly, 5, 48-62.
Davidson, A (2006). The Oxford Companion to Food. Oxford: Oxford University Press.
Searles, E. (2002). Food and the making of modern Inuit identities. Food and Foodways, 10(1-2), 55-78.
Wikipedia (2013). Blood as food. Located at: http://en.wikipedia.org/wiki/Blood_as_food
Wikipedia (2013). Hematophagy. Located at: http://en.wikipedia.org/wiki/Hematophagy
Over the last decade, my research unit has carried out an increasing amount of research into the psychology of online gambling. In some of our recent research interviewing online gamblers, offline gamblers and non-gamblers, we found that people who gambled online did so because of its (i) convenience, (ii) greater value for money, (iii) the greater variety of games, and (iv) anonymity. Perhaps more interestingly, were the inhibiting reasons that stopped people from wanting to gamble online in the first place. The main inhibiting reason that stopped people gambling online was that offline gamblers and non-gamblers said the authenticity of gambling was significantly reduced when gambling online. We also found a number of other inhibitors of online gambling including (i) the reduced realism, (ii) the asocial nature of the internet, (iii) the use of electronic money, and (iv) concerns about the safety of online gambling websites. The reduced authenticity and realism may help to explain why online live action casino games are seen as increasingly popular among some types of gamblers.
This empirical research also chimes with my own personal psychology of online gambling. One of the main reasons I don’t like gambling at Internet casinos is that I believe the majority of game outcome are likely to be pre-programmed and/or predetermined. To me, this is somewhat akin to playing with imaginary dice! Our empirical research findings also help explain the rise of live online casino gambling. Players not only want increased realism and authenticity, but still have the added advantages of online anonymity while playing.
In online live casino gaming, the anonymity of the Internet allows players to privately engage in gambling without the fear of stigma. This anonymity may also provide the gambler with a greater sense of perceived control over the content, tone, and nature of the online experience. Anonymity may also increase feelings of comfort since there is a decreased ability to look for, and thus detect, signs of insincerity, disapproval, or judgment in facial expression, as would be typical in face-to-face interactions. For activities such as gambling, this may be a positive benefit particularly when losing as no-one will actually see the face of the loser. Anonymity may reduce social barriers to engaging in gambling, particularly those activities thought to be more skill-based gambling activities (such as poker or blackjack) that are relatively complex and often possess tacit social etiquette. The potential discomfort of committing a structural or social faux-pas in the gambling environment because of inexperience is minimized because the player’s identity remains concealed.
Furthermore, one of the main reasons why behaviour online is very different from offline is because it provides a ‘disinhibiting’ experience. One of the main consequences of disinhibition is that on the internet people lower their emotional guard and become much less restricted and inhibited in their actions.
The increase in online live casino gambling has happened alongside the rise of online betting exchanges – the type of online gambling where it could be argued that skill can – to some extent – be exercised. For gamblers, having a punt on live sporting events via betting exchanges is a psychologically safer option because punters know (or can check) who won a particular football or horse race. The playing of live action casino games via the Internet shares some of the psychological similarities of online betting exchanges.
The rise of live online gambling has been coupled with increasingly sophisticated gaming software, integrated e-cash systems, and increased realism (in the shape of “real” gambling via webcams, live remote wagering, and/or player and dealer avatars). These are all inter-linked facilitating factors. Another factor that I feel is really important in the rise of online gambling (including online live action casino games) is the inter-gambler competition. Obviously there is an overlap between competitiveness and skill but they are certainly not the same. What’s more recent research has suggested that being highly competitive may not necessarily be good for the gambler. For instance, Professor Howard Shaffer, a psychologist at Harvard University, claims that men are more likely to develop problematic gambling behaviour because of their conventionally high levels of aggression, impulsivity and competitiveness. Clearly, the idea of the competitiveness of the activity being one of the primary motivations to gamble is well supported.
Based on the fact that so little research has systematically examined the links between gambling and competitiveness, our research unit did some research into this area. We speculated that a gambler who is highly competitive will experience more arousal and stimulation, and be drawn to gambling as an outlet to release competitive instincts and drives. This is likely to occur more in activities like online poker and online live action casino games. Our research did indeed show that problem gamblers were significantly more likely than non-problem gamblers to be competitive.
Being highly competitive may help in explaining why in the face of sometimes negative and damaging financial consequences, gamblers persist in their habit. Psychological research in other areas has consistently shown that highly competitive individuals are more sensitive to social comparison with peers regarding their task performance. Applying this to a gambling situation, it is reasonable to suggest that competitive gamblers may be reluctant to stop gambling until they are in a positive state in relation to opposing gamblers, perhaps explaining why excessive gambling can sometimes occur.
Sociologists have speculated that factors of the human instinctual expressive needs, such as competition, can be temporarily satisfied when engaging in gambling activities. Evidence exists supporting gambling as an instrumental outlet for expressing competitive instinctual urges. The US sociologist Erving Goffman developed what he called the ‘deprivation-compensation’ theory to explain the relationship between gambling and competitiveness. He suggested that the stability of modern society no longer creates situations where competitive instincts are tested. Therefore, gambling is an artificial, self-imposed situation of instability that can be instrumental in creating an opportunity to test competitive capabilities. Again, online live action casino gambling is another gambling form that can facilitate such instinctive needs.
Dr Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK
Goffman, I. (1972). Where the action is. In: Interaction Ritual (pp. 149–270). Allen Lane, London.
Griffiths, M.D. (2010). Gambling addiction on the Internet. In K. Young & C. Nabuco de Abreu (Eds.), Internet Addiction: A Handbook for Evaluation and Treatment. pp. 91-111. New York: Wiley.
Griffiths, M.D. & Parke, J. (2003). The environmental psychology of gambling. In G. Reith (Ed.), Gambling: Who wins? Who Loses? pp. 277-292. New York: Prometheus Books.
Griffiths, M.D., Wardle, J., Orford, J., Sproston, K. & Erens, B. (2009). Socio-demographic correlates of internet gambling: findings from the 2007 British Gambling Prevalence Survey. CyberPsychology and Behavior, 12, 199-202.
Griffiths, M.D., Wardle, J., Orford, J., Sproston, K. & Erens, B. (2011). Internet gambling, health. Smoking and alcohol use: Findings from the 2007 British Gambling Prevalence Survey. International Journal of Mental Health and Addiction, 9, 1-11.
Kuss, D. & Griffiths, M.D. (2012). Internet gambling behavior. In Z. Yan (Ed.), Encyclopedia of Cyber Behavior (pp.735-753). Pennsylvania: IGI Global.
McCormack. A. & Griffiths, M.D. (2012). Motivating and inhibiting factors in online gambling behaviour: A grounded theory study. International Journal of Mental Health and Addiction, 10, 39-53.
McCormack, A. & Griffiths, M.D. (2013). A scoping study of the structural and situational characteristics of internet gambling. International Journal of Cyber Behavior, Psychology and Learning, 3(1), 29-49.
McCormack, A., Shorter, G. & Griffiths, M.D. (2013). An examination of participation in online gambling activities and the relationship with problem gambling. Journal of Behavioral Addictions, 2(1), 31-41.
McCormack, A., Shorter, G. & Griffiths, M.D. (2013). Characteristics and predictors of problem gambling on the internet. International Journal of Mental Health and Addiction, 11, 634-657.
Wardle, H. & Griffiths, M.D. (2011). Defining the ‘online gambler’: The British perspective. World Online Gambling Law Report, 10(2), 12-13.
Wardle, H., Moody, A., Griffiths, M.D., Orford, J. & and Volberg, R. (2011). Defining the online gambler and patterns of behaviour integration: Evidence from the British Gambling Prevalence Survey 2010. International Gambling Studies, 11, 339-356.
In previous blogs, I have examined lots of strange types of addictive and compulsive behaviours including compulsive singing, compulsive hoarding, carrot eating addiction, Argentine tango addiction, compulsive nose-picking, compulsive punning, compulsive helping, obsessive teeth whitening, compulsive list-making, chewing gum addiction, hair dryer addiction, wealth addiction, and Google Glass addiction (to name just a few).
However, while doing some research for a paper I am writing on ‘fishing addiction’ (yes, honestly), I came across an interesting paper on unusual compulsive behaviours caused by individuals receiving medication for Parkinson’s disease ([PD] a degenerative disorder of the central nervous system) and multiple system atrophy ([MSA] a degenerative neurological disorder in which nerve cells inside the brain start to degenerate and with symptoms similar to Parkinson’s disease).
In the gambling studies field there are now numerous papers that have been published showing that some Parkinson’s patients develop compulsive gambling after being treated for PD. According to the Parkinsons.co.uk website, those undergoing PD treatment can have many side effects including addictive gambling, obsessive shopping, binge eating, and hypersexuality. The website also notes other types of compulsive behaviour that have been associated with PD medication including “punding or compulsive hobbyism [when someone does things such as collecting, sorting or continually handling objects]. It may also be experienced as (i) a deep fascination with taking technical equipment apart without always knowing how to put it back together again, (ii) hoarding things, (iii) pointless driving or walking, and (iv) talking in long monologues without any real content”.
The paper that caught my eye was published in a 2007 issue of the journal Parkinsonism and Related Disorders by Dr. Andrew McKeon and his colleagues. They reported seven case studies of unusual compulsive behaviours after treating their patients with dopamine agonist therapy (i.e., treatment that activates dopamine receptors in the body). The paper described some compulsive behaviours that most people would not necessarily associate with being problematic. Below is a brief description of the seven cases that I have taken verbatim from the paper.
- Patient 1: “A 65-year-old female with PD for 9 years developed compulsive eating, and also felt compelled to repetitively weigh herself at frequent intervals during the day and at night. She found her behavior both purposeless and repetitive. Obsessive thoughts were also a feature, as the patient ‘had to’ weigh herself three times each occasion she used the weighing scales”.
- Patient 2: “A 67-year-old female with PD for 8 years played computer games and solitaire card games for hours on end, often continuing to do so through the night. She did not enjoy the experience and found it purposeless, but did so as she felt she had ‘to be doing something’. She also developed compulsive eating and gambling”.
- Patient 3: “A 48-year-old male with PD for 5 years, with little prior interest, developed an intense interest and fascination with fishing. His wife was concerned that he fished incessantly for days on end, and his interest did not abate despite never catching anything. This patient also developed compulsive shopping, spending large amounts of time and money in thrift stores”.
- Patient 4: “A 53-year-old male with PD for 13 years became intensely interested in lawn care. He would use a machine to blow leaves for 6h without rest, finding it difficult to disengage from the activity, as he found the repetitive behavior soothing. He also developed compulsive gambling”.
- Patient 5: “The wife of a 52-year-old male with an 11-year history of PD complained that her husband now spent all of his time on his hobbies, to the detriment of their marriage. The patient made small stained glass windows, day and night. In addition, he would frequently stay awake arranging rocks into piles in their yard, intending to build a wall, but never doing so. He would start multiple projects but complete nothing. He was also noted to have become hypersexual, demanding sexual intercourse from his wife several times daily”.
- Patient 6: “This 60-year-old male, with a history of alcohol abuse and ultimately diagnosed with MSA, relentlessly watched the clock, locked and unlocked doors and continually arranged and lined up small objects on his desk. He also became hyperphagic and hypersexual, developing an intense fascination with pornographic films”.
- Patient 7: “The wife of a 59-year-old male with PD for 1 year described how her husband dressed and undressed several times daily. On one occasion, while guests were at their house for dinner, he spent most of his time in his bedroom repeatedly changing from one pair of trousers into another. This behavior deteriorated considerably on increasing levodopa dose to 1100mg/day, and on a subsequent occasion after reducing quetiapine from 100 to 75 mg/day”.
These cases highlight that the compulsive behaviours that develop following dopamine agonist therapy often co-occur with one or more other compulsive behaviour and that much of these behaviours are repetitive and unwanted. As the authors noted:
“The temporal association between medication initiation and the onset of these behaviors led to our suspicion that medications were causative. In the aggregate, these patients illustrate that the behaviors provoked by drug therapy in parkinsonism cover a broad spectrum, ranging from purposeless and repetitive to complex, reward-oriented behaviors. Punding is the term typically applied to the former, and was seen in Patient 5 (arranging rocks into piles) and Patient 6 (lining up small objects on a desk)…Previous descriptions of pathological behaviors occur- ring with dopaminergic therapy in PD have been notable for the absence of obsessive thoughts accompanying compulsive behaviors, unlike Patient 1 who was remark- able for a counting ritual accompanying repetitive use of a weighing scale. In six of the seven cases, other reward- seeking behaviors (gambling, shopping, hypersexuality or overeating) were present and contemporaneous with these other unusual compulsive behaviors. This suggests that all of these behaviors, while phenomenologically distinct, are all part of the range of psychopathology encapsulated by obsessive-compulsive spectrum disorders”.
According to the Parkinsons.co.uk website, PD sufferers are more likely to experience impulsive and compulsive behaviour if the person is (i) diagnosed with Parkinson’s at a young age, (ii) male, (iii) single and live alone, (iv) a smoker, and (v) someone with a personal or family history of addictive behaviour. The same article also notes that if the PD sufferer has “a history of ‘risk-taking’, such as gambling, drug abuse or alcoholism, [they] may be more likely to develop dopamine addiction”. This is where the PD sufferer takes more of their medication than is needed to control their Parkinson’s symptoms (and known as dopamine dysregulation syndrome). Similarly, Dr. McKeon and colleagues concluded:
“Previously described associated clinical features include a prior history of depressed mood (four patients in this series), disinhibition, irritability and appetite disturbance…A history of problems with impulse control prior to the diagnosis of PD may be a risk factor for developing compulsive behaviors with dopaminergic therapies…although this only pertained to Patient 6…The compulsions were not found to be troublesome by three patients, with complaints regarding behavioral change coming from the patient’s spouse. Our observations affirm the need to check with both patient and family at follow-up visits for the emergence of a variety of troublesome pathological behaviors that may result from dopaminergic therapy, particularly dopamine agonists”.
Dr. Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK
Dodd, M. L., Klos, K. J., Bower, J. H., Geda, Y. E., Josephs, K. A., & Ahlskog, J. E. (2005). Pathological gambling caused by drugs used to treat Parkinson disease. Archives of Neurology, 62, 1377-1381.
Griffiths, M.D. (1996). Behavioural addictions: An issue for everybody? Journal of Workplace Learning, 8(3), 19-25.
Griffiths, M.D. (2005). A ‘components’ model of addiction within a biopsychosocial framework. Journal of Substance Use, 10, 191-197.
Klos, K. J., Bower, J. H., Josephs, K. A., Matsumoto, J. Y., & Ahlskog, J. E. (2005). Pathological hypersexuality predominantly linked to adjuvant dopamine agonist therapy in Parkinson’s disease and multiple system atrophy. Parkinsonism and Related Disorders, 11, 381-386.
McKeon, A., Josephs, K. A., Klos, K. J., Hecksel, K., Bower, J. H., Michael Bostwick, J., & Eric Ahlskog, J. (2007). Unusual compulsive behaviors primarily related to dopamine agonist therapy in Parkinson’s disease and multiple system atrophy. Parkinsonism and Related Disorders, 13(8), 516-519.
Nirenberg, M. J., & Waters, C. (2006). Compulsive eating and weight gain related to dopamine agonist use. Movement Disorders, 21, 524-529.
Pontone, G., Williams, J. R., Bassett, S. S., & Marsh, L. (2006). Clinical features associated with impulse control disorders in Parkinson disease. Neurology, 67, 1258-1261.
Voon, V., Hassan, K., Zurowski, M., De Souza, M., Thomsen, T., Fox, S.,…& Miyasaki, J. (2006). Prevalence of repetitive and reward-seeking behaviors in Parkinson disease. Neurology, 67, 1254-1257.
“Not tonight dear, I’ve got a headache” is a staple (and somewhat stereotypical) phrase typically used by women in various television sitcoms to politely turn down their husband’s sexual advances. However, there is a small minority of individuals where sexual activity can actually trigger headaches (known in the clinical and medical literature as ‘coital cephalalgia’ and ‘benign coital headache’) often occurring at the brink of orgasm. (Here, the term ‘benign’ defines a primary headache syndrome not caused by any intracranial disorder). Often characterized by sufferers as a “severe pain behind the eyes” it can be short-term or long-lasting (up to days in extreme cases), and can affect both sexes across the age spectrum. According to the National Headache Foundation, around 1 in 5 women and 1 in 20 men experience “exertional headaches” (i.e., headaches caused by increased blood pressure in the brain that typically occurs during exercise). Such exercise can in a minority of cases include sexual activity.
One of the earliest recorded cases of coital cephalalgia – at least one of the earliest I found when I did an online literature search – was published in a 1974 issue of the Irish Journal of Medical Science by Dr. Edward Martin. He published six case studies of “a benign syndrome of recurrent headache during sexual intercourse”. For instance, one of his cases was a 42-year old male engineer that claimed he suffered migraine headaches during sex (lasting from 10 to 60 minutes). It first occurred just two weeks after marrying his wife and then carried on at regular intervals. The headache always occurred “abruptly at the onset of orgasm”. After about a year, the headaches subsided to the point where they were only occasional. (Other articles I have read say that the first paper published on this topic was by Dr. J.W. Lance who wrote a paper entitled ‘Headaches related to sexual activity’ in the Journal of Neurology, Neurosurgery, and Psychiatry. However, that paper was published two years after the one by Dr. Martin). Another early paper published by Dr. M. Porter and Dr. J. Jankovic, in a 1981 issue of the Archives of Neurology reported eight cases of benign coital cephalalgia (BCC), “an acute headache that is time related to sexual intercourse” (and a variant of migraine). The authors reported that all eight sufferers were successfully treated with propranolol hydrochloride.
In a 1988 issue of Cephalalgia, Dr. J.M. Martinez and his colleagues reported three cases of benign coital cephalalgia (all of who had a history of migraine). Comparing their own cases with those that had previously been published, they concluded that such sex-related headaches may have resulted from heart problems (“ischaemic disturbances”) triggered by “haemodynamic changes occurring in orgasm”. There is also some evidence that the condition may have a partly genetic basis as a 1986 paper By Dr. D.R. Johns in the Archives of Neurology reported four cases of benign sexual headache (BSH) in four sisters from the same family. He reported the most severely affected of the sisters was successfully treated with propranolol hydrochloride (as reported above), and that BSH was a variant of migraine.
In a 2005 review paper by Polish medic Dr. I. Domitrz, I. (published in the journal Ginekologia Polska) on primary headaches associated with sexual activity], it was noted that BCH was rare and that:
“The pathogenesis of this type of headache remains unknown. Clinical manifestation is typical and connected with three phases of sexual activity. Coital cephalalgia is divided into two subtypes: preorgasmic and orgasmic headache. Some authors specify the third type–postural type. Preorgasmic headache starts as a dull bilateral ache and increases with sexual excitement. Orgasmic headache has sudden, intense character and occurs at orgasm. Postural headache has been reported to develop after coitus”.
In a 1992 issue of the journal Cephalalgia, Danish doctors Dr. J.R. Østergaard and Dr. M. Kraft studied the natural history of patients with a diagnosis of benign coital headache (BCH) that presented themselves for treatment in their clinic over a 13-year period (1978-1991). Of the 32 patients that had been treated for BCH, 26 of them participated in their follow-up study. They reported that 13 patients (50% of their sample) had recurrent attacks of coital headaches separated by intervals of up to 10 years. Of these 13, eleven of them “suffered a concomitant primary headache whereas this was present in only one of those patients without recurrent attacks of coital headache”. Apart from one patient who suffered blurred vision, the headaches were not too severe as there were no reports of vomiting, visual disturbances, sensory/motor disturbances, or unconsciousness. The paper concluded that BCH can clearly be “distinguished from headaches due to cerebral aneurysm or arteriovenous malformation rupture. The presence of a concomitant primary headache syndrome is a risk-factor for recurrence of coital headache”.
Arguably the most well known researcher in the field of sexual headaches is the German Dr. Achim Frese who has published a whole series of papers with his team on the topic. In a 2005 review paper in the journal Practical Neurology, Frese and his colleague Dr. Stefan Evers noted that:
“The frequency of headache associated with sexual activity is unknown. In the only population-based epidemiological study, the lifetime prevalence was about 1% with a wide confi dence interval, similar to the frequency of benign cough headache and benign exertional headache (Rasmussen & Olesen 1992). Very likely, the frequency is underestimated because patients often feel too embarrassed to report intimate details about their sexual activities. We estimate that patients with headache associated with sexual activity account for about 1% of all headache patients who are referred to our supraregional headache clinics”.
In 2003, Frese and colleagues examined the demographic and clinical features of headaches associated with sexual activity (HSA) in the journal Neurology. Between Over a five-year period (1996-2001), they interviewed 51 patients with the diagnosis of HAS. The average age of onset was just under 40 years of age and there were approximately three times more males with HSA. They also reported that 11 of their participants had HSA type 1 (i.e., dull subtype), which gradually increased with increasing sexual excitement. The remaining 40 participants had HSA type 2 (i.e., explosive subtype). There were no participants with HSA type 3 (i.e., postural subtype). HSA wasn’t dependent on any specific sexual habits and most often occurred during sexual activity with their usual partner (94%) and during masturbation (35%). There were no differences between HSA types 1 and 2 in relation to demographic factors, clinical features, or comorbidity, except for a higher probability of stopping the attack by breaking off sexual activity in HSA type 1.
In 2007, Frese and his colleagues published a paper in the journal Cephalagia looking at the prognosis and treatment of HSA. In this study they followed up 60 HSA cases in an eight-year period (1996-2004). Of the 45 cases that had experienced just single attacks prior to baseline examination, the vast majority (n=37) had no further attacks. The most effective treatment was the use of beta-blockers. They also reported that:
“Seven patients suffered from at least one further bout with an average duration of 2.1 months. One patient developed a chronic course of the disease after an episodic start. Of the 15 patients with chronic disease at the first examination, seven were in remission and five had ongoing attacks at follow-up…Episodic HSA occurs in approximately three-quarters and chronic HSA in approximately one-quarter of patients. Even in chronic HAS, the prognosis is favourable, with remission rates of 69% during an observation period of 3 years”.
In an earlier 2003 paper (also in the journal Cephalgia), Frese and colleagues examined the cognitive processes of people with type 2 HSA (i.e., the explosive subtype) by measuring event-related potentials (ERPs). They measured visual ERPs in 24 individuals with HSA outside the headache period. These individuals were then compared to a control group (age- and sex-matched). They found that those with HSA type 2 have a loss of cognitive habituation as measured by ERP and that their ERP patterns were very similar to that in observed migraine sufferers.
Earlier this year, Frese and colleagues published an observational study in the journal Cephalagia examining whether having sex could actually alleviate headaches (including migraines). From their previous research, they noted that headaches associated with sexual activity were well-known but that some case reports in the literature suggest that sexual activity during a headache might relieve the pain (in at least some patients). The research team sent a questionnaire to 800 migraine patients and 200 patients with other kinds of headache (called ‘cluster’ headaches). The paper reported that:
“In migraine, 34% of the patients had experience with sexual activity during an attack; out of these patients, 60% reported an improvement of their migraine attack (70% of them reported moderate to complete relief) and 33% reported worsening. In cluster headache, 31% of the patients had experience with sexual activity during an attack; out of these patients, 37% reported an improvement of their cluster headache attack (91% of them reported moderate to complete relief) and 50% reported worsening. Some patients, in particular male migraine patients, even used sexual activity as a therapeutic tool. The majority of patients with migraine or cluster headache do not have sexual activity during headache attacks. Our data suggest, however, that sexual activity can lead to partial or complete relief of headache in some migraine and a few cluster headache patients”
Chakravarty, A. (2006). Primary headaches associated with sexual activity—some observations in Indian patients. Cephalalgia, 26, 202-207
Domitrz, I. (2005). Primary headache associated with sexual activity]. Ginekologia polska, 76, 995-999
Frese, A., Eikermann, A., Frese, K., Schwaag, S., Husstedt, I. W., & Evers, S. (2003). Headache associated with sexual activity Demography, clinical features, and comorbidity. Neurology, 61, 796-800.
Frese, A., & Evers, S. (2005). Primary headache syndromes associated with sexual activity. Practical Neurology, 5, 350-355.
Frese, A., Frese, K., Ringelstein, E. B., Husstedt, I. W., & Evers, S. (2003). Cognitive processing in headache associated with sexual activity. Cephalalgia, 23, 545-551
Frese, A., Gantenbein, A., Marziniak, M., Husstedt, I. W., Goadsby, P. J., & Evers, S. (2006). Triptans in orgasmic headache. Cephalalgia, 26, 1458-1461
Frese, A., Rahmann, A., Gregor, N., Biehl, K., Husstedt, I. W., & Evers, S. (2007). Headache associated with sexual activity: prognosis and treatment options. Cephalalgia, 27, 1265-1270
Hambach, A., Evers, S., Summ, O., Husstedt, I. W., & Frese, A. (2013). The impact of sexual activity on idiopathic headaches: An observational study. Cephalalgia, 33, 384-389
Johns, D. R. (1986). Benign sexual headache within a family. Archives of Neurology, 43, 1158-1160.
Lance, J.W. (1976). Headaches related to sexual activity. Journal of Neurology, Neurosurgery and Psychiatry. 39, 1226-30.
Martin, E. A. (1974). Headache during sexual intercourse (coital cephalalgia). Irish Journal of Medical Science, 143, 342-345.
Martinez, J. M., Roig, C., & Arboix, A. (1988). Complicated coital cephalalgia: three cases with benign evolution. Cephalalgia, 8, 265-268
Ostergaard, J. R., & Kraft, M. (1992). Benign coital headache. Cephalalgia, 12, 353-355
Pascual, J., Iglesias, F., Oterino, A., Vazquez-Barquero, A., & Berciano, J. (1996). Cough, exertional, and sexual headaches An analysis of 72 benign and symptomatic cases. Neurology, 46, 1520-1524
Porter, M. & Jankovic, J. (1981). Benign coital cephalalgia: differential diagnosis and treatment. Archives of Neurology, 38(11), 710-712.
Rasmussen, B.K. & Olesen, J. (1992) Symptomatic and nonsymptomatic headaches in a general population. Neurology, 42, 1225–31.
Silbert, P. L., Edis, R. H., Stewart-Wynne, E. G., & Gubbay, S. S. (1991). Benign vascular sexual headache and exertional headache: interrelationships and long-term prognosis. Journal of Neurology, Neurosurgery and Psychiatry, 54, 417-421
In a previous blog I briefly overviewed Alien Hand Syndrome. Since writing that blog I came across an interesting case of alien hand syndrome published in a 2000 issue of the American Journal of Physical Medicine and Rehabilitation by Dr. B. Hai and Dr. I. Odderson. They reported an unusual case in which their patient had a right hemispheric stroke and subsequently experienced what the authors described as embarrassing manifestations of Alien Hand Syndrome in the form of involuntary masturbation. The case involved a 73-year old man who was brought into a hospital emergency ward by his wife because of a sudden loss of movement in the left-hand side of his body (including a slight droop on the left-hand side of his face), slurred speech and poor balance. Furthermore, he could stand if helped but was unable to walk unaided. The man had obviously had a stroke but four days later he started to experience involuntary movements of his left arm and claimed his left hand “has a mind of his own”. The paper reported that:
“He developed a tonic grasp reflex with inability to release. He also had a tendency to reach and grasp onto objects with the left hand, such as the telephone cord or the remote control for the television, and was unable to release despite verbal commands. He would persistently grab his comb or fix the collar of his shirt. He also demonstrated difficulty performing bimanual activities, such as eating”
Most worryingly, the man’s wife expressed extreme concern when her husband’s left hand would expose his genitals and start to masturbate in public. The involuntary masturbation happened on numerous occasions when talking with the nurses and doctors in the hospital, and only ever occurred with his left hand (even though the man was right-handed). The man denied that he had any history of “excessive self-stimulation, sexual dysfunction, or exhibitionism”. While in hospital, the man was dismayed and frustrated that he was unable to stop his left hand stimulating his genitals in front of other people. The authors reported that:
“A clinical impression of [Alien Hand Syndrome] was made, and magnetic resonance imaging of the brain showed an acute infarct [dead tissue] in the medial right frontal lobe [of his brain] in the anterior cerebral artery distribution involving the right anterior cingulate gyrus and the corpus callosum. After [three weeks] of acute inpatient rehabilitation, the patient was able to walk with a standard walker and negotiate stairs with rails with contact guard assist. He also began to use his left hand for bimanual activities. He was subsequently discharged to home with his family”.
After a month of treatment, the man was able to walk again unassisted but his left hand was still not under his own control (and telling the medical staff that his hand “still has a mind of his own and won’t turn things loose”). However, the good news was that the involuntary masturbation in public subsided and eventually ceased. The authors of the paper claim this is a very rare case because their patient displayed “an unusual and disturbing manifestation of uncontrolled involuntary genital fondling with the nondominant, apraxic hand and with mirroring hand movements during eating”. The authors also noted that the involuntary movements of the man’s left hand never occurred while they were carrying out medical tests and suggested that their findings indicate “the possibility of the presence of a dexterous ‘alien’ mode of control that can be distinguished from a more clumsy and slow ‘voluntary’ mode of control”. Although there is no known treatment for AHS, as I noted in my previous blog on the topic, the symptoms can be minimized and managed to some extent by keeping the affected hand occupied and involved in a task (e.g., by giving it an object to hold in its grasp). This would seem to explain why the man never masturbated while undergoing medical tests (i.e., his hands were being occupied). The authors also noted that:
“So far, at least two types of [Alien Hand Syndrome] have been described. The callosal type, as seen in our patient (lesion involving the corpus callosum with or without frontal damage), is characterized by frequent intermanual conflict and apraxia of the affected limb. The frontal type (lesion involving the left mediofrontal and callosal) is associated with dominant hand grasp reflex, compulsive movements (such as groping), restraining actions, and compulsive manipulation of tool [Feinberg, Schindler & Flanagan, 1992]”.
As I noted in my previous blog on AHS, research indicates that AHS sufferers often personify the alien hand and may believe the hand is ‘possessed’ by some other spirit or alien life form. Their hands may even appear to act in opposition to each other (such as when AHS sufferers who are also cigarette smokers put a cigarette in their mouth to set it alight, only for the alien hand to pull it out and throw the cigarette away). Such behaviour is an example of ‘intermanual conflict’ and has been given the name ‘diagnostic ideomotor apraxia’.
A number of published papers have reported that involuntary masturbation can be associated with other conditions. For instance, it has been associated with temporal lobe epilepsy. Dr. M. Cherian reported the case of excessive masturbation in a young girl in a 1997 issue of the European Journal of Pediatrics. However, until the publication of this case of AHS, it had not ever been associated with having a stroke. Dr. Hai and Dr. Odderson conclude:
“Although [Alien Hand Syndrome] is a rare phenomenon, this condition should be considered in patients who present with a feeling of alienation of one or both upper limbs accompanied by complex purposeful involuntary movement. It must be differentiated from limb neglect and anosognosia, which present with dissociation from the limb as perceived object (i.e., where the limb is not perceived as a part of the “self”), but without involuntary movement and without dissociation from control over purposeful complex action of the affected limb (i.e., where the actions of the limb are perceived as self-generated). Further studies are required to elucidate a definite anatomical explanation that can lead to accurate diagnosis, specific treatment, and rehabilitation of these patients”
Biran, I. & Chatterjee, A. (2004). Alien Hand Syndrome. Archives of Neurology, 61, 292-294.
Cherian, M.P. (1997). Excessive masturbation in a young girl: A rare presentation of temporal lobe epilepsy. European Journal of Pediatrics, 156, 249.
Doody, R.S. & Jankovic, J. (1992). The alien hand and related signs. Journal of Neurology, Neurosurgery and Psychiatry, 55, 806-810.
Feinberg, T.E., Schindler, R.J. & Flanagan, N.G. (1992). Two alien hand syndromes. Neurology, 42, 19-24.
Hai, B.G.O., & Odderson, I.R. (2000). Involuntary masturbation as a manifestation of stroke-related alien hand syndrome. American Journal of Physical Medicine & Rehabilitation, 79, 395-398.
Jacome, D.E. & Risko, M.S. (1983). Absence status manifested by compulsive masturbation. Archives of Neurology, 40, 523-524.
Scepkowski, L.A. & Cronin-Golomb, A. (2003). The alien hand: Cases, categorizations, and anatomical correlates. Behavioral and Cognitive Neuroscience Reviews, 2, 261-277.