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Die another day: A brief look at ‘addiction to near death’

In previous blogs I have examined both people’s fascination with death and human near death experiences (NDEs). Another aspect to NDEs that I didn’t mention in those articles was the idea of people being “addicted” to NDEs. Arguably, most people’s perceptions of ‘near death addiction’ are probably based on the 1990 US film Flatliners. In that film, a group of five medical students (played by Keifer Sutherland, Kevin Bacon, Julia Roberts, Oliver Platt and William Baldwin) attempt to examine whether there is anything beyond death by carrying out experiments into NDEs. Keifer Sutherland’s character (Nelson) is continually made to experience clinical death (i.e., flatlining with no heartbeat) before being brought back to life by his classmates.

This Hollywood portrayal of possible ‘near death addiction’ bears little resemblance to the academic literature – most of which has been written from a psychodynamic perspective – and relates more to continual self-destructive experiences (usually by adolescents or young adults). The concept of ‘addiction to near death’ (ATND) originates from the writings of Dr. Betty Joseph, a distinguished psychoanalytic clinician often lauded as “the psychoanalysts’ psychoanalyst” and known for her work with highly resistant ‘difficult to treat’ patients. Dr. Joseph first wrote about the ‘addiction to near death’ concept in a 1982 issue of the International Journal of Psychoanalysis. This form of masochistic pathology was a concept that she found useful when working with psychologically dysfunctional adolescents. As Dr. Janet Shaw noted in a more recent 2012 paper on ATND in the Journal of Child Psychotherapy:

“At [the adolescent] stage of development, there is a tendency for adolescents who are troubled to turn to destructive or self-destructive behaviour, suicidal ideation, self-harm, self-starvation and inappropriate sexual behaviour. This is often profoundly shocking and alarming to others, especially if the young person finds the impact on others pleasurable. [Betty] Joseph described a patient addicted to near death as being caught up in a wish to gain pleasure by destroying both himself and the analytic relationship…[She] described masochistic destruction of the self taking place with libidinal satisfaction, despite much concomitant pain. The masochistic position is deeply addictive and this way of using pain for the purposes of pleasure becomes habitual. She summed this up as, ‘the sheer unequalled sexual delight of the grim masochism’ and described the awful pleasure that is achieved in this way”.

However, as Dr. Shaw rightly points out, not all types of destructive and self-destructive behaviour fall into such a category. In her 1982 paper, Dr. Joseph outlined case studies she had treated psychoanalytically from her private practice. Here, she described the masochistic dynamics of her patients, and how hard it was for them to alter these dynamics and get better. She noted that one of the key aspects of the dynamics she described was that her patients derived immense libidinal satisfaction from engaging in destructive near-death behaviours. More specifically, she wrote:

“There is a very malignant type of self-destructiveness, which we see in a small group of our patients, and which is, I think, in the nature of an addiction – an addiction to near-death. It dominates these patients’ lives; for long periods it dominates the way they bring material to the analysis and the type of relationship they establish with the analyst; it dominates their internal relationships, their so-called thinking, and the way they communicate with themselves. It is not a drive towards a Nirvana type of peace or relief from problems, and it has to be sharply differentiated from this. The picture that these patients present is, I am sure, a familiar one – in their external lives these patients get more and more absorbed into hopelessness and involved in activities that seem destined to destroy them physically as well as mentally, for example, considerable over-working, almost no sleep, avoiding eating properly or secretly over-eating if the need is to lose weight”.

In a 2006 issue of Psychanalytic Psychology, Dr. William Gottdeiner also noted that the ATND is such a strong motive that successful treatment of such individuals is unusually difficult. However, Dr. Gottdeiner asserted that one of the severe weaknesses of Joseph’s writings is that she failed to provide in-depth clinical examples of anyone who had engaged in potentially deadly activities. This, Gottdeiner contended, threatened the validity of the ATND construct. Despite such inherent weaknesses, Gottdeiner still believed the ATND construct had strong face validity (i.e., “there are people who seem to repeatedly engage in potentially lethal behavior, making the ATND construct plausible”). Consequently, Gottdeiner tested the construct validity of ATND on females with substance use disorders (SUDs). His argument was that:

“If individuals who are diagnosed with an SUD are successfully treated and they continue to engage in potentially deleterious behavior, then that finding would support the notion that the individual has an addiction to near-death experiences, and that the individual’s substance abuse was a comorbid disorder”.

Gottdeiner’s paper attempted to validate the ATND construct via secondary analysis “of data from a treatment outcome study of individuals who were in residential therapeutic community treatment for SUDs and who received simultaneous safe-sex education during treatment”. His study findings showed that despite safe-sex education and sexual activity in the therapeutic communities being prohibited, that some of the participants still engaged in risky sexual behaviour (irrespective of whether their sexual partners were HIV-positive or not). Gottdeiner argued that these findings tentatively supported the ATND construct. However, Gottdeiner was the first to admit that his study had inherent weaknesses. As he noted:

The limitations were: data were from retrospective self-reports [and] contained no baseline measures of sexual activity, safe-sex knowledge, condom use, HIV status; it had no male participants, no specific questions about near-death behavior, nor whether alternative safe-sex activities were practice…The limitations of [the] study are considerable, and some might even argue that the connection between the ATND construct and the data presented herein is too much of a stretch to be scientifically useful…Obviously, stronger data would lead to stronger conclusions. Despite the limitations of this study, the findings should motivate clinicians to more seriously consider the existence of an addiction to near-death in their clients”.

More recently, Dr. Janet Shaw examined the ATND construct through the description and evaluation of an in-depth case study account of an adolescent female (‘Susan’). Her paper explored “the way in which pleasure, which is sadistic and masochistic in nature, is associated with cruelty towards the self or others in adolescence”. Dr. Shaw wrote that it felt as if Susan’s main aim was to torment her. As Shaw reported:

“In addition to suicide threats, similar to those she made in the assessment, she made constant reference to systematically starving herself. She was painfully thin, although not actually anorexic and she was poisoning herself by repeatedly taking paracetamol. Susan’s threats to self-harm had a deeply disturbing quality and she clearly enjoyed making them. There was a wish to punish me, as well as herself, through her phantasised attacks…The case material is an example of an adolescent girl with ‘an addiction to near death’ constituting a dominant way of relating to others. Her relentless and manipulative references to self-harm, suicide and dangerous behaviour at various stages of the work were designed to shock and alarm…Susan’s self-destructive behaviour was also continuing in relation to her self- starvation. She said she took laxatives in an attempt to lose more weight. She was becoming dangerously thin and three years into her psychotherapy an appointment with the referring psychiatrist resulted in a diagnosis of anorexia nervosa”.

This quote doesn’t do justice to the very detailed account that Dr. Shaw provided in her lengthy paper. However, her written account is heartfelt and brutally honest. Shaw concludes that the compelling power of addiction overviewed in Susan’s case mustn’t be underestimated. As she notes:

“The narcissistic idealisation of sadistic and masochistic behaviour offers some protection from fear and terror for the patient, but the consequence is to severely limit capacity for thought and imagination, and to restrict awareness. ‘Addition to near death’ forms a small but significant component of the clinical casework of a child and adolescent psychotherapist: it is hoped that Susan’s case material serves to illuminate the phenomenon further and its technical challenges”.

Whether the clinical case of Susan provides any more evidence for validation for Joseph’s ATND construct than the more empirical work of Gottdeiner is debatable. However, this is certainly a fascinating – if somewhat harrowing – area of clinical and academic work that certainly warrants further empirical examination.

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

Further reading

Gottdiener, W.H. (2006). A preliminary test of the Addiction-to-Near-Death construct. Psychoanalytic Psychology, 23, 661-666.

Joseph, B. (1982). Addiction to near death. International Journal of Psychoanalysis, 449-456.

Joseph, B. (1988). Addiction to near death. In Bott Spillius, E. (Ed.) Melanie Klein Today (pp.311-323). London and New York: Routledge.

Ryle, A. (1993). Addiction to the death instinct? A critical review of Joseph’s paper ‘Addiction to near death’. British Journal of Psychotherapy, 10, 88–92.

Shaw, J. (2012). Addiction to near death in adolescence. Journal of Child Psychotherapy, 38, 111-129.

Eat to the beat: What is the relationship between exercise addiction and eating disorders?

In previous blogs I briefly examined both exercise addiction and eating addiction. However, there is some research that these two disorders sometimes co-occur. In some of the papers I have co-written we have reviewed the evidence as to whether exaggerated exercise behaviour is a primary problem in the affected person’s life or whether it emerges as a secondary problem in consequence of another psychological dysfunction. In the former case, the dysfunction is usually classified as primary exercise addiction because it manifests itself as a form of behavioural addiction. In the latter case, it is usually termed as secondary exercise addiction because it co-occurs with another dysfunction, typically with eating disorders, such as anorexia nervosa or bulimia nervosa.

In primary exercise addiction, the motive for over-exercising is typically geared toward avoiding something negative, although the affected individual may be totally unaware of their motivation. It is a form of escape response to a source of disturbing, persistent, and uncontrollable stress. However, in the case of a secondary exercise addiction, the excessive exercise is used as a means of weight loss (in addition to very strict dieting). Thus, secondary exercise addiction has a different etiology than primary exercise addiction. Nevertheless, it should be highlighted that many symptoms and consequences of exercise addiction are similar whether it is a primary or a secondary exercise addiction. The distinguishing feature between the two is that in primary exercise addiction, the exercise is the main objective, whereas in secondary exercise addiction, weight loss is the main objective, while exaggerated exercise is one of the primary means in achieving the objective.

In a qualitative study published by Dr Diane Bamber (University of Cambridge), she and her team interviewed 56 regularly exercising adult women. On the basis of the analysis of the results, the authors identified three factors in the diagnostic criteria of secondary exercise addiction. Among these factors, only the presence of eating disorder symptoms differentiated secondary from primary exercise addiction. The other two factors (i.e., dysfunctional psychological, physical, or social behaviour, and the presence of withdrawal symptoms) were nonspecific to secondary exercise addiction.

However, Dr Michelle Blaydon (formerly of the University of Hong Kong) and colleagues attempted to further sub-classify secondary exercise addiction based on the primary source of the problem, which in their view was related to either a form of eating disorder or to an exaggerated preoccupation with body image. Although this appears to have face validity, to date, there is no empirical evidence for such speculation. Furthermore, a different research study by Dr Diane Bamber found no evidence for primary exercise addiction. In fact, they believe that all problematic exercise behaviours are linked to eating disorders. However, this view remains critically challenged in the literature and there are documented case studies – including one that I published myself back in 1997 where no eating disorders were present at all.

In addition to several studies that have reported disordered eating behaviour often (if not always) accompanied by exaggerated levels of physical exercise, the reverse relationship has also been established. Individuals affected by exercise addiction often (but not always) show an excessive concern about their body image, weight, and control over their diet. This co-morbidity makes it difficult to establish which is the primary disorder. This dilemma has been investigated using trait and personality-oriented investigations. In an early but widely cited controversial study led by Dr Alayne Yates (University of Hawaii) concluded that addicted male long-distance runners resembled anorexic patients on a number of personality dispositions (e.g., introversion, inhibition of anger, high expectations, depression, and excessive use of denial) and labelled the similarity as the “anorexia analogue” hypothesis.

To further test the hypothesis, Yates and colleagues examined the personality characteristics of 60 male obligatory exercisers and then compared their profiles with those of clinical patients diagnosed with anorexia nervosa. While the study did not lend support to the hypothesis, the authors claimed that running and extreme dieting were both dangerous attempts to establish an identity, as either addicted to exercise or anorexic. The study has been criticized for a number of shortcomings, including the lack of supporting data, poor methodology, lack of relevance to the average runner, over-reliance on extreme cases or individuals, and exaggerating the similarities between the groups.

Indeed, later investigations also failed to reveal similarities between the personality characteristics of people affected by exercise addiction and those suffering from eating disorders. Therefore, the anorexia analogue hypothesis has failed to secure empirical support. Numerous studies have further examined the relationship between exercise addiction and eating disorders but no consensus has emerged. One reason for the inconsistent findings may be attributed to the fact that the extent of co-morbidity could vary from case to case depending on personality predispositions, the underlying psychological problem that has led to exercise addiction, and/or the interaction of the two, as well as the form and severity of the eating disorder.

A French study led by Professor Michel Lejoyeaux (Bichat and Maison Blanche Hospital) on 125 Parisian male and female current exercise addicts reported that 70% of their sample were bulimic. In another US study by Dr Patricia Estok and Dr Ellen Rudy among 265 young American adult women runners and non-runners, 25% of those who ran more than 30 miles per week showed a high risk for anorexia nervosa. In studies of people with eating disorders, a study by Peter Lewinsohn (Oregon Research Institute, US) found excessive exercise activity among males with binge eating disorders, but not females. However, the percentage overlap was not reported. Finally, in a review by Marilyn Freimuth (Fielding Graduate University, US), she and her colleagues reported that among people with eating disorders, 39% to 48% also experienced an exercise addiction.

Basically, the major weakness of the literature is the complete lack of large-scale studies. In a recent review of the addiction co-morbidity literature that I did with Dr Steve Sussman and Nadra Lisha (University of Southern California), we didn’t locate a single study on the co-occurrence of exercise addiction with other disorders with a sample size of more than 500 participants.

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

Further reading

Bamber, D.J., Cockerill, I.M., Rodgers, S., & Carroll, D. (2003). Diagnostic criteria for exercise dependence in women. British Journal of Sports Medicine, 37(5), 393–400.

Berczik, K., Szabó, A., Griffiths, M.D., Kurimay, T., Kun, B. & Demetrovics, Z. (2012). Exercise addiction: symptoms, diagnosis, epidemiology, and etiology. Substance Use and Misuse, DOI: 10.3109/10826084.2011.639120.

Blaydon, M.J., & Lindner, K. J. (2002). Eating disorders and exercise dependence in triathletes. Eating Disorders, 10(1), 49-60.

Blaydon, M.J., Lindner, K. J., & Kerr, J. H. (2004). Metamotivational characteristics of exercise dependence and eating disorders in highly active amateur sport participants. Personality and Individual Differences, 36(6), 1419-1432.

Estok, P.J., & Rudy, E.B. (1996). The relationship between eating disorders and running in women. Research in Nursing & Health, 19, 377-387.

Freimuth, M., Waddell, M., Stannard, J., Kelley, S., Kipper, A., Richardson, A., & Szuromi, I. (2008). Expanding the scope of dual diagnosis and co-addictions: Behavioral addictions. Journal of Groups in Addiction & Recovery, 3, 137-160.

Griffiths, M. D. (1997). Exercise addiction: A case study. Addiction Research, 5, 161-168.

Lejoyeux, M., Avril, M., Richoux, C., Embouazza, H., & Nivoli, F. (2008). Prevalence of exercise dependence and other behavioral addictions among clients of a Parisian fitness room. Comprehensive Psychiatry, 49, 353-358.

Lewinsohn, P.M., Seeley, J.R., Moerk, K.C., & Striegel-Moore, R.H. (2002). Gender differences in eating disorder symptoms in young adults. International Journal of Eating Disorders, 32, 426-440.

Sussman, S., Lisha, N. & Griffiths, M.D. (2011). Prevalence of the addictions: A problem of the majority or the minority? Evaluation and the Health Professions, 34, 3-56.

Szabo, A. (2010). Addiction to exercise: A symptom or a disorder? New York, NY: Nova Science Publishers.

Yates, A., Leehey, K., & Shisslak, C. M. (1983). Running – an analogue of anorexia? New England Journal of Medicine, 308(5), 251-255.

A glutton for reward (rather than punishment)? A brief psychological overview of excessive and addictive eating

In a previous article in this blog on shopping addictions, it was highlighted that the form of excessive or addictive behaviour someone develops may depend upon gender. As I noted in that article, men are more likely to be addicted to drugs, gambling and sex whereas women are more likely to suffer from ‘mall disorders’ such as eating and shopping. Food is – of course – a primary reward as it is necessary for our survival. However, it is this reward that gives highly palatable food (such as sugar) its addictive potential, leading to excessive eating as an addictive behaviour. Possible reasons behind such excessive eating in today’s society are many, including the increasing availability of food, a more inactive lifestyle, and financial considerations. Furthermore, as a means of mood enhancement, food is highly rewarding, easily available, low-cost and most of all it is legal!

Such justifications demonstrate some degree of explanatory power, contributing to research into the topic of excessive eating as an area of increasing interest. However, no such explanations address the critical question of why certain people seem to overeat, despite repeated efforts not to. The majority of obese cases tend to result from an over-consumption of energy, independent from a lack of physical activity. Therefore it may be people, rather than food, that need to be of focus here.

Prevalence rates for excessive and addictive eating are highly variable. Past year prevalence rates of eating disorders (particularly binge eating disorder, among older teens and adults typically varies between 1 to 2% but much higher figures have been reported in a variety of studies in a number of different countries (between 6% and 15% depending upon the sample). Based on these many studies that included samples of at least 500 participants, Professor Steve Sussman, Nadra Lisha (both at the University of Southern California) and myself estimated a past year prevalence rate of 2% for eating addiction among general population U.S. adults.

Reward sensitivity is a personality construct of Jeffrey Gray’s Reinforcement Sensitivity Theory, and is thought to control approach behaviour, by means of the dopamine reward centre. Individuals that are highly sensitive to reward are more prone to detect signals of reward in their environment (such as food) resulting in approaching these rewards more frequently, along with responding quicker and more strongly. Research demonstrates associations between reward sensitivity and increased food cravings, body weight, binge eating, and a preference for high fat food. Such findings offer a possible explanation for why only some individuals eat excessively when reward, particularly that produced by food, is a process available to all.

An excessive appetite for food has long been linked to emotional eating with research demonstrating that refined food addicts specifically report eating when they feel anxious. For instance, this is demonstrated in the eating habits of overweight Americans, revealing that women tend to binge eat when they feel lonely or depressed, while men overeat in positive social situations. Research dating back to the early 1990s found that women being treated for eating disorders described feeling less anxious as an episode of binge eating went on. Such research suggests that highly anxious people are more likely to turn to food for comfort, leading to excessive eating, yet in turn cause themselves more anxiety when this comfort is unavailable. For instance, this is demonstrated in the eating habits of overweight Americans, revealing that women tend to binge eat when they feel lonely or depressed, while men overeat in positive social situations.

Research has shown that obese people score higher on impulsiveness personality scales. Impulsivity is a tendency to ‘act on the spur of the moment’, often associated with a failure to learn from negative experience, wherein individuals know the appropriate way to behave but fail to act accordingly. Refined food addicts eat for a ‘pick-me-up’, although they are aware that they are not hungry, suggesting a correlation between reward sensitivity and impulsive reactions to such reward cues. Impulsive individuals have a tendency to react to stress and anxiety, with a craving for immediate satisfaction as a form of relief. Although eating may deliver this reward or relief, it may then condition impulsive individuals to react quickly, with this inapt response, to such feelings in the future; such as with feelings of hunger when feeling anxious. This could explain why repeated attempts to restrict food intake and lose weight, so often results in relapse in obese people.

Associations have also been observed between self-esteem and a variety of excessive eating behaviour populations, such as restrained eaters, bulimic patients, and binge eaters. One explanation for this suggests that individuals with low self-esteem have lower expectations for personal performance, resulting in less effort being made to resist challenges and temptations to their diets. This offers another explanation that individuals with low self-esteem depend more on external cues to control eating, such as how food looks, rather than internal cues, such as hunger, indicating reward sensitivity and resulting in dieters with low self-esteem overeating. Here, low self-esteem combined with reward sensitivity and its further correlations to impulsivity and anxiety, seem to demonstrate a destructive model of influence on behaviour, one trait further amplifying the next leading to continuous eating to excess.

In relation to low self-esteem, low social desirability has been seen to correlate significantly with restrained eating in obese people. High social desirability is most commonly associated with a desire for thinness. Therefore, although an association with eating behaviour exists, high social desirability is more likely to correlate with anorexic behaviours as opposed to excessive eating. Low social desirability, combined with low self-esteem as a cause or effect, could contribute to explaining excessive eating in some individuals, which in turn could be reasoned by contributions of all traits previously mentioned.

Finally, Professor Elizabeth Hirschman at Rutgers University has proposed a general model of addictive consumption that interrelates excessive and compulsive consumption behaviour. This model suggests similar characteristics people exhibit, along with common causes, patterns of development, and the similar functions such behaviours serve for individuals. Many of these have been previously associated with excessive eating in particular, further suggesting a general consumption personality principle.

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

Further reading

Davenport, K., Houston, J. & Griffiths, M.D. (2012). Excessive eating and compulsive buying behaviours in women: An empirical pilot study examining reward sensitivity, anxiety, impulsivity, self-esteem and social desirability. International Journal of Mental Health and Addiction, DOI 10.1007/s11469-011-9332-7.

Davis, C., Levitan, R. D., Smith, M., Tweed, S. & Curtis, C. (2006) Associations among overeating, overweight, and attention deficit/hyperactivity disorder: A structural equation modelling approach. Eating Behaviors, 7, 266–274.

Hirschman, E.C. (1991) Recovering from drug addiction: A phenomenological account. In Sherry, J.F and Sternthal, B (Eds.), Advances in Consumer Research. Association for Consumer Research, 18, 541-549.

Hodgson R.J., Budd R. & Griffiths M. (2001). Compulsive behaviours (Chapter 15). In H. Helmchen, F.A. Henn, H. Lauter & N. Sartorious (Eds) Contemporary Psychiatry. Vol. 3 (Specific Psychiatric Disorders). pp.240-250. London: Springer.

Sussman, S., Lisha, N. & Griffiths, M.D. (2011). Prevalence of the addictions: A problem of the majority or the minority? Evaluation and the Health Professions, 34, 3-56.

Trinko, R., Sears, R. M., Guarnieri, D. J. & DiLeone, R. J. (2007) Neural mechanisms underlying obesity and drug addiction. Physiology & Behavior, 91, 499–505.