Strange fascinations: A brief look at unusual compulsive and addictive behaviours

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

Further reading

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.

That’ll do icily: A brief look at pagophagia

In a previous blog on five ‘weird addictions’ I briefly mentioned pagophagia, a craving and compulsion for chewing ice. Pagophagia is a type of pica (which I also covered in a previous blog). Pica is defined as the persistent eating of non-nutritive substances for a period of at least one month, without an association with an aversion to food. Although the incidence of pagophagia appears to have increased over the last 30 years in westernized cultures, Dr. B. Parry-Jones (in a 1992 issue of Psychological Medicine) carried out some historical research and pointed out that both Hippocrates and Aristotle wrote about the dangers of excessive intake of iced water. Parry-Jones also noted that references to disordered eating of ice and snow were also recorded in medical textbooks from the sixteenth century. However, the first contemporary reference to pagophagia appears to have been a 1969 paper by Dr. Charles Coltman in the Journal of the American Medical Association entitled ‘Pagophagia and iron lack’.

Pagophagia is closely associated with iron deficiency anemia but can also be caused by other factors (biochemical, developmental, psychological, and/or cultural disorders). If pagophagia is due to iron deficiency (such as case studies of those with sickle cell anemia), it may sometimes be accompanied by fatigue (e.g., being tired even when performing normally easy tasks). Dr. Youssef Osman and his colleagues published a number of case reports of pagophagia in a 2005 issue of the journal Pediatric Haematology and Oncology including the case of a child with sickle cell anemia and rectal polyps (that caused a lot of bleeding and made the anemia worse):

“An 8-year-old Omani boy, a known case of sickle cell anemia…presented with history of craving for ice. The child was noticed over the last 4 months to like drinking very cold water and to open the deep freezer and scratch the ice and eat it. The parents tried to stop him from doing so, but they failed…The child was started on oral iron therapy…and his craving for ice was completely stopped. Meanwhile, the rectal polyp was removed surgically”.

Other potential health side effects include constant headaches (a ‘brain freeze’ similar to ‘ice cream headache’) and teeth damage although this is thought to be relatively rare. However, a recent paper by Dr. Yasir Khan and Dr. Glen Tisman in the Journal of Medical Case Reports highlighted the case of a 62-year-old Caucasian man who presented with bleeding from colonic polyps associated with drinking partially frozen bottled water.

Khan and Tisman also suggested that some people who are deficient in iron experience tongue pain and glossal inflammation (glossitis). Others claim that chewing ice may help those with stomatitis (i.e., inflammation of the mucous lining inside the mouth). A recent 2009 case study published by Dr. Tsuyoshi Hata and his colleagues in the Kawasaki Medical Journal, reported the case of a 37-year old Japanese women who ate copious amounts of ice to relieve the pain of temporomandibular joint disorder (i.e., chronic pain in the joint that connects the jaw to the skull). Khan and Tisman also claim that the classical symptoms of pagophagia have changed in the last 40 years since Dr. Coltman’s initial paper in the Journal of the American Medical Association.

“This may probably be the result of advances in technology and changes in culture. When initially described [by Coltman], pagophagia was defined as the excessive ingestion of ice cubes from ice trays and the ingestion of ice scraped from the wall of the freezer. With the advent of ice cube makers and auto defrosters, the presentation of pagophagia has changed in a subtle manner as described in…our patients. Now we observe a subtler ingestion and/or sucking of ice cubes from large super-sized McDonald’s-like cups and from the use of popular bottled water containers that have been frozen”.

There have been few epidemiological studies examining the prevalence of pagophagia. Such estimates vary widely within particular populations but (according to Dr. Youssef Osman and his colleagues) have been shown to be more common in low socioeconomic and underdeveloped areas. Pagophagia is thought to be relatively harmless in itself or to one’s health, although there are some claims in the literature that pagophagia can be addictive. However, empirical reviews suggest that pagophagia (and pica more generally) is part of the obsessive-compulsive disorder spectrum of diseases. As a consequence, some case studies even suggest that ice chewing compromises their ability to maintain jobs or personal relationships.

Treatment for pagophagia can often be overcome with iron therapy and Vitamin C supplements (to supplement iron deficiency if that is the cause). For instance, Dr. Mark Marinella in a 2008 issue of the Mayo Clinic Proceedings successfully treated a 33-year old woman with pagophagia following complications with gastric bypass surgery:

“The patient received red blood cells, iron sucrose, and levofloxacin. On further questioning, the patient denied taking vitamin, mineral, or iron supplements since surgery and reported prolonged, heavy menstrual cycles. She consumed large amounts of ice daily for several months. The patient’s husband frequently observed her in the middle of the night with her head in the freezer eating the frost off the icemaker. The patient admitted to awakening several times nightly for months with an uncontrollable compulsion to eat the frost on the icemaker. This craving resolved after transfusion and iron administration”

However, if the condition is psychologically or culturally based, iron and vitamin supplements are unlikely to work, and other psychological treatments (such as cognitive-behavioural therapy) are likely to be employed.

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

Further reading

Coltman, C.A. (1969). Pagophagia and iron lack. Journal of the American Medical Association, 207, 513-516.

de Los Angeles, L., de Tournemire, R. & Alvin, P. (2005). Pagophagia: pica caused by iron deficiency in an adolescent. Archives of Pediatrics, 12, 215-217.

Edwards, C.H., Johnson, A.A., Knight, E.M., Oyemadej, U.J., Cole, O.J., Westney, O.E., Jones, S. Laryea, H. & Westney, L.S. (1994). Pica in an urban environment. Journal of Nutrition (Supplement), 124, 954-962.

Hata, T., Mandai, T., Ishida, K., Ito, S., Deguchi, H. & Hosoda, M. (2009). A rapid recovery from pagophagia following treatment for iron deficiency anemia and TMJ disorder accompanied by masked depression. Kawasaki Medical Journal, 35, 329-332.

Khan, Y. & Tisman, G. (2010). Pica in iron deficiency: A case series. Journal of Medical Case Reports, 4, 86. Located: http://www.jmedicalcasereports.com/content/4/1/86

Kirchner, J.T (2001). Management of pica: A medical enigma. American Family Physician, 63, 1177-1178.

Marinella, M. (2008). Nocturnal pagophagia complicating gastric bypass. Mayo Clinic Proceedings, 83, 961

Osman, Y.M., Wali, Y.A. & Osman, O.M. (2005). craving for ice and iron-deficiency anemia: a case series. Pediatric Hematology and Oncology, 22, 127-131.

Parry-Jones, B. (1992). Pagophagia, or compulsive ice consumption: A historical perspective. Psychological Medicine, 22, 561-571.

Flaw management: A brief psychological overview of Body Dysmorphic Disorder

Over the last few years, Body Dysmorphic Disorder (BDD) has become the focus of increasing media attention particularly in relation to being cited as one of the main reasons why people seek out cosmetic surgery, as well as being implicated in a wide variety of diverse medical and/or psychiatric conditions including people with eating disorders, obsessive-compulsive disorders, and apotemnophilia (i.e., the desire to be an amputee).

At its simplest level, BDD is a distressing, handicapping, and/or impairing preoccupation with an imagined or slight defect in body appearance that the sufferer perceives to be ugly, unattractive, and/or deformed (hence the recent upsurge in relation to those with an insistent desire for plastic surgery). BDD sufferers can think about their perceived defect for hours and hours every day. Other BDD sufferers may indeed have a minor physical abnormality, but the concern attached to it is regarded as grossly excessive. There are hundreds of published papers on BDD but most of this article is based on the writings and reviews of Dr Katharine Phillips (Professor of Psychiatry and Human Behavior, Warren Alpert Medical School of Brown University, USA) and the British psychiatrist Dr David Veale (The Priory Hospital North London).

People with BDD have been written about for more than 100 years and there has been a large increase in research into BDD over the last two decades. Like pathological gambling, the criteria for BDD changed quite radically between the publication of the American Psychiatric Association’s DSM-III (1980), and DSM-IV (1994). Until relatively recently, BDD used to be called ‘’dysmorphophobia’. In the DSM-III, BDD didn’t have any specified diagnostic criteria and was only mentioned as an example of an atypical somatoform disorder. In the revise edition of the DSM-III (1987), BDD became a separate disorder in the somatoform section. Subtle changes were then made to the DSM-IV criteria.

Arguably the most notable change was that the distinction between ‘delusional’ and ‘non-delusional’ BDD was diminished due to empirical evidence showing that the delusional and non-delusional variants of BDD may be variants of the same disorder (it should also be noted that in the World Health Organization’s International Classification Diseases (ICD-10), BDD is classified as a type of hypochondriacal disorder along with hypochondriasis, in the somatoform section). There is frequent comorbidity in BDD (e.g., social phobia, depression, suicidal ideation, and obsessive-compulsive disorder). In fact, almost all BDD sufferers engage in at least one compulsive behaviour such as compulsive checking of mirrors, excessive grooming and make-up application, excessive exercise, repeatedly asking other people how they look, compulsive buying of beauty products, and persistent seeking of cosmetic surgery. These behaviours can become potentially all encompassing and consuming, and like many addictive behaviours become unpleasurable and typically difficult to control or resist. The current DSM-IV diagnostic criteria for body dysmorphic disorder are that there is:

• Preoccupation with an imagined defect in appearance. If a slight physical anomaly is present, the person’s concern in markedly excessive;
• The preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning
• The preoccupation is not better accounted for by another mental disorder (e.g., dissatisfaction with body shape and size in Anorexia Nervosa)

Dr David Veale notes that among BDD sufferers, any body part may be the preoccupying focus. However, research has indicated that most BDDs involve skin, hair, or facial features (e.g., eyes, nose, lips) that the sufferer feels is flawed (e.g., acne), out of proportion and/or asymmetric. Research has also shown that the pre-occupying focus can change over time. Dr Veale speculates that this changing focus may explain why some people are never happy after cosmetic surgery procedures. Sufferers may repeatedly examine the ‘‘defect’’ that for some may become obsessive and/or compulsive.

A couple of empirical studies have reported the prevalence of BDD as 0.7% in the general population. The prevalence rate among other specific groups – such as adolescents and young adults – tend to be a little higher, and among some groups it is significantly higher. For instance, much higher prevalence rates of BDD have been reported among people wanting plastic surgery (5%) and among dermatology patients (12%).

Dr Veale notes there are very limited data on the risk factors associated with the development of BDD. Furthermore, those factors that have been associated with BDD may not be unique or specific to BDD (for instance, risk factors such as poor peer relationships, social isolation, lack of support in the family, and/or sexual abuse). Risk factors identified in BDD include:

• Genetic predispositions;
• Shyness, perfectionism, or an anxious temperament;
• Childhood adversity (e.g., teasing or bullying about appearance)
• A history of dermatological or other as an adolescent (e.g., acne) that has since been resolved.
• Being more aesthetically sensitive than average
• Greater aesthetic perceptual skills, manifested in their education or training in art and design.

Although there are various worldwide case studies, most published studies on BDD comprise people from Westernized societies. Dr Katharine Phillips and her colleagues claim there are no studies that have directly compared BDD’s clinical features across different countries or cultures but concluded that BDD studies from around highlighted there were more similarities than differences. Dr Phillips says that men and women had many similarities in these studies (demographic and clinical characteristics). She has also reported that both male and female BDD sufferers are equally likely to seek and receive dermatological and cosmetic treatment.

Dr Veale claims that although there are broad similarities between the genders there are some gender differences. For instance, men with BDD show a greater preoccupation with their genitals, and women with BDD are more likely to have a co-morbid eating disorder. Perhaps somewhat predictably, female BDD sufferers have a greater preoccupation with weight, hips, breasts, legs, and excessive body hair. They are also more likely than BDD males to conceal perceived defects with make-up, to check mirrors, and to pick at their skin. Male BDD sufferers have a greater preoccupation with muscle dysmorphia, and thinning hair. Compared to females, BDD males are more likely to be single, and have a substance-related disorder.

The most recent review by Dr Phillips and her colleagues concluded that: “Much more research is needed on all aspects of BDD. Advances in knowledge will likely lead to future refinements of this disorder’s diagnostic criteria and an increased understanding of the relationship between BDD’s delusional and non-delusional forms as well as BDD’s relationship to other psychiatric disorders”.

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

Further reading

Didie, E.R., Kuniega-Pietrzak, T., Phillips, K.A. (2010). Body image in patients with body dysmorphic disorder: evaluations of and investment in appearance, health/illness, and fitness. Body Image, 7, 66–69.

Kelly, M.M., Walters, C. & Phillips, K.A. (2010). Social anxiety and its relationship to functional impairment in body dysmorphic disorder. Behavor Therapy, 41, 143-153.

Mancuso, S., Knoesen, N. & Castle, D.J. (2010). Delusional vs nondelusional body dysmorphic disorder. Comprehensive Psychiatry, 51, 177-182.

Phillips, K.A. (2005). The Broken Mirror: Understanding and Treating Body Dysmorphic Disorder. New York: Oxford University Press.

Phillips, K.A. (2009). Understanding Body Dysmorphic Disorder: An Essential Guide. New York: Oxford University Press.

Phillips K.A. & Diaz, S.F. (1997). Gender differences in body dysmorphic disorder. Journal of Nervous and Mental Diseases, 185, 570–7.

Phillips, K.A., Wilhelm, S., Koran, L.M., Didie, E.R., Fallon, B.A., Jamie Feusner, J. & Stein, D.J. (2010). Body Dysmorphic Disorder: Some key issues for DSM-V. Depression and Anxiety, 27, 573-59.

Phillips, K.A., Menard, W. & Fay C. (2006). Gender similarities and differences in 200 individuals with body dysmorphic disorder. Comprehensive Psychiatry, 47, 77–87.

Phillips, K.A., Didie, E.R., Menard, W., et al. (2006). Clinical features of body dysmorphic disorder in adolescents and adults. Psychiatry Research, 141, 305–314.

Veale, D. (2004). Body dysmorphic disorder. Postgraduate Medical Journal, 80, 67-71.

Veale. D. (2004). Advances in a cognitive behavioural model of body dysmorphic disorder. Body Image, 1, 113-125.