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Bog standard: A brief look at toilet tissue eating

In previous blogs I have looked at pica (i.e., the eating of non-nutritive items or substances) and subtypes of pica such as geophagia (eating of soil, mud, clay, etc.), pagophagia (eating of ice), acuphagia (eating of metal), and coprophagia (eating of faeces). It wasn’t until I started to research on specific sub-types of pica, that I discovered how many different types of non-food substances had been identified in the academic and clinical literature. For instance, Dr. V.J. Louw and colleagues provided a long list in a 2007 issue of the South African Medical Journal including cravings for the heads of burnt matches (cautopyreiophagia), cigarettes and cigarette ashes, paper, starch (amylophagia), crayons, cardboard, stones (lithophagia), mothballs, hair (trichophagia), egg shells, foam rubber, aspirin, coins, vinyl gloves, popcorn (arabositophagia), and baking powder. Most of these are generally thought to be harmless but as Louw and colleagues note, a wide range of medical problems have been documented:

“These include abdominal problems (sometimes necessitating surgery), hypokalaemia, hyperkalaemia, dental injury, napthalene poisoning (in pica for toilet air-freshener blocks), phosphorus poisoning (in pica for burnt matches), peritoneal mesothelioma (geophagia of asbestos-rich soil), mercury poisoning (in paper pica), lead poisoning (in dried paint pica and geophagia), and a pre-eclampsia-like syndrome (baking powder pica)”.

In the clinical literature, the eating of paper has been occasionally documented (although anecdotal evidence suggests this is fairly common and I remember doing it myself as a child). A review paper on pica by Dr. Silvestre Frenk and colleagues in the Mexican journal Boletín Médico del Hospital Infantil de México highlighted dozens of pica-subtypes and created many new names for various pica sub-types. They proposed that people who eat paper display ‘papirophagia’ (in fact if you type ‘papirphagia’ into Google, you only get one hit – the paper by Silvestre and colleagues – although this blog may make it two!). Eating paper is not thought to be particularly harmful although I did find a case of mercury poisoning because of ‘paper pica’ (as the authors – Dr. F. Olynk and Dr. D. Sharpe – called it) in a 1982 issue of the New England Journal of Medicine.


One sub-type of papirophagia is the eating of toilet paper. As far as I am aware, there is only one case study in the literature and this was published back in 1981, Dr. J. Chisholm Jr. and Dr. H. Martín in the Journal of the National Medical Association. They described the case of a 37-year old black woman with an “unusually bizarre craving” for toilet tissue paper. The authors reported that:

“[The] woman was referred for evaluation of disturbed smell and loss of taste for over one year. These were associated with chronic fatigue and listlessness. During this same period of time, she rather embarrassedly admitted to an overwhelming desire to eat toilet tissue. Frequently, she would awaken at night and dash to her bathroom to eat toilet tissue. No other type(s) of pica were admitted. In addition, she gave a long history of menorrhagia and frequently passed vaginal blood clots during her menses. Her libido was normal and there was no history of poor wound healing, skin or mucous membrane lesions, or intestinal symptoms. Her dietary history suggested a high carbohydrate diet, and due to a mild exogenous obesity she intermittently resorted to a vegan-like diet that included beans and various seeds”

A variety of medical tests were carried out and she was diagnosed with combined iron and zinc deficiency. She was treated with iron and zinc tablets and within a week, both her taste and smell had returned, and her energy levels greatly improved. Zinc deficiencies can lead to a wide variety of clinical disorders including loss of small and taste, anorexia, dwarfism (i.e., growth retardation), impaired wound healing, and geophagia. The woman’s (sometimes) vegan diet may have been to blame for her zinc deficiency as the authors noted that:

Although vegetables contain zinc, vegans should be made aware that zinc from plant sources is not readily absorbed because naturally occurring phytates, particularly high in beans and seeds, reduce zinc gastrointestinal absorption. Carbohydrates are very poor sources of zinc. Chronic iron deficiency secondary to chronic menorrhagia accounts well for the anemia, fatigue, and unusual pica for toilet tissue noted in this patient”.

Paper pica has occasionally been mentioned in other academic papers although details have typically been limited. For instance, a 1995 paper in the journal Birth by Dr. N.R. Cooksey on three cases of pica in pregnancy reported that one of the women chewed non-perfumed blue toilet paper during the first trimester of her pregnancy (and was forced by her mother to stop). There was also a 2003 paper published by Dr. Dumaguing in the Journal of Geriatric Psychiatry and Neurology examining pica in mentally ill geriatrics. One of the cases mentioned was a 76-year old patient that not only ingested their medication (an emollient cream for arthritis) but was also recorded eating toilet paper, napkins, Styrofoam cups, crayons, and other patients’ medications.

A more recent 2008 paper by Dr. Sera Young and her colleagues in the journal PLoS ONE, critically reviewed procedures and guidelines for interviews and sample collection in relation to pica substances. In describing the protocols involved, they referred to paper pica in the questions that should be asked:

“What is the local name, brand name, or type of pica substance desired or consumed? This will help others to know if this substance has already been studied and assist interested researchers in obtaining subsequent samples at a later date. Furthermore, different manufactured products may contain different materials, e.g. Crayola chalkboard chalk contains slightly different ingredients from other brands. Similarly, the consequences of toilet tissue paper consumption are different from those of eating pages of a novel; information would be lost if the substance was simply described as paper. For these reasons, the substance consumed should be described in as much detail and as accurately as possible”.

Personally (and based on anecdotal evidence), I think that papirophagia is not overly rare (especially among children – although I admit this may be more out of curiosity that craving) but the clinical literature suggests that it is a fairly rare disorder found amongst distinct sub-groups (pregnant women, the mentally ill). Given the fact that for most people eating paper would not cause any problems, this would provide the main reason why so few cases end up seeking medical, clinical, and/or psychological help.

Dr Mark Griffiths, Professor of Behavioural Addiction, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Further reading

Chisholm Jr, J. C., & Martín, H. I. (1981). Hypozincemia, ageusia, dysosmia, and toilet tissue pica. Journal of the National Medical Association, 73(2), 163-164.

Cooksey, N.R. (1995). Pica and olfactory craving of pregnancy: How deep are the secrets? Birth, 22, 129-137.

Dumaguing, N.I., Singh, I., Sethi, M., & Devanand, D.P. (2003). Pica in the geriatric mentally ill: unrelenting and potentially fatal. Journal of Geriatric Psychiatry and Neurology, 16, 189-191.

Frenk, S., Faure, M.A., Nieto, S. & Olivares, Z. (2013). Pica. Boletín Médico del Hospital Infantil de México, 70(1), 55-61

Louw, V.J., Du Preez, P., Malan, A., Van Deventer, L., Van Wyk, D., & Joubert, G. (2007). Pica and food craving in adults with iron deficiency in Bloemfontein, South Africa. South African Medical Journal, 97, 1069-1071.

Olynyk, F., & Sharpe, D. H. (1982). Mercury poisoning in paper pica. The New England Journal of Medicine, 306, 1056 -1057.

Young, S.L., Wilson, M.J., Miller, D., Hillier, S. (2008). Toward a comprehensive approach to the collection and analysis of pica substances, with emphasis on geophagic materials. PLoS ONE, 3(9), e3147. doi:10.1371/journal.pone.0003147

Sporn again: A brief look at the evolution of ‘metrosexuality’

Back in 1994, the journalist Mark Simpson coined the term ‘metrosexual’ in an article in the British newspaper The Independent. The Wikipedia entry on metrosexuality notes:

“Metrosexual is a neologism, derived from metropolitan and heterosexual, coined in 1994 describing a man (especially one living in an urban, post-industrial, capitalist culture) who is especially meticulous about his grooming and appearance, typically spending a significant amount of time and money on shopping as part of this. The term is popularly thought to contrast heterosexuals who adopt fashions and lifestyles stereotypically associated with homosexuals, although, by definition given by [Mark Simpson], a metrosexual ‘might be officially gay, straight or bisexual’”

To be honest, I had never come across the term metrosexual until 2005 (although I was well aware of the male grooming, vain, image conscious, and product-consuming males typified by ex-footballer David Beckham). I was doing some consultancy with an online poker firm about different types of poker player and the press campaign that followed the publication of my report was headlined ‘betrosexuals’ (because it highlighted gender swapping by online poker players – an area that I then went on to research more academically – see ‘Further reading’ below). It was only at this point I was told that ‘betrosexual’ was a play on the word ‘metrosexual’.

The reason I mention all of this is because earlier today I did a BBC radio interview about the rise of the ‘spornosexual’ (yet another term I had never heard of until I was asked to appear on the programme). ‘Spornosexual’ is another term coined by Mark Simpson (as noted in the Wikipedia entry):

“A neologism combining sports, porn, and metrosexual, and used to describe an aesthetic adopted by many men who consume both sports and pornography. The spornosexual style emphasises heavy, lean musculature, and certain kinds of tattooing. The term entered the popular lexicon through a 2014 Daily Telegraph article by Mark Simpson…In 2006, Mark Simpson already wrote about ‘sporno’ for Out Magazine: ‘whole new generation of young bucks, from twinky soccer players like Manchester United’s Alan Smith and Cristiano Ronaldo to rougher prospects like Chelsea’s Joe Cole and AC Milan’s Kaká, keen to emulate their success, are actively pursuing sex-object status in a postmetrosexual, increasingly pornolized world”.

In short (and according to an article in the Washington Post), spornosexuals are simply the “hyper-sexualized, body-obsessed cultural offspring of the metrosexual”.To be honest, reading this definition makes me think that ‘spornosexuals’ have been around for a few decades now as these types of men were well described at length by Bret Easton Ellis in his 1991 novel American Psycho (minus the tattooing). Simpson claimed in his recent article in the Daily Telegraph that metrosexuality had evolved and that the “new wave” had put the ‘sexual’ into ‘metrosexuality’, had become “totally tarty”, and that such men should be called ‘spornosexuals’. More specifically, Simpson claimed:

“With their painstakingly pumped and chiselled bodies, muscle-enhancing tattoos, piercings, adorable beards and plunging necklines it’s eye-catchingly clear that second-generation metrosexuality is less about clothes than it was for the first. Eagerly self-objectifying, second generation metrosexuality is totally tarty. Their own bodies (more than clobber and product) have become the ultimate accessories, fashioning them at the gym into a hot commodity – one that they share and compare in an online marketplace. This new wave puts the ‘sexual’ into metrosexuality. In fact, a new term is needed to describe them, these pumped-up offspring of those Ronaldo and Beckham lunch-box ads, where sport got into bed with porn while Mr Armani took pictures. Let’s call them “spornosexuals”…Glossy magazines cultivated early metrosexuality. Celebrity culture then sent it into orbit. But for today’s generation, social media, selfies and porn are the major vectors of the male desire to be desired. They want to be wanted for their bodies, not their wardrobe. And certainly not their minds”

I tracked down Simpson’s 2006 article on ‘sporno’ published in Out magazine in which he claimed sport was the “new gay porn” because (for instance) footballers like David Beckham and Freddie Ljungberg had posed for gay magazines. He also made reference to metrosexual Gavin Henson (“rugby’s answer to David Beckham”) who loves shaving his legs and wears fake tan on the pitch. Simpson claimed:

“Sporno-sport that acknowledges and exploits the voyeuristic, usually homoerotic, thrill that fit male bodies throwing themselves against other fit male bodies can generate is already the acceptable, ruddy-cheeked outdoor-broadcasting face of porn. At least in soccer- and rugby-playing pagan Europe and Australia but it can be only a matter of time before it conquers the God-fearing, football-playing United States too…Being equal opportunity flirts, today’s sporno stars want to turn everyone on. Partly because sportsmen, like porn stars, are by definition show-offs, but more particularly because it means more money, more power, more endorsements, more kudos. It acknowledges the consumerist, showbiz direction that sport is moving in and engorges and inflates their career portfolio to gargantuan proportions”.

Simpson asserted that Beckham was a household name in America because he was a sporno star (rather than sports star) due to his high profile body adorning adverts and fetishizing himself. Beckham’s masculinity had become commodified, and in our highly consumerist culture “envy and desire are almost indistinguishable”. As a father of two sons and a daughter, I do worry how the perfect body images they see in the print and broadcast media may affect their own self-esteem. Although I had often thought about the pursuit of bodily perfection in terms of my daughter’s adolescent development, it’s not something I had thought about in relation to my sons. As a psychologist that specializes in addictive and obsessive behaviour, I am only too aware of the rise in male eating disorders, but the rise of the metrosexual is likely to be a contributory factor. In the Washington Post article on spornosexuality, the journalist Abby Phillip interviewed the branding expert (and author of the 2006 book The Future of Men) Marian Salzman. Salzman claimed that metrosexuality had indeed involved but not in the way that Simpson hoped:

“The word metrosexual has outgrown Simpson’s narcissistic depiction and now transcends narrow stereotypes to describe a whole range of traits. And the metrosexuals themselves are now men who don’t unquestioningly assume that there’s just one way of being a man”.

Based on what I have read so far, I don’t think that the term ‘spornosexuality’ will catch the public’s imagination in the same way as metrosexuality (in fact, I’m yet to be convinced that spornosexuality is significantly different from metrosexuality). That doesn’t mean the stereotypes attributed to such a term don’t exist. However, the jury is out on if there will be any long-lasting psychological consequences of identifying oneself as a spornosexual.

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

Further reading

Daily Mirror (2005). Betrosexuals. August 12. Located at:

Griffiths, M.D., Parke, J., Wood, R.T.A. & Rigbye, J. (2010). Online poker gambling in university students: Further findings from an online survey. International Journal of Mental Health and Addiction, 8, 82-89.

Phillip. A. (2014). Step aside, metrosexuals, and make way for…the spornosexual man? Washington Post, June 10. Located at:

Salzman, M. (2006). The Future of Men: The Rise of the Übersexual and What He Means for Marketing Today. London: Palgrave.

Simpson, M. (2006). Sporno. Out, June 19. Located at:,0

Simpson, M. (2014). The metrosexual is dead. Long live the ‘spornosexual’. Daily Telegraph, June 10. Located at:

Wikipedia (2014). Metrosexual. Located at:

Wikipedia (2014). Spornosexual. Located at:

Wood, R.T.A., Griffiths, M.D. & Parke, J. (2007). The acquisition, development, and maintenance of online poker playing in a student sample. CyberPsychology and Behavior, 10, 354-361.

Give me strength: Muscle Dysmorphia as an addiction

Muscle Dysmorphia (MD) describes a condition characterised by a misconstrued body image in individuals interpret their body size as both small and weak even though they may look normal or even be highly muscular. Those experiencing the condition typically strive for maximum fat loss and maximum muscular build. MD can have potentially negative effects on thought processes including depressive states, suicidal thoughts, and in extreme cases, suicide attempts. These negative psychological states have also been linked with concurrent use of Appearance and Performance Enhancing Drugs (APED) including Anabolic Androgenic Steroids (AAS).

MD was originally categorised in 1993 by Dr. H.G. Pope and colleagues (in the journal Comprehensive Psychiatry) as Reverse Anorexia Nervosa, due to characteristic symptoms in relation to body size. It has been considered to be part of the spectrum of Body Dysmorphic Disorders (BDD) referring to a range of conditions that tap into issues surrounding body image and eating behaviours. Consequently, there is a lack of consensus amongst researchers whether MD is a form of BDD, Obsessive-Compulsive Disorder (OCD) or a type of eating disorder. Earlier this year, Andy Foster, Dr. Gillian Shorter and I published a paper in the Journal of Behavioral Addictions about the ‘Addiction to Body Image’ model, and arguing that MD could perhaps be conceptualized as an addiction.

Our ‘Addiction to Body Image’ (ABI) model attempts to provide an operational definition and to introduce a standard assessment across the research area. The ABI model uses my addiction components model (outlined is a previous blog) as the framework in which to define muscle dysmorphia as an addiction. For the purposes of our paper, body image was defined using Sarah Grogan’s definition (from her 2008 book Body image: Understanding body dissatisfaction in men, women, and children) who said it was a person’s “perceptions, thoughts and feelings about his or her body”. We argued that the addictive activity in MD is the maintaining of body image via a number of different activities such as bodybuilding, exercise, eating certain foods, taking specific drugs (e.g., anabolic steroids), shopping for certain foods, food supplements, and/or physical exercise accessories, etc.).

In the ABI model, the perception of the positive effects on the self-body image is accounted for as a critical aspect of the MD condition. The maintenance behaviours of those with ABI may include healthy changes to diet or increases in exercise. However, such behaviours can hide or mislead those with ABI away from the negative thought processes that are driving their addiction. It is in the cognitive dysfunction of MD where we believe there is a pathological issue, and why the field has encountered problems with the criteria for the condition. The attempt to explain MD in the same manner as other BDDs may not be adequate due to the cognitive dysfunction occurring in the context of the potentially positive physical effects via improvements in shape, tone, and/or health of the body.

We also argued that there is a difference in the cognitive dysfunction with a misconstrued self-body image compared to other BDDs. The cognitive dysfunction causes the individual with MD to have a misconstrued view of their own body image, and the person believes they are small and puny. This negative mindset has the potential to cause depression and other disorders, and may facilitate the addiction. Unlike other conceptualizations of MD in the BDD literature, we would argue that the agent of the addiction is the perceived body image that is maintained by engaging in secondary behaviours such as specific types of physical activity and food. The most important thing in the life of someone with MD is how their body looks (i.e., their body image). The behaviours that the person with MD engages in (such as excessive exercise or disordered eating) are merely the vehicles by which their addiction (i.e., their perceived body image) is maintained.

Based on empirical evidence to date, we proposed that Muscle Dysmorphia could be re-classed as an addiction due to the individual continuing to engage in maintenance behaviours that cause long-term psychological damage. More research is needed to explore the possibilities of MD as an addiction, and how this particular addiction is linked to substance use and/or other comorbid health conditions. Controversy about the conceptual measurement of the condition, has led to a number of different scales adapted from different criteria that may not fully measure the experience of MD.

However, a group of questions that might test the applicability of the ABI approach to measuring and conceptualising MD have not been asked. Questionnaires such as the Exercise Addiction Inventory and the Bergen Work Addiction Scale (two scales that I co-developed) could be adapted to fit MD characteristics. Adequate conceptualisation is key to explore the clinically relevant condition. This new ABI approach may also have implications for diagnostic systems around similar conditions such as other BDDs or eating disorders.

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

Additional input: Andy Foster and Dr. Gillian Shorter

Further reading

Andreassen, C.S., Griffiths, M. D., Hetland, J. & Pallesen, S. (2012). Development of a Work Addiction Scale. Scandinavian Journal of Psychology, 53, 265-272.

Foster, A.C., Shorter, G.W.& Griffiths, M.D. (2014). Muscle Dysmorphia: Could it be classified as an Addiction to Body Image? Journal of Behavioral Addictions, in press.

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

Griffiths, M. D. (2005). A ‘components’ model of addiction within a biopsychosocial framework. Journal of Substance Use, 10, 191-197.

Griffiths, M. D., Szabo, A., & Terry, A. (2005). The Exercise Addiction Inventory: A quick and easy screening tool for health practitioners. British Journal of Sports Medicine, 39, 30-31.

Grogan, S. (2008). Body image: Understanding body dissatisfaction in men, women, and children. London: Routledge.

Mosley, P.E. (2009). Bigorexia: Bodybuilding and muscle dysmorphia. European Eating Disorders Review. 17, 191-198.

Murray, S. B., Rieger, E., Touyz, S. W., & De la Garza Garcia, Y. (2010). Muscle Dysmorphia and the DSM-V Conundrum: where does it belong? International Journal of Eating Disorders, 43, 483-491.

Nieuwoudt, J. E., Zhou, S., Coutts, R. A., & Booker, R. (2012). Muscle dysmorphia: Current research and potential classification as a disorder. Psychology of Sport and Exercise, 13, 569-577.

Olivardia, R. (2001). Mirror, mirror on the wall, who’s the largest of them all? The features and phenomenology of muscle dysmorphia. Harvard Review of Psychiatry, 9, 254–259.

Phillips, K. A. & Hollander, E. (1996). Body dysmorphic disorder.In T.A. Widige, A.J. Frances, H.A. Pincus, R. Ross, M.B. First, & W.W. Davis, Eds. DSM-IV Sourcebook, Volume 2. Washington DC: American Psychiatric Association.

Philips, K. A., Gunderson, C. G., Mallya, G., McElroy, S. L., & Carter, W. (1998). A comparison study of body dysmorphic disorder and obsessive-compulsive disorder. Journal of Clinical Psychiatry, 59, 568–575.

Pope, H. G., Jr., Gruber, A. J., Choi, P., Olivardia, R., & Phillips, K. A. (1997). Muscle dysmorphia. An underrecognised form of body dysmorphic disorder. Psychosomatics, 38, 548–557.

Pope, H. G., Jr., Katz, D. L., & Hudson, J. I. (1993). Anorexia nervosa and ‘‘reverse anorexia’’ among 108 male bodybuilders. Comprehensive Psychiatry, 34, 406–409.

Pope, C. G., Pope, H. G., Menard, W., Fay, C., Olivardia, R., & Phillips, K.A. (2005). Clinical features of muscle dysmorphia among males with body dysmorphic disorder. Body image, 2, 395-400.

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

Fat chance: The British ‘obesity epidemic’

Obesity has become a major problem across the Western world including Great Britain. Some academic scholars claim that obesity is a natural consequence of ‘food addiction’. While I can share this viewpoint, there are many examples of obese people whose eating behaviour would not be classed as addicted using the addiction components model. However, that does not mean obesity is not a problem. Academically, I only became interested in obesity when I was appointed a member of the Department of Health’s Expert Working Group on Sedentary Behaviour, Screen Time and Obesity chaired by Professor Stuart Biddle and led to a major report that we published on obesity and sedentary behaviour in 2010 (see ‘Further reading).

Obesity is measured using a calculation based on a person’s Body Mass Index (BMI). BMI is calculated by dividing a person’s weight measurement [in kilograms] by the square of their height [in metres]. In adults, a BMI of 25kg/m2 to 29.9kg/m2 means that person is considered to be overweight, and a BMI of 30kg/m2 or above means that person is considered to be obese. A recent 2013 report by the Health and Social Care Information Centre presented a range of information on obesity in England drawn together from a variety of sources. The report noted that:

“NICE [National Institute for Health and Care Excellence] guidelines on prevention, identification, assessment and management of overweight and obesity highlight their impact on risk factors for developing long-term health problems. It states that the risk of these health problems should be identified using both BMI and waist circumference for those with a BMI less than 35kg/m2. For adults with a BMI of 35kg/m2 or more, risks are assumed to be very high with any waist circumference”.

The main source of the report’s data on the prevalence of overweight and obesity is taken from the annual Health Survey for England (HSE) that is written by NatCen Social Research, and published by the Health and Social Care Information Centre (HSCIC). Most of the information presented in the 2013 report is taken from the HSE 2011.The main findings were that:

  • The proportion of adults with a normal Body Mass Index (BMI) decreased from 41% to 34% among men and from 50% to 39% among women between 1993 and 2011.
  • The proportion that were overweight including obese increased from 58% to 65% in men and from 49% to 58% in women between 1993 and 2011.
  • There was a marked increase in the proportion of adults that were obese from 13% in 1993 to 24% in 2011 for men and from 16% to 26% for women.
  • The proportion of adults with a raised waist circumference increased from 20% to 34% among men and from 26% to 47% among women between 1993 and 2011.
  • In 2011, around three in ten boys and girls (aged 2 to 15) were classed as either overweight or obese (31% and 28% respectively), which is very similar to the 2010 findings (31% for boys and 29% for girls).
  • In 2011/12, around one in ten pupils in Reception class (aged 4-5 years) were classified as obese (9.5%) which compares to around a fifth of pupils in Year 6 (aged 10-11 years) (19.2%).
  • In 2011, obese adults (aged 16 and over) were more likely to have high blood pressure than those in the normal weight group. High blood pressure was recorded in 53% of men and 44% of women in the obese group and in 16% of men and 14% of women in the normal weight group.
  • Over the period 2001/02 to 2011/12 in almost every year more than twice as many females than males were admitted to hospital with a primary diagnosis of obesity.
  • In 2011, there were 0.9 million prescription items dispensed for the treatment of obesity, a 19% decrease on the previous year.

Using regression analysis, the HSE also examined the risk factors associated with being overweight and obese. For both men and women, being ‘most at risk’ was positively associated with: age; being an ex-cigarette smoker; self-perceptions of not eating healthily; not being physically active; and hypertension. Income was also associated with being ‘most at risk’, with a positive association for men and a negative association for women. It was also reported that among women only, moderate alcohol consumption was negatively associated with being ‘most at risk’.

Another summary report on adult weight published earlier this year by the National Obesity Observatory briefly reviewed the scientific data and concluded that in the UK: (i) an estimated 62% of adults (aged 16 and over) are overweight or obese, and that 2.5% have severe obesity; (ii) men and women have a similar prevalence of obesity, but men (41%) are more likely to be overweight than women (33%); (iii) the prevalence of obesity and overweight changes with age, and prevalence of overweight and obesity is lowest in the 16-24 years age group, and generally higher in the older age groups among both men and women; and (iv) women living in more deprived areas have the highest prevalence of obesity and those living in less deprived areas have the lowest, but there is no clear pattern for men.

The 2013 Health and Social Care Information Centre report also contextualized the obesity problem in the UK by comparing obesity rates with other European countries and worldwide using data published by the Organisation for Economic Co-operation and Development (OECD). In 2012, the OECD has published a number of ‘Health at a Glance’ reports including one on European health comparisons, and one on worldwide health comparisons (published in 2011). The data from these reports was summarised as follows:

“More than half (52%) of the adult population in the European Union reported that they were overweight or obese. The obesity rate has doubled over the last twenty years in many European countries and stands at between 7.9% in Romania and 10.3% in Italy to 26.1% in the UK and 28.5% in Hungary. The prevalence of overweight and obesity among adults exceeds 50% in 18 of 27 EU member states…[Worldwide] more than half (50.3%) of the adult population in the OECD reported that they were overweight or obese. The least obese countries were India (2.1%), Indonesia (2.4%) and China (2.9%) and the most obese countries were the US (33.8%), Mexico (30.0%) and New Zealand (26.5%). Obesity prevalence has more than doubled over the past 20 years in Australia and New Zealand. Some 20-24% of adults in Australia, Canada, the United Kingdom (UK) and Ireland are obese, about the same rate as in the United States in the early 1990s. Obesity rates in many western European countries have also increased substantially over the past decade. The rapid rise occurred regardless of where levels stood two decades ago. Obesity almost doubled in both the Netherlands and the UK, even though the current rate in the Netherlands is around half that of the UK”.

From an addiction perspective, there’s also some interesting data examining the co-relationship between obesity and drinking alcohol. For instance, a 2012 report by Gatineau and Mathrani examining the relationship between obesity and alcohol consumption reviewed the literature and made a number of conclusions. These were that (i) there is no clear causal relationship between alcohol consumption and obesity, although there are associations between alcohol and obesity and these are heavily influenced by lifestyle, genetic and social factors; (ii) many people are not aware of the calories contained in alcoholic drinks; (iii) the effects of alcohol on body weight may be more pronounced in overweight and obese people; (iv) alcohol consumption can lead to an increase in food intake; (v) heavy, but less frequent drinkers seem to be at higher risk of obesity than moderate, frequent drinkers; (vi) the relationships between obesity and alcohol consumption differ between men and women; (vii) excess body weight and alcohol consumption appear to act together to increase the risk of liver cirrhosis; and (viii) there is emerging evidence of a link between familial risk of alcohol dependency and obesity in women.

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

Further reading

Biddle, S., Cavill, N., Ekelund, U., Gorely, T., Griffiths, M.D., Jago, R., et al. (2010). Sedentary Behaviour and Obesity: Review of the Current Scientific Evidence. London: Department of Health/Department For Children, Schools and Families.

Gatineau, M & Mathrani, S. (2012). Obesity and alcohol: An overview. Oxford: National Obesity Observatory.

Health and Social Care Information Centre (2013). Statistics on Obesity, Physical Activity and Diet: England, 2013. London: Health and Social Care Information Centre.

Organisation for Economic Co-operation and Development (2011). Health at a Glance 2011. Available at: 05858.pdf

Organisation for Economic Co-operation and Development (2012). Health at a Glance: Europe 2012. Available at: nceeurope.htm

National Obesity Observatory (2013). Adult weight. Oxford: National Obesity Observatory.

Riding high: Can cycling be addictive?

One of the many music books I got for Christmas this year was David Buckley’s excellent 2012 biography of Kraftwerk. Given the media shyness of the band since their official formation in 1970, I was surprised that there was enough material to even fill a chapter, let alone a whole book. However, I read the whole book by December 27th and one of the things I found most fascinating was the claim that the two key founding members of the band – Ralf Hütter and Florian Schneider – were obsessed with cycling. Cycling was so much a part of their daily lives from the early 1980s that – according to the other members of the ‘classic’ line-up, Karl Bartos and Wolfgang Flür – it partly explains (along with the band’s perfectionist nature) the relatively low number of albums they released between 1981’s seminal Computer World and the present day. Even the most casual of Kraftwerk observers are probably aware of the band’s love of cycling as they released a single in 1983 about the Tour De France, and then 20 years later released their  2003 album Tour De France Soundtracks (their most recent album of original music).

People often talk about the ‘cycle of addiction’ but rarely about ‘addiction to cycling’ except occasional academic references in relation to exercise addiction (including some papers I have published myself). For instance, Dr. John Kerr in his 1997 book Motivation and Emotion in Sport speculated on the likely meta-motivational style of those people who are addicted to exercise. Dr. Kerr noted that it was the endurance type exercise activities (e.g. running, cycling, swimming, aerobics and weight training) that are most often associated with exercise addiction and dependence.

David Buckley devotes a whole section in his Kraftwerk biography to Hütter and Schneider’s obsession with cycling. He notes that “there is something compulsive about cycling; and this is not simply based on anecdotal evidence”, something with which I would concur based on the small amount of scientific evidence examining various types of exercise addiction. Most of the section on ‘cycling addiction’ relates to Hütter (although Schneider appears to be as equally enthusiastic about the joy of cycling). Buckley reported that:

“Ralf Hütter…the man-machine became the human bicycle. There is no denying that cycling was, and indeed still is, very important for Ralf Hütter…It is probably inaccurate to describe his passion for cycling as a hobby…it became more like a second (unpaid) job…The main problem with the [cycling] was, firstly, it took a huge chunk out of the conventional working day, and secondly, the effect of the work-out on the motivation of the individual”.

As Buckley then noted, after six hours cycling, the last thing Hütter wanted to do was work when he finally got to their infamous Kling Klang studio. He then went on to note:

“As [Hütter’s] fitness levels increased, he began attempting harder and harder climbs, longer and longer routes…[Hütter] estimated that at his peak, he was cycling around 200 kilometres a day. It had been reported that on occasion on Kraftwerk tours, the bus would drop [Hütter] off around 100 kilometres from the venue, and [Hütter] would complete the final stretch on his bike”.

To those of us who work in the addiction studies field, this description of engaging in ‘harder and harder [cycling] climbs’ by Buckley appears to be an example of ‘tolerance’ in all but name (i.e., the needing of more and more of an activity to gain the desired mood modification effect). Ralf Dorper, founder member of another of my favourite 1980s bands, Propaganda, said that in the mid-1980s:

“The only chance to meet Kraftwerk…would have been at one of these cycling shops. But then [Hütter and Schneider] got more and more into it, and they went to the really specialist shops outside of Dusseldorf…They would probably easily do 50 to 100 kilometres a day”.

Kraftwerk member Wolfgang Flür noticed his band members shift their focus away from music and on to cycling. He said that his colleagues became “fanatics” and “insane” about their cycling, and he also claimed in an interview with Buckley that cycling was an addiction and “became a kind of drug” for Hütter. Buckley also recounts Hütter’s cycling accident that left him in a coma. The most amusing anecdote was that on coming out of his coma, Hütter’s alleged first words were “Is my bike OK? What happened to my bike?” (something that Hütter denied in a June 2009 interview with British newspaper The Guardian). Hütter doesn’t deny his cycling passion and noted in one online interview I came across that:

Cycling is the man-machine, it’s about dynamics, always continuing straight ahead, forward, no stopping. He who stops falls over. There are really balanced artists who can remain upright at a standstill, but I can’t do that. It’s always forwards”

If newspaper reports are to be believed, Hütter may not be the only pop musician with a cycling addiction. An article in an October 2009 issue of The Guardian claimed that Gary Kemp of Spandau Ballet was “now a road cycling addict” based on his new-found enthusiasm for cycling. The article then went on to talk about Ralf Hütter and that “his obsession with [cycling] reportedly became so all-encompassing it threatened the group”.

Arguably the most infamous ‘cycling addict’ was the 55-year old American man ‘Tom’ from Mt. Pleasant (Texas) who appeared on the US television show My Strange Addiction who cycles eight hours a day, seven days a week (over one million miles in a 25-year period). According to the show, Tom rides his bike at home, outside, and even in his office as he works. It was also revealed that Tom was in constant stress from his cycling, and that his constant cycling had made it painful for him to stand, and can barely walk. Alternatively, there is also an amusing 2010 article by Diana North listing ‘26 signs of cycling addiction’ (e.g., ‘Have you seriously considered building a second bike room addition to your home?’, ‘Are there more than three bike-related tattoos on your body?’, ‘Do people leaving messages on your voicemail start with “I know you’re on your bike right now, but…?”, etc.). There are also a variety of online accounts (mostly by cyclists) questioning whether their passion is an addiction such as an article by Scott Saifer in the magazine Road: The Journal of Road Cycling and Culture, an e-zine article by Nebojsa Djekanovic, and a personal account by ‘Doug’ who runs the Cycle Hub blog).

Although there is a fairly established scientific literature on exercise addiction in general, there is almost nothing on cycling addiction specifically (although I did come across one online article where a professional cyclist had adapted the Internet Addiction Test for other cyclists to self-diagnose whether they are addicted to cycling). A fairly recent 2007 book entitled Exercise Dependence edited by Drs. John Kerr, Koenraad Lindner and Michelle Blaydon had about 20 mentions of cycling in the context of exercise addiction (although again almost nothing specific). Most of the references were in relation to cycling being one of the endurance sports that can also be engaged in individually, and that individual endurance sports are more highly associated with exercise addiction.

There are also occasional references to triathletes (who run, cycle and swim) being dependent and/or addicted to exercise. There was also reference to research examining eating disorders among different professional athletes (as there is a relationship between exercise addiction and eating disorders that I reviewed in a previous blog). Kerr and colleagues quoted a group of 1990s studies by Dr. J. Sundgot-Borgen showing that the prevalence of eating disorders among elitist cyclists was 20% compared to cross-country skiers (33%), middle and long distance runners (27%), swimmers (15%) and orienteers (0%). Interestingly, one of the traits that appears to be associated with exercise addiction is perfectionism according to a 1990 paper by Dr. Caroline Davis that appeared in the journal Personality and Individual Differences (which when linked back to Ralf Hütter’s experiences in Kraftwerk made me raise an eyebrow).

There is also some preliminary evidence that professional cyclists may be more prone to drug addictions than other groups of people. Although I was unable to fully read a French paper by Dr. J.C. Seznec in a 2002 issue of the Annales Medico-Psychologiques Revue Psychiatrique, the author claimed that sportsmen were specifically vulnerable to addiction. Seznec – a psychiatrist and sports doctor – highlighted there are some factors (predisposing factors, initiation factors and maintenance factors) that explain the association. Seznec concluded that:

“These addictions seem to be in direct relation with the brutal transformation that high-level sport towards professionalism suffered. This study makes us conclude that the practising of a professional sport predisposes to the development of an addiction and that it requires a specific preventive help”.

I’m certainly of the opinion that it is theoretically possible to be addicted to cycling, although the number of people genuinely affected is likely to be small. This is one area that I might consider doing some personal research into – especially if it meant I could interview the members of Kraftwerk!

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

Further reading

Allegre, B., Souville, M., Therme, P. & Griffiths, M.D. (2006). Definitions and measures of exercise dependence, Addiction Research and Theory, 14, 631-646.

Berczik, K., Szabó, A., Griffiths, M.D., Kurimay, T., Kun, B. & Demetrovics, Z. (2011). Exercise addiction: Symptoms, diagnosis, epidemiology, and etiology. Substance Use and Misuse, 47, 403-417.

Buckley, D. (2012). Kraftwerk Publication. London: Omnibus.

Davis, C. (1990). Weight and diet preoccupation and addictiveness: The role of exercise. Personality and Individual Differences, 11, 823-827.

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

Griffiths, M. D., Szabo, A., & Terry, A. (2005). The exercise addiction inventory: a quick and easy screening tool for health practitioners. British Journal of Sports Medicine, 39(6), e30-31.

Kerr, J. H. (1997) Motivation and Emotion in Sport: Reversal Theory. Hove: Psychology Press.

Kerr, J.H., Lindner, K.J. & Blaydon, M. (2007). Exercise Dependence. Oxford: Routledge.

Seznec, J. C. (2002). Toxicomanie et cyclisme professionnel [Drug addiction and professional cycling]. Annales Medico-Psychologiques Revue Psychiatrique, 160, 72-76.

Sundgot-Borgen, J. (1993). Prevalence of eating disorders in female elite athletes. International Journal of Sport Nutrition, 3, 29-40.

Sundgot-Borgen, J. (1994). Eating disorders in female athletes. Sports Medicine, 17, 176-188.

Sundgot-Borgen, J. (1994) ‘Risk and trigger factors for the development of eating disorders in female elite athletes. Medicine and Science in Sports and Exercise, 26, 414-419.

Sundgot-Borgen, J., Torstveit, G. and Klungland, M. (2004). Prevalence of eating disorders in elite athletes is higher than in the general population. Clinical Journal of Sport Medicine, 14, 25-32.

Terry, A., Szabo, A., & Griffiths, M. D. (2004). The exercise addiction inventory: A new brief screening tool. Addiction Research and Theory, 12, 489-499.

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.

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.

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.