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Doctor, doctor: What can British GPs do about problem gambling?

A study published in the British Journal of General Practice in March 2017 reported that of 1,058 individuals surveyed in GP waiting rooms in Bristol (UK), 0.9% were problem gamblers and that a further 4.3% reported gambling problems that “were low to medium severity”. This is in line with other British studies carried out over the last decade which have reported problem gambling prevalence rates of between 0.5% and 0.9%.

I have long argued that problem gambling is a health issue and that GPs should routinely screen for gambling problems. Back in 2004, I published an article in the British Medical Journal about why problem gambling is a health issue. I argued that the social and health costs of problem gambling were (and still are) large at both individual and societal levels.

uk-gambling-trade-bodies-unite-to-improve-responsible-gaming

Personal costs can include irritability, extreme moodiness, problems with personal relationships (including divorce), absenteeism from work, neglect of family, and bankruptcy. Adverse health consequences for problem gamblers and their partners include depression, insomnia, intestinal disorders, migraine, and other stress related disorders. In my BMJ article I also noted that analysis of calls to the GamCare national gambling helpline indicated that a small minority of callers reported health-related consequences as a result of their problematic gambling. These included depression, anxiety, stomach problems, and suicidal ideation. Obviously many of these medical problems arise through the stress of financial problems but that doesn’t make it any less of a health issue for those suffering from severe gambling problems.

Research published in the American Journal of Addictions has also shown that health-related problems can occur as a result of withdrawal effects. For instance, one study by Dr. Richard Rosenthal and Dr. Henry Lesieur found that at least 65% of pathological gamblers reported at least one physical side effect during withdrawal, including insomnia, headaches, loss of appetite, physical weakness, heart racing, muscle aches, breathing difficulty, and chills.

Based on these findings, problem gambling is very much a health issue that needs to be taken seriously by all in the medical profession. GPs routinely ask patients about smoking cigarettes and drinking, but gambling is something that is not generally discussed. Problem gambling may be perceived as a grey area in the field of health, and it is therefore very easy for those in the medical profession not to have the issue on their wellbeing radar. If the main aim of GPs is to ensure the health of their patients, then an awareness of gambling and the issues surrounding it should be an important part of basic knowledge and should be taught in the curriculum while prospective doctors are at medical school. One of the reasons that GPs don’t routinely screen for problem gambling is because they are not taught about it during their medical training and therefore do not even think about screening for it in the first place. As I recommended in a report commissioned by the British Medical Association, the need for education and training in the diagnosis, appropriate referral and effective treatment of gambling problems must be addressed within GP training. More specifically, GPs should be aware of the types of gambling and problem gambling, demographic and cultural differences, and the problems and common co-morbidities associated with problem gambling. GPs should also understand the importance of screening patients perceived to be at increased risk of gambling addiction, and should be aware of the referral and support services available locally.

I also recommended that treatment for problem gambling should be provided under the NHS (either as standalone services or alongside drug and alcohol addiction services) and funded by gambling-derived profit revenue.

Back in 2011, Dr. Jane Rigbye and myself published a study using Freedom of Information requests to ask NHS trusts if they had ever treated pathological gamblers. Only 3% of the trusts had ever treated a problem gambler and only one trust said they offered dedicated help and support. I’m sure if we repeated the study today, little will have changed.

It is evident that problem gambling is not, as yet, on the public health agenda in the UK. NHS services – including GP surgeries – need to be encouraged to see gambling problems as a primary reason for referral and a valid treatment option. Information about gambling addiction services, in particular services in the local area, should be readily available to gamblers and GP surgeries are a good outlet to advertise such services. Although some gambling services (such as GamCare, the gambling charity I co-founded) provide information to problem gamblers about local services, such information is provided to problem gamblers who have already been proactive in seeking gambling help and/or information. Given that very few GPs could probably treat a problem gambler, what they must have is the knowledge of who they can refer their patients to.

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

Further reading

Calado, F. & Griffiths, M.D. (2016). Problem gambling worldwide: An update of empirical research (2000-2015). Journal of Behavioral Addictions, 5, 592–613.

Cowlishaw, S., Gale, L., Gregory, A., McCambridge, J., & Kessler, D. (2017). Gambling problems among patients in primary care: a cross-sectional study of general practices. British Journal of General Practice, doi: bjgp17X689905

Griffiths, M.D. (2001). Gambling – An emerging area of concern for health psychologists. Journal of Health Psychology, 6, 477-479.

Griffiths, M.D. (2004). Betting your life on it: Problem gambling has clear health related consequences. British Medical Journal, 329, 1055-1056.

Griffiths, M.D. (2007). Gambling Addiction and its Treatment Within the NHS. London: British Medical Association (ISBN 1-905545-11-8).

Griffiths, M.D. & Smeaton, M. (2002). Withdrawal in pathological gamblers: A small qualitative study. Social Psychology Review, 4, 4-13.

Rigbye, J. & Griffiths, M.D. (2011). Problem gambling treatment within the British National Health Service. International Journal of Mental Health and Addiction, 9, 276-281.

Rosenthal, R., & Lesieur, H. (1992). Self-reported withdrawal symptoms and pathological gambling. American Journal of the Addictions, 1, 150–154.

Wardle, H., Moody. A., Spence, S., Orford, J., Volberg, R., Jotangia, D., Griffiths, M.D., Hussey, D. & Dobbie, F. (2011).  British Gambling Prevalence Survey 2010. London: The Stationery Office.

Wardle, H., Sproston, K., Orford, J., Erens, B., Griffiths, M.D., Constantine, R. & Pigott, S. (2007). The British Gambling Prevalence Survey. London: The Stationery Office.

Lust discussed: A brief overview of our recent papers on sex addiction

Following my recent blogs where I outlined some of the papers that my colleagues and I have published on mindfulness, Internet addiction, gaming addiction, youth gambling, exercise addiction, and shopping addiction, here is a round-up of recent papers that my colleagues and I have published on sex addiction.

Griffiths, M.D. & Dhuffar, M. (2014). Treatment of sexual addiction within the British National Health Service. International Journal of Mental Health and Addiction, 12, 561-571.

  • At present, the prevalence of rates of sexual addiction in the UK is unknown. This study investigated what treatment services were available within British Mental Health Trusts (MHTs) that are currently provided for those who experience compulsive and/or addictive sexual behaviours within the National Health Service (NHS) system. In March and April 2013, a total of 58 letters were sent by email to all Mental Health Trusts in the UK requesting information about (i) sexual addiction services and (ii) past 5-year treatment of sexual addiction. The request for information was sent to all MHTs under the Freedom of Information Act (2001). Results showed that 53 of the 58 MHTs (91 %) did not provide any service (specialist or otherwise) for treating those with problematic sexual behaviours. Based on the responses provided, only five MHTs reported having had treated sexual addiction as a disorder that took primacy over the past 5 years. There was also some evidence to suggest that the NHS may potentially treat sexual addiction as a secondary disorder that is intrinsic and/or co-morbid to the initial referral made by the GP. In light of these findings, implications for the treatment of sex addiction in a British context are discussed.

Dhuffar, M. & Griffiths, M.D. (2014). Understanding the role of shame and its consequences in female hypersexual behaviours: A pilot study. Journal of Behavioural Addictions, 3, 231–237.

  • Background and aims: Hypersexuality and sexual addiction among females is a little understudied phenomenon. Shame is thought to be intrinsic to hypersexual behaviours, especially in women. Therefore, the aim of this study was to understand both hypersexual behaviours and consequences of hypersexual behaviours and their respective contributions to shame in a British sample of females (n = 102). Methods: Data were collected online via Survey Monkey. Results: Results showed the Sexual Behaviour History (SBH) and the Hypersexual Disorder Questionnaire (HDQ) had significant positive correlation with scores on the Shame Inventory. The results indicated that hypersexual behaviours were able to predict a small percentage of the variability in shame once sexual orientation (heterosexual vs. non-heterosexual) and religious beliefs (belief vs. no belief) were controlled for. Results also showed there was no evidence that religious affiliation and/or religious beliefs had an influence on the levels of hypersexuality and consequences of sexual behaviours as predictors of shame. Conclusions: While women in the UK are rapidly shifting to a feminist way of thinking with or without technology, hypersexual disorder may often be misdiagnosed and misunderstood because of the lack of understanding and how it is conceptualised. The implications of these findings are discussed.

Dhuffar, M. & Griffiths, M.D. (2015). A systematic review of online sex addiction and clinical treatments using CONSORT evaluation. Current Addiction Reports, 2, 163-174.

  • Researchers have suggested that the advances of the Internet over the past two decades have gradually eliminated traditional offline methods of obtaining sexual material. Additionally, research on cybersex and/or online sex addictions has increased alongside the development of online technology. The present study extended the findings from Griffiths’ (2012) systematic empirical review of online sex addiction by additionally investigating empirical studies that implemented and/or documented clinical treatments for online sex addiction in adults. A total of nine studies were identified and then each underwent a CONSORT evaluation. The main findings of the present review provide some evidence to suggest that some treatments (both psychological and/or pharmacological) provide positive outcomes among those experiencing difficulties with online sex addiction. Similar to Griffiths’ original review, this study recommends that further research is warranted to establish the efficacy of empirically driven treatments for online sex addiction.

Dhuffar, M. & Griffiths, M.D. (2015). Understanding conceptualisations of female sex addiction and recovery using Interpretative Phenomenological Analysis. Psychology Research, 5, 585-603.

  • Relatively little research has been carried out into female sex addiction. There is even less regarding understandings of lived experiences of sex addiction among females. Consequently, the purpose of the present study was to examine the experiences of female sex addiction (from onset to recovery). This was done by investigating the experiences and conceptualisations of three women who self-reported as having had a historical problem with sex addiction. An interpretative phenomenological analysis (IPA) methodology was applied in the current research process in which three female participants shared their journey through the onset, progression, and recovery of sex addiction. The IPA produced five superordinate themes that accounted for the varying degrees of sexual addiction among a British sample of females: (1) “Focus on self as a sex addict”; (2) “Uncontrollable desire”; (3) “Undesirable feelings”; (4) “Derision”; and (5) “Self help, treatment and recovery”. The implications of these findings towards the understanding and the need for the implementation of treatment are discussed.

Dhuffar, M., Pontes, H.M. & Griffiths, M.D. (2015). The role of negative mood states and consequences of hypersexual behaviours in predicting hypersexuality among university students. Journal of Behavioural Addictions, 4, 181–188.

  • The issue of whether hypersexual behaviours exist among university students is controversial because many of these individuals engage in sexual exploration during their time at university. To date, little is known about the correlates of hypersexual behaviours among university students in the UK. Therefore, the aims of this exploratory study were two-fold. Firstly, to explore and establish the correlates of hypersexual behaviours, and secondly, to investigate whether hypersexuality among university students can be predicted by variables relating to negative mood states (i.e., emotional dysregulation, loneliness, shame, and life satisfaction) and consequences of hypersexual behaviour.

Van Gordon, W., Shonin, E., & Griffiths, M.D. (2016). Meditation Awareness Training for the treatment of sex addiction: A case study. Journal of Behavioral Addictions, in press.

  • Sex addiction is a disorder that can have serious adverse functional consequences. Treatment effectiveness research for sex addiction is currently underdeveloped, and interventions are generally based on guidelines for treating other behavioural (as well as chemical) addictions. Consequently, there is a need to clinically evaluate tailored treatments that target the specific symptoms of sex addiction. It has been proposed that second-generation mindfulness-based interventions (SG-MBIs) may be an appropriate treatment for sex addiction because in addition to helping individuals increase perceptual distance from craving for desired objects and experiences, some SG-MBIs specifically contain meditations intended to undermine attachment to sex and/or the human body. To date, no study exploring the utility of mindfulness for treating sex addiction has been conducted. This paper presents an in-depth clinical case study of a male individual suffering from sex addiction that underwent treatment utilising an SG-MBI known as Meditation Awareness Training (MAT). Following completion of MAT, the participant demonstrated clinically significant improvements regarding the addictive sexual behaviour, as well less depression and psychological distress. The MAT intervention also led to improvements in sleep quality, job satisfaction, and non-attachment to self and experiences. Salutary outcomes were maintained at six-month follow-up. The current study extends the literature exploring the applications of mindfulness for treating behavioural addiction, and findings of this case study indicate that further clinical investigation into the role of mindfulness for treating sex addiction is warranted.

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

Further reading

Griffiths, M.D. (2000). Excessive internet use: Implications for sexual behavior. CyberPsychology and Behavior, 3, 537-552.

Griffiths, M.D. (2001). Addicted to love: The psychology of sex addiction. Psychology Review, 8, 20-23.

Griffiths, M.D. (2001). Sex on the internet: Observations and implications for sex addiction. Journal of Sex Research, 38, 333-342.

Griffiths, M.D. (2004). Sex addiction on the Internet. Janus Head: Journal of Interdisciplinary Studies in Literature, Continental Philosophy, Phenomenological Psychology and the Arts, 7(2), 188-217.

Griffiths, M.D. (2010). Addicted to sex? Psychology Review, 16(1), 27-29.

Griffiths, M.D. (2012). Internet sex addiction: A review of empirical research. Addiction Research and Theory, 20, 111-124.

Griffiths, M.D. (2012). The use of online methodologies in studying paraphilia: A review. Journal of Behavioral Addictions, 1, 143-150.

Griffiths, M.D. & Dhuffar, M. (2014). Collecting behavioural addiction treatment data using Freedom of Information requests. SAGE Research Methods Cases. Located at: DOI: http://dx.doi.org/10.4135/978144627305014533925

Tech’s appeal: Another look at Internet addiction

Generally speaking, Internet addiction (IA) has been characterized by excessive or poorly controlled preoccupation, urges, and/or behaviours regarding Internet use that lead to impairment or distress in several life domains. However, according to Dr. Kimberly Young, IA is a problematic behaviour akin to pathological gambling that can be operationally defined as an impulse-control disorder not involving the ingestion of psychoactive intoxicants.

Following the conceptual framework developed by Young and her colleagues to understand IA, five specific types of distinct online addictive behaviours were identified: (i) ‘cyber-sexual addiction’, (ii) ‘cyber-relationship addiction’, (iii) ‘net compulsions (i.e., obsessive online gambling, shopping, or trading), (iv) ‘information overload’, and (v) ‘computer addiction’ (i.e., obsessive computer game playing).

However, I have argued in many of my papers over the last 15 years that the Internet may simply be the means or ‘place’ where the most commonly reported addictive behaviours occur. In short, the Internet may be just a medium to fuel other addictions. Interestingly, new evidence pointing towards the need to make this distinction has been provided from the online gaming field where new studies (including some I have carried out with my Hungarian colleagues) have demonstrated that IA is not the same as other more specific addictive behaviours carried out online (i.e., gaming addiction), further magnifying the meaningfulness to differentiate between what may be called ‘generalized’ and ‘specific’ forms of online addictive behaviours, and also between IA and gaming addiction as these behaviours are conceptually different.

Additionally, the lack of formal diagnostic criteria to assess IA holds another methodological problem since researchers are systematically adopting modified criteria from other addictions to investigate IA. Although IA may share some commonalities with other substance-based addictions, it is unclear to what extent such criteria are useful and suitable to evaluate IA. Notwithstanding the existing difficulties in understanding and comparing IA with behaviours such as pathological gambling, recent research provided useful insights on this topic.

A recent study by Dr. Federico Tonioni (published in a 2014 issue of the journal Addictive Behaviors) involving two clinical (i.e., 31 IA patients and 11 pathological gamblers) and a control group (i.e., 38 healthy individuals) investigated whether IA patients presented different psychological symptoms, temperamental traits, coping strategies, and relational patterns in comparison to pathological gamblers, concluded that Internet-addicts presented higher mental and behavioural disengagement associated with significant more interpersonal impairment. Moreover, temperamental patterns, coping strategies, and social impairments appeared to be different across both disorders. Nonetheless, the similarities between IA and pathological gambling were essentially in terms of psychopathological symptoms such as depression, anxiety, and global functioning. Although, individuals with IA and pathological gambling appear to share similar psychological profiles, previous research has found little overlap between these two populations, therefore, both phenomena are separate disorders.

Despite the fact that initial conceptualizations of IA helped advance the current knowledge and understanding of IA in different aspects and contexts, it has become evident that the field has greatly evolved since then in several ways. As a result of these ongoing changes, behavioural addictions (more specifically Gambling Disorder and Internet Gaming Disorder) have now recently received official recognition in the latest (fifth) edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Moreover, IA can also be characterized as a form of technological addiction, which I have operationally defined as a non-chemical (behavioural) addiction involving excessive human-machine interaction. In this theoretical framework, technological addictions such as IA represent a subset of behavioural addictions featuring six core components: (i) salience, (ii) mood modification, (iii) tolerance, (iv) withdrawal, (v) conflict, and (vi) relapse. The components model of addiction appears to be a more updated framework for understanding IA as a behavioural addiction not only conceptually but also empirically. Moreover, this theoretical framework has recently received empirical support from several studies, further evidencing its suitability and applicability to the understanding of IA.

For many in the IA field, problematic Internet use is considered to be a serious issue – albeit not yet officially recognised as a disorder – and has been described across the literature as being associated with a wide range of co-occurring psychiatric comorbidities alongside an array of dysfunctional behavioural patterns. For instance, IA has been recently associated with low life satisfaction, low academic performance, less motivation to study, poorer physical health, social anxiety, attention deficit/hyperactivity disorder and depression, poorer emotional wellbeing and substance use, higher impulsivity, cognitive distortion, deficient self-regulation, poorer family environment, higher mental distress, loneliness, among other negative psychological, biological, and neuronal aspects.

In a recent systematic literature review conducted by Dr. Wen Li and colleagues (and published in the journal Computers and Human Behavior), the authors reviewed a total of 42 empirical studies that assessed the family correlates of IA in adolescents and young adults. According to the authors, virtually all studies reported greater family dysfunction amongst IA families in comparison to non-IA families. More specifically, individuals with IA exhibited more often (i) greater global dissatisfaction with their families, (ii) less organized, cohesive, and adaptable families, (iii) greater inter-parental and parent-child conflict, and (iv) perceptions of their parents as more punitive, less supportive, warm, and involved. Furthermore, families were significantly more likely to have divorced parents or to be a single parent family.

Another recent systematic literature review conducted by Dr. Lawrence Lam published in the journal Current Psychiatry Reports examined the possible links between IA and sleep problems. After reviewing seven studies (that met strict inclusion criteria), it was concluded that on the whole, IA was associated with sleep problems that encompassed subjective insomnia, short sleep duration, and poor sleep quality. The findings also suggested that participants with insomnia were 1.5 times more likely to be addicted to the Internet in comparison to those without sleep problems. Despite the strong evidence found supporting the links between IA and sleep problems, the author noted that due to the cross-sectional nature of most studies reviewed, the generalizability of the findings was somewhat limited.

IA is a relatively recent phenomenon that clearly warrants further investigation, and empirical studies suggest it needs to be taken seriously by psychologists, psychiatrists, and neuroscientists. Although uncertainties still remain regarding its diagnostic and clinical characterization, it is likely that these extant difficulties will eventually be tackled and the field will evolve to a point where IA may merit full recognition as a behavioural addiction from official medical bodies (ie, American Psychiatric Association) similar to other more established behavioural addictions such as ‘Gambling Disorder’ and ‘Internet Gaming Disorder’. However, in order to achieve official status, researchers will have to adopt a more commonly agreed upon definition as to what IA is, and how it can be conceptualized and operationalized both qualitatively and quantitatively (as well as in clinically diagnostic terms).

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

Please note: This article was co-written with Halley Pontes and Daria Kuss.

Further reading

Griffiths, M.D. (2000). Internet addiction – Time to be taken seriously? Addiction Research, 8, 413-418.

Griffiths, M.D. (2010). Internet abuse and internet addiction in the workplace. Journal of Workplace Learning, 7, 463-472.

Griffiths, M.D., Kuss, D.J., Billieux J. & Pontes, H.M. (2016). The evolution of internet addiction: A global perspective. Addictive Behaviors, 53, 193–195.

Griffiths, M.D. & Pontes, H.M. (2014). Internet addiction disorder and internet gaming disorder are not the same. Journal of Addiction Research and Therapy, 5: e124. doi:10.4172/2155-6105.1000e124.

Király, O., Griffiths, M.D., Urbán, R., Farkas, J., Kökönyei, G. Elekes, Z., Domokos Tamás, D. & Demetrovics, Z. (2014). Problematic internet use and problematic online gaming are not the same: Findings from a large nationally representative adolescent sample. Cyberpsychology, Behavior and Social Networking, 17, 749-754.

Kuss, D.J. & Griffiths, M.D. (2015). Internet Addiction in Psychotherapy. Basingstoke: Palgrave Macmillan.

Kuss, D.J., Griffiths, M.D. & Binder, J. (2013). Internet addiction in students: Prevalence and risk factors. Computers in Human Behavior, 29, 959-966.

Kuss, D.J., Griffiths, M.D., Karila, L. & Billieux, J. (2014). Internet addiction: A systematic review of epidemiological research for the last decade. Current Pharmaceutical Design, 20, 4026-4052.

Kuss, D.J., Shorter, G.W., van Rooij, A.J., Griffiths, M.D., & Schoenmakers, T.M. (2014). Assessing Internet addiction using the parsimonious Internet addiction components model – A preliminary study. International Journal of Mental Health and Addiction, 12, 351-366.

Kuss, D.J., van Rooij, A.J., Shorter, G.W., Griffiths, M.D. & van de Mheen, D. (2013). Internet addiction in adolescents: Prevalence and risk factors. Computers in Human Behavior, 29, 1987-1996.

Lam, L.T. (2014). Internet Gaming Addiction, Problematic use of the Internet, and sleep problems: A systematic review. Current Psychiatry Reports, 16(4), 1-9.

Li, W., Garland, E.L., & Howard, M.O. (2014). Family factors in Internet addiction among Chinese youth: A review of English-and Chinese-language studies. Computers in Human. Behavior, 31, 393-411.

Pontes, H. & Griffiths, M.D. (2015). Measuring DSM-5 Internet Gaming Disorder: Development and validation of a short psychometric scale. Computers in Human Behavior, 45, 137-143.

Pontes, H.M., Kuss, D.J. & Griffiths, M.D. (2015). The clinical psychology of Internet addiction: A review of its conceptualization, prevalence, neuronal processes, and implications for treatment. Neuroscience and Neuroeconomics, 4, 11-23.

Pontes, H.M., Szabo, A. & Griffiths, M.D. (2015). The impact of Internet-based specific activities on the perceptions of Internet Addiction, Quality of Life, and excessive usage: A cross-sectional study. Addictive Behaviors Reports, 1, 19-25.

Tonioni, F., Mazza, M., Autullo, G., Cappelluti, R., Catalano, V., Marano, G., … & Lai, C. (2014). Is Internet addiction a psychopathological condition distinct from pathological gambling?. Addictive Behaviors, 39(6), 1052-1056.

Widyanto, L. & Griffiths, M.D. (2006). Internet addiction: A critical review. International Journal of Mental Health and Addiction, 4, 31-51.

Young, K. (1998). Caught in the net. New York: John Wiley

Young K. (1999). Internet addiction: Evaluation and treatment. Student British Medical Journal, 7, 351-352.

Against all odds: The rise and rise of gambling

In many areas of the world, gambling has become a popular activity. Almost all national surveys into gambling have concluded that most people have gambled at some point in their lives, there are more gamblers than non-gamblers, but that most participants gamble infrequently. Commissions and official government reviews in a number of countries including the United States, United Kingdom, Australia and New Zealand have all concluded that increased gambling availability has led to an increase in problem gambling. Estimates of the number of problem gamblers vary from country to country but most countries that have carried out national prevalence surveys suggest around 0.5%-2% of individuals have a gambling problem.

In May 2013, the new criteria for problem gambling (now called ‘Gambling Disorder’) were published in the fifth edition of the American Psychiatric Association’s Diagnostic and Statistical Manual for Mental Disorders (DSM-5), and for the very first time, problem gambling was included in the section ‘Substance-related and Addiction Disorders’ (rather than in the section on impulse control disorders). Also included in the Appendix of the DSM-5 as a potential addiction was Internet Gaming Disorder (i.e., online video game addiction). Although most of us in the field had been conceptualizing problematic gambling and video gaming as addictions for many years, this was arguably the first time that an established medical body had described them as such. For me, gambling and gaming addictions should not be considered any differently from other more traditional chemical addictions (e.g., alcohol addiction, nicotine addiction). Consequently, there is no theoretical reason why other problematic and excessive activities that do not involve the ingestion of a psychoactive substance cannot be deemed as legitimate behavioural addictions in the years to come (e.g., shopping addiction, sex addiction, work addiction, exercise addiction, etc.).

Gambling is a multifaceted rather than unitary phenomenon. Consequently, many factors are involved in the acquisition, development and maintenance of gambling behaviour. Such factors include an individual’s biological and genetic predisposition, their social environment, psychological variables (personality characteristics, attitudes, expectations, beliefs, etc.), macro-situational characteristics (how much gambling is marketed and advertised, the number of gambling venues within a jurisdiction, where the gambling venue is located), micro-situational characteristics of the gambling environment (on-site cash machine, provision of free alcohol, floor layout etc.), and the structural characteristics of the gambling activity itself (jackpot size, stake size, the number of times a individual can gamble in a given time frame, etc.). Most research has tended to concentrate on individual characteristics (personality, genetics, family and peer influence) rather than situational and structural characteristics.

The introduction of national lotteries, the proliferation of slot machines, the expansion of casinos, and the introduction of new media in which to gamble (e.g., Internet gambling, mobile phone gambling, interactive television gambling, gambling via social networking sites), has greatly increased the accessibility and popularity of gambling worldwide, and as a result, the number of people seeking assistance for gambling-related problems. In addition, the rise of remote gambling via the internet and mobile phones has arguably changed the psychosocial nature of gambling. I have also published a number of studies showing that to vulnerable and susceptible individuals (e.g., problem gamblers, minors, the intoxicated, etc.), the medium of the internet may facilitate and fuel problematic and addictive behaviours.

There are many known factors that make online activity potentially problematic to a minority of individuals. This includes factors such as easy accessibility, affordability, anonymity, convenience, escape, and disinhibition. Some of these factors can change the psychological experience of gambling. For instance, gambling with virtual representations of money online lower the psychological value of the money and people tend to spend more with virtual representations of money than if they were gambling with physical money. Also, when people lose money online it is a different psychological experience because no-one can see anyone losing face-to-face. As a result, there is less guilt and embarrassment about losing and vulnerable individuals may be tempted to spend more time and money than they had originally intended.

One very salient trend that has implications for gambling (and arguably problem gambling) is that technology hardware is becoming increasingly convergent (e.g., internet access via smartphones and interactive television) and there is increasing multi-media integration such as gambling and video gaming via social networking sites. As a consequence, people of all ages are spending more time interacting with technology in the form of internet use, playing videogames, watching interactive television, mobile phone use, social networking, etc. In addition to convergent hardware, there is also convergent content. This includes some forms of gambling including video game elements, video games including gambling elements, online penny auctions that have gambling elements, and television programming with gambling-like elements.

One of the key drivers behind the increased numbers of people gambling online and using social networking sites is the rise of mobile gambling and gaming. Compared to internet gambling, mobile gambling is still a relatively untapped area but the functional capabilities of mobile phones and other mobile devices are improving all the time. There are now hundreds of gambling companies that provide casino-style games to be downloaded onto the gambler’s smartphone or mobile device (e.g., tablet or laptop). This will have implications for the psychosocial impact of gambling and will need monitoring. Like online gambling, mobile gaming has the capacity to completely change the way people think about gambling and betting. Mobile phones provide the convenience of making bets or gambling from wherever the person is, even if they are on the move.

One of the most noticeable changes in gambling over the last few years – and inextricably linked to the rise of mobile gaming – has been the large increase of in-play sports betting. Gamblers can now typically bet on over 60 ‘in-play’ markets while watching a sports event (such as a soccer match). For instance, during a soccer game, gamblers can bet on who is going to score the first goal, what the score will be after 30 minutes of play, how many yellow cards will be given during them game and/or in what minute of the second half will the first free kick be awarded. Live betting is going to become a critical activity in the success of the future online and mobile gambling markets.

The most salient implication of ‘in-play’ sports betting is that it has taken what was traditionally a discontinuous form of gambling – where an individual makes one bet every Saturday on the result of the game – to one where an individual can gamble again and again and again. Gaming operators have quickly capitalized on the increasing amount of televised sport. In contemporary society, where there is a live sporting event, there will always be a betting consumer. ‘In-play’ betting companies have both catered for the natural betting demand but introduced new gamblers in the process. If the reward for gambling only happens once or twice a week, it is completely impossible to develop problems and/or become addicted. ‘In-play’ has changed that because there are soccer matches on almost every day of the week making a daily two-hour plus period of betting seven days a week.

New technologies in the form of behavioural tracking have helped online gambling companies keep track of players by noting (among many other things) what games they are playing, the time spent playing, the denomination of the gambles made, and their wins and losses. Although such technologies can potentially be used to exploit gamblers (e.g., targeting the heaviest spenders with direct marketing promotions to gamble even more), such technologies can also be used to help gamblers that may have difficulties stopping and/or limiting their gambling behaviour. Over the past few years, innovative social responsibility tools that track player behaviour with the aim of preventing problem gambling have been developed. These new tools are providing insights about problematic gambling behaviour. A number of European jurisdictions (such as Germany and The Netherlands) are now considering whether such tools should be mandatory for gaming operators to use especially as such tools are already being used in Sweden, Norway, Finland and Austria.

Although gamblers are ultimately responsible for their own behaviour, gambling can be minimised via both governmental policy initiatives (age restrictions, marketing and advertising restrictions, no gaming licenses unless operators display the highest standards of social responsibility to their clientele, etc.) and gaming operator initiatives (self-exclusion programs, information about games so gamblers can make informed choices, limit-setting tools that allow gamblers to set time and money loss limits, staff training on responsible gambling, referral to gambling treatment providers, etc.). Problem gambling can never be totally eliminated but harm minimisation practices can be put in place to keep the problem to a minimum. Treatment for gambling addiction should be free and paid for by gambling industry profits (either in the form of voluntary donations to a charitable trust or – if that doesn’t work – a statutory levy). In short, any jurisdiction that has legalised and liberalised gambling has a duty of care to put a national social responsibility infrastructure in place to prevent, minimise, and treat problem gambling as they would with any other consumptive and potentially addictive behaviour (e.g., drinking alcohol, smoking cigarettes, etc.)

Please note: A version of this article first appeared in Science and Technology (Pan European Networks) magazine (Volume 15, pages 153-155).

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

Further reading

Griffiths, M.D. (2003). Internet gambling: Issues, concerns and recommendations. CyberPsychology and Behavior, 6, 557-568.

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

Griffiths, M.D. (2011). Gaming convergence: Further legal issues and psychosocial impact. Gaming Law Review and Economics, 14, 461-464.

Griffiths, M.D. (2012). Mind games (A brief psychosocial overview of in-play betting). i-Gaming Business Affiliate, June/July, 44.

Griffiths, M.D. (2012). Internet gambling, player protection and social responsibility. In R. Williams, R. Wood & J. Parke (Ed.), Routledge Handbook of Internet Gambling (pp.227-249). London: Routledge.

Griffiths, M.D., King, D.L. & Delfabbro, P.H. (2014). The technological convergence of gambling and gaming practices. In Richard, D.C.S., Blaszczynski, A. & Nower, L. (Eds.). The Wiley-Blackwell Handbook of Disordered Gambling (pp. 327-346). Chichester: Wiley.

Griffiths, M.D. & Parke, J. (2003). The environmental psychology of gambling. In G. Reith (Ed.), Gambling: Who wins? Who Loses? (pp. 277-292). New York: Prometheus Books.

Kuss, D.J. & Griffiths, M.D. (2012).  Internet gambling behavior. In Z. Yan (Ed.), Encyclopedia of Cyber Behavior (pp.735-753). Pennsylvania: IGI Global.

McCormack, A. & Griffiths, M.D. (2013). A scoping study of the structural and situational characteristics of internet gambling. International Journal of Cyber Behavior, Psychology and Learning, 3(1), 29-49.

Meyer, G., Hayer, T. & Griffiths, M.D. (2009). Problem Gaming in Europe: Challenges, Prevention, and Interventions. New York: Springer.

Parke, J. & Griffiths, M.D. (2007). The role of structural characteristics in gambling. In G. Smith, D. Hodgins & R. Williams (Eds.), Research and Measurement Issues in Gambling Studies (pp.211-243). New York: Elsevier.

Pontes, H. & Griffiths, M.D. (2014). The assessment of internet gaming disorder in clinical research. Clinical Research and Regulatory Affairs, 31(2-4), 35-48.

Zangeneh, M., Griffiths, M.D. & Parke, J. (2008). The marketing of gambling. In Zangeneh, M., Blaszczynski, A., and Turner, N. (Eds.), In The Pursuit Of Winning (pp. 135-153). New York: Springer.

The must of lust discussed: Why isn’t sex addiction in the DSM-5?

Please note: A shorter and slightly different version of this blog first appeared on addiction.com

Sex addiction appears to be a highly controversial area among both the general public and those who work in the addiction field. Some psychologists adhere to the position that unless the behaviour involves the ingestion of a psychoactive substance (e.g., alcohol, nicotine, cocaine heroin), then it can’t really be considered an addiction. But I’m not one of them. If it were up to me, I would have given serious consideration to including sex addiction in the latest (fifth) edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Given that ‘gambling disorder’ was reclassified from a disorder of impulse control to a behavioural addiction in the DSM-5, there is now no theoretical reason why other behavioural addictions can’t be added in the years to come. So why wasn’t sex addiction included in the latest DSM-5? Here are some possible reasons.

Some researchers think that sex addiction just doesn’t exist (for moral and theoretical reasons): Many scholars have attacked the whole concept of sex addiction saying it is a complete myth. It’s not hard to see why, as many of the claims appear to have good face validity. Many sociologists would argue that ‘sex addiction’ is little more than a label for sexual behaviour that significantly deviates from society’s norms. The most conventional attack on sex addiction is a variation on the position outlined in my introduction (i.e., that ‘addiction’ is a physiological condition caused by ingestion of physiological substances, and must therefore be defined physiologically). There are also attacks on more moral grounds with people saying that if excessive sexual behaviour is classed as an addiction it undermines individuals’ responsibility for their behaviour (although this argument could be said of almost any addiction).

The word ‘addiction’ has become meaningless: There are also those researchers within the social sciences who claim that the every day use of the word ‘addiction’ has rendered the term meaningless (such as people saying that their favorite television show is ‘addictive viewing’ or that certain books are ‘addictive reading’). Related to this is that those that work in the field don’t agree on what the disorder (e.g. ‘sex addiction’, ‘sexual addiction’, ‘hypersexuality disorder’, ‘compulsive sexual behaviour’, ‘pornography addiction’, etc.) should be called and whether it is a syndrome (i.e., a group of symptoms that consistently occur together, or a condition characterized by a set of associated symptoms) or whether there are many different sub-types (pathological promiscuity, compulsive masturbation, etc.). 

There is a lack of empirical evidence about sex addiction: One of the main reasons that sex addiction is not yet included in the DSM-5 is that the empirical research in the area is relatively weak. Although there has been a lot of research, there has never been any nationally representative prevalence surveys of sex addiction using validated addiction criteria, and a lot of research studies are based upon those people who turn up for treatment. Like Internet Gaming Disorder (which is now in the appendix of the DSM-5), sex addiction (or more likely ‘Hypersexual Disorder’) will not be included as a separate mental disorder until the (i) defining features of sex addiction have been identified, (ii) reliability and validity of specific sex addiction criteria have been obtained cross-culturally, (iii) prevalence rates of sex addiction have been determined in representative epidemiological samples across the world, and (iv) etiology and associated biological features of sex addiction have been evaluated.

The term ‘sex addiction’ is used an excuse to justify infidelity: One of the reasons why sex addiction may not be taken seriously is that the term is often used by high profile celebrities as an excuse by those individuals who have been sexually unfaithful to their partners (e.g., Tiger Woods, Michael Douglas, David Duchovny, Russell Brand). In some of these cases, sex addiction is used to justify the individual’s serial infidelity. This is what social psychologists refer to as a ‘functional attribution’. For instance, the golfer Tiger Woods claimed an addiction to sex after his wife found out that he had many sexual relationships during their marriage. If his wife had never found out, I doubt whether Woods would have claimed he was addicted to sex. I would argue that many celebrities are in a position where they were bombarded with sexual advances from other individuals and succumbed. But how many people wouldn’t do the same thing if they had the opportunity? It becomes a problem only when you’re discovered, when it’s in danger of harming the celebrity’s brand image.

The evidence for sex addiction is inflated by those with a vested interest: One of the real issues in the field of sex addiction is that we really have no idea of how many people genuinely experience sex addiction. Sex addiction specialists like Patrick Carnes claims that up to 6% of all adults are addicted to sex. If this was really the case I would expect there to be sex addiction clinics and self-help support groups in every major city across the world – but that isn’t the case. However, that doesn’t mean sex addiction doesn’t exist, only that the size of the problem isn’t on the scale that Carnes suggests. Coupled with this is that those therapists that treat sex addiction have a vested interest. Out simply, there are many therapists worldwide who make a living out of treating the disorder. Getting the disorder recognized by leading psychological and psychiatric organizations (e.g., American Psychiatric Association, World Health Organization) legitimizes the work of sex addiction counselors and therapists so it is not surprising when such individuals claim how widespread the disorder is.

There may of course be other reasons why sex addiction is not considered a genuine disorder. Compared to behavioural addictions like gambling disorder, the empirical evidence base is weak. There is little in the way of neurobiological research (increasingly seen as ‘gold standard’ research when it comes to legitimizing addictions as genuine). But carrying out research on those who claim to have sex addiction can face ethical problems. For instance, is it ethical to show hardcore pornography to a self-admitted pornography addict while participating in a brain neuroimaging experiment? Is the viewing of such material likely to stimulate and enhance the individual’s sexual urges and result in a relapse following the experiment? There are also issues surrounding cultural norms. The normality and abnormality of sexual behaviour lies on a continuum but what is considered normal and appropriate in one culture may not be viewed similarly in another (what is often referred to by sociologists as ‘normative ambiguity’). Personally, I believe that sex addiction is a reality but that it affects a small minority of individuals. However, many sex therapists claim it is on the increase, particularly because the Internet has made sexual material so easy to access. Maybe if sex addiction does eventually make it into future editions of the DSM, it will be one of the sub-categories of Internet Addiction Disorder rather than a standalone category.

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

Further reading

Dhuffar, M. & Griffiths, M.D. (2014). Understanding the role of shame and its consequences in female hypersexual behaviours: A pilot study. Journal of Behavioural Addictions, 3, 231–237.

Dhuffar, M. & Griffiths, M.D. (2015). A systematic review of online sex addiction and clinical treatments using CONSORT evaluation. Current Addiction Reports, DOI 10.1007/s40429-015-0055-x

Goodman, A. (1992). Sexual addiction: Designation and treatment. Journal of Sex and Marital Therapy, 18, 303-314.

Griffiths, M.D. (2000). Excessive internet use: Implications for sexual behavior. CyberPsychology and Behavior, 3, 537-552.

Griffiths, M.D. (2001). Sex on the internet: Observations and implications for sex addiction. Journal of Sex Research, 38, 333-342.

Griffiths, M.D. (2001). Addicted to love: The psychology of sex addiction. Psychology Review, 8, 20-23.

Griffiths, M.D. (2010). Addicted to sex? Psychology Review, 16(1), 27-29.

Griffiths, M.D. (2012). Internet sex addiction: A review of empirical research. Addiction Research and Theory, 20, 111-124.

Griffiths, M.D. & Dhuffar, M. (2014). Treatment of sexual addiction within the British National Health Service. International Journal of Mental Health and Addiction, 12, 561-571.

Kafka, M. P. (2010). Hypersexual disorder: A proposed diagnosis for DSM-V. Archives of Sexual Behavior, 39, 377–400.

Orford, J. (2001). Excessive sexuality. In J. Orford, Excessive Appetites: A Psychological View of the Addictions. Chichester: Wiley.