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Episode 54

Donald Black, MD, gives a masterclass lecture on behavioral addictions and Renee Kohanski talks about what normal is. 

Show Notes By Jacquiline Posada, MD.

• Gambling disorder (previously pathological gambling) is widespread, though not commonly assessed
• Patients may not volunteer information related to gambling unless asked, so questions about gambling should be included in routine questioning
• Assessment should include questions about legal and illegal gambling
• • Explore extent: Ask about the level of financial burden; impact on home life, such as marital problems and divorce; legal complications like bankruptcy. Finally, ask about suicide risk related to gambling 
• Treatment: There is strong data for SSRI medications and naltrexone for urges
• • Therapy is more efficacious, such as CBT therapy and Gamblers Anonymous 
  • In certain states, such as Iowa, a person can ask for "self-exclusion," which is essentially banning oneself from a casino or lottery. Also, participation in gambling results in arrest

Behavioral addictions: Behavior that is out of control and has qualities and consequences similar to drug and alcohol addiction

• Examples include gambling disorder, compulsive buying, compulsive sexual behaviors (hypersexuality), and Internet addiction
• • Gambling disorder is similar enough to substance addictions that it is included in the DSM-5 in the "substance-related and addictive disorder"
  • Addiction neurocircuitry active in these behavioral addictions: Dopamine driven in the nucleus accumbens
• Compulsive shopping: primarily a female disorder, onset in late 20s, with shopping and spending that are chronic and problematic
• • CBT programs developed to target compulsive shopping, studies about medications for this disorder are mixed
• Compulsive sexual behavior: Primarily a male disorder affecting 5% of the population; onset late teens, early 20s. The addiction will combine conventional sexual behaviors taken to extremes often combined with an addiction to pornography
• • This disorder will often overlap with an Internet addiction
  • No evidence-based treatments exist, though CBT-driven models and 12-step programs exist
  • SSRI or TCA antidepressants may be helpful in dampening sex drive
• Internet addiction has developed in our technologically enabled world; most psychiatrists have encountered this addiction.
• •  Most data come from Asia, where children are exposed to technology at an even earlier age than in the U.S.
  • China has developed residential treatment programs involving individual and group therapies. 

References

• Black DW. Can J Psychiatry. 2013 May;58(5):249-51. "Behavioral addictions as a way to classify behaviors"
• Dell'Osso B et al. Eur Arch Psychiatry Clin Neurosci. 2006 Dec;256(8):464-75. "Epidemiologic and clinical updates on impulse control disorders: a critical review"
• National Council on Problem Gambling. State by state help for problem gambling
• Zajac K et al. Psychol Addict Behav. 2017 Dec;31(8):979-94. "Treatments for Internet gaming disorder and Internet addiction: A systematic review"