Mednotes

L3 Psych Med Vertical Behavioural addictions

Properties2
tagspsychmedvertical, lecture
aliasesL3 Psych Med Vertical Behavioural addictions

24 min read

Overview

A vertical-module lecture on behavioural (non-substance) addictions, taught by a clinical psychologist and the clinical manager of the Specialist Addiction Service. It moves through five sections: definitions and neuropsychology, diagnosis, prevalence, impact, and treatment/management. The unifying idea is that behaviours can drive the same dopamine reward pathway as substances, so they produce the same neuroadaptations, meet formal DSM-5-TR criteria (gambling disorder), and respond to the same tiered clinical approach: routine inquiry, screening, brief intervention, and referral. The lecture opens with the whakataukī “He aroha whakatō, he aroha puta mai” (if kindness is sown, then kindness you shall receive), glossed as showing that generous and supportive actions are often reciprocated.

Learning objectives

The lecture sets seven objectives:

  1. Define behavioural addiction.
  2. Know the difference between behavioural and chemical/substance addictions.
  3. Understand the difference between addiction and dependence.
  4. Discuss the neuropsychology of addiction, with specific reference to dopamine and the brain’s pleasure-pain balance.
  5. Describe how doctors can screen for addictions, including behavioural addictions.
  6. Describe how doctors can treat people suffering from addiction, including behavioural addictions.
  7. Indicate when and where doctors can refer people suffering from addiction, including behavioural addictions.

Defining addiction

  • Etymology: from the Latin addictus, meaning “to devote, sacrifice, sell out, betray, or abandon”.
  • The term is commonly used to refer to a form of self-imposed enslavement.
  • Addiction, American Psychiatric Association definition: “Continued, compulsive use of substances or behaviours despite harmful consequences”.
  • Non-substance-related / process / behaviour addiction is defined as the overwhelming impulse to engage in a certain behaviour despite negative consequences.
  • Popular media portrayals of substance and behavioural addiction were shown as examples (The Queen’s Gambit, House M.D., PainKiller, Black Rabbit).

Addiction versus dependence

Two separate constructs, each with its own defining features.

  • Addiction, the 4 C’s: Consequences, Cravings, Compulsions, Control.
  • Dependence: Tolerance and Withdrawal.

Neuropsychology: dopamine and the pleasure-pain balance

  • Dopamine has an important role in addiction. The slide reproduces the standard synaptic dopamine pathway: dopaminergic (dopamine-producing) nerve cells, synaptic vesicle, dopamine, synaptic cleft, dopamine receptor, dopamine metabolites, signal, and dopamine-receiving nerve cells.
  • The same dopamine pathway diagram is used again to show dopamine release during behavioural addictions, with gambling (pokies/slot machines) and phone/dating-app use as the triggering behaviours. This is the lecture’s core link between behavioural and substance addiction: the behaviour drives the same release pathway.
  • The brain’s pleasure-pain balance is presented as a see-saw between pleasure and pain, shown in the non-addicted state as a balance and in addiction as a scale tipped so that a small reward is outweighed.
  • In addiction, neuroadaptations in the brain drive two outputs: tolerance and cross addiction. The slide names cross addiction as an output but does not define the term. [slide does not elaborate]

Warning

On the dopamine slide, coloured arrows link a cricket-match action photo to specific labelled parts of the dopamine diagram, apparently illustrating that an exciting or unpredictable sporting moment triggers dopamine release comparable to addictive behaviours. The arrows are not captioned, so the precise intended mapping between each arrow and each diagram element is not stated on the slide.

Common types of behavioural addiction

Eleven categories are listed: shopping, gaming, plastic surgery, binge eating, social media, exercise, work, gambling, pornography, internet / ipurangi, sex.

Diagnosis: gambling disorder (DSM-5-TR)

Gambling disorder (F63.0) is classified under non-substance-related disorders.

Core criterion: persistent and recurrent problematic gambling behaviour leading to clinically significant impairment or distress, as indicated by four or more of the following in a 12-month period:

  1. Needs to gamble with increasing amounts of money in order to achieve the desired excitement.
  2. Is restless or irritable when attempting to cut down or stop gambling.
  3. Has made repeated unsuccessful efforts to control, cut back, or stop gambling.
  4. Is often preoccupied with gambling (persistent thoughts of reliving past gambling experiences, handicapping or planning the next venture, thinking of ways to get money with which to gamble).
  5. Often gambles when feeling distressed (helpless, guilty, anxious, depressed).
  6. After losing money gambling, often returns another day to get even (“chasing” one’s losses).
  7. Lies to conceal the extent of involvement with gambling.
  8. Has jeopardised or lost a significant relationship, job, or educational or career opportunity because of gambling.
  9. Relies on others to provide money to relieve desperate financial situations caused by gambling.

Exclusion: the gambling behaviour is not better explained by a manic episode.

Course specifiers:

  • Episodic: meeting diagnostic criteria at more than one time point, with symptoms subsiding between periods of gambling disorder for at least several months.
  • Persistent: experiencing continuous symptoms, meeting diagnostic criteria for multiple years.

Remission specifiers:

  • In early remission: after full criteria were previously met, none of the criteria have been met for at least 3 months but for less than 12 months.
  • In sustained remission: after full criteria were previously met, none of the criteria have been met during a period of 12 months or longer.

Severity specifiers:

  • Mild: 4 to 5 criteria met.
  • Moderate: 6 to 7 criteria met.
  • Severe: 8 to 9 criteria met.

Prevalence: New Zealand gambling statistics

  • New Zealanders spent 371 million more than the previous year (source: pgf.nz).

Ministry of Health intervention-service data, years July 2004/June 2005 through July 2022/June 2023:

  • Total clients (all interventions): total clients rose sharply from about 2,500 in 2004/05 to a peak of about 13,000 around 2010/11, then declined gradually to about 10,500 by 2022/23. New clients follow a similar but lower curve (peak about 10,000, ending about 7,500). Existing clients rise slowly and stay low throughout (about 2,500 to 3,000).
  • By ethnicity: “Other” rises earliest and highest, peaking about 7,000 around 2010/11 then declining to about 5,000 to 5,500. Māori rise to a plateau around 4,000 to 5,000. Pacific stay lower, ending around 2,500 to 3,000. Asian are lowest throughout, rising gradually to about 1,500 to 2,000.
  • By gender: female and male lines track closely together throughout, both rising from about 1,500 to 2,000 to a peak of about 6,500 to 7,000 around 2010/11 to 2015/16, then declining to about 4,500 to 5,000 by 2022/23, with female consistently slightly above male.
  • By client type: gamblers rise from about 2,500 to a peak of about 9,500 around 2010/11, then decline and fluctuate around 6,000 to 7,000. Family/affected others stay consistently lower, rising gradually from about 500 to about 4,000 with a slight decline toward the end. The service therefore also carries a substantial caseload of people affected by someone else’s gambling.
  • By age group (excluding brief interventions, 2016/17 to 2022/23): the age-band composition of clients is broadly stable across these years, with 25-34, 35-44 and 45-54 forming the large bands and the older and younger bands smaller.

Impact

  • The lecture frames harm as a property of the product, not the person. Quoted: “It’s about addictive pokie machines and harmful gambling products, not about the individual … the choice is actually taken away when it starts impacting your brain … it’s like a dopamine hit, and pokie machines are designed to be addictive. So once somebody starts gambling and if they’re gambling regularly, once they actually get addicted, their brain is telling them ‘gamble more, gamble more’.”
  • Machine design exploits the reward system: “The pokie machine’s got bells and whistles that happen when you’ve nearly won, even if you haven’t actually won.” The near-miss is rewarded like a win.
  • Case example: New Zealand footballer Clayton Lewis, “The $10,000 decision that cost an All White his career”. His lawyer told the court that Lewis was in the grips of a serious gambling addiction when he was “targeted and exploited” by his team captain.
  • Quoted on demographics: “There’s a problem that almost nobody speaks about in New Zealand society, which is the prevalence and the extent of gambling addiction. But of all the demographics, the really serious one is young athletes, particularly young male athletes.”
  • Imagery of financial and compulsive-screen harm accompanies this section (stock-trading on a phone, scattered dollar bills, a person chained before a burning monitor).

Treatment and management

Overall approach: a combination of psychotherapies, pharmacotherapy, and support groups.

Evidence from the cited review (Bodor, Ricijaš and Filipčić, “Treatment of gambling disorder: review of evidence-based aspects for best practice”):

  • Problem: despite a significant body of literature on treatment, there are still insufficient evaluation studies of effectiveness, and no firm conclusions on which specific treatment elements contribute to it.
  • The most successful therapeutic protocols are psychological interventions, especially those based on cognitive-behavioural therapy/methods and/or motivational interviewing.
  • Other interventions with promising results: different self-help interventions, and mindfulness.
  • Couples therapy and support groups may have positive effects in terms of increasing therapeutic adherence and retention.
  • Pharmacotherapy is especially useful in patients with comorbidities.
  • Summary: gambling disorder is a complex mental health problem caused by a wide spectrum of biological, psychological and social risk factors. Treatment options need to be wide, flexible, accessible and economically justified, providing early inclusion, retention, and sustainability of long-term effects, that is, abstinence and higher quality of psychosocial functioning.

Treatment components, with cognitive behavioural therapy at the centre and five complementary/overlapping components around it:

  • CBT: gold standard (the central component).
  • Motivational interviewing.
  • Pharmacotherapy.
  • Group therapy and support groups.
  • Mindfulness-based interventions.
  • Financial counselling and relapse prevention.

What this means for you as a future doctor

A four-step clinical sequence:

  1. Routine inquiry.
  2. Screening and diagnosis.
  3. Treatment (given as “Treatment (Brief Intervention)” on its first appearance and simply as “Treatment” on its second).
  4. Refer for professional support.

You are not expected to be an expert. Stated requirement: if you are not an expert in alcohol, tobacco, other drugs and gambling, “a basic understanding of risks and harms and a working knowledge of simple interventions to reduce harm, including referral options, are the essential requirements.”

The DRUGS mnemonic for screening and brief intervention

Attributed to Anna Lembke, MD, Professor of Psychiatry and Behavioral Sciences, Stanford Medicine:

  • D: Data.
  • R: Reasons for use.
  • U: Unintended consequences.
  • G: Gedankenexperiment.
  • S: Second look.

[slide gives the five words only and does not elaborate on each step]

Stages of brief intervention

In order:

  1. Introduce the subject.
  2. Screen (= Ask).
  3. Provide feedback and brief advice.
  4. Listen for readiness and confidence.
  5. Provide further brief intervention.

Then exit. The governing rule: exit at any stage if the person indicates that they do not wish to continue.

Matching intervention to level of risk and harm

A three-tier pyramid (adapted from SAMHSA 2006), top to bottom:

Level of risk and harmIntervention type
Dependent/addictedRefer to specialist service if possible
Harmful or hazardous use/behaviourProvide brief intervention
Low risk or abstinentAffirm, no further intervention

Principles of care

The SPIRIT of CEP, four stated elements [slide does not expand either acronym]:

  • Person-focused care: personal strengths, vision of well-being, and meaning in life.
  • Wellbeing-orientated care: using quality of life as the most important outcome, and focusing equally on enhancing positive attributes and removing barriers to well-being.
  • Integrated care: driving care from the needs of the person and fitting the service around these rather than vice versa.
  • Walking the talk: put it into practice, incorporate specific techniques into clinical work.

The 7 key principles, presented as interlocking gears that work together as connected parts of one system: Cultural, Wellbeing, Integration, Motivation, Engagement, Assessment, Management.

Strategies to enhance engagement

Explore values and vision of well-being. Treat hostility and emotional dysregulation early. Clearly structured sessions. Adapt to coping style. MI engagement interview. Cognitive mapping. Peer support to engage. Remove barriers. Consistency of approach. Adapt for cultural needs. Autonomy-supportive environment (3 to 5 choices). Assertive follow-up.

Screening and assessment

Screening tools must be formal evidence-based tools that have a proven validity, with scores that reflect substance use issues. To be effective they should be:

  • Easily available.
  • Brief and easy to score.
  • Able to identify all those likely to have a problem.

Assessment sequence:

  1. Screening, for example WHO ASSIST, EIGHT, Modified MINI, SACS.
  2. Triage.
  3. Comprehensive assessment: diagnoses, CEP not only primary or secondary.
  4. Individual problems: physical health, ABI, relationships, parenting, employment.
  5. Formulation: vulnerability, triggers, maintaining factors and strengths.

CAGE-AID

Each affirmative response earns one point. One point indicates a possible problem. Two points indicate a probable problem and require further assessment. All four items use a six-month time frame and are answered yes/no:

  1. In the last six months, have you felt you should cut down or stop drinking or using drugs?
  2. In the last six months, has anyone annoyed you or gotten on your nerves by telling you to cut down or stop drinking or using drugs?
  3. In the last six months, have you felt guilty or bad about how much you drink or use drugs?
  4. In the last six months, have you been waking up wanting to have an alcoholic drink or use drugs?

AUDIT alcohol screen

Only complete this screen if the person has consumed any alcohol in the past 12 months. The ten questions cover use of alcoholic beverages during the last 12 months. A “drink” is defined as 300 mL (half pint of beer), 100 mL (small glass of wine) or 30 mL (single spirits).

The response options differ by item, so score each item on its own scale:

Alcohol consumption subscale (items 1 to 3)

  1. How often do you have a drink containing alcohol? Never 0, Monthly or less 1, 2 to 4 times a month 2, 2 to 3 times a week 3, 4 or more times a week 4.
  2. How many drinks containing alcohol do you have on a typical day when you are drinking? 1 or 2 = 0, 3 or 4 = 1, 5 or 6 = 2, 7 to 9 = 3, 10 or more = 4. (A quantity item, not a frequency item.)
  3. How often do you have six or more drinks on one occasion? Never 0, Less than monthly 1, Monthly 2, Weekly 3, Daily or almost daily 4.

Add items 1, 2 and 3. At risk of harm if men score 5 or more or women score 4 or more.

Symptoms of dependence subscale (items 4 to 6), each scored Never 0, Less than monthly 1, Monthly 2, Weekly 3, Daily or almost daily 4:
4. How often during the last year have you found that you were unable to stop drinking once you had started?
5. How often during the last year have you failed to do what was normally expected from you because of drinking?
6. How often during the last year have you needed a first drink in the morning to get yourself going after a heavy drinking session?

Add items 4, 5 and 6. 4 or more indicates you may be psychologically or physically dependent on alcohol.

Alcohol-related problems subscale (items 7 to 10)
7. How often during the last year have you had a feeling of guilt or remorse after drinking? Never 0, Less than monthly 1, Monthly 2, Weekly 3, Daily or almost daily 4.
8. How often during the last year have you been unable to remember what happened the night before because you had been drinking? Never 0, Less than monthly 1, Monthly 2, Weekly 3, Daily or almost daily 4.
9. Have you or someone else been injured as the result of your drinking? No 0, Yes but not in the last year 2, Yes during the last year 4.
10. Has a relative, friend, or a doctor or other health worker been concerned about your drinking or suggested you cut down? No 0, Yes but not in the last year 2, Yes during the last year 4.

Add items 7 to 10. 4 or more indicates significant problems. Note that items 9 and 10 use a three-option 0/2/4 scale, not the five-option 0 to 4 scale.

Total AUDIT score is the total of all the sub-scales, that is, the total of the answers to all the questions. Interpret in conjunction with the sub-scale scores where appropriate:

  • 0 to 7: low risk drinking.
  • 8 to 12: risky drinking.
  • 13 or more: problematic or dependent drinking.

Referral: the Specialist Addiction Service

Specialist Addiction Service (SAS) / Tohunga Puawaitanga Ratonga, Te Whatu Ora. Main Block, Ground Floor, Wakari Hospital, Taieri Road, Dunedin. Phone 476 9760 or 0800 44 33 66. Email SAS.Otago@southerndhb.govt.nz. Emergency Psychiatric Services: (03) 474 0999 or 0800 44 33 66.

What SAS provides:

  • Assessment of needs in relation to addiction.
  • One-to-one counselling and case management in relation to substance use.
  • Opioid Substitution Treatment (OST).
  • Assessment and referral to residential addiction services, including medical withdrawal (detox) services.
  • Advice and support regarding compulsory treatment under the Substance Addiction Act.

Regional SAS contacts: Dunedin (Main Block, Wakari Hospital) (03) 476 9760; Waitaki (2 Trent St, Oamaru) (03) 433 0002; Clutha (24 Clyde St, Balclutha) (03) 419 0440; Dunstan (Hospital St, Clyde) (03) 440 4308; Queenstown (9 Douglas St, Frankton) (03) 441 0010; Invercargill (Elles Road, Gate 2, Southland Hospital) (03) 214 5786.

Conclusion of the lecture: recovery is [IM]POSSIBLE, presented as the word “IMPOSSIBLE” with the “IM” cut off, that is, recovery is possible.

Looking after yourself, and other resources

Dealing with addiction can be very stressful and dangerous, and dealing with disclosures and requests for support can also be challenging. What you can do:

  • Discuss with peers and senior colleagues (multidisciplinary team).
  • Utilise supervision processes wherever available.
  • Seek support for yourself, and/or refer patients.

Services given:

  • Student Health services: free phone 0800 479 821, tel 64 3 479 8212 (or 8212 within the University).
  • Associate Dean Student Affairs: penelope.eames@otago.ac.nz, tess.patterson@otago.ac.nz.
  • Alcohol and drug helpline: 0800 787 797.
  • Gambling Helpline NZ: 0800 654 655 or text 8006. Māori Gambling Helpline: 0800 654 656.
  • Overeaters Anonymous South Island: (03) 365 3812.
  • Support groups: Al-Anon 0508 425266; Alcoholics Anonymous 0800 229 6757; Narcotics Anonymous 0800 628 632. Various anonymous groups, meeting places and times at https://www.12steps.nz/.
  • Family (whānau) support, Able Southern Family Support: Dunedin (03) 455 5973; Invercargill (03) 218 2100; Alexandra (03) 448 9303; Oamaru (03) 434 1130.

Self-test

  1. Define addiction using the American Psychiatric Association definition given in the lecture.
  2. Give the Latin origin of the word “addiction” and its meaning.
  3. Define non-substance-related (process/behaviour) addiction.
  4. List the 4 C’s of addiction and state what distinguishes dependence from addiction.
  5. Name the two consequences that neuroadaptations in the brain are shown to drive in addiction.
  6. Describe, in order, the components of the synaptic dopamine pathway as the lecture labels it.
  7. Explain the link the lecture draws between behavioural addictions such as gambling and phone use, and substance addiction.
  8. List at least eight of the eleven common types of behavioural addiction given.
  9. State the core diagnostic criterion for gambling disorder: how many criteria, over what period, and with what consequence for the person.
  10. List six of the nine DSM-5-TR criteria for gambling disorder.
  11. What condition must gambling behaviour not be better explained by, for gambling disorder to be diagnosed?
  12. Distinguish the episodic from the persistent course specifier for gambling disorder.
  13. Distinguish early remission from sustained remission in gambling disorder.
  14. Give the criterion counts for mild, moderate and severe gambling disorder.
  15. How much did New Zealanders spend on gambling in the 2021/22 financial year, and how much was that above the previous year?
  16. Describe the trend in total clients recorded for gambling interventions from 2004/05 to 2022/23.
  17. What does the client-type graph show about who uses gambling intervention services, besides gamblers themselves?
  18. Which gender has consistently slightly more clients assisted, and how do the two lines compare in shape?
  19. Explain how pokie machine design contributes to harm, according to the quote used in the lecture.
  20. Which demographic did the 1News interviewee single out as the “really serious one” for gambling addiction in New Zealand?
  21. According to the cited review, which therapeutic protocols are the most successful for gambling disorder, and in which patients is pharmacotherapy especially useful?
  22. Name the central treatment component in the lecture’s treatment diagram and the five components surrounding it.
  23. List the four steps of the doctor’s role in addiction, from routine inquiry onwards.
  24. What does the lecture say is the essential requirement for a doctor who is not an expert in alcohol, tobacco, other drugs and gambling?
  25. Expand the DRUGS mnemonic.
  26. List the stages of a brief intervention in order, and state the rule about exiting.
  27. A patient screens as engaging in harmful or hazardous use. What intervention type does the risk pyramid direct you to, and what would you do instead if they were dependent/addicted, or low risk/abstinent?
  28. Name the four elements of the SPIRIT of CEP and give the content of two of them.
  29. List the 7 key principles.
  30. State the three requirements for a screening tool to be effective, and the standard the tools themselves must meet.
  31. List the five steps of the assessment sequence, and name two screening tools given as examples.
  32. Give the two scoring thresholds for CAGE-AID and the time frame its items use.
  33. A man completes the AUDIT and reports drinking 2 to 3 times a week, typically 5 or 6 drinks, with six or more drinks on one occasion less than monthly. Calculate his alcohol consumption subscale score and state whether he is at risk of harm.
  34. Why can you not score AUDIT item 1 using the “Never / Less than monthly / Monthly / Weekly / Daily or almost daily” scale?
  35. Give the three total-score bands for the AUDIT and their interpretations.
  36. What subscale score on AUDIT items 4 to 6 suggests possible psychological or physical dependence?
  37. Name four services offered by the Specialist Addiction Service.
  38. What three things does the lecture advise you to do for yourself when dealing with addiction disclosures?

Answers

Graph View

Backlinks