The term ‘addiction’ is an often over-used description when used by the general public, and reluctantly used by many mainstream health providers because the term doesn’t currently appear in mental health assessment manuals (1),(2). It is essentially a lay term that has a range of definitions, but is an accepted term that most would apply to a person’s dependence upon the use of a ‘strong’ substance when speaking literally, and upon broad range of lesser substances, or, more recently, behaviours when speaking figuratively. An example of the latter may be ‘I’ve become addicted to coffee!’ or ‘I’m addicted to watching Coronation Street’. Unfortunately by aligning behaviours with these ‘lesser’ substances, the general perception may be that behaviours that are often categorized as addictions, are less problematic than stronger substances such as alcohol, nicotine, or even methamphetamines.

What is an ‘addiction’ ?
A general description of an addiction to a stronger substance would generally include a preoccupation with obtaining and using the substance, requiring more of the substance over time to maintain the same effect as in the past (developing a ‘tolerance’), negative effects when trying to cut down or stop its use (‘withdrawal effects’) and continued use despite negative effects. Another may be unsuccessful attempts to cut down or stop using the drug. These symptoms are described in dependence terms in the diagnostic literature, particularly as psycho-active substance dependence. Yet many behaviours will develop similar symptoms, with the possibility that the withdrawal effects appear to be less acute physically. Examples of behaviours that appear to indicate that a person may have lost much of the control to reduce or stop repeating the behaviour are problem gambling, ‘compulsive’ spending or buying, sexual addiction and Internet pornography viewing, and even ‘video’ game addiction. Only the first behaviour, problem gambling when at its extreme Pathological Gambling Disorder) (1), is recognized by diagnostic criteria, and then only in a wash-up category labelled Impulse Disorders Not Categorised Elsewhere. Some of the criticisms reached to inclusion of behaviours as a serious addiction could be the absence of some of the biological ‘markers’ in the central nervous system (CNS) found with substance dependence, and the inability to determine whether the person has lost control of their ability to stop the behaviour (or simply chooses not to). Yet the inability to identify physical changes to the CNS doesn’t mean they don’t exist and proof of inability to stop can just as easily be said of substance dependence. More likely may be the readiness of society to label behaviours as ‘addictive’ reduces health professionals from treating these as a serious category, while most addictive substances are readily identified as toxic in larger quantities. However, there are now indications that behavioural addictions may be welcomed into the fold of ‘addictions’ as new definitions develop for an addiction that suggest there may be an underlying risk that may be displayed in a range of specific drug or behavioural excesses (3). This however is still at the discussion stage and behaviours appear to remain largely unaccepted at the mainstream diagnostic table. A logical conclusion could be reached that these behaviours are less problematic than chemicals even when symptoms are common to both. Indeed, many members of the public appear to assume that, for example, problem gambling and excessive Internet pornography viewing, even in extreme quantities, are due to weakness or indulgence on the part of the person. During the past decade of training many health professionals, social workers and even industry representatives in identifying problem gamblers, there has been an initial perception that people with gambling issues could change their behaviour if they chose to.

Behavioural addictions do have varying degrees of harm that result from them, however the most problematic has been problem gambling, with Internet pornography addiction possibly coming in second place.

Internet Pornography Addiction
Taking the lesser problem first, this is not something that is even considered as a widespread issue, or if so, is considered to be irretrievably linked to paedophilia. And therein perhaps lies the problem. Almost all of thee individuals are likely to be males from the limited help-seeking that occurs. There is the view that these may be dangerous people who will ultimately be driven by their predilection to prey on women or even children. Yet in many cases, people who develop this behaviour are anxious, self-critical individuals who are less able to participate in a real life relationship, and prefer the range, accessibility, control without rejection, and become fixated upon the perfection that only digital photography can provide. As previously exciting images become boring, often more explicit images become necessary, but moreso new images that can be displayed and promptly discarded. With explicit images come likelihood that these images will cause both shock and disgust if discovered by a family member, or perhaps more likely, an employer. Many employers regard accessing pornography as contrary to company policy with termination of employment being a likely event. Little research has been carried out in this field, largely because of the reluctance of people to disclose their behaviour. It was noted in the ’60 Minutes’ programme on Internet pornography in 2003 that many organizations contacted during the programme stated off-the-record that accessing pornography was a major reason for termination of employment. My own clients who seek help for his behaviour are often living under substantial stress, afraid of disclosure in new employment, often accessing pornography when stress is high, and using the behaviour as a temporary stress reducer that appears to occur without conscious planning. Shame and guilt creates a cycle of increased accessing of images, longer sessions, and greater likelihood of disclosure. When images become too explicit there is always the possibility of an offence under the Films, Videos & Publications Act 1993 where the images are identified as degrading. Disclosure can result in loss of employment, depression, relationship problems, and social repugnance. Isolation from support, loss of future employment opportunities, public exposure when images become too explicit, and depression can result in suicidal ideation.

Pathological or compulsive gambling
Greater knowledge and understanding exists for this addiction, although misconceptions abound as to ability to control. Currently both males and females may be affected in equal numbers, largely due to the predominance of problems due to gambling machines (4). These machines are more likely to be accessed by females and appear to be more addictive, and within a much briefer period. Problem gambling in modes where there are greater skill factors, such as track racing and sports gambling, are almost entirely represented by males. An over-estimate in predictive outcomes and in skills to perceive them can cause substantial losses by male gamblers within a relatively brief period. As the ‘chasing’ of losses increase, preoccupation with gambling on the specific mode increases, and gambling may be perceived as both the cause of, and solution to, the growing problem. Depression, anxiety and alcohol misuse between gambling sessions become commonplace, with family and work dysfunction isolating the gambler, and realization that losses exceed ability to make good the damage (5). Often lines are crossed that may first be explained by skewed self-thoughts, such as ‘borrowing’ rather than stealing growing amounts of money to sustain the gambling. Once again, thoughts of suicide become commonplace as a solution to insurmountable debt and relationship damage, with isolation, loss of future opportunities contributing to the decision. Lack of symptoms of the gambling then work against the inability to convince family members of gambling restraint. Pressure of creditors, lack of trust from others over extended periods, inability to adjust from ‘instant gratification’ of stress reduction (through gambling) to delayed gratification or ongoing pressures, can gradually resolve into attempts on one’s life. The diagnostic criteria indicate that 20% of those who meet Pathological Gambling Disorder will attempt suicide (1). Research again is difficult to conduct, because of both the lack of sound data collection and the misattribution of many vehicle ‘accidents’ as due to the influence of alcohol. A recent study of people admitted to hospital after a suicide attempt found 17% were positive on a problem gambling screen, compared with an estimated 2% of the population meeting the criteria of Pathological Gambling Disorder (6).

Males affected by behavioural addictions with suicidal ideation
Males often present with cognitive explanations for their behaviour, and may be uncomfortable initially discussing emotional effects of the behaviour on themselves. Suppressed emotions can seem appropriate to many males where partners are displaying high levels of emotion as a result of disclosure of an unexpected crisis. Cognitive rationale, however skewed, can appear to be far more acceptable than emotion, especially where there is an underlying acceptance of responsibility, shame and guilt that purveys the thoughts of the male with a behavioural addiction. Inability to control the behaviour is a weakness that can appear unacceptable to a considerably damaged male sense of self.

Yet there can be a readiness to talk about past thoughts of suicidal ideation if broached directly, although these can be dismissed with poorly considered rationale. A common statement may be that they could not take their own life because they could not leave their children or wife unsupported. This can just as quickly change to a rationale (by the gambler) that they would be better off without the gambler.

Approaching the question unemotionally can be an effective and necessary process when dealing with problem gambling, or where there has been a crisis with Internet pornography addiction. Normalising the thoughts of self-harm to avoid further shame and guilt, and assessing the risk can be an essential early step in this therapy. Asking whether there have been such thoughts, how recently, whether there was a particular ‘plan’ to put it into effect, and past attempts are all important steps to assess the appropriateness of involving others to prevent or lower the risk. Motivational Interviewing can be a very effective approach (7). The empathy, reflection of statements supporting change, resolving ambivalence often found in suicidal ideation, and increasing motivation through enhancement of self-effectiveness and importance of surviving, all provide a sound approach to avoid suicidal behaviour.

In many cases reaching a contract may not be as effective (due to impulsive reactions to stress) as enhancing self-assessment, encouraging thoughts of reassessing values, and increasing support. Group work can provide a new support structure, although considerable motivation may be necessary in order to ensure attendance. Secrecy, shame and common-place relapses that occur in behavioural addictions can require the therapist to provide a high belief in trust from the male with a behavioural addiction.

These outcomes of isolation, public and family rejection, loss of future opportunities of financial recovery or acceptance, can result in high levels of the egoistic and anomie rational identified by Durkheim (8) as leading to many suicides. In addition, when the need for instant solutions combines with viewing suicide as itself a solution to an insolvable situation, suicide can appear a logical and rationale solution from a cognitive viewpoint.

Summary
Many behavioural addictions may have consequences that exceed substance addictions, due in part to poor public perception of ability to control. The loss of valuable assets and relationships, both in the present and the future, can heighten thoughts of suicide as a solution. Emotional avoidance by many males suggests that a cognitive approach combined with Motivational Interviewing may motivate behaviour change, and assist to resolve to persevere in rejecting suicide as a solution to substantial reversal of fortunes and relationships that can occur as a result of seemingly, ‘lesser’ addictions of behaviour.

References

(1) American Psychiatric Assn. Diagnostic and statistical manual of mental disorders. 4th Ed. Washington DC:APA, 1994
(2) World Health Organisation. The ICD-9 Classification of Mental and Behavioural Disorders. Geneva; WHO 1977.
(3) Shaffer H, LaPlante D, LaBrie R, Kidman R, Donato A & Stanton M (2004) Toward a syndrome model of addiction: multiple manifestations, common etiology. Harvard Review of Psychiatry 12(6): 367-374
(4) Paton-Simpson GR, Gruys MA, Hannifin JB. Problem gambling counselling in New Zealand: 2003 National Statistics. Wellington. The Problem Gambling Committee; 2004.
(5) Potenza MN, Fiellin DA, Heninger GR, et al. Gambling: an addictive behavior with health and primary care implications. J Gen Intern Med 2002; 17:721-732.
(6) Penfold A (2004) Suicide, alcohol & gambling: increasing the odds. Paper presented at the National Association for Gambling Studies Conference, November, Gold Coast.
(7) Miller W & Rollnick S (2002) Motivational Interviewing (2nd ed): preparing people for change. NY: Guildford Press.
(8) Durkheim E (1897) Suicide (2nd ed) English translation by J.A. Spaulding & G Simpson (1951) NY: Free Press