Showing posts with label sex addiction. Show all posts
Showing posts with label sex addiction. Show all posts

Monday, May 7, 2012

Gateway to Absurdity


State law criminalizes “gateway sexual activity.”

It’s the gateway to hell and perdition, that’s what it is. It doesn’t necessarily lead to drugs but it will drag you in the direction of Ess Eee Exx. And while sex is probably not addictive in the traditional sense, it is always and inevitably very bad when unaccompanied by marriage and the procreative urge.

Like anthropology’s search for the “missing link,” or the physicist’s search for a “unified field theory,” psychologists and social workers have spent decades hunting for the mythical gateway drug. This is the drug that, when used regularly, will head you reliably down the path of full-blown addiction. The findings of addiction medicine now make the identification of any kind of universal gateway drug an antique pursuit. Every addict finds his or her own gateway, and pushes through. If any drugs qualify as gateway drugs in a broad sense, it would have to be alcohol and tobacco, simply on the basis of ready availability.

But a gateway for full-blown recreational teenage sex—did you ever think about that? One might have thought the legislators would answer, yes, it’s called puberty, and move on. But no. The Tennessee legislature, led by Rep. Jim Gotto (R), managed to push through a bill  “allowing parents to sue teachers and other outside parties for ‘promoting or condoning gateway sexual activity’ by students.”

Interestingly, the bill apparently fails to define such activity in concrete terms. Evidently, Rep. Gotto has attempted to outlaw “first base.” Or, as TPMMuckraker put it, “other things.” Gateway sexual activity is defined, according to what I shall dub the bill’s "money" sentence, “sexual conduct encouraging an individual to engage in a non-abstinent behavior.” Okay, then. Earnest glances, hair tossing, hand holding—all potentially actionable, should any sex ed teachers be caught “promoting” such activities.

And not without reason: According to data released last month by the National Center for Health Statistics, the states with the highest teen birth rate in 2010 include Tennessee, which ranked 10th worst with 43.2 births per 1,000 teenage girls. And according to a 2009 risk behavior study in Memphis City, 61 percent of high school students have had sex, along with 27 percent of middle school students, putting Memphis City, and by extension Tennessee, considerably above the national average.

Apparently, the real target here is Planned Parenthood, which has been known to provide sex education information in Tennessee schools, and which would be facing fines and penalties under the new law. The bill calls for abstinence-only instruction.

Photo Credit: http://cbcpforlife.com/?p=4277

Saturday, June 25, 2011

That Pesky Gambling Question


The DSM-V is set to label problem gambling an addiction.

Nobody has ever bet enough on the winning horse.
Unknown wise person

I used to gamble. Back when I did, I was also an active alcoholic and a chain smoker. Camel filters, if you’re wondering. And we had a running joke, my wife and I, although the humor leaked out of it for her pretty quickly. We would breach the doors of the gambling palace, and plunge into the dark, icy interior of a casino at Las Vegas or Tahoe, and stand on the edge of the gaming room, taking it all in for a moment. “Ah,” I would say, surveying the roomful of cigarette smokers with drinks in their hands, making bets or hitting buttons at one o’clock in the morning, “my kind of people.”

Gambling can be defined as an activity in which something of value is put at risk in a situation where the outcome is uncertain.This post was chosen as an Editor's Selection for ResearchBlogging.org That’s really all there is to it. Howard J. Shaffer and Ryan Martin, whose article in the Annual Review of Clinical Psychology, “Disordered Gambling: Etiology, Trajectory and Clinical Considerations,” takes on all the interesting questions about gambling as an addictive disease, have chosen to favor the term “disordered gambling.” Just as there are divisions between alcoholic drinking, heavy drinking, and social drinking, there are similar states we can call pathological gambling, excessive gambling, and social gambling. On the problematic end of the scale, pathological or problem gambling has proven to be “a more complex and unstable disorder than originally and traditionally thought.” No kidding. Once the neurophysiology of the gambling state of mind came under scrutiny, the parallels with addiction cropped up so rapidly that investigators have been hard pressed to come up with suitable explanations for it all.

The new DSM-V proposes to shift pathological gambling from “impulse control disorder” to the new category of “addiction and related disorders.” So it’s a good time to rethink the question along with the psychiatric community.

In the traditional view, pathological gambling was a matter of exposure to the proper stimuli—it could happen to anyone. But as more and more gambling outlets and opportunities bloomed in Nevada, on reservations and riverboats, and in convenience stores, that view began to fall out of favor, because a funny thing happened. According to Shaffer and Martin, the prevalence of pathological gambling has remained stable over the past 35 years, even as opportunities to gamble have exploded. The lifetime prevalence rate of pathological gambling in the U.S. in the mid-1970s was 0.7%, say the authors, and by 2005, U.S. lifetime rates had actually fallen slightly, to 0.6% or less. Where was the concomitant explosion in the number of pathological gamblers?

Next, researchers got technical, wondering whether certain types of gambling, or certain types of gambling machines, were more “addictive” than others. They quickly ran into the same kind of trouble substance abuse researchers got into when they first tried ranking drugs according to strict hierarchies of addictiveness. In so doing, the staggering metabolic diversity of the human animal got lost in the shuffle, as did the fact that my metabolism and my behavior when taking drugs, or knocking one back, or losing money in a casino, is going to be different from yours.

Then came Internet gambling. In 1996, the first online casino to accept real money began operation, and by 2001, there were more than a thousand. Previously, researchers had to rely mostly on the time-honored but not always accurate system of self-reporting. If you ask people why they gamble, they tend to answer that they do it for the fun, the excitement, the challenge, and the chance to win some money. But what gamblers can’t recall very well are specific patterns of play over time that might benefit researchers. For example, in a 2009 study in which observers actually watched gamblers gambling, one long-standing observation from the self-report literature—gamblers become more liberal risk takers as they approach the end of a gambling session in a behavior called “chasing”—didn’t prove out. When researchers watched actual gamblers in action on the Internet, or playing lotteries, they found that problem gamblers in fact began betting more conservatively as they approached the end of their gambling, the authors write.

Another approach is to consider risk factors of all kinds—neurobiological, psychological, and social—and look for similarities between those for substance addiction, and those for “activity-based expressions of addiction.” The “syndrome model,” or what I usually call the umbrella model, derives from neurobiological research suggesting that “addictive disorders might not be independent: each outwardly unique addiction disorder might be a distinctive expression of the same underlying addiction syndrome…. The specific objects of addiction play a less central role in the development of addiction than previously thought….”

 All of this opens the door to some informed speculation about a broader range of disorders that may lurk beneath the umbrella of the addictive disease concept. Among these are such conditions as body dysmorphic disorder, bulimia, depression, and extreme PMS, which are all found more often in addict populations. In addition, impulsivity and low “harm avoidance” are behavioral traits often found in association with addiction. Shaffer and Martin call these “shadow syndromes,” and they are found to be associated with BOTH substance and behavioral addictions.

But what, exactly, is the high in gambling? The researchers believe that, “similar to ingesting stimulants, there is evidence that gambling is associated with autonomic arousal including elevated blood pressure, heart rate, and mood.” That's not very specific, and could also describe a craving for teddy bears. But recently, fascinating evidence of neurobiological influences on gambling arose when Parkinson’s’ patients on strong dopamine agonist treatments, with no history of gambling whatsoever, began behaving for all the world like pathological gamblers. I cannot imagine a better suggestion of neurogenetic involvement than this unexpected finding. Previous research had shown that dopamine-active drugs were capable of increasing the incidence of other addictions, too. Shaffer and Martin list compulsive eating, compulsive sexual behaviors, and compulsive shopping as activities that can also be boosted with dopamine agonists or diminished by lowering dopamine activity. 

And it does not strike me as surprising to learn that, yes, gambling problems tend to run in families, or that twins studies show that pathological gambling is higher among twins born to pathological gamblers than twins born to non-gamblers. It is the same evidence anyone can bring forth to bolster the argument for neurobiological influences on alcoholism, heroin addiction, and the like. “In sum” Shaffer and Martin conclude, “genetic influences might not determine the development of specific expression of addiction; however, genetics does influence the risk of addiction in general.”

If all of this is true, we should expect to see a corresponding connection between pathological gambling and substance abuse disorders. Some degree of overlap would be good evidence. And we have it in spades. Pathological gamblers are five and a half times more likely to have suffered from a substance abuse disorder. “75% of PGs (pathological gamblers) have had an alcohol disorder, 38% have had a drug use disorder and 60% have had nicotine dependence.” Also, “PGs are 4 times more likely than non-PGs to experience a mood disorder in their lifetime….”

So when I used to stand on the edge of the casino floor, as an alcoholic and a nicotine addict, casually calling those gamblers my kind of people, I think I was more right than I ever could have guessed.

Does all this mean that playing games on the Internet is an addictive behavior if making bets with real money is involved? The authors crunched the studies on that question, and discovered that maybe 1% of the Internet population has used the Internet for gambling purposes, and that “the case of Internet gambling provides little evidence that exposure is the primary driving force behind the prevalence and intensity of gambling…. The relationship between the extent of gambling ‘involvement’ is a better predictor of disordered gambling than any particular game that people play.”

By gambling involvement, the authors mean the number of different kinds of games a gambler plays. The more he or she plays, the more likely they are, or are likely to become, problem gamblers. However, it’s not hard to see where the online notion came from. Gambling folklore has always held that addiction is more of a risk with electronic gambling devices like slot machines and 5-Card Draw machines, than with traditional table games like roulette and craps. But the authors don’t find any convincing clinical evidence for this assertion at all. Internet gambling isn’t more addictive, and doesn’t confer any extra risk on people participating in other forms of gambling.

Here is a list of potential gambling behaviors that Shaffer and Martin believe might be risk factors to look out for in the development of problem gambling, with my additions in parentheses showing the connections to other drug addictions.

--Betting Intensity: how many bets per day. (With alcohol, how many drinks.)

--Gambling Frequency: number of gambling days (Number of drinking days.)

--Gambling Trajectory: tendency to increase the amount of wagered money. (Tolerance, in the case of drugs and alcohol.)

--Gambling Variability: deviation from consistent gambling pattern. (Inability to predict duration or outcome of drinking event.)

But if we list gambling under Addiction and Related Disorders, must we list all the possible variations on the theme—shopping and sex and all the rest, even though the picture is still fuzzy? No, the authors argue, we don’t. Not right this minute. But gambling is ready to join the roster. Shaffer and Martin would like to see their syndrome model of addiction used to identify “core features of addiction and then illustrate these with substance-related and behavioral expressions of this diagnostic class. Conceptualizing addiction this way avoids the incorrect view that the object causes the addiction and shifts the diagnostic focus toward patient needs.”

Shaffer HJ, & Martin R (2011). Disordered gambling: etiology, trajectory, and clinical considerations. Annual review of clinical psychology, 7, 483-510 PMID: 21219194

Graphics Credit: http://gamblinghelp.org/pages/resources/toolkits.php 

Saturday, January 31, 2009

America Anonymous—Book Review


Sex, drugs, and shoplifting.

New York Times magazine contributor Benoit Denizet-Lewis interweaves eight personal stories of addiction and obsession and ties them in with a well-researched summary of the drug treatment business in his new book, America Anonymous. Offering deft portraits of people suffering from various forms of addiction and compulsion, Denizet-Lewis brings to life much of the denial, prevarication, giddy hopes of victory, incomprehensible relapses, and endless stream of lies and broken promises with which so many active addicts string together their fractured narratives.

By design, Denizet-Lewis swings wide when it comes to defining addiction. In addition to alcoholics and drug addicts, the author, a self-confessed sex addict, includes in his case histories a woman who is a serial shoplifter, a body builder addicted to steroids, a fifty year-old compulsive eater, and a college student addicted to pornography.

“I believe in an expanded understanding of addiction, “ Denizet-Lewis writes. “That is, I believe that gambling, sex, food, spending, and work (to name a few) can, for some people be as addictive and debilitating as an addiction to drugs.”

While I am not as convinced as the author that the scientific evidence is beginning to weigh heavily on the side of accepting behavioral compulsions as classic addictions, I can only agree when he points out that, for all the heady buzz about addiction medicine and pills for alcoholism, 12 Step programs—which originated more than 50 years ago--still arguably represent the most effective approach to treating addiction that we know of. In addition, Denizet-Lewis writes, doctors and clinicians have been promising medical treatments for addiction for 200 years now, and only in the last ten years or so has there been any real progress.

Point taken. The author basically accepts that addictions are chronic diseases with genetic components, “and an onset and course that vary depending on behavior and environmental factors.” Scientific information is presented accurately and in an understandable fashion. Denizet-Lewis knows his subject, even if he uses that data to reach different conclusions than I do. I liked this book, even though I am at odds with many of its arguments.

So, what do Denizet-Lewis’s people teach us about addiction? The crucial need for honesty, to begin with. “If we’re not rigorously honest,” one addict says, “we can’t recover. It’s impossible.” This rule applies to the healers as well. The author quotes one researcher succinctly: “I would distrust anyone who says they can cure addiction.” This sentence alone, if absorbed by addicts seeking treatment, could save them considerable time, money and self-esteem. The author also quotes addiction researcher Anna Rose Childress to good effect: “Relapse is not a failure of treatment. Relapse is part of the disorder.”

What runs through all the personal sagas is the desire of the subjects to feel normal—to “feel feelings” in a normal way. The author offers compelling narratives that catch the flavor of the addicted way of life, a combination of monotony, mood swings, and fear. Denizet-Lewis is particularly adept at making us care about what happens to these people, and we read the book with a hopefulness laced with dread. We know it cannot end happily for everyone. And it does not.

In the end, the author concludes that most forms of addiction can be accounted for by the childhood trauma model. Since a good deal of sex therapy centers on this conception, perhaps the author’s conclusions in this regard are not surprising. However, trauma theories about the origin of addiction have not translated into reliable and effective treatments for addiction, either. And such theories have had a long run, starting even before Freud.

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