Is Shoplifting the Opiate of the Masses?

Another look at "behavioral addictions" and the DSM-V.

The DSM-V, when it debuts it 2012, is set to replace the category of “Substance-Related Disorders” with a new category entitled "Addiction and Related Disorders."  Gambling is the only behavioral addiction currently recommended for inclusion, but some experts have set their sights on shoplifting—an activity that is even more difficult to picture as a legitimate addiction than gambling. Or is it?

Long before gambling was widely looked upon as an addictive disorder, compulsive shoplifting already had a name: kleptomania. The National Association for Shoplifting Prevention claims that about 9-10% of the population show a “lifetime prevalence” for shoplifting. This is remarkably similar to the percentages commonly bandied about for alcoholics, drug addicts, unipolar depressives,  compulsive gamblers, and compulsive overeaters.

A recent University of Florida survey pegged shoplifting losses, or “shrink,” in 2009 at more $11 billion annually. Plato, in The Republic, wanted to know whether thieves are made or born. It’s a good question. Curiously, the stealing doesn’t seem to be about money: The most recent study measuring income and shoplifting shows that Americans with incomes over $70,000 shoplift 30% more more than their fellow citizens earning less than $20,000 a year. And the actual items stolen by compulsive shoplifters often seem nonsensical, or even surreal. As director John Waters said of Pink Flamingos’ star and compulsive shoplifter Divine: “I saw him walk out of a store once with a chain saw and a TV.”

There is a definite “rush” to the act of stealing, writes Rachel Shteir in The Steal, her informative book about shoplifting. One shoplifter said it was equal to drugs but only lasted a few minutes—“And you’re back to yourself again. In your mind, you think, It was all for a stupid blouse, or stupid soap. For this, I risked everything.” Another source quoted in the book says, “I shoplifted every day, like someone with a drug addiction.”  Seconds before another women is arrested, she quizzes herself: “All she needs in the world is one crummy formal dress so why is there a blue silk jacket, one that she doesn’t particularly like, in her camera bag?” And a shoplifting Lee Grant says in the movie Detective Story: “I didn’t need it. I didn’t even like it.” The objects seem to lose their intrinsic value once they have been stolen, and the shoplifter must get high again with another theft.

If, as some neurobiological researchers insist, addictive disorders are not independent disorders, but outward manifestations of an underlying disease pathology called addiction syndrome, then the definition might be stretched to include gambling, shoplifting, and certain other “activity-based expressions of addiction.” Sometimes the alcoholic, the drug addict, the depressive, the compulsive gambler, and the obsessive overeater are all one and the same person. And drug addicts show a remarkably ability to substitute one drug for another. Perhaps a recovering cocaine addict might hope to assuage that sense of craving, of inchoate need, through excessive gambling. Or a shoplifter might use alcohol as a means of dampening the impulse to steal compulsively. While we don’t use the term kleptomania anymore, “shoplifting crops up as a symptom of many types of mental illnesses—bipolar disorders and anxiety disorders as well as substance abuse, eating disorders, and depression,” writes Shteir. Compulsive shoplifting, Shteir concludes, is “as difficult to stamp out as oil spills or alcoholism.”

For some, shoplifting brings a rush “similar to a cocaine or heroin high,” according to psychiatist Jon Grant at the University of Minnesota School of Medicine. To find out just how similar, psychiatrists there tried treating shoplifters with naltrexone, a drug that blocks opioid receptors and is used to treat alcoholism and heroin addiction. In 2009, in an article for the April issue of Biological Psychiatry, Grant and colleagues at the University of Minnesota School of Medicine recorded the results of their work with 25 kleptomaniacs, most of them women. All of the participants had been arrested for shoplifting at least once, and spent at least one hour per week stealing. The 8-week study is believed to be the first placebo-controlled trial of a drug for the treatment of shoplifting. In the April 10 issue of Science, Grant said that “Two-thirds of those on naltrexone had complete remission of their symptoms.”

Photo Credit: http://www.zawaj.com

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. 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 

A Drug for Kleptomania?

Naltrexone curbs shoplifting.

It seems like such an unlikely finding: In a University of Minnesota study of kleptomania—the compulsion to steal—a popular medicine used to treat both heroin addiction and alcoholism drastically reduced stealing among a group of 25 shoplifters. The drug, naltrexone, blocks brain receptors for opiates. It is one of the few drugs available for the treatment of alcoholism, and continues to gain momentum as a treatment for opiate addiction.

In an article for the April issue of Biological Psychiatry, Jon Grant and colleagues at the University of Minnesota School of Medicine record the results of their work with 25 kleptomaniacs, most of them women. All of the participants had been arrested for shoplifting at least once, and spent at least one hour per week stealing. The 8-week study is believed to be the first placebo-controlled trial of a drug for the treatment of shoplifting.

In the April 10 issue of Science, Grant said that “Two-thirds of those on naltrexone had complete remission of their symptoms.” According to Samuel Chamberlain, a psychiatrist at the University of Cambridge in the U.K., the study strongly suggests that “the brain circuits involved in compulsive stealing overlap with those involved in addictions more broadly.” The study, in short, strengthens the hypothesis that the shoplifting “high” may have much in common with the high produced by heroin or alcohol.

Researchers are also working with the drug memantine as a treatment for compulsive stealing.

The finding lends additional evidence to the theory that shoplifting is a dopamine- and serotonin-driven disorder under the same medical umbrella as drug addiction and alcoholism. Preliminary research has shown that naltrexone may also have an effect on gambling behavior.

If so-called “behavioral addictions” continue to display biochemical similarities with “chemical addictions,” the move to broaden the working definition of addiction will continue to intensify. And the same sorts of questions that plague addiction research will be replayed in the behavioral sphere: What level of shoplifting constitutes the disorder called kleptomania? Isn’t the medicalization of shoplifting just a way to excuse bad behavior? Is medical treatment more effective than jail time? From a legal point of view, what is the the difference between kleptomania and burglary?

In his book, America Anonymous, Benoit Denizet-Lewis quotes lead study author Jon Grant: “With all addictions, a person’s free will is greatly impaired, but the law doesn’t want to entertain that.... Why shouldn’t someone’s addiction be considered as a mitigating factor, especially in sentencing?”

Photo Credit: Napo Hampshire Branch

addiction drugs

Compulsive Gambling [Guest Post]

14 hours at the roulette wheel.

[Editors Note: Addiction Inbox has not covered the so-called behavioral or non-traditional addictions--Internet addiction, video game addiction, compulsive shopping and compulsive gambling--because I am not yet convinced that such behaviors show the same chemical and often inheritable propensities associated with alcoholism and other drug addictions. From time to time, however, I offer up an alternative view. The following excerpt has been taken from www.utahstories.com with the kind permission of the author.]


Guest Post by Leo Dirr

If you eat one meal a day and it's a buffet, you might be a compulsive gambler.

That odd, little nugget of wisdom dawned on me while I was wallowing in misery in front of an overloaded plate of tamales and tacos and taters and gravy. Gambler, me? A compulsive gambler? Hmmm.

I guess it takes one to know one. Yep. I had to lose thousands of dollars and countless hours of sleep before I could finally come to grips with my addiction. And at the buffet table, no less. At least the hot chocolate refills were free.

Oh, I had me some grand times. Vegas, Reno, Elko, Mesquite, Wendover. Nevada casino towns that called my name. I played roulette for up to 14 straight hours at a stretch. I never even left the table to take a leak.

I was too zoned in on the game. One time a busty babe sitting next to me at the blackjack table was literally rubbing her hands all over my body, and all I could think about was my next bet. Nothing personal. But while I was gambling, sex never crossed my mind.

As long as I had chips, nothing else mattered. I was completely in tune with my inner gambler. That sense of escapism must have been the draw, the thing that sucked me in again and again. It couldn't have been possible that I actually wanted to throw away all of my money.

Or did I? During my travels, I met a once-wealthy oil man who literally lost millions to the casinos. By the time I stumbled upon him, he was relying on the generosity of a well-heeled friend just to stay off the streets. His sad story did not save me.

I was hooked. I adored the casinos. The glitz of the lights, the sounds of the slots, the hope in the air. It all made me feel so alive.

Gambling thoughts monopolized my ADD-addled brain. Daily rituals that most people relish, or at least tolerate, were unbearably boring to me. The only excitement I could find was of the Ace-King kind. I used to calculate roulette payouts while I was brushing my teeth. It was bad.

Oh, I didn't always lose. Sometimes I won - and won big. But the casinos call their table areas "pits" for a reason. The more I won, the deeper my happy, little gambling hobby sank into a dark and dangerous compulsion.

I literally couldn't stay away. I always gave back everything I'd won, and then some. At one point, I was actually using my Nevada casino winnings to buy Idaho lottery tickets.

That sounds crazy, I know. But is it any crazier than eating all your meals at a buffet? Not really. The crazy part is that I don't really feel bad about any of it. I saw my share of weird things and weirder people along the way. And yes, I lost a ton of money.

But hey, what do you expect? I'm a compulsive gambler.

Some Sobering Statistics

* 15 million people display some sign of gambling addiction
* "Players" with household incomes under $10,000 bet nearly three times as much on lotteries as those with incomes over $50,000
* The average debt incurred by a male pathological gambler in the U.S. is between $55,000 and $90,000 (it is $15,000 for female gamblers)
* The suicide rate for pathological gamblers is twenty times higher than for non-gamblers (one in five attempts suicide)
* Sixty-five percent of pathological gamblers commit crimes to support their gambling habit

(Source: http://www.overcominggambling.com)

If you want to seek help, visit the National Council on Problem Gambling's Web site.

Photo Credit: Carroll College