Martha Shaw

Internet addiction: definition, assessment, epidemiology and clinical management.

Internet addiction is characterized by excessive or poorly controlled preoccupations, urges or behaviours regarding computer use and internet access that lead to impairment or distress. The condition has attracted increasing attention in the popular media and among researchers, and this attention has paralleled the growth in computer (and Internet) access.Prevalence estimates vary widely, although a recent random telephone survey of the general US population reported an estimate of 0.3–0.7%.The disorder occurs worldwide, but mainly in countries where computer access and technology are widespread. Clinical samples and a majority of relevant surveys report a male preponderance. Onset is reported to occur in the late 20s or early 30s age group, and there is often a lag of a decade or more from initial to problematic computer usage.Internet addiction has been associated with dimensionally measured depression and indicators of social isolation. Psychiatric co-morbidity is common, particularly mood, anxiety, impulse control and substance use disorders. Aetiology is unknown, but probably involves psychological, neurobiological and cultural factors.There are no evidence-based treatments for internet addiction. Cognitive behavioural approaches may be helpful. There is no proven role for psychotropic medication. Marital and family therapy may help in selected cases, and online self-help books and tapes are available. Lastly, a self-imposed ban on computer use and Internet access may be necessary in some cases.

Neuropsychological characteristics and personality traits in pathological gambling.

INTRODUCTION Pathological gambling disorder (PG) has been associated with fronto-temporal dysfunction and maladaptive personality traits, such as impulsivity and novelty seeking. The purpose of this study was to examine the predictive variance of neuropsychological and personality characteristics in PG. METHODS Persons with PG (n=25) and a comparison group (n=34) were administered a battery of neuropsychological tests, the Temperament and Character Inventory, and the Barratt Impulsiveness Scale. Subjects with PG had evidence of fronto-temporal dysfunction as assessed by the Stroop, Wisconsin Card Sorting Test-64, Wechsler Adult Intelligence Scale Letter-Number Sequencing, Controlled Oral Word Association Test, and Boston Diagnostic Aphasia Examination Animal Naming Test. RESULTS Subjects with PG also had impaired decision making on the Iowa Gambling Task. PG subjects had elevated levels of impulsivity, novelty seeking, and harm avoidance, and lower levels of self-directedness and cooperativeness. Logistic regression analyses indicated that neuropsychological variables did not add significant incremental variance over personality traits in predicting PG (Block chi-square=5.19, P=.074), while personality variables added significant incremental variance over neuropsychological traits in predicting PG (Block chi-square=25.13, P<.001). CONCLUSION These results suggest that personality traits are better predictors than neuropsychological characteristics of whether someone has PG.

The effect of pathological gambling on families, marriages, and children.

Pathological gambling (PG) is widely reported to have negative consequences on marriages, families, and children. Empirical evidence is only now accumulating but when put together with anecdotal information, the extent of these problems is clear. PG contributes to chaos and dysfunction within the family unit, disrupts marriages, leading to high rates of separation and divorce, and is associated with child abuse and neglect. Divorce rates are high, not surprising in light of reports that these marriages are often abusive. Research shows that the families of pathological gamblers are filled with members who gamble excessively, suffer from depressive or anxiety disorders, and misuse alcohol, drugs, or both. Families of persons with PG are also large, a variable independently related to family dysfunction. The authors review the evidence on the impact of PG on families, marriages, and offspring, and make recommendations for future research targeting these problems.

Neuropsychological performance, impulsivity, ADHD symptoms, and novelty seeking in compulsive buying disorder.

We examined the neuropsychological performance of people with compulsive buying disorder (CBD) and control subjects, along with trait impulsivity, symptoms of attention deficit hyperactivity disorder (ADHD), and selected personality characteristics. Subjects received a comprehensive neuropsychological test battery, depression and ADHD symptom assessment, the Barratt Impulsiveness Scale, and a version of the Temperament and Character Inventory. Persons with CBD (n=26) and controls (n=32) were comparable in terms of age, sex, and years of education. Subjects with CBD had a mean age of 36.3 years (S.D.=15.7) and an age at onset of 19.7 years (S.D.=7.0). Compulsive buyers had more lifetime mood, anxiety, and impulse control disorders. People with Compulsive buying performed significantly better on the Wechsler Abbreviated Scale of Intelligence Picture Completion task, a test of visual perception; otherwise, there were no consistent differences in neuropsychological measures. They also had elevated levels of self-reported depression, ADHD symptoms, trait impulsivity, and novelty seeking. In conclusion, compulsive buyers have greater lifetime psychiatric comorbidity than controls, and higher levels of self-rated depression, ADHD symptoms, trait impulsivity, and novelty seeking. The present study does not support the notion that there is a pattern of neuropsychological deficits associated with CBD.

Pathological gambling: relationship to obesity, self-reported chronic medical conditions, poor lifestyle choices, and impaired quality of life.

BACKGROUND Pathological gambling (PG) is an important public health problem that is prevalent, costly to society, and associated with substance misuse, depression, domestic violence, crime, and suicide. Despite these challenges, little is known about the physical health and medical correlates of PG. The goal of this project was to assess self-reported chronic medical conditions, medication usage, lifestyle choices, health care utilization, quality of life variables, and body mass index (BMI) in persons with and without PG. METHODS Subjects with PG and community controls were systematically assessed for their medical health, lifestyle choices, medication usage, and health care utilization. We administered the Medical Outcome Study Short-Form 36 Health Survey to assess perceived health and quality of life. BMI was calculated for all subjects. Obesity was defined as having a BMI≥30kg/m(2). RESULTS We compared 95 subjects with DSM-IV PG (South Oaks Gambling Screen [SOGS] score≥5) and 91 control subjects without PG (SOGS≤2) selected through random digit dialing from the general community. PG subjects and controls were similar in age and gender. Persons with PG had more medical and mental health conditions than controls, and were more likely to avoid regular exercise, smoke≥1 pack/day, drink≥5 servings of caffeine daily, and watch television≥20hours/week. They had more emergency department visits for physical and mental health conditions, were more likely to have been psychiatrically hospitalized in the past year, and were more likely to take psychotropic medication. They were less likely to have had regular dental visits and were more likely to put off medical care due to financial problems. Severity of gambling was positively correlated with number of medical conditions. Persons with PG had poorer self-reported health perceptions on all but one SF-36 subscale. Importantly, persons with PG had a higher BMI than controls and were more likely to be obese. CONCLUSIONS PG is associated with obesity, chronic medical conditions, poor lifestyle choices, worse quality of life, and the use of costly forms of medical care. Pathological gamblers are less likely to receive regular dental care and are more likely to be unable to pay for medical care. The implications of the findings are discussed.

A Direct, Controlled, Blind Family Study of DSM-IV Pathological Gambling

OBJECTIVE Pathological gambling is a major public health problem. We sought to examine the familiality of pathological gambling and determine patterns of familial aggregation of disorders. METHOD We assessed probands with DSM-IV pathological gambling, controls, and their first-degree relatives. Detailed family history information was collected on relatives who were deceased or unavailable. RESULTS Ninety-five pathological gambling probands, 91 controls, and their 1,075 first-degree relatives over age 18 (537 relatives of pathological gambling probands, 538 relatives of controls) were evaluated between February 2005 and June 2010. Relatives were assessed blind to proband status. Best estimate diagnoses were assigned. Rates of lifetime pathological gambling (definite/probable) was significantly greater among the first-degree relatives of probands with pathological gambling than among comparison relatives (11% vs 1%, OR = 8.19, P < .001). The prevalence of pathological gambling and subclinical pathological gambling combined was 16% and 3% in case and control relatives, respectively (OR = 6.57, P < .001). Pathological gambling relatives had higher rates of major depression (OR = 1.49, P < .05), bipolar disorder (OR = 3.82, P < .05), any mood disorder (OR = 1.59, P < .05), social anxiety disorder (OR = 4.76, P < .01), any substance use disorder (OR = 1.47, P < .05), posttraumatic stress disorder (OR = 2.59, P < .05), and antisocial personality disorder (OR = 3.72, P < .001). Antisocial personality disorder (OR = 3.12, P < .01), social anxiety disorder (OR = 4.15, P < .01), and posttraumatic stress disorder (OR = 2.85, P < .05) were more frequent in case relatives independent of the presence of pathological gambling. Age at onset of pathological gambling in case probands (< 40 years/≥ 40 years) was not related to familiality in their first-degree relatives (OR = 1.03, P = .927). CONCLUSIONS Pathological gambling is familial. Mood and substance use disorders may emerge as a consequence of the pathological gambling or as a more complex syndrome. In contrast, antisocial personality disorder, social anxiety disorder, and posttraumatic stress disorder may share a common familial etiology with pathological gambling. The phenotype may extend beyond pathological gambling to include subclinical forms of the disorder.

Neuropsychological performance, impulsivity, symptoms of ADHD, and Cloninger's personality traits in pathological gambling

Pathological gambling (PG) is a prevalent public health problem associated with fronto-temporal dysfunction and maladaptive personality traits. To further test these associations, we assessed neuropsychological performance in pathological gamblers (PGs) and controls. We also examined selected personality characteristics and symptoms of attention deficit hyperactivity disorder (ADHD). Subjects were recruited from the community. All received a comprehensive neuropsychological battery, the ADHD Rating Scale, and personality measures including the Barratt Impulsiveness Scale and a version of the Temperament and Character Inventory. People with DSM-IV PG (n = 54) and controls (n = 65) were comparable in age, sex, and education level. PGs were more likely to have comorbid lifetime mood, anxiety, and substance use disorders; antisocial personality disorder; and other impulse control disorders. PGs performed significantly worse on the Wisconsin Card Sort Test-64 perseverative responses subscale and the Trails B test; they also had lower performance and full scale IQs. PGs had elevated levels of depression, ADHD symptoms, trait impulsivity, novelty seeking, and harm avoidance, but lower levels of reward dependence. High levels of self-reported impulsivity or ADHD symptoms in PGs did not predict worse neuropsychological performance. We conclude that PGs performed worse than controls on two measures of executive function and had lower IQs. They also had more psychiatric comorbidity, higher levels of trait impulsivity and ADHD symptoms, and both novelty seeking and harm-avoidance, but lower levels of reward-dependence. This study does not support the notion that there is a pattern of neuropsychological deficits associated with high levels of impulsivity or ADHD symptoms in PGs.

Age at onset of DSM-IV pathological gambling in a non-treatment sample: Early- versus later-onset.

BACKGROUND Pathological gambling (PG) is a prevalent and impairing public health problem. In this study we assessed age at onset in men and women with PG and compared the demographic and clinical picture of early- vs. later-onset individuals. We also compared age at onset in PG subjects and their first-degree relatives with PG. METHOD Subjects with DSM-IV PG were recruited during the conduct of two non-treatment clinical studies. Subjects were evaluated with structured interviews and validated questionnaires. Early-onset was defined as PG starting prior to age 33years. RESULTS Age at onset of PG in the 255 subjects ranged from 8 to 80years with a mean (SD) of 34.0 (15.3) years. Men had an earlier onset than women. 84% of all subjects with PG had developed the disorder by age 50years. Early-onset subjects were more likely to be male, to prefer action games, and to have substance use disorders, antisocial personality disorder, attention deficit/hyperactivity disorder, trait impulsiveness, and social anxiety disorder. Later-onset was more common in women and was associated with a preference for slots and a history of sexual abuse. CONCLUSIONS Age at onset of PG is bimodal and differs for men and women. Early-onset PG and later-onset PG have important demographic and clinical differences. The implications of the findings are discussed.

The relationship of DSM-IV pathological gambling to compulsive buying and other possible spectrum disorders: results from the Iowa PG family study.

This study investigates the possible relationship between pathological gambling (PG) and potential spectrum disorders including the DSM-IV impulse control disorders (intermittent explosive disorder, kleptomania, pyromania, trichotillomania) and several non-DSM disorders (compulsive buying disorder, compulsive sexual behavior, Internet addiction). PG probands, controls, and their first-degree relatives were assessed with instruments of known reliability. Detailed family history information was collected on relatives who were deceased or unavailable. Best estimate diagnoses were assigned blind to family status. The results were analyzed using logistic regression by the method of generalized estimating equations. The sample included 95 probands with PG, 91 controls, and 1075 first-degree relatives (537 PG, 538 control). Compulsive buying disorder, having 1–2 spectrum disorder(s), and having “any spectrum disorder” were more frequent in the PG probands and their first-degree relatives vs. controls and their relatives. Spectrum disorders were significantly more prevalent among PG relatives compared to control relatives (adjusted OR = 8.37), though much of this difference was attributable to the contribution from compulsive buying disorder. We conclude that compulsive buying disorder is likely part of familial PG spectrum.

Five-year follow-up of people diagnosed with compulsive shopping disorder

BACKGROUND The authors assessed clinical symptoms and self-reported shopping and spending behavior in people diagnosed with compulsive shopping (CS) at a 5-year follow-up interview. METHODS All met the criteria of McElroy et al. for lifetime CS and had the disorder for >1year. Structured and semistructured instruments and self-report questionnaires were used to collect data. RESULTS Of the original 26 subjects, 17 (65%) were interviewed and are the focus of this report. At follow-up, their ages ranged from 23 to 67years (mean=44years). Lifetime psychiatric comorbidity was common, but few had current psychiatric disorders at follow-up. Interest in shopping and spending decreased for eight (47%), stayed the same for five (29%), and increased for four (24%) subjects. Eleven subjects (65%) reported having attempted to quit their CS and three (18%) reported successfully doing so. Triggers for returning to CS included feelings of pressure/excitement/tension to shop; boredom; negative feelings such as sadness, depression, frustration, or anger; and the desire for positive feelings like happiness, power, or elation. Mean scores on the Compulsive Buying Scale (CBS) and the shopping version of the Yale-Brown Obsessive-Compulsive Scale showed overall improvement in CS symptoms (d=1.16 and d=-1.19, respectively); subjects were also less impulsive (d=-0.48). At baseline and follow-up, those with a lifetime mood disorder tended to have greater CS severity. CONCLUSIONS While the subjects showed overall improvement, most had ongoing symptoms of CS. The implications of the findings are discussed.