Behavioral Addictions _ _______________________________________________________________________
Twelve-Step Programs Introduced in 1935, Alcoholics Anonymous (AA) is the origi- nal and best-known 12-step program. It was followed by Nar- cotics Anonymous (NA), introduced in the 1950s. Twelve-step programs constitute a specific form of group-mediated recovery from substance and behavioral addictions. They are member- led groups of people with similar addictions who are commit- ted to helping each other—new members in particular—achieve and maintain sobriety. The 12 steps refer to a specific program of recovery. In a very brief description, members of a 12-step program come to understand their powerlessness in controlling the addiction; develop a relationship(s) with a power outside oneself (i.e., a sponsor [mentor], the 12-step group, a therapist, a Higher Power of their definition, or any combination) to best protect against relapse and ensure continued recovery; identify and work through character defects; amend past harms; and become useful to others struggling with addiction. Since the introduction of AA and NA, several 12-step programs have been adapted for specific behavioral addictions [76]. The exact mechanisms of 12-step group involvement that underlie their efficacy are multiple and difficult to disentangle. For example, admitting being powerless over the addiction could permit greater control over the addictive behavior through changes in decision-making processes. Social interac- tions likely influence efficacy through contact with similarly motivated peers with a shared goal and social norm of absti- nence, and access to sponsors for guidance in developing skills for managing crises. Specific aspects may operate through different mechanisms; influences on decision-making and risk-taking behaviors may occur through 12-step meetings and discussions with sponsors [84]. Combined Approaches Preliminary studies suggest that combining several therapeutic strategies may be more effective than a single approach. Such approaches may include CBT, cognitive bias modification, CET, and/or mindfulness-based stress reduction, delivered in group, individual, family therapy, or school-based formats, with different strategies complementing aspects of the others. Combining behavioral and pharmacologic therapies can also be considered. PHARMACOTHERAPIES Almost all behavioral addictions were originally understood through the obsessive-compulsive spectrum model. By exten- sion, and based on efficacy in OCD, selective serotonin reuptake inhibitors (SSRIs) became the most widely used drug class in the treatment of behavioral addictions, but they showed minimal benefit. More recently, neuroscience research identified similarities in the core features of behavioral and substance addictions, and the obsessive-compulsive spectrum model was discarded in favor of better-fitting addiction disor- der models. Naltrexone, an opioid receptor antagonist with efficacy in substance use disorders, has suggested benefit in behavioral addictions, but there is evidence of possible adverse effect [22; 85].
The brain opioid system may contribute to social attachment and bonding, and brain opioid theory of social attachment posits that endogenous opioids may mediate reward effects in social connection and closeness. The possible effect of exogenous (drug) opioids on social reward is a new area of study. One trial randomized healthy volunteers to naltrexone or placebo and then to the alternate treatment 10 days under double-blind conditions. Participants noted significantly less sense of social connection on naltrexone, which was not explained by changes in emotional state. The findings support endogenous opioid contribution to social bonding and raise unexplored questions of whether diminished social bonding contributes to patient drop-out in naltrexone studies [86; 87]. GAMBLING DISORDER Gambling is a popular activity in many cultures, and most people have gambled at some point or do so infrequently, without harm. A subgroup of individuals unable to control their gambling can develop gambling disorder, with potentially severe financial, emotional, relationship, occupational, and possible legal consequences. The accessibility, affordability, and anonymity of Internet gambling may facilitate disordered behavior in predisposed gamblers [88]. A key determinant in the development of gambling disorder is the structural char- acteristics of the game [89]. EPIDEMIOLOGY In North America, gambling disorder affects 0.42% of the general population in their lifetime (0.64% among men, 0.23% among women) and 0.16% in the past year [90]. In epidemiologic studies, women represent about 32% of people with gambling disorder and show a telescoping phenomenon of later onset and more rapid progression also observed in women with alcohol use disorder [85]. Financial and marital problems are common among people with gambling disorder. Many of these patients also engage in illegal behaviors, including stealing, embezzlement, and fraud (e.g., writing bad checks), to fund their gambling or to cover past losses. Usually resulting from financial and legal problems, suicide attempts are common and have been reported in 17% of people in treatment for gambling disorder [85]. Among treatment-seeking disordered gamblers, women initiate gambling at an older age than men (31.3 years versus 22.4 years) and have a significantly shorter time from gambling initiation to meeting DSM criteria for gambling disorder (8.33 years versus 11.97 years). As noted, this phenomenon is consistently found in women with substance use disorders as well [91]. Individuals with subclinical but problematic gambling are referred to as “problem gamblers.” Studies conducted from 2000 to 2015 found past-year adult problem gambling rates of 2% to 5% in North America [92]. Problem gamblers account for almost one-third of total industry revenue [93]. Those with
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