________________________________________________________________________ Behavioral Addictions
Cigarette smoking is highly prevalent in gambling disorder, and nicotine dependence is associated with greater gambling severity. Imaginal desensitization plus NAC was evaluated in patients with gambling disorder and nicotine dependence. After six weeks, subjects randomized to NAC or placebo both showed significant benefit from imaginal desensitization, but at three-month follow-up, NAC led to significant additional benefit in gambling severity reduction compared with placebo [135]. Other glutamate agents, such as topiramate, have not shown benefit [85]. Gamblers Anonymous Founded in the 1950s, Gamblers Anonymous (GA) is a mutual help fellowship based on the 12-step program of AA. With meetings in most North American communities, GA is established worldwide as a resource for people struggling with gambling problems. GA groups are peer-led and abstinence- focused and represent the most widely available option for recovery from gambling disorder [136]. Some GA meetings welcome family and friends to attend “open meetings,” rec- ognizing the impact of disordered gambling often extends far beyond the patient and that support from non-gambling family and friends can be integral to recovery. Local groups can be found online at http://www.gamblersanonymous.org/ ga/content/about-us [113]. GA has a unique culture of recovery, distinct from AA and NA in specific areas. For example, GA recognizes that for many new members, addressing the crippling financial consequences is vitally important for their recovery. Senior members who con- fronted and resolved their own financial consequences guide and support the new members through these challenges [136]. GA members tend to have more severe gambling symptoms, are more motivated for treatment, and have greater involve- ment with professional gambling treatment. GA involvement is positively associated with abstinence and improvements in abstinence, and with increased readiness for change, adaptive coping skills, and higher leisure activity involvement [136]. GA can be used alone or combined with other interventions. Individuals who engage in GA and professional treatment have better gambling outcomes than those who receive professional care alone. GA is also a valuable resource if remitted gambling problems recur in the future [34]. The potentially severe consequences of gambling disorder elevate the need to identify factors that support gambling abstinence. In a study of GA members, the greatest predictors of gambling abstinence were participation and involvement in GA, support from family and friends, and connections with other GA members. Relapse was strongly predicted by high gambling urges and erroneous gambling cognitions [93]. Of note, GA meeting attendance may be helpful, but involvement with GA meetings and members carried the greatest protec-
tion from relapse. GA and CBT are the two most widely used approaches for gambling disorder. A review of published evi- dence concluded that combining GA and CBT may enhance therapy engagement and reduce relapse risk [120].
ADDICTIVE SEXUAL BEHAVIOR Persons with sexual addictions can spend vast amounts of time pursuing sexual encounters to the detriment of their marital, occupational, financial, and physical well-being and function. When human immunodeficiency virus (HIV) or other sexually transmitted infection (STI) exposure is possible, the behavior can be life-threatening. The lack of consensus of how to conceptualize problematic sexual behavior has invited explanatory paradigms using obsessive-compulsive, impulse control, addiction, and biopsychosocial models [76; 137]. Reports in the medical literature of patients seeking pro- fessional help for extremely frequent or hypersexual urges and behaviors date to the early 1800s [138]. In addition to well-characterized manifestations of sexual addiction, more recently developing contexts include methamphetamine- driven hypersexuality in the gay community and the use of location-based online dating platforms. Arguably the most important development in the field of addictive sexual behavior is Internet-mediated sex addiction, more frequently involving pornographic videos and masturbation [15]. The terms sex addiction, sexual addiction, addictive sexual behavior, compulsive sexual behavior, hypersexual disorder, sexual compulsivity, and sexual impulsivity describe roughly the same phenomenon [139]. Other related terms include [11; 140; 141]: • Paraphilias: Behaviors deemed socially unacceptable that involve non-human objects, suffering of self or partner, children, or a non-consenting person (e.g., fetishism, exhibitionism, pedophilia) • Nonparaphilic: More typical sexual behaviors that include compulsive sexual acts with multiple partners, constant fixation on a partner that may be considered unobtainable, compulsive masturbation, compulsive use of pornography, and compulsive sex and sexual acts within a consensual relationship • Geo-locating social media: Online dating applications (apps) that use geo-positioning satellite (GPS) technolo- gies in smart phones to provide the proximity of users from each other
EPIDEMIOLOGY, RISK FACTORS, AND COMORBIDITY
Addictive sexual behavior may be relatively common, and while no epidemiologic data are available, researchers estimated a lifetime prevalence of 2% to 6% and rates of 2.0% to 3.7% among American college students [142]. Some data suggest
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