Psychology of addictive behaviour

Definition of addition:

Most of these only consider addiction to drugs (chemical addiction):

World Health Organisation (WHO): ‘a state of periodic or chronic intoxication produced by repeated consumption of a drug;
natural or synthetic.’

Concise Oxford Dictionary: ‘An addict is a person addicted to a habit, especially one dependent on a specific drug.’

However, although most early research centred on drug taking, other behavioral addictions are now recognized, for example:
gambling, eating, sex, exercise, work, internet, shopping etc…

Most modern definitions of addictive behaviour involve ‘loss of control’ or ability to regulate behaviour:

‘A repeated habit pattern that increases the risk of disease and/or associated personal and social problems. Addictive
behaviours are often experienced subjectively as ‘loss of control’ – the behaviour contrives to occur despite volitional attempts
to abstain or moderate use.’

Krivanck (1988) believes addiction is best seen as a process rather than a behaviour or entity and also best explained on a
spectrum of severity. However, loss of control is subjective and raises ethical issues since it suggests a certain level of
culpability and blame.
Addiction as Disease (AAD)

Our stereotypical view of an addict is likely to be based on one addicted to drugs, particularly alcohol. This view sees an
individual compelled to continually take the substance to avoid symptoms of withdrawal and who undergoes changes in behaviour,
willing for example, to commit crimes and neglect their job and loved ones in order to feed their habit.

Criticisms of AAD

 Often the addiction is more a symptom of other underlying disorders such as depression. The addiction as simply
worsened their condition.
 There is the issue of degrees and social setting and expectations. For example binge drinking is seen as acceptable in
some settings and communities as is the smoking of cannabis. We therefore have an issue of deciding when there is a
problem and of where the cut-off point should be.
 Addiction, as with other behavioural disorders, tend to be more complex than physical issues. It isn’t easy to distinguish
causes from symptoms. The model also fails to explain why following what seems like a cure, and restraint from taking
the drug, the relapse rate is so high (65% in the first year).

Behavioural addictions

Can behavioural addictions such as gambling be classified similarly to chemical addiction?

Clinical criteria of addiction (Carnes 1991):

1. A behaviour that is out of control

2. Severe consequences
3. Inability to stop despite these consequences
4. Persistent pursuit of self-destructive or risky behaviour
5. Desire to stop the behaviour
6. Use of the behaviour as a coping strategy
7. Increasing levels of the behaviour needed to get the same effect (tolerance)
 8. Lots of time spent both in trying to engage in the behaviour as well as recovery
9. Severe mood changes when carrying out the behaviour
10. Social, occupational, and recreational activities sacrificed

Griffiths (1996) believes these ten criteria can be subsumed nicely into the following six:

1. Salience:

The behaviour becomes the most important thing to the person and they have it on their minds for much of the time. Alcohol and
nicotine addicts tend not to be so obvious in this regard, since they are able to combine their addiction with other behaviours in
social settings. However, once deprived of their fix, salience becomes far more apparent.

2. Mood modification

The addict gets a rush or buzz when engaged in the behaviour. The addict is also able to use their behaviour to bring about a
mood change. Interestingly, the same chemical or behaviour can alter mood in different directions depending on time or setting.
Nicotine can stimulate in the morning or relax before sleep.

3. Tolerance

Usually associated with chemical addiction such as alcohol or heroin, this one can also be applied to behaviours. Basically the
addict needs bigger and bigger hits to get the same effect as they did initially with smaller amounts. Risk-taking behaviour, for
example, tends to get more extreme over time.

4. Withdrawal symptoms

Changes in mood, shakes, irritability etc. as a result of cessation. Applies to behavioural as well as chemical addiction.
5. Conflict

The pursuit of short term pleasure can cause conflict with other; parents, spouse, friends and can also result in conflict within
the person.

6. Relapse

A tendency to return to the behaviour, months or even years after an apparent ‘cure.’ Again this is just as common with
behavioural addiction as it is with chemical.

Griffiths believes that all six need to be present for a diagnosis of addiction. However, others disagree, believing that addiction
doesn’t always result in undue disruption to a person’s lifestyle and occasionally no withdrawal symptoms are experienced on
cessation.

Addiction or enthusiasm?

If it adds quality to a person’s life: Enthusiasm

If it detracts from a person’s life: Addiction

Models of addiction

Biological or Medical model:

Addiction is the result of something physical. This could be genes, brain chemicals or brain structure. The biological model of
addiction is unusual however, in that it has some overlap with the behaviourist explanation.

Psychological models

Behaviourist:

Considers addictions to be learned either by operant or classical conditioning, or perhaps by social learning and vicarious
reinforcement.

Cognitive:

Considers the role of decision making, faulty thinking, perceptual biases and relapse prevention.

Social:

Considers the importance of social and situational variables (experiential model) and of weak character (moral model).

Biological or medical model

It is worth mentioning at the outset that the medical model is generally better at explaining chemical addiction than it is
behavioural and it is better at explaining maintenance of an addictive habit than it is acquisition.

Fowler (2007) looked at the cases of over 1000 twins and found that environmental and social factors were crucial in the
initiating of addictive behaviours (including nicotine, alcohol and cannabis) whereas genetic and neurological factors were most
closely linked with maintenance and the behaviours becoming heavier.

Addiction to chemical substances is due to physiological changes in brain structure and changes in brain chemistry.

Neurotransmitters

Addictive chemicals tend to be chemically very similar to naturally occurring brain chemicals such as dopamine. They are
therefore able to activate nerve pathways in the brain and send abnormal messages; for example cannabis and heroin.

Cocaine on the other hand works by stimulating nerve endings into producing very large amounts of natural neurotransmitters
that have a stimulating effect on areas of the brain.
Reward centres (mesolimbic system)

Be warned this isn’t easy stuff, and introduces you to a few brain areas, not before encountered.

Olds and Miller (1954) found that rats will press a lever to electrically stimulate certain brain areas, and will do so in preference
to food and even sex! It is worth pointing out that pleasure is a very adaptive experience. If we didn’t find food and sex
pleasurable we’d starve to death or not reproduce!

A number of brain areas have been

associated with reward. We shall
only consider some of the major
constituents of the mesolimbic
system (MSL).

Ventral tegmental area (VTA)

The VTA is comprised of dopamine neurons. Nearly all drugs that result in addiction increase levels of dopamine in the MLS.
Dopamine neurons respond when stimulation similar to reward is present. Dopamine is released into the forebrain and nucleus
accumbens (NAcc).

Nucleus accumbens (NAcc)

The NAcc is comprised of mostly GABA neurons. It seems that the NAcc is involved in acquiring and triggering conditioned
behaviours and seems to be involved in increased sensitivity to drugs as addiction progresses.

Prefrontal cortex (PFC)

The PFC is responsible for executive functions; cast your memory back to the working memory model at AS. The central
executive appears to be located in the PFC. It seems that the PFC is able to override or moderate our baser instinctive drives
that may be triggered by the lower centres of the brain including the limbic system. However, it seems that some drugs can
block these higher functions leaving us unable to suppress less appropriate responses and control our behaviour.

Certain areas of the PFC appear to have quite specific functions, for example there seems to be areas responsible for inhibiting
behaviours that may bring short term reward at the expense of long term losses; which would include most drug-taking habits.
Damage or impairment to these areas would lead us prone to making bad choices for short term gain.

There is evidence from some addicts that this is the case. However, there is the usual issue of cause and effect. It could be
that addiction leads to brain damage in these locations.

Other areas such as the basolateral amygdala seem to be involved in motivation. The hippocampus has a role in memory and
learning and seems to alter dopamine levels in the NAcc and VTA.

Regardless of the complex pathways involved, what seems clear is that addictive drugs over-stimulate dopamine pathways and
flood the brain with dopamine. This is associated with feelings of intense pleasure, resulting in euphoria and repeated use.

Tolerance (desensitisation)
Repeated drug use will result in consistently high levels of dopamine. Eventually the brain will adapt by producing less dopamine
resulting in a dampening down and less experience of pleasure. To achieve the same result, increased quantities of the drug will
be needed. Not only does the pleasure disappear but it can be replaced by unpleasant effects, particularly anxiety. The drug
user now has to take drugs, not to get the pleasure as initially, but to stave off the unpleasant side effects and withdrawal
symptoms (in behaviourist terms the drug is now acting as a negative reinforcer… removing the unpleasant).

Genetics of addictive behaviour

Clearly if there is a genetic factor we would expect to see trends for the disorder in families and similarities between people
most closely related.

Sarafino (1990) found that children born of alcoholic parents were four times more likely than usual to develop drinking problems
themselves. Clearly this in itself doesn’t rule out shared environment as a contributory factor, but the tendency still remained
true even when the children had been adopted by non-alcoholic parents.

Agraval and Lynskey (2008) compared MZ and DZ twins and concluded that there was a moderate to high concordance rate (0.3
to 0.7) for addiction to a variety of drugs. However, they also reported that age, gender and culture were also major
contributory factors; all of which would be the same for MZ twins!

Specific genes

Modern techniques with DNA have allowed specific genes to be isolated for certain behaviours and conditions. However, with
psychological disorders these aren’t usually so clear cut.

Agraval et al (2008) believed that chromosomes 18 and 19 might be related to cannabis use.

Higuchi et al (2008) reported that Mpdz gene may predispose some animals to alcohol addiction. I’ll consider the role of DRD2 in
more detail on the next page.
Indirect effects

As with many behaviours, it may be difficult to pin down a specific gene as predisposing to a specific behaviour. However, genes
may be related to certain, broader personality types that then may predispose certain behaviours.

With addiction, certain

genes may predispose the
individual to antisocial and
attention seeking
behaviour. Attention
seeking behaviour has
been linked with
alcoholism (Jang et al
2008) and with gambling
(Comings et al 1996).
Evaluation of medical model

As always the medical model offers a reductionist model of a complex behaviour. It fails to take into account social and cultural
factors as well as other situational and dispositional factors to be considered when we look at vulnerability. For example, self
esteem and the attribution process.

The brain mechanisms involved in any behaviour seem to be multifarious. A particular chemical can effect many different
pathways in the brain and sometimes even result in what appear to be incongruous results. For example nicotine appears to be
able to increase arousal whilst decreasing stress, which if you cast your minds back to AS would seem to be impossible.

Evaluation of gene evidence

Some specific genes have been implicated in specific addictions, but then subsequent research has found that many with that
addiction don’t possess that particular variant of gene.

DRD2 variant A1

One such gene is the DRD2 gene that codes for D2 dopamine receptors. This variant has been linked with smokers (48%),
alcoholics (42%), gamblers (50%) as well as with other disorders, particularly autism. It is also found in 25% of the general
population, many we have to assume have no obvious psychological or behavioural issues.

However, its role in dopamine pathways makes it an obvious candidate for involvement in addiction given the crucial role dopamine
appears to play in the addiction process.

Basically those with the A1 variant have significantly fewer dopamine receptors, so think about what that might mean in
practice. Fewer dopamine receptors would seem to suggest less pleasure! It might therefore follow that to get the same amount
of pleasure as a ‘normal’ brain the person would need to engage in more of the pleasurable behaviour, e.g. drink more alcohol.
This is similar to Eysenck’s physiological explanation of extroversion. According to Eysenck, extroverts have lower levels of
cortical arousal so need to seek out additional stimulation. This appears to be true of addicts but regarding lowered levels of
pleasure.

Interestingly, it might also explain why those brought up in poverty (both in terms of wealth and environment) may be more prone
to taking drugs. A lack of environmental pleasure is compensated for by taking chemicals. Those in more stimulating
surroundings don’t need the extra buzz, even if their brains lack the D2 receptors.

The medical model therefore might explain individual differences and why some people who experience the same situational
stimuli are less likely to develop addictive behaviours.

Psychological explanations of addictive behaviour

Behaviourist

As you’d expect, here we shall consider the idea that addictive behaviour is learned. In practice this has proved to be the most
successful approach in treating addiction so would appear have some validity. First, by way of background information we shall
consider the idea of schedules of reinforcement. I shall explain these mostly in terms of Skinner’s work on lever-pressing rats,
however, similar patterns can be seen in human behaviour.

As always with the behaviourist approach it is useful to consider Mowrer’s two stage approach when explaining the acquisition and
maintenance of any behaviour:

Acquisition: explains how the behaviour is initially acquired. Usually this is through
 an association (classical conditioning), for example an association between gambling
and buzz or chemical substance and excitement or relaxation etc.

Social learning theory could also initiate the behaviour, seeing others enjoy chemical
substances or the seemingly weekly coverage of millionaire lottery winners. This
acts as vicarious reinforcement.

Maintenance: best explained by operant conditioning. An initial win or buzz acts as

a powerful reinforcer that makes the behaviour more likely in future. Also the
punishment of withdrawal symptoms will also act to maintain future repetition. For
a fuller discussion of the reinforcement it is necessary to consider schedules of
reinforcement, outlined below:

Schedules of reinforcement

Continuous schedule

Operant conditioning is based on the idea of a behaviour reinforced is likely to be repeated. However, the behaviour does not
need to be reinforced every time it is performed for the learning to take place. In fact if a rat were to be fed every time it
pressed a lever (continuous reinforcement) it would very soon become full and lose interest. Drinks machines operate on this
schedule. Put money into a drinks machine you expect to get something out every time. If you don’t you stop the behaviour
straight away… it becomes extinguished. If you want to maintain a behaviour, in the absence of reward, for example as is needed
in casinos, bingo halls, amusement arcades, you need to adopt a more irregular schedule of reinforcement.

Other schedules can be based on time (interval) or number of behaviours performed (ratio).
Interval schedules

A behaviour may be rewarded every 5 minutes providing the behaviour has occurred in that time. This is called fixed interval.
Payment at the end of the month would be a human example. Alternatively, reward may be on a variable interval schedule.
Reward may be after 5 minutes, or sometimes 15, perhaps sometimes 2 minutes etc. This is less predictable and leads to slower
extinction. If after 5 minutes there is no reward the animal keeps pressing. Perhaps reward may be after 25 minutes this time.

Ratio schedules

Time is no longer an issue. In rat terms reward occurs after so many presses. This may be every 10 presses (fixed interval) or it
may be variable ratio.

Variable ratio

This is the most unpredictable of all patterns of reinforcement. Some times the rat will be reinforced after 20 presses,
sometimes 200 etc. This shows the slowest of all extinction rates, the rat may go on pressing the lever hundreds of times
without receiving any food. A VR10 schedule (average of 10 presses needed for reinforcement) produces a fast and long
lasting lever pressing in rats. No surprises therefore that fruit machines and other forms of gambling are based on this
schedule. The victim has no idea when the next payout will be, but continues putting in money long after the rewards have
stopped. All forms of praise for weight loss, body art, fast driving etc. are based on this schedule, ensuring that behaviour is
maintained long after the reinforcement ceases.

Operant conditioning of this sort is better at explaining maintenance as opposed to initial acquisition.

However, it is effective at explaining both chemical and behavioural addiction via the process of reinforcement. Chemical
addiction can also be explained in terms of avoidance of the punishment of withdrawal.
The behaviourist model always emphasises the role of environmental factors in shaping our behaviour. It has long been known
that environment is crucial in relapse following treatment so the behaviourist approach has been one of the more successful
approaches in the treatment of addictive behaviour.

As early as 1948, Wikler found that heroin addicts were far more likely to relapse when in a similar situation or with the same
people as when indulging in the habit originally.

Shiffman (1996) asked former smokers to record when and where they relapsed and foud it was always in situations were readily
available and when with other smokers.

Evaluation of behaviourist approach

Operant conditioning is very good at explaining the maintenance of addictive behaviour and at its persistence via the deliberate
use of variable ratio schedules of reinforcement.

However, classical conditioning is not so useful in explaining behavioural addictions. If addiction is due to an association between
gambling behaviour (for example) and winning, then why do addicts continue to gamble even after a very long losing streak? Why
doesn’t the behaviour become extinguished?

With chemical addiction the association of behaviour followed by buzz remains so will not extinguish.

However, classical can explain spontaneous recovery of the behaviour. Following a long period of abstinence, one slip can cause
relapse since it triggers the long-lost association.

As always the model can be criticized for being reductionist. It takes a complex human behaviour and attempts to explain it in
terms of contingencies and patterns of reward. It takes no account of individual differences or thought processes. We are all
exposed to similar media pressures and gambling opportunities so why do some of us resist and others succumb?
Cognitive model

No surprises from the cognitive perspective either. This approach always emphasizes the importance of perceptions and thinking
as well as schemas. In its simplest form the cognitive approach assumes that addiction behaviour is due to irrational beliefs. For
example regular gamblers have the irrational belief that the odds are not stacked against them and tend to over-estimate the
extent to which their behaviour can affect outcomes. In particular they tend to under-estimate the money they put in whilst
over-estimating their winnings. Unlike the medical and behaviourist models the cognitive model considers the thinking that
underlies the behaviour.

Self-medication

This approach assumes there are reasons for the person’s choice of ‘addiction.’ Although they don’t set out with the intention of
becoming addicted , there is a reason why, for example, alcohol is the drug of choice rather than cigarettes. The person may be
overly anxious or feel that they’re lacking in confidence. Alcohol would therefore be seen as a way of overcoming these
problems. If the issue is stress, nicotine may be the drug of choice. However, although there may be some face validity here,
very often the drug of choice does not have the desired effect. Nicotine increases stress levels and former smokers who have
kicked the habit generally experience less stress. However, as always with the cognitive model, it is the individuals perception
that is important. Parrott (1988) explains this in terms of withdrawal symptoms. Abstaining from nicotine, even for a brief
period, causes increased stress and anxiety in the form of cravings. Smoking immediately removes this anxiety and in the very
short term reduces the perception of stress. Longer term use however, increases stress but this isn’t noticed.

Evaluation

The model does assume an underlying or prior psychological problem, such as stress. This isn’t always apparent in addicts.
However, Sanjun et al (2009) reported that some women who suffer frequent sexual abuse drink excessively often do develop
drinking problems. In this case the alcohol acts to help remove their sexual inhibitions, making the abuse that little bit more
tolerable.

Griffiths’ Heuristics
Much more familiar ground now, for those of you who understand the usual workings of the cognitive model. As we saw at AS and
then again with Piaget, schemas play an important role in mental process (cognition) and are useful in explaining all manner of
behaviours.

Schemas (I refuse to use that horrible word ‘schemata’ as the plural)

Schemas are essentially ‘mental representations’ that allow us to picture, visualize etc. all manner of situations, events, objects.
We all have a schema for ‘dog’ that kicks in when one is mentioned. Schemas allow us to be ‘cognitive misers’ providing us with
existing templates and saving valuable mental processing time. Remember that stereotypes are essentially schemas for people
(individuals or groups). So where is this leading?

Heuristics

A heuristic (like a schema or stereotype) is a mental shortcut that allows us to make judgments and decisions, with minimal
thinking effort involved.

Heuristics of addictive behaviour are perhaps easiest understood if we apply them to gambling.

Gambling is surely a perfect example of irrational thinking. Its very premise seems to be built on a falsehood; the erroneous
belief that an individual can beat the odds. Griffiths suggests a number of such heuristics. We shall consider a few of them:

Gambler’s fallacy seems to be an obvious starting point: the idea that random events equal themselves out over time. “I haven’t
had a win for three months so it’s my turn soon.” With the lottery, the idea that a number hasn’t been drawn for twelve weeks so
it must come up this time.

Availability bias: is in some respects the above heuristic in reverse. The notion that because something has happened in the past
it will occur again in the future. Big winners on the lottery get oodles of coverage leading us to think it’s a common occurrence
and hence likely to happen to us too. In the early days of the lottery it soon became apparent that the number 44 was being
drawn more than the others. Result, everyone was picking the number 44!

Sunk cost bias: another possible explanation of the gambler’s fallacy. Playing a game costs money, we expect something in
return sooner or later. Having made that initial investment and not had a return we feel obliged to continue so we don’t lose out.
Long term we could potentially lose a lot more!
Representativeness bias: the tendency to confuse a representative sample with a random sample. Clearly games like the lottery
require a random drawing of numbers. However, when we come to chose a random sample we tend to pick numbers that best
represent the spectrum 1 to 49. As a result we are likely to chose a single number, one from the twenties, thirties etc. The
exception to this is the estimated thousands that pick 1,2,3,4,5,6!

Illusion of control: gamblers tend to over-estimate the amount of control they have. With the lottery this is minimal, however, I
suppose being able to chose your numbers provides some semblance of control. The illusion of control is more likely with fruit
machines which give the impression of control with features such as ‘nudge’ and ‘hold’ even though in practice very little skill is
involved.

As well as heuristics there is also a tendency by many gamblers to make it personal. Gamblers will switch from one bandit to
another, claiming the first one doesn’t like them. Some thin k they can con the machine by only putting in £1 at the outset.

Evaluation

As is usually the case with cognitive explanations it’s difficult to disentangle cause and effect (chicken and egg if you will).
Research disagrees over what comes first the irrational thinking and heuristics (which the model assumes are causes of
addiction) or the addiction, making the heuristics mere symptoms of the addiction.

Think of similar problems we’ve seen before:

Does faulty perception of body image create anorexia or is it a symptom?

Does negative thinking cause depression or is it a symptom?

Assuming that the heuristics pre-date the addiction then how do they arise? Why don’t we all develop this way of thinking?
What makes some people more susceptible than others? Individual factors such as these seem best explained by the biological
model and the possibility of some brains being more or less sensitive to dopamine and its rewarding effects; this in turn being
determined by our genes. Or perhaps dispositional factors such as the fabled ‘addictive personality’ that again predisposes some
of us to all manner of addictive behaviours.

It would seem logical to conclude that games based on skill (or at least the perception of skill) would be more addictive given the
cognitive explanation and its ideas of illusions of skill etc. In games that are clearly random such as the lottery, the illusion of
skill and control is going to be minimal in comparison to other forms of gambling such as cards (perhaps excluding pontoon). Fruit
machines employ what are called structural techniques to make repeat gambling more likely. Lots of flashing lights and near wins
to provide reinforcement (without money) and features such as nudge and ladders that give the impression of control.

Where does this leave us?

It is clear from all that has preceded, that neither cognitive, biological, behavioural nor structural characteristics are sufficient
in their own right to explain the complexity of addiction. In some way or other all of them combine to create addiction.

Explaining specific addictions:

Kleptomania

Etiology

Kleptomania appears to be much more common in females, but little is understood about the etiology. There is also some association
with other disorders such as depression and anxiety.

Symptoms

Kleptomania involves the failure to resist impulses to steal things that are not needed for either personal use or for their monetary value.
There is typically anxiety prior to the act of theft and relief or gratification afterward. If the theft is related to vengeance or psychosis,
kleptomania should not be diagnosed. (Kleptomania is quite rare, where common shoplifting is not).

Treatment

Treatment typically involves behavior modification. Other treatment approaches involve seeing the theft as an unconscious process and
analyzing it as such may assist in gaining insight and eventually extinguishing the behavior.

Pyromania is an impulse control disorder[1] in which individuals repeatedly fail to resist impulses to deliberately start fires,[1] in order to
relieve tension, for gratification or relief. The term pyromania comes from the Greek word πῦρ ('pyr', fire). Pyromania and pyromaniacs
are distinct from arson, the pursuit of personal, monetary or political gain. It is multiple deliberate and purposeful fire setting rather than
accidental.[2] Pyromaniacs start fires to induce euphoria, and often fixate on institutions of fire control like fire stations and firefighters.
Pyromania is a type of impulse control disorder, along with kleptomania, compulsive gambling, trichotillomania and others.

The appropriate treatment for pyromania varies with the age of the patient and the seriousness of the condition. For children and
adolescents treatment usually is cognitive behavioural therapysessions in which the patient’s situation is diagnosed to find out what may
have caused this impulsive behaviour. Once the situation is diagnosed, repeated therapy sessions usually help continue to a recovery
(Frey 2001).AS7 Other important steps must be taken as well with the interventions and the cause of the impulse behaviour. Some other
treatments measures include, parenting training, over-correction/satiation/negative practice with corrective consequences, behavior
contracting/token reinforcement, special problem-solving skills training, relaxation training, covert sensitization, fire safety and prevention
education, individual and family therapy, and medication.[11] The prognosis for recovery in adolescents and children who suffer from
pyromania depends on the environmental or individual factors in play, but is generally positive. Pyromania is generally harder to treat in
adults, often due to lack of cooperation by the patient. Treatment usually consists of more medication to prevent stress or emotional
outbursts (Oliver) in addition to long-term psychotherapy (Frey 2001). In adults, however, the recovery rate is generally poor and if an
adult does recover it usually takes a longer period of time (Frey 2001).

Pathological gambling disorder occurs when a person gambles compulsively to such an extent that the wagering
has a severe negative effect on his or her job, relationships, mental health, or other important aspects of life. The
person may continue to gamble even after they have developed social, economic, interpersonal, or legal problems
as a result of the gambling.

Description

Pathological gambling disorder is characterized by uncontrollable gambling well beyond the point of a social or
recreational activity, such that the gambling has a major disruptive effect on the gambler's life. People who are
pathological gamblers may lose their life savings, and may even commit crimes (stealing, embezzling, or forging
checks) to get money for their "habit." Relationships and jobs may also be lost as a result of the disorder.
Pathological gambling disorder is an example of a process, or behavioral, addiction , as distinct from an
addiction to such substances as food, drugs, tobacco, or alcohol. In process addictions, the characteristic "rush" or
"high" comes from the series of steps or actions that are involved in the addictive behavior. With gambling, the
"high" may be stimulated by the social atmosphere or group setting of the casino, race track, or bingo hall as well
as by the excitement of risk-taking. Some gamblers have a "lucky" outfit, item of clothing, or accessory that they
wear or take along when gambling; sometimes putting on the outfit or item in question is enough to start the
"rush."

People with pathological gambling disorder may engage in many different types of gambling activities. These may
include games of chance that are found in casinos, such as slot machines, card games, and roulette. Many of these
games are now available on the Internet, the chief difference being that the bettor uses a credit card instead of
cash or chips. Other gambling activities may include the state lottery, horse or dog racing, or even bingo. The
person may place bets on the outcome of an election, baseball or football games, or even the weather on a
particular day. Pathological gambling usually develops slowly over time; people tend to begin with acceptable
levels of social or recreational gambling and slowly progress to pathological gambling. In most cases the disorder
develops slowly over a period of years; however, there are cases of patients who gambled socially for decades and
then began to gamble compulsively under the impact of a major life stressor, such as divorce or being laid off from
work.

Treatments

There are a number of different treatments for pathological gambling disorder. Psychodynamic
psychotherapy attempts to uncover any underlying psychological factors that trigger the gambling. For people
who are gambling to escape, such as those who are depressed, this approach may be very successful. Treating any
substance abuse problems that may coexist with the pathological gambling can also be helpful. Other types of
treatments involve behavioral techniques used to teach relaxation and avoidance of stimuli associated with
gambling. Aversion therapy appears to be successful in treating pathological gambling disorder in highly
motivated patients with some insight into the problem, but is not helpful for patients who are less educated or
resistant to behavioral methods of treatment.

Vulnerability to Addiction
The syllabus specifies self esteem, attribution for addiction and social context

Again there appears to be some confusion reading through the different text books aimed at this specification. Eysenck spends
a lot of time discussing biosocial influences, whereas Flanagan and Gross devote half of their coverage specifically to media. I’ve
tried to disentangle this and present it in, what to me at least, seems a more logical manner.

Attributions for addiction

This first section (rest of this page) is designed for background information only. It isn’t tackling the issue of addiction, merely
providing a little explanation of what attribution theory is and what it seeks to explain. Therefore to keep the usual moaning
Minnies happy (you know who you are), I shall italicize the offending material J

Attribution is an interesting topic in its own right. Basically it considers the means by which we seek to explain the behaviour of
others as well as our own.

Generally speaking we tend to use dispositional factors to explain the behaviour of those we don’t know and situational factors to
explain our own behaviour. I’ll explain with the most obvious example. You see a person being rude in Sainsburys queue. A little
old granny pushes in front of you, let’s say! Having never met her before, we assume she’s rude. We attribute (that word) her
rudeness to dispositional (in this case personality) factors.

However, if we have our own rudeness pointed out we are likely to attribute it to an environmental or situational factor.
Something that emphasizes the peculiarity of the situation we found ourselves in. We were in a hurry, we didn’t see the queue
etc.

This is called the fundamental attribution error (FAE).

Other explanations for the FAE might include:

Actor-observer bias:

We see ourselves as complex and unpredictable and certainly object to attempts to categorise us. As a result we like to see our
own behaviour as flexible and adapting to our circumstances. On the other hand we feel happier being able to predict the
behaviour of others so we look for more straight forward and unchanging explanations of their behaviour based on the more
constant characteristics of personality and disposition.

Self serving bias

Acts to protect self esteem. We can explain other people’s behaviour in any way we see fit. However, we like to see our own
behaviour in as positive a way as possible. When we know we’ve done wrong we protect our ego by looking for the positives.

Triadic influence theory (Sussman et al (2000))

As you guessed this considers three factors, but they do seem to be catch-all criteria:

 Extrapersonal (interaction with peers, social group, parents etc. and media)
 Attitude and cultural (presumably society, culture and norms)
 Intrapersonal (genetics, self esteem, attributions, personality etc)
They looked at over 700 high risk youths from a collection of ‘alternative high schools’ in California. Basically these were set up
to provide additional support for those seen as being at risk either due to poor academic achievement or behavioural and
emotional factors. They provide an education grounded in more practical skills and a higher teacher to student ration.

They essentially found that the best predictors of drug addiction were the students themselves. Those who had used drugs or
intended to use drugs or were concerned about later drug use, were, twelve months later. The most likely to have become
addicts.

Extrapersonal and Intrapersonal

Sussman and Ames (2001) simplified the above three factors down to just these two

Extrapersonal

This covers demographic (such as age and gender), environmental, cultural and social.

I won’t cover the whole list but rather concentrate on a few examples from each area.

Environmental

 Neighbourhood: Lack of organisation or authority in an area results in social disobedience such as excessive use of alcohol
or drug addiction. Often the design of buildings in such areas adds to the problem with few open spaces. Planners of
inner city areas include few parks but are more likely to design developments with many out of view places were a whole
range of illegal or undesirable behaviours can be carried out in private.
 Deprivation: Here referring to economic deprivation. Low SES results in higher levels of rime as people with low incomes
may find it useful to supplement income with illegal activities such as peddling cheap cigarettes or illegal drugs. Lack of
money limits the range of activities available so is associated with boredom which in turn may lead to drug use. However,
drug taking is also associated with decline in SES so cause and effect are difficult to unravel.
 Availability: Bit obvious I guess… but you can only take what is available. Specifically in this case you need: a. an easy and
uninterrupted method of distribution, b. knowledge of where and how the products can be purchased, c. the ability to buy
(i.e. money).
Cultural

Determines what is available and our prevailing ideas and attitudes about the behaviours.

Cannabis

The Netherlands are famous for their liberal attitude to cannabis. In other parts of the World, including the UK, it isn’t even
available fore medical use. There has been widespread criticism in recent years for the confused message coming from the
British government who first down-graded cannabis from category B to C (2004), but in 2008 reinstated its grade B status.

Alcohol

In Europe there tends to be a more relaxed view of alcohol consumption. The French particularly are famed for allowing children
to drink alcohol at the table, almost regarding wine as food. In the USA however, there are far stricter views. Most states have
a minimum drinking age of 21. Barbara Bush (daughter of George W) was sentenced to eight hours community service in 2001 for
consuming alcohol at the dangerously young age of 19! What kind of crazy bitch is she!!!

Note: the USA’s hard line approach to alcohol isn’t new. In 1919 the eighteenth amendment to the constitution banned alcohol
from public sale. Prohibition wasn’t repealed until 1933, despite being largely flouted in the latter stages.

Social context

Alcohol also provides a very good example of how social norms can impact on attitudes and behaviour towards addictive habits.
Opiate use really took off around the turn of the eighteenth into the nineteenth century. It was widely used recreationally and
seen as a cure-all or panacea for a wide range of illnesses. Examples of its marketing include: Dover’s Powders, marketed as a
cure for gout and Godfey’s Cordial which was sold as a “soother” for crying babies! Usually it was taken as a tincture with alcohol
and referred to as laudanum. Apparently it was particularly popular in the Fens. The city of Ely was known as the ‘opium eating
city.’ It wasn’t until 1868 that availability was restricted to use by pharmacists only.

Recently smoking has become increasingly socially unacceptable and numbers of smokers in the UK has declined significantly in
the past thirty years.

Models of Prevention and Types of Intervention

Not the most clearly defined of AQA topics it has to be said, but broadly speaking they want us to look at ways in which
addiction can be understood in terms of personal intention and then the ways psychologists or others can intervene to alter these
intentions. Hopefully it will all make more sense as we wade through the topic. Be warned however, enjoyable this topic is not!

Overview:

Methods of Prevention:

Two strikingly similar theories:

 Theory of Reasoned Action

 Theory of Planned Behaviour

Types of Intervention

More familiar ground

  Biological
 Behavioural
 Cognitive (CBT in Fact)
 Self help
 Public Health interventions

Here goes

Types of Intervention

Introduction

We shall now consider steps that can be taken by professionals or by governments to intervene and attempt to influence
intentions and/or behaviour. Essentially these measures are aimed at subjective norms and personal attitudes in an attempt to
strengthen or support our intentions.

Biological Interventions

These tend to be limited and based around drugs of one sort or another. They are most commonly applied to drug addicts,
alcoholics and smokers.

Drugs can fall into one of three basic categories:

1. Aversion

These are drugs that produce unpleasant consequences such as vomiting and nausea especially when taken alongside other drugs.
Example: antabuse (disulfiram) for the treatment of alcoholics.

2. Agonist

These act as a less harmful replacement for the dependent drug, resulting in fewer side effects and allowing gradual and
controlled withdrawal from the substance. Ideally they should be accompanied by counselling and rehabilitation.

Example: methadone for the treatment of heroin addiction.

3. Antagonist

These block the effects of the target drug and prevent them from having the desired effect.

Example: naltrexone for the treatment of opiate addictions

We shall now consider each one in more detail as we look at ways of treating various addictions:

Biological interventions for alcoholism

Alcoholics can suffer severe withdrawal symptoms including delirium tremens (DTs) if alcohol is removed completely. Often
patients are admitted to hospital during detoxification and given anxiolytics such as benzodiazepines (e.g. valium) to prevent fits
and to reduce the anxiety of being withdrawn. The patient can then gradually be withdrawn from the anxiolytics. Occasionally if
the symptoms aren’t too severe the process can be performed as an outpatient under the supervision of the patient’s GP.

Psychological Interventions

Here we shall consider methods suggested by the behaviourists and by cognitive psychologists.
Behaviourist approach

Cast your minds back to abnormality in year 12. Behaviourist methods of treatment can be split into those based on classical
conditioning (such as aversion therapy) and those based on operant conditioning (such as token economy)

Aversion therapy

Classical (Pavlovian) conditioning centres on learning through association. In this case the idea is to associate the undesirable
behaviour with something unpleasant. Aversion therapy has been most widely applied to alcoholism so we shall concentrate on
this.

A warm salty solution containing an emetic is given to the patient. An emetic is a drug designed to make you throw up!
Behaviourists have a ‘law of contiguity’ which states that two actions that occur together will become associated. Immediately
prior to vomiting the patient is given a shot of alcohol, usually whisky which has a strong and distinctive smell as well as taste.
Ideally the vomiting should then occur just after the drink. The process is repeated on a regular basis with subsequent
treatments involving larger doses of emetic and perhaps various other alcoholic beverages.

There is some research that suggests

the treatment is effective. Meyer and
Chesser (1970) claimed a 50% success
rate twelve months after treatment.
However, most research suggests that
the benefits are only short term. The
issue seems to be that patients have had
years of happy associations before the
bad ones were artificially created.
Smith et al (reported 1997) gave
patients either emetic or electrical
 aversion. Although after six months the
treatment appeared to have been
successful, by twelve months the
majority of those treated had relapsed.

As with antabuse (used by the medical model) inducing vomiting is not a method preferred by patients, so as with antabuse there
is a very high drop out rate from treatment.

Aversion therapy has been used for a host of ‘disorders’ including homosexuality. It has also been used in an attempt to treat
gambling addiction. McConaghy et al 1983, got gamblers to read out lists of words. Each time a word associated with gambling
was read they were given an electric shock! Success rate was put at around 50%.

Contingency Management

This is sometimes referred to as community reinforcement approach and I still think of it as token economy. The Board and
texts however, seem to prefer contingency management so CM it is J

The method is based on operant conditioning so rewards are the order of the day. Patients and those that deal with them
socially or professionally are encouraged to provide rewards when behaviours ‘inconsistent’ with the addictive behaviour are
performed. Usually rewards consist of vouchers (hence ‘token economy’) which can be swapped for goods. In prisons this is
often cigarettes (though this would be unlikely in the case of tackling nicotine addiction).

Evaluation

Davison et al (2004) believes it to be one of the most effective treatments for addiction. Petry et al compared the outcomes of
two groups of alcoholics, one receiving ‘standard outpatient’ care, the other having the same but coupled with CM. The relapse
rate for those getting the CM was significantly lower, 26% compared to 61% for the standard treatment group.

CM has been used to treat other addictions, for example heroin. Sindelar et al (2007) compared groups of heroin users. All
were getting the standard daily treatment with methadone but half were also given CM. Those receiving the CM were far more
likely to test negative for heroin use. (Note: in this case the reward was entry into a draw for those who tested negative.
Winners were given various amounts o money).

Overall

Behaviourist methods, like their theories I guess, are superficial. They tackle the behaviour but not the underlying causes or
predisposition. As a result, although their interventions produce some short term success, in the long term there is a high rate
of relapse.

Cognitive (and Cognitive Behavioural) Interventions

Although usually used to treat depression, as we’ve already seen, CBT has also been applied successfully to the treatment of a
variety of addictions.

The basis of CBT is that behaviour is determined largely by our thoughts and although the patient may not be able to change
their situation they can certainly change the way they think about it.

When applied to alcohol and other drug dependence, CBT teaches the patient how to recognise and then avoid high risk situations
in which they are more likely to drink or use drugs. Although there are a variety of CBTs (rational emotive therapy, rational
behaviour therapy, dialectic behaviour therapy etc) when applied to addiction they all share to main components.

Functional Analysis

The patient (client) and therapist work together to try and recognise under what circumstances the behaviour occurs. They
explore the feelings and motivations before, during and after the event in an attempt to help the patient determine the risk
factors. Functional analysis is useful in helping the patient identify possible reasons for the behaviour.

Skills training

The therapist teaches the patient better or more appropriate coping strategies. This involves unlearning old habits and replacing
them with healthier ones.

Unlike other forms of therapy such as psychoanalysis, CBT is very structured and shorter in duration. The more open ended
psychodynamic techniques can take many months or even years whereas CBT usually lasts 10-15 sessions.

When applied to gambling, we saw earlier in the topic that erroneous beliefs (heuristics) such as an over-perception of control
and under-estimate of losses help to maintain the gambling behaviour. The therapist will help the patient test these faulty
beliefs and replace them with healthier and realistic ideas that hopefully will reduce the urge to gamble.

Self-help interventions

The most popular self-help therapy Worldwide is the one adopted by Alcoholics Anonymous (AA) and their offshoots Gamblers,
Narcotics and even Sexaholics Anonymous. Their motto is ‘One day at a time’ since they believe that addiction can only be
arrested never cured.

They all take the Minnesota 12-step programme as the basis of their intervention.

The sessions are run by former addicts and all those attending must be at rock bottom. They must also attend voluntarily and
show a commitment to overcoming their addiction.

Treatments are based on group therapy in which each addict has to self-disclose the issues they are facing. Others offer advice
and support. Addicts are encouraged to exchange phone numbers and keep in touch between sessions as well.
The Twelve Steps:

1. We admitted we were powerless over alcohol that our lives had

become unmanageable.
2. Came to believe that a Power greater than ourselves could restore
us to sanity.
3. Made a decision to turn our will and our lives over to the care of
God as we understood Him.
4. Made a searching and fearless moral inventory of ourselves.
5. Admitted to God, to ourselves, and to another human being the
exact nature of our wrongs.
6. Were entirely ready to have God remove all these defects of
character.
7. Humbly asked Him to remove our shortcomings.
8. Made a list of all persons we had harmed, and became willing to
make amends to them all.
9. Made direct amends to such people wherever possible, except when
to do so would injure them or others.
10. Continued to take personal inventory and when we were wrong
promptly admitted it.
11. Sought through prayer and meditation to improve our conscious
contact with God as we understood Him, praying only for knowledge of
His Will for us and the power to carry that out.
 12. Having had a spiritual awakening as the result of these steps, we
tried to carry this message to alcoholics, and to practice these
principles in all our affairs.

It is clear from the steps above that the Minnesota approach does rely heavily on spiritually and the power of belief. This does
act as a bar to some people.

Fortunately, a growing body of research suggests the effectiveness of using several fundamental components of behavior and cognitive-
behavioral approaches to treat kleptomania and co-occurring behavior problems (e.g., Gauthier & Pellerin, 1982; Glover, 1985; Grant,
2006a; Kohn & Antonuccio, 2002), including covert sensitization, shaping, behavioral chaining, problem-solving, cognitive restructuring,
and homework (O'Donohue, Hayes, & Fisher, 2003). A thorough functional analysis drives the unique implementation, format, and
structure of each of these techniques for each individual (Haynes & O'Brien, 1990; Kanfer & Saslow, 1965; Kohn & Antonuccio, 2002).
For example, covert sensitization, the "pairing of imagined consequences of stealing with the desire to steal" (Goldman, 1991, p. 993),
can use kleptomania-specific consequences (e.g., getting arrested, going to jail), rather than the commonly used images of nausea or
vomiting (e.g., Cautela, 1966, Glover, 1985) as the aversive event, with high rates of success (Gauthier & Pellerin, 1982; Kohn &
Antonuccio, 2002). In this approach individuals describe the scenario aloud, in vivid detail, allowing their anxiety to increase until they
reach a predetermined end-point, such as spending time in jail or the conclusion of a court trial. Repeated pairings of aversive imagined
consequences can lead to a decrease in expressed stealing behaviors, but also must be accompanied by reinforcement of appropriate
behaviors.

A hallmark of behavioral and cognitive-behavioral interventions is the use of the scientist-practitioner model, and the systematic
measurement of treatment progress which, albeit, relies largely on self-report. As such, an individual's initial treatment gains can be
assessed using Improvement Scaling (IMS; Smith, Cardillo, Smith, & Amezaga, 1998), a versatile self-report measure tailored to each
client's treatment goals that has been successfully utilized in the assessment and treatment of kleptomania (Kohn & Antonuccio, 2002).
The Kleptomania Symptom Assessment Scale (K-SAS; Grant, 2006b) a self-report measure, appears to have
adequate psychometric properties, and is designed to assess change in cognitions, behaviors, and urges during treatment. The BDI-II
(Beck, et al., 1996) and BAI (Beck & Steer, 1993) can also be used to gauge increases and decreases in depressive and anxiety
symptoms.

2. Workplace interventions

These can either be government-led, for example the no smoking in enclosed places legislation introduced in the UK in 2007 or
they can be smaller, localised initiatives adopted by the workplace. An example would be new guidelines for the canteen or
discouraging lunchtime drinking by its employees. These tend to have an advantage in that potentially they could have a large
target population meaning dozens or even millions could be involved and with things like the smoking ban there is built-in social
support. Since everybody in the company is affected then people can rally round and offer encouragement.

In the case of the smoking ban there is evidence that it has drastically reduced smoking whilst at work. The downside is that it’s
probably increased smoking at home as people compensate for their lack of nicotine earlier in the day. This could be having an
adverse effect on children for example.

An Australian study that investigated attitudes immediately and six months after a similar ban in 44 government buildings
suggested immediate resentment and inconvenience which diminished with time. Despite this the ban only resulted in 2%
quitting completely.

In the UK the ban was introduced in July 2007. Between April and December of that year an estimated 250,000 people quit.
Most of these were in the nine months prior to the ban being introduced.

3. Community-based initiatives

The Stanford Five City Project was a large scale community-based intervention designed to test whether a comprehensive
program of community organization and health education would positively alter the behaviour of those involved. Two cities were
targeted and the results compared to three other cities that had not undergone the intervention.

A six year intervention targeted all residents in the two treatment cities and involved a multiple risk factor strategy delivered
through multiple educational channels.

The results showed that the treatment cities produced significantly greater improvements in cardiovascular disease knowledge,
blood pressure, and smoking than the control cities. For example there was a 13% reduction in the number of smokers.

A similar study in North Karelia was launched in 1972 in response to a local petition to get urgent and effective help to reduce
the very high rates of CHD in the area. In cooperation with local and national authorities and experts as well as with WHO, the
North Karelia Project was formulated and implemented to carry out a comprehensive intervention through the community
organizations and the action of the people themselves.
The 25-year results and experiences of the North Karelia Project show that a determined and well thought out intervention
programme can have a major impact on health-related lifestyles and on population risk factors. By 1995 the annual mortality rate
of coronary heart disease in North Karelia in the working age population had fallen approximately 75%, compared with the rate
before the Project.

4. Government initiatives

Broadly speaking governments can intervene in one of two ways.

1. Ban or restrict goods or advertising: As we’ve already seen smoking in public places was banned in the UK in 2007. Prior
to that advertising of tobacco related product had been banned many years earlier, starting with cigarettes and then
extending to cigars and other products. Advertising of alcohol has also been restricted. Although still allowed on TV
advertisers can suggest no link between alcohol and sexual performance or making the consumer appear more attractive.
Advertisers have therefore tended to use humour as with Peter Kay and John Smiths.
2. Increase the cost through taxation. There are regular hikes in taxation on cigarettes and various forms of alcohol. The
idea being that higher cost will reduce consumption, particularly in the young. There have been recent calls for the taxes
to be more targeted. For example increasing the price of alcohol sold in supermarkets where often it becomes a loss-
leader. The BMA (British Medical Association) have called for a minimum ‘per-unit’ price for all alcohol sold in the UK.

Harm minimisation

In recent years public health initiatives have adopted a more realistic harm-minimisation approach.

As we saw in the section on media, very often anti-drug campaigns and pro-health campaigns such as ‘five a day’ increase
knowledge but have little impact on behaviour. As a result, addicts are made aware of the risks but continue the habit.

Many campaigns have therefore focused on making the behaviours safer rather than attempting to stop them. An obvious
example would be increasing awareness of the dangers of sharing needles and ensuring heroin addicts can either obtain clean
needles or know the correct message of sterilization.

They may also advertise the benefits of safer or replacement drugs such as methadone that doesn’t contain unknown
contaminants and can be correctly dosed.

Many, however, resent such information, believing that it seeks to condone the behaviour rather than prevent it from happening
at all.

Schuckit (1985) compared individuals who are genetically at high risk (close relatives who abuse alcohol) with those who are at low
risk. Schuckit suggests that people who are genetically prone to becoming alcoholics may have an impaired ability to perceive the
effects of alcohol.
Peters and Preedy (2002) suggest that half the people who abuse alcohol have a close relative who also abuses alcohol".