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Aggression in Behavioral Addictions

Chapter · February 2023

DOI: 10.1007/978-3-030-98711-4_51-1

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Aggression in Behavioral Addictions

Yui Asaoka and Yukiori Goto

Contents
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Behavioral Addiction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Aggression in Behavioral Addiction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Factors Involved in Aggression of Behavioral Addiction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Insights from Aggression in Drug Addiction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Neuropharmacological Mechanisms of Aggression: Addiction Perspectives . . . . . . . . . . . . . . . . . . . 7
Testosterone and Cortisol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Dopamine and Serotonin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Applications of the Material . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Mini-Dictionary of Terms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Key Facts of Aggression in Behavioral Addiction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Summary Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Abstract
Behavioral addiction is an emerging concept referring to psychiatric conditions
characterized by repeated and uncontrolled urges of seeking specific behaviors
despite negative consequences are expected. As an addictive disorder, several
behavioral problems are thought to mutually be involved in behavioral and drug
addiction, one of which is heighted aggression. Although relatively few studies
have been conducted to examine aggression in behavioral addiction to date, an
emerging picture suggests heterogeneous nature of aggression that depends on

Y. Asaoka
Division of Biological Sciences, Graduate School of Science, Kyoto University, Kyoto, Japan
e-mail: asaoka.yui.38x@st.kyoto-u.ac.jp
Y. Goto (*)
Department of Artificial Intelligence and Technology, Graduate School of Informatics, Kyoto
University, Kyoto, Japan
e-mail: goto.yukiori.5c@kyoto-u.ac.jp

© Springer Nature Switzerland AG 2023 1

C. Martin et al. (eds.), Handbook of Anger, Aggression, and Violence,
https://doi.org/10.1007/978-3-030-98711-4_51-1
2 Y. Asaoka and Y. Goto

subtypes of addiction. In this chapter, a current state of what is known about

aggression and its biological mechanisms is described from the perspective of
behavioral addiction. Then, implications arguing that aggression is a promising
target for understanding not only drug addiction but also behavioral addiction are
given.

Keywords
Addiction · Impulse control disorder · Kleptomania · Paraphilia · Internet ·
Gambling · Gaming · Eating disorder · Dopamine · Serotonin · Cortisol ·
Testosterone · Prefrontal cortex · Behavioral inhibition · Impulsivity

Abbreviations
5-HT Serotonin
5-HIAA 5-Hydroxyindoleacetic acid
BPA Buss-Perry Aggression
CSF Cerebrospinal fluid
DA Dopamine
DSM-5 5th Edition of Diagnostic and Statistical Manual of Mental Disorders
HPA Hypothalamic-pituitary-adrenal
HPG Hypothalamic-pituitary-gonadal
HVA Homovanillic acid
ICD-11 11th Version of International Statistical Classification of Diseases and
Related Health Problems
NAcc Nucleus accumbens
PET Positron emission tomography
PFC Prefrontal cortex
PSAP Point Subtraction Aggression Paradigm
RPA Reactive-Proactive Aggression
SSRI Selective serotonin reuptake inhibitor

Introduction

Aggression is a behavioral and emotional concept, which is not necessarily derived

from a biological foundation.
In a psychological term, aggression is defined as expression of behavior that is
mediated by an intent to harm others or self (Anderson and Bushman 2002).
Aggression is associated with various factors, ranging from cultural to pathological
ones. Heightened aggression has been reported in psychiatric disorders, including
addiction (Girasek et al. 2022), suggesting that physiological mechanisms that
fabricate aggression would also be involved in the pathophysiology of psychiatric
disorders.
A prevailing aggression model in psychology has been proposed by Buss and
Perry, in which aggression consists of four domains: physical, verbal, anger, and
Aggression in Behavioral Addictions 3

hostility (Buss and Perry 1992). Subsequently, another perspective has been added in
the concept of aggression, which decompose aggression into the reactive vs. proactive
dichotomy (Poulin and Boivin 2000), with reactive and proactive aggression delivered
impulsively and goal-directed basis, respectively. In recent years, further emphasis has
been given to self-controlling deficits and impulsivity as the mechanisms that produce
aggression (Denson et al. 2012).
Addiction is a psychiatric condition, primarily referring to abuse and dependence
of addictive substances, such as alcohol, and psychostimulants. However, accumu-
lating evidence suggests that addiction could be a broader spectrum to include not
only substances but also specific behaviors associated with strong rewards, which is
known as behavioral addiction. A number of studies have reported increased aggres-
sion in drug addiction (substance use disorder) and behavioral addiction, but these
studies are often controversial. In this chapter, aggression and its biological mech-
anisms are discussed in the behavioral addiction perspective.

Behavioral Addiction

Behavioral addiction is characterized by repeated compulsive and impulsive seeking

of maladaptive behaviors despite recognizable negative consequences of executing
such behaviors.
The concept of behavioral addiction could be both old and new. Behavioral
addiction was proposed back in the 1960s for compulsive, pathological gambling
(Abrams et al. 1964). Pathological gambling has formally been categorized as an
addictive disorder in the Diagnostic and Statistical Manual of Mental Disorders
published by the American Psychiatric Association when it was revised at the fourth
reversion (American Psychiatric Association 1994), which was subsequently
renamed to gambling disorder with a minor change of its criteria at the current
version (DSM-5; American Psychiatric Association 2013). In 2019, the latest, 11th
version of the International Statistical Classification of Diseases and Related Health
Problems (ICD-11) was published, in which behavioral control problems against the
new technology, such as problematic internet use and gaming disorder, have also
been appended as addictive disorders (World Health Organization 2018).
Nonetheless, the definition of behavioral addiction has not yet been established to
date. In particular, (drug) addiction was once thought to be understood with emo-
tional problems, such as craving to pleasures by taking drugs and aversion to
withdrawals by lack of drugs. Thus, it has to involve a sort of emotional aspects of
symptoms, including salience, mood modification, tolerance, withdrawal symptoms,
conflict, and relapse (Koob 1996). However, recent studies suggest that addiction is
rather contemplated by abnormal learning processes (Everitt and Robbins 2016).
Thus, addiction could be defined as acquired maladaptive behaviors through incen-
tive learning, and under this point of view, the number of psychiatric disorders,
which are currently categorized in “disruptive, impulse control, and conduct disor-
ders,” “obsessive-compulsive and related disorders,” and “feeding and eating disor-
ders” in the diagnostic manuals, is also suggested to meet the criteria of addiction
4 Y. Asaoka and Y. Goto

(Griffiths 2005; Robbins and Clark 2015). Hence, the term “behavioral addiction” is
in general used to refer not only gambling, internet use, and gaming disorders but
also broader symptoms of psychiatric conditions, including paraphilic and
non-paraphilic sexual disorders and kleptomania (Grant et al. 2010).

Aggression in Behavioral Addiction

Addiction and aggression have profound relationships with each other. For instance,
intermittent explosive disorder is an impulse control disorder of aggression charac-
terized by repeated episodes of anger and violence, which is also suggested to meet
the criteria of addiction, since aggression also connotes a rewarding temperament
(Golden and Shaham 2018). Although solid evidence now exists that aggression is
associated with psychiatric disorders (Girasek et al. 2022), this is less and contro-
versial in behavioral addiction, except in some cases, such as eating disorders, which
is suggested to be considered as behavioral addiction (Hebebrand et al. 2014), or
alternately, food addiction (Schulte et al. 2015) has consistently been reported to
exhibit heightened, but primarily internalized, aggression toward themselves,
resulting in self-injuries (Miotto et al. 2008).
Studies investigating aggression in behavioral addiction (a table summarizing
these studies can be downloaded at https://sites.google.com/kyoto-u.ac.jp/goto-
laboratory/downloads) typically utilized self-assessment questionnaires in testing
aggression. The most frequently used questionnaire is the Buss-Perry Aggression
(BPA) questionnaire, which casts the psychological model of aggression with four
domains of allocations: physical, verbal, anger, and hostility (Buss and Perry 1992).
Another questionnaire used, but less extent, to examine aggression is the Reactive-
Proactive Aggression (RPA) questionnaire, which deals with another psychological
concept of aggression where it is divided into the domains of proactive aggression
delivered for goal-directed and perceived benefits and reactive aggression delivered
in response to aggravation and reprisal, respectively (Poulin and Boivin 2000).
Among various subtypes of behavioral addiction, heightened aggression has been
demonstrated mostly in gaming disorder. For instance, positive correlations between
gaming addiction symptoms and overall BPA scores as aggression measures were
observed in Asian (Kim et al. 2008) and European (Caner and Evgin 2021; Mehroof
and Griffiths 2010) populations. Aggression was also found a predictor of gaming
disorder in male adolescents (Jamil et al. 2017). On the other hand, evidence of
heighted aggression in other subtypes of behavioral addiction is sparse. However,
some studies have reported heightened aggression in gambling disorder but less
consistently. Asaoka and colleagues have also recently reported higher aggression in
patients with kleptomania and paraphilia than healthy subjects when aggression is
surveyed with BPA and RPA questionnaires, but not with objective measurements of
aggression (Asaoka et al. 2021).
One of reasons that heightened aggression is more frequently documented in
gaming disorder than other subtypes of behavioral addiction may be related to the
idea that playing violent video games would yield adverse influence that facilitates
aggressive behaviors (Prescott et al. 2018). A number of studies has supported this
Aggression in Behavioral Addictions 5

hypothesis reporting that aggression is more prevalent in subjects who have been
playing violent video games substantially or relatively early in development (Siyez
and Baran 2017). However, recent studies with solid study designs and data analysis
methods counteracted these findings. A longitudinal study on the effects of violent
video game play for 2 months did not find any change in aggression before and after
playing the games (Kuhn et al. 2019). Moreover, playing violent games could either
significantly increase or even lower aggression among heavy players, depending on
how the data are analyzed with different regression models (Lee et al. 2021).
It is also important to note a possibility that self-reported questionnaires may not
accurately evaluate aggression, especially in behavioral addiction. Aggression in
behavioral addiction studies has almost exclusively been tested with self-reported
questionnaires. Such self-reported questionnaire surveys can particularly be prob-
lematic when targets of the studies may be suffering from biased self-recognition,
which is in fact observed in addicts (Moeller and Goldstein 2014). Asaoka and
colleagues have demonstrated that, although behavioral addicts with kleptomania
and paraphilia rated themselves more aggressive than healthy subjects with the BPA
and RPA questionnaires, these patients were found to exhibit comparable levels of
aggression to that of healthy subjects, when aggression was tested implicitly using a
psychological task, such as Point Subtraction Aggression Paradigm (PSAP) test
(Asaoka et al. 2021). In some drug addicts, higher level of aggression was even
observed than that of healthy subjects with the PASP test (Gerra et al. 2004).
However, when antisocial personality disorder exists as a comorbidity of drug
addiction, aggression was found comparable with that of healthy subjects on the
PSAP test, but they still reported themselves more aggressive than healthy subjects
on self-assessment questionnaires (Alcorn et al. 2013). Moreover, patients with
antisocial personality disorder but without a comorbidity of drug addiction also
exhibit no heightened aggression in the PSAP test (Moeller et al. 1998) but report
themselves more aggressive in self-assessment questionnaires (Perdeci et al. 2010).
Thus, a pattern of aggression in patients with kleptomania and paraphilia rather
resembles to antisocial personality disorder than drug addiction. Further investiga-
tions would be compelled to clarify in what extent aggression in behavioral addiction
could be similar to that of drug addiction.
Collectively, since there have been only a limited number of studies that inves-
tigated aggression in behavioral addiction, it is too early and difficult to draw any
conclusion about whether aggression may be altered in this psychiatric condition at
this moment. It is however possible that alterations of aggression may be heteroge-
neous, such that aggression is amplified in some, but not in other, subtypes of
behavioral addiction.

Factors Involved in Aggression of Behavioral Addiction

There could be several factors that contribute to facilitation of aggression in behav-

ioral addiction. Augmented impulsivity in patients has been reported independent of
subtypes of behavioral addiction (a table summarizing these studies can be down-
loaded at https://sites.google.com/kyoto-u.ac.jp/goto-laboratory/downloads),
6 Y. Asaoka and Y. Goto

suggesting that impulsivity is a core feature of behavioral addiction. DSM-5 also

includes impulsivity as one of the diagnostic criteria for behavioral addiction
(American Psychiatric Association 2013).
Since impulsivity could liberate (such as reactive) aggression (Barratt 1994),
aggression is also expected to be heightened in behavioral addiction. However, as
described in the previous section, aggression was found comparable between behav-
ioral addicts and healthy subjects in some cases. Such a discrepancy may suggest
that there could be a mechanism constraining expression of aggression by impul-
sivity, which may be related to subtypes of behavioral addiction. Investigation for
the mechanisms underlying such dissociation between aggression and impulsivity
may be able to provide further insights about the pathophysiology of addiction. For
instance, such mechanisms may be associated with aggression as predisposition (i.e.,
subjects with a higher aggressive personality trait are more prone to addiction) or
consequence (i.e., aggression is heightened as a consequence of addiction) of
addiction.
Self-control is an ability to regulate one’s emotions and actions, in which two
distinct but rather opposite processes are involved: impulsivity and restraint
(Maloney et al. 2012). A suggestion that the quintessence of aggression should be
considered not only with impulsivity but also with self-control deficiency, in general,
has been made (Denson et al. 2012), although there is still a paucity of empirical
evidence to support the relationship between self-control ability and aggression.
Accumulating evidence also suggests that aggression is strongly associated with
social anxiety (Neumann et al. 2010). Behavioral addicts exhibit self-control deficits
(Li et al. 2021) and higher social anxiety, which are present regardless of pre- or
post-symptom development (Weinstein et al. 2015).

Insights from Aggression in Drug Addiction

Many drug addicts can be both perpetrators and victims of violence (Parker and
Auerhahn 1998). However, it is difficult to discern a direct causal relationship
between drug addiction and aggression due to complex relationships. In fact,
addictive substances are not always associated with heightened aggression. Several
addictive substances, such as alcohol, cocaine, amphetamine/methamphetamine,
phencyclidine, and barbiturates, have been demonstrated to produce immediate
aggression (Roth 1994; Reiss and Roth 1993; Boles and Miotto 2003). These
drugs increase violence in both men and women (Fagan 1990; Reiss and Roth
1993), except alcohol, which renders a gender effect that increases violent behaviors
in men, but not in women (Friedman 1998). Other addictive substances increase
aggression while in chronic, abuse conditions, i.e., addiction. Alcohol and cocaine
promote aggression not only in nonaddictive use but also in addiction (Boles and
Miotto 2003). There are also substances that are not associated with aggression
neither acute nor addictive state. Hallucinogens have been shown to decrease
aggression (Fagan 1990), although they may still exacerbate existing violent ten-
dencies (Reiss and Roth 1993). Among addictive substances, marijuana is known to
Aggression in Behavioral Addictions 7

temporarily inhibit aggressive behavior (Reiss and Roth 1993). There is also no
evidence that nicotine is associated with violence, and if there are reports of higher
aggression in smokers, it is most likely the result of other substance use disorders or
comorbid psychiatric disorders (Boles and Miotto 2003). However, these addictive
substances could still induce aggression such as withdrawal symptoms (Roth 1994).
Addictive substances could also affect aggression indirectly (i.e., drugs facilitate
an inherently aggressive personality trait or emotional states for aggression; Fagan
1990; Goldstein 1985; Boles and Miotto 2003). Cohort studies support that individ-
uals with highly aggressive personalities are more prone to drug addiction, such that
this personality factor is suggested to likely be more important than pharmacological
factors (Tomlinson et al. 2016). In particular, an aggressive personality trait is also
associated with heightened aggression in some behavioral addiction, such as gaming
disorder (Hwang et al. 2014).
Collectively, heightened aggression observed in drug addicts may not be a
consequence of (or associated with the process of) addiction itself, as heightened
aggression in drug addiction depends on the types of drugs to be addicted, so as types
of behaviors to be addicted in behavioral addiction, in which heightened aggression
is observed in some but not all of subtypes.

Neuropharmacological Mechanisms of Aggression: Addiction

Perspectives

Several biomarkers have been identified for aggression. Using such biomarkers,
although indirectly, aggression can also be evaluated.

Testosterone and Cortisol

The most recognized and traditional biochemical substance associated with aggres-
sion is the sex hormone testosterone. Blood concentration of testosterone has been
demonstrated to positively correlate with aggression in both male (Book et al. 2001)
and female (Denson et al. 2013) subjects, although recent meta-analysis studies have
unveiled that the correlation between testosterone and aggression is much weaker
than it was thought before and several confounding factors are involved (Book et al.
2001). One such confounding factor is the stress hormone cortisol (Montoya et al.
2012). Studies have shown that peripheral cortisol concentration is negatively
correlated with aggression in various populations (Poustka et al. 2010; Yu and Shi
2009). A correlation between testosterone and aggression is also established under
low, but not high, cortisol concentration at least in male adolescents (Popma et al.
2007). Moreover, stress hormones have been demonstrated to decrease testosterone
both in animals (Bambino and Hsueh 1981) and humans (Cumming et al. 1983),
indicating an inverse relationship of function between testosterone and cortisol.
Therefore, aggression appears to be viable with “high testosterone/low cortisol”
(Montoya et al. 2012).
8 Y. Asaoka and Y. Goto

Some studies investigated peripheral testosterone level in patients with behavioral

addiction. Although increased level of testosterone is associated with risky behaviors
(Stanton et al. 2011) and gambling (Blanco et al. 2001), and higher basal testosterone
is suggested to be a risk factor of gambling disorder (Li et al. 2020), no study has
actually shown elevated testosterone level in patients with gambling disorder
(Blanco et al. 2001). Similarly, higher testosterone is suggested as a risk factor for
gaming disorder (Wang et al. 2019). However, the study that investigated hair
accumulations of testosterone and cortisol, which reflect chronic levels of these
hormones, unveiled no difference between patients with gaming disorders and
healthy subjects (Koenig et al. 2019). Moreover, another study with patients with
kleptomania and paraphilia found even lower basal testosterone levels than that of
healthy subjects (Asaoka et al. 2021).
Patients with behavioral addiction are consistently experiencing higher life stress,
independent of subtypes (e.g., gambling, gaming, internet use, kleptomania, para-
philic and non-paraphilic sex disorders). Accordingly, higher basal cortisol levels
have been reported in patients with gambling disorder (Wohl et al. 2008) as well as
kleptomania and paraphilia (Asaoka et al. 2020a). However, some other studies have
also reported no change of basal cortisol level in patients with gambling disorder
(Paris et al. 2010) and gaming disorder (Kaess et al. 2017), although these studies
also found that the patients exhibited blunted cortisol responses to watching gam-
bling sceneries or playing games.
Collectively, heightened aggression is not well supported in behavioral addiction
if it is based on the observations of peripheral testosterone and cortisol levels, which
is contradicted to that heightened aggression in behavioral addiction patients has
been observed in a significant number of studies. One of reasons that explains such a
discrepancy is that aggression in behavioral addiction may be originated from
alterations of the mechanisms other than hormones. Another reason would be that
allostatic maladaptation of the hypothalamic-pituitary-adrenal (HPA) and hypotha-
lamic-pituitary-gonadal (HPG) axes may take place in behavioral addiction patients
(Biback and Zack 2015), so that aggression level is no longer reflected by the
balance of testosterone and cortisol.

Dopamine and Serotonin

Monoamines, such as dopamine (DA) and serotonin (5-HT), are another class of
molecular substrates that are identified to mediate aggression. Indeed, both DA and
5-HT also play major roles in impulsivity (Dalley and Roiser 2012), which could in
turn cause impulsive, aggressive behaviors (Seo et al. 2008).
Involvements of 5-HT in aggression have been demonstrated in studies, such as
those showing that aggression is negatively correlated with peripheral level of the
5-HT metabolite 5-hydroxyindoleacetic acid (5-HIAA; Higley et al. 1996). Trypto-
phan depletion, which decreases 5-HT synthesis and thereby transmission, has also
been shown to increase aggression (Cleare and Bond 1995), although this effect may
depend on an original trait of aggression, such as whether subjects are aggressive or
Aggression in Behavioral Addictions 9

nonaggressive (Bjork et al. 2000). 5-HT1B receptor is one of the 5-HT receptor
subtypes, working as an autoreceptor to regulate 5-HT release (Engel et al. 1986).
5-HT1B receptor binding potential in the striatum has been shown to be positively
correlated with aggression in violent offenders, but not in nonviolent subjects
(da Cunha-Bang et al. 2017). This finding is, however, the opposite to animal studies
reporting 5-HT1B receptor activation rather than reducing aggression (Nautiyal et al.
2015). Although these studies suggest the relationship between 5-HT and aggres-
sion, no effect of selective serotonin reuptake inhibitor (SSRI) treatments on aggres-
sion has also been demonstrated (O’Donnell et al. 2022), rather making the role of
5-HT in aggression dubious.
DA is also involved in aggression. In rodents, BALB/c strain mice are more
aggressive than A/J strain mice. This observation is associated with lower DA
D1-class receptor, and higher D2-class receptor, expressions in the nucleus
accumbens (NAcc) of BALB/c strain than A/J strain (Couppis et al. 2008). This is
consistent with the study showing that D1 antagonist increases impulsive behaviors
in rodents (van Gaalen et al. 2006). Opponent roles of D1 and D2 receptors in
aggression have also been demonstrated in human studies using positron emission
tomography (PET). Thus, a negative correlation exists between striatal D1 receptor
availability and physical trait aggression (Plaven-Sigray et al. 2014), whereas a
positive correlation has been observed between striatal D2 receptor availability and
social dominance (Cervenka et al. 2010; Martinez et al. 2010), which could be an
indirect measure of aggression, as aggression appears to be associated with social
status (Koski et al. 2015). Accumulating evidence suggests that addiction is a
disorder of maladaptive learning, which involves DA transmission in the NAcc
(Nutt et al. 2015). Although DA transmission in the NAcc is also involved in
aggression (Couppis et al. 2008), and thereby the neural mechanisms mediating
addiction and aggression are partly overlapping, conditioning to addictive sub-
stances and behavioral patterns would not necessarily affect aggression at the
same time.
Based on the observations of the roles of DA and 5-HT in aggression, it is
expected that behavioral additions may involve low 5-HT transmission and alter-
ations of some DA and 5-HT receptor expressions in the striatum. There are several
studies that examined peripheral monoamines and their metabolites in patients with
pathological gambling, but the results are inconsistent. An initial study by Nordin
and colleagues found decreased CSF level of DA and increased level of the DA
metabolite homovanillic acid (HVA) (Bergh et al. 1997). However, a subsequent
study found that cerebrospinal fluid (CSF) 5-HIAA, but not HVA, were significantly
lower in patients with pathological gambling than that of healthy subjects (Nordin
and Eklundh 1999). The same research group later has reported higher CSF levels of
5-HIAA, DA, and HVA and lower level of 5-HT (Nordin and Sjodin 2006). Other
than pathological gambling, adolescents with internet addiction have been shown to
exhibit higher HVA, but not 5-HIAA, than healthy subjects (Korehpaz-Mashhadi
et al. 2022). In contrast, no difference was observed in DA and its metabolites of
male patients with gaming disorder (Paik et al. 2018). In patients with kleptomania
and paraphilia, 5-HIAA and the turnover of 5-HT (the ratio of 5-HIAA to 5-HT)
10 Y. Asaoka and Y. Goto

were not different from those of healthy subjects, but HVA and the turnover of DA
(HVA/DA ratio) were significantly increased (Asaoka et al. 2020b). Collectively,
peripheral monoamine changes in behavioral addiction were highly variable not only
between subtypes but even within the sample populations, and no conclusive
findings have yet been reached.
From the DA and 5-HT receptor perspectives, human neuroimaging studies using
PET have demonstrated increased 5-HT1B receptor binding in the basal ganglia of
patients with gambling disorder (Potenza et al. 2013), which is consistent with
heightened aggression in violent offender (da Cunha-Bang et al. 2017). In drug
addicts, decreased striatal D2 receptor availabilities are consistently described
(Volkow et al. 1990, 1996, 2001). A study was not able to find such decrease of
striatal D2 receptor availability in gambling disorder patients (Clark et al. 2012). In
contrast, other studies found decreased striatal D2 receptor availability in patients
with internet and gaming disorders (Kim et al. 2011; Tian et al. 2014). However, it is
important to note that decreased striatal D2 binding is the opposite to what is
expected for heightened aggression.

Conclusions

The relationships between addiction and aggression have been described in numer-
ous studies. However, aggression in behavioral addiction is still undermined and
controversial compared to that in drug addiction, and further investigation is
required. In behavioral addiction, heightened aggression has been reported in several
studies. However, this is primarily limited to gaming and internet disorders, but not
other subtypes of behavioral addiction. Such a heterogeneous nature of heightened
aggression is similar to drug addiction in which heightened aggression also depends
on the type of drugs that patients are addicted to. This raises a possibility that
heightened aggression observed in addiction may not be caused by a single factor
that is common across all addictions, but multiple factors may be involved. Indeed,
biological mechanisms that alter aggression are also multimodal, involving several
neurotransmitters and hormones.

Applications of the Material

In this chapter, aggression has been reviewed in relation to behavioral addiction,

which raises several issues, such as that aggression is mediated by several factors
that cause heterogeneous alterations of aggression in patients with behavioral addic-
tion, with some subtypes associated with heightened aggression, but others are not.
Investigation to unveil how aggression is altered in some, but not in other, subtypes
of behavioral addiction will provide important insight to further understand the
pathophysiology of behavioral addiction and other related disorders.
Aggression in Behavioral Addictions 11

Mini-Dictionary of Terms

• Aggression. A behavior made to harm toward others or self. Aggression can be

divided into multiple domains, such as the four-domain model of aggression
defined by Buss and Perry (physical and verbal aggression, anger, and hostility)
and reactive vs. proactive dichotomy. In this chapter, the term “aggression” is
used comprehensively to include all aspects, unless otherwise noted.
• Behavioral Addiction. A psychiatric disorder unable to control specific behavior
with urges to seek to execute such behavior despite negative outcomes expected.
In the current diagnostic manuals of psychiatric disorders (i.e., DSM-5 and
ICD-11), gambling disorder, gaming disorder, and problematic internet use are
classified as addiction. However, other psychiatric conditions, which are classi-
fied as impulse control disorders, such as kleptomania, paraphilia, and eating
disorder, have also been suggested to meet the criteria of addiction and generally
considered as behavioral addiction. In this chapter, the term “behavioral addic-
tion” is used to refer conditions with this wider definition.
• Compulsivity. It is conceptually similar to impulsivity, as compulsive behavior is
delivered without purpose and causes adverse consequences. However, it is
different in which compulsivity is associated with repetitive urges.
• Drug Addiction. A psychiatric disorder, also known as substance use disorder,
with compulsive and impulsive seeking and use of substances, which are typi-
cally acting on dopamine transmission directly or indirectly, despite undesirable
consequences. Drug addiction could also be either substance dependence or
independence, which is associated with the presence or absence of withdrawal
symptoms, respectively.
• Impulse Control Disorder. A psychiatric disorder that patients are unable to
inhibit inappropriate behaviors, resulting in social dysfunction. Although the
name of the disorder is impulse control disorder, the disorder is also typically
characterized by compulsive, repetitive urges to seek such inappropriate behav-
iors, such that some disorders classified in this category are thought to meet the
criteria of addiction as well.
• Impulsivity. An unplanned and premature behavior that is triggered by internal or
external stimuli so that it could result in more negative than desirable outcomes.

Key Facts of Aggression in Behavioral Addiction

Aggression may be increased in patients with behavioral addiction; however, this

depends on subtypes, such that heightened aggression is consistently observed in
gaming disorder and problematic internet use but controversial in other subtypes,
such as gambling disorder, kleptomania, and paraphilia. This is relatively consistent
with drug addiction, in which heightened aggression also depends on the types of
substances that patients are addicted to.
12 Y. Asaoka and Y. Goto

Summary Points

• Aggression is heightened in behavioral addiction, but not in all cases.

• Heightened aggression in behavioral addiction is heterogeneous and depends on
subtypes.
• Several factors are involved in heighted aggression in behavioral addiction, such
as aggressive personality trait and impulsivity.
• Some factors underlying heightened aggression are mutual between drug addic-
tion and behavioral addiction.
• Hormones and neurotransmitters that mediate aggression are also involved in
behavioral addiction.
• Alterations of such hormones and neurotransmitters facilitate aggression in some,
but not all, subtypes of behavioral addiction.

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