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Behavioral Addictions
Behavioral Addictions

DSM-5® and Beyond

EDITED BY NANCY M. PETRY

1
1
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ISBN 978–0–19–939154–7

The Diagnostic and Statistical Manual of Mental Disorders, DSM, DSM-IV, DSM-IV-TR, and
DSM-5 are registered trademarks of the American Psychiatric Association. Oxford University Press
USA is not associated with the American Psychiatric Association or with any of its products or
publications, nor do the views expressed herein represent the policies and opinions of the American
Psychiatric Association.

The statements and opinions in the material contained in this Oxford University Press USA
publication and material which may be accessed from the Oxford University Press USA website, or
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Printed in the United States of America
on acid-free paper
For Billy, Hannah, and Noah
 CONTENTS

Contributors╇ix

1. Introduction to Behavioral Addictions╇ 1

Nancy M. Petry

2. Gambling Disorder: The First Officially Recognized

Behavioral Addiction╇ 7
Nancy M. Petry

3. Internet Gaming Disorder: A New Behavioral Addiction╇ 43

Florian Rehbein, Simone Kühn, Hans-Jürgen Rumpf, and Nancy M. Petry

4. Internet Addiction: A Future Addictive Disorder?╇ 71

Hans-Jürgen Rumpf, Ran Tao, Florian Rehbein, and Nancy M. Petry

5. Hypersexual Disorder╇ 101

Megan M. Campbell and Dan J. Stein

6. Compulsive Shopping as a Behavioral Addiction╇ 125

Donald W. Black

7. Exercise Addiction: Diagnosis, Psychobiological Mechanisms,

and Treatment╇ 157
Aviv Weinstein and Yitzhak Weinstein

8. Food Addiction╇ 171

Susan Murray, Mark S. Gold, and Nicole M. Avena
viiicontents

9. Addicted to UV: Evidence for Tanning Addiction 193

Jerod L. Stapleton, Joel Hillhouse, and Elliot J. Coups

10. Conclusions and Future Directions to Advance the Science

and Clinical Care of Behavioral Addictions 221
Nancy M. Petry

Index 231

Nicole M. Avena, PhD
Department of Pharmacology
and Systems Therapeutics
Mount Sinai School of Medicine
New York, NY
Donald W. Black, PhD
Department of Psychiatry
University of Iowa Roy J.
and Lucille A. Carver College
of Medicine
Iowa City, IA
Megan M. Campbell, PhD
Department of Psychiatry
and Mental Health
University of Cape Town
Cape Town, South Africa
Elliot J. Coups, PhD
Rutgers Cancer Institute
of New Jersey
Rutgers, The State University
of New Jersey
New Brunswick, NJ
CONTRIBUTORS
Mark S. Gold, MD
Department of Psychiatry
Washington University School
of Medicine
St. Louis, MO
Joel Hillhouse, PhD
East Tennessee State University
Johnson City, TN
Simone Kühn, PhD
Max Planck Institute for Human
Development
Center for Lifespan Psychology
Berlin, Germany
University Clinic
Hamburg-Eppendorf
Clinic and Policlinic for Psychiatry
and Psychotherapy
Hamburg, Germany
Susan Murray, BS
Department of Pharmacology
and Systems Therapeutics
Mount Sinai School of Medicine
New York, NY
xcontributors
Nancy M. Petry, PhD
Department of Medicine
and Calhoun Cardiology Center
University of Connecticut School
of Medicine
Farmington, CT
Florian Rehbein, PhD
Criminological Research Institute
of Lower Saxony
Hanover, Germany
Hans-Jürgen Rumpf, PD Dipl Psych
Department of Psychiatry
and Psychotherapy
University of Lübeck
Lübeck, Germany
Jerod L. Stapleton, PhD
Rutgers Cancer Institute of
New Jersey
Rutgers, The State University
of New Jersey
New Brunswick, NJ
Dan J. Stein, MD, PhD
Professor and Chair
Department of Psychiatry
University of Cape Town
Cape Town, South Africa
Ran Tao
Addiction Medical Center
General Hospital of Beijing
Military Region
Beijing, China
Aviv Weinstein, PhD
Department of Behavioral Science
University of Ariel
Ariel, Israel
Yitzhak Weinstein, PhD
Ohalo Academic College
College Park, Israel
Tel Hai Academic College
Tel-Hai, Israel
Israel Institute of Technology
Haifa, Israel
 1

Introduction to Behavioral
Addictions
NANCY M. PETRY ■

The concept of behavioral addiction has been a topic of debate for decades.
Research and clinical experiences suggest that behaviors that occur in
extremes can result in substantial problems, regardless of the nature
of the specific activity. People can smoke cigarettes, drink alcohol, use
drugs, gamble, play video games, use the Internet, engage in sexual activi-
ties, shop, exercise, eat, or tan to excess. Growing evidence indicates that
extensive, repetitive, and problematic engagement in these activities can
share some similarities with substance use disorders. Overlap may exist
in terms of phenomenology (craving, tolerance, and withdrawal), natu-
ral history (onset, chronicity, and relapsing course), comorbidity, genetic
overlap and neurobiological mechanisms, and response to treatment. As
the behaviors increase in frequency and duration, they can lead to psy-
chological distress and sometimes even physical impairment, as well as
diminish social, financial, and occupational functioning.
Addiction, however, is a loaded term. It has different meanings to dif-
ferent people. Colloquially, it refers to excessive use of a substance or
participation in a behavior. Clinically, it can signify loss of control and
impairment in functioning. Substance use disorders are often called
“addictions,” and they have been recognized as psychiatric diseases for
2behavioral addictions : dsm - 5 and beyond

decades. Some have argued against the term “addiction” in this context
because it can have pejorative and nonmedical meanings. Others contend
that the term appropriately refers to the nature in which individuals with
substance use disorders consume alcohol and drugs and develop difficul-
ties with other behaviors as well.
In 2013, the publication of the fifth revision of the Diagnostic and
Statistical Manual of Mental Disorders (DSM-5) opened the door for clas-
sification of non-substance addictions—that is, behavioral addictions.
The DSM is the primary psychiatric diagnostic classification system in
the United States, and clinicians and researchers in many other countries
throughout the world apply it as well. For the first time, this manual rec-
ognizes behavioral addictions.
Although the DSM-5 does not officially term substance use disorders
“addictions,” the chapter containing them broadened these conditions to
“Substance-Related and Addictive Disorders.” This chapter now lists sub-
stance use disorders, such as alcohol, opioids, stimulants, cannabis, nico-
tine, hallucinogens, inhalant, and sedatives, along with one non-substance
or behavioral addiction—gambling disorder (Chapter 2).
Formerly termed “pathological gambling,” the DSM has included a
condition related to excessive and problematic gambling since 1980. With
publication of DSM-III and throughout the next 33 years, pathological
gambling was a Disorder of Impulse Control Disorder Not Elsewhere
Classified. The most recent version of the DSM altered the name to “gam-
bling disorder” and moved it alongside substance use disorders as the first
non-substance or behavioral addiction. This change opens the possibil-
ity for classifications of other excessive behavior patterns as addictions
as well.
Although some researchers and clinicians support expansion of addic-
tions as a construct, proliferation of psychiatric conditions can dimin-
ish the legitimacy of the field of psychiatry at large. It is important to
distinguish true mental disorders from high levels of normal behavior
patterns. Surely not everyone should have a psychiatric condition, and
Introduction to Behavioral Addictions 3

if many excessive behavioral patterns are deemed psychiatric disorders

most everyone would be diagnosed with mental illness. This concern is
particularly relevant to the construct of behavioral addictions. Excessive
chocolate eating, even if it is causing weight gain and some distress, does
not constitute a psychiatric disorder.
In preparing for the DSM-5, researchers and clinicians considered
many putative non-substance addictions for inclusion in the manual.
Workgroup members formed specialized subcommittees composed of
experts in specific areas. They reviewed existing literature and made rec-
ommendations regarding whether there was sufficient evidence to pro-
pose new disorders for inclusion in the DSM-5.
Introduction of a new psychiatric diagnosis in the DSM-5 required sci-
entific evidence, confirmed by expert consensus. Clinicians and research-
ers both within and disparate from the specific clinical area reviewed the
data and arguments presented and voted on whether or not data were suf-
ficiently strong to include new conditions in the DSM-5. Prior to official
voting, the workgroups posted online recommendations for changes to
existing disorders and proposals for new disorders, and other clinicians,
researchers, and the public at large could comment on these suggestions
during two open commentary periods.
The American Psychiatric Association noted that newly included dis-
orders must fulfill a clinical need, reflect an underlying psychobiologi-
cal disturbance, and contribute to better assessment and treatment. At
the most basic level, psychiatric disorders must engender clinically sig-
nificant harm, and not merely reflect social deviance or conflicts with
society. New conditions also had to be sufficiently distinct from existing
disorders. Although comorbidity may be high, a newly introduced disor-
der must be distinguishable from existing ones to be uniquely classified.
It must have diagnostic validity, and data must be available indicating
that the proposed criteria reliably and validly classify individuals with the
condition. The DSM-5 added only 15 disorders that were not contained in
the DSM-IV. None were behavioral addictions.
4behavioral addictions : dsm - 5 and beyond

Although no new diagnoses related to behavioral addictions appear in

the DSM-5, Section 3, the research appendix, includes one. The intent of
this section is to stimulate research on conditions that may be psychiat-
ric disorders but for which sufficient data do not yet exist to reliably and
validly classify them. Based on the available published literature through
2012, one behavioral addiction was deemed to have sufficient data to war-
rant its inclusion in the research appendix—Internet gaming disorder
(Chapter 3).
Workgroup members and the scientific community at large considered
other behavioral addictions as well: Internet addiction (Chapter 4), sex
addiction (Chapter 5), shopping addiction (Chapter 6), exercise addic-
tion (Chapter 7), eating addiction (Chapter 8), and tanning addiction
(Chapter 9). This book describes each of these putative behavioral addic-
tions. The chapters outline the existing research related to each condition,
and they also provide rationale as to why the data were not yet sufficient
to include them in the DSM-5.
Although these other conditions are not officially recognized in the
DSM-5, this does not mean they are not psychiatric disorders. Their lack
of inclusion simply reflects a lack of scientific evidence related to diag-
nostic assessment, clinical course, or treatment. As described in the sub-
sequent eight chapters in this book, some have more, and some fewer,
scientific data related to their uniqueness as a psychiatric disorder and
along these dimensions. As science progresses, subsequent versions of the
DSM may officially classify some of them as psychiatric conditions. Until
then, these chapters provide state-of-the-art reviews of the scientific data
surrounding each.
The chapters begin with a global overview of the condition and its
actual or proposed diagnostic criteria. The chapters next outline the vari-
ous instruments designed to assess each condition and their psychometric
properties. Prevalence rates in general populations and specific and clini-
cal populations are detailed. In addition, comorbidities with substance use
and other psychiatric conditions are described. The chapters also review
the risk and protective factors related to each condition, including the
Introduction to Behavioral Addictions 5

biological and genetic data that exist. A section of each chapter reviews
treatments found efficacious in randomized trials or applied clinically
when no or few randomized clinical trials exist. Finally, each chapter
summarizes strengths and limitations of the existing data related to the
condition. For all except gambling disorders, the chapters specify areas
in which additional research is needed for their potential classification
and recognition as unique psychiatric disorders in future editions of the
DSM. Together, these chapters provide a comprehensive and timely scien-
tific review of behavioral addictions. They should be valuable for guiding
future research, and clinical care, across behavioral addictions.
 2

Gambling Disorder
The First Officially Recognized Behavioral Addiction

NANCY M. PETRY ■

Gambling disorder, previously termed pathological gambling, is the first

disorder to be included as a non-substance behavioral addiction in the
fifth edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5; American Psychiatric Association, 2013). This chapter outlines
the DSM-5 classification system for gambling disorder and instruments
that assess it. It details the prevalence rates in the general population
of the United States as well as in other countries throughout the world. The
chapter also describes comorbidities between gambling disorder and other
psychiatric conditions, focusing on its overlap with substance use disorders.
The risk and protective factors are then outlined, including demographic,
psychological, neurophysiological, and genetic risk factors. Finally, the
chapter summarizes both promising psychological and pharmacological
treatments and discusses future research directions to improve the diag-
nosis, prevention, and treatment of this behavioral addiction.

DEFINING FEATURES AND METHODS FOR ASSESSMENT

Gambling disorder is the first “behavioral addiction” listed in the DSM.

The DSM has included gambling disorder, previously termed “patho-
logical gambling” since 1980. However, it was classified as an “Impulse
8behavioral addictions : dsm - 5 and beyond

Control Disorder Not Otherwise Specified” until the publication of the

DSM-5. Given considerable overlap between gambling and substance use
disorders (Petry et al., 2013), it is now included in the “Substance Use and
Related Addictive Disorders” section.
The DSM-5 lists nine criteria, and for a diagnosis one must endorse at
least four of the following: (1) spending a lot of time thinking about gam-
bling or where to get money with which to gamble (i.e., “preoccupation”),
(2) needing to wager with larger amounts (i.e., tolerance), (3) repeated
unsuccessful attempts to stop or control gambling, (4) experiencing with-
drawal symptoms such as restlessness or irritability when trying to cease
or reduce gambling, (5) wagering to escape from problems or to relieve
negative moods, (6) trying to recoup prior gambling losses (i.e., “chasing”),
(7) lying to others about one’s gambling or trying to cover up the extent
of gambling, (8) losing relationships or a career or educational oppor-
tunity due to gambling, and (9) relying on others to relieve a desper-
ate financial situation caused by gambling (i.e., “bailouts”). Although
not a diagnosed psychiatric condition, problem gambling is a term used
to describe meeting less than the requisite number of DSM criteria for
diagnosis.
Structured clinical interviews, employing these DSM criteria, can
diagnose gambling disorder or classify individuals as problem gam-
blers. One structured clinical interview that assesses gambling disor-
der criteria is the Alcohol Use Disorder and Associated Disabilities
Interview Schedule–DSM-IV Version (AUDASIS). It contains 15 items,
with one or two symptoms constituting each of the DSM criteria for
gambling disorder; if respondents endorse either or both items associ-
ated with a criterion, they meet that criterion. Internal consistency of
the items and test–retest reliability are excellent (Grant et al., 2003;
Petry et al., 2005).
Another structured clinical interview is the National Opinion Research
Center DSM-IV Screen for Gambling Problems or NODS (Gerstein et al.,
1999). This instrument also assesses DSM gambling symptoms, again
using one or two items per criterion, although the specific wording of the
items differs from that of the AUDASIS. The test–retest reliability of the
Gambling Disorder 9

NODS is excellent (Gerstein et al., 1999), and validity is well established

in multiple samples (Hodgins, 2004; Petry, 2007; Wickwire et al., 2008;
Wulfert et al., 2005).
The AUDASIS and NODS are the most common diagnostic instru-
ments for gambling disorders. The Canadian Problem Gambling
Severity Index (PGSI) is popular in Canada, and some other countries
have begun using this instrument as well. The PGSI contains nine items,
but the items are not aligned, or intended to relate directly, to the DSM-5
criteria for gambling disorder. Instead, the items reflect more socially
oriented (rather than clinical) aspects of problem gambling. The nine
items are rated on a 4-point scale with total scores ranging from 0 to 27.
Score on the PGSI correlate with other DSM-based scales such as the
NODS (Ferris and Wynne, 2001). Individuals who score 0 are termed
“non-problem gamblers,” and categories of increasing risk range from
“low-risk” to “moderate risk” and “problem gamblers,” depending on
scale scores (Ferris and Wynne, 2001). Although numerous studies have
applied this instrument, some have raised concerns about the nature
of the scoring system and validity of the classification structure. For
example, Orford et al. (2010) compared the PGSI and a DSM-IV scale
using data from 6,161 adult past-year gamblers in the United Kingdom.
Although the PGSI had good internal reliability, the rate of agreement
between the two instruments for identifying individuals with gambling
problems was only modest, and there was evidence that the PGSI may
underestimate gambling problems, particularly in women. Currie et al.
(2013) likewise noted potential problems with the scale. The temporal
stability was adequate during a 14-month interval, but the four proposed
categories of gamblers were not well discriminated. Currie et al. sug-
gested the instrument would benefit from changes in the scoring system
and greater psychometric testing, especially for the at-risk problem gam-
bling classifications.
The South Oaks Gambling Screen (SOGS; Lesieur and Blume, 1987),
similar to the PGSI, is a screener for gambling problems and not
designed to provide diagnoses. It is the oldest and most com-
monly applied screening instrument, and it has been translated into
10behavioral addictions : dsm - 5 and beyond

approximately two dozen languages. This 20-item instrument reflects

older, DSM-III-R criteria for gambling, with an emphasis on assess-
ing financial problems related to gambling. Scores range from 0 to 20,
with scores of 5 or higher typically indicating probable gambling disor-
der. Because this is a screening instrument, however, it, like the PGSI,
does not yield diagnoses, and additional assessment is needed to clas-
sify individuals with gambling disorder. Furthermore, the SOGS has a
high false-positive rate (Stinchfield, 2002), meaning that a fairly large
proportion of persons who score high on the SOGS do not meet DSM
criteria for gambling disorder. Whereas the SOGS and PGSI are appro-
priate for assessing risk, if psychiatric diagnosis is desired, one must
administer a DSM-based instrument.
Other briefer screening instruments also exist, but limited information
about their psychometric properties is available (for review, see Volberg
et al., 2011). Perhaps the most promising involve abbreviated versions
of the NODS. Toce-Gerstein et al. (2009) compared diagnostic status
derived from the 17-item NODS to shorter versions using subsets of 2 to 4
of the NODS items in 8,867 gamblers participating in general popula-
tion surveys. The three questions pertaining to loss of Control, Lying, and
Preoccupation (the NODS-CLiP) identified the vast majority of individu-
als with gambling disorder diagnosed by the full NODS, with excellent
sensitivity and specificity. A follow-up study (Volberg et al., 2011) con-
ducted in high-risk populations (e.g., substance abuse treatment patients
and inner-city medical patients) found that some different NODS items
yielded the greatest diagnostic accuracy, with positive endorsement of
the Preoccupation, Escape, Risked Relationships, and Chasing items best
aligning with the full NODS diagnosis. Although the specific items may
differ depending on the populations assessed, a two-stage procedure may
efficiently identify and then confirm diagnosis of gambling disorder for
research studies or clinical practice settings in which inclusion of a full
gambling diagnosis interview for all respondents or patients would be
burdensome.
Another approach to avoid lengthy questionnaire administration
to individuals unlikely to experience gambling problems is to initially
Gambling Disorder 11

inquire about minimal levels of gambling participation prior to adminis-

tration of a full battery. Epidemiological studies asked gambling disorder
criteria only to individuals who reported gambling a nominal number
of times (e.g., five times) in their lives (e.g., Gerstein et al., 1999; Petry
et al., 2005). Such “gatekeeper” questions, however, should include very
minimum participation histories to avoid missing diagnoses. The diag-
nostic criteria for gambling disorder, similar to those for substance use
disorders, do not involve indices of frequency of gambling or amounts
wagered. Although frequency and quantity indices relate to harms expe-
rienced from gambling, they are not synonymous. For example, some
individuals place bets daily, such as scratch ticket players or lottery play-
ers, but do not suffer from any gambling-related harm. Financially secure
individuals may place very large bets without experiencing any adverse
effects, whereas individuals with low and fixed incomes may place rel-
atively small bets but report severe consequences from their gambling
(Petry, 2003). Similarly, one person can drink daily without developing
alcohol problems, and another binge drinks only occasionally but suf-
fers severe consequences. Although many screening instruments and
diagnostic interviews inquire about frequency and quantity of gambling,
these indices do not factor into diagnoses.

PREVALENCE RATES

Using the previously described instruments, nationally representative

studies of the prevalence rate of gambling disorder have been conducted
in the United States. Other countries, including Canada, the United
Kingdom, Australia, New Zealand, China, Singapore, Italy, Norway,
Sweden, and Switzerland, have also evaluated rates of gambling disorder
in national samples. Although prevalence rates vary depending on the
time frame of assessment and the instrument applied, most surveys reveal
that gambling disorder impacts between 0.1% and 2% of the population.
In the late 1990s, the U.S. government commissioned the National
Gambling Impact Study Commission (Gerstein et al., 1999). This study
12behavioral addictions : dsm - 5 and beyond

surveyed 2,417 randomly selected U.S. adult residents, using the NODS
to assess gambling disorder. It found that the lifetime prevalence rate of
gambling disorder was 0.8%, and the past-year prevalence rate was 0.1%.
Another nationally based telephone survey of 2,638 randomly selected
U.S. adults was conducted at approximately the same time (Welte et al.,
2001). Using the SOGS and another instrument based on DSM criteria,
it found a higher lifetime prevalence rate of approximately 2.0% for gam-
bling disorder.
Two larger nationally based U.S. surveys of gambling disorder were
completed more recently. The National Epidemiologic Survey on Alcohol
and Related Conditions (NESARC) conducted in-person interviews with
more than 43,000 randomly selected adults. It estimated a lifetime preva-
lence rate of gambling disorder of 0.4% (Petry et al., 2005) and a past-year
prevalence rate of 0.2% (Petry et al., 2013). The National Comorbidity
Survey–Replication (NCS-R), composed of 9,282 respondents, likewise
found a lifetime prevalence rate of gambling disorder of 0.6%. In this sur-
vey, the past-year prevalence rate was 0.3% (Kessler et al., 2008).
Other countries have conducted nationally representative epidemio-
logical surveys as well. Two independent studies in Norway found gam-
bling disorder impacted approximately 0.2% of the population (Gotestam
and Johansson, 2003; Lund and Nordlund, 2003). Abbott and Volberg
(2000) found that the prevalence rate of gambling disorder was 0.5% in
New Zealand; Volberg et al. (2001) found a rate of 0.6% in Sweden; and
Orford et al. (2003) and Bondolfi et al. (2000) found rates of 0.8% in the
United Kingdom and Switzerland, respectively. The Australian Institute
for Gambling Research reported one of the highest rates of gambling dis-
order in a primarily English-speaking country of 1.9%, but that rate was
derived from the SOGS, which tends to overestimate prevalence rates.
Using DSM-based criteria, two surveys from Asian countries reported
high rates of gambling disorder as well. The Ministry of Community
Development (2005) in Singapore and Wong and So (2003) in Hong Kong
found rates of 2.1% and 1.8%, respectively. Thus, overall, prevalence rates
for gambling disorder in countries throughout the world appear simi-
lar to those reported in the United States. A meta-analysis estimated the
Gambling Disorder 13

prevalence rate of gambling disorder to be between 0.8% and 1.8% (Stucki

and Rihs-Middel, 2007).

COMORBIDITIES

Gambling disorder is highly comorbid with other psychiatric conditions,

especially substance use disorders. Epidemiological studies provide the
best evidence of comorbidities, and all published general population sur-
veys evaluating both gambling and substance use disorders found sig-
nificant associations between them. For example, the National Gambling
Impact Survey (Gerstein et al., 1999) found that 9.9% of respondents
with gambling disorder met criteria for an alcohol or illicit drug use dis-
order. In contrast, only 1.1% of non-gamblers and 1.3% of recreational
non-problem gamblers had a substance use diagnosis. In the NCS-R
survey, Kessler et al. (2008) reported that rates of substance use disor-
ders were 5.5-fold higher among respondents with a gambling disorder
compared to those without, and 76.3% of individuals with gambling dis-
order also had a substance use disorder. Similarly, the NESARC study
(Petry et al., 2005) noted a strong association between gambling disorder
and substance use disorders. Almost half (47.8%) of individuals identi-
fied with gambling disorder also met criteria for alcohol dependence,
and more than one-third had one or more other substance use disorder,
such as sedative, tranquilizer, opiate, stimulant, hallucinogen, cannabis,
cocaine, inhalant/solvent, or heroin use disorder. In contrast, only 8.8% of
non-gamblers had an illicit drug use disorder. Surveys from other studies
report similar results. In a Canadian survey of 14,934 persons, el-Guebaly
et al. (2006) found that nearly half of those identified with gambling prob-
lems had substance dependence or harmful use of alcohol versus 7.6% of
non-problem gamblers.
Rates of comorbidities with other non-addictive psychiatric disorders
are also high. The NESARC study (Petry et al., 2005) found that rates of
major depression and dysthymia were approximately three times higher
in individuals with gambling disorder than in non-gamblers. Likewise,
14behavioral addictions : dsm - 5 and beyond

the NCS-R study (Kessler et al., 2008) reported major depressive disorder
or dysthymia to be 2.5 times higher in respondents with gambling disor-
der compared to respondents without. In terms of anxiety disorders, the
NESARC survey found that prevalence rates of every anxiety disorder
assessed were significantly elevated among those with gambling disor-
der compared to those without gambling disorder, including generalized
anxiety disorder, panic disorder with and without agoraphobia, specific
phobias, and social phobia (Petry et al., 2005). The NCS-R (Kessler et al.,
2008) also noted significantly increased rates of panic disorder, phobias,
and generalized anxiety disorder in those with gambling disorder com-
pared to those without.
A meta-analysis evaluated the co-occurrence of gambling and other
psychiatric conditions in epidemiological surveys conducted in countries
throughout the world (Lorains et al., 2011). Despite heterogeneity across
studies, gambling disorder was significantly related to nicotine, sub-
stance use, mood, and anxiety disorders. The weighted mean proportions
of individuals with gambling disorder experiencing each of these other
conditions was 60.2%, 57.5%, 37.9% and 37.4%, respectively. Furthermore,
Rush et al. (2008) evaluated the association between substance use disor-
ders, other mental health conditions, and gambling problems. Severity
of gambling problems increased with severity of substance use problems,
but this pattern did not occur with other mental health disorders, and
other conditions did not impact the relationship between gambling and
substance use problems. In summary, strong and consistent relationships
exist between gambling disorder and other psychiatric disorders, but
these associations appear strongest with substance use disorders.
The relationships between gambling disorder and other behavioral
addictions are not yet well understood, in part because there are few
large-scale epidemiological surveys of other behavioral addictions. Most
of those that exist did not assess other psychiatric disorders. Nevertheless,
available data suggest a relationship between gambling and some other
behavioral addictions in adolescents. For example, in an Italian sample
of 2,853 high school students, Villella et al. (2011) found that severity of
gambling problems was positively associated with severity of problems of
Gambling Disorder 15

other putative behavioral addictions, including exercise, Internet, work,

and excessive shopping. In a sample of 1,012 students in Switzerland,
Tozzi et al. (2013) found that problem gambling was related to substance
use as well as Internet addiction problems. Delfabbro et al. (2009) evalu-
ated the relationship between video game playing and gambling disorder
in 2,669 adolescents. Frequency of video game playing was significantly,
albeit modestly, correlated with gambling disorder. Similarly, Walther
et al. (2012) collected data from 2,553 German students aged 12–25 years
and found a small but significant association between gambling and
gaming problems. In a sample of more than 73,000 Korean youth, both
smoking and drug use were significantly related to Internet addiction
problems (Lee et al., 2013). Thus, gambling disorder appears to relate to
other behavioral addictions, but the available data are relatively limited
and primarily restricted to youth and young adults.

RISK AND PROTECTIVE FACTORS

Demographic Correlates

Some demographic characteristics are associated with gambling dis-

order, including gender, age, socioeconomic status, and race/ethnicity.
Males have an increased risk of gambling problems relative to females.
For example, in the NESARC survey (Petry et al., 2005), although the
sample was half male and half female, 72% of the individuals classi-
fied with gambling disorder were male. Likewise, in the NCS-R (Kessler
et al., 2008), men had a 4.5-fold increased risk of developing gambling
disorder compared to women. However, data from this survey also
revealed that this gender differential may relate to a greater propensity
to gamble in men. Men were significantly more likely than women to
report having ever gambled, but men who had gambled were no more
likely than women who had gambled to develop a gambling problem
or to progress from problem gambling to gambling disorder once they
began wagering.
16behavioral addictions : dsm - 5 and beyond

Age is inversely associated with gambling disorder in most epidemio-

logical surveys. For example, in the NCS-R survey (Kessler et al., 2008),
respondents in the 18- to 44-year-old cohort had a fivefold increased risk
of developing gambling disorder relative to cohorts older than age 45 years.
The National Gambling Impact Study (Gerstein et al., 1999) likewise found
that the youngest age groups had an increased rate of gambling disorder
relative to the older age group. However, most nationally representative
studies include only individuals aged 18 years or older. Studies restricted
to adolescent and young adults generally find high rates of gambling dis-
order (Petry, 2005), but assessment instruments for youth often vary from
those for adults (Stinchfield, 2010), as do sampling procedures and survey
designs (Volberg et al., 2010); thus, differences in prevalence rates may be
confounded by differences in methods of assessment. Nevertheless, gam-
bling disorder is typically more prevalent in younger age groups.
In most industrialized countries, gambling disorder is more common
in individuals of racial and ethnic minority backgrounds. For example,
in the U.S. surveys, gambling disorder is more prevalent in African
Americans than it is among European Americans (Kessler et al., 2008;
Petry et al., 2005; Welte et al., 2001). Furthermore, in Canada as well as
the United States, very high rates of gambling problems and gambling
disorder occur in Native Americans as well as in Asian Americans (Petry
et al., 2003; Wardman et al., 2001).
Lower socioeconomic status, which is typically linked with minority
status, is also associated with gambling disorder. Most studies show that
individuals with lower incomes or education are overrepresented among
those with gambling disorder (e.g., Gerstein et al., 1999; Kessler et al.,
2008; Welte et al., 2001).

Personality Factors

In addition to these basic demographic characteristics, impulsivity is

a strong and consistent personality risk factor for gambling disorder.
Impulsivity is a multifaceted construct, involving inattention, disinhibition,
Gambling Disorder 17

risk-taking, sensation seeking, and discounting of delayed and probabi-

listic outcomes (Evenden, 1999). In cross-sectional studies, those with
gambling disorder evidence increased impulsivity, assessed in a variety of
manners, compared to controls (van Holst et al., 2010). Likewise, behav-
ioral and personality measures of impulsivity are higher in substance
abusing populations than in controls (Verdejo-Garcia et al., 2008), with
data indicating that dual addictive problems (e.g., both substance abuse
and gambling disorders) have additive effects on impulsivity (Petry, 2001;
Petry and Casarella, 1999).
Furthermore, prospective studies demonstrate that impulsivity in
childhood can predict later development of gambling problems (Pagani
et al., 2009; Slutske et al., 2012; Vitaro et al., 1999). Likewise, measures of
impulsivity and behavioral disinhibition collected from early childhood
onward predict later onset of substance use and substance use disorders
(Chassin et al., 2004; Guo et al., 2001; Hawkins et al., 1992; Hill et al.,
2000; Kandel et al., 1978; McGue et al., 1997; Sher et al., 2000; Zucker,
2008), suggesting a common link between impulsivity and addictive dis-
orders (Slutske et al., 2005).

Neurobiological Risk Factors

In concert with the associations between impulsivity and addictive dis-

orders, studies have demonstrated some similarities between individuals
with gambling and substance use disorders in terms of impaired func-
tioning in brain regions that relate to impulsive decision-making and
motivational processes more generally. Drugs of abuse increase dopa-
mine transmission on motivational circuits in the brain, including the
striatum and the medial prefrontal cortex (PFC; Wise, 2004), and it is
primarily in these reward and decision areas that differences are noted in
individuals with gambling disorder compared to controls.
The reward deficiency hypothesis predicts that susceptibility to addic-
tion stems from an insensitive dopamine system. According to this the-
ory, individuals with a hypoactive reward system require stronger stimuli
18behavioral addictions : dsm - 5 and beyond

(e.g., drugs and gambling) to activate reward systems. In support of this

theory, positron emission tomography studies indicate that addicted indi-
viduals release less dopamine in response to drug administration than do
controls (Martinez et al., 2007; Volkow et al., 1997), and reduced dopa-
mine receptor density in the striatum has been associated with addic-
tion to numerous substances (Volkow et al., 1996, 2001). In functional
magnetic resonance imaging studies, however, data are mixed (Hommer
et al., 2011). Some studies find a lower striatal response during reward
anticipation tasks in substance users relative to controls (Peters et al.,
2011), and others report enhanced responses (Jia et al., 2011). Different
results may relate to variations in demographic or clinical factors of par-
ticipants, as well as tasks. In addition, in the case of substance use disor-
ders, it is not clear whether continued use of the substance alters brain
structure and functioning or whether deficits precede the onset of sub-
stance use disorders.
Studying non-substance addictions, such as gambling, provides a
method to tease apart direct effects of substances on the brain from struc-
tural and functional impairment. Although gambling may engender neu-
roadaptive changes in the brain, studies of patients with gambling disorder
reveal no gross structural abnormalities in gray or white matter volume
(Joutsa et al., 2011; van Holst et al., 2012a). In terms of functional impair-
ment, one of the earliest studies in gamblers found that signal change in
the ventral striatum and ventral medial PFC was reduced in individuals
with gambling disorder compared to controls and correlated with the
severity of gambling symptoms (Reuter et al., 2005). Balodis et al. (2012)
also reported a reduction in response to rewards in the ventral striatum
among individuals with gambling disorder, but van Holst et al. (2012b)
found that gamblers emitted greater response to rewards in the dorsal stri-
atum compared to controls. Variations in tasks may explain some of these
differences, with data suggesting that gamblers are particularly sensitive
to high-risk rewards. For example, Miedl et al. (2010) found no differences
between gamblers and controls during presentation of low-risk rewards,
whereas enhanced inferior frontal gyrus and thalamus activity occurred
with high-risk rewards. Sescousse et al. (2010) found that individuals
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73. Why does the insect visit the flower?
74. Of what color are the flowers that need night-flying insects?
75. What can you say about the scattering of seeds?
76. How are some seeds blown about?
77. How do birds help in carrying seeds?
78. What is there about seeds to attract the birds?
79 What can you tell me of air-plants?
80. How do they get their nourishment?
81. Tell me something about water-plants.
82. What two shapes of leaves do some water-plants have?
83. Of what shape are most of the leaves that grow under water?
84. Why do they have these fringe-like shapes?
85. Of what shape are leaves that lie upon the water?
86. What kind of leaves have plants that grow in sand?
87. What use do these leaves serve?
88. Why are most plants that grow in sand prickly?
89. What can you tell me of a cactus-plant?
90. What long name have animal-eating plants?
91. What kind of living things do these plants catch and eat?
92. Tell me about the sun-dew.
93. Tell me about the Venus’s fly-trap.
94. Tell me about the pitcher-plant.
95. How do plants foretell changes in the weather?
96. What plants are the best weather prophets?
97. What is the reason of this closing before rain?
98. Of what use is this habit to the flower or seed?
99. Describe a flower clock.
100. Tell me about the hours when some plants open and close.
101. Will these hours of opening change with the time of year?
102. What is it that causes this opening and shutting?
103. Tell me about the sleep of leaves.
104. Of what use is this sleep to the plants?

II.
1. Describe a grasshopper.
2. What is the meaning of his various names?
3. How does the grasshopper make his music?
4. What can you say of Mrs. Grasshopper’s sword?
5. Do all grasshoppers live in the grass?
6. Are the head and chest of an insect in the form of rings?
7. To what order does the grasshopper belong?
8. How many straight-wing families are there?
9. How are they sometimes divided?
10. Tell me about the grasshopper’s legs.
11. Describe his wings.
12. What do grasshoppers eat?
13. Where are the grasshopper’s eggs laid?
14. Tell me how the grasshopper changes from egg to full-grown
grasshopper.
15. Can you tell me of any of his queer ways?
16. Describe some grasshoppers to me.
17. Does the grasshopper migrate?
18. Does the grasshopper live alone?
19. What insect is the robber cousin of the grasshopper?
20. Tell me how a locust differs from a grasshopper.
21. What can you tell me of the numbers of locusts?
22. Tell me what harm locusts do.
23. What means are taken to destroy them?
24. What can you say about their size and color?
25. What insect is the grasshopper’s merry cousin?
26. Describe a cricket.
27. What three kinds of crickets are there?
28. What difference is there between the house and field cricket?
29. What will crickets eat and drink?
30. Tell me how the cricket plays his tunes.
31. Tell me about the life of a field cricket.
32. Describe a mole cricket.
33. Describe a mole cricket’s nest.
34. Tell me something of the mole cricket’s habits.
35. What is it that makes the mole cricket shine sometimes?
36. Why has the mole cricket been called the earth crab?
37. In what is the mole cricket like a mole?

III.
1. To what order of insects do the frog-hoppers belong?
2. What can you tell me about insects of this order?
3. Will you mention some of them?
4. What can you say about their wings?
5. How does the little frog-hopper make the ball of foam?
6. Of what use to him is this ball of foam, or froth?
7. What does the scale bug make for his covering, instead of froth?
8. Which is the largest insect of this order?
9. What name has he besides cicada?
10. Which of the insects of this order is the ant’s cow?
11. Which one carries a light?
12. On what food do all hoppers feed?
13. Where does the cicada lay her eggs?
14. Why does she not put them in a living branch?
15. How does she make the hole in which to put her eggs?
16. Where do the larvæ of the cicada live?
17. What kind of weather does the cicada like?

IV.
1. To what insect order do moths and butterflies belong?
2. How do the feelers of butterflies differ from those of moths?
3. How does the butterfly hold its wings, while at rest?
4. Which side of the butterfly’s wings is more gayly colored?
5. Why is this?
6. How does the moth hold its wings while resting?
7. What are the butterfly’s wings often called?
8. Which has the thicker body, a butterfly or a moth?
9. Which has the more furry coat?
10. Which usually flies by night?
11. Do butterflies ever fly by night?
12. What is the food of these insects?
13. How do bees get honey from flowers?
14. How do they carry this tube when it is not in use?
15. Will you describe this tube?
16. What can you say of the butterfly’s legs and feet?
17. Will you describe the wings of a butterfly?
18. Why is the butterfly the best partner of the flower?
19. Why have butterflies been so much studied?
20. Where are the eggs of butterflies laid?
21. Tell me about butterfly eggs.
22. What is the creature called that comes from a butterfly’s egg?
23. Describe a caterpillar.
24. What is the first act of a caterpillar, after leaving the egg?
25. What does the caterpillar eat?
26. What can you tell me of the horns of the caterpillar of the
swallow-tail butterfly?
27. Why is this butterfly called by this name?
28. What is a girdle caterpillar?
29. How does the caterpillar pass into the pupa state?
30. What, then, is a caterpillar? (It is a butterfly larva.)
31. What effect has the weather on the pupa state?
32. Tell me how the butterfly leaves the pupa case.
33. How does a butterfly spend its time?
34. What does it do in bad weather?
35. Do any butterflies live over winter?
36. How do some caterpillars make a house for the winter?
37. Where is the silk-spinner of a caterpillar?
38. Why does a caterpillar make that sidewise motion with his head?
39. How do some caterpillars build a home for summer?
40. How do some spin or weave a hammock?
41. What can you tell me of the colors of butterflies?
42. Why are these insects called scale-winged insects?
43. What can you tell me of the hawk-moth?
44. In what is it like a humming-bird?
45. Why is one moth called a death’s-head moth?
46. Tell me about the wasp moth.
47. Where does it stay in the pupa state?
48. What is the bombyx?
49. Tell me all you can about the silk-worm.
50. Does the silk-worm moth ever eat?
51. Tell me about its caterpillar and its cocoon.
52. Which moth destroys furs and woollen goods?
53. Tell me about the tinea.
54. What can you tell me of the beauty of moths?
55. How can you capture moths to study or to keep?

V.
1. What is a bird?
2. How are eggs hatched?
3. On what plan is a bird built?
4. What can you say of a bird’s bones?
5. What can you tell me about a bird’s neck?
6. How do the bird’s bones help to keep it up in the air?
7. What shape is the breast-bone of flying birds?
8. What is the shape of the breast-bone of birds that do not fly?
9. In which part of the bird’s wing is the chief length?
10. Which is the short bone of the leg?
11. How many toes have most birds?
12. What is a bird’s beak?
13. Have birds any teeth?
14. What have they instead of teeth, for grinding their food?
15. What are a bird’s short feathers called?
16. Are any places on the body bare of feathers, and why?
17. What can you say of the large feathers?
18. Can birds move their feathers?
19. What else can you tell me about feathers?
20. Why do birds preen or dress their feathers?
21. What can you tell me about the feet of water birds?
22. What can you say about wading birds?
23. What kind of a bill has a duck?
24. How and why does it differ from a hen’s bill?
25. How are the beaks of fish-eating birds formed?
26. What can you learn of a bird’s habits from examining its feet and
beak?
27. What can you tell me about the ostrich?
28. Why is the pigeon such a thirsty bird?
29. How does a swallow feed?
30. Tell me of the shrike, or butcher bird.
31. What different kinds of food do birds eat?
32. What can you tell me of the woodpecker family?
33. Will you tell me how and why birds migrate?
34. Tell me the history of the bobolink.
35. Describe an oriole’s nest.
36. Tell me about a humming-bird’s nest.
37. How do some birds ornament their nests?
38. Do birds ever build a roof over their nests?
39. What are some of our best singing birds?
40. What can you tell me of the blue jay?
41. Tell me how birds care for and defend their young.
42. What birds lay eggs in other birds’ nests?
43. What are some of the enemies of birds?
44. What birds can be called street and field cleaners?
45. Tell me any curious things you have seen or heard about birds.
46. Mention some of the lost birds.
47. How did these birds become extinct?
48. What are the different families of the parrot tribe?
49. In what countries do parrots live?
50. What can you say of their food and habits?
51. Where do canaries come from?
52. Of what color are they in their wild state?

VI.
1. On what plan is a fish built?
2. In what element do fishes live?
3. Where do you suppose men got their first boat patterns?
4. What fish is usually described as a pattern fish?
5. Will you describe a perch?
6. What part answers to the boat’s prow?
7. What part serves for a rudder?
8. How many fins has a perch, and where are they?
9. Which fin is used chiefly for motion?
10. What can you tell me of the eyes of the fish?
11. What use do the gills of a fish serve?
12. What does a fish breathe?
13. Does the fish need oxygen or carbon?
14. How does it get oxygen from the water?
15. Why do fish pant and struggle when taken from the water?
16. What fishes will live longest out of water?
17. What causes the fish taken out of water to die?
18. Where and what is the bladder of the fish?
19. Tell me about the backbone of the fish.
20. What can you say of the other bones of a fish?
21. What do you know about the scales?
22. What senses have fish?
23. How many senses have you? Name them.
24. What kind of blood have fish?
25. Is a whale a fish? What is it?
26. What are some of the largest fishes?
27. What are some of the smallest?
28. Do fishes differ much in form?
29. How do they differ in regard to their eyes?
30. What fishes have no scales?
31. What do some fish have instead of scales?
32. Will you describe fish of the ray family?
33. Describe flat fish.
34. What other odd forms of fish do you remember?
35. Tell me about some queer forms of fish heads and noses.
36. What are some of the weapons of fish?
37. For what do they use these weapons?
38. What can you tell me about the breast fins of fish?
39. To what do the breast fins sometimes change?
40. How are fishes able to climb trees?
41. What do you know about flying fish?
42. What are barbels?
43. What fishes have barbels?
44. Where do the fin family live?
45. How are sea fishes divided?
46. Do fishes ever go from salt to fresh water?
47. For what reason do some fish leave the sea and ascend rivers?
48. Tell me how air is put into tanks of water for fish.
49. How do fish behave if they have not enough air?
50. How does air get into the water of seas, lakes, and rivers?
51. How do fish sometimes help themselves to surface air?
52. What do fishes eat?
53. What is the basking of fish?
54. How are fishes kept in glass tanks?
55. Tell me of some of the queer ways of fish.
56. What about the fighting of fish?
57. How does a fish act when he darts after his food?
58. What are fish eggs called before they are laid?
59. What are they called when first dropped in the water?
60. What are the little fish called soon after they hatch?
61. What do we mean by a school, or shoal, of fish?
62. What can you tell me about skate and dog-fish eggs?
63. How will you know the egg-sacs of a skate from those of a dog-
fish?
64. How do the mackerel and herring leave their eggs?
65. What can you say of the numbers of the eggs of fish?
66. What kind of a nest does the trout make for her eggs?
67. Where and when can you find perch eggs?
68. What can you tell me of the shape and colors of scales?
69. What can you tell me of the scales of the side line of the fish?
70. Of what use is this slipperiness to a fish?
71. Why is it hard for a bird or fish to get a partly swallowed fish from
its throat?
72. Tell me about some pretty fish.
73. Have all fishes teeth?
74. What can you say of the number of teeth in many fishes?
75. Where are these teeth set?
76. What do the French call “teeth in velvet”?
77. What can you tell me about the shape of fish teeth?
78. What kind of a fish is a stickleback?
79. How have some of his fins changed?
80. Tell me about the way sticklebacks can be caught.
81. Tell me something of their habits.
82. How does the stickleback build his home?
83. What do the eggs look like?
84. How does this little father take care of his family?
85. What is one of our largest river fish?
86. How are sturgeon often caught?
87. What do the Russians make from sturgeon?
88. What kind of candles do the Cossacks often have?
89. What are some of the things made from the shark?
90. What can you tell me about the shark?
91. Of what use are fish?
92. How can you learn more about fish?
93. Why in these Readers have you been told a little of many things?
94. Do you think you know a little about how to use your eyes as you
go about the world?
 Transcriber’s note
Minor punctuation errors have been changed
without notice. Inconsistencies in hyphenation have
been standardized. The following printer errors have
been changed.
CHANGED FROM TO
“convovulus had its “convolvulus had its
Page 84:
long” long”
“the star of “the Star of
Page 87:
Bethlehem” Bethlehem”
“leaf up all in a “leaves up all in a
Page 88:
bunch” bunch”
“see Miss “see Mrs.
Page 106:
Grasshopper’s” Grasshopper’s”
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