Process Addictions Erik Sanchez Elizabeth Tse Maleenee Beuhler Nishant Munugala Exercise Dependence

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Process Addictions

  • Erik Sanchez
  • Elizabeth Tse
  • Maleenee Beuhler
  • Nishant Munugala

Exercise Dependence

  • Other names:
    • Exercise addiction
    • Obligatory exercise
    • Compulsive athleticism
    • Compulsive exercise
    • Exercise abuse
    • Anorexia athletica


  • There is no formal DSM-IV definition
  • “…is physical activity that is extreme in frequency and duration, relatively resistant to change, and often accompanied by an irresistable impulse to exercise even when injury, fatigue, or other personal demans persist
  • Source: University of Florida College of Health and Human Performance exercise, Center for Exercise Science

Criteria for Exercise Dependence

  • (1) Tolerance: need for increased amounts of exercise to achieve desired effect; diminished effect with continued use of same amount of exercise
  • (2) Withdrawal: characteristic withdrawal symptoms for exercise (e.g., anxiety, fatigue) or exercise is taken to relieve or avoid symptoms
  • (3) Intention Effect: exercise is often taken in larger amounts or over a longer period than was intended
  • (4) Lack of Control: a persistent desire or unsuccessful effort to cut down or control exercise
  • (5) Time: a great deal of time is spent in activities necessary to obtain exercise (e.g., physical activity vacations)
  • (6) Reduction in Other Activities: social, occupational, or recreational activities are given up or reduced because of exercise
  • (7) Continuance: exercise is continued despite knowledge of having a persisting/recurriing physical or psychological problem that is likely to have been caused or exacerbated by the exercise (e.g., continued running despite injury).
  • (Hausenblas and Downs, 2002)

Signs of Exercise Dependence

  • It interferes with daily activities and relationships.
  • You believe that bad things will happen if you don’t work out.
  • You develop a perfectionist attitude toward exercise and your body.
  • You ignore the signs of illness, injury or fatigue and work out
  • despite them.
  • You set unattainable goals (miles run, hours worked out, percentage of body fat, etc.)
  • You ignore friendships or satisfying hobbies in order to exercise.
  • National Association of Anorexia Nervosa and Associated


  • Psychological
    • Anxiety
    • Depression
    • Worthlessness
    • Insomnia
  • Social
    • Neglect relationships
    • Social withdrawal
  • Physical
    • Damaged tendons, ligaments, bones, cartilage, and joints
    • Loss of muscle mass
    • Ammhenorea (females) - Osteoperosis
    • Eating Disorders
    • Gastro-intestinal blood loss and anemia
    • Myocardial infarction and death
      • Jim Fixx - tolerant to ischemic heart disease


  • OCD Therapist
  • “Third wave” cognitive-behavioral therapy
  • Acceptance and commitment therapy (ACT) for treating many disorders including addiction
    • Major advocate, Steve Hayes
    • Not to fight negative feelings but to accept them as part of life
    • Mindfulness
    • Work toward life values

Treatment (continued)

  • Cognitive therapy strategy is normally to change negative feelings, not accept them
    • Multiple studies showed that ACT proved more effective than regular cognitive therapy including ones on depression (Haynes 2006) and psychotics (Haynes 2002)
    • Criticized for being too much like a religion
  • Tranquilizers
  • Medicine
    • Tranquilizers
    • Antidepressants
  • Treament Centers

Related Disorders

  • Obsessive Compulsive Disorder (OCD)
  • Bulimia Nervosa

Compulsive Overeating

Compulsive Overeating

  • Most people feeling control over eating habits, meaning eating when you are hungry and stopping when you are satisfied.
  • Compulsive behavior is defined as acting on an internal force that leads one to act against their will.
  • Compulsive overeating usually in the form of bingeing or excessive snacking
  • Bulimia Nervosa and Binge Eating Disorder

Binge (DSM-IV)

  • Eating, in a discrete period of time an amount of food that is definitely larger than most people would eat in a similar period of time under similar circumstances
  • A sense of lack of control over eating during the episode
  • People describe feeling that they cannot stop eating or control what or how much they are eating

Bulimia Nervosa

  • Recurrent episodes of binge eating.
  • Recurrent inappropriate compensatory behavior in order to prevent weight gain
    • Purge subtype: self-induced vomiting; misuse of laxatives, diuretics, enemas, or other medications
    • Non-purge subtype: fasting; or excessive exercise
  • These behaviors both occur, on average, at least twice (once) a week for 3 months.
  • Stems from a negative perception body shape and weight.

Binge Eating Disorder

  • Recurrent episodes of binge eating.
  • Marked distress regarding binge eating.
  • The binge eating occurs, on average, at least 2 days a week for 6 months.
  • The binge eating is not associated with the regular use of inappropriate compensatory behaviors.

Causes of Compulsive Overeating

  • Socio-cultural issues:
    • Body image
    • Fast Food Society
    • Diet craze
  • Interpersonal issues:
    • Emotional eating
    • Susceptibility to addiction
  • Self-Regulation Issues

Is Compulsive Eating an Addiction?

Other Indications of Addiction

  • Laboratory findings have provided evidence that binge eating, like addictions, might involve the endogenous opioid systems (Grigson, 2002; Volkow & Wise, 2005) and the mesocortical dopamine system (Davis, Strachan, & Berkson, 2004; Volkow & Wise, 2005).
  • Low levels of dopamine D2 receptors have been reported in individuals with compulsive disorders, including both drug addiction and compulsive overeating
  • Eating disorders and substance-use disorders co-occur at higher than expected rates, particularly among individuals who binge eat(elevated rates of eating disorders are reported by individuals with substance-use disorders)
  • # It has been postulated that compulsive overeating may occur to compensate for reduced activation of reward circuits which are modulated by dopamine Wang et al. (2001)

No Gold Standard

  • It is difficult to determine whether binge eating is an addiction because no gold standard exists by which to judge a behavior as an addiction.
  • Ultimately, whether binge eating is considered an addiction will depend on the breadth of the definition selected.

DSM-IV Substance Dependence Criteria

  • Binge eating larger amounts than intended
  • Persistent desire or unsuccessful efforts to control binge eating
  • Withdrawal (e.g., restlessness, irritability, headaches)
  • Great deal of time spent binge eating or recovering from the effects


  • Community women (N=79) with a current diagnosis of BED
  • The substance-dependence module was used to assess current substance dependence, with the term ‘substance’ referring to binge eating rather than psychoactive drugs.
  • Data collected via interviews
  • Stephanie E. Cassina and Kristin M. von Ranson, a,
  • Department of Psychology, University of Calgary, 2500 University Dr. N.W., Calgary, Alberta, Canada T2N 1N4


  • 92.4% of participants qualified as addicts
  • Participants engaged in a mean of 4.0 eating binges/week (SD=1.8) and had been binge eating for a mean of 14.8 years (SD=11.9).
  • Eating disorder treatment had been sought by 20 participants (25.3%) from a physician, psychiatrist, psychologist, counselor, support group, or 12-step program.
  • Only 6 participants (7.6%) had been formally diagnosed with an eating disorder by a psychologist or psychiatrist.

Current Views & Future Implications

  • Increasing view that some foods are addictive and that eating disorders are a form of addiction is widespread among mental health professionals (Benton, 2010; von Ranson & Cassin, 2007; Wilson, Perrin, Rosselli, Striegel-Moore, DeBar, & Kraemer, 2009).
  • More recently, the notion that obesity might be a form of addiction has been gaining popularity, with the case being made that the study of drug addiction may inform our understanding of obesity (Volkow & Wise, 2005).
  • Future approaches considering treating eating disorders(Bulimia Nervosa and BED)as an addiction may be a key step in finding better treatments

Internet Addiction

What is Internet Addiction?

  • Internet addiction is defined as time-consuming, incontrollable, or distressing internet use which results in social occupational, or financial difficulties.
  • (Dell’Osso et al, 2008)

Some Internet Facts…

  • The internet became commercially available only 20 years ago in the early 1990s.
  • According to the International Telecommunications Union, as of 2009, almost a quarter (~22%) of the world’s population uses the internet.
    • Since the internet is so young, relative to other drugs, internet addiction is a fairly new disorder and has only recently been considered a major treat to society due to its addictive nature.

Types of Internet Addiction

  • Addiction to online video games (role playing games)
  • Online gambling
  • Cybersex
  • Chat rooms

Prevalence of Internet Addiction

  • In an early survey regarding internet addiction it was found that an estimated 6% of internet users fit the profile of an internet addict as is currently defined by the DSM IV. (Greenfield 1999)
  • Similar research has been done around the world.

Prevalence (continued)

  • Since there is no standard diagnostic criteria there is variability in the estimated number of users who are addicted ranging from 6-15%.
  • It was found that the highest rate of addiction was among college students ranging from 13-18.4%.
  • Adolescents from 12-18 years of age had the lowest risk of internet addiction ranging from 4.6-4.7%.

Symptoms of Internet Addiction

  • Excessive, non-essential use of the internet defined by 8-60+ hours/week depending on the criteria used.
  • Loss of sleep.
  • Delay of work.
  • Disregard for normal drives.
  • Seclusion

Possible Causes/Risk Factors of Internet Addiction

  • Quality of Family and Social Life
  • Problems with Partner/Friends
  • Addictive personality
  • Loneliness
  • Social phobias

Consequences of Internet Addiction

  • Loss of Spouse/Significant Other/Problems with relationships
  • Loss of real friends


  • Dysphoria
  • Depression
  • Need of internet
  • Loss of interest
  • Follows typical addiction cycle

Problems with Diagnosis

  • Unlike recreation drugs or drugs of abuse, the internet is usually a vital tool for every day life
    • People tend to rationalize their excessive use of the internet

Prevention of Internet Addiction

  • In India, internet use has been restricted to daytime hours.
  • Various companies have set programs that monitor employee internet use such as Spymonkey
  • Restrictive use set by parents and school for children in grade school (U.S.)

Treatment of Internet Addiction

  • Many treatments have been employed but since internet addiction is such a new phenomenon most treatments have yet to be adequately studied
  • These treatments include: Structured Cognitive Behavioral therapy, interventions, abstinence, restrictive/controlled use, group therapy, 12 step recovery programs and medication


  • Antidepressant Escitalopram (Lexapro)
  • Open label study (n = 19)
    • This means that people knew what they were taking during the first phase
    • Then given placebo or the drug in a double blind study
    • Results: people’s usage of the internet dropped from an average of 36 hours/week to 16 hours/week


Problem Gambling

  • “Problem gambling is gambling behavior which causes disruptions in any major area of life: psychological, physical, social or vocational.” - National Council on Problem Gambling
  • Other names: compulsive gambling, pathological gambling

DSM-IV Symptoms of Problem Gambling

  • May apply to three or more of the following categories:
    • Tolerance
    • Withdrawal
    • Larger amounts - After losing money gambling, often returns another day to get even-chasing
    • Impaired control - neglect of relationships, career, preoccupation of gambling
    • Time spent
    • Continued use despite problems
  • From: American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, 4th edition, 1994.

Diagnostic Criteria

  • Must apply to five or more of the following:
    • Gambling preoccupation
    • Increasing amount of money gambled
    • Lack of success in halting gambling habits
    • Uses gambling as an escape
    • Lies to family members or significant other
    • At risk of losing career or education
    • Lost relationships of close friends/family to gambling
    • Bailout - Needs financial assistance from others

Possible Motivations for Problem Gambling


  • Believed that lower serotonin would be the reason for problem gambling
  • Low norepinephrine levels lead to problem gambling
  • Prone to engaging in high risk activity
  • May also be a way for people to stave off depression
  • Source: New York Times, 1989


  • (Roy et. al., 1988)
  • Subject pool of 17 chronic gamblers
  • Tested urine to measure levels of norepinephrine
  • Results: Had significantly lower amounts of norepinephrine
  • What does this mean?
    • Gives strong evidence that people with lower levels of norepinephrine are more likely to engage in gambling!
    • But the study needs to be repeated for more validity

Gambler’s Fallacy

  • Assumes the likelihood of winning is higher than the likelihood of losing
  • Jane: "I'll be able to buy that car I always wanted soon."
  • Bill: "Why, did you get a raise?"
  • Jane: "No. But you know how I've been playing the lottery all these years?"
  • Bill: "Yes, you buy a ticket for every drawing, without fail."
  • Jane: "And I've lost every time."
  • Bill: "So why do you think you will win this time?"
  • Jane: "Well, after all those losses I'm due for a win."

Consequences of Problem Gambling

  • Financial Debt
  • Increase in the likelihood of engaging in criminal activity
  • Possible suicide


  • About 0.5% of the US population have experienced pathological gambling
    • 0.9-2.3% experienced subclinical pathological gambling


  • Step-based programs
  • Cognitive Behavioral Therapy
  • Antidepressants - SSRIs
  • Group Therapy

References (Exercise)

  • “Compulsive Exercise” Mary L. Gavin, MD Date reviewed: October 2010
  • D. M. W. De Coverley Veale, “Exercise Dependence” British Journal of Addiction 1987,
  • 82, 735-740
  • Hollyann E. Jenkins and M. Williams, Ph.D., Clinical Psychologist. Source: American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision.
  • Washington, DC, American Psychiatric Association, 2000.
  • addiction.php
  • “When working out shifts from a healthy habit to obsession,” Marina Benjamen, Ph.D. http://
  • Eating Disorders Review September/October 2010 Volume 21, Number 5 Adria N. Pearson, Michelle Heffner, and Victoria M. Follette. Foreword by Steven C. Hayes
  • Addiction Rerearch, 1997, Vol. 5 (2) pp.161-168 EXERCISE ADDICTION: A CASE STUDY” MARK CRIFFITHS
  • Heather A. Hausenblas and Danielle Symons Downs, “Exercise Dependence Scale-21 Manual” The Third Wave of Therapy By John Cloud Monday, Feb. 13, 2006 Time Magazine

References cont.

  • Dell'Osso, B., and Et Al. "Escitalopram in the Treatment of Impulsive-compulsive Internet Usage Disorder: an Open-label Trial Followed by a Double-blind Discontinuation Phase." Journal of Clinical Psychiatry 3rd ser. 69 (2008): 452-56. Web. 1 Mar. 2011.
  • Young, Kimberly S., and Cristiano Nabuco De. Abreu. Internet Addiction: a Handbook and Guide to Evaluation and Treatment. Hoboken, NJ: John Wiley & Sons, 2011. Print.
  • Adam, T., and E. Epel. "Stress, Eating and the Reward System." Physiology & Behavior 91.4 (2007): 449-58. Print.
  • Cassin, S., and K. Vonranson. "Is Binge Eating Experienced as an Addiction?" Appetite 49.3 (2007): 687-90. Print.
  • Cota, Daniel. "Cannabinoids, Opioids and Eating Behavior: The Molecular Face of Hedonism?" Web. 08 Mar. 2011. .
  • "Eating Disorders, Addictions, and Unconscious Fantasy." Web. 08 Mar. 2011. .
  • "Eating Disorders, Obesity and Addiction - Wilson - 2010 - European Eating Disorders Review." Wiley Online Library. Web. 08 Mar. 2011. .

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