#66412: Behavioral Addictions

The concept of addiction involving non-substance behaviors as repeated urges to engage in counter-productive activities was introduced in 1990. At the time, behavioral addictions were proposed to encompass obsessive-compulsive disorder (OCD), "compulsive spending" (including gambling), "overeating" (binge eating), "hypersexuality," and kleptomania. It was thought these behaviors were linked to addiction by poor impulse control and self-regulation, which led to repetitive engagement of the behavior despite negative consequences[1,2]. The concept of an obsessive-compulsive spectrum of disorders was proposed in 1993; disorders that featured an inability to control or delay repetitive behaviors were thought to fall on a spectrum from impulsivity to compulsivity [3]. Numerous psychiatric and neurologic disorders were included in this spectrum [4].

Further research suggested that impulsivity and compulsivity appeared in substance and behavioral addictions at different stages, and the "impulsive-compulsive disorder" model was proposed. In this model, impulsivity was dominant in earlier-stage addiction, when behavior is motivated and reinforced by reward, and compulsivity was dominant in later stages, when behavior is motivated and reinforced by avoidance of negative emotional states [5].

An influential 2006 study broadened the definition and core features of addiction as 1) a state of craving or urge that immediately precedes the behavior, 2) impaired ability to control the behavior, and 3) the behavior continues despite negative consequences [6]. Criterion 3 suggested addiction was no longer tethered to substance use. This was cemented in 2011, when the American Society of Addiction Medicine (ASAM) released their definition of addiction. The core features of this definition are [7]:

Numerous repetitive problematic behaviors became suggested as behavioral addictions, but criticism that excessive normal behaviors were becoming overpathologized ensued [4,8,9]. Concerns were raised that such persons could become stigmatized, based in part on study results suggesting that "brain disease" explanations of drug addiction had unforeseen consequences on clinician and public attitudes—the inability of persons with addiction to control behavior being hard-wired into their brains was perceived to make them more dangerous [10]. This concern along with recognition of the roles of prevention and harm reduction in the spectrum of addiction recovery led the ASAM in 2019 to adopt a revised definition of addiction as "a treatable, chronic medical disease involving complex interactions among brain circuits, genetics, the environment, and an individual's life experiences. People with addiction use substances or engage in behaviors that become compulsive and often continue despite harmful circumstances. Prevention efforts and treatment approaches for addiction are generally as successful as those for other chronic diseases" [7].

A major step forward in the recognition of behavioral addictions as addictive disorders came in 2013 with the American Psychiatric Association (APA) publication of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) [11]. In the DSM-5, pathologic gambling was renamed gambling disorder, becoming the first recognized behavioral addiction. This followed decades of research and data demonstrating similarities to substance addictions [8]. Internet gaming disorder and its proposed diagnostic criteria were placed in Section III (Emerging Measures and Models); the body of evidence was extensive, but standardized diagnostic criteria remain absent [12].

Decisions in the DSM-5 concerning behavioral addiction were based on evidence published before 2013 in an emerging and quickly evolving field. While some criticism reflected the premature state of some evidence and lack of consensus, other criticism was directed at decisions to omit behavioral addictions that were viewed as subjective and biased [4].

The ability to delay, withhold, or interrupt a behavioral response is a key aspect of executive function. Suppressing an inappropriate immediate response allows time for other processes (and predicting consequences of possible actions) to promote appropriate behavioral choices. Effective inhibitory control is required for adaptive functioning, such as restraining impulses for spiteful, peculiar, and/or inappropriate expression [11,24].

Impulsivity is complex. It is broadly defined as a predisposition for rapid, unplanned reactions to internal or external stimuli without forethought or regard for negative consequences to self or others [25]. In persons with early-stage substance or behavioral addiction, impulsivity is a powerful mechanism thought to drive pursuit of immediate reward, and it is a temperament vulnerability factor for substance use disorders [26,27,28].

Those with prominent impulsivity traits tend to favor immediate rewards over long-term gains, to have poor capacity to delay gratification or resist urges, to quickly react with poorly planned response to stimuli, to be unreflective in decision-making, to dismiss the negative consequences of one's actions, and to be disinhibited, novelty- and thrill-seeking, and impatient [29]. Impulsivity includes several distinct neurocognitive mechanisms and domains.

Domains of Impulsivity

The four major domains of impulsivity are motor, choice, reflection, and delay discounting. Motor impulsivity (also known as response/rapid-response impulsivity) is defined as an impaired ability to stop motor response following changes in environmental circumstances. Impaired motor response inhibition is highly prominent in attention deficit hyperactivity disorder (ADHD) (the archetypal disorder of impulsivity), pronounced in trichotillomania, and observed in gambling disorder [30,31]. The dimensions of impulsivity are closely associated with behavioral addictions such as social media addiction and problematic smartphone use. For example, motor impulsivity was found to have a strong connection with the components of mood modification and relapse in social media addiction and with the components of conflict and withdrawal in problematic smartphone use, suggesting that motor impulsivity may be a promising and effective target for the prevention and treatment of select behavioral addictions [32].Choice impulsivity is characterized by difficulty in delaying gratification and a tendency to choose immediate small rewards at the expense of larger but delayed rewards. This type of impulsivity is consistently observed in substance use disorder and when money, health, and/or freedom are rewards [33,34,35].

Reflection impulsivity is the diminished ability to collect salient information from the environment before a decision. Reflectively impulsive persons make choices rapidly, rather than waiting for more relevant information to become available. Reflection impulsivity commonly occurs in substance use disorder and gambling disorder [36].

The subjective value of a reward decreases as a function of delay in its delivery; the value of reward is discounted with longer delay. With Internet gaming disorder, the immediate reward of online gaming increasingly comes at the cost of abandoned social and professional activities that yield greater long-term rewards [31,37]. This is referred to as delay discounting.

Measuring Impulsivity

Impulsivity-related behaviors are measured by neuropsychologic testing, personality scales, and neuroimaging. These assessments can be repeated over time to evaluate treatment response [38].

Neuropsychologic tests measure performance (i.e., functioning) in specific cognitive domains (Table 1). Testing during neuroimaging can identify the functional integrity of brain regions that mediate performance on specific neuropsychologic tasks.

Personality scales measure the extent that statements involving impulsive behaviors are endorsed. These statements include: "I make decisions quickly," "I often buy things I cannot afford," or "I act without thinking" [25].

Neuroimaging uses non-invasive technologies to identify brain regions involved in inhibitory control, presence of abnormality, and possible changes with treatment [25]. Neuroimaging has helped identify frontostriatal circuitry as contributing to action inhibition, affective inhibition, cognitive flexibility, and delay discounting. It is now known that frontostriatal circuitry and dopaminergic transmission are common neural substrates that underlie inhibitory control function [39,40].

Compulsivity is less well-defined and investigated than impulsivity, but it is used to describe repetitive and functionally impairing overt or covert behaviors that lack adaptive function. These habitual, stereotyped behaviors are performed inflexibly to avoid perceived negative consequences and persist despite being harmful [41,42].

Compulsive behaviors are inappropriate and have no obvious relationship to a goal. When reward-driven substance use or behavioral pursuits persist over an extended period, reward-based learning mechanisms are thought to develop into compulsive behaviors [26].

Compulsivity appears distinct from impulsivity, but research demonstrates overlapping neural networks involved in both [4]. Deficits in cognitive flexibility may also serve as markers in disorders of addiction to drug or non-drug rewards. There are two subtypes of compulsivity (reversal learning and attentional set shifting) [43]. Reversal learning is the capacity to flexibly switch choices in response to immediate changes in the environment or setting. The orbitofrontal cortex are involved in this type of compulsivity. Attentional set shifting is the ability to shift response sets to a previously irrelevant dimension and involves the lateral prefrontal cortex (PFC).

The reward deficit disorder model describes addictions as chronic relapsing disorders characterized by a compulsion to seek and take the drug or experience the behavior, loss of control over stimuli intake, and emergence of a negative emotional state (e.g., dysphoria, anxiety, irritability) when unable to access the stimulus. The negative emotional state is termed motivational withdrawal syndrome. A key component of addiction is negative reinforcement, which describes engagement in potentially harmful behaviors to alleviate a negative emotional state [45].

"Reward deficit disorder" refers to multiple motivational mechanisms and the progression from impulsivity (positive reinforcement) to compulsivity (negative reinforcement). Compulsivity is thought to result from stress within forebrain structures and dysregulation of neurocircuits involved in reward [45].

In Gray's reinforcement sensitivity theory, behavioral addictions are understood from the context of brain system sensitivity to punishment and reward. Accordingly, punishment sensitivity regulates responses to stimuli perceived as potentially dangerous, leading to their avoidance (behavioral inhibition). Reward sensitivity directs behavior toward appetitive stimuli that provide immediate compensation (behavioral activation) [46,47].

Behavioral addictions have also been examined through the lens of attachment theory. While not specifically a model of addiction, attachment theory helps explain how early environment experiences may shape beliefs and cognitions that increase risks of behavioral addiction. This model posits that the nature and quality of child attachment to a primary caregiver(s) shape the personality, beliefs in responsiveness and trustworthiness of others, and level of interpersonal security in adolescence and adulthood. The primary attachment relationship is thought to form the template from which subsequent relationships are developed [48,49,50].

A child with responsive, consistent early caregiving develops an expectation that others will be available and supportive when needed. In contrast, children raised in negligent, rejecting caregiving environments form negative expectations in future relationships and social interactions. Attachment style influences personality traits, interpersonal behaviors, and competencies that directly impact satisfaction in romance and friendships, emotional functioning, interpersonal communication, and social behavior [48,49,51].

Attachment style may also influence motivation for pathologic behavior. In persons with attachment anxiety, attachment needs are activated by relational or environmental stressors. Some persons with insecure early attachments may display attachment avoidance, which is the absence of desire for closeness in important relationships. In the context of Internet-mediated addictions, the high dependency in attachment anxiety leads individuals to seek comfort and connection online [50,52,53].

In one study of college students, attachment anxiety (both maternal and paternal) significantly predicted pathologic Internet use, but attachment avoidance did not. Maternal attachment anxiety was a significant predictor of male pathologic Internet use, while paternal attachment anxiety was most relevant in female pathologic Internet use. It is important to note that this study examined college students in the United States, where parental roles and attachment patterns may differ from those in earlier international studies [50].

Another interpersonal model is rejection sensitivity, a cognitive-affective worry of rejection that impairs well-being and interpersonal function. Persons who doubt acceptance by others fear and expect rejection, are more hostile and aggressive in relationships, and experience more unstable and dissatisfying relationships that end sooner. They respond to social rejection with hostility, depression, emotional regression, jealousy, and/or over-politeness [36]. Susceptible individuals may turn to Internet-mediated activities first as a way to avoid social interactions; these behaviors may then evolve into addictions.

The components model of addiction defines addiction as any behavior with all six core addiction components [17,55]:

The cognitive-behavioral model addresses the role of motivational drives for reward-seeking and stress-reduction; behavioral control (related to executive inhibition); and decision-making (involving weighing the pros and cons of engaging in motivated behaviors) in addictive behaviors.

Reward and Motivation

Motivational drives linked to reward-seeking importantly contribute to addictive behavior, and diminished executive function/cognitive control over these motivational drives contributes to decision-making that leads to persistent engagement in the behaviors. Enhanced reward sensitivity and decreased loss sensitivity may increase urges to gamble (in gambling disorder) or online game (in Internet gaming disorder) [54].

Executive Control and Behavioral Inhibition

Executive systems exert cognitive and behavioral control over motivational drives, allowing inhibition of desires and control or moderation of reward-seeking behaviors [56,57]. Subjects with behavioral addiction show diminished response-inhibition and cognitive-control responses to addiction-specific stimuli, reflecting cognitive bias and altered set-shifting related to compulsive aspects of addictions. This is a reflection of alterations in executive function and neural processes that underlie attention, response inhibition, and behavioral flexibility [58,59].

Decision-Making

In deciding between pursuit of immediate reward and delayed consequences, individuals with behavioral addictions show strong tendencies for deciding on immediate reward. Decision-making is the final "check point" before a behavior is enacted [54].

Interaction of Cognitive Domains

Increased sensitivity to winning or pleasure can enhance urges to gamble, online game, or engage in sexual activity. Impaired capacity for executive control leads to inadequate control over reward-seeking behaviors, permitting urges and craving to dominate decision-making and lead to addictive behavior patterns. This promotes disadvantageous decision-making for immediate gratification over long-term gains. Gambling or gaming reinforces reward-seeking behaviors, further eroding executive-control abilities and perpetuating addictive behaviors [54].

The theoretical model of Internet gaming disorder links decision-making favoring immediate reward despite long-term negative consequences and motivation-seeking (craving) as drives to experience pleasure and/or reduce stress. The third domain is diminished executive control (inhibition and monitoring) over motivation-seeking, consistent with research of executive functioning in individuals with substance use disorders. This model refers to reward-centered models of substance addiction, such as incentive salience theory. Treatment interventions are suggested to target specific cognitive and motivational factors [54].

The I-PACE model is a theoretic framework for specific Internet-mediated behavioral addictions (e.g., gaming, gambling, pornography/cybersex, buying). According to this model, these addictions are the result of interactions between predisposing factors, moderators, and mediators with impaired executive functioning. Conditioned processes (learning and memory) strengthen these associations in the addiction process. Biopsychologic, personality, and affective factors combine and interact to influence an individual's predisposition for Internet-mediated addictions. Interactions between predisposing affective/cognitive factors and pathologic neuropsychologic functioning during Internet-mediated addictions are bidirectional [60].

Predisposing biopsychologic factors increase vulnerability to emotional disorders and behavioral addiction. Negative early childhood experiences of trauma, emotional or physical abuse, and/or social isolation are linked to insecure attachment styles, which correlate with Internet-mediated behavioral addictions [61]. Adverse early events increase individual vulnerability to intense stress reactivity, mental disorders, and addictive behaviors in adolescence and adulthood [62,63].

Predisposing personality factors include high impulsivity, shyness, neuroticism, low self-esteem, conscientiousness, self-directedness, and procrastination. Affective/cognitive responses to environmental stimuli influence the preference of specific Internet genres. For example, a perceived lack of social support, feelings of isolation, and loneliness are linked to the use (and potential misuse) of Internet genres with prominent communication features (e.g., social networking sites) [64,65]. Specific Internet-mediated addictions are associated with specific personality profiles, such as greater rates of ADHD and impulsivity.

The neural correlates of Internet-mediated addictions reflect a maladaptive interaction between cue-reactivity/craving and reduced prefrontal/executive functioning, also observed in substance addictions. Decisions to reduce craving and increase mood through specific Internet genre use are thought to be the result of increasing dominance of immediate reward and decreasing consideration of longer-term negative impacts [60].

Cognitive-behavioral therapies (CBTs) have evolved over the past 50 years. Behavioral therapy emerged as the "first wave" in the 1950s, followed by a second wave of cognitive therapy in the 1970s. Cognitive therapy and behavioral therapy were combined in the 1980s to become CBT. Since the mid-1990s, a range of third-wave approaches have been introduced, including acceptance and commitment therapy, cognitive-behavioral analysis system of psychotherapy, and functional analytic psychotherapy [71].

Cognitive-Behavioral Therapy

CBT is empirically supported with demonstrated efficacy across a range of substance use disorders [72,73]. CBT may work by strengthening executive control over behaviors through acquisition of cognitive skills. In behavioral addictions, CBT can help individuals improve their inhibitory control ability, recognize maladaptive cognitions, and learn and employ skills for more adaptive decision-making [74,75].

CBT and CBT-related therapies can help patients identify distortions and errors in thinking and the mistaken, irrational beliefs that underpin maladaptive functioning. Patients learn to identify these distortions by monitoring their internal dialogue (e.g., "You can't do that," "Don't even try") and remembering childhood pronouncements (e.g., "You'll never amount to anything," "You're lazy and stupid") that compromise current functioning. Assessing the validity of patients' conclusions and exploring different ways to view themselves and their capabilities are both potent CBT interventions. Through role-playing or in vivo exposure, patients can experiment with alternative views and behaviors. CBT-based approaches also teach coping skills, symptom management, relapse prevention, impulse control, and anger management [76].

CBT for Internet-mediated addiction (CBT-IA) addresses coping styles, Internet-related expectancies, attentional biases, cue-reactivity/craving, executive function, and inhibitory control. The patient's Internet behavior is monitored and analyzed for situational, emotional, and cognitive contexts, and the reinforcing effects of Internet use are considered to help understand the cognitive assumptions and distortions that underlie situational triggers. CBT-IA identifies coping responses and high-risk situations for addictive Internet use, as well as the expectancies, illusions, and reinforcing effects. Cognitive restructuring and reframing target Internet-related cognitive biases [60].

Attentional biases can be decreased by attentional retraining. When combined with the computerized Go/No-Go task (a binary pass/fail test), this approach can improve inhibitory control and executive functioning. Cue-exposure therapy is found to reduce conditioned associations and craving intensity [60].

CBT has evidential support as a treatment for several behavioral addictions. However, there is a nation-wide shortage of clinicians with specialized training in CBT in the United States. Even clinicians who believe they are delivering CBT-based interventions often do not deliver the core components of empirically supported CBT [77].

Cognitive Enhancement Therapy

As discussed, patients with behavioral addictions often show cognitive dysfunction involving elevated impulsivity, impaired cognitive control, and cognitive inflexibility, and therapies that target these domains may be helpful. Cognitive enhancement therapy (CET) involves the repeated practice of cognitive tasks involving problem-solving, response inhibition, visual tracking, and discrimination skills. These skills are practiced several hours per week over several months [57]. CET has resulted in significant improvements in impulsivity and delay discounting in patients with stimulant addiction, and similar strategies should be considered in targeting cognitive dysfunction in persons with behavioral addictions [78].

Persons with gambling or Internet gaming disorder show attentional biases towards Internet cues, and therapies that target such biases may be effective as treatment [79]. Cognitive bias modification specifically targets automatic/implicit processes such as attention bias and approach bias.

Stress intolerance and poor stress coping are strongly associated with behavioral addictions. Mindfulness-based stress reduction interventions target stress reduction, and efficacy is supported in substance addictions. This approach may be particularly helpful in patients with behaviors driven by negative-reinforcement motivations [80].

Dialectical behavior therapy combines elements of CBT with mindfulness and other approaches into a structured treatment approach that emphasizes skills training in mindfulness, distress tolerance, and emotion regulation. Dialectical behavior therapy provides an atmosphere of validation with psychoeducation and coping skills training—core competencies for interpersonal functioning that ordinarily would have been learned growing up in a healthy family environment. The four primary skill sets are mindfulness, emotion regulation, distress tolerance, and interpersonal effectiveness [76].

Mindfulness helps patients cultivate present-moment awareness, enabling them to observe and describe what is occurring without judgment. Mindfulness effectively counteracts viewing the present through the lens of distorted hopes, expectations, and past experiences of rejection and abandonment. Many patients believe they miss their childhood/family/lover, but they actually miss their idealized version of the past, not the reality.

Effective emotion regulation helps patients to not over-react when facing emotions that threaten to overwhelm. Patients learn to become more aware of their feelings, the precursors to losing emotional control, and how to downregulate arousal states to relieve the pressure for impulsive behavior. Up-regulation is also taught, so patients do not ignore faintly recognized but painful reactions alerting them something is not right.

Dialectical behavior therapy also helps patients learn multiple methods of tolerating distress without resorting to self-defeating or self-destructive behavior. One method involves self-soothing by engaging the five senses when experiencing acute interpersonal anxiety or distress. This can involve listening to or singing a favorite song; watching a travel video of a beautiful location; savoring the taste of a favorite food; lighting a candle with a favorite scent; and/or touching or rubbing soft material or a smooth stone.

Interpersonal effectiveness is built by establishing a repertoire of skills that improve unstable relationship patterns. Patients learn skills related to self-respect, assertiveness, inhibition of emotions, and setting and maintaining personal limits and boundaries. Interpersonal effectiveness is the result of psychoeducation about commonly held relationship myths that encourages patients to begin dismantling maladaptive beliefs by developing statements that challenge their narratives.

Clinical psychologists administering dialectical behavior therapy are available after hours for support calls; during these contacts, patients are asked a series of standardized questions that encourage the best use of problem-solving strategies that apply dialectical behavior therapy principles. Typically, therapist-led dialectical behavior therapy consists of 2 introductory psychoeducational sessions; 16 core skill-learning and skill-building sessions on mindfulness, emotion regulation, and distress tolerance; and 2 final review and relapse prevention sessions [81].

The concept of motivational interviewing evolved from experience in the treatment of problem drinkers and was first described in 1983. Motivational interviewing is a systematic, evidence-based approach to complex behavior change. It is unique in eliciting and exploring patients' own arguments for change, evoking intrinsic motivation, and helping patients to resolve their ambivalence about change [82]. It is a directive but nonconfrontational method to bypass unproductive struggles. The therapist engages the patient through empathic listening, open-ended questions, reflective statements, affirmations, and summary statements. By decreasing denial and enhancing motivation, motivational interviewing is a pragmatic, practical approach that focuses on actual change [76].

Motivational interviewing helps empower patients with responsibility for their behavior. By allowing patients to resolve their ambivalence using an approach that gently pushes them, they are more inclined to acknowledge the consequences of their behavior and engage in treatment. More aggressive strategies, sometimes guided by a desire to "confront denial," can fail because they push patients to make changes for which they are not willing or ready [83].

Interpersonal Psychotherapy

Interpersonal psychotherapy (IPT) was originally developed as a treatment for patients with depression, but it has been modified for other clinical populations. It is a brief, focused therapy that targets problem resolution and symptom improvement within four social domains: grief, interpersonal role disputes, role transitions, and interpersonal deficits. Treatment occurs in three phases [81]:

Group Psychodynamic Interpersonal Psychotherapy

Group psychodynamic interpersonal psychotherapy (PIPT) differs from IPT in its de-emphasis of social roles (e.g., role disputes), with greater emphasis placed on present interactions among group members and the therapist. Group PIPT uses cyclical relational patterns and circumplex models (versus social roles) to understand interpersonal patterns. It also applies specific models to elucidate patient attachment needs, negative affect, and behavioral addiction as a coping mechanism [81].

Introduced in 1935, Alcoholics Anonymous (AA) is the original and best-known 12-step program. It was followed by Narcotics Anonymous (NA), introduced in the 1950s. Twelve-step programs constitute a specific form of group-mediated recovery from substance and behavioral addictions. They are member-led groups of people with similar addictions who are committed to helping each other—new members in particular—achieve and maintain sobriety. The 12 steps refer to a specific program of recovery. In a very brief description, members of a 12-step program come to understand their powerlessness in controlling the addiction; develop a relationship(s) with a power outside oneself (i.e., a sponsor [mentor], the 12-step group, a therapist, a Higher Power of their definition, or any combination) to best protect against relapse and ensure continued recovery; identify and work through character defects; amend past harms; and become useful to others struggling with addiction. Since the introduction of AA and NA, several 12-step programs have been adapted for specific behavioral addictions [76].

The exact mechanisms of 12-step group involvement that underlie their efficacy are multiple and difficult to disentangle. For example, admitting being powerless over the addiction could permit greater control over the addictive behavior through changes in decision-making processes. Social interactions likely influence efficacy through contact with similarly motivated peers with a shared goal and social norm of abstinence, and access to sponsors for guidance in developing skills for managing crises. Specific aspects may operate through different mechanisms; influences on decision-making and risk-taking behaviors may occur through 12-step meetings and discussions with sponsors [84].

Preliminary studies suggest that combining several therapeutic strategies may be more effective than a single approach. Such approaches may include CBT, cognitive bias modification, CET, and/or mindfulness-based stress reduction, delivered in group, individual, family therapy, or school-based formats, with different strategies complementing aspects of the others. Combining behavioral and pharmacologic therapies can also be considered.

Many disordered gamblers can trace the course of their disease to an early win, followed by increasing gambling frequency and expenditure. Even early wins of $100 to $500 can increase excitement about gambling, distort self-perceptions of skill or expected returns, and strengthen irrational beliefs about gambling (e.g., illusion of control) [112,113]. Many erroneous beliefs and inaccurate perceptions are rewarded, learned, or become habitual during disordered gambling, and several cognitive distortions are emblematic of gambling disorder, including [71,114]:

Therapies targeting erroneous cognitions, gambling urges, and motivations are effective. A meta-analysis of behavioral therapy outcomes in gambling disorder found an effect size of 2.01 at the end of treatment and 1.59 at follow-up (mean: 17 months). Efficacy seems to diminish over time, but the effect sizes were robust [84,115].

Cognitive-Behavioral Therapies

In the treatment of gambling disorder, cognitive therapy is based on the idea that gambling-related cognitive distortions contribute to disordered behavior. With this approach, the therapist helps patients identify and correct gambling-related cognitive distortions, with the goal of improving gambling abstinence by greater use of logical behavioral choices. One cognitive approach provides up to 20 weekly sessions until the patient stops gambling. Short-term outcomes show superior improvement relative to control groups. A frequent component is relapse prevention, which identifies high-risk situations for relapse and maladaptive beliefs related to control over gambling [113,116].

Behavioral therapies target gambling urges primarily with exposure-based therapies. Exposure therapy is based on classical conditioning paradigms, whereby gambling urges are eliminated through cue exposure with extinction processes. Exposure therapy is thought by some to be more beneficial in gambling disorder than other behavioral therapies, such as aversive therapy [71].

CBT focuses on changing gambling-related cognitions and behaviors; it is effective and improves treatment engagement and outcomes [114]. Brief, four- to six-session CBT interventions show some promise in problem and disordered gambling, but they require further evaluation in broader samples of treatment-seeking gamblers [113,117]. An eight-session CBT intervention for gambling disorder may follow the specific therapeutic focus outlined here [95,113]:

Variants of CBT have been adapted for patients with gambling disorder, with mixed results [118].

According to a Cochrane Review, cognitive-behavioral therapy (CBT) is effective in reducing gambling behavior and other symptoms of pathologic and problem gambling immediately following therapy. However, the durability of therapeutic gain is unknown.

(https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD008937.pub2/full Last Accessed: April 19, 2024)

Level of Evidence: Meta-Analysis

Functional analysis teaches patients with gambling disorder to identify triggers, related feelings, and resultant behaviors; examine the positive and negative consequences of their triggers; and identify cognitive biases, such as luck-related beliefs in their gambling behaviors [84]. The process of developing improved strategies to identify and manage triggers related to craving may increase PFC control over motivational drives involving subcortical brain regions [84]. Increased awareness and understanding of irrational cognitions, such as those related to luck, near-miss events, and chasing behaviors, may increase the balance in activity of brain circuits that code conflicting motivational states [84,119].

Skills training in CBT can include interpersonal skills and conflict resolution methods through role-playing and skills training. These skills are intended to help the person recognize that gambling may provide short-lived reward and enjoyment but problematic long-term consequences of debt, interpersonal conflicts, and/or legal system involvement. This type of intervention further addresses finance management and debt settlement—important concerns in gambling disorder [120].

Brief Motivational Interventions

Brief motivational intervention shows promise in reducing gambling when delivered alone or with other therapies. Brief motivational interventions are often directed at patients with subclinical diagnoses, defined as negative gambling-related consequences without meeting the criteria for gambling disorder. Brief motivational intervention is useful for engaging patients with poor problem recognition in further treatment or for spurring self-directed change. Therapy sessions focus on personalized feedback, brief advice, review of options (e.g., treatment options, change goals), and building self-efficacy, delivered in an empathic manner. In one study, telephone brief motivational intervention combined with a self-help workbook was effective in improving gambling outcomes in problem gamblers [121]. Single-session stand-alone motivational sessions are effective compared with assessment-only control groups [117]. Direct comparisons of motivational therapy and CBT suggest both interventions are equally effective compared with control groups [122].

Gambling Disorder and Comorbid Problem Drinking

Changes in alcohol use patterns during gambling treatment were examined in a study of 163 patients with gambling disorder followed 36 weeks pre-, during, and post-treatment. Overall, alcohol use was decreased during and after treatment, but 31% showed risky drinking during and after treatment. Latent risky drinking was predicted by recent at-risk drinking, male sex, younger age, lower gambling severity, treatment condition, and gambling during treatment. This greater-drinking profile suggested ambivalence about gambling changes during treatment, and those less motivated to change their gambling may be less motivated to reduce their alcohol use [123]. One study found that problem gamblers with co-occurring lifetime alcohol dependence demonstrate addictive behavior across multiple domains and resistance to externally motivated treatment approaches [124].

Treatment for patients with gambling disorder and comorbid risky alcohol use may differ from non-risky drinkers. Disordered gamblers with low-risk alcohol use tend to have positive outcomes with group CBT, while high-risk drinkers tend to respond better to motivational interviewing. Screens for alcohol problems, such as the Alcohol Use Disorders Identification Test (AUDIT), may be used to help guide treatment selection [125].

The most studied medication class in gambling disorder is SSRIs, but results have been mixed at best [85]. Based on possible efficacy in impulsivity treatment, several mood stabilizers have been evaluated in gambling disorder treatment. In one study, lithium was superior to placebo in reducing gambling symptoms during 10 weeks of treatment in patients with gambling disorder and bipolar spectrum disorders. However, olanzapine was found no more effective than placebo [85].

Opioid Receptor Antagonists

Multiple studies have demonstrated the efficacy of opioid receptor antagonists in the treatment of gambling disorder. Opioid antagonists dampen gambling-related excitement and cravings by decreasing dopamine neurotransmission in the nucleus accumbens and interconnected reward and motivational neurocircuitry [85].

In the initial study, naltrexone (mean dose: 188 mg/day) demonstrated superiority to placebo in reducing gambling-related behaviors, thoughts, and urges, and was particularly effective in gamblers with more severe gambling urges [126]. A second naltrexone study confirmed the findings of the initial study over a longer (18-week) period [127]. The efficacy of as-needed placebo or naltrexone (50 mg) and psychosocial support on reduction of gambling severity, gambling-related thoughts and urges, and gambling frequency and expenditures was assessed among 101 problem gamblers over 20 weeks [128]. Overall, the as-needed naltrexone provided no substantial benefit over psychosocial support.

Nalmefene is a long-acting analog of naltrexone administered by injection. Nalmefene efficacy was demonstrated in 207 subjects treated for 16 weeks, with significant reductions in gambling urges, thoughts, and behavior observed in 59% with nalmefene, compared with 34% with placebo [129]. A second nalmefene trial failed to show statistically significant differences from placebo [130]. Subsequent research found low-dose nalmefene significantly more effective than higher doses. Over 16 weeks, nalmefene (25 mg and 50 mg per day) led to significantly greater reductions in pathologic gambling severity than placebo. With nalmefene (25 mg/day), 59.2% of patients were rated as "much improved" or "very much improved," compared with 34.0% with placebo. Nalmefene at a dosage of 25 mg/day was effective and showed few adverse events, but 50-mg and 100-mg doses had intolerable side effects [131].

Catechol-O-Methyl-Transferase Inhibitors

Catechol-O-methyl-transferase (COMT) is an enzyme that degrades dopamine to regulate cognitive functioning in the PFC. As discussed, PFC-mediated cognitive dysfunction is implicated in the pathophysiology of gambling disorder, and a small uncontrolled study evaluated the COMT inhibitor tolcapone in 24 patients with gambling disorder who also received fMRI before and after treatment. Compared with controls, the subjects with gambling disorder showed underactivation during executive planning tasks pretreatment. Tolcapone was associated with statistically significant reductions on measures of pathologic gambling, the extent of which significantly correlated with increased activity in brain areas previously underactive during executive planning challenge [132].

Dopaminergic Modulators

Dopamine binding is positively correlated with gambling severity and impulsivity, and dopamine release in disordered gamblers is related to excitement and worsened behavioral performance. The dopamine-1 (D1) receptor antagonist ecopipam was evaluated in patients with gambling disorder when taken as needed for nine weeks. Compared with placebo, ecopipam led to statistically significant reductions in Yale-Brown Obsessive Compulsive Scale Modified for Pathological Gambling (PG-YBOCS) total score (25.6 baseline vs. 14.0 at study end) and subscales of thought-urge and behavior. Ecopipam may reduce pathologic gambling behavior [133].

Glutamate-Modulating Agents

Another promising area of pharmacotherapy in gambling disorder is glutamate-modulating agents. N-acetylcysteine (NAC), one such agent, was studied in subjects with gambling disorder over eight weeks; responders during open-label were then randomized to NAC or placebo for six weeks. In the open-label phase, 59% experienced significant symptom reductions and were classified as responders. At the end of the double-blind phase, 83% of those assigned to NAC remained responders (vs. 28.6% assigned to placebo) [134].

Cigarette smoking is highly prevalent in gambling disorder, and nicotine dependence is associated with greater gambling severity. Imaginal desensitization plus NAC was evaluated in patients with gambling disorder and nicotine dependence. After six weeks, subjects randomized to NAC or placebo both showed significant benefit from imaginal desensitization, but at three-month follow-up, NAC led to significant additional benefit in gambling severity reduction compared with placebo [135].

Other glutamate agents, such as topiramate, have not shown benefit [85].

Founded in the 1950s, Gamblers Anonymous (GA) is a mutual help fellowship based on the 12-step program of AA. With meetings in most North American communities, GA is established worldwide as a resource for people struggling with gambling problems. GA groups are peer-led and abstinence-focused and represent the most widely available option for recovery from gambling disorder [136]. Some GA meetings welcome family and friends to attend "open meetings," recognizing the impact of disordered gambling often extends far beyond the patient and that support from non-gambling family and friends can be integral to recovery. Local groups can be found online at http://www.gamblersanonymous.org/ga/content/about-us [113].

GA has a unique culture of recovery, distinct from AA and NA in specific areas. For example, GA recognizes that for many new members, addressing the crippling financial consequences is vitally important for their recovery. Senior members who confronted and resolved their own financial consequences guide and support the new members through these challenges [136].

GA members tend to have more severe gambling symptoms, are more motivated for treatment, and have greater involvement with professional gambling treatment. GA involvement is positively associated with abstinence and improvements in abstinence, and with increased readiness for change, adaptive coping skills, and higher leisure activity involvement [136].

GA can be used alone or combined with other interventions. Individuals who engage in GA and professional treatment have better gambling outcomes than those who receive professional care alone. GA is also a valuable resource if remitted gambling problems recur in the future [34].

The potentially severe consequences of gambling disorder elevate the need to identify factors that support gambling abstinence. In a study of GA members, the greatest predictors of gambling abstinence were participation and involvement in GA, support from family and friends, and connections with other GA members. Relapse was strongly predicted by high gambling urges and erroneous gambling cognitions [93]. Of note, GA meeting attendance may be helpful, but involvement with GA meetings and members carried the greatest protection from relapse. GA and CBT are the two most widely used approaches for gambling disorder. A review of published evidence concluded that combining GA and CBT may enhance therapy engagement and reduce relapse risk [120].

In one of few Internet pornography addiction studies involving women, Internet pornography users rated pornographic images as more arousing and reported greater craving for sex than non-users. Craving, sexual arousal, sensitivity to sexual excitation, problematic sexual behavior, and severity of psychological symptoms were predictors of Internet pornography addiction. In contrast, current relationship status, number of sexual contacts, satisfaction with sexual contacts, and use of interactive cybersex were not associated with addiction. The reinforcing nature of sexual arousal, learning mechanisms, and cue reactivity and craving in the development of Internet pornography addiction in women were found consistent with those reported in heterosexual men [148].

In a large community survey, 51% of women and 90% of men reported using Internet pornography. Internet pornography use was associated with sexual dissatisfaction from perceived addiction (perceived compulsivity, effort to access, distress from pornography use) and sexual function problems (sexual dysfunction, compulsion, avoidance). This pattern held for men and women [149].

Growing in popularity and market share, geo-locating social media gives users the ability to find each other for casual sexual encounters ("hook-ups"). Unlike standard online dating apps, location-matching apps typically do not require users to create a profile about themselves; instead, users upload one or more photos. The simplicity of appearance-based selection and proximity accounts for the increasing growth in popularity of location-based dating apps. One of the first such apps, Grindr, was introduced in 2008 specifically for gay and bisexual males, followed by other apps for gay men, lesbians, and heterosexuals (Tinder, Bumble, and others) [141,150].

High-speed broadband Internet access became widely available in the early 2000s. Until the early to mid-2000s, erectile dysfunction (ED) prevalence in sexually active men younger than 40 years of age was low, consistently 2% to 4%. In contrast, studies conducted since 2005 show sharply increased prevalence of ED and low sexual desire in men younger than 40 years of age [151]. For example, new ED diagnoses in active-duty servicemen doubled from 2004 to 2013 [152]. In 2014, 53.5% of men 16 to 21 years of age had symptoms of sexual dysfunction, including ED (26%), low sexual desire (24%), and problems with orgasm (11%) [153]. In 2016, a study of persons 16 to 21 years of age followed over two years found persistent problems in boys/men of low sexual satisfaction (47.9%), low desire (46.2%), and ED (45.3%). Over time, sexual problems declined in women but not men [154]. A 2015 study found ED with low desire for partnered sex was common in men (mean age: 36 years) seeking help for Internet pornography use with excessive masturbation [155].

ED in men younger than 40 years of age is typically diagnosed as psychogenic and linked to stress, depression, generalized anxiety, or performance anxiety. Organic ED, diagnosed in 15% to 20% of cases, is linked to neurologic, hormonal, or anatomic conditions or drug side effects. ED in older men is more often diagnosed as organic, associated with smoking, alcohol use, diabetes, obesity, hypertension, or cardiovascular disease [156]. None of the known correlative factors of psychogenic ED adequately account for the rapid increase in youthful sexual dysfunction. The historical correlates of organic ED in older men have not changed proportionately, or have decreased, in younger men over the past 20 years [151,157].

High-speed, broadband Internet pornography is substantially more sexually arousing than other forms of pornography or fantasy and may become more immersive with three-dimensional technology. Novel sexual visuals trigger greater arousal, faster ejaculation, and more semen and erection activity than familiar visuals; arousal is further increased by ability to self-select material with ease. As an amplified mimic of stimuli with evolutionary salience that human brains have evolved to pursue, Internet pornography is a supernormal stimulus and unique activator of reward, impulsivity, and for some, addiction [151,162,163].

Reward system vulnerability to pathologic learning can make Internet pornography use self-reinforcing. The neural substrates of sexual learning and addiction overlap. Development of addictive Internet pornography use promotes neuroplastic change. The mesolimbic dopamine system receives glutamate inputs from cortical and limbic regions. Glutamate synapses associated with seeking and obtaining a specific reward become altered, enhancing mesolimbic dopamine system response to the specific reward. With the mesolimbic dopamine system sensitized to sexual reward, hyper-reactivity develops to Internet pornography cues [151,163,164].

Reward system hyper-reactivity to Internet pornography cues develops concurrently with hypo-reactivity and down-regulation of response to natural rewards (i.e., partnered sex) [165]. Persons with addictive Internet pornography use show strong preferences for, but rapid habituation to, novel sexual images. This often fuels the search for even more novel sexual images and escalation to hardcore and extreme pornography, indicating decreased reward sensitivity, increased habituation and tolerance, and greater stimulation needed for sexual arousal [151,163,164].

Addictive Internet pornography use is correlated with lower functional connectivity between the striatum and the PFC. Dysfunction in this circuitry is linked to behavioral choices that disregard potentially negative outcomes, including reduced executive control function during exposure to pornographic images [151,166,167,168].

Sexual arousal conditioned to Internet pornography cues promotes sexual dysfunction [159]. Users crave the high levels of novelty, intensity, and arousal of Internet pornography that are difficult to sustain in partnered sex. When high stimulation expectations and requirements are not met, partnered sexual stimulation is ineffective. In some users, a preference for novelty arises from the need to overcome declining libido and erectile function, leading to conditioned preferences for Internet pornography use [169,170].

Pornography use is inversely related to satisfaction with partners, as measured by affection, physical appearance, sexual curiosity, and sexual performance [171]. The caudate is involved in approach-attachment behaviors and motivational states associated with romantic love [172]. Putamen activation is associated with sexual arousal and penile tumescence [173]. Users of more extensive Internet pornography show smaller right caudate and lower putamen activation when viewing sexually explicit still photos. This reflects down-regulation of natural neural response to sexual stimuli from intense, prolonged exposure to pornographic stimuli [174]. Men with greater use of degrading or extreme pornography report more frequent concerns of sexual performance, penis size, and ability to maintain an erection (compared with moderate or non-users) [151,175].

Early sexual conditioning impacts sexual arousal templates. A critical developmental period of sexual behavior forms around initial experiences with sexual arousal and desire, masturbation, intercourse, and orgasm. Younger age of onset for regular Internet pornography use and greater preference for pornography over partnered sex is associated with persistence of this pattern. In 2014, nearly 50% of college-age men reported they were first exposed to Internet pornography before 13 years of age, compared with 14% in 2008 [176,177]. Young adults with addictive Internet pornography use show greater impairments in sexual arousal and erectile function in intimate relationships, but not with pornographic material.

A simple assessment for Internet pornography-related sexual dysfunction is asking the patient whether he can achieve a satisfactory erection and climax when masturbating without Internet pornography. If he cannot, but can easily achieve these goals with Internet pornography, then his sexual dysfunction may be associated with its use. Healthcare providers should also screen for relationship problems, low self-esteem, depression, anxiety, post-traumatic stress disorder, stress, and other mental health problems, but should avoid assuming a psychological cause of otherwise unexplained sexual dysfunction in men younger than 40 years of age. The relationship between psychosocial factors and sexual dysfunction in younger men may be bidirectional and co-occurring or Internet pornography-induced [151].

The first step in the treatment begins with accurate diagnosis that rules out medical causes of hypersexuality. Neurologic disorders associated with hypersexual behavior include Alzheimer disease (4.3% to 9% of these patients experience sexual disinhibition as a result of disease effects on the frontal and temporal lobes), frontotemporal degeneration (associated with impaired regulation of socially acceptable behaviors), and Kleine-Levin syndrome (causes hypersomnia that may lead to abnormal behavior, such as hypersexuality). Some medications or illicit drugs can elevate sexual drive, such as cocaine, methamphetamine, and dopamine agonists used in Parkinson disease [140,179,180].

In patients seeking help for problematic sexual behavior, clinicians are repeatedly recommended to use a patient-tailored, multimodality approach, but there is little published guidance for matching clinical presentation with treatment options. Thus, a group of prominent sexual disorder researchers and clinicians developed a hypersexuality typology that links clinical profile and symptom clusters to suggested treatments. Diverse hypersexual behavioral patterns suggest they may be unrelated phenomena; assumed commonality is erroneous [138].

Paraphilic Hypersexuality

The paraphilic hypersexuality subtype has key features of paraphilic interests and a high frequency of one or more hypersexuality behaviors. Many of these patients lack the strong, internal directedness most men have in their sexual interest(s). Instead, they tend to test out or go along with partners' sexual interests. Interactions with sex workers are based on sex, and for many, a desire to become a part of the sex worker milieu [138].

Paraphilic hypersexuality is remarkable for the sizeable number reporting gynandromorphophilia, a rarely discussed erotic interest in persons with both male and female anatomy (usually full breasts and intact penis) typified by incompletely transitioned male-to-female transgender women. For many, this specific enduring erotic interest leads to confusion over sexual orientation or gender identity and hesitant self-reference as ''mostly heterosexual'' or as bisexual [138].

This clinical characterization of gynandromorphophilia risks pathologizing attraction to transgender women and the women themselves. Care should be taken to avoid doing so in practice settings. Methods to change paraphilic interests into euphilic attraction have no evidence or support. Treatment suggestions include integration of interests that can be expressed alone or with consenting partners, and harm reduction for those interests that cannot. Medication may be highly relevant. SSRIs can reduce libido and impulsivity, but can also delay or prevent ejaculation and lead to seeking greater stimulation sufficient to trigger orgasm [138,184].

Avoidant Masturbation

The primary presenting complaint in patients with avoidant masturbation is the extreme time spent masturbating to pornography. These patients report masturbating many hours daily, job termination from online pornography or masturbation at work, academic failure, and social relationships and other important activities abandoned in favor of masturbation. Paraphilic interests are rare [138].

Many of these patients acknowledge masturbating to avoid tasks or chores. Anxiety or dysthymia are common; masturbation is the cause of, or the coping skill for, negative emotions. Avoidant masturbation does not always interfere with relationship satisfaction or sexual activity, but many have little interest in partnered sex and prefer masturbating to pornography [138].

Avoidance and procrastination motives drive the masturbation. In the gay male community, avoidance may be expressed as excessive time frequenting bathhouses, perusing online hook-up sites, or engaging in anonymous sex with large numbers of partners. With avoidance motivation, treatment is more productive when it addresses avoidance and procrastination instead of masturbation. Motivational interviewing can be very beneficial [138].

Chronic Adultery

In clinical settings, patients with chronic adultery are almost always male and outliers in the frequency of extramarital sexual activities involving one-time hook-ups, on-going relationships, or sex workers. Extreme time involvement seeking or engaging in sex is usually absent [138].

Chronic adulterers frequently state their wives or partners have a condition or history that inhibits sexual enjoyment, such as coital pain disorders (i.e., dyspareunia), low libido, sexual abuse history, or conservative/religious backgrounds. When partners present for therapy, their histories and libido levels usually match their husband's description. Patients may seek treatment motivated by secondary gains from appearing sincere about changing their behavior, without an actual desire to change. In practice, this is less common than assumed; chronic adulterers are generally motivated to change by the time they present for help [138].

Marital distress may be a consequence of most other hypersexuality subtypes, but it is antecedent to chronic adulterer behaviors. While couples therapy is strongly indicated, because many marital issues are unresolvable without partner engagement, spouses often instruct the chronic adulterer to go fix his problem and are unwilling to participate. Mismatching atypically high and low sex drives often predate the marriage; the sex drive discrepancy goes unaddressed, and the high libido is chronically expressed outside the marriage. Demanding the adulterer fix his problem in therapy also serves to distract from or excuse unaddressed issues of the spouse [138].

Sexual Guilt

Patients with sexual guilt self-label as hypersexual or sex addicted and express intense distress, but lack evidence of sexual behavior that exceeds peer group norms. Highly conservative (usually religious) family environments are typically reported; some willfully adopt moralistic standards in adulthood that exceed the dictates of their religious.

Initially presenting with hypersexuality complaints, further assessment will identify sexual guilt and broadly expressed anxiety over sexual urges or interests. Among these patients are androphilic men who reject or resist their sexual orientation and seek treatment for their perception of addiction or compulsion to have sex with men. Psychoeducation and permission-giving is beneficial, and several therapy approaches can address inaccurate beliefs about sexuality and peer norms. These beliefs may reflect explicit religious involvement or other deeply held ideologies, such as gender roles.

The Designated Patient

Romantic partners of designated patients demand they get help and instigate sex disorder clinical assessments. These demands may reflect highly restrictive sexual beliefs with zero-tolerance for masturbation, pornography, or non-procreative sex. Designated patients may self-label as sex addicts (or a similar term) but lack the sexual behavioral patterns. These patients state their partners explicitly believe the problem is theirs to solve. Designated patients are best helped by including the partner in psychoeducation on healthy masturbation and pornography use and communication and assertiveness training. Sex-positive clinicians quickly see partner demands as unnecessarily restrictive. Some patients know this, but agree to the restrictions for the benefit of the relationship.

Better Accounted for as a Symptom of Another Condition

Hypersexuality can be a symptom or sequelae of several non-sexual diagnoses, including some personality disorders, hypomania, developmental delay, disinhibiting brain injuries, neurologic disease, and medication side effects. Borderline personality disorder is the most common associated syndrome and can present as any hypersexuality subtype. In general, personality disorders are distinguished from hypersexualities by the presence of other personality disorder symptoms and not by differences in sexual behaviors.

Cognitive-Behavioral Therapy

CBT can help the patient identify and work through triggers of sexually addictive behavior, permission-giving thoughts that weaken inhibition of the behavior, and the negative consequences of the behavior. Specific CBT approaches have been modified to treat sexually addictive behavior [185,186].

Motivational Interviewing

Motivational interviewing serves to help the patient consider the pros and cons of maintaining the addiction in the context of their overall goals and priorities [187]. Motivational interviewing is less focused on actual behavior change than on bolstering motivation to enter the change process. Advantages of motivational interviewing include the non-confrontational and nondirective nature, which can be more effective in those with low motivation to change [76].

Psychodynamic Therapy

Psychodynamic therapy has relatively few published clinical studies in sexual addiction treatment, but it appears to offer unique advantages [186]. Specifically, psychodynamic treatment can address the factors related to the individual's unique personal history and personality organization and can clarify the specific meaning the addictive behavior holds for the patient. For instance, sexual addiction can reflect a rebellion against a puritanical and authoritarian parent; a form of self-soothing in the context of parental abandonment; a narcissistic need for constant affirmation of one's attractiveness; or a desperate attempt to stave off feelings of emptiness. In most cases, sexually addictive behavior is thought to reflect a disturbance in the core self-concept and/or the capacity for intimate relationships [76].

Psychodynamic psychotherapists recognize the inherent human need for close intimate relationships to help regulate negative and positive emotions, and how this need must be reconciled with feeling dependent on people who remain, in large part, outside of one's control [188,189]. For those with less ability or an inability to tolerate this dilemma, often resulting from maladaptive early attachment, an addictive object can provide a convenient end-run around the vulnerability and relative powerlessness inherent in intimate relationships. In this way, sexually addictive behavior can serve as a transitional object [76].

According to psychodynamic theory, sexually addictive behavior serves as a self-soothing and emotionally regulating "other" that remains under the individual's near-total control. The sexual partners in sexually addictive behavior are rarely experienced as "subjects"—three-dimensional people who can make an emotional impact on the sexually addicted individual outside of his or her control. Instead, they are fleeting "objects," used to gratify an urge and then discarded. Paradoxically, by insisting on total control over the attachment object, the sexually addicted individual loses control and ends up controlled by their addiction. Psychodynamic therapy can help the patient to understand how these dynamics play out in his or her life and to subsequently develop healthier relational patterns [76].

Group Psychotherapy

Group psychotherapy can be highly effective in the treatment of substance and behavioral addictions and, in some cases, is more effective than individual therapy alone [186]. Group therapy serves multiple purposes and probably works through a combination of mechanisms. It provides social support during the difficult change process, information about other group members' experiences and coping strategies, support for a positive new group identity, and confrontation of the denial and rationalizations associated with sexually addictive behavior [76]. Group therapy helps individuals feel less isolated and reduces feelings of shame [145].

Couples Therapy

Due to the negative impact of sex addiction on intimate relationships, couples therapy may offer both the patient and their partner guidance on dealing with this disorder [140].

Few pharmacotherapy studies in sex addiction have been published. The research that has been published focuses on male patients. Clinical experience indicates close monitoring is needed in treating compulsive sexual behavior, as some individuals may increase risky sexual behavior to compensate for the dampening effects of medication on sex drive [85].

In a study of gay and bisexual men with complaints of compulsive sexual behaviors, 12 weeks of citalopram led to greater reductions in desire for sex, frequency of masturbation, and hours of pornography use per week compared with placebo. However, the number of sexual partners during treatment did not differ [190].

Naltrexone was evaluated over eight weeks in non-addicted, methamphetamine-using, binge-drinking men who have sex with men at high risk for HIV. Naltrexone led to significantly greater reductions in overall and condom-less receptive anal intercourse than placebo. Among frequent methamphetamine users, naltrexone led to greater reductions in methamphetamine-using days. Higher naltrexone adherence also led to greater reductions in binge drinking days [191].

The importance of close patient monitoring is underscored by a case report of three heterosexual men (24 to 35 years of age) who developed new-onset problematic sex behaviors during paroxetine (an SSRI) treatment for pathologic pornography use and masturbation. After 10 weeks of paroxetine, all showed marked reductions in anxiety and pathologic pornography use and masturbation and return of normal sexual function. However, by three months, all had new-onset sexual behaviors; none had histories of risky sexual behaviors, affairs, paying for sex, or mania/hypomania symptoms during treatment [192]. Two were in long-term relationships (one married); one was single. All described pride in overcoming inhibitions to take sexual risks with success and felt strongly motivated to continue. Both patients in relationships felt guilt but also elation over new sexual frontiers as both had remained with their first and only sex partner. None wanted to phase-out paid sexual services by increasing pornography and masturbation, which they described as isolating, time-consuming, and humiliating [192].

In this study, the authors explain that an imbalance in reward reactivity and threat reactivity promoted sexual risk-taking; problematic behaviors resulted from increased impulsivity or increased anxiety [192,193]. All three patients regulated their high pretreatment anxiety levels with pathologic pornography use and masturbation. Paroxetine helped decrease amygdala reactivity, which decreased anxiety and subsequently decreased pathologic pornography use and masturbation, with new compulsive sexual behaviors potentially emerging from diminished anxiety [192].

When sexually disordered behavior presents a grave risk to the individual or society, such as persistent uncontrolled pedophilia, anti-androgen therapy has been effective for drastically reducing sexual drive. The side effects with this drug class are notable, and such medications are rarely used outside of serious circumstances in a forensic context [76].

Sex Addicts Anonymous (SAA) is a support group with a purpose of helping others with sex addiction find recovery. This organization operates similarly to AA and uses the 12-step program of recovery. Another 12-step program is Sex and Love Addicts Anonymous (SLAA) [140]. Most SAA, SLAA, and Sexual Recovery Anonymous ("S" meetings) groups admit new members only after screening and approval by the group members. Meetings focus on the goal of helping the new member stop or control his/her pathologic sexual behavior and learn new coping strategies. "S" meeting groups can play an important role in the recovery of patients by helping them become honest with themselves and their families in an atmosphere of support and fellowship [137].

MMORPGs are played online by thousands of gamers simultaneously, spanning vast time zone differences without spatial or temporal boundaries. The design of MMORPGs borrows from operant conditioning, incorporating random, unpredictable reward structures to maximize player engagement and time involvement. The same intermittent schedule of rewards is featured in slot machines and other gambling modes [194].

In MMORPGs, players assume the role of a fictional character and take control of that character's actions while simultaneously interacting with other gamers in a shared, virtual world. This virtual world persists independently of the players; events and interactions between other players continue when one player goes offline [8]. To advance, the player's character acquires new powers, skills, special weapons, or currency as rewards for succeeding in a mission or special quest. Online social interactions occur among players in-game or by regrouping into clans (guilds), a persistent, virtual hierarchical social network of characters with shared backgrounds and objectives [8]. The aspects of a permanent world, reinforcement schedule, and online social interaction contribute to the addictive potential of MMORPGs [196].

The uniquely problematic potential of MMORPGs is under-recognized. A 2016 report stated that only 36.7% of surveyed Canadian psychiatrists believed there was an association between psychopathology and MMORPG engagement [197].

First-person shooter (FPS) is an action game genre and differs markedly from MMORPGs. Players engage in combat with enemies, primarily using firearms. The shoot-to-kill style of FPS games is considered highly arousing and violent, but little research has studied Internet gaming disorder in excessive FPS players [195].

Real-time strategy games are strategic, combat-orientated games that often use forms of strategic simulation. In real-time strategy game matches, strategic decision-making ability directly influences the results and scores. For example, a gamer might hold a combat commander position that requires use of multiple strategies to take over an enemy fortress [195].

Other game genres include arcade games, online sports games, casual games, and other action games [195]. These games are rarely associated with Internet gaming disorder.

Social anxiety is lowest in FPS gamers. FPS players control the game character from a first-person view, making self-confidence crucial for high scores and engagement in competition. Most online FPS players do not play in isolation, and social interaction motivation highly predicts FPS time involvement. FPS players are drawn to competition and challenge [201]. The highly immersive nature and potential for online competition, achievements, and social interaction can reinforce excessive FPS involvement. Social-seeking behavior is inversely related to social anxiety and avoidance [195].

Among the four genre groups, self-esteem was highest in the real-time strategy group, suggesting that the strategic simulation information tasks are more rewarding in gamers with stronger self-esteem. Real-time strategy involves many challenging tasks requiring rapid switching, multiple information sources, and multiple actions for which substantial cognitive flexibility is needed [202]. Successful players must cope with simultaneous and rapidly evolving game situations in real-time, while managing funds, resources, and information concerning their opponent. When managing multiple, simultaneous game strategies, self-esteem can have a decisive effect on judgment and decision-making by reducing gamer anxiety and enhancing performance. Compared to MMORPG players, the lower social anxiety and avoidance scores of real-time strategy players may be related to higher self-esteem. Thus, relatively high self-esteem and low social anxiety and avoidance are the main characteristics in the real-time strategy group [195].

Compared to the other three genres, players of arcade, online sports, and casual games had higher depression scores, with Beck Depression Inventory scores showing "moderate depression," compared with "mild depression" average scores in the other three groups. Games in this category are relatively simple in design and low in complexity, and this game preference is probably motivated by wanting a less challenging game, possibly influenced by the presence of low volition or energy, impaired concentration, or depressed mood [195].

Numerous studies indicate that, for a player subgroup, excessive online gaming can lead to diverse negative psychosocial consequences, including sacrificing work, education, hobbies, socializing, time with partner/family, and sleep, as well as increased stress, absence of real-life relationships, lower psychosocial well-being, loneliness, worse social skills, decreased academic achievement, increased inattention, aggressive/oppositional behavior and hostility, maladaptive coping, decreases in verbal memory performance, maladaptive cognitions, and suicidal ideation [17].

One study evaluated children enrolled in grades 3 to 8 over two years. Higher Internet game involvement, lower social competence, and greater impulsivity were risk factors for developing Internet gaming disorder, while depression, anxiety, social phobia, and declining academic performance were outcomes of Internet gaming disorder. The prevalence rate of Internet gaming disorder was 9%. The authors concluded that Internet gaming disorder can develop without premorbid disorders and persist for years in young Internet gamers [209].

When considering the applicability of cross-cultural epidemiology and risk factors in Internet gaming disorder, cultural differences in attitudes towards Internet use in East Asia and elsewhere should be noted. For instance, parents in East Asia tend to pathologize behaviors that interfere with family or educational pursuits, possibly inflating Internet gaming disorder prevalence rates in Taiwan and South Korea [210]. Individuals who appear addicted to using social media and social networking sites are often engaged online to psychologically compensate for the lack of offline social rewards [15].

Significant predictors of pathologic gaming among adult MMORPG players include expressing "true self" in game, higher levels of social anxiety, larger numbers of in-game social supports, and fewer supportive offline relationships. The number of in-game supports was significantly associated with time spent playing [211].

CBT that addresses specific gaming-related cognitions in Internet gaming disorder may have greater benefit than general approaches that solely address "preoccupation with gaming" (a DSM-5-TR criterion for Internet gaming disorder). Maladaptive cognitions associated with Internet gaming disorder have been identified in cross-sectional studies, but the extent to which these cognitions predict future pathologic gaming behavior requires longitudinal data. In 465 Internet gamers (84% male, mean age: 26.2 years) followed over 12 months, those who developed Internet gaming disorder had significantly higher baseline scores in perfectionism, cognitive salience, and guilt compared with gamers remaining non-problematic. Pathologic gamers who successfully transitioned to being non-problematic gamers had lower baseline perfectionism scores compared with those whose use remained problematic. Cognitive changes accounted for 28% of variance in scores beyond contributions from gender, age, and gaming frequency. Maladaptive gaming-related cognitions could be assessed to better inform treatment targets for CBT [212].

Specific achievement- and immersion-related motives have been identified as strong predictors of problematic online gaming, addiction symptoms, and adverse impact on daily life. Of these motives, problematic use was consistently associated with "advancement" (e.g., the desire to gain power, progress rapidly, accumulate in-game symbols of wealth or status) and "mechanics" (i.e., interest in the rules and system to optimize performance). Immersion-related motives highlighted "escapism." Escapers are motivated by immersion in a virtual reality instead of by reaching game-specific objectives; the game is a dissociative method to escape offline thoughts and problems. Social-related motives (e.g., playing to meet people, teamwork) were unrelated to problematic use [8].

Internet gaming disorder is linked to impulsivity and poor self-regulation, supported by the multidimensional UPPS-P model of impulsivity that describes impulsivity as five related but specific dimensions [213]:

Many studies highlight the strong links between these impulsivity factors and psychiatric disorders such as substance use disorders, gambling disorder, compulsive buying, suicidal ideation/attempts, and aggressive behaviors.

The "urgency" subtype of impulsivity may predict pathologic MMORPG use. Urgency, poor premeditation, and poor perseverance impede the executive functioning required for self-control, inhibitory control, decision-making ability, and resistance to cognitive interference [8].

Internet gaming disorder symptom severity may be highly relevant in adolescents 16 to 18 years of age, which precedes the age of highest Internet use (18 to 24 years). In one study, individuals more hostile at 18 years of age continued MMORPG involvement with higher Internet gaming disorder symptom severity after two years. These results agree with other longitudinal studies that show stability in addictive behavior during adolescence and onset of Internet gaming disorder coinciding with increased real-life problems [209,214]. In contrast, Internet gaming disorder is more transient in adults; this disparity may reflect age-related differences in the progression of addiction [205,215].

Among 3,041 adult recent Internet gamers (60% male), 13.8% met DMS-5 criteria for Internet gaming disorder. Compared with healthy gamers, the Internet gaming disorder group used gaming significantly more often to escape reality and specific issues or as a coping mechanism. They also scored significantly higher on measures of obsession-compulsion, depression, somatization symptoms, interpersonal sensitivity, and impulsivity. Adults with Internet gaming disorder experienced more frequent difficulty in concentrating, loneliness, and insomnia, and were five times more likely to attempt suicide and exhibit aggression. Unlike youth with Internet gaming disorder, no game genre was dominant in adult Internet gaming disorder [216].

Internet gaming disorder-related cognition is more complex than "preoccupation." The primary underlying cognitive factors in Internet gaming disorder (and therapeutic targets for CBT) include [217,218]:

In a study of adolescents, those with Internet gaming disorder reported significantly more maladaptive gaming beliefs than non-disordered respondents. The association between gaming cognitions and Internet gaming disorder symptoms was very large and independent of gaming activity and psychological distress. The distinct problematic cognitions of adolescents with Internet gaming disorder should be addressed in any therapeutic intervention [219].

In the published research to date, psychological treatment is the dominant modality for Internet gaming disorder, with CBTs the most-studied.

Cognitive-Behavioral Therapies

As discussed, maladaptive cognitions are a core feature of Internet gaming disorder and include self-regulation deficits, preference for a virtual life, cognitive bias, impaired cognitive control abilities, cognitive deficits, poor cognitive error processing, and decision-making deficits [204]. CBT addresses these cognitions and is the most widely used psychological treatment for Internet gaming disorder. The first stage of CBT treatment for Internet gaming disorder deals with the behavioral aspects of addicted gaming, and subsequent stages gradually shift the focus toward the development of positive cognitive assumptions. During therapy, addicted gamers identify false beliefs and learn how to modify them into more adaptive ones. CBT also trains patients to monitor their thoughts and to identify affective and situational triggers associated with their addictive gaming behavior [204].

In the treatment of Internet gaming disorder, CBT typically involves 8 to 28 sessions that address psychoeducation, problem identification, healthy communication, Internet awareness, and cessation techniques. Treatment of Internet gaming disorder may also include short-term therapy, group therapy, and systemic therapy with parents/teachers/peer support and multilevel interventions that incorporate motivational interviewing [204].

Although CBT has some efficacy in Internet gaming disorder, the results do not appear to differ from other non-specialized psychological treatments for Internet gaming disorder [225]. One study found that combinations of CBT and medications showed an advantage over monotherapies [226]. To improve patient response and clinical outcomes with standard psychological approaches, therapy modalities have been developed that target the cognitive pathologies and underlying neural substrates specific to Internet gaming disorder [227].

Motivational Enhancement Therapy/CBT

CBT is combined with motivational enhancement therapy (MET/CBT) to move patients from ambivalence to engagement concerning behavioral change. MET/CBT is structured by stages:

MET/CBT has led to decreased symptoms and improved school performance in Internet gaming disorder [204,228].

Craving Behavioral Intervention

Based on cognitive neuroscience and behavioral addiction research, craving behavioral intervention was developed for patients with Internet gaming disorder to reduce cravings and enhance coping skills, which may improve therapeutic outcomes and prevent relapse. Craving behavioral intervention is conducted weekly in a group format with eight to nine participants. Topics for each weekly session include [63]:

Short-Term Treatment of Internet and Computer Game Addiction

Short-term treatment of Internet and computer game addiction (STICA) is a disorder-specific, CBT-based, individual and group treatment lasting three months. The STICA treatment protocol and focus of treatment sessions is organized into three phases [229]. In the early phase, the focus is on patient education on the mechanisms and effects of Internet gaming disorder (e.g., learning theories, development and consequences of Internet gaming disorder, the vicious cycle of addiction). Interventions promote social communication and bonding in the therapy setting. In the middle phase, patients are taught to identify triggers of dysfunctional Internet use (e.g., emotional states, maladaptive cognitions, daily stress) by keeping diaries. A functional analysis of addictive behavior is done, with the goal of enabling functional computer and Internet use by appropriate problem-solving strategies. Patients establish an in-person social network and build a repertoire of alternative activities. Sessions may include exposition training (i.e., confronting and deleting access to critical genre elements, such as the self-created avatar) and skills training (e.g., coping with stress and problems, social skills, building alternative activities) [229]. The last phase is termination and relapse prevention. During this phase, treatment tools are transferred to daily life, including functional computer/Internet use. Relapse prevention tools are provided and practiced.

The efficacy and stability of outcomes following STICA are under evaluation. Early results indicate that nearly 70% of initially enrolled patients completed the three-month treatment, with six-month follow-up showing significant decreases in Internet use, online time, and psychiatric symptomatology [230,231].

Few pharmacotherapy studies have been published in Internet gaming disorder. In one study, adolescents and adults with Internet gaming disorder were randomized to bupropion sustained-release, escitalopram, or a no-treatment control group. After six weeks of therapy, bupropion and escitalopram significantly improved all clinical symptom scores compared with controls. Bupropion led to greater improvements than escitalopram in Internet addiction severity, depression, ADHD, behavioral inhibition and activation, and global functioning. Bupropion and escitalopram were effective in reducing Internet gaming disorder symptoms, but bupropion was more effective in improving attention and impulsivity, important in the management of Internet gaming disorder [232].

Eleven patients with Internet gaming disorder received bupropion treatment for six weeks. Pretreatment MRI imaging showed higher brain activation in the left occipital cuneus, left dorsolateral PFC, and left parahippocampal gyrus compared with healthy controls. After six weeks of bupropion treatment, craving for Internet gaming and cue-induced brain activity in the dorsolateral PFC decreased from pretreatment in patients with Internet gaming disorder [233].

Atomoxetine and methylphenidate were compared in 86 adolescents with Internet gaming disorder and ADHD. After 12 weeks of treatment, both atomoxetine and methylphenidate reduced symptom severity; this reduction correlated with reductions in impulsivity. These results suggest impulsivity may contribute to the development of Internet gaming disorder [170].

A systematic review found that a wide array of pharmacologic treatments (e.g., bupropion, methylphenidate, SSRIs) may be efficacious for treatment of Internet gaming disorder. Across all the clinical trials included in the review, symptom reductions following the administration of pharmacologic treatments ranged from 15.4% to 51.4% [234].

Cognitive-Behavioral Therapy

Therapy variants in binge eating disorder include CBT combined with body image exposure or cognitive restructuring components, and ecologic momentary assessment to increase self-monitoring adherence [81,259,262]. A meta-analysis of studies that randomized patients to CBT or non-treatment (control) found improved binge frequency and abstinence outcomes with therapist-led, partially therapist-led, structured self-help, and guided self-help CBT. Therapist-led CBT outcomes were compelling, with a higher rate of abstinence (59% CBT vs. 11% control), reduction of binge episodes, reduced patient hunger and eating concerns, and improved sense of control over eating. Guided self-help CBT reduced global eating-related psychopathology. When all study results were pooled, CBT and control groups were similar in weight lost and depressive symptom reductions. Therapist-led CBT was much more effective in improving key behavioral and eating-specific psychological domains [81].

In a separate study, patients with clinical or subclinical binge eating disorder were randomized to individual or group CBT. Significant reductions in binge eating frequency and mild weight reduction were shown in both CBT formats at three-year follow-up. Predictors of full, long-term recovery were absence of treatment history with amphetamine derivatives, lower emotional eating, and lower pretreatment binge eating severity. Low emotional eating was the only predictor of weight reduction. Predictors of treatment resistance included overweight in childhood, full binge eating disorder diagnosis, and high prevalence of emotional eating [263].

The American Psychiatric Association recommends that patients with binge-eating disorder be treated with eating disorder-focused CBT or interpersonal therapy, either in individual or group formats. Patients with binge eating disorder who prefer treatment with medication or who have not responded to psychotherapy alone may be treated either with an antidepressant or lisdexamfetamine [364].

Interpersonal Psychotherapy

Patients with binge eating disorder receiving therapist-led CBT and IPT showed differing abstinence trajectories at 46-month follow-up. Patients receiving CBT had high initial abstinence (81%) at the end of treatment, declining to 52% at final follow-up. Patients undergoing IPT had lower post-treatment abstinence (64%), but this increased (to 77%) by last follow-up [264].

Group Psychodynamic Interpersonal Psychotherapy

Compared with patients on a wait list, patients receiving 16 weekly group PIPT sessions showed greater binge frequency reductions (-0.5 vs. -3.0 binge days per week) and greater binge-eating abstinence (9.1% vs. 59.5%) [265]. Group PIPT also led to greater improvements in dietary restraint, depression, and interpersonal problems, but it did not differ from controls in BMI, self-esteem, or susceptibility to hunger at the end of treatment [81].

Behavioral Weight Loss

Behavioral weight loss treatment in binge eating disorder incorporates various behavioral strategies to promote weight loss, such as caloric restriction and increased physical activity. A meta-analysis compared CBT and behavioral weight loss on measures of binge frequency, abstinence, weight, and eating-related psychopathology [81]. Both CBT and behavioral weight loss were associated with substantial improvement in binge frequency, but CBT was superior to behavioral weight loss at the end of treatment and at 12-month follow-up. Behavioral weight loss led to larger BMI reductions than CBT at the end of treatment. There were no differences in binge-eating abstinence or eating-related psychopathology at any point in the study [81]. One study evaluated a combined online intervention for binge eating disorders and high body weight in young adults [266]. Sixty adults 18 to 39 years of age were randomized to a combined condition or a CBT-only condition for eight weeks. Participants self-reported frequency of binge eating, compensatory behaviors, and weight at baseline, four weeks, and eight weeks. Participants also received self-help content for the duration of the study. Both conditions evaluated achieved significant reductions in binge episodes and compensatory behaviors from baseline to 8 weeks, but neither condition demonstrated significant weight loss [266].

Overall, strong evidence shows that second-generation antidepressants, lisdexamfetamine, and therapist-led CBT increases the likelihood of achieving abstinence. CBT and second-generation antidepressants reduce binge frequency, and second-generation antidepressants reduce obsessions and compulsions related to binge eating. Lisdexamfetamine reduces binge frequency and obsessions and compulsions related to binge eating [81].

Lisdexamfetamine

The prodrug lisdexamfetamine is the sole FDA-approved drug for the treatment of moderate-to-severe binge eating disorder. The FDA has withdrawn several investigational or approved binge eating disorder pharmacotherapies from the U.S. market over safety concerns and adverse effects (e.g., sibutramine, rimonabant, d-fenfluramine) [81].

Lisdexamfetamine improved binge-eating outcomes in several rigorously designed studies. In aggregate, patients treated with lisdexamfetamine were 2.61 times more likely to achieve binge-eating abstinence than with placebo [81]. Lisdexamfetamine led to greater reduction in binge-eating days than placebo and was associated with superior eating-related psychopathology and weight-reduction outcomes. The most common side effects reported by patients receiving lisdexamfetamine were gastrointestinal upset, sympathetic nervous system arousal, insomnia, headache, and decreased appetite [81].

Lisdexamfetamine product labeling includes a "limitation of use" that the drug is not indicated for weight loss, its effects on obesity are unknown, and similar medication classes have been associated with cardiovascular adverse events in the past. Lisdexamfetamine is also considered a controlled substance, and the product labeling includes a warning that CNS stimulants have high potential for abuse and dependence. Careful assessment and on-going monitoring for signs of misuse are indicated [261].

Another FDA-approved drug for ADHD treatment, atomoxetine, was significantly superior to placebo in reducing binge eating and achieving binge-eating remission in a small randomized controlled trial [261]. However, its use in the treatment of binge eating disorder is off-label.

Selective Serotonin Reuptake Inhibitors

SSRIs are the most frequently studied binge eating disorder medications, likely due to the efficacy and FDA approval of fluoxetine for bulimia nervosa [261]. Fluoxetine was superior on some measures of binge eating to placebo in a 6-week study, but not in a 16-week trial. In the six-week study, fluoxetine rapidly reduced binge eating versus placebo, but binge eating reduction and abstinence did not differ at study conclusion. Fluoxetine did not differ significantly from sertraline or fluvoxamine, and fluoxetine and fluvoxamine were significantly inferior to CBT alone in another trial [261].

Other SSRIs mostly fail to separate from placebo. Trials of fluvoxamine and escitalopram reported statistically significant differences in weight loss favoring the SSRI. With a mean BMI of 33–40, these patients had a mean weight loss of 2.7–3.52 pounds, which shows reports of statistically significant differences can be clinically irrelevant [261].

Adding fluoxetine or fluvoxamine to CBT or other behavioral treatments did not enhance outcomes compared with either psychological therapy alone [261]. However, the pooled results of seven second-generation antidepressant trials (five SSRIs, one duloxetine, and one bupropion) found patients receiving second-generation antidepressants were 1.67 times more likely to achieve binge-eating abstinence than those receiving placebo. Second-generation antidepressants reduced weekly binge-eating episodes by roughly two-thirds and binge-eating days per week by roughly one day (vs. placebo) [81].

Other Antidepressants

Duloxetine, a serotonin-norepinephrine reuptake inhibitor, was studied in 40 patients with binge eating disorder and comorbid depressive disorder. After 12 weeks, duloxetine (mean dose: 78.7 mg) significantly reduced weekly binge-eating days, binge-eating episodes, and severity ratings for binge eating disorder and depressive disorders compared with placebo. However, it did not differ from placebo in BMI, eating pathology, depression, or anxiety [267].

Antiepileptic Medications

In several randomized controlled trials, topiramate was significantly superior to placebo in more rapid reductions in binge eating, binge-eating remission, and weight loss. Binge-eating remissions in two topiramate studies were 64% and 58%. Adding topiramate (vs. placebo) to CBT significantly enhanced binge-eating remission rates and led to significantly and meaningfully greater weight loss [261]. Aside from lisdexamfetamine, topiramate is the only medication to consistently demonstrate substantial weight loss in patients with binge eating disorder [81].

In one randomized, placebo-controlled trial, 18 patients were randomized to 12 weeks of either phentermine/topiramate or placebo. Eating disorder behaviors, mood, and side effects were measured. Outcome measures included objective binge-eating days/week and binge abstinence. Baseline objective binge-eating days/week decreased from 16.2 to 4.2 with phentermine/topiramate versus 13.2 with placebo. Abstinence rates were 63.6% with phentermine/topiramate versus 9.1% with placebo. Other measured effects with the combination were minimal and similar to placebo [268].

The promising outcomes with topiramate are tempered by high rates of adverse events resulting in study dropout, including sympathetic nervous system arousal, headaches, sleep disturbances, and a collection of other symptoms including rash, high blood pressure, confusion, and taste aversion [81]. Dropout from topiramate is substantially reduced by adding CBT [261].

Other antiepileptics show less robust efficacy than topiramate [261]. Lamotrigine was not superior to placebo, and zonisamide was superior to placebo in more rapid binge-eating reduction and greater weight loss, but binge-eating remissions did not differ [261].

Anti-Obesity Medications

While not a binge eating disorder criterion, obesity is strongly associated with binge eating disorder in epidemiologic studies and is nearly universal in participants in binge eating disorder studies. Orlistat is a peripherally acting drug that blocks fat absorption in the gut without CNS effects. Several trials found orlistat significantly superior to placebo in enhancing weight loss, with no difference in binge eating reductions. Orlistat added to CBT significantly enhanced weight-loss outcomes but not binge eating reductions (compared with placebo). Orlistat or placebo added to behavioral weight loss therapy enhanced weight losses in obese patients without binge eating disorder, but not among obese patients with binge eating disorder [261].

Naltrexone/bupropion and liraglutide have been added as new-generation anti-obesity drugs. Liraglutide is a glucagon-like peptide 1 (GLP-1) receptor agonist that decreases inappropriate glucagon secretion, slows gastric emptying, and decreases food intake. It is approved as an adjunct to a reduced-calorie diet and increased physical activity for chronic weight management in adults who are overweight or obese with one or more comorbidity [269]. The combination naltrexone 32 mg/bupropion 360 mg is approved as an adjunct to a hypocaloric diet and increased physical activity for chronic weight management in adults with obesity or overweight and one or more weight-related comorbidity [270,271].

Disulfiram

A small 12-week trial of disulfiram 250 mg/day significantly decreased binge-eating episodes per week (7.9 pretreatment vs. 0.9 post-treatment), and 58.3% achieved binge-eating remission. However, 25% dropped out from side effects, and the remaining subjects reported drowsiness, headache, dysgeusia, tachycardia, dizziness, and nausea [272].

A small pilot study evaluated single-session transcranial direct current stimulation of the right dorsolateral PFC compared with sham therapy. Transcranial stimulation decreased craving for sweets, savory proteins, and food overall (with the strongest reductions in men), and significantly reduced desire to binge eat in men the day of active treatment. Greater reductions in craving and food intake correlated with less eating for reward motives and greater intent to restrict calories, respectively. Stimulation of the brain may recruit mechanisms that enhanced cognitive control and/or reduced the need for reward. Transcranial direct current stimulation in binge eating disorder was safe, and the results support evaluation of multi-session therapy [273].

Bariatric surgery is a treatment option for binge eating disorder with severe obesity (BMI ≥40 or BMI ≥35 with comorbid conditions). In the past, an eating disorder diagnosis was a contraindication to bariatric surgery, but this restriction has been relaxed. The disability and difficulty achieving stable weight loss with standard behavioral interventions has increasingly led to surgery candidates with binge eating disorder [245,274]. Bariatric surgery can be suitable for selected patients with binge eating disorder, but the extent of weight loss depends on post-surgery binge episode reduction, and 20% to 40% fail to lose sufficient weight or regain significant weight post-surgery [275]. Patients may experience emergent post-bariatric surgery psychiatric comorbidities. Considering the demonstrable and durable behavioral and neuroplastic changes associated with addictive eating behavior, obesity treatment is not realistic for some of these patients [276].

Overeaters Anonymous (OA) is a 12-step program for compulsive overeaters. Binge eating is viewed as a physical, spiritual, and emotional disorder, and OA proposes recovery through change that promotes physical, spiritual, and emotional well-being. Members have stated the tools for spiritual and emotional work provided in OA were essential to recovery. Secure attachment experiences are very likely to occur within OA, in which safe ground is provided and positive attachment figures are accessible. These factors facilitate a corrective emotional experience that compensates for childhood rejection and time spent with a caregiver who lacked the emotional availability required for the creation of a secure attachment [277].

The contribution of secure attachment figures to binge-eating recovery is consistent with other research that connects emotional overeating in women to attachment-related themes of relationship history, addiction as coping mechanism for insecure attachment, emotional eating as reminiscent of ambivalent attachment, and emotional hunger [278].

A study compared characteristics of patients seeking treatment for compulsive buying disorder, gambling disorder, Internet gaming disorder, Internet addiction, or sexual addiction. The results show that although compulsive buying disorder could likely be related to other addictive behaviors, significant differences in its phenomenology exist. Compulsive buying disorder is characterized by a higher proportion of women, older age of onset, poorer general psychopathologic state, higher levels of novelty seeking and harm avoidance, and moderate levels of reward dependence, persistence, and cooperativeness. In this sense, patients with compulsive buying disorder could be described as curious, easily bored, impulsive, and active seekers of new stimuli and reward. At the same time, these patients show pessimism and worry in anticipation of upcoming challenges [280].

Clinical differences were lower compared with sex addiction and higher compared with gambling disorder and Internet gaming disorder. Compulsive buying disorder and sexual addiction showed similar profiles, with their psychopathologic symptoms and personality scores being clearly worse than for gambling and Internet gaming disorder. In behavioral addictions, impulsivity is a core feature, but multiple studies also show high levels of compulsivity [291,292]. This study showed the combination of impulsive/compulsive symptoms is especially prominent in compulsive buying disorder and sex addiction [280]. In hoarding, one of the most commonly reported symptoms is acquiring behavior, and other studies have identified numerous similarities between hoarding and compulsive buying disorder [293].

Gambling disorder and compulsive buying disorder share features, including the urge to achieve immediate gratification or relieve negative emotion through impulsive/compulsive behavior, early onset of problematic addictive behavior, and impaired money management skills [280]. The inability to resist an impulse, drive, or temptation to perform a harmful act is an essential feature of most behavioral addictions [46].

Online compulsive buying disorder was studied in 240 female subjects. The relationship between excitability from shopping and pathologic online buying was partially mediated by expectancies for online shopping (i.e., the expectation that online buying will satisfy urges for excitement, distress relief, or mood elevation). Craving and pathologic online buying were strongly correlated, and increased cue-reactivity (i.e., craving after presentation of online shopping images) was observed solely in individuals scoring high for online compulsive buying disorder. This mediation model explained most of the variance for tendency to develop online compulsive buying disorder [294].

Studies suggest that CBT, dialectical behavior therapy, and psychodynamic psychotherapy may have promising results in treating compulsive buying disorder [282,302]. CBT focuses on identifying factors that maintain and reinforce the problematic buying behavior and delineates strategies for controlling impulsive spending. Maintaining a diary to identify triggers, describe the shopping behavior itself, and record the consequences of compulsive shopping assists patients in understanding behaviors from a different perspective. Additional options include 12-step programs such as Debtors Anonymous, debt consolidation, and credit counseling [282,303].

Group Psychotherapy

Group psychotherapy that uses a CBT approach or cognitive-behavioral methods within an eclectic approach appears beneficial, with durable improvements in reducing distress associated with compulsive buying disorder and maladaptive buying behavior. Research suggests that impulse control training should be a core component of compulsive buying disorder treatment [289]. Attrition rates show that group psychotherapy is not acceptable to all patients with compulsive buying disorder; patient choice and suitability are important considerations [289].

Stepped Care Delivery Model

Evidence suggests that a low-intensity, guided self-help approach to treating compulsive buying disorder was comparable to high-intensity group therapy. If patients can be treated with effective, brief, and less intensive psychological interventions first, this may increase service throughput and efficiency [304]. Studies of Internet-based, therapist-assisted self-help programs also usefully mimic the shift of behavior in online shopping [305]. Research indicates that excitability regarding online shopping and compulsive buying disorder are mediated by Internet use expectancies [294]. Treatments clearly need to reflect the context within which compulsive buying occurs [289].

Effect of Reward and Punishment Sensitivity on Treatment Response

Reward and punishment sensitivity was studied for impact on treatment outcome (12 weekly CBT sessions) in female patients with compulsive buying disorder or gambling disorder [46]. In compulsive buying disorder, higher reward sensitivity was related to poorer treatment adherence but reduced risk of dropout. Patients were likely to have stronger intrusive urges to buy, interfering with ability to curb buying behavior and carry out practice homework for CBT. The lower dropout risk may reflect patient motivation by social factors, with patients more likely to form a therapeutic alliance and not abandon treatment. High punishment sensitivity correlated with harm avoidance; these patients had increased risk of treatment drop-out.

Among all patients, high reward and punishment sensitivity was associated with greater psychopathology; worse psychological adjustment and treatment outcomes; higher novelty-seeking, persistence, and self-transcendence; and low self-directedness and cooperativeness. These results suggest patient response to CBT is conditioned by sensitivity to reward and punishment; compulsive buying disorder and gambling disorder shared this phenotype. This information could be incorporated into targeted interventions to strengthen CBT efficacy in compulsive buying disorder [46].

A review of compulsive buying disorder treatment found few published pharmacotherapy studies. SSRI antidepressants are the most-studied pharmacotherapy, based on the same premise as their use in other behavioral addictions [85]. Evaluations of citalopram, escitalopram, and fluvoxamine have reported mostly negative results, and clinicians should consider psychotherapeutic options before pharmacotherapy [289]. A systematic review of treatment studies found that group CBT is effective in reducing symptoms of compulsive buying disorder, whereas pharmacotherapy with SSRIs or topiramate did not indicate superiority over placebo [306]. One literature review found that a combination of antidepressants and CBT is effective for management of compulsive buying disorder. Serotoninergic antidepressants are effective as monotherapy [302].

The evidence base for psychotherapy in trichotillomania is small, and habit reversal therapy has the greatest empirical support. Habit reversal therapy is a behavioral therapy initially introduced for the treatment of nervous habits and tics. The core components of habit reversal therapy include self-monitoring (e.g., asking the patient to track hair-pulling or skin-picking events), awareness training, competing response training, and stimulus control procedures (e.g., removing hair-pulling or skin-picking cues from the patient's environment) [322].

Habit reversal therapy is generally delivered in weekly 60-minute sessions for 4 to 22 weeks, with more frequent sessions for patients with greater symptom severity. It can be delivered individually, in a group format, or online using a self-help manual [328]. The clinical benefits of trichotillomania symptom reduction have been augmented by adding components of acceptance and commitment therapy or dialectical behavior therapy [329,330]. Patient gains from habit reversal therapy are usually maintained for three to six months. Many clinicians combine habit reversal therapy and CBT, but published data support habit reversal therapy use as a stand-alone, first-line psychotherapy approach in trichotillomania [307]. One small study reported success combining metacognitive therapy with habit-reversal techniques for treatment of trichotillomania [331].

The classification of trichotillomania as an OCD-spectrum disorder has interfered with identifying effective drug treatment. SSRIs have been repeatedly evaluated in trichotillomania, without benefit [308]. The only antidepressant with partial efficacy in trichotillomania is clomipramine, a tricyclic agent [332]. An update of this review found that while there may be beneficial treatment effects for NAC, clomipramine, and olanzapine in adults, the results were based on small sample sizes [333].

Clinical experience and results from a single clinical trial indicate that NAC (1,200 mg twice daily) can reduce hair-pulling urges and may be considered as initial pharmacotherapy. Importantly, NAC may require daily adherence for up to nine weeks for benefits to appear. NAC is well-tolerated, with generally mild side effects of abdominal bloating and flatulence [334]. An updated literature review found that while NAC has proven successful for treatment of trichotillomania, the data are derived from few clinical trials and case reports assessing small numbers of patients [335].

A Cochrane Review found that insufficient evidence from meta-analysis to confirm or refute the efficacy of any agent or class of medication for the treatment of trichotillomania in adults, children, or adolescents. Preliminary evidence suggests there may be beneficial treatment effects for N-acetylcysteine, clomipramine, and olanzapine in adults based on four trials, albeit with relatively small sample sizes.

(https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD007662.pub2/full Last Accessed: April 19, 2024)

Level of Evidence: Meta-Analysis

The atypical antipsychotic olanzapine was evaluated over 12 weeks (mean dose: 10.8 mg/day) and showed significant reductions in trichotillomania symptoms compared with placebo [336]. The propensity to cause metabolic syndrome requires that benefits be carefully weighed against this drug's side effect profile [307].

Dronabinol is synthetic delta-9 tetrahydrocannabinol (THC), the primary psychoactive constituent of cannabis. THC binds to cannabinoid receptors (CB); CB1 receptor activation inhibits glutamate overproduction and resultant excitotoxicity implicated in trichotillomania [308]. A 12-week uncontrolled trial of dronabinol (mean dose: 11.6 mg/day) led to marked reductions in trichotillomania symptoms. Side effects of mild sedation were reported, and no significant effects were found on memory, attention, executive function, or psychomotor speed [337]. Thirty-four adults with trichotillomania were recruited for a randomized, double-blind, placebo-controlled study. Participants received 10-week treatment either with dronabinol (5–15 mg/day) or placebo. Both dronabinol and placebo treatment were associated with significant reductions in symptoms, but dronabinol did not differ significantly from placebo on any measure of efficacy [338].

One study found 24% of persons with kleptomania had attempted suicide, of which 92% attributed the attempt to kleptomania itself [341]. Suicide attempts were associated with comorbid bipolar disorder, other impulse control disorders, and personality disorders (especially borderline and narcissistic). These syndromes share neurobiologic deficits in executive function that also typify kleptomania. Unlike earlier studies, anxiety, depression, and substance use disorders did not correlate with increased risk of suicide attempt. Data on suicides were not included, and this group may have been under-represented. Legal problems did not correlate with suicide risk, but patients who complete suicide after arrest or conviction have been reported. Other suicide risk factors in patients with kleptomania include shame, poor self-esteem, high levels of impulsivity and disinhibition, and social isolation [341,346].

Kleptomania is associated with significant legal consequences. In one study, common legal consequences included being arrested (68.3%), arrested but not convicted (36.6%), convicted and incarcerated after conviction (20.8%), and convicted but not incarcerated after conviction (10.9%) [344].

Kleptomania should be distinguished from ordinary theft, whereby stealing is motivated by the value of the object regardless of whether it was planned or impulsive. Shoplifting and ordinary theft are common, but kleptomania is rare. Some individuals feign symptoms of kleptomania to avoid criminal prosecution, and malingering should be ruled out. Stealing in the context of conduct disorder or antisocial personality disorder is a pattern of antisocial behavior; stealing in the context of acute psychiatric or cognitive symptoms should be distinguished from kleptomania [11,341].

Kleptomania is easy to mis- or overdiagnose because most diagnostic criteria are based on self-report, which is difficult to objectively confirm. Determination that stealing is not committed to express anger or vengeance may require several sessions to understand patient motives for the behavior, as patients are usually secretive and may not be consciously aware of their motive at the time of assessment [350].

CBT is tailored for use in the treatment of kleptomania by applying the following strategies [340]:

CBT or variants of cognitive and behavioral therapies seem promising for kleptomania, but large-scale studies with control groups are lacking. Furthermore, there may be a shortage of clinicians skilled in these therapies for kleptomania [340]. Findings also suggest that patients with kleptomania require longer treatment beyond the standard 6- to 12-session structure of CBT [352].

Memantine is an N-methyl-d-aspartate (NMDA)-receptor antagonist with promising results in substance and behavioral addictions. A small, uncontrolled trial in patients with kleptomania reported that after eight weeks of memantine (up to 30 mg/day), 91.7% met criteria for clinical response (defined as ≥35% improvement in symptom severity and clinician rating of improved/very much improved). All kleptomania disease severity scores decreased, and mood, anxiety, disability scores, and impulsivity improved. Memantine was generally well-tolerated, reduced shoplifting urges and behavior, and improved psychosocial functioning [339].

Naltrexone efficacy was evaluated after eight weeks and led to significantly greater reductions in overall kleptomania severity, stealing urges, and stealing behavior compared with placebo. The mean effective naltrexone dose was 116.7 mg/day, and 92% of subjects completed the study [353]. Naltrexone may decrease dopamine transmission in the nucleus accumbens, thus reducing the reward and reinforcement experienced with stealing and urges to steal [353].

The SSRI escitalopram has shown high response rates in uncontrolled trials, but failed to separate from placebo under double-blinded conditions [354]. Although SSRIs have been considered first-line pharmacotherapy in kleptomania, evidence indicates naltrexone is more effective, especially in patients with greater stealing urges. Patients with urges/cravings to steal and/or a family history of substance use disorders should receive a trial of naltrexone. If kleptomanic symptoms appear within the context of general impulsivity and inattentiveness in ADHD, psychostimulants can be considered. Consider antidepressants or mood stabilizers for comorbid affective disorders [341].

Shoplifters Anonymous defines itself as a 12-step group for compulsive shoplifters, stealers, thieves, and kleptomaniacs. Groups under the names Compulsive Shoplifters Anonymous (CSA) and Cleptomaniacs and Shoplifters Anonymous (CASA) can also be found. Although there is little research about these groups, recommending them in conjunction with medication and individual treatment is reasonable to consider [341].