Behavioural addictions and suicide an under-estimated ...

1. Behavioural addictions and suicidean under-estimated relationship? Sean Sullivan PhD Abacus Counselling & Training Services Ltd

2. What is an �addiction� A lay term that hasn�t been fully accepted by many mainstream health professionals Originally referred to chemical dependence Generally included preoccupation with the addictive substance (funding, obtaining, reflecting)? Also development of a tolerance (more required to attain desired effect), negative withdrawal effects when reduce/stop Includes persistence despite negative outcomes arising from the use of the substance

3. An open category Examples of behavioural addictions are: Problem gambling at its more extreme end (Pathological Gambling Disorder)? Pornography addiction, particularly via the Internet Compulsive spending/buying Sexual addiction Internet addiction �Video� game addiction

4. Can �addiction� be expanded to a behaviour? Often a reluctance to allow this term to be extended beyond its �substance dependence� base Reasons appear varied and not well argued. They include: Lack of biological adaptation markers for behavioural �addiction� No independent proof of lack of control � may choose not to moderate their behaviour Weakens the acceptability or importance of the term �addiction� �where will it end (Internet �addiction�, pornography �addiction� and even chocolate (?) or coffee �addiction�)

5. Why include behaviours in �addictions� The only differences may be the absence of an external chemical introduced into person�s system and less acute withdrawal effects�insufficient reasons in themselves Preoccupation similar Tolerance occurs Some withdrawal � irritability, anxiety Persistence despite negative outcomes can be very high But need for some definition to avoid �devaluing� the term, even when chemicals involved (eg coffee, chocolate, and behaviours, movie �addictions�)?

6. Why include behaviours in �addictions� (contin)? As the new kid on the block, behavioural addictions must overcome many barriers that prevent them being taken seriously: Behavioural addictions are often seen as habits, that the absence of a drug means that there is greater control retained to resist (the drug is to blame)? Those affected are often perceived as weaker, at-risk, and unlike the general population They are often regarded as less important, less problematic, and less life-threatening �often a hierarchy of addictions even by those affected

7. A range of impacts similar to all addictions As with chemical/drug addictions there is often more severe outcomes with different behavioural addictions eg illegal drugs (P, cocaine etc) can have additional consequences to legal drugs eg alcohol However, greater accessibility for legal drugs can have its own problems, as can their widespread social use (I can control my use of alcohol, so why can�t they?)? Some behavioural addictions can have widespread consequences, and result in harm for many others

8. Two examples in more detail Internet pornography addiction Not a recognised mainstream mental health disorder Unknown prevalence but probably widespread (can�t survey for it) and largely males Often perceived as leading to paedophilia or risk to others through self-gratification General negative perception, especially if work with children (regardless of whether their focus is adults)

9. Typical development process Viewing pornography is commonplace, especially with males, so what is different? Extent and consequences place those with this addiction at high risk (objectionable images subject to DIA surveillance and prosecution)? Typical development is casual accessing of pornography that increases to substantial preoccupation and at a time when increased likelihood of disclosure Time spent and extent of the explicitness of the pornography increases (tolerance)?

10. Crisis Shame and attempts to hide the behaviour increases, but impulsiveness also increases Behaviour increases at both work and home (late evening) � discovery common at home Crisis common � discovery at work, or even identification by DIA Commonly, contrary to employment policy and termination of that employment common Reluctance to seek help by males (often distressed female partner initiates counselling

11. Process Marital stress Shame and guilt Attempts to stop often unsuccessful due to high accessibility of the Internet at work, at Internet cafes, and home Powerful process � unlike graphic magazines, images can be changed immediately, more explicit images always available, prompts can invite viewing even when legitimate Internet use Powerful reinforcement particularly for males� sexual gratification with a number of �partners� who are perfect through digital enhancement Perception of total control and no possible rejection

12. Consequences For many, real relationships become less desirable (less than perfect, lack of control, possible rejection)? Boredom equates to tolerance, greater explicitness required, higher risk As with addictions, preoccupation leads to decreased effectiveness and sociability, and isolation Accessing images increases, and becomes the preferred status to avoid negative reality As stress increases, accessing images becomes a way to self medicate, and with more graphic images, possible consequences increases stress

13. Consequences For many, the damage to their social support, loss of employment, loss of the stress relief provided by the behaviour, and ambivalence around common relapses, often leads to depression and anxiety Depression and anxiety may not be overt as these emotions are often suppressed by dissociation with males Many of these people were already depressed and/or anxious and the dissociation provided by pornography on the Internet relieved the constant stress without conscious awareness

14. Additional issues Unlike chemical/drug addiction, where once stopped there is often a rapid improvement in health, behavioural addictions often result in increased depression Reason may be that the problems still exist (disclosure of unacceptable behaviour, loss of employment, loss of trust where symptoms of recovery unclear) while use of the behaviour to escape these dysphoric consequences is lost Social repugnance can lead to other ways to avoid this new reality or may lead to suicidal ideation An example

15. A second behavioural addiction Pathological or compulsive gambling More known about this addiction Is recognised by mainstream health providers Negative consequences may be one of the highest for both chemical and behavioural addictions Affects individuals and on average 7 family members or others Process is similar in many cases to other addictions (gradual adaptation from reward, tolerance, preoccupation, persistence Added factor of an inbuilt solution and no satiation

16. Additional factors Gambling, especially electronic modes which have high addictiveness, are becoming more accessible, and have high current accessibility in NZ Currently, males and females have similar risk High co-occurrence of other problems that often, but not always, develop as the gambling becomes more problematic These additional issues include depression, anxiety, alcohol abuse, family and work dysfunction, poverty, criminal activity to sustain addiction, and suicidal ideation

17. Factors that enhance self harm As with pornography addiction, although gambling is widespread, excessive gambling is viewed as indulgent, untrustworthy, trying to take the easy way to riches, stupid, and because associated crime common, the individual is viewed as inherently bad Relapses are common (cued by advertising, pressure from creditors, dissociation that leads to �casual� gambling opportunities)? Continued lack of trust from others due to lack of symptoms of recovery Guilt, shame, relapses entrench depression and anxiety, with addiction impulsiveness

18. A perceived solution Many problem gamblers choose suicide as an impulsive solution Many will prepare for it over time, others respond impulsively Most do not attempt suicide to draw attention to their circumstances An estimate is that 20% of those diagnosed with Pathological Gambling Disorder will attempt suicide A recent study of those admitted to hospital after a suicide attempt found that 17% were positive on a problem gambling screen (2%-3% in the general population

19. Males and behavioural addictions Because of the lack of prevalence data for these, for many we can only look to presentation rates Few seek help for pornography addiction, but those that do are invariably males Half of those that seek help for gambling are males, largely because gambling machines are the major contributor for problems (75%-85%) and perhaps more than half of players are female. More than 90% of sports and track betting clients are male and view their behaviour as skillful (an ego component). Many male clients present as defensive, and with cognitive rather than emotional perspectives

20. Factors in addressing problem gambling addiction in males Thoughts around suicide are often common-place but sometimes discounted as unlikely When raised, reasons are often given why they wouldn�t (�I couldn�t do that to my children�) but this can change quickly (�My children would be better off without me�)? Levels of anxiety and depression are poorly self-monitored and emotions often suppressed (response often to partner�s overt emotion to the addiction)? However, addressing this with males in a cognitive approach without emotion can assist to raise awareness of this possibility, discuss consequences

21. An approach Often �normalise� these ideations in order to avoid barriers of shame/being unable to cope and to identify extent of risk (thoughts-planning-past attempts)? Often use of Motivational Interviewing can assist by the counselor emotionally �sitting on the fence� but with empathy, resolving ambivalence, motivating self-statements of ability to resolve issues Because of the possible impulsive decision of suicide may occur at any time in the future (continued stress, greater depression) this topic is often raised early in counselling some behavioural addictions, especially problem gambling

22. Some important questions Is this approach successful? Does the raising of the topic of suicide put the idea in the head of a stressed person? Is this cognitive approach always the best approach � are all males the same? Is reaching a �contract� with a client not to attempt suicide ( or at least without first accessing help) effective?

23. Summary Some behavioural addictions, particularly gambling, may have higher risk for suicide than chemical addictions �sudden condemnation on disclosure, criminal prosecution, financial loss (Durkheim�s egoistic/loss of social connections, and anomie/loss normal life)? Less understanding by society, greater willingness to attribute weakness/indulgence, less overt symptoms result in less willingness to trust, greater isolation, less support, greater co-occurring addictions and dysphoria Late help-seeking Those counselling these clients should be aware of greater risk for self-harm and be prepared to address it proactively end