University of Luxembourg. Joël Billieux, Ph.D. (UL / UCL / CHUV / HUG)

Transcription

1 University of Luxembourg Addictive and Compulsive Behaviours Lab (ACB-Lab) Institute for Health and Behaviour How can we conceptualize behavioral addiction without pathologizing common behaviors? Joël Billieux, Ph.D. (UL / UCL / CHUV / HUG) icaad 2018 / LONDON 7-9 May 2018

2 DSM-5: Gambling Disorder Category: Substance-related and addictive disorders DSM5: Addiction and Related Disorders based on: Symptom hall-marks (e.g., cues, craving, lack control) Co-morbidities Shared heritability / genetics Similar brain changes (functional imaging / neuropsychology) Effective treatments Bowden-Jones & Clark (2011 Brit J Psychiatry)

3 International Classification of Diseases (ICD-11) - WHO Section : Disorders Due to Substance Use or Addictive Behaviours Gaming disorder is manifested by a persistent or recurrent gaming behaviour (i.e., digital gaming or video-gaming ) characterised by an impaired control over gaming, increasing priority given to gaming over other activities to the extent that gaming takes precedence over other interests and daily activities and continuation of gaming despite the occurrence of negative consequences. The behaviour pattern is of sufficient severity to result in significant impairment in personal, family, social, educational, occupational or other important areas of functioning. These features and the underlying pattern of gaming are normally evident over a period of at least 12 months in order for a diagnosis to be assigned, although the required duration may be shortened if all diagnostic requirements are met and symptoms are severe. Available from October 2016

4 What we are speaking about???! One of the most popular leisure activities worldwide Example E-sport

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6 Finale : 4 Juin 2016

7 What we are speaking about??? Polarized topic Examples Popular Press Releases

8 Working Hypothesis According to the criteria generally used to identify behavioral addictions, it is likely that the elevated involvement in any type of activity can be considered as a psychiatric disorder Confusion between real disorders and healthy passions and/or dysfunctional coping strategies Inappropriate Treatments Credibility and relevance of (Behavioural) Addiction Research

9 Current trend in Behavioral Addiction Research! Pathologisation of everyday behaviors and leisure activities

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11 DSM-5 and the Behavioral Addiction construct

12 Example of unexpected consequences Side effects The Society for Media Psychology and Technology, Division 46 of the American Psychological Association, recently expresses concern against inclusion of Gaming Disorder in ICD-11 :

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14 Part 1 The SIN of the Confirmatory Approach

15 Criteria transposed from substance abuse Preoccupation Tolerance Withdrawal Loss of control Continued use despite adverse outcomes loss of interests in previous hobbies and entertainment Mood modification Deception (family, friends, psychiatrists) Putting in jeopardy of significant relationships 2013

16 How to create new diagnoses based on old recipes? The 3 steps of the Confirmatory Approach A priori CONCEPTUALISATION of an excessive behavior as a BEHAVIORAL ADDICTION INVESTIGATION OF RISK FACTORS FOR ADDICTIONS ASSESSMENT TOOLS BASED ON DSM CRITERIA FOR SUBSTANCE ADDICTION Symptoms Analyis - Loss of control - Mood regulation - Cognitive salience Main Consequences No consideration of alternative etiological models Focus on symptoms, not on psychological processes No consideration of the uniqueness of the condition Use of standardized interventions inspired from the treatment of addictive disorders Billieux, Schimmenti, Khazaal, Maurage, & Heeren (2015); Journal of Behavioural Addictions

17 Confirmatory approach : The case of tolerance Substance use Need to consume more of the substance to get the same effect Reduced effect when the same quantity is consumed Internet use The need for better computer equipment, more softwares, or more hours of use Mobile phone use A marked increase in the frequency and duration of mobile phone use to obtain the same level of satisfaction The need to substitute operative devices with the new models that appear on the market Block, 2008, American Journal of Psychiatry; Choliz, 2010, Addiction

18 The need to spend increasing amounts of time engaged in Internet games Tolerance IGD criterion [DSM-5, section 3] Are there other plausible alternative explanations to account for playing an increasing amount of time??? There are many legitimate reasons for why an individual wishes to spend more time playing games which have little to do with pathology; as with most things we enjoy, we would like to do it more often Other factors involved (not exhaustive) : Daniel Kardefelt- Winther Contextual factors (e.g., life events) Sociocultural changes (e.g., E-sport) Individual idiosyncratic Motives Daniel Kardefelt-Winther (2015). Addiction Research and Theory

19 Part 2 A Tenable Blueprint for Behavioral Addiction Research

20 How to avoid falling into a trap of the confirmatory approach? (I) Approaching new potential conditions with qualitative methods in highly involved individuals and not online surveys conducted in convenient community samples Phenomenology versus symptom-based approach Similarities versus Dissimilarities with other addictive behaviors Gather preliminary evidence for or against clinical status of the condition

21 Binge Watching TV Series Another Behavioral Addiction?

22 Another behavioral addiction? Binge-watching has been recently added to the literature as a candidate behavioral addiction On the basis of the symptom-based components model of addiction Each of the six items taps into a criterion for addiction : Orosz et al., 2016 Thought of how you could free up more time to watch series? [Salience] Spent much more time watching series than initially intended? [Tolerance] Watched series in order to reduce feelings of guilt, anxiety, helplessness and depression? [Mood modification] Been told by others to cut down on watching series without listening to them? [Relapse] Become restless or troubled if you have been prohibited from watching series? [Withdrawal] Ignored your partner, family members, or friends because of series watching? [Conflict]

23 How to rely on symptom-based atheoretical «models» to create new disorders Brown components model (Brown, 1993; updated by Griffiths, 2005) Salience Applied to Fishing (exemple) Withdrawal Addiction Tolerance Mood Modification Relapse Conflict

24 How to rely on symptom-based atheoretical «models» to create new disorders Brown components model (updated by Griffiths, 2005) Applied to Fishing (exemple) Salience Thinking a lot about fishing Withdrawal Nervous when deprived fishing Addiction Tolerance Mood Modification Relapse Progressive increase in fishing Fishing to relax Failed attempt to reduce fishing Conflict «another weekend spent fishing!!»

25 M. Flayelle Flayelle et al., 2018; Psychology of Popular Media Culture, in press.

26 How to avoid falling into a trap of the confirmatory approach? (II) Shifting from a symptom-based approach to a process-based approach

27 Young Woman (19 yo) seeking treatment for anxiety, depression and romantic problems also presenting a «mobile phone addiction»! Endorsed Criteria (based on Choliz, 2010; Addiction) Typical episode of loss of control Withdrawal [ ] When Uncontrolled she is not use able to reach her boyfriend, she very rapidly becomes upset and anxious. Negative In those impact situations, she cannot stop herself from calling and sending written messages Conscious until she of problematic eventually succeeds use in communicating with him. She reports that, in such situations, she can (without realizing + it) 3 make criteria more within than the 10 last calls 12 or written months messages = Addiction within a few minutes [.]

28 Applying a «Process-based» Approach (or Trans-diagnostic Case Formulation, see Dudley, Kuyken & Padesky, 2011) Low Self-Esteem Insecure Attachement Historical Familial Factors and Psychopathology High Neuroticism and Urgency Traits Cognitive Distortions / Irrational beliefs Dependentrelationship Maintenance Style Reassurance Behaviours Low Impulse Control in Emotional Contexts Repetitive Negative Toughts Negative Affect and Anxiety Symptoms Mobile Phone Addiction Symptoms Billieux et al., 2015; CPP; Figure 2 (p.465)

29 How to avoid falling into the trap of the confirmatory approach? Shifting from a symptom-based approach to a (psychological) process-based approach Dudley, Kuyken & Padesky, 2011; Clinical Psychology Review Billieux et al., 2015; Clinical Psychology and Psychotherapy Example in relation to video game (over)use : GAMING MOTIVES or the functions of gaming

30 Heterogeneous motives underlie video-game use and misuse ACHIEVEMENT Competition Escapism Nick Yee (2006) A model of MMORPGs motives Advancement Mechanics Roleplay IMMERSION Teamwork Exploration Customization Relationship SOCIAL AFFILIATION Socializing

31 Mauro Pesenti Marcantonio Spada Psychologist level 100 In-Game Achievements and rankings

32 Progression System Ex. World of Warcraf (WoW) More power, items, skills Level 1 Level 70 Level 100

33 Social Aspects Teamwork Guilds Rituals Olivier Servais (2012)

34 a. b. c.

35 Sample = 690 MMORPG gamers (World of Warcraft) Hours /week Internet Addiction Test Total Score (Armory) Advancement.37*.47*.26* Mechanics.25*.26*.24* Competition.25*.30*.09 Socializing Relationships.18*.05.15* Teamwork Discovery * Role-Play.11.20* -.06 Customization.18*.24* -.05 Escapism.26*.48*.08 Achievement Social Immersion * Bonnferonni correction : P< Primary disorder VS dysfunctional coping? :

36 Clinical Approach Clinical-case illustrations

37 Case 1 Jerôme The Hardcore Gamer

38 Jerôme The Hardcore Gamer 17 years old. Demand Parents (no explicit demand from Jerôme) Activity MOBA (League of Legend / LOL). 2-4 hours (week) 6-10 hours (weekend) Important to maintain ranking (according to Jerôme) Negative consequences Academic level (important reduction in school grades) Individual level (reduction of sleep quality, weight increase) Social level (conflict with family, growing social isolation)

39 Jerôme The Hardcore Gamer Diagnosis Fulfill proposed criteria for IGD (DSM-5) Occurrence of «craving» (see Ko et al., 2014; J Psychiat Res) Internet Addiction Test (IAT) > 50 No evidenced comorbidity (e.g., depression / anxiety symptoms) Relevant Psychological Factors Motivations to play online (Yee, 2006) : Achievement and Competition Personnality characterized by Impulsivity and Sensation Seeking Poor executive control (e.g., prepotent response inhibition) Elevated self-esteem (IRL versus Virtual Self-Esteem?) Treatment Objective = Controlled use of VG Motivational Interviewing (MI) CBT Addiction inspired (e.g.,at risk situations, coping, relapse prevention, ) Identification of alternative rewarding activities (mastery, self-confidence)

40 Case 2 Renaud The Virtual Leader

41 Renaud The Virtual Leader 23 years old. IT-worker (employed). Single. Demand Explicit demand for a psychological treatment Activity MMORPG (World of Warcraft). Playing for more than 10 years At least 2-3 hours per day (guild master) PvE (collaborative playing) Negative consequences Professional level (reported none) Individual level (low self-esteem, sadness, feeling like avoiding RL experiences) Social level (reported difficulties in meeting people / speaking to women)

42 Renaud The Virtual Leader Diagnoses Fulfill proposed criteria for IGD (DSM-5) Internet Addiction Test (IAT) > 70 Social Anxiety and GAD Relevant Psychological Factors Motivations to play (Yee, 2006) : Socialization, Teamwork and Role-Playing Personnality characterized by introversion and neuroticism Low self-esteem (especially in social and romantic contexts) Treatment CBT Social Anxiety focused (e.g., progressive exposition to anxious situations + cognitive restructuration, reduction of avoidance behaviors) addictive behaviour treatment

43 Case 3 Emma The Escaper

44 Emma The Escaper 22 years old. University Student. Single. Demand Explicit demand for a psychological treatment Activity Video Games in general (especially MMORPGs) Between 6 to 8 hours per day (sometimes more, often the evening) Games with high immersive components (e.g., WoW) Started playing a lot six months ago Negative consequences Academic level (not ready for the next exams, late in the academic program) Individual level (shame, anger against herself, giving up previous hobbies, ruminations and suicidal ideations, ) Social level (progressive isolation and conflicts with the family)

45 Emma The Escaper Diagnoses Fulfill proposed criteria for IGD (DSM-5) Escape / Excessive Gaming despite problems / Loss of Interest / Loss of control / Deception Internet Addiction Test (IAT) > 50 PTSD (victim of a sexual assault) and consecutive major depressive disorder Relevant Psychological Factors and symptoms Motivations to play (Yee, 2006) : Escapism through immersion in a virtual world Neuroticism, low self-esteem, dysfunctional emotion regulation strategies, PTSD-related factors (Ehlers & Clark, 2000, BRAT) Partial memory of the traumatic events Feeling of constant danger («The World is not a safe place») Daily flashbacks and «intrusions» Unadapted coping! Playing as a dissociative strategy (Schimmenti, 2010) Treatment PTSD oriented treatment (e.g., rebuilding and integration of the traumatic memory, Mindfullness [MBSR]) + Drug treatment to treat comorbid depression addictive behaviour treatment

46 How to avoid falling into a trap of the confirmatory approach? (III) Avoiding to conflate Passion and Addiction! A repeated and intensive involvement in an appetitive behaviour is not necessairly a pathology

47 Illustration of the «confirmatory approach» «Dependence rates were 45.1 according to the DSM-IV» Addiction or Passion??? «[ ] one-third described a strong craving for dancing» Craving or Desire???

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49 Past research has used DSM-5 Internet Gaming Disorder criteria without considering functional impairement as a mandatory criterion for diagnosis, resulting in inflated (and unrealistic) prevalence rates (>5%)

50 Some diagnostic items developed for Internet Gaming Disorder (DSM-5) are endorsed by a large proportion of regular video game players. And more than 30% were found to endorse IGD diagnosis

51 How to avoid falling into a trap of the confirmatory approach? (III) Avoiding to conflate Passion and Addiction Necessity to develop consensual and evolving conceptualisation

52 Proposition of an Operational Definition Generated to produce a conceptual debate in the field Modification via inclusion in the Open Science Framework (OFS) Definition has already been updated Billieux et al., 2017; Addiction, 116,

53 Proposition of an Operational Definition (version 2.0) Behavioural Addiction A repeated behaviour leading to a significant harm and distress. The behaviour is not reduced by the person and persists over a significant period of time. The harm or distress is of a functionnally impairing nature. Proposed exclusion criteria The behaviour is better explained by an underlying disorder (e.g., depressive disorder) The functional impairment results from an activity that, although potentially harmful, is the consequence of a willful choice (e.g., high-level sports) The behavior can be characterized as a prolonged, intense involvement that detracts time and focus from other aspects of life, but does not lead to functional impairment or distress The behaviour is the result of a temporary coping strategy as an expected response to common stressors or losses Elements in blue have been amended following peer debate

54 Conclusions and Implications A. Urgent need to shift from a confirmatory and symptom-based approach to a thoeretically grounded and process-based approach Example : I-PACE model of Excessive Internet Use (Brand et al., 2016) B. Improve diagnostic approach of behavioral addiction (e.g., clinical relevance, construct validity) Example : WHO initiative to develop new screening tools (Carragher et al., 2018) C. Acknowledging the differences between high involvement (passion) versus dysfunctional involvement (addiction) D. Develop open science research practices (e.g. pre-registed reports and hypotheses)

55 This talk has been fuelled by continuous discussions with many colleagues, including Daniel King Etta Bowden Jones Susumu Higuchi Adriano Schimmenti Sophia Achab Martial Van der Linden Vladan Starcevic Daniel Kardefelt- Winther

56 Acknowledgments

57 Merci pour votre attention! Twitter people/joel_billieux