AN INVESTIGATION INTO THE POTENTIAL FOR THE INCLUSION OF INTERNET

ADDICTION WITH SUBTYPES AS A BEHAVIORAL ADDICTION IN THE REVISED

DSM-5

A Doctoral Project

Presented to the Faculty

School of Behavioral Sciences

California Southern University

In partial fulfillment of

the requirements for the

degree of

DOCTOR

OF

PSYCHOLOGY

By

Todd (Terrence) L. Love Jr

September, 2014
 ProQuest Number: 3728466

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 ii

© Copyright by

Todd (Terrence) L. Love Jr.

September 2014
 iii

CALIFORNIA SOUTHERN UNIVERSITY

APPROVAL

We, the undersigned, certify that we have read this Doctoral Project and approve it as adequate

in scope and quality for the degree of Doctor of Psychology.

Learner: Todd (Terrence) L. Love Jr.

Title of Doctoral Project: An Investigation into the Potential for the Inclusion of Internet

Addiction with Subtypes as a Behavioral Addiction in the Revised DSM-5

Doctoral Project Committee:

________________________________________________

Project Chair: Kathleen Andrews, Ph.D. Date

________________________________________________

Committee Member: Barbara Lackey, Ph.D. Date

________________________________________________

Committee Member: Roy Sumpter, Ph.D., N.M.D. Date

 iv

DEDICATION

To Leanne, without whom completion of this project would never have been possible.
 v

DOCTORAL PROJECT ABSTRACT

Title: An Investigation into the Potential for the Inclusion of Internet Addiction with Subtypes

as a Behavioral Addiction in the Revised DSM-5

Author: Todd (Terrence) L. Love Jr.

Degree: Doctor of Psychology

Institution: California Southern University

Scope of Study: This study investigates the potential for a diagnosis of Internet Addiction and

it’s associated subtypes as a conditional diagnosis in future revisions of the DSM-5. This

research collects, compiles, and analyzes the existing literature on Internet Addiction and each of

its subtypes, as well as the multiple interrelated topics regarding the broad topic of addiction, the

generalized topic of behavioral addictions, as well as specific representative behavioral

addictions. This comprehensive analysis facilitates a deductive examination of the potential

validity of Internet Addiction as a mental health disorder. This study also investigates the

decision by the American Psychiatric Association (APA) to fundamentally alter the formally

proposed diagnosis of Internet Addiction and insert instead Internet Gaming Disorder as a

conditional diagnosis in the first edition of the DSM-5.

Findings and Conclusions: Over 1,000 peer-reviewed academic articles and books were found

on the various topics investigated, nearly 500 of which were cited in the present study. The

findings of this study indicate sufficient research for the APA to accept the broader diagnosis of

Internet Addiction with subtypes into a revised DSM-5. The study closes with three possible

speculative conclusions as to why the APA made the decision to deny the Internet Addition

diagnosis in favor of its own Internet Gaming Disorder diagnosis in the current DSM-5.

Chair Approval for Publication and Date:

 vi

Table of Contents

Table of Contents
Chapter 1 - Introduction .................................................................................................................. 1  

Introduction ................................................................................................................................. 1  

Problem Statement ...................................................................................................................... 1  

Background of the Problem ........................................................................................................ 3  

Purpose of the Study ................................................................................................................... 4  

Significance of the Study ............................................................................................................ 5  

Research Questions ..................................................................................................................... 6  

Theoretical Framework ............................................................................................................... 6  

Limitations of the Study.............................................................................................................. 7  

Delimitations of the Study .......................................................................................................... 7  

Definition of Key Terms ............................................................................................................. 8  

Chapter 2 - Literature Review....................................................................................................... 10  

Concept of Addiction ................................................................................................................ 10  

DSM history of addiction...................................................................................................... 11  

Neurobiology of addiction. ................................................................................................... 15  

Three-Stage model of addiction. ....................................................................................... 16  

Anti-Reward...................................................................................................................... 18  

Neurobiology of learning, habit, and motivation. ............................................................. 20  

Genetics............................................................................................................................. 21  

Reward Deficiency Syndrome. ......................................................................................... 22  

Molecular. ......................................................................................................................... 23  
 vii

Epigenetics. ....................................................................................................................... 25  

Controversy. .......................................................................................................................... 26  

Behavioral Addictions .............................................................................................................. 28  

History and development. ..................................................................................................... 29  

Literature reviews. ................................................................................................................ 33  

International acknowledgement of behavioral addictions. ................................................... 35  

Neurobiology of behavioral addictions. ................................................................................ 37  

Controversy. .......................................................................................................................... 41  

Proposed for DSM-5. ............................................................................................................ 42  

Pathological Gambling.............................................................................................................. 45  

Diagnostic history of Pathological Gambling. ...................................................................... 46  

Neurobiology of Pathological Gambling. ............................................................................. 48  

Internet Addiction/Internet Use Disorder ................................................................................. 49  

History, classification, and assessment of Internet Addiction. ............................................. 50  

Literature Reviews. ............................................................................................................... 61  

International acceptance of Internet Addiction. .................................................................... 65  

Neurobiology of Internet Addiction...................................................................................... 71  

Controversy. .......................................................................................................................... 75  

Proposed for DSM-5. ............................................................................................................ 76  

Internet Gaming Disorder ......................................................................................................... 78  

Terminology, diagnostic criteria, and assessment. ............................................................... 79  

Distinct from Internet Addiction? ......................................................................................... 81  

Neurobiology of Internet Gaming Disorder. ......................................................................... 82  

 viii

Sexual Preoccupations .............................................................................................................. 83  

Sex Addition and Hypersexual Disorder. ............................................................................. 84  

Neurobiology of SA/HD. ...................................................................................................... 90  

Proposed for DSM-5. ............................................................................................................ 92  

Internet Pornography Addiction. .......................................................................................... 94  

Overlap and differentiation with similar disorders. .......................................................... 95  

History of Internet sex addiction....................................................................................... 96  

Literature reviews and books. ........................................................................................... 98  

Assessment instruments. ................................................................................................. 100  

Treatment. ....................................................................................................................... 104  

Adolescents. .................................................................................................................... 106  

Neurobiology of Internet Pornography Addiction. ......................................................... 107  

Controversy. .................................................................................................................... 109  

DSM-5 .................................................................................................................................... 111  

Inclusion criteria. ................................................................................................................ 111  

Outcomes. ........................................................................................................................... 113  

Addiction generally. ........................................................................................................ 113  

Behavioral Addictions. ................................................................................................... 113  

Pathological Gambling.................................................................................................... 114  

Internet Addiction/ Internet Use Disorder. ..................................................................... 114  

Internet Gaming Disorder. .............................................................................................. 115  

Internet Pornography Addiction. .................................................................................... 116  

Inconsistencies and contradictions. ..................................................................................... 117  

 ix

Addiction generally. ........................................................................................................ 117  

Behavioral Addictions. ................................................................................................... 118  

Gambling Disorder.......................................................................................................... 124  

Internet Addiction/Internet Use Disorder. ...................................................................... 126  

Internet Gaming Disorder. .............................................................................................. 126  

Internet Pornography Addiction. .................................................................................... 135  

Chapter 3 - Methodology ............................................................................................................ 137  

Data Analysis .......................................................................................................................... 138  

Addiction generally. ............................................................................................................ 139  

Neurobiology of Addiction. ................................................................................................ 139  

Behavioral Addictions. ....................................................................................................... 140  

Pathological Gambling........................................................................................................ 140  

Internet Addiction/ Internet Use Disorder. ......................................................................... 141  

Internet Gaming Disorder. .................................................................................................. 141  

Internet Pornography Addiction. ........................................................................................ 142  

DSM-5. ............................................................................................................................... 143  

Chapter 4 - Results ...................................................................................................................... 144  

Research Question 1 ............................................................................................................... 144  

Research Question 2 ............................................................................................................... 144  

Chapter 5: Conclusions ............................................................................................................... 146  

Speculative Conclusion #1: Delivery Mechanism Argument ................................................. 146  

Speculative Conclusion #2: Social Politics............................................................................. 148  

Speculative Conclusion #3: Poor Research, Logic, and Editing ............................................ 156  
 x

Implications for Practice ......................................................................................................... 158  

Directions for Future Research ............................................................................................... 160  

Conclusion .............................................................................................................................. 161  

References ................................................................................................................................... 163  

 1

Chapter 1 - Introduction

Introduction

Many clinicians, researchers, and laypersons around the world agree that individual

behaviors outside the scope of substance abuse can be addictive (Karim & Chaudhri, 2012; Kim

& Seo, 2013; Leeman & Potenza, 2013; Pitchers et al., 2013; Potenza, 2014). Despite the

growing body of scientific evidence supporting both the neurobiological and phenomenological

overlaps between substance abuse and the problematic over-engagement in behaviors such as

gambling, Internet use, video-game playing, and sexual behaviors, the idea that behaviors can be

addictive remains controversial among some members of both the professional and lay

communities. Within the realm of behavioral addictions is the specific problem of Internet

Addiction, which traditionally includes subtypes such as instant messaging, pornography use,

and video games, and was more recently expanded to include social networking (Yau, Crowley,

Mayes, & Potenza, 2012). Internet addiction was proposed nearly ten years ago for inclusion in

the recently released Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-

5). This proposal remained viable until the final vote by the APA Trustees on December 01,

2012, at which time they dismantled and replaced the disorder with one of its subtypes, Internet

Gaming Disorder. To date, the APA has not made known its specific reasons for making this

change, other than implied claims that insufficient research existed to support a diagnosis of

Internet Addiction (APA, 2013a). In this paper, an investigation will be made as to whether

sufficient research exists to warrant the originally proposed Internet Addiction diagnosis in

future revisions of the DSM-5. Additionally, a review of the validity of the APA's claim is

conducted, and an investigation as to why this decision was made will be explored.

Problem Statement
 2

Internet addiction is a growing problem worldwide (Stewart, 2010). The Korean

government has declared Internet addiction a public health crisis, and both the Chinese and

Korean governments have setup mandatory boot camps to wean internet-addicted citizens back

into the offline world (Lee et al., 2013; Stewart, 2010). Mattebo, Tydén, Häggström-Nordin,

Nilsson, and Larsson (2013) found that 96% of a sample of 477 16-yr old males had viewed

Internet pornography in the previous year, with 10% viewing it daily. These researchers found a

correlation between the amounts of time the teenagers spent viewing pornography with increases

in alcohol and tobacco use, obesity, risky sexual behaviors, and truancy. Adult studies

repeatedly illustrate a subset of persons that excessively view Internet pornography despite

negative consequences in their personal and professional lives (Griffiths, 2012). For example,

one clinical case study highlighted a patient who viewed up to eight hours of pornography daily,

resulting in damaged interpersonal relationships and the loss of multiple jobs (Bostwick & Bucci,

2008). Similarly, Andreassen & Pallesen (2013) found addictive use of social networking sites

to be correlated with academic, health, and interpersonal problems.

Despite the growing body of research on the multiple facets of Internet Addiction, the

APA rejected the formal proposal for Internet Addiction to be included in the first release of the

DSM 5. The proposed disorder was narrowed in scope and released as Internet Gaming Disorder

(IGD), leaving Internet Addiction itself unacknowledged, and its other subtypes such as

pornography addiction and social networking addiction explicitly excluded. The question

contained within this paper is whether a sufficient body of research exists to support a full

diagnosis of Internet addiction and its subtypes into future versions of the DSM-5. Benefits of

the establishment of a provisional diagnosis would include increased legitimacy among the

public, increased availability of grant funding for research, and the encouragement of continued
 3

development of clinical methodologies to address the disorder (Hagedorn, 2009; Petry, 2010;

Petry, et al, 2013).

Background of the Problem

Historically the term “addiction” refers to the problematic overconsumption of drugs

and/or alcohol (White, 1998); i.e. substance addictions. Over the course of the last few decades,

the argument has been made that various behaviors, when repeated in problematic ways, also fit

within the addiction model (Bradley, 1990; Goodman, 2008; Griffiths, 1996; Grüsser,

Poppelreuter, Heinz, Albrecht, & Sass, 2007; Hagedorn, 2009; Karim & Chaudhri, 2012; Kim &

Seo, 2013; Marlatt, Baer, Donovan, & Kivlahan, 1988; Miller, 1980; Mudry et al., 2011;

Potenza, 2014). In the previous 10 years, there has been much research on the neurobiology of

addiction, and existence of a common mechanism between substance addictions and behavioral

addictions has emerged (Leeman & Potenza, 2013; Olsen, 2011). As a result, the American

Society of Addiction Medicine (ASAM) formally expanded their definition of addiction in 2011

to include both behaviors and substances:

Addiction is a primary, chronic disease of brain reward, motivation, memory and related

circuitry. Dysfunction in these circuits leads to characteristic biological, psychological,

social and spiritual manifestations. This is reflected in an individual pathologically

pursuing reward and/or relief by substance use and other behaviors. (ASAM, 2011)

Among those “other behaviors” addictions is Internet addiction. In 2008, researchers

proposed a formal diagnostic category of Internet Addiction with the subtypes of excessive

gaming, sexual preoccupations, and e-mail/text messaging, to be included in the version of the

DSM that was under development at the time (Block, 2008). Researchers again formally

proposed this diagnosis in 2010, although the explicit subtypes were removed from the proposal
 4

(Tao, 2010). When the DSM-5 was released in 2013, however, the diagnosis of Internet

Addiction was not included. Instead, the APA partially accepted one of its subtypes, Internet

Gaming Disorder, into Section III: Conditions for Further Study (APA, 2013a).

On the FAQ section of the American Psychiatric Association’s (APA) official DSM-

5.org website, an answer was posted to the following question “How were decisions made about

what would be included, removed, or changed?”:

APA’s goal in developing DSM-5 is an evidence-based manual that is useful to clinicians

in helping them accurately diagnose mental disorders. Decisions to include a diagnosis in

DSM-5 were based on a careful consideration of the scientific advances in research

underlying the disorder, as well as the collective clinical knowledge of experts in the

field. Advances in the science of mental disorders have been dramatic in the past decades,

and this new science was reviewed by task force and work group members to determine

whether diagnoses needed to be removed or changed. (APA, 2013a)

While the above statement provides a broad overview of the general requirements for

inclusion, the APA has not provided a formal or explicit explanation as to how they concluded

that the diagnosis of Internet Addiction did not meet this standard, yet the diagnosis of Internet

Gaming Disorder did meet the standard. As a result, one must piece together an interpretation

based on statements the APA made in the manual itself, in it's white-papers, and in articles

written by Work Group members.

Purpose of the Study

The first purpose of this study is to examine whether sufficient research exists to include

the originally proposed full diagnosis of Internet Addiction and its subtypes into future revisions

of the DSM-5. Internet Addiction encompasses multiple subtypes, and is itself a manifestation
 5

of a larger categorical phenomenon (behavioral addictions). This paper investigates the available

body of scientific knowldge in the areas of both substance and behavioral addictions, as well as

the available research supporting specific behavioral addictions. This paper analyzes the

cumulative research in these interconnecting subject areas, and compares it to the standard put

forth by the APA for inclusion in the manual. As the APA's inclusion of Gambling Disorder was

based largely on a research overlap between pathological gambling and substance use disorders

(Petry et al., 2013), so here will a comparative analysis be made of currently acknowledged

addictions (substance, gambling) with proposed behavioral addictions such as Internet Addiction

and its subtypes. No known study to date has collected and packaged a single representative

body of literature in this fashion. This collection of related subject areas allows for a deductive

reasoning based understanding of Internet Addiction as a potential behavioral addiction. The

second purpose of this study is to investigate why and how the APA made their decision to

rework the diagnosis Internet Addiction into an unannounced diagnosis of Internet Gaming

Disorder, which they included as a research condition in the DSM-5.

Significance of the Study

The establishment of Internet Addiction as a distinct disorder could yield multiple

benefits. Optimally, if finding suggest Internet Addiction is a distinct disorder, it could be

included in next revision of the DSM. Inclusion in the DSM could bring many benefits, for

example, the availability of both public and private grant money. This, in turn, could stimulate

research that furthers the understanding of the disorder. The creation of a diagnosis for Internet

Addiction could also help suffering individuals, the counselors treating them, and society at

large, as it would facilitate the increased training of future clinicians, increased professional and

public understanding of behavioral addictions, and encouragement and support for additional
 6

empirical research related to the various addictive behaviors. Additional clinical benefits could

include a common language within the medical profession, more inclusive treatment approaches

to encompass multiple addictions, and the creation of standardized assessment and treatment

protocols (Hagedorn, 2009). Conversely, the current lack of a formal diagnostic category has led

to an environment where there is a lack of availability of treatment services for Internet

Addiction, as well as a lack of financial support from insurance plans to facilitate treatment. As

recently stated in the LA Times, “Exclude problems from the book and you may be cutting

suffering people off from receiving services and insurance reimbursements that they need”

(Mestel, 2012). Finally, the acknowledgement of a proper diagnosis would provide validation

for the individuals currently suffering from the disorder.

Research Questions

This study aims to answer the following questions:

1. What research supports a diagnosis of Internet Addiction with subtypes into future

revisions of the DSM-5?

2. Why was Internet Addiction not included in the original release of the DSM-5?

Theoretical Framework

This study is a Theoretical Review into the research question at hand. The bulk of this

study examines a near exhaustive literature review covering multiple related areas of content.

First, the general topic of addiction is explored, including its history in the DSM, and its detailed

neurobiology. Next, the categorical topic of behavioral addictions is reviewed, followed by

reviews of several distinct behavioral addictions - pathological gambling, Internet addiction,

Internet gaming disorder, Internet pornography addiction, as well as its partial predecessors of

sex addiction and hypersexual disorder. The neurobiology of all the preceding addictions as well
 7

as their proposals for inclusion in the DSM-5 is discussed. Potential overlap in research for these

interrelated areas will be explored. Finally, the outcome of each of these categories and

disorders in the DSM-5 is reviewed. The methodology utilized is a non-statistically based

analysis, seeking to identify commonalities, differences, and emerging themes within the current

body of literature. A final analysis is then performed to investigate why the APA did not include

the disorder in the first release of the DSM-5.

Limitations of the Study

There is an inherent limitation in conducting a literature review into a rapidly evolving

area. This limitation is that new studies will inevitably be released between the conclusion of the

literature review process and the time of publication of the paper. As such, it can be assumed

that multiple relevant papers have been recently released that are not included within the body of

research contained herein.

There is a final limitation in that this paper is a qualitative analysis combined with a

theoretical presentation. If it is inferred that one reason for the APA’s exclusion of Internet

Addiction from the DSM-5 was its lack of empirically supported research, the eventual

generation of additional quantitative studies could be beneficial.

Delimitations of the Study

This research is largely a meta-analysis of literature reviews on Internet Addiction and

the multiple subject areas that surround and support the topic. The research provides a

representative coverage of all areas contained within the overall topic, however a exhaustive

exploration into the sub-components (assessment instruments, treatment methodologies, etc.) of

the specific areas is not included. Additionally, the research is time delimited in that the origins

of many of the disorders are highlighted, but the coverage between the time of origin and their
 8

current presentations is non-exhaustively reviewed. Finally, the topic of pathological gambling

is reviewed in significantly less detail than the other topics. This is due to the combined factors

of its preexisting inclusion in the DSM as well as its lack of presentation as a primary subtype of

Internet Addiction.

Definition of Key Terms

• Addiction: A progressive disease process characterized by loss of control over use,

obsession with use, continued use despite adverse consequencces, denial that there are

problems, and a powerful tendency to relapse (Inaba & Cohen, 2007, p. 549).

• American Psychiatric Association (APA): The official organization within the American

Medical Association dedicated to the study and practice of Psychiatry. The APA

publishes the Diagnostic & Statistical Manual of Mental Disorders (DSM).

• American Society for Addiction Medicine (ASAM): A newer organization than the

APA, this is the official organization within the American Medical Association dedicated

to the study and practice of Addiction Medicine as a medical sub-specialty.

• Behavioral Addiction: The phenomenon of addiction based on the compulsive

engagement in specific behaviors (gambling, gaming, Internet use, pornography, video

games, etc), as opposed to the ingestion of exogenous chemicals (drugs and alcohol).

• Diagnostic & Statistical Manual of Mental Disorders (DSM): The medical handbook that

defines and specifies diagnostic criteria for mental health and behavioral disorders. The

first edition was released in 1952, and the most recent edition, DSM-5, was released in

May of 2013.

• Internet Addiction: A specific behavioral addiction, marked by the compulsive or out-of-

control use of the internet, repeated failed attempts to stop, and continuation of the
 9

behavior despite negative consequences. Current common subtypes include gaming,

pornography, social networking. Internet Addiction is also referred to as Internet Use

Disorder, however the term Internet Addiction will be used primarly in this study in order

to remain congruent with the larger topic of addiction.

• Neurobiology: The study of the structural, chemical, and electrical components of the

brain and nervous system.

• Section II - Diagnostic Criteria and Codes: The section of the DSM that includes the

currently acknowledged conditions. Diagnoses in this section are considered valid and

official mental conditions by the APA.

• Section III - Conditions for Further Study: The section of the DSM that includes

diagnoses and conditions that the APA deems to have "clear merit" yet currently

insufficient amounts of research for to be officially recognized as disorders. Diagnoses in

this section are explicitly flagged as non-clinical, yet inclusion in Section III establishes

validity for the conditions and opens the door for future research. According to the APA,

"Inclusion of conditions in Section III was contingent on the amount of empirical

evidence available on a diagnosis, diagnostic reliability or validity, a clear clinical need,

and potential benefit in advancing research" (APA, 2013c).

 10

Chapter 2 - Literature Review

In order to best answer the research questions contained within this paper, a broad review

of several seemingly disparate areas is required. For example, the originally proposed diagnosis

of Internet Addiction included three subtypes (email/text messaging, sexual preoccupations,

gaming) (Block, 2008), and two of these subtypes, sexual preoccupations and gaming, each

contain their own bodies of research. Thus, in order to properly examine the research on Internet

Addiction, the scope of the research must be expanded to include these related areas.

Additionally, Internet Addiction (and its subtypes) is considered a behavioral addiction, and thus

the scope of research must be sufficient to provide an understanding of the area of behavioral

addictions. Similarly, behavioral addictions are a subset of the overarching category of

addiction, and thus a proper research inquiry must explore the concept, criteria, and neurobiology

of the disease of addiction, as well as the history of the term itself. The research on these areas

will be examined in reverse order. A thorough review of these areas is also required in

addressing the question as to why Internet Addiction was not included in the DSM-5.

Concept of Addiction

The definition of Addiction varies widely among professionals. For example, the

National Institute of Drug Abuse (NIDA) publicly defines addiction as "a chronic, relapsing

brain disease that is characterized by compulsive drug seeking and use, despite harmful

consequences" (NIDA, 2012). In contrast, the American Society of Addiction Medicine

(ASAM) defines addiction as "a primary, chronic disease of brain reward, motivation, memory

and related circuitry...This is reflected in an individual pathologically pursuing reward and/or

relief by substance use and other behaviors" (ASAM, 2011). Some propose a syndrome model of

addiction (Shaffer et al., 2004), while others argue for delineation between the idea of addiction
 11

and the actual addictive process (Goodman, 2008). As a key component of this research is that it

is criteria based, one must understand the development of addiction related criteria throughout

the history of the DSM in order to understand its current controversy.

DSM history of addiction. The first two versions of the DSM, DSM-I (APA, 1952) and

DSM-I-Special Supplement (APA, 1965), contained only a diagnostic taxonomy with no specific

criteria. In the DSM-I, Addiction was classified under: Personality Disorders - Sociopathic

Personality Disturbance - Addiction. Addiction contained two subcategories; Alcoholism &

Drug Addiction. The DSM-I-Special Supplement, renamed Drug Addiction to Drug

Dependence, and expanded the subcategory of alcoholism to include three subtypes; Episodic

Alcoholic Drinking, Excessive Alcoholic Drinking, and Alcoholic Addiction. The DSM-II

(APA, 1968) introduced the first formal definition of alcoholism: "Alcohol intake is great

enough to damage their physical health, or their personal or social functioning, or when it has

become a prerequisite to normal functioning" (APA, 1968, p.45). Episodic Alcoholic Drinking

is diagnosed when alcoholism is present, and the person is intoxicated between four and 11 times

in a single year. Intoxication is defined as "A state in which the individual's coordination or

speech is definitely impaired or his behavior is clearly altered" (APA, 1968, p. 45). Habitual

Alcoholic Drinking was diagnosed when a person is alcoholic and becomes intoxicated 12 more

times a year, or "are recognizably under the influence of alcohol more than once a week, even

though not intoxicated" (APA, 1968, p .45). Finally, Alcohol Addiction was diagnosed when

there was "Direct or strong presumptive evidence that the patient is dependent on alcohol. If

available, the best direct evidence of such dependence is the appearance of withdrawal

symptoms. The inability of the patient to go one day without drinking is presumptive evidence.
 12

When heavy drinking continues for three months or more it is reasonable to presume addiction to

alcohol has been established” (APA, 1968, p. 45).

The DSM-III (APA, 1980) created a chapter for Substance Use Disorders, separating

them from Personality Disorders. In doing so, they eliminated the category of addiction. The

concept remained, although the term, addiction, was used only one time in a passing reference to

Opioid Dependence; "Once Opioid Dependence is established, the course is a function of the

context of the addiction. For example, the vast majority of persons who became dependent on

heroin in Vietnam did not return to their addiction when back in the United States” (p. 172).

According to Miele, Tilly, First, & Frances (1990), other diagnostic changes from DSM-III to

DSM-III-R, specifically the removal of the requirements of tolerance and withdrawal, focusing

instead more on compulsive use, opened the door for future consideration of behaviors as

addictive.

This chapter introduced a delineation that would remain in effect for the next 33 years;

the differentiation between Substance Abuse and Substance Dependence. The criteria for

Substance Abuse was listed as: "1) Pattern of pathological use, 2) Impairment in social or

occupational functioning due to substance use, and 3) Minimal duration of disturbance of at least

one month" (p.163). The criteria provided for Pathological Use was defined as

Intoxication throughout the day, inability to cut down or stop use, repeated efforts to

control use through periods of temporary abstinence or restriction of use to certain times

of the day, continuation of substance use despite a serious physical disorder that the

individual knows is exacerbated by use of the substance, need for daily use of the

substance for adequate functioning, and episodes of a complication of the substance

intoxication. (p. 164)

 13

Next, Impairment in social or occupational functioning was defined as

Social relations can be disturbed by the individual's failure to meet important obligations

to friends and family, by display of erratic and impulsive behavior, and by inappropriate

expression of aggressive feelings. The individual may have legal difficulties because of

complications of the intoxicated state or because of criminal behavior to obtain money to

purchase the substance...Occupational functioning can deteriorate if the individual misses

work or school, or is unable to function effectively because of being intoxicated. When

impairment is severe, the individual's life can become totally dominated by use of the

substance...” (p.164)

In contrast to the specific criteria set forth for Substance Abuse, Substance Dependence

was defined more loosely as simply

A more severe form of Substance Use Disorder than Substance Abuse...The diagnosis of

all of the Substance Dependence categories requires only evidence of tolerance or

withdrawal, except for Alcohol and Cannabis Dependence, which in addition require

evidence of social or occupational impairment from use of the substance or a pattern of

pathological substance use. (p. 165)

Substance Use Disorder was renamed to Psychoactive Substance Use Disorder in the

DSM-III-R (APA, 1987). The APA committee dedicated to the chapter debated over re-

inclusion of the term Addiction, with a split between clinicians favoring the term addiction, and

non-clinicians favoring the term Dependence (O'Brien, 2011). The non-clinicians won by a

single vote, and, as with the previous edition, the term addiction remained only in a single

passing reference, this time to the "addiction potential" (APA, 1987, p.177) of opiates.

Despite the lack of reinstatement of the term Addiction, the DSM-III-R introduced a
 14

paradigm shift by switching from a focus on rote diagnostic criteria to a syndrome model

(O'Brien, 2011). A unanimous decision was reached on a new conceptualization: "The essential

feature of this disorder is a cluster of cognitive, behavioral, and physiologic symptoms that

indicate that the person has impaired control of psychoactive substance use and continues use of

the substance despite adverse consequences.” (APA, 1987, p.166) The DSM-III-R also

provided a more explicitly honed set of diagnostic criteria. Based largely on the work of

Edwards (1986) on Alcohol Dependence Syndrome, the specificity of criteria for the two

disorders was inversed; wherein a specific list was provided for Substance Dependence, while a

basic list was provided for Substance Abuse. For example, a diagnosis of Substance Dependence

required at least three of nine criteria be met within a one-month period:

(1) Substance often taken in larger amounts or over a longer period than the person

intended, (2) persistent desire or one or more unsuccessful efforts to cut down or control

substance use, (3) a great deal of time spent in activities necessary to get the substance,

taking the substance, or recovering from its effects, (4) frequent intoxication or

withdrawal symptoms when expected to fulfill major role obligations at work, school, or

home, or when substance use is physically hazardous, (5) important social, occupational,

or recreational activities given up or reduced because of substance use, (6) continued

substance use despite knowledge of having a persistent or recurrent social, psychological,

or physical problem that is caused or exacerbated by the use of the substance, (7) marked

tolerance: need for markedly increased amounts of the substance in order to achieve

intoxication or desired effect, or markedly diminished effect with continued use of the

same amount, (8) characteristic withdrawal symptoms, (9) substance often taken to

relieve or avoid withdrawal symptoms (p.167-168).

 15

In contrast, the criteria provided for Substance Abuse was simply

A maladaptive pattern of psychoactive substance use indicated by at least one of the

following: (1) continued use despite knowledge of having a persistent or recurrent social,

occupational, psychological, or physical problem that is caused or exacerbated by use of

the psychoactive substance, (2) recurrent use in situations in which use is physically

hazardous (e.g., driving while intoxicated). (p. 169)

The DSM-IV (APA, 1994) and the DSM-IV-TR (APA, 2001) eliminated the term,

addiction. The criteria for Substance Dependence remained identical, except for the removal of

two items from the list of criteria: "Frequent intoxication or withdrawal symptoms when

expected to fulfill major role obligations at work, school, or home, or when substance use is

physically hazardous", and "Substance often taken to relieve or avoid withdrawal symptoms." In

contrast, two additions were made to the Substance Abuse criteria: "A failure to fulfill major role

obligations at work, school, or home" and "Recurrent substance-related in legal programs"

(APA, 2001, p. 199; APA, 1994, p. 182-183).

Neurobiology of addiction. Olds and Milner first described the concept of a reward

circuit in 1954. Electrodes were placed in various brain regions of laboratory rats. The animals

were given the option of self-administering food and water versus self-administering an electrical

current. Stimulation of certain brain regions was reproducibly preferred over food and water.

This original paradigm has been refined over many years to demonstrate expanded concepts in

re- ward psychology. The basic paradigm is now referred to as Intracranial Self- Stimulation

(ICSS) and it continues to be one of the primary research tools in elucidating the neurobiological

pathways responsible for mediating reward."

All drugs of abuse affect the mesolimbic dopamine (DA) pathway, also known as the
 16

reward center of the brain (Volkow, Wang, Tomasi, & Baler, 2013a; Volkow, Wang, Tomasi, &

Baler, 2013b;). This pathway connects the ventral tegmental area (VTA) to the nucleus

accumbens (NAcc); a brain area heavily connected with pleasure, reinforcement learning,

rewards, and impulsivity. Three other regions that interconnect with the reward center are the

amygdala (positive and negative emotions, emotional memory), hippocampus (processing &

retrieval of long term memories), and the frontal cortex (coordinates & determines behavior).

Taken together, the reward center and its connecting regions modulate, among other things,

pleasure, reward, memory, attention, and motivation (Volkow, Wang, Fowler, Tomasi, &

Telang, 2011).

The reward center serves an evolutionary purpose; rewarding and thereby encouraging

activities necessary for survival (food, sex, etc.). As such, engagement in various behaviors

(food, sex, etc.) similarly activates the mesolimbic dopamine pathway (Potenza, 2014). The past

decade has yielded multiple theories of addiction, all involving the mesolimbic dopamine

pathway and surrounding brain regions and substrates (Volkow & Baler, 2014).

Three-Stage model of addiction. Nora Volkow, the Director of National Institute of

Drugs & Alcohol (NIDA) and a highly published researcher on addiction defined addiction as

the process of change from impulsive to compulsive action, with associated changing brain

circuitry (Volkow, Wang, Fowler, Tomasi, & Telang, 2011). The key to the shift from impulsive

to compulsive behaviors is a transition from positive reinforcement to negative reinforcement,

which leads to the addictive cycle. Volkow, Wang, Fowler, Tomasi, & Telang (2011) described

three stages of the addictive cycle: a) binge/intoxication, b) withdrawal/negative affect, and c)

preoccupation/anticipation.

Volkow, Wang, Fowler, Tomasi, & Telang (2011) referred to stage one as the
 17

"Binge/Intoxication" stage. Although different classes of drugs activate the reward center

through different means, the universal result is a flood of dopamine in the NAcc (reward center).

This results in acute positive reinforcement of the behavior that initiated the flood. In this

impulsive stage, this positive reinforcement results in addictive related learning associations

(Koob & Volkow, 2009). Neuroplastic changes begin to occur, however, as the continued

release of dopamine in the Nacc leads to an increase in dynorphin levels. Dynorphin, in turn,

decreases the dopaminergic function of the reward center, resulting in a decrease of the reward

threshold and an increase in tolerance (Koob & Volkow, 2009; Volkow, Wang, Fowler, Tomasi,

& Telang, 2011).

In stage two - "Withdrawal/Negative Affect" - the dopamine flood has passed and there is

activation of the extended amygdala, an area associated with fear conditioning and pain

processing. The resulting negative emotional state leads to activation of brain stress systems and

dysregulation of anti-stress systems. This leads to a decrease in sensitivity to rewards and an

increase in the reward threshold, resulting in negative reinforcement encouraging the

reinstatement of the addictive behavior. Here, the impulsive behavior shifts to compulsive

behavior, referred to in the model as chronic taking/seeking (Koob & Volkow, 2009; Volkow,

Wang, Fowler, Tomasi, & Telang, 2011).

A key point of this stage is that withdrawal is not about the physiological effects from a

specific substance. Rather, this model measures withdrawal via a negative affect resulting from

the above process. Negative emotions such as anxiety, depression, dysphoria, and irritability are

indicators of withdrawal in this model of addiction (Koob & Volkow, 2009; Volkow, Wang,

Fowler, Tomasi, & Telang, 2011).

A second component of the reward system comes into play here; the mesocortical
 18

dopamine pathway. Like the mesolimbic DA pathway, the mesocortical DA starts in the VTA,

however it terminates in the frontal cortex. Specific affected areas within the frontal cortex

include the dorsolateral prefrontal cortex (DLPFC), responsible for key components of cognition

and executive function, and the ventromedial prefrontal cortex (VMPFC) responsible for

components of inhibition and emotional response. Taken together, the mesocortical dopamine

pathway affects the cognitive component of reward processing (Koob & Volkow, 2009; Volkow,

Wang, Fowler, Tomasi, & Telang, 2011).

This leads to stage three - "Preoccupation/Anticipation" - commonly referred to as

craving. The neuroplastic impairments extend beyond the mesocortical dopamine pathway into

other regions of the prefrontal cortex responsible for motivation, self-regulation/self-control,

delayed reward discounting, and other cognitive and executive functions. Goldstein and Volkow

(2011) developed the Impaired Response Inhibition and Salience Attribution (I- RISA) model to

emphasize the importance of this process. The I-RISA model integrates the increased salience of

learned drug-related cues (resulting from the aforementioned positive and negative reinforcement

of the addictive behavior) with newly developed deficiencies in top-down inhibitory control.

This leaves the individual vulnerable to reinstatement of the behavior, and two primary

mechanisms have been identified; cue-induced reinstatement and stress-induced reinstatement

(Koob & Volkow, 2009; Volkow, Wang, Fowler, Tomasi, & Telang, 2011). Multiple

neuroimaging studies support this model (Ko et al., 2012; Limbrick-Oldfield, Van Holst, &

Clark, 2013), and these impairments are the force behind the "chronic relapsing disorder"

component of the medical definition of the term addiction (ASAM, 2011; Koob, 2011, p.59).

Anti-Reward. Koob, a frequent collaborator with Volkow (Koob & Volkow, 2009) and

supporter of the 3-phase model, also proposed an expansion of the second stage of addiction.
 19

Koob (2013) expanded Solomon & Corbit's (1974) opponent-process model of motivation,

which posits emotional experiences as opposing pairs, operating in a similar manner to the

positive reinforcement transitioning to negative reinforcement shown in stages one and two of

the three stage model above. In the opponent-process model of motivation, a-processes reflect

positive hedonic effects and b-processes reflect negative hedonic effects. The application in

addiction is that a-processes occur first and reflect tolerance. In contrast, the b-processes appear

after the a-process have completed and reflect withdrawal. Solomon and Corbit (1974) used

skydivers as an example of the opposite, wherein the novice skydivers experienced great fear

when they jumped (b-process) and some relief when they landed (a-process). As they repeated

the behavior, the balance shifted such that accomplished skydivers experienced some fear when

they jumped but great relief when they landed. This model has recently been proposed to

explain the occurrence of non-suicidal self-injury ("cutting") (Franklin et al., 2010).

Koob (2013) superimposed a detailed biologic model onto the psychological opponent-

process theory. Steps one and two of the three stage model involve "within-system changes"

marked by decreased reward system function, consisting of an increased reward threshold and a

decreased natural release of dopamine to non-addictive rewards. Koob expanded the model to

incorporate "between-system changes," based largely on the concept of opponent-processes.

Specifically, the "Anti-Reward" theory posits that when the brain reward center is activated,

there is a corresponding engagement of the brain stress systems, in order to limit the reward

response and maintain homeostatic balance of the reward center. The activation of the body's

stress system, in particular the hypothalamic-pituitary-adrenal axis, and the brains stress system,

in particular the corticotrophin-releasing factor (CRF) system. The increased levels of

Dynorphin further increase CRF, and the activation of these systems is responsible for many of
 20

the negative affects associated with the withdrawal stage. Compounding the problem, the brains

anti-stress system also becomes dysregulated, as evidenced by decreases in neuropeptide Y (a

natural anxiolytic in the brain). When the reward center can no longer be returned to its

homeostatic (normal) state, the addicted brain enters an "allostatic" state, wherein the reward

center has an altered set point, leaving the individual susceptible to relapse and dependence.

This is what Koob called the "dark side" of addiction (Koob, 2013, p. 559).

Neurobiology of learning, habit, and motivation. While both the Anti-Reward and I-

RISA models include learning components, other theories of addiction focus primarily on the

learning aspects of addiction, and the biological underpinnings thereof. Hyman (2006) referred

to addiction as the "pathological usurpation of neural processes that normally serve reward-

related learning" (p. 565).

Everitt and Robbins (2005, 2013) proposed a model of addiction as a steady transition

from voluntary actions to habitual actions to compulsive actions. Their model included a

combination of classical Pavlovian stimulus-response conditioning and instrumental learning,

and they present evidence illustrating a shift in brain activity from the ventral striatum (home of

NAcc) to dorsal striatum (brain region established for compulsive behaviors) through the course

of the development of addiction.

Robinson and Berridge (1993, 2008) took the learning model one step further and posited

the "Incentive Salience" theory of addiction. The Incentive Salience theory follows the model of

a hypersensitized mesocorticolimbic DA pathway, however, this theory focuses not on pleasure

or reward, but rather on the motivational attributions attached to the behavior (Smith, Berridge,

& Aldridge, 2011). This model arguably most closely follows the evolutionary purpose of the

reward system, wherein "drugs induce a false signal of a fitness benefit, which bypasses higher-
 21

order information processing" (Stacy & Wiers, 2010, p. 12). This theory explicitly differentiates

"liking" from "wanting" in that the development of addiction progresses along a path of liking

(hedonic reward value) to wanting (motivational adjustment based on salience) (Berridge,

Robinson, & Aldridge, 2009; Robinson & Berridge, 2013). The researchers thus referred to

addiction as a "pathological motivation" (Robinson & Berridge, 2008, p. 3137) resulting in the

core behavioral symptoms of addiction.

Robinson and Berridge (2013) recently updated their model to remove the necessity of

the component of liking, illustrating wanting as the only component of Incentive Sensitization

theory. They did so by transitioning lab rats from "revulsion" (pressing lever dispensed bitter sea

salt) to "wanting," by activating the mesocorticolimbic pathway immediately before the

presentation of the same lever. They thus proposed these results as countering the traditional

Pavlovian conditioning based arguments regarding the learning component of addiction (that

compulsion and cravings are based on prior learned associations), and emphasized how addiction

"hijacks" brain circuits of reward (p. 282).

Genetics. Genetics, as they are relevant here, can be divided into three mechanisms:

Genetic heritability, addiction related genetic expression in the individual, and epigenetics

intersecting the two. In regards to studies of genetic heritability, Swendsen & LeMoal (2011)

estimated genetic factors to contribute to approximately 40% of the disease of addiction. The

authors go on to provide gender specific heritability estimates for specific substances as: 49%

(m) and 64% (f) for alcohol, 44% (m) and 65% (f) for cocaine, 33% (m) and 79% (f) for

marijuana, 43% (m) for opiates, and 53% (m) and 62% (f) for tobacco (p. 80). In their review of

the genetic heritability of behavioral addictions, Lobo & Kennedy (2006) reported pathological

gamblers to be three times more likely to have a parent who is a pathological gambler, and
 22

twelve times more likely to have a grandparent. Blum et al. (2012a) found children of alcoholics

to be 50-60% more likely to become alcoholics, a statistic that exactly matches Leeman &

Potenza's (2013) heritability rate for pathological gamblers.

Volkow and Muenke (2012) reported common genetic factors on both sides of dual

diagnosis; for example, ADHD and substance abuse. Agrawal et al. (2012) performed a

literature review and identified addiction related genes as belonging in one of two categories;

genes that potentiate metabolic changes in response to specific substances, and genes that

influence reward-system behaviors (such as DRD2). These authors also found early stages of

addictive process more tied to environmental factors, while later stages were more tied to

heritability.

Reward Deficiency Syndrome. Blum et al. (1990) identified the genetic connection

between the A1 allele of the Dopamine D2 receptor gene (DRD2) and a propensity to develop

alcoholism. Specifically, they held that carriers of the DRD2-A1 gene have a lesser amount of

D2 receptors. A few years later, Blum, Cull, Braverman, & Comings (1996) proposed that

individuals with this make-up are likely to have interruptions in the mesolimbic reward system,

which they referred to as the "Dopamine Reward Cascade". These interruptions result in a

hypodopaminergic state that yields a predisposition to addictive, compulsive, and impulsive

behaviors, as well as several personality disorders. Blum et al. (1996) coined the term “Reward

Deficiency Syndrome” (RDS) to represent the inborn chemical imbalance that presents as one or

more behavioral disorders. As they continued the research, Blum and his team found that

carriers of the DRD2-A1 gene have approximately 30% - 40% less D2 receptors, and make up

about 33% of the US population (Blum et al., 2012b).

The following list represents specific behavioral problems currently tied to RDS:
 23

• Addictive Behaviors: Severe Alcoholism, Polysubstance Abuse, Smoking, and

Over Eating - Obesity

• Impulsive Behaviors: Attention-Deficit Disorder Hyperactivity, Tics and Tourette

Syndrome, and Autism (including Asperger Syndrome)

• Compulsive Behaviors: Aberrant Sexual Behavior, Internet Gaming and

Obsessive Texting, Pathological Gambling, and Workaholism and Shopaholisnm

• Personality Disorders: Conduct Disorder, Antisocial Personality, Aggressive

Behavior, Pathological Cruelty and Violence. (Blum et al., 2012b)

Although Blum has published articles making arguably outlandish claims such as the use

of genetic testing used to identify political affiliation (Blum et al., 2012c), two recent papers

have proposed an equally intriguing concept. The concept involves the application of genetic

testing (via GARS) to identify chronic pain patients who are genetically at-risk for the

development of addiction in order to help stifle the growing problem of iatrogenically induced

addiction to pain medication (Blum et al., 2013; Blum, Febo, Giordano, Hauser, & Oscar-

Berman, 2013).

Molecular. A large amount of research on the molecular explanation for addiction has

emerged in the last decade, often focusing on the roles of CREB, DeltaFosB, and Glutamate

(Madsen, Brown, & Lawrence, 2012; Nestler, 2008, 2012; Nestler, Barrot, & Self, 2001; Pitchers

et al., 2013; Robison & Nestler, 2011; Robison et al., 2013). The sum of this research indicates

that the flooding of dopamine in the reward center triggers an increase in the production of cyclic

AMP (cAMP), a small molecule that then signals the release of cAMP response element-binding

protein (CREB). CREB is a protein that regulates the expression of specific genes. In this case,

the result is the release of dynorphin, a protein that slows the release of dopamine and inhibits
 24

the VTA, thereby dampening the reward center. Researchers believe this to be the molecular

basis of tolerance, as increased amounts of the drug (or behavior) are required to overdo the

increased amounts of CREB. This process is also involved with dependence, as the inhibited

reward center leaves the individual in a state of anhedonia when abstinent from the source of

problematic dopamine release. When the addict becomes abstinent, CREB levels quickly drop,

tolerance fades, and sensitization begins. At this point, DeltaFosB becomes the predominant

factor.

DeltaFosB is a transcription factor that operates partially in an opposite manner to CREB,

in that it suppresses dynorphin and increases sensitivity in the reward pathway. Whereas CREB

results in negative reinforcement of addictive behavior, DeltaFosB promotes positive

reinforcement of addictive behavior. Whereas CREB builds up quickly in response to drug use

(or addictive behaviors), DeltaFosB builds up slowly. Additionally, whereas elevated CREB

levels dissipate from the reward center quickly, the elevated levels of DeltaFosB remain for

extended periods; weeks or even months. This enhances response to rewards and reward related

cues, leaving the individual sensitive to addiction related cues and vulnerable to compulsive

behaviors and relapse. This extended persistence and its associated implications have lead to

DeltaFosB's reference as the "molecular switch for addiction" (Nestler, 2012).

A third component is the neurotransmitter glutamate. Researchers are finding glutamate

to be intimately involved with the learning component of addiction, and the increased amount of

dopamine in the mesocorticolimbic pathway leads to an increased sensitivity to glutamate. In

turn, the enhanced glutamate sensitivity strengthens and fuels the learning/memory pathways

related to the addiction and its surrounding behaviors (Kalivas & O'Brien, 2007).
 25

Epigenetics. A highly complex and rapidly evolving area in the science of addiction is

epigenetics. Epigenetics is the study of the relationship between environment and genetic

expression, leading Graff, Kim, Dobbin, & Tsai (2011) to state, "Owing to this Janus-faced

property, epigenetic mechanisms provide an organism with the molecular means to promptly

react to environmental contingencies with stable alterations in gene expression" (p. 604). While

the technical details of epigenetic activation (histone tail modification, DNA methylation, and

microRNAs) are beyond the scope of this paper, it should be known that epigenetics can provide

explanations as to why some people, but not all, who contain the DRD2-A1 gene allele develop

the disease of addiction. According to (Wong, Mill, & Fernandes, 2011)

Given that neuronal plasticity has a recognized role in regulating drug addiction, and

epigenetic mechanisms are major mediators of long-term plasticity, epigenetic changes

are probable candidates for maintaining drug addiction. Indeed, emerging evidence

suggests that epigenetic mechanisms may be the molecular basis of drug-induced changes

in gene expression in brain reward regions, contributing to the lasting neural and

behavioural plasticity that underlies addiction. (p. 484)

Roughly speaking, epigenetic studies fall within one of two categories: the effects of

environmental factors, such as stressful life experiences, and/or the direct effects of drugs and

alcohol. For example, Archer, Oscar-Berman, Blum, & Gold (2013), Graff, Kim, Dobbin, &

Tsai (2011), and Masterpasqua (2009) discuss the epigenetic impacts of early life experiences

and environmental stressors. Alternately, Feng & Nestler (2013), Maze & Nestler (2011) and

Robison & Nestler (2011) focus on the epigenetic effects of acute and/or chronic exposure to

drugs.
 26

Controversy. In 2006, the chair of the DSM-5 Task Force on substance abuse co-

published an article with the Director of the National Institute of Drug Abuse. The authors

called for the reinstatement of the diagnostic category of Addiction in the DSM-5 to replace

Dependence (O'Brien, Volkow, & Li, 2006). The authors made multiple arguments supporting

their claim. First, they stated that the term "dependence" can be confusing and misleading, as

physiological dependence on a drug often happens outside the intended use of the word in the

DSM. They cited anti-depressant and beta-blocker medications as examples of drugs that result

in physiological adaptation by the body, yet are in no way substances of abuse. They further

stated that properly administered pain medications often result in physiological dependence,

including symptoms of tolerance and withdrawal. They pointed out that these patients most

often do not exhibit the compulsive drug-seeking behaviors of persons suffering from addiction.

They made the case that confounding the two terms and concepts causes harm when legitimately

needed medications are withheld from non-addicted patients who meet the criteria for substance

dependence. They stated, "In the case of substance use disorders, the medical world drastically

needs a change in labeling. Addiction is a perfectly acceptable word” (p. 765).

Erickson and Wilcox (2006) responded, claiming the word addiction is "unscientific,

overused, misunderstood, and clinically inaccurate" as well as "incredibly stigmatizing"

(p.2015). They claimed that this public stigma is to blame for insurance problems and

insufficient research. O'Brien, Volkow, and Li (2006b) replied, standing behind their initial

position, claiming, "The current classification is an unintentional violation of the Hippocratic

Oath: "First, do no harm." We have created a situation with our terminology that not only

confuses physicians, but also results in needless suffering and mislabeling of patients” (p. 2017).

Miller (2006) affirmed this position, stating that the term dependence results in patients
 27

improperly focusing on the physical elements of their addiction. Kuss (2013) agreed, and

posited that the term addiction removes stigma as he believes it indicates a neurobiological basis

for the disorder.

Erickson (2008) restated his position, adding four specific, albeit sometimes illogical,

arguments. First, Erickson claimed that the term addiction "is used to describe impulsive or

compulsive behaviors associated with sex, the Internet, gambling, pornography, and others for

which there is no proven relationship to neurochemical pathology of the mesolimbic dopamine

system, the primary site of chemical dependence" (p. 2). In making this argument, Erickson

entirely overlooked the multitude of scientific research on the neurobiology of behavioral

addictions, including the collection of studies sufficient to warrant pathological gambling’s

existence in the DSM. Erickson's remaining arguments pondered the impact of a terminological

change upon preexisting journals and organizations that use the term dependence, government

agencies, and researchers. "Will entities such as the National Council on Alcoholism and Drug

Dependence and its 100 nationwide affiliates...have to change their names?” (p. 2). In doing so,

Erickson remained silent on the then recently proposed legislation by Vice President Biden and

Nora Volkow to rename the National Institute on Drug Abuse to the National Institute on

Diseases of Addiction (Recognizing Addiction as a Disease Act of 2007).

As part of his position, Erickson referred to addiction as an overused term in pop culture,

citing what he believed to be inappropriate uses of the phrase as: "addicting antidepressants, cell

phone addiction, addiction to oil, exercise addiction, and tanning booth addiction" (p. 1).

Despite Erickson's arguably inappropriate use of sarcasm, numerous scientific studies have

emerged on all his examples, with the single exception of "addiction to oil"; antidepressant

addiction (Guillem & Lepine, 2003; Kisa, Bulbul, Aydemir, & Goka, 2007; Vadachkoria,
 28

Gabunia, Gambashidze, Pkhaladze, & Kuridze, 2009), cell phone addiction (Hong, Chiu, &

Huang, 2012; Khang, Woo, & Kim, 2012; Koo, 2013), exercise addiction (Costa, Cuzzocrea,

Hausenblas, Larcan, & Oliva, 2012; Freimuth, Moniz, & Kim, 2011; Landolfi, 2013;

Lichtenstein, Larsen, Christiansen, Støving, & Bredahl, 2014; Müller et al., 2014; Weinstein &

Weinstein, 2013), and tanning addiction (Hillhouse et al., 2012; Kourosh, Harrington, &

Adinoff, 2010; Mosher & Danoff-Burg, 2010).

The chair of the DSM-5 Task Force on substance abuse published a second article in

2011 walking-through the aforementioned history of the addiction terminology in the DSM

(O'Brien, 2011). O'Brien reiterated his 2006 position in favor of the word addiction over

dependence, and stated that the DSM-5 will include changes in terminology, including the

relabeling of the Substance Abuse section to "Addiction and Related Disorders". He went on to

state, however, that while the term dependence will be eliminated, it would not be replaced with

a diagnosis of "Addiction". Rather, the separate diagnoses of abuse and dependence will be

collapsed into a single diagnosis of "substance use disorder".

Behavioral Addictions

Internet Addiction is categorized as a behavioral addiction as it does not involve the

ingestion of any exogenous chemicals. As such, research on the both categorical and specific

topic of behavioral addictions is required to support a hypothesis of Internet Addiction as a valid

behavioral addiction. Karim and Chaudhri (2012) defined behavioral addictions as "The use of

repetitive actions, initiated by an impulse that can’t be stopped, causing an individual to escape,

numb, soothe, release tension, lessen anxiety or feel euphoric, may redefine the term addiction to

include experience and not just substance” (p. 14). These authors acknowledge multiple terms

used to describe the concept of behavioral addictions, including natural addictions and process
 29

addictions. Additionally, these authors illustrated the varied conceptualizations of the disorder,

such as impulse control disorders, impulsive-compulsive disorders, and obsessive-compulsive

disorders. Similarly, Grant, Schreiber & Odlaug (2013) posits the core feature of behavioral

addictions as "the failure to resist an impulse, drive, or temptation to perform an act that is

harmful to the person or others" (p. 252).

History and development. The acknowledgement of behavioral addictions can be

traced as far back as Miller's 1980 paper, "The addictive behaviors: Treatment of alcoholism,

drug abuse, smoking and obesity". In 1985, Orford presented the "excessive appetites" model of

addiction, in which he included gambling, eating, and sex, alongside chemical addictions.

Schaef (1987) proposed a terminological split between substance addictions and what he called

process addictions. "The second type, process addiction, comprises a series of potentially

pathological behaviors that expose individuals to “mood-altering events” by which they achieve

pleasure and become dependent". Marlatt, Baer, Donovan, and Kivlahan (1988) referred to

addictive behaviors as

A repetitive habit pattern that increases the risk of disease and/or associated personal and

social problems. Addictive behaviours are often experienced subjectively as "loss of

control" - the behaviour contrives to occur despite volitional attempts to abstain or

moderate use. These habit patterns are typically characterized by immediate gratification

(short-term reward), often coupled with delayed deleterious effects (long-term costs).

Attempts to change an addictive behaviour (via treatment or self-initiation) are typically

marked with high relapse rates. (p.224)

Marks (1990) began an editorial exchange when he published an article positing the

category of "Behavioral Addictions," wherein he stated

 30

Repetitive routines are not called addictions until their frequency/intensity leads to

handicap, and then usually only when they aim at obtaining chemicals. Less often, the

addiction label is also given to behavioural excesses that have no external substance as a

goal. They can be called behavioural (non-chemical) addictions. (p. 1389)

Marks included a full-page table where he outlined eight key features of addiction, and cross-

referenced chemical addictions with behaviors such as bulimia, hypersexuality, and spending.

Marks eight key features of addiction were

(1) Urge to engage in counterproductive behavioral sequence; craving,

(2) mounting tension until the sequence is completed,

(3) completing the sequence rapidly switches off the tension temporarily ('quick fix'),

(4) return of the urge over hours, days or weeks, (withdrawal symptoms)

(5) external cues for the urge unique to the particular addictive syndrome,

(6) secondary conditioning of the urge to both environmental and internal cues,

(7) hedonic tone in early stage of addiction

(8) habituation of craving and withdrawal by cue exposure. (p. 390)

Marks presented a full match between chemical addictions and spending, hypersexuality,

and, bulimia. Further, he speculated common brain mechanisms, similar conditioning

mechanisms, habituation, and similar therapeutic methods of relapse prevention and long-term

management of the disorders.

Bradley (1990) largely concurred with Marks, and proposed expanding the model to

include compulsive use of video games, exercise addiction, problem gambling, and

workaholism. Miele, Tilly, First, and Frances (1990) were skeptical, pointing out that Marks

definition was based on DSM-III-R criteria, which they believed was too broad and would
 31

possibly be narrowed by the then upcoming DSM-IV. Overall, however, they lauded Marks

efforts, concluding that the distinctions between chemical and behavioral addictions may

dissolve as more research is collected.

The same year, Goodman presented an article addressing the inconsistent use of word

addiction and its impacts. He pointed out the sole use of the term in the DSM-III-R was sex

addiction. He contrasted its marginalization with the ongoing establishment of a new field of

addiction science, and what he considered problematic disconnections between psychiatry and

psychology, addiction medicine and 12-step treatment programs, and the mental health

establishment as a whole. In response, Goodman (1990) proposed a diagnosis of "Addictive

Disorder", and presented specific criteria based on DSM-III-R substance dependence and

pathological gambling. Goodman conceptualized and summarized the proposed diagnosis as

Addiction may be defined as a process whereby a behavior, that can function both to

produce pleasure and to provide relief from internal discomfort, is employed in a pattern

characterized by (1) recurrent failure to control the behavior (powerlessness) and (2)

continuation of the behavior despite significant negative consequences

(unmanageability). This informal definition is comparable to the initial statement in

DSM-III-R regarding Psychoactive Substance Dependence: "The essential feature of this

disorder is a cluster of cognitive, behavioral, and physiologic symptoms that indicate that

the person has impaired control of psychoactive substance use and continues use of the

substance despite adverse consequences.” (p.1404)

Griffiths (1996) provided a literature review where he cited early studies on postulated

behavioral addictions such as sex addiction, gambling addiction, and television addiction. He

concluded with the emphatic statement "Addictions are not just restricted to drug-ingested
 32

behaviours and that evidence is growing that excessive behaviours of all types do seem to have

many commonalities...Behavioural addictions do exist, and should be treated no differently from

... (chemical) addictions" (p. 25).

Goodman (2001) reiterated his proposed Addictive Disorder diagnosis, and reworded his

1990 proposed criteria based on the DSM-IV-TR Substance Use Disorder criteria:

A maladaptive pattern of behavior, leading to clinically significant impairment or

distress, as manifested by three (or more) of the following, occurring at any time in the

same 12-month period:

1. Tolerance, as defined by either of the following:

a. A need for markedly increased amount or intensity of the behavior to achieve the

desired effect

b. Markedly diminished effect with continued involvement in the behavior at the same

level of intensity

2. Withdrawal, as manifested by either of the following:

a. Characteristic psychophysiological withdrawal syndrome of physiologically described

changes and/or psychologically described changes upon discontinuation of the behavior

b. The same (or a closely related) behavior is engaged in to relieve or avoid withdrawal

symptoms

3. The behavior is often engaged in over a longer period, in greater quantity, or at a

higher level of intensity than was intended

4. There is a persistent desire or unsuccessful efforts to cut down or control the behavior

5. A great deal of time is spent in activities necessary to prepare for the behavior, to

engage in the behavior, or to recover from its effects

 33

6. Important social, occupational, or recreational activities are given up or reduced

because of the behavior

7. The behavior continues despite knowledge of having a persistent or recurrent physical

or psychological problem that is likely to have been caused or exacerbated by the

behavior. (p.195-196)

Similarly, Lemon (2002) published a literature review where he concluded,

On the grounds of behavioural similarity, neurochemistry, neuroanatomy and subjective

reports, behavioural addictions appear to be a valid concept. Behaviours exhibiting the

compulsion, tolerance, withdrawal and relapse potential characteristic of substance

addictions seem to have no good distinction from such addictions apart from the absence

of a specific psychoactive substance. The development of a pattern of absorption in the

addiction and loss of adaptive functioning seem indistinguishable. (p. 48)

Potenza (2006) published a literature review, based on his expertise in pathological

gambling, where he suggested "non-substance-related conditions" be considered for inclusion in

the Addictive Disorders section of the DSM-5. He summarized three key elements of addiction

as "(1) craving state prior to behavioral engagement, or a compulsive engagement; (2) impaired

control over behavioral engagement; and (3) continued behavioral engagement despite adverse

consequences" (p. 143). Potenza then proposed the logic that acceptance of these elements as

core components of addiction, behavioral disorders matching the same components should be

considered addictions. Potenza cited similar biochemistry and neurocircuitry, including the

mesolimbic dopamine pathway, and the reward deficiency model.

Literature reviews. Albrecht, Kirschner, and Grüsser (2007) published a review on the

diagnostic instruments available at the time for behavioural addictions. These authors found
 34

verified assessment measures for behavioral addictions such as pathological gambling,

compulsive exercise, compulsive buying, compulsive exercise, workaholism, computer

addiction, Internet addiction, and sexual addiction. Grant, Potenza, Weinstein, and Gorelick

(2010) proposed a common natural history, neurobiology, phenomenology, and response to

treatment for compulsive buying, compulsive sexual behavior, gaming, Internet use,

kleptomania, pathological gambling, and tanning as behavioral addictions. Additionally,

Sussman, Lisha, & Griffiths (2011) estimated 12-month US population prevalence rates for

eating (2%), exercise (3%), internet use (2%), gambling (2%), love (3%), sex (3%), and

shopping (6%) as behavioral addictions.

Mudry et al. (2011) conducted a literature review based on a combination of the terms

abuse/misuse, addiction, compulsivity, dependence, excessive, impulse control, and pathological

with buying/shopping, eating, exercise, gambling, gaming/video games, internet, sex, and work.

These authors found 361 articles, 47% of which were review articles, 34% were empirical

studies, and 17% were commentaries. The authors also found 47% of the articles followed the

addiction model, 9% followed the ICD model, and 2% followed the OCD spectrum model.

These authors concluded that there was an overall lack of agreement and consistency among the

research in this area.

In their literature review of the epidemiology, neurobiology, and treatment options of

behavioral addictions, Karim & Chaudhri (2012) indicated an increased legitimacy of the

disorders, which they also referred to as impulsive-compulsive behaviors, and process

addictions. These authors specifically referenced "gambling, eating, sex, shopping, use of the

Internet or videogames or even exercising, working or falling in love" (p. 5) as examples of

behavioral addictions. These authors provided clinical presentations, including support for
 35

similar epidemiology, neurobiology, and treatment options for these specific behavioral

addictions.

Luijten, M., et al. (2014) recently conducted a literature review of ERP and fMRI studies

on the topic of behavioral addictions. These authors reviewed 19 ERP and 22 fMRI studies on

eating disorders, gambling, gaming, Internet overuse, and substance use. In their reviewed, they

highlighted similarities between specific brain regions involved with inhibitory control, error

processing. The authors concluded that their findings support addiction theory of excessive

behavior patterns.

Most recently, Grant & Chamberlain (2014) investigated the behavioral addictions of

compulsive buying, gambling disorder, Internet addiction, and kleptomania. The authors first

reviewed existing knowledge on behavioral inhibition involved with substance use. The authors

then looked for an overlap with substance use disorders and the aforementioned behavioral

addictions. These authors had a specific focus on impulsive choice and action, and concluded

that behavioral addictions to be similarly associated with impulsivity as substance use disorders.

International acknowledgement of behavioral addictions. Further support for the

concept of addictive behaviors is evidenced by the multiple international peer-reviewed

academic journals specifically directed towards behavioral addictions. These journals include

"Addictive Behaviors" (published by Elsevier since 1976), "Journal of Behavioral Addictions"

(online open-access journal published by Akadémiai Kiadó since 2011), and "Psychology of

Addictive Behaviors" (published by the American Psychological Association since 1987).

Examples of journals dedicated to specific behavioral addictions include "Cyberpsychology,

Behavior, & Social Networking" (published by Mary Ann Liebert since 1998), "Journal of
 36

Gambling Studies" (published by Springer since 1985), and "Sexual Addiction & Compulsivity"

(published by Taylor & Francis since 1994).

Italian researchers assessed 2,583 high school subjects for a myriad of behavioral

addictions: Compulsive Buying, Exercise Addiction, Internet Addiction, Pathological Gambling,

and Work Addiction. These researchers administered validated screening tools for each of the

measured addictions (the Compulsive Buying Scale (CBS), the Exercise Addiction Inventory

(EAI), the Internet Addiction Test (IAT), the South Oaks Gambling Screen- Revised Adolescent

(SOGS-RA),and the Work Addiction Risk Test (WART)) and found overal prevelance rates of

11.3% for Compulsive Buying, 8.5% for Exercise Addiction, 1.2% for Internet Addiction, 7.0%

for Pathological Gambling, and 7.6% for Work Addiction. These researchers concluded by

supporting the hypothesis of a common underlying mechanism across all behavioral addictions.

Japanese researchers Masaki, Tsuchida, Kitabayashi, Tani, & Fukui (2007) published a

literature review articulating the mounting evidence for inclusion of addictive behaviors into the

addiction category. These researchers referenced studies illustrating the same mesolimbic

dopamine reward system as involved in bing eating, gambling, sexual behaviors, self-injury, and

shopping. In the same year, German researchers Grüsser, Poppelreuter, Heinz, Albrecht, & Sass

(2007) published an article where they proposed an independent diagnostic category for

Behavioral Addictions, based on parallels of pathological abuse of the reward-center for the

purposes of coping with negative mood states by drug and non-drug users. More recently,

German researchers Mann, Fauth-Buhler, Seiferth, & Heinz (2013) published an article where

they proposed the need to categorize gambling and computer/internet use as Behavioral

Addictions. Additionally, they proposed the application of the behavioral addiction model be

applied to compulsive buying, excessive sexual behavior, and obesity.

 37

Korean researchers Kim & Seo (2013) superimposed the DSM-IV-TR criteria for alcohol

dependence upon excessive gambling, Internet use, sex, and shopping. Whereas many previous

authors used gambling as the behavioral prototype, these authors used Internet addiction as the

model for behavioral addictions. These authors illustrated a detailed understanding of

neurobiology of the reward center, and referenced fMRI studies showing similar cue-induced

craving responses between Internet gaming addicts and substance abusers. Additionally, they

cited other Korean studies finding neuroanatomical similarities between Internet addicts and

substance abusers. These authors espoused their justifiable, but mistaken, belief that in the then

upcoming DSM-5 a "new title of ‘Addiction Related Disorders’ has been added based on the

results of clinical studies in the effort to develop an integrative concept encompassing substance

and behavioral addiction in one category" (p. 646).

Neurobiology of behavioral addictions. Koob and Le Moal (2008) dedicated the final

section of their highly detailed review of the allostatic brain reward/anti-reward system to the

topic of "Nondrug Addictions". These authors intertwined non-drug and drug addictions, and

concluded with the statement, "A case can be made that there is strong face validity with the

addiction cycle of preoccupation/anticipation (craving), binge/intoxication, and

withdrawal/negative affect stages for compulsive gambling, compulsive shopping, compulsive

eating, compulsive sexual behavior, and compulsive exercise” (p.46).

In their literature review comparing behavioral addictions and substance use disorders,

Grant, Brewer, & Potenza (2006) specifically referenced pathological gambling, kleptomania,

pyromania, compulsive buying, and compulsive sexual behavior as examples of behavioral

addictions. These authors investigated biochemical, functional neuroimaging, genetic studies,

and treatment research, and concluded that the studies "suggested a strong neurobiological link
 38

between behavioral addictions and substance use disorders” (p.92). Grant, Potenza, Weinstein,

& Gorelick (2010) found behavioral addictions and chemical addictions to overlap in multiple

areas, including comorbidity, course (chronic relapse), genetic contribution, neurobiology (brain

glutamatergic, opioidergic, serotonergic and dopamine mesolimbic systems), phenomenology

(craving, intoxication, withdrawal), tolerance, and treatment response. Similarly, in their

literature review of the epidemiology, neurobiology, and treatment options of behavioral

addictions, Karim & Chaudhri (2012) indicated an increased legitimacy the disorders, which they

also refer to as impulsive-compulsive behaviors, and process addictions. These authors

specifically referenced eating, exercising, falling in love, gambling, internet use, sex, shopping,

videogames, and working as examples of behavioral addictions.

Leeman and Potenza (2013) conducted a thorough literature review of the

neurobiological studies on behavioral addictions, "A Targeted Review of the Neurobiology and

Genetics of Behavioural Addictions: An Emerging Area of Research." This article contains 197

references, and breaks the findings down into three categories: brain function and neuroimaging

results, neurotransmitter systems, and genetics. The authors summarized each category into its

own full-page table, outlining six behavioral addictions: gambling, Internet, gaming, shopping,

kleptomania, and sex. The left column of the table included a summary of the existing research

on the specific behavioral addiction, and the right column contrasted them with corresponding

findings for substance abuse. The authors concluded that there is limited but emerging data

connecting different behavioral addictions with existing research on substance abuse.

In his detailed article, "Natural rewards, neuroplasticity, and non-drug addictions," Olsen

(2011) declared, "there is a glut of evidence that natural rewards are capable of inducing

plasticity in addiction-related circuitry” (p.14). Olsen cites fMRI studies showing gambling,
 39

shopping, sex (orgasm), video games, and the sight of appetizing food to activate the

mesocorticolimbic system and extended amygdala in the same manner, as do drugs of abuse.

Olsen concluded that, "Extensive data suggests that eating, shopping, gambling, playing video

games, and spending time on the Internet are behaviors that can develop into compulsive

behaviors that are continued despite devastating consequences” (p. 14).

Blum has consistently included addictive behaviors in his constellation of domains

impacted by RDS. In an early paper on the reward cascade, Blum et al (2000) stated that a lack

of D2 receptors leaves individuals at a high risk for addictive, compulsive, and impulsive

behavioral propensities, including alcoholism, cocaine, heroin, marijuana, and nicotine use,

glucose bingeing, pathological gambling and sex addiction. The following list represents

specific behavioral problems currently tied to RDS: Addictive Behaviors: Severe Alcoholism,

Polysubstance Abuse, Smoking, and Over Eating – Obesity, Compulsive Behaviors: Aberrant

Sexual Behavior, Internet Gaming, and Pathological Gambling (Blum et al., 2012d).

According to Smith (2012), brain science studies such as these and others led to ASAM's

inclusion of behaviors into its formal definition of addiction. As such, the formal "Short

Definition of Addiction" released in 2011 reads as follows:

Addiction is a primary, chronic disease of brain reward, motivation, memory and related

circuitry. Dysfunction in these circuits leads to characteristic biological, psychological,

social and spiritual manifestations. This is reflected in an individual pathologically

pursuing reward and/or relief by substance use and other behaviors.

Addiction is characterized by inability to consistently abstain, impairment in behavioral

control, craving, diminished recognition of significant problems with one’s behaviors and

interpersonal relationships, and a dysfunctional emotional response. Like other chronic

 40

diseases, addiction often involves cycles of relapse and remission. Without treatment or

engagement in recovery activities, addiction is progressive and can result in disability or

premature death. (ASAM, 2011)

ASAM provides specific examples of addictive behaviors in the first paragraph of the Long

Definition of Addiction:

Addiction also affects neurotransmission and interactions between cortical and

hippocampal circuits and brain reward structures, such that the memory of previous

exposures to rewards (such as food, sex, alcohol and other drugs) leads to a biological

and behavioral response to external cues, in turn triggering craving and/or engagement in

addictive behaviors. (ASAM, 2011)

Additionally, the phrase "Addictive behaviors" in used in the Long Definition of

Addiction 13 times. This phrase is expounded upon in explanatory footnote three:

In this document, the term "addictive behaviors" refers to behaviors that are commonly

rewarding and are a feature in many cases of addiction. Exposure to these behaviors, just

as occurs with exposure to rewarding drugs, is facilitative of the addiction process rather

than causative of addiction. The state of brain anatomy and physiology is the underlying

variable that is more directly causative of addiction. Thus, in this document, the term

“addictive behaviors” does not refer to dysfunctional or socially disapproved behaviors,

which can appear in many cases of addiction. Behaviors, such as dishonesty, violation of

one’s values or the values of others, criminal acts etc., can be a component of addiction;

these are best viewed as complications that result from rather than contribute to addiction.

(ASAM, 2011)
 41

Controversy. The concept of Behavioral Addictions has not been without its

controversy. For example, Starcevic (2013) stated

Behavioural addiction itself is a problematic construct, as it implies that any behaviour

that is rewarding can be addictive. In other words, any pleasurable activity performed in

excess and having some negative consequences would constitute an addiction. Thus,

people could be ‘addicted’ to eating, having sex, exercising, shopping, working or even

indulging in hobbies such as model railroading. (p. 16)

Despite Starcevic's attempt to provide exaggerated examples, large amounts of research

has been conducted on all his referenced areas, with the exception of model railroading: for

example, addictive eating (Ahmed, Guillem, & Vandaele, 2013; Balodis, Grilo, et al., 2013;

Balodis, Kober, et al., 2013; Blum, Oscar-Berman, Barh, Giordano, & Gold, 2013; Clark &

Saules, 2013; Gearhardt, Boswell, & Potenza, 2014; Rodgers, Melioli, Laconi, Bui, & Chabrol,

2013; Volkow, Wang, Tomasi, & Baler, 2013a; Volkow, Wang, Tomasi, & Baler, 2013b),

addictive exercising (Costa, Cuzzocrea, Hausenblas, Larcan, & Oliva, 2012; Freimuth, Moniz,

& Kim, 2011; Landolfi, 2013; Lichtenstein, Larsen, Christiansen, Støving, & Bredahl, 2014;

Müller et al., 2014; Weinstein & Weinstein, 2013), sex (see further in this paper), compulsive

shopping/spending/buying (Black, Shaw, McCormick, Bayless, & Allen, 2012; Hartston, 2012;

Lejoyeux & Weinstein, 2010; Murali, Ray, & Shaffiullha, 2012; Rose & Dhandayudham, 2014;

Starcke, Schlereth, Domass, Schöler, & Brand, 2013), and workaholism (Andreassen, 2013;

Andreassen, Griffiths, Hetland, & Pallesen, 2012; Sussman, 2012).

Starcevic (2013) went on to further proselytize the potential harm incurred by a

psychiatric diagnosis of behavioral addiction, holding that if the ASAM definition of addiction

was used as the basis for a behavioral addiction diagnosis, it would lead to an "epidemic of
 42

behavioural addictions" (p. 16).

Proposed for DSM-5. Hagedorn (2009) represented the position of the American

Counseling Association's International Association of Addictions and Offender Counseling

(IAAOC) when he made a formal call for a diagnosis of Addictive Disorders to be included in

the DSM-5. In his article, Hagedorn countered what he considered to be the three primary

arguments against the existence of behavioral addictions. They are the lack of physiological

tolerance and withdrawal, differences in the recovery process, and the better placement of the

disorders in other sections of the DSM.

In regards to the argument regarding addiction as a purely physiological disorder,

Hagedorn referenced both the 2006 editorial debate in AM J Psychiatry and the 2008 debate in

Alcoholism: Clinical & Experimental Research. Hagedorn countered their arguments by citing

the DSM criteria for dependence, pointing out that the required number of criteria for a diagnosis

could be met without the inclusion of tolerance and withdrawal. Hagedorn went on to cite the

DSM-IV-TR's statement that "neither tolerance nor withdrawal is necessary or sufficient for a

diagnosis of Substance Dependence" (APA, 2000, p. 194).

As an addition to his argument, Hagedorn could have cited the detailed works of Volkow,

Koob, et al, who established tolerance and withdrawal as a psychological, affective process.

Additionally, Hagedorn could have addressed the first of Erickson’s four points in his 2008

article regarding his issue with the term addiction when it is "used to describe impulsive or

compulsive behaviors associated with sex, the Internet, gambling, pornography, and others for

which there is no proven relationship to neurochemical pathology of the mesolimbic dopamine

system, the primary site of chemical dependence" (p. 2). The myriad of articles cited throughout

this document flatly counter this claim.

 43

In regards to the argument that defining the recovery process from behavioral addictions

is problematic, Hagedorn acknowledged that the common abstinence-based model used in

chemical addictions is not feasible for recovery from behavioral addictions. In response,

Hagedorn cited existing research calling for the reevaluation of the broadly focused abstinence

model. In doing so, Hagedorn insinuated the Harm Reduction concept and posited the recovery

model of replacing specific unhealthy out-of-control behaviors with healthy and manageable

behaviors.

Hagedorn presented multiple responses to the argument that addictive behaviors are

already contained in other sections of the DSM. For example, he cited Brewer & Potenza's 2008

detailed argument that many ICD's better fit the addiction model, as contrasted with addictive

behaviors classified as ICD's. Additionally, Hagedorn cited the required ego-dystonic

component of ICD's as not present in all cases of addictive behaviors. Similarly, Hagedorn ruled

out the placement of addictive behaviors in the OCD category due to the OCD element of non-

pleasure in the activity as inconsistent with many addictive behaviors, often engaged in for

pleasure purposes.

Hagedorn (2009) proposed adaption of Goodman's (2001) "Addictive Disorder"

diagnosis, and offered the addition of 8 subtypes:

1. Eating type. e.g., binging, restricting, and/or purging.

2. Exercise type. e.g., running, gym activities, and exercise classes.

3. Gambling type. e.g., betting on sports events and playing machines or table

games.

4. Internet type. e.g., gambling, sex, instant messaging, purchasing, information

surfing, role playing, and gaming.

 44

5. Sexual type. e.g., masturbation, pornography, multiple sexual partners, and

exhibitionism.

6. Spending type. e.g., purchasing gifts or buying unnecessary or multiple items.

7. Work type. e.g., spending excessive time or energy on work projects.

8. Addictive disorder, NOS. A maladaptive pattern of addictive behaviors that do

not meet the criteria of any specific addictive disorders subtype, leading to

clinically significant impairment or distress, as manifested by three (or more) of

the criteria for an addictive disorder, occurring at any time in the same 12-month

period. Examples of behaviors that may be found in this category include

television viewing, video gaming, religious practices, and relationships. (p.121-

123)

Hagedorn's article included results of a study wherein masters and doctoral level

clinicians, as well as educators and graduate students, were interviewed regarding the proposed

diagnosis. These results illustrated that 54% totally supported the diagnosis, 38% supported with

reservations, and 8% had no opinion.

Hagedorn emphasized that the creation of a diagnosis for addictive disorders would help

the suffering individuals, the counselors treating them, and society at large. Hagedorn stated that

the creation of a diagnosis for behavioral addictions would facilitate the increased training of

future clinicians, increased professional and public understanding of addictions, and

encouragement and support for additional empirical research related to the various addictive

disorders. He went on to posit multiple clinical benefits, such as a common language within the

medical profession, more inclusive treatment approaches to encompass multiple addictions, and

the creation of standardized assessment and treatment protocols.

 45

Hagedorn suggested that the lack of a formal diagnostic category has led to an

environment where there is a lack of availability of treatment services for process addictions and

a lack of financial support from insurance plans to facilitate treatment. Hagedorn elaborated on

this position by presenting compiled estimates for the number of people suffering from

behavioral addictions and overlaid them with the number of matching specialized treatment

centers existing at the time. Specifically, he cited 88 treatment centers available to treat the

estimated 14 to 26 million individuals who have an eating disorder (1:227,000 ratio), 30

treatment centers available to treat the estimated six to nine million individuals with a

compulsive gambling disorder (1:250,000 ratio), 25 treatment centers available for the estimated

17 to 37 million individuals with sex addiction (1:1,080,000 ratio), and 10 treatment centers

available for the 17 to 41 million people with internet addiction (1:2,900,000 ratio) (Hagedorn,

2009, p. 110-111).

Grant, Potenza, Weinstein, and Gorelick (2010) support the notion, offering the following

conclusion to their literature review on behavioral addictions:

Growing evidence suggests that behavioral addictions resemble substance addictions in

many domains, including natural history, phenomenology, tolerance, comorbidity,

overlapping genetic contribution, neurobiological mechanisms, and response to

treatment, supporting the DSM-V Task Force proposed new category of Addiction and

Related Disorders encompassing both substance use disorders and non-substance

addictions. Current data suggest that this combined category may be appropriate for

pathological gambling and a few other better-studied behavioral addictions, e.g., Internet

addiction. (p. 1)

Pathological Gambling
 46

The most commonly accepted behavioral addiction is pathological gambling. Ashley and

Boehlke (2012) referred to Pathological Gambling as a "hidden addiction" because there are no

physical symptoms like in chemical addictions (needle marks, red eyes, slurred speech, etc).

In their review on Behavioral Addictions, Clark & Limbrick-Oldfield (2013) referred to

pathological gambling as the "prototypical" behavioral addiction (p. 655). The recent acceptance

of pathological gambling as a behavioral addiction is relevant to the exploration of Internet

Addiction as a behavioral addiction due to their common characteristics, diagnostic criteria,

neurobiology, and overlapping research histories.

Diagnostic history of Pathological Gambling. Pathological Gambling was first

included as a mental disorder in the DSM-III (APA, 1980). The initial criteria were

predominately focused on the consequences of behavior. A diagnosis required meeting a

minimum of three of seven criteria such as arrests, defaulting on debts, disrupted relationships,

lost job, lost money, or the use of loan sharks. An exclusionary criterion of Antisocial

Personality Disorder was included. The diagnostic criteria in the DSM-III-R refocused from

consequences to behaviors. The diagnosis required meeting a minimum of four of nine factors,

such as preoccupation, spending larger amounts of time and/or money than intended, or failed

efforts to stop the behavior. The DSM-III-R did not include any exclusionary criteria.

The list of criteria in the DSM-IV and DSM-IV-TR was expanded to ten. Two are similar

to DSM-III consequences, six are similar to DSM-III-R behaviors, and two are new criterions.

The new criteria involve "chasing one’s losses" and the need for a "financial bailout" (APA,

2001, p. 674). Additionally, an exclusionary criterion of manic episodes was added. A formal

diagnosis required meeting a minimum of five of the ten following criteria:

A. Persistent and recurrent maladaptive gambling behaviors as indicated by five (or

 47

more) of the following:

1. is preoccupied with gambling, (e.g., preoccupied with reliving past gambling

experiences, handicapping or planning the next venture, or thinking of ways to get money

with which to gamble)

2. needs to gamble with increasing amounts of money in order to achieve the desired

excitement

3. has repeated unsuccessful efforts to control, cut back, or stop gambling

4. is restless or irritable when attempting to cut down or stop gambling

5. gambles as a way of escaping from problems or relieving a dysphoric mood (e.g.,

feelings of helplessness, guilt, anxiety, or depression)

6. after losing money gambling, often returns another day to get even (chasing ones

losses)

7. lies to family members, therapists, or others to conceal the extent of involvement with

gambling

8. has committed illegal acts such as forgery, fraud, theft, or embezzlement to finance

gambling

9. has jeopardized or lost a significant relationship, job, or educational or career

opportunity because of gambling

10. relies on others to provide money to relieve a desperate financial situation caused by

gambling. (APA, 2001, p. 674)

Pathological Gambling was categorized as an Impulse Control disorder (ICD) in the

DSM-III through DSM-IV-TR. The defining features of ICD's are "tension or arousal before

committing the act” and “pleasure, gratification or relief at the time of committing the act”
 48

(APA, 2001, p. 663). In contrast, the defining features of Obsessive-Compulsive Disorders

(OCDs) are "recurrent obsessions or compulsions that are severe enough to be time consuming

or cause marked distress or significant impairment" (APA, 2001, p. 456). The compulsive

actions are thus taken to relieve the obsessive thoughts. As such, ICD's and OCD's have been

hypothesized to constitute a spectrum, with the ego-syntonic impulsive acts found in ICD's

placed on the one end, and the ego-dystonic compulsive acts found in ICD's placed on the other

(El-Guebaly, Mudry, Zohar, Tavares, & Potenza, 2011).

Neurobiology of Pathological Gambling. In addition to the aforementioned research

into the neurobiology of both substance abuse and behavioral addictions, there is a substantial

body of research specifically into the neurobiology of pathological gambling. Indeed, many of

the above mentioned studies on behavioral addictions use pathological gambling as the

prototype. Other studies directly compare and contrast the neurobiology of pathological

gambling with the neurobiology of substance use disorders. For example, Potenza (2013; 2008)

published two literature reviews specific to the neurobiology of pathological gambling. In his

first literature review, investigating commonalities between pathological gambling and substance

abuse, Potenza (2008) found similarities to extend to clinical, genetic, epidemiological,

phenomenological and other biological domains, and raised the question as to whether

pathological gambling would be more appropriately categorized as a behavioral addiction.

These findings are reinforced in his second study, in which he found multiple brain regions

(ventral striatum, ventromedial prefrontal cortex, insula, among others), and neurotransmitter

systems (norepinephrine, serotonin, dopamine, opioid and glutamate) to be problematic in

pathological gamblers (Potenza, 2013).

Building upon such research, Leeman & Potenza (2012) published a review on the
 49

similarities and differences between pathological gambling and substance use disorders. These

authors illustrated multiple similarities between pathological gambling (PG) and substance use

disorders (SUDs) in regards to brain function (frontal cortices, striatum and insula) and

neurotransmitter system research findings (dopamine, serotonin, opioids, glutamate and

norepinephrine). Similarly, el-Guebaly, Mudry, Zohar, Tavares, & Potenza (2012) published a

review investigating the appropriateness of fit of pathological gambling as an impulse control

disorder or as an addictive disorder. Based on findings of applicable neurotransmitters,

neurocircuitry, and genetics, as well as response to pharmacotherapies, these authors posited a

greater connection pathological gambling and substance use disorders than between pathological

gambling and impulse control disorders. As a final example, Brevers & Noël (2013) published a

literature review where they found pathological gambling to fit within the I-RISA, Anti-Reward,

Incentive Salience/Sensitization, and habit models of addiction. Similarly, Gyollai et al., (2013)

published a literature review on the genetics of pathological gambling and conclude by

validating its inclusion in the RDS constellation of behaviors.

Internet Addiction/Internet Use Disorder

Researchers have been studying Internet Addiction for nearly two decades. Clinicians

and researchers have been regularly developing and evaluating assessment criteria and

instruments, as well as treatment approaches. As will be illustrated later in this paper, research

into these and other subtopics is required for inclusion in the book. When reviewing Internet

Addiction in order to address the research questions contained within this study, it is also

important to understand both the similarities and discrepancies of differing concepts and

terminology associated with the phenomenon. From there, a complete understanding of the

literature and science can emerge.

 50

History, classification, and assessment of Internet Addiction. The concept of

"Internet Addiction" was first posted by Goldberg in 1996 on the now defunct "Psychology of

the Internet" mailing list (Suler, 1998). Goldberg’s post was a hoax, jokingly announcing the

formation of an Internet Addiction Support Group (IASG). In doing so, however, he proposed

the novel concept of Internet Addiction Disorder (IAD), along with a detailed set of criteria for

the disorder:

Internet Addiction Disorder (IAD) - Diagnostic Criteria:

A maladaptive pattern of Internet use, leading to clinically significant impairment or

distress as manifested by three (or more) of the following, occurring at any time in the

same 12-month period:

(I) tolerance, as defined by either of the following:

(A) A need for markedly increased amounts of time on Internet to achieve satisfaction

(B) markedly diminished effect with continued use of the same amount of time on

Internet

(II) withdrawal, as manifested by either of the following

(A) the characteristic withdrawal syndrome

(1) Cessation of (or reduction) in Internet use that has been heavy and prolonged.

(2) Two (or more) of the following, developing within several days to a month after

Criterion 1:

(a) psychomotor agitation

(b) anxiety

(c) obsessive thinking about what is happening on Internet

(d) fantasies or dreams about Internet

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(e) voluntary or involuntary typing movements of the fingers

(3) The symptoms in Criterion 2 cause distress or impairment in social, occupational or

another important area of functioning

(B) Use of Internet or a similar on-line service is engaged in to relieve or avoid

withdrawal symptoms

(III) Internet is often accessed more often or for longer periods of time than was intended

(IV) There is a persistent desire or unsuccessful efforts to cut down or control Internet

use

(V) A great deal of time is spent in activities related to Internet use (e.g., buying Internet

books, trying out new WWW browsers, researching Internet vendors, organizing files of

downloaded materials.)

(VI) Important social, occupational, or recreational activities are given up or reduced

because of Internet use.

(VII) Internet use is continued despite knowledge of having a persistent or recurrent

physical, social, occupational, or psychological problem that is likely to have been caused

or exacerbated by Internet use (sleep deprivation, marital difficulties, lateness for early

morning appointments, neglect of occupational duties, or feelings of abandonment in

significant others). (Suler, 1998)

Although intended as a joke, Goldberg's post laid the groundwork for what would

become an ongoing "sandbox" regarding both terminology and diagnostic criteria for the concept

of Internet Addiction. Later the same year, Young presented the first empirical research on

Internet Addiction at the American Psychological Association's annual conference (Young,

1996). In this paper, Young used the DSM-IV criteria for Pathological Gambling, modified to
 52

create the impulse-control disorder of Internet Addiction. From there, she went to develop a

scaled 8-question instrument, known as the Young Diagnostic Criteria (YDQ or simply DQ)

(Young, 1996). Two years later, Young slightly revised her test to include some criteria for

substance abuse. In doing so, she created the 20-question Internet Addiction Test (IAT) (Young,

1998). Additionally, Young expanded her analysis of Internet Addiction to cover a medley of

behaviors and impulse control problems. In doing so, she created five specific subtypes:

1) Cybersexual addiction (cybersex, cyberporn)

2) Cyber-relationship addiction

3) Net compulsions (day-trading, gambling, shopping)

4) Information overload: (database searches, web surfing)

5) Computer addiction (video games) (Young, 1999)

Although Young's work was considered the primary authority on Internet Addiction at

the time, there were a few other instruments developed in parallel. Brenner (1997) created the

Internet-Related Addictive Behavior Inventory (IRABI), a 32-question tool using a true/false

scale. The IRABI showed high reliability and was later translated by Chou & Hsiao (2000) and

adapted for the Chinese culture (C-IRABI). Morahan-Martin and Schumacher (2000) developed

the Pathological Use Scale (PIUS) to measure Problematic Internet Use (PIU) in college

students. The authors defined PIU as "Internet use which causes a specified number of

symptoms, including mood-altering use of the Internet, failure to fulfill major role obligations,

guilt, and craving" (p.14). As such, they developed a 13-question scale to measure the impact of

excessive Internet use on individual’s academics, interpersonal relationships, moods, and stress

levels. Their analysis yielded high reliability and good construct validity for this scale

(Morahan-Martin & Schumacher, 2000).

 53

In 2001, Beard and Wolf proposed a modification to the YDQ criteria (m-YDQ). Their

recommendation included a division of the criteria into two sets: 1-5 and 6-8. The new model

required all five of the first set of criteria to be met and at least one of the last three criteria be

met. The rationale of the modification was that it is possible to meet the entire first set of criteria

without impairment in daily functioning. As the second set of criteria reflects actual impairment,

one need only meet a single item in order to reflect the impact of pathological use. The complete

set of criteria used on both tests is as follows:

1. Is preoccupied with the Internet (think about previous online activity or anticipate next

online session).

2. Needs to use the Internet with increased amounts of time in order to achieve

satisfaction.

3. Has made unsuccessful efforts to control, cut back, or stop Internet use.

4. Is restless, moody, depressed, or irritable when attempting to cut down or stop Internet

use.

5. Has stayed online longer than originally intended.

6. Has jeopardized or risked the loss of a significant relationship, job, educational or

career opportunity because of the Internet.

7. Has lied to family members, therapist, or others to conceal the extent of involvement

with the Internet.

8. Uses the Internet as a way of escaping from problems or of relieving a dysphoric mood

(e.g., feelings of helplessness, guilt, anxiety, depression). (Beard & Wolf, 2001; Young,

1999)

Griffiths (2000a) agreed that Internet addiction exists, but only for an "exceedingly tiny
 54

minority" (p. 417). An expert in pathological gambling, Griffiths defined addictive behaviors as

those that fit a list of six criteria; salience (behavior becomes top life priority), mood

modification ("buzz", high, escape, numbing), tolerance (increased time needed to achieve

modification), withdrawal (negative mood states when offline), conflict (interpersonal problems

resulting from overuse), and relapse (recurring return to Internet use after attempts to stop). In

the same year, Griffiths (2000b) published an article offering five case studies of which he

argued only two fit the criteria for addiction. He believed that the excessive Internet usage in the

other three cases was "purely symptomatic" (p.216) of an alternate psychological concern.

Davis (2001) referred to the use of the term Internet Addiction term as a "misnomer"

(p.187), citing the DSM-IV's exclusion of non-chemical addictions. As such, Davis introduced

the term Problematic Internet Use (PIU), a term that remains the top contender to the term

Internet Addiction. Davis moved away from the addiction model by proposing PIU as patterns

of maladaptive behaviors and cognitions regarding Internet use that result in negative life

outcomes. Davis proposed two forms of PIU: specific and generalized. Specific PIU (SPIU)

refers to overuse of content-specific behaviors on the Internet, such as cybersex, gambling, or

stock trading. While explicitly avoiding the term addiction in regards to these behaviors, Davis

argued that these specific problematic behaviors would manifest in an alternative way in the

absence of the Internet. Conversely, generalized PIU (GPIU) is a broader overuse of the Internet

that results in negative life consequences. Davis stated symptoms of GPIU as content-neutral

Internet-related maladaptive behaviors and cognitions related to Internet use that are not linked

to any specific content. Rather, GPIU occurs when an individual develops problems due to the

unique interactive context of the Internet. As restated by Caplan (2002), "They are drawn to the

experience of being online, in and of itself" (p.553). The next year, Davis developed his own
 55

scale called the Online Cognition Scale (OCS). Davis based this instrument not only on his

previous work on problematic cognitions (vs. behaviors), but also on preexisting instruments

measuring depression, impulsivity, pathological gambling, and procrastination (Davis, Flett, &

Besser, 2002). The scale has high reliability and construct validity, and yields four factors

connected to problematic Internet use: loneliness/depression, diminished impulse control,

distraction, and social comfort.

Caplan (2002) further addressed the growing disagreement regarding the use of the term,

addiction, as applied to excessive Internet use. He stated three primary concerns: a lack of

"conceptual or theoretical specificity" (p.555), a lack of empirical research supporting the

alignment of excessive Internet use as an addiction, and that the addiction model does not

address the actual online behaviors, some of which might be problematic and some of which may

not. As such, Caplan preferred to use Davis's (2001) term Problematic Internet Use (PIU).

Caplan focused on GPIU as the larger problem, and developed a new assessment instrument, the

Generalized Problematic Internet Use Scale (GPIUS). In developing the GPIUS, Caplan

collected content from three sources; specific problematic behaviors, cognitions, and outcomes

referenced by Davis (2001), a review of pre-existing assessment instruments for Internet

addiction, and Caplan's own theoretical contributions (Caplan, 2002). The result was an

instrument with strong reliability and construct validity that focused on the following seven sub-

dimensions: Mood alteration, perceived online social benefits, Internet related negative

outcomes, compulsive Internet use, excessive time online, offline withdrawal symptoms, and

perceived online social control. Caplan later revised the instrument (GPIUS-2) to include the

dimension of deficient self-regulation (Caplan, 2010).

Chen et al. (2003) developed a tool to assess Internet addiction in the Chinese population.
 56

This tool, the Chen Internet Addiction Scale (CIAS), is a 26-item self-report that measures five

dimensions that are largely similar to those measured in the western-based instruments:

compulsive use, tolerance, withdrawal, psychosocial problems, and physical health. Their

psychometric testing showed good reliability and construct validity for this instrument (Chen et

al., 2003).

Shapira et al. (2003) published an article specifically positing the classification of PIU as

an impulse-control disorder rather than an addiction. The author’s first reference Griffiths

(2000a) model of behavioral addictions, and then presented their own simplified set of three

criteria for PIU:

A. Maladaptive preoccupation with Internet use, as indicated by at least one of the

following:

1. Preoccupations with use of the Internet that are experienced as irresistible.

2. Excessive use of the Internet for periods of time longer than planned.

B. The use of the Internet or the preoccupation with its use causes clinically significant

distress or impairment in social, occupational, or other important areas of functioning.

C. The excessive Internet use does not occur exclusively during periods of hypomania or

mania and is not better accounted for by other Axis I disorders. (p.213)

Nicolas and Nicki (2004) published an article in which they made a bold statement:

Despite the fact that there has been a great deal of media attention paid to so-called

“Internet addiction,” there is very little scientific evidence to support a claim of Internet

addiction being a widespread phenomenon. The evidence that exists is based on poorly

designed assessment measures and biased sampling techniques. Furthermore, many

studies have used weak and inconsistent criteria in their identification of Internet addicts.
 57

(p.381)

In making these claims, the authors made no reference to the already established and

validated CIAS, GPIUS, IAT, IRABI, OCS, YDQ, or m-YDQ. Instead, they claimed that the

purpose of their study was to take the first steps towards creating a new instrument, the Internet

Addiction Scale (IAS), with "acceptable" (p. 381) psychometric properties "so that Internet

addiction might be more meaningfully assessed” (p.381). They based the IAS on the DISM-IV-

TR criteria for Substance Dependence, and two of Griffiths (2000a) six criteria: salience and

mood modification. As is the case with the instruments overlooked in the article, their testing

yielded high reliability and good construct validity for the IAT (Nicolas & Nicki, 2004).

Concerned about the "absence of consensus on a universal theoretical framework, or on

definitions, criteria, and core elements" (p.1), Meerkerk, Van Den Eijnden, Vermulst, &

Garretsen (2009) created the Compulsive Internet Use Scale (CIUS). These authors used

Compulsive Internet Use (CIU) as the preferred alternate to Internet Addiction, and made no

mention of the term Problematic Internet Use (PIU). The authors acknowledged the IAT, IAS,

GPIUS, and OCS as valid existing tests for Internet addiction, however they believed these tests

were too long and cumbersome to be universally useful instruments. As such, they created the

CIUS to be a "short, easily administered, psychometrically sound, and valid instrument to assess

the severity of compulsive Internet use" (p.1). The authors reviewed the previous instruments

and extracted what they considered to be seven primary and core dimensions: preoccupation,

conflict, coping, loss of control, lying about involvement, tolerance, and withdrawal symptoms.

Their testing revealed the CIUS to be reliable, with good construct validity, and having

concurrent validity with the OCS (Meerkerk, Van Den Eijnden, Vermulst, & Garretsen, 2009).

Van Rooij, Schoenmakers, Van de Eijnden, & Van de Mheen (2010) attempted to
 58

separate GPIU from SPIU. More specifically, their intent was to "distinguish between the

medium of Internet and its specific applications" (p. 51). These authors utilized data from two

national Dutch studies; a 2007 survey with 4,920 responses, and a 2008 survey with 4,753

responses. The authors segregated the responses into what they considered to be five key subject

areas of compulsive use: chatting, mailing, surfing, gaming, and social networks. The authors

then further expanded and subdivided the results into the following ten categories: "surfing, e-

mailing, downloading, social networking (including forums), (we)blogging, Habbo Hotel (a

virtual world/chat room), casual games (browser based), online games (multiplayer online),

chatting (anonymous), MSN (rebranded to Windows Live Messenger in 2005), and a

miscellaneous category ‘‘other" (p. 53).

Despite the apparent thoroughness of the data collection, these researchers appear to have

a perplexingly fundamental misunderstanding of the Internet. The use of a verb to define a

category creates the same problem they are attempting to resolve - confounding general use

(surfing) with specific use (surfing). As an example, the category/action "surfing" is

meaningless without definition, as it could be used to refer to surfing pornography sites

(pornography addiction), or surfing retail sites (shopping addiction). As another example, the

MSN category is wrought with problems. MSN is a content-aggregator/search-engine website,

and thus logically belongs in the surfing category. Additionally, however, the specific text in the

article titles the category as "MSN (rebranded to Windows Live Messenger in 2005)" (p. 53).

Windows Live Messenger is an instant messaging site, and thus logically belongs in the chatting

category. A research paper is clearly problematic if one category better qualifies as a member of

two other categories.

Sim, Gentile, Bricolo, Serpelloni, & Gulamoydeen (2012) also argued against the
 59

application of the addiction model, proposing instead "Pathological Technology Use” (PTU),

which then subsumes computer, Internet, and video game use. Somewhat inconsistently, these

researchers also argued that addictive behaviors on the Internet could be addressed through their

underlying content area, but problematic behaviors on the Internet could not:

Some researchers of Internet addiction have suggested that there are several distinct types

of Internet addiction, including addiction to online sex and addiction to online gambling.

We feel that these issues are not the same as pathological Internet use, and would be

better defined as other types of impulse control disorders, as the underlying disorder is

about sex or gambling and the Internet is simply the delivery mechanism used. Treating a

pathological gambler’s computer use is unlikely to resolve the underlying problem. (p.

749)

The components of their argument are not entirely original. Griffiths (1995; 2013)

considered the concept of primary and secondary addictions. He proposed primary addictions as

"those in which a person is addicted to the activity itself, and that individuals love engaging in

the activity whether it is gambling, sex, or playing video games" (p. 1). In contrast to the "buzz"

or "high" from primary addictions, Griffiths theorized secondary addictions as those behaviors

engaged in for the purposes of numbing and escape. Based on this distinction, Griffiths

identified secondary addictions as easier to treat, as the addiction is but a symptom of another

problem. Griffiths (2008) later restated his 1995 position as

There are clearly many types of addiction including ‘primary addiction’ (where the

person is addicted to the activity itself) and ‘secondary addiction’ (where the person’s

addiction is symptomatic of other problems). Put simply, addictions should be defined in

terms of the resultant behaviour of the individual not the cause(s) of the behaviour. (p.
 60

184)

Yau, Crowley, Mayes, and Potenza (2012) echoed this sentiment, stating

Approximately 86% of IA cases have another DSM-IV-TR diagnosis present, leading

some to argue that the Internet in itself is not an issue; rather, the content (e.g. gambling,

pornography, or gaming...) to which it facilitates access is the concern. Whether

comorbidities with such conditions as pathological gambling, hypersexual disorder or

problematic video-gaming (PVG) may define IA and be reflected in shared etiological

factors or may reflect IA being a “secondary disorder” remains an important and debated

consideration. (p. 2)

Other recent studies have corroborated the addiction model. For example, Kuss, Griffiths,

Karila, & Billieux (2013) concluded that the concept of Internet addiction matches Shaffer's

syndrome model of addiction (wherein all addictions share a common neurobiological and

phenomenological course (Shaffer et al., 2004)). Similarly, Kuss, Shorter, van Rooij, Griffiths,

& Schoenmakers (2013) recently concluded that Internet addiction matches Griffith's

components model of addiction (salience, mood modification, tolerance, withdrawal symptoms,

conflict, and relapse (Griffiths, 2005).

Jelenchick et al. (2014) recently developed the Problematic and Risky Internet Use

Screening Scale (PRIUSS). These authors posited Problematic Internet Use (PIU) as a distinct

but "highly comparable" (p. 172) concept to Internet Addiction or Compulsive Internet Use.

Citing their previous work on PIU (Moreno, Jelenchick, & Christakis, 2013), the authors listed

Emotional Impairment, Impulsive Internet Use, Internet Use Dependency, Physical Impairment,

and Psychosocial Risk Factors as the primary elements of the PIU conceptual framework. Note

that the term PIU is becoming increasingly accepted in the most current research circles,
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bringing with it another term: At-Risk Problematic Internet Use (ARPIU). For example, two

studies were published during the making of this paper that investigated factors differentiating

ARPIU users from non-ARPIU users (Yau et al., 2014; Yau, Potenza, & White, 2013).

Literature Reviews. There have been many literature reviews published in the last five

years on the topic of Internet addiction, with at least seven published within the last five years:

Billieux & Van der Linden, (2012); Byun et al., (2009); Kuss, Griffiths, Karila, & Billieux,

(2013); Moreno, Jelenchick, Cox, Young, & Christakis, (2011); Weinstein, (2010); Weinstein &

Lejoyeux, (2010); Winkler, Dorsing, Rief, Shen, & Glombiewski (2013). A key disparity among

these reviews is the inclusion/exclusion of certain assessments and disagreement over

terminology.

Byun et al. (2009) reviewed the period 1996-2006, querying unnamed "academic

databases" (p.204), as well as the Google and Yahoo! search engines using the keywords Internet

addiction, Internet addicted, problematic Internet usage, and computer addiction. Their initial

search yielded 120 articles, with a final count of 39 articles after they screened for scope and

scientific methodologies. These authors acknowledge the problems with terminology, citing the

current terms as Cyberspace Addiction, Internet Addiction Disorder, Online Addiction, Net

Addiction, Internet Addicted Disorder, Pathological Internet Use, and High Internet Dependency.

As did Chou et al. (2005), these researchers choose Internet Addiction as the preferred term.

Byun et al. (2009) reference the same tests as did Chou, Condron, & Belland (2005), including

Goldberg's IAD, however they do include Young's IAT.

Weinstein & Lejoyeux (2010) reviewed articles exclusively on "Internet addiction" and

"problematic Internet use" published in Medline and PubMed between 2000-2009. This overlaps

with Byun et al.'s (2009) study by 6 years. The authors stated 3 arguments for nosology of
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Internet Addiction; an impulse control disorder placed somewhere on OCD spectrum, an impulse

control disorder removed into its own stand-alone category, or as a member of the Behavioral

Addiction spectrum believed at the time to be created in the DSM-5. The authors further stated

the importance of investigating similarities between Internet addiction and substance abuse, and

highlight Block's (2008) four key components for a diagnosis of Internet addiction: 1) excessive

Internet use, 2) withdrawal, 3) tolerance, and 4) adverse consequences. Weinstein and Lejoyeux

(2010) stated "There are currently no diagnostic instruments for Internet addiction that show

adequate reliability and validity across countries” (p.278). This is perplexing because the

authors immediately proceeded to provide a partial list of the predominant assessment

instruments and the countries in which they have been validated, specifically referencing the IAT

and its validation in multiple countries, the CIAS and its use in China and Taiwan, and the

Compulsive Internet Use Scale (CIUS) from Holland. It is also perplexing that the authors of

this 2010 article chose to provide internet addiction prevalence rates in the USA based on an

ABC-NEWS survey conducted in 1999.

Moreno, Jelenchick, Cox, Young, and Christakis (2011) conducted a specialized study

attempting to evaluate prevalence rates of Internet addiction among US college students. These

authors also referenced the terms Internet Addiction and Problematic Internet Use (PIU) as

interchangeable, however they choose PIU as their primary term. Their search range had no start

date and an end date of July 2010. This overlapped the time range of the Byun et al. (2009)

study by 6 years, and all of the Weinstein & Lejoyeux (2010) study. While Weinstein &

Lejoyeux searched Medline & PubMed for articles on "Internet addiction", these authors

reviewed PubMed, PsycINFO, and the Web of Knowledge using the terms Internet addiction,

compulsive Internet use, problematic Internet use, pathological Internet use, Internet dependence,
 63

and excessive Internet use. This broad search yielded 658 initial results, which the authors

reduced to a final count of eight using a Strengthening the Reporting of Observational Studies in

Epidemiology (STROBE) quality review tool. Although the authors referenced 13 assessment

tools, including the CIAS, CIUS, GPIUS, IAT, PIU, and the YDQ, only one of the articles

utilized was based on an established scale (the IAT). Of the remaining seven studies, four

utilized individually developed assessment instruments based on DSM-IV criteria for substance

use, and three use unique scales. This could be a contributing factor to the author’s conclusion

that "The evaluation of PIU remains incomplete and is hampered by methodological

inconsistencies" (p.797).

Billieux and Van der Linden (2012) referred to the terminology debate as only consisting

of Internet Addiction vs. Pathological Internet Use. The authors stated a preference for the term

Problematic Internet Use (PIU), although they acknowledge PIU as being either a behavioral

addiction or impulse control disorder. They reported the CIUS, GPIUS, IAT, and OCT as the

primary assessment instruments for PIU. They concluded by reiterating that the PIU construct

still lacked uniform conceptualization, and stated that more research and theoretical elaboration

is required. Carli et al. (2012) investigated co-occurring disorders. Of the twenty studies they

reviewed, 100% were correlated with symptoms of ADHD, 75% with depression, 66% with

hostility/aggression, 60% with obsessive-compulsive symptoms, and 57% with anxiety.

Researchers from the National Institute of Psychiatry in Mexico also conducted a review

on the topic of Internet addiction. These researchers investigated the classification, comorbidity,

diagnosis, electrophysiology, epidemiology, molecular genetics, neuroimaging, and treatment

(pharmacological and non-pharmological) of the disorder. Based on their findings, the

researchers concluded that, "considerable clinical and neurobiological research has been done on
 64

the subject...with research pouring in data from different parts of the world" (Pezoa-Jares,

Espinoza-Luna, & Vasquez-Medina, 2012, p.1,7).

Winkler, Dorsing, Rief, Shen, and Glombiewski (2013) conducted a literature review on

publications studying treatment for Internet addiction. These authors used broad inclusion

criteria coupled with stringent exclusion criteria. Their search returned sixteen studies, twelve of

which were psychologically based, three were pharmacologically based, and one was a mix of

the two. Four of the studies were based on Cognitive Behavioral Therapy, one was based on

Reality Therapy, one was based on Acceptance and Commitment therapy, and seven were multi-

modal counseling programs. The authors further segregated the studies into eleven individual

therapy and six group therapy models. In their conclusion, these authors posit an interesting

notion. While group counseling generally considered the preferred modality for treating

addiction in general, these authors concluded that individual counseling is the better modality for

IA patients. They based their conclusion on the fact that many studies found social issues (high

levels of isolation and social anxiety, combined with low levels of social skills) to be common

among persons addicted to the Internet.

Kuss, Griffiths, Karila, and Billieux (2013) conducted a literature review restricted to

empirical studies that were conducted on greater than 1,000 participants. Among the 68 studies

they reviewed, these authors found no consistent definition of Internet addiction. These authors

identified 21 assessment instruments of varied methodology and psychometric properties. They

reported widely ranging prevalence rates, which they attributed largely to the non-standardized

criteria and assessment instruments. For example, reported adolescent prevalence rates ranged

from 0.8% in Italy to 26.7% in Hong Kong. Similarly broad, reported adult prevalence rates

ranged from 1% in Norwegian adults to 22.8% in Iranian adults. Considering their study to be
 65

epidemiologically based, these authors investigated comorbid symptoms, Internet use variables,

psychosocial factors, and sociodemographic variables. In articulating the need for further

research, these authors concluded that the heavy comorbidity with substance abuse problems

could indicate common neurobiological and psychosocial features.

International acceptance of Internet Addiction. Many countries outside the USA have

been more open-minded in their acceptance of the concept of Internet Addiction. International

research teams have conducted multiple studies on the subject. Listed below is a thorough, but

not exhaustive, representation of international research on Internet Addiction.

Khazaal et al. (2011) stated that from 2000 to 2010 Internet users in the Arab world

increased by 2500% to 65.4 million persons. These researchers noted concern over a lack of

assessment tools available in this region. As such, they created an Arabic language version of

the CIUS. Their analysis yielded similar positive psychometric properties for this translated test

when contrasted with the original language CIUS (Khazaal et al., 2011).

Su, Fang, Miller, and Wang (2011) used the YDQ to measure Internet Addiction among

College Students in Beijing. Their study found that over ten percent of college students suffered

from Internet Addiction, leading both the Department of Applied Psychology, College of

Humanities and Social Sciences, Fuzhou University, and the National Key Laboratory of

Cognitive Neuroscience and Learning, Institute of Developmental Psychology, Beijing Normal

University, to acknowledge Internet Addiction as a serious problem among college students in

China.

Du, Jiang, and Vance (2010) investigated therapeutic methods for Internet Addiction.

They used the m-YDQ to generate a test sample of Internet addicted adolescents in Shanghai to

contrast with controls. Using a school-based group CBT treatment model, the researchers found
 66

improvements in behavioral and self-management modes as well as the students' ability to

regulate emotional states. Additionally, the Tao et al. (2010) paper, considered authoritative by

members of both the APA and ASAM in the US, was generated by a group of researchers from a

military hospital in Beijing.

Researchers at Masaryk University in the Czech Republic accepted the Griffiths (2000a)

model of Internet Addiction and utilized it to study factors such as the associations between

online friendships and Internet Addiction (Smahel, Brown, & Blinka, 2012). Their study of

Czech youths, ages 12–26 years, found rates of Internet Addiction to be consistent across age

and gender. The study concluded that individuals suffering from Internet Addiction develop a

preference for maintaining friendships online, allowing off-line relationships to attenuate

(Smahel, Brown, & Blinka, 2012).

Researchers in Finland created a Finnish version of the IAT (Korkeila, Kaarlas,

Jääskeläinen, Vahlberg, & Taiminen, 2010). As with other international versions of the IAT

that were translated and then back-translated, the Finnish IAT was found to be psychometrically

sound. These authors additionally investigated their subjects preferred activities on the internet.

They found "adult entertainment" to be the most common reason for compulsive use, followed

by chatting, and then gaming as the third use. Note that these reasons exactly match Block's

(2008) originally proposed subtypes of Internet Addiction.

Khazaal et al. (2008) created a French language version of the IAT with the specific

intent of measuring the test's psychometric properties in a foreign language. In line with their

expectations, the researchers found a positive correlation between scores on the translated IAT

and excessive time spent online. Their confirmatory factor analysis yielded a psychometrically

sound one-factor model of the IAT when translated into foreign languages (Khazaal et al., 2008).
 67

Wolfling, Buhler, Lemenager, Morsen, and Mann (2009) estimated that up to 1.5 million people,

or 3% of the German population, are at risk for Internet addiction. Barke, Nyenhuis, andKröner-

Herwig (2012) reviewed multiple international studies that successfully utilized the IAT, and

subsequently created a German-language version of the test. They validated the German version

of the IAT as containing good psychometric properties. In parallel, Pawlikowski, Altstötter-

Gleich, & Brand (2013) created a shortened 12-question version of the IAT (s-IAT). As with the

standard German language version, psychometric testing yielded a positive two-factor structure.

Similarly, Wartberg, Petersen, Kammerl, Rosenkranz, & Thomasius (2013) created a German-

language translation of the CIUS, claiming it to be a "valid and suitable diagnostic tool for

measuring problematic to pathological Internet use" (p.1).

Siomos, et.al (2012) conducted a study of the entire adolescent population of the island of

Kos in Greece. They used the YDQ to determine an Internet addiction rate of 8.2% among

Greek young. They also find the most common activities engaged in by Internet addicts to be

viewing online pornography, online gambling, and online gaming.

Chang and Man Law (2008) reviewed all previously mentioned assessment instruments

and decided to further the research exploring the factorial structures of the IAT. They used

English and Chinese versions of the IAT to survey 410 undergraduate students in Hong Kong.

Their psychometric analysis validated three primary dimensions of the IAT. Fu, et al. (2010)

acknowledged Internet addiction as a growing concern, but one still surrounded with uncertainty

among the professional community. These researchers translated the YDQ into Chinese,

referring to the YDQ as "one of the most widely used instruments to assess Internet addiction"

(p.490). Based on the results of their study, they suggested that 6.7% of adolescents in Hong

Kong are addicted to the Internet. Lai et al. (2013) validated the psychometric properties of the
 68

IAT when translated into Chinese. They collected data from a pool of 844 adolescents in Hong

Kong, and contrasted the results with findings from a newly revised version of the CIAS (CIAS-

R). The researchers concluded that the IAS was both valid and reliable as applied to Chinese

adolescents (Lai et al., 2013).

Multiple researchers presented on the topic of Internet Addiction at the 2012 Annual

Indian Psychological Science Congress conference in Chandigarh. Sood, Bakhski, and Sharma

(2012) presented a summary of their recent study assessing the relationship between Internet

addiction and mental health. They used the IAT to illustrate a significant correlation between

Internet Addiction and coexisting mental health concerns in India. Yadav, Banwari, Parmar, and

Maniar (2013) studied 622 high-school students in India, and found an 11.8% prevalence rate

among their subjects. Finally, Vidyachathoth, Kumar, & Pai (2014) studied Internet Addiction

in undergraduate medical students in Mangalore, India. These authors administered the IAT to

90 first-year students and reported a positive correlation between the disorder and negative

affect.

Similarly, Salehi, Khalili, Hojjat, Salehi, & Danesh (2014) studied Internet Addiction in

Iranian medical students. These researchers administered the CIAS to 383 medical students and

found 5.2% to be addicted, with another 2.1% considered at-risk problematic users. These

authors reported multiple risk factors, including the uniquely measured variables of cigarette,

coffee, and tea consumption.

Despite ongoing controversy in the USA, Italian researchers consider the scientific

literature sufficient to prove the existence of Behavioral Addictions, including Eating Disorders,

Internet Addiction, Pathological Gambling, Sex Addiction, and Video Game Addiction.

Assuming Young's IAT as the de facto standard for measuring Internet Addiction, Ferraro, Caci,
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D'amico, & Blasi (2006) created an Italian language version of the test. Although they did not

provide data regarding the reliability of their translated instrument, the researchers concluded

that Italian youth were more at risk for Internet addiction than were Italian adults. Faraci,

Craparo, Messina, and Severino (2013) tested this Italian-language version of the IAT and

conclude that it is psychometrically sound. These researchers noted concern, however, regarding

the differing factorial structures found in previous studies (Barke, Nyenhuis, &Kröner-Herwig,

2012; Chang & Man Law, 2008; Khazaal et al., 2008).

Hawi (2012) administered the Arabic version of the IAT to 833 Lebanese adolescents,

and found a 4.2% prevalence rate of the disorder. Hawi found the higher an individual’s

deficiency needs the greater likelihood that the disorder would emerge. Hawi listed example

deficiency needs as low self-esteem and low self confidence.

Guan, Isa, Hashim, Pillai, and Singh (2012) created a Malaysian-language version of the

IAT to facilitate clinical and research needs in the Malaysian population. Testing the instrument

among a sample of 162 medical students, the researchers indicated the Malaysian version of the

IAT shows good internal consistency and concurrent validity with the CIUS. Their psychometric

analysis yielded a five-factor structure for the Malaysian IAT.

As previously mentioned, Dutch researchers Meerkerk, Van Den Eijnden, Vermulst, &

Garretsen (2009) created the aforementioned CIUS and validated it among subjects in the

Netherlands. These authors found their instrument to be useful for not only measuring the

severity of the problem, but also in identifying at-risk populations. This is the only

internationally developed test to obtain use among US researchers.

Pontes, Patrão, and Griffiths (2014) created a Portuguese language version of the IAT.

Concerned about the lack of research into the problem of Internet Addiction in Portugal. These
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authors administered the Portuguese language version IAT to 593 Portuguese students, and their

subsequent analysis found the test to be psychometrically sound. These researchers also

uniquely investigated potential protective factors from Internet Addiction. They found that being

in a romantic relationship was a protective factor, while having an offline hobby was not a

protective factor.

Chang, Chiu, Lee, Chen, and Miao (2014) acknowledged Internet Addiction as an

"emerging public health problem "(p. 3) in Taiwan. These authors cited many of the studies and

literature reviews included in the present study, but noted that there is a lack of longitudinal

studies, particularly on the risk factors leading to and sustaining Internet Addiction. These

authors studied 2,315 Taiwanese adolescents, first in 10th grade and then in 11th grade. They

found that of the 605 students diagnosed with Internet Addiction in the 10th grade, 63.3% (383)

carried the problem forward with them to the next year.

Internet Addiction is considered to be among the most "serious public health issues" in

South Korea (Ahn, 2007, p.294). Citing an 8.5% prevalence rate of Internet addiction among the

Korean population, Lee et al. (2013) created a Korean-language version of the IAT (K-IAT).

The IAT was chosen based on its "excellent psychometric properties...well documented in the

literature" (p.753). The researchers cited the positive measures of reliability and validity

reported in multiple foreign language translations of Young's original test. They concluded that

the K-IAT is reliable, and has good concurrent, convergent, and factorial validity (Lee et al.,

2013).

Canan, Ataoglu, Nichols, Yildirim, and Ozturk (2010) considered Internet Addiction to

be a "growing problem among Turkish adolescents" (p.317). These researchers acknowledge the

validity of both the GPIUS and the PIUS, however they chose to translate the significantly less
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well-known IAS, based on its more complex factorial structures. The researchers concluded that

the translated version is psychometrically sound, and demonstrates test-retest reliability and

strong construct validity. Gunuc and Dogan (2013) also studied Internet Addiction in Turkish

adolescents and found an inverse relationship between real-life social supports and Internet

Addiction in their population.

Neurobiology of Internet Addiction. In addition to the studies connecting behavioral

addictions with established neuroscience of addiction, such as 3-phase model or the anti-reward

system, research has identified multiple facets of neurobiological abnormalities in Internet

addicted subject when compared with controls. For example, researchers in the Max Planck

Institute in Germany used voxel-based morphometry to analyze the MRI results of subjects self-

identified as excessive Internet users (Kühn & Gallinat, 2014a). Their analysis yielded a

significant negative association between IAT scores and a grey matter reduction in right frontal

pole. The researchers indicated that striatal over-activation in this region may be the

consequence of a reduction in top- down control attempted by the frontal pole. The authors also

state that these changes in the fronto-striatal circuitry are similar to changes reported in substance

addiction. The authors offered a closing limitation that a longitudinal study is necessary to

determine whether the grey matter reduction is the result of excessive Internet use, or if it

represents a preexisting state of the individual that predisposes them to impulsive pleasure

seeking and rewards leaving them vulnerable to Internet Addiction.

Much of the research into the neurobiology of Internet addiction has been conducted

outside of the United States, most often in Asian countries. For example, Hong et al. (2013),

Yaun et al. (2011), and Zhou et al. (2011) all conducted studies investigating the physical gray

matter changes occurring in persons with Internet addiction compared with controls. Hong et al.
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(2013) found Internet addicted subjects to have decreased cortical thickness in the right lateral

OFC (reward-oriented decision-making). Zhou et al. (2011) found decreased gray matter in the

left anterior cingulate cortex (decision making, reward processing), left insula (addiction), left

lingual gyrus (reward processing), and left posterior cingulate cortex (emotional behavior) of the

brains of Internet addicted subjects. Yuan's 2011 study replicated the Zhou et al. 2011 study.

Citing the Zhou study, these researchers found decreased brain matter density in brain areas

involved with the bilateral dorsolateral prefrontal cortex (decision making, working memory),

and the orbitofrontal cortex (decision making) (Yaun et al., 2011).

Similarly, in studies of white matter integrity both Lin et al. (2012) and Joutsa,

Saunavaara, Parkkola, Niemela, & Kaasinen (2011) conducted controlled studies in which both

found decreased white matter integrity (lower fractional anisotropy, higher mean diffusivity) in

many of the same areas, including the inferior fronto-occipital fasciculus, internal capsules,

corpus callosum, and cingulum. The important difference between these two studies is that Lin

et al. (2012) compared Internet addicted patients with controls, while Joutsa, Saunavaara,

Parkkola, Niemela, & Kaasinen (2011) compared pathological gamblers with controls.

Interestingly, Lin, Wu, Zhu, & Lei (2013) also found decreased white matter integrity FA in the

left anterior corpus callosum of chronic cigarette smokers.

Using positron emission tomography (PET) scans, Kim et al. (2011) found decreased

dopamine receptor availability in regions of the brain associated with addiction. Similarly, Hou

et al. (2012) used single photon emission computed tomography (SPECT) to illustrate decreased

expression of striatal dopamine transporters (DAT) in Internet Addicted patients. Conversely,

Zhang, Jiang, Lin, Du, & Vance (2013) assayed neurotransmitter levels in blood serum and

found no difference in dopamine and serotonin levels between internet addicted and control
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subjects. Instead, they found lower levels of norepinephrine in the Internet addicted subjects.

Liu et al. (2010) conducted a novel study wherein they used the regional homogeneity

(ReHo) method to analyze the blood oxygen level-dependent (BOLD) signals within a resting

state fMRI scan of internet addicted patients (screened via the Beard & Wolf modified YDQ).

These researchers found enhanced synchronization among the cerebellum, brainstem, limbic

lobe, frontal lobe, and apical lobe. The researchers indicated that these regions may be

associated with the reward pathways, leading them to conclude that internet addiction may result

in a strengthening of the reward system.

Lin, Kuo, Lee, Sheen, and Chen (2013) investigated potential changes in the autonomic

nervous system of Internet addicted students. They used the Chinese Internet Addiction Scale to

enroll a cohort of 252 subjects aged 12-15 years. Measuring specific components of heart rate

variability, these authors found higher sympathetic activity and lower parasympathetic activity

when compared with controls. These authors noted a potentially confounding variable of

insomnia, increased rates that have been correlated with Internet addiction (Jenaro, Flores,

Gómez-Vela, González-Gil, & Caballo, 2007).

Zhou, Yuan, Yao, Li, and Cheng (2010) used electroencephalography (EEG) technology

to measure and contrast the event-related potentials (ERPs) on Internet addicted subjects

(screened using the YDQ) and control subjects. According to the authors, ERP's illustrate the

electrical activity in the brain, and low amplitude ERP's in specific brain regions are associated

with high levels of impulsivity. The authors stated, "Within neuropsychology and cognitive

neuroscience, impulsivity is often equated with the term ‘disinhibition’, referring to the idea that

top-down control mechanisms ordinarily suppress automatic or reward-driven responses that are

not appropriate to the current demands” (p.233). The researchers concluded that their study
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clearly demonstrated higher impulsivity in PIU subjects than controls, and indicated common

neuropsychological and ERPs characteristics with other disorders, such alcoholism, drug

addiction, and pathological gambling.

Zhou, Li, and Zhu (2013) took EEG measurements on IAD subjects (screened using the

m-YDQ) in order to measure event-related negativity (ERNs). ERN's are a subset of ERP's and

illustrate brain error when subjects attempt to control attention and impulsivity. The lower the

ERN's, the greater chance that the brain will not auto-correct faulty cognitions. The authors cited

studies illustrating low ERN's in ADHD and substance abuse patients having difficulty

suppressing the urge to accept short-term rewards despite negative long-term consequences. The

authors report decreased ERN's in the IAD subjects compared to controls. Attributing the low

ERN's to deficits in executive functioning, these researchers also claimed that their results

clearly indicated higher impulsivity in IAD subjects than controls. These authors also found

neuropsychological and ERN characteristics in common with other disorders, such as substance

abuse and pathological gambling.

Yu, Zhao, Li, Wang, and Zhou (2009) conducted a small study investigating P300 levels

of Internet addicted subjects compared to controls. These authors found Internet addicted

subjects to have a significantly increased P300 amplitudes and a significant increase in P300

latencies. In partial contrast, Ge et al. (2011) found Internet addicted subjects to have similar

P300 amplitudes as controls, but significantly increased P300 latencies. These authors also

found these P300 latency increases to return to normal levels after subjects completed a three-

month CBT program.

Finally, Montag, Kirsch, Sauer, Markett, & Reuter (2012) claimed they may have found a

molecular indicator of Internet Addiction via the gene coding for the nicotinic acetylcholine
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receptor subunit alpha 4 (CHRNA4). These researchers collected DNA samples from 132

Internet addicted subjects (screened via the IAT) and 132 controls. The researchers found a

significant increase in a specific polymorphism on the CHRNA4 gene in the Internet addicted

subjects. Lee et al. (2008) found a similar increase in the homozygous short allelic variant of the

serotonin transporter gene 5HTTLPR.

Controversy. The controversy over the concept of behavioral addictions can be entirely

overlaid with the controversy over the concept of Internet addiction. For example, Starcevic

(2010) argued, "Internet addiction” is a troublesome term, not only because of its pejorative

connotations, but also because there is no evidence that this is really an addictive disorder, i.e.,

that it is characterized by the hallmarks of substance addiction such as tolerance and withdrawal"

(p.92). In making this argument, Starcevic revealed his fundamental misunderstanding of the

characteristics of addiction: that physiological tolerance and withdrawal are not components of

the disease of addiction (See DSM-IV TR, "Neither tolerance nor withdrawal is necessary or

sufficient for a diagnosis of Substance Dependence" (APA, 2001, p. 194) and DSM-5, "Neither

tolerance nor withdrawal is necessary for a diagnosis of a substance use disorder” (APA, 2013,

p. 484)). Kim and Kim (2010) argued that the Internet is simply a medium of content, and one

cannot be addicted to media separate from its content; "Internet users are no more addicted to the

Internet than alcoholics are addicted to bottles" (p. 389). This is an arguably flawed analogy, as

the content of bottles is heterogeneous (whisky, wine, beer, etc.), and alcoholics are generally

addicted to any content contained within the bottle. King and Delfabbro (2013a) proposed a

similar counter argument when they stated that gambling addiction involves addiction to a

delivery mechanism (slot machine, deck of cards, etc.), as does gaming addiction (game console,

computer, handhelds, etc.). Starcevic (2013) furthered this argument when he stated, "Being
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addicted to the Internet implies addiction to a “delivery mechanism” or more precisely, addiction

to a medium, a means to an end or a vehicle for achieving something. Therefore, Internet

addiction is as meaningful a term as “casino addiction,” which would denote addictive gambling

in casinos” (Starcevic, 2013, p.17). King and Delfabbro (2013a) articulated this concern more

rationally when they stated, "The main limitation of the DSM-5 Internet use disorder is that it is

an over inclusive concept that does not actually refer to any specific addictions to the Internet"

(p.21).

Proposed for DSM-5. In 2008, Block published an editorial formally proposing Internet

Addiction for inclusion in the DSM-5. Blurring terminological lines, Block posited "Internet

Addiction" as a "compulsive-impulsive spectrum disorder" (p.306). Block offered three

subtypes of Internet Addiction; excessive gaming, sexual preoccupations, and e-mail/text

messaging. Yau, Crowley, Mayes, and Potenza (2012) later suggested the addition of a fourth

subtype of social networking. Although Block did not offer a formal assessment tool, he

suggested that all three subtypes share the same four components, similar to those found at the

core of both substance abuse and pathological gambling:

1) Excessive use, often associated with a loss of sense of time or a neglect of basic drives,

2) Withdrawal, including feelings of anger, tension, and/or depression when the computer

is inaccessible,

3) Tolerance, including the need for better computer equipment, more software, or more

hours of use, and

4) Negative repercussions, including arguments, lying, poor achievement, social

isolation. (p.306)

Tao et al. (2010) published an article in response to Block's (2008) call for Internet
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Addiction to be included in the DSM-5. Echoing Block's model of three subtypes (excessive

gaming, sexual preoccupations, and e-mail/text messaging) these researchers filled in the missing

pieces by offering specific criteria for a diagnosis. Their proposal included Beard's (2001)

modification of the YDQ requiring both/and symptom criteria, Shapira's (2003) exclusion

criteria, as well as the addition of specific impairment criteria, and course criteria:

(a) Symptom criterion - All the following must be present:

• Preoccupation with the Internet (thinks about previous online activity or

anticipates next online session)

• Withdrawal, as manifested by a dysphoric mood, anxiety, irritability and boredom

after several days without Internet activity

• At least one (or more) of the following:

o Tolerance, marked increase in Internet use required to achieve satisfaction

o Persistent desire and/or unsuccessful attempts to control, cut back or discontinue

Internet use

o Continued excessive use of Internet despite knowledge of having a persistent or

recurrent physical or psychological problem likely to have been caused or exacerbated by

Internet use

o Loss of interests, previous hobbies, entertainment as a direct result of, and with

the exception of, Internet use Uses the Internet to escape or relieve a dysphoric mood

(e.g. feelings of helplessness, guilt, anxiety)

(b) Exclusion criterion

• Excessive Internet use is not better accounted for by psychotic disorders or

bipolar I disorder
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(c) Clinically significant impairment criterion

• Functional impairments (reduced social, academic, working ability), including

loss of a significant relationship, job, educational or career opportunities

(d) Course criterion

• Duration of Internet addiction must have lasted for an excess of 3 months, with at

least 6 hours of Internet usage (non-business/non-academic) per day. (p.563)

This diagnosis was later renamed to Internet Use Disorder (IUD), although when, how,

and by who is not clear. The IUD name, however, appeared to be the sustained belief by many

in the field until the DSM-5 was finally released (King & Delfabbro, 2013a; Starcevic, 2013a):

Mental health professionals’ and researchers’ extensive proposals to include Internet

addiction as mental disorder in the forthcoming fifth edition of the Diagnostic and

Statistical Manual of Mental Disorders (DSM-V) will come to fruition as the American

Psychiatric Association accepted to include Internet use disorder as mental health

problem worthy of further scientific investigation. (Kuss & Griffiths, 2012, p. 348)

Internet Gaming Disorder

Research into video-gaming addiction can be traced as far back as 30 years, when Soper

& Miller (1983) investigated gaming as a problem for students. Brown (1991) proposed the idea

of video games as addictive as part of his previously mentioned publication on criteria for

behavioral addictions. As have been behavioral addictions in general, video game addiction has

long been a subject of controversy. For example, Wood (2008), a gaming industry consultant,

began an editorial exchange by presenting multiple arguments against the existence of video

game addiction. His arguments included the claim that video game addiction doesn’t exist

because there is no formal diagnosis of video game addiction, people labeled video game addicts
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may simply have time management problems or choose to game excessively in other to avoid

other problems, and that if games were addictive, more people would be addicted to them.

Griffiths (2008) responded, pointing out that the "it doesn’t exist because it doesn’t exist"

argument is comparable to the arguments leveled against pathological gambling in prior decades,

and he also pointed out that substance abusers are often attempting to avoid life problems.

Turner (2008) concurred with Griffiths' argument that drug and alcohol abuse often begins with a

desire to avoid other problems, citing Homer Simpson, "Here’s to alcohol – the cause of, and

solution to, all of life’s problems” (Brooks et al., 1989–2014). Turner also responded to the

Wood's "if it were addictive, more people would be addicted to it" argument, stating that if it

were true, alcoholism and drug addiction wouldn’t exist as only a minority of users become

addicted.

Terminology, diagnostic criteria, and assessment. In recent years, much of the

research on video game addiction has become more narrowly focused to the scope of online

gaming. Kuss and Griffiths (2012a) published a literature review covering 58 empirical studies

on what they referred to as Internet Gaming Addiction. These authors found the current breath

of literature on Internet gaming addiction to be "copious in scope", and divided the results into

three broad categories; etiology, pathology, and ramifications of Internet gaming addiction. The

authors then further sub-divided the studies into the following ten categories: 12 studies on

personality traits of gamers, 13 studies on motivations for gaming, 4 studies on the structure of

games, 7 studies on the neurobiology of Internet gaming addiction, 5 studies on comorbidities, 7

studies on classification/assessment, 10 studies on epidemiology, 10 studies on phenomenology,

19 studies on the negative consequences of Internet gaming addiction, and 3 studies on treatment

options. While the research was plentiful, the authors also found the subject area to be
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inconsistent and disorganized. For example, among the seven studies on classification and

assessment of Internet gaming addiction, the authors found five differing sets of terminology in

addition to their own; compulsive Internet use (van Rooij et al. 2010), problem video game

playing (King et al. 2009), problematic online game use (Kim & Kim, 2010), video game

addiction (Skoric et al. 2009), and online gaming addiction (Charlton & Danforth, 2007).

Kuss & Griffiths (2012b) published a second literature review the same year, this one

focused on children and adolescents. In this study, they explicitly referred to online gaming

addiction as a behavioral addiction, and cited 30 studies. They divided the studies based upon

the diagnostic criteria utilized by the authors to identify Internet Gaming Addiction: 18 papers

utilized the Pathological Gambling criteria, three utilized the Substance Use Disorder criteria,

three utilized a combination of the two, four were based on miscellaneous criteria, and two were

based solely on parental reports.

Kuss and Griffiths (2012b) also found lack of uniformity in the area of online gaming

disorder to be readily apparent as evidenced by the use of more than 14 different assessment

instruments among the 30 papers. For example, of the 18 papers using the Pathological

Gambling criteria, 6 used the "Internet Addiction Test" (Young, 1998), three used the "Game

Addiction Scale" (developed by Lemmens, Valkenburg, & Peter (2009)), three used the

"Pathological Video Game Use Scale" (developed by Gentile (2009)), three used the Internet

Addiction Scale (developed by Lin & Tsai (1999)), two studies used the CIUS, and Choo et al.

(2010) developed their own "Pathological Video Gaming Scale." Of the three based on

Substance Use Disorder criteria, two utilized the "Assessment of Computer Game Addiction in

Children – Revised" (developed by Thalemann, Albrecht, Thalemann, & Grüsser (2004)), and

one used the developed their own "Video Game Dependency Scale" (developed by Rehbein,
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Borchers, & Niedersachsen (2009)). Of the three combination scales, Salguero & Moran (2002)

developed their own " Problematic Video Game Playing (PVP) Scale," Skoric, Teo, & Neo

(2009) developed their own "Assessment of Addiction Tendencies" scale, and Baer, Bogusz, &

Green (2011) developed their own Computer/Gaming-station Addiction Scale (CGAS). Of the

four miscellaneous scales, only one used the Chinese Internet Addiction Scale (Chen et al.,

2003). Chiu, Lee, and Huang (2004) developed their own "Game Addiction Scale," Kim & Kim

(2010) developed their own "Problematic Online Game Use Scale," and King & Delfabbro

(2009) developed their own unnamed set of questions. Other scales not mentioned in this review

are the Korean Internet Game Addiction Scale (Lee & Ahn, 2002), Online Game Addiction

Scale (Lee & Han, 2007), and the "Problem Online Game Use" scale (Kim & Kim, 2010).

As a response to the above, King, Haagsma, Delfabbro, Gradisar, & Griffiths (2013)

conducted a literature review on the assessment and definition of pathological video-gaming.

These authors found "multiple inconsistences" raising "significant concerns" (p. 339). Using the

2009 Groth-Marnatt "Handbook of Psychological Assessment" as a guide, the authors went on to

state, "Disconcertingly, no two instruments are alike in their theoretical orientation and ability to

‘map out’ diagnostic features of problem video-gaming behavior” (p. 339). The authors

concluded by suggesting the PVP, IAT, and adopted DSM-IV-TR pathological gambling criteria

may provide the best measurement and clinical information for pathological video-gaming.

Distinct from Internet Addiction? In contrast to the previous view of gaming as one of

multiple subtypes of Internet addiction (Block, 2008; Tao et al., 2010), another perspective

proposed that the two be differentiated. For example, Lemmens, Valkenburg, & Peter (2009)

referred to Internet addiction and gaming addiction as "distinct, albeit related, concepts" (p. 90).

Similarly, Kim & Kim (2010) stated that gaming as a subtype of Internet Addiction was
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insufficient, as there are multiple forms of gaming that differ in many ways. As such, they

proposed that gaming be separated from Internet addiction, offering the new term Problem

Online Game Use (POGU).

Despite the previously mentioned psychometric issues, Van Rooij, Schoenmakers, Van

de Eijnden, & Van de Mheen (2010) published results concluding that the strongest correlation

between compulsive Internet use and the specific content area of online gaming. In regards to

other content areas, the authors stated, "No relationship was found between CIU and surfing or

emailing, although surfing is one of the most popular activities on the Internet” (p. 55). As such,

these authors argued for the creation of a category of "compulsive online gamers," as distinct

from compulsive Internet users in general.

A final representative public exchange over the differentiation between Internet Use

Disorder and Internet Gaming Disorder occurred at the beginning of 2013. Starcevic (2013a),

seen in prior sections as an overall opponent of the concept of behavioral addictions in general,

argued that if Internet addiction were to exist, the diagnosis of Internet Use Disorder should be

replaced with more specific online addictions, which he refers to as including "gaming,

gambling, viewing pornography and related sexual behaviours, shopping, chatting, sending

messages, etc” (p. 17). King and Delfabbro (2013a) agreed in part with Starcevic, and expanded

his proposition that not only should Internet addiction and internet gaming disorder be separated,

Internet gaming disorder should be reworked into a "video game disorders" diagnosis in order to

reflect the fact that addictive use of gaming is not explicitly limited to online games.

Neurobiology of Internet Gaming Disorder. As stated above, it can be difficult to

untangle whether studies are specific to Internet gaming disorder, or cover Internet addiction in

general. For example, Weinstein & Lejoyeux's (2013) review, "New developments on the
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neurobiological and pharmaco-genetic mechanisms underlying internet and videogame

addiction" contains the phrase "Internet and videogame addiction" consistently throughout their

paper, although the scope of their review is specific to gaming. Similarly, Kuss & Griffiths

(2012c) published a literature review on the neurobiology of "Internet and Gaming Addiction",

in which they cite a mix of studies that are either specific to subjects addicted to internet gaming

or subjects that are internet addicted without any specific sub-type identifier. Regardless, it is

critical to note that much of the results of both reviews are directly in line with many of the

aforementioned neurobiology of addiction findings, specifically referencing authors such as

Volkow (3-phase model of addiction), Koob (Anti-Reward), and Everitt & Robbins (actions->

habits->compulsions). As part of these findings, the mesocorticolimbic reward system was

found to be impacted in the same manner as with substance abuse, as was the cue-induced

craving phenomenon.

Other studies, however, go beyond the primary findings in the general neurobiology of

addiction papers, and incorporate similar findings to the broader Internet addiction studies. For

example, neuroanatomical studies found decreased gray matter density (Han, Lyoo, & Renshaw,

2012), and abnormal white matter integrity (Lin et al., 2012) in both Internet and gaming addicts.

Littel et al. (2012) found reduced ERP amplitudes for Internet and gaming addicts, distinct from

controls and similar to substance abusers. Investigating cue-induced cravings, Ko et al. (2012)

conducted an fMRI-based study to illustrate similar brain activation in game addicts as with

chemical addicts. Han et al. (2011) conducted a similar study wherein they found similar cue-

induced cravings with gaming addicts as with drug abusers and pathological gamblers.

Sexual Preoccupations

The second of Block's (2008) three subtypes of Internet Addiction was "sexual
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preoccupations" (p. 306). Just as Internet addiction cannot be looked-at in a vacuum, its

subtypes also cannot be studied in a vacuum. Sexual Preoccupations is a vague term that

arguably encompasses a wide range of behaviors. Although French physician M. D. T. Bienville

coined the term "nymphomania" over two centuries ago (Groneman, 2001), professionals in

todays field of mental health have been debating the details of terminology and classification of

the problem of sexual excesses for the past several decades (Barth & Kinder, 1987; Carnes,

1983; Coleman, 1986; Goodman, 1992; Hall, 2014; Kor, Fogel, Reid, & Potenza, 2013; Orford,

1978). For many years, the two primary, albeit somewhat competing, models have been the

addiction model and the hypersexual model. Both models have been well researched, and both

problems extend into Internet-related behaviors. More recently, however, research focus has

gone directly to the problem of Internet Pornography Addiction. A proper understanding of the

research supporting Internet Pornography addiction requires an understanding of the collective

findings of all three models of "sexual preoccupations".

Sex Addition and Hypersexual Disorder. There has been much research into the

addictive model of out of control sexual behaviors. Patrick Carnes first identified the term

Sexual Addiction in his book The Sexual Addiction (1983a), quickly renamed Out of the

shadows: Understanding Sexual Addiction (1983b; 1992; 2011). Goodman (1992), previously

referenced as an early proponent of behavioral addictions in general, was the second major figure

to support the sex addiction model. Goodman went on to affirm the validity of his proposed

Addictive Disorder diagnostic criteria as an appropriate application for sex addiction. Several

years later, Goodman (2001) formally reintroduced his aforementioned Addictive Disorders

diagnosis and associated specific criterion. Garcia and Thibaut (2010) conducted a literature
 85

review nearly ten years later, illustrating the still existing debate over terminology/classification,

and also concluded that the addiction model best fit the disorder.

There is over 30 years of available research into treatment options for sex addiction.

Carnes was the first to offer treatment options for sex addiction, introducing a specific CBT

based treatment model for sex addiction (1983b; 1989a; 1991), as well as encouraging the

application of the 12-step model (1989b; 2012). Carnes proposition of the 12-step model was

successful, and today there are multiple 12-step programs dedicated to sex addiction, including

Sex Addicts Anonymous, Sex & Love Addicts Anonymous, Sexaholics Anonymous, Sexual

Compulsives Anonymous, and COSA (Codependents of Sex Addicts) (Dawson & Warren,

2012). Goodman (1992; 1993) was also an early publisher on treatment models, as he proposed

an integrated treatment model that included both individual and group therapy, based on both

psychodynamic and CBT techniques, as well as pharmacological interventions. Studies that are

more recent indicate these to still be the primary methods of treatment for sex addiction (Dawson

& Warren, 2012; Inescu Cismaru, Andrianne, Triffaux, & Triffaux, 2013; Rosenberg, Carnes, &

O'Connor, 2012).

In addition to studies focused on treatment options available for sex addiction,

researchers have conducted multiple studies on the role of the therapist treating sexually addicted

clients (Hagedorn, 2009a, 2009b; Schneider & Levinson, 2006). Hagedorn (2009a) identified

two primary counseling certifications specific to sex addiction available to licensed clinicians;

Certified Addiction Specialists (CAS-S) with a specialty in sexual addiction (certified by the

American Academy of Health Care Providers in the Addictive Disorders) and Certified Sex

Addiction Therapists (CSAT; certified through the International Institute for Trauma and

Addiction Professionals (IITAP)).

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Hook, Hook, Davis, Worthington, and Penberthy (2010) conducted a review of the

available assessment instruments for sex addiction. These authors identified seventeen distinct

instruments (Carnes, 1989a; Carnes & O’Hara, 2000; Carnes & Weiss, 2002; Coleman, Miner,

Ohlerking, & Raymond, 2001; Delmonico & Miller, 2003; Delmonico, Bubenzer, & West, 1998;

Exner, Meyer‐Bahlburg, & Ehrhardt, 1992; Garos & Stock, 1998; Kafka, 1991; Kalichman et al.,

1994; McBride, Reece, & Sanders, 2008; Mercer, 1998; Morgenstern et al., 2011; Morgenstern,

Parsons, J., Muench, F., Hollander, E., Bimbi, D., & Irwin, T, 2004; Muench et al., 2007;

Raymond, Lloyd, Miner, & Kim, 2007). New instruments and changes to existing instruments

for measuring sex addiction have evolved since the time of the Hook, Hook, Davis, Worthington,

& Penberthy (2010) review (Carnes et al., 2012; Carnes, Green, & Carnes, 2010).

Finally, recent research has emerged positing a split or potential subtyping within the

concept of sex addiction. Hall (2013) proposed the OAT model, wherein the variables of

Opportunity, Attachment, and Trauma intersect to create different forms of sex addiction. For

example, while traditional sex addition is often considered rooted in attachment issues or

childhood trauma, the rapid influx of Internet pornography has created what she calls an

opportunity based etiology of the disorder. Similarly, Riemersma & Sytsma (2013) posited a

distinction between what they call "Classic" and "Contemporary" sex addiction, wherein classic

sex addiction is often rooted in long history's of trauma and attachment issues, while

contemporary sex addiction is a rapid onset problem, often rooted in access to Internet

pornography. This is a simplification of both models, however the common feature is the

distinction between a traditional trauma-based etiology and trauma-neutral individual response to

todays supernormal stimuli of Internet pornography.

Alfred Kinsey used the term hypersexual in his 1948 book Sexual Behavior and the
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Human Male. According to Orford (1978), “Eisenstein listed 'hypersexuality' as one of six types

of sexual problem affecting marriage although he believed it was not a clinical entity in itself,

but rather a manifestation of neurosis” (Eisenstein, 1956, as cited by Orford, 1978, p.301). In

this same work, Orford laid the foundations of hypersexuality as an addictive behavior,

paralleling it to excessive drinking and excessive gambling (Orford, 1978).

Harvard Professor Martin Kafka was an early proponent of distancing out-of-control

sexual behaviors from the addiction model. Kafka initially referred to out of control sexual

behaviors as non-paraphilic sexual addictions (NPSA's). Kafka argued NPSA's included

compulsive masturbation, ego-dystonic promiscuity, and pornography dependence (Kafka,

1991). In 1999, Kafka proposed hypersexual desire as a relabeled classification of NPSA's.

Kafka specifically posited hypersexual desire as an "alternative nosological construct" that

avoids the controversy of the terms addiction, compulsivity, and impulsivity (p. 519). Kafka

furthered this model in his 2001 publication, using the term nonparaphilic hypersexual behavior

disorders. Kafka proposed the following subtypes, each listed with its prevalence rate found in

his empirical research; compulsive masturbation (70%), protracted promiscuity (50%),

pornography dependence (50%), telephone sex dependence (25%), severe sexual desire

incompatibility (12%), cybersex dependence (n/a), and paraphilia related disorder not otherwise

specified (n/a) (p. 227).

Kafka specifically stated that cybersex dependence was not measured in his study, and

cited instead research from others in the field (ex. Cooper, Delmonico, & Burg, 2000). Kafka

stated that those studies found males used the Internet to access pornography for physical

stimulation, while women used the Internet to access chat rooms for emotional stimulation. As

such, Kafka believed that internet pornography use better fit under his pornography dependence
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subtype, leaving only "explicit sexual behavior accompanied by interpersonal communication in

chat rooms (analogous to telephone sex)" (p. 235) in the cybersex category. Pointed out as

"noteworthy" the fact that self-identified sexually compulsive via the computer spend the same

amount of time as people measured with PA's and PRD's in his prior studies (p. 236).

Kaplan and Krueger (2010) performed an extensive literature review on hypersexual

disorder. They explored the proposed diagnostic criteria for HD, and performed a mini-literature

review on each proposed subtypes. These authors found the masturbation subtype to have the

most empirical support, in contrast to the strip club subtype, of which they found no empirical

support. These authors found a prevalence rate of between 3% and 6%, with a majority of

sufferers to be male. Overall, however, these authors found there to shortage of epidemiological

data on HD. These authors also presented a theory-neutral review of what they considered the

five primary theories of etiology of HD: neurobiological (including as a condition secondary to

other medical disorders), addiction model, psychodynamic, dual control, impulsivity, and OCD

spectrum. They briefly highlighted critiques of the disorder, focusing primarily on concerns

about artificial cultural norms and the impact of labeling individuals. Finally, they reviewed

assessment instruments and primary treatment modalities. They specifically highlighted the

aforementioned CSBI, SCS, and SAST assessment measures. Finally, they identified primary

treatment modalities as CBT (relapse prevention and behavior therapy in particular),

psychodynamic psychotherapy, 12-step addiction model, couples therapy, comorbidity treatment,

and pharmacological. They concluded with the statement that "It is clear that a condition of

hypersexuality exists in which some individuals are unable to control their sexual behavior as

compared with those who choose to act in a self-centered manner with disregard for others" (p.

193), and argued for the importance of continued research.

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Karila et al. (2013) began their recent literature review by stating that although SA/HA

has caused serious psychosocial distress for many clients, psychiatrists have problematically

ignored it. They attributed the lack of empirical evidence as the result of the disease's exclusion

from the DSM. These authors found prevalence rates of SA/HD to range from 3% to 6%. They

pointed out the similarity of negative consequences of SA/HD as with substance abuse disorders,

and highlighted the comorbidies between SA/HD and substance abuse, as well as other

psychiatric disorders. Authors also found that research on sexual addiction has expanded rapidly

in recent years, and pointed out the development of multiple screening tools as an example.

Hook, Reid, Penberthy, Davis, and Jennings (2013) conducted a recent literature review on

available treatments for hypersexual disorder (including the terms sexual addiction, sexual

compulsivity, and sexual impulsivity). The authors found 14 studies, which they divided into

"Drug" and "Therapy," which they further subdivided into individual and group based therapy.

The individual therapy studies included two based on Acceptance and Commitment Therapy

(ACT), and one using CBT-based online psychoeducational program. The group studies

included a traditional group therapy model, a single 28-day inpatient treatment center, a brief

multimodal experiential group therapy model, and a group hybrid model of Readiness to Change

(RtC), Cognitive Behavioral Therapy (CBT), and Motivational Interviewing (MI) intervention.

Naficy, Samenow, and Fong (2013) conducted a literature review on pharmaceutical

treatments for hypersexual disorder (also including the terms sexual addiction, sexual

compulsivity, and sexual impulsivity). These authors found different classes of anti-depressants,

a mood stabilizers and the opiate antagonist naltrexone (Raymond, Grant, Kim, & Coleman,

2002). Based on the high rate of comorbidity with ADHD, authors recommended

psychostimulant medication as a possible adjunct tool for that population.

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Neurobiology of SA/HD. Childress et al (2008) conducted a study in which they took

fMFI scans of cocaine addicted patients presented with rapid (33 millisecond), preconscious

visual cues (drug-related images). The same subjects were later shown preconscious sexually

related visual cues (erotic images). The researchers found activation of the same limbic

system/reward circuitry in subjects shown sexual cues as when shown drug-related cues. In their

literature review of the neuroimaging studies of the human sexual response cycle, Georgiadis &

Kringelbach (2012) concluded, "it is clear that the networks involved in human sexual behavior

are remarkably similar to the networks involved in processing other rewards” (p. 74).

Frascella, Potenza, Brown, and Childress (2010) conducted a literature review contrasting

three specific behaviors with alcoholism: pathological gambling, obesity, and the mechanics of

sexuality. The authors broadened the scope of the Childress et al (2008) study, and concluded:

Functional brain imaging studies of sex, romantic love and attachment provide ample evidence

for an extended but identifiable system central to natural, non-drug reward processes and

survival functions... The overlap of classic reward brain areas involved in sexual arousal, love

and attachment is complete (VTA, accumbens, amygdala, ventral pallidum, orbitofrontal cortex).

Speculation is justified that associates survival-level natural rewards with substance addictions,

expanding the brain systems to be addressed in therapy, and increasing our understanding of the

necessary tenacity of the behaviors. (p. 15)

As stated previously, the RDS model includes problematic sexual behaviors in a list of

RDS-related problems (Blum et al., 2012a; Blum et al., 2010; Blum, Gardner, Oscar-Berman, &

Gold, 2012; Comings & Blum, 2000). The term “Reward Deficiency Syndrome” has become

accepted enough that it is now included in the Microsoft Dictionary, defined as “A brain reward

genetic dissatisfaction or impairment that results in aberrant pleasure seeking behavior that
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includes drugs, excessive food, sex, gaming/gambling and other behaviors” (Downs et al., 2013,

p.2). Note, however, that the inconsistency in terminology exists here too. For example, in some

articles, the specific term "Sex addiction" has been utilized, (Blum et al., 1996; Blum et al.,

2011; Blum et al., 2012c; Blum et al., 2012d), while other articles use the terms compulsive sex

and hypersexuality (Blum et al., 2008).

Perhaps the largest volume of studies indicating a neurobiological basis for sex addiction

involves the transcription factor DeltaFosB. It has been well established that drugs of abuse

elevate levels of the transcription factor DeltaFosB in the reward center, resulting in enhanced

response to rewards and reward related cues, increased sensitivity to addiction related cues, and

heightened vulnerability to compulsive behaviors and relapse (Grueter, et al., 2013; Nestler,

2013; Robison et al., 2013; Pitchers, 2013). Researchers have genetically modified mice to

overproduce DeltaFosB in the reward center at similar levels to those of drug addicted mice.

When presented with cocaine for the first time, these mice showed increased sensitivity to the

drug and responded and behaved in manners similar to those of rats who had become addicted

through chronic use (Muschamp, Nemeth, Robison, Nestler, & Carlezon Jr, 2012). Multiple

tests using Syrian hamsters treated to overproduce DeltaFosB have focused on the effects of

sexual behavior, and found a similarly enhanced sensitivity to sexual activity (Been, Hedges,

Vialou, Nestler, & Meisel, 2013; Hedges, Chakravarty, Nestler, & Meisel, 2009). Wallace, et al.

(2008) naturally induced this sensitivity in laboratory rats via "chronic sexual behavior." These

authors found repeated sexual experience significantly increased DeltaFosB levels in the NAc

compared with controls, although the rates of increase were lesser than with drugs of abuse.

Pitchers et al. (2010b) similarly illustrated the production of high levels of DeltaFosB in the

nucleus accumbens, further finding this elevation to be critically involved in the reinforcing
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effects of sexual reward. Investigating the combination of natural and drug rewards, Pitchers et

al. (2010a) found mice to have increased sensitivity to amphetamines after repeated sexual

experiences. These authors concluded, "Sexual experience induces functional and

morphological alterations in the mesolimbic system similar to repeated exposure to

psychostimulants" (p.1). Pitchers et al. (2013) confirmed these findings, illustrating that natural

rewards (sexual behavior) and drugs of abuse (amphetamines) act on the same reward center

pathways, further supporting the argument for behavioral addictions, including sex addiction.

Proposed for DSM-5. The term sex addiction has a brief history in the DSM. The

DSM-III-R (APA, 1987). subdivided the Sexual Disorders chapter into the diagnostic categories

of Paraphilia’s, Sexual Dysfunctions, and Other Sexual Disorders (APA, 1987, p.8). In the Other

Sexual Disorders category, only a single diagnosis is available; Sexual Disorder Not Otherwise

Specified. Three examples were included, with the second example actually containing the term

sexual addiction; “(2) distress about a pattern of repeated sexual conquests or other forms of

nonparaphilic sexual addiction, involving a succession of people who exist only as things to be

used” (APA, 1987, p.296). The category Other Sexual Disorders: Sexual Disorder Not

Otherwise Specified was removed from DSM-IV (APA, 1994), taking with it the sexual

addiction language.

In contrast, the World Health Organization (WHO) has included two related categories in

its current International Classification of Diseases (ICD) manual (released in 1992, revised in

2010). ICD-10 diagnostic category/code F52.7 is reserved for "Excessive Sexual Drive", which

includes specific subtypes of "Nymphomania" (female excessive drive) and "Satyriasis" (male

excessive drive). Additionally, ICD-10 diagnostic category/code F98.8 refers to "Other specified

behavioural and emotional disorders with onset usually occurring in childhood and adolescence.”
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Subtypes of F98.8 include Attention deficit disorder without hyperactivity, Excessive

masturbation, Nail-biting, Nose-picking, and Thumb-sucking.

In 2010, Kafka, a member of the official DSM-5 workgroup for the Sexual & Gender

Identity Disorders category, officially proposed the following criteria for Hypersexual Disorder

to be included in the DSM-5:

A. Over a period of at least 6 months, recurrent and intense sexual fantasies, sexual

urges, and sexual behavior in association with four or more of the following five

criteria:

a. Excessive time is consumed by sexual fantasies and urges, and by

planning for and engaging in sexual behavior.

b. Repetitively engaging in these sexual fantasies, urges, and behavior in

response to dysphoric mood states (e.g., anxiety, depression, boredom, and

irritability).

c. Repetitively engaging in sexual fantasies, urges, and behavior in response

to stressful life events.

d. Repetitive but unsuccessful efforts to control or significantly reduce these

sexual fantasies, urges, and behavior.

e. Repetitively engaging in sexual behavior while disregarding the risk for

physical or emotional harm to self or others.

B. There is clinically significant personal distress or impairment in social,

occupational, or other important areas of functioning associated with the

frequency and intensity of these sexual fantasies, urges, and behavior.

C. These sexual fantasies, urges, and behavior are not due to direct physiological
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effects of exogenous substances (e.g., drugs of abuse or medications), a co-

occurring general medical condition, or to manic episodes.

D. The person is at least 18 years of age.

Specify if masturbation, pornography, sexual behavior with consenting adults, cybersex,

telephone sex, and strip clubs. (Kafka, 2010a, p. 379)

Reid et al. (2012) published a study titled “Report of Findings in a DSM-5 Field Trial for

Hypersexual Disorder.” Using the above instruments, the findings of their study validated the

proposed criteria, finding that it was able to correctly diagnose with 93% accuracy. Thus, the

report provided the following conclusion:

The HD criteria proposed by the DSM-5 Work Group on Sexual and Gender Identity

Disorders appear to demonstrate high reliability and validity when applied to patients in a

clinical setting among a group of raters with modest training on assessing HD. (Reid,

et.al. 2013, p.1)

Internet Pornography Addiction. As previously stated, "sexual preoccupations" was

listed as a subtype of Block's (2008) original proposal for Internet Addiction. Note that, as is the

case with Sex Addiction/Hypersexual Disorder, there is inconsistency in the terminology used to

describe sexual behaviors conducted over the Internet. In his literature review, Döring (2009)

interchangeably used terms such as Internet sexuality, online sexual activities (OSA), online

sexuality, and cybersexuality. In doing so, he referred to six primary areas of online sexuality:

pornography, sex contacts, sex education, sex shops, sex work, and sexual subcultures.

Shaughnessy, Byers and Walsh (2011) grouped online sexual activities into three categories:

solitary-arousal (e.g. watching pornography), partnered-arousal (e.g. sex chats), and non-arousal

activities (e.g. information search). Two of these three authors went on to define cybersex as
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"sexual communication between at least two people that is focused on sexual relations and

occurs via synchronous Internet modes" (Shaughnessy, Byers & Thornton, 2011, p. 86). In

contrast, Laier, Pawlikowski, Pekal, Schulte, & Brand (2013) used the term cybersex to refer to

any online sexual behaviors.

While there is an argument for a differentiation between online pornography use and

cybersex (see below), for the purposes of this discussion, unless stated otherwise the terms

cybersex, Internet sex addiction, Internet sexual behaviors, online sexual behaviors, and

pornography addiction will be used to encompass Internet pornography addiction. Additionally,

the full term Internet pornography can be assumed when an author simply references

pornography as a form or subtype of Internet addiction.

Overlap and differentiation with similar disorders. Griffiths (2012) believed that there

are overlaps between the phenomena of Internet sex addiction, Internet addiction, and sex

addiction. Regarding the overlap between Internet sex addiction and Internet addiction, several

authors, as previously stated, have included online sexual behaviors as a subtype of Internet

addiction. For example, Young (1999) included sexually related behaviors as two of her five

original subtypes of Internet addiction; cybersexual addiction (cybersex, cyberporn), and cyber-

relationship addiction (Young, 1999). Davis (2001) listed cybersex as an example of an SPIU.

Block's (2008) proposal for a diagnosis of Internet addiction, echoed informally by Tao, et al.

(2010), included subtypes of excessive gaming, sexual preoccupations, and e-mail/text

messaging. Similarly, Hagedorn (2009) listed pornography as a component of one of his eight

subtypes of his proposed diagnosis of Addictive Disorders.

Other authors have argued for the extraction of online sexual behaviors from Internet

addiction. For example, Griffiths (2013) listed sexual behaviors as a primary addiction in his
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differentiation between primary and secondary addictions. As previously discussed, a key

argument against the concept of Internet addiction is that the Internet is a delivery mechanism,

and that addiction can only occur with a specific behavior. For example, Yau, Crowley, Mayes,

& Potenza (2012) referenced pornography as a more appropriate example of addictive content on

the Internet, as contrasted with the Internet itself as a delivery mechanism. Similarly, in their

published editorial dialogs both Starcevic (2013) and King & Delfabbro (2013a) agreed that

viewing pornography would be one of several more accurate diagnostic categories than would be

Internet addiction itself.

Regarding the overlap between sex addiction and Internet sex addiction, some authors,

such as Kafka (2010, 2013), specifically argue for a differentiation between Internet sexual

behaviors and pornography based largely on the interactive component of ‘cybersex’ as

contrasted with the static component of pornography. Additionally, both Kafka (2013) and

Griffiths (2012) point out the potential confounding factor that pornography is available both

online and offline. This dichotomy can also be evidenced in Young's work, as a key difference

between her two subtypes of sexually related behaviors on the Internet. Note again the

inconsistencies in terminology; whereas Kafka (2010, 2013) used the term cybersex to refer to

the interactive behavior that he differentiates from pornography, Young (1999) equated the terms

cybersex and cyberporn, and used the term cyber-relationships to refer to the interactive

component of Internet based sex addiction.

History of Internet sex addiction. Articles regarding Internet based sex addiction date

back as far as research on Internet addiction itself. Bingham and Piotrowski (1996) first

published on the specific topic "on-line sexual addiction." Delmonico (1997) next published an

article titled "Cybersex: High tech sex addiction" in which he posited four potential explanations
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for the rise in Internet based sex addiction; anonymity, fantasy, isolation, and low cost.

Delmonico also identified what he considered to be three primary forms of cybersex; online

pornography exchange, real time sexual exchanges, and multimedia software. In 1999,

Delmonico & Carnes published on "Virtual Sex Addiction", where they identified online sexual

behaviors as having addictive properties strong enough to become an addict’s drug of choice

(DoC).

Arguably, the most prolific early author on cybersex addiction was Stanford Professor Al

Cooper. Cooper referred to Internet sexual content as the "crack cocaine of sex addiction"

(Cooper, 2002), and posited a three factor model he called the "Triple-A-Engine" to explain the

rapid growth of Internet pornography; Affordability (often free or low cost), accessibility

(available 24/7), and anonymity (perceived anonymity) (Cooper, 1998). Cooper, Putnam,

Planchon, and Boies (1999) identified three types of Internet pornography users: recreational, at-

risk users, and sexual compulsives. These authors also proposed multiple treatment options for

cybersex addiction, including models specific to each type of user. Young, Griffin-Shelley,

Cooper, O'mara, and Buchanan (2000) developed a variant of the Triple-A-Engine called the

ACE model (Anonymity, Convenience, Escape). The primary difference between the two was

that the Triple-A-Engine refers to the draw to nonspecific Internet sexual behavior, whereas the

ACE model was designed to explore the rise in online infidelity, also known as cyberaffairs.

Cooper, Scherer, Boies, and Gordon (1999) conducted a large survey (n=9,177) and

reported 8% of respondents to be compulsive with their online sexual behaviors, and 17% were

at-risk. Similarly, Cooper, Delmonico, & Burg (2000) conducted a large survey (n=9,265) and

divided the responses into four categories: nonsexually compulsive, moderately sexually

compulsive, sexually compulsive, and cybersex compulsive. The authors reported 17% of
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respondents to be within the problematic range, 4.6% to be sexually compulsive, and 1%

cybersex compulsive. Cooper, Delmonico, Griffin-Shelley, and Mathy (2004) also conducted a

large survey of Internet users (n>7,000). These authors used the term online sexual activity

(OSA), to refer to any form of sexually related behavior over the Internet, positive or

problematic. Examples of positive online sexual activity included education and exploration,

whereas problematic expressions of sexuality included multiple forms of cybersex. The authors

identified three criteria for problematic behaviors: obsession, compulsion, and consequences.

Literature reviews and books. Griffiths has conducted multiple literature reviews of

varying titles over the years; "Sex on the Internet" (2001), "Sex Addiction and the Internet"

(2004), and "Internet sex addiction" (2012). In his first two reviews, Griffiths concluded that,

despite the limited availability of empirical studies on the topic, the application of the addiction

model to problematic online sexual activities is a viable concept. In his most recent review,

Griffiths (2012) concurred with his earlier studies, and stated that the key feature of the

application of the addictive model is not the excessive use, but rather the accompanying negative

consequences of the behavior. Griffiths supported the creation of an Internet sex addiction

diagnosis for a reason contrary to many opponents of the concept; the diagnosis would

destigmatize individuals from persons with sexual behavior problems to persons with a genuine

mental disorder. Griffiths posited that the ability to move away from implications of deviance

and towards the disease model would help afflicted people more quickly move into treatment.

Griffiths (2012) also overlaid the concept of Internet sex addiction upon Goodman's

(2002) diagnostic criteria for sex addiction (and behavioral addictions in general). In doing so,

he made the point that Internet sex addiction could fit as a subtype of both Internet addiction and

sex addiction. In his conclusion, Griffiths articulated the need for research to investigate and
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differentiate multiple nuanced areas. For example, the need to differentiate between sex

addiction and Internet sex addiction, as well as between Internet sex addiction and internet

addiction. Additionally, Griffiths highlighted a need to differentiate between offline sexual

compulsivity and exclusively online sexual compulsivity. Finally, Griffiths stated a need for

research to distinguish people who use the Internet to improve their offline sex life and those

who use it to substitute an offline sex life.

It should be noted that this author curiously omitted the term pornography (or porn*)

from his search criteria, searching instead only on the following terms: cybersex*, sex*, Internet,

online, addict*, excess*, and compuls* (Griffiths, 2012, p.115). Despite this seemingly glaring

omission, there are 22 mentions of pornography within the study. In regards to further

limitations of the scope of the study, the author himself points out the fact that all studies

analyzed were from western countries.

Many books specific to pornography addiction have been published. For example, several

books have been published by established professionals in the addictions field, such as:

Confronting Your Spouse's Pornography Problem (Reid & Gray, 2006), Cybersex exposed

(Schneider & Weiss, 2001), In the Shadows of the Net (Carnes, Griffin, Delmonico, & Moriarty

(2001), Sex & the Internet (Cooper, 2002), Tangled in the Web (Young, 2001), The Porn Trap

(Maltz & Maltz, 2008), and Untangling the web (Weiss & Schneider, 2006). Former corporate

executive Michael Leahy published three popular books on pornography addiction: Porn Nation:

Conquering America’s #1 Addiction (Leahy, 2008), Porn @ Work: Exposing the Office's #1

Addiction (Leahy, 2009), Porn University (Leahy, 2009). Additionally, there are multiple

Christian based books on pornography addiction, including Conquering Pornography:

Overcoming the Addiction: A Practical, Faith-Based Journey (Frederick, 2007), He Restoreth

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My Soul; Understanding and Breaking the Chemical and Spiritual Chains of Pornography

through the Atonement of Jesus Christ (Hilton, 2010), No More Hiding, No More Shame:

Finding Freedom from Pornography Addiction (McNamara, 2011), and Overcoming

Pornography Addiction: A Spiritual Solution (Bransfield, 2013).

Assessment instruments. In addition to the aforementioned tests designed to measure

both Internet addiction and sex addiction, there are multiple tests designed specifically for the

intersection of the two. Introduced in the late 1990's, the Internet Sex Screening Test (ISST) is

one of the oldest measures for Internet sex addiction (Delmonico & Carnes, 1999). The test is

designed to measure three domains: obsession, loss of control, and significant life consequences.

The test was validated with a large sample (n=6,088) collected over a two-year period

(Delmonico & Miller, 2003). The test was again validated recently in a Spanish population

(n=1,239 college students), wherein the authors concluded; "the instrument had adequate

convergent and discriminant validity and was related to other behaviors such as the use of

pornography, internet addiction, number of hours online and sexual frequency" (Ballester Arnal,

Gil Llario, Gomez Martinez, & Gil Julia, 2010, p. 1048).

The Cyber-Pornography Use Inventory (CPUI) was modeled after the ISST, however its

focus was narrowed to specifically target the use of Internet pornography (Grubbs, Sessoms,

Wheeler, & Volk, 2010). The CPUI was initially tested on a convenience sample of 584 students

at a Christian university, and the results were divided into three factors: "Addictive Patterns",

"Guilt Regarding Online Pornography Use," and "Online Sexual Behavior-Social" (p. 114).

Sessoms (2011) conducted a follow-up test contrasting results of the CPUI in both religious and

secular populations. The results indicated significantly higher use of pornography use in secular

subjects, however the religious subjects scored significantly higher on both the Guilt and
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Addictive Patterns subscales. These results suggest partial validity to previously mentioned

concerns about the concept of sex addiction being inappropriately intertwined with cultural

norms. Indeed, Grubbs conducted two further tests, using the CPIU and a custom scale, to

measure what he called "perceived addiction" (Grubbs, Exline, Pargament, Hook, & Carlisle,

2014; Grubbs, Volk, Exline, & Pargament, 2013). In the second study, the authors concluded

that there was a "robust positive relationship" (Grubbs, Exline, Pargament, Hook, & Carlisle,

2014, p. 1) between religiosity and the individuals subjective perception that they were addicted

to Internet pornography.

Hald and Malamuth (2008) developed the Pornography Consumption Effect Scale

(PCES) in order to measure two contrasting areas of impact pornography can have upon the

individual; a Positive Effect Dimension (PED) and a Negative Effect Dimension (NED). Hald,

Smolenski, and Rosser (2013) presented an updated version of the PCES to a sample of

homosexual males. These authors found a strong correlation (97%) with increased use of

sexually explicit media (SEM) and increased levels of PED. In contrast, only 3% of the sample

reported levels of NED.

Conversely, Wetterneck, Burgess, Short, Smith, & Cervantes (2012) administered the

PCES to a random sample (n=495) and found measured of impulsivity and compulsivity to be

positively correlated with the number of hours per week spent on Internet pornography use

(referred to as (IP) by these authors). The results also showed the number of hours spent on IP to

correlate positively with increased reports of problematic effects. Additionally, individuals

reporting high levels of problematic use also reported higher levels of both PED and NED. The

authors found these results to be consistent with Mick & Hollander's (2006) reinforcement theory

of IP, wherein pornography use follows the same schedule of both positive and negative
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reinforcement, as does substance abuse.

Brand et al. (2011) modified Young's (1998) original Internet Addiction Test (IAT) in

order to make it more directed towards sexual behavior. They named the test IATsex, and

specifically replaced the terms "online" with "online sexual activity” and "Internet" with

"Internet sex sites." Similarly, Laier, Pawlikowski, Pekal, Schulte, & Brand (2013) adjusted the

short version of the Internet Addiction Test (s-IAT) (Pawlikowski, Altstötter-Gleich & Brand,

2013) into a test specific to sexual behaviors. These authors used the same logic as did Brand et

al. (2011), and named their test the Internetsex Addiction Test (s-IATsex).

Reid, Li, Gilliland, Stein, and Fong (2011) developed and validated the Pornography

Consumption Inventory (PCI) as an instrument to measure the motivations for the use of Internet

pornography by men with hypersexual disorder. The test is divided into four subscales:

emotional avoidance, excitement seeking, sexual curiosity, and sexual pleasure. While the study

is specific to the concept of hypersexual as distinct from sexual addiction, the findings can also

be directed toward the addiction model. For example, the use of Internet pornography as a

coping mechanism for negative emotions, as evidenced by the correlation of high scores on the

PCI high levels of emotional avoidance. The authors consider a clinical benefit of the tool as

means of uncovering underlying drivers for problematic pornography use that can be further

explored in therapy. Similarly, Kraus & Rosenberg (2014) posit their newly developed

Pornography Craving Questionnaire (PCQ-12) as a tool to measure levels of craving resulting

from cue-induced stimuli. This test is based on multiple existing instruments used to measure

cravings for various drugs and alcohol, and is still under development.

The most recent, and arguably the most robust, instrument to measure Internet

pornography use is the Problematic Pornography Use Scale (PPUS) (Kor et al., 2014). The
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authors cite the result of Short, Black, Smith, Wetterneck, & Wells (2012) literature review in

which the authors concluded there to be a significant lack of psychometrically sound instruments

specific to the use of internet pornography. As such, Kor et al. (2014) developed and validated

the PPUS through a series of three studies designed to measure and optimize its psychometric

properties. In contrast to the PCI's focus on the hypersexual paradigm, the PPUS was designed

to support the addiction paradigm. In doing so, the test was developed to measure four key

elements of the addiction model: excessive engagement in the problematic behavior,

urge/craving to engage in the problematic behavior, loss of control over the problematic

behavior, and continuation of the problematic behavior despite negative consequences. The

initial design of the test pulled questions from existing instruments such as the Internet Addiction

Test, Hypersexual Behavior Inventory, and the Cyber-Pornography Use Inventory. The authors

also developed other questions based on the addiction model.

In addition to measuring elements of the addiction model, the authors hypothesized,

based on their literature review, additional problematic elements of mental health to be present in

persons addicted to pornography. As such, in the third study they tested for convergent validity

and construct validity against the following instruments: Brief Symptom Inventory (BSI)

(Derogatis & Melisaratos, 1983), the Experiences in Close Relationships scale (ECR) (Brennan,

Clark, & Shaver, 1998), the Pornography Consumption Inventory (PCI) (Reid, Li, Gilliland,

Stein, & Fong (2011), the Rosenberg Self- Esteem scale (RSE) (Rosenberg, 1965), the South

Oaks Gambling Screen-RA (SOGS-RA) (Winters, Stinchfield, & Fulkerson, 1993), and the

Traumatic Experiences Questionnaire (TEQ) (Nijenhuis, der HartO, & Vanderlinden, 1999).

The initial test contained 43 questions, which the authors reduced to 21 in the second

study, and 12 in the third. Statistical analysis based on the addiction theory yielded a four-factor
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model of 1) distress and functional problems, 2) excessive use, 3) control difficulties, and 4) use

for escape/avoid negative emotions. Additionally, high PPUS scores correlated with measures of

psychopathology, low self-esteem, and poor attachment.

Finally, Downing, Antebi, & Schrimshaw (2014) modified the CIUS (Meerkerk, van den

Eijnden, Vermulst, & Garretsen, 2009) to measure compulsive use of sexually explicit media

(SEM). These authors somewhat incorrectly claim an absence of psychometrically validated

instruments to measure online sexual behavior, as the IAT is a psychometrically validated

instrument of out-of-control behavior that has been modified to measure sexual behaviors (Brand

et al., 2011; Laier, Pawlikowski, Pekal, Schulte, & Brand, 2013). It could potentially be argued

that the tests can be differentiated in that the IAT follows the addiction model while the CIUS

follows the compulsivity model, however this is a very gray line, and a careful examination of

both tests reveals substantial similarities in measurements. Additionally, while these authors

correctly reference the Pornography Consumption Effect Scale (PCES) (Hald & Malamuth,

2008) as an instrument designed to measure effects of compulsive use, they neglected to

reference Wetterneck, Burgess, Short, Smith, & Cervantes's (2012) use of the test to measure

impulsivity and compulsivity.

Treatment. Multiple treatment modalities have been implemented for working with

patients addicted to Internet pornography. Young (2007) successfully utilized a cognitive

behavioral model with a population of 114 subjects in her Internet recovery clinic. 70% of the

subject’s problematic behaviors were sexually based (40% sex chat, 30% pornography viewing).

She formalized the process into what she called the Cognitive Behavioral Therapy for Internet

Addiction (CBT-IA) model. This model consists of three phases: behavior modification,

cognitive restructuring, and harm reduction techniques (Young, 2011). Ford, Durtschi, and
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Franklin (2012) reported successful utilization of the structural therapy model for a couple

struggling with Internet pornography addiction. Twohig and Crosby (2010) successfully utilized

the Acceptance and Commitment Therapy (ACT) for use with a small group of clients (n=6), and

found an 85% reduction in the compulsive viewing of Internet pornography. Crosby (2011)

followed this study with a randomized clinical trial of 28 clients, and found a 93% decrease in

compulsive pornography viewing after completion of a 12-week program. Woods (2013)

implemented a psychoanalytic group therapy model for clients reporting compulsive use of

Internet pornography. Not all treatment approaches have been successful. Orzack, Voluse,

Wolf, and Hennen (2006) implemented a 16-week psychoeducational group therapy program

based on a combination of Cognitive Behavioral Therapy (CBT), Motivational Interviewing

(MI), and Readiness to Change (RtC) interventions. While member’s self-reported

improvements in their quality of life and decreases in their depressive symptoms, they did not

report a reduction in the amount of time they spent using the Internet for sexual behavior.

Finally, Hinman (2013) conducted a mixed method analysis of professional counselors

views on their competencies to treat clients with Internet pornography addiction. Hineman found

counselors to be the most comfortable talking about sexual expression, less comfortable talking

about pornography use, and the least comfortable talking about specific topics within

pornography. Hineman also found several global themes within his research, including a need

for inclusion of process addictions training within the counselor education model, and specific

acknowledgement of Internet pornography addiction.

Specific pharmaceutical interventions such as Naltrexone have been targeted to Internet

pornography addiction. In their case series on the efficacy of Naltrexone in treating pornography

addiction, Bostwick & Bucci (2008) discuss the Incentive Salience Circuitry (ISC) found within
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the reward system. The ISC includes the previously mentioned VTA and NAc, but also the

amygdala and an expanded role of the PFC in order to modulate the ISC's ability to assign

positive or negative valence to a stimulus. The ISC involves the release of endogenous opioids

(endorphins) that prevent GABA release, whose role is to decrease the inhibitory functions of

dopamine production. Naltrexone is an opioid receptor antagonist, allowing increased

production of GABA, which decreases dopamine levels in the NAc. Thus, the administration of

naltrexone allows for the decreased sensitization to the use of pornography via its loss of

salience, essentially dismantling the impact of previous reward related learning. Raymond,

Grant, and Coleman (2010) have confirmed similar results using Naltrexone to treat a range of

compulsive sexual behaviors, including the compulsive use of pornography.

Adolescents. Multiple studies have investigated the impact of Internet pornography upon

adolescents. Wolak, Mitchell, and Finkelhor (2007) conducted a US survey of 1,500 Internet

users aged 10 to 17, and found that 42% viewed internet pornography in the recent year, 66% of

which was unwanted and accidental. Levin, Lillis, and Hayes (2012) investigated the

relationship between problematic pornography use and experiential avoidance in 157 US college

students. These authors found a significant correlation between Internet pornography use and

levels of anxiety, depression, stress, and social functioning. Luder et al. (2011) surveyed 7,529

Swiss adolescents aged 16-20 and found no association between Internet pornography exposure

and off-line sexual behaviors. In contrast, Svedin, Akerman, & Priebe (2011) surveyed 2,015

male Swiss students (age 18) and found frequent users to also have behavioral problems,

including increased consumption of alcohol and greater levels of off-line sexual behavior. While

Ma & Shek (2013) found low levels of pornography use among early adolescents (age 12) in

Hong Kong, Mattebo, Tydén, Häggström-Nordin, Nilsson, & Larsson (2013) conducted a survey
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of 477 adolescent males in Sweden (age 16) and found that 96% had viewed pornography with

10% viewing on a daily basis. Hald and Mulya (2013) conducted a survey of Indonesian college

students and found usage rates similar to those of students in more liberal western countries.

These researchers also found correlations between pornography use and non-marital sexual

activity. Behun, Manning, and Reid (2012) conducted a recent literature review on adolescent

pornography use. These authors found that adolescents who viewed pornography were more

likely to develop unrealistic sexual values and beliefs, and decreases in emotional connection

with family, self-concept, body-image, and levels of social integration. Additionally, these

authors found that adolescents who viewed pornography were more likely to show increases in

conduct problems, depressive symptoms, and higher levels of delinquent behavior.

Neurobiology of Internet Pornography Addiction. Brand, et al. (2011) found that the

amount of time spent looking at pornography is not as relevant factor for addiction as is the

degree of internal response to looking at pornography. These authors connected their findings

with the established studies on cue-reactivity in alcohol/drug addicted patients. Indeed, cue-

reactivity is one of two key factors for relapse as established by ASAM, and is a major

component of the leading neurobiological three-phase model of addiction.

In his popular book on neuroplasticity, "The brain that changes itself" Doidge (2007)

summarizes much of the above research, and stated that the continued release of dopamine into

the reward system when an individual watches pornography stimulates neuroplastic changes that

reinforce the experience. Doidge goes on to explain how these neuroplastic changes build brain

maps for sexual excitement. He introduces an additional component of tolerance, in that

previously established brain maps for ‘natural’ sexuality cannot compare to the newly developed

and continuously reinforced maps generated by watching pornography, and thus the addicted
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individual progresses to more explicit and graphic pornography in order to maintain the higher

level of excitement.

Neurosurgeons Hilton & Watts (2011) published a commentary titled "Pornography

addiction: A neuroscience perspective." These authors provided a short literature review

renewing the argument that all addictions operate via the same underlying mechanisms. The

authors included many of the previously mentioned studies; the role of DeltaFosB in natural

addictions (sexual behavior), neuroanatomical changes caused by excessive behaviors (eating

behaviors), changes in dopamine receptor density in obesity, influence of excessive behaviors

(pathological gambling) on the reward center. In their response to a rebuttal to their paper,

Hilton & Watts elaborated on the importance of taking a broader view of existing research,

concluding, "Our premise is that selective atrophy of cortical areas associated with reward

pathways may be viewed in a neuromodulatory light, given current research confirming

neuroplasticity in overindulgence in natural rewards, specifically sexuality." (Reid, Carpenter, &

Fong, 2011, p.6). Hilton (2013) published a second and similar literature review, again

emphasizing the critical role of DeltaFosB research as informing the study of not only sexuality

in general but the more specific scope of pornography consumption.

Although more neuropsychological than neurobiological, multiple studies have been

conducted investigating the impacts of pornography on cognitive operations. For example,

Laier, Schulte, & Brand (2012) conducted a study wherein they found that subjects had

decreased working memory performance after viewing pornographic images as contrasted with

viewing emotionally negative, positive, or neutral images. Similarly, Laier, Pawlikowski, Pekal,

Schulte, & Brand (2013) illustrated increased cue reactivity and cravings by sexually addicted

subjects (as measured by the s-IATsex) as contrasted with non-addicted subjects. In a related
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study, Laier, Pawlikowski, & Brand (2014) found subjects decision making effectiveness to be

influenced by the viewing of pornographic images. The authors theorized that the impaired

decision-making abilities could contribute to the poor decisions and harmful consequences

experienced by persons compulsively viewing pornography.

Most recently, multiple fMRI studies have emerged that support the concept of excessive

pornography consumption as an addictive behavior. For example, neuroscientists at the

University of Cambridge conducted a controlled study they scanned the brains of self-reported

pornography addicts and compared them to controls. The researchers found the fMRI scans of

the pornography addicted subjects to match those of drug addicts and alcoholics in regards to

mesolimbic system activation (Voon et al., 2014). This study, considered landmark by many,

was a key component a BBC Channel 4 documentary called "Porn On The Brain" (MacRae,

2013). Similarly, the previously mentioned researchers at the Max Planck Institute in Germany

also used voxel-based morphometry to analyze the fMRI results of subjects self-identified as

excessive Internet users (Kühn & Gallinat, 2014). Their results indicated a significant

connection between the number of hours subjects spent viewing pornography and decreases in

grey matter volume in the areas of the brain associated with cognitive control. The scans also

showed increased cue-reactivity and reward processing. These findings are directly in line with

the widely accepted theories of addiction posited by Volkow and the NIDA.

Controversy. There are multiple points of controversy surrounding the concept of

Internet pornography as addictive in both the academic and lay community. Some criticize the

idea from an economic model (Voros, 2009), while others view the concept as a guised attack on

the freedom of speech (Clarkson & Kopaczewski, 2013). The most persistent critics, however,

come from within the field of psychology itself. For example, in the aforementioned literature
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review by Hilton & Watts (2011), wherein they provided an argument for the validity of

pornography addiction, Reid, Carpenter, & Fong, (2011) published a rebuttal in which they

claimed the conclusion was "speculative not scientific" based primarily on the fact that studies

specific to Internet pornography addiction were not yet available. Additionally, Steele, Staley,

Fong, & Prause (2013) conducted a study wherein they measured P300 ERP levels of self-

reported individuals with compulsive sexual behavior problems. Based on the EEG results, these

authors claimed their subjects were not suffering from the disease of addiction and instead

simply had higher levels of sexual desire. Despite the fact that the study was highly criticized in

terms of its methodology, conclusions, and presumed bias (Hilton, 2014), the study has been

widely reported in popular media as de facto evidence against the existence of pornography

addiction.

The most recent academic criticism to the concept of pornography as addictive is "The

Emperor Has No Clothes: A Review of the ‘Pornography Addiction’ Model" (Ley, Prause, &

Finn, 2014). This article has been heavily criticized for its scientific inaccuracies and logical

inconsistencies. For example, these authors state in their introduction, “In fact, most scientists

have overtly rejected the addiction model [3,4]". This single example illustrates two problems.

First, they cited studies that represent a minority view as support of their claims that it is the

majority view. Second, their studies do not support the conclusion they are citing them for.

Specifically, the second study they cited as evidence that scientists reject the addiction model

actually concluded, "Available data suggest that considering HD within an addiction framework

may be appropriate and helpful” (Kor, Fogel, Reid, & Potenza, 2013, p.40). Despite its

problems, this article has been highly cited in the popular press as de facto evidence against the

existence of Internet pornography addiction.

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DSM-5

On December 01, 2012, the Trustee's of the American Psychiatric Association voted on

the final version of the DSM-5, which was subsequently released in May 2013. This was the

first revision of the book in thirteen years, which the APA claimed cost $20 - $25 million to

produce (APA, 2014). The APA also claimed that more than 160 world-renowned clinicians and

researchers made up the DSM-5 Task Force and Work Groups, along with "contributions from

more than 1,500 experts in psychiatry, psychology, social work, psychiatric nursing, pediatrics,

neurology, and other related fields from 39 countries" (APA, 2013f). They further claimed the

draft criteria were opened for public review and comment three times throughout the process,

and that 11,000+ comments were received and considered. Finally, they stated that the proposed

changes were reviewed by two independent panels appointed by the APA Board of Trustees

before the final vote by the Trustees themselves: a Scientific Review Committee, and a Clinical

and Public Health Committee (APA, 2013f).

Inclusion criteria. It is important to note that there are two possible locations within the

DSM for the placement of the disorders under review in this paper: Section II (Diagnostic

Criteria and Codes) or Section III (Conditions for Further Study). Diagnoses located in Section

II are considered “official” diagnoses, while diagnoses located in Section III are considered

provisional, for research purposes only. It is also important to note that there are ostensibly

different standards for inclusion in the two differing sections of the DSM-5. There are numerous

publications articulating the scientific objectives behind the development of the core DSM-5.

For example, early in the process, the DSM-5 Task Force Chairmen and key writers published a

book discussing the importance of integrating advances in neuroscience, the importance of

shifting to dimensional categorizations, as well as the importance of adding/removing items from

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prior versions. Later in the process, DSM-5 Task Force Chairmen and other key writers Regier,

Narrow, Kuhl, and Kupfer (2011) published an entire book dedicated to the "conceptual

development of the DSM-5". Unfortunately, this book was quickly criticized as lacking a

"coherent, overriding vision that will provide future nosologists and historians with a clear idea

of what was done and why" (Zimmerman, 2011, p. 1122). After the book was released, various

involved authors published detailed results on three sets of field trials during the development

process; the first on study design, sampling strategies, implementation, and analytic approaches

(Clarke et al., 2013), the second on test-retest reliability of selected categorical diagnoses (Regier

et al., 2013), and the third on the development and reliability testing of cross-cutting symptom

assessments (Narrow et al., 2013).

In contrast, there are only limited numbers of statements available for understanding what

qualified for inclusion in Section III. In the Disorders for Further Study section of their white-

paper “Making a Case for New Disorders”, the APA made a very vague and generic statement:

Including a disorder in Section 3 indicates that enough evidence suggests a condition has

an impact on individuals’ functioning and/or level of distress. But it also signals that

further study is needed before the condition can be accurately described and reliably

diagnosed. (APA, 2013e)

In their white-paper specifically focused on Section III, contrast, the APA included slightly more

details, although specific elaboration on the stated criteria was never offered:

Some proposed conditions had clear merit but ultimately were judged to need further

research before they might be considered as formal disorders. Inclusion of conditions in

Section III was contingent on the amount of empirical evidence available on a diagnosis,

diagnostic reliability or validity, a clear clinical need, and potential benefit in advancing
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research. Additional research may result in new information and data that can guide

decisions in future editions of DSM. (APA, 2013c)

Outcomes. The DSM-5 does not deliver all that was promised. For example, not all of

the terminological changes that were announced made it to the final release. Additionally, not all

of the additions that were announced made it to the final release. The details of the multiple

outcomes are highlighted below.

Addiction generally. The "Substance Related Disorders" chapter was renamed to

"Substance Use and Addictive Disorders," instead of the previously announced "Addiction and

Related Disorders" (O'Brien, 2011). Consistent with O'Brien's 2011 article, the category

"Substance Use Disorder" was retained, with Abuse and Dependence collapsed into a single list.

There were minimal changes in the new list of criteria: the legal issues criteria, added in DSM-

IV, were removed, and a criteria for craving was added. Additionally, the threshold for the

substance-use disorder diagnosis is two; squarely between the previous one for Abuse and three

for Dependence.

Behavioral Addictions. As previously stated, despite the fact that the proposed chapter

names offered for the entirety of the multi-year public commentary window were "Addictive

Disorders" and "Addiction Related Disorders," the chapter in the final version of the DSM-5 was

renamed to "Substance Related and Addictive Disorders." Within the chapter, there is a category

called "Non-Substance-Related Disorders," with the sole diagnosis of "Gambling Disorder." The

traditional Not Otherwise Specified (NOS) catchall diagnosis was removed from the entire

DSM-5, and replaced with an "Other <problem> Disorder" diagnosis. While the "Substance-

Related Disorders" section included an "Other (or Unknown) Substance–Related Disorders"

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diagnosis, the Non-Substance Related Disorders section did not include a catchall. It should be

noted that this is one of very few sections in the DSM-5 where the catchall was omitted.

Pathological Gambling. The APA reformulated the ICD's reformulated into a chapter

named "Disruptive, Impulse-Control, and Conduct Disorders” in the DSM-5, containing such

disorders as Conduct Disorder, Intermittent Explosive Disorder, Kleptomania, Oppositional

Defiant Disorder, Pyromania, and a reference to Antisocial Personality Disorder. Similarly, the

OCD's were removed from the Anxiety Disorders section and placed in their own "Obsessive-

Compulsive and Related Disorders" chapter, containing disorders such as OCD, Body

Dysmorphic Disorder, Hoarding Disorder, Trichotillomania, and Excoriation (APA, 2013).

The APA renamed Pathological Gambling to "Gambling Disorder" in the DSM-5, and

placed it in the Substance Related and Addictive Disorders" chapter. Petry et al. (2013)

published a position paper regarding the decisions of the DSM-5 Task Force. They stated that

the name was changed because the term pathological had become "outdated and pejorative"

(Petry et al., 2013, p. 2). They stated that other terms considered were "compulsive gambling,"

dropped due to the terminological overlap with Anxiety Disorders, and ‘‘problem gambling,’’

dropped because the term was previously used as a sub-diagnostic threshold condition. Other

changes made were that the "illegal acts" criteria was removed from the Disordered Gambling

diagnosis, and the minimum criteria requirement was reduced from five to four in the DSM-5.

Internet Addiction/ Internet Use Disorder. A diagnosis of Internet Addiction/Internet

Use Disorder was not included in Section III of the DSM-5. In what may have been a surprise to

everyone in the field, the APA Board of Trustee's renamed Internet Use Disorder to Internet

Gaming Disorder (IGD) at the final (12/02/2012) vote for the DSM-5. This was done without

the opportunity for public notice and comment. The unexpected nature of the change and
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corresponding surprise to the professional community can be evidenced by the number of papers

published in 2013 that explicitly refer to "Internet Use Disorder" as a Section III diagnosis in the

DSM-5 (King & Delfabbro, 2013a; Kuss & Griffiths, 2012c).

Internet Gaming Disorder. As previously stated, a new diagnostic category for Internet

Gaming Disorder appeared in the final version of the DSM-5.

The diagnostic criteria for Internet Gaming Disorder are listed in Section III of the DSM-5 as

follows:

Persistent and recurrent use of the Internet to engage in games, often with other players,

leading to clinically significant impairment or distress as indicated by five (or more) of

the following in a 12-month period:

1. Preoccupation with Internet games. (The individual thinks about previous gaming

activity or anticipates playing the next game; Internet gaming becomes the dominant

activity in daily life). Note: This disorder is distinct from Internet gambling, which is

included under gambling disorder.

2. Withdrawal symptoms when Internet gaming is taken away. (These symptoms are

typically described as irritability, anxiety, or sadness, but there are no physical signs of

pharmacological withdrawal.)

3. Tolerance—the need to spend increasing amounts of time engaged in Internet games.

4. Unsuccessful attempts to control the participation in Internet games.

5. Loss of interests in previous hobbies and entertainment as a result of, and with the

exception of, Internet games.

6. Continued excessive use of Internet games despite knowledge of psychosocial

problems.
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7. Has deceived family members, therapists, or others regarding the amount of Internet

gaming.

8. Use of Internet games to escape or relieve a negative mood (e.g., feelings of

helplessness, guilt, anxiety).

9. Has jeopardized or lost a significant relationship, job, or educational or career

opportunity because of participation in Internet games. Note: Only nongambling Internet

games are included in this disorder. Use of the Internet for required activities in a

business or profession is not included; nor is the disorder intended to include other

recreational or social Internet use. Similarly, sexual Internet sites are excluded.

Specify current severity:

Internet gaming disorder can be mild, moderate, or severe depending on the degree of

disruption of normal activities. Individuals with less severe Internet gaming disorder

may exhibit fewer symptoms and less disruption of their lives. Those with severe

Internet gaming disorder will have more hours spent on the computer and more severe

loss of relationships or career or school opportunities. (APA, 2013a, p.795)

Internet Pornography Addiction. As it was never proposed for inclusion, Internet

Pornography Addiction was not included in the DSM-5. A related variant of the problem,

however, was proposed (Hypersexual Disorder). Despite the empirical validation of the

proposed diagnosis (Reid, et al., 2012), the Board of Trustees of the American Psychiatric

Association voted in December 2012 to exclude Hypersexual Disorder from Section III of the

DSM-5. To date, the APA has remained silent on the specifics of why/how they came to this

decision. Although the diagnosis was proposed to the Sexual Disorders workgroup, the only

statements regarding the discussion of excessive sexual behaviors for the DSM-5 are embedded
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in statements regarding the combination of substance and behavioral addictions, or in the

discussion of behavioral addictions in general. For example, in their abovementioned article,

Petry & O'Brien (2013) stated, "Excessive eating and sexual behaviors were discussed with the

eating disorders and sexual disorders work-groups, and it was decided that there was insufficient

published data to group these clinical phenomena with SUDs" (p.1186). Additionally, in his

abovementioned article, Potenza (2014) affirmed the discussions between the workgroups,

although he also listed exercise and shopping as behavioral addictions that were discussed.

Inconsistencies and contradictions. A detailed investigation of the DSM-5, as well as

the public statements made by the APA both before and after its release reveals a myriad of

inconsistencies. Some of these inconsistences are slight, while others illustrate the APA directly

contradicting itself.

Addiction generally. The first inconsistencies can be found via the APA's decision to

avoid the use of the term addiction when they abandoned the proposed Addiction and Related

Disorders chapter name, and downplayed the use of the term addiction throughout much of the

DSM-5. For example, the APA included a specific disclaimer in the DSM-5:

Note that the word addiction is not applied as a diagnostic term in this classification,

although it is in common usage in many countries to describe severe problems related to

compulsive and habitual use of substances. The more neutral term of substance use

disorder is used to describe the wide range of the disorder, from a mild form to a severe

state of chronically relapsing, compulsive drug taking. Some clinicians will choose to use

the word addiction to describe more extreme presentations, but the word is omitted from

the official DSM-5 substance use disorder diagnostic terminology because of its

uncertain definition and its potentially negative connotation. (APA, 2013a, p.485)
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The inconsistency here is the APA's own use of the term within the book, such as in

Section III for Internet Gaming Disorder, wherein they stated, "The literature does describe many

underlying similarities to substance addictions, including aspects of tolerance, withdrawal,

repeated unsuccessful attempts to cut back or quit, and impairment in normal functioning" (APA,

2013d, p. 796). The APA also inconsistently, but regularly, used the term addiction in most of

its white-papers about the DSM-5 (see below). As will be seen throughout many of the quotes

contained in this chapter, the APA regularly and repeatedly used the term addiction despite their

specific disclaimer quoted above.

Behavioral Addictions.

As previously stated, the DSM-5 does not include an explicit category for Behavioral

Addictions, but instead includes a category of Non-Substance-Related Disorders within the

Substance-Related and Addictive Disorders chapter. This is in direct contradiction to the leading

statement in the Addictive Disorders section on their white-paper on the new chapter: “The

chapter also includes gambling disorder as the sole condition in a new category on behavioral

addictions” (APA, 2013e). Nevertheless, the APA made a categorical statement in the

introduction to the Substance Related and Addictive Disorders chapter in which they discounted

the existence of Behavioral Addictions and excluded them from the book:

Thus, groups of repetitive behaviors, which some term behavioral addictions, with such

subcategories as “sex addiction,” “exercise addiction,” or “shopping addiction,” are not

included because at this time there is insufficient peer-reviewed evidence to establish the

diagnostic criteria and course descriptions needed to identify these behaviors as mental

disorders. (APA, 2013a, p. 481)

Somewhat confusingly, this statement was made immediately after stating that some
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behaviors are addictive, gambling in particular:

In addition to the substance-related disorders, this chapter also includes gambling

disorder, reflecting evidence that gambling behaviors activate reward systems similar to

those activated by drugs of abuse and produce some behavioral symptoms that appear

comparable to those produced by the substance use disorders. (APA, 2013a, p. 481)

To further the confusion, the APA later went on to state

Although some behavioral conditions that do not involve ingestion of substances have

similarities to substance-related disorders, only one disorder—gambling disorder—has

sufficient data to be included in this section. (APA, 2013a, p.586)

Further in the book, the APA went on to again violate their original statement against

behavioral addictions by including Internet Gaming Disorder:

...however, there are other behavioral disorders that show some similarities to substance

use disorders and gambling disorder... and the one condition with a considerable

literature is the compulsive playing of Internet games....The DSM-5 work group...found

some behavioral similarities of Internet gaming to gambling disorder and to substance use

disorders. (p. 586)

A final, but equally large, inconsistency regarding behavioral addictions is found in the

incongruence between the content of the DSM-5 and it's corresponding white-papers. As

previously mentioned, the APA stated in their Substance-Related and Addictive Disorders white-

paper: "The chapter also includes gambling disorder as the sole condition in a new category on

behavioral addictions" (APA, 2013b). This is consistent with the official APA News Release on

February 10, 2010 subtitled "New Category of Behavioral Addictions Also Proposed", wherein

they stated: "The DSM Substance-Related Work Group members also have recommended a new
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category of behavioral addictions, in which gambling will be the sole disorder" (APA, 2010).

While it is understandable that the final release of the book in 2013 does not include categories

proposed in 2010, it is not understandable how the 2013 press release for the book uses the term

behavioral addictions, or how the APA then discounts both the terms "behavioral addictions" and

"addiction". Put together, this illogic begs the following question: Do behavioral addictions

exist or do they not?

In regards to the statement that "insufficient peer-reviewed evidence to establish the

diagnostic criteria and course descriptions" (p.481), the application of a requirement for

established diagnostic criteria to exclude behavioral addictions is perplexing, especially

considering the fact that the diagnostic criteria for Gambling Disorder are the essentially the

same as those proposed for behavioral addictions (Goodman, 2001; Griffiths, King, &

Demetrovics, 2014). The statement in its entirety is somewhat absurd given that the disorders

they reference (sex addiction, exercise addiction, and shopping addiction) are all diagnoses that

were never actually proposed for consideration or inclusion in the book. This use of this

standard becomes particularly problematic when one considers the fact that the many of the

criteria for Internet Gaming Disorder were taken verbatim from the criteria for Internet

Addiction, with the addition of the word "gaming". Otherwise, the use of these standards to

exclude Internet Addiction in favor of Internet Gaming Disorder appears ignorant at best and

disingenuous at worst.

Petry (DSM-5 Substance-Related Disorders Work Group Member) and O'Brien (DSM-5

Substance-Related Disorders Work Group Chair) published an editorial wherein they made an

indirect statement illustrating their discomfort with behavioral addictions in general:

The inclusion of Internet gaming disorder in Section 3 of DSM-5 opens discussions for
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other ‘behavioral addictions’, a highly controversial topic. Introducing conditions into

the DSM-5 that are not well established or that do not cause significant distress and

impairment (e.g. chocolate addiction) will lower the credibility of psychiatric disorders

more generally, thereby undermining the seriousness of psychiatric disorders. (p. 1187)

Note that although Petry has used her "chocolate addiction" example multiple times over

the years (Petry, 2006, 2011) as an example to dampen the allowance of behavioral addictions,

this appears to be a statement of misleading rhetoric as only one peer-reviewed paper positing

this addiction currently appears on Google Scholar using a non-time-limited search

(Hetherington & MacDiarmid, 1993). In contrast, a search on a more reasonably scoped "sugar

addiction" yields multiple results in the previous few years (Ahmed, Guillem, & Vandaele, 2013;

Benton, 2010; Fortuna, 2010; Peters, 2011). If one were to broaden the scope further, it would

be revealed that Volkow alone has published three papers in the last year focusing on obesity as

a behavioral addiction (Savage et al., 2014; Volkow, Wang, Tomasi, & Baler, 2013a; Volkow,

Wang, Tomasi, & Baler, 2013b).

The following year, Petry et al. (2014) (author list includes O’Brien) published an

editorial formally addressing two controversies: "Controversy A: The decision to include non-

substance addictions in DSM-5" and "Controversy B: How to assess the DSM-5 criteria for

Internet Gaming Disorder". In regards to the first controversy, these authors stated

The DSM-5 Workgroup reviewed the literature on non-substance addictive behaviors,

including gambling, Internet gaming, Internet use generally, work, shopping and

exercise. They voted to move gambling disorder to the substance-related and addictive

disorders section in DSM-5 because of its overlap with substance use disorders in terms

of etiology, biology, comorbidity and treatment. In terms of the other putative non-
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substance addictions, the DSM-5 Workgroup voted to include only one other condition—

Internet gaming disorder. This decision was based upon the large number of studies of

this condition and the severity of its consequences. (p.2)

This statement implies that etiology, biology, comorbidity, and treatment are key factors

needed to justify the inclusion of a disorder as worthy of official consideration. Dozens of

articles have been identified throughout this paper exploring these same areas in regards to

Internet addiction and its subtypes, and if one were to pick a single topic from the list, perhaps

the strongest scientific evidence in support of this standard comes from research into the

neurobiology of behavioral addictions. Leeman and Potenza's 2013 detailed literature review of

197 studies compared and contrasted the brain function and neuroimaging results,

neurotransmitter systems, and genetics of multiple behavioral addictions (gambling, Internet use,

video game playing, shopping, kleptomania, and sex) with the findings of substance abuse

research. Grant, Brewer, and Potenza (2006) concluded their literature review with the statement

"Biochemical, functional neuroimaging, genetic studies, and treatment research have suggested a

strong neurobiological link between behavioral addictions and substance use disorders" (p.92), a

statement similar to Olsen's (2011) "glut of evidence" regarding the same.

Petry et al. (2014) went on to state

With the exception of gambling and internet gaming, the DSM-5 Workgroup concluded

that research on other behavioral addictions was relatively limited, the adverse

consequences were less well documented or less reflective of clinically significant

impairment or the behavior pattern was not well aligned with substance use disorders.

Therefore, no other non-substance addictions are included in DSM-5. Although many

researchers and clinicians in these fields are likely to disagree with this decision, the
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issues and criteria outlined below ultimately may guide the study of other conditions,

with the explicit understanding that application of internet gaming criteria to other

conditions is not appropriate unless the reliability and validity of the criteria, and

thresholds for diagnosis, are independently established for other manifestations of

internet use or other non-substance-related excessive behavioral patterns. (p. 2)

It should be noted that the sole reference these authors made in support of behavioral

addictions is a nine-year-old study published by the first author of the paper in question (Martin

& Petry, 2005). The multitudes of papers published by other authors during the same time

period, such as the 43 articles and reviews on the topic of Behavioral Addictions identified

within this present paper, were not mentioned.

Potenza (2014) recently published an editorial wherein he abstractly discussed the

process of the DSM-5 Substance Related Disorders Work Group. He acknowledged the

consideration of behavioral addictions such as Internet, exercise, shopping, food/obesity, sex,

and television, and also cited the APA's reasoning for their lack of inclusion; “at this time there

is insufficient peer-reviewed evidence to establish the diagnostic criteria and course descriptions

needed to identify these behaviors as mental health disorders” (APA, 2013, p. 481). Despite this

claim, research continues to emerge in all these areas. For example, numerous articles pertaining

to Internet and sex addiction can be found elsewhere in this document, and sample references for

the remaining addictions include: exercise (Costa, Cuzzocrea, Hausenblas, Larcan, & Oliva,

2012; Freimuth, Moniz, & Kim, 2011; Landolfi, 2013; Lichtenstein, Larsen, Christiansen,

Støving, & Bredahl, 2014; Müller et al., 2014; Weinstein & Weinstein, 2013),

shopping/spending/buying (Black, Shaw, McCormick, Bayless, & Allen, 2012; Hartston, 2012;

Lejoyeux & Weinstein, 2010; Murali, Ray, & Shaffiullha, 2012; Rose & Dhandayudham, 2014;
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Starcke, Schlereth, Domass, Schöler, & Brand, 2013), and television (Sussman & Moran, 2013).

The concept of food as addictive has been particularly studied in recent years, including heavy

research into the neurobiological components of binge eating and obesity (Ahmed, Guillem, &

Vandaele, 2013; Balodis, Grilo, et al., 2013; Balodis, Kober, et al., 2013; Blum, Oscar-Berman,

Barh, Giordano, & Gold, 2013; Clark & Saules, 2013; Gearhardt, Boswell, & Potenza, 2014;

Rodgers, Melioli, Laconi, Bui, & Chabrol, 2013; Volkow, Wang, Tomasi, & Baler, 2013a;

Volkow, Wang, Tomasi, & Baler, 2013b).

Finally, other behavioral addictions under investigation include workaholism

(Andreassen, 2013; Andreassen, Griffiths, Hetland, & Pallesen, 2012; Sussman, 2012),

nonsuicidal self-injury (NSSI) ("cutting") (Franklin et al., 2010), social networking generally

(Andreassen & Pallesen, 2013; Emre & İŞBULAN, 2012; Karaiskos, Tzavellas, Balta, &

Paparrigopoulos, 2010; Kuss & Griffiths, 2011; Salehan & Negahban, 2013; Weiss & Samenow,

2010), and Facebook specifically (Andreassen, Torsheim, Brunborg, & Pallesen, 2012;

Carmody, 2012; Griffiths, 2012; Kittinger, Correia, & Irons, 2012; Koc & Gulyagci, 2013;

Rosen, Whaling, Rab, Carrier, & Cheever, 2013).

Gambling Disorder. The inclusion of Gambling Disorder in the Substance Related and

Addictive Disorders chapter of the DSM-5 was consistent with existing research. As previously

mentioned, the APA stated that the reason Gambling Disorder was moved to the Substance

Related and Addictive Disorders section was due to its “reflecting evidence that gambling

behaviors activate reward systems similar to those activated by drugs of abuse and produce some

behavioral symptoms that appear comparable to those produced by the substance use disorders"

(APA, 2013a, p. 481). Although somewhat infrequently referenced by the APA, the use of

reward system activation as a benchmark for consideration of a behavior as addictive is one of

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the most scientifically logical standards presented due to its underpinnings in the biological basis

of behavior. However, this standard expands beyond rather than limits to the scope of

pathological gambling, as multiple papers and reviews have shown other behavioral addictions

similarly engage the mesocorticolimbic dopamine pathway in problematic manners. For

example, experts in the neurobiology of substance abuse, Koob & Le Moal (2008) articulated

detailed reward system activation between substance abuse and, not only compulsive gambling,

but also compulsive eating, compulsive exercise, compulsive sexual behavior, and compulsive

shopping. Leeman and Potenza (2013) confirmed this statement with their full-page table of

comparison studies regarding the neurobiology not only of gambling but also gaming, Internet

use, kleptomania, sex, and shopping. Additionally, studies are emerging on a regular basis

identifying mesolimbic activation for Internet related behaviors (Brand, Young, & Laier, 2014;

Kühn & Gallinat, 2014; Kühn S, 2014).

In 2006 and again in 2010, Petry published editorials arguing for the inclusion of

pathological gambling in the substance abuse section of the then upcoming DSM-5. She citied

multiple studies showing similar presentations of symptoms between the two disorders, as well

as studies showing a similar neurobiological basis, including genetics, and similar treatment

successes. She listed potential benefits of the categorical change as improved screening and

treatment opportunities. Petry et al. (2013) again cited the benefits of placing Gambling

Disorder in the Substance Related and Addictive Disorders chapter as improved screening and

interventions in SUD treatment centers, enhanced likelihood of treatment, a greater awareness of

the problem by medical professionals, increased public health awareness, increased funding,

increased likelihood of insurance coverage, and that it "may reduce public health burden of

gambling disorders" (p. 6). While these are valid and important points, the research shown in
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this paper illustrates that these same benefits would be realized by the inclusion of other

behavioral addictions, such as Internet Addiction, or even behavioral addictions as a whole into

the DSM-5.

A final inconsistency to note here is that while arguing for strict standards for inclusion in

the DSM-5, the APA actually reduced the number of criteria required for a diagnosis of

Gambling Disorder from five to four. Petry (2006) argued that the previously increased

minimum number of diagnostic criteria, from three in the DSM-III to four in the DSM-III-R to

five in the DSM-IV/DSM-IV-TR, resulted in a diagnosis of Pathological Gambling as "possibly

more difficult than substance use disorders" (p. 154). Additionally, Petry et al. (2013) cited

multiple studies showing a greater diagnostic accuracy with this reduction. While this may be

the case, the conflict here is the APA's raising the bar for mere inclusion of some disorders (see

Internet Addiction below) while lowering the bar for a full diagnosis of other similarly situated

disorders.

Internet Addiction/Internet Use Disorder. To this author’s knowledge, the reworking of

the proposed Internet Addiction/Internet Use Disorder to Internet Gaming Disorder was done

without the opportunity for public/professional Notice & Comment. Retrospective review to

support this claim is difficult to perform, as the APA now requires a password to view any

previously proposed revisions on the official dsm5.org website. No articles have been published

articulating the decision to change the diagnosis, and no mention is made on the DSM-5/ICD-11

watchdog site dxrevisionwatch.org. Additionally, there is no mention of this decision in any of

the published books about the DSM-5 development (Greenberg, 2013; Paris & Phillips, 2013).

Internet Gaming Disorder. Although some critics of the proposed IUD suggested

Internet gaming as a better diagnostic category (Starcevic, 2013a), a formal proposal to rename
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the diagnosis was never published, and, to date, no official rationale for the change has been

provided. The APA made several statements in support of the decision to include IGD in the

DSM-5 (see below), however they made no mention of the final-hour decision to repackage

another formally proposed diagnosis.

In the introduction to the Internet Gaming Disorders section of the DSM-5, the APA

referred to "...other behavioral disorders that show some similarities to substance use disorders

and gambling disorder... and the one condition with a considerable literature is the compulsive

playing of Internet games...” (APA, 2013a, p. 796). The subjective phrase "considerable

literature" is impossible to decipher, as there is no formal standard offered. What is the

requirement for a "considerable literature"? While there is indeed a considerable literature of

studies accrued regarding Internet Gaming Disorder, this paper has illustrated that there is a

similarly considerable literature accrued for Internet Addiction itself. Entirely inconsistently, the

APA allowed a new disorder in Section III that contained the opposite of a “considerable

literature”. The APA cites a mere 10 references for “Suicidal Behavior Disorder”, only three of

which were published within the previous five years (all in 2012). Of the remainder, two studies

were published within the last 10 years (2005, 2007), four studies were published within the last

15 years (2002, three in 2003), and one study was published exactly 25 years ago (1989). While

this comparison is in no way intended to discount the seriousness and importance of suicidal

behavior, it offers a stark contrast to the claimed robust research requirement.

In support of their “considerable literature” statement, the APA went on to state that the

DSM-5 work group reviewed over 240 articles on the topic of Internet Gaming Disorder, finding

"some behavioral similarities of Internet gaming to gambling disorder and to substance use

disorders" (APA, 2013a, p. 796). While it is true that hundreds of articles have been published,
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and that similarities between Internet Gaming and gambling behaviors have been established, the

overall validity of their claimed research is questionable. This concern is based on the fact that

they openly confused the concept of Internet Addiction with Internet Gaming Disorder, a

subtype, stating, "Internet gaming disorder (also commonly referred to as Internet use disorder,

Internet addiction, or gaming addiction) has merit as an independent disorder" (APA, 2013a, p.

796). While the use of intermixed terminology is not uncommon, the accuracy of the analysis is

suspect. The APA included 14 references for Internet Gaming Disorder in the DSM-5 to support

the diagnosis. Thirteen of these references are to peer-reviewed journals, and one is a reference

to a pop-culture magazine article ("Wired") about Internet Addiction in China. Among the peer-

reviewed articles, only three articles are actually specifically focused on Internet Gaming, (Du et

al., 2011; Han et al, 2010; Van Rooij et al., 2011). Of the 10 remaining articles, four studies

refer to gaming as one of three subtypes of Internet Addiction (Kim et al., 2011; Shek et al.,

2009; Tao et al., 2010; Weinstein & Lejoyeux, 2010; Zhou et al., 2011), one references gaming

as one of ten subtypes (Widyanto et al., 2011), three make use of the terms "game" and "gaming"

interwoven with other Internet related terms such as "gambling" and "pornography" (Fu et al.,

2010; Tsitsika et al., 2011; Yuan et al., 2011), and two refer to "Internet use" generally with no

subtypes (Fu, Chan, Wong, & Yip, 2010; Ko, Yen, Chen, Chen, & Yen, 2005).

The APA also stated in their press release/fact sheet on Internet Gaming Disorder

The studies suggest that when these individuals are engrossed in Internet games, certain

pathways in their brains are triggered in the same direct and intense way that a drug

addict’s brain is affected by a particular substance. The gaming prompts a neurological

response that influences feelings of pleasure and reward, and the result, in the extreme, is

manifested as addictive behavior. (APA, 2013d)

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This statement leads back to the original statement about reward center activation made

in regards to the justification for including gambling in the Substance Related and Addictive

Disorders chapter. This is a partially illogical standard to use to justify the inclusion of Internet

Gaming Disorder at the expense of Internet Addiction with subtypes considering the fact that a

majority of the neuroimaging studies cited in the DSM-5 are unspecific to internet gaming (see

further in this paper).

The APA provided a familiar sounding description in the Diagnostic Features section of

Internet Gaming Disorder:

The literature does describe many underlying similarities to substance addictions,

including aspects of tolerance, withdrawal, repeated unsuccessful attempts to cut back or

quit, and impairment in normal functioning…Internet gaming disorder is a pattern of

excessive and prolonged Internet gaming that results in a cluster of cognitive and

behavioral symptoms, including progressive loss of control over gaming, tolerance, and

withdrawal symptoms, analogous to the symptoms of substance use disorders. As with

substance-related disorders, individuals with Internet gaming disorder continue to sit at a

computer and engage in gaming activities despite neglect of other activities…If they are

prevented from using a computer and returning to the game, they become agitated and

angry. They often go for long periods without food or sleep. Normal obligations, such as

school or work, or family obligations are neglected… The essential feature of Internet

gaming disorder is persistent and recurrent participation… Attempts to direct the

individual toward schoolwork or interpersonal activities are strongly resisted. Thus

personal, family, or vocational pursuits are neglected. When individuals are asked, the

major reasons given for using the computer are more likely to be “avoiding boredom”
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rather than communicating or searching for information. (APA, 2013a, p. 796-797)

Similarly, the APA stated in the Functional Consequences of Internet Gaming Disorder

section of the diagnosis

Internet gaming disorder may lead to school failure, job loss, or marriage failure. The

compulsive gaming behavior tends to crowd out normal social, scholastic, and family

activities. Students may show declining grades and eventually failure in school. Family

responsibilities may be neglected. (APA, 2013a, p. 797)

These statements sound familiar because they nearly identically overlap with the criteria

for Substance Use Disorder, Pathological Gambling, Goldberg’s criteria for his proposed Internet

Addiction Disorder (Suler, 1998), Young’s criteria for her proposed Internet Addiction diagnosis

(Young, 1996), Beard & Wolf’s modification to Young’s criteria (Beard & Wolf, 2001),

Goodman’s proposed criteria for Addictive Disorders (Goodman, 2001), and Hagedorn’s follow-

up call for an Addictive Disorders diagnosis in the DSM-5 (Hagedorn, 2009). The IGD criteria

meet Potenza’s suggested three core elements of a “non-substance addiction”: "(1) craving state

prior to behavioral engagement, or a compulsive engagement; (2) impaired control over

behavioral engagement; and (3) continued behavioral engagement despite adverse consequences"

(Potenza, 2006, p. 143). Griffiths similarly matched the IGD criteria to his own components

model:

Preoccupation with internet games (salience); withdrawal symptoms when internet

gaming is taken away (withdrawal); the need to spend increasing amounts of time

engaged in internet gaming (tolerance); unsuccessful attempts to control participation in

internet gaming (relapse/loss of control); loss of interest in hobbies and entertainment as

a result of, and with the exception of, internet gaming (conflict); continued excessive use
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of internet games despite knowledge of psychosocial problems (conflict); deception of

family members, therapists or others regarding the amount of internet gaming (conflict);

use of the internet gaming to escape or relieve a negative mood (mood modification); and

loss of a significant relationship, job, or educational or career opportunity because of

participation in internet games (conflict). (Griffiths, King, & Demetrovics, 2014, p.3)

Considering the fact that although the APA acknowledged the root of the IGD criteria as

adapted from Tao et al.’s 2010 proposed diagnosis for Internet Addiction disorder, which

informally included thee subtypes of Internet addiction and was itself based on Block's (2008)

proposal for Internet Addiction, which formally included the same three subtypes, it is

paradoxical and ironic that they embraced gaming but explicitly prohibited the other two

subtypes. For example, they stated in the Differential Diagnosis section for IGD

Excessive use of the Internet not involving playing of online games (e.g., excessive use

of social media, such as Facebook; viewing pornography online) is not considered

analogous to Internet gaming disorder, and future research on other excessive uses of the

Internet would need to follow similar guidelines as suggested herein. (APA, 2013a, p.

797)

Secondary sources do little to shed light upon the decision to covert Internet Use Disorder

to Internet Gaming Disorder. The aforementioned Petry & O'Brien (2013) editorial could

arguably be considered a quasi-official statement on Internet Gaming Disorder. Although the

authors stated, "This editorial provides an overview of the evidence that the work-group

considered, the status of Internet gaming disorder in the DSM-5 and rationale for the

recommendations” (p. 1186), no mention was made of the decision to rework the Internet Use

Disorder diagnosis into Internet Gaming Disorder. Instead, the authors made a similarly
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confused statement to the one found in the DSM-5: "Well over 250 publications exist on Internet

gaming disorder, also referred to as gaming or Internet use disorder, gaming or Internet

addiction, gaming or Internet dependence, pathological or problematic gaming, etc" (p. 1186).

Shortly thereafter, Petry, et al. (2014) discussed "Controversy B: How to assess the

DSM-5 criteria for Internet Gaming Disorder,” wherein they stated

Few studies compared different forms of Internet activities, and those that did found that

Internet gaming appears to be distinct from other excessive online or electronic

communication activities such as social media use, Internet gambling (included under

gambling disorder), pornography viewing, etc. with respect to prevalence rates,

etiologies, characteristics of individuals participating in them and risks for harm. Because

of the distinguishing features and increased risks of clinically significant problems

associated with gaming in particular, the Workgroup recommended the inclusion of only

Internet gaming disorder in Section 3 of the DSM-5. (p.2)

It should be noted that these authors make no mention of the importance of neurobiology.

This is inconsistent with the previously acknowledged common neurobiology across gaming

users and behavioral addictions in general, as well as the fact that a majority of the references in

the DSM-5 illustrate a common neurobiology across all the Internet related behaviors. For

example, the APA stated in the Associated Features Supporting Diagnosis section of IGD:

"Individuals with compulsive Internet gaming have demonstrated brain activation in specific

regions triggered by exposure to the Internet game but not limited to reward system structures

(APA, 2013a, p. 797)". As we have seen, both Koob & Le Moal (2008) and Leeman & Potenza

(2013) have published literature reviews illustrating the same brain activation across a wide

spectrum of behaviors. Another inconsistency can be found here in that of the two studies cited
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by the APA to support this statement, only one is a study focused exclusively on gaming (Du et

al. 2011). Inconsistent with the APA's intended use of the citation, the authors of the second

study stated: "The IAD subjects used the internet almost everyday, and spend more than 8

hours... everyday in front of the monitor, mostly for chatting with cyber friends, playing online

games, and watching online pornographies or adult movies" (Kim, et al. 2011, p. 2).

In their article, Petry, et al. (2014) referred, however, to "distinguishing

features...associated with gaming in particular" (p.2). There are no specific details or references

provided to support this statement, however the sentence immediately prior references the

previously mentioned poorly constructed Van Rooij study that concluded

Although most Internet applications have a social nature, online gaming is the only

example that combines a distinct reward structure, an open-ended design, and a strong

social component. This means that online games are likely to be more demanding or

‘‘addictive’’ than the other Internet applications. (Van Rooij, Schoenmakers, Van de

Eijnden, & Van de Mheen, 2010, p. 52)

This supposition is consistent with statements made by the APA throughout the IGD

section regarding a social component to some Internet games:

The essential feature of Internet gaming disorder is persistent and recurrent participation

in computer gaming, typically group games, for many hours. These games involve

competition between groups of players (often in different global regions, so that duration

of play is encouraged by the time-zone independence) participating in complex structured

activities that include a significant aspect of social interactions during play. Team aspects

appear to be a key motivation. (APA, 2013a, p. 797)

The acknowledgement of the importance of social interaction and variable reinforcement

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is in no way unique to Internet gaming. Indeed, Young emphasized cybersex and cyber-

relationships as two factors in her initial list of subtypes for Internet Addiction (Young, 1998).

Davis (2001) also listed cybersex as a manifestation of SPIU. Further, Tsitsika et al. (2011)

(whose study was cited by the APA in the IGD diagnosis) found online social networks,

gambling, role-play games, and pornography viewing as risk factors for Internet addiction.

Finally, the influence of social interaction is inherent in the concept of social

networking/FaceBook addiction (Andreassen & Pallesen, 2013; Andreassen, Torsheim,

Brunborg, & Pallesen, 2012; Balakrishnan & Shamim, 2013; Carmody, 2012; Emre &

İŞBULAN, 2012; Griffiths, 2012; Karaiskos, Tzavellas, Balta, & Paparrigopoulos, 2010;

Kittinger, Correia, & Irons, 2012; Koc & Gulyagci, 2013; Kuss & Griffiths, 2011; Milošević-

Đorđević & Žeželj, 2014; Rosen, Whaling, Rab, Carrier, & Cheever, 2013; Salehan &

Negahban, 2013; Weiss & Samenow, 2010). It is thus unsound to use this concept as a

delineating factor separating gaming addiction from the other abovementioned behavioral

addictions.

In spite of Petry, et al.'s (2014) unequivocal statement that the studies that compared the

different forms of Internet activities all found gaming to be distinct, other studies do exist

indicating otherwise. For example, Meerkerk, Eijnden, & Garretsen (2006) investigated 11

potential activities in which people engage on the Internet. The authors found gaming and

erotica (pornography) to be primary uses of the Internet using a cross-sectional analysis. Using a

longitudinal analysis, however, erotica was the strongest predictor of Internet addiction.

Accordingly, Potenza (2014) made the following statement in his recent editorial

Internet gaming disorder has been included in the DSM-5 as a condition requiring further

study (Petry & O'Brien, 2013). The inclusion of specific diagnostic criteria for this
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disorder should help advance clinical and research efforts into its prevalence and impact,

and thus its inclusion in DSM-5 represents a significant advance. However, Internet

gaming may represent just one facet of problematic use of the Internet and the potential

impact of other Internet-related behaviors (e.g., social networking, shopping,

pornography viewing, gambling) warrants consideration. (p. 1)

Finally, a paradox is contained within Petry et al.'s (2013) statement regarding the need

for "reliable and valid criteria" to support future Internet related diagnoses, in that the criteria

presented for diagnosing Internet gaming disorder are based largely on reliable and validated

criteria and assessment instruments initially designed for diagnosing Internet addiction.

Internet Pornography Addiction. As is the case with Behavioral Addictions, Internet

Pornography Addiction was never independently proposed for inclusion in the DSM-5, and thus

a diagnosis was not provided. Instead, pornography was originally intended to be a subtype of

Internet Addiction. The validity of this as a subtype of a condition worth further study can be

evidenced by the more than 75 books and papers articles cited in this paper on the topic of

problematic online sexuality, nearly a third of which are peer-reviewed articles that specifically

include "pornography" in the title (as contrasted with terms such as cybersex, "internet sex

addiction", etc.).

As with Internet Addiction, Hypersexual Disorder remained a proposed Section III

diagnosis for the DSM-5 until the final vote in December 2012, at which time the proposed

diagnosis was voted out without specific explanation. Petry and O'Brien (2013) made brief

mention of the decision in their unofficial paper on Internet Gaming Disorder: "Excessive eating

and sexual behaviors were discussed with the eating disorders and sexual disorders work-groups,

and it was decided that there was insufficient published data to group these clinical phenomena
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with SUDs" (p. 1186). An inference of a possible decision point may be extracted from this

statement. Specifically, the problem may have been that Hypersexual Disorder was proposed for

inclusion as a Sexual Disorder rather than as an Addictive Disorder.

In the conclusion to his editorial debate on HD, Winters (2010) made a brief but valid

point that Hypersexual Disorder may not belong in the Sexual Disorders category. Winters

referenced Kafka's (2010) own acknowledgment of the potential positive fitment of HD within

the Behavioral Addictions framework. Similarly, Kor, Fogel, Reid, & Potenza (2013) published

an analysis where they concluded that the addiction model may best fit out-of-control sexual

behavior. While there is logic in Kafka's placement of HD within the Sexual Disorders section

based on its counterbalancing of the pre-existing Hyposexual Disorder diagnosis, this decision

does validate claims of inconsistency of research, as much research on out-of-control sexual

behavior utilizes either the compulsion or addiction model, rather than as a disorder of sexual

desire.

The impact of the proposal of Hypersexual Disorder to the Sexual Disorders Work Group

is unknown to this author. Petry and O'Brien's statement clearly indicates that there were at least

discussions between the two work-groups, although the extent and formality of which are

unstated. It is also unknown whether a diagnosis proposed for one chapter could even be

transferred to another chapter (from Sexual Disorders to Addictive Disorders), or if procedure

requires a new presentation in the second chapter at a later date. However, the unofficial

statements made by Work-Group members may be the best indicator of the true explanation for

the exclusion of HD from the DSM-5.

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Chapter 3 - Methodology

The research method used for this project was a Theoretical Study. This university

defines a theoretical study as "an extensive search, review, analysis, and interpretation of already

published studies in order to find new meaning" (CalSouthern, 2014). In this case a detailed

literature review was conducted on multiple subject areas, however what distinguishes this study

from a traditional literature review is that the research collected for this project was not analyzed

and summarized based on the content found therein. Rather, the research was used to critically

evaluate the conclusions others have drawn from it regarding an outside issue. Specifically, the

research contained within this project is presented to support the theory sufficient research exists

to justify the inclusion of Internet Addiction and its subtypes in the DSM-5, and that the APA

came to an erroneous conclusion when they analyzed similar research and decided to exclude

Internet Addiction in favor of one of its specific subtypes (Internet Gaming Disorder). In this

manner, a Theoretical Review allows for the presentation of a deductive approach, as opposed to

the more mechanistic approach contained within the traditional literature review.

The theoretical study format is a valuable addition to the field of scientific inquiry.

Empirical research, both quantitative and qualitative, is important in that develops and tests

hypothesis. Literature reviews collect, compile, and analyze existing empirical research.

Theoretical studies build upon the two, and can serve as both precursors to and redirection of

these other forms of scientific research. Precursors in that they can serve to direct the

development of theory’s that are later tested via empirical studies. Redirectors in that they can

provide alternative conclusions to existing studies, reviews, and proposals (Cone & Foster,

1993).

To conduct the research, an extensive literature search and review was performed
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utilizing a variety of sources: Multiple EBSCO collections (including ERIC, LISTA,

PsychARTICLES, PsychEXTRA, PsychINFO, Psychology & Behavioral Sciences, and

SocINDEX), Google Scholar, PubMed, and multiple ProQuest collections (including Central,

Dissertations & Thesis, Psychology, and Social Science). The reference management tool

EndNote (Thompson Reuters) was used to build a database of all articles considered. This tool

provided the ability to sort and categorize the articles into topics and subtopics. A universal

inclusion criterion was publication in a peer-reviewed journal. A secondary inclusion criterion

was based on publication date, with differing time-delimitations set based on the specific

topic/category being investigated (see details below). More than 1,000 articles were downloaded

and reviewed, of which over 400 met full criteria and were included in this final paper. The most

frequently encountered author was Griffiths, with 45 articles reviewed during the project, 21 of

which were included in the final paper. The second most frequently encountered author was

Potenza, with 29 articles reviewed for the project, 15 of which were included in the final paper.

Continuous rechecks of the more rapidly emerging subject areas (ex. both DSM-5 and Internet

related topics) were performed in an effort to remain current with the expanding body of

knowledge.

Data Analysis

The crux of the first research question (What research supports a diagnosis of Internet

Addiction with subtypes into future revisions of the DSM-5?) can largely be considered as

volumetric. In other words, if the extent of a potential diagnosis's existing research is a key

component of its inclusion in the DSM-5, then the quantitative volume of research is highly

relevant. Additionally, a deductive reasoning approach was used to investigate the answer to this

research question. As such, articles not only on Internet Addiction and its subtypes were
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relevant, but articles on its building blocks, such as behavioral addictions and components of the

topic of addiction in general, were also considered relevant to answering this research question.

A key to answering the second research question (Why was Internet Addiction not

included in the original release of the DSM-5?) is the topic of controversy. As such, both current

and historical components of the debate were considered. Again, a deductive reasoning

approach was utilized: The validity of Internet addiction is partially dependent upon the

acceptance of behavioral addictions, which is itself partially dependent upon the acceptance of

the concept of addiction in general.

Addiction generally. A database search on this topic yielded an overwhelming volume

of results, most of which were unrelated as they were articles about the topic of addiction (not

relevant), as opposed to articles about the use of the term addiction (relevant). As such, an initial

search was conducted using the combined terms "Addiction" and "DSM-5" (or DSM-IV). From

there, a historical timeline of the argument was constructed using references extracted from

articles containing the most recent debate on the topic. Additionally, all prior versions of the

DSM were downloaded and reviewed (freely available on psychiatryonline.org).

Neurobiology of Addiction. The scope of this topic was limited to the previous ten

years, with primary focus given to articles published in the past five years. Older publications

considered key developments within the scientific advancement of this field were also included

(ex. Blum et al., 1990; Nestler, Barrot, & Self, 2001; Olds & Milner, 1954; Robinson &

Berridge, 1993; Solomon & Corbit, 1974). The following search terms and their derivatives

were used in multiple combinations with database wildcards (*) as needed: Addict* (to allow for

both addict, addicted, and addiction), DeltaFosB, genetic*, epigenetic*, neurobiolog* (to allow

for both neurobiology and neurobiological), "reward deficiency syndrome", and "substance*
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abuse*". A final confirmatory search was conducted using the name of specific authors

identified as key researchers/publishers in the field: Volkow, Koob, Le Moal, Everett, Robbins,

Robinson, Berridge, Nestler, Pitchers, Blum, and O'Brien. Over 200 articles were reviewed, 46

of which were included in the final reference list. The remaining articles were discarded due to

their redundant explanations of the neurobiological underpinnings of the disease of addiction.

Behavioral Addictions. This scope was not time-delimited, as it is an emerging topic

whose entire historical context is relevant. Analytical priority, however, was given to articles

published by key authors, literature reviews, and articles published via a newest to oldest

methodology. The following search terms and their derivatives were used in multiple

combinations: Addict*, behavior* (to allow for both behaviors and behavioral), compulsive, non-

drug, and non-substance. Griffiths, Potenza, Sussman, and Weinstein were identified as key

authors with repeated publications in this area. Over 100 articles were reviewed, 54 of which

were included in the final reference list. The inclusion criterion for these articles was based on

their unique or collective contributions to the research questions. "Collective contributions"

would be the use of a single literature review article in place of the collection of the individual

studies cited within said literature review.

Pathological Gambling. As Pathological Gambling has been a highly published topic

for many years, the time scope of this topic was the most limited, restricted to articles published

in the previous five years. Allowances were made for older articles published by key authors.

Multiple combinations of the following search terms and their derivatives were used in

conducting the research: Compulsive, gambl* (to allow for both gambling and gamblers),

"pathological gambl*", "problem* (to allow for both problem and problematic) gambl*", and

"neurobio* gambl*". A relevant key author identified in this area was Petry. Note that key
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authors previously referenced in other subject areas are not re-listed here (ex. Potenza). This rule

applies for all author lists in this chapter. A total of 55 articles were reviewed, and 12 were

included in the final paper.

Internet Addiction/ Internet Use Disorder. Another emerging topic, there was no

time-scope set for this topic, although priority was given to articles published in the previous ten

years. Both books and journal articles were included in the scope of this topic, and the following

search terms and their derivatives were used in multiple combinations: Addict*, compulsive,

"compulsive internet", cyber, Internet, "Internet use", online, and "problem* Internet". Young

was a key author identified in this area. Of the more than 300 articles reviewed, 82 were used in

the final work-product based on their specific relevance to Internet Addiction as a mental health

diagnosis. Conversely, articles on Internet Addiction as a societal or sociological issue were not

included.

Internet Gaming Disorder. No time-limitation was placed on this topic, and the

following search terms and their derivatives were used in multiple combinations: Game, games,

gamers, gaming, "compulsive game/es/ers/ing), "online game/es/ers/ing", and "problem*

game/es/ers/ing". Note that the wildcard search gam* was not used as it encompasses an

overbroad vocabulary (ex. Gambia, gambit, gamble, gambrel, gamete, gamma, etc.). All

Internet Gaming Disorder references in the DSM-5 were reviewed. Among others previous

listed, Kuss was an additional key author identified in this area. One hundred seventy seven

articles were reviewed, and 50 were included in the final paper. A less-than-exhaustive final

selection approach was taken based on the fact that the APA already approved IGD as a

research-worthy diagnosis, and thus the full volume of articles in this subject area was not

needed to support either research question.

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Internet Pornography Addiction. Research into the area of addictive sexual behaviors

on the Internet began with an inquiry into Sex Addiction and Hypersexual Disorder. The scope

of this research also included both books and journal articles, and there was no specific time-

delimitation. As with behavioral addictions, however, analytical priority was placed upon

articles published by key authors, literature reviews and articles published via a newest to oldest

methodology. The following search terms and their derivatives were used in multiple

combinations: "Compulsive sex", hypersexual, "hypersexual disorder", "impulsive sex", "out of

control sex", "problem* sex*", sex, and "sex addict*". Of the 327 books and articles reviewed,

60 included the term "hypersexual" in the title, and more then 80 included the phrase "sex

addiction". Key authors identified in this area include Carnes, Coleman, Goodman, Kafka, and

Reid. Seventy-two total articles were referenced in this part of the paper. As with Internet

Addiction, sociologically oriented articles that met the above criteria were excluded from the

final reference list.

There was no time scope placed upon the research into the area of Internet Pornography

Addiction, although a large amount of manual screening was required, as many results were

articles about Internet pornography but focused on sub-topics unrelated to

addictive/compulsive/problematic usage (ex. content analysis, feminism, freedom of speech,

morality concerns, sociological impact, etc.). Additional screening was required to differentiate

articles about Internet pornography (included) and non-Internet pornography (not included).

Multiple combinations of the following search terms and their derivatives were used: Porn* (to

allow for porn, pornographic, and pornography), addict*, compulsive, cyber, Internet, online,

problem*. Cooper, Delmonico, and Hilton were key authors published in the field. Of the

nearly 200 total articles reviewed, 24 used the term cyber, 37 used the phrase "Internet sex", and
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72 used the term porn*. A total 78 were included in the final research. The delineation between

sociological and psychological approaches was again a key variable for the final selection.

DSM-5. The search terms DSM-5 and DSM-IV were used when researching this section,

and there was no time limit placed on the inclusion criteria for this topic. The DSM-5 itself was

extensively reviewed, as was the APA's primary website. Seventy-three total articles, books,

press releases, blogs, and websites were reviewed, 43 of which were included in the final paper

as relevant to the research questions.

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Chapter 4 - Results

The paper sought to answer the following two questions:

1. What research supports a diagnosis of Internet Addiction with subtypes into

future revisions of the DSM-5?

2. Why was Internet Addiction not included in the original release of the DSM-5?

Research Question 1

There is more than enough peer-reviewed published research available to support a

conditional diagnosis of Internet Addiction with its subtypes in future revisions of the DSM-5.

There are literally hundreds of articles devoted to the problem of Internet Addiction and its

related subsets. These articles illustrated research into multiple subtopics, such as

psychometrically validated assessment instruments, the application of multiple evidence-based

treatment approaches, and detailed investigations on neurobiology. This study referenced over

200 articles cited on the narrowed topic of Internet addiction and its subtypes, of which only four

were explicitly against the inclusion of the diagnosis. The APA Work Group acknowledged

reviewing 240 articles themselves, allegedly specific to the narrower topic of Internet Gaming

Disorder. These numbers nearly doubled in the present study when the scope was expanded to

include research on Internet Addiction's building block of behavioral addictions. While this

research may not be sufficient to meet criteria for a full Section II diagnosis, it certainly meets

the standard of inclusion for Section III as put forth by the APA: "Inclusion of conditions in

Section III was contingent on the amount of empirical evidence available on a diagnosis,

diagnostic reliability or validity, a clear clinical need, and potential benefit in advancing

research" (APA, 2013c).

Research Question 2
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To date, the APA has not provided a formal explanation to as to how they came to the

decision rework the formally proposed diagnosis of Internet Addiction/Internet Use Disorder into

Internet Gaming Disorder. In contrast, explicit articulations regarding the decision process

behind other changes in this realm (gambling, gaming, substance abuse) have been provided

(Hasin, Fenton, Beseler, Park, & Wall, 2012; Petry et al., 2013; Petry & O'Brien, 2013; Saha et

al., 2012). This outcome is but one of multiple inconsistencies that can be found throughout the

APA's decision process and the DSM-5 publication itself. Put together, this pattern of

inconsistencies leads towards three possible speculations as to why the disorder was excluded

from the manual: The Delivery Mechanism Argument, Social Politics, and Poor Research,

Logic, & Editing. Each of these will be discussed further below.

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Chapter 5: Conclusions

"There are in fact two things, science and opinion; the former begets knowledge, the latter

ignorance." - Hippocrates

"The greatest deception men suffer is from their own opinions." - Leonardo da Vinci

"By denying scientific principles, one may maintain any paradox." - Galileo Galilei

"Science doesn’t do common sense, science needs data. And until that data is put forth as

hard fact, the medical community will not recognize porn addiction as a condition."

Martin Daubney, Porn on the Brain, BBC Channel 4, 16:27.

On December 01, 2012, the Trustee's of the American Psychiatric Association voted on

the final version of the DSM-5. Released in May 2013, the DSM-5 was the first revision of the

book in thirteen years. Internet Addiction/Internet Use Disorder was formally proposed as a new

disorder, but was not included. Instead, the APA created a diagnosis of Internet Gaming

Disorder behind closed doors. This diagnosis was never formally proposed, and to date, no

specific reason or justification has been provided for the change. This paper examined the

existing research on both disorders, as well as the broader category of behavioral addictions.

Based on the tremendous amount of data on multiple facets of the topic, the logical conclusion

drawn is that there was sufficient data to justify a diagnosis of Internet Addiction with subtypes

as a conditional diagnosis in future versions of the DSM-5. As to why it was not included, the

research leads towards three possible speculative conclusions.

Speculative Conclusion #1: Delivery Mechanism Argument

It can be logically speculated that a representative argument for the change in diagnosis

may have been the "delivery mechanism argument" (Kim & Kim, 2010; King & Delfabbro,

2013a; Starcevic, 2013b). This argument holds that the Internet is only a delivery mechanism for
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other forms of media, and one cannot be addicted to a delivery mechanism. An analogy was

made that alcoholics are not addicted to bottles. This speculation is supported by the fact that the

larger diagnosis, Internet Use Disorder, was reworked into the more content specific diagnosis of

Internet Gaming Disorder. This would be a logically justifiable position to take, as it matches

Davis's (2001) original concept of Specific Problematic Internet Use (SPIU), as well as Brand,

Lair, & Young's (2014) updated version of Specific Internet Addiction (SIA). This also matches

Griffiths proposed differentiation between addictions to the Internet and addictions on the

Internet (Griffiths, King, & Demetrovics, 2014).

If the delivery mechanism argument is the concern of the APA, however, an easier and

perhaps more consistent decision would have been to maintain the proposed diagnosis of Internet

Addiction but simply require a subtype; gaming, pornography, social networking, shopping, etc.

The exact same criteria, references, and most of the wording currently listed for Internet Gaming

Disorder could have been kept, with only the word "behavior" used in lieu of the word "gaming".

The concern of becoming addicted to a delivery mechanism would be removed, and scientific

progress could continue into the broad range of potentially problematic behaviors involving

Internet use. This idea has been proposed multiple times, both historically (Block, 2008) and

recently (King & Delfabbro, 2013a; Potenza, 2014). Additionally, some leading researchers in

the field are already using this model. For example, Guangheng Dong, arguably the most

prolific researcher/publisher on the neurobiology of Internet Gaming Disorder, often referred to

IGD as a subtype of Internet Addiction before the release of the DSM-5 (Dong, DeVito, Huang,

& Du, 2012; Dong, Huang, & Du, 2011; Dong, Huang, & Du, 2012) and continued to do so

(albeit intermittently) after it was released (Dong, Hu, & Lin, 2013; Dong, Lin, Zhou, & Lu,

2014), indirectly rejecting the APA's reformulation of the disorder.

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Speculative Conclusion #2: Social Politics

The Trustee's of the APA made decisions and statements that simply cannot be defended

scientifically and instead lend themselves towards social politics as the root of the decisions. For

example, as previously stated, ASAM released a new highly scientific and very specific formal

definition of addiction in 2011, which not only pronounced addiction as a medical disorder, but

also explicitly referenced the concept of behaviors as addictive. As also previously mentioned,

Vice President Joe Biden and leading addiction neuroscientist Nora Volkow proposed the

"Recognizing Addiction as a Disease Act of 2007" in an attempt to rename the National Institute

on Drug Abuse to the National Institute on Diseases of Addiction in effort to represent the fact

that the disease at hand is broader than just exogenous chemical issues. Despite this progress

advanced by such organizations and top experts in the field, the APA explicitly disavowed the

both the word addiction and the category of behavioral addictions in the DSM-5. It can only be

speculated as to whether the American Psychiatric Association requires more stringent evidence

for the acknowledgement of medical disorders than does a specialty group such as the American

Society of Addiction Medicine, or if there is another unspoken standard, reason, or issue at play.

Support for the social politics speculative conclusion begins to further emerge when

looking through the lens of the decision behind the above statement. Gary Greenberg published

a detailed, albeit negatively biased, documentary about the development of the DSM-5. In his

book, Greenberg discussed the 2011 APA annual meeting wherein he documented O'Brien

(DSM-5 Substance Use Disorders Work Group Chair) as stating in his presentation: "When you

have the president talking about addiction to oil, the word has lost its pejorative tone" (O'Brien,

as cited by Greenberg, 2010, p. 318). Greenberg also noted O'Brien's statement that the word

addiction is "what the average doctor is going to call it" (O'Brien, as cited by Greenberg, 2010, p.
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318-319). Nonetheless, the term was voted out of the DSM-5. Perplexingly, O'Brien published

an article later that year supporting the decision he previously opposed:

Some working-group members voted in favor of a return to the use of the word

“addiction” because the word has become so commonplace in recent years and does not

seem pejorative to them. The media has stories about “addiction to oil” and women wear

tee-shirts emblazoned with “addiction to pink” or to shopping, etc. Of course,

connotations of words change with time and culture; we acknowledge that there are no

current studies that can be cited on whether the choice of labels might be pejorative.

Because some scientists remain opposed to the use of the word “addiction,” we proposed

a compromise. The proposed label in DSM-V is now called “substance use disorder,”

with severity rated according to the number of symptoms (O'Brien, 2011, p. 1).

In hindsight, this statement indicates peer and public pressure as the potential motivation for the

DSM-5's Work Group's backing away from the term addiction. Beyond the irony of the fact that

this statement was published in the scholarly journal named "Addiction", this decision and

statement is highly perplexing and entirely inconsistent with O'Brien's previous claim that the

DSM-III-R's Substance Abuse committee made a "serious mistake" with their decision to omit

Addiction as a diagnostic category in the DSM-III-R (O'Brien, Volkow, & Li, 2006a, p.764). In

that article, the authors stated, "In the case of substance use disorders, the medical world

drastically needs a change in labeling. Addiction is a perfectly acceptable word” (p. 765).

There is indeed broad acceptance of the term addiction in the medical world outside of

the American Psychiatric Association. For example, two highly-regarded medical organizations

have been established in this subject area: First, the previously mentioned American Society of

Addiction Medicine, which is a specialty society within of the American Medical Association
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House of Delegates. Second, the American Academy of Addiction Psychiatry, which is an

official allied organization of the APA, and one of 24 member organizations within the

American Board of Medical Specialties (ABMS).

The APA made another confusing statement involving the word addiction in the

Diagnostic Features section of Internet Gaming Disorder, when they stated that "other

behavioral disorders that show some similarities to substance use disorders and gambling

disorder for which the word addiction is commonly used in nonmedical settings" (APA, 2013a,

p.796). As written, the scope of "nonmedical settings" is unclear. For example, does this

include the Charles O’Brien Center for Addiction Treatment at the University of Pennsylvania

Perleman School of Medicine? Perhaps this organization is a medical setting because they focus

on chemically based issues rather than non-chemically induced problematic behaviors? Does the

statement instead focus on facilities that cover non-substance addictions such as any of the eighty

treatment centers for compulsive gambling listed on the National Association of Addiction

Treatment Providers (NAATP) website? Note that these facilities may have recently been

"converted" into medical settings due to the inclusion of Gambling Disorder in the DSM-5.

Similarly, where does this leave treatment centers that treat legitimate substance use and/or

gambling disorders plus other out-of-control behaviors such as eating disorders or sex addiction -

are these medical or non-medical facilities? Finally, it can be assumed that the APA was not

referring to the Chinese medical treatment centers for Internet Addiction that they acknowledge

in their next sentence: "Internet gaming has been reportedly defined as an “addiction” by the

Chinese government (Stewart 2010), and a treatment system has been set up" (APA, 2013a, p.

796).

Additional evidence supporting the social politics conclusion can be found in secondary
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sources such as books. Although this trend began before the release of the DSM-5 (see

"Destructive Trends in Mental Health: The Well-Intentioned Path to Harm" by Wright &

Cummings, 2005) multiple books have been dedicated to the specific development and/or

analysis of the DSM-5. For example, Greenburg's previously mentioned opinionated

documentary "The Book of Woe: The DSM and the Unmaking of Psychiatry", in which he

reported in great detail not only the development of the DSM-5, but also the history of all its

predecessors. Greenburg documents examples of the influence of social politics on the book,

such as the addition and subsequent removal of homosexuality as a mental disorder, to newer

scandal's, such as child psychiatrist Joseph Biederman's $1.6 million in payments from drug

companies in the late 90's/early 2000's to promote the diagnosis of childhood bipolar disorder

and encourage medications for its treatment. Greenburg also documented the increasingly

negative interactions between the DSM-5 Task Force leadership and Robert Spitzer, the DSM-III

Task Force Chair (who was denied access to DSM-5 committee meeting minutes despite public

claims of transparency).

One controversy of particular note is the public resignation of two members of the DSM-

5 Personality Disorders Work Group. Dr.'s Roel Verheul and John Livesley articulated their

reasons in an email sent to the chair of the DSM-IV Task Force:

It [DSM-5 Personality Disorders Work Group] has also demonstrated an inability to

respond to constructive feedback both from within the Work Group and from the many

experts in the field who have communicated their concerns directly and indirectly...

Early on in the DSM-5 process, we developed major concerns about the Work Group's

mode of working and its emerging recommendations that we communicated to the Work

Group and Task Force. We did not resign earlier because we continued to cherish the
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hope that eventually science and common sense would prevail and that there would be an

opportunity to construct a coherent, evidence-based classification that would help to

advance the field and facilitate patient care. In the spring of this year, it became apparent

that is was not going to happen...

Second, the proposal displays a truly stunning disregard for evidence. Important aspects

of the proposal lack any reasonable evidential support of reliability and validity. For

example, there is little evidence to justify which disorders to retain and which to

eliminate. Even more concerning is the fact that a major component of the proposal is

inconsistent with extensive evidence. The latter point is especially troublesome because it

was noted in publication from the Work Group that the evidence did not support the use

of typal constructs of the kind recommended by the current proposal. This creates the

untenable situation of the Work Group advancing a taxonomic model that it has

acknowledged in a published article to be inconsistent with the evidence.

For these and other reasons, we felt that the only honest course of action was to resign

from the Work Group. (Verheul & Livesley, as quoted by Frances, 2012b)

Note that these authors are not specifically referring to dysfunction within the Substance Use

Disorders Work Group, their statements may be taken as theoretical indicators of the overall

dysfunction and potential lack of scientific integrity found throughout the DSM-5 development

process.

Paris and Philips (2013) published a highly articulate and detailed book, "Making the

DSM-5: Concepts and Controversies". In their book, Paris & Phillips presented a broad range of

perspectives on psychiatry and the DSM-5. For example, an entire chapter is devoted to a micro-

based analysis of the role of individuals on the development of the book. The chapter author, a
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historian of psychiatry, highlighted the internal battle for decision making split between

authoritarian and consensus based approaches. This chapter includes discussion of Robert

Spitzer's pivotal differentiation between psychiatry and psychoanalysis, and his attempt to define

mental disorder as a subset of medical disorder in the DSM-III (a notion so strongly opposed at

the time by the American Psychological Association that he eventually had to compromise on a

watered-down definition) (Shorter, 2013). Conversely, the book includes a macro-based chapter

devoted to a broad focus picture in which the author presents a detailed argument for what he

called the "Mental Health-Medical-Industrial Complex" (MHMIC) in which the APA is but one

of 10 elements (other elements include the millions of consumers, pharmaceutical industry, for-

profit service industry, US healthcare system, US politics, advertising and mass media, NIMH,

popular demand, and academic medical centers) (Sadler, 2013). While the book does not focus

on the topic of addiction or substance abuse, the book presents a highly concerning and

disturbing view of the DSM that is highly supportive of social politics as a root of the APA's

decision to rework Internet Addiction in the DSM-5.

On the opposite end of the academic spectrum is Dr. Allen Frances, who is perhaps the

most outspoken critic of the DSM-5 from within the professional community. Similar to Spitzer,

Frances speaks from a somewhat authoritative position, as he was the Chair of the DSM-IV Task

Force. Frances maintains two blogs about /against the DSM-5, one on Psychiatric Times and the

other on the Psychology Today website. In his various posts, France repeatedly accused the

APA of "diagnostic inflation", "diagnostic imperialism", and claims the APA holds an unfair

monopolistic control over the development and formalization of the diagnostic nosology and

criteria sets (Frances, 2012a). Note that there is some validity to Frances's monopoly claim, as

he referenced the formal concerns voiced by the American Counseling Association, British
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Psychological Society (BPS), and 16 divisions of the American Psychological Association

(unified concern letter) - none of these formal concern letters resulted in changes to the DSM-5

development or outcome. Frances also referenced international calls for a DSM-5 boycott from

Australia, England, France, Italy, and Spain.

While Frances presents himself as a whistleblower of sorts regarding the internal politics

behind the development of the DSM-5, the content of public challenges to Frances's own blog

statements can be taken as evidence of the social politics conclusion as existing prior to the

development of the DSM-5. For example, regular blogger for Psychiatric Times Nassir Ghaemi

responded to one of Frances's Psychology Today blog posts with a response titled "DSM-5: If

you don't like the effects, look at the causes" in which he took Frances's complaints and turned

them back on Frances himself. He quoted a DSM-IV Task Force member as telling him that

Frances gave the DSM-IV Task Force members three overarching principals to follow: "1) To

make no changes unless the scientific evidence was extremely strong, 2) To make no changes

that would lead to radical changes in the document, and 3) To make no changes that would harm

insurance reimbursement to clinicians" (Ghaemi, 2013). Ghaemi claimed that "science plays a

second fiddle in DSM revisions" as a result of these principals. Frances replied in complete

agreement with the first two statements, but challenged the third. Interestingly, Frances stated

these principals were pragmatic not political, and specifically stated "The science is always

incomplete and never clear cut. Data doesn’t jump up, grab you by the throat, and tell you what

to do. The science is always subject to different interpretations" (Frances, 2013a).

In an oddly specific contradiction to this statement (particularly in regards to the grab-you-by-

the-throat metaphor), Frances was quoted in another interview as stating

With DSM-IV, we were determined to be as modest as possible in ambition and as

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careful as possible in methodology. We had a very high threshold for change; people had

to jump through hoops to convince us. And we rejected 92 of 94 proposed diagnoses. We

told the experts, "You're not going to get anything in here unless the data grabs you by

the throat” (O'Brien 2013, as cited by Mechanic, 2013).

Unfortunately, many of Frances's statements are hyperbolic and frequently patently

incorrect. For example, Frances made a post on psychiatry.org that was copied to other medical

sites such as Psychology Today, Psychiatric Times, and Medscape Psychiatry, as well as

multiple mass media outlets such as the Huffington Post. In the post, titled "DSM-5 is a guide,

not a bible - Simply ignore its 10 worst changes", Frances made multiple exaggerated and

alarmist claims. He spoke negatively on the topic of this paper in item eight:

DSM-5 has created a slippery slope by introducing the concept of behavioral addictions

that can eventually spread to make a mental disorder of everything we like to do a lot.

Watch out for careless over-diagnosis of Internet and sex addiction and the development

of lucrative treatment programs to exploit these new markets. (Frances, 2012a)

Frances repackaged many of his posts into a book, which he titled "Saving Normal: An

Insider's Revolt Against Out-of-Control Psychiatric Diagnosis, DSM-5, Big Pharma, and the

Medicalization of Ordinary Life" (Frances, 2013b). In his book, Frances repeatedly made

statements illustrating a level of ignorance incongruent with an individual of his level of

professional education. For example, he disputes the concept of behavioral addictions based on

his uninformed claims that physiological tolerance and withdrawal are mandatory. Frances also

made the claim that the application of an addiction diagnostic label will absolve people of

personal responsibility - an unconscionable statement for a mental health provider.

Frances did, however, make brief honest acknowledgements that the addictive behaviors
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can indeed be highly problematic for some. Unfortunately, he then went on to dismiss the

possibility of the problem as a psychiatric diagnosis for apparently naive reasons such as "We

don't know how to define Internet Addiction in a way that will not also mislabel the many who

are doing just fine being chained to their electronics" (Frances, 2013b, p.192). Here, Frances

chose to ignore the mandatory diagnostic criteria of functional impairment that he referenced two

sentences prior. Frances made an additional statement illustrating either a complete lack of due

diligence on his part or an element of academic insincerity when he states: "So far the research

on "Internet Addiction" is remarkably thin and not very informative" (Frances, 2013b, p.192).

The nearly 100 papers cited in this project, many of which are highly detailed and scientific,

indicate otherwise.

Final evidence in support for the social politics speculative conclusion came from a

personal interview with a leading proponent of Sex Addiction, Rob Weiss, in which he detailed a

dinner conversation he had with two DSM-5 Work Group members (whose names he kept

anonymous). Weiss was interested in understanding why the APA voted Hypersexual Disorder

out of Section III at the final hour, and was shocked to hear their true position. Weiss

paraphrased the Work Group members statement as: "Ultimately the research wasn’t the

deciding factor... there is no political will within the APA to have consensual sexual behavior

viewed as problematic" (Weiss, 2014). This is direct evidence, albeit hearsay, of social politics

driving the final decisions for what was excluded from the DSM-5.

Speculative Conclusion #3: Poor Research, Logic, and Editing

A third speculative conclusion is poor research, logic, and editing. Some of the APA's

logic is hard to understand and easy to challenge. For example, they stated that there was not

enough research to include Internet Addiction but there was enough research to include Internet
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Gaming Disorder. They then primarily cited research on Internet Addiction to order to support

this position. This is somewhat akin to A ≠ B but B = A. Equally illogical and inconsistent is

the fact that the APA simultaneously acknowledged and denied addiction as a medical concept,

as well as behavioral addictions as a valid category within the spectrum of addictive disorders.

The illogic can be highlighted by noting that they made both disavowments in their chapter on

Substance-Related and Addictive Disorders. This paper has illustrated other inconsistences

regarding the naming of the disorder. For example, in addition to the previously mentioned

overlapping of the terms Internet Use Disorder, Internet Addiction, and Internet Gaming disorder

in Section III of the DSM-5, O'Brien proudly stated in his APAeducation online CME about the

DSM-5 Substance Related and Addictive Disorders chapter: "They [researchers in Asian

countries] call it Internet Addiction, but we prefer to call it Internet Gaming Disorder" (O'Brien,

2014).

The most telling example of the APA's inconsistences and inaccuracies surrounding this

topic can be found in one of their official news releases regarding the DSM-5, in which the APA

announced the creation of the Section III diagnosis of "Internet Use Gaming Disorder" (APA,

2012). Of course, this disorder does not, and never did, exist. Further examples of the potential

disconnect between different departments within the APA can be seen in other news releases.

For example, the APA stated in multiple news releases that they had created a new category of

Behavioral Addictions (APA, 2014a, 2010). As we have seen in this paper, however, the reality

is that the text within the DSM-5 itself only acknowledges Gambling Disorder, and explicitly

disavows "Behavioral Addictions" (APA, 2013a). This also illustrates a pattern of

inconsistencies, and/or illogic.

Perhaps the most unexpected example is the arguably racist statement made by the APA
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in the Risk and Prognostic Factors section of the IGD diagnosis in the DSM-5 that takes cultural

unawareness and insensitivity to a new level: "Genetic and physiological: Adolescent males

seem to be at greatest risk of developing Internet gaming disorder, and it has been speculated that

Asian environmental and/or genetic background is another risk factor, but this remains unclear"

(APA, 2013a, p. 797). Somehow, the American Psychiatric Association managed to explicitly

state in their "bible" that Asians may be genetically predisposed to develop Internet Gaming

Disorder! Of the hundreds of articles reviewed by this author, such a claim has never been

intimated, much less explicitly stated. Perhaps the APA intended to reference the Asian culture

as an environmental risk factor (an arguably less racist claim) rather than as a genetic risk factor.

Unfortunately, the only environmental risk factor listed is the powerhouse: "Computer

availability with Internet connection <sic> allows access to the types of games with which

Internet gaming disorder is most often associated” (APA, 2013a, p.797). Put together, the APA

formally postulated that adolescent Asian males with Internet connected computers are the most

likely persons to develop this disorder. This is an embarrassment to the entire field of mental

health, and one expects better editing from a book that cost $25 million dollars to produce. This

in itself serves as de facto evidence of poor research and/or editing.

Implications for Practice

The Diagnostic and Statistical Manual of Mental Disorders (DSM), often referred to as

the "bible of psychiatry", is utilized nationwide by medical doctors of all specialties, from

psychiatrists to primary care physicians, to diagnose mental disorders. The use of the book,

however, extends far beyond the realm of medical doctors. The APA outlined the function of the

book as follows: "It standardizes diagnoses by psychiatrists, psychologists, social workers,

nurses, and other health and mental health professionals, but it also informs research, public
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health policy, education, reimbursement systems, and forensic science" (APA, 2013g). In their

letter of concern to the APA, the American Counseling Association stated that because their

membership base contains 120,000 licensed professional counselors in the USA, they are the

second largest user of the DSM beyond medical doctors (ACA, 2011). Social workers and the

array of other mental health providers in the US also utilize this manual. Swizz researcher

Uchtenhagen (2011) acknowledged the DSM as a preferred instrument for clinical research into

the addictions in many European countries. In her blog on the Psychiatric Times, Dr. Sharon

Packer predicted

DSM carries greater significance to nonpsychiatrists. No doubt it will inspire

dissertations on the history of psychiatry and the philosophy of science. It will fuel anti-

psychiatrists who view DSM as a political (or maybe economic) tool rather than a

scientific statement. (Packer, 2013)

On an abstract level, Petry articulated the benefits of a disorder being included in the

DSM as follows

Societal interest with excessive behavior patterns cannot be separated entirely from

science or medicine, but weighing the evidence along with the costs and benefits of

changing is necessary for advancing the field as a whole. Society and individuals may

benefit from expanding scientific classification systems to include other excessive

behavior patterns. (Petry, 2006, p.157-158)

On a more specific level, the greatest benefits come from inclusion in the mainline DSM

(Section II). Perhaps one of the most important benefits stems from the fact that most health

insurance companies require a DSM diagnosis code to authorize payments and reimbursements

for treatment. This, in turn, creates greater opportunities for treatment providers and programs to
 160

become established and provide needed medical services to suffering individuals.

The APA formally outlined the benefits of a diagnosis being included in Section III of the

DSM in the introduction to the "Conditions for Further Study" chapter in which they stated

Proposed criteria sets are presented for conditions on which future research is

encouraged... and are intended to provide a common language for researchers and

clinicians who are interested in studying these disorders. It is hoped that such research

will allow the field to better understand these conditions and will inform decisions about

possible placement in forthcoming editions of DSM. (APA, 2013a, p. 586)

Conversely, the impact of not being included in the DSM is great:

Research is needed to explore the connections among these disorders and with the

substance addictions. Researchers have been further hampered by the lack of federal

funding in this area, and have had to turn to industry or private foundations for support.

Until the federal government chooses to broaden its concept of addictions, funding will

probably continue to be limited, and require that scientists be creative in conducting

research. The creation of a proposed behavioural addictions category in DSM-5 may help

push this process along by recognizing that scientific and clinical evidence supports the

connection among these disorders. (Black, 2013, p.250)

Directions for Future Research

The present study contributes to the broader field of knowledge in multiple ways. First, it

compiles and illustrates the volume of research available on the multiple facets of Internet

Addiction, it's subtypes, and the broader topic of Behavioral Addictions in general. The study

has also identified the problematic logic and decision-making put forth by the APA.

The common language acknowledged by the APA as necessary for IGD's transition from
 161

Section III to Section II of the DSM is desperately needed for all variants of Internet Addiction.

Researchers investigating Internet Gaming Disorder should follow the model put forth by some

Asian researchers of explicitly acknowledging Internet Gaming Disorder as a subtype of Internet

Addiction, rather than simply accepting the APA's reworking of the larger disorder. Future

research is particularly needed for Internet Pornography Addiction. Common sense dictates a

conclusion that the compulsive over-use of pornography is a behavioral addiction, however there

is a significant dearth of research into this particular subtype. The amount of research being

conducted into Internet Gaming Disorder should be also be placed on Internet Pornography

Addiction.

Conclusion

According to internetlivestats.com (2014), there were over 2.9 billion Internet users

worldwide at the beginning of 2014. That number is projected to surpass 3 billion by the

beginning of 2015. The United States has the second largest number of Internet users in the

world: 279 million, which is 86.75% of our total Population. While addiction to the Internet has

been acknowledged outside the US with language as severe as "public health crisis", the

American Psychiatric Association denies its existence. Rather, the APA has acknowledged only

video games on the Internet as potentially addictive. In doing so, they contributed to the problem

they purport to provide guidance to resolve. In other words, without acknowledgement in the

DSM, the other Internet related addictions will have limited access to the funds needed to

provide sufficient research results to establish the validity of the disorder. As such, the APA has

currently created an unnecessarily difficult circle to enter. Ko et al. (2014) recently published a

study wherein they validated the diagnostic accuracy of the DSM-5 criteria for Internet Gaming

Disorder (although they suggested adding craving as an additional element). In their conclusion,
 162

these authors stated that it is impractical to further define each addictive activity (pornography,

social networking, etc.) on the Internet as a distinct disorder, as opposed to subtypes of a larger

disorder. This is unfortunately exactly what the APA has proposed be done:

Excessive use of the Internet not involving playing of online games (e.g., excessive use

of social media, such as Facebook; viewing pornography online) is not considered

analogous to Internet gaming disorder, and future research on other excessive uses of the

Internet would need to follow similar guidelines as suggested herein. (APA, 2013a, p.

797-798)

 
 163

References

American Counseling Association (ACA). (2011). Open letter to the APA. Retrieved from

http://www.counseling.org/Resources/pdfs/ACA_DSM-5_letter_11-11.pdf

American Psychiatric Association (APA). (1952). Diagnostic and statistical manual of mental

disorders, (4th ed.), text revision (DSM-IV-TR). Washington, DC: Author.

American Psychiatric Association (APA). (1968). Diagnostic and statistical manual of mental

disorders, (2nd ed.). (DSM-II). Washington, DC: Author.

American Psychiatric Association (APA). (1980). Diagnostic and statistical manual of Mental

disorders, (3rd ed.). (DSM-III). Washington, DC: Author.

American Psychiatric Association (APA). (1987). Diagnostic and statistical manual of mental

disorders, (3rd ed) Revised (DSM-III-R). Washington, DC: Author.

American Psychiatric Association (APA). (1994). Diagnostic and statistical manual of mental

disorders, (4th ed.) (DSM-IV). Washington, DC: Author.

American Psychiatric Association (APA). (2001). Diagnostic and Statistical Manual of Mental

disorders, (4th ed.), text revision (DSM-IV-TR). Washington, DC: Author.

American Psychiatric Association (APA). (2010). DSM-5 proposed revisions include mew

category of Addiction and Related Disorders [Press release]. Retrieved from

http://www.dsm5.org/Newsroom/Documents/Addiction%20release%20FINAL%202.05.

pdf

American Psychiatric Association (APA). (2013a). Diagnostic and statistical manual of mental

disorders. (5th ed.). (DSM-V). Arlington, VA: Author.

American Psychiatric Association (APA). (2013b). Substance-Related and Addictive Disorders.

Retrieved from http://www.psychiatry.org/File%20Library/Practice/DSM/DSM-5/DSM-

 164

5-Substance-Use-Disorder.pdf

American Psychiatric Association (APA). (2013c). Section III. Retrieved from

www.psychiatry.org/File%20Library/Practice/DSM/DSM-5/DSM-5-Section-III.pdf

American Psychiatric Association (APA). (2013d). Internet Gaming Disorder. Retrieved from

http://www.psych.org/File%20Library/Practice/DSM/DSM-5/DSM-5-Internet-Gaming-

Disorder.pdf

American Psychiatric Association (APA). (2013e). Making a Case for New Disorders. Retrieved

from http://www.psych.org/File%20Library/Practice/DSM/DSM-5/DSM-5-Making-

Case-for-New-Disorders.pdf

American Psychiatric Association (APA). (2013f). The People Behind DSM-5. Retrieved from

http://www.psychiatry.org/File%20Library/Practice/DSM/DSM-5/people-behind-dsm-

5.pdf

American Psychiatric Association (APA). (2013g). From Planning to Publication: DSM-5.

Retrieved from http://www.psychiatry.org/File%20Library/Practice/DSM/DSM-5/dsm-5-

development.pdf

American Psychiatric Association (APA). (2014). Frequently Asked Questions: APA DSM-5.

Retrieved from http://www.dsm5.org/about/pages/faq.aspx#5

American Society of Addiction Medicine (ASAM). (2011). Public Policy Statement: Definition

of Addiction. Retrieved from www.asam.org/research-treatment/definition-of-addiction

National Institute on Drug Abuse (NIDA). (2012). The Science of Drug Abuse and Addiction.

Retrieved from http://www.drugabuse.gov/publications/media-guide/science-drug-abuse-

addiction
 165

Agrawal, A., Verweij, K. J., Gillespie, N. A., Heath, A. C., Lessov-Schlaggar, C. N., Martin, N.

G., . . . Lynskey, M. T. (2012). The genetics of addiction-a translational perspective.

Transl Psychiatry, 2(7), e140. doi: 10.1038/tp.2012.54

Ahmed, S. H., Guillem, K., & Vandaele, Y. (2013). Sugar addiction: pushing the drug-sugar

analogy to the limit. Curr Opin Clin Nutr Metab Care, 16(4), 434-439. doi:

10.1097/MCO.0b013e328361c8b8

Ahn, D. H. (2007). Korean policy on treatment and rehabilitation for adolescents’ Internet

addiction. Paper presented at the 2007 International Symposium on the Counseling and

Treatment of Youth Internet Addiction, Seoul, Korea.

Albrecht, U., Kirschner, N. E., & Grusser, S. M. (2007). Diagnostic instruments for behavioural

addiction: an overview. Psychosoc Med, 4, Doc11.

Allen, P. J., Batra, P., Geiger, B. M., Wommack, T., Gilhooly, C., & Pothos, E. N. (2012).

Rationale and consequences of reclassifying obesity as an addictive disorder:

neurobiology, food environment and social policy perspectives. Physiol Behav, 107(1),

126-137. doi: 10.1016/j.physbeh.2012.05.005

Andreassen, C. S. (2013). Workaholism: An overview and current status of the research. Journal

of Behavioral Addictions, In Press, 1-11.

Andreassen, C. S., Griffiths, M. D., Hetland, J., & Pallesen, S. (2012). Development of a work

addiction scale. Scand J Psychol, 53(3), 265-272. doi: 10.1111/j.1467-9450.2012.00947.x

Andreassen, C. S., & Pallesen, S. (2013). Social network site addiction - An overview. Curr

Pharm Des.

Andreassen, C. S., Torsheim, T., Brunborg, G. S., & Pallesen, S. (2012). Development of a

Facebook Addiction Scale. Psychol Rep, 110(2), 501-517.

 166

Archer, T., Oscar-Berman, M., Blum, K., & Gold, M. (2012). Neurogenetics and epigenetics in

impulsive behaviour: Impact on reward circuitry. J Genet Syndr Gene Ther, 3(3),

1000115. doi: 10.4172/2157-7412.1000115

Archer, T., Oscar-Berman, M., Blum, K., & Gold, M. (2013). Epigenetic modulation of mood

disorders. J Genet Syndr Gene Ther, 4(120). doi: 10.4172/2157-7412.1000120

Ashley, L. L., & Boehlke, K. K. (2012). Pathological gambling: a general overview. J

Psychoactive Drugs, 44(1), 27-37.

Ashton, K., Heinberg, L., Merrell, J., Lavery, M., Windover, A., & Alcorn, K. (2013). Pilot

evaluation of a substance abuse prevention group intervention for at-risk bariatric surgery

candidates. Surg Obes Relat Dis, 9(3), 462-467. doi: 10.1016/j.soard.2013.01.016

Baer, S., Bogusz, E., & Green, D. A. (2011). Stuck on screens: Patterns of computer and gaming

station use in youth seen in a psychiatric clinic. Journal of the Canadian Academy of

Child and Adolescent Psychiatry, 20(2), 86.

Balakrishnan, V., & Shamim, A. (2013). Malaysian Facebookers: Motives and addictive

behaviours unraveled. Computers in Human Behavior, 29(4), 1342-1349.

Ballester Arnal, R., Gil Llario, M. D., Gomez Martinez, S., & Gil Julia, B. (2010). [Psychometric

properties of an instrument for assessing cyber-sex addiction]. Psicothema, 22(4), 1048-

1053.

Balodis, I. M., Grilo, C. M., Kober, H., Worhunsky, P. D., White, M. A., Stevens, M. C., . . .

Potenza, M. N. (2013). A pilot study linking reduced fronto–Striatal recruitment during

reward processing to persistent bingeing following treatment for binge-­‐‑eating disorder.

International Journal of Eating Disorders. doi: 10.1002/eat.22204

Balodis, I. M., Kober, H., Worhunsky, P. D., White, M. A., Stevens, M. C., Pearlson, G. D., . . .
 167

Potenza, M. N. (2013). Monetary reward processing in obese individuals with and

without binge eating disorder. Biol Psychiatry, 73(9), 877-886. doi:

10.1016/j.biopsych.2013.01.014

Bancroft, J., & Janssen, E. (2000). The dual control model of male sexual response: a theoretical

approach to centrally mediated erectile dysfunction. Neurosci Biobehav Rev, 24(5), 571-

579.

Barke, A., Nyenhuis, N., & Kroner-Herwig, B. (2012). The German version of the Internet

addiction test: a validation study. Cyberpsychology, Behavior and Social Networking,

15(10), 534-542. doi: 10.1089/cyber.2011.0616

Barrett, D. (2010). Supernormal stimuli: How primal urges overran their evolutionary purpose.

New York, NY: WW Norton & Company.

Barth, R. J., & Kinder, B. N. (1987). The mislabeling of sexual impulsivity. J Sex Marital Ther,

13(1), 15-23. doi: 10.1080/00926238708403875

Beard, K. W. (2005). Internet addiction: a review of current assessment techniques and potential

assessment questions. CyberPsychology & Behavior, 8(1), 7-14. doi:

10.1089/cpb.2005.8.7

Beard, K. W., & Wolf, E. M. (2001). Modification in the proposed diagnostic criteria for Internet

addiction. CyberPsychology & Behavior, 4(3), 377-383.

Been, L., Hedges, V., Vialou, V., Nestler, E., & Meisel, R. (2013). ΔJunD overexpression in the

nucleus accumbens prevents sexual reward in female Syrian hamsters. Genes, Brain and

Behavior, 12(6), 666-672.

Billieux, J., & Van der Linden, M. (2012). Problematic use of the Internet and self-regulation: A

Review of the Initial Studies. Open Addiction Journal, 5(1), 24-29.

 168

Bingham, J. E., & Piotrowski, C. (1996). On-line sexual addiction: a contemporary enigma.

Psychol Rep, 79(1), 257-258.

Black, D. W. (2013). Behavioural addictions as a way to classify behaviours. Canadian Journal

of Psychiatry, 58(5), 249-251.

Black, D. W., Shaw, M., McCormick, B., Bayless, J. D., & Allen, J. (2012). Neuropsychological

performance, impulsivity, ADHD symptoms, and novelty seeking in compulsive buying

disorder. Psychiatry Res, 200(2-3), 581-587. doi: 10.1016/j.psychres.2012.06.003

Block, J. J. (2008). Issues for DSM-V: Internet addiction. American Journal of Psychiatry,

165(3), 306-307. doi: 10.1176/appi.ajp.2007.07101556

Blum, K., Chen, A., Giordano, J., Borsten, J., Chen, T. H., Hauser, M., . . . Barh, D. (2012d). The

addictive brain: all roads lead to dopamine. J Psychoactive Drugs, 44(2), 134-143.

Blum, K., Chen, A. L. C., Chen, T. J., Braverman, E. R., Reinking, J., Blum, S. H., . . . Williams,

L. (2008). Activation instead of blocking mesolimbic dopaminergic reward circuitry is a

preferred modality in the long term treatment of reward deficiency syndrome (RDS): a

commentary. Theoretical Biology and Medical Modelling, 5(24), 1-16. doi:

10.1186/1742-4682-5-24

Blum, K., Cull, J., Braverman, E., & Comings, D. (1996). Reward deficiency syndrome.

American Scientist, 84(2), 132-145.

Blum, K., Fornari, F., Downs, B. W., Waite, R. L., Giordano, J., Smolen, A., . . . Braverman, E.

R. (2011). Genetic Addiction Risk Score (GARS): Testing For Polygenetic Predisposition

and Risk to Reward Deficiency Syndrome (RDS).

Blum, K., Gardner, E., Oscar-Berman, M., & Gold, M. (2012). “Liking” and “wanting” linked to

Reward Deficiency Syndrome (RDS): Hypothesizing differential responsivity in brain

 169

reward circuitry. Curr Pharm Des, 18(1), 113.

Blum, K., Giordano, J., Morse, S., Liu, Y., Tan, J., Bowirrat, A., . . . Madigan, M. (2010).

Genetic Addiction Risk Score (GARS) analysis: Exploratory development of

polymorphic risk alleles in poly-drug addicted males. IIOAB J, 1(2), 169-175.

Blum, K., Han, D., Giordano, J., Lohmann, R., Braverman, E. R., Madigan, M. A., . . . Downs,

B. (2013b). Neurogenetics and nutrigenomics of Reward Deficiency Syndrome (RDS):

Stratification of addiction risk and mesolimbic nutrigenomic manipulation of

hypodopaminergic function Omics for Personalized Medicine (pp. 365-398): Springer.

Blum, K., Han, D., Oscar-Berman, M., Reinl, G., DiNubile, N., Madigan, M. A., . . . Westcott,

W. (2013). Iatrogenic opioid dependence is endemic and legal: Genetic addiction risk

score (GARS) with electrotherapy a paradigm shift in pain treatment programs. Health,

5(11A), 16-34. doi: 10.4236/health.2013.511A1004

Blum, K., Noble, E. P., Sheridan, P. J., Montgomery, A., Ritchie, T., Jagadeeswaran, P., . . .

Cohn, J. B. (1990). Allelic association of human dopamine D2 receptor gene in

alcoholism. JAMA, 263(15), 2055-2060. doi: 10.1001/jama.1990.03440150063027

Blum, K., Oscar-Berman, M., Barh, D., Giordano, J., & Gold, M. (2013). Dopamine genetics and

function in food and substance abuse. Journal of genetic syndrome & gene therapy,

4(121). doi: 10.4172/2157-7412.1000121

Blum, K., Oscar-Berman, M., Bowirrat, A., Giordano, J., Madigan, M., Braverman, E. R., . . .

Simpatico, T. (2012c). Neuropsychiatric genetics of happiness, friendships, and politics:

hypothesizing homophily ("Birds of a Feather Flock Together") as a function of reward

gene polymorphisms. J Genet Syndr Gene Ther, 3(112). doi: 10.4172/2157-

7412.1000112
 170

Blum, K., Oscar-Berman, M., Giordano, J., Downs, B., Simpatico, T., Han, D., & Femino, J.

(2012b). Neurogenetic impairments of brain reward circuitry links to Reward Deficiency

Syndrome (RDS): Potential nutrigenomic induced dopaminergic activation. Journal of

genetic syndrome & gene therapy, 3(4). doi: 10.4172/2157-7412.1000e115

Blum, K., Sheridan, P. J., Wood, R. C., Braverman, E. R., Chen, T. J., Cull, J. G., & Comings, D.

E. (1996). The D2 dopamine receptor gene as a determinant of reward deficiency

syndrome. J R Soc Med, 89(7), 396-400.

Blum, K., Werner, T., Carnes, S., Carnes, P., Bowirrat, A., Giordano, J., . . . Gold, M. (2012a).

Sex, drugs, and rock ‘n’roll: hypothesizing common mesolimbic activation as a function

of reward gene polymorphisms. J Psychoactive Drugs, 44(1), 38-55.

Bostwick, J. M., & Bucci, J. A. (2008). Internet sex addiction treated with naltrexone. Mayo

Clinic Proceedings, 83(2), 226-230.

Bradley, B. P. (1990). Behavioural addictions: Common features and treatment implications.

British Journal of Addiction, 85(11), 1417-1419.

Brand, M., Laier, C., Pawlikowski, M., Schachtle, U., Scholer, T., & Altstotter-Gleich, C.

(2011). Watching pornographic pictures on the Internet: role of sexual arousal ratings and

psychological-psychiatric symptoms for using Internet sex sites excessively.

Cyberpsychol Behav Soc Netw, 14(6), 371-377. doi: 10.1089/cyber.2010.0222

Bransfield, J. B. (2013). Overcoming Pornography Addiction: A Spiritual Solution: Paulist Press.

Brennan, K. A., Clark, C. L., & Shaver, P. R. (1998). Self-report measurement of adult

attachment. Attachment theory and close relationships, 46-76.

Brenner, V. (1997). Psychology of computer use: XLVII. Parameters of Internet use, abuse and

addiction: the first 90 days of the Internet Usage Survey. Psychological reports, 80(3),
 171

879-882.

Brevers, D., & Noël, X. (2013). Pathological gambling and the loss of willpower: a

neurocognitive perspective. Socioaffective Neuroscience & Psychology, 3.

Brewer, J. A., & Potenza, M. N. (2008). The neurobiology and genetics of impulse control

disorders: relationships to drug addictions. Biochem Pharmacol, 75(1), 63-75. doi:

10.1016/j.bcp.2007.06.043

Brooks, J. L., Groening, M. & Simon, S.,[executive producers] (Writer). (1989-2014). The

Simpsons [television show]. 20th Century Fox Television.

Brown, R. I. F. (1991). Gaming, gambling and other addictive play. In J. H. Kerr & M. J. Apter

(Eds.), Adult play: A reversal theory approach (pp. 101-118). Amsterdam: Swets &

Zeitlinger.

Byun, S., Ruffini, C., Mills, J. E., Douglas, A. C., Niang, M., Stepchenkova, S., . . . Atallah, M.

(2009). Internet addiction: metasynthesis of 1996-2006 quantitative research.

CyberPsychology & Behavior, 12(2), 203-207.

Canan, F., Ataoglu, A., Nichols, L. A., Yildirim, T., & Ozturk, O. (2010). Evaluation of

psychometric properties of the internet addiction scale in a sample of Turkish high school

students. Cyberpsychology, Behavior and Social Networking, 13(3), 317-320.

Caplan, S. (2002). Problematic Internet use and psychosocial well-being: development of a

theory-based cognitive–behavioral measurement instrument. Computers in Human

Behavior, 18(5), 553-575.

Caplan, S. (2010). Theory and measurement of generalized problematic Internet use: A two-step

approach. Computers in Human Behavior, 26(5), 1089-1097.

Carli, V., Durkee, T., Wasserman, D., Hadlaczky, G., Despalins, R., Kramarz, E., . . . Brunner,
 172

R. (2012). The association between pathological Internet use and comorbid

psychopathology: a systematic review. Psychopathology, 46(1), 1-13.

Carmody, C. L. (2012). Internet Addiction: Just Facebook Me! The Role of Social Networking

Sites in Internet Addiction. Computer Technology and Application, 3.

Carnes, P. (1983a). The sexual addiction. Minneapolis, MN: CompCare Publications

Carnes, P. (1983b). Out of the Shadows: Understanding Sexual Addiction. Minneapolis, MN:

Compcare Publications.

Carnes, P. (1989a). Contrary to love: Helping the sexual addict. Minneapolis, MN: CompCare

Publishers.

Carnes, P. (1991). Don't call it love: Recovery from sexual addiction. New York, NY: Bantam

Books.

Carnes, P. (2011). Out of the shadows: Understanding sexual addiction, (3rd edition).

Minneapolis, MN: Compcare Publications.

Carnes, P. (2012). A gentle path through The Twelve Steps: The classic guide for all people in

the process of recovery. Center City, MN: Hazelden Publishing.

Carnes, P., Green, B., & Carnes, S. (2010). The same yet different: Refocusing the Sexual

Addiction Screening Test (SAST) to reflect orientation and gender. Sex Addict

Compulsivity, 17(1), 7-30.

Carnes, P., & O’Hara, S. (2000). The Women’s Sexual Addiction Screening Test. Wickenburg,

AZ: Unpublished measure.

Carnes, P., & Weiss, R. (2002). The Sexual Addiction Screening Test for Gay Men. Wickenburg,

AZ: Unpublished measure.

Carnes, P. J., Green, B. A., Merlo, L. J., Polles, A., Carnes, S., & Gold, M. S. (2012). PATHOS:
 173

a brief screening application for assessing sexual addiction. J Addict Med, 6(1), 29-34.

doi: 10.1097/ADM.0b013e3182251a28

Carnes, P. J., Griffin, E., Delmonico, D., & Moriarty, J. M. (2001). In the shadows of the net:

Breaking free of compulsive online sexual behavior. Center City, MN: Hazelden

Publishing.

Carnes, P. J., Murray, R. E., & Charpentier, L. (2005). Bargains with chaos: Sex addicts and

addiction interaction disorder. Sex Addict Compulsivity, 12(2-3), 79-120. doi:

10.1080/10720160500201371

Carter, D. R., & Ruiz, N. J. (1996). Discriminant validity and reliability studies on the Sexual

Addiction Scale of the Disorders Screening Inventory. Sexual Addiction & Compulsivity:

The Journal of Treatment and Prevention, 3(4), 332-340.

Chang, F.-C., Chiu, C.-h., Lee, C.-M., Chen, P.-h., & Miao, N.-F. (2014). Predictors of the

initiation and persistence of Internet addiction among adolescents in Taiwan. Addictive

behaviors.

Chang, M. K., & Man Law, S. P. (2008). Factor structure for Young’s Internet Addiction Test: A

confirmatory study. Computers in Human Behavior, 24(6), 2597-2619. doi:

10.1016/j.chb.2008.03.001

Charlton, J. P., & Danforth, I. D. (2007). Distinguishing addiction and high engagement in the

context of online game playing. Computers in Human Behavior, 23(3), 1531-1548. doi:

10.1016/j.chb.2005.07.002

Chen, S., Weng, L., Su, Y., Wu, H., & Yang, P. (2003). Development of a Chinese Internet

addiction scale and its psychometric study. Chinese Journal of Psychology, 45(3), 279.

Childress, A. R., Ehrman, R. N., Wang, Z., Li, Y., Sciortino, N., Hakun, J., . . . O'Brien, C. P.
 174

(2008). Prelude to passion: limbic activation by "unseen" drug and sexual cues. PLoS

One, 3(1), e1506. doi: 10.1371/journal.pone.0001506

Chiu, S. I., Lee, J. Z., & Huang, D. H. (2004). Video game addiction in children and teenagers in

Taiwan. Cyberpsychol Behav, 7(5), 571-581.

Choo, H., Gentile, D. A., Sim, T., Li, D., Khoo, A., & Liau, A. K. (2010). Pathological video-

gaming among Singaporean youth. Annals Academy of Medicine Singapore, 39(11), 822.

Chou, C., Condron, L., & Belland, J. C. (2005). A review of the research on Internet addiction.

Educational Psychology Review, 17(4), 363-388. doi: 10.1007/s10648-005-8138-1

Chou, C., & Hsiao, M.-C. (2000). Internet addiction, usage, gratification, and pleasure

experience: the Taiwan college students’ case. Computers & Education, 35(1), 65-80.

Clark, L., & Limbrick-Oldfield, E. H. (2013). Disordered gambling: a behavioral addiction.

Current opinion in neurobiology, 23(4), 655-659. doi:

http://dx.doi.org/10.1016/j.conb.2013.01.004

Clark, S. M., & Saules, K. K. (2013). Validation of the Yale Food Addiction Scale among a

weight-loss surgery population. Eating behaviors, 14(2), 216-219.

Clarke, D. E., Narrow, W. E., Regier, D. A., Kuramoto, S. J., Kupfer, D. J., Kuhl, E. A., . . .

Kraemer, H. C. (2013). DSM-5 field trials in the United States and Canada, Part I: study

design, sampling strategy, implementation, and analytic approaches. Am J Psychiatry,

170(1), 43-58. doi: 10.1176/appi.ajp.2012.12070998

Clarkson, J., & Kopaczewski, S. (2013). Pornography addiction and the medicalization of free

speech. Journal of Communication Inquiry, 37(2), 128-148.

Coleman, E. (1986). Sexual compulsion vs. sexual addiction: The debate continues. SIECUS

report, 14(6), 7-11.

 175

Coleman, E. (2011). Impulsive/compulsive sexual behavior: Assessment and treatment. The

Oxford handbook of impulse control disorders, 375.

Coleman, E., Gratzer, T., Nesvacil, L., & Raymond, N. C. (2000). Nefazodone and the treatment

of nonparaphilic compulsive sexual behavior: a retrospective study. J Clin Psychiatry,

61(4), 282-284.

Coleman, E., Miner, M., Ohlerking, F., & Raymond, N. (2001). Compulsive sexual behavior

inventory: a preliminary study of reliability and validity. J Sex Marital Ther, 27(4), 325-

332. doi: 10.1080/009262301317081070

Comings, D. E., & Blum, K. (2000). Reward deficiency syndrome: genetic aspects of behavioral

disorders. Prog Brain Res, 126, 325-341. doi: 10.1016/S0079-6123(00)26022-6

Cone, J. D., & Foster, S. L. (1993). Dissertations and theses from start to finish: Psychology and

related fields: American Psychological Association.

Cooper, A. (1998). Sexuality and the Internet: Surfing into the new millennium.

CyberPsychology & Behavior, 1(2), 187-193.

Cooper, A. (2002). Sex and the Internet: A guidebook for clinicians. New York, NY: Brunner-

Routledge.

Cooper, A., Delmonico, D. L., & Burg, R. (2000). Cybersex users, abusers, and compulsives:

New findings and implications. Sexual Addiction & Compulsivity: The Journal of

Treatment and Prevention, 7(1-2), 5-29.

Cooper, A., Delmonico, D. L., Griffin-Shelley, E., & Mathy, R. M. (2004). Online sexual

activity: An examination of potentially problematic behaviors. Sex Addict Compulsivity,

11(3), 129-143.

Cooper, A., Putnam, D. E., Planchon, L. A., & Boies, S. C. (1999). Online sexual compulsivity:
 176

Getting tangled in the net. Sexual Addiction & Compulsivity: The Journal of Treatment

and Prevention, 6(2), 79-104.

Cooper, A., Scherer, C. R., Boies, S. C., & Gordon, B. L. (1999). Sexuality on the Internet: From

sexual exploration to pathological expression. Professional Psychology: Research and

Practice, 30(2), 154. doi: 10.1037/0735-7028.30.2.154

Costa, S., Cuzzocrea, F., Hausenblas, H. A., Larcan, R., & Oliva, P. (2012). Psychometric

examination and factorial validity of the Exercise Dependence Scale-Revised in Italian

exercisers. Journal of Behavioral Addictions, 1(4), 186-190.

Crosby, J. M. (2011). Acceptance and commitment therapy for the treatment of compulsive

pornography use: A randomized clinical trial. (http://digitalcommons.usu.edu/etd/999),

Utah State University, All Graduate Theses and Dissertations. . (Paper 999)

Davis, R. A. (2001). A cognitive-behavioral model of pathological Internet use. Computers in

Human Behavior, 17(2), 187-195.

Davis, R. A., Flett, G. L., & Besser, A. (2002). Validation of a new scale for measuring

problematic Internet use: Implications for pre-employment screening. CyberPsychology

& Behavior, 5(4), 331-345. doi: 10.1089/109493102760275581.

Dawson, G. N., & Warren, D. E. (2012). Evaluating and treating sexual addiction. Am Fam

Physician, 86(1), 74-76.

Delmonico, D., & Miller, J. (2003). The Internet Sex Screening Test: A comparison of sexual

compulsives versus non-sexual compulsives. Sexual and Relationship Therapy, 18(3),

261-276.

Delmonico, D. L. (1997). Cybersex: High tech sex addiction. Sexual Addiction & Compulsivity:

The Journal of Treatment and Prevention, 4(2), 159-167. doi:

 177

10.1080/10720169708400139

Delmonico, D. L., Bubenzer, D. L., & West, J. D. (1998). Assessing sexual addiction with the

sexual dependency inventory-revised. Sexual Addiction & Compulsivity: The Journal of

Treatment and Prevention, 5(3), 179-187.

Delmonico, D. L., & Carnes, P. J. (1999). Virtual sex addiction: When cybersex becomes the

drug of choice. CyberPsychology & Behavior, 2(5), 457-463. doi:

10.1089/cpb.1999.2.457

Derogatis, L. R., & Melisaratos, N. (1983). The Brief Symptom Inventory: an introductory

report. Psychol Med, 13(3), 595-605.

Doidge, N. (2007). The brain that changes itself: Stories of personal triumph from the frontiers

of brain science. New York, NY: Penguin Group.

Döring, N. M. (2009). The Internet’s impact on sexuality: A critical review of 15years of

research. Computers in Human Behavior, 25(5), 1089-1101. doi:

10.1016/j.chb.2009.04.003

Downs, B., Oscar-Berman, M., Waite, R., Madigan, M., Giordano, J., Beley, T., . . . Blum, K.

(2013). Have we hatched the addiction egg: Reward Deficiency Syndrome Solution

System™. Journal of genetic syndrome & gene therapy, 4(136), 14318. doi:

10.4172/2157-7412.1000136

Du, Y. S., Jiang, W. Q., & Vance, A. (2010). Longer term effect of randomized, controlled group

cognitive behavioural therapy for Internet addiction in adolescent students in Shanghai.

Australian and New Zealand Journal of Psychiatry, 44(2), 129-134. doi:

10.3109/00048670903282725

el-­‐‑Guebaly, N., Mudry, T., Zohar, J., Tavares, H., & Potenza, M. N. (2012). Compulsive features
 178

in behavioural addictions: the case of pathological gambling. Addiction, 107(10), 1726-

1734. doi: 10.1111/j.1360-0443.2011.03546.x

Emre, Ç., & İŞBULAN, O. (2012). A new addiction for teacher candidates: Social Networks.

TOJET, 11(3).

Exner, T. M., Meyer-­‐‑Bahlburg, H. F., & Ehrhardt, A. A. (1992). Sexual self control as a

mediator of high risk sexual behavior in a New York city cohort of HIV+ and HIV-­‐‑gay

men. J Sex Res, 29(3), 389-406.

Faraci, P., Craparo, G., Messina, R., & Severino, S. (2013). Internet Addiction Test (IAT): which

is the best factorial solution? J Med Internet Res, 15(10), e225. doi: 10.2196/jmir.2935

Feng, J., & Nestler, E. J. (2013). Epigenetic mechanisms of drug addiction. Curr Opin

Neurobiol, 23(4), 521-528. doi: 10.1016/j.conb.2013.01.001

Ferraro, G., Caci, B., D'amico, A., & Blasi, M. (2007). Internet addiction disorder: An Italian

study. CyberPsychology & Behavior, 10(2), 170-175. doi: 10.1089/cpb.2006.9972.

Festl, R., Scharkow, M., & Quandt, T. (2012). Problematic computer game use among

adolescents, younger and older adults. Addiction, 108(3), 592-599. doi:

10.1111/add.12016

Ford, J. J., Durtschi, J. A., & Franklin, D. L. (2012). Structural therapy with a couple battling

pornography addiction. The American Journal of Family Therapy, 40(4), 336-348.

Fortuna, J. L. (2012). The obesity epidemic and food addiction: clinical similarities to drug

dependence. J Psychoactive Drugs, 44(1), 56-63.

Frances, A. (2012a). DSM-5 is a guide, not a bible—simply ignore its 10 worst changes.

Retrieved from http://www.psychiatrictimes.com/blogs/dsm-5/dsm-5-guide-not-bible—

simply-ignore-its-10-worst-changes
 179

Frances, A. (2012b). Two who resigned from DSM-5 explain why. Retrieved from

http://www.psychologytoday.com/blog/dsm5-in-distress/201207/two-who-resigned-dsm-

5-explain-why

Frances, A. (2013a). Pragmatism in psychiatric diagnosis: A response to Dr. Nassir Ghaemi.

Retrieved from http://www.psychologytoday.com/blog/dsm5-in-

distress/201301/pragmatism-in-psychiatric-diagnosis

Frances, A. (2013b). Saving normal: An insider's revolt against out-of-control psychiatric

diagnosis, DSM-5, big pharma and the medicalization of ordinary life. New York, NY:

HarperCollins.

Franklin, J. C., Hessel, E. T., Aaron, R. V., Arthur, M. S., Heilbron, N., & Prinstein, M. J.

(2010). The functions of nonsuicidal self-injury: Support for cognitive–affective

regulation and opponent processes from a novel psychophysiological paradigm. Journal

of abnormal psychology, 119(4), 850. doi: 10.1037/a0020896

Frascella, J., Potenza, M. N., Brown, L. L., & Childress, A. R. (2010). Shared brain

vulnerabilities open the way for nonsubstance addictions: carving addiction at a new

joint? Ann N Y Acad Sci, 1187, 294-315. doi: 10.1111/j.1749-6632.2009.05420.x

Frederick, D. (2007). Conquering Pornography: Overcoming the Addiction: A Practical, Faith-

Based Journey: WinePress Publishing.

Freimuth, M., Moniz, S., & Kim, S. R. (2011). Clarifying exercise addiction: differential

diagnosis, co-occurring disorders, and phases of addiction. International journal of

environmental research and public health, 8(10), 4069-4081. doi: 10.3390/ijerph8104069

Fu, K. W., Chan, W. S., Wong, P. W., & Yip, P. S. (2010). Internet addiction: prevalence,

discriminant validity and correlates among adolescents in Hong Kong. British Journal of
 180

Psychiatry, 196(6), 6.

Garcia, F. D., & Thibaut, F. (2010). Sexual addictions. Am J Drug Alcohol Abuse, 36(5), 254-

260. doi: 10.3109/00952990.2010.503823

Garos, S., & Stock, W. A. (1998). Measuring disorders of sexual frequency and control: The

Garos Sexual Behavior Index. Sexual Addiction & Compulsivity: The Journal of

Treatment and Prevention, 5(3), 159-177.

Ge, L., Ge, X., Xu, Y., Zhang, K., Zhao, J., & Kong, X. (2011). P300 change and cognitive

behavioral therapy in subjects with Internet addiction disorder A 3-month follow-up

study. Neural Regen. Res, 6(26).

Gearhardt, A. N., Boswell, R. G., & Potenza, M. N. (2014). Neuroimaging of Eating Disorders,

Substance Use Disorders, and Addictions: Overlapping and Unique Systems. Research,

Clinical and Treatment Perspectives, 71.

Gentile, D. (2009). Pathological video-game use among youth ages 8 to 18: A national study.

Psychological science, 20(5), 594-602.

Georgiadis, J. R., & Kringelbach, M. L. (2012). The human sexual response cycle: brain imaging

evidence linking sex to other pleasures. Prog Neurobiol, 98(1), 49-81. doi:

10.1016/j.pneurobio.2012.05.004

Ghaemi, N. (2013). DSM-5: If you don't like the effects, look at the causes: The problems of

DSM-5 were caused by DSM-III and IV. Retrieved from

http://www.psychologytoday.com/blog/mood-swings/201301/dsm-5-if-you-dont-the-

effects-look-the-causes

Gold, S. N., & Heffner, C. L. (1998). Sexual addiction: many conceptions, minimal data. Clin

Psychol Rev, 18(3), 367-381.

 181

Goldstein, R. Z., & Volkow, N. D. (2011). Dysfunction of the prefrontal cortex in addiction:

neuroimaging findings and clinical implications. Nat Rev Neurosci, 12(11), 652-669. doi:

10.1038/nrn3119

Goodman, A. (1990). Addiction: definition and implications. British Journal of Addiction,

85(11), 1403-1408.

Goodman, A. (1992). Sexual addiction: designation and treatment. J Sex Marital Ther, 18(4),

303-314. doi: 10.1080/00926239208412855

Goodman, A. (1993). Diagnosis and treatment of sexual addiction. J Sex Marital Ther, 19(3),

225-251. doi: 10.1080/00926239308404908

Goodman, A. (2001). What's in a name? Terminology for designating a syndrome of driven

sexual behavior. Sex Addict Compulsivity, 8(3-4), 191-213. doi:

10.1080/107201601753459919

Goodman, A. (2008). Neurobiology of addiction. An integrative review. Biochem Pharmacol,

75(1), 266-322. doi: 10.1016/j.bcp.2007.07.030

Graff, J., Kim, D., Dobbin, M. M., & Tsai, L. H. (2011). Epigenetic regulation of gene

expression in physiological and pathological brain processes. Physiol Rev, 91(2), 603-

649. doi: 10.1152/physrev.00012.2010

Grant, J. E. (2008). Impulse control disorders: a clinician's guide to understanding and treating

behavioral addictions: WW Norton & Company.

Grant, J. E., & Chamberlain, S. R. (2014). Impulsive action and impulsive choice across

substance and behavioral addictions: Cause or consequence? Addict Behav. doi:

10.1016/j.addbeh.2014.04.022

Grant, J. E., Potenza, M. N., Weinstein, A., & Gorelick, D. A. (2010). Introduction to behavioral
 182

addictions. Am J Drug Alcohol Abuse, 36(5), 233-241. doi:

10.3109/00952990.2010.491884

Grant, J. E., Schreiber, L. R., & Odlaug, B. L. (2013). Phenomenology and Treatment of

Behavioural Addictions. Canadian Journal of Psychiatry, 58(5).

Greenberg, G. (2013). The book of woe: The DSM and the unmaking of psychiatry: Penguin.

Griffiths, M. (1996). Behavioural addiction: an issue for everybody? The Journal of Workplace

Learning, 8(3), 19-25.

Griffiths, M. (2001). Sex on the Internet: Observations and implications for Internet sex

addiction. J Sex Res, 38(4), 333-342. doi: 10.1080/00224490109552104

Griffiths, M. (2004). Sex addiction on the Internet. Janus Head, 7(1), 188-217.

Griffiths, M. (2005). A'components' model of addiction within a biopsychosocial framework.

Journal of Substance Use, 10(4), 191-197.

Griffiths, M. (2008). Diagnosis and management of video game addiction. New Directions in

Addiction Treatment and Prevention, 12(3), 27-41.

Griffiths, M. D. (2000). Internet addiction-time to be taken seriously? Addiction Research &

Theory, 8(5), 413-418.

Griffiths, M. D. (2000). Does Internet and computer" addiction" exist? Some case study

evidence. CyberPsychology and Behavior, 3(2), 211-218.

Griffiths, M. D. (2008). Videogame addiction: Further thoughts and observations. International

Journal of Mental Health and Addiction, 6(2), 182-185.

Griffiths, M. D. (2012). Facebook addiction: concerns, criticism, and recommendations--a

response to Andreassen and colleagues. Psychol Rep, 110(2), 518-520.

Griffiths, M. D. (2012). Internet sex addiction: A review of empirical research. Addiction

 183

Research & Theory, 20(2), 111-124. doi: 10.3109/16066359.2011.588351

Griffiths, M. D., King, D. L., & Demetrovics, Z. (2014). DSM-5 internet gaming disorder needs

a unified approach to assessment. Neuropsychiatry, 4(1), 1-4. doi: 10.2217/NPY.13.82

Groneman, C. (2001). Nymphomania: A history: WW Norton & Company.

Groth-Marnat, G. (2009). Handbook of psychological assessment (5th ed.). Indianapolis, IN:

John Wiley & Sons.

Grubbs, J. B., Exline, J. J., Pargament, K. I., Hook, J. N., & Carlisle, R. D. (2014). Transgression

as Addiction: Religiosity and Moral Disapproval as Predictors of Perceived Addiction to

Pornography. Arch Sex Behav, 1-12. doi: 10.1007/s10508-013-0257-z

Grubbs, J. B., Sessoms, J., Wheeler, D. M., & Volk, F. (2010). The Cyber-Pornography Use

Inventory: The development of a new assessment instrument. Sex Addict Compulsivity,

17(2), 106-126.

Grubbs, J. B., Volk, F., Exline, J. J., & Pargament, K. I. (2013). Internet pornography use:

perceived addiction, psychological distress, and the validation of a brief measure. J Sex

Marital Ther(ahead-of-print). doi: 10.1080/0092623X.2013.842192

Grueter, B. A., Robison, A. J., Neve, R. L., Nestler, E. J., & Malenka, R. C. (2013). ∆ FosB

differentially modulates nucleus accumbens direct and indirect pathway function.

Proceedings of the National Academy of Sciences, 110(5), 1923-1928. doi:

10.1073/pnas.1221742110.

Grüsser, S., Poppelreuter, S., Heinz, A., Albrecht, U., & Sass, H. (2007). Behavioural addiction:

an independent diagnostic category?]. Nervenarzt, 78(9), 997. doi: 10.1007/s00115-007-

2281-5

Guan, N. C., Isa, S. M., Hashim, A. H., Pillai, S. K., & Singh, M. K. H. (2012). Validity of the
 184

Malay version of the internet addiction test: a study on a group of medical students in

Malaysia. Asia-Pacific Journal of Public Health.

Guillem, E., & Lepine, J. (2003). Does addiction to antidepressants exist? About a case of one

addiction to tianeptine]. L'Encéphale, 29(5), 456.

Gunuc, S., & Dogan, A. (2013). The relationships between Turkish adolescents’ Internet

addiction, their perceived social support and family activities. Computers in Human

Behavior, 29(6), 2197-2207.

Gyollai, A., Griffiths, M. D., Barta, C., Vereczkei, A., Urban, R., Kun, B., . . . Demetrovics, Z.

(2013). The Genetics of Problem and Pathological Gambling: A Systematic Review.

Curr Pharm Des.

Hagedorn, W. B. (2009). The call for a new Diagnostic and Statistical Manual of Mental

Disorders diagnosis: Addictive disorders. Journal of Addictions & Offender Counseling,

29(2), 110-127. doi: 10.1002/j.2161-1874.2009.tb00049.x

Hagedorn, W. B. (2009a). Sexual addiction counseling competencies: Empirically-based tools

for preparing clinicians to recognize, assess, and treat sexual addiction. Sex Addict

Compulsivity, 16(3), 190-209. doi: 10.1080/10720160903202604

Hagedorn, W. B. (2009b). Preparing competent clinicians: Curricular applications based on the

sexual addiction counseling competencies. Sex Addict Compulsivity, 16(4), 341-360. doi:

10.1080/10720160903399855

Hald, G. M., & Malamuth, N. M. (2008). Self-perceived effects of pornography consumption.

Arch Sex Behav, 37(4), 614-625. doi: 10.1007/s10508-007-9212-1

Hald, G. M., & Mulya, T. W. (2013). Pornography consumption and non-marital sexual

behaviour in a sample of young Indonesian university students. Cult Health Sex, 15(8),
 185

981-996. doi: 10.1080/13691058.2013.802013

Hald, G. M., Smolenski, D., & Rosser, B. (2013). Perceived effects of sexually explicit media

among men who have sex with men and psychometric properties of the Pornography

Consumption Effects Scale (PCES). J Sex Med, 10(3), 757-767.

Hall, P. (2013). A New Classification Model for Sex Addiction. Sex Addict Compulsivity, 20(4),

279-291.

Hall, P. (2014). Sex addiction–an extraordinarily contentious problem. Sexual and Relationship

Therapy, 29(1), 68-75. doi: 10.1080/14681994.2013.861898

Han, D. H., Bolo, N., Daniels, M. A., Arenella, L., Lyoo, I. K., & Renshaw, P. F. (2011). Brain

activity and desire for Internet video game play. Compr Psychiatry, 52(1), 88-95. doi:

10.1016/j.comppsych.2010.04.004

Han, D. H., Lyoo, I. K., & Renshaw, P. F. (2012). Differential regional gray matter volumes in

patients with on-line game addiction and professional gamers. J Psychiatr Res, 46(4),

507-515. doi: 10.1016/j.jpsychires.2012.01.004

Hardy, S. A., Ruchty, J., Hull, T. D., & Hyde, R. (2010). A preliminary study of an online

psychoeducational program for hypersexuality. Sex Addict Compulsivity, 17(4), 247-269.

Hartston, H. (2012). The case for compulsive shopping as an addiction. J Psychoactive Drugs,

44(1), 64-67.

Hasin, D. S., Fenton, M. C., Beseler, C., Park, J. Y., & Wall, M. M. (2012). Analyses related to

the development of DSM-5 criteria for substance use related disorders: 2. Proposed

DSM-5 criteria for alcohol, cannabis, cocaine and heroin disorders in 663 substance

abuse patients. Drug and alcohol dependence, 122(1), 28-37.

Hawi, N. S. (2012). Internet addiction among adolescents in Lebanon. Computers in Human

 186

Behavior, 28(3), 1044-1053.

Hedges, V. L., Chakravarty, S., Nestler, E. J., & Meisel, R. L. (2009). Delta FosB overexpression

in the nucleus accumbens enhances sexual reward in female Syrian hamsters. Genes

Brain Behav, 8(4), 442-449. doi: 10.1111/j.1601-183X.2009.00491.x

Hillhouse, J. J., Baker, M. K., Turrisi, R., Shields, A., Stapleton, J., Jain, S., & Longacre, I.

(2012). Evaluating a measure of tanning abuse and dependence. Archives of

Dermatology, 148(7), 815-819. doi: 10.1001/archdermatol.2011.2929

Hilton, D. (2010). He Restoreth My Soul; Understanding and Breaking the Chemical and

Spiritual Chains of Pornography through the Atonement of Jesus Christ. San Antonio,

TX: Forward Press Publishing.

Hilton, D. L. (2013). Pornography addiction-a supranormal stimulus considered in the context of

neuroplasticity. Socioaffective Neuroscience & Psychology, 3. doi:

10.3402/snp.v3i0.20767

Hilton, D. L. (2014). ‘High desire’, or ‘merely’an addiction? A response to Steele et al.

Socioaffective Neuroscience & Psychology, 4.

Hilton, D. L., & Watts, C. (2011). Pornography addiction: A neuroscience perspective. Surgical

neurology international, 2.

Hinman, B. K. (2013). Mixed Methods Analysis of Counselor Views, Attitudes and Perceived

Competencies Regarding the Treatment of Internet Pornography Addiction. (Doctor of

Philosophy), Western Michigan University, Dissertations. (Paper 207.)

Holden, C. (2010). Behavioral addictions debut in proposed DSM-V. Science, 327(5968), 935-

935. doi: 10.1126/science.327.5968.935

Hong, F.-Y., Chiu, S.-I., & Huang, D.-H. (2012). A model of the relationship between
 187

psychological characteristics, mobile phone addiction and use of mobile phones by

Taiwanese university female students. Computers in Human Behavior.

Hong, S. B., Kim, J. W., Choi, E. J., Kim, H. H., Suh, J. E., Kim, C. D., . . . Yi, S. H. (2013).

Reduced orbitofrontal cortical thickness in male adolescents with internet addiction.

Behavioral and Brain Functions, 9, 11. doi: 10.1186/1744-9081-9-11

Hook, J. N., Hook, J. P., Davis, D. E., Worthington, E. L., Jr., & Penberthy, J. K. (2010).

Measuring sexual addiction and compulsivity: a critical review of instruments. J Sex

Marital Ther, 36(3), 227-260. doi: 10.1080/00926231003719673

Hook, J. N., Reid, R. C., Penberthy, J. K., Davis, D. E., & Jennings, D. J. (2013).

Methodological review of treatments for nonparaphilic hypersexual behavior. J Sex

Marital Ther(ahead-of-print). doi: 10.1080/0092623X.2012.751075

Hou, H., Jia, S., Hu, S., Fan, R., Sun, W., Sun, T., & Zhang, H. (2012). Reduced striatal

dopamine transporters in people with internet addiction disorder. J Biomed Biotechnol,

2012, 854524. doi: 10.1155/2012/854524

Hyman, S. E., Malenka, R. C., & Nestler, E. J. (2006). Neural mechanisms of addiction: the role

of reward-related learning and memory. Annu Rev Neurosci, 29, 565-598. doi:

10.1146/annurev.neuro.29.051605.113009

Inaba, D., & Cohen, W. E. (2007). Uppers, downers, all arounders. (6th ed.). Medford, OR:

CNS Publications.

Inescu Cismaru, A., Andrianne, R., Triffaux, F., & Triffaux, J. M. (2013). [Can we treat sexual

addiction ?]. Rev Med Liege, 68(5-6), 354-358.

internetlivestats. (2014). Number of Internet Users. from

http://www.internetlivestats.com/internet-users/
 188

Jelenchick, L. A., Eickhoff, J., Christakis, D. A., Brown, R. L., Zhang, C., Benson, M., &

Moreno, M. A. (2014). The Problematic and Risky Internet Use Screening Scale

(PRIUSS) for adolescents and young adults: Scale development and refinement.

Computers in Human Behavior, 35, 171-178.

Jenaro, C., Flores, N., Gómez-Vela, M., González-Gil, F., & Caballo, C. (2007). Problematic

internet and cell-phone use: Psychological, behavioral, and health correlates. Addiction

Research & Theory, 15(3), 309-320. doi: 10.1080/16066350701350247

Joutsa, J., Saunavaara, J., Parkkola, R., Niemela, S., & Kaasinen, V. (2011). Extensive

abnormality of brain white matter integrity in pathological gambling. Psychiatry Res,

194(3), 340-346. doi: 10.1016/j.pscychresns.2011.08.001

Kafka, M. P. (1991). Successful antidepressant treatment of nonparaphilic sexual addictions and

paraphilias in men. J Clin Psychiatry, 52(2), 60-65.

Kafka, M. P. (1994). Sertraline pharmacotherapy for paraphilias and paraphilia-related disorders:

an open trial. Ann Clin Psychiatry, 6(3), 189-195.

Kafka, M. P. (1997). Hypersexual desire in males: an operational definition and clinical

implications for males with paraphilias and paraphilia-related disorders. Arch Sex Behav,

26(5), 505-526.

Kafka, M. P. (2010a). Hypersexual disorder: a proposed diagnosis for DSM-V. Arch Sex Behav,

39(2), 377-400. doi: 10.1007/s10508-009-9574-7

Kafka, M. P., & Hennen, J. (2000). Psychostimulant augmentation during treatment with

selective serotonin reuptake inhibitors in men with paraphilias and paraphilia-related

disorders: a case series. J Clin Psychiatry, 61(9), 664-670.

Kafka, M. P., & Prentky, R. (1992). Fluoxetine treatment of nonparaphilic sexual addictions and
 189

paraphilias in men. J Clin Psychiatry, 53(10), 351-358.

Kalichman, S. C., Johnson, J. R., Adair, V., Rompa, D., Multhauf, K., & Kelly, J. A. (1994).

Sexual sensation seeking: Scale development and predicting AIDS-risk behavior among

homosexually active men. Journal of personality assessment, 62(3), 385-397.

Kalivas, P. W., & O'Brien, C. (2007). Drug addiction as a pathology of staged neuroplasticity.

Neuropsychopharmacology, 33(1), 166-180.

Kaplan, M. S., & Krueger, R. B. (2010). Diagnosis, assessment, and treatment of hypersexuality.

J Sex Res, 47(2), 181-198. doi: 10.1080/00224491003592863

Karaiskos, D., Tzavellas, E., Balta, G., & Paparrigopoulos, T. (2010). P02-232-Social network

addiction: a new clinical disorder? European Psychiatry, 25, 855.

Karila, L., Wery, A., Weinstein, A., Cottencin, O., Reynaud, M., & Billieux, J. (2013). Sexual

addiction or hypersexual disorder: Different terms for the same problem? A Review of

The Literature. Curr Pharm Des.

Karim, R., & Chaudhri, P. (2012). Behavioral addictions: an overview. J Psychoactive Drugs,

44(1), 5-17.

Kesici, Ş., & Şahin, İ. (2009). A comparative study of uses of the Internet among college

students with and without Internet addiction. Psychological reports, 105(3), 1103-1112.

doi: 10.2466/PR0.105.F.1103-1112

Khang, H., Woo, H. J., & Kim, J. K. (2012). Self as an antecedent of mobile phone addiction.

International Journal of Mobile Communications, 10(1), 65-84. doi:

10.1504/IJMC.2012.044523

Khazaal, Y., Chatton, A., Atwi, K., Zullino, D., Khan, R., & Billieux, J. (2011). Arabic

validation of the Compulsive Internet Use Scale (CIUS). Subst Abuse Treat Prev Policy,
 190

6, 32. doi: 10.1186/1747-597x-6-32

Khazaal, Y., Chatton, A., Horn, A., Achab, S., Thorens, G., Zullino, D., & Billieux, J. (2012).

French validation of the compulsive internet use scale (CIUS). Psychiatr Q, 83(4), 397-

405. doi: 10.1007/s11126-012-9210-x

Kim, J. H., & Seo, J. S. (2013). Beyond substance addiction: broadening the concept of addiction

to include behavioral addiction. J Korean Med Sci, 28(5), 646-647. doi:

10.3346/jkms.2013.28.5.646

Kim, M. G., & Kim, J. (2010). Cross-validation of reliability, convergent and discriminant

validity for the problematic online game use scale. Computers in Human Behavior, 26(3),

389-398.

Kim, S. H., Baik, S. H., Park, C. S., Kim, S. J., Choi, S. W., & Kim, S. E. (2011). Reduced

striatal dopamine D2 receptors in people with Internet addiction. Neuroreport, 22(8),

407-411. doi: 10.1097/WNR.0b013e328346e16e

King, D., & Delfabbro, P. (2009). Understanding and assisting excessive players of video games:

A community psychology perspective. The Australian Community Psychologist, 21(1),

62-74.

King, D. L., & Delfabbro, P. H. (2013a). Issues for DSM-5: Video-gaming disorder? Australian

and New Zealand Journal of Psychiatry, 47(1), 20-22.

King, D. L., Delfabbro, P. H., & Zajac, I. T. (2011). Preliminary validation of a new clinical tool

for identifying problem video game playing. International Journal of Mental Health and

Addiction, 9(1), 72-87. doi: 10.1007/s11469-009-9254-9

King, D. L., Haagsma, M. C., Delfabbro, P. H., Gradisar, M., & Griffiths, M. D. (2013). Toward

a consensus definition of pathological video-gaming: a systematic review of

 191

psychometric assessment tools. Clin Psychol Rev, 33(3), 331-342. doi:

10.1016/j.cpr.2013.01.002

Kinsey, A. C., Pomeroy, W. B., & Martin, C. E. (1948). Sexual behavior in the human male.

Kisa, C., Bulbul, D. O., Aydemir, C., & Goka, E. (2007). Is it possible to be dependent to

Tianeptine, an antidepressant? A case report. Prog Neuropsychopharmacol Biol

Psychiatry, 31(3), 776-778. doi: 10.1016/j.pnpbp.2007.01.002

Kittinger, R., Correia, C. J., & Irons, J. G. (2012). Relationship between Facebook use and

problematic Internet use among college students. Cyberpsychol Behav Soc Netw, 15(6),

324-327. doi: 10.1089/cyber.2010.0410

Klontz, B. T., Garos, S., & Klontz, P. T. (2005). The effectiveness of brief multimodal

experiential therapy in the treatment of sexual addiction. Sex Addict Compulsivity, 12(4),

275-294.

Ko, C.-H., Liu, G.-C., Yen, J.-Y., Yen, C.-F., Chen, C.-S., & Lin, W.-C. (2012). The brain

activations for both cue-induced gaming urge and smoking craving among subjects

comorbid with Internet gaming addiction and nicotine dependence. Journal of psychiatric

research, 47(4), 486-493. doi: 10.1016/j.jpsychires.2012.11.008

Ko, C.-H., Yen, J.-Y., Chen, S.-H., Wang, P.-W., Chen, C.-S., & Yen, C.-F. (2014). Evaluation

of the diagnostic criteria of Internet gaming disorder in the DSM-5 among young adults

in Taiwan. Journal of psychiatric research, 53, 103-110.

Koc, M., & Gulyagci, S. (2013). Facebook addiction among Turkish college students: the role of

psychological health, demographic, and usage characteristics. Cyberpsychol Behav Soc

Netw, 16(4), 279-284. doi: 10.1089/cyber.2012.0249

Koo, H.-Y. (2013). Development of a cell phone addiction scale for Korean parents of young
 192

children. Child Health Nursing Research, 19(1), 29-38.

Koob, G. F. (2011). Neurobiology of addiction. FOCUS: The Journal of Lifelong Learning in

Psychiatry, 9(1), 55-65.

Koob, G. F. (2013). Negative reinforcement in drug addiction: the darkness within. Curr Opin

Neurobiol, 23(4), 559-563. doi: 10.1016/j.conb.2013.03.011

Koob, G. F., & Volkow, N. D. (2009). Neurocircuitry of addiction. Neuropsychopharmacology,

35(1), 217-238. doi: 10.1038/npp.2009.110

Kor, A., Fogel, Y., Reid, R. C., & Potenza, M. N. (2013). Should Hypersexual Disorder be

classified as an addiction? Sex Addict Compulsivity, 20(1-2). doi:

10.1080/10720162.2013.768132

Kor, A., Zilcha-Mano, S., Fogel, Y., Mikulincer, M., Reid, R. C., & Potenza, M. N. (2014).

Psychometric development of the Problematic Pornography Use Scale. Addictive

behaviors, 39(5), 861-868. doi: 10.1016/j.addbeh.2014.01.027

Korkeila, J., Kaarlas, S., Jääskeläinen, M., Vahlberg, T., & Taiminen, T. (2010). Attached to the

web—harmful use of the Internet and its correlates. European Psychiatry, 25(4), 236-

241.

Kourosh, A. S., Harrington, C. R., & Adinoff, B. (2010). Tanning as a behavioral addiction. Am

J Drug Alcohol Abuse, 36(5), 284-290. doi: 10.3109/00952990.2010.491883

Krafft-Ebbing, R. (1886). Psychopathia Sexualis: A Medico-Forensic Study New York, NY: GP

Putnam's Sons.

Kraus, S., & Rosenberg, H. (2014). The Pornography Craving Questionnaire: Psychometric

properties. Arch Sex Behav, 43(3), 1-12. doi: 10.1007/s10508-013-0229-3

Kühn, S., & Gallinat, J. (2014a). Brains online: structural and functional correlates of habitual
 193

Internet use. Addict Biol. doi: 10.1111/adb.12128

Kühn S, G. J. (2014b). Brain structure and functional connectivity associated with pornography

consumption: The brain on porn. JAMA Psychiatry. doi: 10.1001/jamapsychiatry.2014.93

Kupfer, D. J., First, M. B., & Regier, D. A. (2008). A research agenda for DSM V. Arlington,

VA: American Psychiatric Pub.

Kuss, D. J. (2013). Internet gaming addiction: current perspectives. Psychol Res Behav Manag,

6, 125-137. doi: 10.2147/PRBM.S39476

Kuss, D. J., & Griffiths, M. D. (2011). Online social networking and addiction--a review of the

psychological literature. Int J Environ Res Public Health, 8(9), 3528-3552. doi:

10.3390/ijerph8093528

Kuss, D. J., & Griffiths, M. D. (2012a). Internet gaming addiction: A systematic review of

empirical research. International Journal of Mental Health and Addiction, 10(2), 278-

296. doi: 10.1007/s11469-011-9318-5

Kuss, D. J., & Griffiths, M. D. (2012b). Online gaming addiction in children and adolescents: A

review of empirical research. Journal of Behavioral Addictions, 1(1), 3-22.

Kuss, D. J., & Griffiths, M. D. (2012c). Internet and gaming addiction: A systematic literature

review of neuroimaging studies. Brain Sciences, 2(3), 347-374. doi:

10.3390/brainsci2030347

Kuss, D. J., Griffiths, M. D., Karila, L., & Billieux, J. (2013). Internet Addiction: A Systematic

Review of Epidemiological Research for the Last Decade. Curr Pharm Des.

Kuss, D. J., Shorter, G. W., van Rooij, A. J., Griffiths, M. D., & Schoenmakers, T. M. (2013).

Assessing Internet Addiction using the Parsimonious Internet Addiction Components

Model—A preliminary study. International Journal of Mental Health and Addiction, 1-

 194

16. doi: 10.1007/s11469-013-9459-9

Kuzma, J. M., & Black, D. W. (2008). Epidemiology, prevalence, and natural history of

compulsive sexual behavior. Psychiatr Clin North Am, 31(4), 603-611. doi:

10.1016/j.psc.2008.06.005

Lai, C.-M., Mak, K.-K., Watanabe, H., Ang, R. P., Pang, J. S., & Ho, R. C. (2013). Psychometric

properties of the Internet Addiction Test in Chinese adolescents. Journal of pediatric

psychology, 38(7), 794-807. doi: 10.1093/jpepsy/jst022

Laier, C., Pawlikowski, M., Pekal, J., Schulte, F. P., & Brand, M. (2013). Cybersex addiction:

Experienced sexual arousal when watching pornography and not real-life sexual contacts

makes the difference. Journal of Behavioral Addictions, 1-8.

Landolfi, E. (2013). Exercise Addiction. Sports Medicine, 43(2), 111-119. doi: 10.1007/s40279-

012-0013-x

Leahy, M. (2008). Porn Nation: Conquering America's# 1 Addiction: Moody Publishers.

Leahy, M. (2009). Porn@ Work: Exposing the Office's# 1 Addiction: Moody Publishers.

Leahy, M. (2009). Porn University: What college students are really saying about sex on

campus: Moody Publishers.

Lee, C., & Han, S. (2007). Development of the scale for diagnosing online game addiction. Paper

presented at the Proceedings of the 3rd WSEAS/IASME International Conference on

Educational Technologies.

Lee, H., & Ahn, C. (2002). Development of the internet game addiction diagnostic scale. The

Korean Journal of Health Psychology, 7(2), 211-239dfs.

Lee, K., Lee, H.-K., Gyeong, H., Yu, B., Song, Y.-M., & Kim, D. (2013). Reliability and validity

of the Korean version of the Internet Addiction Test among college students. Journal of
 195

Korean medical science, 28(5), 763-768. doi: 10.3346/jkms.2013.28.5.763

Lee, Y. S., Han, D. H., Yang, K. C., Daniels, M. A., Na, C., Kee, B. S., & Renshaw, P. F. (2008).

Depression like characteristics of 5HTTLPR polymorphism and temperament in

excessive internet users. J Affect Disord, 109(1-2), 165-169. doi:

10.1016/j.jad.2007.10.020

Leeman, R. F., & Potenza, M. N. (2013). A targeted review of the neurobiology and genetics of

behavioural addictions: an emerging area of research. Can J Psychiatry, 58(5), 260-273.

Lejoyeux, M., & Weinstein, A. (2010). Compulsive buying. Am J Drug Alcohol Abuse, 36(5),

248-253. doi: 10.3109/00952990.2010.493590

Lemmens, J. S., Valkenburg, P. M., & Peter, J. (2009). Development and validation of a game

addiction scale for adolescents. Media Psychology, 12(1), 77-95.

Lemon, J. (2002). Can we call behaviours addictive? Clinical Psychologist, 6(2), 44-49.

Levin, M. E., Lillis, J., & Hayes, S. C. (2012). When is online pornography viewing problematic

among college males? Examining the moderating role of experiential avoidance. Sex

Addict Compulsivity, 19(3), 168-180.

Ley, D., Prause, N., & Finn, P. (2014). The emperor has no clothes: A review of the

‘Pornography Addiction’ model. Current Sexual Health Reports, 6(2), 94-105. doi:

10.1007/s11930-014-0016-8

Lichtenstein, M. B., Larsen, K. S., Christiansen, E., Støving, R. K., & Bredahl, T. V. G. (2014).

Exercise addiction in team sport and individual sport: Prevalences and validation of the

exercise addiction inventory. Addiction Research & Theory(0), 1-7. doi:

10.3109/16066359.2013.875537

Limbrick-Oldfield, E. H., Van Holst, R. J., & Clark, L. (2013). Fronto-striatal dysregulation in
 196

drug addiction and pathological gambling: Consistent inconsistencies? NeuroImage:

Clinical, 2, 385-393. doi: 10.1016/j.nicl.2013.02.005

Lin, F., Wu, G., Zhu, L., & Lei, H. (2013). Heavy smokers show abnormal microstructural

integrity in the anterior corpus callosum: A diffusion tensor imaging study with tract-

based spatial statistics. Drug and alcohol dependence, 129(1), 82-87.

Lin, F., Zhou, Y., Du, Y., Qin, L., Zhao, Z., Xu, J., & Lei, H. (2012). Abnormal white matter

integrity in adolescents with internet addiction disorder: a tract-based spatial statistics

study. PLoS One, 7(1), e30253. doi: 10.1371/journal.pone.0030253

Lin, P. C., Kuo, S. Y., Lee, P. H., Sheen, T. C., & Chen, S. R. (2013). Effects of Internet

Addiction on heart rate variability in school-aged children. J Cardiovasc Nurs. doi:

10.1097/JCN.0b013e3182a477d5

Lin, S., & Tsai, C. (1999). Internet addiction among high schoolers in Taiwan. Paper presented

at the American Psychological Association Annual Meeting, Boston.

Littel, M., van den Berg, I., Luijten, M., van Rooij, A. J., Keemink, L., & Franken, I. H. (2012).

Error processing and response inhibition in excessive computer game players: an event-

related potential study. Addict Biol, 17(5), 934-947. doi: 10.1111/j.1369-

1600.2012.00467.x

Liu, J., Gao, X., Osunde, I., Li, X., Zhou, S., Zheng, H., & Li, L. (2010). Increased regional

homogeneity in internet addiction disorder a resting state functional magnetic resonance

imaging study (2009). Chin Med J (Engl), 123(14), 1904-1908.

Lortie, C. L., & Guitton, M. J. (2013). Internet addiction assessment tools: dimensional structure

and methodological status. Addiction, 108(7), 1207-1216. doi: 10.1111/add.12202

Luder, M.-T., Pittet, I., Berchtold, A., Akré, C., Michaud, P.-A., & Surís, J.-C. (2011).
 197

Associations between online pornography and sexual behavior among adolescents: Myth

or reality? Arch Sex Behav, 40(5), 1027-1035.

Luijten, M., Machielsen, M. W., Veltman, D. J., Hester, R., de Haan, L., & Franken, I. H. (2014).

Systematic review of ERP and fMRI studies investigating inhibitory control and error

processing in people with substance dependence and behavioural addictions. J Psychiatry

Neurosci, 39(3), 149-169.

Ma, C., & Shek, D. (2013). Consumption of pornographic materials in early adolescents in Hong

Kong (2013). J Pediatr Adolesc Gynecol, 26(3 Suppl), S18-25. doi:

10.1016/j.jpag.2013.03.011

MacRae, F. (2013). Compulsive pornography users shows the same brain activity as alcoholics

and drug addicts. from http://www.dailymail.co.uk/news/article-2428861/Porn-addicts-

brain-activity-alcoholics-drug-addicts.html

Madsen, H. B., Brown, R. M., & Lawrence, A. J. (2012). Neuroplasticity in addiction: cellular

and transcriptional perspectives. Front Mol Neurosci, 5, 99. doi:

10.3389/fnmol.2012.00099

Maltz, W., & Maltz, L. (2008). The Porn Trap: The Essential Guide To Overcoming Problems

Caused By Pornography. New York, NY: Harper Collins.

Mann, K., Fauth-Buhler, M., Seiferth, N., & Heinz, A. (2013). [The concept of behavioral

addiction and limits of the term addiction]. Nervenarzt, 84(5), 548-556. doi:

10.1007/s00115-012-3718-z

Marks, I. (1990). Behavioural (non-­‐‑chemical) addictions. British Journal of Addiction, 85(11),

1389-1394.

Marlatt, G. A., Baer, J. S., Donovan, D. M., & Kivlahan, D. R. (1988). Addictive behaviors:
 198

Etiology and treatment. Annu Rev Psychol, 39(1), 223-252. doi:

10.1146/annurev.ps.39.020188.001255

Martin, P. R., & Petry, N. M. (2005). Are Non-­‐‑substance-­‐‑related Addictions Really Addictions?

The American Journal on Addictions, 14(1), 1-7.

Masaki, D., Tsuchida, H., Kitabayashi, Y., Tani, N., & Fukui, K. (2007). [Addictive behavior

disorders]. Nihon Arukoru Yakubutsu Igakkai Zasshi, 42(5), 469-477.

Masterpasqua, F. (2009). Psychology and epigenetics. Review of General Psychology, 13(3),

194. doi: 10.1037/a0016301

Mattebo, M., Tydén, T., Häggström-Nordin, E., Nilsson, K. W., & Larsson, M. (2013).

Pornography consumption, sexual experiences, lifestyles, and self-rated health among

male adolescents in Sweden. Journal of Developmental & Behavioral Pediatrics, 34(7),

460-468. doi: 10.1097/DBP.0b013e31829c44a2.

Mayfield, D., McLeod, G., & Hall, P. (1974). The CAGE questionnaire: validation of a new

alcoholism screening instrument. Am J Psychiatry, 131(10), 1121-1123.

Maze, I., & Nestler, E. J. (2011). The epigenetic landscape of addiction. Annals of the New York

Academy of Sciences, 1216(1), 99-113. doi: 10.1111/j.1749-6632.2010.05893.x

McBride, K. R., Reece, M., & Sanders, S. A. (2008). Predicting negative outcomes of sexuality

using the Compulsive Sexual Behavior Inventory. International Journal of Sexual

Health, 19(4), 51-62.

McNamara, B. E. (2011). No more hiding, no more shame: Finding freedom from Pornography

Addiction: Tate Publishing.

Mechanic, M. (2013). Psychiatry's new diagnostic manual: "Don't buy it. Don't use it. Don't

teach it.". from http://www.motherjones.com/politics/2013/05/psychiatry-allen-frances-

 199

saving-normal-dsm-5-controversy

Meerkerk, G.-J., Eijnden, R. J. V. D., & Garretsen, H. F. (2006). Predicting compulsive Internet

use: it's all about sex! CyberPsychology & Behavior, 9(1), 95-103. doi:

10.1089/cpb.2006.9.95.

Meerkerk, G. J., Van Den Eijnden, R. J., Vermulst, A. A., & Garretsen, H. F. (2009). The

Compulsive Internet Use Scale (CIUS): some psychometric properties. Cyberpsychol

Behav, 12(1), 1-6. doi: 10.1089/cpb.2008.0181

Mercer, J. T. (1998). Assessment of the Sex Addicts Anonymous Questionnaire: Differentiating

between the general population, sex addicts, and sex offenders. Sexual Addiction &

Compulsivity: The Journal of Treatment and Prevention, 5(2), 107-117.

Mick, T. M., & Hollander, E. (2006). Impulsive-compulsive sexual behavior. CNS Spectr,

11(12), 944-955.

Miele, G. M., Tilly, S. M., First, M., & Frances, A. (1990). The definition of dependence and

behavioural addictions. British Journal of Addiction, 85(11), 1421-1423.

Miller, W. R. (1980). The addictive behaviors: Treatment of alcoholism, drug abuse, smoking

and obesity: Pergamon Pr.

Milošević-Đorđević, J. S., & Žeželj, I. L. (2014). Psychological predictors of addictive social

networking sites use: The case of Serbia. Computers in Human Behavior, 32, 229-234.

Miner, M. H., Coleman, E., Center, B. A., Ross, M., & Rosser, B. R. (2007). The compulsive

sexual behavior inventory: psychometric properties. Arch Sex Behav, 36(4), 579-587. doi:

10.1007/s10508-006-9127-2

Miner, M. H., Raymond, N., Mueller, B. A., Lloyd, M., & Lim, K. O. (2009). Preliminary

investigation of the impulsive and neuroanatomical characteristics of compulsive sexual

 200

behavior. Psychiatry Res, 174(2), 146-151. doi: 10.1016/j.pscychresns.2009.04.008

Mitzner, G. B., Whelan, J. P., & Meyers, A. W. (2011). Comments from the trenches: proposed

changes to the DSM-V classification of pathological gambling. Journal of Gambling

Studies, 27(3), 517-521. doi: 10.1007/s10899-010-9225-x

Montag, C., Kirsch, P., Sauer, C., Markett, S., & Reuter, M. (2012). The role of the CHRNA4

gene in Internet addiction: a case-control study. J Addict Med, 6(3), 191-195. doi:

10.1097/ADM.0b013e31825ba7e7

Morahan-Martin, J., & Schumacher, P. (2000). Incidence and correlates of pathological Internet

use among college students. Computers in Human Behavior, 16(1), 13-29.

Moreno, M. A., Jelenchick, L., Cox, E., Young, H., & Christakis, D. A. (2011). Problematic

Internet use among US youth: a systematic review. Archives of pediatrics & adolescent

medicine, 165(9), 797.

Moreno, M. A., Jelenchick, L. A., & Christakis, D. A. (2013). Problematic Internet use among

older adolescents: A conceptual framework. Computers in Human Behavior, 29(4), 1879-

1887. doi: 10.1016/j.chb.2013.01.053

Morgenstern, J., Parsons, J., Muench, F., Hollander, E., Bimbi, D., & Irwin, T. (2004).

Understanding and treating compulsive sexual behavior. Paper presented at the

American Psychiatric Association Annual Conference, New York, NY.

Morgenstern, J., Muench, F., O'Leary, A., Wainberg, M., Parsons, J. T., Hollander, E., . . . Irwin,

T. (2011). Non-paraphilic compulsive sexual behavior and psychiatric co-morbidities in

gay and bisexual men. Sex Addict Compulsivity, 18(3), 114-134.

Mosher, C. E., & Danoff-Burg, S. (2010). Addiction to indoor tanning: relation to anxiety,

depression, and substance use. Archives of Dermatology, 146(4), 412. doi:

 201

10.1001/archdermatol.2009.385.

Mudry, T. E., Hodgins, D. C., el-Guebaly, N., Cameron Wild, T., Colman, I., B Patten, S., &

Schopflocher, D. (2011). Conceptualizing excessive behaviour syndromes: A systematic

review. Current Psychiatry Reviews, 7(2), 138-151. doi: 10.2174/157340011796391201

Muench, F., Morgenstern, J., Hollander, E., Irwin, T., O'Leary, A., Parsons, J. T., . . . Lai, B.

(2007). The consequences of compulsive sexual behavior: The preliminary reliability and

validity of the Compulsive Sexual Behavior Consequences Scale. Sex Addict

Compulsivity, 14(3), 207-220.

Müller, A., Cook, B., Zander, H., Herberg, A., Müller, V., & de Zwaan, M. (2014). Does the

German version of the Exercise Dependence Scale measure exercise dependence?

Psychology of Sport and Exercise, In Press. doi:

http://dx.doi.org/10.1016/j.psychsport.2013.12.003

Murali, V., Ray, R., & Shaffiullha, M. (2012). Shopping addiction. Advances in Psychiatric

Treatment, 18(4), 263-269. doi: 10.1192/apt.bp.109.007880

Muschamp, J. W., Nemeth, C. L., Robison, A. J., Nestler, E. J., & Carlezon Jr, W. A. (2012).

ΔFosB enhances the rewarding effects of cocaine while reducing the pro-depressive

effects of the kappa-opioid receptor agonist U50488. Biol Psychiatry, 71(1), 44-50. doi:

10.1016/j.biopsych.2011.08.011

Naficy, H., Samenow, C. P., & Fong, T. W. (2013). A review of pharmacological treatments for

hypersexual disorder. Sex Addict Compulsivity, 20(1-2), 139-153.

Narrow, W. E., Clarke, D. E., Kuramoto, S. J., Kraemer, H. C., Kupfer, D. J., Greiner, L., &

Regier, D. A. (2013). DSM-5 field trials in the United States and Canada, Part III:

development and reliability testing of a cross-cutting symptom assessment for DSM-5.

 202

Am J Psychiatry, 170(1), 71-82. doi: 10.1176/appi.ajp.2012.12071000

Nestler, E. J. (2008). Review. Transcriptional mechanisms of addiction: role of DeltaFosB.

Philos Trans R Soc Lond B Biol Sci, 363(1507), 3245-3255. doi: 10.1098/rstb.2008.0067

Nestler, E. J. (2012). Transcriptional mechanisms of drug addiction. Clin Psychopharmacol

Neurosci, 10(3), 136-143. doi: 10.9758/cpn.2012.10.3.136

Nestler, E. J. (2013). Cellular basis of memory for addiction. Dialogues Clin Neurosci, 15(4),

431-443.

Nestler, E. J., Barrot, M., & Self, D. W. (2001). DeltaFosB: a sustained molecular switch for

addiction. Proc Natl Acad Sci U S A, 98(20), 11042-11046. doi: 10.1073/pnas.191352698

Nichols, L. A., & Nicki, R. (2004). Development of a psychometrically sound internet addiction

scale: a preliminary step. Psychology of Addictive Behaviors, 18(4), 381.

O'Brien, C. (2011). Addiction and dependence in DSM-­‐‑V. Addiction, 106(5), 866-867. doi:

10.1111/j.1360-0443.2010.03144.x

O'Brien, C. (2014). DSM-5: Substance Related and Addictive Disorders (Archived Webinar).

Olds, J., & Milner, P. (1954). Positive reinforcement produced by electrical stimulation of septal

area and other regions of rat brain. J Comp Physiol Psychol, 47(6), 419-427. doi:

10.1037/h0058775

Olive, M. F., Cleva, R. M., Kalivas, P. W., & Malcolm, R. J. (2012). Glutamatergic medications

for the treatment of drug and behavioral addictions. Pharmacol Biochem Behav, 100(4),

801-810. doi: 10.1016/j.pbb.2011.04.015

Olsen, C. M. (2011). Natural rewards, neuroplasticity, and non-drug addictions.

Neuropharmacology, 61(7), 1109-1122. doi: 10.1016/j.neuropharm.2011.03.010

Orford, J. (1978). Hypersexuality: implications for a theory of dependence. Br J Addict Alcohol

 203

Other Drugs, 73(3), 299-210.

Orford, J. (1985). Excessive appetites: A psychological view of addictions.: Wiley, Chichester.

Organization, W. H. (1992). ICD-10: International statistical classification of diseases and

related health problems: 10th revision: World Health Organization.

Orzack, M. H., Voluse, A. C., Wolf, D., & Hennen, J. (2006). An ongoing study of group

treatment for men involved in problematic Internet-enabled sexual behavior.

Cyberpsychol Behav, 9(3), 348-360. doi: 10.1089/cpb.2006.9.348

Packer, S. (2013). The top five psychiatry events of 2013. from

http://www.psychiatrictimes.com/blogs/top-five-psychiatry-events-2013

Paris, J., & Phillips, J. (2013). Making the DSM-5. New York: NY: Springer.

Pawlikowski, M., Altstötter-Gleich, C., & Brand, M. (2013). Validation and psychometric

properties of a short version of Young’s Internet Addiction Test. Computers in Human

Behavior, 29(3), 1212-1223. doi: 10.1016/j.chb.2012.10.014.

Petry, N. M. (2006). Should the scope of addictive behaviors be broadened to include

pathological gambling? Addiction, 101(s1), 152-160.

Petry, N. M. (2010). Pathological gambling and the DSM-V. International Gambling Studies,

10(2), 113-115. doi: 10.1080/14459795.2010.501086

Petry, N. M. (2011). Commentary on Van Rooij et al.(2011):‘Gaming addiction’–a psychiatric

disorder or not? Addiction, 106(1), 213-214.

Petry, N. M. (2013). Commentary on Festl et al. (2013): Gaming addiction--how far have we

come, and how much further do we need to go? Addiction, 108(3), 600-601. doi:

10.1111/add.12044

Petry, N. M., Blanco, C., Auriacombe, M., Borges, G., Bucholz, K., Crowley, T. J., . . . O'Brien,
 204

C. (2013). An overview of and rationale for changes proposed for Pathological Gambling

in DSM-5. J Gambl Stud, 1-10. doi: 10.1007/s10899-013-9370-0

Petry, N. M., & O'Brien, C. P. (2013). Internet gaming disorder and the DSM-­‐‑5. Addiction,

108(7), 1186-1187. doi: 10.1111/add.12162

Petry, N. M., Rehbein, F., Gentile, D. A., Lemmens, J. S., Rumpf, H. J., Mößle, T., . . . Borges,

G. (2014). An international consensus for assessing internet gaming disorder using the

new DSM-­‐‑5 approach. Addiction. doi: 10.1111/add.12457

Pezoa-Jares, R., Espinoza-Luna, I., & Vasquez-Medina, J. (2012). Internet Addiction: A review.

J Addict Res Ther S, 6, 2. doi: 10.4172/2155-6105.S6-004

Pitchers, K. K., Balfour, M. E., Lehman, M. N., Richtand, N. M., Yu, L., & Coolen, L. M.

(2010a). Neuroplasticity in the mesolimbic system induced by natural reward and

subsequent reward abstinence. Biol Psychiatry, 67(9), 872-879. doi:

10.1016/j.biopsych.2009.09.036

Pitchers, K. K., Frohmader, K. S., Vialou, V., Mouzon, E., Nestler, E. J., Lehman, M. N., &

Coolen, L. M. (2010b). DeltaFosB in the nucleus accumbens is critical for reinforcing

effects of sexual reward. Genes Brain Behav, 9(7), 831-840. doi: 10.1111/j.1601-

183X.2010.00621.x

Pitchers, K. K., Vialou, V., Nestler, E. J., Laviolette, S. R., Lehman, M. N., & Coolen, L. M.

(2013). Natural and drug rewards act on common neural plasticity mechanisms with

DeltaFosB as a key mediator. J Neurosci, 33(8), 3434-3442. doi: 10.1523/jneurosci.4881-

12.2013

Pontes, H., Patrão, I., & Griffiths, M. (2014). Portuguese validation of the Internet Addiction

Test: An empirical study. Journal of Behavioral Addictions, 3(2), 3. doi:

 205

10.1556/JBA.3.2014.2.4

Potenza, M. N. (2006). Should addictive disorders include non-­‐‑substance-­‐‑related conditions?

Addiction, 101(s1), 142-151. doi: 10.1111/j.1360-0443.2006.01591.x

Potenza, M. N. (2008). Review. The neurobiology of pathological gambling and drug addiction:

an overview and new findings. Philos Trans R Soc Lond B Biol Sci, 363(1507), 3181-

3189. doi: 10.1098/rstb.2008.0100

Potenza, M. N. (2013). Neurobiology of gambling behaviors. Current opinion in neurobiology,

23(4), 660-667. doi: http://dx.doi.org/10.1016/j.conb.2013.03.004

Potenza, M. N. (2014). Non-substance addictive behaviors in the context of DSM-5. Addict

Behav, 39(1), 1-2. doi: 10.1016/j.addbeh.2013.09.004

Prause, N., Staley, C., & Fong, T. W. (2013). No evidence of emotion dysregulation in

“hypersexuals” reporting their emotions to a sexual film. Sex Addict Compulsivity, 20(1-

2), 106-126. doi: 10.1080/10720162.2013.772874

Quadland, M. C. (1985). Compulsive sexual behavior: definition of a problem and an approach

to treatment. J Sex Marital Ther, 11(2), 121-132. doi: 10.1080/00926238508406078

Raymond, N. C., Coleman, E., & Miner, M. H. (2003). Psychiatric comorbidity and

compulsive/impulsive traits in compulsive sexual behavior. Compr Psychiatry, 44(5),

370-380. doi: 10.1016/S0010-440X(03)00110-X

Raymond, N. C., Grant, J. E., & Coleman, E. (2010). Augmentation with naltrexone to treat

compulsive sexual behavior: a case series. Ann Clin Psychiatry, 22(1), 56-62.

Raymond, N. C., Grant, J. E., Kim, S. W., & Coleman, E. (2002). Treatment of compulsive

sexual behaviour with naltrexone and serotonin reuptake inhibitors: two case studies. Int

Clin Psychopharmacol, 17(4), 201-205.

 206

Raymond, N. C., Lloyd, M. D., Miner, M. H., & Kim, S. W. (2007). Preliminary report on the

development and validation of the Sexual Symptom Assessment Scale. Sex Addict

Compulsivity, 14(2), 119-129.

Regier, D. A., Narrow, W. E., Clarke, D. E., Kraemer, H. C., Kuramoto, S. J., Kuhl, E. A., &

Kupfer, D. J. (2013). DSM-5 field trials in the United States and Canada, Part II: test-

retest reliability of selected categorical diagnoses. Am J Psychiatry, 170(1), 59-70. doi:

10.1176/appi.ajp.2012.12070999

Regier, D. A., Narrow, W. E., Kuhl, E. A., & Kupfer, D. J. (2011). The conceptual evolution of

DSM-5. Arlington, VA: American Psychiatric Pub.

Reid, R. C. (2010). Differentiating emotions in a sample of men in treatment for hypersexual

behavior. Journal of Social Work Practice in the Addictions, 10(2), 197-213. doi:

10.1080/15332561003769369

Reid, R. C. (2010). Investigating executive functions in men seeking help for hypersexual

behavior using neuropsychological testing. (PhD), Brigham Young University.

Reid, R. C., & Carpenter, B. N. (2009). Exploring relationships of psychopathology in

hypersexual patients using the MMPI-2. J Sex Marital Ther, 35(4), 294-310. doi:

10.1080/00926230902851298

Reid, R. C., Carpenter, B. N., Gilliland, R., & Karim, R. (2011). Problems of self-concept in a

patient sample of hypersexual men with attention-deficit disorder. J Addict Med, 5(2),

134-140. doi: 10.1097/ADM.0b013e3181e6ad32

Reid, R. C., Carpenter, B. N., Hook, J. N., Garos, S., Manning, J. C., Gilliland, R., . . . Fong, T.

(2012). Report of findings in a DSM-5 field trial for hypersexual disorder. J Sex Med,

9(11), 2868-2877. doi: 10.1111/j.1743-6109.2012.02936.x

 207

Reid, R. C., Cooper, E. B., Prause, N., Li, D. S., & Fong, T. W. (2012). Facets of perfectionism

in a sample of hypersexual patients. J Nerv Ment Dis, 200(11), 990-995. doi:

10.1097/NMD.0b013e3182718d67

Reid, R. C., Davtian, M., Lenartowicz, A., Torrevillas, R. M., & Fong, T. W. (2013).

Perspectives on the assessment and treatment of adult ADHD in hypersexual men.

Neuropsychiatry, 3(3), 295-308.

Reid, R. C., Dhuffar, M. K., Parhami, I., & Fong, T. W. (2012). Exploring facets of personality

in a patient sample of hypersexual women compared with hypersexual men. J Psychiatr

Pract, 18(4), 262-268. doi: 10.1097/01.pra.0000416016.37968.eb

Reid, R. C., Garos, S., & Carpenter, B. N. (2011). Reliability, validity, and psychometric

development of the Hypersexual Behavior Inventory in an outpatient sample of men. Sex

Addict Compulsivity, 18(1), 30-51.

Reid, R. C., Garos, S., & Fong, T. (2012). Psychometric development of the hypersexual

behavior consequences scale. Journal of Behavioral Addictions, 1(3), 115-122.

Reid, R. C., & Gray, D. (2006). Confronting Your Spouse's Pornography Problem: Silverleaf

Press.

Reid, R. C., Karim, R., McCrory, E., & Carpenter, B. N. (2010). Self-reported differences on

measures of executive function and hypersexual behavior in a patient and community

sample of men. Int J Neurosci, 120(2), 120-127. doi: 10.3109/00207450903165577

Reid, R. C., Li, D. S., Gilliland, R., Stein, J. A., & Fong, T. (2011). Reliability, validity, and

psychometric development of the pornography consumption inventory in a sample of

hypersexual men. J Sex Marital Ther, 37(5), 359-385. doi:

10.1080/0092623X.2011.607047
 208

Reid, R. C., Stein, J. A., & Carpenter, B. N. (2011). Understanding the roles of shame and

neuroticism in a patient sample of hypersexual men. J Nerv Ment Dis, 199(4), 263-267.

doi: 10.1097/NMD.0b013e3182125b96

Riemersma, J., & Sytsma, M. (2013). A new generation of Sexual Addiction. Sex Addict

Compulsivity, 20(4), 306-322. doi: 10.1080/10720162.2013.843067

Robinson, M. J., & Berridge, K. C. (2013). Instant transformation of learned repulsion into

motivational "wanting". Curr Biol, 23(4), 282-289. doi: 10.1016/j.cub.2013.01.016

Robinson, T. E., & Berridge, K. C. (1993). The neural basis of drug craving: an incentive-

sensitization theory of addiction. Brain research reviews, 18(3), 247-291.

Robinson, T. E., & Berridge, K. C. (2008). The incentive sensitization theory of addiction: some

current issues. Philosophical Transactions of the Royal Society B: Biological Sciences,

363(1507), 3137-3146. doi: 10.1098/rstb.2008.0093

Robison, A. J., & Nestler, E. J. (2011). Transcriptional and epigenetic mechanisms of addiction.

Nat Rev Neurosci, 12(11), 623-637. doi: 10.1038/nrn3111

Robison, A. J., Vialou, V., Mazei-Robison, M., Feng, J., Kourrich, S., Collins, M., . . . Nestler,

E. J. (2013). Behavioral and structural responses to chronic cocaine require a feedforward

loop involving DeltaFosB and calcium/calmodulin-dependent protein kinase II in the

nucleus accumbens shell. J Neurosci, 33(10), 4295-4307. doi: 10.1523/jneurosci.5192-

12.2013

Rodgers, R. F., Melioli, T., Laconi, S., Bui, E., & Chabrol, H. (2013). Internet addiction

symptoms, disordered eating, and body image avoidance. Cyberpsychol Behav Soc Netw,

16(1), 56-60. doi: 10.1089/cyber.2012.1570

Rose, S., & Dhandayudham, A. (2014). Towards an understanding of Internet-based problem

 209

shopping behaviour: The concept of online shopping addiction and its proposed

predictors. Journal of Behavioral Addictions, 3(2), 83-89. doi: 10.1556/JBA.3.2014.003

Rosen, L. D., Whaling, K., Rab, S., Carrier, L. M., & Cheever, N. A. (2013). Is Facebook

creating “iDisorders”? The link between clinical symptoms of psychiatric disorders and

technology use, attitudes and anxiety. Computers in Human Behavior, 29(3), 1243-1254.

doi: 10.1016/j.chb.2012.11.012

Rosenberg, K. P., Carnes, P., & O'Connor, S. (2012). Evaluation and treatment of Sex Addiction.

J Sex Marital Ther. doi: 10.1080/0092623x.2012.701268

Rosenberg, M. (1965). Society and the adolescent self-image. Princeton, NJ: Princeton

University Press.

Sadler, J. Z. (2013). Considering the economy of DSM alternatives. In J. Paris & J. Phillips

(Eds.), Making the DSM-5 (pp. 21-38). New York, NY: Springer.

Saha, T. D., Compton, W. M., Chou, S. P., Smith, S., Ruan, W., Huang, B., . . . Grant, B. F.

(2012). Analyses related to the development of DSM-5 criteria for substance use related

disorders: 1. Toward amphetamine, cocaine and prescription drug use disorder continua

using Item Response Theory. Drug and alcohol dependence, 122(1), 38-46.

Salehan, M., & Negahban, A. (2013). Social networking on smartphones: When mobile phones

become addictive. Computers in Human Behavior, 29(6), 2632-2639.

Salehi, M., Khalili, M. N., Hojjat, S. K., Salehi, M., & Danesh, A. (2014). Prevalence of Internet

Addiction and associated factors among medical students from Mashhad, Iran in 2013.

IRan Red Crescent Med J, 16(5).

Samenow, C. (2010). A Biopsychosocial Model of Hypersexual Disorder/Sexual Addiction. Sex

Addict Compulsivity, 17(2), 69-81. doi: 10.1080/10720162.2010.481300

 210

Savage, S. W., Zald, D. H., Cowan, R. L., Volkow, N. D., Marks-­‐‑Shulman, P. A., Kessler, R. M.,

. . . Dunn, J. P. (2014). Regulation of novelty seeking by midbrain dopamine D2/D3

signaling and ghrelin is altered in obesity. Obesity. doi: 10.1002/oby.20690

Schaef, A. W. (1987). When society becomes an addict. New York, NY: Harper Collins.

Schneider, J. P., & Levinson, B. (2006). Ethical dilemmas related to disclosure issues: Sex

addiction therapists in the trenches. Sex Addict Compulsivity, 13(1), 1-39. doi:

10.1080/10720160500529193

Schneider, J. P., & Weiss, R. (2001). Cybersex exposed: Simple fantasy or obsession? Center

City, MN: Hazelden Information & Educational Services.

Schultz, K., Hook, J. N., Davis, D. E., Penberthy, J. K., & Reid, R. C. (2013). Nonparaphilic

hypersexual behavior and depressive symptoms: A meta-analytic review of the literature.

J Sex Marital Ther(ahead-of-print). doi: 10.1080/0092623X.2013.772551

Sessoms, J. (2011). The Cyber Pornography Use Inventory: Comparing a religious and secular

Sample. Liberty University.

Shaffer, H. J., LaPlante, D. A., LaBrie, R. A., Kidman, R. C., Donato, A. N., & Stanton, M. V.

(2004). Toward a syndrome model of addiction: multiple expressions, common etiology.

Harv Rev Psychiatry, 12(6), 367-374. doi: 10.1080/10673220490905705

Shapira, N. A., Lessig, M. C., Goldsmith, T. D., Szabo, S. T., Lazoritz, M., Gold, M. S., & Stein,

D. J. (2003). Problematic internet use: proposed classification and diagnostic criteria.

Depression and anxiety, 17(4), 207-216.

Shaughnessy, K., Byers, E. S., & Walsh, L. (2011). Online sexual activity experience of

heterosexual students: gender similarities and differences. Arch Sex Behav, 40(2), 419-

427. doi: 10.1007/s10508-010-9629-9

 211

Shaughnessy, K., Byers, S., & Thornton, S. J. (2011). What is cybersex? Heterosexual students’

definitions. International Journal of Sexual Health, 23(2), 79-89.

Shorter, E. (2013). The history of DSM. In J. Paris & J. Phillips (Eds.), Making the DSM-5 (pp.

3-19). New York, NY: Springer.

Sim, T., Gentile, D. A., Bricolo, F., Serpelloni, G., & Gulamoydeen, F. (2012). A conceptual

review of research on the pathological use of computers, video games, and the Internet.

International Journal of Mental Health and Addiction, 10(5), 748-769. doi:

10.1007/s11469-011-9369-7

Siomos, K., Floros, G., Fisoun, V., Evaggelia, D., Farkonas, N., Sergentani, E., . . . Geroukalis,

D. (2012). Evolution of Internet addiction in Greek adolescent students over a two-year

period: the impact of parental bonding. European child & adolescent psychiatry, 21(4),

211-219. doi: 10.1007/s00787-012-0254-0

Skoric, M. M., Teo, L. L., & Neo, R. L. (2009). Children and video games: addiction,

engagement, and scholastic achievement. Cyberpsychol Behav, 12(5), 567-572. doi:

10.1089/cpb.2009.0079

Smahel, D., Brown, B. B., & Blinka, L. (2012). Associations between online friendship and

Internet addiction among adolescents and emerging adults. Developmental psychology,

48(2), 381. doi: 10.1037/a0027025

Smith, I. D. (2012). Addicted to ‘addiction’? Commentary on … Shopping addiction and

Internet Sex Addiction. Advances in Psychiatric Treatment, 18(4), 278-279. doi:

10.1192/apt.bp.111.009902

Smith, K. S., Berridge, K. C., & Aldridge, J. W. (2011). Disentangling pleasure from incentive

salience and learning signals in brain reward circuitry. Proc Natl Acad Sci U S A,
 212

108(27), E255-264. doi: 10.1073/pnas.1101920108

Solomon, R. L., & Corbit, J. D. (1974). An opponent-process theory of motivation. I. Temporal

dynamics of affect. Psychol Rev, 81(2), 119-145.

Sood, S., Bakhski, A., & Sharma, S. (2012). Psychological well being: Building bridges for

tomorrow. Paper presented at the 2nd Indian Psychological Science Congress,

Chandigarh, India. Internet retrieved from

Soper, W. B., & Miller, M. J. (1983). Junk-time junkies: An emerging addiction among students.

School Counselor.

Spada, M. M. (2014). An overview of problematic Internet use. Addictive behaviors, 39(1), 3-6.

doi: 10.1016/j.addbeh.2013.09.007

Stacy, A. W., & Wiers, R. W. (2010). Implicit cognition and addiction: a tool for explaining

paradoxical behavior. Annu Rev Clin Psychol, 6, 551. doi:

10.1146/annurev.clinpsy.121208.131444

Starcevic, V. (2013). Is Internet addiction a useful concept? Australian and New Zealand Journal

of Psychiatry, 47(1), 16-19.

Starcke, K., Schlereth, B., Domass, D., Schöler, T., & Brand, M. (2013). Cue reactivity towards

shopping cues in female participants. Journal of Behavioral Addictions, 2(1), 17-22.

Storholm, E. D., Fisher, D. G., Napper, L. E., Reynolds, G. L., & Halkitis, P. N. (2011a). A

psychometric analysis of the Compulsive Sexual Behavior Inventory. Sex Addict

Compulsivity, 18(2), 86-103.

Storholm, E. D., Fisher, D. G., Napper, L. E., Reynolds, G. L., & Halkitis, P. N. (2011b).

Proposing a tentative cut point for the Compulsive Sexual Behavior Inventory. Arch Sex

Behav, 40(6), 1301-1308. doi: 10.1007/s10508-010-9712-2

 213

Su, W., Fang, X., Miller, J. K., & Wang, Y. (2011). Internet-based intervention for the treatment

of online addiction for college students in China: a pilot study of the Healthy Online Self-

helping Center. Cyberpsychology, Behavior, and Social Networking, 14(9), 497-503. doi:

10.1089/cyber.2010.0167

Suler, J. (1998). Internet Addiction support group.

Sussman, S. (2007). Sexual addiction among teens: A review. Sex Addict Compulsivity, 14(4),

257-278.

Sussman, S. (2013). Workaholism: a review. J Addict Res Ther, Suppl 6(1). doi: 10.4172/2155-

6105.S6-001

Sussman, S., Lisha, N., & Griffiths, M. (2011). Prevalence of the addictions: A problem of the

majority or the minority? Evaluation & the health professions, 34(1), 3-56. doi:

10.1177/0163278710380124

Sussman, S., & Moran, M. B. (2013). Hidden addiction: Television. Journal of Behavioral

Addictions, 2(3), 1-8.

Svedin, C. G., Akerman, I., & Priebe, G. (2011). Frequent users of pornography. A population

based epidemiological study of Swedish male adolescents. J Adolesc, 34(4), 779-788.

doi: 10.1016/j.adolescence.2010.04.010

Tao, R., Huang, X., Wang, J., Zhang, H., Zhang, Y., & Li, M. (2010). Proposed diagnostic

criteria for internet addiction. Addiction, 105(3), 556-564. doi: 10.1111/j.1360-

0443.2009.02828.x

Tejeiro Salguero, R. A., & Moran, R. M. (2002). Measuring problem video game playing in

adolescents. Addiction, 97(12), 1601-1606.

Tonioni, F., Mazza, M., Autullo, G., Cappelluti, R., Catalano, V., Marano, G., . . . Lai, C. (2014).
 214

Is Internet addiction a psychopathological condition distinct from pathological gambling?

Addict Behav, 39(6), 1052-1056. doi: 10.1016/j.addbeh.2014.02.016

Tsitsika, A., E., C., A., L., Janikian, M., Freskou, A., Marangou, E., . . . Kafetzis, D. (2011).

Determinants of Internet addiction among adolescents: a case-control study.

ScientificWorldJournal, 11, 8.

Turner, N. E. (2008). A comment on “problems with the concept of video game ‘Addiction’:

Some case study examples”. International Journal of Mental Health and Addiction, 6(2),

186-190.

Twohig, M. P., & Crosby, J. M. (2010). Acceptance and commitment therapy as a treatment for

problematic internet pornography viewing. Behav Ther, 41(3), 285-295. doi:

10.1016/j.beth.2009.06.002

Uchtenhagen, A. (2011). New and remaining problems with DSM-V. Addiction, 106(5), 888-

889; discussion 895-887. doi: 10.1111/j.1360-0443.2010.03328.x

University, C. S. (2014). Doctoral Project Manual.

Vadachkoria, D., Gabunia, L., Gambashidze, K., Pkhaladze, N., & Kuridze, N. (2009). Addictive

potential of Tianeptine - the threatening reality. Georgian Med News(174), 92-94.

Van Rooij, A. J., Schoenmakers, T. M., Van de Eijnden, R. J., & Van de Mheen, D. (2010).

Compulsive internet use: the role of online gaming and other internet applications.

Journal of Adolescent Health, 47(1), 51-57. doi: 10.1016/j.jadohealth.2009.12.021

Vidyachathoth, K. B., Kumar, N., & Pai, S. (2014). Correlation between affect and Internet

Addiction in undergraduate medical students in Mangalore. J Addict Res Ther, 5(175), 2.

Villella, C., Martinotti, G., Di Nicola, M., Cassano, M., La Torre, G., Gliubizzi, M. D., . . .

Conte, G. (2011). Behavioural addictions in adolescents and young adults: results from a
 215

prevalence study. J Gambl Stud, 27(2), 203-214. doi: 10.1007/s10899-010-9206-0

Volkow, N. D., & Baler, R. D. (2014). Addiction science: Uncovering neurobiological

complexity. Neuropharmacology, 76 Pt B, 235-249. doi:

10.1016/j.neuropharm.2013.05.007

Volkow, N. D., & Muenke, M. (2012). The genetics of addiction. Hum Genet, 131(6), 773-777.

doi: 10.1007/s00439-012-1173-3

Volkow, N. D., Wang, G. J., Fowler, J. S., Tomasi, D., & Telang, F. (2011). Addiction: beyond

dopamine reward circuitry. Proc Natl Acad Sci U S A, 108(37), 15037-15042. doi:

10.1073/pnas.1010654108

Volkow, N. D., Wang, G. J., Telang, F., Fowler, J. S., Thanos, P. K., Logan, J., . . . Pradhan, K.

(2008). Low dopamine striatal D2 receptors are associated with prefrontal metabolism in

obese subjects: possible contributing factors. Neuroimage, 42(4), 1537-1543. doi:

10.1016/j.neuroimage.2008.06.002

Volkow, N. D., Wang, G. J., Tomasi, D., & Baler, R. D. (2013a). The addictive dimensionality

of obesity. Biol Psychiatry, 73(9), 811-818. doi: 10.1016/j.biopsych.2012.12.020

Volkow, N. D., Wang, G. J., Tomasi, D., & Baler, R. D. (2013b). Obesity and addiction:

neurobiological overlaps. Obes Rev, 14(1), 2-18. doi: 10.1111/j.1467-789X.2012.01031.x

Voon, V., Mole, T. B., Banca, P., Porter, L., Morris, L., Mitchell, S., . . . Irvine, M. (2014).

Neural correlates of sexual cue reactivity in individuals with and without compulsive

sexual behaviours. . PLoS One, 9(7), e102419. doi: 10.1371/journal.pone.0102419

Wainberg, M. L., Muench, F., Morgenstern, J., Hollander, E., Irwin, T. W., Parsons, J. T., . . .

O'Leary, A. (2006). A double-blind study of citalopram versus placebo in the treatment

of compulsive sexual behaviors in gay and bisexual men. J Clin Psychiatry, 67(12),
 216

1968-1973.

Wallace, D. L., Vialou, V., Rios, L., Carle-Florence, T. L., Chakravarty, S., Kumar, A., . . .

Bolanos-Guzman, C. A. (2008). The influence of DeltaFosB in the nucleus accumbens on

natural reward-related behavior. J Neurosci, 28(41), 10272-10277. doi:

10.1523/JNEUROSCI.1531-08.2008

Wallace, P. (2014). Internet addiction disorder and youth: There are growing concerns about

compulsive online activity and that this could impede students' performance and social

lives. EMBO Rep, 15(1), 12-16. doi: 10.1002/embr.201338222

Wan, M., Finlayson, R., & Rowles, A. (2000). Sexual dependency treatment outcome study.

Sexual Addiction & Compulsivity: The Journal of Treatment and Prevention, 7(3), 177-

196.

Wartberg, L., Petersen, K. U., Kammerl, R., Rosenkranz, M., & Thomasius, R. (2013).

Psychometric validation of a German version of the Compulsive Internet Use Scale.

Cyberpsychol Behav Soc Netw. doi: 10.1089/cyber.2012.0689

Weinstein, A., & Lejoyeux, M. . (2010). Internet addiction or excessive internet use. . Am J Drug

Alcohol Abuse, 36(5), 6.

Weinstein, A., & Lejoyeux, M. (2013). New developments on the neurobiological and

pharmaco-­‐‑genetic mechanisms underlying internet and videogame addiction. The

American Journal on Addictions.

Weinstein, A., & Weinstein, Y. (2013). Exercise Addiction- diagnosis, bio-psychological

mechanisms and treatment issues. Curr Pharm Des.

Weiss, R. (2014). [Personal communication].

Weiss, R., & Samenow, C. P. (2010). Smart phones, social networking, sexting and problematic
 217

sexual behaviors—a call for research. Sex Addict Compulsivity, 17(4), 241-246.

Weiss, R., & Schneider, J. P. (2006). Untangling the web: Sex, porn, and fantasy obsession in

the internet age. New York, NY: Alyson Publications, Inc.

Wetterneck, C. T., Burgess, A. J., Short, M. B., Smith, A. H., & Cervantes, M. E. (2012). The

Role of sexual compulsivity, impulsivity, and experiential avoidance in Internet

pornography use. Psychological Record, 62(1).

Winkler, A., Dorsing, B., Rief, W., Shen, Y., & Glombiewski, J. A. (2013). Treatment of

Internet addiction: a meta-analysis. Clin Psychol Rev, 33(2), 317-329. doi:

10.1016/j.cpr.2012.12.005

Winters, J. (2010). Hypersexual disorder: a more cautious approach. Arch Sex Behav, 39(3), 594-

596. doi: 10.1007/s10508-010-9607-2

Winters, K. C., Stinchfield, R. D., & Fulkerson, J. (1993). Toward the development of an

adolescent gambling problem severity scale. Journal of Gambling Studies, 9(1), 63-84.

Wolak, J., Mitchell, K., & Finkelhor, D. (2007). Unwanted and wanted exposure to online

pornography in a national sample of youth Internet users. Pediatrics, 119(2), 247-257.

doi: 10.1542/peds.2006-1891

Wolfling, K., Buhler, M., Lemenager, T., Morsen, C., & Mann, K. (2009). [Gambling and

internet addiction: review and research agenda]. Nervenarzt, 80(9), 1030-1039. doi:

10.1007/s00115-009-2741-1

Wong, C. C., Mill, J., & Fernandes, C. (2011). Drugs and addiction: an introduction to

epigenetics. Addiction, 106(3), 480-489. doi: 10.1111/j.1360-0443.2010.03321.x

Wood, R. T. (2008). Problems with the concept of video game “addiction”: Some case study

examples. International Journal of Mental Health and Addiction, 6(2), 169-178.

 218

Yadav, P., Banwari, G., Parmar, C., & Maniar, R. (2013). Internet addiction and its correlates

among high school students: A preliminary study from Ahmedabad, India. Asian journal

of psychiatry, 6(6), 500-505.

Yau, Y. H., Crowley, M. J., Mayes, L. C., & Potenza, M. N. (2012). Are Internet use and video-

game-playing addictive behaviors? Biological, clinical and public health implications for

youths and adults. Minerva psichiatrica, 53(3), 153.

Young, K. (1998). Internet addiction: The emergence of a new clinical disorder.

CyberPsychology & Behavior, 1(3), 237-244.

Young, K. (1999). Internet addiction: Evaluation and treatment. Student British Medical Journal,

7, 394–436. doi: 10.1136/sbmj.9910351

Young, K. S. (1996). Internet addiction: The emergence of a new clinical disorder. Paper

presented at the 104th annual meeting of the

American Psychological Association, Toronto, Canada. Internet retrieved from

Young, K. S. (2001). Tangled in the Web: Understanding cybersex from fantasy to addiction.

New York, NY: 1st Books Library.

Young, K. S. (2007). Cognitive behavior therapy with Internet addicts: treatment outcomes and

implications. Cyberpsychol Behav, 10(5), 671-679. doi: 10.1089/cpb.2007.9971

Young, K. S. (2011). CBT-IA: The first treatment model for Internet Addiction. Journal of

Cognitive Psychotherapy, 25(4), 304-312. doi: 10.1891/0889-8391.25.4.304

Young, K. S., Griffin-Shelley, E., Cooper, A., O'mara, J., & Buchanan, J. (2000). Online

infidelity: A new dimension in couple relationships with implications for evaluation and

treatment. Sexual Addiction & Compulsivity: The Journal of Treatment and Prevention,

7(1-2), 59-74.
 219

Yu, H., Zhao, X., Li, N., Wang, M., & Zhou, P. (2009). Effect of excessive Internet use on the

time–frequency characteristic of EEG. Progress in Natural Science, 19(10), 1383-1387.

doi: 10.1016/j.pnsc.2008.11.015

Yuan, K., Qin, W., Wang, G., Zeng, F., Zhao, L., Yang, X., . . . Tian, J. (2011). Microstructure

abnormalities in adolescents with internet addiction disorder. PLoS One, 6(6), e20708.

doi: 10.1371/journal.pone.0020708

Zhang, H. X., Jiang, W. Q., Lin, Z. G., Du, Y. S., & Vance, A. (2013). Comparison of

psychological symptoms and serum levels of neurotransmitters in shanghai adolescents

with and without internet addiction disorder: a case-control study. PLoS One, 8(5),

e63089. doi: 10.1371/journal.pone.0063089

Zhang, Y., von Deneen, K. M., Tian, J., Gold, M. S., & Liu, Y. (2011). Food addiction and

neuroimaging. Curr Pharm Des, 17(12), 1149-1157.

Zhou, Y., Lin, F. C., Du, Y. S., Qin, L. D., Zhao, Z. M., Xu, J. R., & Lei, H. (2011). Gray matter

abnormalities in Internet addiction: a voxel-based morphometry study. Eur J Radiol,

79(1), 92-95. doi: 10.1016/j.ejrad.2009.10.025

Zhou, Z., Li, C., & Zhu, H. (2013). An error-related negativity potential investigation of

response monitoring function in individuals with internet addiction disorder. Front Behav

Neurosci, 7, 131. doi: 10.3389/fnbeh.2013.00131

Zhou, Z., Yuan, G., Yao, J., Li, C., & Cheng, Z. (2010). An event-­‐‑related potential investigation

of deficient inhibitory control in individuals with pathological Internet use. Acta

Neuropsychiatrica, 22(5), 228-236. doi: 10.1111/j.1601-5215.2010.00444.x

Zimmerman, M. (2011). The conceptual evolution of DSM-5. American Journal of Psychiatry,

168(10), 1122-1122.
220