Service Development for Behavioural Addictions: AIIMS Experience

Introduction

Addictive disorders have been identified as significant contributors to the global burden of disease (1). These are not only associated with the adverse health consequences such as increased morbidity and mortality, but also impact the familial, social, occupational, financial and legal domains of life. The adverse consequences associated with addictive disorders extend beyond the individual to the family and community.

Traditionally, addictive disorders have largely been attributed to the use of psychoactive substances. In fact, the terms addictive disorders and substance use disorders have been used interchangeably in literature. A psychoactive substance is a chemical that acts upon the brain, resulting in changes in perception, mood, consciousness, cognition, and/or behaviour. However, during the past two decades it has been increasingly realised that while certain addictive disorders are related to the use of psychoactive substances, there are other addictive disorders that do not include use of the psychoactive substances. These addictive disorders are known as behavioural addictions. Non-substance addictions, non-chemical addictions and process addictions are some other terms used to describe these conditions. Some of the commonly described and reported behavioural addictions in the literature include gambling disorder, internet gaming disorder, internet addiction and sexual addiction.

Prevalence of Behavioural Addictions

While the behavioural addictions have generated a considerable interest among researchers over the past few decades, there are only a few large-scale studies that have explored the prevalence of these conditions. There is a considerable variation in the reported prevalence of different behavioural addictions across studies. This difference in prevalence rates can be attributed to the differences in the study design, definition of behavioural addictions, diagnostic criteria, choice of screening instrument, and type of population studied among others. In an earlier report, the prevalence of adult gambling disorder has been found to vary from 0.1% to 2.7% (2). The proportion of persons with pathological gambling is relatively higher among college students (3). The prevalence of internet addiction among adolescents has been reported to vary from 4.0% to 19.1% (3). The reported range of internet addiction among adults is 0.7% to 18.3% (3). The prevalence rates for problematic video game playing among adolescents have been reported to vary from 4.2% to 20.0% across studies (3). There is limited literature on other behavioural addictions to make firm conclusions about their prevalence rates.

An Indian study in selected urban localities of Bengaluru reported prevalence rates of 1.3% for internet addiction (2% males and 0.6% females) and 4.1% for mobile phone overuse (5% males and 3.1% females)(4). A comparative study among medical students across three countries (including India) found 0.5 % of the students to score in the range of severe problematic internet use (5). A recent survey among the attendees of a trade promotion event found that 15% of the respondents endorsed five or more features (out of nine) of behavioural addictions related to use of mobile technology (6). Most of the Indian studies on problematic internet use have focused on the students. Table 1 presents the summary of Indian studies that have explored prevalence of internet addiction/problematic internet use among students (7-26).

Nosological Journey

The concept of behavioural addiction, while relatively new, has been documented for quite some time in the medical literature. Gambling disorder, one of the most well researched and described behavioural addictions, was first introduced in the 3rd Diagnostic and Statistical Manual (DSM-III) in 1980 (27). However, it was listed as pathological gambling under impulse control disorder. This was a reflection of the earlier conceptualization of pathological gambling as a disorder on impulsive-compulsive spectrum rather than being a clear addictive disorder. It was retained in DSM III R, DSM IV and DSM IV Text Revision (TR) as impulse control disorder (28). The International Statistical Classification of Diseases and Related Health Conditions (ICD-10) also classified pathological gambling as a habit and impulse disorder.

However, the growing body of research over the past two decades fuelled the emerging consensus that pathological gambling is closer to the addictive disorder. The behavioural addictions have made a formal debut in the most recent version of 5th edition of Diagnostic and Statistical Manual, i.e. DSM 5 (29). In fact, the DSM 5 has witnessed a paradigm shift with relabelling of the category of 'substance-related disorders' as 'substance-related and addictive disorders'. Gambling disorder is the first disorder to be listed as a behavioural addiction under this category. The upcoming revision of ICD, i.e. ICD 11 is also likely to follow the suit and introduce the behavioural addictions (30). Lack of sufficient peer reviewed evidence on other behavioural addictions has been cited as the only reason for their non-inclusion in DSM 5.

Behavioural Addictions: Proximity to Substance Use Disorders

The current conceptualisation of behaviour addictions groups these disorders closer to psychoactive substance use related addictions. Research studies have found multiple commonalties between these two sets of disorders. The co-occurrence rate of behavioural addictions and psychoactive substance use related addictions has been found to be high in clinical as well as epidemiological studies (31-33). Rapid reward discounting, poor performance on decision-making tasks, and diminished performance on tests of inhibition, cognitive flexibility, and planning tasks are cognitive deficits shared by persons with behavioural addictions as well as psychoactive substance use related addictions (2). Neurobiological studies have implicated similar brain regions (e.g. reward pathway, dorsolateral prefrontal cortex) and neurotransmitters and related enzymes (e.g. dopamine levels, platelet monoamine oxidase B activity) in emergence of both behavioural addictions and psychoactive substance use related addictions. Also, genetic studies have reported higher rates of substance use disorders among first degree relatives of persons with behavioural addictions. Finally, similar treatment approaches (pharmacological as well as non-pharmacological) have been found to be beneficial for the two sets of disorders (2).

Despite these similarities, behavioural addictions differ from psychoactive substance use related addictions on multiple accounts. Many of the bio-psycho-social underpinning related to behavioural addictions still remains largely unexplored. It is likely that despite of many commonalities between behavioural addictions and psychoactive substance use related addictions, it shall be too simplistic to see the two as a unitary concept. A better understanding of behavioural addictions consequent to ongoing research should help settle this debate in future.

Management of Behavioural Addictions

The research on management of behavioural addictions is still in its infancy. However, there is published evidence that can be used to guide clinical management of these disorders. It is recommended to follow an integrated approach that includes a mix of pharmacological and non-pharmacological interventions. The medicines that have been found to be effective in management of behavioural addictions have been summarised in Table 2.

The non-pharmacological interventions that have been explored for management of behavioural addictions include cognitive behaviour therapy, behaviour therapy, time management skills, solution focused brief therapy, and a combination of group and individual therapies. A meta-analysis on effectiveness of treatment modalities for internet addiction found psychological as well as pharmacological treatment to be beneficial in management of internet addiction (34). Indian Psychiatric Society has in recent past published guidelines on management of behavioural addictions (35). It is also important to identify and manage the co-occurring mental disorders and substance use related disorders among persons with behavioural addictions.

Addressing Behavioural Addictions in the Country: the AIIMS Initiative

The growing recognition of the behavioural addictions globally and increasing clinical queries catalysed the ongoing deliberations on setting up services for addressing behavioural addictions at the All India Institute of Medical Sciences (AIIMS), New Delhi. This led to establishment of what is arguably the first Behavioural Addictions Clinic (BAC) in the country that is aimed at addressing all types of behavioural addictions. While initiatives taken so far in this area have targeted a particular type of behavioural addiction, the BAC at AIIMS caters to all types of non-substance use-related addictive disorders. The clinic is an initiative of the Department of Psychiatry and National Drug Dependence Treatment Center (NDDTC), AIIMS, New Delhi.

The BAC is housed in the Department of Psychiatry at AIIMS, New Delhi. It is a weekly clinic, that is held in the out-patient setting on every working Saturday. The clinic is run by a team of mental health professionals that include faculty from psychiatry and clinical psychology. The clinic has witnessed a gradual but steadily increasing clinical consultations since its inception. The clinic offers comprehensive screening, assessment and management services for behavioural addictions. Another emphasis at the clinic is for assessment and management of co-occurring mental and substance use disorders among those with behavioural addictions.

The most commonly observed behavioural themes include excessive and problematic use of internet, social media platforms, internet-based games, online pornography and gambling. Almost all the cases presenting to us have experienced significant socio-occupational dysfunction. In fact, emergence of this dysfunction is the most important reason for help seeking. Some of the commonly observed dysfunctions include declining academic performance, discontinuation of studies, financial losses, and interpersonal conflicts. Presence of co-occurring mental and substance use disorders is another significant findings among these cases. While a few persons seek help on their own, majority attend the clinic on insistence and persuasion of care givers. They are mostly young school-/ college-going adolescents who actively deny their internet/smartphone use as problematic or having addiction. However, majority of the patients are male youth with age ranging between 16 and 25 years. The clinic has also witnessed consultation concerning the controversial 'Blue Whale Challenge'.

Apart from setting up clinical service, the BAC has also taken certain public health initiatives on the behavioural addictions. These include a collaboration with South East District Delhi Police to spread awareness on safe and healthy use of internet. The BAC, AIIMS is a collaborating partner of Delhi Police in this initiative targeted at the school students. Also, the BAC has contributed to the media reports on behavioural addictions aimed at increasing awareness among general public about this issue and spreading the information about the availability of such services. Additionally, the BAC has also participated in screening camps in collaboration with other medical institutes, where the visitors of the camp have been screened for presence of behavioural addictions related to use of mobile technology. Apart from this, contributions were made to the first ever consultative meeting on public health implications of excessive use of the internet, computers, smart phones and similar electronic devices organised by the World Health Organization (WHO) (36).

The BAC is also engaged in carrying out research activities on the themes related to behavioural addictions. While some of these projects have been completed others are underway. The findings from these studies have been published in peer reviewed academic journals (5, 6, 37). The clinic proposes to conduct studies on prevalence, bio-psychosocial correlates, and awareness and attitude towards the behavioural addictions. This is in keeping with the current conceptualisation of behavioural disorders as having bio-psychosocial underpinnings.

Way Ahead

The BAC at AIIMS recognises and realizes that behavioural addictions are a growing problem of public health importance. There is a need to spread awareness on presence of the problem as well as existing services for taking care of the same. The BAC aims to extend the public health campaign to a wider section of population. Also, it aims to expand research on various domains of these disorders. The clinic also aims to bring out recommendations and guidelines on prevention, screening, assessment and management of behavioural addictions. Presently, the BAC is well prepared and well placed to assume the leadership role in this area with contribution and participation of various stakeholders.