Childhood traumas and addiction

CHAPTER 1 INTRODUCTION

TRAUMA

Traumas are often thought of as difficult-to-manage events that are psychologically exhausting for the individuals who experience them. (Briere and Scott, 2006; Straussner and Calnan, 2014). For post-traumatic stress disorder (PTSD) and acute stress disorder, she identified the causative factors for the traumatic event as: actual or threatened death, exposure to or witnessing sexual abuse through serious injury or direct experience, such an event from a close friend or family member. repeated exposure to distressing details about learning or traumatic events (not through electronic media, television, movies, or pictures unless work-related). DSM-5 (American Psychiatric Association, 2013), Individuals’ reactions to traumatic stressors vary; some develop severe trauma reactions and PTSD from the experience, while others have little reaction when exposed to the same event. Various factors such as the pre-traumatic characteristics and experiences of the individual, the nature and severity of the traumatic event, individual perceptions and post-traumatic experiences interact and contribute to the development of the trauma response (Straussner & Calnan, 2014). In fact, most individuals experience a traumatic stressor (56%) throughout their lives, and few (8%) develop PTSD (Kessler et al, 1995). Individuals experiencing traumatic stressors may experience chronic and pathological or delayed responses. Apart from this, after being exposed to a potentially traumatic event, these individuals can display resilience and continue their lives in a healthy way (Bonanno, 2004). Individuals may experience acute stress disorder that resolves within a month, develop more severe PTSD, or develop other disorders and symptoms such as depression, anxiety, dissociation, and substance use (Kolk, 2005; Wiechelt, 2014; Wiechelt & Gryczynski, 2012). To say that traumas experienced in childhood are associated with substance use disorders (Zhang et al., 2020) and behavioral addictions such as gambling (Horak et al., 2020), internet use disorder (Grajewski and Dragan, 2020; Kircaburun et al., 2019). possible (Dalbudak et al., 2014; Evren et al., 2019).

DEPENDENCE

TDK explained addiction as a state of being dependent. Another definition for addiction was made by the Who as “a set of psychological, behavioral and cognitive phenomena in which a substance or type of substance takes precedence over its previously valuable behaviors” (2018). Addiction is considered as a brain disease and includes concepts such as “tolerance, withdrawal, unsuccessful quit attempts, continuing to use despite harm, desire to use, spending most of the time, loss of control” (Ögel, 2017), (Hollander, 2012) . Although taking substances from the outside is the most common thought that comes to mind for addiction, behavioral disorders such as gambling, sex and the internet are among the factors that cause addiction by affecting the reward mechanism system (Greenfiel, 1999), (Ögel, 2017), (Griffiths, 2000).

CHAPTER 2

2.1. SECTIONS AFFECTED BY TRAUMA

2.1.1. COGNITIVE IMPACTS

He evaluated how the child made sense of traumatic experiences by looking at the child’s awareness in the cognitive developmental stage. He believes that Piaget’s understanding of egocentrism is the biggest factor in translating the child’s causality of events. Therefore, children are likely to blame themselves for their victimization, and distressing events may cause them to fear a repeat of these events. Victims may develop defenses against traumatic memories and thoughts. Children and adolescents can use various defensive functions to avoid thinking about a traumatic event and gain dominance or control over the event. This can also cause memory impairment. This, in turn, can affect intellectual functioning or the ability to perform in the present or think about the future (Mowbray, 1988). Traumatized children may experience intolerable, intrusive thoughts or images. Generally, while avoiding situations, people or objects that remind them of a particular event, they consciously try to suppress them (Pynoos and ARK., 1987; Terr, 1984). Using a variety of defenses to forget the event or avoid reminders can help guard against the overwhelming feelings of helplessness that are often the core experience of traumatic situations (Van der Kolk, 1987). She recorded the defenses of internalizing anger and identifying with aggressors in the case of traumatized boys (Pynoos & Eth, 1984); he observed that girls internalize hopelessness and helplessness and identify with the victims (Green, 1985; Terr; 1985; Wohl & Kaufman, 1985).

2.1.2. SENSORY EFFECTS

Most researchers agree that children respond to stress in one of two ways after trauma: either in an overreactive mode with anxiety and hyperactivity, or in an overreacting and withdrawing mode, both socially and emotionally (Horowitz, 1976; van der Kolk, 1988; Zimrin, 1986). For example, traumatized children have been observed to exhibit emotional lability (Nurcombe, 1986; Simonds & Glenn, 1976); These children are more likely to express feelings of anger and irritability (Pynoos & Nader, 1988; Pynoos et al., 1987); and “their ability to regulate emotions is reduced” (van der Kolk, 1987). Similarly, it has been observed that they restrict their emotions or show an inability to express and experience their emotions (Doyle & Bauer, 1988; Green, 1985; Holaday, Armsworth, Swank, & Vincent, 1992).

2.1.2. EMOTIONAL REACTIONS

Numerous emotional responses have been reported from studies of children experiencing various forms of trauma. It has been observed that traumatized children generally show a high sense of vulnerability and sensitivity to environmental threat. That is, they tend to re-experience events emotionally, both from reminders of the event and from intervening thoughts or images of the event (Rosenheck & Nathan, 1985; van der Kolk, 1987b). They found that these children and adolescents have lower tolerance for stress and may feel more overwhelmed overall (Holaday et al., 1992). The child’s level of development at the time of trauma appears to be an important factor in determining the emotional response. For example, children who were abused before the age of two showed anger and sadness until the age of six; Children aged four to six years exhibited irritability, anxiety, strain, and withdrawal when abuse occurred (Erickson & Egeland, 1987; Howes & Espinosa, 1985). However, as discussed in the following section, the diversity of responses to trauma in general is similar regardless of the triggering event. In these children, reactions such as depressive reactions, excessive crying, grief and anhedonia were detected (Milgram et al., 1988).

2.1.3. CRIME AND SHAME

Terr (1984) and Zimrin (1986) found that the children they studied experienced extreme guilt and shame from experiencing difficulties that others did not experience. In addition, traumatized children evaluated their behavior in these situations harshly and experienced shame and self-blame (Holaday et al., 1992; Terr, 1984; Zimrin, 1986). These children have experienced feelings of distress, helplessness, and powerlessness. When analyzing the drawings of traumatized children, they stated that the drawings “reflect feelings of helplessness, powerlessness, fragmentation, depression, anger and anxiety”. It has been observed that these children avoid social isolation symptoms, lack of confidence, and general fear of interpersonal contact. (Wohl & Kaufman, 1985), Other researchers (Milgram et al., 1988; Pynoos et al., 1987; Zimrin, 1986) stated that frightening thoughts about the event can immediately reveal feelings of anxiety, inability to relax, helplessness, hopelessness, and fear. . Holaday et al. (1992) stated that passivity in decision-making may result from a sense of powerlessness to affect the lives of traumatized children.

2.1.3. SELF PERCEPTIONS

Many studies have documented changes in self-perceptions or feelings towards self among traumatized children and adolescents. These include low self-esteem, poor self-concept, and negative body image (Kinard, 1980; Oates et al., 1985; Tong et al., 1987). Lack of self-confidence has also been documented in various trauma groups (Armsworth & Turboff, 1990; Holaday et al., 1992). Other research has found that traumatized children feel worthless and believe they deserve their destiny (Doyle & Bauer, 1988; Terr, 1988; Zimrin, 1986). It has been observed that traumatized children develop an extreme sense of vulnerability and sensitivity to environmental threat. It has been stated that these feelings arise from internalized thoughts and images as well as physical reminders. (Rosenheck and Nathan, 1985; van der Kolk 1987). Feelings of apathy, withdrawal, and low motivation have also been reported in these children, which may be evidence of resignation to a perceived inability to control events (Eth & Pynoos, 1984; Mowbray, 1988). Fears and feelings of vulnerability are not limited to children’s personal safety. Extreme fear and concern for the safety of family members has been documented by Pynoos et al. (1987). Many behavioral response patterns following traumatic events have been documented. It has been observed that traumatized children are more likely to display aggression towards their peers (Burke et al., 1982; George & Main, 1979; Hoffman-Plotkin & Twentyman, 1984), parents, teachers, and authority figures. (Friedrich, 1987; Kinard, 1980); These children may be violent towards animals (Friedrich et al., 1988; Friedrich and Reams, 1987). In addition, they have a tendency to harm themselves more than their peers (Green, 1983; Zimrin, 1986) and may show extreme adjustment difficulties (Farber & Joseph, 1985). They are more likely to become chemically dependent (Cavaiola & Schiff, 1988); they are likely to engage in antisocial or criminal activities (Frederick, 1985; McCormack et al., 1986; Shore, Tatum et al., 1986); exhibiting intergenerational abuse (Gelardo & Sanford, 1987); and prostitution (James & Meyerding, 1977) and illegal behavior (Rimza & Berg, 1988).

2.1.4. PHYSIOLOGICAL-SOMATIC EFFECTS

Van der Kolk (1988) stated that trauma affects both the psyche and the body, and most PTSD symptoms are caused by physiological and neurochemical changes. According to Van der Kolk (1987b), traumatized people are afraid to “get into their own minds” to cope with the memories, fears, terror, or effects of the traumatic event, and may therefore experience the bodily manifestations of these traumas as a means of protection. This, in turn, results in multiple bodily outputs triggered by physiological or neurochemical changes in the brain (van der Kolk, 1984).

CHAPTER 3

3.1. SUBSTANCE ADDICTION

Alcohol, tobacco, heroin and many other drugs can be found in our society. While illness, death, low productivity, and crime are associated with drug addiction, it has an overall immeasurable emotional and social cost. Psychologists and psychiatrists define addiction as a neuropsychiatric disorder characterized by a recurrent desire to continue despite harmful consequences. (Goldstein and Volkow, 2002). Concrete diagnostic criteria for substance abuse (or drug addiction (Camí J, Farré M 2003)) are set in the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) or the International Classification of Diseases and Related Health Problems (ICD-10) and are used to diagnose addiction and It is widely used to evaluate treatment.

Addiction can be defined as the loss of control over drug use or the behavior of seeking and taking drugs despite negative consequences (Nestler, 2001). Substance abuse (or drug addiction) is a neuropsychiatric disorder characterized by a recurrent urge to continue using the substance despite harmful consequences. (Goldstein and Volkow, 2002). This drug-seeking behavior is associated with craving and loss of control. (Shaffer et al., 1999). Addiction results from acts of drug use and often requires repeated exposure. This process is strongly influenced by both a person’s genetic makeup and the psychological and social context in which drug use occurs.

DSM-V – 2013 In general, the diagnosis of a substance use disorder is based on a pathological pattern of behavior related to substance use.

Criterion A: Development of a substance-specific syndrome due to recent ingestion of a substance.

Criterion B: The changes can be attributed to the physiological effects of the substance on the central nervous system.

Criterion C: The substance-specific syndrome causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Criterion D: Symptoms are not attributable to another medical condition and are not better explained by another mental disorder.

3.2. DIAGNOSIS OF SUBSTANCE ADDICTION

In general, drug addiction or substance use disorder can be diagnosed after thorough evaluation by a clinical psychologist, psychiatrist, or licensed alcohol and drug counselor. Current diagnostic criteria are included in the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) (DSM V, 2013). These include:

① Taken in larger quantities or over a longer period of time than intended;

② A persistent desire or unsuccessful effort to reduce or control the use of the drug/substance;

③ A lot of time is spent on activities necessary to obtain and use drugs/substances or recover from their effects;

④ Craving or a strong desire or urge to use the drug/substance;

⑤ Repetitive use resulting in failure to fulfill important role obligations at work, school or home;

⑥ Continuing to use despite persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of drugs;

⑦ Giving up or reducing significant social, occupational or recreational activities due to drug/substance use;

⑧ Repetitive use, even in situations where it is physically dangerous;

⑨ Continuing drug/substance use despite knowledge of a likely, persistent or recurrent physical or psychological problem that is likely to be caused or exacerbated by the drug;

⑩ Tolerance defined by either: (a) intoxication or the need for a markedly increased amount of drug/substance to achieve the desired effect, (b) markedly diminished effect with continued use of the same amount of drug/substance;

⑪ Withdrawal as manifested by any of the following: (a) the characteristic withdrawal syndrome for the drug/substance, (b) the drug/substance taken to alleviate or prevent withdrawal symptoms.

These 11 criteria can be subdivided into impaired control over the substance (criterion 1-4), social impairment (criterion 5-7), risky use (criterion 8-9) and pharmacological criteria (criterion 10-11). It should be noted, however, that different types of drugs meet different sets of withdrawal criteria, and therefore specific diagnoses should refer to drug-specific sets of withdrawal criteria.

CHAPTER 4

4.1. SUBSTANCE ADDICTION AND CHILDHOOD TRAUMA

There is ample evidence to support that exposure to early childhood and adolescence trauma is strongly associated with substance abuse in adulthood and may contribute as a risk factor for addiction later in life (Kendler et al., 2000; Molnar et al., , 2001; Nelson et al., 2006; Sinha, 2001, 2008). Exposure to stress during childhood and adolescence may alter the development of brain regions responsible for regulating emotional and behavioral stress responses, decision making, reward behaviors, and impulsivity, including the prefrontal cortex (Blanco et al., 2015; Heinrichs, 2005; McCrory et al. , 2012; Sinha, 2008). There may also be interactions between childhood trauma and lack of parental or social support, maladaptive coping skills, and daily stress levels that contribute to drug addiction later in life (Sinha, 2001). Trauma experienced in adulthood is also associated with the risk of substance abuse. For example, cocaine-dependent individuals report significantly more types of lifetime trauma than cocaine-dependent individuals (Afful et al., 2010). In addition, studies (Miranda et al., 2002) have also revealed that 60-70% of women enrolled in substance abuse treatment report a history of partner violence in which substances can be used as a coping method (Lincoln et al., 2006). However, there is solid evidence of an association between war-related post-traumatic stress disorder (PTSD) and subsequent substance abuse (Bremner et al., 1996; Davis and Wood, 1999; McFall et al., 1991; Seal et al. , 2012). In addition, PTSD and substance use disorder comorbidity is extraordinarily high (Brady et al., 2004), especially opioid addiction (Fareed et al., 2013). Traumatic events can trigger chronic stress, as evidenced by (American Psychiatric Association, 2013; Reddy, 2013), for which it can often be used to escape from distressing emotions and traumatic memories (Brady et al., 2004). This hypothesis can be extended to include trauma survivors who recover from trauma without a clinical diagnosis of PTSD and then use it to cope with non-traumatic distress in daily life, leading to a cycle of addiction (Bremner et al., 1996; Charney et al., 1993). ).

CHAPTER 5

5.1. SUBSTANCE ADDICTION TREATMENT

CBT for substance abusers encompasses a variety of interventions emphasizing different goals. This section covers individual and group treatments, including motivational interventions, motivational interviewing, CBT, and related interventions that focus on functional analysis. (Kathryn et al., 2010).

5.2. MOTIVATIONAL INTERVENTIONS

At the beginning of considering treatment, motivation for treatment and the possibility of adherence to treatment should be considered. Motivation development techniques have been created and tested to address motivational barriers to change. Motivational interviewing (Miller WR and Rollnick S, 2002) is an approach based on adherence to a wide variety of other disorders and behaviors, including application to targeting ambivalence to behavior change relative to drug and alcohol use, and then applying motivation and increasing adherence to CBT for anxiety disorders (Merlo et al., 2009; Westra et al., 2009). Treatments based on the motivational intervention model are used as stand-alone interventions and in conjunction with other treatment strategies for substance abusers. A meta-analytic review of interventions based on motivational interventions found similar efficacy in comparisons of effect sizes and active treatment between studies in the small to medium range for alcohol and medium range for drug use compared with placebo or untreated control (Burke et al., 2003). Motivational interventions are typically delivered in an individual format (although group formats are also used), usually consisting of a short treatment episode. More efficacy can be achieved when higher doses of therapy are used (Burke et al., 2003).

5.3. MOTIVATIONAL INTERVIEW TECHNIQUES

Monitoring use is another important technique and an ongoing part of the treatment procedure. It serves two purposes: first, the patient gains insight into their own internet behavior, and second, it serves as a reminder of progress (or lack of progress) for patients. Therefore, all patients keep a diary to monitor their use during treatment. Treating therapists state that monitoring use is effective for internet addiction. Third, functional analysis aims to identify the antecedents (risk factors) for behavior, actual behavior and its consequences. Therapists think that the functional analysis technique can be used for internet addiction, but they state that the behavioral sequence can be followed without using the full, time-consuming functional analysis form, as the risk factors and consequences are clarified and are taken care of from the beginning of the treatment (Rooij et al., 2010).

Setting Goals for Treatment: Gaining Control, Reducing Use, and Learning to Fill Leisure. All patients share the same global goal: They want to regain control of their Internet use. For most patients, internet use has become a strong habit that either takes up too much free time (and for one patient, time at work) or has other negative effects. Therefore, the main goal for most patients is to reduce the time spent on their favorite internet application. Among therapists, one of the main problems with goal setting is the issue of “withdrawal” versus controlled use. Since internet use is a necessary component of daily life, most patients seek to reduce their use of their problematic practices or stay away from the internet; Complete abstinence from internet use is not the goal. If patients are successful in reducing the time spent on the Internet, the patient is immediately given a large amount of time, which leads to a second treatment goal: it is important to learn to satisfactorily evaluate and structure leisure time so as not to become bored and re-enter the Internet intensively. This goal includes finding new activities that do not involve the internet and have more constructive payoffs in terms of combating loneliness and other consequences of an unstable lifestyle (dance lessons, resuming an old sport). For some patients, this also means that they need to develop their social skills to deal with new social encounters and ‘real life’ contacts. As mentioned earlier, excessive internet use was not actually a problem for some patients. In these cases, alternative goals were determined by therapists (Beard & Wolf, 2001). Change in Planning: Patients Are Creative in Self-Control, But Abstinence Is Undesirable. Therapists state that patients are creative in finding measures to control their own behavior. Examples include: deciding what to do before turning on the computer, removing automatic notifications of new emails, grouping emails into groups and not replying to irrelevant ones, sending do not disturb messages on social networking sites, using a laptop instead of a computer (this is more annoying over time), blocking the credit card and tracking the time spent on behavior using a stopwatch. For example, one patient unplugged the power cord from the computer after using it and gave it to his girlfriend to help control her behavior. For many patients, the best intervention seems to be the simple act of monitoring usage. An interesting approach used by some therapists was to have an internet-free day as a way for the patient to get used to the idea of ​​filling their spare time with activities other than internet use. Unfortunately, patients were less happy with this approach. Two of them even refused to try this option. Finally, therapists note that most patients have some form of overconfidence in setting goals that they often have to set during treatment because they are unattainable. The main reason for this is that internet use is more necessary for daily functioning than patients initially assumed (Miller and Rollnick., 2002).

5.4. COGNITIVE AND MOTIVATIONAL STRATEGIES

Once high-risk situations and events are identified (including internal cues such as people and places and changes in affect), these events can be directed to change the likelihood of encountering them (such as rehearsing non-drug alternatives by providing alternative non-drug activities or sober activities). In addition to motivational and cognitive interventions in order to increase motivation for these alternative activities, efforts can be made to reduce cognitions that increase the likelihood of drug use. In addition to the elements of assessment, objective presentation of information, and explanation and discussion of ambivalence about drug abstinence, broader cognitive strategies, including rationalizing use, may target substance abuse-specific cognitive distortions (e.g. I will only use this once). , ”’One drink won’t hurt me””It was a bad day, I deserved it”) and don’t give up (e.g. ”Even if I try” ”I’ll always be an addict”). In such situations, obtaining evidence from the patient that these thoughts are correct can help identify alternative assessments that may be more congruent and better reflect the patient’s experience. Similarly, providing psychoeducation about the nature of such thoughts and the role they can play in recovery can help the patient become aware of how such thought patterns contribute to the maintenance of the disorder. As with other disorders, rehearsal of cognitive restructuring in the context of drug cues can increase the usability of these skills outside of the treatment setting (Otto et al., 2007). As part of cognitive restructuring, expectations or beliefs about the consequences of use are another important target for intervention. It has been widely observed that patients maintain a belief that the use of a particular substance will help some problematic aspects of their life or particular situation. For example, a patient may think that a family vacation without alcohol will not be enjoyable. Similar to cognitive restructuring techniques, evaluating evidence for expectations and designing behavioral experiments can be used to target this issue. In this case, the patient will be encouraged to avoid drinking at the holiday party and to evaluate how fun the event was. In addition, the patient can evaluate evidence from past vacations to compare the consequences and benefits of alcohol use in these settings (Kathryn et al., 2010).

5.5. RECURRENCE PREVENTION AND OTHER TREATMENTS

Another well-researched cognitive behavioral approach to drug use has emphasized a functional analysis of cues to drug use and the systematic training of alternative responses to these cues. The relapse prevention approach focuses on identifying and preventing high-risk situations (for example, favorite bars, friends using) in which the patient may be more prone to substance use (Marlatt and Gordon, 1985). Relapse prevention techniques involve questioning the patient’s perceived expectations. The positive effects of use and psychoeducation are within the scope of the techniques to help the patient make a more informed choice in the threatening situation. A meta-analysis examining the effectiveness of relapse prevention in 26 studies examining alcohol and drug use disorders, as well as smoking, a small effect of relapse prevention in reducing substance use (r 5 0.14), but a large effect for improvement overall (r 5 0.48) (Irvin et al., 1999). In addition to participating in functional cues for drug use, similar CBT strategies have been developed, which may include broader psychoeducation, cognitive reassessment, skills training, and other behavioral strategies. Individual CIS packages vary in the degree to which each of these components is used. For example, a cognitive-behavioral intervention for cocaine addiction developed by Carroll (Carroll, 1998) includes components of functional analysis, behavioral strategies to avoid triggers, and improve problem-solving, drug rejection, and coping skills. Evidence for the efficacy of CBT for substance abusers is supported in meta-analytical reviews with low-mid-range effect size estimates using heterogeneous comparison conditions (Dutra et al., 2008) and large effect sizes compared to untreated control groups.

CHAPTER 6

6.1. INTERNET ADDICTION

“Internet addiction is a broad context, addiction encompasses many behavioral and impulsive control problems. For example, internet addiction, internet impulse behavior, information addiction, computer addiction etc.” They defined it as (Armstrong, 2001). However, they preferred the term pathological internet use instead of internet addiction (pathological internet use); They claimed that the term addiction is the psychological and physical dependence of an organism on the use of a chemical or narcotic substance (Davis, 2001). They defined Internet addiction as: “A person’s excessive use of the Internet caused by a mental and behavioral disorder, where it includes a strong desire to stop reuse of the Internet or reduce Internet withdrawal. Similarly, it may be associated with mental and physical symptoms” (Tao R, et al., 2008). He defines Internet addiction as “a chronic or cyclical obsession that creates tensions and tolerances that increase the time spent on the Internet, while creating an irresistible desire to reuse, resulting from repeated use of the Internet” (Yang, 2008). Internet addiction includes psychological and physical addiction. As a result of this irrational overuse behavior, internet addiction can eventually lead to personal, social and psychological damage along with somatic symptoms”. These two definitions are both comprehensive definitions of internet addiction and are widely used. Internet addiction can be divided into six types: (1) online gaming addiction, (2) cyber-relational addiction, (3) cyber-sexual addiction, (4) information overload, (5) cyber impulse action, and (6) computer technology addiction. .

6.2. DIAGNOSIS OF INTERNET ADDICTION

Young (Young KS, 1996). According to 10 criteria for pathological gambling in DSM-IV, eight questions specific to internet addiction were determined:

① Do you feel preoccupied with the Internet (think previous online activity or anticipate next online session)?

② Do you feel the need to use the internet in increasing amounts to ensure your satisfaction?

③ Have you made repeated unsuccessful attempts to control, reduce or stop Internet use?

④ Do you feel restless, depressed or irritable when trying to reduce or stop Internet use?

⑤ Do you stay online longer than originally intended?

⑥ Have you endangered or risked losing a significant relationship, job, education or career opportunity because of the internet?

⑦ Have you lied to family members, therapists or others to hide the extent of your dependence on the Internet?

⑧ Do you use the Internet as a way to escape from problems or to get rid of a dysphoric mood (eg feelings of helplessness, guilt, anxiety, depression)?

Patients were considered “addicted” when they answered “yes” to five (or more) of the questions and their behavior could not be better explained by a Manic Episode. The cut-off score of “five” was consistent with the number of criteria used for Pathological Gambling and was seen as a sufficient number of criteria to distinguish between normal and pathologically addictive internet use. Professor Tao Ran, who framed the “criteria for clinical diagnosis of internet addiction”, believes that criteria for determining the degree of internet addiction should be combined with the following to create a comprehensive assessment:

(1) standard disease course (eg, mean daily continuous internet use greater than 6 hours and meeting symptomatic standard reached or exceeded by 3 months);

(2) Social functioning (ie, learning, working and communication skills) is impaired due to prolonged Internet access;

(3) have demonstrated symptomatic criteria.

Specific symptom criteria include: prolonged, repetitive use of the Internet, the purpose of using the Internet for learning and non-studying, or not helping their own learning and work, according to the following symptoms:

(1) a strong desire or urge to use the Internet;

(2) whole body discomfort, irritability, inability to concentrate. Zou et al. 33. Irregular sleep and other withdrawal reactions when reducing or stopping Internet use; The withdrawal response can also be achieved through the use of other similar electronic media (television, hand game, etc.).

(3) should be facilitated by meeting at least one of the following five:

① increased use of internet time and input level to achieve satisfaction;

② difficulty controlling the start, end and duration of internet use despite repeated attempts to stop it;

③ persistent use of the Internet, regardless of obvious harmful consequences;

④ reducing or abandoning other interests, entertainment or social activities due to internet use;

⑤ using the internet to escape from problems or alleviate negative emotions (Tao R, Wang JN, Huang XQ, Liu CY, Yao SM, Xiao LJ 2008).

6.3. GAME AND INTERNET ADDICTION

It has been associated with emotional abuse and game addiction. Emotional abuse has been defined as verbal attacks on the child’s sense of worth or well-being, or any humiliating or humiliating behavior towards the child by an adult or older person (Bernstein et al., 2003) being, care, support). Past research has shown that emotional abuse is associated with various social, emotional and behavioral problems (Maguire et al., 2015). Playing games to regulate the onset of these problems and negative mood is a diagnostic criterion at this stage (American Psychiatric Association, 2013). Numerous studies have emphasized that escapism motives predict the addictive use of online games (eg, problematic and addictive internet use (Dalbudak, 2014). Gaming is a diagnostic criterion for the onset of these problems and regulating negative moods (American Psychiatric Association, 2014). 2013. Furthermore, numerous studies have emphasized that escapism motives increase the addictive use of online games (eg, problematic and addictive internet use (Dalbudak, 2014).

The Cognitive-Behavioral Model for Pathological Internet Use (Caplan, 2010) suggests that individuals with psychological problems tend to prefer online interaction, which may lead to Internet use for mood regulation. This pathway can result in inadequate self-regulation that leads to the development of pathological use of the Internet. The Person-Impact-Cognition Interaction (I-PACE) model recently reviewed by (Brand et al., 2019) claims that early childhood negative experiences are among the predisposing variables of addictive behaviors such as addictive internet use. The I-PACE model provides a framework that argues that the interaction between executive functions, such as emotional and cognitive responses to a given stimulus and reduced inhibitory control, contributes to the development of addictive behaviors. Consistent with these theoretical models, addictive use of the Internet can be viewed as a psychological mechanism for coping with the psychological pain of negative early experiences. Recent studies have shown that depression and/or anxiety (Grajewski & Dragan, 2020; Shi et al., 2020), alexithymia (Schimmenti et al., 2017), low self-esteem (Zhang et al., 2012) and emotion regulation disorder (Grajewski and Dragan, 2020; Shi et al., 2020).

The nature of online activities includes experiences that can evoke feelings of dissociation, such as not understanding how time flies, feeling like someone else, and fainting. Therefore, these reinforced dissociative experiences in the network can lead to addictive online behavior (Griffiths, 2003). Boysan et al. (2019) proposed the term “online dissociation”, which reflects the dissociation experiences experienced during online activities such as identity confusion, escaping from reality, observing reality and losing the sense of reality.

6.4. INTERNET ADDICTION TREATMENT

Setting a Starting Point: Three techniques are used to set a starting point for treatment, but not all techniques appear to be equally effective when treating internet addiction. First, treating therapists are divided on the feasibility of exercising the disadvantage/advantage balance, as it is most beneficial to people who are still considering change. In this case, most patients are already motivated to change. On the other hand, it seems beneficial for patients to write down the (long-term) disadvantages of behaviors that are more easily overlooked in conversation. Therefore, it can provide a useful starting point for the solution.

CHAPTER 7

7.1. Gambling Addiction

7.1.1. PATHOLOGICAL GAMBLING

Gambling, a common activity around the world, involves risking something of value in the hope of obtaining something more valuable. (Fauth-Bühler et al., 2017). Adult gambles without problems. In the general population, the lifetime prevalence of pathological gambling is approximately 0.4-1.0% (DSM-V). Pathological gambling can be defined as a disorder that results in frequent and repeated gambling that dominates the patient’s life in a way that damages social, occupational, financial and family values ​​and commitments (Fauth-Bühler et al., 2017). Excessive gambling was first recognized as a psychiatric disorder in the ninth edition of the International Classification of Diseases (WHO, 1977). Three years later, pathological gambling was added to the US diagnostic coding of the Diagnostic and Statistical Manual of Mental Disorders, third edition (DSM-III). The original diagnostic criteria included in the DSM-III were based on the clinical experience of several professors at the time; this emphasized damage and disruption to the individual’s family, personal or professional pursuits, and money-related matters. In this edition, gambling addiction is classified as an impulse control disorder (ICD-10). In the next edition, the criteria for gambling addiction were revised to reflect its similarity to substance abuse, such as the addition of “repeated unsuccessful attempts to control, reduce, or stop gambling” (DSM-IV). In the DSM-IV, gambling addiction is classified under the heading “Impulse Control Disorders Not Elsewhere Classified”. While the growing scientific literature on gambling addiction is revealing common elements with substance use disorders, gambling addiction has been carried along with “Substance-Related and Addictive Disorders” in the fifth revision of the DSM (DSM-V). Also, gambling addiction has been renamed “gambling disorder” in the DSM-V. Today, gambling addiction is a non-substance related disorder or behavioral addiction.

7.1.1.1. PATHOLOGICAL GAMBLING VS FUN

It is known that someone who is too involved in gambling tends to gamble pathologically. But where should we draw the line? Fong et al. (Fong et al., 2012) summarized the differences between the recreational gambler and the pathological gambler. They described two cases of gamblers;

Gambler 1: Fun Gambler

• 67 year old retired doctor who plays poker at the casino 5 times a week and up to 5 hours per game.

• Gambling limits have not been increased in the last 20 years.

• Never stayed in the casino longer than the scheduled time.

• Allocates appropriate time for exercise and family.

• Financially comfortable with a retirement account.

• The family is aware of the gambling behavior.

Gambler 2: The Pathological Gambler

• Twenty-year-old college student who gambles whenever he has money.

• Skips classes and assignments to gamble instead.

• He engages in bank fraud and steals from his girlfriend to finance gambling.

• Has attempted to quit or cut down on gambling 10 times in the last 2 years.

• Hides gambling behavior from family and friends.

• Uses money from financial aid and scholarships to gamble.

• About to be expelled from university due to bad grades and financial situation.

Compared to the first gambler, the second gambler is unable to control his gambling and experiences significant negative consequences from his gambling behavior.

7.2. DIAGNOSIS OF GAMING ADDICTION

To be diagnosed with a gambling disorder according to the DSM-V, a person must meet at least 4 out of 9 diagnostic criteria within a 12-month period. See below for the DSM-V diagnostic criteria for gambling disorder:

1. The need to gamble with increasing amounts of money to obtain the desired excitement.

2. Is restless or irritable when trying to stop or quit gambling.

3. Made repeated unsuccessful efforts to control, reduce, or stop gambling.

4. Frequent preoccupation with gambling (for example, having persistent thoughts such as reliving past gambling experiences, preventing or planning the next attempt, thinking of ways to earn money for gambling).

5. Often gambles when feeling distressed (eg helpless, guilty, anxious, depressed).

6. After losing money in gambling, he often returns to another day to seek revenge (“chasing one’s losses”).

7. He lies to hide the extent of his relationship with gambling.

8. Endangered or lost a significant relationship, job, or educational or career opportunity due to gambling.

9. Relies on others to provide money to alleviate hopeless financial situations caused by gambling.

7.3. GAMBLING ADDICTION AND CHILDHOOD TRAUMA

Gambling addiction is classified as a behavioral disorder and has some phenotypic similarities with substance use disorders. Childhood distress and life stressors are associated with an increased risk of substance use in adulthood. (Felsher et al., 2010). Certain types of childhood trauma can have varying degrees of influence on the development of certain types of behavioral addictions, such as gambling addiction. Emotional neglect and physical neglect emerged as the most frequently confirmed type of childhood trauma in gambling addicted participants, regardless of trauma severity (Felsher et al. 2010). It has been shown that the relationship between childhood trauma and problematic gambling is affected by various other factors such as stress (Bergevin et al., 2006; Lane et al., 2016; Scherrer et al., 2007).

The article “Adverse Childhood Experiences and Gambling: Results of a National Study” by Sharma and Sacco is a new review of childhood trauma and gambling. Findings from this study suggest that adverse childhood events are associated with gambling problems, among other mental health problems. Prevention and treatment efforts for children and youth who experience adverse childhood events can reduce the risk of later developing gambling problems (Wiechelt & Straussner, 2015).

7.4. GAMING ADDICTION TREATMENT

Cognitive-behavioral therapy is currently recognized as the most effective treatment for gambling disorder. This type of therapy assumes the fact that irrational thoughts linked to a person’s ability to control the game and predict victory represent the main factors determining the development and maintenance of this pathology (Korn and Toneotta, 2004). The relevant literature includes more cognitive-behavioral therapy models for gambling addiction (Roylu N and Oei TP, 2010; Disney et al., 2011; Blaszcznski and Nower, 2002; Toneatto, 2002); (Apodaca and Miller, 2003; Hodgins et al., 2001; Petry et al., 2006); conducted a comparative study of 231 compulsive gamblers, which they divided into three groups: the first group was treated using the Gambler Anonymous method, the second group was treated using GA with the help of cognitive behavioral therapy guidance, the third group participated in the GA groups and eight individual CBT sessions. Improvements were found in 59% of the participants who benefited from CBT, 39.2% of those who completed the exercises in the CBT books, and 34% of those who participated in the GA groups only (Ladouceur et al. 2002). They proposed a therapy model for gambling addiction treatment that includes the following five steps:

• Information in terms of general aspects of the game;

• Changing the gambler’s irrational beliefs with how gambling activities are conducted;

• Development of new coping skills and problem solving;

• Acquiring social skills;

• Learning some relapse prevention techniques.

recommends a cognitive-behavioral therapy group therapy protocol lasting eight sessions at a weekly frequency. The assignment of the session, which includes the protocol (Petry, 2005):

• General information, presenting the reward system for game avoidance and identifying these factors, contributing factors to the urge to play;

• functional analysis of gambling behavior;

• Increased frequency of enjoyable activities;

• Automatic management plan;

• Coping with the urge to gamble;

• Training for assertiveness and the ability to refuse play;

• Changing irrational thoughts;

• Planning for emergencies and prevention of relapse.

7.5. CIS FOR GAMBLING ADDICTION

He proposed a model in which the main components refer to the restructuring of the gambler’s environment to be less conducive to pathological gambling; Patients are first taught to identify their irrational thoughts about gambling, to understand the connection between these thoughts and pathological gaming behaviors, and to identify new coping methods (Ledgerwood & Petry, 2005), and suggested a cognitive-behavioral therapy model that includes four steps (Roylu & Oei, 2010):

• Evaluating the client’s problems and needs, training, and motivations to change dysfunctional behaviors using motivational interviewing techniques;

• Introducing the gambler to the basic strategies of cognitive-behavioral therapy used to stabilize the gambler’s compulsive gambling behavior and to minimize the negative effects in case of relapse;

• Learning some coping methods in terms of maintaining positive changes in play behavior;

• Learning strategies for maintenance of therapeutic gains and prevention of relapse.

Introduced a self-help program for gamblers consisting of the following steps. (Blaszczynsky, 2010):

• Increasing motivation to stop the game;

• Monitoring of gambling behavior;

• Controlling the urge to gamble by following relaxation techniques;

• Identifying irrational thoughts and replacing them with other rationalities;

• Prevention of relapse;

• Learning about new ways to get family support.

He proposed a different model while using an alternative to cognitive-behavioral therapy (Wulfert et al., 2003) for the treatment of gambling addiction, which includes motivational interviewing techniques, cognitive-behavioral therapy, and relapse prevention techniques. Increasing motivation when the key concepts are: it is essential to increase the motivation of the gambler to observe the product of change; motivation is a dynamic feature; and motivation is influenced by external factors, including the counselor’s behavior and attitude. (Miller & Rollnick, 2004) The advantages of cognitive-behavioral therapy are that it is a well-structured type of therapy, performed in a limited time frame, requires less cost than other types of therapy, and provides long-term results. In studies conducted so far, the success rates of this type of treatment for gambling addiction range from 36% (Sylvain et al., 1997) to 42% (Ladouceur et al., 1998); up to 72% (Tolchard et al., 2000) up to 77% (Ladouceur et al., 2003); to 49% (Petry, 2005); and 74% (Rizeanu, 2014).

Treatment of gambling disorder presents many problems, first of all, because pathological gambling has only recently been recognized as a disorder in its own right, insufficient research has been done, and there is a lack of trained professionals. It is important to provide psychological and psychiatric services in this area. In Romania, the cognitive-behavioral therapy model for gambling addiction was introduced, mainly based on cognitive restructuring techniques and with the following key objectives:

• Reducing the consequences of gambling disorders that interfere with the daily functioning of gamblers;

• prevent or reduce the risk of developing gambling addiction behavior;

• Managing the negative emotionality associated with this disorder (depression, anxiety, stress);

• Meeting the need for entertainment and developing new and pleasant recreational and social activities that do not risk having a devastating effect on the lives of the subjects.

The model includes several stages such as assessment and formulation, introduction to psychoeducation and ABCDE model, cognitive restructuring, problem solving training, assertiveness skills training, and relapse prevention. In the clinical evaluation stage, the individual’s participation in the therapeutic process is examined by increasing the motivation to change the gambling behavior and the following points are clarified (Rizeanu, 2013):

• The source of the individual’s pathological gambling problems;

• Etiological and maintenance factors;

• The extent to which subjects have access to psychological support and the effectiveness of the support they receive;

• Whether they sought treatment on their own initiative or at the request of their friends;

• How they are aware of our specialist psychological services;

• The reasons for this if they have not reached psychological support. Active listening, reflection, nonverbal communication (maintaining visual contact, clear body posture, non-evaluative facial expression, tonal consistency, etc.) and verbal communication (eg the meaning of what is said).

Dryden and Matweychuk believe that maintaining benefits from treatment requires the development of coping skills in relation to risk situations and future temptations as long as addictive behavior relapses; the authors offer the following recommendations (Dryden, 2000).

• Develop a few healthy beliefs, such as letting go of the habit of pleasing others and putting yourself first and others second;

• Create (or develop) several social interests: understand that the people around you have their own desires and goals in life and cannot always provide you with unconditional support, you should also consider how you can support and stand by them;

• Learn how to take control of your life; don’t let your addictive behaviors control your life;

• Develop a high tolerance for disappointment so that you can achieve the goals you have set for yourself;

• Be flexible to deal with the next challenges in your life;

• Learn to accept uncertainty, because we live in a world of possibilities where nothing is absolutely certain;

• Develop your creativity so you can find new ways to spend your time;

• Think logically, set short and long-term goals and consider the possible consequences of your actions;

• Learn to accept yourself unconditionally without making global judgments about who you are as a person;

• Take only limited risks to increase your chances of achieving the goals you have set for yourself;

• Adopt the philosophy of long-term hedonism, balancing between immediate gratification and long-term gratification;

• Take responsibility for your own negative emotions without attributing them to external causes;

• Adopt a healthy lifestyle with a healthy ratio of work, rest, sports and leisure activities;

• Develop a sense of humor to maintain a good temper even in the face of difficulties.

CHAPTER 8

8.1. CBT THERAPY CHILDHOOD TRAUMA

8.1.1. TRAUMA-FOCUSED COGNITIVE BEHAVIOR THERAPY

Trauma-Focused Cognitive Behavioral Therapy (Cohen et al., 2017) is an evidence-based and manual treatment for children aged 3 to 18 years who show signs of post-traumatic stress related to any traumatic event they may have experienced or witnessed. However, it is not necessary for a child to have a full diagnosis of PTSD to participate in CBT. CBT is typically given in 12 to 16-week sessions. In reviews of research on the treatment of children with symptoms of post-traumatic stress (ie, Chadwick Center for Children and Families 2004; Chadwick Center for Children and Families and Child and Adolescent Services Research Center 2018; Saunders et al., 2004; Silverman et al., 2008), CBT was the only treatment with the highest score (ie, evidence-based practice) across all reviews. Due to the positive results of CBT in children with a history of trauma and post-traumatic symptoms, wide dissemination continues across the country through various projects with different funding sources (Sigel et al., 2013). For children aged three to five years, CBT has shown effectiveness in reducing PTSD symptoms, depression, anxiety, and behavioral problems in children (Cohen and Mannarino, 1996; Cohen and Mannarino, 1997; Deblinger et al., 2011; Mannarino et al., 2012) . For this age range, CBT has also been shown to improve parenting skills and parental support of the child, and reduce parental distress (Deblinger et al., 2011; Mannarino et al., 2012). The therapeutic components of CBT include psychoeducation about trauma; parenting abilities; development of relaxation and other coping skills; emotion identification; understand the connections between thoughts, feelings and behaviors; verbalizing the child’s narrative of the traumatic event(s) witnessed or experienced and related thoughts, feelings and behaviors; gradual exposure to reminders of the traumatic event(s) to teach young people how to manage exposure to such reminders; joint caregiver-child business; and improve security/prevention skills. Most sessions are split evenly between the child and the caregiver, and the therapist conducts a single session with each person. However, some sessions are conducted as combined sessions with the entire child, caregiver and therapist. CBT is structured and focuses directly on the impact of traumatic stress. The practice is consistent with the principles of cognitive-behavioral, exposure, and parenting therapies widely accepted by mental health professionals.

CHAPTER 9

9.1. EMDR THERAPY CHILDHOOD TRAUMA

9.1.1. TREATMENT OVERVIEW

EMDR therapy is an eight-stage therapeutic approach that addresses negative life experiences that are presumed to be the basis of a wide variety of pathologies, other than those resulting from organic deficiency (Shapiro, 2001). The number of sessions and the length of the various phases depend on the complexity of the case. For example, single trauma PTSD can be successfully treated in three sessions (Wilson et al., 1995, 1997). In such cases, the anamnesis and preparation phases can be performed in the first session, and the evaluation and reprocessing phases (desensitization, placement, body scanning) can be opened in the second session and completed in the third session. The closing phase stabilizes the individual and ends the session, while the reevaluation phase initiates the session after reprocessing. For those with complex PTSD, the history-taking and preparation phases may be spread over more sessions to ensure that the case has been comprehensively evaluated and the client has sufficient determination to act to begin the procedure. Similarly, rework will require additional sessions to adequately treat multiple traumas.

The overall goal of EMDR therapy is to restore good mental health by helping clients reprocess memories of negative life experiences, resulting in spontaneous changes in emotion, cognition, physical sensations, and behavior. As illustrated in the Treatment section, standardized procedures are used to access dysfunctionally stored memories while simultaneously facilitating the information processing system by promoting internally generated associations that arise in consciousness during sequential dual stimulations of attention (visual, auditory, or tactile). This stimulation is applied by asking the client to follow a light or the clinician’s finger back and forth in horizontal sweeping movements while following their internal response. After about 30 seconds, the clinician stops the dual stimulation and asks the client to briefly report their experience, making sure that the procedure has taken place. Rather than maintaining sustained attention on the original event or attempting to reinterpret the experience that characterizes exposure-based therapies, the EMDR client often tries to “let whatever happens” and what is in consciousness.

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