Thu

26

May

2016

Concentra to Acquire Occupational Health + Rehabilitation Inc; Will Expand Company's Health Services Division in New and Existing Markets in New England, the Mi

ADDISON, Texas--(BUSINESS WIRE)--Aug. 8, 2005--Concentra Operating Corporation ("Concentra" or the "Company") today announced that it has executed a definitive agreement to merge Occupational Health + Rehabilitation Inc ("OH+R") (OTC:OHRI), a leading occupational healthcare provider with 34 centers in 10 states, with its Concentra Health Services division. When completed, the transaction will extend the reach of Concentra's occupational health division to six new states and strengthen the presence of its existing network of health centers.

Terms of the merger agreement call for Concentra to acquire all of the outstanding common stock of OH+R for an aggregate purchase price of approximately $48.6 million plus retained cash. The purchase price will be reduced by certain outstanding indebtedness and other items. Concentra currently intends to use its unrestricted cash balances to fund the transaction and expects to complete the acquisition in the fourth quarter of this year, subject to the approval of the agreement by OH+R's stockholders and other customary conditions.

In 2004, OH+R, headquartered in Hingham, Massachusetts, reported approximately $57 million in revenue and handled approximately 508,000 patient visits. During the same period, Concentra's Health Services division reported $577 million in revenues and more than 5.9 million patient visits. Concentra's Health Services division represented 52% of Concentra's total revenue during 2004. At June 30, 2005, Concentra had 268 centers operating in 34 states. After integrating OH+R's operations, Concentra will have 294 centers that will be located in 40 states.

Commenting on the announcement, Concentra's President and Chief Executive Officer, Daniel J. Thomas, said, "OH+R's occupational healthcare centers will significantly enhance our national presence. In addition to providing centers that will be complementary to our existing operations in the states of Connecticut, Missouri, New Jersey, and Tennessee, OH+R provides us with the ability to expand into the states of Maine, Massachusetts, New Hampshire, New York, Rhode Island, and Vermont. With this transaction, not only will we be able to offer existing customers of OH+R a continuation of the exceptional levels of service they have received, but we will also be in a position to offer Concentra's national and regional clients more locations where they can access our well-recognized workers' compensation and occupational healthcare services. The addition of OH+R will further enhance our stature as the largest provider in the country and will provide us with roughly a 10% share of the national workplace injury market."



John C. Garbarino, President and Chief Executive Officer of OH+R, added, "In the Heroin Treatment specialized world of occupational health, we have known and developed relationships with Concentra - the industry leader - for more than a decade. We share a similar culture built upon commitment to quality patient care and client service, and we understand that it Opioid Addiction is our talented and dedicated staff that drive Opioid Medications our success. I am particularly excited about this combination and what it means for all of us at OH+R."

Reflecting on the announcement, Keith Newton, President of Concentra Health Services, stated, "We are delighted to expand our service capabilities to develop a stronger presence and to better serve local employers. OH+R has been committed to providing the most comprehensive medical treatment for injured employees - a treatment philosophy that parallels that of Concentra. With additional scale that will be created by this transaction, we not only expand our role as the nation's largest occupational healthcare provider, we also strengthen our competitive position in the northeastern region of the country."



Concentra Operating Corporation, a wholly owned subsidiary of Concentra Inc., is the comprehensive outsource solution for containing healthcare and disability costs. Serving the occupational, auto and group healthcare markets, Concentra provides employers, insurers and payors with a series of integrated services which include employment-related injury and occupational health care, in-network and out-of-network medical claims review and repricing, access to specialized preferred provider organizations, first notice of loss services, case management and other cost containment services. Concentra provides its services to approximately 136,000 employer locations and 3,700 insurance companies, group health plans, third-party administrators and other healthcare payors. Through its health centers, Concentra has approximately 680 affiliated primary-care physicians. The Company also operates the FOCUS network, a national workers' compensation provider network that includes 544,000 individual providers and over 4,400 acute-care hospitals nationwide.

This press release contains certain forward-looking statements, which the Company is making in reliance on the safe harbor provisions of the Private Securities Litigation Reform Opioid Medications Act of 1995. Investors are cautioned that all forward-looking statements involve risks and uncertainties, and that the Company's actual results may differ materially from the results discussed in the forward-looking statements. Factors that could cause or contribute to such differences include, but are not limited to, the potential adverse impact of governmental regulation on the Company's operations, changes in nationwide employment and injury rate trends, interruption in its data processing capabilities, operational, financing and strategic risks related to the Company's capital structure, acquisitions and growth strategy, possible fluctuations in quarterly and annual operations, possible legal liability for adverse medical consequences, competitive pressures, adverse changes in market conditions for the Company's services, and dependence on key management personnel. Additional factors include those described in the Company's filings with the Securities and Exchange Commission.



Concentra Operating Corporation

Daniel J. Thomas, 972-364-8111

or

Thomas E. Kiraly, 972-364-8217

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Wed

25

May

2016

Behavioral addictions: an overview. - Free Online Library

Rapid advances in technology, overstimulation and the subsequent

diminishing effort towards emotional growth and awareness are making

some individuals more susceptible to "out of control

behaviors." The concept of self medicating with substances is

well-known, but how about self medicating with behaviors? 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.

The word addiction can be defined in many ways. Traditionally, the

dependence on exogenous drugs of abuse causing neuroadaptation has

served as a primary definition. But some would argue that specific

behaviors in a vulnerable individual can also lead to an addictive

state. Critics, however, report that the inclusion of behavioral

addictions may "medicalize" bad behaviors and blur the line of

demarcation between an excessive bad behavior and a true addiction.

There is a distinct possibility that adding many more disorders to the

Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition

(DSM-IV; APA 2000) may effectively dilute pathological behavior and

pathologize variants of normative behavior, subsequently increasing the

general public's suspicion of the validity of psychiatric

disorders. If everyone meets criteria for a disorder, is there really an

effective diagnostic system?



There is great debate over how to classify nonsubstance addictions

within the diagnostic classification of mental disorders. Many have

suggested that the constellation of symptoms and impairments in

functioning associated with "behavioral disorders" are simply

symptoms of other disorders and do not have enough in common to warrant

their own category let alone individual disorder status such as

"sex addiction," "compulsive shopping" and

"pathological gambling." However, recent findings are shedding

new light on the shared attributes of this class of impulse control

disorders and forging a better understanding of how they develop.

Historically, both the construction and development of DSM criteria

in the field of psychiatry and the boundaries between normative behavior

and disordered or abnormal behavior have been riddled with controversy,

with significant research findings ultimately defining the criteria for

a disorder.



NEUROBIOLOGICAL MECHANISMS OF ADDICTION



When reviewing the neurobiological correlates of addiction, it is

usual to start with the brain reward circuitry. This region is

significant for understanding the origins of how addictive related

behaviors may emerge. Motivation is an ancient and evolutionarily

conserved phenomenon. As a species, the genetic drive for survival

requires incentivizing the acquisition of vital resources such as food,

water, shelter and sex. In an age where resources were scarce and the

availability of these assets was the key to life or death, strongly

imprinting the location and availability of resources and mates ensured

prosperity.



Over time, the brain has developed mechanisms to reinforce these

behaviors; this neural circuit has been defined as the mesolimbic reward

system (Di Chiara 1998). The neuropharmacological mechanisms that

mediate this circuit appear to involve several different

neurotransmitter systems collectively; however the dopaminergic and

endogenous opioid systems appear to be the most influential in

regulating "rewarding behaviors." Addiction has traditionally

been defined as dependence on a drug that can pharmacologically

"hijack" reward circuitry mediated by its effect on the brain

and body (the neuromimetic effect of drug administration). However, it

could be suggested that any stimuli (drug or behavior) that transforms

basic drives required for survival (natural rewards like feeding,

thirst, reproduction) into actions of craving/seeking behaviors or

repetitive out-of-control behaviors may make it plausible that addiction

can occur even in the absence of drug taking. Thus, behavioral

addictions may share many of the same pathways associated with chemical

dependence. A growing theory is that if one can alter neurocircuitry

with illicit drugs and pharmacology, then one can alter it with behavior

as well (Holden 2001).



In addition to similarities in clinical overlap, the common

currency of both drug and behavioral addiction is learning and memory

(Hyman 2005). Cravings are triggered by memories, affective states and

situations associated with both out-of-control behaviors and drug use

(Martin & Petry 2005). Cue-induced behaviors likely evolved along

side the pleasure system to provide a memory of both rewarding as well

as aversive stimuli. These signals would both help drive behaviors that

would benefit us and avoid circumstances that would prove detrimental.

In the case of addictions, cues can be so strong that they reinforce

particular behavioral patterns despite their negative consequences.

Repetitive behavioral patterns help establish and maintain the

cue-induced behaviors associated with addiction through neuroadaptation.



Neuroadaptation and neural plasticity are the hallmarks of the

adaptive brain. In response to a drug or behavior, neuroadaptations

occur in centers of the brain associated with reward, emotion, and

decision-making through plasticity changes and relearning, which elicits

behavioral reinforcement and habit formation during addiction.

Sensitization, a neuroadaptive response, greatly dependent on context

and learning, alters neuronal circuitry involved in the normal processes

of incentive, motivation and reward, and thus is equally applicable to

"out of control drug use" or "non drug" problematic

behaviors (Martin & Petry 2005). These types of neurochemical adaptations also occur in areas of the brain critical to higher order

decision-making.



The reward circuit is closely tied with the executive

function/decision-making centers of the brain, the prefrontal cortex and

orbitofrontal gyrus. Studies suggest that impulse control disorders,

like addiction, lead to dysregulation of the prefrontal cortex circuitry

(Jentsch & Taylor 1999). Impulsivity is often defined as something

that has a sense of urgency or lack of premeditation, an act that

restricts evaluation and decision-making. Indeed all of these features

tend to define the manner in which drug use manifests itself as one

transitions into an "addictive state." An important function

of this brain region is that it acts as the "brake system" for

the brain by sending stop signals to inhibit the execution of distinct

behaviors or actions.



Drugs of abuse have been shown to alter glutamate and dopamine

functioning in the prefrontal cortex which may compromise its ability to

direct inhibitory regulation (Kalivas & O'Brien 2008); the same

may be true for behavioral disorders. It is of note that the prefrontal

cortex receives and sends projections to reward, memory, emotion, and

stress centers of the brain, all regions that play a substantive role in

the addiction process. Thus the impulsive aspects of addiction mediated

by alterations in the prefrontal cortex appear to alter the brain's

behavioral inhibitory system, opening the door for repetitive

maladaptive behaviors.



A SHARED APPROACH TO ADDICTION



There has been a trend toward thinking about non-drug addictions as

sharing neurobiological mechanisms with substance abuse and dependence (Deadwhyler 2010; Petry 2006; Volkow & Wise 2005). Drugs of abuse

are thought to hijack neural circuits that underlie encoding of natural

rewards and plasticity in this circuitry. It has been suggested that

these changes may be responsible for the behavioral plasticity

associated with increased craving and drug seeking seen in addictive

states (Kalivas & O'Brien 2008). Evidence of hijacking is seen

in several brain regions known to affect executive function, reward

processing and motivation. (Koob & Volkow 2010). It is widely

thought that this plasticity underlies the maladaptive changes in

behavior associated with addiction (Olsen 2011). In humans, some of

these changes include impaired decision-making, anhedonia, craving

tolerance, withdrawal and high rates of relapse (Potenza 2006; Bechara

2005).



Similarities between substance and non substance rewards can be

seen in imaging studies as well. Functional neuroimaging studies in

humans have shown that seeing appetizing food (Wang et al. 2004b), the

act of gambling (Breiter et al. 2001), shopping (Knutson et al. 2007)

and playing video games (Hoeft et al. 2008) activate similar brain

regions, including the mesocorticolimbic system and extended amygdala,

as do drugs of abuse (Volkow & Fowler 2000). Looking at a

traditional description of "addicted states," we may find

substance induced and behavioral conditions both meet criteria.

Addictive states are characterized by changed reinforcement

contingencies, significant anhedonia, the incapacity to experience

day-to-day pleasures due to reduced sensitivity to endogenous brain

dopamine, and a striking responsiveness to cues that are both internal

to the individual and within the environment associated with the

behavior or drug use (Volkow & Fowler 2000; Childress et al. 1999).



These behavioral correlates suggest that nonsubstance addictions

share similar neuroadaptations. Further support for this concept comes

from studies showing medication-induced increases in nondrug rewards for

activities including gambling, shopping or sex in patients taking drugs

that activate the dopaminergic system (Evans et al. 2006). Thus it

appears that dopamine dysregulation is a common thread in both chemical

and behavioral addictions.



In looking at the numbers, epidemiological reports estimate

prevalence rates in the United States at 1% to 2% for pathological

gambling (Potenza et al. 2003; Welte et al. 2001), 5% to 6% for

compulsive shopping, (Black 2007; Koran et al. 2006), 3% to 6% for

compulsive sexual behavior (Black 2000), 2.8% for binge eating disorder (Hudson et al. 2007) and .5 to 1% for kleptomania (McElroy et al. 1991).

Currently, the impulse control disorders have a small sectionintheDSM

IV-TR (intermittent explosive disorder, kleptomania, pyromania,

trichotillomania, pathological gambling) with some behaviors simply

classified under impulse control disorder NOS. Although the term

"addiction" is not utilized in the DSM-IV, substance use

disorders are categorized according to the substance causing the

problems and then grouped by abuse, dependence, withdrawal and

intoxication. Within the DSM-IV, behavioral addictions have been grouped

under categories including: "impulse control disorders not

otherwise specified," "eating disorders" and

"substance-related disorders," (Potenza 2006; Holden 2001). As

understanding of these disorders expands, a better grasp of the

etiology, prevalence, and neurobiological underpinnings will likely

emerge around these "behavioral addictions."



BINGE EATING



Food is an essential component to every organism on the planet.

From single celled bacteria to multicelled organisms such as ourselves,

almost every living thing has some means of consuming and metabolizing

nutrients to get energy for survival. However, the modern era has

ushered in a growing population with an unhealthy relationship to food.

Within this population exists a growing subgroup of compulsive eaters

whose relationship with food in many ways mimics the criteria currently

reserved for addictive disorders. These individuals display both

compulsive consumption and preoccupation with certain foods, leading

some to categorize them as "food addicts."



Compulsive overeating, also referred to as food addiction, is

characterized by an obsessive-compulsive relationship to food. An

individual suffering from compulsive overeating disorder engages in

frequent episodes of uncontrolled eating, during which they may feel

frenzied or out of control, often consuming food past the point of being

comfortably full. Unlike individuals with bulimia, compulsive overeaters

do not attempt to compensate for their binging with purging behaviors

such as fasting, laxative use or vomiting. Compulsive overeaters will

typically eat when they are not hungry. Their obsession is demonstrated

in that they spend excessive amounts of time and thought devoted to

food, and secretly plan or fantasize about eating alone. Binge Eating

Disorder (BED) is the most common eating disorder in the United States,

affecting 3.5% of females and 2% of males, and is prevalent in up to 30%

of those seeking weight loss treatment (Smith et al. 1998). The DSM-IV

(APA 2000) defines Binge Eating Disorder as a type of eating disorder

not otherwise specified, that is characterized by recurrent binge eating

without the regular use of compensatory measures to counter the binge

eating and a minimum of two binge eating episodes a week for at least

six months.



The neurobiological mechanisms underlying the behaviors that result

in pathological overeating are multifaceted. "The regulation of

food intake is a complex balance between excitatory and inhibitory

processes. The excitatory processes arise from the body's needs for

nutrients and calories. The inhibitory processes arise from satiety signals after food consumption" (Bassareo & Di Chiara 1999).

From an evolutionary standpoint the drive for food acquisition is

incredibly powerful for humans and animals. The consumption of food is a

vital component of our every day lives. Motivation and cue-induced

behaviors directed toward food sources ensured that early man would

succeed in the race for survival. However, with the advent of the

industrial revolution, resources like food have become more easily

accessible to the masses in a manner never before seen. For some, it may

be that caloric-based resources strongly activate reward and cue based

brain centers in a similar fashion to drugs of abuse.



This compounded with the abundant availability of food to many may

prove a downward spiral into an addiction-like disorder: compulsive

eating. Indeed, neurobiological studies suggest correlates between the

neurocircuitry recruited in substance abuse and compulsive food

consumption. It has been shown that palatable foods have the potential

to increase neuropeptides associated with regulating the brain's

pleasure system (Kelley et al. 2005). Brain imaging studies in humans

implicate the involvement of dopamine-modulated circuits in pathological

eating behavior (Wang et al. 2004a). Further, food cues increase

striatal extracellular dopamine as well as metabolism in the

orbitofrontal cortex, a brain region associated with executive

functions, suggesting activation of both motivational and

decision-making centers of the brain (Wang, Volkow & Thanos 2009).



Just as various drugs promote different degrees of dependence,

foods also differ in their capacity to promote abuse (Volkow & Wise

2005). Highly palatable foods such as those high in fats and sugars have

been shown to strongly activate mesolimbic dopaminergic circuits within

the brain (Sharf, Lee & Ranaldi 2005). Similar to drug-addicted

subjects, striatal dopamine D2 receptor availability is reduced in obese

subjects, which could explain how food could temporarily compensate for

understimulated reward circuits in these individuals. Decreased DA D2

receptors in obese subjects are also associated with decreased

metabolism in prefrontal cortical regions involved in inhibitory

control, which may underlie their inability to control food intake

(Volkow, Wang & Telang 2008); Volkow suggests that, "Dopamine

deficiency in obese individuals may perpetuate pathological eating as a

means to compensate for decreased activation of these circuits." In

conjunction with dopamine, the serotonin system been shown to play a

distinctive role in modulating appetitive behaviors (Blundell 1984).

Evidence suggests that serotonin is a key regulator of the satiety or

"stop eating" signal in the brain (Halford et al. 1998).

Serotonergic agonists and reuptake inhibitors have been shown to

significantly reduce binge-eating frequency and suppress excess food

consumption in human populations (Appolinario & McElroy 2004;

Halford & Blundell 2000). Congruently, the serotonergic system

appears to play a significant role in several drugs of abuse including

cocaine, alcohol, and methamphetamine (Kenna et al. 2009; Filip et al.

2005), indicating that there may be shared pathways between substance

abuse and binge eating disorders. Although the DSM-IV does not classify

food as a substance of abuse, the neurobiological, clinical and

behavioral findings suggest that binge eating fits into the framework of

addictive disorders.



Treatment options for compulsive eating disorder include

pharmacological and behavioral interventions. Randomized controlled

trials using cognitive behavioral therapy and brief psychoeducation have

led to improved outcomes with binge eating symptoms (Carter et al.

2003). Some success has been seen with antidepressants such as

serotonergic reuptake inhibitors such as fluoxetine, fluvoxamine,

sertraline and citalopram. Other options that have also shown promise

are anticonvulsants like topiramate that modulate voltage-gated ion

channels and glutamatergic receptors (Marazziti et al. 2011; Appolinario

& McElroy 2004), suggesting a role for these transmitter systems in

regulating this behavior. Given the known risks associated with

compulsive overeating, such as obesity and increased morbidity and

mortality, further investigation is warranted to better understand

treatment options and factors that have contributed to this epidemic.



DISORDERED GAMBLING



The Substance Use Disorders Workgroup of the American Psychiatric

Association DSM committee has proposed several changes to the current

DSM-IV classification of pathological gambling. The workgroup has

proposed to rename the pathological gambling disorder as disordered

gambling and to reclassify the disorder from the section on impulse

control disorders not elsewhere classified to the substance related

disorders (which is to be renamed as addiction and related disorders)

(Hodgins, Stea & Grant 2011).



The access and availability of gambling opportunity is the highest

it has ever been worldwide. Online gaming environments, casinos,

destination resorts, sports betting, spread betting, bingo, slot

machines, private betting, horse races, card games, and lottery tickets

are collectively receiving increased attention from the general public

throughout the world. The desire and willingness to wager money or other

items of value on randomly established outcomes seems universal.

Although most individuals participate in gambling as an enjoyable social



activity, a small group of people become too seriously involved in terms

of time invested and money wagered and they continue to gamble despite

substantial and negative personal, social, family, and financial

effects. (Hodgins, Stea & Grant 2011)



Epidemiological research, along with studies in treatment-seeking

samples, finds high rates of comorbidity (Petry 2009). In data from the

National Epidemiologic Survey on Alcohol and Related Conditions (NESARC)

study, pathological gamblers had an increased risk of having a diagnosis

of alcohol misuse in their lifetimes by a factor of six and an increased

risk of having a substance use disorder by a factor of four compared to

nongamblers. Also, rates of manic episodes were eight times higher in

pathological gamblers, major depression and dysthymia were three times

higher in pathological gamblers and generalized anxiety disorder, panic

disorder and specific phobias were each more than three times higher

(Petry, Stinson & Grant 2005). Also, most studies of

treatment-seeking samples find that individuals with both substance

abuse and disordered gambling have more severe problems than individuals

with either disorder alone. (Langenbucher et al. 2001)



The research base on pathological gambling is not substantial but

there are comparative studies looking at drug addiction and pathological

gambling (PG). From a clinical perspective, gamblers report subjective

cravings as powerful as drug abusers, they report "highs"

similar to drug highs, they show withdrawal symptoms and autonomic

instability when not gambling, and they may throw away everything in

their life to gamble.



The behaviors that characterize problematic gambling (chasing

losses, preoccupation with gambling, inability to stop) are impulsive in

that they are often premature, poorly thought out, risky, and result in

deleterious long-term outcomes (Chamberlain & Sahakian 2007).

Deficits in aspects of inhibition, working memory, planning, cognitive

flexibility and time management or estimation are more common in

individuals with pathological gambling problems than healthy volunteers

(Hodgins, Stea & Grant 2011). Distorted cognitions in gambling

disorders may include: magnification of gambling skill, superstitious

beliefs, interpretative biases, temporal telescoping, selective memory,

predictive skill, illusions of control over luck, and illusory

associations. (Hodgins, Stea & Grant 2011)



Research studies looking at the relationship between gambling and

substance use disorders reveal similar performance on personality and

neurocognitive assessments of impulsivity, with both groups having high

scores on self-reported measures of impulsiveness and sensation seeking

(Petry 2001). Both show similar clinical courses and similar clinical

characteristics including things like tolerance, withdrawal, craving

states and repeated attempts to cut back or quit. Thus there appears to

be substantive similarities between the systems and circuits associated

with chemical and gambling addictions.



Among those who do seek treatment, Gamblers Anonymous (GA) is the

most commonly utilized approach. GA is a 12-Step support group based on

the principles of Alcoholics Anonymous (Petry 2009). In many

epidemiological studies, an estimated 36% to 46% of pathological

gamblers are in recovery (Hodgins, Wynne & Makarchuk 1999).

Treatment for pathological gambling and problem gambling is varied and

may include: GA, cognitive behavioral therapy, pharmacotherapy,

motivational enhancement therapy, family therapy, brief therapy,

residential treatment and for some, natural recovery.



Neuroimaging studies reveal decreased activation of the

ventro-medial prefrontal cortex (vmPFC) in pathological gambling

subjects during presentation of gambling cues (videos), which resembles

cocaine addicts watching a cocaine video, with relatively less

activation in regions implicated in judgment and motivation (Potenza et

al. 2003). This suggests that the decision-making faculties are

inhibited in these individuals. Neuroimaging studies in pathological

gamblers have indicated diminished ventral striatum, ventromedial

prefrontal cortex and ventrolateral prefrontal cortex activity during

rewarding events, suggestive of a blunted neurophysiological response to

rewards and losses (Reuter et al. 2005). The work of Slutske and

colleagues (2000) strongly suggests that pathological gambling is

genetically related to substance addictions. Low 5-HIAA levels have been

found to correlate with high levels of impulsivity and sensation seeking

and have been found in pathological gambling and substance use disorders

(Potenza, Kosten & Rounsaville 2001). Baseline decreases in

serotonergic tone have been observed in comparison to nongambling

controls (Linnoila et al. 1983) and a euphoric "high" in

gamblers is seen after administration of 5HT2C agonists (Potenza 2008).

Also, PG has been shown to lead to elevations in noradrenaline and

comparatively elevated heart rates (Potenza 2008).



Currently, there are no FDA-approved medications to treat

pathological gamblers. It appears that three types of medications have

some efficacy in treating PG: opiate antagonists, mood stabilizers and

antidepressants. Results from two double-blind, placebo controlled

studies of naltrexone and two multicenter double-blind,

placebo-controlled trials of nalmefene suggest efficacy of opioid

antagonists in reducing the intensity of urges to gamble, gambling

thoughts, and gambling behavior (Hodgins, Stea & Grant 2011). Opiate

antagonists have been shown to decrease the craving for gambling in a

similar fashion to craving in alcoholics, and elevated rates dopamine in

individuals with PG and alterations in the A1 allele of the dopamine D2

receptor gene suggest that the reward associated neurotransmitter

systems are playing a significant role in driving the addiction process

in this disorder (Goodman 2008; Potenza 2008). The use of paroxetine and

other SSRIs, lithium and other mood stabilizers for pathologic gamblers

with bipolar symptoms, and the glutamate modulator N-acetyl cysteine have shown some positive effects. Because improvement in glutamatergic

tone in the nucleus accumbens has been implicated in reducing the

reward-seeking behavior in addictions (Kalivas, Peters & Knackstedt

2006), N-acetyl cysteine has been studied in the treatment of

pathological gambling and has had positive effects on urges and gambling

behavior (Grant, Kim & Odlaug 2007).



HYPERSEXUAL DISORDER



Sex addiction (also known as compulsive sexual behavior or

hypersexual disorder) is a controversial topic in both science and

media. There is a lot of press but not much scientific evidence. Sex

addiction could be described as a debilitating problem which may include

impairment in physical health function, cognition, impulse control,

attachment, intimacy and mood or it could simply be a convenient excuse

for an individual's indiscretions.



There will always be controversy when any class of behaviors,

including sexual behaviors, that are considered to be intrinsically

"normal" are medically "pathologized." (Money 1994)

The primary criticism of compulsive sexual behavior or hypersexual

disorder is that it may simply be a symptom of an underlying Axis I

disorder and not a true disorder itself. In one study of compulsive

sexuality, 88% of the sample met diagnostic criteria for an Axis I

disorder at the time of the interview and 100% met criteria for an Axis

I disorder at some time in their lives, with the most common diagnoses

being mood and anxiety disorders (Raymond, Coleman & Miner 2003).

Compulsive sexual behavior has been estimated to have a prevalence of

between 3% and 6% in the United States (Black 2000). Most individuals

with hypersexuality are male but studies that have examined both sexes

report a proportion of 8% to 40% female (Kaplan & Krueger 2010).



Sexuality is dependent on many factors, including individual and

relationship variables, societal values, cultural mores, and ethnic and

religious beliefs. In discussing hypersexuality, these contexts need to

be considered (Kaplan & Krueger 2010). The challenge is in defining

abnormal and pathological sexual practices. For example, a Swedish study

found that simple frequency of sexual activity alone was insufficient to

establish pathology; high frequency of sexual behavior with a stable

partner was associated with better psychological functioning, whereas

solitary or impersonal sexual behavior was associated with psychiatric

disorders and psychosocial dysfunction (Langstrom & Hanson 2006)



In defining aberrant sexual behavior, Carnes and Wilson (2002)

proposed that sexually addictive behaviors include compulsive

masturbation, affairs, use of prostitutes, pornography, cybersex,

prostitution, voyeurism, exhibitionism, sexual harassment and sexual

offending. Coleman, Raymond and McBean (2003) defined compulsive sexual

disorders as compulsive cruising and multiple partners, compulsive

fixation on an unattainable partner, compulsive autoeroticism,

compulsive use of erotica, compulsive use of the Internet, compulsive

multiple love relationships, and compulsive sexuality in a relationship.



Hypersexual Disorder has been proposed as a new psychiatric

disorder for consideration in the Sexual Disorders section for DSM-V.

Hypersexual Disorder is conceptualized as primarily a nonparaphilic

sexual desire disorder with an impulsivity component (Kafka 2010).

Proposed diagnostic criteria for Hypersexual Disorder (American

Psychiatric Association DSM-5 Development 2010) include:



A. Over a period of at least six months, recurrent and intense

sexual fantasies, sexual urges, and sexual behavior in association with

four or more of the following five criteria:



1. Excessive time is consumed by sexual fantasies and urges, and by

planning for and engaging in sexual behavior.



2. Repetitively engaging in these sexual fantasies, urges, and

behavior in response to dysphoric mood states (e.g., anxiety,

depression, boredom, irritability).



3. Repetitively engaging in sexual fantasies, urges, and behavior

in response to stressful life events.



4. Repetitive but unsuccessful efforts to control or significantly

reduce these sexual fantasies, urges, and behavior.



5. 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 effects of exogenous substances (e.g., drugs of

abuse or medications) 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, Strip Clubs, Other.



There is a paucity of literature on brain imaging during

conventional or pathological sexual functioning. Research utilizing

neuropsychological testing with self-reported behavior has shown a

positive correlation between hypersexual behavior and global indices of

executive dysfunction including features of impulsivity, cognitive

rigidity, poor judgment, and deficits in emotional regulation (Reid et

al. 2009). Also, diffusion tensor imaging, psychometric testing and the

Go-No-Go procedure revealed higher impulsivity scoring in compulsive

sexual behavior patients than controls, with hypersexual patients having

higher superior frontal region mean diffusivity than controls (Miner et

al. 2009). Patients with hypersexual disorder do report feeling out of

control and anxious, with obsessional thinking, mood instability and

significant impairment in their daily lives.



Reward circuits such as dopaminergic and endogenous opiate systems

have been implicated in the process of sexual behavior in much the same

way as substance abuse (Goodman 2008). An interesting piece of evidence

around the role of the reward system in these disorders comes out of the

Parkinson's field, where treatment with dopamine agonists leads to

increased vulnerability to impulse control disorders such as

pathological gambling, hypersexuality, compulsive shopping and

compulsive eating (Vilas, Pont-Sunyer & Tolosa 2012).



A case study of Internet-based sex addiction involving

preoccupation with Internet pornography, extended and frequent

masturbation and unprotected sex with cyber contacts revealed

interesting diagnostic and treatment-based findings. The patient was

initially prescribed an antidepressant (sertraline) with both individual

and group therapy and 12-Step work with Sex Addicts Anonymous with

little improvement. After the addition of naltrexone (an opiate

antagonist), the patient reported significant improvement in his

cravings. When the naltrexone was discontinued, the patient's

cravings returned and when he was put back on the medication, the urges

diminished (Bostwick & Bucci 2008). Two double-blind,

placebo-controlled studies reveal decreased symptoms using medication

compared to baseline. The first, by Kruesi and colleagues (1992),

compared clomipramine versus desipramine, with a two-week, single-blind

placebo lead in. Both drugs decreased paraphilic symptoms. The second

study by Wainberg (2006) compared citalopram with a placebo for the

treatment of compulsive sexual behaviors in gay and bisexual men. In the

study, results included a significant decrease in sexual desire and

drive as well as frequency of masturbation and pornography use.

Additional treatment includes: cognitive behavioral therapy

psychodynamic psychotherapy (exploring family of origin, trauma and

underlying factors) and 12-Step groups with a focus on sexual behavior,

including Sex and Love Addicts Anonymous, Sex Addicts Anonymous and

Sexaholics Anonymous (Kaplan & Krueger 2010).



COMPULSIVE BUYING DISORDER



Like other behavioral addictions, shopping addiction is a

controversial idea. Many experts recoil at the idea that excessive

spending can constitute an addiction, believing there has to be physical

tolerance and withdrawal to be diagnostically classified as such. One of

the unifying components of all addictions lies in the reinforcing

properties of these behaviors and substances. Although there is

variability in the definition of pathological spending, experts define

compulsive buying disorder (CBD) as a disorder associated with

compulsive thoughts or impulses to purchase unnecessary or large amounts

of items despite its negative consequences. The classification of

compulsive buying disorder remains unclear; however, McElroy and

colleagues (1995) have developed diagnostic criteria for compulsive

shopping in research settings, which include: (1) frequent preoccupation

with shopping or intrusive, irresistible, "senseless" buying

impulses; (2) clearly buying more than is needed or can be afforded; (3)

distress related to buying behavior; and (4) significant interference

with work or social functioning.



Epidemiological reports suggest that there is a 2% to 8% prevalence

of compulsive shopping in the U.S. based on results of a survey in which

the Compulsive Buying Scale (CBS) was administered to 292 individuals in

Illinois (Claes et al. 2011; Black at el. 2001). The data on gender

differences with compulsive buying disorder is mixed; however, some

estimate that the gender ratio is nine to one (female to male) (Claes et

al. 2011; Black at el. 2001). However, Koran and colleagues (2006)

report that compulsive buying disorder is nearly equal in men and women

(5.5% and 6.0%), respectively. This finding implies that the gender

disparity may be smaller than previous reports suggest and that men may

be underrepresented in samples.



Compulsive buying is typically chronic or intermittent, with an age

of onset that ranges from 18 to 30 years and a greater proportion of

these individuals reporting incomes under $50,000 (Black 2007).

Psychiatric comorbidities often include mood disorders (21% to 100%),

eating disorders (8% to 85%), substance abuse disorders (24% to 46%) and

other impulse control disorders. Furthermore, some studies suggest that

nearly 60% of compulsive buyers meet criteria for at least one

personality disorder (Black 2007).



Although widespread consumerism has escalated in recent years,

compulsive shopping is not a new disorder but rather was identified over

a century ago. Kraepelin gave it the name oniomania, which is roughly

translated as "buying mania." As such, it has been a

long-known phenomenon but only recently suggested to fit into the

behavioral addiction spectrum (Brewer & Potenza 2008). Although this

concept has historical recognition, there is no clear consensus on the

difference between normal shopping, occasional splurges and shopping

addiction. Black and colleagues (2001) report that individuals with

compulsive buying disorder are preoccupied with shopping and spending

and typically spend hours each week engaged in these behaviors. They

identified four distinct phases of compulsive buying disorder, including

anticipation, preparation, shopping, and spending. Many compulsive

buyers describe an escalating level of anxiety that can only be relieved

when they engage in the act of spending. Lee and Miltenberger (1997)

reported that negative emotions, such as anger, anxiety, boredom and

self-critical thoughts, were the most common antecedents to shopping

binges, while euphoria or relief of the negative emotions were the most

common consequences. They reported that there are several

characteristics that compulsive buying shares with other addictions. For

instance, shopping addicts become preoccupied with spending, and devote

significant time and money to the activity. Similar to drug abuse,

shopping addiction is highly ritualized and follows an addictive course

where the individual is consumed by thinking and planning the next

shopping trip, and engaging in the act of buying itself or returning

purchases leads to pleasure and relief of negative feelings. The

frequency of pathological shopping episodes can range from once a month

to once a day, depending on available funds. Similar to substance abuse,

after the act of compulsive shopping, the individual may experience

exhaustion or a let down. Once the purchase is complete, it often leads

to feelings of guilt, disappointment and shame.



The etiology and mechanisms of action behind compulsive spending

are poorly understood; however, new research is shedding light on shared

addiction associated circuitry that may mediate this behavior. There is

a distinction to be made between window-shopping and compulsive

spending; the actual addictive process in this disorder is driven by the

process of spending money. The act of compulsive spending subsequently

requires recruitment and possible dysregulation of distinct

decision-making circuits in the brain.



The role of opiate, serotonergic and dopaminergic systems have all

been suggested in compulsive buying disorder (Mueller et al. 2010),

however at present no definitive evidence has strongly linked these

systems with it. Although clinical studies suggest that citalopram, a

selective serotonin reuptake inhibitor (SSRI), may have some beneficial

effects in preventing relapse to compulsive buying disorder patients,

use of other SSRIs like fluvoxamine has proven inconclusive (Koran et

al. 2006). A key indicator seems to stem from the field of

Parkinson's disease, where patients maintained on a dopamine

precursor L-DOPA or dopamine agonists tend to have higher rates of

compulsive shopping, as well as other behavioral addictions (Djamshidian

et al. 2010; Nirenberg & Waters 2006). In fact it has been shown

that L-DOPA increased reward learning and risk taking in human imaging

data (Pessiglione et al. 2006). This suggests that dopamine may play a

distinctive role in driving craving and seeking, reward prediction, and

decision-making aspects of behavioral addictions in a similar manner to

drugs of abuse (Berridge 2007; Volkow & Wise 2005). As shown in

previous sections, these systems play a significant role in regulating

emotional affect as well as reward systems in the brain and thus

represent key components in the addiction process. Compulsive buying

disorder shares behavioral features such as escalation and tolerance, in

the form of needing to spend more money in order to receive fulfillment

from a shopping binge--both hallmarks of addiction. It is clear that the

behavioral traits associated with these maladaptive behaviors share a

substantial homology with substance abuse and it stands to reason that

similar brain systems are recruited and altered during the etiology of

the disorder. However, a more rigorous approach is needed to understand

the neurobiological mechanisms underlying compulsive buying disorder.



The social, psychological and biological factors surrounding

compulsive spending make it an interesting and complex condition.

Additional studies are needed to better understand the etiology,

differential diagnosis and treatment of this disorder. There are no

published reports describing psychotherapy-focused trials for compulsive

buying disorder. However, some preliminary findings suggest that

cognitive behavioral therapy and dialectical behavioral therapy may have

promising effects. Treatment outcome studies using SSRIs such as

citalopram and fluvoxamine also seem to show a therapeutic benefit for

individuals with compulsive buying disorder. However, further research

is needed to identify the mechanisms that drive this behavior in order

to create more efficacious treatment options.



INTERNET ADDICTION DISORDER

There is increasing attention on cyberspace social pathologies,

which some would call technical addictions. As with other behavioral

addictions, Internet abuse has been a controversial idea and one of the

most challenging tasks has been to arrive at a comprehensive definition

of the concept. Experts have not been able to come to a consensus on a

name, however, there are as many as six different terms associated with

Internet addiction, including "Internet Addiction Disorder

(IAD)," "Pathological Internet Use," "Excessive

Internet Use," and "Compulsive Internet Use" (Widyanto,

Griffiths & Brunsden 2011).



Internet addiction is a relatively new concept in psychiatry and

not yet recognized by the DSM-IV. However, some definitions of

compulsive Internet use in the literature have been derived from DSM-IV

criteria for addiction and impulse control disorder. First introduced by

Goldberg (1995) and Substance Abuse made popular Addiction Medication in Young's (1996) pioneering

research, the term Internet addiction disorder (IAD) has been defined as

"the compulsive overuse of the Internet and the irritable or moody

behavior when deprived of it" (Mitchell 2000). Some prefer a more

holistic definition that suggests that an individual's

psychological state, which includes both mental and emotional states, as

well as scholastic, occupational and social interactions, is impaired by

the overuse of the Internet (Beard 2005). Shapira and colleagues (2003)

state that in order to diagnose the presence of Internet addiction

disorder, individuals must meet the following criteria: (1) the

excessive use of the Internet beyond the time allotted and/or

irresistible urge to be preoccupied with the Internet; (2) an

impairment, distress or poor functioning in social settings caused from

a preoccupation with the Internet; and (3) the excessive use of the

Internet is not associated exclusively with periods of hypomania or

mania and cannot be entirely accounted for by Axis I clinical disorders.

Griffiths (2000) believes that technical addictions are a branch of

behavioral addictions that satisfy six criteria for addiction: salience,

mood modification, tolerance, withdrawal, conflict, and relapse.



The Rehabilitation true prevalence of Internet addiction in the U.S. is unknown;

however, Young (1998) estimated the figure to be between 5% and 10% of

all online users, which is approximately two and five million Internet

addicts. Other estimates vary greatly, from as low as 3% reported by

Mitchell (2000) and Whang, Lee, and Chang (2003), to as high as 80% in

Young's original study (1998). The demographic on who is more

likely to be affected by Internet addiction is mixed and not a

homogenous group. However, Mafe and Blas (2006) constructed a profile of

Internet-dependent users as young, highly educated individuals having a

close connection with the Internet. Other researchers have identified

Internet addiction-prone individuals as single, males, college students,

gays, middle-aged females and the less educated (Soule, Shell &

Kleen 2003). There is mixed data on gender disparities, although, more

recent research suggests that that there is no correlation between

gender and length of Internet use (Soule, Shell & Kleen 2003).

Common psychiatric comorbidities with Internet addiction include

depression, bipolar disorder, substance abuse disorder, pathological

gambling and sexual compulsions (Morahan-Martin 2005).



After a decade or more of academic research, the etiology and

mechanisms of action behind pathological Internet use are not well

developed. Research in this area is limited, with few studies using

control groups, randomization, or well-validated measures. The

reward-deficiency hypothesis suggests that those who achieve less

satisfaction from natural rewards turn to substances to seek an enhanced

stimulation of reward pathways (Blum et al. 1996). Internet use provides

immediate reward and gratification, similar to substance use.

Individuals with certain personality attributes such as impulsivity, low

self-esteem and introversion have a greater propensity to Internet

addiction. Internet use may be used as a compensatory tool for certain

deficiencies with social skills and interpersonal relationships. There

has been a range of psychological and behavioral theories that have been

proposed to explain Internet addiction. Hammersley (1995) has suggested

a number of psychological reasons why the Internet is highly reinforcing

for some people: (1) it allows correspondence with people who share

mutual interests; (2) it puts people in touch with other people who

would otherwise never meet; (3) the costs of communicating is low; (4)

there is a substantial "puzzle" element to using the Internet,

and many people find puzzling tasks reinforcing; (5) people can download

software toys, some of which are reinforcing; (6) people can keep in

touch with friends with minimal time and financial costs; (7) it gives

people feelings of status and modernity, which may bolster self-esteem;

(8) it allows people to be taken seriously and listened to; and (9) it

allows people to present a "well-managed" persona, which may

deviate in significant ways from one's everyday, face-face persona.

Others have described a cognitive behavioral model (Davis 2001) where

Internet addiction may result when some psychological factor causes an

individual to be vulnerable to dependence on new online content, which

is followed by obsessive thoughts and then the perception that the

Internet is a "friend." This may be reinforced by the

decade-long trend of people spending increasingly more time with

technology than with humans. There has been a shift away from family and

peers to mass media technology as the primary socialization agents.



Treatment strategies for pathological Internet use are

under-researched and there is limited published data on effective

therapeutic modalities. Young (1999) points to the usefulness of

cognitive behavioral therapy for compulsive Internet use. He suggests

that catastrophic thinking might contribute to compulsive Internet use

in proving a psychological escape mechanism to avoid real or perceived

problems. He also hypothesized that those who suffer from negative core

beliefs and cognitive distortions may be more drawn to anonymity of the

Internet in order to overcome perceived adequacies. Cognitive behavioral

therapy and psychoeducation seem to have promising results for the

treatment of Internet addiction (Young 2007).



Unfortunately, there are no published controlled trials to evaluate

pharmacological interventions. Some experts believe that a similar

pattern of cortical arousal exists in pathological gamblers, substance



abusers and Internet abusers, and naltrexone may mitigate problematic

impulse control behaviors in some individuals (Yellowless & Marks

2007). Research has shown adding naltrexone to a mediation regimen that

already includes an SSRI coincided with a decline in symptoms of

Internet addiction (Bostwick & Bucci 2008). More research is needed

to clarify the mechanism by which naltrexone and SSRIs extinguish

addictive behavior.



There is no doubt that the Internet usage among the general

population will continue to increase over the next few years. Future

studies are needed to examine the quantitative and qualitative effects

of Internet abuse, while also investigating treatment differences among

the various types of Internet addictions.



VIDEOGAME ADDICTION



Video games have been a part of American culture since the late

1950s, and their prominent role in the lives of American youth has led

to increased public scrutiny of the effects and potential harms of video

game usage, including the potential of socially maladaptive behaviors

such as increased short-term aggressiveness and overuse syndromes (CSAPH Report 2006). In June of 2007, the American Medical Association Council

on Science and Public Health considered whether "videogame

addiction" could be a disorder.



In the U.S. alone, the sale of video games and related products

reportedly grossed between $7 and $10 billion in 2004. Although 70% to

90% of U.S. youth play video games, in 2005 a national survey identified

the prototype gamer as a 30-year-old male who averages between 6.8 and

7.6 hours weekly playing video games (ESA 2006, 2005).



Using World Health Organization criteria, a gaming addiction rate

of 12% was found by researchers in the United Kingdom who polled 7,000

gamers (Grusser et al. 2007). Research in the United States has

estimated that anywhere from a small minority to as much as 10% to 15%

of players may be affected (Chak & Leung 2004).



Psychosocial effects of video games are varied. Some studies have

found that exposure to video game violence may promote increased

aggressive behaviors and decreased prosocial behaviors in social

interactions. (Sheese& Graziano 2005; Vastag 2004) Although overuse

can be associated with any type of video game, it is most commonly seen

among those using massively multi-player online role-playing games

(MMORPG), who represent approximately 9% of gamers (ESA 2005). The

MMORPG are very interactive, social and competitive and primarily

focused on fantasy. Researchers have attempted to examine the type of

individual most likely to be susceptible to such games, and current data

suggest these individuals are somewhat marginalized socially, perhaps

experiencing high levels of emotional loneliness and/or difficulty with

real life social interactions. (Allison et al. 2006) Current theory is

that these individuals achieve more control of their social

relationships and more success in social relationships in the virtual

reality realm than in real relationships (CSAPH Report 2006). Symptoms

of time usage and social dysfunction/disruption appear in patterns

similar to that of other addictive disorders (Tejeiro et al. 2002).

Additionally, dependence-like behaviors are more likely in children who

start playing video games at younger ages (Grusser et al. 2007).



Although there are very few research studies looking at imaging or

treatment, evidence for striatal dopamine release during video game

playing was detected in a positron emission tomography study (Koepp et

al. 1998). Areas of research on potential health effects of video games

that are receiving increasing attention include attention

deficit/hyperactivity disorders (ADHD) and neurology (Chan &

Rabinowitz 2006).



OTHER BEHAVIORAL ADDICTIONS



There are many other potential behaviors that may have addictive

properties, but there is little published data on these conditions. The

terms "love addiction or pathological attachment," "work

addiction," "exercise addiction" and others have been

discussed. And of course, the current impulse control disorders listed

in the DSM-IV classification need more data. There is very little

research to support any of these "other" conditions that are

not currently in the DSM being a true disorder, but clinically there are

many individuals who report symptoms that warrant further discussion.



CONCLUSION



We live in an overstimulated society and rapid advances in

technology and abundant availability to stimuli and resources may play a

role in the increased prevalence of behavioral disorders. 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. The core feature of these behaviors

as well as substance use disorders appears to be impulsivity. Impulse

control disorders primarily involve a hedonic quality--sex, gambling and

stealing are all associated with a rush or a high (Grant, Brewer &

Potenza 2006).



The difficult part of defining impulse control disorders involves

comorbidity and the complex relationship between affect and impulsivity.

How do you know if the symptoms originate from the proposed primary

disorder? Some critics argue that behavioral conditions are simply

secondary manifestations of underlying psychiatric illnesses including

mood disorders, anxiety disorders, ADHD, personality disorders and other

disorders. The repetitive behavior is simply an adaptation or compulsion

to avoid discomfort.



As research in nondrug addiction progresses, knowledge gained from

the fields of drug addiction, motivation and obsessive-compulsive

disorder will contribute to the development of therapeutic strategies

for nondrug addictions (Olsen 2011). There is emerging clinical evidence

that medications used to treat chemical dependency may be successful in

treating nondrug addictions. For example, naltrexone, nalmefine,

N-acetyl-cysteine and modafanil have all been reported to reduce craving

in pathological gamblers (Grant et al. 2006). Opiate antagonists have

also shown promise in the treatment of pathological gambling and

compulsive sexual behavior (Grant & Kim 2001) and topirimate has

shows some success in reducing binge episodes (McElroy et al. 2007).



Similarities between nondrug and drug addictions include craving,

impaired control over the behavior, tolerance, withdrawal and high rates

of relapse (Potenza 2006). It makes sense that natural rewards can cause

neuroadaptation since learned associations between things such as food

or sexual opportunities and the conditions which maximize availability

is beneficial from a survival standpoint and is a natural function of

the brain (Alcock 2005). In some individuals, this plasticity may

contribute to a state of compulsive engagement in behaviors that

resembles drug addiction (Olsen 2011). Similar to chemical addictions,

there appears to be a transition period between moderate and compulsive

use (Grant, Brewer & Potenza 2006). 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 (Davis & Carter

2009). Clinically, patients may shift from a normative behavioral set

point to a pathological one when influenced by comorbidities or

environmental stimuli. These addiction and related disorders appear to

work on a spectrum.



It is clear there is a substantial amount of overlap between

behavioral addictions and substance abuse. Despite this commonality,

there haven't been many studies evaluating shared neurobiology,

although the research in binge eating and pathological gambling is

slowly growing. At a minimum, we need researchers to better define these

conditions with uniform diagnostic criteria and develop universal, valid

screening measures. Awareness is building and research is beginning to

coalesce around defining the biological systems that drive these types

of disorders. The National Institute on Drug Abuse (NIDA 2002), a

research-funding agency in the United States, has cited the importance

of studying nondrug behaviors/disorders (obesity, pathological gambling,

etc.) in understanding substance dependence. Indeed, in gaining a better

understanding of behavioral addictions it may prove that we gain a

stronger theory of the overall mechanisms that comprise our perception

of "addiction."



DOI: 10.1080/02791072.2012.662859



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Reef Karim, D.O. (a) & Priya Chaudhri, Ph.D. (b)



(a) Assistant Clinical Professor, UCLA Semel Institute for

Neuroscience & Human Behavior, Department of Psychiatry, Los

Angeles, CA.



(b) Adjunct Faculty, University of California, San Diego, San

Diego, CA.



Please address correspondence to Reef Karim, D.O., The Control

Center, 9777 Wilshire Blvd, Suite 704, Beverly Hills, CA 90210; phone:

(310) 271 8700; email: Reef@doctorreef.com



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Tue

01

Mar

2016

Breast Enhancement Has Become A Billion Dollar Industry



Breast enhancement has become a billion dollar industry. Many women are choosing to get breast enlargement surgery, breast reduction surgery, breast lift surgery, natural breast enhancement, among other things. More and more medical students are going into the cosmetic surgery field because of the potential growth in popularity over the next 10-20 years. Even herbal remedies are popping up all over the market for women who prefer natural breast enhancement. Herbal breast pills are supposed to gradually enhance breasts for a natural appearance.

Many women prefer this option, because there are no risks or scars associated with it, whereas breast implants can look fake and unattractive. Comprehensive research is being done to find herbs that can naturally cause breast enlargement. Certain blends and formulations of herbs have proven to be effective for breast enhancement for many women. These natural remedies may not work for everyone, but herbal breast enlargement is worth a try if you are looking to enhance your breasts. You will find a lot of information on the internet about cosmetic surgeons who specialize in breast enlargement. Read the information on their websites and educate yourself about breast enhancement procedures and different kinds of implants. Most likely, you will find very useful tips and advice given by actual patients who have had any breast enlargement procedure done. You can look at the photographs and judge for yourself. But, remember, they will only post the best-looking results on the website.

It would be best to find a breast enlargement forum or blog where you can find honest answers and results about breast enhancement. If you feel pressured by society or even a loved one to undergo breast enlargement surgery, do not get it done. You need to understand that even cosmetic surgery is very risky. If you are looking into breast enhancement because someone else is making you feel insecure about your body, then surgery is not a logical, reasonable decision. Most insecurities are deep-rooted and breast enlargement will not make those feelings disappear. Some women see a therapist or counselor before undergoing any cosmetic surgery procedure to ascertain if she is doing it for the right reasons. Obviously, trying a natural method such as herbal breast pills, is a good choice for women who would like to make minor changes. If you have any abnormality, you should see a doctor about the best options for breast enhancement. A skilled, certified cosmetic surgeon can correct many severe abnormalities. Please gather as much information as you can, and even talk with a therapist if you have overwhelming feelings of insecurity about your body, before making any major decision about breast enhancement.

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Fri

23

Jan

2015

Solid Ways To Handle Your Own Finances

When you are probably the millions living paycheck to paycheck, taking control of your individual finances is totally necessary. This could mean learning to reside in a completely different way than you are used to. Keep to the advice below to manage your personal finances and ease the transition on the changes you should make.

Speak with different loan officers before signing anything. Be sure to read across the lending contract thoroughly to assure that you are currently not getting in to a mortgage that has hidden charges, and this the regards to the loan are simply as you may and the lender had consented to.

An investing system with good probability of successful trades, fails to guarantee profit if the system does not have a thorough approach to cutting losing trades or closing profitable trades, within the right places. If, as an example, 4 away from 5 trades sees a return of 10 dollars, it will require merely one losing trade of 50 dollars to reduce money. The inverse is likewise true, if 1 away from 5 trades is profitable at 50 dollars, you can still consider this system successful, when your 4 losing trades are merely 10 dollars each.



In case you are comfortable with paying your bills by mail, it can be optimal to switch to online bill pay. Every bill which you send out by mail will cost you 40-50 cents with postage. Pay online so there is no need to be concerned about this fee inside your daily and weekly expenses.

When paying off your debt avoid unnecessary expenses for example credit monitoring services. You can actually attain a free of charge credit profile from all the three credit rating agencies each year. Apply the excess cash to the debt rather than paying a third party company to keep track of your credit score.

Bonds certainly are a very stable and solid investment that you could make if you would like plan for the future. These forms of investments are purchased at a small part of what they will be worth in the foreseeable future. Put money into bonds in order to earn a great payback in the future upon maturity.

Rule #1 of good personal finance is "income must exceed expenditures." People that do not have an affordable budget or who earn less than they spend, will undoubtedly find yourself deeper in debt. Calculate your total earnings, then spend below that mark.

Make your home's appraisal in your mind whenever your first property tax bill is released. Consider it closely. If your tax bill is assessing your home to become far more then what your house appraised for, you must be able to appeal your bill. This could save you quite a bit of money.

Try paying for your meal as well as other daily purchases on a charge card. Then, at the conclusion of the month, repay that visa or mastercard completely. This demonstrates that you're capable of being responsible when borrowing money which you'll pay it back. This really is a nice, good way to improve your credit ranking.

Recycle and reuse to save lots of big bucks. Why constantly improve the environmental problems related to manufacturing and landfills? Everything that can possibly be reused should be reused. It's not shameful to achieve this. It really is practical and admirable not simply from an environmental standpoint but in addition from a personal finance standpoint.

Use cash for purchases. Eliminate bank cards and atm cards and utilize cash for purchases. Utilize the envelope system to allocate a spending budget for monthly expenses. Have a separate envelope for every single different form of expense, and set a specific volume of cash in every one. In this way, you won't over-spend on any monthly expenses. Advisable is usually to have another envelope marked 'emergency', containing cash that could just be used if really necessary. Seal this envelope, as as a result you less inclined to 'borrow' from using it.

Your individual finances don't have to be the origin of endless worry and frustration. By applying the ideas you might have just learned, you may master almost any financial circumstances. Before you realize it, you'll have turned what was once your biggest anxieties into one of your greatest strengths.

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Fri

16

Jan

2015

Getting Charge Of Your Money Is To Your Advantage





Economic times take time and effort, and you're not the only one if you're feeling the consequences in the economy in your personal pocketbook. While financial problems might be devastating and worrying, they are not permanent. Here are ideas to help help you on personal financing to get away from debt or start planning for future years.

Never use credit cards for money advances. The rate of interest on the money advance could be almost double the amount rate of interest with a purchase. The interest on cash advances is additionally calculated from the moment you withdrawal the bucks, so that you will still be charged some interest even if you repay your charge card entirely following the month.

If one features a hobby like painting or woodcarving they may often turn that into another stream of revenue. By selling the products of ones hobby in markets or over the internet anybody can produce money to use nonetheless they best see fit. It will give a productive outlet for the hobby of choice.

Learn indications of financial distress to your lender and steer clear of them. Suddenly opening multiple accounts or seeking to are huge warning signs on your credit report. Using one visa or mastercard to repay another is an indication of distress at the same time. Actions such as these tell a prospective lender that you are currently incapable of survive on your current income.

Pay back your items with the higher interest before working on the less or no interest debt. Make payment on minimums on a high interest card can cost you hundreds of dollars more than it ought to. List out the interest rates of the cards you might have and pay back the very best ones without delay.

Save a set amount from each check you obtain. About to save whatever remains once the month has ended is not a good idea. When you know the money is unavailable, it lessens the chance you are going to spend it.



Whether you monitor your personal finances online or on paper, it is quite vital that you review your general situation each month. Try to find any unexpected alterations in your debts, shortfalls inside your credits, or irregularities within the dates that cash changes hands. Noting these changes and making up them is a major a part of staying on the top of your financial circumstances.

When you have to go to the store, try and walk or ride your bike there. It'll help you save money two fold. You won't must pay high gas prices to hold refilling your vehicle, for one. Also, while you're at the store, you'll know you will need to carry anything you buy home and it'll stop you from buying facts you don't need.

The best way to spend less, with gas being as expensive as it is, is to cut down on the driving. When you have several errands to perform, make an effort to do them altogether in a trip. Connect each of the places you have to head to into an effective route to save mileage, as well as in effect, reduce gas.

Your old laptop can make you some additional money if you need it. A broken laptop is definitely worth a little bit something, and one that may be working or fixable is worth a lot more. Selling something as simple as a laptop could possibly get your gas for several weeks or perhaps a month.

If someone is involved about conserving money for their personal finance they should think about buying only essential items. By not purchasing unneeded things an individual can take full advantage of their money and save what they have remaining from purchasing their needed items. This can allow someone to build their personal finance.

If you cannot avoid eating at restaurants from your schedule then the best way to save money is to pick from the dollar menu. You can find two chicken sandwiches as well as a soda for 3 bucks sometimes. This surpasses its six dollar alternative about the combo menu, and saves you money.

Do not, if it is possible, spend more money than you make. Obviously, situations arise, and sometimes it is alright to borrow money. However, you should live below your means. Sacrifice a little bit now, and then you are going to reap greater benefits than you can think of.

Remember that developing good financial habits is a continual process. It won't happen overnight, but you could make real improvement, should you achieve consistancy more than a span of a few months. It can be never past too far to start having your finances to be able, so don't ever doubt that you could turn things around.

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