Journal of Affective Disorders 125 (2010) 82–88

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Journal of Affective Disorders

j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / j a d

Research report

Behavioural addictions in bipolar disorder patients: Role of impulsivity and

personality dimensions
Marco Di Nicola ⁎, Daniela Tedeschi, Marianna Mazza, Giovanni Martinotti, Desiree Harnic,
Valeria Catalano, Angelo Bruschi, Gino Pozzi, Pietro Bria, Luigi Janiri
Institute of Psychiatry, Bipolar Disorder Unit, Catholic University Medical School, Rome, Italy

a r t i c l e i n f o a b s t r a c t

Article history: Background: Behavioural addictions (BAs) can be understood as disorders characterized by
Received 12 August 2009 repetitive occurrence of impulsive and uncontrolled behaviours. Very few studies have
Received in revised form 19 December 2009 investigated their association with mood disorders. The present study was undertaken to
Accepted 20 December 2009 determine the prevalence of the main behavioural addictions in a sample of bipolar outpatients
Available online 18 January 2010
in euthymic phase or stabilised by medications and to investigate the role of impulsivity and
temperamental and character dimensions.
Keywords: Methods: One-hundred-fifty-eight Bipolar Disorder (BD) (DSM-IV) outpatients were assessed
Bipolar disorder
with tests designed to screen the main behavioural addictions: pathological gambling (SOGS),
Behavioural addictions
compulsive shopping (CBS), sexual (SAST), Internet (IAD), work (WART) and physical exercise
Impulsivity
Personality dimensions (EAI) addictions. TCI-R and BIS-11 were administered to investigate impulsivity and
personality dimensions mainly associated with BAs. The clinical sample has been compared
with 200 matched healthy control subjects.
Results: In bipolar patients, 33% presented at least one BA respect to the 13% of controls.
Significantly higher scores at the scales for pathological gambling (p b .001), compulsive buying
(p b .05), sexual (p b .001) and work addictions (p b .05) have been found. Self-Directness
(p = .007) and Cooperativeness (p = .014) scores were significantly lower while impulsivity
level was significantly higher (p = .007) in bipolar patients with BA than those without BA.
Conclusions: To our knowledge, this is the first study investigating the prevalence of
behavioural addictions in BD showing a significant association of these disorders. BAs are
more frequent in bipolar patients than in healthy controls and are related to higher impulsivity
levels and character immaturity.
© 2010 Elsevier B.V. All rights reserved.

1. Introduction harmful to oneself and/or others, an increasing sense of

Behavioural addictions (BAs) can be understood as
disorders characterized by repetitive occurrence of impulsive
and uncontrolled behaviours that cause psychological, social
and working problems, sometimes also legal and economic
consequences. Core features of these disorders are failure to
resist an impulse, drive or temptation to perform some act
⁎ Corresponding author. Institute of Psychiatry, Bipolar Disorder Unit,
Catholic University Medical School, Largo Agostino Gemelli, 8, Rome 00168,
Italy. Tel.: + 39 3406860419; fax: + 39 0697276550.
E-mail address: mdnicola@libero.it (M. Di Nicola).
tension or excitement before acting out, a sense of pleasure,
and gratification or release at the time of the behaviour or
shortly thereafter (Leioyeux et al., 2000).
Behavioural addictions include indulgence in gambling,
shopping, sex, Internet, affective relationships, work, physical
activity or even food. All these activities are part of life and do
not have any negative impact in the normal course; in fact, it
is not the object that determine the addiction but a
particularly intense and rigid relationship between the addict
and the activity of choice (Keane, 2004).
DSM-IV does not contemplate any category neither
diagnostic criteria for BAs with the exception of pathological

0165-0327/$ – see front matter © 2010 Elsevier B.V. All rights reserved.
doi:10.1016/j.jad.2009.12.016
 M. Di Nicola et al. / Journal of Affective Disorders 125 (2010) 82–88
gambling which is coded as an Impulse Control Disorder (ICD)
(APA, 2000). Other BAs such as compulsive computer use,
compulsive sexual behaviour, and compulsive buying have
been proposed to be included in ICD not otherwise specified
(NOS) (Kuzma and Black, 2005). However, the discussion is
still open whether BAs are related to mood disorders (Wise
and Tierney, 1994), substance use disorders (Marks, 1990), or
impulse control disorders (Christenson et al., 1994) or
whether they fall within an obsessive–compulsive disorder
spectrum (Black et al., 1998; Lee and Mysyk, 2004).
Comorbidity rates between BAs and mood disorders have
not been systematically investigated and results are debated.
Studies have reported high rates of major depression and
dysthymia among pathological gamblers (Bland et al., 1993;
Cunningham-Williams et al., 1998; Petry et al., 2005). An
epidemiological study from el-Guebaly et al. (2006) underlined
that the risk of moderate/high severity gambling was 1.7 times
higher in subjects with mood disorders and that those with
affective disorders were 5 times more likely to be moderate/
high severity gamblers. In 24 compulsive buyers, Christenson
et al. (1994) reported that 50% was affected by major depres-
sion. Lejoyeux et al. (1997) found a prevalence of compulsive
buying disorder of 31.9% in a sample of 119 depressed subjects.
In a more recent study, Lejoyeux et al. (2002) reported that
compulsive buying in depressed patients was significantly
associated with comorbid Impulse Control Disorders (ICDs). A
39% comorbidity for major depression or dysthymia was found
in thirty-six subjects affected by compulsive sexual behaviour
(Black et al., 1997). Also for Internet addiction the association
with depressive disorders seems to be frequent (Mihajlović
et al., 2008; Shaw and Black, 2008).
With regard to bipolar disorders very few studies have been
conducted. Zimmerman et al. (2006) found that subjects with
pathological gambling (PG) had significantly more axis I
disorders than subjects without PG, with higher rates of bipo-
lar disorder. Results from the Canadian Community Health
Survey (McIntyre et al., 2007) reported a significantly higher
prevalence of PG among the population with bipolar disorder
as compared to the general population and those with major
depressive disorder. Shapira et al. (2000) in twenty subjects
with problematic Internet use found a lifetime diagnosis of
bipolar disorder (with 12 having bipolar I disorder) in 14 of
them.
Lejoyeux et al. (1997) showed that in a sample of
depressed patients, compulsive buying was significantly
associated with a high level of impulsivity. In most cases of
behavioural dependence disorders, a high level of impulsivity
and sensation-seeking or novelty seeking could determine an
increased risk (Leioyeux et al., 2000).
The present study was undertaken to determine the
prevalence of the main behavioural addictions in a sample of
bipolar outpatients, and whether behavioural dependences
have clinical specificities. In particular we aimed: (i) to
estimate the prevalence of BAs (pathological gambling,
compulsive buying, Internet addiction disorder, sexual,
work and physical exercise addictions) in a sample of bipolar
patients in euthymic phase or stabilised by medications in
comparison with matched healthy control subjects; (ii) to
underline any possible correlation among the BAs scales and
between BAs, impulsivity and personality dimensions; (iii) to
compare bipolar disorder patients with and without BA for
83
socio-demography, prevalence of bipolar disorders types,
onset and duration of illness, association with comorbid axis I
and II disorders, impulsivity level and temperamental and
character dimensions.
2. Methods
Participants were recruited from September 2006 to
October 2008 among outpatients referring to the Bipolar
Disorder Unit Treatment of the Day-Hospital of Clinical
Psychiatry of the University General Hospital “A. Gemelli” in
Rome.
Two-hundred-fifty-two subjects were consecutively
screened. Inclusion criteria were: 1) currently meeting DSM-
IV criteria for Bipolar Disorder I (BP-I), Bipolar Disorder II (BP-II)
or Cyclothymic Disorder (CtD); 2) age 18 to 75 years; 3) the
property of spoken and written Italian language.
Subjects were excluded if any of the following conditions
was present: 1) a diagnosis of mental retardation or docu-
mented IQb 70; 2) comorbidity with schizophrenic disorders
or severe neurological diseases; 3) active suicidal ideation;
4) current mania; 5) unstable general medical conditions;
6) clinically significant pre-study physical exam, electrocardio-
gram, haematological and biochemical analyses of blood
samples, hormonal evaluation including thyroid hormones, or
urinalysis abnormalities indicating serious medical disease
impairing evaluation; 7) alcohol/substance intoxication at the
moment of the assessment as to toxicological analysis.
BP diagnosis was preliminary established by trained
psychiatrists using the Structured Clinical Interview for
DSM-IV Axis I Disorders (SCID-I) (First et al., 1995).
Personality disorders were diagnosed through the Structured
Clinical Interview for DSM-IV Axis II Disorders (SCID-II) (First
et al., 1990).
At the same time, healthy control subjects (HC) have been
enrolled. HC subjects were free of any Axis I psychopathology
as determined by the SCID-I, Non Patient edition (SCID-I/NP)
(First et al., 2002).
2.1. Procedure
After the establishment of the Bipolar Disorder diagnosis,
an anamnestic interview was administered to obtain socio-
demographic information, medical and psychiatric history,
and psychiatric familiar history.
Each patient has been evaluated after a period of at least
two months from the last acute phase of disease. According to
the clinical and testing evaluation [Clinical Global Impres-
sion-Severity 3–4 (Guy, 1976); Hamilton Depression Rating
Scale b 8 (Hamilton, 1960); Young Mania Rating Scale b 6
(Young et al., 1978)] recruited subjects were mildly or
moderately ill and out of any hypomanic/manic or depressed
state.
Raters (MDN and MM) were specifically trained and showed
a good inter-rate reliability on all instruments (kN0.80).
At the evaluation session, patients followed a naturalistic
maintenance treatment, with atypical antipsychotics (olanza-
pine, quetiapine, and aripiprazole), established mood stabilisers
and new antiepileptic drugs (lithium, valproate, carbamazepine,
topiramate, and oxcarbazepine), antidepressants (SSRI, SNRI,
NaSSA, and unspecific antidepressants).
84 M. Di Nicola et al. / Journal of Affective Disorders 125 (2010) 82–88
Each patient was administered a battery of self-report
questionnaires to screen the main behavioural addictions, the
Italian version of both the Temperament and Character
Inventory — Revised version (TCI-R) (Cloninger, 1999;
Martinotti et al., 2008) and the Barratt Impulsiveness Scale
version 11 (BIS-11) (Barratt and Stanford, 1995; Fossati et al.,
2001). The SCID I and II were administered firstly (day 1), the
behavioural addiction's questionnaires and the BIS-11 were
administered during a following morning session not ex-
ceeding 1 h, and were always completed in the same order of
sequence (day 2). The TCI-R was filled out in another morning
session (day 3).
2.2. Assessment instruments
1) The South Oaks Gambling Screen (SOGS) (Lesieur and
Blume, 1987). A 20-item questionnaire based on DSM-III
criteria used as a screening device to identify pathological
gambling.
2) Compulsive Buying Scale (CBS) (Faber and O'Guinn, 1992a,
b). It contains 13 items derived from previous research
and theoretical models of compulsive buying. Subjects
were asked to rate how true each item was for them on a
scale ranging from 1 (not at all) to 7 (very much). The scale
has a negative cut-off so that the more negative are the
scores the more severe is the compulsive buying behaviour.
3) Sexual Addiction Screening Test (SAST) (Carnes, 1991),
designed to assist in the assessment of sexually compul-
sive behaviours which may indicate the presence of sex
addiction. Developed in cooperation with hospitals,
treatment programs, private therapists and community
groups, the SAST provides a profile of responses which
help to discriminate between addictive and non-addictive
behaviour. It consists of 25 dichotomous yes/no items.
4) Internet Addiction Disorder test (IAD) (Young, 1996). A 20-
item Internet Addiction Test. Widyanto and McMurran
(2004) report that items reflect six underlying dimensions
of Internet addiction: salience, excessive use, neglect of
work, anticipation, lack of control and neglect of social life.
Items are rated on a 5-point scale, where 1 = very rarely
and 5 = very frequently.
5) Work Addiction Risk Test (WART) (Robinson and Post,
1994). This 25 items survey more recently specifying five
underlying dimensions of compulsive tendencies, control,
impaired communications/self-absorption, inability to
delegate, and self-worth (Flowers and Robinson, 2002).
6) Exercise Addiction Inventory — Short Form (EAI) (Griffiths
et al., 2005). It consists of six statements based on a
modified version of the components of behavioural
addiction (Griffiths, 1996). Each statement had a five
point Likert response option coded so that high scores
reflected attributes of addictive exercise behaviour: 1 1/4
“Strongly disagree”, 2 1/4 “Disagree”, 3 1/4 “Neither agree
nor Disagree”, 4 1/4 “Agree”, 5 1/4 “Strongly Agree”.
7) Temperament and Character Inventory — Revised version
(TCI-R) (Cloninger, 1999; Martinotti et al., 2008). It is a
true/false questionnaire measuring temperament (4
dimensions: Novelty Seeking/NS, Harm Avoidance/HA,
Reward Dependence/RD, and Persistence/PE) and charac-
ter (3 dimensions: Self Directness/SD, Cooperativeness/CO
and Self Trascendence/ST).
8) Barratt Impulsiveness Scale — 11 (BIS-11) (Barratt and
Stanford, 1995; Fossati et al., 2001). It is a 30 items self-
reported questionnaire that investigate impulsivity di-
mension; it includes three subscales: Attentional (pro-
blems related to concentrating/paying attention), Motor
(fast reactions and/or restlessness), and Non-planning
(orientation toward the present rather than to the future).
To the control sample only the scales for BAs assessment
were administered.
Anonymity has been guaranteed to all the participants;
the study protocol complied fully with the guidelines of the
Ethics Committee of the Catholic University of Rome, and was
approved by the Institutional Review Boards in accordance
with local requirements. It was conducted in accordance with
Good Clinical Practice guidelines and the Declaration of
Helsinki (1964) and subsequent revisions. Written informed
consent was asked after a complete description of the study
was provided to each subject. Each patient at the presence of
a family member or a caregiver was informed that non-
compliance, or the inability to fill in the questionnaires would
lead to their exclusion from the study. However, patients
were free to leave the study at any time. All subjects
participate without receiving any form of payment.
2.3. Statistical analysis
Since all the BA scales except of WART, checked using the
Kolmogorov–Smirnov one-sample test, were not normally
distributed both in bipolar subjects (SOGS: Z = 4.272,
p b .001; CBS: Z = 1.577, p = .014; SAST: Z = 1.422, p = .035;
IAD: Z = 3.326, p b .001; WART: Z = .424, p = .994; EAI:
Z = 1.952, p = .001) and healthy controls (SOGS: Z = 6.366,
p b .001; CBS: Z = 1.437, p = .032; SAST: Z = 3.565, p b .001;
IAD: Z = 3.363, p b .001; WART: Z = 1.089, p = .187; EAI:
Z=1.797, p=.003), the principal outcome analysis consisted
of non parametric Mann–Whitney U test for comparison
between the two groups.
Spearman's coefficient of rank correlation was calculated
to examine the relationship between BA scales, TCI-R
dimensions and BIS-11 score.
Comparison between bipolar patients presenting with and
without BAs was made for continuous variables by using the
independent Student's t test, and for discrete variables by the
Chi-square test.
Finally, to determine what factors, if any, were associated
with BAs, we entered variables that were significant at p b .10
in the bivariate analyses into a multivariable model using
logistic regression. We examined all variables for multi-
collinearity. The Hosmer–Lemeshow goodness-of-fit statistic
was used to check the fit of the model. Findings were reported
as Odds Ratios (ORs) and p values.
Statistical significance was determined at the.05 level of
confidence.
3. Results
Eighty-one patients were excluded because they failed in
the fulfilment of inclusion criteria; 171 were tested on day 1.
Thirteen were dropped-out (4 at day 2 and 9 at day 3)
because of lack of compliance and were not considered in the
 M. Di Nicola et al. / Journal of Affective Disorders 125 (2010) 82–88 85

study. One-hundred-fifty-eight bipolar patients were finally

included in the study. Two-hundred HC subjects paired to
patients for gender, age and education have been considered
for the analysis.
Socio-demographic characteristics and clinical data of the
samples are illustrated in Table 1. All subjects enrolled for the
study were Caucasians.
In the clinical sample, comorbid Axis I disorders were in
the area of anxiety (n = 16). The additional Axis II diagnosis
were: borderline (n = 8), avoidant (n = 9), histrionic
(n = 14), passive–aggressive (n = 8), schizoid (n = 7) and
Non Otherwise Specified (NOS) (n = 8) personality disorders.
Substance misuse was present in 30% of the BP subjects
(n = 47), twelve subjects (7.6%) reported previous suicide
attempts.

3.1. Patients vs. controls

In Fig. 1 percentages of subjects that reach the cut-off at
the questionnaires for the screening of behavioural addictions
are described.
In bipolar patients, 33% (n = 52) reached the cut-off for at
least one BA while among healthy control subjects only the
13% (n = 16) did it.
Bipolar patients were significantly more likely to report
higher mean scores to the BAs screening instruments with the
exception of the physical exercise and Internet ones, than the
control group (Table 2). Interestingly, the mean score to the
IAD for the screening of Internet addiction was significantly
Table 1
Socio-demographic and clinical data of bipolar disorder subjects and healthy
controls. Percentages are given in brackets.
Fig. 1. Percentages of subjects that reach the cut-off at the questionnaires for
the screening of behavioural addictions. Legend: SOGS: The South Oaks
Gambling Screen; CBS: Compulsive Buying Scale; SAST: Sexual Addiction
Screening Test; IAD: Internet Addiction Disorder test; WART: Wart Addiction
Risk Test; EAI: Exercise Addiction Inventory.
higher (p b .001) in the healthy control group than in the
clinical sample, although nobody reached the cut-off for
Internet Addiction diagnosis (Table 2, Fig. 1).
3.2. Correlations in BD patients group
Spearman's correlations between BAs scores are described
in Table 3 while correlations between BAs, TCI-R and BIS-11
scores are shown in Table 4.
3.3. Bipolar patients with (BA+ group; n = 52) and without
behavioural addictions (BA− group; n = 106)

Bipolar patients Healthy controls

BA+ group were more likely to be unemployed (χ2 = 5.368,
N 158 200 p = .021) and comorbid for an Axis II personality disorder
Gender (males) 65 (41) 80 (40)
(χ2 = 5.162, p = .023) than the BA− group.
Age (M ± SD) 48.7 ± 12.7 46.2 ± 13.8
Student's t test revealed that Self-Directness (t = 2.760,
Marital status p = .007) and Cooperativeness (t = 2.520, p b .014) scores were
Single 52 (33) 72 (36) significantly lower and impulsivity level was significantly
Married 76 (48) 100 (50) higher (t = −2.737, p = .007) in patients BA+ than those BA−.
Separated/divorced 21 (13) 20 (10)
Widowed 9 (6) 8 (4)

Level of education
Table 2
Elementary school 3 (2) 0
Mann–Whitney U test for comparison of BAs mean scores between bipolar
Lower secondary school 32 (20) 24 (12)
disorder patients (BD) and healthy controls (HC). Legend: SOGS: The South
High school education 88 (56) 120 (60)
Oaks Gambling Screen; CBS: Compulsive Buying Scale; SAST: Sexual
Degree 35 (22) 56 (28)
Addiction Screening Test; IAD: Internet Addiction Disorder test; WART:
Wart Addiction Risk Test; EAI: Exercise Addiction Inventory.
Employment condition
Regular job 68 (43) 104 (52) Subjects Mann–Whitney U
Occasionally employed 11 (7) 30 (15)
Unemployed 44 (28) 30 (15) BD (n = 158) HC (n = 200) Test
Student 8 (5) 14 (7)
M ± SD M ± SD Z p value
Retired 27 (17) 22 (11)
SOGS .87 ± 2.3 .23 ± 1.29 − 3.754 b.001 ⁎
Bipolar diagnosis CBS .56 ± 2.58 1.33 ± 1.8 − 2.032 .042 ⁎
BP-I 71 (45) – SAST 4.17 ± 3.89 2.32 ± 4.06 − 5.349 b.001 ⁎
BP-II 44 (28) – IAD 25.6 ± 11.7 28.14 ± 10.52 − 3.950 b.001 ⁎
CtD 43 (27) – WART 52.66 ± 13.91 48.47 ± 11.14 − 2.794 .005 ⁎
Onset of illness (age) (M ± SD) 30.1 ± 8.4 – EAI 11.22 ± 5.96 11.11 ± 4.91 −.566 .571 n.s.
Duration of illness (M ± SD) 19.7 ± 13.7 –
n.s.: not significant.
BP-I, Bipolar Disorder I; BP-II, Bipolar Disorder II, CtD, Cyclothymic Disorder. ⁎ Difference is statistically significant.
86 M. Di Nicola et al. / Journal of Affective Disorders 125 (2010) 82–88

Table 3 Dependence” (RD) and significantly elevated traits (t =

Spearman's correlations between mean scores at the BA scales in bipolar −4.288, p b .001) of “Persistence” (P) than subjects without
disorder patients (n = 158); ** = p b .01; * = p b .05. Legend: SOGS: The
South Oaks Gambling Screen; CBS: Compulsive Buying Scale; SAST: Sexual
behavioural dependence (WO+ vs. BA−, RD mean ± SD:
Addiction Screening Test; IAD: Internet Addiction Disorder test; WART: Wart 90.10 ± 14.26 vs. 100.58 ± 14.23; P mean ± SD: 134.20 ±
Addiction Risk Test; EAI: Exercise Addiction Inventory. 16.65 vs. 105.02 ± 20.23).
Regarding impulsivity assessed with BIS-11, higher levels
SOGS CBS SAST IAD WART EAI
respect to bipolar patients without BA (n = 106; mean ± SD:
SOGS – −.255* .346** .311** .181 .151 58.37 ± 10.43) were found for pathological gamblers (n = 11;
CBS −.255* – −.388** −.229* −.145 − 1.145
mean ± SD: 73.5 ± 7.09; t = −3.45, p = .001) and compulsive
SAST .346** −.388** – .322** .143 .301**
IAD .311** −.229* .322** – .268** .312** buyers (n = 27; mean ± SD: 67.31 ± 12.06; t = − 2.68,
WART .181 −.145 .143 .268** – .198* p = .009); a trend toward significance was observed in
EAI .151 −.145 .301** .312** .198* – exercise addicted bipolar patients (n = 6; mean± SD: 70.33 ±
11.85; t = −1.922, p = .060).

There was no statistical difference between BA+ and BA− 4. Discussion

bipolar patients in terms of gender, age, level of education,
bipolar spectrum diagnosis, onset and duration of illness, Lifetime prevalence rate of bipolar spectrum disorders is
comorbid Axis I disorders, substance misuse and the presence up to 6.5% in the general population (Vornik and Brown,
of previous suicide attempts. 2006). Studies reported that bipolar disorder patients tend to
Considering all bipolar subjects, logistic regression anal- be impulsive and engage both in risky behaviours and
ysis showed that those with a higher Cooperativeness pleasurable activities with potential for negative conse-
(OR = 0.9; p = .042) and without a comorbid Axis II diagnosis quences (APA, 2000; Kathleen Holmes et al., 2009). Further,
(OR = 0.15; p = .003) have a lower risk to develop a beha- BD is strongly associated with alcohol/substance use dis-
vioural addiction. orders with rates significantly higher than in the general
Finally, we analysed the differences between subjects with population (e.g.: Vornik and Brown, 2006; Regier et al., 1990;
each behavioural addiction and those without co-occurring Frye and Salloum, 2006).
BA. Because of the small size of the population enrolled, The extension of the definition of “dependence” leads to
statistical differences could not be determined. the consideration of some impulsive behaviours as a form of
Compulsive buyers bipolar patients (CB+; n = 27) were addictive disorder (Leioyeux et al., 2000). According to some
more frequently comorbid for an Axis II personality disorder researchers, addictions, whether induced by psychoactive
(χ2 = 7.27, p = .007) and reported significantly lower scores substances or behaviours, share common neurobiological
(t = 2.090, p = .041) at the character dimension of “Cooper- mechanisms, through the activation of the reward pathways
ativeness” (C) as to the TCI-R, than patients without and the involvement of multiple neurotransmitter systems,
behavioural dependence (BA−; n = 106) (CB+ vs. BA−, the dopaminergic firstly, the endogenous opioids and the
mean ± SD: 118.77 ± 17.53 vs. 128.75 ± 14.91). serotoninergic secondly (Keane, 2004) and clinical manifes-
Also bipolar patients with co-occurring sexual addiction tations such as mood modifications, tolerance, withdrawal
(n = 5) reported significantly higher rates of comorbidity and relapse so that the addiction process could be considered
with a personality disorder as to the DSM-IV compared to as unitary (Goodman, 1993; Shaffer, 1999; Gossop, 2001;
patients without behavioural addiction (BA−; n = 106) Baiocco et al., 2005).
(χ2 = 4.035, p = .045). Several studies have investigated the prevalence of
Workaholic bipolar patients (WO+; n = 21) showed substance use disorders in bipolar patients documenting the
significant lower level (t = 2.015, p = .048) of “Reward strong association between these two syndromes (e.g.: Regier
et al., 1990; Brooner et al., 1997; Kessler et al., 1997; Sonne
and Brady, 1999; Grant et al., 2004; Merikangas et al., 2007)
while very few studies have explored the occurrence of BAs in
Table 4
Spearman's correlations between TCI-R dimensions, BIS-11 total score and these patients.
mean scores at the BA scales in bipolar disorder patients (n = 158); ** = To our knowledge this is the first study investigating the
p b .01; * = p b .05. Legend: SOGS: The South Oaks Gambling Screen; CBS: prevalence of behavioural addictions in bipolar outpatients in
Compulsive Buying Scale; SAST: Sexual Addiction Screening Test; IAD: euthymic phase of disease or stabilised by medications and
Internet Addiction Disorder test; WART: Wart Addiction Risk Test; EAI:
examining the association of these disorders with impulsivity
Exercise Addiction Inventory; NS: Novelty Seeking; HA: Harm Avoidance;
RD: Reward Dependence; P: Persistence; SD: Self Directness; C: Coopera- level and personality dimensions. We focused on pathological
tiveness; ST: Self Trascendence; BIS-11: Barratt Impulsiveness Scale-11. gambling, compulsive shopping, sexual, Internet, work and
physical exercise addictions.
SOGS CBS SAST IAD WART EAI
In bipolar disorder sample 33% of subjects reported at
NS .305** −.298** .220 .135 −.050 .048 least one BA, according to the established cut-off of the scales,
HA −.004 .009 .083 .023 −.002 .078
while in healthy controls group only the 13% did it; bipolar
RD −.047 −.157 .184 −.061 −.090 .094
P −.032 −.047 −.026 .059 .436** .044
patients reported also significantly higher scores at the scales
SD −.398** .279* −.405** −.300** −.141 −.109 for pathological gambling, compulsive buying, sexual addic-
C −.220 .299** −.210 −.144 −.108 −.063 tion and work addiction than controls.
ST .018 −.248* .086 .086 .175 .168 Compulsive buying was the BA most represented in our
BIS-11 total .333** −.347** .253* .278* .083 .270*
sample: it has resulted in a comorbid disorder for the 17% of
 M. Di Nicola et al. / Journal of Affective Disorders 125 (2010) 82–88
bipolar subjects and strongly associated with other BAs, in
particular with pathological gambling, sexual and Internet
addictions.
Our findings showed that in bipolar patients all beha-
vioural addictions, with the exception of the work one, were
associated with high levels of impulsivity. We could hypoth-
esize that these patients use BAs as well as abusers use
substances: to reduce the activation given by the impulsivity
and more generally by the immaturity of character.
In fact, comparing bipolar patients with and without BA
we have found that bipolar patients with at least one BA
reported higher impulsivity, lower self-directness and coop-
erativeness, underlining the presence of a general immaturity
of personality, that could be compensated with inadequate
behaviours. Further, BA+ patients were significantly more
unemployed and comorbid for a personality disorder as to the
DSM-IV than BA− patients.
Concerning the association between BAs scores and
temperamental and character dimensions, high Novelty
Seeking (NS) was found to be correlated with the presence
of behaviours referable to pathological gambling (SOGS) and
compulsive buying (CBS). These data confirm what has
already been reported in previous studies (Leioyeux et al.,
2000). Furthermore, novelty seeking and impulsivity have
been suggested to be behavioural markers of the propensity
to take addictive drugs (Wills et al., 1994; Chakroun et al.,
2004; Kreek et al., 2005): it seems that these traits favour the
engage also in behavioural dependences. Additionally, com-
parable to substance use disorders, it is possible that
excessive reward-seeking behaviours can alleviate negative
mood states (Grüsser et al., 2007) so that behavioural
addictions may become an available resource to cope with
stress factors associated with the bipolar illness.
The temperamental dimension of Persistence (P) that
characterizes industrious and hard working despite frustra-
tion and fatigue individuals (Martinotti et al., 2008) and
scores at WART, screening the work addiction, were in a
significant positive correlation. Furthermore, bipolar patients
with comorbid work addiction reported significantly higher
scores at this dimension and significantly lower traits of
Reward Dependence (RD) than patients without behavioural
addictions. In fact, ‘workaholics’ show an inability to self
regulate their emotional states. In spite of serious negative
consequences and aside from reward, they will continue to
act out the negative pattern affecting their life.
High scores at the scales indicating the presence of
behaviours referable to compulsive buying, pathological gam-
bling, sexual and Internet addiction were associated with low
Self Directness (SD) expressing the individual's competence
toward autonomy, reliability, and maturity (Martinotti et al.,
2008). Cooperativeness (C) was in a significant positive
correlation with compulsive buying; further, compulsive buyers
bipolar patients reported significantly lower scores at this di-
mension respect to patients without behavioural dependences,
suggesting that an improvement in social skills such as support,
collaboration and partnership (Martinotti et al., 2008) is a
protective factor for the development of compulsive shopping.
Our study presents some limitations: the psychometric
scales administered are all screening instruments, and they
may have overestimated the prevalence rates of the disorders;
some results could not have been detected because the relative
87
small number of patients enrolled. Besides, results could have
been influenced by the concurrent pharmacological treatment.
We recruited patients in euthymic phase of disease from at least
two months: the relative short timeframe considered could
have affected the prevalence rate of behavioural addictions but
comparing those euthymic from 2 to 5 months (n = 71) with
those from more than 5 months (n = 87) we did not find any
significant difference (data not shown). Therefore, it is possible
for us to state that detected addictive behaviours in our sample
are not traced back to depressive or manic/hypomanic state of
disease.
Summarizing, our data emphasizes the higher frequency
of association between bipolar disorder and behavioural
addictions compared to non clinical population. As to our
results, we believe that behavioural addictions could repre-
sent comorbid conditions of bipolar disorders that need to be
investigated and assessed. A better understanding of these
dimensions could help to reduce harmful behaviours and the
risk of relapses and may have a direct impact on psycho-
educative interventions.
The presence of BAs in our sample results to be associated
with high level of impulsivity and with temperamental and
character dimensions. Besides, the subgroup of bipolar
patients with co-occurring BA was more frequently unem-
ployed and comorbid with a personality disorder, more
impulsive and with a general character immaturity. Finally,
bipolar subjects with a higher cooperativeness and without a
comorbid Axis II diagnosis have a lower risk to develop a
behavioural addiction.
To date there is no consistent concept for diagnosis of BAs in
DSM-IV or treatment guidelines for these disorders, and their
classification is uncertain. However, the elevated number of
subjects seeking treatment and the high frequency of comor-
bidity with other psychiatric disorders emphasize the impor-
tance of a clear conceptualisation of the so-called behavioural
addictions and their successful treatment.
These observations need to be replicated in a larger popu-
lation; further studies are also necessary to understand the
biological substrates that contribute to the overlap between
bipolar disorder and behavioural dependences and to assess
the role of BAs in terms of relapses and severity of illness.
Role of funding source
No pharmaceutical and industry support was employed in this study.
Conflict of interest
All authors declare there are no conflicts of interest.
Acknowledgments
We wish to thank Prof. Livia De Giovanni for the support in
the statistical analysis, Dr. Stella Luongo, Leonarda Marcone,
Eleonora Chillemi and Demetrio Cara for data collection.
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