Love Addiction: “I Can’t be with You, I Can’t be without You.” Psychological Aspects and Clinicals Intervention
Introduction
Love as an Addiction
Romantic love is a universal phenomenon that every individual seeks during his life, for the purposes of reproduction and survival. Love inevitably influences the quality of life of each subject, as it can bring joy and happiness, but also pain and suffering. It has been the object of interest of artists, singers, poets and philosophers, who described it as a deep and intense feeling, capable of causing both euphoria and despair. In this regard, Ovid wrote: “I cannot live without you or with you”; in Plato’s Symposium, Aristophanes argued that, in the beginning, man was a perfect and complete being, a creature with four arms, four legs and one head with two faces; there was, therefore, no distinction between man and woman. To reduce the superiority of men, Zeus, envious of their perfection, decided to divide them in two, condemning them to the continuous search for their half, to recover the lost perfection and feel complete again. From this, it emerges the common conviction of having to find one’s own soul mate, “the other half of the apple” that can fill its own void, a conviction that influences people’s behavior and how they conceive love. The English term “addiction” comes from the Latin “addictus” which means “ enslave “. The expression is also used for the use and abuse of chemicals. In recent years, the scientific community has also treated behavioral addictions that are obsessively repeated, these addictions however, are socially accepted and refer to “new addiction” and dependent love, can take on the connotation of slavery.
The boundary between love and emotional dependence is thin, in the early stages of a relationship is physiological the need to want to spend more time with your partner, the addiction to the loved one and his idealization, are part of the physiological process, in a healthy relationship, these aspects gradually fade with time, leading to seeing and accepting the partner in its uniqueness, despite differences; while, in emotional dependence, idealization persists excessively and one-way, The desire of the other becomes a compulsive and necessary need to function, and you continue to remain in a relationship despite the negative consequences. In the literature, there is no unanimous agreement on the relationship between love and addiction; in this regard, Earp and colleagues [1] have proposed two perspectives: the narrow view and the broad view. The narrow view considers love as an affective dependence, only in some conditions, in reference to the phases of falling in love and the most extreme and pathological behaviors. Advocates of this view consider aspects such as: sexual compulsions, pedophilia, toxic or abusive relationships, abnormal attachment and lack of tolerance of the negative outcomes of life and relationships [2,3]. According to neuroscientists and psychiatrists, the prevailing model of substance dependence assumes that drugs generate addiction, as they gradually trigger abnormal and non-natural functioning patterns [4], therefore, addictive behaviors are the result of brain processes not present in the brain of unrelated subjects.
Volkow and colleagues [5] have shown how the intake of substances activates neurotransmitters in the brain to create reward signals, learning patterns occur in the brain cellular adaptation that would not occur if there were no intake of substances. The addict who continuously searches for drugs acts a typical drug addict behavior. Other researchers have, instead, found behavioral and neurological similarities between, for example, those who take food uncontrollably and those who use substances. The narrow view of affective dependence, therefore, argues that one can be dependent on love, but only in the presence of abnormal brain processes, analogous to those that form when taking illicit drugs. The lover suffers from addiction if he engages in sexual behavior or abnormal attachment, probably related to abnormal brain processes, therefore his search for love:
1) Interferes with his ability to carry out daily life activities.
2) Prevents healthy relationships.
3) It has negative consequences for themselves or for others. The broad view considers love an addiction, i.e. being in love is equivalent to being addicted, with similar chemical and behavioral processes [6,7]. Proponents of this view place emphasis on the similarities of experience between addicts and those involved in a phase of falling in love. Such analogies are found as stated by Fisher and colleagues [6] in “mood swings, desire, obsession, compulsion, distortion of reality, emotional dependence, personality changes, risk taking and loss of self-control”.
Burkett and Young [7] hypothesize that there is “a deep and systemic concordance between the brain regions and the neurochemicals involved in both addiction and social attachment”. Love produces a gratification, similar to that obtained from drugs, food, gambling, or sex [4,8,9]. Addictions are appetites that each individual possesses and such appetites if they are not satisfied for a long time, manifest themselves in a more intense way. Therefore, each individual is dependent on something, food, sex or love; what differs is the intensity with which it manifests itself [1].
Affective Dependence
Affective addiction [love addiction], a term introduced for the first time by Peele and Brodsky [10] in Love and addiction, is a widespread problem, especially in women. Affective dependence is a new addiction that refers to a series of dysfunctional behaviors, in which the object of dependence is not a substance, but a socially accepted behavior or activity; however, it has not yet been included in any nosographic system, therefore, there are no recognised diagnostic criteria for diagnosis, nor a precise definition. Despite this, several scholars, including Reynaud and collaborators [3] have proposed a number of criteria similar to those for substance dependence. They define emotional dependence as “A maladaptive or problematic love relationship pattern leading to clinically significant impairment or distress, as manifested by three [or more] of the following [the first five of which occur at any time in the same 12-month period]” [3]:
1. Presence of withdrawal syndrome in the absence of a loved one, characterized by significant suffering and compulsive need of the other.
2. A considerable amount of time invested in the relationship [or with thought].
3. Reduction of important social, professional, or recreational activities.
4. Persistent desire or unsuccessful efforts to reduce or control the relationship.
5. Continuation of the report despite the existence of problems created by the report.
6. Presence of attachment difficulties, as demonstrated by at least one of the following:
a) Repeated love relationships exalted without any lasting period of attachment.
b) Repeated painful love relationships characterized by an insecure attachment.
The “women who love too much” [Robin Norwood] tend to enter relationships with distant people, cold, unable to enter into intimacy, with the belief that with their love they can change them; a vicious circle is thus established that confirms the belief that we are not worthy of being loved, increasing their suffering. In addition, the attitude of the other is justified, attributing it to traumatic or painful situations experienced during childhood. The relationship, despite causing pain, is not interrupted, as it has become the center of their life: the desire to spend as much time as possible with the loved one increases, when this does not happen you think obsessively about the relationship; his absence is experienced as intolerable; you lose interest in everything that was important before; friends, family, work/ study take second place. The partner is idealized, and it is thought that without him his existence has no meaning. Their goal is to take care of the partner, putting them completely aside, until they cancel themselves. One’s well-being depends on one’s partner and they tend to entrust responsibility for one’s own happiness to the other.
Psychobiology of Affective Dependence
Studies have shown that all forms of dependence are based on a common substrate, the mesolimbic reward system. It consists of a network of brain structures which are activated in response to pleasant stimuli, rewarding and that interact with each other for the regulation of motivated behavior, for associative learning and for the attribution of salience. This system consists of some main areas:
1. The ventral tegmental area [VTA] is a group of neurons located at the base of the midbrain. Dopaminergic cells of the Mess corticolimbic system originate in VTA, which play a crucial role in the reward system.
2. The nucleus accumbent is a brain region located in the basal forebrain, and also plays a fundamental role in the reward system. It is involved in motivated behavior, the regulation of pleasure and gratification associated with specific stimuli and, therefore, in learning by reinforcement.
3. The prefrontal cortex, is localized in the anterior portion of the frontal lobe of the brain, precedes the primary motor cortex and the premotor cortex. It is a cortex involved in several higher cognitive functions, such as planning, motivation, cognitive control, regulation of social and emotional behavior; specifically, the frontal orbiting cortex is involved in decision-making processes. In relation to addictions, it has been observed that the activity of the prefrontal cortex increases during abstinence, thus demonstrating that it has a role in the reiteration of addictive behaviors [11]. Furthermore, by being implicated in executive control over decision-making processes, Goldstein and Volkow [12] suggest that an alteration in the way it works may result in the loss of impulse behavior control, Decisions are therefore taken based on an immediate reward; at the expense of the negative consequences of one’s conduct.
4. The limbic system, responsible for motivation and reward, regulates emotions and stores emotionally significant events. It is formed by two structures, amygdala, and field, important for emotions and memory. In particular, the amygdala is in the anterior portion of the medial temporal lobe of the brain and plays a crucial role in the processing and regulation of emotions especially negative ones [such as fear, sadness, anxiety] it is also involved in the formation and storage of memories related to emotional experiences, associating emotions with events. The hippocampus is localized in the medial portion of the temporal lobe and is implicated in learning and memory processes, especially in the encoding of memories and emotional valences related to such memories [13].
At the neurobiological level, studies of biochemistry, functional neuroimaging and genetics highlight a close relationship between behavioral addictions and substance dependence [14], as, for example, food, gambling, Affective dependence are activities that activate the circuits responsible for gratification, like those caused by the use of drugs [15]. Goodman [16] hypothesized that behavioral addictions are the basis of a common “additive process” resulting from the alteration of three functional systems: “motivation-gratification”, “regulation of affections” and “behavioral inhibition”. the negative consequences of their conduct.The alteration of the motivation-gratification system causes unpleasant sensations in the subject, this causes the conducts capable of activating the gratification system to acquire greater reinforcement [16]. The alteration of the regulation of affections leads the individual to avoid painful emotions, experienced as intolerable and which he is unable to control [16]. The alteration of the mechanisms of behavioral inhibition, finally, determines in the individual the need to perform a behavior able to activate the gratification system, without thinking about the negative consequences that it determines in the long term [16].
Pathological Addictions: Maccanisms
In recent years, the idea is spreading that the term addiction can also refer to the recurrence of behaviors, which we feel the need to implement compulsively. The characteristic of these behaviors is that they are socially accepted, which are part of their daily life; in this case, we speak, therefore, of behavioral dependence or new addiction defined as “a group of heterogeneous disorders […] that imply an involvement in a repetitive and persistent habit, aimed at changing the state of consciousness of the individual, and that in the long term involve a significant impairment of the sphere of work, affective-relational and social of the subject” [15]. These include pathological gambling, compulsive shopping, addictions to work, study, technology, sex, exercise, food, and relationships. However, the scientific community recognizes only pathological gambling, including it in the DSM-V among the “disorders related to substances and addiction disorders” [APA, 2013]. The English terms “dependence” and “addiction” are both translated, in Italian, with a single term “dependence”; however, these English terms refer to two different phenomena: the first indicates the physical dependence on the substance that the body needs to function; the second indicates, instead, psychological dependence on a pleasant stimulus. A subdivision of addictions that is based on social regulators is due to Francisco Alonso-Fernández [17], who distinguishes “social or legal addictions” that include legal drugs [such as alcohol, drugs, tobacco, etc.] and socially accepted activities [such as eating, working, shopping, playing], “antisocial or illegal addictions” that include drug addiction and illegal activities [such as cocaine, heroin, cannabis, non-consensual sex] [17].
From a symptomatologic point of view, there are many similarities between behavioral and substance use addictions:
• The individual is unable to control his or her behavior by acting compulsively, which gives him or her pleasure.
• Shows craving, defined as “an attraction, of varying intensity, towards certain psychotropic substances of abuse[…] at high levels of intensity, intense and serious psychophysical alterations appear that lead the subject to think only about the substances from which he is attracted and the means by which to obtain them” [18];
• Can develop abstinence in case of absence of the object of dependence and tolerance that is, the rewarding effects are no longer due to the repeated use of the same dose of the substance or the compulsive implementation of an activity and consequently, the individual is forced to increase the dose or activity to achieve the initial effect.
• The individual persists in behavior despite the negative consequences it entails.
In addition to symptomatology, drug and behavioral addictions have similar neurobiological mechanisms. Several studies have shown that when the subject acts a behavior that causes pleasure and gratification, this system is activated, resulting in a strengthening of the behavior itself, as it is encoded in memory as positive. It is a physiological system that is usually activated by adaptive behaviors, necessary for survival, such as eating, drinking etc.; however, the alteration of this circuit is also at the base even addictive behavior [18]. A malfunction of the brain mechanisms involved in gratification and motivation involving the meso-cortico-limbic circuits, seems to be the basis of both substance and behavioral addictions. The regulation of these mechanisms is made possible by the interaction of different neurotransmitter systems; in particular, in addiction a crucial role is played by the dopaminergic system, which regulates the motivation that guides the search for rewarding stimulus [20]. Dopamine produces different effects on motivated behaviors depending on how it reacts to two different motivational stimuli: appetitive stimuli, which push the individual to get a reward, and consumer stimuli, that keep the subject’s proximity to the reward. Both stimuli activate the dopaminergic neurons of the neocortical pathway; whereas, the dopaminergic neurons of the mesolimbic pathway, considered the pleasure pathway, are activated only by consumer stimuli [19].
In addition to the dopaminergic system, other systems involved in addiction mechanisms are:
• The serotonergic system, the alteration of which appears to be related to impulsive behavior, typical of addiction [15]. The authors of this theory believe that the basis of the phenomenon of craving and relapses is the process of incentive sensitization [15,20,21]. In addition, such process simple modifications of the synaptic plasticity in the nucleus accumbent and in the cortex of neurotransmitter systems such as serotonin, glutamate, noradrenaline, and GABA [15]. Some authors [15,20,21] believe that similar alterations of the circuits involved in the incentive salience are also the basis of dysfunctional behaviors typical of new addiction; Therefore, stimuli and contexts related to compulsive behavior could assume abnormal incentive-motivational properties. However, to date, there are insufficient experimental tests to support this hypothesis.
Etiopathogenesis of Affective Dependence
It has been seen how neurobiological aspects favor the onset and maintenance of affective dependence. However, it cannot be explained solely in biological terms since affective dependence is a complex and multifactorial phenomenon. For an exhaustive understanding of it, therefore, one must also consider psychological factors [such as attachment, emotional dysregulation] and sociocultural factors [such as media influence and cultural expectations], all factors that interact with each other in the determination of this type of dependence.
Psychological Factors: Attachment
John Bowlby developed the theory of attachment [22] which emphasizes the importance of the mother-child relationship and how these early relationships can influence the child’s social and emotional development. Bowlby criticizes the prevailing theories of the time, according to which the child would seek the proximity of the reference figure only to satisfy the need for nourishment. He believes that the child has an innate tendency to establish strong emotional ties with the attachment figure and seeks its proximity to gain protection and security. He calls attachment behavior “any form of behavior that leads a person to achieve or maintain closeness with another individual”, usually the mother. It is activated by distance from the reference figure and is inhibited by its proximity. Bowlby’s theory has found important confirmation in Mary Ainsworth [23], who invented the strange Situation, a standardized observational procedure that allows to evaluate the attachment of the child from twelve months of age. It is an experimental situation consisting of 8 micro episodes, lasting about three minutes each, in which the behavior of the child is observed in the presence of the mother, when it is separated from her and at the time of reunification (Figure 1). Other scholars have added other styles of attachment, notably:
• At Main and Solomon [24,25] we owe the introduction of the disorganized/disoriented attachment observed in children with mothers who did not process a trauma or mourning during their childhood [26];
• Crittenden has introduced avoidant/ambivalent attachment that seems to correspond to a defensive strategy against abusive mothers [26].
Figure 1
Several studies have examined the relationship between attachment styles and obsessive love, Hazan and Shaver [27] were the first to broaden the theory of attachment to adult romantic relationships, suggesting that the anxious-attachment style could be a risk factor for the development of obsessive love. Feeney and Noller [28] conducted a study involving a sample of 374 university students [162 males and 212 females] aged 17-58 and almost all single. A series of questionnaires were administered that evaluated the attachment style and the love style and the results showed that the anxious-ambivalent attachment group reported high levels of dependence, the desire to be involved in romantic relationships, although these were characterized by less stability. They also highlighted a greater propensity for obsessive concern, idealization of the partner to rely on, and emotional dependence. Otherwise, subjects with safe and avoidant attachment were characterized by greater self-confidence and others, stable and positive relationships, the latter by the tendency to avoid intimacy, little or no intense relationships. This study seems to confirm that the style of attachment affects adult romantic relationships and that the anxious-ambivalent attachment style may be the basis for the development of love addiction. The study of Ahmadi, et. al. [29] aimed to investigate the relationship between obsessive love and attachment styles. It was conducted on a sample of 290 students [117 females and 173 males]. They were given the Passionate Love Scale [PLS] and the Adult Attachment Inventory. The results showed a significant relationship between anxious-ambivalent attachment style and obsessive love. The child, with such a style of attachment, manifests separation anxiety because of a reference figure who tends to have an inconsistent attitude. As a result, as adults these individuals show a constant concern for their relationships and fear separation, rejection and betrayal by the partner, becoming dependent on them.
This study also confirms that the anxious-ambivalent attachment style can determine the development of obsessive love. A more recent study aimed at investigating the relationship between attachment styles and obsessive love style is that of Honari and Saremi [30]. The sample consisted of 306 students, who were given the following questionnaires: Adult Attachment Style [AAQ] and Love Attitude Style [LAS]. From such a study emerged a significant association between the obsessive love style and the anxious-ambivalent attachment style; while the same could not be said about the relationship between safe and insecure-avoiding attachment styles and obsessive love. This study also concludes that the anxious-ambivalent attachment style can predict obsessive love style. In this regard, the authors stress that evaluating attachment styles is important as it allows prediction of people’s love styles. Borgioni [31] also associated affective dependence with anxious-ambivalent attachment. Subjects with this style of attachment had a caregiver present intermittently and often assumed the role of “adult child”, as they were the ones to take care of the parents. In adult romantic relationships these subjects tend to unconsciously recreate the same dynamics that were created with the parent. Research in the literature seems to confirm that anxious-ambivalent attachment is at the origin of affective dependence, also given the overlap of their typical characteristics. For example, concern, vigilance, rumination are factors that are observed in romantic love [32,33] and obsession [American Psychiatric Association, 2000], but are also linked to anxious attachment. It should be noted, however, that some research indicates that attachment is not stable over time and may be influenced by further relationships. For example, Belsky, et al. [34] indicate that, after three months from the initial administration of the attachment assessment questionnaires, about fifty percent of people have a different attachment style. However, the research has shown that the first experiences with the caregiver have quite important effects on the development of affective dependence.
Adult Attachment and Self-Esteem
According to Bowlby’s theory, the first relationships with the reference figures are internalized by the child and constitute the internal operating models [MOI]. The latter are mental representations of self and attachment figure that are formed during childhood, but remain over time, as they influence future interpersonal relationships, orient the subject’s worldview, behavior, and his beliefs and expectations [27]. In accordance with this concept of Bowlby, Bartholomew, and Horowitz [35] developed an “adult attachment model”. From the combination of two dimensions, the “model of self” and the “model of the other”, or the positive or negative perception that each has of oneself and the other, they have identified four different styles of adult attachment: The secure attachment style manifests itself in subjects who have a positive perception of both themselves, as they feel lovable, and others, as they expect people to be available. In addition, they are comfortable with intimacy and autonomy, and possess adequate emotional regulation strategies; The insecure, concerned attachment style is observed in subjects who, having a negative view of themselves, feel inadequate, while others are assessed positively. Such individuals need support, love, and seek the approval of others; The insecure attachment style of the buffer manifests itself in subjects who have a positive image of themselves and a negative view of others, who are considered unreliable. In addition, these subjects tend to avoid intimate relationships; Fearful insecure attachment style is typical of subjects who have a negative view of both them and others. Such individuals desire contacts and intimacy, however, given the lack of trust in others and the fear of being rejected, they avoid intimate relationships. Individuals with concerned attachment and those with fearful attachment, therefore, tend to manifest greater dependence on others.
In this regard, Gori, et. al [36] conducted research with the aim of analyzing variables that may be associated with affective dependence, with particular attention to adult attachment patterns and self-esteem. The research involved a sample of 300 individuals engaged in a love relationship. Subjects were given the following questionnaires: Love Addiction Inventory – Short form [LAI – SF], Relationship Questionnaire [RQ] and Rosenberg self-esteem Scale [RSES]. The results of such research showed, first, a significant relationship only between affective dependence and concerned and fearful adult attachment; Secondly, it emerged that self-esteem plays a mediating role in the relationship between adult attachment patterns and emotional dependence. Individuals who present these attachment styles have a negative view of themselves [37], as a result they show low levels of self-esteem, factors that can lead to dysfunctional relationships characterized by excessive dependence on the partner [38]. In the literature there are studies that examined the relationship between self-esteem and attachment, the results, showed that there is an association between insecure attachment and low self-esteem levels [39,40]; it is also shown that low levels of self-esteem can lead to the onset of interpersonal dependence [38]. However, the authors of this research believe it is necessary to emphasize that it may be the affective dependence itself that influences the self-esteem of the subject, thus determining a vicious circle.
Trauma, Dissociation and Emotional Dysregulation
Several studies have shown that pathological addictions are closely related to both childhood trauma and to emotional dissociation and dysregulation [41,42]. Exposure to childhood relational trauma, such as experiences of emotional deprivation, physical, sexual and/ or psychological abuse, can lead to conditions such as dissociation and emotional dysregulation. Dissociation is defined as a “disintegration of normally integrated functions of consciousness, memory, identity, or perception of the environment” [43]. It is a defense mechanism that isolates from his consciousness a painful experience and the emotions connected to it; It has, therefore, the aim of protecting the ego from pain through the alteration of the state of consciousness, inhibiting information experienced as intolerable and creating a more positive reality in which to take refuge [44]. Dissociation is not a dysfunctional aspect; however, a pathological recourse to this type of mechanism can lead to an impoverishment of the personality of the subject, a compromise of the sense of continuity of one’s identity, detachment from reality, causing a deficit in mentalization and self-regulation of emotions [42]. The child, in his first years of life, does not have the ability to independently regulate their emotional states; Therefore, it is necessary the intervention of the caregiver to help him manage his emotions and at the same time allow him to learn the ability to manage them independently [45]. The “good enough” caregiver Winnicott [46] will be able to provide adequate responses to the emotional states of the child and this will allow him to develop a “theory of mind” [47] becoming aware of his own emotions and those of others; This happens, therefore, in the case of a secure attachment with the parent. The child thus gradually learns and develops the ability to regulate his emotions independently [45].
Otherwise, if the child has experienced an emotionally neglectful caregiver, who is not able to regulate his emotions, he will not develop the ability to mentalize and regulate his emotions [45]. Rather, he will find himself in a state of emotional dysregulation, that is, he will not be able to regulate his emotions on his own and will have difficulty tolerating negative emotional states. As a result, the subject will most likely have to resort to an external regulator that allows him to return to a state of rest. Such a regulator can be identified in a substance or dependent behavior, the use of which represents a dysfunctional strategy of emotional self-regulation; this can lead to the onset of a pathological dependence, where the object of dependence would represent an external regulator of one’s emotional states [44]. In the literature there are several studies by Caretti and collaborators that highlight the significant correlation between dissociation and emotional dysregulation, resulting from relational trauma, and the different forms of pathological dependence. About love addiction, Stavola, et al. [46] conducted research to assess the predisposing factors of this type of addiction. They hypothesized that the dissociation and emotional dysregulation that occur as a result of a childhood relational trauma and insecure attachment style are the basis of emotional dependence. The results confirmed what the authors had assumed, as a significant association emerged between trauma, attachment, dissociation, and emotional dysregulation, confirming them as predisposing factors to love addiction. child has experienced an emotionally neglectful caregiver, who is not able to regulate his emotions, he will not develop the ability to mentalize and regulate his emotions [45]. Sociocultural factors in addition to neurobiological aspects and psychological factors, there are also sociocultural factors underlying affective dependence. The mass media seem to have a significant influence on the development of affective addiction [47]: movies, TV series, songs, novels often tend to represent love in a pathological way [48,49].
Vannini and Myers [50] conducted a study to analyze the lyrics of albums belonging to the musical genre “teen pop”, a genre of music that is aimed primarily at a teenage audience. The main theme of these songs is romantic love, which is described as an intense desire, “an overwhelming and painful experience”. Described lovers tend to have obsessive thoughts and feelings and idealize their partner. Often the lyrics of these songs convey the idea that you cannot live without the other person, now indispensable. These kinds of songs can have a significant impact on young teens, who use the meaning of lyrics to build their identity, to understand how relationships work. These texts convey a kind of pathological love, which is represented as ideal love, can affect the way young adolescents conceive love and what they expect from relationships. Even movies often transmit dysfunctional relational dynamics, and this can lead teenagers to search for those same dynamics, considered right. In addition, affective dependence seems to prevail in women, for example, Miller [50] claims that 99% of affective dependent subjects are female. According to Sussman [47] gender would affect the ways in which emotional dependence manifests itself. In this a key role is played by culture, which seems to strengthen affective dependence: the gender stereotype sees women as too sensitive, naive, weak, passive, not very rational, dependent, dedicated to the care of others, putting aside herself, submissive to the will of others; while, man tends to be seen as more rational, stronger and independent. Such stereotypes can influence the behaviour of women, who, to conform to cultural expectations, risk entering into dysfunctional, potentially dangerous relationships.
Anxious and Depressive Symptoms
Affective dependence can significantly affect the psychological and physical well-being of the person. For the affective dependent subjects, the relationship with the partner becomes of fundamental importance; consequently, everything that does not concern the relationship passes into the background: they lose interest in activities that they loved to practice previously, are unable to concentrate on work and study, friendships and family relationships are neglected. All this can lead to social isolation. Moreover, the fear of losing a partner, of being abandoned or rejected, can make the affective employee experience strong anxious and depressive states. Excessive worry and anxiety can lead to the development of a real generalized anxiety disorder that is characterized by the presence of “physical symptoms [muscle tension, restlessness, easy fatigue], neurovegetative [tachycardia, dyspnea, tremors, dizziness] and psychological [difficulty concentrating, irritability]” [19]. The affective employee may also develop a “major depressive disorder” [16] whose main symptoms are: depressed mood, loss of interest or pleasure in previous activities, impaired weight and appetite, loss of energy and fatigue, insomnia or hypersomnia, feelings of guilt and self-assessment, difficulty in contracting and suicidal thoughts [16]. Fisher and colleagues [51] point out that romantic rejection can compromise the subject’s psychological health, inducing clinical depression and in the most extreme cases can lead to suicide. It can also impair physical health, as an increase in blood pressure and a lowering of the immune system may occur, due to severe stress [52]. Even more serious consequences occur when the partner, to whom you are emotionally dependent, decides to end the relationship or when you remain in a dysfunctional relationship, despite being dangerous to your life.
Intimate Partner Violence
Affective addicts tend to enter relationships with abusive, abusive, violent, manipulative and detached persons [3]. A peculiar feature of affective dependence is that, despite suffering, the dependent subject cannot end the relationship and causes the behavior of the partner to be attributed to the traumas of his childhood [53]. The “women who love too much” have the dysfunctional belief that it is only by sacrificing and dedicating themselves totally to the other, cancelling sexless, that they can help the partner. This belief only feeds the permanence in the relationship; permanence that can prove lethal for one’s life. They do not manage to separate from their partner, as it would be too painful for them and prefer, rather, to cling to the illusion and hope that the partner changes, a wait that turns out to be useless as this will never happen. The risk that the affective addicted may face is that of entering abusive relationships, becoming a victim of domestic violence, which in English is called intimate partner violence. The UN defines IPV as “the behavior of an intimate partner or ex-partner that causes physical, sexual or psychological harm, including physical aggression, sexual coercion, psychological abuse or controlling behavior” [UN, 1993]. In addition, it is very important to understand the dynamic between the affective addicted and the abusive and violent partner, because it becomes even more difficult for her to end the relationship. In this regard, Lenore Walker [54] has developed a model of “cycle of violence” that defines “the progressive and ruinous vortex in which the woman is swallowed by the continuous, systematic, and therefore cyclical violence, by the particular party, the author believes that there are three phases of domestic violence: “phase of construction of tension”, “explosion or violence phase” and “reconciliation/ honeymoon phase” [55].
The first phase of construction of tension [“tension building phase”] is characterized by the progressive increase of tension in the relationship, due to frequent conflicts and verbal violence against the victim. The latter perceives that the partner is always nervous and irritated; therefore, to avoid further conflicts, the victim will tend to take a pandering attitude, trying to appease the partner. In the second phase of explosion or violence [“explosion phase”] there occurs the loss of control by the aggressor that results in real violence. This may include physical, psychological and/or sexual abuse of the victim. In the third phase of reconciliation/honeymoon [“honeymoon phase”] the aggressor, can show repentance, seeming, kind, makes romantic gestures, apologizes and promises that it will not happen anymore, that will change, manipulating thus the victim, who will sincerely believe his aggressor, and will continue to hope that the relationship will improve and that he can really change [56]. However, unfortunately, this will never materialize in fact, following the “honeymoon” phase, the cycle starts again from the first phase. This pattern of behavior can help to strengthen the dependency of the victim, who will feel responsible and take the blame for the situation, believing that she deserves it, further undermining the already low self-esteem. Moreover, as the dysfunctional relationship continues, these phases will occur more frequently, more intensely and more rapidly, to the point that psychological, physical, economic, and sexual violence leads to feminicide. November 25 is the international day against violence against women, “wounded, massacred, humiliated women who carry in their body and soul the bruises of what was thought to be love” “When being in love means suffering, we are loving too much. [..] When we justify her moods, her bad temper, her indifference, or consider them the consequences of an unhappy childhood and try to become her therapist, we love her too much. […] When our relationship with him jeopardizes our emotional well-being, and perhaps even our health and safety, we are loving too much” [54]. The criminal analysis service reports that from 1 January to 3 September 2023 there were 225 murders, of which 77 are female victims, 61 killed in the family/ affective; 38 of these died because of the partner or former partner (Ministry of the Interior, 2023).
Individual Therapies
According to some authors, among individual therapies, cognitive behavioral therapy and psychodynamic treatment could be beneficial in the treatment of affective dependence [55]. Some authors have suggested that cognitive behavioral therapy (CBT) may have a potential benefit in treating affective dependence. Automatic thoughts and cognitive distortions (such as generalization, catastrophization) could play a decisive role in maintaining affective dependence [55]. Cognitive behavioral therapy could be effective in addressing these distortions, through cognitive restructuring: fundamental is, therefore, to make the patient aware of his patterns of negative thoughts and adopt appropriate strategies to modify them. However, again, there are no studies on the use of CBT in the treatment of affective dependence [55].
Drug Treatment
Although there is no scientific evidence in the literature to prove the efficacy of a drug treatment of affective dependence, Sanches, and John [55] suggest that the phenomenological characteristics and neurobiological mechanisms involved in this condition, suggest that the use of drugs may be beneficial for the treatment of affective dependence. However, the bioethical implications must be considered; in particular, Earp and colleagues [57] have highlighted some situations in which it would be justified to use drug treatment for affective dependence. According to these authors, it can be considered to treat love using drugs only when this causes pain and suffering to the patient, as in the case of domestic violence, or when psychological treatments are not sufficient [56]. Sanches and John [55] hypothesize that affective dependence can be treated using drugs such as antidepressants, mood stabilizers, antipsychotics, and exogenous neuropeptides. Since obsessive-compulsive disorder (OCD) and some cases of affective dependence have similar phenomenological characteristics, the authors hypothesize that antidepressants, specifically selective serotonin reuptake inhibitors [SSRIs] may also play a role in the management of affective dependence, given the effectiveness of SSRIs in the treatment of DOC [55]. SSRIs may be useful in reducing obsessive thoughts, typical of both phenomena [56] In addition, affective dependence and impulsiveness are strongly correlated, which suggests that mood stabilizers may play a role in managing this condition [55]. Further drugs that could be useful in the treatment of affective dependence are antipsychotics, due to their function as dopamine antagonists. Antipsychotics could modulate the dopaminergic activity that is activated during falling in love [55]. As for exogenous neuropeptides, studies have shown that vasopressin and oxytocin are involved in the attachment system. Finally, it could be hypothesized that drugs used to treat addictions may be beneficial for the treatment of love addiction, given the similarity between the two conditions: for example, naltrexonee buprenorphine [55]. The authors stress the importance of further studies to investigate whether these drugs can benefit the treatment of affective dependence [55].
Group Therapy
Group therapy is considered by many authors as the treatment of choice for affective dependence [55]. Yalom [56] identified several factors that appear to be therapeutic within a group, such as: “the infusion of hope, universality, information, altruism, corrective recapitulation of the family primary group, the development of socialization techniques, imitative behavior, interpersonal learning, group cohesion, catharsis and existential factors” [56]. Within a group, therefore, a climate of trust will be created that will allow patients to tell each other without shame. This will allow members of the group to find emotional support, to feel understood and less alone, as they all share the same issue. In addition, listening to the story of others can stimulate important reflections in the patient who faces that same pain. However, there are no studies showing the effectiveness of these selfhelp groups [55].
Conclusion
During this review, we have deepened the affective dependence and we have seen that it is a complex phenomenon that involves several factors and significantly influences the psychological well-being of the people involved. The findings from this work emphasize the importance of the quality of primary relationships, as it was seen as an anxious attachment-ambivalent, having experienced relational traumas in childhood are actors predisposed to affective dependence. Studies have shown that at the base of love addiction there are neurobiological mechanisms analogous to those that occur in substance dependence. It also emerged that society and culture play a crucial role in maintaining this condition, suggesting the importance of primarily cultural change. Subjects with affective dependence tend to enter into abusive relationships, with the risk of becoming victims of domestic violence, and this makes us reflect on the importance of paying more attention and gaining greater awareness of this issue. “The general objective that every woman must achieve is the conquest of independence and emotional autonomy, without suffering the bullying of those who want to prevail by inducing feelings of guilt. And do not call it love, love is another thing, because to love is to give oneself in a perspective of reciprocity and sharing”[57].
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