INTRODUCTION

Affective dependence, counted among the pathological addictions defined without substance or new addiction, is also known in the scientific literature as love addiction, affective addiction, or emotional dependence.

Currently, these new behavioral addictions are defined as pathological conditions that do not involve the ingestion of a chemical substance. These are essentially behaviors that are commonly accepted and not stigmatized by society as in the case of substance consumption.¹

Love addiction presents itself as an incessant need for the presence of the other indispensable for one’s life, a relationship within which purely dysfunctional behaviors associated with a recurrent fear of abandonment are implemented.

Especially when we talk about love, since ancient centuries, we refer to a courteous feeling under control or as an alternative form of love for God, but few are the examples reported of the other side of this passionate force, the true one that sometimes it hurts.²

It follows that this series of terminologies and ideas associated with love has created an inconsistent perception of itself.

Its appearance in the literature can be traced back to the mid-eighties³ but the scientific interest in it was born about ten years ago, and despite this behavioral dependence it is not yet included in any nosographic classification, the first change for the conceptualization of behavioral addictions occurs in May 2013. In fact, in that year, the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders included the “Disorders not related to substances” in the section on Substance-Related Disorders and Addiction Disorders.⁴

When we refer to love addiction, we are alluding to all those changes that suffocate and suppress the life of these “addicted” subjects and the people who are close to them.⁵ There are various elements of immaturity within a relationship, especially obsessive ones, and these fall into the categories of interest of many scholars who want to analyze them above all longitudinally.

Going deeper and deeper into the heart of this study, we come to the awareness of how pervasive and disabling this form of addiction can be; in fact, this condition can reach extreme levels resulting in physical and psychological abuse.⁵ However, the even more disconcerting fact is the inability of dependent subjects to leave their partner despite the abuses. Logically it follows that in a healthy love relationship the care of the partner has a limited duration and that one’s psychophysical health, social and family life are preserved.

Love addiction generally occurs in a subset of the population and some epidemiological data, subsequently also many books, report that a high percentage most exposed to this addiction is the female population.³

Of course, not all lovers develop this pathology, in fact, we speak of emotional dependence when the partner becomes the center of the world, and a disorganization of the individual’s psychological characteristics and social life slowly follows one another.⁶

There is a great gender difference in psychic functioning, and this leads the male population to react differently than the female sex.⁷

The latter seems naturally inclined to think continuously about that painful situation of love experienced, as if this made him relive that situation in order to be able to control or modify it in some way.⁸ If women withdraw into themselves and into their own pain, on the contrary, men remove all memories and what causes anguish from their minds, devoting themselves entirely to something else; in fact, in most cases when the relationship ends, men are more likely to resort to external factors such as alcohol and drugs, reiterating the mode of intercourse.⁵

Erroneously, especially in recent years, emotional dependence has been trivially considered a behavioral addiction by not considering its real danger in the psychopathological manifestation of an individual’s personality.⁶ To date, it is very difficult for professionals to diagnose love addiction since it is a pathology still little studied with insufficient theoretical data, which does not allow an official classification of adequate diagnostic criteria.

It is currently difficult to trace the origin of the disorder but what he knows for sure is that the basis of this pathological condition is similar to drug or alcohol addiction. As time progresses, the emotional addict, just like in substance use disorder, spends all the time available around the partner and voluntarily chooses to start avoiding other social contacts - not only in the friend sphere but above all in the family sphere, work, interests, and hobbies are gradually abandoned.⁹

The characteristics of this love addiction show a person with insecure attachment, low self-esteem, and extreme need for reassurance.

There are many articles in the literature that, in fact, compare: the diagnostic criteria of substance addiction to love addiction, articles that use behavioral dependence rating scales for the analysis of emotional dependence,¹⁰ articles that have tried to investigate implications on treatment by advancing hypotheses in favor of cognitive behavioral therapy (CBT) or group psychotherapy,¹¹ articles that propose useful criteria for the identification of affective addiction through comparison with substance addiction,¹² obsessive compulsive disorder or mood disorders.¹¹ Yet, despite these data, there are still very few applied studies on a real sample of the reference population. There are still too many questions that must be placed in the answers of science, especially regarding the methodology of intervention for the phases of prevention and therapeutic treatment.

The object of the work of this systematic review is to deepen the current studies present in the scientific panorama, to try to investigate what could be the indications of future possibilities of diagnosis and specific intervention methods which, to date, are still far away.

MATERIALS AND METHODS

Research Object

The purpose of this research is to verify the current diagnostic paradigms associated with this new behavioral dependence, to investigate in depth what has not yet emerged, to search for strong and weak correlations with other theoretical constructs, to investigate which evaluation scales are currently used and to outline a design guide that allows scholars to move between current scientific discoveries.

Search Strategies

The systematic review was completely carried out according to the PRISMA 2020 guidelines for systematic review by PRISMA Group.¹³ The bibliographic research was carried out from November 2021 until July 2022 in the databases of the PubMed, National Center for Biotechnology Information (NCBI), PsycINFO, MDPI, APA, ScienceDirect, SAGE Journals, and ReserchGate sites using the following search term strings: (“love addiction”) OR (“love disorder”) OR ("emotional dependence) OR (“new addiction”) OR (“romantic Obsession”) OR (“maladaptive romantic love”). The electronic searching was supplemented by hand searching the reference list in the included review articles and analyzing four books to identify any additional sources.

Eligibility Criteria

We have included every article written in English with no time limit on publication date, meeting the following criteria:

1. Participants: patients suffering from love addiction.

2. Intervention: any type of analysis that deepens the passionate love in subjects involved in long and short-term relationships. At the time of the research, being engaged in a relationship was not considered an important criterion, on the contrary, what was taken into consideration is having had intense love experiences.

3. Comparison: psychological characteristics of the subjects before and after the romantic experience through evaluation scales.

4. Outcomes: attachment styles, types of love, personality, levels of satisfaction and impulsivity were considered, also for subsequent therapeutic choices.

Data Extraction

The data was extracted using a basic format that included for each article: language, year, title, sample, types of intervention, frequency and duration of the interventions.

Risk of Bias Assessment

The risk of bias for the included studies was assessed with Cochrane risk-of-bias too for randomized trials, version 2 (RoB 2) by Sterne et al.¹⁴

RESULT

Characteristics of the Included Studies

The total articles that appeared from the search phase in the databases listed above produced a total of 95 studies. During the review we also identified 7 other articles that were not detected by the research but that other analyzed have cited. After this first phase, following a careful analysis of the title and year of publication - a fundamental phase for the inclusion of only recent studies from the 90s onwards, 46 duplicate articles were eliminated, thus identifying 56 unique articles.

The small number of articles is very limiting, it in turn highlights how these new addictions are a new field yet to be explored in depth.

The consequential unique articles were further examined, through the analysis of abstracts, language in which they were published and research content - as many of these articles contain information related to brain structures and the action of various associated neurotransmitters, not compatible with the established theme of the paper. Thus, 34 articles were eliminated, the rest were read in full and only after further analyzes were another 17 articles eliminated which did not correspond to the eligibility criteria, in particular regarding comparison and outcomes; they were articles that did not analyze psychological characteristics during relationships but simply obsessive jealousy. The final qualitative number of total studies included in the research was 5.

The above description, reporting which items to include and which to exclude, is summarized in the flowchart in Figure 1. The data extraction has been simplified in Table 1. Furthermore, the last part concerning the risk of bias control analysis with the RoB2 tool was summarized in Figure 2.

Figure 1.PRISMA (2020) Flow Diagram.

Figure 2.Cochrane risk-of-bias tool (RoB 2).

Table 1.

Legend: LAI = Love Addiction Inventory; PANAS = Positive and Negative Affect Schedule; LASA = Love Addiction Self Assesment; LAI-SF = Love Addiction Inventory – Short Form; RBI = Relationship Belif Inventory; PLS = Passionate Love Scale; AAI = Adult Attachment Inventory; SCID = Clinical Interview For Diagnosis; SDQ = Sociodemographic Data Questionnair; BDI = Beck Depressione Inventory; STAI = State- Trait Anxiety Inventory; BIS = Barrat Impulsiveness Scale; TCI = Self reporting true or false; RAS = Relationship Assesment Scale; LAS = Love Attitudes Scale;

Table 1.Cont.

Table 1.Cont.

Table 1.Cont.

Psychometric characteristics of love addiction

The first research by Costa et al.,¹⁰ in addition to the complex psychometric characteristics of love addiction, refer to one of the biggest problems currently of this addiction, namely the lack of tools that can fully evaluate it.

Many studies over time have tried to understand and define the psychology of love, many factors underlying this construct, its problems and also its correlations have been explored. Even today there is no official classification of the criteria that concern it, much less a certified evaluation scale. Despite this, many scales, albeit obsolete, have been developed in the scientific landscape to try to enter this new and interesting world.

However, what the authors of this article want to highlight is that these scales, especially those recently developed, and available for the most part online, have been built without theoretical bases or well-defined constructs. It is precisely from this consideration that the desire to create a sufficiently robust staircase to be able to definitively frame this theoretical construct that has become fundamental in our days arises.

Costa et al.,¹⁰ present in their study for the first time the Love Addiction Inventory (LAI), a scale constructed by referring as a theoretical construct to the model of the components of dependence by Griffiths¹⁵ giving particular importance to its six dimensions: salience, tolerance, mood change, relapse, withdrawal and conflict. The Love Addiction Inventory consists of 24 total items, of which four indicators for each of the six dimensions, which perfectly frame the dysfunctional character of the emotional employee. Although all dimensions are fundamental in the analysis of love addiction, the areas to which particular attention is given are the dimension of mood modification and conflict, since they embody all the characteristics hitherto considered fundamental that allow to diagnose the presence of this disorder. In the area of mood modification the subject will have to respond to statements, such as: “You spend time with your partner to forget about your suffering” or “Stay with your partner to relieve stress”; while as regards the conflict area, they are reported statements such as: “Giving up your hobbies to be with your partner” or “Giving up your family and social commitments because of the relationship with your partner”.

In order to verify the effectiveness of LAI, two studies were created using different samples but with the same characteristic, that is, being involved in a romantic relationship for at least six months. Both studies confirm how these six dimensions, initially created for addiction in general, almost flawlessly reflect affective addiction, obtaining a great level of internal reliability. Although this new tool is optimal by evaluating emotional dependence as a continuous variable, it does not allow us to observe individuals at risk. Therefore, the ideal would be to repeat this study with the same scale for a longer period of time and especially on a larger population.

Style of attachment and obsessive love

Two studies in particular investigated the relationship between attachment styles and emotional dependence. Stackert et al.¹⁶ reported how individual differences in attachment styles allow for specific consequences in future relationships, in particular how irrational beliefs affect satisfaction within a love relationship. These dysfunctional beliefs were theorized in the 1960s by Albert Ellis,^17(p1421) in reference to cognitive-behavioral theory. They arise from an emotional distress that involves the formation of rigid structures of thought that cause the acceptance of a series of purely unreal beliefs. The latter especially threaten the relationships of individuals with an insecure attachment style. According to this viewpoint, romantic love must be considered as an attachment process in which a person binds himself emotionally and emotionally to his partner, just like a child would do with his parents.

Furthermore, in this study, special scales were used both to verify adult attachment style (AAQ) and relationship satisfaction (RAS), and to evaluate relationship-specific unreal beliefs (RBI).

The results of the following study confirm that: participants described with an insecure attachment style have stronger unreal beliefs than subjects with a secure attachment style and, as described above, these beliefs offer a huge obstacle in the love relationship. Women showed greater sensitivity in the relationship and showed irrationality regarding the disagreement, while men showed greater irrationality regarding sexual perfectionism.

Ahmadi et al.¹⁸ propose a study focusing on which attachment style is most likely to be related to the development of love addiction. To analyze the different attachment styles, the Passionate Love Scale (PLS) was used, consisting of 30 items on a nine-point scale. According to the PLS, high scores correspond to high levels of love.

The results of the scale showed that the ambivalent attachment style proves to have a strong significant correlation with this new addiction, but the confirmation came from the multiple regression analysis which outlines how only an ambivalent attachment style can predict emotional dependence. (F = 22.43, p <0.001).

Styles of love and personality

Although there are currently no studies in the literature focusing on typical personality traits in individuals with love addiction, Eglacy et al.¹⁹ attempted to propose a study investigate personality differences and relational aspects in healthy people with LA. This research is based on Lee’s²⁰ theoretical foundation of the six love styles: "Eros (passionate love), Ludus (love as a game), Storge (love of friendship), Mania (dependent, possessive), Pragma (logical love) and Agape (selfless and benevolent love). " Based on these styles, there is a particular personality that can be subject to dependent love.

The sample for this research consists of 89 subjects, aged 21 to 50, including 50 with love addiction and 39 healthy. The homogeneity between the samples was verified with the SDQ, the application of the Beck Depression Inventory (BDI) and the State-Trait Anxiety Inventory (STAI), as it is important to evaluate the possible presence of depressive and anxious symptoms that could interfere with the personality assessment. Tools were also used to check personality variables, including the Barrat Impulsiveness Scale (BIS), to assess impulsiveness, and the TCI33, for temperament. Finally, the RAS and LAS scales were used for the analysis of the variables of love addiction.

The results of these analyzes are very important as they identified that the subjects with emotional dependence not only reported a high level of impulsiveness but also high levels of temperament, avoidance of harm and self-transcendence - which outlines the difficulties that children have. subjects in establishing a limit between themselves and others. The analysis concluded that the love styles associated with love addicted are mania and agape.

Long-term relationships and LA

The latest research focuses on the amount of time in which romantic feeling remains, present in the early stages of falling in love. There are many theories about it, but few tested in the field. Acevedo et al.²¹ consider elapsed time as a valid variable. In fact, the durability of romantic love during the relationship can turn into feeling of companionship, except for some cases in which it turns into obsessive love. In this study, the authors considered various type to analyze long-term and short-term effects.

In the first study, 156 heterosexual couples were analyzed. Each couple had completed a PLS pre-test and a scale that assesses desirability in the marital setting. The analysis gave a negative result because obsessive love is negatively associated with long-term relationships, addiction may exist, but it is rarer in romantic love.

The second study focuses mainly on the analysis of short and long-term relationships. The sample was divided into 17 in one group for the analysis of short-term relationships and 10 in the other for long-term relationships.

Among the various tools used in the analysis it is possible to find: the PLS for coding romantic love with obsession, the Rubin Love Scale (LSR) for coding love between mates, the Dyadic Adjustment Scale (DAS) for coding of the dyadic adjustment, the Relationship Assessment Scale (RAS) and the Relationship Rating Form (RAF) to estimate the responses of couples along the rating scale.

The research results show that romantic love with obsession is present with a higher percentage in the sample of short-term relationship subjects, on the contrary it is negative and with minimal presence in long-term relationships (Q 7.10, p .01).

DISCUSSION

As we saw during this review, many research attempts to systematically analyze the main studies that have compared emotional dependence with other theoretical constructs, such as the influence of attachment styles, impulsivity, satisfaction, temperament, or self-transcendence.

Currently, as hypothesized, there are no valid alternatives that can allow an officially recognized classification of the diagnostic criteria of this disorder. At the same time, the review made it possible to analyze: the Love Attitude Scale (LAS), one of the main scales used in literature, and the Love Addiction Inventory (LAI), an inventory on emotional addiction idealized recently but with excellent results already in its first applications.

A limitation of these studies is determined by the extreme heterogeneity of the included studies. This level of heterogeneity could be related to the little theoretical availability that exists for this new addiction which is still little studied. Other reasons could relate to the methods adopted, the setting used to recruit the subjects, the age and gender of the samples studied, and the inclusion criteria of the subjects examined.

By critically evaluating the various studies, it is possible to consider how unreliable results could be due to the narrowness and consequent inadequacy of the number of subjects analyzed.

In fact, in most of the studies we observe many quantitative gender differences since a quantitatively higher number of women is considered than men; this could certainly affect future research. A striking example of this phenomenon can be found in the studies by Costa et al.¹⁰ In the first study¹⁰ it is reported that out of a total sample of 329 subjects only 19 are men and the remaining 310 places are occupied by the female population. The same is present in his second study, in which the sample is mainly composed of 316 women and 18 men.

It was also highlighted how often, during the choice of the sample, for research concerning emotional dependence, researchers often consider subjects who have had or have relationship experiences, from a minimum time of six months to a maximum of years. On the contrary, it would be interesting for the comparison between groups, to add the critical eye of subjects who have never had a relationship or have been free for a long time. This data could in fact be very valuable, since it would critically help the analysis for the development of preventive forms and for the risk assessment of LA.

Subsequently, particular attention was paid to the evaluation of the observation times and the duration of the research. Currently it has not been possible to find any article that analyzes love addiction longitudinally and although this may be a very complex idea in its application, it is necessary.

Finally, as a final note, it was found that the studies analyzed showed similar levels of association, this is because most of the research was conducted in America and Italy. Therefore, it would be very interesting to analyze how the different countries, geographically located, consider this dependence.

CONCLUSION

In conclusion, we currently know that emotional dependence presents an ever-greater risk for our population, and it becomes the task of psychologists to highlight the consequent risk factors for psychophysical health.

The little knowledge in the field of these new addictions prevents us from making coherent assumptions about the possible causes of these and other future relationships.

In fact, to date, it is not possible to draw definitive conclusions regarding current research objectives in the field of this new form of dependence, since only a limited number of studies have analyzed these variables. Well, it becomes increasingly important to specify how a possible definitive clinical diagnosis would indicate the beginning of a path of knowledge and care for the love addicted who requires not only adequate staff but above all forms of intervention and treatment that last over time.

In addition, is necessary to point out that, despite the changes reported in the DSM-5, to date there is neither a classification nor diagnostic criteria that officially identify affective dependence.

According to clinical psychology and to our findings, the right way to use for this disorder is the application of group psychotherapy. The scientific landscape suggests that most group therapies and other types of group programs are successful because these dynamics involve reward and attachment systems in the brain in most subjects. As reported by Fisher,⁹ participation in group programs can be important for rejected lovers as well as those addicted to substances such as alcohol or those with a behavioral addiction, such as gambling. In this sense, psychotherapy represents a fundamental methodology, as the subject, thanks to the presence of others, recognizes his own distortions of reality, over time breaking down the defenses that do not allow him to see the truth about his personal history.

And although this recognition of one’s dysfunctional habits can cost years; it is necessary to consciously arrive at its realization by yourself. The group welcomes and transforms those negative feelings that have convinced people to think they deserve that kind of pain.

However, in this climate of innovation, due to the lack of studies on the argument new ones on larger samples are needed to identify diagnostic criteria and other types of therapy.