Patients treated for one addiction frequently develop another, leaving therapists feeling trapped in a very serious game of Whack-a-Mole.
Famously, Bill W., the founder of Alcoholics Anonymous, developed sexual compulsive behavior and other process disorders after he became sober. Other individuals treated for substance abuse may become gamblers or uncontrolled gamers. This often unexpected crossover illuminates certain commonalities between chemical dependency and process addictions.
Fifteen years ago, research by Kenneth Blum, PhD, a RiverMend Scientific Advisory Board member, and colleagues described a reward deficiency syndrome active in gambling, sexual compulsivity, and overeating as well as in alcoholism and substance abuse. They suggested that a variant of a dopamine receptor could be a factor in many compulsive or addictive behaviors.
More recently, neuroimaging research by Eric Stice, PhD, at the Oregon Research Institute, also a RiverMend Health Scientific Advisory Board member, bore out their hypothesis and identified a genetic polymorphism that affected dopamine signaling and reduced an individual’s experience of reward for certain behaviors. This genetic difference occurs more commonly in individuals who have process addictions and, in Stice’s study, it was more prevalent among overeaters.
Even before functional magnetic resonance imaging (fMRI) enabled us to see the neural pathways affected by addiction, physicians noted that behavioral addictions appeared to operate on the same reward pathways as chemical addictions and produce the same patterns. In the 1800s, social commentators called the tendency to addictions “intemperance” and warned that alcohol and tobacco use would lead to excesses in the food consumption, sexual activity, and other behaviors. Today, the term used is Addiction Interaction Disorder and it is understood to include gambling, gaming, food, sex, work, certain financial behaviors, and even religiosity.
A major factor in relapse
Because addictions can play out in so many ways, the failure to address companion addictions is often a major factor in relapse in chemical dependency, as one addiction may support or stimulate another. Consequently, all patients in treatment for one addiction should be carefully screened for others that may be less obvious or currently suppressed.
Superficial screening may not reveal these other addictions. Frequently, spouses or other close family members need to provide input to uncover additional addictive behaviors because the patient is secretive about them or does not see them as relevant to the current course of treatment — or recognize them as addictions.
Process addicts may become preoccupied and obsessed with their compulsions and ignore the danger posed to their lives and general well-being. Consequently, addiction must be treated comprehensively as a full spectrum disorder with attention to causes, triggers, issues of identity, and trauma rather than as a standalone condition.
Since the neuroscience for all addictions share significant commonalities, addicts must understand the risk of replacing chemical dependency with another form of addiction and be prepared to address potentially problematic behaviors as soon as they appear. Most often, replacement addictions will develop six months to a year after a patient stops abusing alcohol or other substances.
All addictions should be treated aggressively
Patrick Carnes outlined a three-part strategy to help addicts understand their addiction, build an awareness of the biochemistry of addiction, and provide tools for sustaining recovery. He recommends first developing a timeline that documents key events in the patient’s life, including the onset of each addiction, low points, and other important dates. This gives the patient and the treatment team a visual representation of the addiction and often enables a discussion of triggering events and consequences of the addiction.
Next, he recommends a neuropathic interview in which the patient is briefed on the biochemistry of the brain and the neural pathways that come into play in addiction. This discussion relieves many patients of the shame of addiction as they recognize their behavior not as a moral failing but as a disorder with a genetic and biochemical foundation. This new understanding also helps patients see how addiction may take multiple forms, all with the same etiology. As awareness builds, patients may share more about other potentially disordered behaviors in their lives.
¬The third step involves a self-assessment guided by the therapist to help patients identify their specific patterns of addiction and how their addictions have developed. The patient also learns the common characteristics of all addictions. In total, the three steps give the addict insight into the power and course of addictions, how addictions interact, and what conditions make them most vulnerable to relapses or new addictions.
At the conclusion of treatment, patients with process addictions are encouraged to follow a program very similar to the one recommended for alcoholics and substance abusers, including a 12-step program specific to their addiction. They should also engage in alternative coping and soothing strategies such as meditation, yoga, ongoing therapy, and a moderate exercise program combined with optimal nutrition.
Following these strategies should give therapists some confidence that they can help their patients find a pathway to breaking their addictions without fear of having to treat other addictions that arise unnecessarily.