Overview of Behavioral Addictions: Part 1 of 3
Dr. Dawn-Elise Snipes defines behavioral addictions as compulsive use of substances, people, or activities, tracing how poor early bonding and low confidence create risk. She maps the path from recreational use to compulsion and outlines DSM criteria and assessment tools clinicians can use immediately.
Chapters
Welcome to your presentation. The overview of behavioral addictions brought to you by allce.com. Throughout this course, we're going to define addiction, define behavioral addictions, examine some of the most common behavioral addictions, explore similarities and differences between behavioral and chemical addictions, and discuss the similarities and differences in treatment between chemical and behavioral addictions. So let's start out by talking about what is an addiction? It's a substance, a person, or an activity. And that's the first part that I really want you to think about. It's not just a substance. A lot of people, when they think about addiction, think about chemical addictions. And it's not just a chemical addiction. It's a substance, a person, or an activity. Pretty much anything that can help someone feel like they're escaping outside of oneself. We generally don't find that kind of stuff within. Used to escape from emotional or physical pain. Now some of you are probably going, well, you know, what's wrong with if you've had a bad day going out and having a couple beers? Nothing at all. I mean, is it the best way to cope? Not necessarily, but a lot of people do it and don't have any problems. Are they addicts? No, the addict part or the addiction part comes in when you continue to do that despite negative consequences. So some people will have a bad day. They'll go out, go out, have a few drinks, chill out, get up the next morning, be like, okay, you know, let's start again. They don't have a problem. It's when you do it habitually and it starts causing other problems. Anywhere from legal issues, family issues, work issues, health issues, and you continue to do it that we look at. Why is this so compelling? So during this course, I'm going to ask you to take a little bit of a paradigm shift. I want you to think of addiction not as a disorder, but as something someone chose or developed as a survival purpose. They could not deal with life on life's terms with the tools they had when that started. Now, that may have been when they were nine. That may have been when they were 29. But whatever it was, this addiction was the best way they had to cope until now because of that. Because the addiction is the one thing that hasn't let them down. And if it's an addiction, they've probably been doing it enough that they need to use in order to even feel normal. It's become their best friend. It's something that's always with them, something they're always thinking about. Everyone's ability to deal with life on life's terms differs. So it's not fair for us to go, well, you know, I don't see where that history that you described to me really is all that bad. So I'm wondering where this addiction came from. Everybody's perception of what happens and everybody's ability to cope with that perception of what happens Is unique to them. So what we need to know is their coping skills got overwhelmed, they didn't have the skills to deal with it, and so they needed to develop something to survive until they could develop better alternatives. Finally, I want you to remember that patients can address the way issues from the past are impacting them today. With addiction especially, it's important to really try to give somebody hope. The minute they come in, the minute they finish their assessment, I want them to walk out of your office with at least one or two tools or activities that they can start doing to start feeling better. Walking out of an assessment, going, well, you can start treatment three weeks from Thursday. That doesn't really give them hope. That's like, okay, fine, you know, I'll show up three weeks from Thursday. And maybe something we do might help. With addictions, we need to strike while the iron is hot, while they're ready. Unlike depression and anxiety and things that kind of make people miserable, Addiction has some benefits to it. So the motivation to change waxes and wanes. And it's important to really keep people moving along in a forward direction. So how do addictions start? There are a lot of different theories, and we could spend weeks theorizing about different ways or reasons addictions start. There are a few that seem to be pretty common, and we're going to talk about those right now. First, the lack of early bonding, the trust, mistrust. When I worked in a residential setting with mothers and babies, One of the things that I would see would be moms took their babies, put them in a swing, let them swing for eight hours, they would get them out when the child started to cry in order to change its diaper, feed it, and put it back in the swing or put it down for a nap. There was very little attention to what the child needed. It was more about what the mom wanted to do with the child at that point in time. So the child didn't really learn to interpret its own inner cues. It didn't learn to trust its own inner instincts that, I'm hungry, I'm cold, I'm scared, I'm stressed, I'm overtired. It was whatever the parent wanted to do. So when children grow up and they haven't learned to trust those basic instincts. It's hard for them to identify feelings, which means stuff builds up. If they can't identify it, they can't really deal with it. If they can't deal with it, eventually it's all going to just come bleh. Spilling out. So lack of early bonding is a big one that we need to look at in terms of not only the cause of the addiction, but also what are we going to do for the recovery process. Most addicts need to learn to trust their own cues. Most of them probably never learned to effectively do it to begin with. Some of them did, but they've started ignoring those cues, which is why the relapses come from out of the blue. Nothing comes from out of the blue. You weren't paying attention, but it doesn't come from out of the blue. The other thing that happens in this early bonding phase, this is the pre preschool phase, is, is children learn to trust other people and they learn to trust themselves. If they don't have an emotionally available, stable caregiver during this period, they're going to have difficulty forming healthy relationships in the future, and they're probably going to cling to unhealthy relationships and try to find things to make them feel safe. Okay, so let's move on to lack of confidence. Once kids get into elementary school and middle school, you have that industry versus inferiority period. And some of you are probably recognizing Erickson's stages right now. Industry and inferiority is kind of a big. There's two Ericksonian stages, but it kind of all builds toward helping people develop self confidence that if they try to do something, they will succeed. Or if they try and fail, that's okay. This is when children learn it's okay to fail. The point is, or the important thing is that you try. When children don't learn this, then they're afraid to try, they're afraid to think, they're afraid to initiate. So then they become dependent on other people to tell them how they should feel, what they should do. If they don't have positive, healthy people in their life to do that, then they start making poorer choices. And really, is this a way that we really want people to live as adults waiting to be told what to do, what to think, what to feel? Then we move on to the stages of identity versus role confusion and intimacy. This is your early and late adolescence. People start forming relationships and they learn who they are, what their values are, what they stand for. If they're constantly Being told they're wrong, or if they're constantly just desperately seeking approval from other people and they don't have self approval, then you're going to have somebody who defines themselves by their relationships, by their activities, by their finances, by what they have instead of by who they are, which again can create some problems. So there are, those are three of the developmental areas that we want to look at for what is motivating this distress. The person is experiencing other things that can cause or make worse an addiction. People may start with recreational use and you know, they go out, they drink, makes them feel good, then they have a bad day, they drink, makes them feel good. They're like, oh, there's a pattern here. I think I want to keep doing this. After a little bit of recreational use, it becomes more frequent. The increase in frequency starts causing changes in brain chemistry, changes in friends, changes in priorities. And you see where we're starting to head down this path. The other one, which I put in the same bullet point, is prescribed use. Some people after they've had a surgery will have opiates. They will be prescribed Vicodin or oxycodone or hydrocodone, and they take it and it makes the pain stop. You know, it makes the pain stop really good. But some people also find that it gives them energy, it makes them feel good. It's their, you know, for lack of a better term, I'm going to paraphrase when one of my clients called it. It's a screw it pill. They take it, they don't care, the anxiety goes away and they feel like they're uber selves. This is important to remember people who start using opiates and start abusing opiates. We really want to look for some anxiety issues in addition to obviously chronic pain and just the general addiction issues. But prescribed use can become addictive use when the person taking that prescription finds that it makes them feel really good and they start using it for purposes other than recovering from that particular injury, pain. And finally, mental health issues. And this is one of my many soapboxes. People who have undiagnosed mental health issues may self medicate with drugs, alcohol, behavioral addictions. People who have addictions may cause mental health issues. They may cause brain chemistry to change. Even if they don't. Some of the fallout from their addiction, the social consequences, occupational consequences, cognitive consequences from their addiction may start producing symptoms of depression and, or anxiety. And we're going to talk about that more later. It's important to me that you think about whether it really matters whether someone started their addiction before or after the mental health issues. Because once they stop using, regardless of when it started, they're still going to have that mental health issue. And until, you know, say it started because of the addiction. All right, that's fine. Once the brain chemistry balances out and once they deal with all the fallout from their addiction, then, you know, maybe they're going to be hunky dory. But that could be two years from now. Is the person going to be able to white knuckle it without their addiction, but with all of this anxiety or depression, are they going to be able to just hold on for dear life without addressing the mental health issues from a pharmacological standpoint or from a counseling standpoint? Again, addiction starts for a myriad of reasons. We don't really know why some people develop and some people don't. We know there are some risk and protective factors, but that's a whole different class. Keep in mind though, that an addiction starts as the person's best way to survive because they've exhausted everything else with the tools they have at a given time. Now, if somebody's addiction or their addictive behavior started back when they were nine, nine year olds don't have a whole lot of tools. If they come to you when they're 29, they've probably picked up a couple along the way. That's awesome. We can build on that. But they're still acting like the nine year old because they haven't made that transition in their mind to say, you know, I can deal with this differently now. So now we have the gelenic curve. The gellenic curve is basically a rough representation of what happens when people start using recreationally, become addicted, hit bottom, get treatment, and find recovery. Which is all well and good. Now I have simplified it greatly. If you google it, you can see all the other little sub things that I took out. With the genic curve, we want to focus on the fact that generally any addiction is going to start with some sort of incidental exposure, recreational use, and let's use gambling as an example here. Recreational gambling, betting on football games, having fantasy football, going to poker nights. A lot of people do those things. Are they addicts? No. However, sometimes when people know that something makes them feel good and then they have a bad day or something happens, the bottom falls out. They may turn to whatever that is to help them escape from it. And they're not really dealing with whatever it is that caused their upset. And maybe it's not something they can really deal with right now, but they turn to something to escape. They start to realize that whatever this tool is works really well, so they want to do it again. They also realize that whatever this tool is is really fun. It makes them feel good, so they want to do it even when they're not overly stressed or overly anxious. Gambling have people start having an increased craving for gambling. That increased craving for that rush. So increased triggers start to develop. It's not just when you have a bad day or Friday nights with the boys. It's whenever there's a horse race or whenever you can get online. Because unfortunately, now gambling you can do 24, 7, 365. On the Internet, people become unable to discuss their problems. They're just, there's so many problems, they don't know where to begin. They realize that their addiction may be causing some problems, but they don't know how to express it or how to talk to people about it. They don't really understand why it's a problem yet, but they're getting the feeling that this is probably not helping. So efforts to control whatever the addiction is start to fail. So they still, they say, okay, I'm only going to go play poker on the weekends. But before they know it, they're back online. Playing poker at 11 o' clock at night and not getting to bed until 4 or 5 in the morning and then having to be at work the next day. They continue to use despite negative consequences. So they're realizing it may be causing a problem. They're starting to realize that they think about it all the time. They're starting to realize that they feel like they're missing something if they're not engaging in that behavior. So it starts impacting other areas of their life. They start kind of setting aside relationships, setting aside other hobbies, setting aside things so they can focus on this, whatever this addiction is that makes them feel better. The other thing that's happened at this point is they're doing what's called chasing the high. The first time they do it, whether it's bungee jumping, skydiving, gambling, whatever the issue is, or whatever the addiction is, that first time produces an amazing euphoric rush. After that is never quite the same. So then they need to intensify it or mix it with something. So we'll just take bungee jumping, for example, because that seems like, you know, a rush. The first time you do it, it's a rush. The second time you do it, you're like, no, I've already done that before. So now let's try it where I'm bungee jumping off a bridge and I actually get dunked in the water or something. I've heard of that. I wouldn't do it myself, but I wouldn't bungee jump either. Increasing the intensity, increasing the risk that something could go wrong, produces more of that adrenaline rush. When people finally realize that the consequences of the addiction are worse than whatever they have to face, or they can't deal with the negative consequences, and they're just like, I can't deal with. Without the addiction, I can't deal with the addiction. I just. I can't deal. That's when we find bottom, and that's when people are generally first motivated to seek help. So the person makes a decision to change. One of the things we want to do or help our clients do is help them understand and address the reasons for the original distress. Why was it you started using in the first place? This will help us understand more what underlying issues there are. Because it's not just the addiction. It is not just the mental health issue. It's not just the relationship issues. There's a lot of stuff there. So what is it when you first started using? Tell me about what was going on. What was the original distress? When things started to get out of control. And then we need to look at the distress or the fallout created from the addiction. You're here in my office. You've decided that this is a problem. What leads you to believe or what evidence do you have that tells you this is a problem? Why are you here? They'll have a litany of things. Whether it's, my probation officer told me I had to, or my spouse told me I had to, or they actually identify some of the reasons that they feel they need to. They're going to start identifying some of those biopsychosocial consequences, their addiction, and we want to make note of those because they're going to have to clean up this mess before they can really move into the maintenance phase. The next thing we want to do, once we kind of figure out where it started and what's maintaining it and kind of get the lay of the land, we want to address any physical issues maintaining their distress. Do they have chronic pain? If they were abusing opiates, their body may not be producing the same level of natural opioids. So we may need to look at helping them understand the fact that it's going to take a little while for their body to kick back in and start making those natural painkillers so they don't feel as achy all the time. If they have other issues with chronic pain, a doctor can address those. But chronic pain is going to make people probably. Probably not sleep as well. It tends to make people a little grumpier, which are vulnerabilities for going to some sort of an addiction that just kind of numbs everything out. We also want to look at physical issues like hypothyroid that may be contributing to depression or anxiety that is again, motivating or causing the person to feel distress, which leads them to use to escape from the distress. Once we rule out the physical issues, you know, those are some of the really. I don't want to say easy fixes, but if there are some things there we can tweak and we can start getting people's circadian rhythms back into whack and we can start getting them to eat something that vaguely resembles nutritious food. I'm not saying make huge changes in their diet because, number one, that won't last. Number two, they're not going to enjoy it. So number three, they're not going to keep doing it. We want them to start living a reasonably healthy lifestyle for them. Then we want to start working on helping them develop healthy coping skills. So do we reinvent the wheel? No, please don't. One of the things you want to do is ask them in the past. Well, let's look at last week. Last week, when you were not engaging in your addiction, what were you doing? Sleeping, spending time with the kids, reading a book, at the gym, at work, they can list off whatever they were doing. That's what we call exceptions. We want them to do that more. And this is one of the tools. They can walk out of your office after an assessment. This is one of the tools they will have that they can start doing. Does it solve all the underlying issues? Heck, no. Does it help them cut down on their addictive behaviors? It very well may. So we need to start talking about what are your exceptions? What are the times when you're not engaging in this behavior? What's different? The other thing you can look at is, was there ever a period where you weren't using what was different then? Or if you can remember back before you started using what was different? What did you do to cope? How did you deal with stress? A lot of people tend to say that they were living a healthier lifestyle. Sleeping regularly, eating pretty well, going to the gym, yada, yada, yada. So those are the things we want to hone in on. Whatever has worked for them. In the past. And we want to build on those. Once we start building these coping skills, getting their circadian rhythms back into whack, helping them recover physically from anything that the addiction has done, from any of the neurochemical changes, any of the physical issues. We're helping them develop these coping skills now. They can start feeling better and start figuring out who they are. You notice I haven't gotten to that whole support system yet. Hopefully they're going to support group meetings and they've got some social supports, but they need to figure out why they like them before they start trying to get a whole bunch of other people in their circle. They need to work on their self esteem and then start rebuilding that healthy support network. Now again, when they walk out of your office with a list of exceptions, things they can do when they start craving, but right now they are determined to not use, they have that list of exceptions. I'm hoping they will also have a list of two or three people that they can call. And I keep talking about lists and having it. It's important to write it down. When people start craving, it's almost like they go into sort of a crisis state. They're not going to think as clearly. So if they have it written down either in their phone or on an index card in their wallet, they're going to be a lot more likely to use these tools. So let's look at the DSM criteria for addiction. And you know, whether you like the DSM or not, it gives us a good reference that we can look at. So tolerance. Does somebody need an increase in amount in order to get the same effect? Or do they need to start combining things in order to get the same effect? So with alcohol, did the person go from wine to Everclear? That's kind of a big jump when we're talking about gambling. Did the person go from playing quarter slots to, you know, betting hundreds or thousands of dollars at a time? I don't know a lot about gambling. So in order to get the same rush at a certain point, risking a buck 25 in quarters isn't really going to do it for you, even if you do get the occasional payout. Characteristic withdrawal symptoms. Now these can be physical or psychological, and generally they're both the psychological withdrawal symptoms. Craving it, thinking about it, sort of obsessing, if you will, about whatever the addiction is, you want to get back to it because you want to feel that euphoria. Anytime you experience that euphoria, all the things that are going on around you become conditioned stimuli, substances are taken or the addiction is used in larger amounts for a longer period than intended. So maybe you intend, you know, we'll stick with gambling. Maybe you intend to get online, wind down a little bit, play poker online for an hour before bed. Before you know it, you have spent $10,000 and it's 3am that's indicating kind of a loss of control. There's also a persistent desire or repeated unsuccessful efforts to attempt to quit. Most people don't come to treatment going, you know, I've got this problem and yeah, I've never tried to quit. I don't know if I can or not, but I figured I ought to talk to somebody. Generally they come to you feeling pretty defeated, going, I've tried, I've tried to cut back and I just can't seem to end up back in the same place. A lot of time or activity is spent obtaining, using or recovering from the addiction. When we talk about gambling, obtaining, figuring out who you're going to bet on, doing your research, all that stuff. If we're talking about fantasy football or ponies or stocks, using the time you're actually spending gambling and recovering from. So the first thought is recovering financially if you didn't win. But there's also a lot of physical recovery that happens for a lot of people because for two, well, at least two reasons. Number one, your body is not meant to have so many episodes of tension and release in one 24 hour period. A gambler can really wear themselves out, wear their dopamine systems out, wear their stress levels out, whatever you want to, however you want to put it to your patience. Doing that enough times in one day is exhausting. Additionally, a lot of people who gamble are gambling when it is you the wee hours of the morning. They're gambling in addition to working, in addition to being a family person, in addition to other stuff. So they need to recover from not sleeping. Important social, occupational, recreational activities are given up or reduced. Well, some people choose to recover by saying, well if I gamble all night long, then I've got to choose whether I'm going to go to my kids recital or I'm going to take a nap. And they choose the nap. Recreational activities like hunting, golfing, fishing, exercising, reading, you know, whatever the hobbies are, start to go by the wayside so they can spend more time using and recovering or preparing to use and recovering and use continues despite knowledge of adverse consequences. Not all gamblers lose. Some gamblers are very, very good at what they do, so the money influx is extremely rewarding. However, they still Find themselves miserable and everything else is falling apart. They continue to use. Why do they continue to gamble? Because when they're gambling, they are focused on nothing but the game. They are focused on nothing but the process. It's a time for them to escape, a time for them to do something they know they have some semblance or they feel they have some semblance of control of. So let's talk about some of these adverse consequences. Emotional problems. Depression. Hopeless and helpless. When we think of depression, people feel hopeless and helpless. Now, they may have felt hopeless and helpless before their addiction, but then they get into their addiction and things start falling apart. And guess what? They're going to likely feel hopeless and helpless when they sober up. When they're not using, they may look around and be like, oh my gosh, I don't even know where to start to clean up this mess. And they feel hopeless and helpless, so they resume their addiction. Anxiety is sort of a different twist on it. Some people sober up and they look around and they're like, oh my gosh, I don't even know how to deal. And they start getting really anxious because they don't have the tools to deal with what they've done. They feel guilty about what they've done and it starts this very rapid out of control spiral. If they had pre existing anxiety, then whenever they're not engaging in their addiction, when they sober up, they start to feel that anxiety or depression again. So it's important to remember that either way, as soon as they quit using their substance of choice, whether the mental health came before or during the addiction, they're going to feel the mental health. And we need to be there to prepare them for it and to help them work through it. And then anger and resentment. Most addicts will go through a period where they feel angry and resentful at everybody else in their life. They don't want you to mess with their addiction. They don't want you to talk to them. They feel like every time you talk to them, you're judging them. We need to help people start seeing this. So in their addiction, when they start acting like this, they start pushing people away, push away their healthy, sober supports. When they come to you and they say that they've pushed everybody away, they may, may have, or they say they have nobody they can count on, they may not. So we need to ask them a little bit more, okay, before this happened, who could you count on? And we need to help them understand where that anger and resentment came from. Anger is a very, very, very Functional protective mechanism. It ramps up that fight or flee reaction. It tells a person there's a threat. Now, they may not actually have a threat, but they perceive a threat. So we need to help them understand how those people were perceived as threats and decide now whether they are actually threatening or. Or whether they were trying to be helpful. Cognitive problems. Memory problems. Memory loss, blackouts. When we're talking about chemical addictions, people will actually drink to the point they blackout and can't remember anything. But when you have people who are in using a behavioral addiction, they will also talk about losing time. They remember starting and they remember stopping. But there's no possible way. Eight hours passed, and you're like, yep, eight hours passed. They can't really remember what happened in there. It's not that they were unconscious. They were just so focused on that behavior that they were not paying attention to anything else, including time. Confusion and memory loss are both very common. When you have somebody who's not getting enough sleep, when their circadian rhythms are out of whack, when they are anxious and depressed. Think about your DSM criteria for depression and anxiety. Difficulty concentrating, and then paranoia. Paranoia is an interesting one because it usually starts to rear its head when the person has become best friends, if you will, with their addiction. They don't want anybody to take that addiction away. And deep down inside, they are already probably judging themselves. And they know what they're doing is destructive. So they start feeling like everybody else is judging them. They're judging themselves deep down inside, but they start projecting that onto other people. So we need to help people, you know, address the paranoia and figure out what they think about things and how to handle relationships and those other sorts of things. Now, paranoia, that's more like hallucinations, delusions, that's a whole different ball game. We're not talking about that. We're talking about a fear that they're being judged or that somebody is going to make them stop using. Continued use, despite physical problems. Hepatitis, HIV and STDs. We talk about that a lot when we're talking about chemical addictions. But when we're talking about some of the other addictions, it may not be all that much of a stretch. Sex addiction, hepatitis, HIV and STDs. Definitely a risk. When we talk about gambling, eating disorders, shopping addiction, any of those other behaviors, we may see inadequate sleep and or nutrition, which will have negative consequences on the person, reduced immune system being one of them, and injuries either due to falls or due to the consequences of the environments that they're putting Themselves in. Use continues despite adverse consequences, including relationship issues. They start lying to their significant others, manipulating and being secretive. This is that paranoia we were just talking about. They're trying to keep hold of their addiction because it's the one thing that makes them sort of able to get from wake up to go to bed. They start lying to people, manipulating, being secretive. They may change friends, not only because their attitude has changed and they've got some paranoia and depression and anger going on, but also because they are going to gravitate more toward friends that share a similar interest or addiction. They may also have difficulty getting along with others because of guess what? That paranoia, anxiety, depression, lying, manipulation and secrecy. So we see where relationships start to fall apart and the healthy relationships go to the wayside. Your dysfunctional relationships, your relationships that are bonded around an addiction become stronger. Occupational issues. If you're staying up all night gambling, you may not go to work. And even if you do go to work, your work product may not be so hot. So we need to look at that. If it starts causing problems, and not just job loss, but if it starts causing problems like reductions in annual evaluations or getting reprimanded at work, those are all problems. I do want to point out here that more than 50% of people who are active alcoholics are employed full time. That's important because alcohol is one of those that you can smell on the breath. That has a lot of other consequences that may affect people at work. So then when we're talking about other things like gambling, food addiction, sex addiction, pornography addiction, those also can cause adverse consequences on the job. And there's a high likelihood that people with those addictions are employed full time. So just because somebody is employed doesn't mean that the addiction is not negatively impacting them. In fact, some people use work to escape. But that's a whole different topic that we'll get into at another point. And finally, use continues despite adverse consequences. When we're talking about spiritual issues. When people get into their addiction, hope is gone. They have tried to stop. They have tried to make things better. They have not had the appropriate skills or tools to do so. So they have failed. When they fail, they start to feel hopeless. They start to lose faith in themselves, in other people, in the system, in their higher power, because they keep failing and their hope is gone. Well, if you have no faith that anything you do is going to help, and you have no hope that things are going to get better, then why try to continue to do the next right thing? Why not do whatever makes you happy? So integrity out the window. Then we move down to discipline. Well, if you're doing what's making you happy, you're probably not going to be disciplined about taking care of yourself, going to work, doing all those things that we're supposed to do. All of that starts causing a cascade effect of things falling apart in the life. We move down to courage. Courage is facing all that stuff and doing the next right thing, even though it may not be our favorite choice. Well, if anything we do is going to fail anyway, why try? Why even have the courage to do it? And then people start losing compassion, not only for others, but for themselves. A lot of addicts really hate themselves when they come to treatment. They don't have any compassion. They don't see it as the only tool they had to survive until now. They see it as a moral defect. We need to help them bring back compassion not only for themselves, but for others. Okay, so we've gone over the differences or the development of addictions. We've talked a little bit about behavioral addictions. We're going to get into comparing and contrasting in the next section. But for right, right now, I'd like to take a 10 minute break. If you have any questions or comments, please ask me during the break and then we will resume.
