Proposing a New Diagnosis and Theory for Patients with Multiple Addictions
By James Slobodzien, Psy.D., CSAC


Experts in the field of addictions are presently purporting that between 3 and 6 percent of the world’s population (193 to 386 million people) are presently affected by a sexual dependency or compulsivity (Carnes, 2005). Sexual dependency is a diagnosable and treatable disease, which today is generally, regarded in about the same way that alcoholism and drug addiction (chemical dependency) was regarded 40 years ago. Even so, there still exists a wide range of understandable misunderstandings about compulsive sexual acting out, created out of ignorance about the nature of sexual addiction, and supported and perpetuated by the multibillion dollar pornography industry.

Sexual Dependency - is a global term that covers a wide range of maladaptive and self-defeating behavior patterns and relationships such as:

1. Love Addiction – a disorder in which individuals repeatedly become involved in enmeshed, intense, codependent relationships, even when those relationships or partners are destructive;
2. Romance Addiction - a disorder in which individuals become obsessed with the intrigue and the pursuit of romance and thrive on the thrill of the chase, but find it impossible to sustain a committed, intimate relationship with another person;
3. Sexual Anorexia – a disorder in which individuals become dominated and obsessed with the emotional, physical, and mental task of avoiding sex; and
4. Sex Addiction – a disorder in which individuals become obsessed with sexually-related, compulsive self-defeating maladaptive behavior.

But can one really be addicted to love as the popular 80’s song proclaims? In a recent research study, (Aron, A. 2005) published in the June issue of the Journal of Neurophysiology, researchers used functional MRI to watch the real-time brain activity of 17 college students (10 women, seven men), all of whom were in the early weeks or months of new love. These researchers concluded that, love may vie for the same real estate in the brain as drug addiction. “Early love, rooted as it is in the caudate nucleus, is all about addiction.” "It is a drug addiction." "It's certainly got some of the main characteristics of drug addiction -- as with drugs, once you fall in love you need that person more and more, so much so that, after a while, you have to marry them. There are other things, too -- real dependence, personality changes, withdrawal symptoms." “And just like the need for cocaine or heroin, love can make people do crazy, sometimes dangerous things.” According to Aron (2005), the findings help explain instances where people fall in love with people they aren’t even sexually attracted to; or why others can feel equally strong, sudden emotion for a newborn child or even God.

So does this mean that all people who are newly in love have an addiction? Are all men who look at pornography addicted? Are all women who read romance novels addicted? Are all people who avoid sex considered sexual anorexics? No, no, no, and no. Then how can we differentiate between addiction and healthy relationships? Like other forms of addictive diseases and lifestyle disorders such as chemical dependency, pathological gambling, eating disorders, and religious addiction -

Sexual dependency is characterized by an addictive cycle of:

1. Obsession or preoccupation;
2. Ritualization;
3. Compulsive behaviors;
4. Loss of control and despair; and
5. Shame and guilt that perpetuates a maladaptive belief system of impaired thinking and unmanageability.

Typically, sexual addictive patterns are considered pathological problems when issues concerning sexual behaviors become the focus of life, causing feelings of shame, guilt, and embarrassment with related symptoms of depression and anxiety that cause significant maladaptive social and/ or occupational impairment in functioning. Addicts don’t use sex for affection or recreation, but for the management of anxiety and/ or emotional pain.

We must consider that some people develop dependencies on certain life-functioning activities such as sex that can be just as life threatening as drug addiction and just as socially and psychologically damaging as alcoholism.

Sexual addiction takes many forms with various levels of severity to include:
1. Controversial behaviors (obsessions with pornography, and sex with strangers to engaging in cyber-sex);
2. Unacceptable behaviors (exhibitionism, voyeurism, indecent phone calls); and
3. Profound Sex offender behaviors (rape, incest, and child molestation).

Though solitary forms of this addiction may not be overtly risky, they can be part of a pattern of distorted thinking and identity conflict that can escalate to involve harming the self and others. An example of a Sexual Disorder (NOS) or Not Otherwise Specified in the DSM-IV-TR, (2000) includes: distress about a pattern of repeated sexual relationships involving a succession of lovers who are experienced by an individual only as things to be used. (It should be noted that the Diagnostic and Statistical Manual of Mental Disorders has never used the word “addiction” to describe any of its disorders).

The defining elements of this kind of addiction are its secrecy and escalating nature, often resulting in diminished judgment and self-control (Carnes, 1994).

Brief History of Sex Addiction

In 1976, a suburban hospital administrator asked Dr. Patrick Carnes to start an experimental program for chemically dependent families. The theoretical constructs of the program originated in general systems theory, especially as it applied to families and the 12-steps of Alcoholics Anonymous. One of the many factors which stood out from a family perspective was that the addictive compulsivity had many forms other than alcohol and drug abuse including overeating, gambling, shoplifting, and sexuality. Members of groups like Overeaters Anonymous and Gamblers Anonymous had already pioneered in applying the 12-steps to other addictions so the Family Renewal Center extended its programming based on the 12-steps, to sexual addiction.

In 1983, Dr. Patrick Carnes formally introduced the concept of sexual addiction to the world in a text entitled “Out of the Shadows.” Since then the field of sexual addiction and compulsive sexual behavior has developed dramatically. Terms such as addiction, compulsivity, hyper-sexuality, and “Don Juanism,” all have been used to describe what generically could be called "out of control sexual behavior." Regardless of its name, clinicians from all fields agree that a syndrome exists in which individuals have a sense that they have lost control over their sexual behavior.

According to the Society for the Advancement of Sexual Health (SASH), sexual addiction is a persistent and escalating pattern or patterns of sexual behaviors acted out despite increasingly negative consequences to self or others. The fundamental nature of all addiction is the addicts' experience of helplessness and powerlessness over an obsessive-compulsive behavior, resulting in their lives becoming unmanageable. The addict may be out of control. They may experience extreme emotional pain and shame. They may repeatedly fail to control their behavior. They may suffer one or more of the following consequences of an unmanageable lifestyle: a deterioration of some or all supportive relationships; difficulties with work, financial troubles; and physical, mental, and/ or emotional exhaustion which sometimes leads to psychiatric problems and hospitalization. Addictions tend to arise from the same backgrounds: families with co-dependency including multiple addictions; lack of effective parenting; and other forms of physical, emotional and sexual trauma in childhood.

The Society for the Advancement of Sexual Health (SASH, 2005) report that the symptoms of sexual compulsivity often accompany other addictive behaviors:

Alcohol and Drug Addiction – Alcohol and drugs alter libido, enhancing it early in drug addiction and inhibiting it later. There is a pattern in cocaine addiction of selling sexual favors for cocaine. As the cost of drug addiction increases, the drug addict usually can't afford the drug from ordinary job income, and must resort to (either/or) stealing, drug dealing or prostitution to support their habit. Alcohol and many drugs cause blackouts or amnesia during the drug using experience, and if sex is coupled with that drug using experience then the details of the sexual experience may not be remembered.

Food Addiction - Sexual anorexia or pathological self-denial of healthy sex is a frequent accompaniment of overeating and anorexia nervosa.

Pathological Gambling - The lifestyle of the gambler often includes hyper-sexuality, where both compulsions feed the false sense of self-esteem of the addict.

Religious Addiction - Compulsive religiosity sometimes accompanies sexual addiction as the sex addict is seeking religion to lessen guilt and shame. The beginnings of compulsive religiosity may signal the onset of a period of sexual anorexia.

Multiple Addictions

Since it is impossible to expect treatment for one addiction to be beneficial when other addictions co-exist, the initial therapeutic intervention for any addiction needs to include an assessment for other addictions. National surveys revealed that a very high correlation exists between sexual addiction and other substance abuse and behavioral addictions. Sexual addicts who have reported experiencing multiple addictions include sexual addiction and:
§ Chemical dependency (42%)
§ Eating disorder (38%)
§ Compulsive working (28%)
§ Compulsive spending (26%)
§ Compulsive gambling (5%)
Poor Prognosis

We have come to realize today more than any other time in history that the treatment of lifestyle diseases and addictions are often a difficult and frustrating task for all concerned. Repeated failures abound with all of the addictions, even with utilizing the most effective treatment strategies. But why do 47% of patients treated in private addiction treatment programs (for example) relapse within the first year following treatment (Gorski, T., 2001)? Have addiction specialists become conditioned to accept failure as the norm? There are many reasons for this poor prognosis. Some would proclaim that addictions are psychosomatically- induced and maintained in a semi-balanced force field of driving and restraining multidimensional forces. Others would say that failures are due simply to a lack of self-motivation or will power. Most would agree that lifestyle behavioral addictions are serious health risks that deserve our attention, but could it possibly be that patients with multiple addictions are being under diagnosed (with a single dependence) simply due to a lack of diagnostic tools and resources that are incapable of resolving the complexity of assessing and treating a patient with multiple addictions?

Diagnostic Delineation

Thus far, the DSM-IV-TR has not delineated a diagnosis for the complexity of multiple behavioral and substance addictions. It has reserved the Poly-substance Dependence diagnosis for a person who is repeatedly using at least three groups of substances during the same 12-month period, but the criteria for this diagnosis do not involve any behavioral addiction symptoms. In the Psychological Factors Affecting Medical Condition’s section (DSM-IV-TR, 2000); maladaptive health behaviors (e.g., unsafe sexual practices, excessive alcohol, drug use, and over eating, etc.) may be listed on Axis I, only if they are significantly affecting the course of treatment of a medical or mental condition.

Since successful treatment outcomes are dependent on thorough assessments, accurate diagnoses, and comprehensive individualized treatment planning, it is no wonder that repeated rehabilitation failures and low success rates are the norm instead of the exception in the addictions field, when the latest DSM-IV-TR does not even include a diagnosis for multiple addictive behavioral disorders. Treatment clinics need to have a treatment planning system and referral network that is equipped to thoroughly assess multiple addictive and mental health disorders and related treatment needs and comprehensively provide education/ awareness, prevention strategy groups, and/ or specific addictions treatment services for individuals diagnosed with multiple addictions. Written treatment goals and objectives should be specified for each separate addiction and dimension of an individuals’ life, and the desired performance outcome or completion criteria should be specifically stated, behaviorally based (a visible activity), and measurable.

New Proposed Diagnosis

To assist in resolving the limited DSM-IV-TRs’ diagnostic capability, a multidimensional diagnosis of “Poly-behavioral Addiction,” is proposed for more accurate diagnosis leading to more effective treatment planning. This diagnosis encompasses the broadest category of addictive disorders that would include an individual manifesting a combination of substance abuse addictions, and other obsessively-compulsive behavioral addictive behavioral patterns to pathological gambling, religion, and/ or sex / pornography, etc.). Behavioral addictions are just as damaging - psychologically and socially as alcohol and drug abuse. They are comparative to other life-style diseases such as diabetes, hypertension, and heart disease in their behavioral manifestations, their etiologies, and their resistance to treatments. They are progressive disorders that involve obsessive thinking and compulsive behaviors. They are also characterized by a preoccupation with a continuous or periodic loss of control, and continuous irrational behavior in spite of adverse consequences.

Poly-behavioral addiction would be described as a state of periodic or chronic physical, mental, emotional, cultural, sexual and/ or spiritual/ religious intoxication. These various types of intoxication are produced by repeated obsessive thoughts and compulsive practices involved in pathological relationships to any mood-altering substance, person, organization, belief system, and/ or activity. The individual has an overpowering desire, need or compulsion with the presence of a tendency to intensify their adherence to these practices, and evidence of phenomena of tolerance, abstinence and withdrawal, in which there is always physical and/ or psychic dependence on the effects of this pathological relationship. In addition, there is a 12 - month period in which an individual is pathologically involved with three or more behavioral and/ or substance use addictions simultaneously, but the criteria are not met for dependence for any one addiction in particular (Slobodzien, J., 2005). In essence, Poly-behavioral addiction is the synergistically integrated chronic dependence on multiple physiologically addictive substances and behaviors (e.g., using/ abusing substances - nicotine, alcohol, & drugs, and/or acting impulsively or obsessively compulsive in regards to gambling, food binging, sex, and/ or religion, etc.) simultaneously.

Conclusion

Considering the wide range of sexual behaviors in our world today, one should always take into account an individual’s ethnic, cultural, religious, and social background prior to making any clinical judgments, and it would be wise to not over-pathologize in this area of Sexual Dependency. However, since successful treatment outcomes are dependent on thorough assessments, accurate diagnoses, and comprehensive individualized treatment planning - poly-behavioral addiction needs to be identified to effectively treat the complexity of multiple behavioral and substance addictions.

Since chronic lifestyle diseases and disorders such as diabetes, hypertension, alcoholism, drug and behavioral addictions cannot be cured, but only managed - how should we effectively manage poly-behavioral addiction?

The Addiction Recovery Measurement System (ARMS) is proposed utilizing a multidimensional integrative assessment, treatment planning, treatment progress, and treatment outcome measurement tracking system that facilitates rapid and accurate recognition and evaluation of an individual’s comprehensive life-functioning progress dimensions. The ARMS hypothesis purports that there is a multidimensional synergistically negative resistance that individual’s develop to any one form of treatment to a single dimension of their lives, because the effects of an individual’s addiction have dynamically interacted multi-dimensionally. Having the primary focus on one dimension is insufficient. Traditionally, addiction treatment programs have failed to accommodate for the multidimensional synergistically negative effects of an individual having multiple addictions, (e.g. nicotine, alcohol, and obesity, etc.). Behavioral addictions interact negatively with each other and with strategies to improve overall functioning. They tend to encourage the use of tobacco, alcohol and other drugs, help increase violence, decrease functional capacity, and promote social isolation. Most treatment theories today involve assessing other dimensions to identify dual diagnosis or co-morbidity diagnoses, or to assess contributing factors that may play a role in the individual’s primary addiction. The ARMS’ theory proclaims that a multidimensional treatment plan must be devised addressing the possible multiple addictions identified for each one of an individual’s life dimensions in addition to developing specific goals and objectives for each dimension.

Partnerships and coordination among service providers, government departments, and community organizations in providing addiction treatment programs are a necessity in addressing the multi-task solution to poly-behavioral addiction. I encourage you to support the addiction programs in America, and hope that the (ARMS) resources can assist you to personally fight the War on poly-behavioral addiction.

For more info see:
Poly-Behavioral Addiction and the Addictions Recovery Measurement System (ARMS)
By James Slobodzien, Psy.D. CSAC at:
http://www.geocities.com/drslbdzn/Behavioral_Addictions.html 

National Council on Sexual Addiction & Compulsivity
P.O. Box 725544
Atlanta, GA 31139
(770) 541-9912
http://www.ncsac.org 
Sexual Addiction Resources
http://www.sexhelp.com 

James Slobodzien, Psy.D. CSAC, is a Hawaii licensed psychologist and certified substance abuse counselor who earned his doctorate in Clinical Psychology. The National Registry of Health Service Providers in Psychology credentials Dr. Slobodzien. He has over 20-years of mental health experience primarily working in the fields of alcohol/ substance abuse and behavioral addictions in medical, correctional, and judicial settings. He is an adjunct professor of Psychology and also maintains a private practice as a mental health consultant.

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