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Sex, Love
and Poly-Behavioral Addiction
by: James Slobodzien
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.
References
American Psychiatric Association: Diagnostic and Statistical
Manual of Mental Disorders, Fourth Edition,
Text Revision. Washington, DC, American Psychiatric Association,
2000, p. 787 & p. 731.
American Society of Addiction Medicine’s (2003), “Patient
Placement Criteria for the
Treatment of Substance-Related Disorders, 3rd Edition, Retrieved,
June 18, 2005, from:
http://www.asam.org/
Arthur Aron, Ph.D., professor, psychology, State University of New
York, Stony Brook; Helen
Fisher, research professor, department of anthropology, Rutgers
University, New Brunswick, N.J.;
Paul Sanberg, Ph.D.,professor, neuroscience, and director, Center
of Excellence for Aging and
Brain Repair,University of South Florida College of Medicine,
Tampa; June 2005, the Journal of
Neurophysiology
Carnes, P.J. (1983). Out of the Shadows: Understanding Sexual
Addiction. Minneapolis, MN: Compcare.
Carnes, P.J. (1989). Contrary to Love: Helping the Sexual Addict.
Minneapolis, MN: Compcare.
Carnes, P.J. (1991). Don't Call it Love. Minneapolis, MN: Gentle
Press Publishing.
Carnes, P.J. (1997). Sexual Anorexia: Overcoming Sexual
Self-hatred. Center City, MN: Hazelden.
Carnes, P.J., & Delmonico, D.L. (1994). Sexual Dependency
Inventory. Wickenburg, AZ: The Meadows Institute.
Carnes, P.J., Delmonico, D.L., & Griffin, E. J. (2001). In the
Shadows of the Net: Breaking Free of
Compulsive Online Sexual Behavior. Center City, MN: Hazelden.
Delmonico, D.L. (1997). Internet Sex Screening Test. [Online].
Available at: http://www.sexhelp.com
Delmonico, D.L., Griffin, E.J., & Moriarity, J. (2001). Cybersex
Unhooked: A Workbook for Breaking Free From Online Compulsive
Sexual Behavior. Wickenburg, AZ: Gentle Path Press.
Gorski, T. (2001), Relapse Prevention In The Managed Care
Environment. GORSKI-CENAPS Web
Publications. Retrieved June 20, 2005, from: www.tgorski.com
Lienard, J. & Vamecq, J. (2004), Presse Med, Oct 23;33(18 Suppl):33-40.
Marlatt, G. A. (1985). Relapse prevention: Theoretical rationale
and overview of the model. In G. A.
Marlatt & J. R. Gordon (Eds.), Relapse prevention (pp. 250-280).
New York: Guilford Press.
Schneider, J.P. (1994). Sex addiction: Controversy within
mainstream addiction medicine, diagnosis based on the DSV-III-R
and physician case histories. Sexual Addiction & Compulsivity:
Journal of Treatment and Prevention, 1(1), 19-44.
Slobodzien, J. (2005). Poly-behavioral Addiction and the
Addictions Recovery Measurement System (ARMS), Booklocker.com,
Inc., p. 5.
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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