 Welcome back to the overview of behavioral addictions. This is part two. So in the last section, we reviewed the DSM criteria for substance dependence because they don't use the term addiction. Now we're going to talk about basically the same thing, but an easy mnemonic to remember it. This is on the ASAM's website, but I put it here so you can have it easily accessible. Inability to consistently abstain. They try to stop and they can't. Impairment in behavioral control. They use more energy, spend more time doing it than they expected. Craving, increased hunger for the drugs or the rewarding experiences. This is where we're talking about the withdrawal if we're kind of comparing it to the DSM. D is diminished recognition of significant problems with one's behaviors and interpersonal relationships. That's that last criteria that we've spent quite a bit of time on the continued despite negative consequences. And E is a dysfunctional, emotional response. People who are in the midst of an addiction are probably experiencing some depression, some anxiety, some paranoia, some anger and agitation. So we want to look at that. Just like in the DSM, you don't have to have every single criteria. With this mnemonic, you don't have to have every single criteria. But I can honestly say that every person with an addiction that I've worked with has met every single one of these. So it's a good rule to use to initially kind of try to screen someone. Chemical addictions. Substances directly impact the brain and or nervous system. We know that most substances people take will cross the blood-brain barrier and produce some sort of happy effect, euphoric effect. Behavioral addictions are actually very similar. Now they may not produce it as quickly or to the same intensity. But if we look at behavioral addictions, we can identify that they also have pretty significant impacts on the reward pathways in the brain. Adrenaline rush. I've worked with, I've been around a lot of people who are adrenaline junkies. And again, does that mean that they are addicts? No. But it does mean they seek out high adrenaline situations, bungee jumping, skydiving, race car driving, those sorts of things. So the adrenaline rush is something that we can all sort of relate to. You have probably at one point or another been in a situation where you've experienced one, a euphoric one, not, oh my gosh, I almost ran off the road and got killed kind of adrenaline rush. But you know how doing something can cause that rush. Just like I talked about in the previous section, if you're an adrenaline junkie doing the same thing repeatedly, eventually we'll get tedious. So you need to increase the intensity. If you're, I have a friend who used to compete in motocross. And when you start learning to do motocross, you take the easy courses. When you start becoming more competitive, you're doing much more challenging courses and doing things that are a whole lot riskier. So you're getting that adrenaline rush by intensifying the activity or changing it up. Dopamine rush. There are a lot of things, sex for example. Work on those dopamine pathways. Certain foods are hypothesized to also work on the dopamine pathways. Endorphin rush. This is more from exercise. If you've been a distance runner, you're endorphins or your natural, your body's natural painkillers. A distance runner has experienced it. I've also experienced it once and I'll share this little story with you. My best friend just absolutely loves hot peppers and I'm like, you know, whatever, I can take whatever pepper you throw in my way. And so I decided that I was going to grow some hot peppers. And I'm not talking just the regular run of the mill hot peppers. I'm talking ghost peppers. I'm talking Jamaican peppers. And so I grew them and I had them outside. And I noticed that one had been pecked by the chicken. So I was like, well, I can't save that anyway. So I might as well see what this one tastes like because I'd never had a Jamaican pepper before. I bit into it and let me tell you, I have never experienced a pain so intense in my entire life. But my body, after some cajoling, actually did excrete a bunch of natural endorphins to kind of numb the pain and make it go away. So there are some activities. Anything that really basically causes pain may cause your body to excrete natural endorphins. Now oxytocin is an interesting one. Oxytocin is that chemical that's released between mother and baby when they're bonding. It's released between people when they hug, when they bond. If someone, thinking back to the last presentation, didn't have any good bonding experiences as infants, they may continue to seek out that bonding in order to fulfill a hole or a loss that they haven't grieved or dealt with yet. So oxytocin is definitely a powerful chemical or hormone that we really want to think about when we're looking at what is the reason, what is the benefit of this behavior to this person at this time. So let's move on and talk about some similarities and differences between chemical and behavioral addictions. Both cause chemical reactions in the brain. We just talked about that. Both are a tool to escape or avoid a pain. Talked about that. Both produce a tolerance so you may need more or a change up in the activity in order to get the same experience. Both have psychological withdrawal symptoms. When you are not exposed to it, when you can't access it, you start getting nervous. You start thinking about it more. The more you think about it, the more stressed you get, the more stressed you get, the more you think about it, you see where we're going with this. So the psychological withdrawal symptoms can be very powerful for a lot of people. And both of them can have devastating biopsychosocial consequences. When you think of behavioral addictions, if you think of gambling, then you're probably going with one that is easy to come up with some negative biopsychosocial consequences. In the third section of this presentation, we're going to talk about exactly what consequences might occur for people given different behavioral addictions. And the intensity varies, obviously that's gonna happen. But it's important to remember that what is devastating for one person may not be as big of a deal for another. It's also important to remember, and this is a difference, abstinence is not possible or even ideal for some behavioral addictions. When we're talking about sex, food, shopping and exercise, those are the four that come to the forefront of my mind right now. Some people will choose to abstain and that is entirely legitimate choice. The majority of people are going to tell you that they don't wanna go without sex for the rest of their life. So we need to figure out how to help them have a healthy relationship without taking sex to the addictive capacity that it has gotten to. Food, we can't abstain from food, we just can't. And most people, if you talk to people who are food addicts, who are binge eaters, it's not just one food, it's not just chocolate, it's not just peanut butter, pizza. It's a whole range of high fat, high processed, high sugar type foods. But if you take that away from them, they may go to meat and potatoes because it still serves the similar sort of purpose. Now here's another one of my little soap boxes, so soap box warning just right here. Many treatment centers ignore the substitution of a behavioral addiction for a chemical addiction. When I was working in residential treatment centers, I would see people come in, they would give up their drug of choice, score, kudos, didn't wanna have it in the facility, but they would pick up something else. Now one of the treatment centers I worked in was a co-educational treatment center and you see where I'm going with this. You would be amazed at how nimble some people are when it comes to finding an alternate addiction to engage in. They would crawl through drop ceilings to get from one room to another to have sex. They would find the most unbelievable situations or circumstances. They were very crafty and very resourceful and it was a matter of taking that and using it for something that was recovery based not maintaining their addiction. But what just absolutely kills me is when I see people leaving a treatment center and they haven't used their drug of choice in three weeks, a month, six months, yay. Does that mean they're in recovery? No, no, in my mind that does not equate to recovery because all they're doing is not using that particular substance. How are they coping? Have they developed healthier coping skills? Have they developed healthy social support systems? Are they able to deal with life on life's terms and actually do it? That's when we start talking about recovery. Most of the time people leave and they've just substituted one addiction for another. They're not in recovery. They are just waiting to pick up again. Now they may not realize that and that's what bothers me I guess is not so much that they substituted one addiction for another. That's a pretty natural self-preservation mechanism but the fact that A, the treatment staff doesn't pick up on it and B, they walk out of there thinking that they're fixed and it just kills me because most of the time I can see the fact that they are not coping any better. They're just kind of white knuckling it and holding on for dear life and hoping that they can keep going on. Just hold on like this. Pretend you're holding on to a rope over the side of a cliff. You don't wanna die so you're holding on to that rope for dear life. At a certain point, that grip is gonna give out. At a certain point, that grip is gonna give out. You still don't wanna die but you can't hold it together anymore. It's an important concept for people to start wrapping their heads around early in treatment. It's a whole change or adjustment in the way they deal with things and I believe we build on the skills that they already have. I don't want them to change who they are. I want them to be a better version of who they are. I want their coping skills to be stronger. I want them to build upon what they already know because they're going to use that much more effectively than if I give them something from out of left field and they're gonna be like, I'll try it but I'm not making any guarantees. So here's a question. Is an alcoholic who hasn't had a drink in three weeks actually in recovery? Likewise, is an addict who hasn't used his drug of choice in three months actually in recovery? And I'll throw a little bit of a spin on it. Is an addict who hasn't used his drug of choice in three months but is drinking but is not drinking to excess or to a point where it's causing negative consequences? Is he or she in recovery? I can, from my own point of view, I can say the first two are not in recovery or we don't know if they're in recovery because we don't know how they're coping with life on life's terms. We need to know more than that. Have they developed stronger coping skills? Can they do that without substituting an addiction? If they have, if they can, then they are in recovery. Recovery is about a healthier lifestyle and a happier lifestyle. So let's think about some behaviors that your patients engage in when they're deprived of their addiction of choice. Sex, gambling, you'd be amazed at what people can find a bet on. Those are two of them. Eating is another one. Like I said, a lot of people I see go through residential, they come in for a 30-day program and they leave 20 pounds heavier. And most of them, you know, there was probably some nutritional deficit that needed to be addressed. But for the most part, it was because they chose to eat and stuff their feelings and escape through the use of carbohydrates and fats. So behavioral substitutions. They drop back to what they can access because they're resourceful. What function are these behaviors serving? They're helping the person avoid feeling what they're dealing with and maybe even avoid dealing with it. One of the things that we say in recovery is the greatest thing about recovery is you start to feel feelings. And one of the crappiest things about recovery is that you start to feel feelings because it's exhausting and it hurts. You can't just numb it out and let it go. So behavioral addictions. We're talking about food. We're talking about sex, pornography, gambling, shopping, exercise, internet, relationships. Any of these can be used to help somebody feel or help somebody focus on something other than the present moment. And we know a lot of people with addictions focus on the past, focus on the future, focus outside of themselves on what everybody else is doing, but they don't focus on the moment and they don't focus on themselves. So behavioral addictions serve as that distraction. A couple of things that I have picked up over my years of working with people with co-occurring disorders is generally the more primitive, the primary addiction or the more fundamental need it meets the earlier it started. I found that people whose addictions began or their addictive behaviors began or their coping skills got overwhelmed, however you wanna say it. In an earlier age, like nine, tend to fare, well, not fare worse, but they tend to have fewer coping skills. They tend to have more primitive addictions to start out with or more primitive addiction substitutions. Now, if they started smoking weed when they were nine and yes, a lot of people do, by the time they're seeing you when they're 29, they've probably progressed with their substance. If they started their behavioral addiction, pornography, when they were, we'll stick with nine. And yes, again, I've worked with a couple of clients who have started as early as seven, eight, nine. So if they started viewing pornography at seven or eight or nine and you're seeing them in their 19, they've probably gone through quite a bit of different pornography and they're probably needing something pretty shocking in order to get the same effect. So we wanna look and if somebody started back that early, what need was it meeting back there? Was it survival? Was it love? Was it comfort? We need to figure out what the underlying distress is. Once an addiction starts, once the coping skills get overwhelmed, psychosocial development either slows or stops. It kind of gets stunted at that point. Now, why is that? A lot of it is because the person is focused on escaping and feeling better. They're focused on their addiction. So they're not devoting time to forming relationships, developing stronger coping skills, reaching out for resources. They are staying in their bubble, if you will. It's not, again, this is not true of everybody, but these are some general rules that I have found to hold true 90% of the time or better when I've been working with clients. So some basic behavioral principles we need to remember. When faced with two choices, the tendency is to choose the more rewarding option. If you're faced with a plate and you've got celery or chocolate, what are you gonna choose? Well, if we're just going off of our sort of knee-jerk reaction, you're probably gonna go towards the chocolate. If you stop and think and remember that you're trying to eat healthier and you just ran six miles in the morning, you may choose the celery. Attics have difficulty with that whole stop and think. So we need to remember that when faced with two options, looking for the long-term goals, the good orderly direction, that's probably not gonna happen when they're in their addiction. They need the pain to stop right now. They need the pleasure right now. It's about immediate gratification. Okay, so what do we do with that? To increase motivation for change, to increase motivation for looking at the long-term goals, the less rewarding choice must become more rewarding. So why is treatment? Why are we gonna choose treatment and these new coping skills overusing? We need to help people increase their motivation, see the benefits, feel the benefits of change. Part of that comes from making sure that they have frequent small rewards. Getting through a week of treatment, getting through a certain situation without using. There needs to be a lot of positive reinforcement and a lot of encouragement in order to help them get the same sort of warm and fuzzy feeling, if you will, that they've been trying to find for so long. Sometimes warm and fuzzy is not enough though. The alternate behaviors need to be equally as rewarding or close to it as the addiction. You're not gonna take somebody who is a hardcore gambler and they easily go into a game with 10,000 and hopefully walk out with 100,000, but we're talking big numbers there. So telling them to substitute that with going on a walk in a park probably is not going to meet the same, need is not gonna produce the same rush. So we need to figure out what the, need the addictions meeting and another way to help them deal with it. Is it helping them avoid stress, avoid thinking about money problems? Okay, so we need to address the money problems and we need to find another way to deal with stress. When you're working with people, we all work with people, and you're assessing a person for a mental health issue. It's important to ask about how they cope and apply what we call the cage questionnaire. It's a screening tool initially developed for alcoholism. Why is this? Another one of the soapboxes because co-occurring disorders are the expectation, not the exception. Addiction and mental health disorders occurring together are the expectation, not the exception. Okay, so if somebody presents for mental health issues, we have in the back of our mind that they're probably having difficulty coping. And we wanna know, are there any addictions? Are there any dysfunctional coping behaviors that might be A, contributing to the depression, but B, being used in order to try to deal with the depression, but not being used effectively. So, have you ever needed to cut down on your use? Well, stick with gambling, because we've used that one so far. Have you ever felt the need to cut down on your gambling? If so, tell me about that. Why did you feel you needed to cut down? Whose idea was it? What kinda got that feeling going on? Have people annoyed you by criticizing your gambling, telling you you gambled too much, or you're too risky, or whatever the case may be? Have people criticized your gambling? Have you ever felt guilty about your gambling? Maybe you gambled away your kid's entire college tuition. That might be something that would cause some guilt. Or maybe you decided to stay home and gamble online instead of going to your kid's football game. That might cause some guilt. Okay, now here's where we change it up a little bit, because in the original cage, it talked about E stood for eye-opener. Did you have to have a drink first thing in the morning to feel like you could function? When we're talking about behavioral issues, we wanna talk about have you eliminated or reduced important roles, tasks, or relationships? Have you let everything else fall to the wayside so you could focus on your addiction? A yes to two of these or more may indicate that there's a problem. When assessing someone with other addictions, it's also important to look for behavioral addictions. Why? Well, one of the things that we have with substance addictions, like I said, when people go into treatment, we see them very easily replace behavioral addictions for the substance if they can't get their substance. So we need to know what their go-to behavioral addictions are so we can be on the lookout for them during the recovery process so we can help them actually deal with life on life's terms instead of just find a different way to run away from it. When assessing someone with a family history of addiction, even if they're not addicted right now, even if they're not experiencing an addiction right now, then they're probably in your office for a mental health reason. If there's a family history of addiction, then they grew up using social learning theory, observing people use, despite negative consequences, to escape from distress. So they've seen it work for other people, which means they may have that, and they probably do have that in their arsenal as a tool to deal with stress. Now, will it become used as a coping skill and become a problem for them? Not always, but if they've seen it work for other people, we know that it's in their repertoire and we know we need to be aware of it. It's also important to remember in an assessment and as you're doing ongoing assessments and reassessments and discharge planning, and just remember it all the time, that behavioral addictions are often a relapse warning sign for other mental health or addictive issues. So if someone starts gambling a lot or compulsively shopping or binge eating, that tells me, I'm not talking about one time or here and there, I'm talking about a habitual pattern. That tells me they're trying to escape their experiencing distress, which means that either they're going to eventually progress, intensify, back to their other addiction, or and or that mental health issue, the depression, the anxiety, the bipolar, the schizophrenia, whatever, is not being adequately addressed and they're starting to have a relapse of their mental health issue and they're trying to, again, white-knuckle it, they're trying to hold on, they're trying to keep from feeling bad and they're not using the healthiest coping skills. So behavioral addictions, even before they start to get to the point where they're causing a whole lot of problems, if you know that people, somebody has a habit, somebody has a tendency to gravitate toward internet addiction or gambling addiction, then we need to look and say, okay, how much have you been using that? We need to keep a chart, keep a log, keep an awareness. So when that starts to become dysfunctional use or before it becomes dysfunctional, ideally, the person can address it with their therapist and keep it from becoming a big problem. Okay, that was a short section. So we're gonna take another 10-minute break. When we come back, we're gonna go through the vignettes that talk about applying the principles of addiction and the diagnostic criteria for addiction and treatment principles to some of the more common behavioral addictions.