This chapter brings together the results that have been presented in the thesis. The first section of this chapter looks at the main aims and context of the research. The second section summarises the main findings in relation to possible implications and ideas for future research.

Index

Section One

11.1. Main purpose of the research

The main purposes of the research were to: (a) determine whether Stephenson et al’s (1995) factor analytic study of addictive orientation in addicts was replicable; (b); explore addictive orientations in relation to a non-addict population (c) Explore the significance of the concept of addictive orientation in terms of gender differences. (d) Investigate the possible contribution of personality and psychiatric symptom variables to our understanding of addictive orientations in the clinical population. In sum, a series of exploratory studies investigating the potential and possible meaning of addictive orientation.

11.2 Part one: Background to the research (chapters, one, two, three and four)

As the research was set in a specific treatment setting it was important to conceptualize the research and so chapter one outlined the origins of the AA movement and some of its central assumptions such as the disease concept and spirituality. Chapter two described how PROMIS, a Minnesota method centre, interprets the concept of addiction and how the centre treats addiction. This was important as the range of behaviours to be included in the research was already determined by the treatment philosophy and context. Due to this fact a number of behaviours were included that are not typically seen as addictions, such as work addiction or relationship addiction.

In chapter three literature was examined to investigate the central features of addiction in order to assess the appropriateness of the incorporation of other “addictive” behaviours not traditionally viewed as addictive. Interestingly, when exploring the relevant literature it was found that the behaviours which are considered addictive have started appearing in research more recently and that similarities across addictive behaviours are being documented. From this basis a number of arguments were made for their inclusion and the phenomenon of cross addiction was also explored.

The starting point of the current research stemmed from a piece of previous work which had been conducted on an older version of the current Shorter PROMIS questionnaire (Stephenson et al, 1995). This research suggested that the addictive behaviours under consideration seemed to fall into broad categories, Hedonism and Nurturance, and it was these two broad categories that was to provide the starting point of the current research. Chapter four initially outlined the development of the shorter PROMIS questionnaire, looked in further detail at the dimensions and items on the questionnaire and then went on to explore the rationale for a replication of Stephenson et al’s (1995) research with the use of a control group.

11.3. Part two: The exploration of addictive orientation (chapters five, six and seven)

Chapter five of this thesis described a study which sought to determine whether Stephenson et al’s (1995) factor analytic study of addictive orientation in addicts was replicable. Using the Shorter PROMIS Questionnaire a four-factor solution revealed the optimum number of factors for the clinical data. The four factors were called Self oriented nurturance, Other oriented nurturance (these two factors previously formed the Nurturance factor in Stephenson et al’s 1995 study), and Sensation seeking hedonism, Power related hedonism (these two factors previously formed the Hedonism factor (op cit)).

Self orientated nurturance (both food dimensions, shopping and caffeine) was seen to be related to a tension around the control of the body, and the alteration of internal state through the focussing on the physical.

Other orientated nurturance (both compulsive helping dimensions and work) was seen to be related to the focussing on helping of others and determined engagement with work.

Sensation seeking hedonism (Drugs, prescription drugs, nicotine and marginally alcohol) seemed to be contain the “traditional” forms of mood alteration as it contained the more radical, reckless and pharmacological addictions.

Power related hedonism (Both relationship dimensions, sex and gambling) The significance of the clustering of these dimensions seemed to related to power

Conclusions from chapter five:

It was concluded that the dominant approach has been to consider addictive behaviours quite separately. However an increase in the reporting of the phenomenon of cross-addiction, and the results from this and the earlier related study suggest that it is important to look at addiction in terms of addictive orientation. The literature, indeed, shows high rates of cross addiction e.g. high rates of multiple substance disorders particularly nicotine, alcohol, cannabis and cocaine (Muesler et al, 1998) The present findings support the notion that proneness to addiction may be general up to a certain point, given the covariation of the different behaviours. Nevertheless, the factor analyses suggest that the four orientations emerge clearly from the overall pattern of covariation.

The shorter PROMIS questionnaire in a non-treatment population (Chapter six)

This chapter explored the possibility of the presence of parallel forms of orientation occurring in non-addicts. What was found was, in the same way as for the clinical sample, a four-factor solution. Looking at both sets of factors (from treatment and non-treatment populations), what was most striking was that a high degree of correspondence between the factorial structures between the two samples was found.

From these results it seems that in terms of addictive orientation a pattern already exists in the non-addict population. What this may suggest is that the combination of addictive behaviours which are commonly used by addicts, are built upon an already occurring orientations towards certain clusters of behaviours. If this is the case then it would seem that addictive orientation in addicts has, in some way, its roots in normal non-problematic behaviour, in a way not previously anticipated.

These results indicate that consideration must be given to why this pattern also appears in a non-addict sample As the other studies in the thesis consider only an addict population this question would be an interesting target for future research.

It may also be interesting to look at differences in drives, motivations and expectations in terms of what specific benefits, feelings etc. are gained with certain combinations of addictive behaviors being used, as it is likely that this sort of information would have implications for clinical populations. For instance examining whether there is a correspondence between non-addict and addict motivations for the use of the various orientations of addictive behaviour. Would any similarities be found between non-addicts and addicts who share an involvement with the same orientation ? Taking a more dimensional approach to addiction in terms of a pattern of behavioural usage being present in a non-treatment population (albeit at a lower level) allows us to study addictive behaviour within a non-clinical group with an eye to enhancing our understanding of disordered functioning.

The development of the idea of a “Continuation hypothesis of addiction”

These results suggest the possibility of considering addictive behaviour not as a bi-modal, or an "either/or" phenomenon, with non-addicts being completely different from addicts, but a phenomenon which is represented in a more continuous way than perhaps previously thought. This is because meaning and significance seems to found in the clustering of certain behaviours within a non-addict’s behavioural repertoire. If this is the case then the placing of individuals into either/or categories (i.e. either disordered or not) could be seen as erroneous, because it implicitly ignores the potential for variation being present in disorders. If there is significance in the clustering of addictive behaviours in non-addicts then further comprehension of the manifestation and generation of addictive disorders may improve from this information, and consequently the likelihood of prevention, early detection and treatment of addiction may increase.

There is some previous research that may provide support for a more general continuity hypothesis of addiction, for example, in bulimia research there has been debate as to whether this disorder represents an extreme end on a continuum of weight preoccupation and dieting, or is somehow categorically different from sub-threshold bulimia or an absence of eating disorders (Polivy & Herman, 1987). Interestingly a recent study (Stice et al, 1998) indicated that the continuity hypothesis is supported for both weight concern and psychopathology. This seems to make implicit sense, and if this ideas was tested across a whole range of behaviours it may indicate these behaviours are routinely used in the vast majority of cases in a non problematic fashion, and that the idea of viewing these disorders in terms of a continuum is valid and useful. From this, further understanding of the development of addiction may be possible.

Investigation into gender differences in addictive orientation in addicts and non addicts (chapter seven)

Chapter seven of this thesis described a factor analytic study that sought to determine whether there are differences in factor structure according to gender. This having been found to be the case, the significance of these orientations in terms of gender differences was explored. Though differences were found across the four samples (male addict, female addict, male non-addict female non-addict) a number of dimensions were found that cluster together.

It was posited that there may be a number of reasons why certain behaviours may occur together and why differences may be found between genders. For instance an individual's set of gender-role expectations may exert a dominating influence on one's sense of self, in terms of which behaviours are viewed as acceptable to be engaged in. From the results, discussion centered on the possibility of the differing experiences of the two genders contributing to the orientation towards certain behaviours. An argument was constructed that related male’s better honed involvement in Sensation seeking hedonism (substances), and Power related hedonism (relationships), to delinquency, social roles and conduct disorder. For females an argument was made that relates females' propensity to eating disordered behaviour to their involvement in behaviours in the Self orientated nurturance factor (food).

11.4. Part three: The contribution of personality and psychiatric symptomatology to addiction (chapters eight, nine and ten)

In chapter eight the possibility of personality variables contributing to the further comprehension of addictive orientation was explored using current literature. In general it was found that the attempt to find an “addictive personality” has not been successful and that many personality variables have been linked to addictive behaviour. In chapter nine, using the Interpersonal adjective scales (IASR-B5), the role played by personality in relation to the addictive orientations for males and females in the clinical sample was investigated using regression analysis. It was found that the personality variables were differentially associated with the four factors for both males and females. This study has helped to explain why there isn’t a single addictive personality, as it seems that from the Five factor model of personality the dimensions seem to contribute to different underlying dimensions of addictive behavior. Consequently one implication from this and earlier research is that the construct of personality should be considered to be of potential importance in the comprehension of addiction.

So, even though previously a strong argument was made to support the idea that there may be a number of commonalties which run beneath many of the addictive behaviours, when it comes to involvement of gender and personality dimensions, differences in terms of associated personality characteristics can be shown. This is important, as with additional explanatory information attached to the different factors of addictive orientation, investigating further the significance of different “drives” or motivations behind addictive behaviour may be possible.

A very brief summary of the main findings will be drawn together here in conjunction with a consideration of their theoretical implications.

The role of Conscientiousness

Out of the five personality dimensions one of the more key findings was the presence or absence of Conscientiousness; with Conscientiousness being associated with the “Other Orientated Nurturance” (compulsive helping) and negative Conscientiousness being associated with the “Sensation seeking hedonism” (Drugs). This suggested that, in general, this personality variable is important in Hedonistic behaviours. There seems to be inherent sense in this association as the nature of this cluster of behaviours has the feel of recklessness, selfishness and carelessness. It was also found that the personality construct of low Conscientiousness is for some reason a more important contributing personality variable for males than it is for females. This may be explained perhaps simplistically through differences in gender expectations, in that it is more acceptable for males to be delinquent and therefore to be engaged in these behaviours.

The role of Neuroticism

Out of the five personality dimensions another of the more key findings is the contribution of Neuroticism. Neuroticism though present in both the male and female Self Orientated Nurturance factor (food) had a particularly strong association with the female population. This suggests that, in general, this personality variable has an important role in the female Self Oriented Nurturance factor (food). So in the same way as Conscientiousness may contribute to the hedonistic areas in males in particular, so Neuroticism may be a cardinal aspect for the Self oriented nurturance factor (food). Previous research has indicated a link between neuroticism and eating disorders (e.g. De Silva (1987). However, with these present results, it seems that the association of neuroticism extends beyond that of eating disorders to encompass other addictive behaviors.

In addition to this, the dominance of females in the eating disordered sample must be noted as it may indicate that being female has something to do with what is driving women to choose this particular cluster of behaviors. This has considerable support as the relationship between being female and eating disorders is well established. For example, a meta-analysis of 22 studies supported an overall positive relationship between femininity and disordered eating (Murnen & Smolak, (1970).

Five factor measures of personality in conjunction with addictive orientation may be important for research on patient treatment program matching, as testable predictions for which specific techniques might be more effective for which types of individuals can be made. For example, treatment for those scoring high on neuroticism might include behavioural techniques to manage overwhelming stress and emotions. For those who are impulsive, treatment approaches which provide instant and concrete contingent reinforcement for abstinence in the form of pleasing rewards may be useful.

Psychiatric symptomatolgy

Chapter ten of this thesis describes a study that considered how psychiatric symptomatology may contribute to the comprehension of addictive orientation for males and females. An initial finding indicated that the most important difference between males and females in terms of BSI scores was the level of symptom reporting which on intake was higher in females than in males. After six weeks of treatment however, the female’s scores were found to have reduced to a level which was lower than the males 6 week scores. This, it was posited, may indicate that the treatment at PROMIS is particularly helpful and successful for women.

Using regression analysis it was found that these psychiatric symptomatology variables were differentially associated with the four factors for both males and females. One of the main findings was that more than double of the symptomatology variance was explained by the factor scores for females than it was for males, this possibly indicating that for women, addiction has more to do with psychiatric distress than it does for men. This particular finding seems to mirror other findings of increased psychiatric severity in females (e.g. Benishek, 1992).

Examining the most important factorial predictors for psychiatric symptomatology, it was found that on entry to treatment for males it was the Power related hedonism factor (relationships) that was the leading predictor for the various symptoms, and for women it was found to be Self orientated nurturance factor (food). Primarily as in the light of previous findings, differences have been revealed in relation to the different types of disorders that tend to dominate in men and women. From the results it could be said that gender-related power relationships underlie at least some aspects of addictive disorders in men and women. It can be noted that this position has a distinct resonance with the findings from the previous study involving personality.

Are addictions gendered disorders?

At the beginning of the thesis a case was made to support the position that a wide variety of behaviors may be considered to be addictive. We found an overall positive correlation between the said behaviors. However, it was only when the factor analyses were conducted that a pattern was revealed locating more precisely the strongest associations between these behaviours.

Importantly, differences were observed in the factorial structure for males and females (in both addict and non-addict populations), and these different factors were found to have different associations with personality and psychiatric symptom variables. This may have implications for the understanding of the differing expressions of addiction according to gender. This is because it appears that gender is impacting the behaviors chosen by addict and non-addicts. For instance when looking at the scores across the populations, men scored higher than women on behaviours such as gambling and women scored higher on the food related behaviors. So it seems that even though an argument can be made of for the behaviors' similarity at another level, a marked difference in relation to their use is also revealed.

Strongly related to these findings, is the fact that women suffer from eating disorders more often than men, and that men suffer more often from substance use disorders and gambling (Feid & Burr, 2000). Concerns with diet and the body are stereotypically feminine, while substance use and gambling are stereotypically masculine behaviours, and it is this gender stereotyping which drives a course of least resistance into addictive usage. Addictive usage may be said to build upon sets of behaviours that are in some way already socially activated or stimulated.

Two notable differences can now be considered in relation to factorial structure, to illustrate these gender differences. Whereas exercise failed to load on any of the factors in the male sample, in the female samples it loads strongly with the Self Oriented Nurturant factor (food), appearing with Caffeine and both of the Food dimensions. It was said that this factor seems to be to do with self control, especially relating to body image, and if this is the case then exercise fits well with this interpretation. This is because if compulsive exercise is used in conjunction with under eating and the use of caffeine (perhaps to moderate over eating), this constellation of behaviours will all contribute to weight regulation.

Work has been conducted on the relationship between gender role identification and its relationship to eating disorders, and there is a growing literature which addresses the specifically gendered nature of women’s eating problems (e.g. Dolan, & Bitzinger, 1994). In relation to what contributing forces are influential, Klingenspor (1994), talking about bulimia, argues that it is the central place that beauty plays in the social construction of femininity and the current physical ideal of extreme thinness that in part explains the emergence of this new eating disorder.

Again in relation to gender, a study looking at the relationship between gender identity and bulimia indicated that bulimic individuals under-identified with masculine attributes, this suggesting that identifying with masculine attributes may be an effective strategy for achieving a positive self concept and for indirectly reducing the risk of eating disorders (Klingenspor, 1994). In another study, the role of both sexual orientation and gender related personality traits were examined in relation to disordered eating attitudes and behaviour. It was found that for both men and women irrespective of sexual orientation, it was higher scores on negative femininity that predicted higher levels of disordered eating (Lakkis, Ricciardelli and Williams, 1999). These studies help to support the position that eating disorders are to a certain degree gendered disorders.

In relation to the role of socialisation and attitudes of acceptability it is of interest to note that in the male samples sex appeared with both forms of the relationship dimensions whereas with the non-addict female sample it failed to load on any of the factors. Interestingly, it has been noted that incidence rates and approval of premarital sexual behaviour and of many sexual risk practices continue to be higher for men than for women (Oliver & Hyde, 1993) It has also been argued that a variety of different perspectives such as socio-biological, social learning, social role and script theories all expect women to have more negative attitudes toward casual, premarital sex than do men (op cit). So again perhaps what we are seeing is the formation of attitudes towards various behaviours being influenced by the contribution of the socialisation of gender role. In addition to this, research has indicated that the rate and approval of risk behaviours such as delinquency and to a lesser extent, alcohol and drug use continue to be higher for men than for women (e.g. Magurie, & Pastore, 1997; Maxim & Keane, 1992)

How to view these gender differences

It seems then that there is evidence in conjunction with the present findings that indicate that the gender differences in patterns of addictive usage may have something to do with the socialisation of gender role. It is interesting to note that this idea goes some way to reinforce the conclusions of previous research, which has suggested that one way of looking at gender differences in the patterns of addiction is that socialisation somehow encourages the internalisation, or externalisation, of problems (with women internalising and men externalising their problems; Huthar, 1996).

The involvement of personality and psychiatric symptomatology variables can also be interpreted as elements which highlight the importance of clusters of behaviours into internalised or externalised expressions. For example the relative importance of neuroticism for the Self oriented nurturance (food) factor for females, may be explained by the tendency for problems to be internalised. In support of this, Broidy & Agnew (1997) argue that the lower rate of female delinquency may be explained by females being more likely to respond to strain and stressors with depression, i.e. internalising rather than externalising.

The importance of negative Conscientiousness in relation to the Sensation Seeking Hedonism (drugs) factor for men, provides an interesting potential overlap with this finding, in that much research has shown that antisocial personality disorder is strongly associated with substance use disorders (Regier et al, 1990), in both clinical (e.g. Hesselbrock, Meyer & Keener, 19856) and general populations (e.g. Helzer & Pryzbeck, 1988). It can be said that it would be expected that low conscientiousness would be associated with this personality disorder, and if this was found to be the case then it would seem likely that personality is a contributing factor to the development of a range of activities which can be termed as anti-social.

Considering the personality variables associated with both anti-social personality disorder and the hedonistic factors, a deviance proneness model emphasising underlying traits may have considerable explanatory power. It would be interesting to investigate the interaction of low conscientiousness, anti-social personality disorder and substance use disorder, as it may be predicted that those with particularly low conscientiousness would be more likely to exhibit anti-social personality disorder and be more likely to be addicts engaged addictively with behaviours from the hedonistic arena.

One important caveat must be entered here: the direction of causality. So for instance, it could be the case that substance abuse may contribute to anti-social personality disorder like symptoms, such that rather than anti-social personality disorder being a risk factor for substance abuse, it is simply a by- product.

It would seem pertinent therefore for researchers to direct attention to the range of psychological and social factors that make men more at risk for developing culturally orientated drug problems, and for women, culturally orientated eating disorders. Perhaps thought could also be given to the possibility of males and females better responding to specifically designed treatment which considers the importance of these factors.

Understanding the increase in male eating disorders and the increase in female delinquency

Even though both men and women are affected by addiction and there may be a number of common factors which increase the likelihood of addictive use occurring, it seems that it may be something to do with gender which propels males and females into different courses of activity. Biological mechanisms acting through hormonal effects on the brain are plausible, but hard to test. This is because any biological explanation of observed sex differences in addiction needs to also to consider how the social position of women in society may influence their addictive involvement. The full explanation for the sex differences is likely to combine factors related to expression of distress biology and social situation.

Having said that, it is imperative that research should investigate the factors which seem to drive men and women into certain methods of mood alteration, whether this is within a normal range of usage or pathological range; obviously there is a degree of cross over. For instance it has been argued that women are catching up with men’s drinking and drug use, and it is now recognised that some men suffer from eating disorders, though still at much lower rates then women (Feid & Burr, 2000). Nonetheless it must be said that some separation still remains, this being illustrated in the diagnostic breakdown of the present clinical sample. However, how are we to view those that seem to buck the trend and opt for a non gender typical engagement in addictive behaviour ?

Currently, women’s drinking and drug use seem to be more socially acceptable than men’s eating disorders. Perhaps this is because as society becomes less heavily gendered, stereotypically “masculine” behaviour has become more acceptable for women than stereotypically “feminine” behaviour is for men (Reid & Burr, 2000). In conjunction to the present findings, a recent study reported that women with higher levels of masculine personality traits and egalitarian gender role attitudes were more likely to have multiple partners and use alcohol or drugs (Nicholson, White & Duncan, 1999) i.e. move into the traditionally male area of mood alteration. From this finding it seems as though the idea that engagement in addictive behaviour certainly does have much to do with gender identity.

It is likely that populations of individuals whose addictive inclinations are not gender typical would be interesting groups to focus on. As when women become involved in hedonistic type areas, it can be argued that not only are they being deviant they are also shunning cultural norms regarding their behaviour, and hence may be regarded as being “doubly deviant” (Heimer, 1996). Locating processes involved in this would be a worthwhile pursuit.

Theorists argue that focusing on lives in context is needed to understand differences in risk behaviours (Chesney-Lind, 1989). This it seems is especially applicable in the field of addiction as it may be said that conventional ideas of addiction have been largely constructed to explain male addiction. If this is the case it may be argued that consideration and investigation into the complexity and richness of men’s and women’s lives may reveal important insights into the many questions surrounding gender and addiction. It may even be the case that separate theories are required to account for male and female addiction.

A required component of future research may be to attempt to contextualise the sociological and cultural variations in women’s and men’s lives, as it is important to place addiction within the context of contemporary society; to talk about both theory and life experiences of addicts. It is likely that women and men may engage in the same behaviours for different reasons (Waldron, 1997). One implication is that this may cause differences in how to best to approach and treat these problems.

11.5. Further implications and future research
(a) the appeal of a dimensional approach to addiction

It has been said that in their early stages all sciences tend to order their variables into separate or discrete classes (Hempel 1961). As progress within the discipline occurs, advanced methods of analysis become available to enable scientists to deal with the interplay of elements comprising their field, and thereby to specify how formerly unconnected characteristics overlap and interrelate. It can be argued that this is particularly applicable in the field of cross addiction and the related findings of co-morbidity. As the field progresses addictive disorders may be less likely to be seen as discrete and independent, and more as converging and reciprocal, exhibiting both interconnected and distinct features.

An approach that could be explored that may help to provide further understanding with more valid indices of addiction, is to emphasise a move from a categorical to a dimensional approach in describing addiction. It is possible that given the extent of cross addiction, the syndrome approach, which may be well suited to describing illnesses, is poorly adapted for describing the subtleties of individual differences in addiction and would be better served by a dimensional approach which would provide a more comprehensive assessment of addictive activity.

It has been argued that it may be important to look at addiction in a dimensional fashion rather than at individual areas, that investigating the found orientations further will reveal further the significance of certain behaviours clustering together. What has been previously reported is that alcohol and drugs alleviate a variety of different factors such as social problems, insomnia, depression etc. but it is rarely reported that specific substances are sought to alleviate specific symptoms (Muesler et al 1998). Further research may also indicate that even though many different problems may be alleviated through addictive involvement, the method of mood alternation seems to differ according to gender, to the extent that clustering of behaviours occurs also in non-treatment populations. So, in a way, rising above this level of problem driven analysis and concentrating on the processes which mediate this gender patterning may be an interesting area to focus on.

(b) Idea of a multiple risk factor model

It may be useful to formulate a theoretical model which expands and synthesises personality, patterns of consumption, into a single paradigm that attempts to account for the patterns of addictive use. This integrated model would provide an explanation for how addicts may develop their behaviours and most importantly consider differences in gender. It attempts to advance our understanding of addiction in a number of ways: (1) by emphasising the pattern of addictive use in non-addict and addicted populations; (2) the consideration of personality; (3) the consideration of other psychiatric associations, and (4) emphasising the importance of social structures.

It has been said that it is useful to consider a range of behaviours simultaneously, and to examine the various influences which impinge on addictive behaviour. Nonetheless, it is still crucial to carry on the important work regarding individual addictions and contributing causative factors. For instance, a whole range of behaviours engaged in to excess can be seen as addictive, and this may point to a neuro-chemical substrate which makes those areas particularly prone to abuse. If it is the case that there is a biological substrate that forms the basis of a link between various addictive areas then these mechanisms need to be understood.

In addition to this it is quite a challenge to better understand the array of biological, environmental and psychosocial factors that contribute to the aetiology of addiction in order to respond better to addictive disorder. So the most appropriate research model will highlight the importance of the incorporation of biological, socio-cultural, situational and psychological factors.

(c) The use of non-addicts when investigating the role of personality and psychiatric symptoms in relation to addictive orientation

The investigation of non-addicts has been particularly useful in these studies. The further use of non-addict samples would be interesting to explore further, for instance, what role personality variables play in relation to the development of the orientations in normal and clinical samples. If so then perhaps considering what level of certain personality characteristics tend to be present for people to go on to develop these problematic behaviors is one possible question that should be answered. It is also important to examine whether or not psychiatric symptomatology variables, or depressive or anxious tendencies etc., are in any way involved in the found pattern of addictive orientation in normal samples. This again may further the comprehension of how certain disorders develop.

(d) The influence of co-morbidity

It was seen that with this clinical sample there was a high degree of psychiatric symptom reporting, and it is fair to say that relatively little attention is being paid to the influence of co-morbidity on experimental results. Thus it is difficult to be confident that existing findings are attributable solely to the disorder of interest and are not an artefact of co-morbid psychopathology or general psychiatric distress. Further work with addicts should consider other symptoms that are experienced, together with to full consideration of cross addictive potential. For instance an individual may present with alcoholism when in fact other disorders, albeit at a minimal level, are also present. As alcoholism is a conventional problem the associated factors may well not be addressed, but for further comprehension of addictive behaviours a full and comprehensive history would be important in future research.

Finally, it should be said that those involved in the treatment of addictive disorders need to be aware of the widespread nature of the phenomenon of cross addiction, and to consider using the four factors as an important consideration in the organisation of treatment.

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