Index

3.1 Introduction

The quest to “mood alter” is not a new phenomenon, though in the present day it often seems that the availability of mood altering substances or behaviours is greater than heretofore. As in every epoch there seems to be an ever- increasing concern about the use of substances and the potential for deleterious consequences of substance use.

As addiction is not a new concept it is surprising, given its long history, that the definition of addiction is still in dispute. Gilbert (1995) has posited that “addiction” as a scientific concept in fact has little meaning as it employed in different ways by different writers, and there has been no agreement on its interpretation or underlying theory. This in part is due to the fact that the term is being applied to an ever increasing range of substances and behaviours. Indeed it was seen in the previous two chapters that Twelve Step philosophy has embraced a large number of addictive behaviours and advocates the same treatment for all. This process of applying the concept of addiction to more and more behaviours is also partially supported from research that seems to suggest that there may be a common addictive tendency (be it psychological, biological or behavioural) which is manifested in a variety of addictive areas. A further problem lies in the increasing number of research findings which link and find co-occurrences between many of the addictive behaviours that at one time were thought to occur quite separately. This phenomenon is often termed “cross-addiction” or, “co-variation” of addictive behaviours.

One primary aim of this chapter is to investigate, describe and define the co-variation of addictive behaviours in order to evaluate the importance of this emerging phenomenon. With this aim in mind, the chapter aims to describe first the development of the concept of addiction and then to explore its central features as applied more or less uncontroversially to substance abuse in order to provide a basis for inferring whether or not it is justified to include behaviours not commonly regarded as “addictive”, such as gambling, sex, food starvation or shopping. This will lead to the questioning of the common assumption that the term addiction implies only the use of substances such as heroin or alcohol.

The importance of the concept of “cross addiction” will be examined in the second section in a review of studies that suggest differing views of its occurrence. Biological, pharmacological, and psychological evidence will be considered, as these different levels of interpretation may all throw light on the investigation of “cross addiction”.

Finally, acknowledging the importance of conducting research on a wide range of addictive behaviours, it will be maintained that it is on the psychological level that some of the more fruitful research may be found in unifying the range of potentially addictive areas. The chapter concludes with a discussion of Stephenson, Maggi, Lefever & Morojele’s (1995) factor analytic study of a wide range of addictive behaviours. The need to replicate that study using revised scales, and employing a control group will be highlighted.

3.2 The development of the concept of addiction

Intuitively, the term addiction does not pose definitional problems for most people, as any behaviour engaged in to great excess, in an apparently irrational way, is usually perceived as being abnormal and meriting treatment of some kind, especially if it is likely to have an adverse effect upon the lives of both the individual concerned and those with whom that person lives and works. In contrast, clinically, the field of addiction has been in flux for some time and is characterised by a variety of perceptions about the nature of addiction and the requirements of rehabilitation. For example, the term addiction is often used in a pejorative sense in suggesting that the behaviour in question is a form of disease requiring some form of medical intervention (Eysenck, 1997). Others have suggested, however that it would be prudent to avoid completely a comprehensive definition of the term addiction as the exercise has already defeated several WHO committees in the past (Berridge, 1985). Nonetheless, where a large number of behaviours are to be considered together theoretically and clinically, as in the present study, the definition of addiction is an important issue, and investigating the development of the term and meaning has much relevance.

The history of the concept of addiction indicates that the definitions of abuse and dependence on substances have changed dramatically over time. These changes in attitude can also be linked with not only medical and scientific knowledge but also moral grounds and public belief. The historic, “moral” view of addiction will be briefly considered followed by the current medical disease model of addiction. Following this introduction the definitions provided by DSM IV, and concepts of the dependence syndrome (Edwards and Gross 1976; Edwards, Arif and Hodgeson, 1981) will be examined.

3.2.i. Historical and moral approaches

Addiction is commonly held to be detrimental to character, and to health, so the importance of a cultural and historic interpretation of what can be considered to be addictive and hence dangerous is paramount. For instance at one time both opium and cocaine were used extensively in medical practice, and opium in the eighteenth and nineteenth century was so widely acceptable that a little over a century ago it could be bought in most grocery shops (White, 1988). Examples such as these indicate that throughout history there have been moves from general acceptance of certain substances to almost total rejection. A further example concerns tobacco, as this at one time was seen as a panacea for various ills and even as having medically valuable properties (Berridge, 1985). This is not to say that there was no concern surrounding tobacco, as in 1908 legislation was passed prohibiting the sale of tobacco to those under sixteen years of age. This concern though concentrated on the moral degeneracy of cigarette addicts rather than constituting a medical worry (op cit), as in this particular epoch a moral view of addiction was in place.

The moral view is based on the notion of free will (McMurran, 1994), which postulates that people are free to choose their behaviour in any situation. A person involving themselves in a behaviour that could be said to contravene social norms could, according to this perspective, be seen as weak and feckless, and the activity essentially as a bad habit. Interestingly, a study by Orford and McCartney (1990) indicated that excessive gambling is seen by the general public in more moral terms than other addictive behaviours such as substance use and excessive eating. Excessive gambling is now more readily seen in terms of vice or a lack of will power, in the same way that other substances, such as alcohol, have been seen in the past.

3.2.ii. Disease model

This next general trend was promoted by developments within the natural sciences and medicine. The idea of free will and individual responsibility gave way to the scientific presumption of determinism (McMurran, 1994). This proposes that events must have a cause, and that the cause must be able to be found using scientific inquiry and logic. This view encouraged the application of medical rather than moral concepts to addiction. It can be argued that it is in this way that undesirable behaviours came to be viewed as the symptoms of physical malfunction and, where no physical cause was apparent, the notion of “mental illness” was applied. Research over the past 20 years or so has been dominated by the disease model of addiction which suggests that addiction, and drug addiction in particular, is a chronic and relapsing disease that results from the prolonged effects of drugs on the brain.

A central tenet of the disease model of addiction is that of “loss of control” (Edwards and Gross, 1976). This refers to the individual’s experience of an overwhelming desire to engage in heavy and repetitive drug/alcohol taking behaviours, and a sense of powerlessness over the behaviour that he/she may be engaged in. In The Disease Concept of Alcoholism, Jellinek (1960) describes an alcohol addict as an individual who experiences problem drinking in conjunction with tolerance, withdrawal symptoms, and either loss of control or inability to abstain. The “loss of control” concept in general contains three core components that are frequently utilised in the discussion of addiction. The first is “tolerance”. Tolerance is said to be evident when after exposure and repeated use an increase in the amount of the drug is needed to produce the same effect. On a pharmacological level this behaviour can be translated into a brain adaptation to repeated exposure to a drug such that the pharmacological response is diminished. The second assumption is that of “withdrawal” symptoms. These are experienced when the effects of the drug wear off, and they vary according to the substance taken. Common withdrawal symptoms include tremor, hot flushes, and nausea, and these are typically relieved by another dose of the drug. The third factor that appears along side withdrawal is that of “craving” and this refers to the addict’s experience of an overwhelming desire to take the particular drug of choice, even in the light of persistent problems caused by the substance use.

Earlier definitions of addiction concentrated on the role of tolerance, and withdrawal. Unfortunately the picture is more complex than this, as if tolerance and withdrawal were the only problems in addiction then a simple detoxification program, where the body is allowed to cleanse itself while the individual receives medication to block the withdrawal symptoms, would be effective treatment and there would be no return to the drug taking behaviour. In the case of someone who is “addicted”, detoxification is at best only the first step of treatment, and the prevention of relapse is the more difficult goal once the individual has reached a drug free state.

3.2.iii. Dependence

More recent definitions of addiction have emphasised the role played by psychological components of dependence, this being prompted by a now classic paper of Edwards and Gross (1976). Dependence is primarily a measure of compulsive use, and is an important factor when considering other behaviours, such as gambling and overeating, with less defined withdrawal responses that, none-the-less, have other shared features of addiction such as craving, and a relapse response.

The alcohol dependence syndrome (Edwards and Gross, 1976) provided a different perspective on alcoholism and de-emphasised the idea that alcohol consumption was a bimodal entity, with alcoholics forming the second mode with a distinctly higher consumption level than non-addicts (Davies, 1997) . It aimed to consider a wide variety of variables such as the pharmacological, and environmental, and was therefore more inclusive and wide ranging than traditional concepts of alcoholism. The three lines of argument centred around the possibility of (i) a return to normal drinking, (ii) people being able to move in and out of periods of troubled drinking and (iii) alcohol consumption statistics which indicated that within the population of all drinkers the distribution of consumption was uni-modal. Importantly, this conception of addiction, it has been pointed out, could also be said to apply to other forms of addictive behaviour (Davies, 1997)

As early as 1964 the World Health Organisation suggested that the term addiction be replaced by dependence, pointing out that addiction was no longer a scientific term (Kaplan, Husch & Bieleman, 1994) . The WHO’s resistance to the term addiction was an attempt to restrict the widespread use of disease formulations, in which individuals who were psychologically dependent were portrayed as being the helpless victims of some physical process (Marks, 1990). Interestingly, Marks (1990) argues that hypersexuality is best conceptualised as a dependence syndrome rather than an addiction. The WHO defies psychic dependence as:

Repeated urges to engage in a particular behavioural sequence that is harmful.

Mounting tension until the sequence is completed.

Rapid but temporary reduction in tension by completing the sequence.

Gradual return of the urge over hours, days or weeks.

External cues for the urge unique to the particular addictive syndrome.

Secondary conditioning of the urge to both environmental and internal cues (Marks, 1990, p.1391)

3.3. DSM IV (Diagnostic and Statistical Manual of Mental Disorders, 1994)

It is important to look at the standard definitions of addiction to see how decisions are currently made by professionals dealing with addiction and the DSM IV is a widely cited authority. Pathological use of substances that affect the central nervous system are said to fall into two categories, Substance Abuse, and Substance Dependence. Together these constitute the major DSM IV Category “Substance Related Disorders”. In substance abuse a person uses drugs to such an extent that he or she is often intoxicated throughout the day and fails in important obligations and in attempts to abstain, but there is no physiological dependence. Substance dependence is a more severe abuse of a drug often accompanied by a physiological dependence on it made evident by tolerance and withdrawal symptoms.

The criteria for substance dependence are the presence of at least three of the following; 1. Tolerance develops, indicated by (a) larger doses of the substance being needed to produce the desired psychological effect, and (b) the effects of the drug becoming markedly less observable if only the usual amount is taken. 2. Withdrawal symptoms develop when the person stops taking the substance or reduces the amount normally taken. The person may also use the substance to relieve or avoid withdrawal symptoms. 3. The person uses more of the substance or uses it for a longer time than intended. 4. The person recognises excessive use of the substance, may have tried to reduce it but has been unable to do so. 5. Much of the person’s time is spent in efforts to obtain the substance or recover from its effects. 6. Substance use continues despite psychological or physical problems caused or made worse by the drug. 7. Many of the activities (work, recreation, socialising) are given up or reduced in frequency because of the use of the substance. Substance dependence can be diagnosed as either with or without physical dependence. For the diagnosis of substance abuse the person must have one of the following problems due to recurrent drug use: 1. Failure to fulfil major obligations, e.g., absences from work or neglect of children. 2. Exposure to physical dangers such as operating machinery or driving while intoxicated. 3. Legal problems such as arrests for disorderly conduct or traffic offences, and 4. Persistent social or interpersonal problems, such as arguments with their partner.

Interestingly Jaffe (1980) has noted that physical dependence and addiction are not necessarily synonymous, as physical dependence may exist without addiction and in some circumstances addiction may exist without physical dependence. This is particularly important when considering other addictive behaviours such as shopping, work or exercise as with these behaviours there may not be clear and identifiable physical dimensions, such as withdrawal tremors and sweats that are associated with withdrawal from alcohol. Though with these other non-substance based behaviours, the addictive characteristics which are more psychological, such as recognition of the need to reduce the addictive behaviour but being unable to do so, are none-the-less apparent.

It can be seen that the definition of addiction has evolved, and now addiction is seen a syndrome characterised by, typically, compulsive drug-seeking behaviour that results in an impairment in social and psychological function or damage to health. Even after detoxification and long periods of abstinence relapse may occur frequently and the common behaviour pattern is manifested by repeated return to drug-taking behaviour that is often patently self destructive.

3.4 Other behaviours being considered

Core ideas about addiction have begun to change radically over the past 20 years or so. At the centre of these changes involves the belief that the pharmaceutical properties of an addictive drug may play only a minor role in addiction. This has opened wide the definitional door, and definitions of addiction that refer to repeated ingestion of a drug have been replaced by definitions that refer to compulsive repetition of behaviour. The broad characteristics of drug addiction have been identified in a range of behaviour patterns that do not involve drugs or alcohol. Many contemporary definitions of addiction, coming mainly from psychologists, therefore include addictive behaviours as well as addiction to substances. For example; McMurran (1994, p.6) states:

“Addiction may be defined as a degree of involvement in a behaviour that can function both to produce pleasure and to provide relief from discomfort, to the point that the costs appear to outweigh the benefits. Heavy involvement in an addictive behaviour is often accompanied by the recognition on the part of the ‘addict’ of the physical, social or psychological harm he or she incurs and an expressed desire to reduce or cease the addictive behaviour, yet, despite this, change is no easy matter”.

The term addiction has been used mainly for problems caused by the use of alcohol and illegal drugs and tobacco, with a number of good reasons. Alcohol has been described as, “Our favourite drug” (Royal College of Psychiatrists, 1987) and it is known that heavy drinking is associated with morbidity and premature mortality. In terms of the numbers that are affected by alcoholism the estimates vary, an American study undertaken by NIAA in 1985 noted not only an alarmingly high incidence but an interesting gender distinction. With 2.5 million women being found to be alcohol abusers and more than 3.3 million were alcohol dependent, which represents approximately 6 million women, or 6 percent of the adult female population. In comparison, it was estimated that 12.1 million alcoholics are men, representing 14 percent of the adult male population, hence it is assumed that there are approximately two males for every female alcoholic.

A further cause for the emphasis on drugs is the increase in registered addicts. The total number of narcotic addicts known to the Home office in 1970 was 1,426 and by 1995 this had risen to 37,164 (Royal College of Psychiatrists, 1987). Another way of investigating the increasing involvement with drugs is crime statistics and these show a similar pattern of increase. In 1960 there were 235 cannabis convictions and by 1985 this had risen to 17,559 (op cit). Another area which is being increasingly recognised is the dependence on prescribed medication. Even though it is clear that medication involves the use of a pharmacological agent it is easy to overlook the addictive potential of such medication and the negative consequences which may occur. For instance dependence upon psychotropic medication is often found together with alcohol abuse in women entering treatment programs, for example in one study tranquillisers and sedatives were used by 43 percent of female patient’s compared to 20 percent of men (Celentano & McQueen, 1984) Another issue being raised involves the questioning of the figure that estimates that two thirds of all psychotropic medication is prescribed for women (Prather, 1990).

Nicotine, however, is probably the most widespread addiction, though it attracts different “treatments” and though declining in acceptability is still seen as more normal in comparison to other addictive substances, save alcohol. The trend in smoking seems to be one of increase especially in particular age ranges. A survey conducted by National Opinion Poll indicated that 42 per cent of 18-24 years olds smoked in 1984 in comparison to 37 per cent in 1981. There is no doubt that smoking has severe consequences as it has been reported that it is the main cause of disease leading to early death in England and it is estimated that it caused over 120,000 deaths in the UK in 1995 (Callum, 1998). However, in terms of addictive acceptability, smoking is socially, and legally far more acceptable than heroin, though in terms of annual fatality rates nicotine causes far more deaths than heroin and other Class A drugs put together (op cit)

However, other behaviours are now being considered as addictive and at first glance the major difference to be noted is that a number of them have no obvious relationship to a noxious substance i.e. anorexia and gambling. Addictive characteristics and similarities are seen to be apparent in a wide range of behaviours. Some of these behaviours where a case is being made for “addictive status” will be considered next.

Caffeine

This substance currently has a benign public image being most often viewed as a harmless substance in tea, coffee and cola drinks, and used by approximately 80 percent of the world’s population (James, 1997). With its consumption so high, and caffeine being a mood altering substance, this world wide level of usage makes caffeine the most commonly used psychoactive substance (Op cit). Its appeal possibly reflects its reinforcing properties of taste, its beneficial psychoactive effects and the desire to avoid withdrawal. However, its inclusion in innocuous drinks means it is not ‘naturally’ classifiable with other substances of dependence. However, as it is psychoactive and has an associated withdrawal syndrome characterised by lethargy, fatigue and headaches, it is now included in the Diagnostic and Statistical Manual of Mental Disorders IV (1994) as a drug of dependence.

Eating Disorders

It has been argued that eating disorders share characteristics, such as craving, with other addictive disorders (e.g. Hetherington & Macdiarmid, 1993), though this idea has been challenged on the basis that the characteristics that they are thought to share are superficial (Wilson, 1993). It can be seen though that an overwhelming compulsion to overeat may be similar to the overwhelming drive to drink or to take drugs, despite a wish to do otherwise. Even though other explanations may be found, such as obesity may also be caused by sedentary lifestyle, and high fat consumption, the addictive qualities of overeating, and its high incidence, cannot be overlooked. In terms of incidence of obesity the proportion of men and women who are clinically obese was found to be 1 in 6 men and 1 in 5 women in 1997 (Health survey for England, 1997) Of further interest is that in the same way as with alcoholism being reported as affecting more men than women (NIAAA, 1985) men are reported as representing only 10 percent of eating disorder (anorexia and bulimia) cases (Andersen and Holman, 1997).

Sex addiction

In the 1980’s hyper-sexuality re-emerged under the label “sexual addiction”, being conceptualised as a behavioural addictive disorder similar to chemical addictions. According to Goodman (1992), sex, alcohol and drug addiction are better described not as varieties of addiction, but as manifestations of a basic underlying addictive disease process. The phenomenon of “sex addiction” has certainly started to receive attention (e.g. Carnes, 1983;1991), though it can be said that this is still with a degree of reservation. For instance research by Travin (1995) suggests four possible models for compulsive sexual behaviour, with only one being a classification that incorporates “sex” as a bona fide addiction.

Co-dependency or Compulsive helping

The term co-dependency at one time was used to refer to a dysfunctional relationship between an alcoholic and a committed, supportive partner. Initial conceptualisations of this dependency included features such as attempts to control an alcoholic’s drinking by repeatedly seeking to protect, control and change the alcoholic despite low success rate of these efforts. The term has now been expanded and has become more frequently recognised as a unique disorder, not necessarily involving a relationship with an alcoholic or drug disordered individual. (O’Gorman, 1991).

Cermak (1986) outlines five major characteristics of co-dependency. First, co-dependents make a continual investment of self esteem in the ability to influence or control feelings and behaviour in the self and others despite painful consequences. Second, co-dependents assume responsibility for meeting the needs of others to the exclusion of his or her own needs. Third, co-dependents suffer anxiety in periods of intimacy or separation because of poor personal boundaries. The fourth characteristic is that the co-dependent often becomes emotionally involved in relationships with personality disordered drug dependent and other compulsive people. Cermak (op cit) finally states that co-dependents can exhibit constriction of emotions, depression, hyper vigilance, compulsions, and anxiety. A succinct definition defines co-dependency as, “Any suffering and or dysfunction that is associated with or results from focusing on the needs and behaviours of others” (p. op cit). This definition comes very close to PROMIS’s definition of compulsive helping as an addictive behaviour in its own right.

Technological addictions such as computer playing (Griffiths, 1995), and the possibility of exercise as an addiction (de le Torre, 1994) have also been mooted, with more or less theoretical conviction. The benefits of exercise are apparent enough, but like other beneficial behaviours, including, it now seems, alcohol, abuse is a real enough possibility, as in exercising whilst injured and consequently making the injury worse.

There is a potential theoretical and practical benefit from including other behaviours in the discussion of addiction. Previously unforeseen similarities may throw a more general light on the characteristics of addictive behaviours. The description of similarities and differences may promote theoretical advances and have implications for appropriate treatment. Much may thereby be learnt from the sharing of information from these quite disparate behaviours. This in turn may create a more unified approach to the understanding of excessive behaviours, and perhaps lessen a one-sided emphasis on the more male and ‘aggressive’ forms of addiction.

The addictions considered thus far do not include all the possible substances and behaviours that can be addictive. Craving for more of an activity, tolerance of increased amount of the activity, and withdrawal effects when the activity is discontinued have been documented for a number of different behaviours. Other “excessive appetites” which appear to fulfil certain addictive criteria include gambling (Wray & Dickerson, 1981), repeated pathological love relationships (Peele, 1985), and overeating (Orford 1985). The theme that seems to run concurrently though all of the possible behaviours and which is possibly rather underplayed, is that what is attained through engaging in these behaviours is some type of change in state or mood, which tends to be satisfying or pleasurable.

It can be argued that attitudes, fashions and morality change towards addictive behaviour, especially when evidence come to light about the harmful consequences of a substance. For instance at one time it was regarded quite chic to smoke but with the growing awareness of the number of smoking related disorders and deaths it is now a top priority of government to encourage smokers to stop. Today’s Casanovas may object and claim that their appetite for sex is normal enough to them, and possibly it won’t be until enough evidence comes to light regarding what the behaviour may signify personally and socially that attitudes will change. Ultimately though what is considered to be an addiction to some is clearly not to others.

The established view tends to resist extension of the concept of addiction to include an increasing variety of behaviours. A number of objections are often raised: mainly it is said that an addiction must be a result of “taking” i.e. ingesting drugs (Griffiths, 1994), so this view rules out the possibility of an eating disorder or work(aholism) being classified as bona fide candidates for the addiction label.

3.5. Criteria for further behavioural inclusion

Such diverse inclusions in the addiction remit as considered above can be seen to fit with a number of definitions of addiction, which emphasise generic psychological processes and social consequences, without reference to pharmacological concomitants.

Marlatt et al. (1988, p.224) considers addiction to be, “...a repetitive habit pattern that increases the risk of disease and/or associated personal and social problems. Addictive behaviours are often experienced subjectively as “loss of control”- the behaviour contrives to occur despite volitional attempts to abstain or moderate use. These habit patterns are typically characterised by immediate gratification (short term reward), often coupled with delayed deleterious effects (long term costs). Attempts to change an addictive behaviour (via treatment or self initiation) are typically marked with high relapse rates.”

Given this definition, only culturally and medically determined criteria can serve to restrict application of the concept to alcohol and drugs. For some time there has been increasing interest in the examination of common dynamics that appear to be common across various compulsive behaviours (e.g. Miller, 1980; Levinson, Gerstein & Maloff 1983; Orford, 1985 and Stephenson et al 1995) And phenomena such as alcoholism, drug addiction, gambling and work addiction have been conceptualised as similar conditions that share a common addictive syndrome (Keller, 1972; Leon, Kolotkin & Korgeski, 1979; Mule, 1981, Platt, 1975; Scott, 1983).

The theoretical ambition to unify addictive behaviours appears repeatedly (e.g. Donegan, Rodin, O’Brien & Solomon, 1983, Marks, 1990). It must be said that this still attracts criticism, as it is claimed in particular that terming both repetitive behaviour and repetitive drug use as addictive may trivialise the concept of addiction (Jaffe, 1990). For instance, it has been suggested that those who exercise well beyond the healthy level of three to five workouts per week are probably doing so for reasons other than to maintain fitness, and it has accordingly been proposed that excessive exercising may be addictive (Veale, 1987). Even though vigorous exercise can elevate mood and produce a euphoric state of well being, this being linked to the production of endorphins, it could be argued that to compare “addiction to exercise” to addiction to drugs or alcohol is facile. Nevertheless it is the case that various “bona fide” characteristics of addiction, like withdrawal symptoms, do apply to the newly proposed addictions. For example, there is evidence of withdrawal symptoms such as anxiety, depression, irritability and insomnia after stopping regular exercise (op cit).

These current views posit that there may be a common addictive process which can appropriate many different activities, a number of which may not normally be thought as being potentially addictive. Some levels of analysis mentioned to date include the biological, cognitive, and psychological; and addiction may be analysed at all these levels. Psychological approaches in particular have tended emphasise the common features of addictive behaviours, whether they involve drugs or not (e.g. Orford, 1985). However, others such as the biological have also emphasised the similarities in brain reward systems across a range of behaviours and substances. Moreover, it is also claimed that the self-starvation in anorexia and excessive exercise can in some ways perform a similar function to alcohol, in that they can induce certain psychotropic effects, or altered states of consciousness that can be experienced as a sense of well-being. Just as a few drinks can give a person “courage” to face a difficult or uncomfortable situation, so the starvation high can create a sense of well-being and prevent awareness of those aspects of the person’s life that are difficult (Slade and Duker, 1988)

We have seen that the main way of evaluating whether any number of behavioural excesses are indeed addictions is to compare them against clinical criteria for other established addictions, and this section concludes with two further attempts to unify a number of conventionally different addictive behaviours.

Donegan et al (1983) outlined six properties which addictive substances and behaviours like gambling, have in common. These properties comprised (1) Ability of the substance to act as an instrumental reinforcer. (2) Acquired tolerance, in that repeated use of either substance or behaviour can result in reduced effectiveness. (3) Development of dependence with repeated use where repeated use produces withdrawal effects that motivate further use. (4) Affective contrast, this is where the substance or behaviour tends to produce an initial affective state (euphoria) which is then followed by an opposing state (dysphoria). (5) Ability of the substance or behaviour to act as an effective Pavlovian unconditioned stimulus. (6) Ability of various states (general arousal, stress, pain) to influence substance or behavioural use.

Marks (1990) argues that one factor which is common to the areas seen as behavioural addictions is that they consist of repetitive sequences of behaviours which are maladaptive and counterproductive. Many of Marks’s (1990) unifying features of addictive substances and behaviours are similar to Donegan et al’s (1983) e.g. the behaviours act as operant reinforcers and as Pavlovian unconditioned stimuli, and an initial positive mood is followed by dysphoria. In conjunction with gambling, hyper-sexuality, overeating and overspending he includes, perhaps more controversially, behavioural areas such as kleptomania and obsessive compulsive disorders. His claim is based on shared patho-physiologies and he argues that all are, “Disorders of impulse control and self regulation” (Marks, 1990 p. 1389).

Marks argues that in common across dependence syndromes, substance abusers become both behavioural and chemical addicts. As they become conditioned to cues connected with their drug taking, they become aroused not only by using their drug of choice but also by the routine of preparing and administering it, and to other external cues such as places and things associated with it. From this central argument of essential similarity he suggests that there may be common treatment approaches for both chemical and behavioural addictions (Marks, 1990)

Additional problems when investigating a wide range of addictive behaviours: Inconsistencies in the attention paid to different addictions

Commenting on Marks (1990), Jaffe (1990) said, “...seeing these behaviours as members of a super-category suggests that they are all amenable to behavioural intervention, inspiration, or changes in values and beliefs. We risk the trivialisation of some of the commonest and most destructive of human problems” (p.1427)

When looking at the inclusion of other substances and behaviours the above statement made in response to Mark’s (1990) is an important but essentially misguided comment. Marks calls into question the common belief that illegal substances like heroin or cocaine cause the most severe problems in society, pointing out that it is the legal drugs such as nicotine and alcohol that cause the most devastating problems in society in terms of health costs and life lost. Certainly it seems strange that there is continuing advertising from the tobacco industry when its product kills more than 100,000 people each year (Royal College of Psychiatrists, 1987). Identifying what constitutes the most destructive of human problems isn’t so straightforward. It can also be argued that it isn’t just consequences such as disease and death that need to be considered, but severe psychological anguish and anxiety that is often produced when in a cycle of addiction, for example in the case of compulsive gambling.

One of the areas of imbalance is the attention given to drugs which are prescribed, such as sleeping tablets, tranquillisers, and certain over-the-counter medicines, on the one hand, and illicit drugs on the other. In the 1980’s over 4 million pounds was spent on anti-heroin publicity (Royal College of Psychiatrists, 1987), with little attention being paid to the problems of legally prescribed medicines. In addition to this it has been noted that it is predominately women who often turn to the addictive use of prescribed drugs (Downing, 1991). A clinical study which provides support for this position found that tranquillisers and sedatives were used by 43 percent of female patients compared to 20 percent of men (Clentano & McQueen, 1984). One argument which has been put forward to explain this discrepancy is that the use of prescribed medication by women is more acceptable than illegal drug taking and therefore a socially sanctioned way to mood alter (Downing, 1991)

From this evidence it can be seen that there are currently serious inconsistencies in attitudes towards the harmful effects of different substances, and similarities between so called illicit drugs and prescribed drugs have been overlooked in terms of their addictive potential. Even though the idea of caffeine addiction may seem peculiar, the fact is that whilst it has been indicated that most people can consume caffeine in a controlled manner, there are those who use caffeine compulsively (Kendler & Prescott, 1999). This type of evidence surely increases the possibility that this may be the case with other addictive behaviours, and if so searching for general explanations for these phenomena is an intriguing and worthwhile pursuit.

However, Satel (1993) has argued that the inclusion of any and all compulsive and self- destructive behaviour under the term addiction, risks premature stereotyping of the identified problem, thus preventing the detection of potential coexisting or underlying conditions. Others continue to argue that addiction should be restricted to the use of substances which cause a physiological change to take place in the body (Rinehart & McCabe, 1997).

3.6. Addiction and its association with crime

It is very clear that illegal drug taking is associated with numerous negative health, psychological and social problems (e.g. accidents, social functioning and criminal activity). For instance, opiate users have consistently reported disproportionately high levels of involvement in criminal behaviours such as prostitution, burglary and street robbery (Dembo, Williams, Fagan, & Schmeidler, 1993). It has been suggested that these crimes are committed largely to fund their drug habits (Biron, Brochu, & Desjardins, 1995). For example, heroin addicts who use cocaine show a higher risk profile for HIV, engage in a wider variety of criminal activities, and report more alcohol use (Grella, Anglin, & Wugalter, 1995: Leukefeld, Gallego, & Farabee, 1997). However, it is also important to remember that some substance misuse, particularly of alcohol, cocaine and heroin, is intrinsically associated with higher levels of risk taking, aggression, and criminality (Dembo, 1996)

Interestingly there a number of researchers who argue that criminal behaviour and a variety of addictive behaviours are all part of a “hedonistic” lifestyle (Stephenson, Maggi, & Lefever, 1997) or one in which offending and substance abuse are part of a lifestyle of “conspicuous consumption” (Parker, 1996). However, any associations between substance abuse and criminality are far from simple. As an alternative to the “lifestyle” hypothesis, crime itself has been characterised as a behaviour that can become addictive. It has been argued that committing criminal acts is as strongly addictive as is the craving for illicit substances or alcohol (Hodge, 1991). This is an interesting point and is perhaps a further argument for treating chemical and other addictions as examples of essentially the same process.

It can be gathered from this brief review of additional viewpoints that it is important to identify the processes underlying different addictive behaviours rather than emphasising the destructive characteristics of addiction to illegal substances. This approach facilitates an informed debate not only on appropriate treatment for addictive behaviours, but also on the wider social and political issues raised by the debate.

3.7. “Cross addiction”

“Cross addiction” is a term that is becoming fashionable, but it is as yet characterised by a number of disparate ideas and does not have a generally accepted definition. It sometimes refers merely to addictions exhibited simultaneously by one individual, but it may also refer to those who switch from addiction to another over time by way of substitution of one for another. Such confusions require clarification.

Let us try to delineate the different interpretation placed upon the term cross-addiction in order to facilitate the development of a systematic operational terminology.

For a number of years now it has been noted that an addict often displays a number of addictive tendencies. For instance, links between drug addiction and alcoholism have frequently been thought worthy of analysis and is now where this elusive concept of cross addiction is tolerated. With alcoholics for instance, one of the most consistently documented co-occurring disorders is other substance use, others being mood, anxiety and schizophrenic disorders (Kessler, Crum, Warner, Nelson, Schulenberg & Anthony, 1997). The underlying process is frequently seen to be similar for alcoholism and drug addiction, and it is assumed the majority of factors that apply to addiction to alcohol can also apply to drug addiction, regardless of which drug is used.

Interestingly, it has been reported that across a wide range of the addictive behaviours there is evidence of “spontaneous change” (McCartney, 1996). This is said to occur when addictive behaviour is modified without the use of formal treatment. This evidence goes against the commonly held belief that addiction is difficult to change. What could be happening here is that when one substance is given up, another has been taken up. Indeed in McCartney (1996) argues that substitution behaviour may be important, when initially giving up an addiction, though it should not be assumed that use of substitutes necessarily constitutes a problem.

The relationship between eating disorders and substance abuse disorders has received a lot of attention in recent years, and even though the estimates of the extent of their co- morbidity vary depending on the subtype of eating disorder, it seems that co-occurrence is still substantial (Davis & Claridge, 1998). In addition to this the presence of other addictive behaviours occurring alongside sex addiction has been noted. Carnes (1991) when considering factors that increase the probability of someone suffering from sex addiction, has recognised that the presence of other addictive behaviours such as gambling, alcoholism or chemical dependency, increases this likelihood.

Despite a growing recognition that a whole range of behaviours has the potential for addiction, there has been little research that has attempted to investigate the relationships across a wide range of addictive behaviours and substances. However, multiple drug use is well documented, and the traditional distinction made between illegal and prescribed medication is seen to be less than useful, because recreational drug addicts frequently abuse prescribed medication, and it is known that prescription drugs in their own right are often addictive. Relationships between drug addiction and other chemical and behavioural addictions have also been observed, and such relationships have been attributed to a variety of mechanisms that are relevant to the explanation of cross-addiction. We shall now examine some of these.

It can be argued that when a number of behaviours are used addictively, these may represent different manifestations of an underlying predisposition to addictive behaviour. This may be due to a genetic vulnerability, or because of a common addictive personality style, which itself may have an genetically based biological component (Holderness, Brooks, Gunn & Warren 1994). Another possibility is that individuals may start to use or abuse substances or start to use other behaviours to cope with problems arising from their existing addiction. A further hypothesis is that an addiction to one substance creates psychological and behavioural coping patterns that leave the individual vulnerable to developing another coping mechanism or addiction.

3.8. Mechanisms relevant to the explanation of cross addiction

Triggers

A number of addictive behaviours may be related on a behavioural level in that the use of one substance acts as a trigger for the use of another substance. For instance, the immediate effects of smoking on drinking behaviour have been examined and it has been suggested that rate of smoking increases as a function of alcohol intake (Griffiths, Begelow, and Liesbson, 1976) It seems that the use of a substance is triggering the use of another, although the explanation of the triggering effect remains unclear.

Substitution

Substitution occurs when one substance is reduced or stopped and an associated increased use of, or substitution by another substance occurs. This phenomenon of switching addictions has been observed in clinical practice for some time (Blume, 1994), and in non-clinical situations the phenomenon of gaining weight after stopping smoking is well known. Few controlled studies have been conducted which investigate the relationships between addictive problems in terms of trigger and replacement, though it is recognised that replacement does occur. For instance it is increasingly recognised that the frequency of substance abuse in anorexia is such that the introduction of appetite suppressants such as fenfluramine are best avoided because of their addictive potential (Slade and Duker 1988). It has been suggested that when an anorexic’s or bulimic’s control system slips, other behaviour may be engaged in, “Then she may resort to drink, drugs, become promiscuous in her sexual relationships, be totally spendthrift” (Op cit 1988, p.47). It has also been argued that alcohol and food are used interchangeably as addictive substances (Yeary, 1987), and that one of these disorders often readily takes the place of the other (Taylor, Peveler, Hibbert, & Fairburn, 1993)

Implications of substitution

It has already been said that addictive disorders are chronic and long term, though there has been a tendency for doctors and the general pubic to view addictions as acute disorders that with detoxification leads to treatment and cure. So the simplistic assumption is that when an individual relapses (i.e. uses the substance again) treatment has failed, and if the individual doesn’t use the substance then the treatment has been a success. Substitution suggests that even in the absence of relapse, addiction may continue, albeit to another substance or behaviour. If the underlying disorder persists, then the observation of cross addiction in terms of one drug or behaviour being replaced by another, is important in terms of treatment because it is implied that if the underlying disorder is not treated then the problems may persist, although manifested differently.

It would be interesting to investigate systematically the usage of other behaviours once treatment has been completed to see whether other addictive behaviours are being substituted. For instance, once an alcoholic stops drinking, is there an associated increase in nicotine use, or do they work compulsively?

The importance of the phenomenon of concurrent usage

This phenomenon has received rather more research interest and is probably more frequently observed in clinical settings. For instance most alcoholics under the age of 30 are addicted to at least one other drug, often becoming addicted to alcohol first and then going on to develop other drug addictions (Miller, Gold & Belkin 1990). Some studies have indicated that the majority of alcoholics smoke, and that drug addicts also smoke early in their initiation, and use alcohol (e.g., Miller, 1991). Interestingly in a study by Von Knorring & Oreland (1985) male smokers from the general population were found to be more prone to abuse alcohol, glue, prescription and illicit drugs.

An increasing number of studies have highlighted the co-morbidity between eating disorders and alcohol abuse (for a review see Holderness, Brooks, Gunn, & Warren, 1996), though binge eating is a type of eating disorder that has been most often theoretically linked to alcoholism (e.g. Hudson, Pope, Jonas & Uurgelum-Todd 1983). This disorder is seen by some as sharing common signs or symptoms of addiction, with its characteristic factors such as preoccupation with food, loss of control over food intake and problematic eating behaviour in spite of negative consequences (Scott, 1983).

Theoretically, pathological gambling, eating disorders and substance use disorders have been linked due to common factors in their natural history and the phases of their treatment (Lesieur & Blume 1993). It has also been reported frequently that dieting and bingeing co-occur (Heatherton & Polivy, 1990)

The coexistence of pathological gambling and alcohol/drug addiction has also been investigated (Griffiths, 1994, Blume, 1994). Work has also indicated an increased incidence of nicotine dependence with bulimia (Tordjman, Zittourn, Anderson and Flament, 1994). In another study links were found between anorexia and compulsive exercising (Long, Smith, Midgley and Cassidy, 1993). It can be seen from this brief review that investigation into “pairs” of addictive behaviours is common.

Implications of concurrent usage

It has been argued that the clinician must identify the nature and extent of concurrent drug use in alcoholic populations as this is an important step in both diagnostic evaluation and treatment planning (Miller & Mirin, 1989). This is because where addicts are using or abusing a combination of alcohol and or other drugs, the physical picture becomes even more complex and treatment priorities have to be established. Primarily this is because it treatment must be easier when there is only one “layer” of altered thinking to get through. For example, when treating an anorexic, treatment is hard enough when there are only the changes brought about by starvation and the psychological complexity of the disorder. Where substances are being abused as well, there is the possibility of unaccountable possible variations in mood and experience as a result of biochemical changes brought about by the additional impact of the ingestion of various kinds of substances.

In relation to relapse, it has been reported that continued drug use after treatment for alcoholism may be implicated as a potential relapse indicator, and that in general alcoholic substance users have greater dysfunction than alcohol only users (Sokolow, Welte, Hynes & Lyons, 1981). This seems reasonable, because if another substance is still being used post-treatment it would indicate that the central issues of addiction haven’t been effectively dealt with. In addition to this, in a study investigating the use of nicotine and caffeine in alcohol dependent individuals it was found that the intake of both of these substances significantly increased following abstinence from alcohol (Aubin, Laureaux, Tilkete, & Barrucand, 1999) .

The high incidence of multiple drug addiction among alcoholics, with some studies putting the figure as over 85 percent (Miller, 1991), provides good evidence for a common process underlying alcohol and drug addiction and further reason to investigate systematically other behaviours which have been reported to co-exist with drug addiction and alcoholism. With such investigations it may then be possible to start to demystify these patterns and any similarities and differences in the experiences and events associated with addictive behaviour may be highlighted. For instance the high rates of relapse often reported may in part be linked to a continued use of another form of addictive behaviour which eventually leads the addict back to the original habit.

It is also important to establish whether or not there are systematic links between different addictions, in order to establish whether separate and different, treatments are, or are not, required. If systematic links are observed, these may be attributed to a common process, or processes, which may be addressed in treatment. For instance it has been proposed that alcohol, food, and drugs may serve the same purpose as compensatory substances that minimise the impact of ego deficits (Brisman, & Seigel, 1984). In this case, the actual behaviour is not the crucial area to emphasise; the focus may be better placed on the function that alcohol, drugs or food serve.

A number of possible physiological and psychological factors have been identified that may “unify” a range of addictive behaviours, and these will be briefly reviewed here.

3.9 Different levels of analysis that may help unify diverse addictive modalities

Neurotransmitters

In general it is thought by neurologists that chemical addiction results from adaptations in specific brain neurones, caused by repeated exposure to a drug of abuse. It is these adaptations in combination that produce the complex behaviours that are features of an addicted state, and it is claimed that progress is being made in the identification of such adaptations and relating them to specific behavioural features of addiction. It is accepted that at its core addiction entails a biological process which involves the effects of repeated exposure to a biological agent (drugs, neurotransmitters) on a biological substrate (the brain) over time. The behaviours that are emphasised are predominately substance based, though it has been proposed that similar processes may be applicable to the full range of addictive behaviours (Koob & Le Moal, 1997), and that these will be uncovered in time. In a recent review it was concluded that the most likely biological candidates involved in the maintenance and progression of anorexia and bulimia are dysfunctions in the serotonin and the endorphin regulatory systems. Interestingly, as disturbance in these two systems are not specific or unique to the eating disorders, it is possible that they represent a common pathway for many related disorders (Ericsson, Poston, Walker & Foreyt, 1996).

Thus, it has been suggested that there may be a common neurobiology of addiction covering a large number of behaviours. The underlying premise is centered around the possibility that various addictions, chemical, substance and behavioural (e.g. heroin, binge eating and gambling) have the same pattern of, “spiralling dysregulation of brain reward systems” (op cit p.53), which progressively increases and results in compulsive use and loss of control over the chemical, substance or behaviour. It is acknowledged that psychology has uncovered the idea of an addiction cycle where an initial lapse can lead to large-scale breakdown in self-regulation, and that this can lead to spiralling distress and eventually to addiction. The important point here is the contribution of neurobiology, in that it has started to identify neurobiological elements that may underlie this process.

The neurobiological mechanisms for the positive reinforcing effects of drugs include the mesocorticolimbic dopamine system and it thought that for cocaine, amphetamines and nicotine the facilitation of dopamine neurotransmission in these systems seems to be important for the acute reinforcing actions of these drugs (Koob & Le Moal, 1997). The picture is not clear for opioids, as these involve a dopamine independent and dependent system (op cit). Alcohol seems to interact with ethanol-sensitive elements in many neurotransmitter receptor systems that are present in the mesocorticolimbic dopamine system and the system has also been implicated for tetrahydrocannabinol (THC) (Chen, Paredes, Lowinson & Gardner, 1991 in Koob & Le Moal, 1997). The psychological elements of failure to self-regulate may affect different parts of the addiction cycle and these components may be reflected in changes in different aspects of reward neurocircuitry. Studies have shown how stress-like stimuli activate the mesocortcolimbic system which in turn effects the rapid reinstatement of intravenous drug self administration that had been previously extinguished (Koob & Le Moal, 1997).

Non-substance related addictions may also be implicated in this neurological process. Homeostasis occurs when an organism maintains equilibrium in all of its systems including the brain reward system; that is, the organism uses physiological and cognitive or behavioural capabilities to maintain its state. Importantly, dysregulation of this homeostasis can also occur with compulsive use of non-drug reinforcers, as similar patterns of the spiralling addiction cycles have been observed with gambling, exercise, sex and other addictive behaviours. The same neurobiological dysregulations and breaches of homeostasis may be occurring within the same neurocircuitry implicated in drug dependence. Data in this area is already coming forward. For example Thoren, Floras, Hoffmann & Seals (1990) proposed that prolonged rhythmic exercise can activate central opioid systems which may account for the analgesic and behavioural effects of exercise and may eventually explain why it can be addictive.

The case for linking certain addictive disorders with eating disorders, especially craving for carbohydrate, is supported by several plausible common etiological mechanisms. It has been proposed that some individuals utilise food to regulate mood via its rewarding or distracting properties (Morris & Reilly, 1987). In conjunction to this, dysfunction in the serotonin, dopamine and opiod systems have been implicated also in depression, anxiety, eating and addictive disorders. As feeding and preference for sweet foods may be mediated by dopamine (Hernandez & Hoebel, 1988), and serotonin metabolism both modulates and is modulated by dietary carbohydrate intake, it is conceivable that such dysfunctions in these systems also alter appetite.

It has also been proposed that self-starvation is itself a chemical dependence in that the auto-addiction opioid model proposes that a chronic eating disorder, whether anorexia or bulimia, is an addiction to the body’s endogenous opioid system. This is thought to be almost identical to the behaviour and the psychology of substance abuse in general (Marrazzi & Luby 1987).

Interesting, with reference to the auto-opioid theory of eating disorders, is the fact that appetite dysfunction and strenuous activity stimulate endorphin activity and that a high percentage of anorexia and bulimia patients are hyperactive during the acute phase of these disorders (Slade & Duker, 1988).

The importance of genetic factors in use and dependence on psychoactive drugs has been investigated across a number of different areas such as smoking (Heath, Cates, Martin, Meyer, Hewitt, Neale & Eaves 1993), alcohol (McGue, 1994) and illicit drugs (Tsuang, Lyons, Eisen, Goldberg, True, Meyer, & Eaves, 1996). Genetic risk factors could be operating at many levels including personality, vulnerability to psychopathology and metabolism. Recent research has found that similar to previous findings with other licit and illicit drugs, individual differences in caffeine use, intoxication, tolerance and withdrawal are substantially influenced by genetic factors (Kendler & Prescott,1999). These types of results have implications regarding the status of caffeine as a drug of dependence.

Personality

Addictive tendencies may be linked in a general way or ways, to differences in personality. There are inherent difficulties investigating this suggestion. It has been seen that drugs have pharmacological effects on the brain, some of which may result in long term changes, which may critically affect behaviour and any manifestation of personality functioning (Koob & Le Moal, 1997). One main problem with investigating personality is that personality may have been altered by addiction and it is a question of deciding whether personality characteristics contributed to addiction or whether addiction produced certain personality characteristics.

For instance it has been noted that anorexia/bulimia may belong to the same order of problems as drug addiction and alcoholism, and that like these other behaviours it is a condition in which the individual’s actions produce physical and psychological changes. It has been reported that with the sustained and successful restriction of food intake in anorexia an individual’s personality is changed often beyond recognition, as with alcoholism and drug addiction (Slade and Duker, 1988).

It has been posited that a possible underling issue in those who are suffering from drug addiction is, “...that many substance abusers lack the capacity to cope with any extremely painful affective situation” (Jennings, 1991 p.221). If this is extrapolated to include other addictive disorders it could be a useful contribution to the comprehension of the use of a variety of substances and behaviours at a later date.

(Personality in relation to addiction is explored in more detail in chapter eight)

Sociological

One of the leading authorities in the field of exercise addiction is Yates (1991) and her research has been particularly concerned with the relationship between exercise addiction and eating disorders. She points out that it is not mere coincidence that both sets of behaviours occur in those societies where individuals are encouraged to achieve, to become “someone”, and to develop their self worth. For those who experience extreme pressure from such coercion, intensive exercise and eating disordered behaviour are frequently the means adopted for taking greater control of their lives by setting specific goals, such as miles run or weight lost, and seeking to achieve them. If this hypothesis is extended the use of other behaviours such as illicit and licit drugs, and alcohol, may be an escape response to the mounting pressures of day to day living.

3.10. Studies that have attempted to look at a wider cross section of addictive behaviours

The development of the MacAndrew Scale (MAC) is one of the few pieces of research that has attempted to investigate addiction proneness more generally. The MAC is derived from the MMPI and has been demonstrated to be able to tap a common personality or behavioural dimension across at least 2 types of addiction problems: alcoholism and opiate addiction. A study by Leon, Kolotkin & Korgeski, (1979) investigated similarities in scores on the MAC across patients with obesity, anorexia and smoking problems. The study revealed that a proportion of male smokers indicated other habit problems such as excessive drug taking and scored within an additive range. Similarly, massively obese persons had MAC scores close to the addictive range, though the moderately obese, the anorexic and the female smoking groups did not score in the addictive range. This provides a degree of support for the idea that a more general addictive behavioural pattern exists, though only in a proportion of male smokers and the massively obese. Interestingly in this study it was found that a number of participants’ scores did not differ significantly from control subjects. This may indicate that the general addictive process may only be apparent in a proportion of people engaging in addictive behaviours. Needless to say this does not exclude others from experiencing problems at a later stage, as there was no control for stage of addiction, which indeed may be an influential factor.

In another study by Griffin-Shelley, Sandler & Lees (1992) it was indicated that there was a presence of multiple addictions in a population of adolescents in treatment for psychological problems coupled with chemical dependencies. Other compulsive problems that were being expressed included, sex, relationships, gambling and food. Symptoms of alcoholism were detected in more than 8 out of 10 of the participants.

Stephenson et al’s (1995) Study

In the above study using the PROMIS questionnaire (Lefever 1988), a wide range of substances and behaviours in the addictive domain was investigated in a group of people who were undergoing treatment for addictive problems. A two factor solution was found and will be briefly described here. The first factor, Hedonism, comprised recreational drug use, prescription drug use, alcohol use, sex exploitation, relationship exploitation, gambling and nicotine use. The second factor Nurturance, comprised food bingeing, food starving, caffeine, shopping/spending stealing, compulsive helping, exercise and work. These findings go some way in the clarification of “cross-addiction” in that it is suggested that addictive behaviour co-varies in systematic ways in men and women. For example, from these results Stephenson et al (1995 p.259) point out that, “Nicotine consumption is more likely to occur together with gambling and sex than it is with overeating or caffeine consumption”.

These are very interesting findings, as instead of all potentially addictive behaviours being seen as the same and used either singularly or together in a random fashion, there seems to be some significance in the selection of various behaviours. This offers a way to put into context some of the previously mentioned results regarding the findings of co-occurrences of paired behaviours (E.g. Miller & Mirin, 1989). It may be the case that at some level all forms of addictive behaviour are linked or correlated thus explaining the great variation in reported levels of correlation across large number of behaviours. But possibly it is at a second-order level that general orientations occur.

It has been seen that Twelve Step methodology adheres to the assumption that “the Programme” is an appropriate treatment for all types of addiction. But if it were to be found that there is significant co-variation in addictive behaviours, this may lead to the generation of new ideas for the complex task of treating these disorders.

The prevailing opinions at the moment seem to recognise the similarities between addictive behaviours. The question which needs to be asked is to what extent these behaviours serve the same function. On the one hand we have the position that these behaviours are separate i.e. alcoholism is completely different from eating disorders. On the other hand there is strong case that functional similarities between these addictive behaviours are to be found. Is there room here for a middle ground which acknowledges the differences and at the same time takes into account the similarities? Further research into this area may elucidate this problem, and an interesting way to achieve this would be to replicate and pursue Stephenson et al’s (1995) findings.

In the next chapter the development of the Shorter PROMIS Questionnaire is looked at in conjunction with methodological reasons why a replication is desirable.

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