Index

4.1. The phenomenon of cross addiction and the attempt to simultaneously assess a range of addictive behaviours

In the previous chapter evidence was examined regarding the incidence, implications and possible explanations of cross addiction. This material supports the argument in favour of the simultaneous assessment of multiple addictive behaviours. This is because of consistent findings suggesting that a large degree of co-occurrence exists. For example, in Miller, Gold and Belkin’s (1990) investigation it was suggested that most alcoholics under the age of 30 are addicted to at least one other drug. Other studies have indicated the phenomenon of substitution in that once one addictive behaviour has been given up or reduced, there is often a corresponding increase in another (Gendall, Sullivan, Joyce, Fear, Bulik, 1997). One implication from these types of studies is that the investigation into the relationship between addictive behaviours is a pertinent quest in the treatment of addiction bearing in mind the possible interdependence of addictive disorders.

It was also noted in the previous chapter that a large number of studies have indicated links across a wide range of addictive behaviours. However, it appears that Stephenson et al’s (1995) study, using the PROMIS Questionnaire, is the only study to date where a large and diverse number of addictive behaviours have been systematically linked, and the interdependence of addictive behaviours explored in depth.

4.2. The Development of the PROMIS Questionnaire

The original version of the PROMIS Addiction Questionnaire (Lefever, 1988) was developed in order to assess cross addiction, with the aim of facilitating appropriate treatment of patients admitted to the PROMIS Recovery Centre. This questionnaire consisted of 16 scales, each assessing one addictive behaviour: the use of Nicotine, Recreational drugs, Prescription drugs, Gambling, Sex, Caffeine, Food bingeing, Food starving, Exercise, Shopping, Work, Relationships Dominant and Submissive, and Compulsive helping Dominant and Submissive. Each of the scales contained 30 items each contributing a score of “1” to its respective scale.

The scale items were designed to reflect the central features of addictive behaviour in a uniform and analogous way across the 16 scales. These parallel and characteristic areas applied to the 16 scales included the following: 1. Preoccupation, 2. Use alone, 3. Use for effect, 4. Use as a medicine, 5. Protection of supply, 6. Using more than planned, and 7. Increased capacity.

Preliminary evidence supporting the validity of the PROMIS Questionnaire scales was provided in an archival study conducted by Stephenson et al. (1995). In this study systematic questionnaire data were collected from 471 patients admitted consecutively to the centre between 1988 and 1993, and these were used in a factor analytical study. Stephenson et al. (1995) conducted separate factor analyses on the sixteen scales and discovered that the scale scores had a reliability coefficient (Cochran’s Q statistic) in the region of .9 for each scale. They also found a statistically significant relationship between diagnosis and mean scale scores. Based on the results of these and additional factor analyses the highest loading items were selected, and in some cases combined and rewritten, to produce a set of items that had equivalent scale reliability, and formed the basis of a shortened version of the questionnaire, the Shorter PROMIS Questionnaire (SPQ).

4.3. Results from Stephenson et al’s 1995 Factor analytic study

The results from this study revealed two principal factors. One factor, termed Hedonism, comprised the following behaviours: Recreational drugs, Prescription drugs, Alcohol, Sex, Relationships, Gambling and Nicotine. Looking at the addictive behaviours making up the Hedonism factor it was thought that they reflect a concern with self indulgence, sensation seeking and excitement and pleasure through adventure. The second factor, termed Nurturance, comprised Food bingeing, Food starving, Caffeine, Shopping, Exercise and Work. The behaviours in this factor were thought to reflect a preference towards more home based, safe and socially acceptable behaviours that are more to do with the care of self and others. It may be noted at this point that factor one (Nurturance) accounted for 27.1 percent of the variance, factor two (Hedonism) accounted for 16.3 percent of the variance.

This pattern of co-variation indicated that patients with food problems are differentiated from others, being high on Nurturance and low on Hedonism. Patients with Alcohol problems were high on Hedonism and low on Nurturance, but were not so clearly identified with Hedonism as those with Drug problems. These findings go some way in the clarification of the incidence of “cross addiction” in that the results suggest that addictive behaviours tend to co-vary in systematic ways. However, there were a number of limitations to this study.

4.4. Problems with Stephenson et al’s (1995) study; the need for replication

Problems with this original study stem largely from the fact that the data were collected in the context of treatment rather than research. In this study this problem has been rectified in that each questionnaire was administered in a conventional psychometric testing context, with clear instructions being given by a trained psychologist.

The decision was also taken to employ a non-treatment control group who completed the same questionnaire. Comment has been elsewhere made about the lack of available evidence on the normal level of consumption, or behavioural engagement in addictive behaviours, in the normal population (Davies, 1997).

A further limitation concerned the construction of the first questionnaire. The 16 scales were completed sequentially so the 30 items for each scale were completed in one block e.g. all the alcohol items were answered together. It is possible that when questions were presented in this way respondents were able to look at the various sets of questions and decide that a particular set were not applicable to him/her, and hence tended to respond accordingly, en bloc. In the present questionnaire items were presented randomly thereby reducing the probability of this occurring.

Perhaps because of these problems, a number of trends in the data could not be reliably explored in that study. For example, there were suggestions that a three or four factor solution might be appropriate, and there were interesting indications of gender differences in factor structure. A replication of this study needs to be conducted to develop further the suggested pattern of addictive orientations.

Identifying patterns in addictive behaviour is useful for a number of reasons. First it may help in the development of theory. For example, if gambling, recreational drugs and sex co-vary, this might be taken to suggest that a propensity for risk-taking is an underlying characteristic of individuals with an addictive problem in one of these areas. This in turn may have implications for treatment, helping counsellors to address appropriate and important motivations. Patterns of cross-addiction may also aid in the identification of those individuals who may be prone to addictive illness in related areas, which would be important in terms of prevention and treatment. It should also be noted that research generally could be better focused if patterns of co-variation are better identified and reliably assessed. For example, it will be seen that the significance of alcohol addiction is not fixed, but varies according to overall addictive orientation, in relation to gender.

Considering the possibility of a behavioural orientation in a normal population may also be beneficial, as the substances and activities engaged in addictively for some people are to others part of a normal and harmless behavioural repertoire. If the pattern of co-variation is essentially similar in non-treatment groups, this would suggest the existence of an addictive continuum, with normal use of the behaviour or substance at one extreme and addiction at the other. If we could ascertain that the manifestation of addiction is an extension of normal and healthy behavioural patterns, this may help in the comprehension of the phenomenon. From this position it may then be possible to ascertain why certain individuals are attracted to different methods of mood alteration. If this proved to be possible, it would create a challenge to the idea that an addict’s behaviour is somehow qualitatively different from non-addicts’ engagement in such substances and behaviours.

4.5. The Shorter PROMIS Questionnaire

The original PROMIS questionnaire was constructed and administered in the context of treatment. The Shorter PROMIS Questionnaire (SPQ) was introduced as a replacement for clinical use with new patients, with its use in research in mind. Its development and validation is described in Appendix 1. This study used comparison and cut-off scores derived from the non-clinical community sample population. Convergent and divergent validity were demonstrated with subsets of the clinical sample who had completed other relevant validated scales. In brief a standardised clinical cut-off score was produced with the 90th percentile of scale scores derived from a normative group of 508 individuals. These cut-offs correctly identified 78 percent to 100 percent of cases within clinical criterion groups of specific disorders picked from 497 consecutive treatment admissions. The clinical sample also completed other validated scales assessing gambling, eating alcohol and drug use; correlations were typically .7 with relevant SPQ scales. The SPQ food, drug and alcohol scales matched validated comparison scales in the strength of their relationship to relevant clinical criterion groups. Internal consistency was high for all scales and retest reliability was generally good. This work was conducted whilst at PROMIS in conjunction with others and the full results contained in the subsequent paper is presented in Appendix 1. The SPQ has provided the material for the present studies.

Instructions for completing the questionnaire

The 160 items were administered in a random order and the instructions regarding each of the behaviours were presented at the start of the questionnaire: A number of the addictive behaviours contained certain terms which have general meanings attached to them, so the following instructions were given for clarification.

"Tobacco" should be taken to mean either tobacco, cigarettes, cigars, snuff, tobacco bags and nicorette chewing gum.

"Drugs" should be taken to mean: cannabis, heroin, cocaine, LSD, magic mushrooms, `designer drugs', amphetamines and other stimulants.

"Prescription drugs" or "Medication" refers to tranquillisers, anti-depressants, painkillers, cough mixtures and cold cures, sleeping tablets, slimming pills, antihistamines.

In this present study respondents were asked to read each question carefully before answering and to place a cross on the scale (between one and six) to indicate the extent to which the statement is ‘like you’ or ‘not like you’. There were 10 items per scale and scores on each scale ranged from 0 to a maximum of 50.

4.6. The dimensions of the SPQ

In the next section behaviours contained in the SPQ are looked at more closely with items on the questionnaire being used to illustrate how (1) the central features of addictive behaviour are investigated in a uniform way and (2) which underlying construct the different items are designed to measure. Greater emphasis will be placed on the behaviours which are not commonly viewed as addictive such as compulsive helping and relationships.

4.6.i. Substances

We shall first look at the substances which are covered by the SPQ as these have traditionally been seen as areas which people become addicted to. After this section other behaviours can then be detailed and with this how the items are used in a congruent fashion across the different behavioural areas will be illustrated.

Alcohol

Alcoholism is one of the more accepted forms of addictive behaviour. Items included on this dimension include the following. Item (18) “I have found that having one drink tended not to satisfy me but made me want more” (Preoccupation). A positive response to this item may reveal the difficulty of satisfying a craving for alcohol. Item (136) “I have deliberately had an alcoholic drink before going out to a place where alcohol may not be available” (Protection of supply). This item evaluates behaviour relating to maintaining a certain level of alcohol and regularity of supply, in that the person’s coping strategy is to drink in order to manage being present in a situation where alcohol isn’t available. Item (43) “I have used alcohol as both a comfort and a strength” (Emotional support, protection of supply). This reflects alcohol’s use for emotional reasons.

Drugs

Drug addiction is another of the more readily accepted forms of addictive behaviour. Items included on this dimension include the following. Item (24) “I have had a sense of increased tension and excitement when I knew that I had the opportunity to get some drugs” (Preoccupation). This item reflects the preoccupation which is involved in the addictive process, in this situation prior to drug use. Item (76) “I have tended to use drugs as both a comfort and strength” (Emotional support, protection of supply). This in the same way as for the alcohol dimension reflects one of the drives behind the usage as an emotional one. Item (143) “I have tended to use more drugs if I have got more” (Higher capacity). This item is checking the tendency of an increased capacity and drive for more of the addictive substance.

Prescription drugs

The abuse of prescription drugs although acknowledged is not as prevalent in the literature as illegal drug abuse. The SPQ however aims to assess the behaviour in the same way as other forms of addictive behaviour. For example Item (92) “If my prescription medicines supply was being strictly controlled I would hang onto some old tablets even if they were definitely beyond their expiry date.” (Protection of supply). This item checks how difficult it is for the individual to leave some of the substance (here prescription drugs), and is therefore picking up on the preoccupation of having to have a supply readily available. Item (153) “I have been irritable and impatient if my prescribed medication is delayed for ten minutes” (Preoccupation). This item reflects the urgency which is linked to the individual receiving his/her drug of choice. Item (125) “If I had run out my prescribed medication I would take an alternative even if I was not sure of its effects”. (Using for effect). This item looks at how the addict’s drive for a change in mood state is driven to the extent that they may use an alternative even if unsure of the consequences.

Nicotine

Nicotine addiction is another well accepted form of addiction. Item (21) “I have tended to use nicotine as both a comfort and strength even when I feel that I didn’t want any” (Emotional support, protection of supply). Again in the same was as with item (43, alcohol) the degree to which the substance is being used for emotional reasons is assessed. Item (47) “I have been afraid that I will put on excessive amounts of weight or become particularly irritable or depressed if I give up using nicotine altogether” (Using more than planned). This item is looking at fear of loss of control and reflects concern with other changes of behaviours if the substance is stopped. Item (83) “I have continued to use nicotine even when I have had a bad cold or even more serious respiratory problem” (Higher capacity than others). This item looks pragmatically at the failure to control nicotine usage as it is assessing continued use despite detrimental effects.

Caffeine

Even though caffeine may not be a widely accepted substance of dependence and when viewed alongside alcohol and drugs may even seen to be a frivolous substance to include. However as was seen in chapter three it is included in the DSM IV (1994), and as it may be linked with other forms of addictive behaviour is worthy of consideration.

Item (28) “I have felt it would be more painful for me to give up caffeine than to give up a close friendship” (Preoccupation). This item looks at the intensity of the relationship or figural position that caffeine has in the individual’s life. Item (52) “I have tended to time my intake of caffeine so that others are not really aware of my total intake” (Protection of supply). This item looks at the strategy taken when in front of others so the caffeine intake is deliberately hidden. This helps to reveal the sufferer’s obsession with the behaviour. Item (60) “I have had a sense of increased tension and excitement when I buy caffeine substances or when I see advertisements for them” (Preoccupation). This item is checking the physical sense of increased tension which occurs when anticipating caffeine usage and reflects the preoccupation which is involved in the addictive process.

4.6.ii. Process related addictions (Relationships and Compulsive helping)

These behaviours are somewhat more controversial areas for addictive inclusion in spite of increasing numbers of publications (e.g. O’Gorman, 1991) aimed to help those suffering from these said addictions. Within treatment contexts however these behaviours are often seen as appearing in conjunction to other addictions

Relationships

Peele (1975) was one the first researchers to look at relationship addiction. He stated in his book that, “ Many of us are addicts, only we don’t know it. We turn to each other out of the same needs that drive some people to drink and others to heroin. Interpersonal addiction - love addiction - is just about the most common yet least recognised form of addiction we know” (p.1, (1975)

Relationships it can be argued may be an ideal vehicle for addiction as a relationship can exclusively claim a person’s consciousness in a similar way as the obsession with a substance can. This is because when a person goes to another with the aim of filling an inner void or making themselves feel better the relationship may quickly become the centre of his or her life. The relationship is used primarily for their mood altering effect on the addict, irrespective of whether the relationship has any long term prospects and irrespective of the amount of damage that may come from that relationship.

A succinct way of understanding the more unconventional forms of addiction is to compare it to primary addiction to substances, as addictive behaviours or relationships are driven by the general feeling, “I need you to fix me” (Lefever, 1988). The addict may turn to alcohol or drugs or nicotine or gambling or another human being or several other human beings and the relationship with these other people may be totally interchangeable with relationships with addictive substances of behaviours. Relationship addiction can be described as the pursuit of relationships in an attempt to relieve emotional pain, and for this behaviour to be considered to be addictive it needs to be compulsive, out of control and for it to continue in spite of adverse effects on the individual’s life.

The behaviours of choice related to this form of addiction include, any repetitive, compulsive activity, either dominant or submissive, potentially damaging to others or potentially damaging to the individual, that leaves other people in the situation whereby, out of concern for the individual’s action, they are led to focus much of their attention upon the individual’s demands or needs. Thus, addictive relationships with other people may be used as a form of “drug” that is either dominant (stimulating) or submissive (tranquillising) in its effect (Lefever, 1988)

Relationship submissive (Tranquillising)

Item (6) “I have tended to be upset when someone close to me takes care of someone else” (Use alone). This item illustrates the preference for the relationship between the addict and his or her substance or behaviour (here relationships) to be primary in nature. Item (87) “I have felt an overwhelming sense of excitement when I find a new person to look after my needs or a new way in which an existing partner can look after them better” (Preoccupation). In a similar way as with item 60 (caffeine) this item is looking at the mounting tension and excitement which occurs when anticipating the use of the behaviour of choice (here relationships). Item (124) “I have tended to get irritable and impatient when people look after themselves rather than me” (Preoccupation). This item corresponds to the items which ask whether a slight delay in either obtaining a drink or a coffee etc. would make them irritable, here however the situation which is linked to irritability is posited as “people looking after themselves rather than me”.

Relationship dominant (stimulating)

Item (29), “I have found it difficult to take up a position of power or influence when it is available, even if I do not really need it and can seen no particular use for it” (Protection of supply). Here what is looked at is how the normal feelings of satisfaction are not relevant, as agreement with this item reflects an increased drive for more power over others. Item (118), “I have tended to use a position of power or influence as a comfort and strength regardless or whether there are particular problems needing in my attention in other aspects of my life” (Emotional support, protection of supply). Again in the same was as with item 43 (alcohol) the degree to which the behaviour is being used for emotional reasons is assessed. Item (160), “I have tended to neglect other aspects of my life when I have felt that my position of power or influence is under threat” (Protection of supply). This item illustrates the obsession with predictable regularity of supply, in this case for the need to have power or influence over others. This is because the unpredictable is very unsettling for the addict and therefore precautions to ensure the demand for power is met may lead to carelessness in other aspects of the individual’s life.

Compulsive helping

The term compulsive helping stems from the idea of “co-dependence” which originated with the description of the impact of alcoholism on others, primarily the adult children of alcoholics. It has now become a movement unto itself and has been defined as any suffering and or dysfunction that is associated with or results from focusing on the needs and behaviours of others (Whitfield, 1989). O’Gorman and Oliver-Diaz, (1987) view co-dependency as a form of “learned helplessness” which consists of family traditions and rituals which are taught from one generation to the next concerning how the family teaches intimacy and bonding. It is still a relatively murky area it has been argued that its definitions still lack the precision which is needed for professional consensus, and that co-dependency has received little empirical support for the construct (Collins, 1993). An example of this confusion stems from a study by Rude & Burnham (1995) where it was demonstrated that questionnaires used to measure dependency tend to confuse healthy attachment needs with the extreme and generalised need to obtain other approval (“neediness).

Even though there is a background of literature being formed concerning co-dependency it is important to focus on PROMIS’s conception of the term. Compulsive helping is thought to be the mirror image of primary addiction to mood altering substances behaviours and relationships and is based on the principle of “I need you to need me”. Instead of the addict seeking something externally to make them feel better, the compulsive helper offers him or herself to other people to help them, and thereby to help him or herself to feel needed and valued. Compulsive helping is thought to be psychologically destructive, as seeking one’s self esteem from others is exhausting and does not lead to the development of healthy relationships. Compulsive helping is thought to be an addictive process, being progressive and destructive in just the same way as any other addictive or compulsive behaviour. The “drugs” of compulsive helping are care-taking (far beyond normal caring) and self-denial (far beyond normal kindness or selflessness and more akin to self-abasement) In the same way as for Relationship addiction compulsive helping can be sub-divided into different categories of emotional blackmail, dominant and therefore stimulating for the addict and submissive, tranquillising for the addict.

Compulsive helping dominant (stimulating)

Item (32) “I have preferred to look after other people on my own rather than as part of a team” (Use alone). This item illustrates the primary nature of the relationship between the helper and his or her helping activities in the sense that there is preference for the helping to be conducted on his/her own. Item (49) “I have found life rather empty when someone for whom I was caring gets better and I have felt resentful at times when I am no longer needed” (Preoccupation). This item in the same way as with Item 18 (alcohol) indicates that agreement with this item may reveal the difficulty of satisfying the need to help. Item (69) “I have tended to use my self-denial and care-taking for others as both a comfort and strength for myself” (Emotional support, protection of supply). Again in the same was as with items 43 (alcohol) and 21 (nicotine) the degree to which helping is being used for emotional reasons is assessed. Item (122) “I have found it difficult to leave any loose ends in a conversation in which I am trying to be helpful” (Using more than planned) In a similar way to Item (92) (Prescription drugs) this item shows how normal feelings of satisfaction are not relevant and here there is an attempt to return to a situation to satisfy this craving for more, in this case helping.

Compulsive helping submissive (tranquillising)

Item (35) “Other people have tended to express concern that I am not doing enough for my own pleasure” (Higher capacity than others). This item uses the opinions of others in the individual life to assess how intrusive their helping is. Item (58) “I have tended to remain loyal and faithful regardless of what I may endure in a close relationship” (Using more than planned). This item illustrates that normal feelings of satisfaction i.e. having done enough, the need to be needed is so overwhelming that even when negative consequences to the self mount he/she remains in the relationship. Item (158) “I have felt most in control of my feelings when performing services of one kind or another for someone else” (Using for effect). This item looks at the extent to which their helping is being used to control their feelings.

4.6.iii. Food related addictions

Food bingeing and food starving though perhaps still controversially included in the addiction remit have increasing received attention as possible candidates for addictive behaviour (e.g. Hetherington & Macdiarmid, 1993).

Food bingeing

Item (85) “I have often preferred to eat alone rather than in company” (Use alone). This item looking at preference for use alone as the primary nature of the relationship between the addict is thought to be a key element of addictive behaviour. Item (116) “I have had three or more different sizes of clothes in my adult (non-pregnant if female), wardrobe” (Using more than planned). This item looks at repeated attempts to control the overeating behaviour which have failed, this being reflected in the need to have a variety of sizes in clothes to accommodate these fluctuations. Item (71) “Other people have expressed repeated serious concern about my excessive eating” (Higher capacity than others). This item aims to obtain some objectivity through the use of other people’s opinions on the individual’s excessive eating.

Food starving

Item (109) “When I have eaten in company I have tended to time my eating as a form of strategy so that others are not really aware of just how little I am eating” (Protection of supply). This item like with item 52 (caffeine) this item looks at the strategy taken when in front of others. Here the deliberately hidden under-eating reveals the sufferers obsession with the behaviour, and hence how protective they are around its possible detection. Item (139) “I have become irritable and impatient at meal times if someone has tried to persuade me to eat something” (Preoccupation). This item is related to items where which questions the response to a delay of their substance of choice. For the starver or anorexic instead of the threat of a substance being withheld and this causing irritability, the plight of these individuals is different as their behaviour of choice is that of not eating or eating as little as possible. So this item assesses the degree of irritability attained they are threatened with having food forced upon them. Item (13) “In a restaurant or even at home I have often tried to persuade others to choose dishes that I knew I would like even though I would probably refuse to eat them”. (Preoccupation) This item looks at the extent to which the individual is preoccupied, here with the idea of not eating favoured foods.

4.6.iv. Behavioural addictions

The SPQ assesses a wide range of behavioural addictions all of which have appeared in previous literature.

Work

Item (56) “When working with others I have tended to disguise the full amount of time and effort that I put into my work” (Protection of supply). Again in the same way as item (109) (food starving), and item 52 (caffeine) this item looks at the strategy taken to deliberately hide the amount that the individual is engaged with their behaviour or substance, in this case working. Item (102) “Other people have expressed repeated serious concern over the amount of time I spend working” (Higher capacity than others). Again in the same way as with item (71) food bingeing, this item aims to obtain some objectivity on the situation concerning work through the use of other people’s opinions. Item (133) “I have found that once I start work in any day I find it difficult to get “out of the swing of it and relax” (Using more than planned). This item is looking at the extent to which the individual is becoming more engaged in working than perhaps intended, here with the essence of this is tapping “once started difficult to stop”.

Shopping

Item (93) “I have bought things not so much as a means of providing necessities but more as a reward that I deserve for the stresses that I endure” (Using for effect). This item assesses the extent that the shopping is being used for its tranquillising effects and its use in response to stress rather than for the original generally understood purpose. Item (80) “I have often bought so many goods (groceries, sweets, household goods, books etc.) that it would take a month to get through them” (Preoccupation). This item illustrates the impossibility of satisfying a craving, in that there is an almost relentless search for more and more goods, in a similar way that a drug addict may be on an almost constant search for more drugs. Item (48) “I tend to use shopping as both a comfort and a strength even when I do not need anything” (Emotional support, protection of supply). Again in the same was as with item (43) (alcohol) the degree to which shopping is being used for emotional reasons is assessed.

Sex

Item (2) “I have found it difficult to pass over opportunities for casual or illicit sex” (Using more than planned). This item is looking at how normal feelings of satisfaction are not applicable here and continued “use” occurs. This is because the engagement with the addictive behaviour is compulsive, this item can be found in a similar form on the alcohol dimension where the question is posed is “ I have found it strange to leave half a glass of (alcoholic) drink”. Item (75) “I have found that making a sexual conquest has caused me to lose interest in that partner and led me to begin, looking for another” (Preoccupation). This item illustrates the impossibility of satisfying a craving, and once satisfied there is a fast return to the search for more stimulation. Item (128) “I have had sex with someone that I dislike” (Using for effect). Again this item assesses the degree to which the desire for the behaviour (in this case for sex) is dominating to such an extent that the individual is willing to have sex with someone that they actually dislike. In this way the person who they dislike can be seen to be used as an “available alternative”.

Gambling

Item (65) “I have stolen or embezzled to cover gambling losses or to cover my losses in risky ventures” (Higher capacity than others). This item looks at the failure to control the addictive behaviour, and how the gambling or risk taking continues even though negative consequences mount. Item (89) “Other people have expressed repeated serious concern over my gambling or risk taking” (Higher capacity than others). Again in the same way as with the item (71) on the food bingeing dimension this item aims to obtain some objectivity from the use of other people’s opinions. Item (137) “When my favourite form of gambling or risk taking is unavailable I have gambled on something else I normally disliked” (Using for effect). This item aims to capture the strength of the drive that pushes the individual into the use of behaviours that may have a similar effect but would not be normally chosen (this item has also been illustrated in the prescription drugs and sex dimensions)

Exercise

Item (129) “I have often taken exercise just to tire myself sufficiently for sleep” (Use as a medicine). This item indicates the level of preoccupation that is part of the addictive process, and illustrates how the behaviour is being used for its tranquillising effects (for other substances or behaviours this may include any medicinal type effects). Item (19) “I have preferred to exercise alone rather than in company” (Use alone). This item looks at the primacy of the addict’s relationship to his or her behaviour of choice (here exercise). Item (33) “I have often tried to take exercise several times a day” (Protection of supply) This item assesses the extent to which the individual needs to keep the altered state “topped up” throughout the day, in this case with the possibility of the individual’s endorphin levels being maintained.

In the next chapter the factor analytic replication of Stephenson et al’s (1995) study is conducted using the revised scales and a new clinical population.

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