Screening for Poly-Behavioral Addiction

With the end of the Cold War, the threat of a world nuclear war has diminished considerably. It may be hard to imagine that in the end, comedians may be exploiting the humor in the fact that it wasnít nuclear warheads, but ìFrench friesî that annihilated the human race, when considering that food addictions and their related diseases now afflict more people globally than malnutrition. The behavioral addiction disorders (e.g., food addictions, pathological gambling, and other obsessively-compulsive behavioral-patterns to religion, and/ or sex / pornography, etc.) are just as damaging, psychologically and socially as alcohol and drug abuse tracking number usps.

On a more serious note, lifestyle diseases and addictions are the leading cause of preventable morbidity and mortality taking more than one million (1,000,000) U.S. lives a year, yet brief preventive behavioral assessments and counseling interventions are under-utilized in health care settings (Whitlock, 2002). The U.S. Preventive Services Task Force concluded that effective behavioral counseling interventions that address personal health practices hold greater promise for improving overall health than many secondary preventive measures, such as routine screening for early disease (USPSTF, 1996). Common health-promoting behaviors include healthy diet, regular physical exercise, smoking cessation, appropriate alcohol/ medication use, and responsible sexual practices to include use of condoms and contraceptives.

Multiple Addictions and Poor Prognosis

Since it is impossible to expect treatment for one addiction to be beneficial when other addictions co-exist, the initial therapeutic intervention for any addiction needs to include an assessment for other addictions. National surveys revealed that a very high correlation exists between substance abuse and behavioral addictions. Repeated failures abound with all of the addictions, even with utilizing the most effective treatment strategies. But why do 47% of patients treated in private addiction treatment programs (for example) relapse within the first year following treatment (Gorski, T., 2001)? Have addiction specialists become conditioned to accept failure as the norm? There are many reasons for this poor prognosis.

Some would proclaim that addictions are psychosomatically- induced and maintained in a semi-balanced force field of driving and restraining multidimensional forces. Others would say that failures are due simply to a lack of self-motivation or will power. Most would agree that lifestyle behavioral addictions are serious health risks that deserve our attention, but could it possibly be that patients with multiple addictions are being under diagnosed (with a single dependence) simply due to a lack of diagnostic tools and resources that are incapable of resolving the complexity of assessing and treating a patient with multiple addictions?

The Addictions Recovery Measurement System (ARMS), along with 350 national organizations and 250 State public health, mental health, substance abuse, and environmental agencies support the U.S. Department of Health and Human Services, ìHealthy People 2010î program. This national initiative recommends that primary care clinicians utilize clinical preventive assessments and brief behavioral counseling for early detection, prevention, and treatment of lifestyle disease and addiction indicators for all patientsí upon every healthcare visit. The ARMS theory proposes a new diagnosis. Poly-behavioral addiction is the synergistically integrated chronic dependence on multiple physiologically addictive substances and behaviors (e.g., using/ abusing substances – nicotine, alcohol, & drugs, and/or acting impulsively or obsessively compulsive in regards to gambling, food binging, sex, and/ or religion, etc.) simultaneously (Slobodzien, J., 2005).

The ARMS prognostication system supports the Five Aís construct (a model adapted from tobacco cessation interventions) as a brief screening behavioral counseling system. This guideline (Morgan and Fox, 2000) provides different brief interventions for treating patients based on their lifestyle disease indicators and addictive behavior status. Health care providers should:

∑ Ask patients about disease/ addiction health indicators (e.g. if they use tobacco, alcohol, drugs, exercise, diet, gamble, practice risky sexual behaviors, etc.). An office wide system can be implemented to ensure that all patients are queried regarding risky behaviors.
∑ Advise patients to quit–advice should be clear, strong, and personalized.
∑ Assess willingness to make a quit attempt in the next 30 days. Provide a motivational intervention for those unwilling to quit at this time.
∑ Assist patients in their efforts to quit: (1) Patients should set a quit date and remove addictive products (triggers) from their environment. (2) Provide practical counseling. Total abstinence is the key objective. Patients should limit alcohol use and anticipate and plan for challenges and triggers. (3) Offer support and suggest that patients seek support from their friends and family. (4) Recommend appropriate first- or second-line pharmacotherapies.
∑ Arrange follow-up within the first week after the quit date to prevent relapse.

Accurate diagnosis is dependent on a thorough multidimensional assessment process along with the possible help of a multidisciplinary treatment team approach. Behavioral Medicine practitioners have come to realize that although a disorder may be primarily physical or primarily psychological in nature, it is always a disorder of the whole person ñ not just of the body or the mind. The ARMS approach examines the broad bio-psychosocial context of the individual (e.g., biomedical, behavioral, interpersonal, social, cultural, spiritual, and self-regulative factors, etc.), when assessing an individual to determine the presence of a lifestyle addiction. It is concerned with the health choices individuals make as well as modifying and altering unhealthy lifestyles to directly reduce illness and illness behavior that predisposes them to other physical illnesses.

The ARMS battery of dimensional assessment and screening instruments focus on the multidimensional aspects of diagnosis, but continue to promote the standard screening instruments for specific substance abuse addictions (e.g., CAGE, MAST, AUDIT, SASSI, etc.). The ARMS battery can also assist with developing the other four DSM axes of a clinical diagnosis. The Multidimensional Psychosocial Stressors Inventory (MPSI) is utilized to narrow down a list of axis one diagnoses and axis four stressors. The Personality Feature Checklist (PFC) can assist with identifying an individualís personality traits on axis two that may be contributing to his addictive life-style.

The General Health Risk Assessment (GHRA) can assist with identifying physical symptoms and other addictive behaviors to consider alternative axis three diagnoses. The Religious Attitudes Inventory (RAI) can assist with assessing a patientís spiritual/ religious life-functioning dimension. The Prognostic Assessment Gauge (PAG) cumulative score can objectively reveal a prognostic level of functioning for axis five. This thorough assessment approach attempts to leave no stone unturned. The following brief screening tool is just one of twelve screening instruments proposed in the Addictions Recovery Measurement System to assist providers with the poly-behavioral addiction assessment process:

Behavior Risk Assessment Screen (BRAS) Fact Sheet

The Behavior Risk Assessment (BRA) is an efficient and effective screening tool used for early detection of unhealthy life-style practices before they manifest themselves as major health problems. It is comprised of the following six screening tools: 1) Substance Intake Screen: (Nicotine, Alcohol, Illegal Drugs), 2) Eating Attitude Screen, 3) Exercise Pattern Screen, 4) Sleep Pattern Screen, 5) Sexual Practice Screen, 6) Gambling Practice Screen, and the 7) Risky Behavior Screen.

Target Population: Adults ñ diagnosed with Alcohol/ Substance Abuse or Dependence Disorders and/ or other behavioral addictions, (e.g., gambling, eating, sex, religious addictions, etc.). For adults in both inpatient and outpatient settings.

Administrative Issues: The BRA has 21 items that an individual can answer within minutes. It is easily scored, and the results can be quickly integrated into the Prognostic Assessment Gauge for a cumulative prognosis score.

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