One Addiction Sparks Another

In my experience of counseling and operating a transitional sober living community for those in early recovery, I have found that there are numerous misconceptions about co-addictions with regard to what they are, how they work, and what causes them.  This series of blogs will attempt to explain some of the fundamentals of co-addiction and how they can affect the life of the addict and the family system.

What is Addiction?

Let’s start by defining addiction as a primary, predictable, progressive, permanent, chronic and potentially fatal, and treatable disease prone to relapse:  more on the clinical definition of addiction later.

In common language, the term addiction is loosely used to describe an individual with substance dependence and/or an impulse control disorder.  Substance dependence includes common terms such as alcoholic and addict, as well as other defamatory terms such as drug addict, drunk, crack-head, pot-head, and junkie, amongst others.  Impulse control disorders include common terms such as sex addict, gambling addict, work-a-holic, bulimic, anorexic, compulsive spender, etc.

Substance Dependence

There is a difference between substance abuse and substance dependence.  The following diagnostic criteria are listed in the DSM-IV for substance dependence (aka Alcohol and other drug addiction):

 

A maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by three (or more) of the following occurring at anytime in the same twelve month period:
  1. Tolerance, as defined by either of the following:
(a) a need for markedly increased amounts of the substance to achieve intoxication or desired effect
(b) markedly diminished effect with continued use of the same amount of the substance
  1. Withdrawal, as manifested by either of the following:
(a) the characteristic withdrawal syndrome for the substance
(b) the same (or closely related) substance is taken to relieve or avoid withdrawal symptoms
  1. The substance is often taken in larger amounts or over a longer period than was intended
  2. There was a persistent desire or unsuccessful efforts to cut down or control substance use
  3. A great deal of time is spent in activities necessary to obtain the substance (e.g., visiting multiple doctors or driving long distances), use the substance (e.g., chain smoking), or recover from its effects
  4. Important social, occupational, or recreational activities are given up or reduced because of substance use
  5. The substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to be caused or exacerbated by the substance (e.g., current cocaine use despite recognition of cocaine-induced depression, or continued drinking despite recognition that an ulcer was made worse by alcohol consumption)
  6. Specify if:
  • With Physiological Dependence: Evidence of tolerance or withdrawal (i.e., either item 1 or 2 is present)
  • Without Physiological Dependence: No evidence of tolerance or withdrawal (i.e., neither item 1 nor 2 is present).

Common substance-related addictions include:

Alcohol Licit Drugs (prescriptions) Illicit Drugs (street drugs)
Nicotine (tobacco) Caffeine Inhalants

 

 

In the last posting we explored Substance Dependence as an addiction.  But what of impulse control disorders?

Impulse Control Disorder

There are other forms of addiction in addition to alcohol and other drugs.  Addictions classified as Impulse Control Disorders will use the following set of diagnostic criteria:

 

  • A pattern to resist impulses to engage in specific alcohol and other drug use behavior, or other impulse control behavior.
  • Frequent engaging in that behavior to a greater and greater extent or over a longer period of time than intended.
  • Persistent desire or unsuccessful efforts to stop, reduce, or control those behaviors.
  • Inordinate amount of time spent in obtaining alcohol or other drugs or other impulsive behaviors.
  • Preoccupation with the behaviors or preparatory activities.
  • Frequent engaging in the behaviors when expected to fulfill occupational, academic, domestic, or social obligations.
  • Continuation of the behavior despite knowledge of having a persistent or recurrent social, financial, psychological, or physical problem that is caused or worsened by the behavior.
  • Need to increase the intensity, frequency, number, or risk of behaviors to achieve the desired effect, or diminished effect with continued behaviors at the same level of intensity, frequency, number, or risk.
  • Giving up or limiting social, occupational, or recreational activities because of the behavior.
  • Distress, anxiety, restlessness, or irritability if unable to engage in the behavior.

Common Impulse Control Disorders include:

Eating Gambling Spending
Sex Work Anger
Relationships Excitement Stealing
Fire Starting Pulling Out Hair Paraphilias

 

What is Co-Addiction?

In simple terms, a co-addiction is when one addiction or impulse control disorder is combined with another addiction or impulse control disorder.  Here are three ways to view co-addictions:

It is also possible to have multiple addictions occurring at the same time in the same individual:

Co-addictions can sometimes also be referred to as co-occurring disorders.  However, in practice, the term co-occurring disorder is normally used by a physician or licensed therapist when addiction is combined with a personality disorder such as schizophrenia or multiple personality disorder.  The term is usually reserved for patients requiring treatment from multiple therapeutic disciplines.

Common examples of Co-Addictions include:

Alcoholism and
Licit Drug Addiction
Illicit Drug Addiction and
Pathological Gambling
Anorexia/Bulimia and
Nicotine Addiction

 

Co-addictions occur for the same reasons as primary addictions occur.  In a clinical sense, there is no difference between a primary addiction and a co-addiction.  However, individuals will often attempt to fool themselves into thinking a co-addiction is not a problem because it is not their primary addiction.  For example, many individuals that are opiate addicts will attempt to continue drinking alcohol because they will not consider themselves alcoholic.  Inevitably the alcohol use leads back to the opiate use because the effects on the midbrain and neurotransmitters are nearly the same with regard to euphoric reward and mood changes.

 

Another common misconception is the alcoholic that goes to the doctor and is prescribed an opiate for chronic pain management.  Inevitably, the opiate use will increase until it is no longer enough and the alcohol will come back into the picture.  Or perhaps an alcoholic/addict will convince him/herself that working 18 hour days seven days a week is better than using alcohol and drugs, not realizing that they have substituted one addiction for another.  In this scenario, again, eventually the addict will go back to the alcohol and other drug use to compensate when the work-a-holic behaviors are no longer enough.

 

 

 

Co-Addiction in the Family System

The family members of addicts can be prone to codependency.  Codependency is an addictive process, a disorder just like any other addiction.  Codependency can be described as a dysfunctional pattern of living in which one overreacts to things going on outside of oneself and under reacts to what is going on inside of oneself.  Codependency may involve compulsive behaviors and dependence upon approval from others in order to achieve a sense of safety, identity, and self-esteem.  Codependents may put all their efforts into those around them, neglecting to fully take care of themselves, especially emotionally.  Codependency is a disorder that, if left untreated, can lead to co-addictions such as eating disorders, substance dependence, work-a-holism and compulsive spending.

 

As a general rule of thumb, those who are substance dependent (addicts) are usually codependent, and those who are in the family system of the addict (close relations and family members) are usually codependent.

Timmen Cermak, M.D., suggests that co-dependency is a personality disorder.  His reason is that when specific personality traits become excessive and maladaptive and cause significant impairment in functioning or cause significant distress, this warrants a personality disorder diagnosis.  Dr. Cermak, T.L. “Diagnosing and Treating Co-Dependence.” Minneapolis, MN: Johnson Institute, (1986) proposes the following diagnostic criteria for this disorder:

  • Continued investment of self-esteem in the ability to control both oneself and others in the face of serious adverse consequences.
  • Assumption of responsibility for meeting others’ needs to the exclusion of acknowledging one’s own.
  • Anxiety and boundary distortions around intimacy and separation.
  • Enmeshment in relationships with personality disordered, chemically dependent, other co-dependent, and/or impulse-disordered individuals.
  • Three or more of the following:
    1. Excessive reliance on denial
    2. Constriction of emotions (with or without dramatic outbursts)
    3. Depression
    4. Hyper vigilance
    5. Compulsions
    6. Anxiety
    7. Substance Abuse
    8. Has been (or is) the victim of recurrent physical or sexual abuse
    9. Stress-related medical illnesses
    10. Has remained in a primary relationship with an active substance abuser for at least two years without seeking outside help

 

Codependency is more easily identified by looking at typical codependent traits.

Concealing behavior of the addict Feeling superior to the addict
Efforts to confront the addict with his or her
problem
Creating alibis, excuses and justifications to
others
Intense mood swings from high to low Denial of the obvious
Overlooking the addict’s behavior Rationalizing the addict’s behavior
Protecting the addict from consequences of their
behavior
Self-righteous criticism and judgment of the
addict
Distrust of those outside the family because of the addict Belief that if the addict changed, all problems would disappear
Attempts to catch or trap the addict Threatening the addict
Efforts to exact promises from the addict Strategies to control sexual activity of the addict
Feelings of responsibility for the addict’s behavior Being sexual with the addict to prevent the addict from being sexual with others
Fantasizing and obsessing about the addict’s problem Neglect of spiritual pursuits including prayer and meditation
Feelings of depression and remorse Suicidal attempts or thoughts
Loss of friendships Deterioration of family pride
Secret pacts with other family members Feeling distant from other family members
Distrust of each other within the family Loss of self-esteem or self-respect
Growing self-doubt and fear Feeling unique and/or alone
Accidents, illness, or injury due to the stress of addiction in their life Efforts to control family expenditures with increasing failure to do so
Changes in eating or sleeping patterns Unusual dreams
Loss of time on the job Decreased ability to work or function
Growing resentments and disappointments Increasing financial problems
Engaging in self-defeating or degrading behaviors Overextension and over-involvement in work or outside activities
Taking over of duties and responsibilities of the addict in an effort to keep family life “normal”

 

 

 

Treatment

Therapeutic treatment for most co-addictions is very similar, if not identical, to the primary addiction.  Therefore, it is advisable for the patient to undergo treatment for all co-addictions and impulse control disorders at the same time:  it will actually make the process of arresting the diseases easier for the patient in the long-term.  For example, an alcoholic who is also a nicotine addict should undergo therapeutic treatment for both addictions at the same time while under the care of a therapist or physician.

It is important to stress that any recovery effort for addiction and/or codependency should include a three-pronged approach:
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With prudence, intention, and accurate thought shored up by knowledge of addiction and co-addiction, there is tremendous hope that an individual’s long-term recovery effort and improved quality of life is possible.

 

By Andrew Martin, MBA, LAADC, SAP, CA-CCS

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