Pathological Eating Disorders and Poly-Behavioral Addiction

When considering that pathological eating disorders and their related diseases now afflict more people globally than malnutrition, some experts in the medical field are presently purporting that the world’s number one health problem is no longer heart disease or cancer, but obesity. According to the World Health Organization (June, 2005), “obesity has reached epidemic proportions globally, with more than 1 billion adults overweight - at least 300 million of them clinically obese - and is a major contributor to the global burden of chronic disease and disability. Often coexisting in developing countries with under-nutrition, obesity is a complex condition, with serious social and psychological dimensions, affecting virtually all ages and socioeconomic groups.” The U.S. Centers for Disease Control and Prevention (June, 2005), reports that “during the past 20 years, obesity among adults has risen significantly in the United States. The latest data from the National Center for Health Statistics show that 30 percent of U.S. adults 20 years of age and older - over 60 million people - are obese. This increase is not limited to adults. The percentage of young people who are overweight has more than tripled since 1980. Among children and teens aged 6-19 years, 16 percent (over 9 million young people) are considered overweight.”

Morbid obesity is a condition that is described as being 100lbs. or more above ideal weight, or having a Body Mass Index (BMI) equal to or greater than 30. Being obese alone puts one at a much greater risk of suffering from a combination of several other metabolic factors such as having high blood pressure, being insulin resistant, and/ or having abnormal cholesterol levels that are all related to a poor diet and a lack of exercise. The sum is greater than the parts. Each metabolic problem is a risk for other diseases separately, but together they multiply the chances of life-threatening illness such as heart disease, cancer, diabetes, and stroke, etc. Up to 30.5% of our Nations’ adults suffer from morbid obesity, and two thirds or 66% of adults are overweight measured by having a Body Mass Index (BMI) greater than 25. Considering that the U.S. population is now over 290,000,000, some estimate that up to 73,000,000 Americans could benefit from some type of education awareness and/ or treatment for a pathological eating disorder or food addiction. Typically, eating patterns are considered pathological problems when issues concerning weight and/ or eating habits, (e.g., overeating, under eating, binging, purging, and/ or obsessing over diets and calories, etc.) become the focus of a persons’ life, causing them to feel shame, guilt, and embarrassment with related symptoms of depression and anxiety that cause significant maladaptive social and/ or occupational impairment in functioning.

We must consider that some people develop dependencies on certain life-functioning activities such as eating that can be just as life threatening as drug addiction and just as socially and psychologically damaging as alcoholism. Some do suffer from hormonal or metabolic disorders, but most obese individuals simply consume more calories than they burn due to an out of control overeating Food Addiction. Hyper-obesity resulting from gross, habitual overeating is considered to be more like the problems found in those ingrained personality disorders that involve loss of control over appetite of some kind (Orford, 1985). Binge-eating Disorder episodes are characterized in part by a feeling that one cannot stop or control how much or what one is eating (DSM-IV-TR, 2000). Lienard and Vamecq (2004) have proposed an “auto-addictive” hypothesis for pathological eating disorders. They report that, “eating disorders are associated with abnormal levels of endorphins and share clinical similarities with psychoactive drug abuse. The key role of endorphins has recently been demonstrated in animals with regard to certain aspects of normal, pathological and experimental eating habits (food restriction combined with stress, loco-motor hyperactivity).” They report that the “pathological management of eating disorders may lead to two extreme situations: the absence of ingestion (anorexia) and excessive ingestion (bulimia).”

Co-morbidity & Mortality

Addictions and other mental disorders as a rule do not develop in isolation. The National Co-morbidity Survey (NCS) that sampled the entire U.S. population in 1994, found that among non-institutionalized American male and female adolescents and adults (ages 15-54), roughly 50% had a diagnosable Axis I mental disorder at some time in their lives. This survey’s results indicated that 35% of males will at some time in their lives have abused substances to the point of qualifying for a mental disorder diagnosis, and nearly 25% of women will have qualified for a serious mood disorder (mostly major depression). A significant finding of note from the NCS study was the widespread occurrence of co-morbidity among diagnosed disorders. It specifically found that 56% of the respondents with a history of at least one disorder also had two or more additional disorders. These persons with a history of three or more co-morbid disorders were estimated to be one-sixth of the U.S. population, or some 43 million people (Kessler, 1994).

McGinnis and Foege, (1994) report that, “the most prominent contributors to mortality in the United States in 1990 were tobacco (an estimated 400,000 deaths), diet and activity patterns (300,000), alcohol (100,000), microbial agents (90,000), toxic agents (60,000), firearms (35,000), sexual behavior (30,000), motor vehicles (25,000), and illicit use of drugs (20,000). Acknowledging that the leading cause of preventable morbidity and mortality was risky behavior lifestyles, the U.S. Prevention Services Task Force set out to research behavioral counseling interventions in health care settings (Williams & Wilkins, 1996).

Poor Prognosis

We have come to realize today more than any other time in history that the treatment of lifestyle diseases and addictions are often a difficult and frustrating task for all concerned. 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 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?

Diagnostic Delineation

Thus far, the DSM-IV-TR has not delineated a diagnosis for the complexity of multiple behavioral and substance addictions. It has reserved the Poly-substance Dependence diagnosis for a person who is repeatedly using at least three groups of substances during the same 12-month period, but the criteria for this diagnosis do not involve any behavioral addiction symptoms. In the Psychological Factors Affecting Medical Condition’s section (DSM-IV-TR, 2000); maladaptive health behaviors (e.g., overeating, unsafe sexual practices, excessive alcohol and drug use, etc.) may be listed on Axis I only if they are significantly affecting the course of treatment of a medical or mental condition.

Since successful treatment outcomes are dependent on thorough assessments, accurate diagnoses, and comprehensive individualized treatment planning, it is no wonder that repeated rehabilitation failures and low success rates are the norm instead of the exception in the addictions field, when the latest DSM-IV-TR does not even include a diagnosis for multiple addictive behavioral disorders. Treatment clinics need to have a treatment planning system and referral network that is equipped to thoroughly assess multiple addictive and mental health disorders and related treatment needs and comprehensively provide education/ awareness, prevention strategy groups, and/ or specific addictions treatment services for individuals diagnosed with multiple addictions. Written treatment goals and objectives should be specified for each separate addiction and dimension of an individuals’ life, and the desired performance outcome or completion criteria should be specifically stated, behaviorally based (a visible activity), and measurable.

New Proposed Diagnosis

To assist in resolving the limited DSM-IV-TRs’ diagnostic capability, a multidimensional diagnosis of “Poly-behavioral Addiction,” is proposed for more accurate diagnosis leading to more effective treatment planning. This diagnosis encompasses the broadest category of addictive disorders that would include an individual manifesting a combination of substance abuse addictions, and other obsessively-compulsive behavioral addictive behavioral patterns to pathological gambling, religion, and/ or sex / pornography, etc.). Behavioral addictions are just as damaging - psychologically and socially as alcohol and drug abuse. They are comparative to other life-style diseases such as diabetes, hypertension, and heart disease in their behavioral manifestations, their etiologies, and their resistance to treatments. They are progressive disorders that involve obsessive thinking and compulsive behaviors. They are also characterized by a preoccupation with a continuous or periodic loss of control, and continuous irrational behavior in spite of adverse consequences.

Poly-behavioral addiction would be described as a state of periodic or chronic physical, mental, emotional, cultural, sexual and/ or spiritual/ religious intoxication. These various types of intoxication are produced by repeated obsessive thoughts and compulsive practices involved in pathological relationships to any mood-altering substance, person, organization, belief system, and/ or activity. The individual has an overpowering desire, need or compulsion with the presence of a tendency to intensify their adherence to these practices, and evidence of phenomena of tolerance, abstinence and withdrawal, in which there is always physical and/ or psychic dependence on the effects of this pathological relationship. In addition, there is a 12 - month period in which an individual is pathologically involved with three or more behavioral and/ or substance use addictions simultaneously, but the criteria are not met for dependence for any one addiction in particular (Slobodzien, J., 2005). In essence, 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.

New Proposed Theory

The Addictions Recovery Measurement System’s (ARMS) theory is a nonlinear, dynamical, non-hierarchical model that focuses on interactions between multiple risk factors and situational determinants similar to catastrophe and chaos theories in predicting and explaining addictive behaviors and relapse. Multiple influences trigger and operate within high-risk situations and influence the global multidimensional functioning of an individual. The process of relapse incorporates the interaction between background factors (e.g., family history, social support, years of possible dependence, and co-morbid psychopathology), physiological states (e.g., physical withdrawal), cognitive processes (e.g., self-efficacy, cravings, motivation, the abstinence violation effect, outcome expectancies), and coping skills (Brownell et al., 1986; Marlatt & Gordon, 1985). To put it simply, small changes in an individual’s behavior can result in large qualitative changes at the global level and patterns at the global level of a system emerge solely from numerous little interactions.

The ARMS hypothesis purports that there is a multidimensional synergistically negative resistance that individual’s develop to any one form of treatment to a single dimension of their lives, because the effects of an individual’s addiction have dynamically interacted multi-dimensionally. Having the primary focus on one dimension is insufficient. Traditionally, addiction treatment programs have failed to accommodate for the multidimensional synergistically negative effects of an individual having multiple addictions, (e.g. nicotine, alcohol, and obesity, etc.). Behavioral addictions interact negatively with each other and with strategies to improve overall functioning. They tend to encourage the use of tobacco, alcohol and other drugs, help increase violence, decrease functional capacity, and promote social isolation. Most treatment theories today involve assessing other dimensions to identify dual diagnosis or co-morbidity diagnoses, or to assess contributing factors that may play a role in the individual’s primary addiction. The ARMS’ theory proclaims that a multidimensional treatment plan must be devised addressing the possible multiple addictions identified for each one of an individual’s life dimensions in addition to developing specific goals and objectives for each dimension.

The ARMS acknowledges the complexity and unpredictable nature of lifestyle addictions following the commitment of an individual to accept assistance with changing their lifestyles. The Stages of Change model (Prochaska & DiClemente, 1984) is supported as a model of motivation, incorporating five stages of readiness to change: pre-contemplation, contemplation, preparation, action, and maintenance. The ARMS theory supports the constructs of self-efficacy and social networking as outcome predictors of future behavior across a wide variety of lifestyle risk factors (Bandura, 1977). The Relapse Prevention cognitive-behavioral approach (Marlatt, 1985) with the goal of identifying and preventing high-risk situations for relapse is also supported within the ARMS theory.

The ARMS continues to promote Twelve Step Recovery Groups such as Food Addicts and Alcoholics Anonymous along with spiritual and religious recovery activities as a necessary means to maintain outcome effectiveness. The beneficial effects of AA may be attributable in part to the replacement of the participant's social network of drinking friends with a fellowship of AA members who can provide motivation and support for maintaining abstinence (Humphreys, K.; Mankowski, E.S, 1999) and (Morgenstern, J.; Labouvie, E.; McCrady, B.S.; Kahler, C.W.; and Frey, R.M., 1997). In addition, AA's approach often results in the development of coping skills, many of which are similar to those taught in more structured psychosocial treatment settings, thereby leading to reductions in alcohol consumption (NIAAA, June 2005).

Treatment Progress Dimensions

The American Society of Addiction Medicine’s (2003), “Patient Placement Criteria for the Treatment of Substance-Related Disorders, 3rd Edition”, has set the standard in the field of addiction treatment for recognizing the totality of the individual in his or her life situation. This includes the internal interconnection of multiple dimensions from biomedical to spiritual, as well as external relationships of the individual to the family and larger social groups. Life-style addictions may affect many domains of an individual's functioning and frequently require multi-modal treatment. Real progress however, requires appropriate interventions and motivating strategies for every dimension of an individual’s life.