“There is one addiction process …” Gabor Maté

UNDERSTANDING CO-OCCURRING DISORDERS

Author of “In the Realm of Hungry Ghosts”, Gabor Maté, goes on to say that this one addiction process shows up in a variety of ways: substances, food-related, shopping, gambling, sex, compulsive Internet use, or workaholism.

Ask anyone who struggles with addiction whether they have more than one thing they’re addicted to … the answer is usually “yes”.

These multiple addictions can also be referred to as “co-occurring addictions” or “cross addictions”. And it’s crucial they be addressed for anyone who is wanting long-term health and recovery.

Many people who experience substance misuse or addiction struggle with other addictive processes. For some, these additional addictive or compulsive processes occur alongside their substance use. For example, excessive cocaine use often accompanies compulsive sexual behaviour. Gambling addiction often overlaps with alcohol use disorders.

Others may engage in a process known as “switching addictions” - attempts to stop one addiction results in an increase in addictive use of another substance or behaviour such as disordered eating or excessive internet use increasing when substance use ends.

Either way, the problem is still the problem – co-occurring addictions and compulsive behaviours are just another sign something is driving the desire to mood-alter and numb. 

Research indicates that many of the same factors leading to substance addiction also lead to behavioural addictions. People are often reluctant to talk about these compulsive behaviours, or they are seen as less significant. The research also tells us that process addictions like Internet use, gambling, the use of pornography, and shopping can affect our brain, our nervous system, and our overall functioning in some the same ways that substance addiction does. It’s vital we are talking about how multiple and co-occurring addictions make a significant contribution to the problem of addiction for many people.

Behavioural Addictions and Compulsive Behaviours

The American Society of Addiction Medicine (ASAM) has recently included behavioural addiction in their definition of addiction as a chronic brain disorder, officially proposing that addiction is not just limited to substance use. Some of the behaviours that are often included in the category of addiction include gambling, compulsive buying, disordered eating, sexual behaviours, and internet use.

There is a higher rate of behavioural addiction among those with substance addiction. 28% of those with an alcohol use disorder have a behavioural addiction - almost double the rate for those who are not addicted (15%).

The research tells us that these behaviours operate in ways that are similar to substance use patterns – they activate the pleasure-reward circuit in similar ways. There is an ongoing, unhealthy engagement in the behaviour despite the negative consequences that occur, excessive time is spent engaging in the behaviour, and there is a loss of control over the behaviour. In addition to these similarities, behaviour addictions also create the same patterns of tolerance, withdrawal, and craving that substance use disorders create.

Research also tells us that the same things that move people towards substance misuse and addiction are also factors in behavioural addictions – the same genetic and neurobiological factors as well as the same experiential factors including a history of trauma and adverse childhood experiences. This would explain why those who experience more challenges with self-control and self-regulation often have behavioural addictions or engage in compulsive use of something like gambling or emotional eating.

Most likely, these types of addictive behaviours are just another symptom of the underlying problems of unresolved trauma and adverse childhood experiences.

Gambling
The most recent edition of the Diagnostic and Statistics Manual of Mental Disorders (DSM5) included gambling as an official addictive disorder alongside substance use disorders. Between 25-63% of problem gamblers have a substance use disorder. 73% of those who experience problem gambling will also have an alcohol use disorder at some point in their life.

Internet Addiction
Excessive computer use (gaming or social media) and online shopping are often problem behaviours that follow similar patterns as substance use disorders. Internet addiction is more common among those receiving treatment for substance misuse than the general population. This is especially true for young men enrolled in treatment programs for cannabis or problem gambling.

Sexual Behaviours
Many of the patterns of compulsive sexual behaviour resemble patterns of substance use and gambling addiction: loss of control, continued use despite negative consequences, and preoccupation with the behaviour. Patrick Carnes, the leading expert in sexual addiction, states that between 42 and 73% of people in substance addiction treatment programs report they also engage in some type of compulsive sexual behaviour.

Disordered Eating
There are many types of disordered eating patterns: anorexia and bulimia nervosa, extreme dieting, over-eating, or restricted eating can all be included in disordered eating patterns. Research shows a significant connection between substance misuse and eating disorders. Women with a substance use disorder or an eating disorder are 4 times more likely to develop the other disorder.

Different Ways That Addictions Can Overlap

The information about co-occurring addictions and compulsive behaviours is meant to encourage us to consider how these overlapping behaviours add to the unmanageability of substance misuse and addiction. Patrick Carnes says it best:

Each addiction brings unmanageability to a person’s life. It would be negligent to think “that the resulting chaos from each does not compound the problems of the others.

He has identified many ways that different addictions interact – the various ways more than one addiction or compulsive behaviour shows up in the life of someone experiencing addiction. These are crucial patterns to recognize and deal with if recovery and increased health is the goal.

Numbing
One behaviour or substance creates intense activation followed by another that is meant to provide a sense of numbing. Someone who engages in compulsive sexual behaviour and then numbs shame with alcohol or heroin is an example of this.

Disinhibiting
The opposite of numbing is that one addiction is used to lower inhibitions facilitating engagement in another addiction. Alcohol or cocaine might be used to lower inhibitions to participate in compulsive sexual behaviour or other substance use such as crack.

Intensification
The synergistic effect that occurs when addictions occur together to intensifying each other. Neither addiction is enough on its own – only simultaneous use provides the desired effect. Example: the sex addict who uses cocaine or crystal methamphetamine to achieve the intense sexual experience they desire. Both addictions tend to progress into greater addiction simultaneously.

Replacement
One addiction simply replaces another with the same intensity and compulsivity. One addiction begins after another has been addressed. Examples: Someone who starts engaging in disordered eating or compulsive sexual behaviours after completing a substance addiction program.

Alternating Addiction Cycles
When the focus of addiction shifts between two or more substances or behaviours over a period of time. An example of this pattern would be someone who alternates between alcohol and cocaine to manage weight issues. It could also include alternating between restricting and binging patterns as well as substance misuse as a way of dealing with weight-related concerns and the painful emotions that arise from the pattern.

What Does All This Mean?

The traditional view of addiction as addiction to one substance or one behaviour is no longer helpful, especially in light of how many compulsive behaviours are intertwined with substance misuse for many.  And we can add to the list of addictive and compulsive behaviours. Other areas of concern include workaholism, obsessive exercise, or love addiction to name a few.

We also need to see these various co-occurring addictions and compulsive behaviours are simply additional symptoms of the problem rather than being different “problems”.  While each one of these behaviours certainly creates additional negative consequences as well as additional health or mental health issues, they are not separate problems.

As Gabor Maté argues: there is “one addiction process”. The problem is the problem. And simply put – that problem is a dysregulated nervous system, most likely the result of trauma or adverse childhood experiences.