© 2012 Addiction Interaction Disorder: Understanding Multiple Addictions Patrick J. Carnes, Ph.D

© 2012

Addiction Interaction Addiction Interaction Disorder: Disorder:

Understanding Multiple Understanding Multiple AddictionsAddictions

Patrick J. Carnes, Ph.D.Patrick J. Carnes, Ph.D.

© 2012

Gambling Gambling (N=103)(N=103)

83%

48%

31%

0%

50%

100%

Sexual Addiction Sexual Anorexia Both

© 2012

Alcoholism Alcoholism (N=740)(N=740)

80%

52%

33%

0%

50%

100%


© 2012

Substance Abuse Substance Abuse (N=664)(N=664)

82%

49%

33%

0%

50%

100%


© 2012

Eating Disorder Eating Disorder (N=213)(N=213)

65% 66%

33%

0%

50%

100%


© 2012

Addiction InteractionAddiction Interaction

0%

50%

100%

Eating Disorder


0%

50%

100%

Alcoholism


0%

50%

100%

Substance Abuse


0%

50%

100%

Gambling


© 2012

Challenges to RecoveryChallenges to RecoveryAddiction is a brain diseaseAddiction is a brain disease

© 2012

Addiction is a brain disease Addiction is a brain disease expressed in the form of expressed in the form of

compulsive behavior.compulsive behavior.

Alan I. Leshner, MDAlan I. Leshner, MDFormer director of the National Former director of the National

Institute on Drug AbuseInstitute on Drug Abuse

© 2012

NeurochemistryNeurochemistry

Normal Obese

Red indicates high number of receptors for dopamine

Hans Breiter, director of the Motivation and Emotion Neuroscience Center at Massachusetts General Hospital

Nucleus Accumbens—Brain’s Reward Center

People short of dopamine have difficulty feeling joy.

Alcoholic Cocaine

© 2012

00

5050

100100

150150

200200

00 6060 120120 180180

Time (min)Time (min)

% o

f Bas

al D

A O

utpu

t%

of B

asal

DA

Out

put

NAc shellNAc shell

EmptyEmpty

BoxBox FeedingFeeding

Source: Di Chiara et al.Source: Di Chiara et al.

FOODFOOD

100100

150150

200200

DA

Conc

entr

ation

(% B

asel

ine)

DA

Conc

entr

ation

(% B

asel

ine)

MountsMountsIntromissionsIntromissionsEjaculationsEjaculations

1515

00

55

1010

Copulation FrequencyCopulation Frequency

SampleNumberSampleNumber

11 22 33 44 55 66 77 88 99 1010 1111 1212 1313 1414 1515 1616 1717

ScrScr ScrScrBasBas Female 1 PresentFemale 1 Present

ScrScrFemale 2 PresentFemale 2 Present

ScrScr

Source: Fiorino and PhillipsSource: Fiorino and Phillips

SEXSEX

Natural Rewards Elevate Dopamine Levels

©2008 Patrick J. Carnes, PhD

© 2012

00100100200200300300400400500500600600700700800800900900

1000100011001100

00 11 22 33 44 5 hr5 hr

Time After AmphetamineTime After Amphetamine

% o

f B

as

al

Re

lea

se

% o

f B

as

al

Re

lea

se

DADADOPACDOPACHVAHVA

AccumbensAccumbens AMPHETAMINEAMPHETAMINE

00

100100

200200

300300

400400

00 11 22 33 44 5 hr5 hrTime After CocaineTime After Cocaine

% o

f B

as

al

Re

lea

se

% o

f B

as

al

Re

lea

se

DADADOPACDOPACHVAHVA

AccumbensAccumbensCOCAINECOCAINE

00

100100

150150

200200

250250

00 11 22 3 hr3 hr

Time After NicotineTime After Nicotine

% o

f B

as

al

Re

lea

se

% o

f B

as

al

Re

lea

se

AccumbensAccumbensCaudateCaudate

NICOTINENICOTINE

Source: Di Chiara and ImperatoSource: Di Chiara and Imperato

Effects of Drugs on Dopamine LevelsEffects of Drugs on Dopamine Levels

100100

150150

200200

250250

00 11 22 33 4hr4hrTime After EthanolTime After Ethanol

% o

f B

as

al

Re

lea

se

% o

f B

as

al

Re

lea

se

0.250.250.50.5112.52.5

AccumbensAccumbens

00

Dose (g/kg ip)Dose (g/kg ip)

ETHANOLETHANOLETHANOLETHANOL

© 2012

Common Language of Common Language of Technological ChangeTechnological Change

Internet sex as the “crack cocaine” of sexual Internet sex as the “crack cocaine” of sexual compulsivity compulsivity

– – Al Cooper Ph.D.Al Cooper Ph.D.

Machine video poker as the “crack cocaine” of compulsive gambling

– Robert Hunter, Ph.D..

© 2012

Definition of a Black Hole:Definition of a Black Hole:

A celestial phenomenon when a A celestial phenomenon when a massive star collapses from its massive star collapses from its own gravity. A black hole has own gravity. A black hole has

such a strong pull that not even such a strong pull that not even light can escape from it.light can escape from it.

© 2012

Addiction InteractionAddiction Interaction

An addiction phenomenon where An addiction phenomenon where multiple addictions combine to multiple addictions combine to overwhelm a person by their overwhelm a person by their

complexity and power. complexity and power. Phenomenon is so strong, no Phenomenon is so strong, no

specific focus is strong enough to specific focus is strong enough to escape from it.escape from it.

© 2012

Challenges to RecoveryChallenges to Recovery

Addiction is a brain diseaseAddiction is a brain disease

• Addiction can be the gateway to the pursuit of excellence

© 2012


Addiction is a brain diseaseAddiction is a brain disease

• Addiction can be the gateway to the pursuit of excellence

• Addiction often has a trauma component

© 2012

ABUSE AND ADDICTIONABUSE AND ADDICTION265 Indicated Some Abuse (92.3%)

(N=264)

One Addiction

2 – 3 Addictions

4+ Addictions

Sexual

No 11

35

17____63

23.9%

Yes 31

60

110____201

76.1%

No 26

51

36____113

42.8%

Yes 16

44

91____151

57.2%

No 7

10

4____21

8.0%

Yes 35

85

123____243

92.0%

Physical Emotional

© 2012

© 2012

National Violence Against National Violence Against Women SurveyWomen Survey

Persons raped or physically assaulted in Persons raped or physically assaulted in lifetime by sex of victimlifetime by sex of victim

Women -- 55% or 55,383,350 Women -- 55% or 55,383,350

Men -- 67% or 61,955,644Men -- 67% or 61,955,644

Last twelve months:Last twelve months:

Women -- (302,091) 1,913,243Women -- (302,091) 1,913,243

Men -- (92,748) 3,153,432Men -- (92,748) 3,153,432

© 2012

NAVW SurveyNAVW Survey

Seventy-six per cent of the women who were Seventy-six per cent of the women who were raped and/or physically assaulted since the age raped and/or physically assaulted since the age of 18 were assaulted by a current or former of 18 were assaulted by a current or former husband, cohabiting partner, or date.husband, cohabiting partner, or date.

Another twenty six per cent knew their Another twenty six per cent knew their assailant.assailant.

Only fourteen per cent were victimized by a Only fourteen per cent were victimized by a stranger.stranger.

© 2012

Compulsive Attachment: Compulsive Attachment: Key CharacteristicsKey Characteristics

Troubled peopleTroubled people

Hero and pathological givingHero and pathological giving

High Intensity and DramaHigh Intensity and Drama

Boundary CollapseBoundary Collapse

Impression ManagementImpression Management

Conflict AvoidanceConflict Avoidance

© 2012

““The addictive dependence on The addictive dependence on feelings of pain…”feelings of pain…”

Alice Miller, The Drama of the Alice Miller, The Drama of the Gifted ChildGifted Child

• despair • intensity/risk • self-loathing • shame • misery • rage

© 2012

Addiction Interaction Addiction Interaction DisorderDisorder

Addictions more than coexist, Addictions more than coexist, they interact, reinforce, become they interact, reinforce, become

part of one another. They become part of one another. They become packages.packages.

© 2012

© 2012

Cross ToleranceCross Tolerance

A. Simultaneous increase in addictive behavior A. Simultaneous increase in addictive behavior in two or more addictions.in two or more addictions.

B. Transfer of a high level of addictive activity B. Transfer of a high level of addictive activity with little or no developmental sequence.with little or no developmental sequence.

© 2012

Withdrawal MediationWithdrawal Mediation

One addiction serves to One addiction serves to moderate, relieve, or avoid moderate, relieve, or avoid withdrawal from another.withdrawal from another.

© 2012

ReplacementReplacement

One addiction replaces another One addiction replaces another with majority of emotional and with majority of emotional and

behavioral features.behavioral features.

© 2012

Alternating Addiction Alternating Addiction CyclesCycles

Addictions cycle back and forth Addictions cycle back and forth in a patterned systemic way.in a patterned systemic way.

© 2012

Masking Masking

Addict uses one addiction to Addict uses one addiction to cover up for another, perhaps cover up for another, perhaps more substantive addiction.more substantive addiction.

© 2012

RitualizingRitualizing

Addictive behavior of one Addictive behavior of one addiction serves as a ritual addiction serves as a ritual pattern to engage another.pattern to engage another.

© 2012

IntensificationIntensification

Fusion dependence: neither Fusion dependence: neither addiction separately is sufficient; addiction separately is sufficient;

only simultaneous use is only simultaneous use is sufficient.sufficient.

© 2012


Partial Fusion: Addict combines Partial Fusion: Addict combines addictions in such a fashion to be addictions in such a fashion to be more potent than each addiction more potent than each addiction separately; addictions are used separately; addictions are used independently part of the time.independently part of the time.

© 2012


Binge Features: episodic multiple Binge Features: episodic multiple use, yet functionally independent use, yet functionally independent

of one another.of one another.

© 2012

© 2012

© 2012

NumbingNumbing

Addiction is used to medicate Addiction is used to medicate shame or pain caused by other shame or pain caused by other

addiction or addictive bingeing.addiction or addictive bingeing.

© 2012

DisinhibitingDisinhibiting

One addiction is used to lower One addiction is used to lower inhibitions for other addictive inhibitions for other addictive

acting out.acting out.

© 2012

Combining Combining

Mixing addictive experiences to Mixing addictive experiences to moderate responses due to moderate responses due to neuropathway interaction.neuropathway interaction.

© 2012

Addiction Interaction: Patient Addiction Interaction: Patient Recognition (N=650)Recognition (N=650)

Cross Tolerance – 59%Cross Tolerance – 59%

Withdrawal Mediation – 59%Withdrawal Mediation – 59%

Numbing – 59%Numbing – 59%

Fusion –57%Fusion –57%

Masking – 56%Masking – 56%

© 2012

Addiction Interaction: Patient Addiction Interaction: Patient Recognition (N=650)Recognition (N=650)

Replacement – 47%Replacement – 47%

Disinhibiting – 46%Disinhibiting – 46%

Ritualizing – 44%Ritualizing – 44%

Combining – 38%Combining – 38%

Alternating Addiction Cycles –36%Alternating Addiction Cycles –36%

© 2012

Addiction Interaction Paradigm Addiction Interaction Paradigm Changes:Changes:

Diagnostic Framework: revision of DSMDiagnostic Framework: revision of DSMTreatment Process: depth and scopeTreatment Process: depth and scopeTreatment Focus: the underlying issuesTreatment Focus: the underlying issuesRelapse Prevention: addictions as packagesRelapse Prevention: addictions as packagesAltered Strategies: first step, screen, Altered Strategies: first step, screen, neuropathways neuropathways Mirror Patient Realities: professional Mirror Patient Realities: professional allegiancesallegiances

© 2012


Addiction is a brain diseaseAddiction is a brain disease• Addiction can be the gateway to the pursuit of

excellence• Addiction often has a trauma component• Addiction can take many forms

• Addiction treatment is difficult to access for many

© 2012


Addiction is a brain diseaseAddiction is a brain disease• Addiction can be the gateway to the pursuit of

excellence• Addiction often has a trauma component• Addiction can take many forms• Addiction treatment is difficult to access for many

• Addiction and recovery interfere with advocacy

© 2012

Additional InformationAdditional Information

© 2012

For more on the Certified Sex Addiction Therapist (CSAT) For more on the Certified Sex Addiction Therapist (CSAT) trainings, the task-centered approach to addiction recovery, trainings, the task-centered approach to addiction recovery,

and assessment testing for sexual, work and financial and assessment testing for sexual, work and financial issues go to:issues go to:

www.IITAP.comwww.IITAP.com

or email or email [email protected]@IITAP.com

or callor call(480) 575-6853(480) 575-6853

© 2012

Gentle Path PressGentle Path PressFor books, workbooks, CDs & DVDsFor books, workbooks, CDs & DVDs

on the subject of sex addiction and recovery,on the subject of sex addiction and recovery,

please visit:please visit:

www.GentlePath.comwww.GentlePath.com

or callor call

(800)708-1796(800)708-1796

© 2012

SexHelpSexHelp

For additional information aboutFor additional information about

Dr. Patrick Carnes, links to other resources,Dr. Patrick Carnes, links to other resources,

current topics in research, and popular literature, current topics in research, and popular literature, go to:go to:

www.SexHelp.comwww.SexHelp.com

Documents

© 2012 Addiction Interaction Disorder: Understanding Multiple Addictions Patrick J. Carnes, Ph.D