At the May 2012 American Psychiatric Association’s Annual Meeting a broader definition of addiction was widely debated. Agreement was ultimately reached to revise and expand the definition of addiction while reducing the number of symptoms required to make the diagnosis.
The proposed DSM-5 Manual to be published in May 2013 would introduce a catchall phrase, “Behavioral Addictions.” The DSM-5 Task Force has suggested a new category–Addictions and Related Disorders (Grant, 2010). This would include substance-related and nonsubstance/behavioral addictions. The addiction field has evolved to describe this cluster of disorders as “Process Addictions” (Smith, 2012). This expansion of the addiction definitions is based on an understanding that both psychoactive drugs and certain behaviors that produce a surge in dopamine in the midbrain are the biological substrate for addictive behaviors. Further, individuals who are genetically predisposed to addiction are at a higher risk for this “reward deficiency syndrome” due to interplay of genetic and environmental factors.
The peak incidence for the onset of addiction is between ages 15 to 21. Since most treatment programs are adult-oriented, they often miss early onset process addiction. Clinical experience indicates that many process addictions occur in association with early onset adolescent addiction. The study of process addictions in adult populations is more advanced, expanding and improving treatment options. Unfortunately, at this time, early intervention opportunities for adolescents, particularly in the medical system, remain underserved (Ashley, 2012). Adolescent treatment programs, such as Newport Academy, have indicated that the major process addictions in adolescence are food, Internet/sex and related activities–which include social media sites (Facebook, Tumblr), texting, illicit content sharing by photo or webcam and multiplayer interactive online gaming.
There is increasing attention on cyberspace and social pathologies, which some would call technical addictions. As with other behavioral addictions, Internet abuse has been a controversial idea, and it has been a challenging task to arrive at a comprehensive definition of the concept. Experts have not been able to come to a consensus on a name; however, the different terms associated with Internet addiction include “Internet Addiction Disorder (IAD),” “Pathological Internet Use,” “Excessive Internet Use,” and “Compulsive Internet Use” (Karim, 2012)
Compulsive Sexual Behavior or Hypersexual Disorder
Sex addiction, as it is known in nonclinical vernacular, is a controversial topic in both science and media. Sex addiction could be described as a debilitating problem, which might include impairment in physical health function, cognition impulse control, attachment, intimacy and mood; or it could simply be a convenient excuse for an individual’s indiscretions. In defining aberrant sexual behavior, Carnes and Wilson (2002) proposed that sexually addictive behaviors include compulsive masturbation, affairs, use of prostitutes, pornography, voyeurism, exhibitionism, sexual harassment and sexually offending. Hypersexual Disorder has been proposed as a new psychiatric disorder for consideration in the Sexual Disorders section for DSM-5. Hypersexual Disorder is conceptualized as primarily a nonparaphilic sexual desire disorder with an impulsivity component. While there is a paucity of literature on brain imaging during conventional or pathological sexual functioning, research utilizing neuropsychological testing with self-reported behavior has shown a positive correlation between hypersexual behavior and global indices of executive dysfunction including features of impulsivity, cognitive rigidity, poor judgment and deficits in emotional regulation. (Karim, 2012)
Accessing Scientific Principles for Understanding Comorbid Addiction
The new definition of addiction by ASAM recognizes the symptoms of addiction are the result of complicated neurobiological processes that are, in part, the culmination of genetic predisposition combined with psychological forces.(ASAM 2011). This recognition has led to the understanding that other behaviors resulting from brain dysfunction, called process addictions, can be treated as comorbid disorders. Brain research is being used to understand all early onset brain disorders with a strong genetic component. Applying scientific principles to substance and the process addictions, Dan Amen has describe the clinical utility of Brain SPECT Imaging in process addictions, which helps clinicians understand and direct treatment for complex cases of obesity and sexual addictions (Amen, 2012). Blum has described the prominent role of the nucleus accumbens within the ventral striatum in mediating the reinforcing effects of drugs of abuse as well as food, sex and the process addictions. He has recommended that scientists and clinicians embark on researching use of neuroimaging tools with dopamine agonistic agents to target specific gene polymorphisms systemically for treating sexual addiction (Blume, 2012). Jeff Fortuna (2012) has described the skyrocketing obesity epidemic and the role of sugar addictions as an addictive agent that primes endorphin as well as dopamine in the nucleus accumbens. He also referred to the location of this site as the hedonic hot spot within the outer shell of the nucleus accumbens. Numerous studies have confirmed the opioid circuits in this region are central to sweet preference, supporting the clinical observation of the relationship between drug addiction and sugar addiction in the brain.
Introduction to Food Process Addiction
Food addiction has become a relatively common problem in the United States as well as in many developed nations throughout the world. Food addiction is primarily characterized by episodes of bingeing on sugar-dense and fat-dense foods such as cookies, ice cream, pizza, chocolate and a wide variety of other foods. Current research by a number of clinicians (Gearhardt et al., 2011; Burger & Stice, 2010) has documented that sugar has potent psychoactive properties in the nucleus accumbens and prefrontal cortex. Specifically, sugar causes the priming of endorphin and dopamine within the nucleus accumbens. However, the priming of endorphin only happens when people binge on large quantities of sugar-dense foods. Fortuna (2012) has noted that bingeing, not BMI (body mass index), predicts the euphoria derived from sugar-dense foods. In that regard, many adolescents and adults that appear lean are addicted to food nevertheless.
More recently, other researchers (Gearhardt et al., 2011) have discovered that sugar-dense food can produce tolerance in a manner similar to drugs, specifically in the lateral orbitofrontal cortex (OFC). For example, during the early stages of drug use a small dose of the drug triggers a “priming effect,” that is, an exaggerated euphoric response. It has been postulated that over time, individuals become physiologically dependent, and a small amount of the drug is no longer effective; a larger dose is necessary to achieve tranquilization or “euphoria.” This appears to be due to cellular differences and/or adaptation in the central nervous system (CNS) reward circuitry (the nucleus accumbens and limbic cortex) as well as hypoactivation in the lateral OFC. In a similar manner, consumption of a highly palatable food produces euphoria or tranquilization (e.g., calmness) in the naïve food addict. Over time, these effects diminish and notably higher quantities of food (e.g., bingeing) are required to achieve euphoria. Therefore, there are striking clinical similarities between food addiction and drug dependence: craving, tolerance, and bingeing.
Binge-Prone Environments in the United States
It has become apparent that we live in an obese and binge-prone food environment in the United States. An example of this is the sheer number of fast food restaurants: in 1950, there were fewer than 600 fast food restaurants. As of 2010, there are more than 230,000 fast food restaurants in the United States. Many of these fast food restaurants are located less than one-half mile from elementary schools (Davis & Carpenter, 2009). As such, many children and adolescents frequent these outlets several times per week. These fast food establishments have become the “hang out” for many adolescents. Many fast food restaurants are not only adjacent to schools, but they are often in between the school and the home.
In addition, the average adolescent consumes between two and three pounds of sugar per week (Gupta, 2008). Numerous studies have confirmed that sugar-dense, fat-dense refined foods are addictive. The most abundant sources of sugar in the adolescent diet are soda, candy, breakfast cereals, toaster pops and a wide variety of sweet snacks. Soda, in particular, is a culprit. Soda, which is essentially sugar water, is included in the overwhelming number of fast food meals. The average 12-ounce can of soda (a small-sized serving) contains 11 teaspoons of sugar. Each teaspoon is four grams. Therefore, in one soda there are 44 grams of sugar. If a child consumes three, 12-ounce sodas per day that adds up to 132 grams of sugar per day. In one week that would be a total of 928 grams of sugar (28 grams per oz X 33 ounces), which is slightly over 2 pounds per week. Therefore, at the end of one year, that adds up to a whopping 107 pounds of sugar. Moreover, that is strictly the amount of sugar intake from one food: soda.
The Rudd Center at Yale University recently did a seminal research study that analyzed the nutritional composition of meal entrees at the eight largest fast food restaurant chains in the United States (FACTS, 2010, Brownell K, Harris, J. Fast Food Facts: Food Advertising to Children and Teen Score. Rudd Center: Yale University. December 2010) They noted that out of some 3,039 different entrees that a child or an adolescent could order for lunch or for dinner, only 12 met/meet the nutritional standards set by the Institute for Medicine and the USDA (that is, only 12 out of 3,039–less than 0.004%). Again, we have obese- and binge-prone food environments throughout the United States.
Self-Medicating with Food
Many people self-medicate with food whether they are hungry or not. Some individuals overeat when they have anxiety–often pent-up feelings from a stressful day. For many it is a diversion, a means of avoiding dealing with an unresolved issue or gestalt. Some may even try to eat or drink away their anger, their sadness or their fear. Clearly, many people self-medicate with food.
An all-important message to impart to recovering adolescents is that there are healthy foods that aid in relapse prevention and better brain health. Newport Academy has employed this holistic and mindful practice since inception.
The Default Foods Concept (Preventing Hypoglycemia): A Novel Solution
We have known for decades that hypoglycemia is not a major cause of drug dependence, but it is a major cause of relapse (Schulz, 1997; Bang, 1991). The issues are sometimes referred to as the HALT theme: “don’t get too hungry, too angry, too lonely and too tired.” Anyone can probably relate to the issue of having skipped breakfast and lunch. By midafternoon, one is hypoglycemic in that they are irritable, depressed, tired–and their attention span is zip. As a clinical concern, during and posttreatment, the awareness of the effects of a proper brain-healthy diet can be proactive and preventative practice that a recovering individual can utilize. If the recovering addict’s blood-sugar gets too low, he or she may look to take the “edge off” an unpleasant emotional state, even if created by an avoidable hypoglycemic state, which may promote a relapse situation that triggers cravings. Then, by attempting to self-medicate with the wrong substance–potentially their drug of choice or another addictive behavior (i.e., gambling, sex, food or shopping)–a sustained endangering relapse can occur as a result.
In 2007, Fortuna (2012) developed the concept of “default foods.” Simply stated, default foods are foods that are good for you and that you enjoy eating. This could be a fruit, such as a peach or an apple: it tastes good and at the same time has inherent health benefits. The benefits could be from the vitamins and fiber in the fruit as well as from other macronutrients (i.e., high quality protein, Omega 3 fatty acids). This wise nutritional application prevents emotional dysregulation and is a logical extension of the relapse prevention slogan “HALT” heard commonly in Alcoholics Anonymous and other 12-Step programs.
Taste Preferences Knowledge: Driving Forces in Treatment and Prevention
Sir Francis Bacon said, “Knowledge is power.” Education empowers the making of healthier nutrition choices. It is the best type of prevention. In two separate studies, researchers noted that nutrition knowledge together with individual taste preferences are driving forces in eating fruit and vegetables in a large sample of children in Europe (Brug et al., 2008). They found that taste preference for specific fruits and vegetables was the primary determinant for eating fruit and vegetables. In addition, the same researchers noted that the availability of favorite fruits and vegetables in the home was a separate and important determinant. Similarly, Neumark-Szainer (2003) found that home availability and taste preferences were the greatest predictors of fruit and vegetable consumption.
In addition, recent studies (Krølner et al., 2011; Fischer et al., 2011) have identified that a quantitative nutrition knowledge base is a powerful determinant of adolescent fruit and vegetable intake. Specifically, Krølner and associates conducted a comprehensive review of 31 different studies that examined differences in fruit and vegetable intake among children and adolescents. They noted that the nutrition knowledge base was the single greatest predictor of fruit and vegetable intake. Moreover, they noted that it was not just the knowledge base of children, but the nutrition knowledge base of parents as well. These findings indicate that comprehensive nutrition education programs need to be made available. This is particularly true in programs that offer support for parents and guardians of at-risk children and adolescents who are addiction prone, and who have unhealthy diets and an inadequate nutrition knowledge base.
Comprehensive Adolescent Treatment for Substance and Process Addiction
The clinicians at Newport Academy have observed that, to date, out of 70 adolescent females admitted to Newport Academy for substance abuse treatment and co-occurring process addiction, 57% were diagnosed with a food addiction and a process addiction other than food that involved Internet/sex/self-harm or all three. Therefore, a majority of the female substance abusers admitted for treatment had a co-occurring process addiction requiring additional treatment planning.
An integrating treatment approach within a substance abuse program is complex but necessary for successful outcomes with all process addictions. Co-morbid and early-onset treatment for drug addiction and process addictions requires thorough assessment and application of multidisciplinary treatment modalities.
The assessments of process addictions are more challenging to diagnose because substance abuse disorders are easily verified through on-hand testing tools and confirmed by laboratory urine testing. Some parental reporting includes process addiction content; however, it is common for parents to be unaware of these comorbid behaviors as being contributing factors in comprehensive addiction treatment. In addition, many adolescents are protective and secretive about behaviors belonging to their emerging teen identity. Therefore, teens tend to hide or minimize their food intake, sexual activity or illicit Internet use. Where they may be able to identify the negative consequences of substance use, they do not always associate those consequences with their process addiction. Teens can easily rationalize their behavior as normal adolescent behavior where “everyone does it” with some truth. During the course of assessment and subsequent treatment, most do not possess adequate self-awareness of even having a process addiction; therefore, not surprisingly, they lack any intention of changing a harmful behavior they would likely consider normal or peer-typical.
When there is not a primary diagnosis of Internet addiction, and there is a primary diagnosis of a substance abuse disorder, eating disorder, or mental health disorder, these presenting concerns are addressed early in treatment. In a supervised and safe environment, teens at Newport Academy are away from time-consuming activities considered typical adolescent distractions and mostly concerned with social status, peer approval, sexual attraction/arousal and social media via texting or the Internet. Because this is not apparent from the teen’s perspective, treating these process addictions does not occur in the early stage of treatment. As the process addictions are uncovered in the ongoing assessment process, they are integrated as the client progresses and gains the self-awareness of how these additional behaviors trigger and mimic their other addiction behaviors.
One aspect of treatment that Newport Academy utilizes to promote self-awareness and overall health is to educate adolescents about the neurological similarities common to all process addictions. This is accomplished by utilizing an ongoing 16-week series designed by Dr. Daniel Amen, founder of the Amen Clinics, Inc., entitled “Making a Good Brain Great.”Dr. Amen’s research-based course is founded on the world’s largest brain imaging database. This course has a psychoeducational brain healthy focus, providing adolescents a comprehensive knowledge for substance abuse, food /eating disorders and the other process addiction revealed in treatment. This educational presentation also focuses on relapse prevention for any applicable addictive/process disorder from a safety-minded post-treatment perspective. Learning relapse prevention tools is crucial for successful recovery for both substance abuse disorders and co-occurring process addictions. In addition to Dr. Amen’s “Making a Good Brain Great” curriculum, during treatment at Newport Academy, through interactive presentations conducted by a clinical nutritionist and cooking demonstrations with the on-staff chef, teens are educated on healthy carbohydrate, fat, and protein choices. They are able to identify those default foods and request a “favorite” default food to include into a meal or snack. They learn moderation with healthy carbohydrates as being of paramount importance in recovery. In addition to meeting with the clinical nutritionist, teens have an initial assessment with a registered dietician and weekly groups to address body image issues. In the event that a resident is diagnosed with an eating disorder, the registered dietician, who specializes in treating eating disorders, continues to assess and treat the teen in individual sessions.
In treatment, food experimentation is the most accessible means of attempting to self-medicate (Johnson & Alberici, 1999). Occasionally, adolescents inventively attempt to experiment with different random food substances. This tendency has created clinical vigilance for this in-treatment cross-addiction threat. Treatment options for food addiction vary from treatment of other process addictions. In working with teens with food addiction, the approach is “restrictive/controlled” use of food along with psychoeducation and an individualized meal plan. While most large institutional treatment facilities have cafeteria style meals where little focus is placed on meal ingredients, at Newport Academy healthy nutritious meals are prepared absent of “binge prone” foods such as sugars, caffeine, and refined and processed carbohydrates.
Case Study: Substance and Co-occurring Process Addiction: Food/Eating Disorder
Jenny entered treatment for substance abuse but once in treatment transferred her addiction to food. She would often ask for seconds, take food off other plates and request snacks. Newport Academy assists residents in learning appropriate brain healthy nutritional practices and avoiding the potential of cross-addiction to food by plating meals, where Jenny experienced portion control. Once meals were plated, the remaining food put away and under supervision, food sharing is not allowed. Jenny, along with the other clients, had to sit at the dinner table for 30 minutes at mealtimes engaging in mindful eating. In addition, based on Jenny’s diagnosis, she was not allowed to go to the restroom for 60 minutes after meals without privacy- preserving supervision. Jenny continued to receive nutritional counseling from a registered dietician and clinical nutritionist. These supportive nutritional efforts were reinforced in individual, group and family therapy to uncover the underlying issues that contributed to her poor self-esteem and body image and negative emotions of anxiety, depression, anger and loneliness, which were contributing to her wanting to self-medicate with food before the age when drugs were not readily available.
Aside from food/eating disorders, the treatment for other process addictions, including the treatment for Internet/sex and self-harm, are based first on providing a safe environment that can safeguard initial abstinence. From there, a universal 12-Step template, a widely acknowledged basis for recovery, and one that is not solely applied to substance abuse, is initiated. This client-specific approach is then applied, as it pertains to the resident’s individual substance addiction and process addiction needs. The 12-step model is a critical foundation as it supports initial abstinence while providing flexibility and inclusion for various forms of psychoanalytic modalities to uncover and treat causation factors that contributed to creating the initial process addiction patterns.
The majority of teens enter treatment with an addiction to sex or the Internet. Newport Academy maintains gender-specific environments with 24/7 supervision. Abstinence from sex, use of the Internet and engagement in all other process addictions are assessed and monitored from the time of preadmission and throughout, including parental involvement in discharge planning.
Many treatments have been attempted for Internet addiction but since it is such an evolving and recent phenomenon, most treatments have yet to be adequately studied. The research in this area is ongoing. Treatments include structured cognitive behavioral therapy and dialectical behavior therapy (DBT) interventions.
At Newport Academy, Internet addiction is first approached using abstinence through supervised restrictive/controlled use. For many teens their sex addiction is a byproduct of the Internet use, thus the two must be addressed simultaneously. Teens use the Internet to solicit strangers as friends on Facebook and other social media sites. Teens lacking healthy boundaries and self-esteem, succumb to requests for provocative photos, posting or e-mailing these to strangers. For adolescents with Internet/sex addiction initially there is abstinence until the teen is able to enhance self-esteem, build boundaries and explore their own need for approval through sex. A restrictive/controlled program may be one recommendation for parents as an aspect of discharge planning.
Case Study: Substance and Co-occurring Process Addiction: Internet/Sex Addiction
Lindsay was a 16-year-old entering treatment due to ongoing issues with increased sexual activity and an inability to refrain from such behavior despite a desire to do so. Lindsay habitually sent naked pictures of herself to men, entered into relationships with older married men she met online and posted videos of herself in adult chat rooms. Early in treatment, her emotional and compulsive attachment to social media interaction became evident. Her parents had indicated that she spent hours a day online and would sneak out of the house to meet strangers. During the course of treatment, Lindsay was able to identify her feelings of abandonment and rejection from her biological father. She was able to work through her desire to act out with older man as a way to fill the void of the loss of relationship with her father, while getting in touch with the feelings of regret and despair she felt after each sexual encounter. Lindsay entered into a contract in which she agreed not to engage in any sexual activity for one year. Lindsey was not allowed any Internet access, and texting capabilities were prohibited on her phone for 90 days, with an assessment scheduled at the end of that time.
When working with sex and Internet addictions with adolescents it is best to begin with an abstinence model. During treatment, the therapist assists the client in building boundaries, enhancing self-esteem, changing their identity, and developing positive social and coping skills. Prior to discharge, again working with a therapist, the teen will either delete their entire Facebook account or delete the inappropriate contacts, messages and photos. If the Facebook account is not deleted, the home contract will not allow the teen to access the site for a minimum amount of time. Thereafter, a new or the existing account is activated with restrictive and controlled use. This includes parental controls with sharing of passwords, limited amount of time allowed online per day, and so forth. Websites such as tumblr, in which teens can share their negative feelings and receive support from strangers with similar issues of self-harm, depression, sex, and so on, are deleted, and access to all such sites are prohibited in the future.
Case Study: Substance and Co-occurring Process Addictions: Multiple Cross-addictions
Jordan was a 15-year-old female with various addictions including alcohol, bulimia, sex and self-harm. She engaged in codependent relationships and often lost her own identity within these relationships, spending her time focused on “saving their lives” as opposed to saving her own. Treatment consisted of assisting her in understanding the ways in which she engaged in unhealthy, codependent relationships and how she used sex to gain approval from peers, ultimately making her feel depressed and leading to self-harm and suicidal ideation. She worked in individual and group therapy to gain an increased understanding of requisites of friendship and her need for boundaries. She established boundaries she felt she deserved in friendships and relationships and placed therapist-monitored phone calls to former friends to assert new boundaries and effectively end those relationships. Working with her therapist, she deleted all negative peer groups on Facebook and deleted her tumblr account. She was able to view the negative peer groups and tumblr as negative coping techniques that allowed her to continue to engage in negative behaviors. She created a new identity, developing positive coping skills for her cravings for sex and self-harm behaviors. She entered a contract where she agreed to avoid sexual relationships for one year. She agreed if she met someone she would slowly build a friendship based on shared interests and mutual respect and introduce them to her parents.
In summary, the focus of Newport Academy’s adolescent treatment facilities is on a brain healthy, holistic and individualized approach that includes family involvement. Treatment consists of a multidisciplinary psychoanalytic model (Amen & Smith, 2010). This approach requires that unhealthy lifestyles consisting of comorbid process addiction issues be uncovered and treated in concert with the presenting substance abuse problem. Rather than focus on the symptoms–the external manifestations–focus is placed on the underlying causal issues. This thoughtful and comprehensive approach is required for lasting recovery to be accomplished.
A special thank you to Jamison Monroe, Founder of Newport Academy, for his support of this work.
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