Screening for Poly-Behavioral Addiction


Introducing the Behavior Risk Assessment Screen (BRAS) for Patients
with Multiple Addictions.


By James Slobodzien, Psy.D., CSAC

With the end of the Cold War, the threat of a world nuclear war
has diminished considerably. It may be hard to imagine that in the
end, comedians may be exploiting the humor in the fact that it
wasn't nuclear warheads, but "French fries" that annihilated the
human race, when considering that food addictions and their related
diseases now afflict more people globally than malnutrition.

The
behavioral addiction disorders (e.g., food addictions, pathological
gambling, and other obsessively-compulsive behavioral-patterns to
religion, and/ or sex / pornography, etc.) are just as damaging,
psychologically and socially as alcohol and drug abuse.


On a more serious note,
lifestyle diseases and addictions
are the leading cause of preventable morbidity and mortality taking
more than one million (1,000,000) U.S. lives a year, yet brief
preventive behavioral assessments and counseling interventions are
under-utilized in health care settings (Whitlock, 2002). The U.

S.
Preventive Services Task Force concluded that effective behavioral
counseling interventions that address personal health practices
hold greater promise for improving overall health than many
secondary preventive measures, such as routine screening for early
disease (USPSTF, 1996). Common health-promoting behaviors include
healthy diet, regular physical
exercise, smoking cessation,
appropriate alcohol/ medication use, and responsible sexual
practices to include use of condoms and contraceptives.
Multiple Addictions and Poor Prognosis
Since it is impossible to expect treatment for one addiction to be
beneficial when other addictions co-exist, the initial therapeutic
intervention for any addiction needs to include an assessment for
other addictions.

National surveys revealed that a very high
correlation exists between substance abuse and behavioral
addictions. 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 addiction 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?
The Addictions Recovery Measurement System (ARMS), along with 350
national organizations and 250 State public health, mental health,
substance abuse, and environmental agencies support the
U.S.

Department of Health and Human Services, "Healthy People 2010"
program. This national initiative recommends that primary care
clinicians utilize clinical preventive assessments and brief
behavioral counseling for early detection, prevention, and
treatment of lifestyle disease and addiction
indicators for all patients' upon every healthcare visit. The ARMS
theory proposes a new diagnosis. 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 (Slobodzien,
J., 2005).


The ARMS prognostication system supports the Five A's construct
(a model adapted from tobacco cessation interventions) as a brief
screening behavioral counseling system. This guideline (Morgan and
Fox, 2000) provides different brief interventions for treating
patients based on their lifestyle disease indicators and
addictive behavior status. Health care providers should:
* Ask patients about disease/ addiction health indicators (e.g.

if
they use tobacco, alcohol, drugs,
exercise,
diet, gamble, practice risky sexual
behaviors, etc.). An office wide system can be implemented to
ensure that all patients are queried regarding risky
behaviors.
* Advise patients to quit--advice should be clear, strong, and
personalized.


* Assess willingness to make a quit attempt in the next 30 days.
Provide a motivational intervention for those unwilling to quit at
this time.
* Assist patients in their efforts to quit: (1) Patients should
set a quit date and remove addictive products (triggers) from their
environment. (2) Provide practical counseling.

Total abstinence is
the key objective. Patients should limit alcohol use and anticipate
and plan for challenges and triggers. (3) Offer support and suggest
that patients seek support from their friends and family. (4)
Recommend appropriate first- or second-line
pharmacotherapies.


* Arrange follow-up within the first week after the quit date to
prevent relapse.
Accurate diagnosis is dependent on a thorough multidimensional
assessment process along with the possible help of a
multidisciplinary treatment team approach. Behavioral Medicine
practitioners have come to realize that although a disorder may be
primarily physical or primarily psychological in
nature, it is always a disorder of
the whole person - not just of the body or the mind. The ARMS
approach examines the broad bio-psychosocial context of the
individual (e.

g., biomedical, behavioral, interpersonal, social,
cultural, spiritual, and self-regulative factors, etc.), when
assessing an individual to determine the presence of a
lifestyle addiction. It is
concerned with the health choices individuals make as well as
modifying and altering unhealthy lifestyles to directly reduce
illness and illness behavior that predisposes them to other
physical illnesses.


The ARMS battery of dimensional assessment and screening
instruments focus on the multidimensional aspects of diagnosis, but
continue to promote the standard screening instruments for specific
substance abuse addictions (e.g., CAGE, MAST, AUDIT, SASSI, etc.).


The ARMS battery can also assist with developing the other four DSM
axes of a clinical diagnosis. The Multidimensional Psychosocial
Stressors Inventory (MPSI) is utilized to narrow down a list of
axis one diagnoses and axis four stressors. The Personality Feature
Checklist (PFC) can assist with identifying an individual's
personality traits on axis two that may be contributing to his
addictive life-style. The General Health Risk Assessment (GHRA) can
assist with identifying physical symptoms and other addictive
behaviors to consider alternative axis three diagnoses.

The
Religious Attitudes Inventory (RAI) can assist with assessing a
patient's spiritual/ religious life-functioning dimension. The
Prognostic Assessment Gauge (PAG) cumulative score can objectively
reveal a prognostic level of functioning for axis five. This
thorough assessment approach attempts to leave no stone unturned.
The following brief screening tool is just one of twelve screening
instruments proposed in the Addictions Recovery Measurement System
to assist providers with the poly-behavioral addiction assessment
process:
Behavior Risk Assessment Screen (BRAS)
Fact Sheet

The Behavior Risk Assessment (BRA) is an efficient and effective
screening tool used for early detection of unhealthy life-style
practices before they manifest themselves as major health problems.


It is comprised of the following six screening tools: 1) Substance
Intake Screen: (Nicotine, Alcohol, Illegal Drugs), 2) Eating
Attitude Screen, 3) Exercise Pattern Screen, 4) Sleep
Pattern Screen, 5) Sexual Practice Screen, 6) Gambling Practice
Screen, and the 7) Risky Behavior Screen.
Target Population Adults - diagnosed with Alcohol/ Substance
Abuse or Dependence Disorders and/ or other behavioral addictions,
(e.g., gambling, eating, sex, religious addictions, etc.

). For
adults in both inpatient and outpatient settings.
_________________________
Administrative Issues The BRA has 21 items that an individual can
answer within minutes. It is easily scored, and the results can be
quickly integrated into the Prognostic Assessment Gauge for a
cumulative prognosis score.


_________________________
Scoring Time required: 10 minutes
Scored by Clinician
See scoring guide
_________________________
Clinical Utility In addition to the BRA's effectiveness in
initially detecting an individual's risk for potential health, and/
or other addictive problems, it can also be used as an awareness
education tool for the prevention of behavioral health
problems.
_________________________
Research Applicability The BRA's brevity, ease of administration
and scoring, and availability of computer format for data storage
and analysis make it highly useful for research applications. Based
on independent interviews by a mental health professional, the BRA
administered by primary care practitioners' demonstrated good
accuracy (sensitivity and specificity) for collecting significant
clinical history data in a timely manner for prognostic
decision-making. Treatment outcome studies are presently in
process.


Copyright, and Source
© March 2004 by James Slobodzien, Psy. D.
------------------------------------------------------------------------------------------------

Behavior Risk Assessment Screen (BRAS)
Name: _______________________________ Date:
____________________________
Signature: ____________________________ SSN:
____________________________
The Behavior Risk Assessment Screen is comprised of the
following seven screening scales:
A. Substance Intake Screen
B.

Eating Attitude Screen
C. Exercise Pattern Screen
D. Sleep Pattern Screen
E. Sexual Practice Screen
F.

Gambling Practice Screen
G. Risky Behavior Screen
Instructions:
Following are groups of statements that are numbered and weighted
- 10, 20, or 30. Please read each group of statements carefully.
Then pick out the one statement in each group that is most true for
you, and circle the number beside the statement that you
pick.


NOTE: Be sure to read all the statements in each group, and circle
just one number beside the statements that you pick.
A. Substance Intake Screen: Score = ___
(Total - Nicotine, Alcohol, Illicit drugs & Caffeine Scores
and divide by 4= ___ (Total Score)
Nicotine Use Score = ___
1. I do not smoke cigarettes, cigars, or pipes or use smokeless
"chewing" tobacco, and I am not exposed to tobacco smoke regularly.


Yes (30 points)
2. I typically smoke a pack or more daily, and/ or chew more than
a can of tobacco per day. Yes (10 points)
Alcohol Use Score = ___
1. (Male) I do not drink alcoholic beverages, or if I drink, I do
not consume more than 2-standard alcoholic drinks per occasion, or
more than 14-drinks per week.


(Female) I do not drink alcohol, or if I drink, I do not consume
more than 1-standard alcoholic drink per occasion, or more than
7-drinks per week.
(Male & Female) I never drink while having medical problems
(e.g., female- pregnancy, etc.

) or while operating machinery. Yes
(30 points)

I drink, but I do not consume more than 3 (female) or 4 (male)
standard alcoholic drinks per occasion on any one day of the week.
Yes (20 points)
I typically consume 4 or more standard alcoholic drinks per
occasion, and typically consume more than 14-standard drinks per
week. Yes (10 points)
Illicit Drug Use (e.

g., All street drugs: marijuana, cocaine,
methamphetamine (ICE), ecstasy, LSD, Heroin, including
un-prescribed medications, inhalants, and/ or unauthorized
supplements - "Ephedra", or excessively used "over-the-counter
medications", etc.). Score = ___
1.

I have not ever used illicit "street drugs" and/ or taken
addictive prescription medications for long periods in the past,
and I do not presently use illicit drugs or take addictive
prescription medications. Yes (30 points)
2. I have used illicit "street drugs" and/ or have taken addictive
prescription medications for long periods in the past. Yes (20
points)
3.

I use illicit "street drugs" and/ or take addictive medications
frequently or whenever I get the opportunity. Yes (10 points)
Caffeine Intoxication (e.g., coffee, soda, tea, & other
caffeine products, etc.

)
Score = ___
1. My use of caffeine products has not caused distress or
impairment in my social, occupational, or other important areas of
my life. Yes (30 points)
2. My use of caffeine products has caused physical symptoms (e.

g.,
restlessness, nervousness, excitement, and/ or insomnia, etc.),
that have resulted in impairment in my social, occupational, or
other important areas of my life.
Yes (10 points)
B.

Eating Attitude Screen: Score = ___
1. Issues concerning my weight and/ or eating habits have not
caused me to feel shame, guilt, embarrassment, and/ or low
self-esteem, as my relationship with food has never been one of the
problem areas in my life. Yes (30 points)
2. Issues concerning my weight and/ or eating habits have been a
focus of my life, causing me to sometimes feel shame, guilt,
embarrassment, and/ or low self-esteem, as I tend to overeat, under
eat, binge, purge, and/ or obsess over
diets and calories Yes (10
points)
C.

Exercise Pattern Screen: Score =
___
1. On average, I exercise five times or more per
week for 30 minutes or more each time and/or have vigorous activity
three times or more per week for 20 minutes or more each time. = 30
points
2. On average, I exercise once or twice a week for
30 minutes or more each time.

= 20 points
3. I don't exercise and/ or don't have a
regular exercise program that I follow. =
10 points
D. Sleep Pattern Screen: Score = ___
1.

On average, I typically get between 7 and 8 hours of sleep
daily.
= 30 points
2. On average, I typically get less than 4 hours of sleep daily or
more than 11
hours of sleep daily. = 10 points
E.

Sexual Practice Screen: Score = ___
1. I have always abstained from sexual relationships or I have
always practiced safe sex (e.g., used condoms/ contraceptives
appropriately, etc.

) and have no prior history of STD's, multiple
sex partners, or of sharing needles with anyone.
Yes (30 points)
2. I have not always practiced safe sex and/ or have had multiple
sex partners.
Yes (20 points)
3.

I have not always practiced safe sex, and/ or - I presently
have multiple sexual partners and/ or have a prior history of STD's
and/ or a history of sharing needles with others.
Yes (10 points)
F. Gambling Practice Screen: Score = ___
1. I have never gambled, or I have never gambled with more than
$100.

00 on any one- day, and it was purely for social
entertainment. My gambling has never resulted in adverse
consequences to others or myself.
Yes (30 points)
2. Gambling is sometimes a part of my recreational activities, but
I have never gambled with more than $1000.

00 on any one-day.
Periodically I have suffered from some negative consequences, but I
have never lost control over this behavior. Yes (20 points)
3. I have gambled with more than $1000.

00 on any one-day and/ or I
have a continuous or periodic loss of control over gambling
behaviors; and/ or a preoccupation with gambling and obtaining
money for gambling; and/ or a pattern of continuing to gamble in
spite of adverse consequences. Yes (10 points)
G. Risky Behavior Screen: Score = ___

I do not have a pattern of practicing the following risky
behaviors:

a. Drinking alcohol and/ or using mind altering drugs and driving
a motor vehicle, or riding with someone
that does;
b.

Drinking alcohol and/ or using mind altering drugs and
operating machinery, and/ or using a firearm, explosive devices,
and/ or exposing myself to medicines, chemicals, and/ or
poisons;
c. Drinking alcohol and/ or using mind altering drugs and
bicycling, swimming, diving, boating, or performing other
potentially hazardous recreational activities;
d. Driving/ riding a motor vehicle and not using seatbelts or
a helmet;
e. I do not have a history of having obsessive thoughts and/ or
impulsive behaviors that have resulted in negative consequences
(e.

g., alcohol/ substance abuse, sexual promiscuity, speeding/
reckless driving, and/ or other aggressive impulses, resulting in
motor vehicle crashes, falls, fires, near
drowning, near suffocation, poisoning - incidents, assault,
self-harm, damage or loss to personal or other's property, or other
dangerous behaviors, etc.). Yes (30 points)
2.

I have a history (more than one incident) of the above risky
behaviors, and/ or of having obsessive thoughts and impulsive
behaviors that have resulted in some negative consequences, (e.g.,
alcohol/ substance abuse, sexual promiscuity, speeding/ reckless
driving, other aggressive impulses, resulting in motor
vehicle crashes, falls, fires, near
drowning, near suffocation, poisoning - incidents, assault,
self-harm, damage or loss to personal or other's property, or other
dangerous behaviors, etc.).


Specify behavior(s): _________________________ Yes (10 points)
Scoring: The Addictions Recovery Measurement System utilizes an
arbitrary, but standardized "weighted" classification process to
assign different intensity levels of prognostic factors relative to
each individual's test scores (e.g., Clinical Evaluation Guide: 10
points = High Risk with chronic & severe symptoms; 20 points =
Moderate Risk with acute & moderate symptoms; and 30 points =
Low Risk with no present acute symptoms, etc.).

This method is used
in an attempt to objectively measure, integrate, and systematize
the collection, tabulation, interpretation, and graphical display
of the ARMS screening instrument test results.
Behavior Risk Assessment (BRA) Tabulation Guide: (Example)
1. Substance Intake Screen: Nicotine Score = 30
Alcohol Score = 10
Illegal Drugs Score = 20
Caffeine Score = 10 (Divide by 4) 70 = 17.5 Score = 17.

5
2. Eating Attitude Screen Score = 30
3. Exercise Pattern Screen Score = 30
4. Sleep Pattern Screen Score = 30
5.

Sexual Practice Screen Score = 20
6. Pathological Gambling Screen Score = 20
7. Risky Behavior Screen Score = 10
(Score) divided by 7 multiplied by 3.33 Total Score =157.

5
157.5 divided by 7 = 22.5 x 3.33 = 74.

9
Cumulative PAG Score = 74.9
Prognostic Assessment Gauge (PAG) - Interpretive
Guide:
___ Excellent = 80 to 100 (e.g., optimal level of functioning,
etc.

)
75_ Good = 60 to 80 (e.g., above satisfactory level of
functioning w/
Mild symptoms)
___ Fair = 40 to 60 (e.g.

, satisfactory level of functioning
w/
Moderate symptoms, etc.)
___ Poor = 20 to 40 (e.g., unsatisfactory level of functioning
w/
Severe symptoms, etc.

)
___ Guarded = 0 to 20 (e.g., eminent danger to self or others,
etc.)
The Prognostic Assessment Gauge (PAG) Score can be used to score
just one or all twelve -
ARMS - screening instruments.

It is utilized as an indication of
how well an individual is coping
at the present time. It summarizes an individual's overall
psychological, social, and occupational
functionability and may similarly represent an objective DSM-IV,
Axis V - Global Assessment of
Functioning (GAF) score.
NOTE: Each individual item in the (10) high-risk category should
be screened for further
assessment.

Conclusion
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.
For more info see:
Poly-Behavioral Addiction and the Addictions Recovery Measurement
System (ARMS)
at:
.geocities.

com/drslbdzn/Behavioral_Addictions.html
James Slobodzien, Psy.D. CSAC, is a Hawaii licensed psychologist
and certified substance abuse counselor who earned his doctorate in
Clinical Psychology.

The National Registry of Health Service
Providers in Psychology credentials Dr. Slobodzien. He has over
20-years of mental health experience primarily working in the
fields of alcohol/ substance abuse and behavioral addictions in
medical, correctional, and judicial settings. He is an adjunct
professor of Psychology and also maintains a private practice as a
mental health consultant.


References
American Psychiatric Association: Diagnostic and Statistical
Manual of Mental Disorders, Fourth Edition,
Text Revision. Washington, DC, American Psychiatric Association,
2000, p. 787 & p. 731.


American Society of Addiction Medicine's (2003), "Patient
Placement Criteria for the
Treatment of Substance-Related Disorders, 3rd Edition, Retrieved,
June 18, 2005, from:
.asam.org/
Arthur Aron, Ph.D.

, professor, psychology, State University of New
York, Stony Brook; Helen
Fisher, research professor, department of anthropology, Rutgers
University, New Brunswick, N.J.;
Paul Sanberg, Ph.D.

,professor, neuroscience, and director, Center
of Excellence for Aging and
Brain Repair,University of South Florida College of Medicine,
Tampa; June 2005, the Journal of
Neurophysiology
Gorski, T. (2001), Relapse Prevention In The Managed Care
Environment. GORSKI-CENAPS Web
Publications. Retrieved June 20, 2005, from: www.

tgorski.com
Lienard, J. & Vamecq, J. (2004), Presse Med, Oct 23;33(18
Suppl):33-40.


Morgan, G.D.; and Fox, B.J.

Promoting Cessation of Tobacco Use.
The Physician and Sports medicine. Vol 28- No. 12, December
2000.


Slobodzien, J. (2005). Poly-behavioral Addiction and the
Addictions Recovery Measurement System (ARMS), Booklocker.com,
Inc.

, p. 5.
Whitlock, E.P.

Evaluating Primary Care Behavioral Counseling
Interventions: An Evidence-based Approach. Am J Prev Med
2002;22(4): 267-84.
U.S.

Department of Health and Human Services. Healthy People 2010
(Conference Edition). Washington, DC: U.S.

Government Printing
Office; 2000.
James Slobodzien, Psy.D., CSAC, is a Hawaii licensed
psychologist and certified substance abuse counselor who earned his
doctorate in Clinical Psychology.

The National Registry of Health
Service Providers in Psychology credentials Dr. Slobodzien. He has
over 20-years of mental health experience primarily working in the
fields of alcohol/ substance abuse and behavioral addictions in
medical, correctional, and judicial settings. He is an adjunct
professor of Psychology and also maintains a private practice as a
mental health consultant.



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