Screening for Poly-Behavioral Addiction

Introducing the Behavior Risk Assessment Screen				methamphetamine (ICE), ecstasy, LSD, Heroin, including
(BRAS) for Patients with Multiple Addictions.				un-prescribed medications, inhalants, and/ or
				unauthorized supplements - "Ephedra", or excessively
With the end of the Cold War, the threat of a world				used "over-the-counter medications", etc.). Score =
nuclear war has diminished considerably. It may be				___
hard to imagine that in the end, comedians may be				1. I have not ever used illicit "street drugs" and/ or taken
exploiting the humor in the fact that it wasn't nuclear				addictive prescription medications for long periods in
warheads, but "French fries" that annihilated the human				the past, and I do not presently use illicit drugs or take
race, when considering that food addictions and their				addictive prescription medications. Yes (30 points)
related diseases now afflict more people globally than				2. I have used illicit "street drugs" and/ or have taken
malnutrition. The behavioral addiction disorders (e.g.,				addictive prescription medications for long periods in
food addictions, pathological gambling, and other				the past. Yes (20 points)
obsessively-compulsive behavioral-patterns to religion,				3. I use illicit "street drugs" and/ or take addictive
and/ or sex / pornography, etc.) are just as damaging,				medications frequently or whenever I get the
psychologically and socially as alcohol and drug abuse.				opportunity. Yes (10 points)
On a more serious note, lifestyle diseases and				Caffeine Intoxication (e.g., coffee, soda, tea, & other
addictions are the leading cause of preventable				caffeine products, etc.)
morbidity and mortality taking more than one million				Score = ___
(1,000,000) U.S. lives a year, yet brief preventive				1. My use of caffeine products has not caused distress
behavioral assessments and counseling interventions				or impairment in my social, occupational, or other
are under-utilized in health care settings (Whitlock,				important areas of my life. Yes (30 points)
2002). The U.S. Preventive Services Task Force				2. My use of caffeine products has caused physical
concluded that effective behavioral counseling				symptoms (e.g., restlessness, nervousness, excitement,
interventions that address personal health practices				and/ or insomnia, etc.), that have resulted in impairment
hold greater promise for improving overall health than				in my social, occupational, or other important areas of
many secondary preventive measures, such as routine				my life.
screening for early disease (USPSTF, 1996). Common				Yes (10 points)
health-promoting behaviors include healthy diet, regular				B. Eating Attitude Screen: Score = ___
physical exercise, smoking cessation, appropriate				1. Issues concerning my weight and/ or eating habits
alcohol/ medication use, and responsible sexual				have not caused me to feel shame, guilt,
practices to include use of condoms and				embarrassment, and/ or low self-esteem, as my
contraceptives.				relationship with food has never been one of the
Multiple Addictions and Poor Prognosis				problem areas in my life. Yes (30 points)
Since it is impossible to expect treatment for one				2. Issues concerning my weight and/ or eating habits
addiction to be beneficial when other addictions				have been a focus of my life, causing me to
co-exist, the initial therapeutic intervention for any				sometimes feel shame, guilt, embarrassment, and/ or
addiction needs to include an assessment for other				low self-esteem, as I tend to overeat, under eat, binge,
addictions. National surveys revealed that a very high				purge, and/ or obsess over diets and calories Yes (10
correlation exists between substance abuse and				points)
behavioral addictions. Repeated failures abound with all				C. Exercise Pattern Screen: Score = ___
of the addictions, even with utilizing the most effective				1. On average, I exercise five times or more per week
treatment strategies. But why do 47% of patients				for 30 minutes or more each time and/or have
treated in private addiction treatment programs (for				vigorous activity three times or more per week for 20
example) relapse within the first year following				minutes or more each time. = 30 points
treatment (Gorski, T., 2001)? Have addiction specialists				2. On average, I exercise once or twice a week for
become conditioned to accept failure as the norm?				30 minutes or more each time. = 20 points
There are many reasons for this poor prognosis.				3. I don't exercise and/ or don't have a regular exercise
Some would proclaim that addictions are				program that I follow. = 10 points
psychosomatically- induced and maintained in a				D. Sleep Pattern Screen: Score = ___
semi-balanced force field of driving and restraining				1. On average, I typically get between 7 and 8 hours of
multidimensional forces. Others would say that failures				sleep daily.
are due simply to a lack of self-motivation or will				= 30 points
power. Most would agree that lifestyle behavioral				2. On average, I typically get less than 4 hours of sleep
addictions are serious health risks that deserve our				daily or more than 11hours of sleep daily. = 10 points
attention, but could it possibly be that patients with				E. Sexual Practice Screen: Score = ___
multiple addictions are being under diagnosed (with a				1. I have always abstained from sexual relationships or I
single dependence) simply due to a lack of diagnostic				have always practiced safe sex (e.g., used condoms/
tools and resources that are incapable of resolving the				contraceptives appropriately, etc.) and have no prior
complexity of assessing and treating a patient with				history of STD's, multiple sex partners, or of sharing
multiple addictions?				needles with anyone.
The Addictions Recovery Measurement System				Yes (30 points)
(ARMS), along with 350 national organizations and 250				2. I have not always practiced safe sex and/ or have
State public health, mental health, substance abuse, and				had multiple sex partners.
environmental agencies support the U.S. Department				Yes (20 points)
of Health and Human Services, "Healthy People 2010"				3. I have not always practiced safe sex, and/ or - I
program. This national initiative recommends that				presently have multiple sexual partners and/ or have a
primary care clinicians utilize clinical preventive				prior history of STD's and/ or a history of sharing
assessments and brief behavioral counseling for early				needles with others.
detection, prevention, and treatment of lifestyle disease				Yes (10 points)
and addiction indicators for all patients' upon every				F. Gambling Practice Screen: Score = ___
healthcare visit. The ARMS theory proposes a new				1. I have never gambled, or I have never gambled with
diagnosis. Poly-behavioral addiction is the synergistically				more than $100.00 on any one- day, and it was purely
integrated chronic dependence on multiple				for social entertainment. My gambling has never
physiologically addictive substances and behaviors (e.g.,				resulted in adverse consequences to others or myself.
using/ abusing substances - nicotine, alcohol, & drugs,				Yes (30 points)
and/or acting impulsively or obsessively compulsive in				2. Gambling is sometimes a part of my recreational
regards to gambling, food binging, sex, and/ or religion,				activities, but I have never gambled with more than
etc.) simultaneously (Slobodzien, J., 2005).				$1000.00 on any one-day. Periodically I have suffered
The ARMS prognostication system supports the Five				from some negative consequences, but I have never
A's construct (a model adapted from tobacco				lost control over this behavior. Yes (20 points)
cessation interventions) as a brief screening behavioral				3. I have gambled with more than $1000.00 on any
counseling system. This guideline (Morgan and Fox,				one-day and/ or I have a continuous or periodic loss of
2000) provides different brief interventions for treating				control over gambling behaviors; and/ or a
patients based on their lifestyle disease indicators and				preoccupation with gambling and obtaining money for
addictive behavior status. Health care providers should:				gambling; and/ or a pattern of continuing to gamble in
Â· Ask patients about disease/ addiction health				spite of adverse consequences. Yes (10 points)
indicators (e.g. if they use tobacco, alcohol, drugs,				G. Risky Behavior Screen: Score = ___
exercise, diet, gamble, practice risky sexual behaviors,				1. I do not have a pattern of practicing the following
etc.). An office wide system can be implemented to				risky behaviors:a. Drinking alcohol and/ or using mind
ensure that all patients are queried regarding risky				altering drugs and driving a motor vehicle, or riding with
behaviors.				someone that does;b. Drinking alcohol and/ or using
Â· Advise patients to quit--advice should be clear,				mind altering drugs and operating machinery, and/ or
strong, and personalized.				using a firearm, explosive devices, and/ or exposing
Â· Assess willingness to make a quit attempt in the				myself to medicines, chemicals, and/ or poisons;c.
next 30 days. Provide a motivational intervention for				Drinking alcohol and/ or using mind altering drugs and
those unwilling to quit at this time.				bicycling, swimming, diving, boating, or performing other
Â· Assist patients in their efforts to quit: (1) Patients				potentially hazardous recreational activities;d. Driving/
should set a quit date and remove addictive products				riding a motor vehicle and not using seatbelts or a
(triggers) from their environment. (2) Provide practical				helmet;e. I do not have a history of having obsessive
counseling. Total abstinence is the key objective.				thoughts and/ or impulsive behaviors that have
Patients should limit alcohol use and anticipate and plan				resulted in negative consequences (e.g., alcohol/
for challenges and triggers. (3) Offer support and				substance abuse, sexual promiscuity, speeding/
suggest that patients seek support from their friends				reckless driving, and/ or other aggressive impulses,
and family. (4) Recommend appropriate first- or				resulting in motor vehicle crashes, falls, fires, near
second-line pharmacotherapies.				drowning, near suffocation, poisoning - incidents, assault,
Â· Arrange follow-up within the first week after the				self-harm, damage or loss to personal or other's
quit date to prevent relapse.				property, or other dangerous behaviors, etc.). Yes (30
Accurate diagnosis is dependent on a thorough				points)
multidimensional assessment process along with the				2. I have a history (more than one incident) of the
possible help of a multidisciplinary treatment team				above risky behaviors, and/ or of having obsessive
approach. Behavioral Medicine practitioners have come				thoughts and impulsive behaviors that have resulted in
to realize that although a disorder may be primarily				some negative consequences, (e.g., alcohol/ substance
physical or primarily psychological in nature, it is always				abuse, sexual promiscuity, speeding/ reckless driving,
a disorder of the whole person - not just of the body				other aggressive impulses, resulting in motor vehicle
or the mind. The ARMS approach examines the broad				crashes, falls, fires, near drowning, near suffocation,
bio-psychosocial context of the individual (e.g.,				poisoning - incidents, assault, self-harm, damage or loss
biomedical, behavioral, interpersonal, social, cultural,				to personal or other's property, or other dangerous
spiritual, and self-regulative factors, etc.), when				behaviors, etc.).
assessing an individual to determine the presence of a				Specify behavior(s):
lifestyle addiction. It is concerned with the health				_________________________ Yes (10 points)
choices individuals make as well as modifying and				Scoring: The Addictions Recovery Measurement
altering unhealthy lifestyles to directly reduce illness and				System utilizes an arbitrary, but standardized
illness behavior that predisposes them to other physical				"weighted" classification process to assign different
illnesses.				intensity levels of prognostic factors relative to each
The ARMS battery of dimensional assessment and				individual's test scores (e.g., Clinical Evaluation Guide: 10
screening instruments focus on the multidimensional				points = High Risk with chronic & severe symptoms;
aspects of diagnosis, but continue to promote the				20 points = Moderate Risk with acute & moderate
standard screening instruments for specific substance				symptoms; and 30 points = Low Risk with no present
abuse addictions (e.g., CAGE, MAST, AUDIT, SASSI,				acute symptoms, etc.). This method is used in an
etc.). The ARMS battery can also assist with				attempt to objectively measure, integrate, and
developing the other four DSM axes of a clinical				systematize the collection, tabulation, interpretation, and
diagnosis. The Multidimensional Psychosocial Stressors				graphical display of the ARMS screening instrument
Inventory (MPSI) is utilized to narrow down a list of				test results.
axis one diagnoses and axis four stressors. The				Behavior Risk Assessment (BRA) Tabulation Guide:
Personality Feature Checklist (PFC) can assist with				(Example)
identifying an individual's personality traits on axis two				1. Substance Intake Screen: Nicotine Score = 30
that may be contributing to his addictive life-style. The				Alcohol Score = 10
General Health Risk Assessment (GHRA) can assist				Illegal Drugs Score = 20
with identifying physical symptoms and other addictive				Caffeine Score = 10 (Divide by 4) 70 = 17.5 Score =
behaviors to consider alternative axis three diagnoses.				17.5
The Religious Attitudes Inventory (RAI) can assist with				2. Eating Attitude Screen Score = 30
assessing a patient's spiritual/ religious life-functioning				3. Exercise Pattern Screen Score = 30
dimension. The Prognostic Assessment Gauge (PAG)				4. Sleep Pattern Screen Score = 30
cumulative score can objectively reveal a prognostic				5. Sexual Practice Screen Score = 20
level of functioning for axis five. This thorough				6. Pathological Gambling Screen Score = 20
assessment approach attempts to leave no stone				7. Risky Behavior Screen Score = 10
unturned. The following brief screening tool is just one				(Score) divided by 7 multiplied by 3.33 Total Score
of twelve screening instruments proposed in the				=157.5
Addictions Recovery Measurement System to assist				157.5 divided by 7 = 22.5 x 3.33 = 74.9
providers with the poly-behavioral addiction				Cumulative PAG Score = 74.9
assessment process:				Prognostic Assessment Gauge (PAG) - Interpretive
Behavior Risk Assessment Screen (BRAS)				Guide:
Fact Sheet				___ Excellent = 80 to 100 (e.g., optimal level of
The Behavior Risk Assessment (BRA) is an efficient				functioning, etc.)
and effective screening tool used for early detection				75_ Good = 60 to 80 (e.g., above satisfactory level of
of unhealthy life-style practices before they manifest				functioning w/
themselves as major health problems. It is comprised				Mild symptoms)
of the following six screening tools: 1) Substance Intake				___ Fair = 40 to 60 (e.g., satisfactory level of
Screen: (Nicotine, Alcohol, Illegal Drugs), 2) Eating				functioning w/
Attitude Screen, 3) Exercise Pattern Screen, 4) Sleep				Moderate symptoms, etc.)
Pattern Screen, 5) Sexual Practice Screen, 6)				___ Poor = 20 to 40 (e.g., unsatisfactory level of
Gambling Practice Screen, and the 7) Risky Behavior				functioning w/
Screen.				Severe symptoms, etc.)
Target Population Adults - diagnosed with Alcohol/				___ Guarded = 0 to 20 (e.g., eminent danger to self or
Substance Abuse or Dependence Disorders and/ or				others, etc.)
other behavioral addictions, (e.g., gambling, eating, sex,				The Prognostic Assessment Gauge (PAG) Score can
religious addictions, etc.). For adults in both inpatient and				be used to score just one or all twelve -
outpatient settings.				ARMS - screening instruments. It is utilized as an
_________________________				indication of how well an individual is copingat the
Administrative Issues The BRA has 21 items that an				present time. It summarizes an individual's overall
individual can answer within minutes. It is easily scored,				psychological, social, and occupationalfunctionability and
and the results can be quickly integrated into the				may similarly represent an objective DSM-IV, Axis V -
Prognostic Assessment Gauge for a cumulative				Global Assessment of
prognosis score.				Functioning (GAF) score.
_________________________				NOTE: Each individual item in the (10) high-risk category
Scoring Time required: 10 minutes				should be screened for furtherassessment.
Scored by Clinician				Conclusion
See scoring guide				Since successful treatment outcomes are dependent
_________________________				on thorough assessments, accurate diagnoses, and
Clinical Utility In addition to the BRA's effectiveness in				comprehensive individualized treatment planning, it is no
initially detecting an individual's risk for potential health,				wonder that repeated rehabilitation failures and low
and/ or other addictive problems, it can also be used				success rates are the norm instead of the exception
as an awareness education tool for the prevention of				in the addictions field, when the latest DSM-IV-TR does
behavioral health problems.				not even include a diagnosis for multiple addictive
_________________________				behavioral disorders. Treatment clinics need to have a
Research Applicability The BRA's brevity, ease of				treatment planning system and referral network that is
administration and scoring, and availability of computer				equipped to thoroughly assess multiple addictive and
format for data storage and analysis make it highly				mental health disorders and related treatment needs
useful for research applications. Based on independent				and comprehensively provide education/ awareness,
interviews by a mental health professional, the BRA				prevention strategy groups, and/ or specific addictions
administered by primary care practitioners'				treatment services for individuals diagnosed with
demonstrated good accuracy (sensitivity and				multiple addictions. Written treatment goals and
specificity) for collecting significant clinical history data in				objectives should be specified for each separate
a timely manner for prognostic decision-making.				addiction and dimension of an individuals' life, and the
Treatment outcome studies are presently in process.				desired performance outcome or completion criteria
Copyright, and Source				should be specifically stated, behaviorally based (a
Â© March 2004 by James Slobodzien, Psy. D.				visible activity), and measurable.
Behavior Risk Assessment Screen (BRAS)				For more info see:
Name:				Poly-Behavioral Addiction and the Addictions
_______________________________ Date:				Recovery Measurement System (ARMS)at:
____________________________				James Slobodzien, Psy.D. CSAC, is a Hawaii licensed
Signature: ____________________________				psychologist and certified substance abuse counselor
SSN: ____________________________				who earned his doctorate in Clinical Psychology. The
The Behavior Risk Assessment Screen is comprised				National Registry of Health Service Providers in
of the following seven screening scales:				Psychology credentials Dr. Slobodzien. He has over
A. Substance Intake Screen				20-years of mental health experience primarily working
B. Eating Attitude Screen				in the fields of alcohol/ substance abuse and
C. Exercise Pattern Screen				behavioral addictions in medical, correctional, and judicial
D. Sleep Pattern Screen				settings. He is an adjunct professor of Psychology and
E. Sexual Practice Screen				also maintains a private practice as a mental health
F. Gambling Practice Screen				consultant.
G. Risky Behavior Screen				References
Instructions:				American Psychiatric Association: Diagnostic and
Following are groups of statements that are numbered				Statistical Manual of Mental Disorders, Fourth Edition,
and weighted - 10, 20, or 30. Please read each group				Text Revision. Washington, DC, American Psychiatric
of statements carefully. Then pick out the one				Association, 2000, p. 787 & p. 731.
statement in each group that is most true for you, and				American Society of Addiction Medicine's (2003),
circle the number beside the statement that you pick.				"Patient Placement Criteria for the
NOTE: Be sure to read all the statements in each				Treatment of Substance-Related Disorders, 3rd Edition,
group, and circle just one number beside the				Retrieved, June 18, 2005, from:
statements that you pick.				Arthur Aron, Ph.D., professor, psychology, State
A. Substance Intake Screen: Score = ___				University of New York, Stony Brook; Helen
(Total - Nicotine, Alcohol, Illicit drugs & Caffeine Scores				Fisher, research professor, department of
and divide by 4= ___ (Total Score)				anthropology, Rutgers University, New Brunswick, N.J.;
Nicotine Use Score = ___				Paul Sanberg, Ph.D.,professor, neuroscience, and
1. I do not smoke cigarettes, cigars, or pipes or use				director, Center of Excellence for Aging and
smokeless "chewing" tobacco, and I am not exposed				Brain Repair,University of South Florida College of
to tobacco smoke regularly. Yes (30 points)				Medicine, Tampa; June 2005, the Journal of
2. I typically smoke a pack or more daily, and/ or chew				Neurophysiology
more than a can of tobacco per day. Yes (10 points)				Gorski, T. (2001), Relapse Prevention In The Managed
Alcohol Use Score = ___				Care Environment. GORSKI-CENAPS Web
1. (Male) I do not drink alcoholic beverages, or if I drink, I				Publications. Retrieved June 20, 2005, from:
do not consume more than 2-standard alcoholic drinks				Lienard, J. & Vamecq, J. (2004), Presse Med, Oct
per occasion, or more than 14-drinks per week.				23;33(18 Suppl):33-40.
(Female) I do not drink alcohol, or if I drink, I do not				Morgan, G.D.; and Fox, B.J. Promoting Cessation of
consume more than 1-standard alcoholic drink per				Tobacco Use. The Physician and Sports medicine. Vol
occasion, or more than 7-drinks per week.				28- No. 12, December 2000.
(Male & Female) I never drink while having medical				Slobodzien, J. (2005). Poly-behavioral Addiction and the
problems (e.g., female- pregnancy, etc.) or while				Addictions Recovery Measurement System (ARMS),
operating machinery. Yes (30 points)				Booklocker.com, Inc., p. 5.
2. I drink, but I do not consume more than 3 (female) or				Whitlock, E.P. Evaluating Primary Care Behavioral
4 (male) standard alcoholic drinks per occasion on any				Counseling Interventions: An Evidence-based
one day of the week. Yes (20 points)				Approach. Am J Prev Med 2002;22(4): 267-84.
3. I typically consume 4 or more standard alcoholic				U.S. Department of Health and Human Services.
drinks per occasion, and typically consume more than				Healthy People 2010 (Conference Edition). Washington,
14-standard drinks per week. Yes (10 points)				DC: U.S. Government Printing Office; 2000.
Illicit Drug Use (e.g., All street drugs: marijuana, cocaine,

Lapsi

Screening for Poly-Behavioral Addiction