August 4, 2014

The Cross-Addiction Conundrum

Deni Carise names it, “The Disease of More.” Constance Quinn likes the inherent power of “chosen behaviors.” Alison Smela uses the term, “obsession of the body and mind.” And Judi Hollis boils it down to “self-destruction.”

Whatever it’s called, addiction is tenacious. And its clever little tentacles will travel along neural pathways looking for a new pleasure source whenever its former favorite is shut out.

“I’m never surprised to see someone in recovery from drugs or alcohol then develop something different, like an eating disorder, compulsive gambling or shopping,” says Carise, Ph.D., chief clinical officer and senior vice president at Phoenix House, which operates more than 120 drug and alcohol treatment and prevention programs in 10 states.

Technological advancements, particularly in the area of neuroimaging, have enabled researchers to peer inside the brains of people with addictions. What they found in study after study is that their reward system (largely the neurotransmitter dopamine) is very, very thirsty. Meanwhile, their brain’s control centers are underachievers.

“This is the disease of more,” Carise says. “More fun, more highs, more excitement. If something is good, more is always better.”

Quinn, DSW and a licensed clinical social worker, is site director at the New York Renfrew Center, which specializes in treating eating disorders at two inpatient and ten outpatient facilities. She sees behavior replacement, commonly called “cross-addiction,” all the time.

“Addictive behaviors are compulsive and compelling,” Quinn says. “Someone who hasn’t had a drink in five years still has those grooves in the neural pathways that want to be satisfied.”

Suddenly, she says, that satisfaction might come from three pints of Haagen Daz, and then comes the compulsion to get rid of it by purging.

“The pleasure center is still there saying, ‘What about me? What about me? Feed me!” says Quinn.

Judi Hollis, Ph.D., a licensed counselor, motivational speaker and author of several books, points to the famed father of psychoanalysis in naming the driver of addiction.

“Freud said we all have ambivalence concerning life and death,” Hollis says. “Until we give into self-destruction, we will keep turning to another substance, or guy, or gambling—all of it, to continue to hurt ourselves.”

Obese her whole life, Hollis became a social worker among the alcoholic and addicted population. In time, she realized her eating behaviors were an addiction, too. She found Overeaters Anonymous, lost 75 pounds, maintained the loss, and began work as a motivational speaker. Then she had a divorce and was confronted by her alcoholism.

“I was so busy, focused on the eating, that I didn’t notice the other problem. I was always able to get control again. I didn’t think it was the same as my out-of-control eating,” she says.

She learned otherwise.

“I’m 22 years sober in AA,” Hollis says.

Some counselors compare cross-addiction to that arcade game where the little gopher pops up in all the different holes, Carise says. “You hit one down and another pops up.”

And so on. And so on. And so on.

The phenomenon at work

Alison Smela, 50, was a round-the-clock alcoholic with a 28-year drinking career before she entered detox and treatment on Jan. 4, 2002.

She hasn’t had a drink in 10 years, but she did have a three-month stint in the Renfrew Center, Philadelphia, in 2008 for a serious case of anorexia nervosa.

In retrospect, she says she realized the addictions were co-occurring and feeding off one another. The alcohol quieted the anorexia, which then amplified when the drink was gone.

“It was very much like a pendulum. When I was getting vibes that people felt I was drinking too much, the eating disorder would ramp up. Then someone would say something about food, and the drinking would get worse,” says the self-described former corporate workaholic.

“I was at the pinnacle of my career when my alcoholism reached its peak. My drink of choice was wine and it was always with me,” Smela says.

An executive and vice president managing multi-million dollar accounts for major ad agencies, her addictive destruction rose along with her business stature.

At admissions intake at Hazelden, Smela says, “I was the alcoholic who didn’t breathe a sober breath. I had a drink by 9 in the morning, and kept going all day.”

At Hazelden, she came to understand the jig was up.

But, she adds, “I was already tracking in the diet mindset. It was like white noise to me. I wasn't willing or ready to look at it. It was the one thing I could control when a lot of things were out of control.”

At first her weight loss was slow, but constant. And then it began to plummet.

“The people closest to me saw it and were like, ‘Oh my God, what is happening here?” she recalls.

In 2008, at Renfrew, Philadelphia, she was confined to a wheelchair for three weeks to preserve her energy.

“My health was so compromised,” she says. “By the time I got there I knew that I was on my way out.”

Smela stayed at Renfrew for three months. When she came home, Smela and her husband agreed she would leave the corporate world. Today she dedicates herself to Twelve Step recovery work, her blog, Alison’s Insights at, and writing a book focusing on women undertaking recovery later in life.

“My desire to run from life is my default mode. I can mentally leave the space by focusing heavily on something else,” she says. “I need to stay in the present; I need to deal only with the facts.”

Hence, the title of her book: Slow Deep Breaths.

“That is what recovery takes: one slow deep breath at a time,” Smela says. “Slow it down; slow and steady. It’s not just putting the booze down. It's not just eating a turkey sandwich. It’s looking at what’s going on with Alison.”

And what’s going on with Alison is that she no longer indulges in her addictions.

“Today,” she emphasizes. “Today I’m pretty sure I won’t have a drink. And I’m pretty sure I’m going to eat well.”

Getting in front of the problems

At Renfrew, Quinn says, they operate under the philosophy that rather than labeling a whole person “addict,” it is more helpful to refer to “addictive behaviors.”

This language is especially effective when considering common cross-addictions, such as gambling, shopping, sexual promiscuity, pornography, self-mutilation, eating disorders, exercise and the Internet.

“A lot of times patients reduce the symptoms but don’t get to what is driving the engine and that critical insight and self-awareness,” Quinn says. “Grief, loss and trauma are key triggers in terms of transfer of addiction.”

Smela not only had her own struggles with cross-addiction, but also saw it in others.

“Cross-addiction is shockingly not rare. At Renfrew, women 30 and beyond would come up to me quietly and say, ‘I think I might have something going on with drinking,’” she says.

To uncover co-occurring and potential cross-addictions, Renfrew does baseline testing. They assess the level of symptoms and a constellation of variables and try to “tease out” a plan to simultaneously treat the eating disorder along underlying psychological and biological issues. This, science shows, reduces the risk of cross-addiction.

“What Renfrew has done is really acknowledge that the eating disorder doesn’t exist in a vacuum,” Quinn says. “We have specialized tracks of treatment.”

Hollis believes the bulk of the answers come in easily accessed, affordable Twelve Step meetings and literature.

“What we need are personality changes,” she says. “I needed to become a person who doesn’t want to slap herself.”

By going through the Twelve Steps of recovery, Hollis says, people give up dishonesty and control, and learn to join their fellow human beings on a spiritual path.

“What is needed here is to change our behaviors so that we like ourselves enough to give up self-destruction. And if we don’t do that, we will just transfer to the next obsession down the road,” she says.

In considering solutions, Carise goes back to the “Whac-a-Mole” analogy.

“The goal in treatment is to try and get things that could be beneficial to pop up,” she says. “Sure, a person could go off into gambling. But the same person also could apply that same intensity to parenting, work, or school.”

Providers and individuals need to identify what they really want to achieve.

“They are looking for something to take away the pain or fulfill the thrill-seeking side of them,” Carise says. “Addicts have a lot of energy and if you can focus it into a positive thing, they can go on to do amazing things.”

As a recovering cocaine addict and alcoholic with 26 years of sobriety, Carise would know.

“It’s probably no coincidence that I ride an Italian race motorcycle. Or that when I got sober I took up skydiving,” she says. “I was pathologically driven to go back to school. I started community college and nine years later was in a post-doctoral program at U-Penn. You can't do that any faster than that.”

To say recovery has worked out well for her is an understatement.

“You have to replace the need for thrill or challenge with positive things; something that rewards, rather than hurts.”

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