Biopsychosocial Assessment

For this Discussion, review the Learning Resources attached below. Create a fictional case study of a client with an addiction disorder that affects at least two life domains.  Provide the following information:

  • Age of the client
  • Type of addiction and what is the source of the addiction (e.g., cocaine, alcohol, nicotine)
  • Describe the client’s ethnicity
  • Describe the client’s relationships
  • Describe the client’s current health
  • Describe the client’s social life
  • Describe the client’s psychological well being.

Please remember that you are presenting a case study as though you are a counselor sharing this case in clinical supervision

CURRENT OPINION PIECE

A ‘components’ model of addiction within a biopsychosocial framework

MARK GRIFFITHS

International Gaming Research Unit, Psychology Division, Nottingham Trent University, Nottingham,

UK

Abstract There is now a growing movement that views a number of behaviours as potentially addictive including many that do not involve the ingestion of a drug (such as gambling, sex, exercise, videogame playing and Internet use). This paper argues that all addictions consist of a number of distinct common components (salience, mood modification, tolerance, withdrawal, conflict and relapse). The paper argues that addictions are a part of a biopsychosocial process and evidence is growing that excessive behaviours of all types do seem to have many commonalities. It is argued that an eclectic approach to the studying of addictive behaviour appears to be the most pragmatic way forward in the field. Such commonalities may have implications not only for treatment of such behaviours but also for how the general public perceive such behaviours.

Introduction

Certain individuals use certain substances in certain ways, thought at certain times to be

unacceptable by certain other individuals for reasons both certain and uncertain.

(Burglass, & Shaffer, 1984, p. 19)

Conceptualizing addiction has been a matter of great debate for decades. Although the

opening quote is not recent, it still holds true despite the enormous amount of research into

addictive behaviours. Any conceptualization of addiction has implications for several

groups of people (e.g. addicts, their families, researchers, practitioners, policy makers, etc.).

Obviously, the needs of these groups may not be equally well served by certain models, and

in some cases there will be absolute incompatibility. Any framework for the conceptualiza-

tion of addiction must allow for the bottom-up development and integration of theory by

each of these groups – that is, it must be flexible, accountable, integrative and reflexive.

For many people the concept of addiction involves taking of drugs (e.g. Rachlin, 1990;

Walker, 1989). Therefore it is perhaps unsurprising that most official definitions

Correspondence: Mark Griffiths, International Gaming Research Unit, Psychology Division, Nottingham Trent University,

Burton Street, Nottingham NG1 4BU, UK. Tel: +44 115 8485528. Fax: +44 115 9486826. E-mail: mark.griffiths@ntu.ac.uk

Journal of Substance Use, August 2005; 10(4): 191–197

ISSN 1465-9891 print/ISSN 1475-9942 online # 2005 Taylor & Francis Group Ltd

DOI: 10.1080/14659890500114359

 

 

concentrate on drug ingestion. Despite such definitions, there is now a growing movement

(e.g. Miller, 1980; Orford, 2001; Shaffer et al., 2004) which views a number of behaviours

as potentially addictive including many behaviours which do not involve the ingestion of

a drug. These include behaviours as diverse as gambling (Griffiths, 1995), overeating

(Orford, 2001), sex (Carnes, 1983), exercise (Terry, Szabo, & Griffiths, 2004), videogame

playing (Griffiths, 2002), love (Peele, & Brodsky, 1975), Internet use (Griffiths, 2000) and

work (Griffiths, 2005). Such diversity has led to new all-encompassing definitions of what

constitutes addictive behaviour. One such definition is that of Marlatt, Baer, Donovan,

and Kivlahan (1988, p. 224), who define addictive behaviour as:

…a repetitive habit pattern that increases the risk of disease and/or associated personal

and social problems. Addictive behaviours are often experienced subjectively as ‘loss of

control’ – the behaviour contrives to occur despite volitional attempts to abstain or

moderate use. These habit patterns are typically characterized by immediate gratification

(short term reward), often coupled with delayed deleterious effects (long term costs).

Attempts to change an addictive behaviour (via treatment or self initiation) are typically

marked with high relapse rates.

In addition, it has been argued that addiction is most usefully described as a process

(Krivanek, 1988), with involvement in addictive behaviour being placed upon a spectrum

of severity of use and abuse (McMurran, 1994). The boundaries of this formulation are

flexible enough to include both substance and non-substance behaviours and to account for

the inclusion of a wide variety of influencing factors. However, on an ethical level, the

emphasis on the ‘subjective experience’ of loss-of-control means that the above definition

does not locate the problem entirely within the individual concerned, but nor does it

preclude our attribution of some responsibility to that individual.

It is also important to acknowledge that the meanings of ‘addiction’, as the word is

understood in both daily and academic usage, are contextual, and socially constructed

(Howitt, 1991; Irvine, 1995; Truan, 1993). We must ask whether the term ‘addiction’

actually identifies a distinct phenomenon – something beyond problematic behaviour –

whether socially constructed or physiologically based. If so, what are the principal features

of this phenomenon? If we argue that it is hypothetically possible to be addicted to

anything, it is still necessary to account for the fact that many people become addicted to

alcohol but very few to gardening. Implicit within our understanding of the term ‘addiction’

is some measure of the negative consequences that must be experienced in order to justify

the use of this word in its academic or clinical context. It seems reasonable at this stage to

suggest that a combination of the kinds of rewards (physiological and psychological) and

environment (physical, social and cultural) associated with any particular behaviour will

have a major effect on determining the likelihood of an excessive level of involvement in any

particular activity.

The way of determining whether non-chemical (i.e. behavioural) addictions are addictive

in a non-metaphorical sense is to compare them against clinical criteria for other

established drug-ingested addictions. This method of making behavioural excesses more

clinically identifiable has been proposed for behavioural addictions such as ‘television

addiction’ (McIlwraith, Jacobvitz, Kubey, & Alexander, 1991) and ‘amusement machine

addiction’ (Griffiths, 1991, 1992). Further to this, authors such as Brown (1993) and

Griffiths (1996) have postulated that addictions consist of a number of common

components. Griffiths’s (1996) components of addiction (modified from Brown, 1993)

192 M. Griffiths

 

 

are salience, mood modification, tolerance, withdrawal, conflict and relapse. These are

described in more detail below with some relevant examples.

Salience

This refers to when the particular activity becomes the most important activity in the

person’s life and dominates their thinking (preoccupations and cognitive distortions),

feelings (cravings) and behaviour (deterioration of socialized behaviour). For instance, even

if the person is not actually engaged in the behaviour they will be thinking about the next

time they will be. Three separate quotes from Griffiths’s (1995) studies of slot machine

addicts highlight the concept of salience in gambling:

If I wasn’t actually gambling I was spending the rest of my time working out clever little

schemes to obtain money to feed my habit. These two activities literally took up all my

time (Extract 1, p. 253).

Gamble, gamble, gamble your life away…you might as well have put it down the

drain. You’ve got to face the truth that you’re having a love affair, and it’s with a

machine whose lights flash, takes your money and kills your soul (Extract 2, p. 253).

During four or five years of compulsive gambling I think I missed about six or seven

days of playing fruit machines – keeping in mind that about four or five of those days

were Christmas days where it was impossible to gain access to a gambling machine…As

you have probably gathered, I ate, slept and breathed gambling machines…I couldn’t

even find time to spend with the people I loved…The machines were more important

than anything or anyone else. All I can remember is living in a trance for four years…as if

I’d been drunk the whole time (Extract 3, p. 253).

It should also be noted that some addictive behaviours such as smoking (nicotine) and drinking

(alcohol) are activities that can be engaged in concurrently with other activities and therefore do

not tend to dominate an addict’s thoughts or lead to total preoccupation. For instance, a

smoker can carry around their cigarettes and still engage in other day-to-day activities.

However, if that person was in a situation that they were unable to smoke for a long period

(such as a 24-hour plane flight), smoking would be the single most important thing in that

person’s life and would totally dominate their thoughts and behaviour. This is what could be

termed ‘reverse salience’ with the addictive activity becoming the most important thing in that

person’s life when they are prevented from engaging in the behaviour.

Mood modification

This refers to the subjective experience that people report as a consequence of engaging in

the particular activity (i.e. they experience an arousing ‘buzz’ or a ‘high’ or paradoxically a

tranquillizing and/or destressing feel of ‘escape’ or ‘numbing’). What is interesting is that a

person’s drug or activity of choice can have the capacity to achieve different mood-

modifying effects at different times. For instance, a nicotine addict may use cigarettes first

thing in the morning to get the arousing ‘nicotine rush’ they need to get going for the day.

By the end of the day they may not be using nicotine for its stimulant qualities, but may in

fact be using nicotine as a way of destressing and relaxing. It could be argued that in these

situations, psychology to some extent overrides physiology because of expectation effects.

‘Components’ model of addiction 193

 

 

In essence, many addicts use substances and behaviours as a way of producing a reliable

and consistent shift in their mood state as a coping strategy to ‘self-medicate’ and make

themselves feel better in the process. Such mood-modifying experiences are also common

in many behavioural addictions such as gambling. These have included both subjective self-

reports from interviews and questionnaires (Dickerson, & Adcock, 1987; Griffiths, 1990)

and objective experimental studies that have measured heart rate as an indicator of arousal

(Griffiths, 1993; Leary, & Dickerson, 1985).

Tolerance

This refers to the process whereby increasing amounts of the particular activity are required

to achieve the former effects. The classic example of tolerance is a heroin addict’s need to

increase the size of their ‘fix’ to get the type of feeling (e.g. an intense ‘rush’) they once got

from much smaller doses. In gambling, tolerance may involve the gambler gradually having

to increase the size of the bet to experience a mood-modifying effect that was initially

obtained by a much smaller bet. It may also involve spending longer and longer periods

gambling. Tolerance is well established in psychoactive substance addictions and there is

growing evidence in the field of behavioural addictions.

For instance, Griffiths (1993) appeared to show that tolerance could be observed in an

experimental situation involving gamblers. He found that both regular and non-regular slot

machine gamblers’ heart rates increased significantly during the playing period by

approximately 22 beats per minute. However, the interesting finding was that after playing

slot machines, regular gamblers’ heart rates started to decrease at once, whereas non-

regular gamblers’ heart rates did not change significantly. In terms of an addictive model of

gambling, both regular and non-regular gamblers get a ‘high’ physiologically when playing,

but the non-regular gamblers stay ‘higher’ for longer, meaning they do not have to gamble

as fast or as often to induce the arousal peaks. Regular gamblers, in contrast, could be seen

as becoming more tolerant to the gambling ‘highs’, meaning they have to gamble either

faster or more often to experience the initially desired effect. It was argued by Griffiths

(1993) that the study could be viewed as the first to show an objective measure of tolerance

in gambling.

Withdrawal symptoms

These refer to the unpleasant feeling states and/or physical effects which occur when the

particular activity is discontinued or suddenly reduced. Such withdrawal effects may be

psychological (e.g. extreme moodiness and irritability) or more physiological (e.g. nausea,

sweats, headaches, insomnia and other stress-related reactions). Withdrawal effects are well

documented in drug addictions (Orford, 2001) and there is growing evidence that

behavioural addictions such as pathological gambling also feature withdrawal symptoms

(Griffiths, 2004). For instance, Rosenthal and Lesieur (1992) found that at least 65% of

pathological gamblers reported at least one physical side-effect during withdrawal including

insomnia, headaches, upset stomach, loss of appetite, physical weakness, heart racing,

muscle aches, breathing difficulty and/or chills. Their results were also compared to the

withdrawal effects from a substance-dependent control group. They concluded that

pathological gamblers experienced more physical withdrawal effects when attempting to

stop than the substance-dependent group.

194 M. Griffiths

 

 

Conflict

This refers to conflicts between the addict and those around them (interpersonal conflict)

or from within the individual themselves (intrapsychic conflict) which are concerned with

the particular activity. Continual choosing of short-term pleasure and relief leads to

disregard of adverse consequences and long-term damage which in turn increases the

apparent need for the addictive activity as a coping strategy. The conflict in the addict’s life

means that they end up compromising their (1) personal relationships (partner, children,

relatives, friends, etc.), (2) working or educational lives (depending on what age they are)

and (3) other social and recreational activities. Intrapsychic conflict may also be

experienced in the form of addicts knowing that they are engaged heavily in the behaviour

and want to cut down or stop – but find they are unable to do so, experiencing a subjective

loss of control.

Relapse

This refers to the tendency for repeated reversions to earlier patterns of the particular

activity to recur and for even the most extreme patterns typical of the height of the

addiction to be quickly restored after many years of abstinence or control. The classic

example of relapse behaviour is in smokers who often give up for a period of time only to

return to full-time smoking after a few cigarettes. However, such relapses are common in all

addictions including behavioural addictions such as gambling (Griffiths, 2002).

Griffiths (2002) has argued that all these components need to be present for a behaviour

to be operationally defined as addictive. It is clear that some individuals engage in

behaviours that have addictive elements without it necessarily being a full-blown addiction.

For instance, if someone has no negative withdrawal effects after stopping their excessive

behaviour, are they really addicted? If the excessive behaviour does not conflict with

anything else in that person’s life, can it be said to be an addiction? The difference between

an excessive healthy enthusiasm and an addiction is that healthy enthusiasms add to life

whereas addictions take away from it.

Addictions always result from an interaction and interplay between many factors

including the person’s biological and/or genetic predisposition, their psychological

constitution (e.g. personality factors, unconscious motivations, attitudes, expectations

and beliefs, etc.), their social environment (i.e. situational characteristics) and the nature of

the activity itself (i.e. structural characteristics) (Griffiths, 1999). These many factors

highlight the interconnected processes and integration between individual differences (i.e.

personal vulnerability factors), situational characteristics, structural characteristics and the

resulting addictive behaviour. Each of these three general sets of influences (i.e. individual,

structural and situational) can be subdivided much further depending on the type of

addiction.

It is clear that many research paradigms are insular and inadequate in explaining

addiction. Addiction is a multifaceted behaviour that is strongly influenced by contextual

factors that cannot be encompassed by any single theoretical perspective. These factors

include variations in behavioural involvement and motivation across different demographic

groups, structural characteristics of activities/substances and the developmental or

temporal nature of addictive behaviour. Research and clinical interventions are best served

by a biopsychosocial approach that incorporates the best strands of contemporary

psychology, biology and sociology.

‘Components’ model of addiction 195

 

 

Griffiths and Larkin have suggested there are core components of what a successful

theory of addictions should contain (Griffiths, & Larkin, 2004; Larkin, & Griffiths, 1998).

A successful theory must (1) synthesize pharmacological, cultural, situational and

personality factors, (2) account for the varying nature of addiction across cultures,

individuals and time, (3) account for commonalities between all addictions and (4) be

faithful to lived human experience.

Larkin and Griffiths (1998; Griffiths, & Larkin, 2004) have also argued the case for a

complex systems model of addiction: ‘complex’ for obvious reasons, and ‘systems’ after

Davies (1992, p. 163), who argued that alternative explanations for excessive behaviour

require:

…the development of a ‘system’ within which drug use is conceived of as an activity

carried out for positive reasons, by people who make individual decisions about their

substance use, and who may take drugs competently as well as incompetently.

Gambino and Shaffer (1979) have emphasized the difficulties of reintegrating research and

practice in the area of addiction. On the basis of Polkinghorne’s (1992) observations on the

nature of such divisions, a more flexible theoretical approach, such as the complex systems

model, ought to go some way toward bridging the epistemological gap.

The complex systems model corresponds well to the biopsychosocial approach to

addiction (e.g. Marlatt et al., 1988; McMurran, 1994). It may also be considered to be a

descendant of previous multifactorial approaches to the addiction process (e.g. Wanberg, &

Horn, 1983; Zinberg, 1984). Obviously, from the perspective of the complex systems

model, it is possible to consider the interaction of both the common and the unique

elements of any specific individual’s situation. This includes psychological, physiological,

social and cultural factors that may be particular to any individual. It also allows for

consideration of the pharmacological properties of specific substances, or the reinforcing

properties of certain kinds of gaming machines (see Griffiths, 1995). It is important,

therefore, to point out that this is not a return to siting the property of ‘addictiveness’ as

located within particular substances (or within particular activities). However, it is

necessary to be aware of effects that may be common to certain kinds of substances or

activities, but not to others.

Hopefully, what this paper has demonstrated is that addictions are a part of a

biopsychosocial process and not just restricted to drug-ingested behaviours. Evidence is

growing that excessive behaviours of all types do seem to have many commonalities and this

may reflect a common aetiology of addictive behaviour. Such commonalities may have

implications not only for treatment of such behaviours but also for how the general public

perceive such behaviours.

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