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)
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
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)
2. 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)
3. 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 = ___
1. 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/
___ 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
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)
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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