EXAMINATION OF THE DISORDERS

 

In viewing behavior as excessive, we might readily ask by what means or standard does one judge behavior as abnormal or deviant? The direct simple approach would be to consult the American Psychiatric Association's Manual of Mental Disorders (DSM-IIl). A more pragmatic approach would be simply to determine whether the behavior is harmful to the individual (deleterious medical consequences), to society (violence, stealing, impaired driving, financial dependency) or a combination of both. Once a consensus is achieved then the object of the exaggerated behavior (ie, the volitional disorder itself) may be examined (Table 1). The question is what factors or forces control the chosen excessive behavior (drugs, food, gambling, sex, work, etc.)? Does environment, socioeconomic status, position, education, and genetics contribute to the disorder engaged? Is the choice of activity solely conscious or does the unconscious play a role? However chosen, it certainly appears that the individual does not normally "decide" to become drug dependent or alcoholic or obese, etc, but in all probability over time and through continued reinforcement falls into the excess pattern which culminates in, at the very least, a psychic dependency.

The question is of course whether a commonality of processes exists between the various forms of excessive behavior (Table 2). If so, what are the shared properties and characteristics (etiological, biological, sociological, psychological) of the various volitional disorders (Table 3)? If a common thread or denominator runs through the affected individuals, then one might expect as commonplace the substitution of one substance for another (eg, methadone for heroin), or the excessive use reliance or dependence on several substances at the same time (heroin, alcohol, tobacco, marihuana, stimulants), or one behavioral disorder for another (overeating for smoking), or involvement in a plethora of overactive behaviors in the realms of drinking, eating, smoking, sex, gambling, etc, simultaneously. If such a commonality between behavior patterns in fact does occur, then a general theory might identify and provide a cogent explanation for the underlying cause of the exaggerated behaviors. Thus, the volitional disorders may simply be the end result of a conflict between internal and external forces (Table 4); such as: (a) predisposition (genetic, nutrition, sociocultural, socioeconomic, temperament); (b) environment (the external surroundings may enhance or inhibit the predisposing forces); (c) fortifications (behavior is reinforced through repetition and interactions of a pharmacological, biochemical, psychological or sociological nature); (d) tolerance (continued interaction of the substance or exaggerated behavior with the physiological system); (e) physiochemical adjustment (homeostatic mechanisms require continued substance use or excessive activity to prevent a negative adjustment in the system); (f) abstinence (withdrawal symptoms occur when the level of substance use or activity is insufficient to maintain the dependent state); (g) hypophoria (negative feeling states relieved by excessive behavior).

 

An example of how the excessive behavior occurs might be provided by the socioeconomically deprived ghetto youngster who becomes involved with heroin use through peer pressure and finds such use an acceptable means of alleviating negative personal feelings (anxiety, insecurity, hostility, frustration) allowing him to "feel good" about himself and his environment. On the other hand a middle class Irish Catholic white male may resort to excessive alcohol use as the preferred vehicle for alleviating his hypophoric state and thus capture the same "feel good" aura. It is of course not difficult to draw similar profiles for overeaters, excessive smokers, anorexics, compulsive gamblers, compulsive and excessive sport activists, overworkers, and television addicts. It the etiology of the volitional disorders (Table 5) can be identified irrespective of the chosen excessive behavior, then an effective therapeutic remedy can be found. Hopefully, a basic therapeutic modality might unfold allowing for a direct attack at the psychic source of the disorder, leading to an extinction of the outward exaggerated behavioral expression. The modality must also be capable of altering or assisting in correcting the physiological as well as the socioeconomic correlates of the disorder.

It is worthwhile to comment at this point on the various components which may characterize the volitional disorders (Table 6). These appear to be an illusionary conception of an exalted superior state (grandiosity). Hypophoria, compulsivity, obsession, and loss of control over one's behavior; also depression, insecurity, frustration and anxiety may be present.

 

Oftentimes, failure to control impulses and obsessional difficulties result in excessive behavior (eg, drinking bouts and binge eating) that allows one for the moment to overcome personal inadequacies and resort to illusionary powers with the concomitant fulfillment of a fantasy life (grandiosity). Of course if all control is lost then euphoric grandiosity may occur in the fantasies of a complete intoxicated state.

 

Although some components of the volitional disorders may be described, not all aspects of this extremely complex problem are known. An extensive multifaceted effort (psychological, biochemical, pharmacological, economical, sociological) is required to gain full insight into the nature of these disorders. However, at present millions of individuals suffer at some dysfunctional level from these exaggerated behaviors and often require treatment which must take into consideration the physiological, psychological, and socioeconomic aspects of the problem, but the key to effective therapy is the inner dynamics of the compulsion. In most cases the physiological component of the excessive behavior and the socioeconomic issues can be suitably rectified. The dilemma of course is how can one overcome by sheer willpower the behavior, when the inherent defect is also part of the function. Thus, the compulsions and obsessional difficulties cannot be readily resolved merely by calling upon one's will, determination, and inner strength. The inner dynamics or the psycho-dynamics as I have suggested must be fully understood to successfully treat and resolve the disorder, then and only then might the individual be able to effectively abandon the excessive behavior.

 

TREATMENT

 

Let us now examine the various therapeutic modes available for the volitional disorders (Table 7). Certainly the need to alter excessive behavior through behavioral modification (Kokes, 1981) seems obvious. Some success can be obtained with individuals placed in a well-designed multiple component treatment program which involves contingency management, relaxation training, desensitization, covert sensitization, and self-control techniques. It is also important for treatment of this kind that the patient not exhibit signs of chronic psychopathology (ie, psychopath, sociopath). Behavioral therapy, even if not fully effective, is often very useful in the development of behaviors necessary for life management outside the treatment setting.

An extremely interesting theoretical approach to the understanding of volitional disorders is Solomon's opponent-process theory of motivation (Solomon, 1977) in which an initial arousal or response to stimuli is followed by an opposite or opponent process. Unfortunately, the opponent-process system of motivation presents an extremely difficult therapeutic challenge because of the enormous variety of influences that sustain it.

A rather obvious approach to the treatment of excessive behaviors has been suggested by Falk (1981) in which the environment generates and sustains the exaggerated behavior. Therefore, an alteration in the environment, the removal of its conditions, or lastly a total change in the environment should be sufficient to provide the necessary therapy to alter the excessive activity. The difficulty with this approach is that the problem is multifaceted and therefore, not easily resolved by altering one condition.

 

Some success in treating these problems has been achieved by the various anonymous organizations, (A.O.) such as: alcoholics, obesity, and gambling. These organizations all emphasize the need to rely on a spiritual being or supernatural power for the necessary strength to overcome the exaggerated behavioral activity. In addition to the A.O.s, various drug-free therapeutic communities have also achieved a measure of effectiveness through the combined efforts of both staff and clients in rehabilitating drug abusers.

 

The major chemotherapeutic approaches as you well know are: opiate agonist (eg, methadone); opiate antagonist (eg, naltrexone); agonist-antagonist (eg, buprenorphine); and the use of major and minor tranquilizers. Some success has been achieved using the drug therapy technique in treating drug abusers, depending somewhat on the criteria used for rehabilitation in a given program.

 

A valid treatment program for the volitional disorders as indicated previously must be approached from three points of view, (Table 8) namely: (a) physiological, (b) psychological, and (c) socioeconomic (Saltzman, 1980; Wurmster, 1972).

 

Some addictions like drugs, alcohol, and food, involve all three factors. Others like compulsive sports, compulsive gambling, and overworking seem to be exclusively tied to psychological elements. The psychological factors, however, must transcend and permeate the total program since it is the inner motivational forces that initiate and sustain the disorder and lays the groundwork for the substitution of one behavior for another.

 

Wurmser (1972) described the interacting facets of the etiology of drug dependence (see Table 5) with a series of six concentric circles: (a) inner problems, (b) family, (c) peer group, (d) society, (e) cultural values, and (f) philosophical problems. The first five relate to psychosocial factors and confirm the impression that psychodynamic insight must be present in the therapy program. An overemphasis on the psychological factors however without altering the physiological or socioeconomic aspects would achieve minimal results with maximum outlays of money.

 

As with all compulsions, external force, persuasion, threat, humiliation or punishment cannot undo the disorder which has inner dynamics that must be exposed and understood. The addict must be aware of his grandiosity and accept some limitations thereof and commitments to realistic potentials. There is a need to develop techniques for dealing with feelings of powerlessness and helplessness other than through compulsive rituals and illusory feelings of strength and power.

 

The question again is how does one use determination and will to overcome defects when such defects are due to a disorder of the will; and where the focus and preoccupation on the goal interferes with its attainment? Thus, in the case of compulsion neurotics, they must be healed with the aid of functions that are themselves affected by the disorder. The technique of paradoxical intention, may be useful in this regard since, the destructive behavioral disorder can be overcome by advising and encouraging its persistence. Paradoxically such an emphasis can result in the abandonment of the symptoms. Paradoxical intention is occasionally successful because apparently it removes the focus from overcoming the symptoms, to an exaggeration of them.

 

Generally, the individual does not enter treatment to terminate the disorder but to get help in making it tolerable or to be relieved of the exhausting effort to maintain it. To abandon compulsive behavior is a matter of finally recognizing one's personal helplessness with the problem. By giving up absolute control over the compulsive behavior reasonable controls may be exerted without grandiose pretensions of invulnerability. The recognition of one's powerlessness cannot be simply verbal, it must go much deeper since, it is the compulsive's verbal capacity that allows circumvention of commitments and maintenance of grandiosity, thereby never really accepting a deficiency.

 

The achievements of Alcoholics Anonymous illustrate this point even though its success has often been justified by the assumption of a spiritual order rather than psychological readjustments. The process of "surrender" in AA involves the alcoholic's recognition of the compulsive nature of drinking, and the inability to resolve it by will.

 

Efforts to force or encourage the addict to relinquish the compulsion by willpower, persuasion, moral injunction, etc, will be of no avail. Support for undoing the compulsive behavior must come through the simultaneous recognition of an inner strength and the ability to do so by the combined utilization of physiological, psychological, and socioeconomic resources. Under these conditions an individual may be able to strengthen his capacities for decisive commitment and determined effort to function without the use of chemicals or compulsive rituals. The psychodynamics of excessive behavior, therefore, constitutes the overall umbrella under which all modalities of treatment must operate in order to be successful.

 

REFERENCES

 

Falk JL: The environmental generation of excessive behavior. In: SJ Mule (ed.),

Behavior in Excess: An Examination of the Volitional Disorders. New York: Free Press, 1981 (in press)

Kokes RF: Behavior therapy in the treatment of behavior in excess. In: SJ Mule (ed.), Behavior in Excess: An Examination of the Volitional Disorders. New York: Free Press, 1981 (in press)

Mule SJ: Introduction. In: SJ Mule (ed.), Behavior in Excess: An Examination of the Volitional Disorders. New York: Free Press, 1981 (in press)

Saltzman L: Psychodynamics of the addictions. In: SJ Mule (ed.), Behavior in Excess:

An Examination of the Volitional Disorders. New York: Free Press, 1981 (in press) Saltzman L: Treatment of the Obsessive Personality. New York: Aronson, 1980 Solomon RL: An opponent-process theory of acquired motivation: IV. The affective

dynamics of addiction. In: JD Maser and MEP Seligmans (eds.), Psychopathology

Experimental Models. WH Freeman Co., pp 66-103, 1977

Wurmster L: Drug abuse-nemesis of psychiatry. Int J Psychiatry 10:94-107, 1972