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One way that many mental health researchers conceptualize the development of some particular type of disorder is the use of a stage model of development.
Stage models of development have been extremely popular in the fields of psychology and sociology for decades, and they have been used to explain how many types of attributes progress over time. One of the first psychological stage models of human development came from Sigmund Freud where he outlined his famous stages of human personality development (e.g., oral stage, anal stage, etc.). Other stage models of development have attempted to outline the development of numerous physical, emotional, and mental factors.
- First, the stages are relatively discrete. There are specific boundaries that can identify at what stage in the development of some function or condition an individual is. These boundaries may not always be clear, but in theory, they are discrete and apart from one another.
- Stage models of development assume that people progress through the stages in a specified order, and the order is generally the same for everybody. Of course, there is always some individual variation that occurs in development; however, the order of the stages and the manner through which individuals progress through them is relatively stable.
- The specific stages in the model can be identified by factors that signal that the individual is in that stage. Each stage has at least one specific attribute or skill that sets it apart from the stages that occur prior to it.
However, scholarly theorists of behavior (particularly psychologists) point out that these models have a number of limitations, and they do not always fully describe the development of an attribute, a specific behavior, or a disorder.
There are numerous stage models that attempt to explain the development of addictive behaviors. Many of these models originally described the development of alcoholism or alcohol use disorders. Several of the more prominent models are discussed below.
The Jellinek ModelEven though the model is fraught with flaws and lacks research support, one of the most popular models of the development of addictive behavior is the Jellinek model. The Jellinek model gained popularity with individuals in Alcoholics Anonymous and has been applied to a number of other 12-Step programs and other substance use disorders and behavioral addictions.
- M. Jellinek was a physiologist who was interested in the development of alcoholism. He proposed the following progression of alcoholism:
- The pre-alcoholic phase: In the pre-alcoholic phase, the person begins drinking alcohol in social situations and begins to associate alcohol use with other benefits, such as a reduction of stress or tension. The person may begin to use alcohol to address these types of situations and may begin to develop tolerance to it. Some individuals will have a predisposition to alcoholism and will eventually move on to the next phase.
- The prodromal stage: In the prodromal stage, the person begins to drink alcohol as a coping mechanism and starts to display certain symptoms, such as increasing consumption of alcohol, frequent hangovers, and blackouts. The presence of blackouts signifies this stage from the prior stage. Jellinek believed that at this stage, the individual still exhibited a certain amount of control over their alcohol use despite these very serious symptoms.
- The crucial phase: When the person reaches the crucial phase of alcoholism, several events have occurred (loss of control is the defining factor in this stage):
- The person no longer has control over their drinking. When they begin drinking alcohol, they cannot stop.
- Because the person has lost control of their alcohol use, they make excuses for their drinking.
- The person attempts to control their drinking by establishing specific guidelines as to when they can and cannot use alcohol, although these guidelines rarely work.
- The person begins to experience problems with physical health and mental functioning, and may even be hospitalized.
- The person begins to use alcohol just to get through the day, such as taking a drink first thing in the morning, having a set drinking routine at work, and drinking at specific time periods.
- The above routine is often an attempt to cope with the development of both tolerance to alcohol and withdrawal symptoms (the onset of physical dependence).
Jelinek also outlined five types of alcoholics, such as the alpha alcoholic, beta alcoholic, gamma alcoholic, etc. This basic stage model originally outlined by Jellinek has also been adapted by a number of other organizations as a general outline for the development of addictive behaviors.
This model of addiction is extremely popular in the 12-Step community and has been adopted to explain a number of different types of addictive behaviors. However, the model has serious flaws in both its content and its methodology.
First, Jellinek used a very small sample of AA members to validate the stages in his model. Most of these individuals already believed his hypothesized progression of alcoholism. His data collection and data analysis was extremely biased. Second, a number of the signature markers in the stages, such as blackouts, a complete loss of control over alcohol use, etc., are not universally recognized in individuals who may even have severe alcohol use disorders. In addition, Jellinek’s original model did not apply to women who may actually demonstrate a slightly different progression in addictive behaviors than men. Finally, there is very little empirical research evidence to support Jellinek’s model of the development and progression of alcoholism or his different types of alcoholics.
Dr. George E. Valliant was a psychiatrist who specialized in addiction, particularly addiction to alcohol. Valliant developed a very simple approach to conceptualizing the development of alcoholism (and hence addiction) in his classic works The Natural History of Alcoholism and a later revision The Natural History of Alcoholism Revisited. The approach describes three general stages:
- Asymptomatic use (asymptomatic drinking): In the initial stage, an individual typically uses alcohol or other drugs in social settings or at specific gatherings and may not experience issues with control or use of the drug. They may sometimes overindulge and may experience hangovers or other ramifications of their occasional overindulgence; however, this is not normal for them and occurs only occasionally.
- Abuse: Some people will begin to use alcohol or a drug to help them deal with specific problems they face. Often, these problems include stress in their relationships or at work, psychological problems like depression, as a means to escape, etc. When these people begin to misuse alcohol or drugs in this manner, they begin to also experience negative ramifications associated with their use of drugs or alcohol. The person views their drug use as important to them despite these negative and stressful ramifications associated with their drug use.
- The alcohol-dependent (or drug-dependent) person: When a person has developed a specific addiction, such as alcoholism, they demonstrate four specific symptoms:
- Marked tolerance to their drug of choice
- The development of withdrawal symptoms when they are not able to use the drug
- A loss of control over their drug use, such that they are unable to predict how much of the drug they will take once they start using it
- Significant impairment in life (particularly in work, relationships, and physical health)
As one may gather from Valliant’s three-stage model, the progression also parallels the general diagnostic scheme used in the diagnosis of substance use disorders and behavioral addictions. Because the model is very general, simple, and has significant diagnostic validity, the model became quite popular in formal psychological and psychiatric circles. However, the current conceptualization of substance use disorders does not require the development of physical dependence (tolerance and withdrawal) for an individual to be diagnosed with even a serious substance use disorder. One of the reasons for this is during Valliant’s time, the number of drugs that were considered to be “addictive” were far fewer in number then in the current era; hence, addictive behaviors were often defined by the development of physical dependence. Thus, while the model is simple, descriptive, and had diagnostic utility at one time, many people who are diagnosed with substance use disorders these days would not follow the progression associated with this stage model, as they do not develop significant issues with withdrawal symptoms.
Over the last two decades, the development of neuroimaging techniques has led to a whole different approach to conceptualizing human development. Instead of looking specifically at behavior, many researchers use animal models, behavioral studies of people, and neuroimaging studies to help them explain how specific mental health disorders may develop.
A recent model that strongly resembles a reworking of Valliant’s model came from addiction researchers Nora D. Volkow, MD; George F. Koob, PhD; and A. Thomas McLellan, PhD, and it is heavily based on neurobiological studies of individuals with certain types of addictions and on animal models of addiction. The researchers separate the current diagnostic terminology used in the diagnosis of addictive behaviors, substance use disorder, as being separate from their personal definition of addiction, which is the most severe presentation of a substance use disorder where the individual has no control over their drug use despite a complete lack of research evidence to suggest that these two categories actually exist and that individuals diagnosed with even the most severe substance use disorders have absolutely no control over their substance use. Nonetheless, the researchers propose the following three stages associated with their definition of addiction (but not of substance use disorders):
- Binge and intoxication: This stage model also has similarities to the model of classical conditioning used by Ivan Pavlov; readers may recall the story of Pavlov’s dogs that is taught as part of any introductory psychology class. Using an addictive drug leads to a release of dopamine in the brain that signifies the drug as rewarding. Over time, the brain learns to associate the reward and the environmental stimuli that occur with its presentation (the drug use and other closely associated events).
When a person keeps using drugs, their brain often becomes activated by associations that occur when the individual uses drugs. Like Pavlov’s dogs who learned to salivate at the ringing of a bell when food was presented with a bell, individuals who have addictions begin to experience cravings when they are reminded or have any associations of the rewarding effects of their drug use. These cravings are primarily neurobiological nature and represent the changes in the brain that occur as a result of the normal process of learning and as a result of the alterations that repeated drug use enforces on the brains of these individuals.
- Withdrawal and negative affect: As the person chronically uses their drug of choice, the brain adjusts such that they find it difficult to experience enjoyment or pleasure at the same level they once did. This includes their use of the drug or engaging in other activities that they once enjoyed. On the other hand, sensitivity to negative stimuli is increased. This includes sensitivity to withdrawal symptoms. This decrease in the inability to experience pleasure and increase in negative emotional states results in the person’s drug use primarily being fueled by an attempt to avoid negative symptoms, such as cravings and withdrawal.
The explanation and the features that occur in this stage are heavily borrowed from an earlier theory of addictive behaviors known as the incentive sensitization theory. Again, the changes are primarily due to alterations in an individual’s neurobiology that occur as a result of interaction between experience and physiology.
- Preoccupation and anticipation: Over time, the individual becomes focused on their drug use, satisfying cravings and avoiding negative feelings. As the person uses more and more of the drug, it also affects other areas of the brain, including areas associated with decision-making, behavior regulation, and the ability to monitor behavior objectively. These changes explain many of the irrational types of behaviors that individuals use to explain their drug use and to continue to rationalize and engage in such use.
The major issue with this stage model is it that it describes the behavior of a very circumscribed group of individuals with severe substance use disorders and significant physical dependence. The model is not applicable to the majority of individuals who are diagnosed with substance use disorders (even those who may be diagnosed with severe substance use disorders). The model relies heavily on the development of physical dependence, and even individuals who are diagnosed with severe substance use disorders may not develop significant physical dependence to drugs or alcohol. Moreover, if any form of addiction at any level is primarily a neurobiological event then individuals who attempt to recover from addictions would find the best available forms of treatment, such as therapy, support group participation, etc., useless as their brains have been rewired to the point where they can no longer choose not to use drugs. Even all of the assistance and support of others would not significantly help individuals whose brains drive them to choose to use drugs and whose brains do not allow them not to make a choice not to use drugs.
While many theorists now view addiction as a disease, these theorists view the disease model of addiction as an extreme manifestation of purely biological events that rob a person of their reasoning abilities. This model has little diagnostic utility and most likely explains the behavior of a very small proportion of individuals with substance use disorders.
Some General Problems with Stage Models of AddictionThe most popular stage models of addiction remain focused on the development of physical dependence as the driving force in the maintenance of addictive behaviors. Physical dependence is often viewed as a biological change in the person’s central nervous system. These changes result in an individual being unable to make rational choices. While it is certainly true that chronic drug abuse does result in significant brain alterations, individuals still retain some important aspects of choice unless they suffer significant global brain damage.
There are no formal diagnostic neurobiological markers that can diagnose any substance use disorder or any level of substance abuse (e.g., levels of mild, moderate, severe, extremely severe, etc.). Thus, any hypothesized neurobiological changes that may occur in individuals who have even the most severe forms of substance abuse cannot be used to delineate the stages of addiction hypothesized by the researchers. Moreover, a number of other sources point out that many individuals with even severe addictions choose to change their behavior once they are motivated to do so (see Addiction: A Disorder of Choice; Choice, Behavioral Economics, and Addiction).
Very often, clinical researchers suffer from a cognitive bias referred to as “the clinician’s illusion” where clinicians who most often see extreme cases attempt to make generalizations based on extreme aspects of behavior and significant dysfunction. Often, these theories do not apply to the majority of individuals who are actually diagnosed with substance use disorders. For instance, epidemiological research has consistently found that the majority of individuals who were once diagnosed with substance use disorders and who report successfully changing their behavior have done so by choosing to no longer engage in their drug use to the extent that they did previously.
There are numerous different stage theories that attempt to explain the progression of an addiction. Even the most popular and most recent of these theories have a number of significant flaws. However, based on the above stage models, it can be surmised that the development of a substance use disorder (addiction) in most individuals occurs over the following general course:
- It begins with a period of occasional or recreational use.
- It progresses to increased use of the substance as a method to cope with some perceived deficiency, some form of stress, or to escape.
- Escalating use of a substance begins to interfere with the individual’s health or normal functioning. This may lead to the development of issues controlling use of the drug, such that the individual continues to use the drug even though such use results in a number of different negative ramifications for them. Often, these individuals do not believe they are having issues with controlling their use of the drug and rationalize such use.
- Some individuals continue their drug use in spite of very clear signs that it has resulted in significant impairment or dysfunction in important aspects of life. These signs include issues with the legal system, issues with their career or education, relationship issues, financial issues, and/or physical and mental health issues. Some of these individuals may continue to rationalize their drug use even though it is clear that it is resulting in major problems.
- Some individuals eventually begin to realize that their drug use is problematic for them, though many do not.
- The development of tolerance and withdrawal may occur in the middle to later stages of this process, but it occurrence is neither necessary nor sufficient to indicate that the individual has developed any form of substance use disorder. However, the development of physical dependence nearly always exacerbates the issues associated with substance abuse and results in the cycle of addiction being more difficult to overcome.
One of the interesting observations regarding these theories is that the stage theories of recovery or change are far better developed than the stage theories that attempt to describe how an addiction develops in the first place. Perhaps one reason for this is that the development of addictive behaviors across individuals has quite a bit of individual variation, whereas recovery from substance use disorders or addictive behaviors typically follows a very set and general template.
The Health Complications of Addiction
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