Frank S H
Department of Family Medicine, Case Western Reserve University, School of Medicine, Cleveland, Ohio.
Fam Pract. 1993 Mar;10(1):23-33. doi: 10.1093/fampra/10.1.23.
Most issues of emotional health seen in primary care do not fit standard psychiatric labelling. An integrative model is described for understanding the relationships between stress, control and dependent behaviours with clinical utility for primary care. In this model, expectations disease occurs when expectations consistently disable rather than enable. This clinical diagnosis is characterized by five disorders of control which contribute to recurring episodes of loss of control. Disorders of control include, 1) unmet or excessive need for control, 2) impaired recognition of controllability, 3) misattribution of control, 4) control dissimulation and 5) fear of loss of control. Definitions and behavioural consequences for each control disorder are described. Loss of control is defined as a cascade of behaviours invoked to avoid or diminish chaotic or dissonant thinking through actions one would not deliberately choose (or not choose to the same degree) while feeling in control. Examples of loss of control include substance abuse, anger (rage or violence), binge behaviours (eating, shopping, gambling, sex, overwork), depression, panic and somatization. Loss of control paradoxically results in a transient sense of relief or shift of focus from the problem stimulus, but inevitably creates further problems over time. Expectations disease is determined not by the presence or absence of control disorders, but by the degree to which these problems exist--their chronicity, intensity and rigidity. For some, this disorder may be acute or intermittent, for others chronic; for some, a nuisance, for other, disabling. Short-term intervention for patients who present with clear distress, but unclear diagnosis is discussed. Advantages and disadvantages of the model are detailed.
初级保健中出现的大多数情绪健康问题并不符合标准的精神病学标签。本文描述了一种综合模型，用于理解压力、控制和依赖行为之间的关系，对初级保健具有临床实用性。在这个模型中，当期望持续导致功能失调而非发挥促进作用时，就会出现期望疾病。这种临床诊断的特征是五种控制障碍，这些障碍会导致反复出现的失控发作。控制障碍包括：1）未满足或过度的控制需求；2）对可控性的认知受损；3）控制的错误归因；4）控制伪装；5）对失去控制的恐惧。文中描述了每种控制障碍的定义和行为后果。失控被定义为一系列行为，这些行为是为了通过人们在感觉可控时不会故意选择（或不会以相同程度选择）的行动来避免或减少混乱或不和谐的思维。失控的例子包括药物滥用、愤怒（狂怒或暴力）、暴饮暴食行为（饮食、购物、赌博、性行为、过度工作）、抑郁、恐慌和躯体化。矛盾的是，失控会导致暂时的缓解感或注意力从问题刺激上转移，但随着时间的推移不可避免地会产生更多问题。期望疾病不是由控制障碍的存在与否决定的，而是由这些问题存在的程度决定的——它们的慢性、强度和僵化程度。对一些人来说，这种障碍可能是急性的或间歇性的，对另一些人来说是慢性的；对一些人来说是个麻烦，对另一些人来说则是致残的。文中讨论了对表现出明显痛苦但诊断不明确的患者的短期干预措施。详细阐述了该模型的优缺点。
