Resisting temptation: a psychological analysis

Treatment of Compulsive Over-exercising in Anorexia Nervosa: A Case Study

Despite being a long recognized feature of Anorexia Nervosa, exercising has been largely neglected as a topic for research and treatment. An increasing cultural emphasis on fitness has highlighted the dangers of becoming addicted to exercise and its role in the development and maintenance of Anorexia Nervosa. Most estimates of the incidence of exercise addiction in the anorexic population are high, and the behaviour would appear to pre- and post-date the eating disorder.

In view of this, the development of an effective treatment method for this particular problem is needed. One such approach that employs cognitive behavioural techniques, including exposure and response prevention is described and illustrated by case example.

The self-control costs of fighting the temptation to drink

Being exposed to the sight and smell of an alcoholic beverage and not drinking it should require self-control. On the basis of the self-control strength model (M. Muraven & R. F. Baumeister, 2000), exerting self-control should lead to poorer performance on subsequent self-control tasks. Using a cue exposure paradigm, the authors had 160 social drinkers alternately sniff water and alcohol. After each trial, the drinkers engaged in 2 self-control tasks: squeezing a handgrip and a self-stopping task. Performance on these tasks was worse after sniffing alcohol than after sniffing water. Mood and arousal did not mediate the effects; urge to drink was negatively related to outcomes. The effects were stronger for individuals high in trait temptation to drink. Resisting the temptation of drinking appears to undermine self-control capacity.

Daily Fluctuations in Self-Control Demands and Alcohol Intake

Predictions made by the self-control strength model were tested in a sample of underage social drinkers using ecological momentary assessment methodology. On days that participants experienced more self-control demands than average, they were more likely to violate their self-imposed drinking limit after controlling for mood and urge to drink. There was no relationship between self-control demands and urge or intention to drink, nor were self-control demands related to plans to limit drinking. When individuals planned to limit their alcohol intake, they were more affected by self-control demands than when they did not plan to limit their alcohol intake. Trait self-control moderated these relationships. Consistent with the self-control strength model, it appears that exerting self-control in nondrinking areas undermines individuals' capacity to exert self-control of drinking in daily life.

Measures and models of nicotine dependence: positive reinforcement

This paper addresses the problem of assessing nicotine dependence. The main objective is to develop theory-led suggestions for measures that will be relevant in the early phases of tobacco use, as well as in established smokers. Theoretical models of addiction falling into the general class of 'positive reinforcement theories' were identified and reviewed. From this review a number of drug effects and patterns of behaviour were distilled and categorized as either vulnerability or dependence indicators. A comparison of those features with the International Classification of Diseases (ICD-10) and Diagnostic and Statistical Manual (DSM-IV) diagnostic systems shows that neither system includes detailed assessment of vulnerability indicators. It is argued that measurement of vulnerability indicators, in addition to dependence indicators, may add to the predictive validity of assessments carried out in early career tobacco users, especially where there is limited evidence of established dependence. In addition, it is suggested that examination of measures that differentiate a subgroup of early career smokers termed 'rapid accelerators' may prove profitable and enable identification of the key parameters of nicotine reinforcement.

Learning the language of abstinence in addiction treatment: some similarities between relapse-prevention with disulfiram, naltrexone, and other pharmacological antagonists and intensive "immersion" methods of foreign language teaching

Relapse-prevention (RP) is an educational process. Learning to abstain from alcohol or opiates after years of dependence involves selectively suppressing old, maladaptive habits of thought and behavior and establishing new, adaptive ones. This process resembles foreign language (FL) learning. Effective FL teaching techniques are relevant to RP. "Immersion," the most effective FL teaching method, discourages students from using their first language ab initio, requiring them to use the FL instead, however inexpertly. It resembles exposure and response-prevention for phobic or compulsive disorders. Supervised disulfiram aids RP by discouraging alcoholics from responding to real-life drinking cues in the "language" of excessive drinking, requiring them, ab initio, to practice new, alcohol-free responses. Supervised or depot naltrexone acts similarly in opiate dependence. We discuss the concept of antagonist-assisted abstinence.

Self-control and alcohol restraint: an initial application of the self-control strength model

Individuals whose self-control strength is depleted through the prior exertion of self-control may consume more alcohol in situations that demand restraint. Male social drinkers either exerted self-control by suppressing their thoughts or did not exert self-control while doing arithmetic. They then sampled beer. Participants expected a driving test after drinking and therefore were motivated to limit their intake. Individuals who suppressed their thoughts consumed more and achieved a higher blood alcohol content than those who did arithmetic. The groups did not differ in mood, arousal, or frustration. Individuals higher in trait temptation to drink consumed more after suppressing their thoughts relative to those lower in trait temptation. Alcohol intake may be a function of temptation to drink and self-control strength.

Interrupting the binge-purge cycle in bulimia: the use of planned binges

OBJECTIVE

To describe the rationale and use of a new procedure aimed at bringing binge/purge behavior directly under therapeutic control via the use of planned binges.

METHOD

Research investigating the specific effects of the various cognitive and behavioral components of the standard cognitive-behavioral treatment (CBT) approach for bulimia nervosa is examined in combination with comprehensive reviews of the treatment outcome literature.

RESULTS

These reviews suggest that while treatment has largely been effective at reducing binge-purge frequencies, it does not result in the elimination of the presenting problem for a significant proportion of participants. Evidence is presented to suggest that this may be accounted for by cognitive-behavioral approaches employing indirect procedures to bring the disordered patterns of eating under control. The application of the planned binge approach is illustrated by two cases treated at the University of New South Wales Post Graduate Psychology Clinic.

DISCUSSION

These cases in combination with the analysis of the potential deficits of the standard behavioral procedures employed in CBT provide tentative support for the use of planned binges as an addition to the strategies currently used in the treatment of binge and purge behavior. In conclusion the paper explores some of the ethical implications raised by asking subjects to engage in their problematic behavior.

The Fifth Thomas James Okey Memorial Lecture: research and practice: the necessary symbiosis

What relationship should exist between research and practice in the field of addictive behaviour? Are the perspectives essentially independent, or is there a necessary interaction? The extent of productive interaction is considered in three examples; (i) detoxification, (ii) stable abstinence, and (iii) goals other than abstinence. Changes are occurring in the drugs being used, the extents and types of associated co-morbidity, the levels of public and professional concern, and the explanatory paradigms which are dominant; and so it will be increasingly important for both practitioners and researchers to be sensitive and reactive to these changing circumstances. The most productive state for both research and practice will exist when they both feed off, and feed into each other--when there is indeed a necessary symbiosis.

Young offenders and alcohol-related crime: what interventions will address the issues?

Although most young offenders will grow out of both drinking and crime, interventions aimed at reducing crime through reducing drinking or reducing drinking so as to reduce health and social problems are important for some offenders. Where the aim is to reduce crime by reducing drinking, it is essential to assess carefully the relationship between the two in each person to ensure that this is logical. Since most adolescents drink and since controlled drinking is achievable by younger people with fewer alcohol-related problems, moderation rather than abstinence is a realistic goal for most young offenders. Behavioural self-control training is one type of intervention which can effectively encourage moderate drinking, but this has to be conducted in ways that will engage young offenders' interest, for example through self-help manuals, developing peer interventions and using simulated bar settings. In addressing the questions of which types of people commit which types of crime and what part alcohol plays in setting the conditions for crime to occur, studying the effects that young offenders expect alcohol to have under various conditions may contribute to the development of cognition modification components of interventions and enable better matching of clients with programmes.

Contributions to a social conditioning model of cocaine recovery

This article describes recent developments in a theory of recovery from drug addiction and in the adaptation of Recovery Training and Self Help (RTSH) to cocaine addiction. RTSH is an example of a new element of treatment known as "relapse prevention" (RP), which is an application of the discovery that addiction follows the laws of operant conditioning. We learned, however, that to understand and to treat cocaine addiction, we had to expand upon the conditioning paradigm to include a sociological analysis of the deviant lifestyle from which cocaine addiction stems. The theory presented here postulates three stages of recovery from cocaine addiction. Cocaine addicts can recover as outpatients by (1) initially building "walls" against drug triggers and supplies, (2) extinguishing addiction in the protective community of recovering persons, and (3) gradually lowering the walls and expanding beyond the recovering community to function more fully in conventional society. We have developed an outpatient group treatment system based on this recovery model. The Cocaine Recovery System includes a month-long cessation program, followed by a six-month recovery program, and active participation in the recovering community. A professional and a recovering person colead both the cessation and recovery programs, which feature Recovery Training sessions designed to help cocaine addicts achieve treatment goals and avoid or cope with threats to recovery. Clients in the recovery program also meet weekly for a support session, a weekend recreational activity, and individual counseling. The program also encourages group members to attend 12-step fellowship meetings. Clients achieve difficult lifestyle changes by taking a series of "commitment steps," which increasingly engage the clients in a recovering lifestyle and make relapse more difficult.

Cue reactivity in addictive behaviors: theoretical and treatment implications

Several learning theory based models propose that substance users may have conditioned reactions to stimuli (cues) associated with substance use and that these reactions may increase the probability of relapse. The conditioned withdrawal, conditioned compensatory response, and appetitive motivational models were evaluated in light of empirical evidence from cue reactivity studies with alcoholics, smokers, opiate users, and cocaine users. The nature of the stimuli that elicit reactivity and the nature of the responses elicited are most consistent with an appetitive motivational model and do not appear to support the other two models. A few studies have been conducted or are underway that investigate the use of cue exposure with response prevention as a treatment to decrease cue reactivity. Preliminary work with alcoholics, opiate users and cocaine users is promising but insufficient evidence exists to evaluate this approach. The implications for theory and treatment are discussed.