Expectations disease: a model for understanding stress, control and dependent behaviour

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.