Up Close With Dr. E

Models of addiction


When someone asks the question, “which came first, the chicken or the egg” they want you to put in chronological order two different things: an egg and one chicken. If you answer by saying, “the egg came first,” you have also answered a second question, which was hidden beneath the first. The hidden question emerges — which caused the other? Your answer implied that the egg caused or produced a chicken.

Today’s column will ask, which came first, the severe episodes of panic and anxiety, or the alcoholism? The debilitating bouts of black depression, or the cocaine use? The alienation and deep despair of emotional trauma, or the daily use of pot? Before our eager minds jump down into the trenches to answer these questions, let’s hold our current perspective and ask one final question: Why does it even matter which came first? Here is why:

1. Addiction is currently viewed as a specific or separate entity, which is diagnosed by the drug one uses. For example, if one is addicted to cocaine, the primary diagnosis would be: cocaine addiction.

2. The primary diagnosis of a drug problem has been viewed as the sole target of treatment. The logic is simple: since cocaine has destroyed the person’s life, removing the cocaine, and teaching the patient how to live clean and sober is the only treatment goal.

3. The reason a person became addicted is not needed, and so, is never asked. But, what if the cocaine addiction was caused by an underlying disorder, which produced the drug use? What if the person whose life has been crippled by drug use, is using the drug to cope with an undetected psychiatric illness?

These questions lead into a broader model of addiction, which breaks down into two diagnoses. Primary illness: clinical depression. Secondary illness: drug addiction. The model says that the destructive power of the underlying and undetected depression has been hidden under the person’s attempt to use a drug — like alcohol — to reduce the despair of depression.

Let’s review the life of Tom, so his suffering can teach us about addiction. Tom was the youngest child in a family of six. When he entered school, he was so overwhelmed with anxiety that his teacher had to spend time, every morning, calming his fears. What if I lose my homework, what if I get sick? He would always put his hat and coat on 20 minutes before his bus came, because he lived in terror of missing his ride home. By 12, Tom’s tall and lanky body gave him an advantage on the basketball court, where he began to excel. As a high school senior, his 6 feet, 4 inches of height, combined with years of hard practice, helped him to become remembered as the guy who took his team to victory. What was not known about Tom was his debilitating anxiety, which now surged to levels of deep suffering. Prior to each game, his worry made him sick. His fears tore down his ability to sleep, and exhaustion made him fear he was losing his mind. Tom found his mother’s prescription pills for anxiety (Xanax) in the cabinet and discovered their power to tame the beast locked inside his chest. By the time Tom graduated from college, he had perfected his drug combo, which slayed the beast — Xanax, plus beer works every time.

Tom loved his job as a CPA, and he earned a reputation as a reliable professional who never missed a tax deadline. However, when April 15 approached, Tom began to get brutally stressed. So, he increased his pill use, and now, six beers were needed. One night, on his drive home, he ran a stop sign and ended up in a ditch. He had passed out.

Now, allow me to use two different treatment models: Model 1: Tom completed his 28-day detox hospitalization, and upon discharge, was told to continue drug counseling and attend AA (Alcoholics Anonymous). His diagnoses were alcohol and Xanax addiction. Later, Tom’s anxiety began to torture him again, to the point that he could not work. Not understanding what was happening to him, he began to secretly drink and use pills again. Model 2: Tom was first given a comprehensive evaluation, which identified a severe anxiety disorder which began at age 5. His diagnosis was, Primary: Generalized anxiety disorder, Secondary: alcohol and Xanax addiction. His outpatient treatment program taught him skills in managing and reducing his obsessive worry and anxiety. His treatment provider educated Tom, and his family, about how anxiety can cause addiction. Tom was encouraged to attend AA meetings, which expanded his support system.

Summary: Which came first, Tom’s addiction or his anxiety? Does it really matter? Yes. It matters because addiction does not occur in a vacuum, nor does it drop down from outer space. Drug addiction, for many, is a symptom of an undetected, underlying disorder, which needs to be found and fixed.

The content of this article is for educational purposes only and should not be used as a substitute for treatment by a professional. The characters in this story are not real. Names and details have been changed to protect confidentiality.


Dr. Richard Elghammer contributes his column each week to the Journal Review.