Edward J. Khantzian

The self-medication hypothesis of addictive disorders: focus on heroin and cocaine dependence.

Recent clinical observations and psychiatric diagnostic findings of drug-dependent individuals suggest that they are predisposed to addiction because they suffer with painful affect states and related psychiatric disorders. The drugs that addicts select are not chosen randomly. Their drug of choice is the result of an interaction between the psychopharmacologic action of the drug and the dominant painful feelings with which they struggle. Narcotic addicts prefer opiates because of their powerful muting action on the disorganizing and threatening affects of rage and aggression. Cocaine has its appeal because of its ability to relieve distress associated with depression, hypomania, and hyperactivity.

The Self-Medication Hypothesis of Substance Use Disorders: A Reconsideration and Recent Applications

&NA; The self‐medication hypothesis of addictive disorders derives primarily from clinical observations of patients with substance use disorders. Individuals discover that the specific actions or effects of each class of drugs relieve or change a range of painful affect states. Self‐medication factors occur in a context of self‐regulation vulnerabilities–‐primarily difficulties in regulating affects, self‐esteem, relationships, and self‐care. Persons with substance use disorders suffer in the extreme with their feelings, either being overwhelmed with painful affects or seeming not to feel their emotions at all. Substances of abuse help such individuals to relieve painful affects or to experience or control emotions when they are absent or confusing. Diagnostic studies provide evidence that variously supports and fails to support a self‐medication hypothesis of addictive disorders. The cause‐consequence controversy involving psychopathology and substance use/abuse is reviewed and critiqued. In contrast, clinical observations and empirical studies that focus on painful affects and subjective states of distress more consistently suggest that such states of suffering are important psychological determinants in using, becoming dependent upon, and relapsing to addictive substances. Subjective states of distress and suffering involved in motives to self‐medicate with substances of abuse are considered with respect to nicotine dependence and to schizophrenia and posttraumatic stress disorder comorbid with a substance use disorder.

Methylphenidate (Ritalin®) treatment of cocaine dependence—A preliminary report

The authors report on three cases of cocaine dependence treated with methylphenidate. All patients treated showed marked to dramatic improvement with regard to toxic/abstinence signs and symptoms, craving behavior and other behavioral disturbances associated with heavy and chronic cocaine abuse. The authors explore the possibility that cocaine dependence is associated with pre-existing or resulting psychopathology, particularly mood disturbances. Emphasis is also placed on a predisposing or de novo attention deficit disorder (ADD) as possibly contributing to heavy or continued reliance on cocaine.

Acute Toxic and Withdrawal Reactions Associated with Drug Use and Abuse

Abstract A variety of old and new substances and drugs with powerful psychotropic effects have come into common use during the past decade. Patterns of involvement include experimental, occasional,...

Psychodynamic Factors in the Development of Drug Dependence

In this article we have brought to bear on the complex problem of substance dependency the psychodynamic perspective: a model that views the problem from the inner experience and psychological structure of the individual drug user. Chronic drug dependence has been associated with a range of personality styles and psychopathologic conditions but most frequently with character disorder and vulnerability to depression. Regardless of specific symptoms or personality styles, certain characterologic features are repeatedly observed to characterize substance-dependent individuals. These include problems in affect management, narcissism, object relations, judgment, and self-care. These developmentally and structurally determined problems generally predispose individuals to drug dependence because they are the basis of the distresses that are relieved by drug-taking; they specifically predispose to drug dependence because, in various ways, the taking of drugs and the experience of their effects are syntonic with existing modes of defense, adaptation, and self-concept. The actual vulnerability to substance dependency can vary considerably both between individuals and for the same individual at different times. For many, a necessary precipitating event involves a severe crisis in which usual adaptive capacities are diminished and narcissistic vulnerability is intense. Once drug taking is initiated in a susceptible state and the user has experienced adaptive benefit from the experience, a variety of other processes are set in motion that often lead to the state of dependency. These processes include both regressive effects that can exacerbate the original character problem and progressive effects that promote stable functioning. In both cases, however, this may interfere with further maturation of character, particularly when onset of use occurs in adolescence. Dependency involves the gradual incorporation of the drug effects and their experienced need into the defensive structure building activity of the ego itself. Undoing a dependency involves dealing with the unconscious and conscious components of this outcome. The user must be able to relinquish behaviors and drug effects that have come to be experienced as a valued (even if also hated) part of the self-capacity to function, cope, and be comforted in distress.

Part II. Addiction and Psychological Disorders: The Self‐Medication Hypothesis: PSYCHOLOGICAL (STRUCTURAL) VULNERABILITIES AND THE SPECIFIC APPEAL OF NARCOTICS

The study of human dependence on opiates offers an opportunity to understand important, if not basic, aspects of mental life, emotional pain, and mental illness. The addictions are a place where the biology and psychology of the mind meet. It is a place that promises to resolve some of the mysterious manners in which the body and the mind affect each other, and to unravel better the “mysterious leap from the mind to the body,” with which psychoanalysts and clinicians have concerned themselves for a long time. Recent discoveries of the opiate receptors and endogenous opioid peptides have prompted us to consider how the brain and the mind produce their own analgesia for biochemical modulation of physical pain and to consider as well how such processes might also be involved in the modulation and regulation of emotional distress and human psychological suffering. My presentation today will be based on my understanding of opiate dependence as a clinician and as a psychoanalyst.* However, before embarking on such a tack, I experience a certain sense of uneasiness and trepidation in my approach, given that the promising discoveries of opiate receptors and peptides have been based on very sophisticated methods of investigation. These discoveries have been the result of a fast-growing, complex technology that has allowed researchers a more concrete, precise means to examine microscopically, molecularly, and quantitatively how the brain and mind function. In contrast, the approach of a clinician and psychoanalyst involves less precise, more abstract techniques and methods of investigation that attempt to understand and explain the problems of opiate dependence in its human, experiental contexts, usually by studying single individuals in great detail and in depth, one-at-a-time. Such an approach utilizes macroscopic constructs concerned with structures, functions, and qualities of the mind and mental life. The two approaches need not compete, and more likely they are complementary, albeit the focus of their respective interests and observations at times seem far apart. Having expressed a concern at the outset that sounds apologetic, I set it aside and proceed by assuring myself, and hopefully my audience, that my approach is a valid and useful one. It is an approach that needs no apology any more than the pathologist apologizes for the validity and usefulness of autopsies, instead of the electron microscope, in understanding pathology and dysfunction. Considered from a psychoanalytic perspective, opiate dependence may be approached and considered in terms of human processes involving affects,

Reflections on Treating Addictive Disorders: A Psychodynamic Perspective

In this paper I would like to reflect and draw upon apsychodynamic perspective and four decades of work withdrug-dependent patients, to look at the struggles and suf-fering that make addictions so powerful and compelling.Drawing on that perspective and experience, I would thenliketooffersomethoughtsaboutessentialelementsofgoodtreatmentandhowclinicianscandevelopafocustoaddress,understand, and modify in psychotherapy the vulnerabili-ties that have caused drug-dependent individuals to sufferand behave in the ways that they do. The paper will soundfamiliar to many practitioners of my generation, and inthis respect it is intended as a recap and summation of mywork, but it is also my aim to introduce these ideas to anew generation of clinicians who are taking up the chal-lenge to provide a humanistic psychological approach tounderstanding and treating addictive disorders.Treating addictive disorders, as with other medical andpsychiatric conditions, rests on the principle that effectivetreatment best occurs when the underlying processes andmechanisms involved in the disorder are understood andtargeted. Over the past several decades considerable evi-dence has emerged, as recently reviewed by Shedler,

Reflections on Group Treatments as Corrective Experiences for Addictive Vulnerability

Abstract This article addresses how and why groups help people with addictive disorders feel better and change. It advances the position that problems in self-regulation and the psychological suffering that ensues are at the root of addictive disorders. Group work is especially effective in addressing these problems, providing a means of relief, and examining co-occurring characterological problems. The evolution of these ideas and the generation of a model for group therapy for substance abusers are traced over a 30-year period, and a list of principles about how and why group treatments work is presented. In addition, a number of advantages that group psychotherapy has over 12-step programs for some patients are provided. Group psychotherapy is presented as a unique corrective emotional experience.

From Theory to Practice: The Planned Treatment of Drug Users

ACKNOWLEDGMENTS: This interview is part of a project supported by Sandoz, Inc. Without the belief and support of Dr. Craig Burrell, the project would never have been initiated or completed.

Self-Regulation Factors in Cocaine Dependence-A Clinical Perspective'

Individuals prone to substance dependence suffer because they cannot regulate their emotions, self-esteem, and relationships. Furthermore, they suffer with deficits in self-care in which they fail to anticipate harm and danger, including those associated with substance use. Deficiencies in regulating emotions and self-care malignantly combine to make drug experimentation and dependence more likely and compelling.