The Self-Medication Hypothesis

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A Review of the Two Major Theories and the Research Evidence

by E.D.Achalu, Ph.D.

Edward J. Khantzian and David F. Duncan are usually credited with being the originators of the self-medication hypothesis but while theirs are the most fully developed versions there are earlier precedents for the idea. Both Fenichel (1945) and Rado (1957) pointed to an underlying depression as the motive for drug abuse. Glover (1956) went further in suggesting that drugs were used to cope with overwhelming and psychotogenic aggresssion and rage. Rosenfeld (1965) described drug addiction as a defense against psychotic suffering. None of these contributions, however, have had the degree of influence that Duncan and Khantzian have.

Khantzians Model of Drug Abuse as Self-Medication
One of the two major versions of the self-medication hypothesis is the psychoanalytic perspective developed by Edward J. Khantzian and his colleagues at Harvard Medical School. This model arose from Khantzians clinical experience evaluating and treating heroin addicts. He noted that his addict patients had histories of difficulties with aggression and derivative problems of rage and depression that long preceded their use of any illegal drugs. He also found that many of them reported that use of heroin gave them relief from dysphoric feelings of restlessnees, anger, and rage.

Khantzian concluded that the predisposition to become a heroin addict resulted from these problems with aggression -- specifically from inadequate ego mechanisms for controlling and directing aggression. The repeated use of heroin or other opiates as a means of coping with the addicts poorly controlled aggressive drive result in the development of physical dependence. Methadones effectiveness in treating heroin addiction, he argued, is due not only to its prevention of withdrawal illness but also due to its relief of those same dysphoric feelings. This limited formulation of what would become the Self-Medication Hypothesis was published by Khantzian, Mack, and Schatzberg in 1974 in the American Journal of Psychiatry.

Eleven years later the original hypothesis about heroin addiction (Khantzian, Mack, & Schatzberg, 1974) was named the Self-Medication Hypothesis and was elaborated to include cocaine addiction as well (Khantzian, 1985). He now speculated that cocaine has its appeal because of its ability to relieve the distress associated with depression, hypomania, or hyperactivity. The hypothesis was subsequently expanded to include alcoholism, speculating that the addicts use of alcohol, permits the experience of affection, aggression, and closeness in an individuals who is otherwise cut off from their feelings and relationships (Khantzian, 1990). And finally developed into a theory of all drug addictions (Khantzian, 1997 & 1999).

In its fully developed version, Khantzians version of the Self-Medication Hypothesis holds that addiction occurs in a context of self-regulation vulnerabilities -- primarily difficulties in regulating affects, self-esteem, relationships, and self-care. Potential addicts suffer severely from their feelings, either being overwhelmed with painful emotions or seeming not to feel any emotions at all. Drugs of abuse help such individuals to relieve painful emotions or to experience emotions that are confusing or threatening.

Regardless of specific symptoms or personality styles, Khantzian believes that certain character traits are typical of all drug addicts. These include problems in affect management, self esteem, object relations, judgment, and self-care. He argued that these developmentally and structurally determined problems predispose individuals to drug dependence because they are the basis of the distresses that are relieved by drug-taking.

Vulnerability to drug dependence varies greatly both between individuals and for the same individual at different times. In many cases addiction develops in a previous abstainer (or perhaps even in a non-dependent drug user) following some precipitating event that involves a severe crisis in which the individuals adaptive capacities are diminished and narcissistic vulnerability is intense.

Once drug taking has been initiated in a susceptible state and the user has experienced adaptive benefit from the use of the drug, a variety of other processes are set in motion that often lead to addiction. These processes include both regressive effects that can exacerbate the original vulnerability and progressive effects that promote stable functioning. In both cases, however, Khantzian argued that this may interfere with further emotional maturation, particularly when the onset of addiction occurs in adolescence.

The addict's choice of drug, according to Khantzian, was a result of the interaction between the psychopharmacologic properties of the drug and the "primary feeling states" the addict was seeking relief from. The drugs effects substitute for defective or non-existent ego mechanisms of defense. The addicts "drug of choice," therefore, is neither random nor simply the result of current fashion or fad, but rather, results from a process of "self selection" that has been referred to as "preferential drug use" (Milkman & Frosch, 1973) Thus, narcotic addicts prefer opiates because of the relief they provide from the disorganizing and threatening affects of rage and aggression. Cocaine, in turn, has its appeal due to its ability to relieve the distress associated with depression, hypomania, or hyperactivity.

According to Treece and Khantzian (1986) the development of drug dependence involves the gradual incorporation of the drug effects and the need for them into the defensive structure-building activity of the ego itself. Overcoming an addiction, therefore, 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.

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