The Self-Medication Hypothesis

THE SELF-MEDICATION HYPOTHESIS OF ADDICTIVE DISORDER

IMG_1862The Self-Medication Hypothesis (SMH) has evolved out of in-depth psychodynamic study and treatment of individuals with addictive disorders.  The SMH addresses some of the main psychological reasons why individuals become dependent on addictive drugs and give addictions their powerful compelling nature.  There are two principal aspects of the SMH: (a.) addictive drugs relieve human psychological suffering, and (b.) there is a considerable degree of specificity in an individual’s drug-of-choice.  Namely, over a period of time in experimenting with drugs, including alcohol, addictively vulnerable individuals have a discovery that a particular drug relieves painful feeling states that predominate and are problematic for them.  The SMH has focused on three main classes of addictive substances – opiates, depressants, and stimulants.  Opiates (e.g. heroin, oxycodone, hydrocodone). Beyond their generally calming effect on a range of intense emotions, opiates have a powerful dampening and containing action on violent and rageful feelings and appeal to individuals who are unable to control such intense emotions.  Not insignificantly individuals who suffer with PTSD, Borderline Personality and Bi-Polar Disorders, conditions in which rage and intense anger predominate, are powerfully drawn to opiates.  Depressants (e.g. alcohol, Xanax®, barbiturates) Individuals who suffer with a strict conscience (super-ego) find depressants a relaxing drug freeing them of social anxiety and self-consciousness.  More importantly, the SMH suggest that depressants are powerful ego solvents; namely a person who is uncomfortable about or unable to experience feelings of closeness, warmth, and affection discovers that briefly, and therefor tolerably, these drugs help to permit such emotions within oneself and in their interactions with others.  High doses of alcohol can obliterate a wide range of distressful feelings, but not as effectively as opiates.   Stimulants (e.g. cocaine, speed, crystal meth) appeal to high and low energy people and individuals with attention deficit disorders (ADD).  The stimulating properties of these drugs are experienced as antidotes for the low energy, poor self-esteem, and feelings of hopelessness associated with clinical depression and depressive states; high energy individuals (e.g. manic and hypo-manic) welcome the augmenting and energizing effects of these agents that make it easier for them to be and feel the ways they like to be and feel.  Individuals with difficulties in focusing and hyperactivity, especially with ADD, experience a paradoxical effect from stimulants that counter their restlessness, inability to focus, and the distress associated with these conditions.

Inconsistencies and seeming contradictions in the SMH have led to further psychological consideration about how and why individuals become addicted to drugs and alcohol.  For example, many individuals experience the troublesome feelings that addicted people feel but do not become addicted; furthermore, there is at least more pain and suffering that results from addictions than the pain and suffering that leads to addiction.  These issues about the SMH have led to considering the addiction as a self-regulation disorder.  Focusing on the pain and distress involved with addiction has resulted in a more detailed attention to affect life (i.e. feelings), self-esteem, relationships, and self-care, and how dysfunctions and deficits in these aspects of self-regulation lead individuals to self-medicate.  Feelings in addictively prone people are experienced in the extreme – they can be overwhelming and unbearable, or, they can be absent and confusing; sense of self and self-esteem are impoverished and/or lacking; relationships are elusive and feel unmanageable; and all of this is compounded by lack of self-care whereby worry, fear, or caution is absent or underdeveloped in the face of danger and risk, especially those involving addictive activities.  

Major traumatic neglect and abuse have significant damaging and lasting effects on feeling life, sense of self, relationship, and the capacity for self-care, heightening the tendency to resort to using addictive substances to combat the intense, unbearable, confusing feelings such experiences engender.  When feelings are overwhelming and unbearable, high doses of addictive drugs make such feeling more manageable.   When they are vague, confusing or cut-off, some individuals discover that the addiction induced pain and confusion they suffer is a more acceptable alternative to the pain, dysphoria and confusion that they otherwise endure that they do not understand or control.  The operative changes from the relief of feelings to the control of feelings. — E.J. Khantzian

See also Addictive Disorders: Overview; Alcohol Use Disorders: Psychological Factors; Drug Use Disorders: Psychological Factors; Opioid Use Disorders; Stimulant Use Disorders

FURTHER READINGS

Khantzian E. J. (1985b). The self-medication hypothesis of addictive disorders.  American Journal of Psychiatry  142:1259-1264.

Khantzian, E. J. (1997).  The self-medication hypothesis of substance use disorders:  
A reconsideration and recent applications. Harvard Review of Psychiatry.
4:231-244.

           Khantzian, EJ. Treating Addiction as a Human Process.  Northvale NJ:  Jason
          Aronson Inc., 1999.

Self-Medication, Psychoanalytic and Psychodynamic Theories