Although neuroscientists have made major contributions over the past several decades in elucidating the brain mechanisms and underlying neurotransmitter systems involved with addictive drugs, there has been insufficient attention paid to possible psychological mechanisms and vulnerabilities that might explain why addictive substances can be so seductive, consuming and destructive. 

Clearly, regular use of addictive substances cause changes in the brain; produce physical dependence; and when an addicted person’s drug is removed or cut off, symptoms of withdrawal ensue. A wide range of distressing symptoms occur characteristic of the drug upon which the person has become dependent. Many argue that it is the acute and prolonged withdrawal symptoms and distress that cause addicted individuals to revert back to their use of addictive substances.

In this article, I present evidence and a point of view that there are other compelling reasons (having to do with the ability of addictive drugs to relieve a range of distressful states) that make them so appealing. Such a perspective does not and should not compete with the neurobiological aspects of addictive problems. In addition to emphasizing the general pain-removing effects of addictive substances, I’ve identified a number of distressful clinical conditions where the co-occurrence of addiction is particularly high and causes individuals who are so affected to discover the pain-relieving properties of addictive drugs associated with their co-occurring disorders.

This article is based on three premises:

• We are all more or less susceptible to becoming drug dependent.
• Some of us are more susceptible for special reasons.
• Addictive drugs are not universally appealing.

The observations in this article are based on in-depth clinical evaluation and treatment of substance-dependent individuals, spanning a period of four decades; they are complimented by empirical findings from recent psychiatric studies.

Addictive vulnerability

Human nature dictates that challenges involving emotions, relationships, self-esteem and behavior are inescapable. Addictive drugs have appeal because they relieve distress associated with these challenges. Certain life conditions or disorders make addictive behavior more likely. Although in this article I will emphasize certain conditions and types of addiction, I want to stress that it is the human condition that leaves us susceptible to substance use disorders (SUDs). In my experience, human psychological suffering is at the root of addictive disorders; it is not primarily pleasure seeking, reward or self-destruction, as is often suggested. In recent years a metaphor has become popular to capture how addictive drugs captivate a person — namely, that the drugs “hijack” the brain pleasure centers. There is just as much evidence that the drugs hijack the mind — namely, the centers in the brain which regulate emotions and psychological pain. Individuals who succumb to addictive disorders are more often self-medicating the psychological distress or suffering that is associated with their psychiatric disorders.

Many of the observations in this article derive from the self-medication hypothesis (SMH) of addictive disorders, first articulated in 1985 and subsequently updated in 1997 (Khantzian, 1985; 1997). Not infrequently it is referred as one of the “most intuitively appealing theories” of addiction (Glass, 1990). 

There are two basic aspects of the SMH: 1) individuals use, abuse and become dependent upon addictive drugs because they relieve psychological distress; and 2) there is a considerable degree of specificity involved in an individual’s drug preference. Although patients and others may refer to getting “high” or experiencing euphoria on addictive drugs, when further questioned about how the drugs make them feel, individuals describe how addictive drugs relieve dysphoria associated with a range of uncomfortable feelings or painful emotions. The following are some of the distressful states relieved by the main classes of addictive drugs:

• Opiates help a person to feel “calm, mellow or normal”; they counter agitation, aggression and violent feelings.
• Stimulants counter states of low energy, sense of weakness and feeling unloved, often associated with depression; they also boost hyperenergized fast lane people and they calm hyperactive individuals who have attention deficit hyperactivity disorder (ADHD).
• Alcohol/Depressants drown out negative, unwelcome feelings in high doses; or can allow feeling of closeness and warmth in low doses for those who cannot ordinarily allow such reactions — e.g. “I can feel like one of the guys … I can join the human race.”

The above reactions can commonly be elicited by asking the simple question: “What did the drug do for you when you first used it?” It turns out the question is not so simple, in that patients will respond with reactions such as: “it made me feel normal … calm ... mellow for the first time.” Individuals overwhelmed with rage and a sense of falling apart describe how opiates help them to feel more integrated and re-hinged; de-energized and de-activated individuals who are down on themselves say they are able to get going and feel better about themselves with the use of stimulants such as cocaine or crystal meth; expansive bipolar types indicate they feel even better about themselves on stimulants; and restricted people say they can allow, otherwise unallowable, expression of affectionate (and aggressive) feelings and accept them with the loosening effects of alcohol. It is worth noting that a person does not set out to become dependent on opiates, stimulants or depressants. Rather, individuals discover that a particular drug best suits them because it relieves, changes or makes more bearable their feelings and dysphoria. As I indicated at the beginning of this article, addictive drugs are not universally appealing. In my experience, a person discovers that one drug or another is or becomes appealing because that person suffers with certain emotions or distress associated with a psychiatric disorder, a state or condition in which the effect of the drug produces a welcome change or relief.

Based on the above observations I have concluded that addictions are a self-regulation disorder (Khantzian, 1995). Substance users suffer because they have difficulties regulating their emotions, self-esteem, relationships and behavior, especially self-care. A main feature of psychiatric illness is difficulty in self-regulation. Individuals discover, short term, that substances relieve, ameliorate or help control emotional dysregulation associated with psychiatric illness.

Vulnerable populations – a sample

There is a high co-occurrence of SUDs in patients with psychiatric disorders (Kessler, R. C., Crum, R. M., Warner, L. A., Nelson, C. B. et. al.,1997). For the most part, studies documenting this high co-occurrence rate indicate that the psychiatric disorder preceded the SUD. With the pressure for clinicians to document and classify symptoms associated with psychiatric conditions to meet diagnostic criteria for third-party payers, as specified in DSM-IVR, we often lose site of the enormous suffering associated with psychiatric illness. There are several conditions in which there is a significant psychological distress linked to the need to revert to addictive drugs to deal with the associated suffering these conditions entail.

Schizophrenia. Over the past several decades there has been an important development in elucidating the different types of symptoms associated with schizophrenia. Investigators distinguish between positive and negative symptoms, referring to the more florid symptoms of the disorder in the former case, and the more subtle, lingering symptoms in the latter. They are distinguished as follows:

Positive Symptoms

- Hallucinations
- Delusions
- Paranoia
- Agitation
- Aggression

Negative Symptoms

- Alogia (paucity of words)
- Affective flattening
- Anhedonia (inability to feel
pleasure)
- Asociality
- Apathy
- Attentional impairments

These symptoms are painful, disruptive and debilitating, each in their own way. The positive symptoms are frightening, unsettling and often dramatic, threatening to both those who experience them and those who are witness to them. While the positive symptoms are disturbing and painful enough, the negative symptoms are especially crippling in their persistence, and isolating in ways that interfere with necessary human relationships and interactions, giving such patients their indifferent, listless, withdrawn qualities. Some schizophrenic patients, for example, might indicate that the voices they hear can be drowned out or ignored with heavy doses of alcohol. I’ve found that it is the pain and suffering associated with negative symptoms that schizophrenic individuals mainly try to overcome with their use of addictive substances. They are at least (if not more painful), because the negative symptoms are vague, confusing and inaccessible. 

Not surprisingly, addictive drugs ameliorate or change the distress associated with negative symptoms. There is a disproportionately very high co-occurrence of nicotine dependence (a stimulant) among schizophrenic patients. Whereas the occurrence of nicotine dependence is about 24 percent in the general population, it ranges between 70 to 90 percent in schizophrenic populations (Ziedonis, D.M., Kosten, T.R., Glazer, W.M., Frances, R.J., 1994).

There is a surprisingly high incidence of cocaine dependence in this population as well — surprising, in that cocaine itself can precipitate psychosis. I and others (Brady K., Anton R., Ballenger J.C., et. al., 1990) have concluded that such patients are self-medicating the painful negative symptoms —  more often protected from the drug’s disorganizing effect — when they are taking their antipsychotic medications. In one study, the investigators observed that schizophrenic patients admitted to an acute psychiatric unit who were using cocaine had significantly lower scores on negative symptom scales, compared to schizophrenic patients admitted to the same unit who were not using cocaine (Serper, M.R., Albert, M., Richardson, N.A., Dickson, S., Allen, M., and Werner, A., 1995). Yet, when evaluated several weeks later on the same unit, the cocaine-using schizophrenic patients had the same high rates of negative symptoms as the patients who had not been using cocaine on admission. This suggests that the patients using cocaine had experienced temporary relief from their negative symptoms, only for its “benefits” to wane during their hospital stay removed from the cocaine.

Theoretically, opiates would be a calming agent for schizophrenic patients, given its calming effects on the agitation and states of anger and rage which so often is associated with schizophrenia. With the exception of areas where heroin is endemic and easily attainable, the impaired coping skills of schizophrenics make it unlikely they would be able to survive the hazards of acquiring the drug that might relieve the enormous distress and disorganization involved with their disease.

There is evidence that opiates would quiet and contain the disorganization and agitation these patients experience. In 1981, the New York Academy of Science convened a conference in which the role of opiates was considered in mental illness, and possibly in treatment of schizophrenia and other severe psychiatric conditions (Vereby, K., 1982). One possibility being considered was the use of the long acting opiate, methadone, in the treatment of refractory cases of schizophrenia. This consideration was entirely consistent with the emphasis in my previous work on the anti-aggression, anti-disorganization action of opiates. It is also consistent with an earlier European and more recent American experience in which opiates were used for psychotic, agitated patients, refractory to conventional antipsychotic medication. This option has been less necessary with the advent of second generation antipsychotic drugs, such as clozapine. 

Alcohol is the main depressant preferred by schizophrenic individuals. As we have indicated, in heavy doses they can drown out or obliterate unwelcome hallucinations, delusions, and to a lesser extent, paranoia — that is, the positive symptoms. In low to moderate doses, negative symptoms, such as the inability to socialize, apathy and the inability to experience pleasure, are ameliorated. As a patient once reminded me, “Doc, they tell me to go to the social club and mix with the other patients or to go to their dances, but I can’t get there unless I stop by the liquor store and get my pint of rum. Then I feel like I can join the human race and try and have some fun.”

Post-traumatic stress disorder (PTSD). Nowhere is the association between the suffering involved in a psychiatric condition and SUDS more evident than in patients who suffer with PTSD. The odds ratio for SUDs in individuals with PTSD is three to four times greater than individuals without PTSD (Ouimette, P. & Brown, P.J., 2004). The suffering is endless and unrelenting, with multiple manifestations. The following is a summary of the main reactions described in DSM-IVR:

• Re-experiencing the trauma, including: recurrent memories, dreams and related psychological distress
• Persistent avoidance or numbing
• Decreased interest in important activities; feeling of detachment; restricted emotions
• Hyperarousal, including: sleep disturbance, irritability/anger, poor concentration, hypervigilance and increased startle response

As an esteemed colleague, Bessel Van der Kolk, has noted, it is a condition in which there is a failure for time to heal all wounds. Little wonder that such individuals are so prone to turn to the feeling-altering properties of addictive drugs. The drugs counter or change the disrupted emotions, self-esteem, relationships and behaviors that result from PTSD — that is, they experience relief with addictive drugs from their immense problems with self-regulation. Obliterating doses of alcohol counter emotional flooding, and low to moderate doses release them from the affective numbing, associated with PTSD.

Opiates quell or contain the rage and violent feelings experienced by PTSD sufferers, one of the most disquieting and disruptive reactions for self and others who have endured such trauma. Early in our experience, working with traumatized Vietnam veterans, we were most struck with how they reported the calming down of their enduring rage (a result of their combat experiences) when they first used heroin. Is it any surprise that individuals with PTSD report how stimulants, such as cocaine and methamphetamine, act as powerful antidotes to the social withdrawal and anhedonia of PTSD? This explains why PTSD sufferers are drawn to and captivated by these drugs.  

Attention Deficit Hyperactivity Disorder (ADHD). It is estimated that 25 to 50 percent of adolescents with SUDs have ADHD, as estimated by Wilens and Biederman, prominent investigators in the treatment and prevention of ADHD (Wilens, T. & Biederman, J., 2006). These investigators consider ADHD as a developmental disorder, and in their experience, consider it an important antecedent to SUDs. They have evidence that early treatment of ADHD significantly decreases SUDs and cigarette smoking. There is significant older and more recent literature that documents the significant co-
occurrence of anger, anxiety, mood disorders and behavioral problems associated with ADHD. In my opinion and experience (a perspective which Wilens and Biederman endorse) there are heightened self-regulation difficulties in adolescents with ADHD, which predisposes them to SUDs and the need to self-medicate the distress associated with their ADHD. 

Referring back to the three main classes of addictive drugs and their main action or effects that we reviewed previously, it is understandable how individuals with ADHD would be drawn to these addictive drugs, as well as marijuana and nicotine. Given the significant levels of anxiety, anger, depression and behavioral problems with which such individuals struggle, one would correctly expect that stimulants, including nicotine, could paradoxically calm the restlessness or serve as an activating agent for associated depressive symptoms; that the stimulating and sedating properties of cannabis could serve a similar purpose; that alcohol would be disproportionately misused; and that opiates would calm and soothe the angry feelings and irritability with which such individuals struggle.

In the early 1980s, I was beginning to suspect that some of my patients were self-medicating their ADHD symptoms and the related distress associated with the condition.  In 1982, a 30-year-old female patient with an enormous dependence on cocaine (using intra-venously, about $250,000 a year habit —able to do so because she had a connection high in the distribution chain) was referred to me for evaluation. After taking a detailed history, I diagnosed that she suffered with co-occurring ADHD. After consulting with several respected colleagues, I decided to treat her underlying ADHD with methylphenidate (Ritalin®) to my knowledge, not previously tried in such a case. On a high pediatric dose (20 mg, three times per day) she reported feeling calm, able to take a normal nap (usually a coma-like sleep follows acute withdrawal from cocaine); and that for the first time she felt she had a choice to not use the cocaine. I reported this case in 1983, as an extreme case that had marked improvement with the methylphenidate treatment (Khantzian, E.J., 1983).

With 25 years of follow-up on this remarkable case, the patient has not reverted to stimulant dependence, despite her previous exclusive dependence on stimulants prior to her treatment, dating back more than 10 years. Her treatment with methylphenidate — considered by some at the time, to be controversial — was largely ignored until fairly recently. Dr. Frances Levin and associates at Columbia University Medical Center began preliminary studies on the efficacy of stimulant substitution for cocaine and methamphetamine dependence, and demonstrated preliminary encouraging results with stimulant medication substitution (Levin, 2006).

Nicotine Dependence. There is evidence that smoking and nicotine dependence is associated with a range of distressful states (Hughes, J., 2001; Hughes, J.R., 2006; Breslau, N., Kilbey, M.M. & Andreski, P., 1993a). Although nicotine has traditionally been considered a stimulant, the evidence suggests that it has a range of different actions or effects, explainable by the fact that there are subsystems of nicotinic receptor sites in the brain to account for this difference. In this respect, it is somewhat at odds with the premise of the SMH that there is a considerable degree of specificity in a person’s drug of choice. On this basis, Dr. John Hughes, a distinguished researcher on nicotine dependence, has referred to nicotine as a “renaissance drug.” For example, he lists the different actions of nicotine as follows:

• Improves concentration
• Relieves anxiety and depression
• Relieves anger
• Decreases appetite

He then challenges the reader to consider the problems of 16-year-olds. He offers the following:

• Concentrating on school work
• Controlling mood
• Aggression (especially boys)
• Weight gain (especially girls)

Little wonder that the hook is so often set in adolescence for lifetime dependency on nicotine, and why it is one of the most difficult addictions to overcome. To paraphrase Tom Lehrer, from his song, The Old Dope Peddler, the kids of today are the customers of tomorrow.

There are several large epidemiological studies showing a strong association between depressive conditions, and major depression and nicotine dependence, and how the presence of either make quitting more difficult. In one study, drawing on a large national database, the investigators found that smoking rates increased and quit rates decreased as depressive symptoms increased (Anda, R.F., Williamson, D.F., Escobedo, L.G., Mast, E.E., Giovino, G. A. & Remington, P.L., 1990).

With a nine-year follow-up in this same study, there was an 18 percent quit rate in smokers who were not depressed, but only a 10 percent quit rate for the depressed smokers (nearly twice the quit rate for non-depressed smokers). In another large epidemiological-based study, investigators found a strong association between cigarette smoking and major depression (Glassman, A. H., Helzer, J.E., Covey, L. S., Cottler, L.B, Steiner, F., Tipp JS, et. al., 1990). Strikingly, the lead author of the article described how he observed recent quitters develop a gradual onset (over weeks) of severe depression and almost immediate relief within hours of smoking. In an editorial accompanying these two articles, the associate editor of the Journal of the American Medical Association concluded that the data was consistent with and endorsed the self-medication hypothesis (Glass, 1990).

Conclusion

As humans we face lifelong challenges to regulate our emotions, self-esteem, relationships and behaviors.

Addictive drugs interact with the pain and distress these challenges can produce. For some, these challenges are greater than for others. Because of extreme distress or susceptibility to psychiatric illness and behavioral disorders, certain individuals suffer in the extreme, with self-regulation difficulties. Individuals self-medicate with addictive drugs because they provide short-term relief, or make more tolerable psychological pain or the distress associated with psychiatric disorders.

Edward J. Khantzian, MD is Clinical Professor of Psychiatry, Harvard Medical School and Associate Chief of Psychiatry at Tewksbury Hospital. He is President and Chairman of the Board of Directors of Physician Health Services, a subsidiary of the Massachusetts Medical Society. Dr. Khantzian is one of the founders of the American Academy of Addiction Psychiatry and is a past-president of that organization.

References

Anda, R.F., Williamson, D.F., Escobedo, L. G., Mast, E. E., Giovino, G. A., & Remington, P.L. (1990). Depression and the dynamics of smoking: a national perspective. Journal of the American Medical Association. 264:1541-5.
Brady K., Anton R., Ballenger J.C., et. al. (1990). Cocaine abuse among schizophrenic patients. Am J Psychiatry. 147:1164-1167.
Breslau, N., Kilbey, M. M., & Andreski, P. (1993a). Vulnerability to psychopathology in nicotine dependent smokers: an epidemiologic study of young adults. American Journal of Psychiatry. 150:941-6.
Glass, R. (1990). Blue mood, blackened lungs: depression and smoking. Journal of the American Medical Association 264:1583-4.
Glassman, A. H., Helzer, J.E., Covey, L. S., Cottler, L. B, Steiner, F., Tipp JS, et. al. (1990). Smoking, smoking cessation, and major depression. Journal of the American Medical Association 264:1546-9
Hughes, J. (2005). Gambling and Addiction Conference: Finding Common Ground on Prevention, Treatment, and Policy, Las Vegas Nevada. December 7, 2005. 
Hughes, JR. (2001). Why does smoking so often produce dependence? A somewhat Different view. Tobacco Control 10: 62-64.
Kessler, R. C., Crum, R. M., Warner, L. A., Nelson, C. B. et. al. (1997). Lifetime co-occurrence of DSM-III-R alcohol abuse and dependence with other psychiatric disorders in the nation comorbidity survey. Archives of General Psychiatry 54:313-321.
Khantzian E.J. (1985). The self-medication hypothesis of addictive disorders: focus on heroin and cocaine dependence. American Journal of Psychiatry 142(11):1259-1264.
Khantzian E.J. (1997). The self-medication hypothesis of substance use disorders: reconsideration and recent applications. Harvard Review of Psychiatry 4(5):231-244.
Khantzian E.J. (1995). Self-regulation vulnerabilities in substance abusers: Treatment implications. In: Dowling S, ed. The psychology and treatment of addictive behavior.  New York: International University Press.17-41.
Khantzian E.J. (1983). An extreme case of cocaine dependence and marked improvement with methylphenidate treatment. Am J Psychiatry 140:784-785.
Levin, F., et al. (2006). Workshop: Stimulant Pharmocotherapy in Patients with Substance Use Disorders. American Academy of Addiction Psychiatry Annual Scientific Conference, St. Petersburg, Fla., December, 2006.
Ouimette, P. & Brown, P.J. eds. (2004). Trauma and Substance Abuse: Causes, and Consequences, and Treatment of Comorbid Disorders. Washington, DC: 61:
587-588.
Serper, M. R., Albert, M., Richardson, N. A, Dickson, S., Allen, M., & Werner, A. (1995). Clinical effects of recent cocaine use on patients with acute schizophrenia.  American Journal of Psychiatry 152:1464-9.
Vereby, K., ed. (1982). Opioids in Mental Illness. Theories, Clinical Observations, and Treatment Possibilities. Vol. 398.  New York: Annals of the New York Academy of Sciences.
Wilens, T. & Biederman, J. (2006). Alcohol, drugs, and attention-deficit/hyperactivity disorder: a model for the study of addiction in youth. Journal of Psychopharmacology 20:580-588. 
Ziedonis, D.M., Kosten, T.R., Glazer & W.M., Frances, R.J. (1994). Nicotine dependence and schizophrenia. Hosp. Community Psychiatry. 54:204-206.

Comments

Add New Search RSS

Write comment
Name:
Email:	do not notifynotify
Title:
	Please input the anti-spam code that you can read in the image.

Powered by !JoomlaComment 3.26

3.26 Copyright (C) 2008 Compojoom.com / Copyright (C) 2007 Alain Georgette / Copyright (C) 2006 Frantisek Hliva. All rights reserved."