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| Addiction: Disease, Symptom or Choice? |
| Feature Articles - Research/Scientific | |
| Friday, 30 November 2001 | |
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The alternatives in the title of this article are often raised and pitted against each other to explain the nature of addictive conditions. One would not be far off in answering, "true, true, true," since depending on the phase of addictive illness any of the three options might be correct. (At one point, considering the questions raised in the title led me to conclude, "I am not sure.") My reason for coming to such a conclusion is that we often act like we know more than we actually do when it comes to addressing complex issues, which surely is the case regarding the determinants of addiction. For some, addictive illness takes an unrelenting devastating course with all the characteristics of a malignant disease; for others dependency on substances seems to be symptomatically related to a stressful or distressful phase of a person's life and the reliance on drugs or alcohol is transitory and a temporary aberration; and yet for others they simply chose to stop for reasons that are not always clear. Addiction - the drug and the brain If one focuses on the drugs and what happens in the brain, then we are drawn to consider addictive mechanisms, and are more likely to come to the conclusion that an addiction is more like a disease. There is an axiom in the world of addictions field that "we drink a lot because we drink a lot." This axiom is strongly associated with two very important physiologic or addictive processes involved in addictions - tolerance and physical dependence. Tolerance means that an individual needs more and more of the drug to obtain the same effect. Physical dependence means once a person is habituated, abrupt cessation of the drug will result in painful signs and symptoms of physical withdrawal. Although tolerance and physical dependence are more commonly associated with advanced phases of addictive disease, early in the course of addiction to a substance an individual can develop more subtle signs of physical tolerance and withdrawal. This might be evident in states of tension or edginess around "cocktail hour" where, without realizing it, one's need for a drink is being dictated by a chronic state of mild, sub-clinical withdrawal. Obviously in the more extreme cases, the withdrawal is not subtle at all and can be either very painful or life threatening, or both. "Choice" is progressively diminished as the "disease" progresses. That is, the person does not simply choose to drink - they have to drink (or drug). As most addiction professionals know, the disease-symptom-choice debate is one that is hotly debated and often too readily reduced to polarized, either-or arguments. Such debates usually fail to distinguish the reasons for first getting hooked, the reasons for staying hooked, and the reasons for relapse once a person achieves abstinence. Addictive vulnerability - the drug and the person In my own work, I have been mainly interested in the psychological determinants that predispose an individual to become dependent on drugs, including alcohol. Whereas the addictive process that I have just described refers to what is going on in the brain, "addictive vulnerability" refers to what is going on in the person. A term that has come into common usage over the past decade is that drugs "hijack the brain." The employment of this term is not surprising. Over the last quarter of the 20th century, with modern neuro-imaging technology, we have much more clearly mapped and delineated brain structures and function, including how and where in the brain addictive substances go and where they have their effects. Taking such a focus, investigators refer to addictive drugs "hijacking the reward centers of the brain." Indeed this is a parsimonious and useful paradigm taken from such a perspective. If one adopts a perspective that focuses more on human psychological factors involved in the addictions, a perspective not often enough considered, especially in the era of the brain, then it is just as reasonable to conclude that addictive drugs hijack the emotional brain. It is a person, not the brain or a neurosynapse, that picks up a drink or drug. The act is more often a complex one which involves neurophysiologic factors. But it also involves the inner emotional life of person as well as their characteristic ways of dealing with their distress and adaptation to external realities. These factors involve an interaction of one's developmental (growing-up/parenting) environment and their genetic constitution. A case vignette A patient, Bob, with whom I was working in group psychotherapy, provided an opportunity to appreciate how his constitution and early life experiences interacted with the effects of alcohol (Khantzian, 2001). He vividly described how a long-standing sense of feeling constricted and discomforted was dramatically reversed when he took his first drink. He said he always felt lonely and isolated as a child and recalled a pervasive sense of "restriction, suppression, repression, oppression, and depression." Bob was a man who in his life and in the group was not disposed to exaggeration or hyperbole so what he revealed during this characterization of himself in group was of even greater import. After a careful description of the atmosphere around the preparation of his first drink, a gin martini, he described its effect. He said, "I began to feel free - free to feel. I felt happy, even giddy - unashamed, unpretentious, and uninhibited. I felt that I finally was a member of the human race, Ôone of the guys,' and equal to others." If a clinician believes that the effects of a drug on a person are important and in the short term accomplish something for them, then it is not uncommon for patients to convey and for clinicians to hear how addictive drugs can seem like a magic elixir or antidote for inner states of distress. This is what I like to refer to as inner states of "dysphoria," and this clearly was the case for Bob. His reaction could simply be reduced to a disinhibiting effect of alcohol to explain his experience. Some refer to this effect as that of dissolving a person's conscience or "super-ego." I think a better explanation would be to consider the dissolving effects on a person's characteristic defenses or ways of being. To say it another way, alcohol is at least as good an ego solvent as it is a super-ego solvent. The storytelling traditions in group therapy (as well as in AA) provide a powerful vehicle to reveal and understand the nature of an individual and how they suffer. In my estimation, Bob was describing in group the nature of his makeup or the way he had developed in his ego (psychological structures) to cause him to experience life in a particular way - a combination of feeling restricted and uncomfortable - which reacted powerfully with alcohol to make him less restricted and more comfortable. It is in this respect that I think alcohol was hijacking Bob's emotions. The human challenge of self-regulation Bob's case reveals a central challenge for us as human beings, namely the challenge of self-regulation. Early psychoanalysts referred to "survival instincts," but it turns out that our survival (contrary to sub-human species) depends less upon instincts and more upon capacities acquired from our caretaking environment that provide us with (ego) capacities to cope with our inner emotional life and our adjustment to external realities. When they are adequately developed and flexible, we are better equipped to feel comfortable about our own selves, relationships, emotions, and behaviors (especially self-care). These capacities are more or less developed and remain a life-long challenge for most of us to evolve and maintain. When less well developed we are more prone to having difficulty in regulating ourselves. In more extreme cases such as substance abuse and dependence, I consider such conditions as a self-regulation disorder (Khantzian 1990, 1995, 1999). Use of and dependence on substances become a means to compensate for deficits in our ability to regulate our sense of self, our relationships, our emotions, and our self-care. Drugs, including alcohol, are attempts at self-correction which ultimately fail. The problem and the advantage is that, at first, substances of abuse work. It is this aspect of reliance on drugs that cause our patients and clients to first get hooked. The same processes also are more often involved in relapse. As already indicated, the more one uses a substance the more physiological/addictive factors take over to maintain the addiction. In my experience, however, the reasons for getting hooked, continuing to use, and relapsing once abstinent, are powerfully determined by the "discovery" that a particular drug ameliorates or relieves their inner states of disharmony or suffering. Each class of drugs produces different subjective effects, and depending upon what particular emotions predominate in an individual (e.g., rage, depression, tension, anxiety), he or she will discover a "drug-of-choice" (Weider & Kaplan, 1969) or a "drug-of-preference" (Milkman & Frosch, 1973) that best compensates for the pain associated with these emotions when they are intense or unbearable. The discovery that, a) abused drugs relieve suffering, and b) that there is a degree of psychopharmacologic specificity in drug preference has come to be referred to as the "self-medication hypothesis" of addictive disorders (Khantzian, 1985, 1990, 1997, 1999). Although considered controversial by some (Miller, 1994; Vaillant, 1983; Frances, 1997), I believe it offers a powerful explanation in understanding why individuals become and remain dependent on various drugs and why relinquishing their dependence becomes so difficult. Depressants, as Bob's case with alcohol reveals, are very seductive for such individuals because it allows them to feel and express themselves where they are otherwise restricted, overly contained, and dysphoric. In addition, if overwhelmed, high doses of alcohol can obliterate painful or unbearable emotions. In contrast, analgesic opiates are powerful agents to mute and contain rage and aggression which might otherwise be unmanageable. Stimulants such as cocaine and amphetamine cast a wide net because they appeal to both de-energized and hyper-energized individuals. For the former, they activate and help to overcome depressive and anhedonic states; for the latter they augment high-energy states often, for example, in hypomanic individuals; and stimulants also paradoxically calm and focus those who suffer with attentional-hyperactive disorders (ADHD). I realize I have gone into some considerable depth on the "person" or psychological side of the equation. I have done so to provide a basis for demonstrating how addictive mechanisms and the disease concept of addiction cannot be easily separated out from the psychological or symptomatic aspects of addictive disorders, or why sometimes certain individuals simply seem to "choose" to stop or not use. Addictive process - where psychology and biology meet In trying to unravel the "disease-symptom-choice" debate I would refer to the interactions involved as addictive process, a process where psychological and biological factors powerfully converge. In doing so, perhaps I might shed a clearer light on the complex nature of what determines certain features, in a particular phase of addictive illness. On the psychological side, as I have indicated, there is a Ôself-selection" (Khantzian, 1975) or self-medication aspect of addiction in which our patients, short term, discover what drugs work best for them. An illusion is created of "better living through chemistry." However, sooner or later (e.g. with cocaine, most discover it sooner rather than later given its devastating effects) the chemical solution fails, because in the addictive process, another problem develops which I refer to as "disuse atrophy." This term is derived from orthopedics and neurology, referring to how muscles waste away when a limb is not used, such as when a cast is used to mend a bone fracture. The mind is similarly affected when chronic drug use interferes with a person using and developing their psychological capacities (cognitive, perceptual, emotional) to deal with life challenges. Drug dependence blocks normal psychological growth and development. That is, psychological capacities do not develop or they atrophy. Considered in this context, the issue of "choice" becomes an option that is more and more difficult to exercise. Besides the fact that physical dependence makes choice more unlikely, the chronic repetition of meeting a wide range of human challenges and situations by resorting to substances (i.e., discomfort, relationships, sex, work, play, etc.), makes it all the more probable that drug use progressively becomes the only option. The addict uses because they have to. Their choice to do something different is progressively restricted. Compulsion and choice The need to regulate oneself chemically and the brain changes resulting from heavy drug use create a powerful compulsion. Psychology intersects with biology in an addicted individual where their reliance on substances becomes more a matter of need rather than choice. However, this is not an absolute or inevitable outcome. As already indicated, with progression of addictive disorders there is less and less choice. Nevertheless, in all phases of this disorder cessation eventually, if not more often, occurs. There are few successful addicts because the ravages of addiction force a person to eventually stop or else they die. The pathways to abstinence and recovery are multiple and varied. In brief, professional, self-help, and spiritual pathways help individuals to relinquish their reliance on drugs. The choice to then use or not use rests increasingly on the degree to which the person who was addicted has learned to contain and transform those parts that predisposed them to find the effects of the drugs so compelling. This usually means the acceptance of help from others, whether it be a safe and comfortable detoxification, the containing and transforming fellowship of self-help groups, the empathic guidance of a skilled clinician, or a well-trained psychopharmacologist who might effectively target symptoms which the patient might otherwise self-medicate. Edward J. Khantzian, MD, is Clinical Professor of Psychiatry, Harvard Medical School, and a founding member of the Department of Psychiatry at The Cambridge Hospital. He has spent more than 30 years studying psychological factors associated with drug and alcohol abuse. Dr. Khantzian is a practicing psychiatrist and psychoanalyst, participant in numerous clinical research studies on substance abuse, and lecturer and writer on psychiatry, psychoanalysis, and substance abuse problems. References Frances, R.J. (1997). The wrath of grapes versus the self-medication hypothesis. Harvard Review of Psychiatry 4:287-289. Khantzian, E.J. (1975). Self-selection and progression in drug dependence. Psychiatry Digest 10:1 9-22. Khantzian, E. J. (1985). The self-medication hypothesis of addictive disorders. American Journal of Psychiatry 142:1259-1264. Khantzian, E. J. (1990). Self-regulation and self-medication factors in alcoholism and the addictions: Similarities and differences. Recent Developments in Alcoholism, Volume 8, ed. M. Galanter, pp. 225-271. New York: Plenum Publishing Corp. Khantzian, E. J. (1995). Self-regulation vulnerabilities in substance abusers: Treatment implications. The Psychology and Treatment of Addictive Behavior, ed. S. Dowling, pp. 17-41. Madison, Connecticut: International Universities Press. Khantzian, E. J. (1997). The self-medication hypothesis of substance use disorders: A reconsideration and recent developments. Harvard Review of Psychiatry 4:231-244. Khantzian, E. J. (1999). Treating Addictions as a Human Process. Northvale, New Jersey: Jason Aronson, Inc. Khantzian, E. J. (2001). Reflections on group treatments as corrective experiences for addictive vulnerability. International Journal of Group Psychotherapy 51:11-20. Milkman, H., and Frosch, W.A. (1973). On the preferential abuse of heroin and amphetamine. Journal of Nervous and Mental Disease 156:242-248. Miller, N. S. (1994). The interaction between co-existing disorders. Treating Co-existing Psychiatric and Addictive Disorders: A Practical Guide, ed. N. S. Miller, pp. 7-21. Center City, Minnesota: Hazelden. Vaillant, G. E. (1983). The Natural History of Alcoholism. Cambridge, Harvard University Press. Weider, H., and Kaplan, E. (1969). Drug use in adolescents. Psychoanalytic Study of the Child 24: 399-431.              |
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