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

Abstract

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.

Enhanced Sensitivity to the Euphoric Effects of Alcohol in Schizophrenia

“…Further, the effects of alcohol on any of the measures was not influenced by whether subjects were receiving typical or atypical antipsychotics. The results of this study do not support the 'selfmedication' hypothesis of alcohol and substance use in schizophrenia (Khantzian, 1997); alcohol did not reduce any of the core symptoms of the illness similar to a related laboratory study with delta-9-tetrahydrocannabinol (D 'Souza et al, 2005). However, this study excluded alcohol-abusing subjects who may arguably derive 'benefit/s' from alcohol.…”

Childhood predictors of adolescent substance use in a longitudinal study of children with ADHD.

“…The psychostimulant properties of this drug, combined with easy access and decreased legal sanctions compared to nonprescribed stimulant or cocaine use, suggest that children with ADHD might be particularly susceptible to cigarette smoking in adolescence. Specifically, speculations have arisen regarding the propensity for children with ADHD to abuse stimulant-type substances because of the attention-enhancing pharmacologic properties in these drugs (e.g., tobacco, amphetamines, cocaine) that are similar to those of methylphenidate and other central nervous system (CNS) stimulants (Khanzian, 1997;Milberger et al, 1997). Laboratory-based studies of attentional performance have found improvements in vigilance with nicotine challenges for both ADHD and non-ADHD adults (Conners et al, 1996;Levin et al, 1998).…”

Does substance use disorder affect clinical expression in first-hospitalization patients with schizophrenia? Analysis of a prospective cohort

“…Conversely hostility, unusual thought contents, uncooperativeness, and hallucinatory behavior became significantly higher among SUD only one week after admission and lost significance at discharge suggesting that they could be supported by several incoming conditions such as pharmacological side effects or treatment refractory as well as substance withdrawal. Tension is the only item that has become significantly higher in SUD during hospitalization and remained higher at discharge, therefore it could be either an long-term consequence of substance withdrawal or a previous more marked feature of patient with SUD that could have induced a "self-medication" behavior (Khantzian, 1997). Otherwise conceptual disorganization defined by BPRS manual as an affection of thought processes with tangentially, circumstantially and sudden topic shifts is the BPRS dimension that most resembles the bleulerian concept of "spaltung" and it is higher at all three stages of observation in SUD group, regardless of substance withdrawal influences, confirming a worst clinical expression of schizophrenia in patients with SUD.…”