User:Edward J. Khantzian, MD

Dr. Khantzian is the originator and developer of the self-medication hypothesis (SMH) of addictive disorders. In 1985 the American Journal of Psychiatry published a special cover article featuring his observations on how and why individuals become addicted to heroin and cocaine. In an update of the SMH in the Harvard Review of Psychiatry in 1997, he updated the SMH and considered how it applies to nicotine dependence, schizophrenia, and PTSD. The SMH proposes that addictive drugs have their appeal and become compelling principally for two reasons: (1) they relieve human psychological suffering and, (2) there is a considerable degree of specificity in a person’s drug-of-choice. With regard to specificity, clinical experience reveals that individuals resort to more than one class of drugs, often a function of availability wherein they will juggle doses of other drugs to simulate their drug-of- choice, but when pursued more closely an individual will indicate a drug preference. The following is the description of the appeal of the main class of addictive drugs taken from the 1997 update of the SMH: •		Opiates. Besides their general calming and “normalizing” effect, opiates attenuate intense, rageful, and violent affect. They counter the internally fragmenting and disorganizing effects of rage and the externally threatening and disruptive effects of such affects on interpersonal relations. •	Central nervous system depressants (including alcohol). Alcohol’s appeal may reside in its properties as a “superego solvent. However, in my own experience, and based on observations by Krystal, short-acting depressants with rapid onset of action (e.g., alcohol, barbiturates, benzodiazepines) have their appeal because they are good “ego solvents.” That is, they act on those parts of the self that are cut off from self and others by rigid defenses that produce feelings of isolation and emptiness and related tense/anxious states and mask fears of closeness and dependency. Although they are not good antidepressants, alcohol and related drugs create the illusion of relief because they temporarily soften rigid defenses and ameliorate states of interpersonal isolation and emptiness that predispose to depression. •	Stimulants. Stimulants act as augmentors for hypomanic, high-energy individuals as well as persons with atypical bipolar disorder. They also appeal to people who are de-energized and bored, and to those who suffer from depression. In addition, stimulants, including cocaine, can act paradoxically to calm and counteract hyperactivity, emotional lability, and inattention in persons with attention-deficit/ hyperactivity disorder (Khantzian 1983, 1985).