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

Khantzian, Edward J. MD^1,2,3,†

¹Department of Psychiatry, Harvard Medical School, Boston, Mass

²The Cambridge Hospital, Cambridge, Mass

³Tewksbury Hospital, Hathorne Units, Tewksbury, Mass

^†Correspondence: Edward J. Khantzian, Department of Psychiatry, Tewksbury Hospital, 365 East St., Tewksbury, MA, 01876

Original manuscript received 4 April 1996, accepted for publication 30 April 1996; revised manuscript received 20 May 1996.

For comments on this viewpoint, see “The Wrath of Grapes versus the Self-Medication Hypothesis,” by Richard J. Frances, later in this issue.

Harvard Review of Psychiatry 4(5):p 231-244, January 1997. | DOI: 10.3109/10673229709030550

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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.