Drug, Addiction and the Brain

296 Pages·2014·28.36 MB·English

by  George F. Koob, Michael A. Arends and Michel Le Moal

C H A P T E R
1
What is Addiction?
O U T L I N E
Definitions of Addiction 1 Vulnerability to Addiction 11
Drug Use, Drug Abuse, and Drug Addiction 1
Neuroadaptational Views of Addiction 20
Diagnostic Criteria for Addiction 4
Behavioral Sensitization 20
Frequency and Cost of Addiction 5
Counteradaptation and Opponent Process 21
Patterns of Addiction 6
Motivational View of Addiction 22
The “Dependence” View of Addiction 7
Allostasis and Neuroadaptation 25
Psychiatric View of Addiction 8
Psychodynamic View of Addiction 8 Summary 26
Social Psychological and Self-Regulation
Suggested Reading 27
Views of Addiction 11
DEFINITIONS OF ADDICTION drug use, the loss of control over limiting drug
intake, and the emergence of chronic compul-
Drug Use, Drug Abuse, and Drug sive drug seeking that characterize addiction.
Historically, three types of drug use have been
Addiction
delineated:
Drug addiction, formerly known as substance
1) Occasional, controlled, or social use,
dependence (American Psychiatric Association,
2) Drug abuse or harmful use, and
1994), is a chronically relapsing disorder that is
3) Drug addiction as characterized as either
characterized by:
Substance Dependence (Diagnostic and
1) A compulsion to seek and take a drug, Statistical Manual of Mental Disorders, 4th
2) Loss of control in limiting intake, and edition [DSM-IV]) or Dependence (see
3) Emergence of a negative emotional state below, and Tables 1.1 and 1.2).
(e.g., dysphoria, anxiety, irritability) when
More current descriptions have elaborated a
access to the drug is prevented.
continuum of behavioral pathology, from drug
The occasional but limited use of an abus- use to addiction, in the context of substance use
able drug is clinically distinct from escalated disorders.
Drugs, Addiction, and the Brain
1
http://dx.doi.org/10.1016/B978-0-12-386937-1.00001-5 © 2014 Elsevier Inc. All rights reserved.
2
1. WHAT IS ADDICTION?
TABLE 1.1 DSM-5, DSM-IV, and ICD-10 Diagnostic Criteria for Abuse and Dependence
DSM-5 DSM-IV ICD-10
DEPENDENCE
A problematic pattern of substance use A maladaptive pattern of substance use, Three or more of the following have
leading to clinically significant impairment leading to clinically significant impairment been experienced or exhibited at
or distress, as manifested by at least two of the or distress as manifested by three or more of some time during the previous year
following occurring within a 12 month period the following occurring at any time in the
same 12-month period
1. Tolerance is defined by either of the 1. Need for markedly increased 1. E vidence of tolerance, such
following: a) a need for markedly amounts of a substance to achieve that increased doses are
increased amounts of substance to intoxication or desired effect; or required in order to achieve
achieve intoxication or desired effect markedly diminished effect with effects originally produced by
b) a markedly diminished effect with continued use of the same lower doses.
continued use of the same amount of amount of the substance.
substance.
2. Withdrawal is manifested by either of 2. The characteristic withdrawal 2. A physiological withdrawal
the following: a) the characteristic syndrome for a substance or use state when substance
withdrawal syndrome for substance or of a substance (or a closely related use has ceased or been
b) substance is taken to relieve or avoid substance) to relieve or avoid reduced as evidenced by:
withdrawal symptoms. withdrawal symptoms. the characteristic substance
withdrawal syndrome,
or use of substance (or a
closely related substance) to
relieve or avoid withdrawal
symptoms.
3. There is persistent desire or 3. Persistent desire or one or more 3. D ifficulties in controlling
unsuccessful efforts to cut down or unsuccessful efforts to cut down or substance use in terms of
control substance use. control substance use. onset, termination, or levels
of use.
4. Substance is often taken in larger 4. Substance used in larger amounts or None
amounts or over a longer period than over a longer period than the person
was intended. intended.
5. Important social, occupational, or 5. Important social, occupational, or 4. P rogressive neglect of
recreational activities are given up or recreational activities given up or alternative pleasures or
reduced because of substance use. reduced because of substance use. interests in favor of substance
use; or
6. A great deal of time is spent in 6. A great deal of time spent in A great deal of time spent in
activities necessary to obtain activities necessary to obtain, to activities necessary to obtain,
substance, use substance, or recover use, or to recover from the effects of to use, or to recover from
from its effects. substance used. the effects of substance use.
7. Continued substance use despite 7. Continued substance use despite 5. C ontinued substance use
having persistent or recurrent social or knowledge of having a persistent or despite clear evidence of
interpersonal problems caused recurrent physical or psychological overtly harmful physical or
or exacerbated by the effects of problem that is likely to be caused or psychological consequences.
substance. exacerbated by use.
None None 6. A strong desire or sense of
compulsion to use
substance.
Continued
DEfINITIONS Of ADDICTION 3
TABLE 1.1 DSM-5, DSM-IV, and ICD-10 Diagnostic Criteria for Abuse and Dependence—cont’d
DSM-5 DSM-IV ICD-10
ABUSE
A maladaptive pattern of substance use A pattern of substance use that is
leading to clinically significant impairment causing damage to health.
or distress, as manifested by one (or more)
of the following occurring with a 12 month
period
8. Substance use is continued despite 1. Recurrent substance use resulting in The damage may be physical or
knowledge of having a persistent or a failure to fulfill major role mental. The diagnosis requires that
recurrent physical or psychological obligations at work, school, or home. actual damage should have been
problem that is likely to have been caused to the mental or physical
caused or exacerbated by substance health of the user
9. Recurrent use in situations in which it 2. Recurrent substance use in situations
is physically hazardous in which use is physically hazardous.
None 3. Recurrent substance-related legal
problems.
10. Recurrent substance use resulting in a 4. Continued substance use despite
failure to fulfill major role obligations having persistent or recurrent social
at work, school or home or interpersonal problems caused or
exacerbated by the effects of the drug.
11. Craving or a strong desire or urge to None None
use alcohol (or other substance)
TABLE 1.2 Estimated Number and Percentage of Persons of the US Population Aged 12 and Older (N = 258 Million)
Who Ever Used Alcohol, Tobacco, Cannabis, Cocaine, Heroin, or Prescription Opioids, the Number
and Percentage Who Used these Drugs in the Last Year, the Number and Percentage Who Ever Showed
Dependence (DSM-IV Criteria; See Text) in the Last Year, and the Number and Percentage Who Showed
Abuse or Dependence (DSM-5 Criteria; See Text) in the Last Year
Last-Year Use with Last-Year Use with
Ever Used Last-Year Use Dependence Abuse or Dependence
Drug Millions % Millions % Millions % Millions %
Cocaine 36.9 14.6 3.9 1.5 0.58 14.5 0.82 21.1
Stimulants 20.4 7.2 2.7 1.0 0.25 9.3 0.33 12.9
Methamphetamine 11.9 4.6 1.0 0.4 – – – –
Heroin 4.2 1.7 0.6 0.2 0.37 57.0 0.43 65.5
Analgesics 34.2 13.5 11.1 4.3 1.4 12.7 1.8 16.5
Alcohol 211.7 82.1 170.4 65.9 7.8 4.6 16.7 9.8
Tobacco 173.9 67.5 81.9 31.8 – – – –
Cigarettes* 161.8 62.8 67.1 26.1 22.9 34.2 22.9 34.2
Cannabis 107.8 42.0 29.7 11.5 2.6 8.8 4.2 13.9
* There is no abuse category for cigarettes, so the third and fourth columns of the table are identical.
Data from Substance Abuse and Mental Health Services Administration, National Survey on Drug Use and Health, 2011
4
1. WHAT IS ADDICTION?
Diagnostic Criteria for Addiction edition of the DSM (DSM-IV) and ICD-10, with
the exception of the removal of “committing
The diagnostic criteria for addiction, as illegal acts” and the addition of a new “craving”
described in the DSM, have evolved from the criterion. For example, rather than differentiat-
first edition published in 1952 to DSM-IV, with ing “alcoholics” and “alcohol abusers,” the new
a shift from an emphasis on the criteria of tol- classification Substance Use Disorder on Alco-
erance and withdrawal to other criteria which hol encompasses individuals who are afflicted
are more directed at compulsive use. The crite- by the disorder to different degrees, from “mild”
ria for Substance Use Disorders outlined in the (e.g., a typical college binge drinker who meets
DSM-IV closely resemble those outlined in the two criteria, such as alcohol is often taken in
International Statistical Classification of Diseases larger amounts or over a longer period than
and Related Health Problems (ICD-10) for Drug was intended and there is a persistent desire or
Dependence (World Health Organization, 1992; unsuccessful efforts to cut down or control alco-
Table 1.1). The DSM-5 was published in 2013 hol use) to “severe” (e.g., a classic person with
(American Psychiatric Association, 2013). In alcoholism who meets six or more criteria, such
this, the criteria for drug addiction have changed as a great deal of time spent in activities neces-
both conceptually and diagnostically. The new sary to obtain alcohol, use alcohol, or recover
diagnostic criteria for addiction merge the abuse from its effects, recurrent alcohol use resulting in
and dependence constructs (i.e., substance a failure to fulfill major role obligations at work,
abuse and substance dependence) into one con- school, or home, alcohol use despite knowledge
tinuum that defines “substance use disorders” of having a persistent or recurrent physical or
on a range of severity, from mild to moderate to psychological problem, continued alcohol use
severe, based on the number of criteria that are despite persistent social or interpersonal prob-
met out of a total of 11. The severity of a sub- lems, tolerance, and withdrawal).
stance use disorder (addiction) depends on how The terms Substance Use Disorder and Addic-
many of the established criteria are met by an tion will be used interchangeably throughout
individual. Mild Substance Use Disorder is the this book to refer to a usage process that moves
presence of 2–3 criteria, moderate is 4–5 criteria, from drug use to addiction as defined above.
and severe is six or more criteria. These criteria Drug addiction is a disease and, more precisely,
remain basically the same as in the previous a chronic relapsing disease (Figures 1.1 and 1.2).
FIGURE 1.1 Last-year use with abuse or dependence (data from Substance Abuse and Mental Health Services Administration,
National Survey on Drug Use and Health, 2011; see Table 1.2).
DEfINITIONS Of ADDICTION 5
FIGURE 1.2 Stages of addiction to drugs
of abuse. Drug taking invariably begins with
social drug taking and acute reinforcement and
often, but not exclusively, moves in a pattern of
use from escalating compulsive use to depen-
dence, withdrawal, and protracted abstinence.
During withdrawal and protracted abstinence,
relapse to compulsive use is likely to occur
with a repeat of the cycle. Genetic factors, envi-
ronmental factors, stress, and conditioning all
contribute to the vulnerability to enter the cycle
of abuse/dependence and relapse within the
cycle. [Taken with permission from Koob GF, Le
Moal M. Neurobiology of Addiction. Academic
Press, London, 2006.]
The associated medical, social, and occupa- tobacco, 32% of the population used tobacco in the
tional difficulties that usually develop during last year. For cannabis, 13.9% of last-year users met
the course of addiction do not disappear after the criteria for Substance Abuse or Dependence on
detoxification. Addictive drugs produce changes cannabis. For cocaine, 21.1% of last-year users met
in brain circuits that endure long after the person the criteria for Substance Abuse or Dependence on
stops taking them. These prolonged neurochem- cocaine. For heroin, 65.5% of last-year users met
ical and neurocircuitry changes and the associ- the criteria for Substance Abuse or Dependence on
ated personal and social difficulties put former heroin.
patients at risk of relapse, a risk that is > 60% The cost to society of drug abuse and drug
within the first year after discharge. addiction is prodigious in terms of both the
direct costs and indirect costs associated with
secondary medical events, social problems, and
Frequency and Cost of Addiction
loss of productivity. In the United States alone,
A shortcut for examining the frequency of sub- illicit drug use and addiction cost society $161
stance use disorders is to utilize a combination of billion per year in 2011. Alcoholism cost society
the percentage of individuals who have drug abuse $223 billion per year in 2012, and nicotine addic-
and drug dependence as defined by the DSM-IV, tion costs society $155 billion. In terms of health
since no data are yet available for the frequency of burden, alcohol and tobacco use are in the top 10
substance use disorders based on the DSM-5 cri- greatest risk factors for loss of years to disease
teria. Combining the old drug abuse and depen- and disability.
dence criteria yields an approximate percentage Much of the initial research into the neu-
of 15% (38.6 million people as of 2011) for the U.S. robiology of drug addiction focused on the
population who are 12 or older who suffered from acute impact of drugs of abuse (analogous to
Substance Use Disorders for alcohol, tobacco, or comparing no drug use to drug use). The focus
illicit drugs in the last year (Table 1.2). For alco- has shifted to chronic administration and the
hol, 9.8% of last-year users met the criteria for acute and long-term neuroadaptive changes
Substance Abuse or Dependence on Alcohol. For that occur in the brain. Sound arguments have
6
1. WHAT IS ADDICTION?
been made to support the hypothesis that drug taking, intense initial intoxication, the
addictions are similar to other chronic relaps- development of profound tolerance, escalation
ing disorders, such as diabetes, asthma, and in intake, and profound dysphoria, physical dis-
hypertension, in their chronic relapsing nature comfort, and somatic withdrawal signs during
and treatment efficacy (for further reading, see abstinence (Box 1.1). Intense preoccupation with
McLellan et al., 2000). Current neuroscientific obtaining opioids (craving) develops and often
drug abuse research seeks to understand the precedes the somatic signs of withdrawal. This
cellular and molecular mechanisms that medi- preoccupation is linked to stimuli associated
ate the transition from occasional, controlled with obtaining the drug, stimuli associated with
drug use to the loss of behavioral control over withdrawal, and internal and external states of
drug seeking and drug taking that defines stress. A pattern develops in which the drug
chronic addiction. must be administered to avoid the severe dys-
phoria and discomfort of abstinence.
Alcohol substance use disorder or alco-
Patterns of Addiction
holism follows a somewhat different pattern
Different drugs produce different patterns of of drug taking that depends on the sever-
addiction, with an emphasis on different com- ity of the disorder. The initial intoxication is
ponents of the addiction cycle. Opioids are a less intense than opioids, and the pattern of
classic drug of addiction, in which an evolving drug taking often is characterized by binges
pattern of use includes intravenous or smoked of alcohol intake that can be daily episodes or
BOX 1.1
Jimmy pulls out of the graveled driveway she probably is going to the next group session.
onto the smooth asphalt surface of the road. It Dennis’ heart begins to pound – gripped by a
feels so good to drive again after the long months flood of memories about the car, where he and
in “rehab.” No heroin use in over 6 months. ‘‘Not Diana had shared so much cocaine. A wave of
bad,” he congratulates himself. But as he takes intense feeling rushes from the tip of his toes,
the exit to the old neighborhood, his bowels up to his head and back down again. Thoughts
begin to growl. He breaks out in sweat, gripping racing, desire coursing through his body, he
the steering wheel and trying to ignore the raw, turns away from the road home, into the night.
acid taste in the back of his throat. Yawning, eyes As he approaches the familiar buying corner, he
watering, he feels mounting panic, and the desire can taste the cocaine in the back of his throat.
for drugs begins to burn in the pit of his stomach, He is sweating heavily now, ears ringing. “Just
“So much for good intentions,” be mutters, turn- a taste,” he bargains with himself, “just a taste is
ing toward a familiar alley and the drug that will all I’m going to buy.”
make everything right again.
Dennis leaves his cocaine therapy group From: Childress AR, Hole AV, Ehrman RN, Robbins SJ,
McLellan AT, O’Brien CP, Cue reactivity and cue reactivity
full of energy. “I’ve got 30 days clean, and now
interventions in drug dependence. In: Onken LS, Blaine JD,
I’m going for 90!” he yells to a buddy as they Boren JJ (Eds.), Behavioral Treatments for Drug Abuse and
enter their cars. As he leaves the parking lot, a Dependence (series title: NIDA Research Monograph, vol.
137), National Institute on Drug Abuse, Rockville MD, 1993,
familiar white sedan is pulling in – Diana’s car;
pp. 73–95.
DEfINITIONS Of ADDICTION 7
prolonged days of heavy drinking. A binge is craving has been less studied to date, it is most
currently defined by the US National Institute likely linked to both cues and internal states
on Alcohol Abuse and Alcoholism as consum- often associated with negative emotional states
ing five standard drinks for males and four and stress, similarly to other drugs of abuse.
standard drinks for females in a two hour
period, or obtaining a blood alcohol level of
0.08 gram percent. Alcoholism is character- The “Dependence” View of Addiction
ized by a severe emotional and somatic with-
The term “dependence” within the concep-
drawal syndrome and intense craving for the
tual framework of addiction has a confused his-
drug that is often driven by negative emo-
tory. However, discussing the evolution of the
tional states but also by positive emotional
term is instructive. Historically, definitions of
states. Many individuals with alcoholism con-
addiction began with definitions of dependence.
tinue with such a binge/withdrawal pattern
Himmelsbach defined physical dependence as:
for extended periods; for others, the pattern
evolves into opioid-like addiction, in which
“...an arbitrary term used to denote the presence
they must have alcohol available at all times
of an acquired abnormal state wherein the regular
to avoid the consequences of abstinence. administration of adequate amounts of a drug has,
Tobacco addiction contrasts with the above through previous prolonged use, become requisite to
patterns. Tobacco is associated with virtually no physiologic equilibrium. Since it is not yet possible
to diagnose physical dependence objectively with-
binge-like behavior in the binge/intoxication stage
out withholding drugs, the sine qua non of physical
of the addiction cycle. Cigarette smokers who met
dependence remains the demonstration of a charac-
the criteria for substance dependence or depen- teristic abstinence syndrome.”
dence under the DSM-IV and ICD 10 criteria are (Himmelsbach CK. Can the euphoric, analgetic, and
likely to smoke throughout their waking hours physical dependence effects of drugs be separated? IV. With
reference to physical dependence. Federation Proceed-
and experience negative emotional states (dys-
ings, 1943, (2), 201–203).
phoria, irritability, and intense craving) during
abstinence. The pattern of intake is one of highly This definition eventually evolved into the
titrated intake of the drug during waking hours. definition for physical dependence: “intense
Psychostimulants, such as cocaine and physical disturbances when the administration of
amphetamines, show a pattern that has a greater a drug is suspended” (Eddy NB, Halbach H, Isbell
emphasis on the binge/intoxication stage. Such H, Seevers MH. Drug dependence: its significance
binges can last hours or days, often followed by and characteristics. Bulletin of the World Health
a crash that is characterized by extreme dyspho- Organization, 1965, (32), 721–733). However, this
ria and inactivity. Intense craving and anxiety terminology clearly did not capture many of the
occur later and are driven by both environmen- aspects of an addictive process that do not show
tal cues that signify the availability of the drug, physical signs, necessitating the creation of the
and internal states that are often linked to nega- term psychic dependence to capture the behavioral
tive emotional states and stress. aspects of the symptoms of addiction:
Marijuana substance use disorder follows
a pattern similar to opioids and tobacco, with “A condition in which a drug produces ‘a feeling
a significant intoxication stage. As chronic use of satisfaction and a psychic drive that require peri-
continues, subjects begin to show a pattern of odic or continuous administration of the drug to pro-
chronic intoxication during waking hours. With- duce pleasure or to avoid discomfort’…”
(Eddy NB, Halbach H, Isbell H, Seevers MH. Drug
drawal is characterized by dysphoria, irritabil-
dependence: its significance and characteristics. Bulletin of
ity, and sleep disturbances. Although marijuana the World Health Orgaization, 1965, (32), 721–733).
8
1. WHAT IS ADDICTION?
Later definitions of addiction resembled a symptoms will be considered equivalent to
combination of physical and psychic depen- “addiction” remains to be determined.
dence, with more of an emphasis on the psychic
or motivational aspects of withdrawal, rather
Psychiatric View of Addiction
than on the physical symptoms of withdrawal:
From a psychiatric perspective, drug addiction
“Addiction; from the Latin verb ‘addicere,’ to give has aspects of both impulse control disorders and
or bind a person to one thing or another. Generally compulsive disorders. Impulse control disorders
used in the drug field to refer to chronic, compulsive,
are characterized by an increasing sense of ten-
or uncontrollable drug use, to the extent that a person
sion or arousal before committing an impulsive
(referred to as an ‘addict’) cannot or will not stop the
use of some drugs. It usually implies a strong (Psy- act, pleasure, gratification, or relief at the time of
chological) Dependence and (Physical) Dependence committing the act, and regret, self-reproach, or
resulting in a Withdrawal Syndrome when use of guilt following the act (see early versions of the
the drug is stopped. Many definitions place primary
DSM of the American Psychiatric Association). In
stress on psychological factors, such as loss of self-
contrast, compulsive disorders are characterized
control and overpowering desires; i.e., addiction is
any state in which one craves the use of a drug and by anxiety and stress before committing a com-
uses it frequently. Others use the term as a synonym pulsive repetitive behavior and relief from the
for physiological dependence; still others see it as a stress by performing the compulsive behavior.
combination (of the two).”
As an individual moves from an impulsive disor-
(Nelson JE, Pearson HW, Sayers M, Glynn TJ
der to a compulsive disorder, a shift occurs from
(eds.) Guide to Drug Abuse Research Terminol-
ogy. National Institute on Drug Abuse, Rockville MD, positive reinforcement to negative reinforcement
1982). that drives the motivated behavior (Figure 1.3).
Drug addiction progresses from impulsivity to
Unfortunately, the word dependence in this compulsivity in a collapsed cycle of addiction
process has multiple meanings. Any drug can that consists of three stages: preoccupation/antici-
produce dependence if dependence is defined pation, binge/intoxication, and withdrawal/nega-
as the manifestation of a withdrawal syndrome tive affect. Different theoretical perspectives from
upon the cessation of drug use, see above. experimental psychology, social psychology, and
Meeting the ICD-10 criteria for Dependence or neurobiology can be superimposed on these
the DSM-5 criteria for Substance Use Disorder three stages, which are conceptualized as feeding
requires much more than simply manifesting into each other, becoming more intense, and ulti-
a withdrawal syndrome. For the purposes of mately leading to the pathological state known
this book, dependence (with a lowercase “d”) as addiction (Figure 1.4; for further reading, see
will refer to the manifestation of a withdrawal Koob and Le Moal, 1997).
syndrome, and addiction will refer to Depen-
dence as defined by the ICD-10. The terms
Psychodynamic View of Addiction
Dependence (with a capital “D”), addiction, and
alcoholism will be held equivalent for this book. A psychodynamic view of addiction that inte-
The term Substance Use Disorder is defined as grates the neurobiology of addiction was elabo-
a problematic pattern of drug use that leads to rated by Khantzian and colleagues (for further
clinically significant impairment or distress, reading, see Khantzian, 1997) with a focus on the
reflected by at least two the 11 criteria within factors that produce vulnerability to addiction.
a 12 month period (see above). How this clus- This perspective is deeply rooted in the psycho-
ter of cognitive, behavioral, and physiological dynamic aspects of clinical practice developed
DEfINITIONS Of ADDICTION 9
FIGURE 1.3 Diagram showing stages of impulse control disorder and compulsive disorder cycles related to the sources
of reinforcement. In impulse control disorders, increasing tension and arousal occur before the impulsive act, with pleasure,
gratification or relief during the act, and regret or guilt following the act. In compulsive disorders, recurrent and persistent
thoughts (obsessions) cause marked anxiety and stress followed by repetitive behaviors (compulsions) that are aimed at pre-
venting or reducing distress. Positive reinforcement (pleasure/gratification) is more closely associated with impulse control
disorders. Negative reinforcement (relief of anxiety or relief of stress) is more closely associated with compulsive disorders.
[Taken with permission from Koob GF. Allostatic view of motivation: implications for psychopathology. In: Bevins RA, Bardo MT (eds.)
Motivational Factors in the Etiology of Drug Abuse (series title: Nebraska Symposium on Motivation, vol 50). University of
Nebraska Press, Lincoln NE, 2004, pp. 1–18.]
from a contemporary perspective with regard overwhelming and unbearable and may consist of
to substance use disorders. The focus of this an affective life that is absent and nameless. From
approach is on developmental difficulties, emo- this perspective, drug addiction is viewed as an
tional disturbances, structural (ego) factors, per- attempt to medicate such a dysregulated affective
sonality organization, and the building of the state. Patient suffering is deeply rooted in disor-
“self.” dered emotions, characterized at their extremes
Two critical elements (disordered emotions by unbearable painful affect or a painful sense
and disordered self-care) and two contributory of emptiness. Others cannot express personal
elements (disordered self-esteem and disordered feelings or cannot access emotions and may suf-
relationships) were identified. These evolved into fer from alexithymia, defined as “a marked diffi-
a self-medication hypothesis, in which individu- culty to use appropriate language to express and
als with substance use disorders take drugs as a describe feelings and to differentiate them from
means to cope with painful and threatening emo- bodily sensation” (Sifneos PE. Alexithymia, clinical
tions. In this conceptualization, individuals with issues, politics and crime. Psychotherapy and Psy-
addiction experience states of subjective distress chosomatics, 2000, (69) 113–116).
and suffering that may or may not be sufficient in Such self-medication may be drug-specific.
meeting DSM-5 criteria for a psychiatric diagnosis. Patients may preferentially use drugs that fit the
Individuals with addiction have feelings that are nature of their painful affective states. Opiates
10
1. WHAT IS ADDICTION?
FIGURE 1.4 Diagram describing the spiraling distress/addiction cycle from four conceptual perspectives: social psy-
chological, psychiatric, dysadaptational, and neurobiological. Notice that the addiction cycle is conceptualized as a spiral
that increases in amplitude with repeated experience, ultimately resulting in the pathological state known as addiction. (A)
The three major components of the addiction cycle – preoccupation/anticipation, binge/intoxication, and withdrawal/negative affect –
and some of the sources of potential self-regulation failure in the form of underregulation and misregulation. (B) The same
three major components of the addiction cycle with the different criteria for substance dependence incorporated from the
DSM-IV. (C) The places of emphasis for the theoretical constructs of sensitization and counteradaptation. (D) The hypotheti-
cal role of different neurochemical and endocrine systems in the addiction cycle. Small arrows refer to increased or decreased
functional activity. DA, dopamine; CRF, corticotropin-releasing factor. [Taken with permission from Koob GF, Le Moal M. Drug
abuse: hedonic homeostatic dysregulation. Science, 1997, (278), 52–58.]
might effectively reduce psychopathological The Analysis of the Self: A Systematic Approach
states of violent anger or rage. Others who suffer to the Psychoanalytic Treatment of Narcissistic
from hypohedonia, anergia, or lack of feelings Personality Disorders [series title: The Psychoan-
might prefer the activating properties of psycho- alytic Study of the Child, vol 4]. International Uni-
stimulants. Still others who sense themselves as versities Press, New York, 1971). The paradox is
being flooded by their feelings, or cut off from that using drugs to self-medicate emotional pain
their feelings entirely, may opt for repeated will eventually perpetuate it by perpetuating a
moderate doses of alcohol or depressants in a life that revolves around drugs.
medicinal effort to express feelings that they are Self-care deficits reflect an inability to ensure
unable to communicate. The common element of one’s self-preservation and are characterized
the self-medication hypothesis is that each drug by an inability to anticipate or avoid harmful
class serves as an antidote or “replacement for a or d angerous situations and an inability to use
defect in the psychological structure” (Kohut H. appropriate judgment and feeling as guides