People often turn to drug and alcohol use in order to reduce or manage negative or overwhelming emotional states. The “self-medication hypothesis” is a term coined in the 1980’s by Dr. Khantzian, Clinical Professor of Psychiatry at Harvard Medical Center. By the 1990’s the term was used to describe a general model of addiction that posits that people use substances as a self-regulation strategy, due to difficulties in four different areas: self-esteem, emotions, interpersonal relationships, and self-care.
One of the main propositions of the self-medication hypothesis is that a person’s choice of substances (e.g., alcohol, cocaine, heroin) is intimately tied to the particular distressing emotional state that they are trying to manage. For example, individuals who experience anxiety and fear may use alcohol, a central nervous system depressant, because of its calming and sedative effects. Stimulants, such as cocaine or amphetamines may be appealing to those who are avoidant, depressed, or have low self-esteem because of these drugs’ energizing properties (acute effects of stimulants include improvement in mood, increase in energy, self-esteem, self-confidence, and reduction of feelings of emptiness and depression).
But do drugs and alcohol really reduce anxiety or depression? This is an important question and the evidence would allow us to examine whether or not alcohol and drug use works to quell painful emotional states or whether alternative coping strategies may be more effective.
Support for the self-medication hypothesis comes from several different lines of research. Survey studies show high rates of endorsement of “self-medication” among individuals with co-occurring psychological problems and substance use (Back, Brady, Jaanimagi, & Jackson, 2006; Leeise, Pagura, Sareen & Bolton, 2010). Likewise, longitudinal studies – those that follow people over a period of time – tend to support a pathway whereby psychological difficulties emerge first and then are followed by substance use/misuse (Chilcoat & Breslau, 1998). These findings support a therapeutic path focused on helping people resolve underlying psychological issues as a precursor to reduction or elimination of substance use.
Other studies that call into question the self-medication hypothesis show that alcohol and drug use may actually cause or worsen psychological symptoms (Tomlinson and colleagues, 2006) – a process called the rebound effect. After reducing or stopping substance use after extended periods of heavy use, withdrawal symptoms may mimic psychological symptoms such as anxiety and depression, due to neurochemical imbalances in the brain leading to a hyper-excitable central nervous system response. This may then perpetuate a cycle whereby the person uses additional substances to manage the physiological effects of the withdrawal process. Therapeutic interventions in this realm would focus on strategies to reduce or eliminate substance use first, with an eye on the safe and therapeutic management of withdrawal symptoms throughout the process of resolving psychological issues.
The self-medication and rebound hypotheses are both supported in the literature and propose alternative approaches to treatment intervention. Individuals who use substances may experience both processes. In the short-term, substances may indeed serve a self-medication function and reduce painful emotional states. However, as the brain changes over time in response to heavy substance use, a rebound process may occur which can lead to an exacerbation or worsening of psychological symptoms.
In both cases, treatment strategies that focus on the acquisition of coping strategies to deal with anxiety, depression, self-esteem or interpersonal difficulties are essential.
References
Back, S. E., Brady, K. T., Jaanimagi, U., & Jackson, J. L. (2006). Cocaine dependence and PTSD: A pilot study of symptom interplay and treatment preferences. Addictive Behaviors, 31, 351-354.
Chilcoat, H. D., & Breslau, N. (1998). Investigations of causal pathways between PTSD and drug use disorders. Addictive Behaviors, 23, 827-840.
Khantzian, E. J. (1985). The self-medication hypothesis of addictive disorders: Focus on heroin and cocaine dependence. American Journal of Psychiatry, 142, 1259-1264.
Khantzian, E. J. (1997). The self-medication hypothesis of substance use disorders: A reconsideration and recent applications. Harvard Review of Psychiatry, 4, 231-244.
Leeise, M., Pagura, J., Sareen, J., & Bolton, J. M. (2010). The use of alcohol and drugs to self-medicate symptoms of posttraumatic stress disorder. Depression and Anxiety, 27, 731-73
Tomlinson, K. L., Tate, S. R., Anderson, K.G., McCarthy, D. M., & Brown, S. A. (2006). An examination of self-medication and rebound effects: psychiatric symptomatology before and alcohol or drug relapse. Addictive Behaviors, 31(3), 461-474.