Definitions of Addiction
Psychodynamic View of Addiction
A psychodynamic view of addiction that integrates the neurobiology of addiction was elaborated by Khantzian and colleagues (for further reading, see Khantzian, 1997) with a focus on the factors that produce vulnerability to addiction. This perspective is deeply rooted in the psychodynamic aspects of clinical practice developed from a contemporary perspective with regard to substance use disorders. The focus of this approach is on developmental difficulties, emotional disturbances, structural (ego) factors, personality organization, and the building of the “self.”
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 preventing 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.]
Two critical elements (disordered emotions and disordered self-care) and two contributory elements (disordered self-esteem and disordered relationships) were identified. These evolved into a self-medication hypothesis, in which individuals with substance use disorders take drugs as a means to cope with painful and threatening emotions. In this conceptualization, individuals with addiction experience states of subjective distress and suffering that may or may not be sufficient in meeting DSM-5 criteria for a psychiatric diagnosis. Individuals with addiction have feelings that are overwhelming and unbearable and may consist of an affective life that is absent and nameless. From this perspective, drug addiction is viewed as an attempt to medicate such a dysregulated affective state. Patient suffering is deeply rooted in disordered emotions, characterized at their extremes by unbearable painful affect or a painful sense of emptiness. Others cannot express personal feelings or cannot access emotions and may suffer from alexithymia, defined as “a marked difficulty to use appropriate language to express and describe feelings and to differentiate them from bodily sensation” (Sifneos PE. Alexithymia, clinical issues, politics and crime. Psychotherapy and Psychosomatics, 2000, (69) 113–116).
Such self-medication may be drug-specific. Patients may preferentially use drugs that fit the nature of their painful affective states. Opiates might effectively reduce psychopathological states of violent anger or rage. Others who suffer from hypohedonia, anergia, or lack of feelings might prefer the activating properties of psychostimulants. Still others who sense themselves as being flooded by their feelings, or cut off from their feelings entirely, may opt for repeated moderate doses of alcohol or depressants in a medicinal effort to express feelings that they are unable to communicate. The common element of the self-medication hypothesis is that each drug class serves as an antidote or “replacement for a defect in the psychological structure” (Kohut H. The Analysis of the Self: A Systematic Approach to the Psychoanalytic Treatment of Narcissistic Personality Disorders [series title: The Psychoanalytic Study of the Child, vol 4]. International Universities Press, New York, 1971). The paradox is that using drugs to self-medicate emotional pain will eventually perpetuate it by perpetuating a life that revolves around drugs.
FIGURE 1.4 Diagram describing the spiraling distress/addiction cycle from four conceptual perspectives: social psychological, 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 hypothetical 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.]
Self-care deficits reflect an inability to ensure one’s self-preservation and are characterized by an inability to anticipate or avoid harmful or dangerous situations and an inability to use appropriate judgment and feeling as guides in the face of adversity. Thus, self-care deficits reflect an inability to appropriately experience emotions and fully recognize the consequences of dangerous behaviors. Disordered self-care combines with a disordered emotional life to become a principal determinant of substance use disorders. The core element of this psychodynamic perspective is a dysregulated emotional system in individuals who are vulnerable to addiction.
This psychodynamic approach integrates well with the critical role of dysregulated brain reward and stress systems that are revealed by studies of the neurobiology of addiction. From a neurobiological perspective, additional harm to the personality can by produced by the direct effects of the drugs themselves, thus perpetuating or actually creating such character flaws.