One potential explanation for the increased prevalence rate of co-occurring SUDs among patients with psychiatric disorders has been the "self-medication hypothesis" (Khantzian, 1985,1997), which postulates that certain drugs may be particularly reinforcing because of particular patients' specific psychopathology.
Two fundamental assumptions underlie this hypothesis: first, that substances are abused to relieve psychological pain, not just to create euphoria; and second, that there is specificity between patients' "drug of choice" preference and the specific intolerable emotions or symptoms that they are attempting to alleviate. For example, patients with social anxiety may be drawn to alcohol to decrease their symptoms, while patients who are prone to violence and anger outbursts may prefer the calming effects of opioids to the potentially disinhibit-ing effects of alcohol.
A major criticism of the self-medication hypothesis has been its heavy reliance on anecdotal data from patients in psychotherapy and the relative paucity of empirical studies testing it (Aharonovich, Nguyen, & Nunes, 2001). Additionally, intoxicants may produce very different effects acutely compared to the effects of chronic administration. Studies of individuals with heroin (Meyer & Mirin, 1979), cocaine (Post, Kotin, & Goodwin, 1974), and alcohol (Mendelson & Mello, 1966) use disorders have observed a dichotomy between the acute effects of these drugs in producing euphoria or tension relief and the chronic or high-dose effects in producing dysphoria. Several researchers have sought to test empirically the self-medication hypothesis in larger samples. The results have tended not to support the specificity of using a particular addictive substance to alleviate specific psychopathology or mood states (Aharonovich et al., 2001; Weiss, 1992a). However, while not necessarily a validation of the theory that patients use addictive substances to alleviate certain mood states, there is evidence that treating a co-occurring psychiatric disorder (Cornelius et al., 1997; Greenfield et al., 1998) and remission of its symptoms (Hasin, Tsai, Endicott, & Mueller, 1996) can improve SUD outcomes.
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