Week 13:

Models for Psychotropic Drug Addiction

1
Noh Amit

NNNC 6042 Psychopharmacotherapy_Sem II 2019/2020

2 Outline

Models for Psychotropic Drug Addiction

1. Moral theory
2. Self Medication Theory /hypothesis
3. Psychological Models of Addiction
4. Disease Model/Concept of Addiction

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3 Updates on NC 6042 Assignments
 Assignment 2 (Week 11)
 Video+ Slides submission (18/5/2020 / Monday)
 Assignment 2 submission (Softcopy) (25/5/2020 / Monday)

 Assignment 5 (Week 15)

 Video presentation (8/6/2020 / Monday)
 Video submission (15/6/2020 / Monday) UKMFolio

 Assignment 6 (Week 17)

 Infographic submission (29/6/2020 / Monday)

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4 1. The Moral Model/Theory
 explains addiction as a consequence of personal choice
 Individuals are viewed as making decisions to use AOD in a problematic manner
and as being capable of making other choices.
 adopted by certain religious groups as well as by the legal system
 Drunkenness is viewed as sinful behavior by some religious groups (Miller &
Hester, 1995), and the use of alcohol is prohibited by certain religions (e.g., the
Mormon Church)—Addiction to psychotropic drugs?
 From this perspective, religious or spiritual intervention would be necessary to
change behavior.
 Many saw acceptance of a particular religious persuasion as the necessary step to
overcome AOD problems

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 Psychotropic drugs addiction willful misconduct

 the manner in which authority deal with substance misuse may relate to the moral
model
 The moral model is a common way that the general public has of conceptualizing
alcoholics and addicts.

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the language in the field is related to the moral model:

 “Terms such as alcohol abuse, drug abuse, substance abuse all spring from
religious and moral conceptions of the roots of severe alcohol and other drug
problems.... to suggest that the addict mistreats the object of his or her deepest
affection is a ridiculous notion.... Addicts, more than anyone, treat these potions
with the greatest of devotion and respect. ”
 recovery advocates have noted—the moral model of addiction has contributed to
creating a stigma about addiction and addicts. This stigma may cause barriers to
getting help.

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7 2. Self Medication Theory /hypothesis

 During the mid-twentieth century several clinicians alluded to the concept of

'self-medication' as an integral process in the development and maintenance of
drug dependence.
 Fenichel (1946) and Rado (1957) observed that addicts seemed to have
underlying depression, of varying degree, which was deemed to be the motivation
for drug use.

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 Khantzian—The development of drug dependence is based on psychological

suffering, where the specific psychological disturbances of an individual leave a
need for a specific substance, to palliate this pain.
 the greatest strength of this hypothesis is that it offers an explanation for why
only a minority of individuals who use drugs become dependent, whereby the
need to master and convert the passive and confusing experience of psychological
problems is the missing link.
 Such problems include alexithymia, the inability to put feelings into words;
resulting in a compromised ability to process emotions and thus regulate
behaviour that is driven by such emotions.

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 Khantzian et al. (2014) acknowledged that the two main arguments posed against
the SMH are: (1) not all who suffer with pain and distress become drug dependent
and (2) there is as much, if not more, suffering [pain and distress ] as a
consequence of drug use.
 He subsequently proposed that, in light of these questions and issues raised, it
was necessary to adopt a ‘superordinate or more overarching paradigm of the
addictions as a self-regulation disorder.
 (1) and (2) above contribute to concerns that the direction of causality is not
clear-cut, and this shall be analysed through empirical assessment of the temporal
acquisition of substance use and other psychological vulnerabilities.’[the
importance of acknowledging other factors]

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 Khantzian only constructed Self-Medication (SM) into a coherent hypothesis in

1975.
 He initially proposed that inadequate ego-defence mechanisms cause an
individual to find an external means to control aggressive impulses and that
heroin use may successfully do this.
 He further argued that because heroin is able to suppress these impulses,
methadone treatment might actually be doing more than preventing physical
withdrawal, as through its psychotropic similarities to heroin, it may be able to
prevent the dependence-causing dysphoria—a state of unhappy, uneasy,
disatissfied feelings with life (Khantzian, 1975)

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 This hypothesis of heroin addiction was eventually developed to include cocaine

addiction (Khantzian, 1985). Similarly, Khantzian believed that cocaine had its
appeal because its use allowed an escape from disturbances one may experience
from hypomania, hyperactivity or depression.
 Alcoholism was subsequently incorporated into the hypothesis with the idea that
alcohol use facilitates access to feelings and relationships to those who feel cut-
off from them (Khantzian, 1990). This eventually progressed into a fully
developed, more comprehensive theory (Khantzian 1997) that included all drugs
of addiction.

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 This hypothesis proposes that due to arrested emotional or psychosexual

development, one may be subject to overwhelming emotions, or alexithymia—
(inability to identify and express one’s feelings) which form a drive to use a drug
which can provide one with a desired or ‘normal’ affect state, or at least give one
control over the affect one is experiencing.
 One may argue that many individuals experience discomfort of this nature but do
not abuse drugs, which leads to a further proposal that this affect dysregulation
'malignantly combines' with an impaired capacity for self-care (survivability).

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 These self-care problems are believed to derive from developmental deficiencies

that interfere with the ability to predict and protect against harm. Consequently,
this aforementioned combination makes 'experimentation with, dependence on
and relapse to substances more likely and compelling‘ (Khantzian, 2007).
 It is believed that it is more than just the ego strengthening effects of drug use that
leads to dependence. Other contributing factors include the progressive effect of
promoting stable functioning along with the regressive effect of perpetuating or
continuing the existing vulnerability, which enforce continued use.

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 The ‘drug of choice’ concept, coined by Weider and Kaplan is important in

Khantzian’s hypothesis, as he believes the substance one becomes dependent on
is by no means random.
 ‘Preferential drug use’ (Milkman and Frosch, 1973) is proposed by the SMH to be
the result of an interaction between (a) the individual’s primary affect state, (b)
the psychopharmacological profile of the drug, (c) an individual’s personality and
(e) the availability of the substance (Khantzian and Albenese, 2008).

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 The SMH now considers three drug groups to have a distinct

psychopharmacological profile. These are opioids, Central Nervous System
(CNS) depressants (alcohol, benzodiazepines, and barbiturates) and CNS
stimulants (cocaine and amphetamine). The proposed profiles of these drugs and
their corresponding abuser are summarised below:
 Opioids: Opioids are thought to have ‘calming and normalizing effects’
(Khantzian, 1997). The SMH proposes that they function as a means to
temporarily mute or attenuate rage that is believed to be associated with a
traumatic background of abuse, loss or painful disappointment (Khantzian, 1985;
Khantzian and Albanese, 2008).

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 CNS Depressants: The hypothesis proposes that alcohol abusers cut themselves
off from awareness of emotions that may be potentially distressing by employing
rigid defences that can result in disaffected states.
 Among the key psychological features of alcohol are its relaxing and sedating
effects (Dodgen and Shea, 2000). These effects are thought to relieve emotional
tension as they allow defensive structures to be softened (Khantzian, 1997).
Benzodiazepines, now much more commonly used than barbiturates are thought
to follow a similar course to alcohol but in pill form (Winger et al, 2004).

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 CNS Stimulants: The psychological effect of cocaine in the short-term is elevated self-
esteem, confidence, mood and energy state (Dodgen and Shea, 2000). This is due to the
increased dopaminergic and noradrenergic activity secondary to decreased vesicular
reuptake and transport of these monoamines (Winger et al, 2004).
 The SMH proposes that those drawn to use cocaine will be either ‘high energy’ or ‘low
energy’ individuals. The former will have an increased need for elated sensations
(Khantzian, 1985; Khantzian et al. 1990) whilst the latter, who likely mirror a depressive
state, will use cocaine to escape anhedonia-- inability to feel pleasure (Khantzian and
Albanese, 2008).

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18 3. Psychological Models of Addiction
 the most widely held psychological explanations of addiction
 Perhaps the most accepted view, particularly by those outside the addiction field,
is that the problematic use of alcohol and other drugs is secondary to some other
psychological problem or condition. The primary psychological problem causes
emotional pain, and alcohol and other drugs serve to temporarily relieve this pain.
 For example, a woman was sexually molested as a child by a relative. She does
not tell anyone, or her story is not believed, and she does not receive any
assistance. The woman experiences anger, guilt, embarrassment, and anxiety as a
result of the experience and gravitates toward alcohol and other drugs to relieve
these uncomfortable feelings.
 Another example would be the person who suffers from
endogenous(genetic/biological) depression and self-medicates with stimulants to
relieve the constant symptoms of depression.
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 Related to the view that AOD problems are secondary to other psychological
problems is the question about whether an alcoholic or addictive personality
exists. Clearly, there are alcoholics and drug addicts who seem to be free of any
identified psychological problems prior to their problematic use patterns.
 Proponents of psychological explanations of addiction believe that there may be
an "addictive personality" that could be identified and that would explain why
individuals with AOD addictions often have problems with nondrug addictive
behavior (e.g., gambling, food, work, sex) following successful recovery from
their drug of choice.
 However, this effort to identify the "addictive personality" has largely been
unsuccessful. As Miller (1995) noted, "alcoholics appear to be as variable in
personality as are non-alcoholics" (p. 90).

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 Social learning theory—addictive behaviors represent a category of 'bad habits'

including such behaviors as problem drinking, smoking, substance abuse,
overeating, compulsive gambling, and so forth.“
 In this conceptualization, drug use is initiated by environmental stressors or
modeling by others and is reinforced by the immediate effects of the drug on the
feelings generated by the stressor(s) or by acknowledgment or recognition from
role models with perceived status.
 E.g.,--individual who uses alcohol to "unwind" after a stressful day at work. Since
tolerance to alcohol develops, over time this person must use an increasing
amount of alcohol to experience the reinforcing effects of alcohol on tension. A
"bad habit" is developed.

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 Modeling contributed to this first experience and subsequent alcohol use.

 in spite of some negative consequences (nausea and parental anger) there was
sufficient positive reinforcement to increase the probability of repeated use.
 In a social learning model the sociocultural factors …play a role in determining
what type of drug is used, when it is used, and how it is used.
 Eventually, as the individual uses more and more, a physiological state of
dependence occurs, and, consequently, withdrawal symptoms are experienced if
the drug is removed.
 The use of the drug to relieve withdrawal symptoms is highly reinforcing, since
an immediate and effective reduction or elimination of symptoms occurs (Tarter
& Schneider, 1976). The social learning model of addiction has been widely used
in the development of relapse prevention strategies…

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22 4. Disease Model/Concept of Addiction

 Based on disease model of alcoholism (Jellinek, 1960)

 a guiding model for many treatment programs
 the disease concept was originally applied to alcoholism and has been generalized
to addiction to other drugs
 The disease of addiction is viewed as a primary disease. That is, it exists in and of
itself and is not secondary to some other condition. This is in contrast to the
psychological models …in which addictive behavior is seen as secondary to some
psychological condition.

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 In Jellinek's (1952) own words:

 The aggressions, feelings of guilt, remorse, resentments, withdrawal, etc., which
develop in the phases of alcohol addiction, are largely consequences of the
excessive drinking ... these reactions to excessive drinking—which have quite a
neurotic appearance— give the impression of an "alcoholic personality;" although
they are secondary behaviors superimposed over a large variety of personality
types.... (p. 682)

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 Jellinek (1952) also described the progressive stages (3)of the disease of
alcoholism and the symptoms that characterize each stage.
 The early stage, or prodromal phase, is characterized by an increasing tolerance to
alcohol, blackouts, sneaking and gulping drinks, and guilt feelings about drinking
and related behaviors.
 The next stage, the middle or crucial phase, is defined by a loss of control over
drinking, personality changes, a loss of friends and jobs, and a preoccupation with
protecting the supply of alcohol.
 The issue of "loss of control" has come to be a central defining characteristic of
alcoholism and one of the more controversial aspects of the disease concept. We
will examine this issue when discussing criticisms of the disease concept.

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 The late stage, or chronic phase, is characterized by morning drinking, violations

of ethical standards, tremors, and hallucinations.
 It is important to conceptualize these stages as progressive. In other words, the
stages proceed in sequence and, in the disease model of addiction, are not
reversible.
 Therefore, an individual does not go from the middle stage back to the early stage
of alcoholism. The rate at which this progression occurs depends upon factors
such as age, drug of choice, gender, and physiological predisposition (Royce,
1989).

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 Consistent with this concept (that the individual with addictive disease does not
reverse the progression of the disease even with a prolonged period of sobriety) is
the notion that addictive disease is chronic and incurable.
 That is, if an individual has this disease, it never goes away, and there is no drug
or other treatment method that will allow the alcoholic or addict to use again
without the danger of a return to problematic use.
 One implication of this notion is that the only justifiable goal for the alcoholic or
addict is abstinence, which is the stance of Alcoholics Anonymous
 Abstinence must be the goal for those with addictive disease

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Implications to the disease concept:

1. First, if addictive disease is progressive, chronic, and incurable, then it is logical
to assume that a person with this condition who does not enter "recovery" will
eventually die. Death occurs as a result of accidents or the physical effects of
alcohol and other drugs over time. However, most of these individuals are not
identified as dying from addictive disease.
2. If a person has this disease and, for example, the drug of choice of the person is
alcohol, the person will continue to exhibit all the symptoms of the disease if he
or she discontinues the use of alcohol and begins to use some other drug.

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28 Critics of the Disease Concept
 because the majority of the treatment programs are based on the disease concept of
alcoholism, their lobbying, public relations, and advertising efforts inevitably propagate
the disease theme“
 Since the disease concept is widely attributed to Jellinek, much criticism has been directed
at his research, which was the basis for his conclusions about the disease concept.
Jellinek's data were gathered from questionnaires distributed to AA members through its
newsletter, The Grapevine. Of 158 questionnaires returned, 60 were discarded because
members had pooled and averaged their responses. Also, no questionnaires from women
were used. Jellinek himself acknowledged that his data were limited. Therefore, one might
wonder why Jellinek's concept of the disease of alcoholism received such widespread
acceptance. One reason is that the disease concept is consistent with the philosophy of AA,
which is by far the largest organized group dedicated to help for alcoholics.

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 By acknowledging that a small minority of the drinking population is susceptible

to the disease of alcoholism, the (alcohol) industry can implicitly assure
consumers that the vast majority of people who drink are not at risk. This
compromise is far preferable to both the old temperance commitment to
prohibition, which criminalized the entire liquor industry, and to newer
approaches that look beyond the small group diagnosable as alcoholics to focus
on the much larger group of heavy drinkers who develop serious physical,
emotional, and social problems.

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 The progressive nature of addiction has also been criticized. –there is no

inevitable progression of Jellinek's stages of alcoholism
 Defence—Similarly, Royce (1989), in describing the patterns and symptoms of
alcoholism, stated, "Even when progression occurs, it does not follow a uniform
pattern. The steps may be reversed in order, or some steps may be omitted.
Symptoms progress, too; something that was minor in an early stage may appear
later in a different form or to a greater degree.... Rate of progression varies also"
(p. 89). As with ValIant, Royce takes a favorable position toward the concept of
addiction as a disease.

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 Several arguments have been advanced to dispute the notion of loss of control.
Fingarette (1988) pointed out that if alcoholics lack control only after first
consuming alcohol, then they should have no difficulty abstaining. Obviously,
however, alcoholics do have difficulty abstaining.
 If loss of control exists before the first drink (which would explain the difficulty
in abstaining), it implies a difficulty in exercising self-control or willpower, which
is a much different model of addiction.

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32 5 Advantages of the Disease Concept

 (1) Perhaps the greatest advantage to the articulation that addiction is a disease
has been to remove the moral stigma attached to chemical dependency and to
replace it with an emphasis on treatment of an illness. We do not punish a person
for having a disease; we provide assistance.
 (2) In a more functional sense, defining addiction as a disease has also resulted in
treatment coverage by insurance companies. Using medical terminology to
describe addiction has also led to greater interest in scientific research.

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 (3) For the individual who has problems with alcohol or other drugs (and for the
family as well), the concept of a disease removes much of the stigma and
associated embarrassment, blame, and guilt. You would not feel guilty if you
were diagnosed with diabetes and, therefore, a person with addictive disease need
not feel guilty for having this disease.
 As we have said, people who believe that addiction is due to a lack of willpower
or to a moral deficiency may avoid treatment, since the admission of the need for
help is an admission that some character flaw exists. Therefore, an acceptance of
the disease concept may make it easier for some people to enter treatment.

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 (4)…it is clearly understandable to people and provides an explanatory construct

for the differences in their alcohol and other drug-taking behavior compared with
others.
 To reuse the well-worn analogy with diabetes, it is quite clear to the people with
diabetes that they cannot use certain foods in the same manner as those who do
not have diabetes. If they do, there will be certain predictable consequences.
Knowledge about the disease allows the alcoholic or addict to understand that he
or she is physiologically different from others.

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 (5)Finally, the disease concept has a logical treatment objective that follows from
its precepts: abstinence. If you have a physiological condition that results in
severe consequences when alcohol or other drugs are used, you can avoid these
consequences by abstaining from alcohol or other drugs.
 If you attempt to use moderately, you will eventually lose control, progress
through predictable stages, and suffer the consequences. Since most individuals
who seek treatment for alcohol or other drug problems have experienced some
negative consequences already, this argument can be compelling.

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36 3 Disadvantages of the Disease Concept

 (1) The orthodox precepts of the disease concept may not be accurate. There is
not an inevitable and completely predictable progression of symptoms and stages
nor a consistent loss of control. Therefore, individuals with alcohol or other drug
problems who may need some form of intervention or treatment may avoid help
since they do not fit the "disease model.“

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 (2) An adherence to the disease model may also result in a purely medical model
of treatment:
 While this may have the advantage of motivating physicians to treat the alcoholic
in a nonjudgmental way.. .the average American physician is still both reluctant to
treat alcoholics and often ignorant about alcoholism....
 Medical models tend to put the physician in full charge, focus almost exclusively
on physical damage, and perpetuate a medical "revolving door" which is more
humane than the drunk tank/prison but equally ineffective for long-range
treatment. It implies that nonmedical persons are unable to treat the illness....
(Royce, 1989, p. 123)

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 (3) The notion that the disease concept removes responsibility from the alcoholic
or addict for his or her behavior is frequently cited as a disadvantage of this
model (Royce, 1989). Since the alcoholic or addict is "powerless" over the
disease, inappropriate or even criminal behavior may be attributed to the
"disease."
 Relapse may also be blamed on the disease, "If alcoholics come to view their
drinking as the result of a disease or physiological addiction, they may be more
likely to assume the passive role of victim whenever they engage in drinking
behavior if they see it as symptom of their disease....(Marlatt & Gordon, 1985, p.
7).

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39 References

 Fisher, G.L., & Harrisson,T. C. 2012. Substance Abuse: Information for school
counsellors, social workers, therapists, and counsellors (5th ed.). Boston, MA:
Pearson.
 The Self-Medication Hypothesis of Drug Addiction: a Critical Evaluation.

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