In light of the continuing controversy surrounding Whitney Houston's death, including questions of blame and responsibility for what the coroner may determine was an overdose involving drugs and alcohol, here is a look at the science behind the central and often misunderstood concept of self-medication in mental illness, addiction and recovery. My interest in this is both professional and personal. My sister Rita died of a multiple drug cocktail at age 38 -- after a downward slide that began over 20 years earlier and finally caught up with her. She was, like Whitney Houston, a victim of her own demons and a culture that favors self-medication over getting mental health treatment. As both of their premature deaths demonstrate, self-medication and aging don't mix well.
Mystery of the Missing Spoons
When spoons began to disappear from my mother's silverware drawer in the late 1960s, neither my mother nor I suspected my younger sister Rita's dope use. It didn't dawn on us that heroin had be mixed with water and cooked over a flame before it was injected. At that time, my friends and I smoked pot regularly, and we had also tried psychedelics, mushrooms and acid -- tried being the operative word. Rita went further and did it much faster and more overtly. She flew through pot and discovered barbiturates, speed and cocaine.
Heroin was too pricey without help from an older dealer-boyfriend. Nonetheless, by the time she was 16, Rita had made it her drug of choice. Between boyfriends, she stole to finance her new habit. Mom's wedding band was one of the first casualties. Soon, cash could no longer be left in a drawer or purse. This was before drug rehab as a concept had entered the American cultural lexicon, certainly that of the suburban northeast, leaving my mother baffled and ashamed at the behavior of the prettier and once the easier of her two daughters. My mother was an unknowing soldier in what had become all-out guerrilla combat.
What Remains
When President Richard Nixon declared his war on drugs in 1971 -- hopelessly lost in the
four decades since -- it did one constructive thing by creating a new and favorable climate for
research into the causes of addiction. This research gave birth to the field of drug rehabilitation, and out of this wave of new treatments came the theory of self-medication -- the idea that addiction comes about because people are attempting to alleviate the distress of preexisting mental disorders. The concept had come originally from Freud, in 1884, after he noted the antidepressant properties of cocaine.
By the 1970s, the theory of self-medication formally arrived, and immediately caused a storm
of controversy because it challenged views then held by the medical community and law
enforcement that attributed drug abuse to peer pressures, family breakdown, affluence, escapism and lax policing. For the first time, the nation's newly minted white, middle-class drug addicts (typified by my sister) were joining their less affluent urban counterparts, who were already populating U.S. jails and hospitals. Junkies -- hippies, rich and poor, black and white, addicts and alcoholics -- constituted an equal-opportunity mental health crisis for public health doctors on the front lines of treatment in big-city hospital emergency rooms.
The father of the self-medication hypothesis is Edward J. Khantzian, a founding member of the
Psychiatry Department at Harvard's Cambridge Hospital. Writing in 1985, Khantzian stated
his belief that addicts weren't victims of random selection. Instead, he explained, they had a
drug of choice: a specific drug affinity dictated by "psychopharmacologic action of the drug
and the dominant painful feelings with which they struggle." Like Freud, he pointed to the
energizing effect of cocaine and other stimulants in response to the depletion and fatigue of
addicts dealing with preexisting depression. In his patients who abused opiates, including heroin, Khantzian noted their calming effect on the addicts' typically problematic impulsivity. This point particularly hit home for me as I recalled my sister Rita's tendency to get into fist fights with her arresting officers, crash her car and land in the E.R. after passing out in public places.
The idea that human psychological vulnerabilities had anything to do with addiction was a
new piece of the puzzle, and it reflected Khantzian's psychoanalytic background as much as
his clinical work at the Cambridge Clinic. Decades later, self-medication is accepted medicine
within the mental health field. However, broader cultural understanding of its implications
for individuals with undiagnosed mental disorders who may be self-medicating has lagged far
behind; not unlike continuing popular resistance to addiction as a disease over which the addict has little or no control, and widespread refusal to accept the robustly established precept that treatment for addiction is effective.
One of the major stumbling blocks to greater understanding of the principle of self-medication appears to be the culture's continuing confusion about which comes first: the mental illness or the addiction.
One sign of this missing understanding has to be the recent vitriolic "debate" over New Jersey's decision to fly its flag at half-staff in honor of Whitney Houston, one of the century's greatest musical artists; a celebrity whose cause of death will no doubt reflect her two-decade struggle with the disease of addiction but is not likely to include any recognition of an underlying mental disorder.
Chicken or Egg?
The fundamental question of which comes first when someone has what is now called a "dual
diagnosis" remained unanswered up until the 1990s. In 1992, with a first-of-its-kind national
survey of the state of the nation's mental health called the National Comorbidity Survey (NCS),
scientific understanding of comorbid addiction and mental illness went mainstream. The NCS
evaluated 8,098 average Americans, ages 15 to 54, interviewed in face-to-face home settings by trained laypersons -- making them far less able to lessen or deny symptoms and patterns.
Among the striking results of the NCS survey: 45 percent of those people with an alcohol-use
disorder and 72 percent with a drug-use disorder also had at least one other mental disorder.
Perhaps more important at a time when the self-medication theory was still under attack, the
NCS survey provided a concrete and comprehensive answer to the chicken-and-egg question
about addiction and mental illness.
So Which Is It?
The NCS showed that when an alcohol disorder accompanied another mental disorder, the alcohol abuse began after the individual was suffering from symptoms of the other mental disorder, usually a year or more after. Not including other forms of substance abuse, the most common preexisting mental disorders reported among those interviewed were anxiety, depression, and, for men, conduct disorders.
When an updated NCS survey was done with a new group of ten thousand people in 2002
(called the NCS-R, for "replicated"), its findings were strikingly similar to the first. Faring
worst by age group in the 2002 numbers were 36- to 44-year-olds, among whom 37 percent
had anxiety disorders and 24 percent had mood disorders in addition to their alcohol abuse
issues. Depressed women in their 30s and 40s have a 2.6 greater risk for heavy drinking,
compared to those without major depression. It occurred to me as I read these numbers that
age 30 to 44, when comorbid disorders are highest, are also women's prime childbearing years.
A 2012 report by SAMHSA (U.S. Substance Abuse and Mental Health Services Administration) offers an eerie corollary in its finding that 10 percent of American kids today live with an alcoholic parent -- certainly a conservative estimate.
Too Late For So Many
My sister Rita died at 38; a year after an overdose of barbiturates and alcohol put her into a
three-week coma and, upon waking, left her unable to walk or talk. It was the end of a torturous 25 years for her and for those of us forced to helplessly stand by and watch. While packing for a move not long ago, I found a letter I'd received from Rita, written during her first stint in Rockland County Jail for robbery a decade earlier, dated March 1982:
I should have known I was heading for trouble again. I was having black outs from small amounts of liquor (small amounts for me). But I went on another drinking binge and now I'm back here again. I guess I've hit the pits this time. I just finished speaking to a woman from the jail ministry. She's quite sure that God brought me back here to save my life or try again. She may be right. I just feel really bad now that I won't be home for Easter when you come. So much for all that. Meanwhile pray for me, forgive me for letting you all down, try to talk to Mom for me and take care of my beautiful nephew. Love, Rita.
I didn't have any inkling of the unequal effect of alcohol and drugs on different people back in
the 60s when my friends and I started experimenting with whatever we could get our hands on. Back then, I suppose I went no farther than thinking that Rita and others like her were weaker than I was in some fundamental way. Science now illuminates the finer points of the unequal inheritance of predispositions to addiction even in the same family, as well as the debilitating effects on those who carry the heaviest genetic load, especially when they grow up as my sister and I did in a family and culture where, due to the continuing widespread stigma towards those with a mental disorder, self-medication is the preferred option to seeking mental health treatment.
In this broader and hopefully more enlightened context, simplifications like personal weakness
simply don't cut it anymore. It's time for the culture to catch up with the science and practice of treatment and recovery.
Victoria Costello is an Emmy Award winning science writer with articles in Scientific American MIND and Brain World. In addition to HuffPost, she blogs for PsychCentral.com and her own MentalHealthMomBlog. As an advocate for a prevention approach to mental health, she serves on the board of the Mental Health Association of San Francisco and leads workshops for parents and providers around the U.S. Her latest book, A Lethal Inheritance, A Mother Uncovers the Science Behind Three Generations of Mental Illness is available from Prometheus Books.
Follow Victoria Costello on Twitter: www.twitter.com/VCpsych
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Addiction is a brain disease. According to neuroscientists, addicts' brains are physiologically different from non-addicts, particularly in the Limbic "reward" system, which is involved in the sensation of pleasure (getting high), and is central to learning, memory and motivation. Those differences in structure alter brain function, which skews how addicts think and what motivates them to continue to abuse drugs despite worsening repercussions.
The chicken-or-egg question can be stated another way: what comes first, the drug abuse which alters addicts' brains or the altered brain (ie. genetic predisposition to addiction) which propels drug abuse? The answer is probably both. Genetics and environment both play major roles.
The more people understand the science of addiction, the less stigma will attach. Polls also show that if people understand addiction has a biological basis, they support treatment, whereas if they believe it to be a character fault they don't.
For more about the science of addiction, please check out www.AddictScience.com, which discusses the subject in accessible English, from my viewpoint as a sober alcoholic. I hope it can help those struggling with addiction, either their own or a loved one's.
When everyone around them tells them to stop they frequently buy new people to keep close to them. That is very sad and almost impossible to stop.
Victoria
Regardless,i wish hollywood and the media etc, would stop gloifrying drug,acohol and cigerette use. From the sixties well into the eighties, drugs were hip/cool with certian segments of population. The rarely show the destruction they have on people and thjose around them. If want a better picture of the real downside to drugs and acohol, watch the show intervention. people's lives destroyed, families broken up and in some cases death. That is the ugly reality of addiction
Self medication to treat a pain seems only natural to me. The pain is originating from inside the brain. It has physical components to it just like any other pain, except society calls it mental illness (a pejorative term.) I would suggest that all mental illnesses are physical illnesses and should be referred to as such. This would make it more acceptable (culturally) for people already hesistant to seek treatment due to the cultural stigma you refer to.
No doubt there is alot of problems within the "egg" before the "chicken" begins to roast itself in self-destructive behavior due to the power that certain brain chemicals have over the already biologically predisposed. Unfortunately, modern day science only gets updated in peoples mind when there is a celebrity attached to a specific problem. So thank you for taking this opportunity to educate us.
but there are also differences in the way people handle the disease. I'm not sure people can really choose how to deal with it, this would be the the mental issue part.
Society has to find a better way of dealing with this problem asap.
For me, there is another element not to be ignored: spiritual illness. While some aspects of mental illness related to biology and/or environment may start to manifest themselves earlier in childhood, I found the crisis of adolescence to be an existential crisis (though I only fully realized it decades later). In my search for meaning, I could not find adequate meaning either in the outer world or the inner self, until drugs and alcohol came along. Suddenly, meaning! Or at least the illusion of meaning.
The early years of addiction seemed to lead to a fuller, more complete expression of the personality that needed to unfold and develop. But what seemed like a spiritual awakening reversed itself and turned into spiritual decay. The small "hole" inside me, that at first was easily filled with drugs and alcohol, was in fact being made larger by the very substances I used to treat the problem. The cure fed the disease.
Self-medication is a useful term, but it is an incomplete term. It implies the problem that one is trying to "medicate" away is actually a problem that medicine could fix. Maybe. There are certainly mental and physical aspects that a variety of health professionals can help address. But in my experience, and in that of the alcoholics I know, addiction is at least partly a spiritual problem that partly requires a spiritual solution.