Commentary on “Understanding Addictive Vulnerability”

Dr. Khantzian provides a cogent and scholarly argument for a psychodynamic view of addiction with a focus on what factors lead to the vulnerability for addiction. He identifies two critical elements (disordered emotions and disordered self-care) and two contributory elements (disordered self-esteem and disordered relationships). He further argues strongly for a modern self-medication hypothesis where individuals with substance-use disorders are hypothesized to take drugs as a “means to cope with painful and threatening emotions.” Khantzian makes the case that addicted individuals experience states of subjective distress and suffering that may or may not be associated with conditions meeting DSM-IV criteria for a psychiatric diagnosis (American Psychiatric Association, 1994) and consist mainly of feelings that are overwhelming and unbearable, but also may consist of an affective life that is absent and nameless.

Drug addiction is viewed as an attempt to medicate such a negative affective state, and Khantzian marshals significant psychodynamic evidence not only for the negative affective state, but also for the self-medication hypothesis. In addition, he argues that self-medication may be drug-specific, in that patients may have a preferential use of drugs that fits with the nature of the painful feeling states that they are self-medicating (e.g., opiates to counter intense anger and rage, stimulants as augmenting agents for high-energy individuals, energizing agents for low-energy individuals, and depressants for individuals who are tense and anxious). The common element argued by Khantzian is that each class of drugs serves as antidotes or correctives to dysphoric states and acts as a “replacement for a defect in the psychological structure” (Kohut, 1971) of such individuals.

Khantzian further argues that disordered self-care combines malignantly with the disordered emotional life to become th