The Psychoanalysis of a Man with Heroin Dependence: Implications for Neurobiological Theories of Attachment and Drug Craving

Psychoanalytic treatment of a man with heroin dependence is described. The treatment had two phases. In the first, the patient's experience that heroin use gave him pleasure was tempered by increasing awareness that using heroin was making him depressed, caused a panic attack, threatened his relationship with his girlfriend because she was becoming addicted, and undercut his ability to direct his company. He stopped using. The second phase of the treatment featured annihilation anxiety, which was experienced by the patient with the analyst. This transference was ameliorated by interpretation of early experiences of abandonment and then by an enactment where the patient insisted on controlling the degree of contact with the analyst. Having succeeded in regulating closeness to the analyst in this aggressive manner, the patient began to behave this way in other relationships. The use of opioids to regulate attachment, and the activation of endogenous opioid systems by human contact, is discussed as a likely factor underlying the outcome of the analysis. The fact that the patient craved opioids and had drug dreams for them, and yet was able to use alcohol and marijuana recreationally, is discussed with reference to the ventral tegmental dopaminergic SEEKING system.