Three perspectives on addiction

Drive and Instinct-How They Produce Relatedness and Addiction

Addictive drugs are responsible for mass killing. Neither persons with addiction nor the general populace seem conscious of the malevolence of governments and drug dealers working together. How could this be? What is the place of psychoanalysis in thinking about deaths from addiction and in responding to patients with addiction? To answer these questions, we revise concepts of SEEKING, drive, instinct, pleasure, and unpleasure as separable. We review the neurobiological mechanism of cathexis. We discuss how addictive drugs take over the will by changing the SEEKING system. We review how opioid tone in the central nervous system regulates human relationships and how this endogenous hormonal system is modified by external opioid administration. We differentiate the pleasure of relatedness from the unpleasure of urgent need including the urgent need for drugs. We show how addictive drug-induced changes in the SEEKING system diminish dopaminergic tone, reducing the motivation to engage in the pursuit of food, water, sex, sleep, and relationships in favor of addictive drugs. With this neuropsychoanalytic understanding of how drugs work, we become more confidently conscious of our ability to respond individually and socially.

Supportive-Expressive Psychodynamic Psychotherapy for the Treatment of Opioid Use Disorder

The United States is in the midst of an opioid epidemic with over 200,000 deaths per year due to opioid overdoses. There are numerous psychotherapeutic and medication-assisted approaches to treating opioid use disorder, but psychodynamic approaches remain underappreciated and underused. The self-medication hypothesis of substance use disorders is a psychodynamic model, which argues that all substance use disorders serve to defend against intolerable affects. In the case of opioid use disorders, opioids are thought to help defend against intense intolerable feelings of rage and depression associated with trauma. Supportive-expressive psychodynamic psychotherapy is an empirically supported psychodynamic treatment for a wide range of psychological problems, including opioid use disorders. Supportive-expressive psychodynamic psychotherapy focuses on transference analysis using an operationalized conceptualization of transference called the core conflictual relational theme method. This article describes supportive-expressive psychodynamic psychotherapy for opioid use disorders and provides clinical examples of its use in practice. The article describes and illustrates the three phases of supportive-expressive psychodynamic psychotherapy, the formulation of the core conflictual relationship theme, how it is applied when treating people with an opioid use disorder, and how supportive-expressive psychodynamic psychotherapy can be used with other therapies, such as medication-assisted treatments and 12-step programs. Last, this article encourages psychodynamic therapists who are not involved in treating people with an opioid use disorder to engage in treating people with one using supportive-expressive psychodynamic psychotherapy.

The Preponderance of Psychic Elements in Drug Addiction

The clinical perspective used to understand a patient with an addiction affects the course of treatment and the possibilities for recovery. Positivist and pharmacological models have become popular in the treatment of addictions. These models claim that addiction is primarily a pharmacological occurrence and privilege the biochemical effects of specific substances over the intrapsychic conflict of the patient in order to justify the phenomenology of addiction. Although psychoanalytic approaches have been previously used to treat addictive patients, they have frequently been considered unsuitable and inadequate for such cases. The author's purpose is to use the scope that psychoanalytic comprehension provides to examine the subject who is addicted in relation to his or her maturational development; considering the roles played by pleasure, ego defects, and defensive behavior, derived from case vignettes, in order to illustrate the role of intrapsychic life in the maintaining of an addiction.

Delayed Ego Strength Development in Opioid Dependent Adolescents and Young Adults

Objective. To evaluate ego strengths, in the context of Erikson's framework, among adolescents and young adults diagnosed with opioid dependence as compared to non-drug using youth. Methods. Opioid dependent (n = 51) and non-drug using control (n = 31) youth completed the self-administered Psychosocial Inventory of Ego Strengths (PIES). The PIES assesses development in the framework of Erikson's ego strength stages. Multivariate linear regression modeling assessed the independent association of the primary covariate (opioid dependent versus control) as well as potential confounding variables (e.g., psychiatric comorbidities, intelligence) with total PIES score. Results. Mean total PIES score was significantly lower in opioid dependent youth (231.65 ± 30.39 opioid dependent versus 270.67 ± 30.06 control; p < 0.01). Evaluation of the PIES subscores found significant (p < 0.05) delays in all ego strength areas (hope, will, purpose, competence, fidelity, love, care, and wisdom). When adjusting for potential confounders, opioid dependence remained a significant (p < 0.001) independent predictor of total PIES score. Conclusion. Adolescents with opioid dependence demonstrated significant delays in ego strength development. A treatment approach acknowledging this delay may be needed in the counseling and treatment of adolescents with opioid dependence.

Psychoanalytic treatment of psychological addiction to alcohol (alcohol abuse)

The DSM-V Committee plans to abolish the distinction between Alcohol Abuse and Alcohol Dependence (dsm5.org). The author presents a case report as a proof of concept that this distinction should be retained. The author has asserted that Alcohol Abuse is a purely psychological addiction, while Alcohol Dependence involves capture of the ventral tegmental dopaminergic SEEKING system (Johnson, 2003). In psychological addiction the brain can be assumed to function normally, and ordinary psychoanalytic technique can be followed. For the patient described, transference interpretation was the fundamental key to recovery. Alcoholic drinking functioned to prevent this man from remembering overwhelming childhood events; events that were also lived out in his current relationships. Murders that occurred when he was a child were hidden in a screen memory. The patient had an obsessional style of relating where almost all feeling was left out of his associations. After he stopped drinking compulsively, he continued to work compulsively. The maternal transference had to be enacted and then interpreted in order for overwhelming memories to be allowed into conscious thought. After psychoanalysis, the patient resumed drinking and worked a normal schedule that allowed more fulfilling relationships. He had no further symptoms of distress from drinking over a 9-year followup. This case illustrates that Alcohol Abuse is a purely psychological illness, that it does not have the brain changes typical of Alcohol Dependence. Combining epidemiological, neurobiological, longitudinal, and psychoanalytic observations would allow multiple sources of information to be used in creating diagnostic categories. Losing details of human behavior by relying only on epidemiological studies is likely to cause errors in categorization of disorders. In turn, having faulty categories as the basis of further research is likely to impair identification of specific effective treatments.

Adolescent brain development, risk-taking and vulnerability to addiction

Adolescents (12-18 years old) and young adults (18-25 years old), are more likely than older adults to drive-or agree to be driven-recklessly or while intoxicated, to use illicit or dangerous substances and to engage in both minor and more serious antisocial behaviour. Numerous factors during adolescence may lead to or favour initiation of drug use, such as sensation-seeking, gregariousness and social conformity. These aspects, however, cannot be dissociated from the increased sex drive and quest for an integrated self. In the separation-individuation process, relationships with peers play many different roles: a field for experimentation, emotional support, a place for "projection" and "identification", and the possibility of finding a partner. Unsurprisingly, therefore, drug use generally takes place in a group setting. Despite evidence of heightened real-world risk-taking, laboratory studies have yet to yield consistent evidence that adolescents, when on their own, are more inclined towards risky behaviour than their elders. Moreover, their comprehension and reasoning abilities in risky decision-making situations are roughly equivalent to those of adults. Structural and functional neuroimaging studies have shown that neural circuitry undergoes major reorganization during adolescence, particularly in those regions of the brain relating to executive functions, the self and social cognition, and that the "emotional brain" may play a role in that reorganization. Age-related decreases in gray matter volume mainly reflect a reduction in the number of synapses and the complexity of axonal ramifications. By 18-20 years old, most of the subcortical white matter and association pathways have reached a plateau. Risk-taking behavior and novelty-seeking may provide, with an appropriate feed back, a mechanism to optimize brain development in adolescence.

Alcohol addiction and the attachment system: an empirical study of attachment style, alexithymia, and psychiatric disorders in alcoholic inpatients

This study aims at investigating alcoholic inpatients' attachment system by combining a measurement of adult attachment style (AAQ, Hazan and Shaver, 1987. Journal of Personality and Social Psychology, 52(3): 511-524) and the degree of alexithymia (BVAQ, Bermond and Vorst, 1998. Bermond-Vorst Alexithymia Questionnaire, Unpublished data). Data were collected from 101 patients (71 men, 30 women) admitted to a psychiatric hospital in Belgium for alcohol use-related problems, between September 2003 and December 2004. To investigate the research question, cluster analyses and regression analyses are performed. We found that it makes sense to distinguish three subgroups of alcoholic inpatients with different degrees of impairment of the attachment system. Our results also reveal a pattern of correspondence between the severity of psychiatric symptoms-personality disorder traits (ADP-IV), anxiety (STAI), and depression (BDI-II-Nl)-and the severity of the attachment system's impairment. Limitations of the study and suggestions for further research are highlighted and implications for diagnosis and treatment are discussed.

The Mind-Brain Relation and Neuroscientific Foundations: III. Brain and Psychopathology, the Split Brain, and Dreaming

In addition to the findings of neuroscientific research on brain function, reviewed in the previous articles (Meissner, 2006a, 2006b), contemporary findings relevant to the mind-brain relation derive also from the study of the underlying patterns of brain dysfunction related to various forms of psychopathology. Other information derives from study of split-brain conditions and from research on dream processes and their relation to brain mechanisms. Review of these research findings casts further light on aspects of the mind-brain relation and further substantiates a unified theory of mind-brain integration.

The mind–brain relation and neuroscientific foundations: II. Neurobehavioral integrations

Neuroscientific research focuses on the mind-brain relation, particularly with respect to patterns of brain arousal and activity in the production of various forms of behavior, both external and mental behavior. In this article the author reviews neuroscientific findings to demonstrate that there are no activities of the human person, whether in the form of external behavior or purely mental activity, that are not produced by activation of the CNS. Areas considered include information processing, development, brain plasticity, language, memory, and affects.

Addictions and the quest to control the object

Most patients come into psychoanalytic treatment engaged in some form of repetitive, destructive behavior that is an externalization or projection of their internal struggles. One form of this object relational acting-out is the addictions, be they to alcohol, gambling, drugs, sex, procrastination, or other variations. The patient's experience is a "must do-can't stop" one that leaves them both desperate and relieved. Patients come to us wanting help in refraining from these addictive patterns. Sometimes, they are attending a 12-step program or are in a day treatment recovery program but need additional assistance in remaining free from their addictive behaviors. Others seek out psychoanalytic treatment while still involved in their addiction, but wish to stop the behavior and build a more positive plan for their lives. This paper examines the deeper object relational issues that lie behind the addictive process. The transference is often colored by acting-out, by sadomasochistic dynamics, by projective identification, and by fantasies of persecution and loss. Case material is used to explore these specific problems as well as the patient's general difficulties with paranoid-schizoid and depressive functioning.

Psychodynamic psychotherapies: Evidence-based practice and clinical wisdom

This article is based on an exhaustive review of the psychotherapy outcomes literature, undertaken originally at the instigation of the UK Department of Health by Roth and Fonagy (Department of Health, 1995). We have recently updated this review (Fonagy, Target, Cottrell, Phillips, & Kurtz, 2002; Roth & Fonagy, 2004) and extended it to identify all studies of psychoanalytic psychotherapy. The usual methods for identifying studies were employed (Fonagy, Target, et al., 2002; Roth & Fonagy, in press). The key questions that should be asked of this literature given the current state of research in this area (also see Westen, Morrison, & Thompson-Brenner, 2004) are: Are there any disorders for which short-term psychodynamic psychotherapy (STPP) can be considered evidence-based, Are there any disorders for which STPP is uniquely effective as either the only evidence-based treatment or as a treatment that is more effective than alternatives, and Is there any evidence base for long-term psychodynamic psychotherapy (LTPP) either in terms of achieving effects not normally associated with short-term treatment or addressing problems that have not been addressed by STPP? In this context, short-term therapy is conceived of as a treatment of around 20 sessions delivered usually once weekly.

Souffrance psychosociale et antécédents biographiques traumatiques des fumeurs

BACKGROUND

The relationship between smoking and various socio-demographic or socio-economic factors, as well as the interactions between depressive mood and smoking are already known. However, the respective contribution of psychological factors and stressful life antecedents during childhood and adolescence warrants further specification.

METHODS

2315 consecutive subjects, aged 16 to 59, consulting for a free work-up in a preventive health centre, supported by the National French Health insurance system, were invited to fill out a series of questionnaires: the GHQ-28 and the LOT, respectively measuring psychosocial distress and dispositional optimism, as well as a questionnaire on socio-demographic, socio-economic and biographical data.

RESULTS

78.1% complete records could be analysed: the "smokers" group (n = 870, 48.1%) declared a current tobacco consumption of at least one cigarette/day. This group was characterized by a predominance of male subjects, older age, modest educational level, low income level and responded to socio-economic criteria of precariousness more frequently (p < 0.001, except for age: p = 0.006). Smoking was also associated with higher levels of psychosocial distress, as assessed by GHQ-28, especially for the depressive mood and anxiety items of the questionnaire (p < 0.001), and with lower levels of dispositional optimism (p < 0.01). As regards biographical data, smokers were characterized by a way of life marked by financial problems, reduced social contacts, and a higher frequency, before the age of 18, of divorce or separation of the parents (p = 0.002), frequent parental quarrels (p < 0.001) or separation from the parents (p < 0.001). The presence of a depressive mood at GHQ-28 as well as frequent parental quarrels remained independent risk factors for smoking in multiple logistic regression (odds ratio respectively equal to 1.61 and 1.34), after adjustment on gender, educational level and the notion of socio-economic precariousness.

CONCLUSION

These results highlight the complementary role of socio-economic, psychological factors and certain stressful life antecedents among the determinants of smoking and should be taken into account for tailoring smoking cessation programs.

Pain management in the opioid-dependent patient

The opioid-dependent patient presents great challenges for pain management. These challenges are not limited to potential addictive behaviors. In contrast to the profound pain relieving effects of acute opioid intake, chronic opioid intake can promote a counterintuitive state of enhanced pain sensitivity. Multiple biologic mechanisms inducing opioid tolerance and hyperalgesia have recently been elucidated. The potential hyperalgesic state accompanying opioid dependence complicates pain management somewhat for acute pain and cancer pain, but it especially does so for chronic pain. Guidelines for treatment of opioid dependence in the pain patient are proposed. Treatment oriented toward the long term requires limit setting and psychologic support that go beyond simple medication management.

Drug dreams: a neuropsychoanalytic hypothesis

Recent studies have shown that the ventral tegmental pathway stimulates both dreaming and drug craving. To investigate a possible clinical link between these two psychic phenomena, psychotherapy notes from the first six months of an addicted patient's treatment were reviewed, together with verbatim notes from the four years of psychoanalysis that followed. Of 240 dreams reported by the patient,58 had manifest content involving the seeking or using of drugs. There was no particular temporal or emotional thematic pattern to these "drug dreams,"which persisted through four and a half years of sobriety. Drug dreams are observable phenomena that reflect both the innate structure of the brain and neural changes produced by exposure to addictive drugs. In some addicted persons, exposure to drugs produces a fixed change in neurological functioning with which they must contend for years, possibly the rest of their lives. Drug craving meets Freud's defining characteristics for a drive: it is a constant pressure, originating from within the organism, to do work, and it constantly demands satisfaction. Because ego and libidinal drives share a common neural pathway, they should not be separated conceptually. Solms's finding (in press) that the activating systems for dreaming and for craving are identical, a finding based on observations of tumor- or stroke-provoked brain lesions, is confirmed by observation of the dreams of a patient whose brain changes were created by drug exposure. This study provides further evidence that the origin of the dream is a wish.