Tag: Personality Structure

Find the Switch — 4

The Diagnostic and Statistical Manual of Mental Disorders (DSM) provides criteria sets for diagnosing various mental disorders including addiction.1 The surrounding text contains brief sections on “Development and Course” and “Risk and Prognostic Factors.” These passages are seldom helpful for case conceptualizations, that is, understanding how an illness developed and what factors are sustaining it. Clinicians need to look elsewhere.

The Psychodynamic Diagnostic Manual (PDM) is a great place to start.2 Its S Axis explores patients’ subjective experiences in the following domains:

  • Affective states
  • Cognitive patterns
  • Somatic states
  • Relationship patterns

In the case of addiction, PDM-2 notes:

Psychoactive drugs help people who misuse substances to tolerate intolerable feelings. The effects of drugs and alcohol are specific and temporary; the main emotions the person feels will generally determine which type of substance is preferred. Opiates help a person to feel “calm,” “mellow,” or “normal.” Stimulants counter low energy,feelings of weakness, and feelings of being unloved; they may also be employed by high-energy individuals to augment a preferred hypomanic adaptation or to combat depression. Sedatives (e.g., alcohol, benzodiazepines, barbiturates), in low doses, can overcome feelings of isolation and allow feelings of closeness and warmth (e.g., “I can feel like one of the guys ... I can join the human race”); in high doses, they drown out negative, unwelcome feelings and lead to social isolation.3

This perspective reflects Edward Khantzian’s self-medication hypothesis of addiction:

Clearly, there are other determinants of addiction, but I believe a self-medication motive is one of the more compelling reasons for overuse of and dependency on drugs. Clinical findings based on psychoanalytic formulations have been consistent with and complemented by diagnostic and treatment studies that support this perspective [...]. Rather than simply seeking escape, euphoria, or self-destruction, addicts are attempting to medicate themselves for a range of psychiatric problems and painful emotional states.3

Targeting substance use directly — while often necessary at the onset of treatment — seldom provides durable recovery. Psychiatric problems and painful emotional states are the substrate for substance use. These issues need to be explored and addressed or relapse will likely occur.

Here’s an image that I frequently include in lectures for medical students and residents.5 Everyone received addiction treatment prior to time zero (x-axis) and were abstinent from their drug of choice at discharge (y-axis; 1.00 = 100%). Most resumed using substances over the next year.

(I could show you dozens of data visualization like this. I like this one because it includes four substances in the same figure and has a meaningful time scale.)

There are various causes for relapse, however, unaddressed psychiatric symptoms — depression, anxiety, intrusive thoughts and images — are prominent among them. To reduce or eliminate substance use one must find the “switch.” ✸

  1. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR). Washington, DC: American Psychiatric Association, 2022, pp. 543–665
  2. Psychodynamic Diagnostic Manual, 2d ed (PDM-2). New York: Guilford Press, 2017. PDM was first published in 2006. The countdown to PDM-3 is on: it will be available on December 8th, 2025
  3. PDM-2, p. 226
  4. Am J Psychiatry 1985;142(11):1259–1264 (PubMed). This hypothesis generated controversy when people took it farther than Khantzian himself (he never claimed that self-medication was the sole explanation for addiction). His conceptualization, however, has empirical support: see, for example, JAMA Psychiatry 2013;70(7):718–726 (PubMed). The hypothesis is also consistent with my clinical experience. Patients often report that substance use began as chemical coping and eventually turned into addiction
  5. Curr Psychiatry Rep 2011;13(5):398–405 (PubMed)

Series Installments
Find the Switch
Find the Switch — 2
Find the Switch — 3
Find the Switch — 4

Find the Switch — 3

Jean Strobel introduced me to the the “dry drunk syndrome” years ago and it has guideded my work ever since. A well-known pamphlet on the subject states, “Being dry is not the same as contented sobriety.”1 Bev Lemaniak, another important mentor, said it best: There’s more to recovery than sobriety.”

Dick Solberg, the pamphlet’s author, notes:

Dry drunk refers to attitudes and actions that poison our well-being. We keep acting "drunk," even when we're "dry." What's more, these attitudes and actions often show up after we've been sober for a while. They're a sure sign that we're experiencing discomfort in our lives.2

I’d argue that the attitudes and actions are generally present before struggles with alcohol and other drugs develop. They represent the driver or “switch” (and here) for addiction.

Solberg explored some “obvious traits” of those with substance use disorders including grandiosity, judgmentalism, intolerance and impulsivity.3 Some in recovery refer to these are “character defects.”4 From a clinical standpoint, we think in terms of attachment patterns, personality structure, irrational beliefs,5 and so forth. Treatment involves targeting these underlying issues. ✸

  1. R.J. Solberg. The Dry Drunk Syndrome, Revised Edition. Center City, MN: Hazelden, 1993, p. i
  2. Ibid., pp. 1–2; emphasis in the original
  3. Ibid., pp. 3–8
  4. Alcoholics Anonymous, 4th ed. New York: Alcoholics Anonymous World Services, 2001, pp. 58–71, 72–88 (Step 6)
  5. Irrational beliefs, or iBs, are a core feature of rational emotive behavior therapy (REBT), a form of cognitive behavioral therapy. Those with substance use disorders often address awfulizing, frustration intolerance and self-downing by “chemical coping”

Endnote. According to Hazelden, Solberg’s pamphlet was initially published in 1970. It was revised in 1983 and 1993. There have been many different covers over the years and pamphlets are often undated. The copy that Jean Strobel gave to me appears to be a later printing of the first edition (publishing mark: dry drunk is hyphenated).

Solberg also authored The Dry Drunk Revisited, which was published in 1980 and is now out of print.

Many thanks to Chuck B. for helping me understand the publication history.

Series Installments
Find the Switch
Find the Switch — 2
Find the Switch — 3
Find the Switch — 4