Insights on the Insanity of Addiction

Psychiatric TimesVol 32 No 3
Volume 32
Issue 3

In clinical terms, one of the most distinguishing diagnostic features of addictive disorders is that those affected continually and repeatedly revert to their addictive behaviors, despite the devastating negative and adverse consequences.

So much has been said and written about addiction, much of it so wisely put by individuals in and out of recovery. One popular adage is “the definition of insanity is doing the same thing over and over again and expecting a different outcome.” In clinical terms, one of the most distinguishing diagnostic features of addictive disorders is that those affected continually and repeatedly revert to their addictive behaviors, despite the devastating negative and adverse consequences.

In my own career and investigative studies as an addiction specialist spanning many decades, I have emphasized that a primary factor that contributes to repeated abuse is that addictive substances temporarily relieve emotional pain and suffering that otherwise feel unmanageable or intolerable. That is, those who endure such distress self-medicate, and they wittingly or unwittingly provide support for the self-medication hypothesis (SMH) of addictive disorders, a theory that has received much endorsement and at least an equal amount of criticism and rejection.1,2

[[{"type":"media","view_mode":"media_crop","fid":"33252","attributes":{"alt":"addiction","class":"media-image media-image-right","height":"140","id":"media_crop_6431869658057","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"3503","media_crop_rotate":"0","media_crop_scale_h":"160","media_crop_scale_w":"113","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"float: right;","title":" ","typeof":"foaf:Image","width":"99"}}]]On occasion, I somewhat satirically comment that I believe in the SMH more on some days than others. Although I continue to believe that it is a powerful paradigm to explain addictive disorders, today was one of those times when I found myself thinking it does not satisfy the complexities (or perhaps the subtleties) involved in the bedeviling, repetitious, self-harming behaviors associated with addictions. An e-mail from a former patient with whom I had parted ways because I relocated my office to another community, stimulated my thoughts about the irrationality of addiction and doubt and curiosity about the SMH aspect of addiction.


Matthew is a 55-year-old gifted author and college professor of English studies. After struggling for many years as a heavy drinker, he sought out professional help with only modest progress in obtaining control over his drinking. He finally established abstinence and a protracted period of sobriety (5 years) before he started treatment with me. He then immersed himself in AA meetings where he felt supported and found a caring sponsor to work with him.

For reasons not entirely clear but at least to some extent related to recent stressors (some related to chronic musculoskeletal pain), he resorted to periodically drinking large amounts of alcohol. The following e-mail typified that pattern, in this case indicating that his current drinking was in part celebratory:

Dear Dr K,

I finally felt okay physically last week, when my class began. I had a great week, so much so that I wanted to celebrate/prolong and drank a bottle and a half of wine Friday night. Saturday was a total loss, but I managed to get out and buy one bottle of wine, which I consumed. Feel okay now and am ready for 4 straight days of classes.

Not worried about drinking during the class, but certainly when it ends. The whole thing is very strange. I guess my life was turned upside down by the pain in recent months, not able to go to early morning meeting, etc. But something has to give . . . haven’t quite figured it out. Don’t feel committed to sobriety.

Thanks so much for your text. Would love to come see you, but obviously I need to find someone in the area, sooner than later.




I responded to his e-mail as follows:

Dear Matt,

Get back to basics. That should include someone to work with you on the insanity of addiction. You know what to do as well as anyone else, and that is to get a safety net of others who care about and love you. YOU CAN’T DO THIS ALONE.

I would also add that I am not entirely surprised about your notion that when you complete your course, you will be more apt to drink. Perhaps success creates the illusion that you can control the uncontrollable and be immune to the consequences of drinking.

And should you continue to delay in finding someone, come see me in the interval for a sanity check.


I was reminded that persons addicted to substances find countless reasons to drink and drug-to grieve, to celebrate, to heighten feelings, to reduce or drown feelings, to get a job done, to drink when a job is done, and so on. Obviously, the reasons to self-medicate are myriad and the motives, seemingly contradictory.

My response to Matt was guided in part by my unyielding, evolving curiosity and interest in what it is that governs and drives the needs and issues that perpetuate addictions. So notwithstanding the criticisms of self-medication motives, the repetitious nature of the “insanity of addiction” does not necessarily contradict. Rather, it begs the question whether addictive behaviors accomplish or fix anything for those who repeatedly resort to it.

To Matt’s credit, he followed up with several e-mails and a phone call to indicate that he was more aggressively seeking out an addiction counselor locally to obtain support and to regain control of the drinking.


When addicted persons in recovery speak of the puzzling sense of powerlessness and inability to control their drinking, as Matthew suggests in his e-mail, they also often indicate how the irrationality of it is so painful and bedeviling. As I indicated, the irrational component challenges me as well, on some days more than others, including whether the ideas and theories of addiction psychiatry are sufficient to address and explain what seems so unexplainable and confusing.

I offer a few thoughts here, drawing on my clinical experiences and ideas about addiction, which might shed light on what often can seem irrational and incomprehensible. Although modern neuroscience research has yielded important findings on how substances alter the brain and contribute to addictive patterns of use and misuse, such brain changes and mechanisms alone are insufficient to explain the complexities of dependence on alcohol and addictive drugs. I do not suggest that I have all the answers, but I believe that clinical study and treatment of addiction offer valuable insights into repetitious, self-harm behaviors, as unreasonable as they may seem.

In treatment, my patients consistently reveal their life-long difficulties in dealing with their feelings. They have been plagued by issues of poor sense of self and low self- esteem. Their relationships with others suffer, and they find it difficult to practice self-care. Often they fail to appreciate very real danger-in their surroundings and especially those associated with addiction. I refer to these issues as the human challenge of self-regulation. Persons at risk for addiction are underdeveloped or deficient in some or all of these areas.

In my experience, in the context of experimenting with addictive substances, some people discover (italics for emphasis) that addictive substances provide short-term relief from the pain, suffering, and dysfunction associated with their problems in regulating their emotions, low self-esteem, and difficulties with interpersonal relationships. These factors then malignantly interact with deficits in self-care to make addictive attachments more likely.

Thinking about addiction as a self-regulation disorder “helps” in part to explain how addictive substances assist in regulating a wide range of challenges. Considering addiction from such a perspective provides some measure of understanding for what seems so unreasonable, irrational, and incomprehensible.

Returning to Matthew and his dilemma: he knows that resorting to alcohol will be devastating, but he nevertheless feels powerless to avoid that prospect. As we so often say in our work as psychiatrists and mental health professionals, people have their reasons for what they believe, say, and do, as unreasonable and irrational as it may seem. Addicted individuals, including my patient Matthew, do not have exclusive claim to this aspect of human existence.

Related content:Emerging and Current Issues in the Treatment of Substance Use DisordersAddiction Psychiatry: Clinical Insights

This article was originally posted on 2/9/2015 and has since been updated.


Dr Khantzian is Professor of Psychiatry, part time, Harvard Medical School in Boston, and President and Chairman, Board of Directors, Physician Health Services of the Massachusetts Medical Society in Waltham, Mass. He is in private practice and specializes in addiction psychiatry.


1. Khantzian EJ. The self-medication hypothesis of addictive disorders: focus on heroin and cocaine dependence. Am J Psychiatry. 1985;142:1259-1264.

2. Khantzian EJ. The self-medication hypothesis of substance use disorders: a reconsideration and recent applications. Harvard Rev Psychiatry. 1997; 4:231-244.

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