Mind Hacks comments on a strange Guardian story of a man who is still ‘a wreck’ seven years after he stopped his nine-year binge on MDMA (XTC; Ecstasy).

It reveals some of the methodological problems in establishing how harmful MDMA is, since (a) we may not be entitled to extrapolate from extreme use to more moderate recreational use; (b) one has to rule out that observed effects are from the MDMA rather than any concurrent use of other substances. But the most telling point is their last one — “what kind of man would take 40,000 ecstasy pills?”

And so, again, we face the age-old psychiatric equivalent of the chicken and the egg question. Does drug use per se cause the psychopathology (on any of a number of measures) found in substance abusers; or does the psychopathology come first? Durng my residency, I remember one year during which I was supervised by two senior luminaries of psychiatry whose offices were at opposite ends of the corridor I inhabited. The late Norm Zinberg claimed that the psychological alterations were results of the ‘drug, set and setting’ of the drug user; and Ed Khantzian claimed that much of drug abuse was ‘self-medication’, knowingly or unknowingly, of an underlying mental disorder, and thus that the drug abuse could be stabilized or prevented by treatment of the underlying condition. A corollary of this was the ‘drug of choice’ hypothesis, which said that one gravitated to a particular preferred drug in accordance with the nature of one’s underlying diagnosis. Being literally (and memorably) caught in the middle, I sometimes think that my real psychiatric training that year consisted in learning how to be diplomatic, synthetic and integrative in the face of these insistent, and mutually incompatible, didactic stances…. [Here, by the way, Khantzian writes a brief remembrance of Zinberg…]

Related: The Trip of a Lifetime: a new generation researches the medical benefits of the deprecated hallucinogenic drug LSD. (BBC)