Appendix A

Some Basic Problems in Drug Addiction and Suggestions for Research*

by MORRIS PLOSCOWE

VI. PSYCHIATRIC AND PSYCHOLOGICAL FACTORS IN DRUG ADDICTION

As we have seen, medical men have tended to regard drug addiction either as a disease or as a symptom of a disturbed or abnormal personality that requires drugs in order to be able to cope with life's problems. Drug addiction may be considered a disease if the focus of attention is the pathologic process in the human organism created by addiction. A healthy human organism does not need morphine or heroin to ward off withdrawal symptoms. The diseased body of an addict, however, requires its daily dosage of drug for the addict to be comfortable. On the other hand, drug addiction is not an accidental process. Individual factors are at work in the determination of who will and who will not become addicted, even in those areas of our cities, where the incidence of drug use is high. There are individuals who are exposed to drug use, who through an effort of will, strength of character or force of personality reject all contact with narcotic drugs. These individuals will never become drug addicts. There are also some persons who although once addicted, through will power, or force of personality and character manage to stay off drugs. It is obvious that character and personality factors are at work in the selection of addicts and in determining which addicts will relapse to the use of drugs, once they have been taken off drugs.

Who, then, are the individuals who succumb to drug addiction? What factors of personality, of character, of psychological organization or disorganization distinguish the drug addict from the non-addict? Can the phenomenon of drug addiction be explained by the disciplines of psychology and psychiatry? Even the most casual reading of the psychiatric and psychological literature on drug addiction indicates that psychology and psychiatry are still far from satisfactory explanations as to why specific individuals take to drugs, and why others who may be similarly exposed do not take to drugs to resolve their personal problems. Over and over again, one reads that drug addiction is an expression of personality disturbance or maladjustment. An individual takes drugs to overcome the shortcomings of personality which make it difficult for him to cope with the world in which he lives. He needs drugs to enable him to deal with the anxieties and tensions arising from familial conflicts, sexual difficulties and the necessity of growing up and taking one's place in an adult society. A vast majority of drug addict patients, write Vogel, Isbell and Chapman, "... are fundamentally emotionally immature children like persons who have never made a proper adaptation to the problems of living."43 Not all drug addicts, however, fit into a single psychiatric classification or diagnosis. The personality disorders of drug addicts, "... run the gamut of the standard psychiatric nomenclature from the simple anxiety states to the major psychoses."44 Thus, all kinds of people, both normal and abnormal, become drug addicts. This can be seen from the summary by Vogel, Isbell and Chapman of the pioneering work on the classification of drug addicts done by Kolb* and Felix.** *In 1925 Dr. Lawrence Kolb made his pioneer study of 230 drug addicts recruited from prisons, a municipal hospital, a clinic "and other addicts in good social standing in various parts of the country." This fell into the following general classifications: 1. People of normal nervous constitution necessarily or accidentally addicted through medication in course of illness. This group constituted 14% of the total; 9% being necessary addicts and 5% were accidental cases.

2. Care-free individuals, devoted to pleasure, seeking new excitements and sensations, and usually having some ill-defined instability of personality that often expresses itself in mild infractions of social customs. This group constituted 38% of the total.

3. Cases with definite neuroses not falling into classes 2, 4 or 5. This group constituted 13.5% of the total.

4. Habitual criminals, always psychopathic. This group constituted l3% of the total.

5. Inebriates. (Only those who had a definite history of periodic drinking with sprees were considered for this study.) This group constituted 21.5% of the total.

In 1937. Dr. Kolb and Dr. Ossenfort attempted to refine the classification in this earlier study, based upon an analysis of the first 1,750 admissions at Lexington. The addicts were classified as follows: 1. Normal individuals accidentally addicted. This group includes persons of normal nervous constitution accidentally or necessarily addicted through medication in the course of illness.

2. Psychopathic Diathesis. This group includes individuals who show psychopathic dispositions or tendencies characterized by behavior resulting from misinterpretations of environmental settings or situations, but not a well-crystalized personality defect.

3. Psychoneurosis. This group includes individuals suffering with ordinary types of psychoneurosis.

4. Psychopathic personality without psychosis. This group is composed of persons who show deviation of personality usually expressed as constitutional psychopathic inferiority, psychopathic personality or constitutional states, where volitional and emotional control are gravely distorted from the normal.

5. Inebriate. This group includes individuals in whom alcoholic indulgence, either periodic or more or less continuous, played an important role as a precipitating factor in their addiction. They apparently have a so-called inebriate impulse.

6. Drug addiction associated with psychosis. This group includes addicts suffering with frank psychosis, organic, toxic or functional. In 1939. D'. Michael Pescor made an analysis of the personalities of 1036 addicts at Lexington, Kentucky, based upon the aforementioned psychiatric classifications. Dr. Pescor came to the conclusion that the 1036 addicts studied by him fell into the following:

1. Normal individuals, accidentally addicted--3.8%

2. Psychopathic Diathesis--54.5%

3. Psychoneurosis (ordinary type)—6.3%

4. Inebriate -Inebriate Impulse—21.9%

5. Psychopathic Personality Without Psychosis--11.7%

6. Drug Addiction Associated With Psychosis—11.7%

7. Psychosis Caused by Opiates--None.

**Dr. Robert H. Felix, in 1939, attempted to further define three categories in the above Kolb, Ossenfort, Pescor classification, namely the psychoneurotic, the psychopathic personality and the psychopathic diathesis.

His difficulties with these elusive categories are apparent from the following extracts of his article: "The concept of the psychopathic-diathesis group may not be as dear as that of the other two, but probably can best be described as a state in which, because of some ill-defined instability of personality, no better than a border-line adjustment is made. The individual is not fundamentally anti-social and, with some artificial assistance, can make an acceptable adjustment. The most striking characteristic of this group is the fact that, as a whole, they were adjusting marginally before they became acquainted with narcotics. After their first few experiences with the drug, they felt an exhilaration and a sense of relief comparable to the solution of a difficult problem or the shaking off of a heavy responsibility. Many of them also felt an increase in efficiency which, in some cases, at least, appears to have been an actual improvement. Having once found this new world of greater happiness and efficiency, they attempted to regain it and to live therein for all time.

"This phenomenon is not so prominent in the other two groups. The psychoneurotic takes his drugs to relieve himself of whatever type of symptom he may have. The psychopath uses narcotics rather as an aggressive behavior reaction--that is, he feels a desire to be more important or prominent among his associates. He wishes to excel in deeds of daring, to be more clever than his fellows, or to stand out as an object of admiration. Under narcotics, he feels that he has more nearly accomplished these ends. As Kolb has put it, his use of drugs is 'comparable to the compensation of little men who endeavor to lift themselves to greatness.' In other cases, he uses this means to gain an experience of pleasure over and beyond the requirements for comfortable living. He is a hedonist. What he desires to do, he does for the pure pleasure to be derived from it. He is morally defective and hence does not consider social or ethical standards a check upon its activity. The only restraint he recognizes is painful or physical in nature. The patient with a psychopathic predisposition, however, takes his opium as a medicine which he believes-- sometimes with good reason-helps him to make a more satisfactory adjustment to life as he finds it, and without which he feels inadequate to meet many of life's problems. "The same fundamental drive, then, is present in all cases--namely, the desire to derive from life more pleasure and satisfaction, which, after all is a striving present in all mankind. The differentiations made above are probably of theoretical rather than principal importance, but it is felt that they help to clarify the problem." "The kinds of personality disorders which underlie drug addiction have been well described by Kolb and Felix, who list four general personality types.

"The first group is made up of normal persons accidentally addicted. It consists of patients who in the course of an illness have received drugs over an extended period of time and, following relief of their ailments, have continued the use of drugs. These persons are frequently termed ‘accidental' or 'medical' addicts. Such persons are regarded by some authors as constituting a special group of addicts who are different from those persons who began the use of drugs as a result of association with persons who were already addicted. In our experience, all 'medical' addicts have some fundamental emotional problem which causes them to continue the use of drugs beyond the period of medical need. There is, then, no basic difference between 'medical' and 'non-medical' addicts except in the mode of the original contact with drugs. In persons with stable personalities, social pressure, conscience and well balanced emotional makeup negate the pleasure produced by drugs sufficiently to prevent their continued use.

"The second group consists of persons with all kinds of psychoneurotic disorders who, as Felix said, take drugs to relieve whatever symptoms they may have. The manifestation of the neurosis may be anxiety, an obsession or compulsion or any of the great group of psychosomatic disorders.

"The third and largest group consists of psychopathic persons, who ordinarily become addicted through contact and association with persons already addicted. They are generally emotionally undeveloped aggressive hostile persons who take drugs merely for pleasure arising from the unconscious relief of inner tension, as shown by this statement of an addict: I was always getting into trouble before I got on drugs-never could seem to get comfortable; I had to go somewhere and do something all the time. I was always in trouble with the law. Some fellows told me about drugs and how good they made you feel, and I tried them. From then on, I was content, as long as I had my drugs--I didn't care to do anything, but to sit around, talk to my friends occasionally, listen to the radio, and only be concerned with the problem of getting money for drugs. This I usually did by picking pockets or other such petty stuff.

"The fourth and smallest group is characterized by drug addiction with psychosis. The persons in this group, many of whom have borderline mental illness and sometimes frank mental illness, are seemingly able to make a better adjustment while taking drugs. Sometimes it is difficult to establish the diagnosis and not until drugs are withheld, does the psychosis become apparent.

"There is a category of patients not included in the aforementioned groups. Kolb originally listed these as patients with psychopathic diathesis. While it is true that some of these exhibit much of the overt behavior pattern of psychopathic persons, when studied carefully, they usually fall into a milder behavior or character disorder group, which has characteristics of both the psychoneurotic and the psychopathic groups. Included are persons with severe dependency problems, withdrawn schizoid types, emotionally immature adults, as well as those suffering with the milder degrees of maladjustment and inadaptiveness to the complications of living. Felix stated that most of the persons falling into this group were making a marginal adjustment to life before becoming acquainted with narcotics. After their first few experiences with narcotics, they felt an exhilaration and a sense of relief comparable to the solution of a difficult problem or the shaking off of a heavy responsibility. Many of them also felt an increase in efficiency which, in some cases, appeared to have been actual improvement. "In general, persons who never have been able to make a satisfactory adjustment to life, whose adaptive patterns of behavior have been inadequate, frequently find in morphine, much as the tired business man finds in the preprandial cocktail, a means of return to 'normal.' This is a false situation which may be recognized by the tired business man but is not recognized by the drug addict. Our studies indicate that patients who have made a marginal degree of emotional adjustment to life, and then have begun to use drugs, lose some of their normal adaptive patterns of adjustment. This regression in personality represents the greatest danger of drug addiction."45 A consideration of the aforementioned classifications makes it obvious that none of the classifications provide specific explanations for drug addiction. Large numbers of individuals fitting into the categories of psychopathic diathesis, psychopathic personality or psychoneurosis, never take drugs as a means of resolving their personality difficulties or emotional problems. One begins to see the wisdom of Dr. Wikler's observation: "The attractiveness of morphine for certain individuals seems to be related to some of its remarkable pharmacologic properties, namely, its effectiveness in reducing such anxiety as is associated with fear of pain, anger and sexual urges, without seriously impairing the sensorium or the effectiveness of internalized controls on behavior. The intensity of this attraction is enhanced greatly for such individuals as have been unable to gratify these needs by other means, be they 'normal,' neurotic or psychopathic..." "... the degree of attractiveness of morphine is related to 'personality structure' but not necessarily to 'neurosis' or psychopathy as such ..."46 This notion that the use of opiates is a highly individualized process and is not necessarily related to mental pathology is also expressed by Gerard and Kornetsky in their study on "Adolescent Opiate Addiction." They diagnosed 30 narcotic addicts and 30 adolescent non-addicts of roughly similar background and status.

The writers conclude as follows : "... The psychologic and psychiatric data of the study indicated that the addicts exceeded the controls in personality malfunction to a statistically significant and clinically impressive extent. These findings support the hypothesis that youths living in urban areas where illicit opiate use is widespread do not become addicted independently of psychiatric pathology. The data also indicate that the converse need not be true; as youths who exhibit personality malfunction similar to that of addicts need not become addicted. As the writers pointed out previously, becoming an opiate addict is a highly individualized process which can be understood only in the context of the individual's personality structure, past life situation and present interactions with the significant figures of his familial and peer groups."47 The addict as Winick points out: "... is responding to personality problems of great complexity. The drug addict is a person with certain personality characteristics who happens to have selected this way of coping with his problems for a variety of reasons, of which he is usually unaware. Not the least of these reasons is his access to a social group in which drug use was both practised and valued. He takes one drug rather than another because it provides satisfaction for him. Other people with exactly the same kind of personality substratum never become addicts and select other means of expression for their basic conflicts."48