Drug abuse is a complex disease with complex dimensions. The epidemiologists have shown that many, not all, drug abusers come from disadvantaged environments. The psychiatrists and psychologists have long recognized that addicts have pathologic personality characteristics. Haertzen (1978) has recently reviewed a large body of data concerning the MMPI profiles of drug abusers. It is clear that all types of drug abusers including narcotic addicts, alcoholics, and poly-drug abusers have elevated scores on the Psychopathic Deviate (Pd) and the Depression (D) scales. Many addicts also have elevated scores on the Schizophrenia (Sc) and Hypomania (Ma) scale. On the basis of this psychologic testing, therefore, the addict appears to have a diffuse psychopathology. However, addicts seem to be remarkably normal; they have a normal range of intelligence, they show no consistent medical pathologies, and most are not psychotic. What then is their pathology?

 

Their pathology in a large part is characterized by unfulfilled expectations. To political leaders and administrators this is a failure to realize their potential as tax payers; to their neighbors a failure to contribute meaningfully to their communities; to the consumer a failure to be sufficiently productive. The failure of the addict to fulfill social expectations in a society becoming increasingly characterized by mutual dependencies is their pathology (Martin, 1977).

 

The abuses of drugs are cardinal signs of sociopathic behavior. The phenomenon of drug abuse has helped in defining the role of drugs in this destructive subtle psychopathology that has such profound social implications. I would like to review briefly efforts in which I participated over a period of almost twenty years that attempted to define the role of drug use in the pathology of drug abuse and to define the subjective effects of abused drugs that were responsible for their reinforcing effects.

 

Harris Hill and his collaborators (Hill et al, 1963) devised the Addiction Research Center Inventory (ARC1), a 500-item questionnaire containing many questions useful in measuring and conceptualizing subjective effects of drugs. One of the scales of particular importance which was derived from the ARCI was the MBG (morphine benzadrine group) scale. This scale measures feelings of enhanced self image, efficiency, and popularity. In an attempt to validate this scale, as well as other scales and questionnaires, a number of drugs were studied including a variety of narcotic analgesics, agonists-antagonists, amphetamines, and barbiturates. All of these abused drugs produced a dose related increase in the scale scores of the MBG scale. These observations were important for two reasons: (1) The observation that feelings of improved self-image, efficiency, and popularity were changed in a dose related manner suggested that they had an organic neuronal basis. (2) There is every reason to believe that these diverse drugs exert their effects through different modes of action, a point which is discussed later. Thus, the brain appears to have multiple neurohumoral processes that are involved in feelings of well being.

 

The next series of experiments that I would like to turn to were related to the process of physical dependence. The clarification of the concept of physical dependence and the identification of its characteristics were major advances in the study of the addiction process. Drugs such as the narcotic analgesics, barbiturates, and alcohol produce a type of physical dependence characterized by an explosive early abstinent syndrome. Although Himmelsbach (1942) had obtained evidence suggesting that the morphine abstinence syndrome might be prolonged, the first definitive demonstration of a protracted abstinence syndrome was done in rats by Dr. Wikler and myself. In experiments conducted to characterizing the time course of the morphine abstinent syndrome (Martin et al, 1963), the early abstinent syndrome in the rat ran its time course in about three days, and thereafter another abstinent syndrome emerged which had characteristics different from the early abstinent syndrome. This abstinent syndrome persisted and was still present in a diminished form 180 days after the animals had been withdrawn. It was called secondary or protracted abstinence.

 

These studies were subsequently extended to the dog (Martin et al, 1974) and to man (Martin and Jasinski, 1969; Martin et al, 1973). In the study of Martin and Jasinski (1969) patients were admitted to the wards of the Addiction Research Center and had an opportunity to accommodate to the environment; control observations were made three times daily for a period of seven weeks. Patients were then given morphine chronically; the dose was escalated over a five-week period until they were stabilized at 240 mg/day. They remained at this dose level for 29 weeks following which they were withdrawn gradually over a three-week period. During the period of addiction the patients temperature was significantly increased (0.3°C), pupils constricted, and respiratory rate depressed. Following withdrawal, blood pressure, body temperature, and respiratory rate were significantly increased and pupils dilated. This syndrome persisted for about one month following complete withdrawal of the drug. Thereafter, another persisting abstinent syndrome was observed characterized by a significant decrease in blood pressure and body temperature with a marginally significant decrease in pulse rate and constriction of pupils (p < 0.1). This syndrome persisted through the 31st week of abstinence at which time the study was terminated.

 

An analysis of variance was done on these data which segregated out the between subjects, between weeks and between treatments variance. Although changes in blood pressure, temperature, and pulse rate were statistically significant, it was also found that the between subjects variance was only several times less than that of the treatment effects. This indicated that the characteristics of protracted abstinence syndrome fell within the range of normal values for the variables identified and that it would be probably impossible to diagnose protracted abstinence in an individual using these signs.

 

Observations were then extended to determine if protracted abstinence could also be observed following methadone withdrawal and to see if the physiologic changes were associated with changes in mood or feeling states (Martin et al, 1973). There was a protracted methadone abstinence syndrome in which blood pressure and body temperature were significantly less than control levels. Further, the methadone dependent patient in protracted abstinence showed an increase propensity to sleep and exhibited a variety of changes in mood that was characterized by elevated scale scores that indicated negative feeling states and a decrease in scores on scales that indicated positive feeling states. The ARCI and MMPI scales scores which were altered during the cycle of methadone dependence are summarized in Table 1. Thus the protracted abstinence syndrome is associated with feeling states that are opposite in polarity to the euphorigenic actions of the narcotic analgesics, sedative-hypnotics, and amphetamine-like drugs.

The feeling state present in protracted abstinence had some of the characteristics of depression but differed in some respects. Table 2 defines and compares euphoria, hypophoria, and depression. With regard to self-image the euphoric state is polarly opposite to hypophoria except in the estimation of self worth. Hypophoric patients feel they are worthy and deserving even though they are unappreciated. In contrast a high percentage of depressed patients feel unworthy (Woodruff et al, 1967). By and large hypophoric patients feel hopeful, can experience joy, enjoy humor, and laugh readily. In contrast, hopelessness and sadness are among the most common symptoms of depressed patients. Another important difference between the hypophoric and the depressed patient is the lack of guilt feelings in the hypophoric patient.

Analysis of the characteristics of sociopathy led us to identify five major traits: impulsivity, egocentricity, increased need states, feelings of hypophoria, and feelings related to sociopathic impulses. We constructed a questionnaire called the Maturation Scale. It was composed of five subscales which we felt measured existing feelings related to these five traits (Martin et al, 1977). We compared 53 students and teachers at a theologic seminary with 53 subjects who had been treated for alcoholism and 24 prisoners who were narcotic addicts. These subjects completed the Maturation Scale questionnaire, the MMPI, and an indepth Personal History Questionnaire which identified a number of types of sociopathic behavior. A partial content of the Personal History Questionnaire is presented in Table 3 (Hewett et al, 1980). The personal history questionnaire was constructed and scored such that it gave a quantitative estimate of the amount of sociopathic behavior that the subject had been involved in. The results obtained with the Maturation Scale, MMPI, and the Personal History Questionnaire for the three groups of subjects are presented in Table 4. Clearly both the alcoholics and the addicts had significant elevations on all of the subscales of the Maturation Scale, the Pd, Ma and D scale of the MMPI and the Adult Sociopathy Scale of the Personal History Questionnaire (Martin, 1977). These findings on the MMPI are in keeping with data obtained by others. The questions of the Maturation Scale asked the patients how they felt at the time they were completing the questionnaires and the Maturation Scale was devoid of any retrospective questions. The data obtained on these scales were correlated with Adult Sociopathy Scores from the Personal History Questionnaire. All of the subscales of the Maturation Scale and the Pd scale of the MMP1 were significantly correlated with the scores on the Adult Sociopathy Scores (Martin, 1978). These data would indicate that, indeed, alcoholics and narcotic addicts do have an affective disorder and that this disorder of feelings is associated with antisocial behavior.

 

Hypophoria has the dimensions of feelings of lack of efficiency and popularity and a poor self image. As indicated above narcotic analgesics, amphetamines and barbiturates enhance feelings of well being and diminish feelings related to poor self image, inefficiency and unpopularity. In addition other drugs of abuse including marihuana and LSD-like hallucinogens also produce similar feelings of well being.

 

Feeling states may be under the control of proven neurohumors for we know that the narcotic analgesics share many features in common with brain peptides, the enkephalins and endorphins, that amphetamines release dopamine, that the LSD-like hallucinogens mimic the effects of tryptamine and serotonin both of which are endogenous brain transmitters and the barbiturate prolonged the action of the inhibitory transmitter GABA. One can speculate that patients with hypophoria may have a deficiency in one or more of these neurotransmitters involved in feeling states and that their personality disorder could have an organic basis. With the rapid development of the neurosciences it seems well within the realm of possibility that these deficiency states can be identified and diagnosed and that new drugs can be designed and developed which would rectify these disorders. Therefore, various types of antisocial behavior including drug abuse, which has been viewed from the point of view of ethical and a legal perspective, may indeed prove to be mental health disorders amenable to specific chemotherapy.

 

REFERENCES

 

Hewett BB and Martin WR: Psychometric comparisons of sociopathic and psychopathological behaviors of alcoholics and drug abusers versus a low drug use control population. Mt J Addict 15:77-105, 1980

Hill HE, Haertzen CA, Wolbach HB and Miner EJ: The addiction research center inventory: Standardization of scales which evaluate subjective effects of morphine, amphetamine, pentobarbital, alcohol, LSD-25, pyrahexyl and chlorpromazine. Psychopharmacologia 4:167-183, 1963

Himmelsbach CK: Clinical studies of drug addiction; physical dependence withdrawal and recovery. Arch Intern Med 69:776-782, 1942

Martin WR: Drugs and drug addiction. Pg. 1-11 Proceedings of the 39th Annual

Scientific Meeting of the Committee on Problems of Drug Dependence, 1977 Martin WR, Hewett BB, Baker AJ and Haertzen CA: Aspects of the psychopathology

and pathophysiology of addiction. Drug Ale Depend 2:185-202, 1977

Martin WR and Jasinski DR: Physiological parameters of morphine dependence in man-

tolerance, early abstinence, protracted abstinence. J Psychiat Res 7:9-17, 1969 Martin WR, Jasinski DR, Haertzen CA, Kay DC, Jones BE, Mansky PA and Carpenter

RW: Methadone-A reevaluation. Arch Gen Psychiatr 28:286-295, 1973

Martin WR, Wikler A, Eades CG and Prescor FT: Tolerance to and physical dependence

on morphine in rats. Psychopharmacologia 4:247-260, 1963

Woodruff RA, Murphy GE and Herjanic M: The natural history of affective disorders. 1. Symptoms of 72 patients at the time of index hospital admissions. J Psychiatr Res 5:255-263, 1967