By Jack D. Blame, M.D., and Demetrios A. Julius, M.D.
The Clinical-Behavioral Branch, Division of Research, NIDA, is interested in developing a comprehensive and practical approach to treatment of heroin-dependent people and drug abusers more generally.
This approach should be based on a theoretically sound knowledge of the psychiatric status of the drug-dependent person as well as the psychodynamics of drug abuse and psychological dependence.
The goal is to increase the quality of treatment and likelihood of successful therapeutic outcome by focusing on the individual’s intrapsychic dynamics and relevant external factors, in order to select the most suitable treatment. Unfortunately, many gaps still exist in our knowledge about use, abuse, and dependence on opiates and other psychoactive drugs.
One objective of this monograph is to stimulate the development of new research directions and strategies for implementing innovative treatment which take into consideration psychiatric evaluation and psychodynamic understanding.
With this in mind, the first Technical Review of the Psychodynamics of Drug Dependence convened on April 2 and 3, 1976, in Washington, D.C. Participants presented papers from which the substance of this monograph is primarily derived.
To exploit the theoretical groundwork laid at this meeting, the technical review group recommended an ongoing series of small working groups, each of which would focus on a specific issue.
Consequently, a second review group convened on March 17 and 18, 1977, to focus specifically on diagnostic and therapeutic research issues.
The second group included some noted theoreticians and researchers in areas related to drug dependence, among them Harriet Barr, Otto Kernberg, Gerald Klerman, George Woody, Charles O’Brien, Catherine Treece and Henry Rosett, in addition to members of the first group who continue active research in the area.
We wish to thank all of these researchers and clinicians for the high caliber of interest and effort they have contributed. The overview presented in chapter 2 was written before the second conference took place and therefore does not refer to it.
We are, however, gratified to be able to include Dr. Woody’s report as the final chapter of this monograph.
BACKGROUND
Before the early 1970’s, an effort was made with each patient in drug abuse treatment to achieve an understanding of the specific personality structure and the psychodynamic factors contributing to the patient’s drug dependence.
This understanding formed the basis for therapeutic goals and course. Drug abuse treatment has historically utilized therapeutic communities, residential centers, outpatient drug-free treatment clinics, and detoxification clinics.
These treatment modalities have used group therapy, psychopharmacological agents, individual counseling, family therapy and/or a therapeutic milieu as primary behavioral change-producing techniques. The failure of heroin withdrawal alone as a treatment with the goal of long-term continued abstinence has been voluminously documented.
At best, medically controlled detoxification had only immediate and temporary value as a first step in a comprehensive rehabilitation program. Medically regulated detoxification reduced human suffering and freed individuals from their physical dependence on heroin, which permitted a shift in attention to other more constructive pursuits.
However, even long periods of confinement in a hospital, prison, or residential facility with traditional psychotherapeutic intervention have not significantly altered the subsequent relapse to heroin for the vast majority of addicts.
The advent of the methadone maintenance treatment modality and its large-scale application in the late sixties and early seventies in response to an epidemic increase in heroin addiction made dramatic alterations in the philosophy, process, and economics of heroin treatment. Methadone has proved to be an extremely effective pharmacologic agent.
The drug is capable, when prescribed and taken properly, of providing symptomatic relief of the most apparent symptoms of heroin dependence: abstinence symptoms, craving, and blockade of euphoria resulting from opiate injection.
This medication can remove the need for using illicit heroin and potentially allows the individual to alter his deviant lifestyle. However, methadone alone does not alter the underlying psychopathology manifested in compulsive drug abuse and dependence or the unbearable feelings or fears that may trigger the compulsion.
Methadone maintenance is in many ways analogous to the use of phenothiazines in the treatment of schizophrenia. The phenothiazines have dramatic effect on the psychotic manifestations of decompensated schizophrenics, facilitating long-term psychotherapy and rehabilitation, which are important treatment components.
The availability of an effective symptomatic treatment modality, coupled with rapid expansion of the heroin-dependent population, produced an increased demand for treatment. As a result, treatment resources did not keep pace with the increased demand for treatment, producing waiting lists, expanded patient case loads, utilization of paraprofessional counselors, and an emphasis on costeffective treatment.
All these factors contributed to a shift in treatment emphasis from intrapsychic factors to external social and economic aspects of the client’s life. Goals of treatment also concomitantly shifted from basic personality growth and comprehensive personal rehabilitation to social rehabilitation or merely changing social behaviors.
Evaluation of outcome focused on lifestyle (e.g., use of illicit drugs and alcohol abuse, illegal activity, general health, arrests) and social productivity (e.g., employment, educational achievements, marital stability). Despite the substantiated positive effect methadone maintenance has had for many thousands of heroin-dependent individuals on social rehabilitation, the ability to become and remain drug free after treatment has again become a criterion of success for many of those who articulate drug policy.
However, relatively little effort has been made to understand or treat the psychopathology which contributes to the individual’s psychological dependence on heroin and prevents meeting that criterion.
Recently, there has been renewed interest in developing a deeper comprehension of the psychodynamics of drug dependence in the light of recent advances in psychoanalytic ego theory. Much of this interest has been generated by accounts of the thoughtful and provocative clinical work of the psychoanalytic clinicians represented in this monograph working with drug-abusing populations.
These clinicians have proposed major theoretical advances toward achieving an understanding of drug abuse and psychological dependence. Many have extended this theoretical framework to propose implications for psychotherapy and treatment of drug abuse and especially psychological drug dependence.
These contributions, as well as those of others represented in the bibliography, are discussed in the following paper by Khantzian and Treece.
A central issue in evaluating different treatment methods for drug abuse has been increasing dissatisfaction with the uncritical acceptance of “drug abuse” as a diagnostically homogeneous term.
Both the clinical and research literature look generically at the effects of treatment on drug abusers, and only rarely has a clinician or scientist attempted to develop a treatment directed at a more specific diagnostic entity.
Reemphasis on psychiatric diagnosis implicitly reflects a conviction that “drug abuse” is not a genuine diagnostic entity. Rather, it is an attempt to categorize people in terms of an overt behavior which may express several genuine diagnostic entities and which may at times probably exist in the absence of psychopathology.
Yet it is difficult to see how treatment can be efficacious, especially for long-term, rehabilitative goals, so long as we continue to treat individuals having different psychopathologies with a hodge-podge of treatments specific to none of them.
Some may question whether the specialty of psychiatry currently possesses the technology for specific psychiatric diagnosis. It is true that diagnostic classification in psychiatry is in the process of development and refinement in an attempt to integrate new information and perspectives generated by different schools of theoretical orientation, e.g., psychoanalytic ego psychology and biological psychiatry.
The 1968 edition of Diagnostic and Statistical Manual of Mental Disorders (DSM-II) prepared by the American Psychiatric Association represents an attempt to achieve this goal. The APA is currently developing a DSM-III to reflect changes in the field. Concurrently, each of the different schools of thought in psychiatry is clarifying the field from its own unique perspective.
As a result, the scientific literature and popular press abound with a variety of diagnostic nomenclatures for psychiatric patients in general and drug users and abusers in particular. However, this dynamic state of the art and science of psychiatry should not be viewed as a limiting factor. In fact, psychiatry has been undergoing change since its inception.
Generally, this process has resulted in advancement for psychiatry as a medical specialty and better treatment for patients having psychiatric illnesses. Thus, focusing the attention of psychiatric diagnosticians and innovative clinicians on the often-overlooked population of drug abusers has potential benefit for psychiatry as well as afflicted individuals.
DSM-II includes the category “drug dependence” (304) “. . . for patients who are addicted to or dependent on drugs other than alcohol, tobacco, and ordinary caffeine-containing beverages, and unindicated or inappropriately taken prescribed drugs.
The diagnosis requires evidence of habitual use or a clear sense of need for the drug. The diagnosis may stand alone or be coupled with any other diagnosis” (DSM-II, 1968, p. 45).
Indeed, the psychiatric diagnoses of “sociopathic personality disorder” and “psychopathic personality disorder” have been used by some writers in this field in the past, supposedly to clarify what and who a “drug abuser” is.
However, this type of diagnostic effort has merely led to the widespread feeling that these diagnostic labels are no more clarifying than the descriptive label “drug abuser” itself. In fact, these diagnostic categories have now disappeared from the official American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-II), and have been replaced by the term “antisocial personality” (301.7).
The official definition reads, in part, “This term is reserved for individuals who are basically unsocialized and whose behavior pattern brings them repeatedly into conflict with society. They are incapable of significant loyalty to individuals, groups, or social values. They are grossly selfish, callous, irresponsible, impulsive, and unable to feel guilt or to learn from experience and punishment . . .” (DSM-II, 1968, p. 43).
Although this may characterize some drug-dependent individuals, it does not characterize the vast majority. The language of this diagnostic category implies, in effect, that such people are unfit to interrelate with “normal” people and should be seen as a deviant subgroup for whom there is probably little help possible. Applying this type of diagnosis to the drug-dependent’ person is of little practical value.
What is necessary for practical treatment is either to identify other major, treatable components of these individuals’ psychic constellation or to more explicitly and completely diagnose (Gr., dia - through, between; gignoskein - to know) what we now call antisocial personality and other applicable subdiagnoses. With regard to the first necessity, researchers have, for example, begun to demonstrate the existence of a subgroup of dependent individuals who can be diagnosed as depressed.
In an unpublished report, Senay (1975) has demonstrated the existence of significant depressive symptomatology in a group of opiate users in Chicago. Weissman, et al. (1976) have also demonstrated the same result. Using standard rating scales of depression, they have shown that a substantial minority of methadone-maintained patients are, in fact, clinically depressed. The implications of such results, of course, lead to a refinement of treatment plans for such patients.
In this regard, the double-blind placebo-controlled pilot study of Woody, O’Brien, and Rickels (1975) has shown a significant improvement of methadone maintenance patients who received the antidepressant agent, doxepin, over those who received the placebo. However, this was only a preliminary study, and longer term studies utilizing similar designs are now underway to validate these results.
When these studies are completed, they may shed light on which type of treatment is most effective for this subgroup of drug-dependent individuals. From this exemplary exploration of a new diagnostic area we see that there is indeed diagnostic thinking already available to identify one subgroup of drug users.
This thinking also has direct implications for treatment of these individuals. Diagnoses within the general category of “depression” are also continually being refined. Psychopharmacologists have identified syndromes of retarded depressions, agitated depressions, hostile depressions, reactive depressions, and endogenous depressions.
What is of value in this subclassification is that each of these subgroups seems to do better within certain specific treatment regimens.
For example, Gershon, Hekimian, and Floyd (1967)’ have shown, in a placebo-controlled study, that 70 to 80 percent of patients with retarded depressions do best with the tricyclic antidepressants. Hollister and Overall (1965) have also lent supporting evidence for this treatment, in that they found this group of depressions to respond best to imipramine (a tricyclic antidepressant), while thioridazine (a phenothiazine) was of little value.
However, in hostile depressions, the same study found thioridazine and imipramine to be equally effective. And in the reactive depressions, if the patient is receptive to verbal therapy, psychoanalytically oriented psychotherapy produces equally effective, if not superior, results to chemotherapy.
Other schools of theoretical orientation may view depression differently, resulting in other diagnostic terminology, e.g., primary and secondary affective disorder or manic-depressive disease. Nevertheless, the foregoing and other studies have shown how more specific differential diagnoses can improve treatment regimens with correspondingly enhanced chances for successful outcomes.
Returning to the more difficult classification of character or personality disorder such as sociopathic, psychopathic, antisocial, narcissistic, and borderline personality disorders, how can we proceed in the same fashion as we have shown is possible in the classification of depression? Part of the answer may lie within recent advances in psychoanalytic thinking.
The work of Greenacre, Kohut, and Kernberg has deepened and expanded the understanding of character pathology in general, and the so-called borderline and narcissistic personality disorders in particular. This pioneering work, drawing on solid observational and treatment interaction data, is evolving a complex and sophisticated theoretical base upon which can be built further concrete understanding of an enigmatic region of personality pathology.
There is, however, a need to distill and condense much of this thinking down to identifiable subgroups, which then would have specific implications for specific treatment regimens. In applying these new theoretical insights to the diagnostic problem of “drug abusers,” as well as developing new theoretical avenues of their own, researchers such as Khantzian, Wurmser, Krystal, Frosch, Wieder, and Kaplan have all begun the work of distillation of the theoretical work already accomplished.
Their work is now leading to more practical, specific, and operational formulations of diagnosis and consequent treatment planning of drugdependent individuals. The process of arriving at operational diagnostic subcategories, therefore, moves from the more generic to descriptive categories sufficiently refined to indicate actual treatment.
Diagnostically, we proceed from general descriptive terms such as “drug abuser” to more refined descriptors that indicate demographic variables. These include race, socioeconomic status, criminality, exposure to drugs, ethnic background and social environment, among others. These factors aid in understanding drug-dependent individuals, but do not in themselves dictate a complete treatment regimen.
Further refinement leads to more specific diagnostic categories such as those found in the APA’s DSM-II. These diagnoses include subgroups such as depressive neurosis, psychotic depression reaction, manicdepressive illness, or those with descriptive personality disorders.
Categorization can stop at this point or proceed to further refinement, as we have seen in the subgroupings of depression. We advocate further refinement of the psychiatric diagnoses of the DSM-II. This refinement may be especially critical within the category of the antisocial, borderline personality.
Within this subgroup we can begin to look at measures of such personality components as reality testing, structure of defense mechanisms, intactness of ego and super-ego functions, degree of grandiosity, identity diffusion, quality of object relations, and control of affects.
Can we, in fact, begin to define subgroups of individuals on the continuum of character pathology predominantly characterized by defects in one or more of these personality categories? To do so could have significant implications for differentiating treatment approaches. This process of refinement and exploration into undefined areas of personality diagnosis is undertaken by the contributors to this monograph.
Improved psychiatric diagnosis in the field of drug abuse has at least four implications for treatment. The first and most immediately apparent is that patients could, when indicated, receive individual psychotherapy, group therapy, family therapy, or psychopharmacologic agents directed at their psychopathology, such as those already indicated for treatment of depression. This would occur in addition to opiate maintenance therapy, vocational training, and the like, directed at their chronic behavior disorder and social circumstances.
Evolving sophistication in diagnosis of drug-abusing individuals will have implications for those who are evaluating and treating these people. These developments will increase the demand on therapists to be more interested in, to show greater understanding of, and to have deeper empathy for the people they are helping. Specificity in diagnosis will also mean specificity in treatment.
This should then lead to clinic treatment centers where multimodality. approaches allow a wide range of treatment regimens for a wide range of subgroups of “drug abusers.”
Currently, in many treatment programs the major responsibility for the assessment of psychological needs and provision of psychological treatment is given to paraprofessionals who are not trained in psychiatric diagnosis and treatment. Unfortunately, these wellintentioned counselors are not able to make use of the potentially valuable information available to them in planning and providing treatment services.
Thus, the increased participation of psychiatrists in treatment clinics may provide training opportunities and supervision for paraprofessionals. A more subtle implication would be the impact on the clinic as a treatment milieu.
Currently, methadone clinics, for example, are generally structured according to the personal whim of their director or dominant staff members. They can be confronting or lax, can be structured or allow patients great latitude, can be only dispensaries or very active in their patients’ lives. These different clinical structures have radically different implications for different personality types and for different psychopathologies.
The way a clinic interacts with a patient can mean the difference between success or failure in initiating and keeping the patient in treatment. Similarly, the way a clinic is structured is important for the success it will have with different types of psychopathology. For example, with the borderline personality, the need to provide sufficient external structure is felt to be a precondition for treatment.
The role and effect of methadone, residential communities, behavioral therapy, or clinic regulations in providing this need are yet to be determined.
Hence, diagnosis is a necessary condition for providing a clinic milieu that will enhance treatment. Finally, increasing our awareness of the types of psychopathology found in the drug abuse population will also increase our awareness of the psychotropic effects of drugs of abuse. Forexample, it is possible that heroin may have a beneficial effect on some individuals and may even constitute a form of self-medication.
But our current lack of diagnostic specificity hinders understanding the function of abuse drugs in the psychopathology of our patients. It also hinders the exploration of when and how to replace abused drugs in those patients for whom the drug may serve a useful function.
CONCLUSION
Our awareness of the importance of diagnosis in drug abuse is only now emerging. Some of the relevant research questions raised are:
Are there sufficient theoretical positions currently available to generate testable hypotheses for diagnosis and treatment?
Is there a need to develop a more cohesive theory of the psychopathology and psychodynamics of compulsive abuse and psychological dependence?
Do the manifested symptoms of compulsive abuse and psychological dependence (for example, narcotic hunger or craving, abstinence, euphoria) reflect structural defects of symbolic defense mechanisms?
Is there benefit to be gained from availability of comprehensive psychotherapies in treatment programs?
Can more effective treatment approaches be devised utilizing current knowledge?
What are the implications for maintenance drug therapy or use of other psychopharmacologic agents?
What are the implications for length and course of treatment?
Would continued treatment of the patient after the symptom of drug dependence disappeared be beneficial, as in other chronic relapsing disorders with cycles of remission and exacerbation?
What operational formulations can be developed for clinical testing?
There are also questions that relate to the psychopharmacology of opiates and other abused drugs: Are there specific psychotropic effects of opiates which are psychotherapeutic for the individual user?
Do these effects differ for users with varying types and degress of psychopathology? What is the nature of these actions? Do they help bolster underdeveloped defense mechanisms necessary to master tensions and anxieties of daily life problems or intrapsychic conflicts?
The focus of this monograph on the illicit abused drugs, the opiates in particular, represents only a small proportion of abuse substances and habitual behaviors leading to a variety of difficulties for man.
However, the abuse of illicit drugs may be viewed as the most deviant habitual behavior on a continuum which includes excessive use of alcohol, tobacco, and food.
Perhaps a more complete understanding of the more deviant behavior will shed light on the more common but frequently self-destructive behaviors. The Division of Research, NIDA, hopes to stimulate definitive research in these areas.
By encouraging well-conceptualized, welldesigned research protocols, which are also placebo-controlled and double-blinded when necessary, we hope to provide convincing answers to these complex questions for researchers and therapists alike.
The papers presented in this monograph are an initial effort addressed to some of these questions by a group of psychiatrists, most of whom have had considerable experience with patients who are drug abusers and consequently have developed some feeling for the complexity of these questions. The papers range from the theoretical to the clinical and from broad-scope issues to quite precise, limited studies.
Collectively, they give a flavor of the current state of the art.
REFERENCES
Diagnostic and Statistical Manual of Mental Disorders (DSM-II). Washington, D.C. : American Psychiatric Association, 1968, p. 43.
Gershon, S., Hekimian, L.J., and Floyd, A. Pre-clinical-clinical correlation of antidepressant activity: Controlled study of gamfexine and imipramine, Curr Ther Res, 9:349-354, 1967.
Hollister, L.E., and Overall, J.E. Reflections on the specificity of action of antidepressants. Psychosomatics, 6:361-365, 1965.
Overall, J.E., Hollister, L.E., Meyer, F., Kimbell, I., and Shelton, J. Imipramine and thioridazine in depressed and schizophrenic patients. Are these specific antidepressant drugs? JAMA, 189:605-608, 1964.
Senay, E. Depression in Drug Abusers. Chicago, University of Chicago, 1975 (unpublished report).
Weissman, M., Slobetz, F., Prusoff, B., Mezritz, M., and Howard, P. Clinical depression among narcotic addicts maintained on methadone in the community, Am J Psychiatry, 133(12):1434-1438, December 1976.
Woody, G., O’Brien, C., and Rickels, K. Depression and anxiety in heroin addicts: A placebo-controlled study of doxepin in combination with methadone, Am J Psychiatry, 132(4):447-450, April 1975.
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