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Biological, Psychogenic, and
W.K. van Dijk, M.D.
lt should be clear from the start that the following considerations are presented by a clinical psychiatrist. This means that the viewpoint from which the dependence theme will be inspected is largely determined by experiences with the treatment and rehabilitation of individuals who have fallen victim to the problems of abuse of drugs and with the prevention of relapse.
The state of dependence as a behavioral syndrome is characterized by the fact that the person concerned cannot live without the drug he or she is dependent on. This inability may take different forms and grades which depend, amongst other things, on the type of drug. With alcohol we sometimes observe that for some reason the alcoholic is able to abstain for days or weeks or even months; in case of heroin, however, the ability to stop taking the drug is restricted to a few hours only. ln either case, there arises after a shorter or longer interval, more or less spontaneously, a state of inner tension in which the dependent person feels an uncontrollable craving for the drug. Apart from the type of drug used, these differences are influenced by the personality structure, social factors (including treatment), and
This paper is reprinted with permission from Prof. Dr. van Dijk's "Complexity of the Dependence Problem: lnteraction of Biological with Psychogenic and Sociogenic Factors," in Biochemical and Pharmacological Aspects of Dependence and Reports on Marijuana Research, idl! H .M. van Praag (Haarlem, The Netherlands: Bonn, 1971), pp. 6-18.
probably also by the duration of the state of dependence. ln some cases dependence is consistent with a more or less normal way of life, in others it is not. ln the latter case the clinical term "addiction" may be used. lt should be noted that this definition of dependence and addiction does not include nor exclude physiological mechanisms. The terms are used descriptively to characterize behavior or ways of living.
lt is useful not to look at dependence, including addiction, as a separate entity only, but to keep in mind that it must be regarded as the final stage of a process. We may roughly sketch the natural history of the use of a drug leading to dependence as follows.
The first stage is the contact with the drug, which may take place in a medical or a nonmedical setting. After one or more contacts the process may come to a halt, or it may develop into the second stage— experimentation.
The stage of experimentation may assume different forms as to its picture, intensity, and duration, depending on several factors which will be discussed later. After some time has elapsed, the second stage may come to an end, or it may develop into a stage of socially tolerated use which from a psychiatric point of view may be called an integrated mode of use, or it may lead to the stage of excessive use.
The stage of excessive use often carries several risks and damages, which may be of a physical, psychical, or social (interpersonal, economic, legal, moral, etc.) nature. What is to be regarded as a risk or a damage depends largely on the prevailing social habits and customs, on the economic and historical situation, etc. The psychiatrist is inclined to speak of excessive use when there is the threat of an impairment of social, psychological, or physical functioning; certainly this stage will be so labelled if actual damage in one field or other can be demonstrated as being related to the drug habit.
The stage of excessive use as part of a process should be distinguished from incidental excessive use and from periodical excessive use caused by psychiatric factors like recurring depression or epilepsy. lt is a more or less continuous state.
ln a percentage of cases this phase may develop into the syndrome of addiction, which is a more or less terminal state. On the other hand, stopping the excessive use, or a return to integrated use may occur.
The development of the use of a drug leading to dependence is recapitulated in figure 1.
Addiction, which is the extreme form of dependence and which may be considered an illness, is a syndrome showing three main features:
1. lt is damaging to the individual.
2. lt is relatively autonomous. By this we mean that, whatever complex interplay of factors may have led to the phases of excessive use and addiction, once the boundary has been passed, a relatively stable state has come into being, which is more or less independent of the primary generating causes and conditions. As for the treatment, relative autonomy means that in the majority of cases merely removing the initiating factors is not sufficient; special measures have to be taken, aiming at treating the addiction syndrome as such.
3. The addiction syndrome is self-perpetuating, spontaneous recovery being exceptional. On the contrary, if no help is offered there is a tendency to further deterioration.
The courses the process can take in the individual case, the successive stages, and the final state show great variety, depending on the drug involved, the personality structure of the user, and the social context.
During the development of dependence several changes in the features of the stages of drug use occur. They may be described as in figure 2.
(contact, experimentation) addiction)
More freedom *" Lack of freedom
Less risks and damage 'More damage
Abuse possible *- Abuse present
No illness *. State of illness
Operating factors linear * Vicious circles
Extensive research has so far failed to show one simple cause which initiates the process of pathological use of drugs. On the contrary, both research findings and clinical work have made it clear that a complexity of causes and conditions gives rise to the drug-taking process. We may summarize these factors as follows.
Pharmacological Effects of the Drug
We may roughly locate the various drugs on a scale. On one side are the drugs with a strong addictive action (e.g., heroin and morphine), on the other are those to which an addictive power can scarcely be ascribed (e.g., aspirin, chlorpromazine, laxatives, or even petrol or vinegar). The addictive property of a drug depends on the somatic and psychic influences it exercises; in what way these are connected with the chemical structure is largely unknown. All of the addictive drugs have an influence on the feeling or mode of experience of the user.
For practical reasons we may divide them according to their effects: sedating, stimulating, and psychedelic. ln all cases, the drug is taken for its desired action. What in a given case is regarded as desired depends on the following factors.
Personal Factors of the User
ln this dimension, too, we can make a scale with at its extremes persons who have a strong disposition toward excessive use and addiction and those who are scarcely susceptible to it. The former type can be seen to incline toward a dysfunctional use even of nonaddictive or hardly addictive drugs. Often with these persons a triad of features can be found.
1. Feelings of discomfort, tension, and displeasure may easily arise in them, as a result of mild frustrations or even "spontaneously."
2. These unpleasant feelings are very intense or nearly unbearable.
3. They find it impossible to master, sublimate, and canalize such feelings.
The drug may be used to seek relief from the state of tension. To the group of persons not disposed toward abuse belong those in our culture who are impervious to alcohol, tobacco, tea, coffee, sweets, etc.
The personal factors should not be considered to form an invariable and stable system. Age, for example, is an important modifying factor; during puberty and adolescence the risk appears to be increased.
Physical and psychiatric diseases with a debilitating influence should also be kept in mind as predisposing factors.
Social Meaning and Value of a
Along this dimension, factors like the drug being accepted in the
The social meaning of a drug and of drug taking is not only important as an incentive to take drugs, but also as a factor which may have an important influence on the effect of a drug. Here lies a connection with the general pharmacological problem of the placebo effect and of the difference between reactors and nonreactors.
Environmental lnfluences on the User
These can be divided into positive factors, leading to a favorable reaction of the person, and negative ones, causing too great, too small, or inadequate stress. This dimension is of course connected with the second one, above. The same social situation and influence may be experienced by one person as a positive stimulus and as too heavy a burden by another, which he or she may try to get rid of by means of the use of drugs.
ln each individual case the drug-using process starts and develops from the interplay of factors from the dimensions mentioned above; figure 3 summarizes these.
Factors Maintaining the Process
After this brief discussion of the generating factors of the drug-using process, some short remarks will be made about the factors maintaining the process after contact with the drug has been made. This pertains to the question why dependence continues, in spite of its unfavorable effects. We can study these factors best in the case of addiction with its self-perpetuating character. There is as yet no adequate explanation for this remarkable feature of addiction. ln my opinion, however, there are strong indications that an important pathogenic part is played by the mechanism of vicious circles.
A vicious circle may be described as a circular process in which a cause generates a result, which in its turn maintains or reinforces the initial cause. ln addiction we may distinguish four vicious circles.
Pharmacological Vicious Circle
Pharmacological investigations have shown that the repeated use of drugs may cause a change in metabolism. This change may manifest