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1. Pharmacological properties
Strongly addictive drugs (e.g., morphine, heroin)
(e.g., aspirin, laxatives, vinegar)
2. Personal factors:
Strong disposition to excessive use
No disposition to
3. Social meaning and value: Drug accepted or rejected, ritualization, social norms and sanctions (including legal regulations, police actions and jurisdiction), symbolic significance
4. Environmental influences:
itself in the phenomenon of tolerance (after prolonged use an increase of the dose is needed to attain the same effect) and the withdrawal syndrome (a sudden interruption may cause unpleasant and even serious physical and psychological signs and symptoms). ln some types of dependence, the persistent need for the drug and the inclination to increase the dose may be explained by these phenomena. Continuation of the use, however, maintains the metabolic change, which in its turn is responsible for the need to use the drug again. Cause and effect influence each other by means of pharmacological mechanisms. This is the reason we speak of a pharmacological vicious circle, illustrated in figure 4.
Cerebral Vicious Circle
ln some cases the quantitatively and qualitatively excessive use of a drug may have a direct damaging influence on those cerebral functions that form the basis for regulation and integration on the behavioral level. The outcome is a weakening of the strength of the ego. This means that the personal psychical powers to regulate and control the use are reduced. This, in its turn, implies that the motives leading to the use of the drug get the opportunity to assert themselves more easily. Because of this mutual relationship of cause and effect one can also speak of a vicious circle. See figure 5.
Psychic Vicious Circle
This refers to the effects of dysfunctional use in the mental field. ln this case, feelings of guilt and shame, the unpleasant notion that decreasing or abstaining from use would be better, and the disagreeable perspective of the future, etc., play an important role. The easiest and most effective way to get rid of these annoying feelings is to take the drug, and in this way a vicious circle is started. Moreover, we may point at the infantomimetic effect of the use of drugs. By this is meant a regression to a more infantile form of behavior with an increase in the affective and instinctive aspects of behavior and a decrease in
FIGURE 3.—Operating factors in the etiology
FIQURE S.— Corobro-ogo-woakonlng vleloua clrclo
the controlling and synthetic functions of the ego. Describing this process in psychoanalytical terms, we may ascertain a shift from the reality principle to the pleasure-unpleasure principle and an increasing relative predominance of the primary over the secondary process. Since cause and effect influence each other to and fro, we may assess again a vicious circle in the psychic level. (See figure 6.)
Social Vicious Circle
This circular process is based on the fact that drug addiction has social consequences, which in their turn reinforce the use of the drug. The social sequelae may be described as dysfunction, and, finally, a disintegration within the groups the addict is (or was) functioning in. This process has harmful effects on the addicU___We may only mention the reproaches of the spouse and other members oT—the family, the quarrels, the disdain and withdrawal of friends and acquaintances, the tensions and conflicts in the occupational sphere, and, finally, the dropping out from society. This isolation and rejection engender in the subject negative feelings, which foster an attitude of letting oneself go into the state of being an addict. This means a fixation of the role behavior that goes with it and a reinforcement of the identification with a drug-using subculture. As an instance of the latter we may point to the fact that severe penal measures against marijuana users may tip the balance and change an unstable and risky situation into a fixed harmful one.
The social vicious circle is illustrated in figure 7.
After this brief discussion of the principle of the four vicious circles, some general remarks may be added.
1. ln some drugs, e.g., alcohol, all vicious circles mentioned are present, whereas, in others, they are not. ln marijuana, for instance, the pharmacological and the cerebral circuits are lacking, as far as we can see at present.
2. The original pharmacological, cerebral, psychological, and social factors which give rise to the vicious circles are by no means restricted to the state of addiction only. They may already be demonstrated in the earlier stages of the process of drug use. What we can see, however, is that the more the process moves to the stage of excessive use, the more the generating factors are becoming circular. This shift from a linear to a circular mechanism is connected with a developing disequilibrium between the operating factor on the one hand, and the capacity to keep up with this operating factor or its effects on the other.
Finally, when a shift has taken place from linear to circular and when the quantitative influence of the circuits has risen to a critical level, the addictive state has been attained and will be maintained.
3. ln this progress from more linear to more circular action the factors mentioned do not work separately. ln earlier stages they may either cooperate and intensify or, conversely, counterbalance and reduce one another. ln the later phases they mostly reinforce
one another, which explains the relative autonomy and the selfperpetuating nature of addiction.
4. An example of the fact that the factors involved may counterbalance each other may be found in the therapeutic field. lt is often possible in the process of treatment to switch over a heroin addict to methadone and to keep the patient on a stable dose of it by supportive psychic and social measures. ln some cases, the patients themselves try to decrease their dosage, whereas in a nonmedical setting methadone gives rise to addiction with increasing doses in most cases. Here we see that the social and personal factors are able to reduce the pharmacological vicious circle.