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Using Bellak et al.'s (1973) interview and rating scale for ego functioning, "preferential" users of heroin (N=10) or amphetamine (N=10) were interviewed under conditions of abstinence and intoxication with their respectively chosen drugs. Normals (N=10) were interviewed twice while abstinent. Data were analyzed qualitatively and quantitatively to answer--(a) How do preferential users differ from normals and each other under abstinent conditions? (b) How do they differ under conditions of intoxication? (c) How does the drug user differ within himself under conditions of abstinence and intoxication? Subjects were white, male, middle class, 20 to 30 years of age, and nonpsychotic. Dose levels were 15 mg morphine, intramuscular, and 30 mg amphetamine, oral. The purposeful decision to study preferential users of widely disparate pharmacologic agents highlighted differential personality structures as well as basic similarities. Although our observations and findings derive from our low-dose study of preferential users of heroin and amphetamine, similar investigations could examine the preferential use of other psychoactive agents, e.g., barbiturates and hallucinogens. For the purposes of this presentation, we will discuss only a portion of our empirical findings. The full data are available elsewhere (Milkman and Frosch 1973; Frosch and Milkman 1977).
Under the abstinent condition, both drug-using populations showed subnormal ego-function ratings in most categories (figure 1). Amphetamine users showed significantly higher total ego strength than heroin users, whether or not they were intoxicated. Within groups, ego functioning was usually lower in the intoxicated condition with significant differences observed for judgment (amphetamine), regulation and control of drives (both groups), and sense of competence (heroin). Although ego functioning is more adaptive in amphetamine users when both groups are in the intoxicated condition, one cannot, unequivocally, extend this finding beyond the laboratory situation. Experimental doses of 30 mg and 15 mg for amphetamine and heroin users, respectively, may not be comparable in effect to average "field" doses of 310 mg and 100 mg. Even at our reduced doses, however, the results suggest a trend, in both groups, for ego functioning to be negatively affected by the utilization of their respective drugs. It is expected that under conditions of higher doses, greater impairment of ego functioning may be observed and more significance obtained. Differential description of selected ego functions are provided below.
Regulation and control of drives, affects, and impulses refers to the directness of impulse expression and the effectiveness of delay and control mechanisms; the degree of frustration tolerance; and the extent to which drive derivatives are channeled through ideation, affective expression, and manifest behavior. Both groups display significantly less regulation and control of drives, affects, and impulses in the intoxicated condition. The significant drug effect for this function is particularly interesting because it suggests that under intoxication both groups might be expected to have less impulse control and present a greater danger to themselves and/or the community. The heroin user appears as an individual given to sporadic rages, tantrums, or binges. Periods of overcontrol may alternate with flurries of impulsive breakthroughs. This may be observed dramatically when the user voluntarily submits himself to extended periods of increased environmental structure, in drug programs, where impulse expression is minimized. Temporarily the user appears to have adequate impulse control. Suddenly and without warning, however, impulses gain the upper hand and the user is seen on a self-destructive binge. Disciplinary action is taken and once again impulses are quieted through
FIGURE 1.- Mean ego function rating for amphetamine S's, heroin S's, and normals in the abstinent condition with ratings for sexual and aggressive drive strengths
Reprinted with permission of STASH, Inc., from H. Milkman and W. Frosch, 'The Drug of Choice,' Journal of Psychedelic Drugs 9(Winter 1977): 15. Copyright © 1972.
self-regulation, authority, and peer pressures. repeat.
The cycle tends to
For the amphetamine user, impulse expression is less direct, pervasive, and frequent. Aggressive behavior is more often verbal than physical, and fantasies predominate over unusual behavior. Manifestations of drive-related fantasies are seen in quasi-artistic productions, such as "speed freak" drawings, where primitive and threatening fantasies are portrayed. The amphetamine user may sit for hours drawing frightened faces, decapitated bodies, and the like.
Object relations takes into account the degree and kind of relatedness to others, the extent to which present relationships are adaptively patterned upon older ones, and the extent of object constancy. It is interesting to note that for heroin users, the obtained mean for this function was higher in the intoxicated condition. Perhaps in this dose range, heroin tends to reduce anxiety and to allow for a smoother and more relaxed communication between people. This notion supports Hartmann's (1969) observation that "there is an attempt to overcome the lack of affectionate and meaningful object relations through the pseudo-fusion with other drug takers during their common experience." The heroin user is generally detached from others while under stress and strives for nurturant relationships of a dependent nature, leading to stormy or strained attachments. The amphetamine user, although more successful in object relations, tends to become involved in relationships with strong, unresolved oedipal elements. Castration fears tend to manifest themselves in unusual and extreme sexual behaviors, such as Don Juanism and homosexuality. Underlying concerns about masculinity and adequacy are expressed through repetitive sexual activity and a boasting attitude of sexual prowess and potency. Relationships may, however, endure for long periods of time, although they rarely have the stability and sustaining power of the idealized marital situation.
Stimulus barrier indicates the subject's threshold for, sensitivity to, or awareness of stimuli impinging upon various sensory modalities; the nature of responses to various levels of sensory stimulation in terms of the extent of disorganization, withdrawal, or active coping mechanisms employed to deal with medium or low stimulus barriers. Amphetamine users showed significantly higher stimulus barriers than did heroin users in the abstinent condition. Examination of the raw data revealed that 9 of 10 heroin users were rated low. Although it may be argued that long-term involvement with particular drugs may have specific effects on stimulus thresholds, stimulus barrier is considered to be the most constitutionally based ego function (Bellak et al. 1973). The data suggest that amphetamine users, with biologically high thresholds for excitatory stimulation, are seeking homeostasis (equilibrium) through self-medication. Amphetamine seems to put the user into closer touch with environmental stimuli which might otherwise be unavailable because of constitutionally based, high stimulus barriers. Conversely, the heroin user may have a predisposition toward excessive vulnerability to environmental stimuli. The user seeks to raise stimulus thresholds, allowing more adaptive function in a world of relatively painful and extreme stimulation.
Aggressive drive strength assesses overt aggressive behavior (frequency and intensity); associated and substitute aggressive behavior (verbal expressions, etc.); fantasies and other ideation: dreams, symptoms, defenses, and controls. The heroin user is seen as an
individual whose overt acts of aggression are considerably more intense and frequent than average. The occurrence of physical assaultiveness and multiple suicide gestures is common. Hostile punning and witty repartee are often observed. It is speculated that the relative success of residential treatment programs is related to this phenomenon. Intensive confrontation in group therapy (a major treatment modality in drug programs) provides an outlet for excessive aggressive energy. For the amphetamine user, aggressive energy appears to be less excessive and is channeled more adaptively. Periodic breakthroughs of violence occur, but, with the exception of amphetamine psychosis, these expressions are usually not as frequent or intense as the heroin user's. Fantasies of violence are usually expressed verbally and sometimes find their expression through identification with radical political groups. This finding of greater hostility in heroin addicts than amphetamine abusers is echoed in a study (Gossop and Roy 1976) using different scales and a different population.
Although the observations for this study were made while male users were under abstinent and somewhat intoxicated conditions, it must be recalled that our subjects had all been heavy drug users for several years. It is, therefore, difficult to know if our findings represent a factor in the etiology of the pattern of drug use or the result of such drug use and its imposed life patterns. However, quantitative analyses and clinical impressions provide a framework for conceptualizing possible psychological differences between preferential users of heroin and amphetamine. Some speculate that these differences are related to early predrug patterns of childhood experiences.
The heroin user, who characteristically maintains a tenuous equilibrium via withdrawal and repression, bolsters these defenses by pharmacologically inducing a state of decreased motor activity, underresponsiveness to external situations, and reduction of perceptual intake: "...(a) state of quiet lethargy ... [is] ... conducive to hypercathecting fantasies of omnipotence, magical wish-fulfillment and self-sufficiency. A most dramatic effect of drive dampening experienced subjectively as satiation may be observed in the loss of libido and aggression and the appetites they serve." (Wieder and Kaplan 1969).
Our empirical observations support these formulations. Under conditions of low-dose morphine intoxication, heroin users showed improved scores for object relations and sense of reality, suggesting greater relaxation and less pressure from the drives. The finding of decreased libidinal drive strength points to a dampening of sexual appetite. This style of coping is reminiscent of the narcissistic regressive phenomenon described by Mahler (1967) as an adaptive pattern of the second half of the first year of life. It occurs after the specific tie to the mother has been established and is an attempt to cope with the disorganizing quality of even her brief absences. It is as if the child must shut out affective and perceptual claims from other sources during the mother's absence. This concept is consistent with earlier remarks by Fenichel (1945). Addicts are "fixated to a passive-narcissistic aim" where objects are need-fulfilling sources of supply. The oral zone and skin are primary, and self-esteem is dependent on supplies of food and warmth. The drug represents these supplies. Furthermore, heroin users show intolerance for tension, pain, and frustration. Drug
effects partially alleviate these difficulties by reducing the impact of external stimulation through sensory numbing. The specific need gratification of the passive-narcissistic experience reinforces drugtaking behavior.
Relative to abstinence, however, the intoxicated heroin user shows an overall decrement in ego functioning. Regulation and control of drives, affects, and impulses and sense of competence were significantly lowered in our experimental situation. Deficiencies in general adaptive strength and the pressures of physiologic dependency set the groundwork for a vicious cycle. The heroin user must rely increasingly on a relatively intact ego to procure drugs and attain satiation. Ultimately, she or he is driven to withdrawal from heroin by the discrepancy between intrapsychic forces and external demands. Hospitalization, incarceration, and self-imposed abstinence subserve the user's need to resolve growing conflicts with reality.
in contrast to heroin and other sedative drugs, amphetamines have the general effect of increasing functional activity. Extended wakefulness, alleviation of fatigue, insomnia, loquacity, and hypomania are among the symptoms observed. Subjectively, there is an increase in awareness of drive feelings and impulse strength as well as heightened feelings of self-assertiveness, self-esteem, and frustration tolerance. Our observations support most of these generalizations. Amphetamine intoxication produced in our subjects elevated scores on autonomous functioning and sense of competence. Analysis of interview material shows subjective experience of heightened perceptual and motor ability accompanied by feelings of increased potency and self-regard.
As in the case of heroin, the alterations induced by amphetamine intoxication are syntonic with the user's characteristic modes of adaptation. This formulation is in agreement with the observations of Angrist and Gershon (1969) in their study of the effects of large doses (up to 50 mg/hour) of amphetamine: "... it appears that in any one individual, the behavioral effects tend to be rather consistent and predictable ... moreover these symptoms tended to be consistent with each person's personality and style."
Energizing effects of amphetamine serve the user's needs to feel active and potent in the face of an environment perceived as hostile and threatening. Massive expenditures of psychic energy are geared to defend against underlying fears of passivity. Wieder and Kaplan (1969) suggest that the earliest precursor to the amphetamine user's mode of adaptation is the "practicing period" described by Mahler (1967). This period "culminates around the middle of the second year in the freely walking toddler seeming to feel at the height of his mood of elation. He appears to be at the peak of his belief in his own magical omnipotence which is still to a considerable extent derived from his sense of sharing in his mother's magic powers." There is an investment of cathexis in "the autonomous apparatuses of the self and the functions of the ego; locomotion, perception, learning." Our subjects' inflated self-value and emphasis on perceptual acuity and physical activity support the notion that amphetamine use is related to specific premorbid patterns of adaptation. The consistent finding that ego structures are more adaptive in the amphetamine user than they are in the heroin user suggests that regression is to a developmentally more mature phase of psychosexual development.