ABSTRACT
QUANTITATIVE ANALYSIS AND CLINICAL

IMPRESSIONS OF EGO FUNCTIONING IN PREFERENTIAL
ABUSERS OF HEROIN OR AMPHETAMINE

BY

Harvey Bruce Milkman

Although most drug abusers have experienced a variety
of psychotrOpic agents, many abusers experience a prolonged
and distinct preference for a particular drug. This study
was designed to examine the relationships between drug pre-
ference and personality in "preferential" abusers of heroin
and amphetamine.

Addicts who stated a specific preference for one or
the other drug were interviewed under the influence of their
"chosen" drug and in the abstinent condition. A control
group of normals was interviewed twice under abstinent
conditions. Subjects were matched for age, race, social
class and psychOpathology. They were examined with Bellak
and Hurvich's (1969) Interview and Rating Scale for Ego
Functioning, a measure which assesses degree of impairment
in each of 12 specified ego functions; reality testing,

judgment, sense of reality, regulation and control of drives,

Harvey Bruce Milkman

object relations, thought processes, adaptive regression,
defensive functioning, stimulus barrier,sense of competence,
autonomous functioning, and mastery competence. The scale
also provides measures of libidinal and aggressive drive
strengths.

Statistical findings were integrated with clinical
impressions to formulate a comprehensive picture of preferen-
tial drug abuse. Amphetamine abusers were found to have
greater overall ego strength than heroin abusers. Both
groups seemed to decrease in ego functioning capacity in the
intoxicated condition. Though not statistically significant,
the data strongly suggest a continuum of increasing adaptive
strength from the heroin abuser to the amphetamine abuser to
the normal. While interview order had a strong effect on the
addict's performance, it had relatively little effect on the
normal groups.

An ego-analytic frame of reference was used to specu-
late as to the etiology of preferential drug abuse. It was
theorized that the origins of specific drug abuse may be in
the nature of the drug-induced altered ego states. These
may recapture a series of similar experiences, the originals

of which appear to exist in specific phases of child

Harvey Bruce Milkman

develOpment. A particular drug may thus facilitate a specific
regressive solution to conflict and may, therefore, be

preferred.

QUANTITATIVE ANALYSIS AND CLINICAL
IMPRESSIONS OF EGO FUNCTIONING IN PREFERENTIAL

ABUSERS OF HEROIN OR AMPHETAMINE

BY

Harvey Bruce Milkman

A DISSERTATION

Submitted to
Michigan State University
in partial fulfillment of the requirement
for the degree of

DOCTOR OF PHILOSOPHY

Department of Psychology

1974

ACKNOWLEDGEMENTS

It is a special event when a man becomes so inspired
by another's work that he begins to add to that work and in
so doing begins creating on his own. William Frosch provided
spiritual, ideational, and practical backing for this study,
which exceeded my greatest expectations. But it may have
taken me five years longer to complete if not for the
presence of Tippio, a lady whose love is so important that
it cannot wait until later. Thanks to Kenny for keeping me
honest and helping me to think big, throughout. And those
statistics could never have been calculated without the
guidance of Larry Messe who along with Gary Stollak and
Norman Abeles is wise enough to know that education and
learning can occur in realms far removed from the ivory

tower.

ii

TABLE OF CONTENTS

PAGE

LIST OF TABLES . . . . . . . . . . . . . . . . . . . . V
LIST OF FIGURES. . . . . . . . . . . . . . . . . . . . vi
I. INTRODUCTION . . . . . . . . . . . . . . . . . . . l
A. Description of the Study . . . . . . . . . . . l

B. General Introcution to Problem . . . . . . . . 2

C. Physiological Perspective . . . . . . . . . . 4

D. Historical and Demographic Perspective . . . . 9

E. Psychological Perspective . . . . . . . . . . 21

F. Hypotheses . . . . . . . . . . . . . . . . . . 35

II. METHOD. . . . . . . . . . . . . . . . . . . . . . 45
A. Sample . . . . . . . . . . . . . . . . . . . . 45

B. Instruments. . . . . . . . . . . . . . . . . . 46

C. Procedure. . . . . . . . . . . . . . . . . . . 58
III. RESULTS. . . . . . . . . . . . . . . . . . . . . 61
A. Reliability of the Ego Function Rating Scale . 61

B. Effect of Two Interviews on the Normal
Subgroup . . . . . . . . . . . . . . . . . 63

C. Comparison of Heroin Abusers, Amphetamine

Abusers and Normals Under the Condition
of Abstinence . . . . . . . . . . . . . . . 64

iii

TABLE OF CONTENTS, CONTINUED

IV.

D.

Personality Differences Within and Between
Heroin and Amphetamine Abusers .

CLINICAL IMPRESSIONS . .

DISCUSSION. . . . . . . . .

A.

B.

C.

Global Ego Strength . .

Specific Ego Functions.

Theoretical Considerations.

iv

PAGE

. 80

.102

LI ST OF TABLES
TABLE PAGE

1. Correlation Between Scores Obtained from Two
Independent Scorers on the Ego Function Rating
scale C O O O O O O C O O O O O O O O O O O O O O O 61

2. Differences Between First and Second Interviews in
Ego Functions of Normal S's . . . . . . . . . . . . 63

3. Significant F-scores Obtained by Comparing Heroin
Abusers, Amphetamine Abusers, and Normals Under
the Condition of Abstinence . . . . . . . . . . . . 65

4. Significant F-scores Obtained by Comparing Heroin
and Amphetamine Abusers Under Abstinent and
Intoxicated Conditions with Repeated Administration
of the Ego Function Rating Scale. . . . . . . . . . 68
5. Self-Esteem . . . . . . . . . . . . . . . . . . . . 75

6. Style of Relating . . . . . . . . . . . . . . . . . 78

LIST OF FIGURES

FIGURE PAGE
1. Mean Ego Function Ratings for Amphetamine Abusers,
Heroin Abusers, and Normals, in the Abstinent
Condition with Ratings for Libidinal and Aggressive
Drive Strengths . . . . . . . . . . . . . . . . . . 71
2. Mean Ego Function Ratings for Heroin Abusers in
Abstinent and Intoxicated Conditions with Scores
for Libidinal and Aggressive Drive Strength . . . . 72
3.

Mean Ego Function Ratings for Amphetamine Abusers
in Abstinent and Intoxicated Conditions with

Scores for Libidinal and Aggressive Drive Strength 73

vi

I . INTRODUCT ION
A. Description of the Study

This study was designed to examine personality factors
underlying the abuse of two potent psychotropic agents,
heroin and amphetamine. Addicts who stated a specific
preference for one or the other drug were interviewed under
the influence of their "chosen" drug and in the abstinent
condition. A control‘group of normals was interviewed twice
under abstinent conditions. Subjects were matched as
closely as possible for age, race, social class and
psychoPathology. Subjects were examined using Bellak and
Hurvich's (1969) Interview and Rating Scale for Ego
Functioning, a measure which assesses degree of impairment
in each of 12 specified ego functions; reality testing,
judgment, sense of reality, regulation and control of drives,
object relations, thought processes, adaptive regression,
defensive functioning and sense of competence. The scale
also provides measures of libidinal and aggressive drive
strengths. The primary focus of the study was to determine

the particular defects and alterations of ego functions that

characterize abusers of heroin and amphetamine.

B. general Introduction to Problem

 

Drug abuse has become an increasingly critical problem
in America. In recent years heroin has become available on
our streets, marijuana and LSD on our campuses, and bartitur-
ates in our middle class homes. Alcohol continues to infect
over nine million of our citizens, while amphetamines are
sporadically inducing psychosis in individuals throughout the
country. Each year there is an incidence of nearly 8000
deaths due to accidental or intentional overdose of
barbiturates~ heroin has been related to over 50% of pro-
perty crimes in some urban areas (i.e., N.Y.C.), and LSD has
been linked to chromosome damage. Although legislation in
the past 50 years has become more restrictive with regard to
the sale and possession of addictive drugs (Harrison Narcotics
Act, 1914....Dangerous Drug Penalty Act, 1968), the available
evidence suggests that this country's drug problem has
become increasingly severe.

Sociological data provide enlightening clues with
regard to age, and socio-economic status of the drug abuser.

We know for example, that nearly 50% of our nation's drug

addicts are currently living in N.Y.C. (Chein, 1964). The
physiological concepts of tolerance and dependency are well
defined. Our understanding of the psychology of the drug
abuser, however, is far more limited. Psychiatric literature
repeatedly describes and claims to understand the typical
male addict as a depressed, orally dependent individual who
has difficulty in asserting his masculinity and expressing
hostility. In most cases he comes from a broken home with a
domineering mother and hostile or unavailable father
(Hartmann, 1969).

These generalizations are shallow and outdated. A
mother's domineering behavior may lead to her child's
passivity, sexual disturbances, and neurotic symptoms.

These factors are no more specific to drug taking than they
are to neuroses, depressions, delinquencies, and psychoses
(Hartmann, 1969). Furthermore, these explanations cannot
account for the current phenomenon of specificity in drug
abuse. As recent as one decade ago, the drugs most commonly
used were relatively homogeneous in terms of their pharma-
cological affects (i.e., alcohol, opiates). There are now,
however, in massive usage, many potent pharmacologic agents

which produce distinctive experiences (stimulants,

depressants, hallucinogens). The pharmacological and psycho-
logical effects of these drugs are so disparate and specific
that it has become important to ask not only what are the
dynamics of the drug abuser, but what are the personality
mechanisms which underlie the predilection for specific drugs.
This study is designed to uncover the relationships between
personality and two of the most potent and widely abused
pharmacologic agents: heroin and amphetamine. Wilker's
(1953) definition of drug abuse is applied: "The compulsive
use of chemical agents which are harmful to the individual,

the society, or both."

C. Physiological Perspective

A detailed description of the physiology of drug abuse
is beyond the scope of this introduction. An understanding,
however, of basic physiological concepts and mechanisms is
critical for the formulation of a methodology and evaluation
of the biologically based theories of the psychology of drug
abuse, e.g., Eysenck(1957).

Opiates
Heroin is one member of the class of drugs which are

designated Opiate narcotics. In order of addicting potential,

from the most to the least, these drugs include morphine,
heroin, Dilaudid, Demerol, methadone, and codeine (Nyswander,
1959). Like alcohol and barbiturates, these drugs are
described in pharmacological literature as C.N.S. depressants.
Although the exact sites and mechanisms of action are largely
unknown, they share a common ability to depress the functions
of the central nervous system. These physiological effects
are manifest in l) calming or relief of emotional tension or
anxiety: 2) drowsiness, sedation, sleep, stupor, coma, or
general anesthesia; 3) increase of pain threshold; 4) mood
depression or apathy; and 5) disorientation, confusion or
loss of mental acuity (Nowlis, 1969).

Central to an understanding of heroin's addictive
properties are the concepts of tolerance and dependence.
Tolerance results from the capacity of the human body to
alter itself in response to disturbing stimuli. Organs whose
functions are altered by drugs respond by readjusting their
functions to restore the status quo. Repeated doses of the
Opiates will lead the nervous system to function more
energetically to counteract the drug-induced depression. At
this point, the individual has become physically dependent on

the drug. Adjustment to the drug's presence is a gradual

process. If the drug is suddenly withdrawn, the body responds
to the absence of the drug on which it has become dependent
by withdrawal symptoms (Modell & Lansing, 1969). These
symptoms may last from several days to a few weeks, depending
upon the degree of tolerance. They vary from one individual
to another, but usually include muscular pain, inability to
keep still, air hunger, gooseflesh, nausea, bowel urgency,

and anxiety.

The result of the body's ability to adapt to the
Opiates is that the heroin addict must gradually increase his
dose if he is to continue to get ”high". To a person
unaccustomed to morphine, for example, an injection of .004
ounce is normally fatal. In controlled experiments however,
addicts have taken up to 50 times that amount in a single
day (Modell & Landing, 1969). The average does for an addict
is approximately % grain (.001 ounce). This minute amount
which is roughly equivalent to four millionths of the body's
weight, is immediately broken down into morphine and by-
products. The lungs, liver and kidneys collect morphine
readily so that only an estimated 2% Of the original dose
is free to enter brain tissue. This type of evidence lends

support to the notion that the effects of heroin may be due

not so much to the drug, but to a body chemical released or
inhibited by it (Laurie, 1967).
Amphetamines

Broadly classified as C.N.S. stimulants, and colloqui-
ally known as "speed", the amphetamines belong to the class
of drugs which have the general effect of increasing
functional activity. According to the regulations under the
Federal Food, Drug and Cosmetic Act, January, 1966 (Nowlis,
1969), drugs are classified as stimulants if they produce
any of the following: 1) extended wakefulness, 2) elation,
exhilaration, or euphoria (exaggerated sense of well being),
3) alleviation of fatigue, 4) insomnia, irritability or
agitation, 5) apprehension or anxiety, and 6) flight of
ideas, loquacity, hypomania, or transient deleria.

In pharmacological literature, stimulants are grouped
according to the organ sites of primary activity. Because
the amphetamines produce effects resembling those resulting
from stimulation Of the sympathetic nervous system, they are
considered sympathomimetics. Other common sympathomimetic
drugs are ephedrine and epinephrine. Slightly different in
molecular structure, there are quantitative differences in

the potency of various amphetamine-related compounds. In

common usage and in order of increasing potency, these drugs
are amphetamine (Benzedrine), dextroamphethamine (Dexedrine)
and methamphetamine (Methedrine).

Depending upon the dosage, route of administration,
and the specific drug, amphetamines have varying degrees of
the following types of physiological actions: 1) excitatory
action on smooth muscles such as those in blood vessels
supplying insulin, 2) inhibitory action on other smooth
muscles such as those in the intestinal wall, 3) excitation
of heart action resulting in increased heart rate and force
of contraction, 4) metabolic actions such as increases in
the conversion of glycogen into sugar, 5) an excitatory action
of the C.N.S. resulting in respiratory stimulation, an
increase in wakefulness, and a reduction in appetite (Nowlis,
1969).

In contrast to the opiates and some C.N.S. stimulants,
amphetamines do not produce any specifiable withdrawal
symptoms. Tolerance however, does deve10p, and, because
Of the user's need to escape the fatigue and depression
which follows its use, amphetamine is said to lead to
psychological dependency. The normal therapeutic dose ranges

from 5-15 mg. The average intravenous "abuser's" dose,

however, is about 310 mg. Some users have been known to
"shoot" as much as 1000 mg. (Schick, 1969).

Because of the difficulty in defining a discrete
abstinence syndrome, and the knowledge that the amphetamines
were being abused in various countries, the WOrld Health
Organization (1964) formulated a specific definition of drug
dependence of the amphetamine type: A state arising from
repeated administration of amphetamine or an agent with
amphetamineélike effects on a periodic or continuous basis.
Its characteristics include, 1) a desire or need to continue
taking the drug; 2) consumption of increasing amounts to
Obtain greater excitatory and euphoric effects or to combat
more effectively depression and fatigue, accompanied to some
measure by the develOpment Of tolerance; 3) a psychic depen—
dence on the effects of the drug related to a subjective and
individual appreciation of the drug's effects; 4) general
absence of physical dependence so that there is no character-

istic abstinence syndromewhen the drug is discontinued.

D. Historical and Demographic Perspective

Although it had been smoked throughout the world for

many centuries, Opium was not noted for its addictive

10

potential until about 1880, 20 years after the invention Of
the hypodermic needles. The advent of the civil war, the
synthesis and utilization of morphine for the treatment of
wounded soldiers, and the migration of nearly 70,000 Chinese
laborers (many of whom were Opium smokers) led to the increase
of Opium imported to the U.S. from 20,000 pounds in 1866 to
295,000 pounds in 1883 (Lasagna, 1970).

Prior to 1920, the number of narcotics addicts in the
U.S. was greater than it is now. It is commonly estimated
that one out of every 400 people were addicted. Those who
were addicted in the early 1900's used Opium and morphine
preparations, and were primarily Chinese and Caucasian. The
Harrison Narcotics Act of 1914 greatly restricted the supply
Of these drugs. By the years 1940-45 the supply Of Opiates
in this country had become so sparse that the number of
known addicts dropped down to about 20,000. After World
War II heroin again flowed more freely to the U.S., and it is
estimated that the number of addicts rose to approximately
60,000 in the early 1950's. Current estimates range from
100,000 to 200,000 with the majority of addicts living in
large metrOpolitan areas. The addiction services agency in

N.Y.C. now estimates that one in 80 persons in the city is

ll

addicted to narcotics (D. Louria, 1969), compared to one out
of 4,000 persons in the population of the U.S.

Although most illicit traffic of narcotics occurs in
the large city, a relatively small portion of the metrOpolis
is directly involved in the addictive scene. Chein (1964)
found that in the most desolate 15% of the city where 75% of
addicts live one boy in ten tried heroin, and fewer become
addicted. In the ghetto, it is common for adolescents to
"skin pOp" for years without develOping enough of a dependency
to produce withdrawal symptoms.

The mean age of addicts has fallen drastically in the
past 25 years. In 1937, less than one male patient in five
was under 30, while in 1962 almost one-half were (Laurie,
1969). It is currently estimated that as many as one-quarter
Of our present addict population is teenagers. The ethnic
distribution of addicts has also undergone significant
changes. Before WOrld war II, only 10% of the patients at
U.S.P.H. narcotics hospitals were non-white. It is now
estimated that two-thirds of the addicts are Negro or Puerto
Rican. The trend may be reversing, however, as demographic
data begin to show that heroin addiction is rapidly spreading

to the middle class (Time, March, 1970).

12

America's addicts, by virtue of their life style,
socio-economic status, or youth, are for the most part unem-
ployable. Although "dealing” enables some addicts to earn
as much as $500.00 per week (Scher, 1962), most users steal
to support a $100.00 per day habit. It is estimated that ten
million dollars a day in crimes are committed to support
addictive habits (Hekimian, Gershon, 1968).

The frantic need to obtain the drug in the context of
illicit and unsanitary settings can lead to illness and
fatality. In Turkey, one kilogram of heroin is worth $350.00.
When it reaches N.Y. and is "cut" into five dollar bags which
contain only 5% heroin, the drug has a black market value of
$225,000.00. Often users are sold bags of unknown quantity
and quality. Fatalities can result from overdose, hepatitis,
and poisoning. In one year (1969-70) there were an estimated
900 heroin-related deaths (224 of whom were teenagers) in
N.Y.C. (Time, March, 1970).

In attempting to understand the complex question of
why certain individuals turn to heroin, some researchers
have focused on the addict's family life. In Chein's study
(1964), for example, he found that among youthful heroin

users, family life was disturbed by separation, divorce, Open

13

hostility, lack of warmth, or lack Of mutual interest, in 97%
of the cases. In 80% of the homes, the boy experienced an
extremely weak father—son relationship; in 48% the boy had

no father figure during a "significant" part of childhood;
the father figure was cool or hostile in 52%, immoral in 23%.
The mother figure was more important than the father in the
boy's life during late childhood in 73%. The parental
standards were vague or inconsistent in 63%; and in 23% there
was no clear pattern of roles in the formation of disciplinary
policy. Family chaos was found in all users, independent of
whether they were Puerto Rican, Negro, or white.

In another study (Gerard & Kornetsky, 1954) of addicts
at the U.S.P.H. hospital in Lexington, the researchers found
"no essential relationship between drug addiction and socio-
economic groups." The gross aspects of family structures in
which patients were reared were "variable". Mothers:
excessively controlling and strict (40%) or excessively
indulgent, non-disciplinary (48%), and/or seductive (24%).
Fathers: absent, deserted, separated or divorced (60%), or
actively punitive, moralistic (30%), paranoid and controlling
(20%). Relationships between parents: poor (70%), with

father a weak and ineffectual figure held in contempt by the

14

mother and children. The authors concluded that "the least
qualified generalization which could be made about the
families of these patients is that they were of the types
which psychiatric experience suggests are productive of
serious difficulties in adjustment."

Given that an individual's mode Of c0ping with the
difficulties engendered by his family and surroundings
becomes addiction to heroin, his chances Of "cure" seem
exceedingly slim. After having surveyed the literature on
post-institutional adjustment of addicts, Kaplan and Mayero-
witz (1969) conclude: "The best information now available
on what happens to persons treated for drug addiction is
provided by a followvup study of some 1900 cases. Within six
months after having been released from U.S.P.H. service
hospitals for narcotics addiction more than 90% were readdict-
ed."

Stimulants, like opiates, have been used throughout
the world for many centuries. The juices of the coca leaves
(molecularly similar to amphetamine) provided a sense of
well-being and endurance to Andean Indians since before the
Spaniards. Among the synthetic stimulants, amphetamine was

first prepared by Edeano in 1887, and methamphetamine by

15

Ogata in 1919. It was not until 1927 that the psychOpharma-
cological effects of amphetamine were first described.
Benzedrine was first used medically in 1935 in the treatment
of narcolepsy, and was used shortly thereafter as an anorectic.
From the 1930's through the 1950's medical use of amphetamine
became extensive and it was looked upon as a useful and
relatively safe pharmacological agent. As recently as 1963
the AMA Council on Drugs stated that compulsive use of the
amphetamines constitutes a small problem in the United States.
By 1966, however, the AMA Committee on Alcoholism and Addic-
tion noted that sufficient amphetamine products were available
in the United States to supply 25-50 doses to every person in
the country that year (Kramer, 1969).

Stimulant abuse, particularly the intravenous use of
methamphetamine (methedrine), has become a major problem in
many cities throughout the U.S. and Europe. In Stockholm,
for example, there are an estimated 60002fiflicts, most of
whom are intravenously using Preludin and Ritalin. Both
drugs are in the same category as the amphetamines used
here (N.Y. Times, April 10, 1970). In the U.S., studies
show that while 5000 peOple in Oklahoma City are getting

amphetamines illegally, 4000 peOple in San Francisco are

16

regular users (Kramer, 1967). Although heroin may currently
be America's most widely used addictive agent, amphetamine
abuse seems to be a problem of similar magnitude.

Unlike heroin, amphetamine is not a ghetto drug.
Fischmann (1968, Int. Journal of Addictions) gathered impor-
tant demographic data on stimulant users which supports this
notion. He describes a "typical" speed user as a white
"anglo" native to the San Francisco area. He is more
literate, has a somewhat higher 1.0., higher socio-economic
background, more education, than the average narcotic addict.
Fischmann's study seems to be in accord with the finding that
widespread amphetamine abuse is highest amongst medical
personnel, with housewives and nocturnal workers ranking
second and third. The same study also reported amphetamine
abuse to be high in various underworld circles; petty thieves,
convicts and prostitutes (J. Black, N.Y. Times, 1970). A
study conducted by Clark and Funkhauser (1970) lends further
support to the notion that among the middle class, ampheta-
mine is a more preferred drug than heroin. When asked to
rate the personal risk in taking each of a variety of drugs,
respondents rated Opiates and hallucinogens as the most

dangerous drugs, while amphetamine, tobacco and sedatives

17

were regarded as more dangerous than marijuana and alcohol.
The trend toward more youthful abusers of drugs appears
to be manifest in amphetamine as well as heroin abuse. In a
study of 60 amphetamine abusers conducted at Bellevue
Hospital in N.Y.C., the mean age of abusers was found to be
25 years (Angrist, 1969). This mean age seems comparable to
the estimate that more than one-half of the heroin abusers
are under 30, and one—fourth are teenagers. The age of the
abuser and the psychological impact of the drug (see section
on psychological aspects) render the amphetamine addict, for
the most part, unemployable. Although the price of a speed
habit is relatively cheap with respect to heroin ($15-30 per
day in 1972), the addict must often resort to stealing to
maintain his habit. The instability of the youthful
"Speeder" has been Offered as an explanation for speed's
partial exclusion from the lowerclass. "Like the heroin
addict, the speed freak Often works up a costly habit and
the poor must hustle to pay for drugs. . .the junkie is
relatively cool between hits. But the speed freak is gener-
ally so completely disoriented and trapped on his private
24—hour treadmill that hustling is out of the question."

(J. Black, N.Y. Times, June, 1970). Much of the violence

18

that is attributed to the speed community may be related to
the frantic need to Obtain the drug and the inability to
stabilize enough to commit non-assaultive burglaries.
Regretably, the demographic data with regard to
amphetamine abuse is neither as extensive nor well documented
as that of heroin addiction. The apparent gap in the litera-
ture between these very potent and widely used psychotropic
agents is multiple determined. The recency of the phenomenon,
legality of possession and sale, and dramatic impact of toxic
effects are all related to the just emergent exploration of
amphetamine abuse. While heroin addiction has been a major
problem in this country since the turn/of the century,
addiction to stimulants has emerged as a problem within the
past ten years. Although speed may be ultimately as lethal
as heroin, its toll does not show up as directly. One cannot
estimate, for example, that 250 teenage lives are taken each
year as the result of amphetamine addiction. Because
amphetamines are somewhat useful clinically, most states
are still lenient in their legislation with regard to these
drugs. In N.Y.C., for example, the possession of any amount
of amphetamine is merely a misdemeanor. With heroin,

possession of one—eighth of an ounce is a felony, and more

19

than a pound can result in a lifetime sentence. There have
been far more arrests and convictions related to heroin
addiction, and hence more subjects for study.

Although heroin and amphetamine addiction often occur
independently, they are by no means mutually exclusive. An
unknown number Of individuals who are defined by society as
one type of addict or another are more appropriately charac-
terized by the term "status-medicamentosis", a condition
found in individuals who regularly but indiscriminately
medicate themselves with a variety of drugs (Wahl, 1967).

It is documented observation that many stimulant users will
use Opiate or barbiturate drugs to counteract the unpleasant
side effects of amphetamines or psychedelics. Some Opiate
users are known to use stimulants where there is a drought
in their heroin supply. Kramer, et a1. (1967), in his

study of amphetamine abuse at the California Rehabilitation
Center took note of this phenomenon of multiple drug abuse.
Almost all of his subjects had extensive experience with
other drugs, including marijuana, Opioids, and barbiturates,
and most had tried psychedelics. He was able, however, to
differentiate between two discrete categories of amphetamine

users: "preferential" and "facultative". The preferential

20

user has tried opioids in the past but discovered that the
effect produced by amphetamines is preferable to him. The
retreat and somnolence produced by the Opioids are a "waste
of time". The facultative user, on the other hand, prefers
Opioids, but because they are too expensive or difficult to
get, is willing to substitute amphetamines. Kramer concludes
by stating, "Thus it appears that a difference in drug of
choice occurs in drug users, some preferring chemical assis-
tance toward activity—approach, others desiring chemical
assistance for passive solitude."

For many abusers, perhaps a majority, the addictive
agent is determined by features of the user's social setting,
i.e., cost, availability, legality. Clinical experience and
research, however, show that many abusers have a preference
for a particular kind of psychotropic drug. In order to more
clearly assess the relationships between the addictive agent
and the user's personality, subjects in this study are
individuals who have established addiction to a particular
agent as a matter of preference. From here on, reference to
the term drug abuser, in the context Of our develOpment of
hypotheses, shall refer to what Kramer (1967) has defined

as the "preferential drug abuser".

21

E. Psychological Perspective

Pharmacological literature differentiates heroin from
amphetamine in terms of its effects on the C.N.S. Social
data reveal that age and socio-economic status are relevant
variables in understanding the incidence of various types of
drug abuse. Psychology has lagged behind related disciplines,
however, and has not yet defined the psychological differences
between heroin and amphetamine abusers. Primarily because of
the high incidence of heroin abuse in previous years (see
demographic perspective), drug researchers and theorists
have traditionally addressed themselves to the phenomenon
of narcotic addiction. Recently, however, attention has
been turning to the current trends of multiple drug abuse
and addiction to specific pharmacological agents. There is
now a sufficient backlog of theoretical material to begin
testing hypotheses with regard to specific mind influencing
agents: namely heroin and amphetamine.

Early analytic thought viewed addiction in terms of
oral libidinal strivings. In 1905 Freud (YOrke, 1970)
attributed smoking and drinking to oral eroticism, to a

reinforcement of constitutional lip eroticism. Gradually,

22

analytic theory dismissed a purely "oral" interpretation and
began to focus on the more aggressive aspects of addiction.
The emphasis on oral modes that was prominent amongi addicted
patients was seen as a defense against "primitive excretory
sadism" (Glover, 1956). More recent analytic positions
emphasize the role of ego defect and of alterations in ego
functioning.

In Narcotic Bondagp (1957) Rado emphasizes the impor-
tance of regression and defect in ego functioning. "Under
the revised system of psychoanalytic thought, dependence on
narcotic drugs is regarded as a malignant form of miscarried
repair artificially induced by the patient himself...TO ex-
plain the remarkable reaction, we must penetrate into the
deepest and Oldest strata of the mind formed during the early
stages of ontogenic development. The narcotic superpleasure
may be viewed as a developmental derivative of alimentary
orgasm." Rado views depression as a primary etiological
factor. He sees the patient who is about to develop drug
dependence as one who has a long history of intolerance for
pain coupled with "strong but often overcompensated dependency
needs". Pearson (1964) views the addicts dynamics in much

the same way as Rado. Drug abuse is seen as an act of self

23

medication with the pre-addictive personality seeking relief
from a state of "tense depression". The drug experience is
regarded as powerfully reinforcing, but regressive phenomenon.
"When the individual provides himself with a drug that changes
his pain to pleasure and his depression is replaced by an in-
crease in self-esteem, the first step to addiction has
occurred. The mind eXperiences an event it will never for-
get, which may be compared to a trip to the Garden of Eden
or a regression to the blissful state of childhood."(p. 1167)
Using the analytic frame of reference, many researchers
have attempted to uncover important personality variables
related to narcotic addiction. In an intensive research
design by Gerard and Korentsky (1954), 32 Opiate addicts
admitted to the U.S.P.H. service hospital in Lexington were
given complete psychological test batteries (Rorschach, TAT,
Bender, WAIS, Drawings) as well as comprehensive psychiatric
interviews. The researchers found that they were able to
assign four discrete diagnostic categories to their addict
pOpulation: l) overt schizophrenia (19%); 2) incipient
schiZOphrenia (25%); 3) delinquency dominated character

disorders (31%); 4) inadequate personalities (12%).

24

Within the category of character disorders, two types
were identified and dynamic interpretations were given:
1) Pseudo-psychopathic Delinquents - "These patients attempt
to deny and repress their underlying wishes for passivity and
dependency by establishing role systems in which they defined
themselves as if they were dangerous, criminal and strong
men. They had been involved in serious delinquencies (gang
fights) and interpreted this as pleasureable prior to and
during drug abuse." 2) Oral Characters - "The predominant
role systems these patients attempted to establish were those
in which they were nurtured and cared for. They reacted with
rage and refusal of nurturing and had low frustration
tolerance. Delinquency was aimed at punishment and control
of significant figures."

Aside from the four classifications, all boys were
judged to have several features in common. There was a
prevalent mood of depression, which was characterized by
guilt, inadequacy, unworthiness, and pessimism. Problems
in sexual identity and disturbances in interpersonal
relationship were apparent. It was felt that Opiates ful-
filled several adaptive functions: a) The difficulties of

living as a drug addict in our society facilitate denial and

25

avoidance of the patients'-underlying problems. b) Opiate
drug use helped treat overt psychiatric symptomatology:
Obsessions, delusions, anxiety. c) The drugs helped to
control anxiety in interpersonal relating. d) Regressive
and oral satisfactions accompanied by a feeling of separate-
ness and lack of involvement in current difficulties in
living were provided.

Hartmann (1969) has reported the results of one of the
most comprehensive analytic studies of drug abuse. A study
group of the American Association for Child Psychoanalysis
studied drug abuse in 12 adolescent patients. The group
attempted to study parental background with regard to libido,
aggression, superego development, and the relationship of
parent to child. The patients' libido, aggression, and
superego development were studied, as well as ego functioning,
affect and object relationships, both before and after
experience with drugs.

In the course of therapy, 10 of the 12 patients were
using drugs regularly. These patients were considered by the
study group to be orally regressed or fixated. Both ego and
superego functioning deteriorated and became less adequate

while on drugs. This was apparent in impaired functioning

26

in school, difficulty in working efficiently and decreased
reality testing. Eight of the ten patients were depressed
before taking drugs and felt that the drugs helped to allevi—
ate depression. Object relations became more superficial and
contacts were primarily with other drug takers. Fusion
fantasies were prevalent while sexual life more resembled
masturbation than mature emotional relationships.

During childhood, many of the patients had to face
the death of a parent or severe illness in a parent or them-
selves. Although conscious motivation was the avoidance of
painful affects and the alleviation of symptoms, unconscious
motives were considered to be the replacement of a lost Object
and a passive identification with the parent.

Reviewing their own findings, the group concluded,
"If we look at these findings one by one, we must conclude
that none Of them could be called pathognomonic for drug
users or drug addicts." The multiplicity of factors that
seemed to describe the typical addict were summarized as
follows:

1. There is a basic depressive character with early
wounds to narcissism and defects in ego development.

2. There is an intolerance for frustration and pain with

27

a constant need to change a "low" into a "high". This
may come from an early lack Of satisfying object
relations.

3. There is an attempt to overcome the lack of affection-
ate and meaningful Object relations through the
pseudo-fusion with other drug takers during their
common experience.

4. The artificial technique of maintaining self-regard and
satisfaction with drugs results in a change from a
reality—oriented to a pharmacothymic-oriented regimen.
This leads to severely disturbed ego functions and
ultimately to conflict with reality. Eventually the
drug taking becomes a way of life.

Analytically oriented theories and studies of drug
abuse tend to conceive of the drug as a form of self medica-
tion, taken by the addict to reliewaa.sense of "tense
depression" generated by a variety of intrapsychic conflicts.
The ego is seen as "defective" in providing the necessary
internal means for conflict resolution so that an external
agent is employed to fulfill several adaptive functions
(relief from interpersonal anxiety, maintaining self regard,

etc.). The "switch to a pharmacothymic-oriented regimen",

28

however, leads to altered and more severely disturbed ego
functions, and ultimately to greater conflict with reality.
The above generalizations seem applicable to most
types of drug abuse but in their lack of specificity there is
the sacrifice of much information. We are told, for example,
that drug abuse is related to "ego defects", and that the
drug effect produces alterations in ego functioning, some of
which are adaptive. We have little or no information in
regard to which specific ego functions are altered by the use
of which psychotrOpic agent. The abyss in knowledge is even
greater, when one considers the likelihood that specific
pharmacological agents produce differential alterations in
ego functioning. For the most part, psychological literature
on drug abuse does not distinguish between the personalities
involved in specific kinds of drug abuse (heroin and ampheta-
mines in this study). Yet, there is a sufficient body of
psychological (as well as physiological) literature to
suggest that amphetamines and heroin produce differential
psychological effects. If we accept Kramer's (1967) finding
(see social perspective, page 19) that, in some abusers,
specific drug choice is based on preference (rather than on

drug availability), we are faced with the question of how do

29

abusers who "choose" heroin differ from those who "choose"
amphetamine? Regarding the drug state as an altered ego
state, which defects and alterations of ego functions are
characteristic of the abuser who prefers amphetamines to
Opiates?
Ego Psychology and Drug Abuse

The current lack of specificity with regard to the
role of the ego in psychoanalytically oriented studies of
addiction is paralleled by the relative importance that recent
psychoanalytic theory has placed on the role of the ego. More
than a decade ago, Hall and Lindzey (1957) evaluated the
development of ego-psychology: "There is no question as to
how Freud felt regarding the relationship of the ego and the
id. The id is the dominant member of the partnership. . .
The new thinking among psychoanalytic theorists is to play
up the role of ego in the total personality. Not only have
they dealt, with such problems as the development of the
reality principle in childhood, the integrative or synthetic
function of the ego, the auxiliary ego processes of perceiv-
ing, remembering, thinking, and acting and the defenses of
the ego, but there has also been put forward the concept of

the autonomy of the ego. . . . Such an ego pscyhology appears

30

to constitute a radical break from psychoanalytic tradition."
With the increased emphasis on the role of ego in the
total personality, researchers have been striving to define
and enumerate the various possible ego functions. Because of
the complex interrelations of these functions (i.e., reality
testing, defensiveness and object relations) progress has
been slow. Rapaport (1959) conducted an historical survey
of ego functions in which he comments, "The history of ego
psychology would be relatively simple to outline if a precise
definition of the ego and a full listing of its functions
were available." After having extensively reviewed the
literature, Bellak (1968,1969), starting with a list of seven
ego functions, began to develOp definitions and techniques
for the comprehensive assessment of ego functioning. After
several revisions and experimental validations of his scale,
Bellak (1969) has defined the following 12 ego functions:
1) reality testing, 2) judgment, 3) sense of reality,
4) regulation and control of drives, affects and impulses,
5) object (human) relations, 6) thOught processes, 7) adaptive
regression in the service of the ego, 8) defensive function-
ing, 9) stimulus barrier, 10) autonomous functioning,

ll) synthetic integrative functioning, 12) mastery competence.

31

Having definitions of the above characteristics and an
instrument for measuring their relative strengths, (see method
section), we are now in a position to begin formulating hypo-
theses in regard to the specific ego characteristics of drug
abuse. The focus of our study is to determine the particular
defects and alterations of ego functions that characterize
abusers of two widely disparate psychotrOpic agents: heroin
and amphetamine. We shall begin our preliminary analyses of
the psychic meanings of these two drugs by reviewing their
known psychological effects.

The Phenomenology of Drug Abuse

Typical reports on the phenomenology of the two kinds
of drug experiences differ widely. "The action Of (heroin and
morphine) on the C.N.S. is that the addict feels that he has
eaten to his heart's content, experienced full sexual satis—
faction, and eliminated all anxieties as well." (Nyswander,
1956). Although it is a common belief that a primary action
of Opiates is the euphoria that follows its use, Savitt (1963)
points out that the elation produced by these drugs has been
stressed out of pr0portion to the sleep or stupor which soon
follows. The user "seeks desperately to fall asleep as a

surcease from anxiety and drug provides obliteration of

32

consciousness. Well expressed in the vernacular, the addict
goes on the nod."

The amphetamine addict, quite contrary to going on the
"nod", willfully prOpels himself on a "trip" that may last
several days. He desires neither sleep nor quiescence.
Kramer (1969) describes the hyperactivity induced in the
amphetamine user. He views the most striking effect of
amphetamines as its capacity to induce behavior which is
persisted in or repeated for prolonged periods. "If the user
is not too disorganized, the activity may, on the surface at
least, be useful. Dwellings may be cleaned, automobiles
polished or items arranged to an inhuman degree of perfection."
These activities may be only partially completed when another
compulsive task begins. Those with a mechanical bent may
become interested in the non—functional reconstruction of
mechanical devices; others may scribble or write for hours.

High intravenous users of amphetamines almost invari-
ably experience some degree of paranoia. If doses are high
enough and administration is chronic, the reaction is almost
indistinguishable from paranoid schizophrenia. Although it

has been suggested that the drug may merely serve to induce

underlying psychotic trends, the available evidence suggests

33

that "anyone given a large enough dose for a long enough time
will become psychotic" (Kramer, 1969).
Personalipprifferences Between Opiate and Amphetamine Abusers

Given that the two drugs produce widely disparate
psychological effects, what are the personality differences
between individuals who prefer to abuse one or the other
agent? There is a paucity of research in this area, but
there is a sufficient backlog of theoretical material to
begin formulating and testing hypotheses with regard to
distinct types of drug abuse. Recent analytic formulations
relate the use of particular drugs to specific phases of
childhood development and experience, while biologically
based theory suggests that constitutional factors are impor-
tant. We take the position that both factors are important
since personality in general, and ego functioning in particu-
lar, are seen as the integrated result of maturational and
experiential factors.

Weider and Kaplan (1968) theorize that the various
possible states of intoxication are chemically induced
regressive ego states. Different drugs are said to induce
different regressive states that closely resemble specific

phases of early childhood develOpment. "The user harbors

34

wishes or tendencies for a particular regressive conflict
solution which the pharmacology of a particular drug may
facilitate; the repeated experiences of satisfaction
establish preference for the specific drug."

Opiates, which reduce drive, are subjectively experi-
enced as satiation. There is the "loss of libido and
aggression and the appetites they serve." This turning
inward is related to the "narcissistic regressive phenomena",
which is described by Mahler (1968) as characteristic of the
second half of the first year of life. The infant copes
with the mother's absence by a "diminution of motor activity,
an underresponsiveness to external situations, and a reduction
of perceptual intake, as if the child must shut out affective
and perceptual claims from other sources during the mother's
absence" (p. 750).

Stimulants, in contrast to opiates, tend to increase
the awareness of drive feeling and impulse strength and
reduce fatigue. Motoric restless is viewed as an "illusion
of activity which subserves denial of passivity". Stimulant
intoxication is reminiscent of the period described by Mahler
(1968) as the "practicing period" which occurs in the middle

Of the second year. Amphetamine intoxication and the

35

practicing period are both characterized by "a reinforcement
of autonomous ego functions which aid in the neutralization

Of aggressive cathexis Of self and Object representations"
which results in the reinforcement of autonomous ego functions
which aid in the neutralization of aggressive cathexis Of

self and Object representations. "The diminished danger of
Object loss in these analogous ego states facilitates activity

approach in object oriented behavior."

F. Hypotheses

1. Total Ego Strength

Following from Weider and Kaplan's description, the
opiate addict is c0ping with conflicts which are resolved in
a more primitive style than those Of the amphetamine addict.
His regression is to an earlier phase of psycho—sexual
development, and his coping mechanisms involve withdrawal and
under-responsiveness to external stimulation. Using Bellak's
(1969, p. 35) definition of ego strength as "total adaptive
capacity", the Opiate addict at least in the intoxicated
condition, should have less "global ego strength" than the
amphetamine addict.

By viewing the two states of intoxication as analogous

36

to specific regressive ego states, we can formulate hypotheses
with regard to the alterations of particular ego functions.
In Weider and Kaplan's conceptualization of Opiate intoxica-
tion, they describe a condition of reduced drive which is
manifested in "underresponsiveness to external situations,
and a reduction of perceptual intake." The amphetamine
abuser, on the other hand, neutralizes his "aggressive
cathexes of self and Object representations" which results in
the reinforcement of autonomous ego functions and facilitates
"activity approach in Object oriented behavior". Based on
these descriptions, we hypothesize that, in the intoxicated
condition, amphetamine addicts differ from Opiate addicts in
terms of two specific ego functions: 1) autonomous ego
functions, 2) object relations. These functions as well as
ten others to be used in this study, are comprehensively
defined by Bellak (1970).

To avoid redundancy but preserve clarity, a brief
description of each function relevant to the development of
hypotheses shall be given.

2. Autonomous Functioning
Autonomous ego functions involves the degree of impair-

ment of apparatuses of primary autonomy (functional

37

disturbances of sight, hearing, language, etc.) as well as
secondary autonomy (habit patterns, learned complex skills,
etc.). From Weider and Kaplan's description of amphetamine

as a "reinforcer of autonomous functions; as well as labora-
tory experiments (Cameron, 1965) that show amphetamine to
improve certain aspects of intellectual performance, it is
hypothesized that in the respective states of intoxication,
amphetamine addicts will display a greater capacity to
utilize their autonomous ego functions.
3. Object Relations

Object relations, as Bellak (1970) defines the concept,
"contributes to adaptive functioning in so far as one's
relationships with all others, particularly significant
others, is based on an accurate understanding of and response
to the other person for what he is today." The Opiate addict,
turning inward and becoming immersed in "a narcissistic re-
gressive phenomena" in which he shuts out affective claims
from the environment, is hardly in a position to engage in
an independent, empathic relationship with another person.
The amphetamine abuser, also severely regressed, is described,

however, as having "neutralized aggressive cathexes of self

and object representations", thus being less vulnerable to

38

object loss and freer to engage in object oriented activity.
On the bases of these considerations, the amphetamine abuser
is expected to have a greater capacity for object relations

than the heroin abuser.

Weider and Kaplan's conceptualization of the addictive
phenomenon and the hypotheses which have been derived relate,
primarily, to the states of heroin and amphetamine intoxica—
tion. Our frame Of reference which views the utilization Of
a chemical agent as a form of self-medication, to alleviate
conflicts with which the ego cannot cope, leads us to inquire
about the nature of the addictive personality while not under
the influence of an intoxicant. In studying the personality
with and without the drug, it is hoped that greater insight
can be gained into the nature of the psychic meaning and
function of the drug experience.

There is little in the literature from which to draw
hypotheses about personality differences between heroin and
amphetamine addicts while not under the influence of the
drug. Fischmann (1968) although quite unSOphisticated in his
research design, undertook one of the few studies in this
area.

Using a research method based upon the observations of

39

correctional counselors who "had extensive experience with
amphetamine and heroin users", he was able to make some
interesting comparisons between the two types of addicts in
the California Rehabilitation Center.. He states that ampheta—
mine users are continuously reported to be: more Open in
groups, more outgoing, less withdrawn, more flexible, more
hypersensitive, more ready to express insecurity, more
insightful, with more open displays of hostility.

Although the preceding descriptions are based on
behavioral Observations, by implication, the amphetamine
addict has a more integrated ego apparatus than the heroin
addict. These differences, however, are not in accord with
the findings of Ellinwood (1967) who compared psychiatric
interviews and MMPI profiles of both types of addicts. He
found amphetamine abusers to be more withdrawn, sociopathic,
resentful of authority, and they had a higher incidence of
non-drug psychiatric hospitalizations than the usual opiate
addict. MMPI profiles revealed differences between the two
groups in terms of psychOpathic deviance, schiZOphrenia,
psychasthenia, and hypochondriasis. The authors concluded,
"There is evidence from both diagnostic and psychological

test data that amphetamine abusers are different from other

40

addicts. Patients drawn to use amphetamines are more socio-
pathic and exhibit more bizarre and eccentric behavior."
(p. 276).

In evaluating the contradictory findings in the two
studies, one must consider differences in methodology and
subject populations. While the Federal hospital in Lexington
is regarded by many as a last resort for hard core criminal
addicts, the California Rehabilitation Center heavily empha-
sizes treatment and its commitment proceedings are similar
to those employed for the mentally ill. Although Ellinwood
and Fischmann are in discord with respect to the relative
degrees Of ego strength in the two types of abusers, ampheta-
mine addicts appear to both researchers as more "acting out"
in their behavior. What Ellinwood regards as sociOpathic,
Fischmann may have seen as "openness, flexibility, and more
Open displays of hostility". There is an emergent picture of
a more active, aggressive, emotionally labile personality of
the abuser of amphetamines.

4. Regulation and Control of DriveypAffects, and Impulses

The discrepant findings of the investigators in terms
of overall adaptive functioning render us unable to predict

the relative degrees of ego strength in each group of

41

non-intoxicated addicts. We do, however, have some basis for
formulating an hypothesis with regard to the specific ego
function of "Regulation and Control of Drives, Affects and
Impulses." This function concerns the directness of impulse
expression and the effectiveness of delay and control
mechanisms. The non-intoxicated amphetamine addict appears

to differ from his heroin addicted counterpart in this regard.
He is portrayed in the comparative literature as more emotion-
ally labile and given to more extreme expressions of drive
related behaviors. The non—intoxicated amphetamine addict

is predicted to be less adequate in terms of the "Regulation
and Contrl" function of his ego.

So far we have made predictions as to the relative
adequacy of specific ego functions in heroin and amphetamine
addicts under conditions of intoxication and abstinence. A
third area of interest is the alteration of ego functions
within a specific group of abusers. Viewing the psychotropic
agent as a form Of seld medication, we are interested in
assessing how the addict may benefit from self administration
of a particular drug. Within the group of heroin/amphetamine
addicts, how are ego functions altered by the intoxicant?

5. Stimulus Barrier

42

Ellinwood, defining amphetamine abusers as "psycho-
pathic" utilizes Eysenck's (1957) biologically based formu-
lations in explaining the amphetamine addict's attraction to
stimulant drugs. According to Eysenck, it has been demon-
strated that psychopaths show a strong tendency to be
extraverts in their behavior and their test scores. The
extraversion is brought about by the psychopath's constitu-
tional reduction of "internal mechanisms for non-specific
arousal and for retaining the emotional or conditioned
significance of stimuli." In psychopaths, excitatory
potential is weak and its generation is slow. (The reverse
is true of introverts). Ellinwood (1967) theorizes that
amphetamines produce a calming effect on the psychopathic
personality by "stimulating internal arousal mechanisms and
thereby reducing the need for novel environmental stimuli."

Ellinwood's formulations, in accord with analytically
oriented theorists, suggest that the amphetamine abuser,
like the narcotic abuser, is using the drug in an attempt at
self-medication. The stimulant user's sensitivity thresholds
are higher than the heroin addict's, and he alters his state
by employing an agent that lowers these thresholds. Eysenck

(1957) supports this notion in stating, "There is ample

43

clinical evidence to suggest that extraverts, and particularly
psychopaths, are much more tolerant of amphetamine than are
ambiverts and introverts, and that stimulant drugs of this
kind have an ameliorating effect on their behavior. Con-
versely, they do not seem to tolerate depressant drugs as
well, and are affected for the worse by them." Based on

these considerations, amphetamine and heroin abusers are
expected to alter their "stimulus barrier" in the direction

Of greater adaptation through drug intoxication.

Having reviewed the literature with regard to pertinent
aspects of heroin and amphetamine abuse, we have hypothesized
specific disturbances and alterations in ego functioning. Our
predictions have encompassed three broad areas of inquiry:

1) How do intoxicated heroin and amphetamine addicts differ

in specific aspects of ego functioning? 2) How do abstinent
heroin and amphetamine addicts differ in specific aspects of
ego functioning? 3) How do amphetamine/heroin addicts alter
their specific ego functions in the drug induced state?

If the various ego manifestations of heroin and amphe-
tamine abuse differe significantly, the implications for
treatment and future etiological explorations are vast. As

with current research on schiZOphrenia (Bellak, 1969) the

44

study of ego function patterns in this project serves the
primary purpose of differentiating the large group of those
designated as "drug addicts". We are not asserting that the
addictive syndrome is primarily a psychological one, due to
ego function disturbances. Sociological, physiological and
psychological factors seem to be in interaction, and these
factors manifest themselves in affecting general and specific
aspects of ego functioning. The study of these ego functions
may lead back to causitive factors (i.e., "Stimulus Barrier"
disturbance is more likely to be constitutional than "Object
Relations"). Having demonstrated specific ego disturbances,
we will be in a much stronger position to devise more indi-

vidualistic, concrete, and effective treatment programs.

II. METHOD

A. Sample

The subjects were 10 male heroin and 10 male ampheta-
mine abusers and 10 "normals", drawn from Bellevue and from
informal contacts throughout N.Y.C. They were matched as
closely as possible for age, sex, socio-economic status, and
involvement with drugs. The absence of psychotic symptomalo-
logy was necessary for inclusion in the project. Ranging in
age from 21-30, subjects were Caucasian and middle class
(Hollingshead Social Class index). They were diagnosed by
two independent psychiatrists (not connected with this
project) as non-psychotic. Involvement with drugs in the
past year was "preferential", and had reached the level of
"abuse". Administration had been primarily intravenous. The
definitions of "preferential" and "abuse" were based on the
work of other investigators (Kramer, 1967; Shick, 1969) in
the hOpe that this would aid in the comparability of our
findings. The "preferential" abuser of amphetamines
reported that he had tried Opiates but their effects were

experienced as unpleasant to him. We were thus insuring that

45

46

drug choice was not purely a function of social milieu.
"Abuse" was defined in terms of mode of administration
(intravenous) and number of times used in the past month
(amphetamines: 9-30; heroin: more than five times). Average
single doses for amphetamine were in the range of 200-500 mg.,
while doses for heroin ranged from .5-1.5 grams. Subjects

who reported doses in excess of these upper limits were

considered "atypical" and not included in the project.

B. Instruments

The principal instruments used in this project were
designed by Bellak and his colleagues (1968, 1969, 1970).

They included the Interview Guide and coordinated Interview

 

Rating Manual (Bellak, L., Hurvich, M., Gediman, H., 1973).
Although the manual is sufficiently comprehensive to permit
reliable ratings Of ego functions from most clinical inter—
views, the Interview Guide is especially keyed to provide
structured (with some degree of Openendedness) questions,
tapping various areas of egofunctioning. These areas
include: 1) Reality testing, 2) Judgment, 3) Sense Of
reality, 4) Regulation and control of drives, 5) Object

relations, 6) Thought processes, 7) Adaptive regression,

47

8) Defensive functioning, 9) Stimulus barrier, 10) Autonomous
functioning, 11) Synthetic functioning, and 12) Mastery
competence.

Originally designed for research on schiZOphrenia, the
coordinated assessment techniques were considered applicable
to our current project on drug abuse. As Bellak (1968) noted:
"The ego function measuring devices provide a profile of
personality variables that reflect the adaptive strengths and
weaknesses of the individual. One can readily see the
possible applications in drug evaluation. Different drugs
could be assessed with regard to their effects on the various
ego functions. Specific hypotheses could be worked out com-
paring differential outcomes for ego functions associated
with various drugs." (p. 601).

Starting with a consensually validated list of seven
ego functions, Bellak and his colleagues (1968, 1969, 1970)
expanded and continuously revised the list to include 12 ego
functions which "correlate highly but in independently varying
ways with each other and with total ego strength." The
conception of ego functions and attempts to measure them is
modeled after "general factor" conceptions of intelligence.

Ego strength or total adaptive ability can best be understood

48

as a manifestation of a general factor which is interrelated
with a variety of specific factors.

Within the past few years, the scale has been demon-
strated to have sufficient reliability and validity to be
used in the current project. A preliminary analysis
(Bellak, 1969) was conducted on 16 subjects (5 normals,

5 neurotics, 6 schizophrenics). The interview scale, a
standardized psychological test battery (WAIS, Rorschach,
T.A.T. Figure Drawings, Bender Gestalt), and laboratory tests,
were administered to assess ego functioning. The investiga-
tors found that judges could attain high levels of agreement
using the interview manual and, that subjects frOm the three
groups which could be expected to differ in the adequacy of
ego functioning, were found to differ in the predicted
direction on all of the ego functions. Results from the
scale were also in accord with psychological and laboratory
tests.

In a more expansive application, Bellak (1970) admin-
istered the scale to 100 subjects consisting of 50 schizo-
phrenics, 25 neurotics and 25 normals. Subjects were
diagnosed by two different raters (other than the inter-

viewer). The scale was again successful in differentiating

49

the three groups. Product—moment, coefficient correlations,
adjusted for the two judges, using the Spearman-Brown
formula, ranged from .80—.89 on eight of 11 functions.
The Interview:

The Interview Guide contains twelve sets of specific
questions; each set keyed to its correspOnding Ego Function

Scale as written up in the Interview Rating Manual. Where

 

interview questions could not be placed in a pre-arranged
format, or where the subject digresses, the interviewer is
expected to utilize his thorough knowledge Of the Rating
Manual and its relation to the Interview Guide. The primary
purpose Of the clinical interview is to provide data on the
twelve ego functions such that they can be reliably rated.
The guide is deliberately overly broad to include extreme
degrees of adaptive strengths but interviewers are encouraged
to shorten the questioning whenever appropriate. The inter-
viewer is given license to depart from the guide whenever he
sees fit, in eliciting information to maximize reliability of
ratings. Although the guide Offers specific questions, worded
in a particular way, the interviewer is instructed to gear his
verbalization of the questions to the subject's background and

intelligence level. Questions are phrased in such a way as to

50

Object Relations

General Questions Tapping Degree and Type of Disturbance in
Interactions

 

1. How do you get along with peOple, generally? Any
ups and downs? When there is trouble with whom is it most
likely to be? A lover? A friend? Relative? Immediate
family member? Casual acquaintance? A stranger? (Inter-
viewers: Probe for what is most relevant.)

2. As a child, how did you get along with your
parents? What sort of person was your father? Your mother?
(Don't repeat what was Offered from initial rapport section.)

3. Do you feel just plain unlucky when things go bad
with peOple, or is it something else? Something you do?
Specify. What do you suppose really causes trouble or ups
and downs? (Interviewers: Probe for evidence of symbiotic,
narcissistic, sado-masochistic possibilities.)

4. Have you discovered that no matter how hard you
try to avoid them, the same difficulties crop up in most
important relationships? Can you describe these recurrent
difficulties?

5. Have you ever had an unhappy love affair? Did it
break up? How did you feel about that? How did you react?
What about an important friendship that broke up? How did
you feel? How did you react? Were you ever separated from
your parents when you were a child? For how long, and under
what circumstances? How do you remember reacting?

6. When things are going bad, or you feel troubled,
do you prefer company or to be alone? (Interviewers: If
subject shows evidence of dependency, inquire how he feels
and what he does when he wants company but it is not avail-
able.) When do you like to be alone?

7. Do you ever feel lonely even when you are among
friends and peOple you know well? Has it ever been so that
anybody's company would be better than being alone?

Questions to TapyContact Needs and Preggnital Fixations

8. Is it important for you to be very close to some-
one?

9. Would you prefer a great many, a few, or just one
or two friends? Or maybe no friends at all? How many friends

51

do you actually have? Close ones? Acquaintances?
10. How easily are your feelings hurt? Are you sensi-
tive to criticism? To being left out of things?

Opestions to Tap Communication and Empathy

11. How important is it for you to understand and be
understood? Do you ever have a hard time understanding
people and their feelings? Often? What do you think causes
this (whether ease or difficulty)?

12. How well do other peOple understand you? Is it
easy or difficult to make your feelings known to others?

What do you think the difficulty (or ease)? How do you react
when things don't gO so well along these lines?

Questions Tapping Object Choice

13. (If long—term mate has not been found): What
have the difficulties been in finding a suitable partner?
Is this because of a lack of Opportunity to meet the sort
of person you'd like to Spend your time with? Is it due to
something else? What?

52

minimize the social desirability of positive or negative
responses.

Although a total presentation of the interview guide
is beyond the sc0pe of this section, the reader is presented
with the specific questions tapping "Object Relations", so
that he may get a feeling for the interview.

The Rating Process:

The Rating Manual defines a 13 point scale for measur-
ing each of 12 ego functions. In addition, it includes an ID
scale and a Superego scale. Each of the 12 ego function
scales is ordinal; the variables being dimentionalized are
rank ordered along a 13 point continuum. Scale points 1, 3,
5, 7, 9, ll, 13 (referred to as modal stOps) are defined,
while the even numbered stops are not defined. Modal stop #1
represents the most maladaptive manifestation of the function
being rated and modal stop #13 represents the most adaptive.
Scale stOp #11 is defined on all scales as "average";
referring to "absense of any notable maladaptation yet short
of Optimal". The various levels Of adaptation are not based
on statistical norms but on consensually validated notions of
adaptation. Although scale stops are not equidistant from

one another (as in an interval scale) the stOps across all

53

scales are geared to reflect the same degree of adaptation;
i.e., stop #3 on any given scale is approximately equal in
maladaptiveness to stop #3 on other scales.

The rater's major task is to make an accurate global
rating on a 13 point scale for each of the 12 ego functions.
He or she is urged to use whatever information is available,
whether from a specific indicator or from an overall impres-
sion, when making a rating. Degree, intensity, frequency,
pervasiveness, and extensity, of the phenomena being rated
for any scale are always to be kept in mind. Each may super-
cede in importance the specific modal description in
determining the rating. With respect to pervasiveness,
especially, the rater is directed to consider whether the
phenomenon is Observed only during the present, or whether
it is chronic. The more pervasive with respect to long range
time spans, the more maladaptation would be reflected in the
behavior and thus the assigned rating. The rating sheet
allows for each subject to be rated according to lowest
level, highest level, present level and characteristic level.
(In this project we are more concerned with present and
characteristic levels). The rater is cautioned to take

environmental conditions into account when formulating his

54

ratings. He or she considers whether the behavior reflecting
any given function occurs in an "average expectable environ-
ment" or if it occurs following some precipitating, potential-
ly traumatic stress. (A person who hallucinates after a
surgical procedure is not viewed as responding as pathologi-
cally as a person who experiences no precipitating stress.)
After having listened to the entire (taped) interview,
making notes as he or she goes along, the rater is ready to
begin assigning specific ranks to each ego function. Eh;

rating sheets provide sections for recording evidence for

 

each ego function rating. For each function, the component
factors are designated on the rating sheet so the rater can
immediately record his evidence under the component factor to
which it pertains. The rater then picks that scale point
which most closely reflects the subject's level for the given
ego function. He bases the rating on the specific evidence
he has recorded on the rating sheet, qualified by his overall
impression from the entire interview. When the subject falls
between two defined (modal) scale points, then the rating
would be made at the non-defined stop falling between the two
(i.e., 2, 4, 6, etc.). The portion of the guide which defines

"Object Relations" is included below.

55

Object Relations

 

Instructions to Raters:

Component Factors

 

a. the degree and kind of relatedness to others (taking
account Of withdrawal trends, narcissistic self-
concern, narcissistic object choice or extent of
mutuality).

b. the extent to which present relationships are adaptive-
1y or maladaptively influenced by or patterned upon
Older ones.

c. the extent to which he perceives others as independent
entities rather than as extensions of himself.

d. the extent to which he can maintain Object constancy-—
i.e., can sustain relationships over long periods of
time weathering both the physical absence of the
Object and the presence of frustration or anxiety
related to the object.

Object Relations contributes to adaptation insofar as
one's relations with all others, particularly significant
others, is based on an accurate understanding of and response
to the other person for what he is today. Optimal relation-
ships would then be relatively free of maladaptive elements
of the sort suggesting patterns Of interaction which were
more apprOpriate to old situations than to the present. The
most pathological extreme would be essentially an absence of
object relations; next would be present relations based on
early fixations and unresolved conflicts. Optimal relations
would be the most mature: Free of transference distortions,
and gratifying to adult libidinal and ego needs.

Intensity, diversity, pervasiveness and so forth are
not always essential components to span the entire scale, but
to make global ratings, the rater is instructed to keep in
mind the quality of the person's relationships to significant
peOple as having more weight than relationships to peripheral
peOple. For more pathological adaptations the disturbances

56

in object relations will be assumed to extend to a broader
range of contacts than they would in the moderately maladap-
tive categories, where pathology might be limited to one or
two significant relationships.

Scale:

1. Essential lack Of any Object-relatedness. Withdrawal,
as into stupor or muteness; or living like a hermit
or recluse; "relationships" are pre-symbiotic, mostly autistic.

3. Withdrawal in most situations: (but not as extreme or

pervasive as 1.) e.g., schizoid detachment rather than
total withdrawal. Or else severely narcissistic or symbiotic
relationships: e.g., folie a deux, vicarious Objects, in-
tensely sadomasochistic infantile binds. In general, either
under-attachment, or over-attachment of an infantile nature.
Relationships characterized by such childish traits as oral
envy, destructive clinging, intense unresolved ambivalence,
anal sadism. Present relationships characterized by trans-
ference based on very early fixations, and may reflect other
disturbances in early mother-child relationship. Separation
anxiety may be prominent as well as maladaptive reactions to
object loss, loss of love or narcissistic injury.

5. Same as 3., but less pathological, pervasive and
frequent.
7. Relations with significant people are characterized by

neurotic-type interactions. Can be withdrawn, or of
narcissistic (as in object choice) or symbiotic type, but not
as regressed as levels 3. Examples would be Don Juanism, less
infantile forms of sadomasochism, dependency, and where only
some (usually significant) relationships are of this sort.
Relationships might tend toward either the tenuous or the
over-attached type. Would also then include the fringe,
hanger-on person, most of whose relationships are tangential
(yet degree Of detachment less than in 1. or 5.). Trans-
ference from early fixations usually involving strong oedipal
elements are found in current relationships. Castration
concerns (anxiety) would be superimposed upon separation
concerns (anxiety) determining the quality Of relationships.

57

9. (Like 7. but less severe.) E.g., disturbed interac-

tions with fewer peOple, or with one or more peOple but
(less of the time than 7.). Variability and fluctuations are
seen, from stable "average" relationships to the more dis-
turbed.

ll. Tending toward mature, Object relations with "genital"
goals. Occasional difficulties occur, but are resolved
reasonably well.

13. Optimal relationships. No substantial evidence of

fixations or distortions from early relationships.
Gratifications are appropirate to current adult needs. Rela-
tionships are characterized by mutuality and reciprocity, and
are so smooth as to permit Optimal functioning in other areas
as well.

58

C. Procedure

 

The initial phase of this project involved alerting
administrators at various addiction treatment centers through-
out N.Y.C. about the subject requirements for our research.
Communications were arranged so that non-psychotic addicts
(as diagnosed by two independent psychiatrists who were not
directly connected with the study) were referred for possible
participation in the project. Non—psychotic subjects were
screened and eliminated if they did not fulfill the criteria
as outlined in "sample" (p. 45). POpulation means and
variances were matched with respect to age and 1.0. WAIS I.Q.
scores were roughly assessed on the basis of the vocabulary
subtest since it has the highest correlation with total 1.0.
We expected that subjects would be readily accessible. In
the course of six months, over six hundred drug abusers were
admitted to Bellevue psychiatric hospital (Hekimian, Gershon,
1968); approximately one-fifth of whom were heroin addicts
and one-fifth amphetamine addicts.

The initial interview was administered after subjects
had been withdrawn from the addictive agent. Detoxification
was objectively determined by standard laboratory procedures,

i.e., urine analysis, etc. The average length of heroin

59

detoxification is roughly estimated at one week; amphetamine
taking less time. Subjects were matched in terms of length
of institutionalization prior to the baseline interview. The

interview followed the questions outlined in the Interview

 

Qpigg (slightly amended to avoid redundancy in the second
interview). All interviews were tape recorded for rater
evaluation. Each initial interview was expected to last
approximately two hours.

The follow-up interview was administered one (1) to
two (2) weeks after the initial session. Having carefully
assessed the average dose that S's had been taking, (not in
excess of 500 mg. of amphetamine or 1.5 grams of heroin)

S's received a moderate dose of their chosen drug. In the
case Of heroin abuse, morphine was substituted for heroin
because of its legality and pharmacological similarity. The
S's received standard therapeutic doses, 15 mg. morphine,

20 mg. d-amphetamine sulphate. Although each S was inter-
viewed in the drug and intoxicated conditions, he had no
fore-knowledge as to whether he would receive the drug in the
first or second session. Allowing one (1) hour for drug
effects to stabilize, subjects were interviewed for the next

two (2) hours. The entire S - interviewer phase of this

60

project required the closest of medical supervision and
cooperation. Normals were interviewed twice under abstinence,
as a control for interview effects.

The interviewer was the same in each condition and
across all groups. She had no factual knowledge of the
subject's drug classification or state of intoxication. S's
were instructed not to mention specific types of drugs they
have abused, or whether or not they were under the influence
of a drug in the current session. In this way, we hOped
biases and prejudices of the examiner would be minimized,
moderating the tendency to elicit particular responses.
Before tapes were rated, they were pre-edited so that acci-
dental references to particular types of drug abuse were
eliminated from the record. Hence, interviews couldn't he
scored on the basis or pre-conceived notions about types of
abusers. All ratings were conducted without specific know—

ledge of the S's drug preference or state of intoxication.

III. RESULTS

A. .Reliability of the Ego Function Rating Scale

The Ego Function Rating Scale provided quantitative
measurement of 12 ego functions, libidinal and aggressive
drive strength, and super-ego adequacy. Reliability of the
instrument was assessed by comparing the analyses of two (2)
independent raters on 15 randomly selected interviews. The

results of this comparison are presented in Table 1.

Table 1. Correlation Between Scores Obtained from Two
Independent Scorers on the Ego Function Rating
Scale (N=15)

 

 

Scale Dimension r
Autonomous Functioning .74
Synthetic Integrative Functioning .89
Sense of Competence .90
Reality Testing .86
Judgment .93
Sense of Reality .86
Regulation and Control of Drive Affect and
Impulse .87
Object Relations .90
Thought Processes .71
. . . . *
Adaptive Regres31on 1n the SerV1ce of the Ego .59
Defenses .81
Stimulus Barrier .79
Libidinal Drive Strength .78
Aggressive Drive Strength .76*
Super—ego Adequacy .46

 

*insufficient reliability

61

62

These correlation coefficients suggest that with the exception
of Super-ego and Adaptive Regression in the Service of the Ego,
all other dimensions had sufficient reliability for use in
this study. Functions for which adequate reliability were

not obtained were eliminated from further statistical consid-

eration.

63

B. Effect Of Two Interviews on the Normal Subgroup

To assess the effect of repeated interviews, data from
the normal subgroup were submitted to the matched—pair t-test.
(Spence, 1968). The insignificant t-scores indicated that in
normals, ego function ratings are generally unaffected by
familiarity with the interviewer and interviewer setting.

These results are presented in Table 2.

Table 2. Differences Between First and Second Interviews in
Ego Functions of Normal S's4(N=10)

 

 

 

Scale Dimension t
Autonomous Functioning - .29
Synthetic Integrative Functioning - .43
Sense of Competence 1.53
Reality Testing .43
Judgment -l.00
Sense of Reality 1.00
Regulation and Control of Drive, Affect and

Impulse 1.03
Object Relations .30
Thought Processes -l.00
Defenses 3.12*
Stimulus Barrier 1.00
Libidinal Drive Strength 0.00
Aggressive Drive Strength 1.52
*p < (05

The significant t-score for Defenses suggests that normals
were less defensive in their second interview. All other
functions tended to remain consant, independent of repeated

interviews.

 

64

C. Comparison of Heroin Abusersy Amphetamine Abusers and

Normals Under the Condition of Abstinence

Normals in this study were used as a control group.
They received no drugs in either interview. In order to
define personality differences between heroin abusers,
amphetamine abusers and normals, under the condition of
abstinence, the data were submitted to unweighted means of
analysis of variances. Normals were randomly selected such
that for 6, data from the first interview were analyzed,
while the scores for the second interview were examined for
the remainder. In cases of significant differences as a
function of Subject Type, Newman—Keuls tests were conducted
to determine which particular groups differed. (In cases of
significant interactions, tests for simple effects were made
to assess how specific subject types were affected by order
of interview. Table 3 summarizes these analyses by presenting
significant F-scores Obtained by comparing specific ego
functions and libidinal and aggressive drive strengths in
heroin abusers, amphetamine abusers and normals while
abstinent. Figure 1 shows mean ratings for the three groups
in the abstinent condition. Data for Stimulus Barrier were

qualitatively scored and thus not presented in Figure l.

65

Table 3, Significant F-scores obtained by comparing Heroin
Abusers, Amphetamine Abusers, and Normals under the condition
of Abstinence (P < .01)

 

 

 

Scale Dimension A (subject type) B (measure- AB
lst or 2nd
interview)

Autonomous Functioning 8.11

Synth. Integ. l9.14*** 4.08*

Sense Of Competence l4.68*** 3.70*

Reality Testing

Judgment 23.81*** 8.82*

Regulation and Control l4.42*** 4.1l*

Sense of Reality 3.64** 3.20*

Object Relations l9.60***

Thought Processes 5.47 3.93*

Defenses l6.57*** 4.9l**

Stimulus Barrier+ 8.09**

Libidinal Drive Strength

Aggressive Drive Strength 8.10 5.08**

* P '< .10

** P '< .05

*** P < .001

+ rated qualitatively

In all cases of significant main effects for Subject Type,
Newman-Keuls tests indicated that normals and amphetamine
abusers showed significantly more adaptive ego functioning
than heroin abusers. There were no statistically significant

differences between normals and amphetamine abusers. The

66

significant and nearly significant results for Interview

 

Order indicated a trend for subjects to score more adaptively
in the second interview (the abstinent condition was randomly
assigned to either the first or second interview.) Figure 1
shows that with the exception of Autonomous Functioning and
Sense of Competence, there is a trend toward a continuum of
adaptive strength from heroin abusers to amphetamine abusers
to normals. The significant interaction of Subject Type and

Interview Order for Sense of Competence indicated that in

 

either the first or second interview, abstinent amphetamine
abusers had a higher Sense of Competence than heroin abusers.
Normals showed a higher Sense of Competence than heroin
abusers under the first interview but not the second. There
was no apparent difference between normals and amphetamine
abusers, irrespective of interview order. The qualitative
analysis of Stimulus Barrier showed amphetamine abusers as
significantly higher than heroin abusers with no apparent
differences between normals and amphetamine abusers or normals
and heroin abusers. Heroin abusers were seen as having
significantly more aggressive drive strength than ampheta-
mine abusers, with no apparent differences between normals

and amphetamine abusers.

67

D. Personality Differences Within and Between Heroin and

Amphetamine Abusers

 

Drug abusers were interviewed while under the influence
of their preferred drug. Heroin abusers were given 15 mg.
morphine intramuscularly. Amphetamine abusers were given
30 mg. of dextroamphetamine sulphate, orally. Each drug
subject was interviewed once while intoxicated and once while
abstinent. Data for drug subjects were submitted to factorial
analyses of variances to determine differences within and
between heroin and amphetamine abusers, under conditions of
abstinence and intoxication, taking interview order into
account. Table 4 summarizes these analyses by presenting
significant F—scores obtained for specific ego functions and
for libidinal and aggressive drive strengths. In cases of
significant interactions, tests for simple effects were
conducted to determine how subject types were affected by
condition of intoxication and/or order of interview.

Figures 2 and 3 show mean ratings for heroin and ampheta-

mine abusers, under abstinent and intoxicated conditions.

68

H00. V m sat
Ho. V m as
OH. v m s

 

 

 

 

 

 

 

 

 

 

 

 

 

mm.¢ hm.m numcmuum O>AHQ m>fimmwumm¢
amm.m sumcmuum O>AHQ Hmcflpflnaq
HN.® mwmcmwmo
am.v mm.m mmmmmuoum usmsone
.:Hm.ma mcoaumamm humane
Ho.m samo.o aaam.ma OmasmEH paw pommmfl

m>HHQ mo HOHDGOU O .mmm
:mo.m ::nm.m suaammm mo mmcom
km.¢ :gmm.m :4mm.ma unmsmwsb
imm.m mcaumma suaammm
m¢.m awoo.s :4mm.s saamm.mv mocmummeoo mo mmamm
no.6 4:6m.oa .uucsm .mmuaH oaumsucmm
06.4 ::m~.ma mcacoauuasm msoaocous<

Acoflumo

Iflxoucfl Ho A30fl>umucfl

0mm um Ufi mm oucocflumnmv O cam no uwav m Amman mDHUV 4 cowmcmEHQ mamom

 

 

.30. v .3 38m 9.32
cofluocsm omm mg» mo coflumuumflcflfiom pmumommu SDH3 chwuflOGOo poumoaxoucw paw unocaumnm
noon: mummsnd OGHEmumzmfim paw Cwonmm mcflummfioo ha Omsflmuno mmHOomlm uGMOAMHcmHm

¢ MHM¢B

69

A significant main effect for Drug Type was observed for all
Ego Function Rating Scale dimensions with the exception of
Reality Testing and Libidinal Drive Strength. Irrespective
of the subject's condition of abstinence or intoxication,
amphetamine abusers showed scores which indicated a higher
level of adaptive functioning on eight of ten ego functions.
Sense of Competence was significantly higher for amphetamine
abusers under both interview conditions. This function was
rated according to the subject's subjective feelings of self-
worth, independent of underlying defensive maneuvers. Inter—
view Order yielded significant results in five of the 12
rated categories. Subjects had a tendency to score more
adaptively in the second interview, whether or not they were
intoxicated. The only significant result on Condition was
recorded for Regulation and Control of Drive, Affects and
Impulses. Both types of abusers tended to have greater
control of drives, affects and impulses while abstinent.

The nearly significant results for Reality Testing suggests
that subjects tend to preserve a higher level while abstinent.
There were no interactions between Drug Type and Interview
Order, suggesting that drug abusers functioned more adaptively

in their second interview independent of their drug preference.

70

There were two cases in which significant results were ob-
tained for the interaction of Drungype and Condition. Within
heroin abusers, Sense of Competence is higher in the abstinent
condition. Within amphetamine abusers, Judgment tended to be
better without the drug. In one case there was a significant
interaction between Interview Order and Condition. When the
drug was administered in the first interview, Sense of Compe-
tence tended to be lower for both groups. Although there

were no significant differences within or between groups for
Libidinal Drive Strength, the nearly significant interaction
effect of Drungype and Interview Order and Condition,
suggested that within the group of heroin abusers, there was

a higher level of libidinal energy in the first interview,
independent of the state of intoxication. The significant
main effect for Drug Type on Aggressive Drive Strength

showed heroin abusers as having more aggressive drive energy
across both interview conditions. All subjects tended to be

more aggressive in the second interview.

71

HMEHOG U

.numcmuum m>flup Hosea muomamwu whoom swam:

OGHEODOSQEMN .msumcmuum ELMO w>HmmmHmmm cam
Gaoumal HOGHOAQHH Mow wmnflumu Sufi; GOAUHUCOO ucwcflumnm on.» CH mHmEHoc
"Nova “wwhcwoumfifiw wcflfimuwmmfim How mmcflumu cofluocsm omw COOS .H .55me
acoflm mmwcmm .Oonm .mamm .ucou.ammm mo Dame .8 hp .0 Mo .ucH .uocdm
Imoumw< *xmm loo 2%5039 uownno w .mwm mmcmm IUUSO IHHmmm wmcom .nuchm .usfl

I l J J

 

 

 

 

 

 

 

 

J

 

 

 

 

 

 

J

 

 

 

J

 

 

 

L

 

 

l\\\\\\\

 

 

 

 

 

 

 

 

OH

.3

NH

ma

Mean Score

72

.numcmuum w>flup 30H muomammu OHOUm nmflms

UmumonOUGH-I-I .Aoa u 2v numGOHum m>flup O>Hmmoummm was
uamcaumnmhnuu Hmcfipanaa How mmuoom nuaz mcouflpcoo Omumowxouafi paw unocaumnm
"hmM CH mummsnm nacho: How mmcflumu GOHUUGSM com com: .m HMDOHm
acoflm mwcwm .oonm .mamm .ucoo .m no name .umoe .0 mo .ucH .uocnm
Immummm «xom Iwnnfififihfiuomnno w.mmm mmcmm ImUOH .Hmmm mmcmm .QSRW .u5<

 

 

 

 

 

 

 

 

 

 

 

 

 

 

OH

AH

NH

 

 

 

ma

Mean Rating

71

.mhomsnm Osfiimpmxmfiw Lom.r0hoom wrotm Smasooc:av

.5933: gas. you guru . £8..- film:

£39335“ .Sa :5 525.3- 323. £52.33- a...“

”Enrica. . 32.33% 5— lie»... .23, .3323 iii as. ufisagfi,

£3. 5 {i 50.3: Bu 5:33.5326 on. 52. .u 553»
_ E3.- .35» .08.. .53. .950 fine £8... .33. .93 5.: Joni

     

1.9.3.. tan -8 3.53.3336 .13.. «atom -33 4.2.85...

1

 

.041

  

 

 

 

 

 

 

.
.4
w
I.
~
_
_

 

 

 

 

 

 

!
l
5.."
l
L
I
b w
l

 

 

u.—

 

 

 

 

 

 

fl'

 

 

 

 

 

    

 

 

  

 

 

 

 

 

 

 

 

 

a.—
an
9—
a
a
4
o.
m
...,
n
n
h
l
. r . . .
-333 on... 3%..an u. .19 5.3 433 L53 3.23. . .2!
one». 3w.ooua.uh1a.uaou.= uc 3.3... 1.3.0 3 .9...» ...—d: a
. 3 t 53-3.. :35... as .43.. 333. 03.3 .n 8355
2.2.: an 5:5 now .33.. aunt 88$; vi I... 3.39.

v3.3.8.5»- .3: u 3 3 I9; 3 fl
. . .33....- 3:33.33»...

pull non "

I

“as. - .-....h-‘d ..NJ

1&1

r .
“~*~.~-.-I --J

 

 

 

a,

 

 

t

 

L‘m”- .v “~0--'~ -‘ --vn_.¢.. o-oov-.—-,.-..o. oy—“Awfi .fl
‘ . .

‘

w-

 

 

 

.mummsnm osflsmpwxmfim pom mmaoom mzosm mehouc22e

so 7..

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

j fij .14 w... T- A r! 4 1-; ”.14 .1;
: J .f , _ .. m.w .
m a . .. . m
u u A .
m ~ . A a .
m U “M j . g
m . m _. ..
m . u _ . . x
.m w m _ . __
. w . .
.. .. m. . u w
m w . M m . ,
._ .n . \. w . . _ u
m .. h . w .. .
. ‘. m M _ _ m ..
m w “ m .. .
.. v ,4. . m . r s
W. M m . m w w _ h v
. H ... . , . , w I. _ _
.m ... M m , m m . V
M M . . M r ,, . .. w . ..
. . u
_ ._ d w w W ..
M m w h .
. .h .. W w .
r . . m A .. m _
m M w. . ... . V . w
m "_ ‘n w “
v w * o‘ll.‘ - .. H A
. .. H n L
. m. NS .tL. ti..—
0 m. . —
. vDL I|IILV .
Illl . _
hi.
, W
._
Tl“ .. .
,. m

73

.numamnuw m>HHU 30H muomammu wnonom Lmflm*

UmuMUonucH' 8H u 5 .zumcmuum 9,536 w>wmmwhmmm Ucm
ucmcflumnm “U Hmcflmfinfla new mmuoom Sufi; mcofluflwaoo UmumUflxonEa Ucm unmafluwnm
"mmm cfl mummsnm mcflfimumnmEm “Om mcflumn coHuUGSM 0mm Gmwz .m MMDGHm
*GOHw mmcmm .Uoum .mamm .ucoo .m no name .umme .0 Mo .uQH .uocsm
Immnmmd ¥xmm ImQuQWRhEuumnno w.mmm mmcmm Imcdb .Hmwm mmamm.£ucwm .u5¢

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Ha

 

NH

 

 

 

ma

Mean Rating

IV. CLINICAL IMPRESSIONS

Heroin and amphetamine abusers differed markedly in
self-concept. Although both groups had relatively poor object
relations and vocational adjustment, the amphetamine abuser
c0pes with this by a consciously inflated sense of self-
worth. He often views himself as endowed with special sensi—
tivity and unusual capacity for personal growth and social
contribution. He calls attention to his physical appearance
with elaborate costumes, hair styles and jewelry. Decorations
are exhibitionistic and socially alienated. The swastika and
the German cross are not uncommon.

The heroin addict is far less conspicuous in appear-
ance. Hair styles are convential, clothing is shabby and
tatoo and needle marks are shielded by long-sleeved shirts.

He consciously views himself with contempt; his aspirations
are limited to self-maintenance. The examples shown in
Table 5 are illustrative of characteristic differences in
the management of self-esteem. The heroin addict's mood of
depression and despair is contrasted with the amphetamine

abuser's denial of depression and compensatory optimism.

74

75

Table 5. Self - Esteem

 

Heroin Amphetamine

 

Q. How do you feel about yourself generally?

Lousy, I don't like myself. I think I'm all right ya'
know.

Q. What about your looks, do you think you're good looking?
I don't like them and I . I think they're all right, I'm
don't know why. satisfied. Yeh, I think I'm
good looking.

Q. How do you compare with others your age?

Right now I know I don't I don't think I'm as mature,

compare well. I can't con- serious or business—minded as

trol my desire for drugs, a 25-year—old should be. As

I can't be a man, I am a man I'm all right. I'm big

not doing anything. and strong and I try to be
kind. I love women and I dig
kids.

Q. What do you believe that other peOple think of you?

That I'm a c0p out; some I think others like me a

peOple would say degenerate. great deal. They keep saying
they do. They don't really
say it but I know they do. I
make friends easily and people
smile and they embrace me and
make you feel like you're not
rejected.

Q. What kind of person would you like to be?

I'd just like to be average I would like to be free of

and just get along; say drugs. I would like to not
middle class. I want to be ever have to put a grape ice
able to work and be middle pop in my mouth if I didn't

class. I don't have goals want to. Right now I'm taking

76

of making a million or any- grape ice pops. I'm playing

thing, just making a living. with kids. I bought a yo-yo
yesterday. I'm laughing a
lot and enjoying life.

 

The amphetamine abuser is characterized by active con-
frontation with his environment. While the heroin addict
feels overwhelmed by his low self-esteem, the amphetamine
abuser utilizes a variety of compensatory maneuvers. He
reassures and arms himself against a world perceived as
hostile and threatening via physical exhibition of alienated
symbols of power and strength. Identification with radical
political groups further serves the need for active expression
of hostility. Promiscuity and prolonged sexual activity may
be the behavioral expression of needs to demonstrate adequacy
and potency. High level artistic and creative aspirations
are usually unrealized self—expectations, bordering on
delusional grandiosity. Such belief often lead to compulsive
and unproductive behavior. Active participation in hand
crafts, music, drawing or physical labor is striking in nearly
all the amphetamine abusers studied. To maintain his tenuous
sense of self as a potent and potentially productive indivi-

dual, the amphetamine abuser uses many defenses. Denial,

77

projection, rationalization and intellectualization, are
characteristically observed. Equilibrium is maintained at
the cost of great expenditures of psychic and physical energy.
In contrast, conscious of his self contempt and chroni—
cally depressed, the heroin abuser seeks to avoid confronta-
tion with his surroundings. His major pre-occupation is
survival. Rarely identifying with people or causes, he
believes that satisfaction is achieved through self—indulgence.
Like the amphetamine abuser, he perceives the environment as
hostile and threatening, but maintains equilibrium via
withdrawal and passive expression of hostility. His parasitic
relationship to the community is rationalized by perceiving
himself as victim. For the heroin abuser, interpersonal
communication is characterized by an initial front of honesty
and Openness in the service of opportunism. When the facade
is relinquished, the addict appears introverted, distrustful
and lacking in conviction. In contrast to the amphetamine
abuser, thinking is more concrete and personalized, and
defensive structures are more primitive and fragile. Under
stress, repression is easily disrupted, permitting the
emergence of self-derogation, hostile fantasy and impulsive

acting out.

78

Interview material exemplifies these differences
between heroin and amphetamine abusers. The amphetamine
abuser's abstract and intellectualized mode of relating is
contrasted with the heroin addict's concrete and personalized

styles in Table 6.

Table 6. Style of Relating

 

Heroin Amphetamine

 

Q. Do you believe that there is too much expression of
hostility, anger or agression in our society?

Yes...these people who want Gee that's hard...Revolution

all these changes. All is a difficult thing: yes, I
these different groups... think there's too much hostil-
Panthers, Weathermen, it's ity. I think that the

too hostile, it makes me establishment is too hostile
feel uneasy. toward the peOple or the

dissenters. In other words,
I think the right is too
hostile toward the left. If
you have long hair or a beard
which is a protest thing,
they absolutely refuse to
listen to you and become very
violent. Like that thing in
Chicago; it shouldn't have
happened. From the establish—
ment's point of View, they
call us radicals. We really
aren't. I think we're too
lenient towards them. We
should beat them back.

79

Q. What makes you angry?

When peOple criticize me. Apathy makes me angriest.

Q. What do you do (when angry)?

I go all out like war. Sometimes I get angry enough
to point it out to the person
who is being apathetic.

Q. What makes you sad, blue or depressed?

Oh, sad stories, love stor- Poverty makes me the saddest.
ies, people breaking up in There's a difference between
general. sad and concern. When you're

sad it's about yourself or a
personal thing. A concern is,
well, I think I'm concerned
about what's happening to the
country.

 

The personality profiles and illustrative interview
material here presented are abstractions culled from many
subjects. As expected, we found a wide range of individual
variation among the abusers in our experimental pOpulation.
However, these observations provide a framework for concep—
tualizing possible psychological differences between

preferential abusers of heroin and amphetamine.

V. DISCUSSION

A. Global Ego Strength

Tables 3 - 4 summarize results for analyses of vari—
ances comparing heroin and amphetamine abusers under abstinent
and intoxicated conditions. With the exception of Reality
Testing, amphetamine abusers seemed to exhibit significantly
higher ego strength, on each variable considered, across both
interview conditions. This result strongly supports the
hypothesis, using Bellak's (1969) definition of ego strength
as "total adaptive capacity", that the opiate addict has less
"global ego strength" than the amphetamine abuser. It is also
in accord with clinical observations that in heroin abusers,
thinking is more concrete and personalized, regression is to
an earlier level, and defensive structures are more primitive
and fragile.

Although relative to heroin abusers ego functioning is
more adaptive in amphetamine abusers in the intoxicated condi—
tion, one cannot necessarily extend this finding outside of
the laboratory situation. There is no reason to assume, for

example, that experimental doses of 30 mg. and 15 mg. for

80

81

amphetamine and heroin abusers respectively, are comparable in
effect to average "field" doses of 310 mg. and 100 mg. The
results do, however, suggest a trend in both groups for ego
functioning to be negatively affected by the utilization of
their respective drugs. Figure 2 compares mean ego function
ratings for heroin abusers in abstinent and intoxicated
conditions. Seven of the ten means observed are lower in the
intoxicated condition. Figure 3 compares mean ego function ~w’
ratings for amphetamine abusers in both conditions. Nine of
the ten means observed are lower in the intoxicated condition.
There are three cases in which ego functioning is significant-
ly lower in the intoxicated condition (p <.05): Regulation
and Control of Drive, Affect and Impulse (for both groups);
Judgment (for amphetamine abusers); Sense of Competence (for
heroin abusers). A nearly significant result is observed

(p <.lO) for Reality Testing (this function is lower for both
groups in the intoxicated condition). It is speculated that
under conditions of higher doses, greater impairment of ego
functioning could be observed and more significance obtained.
An increase in sample size would also be expected to yield

more significant results.

82

B. Specific Ego Functions

Autonomous functioning; The rating of this function is
based on the degree of impairment of apparatuses of primary
autonomy (functional disturbances of sight,hearing, intention,
language, memory, learning or motor function) and secondary
autonomy (disturbances in habit patterns, learned complex
skills, work routines, hobbies and interests). Although there
are no significant drug effects observed for this function,
amphetamine abusers are significantly more adept across both
interview conditions. Figure 3 reveals respective mean scores
of 6.6 and 9.7 for heroin and amphetamine abusers in the
abstinent condition. Statistical data and interview material
suggest that while amphetamine abusers are relatively unim-
paired in this area (R'normals = 9.5) heroin abusers are
subject to moderately high interference, by conflict, of their
apparatuses of primary and secondary autonomy.

Interview material suggests specific problems in the
areas of concentration, the manifestation of which is rela-
tively high difficulty in carrying out routine tasks, and
engaging in skilled behaviors. Although drug effects were

not significant for either group, it is noteworthy to observe

83

that amphetamine abusers obtain a higher mean score on this
function in the intoxicated condition (see Figure 3). Though
not significant, this observation supports Weider and Kaplan's
(1968) description of amphetamine as a "reinforcer of autono-
mous functions." The data confirms the hypotheses that in
their respective states of intoxication, amphetamine addicts
would display a greater capacity to utilize their autonomous
ego functions.

Synthetic Integrative functioning: The rating of this
function is based on the degree of integration of potentially
incongruent attitudes, values, affects, behaviors and self—
representations; the ability to relate actively psychic and
behavioral events. Although there were no observed drug
effects for this function, amphetamine abusers were signifi—
cantly more adept across both interview conditions. Figure 1
shows respective mean scores of 5.6 and 8.1 for heroin and
amphetamine abusers in the abstinent condition. Although
normals did not significantly differ from amphetamine abusers
on this variable, the obtained mean is noticeably higher (9.8).
Synthetic Integrative functioning is the factor which corre-
lates most highly with total ego strength (Bellak, 1969) and

the data suggest a continuum from heroin abusers to amphetamine

84

abusers to normals along the dimension of total adaptive
capacity.

Statistical data and interview material portray the
heroin abuser as an individual with no consistent life goals,
and serious identity conflicts. There is no adequate
organization in daily life, although simple activities may
be carried out effectively. Psychological mindedness is
virtually absent. For the amphetamine abuser, identity
problems are less severe. Identifications with political
or artistic groups remain moderately stable. Purposeful,
planned actitivies can be carried out but he is usually a
step or two behind in meeting the obligations of everyday
life and carrying out what he has agreed to do. There is
some psychological mindedness but active efforts to relate
different areas of experience are only moderately successful.

Sense of Competence: The rating for this function was

 

based on the subject's overt, conscious statement of his
feelings of adequacy. No attempt was made at assessing the
underlying dynamics for this statement (i.e., unconscious
denial of helplessness, etc.). Scores reflect the person's
expectation of success or the subjective side of actual

performance (how he feels about how he does and what he can

85

do). The data show amphetamine abusers as having a higher
Sense of Competence across both interview conditions. It is
noteworthy to observe that although there was no significant drug
effect for amphetamine abusers on this variable, the obtained
mean (11.9) is higher in the intoxicated condition (see
Figure 3). While amphetamine appears to bolster feelings of
adequacy, heroin appears to have the opposite effect.
Sense of Competence was significantly lower within heroin
abusers under the condition of intoxication. Although normals
did not significantly differ from amphetamine abusers on this
variable, the observed mean was considerably higher for
amphetamine abusers (see Figure l). A dynamic interpretation
of these results is that while the amphetamine abuser is
invested in denying feelings of helplessness and inadequacy,
the heroin addict is prone to accept and wallow in feelings
of hopelessness and despair. These findings are consistent
with clinical impressions of the amphetamine abuser as
bordering on delusional grandiosity with regard to self
expectations, while the heroin addict is concerned with
survival and self-maintenance.

Reality Testing: The rating for this function is based

on the subject's ability to distinguish inner and outer

86

stimuli; his accuracy of perception, including orientation to
time and place; his psychological mindedness or "reflective
awareness." The data show no significant differences between
heroin and amphetamine abusers across both interview condi-
tions. Table 4 does, however, reveal a nearly significant
drug effect within groups. This result suggests that heroin
and amphetamine abusers tended to preserve a higher level of
Reality Testing in the abstinent condition. Although analysis
of variance revealed no significant differences between heroin
and amphetamine abusers and normals on this variable, the
obtained means (see Figure 1) suggest a continuum of adaptive
strengths (7.8, 8.3, 9.8).

Interview and statistical data indicate that abstinent
drug abusers may be given to occasional perceptual errors and
coarse misinterpretations of inner and outer reality but with
a considerable degree of self-recovery leading to objectivity.
Amphetamine abusers tend to have a predisposition toward
projection and rationalization while heroin abusers utilize
more primitive defenses of denial and repression. In both
cases, drug intoxication seems to lower the thresholds of
Reality Testing and increase the addict's potential toward

perceptual distortions and relative out-of—touchness. In most

87

cases, hallucinations and delusions only occur under extreme
conditions such as prolonged amphetamine intoxication or
ingestion of psychedelic drugs.

Judgment: The rating for this function is based on the
subject's anticipation of the consequences of intended
behaviors (legal culpabilities and social censure, disapproval
or inapprOpriateness) and the extent to which manifest
behavior reflects the awareness of these consequences.
Amphetamine abusers tended to have significantly better
Judgment than heroin abusers across both interview conditions.
Although drug intoxication did not significantly impair the
Judgment of heroin abusers in this situation, amphetamine
abusers underwent a significant decrement in their judgmental
capacity while under the influence of amphetamine. Comparison
of heroin and amphetamine abusers and normals in the abstinent
condition found normals and amphetamine abusers as having
significantly better Judgment than heroin addicts with no
statistical difference between amphetamine abusers and normals.
A comparison of the obtained means, however, (Figure 1)
suggests a continuum of adaptation from the heroin addict,
to amphetamine abuser, to normal.

The convergent picture of statistical and interview

88

data portray the heroin addict as an individual with judgment
so defective that he repeatedly causes danger to health, work
and interpersonal relationships. Usually he can verbally
anticipate the consequences of his actions but manifest
behavior rarely reflects this awareness. For the amphetamine
abuser, poor Judgment usually occurs in fairly encapsulated
or conflict—related areas. In cases of drug involvement,
amphetamine abusers are more prone to utilize their ability
to anticipate the consequences of their actions. It is not
unusual, for example, for the amphetamine abuser to take
massive doses of vitamins to compensate for the physical
deterioration known to result from amphetamine abuse.

Sense of Reality: The rating for this function is
based upon the extent to which external events are experienced
as real and as being embedded in a familiar context; the
extent to which the body and its functioning are experienced
as familiar and unobtrusive; the degree to which the person
has developed individuality and self-esteem. Table 4 shows
significant differences between heroin and amphetamine
abusers across both interview conditions. Sense of Reality
was more adaptive in the amphetamine abuser in abstinent and

intoxicated conditions. Under abstinence, normals and

89

amphetamine abusers were significantly more adequate than
heroin abusers. Although normals are not significantly higher
on this function than amphetamine abusers, the obtained mean
scores suggest a continuum of adaptive strength from heroin
abuser to amphetamine abuser to normal (see Figure l).

The combined clinical and statistical impression of
the heroin abuser suggests an individual of quasi-stable
sense of identity but mostly with feedback from outside
sources. When external signals and cues are absent, identity
can become poorly integrated. Occasional derealization and
depersonalization can be observed with some unrealistic
feelings about the body. In most cases self—esteem is quite
low. The amphetamine abuser is less dependent on environ-
mental feedback and depersonalization-like phenomena are more
likely to occur under unusual conditions; falling asleep,
drugs, radical environmental changes. The heroin abuser's
need for external regulation of self—esteem is seen as a
potent factor in the relative success of the therapeutic
community. Peer pressure is generated to support non-
addictive behavior. For an individual lacking in a sense of
independent identity, the group ideal is easily adopted and

until the addict returns to his addictive community, his drug

90

taking and criminal activity may be curtailed.

Regulation and Control of Drive, AffectsL and Impulses:
This function 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. Amphetamine abusers were
more adaptive in this function in both intoxicated and
abstinent conditions. Both groups tended to have less
Regulation and Control of Drive, Affects, and Impulses in
the intoxicated condition. Comparison of heroin abusers,
amphetamine abusers and normals, under abstinence found
amphetamine abusers and normals significantly higher than
heroin abusers with no statistical difference between normals
and amphetamine abusers. The observed means (Figure 1)
suggest a continuum of adaptation for the heroin abuser to
the amphetamine abuser to normals.

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 community. Combined clinical and statistical data

91

present the heroin abuser 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 heroin addict
voluntarily submits himself to extended periods of incarcera-
tion, in drug programs, where impulse expression is minimized.
Temporarily the addict appears to have magnificent impulse
control. Suddenly and without warning, however, impulses
gain the upper hand and once again the addict is seen on a
self—destructive binge. Learning experiences are issued and
once again impulses are quieted through self—regulation and
authoritative and peer pressures. The cycle tends to repeat.

For the amphetamine abuser, 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 through massive expenditures of compulsive energy.
The amphetamine abuser may sit for hours at a time drawing
frightened faces, decapitated bodies, etc.

Object Relations: This rating takes into account the

 

92

degree and kind of relatedness to others; the extent to which
present relationships are adatively patterned upon older
ones: the extent of object constancy. Amphetamine abusers
were significantly more advanced in the quality of their
Object Relations than heroin abusers across abstinent and
intoxicated conditions. Amphetamine abusers and normals were
significantly more adept in this function than heroin abusers.
Although amphetamine abusers did not significantly differ
from normals, examination of the obtained means (Figure 1)
suggests a continuum of adaptation from the heroin abuser to
the amphetamine abuser to normals. The data support hypothe—
sis III, that under conditions of intoxication, amphetamine
abusers tend to be more adequate in Object Relations than
heroin abusers.

It is interesting to note that for heroin abusers, the
obtained mean for this function is higher in the intoxicated
condition (Figure 2). Perhaps in this dose range, heroin
tends to reduce anxiety and 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

93

during their common experience." The general impression of
the heroin abuser is one in which he is detached from people
while under stress and is moderately striving for nurturant
relationships, of a highly dependent nature, leading to
stormy or strained attachments.

The amphetamine abuser, although more advanced in
Object Relations, tends to become involved in relationships
involving strong unresolved oedipal elements. Castration
concerns 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 compulsive 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.

Thought Processes: The rating for this function is
based on the adequacy of processes which adaptively guide
and sustain thought (attention, concentration, anticipation,
concept formulation); the relative primary-secondary process
influence on thought. Amphetamine abusers were higher on

this variable in both abstinent and intoxicated conditions.

94

There were no apparent differences within groups between
intoxicated and abstinent conditions. While abstinent,
amphetamine abusers and normals were significantly more
adept at Thought Processes than heroin abusers. Although
there was no significant difference between normals and
amphetamine abusers, examination of mean scores (Figure 1)
suggests a continuum of adaptation from heroin abusers to
amphetamine abusers to normals.

Clinical and statistical data, combined, portray the
heroin abuser as somewhat distractible, with intruding
thoughts resulting in disruptive communication. There is some
vagueness and lack of specificity in memory and under stress
thinking becomes concrete. Communication is best achieved
on a direct, down to earth basis with little room for the
addict to interpret hidden meanings. Evaluative statements
are likely to be interpreted as absolutes; i.e., "he thinks
I am good” or "he thinks I am bad." In most cases, thinking
is logical and well-ordered.

The amphetamine abuser is far more abstract in his
mode of conceptualizing. Occasionally thinking is disrupted
by tangentially related but irrelevant thoughts. His level

of distractibility is less severe than the heroin addict's

95

and he appears to have the capacity to recover quickly and
respond appropriately. Although thinking is for the most
part logical and well ordered, it may at times become so
abstract that direct communication is extremely difficult.
Defenses: The rating for this function is based upon
the extent to which defenses adaptively or maladaptively
affect ideation and behavior; the extent to which these
defenses have succeeded or failed (degree of emergence of
anxiety, depression or other dysporhic states). Amphetamine
abusers were higher on this variable in both abstinent and
intoxicated conditions. There were no apparent differences
within groups between abstinent and intoxicated conditions.
While abstinent, amphetamine abusers and normals were signi—
ficantly more adept at Defensive functioning than heroin
abusers. Although there was no significant difference
between normals and amphetamine abusers, examination of mean
scores (Figure 1) suggests a continuum of adaptation from
heroin abusers to amphetamine abusers to normals.
Clinically, the heroin abuser appears to be relatively
primitive in his defensive structure. Repression and denial
are massively deployed and withdrawal is a predominant mode.

Under stress, repression is easily disrupted and the emergence

96

of anxiety and depression are readily observed. Defensive
functioning may become minimal, as evidenced by recurrent
outbursts of inner and outer directed aggression.

The amphetamine abuser is characterized by a variety
of defensive maneuvers. He is more successful in preventing
the emergence of anxiety and dysphoric affect but is relative-
ly similar in his sacrifice of Reality Testing (see Figure l).
Denial projection, rationalization and intellectualization are
typically observed.

Stimulus Barrier: The rating for this function is

 

based on 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 c0ping mechanisms employed to deal with
them. Subjects were rated on this variable in terms of high,
medium, or low Stimulus Barriers and weightings of 3, 2, and
l were assigned to the respective categories. While there
were no apparent differences between normals and either drug
group on this variable, amphetamine abusers have significantly
higher Stimulus Barriers than heroin abusers. Examination of

the raw data reveals that six of ten amphetamine abusers

97

interviewed were rated high on this variable (1 low) and nine
of ten heroin abusers were rated low.

The data tend to support Ellingwood's (1967) formula-
tions in explaining a biological predilection for particular
drugs. 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, 1957). The
notion of amphetamine abusers, with biOlogically high
thresholds for exéitatory stimulation, seeking homeostasis
through self-medication, is suggested by the data.
Amphetamine, a C.N.S. stimulant seems to put the abuser into
closer touch with environmental stimuli that might otherwise
be unavailable because of constitutionally based high Stimulus
Barriers. Conversely, the heroin abuser may have a
predisposition toward excessive vulnerability to environmental
stimuli. His use of a depressant drug may have the self
medicating effect of raising stimulus thresholds and
allowing him to function more adaptively in a world of
relatively painful and extreme stimulation.

Libidinal Drive Strength: The rating for this variable

 

takes into account: overt sexual behavior (frequency and

98

intensitY): associated and substitue sexual behavior;
fantasies and other ideation; dreams; symptoms defenses and
controls. There were no statistically significant differences
between heroin and amphetamine abusers and normals in
Libidinal Drive Strength in either intoxicated or abstinent
conditions. Examination of the mean scores for heroin abusers
indicated a mean rating of 7.8 in the intoxicated condition
and 6.6 in the abstinent condition. For this variable, the
higher rating reflected a decrease in drive strength.
Though not statistically significant, this observation is
consistent with subject reports of decreased sexual drive
while under the influence of heroin. There was a significant
interaction between interview order and Libidinal Drive
Strength within heroin abusers. Independent of condition of
intoxication there was significantly higher libidinal energy
in the first interview. This finding is difficult to inter—
pret but we might speculate that since the interviewer was
female, the first interview contact might have stimulated a
degree of sexual arousal which dissipated with increased
exposure and consistent professional orientation.

The finding of nonfsignificance between heroin abusers,

amphetamine abusers and normals on this variable is interesting

99

to note. It is speculated that the lack of sexual involvement
reported by most heroin abusers is more related to a sense of
inadequacy and compensatory style of withdrawal from Object
Relations, than to a deficiency in Libidinal Drive Strength.
Similarly, the reports of excessive promiscuity and compulsive
sexual activity given by amphetamine abusers, may be related
to a style of active confrontation with underlying fears of
helplessness and inadequacy.

,Aggressive Drive Strength: The rating for this
variable was based upon: overt aggressive behavior (frequency
and intensity); associated and substitute aggressive behavior
(verbal expressions, etc.); fantasies and other ideation;
dreams; symptoms, defenses, and controls. Heroin abusers
have significantly higher Aggressive Drive Strength across
both interview conditions. Normals and amphetamine abusers
were significantly lower in Aggressive Drive Strength than
heroin abusers, in the abstinent condition. There was no
apparent difference between normals and amphetamine abusers
on this variable.

The heroin abuser is seen as an individual whose overt
acts of aggression are considerably more intense and frequent

than average. The presence of physical assaultiveness and

100

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. Violent verbal
expressions are often encouraged and readily tolerated, thus
reducing the addict's tendencies toward repression and with—
drawal. This approach seems to be effective in decreasing
the heroin addict's potential for overt violence of an inner
and outer directed nature.

For the amphetamine abuser, aggressive energy appears
to be less excessive and channeled more adaptively. Periodic
breߢhroughs of violence occur but, with the exception of
amphetamine psychosis, these expressions are usually not as
frequent or intense as the heroin addict's. Fantasies of
violence are usually expressed verbally and sometimes find
their expression through identification with radical politi—
cal groups. Artistic productions often reflect bizarre and
destructive ideation. It is suggested that treatment programs
in which strong confrontation is a primary modality are not

as effective in the treatment of amphetamine abuse. For

101

amphetamine abusers, treatment might be geared more at
providing a creative and loosely structured environment for
the investigation of underlying fears of helplessness and
inadequacy.

Interview Effects

 

With the exception of Defensive Functioning, normals
tended to remain consistent in their performance across both
interviews. They were significantly less Defensive (t=3.12,

p (.05) in the second interview situation. It is speculated
that familiarity with the examiner and setting tended to

reduce anxiety and decrease reliance on defensive maneuvers.
All other ego functions remained highly adaptive and relatively
unchanged across both interviews.

In contrast, drug abusers tended to be strongly
affected by repeated interviews. In five cases, ego function-
ing was significantly (p (.05) improved during the second
interview (Autonomous functioning, Synthetic Integrative
functioning, Sense of Competence, Judgment, Regulation and
Control). The obtained near significance (p (.10) in two cases
(Judgment, Thought Processes) reinforces this trend.

Several Speculations are offered to account for this result:

(1) Since normals knew that they would not receive drugs in

102

either interview, their level of understanding and familiarity
with the experimental design was higher throughout. This
would tend to reduce anxiety and provide for a more consistent
performance. (2) Drug abusers interviewed in Bellevue
Psychiatric Hospital might tend to fear psychological
evaluation or physical incarceration because of the nature
of their activities. These fears might tend to dissipate
with increased familiarity towards the interviewer and
setting. (3) Drug abusers have generally less ego strength
and are thereby more highly affected by their immediate
surroundings.

It is interesting to note the nearly significant
interaction effect (Table 3) for Sense of Competence. If
the drug was administered in the first interview, Sense of
Competence tended to be lower for both types of abusers. It
is speculated that the use of drugs in unfamiliar surroundings
tended to render the user more vulnerable to unpleasant

sensations and feelings of being out of control.

C. Theoretical Considerations

Although the observations for this study were made

while male addicts were under abstinent and somewhat

103

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 abusers of heroin and
amphetamine. Some speculate that these differences are
related to early, pre-drug patterns of childhood experiences.

"Having once experienced a particular drug induced
pattern of ego functioning, the user may seek it out again
for defensive purposes as a solution to conflict or for
primary delight. This seeking out of a special ego state
will be related to the individual's previous needs for the
resolution of conflict or anxiety. If a particular drug
induced ego state resolves a particular conflict, an
individual may seek out that particular drug when in that
particular conflict situation. This will result in
preferential choice of drug" (Frosch, 1970).

Weider and Kaplan (1969) define the altered ego state

induced by Opiates, alcohol, barbiturates, and other sedative

104

drugs as "blissful satiation.” As Savitt (1963) pointed out,
the elation produced by these drugs has been stressed out of
porportion to the sleep or stupor which follows. The
transient euphoria preceding the stupor may be related both
to the decreased pressure of the drives, libidinal and
aggressive and to the sense of gratification of needs. The
user "seeks desperately to fall asleep as a surcease from
anxiety, and the drug provides obliteration of consciousness.
Well expressed in the vernacular, the addict 'goes on the
nod'".

The heroin addict who characteristically maintains a
tenuous equilibrium via withdrawal and repression bolsters
these defenses by pharmacologically inducing a state of
decreased motor activity, under responsiveness to external
situations and reduction of perceptual intake ". . .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"
(Weider and Kaplan, 1969).

Though, as expected, the dramatic effects outlined

105

above were not brought on by our low level, experimental dose,
the observed data points in a parallel direction. Elevated
scores for Object Relations, and Sense of Reality, suggest
greater relaxation and less pressure from the drives. Though
not significantly lower, the mean score for Libidinal Drive
Strength points to a dampening of sexual appetite.

Weider and Kaplan further point out that this style of
coping is reminiscent of the Narcissistic Regressive Phenomena
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 c0pe 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 formulation 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. Addicts are intolerant of

tension and cannot stand pain or frustration. In our study,

106

the notion of low pain thresholds is supported by the
observation that nine of the ten addicts interviewed received
a I'low" rating for Stimulus Barrier. Drug effects alleviate
these difficulties by reproducing the "earliest narcissistic
state." The specific need gratification of the passive-
narcissistic regression reinforces drug taking behavior.

The overall decrement in ego functioning (which is
clearly observed in our study, even at this low dose) and
the pressures of physiological dependency, however, set the
groundwork for a vicious cycle. The addict must increasingly
rely on a relatively intact ego to procure drugs and attain
satiation. Ultimately he is driven to withdrawal from heroin
by the discrepancy between intrapsychic needs and external
demands. Hospitalization, incarceration, or self-imposed
abstinence subserve the addict's need to resolve his 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 feeling and impulse strength as well as heightened

107

feelings of self—assertiveness, self-esteem and frustration
tolerance. Though not statistically significant, our
observations support most of these generalizations.
Amphetamine intoxication produced in our subjects elevated
scores on Autonomous Functioning and Sense of Competence.
Interview material suggests a feeling of heightened
perceptual and motor abilities accompanied by a stronger
sense of potency and self—regard.

As in the case of heroin, the alterations induced
by amphetamine intoxication are syntonic with the abuser'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. 1 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 abuser's
needs to feel active and potent in the face of an environment

perceived as hostile and threatening. Massive expenditures

of psychic and physical energy are geared to defend against

108

underlying fears of passivity (Pittel and Hoffer, 1970).
Weider and Kaplan (1969) suggest that the earliest precursor
to the amphetamine abuser'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 magic 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 physicial activity support the notion
that amphetamine abuse is related to specific premorbid
patterns of adaptation. The consistent finding that ego
structures are more adaptive in the amphetamine abuser than
they are in the heroin abuser suggests that regression is
to a later phase of psychosexual development.

Reich's (1960) comments on the "etiology of compensa—
tory narcissistic inflation" may provide further insight into

the personality structure of amphetamine abusers. "The need

109

for narcissistic inflation arises from a striving to overcome
threats to one's bodily intactness." Under conditions of

too frequently repeated early traumatizations, the primitive
ego defends itself via magical denial. "It is not so, I am
not helpless, bleeding, destroyed. On the contrary, I am
bigger and better than anyone else." Psychic interest is
focused "on a compensatory narcissistic fantasy whose
grandiose character affirms the denial." The high level
artistic and political aspirations witnessed in our subjects
appear to be later developmental derivatives of such infantile
fantasies of omnipotence. Although the amphetamine abuser
subjectively experiences increments in functional capacity
and self-esteem, biological and psychological systems are
ultimately drained of their resources. As in the case of
heroin, our study points to an‘overall decrement in ego
functioning under the influence of amphetamine. The
recurrent disintegration of mental and physical functioning
is a dramatic manifestation of the amphetamine abuse

syndrome.

REFERENCES

Angrist, B. and Gershon, S., Amphetamine Abuse in New YOrk
City, 1966 to 1968. Semin. Psychiatry. 1969, Vol. 1,
pp. 195-207.

Bellak, Leopold, Research on Ego Function Patterns:
A Progress Report. The Schizophrenic Syndrome.
Grune & Stratton Inc., 1969, pp. ll-6l.

, Hurvich, M., A Systematic Study of Ego Functions.
The Journal of Nervous and Mental Disease. 1969,
Vol. 148, (6), pp. 569-585.

 

, Hurvich, M., and Crawford, P., Psychotic Egos.
The Psychoanalytic Review. 1970, Vol. 56, (4),
pp. 526-541.

, Hurvich, M., Gediman, H., Ego Functions in
SchiZOphrenicsL Neurotics, and Normals. Wiley, 1973.

, Hurvich, M., Gediman, H., and Crawford, P.,
Study of Ego Functions in Schizophrenic Syndrome.
Arch. Gen. Psychiat. 1970, Vol. 23, pp. 326-336.

 

, Hurvich, M., Silvan, M., and Jacobs, D., Toward
an Ego Psychological Appraisal of Drug Effects.
Amer. J. Psychiat. 1968, Vol. 125:5, pp. 45—56.

 

, and Rosenberg, M., Effects of Anti-Depressant
Drugs on Psychodynamics. Psychosomatics. 1966,
Vol. 7, pp. 106-114.

Black, J., The Speed That Kills. N.Y. Times. March, 1970.
Brenner, C., An Elementary Textbook of Psychoanalysis.

International Universities Press, Inc., New YOrk,
1955, pp. 41-70.

110

111

Cameron, Dale C., Youth and Drugs. JAMA. 1968, Vol. 206,
pp. 1267-1271.

Caperon, J.S., Sprecht, P.G., and Wendt, G.R., Effects of
Amphetamines on Moods, Emotions, and Motivations.
J, Psycho. 1965, Vol. 61, pp. 93-121.

Chein, 1., Gerard, D.L., Lee, R.S., and Rosenfeld, E., The
Road to H. New York, Basic Books, Inc., 1964.

, et-al., Narcotics, Delinquency and Social Policy.
Tavistock London, 1964.

 

Clark and Funkhauser, Psychedelic Drugs. Psychology Today.
April, 1970, Vol. , p. 52.

Davidson, H.A. Confessions of a Goof Ball Addict. American
J. of Psychiatry. 1964, Vol. 120, pp. 750-756.

DiMascio, A., Klerman, G., Psychophysiological Studies of
Psychoactive Drugs. J.: Drugs and Behavior ed. Uhr,
L. and Miller, New York: John Wiley & Sons, 1964,
pp. 360-364.

Edwards, A., Bloom, M., Sohen, S., The Psychedelics: Love
or Hostility Potion? ngchological Reports. 1969,
V01. 24' pp. 843-46.

Ellinwood, E. H., Amphetamine Psychosis: I. Description of
the Individuals and Process. Journal of Mental and
Nervous Diseases. 1967, Vol. 144, pp. 273-283.

Eysenck, H. J., Drugs and Personality, I: Theory and
Methodology. Journal of Mental Science. 1957, Vol.
102. PP. 119-131.

Fenichel, O. The Psychoanalytic Theory of Neurosis.
Norton, New Ybrk, 1945.

112

Fischmann, V.S., Stimulant Users in the California Rehabili-
tation Center. International J. of the Addictions.
1968, Vol. 3, No. 1, pp. 123-129.

Frosch, W.A., The drug abuser's chosen drug. In Pittel, S.M.
Ed. Drug_Use and Drug Subcultures. U. S. Government
Printing Office, Washington, D. C. In press.

Gerard, D.L., and Kornetsky, C., A Social and Psychiatric
Study of Adolescent Opiate Addicts. Psychiat. Ouart.
1954, Vol. 28, pp. 113-125.

Goodman, L., and Gillman, A., The Pharmacological Basis of
Therapeutics. New YOrk: The Mac Millan Co., 1955,
pp. 517-523.

Glover, E., On the Early Development of Mind: Selected
Papers on Psycho-Analysis. N.Y.: Imago Publishing
Co., Ltd., 1956, Vol. I, pp. 187-201.

Haertzen, C. A., Hooks, M. T., Changes in Personality and
Subjective Experience Associated with the Chronic Ad-
ministration and Withdrawal of Opiates. Journal of
Nervous and Mental Disease. 1969, Vol. 148 (6),
pp. 606-614.

Hall, C., Lindzey, G., Theories of Personality. New YOrk:
John Wiley and Sons, Inc., 1957.

Hartmann, D., A Study of Drug-taking Adolescents.
Psychoanalytic Study of the Child. 1969, Vol. 24,
International Universities Press, Inc., pp. 384-397.

Hekimian, L., Gershon, 8., Characteristics of Drug Abusers
Admitted to a Psychiatric Hospital. JAMA. 1968,
Vol. 205, pp. 125-130.

Hill, H.E., Haertzen, D.A., and Glaser, R., Personality
Characteristics of Narcotics as indicated by the MMPI.
J. Gen. Psychol. 1960, Vol. 62, pp. 127-139.

113

Hurst, P., Radlow, R., Perchonok, H., Some Dimensions of Af-
fective Response to Drugs. Psychological Reports.
1969, Vol. 24 (1). PP- 239-261.

, Weidner, Marianna, F., Radlow, R., The Effects
of Amphetamine upon Judgments and Decisions.
Psychgpharmacologica. 1967, Vol. 11 (5), pp. 397-
407.

 

Kaplan, H.E., and Meyerowitz, J., Psychosocial Predictors
of Postinstitutional Adjustment Among Male Drug Ad-
dicts. Arch. of Gen. Psychiatry. 1969, Vol. 20 (3),
pp. 278-284.

Kramer, J.C., Introduction to Amphetamine Abuse. J. of
Psychedelic Drugs. 1969, p. 2.

, Fischman, V.S., and Littlefield, D.C., Amphe-
tamine Abuse: Pattern and Effects of High Doses
Taken Intravenously. J.A.M.A. 1967, Vol. 201 (July),
pp. 89-93, 305.

Lasagna, L., The Many Faces of Drug Abuse. Modern Medicine.
1970, April, pp. 144-176.

 

Laurie, P., Drugs: MedicalL Psychological and Social Facts.
Great Britain: C. Nicholls and Co., Ltd., 1967.

Louria, D.B., The Drug Scene. New Ybrk, N.Y.: McGraw Hill,
1968, Vol. 8, pp. 215.

 

Mahler, M., On Human Symbiosis and the Vicissitudes of Indi-
viduation. J. of Am. Psychoanalytic Association.
1967, Vol. 15, pp. 740-76OL

Mansfield, N.J., Amphetamine and Barbiturate Abuse.
Canada's Mental Health. 1969, Vol. 17 (5), pp. 2-5.

McCormack, A., Toxic Reaction of the Amphetamines. Diseases
of the Nervous System. 1962, Vol. 22 ( ). PP. 219-
224.

114

Mensch, J.N., Psychopathic Condition, Addiction, and Sexual

Deviation. In Handbook of Clinical Psychology. B.B.
Wolman, ed., 1965.

Modell, W., Lansing. A., Drugs. New York: Time, Life
Books, 1969, pp. 50-76.

Nowlis, H., Drugs on the College Campus. New York:
Doubleday and Co., Inc., 1969.

Nyswander, M., The Drug Addict as a Patient. Grune and
Stulton, New York, 1956.

, Drug Addictions. American Handbook of Psychiatry.
S. Arieti, ed., New York: 1959, Vol. 6, pp. 614.

 

Pearson, M., and Little, R., The Addictive Process in Unu-
sual Addictions: A Further Elaboration of Etiology.
Am. J. of Psychiatry. 1969, Vol. 125 (9), pp. 1166-
1171.

Phililipson, R., Modern Trends in Drug Dependence and
Alcoholism. New YOrk: Appelton-Century Crofts,
1970.

Pittel, S.M., Hoffer, R., The transition to amphetamine
abuse. In Ellinwood, E.E. and Cohen, S., Eds.
Current Concepts of Amphetamine Abuse. U. S. Govern-
ment Printing Office, Washington, D.C. In press.

Rado, S., Narcotic Bondage. Amer. J. Psychiat. 1957,
Vol. 114, pp. 165-170.

Rapaport, D., An Historical Survey of Psychoanalytic Ego
Psychology. Identity and the Life Cycle: Selected
Papers, ed. E. Erikson. (Psychological Issues,
Monogram 1). New YOrk: International Universities
Press, 1959.

Reich, A., Pathologic forms of self-esteem regulation.
Psychoanal. Study Child., 15:215-232, 1960.

115

Savitt, R.A., Psychoanalytic Studies on Addiction: Ego
Structure in Narcotic Addiction, Psychoanalytic
Quarterly. 1963, Vol. 32, pp. 43—57.

Scher, J., Patterns and Profiles of Addiction and Drug
Abuse. Arch. of Gen. Psychiatry. 1966, Vol. 15,
pp. 539.

Seevers, M.H., (U. Michigan), Psychopharmacological Elements
of Drug Dependence. JAMA 1968, Vol. 206 (6), pp.
1263—1266.

Shick, R.J., Smith, D., Meyers, F., Use of Amphetamine in
the Haight-Ashbury Subculture. J. of Psychedelic
Drugs. 1969, Vol. 2 (2), pp. 139-161.

Smith, R., The World of the Haight-Ashbury Speed Freek. g,
of Psychedelic Drugs. 1969, Vol 2 (2), pp. 172-188.

Spence, J., Underwood, B., Duncan, C., Cotton, J., Elementapy
Statistics, Appleton-Century-Crofts, New York, 1954,
pp. 142-143.

 

Wahl, C.W., Diagnosis and Treatment of Statusmedicamentosis.
Dis&.Nerv. Syst. 1967, Vol. 28, pp. 318-322.

Weider, and Kaplan, Drug Abuse in Adolescents: Psychody-
namic Meaning and Pharmacogenic Affect. The Psycho-
analytic Study_of the Child. 1968, Vol. 24, pp.
399-431.

Winer, J., Statistical Principles in EXperimental Design,
McGraw-Hill Book Company, 1962,,pp. 452-464.

World Health Organization Expert Committee on Addiction
Producing Drugs. Thirteenth Report, WHO, Technical
Report Series 273, May, 1964.

Yorke, C., A Critical Review of Some Psychoanalytic Litera-
ture on Drug Addiction. Br. J. Med. Psychol., 1970,
Vol. 43, pp. 144.

HICHIGQN STRTE UNIV. LIBRRRIES
111111111111111||1|1||||11|1111111111111
31293010941791