Charles H. Wilber

The psychodynamics of opiate addiction.

Opiate addicts and polydrug, but nonopiate, substance abusers were assessed for depression on the Raskin rating scale for a clinical interview and several self-report measures of depression including the Hamilton, SCL-90, and the recently developed Depressive Experiences Questionnaire (DEQ), which differentially assesses depression focused around neediness from a depression focused around self-criticism (guilt and shame). Opiate addicts were consistently more depressed than polydrug drug abusers on all the measures. On the DEQ, opiate addicts were significantly (p < .001) more depressed than normals and even somewhat more depressed than psychiatric patients. This depression, however, was focused primarily around issues of self-criticism, guilt, and shame rather than issues of dependency, abandonment, rejection, and neglect. Even further, depression focused around self-criticism, as measured on the DEQ, was significantly correlated (p < .001) with the extent to which the polydrug, non-opiate-addicted substance abusers had begun to experiment with opiates. These data suggest that intense depression, particularly depression focused around issues of self-criticism, has an important role in opiate addiction.

Psychological assessment of psychopathology in opiate addicts.

A sample of 99 opiate addicts seeking treatment were assessed on three well established clinical assessment procedures; the Loevinger Sentence Completion, the Bellak Ego Functions Interview, and the Rorschach. Their scores were compared using normal and clinical reference groups. On all three procedures, opiate addicts had a significantly greater impairment than normals but significantly less thought disorder and impairments in ego functions than hospitalized borderline and psychotic patients. The results indicate that a primary disturbance in opiate addicts appears to be their relative inability to conceptualize people as well differentiated, articulated, and involved in meaningful, purposeful, and constructive activity. In addition, opiate addicts appear to have greater affective lability. These difficulties in interpersonal relations and affect modulation are consistent with disturbances in the neurotic range and suggest that opiate addicts have selected a particularly untoward, self-destructive, isolated mode of adaptation for achieving the satisfactions and pleasures most people seek in intimate personal relationships.

Ego development in opiate addicts. An application of Loevinger's stage model.

This paper reports findings from a study of ego functioning in a sample of 97 opiate addicts applying for treatment and a demographically matched control group of 29 applicants at a job training program. Level of ego development was evaluated using the Loevinger Sentence Completion Test. In addition, in the addict sample, we assessed the correlation between level of ego development and other clinical features including present and past drug use, criminal history, psychological symptoms, and social functioning. The mean ego development scores for the opiate addicts and controls were not significantly different although both groups achieved scores that were, on the average, one full stage lower than those obtained in other studies of nonclinical adult populations. Ego development ratings indicated that around one third of both addict and control groups seemed to be relying on internalized standards for self-regulation. Within the addict group, those at lower levels of ego development reported more psychological symptomatology, poorer social functioning, and heavier drug use. Implications for treatment planning and rehabilitative efforts are discussed.

Psychodynamic theories of opiate addiction: New directions for research

Abstract The numerous clinical and research reports on the personality dynamics in opiate addiction present a number of differing and at times contradictory viewpoints. Predominant are formulations that consider opiate addiction as an attempt to deal with intense depression related to feelings of deprivation by seeking a soothing, infantile, symbiotic experience, or as an attempt to seek relief from cruel, harsh, excessively punitive parental standards that create feelings of being unacceptable and worthless, or as a defense against the emergence of profound and overwhelming aggressive impulses that could precipitate an underlying psychotic potential. Clinical and empirical investigations indicate that while there may be a small group of addicts who function at a psychotic or borderline level, most opiate addicts are severely neurotic or character disordered, dealing with intense depression. Clinical experience and research findings indicate that opiate addicts have serious difficulty managing painful, dysphoric affects, especially depression, anxiety and anger. Depression is often considered a central issue for many heroin addicts. Depression in opiate addiction is often discussed as focused around feelings of deprivation, neglect, and a lack of affection and love. But recent evidence suggests that issues of guilt, shame, and profound feelings of self-criticism and worthlessness are paramount. Rather than being able to contain depression and/or anxiety, or finding appropriate ways for expressing their anger, opiate addicts prefer to withdraw from the pain and stress of interpersonal relationships into self-induced grandiose, omnipotent experiences of bliss. Subsequent research is needed to confirm and elaborate these formulations and in particular longitudinal research is needed which will permit the differentiation of whether these personality factors are the cause or the consequence of opiate addiction. Also, while these formulations seem appropriate for opiate addicts as an overall group, evidence suggests that there may be several different subtypes of individuals who are vulnerable to intense involvement with opiate and subsequent research should be directed toward attempting to identify meaningful subtypes among individuals with opiate addiction.

Psychiatric Disorders in Treated Opiate Addicts

The association between opiate addiction and psychopathology has a long history which is now partially supported by empirical data. For example, opiate addicts have been shown to have high rates of depression (Dorus, 1980; Lehman, 1972; Robins, 1974; Rounsaville, 1979; Steer, 1980; Wieland, 1970; Weisman, 1976), antisocial personality characteristics (Craig, 1979), schizophrenia or schizotypal features (Sheppard, 1969; Hekimian, 1968; Zimmering, 1952), manic symptomatology (Craig, 1979; Flemmenbaum, 1974), and alcoholism (Belenko, 1979). The major problem to date, in the studies of psychopathology in opiate addicts, is the measure of psychopathology which has usually been dimensional symptom or personality scales. Diagnostic techniques, particularly the more recently improved measures, have rarely been applied to the opiate addict (Ling, 1973). The result is that there has been a gap between general psychiatric practice and the treatment of opiate abusers. This gap is reflected in the fact that opiate addicts are usually treated in separate specialty clinics. The isolation of the addict in separate treatment programs and from recent developments in psychiatric diagnostic practice could lead to missed opportunities for useful treatment. For example, the opiate addict who is also bipolar might benefit from lithium, or the addict who is also depressed, might benefit from treatment with a tricyclic antidepressant.