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Differentiation of Personality Types Among Opiate Addicts Sidney J. Blatt & William H. Berman Published online: 22 Jun 2011.
To cite this article: Sidney J. Blatt & William H. Berman (1990) Differentiation of Personality Types Among Opiate Addicts, Journal of Personality Assessment, 54:1-2, 87-104y To link to this article: http://dx.doi.org/10.1080/00223891.1990.9673977
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JOL%LVAL OF PERSONALIT'Y ASSESSMENT, I990 -%(I & 2). 87184 Copyright c I%, Lawrence Erlbaum Associates, I x .
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Differentiation of Personality Types Among Opiate Addicts
A wde range of studies indicate :hat although sociopthic characteris:ics are predominant in opmte addiction. de?ress~ve and psvchotic fearsres are aiso frequently observed. T o test the hyporhesis rha: there are rea!iy three n.;Ses of individuals whc become addicted to opiates {rather t;?an a single, predominant personaiiry q l e ) . fiftv-three opiate addircs were @,en the Loevinger Sencence Comple:ion Test, the Beiiak Ego Funcaons Interview. and :he Rorschach. VariAles derived from these three procedures were szbmtteci rc cl~ste: 2nd discriminant knc:inn ana!yses. Three groups or' addicts were ide:~tified-:hose with impaired interpersonal relationships and affecrlve Labihcv rj:%o:, those p~iaariiycharacter:ied by choughr disorder and impaired ego fiinctioning (X%), and 8 group with diminished ideational and verbai acrivitr 128%). Cozipanson of the assessment of these :hree groups wirh inciependenrlv defined normai, neurotic, and schizophrenic samples provided support fm chree opia:eaddicted personality tvpes, each respectiveiv characterized as character disordered, borderline psycho:ic, and depressed. A!though there seems to be a predominance . . of character-dlsorderod individuais w h o hecome addicted to op:zres, :he data indicate sevcral additional r p e s oC nptace addxts w:& different s p e c of pyihopathology who maT;require different ay?p:oaches tc 3anagerneo: and treacnent.
Opiate addicts traditionally have been viewed as a relative'lv hcmogeneous population, and a great deal ai research has been Jevo:ed to the idendication of psychopathology characteristic of the ~ ~ p i caddict. al Earlier ciinicai 2nd ernpirkai research has emphasized the more regressive and pathoiogica! dimerrsions of the typical opiate addicr ipsychotic, borcier'rine, or infantik features). h h r e recent research, however, has found that the typical opate addict is more within :he severely nesrot-ic or character-disordered rsnge with pervasii~ecii5icultg in
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ELATT AND BEIFMAN
familr and social relations, without evidence of psychotic or organic disturbance (e.g., Blatt, Bernan, et al., 1984; McLelian: Woody, & O'Brien, l97Fj. Many studies from d:fferen: conceptual approaches ie.g., errrpirical, descriprive psychiatric, and psychodynamic), rasing different methodological approaches (e.g., Mh,'iPI, cllnicai interview, and the Rorschach? report that there may be more than one type of addict, either in addition to the modal sociopathic or psychopathic character disorder or as subtypes wichin the psychopathic group. For exaxpie, using the structured interview of the Schedule for Affective Disorders and Schizophrenia-Lifetime Versior, ISADS) and the Research Dagraostic Crxeria (RDC), Rmmsa\~i!k, Weissman, Kleber. and Wilber (I982) found that the most common diagnoses in opiace addicc were major depressive disorders, aicoholisrn, and antisocial personslity. They aiso found rhat the prevalence of chmnic minor mood and anxiety disorders ir, opiate addicts was elevated in corr.pariscn to a community sample. En contrast, however, the prevaience of schizophrenia and mania was very low and did not exceeci those for the general population. The clinical eva'iuation of another sample of opiate addicts using the "KDC (RounsaviHe et a!., i 982) found rhat 17% of the opiate addicts had an episode of major depression and 60% had at ieast miidly elevated depressive symp:oms. Craig { 1979a, 1979b) alsc noted consistent reports of elevated Mh4PI scores on 'both the Psychopathic Deviate (Pd) and Depressive (Dl scales of the h.*LMPIfor opiate addicts across a wide range of ages, socioeconomic. ievels, and ~ ~ l t u groups. rd These findings are consistent w:th formulations {BIart & Shichman, 1981) tha:: consider sociopathic character disorder and depression as cioseiy interrelated and much of the andsociai behavior of many sociopaths as masked expressions (lesse, 1374) of severe underlying depression. Other scmdies using the M W I to evaluate opiate addicts have also reported significant elevations a n A4MPE scales other char, Psychopathic Deviate and Depression, ".c!uding Maria (Ma), Hysteria (Fly), Schizophrenia (Sc), i-Iypochondriasis "pseudo-psvchopa~hic~'" de~:);ing underlying wishes for passivitv and dependency; {D) an Infantile "oral" rype of person who seeks :o be cared fcr and nurtured (Gerard & Kornersky. 1955);rc! dominated bv a need far an irresistibie ,, imrnecllate relief i r o n nonpieasure (Silverman & S i l ~ e r r n a n i?liC!: ~ or (d) defective in ego development an6 unabie to deal \\-it6 ps~cho'logicaiconfijc:~ and the demands of external reality. The : \ - p i 4 ad& is ;onsidered as emotionai1,y imnarare, with a s:rong :endencp :o act on primlt~veimp:rises and dri1.e~because of a iack oi eiiective and srabie defenses. There are s e x u s lapses ir? emotional control and reality resting. The addict is also viewed as ~ i a g u e dbv inrense sexuai conflicts? and the drug serves tc; inhibi: r,atxal sessai and aggressive srrivings (Zimrnering, Tallan, Safrir?, & Wortis, i952). kn sum, there may be more chan one type of opiare addic: ir: addicior, :o the more usnai "socioparhic type," inc!:iding some individuais wir h prinariiv depiessive rather than a n t s o a a l symptoms and ochers with psychotic feature: and'or infantik character traits. -4 review of iynsmic theories and research ori opiare addmion (Slatt, StcDoria'id, Sugarman, & W'~':!ber, !95+ snggest: rhat :hex may in fact. b e rhree
different rype5 of opiate abssera. O n e group of opiate add:c:s.
is primarily ar a narcissisric h e 1 of organization--a hordedine i e r d oi pathoiogv between neu-osis anO psychosis (Glover, i9321, with ?&ominan: paranoid {Meerlo, i952; Radc, 1955:: Rosenfeid, i3@: Sirnmei, I W ! and.'o; depressive jA:lams, 197s: Radn, l925:RosenMd, 1RtC! features. For thk gro::;?, opiate ablrse is viewed as an atremp: to establish conro! m7er m.em-)..e!,m:ng affects, such as intense rage (Ciark, 1913;Ki.,antzian. i97+, 192;Khantzian & .< Treece, 1 W ; Sin;mel, 1?+8,!, and possiblv as a defense against a potei;r;zr psychosis ( A d a m , 1O78: Feiix, 1944; Khantzian, !%8; Khantzian & Treece, i971; Khantzian. hlack, G;. Shatzberg, i 5 4 ; Wleher ts Kaplan, 1553:.A s e c o d subgroup is :hought to use opiates as an at:empt to achieve a rimi it it re state of' symbiotic fi.~sion to compensate for a failure ro interzailx a rriahie caring saternal relationship eirher because of severe inl'ancile depri~atlcnor ni-erinduIgence (Crowley, 1933: Hartmann, 1963; Khant:im et z!.,, 1 j T - i ; Krvsiai & R a s h , 1370; h~fcerlo,1352; Raiio, 1354;Simmel, 1945;YorLe, 1310). Fzr thiz . . group, opiate addiction seems :c creace an ilhsior; of narcisslw; cmnipoccnce rhat cornpensayes for feeling vulnerable and insecure iiidarns, 19y8;Gossop. ir ;6:KIeissner, 1980; Wurmser, i974).In a third szSgroup, opiare addxtion seems rc serve as a defense against profoundiv pa:nful, neuroric feelings of lnadequacv, guii:, shame, wor:hiessness, and hopeiessness that are t h e result of 3
q-
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the internalization of harsh judgmental parentai figures (Blatt, Berman: et al., -" ~$34:Harrmann, 1'369: Meerio, 1 9 2 : Mirin, Meyer, & McNarnee, 19'76; Schmideiberg, 1930; Weissrnan, Slobeta, & Prusof;', 1976; Woody, C'Brien: ti Rickeis, 1975: Wurmser, 1974). Addiction seems :L? be z replacement for mature inrerperscnai relationships and a&!t sexualiti; (Fenichel, 1934; Rado, 1926; Sheppard et a]., 1972; Yorkr, 1973) and z defense against experiences of intense acxiery, depression: anci aggresslor. iAcIarns? 1978; Felix, i944; Glover, 1932; Khantziar,, ;99% Krvs:al& Raskin, I9?13L;Simrnel, 1948)or intolerabie scmatk k Kaplan, 1969: znriior psychic pain (Khantziar;. & T'reece, i979; Wieder t Wi'lKer & Rasor, 1953). Thus, from a ncnber oi $ifferefit rhearet:cai perspectives, the iiterarsre suggest chat, in addhorm to tRe modal sociopad~icpersonalisp with depressive {e'earures,there appears to be at Ieast twc: additionai types of individuals who are potentiatBy idnerzkde to opiate aJdxt;on. The study discussed herein is a s empirical zrternp: to ideatifif differerenr subrvpes of psychopathology w:thlx an overail group of apia::e addicts. We (Bistr, Sermar:, er al., 19841 gathered an extensive series of psychoiogicai rests on a sample of opiate addicts, inchcling the Rorschach, the Be!;& Ego Functions Inrerview, 2nd the toevinger Sentence C=or;l~ietio~ Test. Eased on an empirical. rather :ban F: clinical, analysis of this data, we conclsded that the primary dif5cuI:ies of rhe tnrai group cri opiate addicts were rheir inabiky to esrabiish and maictain mezningfid interpersorial relationships and to modulate affects eifectivei;.. The srucly $iscussed here, using sub msltivariate analyses of rhese psvchologicai rest data, idehrifies ~d.,zres the simiiarities and groups within :his sampie of opiate addicts 2nd e,--'*, differences of these subgroups with nard and cIinic~Ireference groups.
METHOD Subjects Several differem szrnples were ased in the study: Opiate addicts were ased for the clmter zna!~sisproper, and other samples were used ro estah!ish comparison gronps m test the validity of the empiricaHy derived clusters c?rl pia are addicts within the primary sample. The chzracteristics of the various sample:. are described next.
The q%izfe sample. Suhjects !or this scudg were 53 opiate-.addicted indivici~ a f (41 s me3 and 12 women) seeking treatment at a drug dependence snit that serves an urinar! and suburban popdatior: of a?proxirna:elv %.X,OOC people, The unir was the point of encry for several treatment modaiities offered to ciients with problems of $rug, but no: alcohot, ahuse, The addicts were screened in an idtiaj inrerview tr: gather clinical and demographic dzta and underwent a u i n e
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test for the presence of opiates. The screening Incerview was condiicted bs a> experienced intewietver who assessed rhe patients for psyciiiatric disorders using the IiDC and SAD5 as a d as che Maudsley Nruroticism Scaie and 2 Saciai Adjustment Scale (SAS; \X.'e:ssma~: &. Botiweli, 1E6).Therapeutic recommezdations and referrals were made at the end of this screer,ing interview. SaSlectc were then asked to parricipate in further evaiuation icr -.vhdzhe-5 w o - ~ i dbe paid $22,. This second session usualiy took piace within :to 3 days afxr the screening interview and alwars prior to the start of treatment. Fifty-rhree subjects over a ?$-month period agreed to par:icipare. These ssbjecrc mere part of a iarger stadc designd t o assess psychopathologs in oyiatt: addim a p ~ l y i n g " fzr xreazmen:. The sample was p r e d ~ m i n n n t iyoung ~ (31 = is.> yearsi, male , . (7@01, single i,6Oo&), White i60"dt wit;> a high sckiool edasation cr less i ;.'.'bb'! from lower socjoecononic iSES) levels (hf = , SEZ en the Hol'lingsheacf-Redlich Scale). Ail sublects had a history of reguixr use of :iiici: opiates (or ar least a period of 1 year, the presence of tolerance ;:.e., need fm increasing doses ta ob:ain desired effects) or wi:h&rawal srmproxs when there was aE arremp: to reiiuce dosage or d i s c o s t i ~ u euie, and a x i n e i i r : : i i pos:rir7c signs of oriate xse. A1i 53 silbjects were given the Loevinger S r x e n c e Ccimpieriori i esr! the De!iek Ego Funcrlons inreriiew, the Rorschach, an6 the Voi-ahlilary,, Sirnihities, BIock Design, and Pictare Arrangement s:;Srests of the 'Xechsier A d d t keliigence Test \W:.4IS>.I c w a r d agaiilst ir;te:\.iewer and rater bias, each . , procedsre was admhscered by a diiieren: staff person and each a.3: scored b\- a &&rent p ~ i of r raters. Inrerviewers and raters a"ercawzre &a: :he s.:bjrcr: were substance abusers, bur unaware of an>-hypotheses or plans ~ O 6ara K a~ai~rses.
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Compszrisorl samples. Thc same assessmen: procechres were also administered
t.5
29 apriicants t o a Comprehensive Employment and Training Act
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icti A) ~ r o g r a m marched , as a g r o q uxth c n e opiate aildiirs for sex! racr, educational ievei. and SES.They; were c x i average 24.9 year. of age, had 11 vears 3i education, and were rated 4.3 in SES based or: rhe Hol'ringshead-Rediic!:
Scaie. Two :h:rcis oitke CETA sample were men, a n J rwe :hir& \sere Caucasian. T h e CETApparticipants were similar in sociai c:rcums:ancec to m a w of rhe addicts {i.e., chronically unemployed and irnpo:*erishedk bs: lacked any history o; arug or aicohoi abuse, neurologic d i ~ t u r h a n c ea~n J anv :ndlcztions ciajcoimi 2nd iilici! psy~hcraciivesubstances ic a urine sample at time of tesrlnp. In addition, data were avadable from orher sources for some ei the pswho, logical test measures used so the opiate addicts couici he compered with p e v i o u s i ~ established n o m s for norrr,a'rs and for neurotic, borderiine, and psYchotii pariects nn the various assessment procedures. In additior, ru piibiishd norms a\!ailable for assessmenr oi ego de\.eiopmenr on the L.se;lmger Sentence Cornpletion l e s r and in the fieliak Ego Fux:ion Inwriieu , R ~ r s c h a c hprnrocois were obcainei-I from 24 psa,chia:ric pariencs hosplcaiized in a long-terx intensive. r
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but open, inpatient treatment faciirtv. These patlents were somewhat younger (M = 23.94 years1 than the opiate and CETA samples, more :r,reliigent (A4 i Q = I I?), and 53x1a more privileged social class.
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Assessment Procedures Loevirlger Sentence Cenrpletion Test.. O p i x e and CETh sufc,jects were adninistered rhe 36 sentence scerns of the Loevinger Sentence Completion Tesr (Loevinger & Re$rnore, 197C; Loevinger & Wessler, 1973). Based on their respcnses to these stems, subjeccs received scores c n individual irems that mere ordered stages of ego sarnmed ra vield a total raw scorc. Utiiizing hier~rchicell~ developrner,:, Loevinger (9996)defined 13 stage5 of egg dweioprnent ranging frorr, presociai and imptilsivc, undifferentiated, primitive stages to states of autonomy and inreration. Higher levels of egc developmen; invo!.i-e a more differentia::eci perreprior, of self, the sociai worid? and of one's th=ights 2nd {eelings about others. Interrater reliabiiity be~weentnTcmdepeniient judges tor rhe scoring of the Loevinger ego stages or: 20 prom~eiswas r. = 39%a findlrzg consistenr wich prior reports. Compsrism data for rbc Loa~ingerSentence Cornpietics, Test was not available for ciinicai samples, but Ho!t (19821presented norms far a normal sanrrpje of :zcncollege men and wornen wth whom he opiate addicts: ca3 'sc compared Betlnk Ego Ftircctiorz ktmiew. The B e k k structured c h i d interview is designed rc. assess e g fijnccioninp ~ in 13 areas: reaiit\: :sting, judgment, sense of reaiir~,reguiation arrd con~roIof drives, affect and impuise conrrd, object relations, thought process, capacity for adapdve regression (Arise), stimdus barrier, astonomoos fiincrioning! synthetic integradiie functiming, and mas. terv and comperencc (Beliak, Hiirvich, Ex Gedinan, 1993). Reliabiiiry estimates of the tu.~ independem raters on each of the Ego Funcdcr, scaks far !5 pro:ocols ranged from .6C to .37?with an arerage ~oefficientel' reliabiiity of .78, Data for conparison of the ego hncticns of the q i a t e addicts enci :he CETA subjecrs were drawn from che norms repor~edby BeIIak ct a!. 119'73) for normal, neurotic, and schizophrenic groaps. 7
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Rorschach Test. The opiate sample, CETA sample: and the psychiatric inpatient sampie were also administered the Rorsc.hact? in a srandard Rapapcrr adminstratiorr (Aliison, Elart, 6r Zirnet, 1968: Rapaporr. Gili, 5r Schafer, 1945j. X prior factor anaiysis (Eilart & Berman, 1985)of I8 Rorscjlach variables, on which rhere have been exter,sive vslldatioz snci research and which seem cIinica!ly reievant to opiate addiction, idectifiec? seven crthogonsl facrors derived from a varirnax rocation. Seven vsriabies were selected :hat best represented each of these seven facrors, These inc!uded: PTolt's (1962, 1966) measures of deie'ense demand and defense e%cti.a.eness, two measures of the q.cialitv of the human figclre seen on the Rorschach. which measrrre the capac::v
OPIATE PERSONALITk' T?PES
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to become mvoived :n appropaate rnterpersonaI relatranshlps tOk r and the tendencb to become ~molvedIn autlstnc fantasies rather than reslistlc relatron, Biart. Schmek. Sr s h p (OK-) ( Blatt, Brennels, Schlmek, & G i ~ k 1976, Brenn~s,i98?!; the weighted experience halance, vrh~ch~ndrca:es a preference Brown, i 13771, an for an ~deat~onal or an affecwe mode of experience (Smger & estimate of thaughc dlsorder on the Rorschach irjlatr & Berman. 1954: Bhtr & R:tzler. 19741, and the percentage of accurately perce~vedresponses IF+ Bk, n h c h :ndlcates the adequacv of reallrv testmg &xch.n S;. Larson, :9Y";.All these \,anaides u ere scored by the judges at levels ofrei:ab:Im greater than 65 Several of these Rorschach variables are summztmn scores that reflect the f~equencyw t h wi-,rcG. a partrcda: type of response occur: In a Rorschach protncoi. Ir: order to conrrol scaastlca!iy for overall respcnse prodactLvnvo - the ~ Rorschach, these summarlon scores were corrected bv covmance tor totd i Cohen, :955: response productiv:q {Cohen t The opiate and CETA sarnpie were also given iou: s-btesrs of the 'GrAIS. Vocab;iarv, Simiaritles. Block Deslgn, and Picture hrrangemenr. Est:ma:es of s verbal, performance, and total IQ were der~vec!from rhese sribcests.
Data Analysis C!uster anahses were conducted or: rhe data obta~nedfrom the 53 opareaddicted subjects in order ro identdy poss:E.ie subgroups o i o a m e addicts. Conceprualiv, duster anaivsis seeks to separate a heterogeneous group of md!\riduals Into subgroups whose members are more s~rndarto each , iOS, 462. Feniche!. 0. (1934). :%tline of c h c a i p::vchoana!ys:s. New York: Norton. Gerard: 3. L.,6r Kornetskv, C . (19551. Arioiescent opiate addictioil: A stud): of cc>nt:ol and a d d m subjects. h,schiutric &cr:er.l:v, 25. $57-486. Glover, E. :1?32i. O n the etioiogv 3f ,icing addic~ion.In E. Glover ((Ed,j. Or; : i ; ~curiy developten: of the mind (pp is?-?i 5:. Netv York: Inrernational Universities Press. Gossop, M. ;19761 Drug depexience and self-esreerra. International joumai of .Addiction, 1:: 742-753. Fiaertzen. C . A.. & %oaks, N-T . (1969). Changes iz personality and subjective experience
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assoiia~edwith chronic adrnin~strationand withdrawai oi opiates .;oumi oj X m n w nnE \'lm;d !heuse, 148, 6%-614. Hartmann, D, (i960). A study of drug-taking adoiescents, i ' s ~ c h r a i ~ : l cS:uci? or [he C;lrid. Z i , 354-398. Hill, H.E., Haerrzen, C. A., & Glaser. ii. (1963:. Persona!ity charac:er~stic: of narcotic adiic:s as indicated by the Mh4Pi. .kumal of Generic Fpcholo~:62. 127-135. Holt. R. 3.. (1962). Manw.' !ofor the smrinp 9: pim? prucrsi mcniiestarm tr, jio~~iju-h reskpxsex (5th ed.j. New York: Research Center for Mentai Health. Holt, R. R. (1966). Measuring libidinai and aggressive motive; and their controis :?v means of the Rorschach rest. In C.Levine (Ed.), . V e b m h s?mps~un;on mammon (pp. I33-ZC1t. Linroin University of Nebraska Press. Holt. R. R. (ia77i. A method for assessing primary manifestat~onsand :heir conrroi or: Rorschach res?znses. in M. Rickers-Ovsiankina (Ed.;, R o ~ ~ i k psydhdop -h i p p 3 : 5 - 4 3 ; . P i u n t i n p s ! XY. Krieger. Kandel. E.i Lon~:dnu.: reseurck on dricg abaue. En>incui findings ianZrne:h&logt& i.:surs. N e w York, Hemisphere Publishing Co. Ktiantzian. E. J. i1994). Opiate addict~or.:A critique oi theory and some implications for rrearmen:. American Jouma! i$ P~~chorhm~py. 28, 59-?il. Khanman, E. j. (!978). The ego, :he self. and opiate ad3ic:ion: Theoretics! and treamen: conside;ation. in:m:iorai Review of ?s?cbamiys;s. 5. 139- L?ri n. Khanrzian, E. 3.. Mack. J. F.. 6i. Stiatzberg, A. F. (1974). Heroir! dse in an at:enpt t r a p e : ~!inicai observations. .4mmmr; jourruri ,?i Psychuqi, GI, !hi?-164. Khan:r;an. E. !., & Treece, C. j. ( l W 3 Heroin addiction. The diagnostic 2iienma fo: ps~chiacr:.. in R. 1,'Plckens . & L. L. Zeston (Eds.:, Psychiatrt: fuao75 :n t x g S m e (p?. Zi-+5:,N e w York: Grune G; Stratton. Knig'r..:, E. G., Sr Prout. C. T. ;1?51i. A study o i resuks :rr hospital treament of $rug addimons. .4me~icm:lourmi oj ?s?chiact~.,!38. 333-308. Korchin. S. J., & Larson. D. G. 1i993. Forrc perception and ego $~nction!n~. 1- ?A I;::ke:s. C?\.siankina (Ed.), l i m s c h i ~ hprychoiop (pp. iF--:87). Hun:!ng:iin.
N V : Krlcper.
Krysral, 3..6i Raskin, I-i. A. 119701. Drug dependence apex? .+ego ,6m~!iofi..Demi:: Wayne k a t e University Press. iesse. S r 1374). hksited depcsstor.. New York: Aronson. Loevinger, 1. (2976. Ego aeueiopmenr. San Francisco: Jossev-Bas. Loewnger: S.. &.Redmore, C. ( 1 9911).Meuswing ego ciec,eio.pmen: il'o;. 1:. San Franascc: jossev-Rass. Loevinger, I., & Wessier, R. ii97Si. Mrcrruing ego cievelofrmm: !Yol. 21. San Francisis. !.xsey-Bass. h.lcL?!lan. A. T., Woodv. C.E.. & O'Brien, C. P. (:97?). Deveiopment oipsychlatx il!ness :n d x g abusers: Possible roie of drug preference. Neu. E ~ g l a dl o u ~ mof l ?.led:::w, 3:s. il. 12-13!!. Meerio, 1. A. M (1952:. Artif~ciaiecstacg: A study of prvchasomatic aspezs d jrug addlctlol-.. !oumd 0:' Newow und Menrai Dmme. 1 !5, 246-266. h4e:ssner. W.W.i19803. Addiction and paranoid process: F~vchoanalvri~ yrspem5:es. inrr*;a:imxli jouna! of Frvihounalvtii ?s);chnr,iprapj. 8:273-3 13. Mirin, S. M., h.leyer, R. E., 5, h4cNarnee. H.E.(1976). Psychopa:hoioy: and rncd during heroin use. Archiues qj Gens& Psychmn;, 33. 1533-1508. Patton? S., Kessier, Ii.,& Kandel, 0. ;1977). Depressive mocd and aclolesl-enr illicir drug use: .4 iongitudinai anaivsis. .Toumai I$ Generic P:ybio~, 2:. 26;-253. kado, 5.(1926.The ps+c effects of intoxicants: .4n attempt to eyoive a ?sv;hortnaivtii :hmn o l morbid cravings. 1n:ena:ionui Jatrrtui oi ?s?cho-Awiysis, y. 7%-?1:., Radi:, . (1Q57).Xarcotic bandage: A general theory ofthe dependence on narcow drugs. .*,rnexo~. l o u m I o:i Ps)i;liatp, 114, 165-17;. kapaporc, D.. Gill, M. M.. & Sitiafer, R.
Journal of Personality Assessment Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/hjpa20
Differentiation of Personality Types Among Opiate Addicts Sidney J. Blatt & William H. Berman Published online: 22 Jun 2011.
To cite this article: Sidney J. Blatt & William H. Berman (1990) Differentiation of Personality Types Among Opiate Addicts, Journal of Personality Assessment, 54:1-2, 87-104y To link to this article: http://dx.doi.org/10.1080/00223891.1990.9673977
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JOL%LVAL OF PERSONALIT'Y ASSESSMENT, I990 -%(I & 2). 87184 Copyright c I%, Lawrence Erlbaum Associates, I x .
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Differentiation of Personality Types Among Opiate Addicts
A wde range of studies indicate :hat although sociopthic characteris:ics are predominant in opmte addiction. de?ress~ve and psvchotic fearsres are aiso frequently observed. T o test the hyporhesis rha: there are rea!iy three n.;Ses of individuals whc become addicted to opiates {rather t;?an a single, predominant personaiiry q l e ) . fiftv-three opiate addircs were @,en the Loevinger Sencence Comple:ion Test, the Beiiak Ego Funcaons Interview. and :he Rorschach. VariAles derived from these three procedures were szbmtteci rc cl~ste: 2nd discriminant knc:inn ana!yses. Three groups or' addicts were ide:~tified-:hose with impaired interpersonal relationships and affecrlve Labihcv rj:%o:, those p~iaariiycharacter:ied by choughr disorder and impaired ego fiinctioning (X%), and 8 group with diminished ideational and verbai acrivitr 128%). Cozipanson of the assessment of these :hree groups wirh inciependenrlv defined normai, neurotic, and schizophrenic samples provided support fm chree opia:eaddicted personality tvpes, each respectiveiv characterized as character disordered, borderline psycho:ic, and depressed. A!though there seems to be a predominance . . of character-dlsorderod individuais w h o hecome addicted to op:zres, :he data indicate sevcral additional r p e s oC nptace addxts w:& different s p e c of pyihopathology who maT;require different ay?p:oaches tc 3anagerneo: and treacnent.
Opiate addicts traditionally have been viewed as a relative'lv hcmogeneous population, and a great deal ai research has been Jevo:ed to the idendication of psychopathology characteristic of the ~ ~ p i caddict. al Earlier ciinicai 2nd ernpirkai research has emphasized the more regressive and pathoiogica! dimerrsions of the typical opiate addicr ipsychotic, borcier'rine, or infantik features). h h r e recent research, however, has found that the typical opate addict is more within :he severely nesrot-ic or character-disordered rsnge with pervasii~ecii5icultg in
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ELATT AND BEIFMAN
familr and social relations, without evidence of psychotic or organic disturbance (e.g., Blatt, Bernan, et al., 1984; McLelian: Woody, & O'Brien, l97Fj. Many studies from d:fferen: conceptual approaches ie.g., errrpirical, descriprive psychiatric, and psychodynamic), rasing different methodological approaches (e.g., Mh,'iPI, cllnicai interview, and the Rorschach? report that there may be more than one type of addict, either in addition to the modal sociopathic or psychopathic character disorder or as subtypes wichin the psychopathic group. For exaxpie, using the structured interview of the Schedule for Affective Disorders and Schizophrenia-Lifetime Versior, ISADS) and the Research Dagraostic Crxeria (RDC), Rmmsa\~i!k, Weissman, Kleber. and Wilber (I982) found that the most common diagnoses in opiace addicc were major depressive disorders, aicoholisrn, and antisocial personslity. They aiso found rhat the prevalence of chmnic minor mood and anxiety disorders ir, opiate addicts was elevated in corr.pariscn to a community sample. En contrast, however, the prevaience of schizophrenia and mania was very low and did not exceeci those for the general population. The clinical eva'iuation of another sample of opiate addicts using the "KDC (RounsaviHe et a!., i 982) found rhat 17% of the opiate addicts had an episode of major depression and 60% had at ieast miidly elevated depressive symp:oms. Craig { 1979a, 1979b) alsc noted consistent reports of elevated Mh4PI scores on 'both the Psychopathic Deviate (Pd) and Depressive (Dl scales of the h.*LMPIfor opiate addicts across a wide range of ages, socioeconomic. ievels, and ~ ~ l t u groups. rd These findings are consistent w:th formulations {BIart & Shichman, 1981) tha:: consider sociopathic character disorder and depression as cioseiy interrelated and much of the andsociai behavior of many sociopaths as masked expressions (lesse, 1374) of severe underlying depression. Other scmdies using the M W I to evaluate opiate addicts have also reported significant elevations a n A4MPE scales other char, Psychopathic Deviate and Depression, ".c!uding Maria (Ma), Hysteria (Fly), Schizophrenia (Sc), i-Iypochondriasis "pseudo-psvchopa~hic~'" de~:);ing underlying wishes for passivitv and dependency; {D) an Infantile "oral" rype of person who seeks :o be cared fcr and nurtured (Gerard & Kornersky. 1955);rc! dominated bv a need far an irresistibie ,, imrnecllate relief i r o n nonpieasure (Silverman & S i l ~ e r r n a n i?liC!: ~ or (d) defective in ego development an6 unabie to deal \\-it6 ps~cho'logicaiconfijc:~ and the demands of external reality. The : \ - p i 4 ad& is ;onsidered as emotionai1,y imnarare, with a s:rong :endencp :o act on primlt~veimp:rises and dri1.e~because of a iack oi eiiective and srabie defenses. There are s e x u s lapses ir? emotional control and reality resting. The addict is also viewed as ~ i a g u e dbv inrense sexuai conflicts? and the drug serves tc; inhibi: r,atxal sessai and aggressive srrivings (Zimrnering, Tallan, Safrir?, & Wortis, i952). kn sum, there may be more chan one type of opiare addic: ir: addicior, :o the more usnai "socioparhic type," inc!:iding some individuais wir h prinariiv depiessive rather than a n t s o a a l symptoms and ochers with psychotic feature: and'or infantik character traits. -4 review of iynsmic theories and research ori opiare addmion (Slatt, StcDoria'id, Sugarman, & W'~':!ber, !95+ snggest: rhat :hex may in fact. b e rhree
different rype5 of opiate abssera. O n e group of opiate add:c:s.
is primarily ar a narcissisric h e 1 of organization--a hordedine i e r d oi pathoiogv between neu-osis anO psychosis (Glover, i9321, with ?&ominan: paranoid {Meerlo, i952; Radc, 1955:: Rosenfeid, i3@: Sirnmei, I W ! and.'o; depressive jA:lams, 197s: Radn, l925:RosenMd, 1RtC! features. For thk gro::;?, opiate ablrse is viewed as an atremp: to establish conro! m7er m.em-)..e!,m:ng affects, such as intense rage (Ciark, 1913;Ki.,antzian. i97+, 192;Khantzian & .< Treece, 1 W ; Sin;mel, 1?+8,!, and possiblv as a defense against a potei;r;zr psychosis ( A d a m , 1O78: Feiix, 1944; Khantzian, !%8; Khantzian & Treece, i971; Khantzian. hlack, G;. Shatzberg, i 5 4 ; Wleher ts Kaplan, 1553:.A s e c o d subgroup is :hought to use opiates as an at:empt to achieve a rimi it it re state of' symbiotic fi.~sion to compensate for a failure ro interzailx a rriahie caring saternal relationship eirher because of severe inl'ancile depri~atlcnor ni-erinduIgence (Crowley, 1933: Hartmann, 1963; Khant:im et z!.,, 1 j T - i ; Krvsiai & R a s h , 1370; h~fcerlo,1352; Raiio, 1354;Simmel, 1945;YorLe, 1310). Fzr thiz . . group, opiate addiction seems :c creace an ilhsior; of narcisslw; cmnipoccnce rhat cornpensayes for feeling vulnerable and insecure iiidarns, 19y8;Gossop. ir ;6:KIeissner, 1980; Wurmser, i974).In a third szSgroup, opiare addxtion seems rc serve as a defense against profoundiv pa:nful, neuroric feelings of lnadequacv, guii:, shame, wor:hiessness, and hopeiessness that are t h e result of 3
q-
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the internalization of harsh judgmental parentai figures (Blatt, Berman: et al., -" ~$34:Harrmann, 1'369: Meerio, 1 9 2 : Mirin, Meyer, & McNarnee, 19'76; Schmideiberg, 1930; Weissrnan, Slobeta, & Prusof;', 1976; Woody, C'Brien: ti Rickeis, 1975: Wurmser, 1974). Addiction seems :L? be z replacement for mature inrerperscnai relationships and a&!t sexualiti; (Fenichel, 1934; Rado, 1926; Sheppard et a]., 1972; Yorkr, 1973) and z defense against experiences of intense acxiery, depression: anci aggresslor. iAcIarns? 1978; Felix, i944; Glover, 1932; Khantziar,, ;99% Krvs:al& Raskin, I9?13L;Simrnel, 1948)or intolerabie scmatk k Kaplan, 1969: znriior psychic pain (Khantziar;. & T'reece, i979; Wieder t Wi'lKer & Rasor, 1953). Thus, from a ncnber oi $ifferefit rhearet:cai perspectives, the iiterarsre suggest chat, in addhorm to tRe modal sociopad~icpersonalisp with depressive {e'earures,there appears to be at Ieast twc: additionai types of individuals who are potentiatBy idnerzkde to opiate aJdxt;on. The study discussed herein is a s empirical zrternp: to ideatifif differerenr subrvpes of psychopathology w:thlx an overail group of apia::e addicts. We (Bistr, Sermar:, er al., 19841 gathered an extensive series of psychoiogicai rests on a sample of opiate addicts, inchcling the Rorschach, the Be!;& Ego Functions Inrerview, 2nd the toevinger Sentence C=or;l~ietio~ Test. Eased on an empirical. rather :ban F: clinical, analysis of this data, we conclsded that the primary dif5cuI:ies of rhe tnrai group cri opiate addicts were rheir inabiky to esrabiish and maictain mezningfid interpersorial relationships and to modulate affects eifectivei;.. The srucly $iscussed here, using sub msltivariate analyses of rhese psvchologicai rest data, idehrifies ~d.,zres the simiiarities and groups within :his sampie of opiate addicts 2nd e,--'*, differences of these subgroups with nard and cIinic~Ireference groups.
METHOD Subjects Several differem szrnples were ased in the study: Opiate addicts were ased for the clmter zna!~sisproper, and other samples were used ro estah!ish comparison gronps m test the validity of the empiricaHy derived clusters c?rl pia are addicts within the primary sample. The chzracteristics of the various sample:. are described next.
The q%izfe sample. Suhjects !or this scudg were 53 opiate-.addicted indivici~ a f (41 s me3 and 12 women) seeking treatment at a drug dependence snit that serves an urinar! and suburban popdatior: of a?proxirna:elv %.X,OOC people, The unir was the point of encry for several treatment modaiities offered to ciients with problems of $rug, but no: alcohot, ahuse, The addicts were screened in an idtiaj inrerview tr: gather clinical and demographic dzta and underwent a u i n e
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test for the presence of opiates. The screening Incerview was condiicted bs a> experienced intewietver who assessed rhe patients for psyciiiatric disorders using the IiDC and SAD5 as a d as che Maudsley Nruroticism Scaie and 2 Saciai Adjustment Scale (SAS; \X.'e:ssma~: &. Botiweli, 1E6).Therapeutic recommezdations and referrals were made at the end of this screer,ing interview. SaSlectc were then asked to parricipate in further evaiuation icr -.vhdzhe-5 w o - ~ i dbe paid $22,. This second session usualiy took piace within :to 3 days afxr the screening interview and alwars prior to the start of treatment. Fifty-rhree subjects over a ?$-month period agreed to par:icipare. These ssbjecrc mere part of a iarger stadc designd t o assess psychopathologs in oyiatt: addim a p ~ l y i n g " fzr xreazmen:. The sample was p r e d ~ m i n n n t iyoung ~ (31 = is.> yearsi, male , . (7@01, single i,6Oo&), White i60"dt wit;> a high sckiool edasation cr less i ;.'.'bb'! from lower socjoecononic iSES) levels (hf = , SEZ en the Hol'lingsheacf-Redlich Scale). Ail sublects had a history of reguixr use of :iiici: opiates (or ar least a period of 1 year, the presence of tolerance ;:.e., need fm increasing doses ta ob:ain desired effects) or wi:h&rawal srmproxs when there was aE arremp: to reiiuce dosage or d i s c o s t i ~ u euie, and a x i n e i i r : : i i pos:rir7c signs of oriate xse. A1i 53 silbjects were given the Loevinger S r x e n c e Ccimpieriori i esr! the De!iek Ego Funcrlons inreriiew, the Rorschach, an6 the Voi-ahlilary,, Sirnihities, BIock Design, and Pictare Arrangement s:;Srests of the 'Xechsier A d d t keliigence Test \W:.4IS>.I c w a r d agaiilst ir;te:\.iewer and rater bias, each . , procedsre was admhscered by a diiieren: staff person and each a.3: scored b\- a &&rent p ~ i of r raters. Inrerviewers and raters a"ercawzre &a: :he s.:bjrcr: were substance abusers, bur unaware of an>-hypotheses or plans ~ O 6ara K a~ai~rses.
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Compszrisorl samples. Thc same assessmen: procechres were also administered
t.5
29 apriicants t o a Comprehensive Employment and Training Act
n--
icti A) ~ r o g r a m marched , as a g r o q uxth c n e opiate aildiirs for sex! racr, educational ievei. and SES.They; were c x i average 24.9 year. of age, had 11 vears 3i education, and were rated 4.3 in SES based or: rhe Hol'ringshead-Rediic!:
Scaie. Two :h:rcis oitke CETA sample were men, a n J rwe :hir& \sere Caucasian. T h e CETApparticipants were similar in sociai c:rcums:ancec to m a w of rhe addicts {i.e., chronically unemployed and irnpo:*erishedk bs: lacked any history o; arug or aicohoi abuse, neurologic d i ~ t u r h a n c ea~n J anv :ndlcztions ciajcoimi 2nd iilici! psy~hcraciivesubstances ic a urine sample at time of tesrlnp. In addition, data were avadable from orher sources for some ei the pswho, logical test measures used so the opiate addicts couici he compered with p e v i o u s i ~ established n o m s for norrr,a'rs and for neurotic, borderiine, and psYchotii pariects nn the various assessment procedures. In additior, ru piibiishd norms a\!ailable for assessmenr oi ego de\.eiopmenr on the L.se;lmger Sentence Cornpletion l e s r and in the fieliak Ego Fux:ion Inwriieu , R ~ r s c h a c hprnrocois were obcainei-I from 24 psa,chia:ric pariencs hosplcaiized in a long-terx intensive. r
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but open, inpatient treatment faciirtv. These patlents were somewhat younger (M = 23.94 years1 than the opiate and CETA samples, more :r,reliigent (A4 i Q = I I?), and 53x1a more privileged social class.
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Assessment Procedures Loevirlger Sentence Cenrpletion Test.. O p i x e and CETh sufc,jects were adninistered rhe 36 sentence scerns of the Loevinger Sentence Completion Tesr (Loevinger & Re$rnore, 197C; Loevinger & Wessler, 1973). Based on their respcnses to these stems, subjeccs received scores c n individual irems that mere ordered stages of ego sarnmed ra vield a total raw scorc. Utiiizing hier~rchicell~ developrner,:, Loevinger (9996)defined 13 stage5 of egg dweioprnent ranging frorr, presociai and imptilsivc, undifferentiated, primitive stages to states of autonomy and inreration. Higher levels of egc developmen; invo!.i-e a more differentia::eci perreprior, of self, the sociai worid? and of one's th=ights 2nd {eelings about others. Interrater reliabiiity be~weentnTcmdepeniient judges tor rhe scoring of the Loevinger ego stages or: 20 prom~eiswas r. = 39%a findlrzg consistenr wich prior reports. Compsrism data for rbc Loa~ingerSentence Cornpietics, Test was not available for ciinicai samples, but Ho!t (19821presented norms far a normal sanrrpje of :zcncollege men and wornen wth whom he opiate addicts: ca3 'sc compared Betlnk Ego Ftircctiorz ktmiew. The B e k k structured c h i d interview is designed rc. assess e g fijnccioninp ~ in 13 areas: reaiit\: :sting, judgment, sense of reaiir~,reguiation arrd con~roIof drives, affect and impuise conrrd, object relations, thought process, capacity for adapdve regression (Arise), stimdus barrier, astonomoos fiincrioning! synthetic integradiie functiming, and mas. terv and comperencc (Beliak, Hiirvich, Ex Gedinan, 1993). Reliabiiiry estimates of the tu.~ independem raters on each of the Ego Funcdcr, scaks far !5 pro:ocols ranged from .6C to .37?with an arerage ~oefficientel' reliabiiity of .78, Data for conparison of the ego hncticns of the q i a t e addicts enci :he CETA subjecrs were drawn from che norms repor~edby BeIIak ct a!. 119'73) for normal, neurotic, and schizophrenic groaps. 7
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Rorschach Test. The opiate sample, CETA sample: and the psychiatric inpatient sampie were also administered the Rorsc.hact? in a srandard Rapapcrr adminstratiorr (Aliison, Elart, 6r Zirnet, 1968: Rapaporr. Gili, 5r Schafer, 1945j. X prior factor anaiysis (Eilart & Berman, 1985)of I8 Rorscjlach variables, on which rhere have been exter,sive vslldatioz snci research and which seem cIinica!ly reievant to opiate addiction, idectifiec? seven crthogonsl facrors derived from a varirnax rocation. Seven vsriabies were selected :hat best represented each of these seven facrors, These inc!uded: PTolt's (1962, 1966) measures of deie'ense demand and defense e%cti.a.eness, two measures of the q.cialitv of the human figclre seen on the Rorschach. which measrrre the capac::v
OPIATE PERSONALITk' T?PES
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to become mvoived :n appropaate rnterpersonaI relatranshlps tOk r and the tendencb to become ~molvedIn autlstnc fantasies rather than reslistlc relatron, Biart. Schmek. Sr s h p (OK-) ( Blatt, Brennels, Schlmek, & G i ~ k 1976, Brenn~s,i98?!; the weighted experience halance, vrh~ch~ndrca:es a preference Brown, i 13771, an for an ~deat~onal or an affecwe mode of experience (Smger & estimate of thaughc dlsorder on the Rorschach irjlatr & Berman. 1954: Bhtr & R:tzler. 19741, and the percentage of accurately perce~vedresponses IF+ Bk, n h c h :ndlcates the adequacv of reallrv testmg &xch.n S;. Larson, :9Y";.All these \,anaides u ere scored by the judges at levels ofrei:ab:Im greater than 65 Several of these Rorschach variables are summztmn scores that reflect the f~equencyw t h wi-,rcG. a partrcda: type of response occur: In a Rorschach protncoi. Ir: order to conrrol scaastlca!iy for overall respcnse prodactLvnvo - the ~ Rorschach, these summarlon scores were corrected bv covmance tor totd i Cohen, :955: response productiv:q {Cohen t The opiate and CETA sarnpie were also given iou: s-btesrs of the 'GrAIS. Vocab;iarv, Simiaritles. Block Deslgn, and Picture hrrangemenr. Est:ma:es of s verbal, performance, and total IQ were der~vec!from rhese sribcests.
Data Analysis C!uster anahses were conducted or: rhe data obta~nedfrom the 53 opareaddicted subjects in order ro identdy poss:E.ie subgroups o i o a m e addicts. Conceprualiv, duster anaivsis seeks to separate a heterogeneous group of md!\riduals Into subgroups whose members are more s~rndarto each , iOS, 462. Feniche!. 0. (1934). :%tline of c h c a i p::vchoana!ys:s. New York: Norton. Gerard: 3. L.,6r Kornetskv, C . (19551. Arioiescent opiate addictioil: A stud): of cc>nt:ol and a d d m subjects. h,schiutric &cr:er.l:v, 25. $57-486. Glover, E. :1?32i. O n the etioiogv 3f ,icing addic~ion.In E. Glover ((Ed,j. Or; : i ; ~curiy developten: of the mind (pp is?-?i 5:. Netv York: Inrernational Universities Press. Gossop, M. ;19761 Drug depexience and self-esreerra. International joumai of .Addiction, 1:: 742-753. Fiaertzen. C . A.. & %oaks, N-T . (1969). Changes iz personality and subjective experience
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