0306-4603/92$5.00 + .OO
Addic.livPBphaviors. Vol. 11,~~. 159-166, 1992
Copyright 0 I992 Pergamon Press Ltd.
Printed in the USA. All rights reserved.
PERSONALITY CHARACI-ERISTICS OF COCAINE AND ALCOHOL ABUSERS: MORE ALIKE THAN DIFFERENT RONALD S. JOHNSON, JACK W. TOBIN, and TONY CELLUCCI Francis Marion College Abstract - Although there is extensive literature describing the characteristics of individuals entering treatment for alcoholism, few research reports are available describing the personality characteristics of individuals addicted to cocaine. Forty-four matched patient pairs, one member of each pair who abused cocaine and the other alcohol, were compared on the basis of their Minnesota Multiphasic Personality Inventory (MMPI) profiles. The subjects were matched on the basis ofage, sex, and race from a larger population enteringan inpatient addiction treatment center. Statistical analysis revealed more similarities than differences between the two groups, with the average profile type for both cocaine and alcohol abusers being 4-2. These results are discussed in the context of previous reports of psychopathology among cocaine abusers and personality theories of drug choice. The number of different code types within each substance abuse group is also reported and the concept of profile heterogeneity supported. Profile subtypes among cocaine patients are described clinically along with their implications for treatment.
INTRODUCTION
There is continuing interest in the personality characteristics of substance abusers entering treatment, much of this literature focusing on the Minnesota Multiphasic Personality Inventory (MMPI). Extensive data are available describing the MMPI characteristics of alcoholics, and this area of research has recently been reviewed by Graham and Strenger ( 1988). The most consistent MMPI finding among individuals who abuse alcohol is an elevation on scale 4, a mean 2-4/4-2 profile and not infrequent elevations on scales 7,8, and 9 (Graham & Strenger, 1988; Morey, Roberts, & Penk, 1987). Various multivariate and cluster analytic research strategies have been used to empirically define subtypes within this population (Morey, Skinner, & Blashfield, 1984; Svanum & Dallas, 198 1). In their review, Graham and Strenger (1988) describe six such profile types along with their associated characteristics; these profile types had been successfully replicated in several studies. A relatively smaller number of studies have been conducted using the MMPI with individuals who are dependent on cocaine (Dougherty & Lesswing, 1989; Helfrich, Crowley, Atkinson, & Post, 1982; Spotts & Shontz, 1983). Dougherty and Lesswing (1989) evaluated 100 cocaine patients during the second week of a 6-week inpatient program. Ninety percent were reported to have significantly elevated MMPI profiles, and 65 of these were characterized by high points on either scale 4 or 9. In an earlier clinical report, Helfrich et al. (1982) reported a 4-8-9-7 profile, while Spotts & Shontz This research project was partially funded by grant #FRA89-76 from the South Carolina Commission on Alcohol and Drug Abuse to Bruce Hall and Francis Marion College. Appreciation is expressed to Dr. Mike Jordan and Dr. Douglas Mandra of Francis Marion College for statistical assistance. Requests for reprintsshould be forwarded to Dr. Ronald S. Johnson, Bruce Hall, 601 GreggAve., Florence, SC 29501 or Mr. Jack Tobin, who is now the Director of Treatment Services, Rubicon Family Counseling Center, 5 10 E. Carolina Ave., Hartsville, SC 29550. 159
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(1983) discovered a 4-9 code type in their sample of nine intensely-studied, nonpatient male cocaine addicts. Other investigators have sought to compare the degree of psychopathology and/or differing personality traits among individuals who abuse different substances (Craig, 1988; Malow, West, Williams, & Sutker, 1989; McLellan, Childress, & Woody, 1985; Rosenthal, Edwards, Ackerman, Knott, & Rosenthal, 1990). Using structured clinical interviews, Malow et al. ( 1989) reported fewer symptoms of borderline and antisocial personality disorder and generally less psychological distress among cocaine abusers relative to opioid addicts. Other studies using the MMPI have similarly found less severe maladjustment among cocaine (vs. heroin) abusers (Craig, 1988; Spotts & Shontz, 1983). In contrast, McLellan et al. (1985) reported greater levels of MMPI-associated psychopathology among a mixed stimulant abuse group compared to opiate abusers, and increasing pathology (i.e., psychiatric symptoms) among the former with continued use. None of these studies included a separate alcohol abuse group. A number of authors have also proposed that drug choice is mediated by such differences in psychopathology (i.e., the self-medication hypothesis) and/or differing personality traits (Khantzian, 1985; McLellan et al., 1985). For example, Dougherty and Lesswing ( 1989) stated that relative to the MMPI literature on alcoholics, cocaine abusers were energized and that this trait of high energy/activity needs was reflected in their drug of choice. Rosenthal et al. ( 1990) did find that alcoholics were more anxious and cocaine abusers more impulsive on the Eysenck Personality Questionnaire. However, a major methodological problem in this literature including the above study is a failure to control for demographics such as age and race that are known to influence personality assessment (Butcher & Tellegen, 1978; Graham, 1987). The purpose of the present study was to provide further information on the personality characteristics of individuals dependent on cocaine and to determine if there are distinctive MMPI code types associated with cocaine abuse. Secondly, the study sought to compare the clinical and personality characteristics of patients who chose to abuse cocaine versus alcohol, controlling for demographic variables. It was expected that any MMPI differences which emerged would have implications for theoretical ideas regarding drug choice and for treatment planning. METHOD
Setting and subjects This research was conducted in a 30-bed private inpatient treatment center for substance abuse in the Southeast. There were 72 male (88%) and 16 female (18%) matched subjects in the study group. This sample was drawn from consecutive admissions over a 23-month period as described below. The program includes a minimum detoxification and assessment period of 24 hours followed by a comprehensive 3 1-day treatment program. The vast majority of patients enter treatment on a voluntary basis, and although a broad spectrum of socioeconomic levels are represented, most clients were employed in blue collar, nonmanagerial jobs. Seventy-seven percent ofthe study group were Caucasian, while 23 percent were black. Their average age was 29 years, with age ranging from 18 to 44. Procedure As part of the intake procedure at the time of admission, all patients were assessed as to the nature of their substance abuse problem and primary drug of choice. Subject
Personality characteristics of cocaine abusers
161
selection involved a two-step process. Initial inclusion criteria were (a) patient age of at least 18 years, (b) primary chemical dependence on either alcohol or cocaine as assessed by DSMIII-R criteria, and (c) completion of a valid assessment protocol. In conjunction with the assessment process, the MMPI is administered to patients within 10 days of admission and scheduled individually such that effects relating to the acute detoxification stage do not distort the results. The MMPI is an actuarial personality inventory and widely used measure of psychopathology in which a person’s responses are compared to those of various patient groups, and hypotheses are derived from the characteristics of individuals who obtain similar profiles. The numerical designation has come to replace the original scale names as the meaning of the clinical scales were redefined by research (refer to Graham, 1987, for further information). In addition to nonreaders, a small percentage of patients (less than 5% of the total admissions) were excluded because their MMPI protocol was ofquestionable validity (defined as F-K exceeding the range + 10 to - 11). The above procedure resulted in two separate groups of patients whose primary drug of choice was alcohol (N = 167) or cocaine (N = 123) and for whom valid MMPI information was available. From these groups, subjects were individually matched on the basis of sex, race and age. This resulted in the final study group of 44 matched pairs. The alcohol group reported their mean duration of use to be 14.9 years (SD = 5.1) while the mean duration of cocaine use was 5.4 years (SD = 4.3). Twenty-two percent of the subjects reported previous admissions for substance abuse. The MMPI data were scored using the traditional norms (K-corrected) for the three validity (L, F, and K), ten clinical, and four supplemental (A, R, ES, and Mac) scales. R E S U L. T S
A canonical discriminant analysis was performed to examine if there was any way (e.g., combination of scales) to look at this data so as to statistically separate the two patient groups. This analysis revealed only one function, and the matched alcohol and cocaine groups did not differ on this function [Hotelling-Lawley trace; F( 17, 70) = 1.467, p < .13]. A multivariate analysis ofvariance (MANOVA) comparing the alcohol and cocaine groups across all scales confirmed these results. Overall, alcoholics and cocaine addicts in our sample could not be discriminated on the basis of their MMPI performance. The only scale for which univariate analyses suggested a significant difference (F( 1,86) = 8.52, p < .004) was scale 0 (social introversion) on which the alcohol patients scored somewhat higher. Figure 1 depicts the average MMPI profile for both alcohol and cocaine patients; visually, there is a high degree of similarity between the profiles. It is necessary, in fact, to go to a three-point code classification to pick up a difference. Both have high points on scales four and two and are only slightly differentiated on the third scale. That is, the average three-point code for alcoholics was 4-2-8 and that for cocaine addicts was 4-2-9. Again, however, these scores were not significantly different. Scores for scale 5 are not plotted because there are separate norms for men and women. However, these scores also did not vary by patient group. It is well-known that mean MMPI profiles often mask a wide variety of different profile types. Megargee ( 1985) has discussed the problem of profile heterogeneity in detail. Inspection of the individual profiles of the matched alcohol and cocaine patients suggested that indeed several profile types existed within the 4-2 mean code type. This aspect of the data was investigated by examining each two-point configuration which
162
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120
*-
Cocaine
El---.
Alcohol
70 -I-
0
LFK Fig.
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1234
I
I
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I
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567890
/
I1
1.Mean MMPI profiles for alcohol and cocaine patients matched
1
I
I
I
A R EsMac
on age. sex, and race
taken individually accounted for at least 10% of the profiles within each group. In that many subject profiles had little separation (e.g., two or three T-score units) between their high peaks, and in keeping with clinical practice, these high point configurations were grouped without regard to order (e.g., considering 4-9 and 9-4 profiles together). Figure 2 presents these data. It is significant that only three profile types (2-4/4-2; 2-7/7-2; and 4-9/9-4) accounted for 10% or more of the cocaine subjects’ profiles and that only the 4-9/9-4 code type accounted for 10% or more of the profiles within the alcoholic group. In fact, there were 29 different two-point codetypes represented within the alcoholic sample and 19 different two-point codetypes within the cocaine sample. These results demonstrate again the concept of profile heterogeneity and suggest somewhat more diversity within the alcoholic as compared to the cocaine patient group. The three code types specified in Figure 2 account for approximately 65% of the cocaine subject profiles, while those same three code types account for only 26% of the alcohol subject profiles. The vast majority of the alcoholics in the matched sample had profiles in the “other” category, and none of these codetypes individually accounted for 10% or more of the profiles. DISCUSSION
Canonical discriminant analysis and multivariate analysis of variance of the MMPI profiles of 44 cocaine addicts and 44 matched alcoholics revealed that their MMPI profile scale means could not be discriminated on the basis of whether the individual abused alcohol or cocaine. Univariate analyses revealed only one significant scale difference, social introversion. However, confidence in even this finding is low in that pre-
163
Personality characteristics of cocaine abusers
8Cl-
m m
COCAINE ALCOHOL
6CIz G z n. 40I_
20
0
2A 42
2.7 72
4.9 9.4
OTHER
PROFILETYPES Fig. 2. Profile types embedded within mean profiles.
vious research has not found that cocaine abusers are more extroverted (Rosenthal et al., 1990; Spotts & Shontz, 1984). In this sample, using the MMPI as the criterion of psychopathology, there was no difference in the degree of disturbance by substance abuse type. Previous investigators who perceived cocaine abusers to be more or less adjusted than other substance abusers need to reflect on the demographic composition of their sample. It is likely that such impressions (at least on the MMPI) reflect the influence of age and racial differences. Although these findings depart from Spotts and Shontz (1983), it is unclear whether their matching was accomplished by individual subject characteristics or group averages. In addition, they had a very small number of nonpatient subjects. Recently, using the statistical strategy of covariance, Cannon, Bell, Fowler, Penk, & Finkelstein (1990) similarly found that MMPI differences between male Veterans Administration alcohol and drug patients (albeit not a polysubstance group) disappeared when the effects of age and race were controlled. Previous research has not found route of administration among cocaine addicts to relate to MMPI defined pathology, although dose level has been modestly correlated with scales F and 4 (Helfrich, et al. 1982). The general MMPI 4-2 profile among alcoholics with secondary elevations on scales 8 and 9 is consistent with the now familiar findings of many research studies (Graham and Strenger, 1988; Megargee, 1985). Previous clinical researchers employing the MMPI with cocaine abusers have also found an overall profile elevation on scale 4 (Craig, 1988; Helfrich et al., 1982) and sometimes 9 (Dougherty & Lesswing, 1989).
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et al
Moreover, the obtained similarity between the mean profiles of the alcoholic and cocaine groups raises the interesting question of whether there is one or more general profile types for individuals entering treatment for chemical dependency (Morey et al., 1987). At the individual patient level, the present results indicate that similar to MMPI research with alcoholics, there is no unitary personality type that is specific to dependence on cocaine. Some interesting comparisons emerged when the different profile types embedded within and contributing to the mean profile were examined. There was somewhat less diversity ofcode types within the cocaine abuse group where the 4-9/9-4, 2-414-2, and 2-717-2 code types accounted for approximately 65% of the profiles. Although the overall findings of no difference between cocaine addicts and alcoholics belies the need for separate treatment programs, such MMPI based subtypes among the cocaine abusers do have implications for therapy. It should be pointed out that clinical descriptions of code types within the MMPI literature are hypotheses based on acturarial group data and should not be taken as absolute or necessarily reflective of an individual’s functioning without further collaborative evidence. With this in mind, however, individuals with a 4-2 configuration are said to have antisocial characteristics such as poor impulse control and lack the ability to delay gratification. They appear to have little respect for societal rules and expectations and resent demands placed on them, particularly by authority figures. Such patients express feelings of worthlessness and remorse after periods ofself-defeating acting out: however. when environmental stress or legal difficulties are resolved, they may show little motivation for continued counseling or psychotherapy (Graham, 1987). These individuals also resemble the classic antisocial personality disordered individual sometimes reflected in the 4-9/9-4 MMPI profile code type represented heavily in our cocaine sample. This latter type, however. is likely to be less remorseful, and may have been engaged in more blatant acting out. They have great difficulty learning from past experience, repeatedly showing disregard for societal limits and standards. Thus. one sub-type within our cocaine sample may be accurately described as an antisocial personality adaptation. A second type of cocaine abuse is reflected in the 2-7/7-2 code type and represents a vastly different personality adaptation with a different set of treatment needs. These individuals are likely to experience depression, anxiety, and an obsessive-compulsive personality adaptation. Excessive worry and anticipation of real or imagined threats are common along with self-reports of fatigue. tiredness, lack of initiative and periods of anhedonia. They may be particularly pessimistic about their own ability to overcome their problems. and they focus on their own flaws and shortcomings. Somatic or hypochondriacal symptoms may reflect their high level of internal stress. These individuals often have a high need for achievement and recognition and are likely to experience guilt when their performance does not match their perfectionistic expectations ofthemselves. They can be quite unassertive, indecisive. and passive-dependent in relationships (Lachar, 1974: Graham, 1987). Clinical experience suggests that often their positive intents for the use ofcocaine include wanting to be strong. confident, and relatively free of anxiety. In contrast, positive intents for cocaine use in the antisocial personality adaptation often include a need for excitement and an attempt, albeit unsuccessful in the long run, to medicate hurt that is often masked by anger. This hurt sometimes emanates from feelings of having been abandoned emotionally by one or both parents during critical periods of early childhood development. Although this analysis rests on clinical judg-
Personality
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of cocaine
abusers
165
ment, it is clear that adequate, individualized treatment planning would result in quite different treatment approaches and strategies for these two different personality styles. It is also clear that the extensive amount of profile heterogeneity within the alcoholic sample necessitates careful individual assessment of the specific needs of that group. The only clear large personality profile code type cluster in that group reflects an antisocial personality style. Twenty-eight different two-point profile code types were found within the alcoholic sample, only one of which (4-9/9-4) accounted for 10% or more of the profiles. The current study is limited in that it was conducted within a single treatment facility at a particular era in time. Moreover, it does not address whether the clinical and personality features found among the cocaine abusers are predisposing influences or consequences of their drug use. However, echoing Craig ( 1988), the results do not provide support for theories that implicate personality factors in drug choice. Rather, they are consistent with the position that the addictive personality is the behavior of substance abuse (Nathan, 1988). A further limitation of the study is that the number of matched pairs was too small to meaningfully look at female cocaine abusers separately. In a recent paper. Macey & Siegfried (1990) reported that gender did interact with substance type in that female cocaine abusers and male alcoholics had higher MMPI scale 4 scores. However, as in earlier studies, age was uncontrolled with female patients reportedly younger in their sample. Further research is needed looking at the characteristics of women who abuse different substances. In conclusion, the strength of the present findings rests on the careful matching of cocaine users entering treatment and inclusion of a separate comparison group of alcoholic patients. With subjects so selected, substance did not differentially relate to pathology and/or personality characteristics on the MMPI. While no data can rule out such differences, the present findings suggest that such substance abuse patients are more alike than different. REFERENCES Butcher, J. N.. & Tellegen, A. (1978). Common methodological problems in MMPI research. Journa/o/Consuhing and Clinical Psychology, 46, 620-628. Cannon, D. S., Bell, W. E., Fowler, D. R., Penk, W. E.. & Finkelstein, A. S. (1990). MMPl diflerencesbetween alcoholics and drug abusers: Effect of age and race. Psychological Assessmenf, 2, 5 l-55. Craig, R. J. (1988). Psychological functioning of cocaine free-basers derived from objective psychological tests. Journal ofClinical Psychology. 44, 599-606. Dougherty, R. J., & Lesswing, N. J. (I 989). Inpatient cocaine abusers: An analysis ofpsychological and demographic variables. Journal of Substance Abuse Treatment. 6.45-47. Graham, J. R. (I 987). The MMPI: A pracficalguide. New York: Oxford University Press. Graham, J. R., & Strenger, V. E. (I 988). MMPI characteristics of alcoholics: A review. Journal ofConsulting and Clinical Psychology, 56, 197-205. Helfrich, A. A., Crowley, T. J., Atkinson, C. A., & Post, R. D. (1982). Clinical profile of I36 cocaine abusers. In L. S. Harris (Ed.), Problems ofdrug dependence 1982 (Research Monograph No. 43. pp. 343-350). Rockville, MD: National Institute on Drug Abuse. Khantzian, E. J. (1985). The self-medication hypothesis of addictive disorders: Focus on heroin and cocaine dependence. American Journal ofPsychiatry, 142, I259- 1264. Lachar, D. ( 1974). The MMPI: Clinical assessmenl and automated interpretation Los Angeles: Western Psychological Services. Macey, E. J., & Siegfried, M. D. (1990). Gender and personality differences in MMPI scores between alcohol and drug abusers. Paper presented at the Southeastern Psychological Association, Atlanta, GA. Malow, R. M., West, J. A., Williams, J., & Sutker, P. B. (1989). Personalitydisordersclassilication and symptoms in cocaine and opioid addicts. Journal of‘Consultin~ and Clinical Psychology. 51, 765-767. McLellan. A. T., Childress, A. R., & Woody, E. G. (I 985). Drug abuse and psychiatric disorder: Role ofdrug choice. In A. I. Alterman (Ed.), Suhstanceahuscandp.sychopa/hology(pp. 137-l 72). New York: Plenum Press.
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Megargee, E. (1985). Assessing alcoholism and drug abuse with the MMPI: Implications for employment screening. In C. D. Spielberger & J. N. Butcher (Eds.). /Idvclnccs in pcwonalif~~ a.s.ses.wzm~(Vol. 5. pp. l-39). Hillsdale, NJ: Lawrence Erlbaum Associates. Morey, L. C., Roberts, W. R., & Penk. W. (1987). MMPI alcoholic subtypes: Replicability and validity ofthe 2-8-7-4 subtype. Journal qj’Ahnorma/ P.s.vchology, 96, I64- 166. Morey. L. C., Skinner, H. A., & Blashfield, R. R. (1984). A typology ofalcohol abusers: Correlates and implications. .Journal ofAbnormal P.s.vcholog.v,93, 408-4 17. Nathan, P. E. (1988). The addictive personality is the behavior ofthe addict. Jo~rrna/o/‘C‘on.s~r//ingand C/it~ical P.sychology. 56, I83- 188. Rosenthal. T. L., Edwards, N. B., Ackerman, B. J., Knott, D. H., & Rosenthal, R. H. (I 990). Substanceabuse patterns reveal contrasting personal traits. Journal c?~Suhsran~cAhrac, 2, 255-263. Spotts, J. V.. & Shontz, F. C. (1983). Psychopathology and chronic drug use: A methodological paradigm. The Intcrnationul Journal o/‘/he Addicrions, 18(5), 633-680. Spotts, J. V.. & Shontz. F. C. (1984). Drugs and personality: Extraversion-Introversion. Jorrrnal q/ C’linical P.sychology 40, 624-628. Svanum. S.. & Dallas, C. L. (198 I). Alcoholic MMPI subtypesand their relationship to patient characteristics, polydrug abuse, and abstinence following treatment. Joztrnal o?~P~~r.tona/i/~~.4.s.scs.s~nmt. 45. 278-287.
Addic.livPBphaviors. Vol. 11,~~. 159-166, 1992
Copyright 0 I992 Pergamon Press Ltd.
Printed in the USA. All rights reserved.
PERSONALITY CHARACI-ERISTICS OF COCAINE AND ALCOHOL ABUSERS: MORE ALIKE THAN DIFFERENT RONALD S. JOHNSON, JACK W. TOBIN, and TONY CELLUCCI Francis Marion College Abstract - Although there is extensive literature describing the characteristics of individuals entering treatment for alcoholism, few research reports are available describing the personality characteristics of individuals addicted to cocaine. Forty-four matched patient pairs, one member of each pair who abused cocaine and the other alcohol, were compared on the basis of their Minnesota Multiphasic Personality Inventory (MMPI) profiles. The subjects were matched on the basis ofage, sex, and race from a larger population enteringan inpatient addiction treatment center. Statistical analysis revealed more similarities than differences between the two groups, with the average profile type for both cocaine and alcohol abusers being 4-2. These results are discussed in the context of previous reports of psychopathology among cocaine abusers and personality theories of drug choice. The number of different code types within each substance abuse group is also reported and the concept of profile heterogeneity supported. Profile subtypes among cocaine patients are described clinically along with their implications for treatment.
INTRODUCTION
There is continuing interest in the personality characteristics of substance abusers entering treatment, much of this literature focusing on the Minnesota Multiphasic Personality Inventory (MMPI). Extensive data are available describing the MMPI characteristics of alcoholics, and this area of research has recently been reviewed by Graham and Strenger ( 1988). The most consistent MMPI finding among individuals who abuse alcohol is an elevation on scale 4, a mean 2-4/4-2 profile and not infrequent elevations on scales 7,8, and 9 (Graham & Strenger, 1988; Morey, Roberts, & Penk, 1987). Various multivariate and cluster analytic research strategies have been used to empirically define subtypes within this population (Morey, Skinner, & Blashfield, 1984; Svanum & Dallas, 198 1). In their review, Graham and Strenger (1988) describe six such profile types along with their associated characteristics; these profile types had been successfully replicated in several studies. A relatively smaller number of studies have been conducted using the MMPI with individuals who are dependent on cocaine (Dougherty & Lesswing, 1989; Helfrich, Crowley, Atkinson, & Post, 1982; Spotts & Shontz, 1983). Dougherty and Lesswing (1989) evaluated 100 cocaine patients during the second week of a 6-week inpatient program. Ninety percent were reported to have significantly elevated MMPI profiles, and 65 of these were characterized by high points on either scale 4 or 9. In an earlier clinical report, Helfrich et al. (1982) reported a 4-8-9-7 profile, while Spotts & Shontz This research project was partially funded by grant #FRA89-76 from the South Carolina Commission on Alcohol and Drug Abuse to Bruce Hall and Francis Marion College. Appreciation is expressed to Dr. Mike Jordan and Dr. Douglas Mandra of Francis Marion College for statistical assistance. Requests for reprintsshould be forwarded to Dr. Ronald S. Johnson, Bruce Hall, 601 GreggAve., Florence, SC 29501 or Mr. Jack Tobin, who is now the Director of Treatment Services, Rubicon Family Counseling Center, 5 10 E. Carolina Ave., Hartsville, SC 29550. 159
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S. JOHNSON
et al.
(1983) discovered a 4-9 code type in their sample of nine intensely-studied, nonpatient male cocaine addicts. Other investigators have sought to compare the degree of psychopathology and/or differing personality traits among individuals who abuse different substances (Craig, 1988; Malow, West, Williams, & Sutker, 1989; McLellan, Childress, & Woody, 1985; Rosenthal, Edwards, Ackerman, Knott, & Rosenthal, 1990). Using structured clinical interviews, Malow et al. ( 1989) reported fewer symptoms of borderline and antisocial personality disorder and generally less psychological distress among cocaine abusers relative to opioid addicts. Other studies using the MMPI have similarly found less severe maladjustment among cocaine (vs. heroin) abusers (Craig, 1988; Spotts & Shontz, 1983). In contrast, McLellan et al. (1985) reported greater levels of MMPI-associated psychopathology among a mixed stimulant abuse group compared to opiate abusers, and increasing pathology (i.e., psychiatric symptoms) among the former with continued use. None of these studies included a separate alcohol abuse group. A number of authors have also proposed that drug choice is mediated by such differences in psychopathology (i.e., the self-medication hypothesis) and/or differing personality traits (Khantzian, 1985; McLellan et al., 1985). For example, Dougherty and Lesswing ( 1989) stated that relative to the MMPI literature on alcoholics, cocaine abusers were energized and that this trait of high energy/activity needs was reflected in their drug of choice. Rosenthal et al. ( 1990) did find that alcoholics were more anxious and cocaine abusers more impulsive on the Eysenck Personality Questionnaire. However, a major methodological problem in this literature including the above study is a failure to control for demographics such as age and race that are known to influence personality assessment (Butcher & Tellegen, 1978; Graham, 1987). The purpose of the present study was to provide further information on the personality characteristics of individuals dependent on cocaine and to determine if there are distinctive MMPI code types associated with cocaine abuse. Secondly, the study sought to compare the clinical and personality characteristics of patients who chose to abuse cocaine versus alcohol, controlling for demographic variables. It was expected that any MMPI differences which emerged would have implications for theoretical ideas regarding drug choice and for treatment planning. METHOD
Setting and subjects This research was conducted in a 30-bed private inpatient treatment center for substance abuse in the Southeast. There were 72 male (88%) and 16 female (18%) matched subjects in the study group. This sample was drawn from consecutive admissions over a 23-month period as described below. The program includes a minimum detoxification and assessment period of 24 hours followed by a comprehensive 3 1-day treatment program. The vast majority of patients enter treatment on a voluntary basis, and although a broad spectrum of socioeconomic levels are represented, most clients were employed in blue collar, nonmanagerial jobs. Seventy-seven percent ofthe study group were Caucasian, while 23 percent were black. Their average age was 29 years, with age ranging from 18 to 44. Procedure As part of the intake procedure at the time of admission, all patients were assessed as to the nature of their substance abuse problem and primary drug of choice. Subject
Personality characteristics of cocaine abusers
161
selection involved a two-step process. Initial inclusion criteria were (a) patient age of at least 18 years, (b) primary chemical dependence on either alcohol or cocaine as assessed by DSMIII-R criteria, and (c) completion of a valid assessment protocol. In conjunction with the assessment process, the MMPI is administered to patients within 10 days of admission and scheduled individually such that effects relating to the acute detoxification stage do not distort the results. The MMPI is an actuarial personality inventory and widely used measure of psychopathology in which a person’s responses are compared to those of various patient groups, and hypotheses are derived from the characteristics of individuals who obtain similar profiles. The numerical designation has come to replace the original scale names as the meaning of the clinical scales were redefined by research (refer to Graham, 1987, for further information). In addition to nonreaders, a small percentage of patients (less than 5% of the total admissions) were excluded because their MMPI protocol was ofquestionable validity (defined as F-K exceeding the range + 10 to - 11). The above procedure resulted in two separate groups of patients whose primary drug of choice was alcohol (N = 167) or cocaine (N = 123) and for whom valid MMPI information was available. From these groups, subjects were individually matched on the basis of sex, race and age. This resulted in the final study group of 44 matched pairs. The alcohol group reported their mean duration of use to be 14.9 years (SD = 5.1) while the mean duration of cocaine use was 5.4 years (SD = 4.3). Twenty-two percent of the subjects reported previous admissions for substance abuse. The MMPI data were scored using the traditional norms (K-corrected) for the three validity (L, F, and K), ten clinical, and four supplemental (A, R, ES, and Mac) scales. R E S U L. T S
A canonical discriminant analysis was performed to examine if there was any way (e.g., combination of scales) to look at this data so as to statistically separate the two patient groups. This analysis revealed only one function, and the matched alcohol and cocaine groups did not differ on this function [Hotelling-Lawley trace; F( 17, 70) = 1.467, p < .13]. A multivariate analysis ofvariance (MANOVA) comparing the alcohol and cocaine groups across all scales confirmed these results. Overall, alcoholics and cocaine addicts in our sample could not be discriminated on the basis of their MMPI performance. The only scale for which univariate analyses suggested a significant difference (F( 1,86) = 8.52, p < .004) was scale 0 (social introversion) on which the alcohol patients scored somewhat higher. Figure 1 depicts the average MMPI profile for both alcohol and cocaine patients; visually, there is a high degree of similarity between the profiles. It is necessary, in fact, to go to a three-point code classification to pick up a difference. Both have high points on scales four and two and are only slightly differentiated on the third scale. That is, the average three-point code for alcoholics was 4-2-8 and that for cocaine addicts was 4-2-9. Again, however, these scores were not significantly different. Scores for scale 5 are not plotted because there are separate norms for men and women. However, these scores also did not vary by patient group. It is well-known that mean MMPI profiles often mask a wide variety of different profile types. Megargee ( 1985) has discussed the problem of profile heterogeneity in detail. Inspection of the individual profiles of the matched alcohol and cocaine patients suggested that indeed several profile types existed within the 4-2 mean code type. This aspect of the data was investigated by examining each two-point configuration which
162
RONALD
S. JOHNSON
et al.
120
*-
Cocaine
El---.
Alcohol
70 -I-
0
LFK Fig.
1
I
1234
I
I
I
I
I
567890
/
I1
1.Mean MMPI profiles for alcohol and cocaine patients matched
1
I
I
I
A R EsMac
on age. sex, and race
taken individually accounted for at least 10% of the profiles within each group. In that many subject profiles had little separation (e.g., two or three T-score units) between their high peaks, and in keeping with clinical practice, these high point configurations were grouped without regard to order (e.g., considering 4-9 and 9-4 profiles together). Figure 2 presents these data. It is significant that only three profile types (2-4/4-2; 2-7/7-2; and 4-9/9-4) accounted for 10% or more of the cocaine subjects’ profiles and that only the 4-9/9-4 code type accounted for 10% or more of the profiles within the alcoholic group. In fact, there were 29 different two-point codetypes represented within the alcoholic sample and 19 different two-point codetypes within the cocaine sample. These results demonstrate again the concept of profile heterogeneity and suggest somewhat more diversity within the alcoholic as compared to the cocaine patient group. The three code types specified in Figure 2 account for approximately 65% of the cocaine subject profiles, while those same three code types account for only 26% of the alcohol subject profiles. The vast majority of the alcoholics in the matched sample had profiles in the “other” category, and none of these codetypes individually accounted for 10% or more of the profiles. DISCUSSION
Canonical discriminant analysis and multivariate analysis of variance of the MMPI profiles of 44 cocaine addicts and 44 matched alcoholics revealed that their MMPI profile scale means could not be discriminated on the basis of whether the individual abused alcohol or cocaine. Univariate analyses revealed only one significant scale difference, social introversion. However, confidence in even this finding is low in that pre-
163
Personality characteristics of cocaine abusers
8Cl-
m m
COCAINE ALCOHOL
6CIz G z n. 40I_
20
0
2A 42
2.7 72
4.9 9.4
OTHER
PROFILETYPES Fig. 2. Profile types embedded within mean profiles.
vious research has not found that cocaine abusers are more extroverted (Rosenthal et al., 1990; Spotts & Shontz, 1984). In this sample, using the MMPI as the criterion of psychopathology, there was no difference in the degree of disturbance by substance abuse type. Previous investigators who perceived cocaine abusers to be more or less adjusted than other substance abusers need to reflect on the demographic composition of their sample. It is likely that such impressions (at least on the MMPI) reflect the influence of age and racial differences. Although these findings depart from Spotts and Shontz (1983), it is unclear whether their matching was accomplished by individual subject characteristics or group averages. In addition, they had a very small number of nonpatient subjects. Recently, using the statistical strategy of covariance, Cannon, Bell, Fowler, Penk, & Finkelstein (1990) similarly found that MMPI differences between male Veterans Administration alcohol and drug patients (albeit not a polysubstance group) disappeared when the effects of age and race were controlled. Previous research has not found route of administration among cocaine addicts to relate to MMPI defined pathology, although dose level has been modestly correlated with scales F and 4 (Helfrich, et al. 1982). The general MMPI 4-2 profile among alcoholics with secondary elevations on scales 8 and 9 is consistent with the now familiar findings of many research studies (Graham and Strenger, 1988; Megargee, 1985). Previous clinical researchers employing the MMPI with cocaine abusers have also found an overall profile elevation on scale 4 (Craig, 1988; Helfrich et al., 1982) and sometimes 9 (Dougherty & Lesswing, 1989).
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Moreover, the obtained similarity between the mean profiles of the alcoholic and cocaine groups raises the interesting question of whether there is one or more general profile types for individuals entering treatment for chemical dependency (Morey et al., 1987). At the individual patient level, the present results indicate that similar to MMPI research with alcoholics, there is no unitary personality type that is specific to dependence on cocaine. Some interesting comparisons emerged when the different profile types embedded within and contributing to the mean profile were examined. There was somewhat less diversity ofcode types within the cocaine abuse group where the 4-9/9-4, 2-414-2, and 2-717-2 code types accounted for approximately 65% of the profiles. Although the overall findings of no difference between cocaine addicts and alcoholics belies the need for separate treatment programs, such MMPI based subtypes among the cocaine abusers do have implications for therapy. It should be pointed out that clinical descriptions of code types within the MMPI literature are hypotheses based on acturarial group data and should not be taken as absolute or necessarily reflective of an individual’s functioning without further collaborative evidence. With this in mind, however, individuals with a 4-2 configuration are said to have antisocial characteristics such as poor impulse control and lack the ability to delay gratification. They appear to have little respect for societal rules and expectations and resent demands placed on them, particularly by authority figures. Such patients express feelings of worthlessness and remorse after periods ofself-defeating acting out: however. when environmental stress or legal difficulties are resolved, they may show little motivation for continued counseling or psychotherapy (Graham, 1987). These individuals also resemble the classic antisocial personality disordered individual sometimes reflected in the 4-9/9-4 MMPI profile code type represented heavily in our cocaine sample. This latter type, however. is likely to be less remorseful, and may have been engaged in more blatant acting out. They have great difficulty learning from past experience, repeatedly showing disregard for societal limits and standards. Thus. one sub-type within our cocaine sample may be accurately described as an antisocial personality adaptation. A second type of cocaine abuse is reflected in the 2-7/7-2 code type and represents a vastly different personality adaptation with a different set of treatment needs. These individuals are likely to experience depression, anxiety, and an obsessive-compulsive personality adaptation. Excessive worry and anticipation of real or imagined threats are common along with self-reports of fatigue. tiredness, lack of initiative and periods of anhedonia. They may be particularly pessimistic about their own ability to overcome their problems. and they focus on their own flaws and shortcomings. Somatic or hypochondriacal symptoms may reflect their high level of internal stress. These individuals often have a high need for achievement and recognition and are likely to experience guilt when their performance does not match their perfectionistic expectations ofthemselves. They can be quite unassertive, indecisive. and passive-dependent in relationships (Lachar, 1974: Graham, 1987). Clinical experience suggests that often their positive intents for the use ofcocaine include wanting to be strong. confident, and relatively free of anxiety. In contrast, positive intents for cocaine use in the antisocial personality adaptation often include a need for excitement and an attempt, albeit unsuccessful in the long run, to medicate hurt that is often masked by anger. This hurt sometimes emanates from feelings of having been abandoned emotionally by one or both parents during critical periods of early childhood development. Although this analysis rests on clinical judg-
Personality
characteristics
of cocaine
abusers
165
ment, it is clear that adequate, individualized treatment planning would result in quite different treatment approaches and strategies for these two different personality styles. It is also clear that the extensive amount of profile heterogeneity within the alcoholic sample necessitates careful individual assessment of the specific needs of that group. The only clear large personality profile code type cluster in that group reflects an antisocial personality style. Twenty-eight different two-point profile code types were found within the alcoholic sample, only one of which (4-9/9-4) accounted for 10% or more of the profiles. The current study is limited in that it was conducted within a single treatment facility at a particular era in time. Moreover, it does not address whether the clinical and personality features found among the cocaine abusers are predisposing influences or consequences of their drug use. However, echoing Craig ( 1988), the results do not provide support for theories that implicate personality factors in drug choice. Rather, they are consistent with the position that the addictive personality is the behavior of substance abuse (Nathan, 1988). A further limitation of the study is that the number of matched pairs was too small to meaningfully look at female cocaine abusers separately. In a recent paper. Macey & Siegfried (1990) reported that gender did interact with substance type in that female cocaine abusers and male alcoholics had higher MMPI scale 4 scores. However, as in earlier studies, age was uncontrolled with female patients reportedly younger in their sample. Further research is needed looking at the characteristics of women who abuse different substances. In conclusion, the strength of the present findings rests on the careful matching of cocaine users entering treatment and inclusion of a separate comparison group of alcoholic patients. With subjects so selected, substance did not differentially relate to pathology and/or personality characteristics on the MMPI. While no data can rule out such differences, the present findings suggest that such substance abuse patients are more alike than different. REFERENCES Butcher, J. N.. & Tellegen, A. (1978). Common methodological problems in MMPI research. Journa/o/Consuhing and Clinical Psychology, 46, 620-628. Cannon, D. S., Bell, W. E., Fowler, D. R., Penk, W. E.. & Finkelstein, A. S. (1990). MMPl diflerencesbetween alcoholics and drug abusers: Effect of age and race. Psychological Assessmenf, 2, 5 l-55. Craig, R. J. (1988). Psychological functioning of cocaine free-basers derived from objective psychological tests. Journal ofClinical Psychology. 44, 599-606. Dougherty, R. J., & Lesswing, N. J. (I 989). Inpatient cocaine abusers: An analysis ofpsychological and demographic variables. Journal of Substance Abuse Treatment. 6.45-47. Graham, J. R. (I 987). The MMPI: A pracficalguide. New York: Oxford University Press. Graham, J. R., & Strenger, V. E. (I 988). MMPI characteristics of alcoholics: A review. Journal ofConsulting and Clinical Psychology, 56, 197-205. Helfrich, A. A., Crowley, T. J., Atkinson, C. A., & Post, R. D. (1982). Clinical profile of I36 cocaine abusers. In L. S. Harris (Ed.), Problems ofdrug dependence 1982 (Research Monograph No. 43. pp. 343-350). Rockville, MD: National Institute on Drug Abuse. Khantzian, E. J. (1985). The self-medication hypothesis of addictive disorders: Focus on heroin and cocaine dependence. American Journal ofPsychiatry, 142, I259- 1264. Lachar, D. ( 1974). The MMPI: Clinical assessmenl and automated interpretation Los Angeles: Western Psychological Services. Macey, E. J., & Siegfried, M. D. (1990). Gender and personality differences in MMPI scores between alcohol and drug abusers. Paper presented at the Southeastern Psychological Association, Atlanta, GA. Malow, R. M., West, J. A., Williams, J., & Sutker, P. B. (1989). Personalitydisordersclassilication and symptoms in cocaine and opioid addicts. Journal of‘Consultin~ and Clinical Psychology. 51, 765-767. McLellan. A. T., Childress, A. R., & Woody, E. G. (I 985). Drug abuse and psychiatric disorder: Role ofdrug choice. In A. I. Alterman (Ed.), Suhstanceahuscandp.sychopa/hology(pp. 137-l 72). New York: Plenum Press.
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Megargee, E. (1985). Assessing alcoholism and drug abuse with the MMPI: Implications for employment screening. In C. D. Spielberger & J. N. Butcher (Eds.). /Idvclnccs in pcwonalif~~ a.s.ses.wzm~(Vol. 5. pp. l-39). Hillsdale, NJ: Lawrence Erlbaum Associates. Morey, L. C., Roberts, W. R., & Penk. W. (1987). MMPI alcoholic subtypes: Replicability and validity ofthe 2-8-7-4 subtype. Journal qj’Ahnorma/ P.s.vchology, 96, I64- 166. Morey. L. C., Skinner, H. A., & Blashfield, R. R. (1984). A typology ofalcohol abusers: Correlates and implications. .Journal ofAbnormal P.s.vcholog.v,93, 408-4 17. Nathan, P. E. (1988). The addictive personality is the behavior ofthe addict. Jo~rrna/o/‘C‘on.s~r//ingand C/it~ical P.sychology. 56, I83- 188. Rosenthal. T. L., Edwards, N. B., Ackerman, B. J., Knott, D. H., & Rosenthal, R. H. (I 990). Substanceabuse patterns reveal contrasting personal traits. Journal c?~Suhsran~cAhrac, 2, 255-263. Spotts, J. V.. & Shontz, F. C. (1983). Psychopathology and chronic drug use: A methodological paradigm. The Intcrnationul Journal o/‘/he Addicrions, 18(5), 633-680. Spotts, J. V.. & Shontz. F. C. (1984). Drugs and personality: Extraversion-Introversion. Jorrrnal q/ C’linical P.sychology 40, 624-628. Svanum. S.. & Dallas, C. L. (198 I). Alcoholic MMPI subtypesand their relationship to patient characteristics, polydrug abuse, and abstinence following treatment. Joztrnal o?~P~~r.tona/i/~~.4.s.scs.s~nmt. 45. 278-287.
