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Psychopathologic Phases Observable in Individuals Using Narcotic Drugs in Excess
By C. C. Wholey, M.D.
Pennsylvania Medical Journal, Vol. 16 (June, 1913), 721-25.
Any individual may become addicted to the excessive use of narcotic drugs. The majority of my cases represent the average individual with the average heredity and environment. These persons have generally acquired their habit accidentally. It is, therefore, fallacious and unjust to refer without qualification to drug users as a class inherently neurotic and degenerate. No drug user should be labeled with the stigma of such terms, however unpromising he may look, unless his history warrants it. It is surprising that drug-taking, particularly alcoholism, is not more prevalent. We are confronted with the fact that many individuals sometime in their lives are fairly well tested as to their ability to withstand alcoholic indulgence. Alcohol is fed to infants; depended upon by the laborer, and by the business man; it appears on tables everywhere as a drink, or in various foods; it is the common medium of good fellowship. The fact that one tenth of the amount of morphine and cocaine imported would suffice for all legitimate medical needs shows how commonly people are exposed to these insidious drugs. They seem to be recklessly prescribed, and are notoriously easy to obtain.
There are many individuals whose powers of resistance, by reason of inheritance and environmental factors, are merely sufficient to enable them to maintain a healthy balance. They have enough nerve stability to carry them through an efficient life provided no exceptional strain is placed upon them. When such persons come into contact with narcotizing drugs, their delicate nervous balance is likely to be overthrown; the nervous organism has no reserve with which to meet the added demand made upon it by the inroads of the drug. These individuals are not necessarily neurasthenic: they have been endowed with no more endurance than the ordinary routine of each day would demand.
There is another individual who is congenitally just short of the balance which the above person normally possesses. This individual is inherently neurotic. His nerve endowment is not quite sufficient to enable him to live from day to day comfortably and effectively. He will, therefore (a mere biologic incident in his struggle for selfpreservation), desperately grasp at whatever seems to aid his own inadequate efforts. When drugs come his way, with their seeming power to increase his flagging energy, or to bring peace and order into his turbulent, chaotic, harrassed existence, it is inevitable that he shall anchor himself by their use. These are individuals whom physicians should particularly safeguard; it is hazardous for them even once to experience the soothing influence of an opiate.
In addition to the normal individuals and the neurotic ones who get into drug habits, there are a few fairly well-defined types, distinctly pathologic, who seem especially likely to become drug users. A type, noticeably prone to narcotism, is that known as the cyclothyrniae, a class of individuals possessing a peculiar emotional instability which, as a general thing, manifests itself in periods of depression alternating with periods of elation. This class represents various shadings within that group of borderland cases showing manic-depressive characteristics. To the casual observer, they may seem merely erratic. We find at times among them people of exceptional talent. And, curiously, it is not so often the depressed individual as the elated who becomes addicted to the excessive use of drugs. This elated, or hyperthymic phase, induces a feeling of good-fellowship, a restlessness, a surplus energy which seems often to find a satisfying outlet in a narcotic, such as alcohol or morphine.
A second pathologic type is that known to psychiatry as the constitutional immoral. Individuals of this class invariably furnish a history of a self-willed childhood. They have been pig-headed, and often cruel, consequently, for the sake of domestic peace, they have as children been pampered and undisciplined. As adults they show underdeveloped moral and ethical sense, impatience at interference, lack of endurance for physical or mental discomfort. Such individuals are often athletic and may be extremely popular with their fellows. But they are irresponsible, out for fun. Naturally they drift into dissipated circles; and hence into the use of narcotics. In this class we find among others the ne'er do well, the tramp, the petty thief, the prostitute. Closely associated with the constitutionally immoral group there are some distinct types which for purposes of diagnosis must be clearly differentiated. One is the high-grade imbecile- another, but recently more generally recognized as of especial significance, is known as the heboid. The latter mental condition is often difficult to recognize. Persons thus afflicted may at puberty suddenly display freakish conduct, and indulgences out of keeping with their former behavior. This heboid condition is sometimes a precursor of dementia praecox.
These psychiatric types must be carefully differentiated in order to deal intelligently with drug addictions. The cyclothymiacs and the constitutional immorals possess an anomalous make-up which often precludes the possibility of cure. They drift from institution to institution, relapsing again and again; the hopeless picture presented by these persons, really mental cases, has done much to create the practically universal skepticism regarding cure for drug addiction.
In addiction to such borderline conditions there are definite insanities upon which drug-taking is frequently engrafted. The individual with early dementia praecox, in his wayward following of the moment's vagary, may become addicted to alcohol or morphine should either come his way; the paretic, as a result of his
gradual mental reduction and of his aeneral mental reduction and of his general ethical and moral let-down, is an easy candidate for drug-habit formation. I note these insanities because the mental condition is sometimes overlooked; and the case carelessly regarded as a mere drug addiction, the patient's eccentricities and abnormalities considered as a result of his habit. I recall cases of paresis and of cerebrospinal lues who have gone for years with their true mental condition unrecognized because they were known to be alcoholics. In this connection it may be interesting to note that if there is a potential or latent psychopathic or neuropathic tendency in an individual, narcotic drugs, particularly alcohol, may bring it into noticeable activity. Convulsions, frequently seen in alcoholic wards and commonly known as "whisky fits," often are found to have an epileptic basis. The alcohol has caused the latent disease to manifest itself. In alcoholics afflicted with tabes, excessive drinking is commonly followed by great exacerbation of the tabetic symptoms. It is further interesting to note in this connection that where there is no underlying mental pathology, alcoholism or morphinism may induce a disease picture closely imitating that peculiar to certain insanities, such as paresis, paranoia or even dementia praecox. The syndrome of paresis is frequently imitated, in the well-defined condition of pseudoparesis. This picture, practically always a result of chronic alcoholism, so closely resembles true paresis in physical signs and mental symptoms as to make laboratory investigation of blood and spinal fluid necessary for differential diagnosis. In pseudoparesis, as in true paresis, the patient may develop a feeling of well-being or euphoria, which gives him a boastful confidence in his ability to do whatever he may wish. He may make the most plausible promises and with such an appearance of sincerity and good faith as to mislead those in authority into permitting him a premature freedom which is invariably followed by relapse, for he is still a mental case, at times entirely irresponsible. The pseudoparetic is a dangerous individual. Liberty for him is likely to be fraught with disastrous consequences to his property and to his family.
Before considering the physiologic and psychic necessity for continuance of drug taking after habit has been established, I wish to speak briefly of how the average individual gets into the morphine habit. And this brings us as physicians face to face with the ugly fact that perhaps the majority of the morphinists in this country today were first prescribed the drug by a physician. Many histories reveal the appalling truth that the administration of the drug as a medicine was needlessly carried on until habit was formed. Usually, I find the patient has at first been ignorant of the nature of the drug; after he has come to the habit stage there is little use to inform him of the harmful nature of his panacea, for he has found that for him it seems good and he will not consider parting with this drug until he has reached that stage where he finds himself so impaired as to be unable longer to hold his own. We find patients who have had given into their own hands the hypodermic needle. The use of the needle practically always insures the formation of the habit. There are of course various other ways of acquiring the habit. Women suffering from dysmenorrhea or headache pass on the word that paregoric, laudanum, etc., is a specific. The easy access to patent medicines, containing morphine, beats a well worn road to habit formation. Yet the fact confronts us that probably the majority of drug addictions can be traced directly to our own prescriptions.
As physiologic and psychic need for continuance has usually been established before the morphinist finally reaches the place where he realizes his condition sufficiently to seek a physician; he has undergone marked changes in body chemistry, and in mental processes and in estimation of ethical values. He presents the picture of abject neurasthenia. He is afraid to continue his drug and has no courage to contemplate the discomfort of discontinuing it. His nervous and mental degeneracy manifests itself largely in fear which dominates his conduct. He fears death, he fears his ability to carry through the day's work; he is afraid of falling into poverty, and is obsessed by the fear that he will not sleep. This factor of fear makes for the continuance of the habit and accounts largely for many relapses when the drug has seemed to be successfully withdrawn.
The fact that a pathologic condition has been induced becomes very evident during the time when therapeutic measures are being applied. "Getting the patient off his drug," as we phrase it, is a small part of the therapy; for when this has been done, we have still a condition to face often brought about by years of artificial metabolic and psychic reaction. There is yet to take place a slow nerve rebuilding, and a tedious mental and ethical reconstruction. The habit of quickly relieving pain has become so deeply rooted in the morphinist that when distress appears, as it will during the long period of rehabilitation, he reacts automatically to the painstimulus in automatic resort to the accustomed drug. The association reaction to pain or fear of pain, with use of morphine has as it were become fixed in his cerebrospinal centers; he may not want to take his drug; he may despise himself immediately after he has resorted to it; he often can not say why or how his relapse came about.
Not only bodily pain but emotional stress such as remorse, or anxiety, and states of fatigue or exhaustion have been associated in the mind of the morphinist with relief following administration of his drug; therefore, when similar states of emotion or exhaustion arise he is bound to react more or less automatically. It is this reaction, irresistible until he has regained his normal vigor, which leads the drug user to so-called lies and deceptions in order to obtain his drug. He can not be judged by standards which apply to normal persons. He is driven by the same instinctive impulse towards what seems to him self-preservation, as is the starving man, who obtains good by stealth or deception, blind to consequences.
In a word, relapse is most often due to a too brief therapy. The patient is not given a chance for complete recovery. He, as well as those having him in charge, is too prone to think that when the drug is entirely eliminated he can go about his business as an ordinary man. This a patient can rarely do; he has first to fight through a Stormy recuperative period of varying length; it may be weeks and it may be months. During this time when he feels upset, or anxious, or depressed, he will be very likely to fall back upon his drug, if he is permitted a freedom which allows him to obtain it.
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