Comparative investigations of the genesis of alcoholism and drug addictionDr. R. Battegay Basle University Psychiatric Clinic (Director: Professor Dr. P. Kielholz)
Alcoholism and drug addiction have certain psychological, sociological and pharmacological origins and phases of development in common. At the same time, drug addiction and alcoholism have their own specific characteristics. Definition of chronic alcoholism.
In what follows we shall deal both with the characteristics common to alcoholism and drug addiction and with their specific characteristics.
According to Staehelin, the basis for all addiction is a need for self-transformation of varying intensity. This need, which finally becomes craving and insatiable, usually originates in a tormenting, intolerable disturbance of the psychic balance either permanent and rooted in the basis of the personality or acquired by it. This craving sometimes results from an aimlessness and inner emptiness based on the way in which a person has lost touch with reality. A further possibility is where the imperious craving for self-transformation arises from the effect of corresponding environmental customs. Lastly, especially so far as drug addiction is concerned, the origin is often uncritical therapeutic treatment which causes or unleashes this insatiable craving.
If the misuse of alcohol or drugs is to be properly designated as addiction, certain pharmacological, psychological and sociological conditions must be fulfilled.
The WHO Expert Committee on Drugs liable to produce Addiction gave the following definition of drug addiction in 1950: "Drug addiction is a state of periodic or chronic intoxication produced by the repeated consumption of a drug (natural or synthetic). Its characteristics include:
An overpowering desire or need (compulsion) to continue taking the drug and to obtain it by any means,
A tendency to increase the dose,
A psychic (psychological) and sometimes physical dependence on the effects of the drug,
An effect detrimental to the individual and to society."
According to Isbell &, White, this definition includes both the opiates and synthetic analgesics and the hypnotics and sedatives (e.g., barbiturates, hydrate of chloral, paraldehyde and bromides), alcohol, cocaine, certain sympaticomimetic amines (e.g., amphetamine and methamphetamine), mescaline and marihuana. Addiction to these drugs differs, however, in many respects. Alcoholism, in particular, has peculiar characteristics which place it in a somewhat special category.
On the basis of our own research and observations, an attempt will be made to illuminate various factors which may play a part in the origin and development of alcoholism. At the same time, comparisons will be made with drug addictions, in which we shall so far as possible base ourselves on findings from research carried out in our clinic. As we have first-hand experience only with regard to alcoholics and anti-neuralgic 1 (and hypnotic), morphine and wake-amine addicts, we are confining our comparisons to these types. We will therefore attempt first to describe the personality of alcoholics and to compare it with that of drug addicts. We will then raise the questions of tolerance and of the physical and psychological dependence on alcohol in comparison with the similar problems for drug addicts. Lastly, we will turn to the question of how far, if there were a hypothetical success in controlling drug addiction, recourse would be had to alcohol as a substitute, and, conversely, how far alcoholism is now being partly replaced by certain drug addictions.
Before we turn to the findings from our research and seek to make a judgement on them, we should explain the concept of alcoholism. By alcoholism we mean, in agreement with the Sub-Committee on Alcoholism of the WHO Expert Committee on Mental Health, "any form of drinking which in its extent goes beyond the traditional and customary 'dietary' use or ordinary compliance with the social drinking customs of the whole community concerned, irrespective of the etiological factors leading to such behaviour and irrespective also of the extent to which such etiological factors are dependent upon hereditary, constitution or acquired physiopathological and metabolic influences ".
Our general view with regard to alcoholics is based on the investigation and observation of 122 patients admitted to our clinic for alcoholism 156 times altogether in 1957/58. Of these alcoholics 18.1% drank both beer and spirits, 16.4% beer only, 13.1% beer, wine and spirits or beer, wine, spirits and new wine (Most),9.0% wine or wine and spirits, 5.7% mixed all kinds of drinks and 4.1% drank spirits exclusively.
In addition, we tested 29 patients in 1959/60, with 35 admissions in all, partly for earlier phases of delirium tremens,
Mainly combinations of phenacetin, caffeine and small dons of a sedative.
particularly to see whether chronic excessive consumption of alcohol or withdrawal of it could be said to cause "physical dependence" or withdrawal symptoms similar to those experienced in certain cases of drug addiction.
A. Hereditary taints of the 122 alcoholic patients a
Including traces of them. (A patient often suffers from several taints.)
The heavy burden of hereditary traits in connexion with alcoholism and abnormalities of character of the most various kinds (imbecile, primitive and irritable-explosive psychopaths predominating), far exceeding the average for the population as a whole, is particularly noteworthy here. This is a situation which M. Bleuler has also noted in his investigation of 50 American alcoholics.
We found a marked proportion of suicide cases in the heredity of these patients. The reason is probably partly to be found in the tendency shown in these families to depression and primitive and short-cut reactions, but partly, too, to a feeling of guilt for the effects of alcoholism or, in other words, social failure. In addition, a somewhat higher proportion of schizophrenics was found in these families than in Bleuler's investigations. The difference may be partly explained by the fact that Bleuler's observations were drawn from socially successful alcoholics, while our findings are based mainly on patients who have not achieved either material or any particular intellectual values in their lives. The relatively high hereditary taint of imbecility and criminality is noteworthy. The large proportion of illegitimate births means that unknown heredity factors play an additional part. Only a few patients may be said definitely to have no hereditary taint.
The alcoholics therefore come from families in which there are constitutional complaints, but also considerable abnormal psychological developments.
Comparison with Drug Addicts
Kielholz found character abnormality of the most various kinds in the ancestry of 74% of 50 chronic morphine addicts. This shows that morphine addicts are obviously drawn far more from constitutionally degenerate personalities. Another and more important difference from the alcoholics is that there are more hyperaesthetic-asthenic, depressive, aggressive, hysterical characters in the heredity of morphine addicts, whereas primitive, irritable-explosive characters predominate in the heredity of alcoholics. Imbecility and suicide are frequent in the heredity of morphine addicts, as in the heredity of alcoholics. Meggendorfer reports, for example, that 13 cases of suicide by relations were found among the 36 morphine addicts investigated by him.
Labhardt, who investigated twenty wake-amine addicts in our clinic, found a large amount of character abnormalities of the most various kinds, psychoses, alcoholism, sexual perversion and also suicidal traits in these patients' heredity.
Persons misusing the anti-neuralgic drugs, which do not come under the narcotics laws, are common in Switzerland (T. Muller &, Kielholz) - misuse often rises to addiction - and are also burdened over the average with character abnormalities in their heredity, although not so much as morphine addicts and wake-amine addicts. An investigation of 109 patients addicted to anti-neuralgic drugs (Battegay) showed that 17.4%suffered from psychopathies of all kinds, so that the character degenerations on the whole corresponded to those in the heredity of alcoholics, there were primitivity, cathexis of the sensibility, tendency to depression, irritability, perversions and infantilism. Here too the very high proportion of alcoholics in the heredity (about 33%) was noteworthy. We regarded this as an indication that the alcoholism of earlier generations was being replaced among these patients by the "more modern "addiction to analgesic drugs. As in Fahrni's cases, the incidence of schizophrenia was relatively high (11%). As with alcoholics and morphine addicts, there was a considerable tendency to suicide (13.7%) and criminality (4.6%) in their families. Of these patients 28.5% had no hereditary taint - i.e., about the same proportion as among the alcoholics.
The father of 4 out of 6 addicts to the non-barbituric hypnotic drug doriden (glutethimide)investigated by us (Battegay) was a drinker or gambler.
Thus there are certain similar taints in the heredity of all these addicts, which, in addition to others, give the impression that these addictions, too, may have common roots.
B. Early Childhood Environment of 122 Alcoholics
As Zuber has shown, a large proportion of alcoholics grew up in incomplete families or outside the family community. Many of these patients were then brought up in an environment likely to inflict traumas on them or environments where they received insufficient affection. The father failed with many of these patients, and alcoholism was mostly the cause of this failure. The father's inadequacy may be expressed in different ways: either he does not care in the slightest about the family or he treats it without understanding, irritably and roughly. The mother too, however, fails in more than an average number of cases in these circles. This makes it obvious that alcoholics often lack a mother's protective care and close affection in their earliest childhood.
Thus, those who later became drinkers had no opportunity in youth to identify themselves with a protective, conscientious father who fulfilled his social duties. There might at best be an identification with the father's wrong attitude to the family, society, work and the higher values with a negative effect on the young man's development, or else a negative identification with the father. Boys and young men who lack the support and example that young people should normally obtain from their father will, therefore, in their helplessness and unprotected state, develop wrongly and turn to drink, either out of insufficient fixity of purpose and out of inner emptiness or because of spite and rejection of their father.
Lack of affection or inadequate affection in early youth by the mother means that these persons seek a "nursing" mother all their lives and therefore remain with an oral fixation. The unsatisfied oral need of early childhood, which strives insatiably for fulfilment, has to be stilled by means of the chronic consumption of alcohol.
The probable result of the craving for a" nursing" mother is the marked longing of alcoholics for security in a "maternal" environment and in the company of people with similar feelings who provide it. The reason why alcoholics are glad to spend their time in the society of similar drinkers is thus intelligible.
Comparison with Drug Addicts
We (Labhardt, Battegay) examined the early childhood environment only of wake-amine and analgesic drug addicts. Among the former in 8 out of 10 cases the early childhood environment was disturbed to a greater or lesser extent by neglect by parents. Of the patients addicted to the less powerful pain-killers 5.5% grew up motherless or with a negligent or unaffectionate mother, 10.1% fatherless or with a negligent or unaffectionate father, 16.5% lived in their early childhood with unaffectionate parents or without parents (in hostels or with foster families). 67.5%of these patients had an outwardly untainted early childhood environment.
C. Body Type a
The figure for women with corresponding body type is given in parentheses.
The body type found among male drinkers is most commonly the asthenic, followed by the athletic. The pyknic type is rarely found among male alcoholics, as Zuber has also noted, whereas it is predominant among female drinkers. As few female patients were investigated, no conclusions can be drawn about the distribution of body type among them.
The relatively low proportion of pyknics among male drinkers may seem surprising, it is often supposed that alcoholics are mainly affectionate, warm-hearted and good-humoured characters. This assumption is not borne out, however, in the distribution of body types among the drinkers investigated by us. Alcoholics are often not a priori such good-humoured drinkers as they are often supposed to be, on the contrary, they are frequently unbalanced, unintegrated personalities who are trying to achieve psychic balance or carefree good humour by means of alcohol.
Comparison with Drug Addicts
Kielholz found 58% asthenics among morphine addicts and there were a great many asthenic types (11 out of 20 patients) among the wake-amine addicts, only 3 out of 20 of these patients was of the pyknic type.
49.5% of the analgesic drug addicts investigated by us were asthenic.
The conclusion to be drawn is that morphine addicts are mostly of the asthenic type, followed by wake-amine and analgesic drug addicts. Among alcoholics, however, the proportion of asthenics is considerably lower, and the proportion of athletic types considerably higher. Only 4.6% of the antineuralgic drug addicts were of the athletic body type. The proportion of pyknics among them was, according to our investigations, somewhat higher than among alcoholics (23.8%).
40.2% of the drinkers examined by us had been criminals in earlier life. The main offences committed by the male patients and, to a lesser extent, by the female patients were offences against property. The relatively infrequent appearance of the pyknic type among the male patients seems to confirm the fact, known from large-scale statistics (Kretschmer), that
Medical definition of chronic alcoholism
the proportion of pyknic types among criminals is below the average for the population. The psychoanalytic theory that alcoholics are subject to an oral fixation also receives confirmation in the light of the frequent offences against property. The imperative demand for the "satiation" of a "greed" and the "insatiable" need to "quench" the"thirst" by alcohol should accordingly originate from one and the same source - the oral frustration of the alcoholic in early childhood. This, however, raises the question of how far the offences may not be the consequences of alcoholism, but, even so, the chronic misuse of alcohol probably merely unleashes or reveals latent pre-dispositions or disturbances in development.
Comparison with Drug Addicts
Offences against the law are not rare among morphine addicts, especially falsification of prescriptions. These offences are mostly the results of the addiction or of withdrawal symptoms, and so should not be regarded as an indication of the primary character of these addicts. However, in isolated cases a predisposition or the result of a defective development may of course be exposed through chronic morphine addiction.
Only a few cases of criminality are known among wake-amine addicts. This is most readily to be explained by the fact that the interruption of misuse of wake-amines on an addictive scale does not entail withdrawal symptoms.
No significant criminality is found among addicts to anti-neuralgic drugs, except as observed above, in their heredity. Withdrawal symptoms certainly occur when the use of these drugs is discontinued, but in Switzerland no prescription has to be obtained for them, so that they can be purchased legally without difficulty.
Like D. Lerch, who found suicidal tendencies in 19.7% of 137 very heavy drinkers, we discovered from anamnesis and the clinical observation period that 22.1% of our alcoholics attempted or threatened suicide. These figures indicate that excessive alcohol consumption is to be regarded in some drinkers as, among other things, a surrogate for suicide.
Comparison with Drug Addicts
Indulgence in narcotic drugs sometimes also indicates an attempt to find a surrogate for death. The evidence for this is the number of suicides by morphine, anti-neuralgic and wake-amine addicts, already noted in the families, and the many attempts at suicide by the patients themselves.
F. Occupation. Social Status
The largest group in the break-down by occupation is that of the unskilled workers. However, a comparatively large number of skilled workers fall victim to alcoholism. Builders, whether labourers or skilled workers, have been entered separately to give an indication of the conditions in this type of work which generate alcoholism. There are also a great many traders, especially commercial travellers. It is therefore especially those engaged in manual labour, but also persons with professions which demand a great deal of travelling, an irregular life and frequent contacts with a variety of acquaintance who are endangered by alcohol more than the general average. This gives an indication of the real significance of actual environmental circumstances in the genesis of alcoholism, besides the factors determined by development and physical make-up.
Women employed in the hotel and inn industry account for by far the greatest majority of female alcoholics. This circumstance too draws attention to the importance of exogenous influences in the origin of alcohol addiction.
Comparison with Drug Addicts
Since the narcotic laws are strictly enforced in most countries, it is now mainly persons in the medical profession who become morphine addicts. In addition, there are persons of the most varied occupations who have once received treatment with morphine or some substitute drug following a painful illness and cannot afterwards relinquish the drug. A further large number is composed even today of inhabitants of certain areas in which the traffic in narcotic drugs flourishes.
The picture of the conditions in which morphine addiction arises is falsified by the general lack of opportunities in most countries to obtain morphine. It may perhaps be assumed that all members of the few occupations which handle this drug are likely to be in danger of addiction, but, countering this assumption, it should be recalled that in countries in which the narcotics laws are strictly enforced all doctors and all other persons connected with the medical profession have at all times plenty of opportunities to evade the narcotic drugs control, yet only isolated members of this profession become morphine addicts. This shows how much more decisive the constitutional factors are for the origin of morphine addiction than they are for alcoholism.
Among the few addicts to dextromoramide (d-2, 2-diphe-nyl-3-methyl-4-morpholino-butyryl-pyrrolidine) (Battegay &, Gnirss) treated in our clinic, the majority, from the point of view of occupation, are energetic, ambitious persons who have perhaps devoted more effort to responsible positions than they were capable of. It should be noted, incidentally, that prescriptions for this drug are not required even yet in some countries. The fact that primary character abnormalities are in the majority among addicts to dextromoramide is evidence of the decisive part played by predisposition in the genesis of this addiction too.
Labhardt found that the overwhelming majority of wake-amine addicts belonged to the medical or academic professions, these patients were mostly distinguished, conscientious and energetic persons. Like the morphine addicts, they often could not achieve their extreme ambitions in the circumstances of their lives, a discrepancy arose between their will and their capacity, between their effort and reality. Environmental conditions may hardly be said to be mainly responsible for this cleavage, but rather the primary basic characteristics of the persons who later became wake-amine addicts. Evidence for this opinion is that the majority of doctors and other persons connected with the medical profession and the academic profession succeed in advancing in similar circumstances.
The break-down by occupation for anti-neuralgic drug addicts points, on the other hand, to the considerable significance of exogenous influences for the origin of misuse and addiction to the less powerful narcotic drugs. Thus, it is mainly women who are burdened both with occupational and household work who take to these analgesics. In addition, persons connected with the medical profession and also chemical workers account for a large proportion of these patients. Practising such dangerous professions, considerable responsibility in professional work, precision work, the practice of art or engaging in occupations on the margin of society seem to be reasons which promote the misuse of, and addiction to, the less powerful narcotic drugs. In any case, here too, not only the environmental influences are decisive, but very probably also the primary character structure, which, after all, conditioned the choice of occupation, are probably equally decisive.
Alcoholism is found in all social strata, but persons less favoured socially are particularly liable to turn to alcohol, whereas in Switzerland morphine is the means of intoxication used by persons in a better social position. The persons who take to wake-amines are fairly similar to the morphine addicts in social status, whereas the addicts to anti-neuralgic and hypnotic drugs are in this respect about mid-way between morphine addicts and alcoholics.
The question of whether an addiction is conditioned mainly by exogenous or endogenous factors cannot be decided on the basis of distribution by occupation and social position, there are only certain indications which make it possible for us to say that sometimes exogenous factors are more responsible for the origin of the addiction and at others endogenous factors have a greater influence. Lastly, it will always be an interrelation of both that leads to addiction, so that exogenous factors are more likely to generate alcoholism and endogenous factors predominate in generating morphine addiction and wake-amine addiction and in misuse of anti-neuralgic drugs external and structural factors give rise to the addiction simultaneously.
In ascertaining the origin, account was taken of the place at which the patients had spent most of their youth. From this point of view, 45.9% of the alcoholics grew up in Basle and its suburbs, 18.9% in towns other than Basle, and 34.4% in the country. The place of origin of 0.8% was not known. The relatively high proportion of patients brought up in the country is striking since our clinic is in the city. The number of those who came from other towns is also fairly large. This distribution of origins is partly to be explained by the fact that the former countrymen and town-dwellers who come from outside feel themselves homeless, lonely and uprooted in their new city environment and are therefore more susceptible to the dangers of alcohol than those who have always lived in the same city environment.
Comparison with Drug Addicts
Virtually the same distribution was found among the addicts to anti-neuralgic drugs whose origin was also investigated. Some three-fifths of these patients came from towns and two-fifths from the country. The fact that it was particularly the feeling of being uprooted which led these patients to become addicted again emerges. This factor has long been known, for example from the large American cities, where the descendants of recently immigrant negroes and Puerto-Ricans living in the slums easily fall victim to narcotic drug addiction owing to their homelessness and lack of roots. But the wake-amine addicts, who all come from city environments, show clearly that yet other factors, which have their roots in the person himself, have a decisive influence on the origin of the addiction. In any case, in judging the influence of origin, it is again clear that external circumstances play a greater part in the case of alcoholics and constitutional reasons exert the greater influence in the case of morphine addicts and those addicted to the stimulant drugs, whereas the misusers of anti-neuralgic and hypnotic drugs come midway between them in this respect too.
H. Marital Status
The tendency towards debasing marriage and to breaking up marriage is considerably higher among drinkers than the average for the population. Marital difficulties are often the result, but also often the cause, of alcoholism.
Comparison with Drug Addicts
As Kielholz notes, almost all female morphine addicts are divorced. This is usually a result of the addiction, husbands very soon leave their wives who have become addicts, while relatively many women care for their addicted husbands and sacrifice themselves for them all their lives.
Of the wake-amine addicts, 50% are still single, as would be expected from their youth. Marital conflicts are frequent among married addicts.
Conditions with those addicted to anti-neuralgic drugs are similar to those of alcoholics. They have a distinct tendency towards marital conflicts.
The alcoholics investigated by us began to drink on an average at the age of 27 (males) or 31 (females), they entered the clinic for the first time at the age of 42 (males) or 44 (females) - i.e., 15 years (males) or 13 years (females) after they began drinking. Within this period these patients obviously drifted into excessive drinking which damaged them individually and socially.
The reason for the shorter period between the beginning of chronic excessive consumption of alcohol and entry into the clinic among women cannot be explained definitely, since we investigated only a few female patients. Perhaps women pass more quickly from symptomatic to addictive drinking once they have fallen victim to alcohol. They are then particularly psychically dependent on the effects of alcohol. As we shall show later, delirium is relatively rarer among females than among males, so that it cannot be assumed that women suffer a physical dependence more rapidly.
According to Jellinek, the transition to excessive drinking obviously conditioned by the emergence of tolerance of the desired effects of alcohol occurs after 10 to 12 years. From then on the alcoholics lose control over themselves and over the amount of alcohol they consume. However, as may be seen from our calculations, they do not enter a psychiatric clinic until one to 5 years later, obviously when they themselves, their neighbours or the authorities have realized their illness as such.
Comparison with Drug Addicts
According to the statistics supplied by Schaumann, the beginning of morphine addiction is to be set at about the age of 30 to 40, since this age group shows the largest number of morphine addicts.
The majority of wake-amine addicts treated in our clinic began misuse at between 20 and 30 years of age.
The misusers of anti-neuralgic drugs began to misuse them at the age of 30 to 34, on an average, they entered the psychiatric clinic for the first time 5 to 7 years later.
Thus, wake-amine addiction began shortly after the patients became adult, at that time personal maturity normally reaches a certain stage, but the occupational development is just beginning. On the other hand, the beginning of drinking, use of morphine and misuse of anti-neuralgic drugs comes at an age at which people as a rule are in full occupational development and have already developed family ties. Thus, with the former it is at the beginning and with the latter during the fulfilment of the tasks assumed by them when they seek refuge in addiction.
Of the 86 males married at the time of admission to our clinic or earlier, 24 (27.9%) were married to women one to 13 years older, 9 (10.7%) to wives of the same age and 39 (45.1%) to younger women. The age of the wives of 14 men (16.3%) was unknown to us. Im Obersteg has already pointed out, on the basis of the findings of his own investigations into very heavy-drinking alcoholics, that drinkers often bind themselves to women older than them. Here again is an indication that drinkers are, among other things "maternally diminished" and therefore seek throughout their lives for a mother to look after them and to "nurse" them, and they often hope to find her in an older wife. The fact that, as a rule, they continue to devote themselves to alcohol after such a marriage betokens that in most cases the search has not succeeded.
The relative figures for females are probably much the same as those for the average of the population, perhaps the proportion of younger husbands is somewhat too high. Of 15 female patients married at the time of admission to the clinic or earlier, 8 had older husbands, 3 husbands of the same age and 2 younger husbands. The age of the husbands of 2 women was not known to us.
Comparison with Drug Addicts
We could not arrive at findings for the drug addicts similar to those which we discovered for the alcoholics.
It was found that several motives frequently combined in originating addiction, so that a patient could be classified under several heads. We found as motivation for misusers of alcohol: 56.5%, a desire for sociability, 37.7%, a desire to allay mainly psychological conflicts, 28.7%, a desire for euphoria, and 23.7%, enjoyment. In addition, the following motivations, among others, came to light: tranquillity and relaxation, inducement to sleep, relief of withdrawal symptoms in barbiturate poisoning or anti-neuralgic drug addiction, stimulation, hostility to society and self-destruction. The motivation changed in the course of the illness in some cases.
The investigation brought out the motivation that drinkers are obviously often driven by the need for a group to shelter them, for a "maternal" environment, and so are driven to frequenting bars and hence into alcoholism. The same problem, which as we have emphasized above, often drives alcoholics to marry older women, but also to committing offences against property, appears to be reflected in this desire to be taken up by a group.
Comparison with Drug Addicts
Kielholz found that only 22% of morphine addicts suffered continuous bodily pain when they entered the clinic and tried to dull it with morphine. This author emphasizes that a disposition to addiction frequently exists even in the "symptomatic morphine users ", in 45% of morphine addicts actually suffering physical pain he found a hereditary characteristic which dearly indicated a constitutional motivation.
In the wake-amine addicts it was mainly an effort to increase their performance, and also to reduce their appetite and weight that led to addiction.
The motive of the majority of patients misusing anti-neuralgic drugs was an attempt to dull bodily or mental pain and, rather less frequently, to increase capacity of performance. A few patients sought tranquillization, and only in very rare instances euphoria.
It again became evident that exogenous factors were predominant in the origin and development of alcoholism, whereas constitutional factors were the cause of the genesis of morphine and wake-amine addiction.
M. Factors directly stimulating Addiction
With 112 patients (91.7%) it was mainly psychological factors that led to the beginning of excessive alcohol consumption. Principally it was "infection" by drinking customs and psychologically burden. some conditions or long-lasting conflicts with the environment, and secondly single psychological traumas and states of depression. In 2 cases (1.7%) withdrawal symptoms of barbiturates or anti-neuralgic drugs were the immediate cause of exorbitant alcoholic consumption. One patient (0.8%) took to alcohol as a result of a psychosomatic complaint and 2 patients (1.7%) as a result of physical complaints. The immediate stimulus was not known to us in 5 cases (4.1%).
Comparison with Drug Addicts
With morphine addicts physical pain was the direct stimulating factor considerably more often. But it was only the direct impetus to beginning addiction. The motivation for the addiction lay deeper. As we have already suggested, only 22% of morphine addicts in actual fact were seeking to allay physical complaints by the use of this drug.
A feeling of weariness and inadequate ability to perform were the immediate factors in stimulating wake-amine addiction, and, in isolated cases, excessive weight, which was felt to be unaesthetic.
Of the patients misusing the less powerful narcotic drugs, 11.9% had taken to misuse or addiction as a result of physical suffering, psychological and psychosomatic factors were the immediate cause that led the other patients to take to anti-neuralgic drugs.
The stimulating factors appear to be of definitely secondary significance, they are merely the last push which "sets the ball rolling".
N. Clinical diagnoses, personality of addicts
If the alcoholism is entered in the clinical diagnosisin combination with other illnesses, only the main diagnosis of them is given.
Drug addiction (anti-neuralgic} in 3 other patients as a secondary diagnosis.
Reactive depression in 3 other patients as a secondary diagnosis.
A significantly higher proportion of abnormalities of character than the average for the population is to be found among alcoholics. According to Lange's data, 6% to 10% may be regarded as psychopathic. Psychopathic alcoholics show a predominance of imbecility, infantility and schizoid characteristics, followed by irritability, depression and sexual perversions. The alcohol presumably allows these people to participate in life despite their innate weaknesses and to live with their inadequate capacity for success in life, their depressions, their aggressiveness against the world around them and against themselves, and their perverse instinctive needs in an apparently harmless form.
Only 4.1% suffered from manifest neurosis· Another 4.1% combined misuse of alcohol with drug addiction.
As Dukor and other authors report, and as may be seen in our tables, most alcoholics are not, however, abnormal characters. They are, it is true, "singled out by a determined characteristic individually... but cannot possibly be described as psychopaths" (Dukor). They have been described by Staehelin as" simple, fairly primitive people... without any higher aims in life whatever... who show a marked herd instinct, gladly gather together, are active in all sorts of associations and thus gradually drift into tippling and drinking ". These, therefore, are the alcoholics who are mainly to be found as regulars in the bars and who pass the time playing cards and drinking because they have no notion of what else to do. The question arises, however, whether a deep need for protection, for a "nurturing soil ", for a "maternal" environment, but also the desire for the possibility of identification with a father, or especially a search for a harmonious family and for a group existence may not cause such drinkers to frequent the bars.
Comparison with Drug Addicts
With morphine addicts, on the other hand, basic character abnormalities are far more predominant, testimony to this are the psychopathies found by Kielholz in the ancestry of 74% of 50 morphine addicts. Morphine addicts include especially asexual, unstable, hypersensitive, aggressive, emotional, uncoordinated, passive asthenics. These characteristics explain why it is precisely with these patients that a cleavage often occurs between their on the whole high expectations and their performance or capacity for success, which they subjectively find inadequate, and which often leads in such people to neurosis, hysterical reactions and states of depression. As among alcoholics, homosexuals are not infrequently found among morphine addicts, according to Meggendorfer. Kielholz found in 60% of our morphine addicts a combination of morphine addiction with misuse of anti-neuralgic or barbiturate drugs. Occasional heavy alcoholic excesses were known to have been indulged in by several patients. This shows that anti-neuralgic drugs, barbiturate drugs and alcohol are as a rule taken only if patients cannot obtain a sufficient quantity of morphine. They were seeking to prevent or bridge over the insomnia and withdrawal symptoms in this way.
Labhardt found 70% of psychopaths among wake-amine addicts. There was a clear predominance of asthenic, sensitive, hysterical and imbecile personalities, followed by sexually abnormal personalities. In 65% of the cases wake-amine addiction was combined with morphine addiction, barbiturate addiction and alcoholism or other addictions.
Among the users of and addicts to anti-neuralgic drugs there were 44% psychopaths, mainly hysterical, sensitive and schizoid, less frequent, but still above the average, were emotionally unstable and imbecilic personalities. There were also abnormally impelled characters. In 11.9% of cases there were neuroses. 7.4% suffered from schizophrenia. In 22.9% addiction to anti-neuralgic drugs was combined with alcoholism. In any comparison of alcoholics with the different types of drug addict, the kernel of alcoholic patients appears very different from the kernel of morphine addicts. The prototype of the drinker is, in Switzerland at least, the integrated socially minded, primitive person without lofty aims, who lives from day to day, taking things as they come and for whom drinking alcohol or sitting together with alcoholics makes up almost the whole content of his life. The typical morphine addict, on thc other hand, is usually unintegrated, hard to penetrate, and sensitive, and finds it hard to express himself, as he has difficulty in adjusting himself. An alcoholic will therefore drink mainly out of a need for company, whereas a morphine addict basically probably takes to the drug in order to bridge over his (subjectively experienced) inadequacy.
Alcoholics and morphine addicts are the final links in a chain, but there are isolated alcoholics who embody the morphine addict's type and a few morphine addicts who correspond more to the alcoholic's type. On this chain misusers of anti-neuralgic drugs come somewhere midway between alcoholics and morphine addicts and wake-amine addicts close to morphine addicts. Other drug addicts could probably be appropriately placed somewhere on such a chain.
O. Tolerance - Physical and Psychological Dependence
We investigated especially with regard to the question of tolerance and physical dependence the case histories of 29 patients (27 men and 2 women) who were treated in our clinic in recent years for delirium tremens, and the total of 36 (34 men and 2 women) who went through phases of delirium tremens in part in the past.
We noted that, in the majority of cases, the delirium is not directly connected with chronic alcoholic consumption. In 33 cases of delirium there was rather an interval on an average of 2 to 3 days - in exceptional cases it lasted 24 hours or 5 days - between the interruption of drinking and the beginning of delirium. The withdrawal period was usually conditioned by a feverish condition or a trauma, especially of the skull, which required rest in bed or hospitalization. In the case of one patient there was an alcohol withdrawal phase three times in connexion with three committals to gaol, where he always fell prey to delirium after an interval of 2 to 4 days. A delirium tremens developed in another patient too after incarceration (withdrawal phase 2 days). In 2 cases of psychosis it could not be ascertained whether there had been an interval between the interruption of drinking and the beginning of the psychosis. Delirium immediately followed a very heavy intake of schnapps only in the case of one excessive schnapps drinker.
The interval occurring in most cases of delirium is, in our opinion, definite evidence that the overwhelming majority of cases of alcohol delirium are to be regarded as withdrawal manifestations. It may only be asked whether these intervals do not give a false impression, because the patients concerned were in a pre-delirious condition quite possibly even before the feverish symptoms and fits referred to above. We believe, however, that this latter possibility must be exluded. Patients give no sign immediately before the onset of the feverish conditions or the fits from which any conclusion can be drawn about the probable outbreak of deliritun. With 2 patients who, as has been said, suffered a typical delirium tremens after committal to gaol, the time of committal and of the beginning of the withdrawal period could certainly not be attributed to a pre-delirious phase beginning at that time. On the other hand, it is more probable that the feverish state or the physical trauma, in addition to imprisonment and the withdrawal from alcohol, promoted the onset of delirium.
Although we speak of the pre-delirious phase, we mean, however, the interval that usually occurs between the interruption of drinking and the onset of delirium- i.e., the withdrawal phase. During this period we can recognize progressive prodromal manifestations. They consist of anxiety and depression, which grow more and more obvious, irritability, motor disturbances, apathy, sweating and a tremor that becomes increasingly severe, in addition, the illusionary failure to recognize environment, and isolated hallucinations.
In 3 cases, a phase of delirium tremens began with an epileptic fit. In other cases, the epileptic fit immediately followed a contusio cerebri, whereas the delirium appeared only after an interval of 4 days. This attack is, however, rather the result of the contusio cerebri than of chronic misuse of alcohol. The 3 epileptic fits mentioned which were followed by delirium are, on the other hand, further indications that the assumption is correct that this psychosis - at least in these three cases - was a withdrawal manifestation.
Investigations of alcoholics in the Addiction Research Center in Lexington, Kentucky, by Isbell, Isbell and collaborators confirm this view. 400 ml or more of 95% ethyl-alcohol was administered to alcoholics daily for 45 days. As the patients were withdrawn from alcohol, typical withdrawal symptoms appeared, such as severe tremor, pronounced hyperreflex action (or even ankle clonus), convulsions of the grand mal type and corresponding findings in the electro-encephalo-grams. The appearance of these phenomena was correlated in due course with the reduction in the alcohol concentration in the blood after the interruption of the drinking.
The single case of delirium which occurred directly following very heavy intake of schnapps in a case of chronic alco holism testifies that very heavy prolonged misuse, and in some cases an abrupt massive intake, of alcohol, especially schnapps, can also lead directly through intoxication to delirium.
Cases of alcohol delirium are, however, to be regarded in the great majority of cases as withdrawal symptoms, in isolated cases as intoxication psychosis.
According to our investigations, the first attack of delirium tremens occurs on an average between the ages of 48 and 50, after I7 to 18 years of continuous very heavy misuse of alcohol. The development of alcoholism towards delirium tremens occurs as follows with these patients: after 10 to 12 years of drinking which is still to a certain extent under control, as we assumed above, in conformity with Jellinek, comes the transition to excessive and uncontrolled drinking. During this period a tolerance of the desired effect of the alcohol has obviously been reached, as we know it does in the case of drug addicts. This requires an increase in the dose and a more intensive sequence of drinking excesses. A physical dependence on alcohol arises as the result of the now almost permanent intoxication, such as we know in the case of addicts to morphine and synthetic substances with morphine-like effects (Eddy and collaborators, Isbell and White, among others), barbiturates (Isbell &, White, Kielholz), hypnotics containing no barbituric acid (Battegay) and anti-neuralgic drugs (Kielholz), but not in wake-amine addicts (Labhardt), where the withdrawal symptoms when alcohol is withdrawn are much more like the symptoms of withdrawal from hypnotic and anti-neuralgic drugs - where these delirium and epileptic fits may also occur - than to those of morphine withdrawal.
In the cases investigated by us, the delirium tremens lasted on an average 4 to 5 days. The waning of physical dependence may be set at the end of the delirium. Yet the alcoholic continues to experience an irrestible desire for alcohol that would lead him to resume drinking immediately after the waning of the psychosis if he were discharged from the protecting environment of the psychiatric clinic without further therapy and without prophylactic measures. It is this psychological craving which led some of the persons who were later to become chronic drinkers to seek refuge originally in alcohol. These are the psychopathic or, in a psychological sense, primary addicts, who seek mainly anaesthesia or euphoria through alcohol. Secondary addicts - i.e., persons who originally drank alcohol for social purposes, out of habit or out of inner emptiness - were not, however, possessed by this irresistible craving at the outset. It developed in them as time went on. There are, however, reflected in the habits of drinking which are acquired by social and habitual drinkers the deepest need for self-transformation, for expanding in an emotionally protective environment, for nurture and protection by mother and father, as we have already observed.
The psychological dependence on alcohol and the drinker's irresistible craving for its effects are based on the need for self-transformation, for conquest of self, which we find to an even more marked extent in drug addicts, especially morphine addicts. This need is the primary impulsion of people who somehow diverge from the norm and are thus excluded from the life and experience of the community. A large proportion of drug addicts, but also some alcoholics, consist of such people, as is manifest from our findings. People who have found alcohol or drugs indispensable for years are, however, comprised in a secondary sense. Yet while the addicts, whether chronic misusers of drugs or of alcohol, believe they are approaching the conquest and fulfilment of their selves, they are in peril of self-destruction.
P. Combination of Alcoholism and Drug Addiction and Substitution of Drugs by Alcohol and vice versa
Drug addicts often tend to misuse of alcohol also, hereditarily they are very heavily tainted with alcoholism. Certain abnormal personalities - e.g., imbeciles and infantiles - are found both among alcoholics and among drug addicts. In addition, drug addicts often try to dissipate all sorts of withdrawal symptoms by the use of alcohol, in which they are usually only partly successful (Isbell and collaborators). According to all views on the subject, it may be assumed that if a prohibition of drugs liable to cause addiction were theoretically 100% effective, alcoholism would become more widespread. It would embrace mainly those who change from drugs to alcohol, whose character structure corresponds to a type of drinker and also to a type of morphine addict. An increased danger of suicide would have to be assumed in the case of persons who have not been successful in changing to alcohol, owing to the high rate of suicide in the families of drug addicts and to the fact already observed that drug addiction may also be regarded as a surrogate for suicide.
Alcoholics are frequently found in the heredity of drug addicts, according to our investigations, so that we must also consider the reverse process, the substitution of drugs for alcohol. Thus, it was particularly noteworthy with the misusers or addicts to anti-neuralgic drugs investigated by us that alcoholism in earlier generations has partly been replaced today by the "more modern" drug addictions.
Definition of chronic alcoholism
Alcoholism and the ever-multiplying drug addictions together embrace more people at the present time than ever. Considerable efforts towards intensifying and spreading prophylatic measures, especially for the "elimination of misuses involving whole nations" (Wolff) and for curbing the unhealthy effects of the spirit of the age are therefore as necessary as ever, especially today. There is even greater need, however, to educate people to understand the weak and the outsiders, in order to give them a possibility of an existence within human society which they too would subjectively find worth living. This would, in the end, be the best prophylaxis of all addictions.
We have attempted, on the basis of investigations into 122 patients who entered our clinic during the year 1957/1958 156 times in all for alcoholism, to ascertain various factors which may play a part in the origin of alcoholism. Corresponding investigations were added for comparison of mor- phine, wake-amine, anti-neuralgic and hypnotic drug addicts. In comparison with the average of the population, a stronger hereditary tainting is found in the alcoholics - only 32.0% were certainly without hereditary taints - especially alcoholism, psychopathics of the most various kinds and suicidal tendencies. A similar situation is found with regard to the drug addicts. However, the character abnormalities were markedly stronger in the heredity of morphine and wake-amine addicts. While 18.9% of the alcoholics showed psychopathies in their heredity, innate character deviations of the most various types are found in the families of 74% of the morphine addicts. 50.8% of the drinkers investigated by us grew up in incomplete families or families inadequate in some other way - i.e., those who later become alcoholics often lack the emotional warmth of a mother in their early youth, or the possibility of identification with a protective and conscientious father. A disturbed early childhood environment may often be discovered by anamnesis, among the wake-amine addicts there was a disturbed childhood in 8 out of 10 cases investigated from this point of view and in 32.1% of the cases of addicts to anti-neuralgic drugs. The asthenic body type is predominant among morphine addicts and wake-amine addicts to an even more marked extent than among alcoholics, misusers of anti-neuralgic drugs are in a middle position in this respect. Frequent criminality occurs among alcoholics (40.2% of our patients had been criminally convicted one or more times, mainly for offences against property). Falsification of prescriptions is the main known offence among morphine addicts, whereas hardly any offences are committed by wake-amine and anti-neuralgic drug addicts. There must be some connexion with the fact that the stimulants leave no withdrawal symptoms and that the less powerful pain-killers can be obtained without prescription in Switzerland.
A marked tendency to suicide is noteworthy both among alcoholics and drug addicts. 21% of our alcoholics attempted or threatened suicide before they entered the clinic. In addition, chronic alcohol or drug consumption often represents an equivalent for suicide. While unskilled workers account for the majority of the alcoholics, a large number of persons engaged in the medical profession are found among morphine and wake-amine addicts. Among the addicts to stimulants there are also many professional persons not belonging to the medical profession. The majority of anti-neuralgic drug addicts are women who suffer a double burden - i.e., housework and an occupation. The investigation of origin shows a high proportion brought up in a rural environment (34.4%) and in towns other than Basle (18.9%). Of the anti-neuralgic drug addicts investigated in this connexion three-fifths came from towns and two-fifths from the country. The feeling of being uprooted and lonely entailed by the change of residence and environment promotes the genesis of addiction. The beginning of misuse of alcohol (27-31 years of age) is about the same as that of morphine and anti-neuralgic drug addiction. Alcoholics enter a psychiatric clinic on an average 13 to 15 years later, while misusers of anti-neuralgic drugs are hospitalized only 5 to 7 years on an average after the beginning of misuse. The tendency towards breakup of
marriage is above the average for the population with all the addicts investigated by us and is either a consequence or one of the causes of addiction. Alcoholics fairly frequently marry women older than themselves. This is one of the symptoms which indicate early childhood oral frustration and a continuing oral fixation. Nothing corresponding about the age of the spouses is known to us with regard to the drug addicts. The motivation for addiction among the alcoholics is often based in environmental circumstances (in 56.5% of the cases it is a seeking for sociability), on the other hand, the motivation for addiction among morphine addicts must be regarded in most cases as an expression of an innate predisposition of character. Correspondingly, psychopathies of some kinds are found much more frequently in morphine and wake-amine addicts than among alcoholics. 43.5% of our alcoholics were merely "ordinary" drinkers, who are certainly marked by a certain type of character - frequently fairly primitive people seeking sociability among "like-minded persons" and without higher aims - but cannot be described as psychopathics.
Among the alcoholics it is therefore mainly exogenous factors and among the morphine and wake-amine addicts rather constitutional factors which are responsible for the genesis of the addiction, whereas among anti-neuralgic drug addicts, exogenous and basic factors are balanced. The alcoholics and the morphine addicts are the final links in a chain, misusers of anti-neuralgic drugs come somewhere in the middle and wake-amine addicts close to the morphine addicts. Most of the other kinds of drug addict could probably be appropriately placed somewhere on such a chain.
On the basis of the phases in the development of alcoholism, of the observed interval between the interruption of drinking and the beginning of delirium in 33 of the 36 alcoholic deliriums investigated, the comparison with the drug addicts and other factors, the hypothesis of a tolerance and physical and psychological dependence in chronic misuse of alcohol is justified.
The question to what extent resort would be had to alcohol in the event of a hypothetical success of the control of drugs liable to produce addiction and, conversely, the extent to which certain drug addictions can be substituted for alcoholism was raised. It was shown that especially those addicts whose character structure conformed to a type of drinker and also to a kind of morphine addict - e.g., infantile or imbecile personalities - would turn to alcohol. The frequent appearance of alcoholism in the heredity of persons addicted to anti-neuralgic drugs, on the other hand, testifies to the fact that alcoholism has already been partly replaced by the "more modern" drug addictions.
The necessity is stressed for prohylactic measures, not only medical, but also of a general humanitarian kind.
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