Psychoanalytic Conceptions of the Mind in Drug Abusers: Methods Exploring Personality Disorders, Traits, and Defense Mechanisms

Sammanfattning: The purpose of the present thesis was to explore the theoretical and clinical implications of personality disorders (PDs), personality traits, and defense mechanisms in drug abusers diagnosed with psychosis and PDs. The prospect was, via four empirical studies and one paper of discussing methodology, to increase the psychodynamic understanding, which might improve the precision in planning treatments for drug abusers. Psychoanalytic conceptions of the mind were underlined. Methods. Four methods were applied: the psychoanalytically oriented percept-genetic techniques of Defense Mechanism Technique modified (DMTm) and Spiral Aftereffect Technique (SAT), plus the interview methods of the Structured and Clinical Interview for DSM (SCID) and the psychoanalytically constructed Karolinska Psychodynamic Profile (KAPP). The 84 subjects were recruited in 1994-96, from a cohort at Sabbatsberg Hospital, Sweden. The first group was diagnosed as 19 DSM-III-R psychotic substance abusers (mixed drugs). The second group consisted of 65 drug abusers (mainly heroin or amphetamine) diagnosed in ten DSM-III-R PDs and classified in three DSM-III-R clusters. Results. In Paper I, according to the DMTm, the 19 psychotic substance abusers showed: their projected selves as petrified, inanimate, or disguised in relation to 'the threatening mother,' deficiency in reality-testing, failing to maintain three emotional barriers: (1) separating from and being different from the other, (2) distinguishing the barrier of gender, and (3) 'the high oedipal position,' concerned with the generation gap. In Paper II, the DMTm results showed the significance of projected introaggression in the 'odd' cluster and inhibition in the 'fearful' cluster. Results also showed that introaggression, barrier isolation, and disappearance of threat were significant to borderline PD. In Paper III, all ten DSM-III-R PDs were explored. The results increased knowledge of what PDs specifically contributed to the correlation between DMTm signs and DSM-III-R clusters. Drug abusers with a primary anti-social PD (ASPD), as related to a comorbid second DSM-III-R PD (n=47 out of 65), were analyzed separately. In Paper IV, the DMTm and the KAPP were applied to the group of the 47 subjects with ASPD and a comorbid second PD. Significant personality traits in relation to the 'dramatic' cluster were severity in: Dependency and separation, Coping with aggressive affect, Alexithymic traits, Normopathic traits, and Sexual satisfaction. Results showed congruence between some of the psychoanalytic constructs in the DMTm and the KAPP. In Paper V, four problems with interviews, as related to the topographic model, were discussed. The problems are: (1) the drug interferes with personality, (2) drug abusers are far from always inpatients between four to six weeks, (3) they suffer from dysfunctional memory, incapacity for psychological reflections, the language itself (alexithymia), and (4) the conditions they must accept to receive clinical care activate manipulative behavior and latent defenses during interviews. Conclusions. Empirical research on theoretical and clinical implications in PDs, traits, and defense mechanisms are crucial parameters to evaluate. For example, motives behind defenses (DMTm), a deepened clinical picture of PDs (DSM-III-R) via the KAPP interview measuring personality traits might be used to form a well-grounded treatment plan for drug abusers. Some methods have a clinical value in applying 'feedback' sessions. Hopefully in future, such empirical studies in personality assessment might constitute a base for evaluation of treatment outcome effects from an evidence-based perspective.