neuropsychodynamics of alcoholism and addiction: personality, psychopathology, and cognitive style

Journal ofSubstance Abuse Treatment, Vol. I, pp. 31-49, 1990 Printed in the USA. All rights reserved.

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ORIGINAL CONTRIBUTION

Neuropsychodynamics of Alcoholism and Addiction: Personality, Psychopathology, and Cognitive Style

LAURENCE MILLER, PhD

The Medical Center at Delray, Florida

Abstract - The literature on the neuropsychology, personality, and psychopathology of alcoholism and addiction is reviewed. Neuropsychological studies of substance abusers have found deficits in abstract concept formation, set-maintenance, set-shifting, behavioral control, and cognitiveflexi- bility. However, the evidence that these deficits are the result of direct substance effects on the brain is slim. Both alcoholics and as-yet nondrinking offspring of alcoholics have been found to be deficient in verbal skills and language functioning. Personality studies of alcoholics and addicts have emphasized such characteristics as field dependency, external locus of control, attenuated time ex- tension, poor ego strength, and disturbed object relations. The psychopathology of alcoholics and opiate abusers seems to be dominated by impulsive character disorder, although there may also be a subgroup of anxious, depressed substance abusers. The present review integrates brain-behavioral perspectives with the data on personality and psychopathology, focusing on the relevance of a mul- tidimensional neuropsychological model to psychodynamic concepts of ego functioning and the substance abusers’problems in the regulation of affect and behavior. It is argued that the concept of cognitive style is useful for understanding the relationship of neuropsychological functioning to personality dynamics, and that this approach can be especially productive in understanding the addictions.

Keywords- Neuropsychology, alcoholism, addiction, personality, cognitive style.

INTRODUCTION

A SUBSTANTIAL PORTION of the population suffers from some form of mental disorder. A substantial portion of the population abuses psychoactive drugs. These groups frequently overlap. From this set of observations stems a body of clinical and experimental research spanning personality, psychodynamics, psychopharmacology, behavior genetics, and criminal justice. Neuropsychology’s contribution within this field has been largely in the area of elucidating brain-behavior relationships in some of the major classes of psychopathology; the abuse of illicit substances has often been regarded as an extraneous or confounding factor.

Until about the last decade, relatively little neuropsychological research had been done in the area of substance abuse itself (with the possible exception of

Correspondence and requests for reprints should be addressed to Laurence Miller, Ph.D., The Medical Center at Delray, 5162 Lin- ton Boulevard, Suite 105, Delray Beach, FL 33484.

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alcohol) and, as a rule, the obverse attitude has been adopted, that is, concurrent psychopathology is viewed as a contaminating variable. As recently as 1981, a widely read review of the neuropsychology of alcohol and drug abuse (Parsons & Farr, 1981) concluded that failure to separate neuropsychological impairment due to substance abuse from that associated with concom- mitant psychopathology was a “pressing problem.”

But are they separable? It is becoming increasingly apparent that substance abuse disorders and their neuropsychological correlates cannot be easily teased apart from the personality and psychopathology variables in which they are frequently embedded and in which they typically come to clinical attention. This was the view of substance abuse adopted by psychoanalysis in the early years of this century, but which was only sparsely referred to after the 1950’s and has only quite recently been the subject of renewed interest (Brickman, 1988; Dodes, 1988; Donovan, 1986; Khantzian, 1982, 1985; Wurmser, 1978, 1982).

Unfortunately, many neuropsychological studies of

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psychopathology have relied on an outmoded localizationist model of brain-behavioral relationships, one which has recently come under criticism (Kiernan, 198 1; Miller, 1986). The present review will attempt to integrate personality, cognitive and brain-behavioral data on alcoholism, and narcotic addiction toward the goal of developing a comprehensive neuropsychodynamic model of the addictions.

NEUROPSYCHOLOGY OF ALCOHOLISM

A number of studies have approached the question of neuropsychological deficits in alcoholism from the perspective of alcohol’s presumed deleterious effect on the brain and therefore on cognitive functioning. Many of these studies have suggested that the typical pattern of neuropsychological deficits characterizing long-term alcohol abuse is one of relatively preserved verbal reasoning and verbal learning skills in the face of impaired visuospatial reasoning, visual memory, and nonverbal abstract problem solving (Miller, 1985; Parsons & Farr, 1981). It should be noted that deficits of this type need have no necessary association with the classic Wernicke-Korsakov syndrome (Victor, Adams, & Collins, 1971), but may contribute to the clinical picture of so-called “alcoholic dementia” (Cut- ting, 1978b; Lishman, 1981).

The nature and degree of recovery from cognitive deficit in abstinent alcoholics also appears to bear a relationship to pattern of impairment, as well as to age and duration of alcohol abuse. Thus, Ellenberg, Rosenbaum, Goldman & Whitman, (1980) found that visuospatial deficits showed slower recovery than verbal functioning, particularly in older subjects with se- rious drinking histories of greater than 12 years. Unlike verbal learning, visuospatial learning seemed to be more sensitive to the effects of longer drinking histories, coupled with greater age. Goldman, Williams, & Klisz, (1983) further explored the effects of age on recovery from alcohol-induced cognitive deficits and concluded that alcoholics over 40 years of age cannot be expected to recover to normal levels on visuospatial tasks, even if abstinence is maintained. However, the issue of age-alcohol interaction is complicated by recent findings that neuropsychological deficits in at least some groups of alcoholics may reflect the effects of age alone (Adams & Grant, 1984; Reige, Thomas- zewski, Lanto, & Netter, 1984), or the coexistence of neuromedical, demographic, personality, and other risk factors associated with the syndrome and lifestyle of alcoholism (Grant, Adams, & Reed, 1984; Tarter & Edwards, 1986, 1988; Tarter, Alterman, & Edwards, 1985). Further, it is possible that whatever genetic/ constitutional diathesis places some individuals at risk for alcoholism may also include a predisposition to certain developmental neurocognitive deficits that

might appear whether or not actual alcohol use oc- curred (Cloninger, 1987; Cloninger, Sigvardsson, & Bohman, 1988; Gabrielli & Mednick, 1983; Goodwin, 1976; Hegedus, Alterman, & Tarter, 1984; Parsons, 1987; Tarter & Edwards, 1986; 1988; Tarter et al, 1985) -although conclusions on this point are not unanimous (Schuckit, Butters, Lyn, & Irwin, 1987).

Tarter & Parsons (1971) administered the Wiscon- sin Card Sorting Test (WCST), a measure of abstract conceptual flexibility, set-formation, set-maintenance, and set-shifting (Milner, 1963), to a group of chronic alcoholics and found that they were impaired in maintaining a cognitive set. That is, the alcoholics tended to interrupt a sequence of correct, positively reinforced trials with errors. The tendency to make such errors in set-maintenance was positively associated with duration of drinking history.

In a later study, Tarter (1973) compared the performance on the WCST of long-term alcoholics, shorter- term alcoholics, and nonalcoholic controls. Both the long-term and short-term alcoholics showed impairment in the ability to maintain a cognitive set, consistent with the finding of Tarter and Parsons (1971). The long-term alcoholics took more trials and made more errors than either the controls or the short-term alcoholics, who did not differ from one another. The long- term alcoholics also made more perseverative errors, indicating that they had greater difficulty in abandon- ing a previously formed concept in the face of nonre- inforcement, that is, they persisted with an erroneous pattern of responding, despite information as to its current nonutility. Tarter (1973) argued that the findings supported a frontal lobe deficit in alcoholics, drawing an analogy to Mimer’s (1963) and others’ findings of similar cognitive deficits in frontal-lesioned patients.

Parker & Noble (1977) investigated the neuropsychological performance of individuals of high educational and socioeconomic status who were characterized as social drinkers. They used a number of measures, including the WCST and the Category Test, a task involving conceptual classification and cognitive flexibility. They found that neither total lifetime consumption, nor current frequency of drinking was related to cognitive performance; rather, there was a significant association between current quantity of alcohol consumed per drinking occasion and impairment of neuropsychological tasks. Most seriously affected were the processes of abstraction, adaptive abilities, and concept formation, whereas basic learning and memory capacities did not show appreciable impairment at the “social drinking” stage.

Cutting (1978a) examined the performance of a group of alcoholics on several measures, including a vocabulary test, a similarities test, proverb interpretation, a test of verbal fluency, a picture recognition test, and a verbal learning test. Alcoholics were inferior to

Neuropsychodynamics 33

controls, and heavy drinkers poorer than moderate ones, on picture memory and verbal fluency, while verbal memory and abstracting ability were not significantly impaired. Cutting interpreted these findings to suggest that predominantly frontal and right temporal areas are involved in the alcoholic cerebral deficit.

Alcoholics and controls were hypothesized by Heil- brun, Tarbox, and Madison (1979) to suffer deficits in cognitive control and internal scanning, according to the principles of Gardner (1961) and Silverman (1964). They used the Stroop Color Word Test, a mirror tracking task, a specially devised self-monitoring task, the WCST, and a self-reinforcement task to examine the performance of alcoholics and controls. Results identified three independent factors: cognitive control, internal scanning, and self-reinforcement. Alcoholics appeared to be deficient in the ability to control their own drinking behavior, and were also less capable in their cognitive control and narrower in their internal scanning on the experimental tasks. Alcoholics were also quite limited in their ability to gauge the extent to which they had influenced their own behavior on the self-reinforcement task. These results suggested to the investigators that skills in the control of behavior may decompensate piecemeal in the course of alcohol addiction. They pointed out that “the potential of a ty- pology based on the cognitive structure underlying the control of behavior seems especially good for prediction of treatment outcome” (p. 397).

Berglund & Risberg (1980) studied regional cerebral blood flow (rCBF) determinations in heavy “bender” drinkers and in alcoholics who had improved their drinking habits over three years. The improved alcoholics showed significantly better scores when tested with a block design task, which was related to normal- ization of rCBF in the inferior frontal region of the brain. These changes were more pronounced among continuous drinkers than among intermittent ones and did not appear to be related to withdrawal reactions. On the basis of these findings the investigators suggested that reversible impairment in alcoholism is related to a defect in activation due to frontal lobe dysfunction at initial testing.

In another study of rCBF which also utilized the Xenon inhalation technique, Berglund et al. (1982) studied recovery in impaired and unimpaired alcoholics, defined as being above or below the median on a task of rapid, alternating alphanumeric scanning, tracking, and set-shifting. The impaired alcoholics initially had significantly lower mean hemisphere blood flow during abstinence, increasing by eight percent from the first to the seventh week, but still not reaching the level of the unimpaired group. Furthermore, for the impaired group the regional blood flow was abnormal in the superior frontal and in the parietal regions of the right hemisphere, an asymmetry which tended to normalize at the seventh week.

Parsons & Leber (1981) reviewed a number of neuropsychological studies from different countries and concluded that alcoholics manifest poorer performance on tests of abstracting, problem-solving, memory, new learning, and perceptual-motor speed. These deficits varied from the borderline or mild to the moderate range of severity and were consistent with those seen in patients with known mild-to-moderate generalized brain dysfunction from other causes. The authors pointed out that these findings were seen in patients who for the most part did not have clinically diagnosable organic brain syndromes and who constituted the majority of patients seen in the treatment programs for alcohol abusers.

Parsons (1983) reported that neuropsychological deficits in alcoholics were inversely related to ratings of their therapeutic benefit and progress during treatment, and that alcoholics and controls differed as much on neuropsychological tests after 13 months of posttreatment abstinence as when they were examined after seven weeks of abstinence. In addition, Parsons reported substantial indirect evidence that at least some of the neuropsychological deficits seen in alcoholics exist premorbidly. In the initial testing after seven weeks of abstinence the alcoholics in the study performed significantly more poorly than nonalcoholic controls on tests of verbal abstracting and problem solving, as well as on perceptual-motor functioning. Differential deficit in learning and memory did not quite reach significance. Patients rated as more improved and having a better prognosis obtained higher verbal intelligence scores, had better short-term visual memory, had fewer errors on visuospatial paired- associates, had fewer perseverative errors on a concept formation task, and had consistently better perceptual- motor performance. In their sample, alcoholics and controls differed on the same two clusters of variables, abstraction/problem solving and perceptual-motor, both initially and at 18 months. Alcoholics who eventually resumed drinking were more impaired than continued abstainers at initial testing and tended to perform more poorly than abstainers at 13 months. Compared to controls, resumers continued to manifest impairment at 13 months, while abstainers showed some mild improvement. It was thus the resumers who were accounting for much of the continuing deficit at the 13 month retesting. So-called “primary alcoholics” differed from “secondary alcoholics” in having almost twice as many symptoms by history of hyperactivity and minimal brain dysfunction, suggesting that a subgroup of alcoholics may well have premorbid cognitive deficits. This point will be further discussed below.

The performance of a group of detoxified male chronic alcoholics was compared by Becker, Butters, Hermann, & D’Angelo, (1983) with that of nonalcoholic controls on a memory task that consisted of learning to associate people’s names with their faces.

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The alcoholics made more errors while learning the face-name associations, and fewer of them were able to reach the learning criterion. However, one hour later the alcoholics were nevertheless able to recognize all of the faces and names used during acquisition. For the alcoholics, the savings score, an index of the relative number of face-name associations retained during the one-hour interval, did not differ significantly from those of the controls. Thus, although they had difficulties acquiring face-name associations, the alcoholics nevertheless were intact in their ability to re- tain the associations in long-term memory. Because recognition of the faces and names was excellent and the retention of the acquired associations seemed relatively intact, the alcoholics’ impaired acquisition of the paired-associate task appeared to be due to their deficit in forming associations between faces and names.

Alterman, Tarter, Petrarulo, & Baughman, (1984) framed their study of alcoholics in terms of the concept of persistence, which they defined as the capacity to temporally organize, sequence, and sustain goal-directed behavior, and which they related to the activity of frontolimbic brain mechanisms. They studied young male (under 40) alcoholics and matched controls on a variety of tasks sensitive to perceptual, motor, and perceptuomotor persistence, respectively. The results indicated that these relatively young alcoholics were impaired in those functions considered to constitute the psychological process of persistence. The absence of a correlation between years of heavy drinking and test performance suggested that the impairments were not merely the consequence of a slow or insidious deterioration, but rather may reflect a vulnerability to the adverse effects of alcohol leading to a rapid decline in capacity-suggesting, once again, that the observed deficits may have preceded the alcoholism.

Kupke & O’Brien (1985) divided older (over 40) alcoholics into two groups: a behaviorally impaired and a behaviorally unimpaired group. All subjects were given a battery of neuropsychological tests. Results showed that the behaviorally impaired group subjects showed greater deficits on tests sensitive to psychomo- tor speed, problem solving that depended on tactual- motor integration or elementary reasoning, visuospatial analysis and synthesis, and memory.

The effects of age, sex, drinking history, and antisocial personality on the WAIS and Halstead-Reitan Neuropsychological Battery subtest scores of alcoholics was examined by Hesselbrock, Weidenman, and Reed (1985). The mean Brain Age Quotient for the total sample was slightly more than one standard deviation below the normative value. Scores on the WAIS were within normal limits for both Verbal and Perfor- mance IQ. Scores on the Halstead-Reitan Battery showed evidence of moderate levels of impairment.

Age was found to be the most significant factor affect- ing neuropsychological performance. It was observed that alcoholic subjects under 40 years of age performed at the lower end of the normal range; older subjects showed mild to moderately severe levels of impairment. Significant interaction effects were observed between age, amount of alcohol consumed, and sex for Tactual Performance Test total time.

The presence of antisocial personality interacted with sex to affect performance on Block Design and the Category Test such that antisocial men performed at higher levels and antisocial women at lower levels than their nonantisocial counterparts. The antisocial personality diagnosis also interacted with alcohol consumption to affect scores on Block Design. The interaction of sex and antisocial personality on Category Test errors and Block Design is notable, according to the investigators, in that nonantisocial women made fewer errors on the Category Test and scored higher on Block Design; antisocial men performed better on both tests than nonantisocial men. Both the Category Test and Block Design require quick judgement in as- sessing a problem situation. This performance by the antisocial men is interpreted by the investigators as being due to the fact that these subjects were younger and needed to think fast in a “street wise” sort of way to survive the antisocial lifestyle. The diagnosis of antisocial personality for women may represent a different constellation of antisocial behaviors than that seen in antisocial men, making antisocial women somehow different. However, performance differences between the sexes could also be explained by an artifact stem- ming from the small number of antisocial women in the sample.

Comment

Neuropsychological studies of alcoholics and heavy drinkers have reported a preponderance of findings in the area of impaired abstract concept-formation, cognitive flexibility, set-maintenance and set-shifting, problem-solving, new learning, and perceptuomotor speed and accuracy. These findings have been associated with those seen in organic frontal lobe impairment, prompting the suggestion that alcohol abuse may be associated with frontal lobe impairment. This has also received some support from neuroimaging studies.

Cognitive-personality factors seen in alcoholics also appear to support a “frontal” interpretation of the alcoholic deficit, for example, poorer cognitive control, narrower internal scanning, and deficient self-judgement (Barnes, 1979). Earlier studies tended to almost uniformly attribute these deficits to the direct toxic effects of alcohol on the brain. While recent evidence has documented the presence of electrophysiological (Porjesz & Begleiter, 1987), cerebral blood flow (Ris-


berg & Berglund, 1987) and radiological (Wilkinson, 1987) abnormalities in individuals who have abused alcohol, the cause and effect relationships between alcohol use and anatomic-physiologic brain status are far from settled (Shaw, 1987; Wilkinson, 1987; Williams, 1987). For example, it is not yet understood to what extent preexisting brain vulnerability may be associated with a predisposition to both alcoholism and alcohol-related cognitive deficits.

In the same way, the research reviewed above suggests that the neuropsychological findings and cognitive-personality features of alcoholics may predate actual drinking and indeed be all of a piece. That is, difficulties in solving neuropsychological test problems may well be related to difficulties in using competent strategies in dealing with life’s problems, and similar neurocognitive dynamics may be involved.

PSYCHODYNAMICS OF ALCOHOLISM

Donovan (1986) has developed a etiologic model of alcoholism which begins by noting the frequent association of both depression and sociopathy with alcoholism. This association is reinforced by the studies of Cadoret, O’Gorman, Troughton, and Heywood, (1985), Cadoret, Troughton, & O’Gorman, (1987), Cloninger et al. (1988), Lewis, Rice, and Helzer, (1983), Stabenau (1984), and Williams & Singh (1986). Soci- opathy, says Donovan, readily shades into generalized forms of personality disorder that are repeatedly associated retrospectively with alcoholism. A number of studies (Barnes, 1979; Devito, Flaherty, & Mozdzierz, 1970; Machover & Puzzo, 1959; Mogar, Wilson, & Helm, 1970; Zwerling, 1959) have all emphasized the weak ego, low frustration tolerance, impulsivity, passive-dependency, and the illusion of omnipotence in the alcoholic, all assumed to predate the addiction. Alcoholics also show more neuroticism, and they are more anxious, hysterical, hypochondriacal, and ambivalent (Barnes, 1979). They suffer from castration anxiety and neurotic guilt (Machover & Puzzo, 1959) and manifest schizoid withdrawal hostility and sexual immaturity (Zwerling, 1959), all measured postmor- bidly, but apparently assumed by the investigators to precede and predispose to the alcoholism.

Psychoanalysis, according to Donovan (1986), has had a long and curiously ambivalent relationship with the addictions. Although promising analytic formulations appeared on the topic at the turn of the century, consistent follow-through has been absent until the last 15 years. Abraham (1908/1973), Glover (1932, 1956), and Rado (1933) pictured the drug and alcohol abuser as in a state of “tense depression” (Rado’s term), narcissistically fixated, ego defective, and ob- sessed with hateful relations toward early internalized objects (persons). Fenichel (1945) contributed a description of the drug and alcohol addict as suffer-

ing from “amorphous tension” and treating others as “deliverers of supplies.” The compulsive substance use was an attempt to quell that tension and achieve the security chronically lacking.

Since 1970, psychoanalysts have contributed a se- ries of increasingly sophisticated studies of the addictive personality. The points of focus and terminology change from one author to the next, but the basic model remains essentially the same: a structural deficit in object relations, usually a fragile self buttressed by defensive grandiosity, leads to weaknesses in the ego and the consequent inability to manage affect and impulse. These two psychostructural deficiencies are necessary and sufficient to produce the addiction, which is seen as a behavioral attempt to compensate for the structural defects by reinforcing ineffective, primitive defenses such as denial.

According to Donovan (1986), antisocial personality and affective disorder do not relate directly to alcohol dependence - a position also suggested by Schuckit (1973, 1979) and corroborated by Vaillant’s (1983) research-but both may well relate to heavy drinking, which in turn triggers the vulnerability in the geneti- cally high-risk person (Cloninger, Reich, & Wetzel, 1979; also see Cloninger, 1987). This model implies that there may be many phenotypically similar but ge- netically different forms of alcoholism, some with a high environmental load and some with a high genetic load. Cloninger et al. (1979) apparently isolated a clearly hereditary form of the illness in the “male- limited” subgroup. This strain may be mediated by a heritable antisocial personality. Regardless of adoptive environment, the sons of severely alcoholic male crimi- nals were at high risk, but the risk may have more to do with impulsivity and antisocial personality (Clon- inger et al., 1988). The model seems to work well also for the female sample, where a high-risk pedigree is triggered by a problematic environment to produce addiction.

Donovan (1986) notes that one way of summing up the conclusions of most or many of the studies on the “alcoholic personality” is in terms of the generalized ego weakness described by the psychoanalysts (Keller, 1972; Pattison, Sobell, & Sobell, 1977; Sutherland, Schroeder, & Tordella, 1950; Syme, 1957). Those with highly disturbed object relations use splitting as a generic defense (Kernberg, 1975; Kohut, 1971). Am- bivalent, balanced conceptions of self and other are never developed, and the person remains prey to inten- sification of affect, marked impulsivity, contradictory behavior, oscillation of self-esteem, and alternating dependency on devaluation of others (Akhtar & Byrne, 1983; Kernberg, 1975; Kohut, 1971). These are the defining personality features of the patient with borderline disorder or pathological narcissism and they are also features of the alcoholic (Adams, 1978; Devito et al., 1970; Krystal, 1977; Machover & Puzzo, 1959;

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Wurmser, 1974; Zwerling, 1959). However, says Dono- van (1986), all alcoholics evidently do not display splitting to the same degree, and pathological drinking itself could easily intensify the splitting. Second, the neuropsychological deficit implicated, which is prob- ably heritable, results in poor planning capacity and problems in affective control (Tarter, Hegedus, Gold- stein, Shelly, Alterman, 1984; Tarter et al., 1985). This liability could easily lead to splitting as a coping mechanism.

Comment

It is indeed remarkable how closely neuropsychological and psychodynamic theories of alcoholism parallel one another in certain fundamental respects. Both emphasize poor self-image and self-control, nonreflec- tiveness, and cognitive rigidity or lability, as well as the role of compromised language mechanisms. Is neuropsychological integrity a prerequisite for health personality functioning?

NEUROPSYCHOLOGY OF NARCOTIC ADDICTION

It is a common clinical observation that very few drug abusers limit themselves to the exclusive use of a sin- gle substance; some combination of drug abuse patterns is the rule (Belenko, 1979; Carlin, 1986; Parsons & Farr, 1981; Rounsaville, Weissman, Crits-Cristoph, Wilber, & Kleber, 1982b; Wilford, 1981). For this rea- son, only a few systematic neuropsychological studies are available that deal with abusers who consistently favor opiates or other narcotics as their drug of choice. The present review will concentrate on neuropsychological studies that have addressed opiate narcotic abuse alone or, when included in a polysubstance abuse pattern, have separately accounted for their effects.

Korin (1984) compared heroin-abusing Vietnam veterans with abusers of nonopiate drugs on a battery of tests and found that the heroin abusers performed worse on the Bender-Gestalt. Korin pointed out that personality trait are also likely to be reflected by the Bender-Gestalt and hence refrained from interpreting the results in terms of neuropsychological deficit in the heroin abusers.

Heroin addicts were compared with both nondrug controls and patients with known cerebral damage on an extensive neuropsychological battery (Halstead- Reitan) in a study by Fields and Fullerton (1975). All tests significantly discriminated between the brain damaged group on the one hand, and the heroin addicts and normal controls on the other; the performance of the heroin addicts and nondrug controls

were almost identical. An interesting, although statis- tically nonsignificant trend was that the heroin addicts outperformed the controls on almost every test, especially on the Category Test, which involves abstract reasoning and conceptual classification. The authors speculate that this seemingly higher conceptual ability of heroin addicts may relate to the manner in which many of these individuals are able to skillfully manipu- late their social environments-the same “street smart” explanation offered to explain the intact performance of alcoholics in the study by Hesselbrock et al. (1985).

Bruhn & Maage (1975) compared four groups of subjects on a variety of intellectual and cognitive tests. The groups were (a) nondrug users; (b) marijuana and hallucinogen users (c) hallucinogen and amphetamine users; and (d) marijuana, hallucinogen, amphetamine, and heroin users. Results yielded no intergroup differences, which the authors interpret as suggesting an absence of any significant effect of these drugs on neu- recognitive functioning, alone or in combination.

In a large-scale study, Grant, et al. (1978a) confirmed an association of polydrug abuse and neuropsychological impairment. Heavy use of CNS depressants (sedative and hypnotic drugs) and opiates was found to be associated with greater likelihood of neuropsychological deficit, whereas no significant association of impairment with other individual substances, including alcohol, was found.

In a related study, Grant et al. (1978b) evaluated the various “risk factors” associated with organic cognitive impairment in polydrug users. The first of these risk factors was found to be heavy use of certain classes of drugs; specifically, extensive abuse of CNS depressants and opiates seemed to represent the most dangerous drug conditions. The second risk factor was age, which appeared to operate in two ways: (a) the older drug abuser has had more time to consume more substances, and (b) as the brain ages it may become less resilient to the effects of drug-induced damage. Educational level emerged as a third risk factor, in that lower levels of educational attainment might be-associated with subtle constitutional neurocognitive disturbances which themselves might be related to increased cerebral vulnerability to the effects of drugs. A fourth risk factor was medical-developmental history, including such events as maternal pregnancy difficulties, se- rious head injury, and surgery with general anesthesia. Finally, psychopathology emerged as a fifth risk factor; in particular, a combination of schizophrenia and polydrug abuse was associated with the worst neuropsychological performances; however, these latter results should be interpreted in light of the fact that schizophrenia itself is frequently associated with significant neuropsychological dysfunction (Goldstein, 1978; Heaton, Baade, & Johnson, 1978; Miller, 1984; Seidman, 1983).

Hill, Reyes, Mikhael, Ayre, (1979) compared her-


oin abusers, alcoholics, and normals on brain CT scan and neuropsychological testing. They found that on several neuropsychological measures alcoholics were most impaired and normals least impaired, with heroin abusers falling in between. Length of opiate abuse career was associated with greater impairment; remis- sion was associated with better performance on some measures and worse performance on others. Overall, neuropsychological findings correlated weakly with CT scan data.

According to Keiser (1975), a Wechsler Digit Span scaled score well above the mean of a subject’s other WAIS subtest scores -called positive Digit Span scatter - correlates with an interpersonal detachment syndrome characterized by anhedonia, superficial relationships, and generally low motivation for social achievement. Keiser & Lowy (1980) compared with WAIS profiles of heroin addicts and nonaddict neurotic-depressive subjects and found that the heroin addicts attained significantly higher average positive Digit Span scatter than the neurotic depressive group. The authors point out that this finding is consistent with the clinical observation that many addicts appear to present an anhedonic-detached personality deviation. They frequently adopt lifestyles that reflect superficial interpersonal relationships, mostly drug-related, that tend to be instrumental rather than affectional and use narcotic drugs as powerful reality-obliterating agents.

Rounsaville, Novelly, Kleber, and Jones (1981) an- alyzed risk factors associated with neuropsychological impairment in heroin addicts who additionally abused other drugs, and found that neuropsychological impairment was not correlated with positive neurologic history (e.g., head injuries), duration or severity of drug use in most drug categories, criminal history, psychiatric symptoms, social functioning, or measures of personality pathology. Impairment was correlated with history of childhood hyperactivity, poor educational achievement and greater use of alcohol, cocaine, or both.

Rounsaville, Jones, Novelly, & Kleber, (1982a) compared opiate addicts (heroin and methadone) with demographically matched nonaddicts and with am- bulatory epileptic patients. The opiate addicts were found to have neuropsychological test scores compa- rable with or superior to the controls, concurring with the main findings of Fields & Fullerton (1975). In- terestingly, the more powerful correlates of neuropsychological functioning in the Rounsaville, et al (1982a) study were demographic. Most notably, addicts with higher educational achievement produced generally superior performance on a number of measures, suggesting that failure to control for intellectual ability and educational level may have something important to do with reports of the “paradoxically” superior performance of some opiate addicts on particular neuropsychological measures.

Comment

It is apparent that the evidence for a direct deleterious effect of opiate drugs on neuropsychological functioning is hardly impressive. Most neuropsychological studies of opiate abusers have found small effects, no effects, or in some cases “paradoxically” better neuropsychological functioning in opiate abusers. When combined in a polysubstance pattern of abuse, opiates do seem to be associated with measurable neuropsychological impairment, but this is difficult to untan- gle from the effects of other drugs, particularly CNS depressants.

If opiate drugs themselves cannot account for the neuropsychological findings in addicted populations, perhaps attention should be focused on the addicted individuals themselves. Some opiate abusers do seem to show impairment on some neuropsychological measures, even as they manifest problems in dealing with life circumstances as a whole. Indeed, the studies by Korin (1974) and Keiser and Lowy (1980) suggest that personality factors cannot be separated from neuropsychological factors in accounting for performance on different measures. Is there some pattern of cognitive, emotional, psychodynamic, and personality factors that characterize opiate abusers likely to show signs of dysfunction on traditional neuropsychological tasks?

PSYCHODYNAMICS OF NARCOTIC ADDICTION

As reviewed by Sutker and Archer (1984), early psychoanalytic formulations tended to equate opiate use with unfulfilled or pathological drive states related to sex and aggression, inabilities to cope with pervasive negative emotions including depression and anxiety, basic ego and superego deficiencies, and general immaturity or childhood fixations. Clover (1932, 1956) hypothesized that drug addiction constituted a defense against sadistic or aggressive impulses and suggested that opiates and other addicting drugs were used by prepsychotic persons to defend against such unaccept- able urges as sadism and homosexuality. Fenichel (1945) speculated that addicts were passive, narcissistic individuals who used drugs to satisfy archaic oral longings (i.e., for food, warmth, security, and self- esteem). Both Clover and Fenichel hypothesized that addicts were fixated at prepsychotic levels of thinking and behavior, and that drugs served homeostatic functions and prevented further psychic regression. Taking a different view, Rado (1933, 1962, 1963, 1964) wrote that narcotic addicts, characterized by exaggerated fears of pain and disordered hedonistic self-regulation, became bonded to narcotics as a consequence of opiate-engendered “superpleasure.”

More recently, Khantzian (1974, 1978, 1979, 1980,

38 L. Miller

1982, 1985; Khantzian, Mack, & Schatzberg, 1974; Treece & Khantzian, 1986) has contributed extensively to the psychodynamic literature on addiction. Among the many factors associated with addiction, Khantzian is most impressed with the enormous, lifelong difficulties heroin addicts have with feelings and impulses associated with aggression. The dysphoric feelings associated with anger, rage, and restlessness are relieved in the short term by heroin and other opiates, and many addicts in a treatment, as they become stabilized on methadone, experience a reduction in their aggression and restlessness. Addicts take advantage of the antiaggression action of opiates in the service of drive defense. Khantzian stresses the disorganizing influence of aggression on ego functions in individuals whose ego stability was already subject to dysfunction and impairment as a result of developmental arrest or regression. He also proposes that the same but sus- tained, longer antiaggression action of methadone is the basis for “success” of methadone maintenance.

Khantzian observes that the addict has special problems in accepting dependency and actively acknowl- edging and pursuing goals and satisfactions related to needs and wants. Extreme and alternating patterns in pursuing need satisfaction are evident: Cooperation and compliance may suddenly alternate with outbursts of rage, refusal, or resistance; passivity and indiffer- ence can shift rapidly or coexist with active, intense, and restless involvements that often lead to danger, violence, and death; disavowal of needs and solici- tousness of others may suddenly convert to angry demands and entitlement that are totally oblivious of other people. To explain such patterns, Khantzian proposes that the rigid character traits and alternating defenses employed by addicts are adopted against underlying dependency needs in order to maintain a costly psychological equilibrium. Prominent defenses and traits include extreme repression, disavowal, self- sufficiency, activity, and assumption of aggressive attitudes.

Addicts’ lifelong experiences and problems with rage and aggression, says Khantzian, most often date back to family and environmental influences where they were subject to physical abuse, brutality, violence, and sadism. Addicts crave less for euphoria than they do for relief from dysphoria associated with anger, rage, and related restlessness which, in the short term, narcotics seem to provide. This is evident in addicts’ descriptions of how narcotics help them to feel normal, calm, relaxed, and soothed, and is even more apparent in observing addicts in treatment as they stabilize on methadone and their aggressiveness and restlessness subside. Opiates counteract regressed, disorganized, and dysphoric ego states associated with overwhelming feelings of rage, anger, and related depression. The effect is particularly appealing and welcome given that the ego capacities in such individ-

uals are weak or absent, especially against aggressive drives. Opiates reverse regressed ego states by counter- acting the disorganizing influences of aggression on the ego, helping addicts to feel and become temporar- ily more integrated and thus better able to cope with life’s demands and challenges.

But whatever equilibrium addicts attain, Khantzian points out, is usually precarious. Given their unstable ego and self-structures for containing feelings and behavior, painful affects of any kind, especially those associated with rage and aggression, tend to compound further a tendency for psychological fragmentation and disorganization. The dysphoria that addicts suffer is intimately associated with the disorganizing influences of these affects and drives. A vicious cycle is set in motion in which shaky or brittle defenses for coping with internal emotions and external reality are further weakened by the uncontrolled aggression, and, given the subjective and objective threatening nature of these feelings in particular, one’s very survival/existence seems more and more at stake. That is, uncontrolled aggression produces disorganization from within by eroding ego structures, and threatens the ego externally by jeopardizing needed relationships and by provoking counterviolence from others. The appeal of opiates resides in the dramatic capacity of these drugs to mute, contain, and eliminate the rage and aggression that disorganizes and disrupts such individuals.

The concept of exogenous opiates as an antiaggression agent might, according to Khantzian, be related to the role that the endogenous opiates (endorphins) play in regulating human aggression. It could be that the brain elaborates endorphins not only to at- tenuate physical discomfort and pain, but also to maintain optimal feeling and comfort states. Endog- enous opiates might be especially critical in regulating human aggression, since aggression, in its controlled forms, is such a necessary part of human experience. Aberration and dysfunction of endorphin activity might be related to the destructive vicissitudes of human aggression.

Many narcotic addicts, notes Khantzian (1985), dis- cover the antirage action of opiates in a context of violence, often murderous, feelings released in them by sedatives and alcohol or as a consequence of amphetamine and cocaine use. For Khantzian (1975), the energizing properties of stimulants, like cocaine, are compelling because they help to overcome fatigue and depletion states associated with depression. In other cases, the use of stimulants leads to increased feelings of assertiveness, self-esteem, and frustration tolerance (Wieder & Kaplan, 1969) and the elimination of feelings of boredom and emptiness (Wurmser, 1974). Khantzian (1979) has proposed that certain individuals use cocaine to augment a hyperactive, restless lifestyle and an exaggerated need for self-sufficiency.

More recently, Khantzian and his associates (Khant-


zian 8z Khantzian, 1984; Khantzian, Gawin, & Kleber, 1984) have considered from a psychiatric/diagnostic perspective a number of factors that might predispose an individual to become and remain dependent on cocaine: (a) preexistent chronic depression, (b) cocaine abstinence depression, (c) hyperactive, restless syndrome or attention deficit disorder, (d) cyclothymic or bipolar illness.

For Treece and Khantzian (1986) characteristic features related to problems with closeness and narcissistic disturbances (especially maintenance of self-esteem) are another important area of vulnerability that predis- poses to drug dependence. Central issues include an inability to turn to others for comfort or to find comfort in others, fear of closeness involving fear of one’s own aggression in relation to others, and intolerance of rejection or other disappointments in relationships.

Khantzian’s own work and that of Wurmser (1974, 1978) and others have consistently emphasized the im- portance of narcissistic vulnerability in the predisposition to narcotic dependence. Hendin (1973) has also noted that special vulnerability of opiate users to dis- appointment and loss of self-esteem leading to rage in intimate relationships. His studies of marijuana and amphetamine users (Hendin, 1974a, 1974b) have tended to emphasize narcissistic issues around competition, achievement, and autonomy. Krystal and Raskin (1970) have similarly described vulnerabilities in internal object relations in sedative-hypnotic users. The vulnerabilities observed to characterize chronic substance abusers are consistent with the psychology of character disorder. These vulnerabilities include (a) major difficulties in tolerating affects, with an incapacity to experience gradation of feelings that enable an emotionally full existence, appropriate anticipation of distress, and the use of affective signals in smooth co- ordination with defensive functions; (b) vulnerability in self-esteem associated particularly with heavy reliance on narcissistic protectiveness and incompletely integrated inner self- and object-images; (c) a range of disturbances in thinking and judgement related to rigid and immature defensive and adaptive coping capacities.

As reported by Nicholson and Treece (198 l), greater impairment in developmental capacities associated with object relations and narcissism was positively related to continued heavy polydrug use in a sample of addicts from a methadone maintenance program. The high prevalence of antisocial personality among narcotic and multidrug users (Craig, 1982; Croughan, Miller, Wagelin, & Whitman, 1982; Koenigsberg, Kaplan, Gilmore, & Cooper, 1985; Nurco, Ball, Shaf- fer, & Hanlon, 1985; Nurco, Shaffer, Ball, Kinlock, & Langrad, 1986) is also related to this point, and it is of interest that such personalities have been viewed psychodynamically as a variant of narcissistic personality disorder (Kernberg, 1975).

Wurmser (1972, 1974, 1978, 1982) believes that nar-

cotics are used as an artificial affect defense, that is, they are compulsively taken to bring about relief from overwhelming feelings. Specifically, drug use is a form of pharmacologically reinforced denial, an attempt to get rid of feelings and thus of undesirable inner and outer reality. This presupposes not solely a particular proneness for this particular defense, but also an in- clination for what Krystal(l977) has described as affect regression, that is, the global, undifferentiated nature of emotions that can often only scantily be put into words and other symbolic forms, but is instead converted into somatic sensations. By this account, many drug abusers are today’s version of conversion hysterics, and the choice of drugs shows some fairly typical correlations with such otherwise unmanageable and deeply terrified affects: opiates and hypnotics are deployed against rage, shame, jealousy; stimulants against depression and weakness; psychedelics against boredom and disillusionment; alcohol against guilt, loneliness, and related anxiety.

In addicts, says Wurmser, there is a remarkable dis- continuity of the sense of self, a global lability with no mediation and no perspective. It is an unreliability that is infuriating for others, humiliating and depression for the addicts themselves. These “ego splits” or “ego discontinuities” are not a defense, but a functional dis- parity and contradictoriness derived from the defense mechanism of denial. In severe depressions the ego almost completely submerges in the archaic superego. Its mirror image is sociopathy where the ego mainly bat- tles against the superego and is allied with the id; while it certainly also makes “inoperative” crucial elements of outer reality, the latter is largely enlisted against the main enemy.

It appears that in addiction this defensive endeavor shifts. The ego deploys such defensive action not only against the superego, but also against external reality. Not only is the latter attacked insofar as it is the bearer of limits, authority, responsibility, and commitment (which is certainly also true in most manifestations of sociopathy), but much more generally, even where it has to do with self-preservation, with anticipation of consequences, with delay and later gratification, with basic contradictions and logical impossibilities. In other words, says Wurmser, in compulsive drug use the ego eventually tries to invalidate not only values, authority, and responsibility (superego), but also the lines drawn between objects, the boundaries between the times, between inside and outside the borders, between social entities, and the limits between concepts. It is an attack on the syllogistic basis of rationality, akin to the same event in psychoses.

Recently, several empirical studies of psychodynamic factors in opiate addiction have been carried out. A sample of opiate addicts seeking treatment were assessed by Blatt et al. (1984a) on several well- established clinical assessment procedures, including

40 L. Miller

the Rorshach. Opiate addicts had significantly greater disturbance than normals but significantly less thought disorder and impairments in ego functions than hospitalized borderline and psychotic patients. The results suggested that a primary disturbance in opiate addicts is their relative inability to conceptualize people as well-differentiated, articulate, and involved in meaningful, purposeful, and constructive activity. In addition, opiate addicts appear to have selected a particularly self-destructive, isolated mode of adaptation for achieving the satisfactions and pleasures most people seek in intimate relationships, consistent with the suggestions of McLelland, Woody, &O’Brien (1979) that the primary difficulties of opiate addicts are in their inability to establish and maintain meaningful interpersonal relationships.

Blatt, Rounsaville, Eyre, & Wilber (1984b) evaluated opiate addicts and polydrug, but nonopiate, substance abusers for depression on a clinical interview rating scale and several self-report measures of depression. Opiate addicts were consistently more depressed than polydrug abusers on all measures. The depression was focused primarily around issues of self-criticism, guilt, and shame rather than issues of dependency, abandonment, rejection, and neglect. Depression focused around self-criticism was significantly correlated with the extent to which the polydrug, nonopiate- addicted substance abusers had begun to experiment with opiates. These data suggest that intense depression, particularly depression focused around issues of self-criticism, has an important role in opiate addiction, a conclusion that has been reinforced by the results of several studies (Kosten & Rounsaville, 1986; Rounsaville et al, 1982b; Rounsaville, Weissman, Kle- ber, & Wilber, 1982c).

The data of Blatt and colleagues’ (1984b) study was consistent with longitudinal studies (e.g., Kandel et al., 1978; Robins, Davis, & Wish, 1977) indicating that opiate addiction usually occurs as a result of a grad- ual progressive involvement with more seriously addictive substances. Opiate addicts, as compared to the polydrug-addicted but nonopiate-addicted substance abusers, were older and more involved with a wide range of drugs. Opiate addiction appears to be the end stage of increasingly chronic substance abuse. While most individuals appear to begin with “soft” drugs, only a few become increasingly involved with more seriously addicting substances such as heroin. The data also suggest that depression is a central issue for those individuals who become involved in opiate addiction. Opiate addicts are significantly more depressed than a group of polydrug abusers who are not yet opiate addicted. The data also clearly indicate that this elevation in depression in opiate addicts is focused primarily around issues of self-criticism, guilt, and shame, rather than issues of dependency and feelings of rejection, abandonment, and neglect.

The finding of a highly significant elevation of self- criticism in opiate addicts is consistent with other findings (Craig, 1979a, 1979b) that the most frequent MMPI profile of opiate addicts is characterized by ele- vations on the Psychopathic deviate (Pd) and Depres- sion (D) scales. Most investigators typically interpret an elevation on the Pd scale as indicating the usual “psychopathic” tendencies, that is, impulsivity, non- conformity, low frustration tolerance, irresponsibility, and irritability (Cleckley, 1982). However, others (e.g., Astin, 1959) have found that elevated Pd scores can have different meanings depending on a variety of factors. Based on their findings, Blatt et al. (1984b) interpret the frequently-found elevated Pd and D scales in addicts not as indicating a ruthless, cold, callous, and distant psychopath, but as indicative of a guilty, sus- picious, withdrawn type of depression. The frequent elevation of the Pd and D scales of the MMPI in opiate addicts suggests a marked vulnerability to a guilt- laden type of depression in which an antisocial individual has marked feelings of being worthless and a failure (Blatt 8z Shichman, 1981).

Thus, for Blatt et al. (1984b), opiate addicts are more chronically addicted individuals who frequently appear to be struggling primarily with intensely painful problems of self-worth. Not only do they report significantly greater degrees of self-criticism, but they report significantly greater social isolation and fewer friends. Their memories of early childhood are filled with negative images of both parents (Kandel et al, 1978; Robins et al., 1977). Also, some findings are consistent with an obsessive-compulsive character structure with paranoid features. Patients with elevated scores on the self-criticism factor often have ac- cess to considerable anger and aggression, and when intensely depressed they can become seriously self- destructive (Blatt, Quinlan, & Chevron, 1982).

Despite their high level of self-criticism, the opiate addicts in Blatt and coworkers’ (1984b) sample also described themselves as significantly more effective than polydrug abusers and general psychiatric patients. This level of effectiveness does not seem to be a denial of their difficulties because the level of this efficacy is somewhat less than, but not significantly different from, the level of efficacy reported by normals. Thus, despite the intensity of their depression, opiate addicts seem to possess considerable resourcefulness. This resourcefulness may be essential in order to exist in a drug culture-to find the funds and establish the con- tacts needed to maintain the habit.

Comment

Psychodynamic interpretations of opiate addiction have stressed the use of these drugs as an aid to ego- reconstitution in the face of ego-destabilizing affects, mainly aggression, which is also related to deficits in


self-esteem and self-efficacy. This lack of ego integration could account for the impulsive (frequently antisocial), “acting-out” behavior, the depression resulting from the inevitable frustrations and inability to deal constructively with them, and the reliance on psy- chopharmacologics as a coping or defense mechanism. Opiates facilitate a withdrawal of the ego from the outside world by blunting the perceptuoaffective apparatus, fostering an inward-turning of attention and maintaining an autistic-like social isolation. In this regard, the empirical studies reviewed in this section have emphasized the impairment in social relations that characterizes opiate-addicted individuals; the evidence seems to suggest that they tend to deal with other people in a utilitarian fashion, rather than as actual human beings.

Importantly, the conceptualization of opiate addiction in terms of psychodynamic ego functioning allows this syndrome to be addressed from the perspective of self- or ego-psychology which, as will be discussed below, has relevance for both neuropsychological and personality functioning. Can a heuristic neuropsychological model of personality and psychopathology be developed that conceptualizes alcoholism and addiction in a comprehensive manner?

TOWARD A NEUROPSYCHODYNAMIC MODEL OF THE ADDICTIONS

A recent review of the field of personality theory (Per- vin, 1985) has stressed the need for an appreciation of the complexity of individual personality functioning in personality research. This is seen as especially true for understanding the relationship between cognitive and affective dimensions of personality and the functioning of people in the natural environment and over extended periods of time. A growing area of interest within this field has been the concept of self-knowledge or self-regulation (Markus, 1983; Pervin, 1985). In this context, the self has been described as “a cognitive structure that influences attention, organization or categorization of information, recall and judge- ments about others” (Pervin, 1985, p. 94).

Freud (189411966, 189611966, 1915/1957, 1923/ 1962) maintained that the transformation of primitive instinctual impulses into consciously acceptable sub- stitutive drive-derivatives involves the utilization of certain cognitive processes such as symbolization and language. However, he failed to elaborate on the roles of these cognitive processes in the development of defenses and personality structure, preferring instead to concentrate on the role of instinct. Later, the ego- psychologists, most notably Hartmann (1939/1958), stressed the significance of constitutionally based mental apparatuses for psychological development, including memory, perception, attention, and intelligence. According to Hartmann, these basic human adaptive

apparatuses comprise a core of adaptive psychological functioning that is relatively independent of instinctual conflict, constituting “the conflict-free ego sphere” (Hartmann, 1939/1958, p. 3). These apparatuses also influence the form of, or preference for, different ways of handling conflict, that is, defense.

The term cognitive style was introduced by Klein (1954) to refer to the arrangement of general regula- tory or control structures in any given individual. Klein suggested that these cognitive controls may have a basis in the types of stable constitutional traits suggested by Hartmann (193911958). Shapiro (1965) has also used the concept of “style” by which he means the overall form or mode of functioning that is characteristic of a particular person, as revealed by various features of his behavior. For Shapiro, “neurotic styles” are the modes of functioning that characterize various neurotic conditions or characterological disorders.

Shapiro (1965) describes four types of neurotic styles: the obsessive-compulsive, the paranoid, the hysteric, and the impulsive. It is this last which is of particular interest to the present discussion (for a com- plete review of neuropyschology, personality, and cognitive style see Miller, in press). According to Shapiro, the distinctive quality of the impulsive style involves an impairment or distortion of normal feelings of deliberateness and intention, resulting in a marked tendency toward impulsive action. In these abrupt, transient, and partial experiences of wanting, choosing, or decid- ing, the sense of active intention and deliberateness is markedly impaired, and this sense of nondeliberate- ness is an important element in impulsive characters’ superficial appearance of self-confidence and freedom from inhibition and anxiety. In fact, Shapiro draws a parallel between the freedom from inhibition that many normal people feel while intoxicated and the impulsive characters’ more or less constant experience of disinhibition; both kinds of people are frequently un- able to account autonomously for their actions, that is, “don’t know what they are doing.”

Each of the qualities of impulsive action - speedi- ness, abruptness, and lack of planning-seems to reflect a deficiency in the mental processes that are normally involved in the translation of incipient mo- tives into actions. A “whim,” Shapiro points out, is or- dinarily either dismissed, or if it accrues attention, interest, and motivation, becomes transformed into a relatively stable goal or desire, thus prompting some kind of autonomous choice or decision. But behavior dominated by the impulsive acting-upon of transient feeling states and short-term goals loses a fundamental self-directedness that is important for overall personality cohesion.

Thus, impulsive personalities are lacking in active interests, aims, values, or goals much beyond the immediate concerns of their own lives. This usually precludes durable emotional involvements, deep

42 L. Miller

friendships, family interests, and even personal career goals, more abstract aims, purposes, or values. The impulsive style involves a deficit in active, searching, critical attention. The so-called “intelligence” of some impulsive characters known as psychopaths is not a planning, abstracting, reflecting intelligence, but neither is it immobilized or disorganized. These individuals often have keen practical intelligence that is suited to the competent execution of their short-range, immediate aims, a cunning/conning kind of skill. A good deal of the “antisocial” behavior of psychopaths, then, may not be so much a direct consequence of any in- nate deficiency of moral values or conscience, as it may follow from the impulsive style itself: the egocentric, concrete viewpoint, general lack of aims and values much beyond immediate, tangible gain and quick, nondeliberate modes of action.

Behavioral research and clinical study have shown that the psychopath is characterized by repetitively impulsive, maladaptive, and antisocial actions, accompa- nied by a seeming inability to profit from corrective experience (Begun, 1976; Cleckley, 1982; Mawson & Mawson, 1977; Millon, 1981). Neuropsychological studies have suggested that psychopaths and delinquents are particularly impaired on measures sensitive to left-hemisphere dysfunction, such as Verbal IQ (Eaker, Allen, & Gray, 1983; Graham & Kamano, 1958; Heilbrun, 1979, 1982; Holland, Beckett, & Levi, 1981; Prentice & Kelly, 1963; Shulman, 1951; Weins, Matarazzo, & Kaver, 1959) and verbal learning disorders (Berman & Siegal, 1976; Bryant, Scott, Golden, 8z Tori, 1984; Hurwitz, Bibace, Wolff, & Rowbotham, 1972; Robbins, Beck, Pries, Cage, & Smith, 1983; Spreen, 1981). In addition, there is evidence from neuropsychological studies on cognitive flexibility, conceptual classification, and set-shifting that psychopaths show frontal-like deficits (Gorenstein, 1982; Hare, 1984; Yeudall, 1977; Yeudall, Fedora, 8z Fromm, 1985), although this is more controversial (see Miller, 1987, 1988 for reviews).

Conceptions of the role of the frontal lobes in cognition and behavior have generally emphasized their controlling or modulating influence as constituting the essential apparatus for organizing the intellectual activity as a whole, including the programming of cognitive activity and the checking of its performance (Damasio, 1979; Luria, 1973, 1980; Teuber, 1964). Luria (1980) has described the functions of the frontal lobes as involving the primary integration of stimuli reaching the organism and the attachment of regula- tory significance to components of this input. The frontal lobes are involved in forming the “provisional basis of action” (Luria, 1980, p. 248), the creation of complex programs of behavior, the constant monitoring of the performance of these programs, and the checking of behavior with comparison of actions performed and the original plans by means of a behav-

ioral feedback system. Thus, according to Luria, the frontal lobes synthesize information both about the outside world and about the internal state of the body, thus providing the means by which the behavior of the organism is regulated in conformity with the effects produced by its actions. The frontal lobes judge and regulate ongoing external perception and calculate appropriate responses to what is being perceived, in order to preserve the overall equilibrium of the individual (Damasio, 1979; Luria, 1980; Nauta, 1971; Teuber, 1964). And for this to occur, optimal negotiation of the social environment is necessary.

Dimond (1980) has advanced the hypothesis that the frontal lobes are the seat of social intelligence for advanced mammals, including man. One important function of the frontal lobes is to regulate important aspects of social behavior involved in resource alloca- tion, reproduction, child-rearing, and group cohesion. Accordingly, to Dimond, damage to the frontal lobes would produce over time a decline in the capacity of the individual to maintain his or her social position, involving a progressive loss of the capacity for aggressive and aversive response. Dimond cites studies (e.g., Frantzen & Myers, 1973) of behavior among members of monkey communities in which loss of aggressiveness and social assertiveness followed frontal lesion- ing. Some studies, however, found that removal of the frontal pole in association with lesions of the limbic system led to an enhancement rather than a diminu- tion of rage. In these cases, Dimond speculates that frontal lobectomy may have had the effect of render- ing it easier for the animal to express any kind of pathological behavior resulting from a disordered brain. That is, removal of frontal cortex led to an increased lability in social relations. For Dimond, then, the running span of day-to-day social conduct has an independent neuropsychological organization. To the extent that the frontal lobes can be said to perform an “executive” function, it is his contention that they do so particularly for social relations.

Markus (1983) speaks of self-schemas which are knowledge structures about the self that derive from past experience and that organize and guide the processing of the self-relevant information contained in the individual’s social experiences. Self-schemas provide for a point of view, an anchor, or a personal frame of reference. They guide the individual in choosing those aspects of social behavior to be regarded as self- relevant, and they function as interpretive frameworks for the reflective understanding of this behavior.

According to Nauta (1971), part of the behavioral effects of frontal lobe destruction can be seen as a consequence of an interoceptive agnosia, that is, an impairment of the subject’s ability to integrate certain information from his internal milieu with the environmental input provided by the neocortical processing mechanisms. This results in a derangement of the nor-


ma1 role of the frontal lobes in facilitating the conver- gence of interoceptive and exteroceptive information. A plan of action, says Nauta, cannot be kept in abey- ance intact for any length of time unless it is repre- sented in matching sensory and affective registries. By this conception, the loss of the frontal lobes as a major mediator of information exchange between the cerebral cortex and limbic system is followed not only by an impairment of strategic choice-making, but also by a tendency of projected or current action programs to become attenuated or overridden by interfering influences. Thus, for Nauta, one of the deficits of the frontal lobe patient lies in an inability to maintain a normal stability-in-time of behavior. The individual’s action programs, once started, are likely to fade out, to in- effectually perseverate, or to become deflected away from the intended goal.

The other, complementary, neuropsychological approach to character disorder and substance abuse is through studies of hemisphericity. In most people, the left hemisphere is specialized for linguistic processing and logical descriptive analysis; it is especially good at perceptual and conceptual analysis of details and oper- ates most effectively within a consecutive temporal framework; it plays a special role in the perceiving of differences and in the interpretation of the literal, syn- tactic, and semantic qualities of spoken communication. The right hemisphere is specialized for spatial processing and imagal coding; it is especially good at the gestaltic synthesis of forms, and is more intuitive and inferential; it seems to operate most effectively in perceiving similarities based on broad qualitative features; it seems to play a special role in facial recognition and in the interpretation of the inflective and prosodic qualities of spoken communication (Hecaen & Albert, 1978; Springer & Deutsch, 1985; Walsh, 1978).

The left hemisphere’s linguistic, self-explicatory ability forms the neural basis for what Dimond (1980) has termed the generative mechanism of self. This system directs the purposive activity of the individual, has a special control over most aspects of the conscious self, and has a major concern with the individual’s interaction with external reality. Dimond (1980) conceives of human mental life as being normally dominated by an ongoing interior monolog which is closely linked to the productive capacity for language and which forms the basis for the generative mechanism of self. Right hemisphere thinking, by contrast, appears more con- cerned with aspects of intrapersonal reality, somatic apperception, and body image, and is less involved in the negotiation of the individual’s needs with the demands and constraints of the objective world. Dimond (1980) concludes that there is left-hemisphere basis for the generative mechanisms of self and identity, identity being expressed in all that the patient says and does.

Joseph (1982) has applied an explicitly neurodevelopmental approach the the question of the social ori- gins of thought and language by noting that the motor areas of the cortex mature before the sensory areas, and that the left hemisphere develops prior to the right. This, he argues, gives the left hemisphere a com- petitive advantage in the acquisition of motor representation, whereas the later-maturing right hemisphere has an advantage in the establishment of sensory- affective representation, including that of limbic mediation of emotion and motivation. Joseph (1982) views thinking as a left hemisphere internalization of language which corresponds to the increased maturation of intracortical and subcortical structures and fiber pathways, and the myelination of the callosal connec- tions that subserve information transfer between the hemispheres. He argues that thought is a means of organizing, interpreting, and explaining impulses that arise in the nonlinguistic portions of the nervous system so that the language-dependent regions may achieve understanding.

For Joseph (1982), internal language is a function of the left hemisphere’s attempt to organize and make sense of behavior initiated by the right half of the brain. Because early in life interhemispheric communication is incomplete, the left hemisphere utilizes language to explain to itself the behavior in which it observes itself to be engaged. As the commissures mature and intrahemispheric and interhemispheric information flow increases, the left also acts to organize linguistically its internal experiences. As the person develops, interhemispheric information exchange con- tinues to grow, and the left hemisphere language substrate increasingly acts to organize (as well as to in- hibit) sensory-limbic right hemispheric transmissions and initiated behaviors. Rather than passively observing the sensory-limbic actions as they occur in the environment, the left hemisphere now actively engages in the formulation of behavior, achieving understanding prior the occurrence of the behavior. At some important stage in normal development, the interpretation or evaluation of a behavior precedes its execution. Be- havior no longer has to be emitted and its effect on the environment overtly observed in order for self- modulation to occur. Vygotsky (1962) saw this process as corresponding to the transformation of egocentric speech into true inner speech. In Joseph’s (1982) neuropsychological formulation, it represents the maturation of the left hemisphere mechanisms responsible for self-articulation.

Markus (1983) makes the point that self-knowledge that can be abstracted, symbolized, and articulated is particularly significant self-knowledge because it can be communicated to others and thus represents those aspects of self that are likely to have the most impact on social behavior. Thus, the construction of a stable ego or self structure involves the elaboration of self-

44 L. Miller

generated and recursively evaluated self-schemas, as well as the integration of these schemas into a cohesive personality framework. In the present neuropsychodynamic formulation, the left-hemisphere verbal autoarticulatory capacity could be used by the frontal lobes both to guide behavior and to appraise feedback from that behavior’s impact on the physical and social world. In this way is self-knowledge progressively developed and an identity hewn from the emotional-perceptual-activity melange of successive daily experiences. The increasing volitional control of the verbal articula- tory capacity also enables the growing person to explicitly communicate, with progressive degrees of refinement, facets of this identity- feelings, desires, perspectives-to others, even as self-communication coevolves. This process facilitates the development of the appreciation of self as actor (Markus, 1983) and so imbues behavior with the volition requisite for truly autonomous action-a psychological capacity quite alien to Shapiro’s (1965) impulsive character style.

If, as is implicit in Joseph’s (1982) argument, the left hemisphere language system serves to organize and give social meaning to feelings and drives, it would not be surprising that individuals arrested at some neurodevelopmental stage associated with language functioning might also be frozen at some immature level and thus suffer an incomplete or distorted self-refer- ential behavior control system. Under conditions of ambiguity, stress, or frustration, especially in social situations, such individuals may preferentially utilize more psychodynamically primitive patterns of behavior, representing partially distorted manifestations of antagonistic-antisocial or approach-prosocial behaviors. In addition, such individuals might be expected to show deficits in other indices of left hemisphere language, such as VIQ-PIQ discrepancies and verbal learning disabilities-which, in fact, is frequently the case for impulsive, antisocial characters. Indeed, Blasi (1980) reports that delinquents tend to use develop- mentally lower modes of moral reasoning than do matched controls. In a related way, reading compre- hension and spelling disturbances have been shown to be associated with a tendency to harbor irrational beliefs (Prola, 1984, 1985).

Thus the impulsive character, who frequently comes to clinical attention as the antisocial personality, alcoholic, or addict, is hypothesized to suffer from a neurodevelopmental maturational deficit which is responsible for a relative inability to use inner speech to modulate attention, affect, thought, and behavior. Under conditions of social frustration or ambiguity, regressive or behaviorally immature coping patterns are utilized to maintain the integrity of the ego (Miller, 1987, 1988). To the extent that ego integrity requires adequate development of certain requisite cognitive capacities - Hartmann’s (1939/ 1958) “conflict-free ego sphere”- a maldevelopment of these capacities may

predispose the utilization of less effective coping strategies. And to the degree that there is overlap between the cognitive style factors involved in personality structure and the particularized cognitive skills necessary for intact neuropsychological test performance, impairment in the one may be associated with deficits in the other. Thus, alcoholics, and drug abusers may be impaired on some measures of conceptual flexibility and reasoning, not because-or at least not on& because-these substances directly poison the brain, but because poor ability in such tasks is part of a larger preexisting constellation of cognitive-personality factors associated with a predisposition to the use of psychoactive substances for exogenous mood control and ego stabilization.

But as the above review has suggested, some narcotic drug abusers do quite well on circumscribed tests of cognitive ability, while others bomb. Why? The rea- son may be that while many drug abusers do appear to be more generally impulsive-antisocial, recall that they also seem to show better ego strength, more “effectiveness” in the environment, and greater resourcefulness (Craig, 1982; Blatt, 1984b). This is not the contradiction it may seem. As Shapiro (1965) and others (e.g., Cleckley, 1982) have argued, impulsive characters often display a keen practical intelligence for immediate matters and may thus appear quite cog- nitively astute in the short run. What is absent is the reflective component of intelligence, the planning and evaluating of more extended sequences of thought and action that have long-range consequences. Not a few clinicians have been impressed by the contrast between the “bright” psychopath with all the right answers during a brief clinical interview or psychological test ses- sion versus the lifelong history of behavior derailment with regard to functioning in the real world. And so with many neuropsychological tests: quick and efficient performance on circumscribed tasks, leading to an im- pression of cognitive proficiency- until such behavior has to be generalized to more comprehensive and important life events. And for those who fail even the immediate tasks, the problems in cognitive flexibility and adaptiveness may be all the more severe.

In this regard, it is also of interest that those at-risk individuals who nevertheless seem to resist careers of alcoholism and addiction, or who are able to recover spontaneously or with help, are also those found to be the least impulsive, most reflective, and highest in ego strength (Leber, Parsons, & Nichols, 1985; Ludwig, 1985, 1988; Nordstrum & Berglund, 1986; Werner, 1986). That many alcoholics, drug abusers, and impulsive characters suffer from verbal deficits highlights the idea that a sense of personal stability-an integrated ego structure -depends on the ability to use internal language codes (cf. Vygotsky’s “inner speech”) to modulate behavior. Lacking this, the sense of self is shaky and fragile, vulnerability to ego disruption by


the effects of overwhelming affect is prominent, and substances which mitigate the disruptions are favored. In terms of the present neuropsychodynamic model, frontal modulation of limbic affects may depend on an intact left-hemisphere language system for optimal behavioral control.

Indeed, the salient characteristic of alcoholics’ and drug abusers’ cognitive-personality functioning described in the present review -cognitive inflexibility, attenuated time perspective, external locus of control, field dependence, deficient ego strength, and poor object relations-are all features of thought and behavior that have been associated with organic frontal lobe impairment. The unique feature of the present argument is that these deficits need not imply that alcoholics have “lesions” in the frontal lobes (or in any other parts of the brain), but rather that individual differences in personality, cognitive style, and neuropsychological task performance are all relatable to differences in cerebral organization. We are all born with different brains, and we all have a unique pattern of talents, weaknesses, aversions, and proclivities that go into forming what we call “personality.”

In sum, an emphasis on cognitive style aspects of personality functioning is not less “neuropsychological” than the narrow localizationist position of ascribing separate behavioral syndromes to individual hemispheres and lobes (Miller, 1986, in press). Rather, an emphasis on cognitive style allows for a more integrated view of brain-behavior dynamics and the tear- ing down of false interdisciplinary boundaries that for too long have hampered research and conceptualization in psychiatric neuropsychology - indeed, neuropsychology as a whole.

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