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Section 23
Anger and Depressive States Among
Treatment-Seeking Drug Abusers
Part One: Discussion

Question 23 | Test | Table of Contents

Among the various theoretical formulations for explaining alcohol and drug addiction, Khantzian’s self medication hypothesis (SMH) has received wide recognition and is still widely debated. Khantzian describes two major aspects of the SMH: 1) substance abusers generally experience higher levels of psychological distress compared to nonclinical populations, and 2) drug users are attracted to different drugs based on how specific drugs (such as cocaine or opiates) alleviate their psychological symptoms.

Numerous studies have shown high levels of distress and high prevalence of psychiatric diagnoses in substance-dependent patients. However, few studies have examined the second portion of the hypothesis.

The SMH is unique in identifying and attributing importance to the pharmacological properties of the addict’s specific drug of choice. Thus, the addiction is conceptualized as the individual’s attempt to fill in gaps in his self-regulatory functions.

In this view, individuals generally gravitate toward and choose a particular drug, because the pharmacological properties may serve to fulfill some specific psychological needs, such as alleviating painful feelings. In the course of experimenting with different drugs, an individual discovers that the action and feelings obtained from the use of one drug is preferable over that of another.  

According to Khantzian, the abuser is, in a sense, prescribing drugs to himself. Based on psychiatric diagnostic findings and clinical observations, Khantzian hypothesized specific psychopharmacologic preference criteria for the opiate-dependent and cocaine-dependent predisposition. Thus, opiate addicts who suffer from rage and aggression are attracted to the drug for its anti-aggressive effects. In contrast, cocaine abusers suffering from emotional distress resulting from depression and low self-worth seek to alleviate these feelings with the stimulating effects of the drug.

Most of the evidence supporting the specificity hypothesis comes from anecdotal data, case studies, and vignettes, collected from a small number of patients who had undergone psychotherapy. Only a few previous studies have explored the specificity hypothesis systematically in larger samples.  The results of these empirical studies tended to question the SMH by generally observing a lack of specificity in drug use to alleviate psychological symptoms. The majority of empirical studies evaluating the SMH recruit their subjects from inpatient populations.

Therefore, the present study, in an effort to increase the generalizability of these findings, evaluated the SMH in outpatient drug abusers. It should be noted, however, that one of the major problems with research regarding the SMH is that there are virtually no studies of patients prior to the onset of their drug use. Thus differential diagnostic data pertaining to primary or underlying affect versus substance- related affect is missing.

Three groups of drug abusers seeking outpatient treatment were evaluated with regard to levels of anger and depression: cocaine abusers, heroin abusers, and marijuana abusers. Because virtually no data exist evaluating anger and depression in marijuana users, this group was added and compared with the other two.

In keeping with the SMH, our predictions were: (1) Aggression, as measured by the STAXI, would be greater in opiate users compared to the cocaine and cannabis users. (2) Depression, as measured by the BDI, would be greater in cocaine users compared to heroin and cannabis users.

Method
Participants were sixty individuals who responded to a general advertisement recruiting individuals seeking treatment for problems with cocaine, heroin, or marijuana use.  As part of the normal assessment process for the program, all participants were administered a clinical interview and given self-report questionnaires (Demographics Questionnaire, the Spielberger STAXI and the Beck Depression Inventory-II). All participants who were included in this study met SCID diagnostic criteria for substance dependence (for their primary drug of choice, i.e. either heroin, cocaine, or marijuana). Thirty-seven (61.6%) denied any alcohol abuse or dependence. Three (5.0%) met current alcohol dependence and five (8.3%) current abuse. For past alcohol use, six (10.0%) met past abuse and four (6.6%) met past dependence. Data was not available for five (8.3%) participants.

Instruments
The following measures were administered to the subjects at the time of the assessment.  The State-Trait Anger Expression Inventory (STAXI) is a 44-item inventory that forms six scales and two subscales. State Anger (S-Anger) is a 10-item scale that measures the intensity of angry feelings at the time of testing. Trait Anger (T-Anger) is a 10-item scale that measures the individual’s disposition to experience anger over time. The T-Anger scale has two subscales: Angry Temperament (T-Anger/T) is a 4-item T-Anger subscale that measures a general propensity to experience and express anger without specific provocation.

Angry Reaction (T-Anger/R) is a 4-item T-Anger subscale that measures individual differences in the disposition to express anger when criticized or treated unfairly by other individuals. Anger-In (AX/In) is an 8-item scale that measures the frequency with which individuals typically hold in or suppress their anger. Anger-Out (AX/Out) is an 8-item scale that measures the frequency with which individuals typically direct their anger toward people or objects in the environment. The Anger Control (AX/Con) is an 8-item scale that measures the frequency with which an individual attempts to control his/her expression of anger. The Anger Expression (AX/EX) scale is based on the responses to the 24 items of the AX/in, AX/Out, and Ax/Con scales, and provides a general index of the frequency with which anger is expressed, regardless of the target of that expression.

The Beck Depression Inventory-II
(BDI-II) is a questionnaire consisting of 21 groups of statements. It measures the severity of self-reported depressive symptoms experienced during the two weeks prior to testing. All of the tests have been shown to possess satisfactory reliability and validity.

Data Analysis
The three groups seeking treatment for cocaine, heroin, or cannabis dependence were compared on each of the measures with one-way Analysis of Variance (ANOVA). When ANOVA was significant, at least at the p < .01 level, comparisons between individual groups were carried out with a t-test.
- Aharonovich, Ph.D., Efrat; Nguyen, M.S., Hueco T.; Nunes, M.D., Edward V.  The American Journal on Addictions, 2001

Anger Management for Substance Abuse and Mental Health Clients

- SAMHSA. (2012). Anger Management for Substance Abuse and Mental Health Clients. U.S. Department of Health and Human Services.

Personal Reflection Exercise #9
The preceding section contained information about anger and depressive states among treatment-seeking drug abusers. Write three case study examples regarding how you might use the content of this section in your practice.
Reviewed 2023

Update
Depression, Suicidality, Substance-Use
and Associated Factors among People Living
with HIV the COVID-19 pandemic in Uganda

Rukundo, G. Z., Wakida, E. K., Karungi, C. K., Asasira, J., Kumakech, E., & Obua, C. (2023). Depression, suicidality, substance-use and associated factors among people living with HIV the COVID-19 pandemic in Uganda. PloS one, 18(5), e0285310.

Peer-Reviewed Journal Article References:
Christ, N. M., Contractor, A. A., Wang, X., & Elhai, J. D. (2020). The mediating effect of rumination between posttraumatic stress disorder symptoms and anger reactions. Psychological Trauma: Theory, Research, Practice, and Policy. Advance online publication.

Harmon-Jones, C., Hinton, E., Tien, J., Summerell, E., & Bastian, B. (2019). Pain offset reduces rumination in response to evoked anger and sadness. Journal of Personality and Social Psychology, 117(6), 1189–1202.

Kelly, E. L., Novaco, R. W., & Cauffman, E. (2019). Anger and depression among incarcerated male youth: Predictors of violent and nonviolent offending during adjustment to incarceration. Journal of Consulting and Clinical Psychology, 87(8), 693–705.

QUESTION 23
Based on psychiatric diagnostic findings and clinical observations, what did Khantzian hypothesize concerning specific psychopharmacologic preferences of opiate addicts and cocaine abusers? To select and enter your answer go to Test.

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