COMPARISON OF PSYCHOMETRIC MEASURES IN PSYCHIATRIC PATIENTS USING HEROIN AND OTHER DRUGS

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1 Journal of Abnormal Psychology 974, Vol. 83, No. 2, COMPARISON O PSYCHOMETRIC MEASURES IN PSYCHIATRIC PATIENTS USING HEROIN AND OTHER DRUGS HYMAN KORIN Veterans Administration Hospital Health Center, Northport, New York and nonopiate users, psychotic and nonpsychotic, were compared on the Bender-Gestalt test, a mental ability scale, and an affect adjective checklist. Analyses of variance and covariance indicated heroin effects were highly significant (p <.0) on the Bender-Gestalt test. Psychosis effects lacked significance on any test. Constricted use of space, a tendency to rotate designs, and perseverations were significantly more frequent in the heroin patients. Total Bender-Gestalt scores of detoxified and nondetoxified heroin users were not significantly different. It is concluded heroin patients show marked perceptual disturbances. In work by this investigator with drug-using patients admitted to a psychiatric hospital, it was noted that those who were heroin dependent tended to produce more striking perceptual distortion on the Bender-Gestalt test than users of other drugs, although many of the heroin patients were nonpsychotic and had been recently detoxified. The trend contrasted with reports of findings in nonaddicts which indicated perceptual distortion on the Bender-Gestalt test was greater in psychotic groups compared to nonpsychotic groups (Bernstein, 963; Hutt & Gibby, 970). Narcotic addiction patients might be expected to show perceptual distortion tendencies. Most researchers hold that these patients have some mental problems or a disturbed personality irrespective of when they are tested (Braucht, Brakarsh, ollingstad, & Berry, 973). Addiction patients have mainly been described as being sociopathic or as having a personality or character disorder. Other narcotic addiction patients, however, have psychoneurotic and psychotic features. Although the personality attributes of these groups have been described, particularly in studies seeking to determine characteristics which may lead to addiction, variables such as are tapped by the Bender-Gestalt test have been neglected. It is possible that the psychological characteristics of addiction patients also reflect changes resulting from addictive and detoxified states. In previous studies of controlled doses of morphine and heroin in addiction subjects and subsequent abstinence, changes of varying significance have been found. Martin and Jasinski ithe author is grateful to the many staff members who aided in conducting the study. Requests for reprints should be sent to Hyman Korin, Veterans Administration Hospital, Northport, New York (969) reported chronic doses of morphine produced physiological changes of unknown significance. Haertzen and Hooks (969) found changes in personality attributes, including mood. They noted that chronic doses of morphine increased hypochondrical symptoms and subsequent abstinence increased depression and anxiety. Wikler (93) found that acute doses of morphine produced changes of doubtful significance on tasks such as code learning, and razer, Jones, Rosenberg, and Thompson (963) found no significant impairment on pursuit rotor and pedometer tasks during chronic heroin intoxification. The subjects in these previous studies had histories of sociopathic behavior and had personality and character disorders. In the present investigation, a comparison was made of the responses on the Bender-Gestalt test of heroin-using and nonopiate-using psychotic and nonpsychotic groups. In addition, tests of mental ability and affect were also administered to determine whether these factors were related. Subjects METHOD orty-four drug-using patients were examined. Twenty-seven of the patients were primarily heroin users, most of whom had also indulged in other drugs. The 7 remaining patients had used a variety of nonopiates including marijuana in most cases, sometimes exclusively and at times mixed with other drugs such as alcohol, amphetamines and occasionally LSD. Drug addiction heroin invariably was the diagnostic classification of the 27 heroin patients. ifteen of these patients also had subclassifications: 6 personality inadequacy or disorder, anxiety neurosis, 3 neurotic depression, 2 psychotic depression, and 3 paranoid schizophrenia.

2 SHORT REPORT 209 In the nonopiate group, one patient was classified drug addiction. The remainder in addition to using drugs were diagnosed, 2 inadequate personality, 2 anxiety neurosis, psychotic depression, 6 paranoid schizophrenia, and S chronic undifferentiated schizophrenia. None of the patients had any obvious brain disease. All the patients were Vietnam era service veterans, ages Education levels were about the same in each group. ourteen of the heroin patients had stopped taking drugs one to three months. Nine of these patients had been detected by the routine administration of urine tests in Vietnam and had just been discharged following 4-0 weeks of detoxification. Of the remaining five "detoxified" patients, one had just been in prison five months, a second was on probation after his arrest for assault and had stopped taking heroin for three months and three had voluntarily applied for psychiatric treatment. No objective evidence was available to check the abstinence statements of the three voluntary patients. The 3 nondetoxified patients and the majority of the nonopiate group had indulged in drugs until the day just prior to their arrival at the hospital. Procedure Each patient was administered the Bender- Gestalt test (Hutt & Gibby, 970), the Kent Series of Emergency Scale D (Kent, 942), and a Multiple Affect Check List (Zuckerman & Lubin, 96S) described as follows:. Bender Gestalt Test: The patient reproduced nine designs shown on cards one at a time, one after the other. The reproductions were scored for 7 factors on the Hutt Psychopathology Scale (Hutt & Gibby, 970) to obtain a single score. All scoring was done without knowledge of the identity or diagnosis of the patient. 2. Kent Series of Emergency Scale: The 0 simple questions of the test were administered verbally. A number of points varying for each question was scored to obtain a total score estimating mental ability. 3. Multiple Affect Adjective Check List Short orm: A list of 48 positive and negative adjectives devised by Zuckerman and Lubin (96S) denoting anxiety, depression, and hostility were presented. The subject checked the words describing how he felt that day. The score consisted of the number of negative adjectives checked and the number of positive adjectives omitted. Treatment of the Data Since the heroin and nonopiate groups consisted of unequal numbers of psychotic and nonpsychotic patients, 2X2 factorial analyses of variance for unequal cells were applied to evaluate the effects of psychosis, drugs, and any combined effect of psychosis and drugs on the various tests (Winer, 97). An analysis of covariance was also employed to correct the Bender- Gestalt scores for the variation on the Kent scores. In addition to comparing total scores on the Bender-Gestalt test, an analysis was also made of differences between the heroin and nonopiate patients on each of the 7 factors of the test. The detoxified and nondetoxified patients of the heroin group were also compared. Test Scores RESULTS The mean scores of the various subgroups on each test and the analysis of variance summary are shown in Table. The Bender-Gestalt scores of the heroin patients were markedly poor regardless of whether psychosis was present. The drug effect was significant ( = 4.99, =l, p<.0). No significant effects were found for the psychosis or interaction between psychosis and drug factors. On the Kent Series of Emergency Scale, the greater the score, the greater was the mental ability. Differences between the mean scores of the subgroups were comparatively small. Mental ability in each subgroup when assessed by norms suggested by Kent (942) was about average to bright normal for the mean and varied from dull normal to superior. No significance was indicated, however, for the psychosis and drug effects or for the interaction of these factors. The Multiple Affect Adjective Check List was omitted in the case of several patients because of time considerations, so that the total N was reduced slightly. The drug and psychosis effects were nonsignificant. The combined effect of these factors reached the.0 level of significance ( = S.04, =, p <.OS), indicative of the marked differences between the means of some of the subgroups. Disturbed affect consisting mainly of depression and anxiety, markedly evident in the heroin-psychotic subgroup (X = 3), is attributable to the responses of two of the five patients who were psychotic depressives and would be expected to have more disturbed affect than other drug users. Significant Pearson correlations between the mental ability and the Bender-Gestalt scores were found in the heroin (.7) and nonopiate

3 20 SHORT REPORT TABLE MEANS, STANDARD DEVIATIONS AND ANALYSIS O VARIANCE RESULTS ON THE BENDER-GESTALT TEST, KENT SERIES op EMERGENCY SCALE, AND MULTIPLE AECT ADJECTIVE CHECK LIST TOR THE HEROIN AND NONOPIATE GROUPS ttb-ther CLASSIIED INTO PSYCHOTIC AND NONPSYCHOTIC SUBGROUPS Group Bender-Gestalt Test Kent Series of Emergency Scale Multiple Affect Adjective Check List Psychotic X SD N Nonpsychotic X SD N Total S ^ Summary of analysis of variance Psychosis (A) Drugs (B) AXB Within *a * a An analysis of covariance correction of the Bender-Gestalt scores for variation on the Kent scores enhances the drug effect ( = 9.0, (If =, p <.0). *P <.OS. (.6) groups. Correlations between either the mental efficiency or Bender-Gestalt scores and the Multiple Affect Adjective Check List results were low and nonsignificant. An analysis of covariance was therefore carried out to determine whether adjustment of the Bender-Gestalt scores for the effect of variation due to mental ability enhanced or diminished the drug effect. A significant enhancement of the drug effect occurred IX.Ol). The Bender-Gestalt mean scores above are averages of total scores based on the summation of values taking into account either the degree or frequency of misreproduction on 7 factors. The mean scores of the heroin and nonopiate groups on each of these factors are shown in Table 2. The greater the mean, the greater was the distortion. Although the mean scores of the heroin and nonopiate groups were high on the Use of Space, Closure, Curvature, Angulation, and Retrogression factors, there was little difference between the groups. The heroin group, however, had the greater score on 3 of the factors (p <.0). Differences were significant, by means of a t test on the Use of Space (p<.02), Rotation (p <.0), and Perseveration factors (p <.0). The Use of Space factor refers to the space between drawings. Invariably there was constriction rather than expansiveness, particularly in the heroin group. Perseverations were found in 0 of the 27 heroin patients in comparison to only 2 in the 7 nonopiate patients. Of the 0 heroin patients, 8 were detoxified. Perseverations occurred in 8 of 4 detoxified patients compared to only 3 nondetoxified patients. The isher exact probability test (Siegel, 96) indicated the frequency of perseverations was significantly greater (p <.0) in the detoxified group. urther, only four fragmentation errors were found in which parts of a figure were excessively separated. All were produced by the detoxified group. Six of seven Collisions, that is, one figure was drawn touching or overlapping a second figure, were found in the heroin group, equally distributed in the detoxified and nondetoxified patients. The mean Collision score in Table 2 includes collision tendencies, the intrusion of one figure into the open space of another, without touching or overlapping. These tendencies were found in the nonopiate as well as heroin patients. Despite these differences on individual factors, the total Bender-Gestalt test score means of the detoxified and nondetoxified subgroups were not significantly different (detoxified group? = 6.79; nondetoxified group X = 9.8), Similarly, differences between the two groups were not significant on the Kent test (detoxified group X 26.4, nondetoxified group X = 27.69)

4 and the Multiple Affect Adjective Check List (detoxified group X = 2.36; nondetoxified group X = 24.8). DISCUSSION Significantly poorer scores were found in the heroin group only on the reproductions of the Bender-Gestalt designs, a task placing emphasis on perceptual-motor performance. More impor- tantly, the distortions of the heroin-nonpsychotic patients, who were by far the majority in the heroin group, were markedly poor for a nonpsychotic group. It turned out the majority of the nonopiate patients were psychotic patients who reproduced the Bender-Gestalt figures more adequately than the heroin nonpsychotics. The low distortion indicated by the mean score of the nonopiate-nonpsychotic patients, however, suggests that had more of the nonopiate patients been nonpsychotic, the results would have been the same. Commonly, perceptual distortion is more frequently seen in psychotic patients. In studies of nonaddicted groups, schizophrenic patients have been reported to perform more poorly on the Bender-Gestalt test than nonpsychotic patients. Some schizophrenic patients, nevertheless, perform adequately on tests. The nonopiatepsychotic patients, marijuana users primarily, were in the latter category. These nonopiate group findings are in agreement with recent reports that marijuana has little if any detrimental effect as commonly used. actors which could not be controlled such as the frequency of use of the drugs, the time of last use of the drugs, and that a third of the heroin group had just arrived from Vietnam may have played a role in producing the findings. The performance of the heroin group might possibly be attributed to the presence of brain dysfunction. Although the Bender-Gestalt test is of doubtful efficacy as an index of brain dysfunction in individual patients, it has been found to differentiate significantly between groups with organic brain disease and functional mental illness (Brilliant & Gynther, 963). Routine neurological examinations of the patients, however, revealed no significant defects were present. Any existing organic impairment would have to be present at a subtle, subclinical level difficult to verify. It is more likely that the responses of the heroin patients reflected personality traits. Personality attributes have been found to be correlated with Bender-Gestalt scores (Haynes, 970). Since the Perseveration distortion occurred mainly in the detoxified patients, these responses may be associated with recent heroin abstinence. In view of SHORT REPORT 2 TABLE 2 MEAN SCORES O HUMAN AND NONOPIATE GROUPS ON EACH O 7 BENDER-GESTALT ACTORS actor Sequence st Drawing Use of Space Collision Shift of Paper Closure Crossing Curvature Angulation Rotation Retrogression Simplification ragmentation Overlapping Elaboration Perseveration Redrawing group group Difference t ** * * Note, N = 27 for the heroin group; n = 6 for the nonopiate group. *p <.0. ** t <.02. the small number of subjects involved, the finding requires further verification. Perseveration tendencies in the behavior of heroin addicts, however, have been noted clinically (Scher, 966). Whether the rotations and constriction in the use of space were the result of stable characteristics or change cannot be readily stated. REERENCES BERNSTEIN, I. H. A comparison of schizophrenics and nonschizophrenics on two methods of administration of the Bender-Gestalt test. Perceptual and Motor Skills, 963, 6, BRAUCHT, G. N., BRAKARSH, D., OLLINGSTAD, D., & BERRY, K. L. Deviant drug use in adolescence: a review of psychological correlates. Psychological Bulletin, 973, 79, BRILLIANT, P., & GYNTHER, M. D. Relationship between performance on three tests for organieity and selected patient variables. Journal of Consulting Psychology, 963, 27, RASER, H.., JONES, B. E., ROSENBERG, D. E., & THOMPSON, A. K. Effects of addiction to intravenous heroin on patterns of physical activity in man. Clinical Pharmacology and Therapeutics, 963, 4, HAERTZEN, C. A., & HOOKS, N. T., JR. Changes in personality and subjective experience associated with the chronic administration and withdrawal of opiates. Journal of Nervous and Mental Disease, 969, 48, HAYNES, J. R. actor-analytic study of performa.nce on the Bender-Gestalt. Journal of Consulting and Clinical Psychology, 970, 34, 34S-347.

5 22 SHORT REPORT HUTT, M, L., & GIBBY, R. G. An atlas for the adaptation of the Bender-Gestalt Test. New York: Grune & Stratton, 970. KENT, G. H. Emergency battery of one-minute tests. Journal of Psychology, 942, 3, MARTIN, W. R., & JASINSKI, D. R. Physiological parameters of morphine dependence in man tolerance, early abstinence, protracted abstinence. Journal of Psychiatric Research, 969, 7, 9-7. SCHER, J. Patterns and profile of addiction and drug abuse. Archives of General Psychiatry, 966, IS, 39-. SIEGEL, S. Nonparametric statistics for the behavioral sciences. New York: McGraw-Hill, 96. WIKLER, A. Opiate addiction: Psychological, neurophysiological aspects in relation to clinical problems. Springfield,.: Charles C Thomas, 93. WINER, B. J. Statistical principles in experimental design. New York: McGraw-Hill, 97. ZUCKERMAN, M., & LusiN, B. Manual for the Multiple Affect Adjective Check List. San Diego, Calif.: Educational and Industrial Testing Service, 96. (Received January 4, 973)