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Anger Management: Cognitive Therapy Interventions7 CEUs Anger Management: Cognitive Therapy Interventions

Section 18
Anger and Depressive States Among
Treatment-Seeking Drug Abusers
Part Two: Results and Conclusion

Question 18 | Answer Booklet | Table of Contents | Anger Management CEU Courses

The sample was composed of 50 men (83%) and 10 women (17%), consisting of Hispanic (42%), Caucasian (32%), and African-American (26%) ethnic origin. The mean age of the sample was 34.0 years (SD = 8.0). There were no significant differences between cocaine, heroin, and marijuana patients with respect to age.

The total mean score of the BDI-II for the three groups of drug users was 23.5 (SD = 11.03). The severity of depression in this group of drug users is approximately twice that of the non-clinical sample group (M = 12.56, SD = 9.93) reported by Beck, Steer, and Brown (BDI-II manual, 1996).  However, the predicted greater depressive state in the cocaine-dependent group was not found. Among the groups, the heroin users were the most depressed, followed by the cocaine users with low levels of moderate depression, and then by the marijuana users with high levels of mild depression. The heroin users’ level of depression was significantly greater than the marijuana users.  Only a trend was found between the depressed heroin users and the cocaine users. Examination of the cognitive and somatic subscales of the BDI suggests that most of the difference in BDI scores between groups is accounted for by the somatic subscale.

The State Anger scale mean was 19.2 (SD= 7.58). This mean value suggests that the substance abusers as a group are experiencing relatively higher levels of intense angry feelings compared to the normal adult male norms (age group 31- 40 years old; M= 11.26, SD= 3.03; female M= 12.61, SD= 4.56). However, there were no differences between the mean of the Trait Anger scale of the substance abusers, which as a group (M = 19.76, SD = 5.80) was similar to norms of the adult population (M= 18.52, SD= 4.80).

There were no significant overall effects of group on any of the anger scales. A one-way ANOVA revealed no main effects on either the State or Trait Anger scales. All three groups mainly reported similar levels of angry feelings and frustration. Interestingly, the groups differed at a trend level (p < .1) for Anger Out and Anger Expression. The cocaine users scored higher on the Anger Out scale. Pairwise comparisons between groups suggest that the cocaine users are more prone to express their anger in aggressive behavior directed either toward a person or an object in the environment. This score was significantly higher than that of the marijuana users and approached significance for the heroin users. No differences were found between the heroin and marijuana users.  Similarly, cocaine users scored higher than marijuana users at a trend level for the Anger Expression scale. The difference between the reported intense angry feelings of cocaine and heroin users was not significant at the p < .05 level. No differences were found between the heroin and marijuana users.

Consistent with many other studies in the literature, the data in the present study suggest substance abusers in our study experience higher levels of psychological distress compared to standard values.  As such, Khantzian’s assertion that the first purpose of the self-medicating is to relieve psychological suffering is supported by our findings. High levels of psychological symptoms have been frequently reported in substance-dependent populations.

However, the data give little support to the psychopharmacological specificity hypotheses stemming from Khantzian’s second aspect of the self-medicating hypothesis, namely, that higher levels of anger would be found among the heroin users and higher levels of depression among the cocaine users. A few subscales show a trend toward slightly more anger in cocaine abusers and more somatic depressive symptoms among opiate addicts. These findings are congruent with studies that suggest an association between cocaine and aggressive and hostile personality traits of cocaine users that react impulsive behaviors and acting out. Examining MMPI data on cocaine abusers, Helfrich and colleagues and Craig found that the mean profile for a group of cocaine patients was a spike 4 code type, which is associated with impulsive behavior, acting out, and poor relationships with authority figures.

The 1985 National Household Survey examined the effects of cocaine by interviewing 500 cocaine users. High frequency of antisocial acts consistent with violent behaviors were reported. Suicide attempts were a consequence of cocaine use for 9% of those assessed.  In a study investigating aspects of violent behaviors associated with cocaine use, a range of behaviors from minor psychological aggression to major physical acts (including murder and rape) were reported.

The findings of higher levels of depression among opiate-addicts are congruent with other reports indicating high prevalence of depression among the opioid-dependent. Weiss et al reported that compared to cocaine abusers and patients dependent on sedative-hypnotics, the opioid dependent patients in their study were significantly more depressed than the aforementioned groups. In clinical studies with opioid-dependent methadone-maintained patients, approximately 40- 85% of methadone maintenance patients have a lifetime comorbid psychiatric disorder, with depressive disorders accounting for approximately 40%to 50% of the comorbidity.  In a more recent study with a similar population, approximately 47%of these patients had a lifetime comorbid psychiatric disorder, but depressive disorders only accounted for approximately 15.8% of the comorbidity. Further analyses conducted with the cognitive and somatic BDI-II subscales indicated that the heroin abusers scored significantly higher on the somatic subscale.

Thus self-reported depression among our opiate addicts may represent somatic complaints related to withdrawal. In a study with methadone patients, Strain reports that recorded levels of depression on the BDI decreased after two weeks of treatment. They suggested that a more accurate assessment of the heroin user’s depression might be obtained if the BDI is administered after several weeks in treatment.

Castaneda and colleagues attempted to assess the validity of the self-medication hypothesis by questioning patients who were being admitted to the psychiatric services of a large metropolitan hospital about the main effect that their primary drug of abuse had on a number of psychiatric symptoms over the past two weeks.

They were also asked to indicate whether each symptom was better, worse, or unchanged following self-administration of the drug. The findings indicated that patients with similar symptomatologies used different drugs, experienced different effects, and developed different expectations about the consequences of drug use, thereby not supporting the self medication hypothesis. In 1994, Castaneda conducted a similar study in which he explored the motivation of patients to seek a specific drug for the relief of a particular set of symptoms. He examined inpatients with an axis I diagnosis of one drug dependence and an axis II diagnosis of personality disorder. The patients were asked to report the effect of the drug of choice on their current symptoms. The results indicated that heroin addicts reported that heroin improved some of their psychiatric symptoms and all of their cognitive dysfunctions, whereas both the cocaine and alcohol users reported that their drug of choice worsened their psychiatric and cognitive symptoms. They concluded that there was little evidence to support the specificity hypothesis. Weiss and others examined the self-medicating hypothesis of drug abuse by studying drug effects and motivation for drug use in a sample of hospitalized drug abusers. Their findings indicated that most patients reported that they used drugs to relieve symptoms of depression and other mood symptoms, regardless of the type of drug.

Our study supports the notion of underlying psychological distress of the substance abuser and is in line with the general thrust of the self-medication hypothesis. However, our study does not support the psychopharmacological specificity hypothesis, that specific psychological distress sustains continued use of one drug over another. This should not discourage attempts to treat symptoms such as depression or anger in carefully selected drug abusers with high levels of such symptoms.
- Aharonovich, Ph.D., Efrat; Nguyen, M.S., Hueco T.; Nunes, M.D., Edward V.  The American Journal on Addictions, 2001

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.

According to the Aharonovich study, what were the STAXI, or anger, differences between cocaine, heroin, and marijuana patients? Record the letter of the correct answer the Answer Booklet.

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