fe 2/. a inbrirk | 198 ~The Kolb Classification of Drug Addicts By M. J. PESCOR SUPPLEMENT No. 155 TO THE PUBLIC HEALTH REPORTS FEDERAL SECURITY AGENCY UNITED STATES PUBLIC HEALTH SERVICE Tuomas Parran, Surgeon General DIVISION OF SANITARY REPORTS AND STATISTICS Cuarues V. AKIN, Assistant Surgeon General, Chief of Division UNITED STATES GOVERNMENT PRINTING OFFICE, WASHINGTON : 1939 For sale by the Superintendent of Documents, Washington, D. C. Price 5 cents (11) THE KOLB CLASSIFICATION OF DRUG ADDICTS By M. J. Puscor, Passed Assistant Surgeon, United States Public Health Service This study attempts to evaluate the Kolb classification of drug addicts as applied to patients undergoing treatment for drug addiction at the United States Public Health Service Hospital in Lexington, Ky. The patients undergoing such treatment are prisoners (who constitute the majority of the admissions), probationers, and volun- taries. The latter enter the hospital of their own accord and may leave whenever they please, but are urged to stay a minimum of 6 months. Probationers are law violators whose sentences have been suspended provided they receive treatment for drug addiction. They must remain in the hospital until pronounced cured by the medical staff, usually about 6 months. Prisoners, of course, are law violators who have definite sentences to serve. The Kolb classification (1) consists of the following major categories: _ (1) Normal individuals accidentally addicted—This group includes persons of normal nervous constitution accidentally or necessarily addicted through medication in the course of illness. (2) Psychopathic diathesis—This group includes individuals who show psychopathic dispositions or tendencies characterized by behavior resulting from misinterpretations of environmental settings or situations, but not a well crystallized personality defect. (3) Psychoneurosis—This group includes individuals suffering with the ordinary types of psychoneurosis. (4) Psychopathic personality without psychosis—This group is composed of persons who show deviation of personality, usually expressed as constitutional psychopathic inferiority, psychopathic personality, or constitutional psychopathic states, where volitional and emotional control are gravely distorted from the normal. (6) Inebriate—This group includes individuals in whom alcoholic indulgence, either periodic or more or less continuous, played an important role as a precipitating factor in the addiction. They apparently have a so-called inebriate impulse. (6) Drug addition associated with psychosis —This group includes _ addicts suffering with frank psychosis, organic, toxic, or functional (7). The data for this investigation were secured from the clinical records of 1,036 patients admitted to the Lexington Hospital during the fiscal year July 1, 1936, to June 30, 1987. Percentage frequencies for the various factors were computed according to their occurrence - in the whole group of 1,036 patients and in the subgroups correspond- ing to the Kolb classification. The frequencies for each subgroup 138009—39 1 4 THE KOLB CLASSIFICATION OF DRUG ADDICTS sent to the penitentiary. He would not have a delinquency record prior to addiction. After addiction his offenses would more than likely be confined to violation of drug laws, for which he would be given at least one penitentiary sentence and at least one jail sentence. He would probably have spent a total of 3 years behind bars on pre- vious sentences. He would give a history of the usual childhood diseases without complications; but as an adult he would be subject to some chronic disease such as heart trouble, arthritis, tuberculosis, or asthma. He would deny any mental disorders; but if he did admit any, it would be a tendency toward neurosis. However, he would readily admit a history of gonorrhea. Ninety-nine chances to one he would have poor dentition, either caries or pyorrhea alveolaris; there would be also a strong possibility of defective vision. However, his physical defects would not prevent him from doing manual labor. The psychologist would probably give him the Army Alpha Test, which would disclose that the hypothetical patient had a mental age of 13 years 8 months. During his stay in the institution he would abide by the regulations, show a good knowledge of his occupational assignment, and would be a willing worker.. He would be accepted by his fellow patients and would like to work with them. The custodial officers would find him pleasant and agreeable. As the time for his release approached he would.maintain that he was through with drugs forever because he did not want to spend the rest of his life in jail, indicating that he still thought. drugs were beneficial, but the penalty outweighed the bene- fit. He would plan to live with responsible relatives largely at the insistence of the hospital officials. However, he would have no offer of employment to look forward to. He would be given an average prognosis for permanent cure, which is a vague way of stating that he would probably relapse. . PSYCHONEUROSIS Psychoneurotic patients account for 6.3 percent of the total number of patients studied. From a statistical standpoint a typical psycho- neurotic would give therapeutic necessity as an excuse for his ad- diction. Morphine would be the first drug used, the drug of choice, the only drug used, and, of course, the last drug used. He would make two or more voluntary attempts to break his habit but would give no history of compulsory treatment. He would relapse to the use of drugs. after each voluntary treatment because of therapeutic necessity, or because of environmental stress and worry. He would have no antisocial record. He would come to the hospital as a vol- untary patient. As a child he would be considered a studious, shut-in, good boy type. He would have a college education and would be engaged in a profes- THE KOLB CLASSIFICATION OF DRUG ADDICTS 5 sional or semiprofessional type of occupation from which he would derive a modest income. He would live in a rural or semirural neigh- borhood. He would be congenially married. His social adjustment on the whole would be considered acceptable despite addiction. He would be a World War veteran. The parental home would have been intact during the patient’s de- velopmental years. The parents would have been in moderate eco- nomic circumstances. His past medical history would reveal chronic diseases during childhood and either neurotic tendencies, frank neuro- ses, or unspecified nervous break downs during adult years. Physical findings would include diseases of the digestive tract, defective vision, and diseases of the respiratory tract, alone orin combination. In other words he would have some chronic condition which would not be serious enough to require infirmary care. He would have a mental age of 15 years or over. He would be uncooperative, demanding his release, and would eventually be discharged against medical advice. He would be unpopular both with his fellow patients and custodial officers because of constant complaining about his physical ailments and of his tendency to shirk work. He would still believe that drugs were beneficial, but that the loss of social esteem and the danger of legal entanglements outweighed the benefit. He would receive inten- sive psychiatric treatment during his period of hospitalization. PSYCHOPATHIC PERSONALITY Individuals given a diagnosis of psychopathic personality comprised 11.7 percent of the whole group of patients. To this were added several patients who were basically psychopathic, but who developed frank psychoses during hospitalization, and also three criminal psy- chopaths who claimed that they were not addicts. The total repre- sentation of the psychopathic group in the present study is, therefore, 13.4 percent instead of 11.7 percent. The statistically typical psychopathic drug addict would rationalize his addiction on the basis of curiosity and association. He would make no voluntary attempts to rid himself of his habit, but would give a history of three or more compulsory cures. However, he would relapse after each cure through association with addicts and the effort to recapture the original thrill. His first arrest would occur before the age of 20 for grand larceny. His antisocial record prior to addiction would include juvenile delin- quency, misdemeanors, and convictions. His antisocial record after addiction would include misdemeanors and convictions, not only for violation of drug laws, but for violation of other laws as well. He would have a record of two or more previous convictions and three or more misdemeanors for which he had spent 2 or more years in jails or penitentiaries. 6 THE KOLB CLASSIFICATION OF DRUG ADDICTS He would be a prisoner patient, single, and either of foreign-born parentage, or else foreign born himself. His parents would be in marginal economic circumstances. The parental home would be uncongenial and characterized by rather loose family ties. He would live in a deteriorated city environment. As a child he would have shown definite antisocial tendencies. As an adult he would make a living by gambling and by extralegal pursuits. His social adjustment would, therefore, be poor both before and after addiction. His institutional adjustment would be so unsatisfactory that sooner or later he would be recommended for transfer as a detriment to the station. He would be reported for violation of institutional rules, custodial officers would consider him as queer or paranoid, and he would be unpopular with his fellow patients. Psychiatric treatment would be emphasized. The prognosis for rehabilitation would be considered as poor. INEBRIATH PERSONALITY The inebriate personalities comprise the second largest group of addicts, accounting for 21.9 percent of the total number of patients tudied. The statistically typical inebriate individual takes to the use of drugs as a means of sobering up. after alcoholic sprees. Mor- phine would be his drug of choice as well as the first drug used. He would have a history of two or more voluntary cures but would relapse “in less than a year after each treatment through the alcoholic route. He would have no history of previous misdemeanors and would be a voluntary patient at the hospital. He would come from a rural or semirural neighborhood. His family history would be positive for alcoholism, and, of course, he himself would be strongly addicted to alcohol. ‘He would have minor physical ailments, but would be able to do manual labor. In all other respects he would not differ from the average addict described under ‘‘psychopathic diathesis.” DRUG ADDICTION ASSOCIATED WITH PSYCHOSIS Only one patient in the entire series was classified in the category of drug addiction associated with psychosis. A number of individuals developed psychoses while hospitalized, but since they did not become addicted as a result of their psychoses they could not be included in the present category. Needless to say, no comparative data can be presented for one case. The patient in this case was an elderly individual who became addicted to morphine after the age of 60 while suffering from a psychosis diagnosed as simple senile deteriora- tion. He took the drug of his own accord to “‘set his mind at rest.” DIFFERENTIAL DIAGNOSIS The normal individual accidentally addicted is readily distinguished from other types of addicts. However, some difficulty may be en- THE KOLB CLASSIFICATION OF DRUG ADDICTS 4 countered in differentiating psychopathic diathesis from psychopathic personality and inebriate personality from psychoneurosis. On the basis of the present findings the chief differences between patients with psychopathic personality and psychopathic diathesis are to be found in the antisocial history... Psychopaths have a delinquency record prior to addiction, as well as after addiction. They do not confine their antisocial acts to violation of drug laws. On the other hand, individuals classified under psychopathic diathesis make an acceptable social adjustment prior to addiction, and after addiction usually confine their social transgressions to violations of drug laws. More specifically, positive criteria differentiating psychopathic per- sonality from psychopathic diathesis may be enumerated in the order of importance as follows: (1) Social adjustment poor both before and after addiction. (2) History of two or more convictions previous to current offense. (3) History of 2 or more years served in previous sentences. (4) Reliance upon illegal means of support. (5) History of convictions prior to addiction. (6) Age when first arrested—under 20 years. (7) Reason for first arrest—grand larceny. (8) Disposition of first arrest—reformatory sentence. (9) History of juvenile delinquency prior to addiction. (10) History of misdemeanors and convictions, not confined to violation of drug laws, after addiction, (11) Decided antisocial tendencies during childhood. (12) Residence in deteriorated, congested areas of population. (18) Uncooperative, violates institutional rules. (14) Unpopular with fellow patients. (15) Recommended for transfer as a detriment to station. (16) Reported as queer or paranoid by supervising officers. (17) Poor prognosis for social rehabilitation. (18) History of three or more compulsory cures for addiction. (19) History of misdemeanors prior to addiction. (20) History of three or more misdemeanors previous to current offense. (21) History of strong tendency to gambling. (22) History of alcoholism. (23) History of tendency toward all vice to excess. (24) Economic status of parents marginal. (25) Mental age 15 years or over. (26) Poor insight. (27) Psychiatric treatment emphasized. The chief distinction between the inebriate personality and the psychoneurotic is that the former has a history of marked alcoholism with sobering up after alcoholic sprees given as an excuse for addiction to drugs, whereas the latter has a history of strong neurotic tenden- cies or unspecified nervous breakdowns with therapeutic necessity or environmental stress given as the reason for addiction. Positive criteria, as determined by the present study, distinguishing the 8 THE KOLB CLASSIFICATION OF DRUG ADDICTS psychoneurotic from the inebriate personality include the following, in order of importance: (1) History of neurotic tendencies, disabling neuroses, or nervous breakdowns in the past. (2) Rationalization for addiction: therapeutic necessity. (8) Described as constant complainer by supervising officers. (4) Psychiatric treatment emphasized. (5) Rationalization for relapse to use of drugs: Therapeutic necessity. (6) Rationalization for relapse to use of drugs: Environmental stress or worry. (7) Drugs used: Morphine only. (8) Last drug used: Morphine. (9) No history of misdemeanors. (10) College education. (11) Physical findings: Diseases of the digestive tract. (12) Physical findings: Diseases of the respiratory tract. (13) Physical summary: Chronic diseases not requiring 6 infirmary care. (14) Unpopular with fellow patients. (15) Shirks work. (16) No record of arrests. (17) High school education. (18) Steady employment, moderate income. (19) Dependent upon relatives for support. (20) Congenially married. (21) United States World War Veteran. (22) History of chronic physical ailments in childhood. (23) History of chronic physical ailments in adult life. (24) No history of venereal disease. (25) Physical findings: Diseases of circulatory system. (26) Physical findings: Defective vision. (27) Uncooperative, violates institutional rules. DISCUSSION The present investigation shows that the Kolb classification is a great deal more satisfactory than simply labeling all addicts as psy- chopaths or even more simply, drug addiction without psychosis. Obviously the latter designation sheds no light on fundamental per- sonality defects. It is equally obvious that all addicts are not psycho- paths. If he does nothing else, Kolb at least shows that all addicts are not cast in the same mold. Certainly the category, ‘normal individual accidentally addicted,” needs no defense. Likewise, “‘psychoneurosis’’ is an acceptable classi- fication since it is a well-recognized psychiatric entity. The same applies to ‘psychopathic personality,” also a well established entity. The only innovations are “psychopathic diathesis’” and “inebriate personality.” Inebriate personality is such an apt term for a certain group of addicts that it should be retained. Arguments have been advanced that inebriety is a symptom of an underlying neurosis. That-may be true. The inebriate impulse may be construed as an obsession, THE KOLB, CLASSIFICATION OF DRUG ADDIOTS 9 warranting a diagnosis of ‘‘002—x21 obsession, 974 dipsomania,’’ thus complying with the list of mental disorders approved by the Council of the American Psychiatric Association (2). However, that is com- parable to substituting a Norman for a pithier Anglo-Saxon. word, “Inebriate personality’ is a much more descriptive term. | The category ‘‘psychopathic diathesis’’ could also be made to con- form with the Standard Classified Nomenclature of Diseases and Conditions (2) by placing it under the designation ‘‘000—x42. psycho- pathic personality with pathological emotionality, 043 emotional in- stability.’”’ However, ‘psychopathic personality’’ carries with it an ugly connotation in the minds of many persons interested in penology and reform. Individuals classified under “psychopathic diathesis” are not so stigmatized. Furthermore, they are not innately antisocial. Their fundamental defect is an ill-defined emotional instability which finds expression in a search for new thrills, excitement, and pleasure. The emphasis on pleasure seeking suggests that ‘“‘hedonistic person- ality’? would be more descriptive of such individuals than the term “psychopathic diathesis.”’ One of the chief objections to the classification “psychopathic diathesis’’ is the ease with which it may be used as a diagnostic waste- basket for doubtful cases. Patients presenting features common to more than one category are almost invariably so classed, a subterfuge out of keeping with Kolb’s intent. In such instances the dominant features should be determined and used as the criteria for the final diagnosis. Diagnoses may also be deferred pending further observa- tion in uncertain cases. Erroneous classification may be avoided by keeping in mind that ‘‘psychopathic diathesis” is applicable only to individuals who have made an acceptable social adjustment prior to addition, whose antisocial acts are confined to violation of drug laws, and who became addicted to drugs on a hedonistic basis. Another failing brought out by this investigation is the tendency to base a diagnosis of psychopathic personality almost purely on an antisocial record antedating addiction to drugs. In other words, the only psychopaths given complete recognition are the asocial or amoral types. It must be remembered that there are also sexual psychopaths and psychopaths with pathological emotionality, for example, schizoid, cyclothymiac, and paranoid personalities. These examples may also live up to the popular conception of a psychopath’s ‘‘ornery”’ tend- encies. SUMMARY 1. Positive criteria differentiating the various categories of the Kolb classification of addicts are presented, as determined by a study of the clinical records of 1,036 patients admitted to the United States 10 THE KOLB’ CLASSIFICATION OF DRUG ADDICTS Public Health Service Hospital at Lexington, Ky., during the fiscal year July 1, 1936, to June 30, 1937. 2. The presetit findings indicate that the Kolb classification is justified: 3. The category, psychopathic diathesis, is overbalanced principally because of a tendency to use it as a repository for doubtful cases. 4, The term hedonistic personality is suggested as a substitute for psychopathic diathesis, since the former more adequately describes the pleasure-seeking type of addicts who make up the latter category. 5. The present findings show a strong tendency to limit a diagnosis of psychopathic personality to those individuals who show a definite asocial or amoral trend. - 6. Itis possible to reconcile the Kolb classification with the Standard Classified Nomenclature of Diseases and Conditions, as explained. in the discussion. ite! REFERENCES (1) Kolb, Lawrence and Ossenfort, W. F.: The treatment of drug addicts at the Lexington Hospital. So. Med. J., 31: 914-922 (August 1988). (2) Statistical Manual for the Use of Hospitals for Mental Diseases. 6th ed. Nat. Committee for Mental Hygiene, New York City, 1934. O