The disease concept is rooted deeply in the beliefs, values, and epistemic state of a particular culture. Correspondingly, the definition of disease is as broad or as narrow as may be held in the mind of the user of the term. The formal meaning is inclusive, and is "a condition of the body that impairs the performance of a vital function." Literally, the word consists of a prefix, "dis" that means "opposite to," and "ease" that means "naturalness or freedoni from pain or discomfort." The requirements for the use of the term disease have been refined, particularly, in recent centuries, evolving from philosophical inquiry and maturing during the "age of reason," when the scientific method become more clearly developed.1
To the present day, a disease must have a firm physical and measurable basis in order to be accepted, and many clinical conditions in psychiatry achieved an unprecedented pathogenic status when biochemical lesions were supported by laboratory methodology. Alcoholism has followed but suffered from a belief that has also plagued psychiatric disorders, although not as severely. That belief is the moral explanation for drinking and other drug use. The concept of free will as a primary explanation remains embedded in the modern notions about the etiology, natural history, and prognosis of alcoholism or drug addiction.25
The belief that the alcoholic and drug addict exercises volition in using alcohol and drugs in spite of adverse consequences follows from the "self-medication" of underlying states or conditions. Reliance on the self-medication theory presupposes an ethical position that precludes alcoholism and drug addiction from being accepted as primar)' or independent conditions in their own right. No doubt alcoholism is a complex disease that does embody moral implications at some point, but clear distinctions between etiology and manifestations of alcoholism (drug addiction) must be maintained before a useful perspective regarding the role of morality can be established.
The history of the disease concept for many conditions has proceeded by similar developments to that of alcoholism. In many ways the disease concept for alcoholism can be viewed as a century or so behind medical diseases and decades behind psychiatric conditions. Not many people debate whether schizophrenia is a defect or weakness of character as they still do regarding alcoholism. Moreover, the role of medication in the treatment of schizophrenia greatly enhances its full acceptance as a disease. Medications are somatic therapies that either have been proved or presumed to act on specific diseased foci in the brain to effect a change.
Although much less is written about the disease concept of drug addiction, there is little evidence that addiction to drugs differs essentially from alcoholism. The finding of drug addiction among alcoholics, i.e., 90% under the age of 30, and similar rates of familial alcoholism among drug addicts support a common basis. Moreover, recent neuropharmacological studies confirm neurochemical sites for drug actions by drugs of addiction, and mechanisms of addictions that are common to alcoholism and drug addiction. For these reasons and others, we will consider drug addiction a disease like alcoholism.
Perhaps the most important purpose in classifying a condition as a disease is to make a diagnosis, formulate a natural history, predict prognosis, and develop treatment strategies. Establishing a disease has practical consequences for those who suffer, and in most instances will result in better treatment outcome for alcoholism. The debate over the legitimacy of alcoholism and drug addiction as diseases wastes time, misdirects research, and deemphasizes die need for diagnosis and treatment.3,6
VICTIM STATE- LOSS OF CONTROL
Rarely overtly stated but clearly central to the concept of a disease is the victim state. As a victim, the afflicted has no control over the onset and progression of the disease if left untreated.7"9 In the disease concept of alcoholism (and drug addiction), the cardinal feature is loss of control over the use of alcohol, manifested by a preoccupation with acquiring, continued use despite adverse consequences, and a pattern of relapse to alcohol. The loss of control, which can actually be inherited, is the sine qua non for alcoholism (and drug addiction) as qualifying for the disease slate. The loss of control signifies a victim state that reflects an alteration of brain function by alcohol or drugs that is not under the conscious volitional control of the individual.11
As pointed out by many scholars, there is no reason why the symptom of loss of control should be expected to be operative in even' alcoholic every minute of even day, any more than the symptoms of hundreds of other diseases are operative 100% of the time, i.e., hallucination or delusions in schizophrenia, chest pain in coronan artery disease, and migraine headache. What is meant by loss of control is that an alcoholic cannot consistently choose whether he or she shall drink or not. There comes an occasion when he or she is powerless, when he or she cannot help drinking. Also, the adverse consequences from drinking (or drug use) are unpredictable and significant. That is the essence of alcohol and drug addiction.10-12
The loss of control may represent an acquired drive state similar to eating, drinking, and sex. Many studies link alcohol/drug actions to regions in the brain where these instincts are located. After stimulation by alcohol and drugs, these drive states appear to entrain drug and alcohol use with the same autonomous, spontaneous, and persistent expression as the instincts. In the case of alcohol/drugs, the drive is an aberrant expression that is ultimately destructive because of the toxicities of the alcohol/drugs and the changes in mental and mood status.
During the 18th century, Benjamin Rush, a signer of the Declaration of Independence and considered by the American Psychiatric Association to be the founder of American psychiatry, was a dedicated proponent of alcoholism as a disease. His first work that detailed alcoholism as a disease was entitled The Effects of Ardent Spirits Upon the Human Body and Mind. In this document, Rush states "drunkenness resembles certain hereditary, family and contagious diseases," and as for etiology, "Nearly all diseases have their predisposing causes," and among those that could cause the "intemperate use of distilled spirits" was an addiction to alcohol.13,14
In the early 19th century, the Protestant clergy joined the physicians in advocating temperance, however, not only for the "disease of intemperance" but for prohibition of general consumption of alcohol. As such, temperance became an ethic of middle-class morality, attaching an increased moral connotation to any drinking, particularly to that of the intemperate use by the alcoholic. The first state-wide prohibition act, the Maine Liquor Law of 1851, was a further attempt to control alcohol use through legislation. Of interest is that the federal Prohibition Act of 1918 was deemed a success in terms of reducing the morbidi tv and mortality from "diseased alcoholic" drinking, but failed because of illicit production and sale of liquor and beer.8,15
Although the emphasis of the social reformer and temperance physicians shifted from the diseased individual to the pervasive control of alcohol use, a small group of physician-scholars encouraged and administered treatment of the inebriates. The first inebriate asylum in the world was founded in 1857 at Binghamton, New York, through the efforts of a physician, Joseph E Turner, the first superintendent. In 1870, a physician group established the American Association for the Cure of Inebriates, and in 1876 inaugurated the Quarterly Journal of Inebriety under the editorship of TD Crofhers, a sophisticated champion of the disease concept. Following a merger with the Medical Temperance Association, the American Association for the Cure of Inebriates became the American Association for the Study of Alcohol and Other Narcotics.1,8,16-18
In many ways the Association conceptualized the physiologic basis for the loss of control over alcohol and drug use and psychological typologies for later formulations of alcohol addiction by other scholars, most notably, EM Jellinek. They separated the "true type" or "genuine inebriate" from the common drunkard, and used various terms to denote the addicted state - usually "chronic alcoholism," "habitual," "inebriety," or "periodic drinking," similar to Jellinek's gamma alcoholic.19 A number of the early specialists in inebriety became active in the larger American Medical Association (AMA). (One of die Associations's most illustrious members, NS Davis of Chicago, was the founder of the AMA, and edited jftyV/A for 6 years).9,17
In spite of the efforts of die Association physicians, prohibition dealt a death blow to the disease concept in American medicine. Physicians were forced to accept the widely held view that alcoholism and other drug addictions were moral and legal problems. Musto19 documents the legal pressure which not only criticized physicians but punished them for prescribing medications to alleviate these disorders. The result was the removal of alcoholism and drug addiction from medical school curricula and the production of several generations of physicians who were ignorant about diagnosing and treating these disorders. Alternatively, against prevailing pressures, Association physicians and some of the temperance movement members worked together in apparently conflicting roles of scientific and religious backgrounds toward a mutual alliance in the origin of the disease concept in the United States, and by collaboration, advanced its growth.20,21
Psychoanalytic theory emerged in the early 1900s in the United States, and with it a new definition of aleo holism, distinctly different in etiology and treatment from the definition used by the Association physicians. According to psychoanalytic doctrine, inebriety or alcoholism was defined as a psychoneurosis with repressed pregenital conflict - probably oral or even uterine in origin - as its basis. No longer were the physiologic underpinnings of loss of control of alcohol use and the psychological concept of "craving" central to the definition of alcoholism.22
Alcoholic drinking was viewed as a symptom of early, traumatic childhood experiences and the inability of a disorganized, ineffectual ego to cope without an escape, crutch, or amnesiac such as alcohol. The influence of the psychoanalytic theory increased following World War I. When the concept of alcoholism as a disease was dropped by American medicine in response to political pressure during Prohibition, a vacuum was created and, in large measure, replaced by psychoanalysis. As a result of these influences, the priman status and independent nature of alcoholism as a disease were not accepted by vast numbers of physicians - including psychiatrists. The psychoanalytic theory of alcohol and drug addictions as symptoms of underlying conflict persists in current popular thought. The current "self-medication hypothesis" is, in part, a refinement of these earh' psychoanalytic formulations, and remains a popular view in psychiatry.5
Psychoanalytic terminology has been useful, however, in providing a description of the changes that occur intrapsychically as a result of the addictive process.23 Also, psychoanalytic theory has been instrumental in articulating the important antecedent childhood factors that determine later personality style and behaviors. Many of these intradynamic processes may provide an explanation for drug and alcohol use, even in abnormal proportions and patterns. However, no evidence shows that psychodyiiamic factors explain the origin and propagation of addictive behavior, particularly, drug and alcohol addiction. No studies have demonstrated the validity of the self-medication hypothesis in generating and sustaining addictive behavior. Generally, these studies reveal the opposite - thai drug or alcohol use continues in spite of a lack of medical ion benefit in addictive use.
NOMENCLATURE AND CLASSIFICATION
Plie Standard Classified Nomenclature of Disease, produced by the National Conference on Nomenclature of Disease, was issued in 1933 with the explicit approval of not only the AMA bul also the American Psychiatric Association (APA). On page 85 of that classic document is the entry *'Alcohol addiction" (000-332). followed by "Alcoholism without psychosis" (000-332), exactly like alcohol addiction.-1 Uw Manual for Coding Causes of Illness, published by the US Public Health Senice in 1944, lists "Alcoholism" (Code 270), and. in the Index "Alcohol addiction" is referred to as Alcoholism.-' The meaning is clear and the implications are unequivocal; alcoholism was considered then as a priman condition, and was coded and treated as any other disease. Unfortunately, in part because the disease concept has not been widely included in medical education, it has not been accepted by most .American physicians.
The AMA did not recognize alcoholism as a disease any more than it ever "recognized" migraine headache as a disease. However, in 1956. a Board of the AMA passed a resolution urging hospitals to admit patients diagnosed as having alcoholism equally with patients admitted under other diagnostic labels. The .'VMA did not need to pass a resolution to establish alcoholism as a disease because it had been already recognized as a disease for the previous 2 centuries. The AMA had, in Iiict, always recognized alcoholism as a disease in the same way as it recognized cardiomyopathy, orchiiis, pneumonia, and even pediculosis. Alcoholism has been listed in the official classification of diseases which the AMA has sponsored ever since the fust publication of that classified nomenclature aiul in all subsequent revisions. Moreover, alcoholism is listed also in the World Health Organization's standard International Classification of Diseases. The AMA apparenti)' found it necessary to clarify its position because of a lack of acceptance of alcoholism as a disease, for the purposes of diagnosis and treatment, by the medical community.26
Alcoholics Anonymous (AA)
The original sell-help group for alcoholics was not AA, but the Washingtonian Movement in 1840. This organization consisted of "sick" intemperate individuals who provided ? heir own resources and method of self-help.-' AA has played an important role in formulating a practical application of the disease concept, and in many ways reflects the development of thought prior to its beginning in 1935.28
The founders of AA, Bill Wilson, a New York stockbroker, and Dr Bob Smith, a surgeon from Akron. Ohio, borrowed heavily from both medicine and psychiatry in their trialand-error formation of a definition of alcoholism that appeared to fit their experience as alcoholics.-'9·4" A New York psychiatrist, William Silkworth, treated Wilson for alcoholism at Towns Hospital in Manhattan. Silkworth, who had detoxified thousands of alcoholics, postulated thai alcoholics possessed a sensitivity, which he termed an "allergy," that distinguished their uncontrolled drinking from those normal drinkers who could exert coni rol. This postulation was Io explain the "obsession and compulsion" Io drink that was experienced and described by many alcoholics. These are two of the distinguishing characteristics of addiction that are represented in preoccupation and compulsivitv. which are central to the DSM-HI-R criteria for the dependence syndrome.
Another psychiatrist, (iari Jung, treated an alcoholic, Roland, who relapsed on his return to the United States. He was then told by Jung that medicine and psychiatry could not help him and that his only hope was to experience a spiritual conversion. Roland influenced Ebby T. an alcoholic friend of Bill Wilson, to join the Oxford group, a spiritual organization thai encouraged membership bv alcoholics. Ebby attained sobriety and made an impression on Wilson, who decided to enter Towns Hospital again for detoxification. It was during this hospitalization in December. 1934 that Wilson had his spiritual experience. This prompted him to read William James' Varieties of Religious Experience. James described the recovery of several alcoholics through religious conversion. He believed that deflation of the ego at depth was necessary tor this conversion.
The actual "treatment" component contained in the Twelve Steps of Alcoholics Anonymous was based significantly on the teaching of the Oxford Group and on the spiritual exercises of St Ignatius, the founder of the Jesuit order of Priests. Also, the concept of "poweiiessncss" over alcohol that is an integral part of Siep 1 is derived from Dr. Silkworth's theory of an "allergy" to alcohol that renders the alcoholic powerless over alcohol and contributes to the compulsion to drink. AA is a parallel extension of the seemingly contradictory union of medicine and religion from the 18th and 19th centuries when Benjamin Rush and other physicians worked alongside the Temperance Movement to administer to the alcoholic.30,31
EM Jellinek. a Yale professor, was concerned by medicine's general abandonment of alcoholics during and following Prohibition. Jellinek wrote what remains the most definitive text on the subject, entitled The Disease Concept of Alcoholism.18 He stressed the importance of "loss of control" as the defining characteristic of alcoholism, or alcohol addiction, as an uncontrollable "craving" for alcohol. He used the term alcoholism because lie did not think the term addiction with its stigma would be generally accepted. Jellinek is responsible for both clarifying and confusing the characteristics of alcoholism because of his emphasis on physiologic tolerance and withdrawal in alcoholism. He used these terms interchangeably with craving, but more recent studies have clearly shown that tolerance and dependence can occur independent of craving or addiction.
Among Jellinek's contributions was the graphic illustration that alcoholism is a progressive disorder that has identifiable hallmarks. He classified five varieties or "species" of alcoholism that could be identified. Gamma and delta alcoholics were physiologically dependent: alpha and beta alcoholics were only psychologically dependent; and epsilon alcoholics were vulnerable to periods of uncontrolled drinking and violence. Only the gamma and delta forms of alcoholism were considered diseases because they manifested the adaptive process of physiologic tolerance and dependence. This contention by Jellinek has led. in part, to the current emphasis on the relationship between tolerance/dependence and addiction, and is reflected in recent diagnostic classifications. 18,32
Vaillant's work. the Natural History of Alcoholism6 describes extensive longitudinal studies that demonstrated alcoholism as a priman disorder, independent of personality type and childhood emotional problems. The ethnicity and family history of alcoholism were the only predictors for alcoholism. Moreover. he showed that loss of control was the distinguishing feature of the disease and could only be fully appreciated after a longitudinal view of alcoholism over a course of decades, perhaps in a shorter duration for the individual.
These findings, among others, were in contradistinction to the prevailing view that alcoholism was an expression of a personality disorder. In DSM-I and DSM-II, alcoholism is listed under personality disorders. It was not until DSM-III that alcoholism was given primary status similar to other psychiatric disorders when it was included as Substance Use Disorder.
CHALLENGES TO THE DISEASE CONCEPT
There have always been challenges to alcoholism as a disease, and the enduring self-medication hypothesis has been joined by the more recent learning theory developed by behavioral psychologists. The self-medication hypothesis states that alcoholism is neither a disease nor a primary condition. The principal error in this contention is that most alcoholics become clinically worse as their addictive drinking increases, and become better when their drinking ceases. One would predict improvement in the alcoholic's clinical state if selfmedication was the goal of the drinking and was effective. Moreover, no studies have demons! rated that alcoholics drink because of ego conflict, whereas controlled studies do show that drinking by alcoholics leads to ego disorganization, which is worsened by continued drinking.33,34 An AA slogan epitomizes this experience of alcoholics: "Nothing is so bad that a drink won't make worse."
The behaviorists believe that alcoholism is not a priman condition but a learned behavior similar to any bad "habit." According to learning theory, there is little acknowledgement of the contribution of neurochemical factors in the brain to the development and maintenance of addiction to alcohol or drugs. ,Also, treatment is based on "operant conditioning" to desensitize the drinker to alcohol, and to allow the alcoholic to return to controlled drinking. There is rejection of the persistent loss of control articulated by Rush, experienced by the founders of .AA. summarized by Jellinek, and emphasized in the criteria for dependence syndrome in DSMIII-R.2
Another competing explanation, the biological and psychopharmacologic theories, assume alcoholism is a manifestation of "underlying" psychiatric disorders. This position is a variant of the self-medication hypothesis, and is subject to the same pitfalls in diagnosis and treatment. No studies show that treatment of anxiety and depression leads to an improvement in alcohol or drug consumption. Many studies show that anxiety and depression are a result of addictive use of alcohol and other drugs, and that alcoholics drink in spile of these symptoms.
The usual medications for affective disorders and schizophrenia have not been shown to be effective in treating the addictive use of alcohol and other drugs. Furthermore, these medications rarely provide even temporary palliation for the consequent anxiety, depression, and psychotic symptoms. Abstinence is much more effective in ameliorating and eliminating these alcohol- and drug-induced psychiatric symptoms.6,33
Another serious threat to the disease concept is the "anti-drug" or "war on drugs" approach used by government agencies. The position that a war should be waged on a disease is complicated by ethical considerations that obscure the centrali ty of a diseased state. We do not advocate a war on cancer or heart disease: rather, we launch research, and educational and treatment programs to control and eradicate these diseases. The recent political thrust for this war has probably undone some of the progress that physicians, including psychiatrists, have achieved in the past few decades.
Familial and genetic studies in the form of twin, adoption, and high-risk paradigms have contributed greatly to establishing the primary status of alcoholism as a disease. :VkM> These lines of evidence clearly show that alcoholism is an inherited disorder, and is independent of other personality and psychiatric disorders.'' The finding of a genetic predisposition indicates that alcoholism has a physical component located in genes on chromosomes. The evidence of this physical basis has significantly advanced the acceptance of alcoholism as a disease by both physicians and lay people. ,s These findings have been followed by technology which continues to add to the evidence that genetic neurochemical correlates are responsible lor the "loss of control" in the expression of alcoholism.
Attitudes play a major role in determining whether a condition is accepted as a disease and how it is diagnosed and treated by physicians. Surveyed psychiatrists generally agree that alcoholism and drug addiction are priman', treatable illnesses. Eighty-eight percent strongly agree that alcoholism is a treatable illness and 58% strongly agree that alcoholism and drug addiction are priman illnesses, with 90% endorsing that abstinence is the treatment goal, indicating a recognition of the importance of loss of control.39
In surveys of the general public. 90% of the respondents support the idea that alcoholism is a disease, and 72% feel that alcoholism is a "progressive physical disease." Moreover, the concept of loss of control is strongly supported; 85%. said that alcoholics are addicted lo alcohol and that without help, problems from drinking gel worse. Unfortunately, the moral stigma is not lost as 20% of those endorsing alcoholism as a disease simultaneously consider it a moral weakness. Moreover, 44% of those rejecting the disease concept consider it a moral weakness.40,41
That alcoholism is not entirely a priman disorder is reflected in these surveys where it is attributed to causes other than disease. When a 1988 Gallup Poll asked members of the general public if alcoholism was a disease. 78% of those who responded agreed strongly that it is, 1 0% agreed somewhat. 6% disagreed somewhat, 5% disagreed strongly, and 1% had no opinion. The same poll showed that the public was uncertain about the exact meaning of the term disease. When people were asked which of a number of options described their feelings about alcoholism, 60% said it was a disease or illness. 31% said it was a mental or psychological problem. 23% reported it as a lack of willpower. 16% reported it as a moral weakness, and 0% were unsure.
Personal Responsibility- Paradoxical to Disease State
In spite of these favorable statistics, other studies reveal that alcoholics are perceived more unfavorably than are persons with other diseases such as epilepsy, and that altitudes toward alcoholics are generally negative. "'- Perhaps the most important and relevant variable is the notion of responsibility. Alcoholics are perceived as responsible for their drinking behavior by a majority of the population in the United States. By contrast, "a disease state" implies the absence of responsibility for causing one's condition and is one of the key characteristics of a "sick role." However, according" to the "disease concept for alcoholism" it is consistent to hold that the alcoholic is not the cause of the alcoholism but must be held accountable for alcoholinduced behavior.28·-9 In a sense, alcoholism (drug addiction) is a "no fault" disease.
This ambivalent attitude is responsible for much of the confusion in regard to diagnosis and treatment. Studies clearly show that "moral problems" result horn addictive use of alcohol and drugs, but no studies confirm that immorality causes use of alcohol and drugs. ,:i These findings have dramatic impact on treatment as well. It has been clinically supported by studies that alcoholics and drug addicts are more likely to accept treatment and commit to a recoven program if they believe they have a disease rather than a moral problem.1,6,47
There is another potential paradox in the fact that spirituality is a major tool among our current forms of treatment for alcoholism and drug addiction. Even more paradoxical is the fact that, although the alcoholic is not at fault for having the disease of alcoholism, personal responsibility is the cornerstone in the process of recoven. There is a volitional component to recoven - to seek and accept treatment for the involitional component, i.e., the loss of control over alcohol or drug use. In order to recover from the diseases of alcoholism and drug addiction, outside help is often necessary to strengthen the volition to maintain abstinence and suppress the loss of control. According to the disease concept, once the loss of control is established it remains for a lifetime in that individual. Numerous studies have confirmed this persistence of the victim stale of loss of control.16-18
In these respects, the addictive disorders are similar to other chronic diseases such as diabetes mellitus, epilepsy, and hypertension. In these disorders, personal responsibility often determines the success or failure of treatment. Perhaps the biggest difference between alcohol/dmg addiction and other diseases is the antisocial behavior that often follows the addictive ingestion of alcohol and other drugs."·1'1 Many have difficulty in distinguishing between the taking of the drug, lor which addicts are not responsible when in the grip of the active disease, and all other behavior, for which they must be held responsible if they are to recover from the addictive disorder.46
CONCLUSIONS- PRESENT AND FUTURE
Despite the high prevalence of drug and alcohol addiction in psvchiatric populations, there is substantial evidence that these disorders are underdiagnosed and misdiagnosed. Ries found that psychiatric inpatient program directors underdiagnosed and misdiagnosed alcoholism by 60%.47 Other authors have found comparable results in inpatient and outpatient psychiatric populations.18,49
Perhaps the greatest indicator of what will be the standard of care for the addicted patient and the attitudes of physicians toward alcoholism/drug addiction as diseases, is the current level of training. Unfortunately, most psychiatric training programs do not have drug and alcohol addiction treatment programs for educational purposes. For those that have specialized "addiction units," the experience does not carry over to the psychiatric units where little or no psychiatric attending supenision for drug or alcohol addiction exists. And the amount of lime spent on the "substance abuse treatment unit" is a fraction of the total resident training, i.e., 1 to 2 mondis out of 48 months. This is a grossly unbalanced experience when considering that over 50%) of the psychiauic patients have a drug and/or alcohol addiction diagnosis.
Training is needed for other staff on the psychiatric units for drug and alcohol intenention. Improving the knowledge and skill of mental health professionals, specifically in the area of drug/alcohol addiction for diagnosis and treatment, is sorely needed. Attention is needed lor special subgroups of dually diagnosed patients such as women, the homeless, recent immigrants and refugees, and those with AIDS.
Curricula in medical education for all professionals should be expanded to include specific topics related to addictive disorders. These topics pertain to interactions of drug and alcohol addiction and psychiatric syndromes, use of psychotropic medications in drug/ alcohol addiction, role of the family or codependenl, the dynamics of the voting adult, chronic patients, assessment instruments and strategies for dual diagnosis, multiple drug addiction, disease concept of drug and alcohol addiction. 12-step self4ielp approaches, intenention methods for crisis and suicidal stales, short- and long-term treatment and aftercare in recoven.47
No doubt the disease concept finalcoholism and drug addiction will survive, but the diagnosis and treatment for those who suffer will be greatly affected by how well it is accepted and integrated into medicine (psychiatry) as an independent disease. Relegation to a secondar)' status will only slow its progress and create unproductive conflict for everyone. Clear goals based on research data, clinical experience, and awareness of attitudes will go a long way toward creative resolutions.
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