The official diagnostic classification in psychiatry provides the last word on what constitutes a psychiatric disease or disorder. The psychiatry establishment has two diagnostic systems, DSM for the USA and ICD for the rest of the world, just to keep things nicely complicated. And confused.
Diagnostic and Statistical Manual of Mental Disorders
In May 2013, the American Psychiatric Association issued the fifth edition of the “Diagnostic and Statistical Manual of Mental Disorders (DSM–5).” Although there is considerable overlap between DSM–5 and DSM–IV, the prior edition, there are several important differences:
Changes Disorder Terminology
- DSM–IV described two distinct disorders, alcohol abuse and alcohol dependence, with specific criteria for each.
- DSM–5 integrates the two DSM–IV disorders, alcohol abuse and alcohol dependence, into a single disorder called alcohol use disorder (AUD) with mild, moderate, and severe sub-classifications.
11th Revision of the International Classification of Diseases (ICD-11)
In June 2018, the World Health Organization (WHO) has released a new and updated version of the International Classification of Diseases (ICD-11). The ICD is the foundation for identifying health trends and statistics worldwide. It provides a common language that allows health professionals to share health information across the globe.
Alcohol in ICD
WHO writes that alcohol use is a unique risk factor for population health as it affects the risks of approximately 230 three-digit disease and injury codes in ICD-10.
The ICD-11 includes a revised definition for alcohol use disorders (AUDs) and, more specifically, for alcohol dependence and the “harmful patterns of alcohol use.”
The meaning and accuracy of terms
Addiction, abuse, disorder, problematic use, and the like are borderless and theory-less entities in the mind of the psychiatry establishment. An individual psychiatrist may understand exactly what she means when she uses one of these words. But she soon discovers that a colleague uses the same word quite differently.
Addiction, abuse, disorder, problematic use, and the like are borderless and theory-less entities in the mind of the psychiatry establishment.”Diyanath Samarasinghe
The basis of classification being in continual flux contributes to the confusion. Diagnostic entities are constantly evolving due in part to not-so-laudable professional motives that have to do with such things as enabling professional fees to be covered by insurance. For whatever reason, muddy conceptualization characterises the basis of most psychiatry diagnoses, and especially those connected to substance use.
Can it matter whether substance addiction is a brain disease or not, when there is no real clarity as to what ‘substance addiction’ is, never mind ‘brain disease’? Markus Heilig and others try, in a recent article, to explain why it does and to convince us that the disease model has merit.
A futile effort, one can be excused for thinking, given the context of imprecise psychiatric nosology. Their piece draws polite comments voicing different views.
One response came from Robin Room, with the title “No level has primacy in what is called addiction: ‘addiction is a social disease’ would be just as tenable”.
Another response came from Justin C. Strickland and Kirsten E. Smith. Their comment carried the title: “The centrality of the brain and the fuzzy line of addiction”.
Both correspondences highlight my question whether it can matter whether substance addiction is a brain disease or not, when there is no real clarity as to what ‘substance addiction’ is, never mind ‘brain disease’.
Keeping the wider context in mind
We must all, Heilig and colleagues included, keep the wider context in mind when trying to move our science forward – for there is potential for significant unwitting harm through our efforts, however well-intentioned, in some sensitive areas of the substance use field.
Powerful commercial entities have a strong interest in the acceptance or rejection of certain views on drug use – especially alcohol use.”Diyanath Samarasinghe
Powerful commercial entities have a strong interest in the acceptance or rejection of certain views on drug use – especially alcohol use. For them, facts and precision matter little. Useful words and vague concepts that can be nicely moulded to fit in with their desired picture of alcohol problems is all that counts.
- ‘Harmful use of alcohol’,
- ‘moderate drinking’,
- ‘safe limits’,
- ‘beverage alcohol industry’,
- ‘cardio-protective effect’, and other such pro-industry terms have all been made part of the mainstream conversation now.
The power wielders currently prefer that alcohol problems are seen as a disease – and one that affects a minority of constitutionally vulnerable users. They’d switch instantly to projecting the opposite view if profit motives required that view to be widely put about – for example, if medical technology suddenly came up with a simple brain intervention that made us all hate alcohol intoxication. Honest debate among professionals can be a source for selective pickings, to spread the view that the controllers wish to promote.
In a remarkabel, new study, McCambridge, Garry, and Room bring to light how the alcohol industry ha worked since the 1950s to mobilize science to shape perceptions of their product, which in turn had key implications for public policy. A key strategy was to direct blame for alcohol harms to the consumer, away from the product (and the producer). McCambridge and colleagues argue the disease concept of alcoholism – pushed systematically by the alcohol industry – may have been particularly distorting of science and to understanding of the problems caused by alcohol in the general population.
More importantly their reflection on the study results highlights the challenge and necessaity of keeping the wider context in mind:
It is challenging to contemplate just how profoundly the alcohol industry may have biased what we think we know about alcohol. Ideas associated with the disease concept of alcoholism were foundational to the modern era of alcohol science and although they were not the sole prerogative of industry, they may have been particularly distorting of science, as well as to experience and understanding of the problems caused by alcohol in the general population.”The Origins and Purposes of Alcohol Industry Social Aspects Organizations: Insights From the Tobacco Industry Documents Jim McCambridge, Jack Garry, and Robin Room Journal of Studies on Alcohol and Drugs 2021 82:6, 740-751
Alcohol and the brain, and the industry
Not all debate is to be discouraged, of course. But we should be wary of those that amount only to sophistry, due to being grounded on vague and malleable premises. The idea of ‘brain disease’ is even fuzzier than what psychiatrists call addiction. Assuming brain disease because interfering with the brain’s structure or workings can change ‘addictive’ alcohol use is a big jump. Mess around with or remove any part of the brain and some urge or behaviour will likely alter – for example, being madly in love. Should features of such love change with, say, removing a piece of the brain’s limbic system, it will not be hard to win agreement from the psychiatry establishment that the original state of being madly in love must indeed have been madness. For we can call the altered function a cure. All it takes is to choose which bit of the brain to chop.
The foregoing argument is closer to the real ‘addiction as disease’ formulation than to an absurd reduction of it. We have the technology to interfere with parts of the brain electrically, magnetically, chemically and mechanically. These can produce changes in thinking, speaking, acting and volition. All behaviour and behaviour change is finally reducible to being brain based. It requires only a little sleight of hand to cast a chosen behaviour change as a cure of a disease. The ability of brain-based interventions to produce a desirable change is then taken as evidence that the original state was a disease. Simple.
The big challenge is learning to discern the devastatingly simple tactics of global opinion controllers, including Big Alcohol. And then to avoid needlessly playing into their hands.”Diyanath Samarasinghe
Commercial entities interested in putting about the view that ‘uncontrolled’ alcohol use is a disease, have such a childishly simple argument in support. Its facile nature is obscured when we seriously debate relative merits or pros and cons. In today’s world, where opinion is increasingly manipulated by another simple strategy – that of controlling what we are incessantly exposed to – our debates suit the manipulators of opinion just fine. The bigger challenge is learning to discern the devastatingly simple tactics of global opinion controllers – and not only about alcohol matters. And then to avoid needlessly playing into their hands.