ALCOHOLISM A SICKNESS?
Alcoholism
The term alcoholism was first used by the Swedish physician and temperance advocate Magnus Huss in 1849 to refer “only to those disease manifestations which, without any direct connection with organic changes of the nervous system, take on a chronic form in persons who, over long periods, have partaken of large quantities of brandy” (Jellinek, 1943:86). It enjoys widespread use, though there been no consensus as to its meaning (Babor and Kadden, 1985; IOM, 1987).
A recent definition, derived through a Delphi process that surveyed persons felt to possess appropriate expertise nominated by 23 professional organizations, is “a chronic, progressive, and potentially fatal biogenetic and psychosocial disease characterized by tolerance and physical dependence manifested by a loss of control, as well as diverse personality changes and social consequences” (Rinaldi et al., 1988:556).
Most persons with clinical experience will immediately recognize this description as applicable to individuals they have seen in practice. This applicability is attested to by the high levels of interrater agreement achieved for the similarly defined diagnosis “alcohol use disorder” in the field trials (Spitzer et al., 1979) of the third edition of the Diagnostic and Statistical Manual of the American Psychiatric Association (DSM-III) (American Psychiatric Association, 1980).
Indeed, persons without clinical experience will nevertheless recognize that the definition applies to some people they have encountered during the course of their everyday lives, as well as to current popular notions of the nature and course of heavy drinking (Mulford and Miller, 1964; Rodin, 1981; Caetano, 1987).
The question, however, is not whether the formulation or formulations embodied in the term alcoholism represents with a high degree of validity some persons with problems around the consumption of beverage alcohol. It does. The question, rather, is whether the formulation or formulations validly represent all those whom the committee would wish to include within the scope of planning, policy development, and treatment.
The committee's view is that the answer is negative—some persons, but not all persons, whom it would wish to include are encompassed by the term alcoholism. The term may with substantial accuracy describe a subset of the target population but does not describe the target population as a whole.
If one consults the vignettes presented at the outset of this chapter, the problem posed for the committee in the use of the term alcoholism can be illustrated. Jimmy is the only one of the eight individuals who would unequivocally meet the definition. Others, such as David and William, might or might not qualify.
Elizabeth represents a particular problem; while she has been brought to clinical attention by an acute medical emergency most commonly seen only in individuals who would meet the definition of alcoholism, and while she is certainly tolerant and almost certainly physically dependent (although given the consistency of her consumption, this has not been tested), “loss of control,” whether subjective or objective, is not clear.
Moreover, in many respects the course of her life does not feature the diverse personality changes and social consequences of the definition. Gregory, although in some respects the person with the most serious problem of all, would clearly not meet the definition. Nor, for other reasons, would George, Sally, or Patrick.
A possible qualification might be introduced: some at least of the individuals in the vignettes and elsewhere who do not qualify as “alcoholics” in terms of the full definition might instead be considered to exhibit the early stages of alcoholism. For example, a 72 year-old widow who was a total abstainer from alcohol for the 52 years of her marriage was prescribed sherry as a sedative hypnotic by an attending physician.
Although she “never drank more than three cordial glasses of sherry in any twenty-four hour period” she is described as “fully alcoholic” because “she would make anyone around her miserable until she got her sherry” (Talbott and Cooney, 1982:15). This behavior is viewed as consistent with the fundamental symptom of alcoholism, defined as “inappropriate, irresponsible, illogical, compulsive lack of control of the drinking” (Talbott and Cooney, 1982:27).
Although it does not preclude the possibility that some form of assistance might be useful in this case, the committee feels that the extension of the definition of alcoholism in such instances is not realistic.
Widespread acceptance of the term alcoholism may be due in part to the remarkable saga of Alcoholics Anonymous (AA), a fellowship devoted to helping those who wish to stop drinking. From its original two members in 1935—Bill W., a stockbroker, and Dr. Bob, a surgeon—it has become an international organization consisting of more than 73,000 groups worldwide, with a current active membership in the United States and Canada of approximately 800,000 (Jackson, 1988). E. M. Jellinek (1890-1963), considered the founding father of scientific studies in this area, did most of his early research on AA members, and his book, The Disease Concept of Alcoholism (Jellinek, 1960), is considered a classic. The National Council on
Alcoholism (NCA), the principal citizen's group involved in the field, was an outgrowth of both AA and the Yale (later Rutgers) Center of Alcohol Studies. Yet the key individuals involved in these significant developments did not see alcoholism as a useful synonym for the totality of problems. Bill W., for example, spoke in “The Big Book” of “moderate drinkers” and of “a certain type of hard drinker” who could experience serious consequences but who were not “real alcoholics” (Alcoholics Anonymous World Services, Inc., 1955:20-21).
In like manner Marty Mann, the first woman to come through Alcoholics Anonymous and the founder of the National Council on Alcoholism, identified “two groups . . . whose drinking is not so easy to distinguish from alcoholic drinking,” which she labeled “heavy drinkers” and “occasional drunks.”
She placed many of her New York friends, with whom she lost contact during her sojourn abroad and her own successful struggle with alcohol problems, in the former category. When she eventually returned to New York,
I met once again many of my own acquaintances of the Twenties. Some of them were still drinking exactly as they had when I had first known them, with no visible harmful effects. The majority, however, today drink comparatively little—at most, social drinking in the strictest sense of the term. None that I have met again has stopped drinking entirely—and none has become an alcoholic. (Mann, 1981:82)
In The Disease Concept of Alcoholism, E. M. Jellinek (1960) identified what he called different “species” of alcoholism. He was particularly concerned with five such species, to which he assigned as identifiers the first five letters of the Greek alphabet—alpha, beta, gamma, delta, and epsilon. Jellinek felt that only the gamma and delta species could be viewed as diseases.
He noted that “obviously there are species of alcoholism . . . which cannot be regarded as illnesses” (p. 35), and added that “all the remaining 19 letters of the Greek and if necessary other alphabets are available for labelling them” (p. 39). Jellinek also mentioned “other species of alcoholism” such as “explosive drinking” and “fiesta drinking,” with the admonition that “the student of the problems of alcohol cannot afford to overlook these behaviors, whether or not he is inclined to designate them as species of alcoholism” (p. 39).
Finally, he observed that “By adhering strictly to our American ideas about ‘alcoholism' (created by Alcoholics Anonymous in their own image) and restricting the term to these ideas, we have been continuing to overlook many other problems of alcohol which need urgent attention” (Jellinek, 1960:35). Jellinek's view of alcoholism as a diverse phenomenon, and of the need to look beyond it in a broad perspective, is consistent with the view of the committee.