What is alcoholism?

Alcohol Health & Research World, Fall, 1991 by Daniel K. Flavin, Robert M. Morse

Current Definitions and Diagnostic Criteria and Their Implications for Treatment

The definition of alcoholism has evolved to reflect recent insights concerning the heterogeneity of the disease and the multiple factors that contribute to its expression.

In his classic text, The Disease Concept of Alcoholism, Jellinek (1960) makes the following observation:

After 20 years [of viewing alcoholism as a disease] it seems in order to analyze what the present status of the illness conception of alcoholism is in America. This task is not as simple as it may seem... one finds difficulties arising out of the fact that alcoholism has too many definitions and disease has practically none.

Since that time, a great deal of effort has been directed toward understanding the nature of alcoholism and clarifying its definition.

The word "alcoholism," originally coined in 1849 by the Swedish physician Magnus Huss, has carried different meanings over the years. These various meanings have reflected popular scientific concepts and sociopolitical realities of the times (Blume 1983). Variations in usage of the term also typify longstanding inconsistencies in terminology and classification applied to alcohol and other drug-related problems, as noted 30 years ago by the World Health Organization (1952). In their recent survey of alcohol and other drug abuse terminology, Rinaldi and colleagues (1988) surmise that the lack of consensus on a lexicon(1) in the addiction field impedes communication between professionals of various disciplines, retards deliberation of public policy, and threatens availability of treatment. Advances are needed in the development and standardization of nomenclature and taxonomy, to facilitate alcohol and other drug research and to improve access to, and quality of, clinical care. This article presents the results of a 2-year multidisciplinary effort by the National Council on Alcoholism and Drug Dependence (NCADD) and the American Society of Addiction Medicine (ASAM) to refine the definition of the term "alcoholism" so as to reflect current clinical data and scientific evidence.

THE MANY MEANINGS OF ALCOHOLISM

Perusal of the various definitions of alcoholism employed over the years reveals that each definition has had a different emphasis, with some degree of overlap. Different definitions have emphasized the following:

* key signs or symptoms associated with problematic alcohol consumption (such as preoccupation with alcohol, loss of control over alcohol use, use of alcohol in excess of what is deemed to be the social norm, craving for alcohol, tolerance, and withdrawal

* consequences of alcohol use

* biological, psychological, or social factors, alone or in combination, that contribute to the etiology of alcoholism

* the nature of alcoholism as a disease or as a behavioral disorder.

Some definitions have described a wider spectrum of alcohol-related problems; for example, Jellinek (1960) chose to define alcoholism as "any use of alcoholic beverages that causes any damage to the individual or society or both."

In 1972, a report published by the National Council on Alcoholism(2) (NCA) described alcoholism as a "pathologic dependency on alcohol." Four years later, NCA and the American Medical Society on Alcoholism(3) (AMSA) published a formal definition of alcoholism:

Alcoholism is a chronic, progressive, and potentially fatal disease. It is characterized by tolerance and physical dependency or pathologic organ changes, or both--all the direct or indirect consequences of the alcohol ingested (Blume et al. 1976).

The report in which this definition was published also details the progressive nature of alcoholism, the physical sequelae of alcohol use, and the phenomena of tolerance and withdrawal, and clarifies the use of such terms as chronic, progressive, tolerance, physical dependency, and pathologic organ changes as they relate to alcoholism (Blume et al. 1976).

Jellinek (1960) has commented that in definition there is nothing sacred and unalterable. Accordingly, research advances and continuing efforts to develop a uniform and reliable taxonomy have led to modifications in the use of terms describing alcohol-related problems and alcoholism. The 1976 NCA/AMSA definition was of a descriptive nature, emphasizing the physiological sequelae of alcohol use. However, this definition is outmoded in that it fails to recognize the spectrum of biological, psychological, and environmental factors that influence the development of alcoholism and its manifestations; therefore, the development of a more comprehensive definition is in order.

DIAGNOSTIC CRITERIA AND THE CONCEPT OF ALCOHOL DEPENDENCE

In 1972, the Criteria Committee of the NCA published formal criteria for diagnosing alcoholism. These criteria focused mainly upon the adverse consequences of drinking and emphasized several key concepts, including the disease process involved in alcoholism, separation of psychiatric diagnoses from the diagnosis of alcoholism, the chronic nature of alcoholism, and the potential for addiction to other drugs in addition to alcohol.