The APA’s DSM lists two broad categories of diagnoses in this area: dependence and abuse. So we have alcohol dependence and alcohol abuse; amphetamines dependence and amphetamines abuse; cocaine dependence and cocaine abuse. And so on.
Dependence is defined by the presence of three or more of the following criteria:
- tolerance, as defined by either of the following:
- a need for markedly increased amounts of the substance to achieve intoxication or desired effect
- markedly diminished effect with continued use of the same amount of the substance
- withdrawal, as manifested by either of the following:
- the characteristic withdrawal syndrome for the substance …
- the same (or a closely related) substance is taken to relieve or avoid withdrawal symptoms
- the substance is often taken in larger amounts or over a longer period than was
- there is a persistent desire or unsuccessful efforts to cut down or control substance use
- a great deal of time is spent in activities necessary to obtain the substance… use the
substance … or recovery from its effects
- important social, occupational, or recreational activities are given up or reduced
because of substance use
- the substance use is continued despite knowledge of having a persistent or recurrent
physical or psychological problem that is likely to have been caused or exacerbated by
the substance …
Abuse is defined as one or more of the following:
- recurrent substance use resulting in a failure to fulfill major role obligations at work,
school, or home …
- recurrent substance use in situations in which it is physically hazardous …
- recurrent substance-related legal problems …
- continued substance use despite having persistent or recurrent social or interpersonal
problems caused or exacerbated by the effect of the substance …
Let’s consider alcohol dependence, which to all intents and purposes is what most people would refer to as alcoholism. A person who drinks, say, half a bottle of whisky every day, who never appears particularly drunk, who becomes extremely sick if he stops drinking, who has made numerous unsuccessful efforts to quit, who has incurred some liver damage, and whose social life has been severely curtailed because of drinking, would normally be called an alcoholic. Some people prefer the term addicted and would describe him as addicted to alcohol. DSM would say that he has a mental disorder called alcohol dependence. The problem with all three terminologies is that they encourage us to blur the distinction between a description and an explanation. This distinction is the central theme of this blog.
The term “alcoholic” for instance, looks like an explanation, is constantly presented as an explanation, and is widely accepted as an explanation, but in fact it is purely descriptive. In the example cited above, imagine the man’s wife confiding in a friend about the problem. She ends by asking: “Why won’t he stop – why can’t he see that he’s killing himself?” And the friend replies: “Because he’s an alcoholic.” But “alcoholic” means a person who continues drinking large quantities of alcohol despite adverse consequences. So all that the friend has said is that the husband is drinking large quantities of alcohol despite adverse consequences because he is drinking large quantities of alcohol despite adverse consequences. Nothing has been added in the way of an explanation. And yet the words themselves often have a measure of comfort for the listener.
Let’s consider another example – a battered woman. She asks a friend: “Why does he beat me all the time? Why is he so mean to me?” The friend replies: “Because he is a jerk!”
Here again, it looks like an explanation. It looks and feels as if the “why” question was adequately answered. But when we remember that a “jerk” is someone who routinely hurts people, we see that the substance of the reply is: he hurts you because he hurts you.
This practice – of presenting descriptions and labels as if they were explanations and their being accepted as such – is deeply embedded in our language and in our communications generally.
Staying with the battered woman – imagine another friend commenting on the situation, saying: “Why does she keep going back to him when he mistreats her so?” And receiving the reply: “Because she is co-dependent.” Here again, it looks as if the “why” question has been answered. But co-dependent means being excessively dependent on the approval of others. So the reply essentially means: she goes back to him because she goes back to him. Co-dependency is simply a label for this kind of self-destructive, overly dependent behavior. Putting a name on a problem can be emotionally soothing, and is perfectly acceptable in ordinary interactive speech. But what the APA has done is take this naming process and presented it as if it were a scientifically validated explanatory system, which DSM most emphatically is NOT.
In addition, it needs to be pointed out that even as a labeling system, the DSM falls short. A person who meets criteria 1, 3 and 5, for instance, receives the same “diagnosis” as a person who meets criteria 2, 4 and 6, even though their history, presentation, and general circumstances may be entirely different.
As with the other human problems addressed in these posts, genuine explanations of alcoholism and drug addiction require a detailed knowledge of the history and circumstances of the individual, coupled with an understanding of the principles underlying behavior acquisition. The general principles are as follows:
1. Alcohol and other drugs of abuse (nicotine, cocaine, heroin, amphetamines, etc.) act on the brains of most individuals in a way that induces a feeling of pleasure.
2. When an activity is followed by a feeling of pleasure, there is an increased probability that the behavior will be repeated. This is the fundamental principle underlying habit formation.
What’s commonly called addiction to alcohol and others drugs is in fact an extremely strong habit. So the question arises: why do some people become addicted (in other words, form this very strong habit), while others do not? In my view, the fundamental issue here is critical self-scrutiny. It is important that as children, we acquire the habit of critical self-scrutiny: the habit of reviewing our actions and deciding from day to day what needs to be changed. One of the realities of life is that if you start drinking large quantities of alcohol, you will begin (quite soon) to incur negative consequences. Hangovers, wasted time, wasted money, painful indiscretions, broken relationships, and lost opportunities are the routine lot of the heavy drinker. Now most people, when faced with this reality, eventually look at themselves in the mirror and say something to the effect: “This is just ridiculous. I have to make some changes.” And they do. The person who has not developed the habit of critical self-appraisal, however, can always find another way of looking at things. A dishonest way – a way that somehow lets him off the hook for the excessive drinking. Examples of this kind of distorted thinking are:
You’d drink too if you had a wife like mine, …troubles like mine, … a job like mine, … children like mine, etc..
I don’t drink as much as _________.
Winston Churchill drank a fifth of whisky a day – it didn’t do him any harm.
These other people are just uptight. They don’t know how to have fun.
I’d be ok if people would stop nagging me.
Etc., etc., etc.
The fact is, there is only one appropriate response to heavy drinking, and it goes something like this:
I’m drinking too much. It’s causing problems in my life. It’s common knowledge that these problems just get worse as long as the drinking continues. I need to cut down drastically or stop altogether.
But the further question arises: Why do some people make this kind of critical self-appraisal and follow through – while others don’t? And this is where we get down to individual cases. How do children acquire the habit of critical self-appraisal? Why is it that some children acquire this habit, while others don’t?