The History of Addiction

 

Adapted from:

Nathan, P. E. (2016). History of the concept of addition (Vol. 12). Annual Review of Clinical Psychology.

 

A recent article in the Annual Review of Clinical Psychology offered a comprehensive historical account of the how our concept of “addiction” has evolved. My personal knowledge base for substance use disorders is woefully inadequate, so I looked forward to reading this article and learning things I should already know. I hope that this summary is helpful to you.

 

The authors point out, not surprisingly, that references to alcohol use and abuse date back as far as the historical record allows – there is good evidence that alcohol was being used in China over 12,000 years ago! Pictographs in Egypt portrayed wine sometime around 4000 B.C., and drinking in Egypt was known to be widespread. The Babylonians’ preferred beer, worshipped a wine goddess, and offered beer and wine to their gods. The Israelites discovered wine about 3,000 years ago – again, Egypt was the culprit since it was during their captivity.

 

Winemaking and consumption is known to have reached Greece around 2000 B. C., and they considered wine their primary beverage. They had drinking parties, referred to as “symposiums” [who knew?]. While that word now usually refers to a serious academic event, there are still some occasions when the word “symposium” (i.e. PTR’s Summer Symposium) has at least a tangential connection to having a good time, and even drinking a little beer on occasion. We can still have fun while we learn. In ancient Rome, wine was seen as a daily necessity.

 

Sacred texts, including the Bible, the Koran, and others, refer to wine and beer and the negative effects they can have on behavior. The Hebrew Bible mentions the effects of consumption more than 130 times (Sasson, 1994). Many prominent biblical figures drank too much, including Noah, Lot, and Samson. Jesus drank wine as well, and appeared to have approved of moderate consumption, though he was critical of drunkenness. The Koran, in contrast, forbids the use of alcohol completely. Buddhist teachings on alcohol consumption are also very clear – alcohol is a poison that clouds the mind (Hanson, 1995). Crocq (2007) summarized as follows:   “The complex etiology of addiction is reflected in the frequent pendulum swings between opposing attitudes on issues that are still currently debated, such as: Is addition a sin or a disease?; should treatment be moral or medical?; Is addiction caused by the substance, the individual’s vulnerability, or psychology, or social factors?; should substances be regulated or freely available?” Of course, these are still questions that are pertinent today.

 

In the Middle Ages people generally did not drink water because it wasn’t safe. Wine accompanied many meals, especially in southern Europe. The lower classes preferred beers and ales, but for the same reasons. Milk was meant for children. With the onset of the Industrial Revolution, with many now working at machines, having to be on time, etc., attempts started to be made to control drunkenness (Austin, 1985)

 

Benjamin Rush (1784) founded the first institution devoted to the treatment of alcoholics in Boston in 1841. He was an advocate for the proposition that alcoholism is a medical disease – not a product of bad character. Kraepelin considered chronic alcoholism to be a medical disorder as well. Personally, he did not like alcohol since his father suffered from the disease and alcohol adversely affected their relationship. Bleuler speculated that alcoholic hallucinosis was a sign of underlying paranoid schizophrenia released by heavy drinking. Freud saw substance abuse and developing from a frustrated quest for nurturance from parents during infancy and early childhood, and a subsequent unconscious dependency need. Attempts to validate these ideas have seen only limited success.

 

Temperance movements began in the late 1700’s and persisted through the 20th century. Again, Benjamin Rush was at the forefront of an early movement when he published An Inquiry into the Effects of Ardent Spirits upon the Human Body and Mind in 1784. Since drinking and domestic violence often co-occurred, the temperance movement combined forces with women’s rights groups, eventually resulting in the 18th (prohibition), 19th (women’s right to vote) and 21st (repeal of prohibition) Amendments. While prohibition in the U.S. reduced arrests for drunkenness, in the short term, it did not solve problems that came about due to alcoholism.

 

A.A. was founded in Ohio in 1935 by Bill Wilson and Dr. Bob Smith. They eventually published “The Big Book” (Wilson, 1939). The central goal of A.A. is to help individuals find a power greater than themselves to help them deal with their addiction, reflecting the underlying premise that it is impossible to quit drinking by oneself. With the publication of The Big Book in 1939, the AA movement grew quickly. It led to the publication of a seminal work in 1960 by Jellinek (1960) This shifted the view to the idea that alcoholism is a disease with strong spiritual roots. AA members claim that there is no other solution than a spiritual solution. Research on the effectiveness of AA is mixed (Kaskutas, 2009).

 

DSM

DSM-I was completed and published in 1952. Two of the 11 categories included alcohol intoxication only, while three included alcohol and drug intoxication. One of the four personality disorder categories was sociopathic personality disturbance, which included four conditions, one of which was addiction. Acute and chronic alcohol and drug intoxication were identified as “brain syndromes” in the first edition of DSM. The latter syndrome included alcoholism and drug addiction. After the publication, Key (1952) argued that alcoholics could be divided into two groups, distinguished by the purpose of their drinking. He recommended treating alcohol addiction with conditioned aversion. Wellman (1954) said that problem drinkers could be divided into two groups:

  1. Primary compulsive types – use alcohol to cope with personality problems present from an early age
  2. Secondary type – transition to heavy social drinking in a more gradual way, with a source in environmental factors, metabolic disease, and blood chemistry

DSM-II did not portray alcoholism as a personality disorder, but identified eight specific brain syndromes associated with alcohol – it was a disease. This idea evolved out of Jellinek’s (see above) delineation of five types of alcoholism, one of which (Epsilon) met the criteria for a disease. Jellinek proposed a concept of alcoholism quite different from AA’s belief in the unity of all species of alcoholism.

 

In response to the problems with both DSMs, the Feighner criteria were published in 1972 (Feighner, 1972). These researchers pushed the continuing investigation of signs and symptoms of psychiatric disorder, including alcohol abuse and alcoholism. Edwards & Gross (1976) first described “alcohol dependence syndrome”, claiming that dependence involved “a narrowing of the drinking repertoire”.

 

Substance use disorders in DSM-III were detailed in a separate section (Chapter 3) and divided into substance abuse and dependence. DSM-II clearly distinguished between substance use, substance abuse, and substance dependence. Five classes of substances were listed that generated both abuse and dependence:

  • Alcohol
  • Barbiturates
  • Opioids
  • Amphetamines
  • Cannabis

Cocaine, phencyclidine, and hallucinogens yielded only symptoms of abuse. Tobacco was associated only with dependence.

The substance dependence category was expanded in DSM-III-R to include symptoms that had formerly been descriptive of substance abuse. Beyond that, DSM-III-R mandated that substance dependence should include both physiological symptoms and behavioral symptoms. Abuse became a residual category for those who had never met criteria for dependence, but had manifested a variety of substance-related problems. DSM-III-R also made increased use of the substance dependence syndrome. It during this period that the influence of genetics began to be addressed. Mayfield and colleagues (2008), after a thorough literature review, concluded that genes and environment influence the development of alcohol dependence.

DSM-IV, of course, brought more changes. This document named the chapter “Substance-Related Disorders”, and it included “disorders related to the taking of a drug of abuse (including alcohol), to the side effects of a medication and to toxin exposure (American Psychiatric Association, 1994). Substances were grouped into 11 classes and there were two distinct categories of disorders, substance use and substance-induced.

DSM-5 covers 10 drug categories and adds gambling disorders, the first time a non-substance-related condition was noted. The authors sought to make clear the belief that the brain mechanisms responsible for the brain reward system are central to the onset and maintenance of addiction. DSM-5 substance-related disorders are separated into substance use disorders and substance-induced disorders. The distinction between substance abuse and substance dependence (in DSM-III and DSM-IV) was eliminated and replaced with a one-dimensional assessment of severity based on the number of symptoms observed. DSM-5 also says “the word addiction is not applied as a diagnostic term in this classification . . . the word is omitted from the official DSM-5 substance use disorder diagnostic terminology because of its uncertain definition and its potentially negative connotations” (American Psychiatric Association, 2013)

It is speculated by Sellman and colleagues (2014) that future research will be directed toward eliminating the abuse-dependence dichotomy. They anticipate that DSM-6 will provide the established link between biomarkers for neurophysiological processes that develop in response to ongoing alcohol use and behavioral symptoms of alcoholism.

 

References:

American Psychiatric Association. (1994). Diagnostic and Statistical Manual of Mental Disorders (Vol. 4). Washington, DC: American Psychiatric Association.

American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (Vol. 5). Washington , DC: American Psychiatric Association.

Austin, G. A. (1985). Alcohol in Western Society from Antiquity to 1800. Santa Barbara, CA: ABC-CLIO.

Crocq, M.-A. (2007). Historical and cultural aspects of man’s relationship with addictive drugs. Dialogues in Clinical Neuroscience, 9, 355-361.

Edwards, G. G. (1976). Alcohol dependence: Provisional description of a clinical syndrome. British Medical Journal, 1, 1058-1060.

Feighner, J. P. (1972). Diagnostic criteria for use in psychiatric research. Archives of General Psychiatry, 26, 57-63.

Hanson, D. J. (1995). Preventing Alcohol Abuse: Alcohol, Culture, and Control. Westport, CT: Praeger.

Jellinek, E. M. (1960). The Disease Concept of Alcoholism. New Haven, CT: Hillhouse Press.

Kaskutas, L. A. (2009). Alcoholics Anonymous effectiveness: Faith meets science. Journal of Addictive Disorders, 28, 145-157.

Key, G. J. (1952). The psychiatric and the medical approach to the problem of alcoholism. South African Medical Journal, 26, 666-671.

Mayfield, R. D. (2008). Genetic factors influencing alcohol dependence. British Journal of Pharmacology, 154, 275-287.

Nathan, P. E. (2016). History of the concept of addition (Vol. 12). Annual Review of Clinical Psychology.

Rush, B. (1784). An Inquiry into the Effects of Ardent Spirits upon the Human Body and Mind. Philadelphia, PA: Bartam.

Sasson, J. M. (1994). the blood of grapes: viticulture and intoxication in the Hebrew Bible. In L. Milani (Ed.), Drinnking in Ancient Societies: History and Culture of Drinks in the Ancient Near East (pp. 399-4419). Padua, Italy: Sargon.

Sellman, J. D. (2014). DSM-5 alcoholism: a 60-year perspective. Australian and New Zealand Journal of Psychiatry, 48, 507-511.

Wellman, M. (1954). The late withdrawal symptoms of alcohol addiction. Canadian Medical Association Journal, 70, 526-529.

Wilson, B. (1939). Alcoholics Anonymous: The Story of How Many Thousands of Men and Women Have Recovered from Alcoholism. Akron , OH: Wilson.

 

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