Psychiatric Times.

The Meaning of Addiction: DSM-5 Gives the Lie to Addiction as a Chronic Brain Disease

By Stanton Peele, JD, PhD | August 24, 2010

Dr Peele was a member of the advisory group for substance-use disorders for DSM-IV, but has no involvement in DSM-5.

Although Charles O’Brien, MD, who heads the substance-related disorders work group, is a vigorous proponent of the notion of addiction as a disease, nothing about the proposed DSM-5 substance-related disorders section supports the idea that the syndrome is best understood as a chronic brain disease.

The return to the terminology of “addiction” and “addictive disorders” (replacing dependence) to subsume substance problems immediately calls into question the classic biochemical model of addiction, which at one time was applied solely to heroin and other narcotics, and then expanded to incorporate cocaine and marijuana, drugs with entirely different chemical and pharmacological profiles. DSM-5 expands the list of drugs now labeled capable of causing addiction well beyond this.

Indeed, it is not clear which drugs cannot result in addiction in susceptible individuals under the right conditions. This, of course, undercuts the whole notion that substances with specific molecular characteristics link with receptor sites hypothesized to unlock the brain’s addictive response. Of course, identifying compulsive gambling as addictive makes the idea that there is an exclusive chemical pathway corresponding with an addictive brain reward system unlikely to the point of fantastical.

But, ultimately, what conclusively refutes the cherished idea that addiction can be traced to a characteristic brain pattern (one measurable by a PET scan) is the gradated severity scale on which addictive disorders are to be scored by DSM-5. As the AA saying does, “You can’t be partially alcoholic (according to AA’s disease notion of alcoholism), any more than you can be partly pregnant.” But DSM-5 says that you can be -– as DSM-IV likewise did with its abuse and partial remission categories. This of course corresponds with epidemiologic data (cf. NESARC) that show people waxing and waning on dependence measures over their lifetimes (more often waning), often within a relatively short time frame.

I have been proposing an experiential model of addiction from the time I wrote Love and Addiction (1975) and The Meaning Addiction (1985). I conceive addiction as a more or less pathological adherence to an involvement - – defined by its experiential benefits for an individual in a specific life circumstance (eg, the Vietnam War theater, adolescence) –- as measured by its negative consequences (more or less as laid out in DSM-IV and repeated in DSM-5). And each subsequent rendition of DSM seems more closely to approximate my model.

[Editor's note: For more on addiction, see New Definition of Addiction: A Chronic Brain Disease, a podcast by Dr Michael Miller, Past President, American Society of Addiction Medicine.]

by Tom O'Connell | January 29, 2011 6:17 PM EST

The notion that"addiction"is a disease is refuted by the lack of specific pathologic change in the brains of addicts; however, there's no doubt it can be a troublesome behavior that requires better understanding, a goal that has been seriously impeded by making drug possession and use a crime.

Rather than enhance our understanding, the modern drug war, as supported both implicitly and explicitly
by Medicine, and Psychiatry, has done enormous social damage and killed innumerable victims.

Tom O'Connell MD

by Teri Murtha | January 10, 2011 9:51 AM EST

Was anyone who actually specializes in addiction on this "committee" or just those affected by it? This is a sad commentary on how ego gets in the way of who will be truly harmed by this, the patient who suffers from addiction. As a clinician, I will use the DSM as an insurance tool only. As for the guy ridiculing AA, I hope too many of his client's who could benefit from this tremendous organization find another clinician without such personal bias.

by Robert Peers | December 26, 2010 6:42 AM EST

It's ridiculous to say addiction is not biological, when addictive substances have such different effects in different people. The most common driver of addiction to food, alcohol, smoking or marijuana is anxiety disorder, whose origins lie in fatty maternal diet during gestation (cortisol crosses the placenta, programming permanent fear in the offspring: 1 in 4 Westerners). Treatment of anxiety with myo-Inositol supplement blocks serotonin 2 A receptors, reduces HPA stress axis activation and cortisol levels, and greatly reduces anxiety-driven cravings within a few days, including smoking. Problem solved! Another driver of drug and alcohol abuse is adult ADHD, caused by maternal consumption of brain-oxidizing refined seed oils in pregnancy (the same oils cause Alzheimer's). About 4% of US adults have residual ADD, which is difficult to treat, especially the frequent impulsive drug abuse. I use fish oil supplements, to improve synaptic density, and I warn such cases to strictly avoid refined seed oils, or to take preventive vitamin E in case of further exposure. Many such cases probably need stimulant medication to reduce their impulsiveness.

by Philip Gianelli | December 20, 2010 2:58 PM EST

My goodness. So many have the answer it amazes me that none are outstandingly successful in their one, polar approach. Perhaps dogma when applied to the human condition can not possibly explain all the possible variants. After the practice of medicine for 20 years I have found that addition treatment, a valid branch of general medicine and psychiatry, is one of the most clinically-based specialties. Each individual has a unique set of circumstances surrounding their disorder. Oh, and yes, it is a disease. The "chemical imbalance"was a term invented by the drug companies to sell us pills on TV. Nothing in the brain is simple nor can it be reduced to a "chemical imbalance".

by Joseph Pierre | December 07, 2010 7:54 PM EST

Nowhere does the issue of free will (e.g. "choice") rear its head so strongly as with addictive disorders. I suppose this is because many, if not most people, can use drugs or alcohol (or gamble) without it becoming a problem "habit,"so it is hard to imagine doing so without control (or at least its illusion).

Still, research data in the form of twin studies, genetic studies, and animal models do indeed strongly support a biochemical basis for addiction, and the relevant genes, neurotransmitters, and reward pathways, while not crystal clear are better elucidated that most other psychiatric disorders. Anyone claiming that addiction is a "choice" needs to be able to account for these data.

The lack of "specific molecular characteristics," "an exclusive chemical pathway," or a "characteristic brain pattern," to explain addiction does not in any way refute a disease model. The brain is an impossibly complex array of interconnected neural networks that can be perturbed in myriad ways - pathophysiologies in psychiatry are never going to be simple, one-lesion-explains-all answers. Nor does the move towards a spectrum model in DSM-5 "refute" addiction as a disease. The pathophysiology of hypertension is similarly complex, and it also occurs along a spectrum - does that mean that it isn't a disease - it's a choice? The finding that certain drugs are more addictive than others also does not detract from a disease model. We know that certain microorganisms are more infectious than others - does this mean that infection aren't diseases?

Many people feel that addiction must be a "choice" because the main "symptom" involves a very specific behavior (e.g. putting a bottle to your lips and drinking) that we think of as a voluntary act (i.e. a "choice"). But as I like to say, all choices are not created equally. We know that certain individuals, by virtue of genetic make-up and other biochemical factors react to addictive substances differently, and that the brain of someone exposed to cocaine on a daily basis reacts very differently to the opportunity to use cocaine compared to someone whose brain is naïve to that experience. This is how biochemistry impacts choice. Addicts know that these behaviors are harmful - why would they "choose" to do them? What about those of us who overeat? Or pick at a scab? Or scatch at a rash? Are these all choices? Does the person with a pruritic rash who risks superinfection have a different kind of choice (to scratch or not to scratch) than someone without a rash?

Psychiatric disorders are all arguably behavioral disorders. Why are we so eager to call addiction a choice, but not depression? Don't depressed patients have a choice to get out of bed in the morning? To eat? To engage in social activity? If we can accept the free will might be abrogated in depression, then why is it different with addiction? On the other hand, if you believe that we always have the ability to choose behaviors, then there is no mental illness.

What is missing in psychiatry is a cohesive model of free will and how it might exist alongside biochemistry. Having genetic or biochemical models for disorders does not render us automatons. There is a biochemical basis for decision making and free will. We will never achieve an integrated behavioral model of addiction that accepts both the possibility of free will and biological determinism when people rigidly adhere to the polarized sides about "choice" vs. "disease."

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References
Peele S, Brodsky A. Love and Addiction. New York: Taplinger; 1975.
Peele S. The Meaning of Addiction. Lexington, MA: Lexington Books; 1985.

The Meaning of Addiction: DSM-5 Gives the Lie to Addiction as a Chronic Brain Disease

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