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Alcoholism was first defined by the American Medical Association as an illness in 1956 and a disease in 1966. Today the disease theory of addiction continues to cause controversy. People with addiction are not permitted to receive Social Security Disability benefits unless they can show that their impairment results from a disease other than addiction. As recently as 1988 the US Supreme court upheld the Veterans’ affairs explanation of “primary alcoholism” as a problem resulting from “willfull misconduct.” Veterans with such primary alcoholism or drug addiction are not entitled to disability benefits due to addiction or to any disability (such as cirrhosis of the liver) that results from addiction. (It is curious to note that this policy applies to diseases resulting from alcohol and illicit drug addiction, but not to diseases that result from the world’s biggest addictive killer—smoking.)

The reasoning of the Veterans’ Administration and Supreme Court—which holds the individual responsible for alcoholism and drug addiction–dates back to antiquity. The Greek philosopher Aristotle wrote of alcoholics: “At one time, then, he had the option not to be sick, but he no longer has it now that he has thrown away his health. When you have discharged a stone it is no longer in your power to call it back; but nevertheless the throwing and casting away of that stone rests with you; …we should never reproach a man who was born blind, or had lost his sight in an illness or by a blow—we should rather pity him; but we should all censure a man who had blinded himself by excessive drinking or any other kind of profligacy.”

One of the barriers to overcoming the stigma against addiction is our use of terminology. The terms disorder and disease are often used interchangeably, but historically we have referred to psychological problems as disorders and physical problems as diseases. You’ll note this discrepancy if you look at the table of contents of the International Classification of Diseases and other Health Problems, a manual used world-wide to classify health problems:

  1. Certain infectious and parasitic diseases (A00-B99)
  2. Neoplasms (C00-D49)
  3. Diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism (D50-D89)
  4. Endocrine, nutritional and metabolic diseases (E00-E89)
  5. Mental, Behavioral and Neurodevelopmental disorders (F01-F99)
  6. Diseases of the nervous system (G00-G99)
  7. Diseases of the eye and adnexa (H00-H59)
  8. Diseases of the ear and mastoid process (H60-H95)
  9. Diseases of the circulatory system (I00-I99)
  10. Diseases of the respiratory system (J00-J99)
  11. Diseases of the digestive system (K00-K95)
  12. Diseases of the skin and subcutaneous tissue (L00-L99)
  13. Diseases of the musculoskeletal system and connective tissue (M00-M99)
  14. Diseases of the genitourinary system (N00-N99)

Likewise, the American Psychiatric Association’s Diagnostic Statistical Manual of Mental Disorders uses the term “disorder” rather than “disease” to classify all mental and behavioral conditions.

While many scientists and physicians use the terms “disorder” and “disease” interchangeably, the terms do have a slightly different meaning. The Oxford English Dictionary explains that “disorder” is “a weaker term than disease n., and not implying structural change.” Harvard behavior psychologist Gene Heyman wrote an entire book arguing that addiction is a disorder not a disease, precisely because he does not believe that there are characteristc neurological abnormalities that underlie addiction. By his understanding of the words, we might consider diabetes a disease because it involves a structural abnormality in the endocrine system and depression a disorder if we are not convinced that it results from any structural abnormality in the brain. If, for instance, all depression were situational or caused by depressive environments, depression could not be considered a disease.

Mental disorders have traditionally been termed disorders rather than diseases for two reasons: 1) The complexity of the brain has impeded science’s discovery of the characteristic structural abnormalities that underlie mental disorders; 2) mental disorders impact human behavior and moral functioning—areas of functioning that have historically been understood not in medical terms but in moral, religious, economic, legal, and political terms.

Consider the case of schizophrenia. Until the early 1970’s, the most widely accepted explanation of schizophrenia was the “schizophrenogenic mother” (Neill, 1990). The schizophrenogenic mother was characterized by a confusing combination of overprotection and rejection. These paradoxical messages put the child into a “double bind” to which psychosis was a maladaptive coping response. In other words, there was nothing structurally wrong with the brain of a person with schizophrenia; there was something wrong with his or her family environment. If we could change the environment, the disorder would go away. Psychodynamic family therapy was considered the most promising solution for restructuring the schizophrenogenic family and resolving the symptoms of schizophrenia.

Later research has disproved any strong link between familial characteristics and psychosis and shown psychodynamic psychotherapy to be ineffective in treating schizophrenia. Today, the prevailing causal explanation of psychosis and other mental disorders is no different than that of other chronic medical conditions. Certain persons are genetically susceptible and these susceptibilities can be activated by environmental factors, including various forms of toxic stress. Moreover, brain imaging techniques have now definitively demonstrated that schizophrenia involves significant and characteristic structural abnormalities in the brain. Evidence of these structural abnormalities has led many scientific and medical institutions to adopt “disease” terminology for schizophrenia, abandoning the more equivocal and ambiguous term “disorder.”

While psychiatry has been diagnosing and treating mental disorders as medical problems for the past several decades, the term disorder has long been used by moral and religious authorities to explain sin and vice. The current Roman Catholic catechism is replete with references to “disordered desires,” “disordered affections,” and “disordered attachments,” all of which are believed to contribute to sinful behavior and to be correctable through faith and religious practice. When used in a moral or religious sense, disorder suggests the existence of a normally functioning brain but an immoral character.

To adopt the disease model of addiction is to reject the ambiguity of disorder terminology and to assert that even “primary” addiction—addiction that has not developed in response to any co-occurring disorder—is a fundamentally involuntary malfunctioning of the motivational system. It is a real disease so we should stop locating it in some ambiguous space between illness and moral failing.

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Ned Presnall

Ned is Executive Director of Clayton Behavioral and Adjunct Professor at Washington University in St. Louis, Missouri. He presents widely on the topics of addiction, mental health, and Medication Assisted Treatment. Ned is passionate about reducing the stigma against persons with addiction and against Medication Assisted Treatment through discourse and public engagement.


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