The modern disease theory of alcoholism states that problem drinking is sometimes caused by a disease of the brain, characterized by altered brain structure and function. Today, alcohol use disorder (AUD) is used as a more scientific and suitable approach to alcohol dependence and alcohol-related problems.
The largest association of physicians – the American Medical Association (AMA) – declared that alcoholism was an illness in 1956. In 1991, the AMA further endorsed the dual classification of alcoholism by the International Classification of Diseases under both psychiatric and medical sections.
Theory
Under the model of alcoholism, alcohol use disorder is viewed as chronic problem for which abstinence is required. A brain disease model of addiction, based on the extent of neuroadaptation and impaired control, is main position advanced for proposing a disease model of alcohol use disorder. However, if managed properly, damage to the brain can be stopped and to some extent reversed. In addition to problem drinking, the disease is characterized by symptoms including an impaired control over alcohol, compulsive thoughts about alcohol, and distorted thinking. Alcoholism can also lead indirectly, through excess consumption, to physical dependence on alcohol, and diseases such as cirrhosis of the liver.
The risk of developing alcoholism depends on many factors, such as environment. Those with a family history of alcoholism are more likely to develop it themselves (Enoch & Goldman, 2001); however, many individuals have developed alcoholism without a family history of the disease. Since the consumption of alcohol is necessary to develop alcoholism, the availability of and attitudes towards alcohol in an individual's environment affect their likelihood of developing the disease. Current evidence indicates that in both men and women, alcoholism is 50–60% genetically determined, leaving 40–50% for environmental influences.
In a review in 2001, McLellan et al. compared the diagnoses, heritability, etiology (genetic and environmental factors), pathophysiology, and response to treatments (adherence and relapse) of drug dependence vs type 2 diabetes mellitus, hypertension, and asthma. They found that genetic heritability, personal choice, and environmental factors are comparably involved in the etiology and course of all of these disorders, providing evidence that drug (including alcohol) dependence is a chronic medical illness.
Genetics and environment According to the theory, genes play a strong role in the development of alcoholism.
Twin studies, adoption studies, and artificial selection studies have shown that a person's genes can predispose them to developing alcoholism. Evidence from twin studies show that concordance rates for alcoholism are higher for monozygotic twins than dizygotic twins—76% for monozygotic twins and 61% for dizygotic twins. However, female twin studies demonstrate that females have much lower concordance rates than males. Reasons for gender differences may include environmental factors, such as negative public attitudes towards female drinkers.
Adoption studies also suggest a strong genetic tendency towards alcoholism. Studies on children separated from their biological parents demonstrates that sons of alcoholic biological fathers were more likely to become alcoholic, even though they have been separated and raised by non alcoholic parents.
In artificial selection studies, specific strains of rats were bred to prefer alcohol. These rats preferred drinking alcohol over other liquids, resulting in a tolerance for alcohol and exhibited a physical dependency on alcohol. Rats that were not bred for this preference did not have these traits. Upon analyzing the brains of these two strains of rats, it was discovered that there were differences in chemical composition of certain areas of the brain. This study suggests that certain brain mechanisms are more genetically prone to alcoholism.
The convergent evidence from these studies present a strong case for the genetic basis of alcoholism.
History Historians debate who has primacy in arguing that habitual drinking carried the characteristics of a disease. Some note that Scottish physician Thomas Trotter was the first to characterize excessive drinking as a mental disease or medical defect.Trotter, T. (Porter, R., ed.), An Essay, Medical, Philosophical, and Chemical, on Drunkenness and Its Effects on the Human Body, Routledge, (London), 1988. (This a facsimile of the first (1804) London edition. The book itself was based on the thesis "De ebrietate, ejusque effectibus in corpus humanum" that Trotter had presented to Edinburgh University in 1788.)
Others point to American physician Benjamin Rush (1745–1813), a signatory to the United States Declaration of Independence, who understood drunkenness to be what we would now call a "loss of control", as possibly the first to use the term addiction in this sort of meaning.Levine, H.G., "The Discovery of Addiction: Changing Conceptions of Habitual Drunkenness in America", Journal of Studies on Alcohol, Vol.39, No.1, (January 1978), pp.143-174. (Reprint: Journal of Substance Abuse Treatment, Vol.2, No.1, (1985), pp.43-57.) Available at
Rush argued that "habitual drunkenness should be regarded not as a bad habit but as a disease", describing it as "a palsy of the will".Valverde (1998, p. 2) Rush expounded his views in a book published in 1808.Rush, B., An Inquiry into the Effects of Ardent Spirits upon the Human Body and Mind: With an Account of the Means of Preventing, and of the Remedies for Curing Them, Thomas Dobson, (Philadelphia), 1808. His views are described by Valverde,Valverde, M., Diseases of the Will: Alcohol and the Dilemmas of Freedom, Cambridge University Press, (Cambridge), 1998. Levine Spode,Hasso Spode, Die Macht der Trunkenheit, Opladen 1993, pp. 124ff. and Perkins-McVey.Matthew Perkins-McVey, "Were the scale of excitability a circle: Tracing the roots of the disease theory of alcoholism through Brunonian stimulus dependence", Studies in History and Philosophy of Science, Vol. 99 (2023): 48 (https://doi.org/10.1016/j.shpsa.2023.03.001) Already in 1802 the prominent German physician Christoph Wilhelm Hufeland had published a book on the "brandy plague" stating that the "infection" with spirits makes it "inevitably necessary to drink ever more."Hasso Spode, "Transsubstantiations of the Mystery: Two Remarks on the Shifts in the Knowledge about Addiction." Social History of Alcohol and Drugs, Vol. 20 (2005): 126 (https://hist-soz.de/publika/SPODE-SHAD20-05.pdf) Later he wrote an enthusiastic preface to the book On the addiction to drink and a rational cure of it by German-Russian physician C. von Brühl-Cramer.C. von Brühl-Cramer, Ueber die Trunksucht und eine rationelle Heilmethode derselben, Berlin 1819 (also publ. in Moscow). As Spode points out, this study marked the birth of a consistent "paradigm" of addiction as a mental illness, although it took many decades until this view was accepted.Hasso Spode, Die Macht der Trunkenheit, Opladen 1993, pp. 127ff. Perkins-McVey argues that Rush, Trotter, and Brühl-Cramer each independently developed their own disease theories of alcoholism as a result of their shared interest in the Brunonian system of medicine, which classified alcohol as a stimulant of the vital force.Matthew Perkins-McVey, "Were the scale of excitability a circle: Tracing the roots of the disease theory of alcoholism through Brunonian stimulus dependence", Studies in History and Philosophy of Science, Vol. 99 (2023): 52 (https://doi.org/10.1016/j.shpsa.2023.03.001) As Perkins-McVey argues, this "understanding of the disease of habitual drunkenness as a phenomena of stimulus dependence is arguably the primary vehicle driving the disease model in the works of Rush, Trotter, and Brühl-Cramer."Matthew Perkins-McVey, "Were the scale of excitability a circle: Tracing the roots of the disease theory of alcoholism through Brunonian stimulus dependence", Studies in History and Philosophy of Science, Vol. 99 (2023): 52 (https://doi.org/10.1016/j.shpsa.2023.03.001) This shifts the discussion away from the question of historical priority, instead identifying a common conceptual influence on early disease theorists.
In 1849, Swedish physician Magnus Huss coined the term alcoholism in his book Alcoholismus chronicus. Some argue he was the first to systematically describe the physical characteristics of habitual drinking and claim that it was a mental disease. However, Huss regarded heavy drinking still as a vice (that causes a destruction of the nervous system).Hasso Spode, Die Macht der Trunkenheit, Opladen 1993, pp. 127ff. Moreover, this came decades after Trotter, Rush, Hufeland and Brühl-Cramer wrote their works, and some historians argue that the idea that habitual drinking was a mental disease emerged even earlier.Along with Levine, see Roy Porter ("Drinking Man's Disease: the 'Pre-History' of Alcoholism in Georgian Britain", British Journal of Addiction 80 (1985): 385–396) who places the idea to emerge with Trotter, Jessica Warner ["'Resolved to Drink No More': Addiction as a preindustrial construct" Journal of Studies on Alcohol 55 (1994): 685–691] who uses a narrow reading of 17th century sermons to place it in the 1600s, Peter Ferentzy ["From Sin to Disease: Differences and similarities between past and current conceptions on 'chronic drunkenness'" Contemporary Drug Problems 28 (2001): 362-90] who successfully challenges Warner's argument by showing that the term "disease" was applied to many conditions that had little to do with physical debility, and James Nicholls ["Vinum Britannicum: The 'Drink Question' in Early Modern England" Social History of Alcohol and Drugs: An interdisciplinary Journal 22 (2008): 6-25] who draws it together and argues that the idea emerged at different times in different places.
Given this controversy, the best one can say is that the idea that habitual alcohol drinking was a disease had become more acceptable by the second half of the nineteenth century, although many writers still argued it was a vice, a sin, and not the purview of medicine but of religion.See, for example, books with such telling titles as John Edwards Todd, Drunkenness, a Vice--not a Disease (1882).
Between 1980 and 1991, medical organizations, including the AMA, worked together to establish policies regarding their positions on the disease theory. These policies were developed in 1987 in part because third-party reimbursement for treatment was difficult or impossible unless alcoholism were categorized as a disease. The policies of the AMA, formed through consensus of the federation of state and specialty medical societies within their House of Delegates, state, in part: The AMA endorses the proposition that drug dependencies, including alcoholism, are diseases and that their treatment is a legitimate part of medical practice.
In 1991, the AMA further endorsed the dual classification of alcoholism by the International Classification of Diseases under both psychiatric and medical sections.
Controlled drinking The disease theory is often interpreted as implying that problem drinkers are incapable of returning to 'normal' problem free drinking, and therefore that treatment should focus on total abstinence. Some critics have used evidence of controlled drinking in formerly dependent drinkers to dispute the disease theory of alcoholism.