Wednesday, 13.12.2017

Peter R. Martin: A historical Vocabulary of Addiction

 Addiction



The word addiction has its origins in the classical Latin addictiōn-addictiō assignment (of disputed property), assigning of a debtor to the custody of his creditor < addict- , past participial stem of addīcere + -iō -ion suffix (OED Online, 2016; OED Online, 2016). The medical meaning of the word corresponds to one of the definitions of addiction found in the Oxford English Dictionary, Third Edition, November 2010, namely, “immoderate or compulsive consumption of a drug or other substance; specifically, a condition characterized by regular or poorly controlled use of a psychoactive substance despite adverse physical, psychological, or social consequences, often with the development of physiological tolerance and withdrawal symptoms; an instance of this” (OED Online, 2016). However, specific reference to a pathological neurobehavioral interaction between an individual and a self-administered (exogenous) neuropsychopharmacologic agent is not the primary meaning of addiction in OED, nor is it the earliest use of the word in history. The earliest recorded written reference in the English language, according to OED, occurred in 1532 (Glasse of Truthe “An ouermoche addiction to priuate appetites, mixed with to moche heedinesse and obstinacy”), where the term was used in its original meaning of dedication, devotion to a thing or an activity.

The first written reference to addiction as it is commonly understood in medicine today comes from the political writer William Pittis in Dr. Radcliffe’s Life & Letters (1716): “The Doctor…made a Forfeit of them, by his too great Addiction to the Bottle, after a very uncourtly manner”.  This is distinctly different from the original meaning of the word, namely, dedication or devotion to an object (the Bottle), as the Bottle actually represents its contents alcohol, clearly understood to be self-administered for recognized neuropharmacological actions, hence, alcohol addiction. First mention of addiction to another neuropsychopharmacologic agent, tobacco, was in reference to the chain smoking 18th century English poet, John Philips, by author and lexicographer, Samuel Johnson, in Prefaces, biographical and critical, to the works of the English poets (1st edition, 1779): “His addiction to tobacco is mentioned by one of his biographers.” Thereby, addiction came to include another commonly used psychoactive agent, suggesting that very diverse substances could share the specific attribute of out-of-control self-administration.  Generalizability of the term beyond alcohol and tobacco is significant because it signals that the agent alone is perhaps less important than the out-of-control and self-destructive manner in which it is self-administered, as suggested by the first appearance of the term drug addiction in The Medical and surgical reporter (1881): “A clerk, aged forty-two years, a widower, no family history of alcoholism, drug addiction, insanity, marked nervous disease, or syphilis” (OED Online, 2016).

Use of the word addiction to specify a medical disorder, according to OED, seems to date to a 1906 entry in the Journal of the American Medical Association (3 March 643/2): “It matters little whether one speaks of the opium habit, the opium disease or the opium addiction.”  Addiction also acquired scientific meaning as evidenced by entries in both pharmacology textbooks (e.g., A. Grollman, Pharmacology & Therapeutics iv. 97, 1951: “Addiction refers to that condition induced by a drug which necessitates the continuation of the drug and without which physical and mental derangements result.”) and in the scientific literature (e.g., Nature 18 September 188/2, 1975: “Most people consider opiate addiction to comprise three major elements: tolerance, physical dependence, and compulsive craving”).

By the 20th century, a syndrome of self-destructive and out-of-control self-administration of various neuropsychopharmacological agents had been described by many of the leaders of modern scientific psychiatry (Nathan, Conrad, & Skinstad, 2016).  Nevertheless, it was believed that these disorders were caused by or were associated with other psychiatric disorders, including melancholia, mania and schizophrenia.  In fact, the word toxicomanie, still widely used in the French language synonymously with addiction, possibly reflects this early confounding of what was considered the primary cause of the observed psychopathology in this syndrome, which due to its self-destructive nature seemed only explicable based on insanity of some form. With elucidation of reward mechanisms in the brain that could shape behavior such as out-of-control self-administration of psychoactive agents, it became feasible to conceptualize addiction as a psychiatric disorder in its own right (Olds, 1958). 

Despite the fact that the word addiction had become associated by usage with a well-recognized medical/psychiatric syndrome, debate continued about whether it was, indeed, the best word to describe the behaviors characterized by out-of-control and self-destructive alcohol/drug use (Jaffe, 1975): “It is possible to describe all known patterns of drug use without the terms addict or addiction.  In many respects this would be advantageous, for the term addiction, like the term abuse, has been used in so many ways that it can no longer be employed without further qualification or elaboration.  However, since it is not likely that the term will be dropped from the language, it is appropriate to make an effort to delimit its meaning.”  Additionally, the most appropriate way to refer to, yet not to stigmatize, those diagnosed with what had slowly become accepted as a medical condition rather than a bad habit, has been a continuing discussion to the present day (Botticelli & Koh, 2016). Deliberations have focused on which term most accurately captures the essence of these behaviors, describing the characteristics of use as abuse (or misuse), non-medical, problematic, pathological, harmful, hazardous, illicit and compulsive, among many others. The World Health Organization (WHO) Expert Committee attempted throughout the 1950s to define addiction applicable to drugs, trying to differentiate addiction from habituation without successful application to clinical practice. In 1964, the WHO Expert Committee introduced the term dependence to replace the terms addiction and habituation. The rationale was that dependence could be used generally with reference to the entire range of psychoactive drugs (e.g., drug dependence, chemical dependence, substance use dependence) or with specific reference to a particular drug or class of drugs (e.g., alcohol dependence, opioid dependence), the term could be dichotomized into complementary components (psychic or physical dependence) and it did not carry a connotation of the degree of health risk or need for legal control of the drug in question. The current WHO International Statistical Classification of Diseases and Related Health Problems 10th Revision (ICD-10) still describes dependence in terms applicable across drug classes with differences in the characteristic dependence symptoms for different drugs (World Health Organization, 2016). 

On the other hand, the American Psychiatric Association (APA) initially conceptualized addiction in the realm of abnormal personality development and sociopathic personality disturbances (Nathan et al., 2016). For the first time, in the Diagnostic and Statistical Manual of Mental Disorders, Third Edition (DSM III), the disorder emerged as a primary diagnosis in its own right as abuse or dependence, not fully resonating with the WHO diagnostic system with its unitary focus on dependence, but nevertheless unifying the disease construct in medicine and as a psychiatric disorder (American Psychiatric Association, 1980).  It was not until DSM-III-R that the notion of the generic substance dependence syndrome for all drugs of abuse received confirmation, however, the construct of abuse and dependence persisted (Kosten, Rounsaville, Babor, Spitzer, & Williams, 1987).  More recently, APA has settled, after many decades of employing abuse and dependence on conceptualizing the breadth of the disorder, on the single term drug use disorder with designation by degrees of severity (mild, moderate and severe based on numbers of criteria satisfied) in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) (American Psychiatric Association, 2013).

An important advance in recent years is recognition that various behaviors, such as gambling, problematic hypersexuality, overeating, etc., can also “hijack” brain reward pathways and thus share similar mechanistic underpinnings and essential clinical features of drug use disorders (Martin, Weinberg, & Bealer, 2007).  In the context of these behavioral or context addictions, the word addiction seems to have returned to its original meaning in OED, namely a habit and inclination towards an out-of-control repetitive behavior, which is endogenous to the organism and does not involve self-administration of an exogenous agent.  The APA Task Force describes these as addictive disorders and includes gambling disorder in the same chapter of the DSM-5 as the substance-related disorders (American Psychiatric Association, 2013).  Nevertheless, questioning whether behaviors other than gambling with comparable psychopathological features merit inclusion in DSM-5 seems to be a continuation of the polemics that seem to haunt the nosology of these disorders (p. 481):  “Thus, groups of repetitive behaviors, which some term behavioral addictions, with such subcategories as sex addiction, exercise addiction, or shopping addiction, are not included because at this time as there is insufficient peer-reviewed evidence to establish the diagnostic criteria and course descriptions needed to identify these behaviors as mental disorders.”

Acceptance in the APA diagnostic terminology of addictive disorders may well suggest that the word addiction has returned to acceptability in medicine; but that seems not to be the case at this stage, as DSM-5 clearly states (p. 485) that “the word addiction is not applied as a diagnostic term in this classification, although it is in common usage in many countries to describe severe problems related to compulsive and habitual use of substances.  The more neutral term substance use disorder is used to describe the wide range of the disorder, from a mild form to a severe state of chronically relapsing compulsive drug taking.  Some clinicians will choose to use the word addiction to describe more extreme presentations, but the word is omitted from the official DSM-5 substance use disorder diagnostic terminology because of its uncertain definition and its potentially negative connotation” (American Psychiatric Association, 2013).

In conclusion, the concept denoted by the word addiction has a history as long as mankind. However, society continues to struggle with the paradox that another human can be engaged in out-of-control and self-destructive behavior without being insane and also what to call this condition despite its acceptance as a brain disorder for some time (Leshner, 1997). This conundrum makes it unacceptable to some to call a well-characterized disorder by its original name and hence, a more acceptable terminology may be needed (Botticelli & Koh, 2016) in order to assuage our guilt for not treating these patients without prejudice, simply as humans suffering from an all too common condition.

 

REFERENCES:

 

American Psychiatric Association (1980). American Psychatric Association: Diagnostic and Statistical Manual of Mental Disorders, Third Edition. Washington, DC.

American Psychiatric Association (2013). American Psychatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Washington, DC: American Psychiatric Association.

Botticelli, M. P. & Koh, H. K. (2016). Changing the language of addiction. JAMA, 316, 1361-1362.

Jaffe, J. H. (1975). Drug Addiction and Drug Abuse. In L.S.Goodman, A. Gilman, A. G. Gilman, & G. G. Koelle (Eds.), The Pharmacological Basis of Therapeutics Fifth ed.,  New York, NY: McMillan Publishing Co. Inc.

Kosten, T. R., Rounsaville, B. J., Babor, F., Spitzer, R. L., & Williams, J. B. (1987). Substance use disorders in DSM-III-R: evidence for the dependence syndrome across different psychoactive substances. British Journal Psychiatry, 151, 834-843.

Leshner, A. I. (1997). Addiction Is a Brain Disease, and It Matters. Science, 278, 45.

Martin, P. R., Weinberg, B. A., & Bealer, B. K. (2007). Healing Addiction: An Integrated Pharmacopsychosocial Approach to Treatment. Hoboken, New Jersey: John Wiley & Sons, Inc.

Nathan, P. E., Conrad, M., & Skinstad, A. H. (2016). History of the Concept of Addiction. Annual Review of Clinical Psychology, 12, 29-51.

OED Online (2016). "addiction, n.". http://www.oed.com/view/Entry/2179?redirectedFrom=addiction& [On-line].

Olds, J. (1958). Self-Stimulation of the Brain. Science, 127, 315.

World Health Organization (2016). International Classification of Diseases, Tenth Revision. http://www.who.int/classifications/icd/en/ [On-line].

 

Peter R. Martin

November 24, 2016