Wednesday, 28.10.2020

Peter R. Martin: Historical Vocabulary of Addiction



         The noun alcoholism was formed within the English language by derivation from a combination of the noun, alcohol with the suffix, -ism (Oxford English Dictionary, 2012b).  The most relevant of the many historical meanings of the noun alcohol is: “a colourless volatile flammable liquid which is naturally produced in aqueous solution by the fermentation of sugars, and which is the intoxicating constituent of drinks such as beer, wine, and spirits (in which it is concentrated by distillation) (Oxford English Dictionary, 2012a).”  The meaning or use of the suffix -ism is designated as: “Forming a term denoting a peculiarity or characteristic… (Oxford English Dictionary, 1989b).” Hence, the original definition of alcoholism was: “consumption of alcohol (ethanol), [especially] when excessive and producing drunkenness or illness; acute or chronic intoxication from alcohol.”  In later use, the meaning was modified to: “the condition of being dependent upon or addicted to alcohol, and unable to limit its consumption to a level which does not produce deleterious physical, mental, or social effects (Oxford English Dictionary, 2012b)”. 

         Considerably before the Swedish physician Magnus Huss first employed scientific Latin to coin the term alcoholismus (1849) for “a diseased condition produced by consumption of alcohol”, the adverse consequences of alcohol had been described.  According to a quote attributed to Lucius Annaeus Seneca, the Roman statesman and philosopher (circa 4 BC - 65 AD), chronic alcohol intoxication was considered a form of insanity: “Drunkenness is nothing but voluntary madness.”  Beginning in the 18th century, physicians depicted the characteristic medical challenges associated with drunkenness and the acute and chronic complications of drinking alcohol (Rush, Thomas, & Andrews, 1790; Trotter, 1804; Woodward, 1838). In literature, the term alcoholism had been used in a non-medical sense, e.g., in his ode to Temperance, First & Last Days of Alcohol the Great John Cowen (1848), wrote: “I lost my work by getting Drunk, And loafing round, and all that.” p.  221; and also, “He came out a decided foe to all Alcoholism”, vii. 42). Ultimately, within a few years after Huss, most languages had incorporated an equivalent and easily recognizable term for alcoholism, e.g., the Swedish alkoholism, German Alkoholismus, and French alcoolisme.   However, the dynamic tension between considering alcoholism a pathological condition under the purview of medicine or a construct reflecting troubles of man within society have remained to the present day (Chaudron & Wilkinson, 1988).

         Even after introduction of the term alcoholism in the scientific/medical literature uptake of its use was not immediate.  The noun inebriety, defined as: “The state or habit of being inebriated; drunkenness, intoxication, inebriation; now chiefly applied to habitual drunkenness, especially when regarded as a disease”, seems to have been the more popular of the two terms, even though their meanings were interchangeable (Arena March 452, 1893:  “Inebriety is a disease of the nervous system, just like epilepsy, chorea, or insanity”) (Oxford English Dictionary, 1989a).  The Quarterly Journal of Inebriety (1876-1914) was published by the American Association for the Study and Cure of Inebriety, formed in 1870 to improve practice at residential treatment institutions.  Its sole editor for 38 years was T.D. Crothers, superintendent at the Walnut Hill Asylum in Hartford, Connecticut and a leading advocate of the medical treatment of inebriety until his death in 1918. The central principle advocated in the journal was the disease concept of inebriety with a commitment to medical knowledge to be used by physicians in the medical treatment of this disorder (Weiner & White, 2007).  The two competing terms were actually combined in the title of an important book of the era Alcoholic inebriety (Kerr, 1894).  Importantly, Kerr states in the preface of the first edition of his book: “The present volume has been written in the hope that it may aid, however feebly, through the medium of the attending practitioner, who I trust will be among my readers, in the enlightenment of the patient, his sorely-tried relatives, and the community, in the great truth that Inebriety is a disease, as curable as most other diseases, calling for medical, mental and moral treatment.” This phrase strongly supports a significant role for the treating physician in healing those suffering from alcoholism. 

         After the Second World War, the World Health Organization (1955) undertook to define alcoholism and to classify it as a medical condition.  In short order, the American Medical Association (AMA) House of Delegates declared (1956, p. 32): “All excessive users of alcohol are not diagnosed as alcoholics, but all alcoholics are excessive users. When, in addition to this excessive use, there are certain signs and symptoms of behavioral, personality and physical disorder or of their development, the syndrome of alcoholism is achieved.” Despite such circumlocution of what it was to be alcoholic, the conclusion of the AMA declaration was unequivocal: “…alcoholism must be regarded as within the purview of medical practice. The Council on Mental Health, its Committee on Alcoholism, and the profession in general recognizes this syndrome of alcoholism as illness which justifiably should have the attention of physicians (American Medical Association, 1956, p. 32).”  Considering alcoholism as a medical illness is still not universal due to the stigma associated with addiction, namely a belief that the affected person brings his suffering upon himself and is the one primarily at fault (Martin, 2016).  This conundrum has not been fully resolved despite major advances in neuroscience that support the status of addiction as a bone fide brain disorder (Leshner, 1997).

         The AMA declaration implied that some drinkers can safely drink alcohol whereas others cannot and only those who developed complications actually have the illness.  Explicating why there might be such differences in sensitivity to drinking alcohol required elucidation of at least two important research issues.  The first concerned understanding hereditary risk for developing alcoholism, a natural application of the rapidly burgeoning genetic revolution in medicine (Begleiter, Porjesz, Bihari, & Kissin, 1984; Omenn & Motulsky, 1972).  The second emerged when it became apparent that much better characterizations of alcoholic phenotype(s) were required beyond the seminal work of Jellinek (1960) in order to understand the genetic underpinnings of the disorder and ultimately its pharmacological treatment (Cloninger, 1987; Lesch et al., 1990).  

         A major advance in conceptualizing the essential underpinnings of alcoholic phenotypes was description of the dependence syndrome by Edwards and Gross (1976), applicable to all drugs of abuse, including alcohol dependence.  The alcohol dependence syndrome, as articulated, is characterized by narrowing of the drinking repertoire, salience of drink-seeking behavior, increased tolerance, repeated withdrawal symptoms, relief and avoidance of withdrawal symptoms, subjective awareness of a compulsion to drink, and reinstatement (of drinking) after abstinence (Edwards & Gross, 1976).  This conceptualization of the dependence syndrome became the diagnostic essence of what was previously known as alcoholism and by the end of the 20th century the official term became alcohol dependence as promulgated by both the World Health Organization in the International Classification of Diseases (1978) and subsequently the American Psychiatric Association Diagnostic and Statistical Manual (1987).  Of note, behavioral characteristics had come to be required for diagnosis of alcohol dependence rather than toxic injury by alcohol to organs of the body which characterized earlier conceptualizations of the disease of alcoholism.  Finally, the accepted term for alcoholism became alcohol use disorder as specified in the most recent version (DSM-5) of the American Psychiatric Association nomenclature (2013).  Nevertheless, the noun alcoholism is an acceptable term, interchangeably used with both alcohol dependence and alcohol use disorder, for what is widely considered a mental illness, commonly associated with diverse medical complications due to the toxicity of alcohol consumption and associated lifestyle.



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June 27, 2019