In 1956, the American Medical Association declared alcoholism a “disease.” More than half a century later, the American Society of Addiction Medicine (ASAM) has proclaimed addiction, including alcoholism and “process” addictions like gambling, to be the same.
According to the ASAM’s definition, published on the group’s website on Monday, addiction is a “primary, chronic disease of brain reward, motivation, memory and related circuitry.” This clarification, which was based on consultations with more than 80 experts, is aimed in part at de-stigmatizing addictive disorders.
That’s an admirable goal. The scientific evidence shows that addiction is rooted in distinct brain changes, just like other mental illnesses such as depression (though in both instances, the same changes are not found in all people with the conditions). The research does clearly show that evidence-based treatment is far more effective at resolving drug abuse problems than law enforcement efforts like incarceration. There’s no justification for treating people with addiction any differently than other patients.
But if you want to reduce stigma, calling something a brain disease may not be the best way to go. Studies that have looked at this question have found that labeling a disorder as “neurobiological” tends to have either no effect on stigma or actually increases it.
For example, a 2010 study published in the American Journal of Psychiatry examined the levels of stigma associated with alcohol dependence, schizophrenia and major depression. In 1996 and again in 2006, researchers surveyed 630 participants about their views on alcoholism. While the percentage of people who said they believed alcoholism was a brain disorder increased from 38% to 47%, that shift was not linked with a decrease in stigma. In fact, over the same time period, the percentage of people who said they thought alcoholism was linked with “bad character” also increased significantly, from 49% to 65%.
Similarly, psychologist Steven Hayes of the University of Nevada found that people’s implicit associations with the word “disease” were as negative as those linked with “drunk” or “intoxicated.” The problem may be that people think of “brain diseases” as fixed and unchangeable; they may also view people whose brains are damaged as potentially dangerously out of control. Genetic explanations of mental illness, which are similarly associated with the perception that the condition is permanent, have also been linked with increased stigma.
The inclusion of the word “chronic” in the ASAM definition doesn’t help here. Although addiction is indeed chronic in some cases, this is not always the case. Research shows that the majority of people who receive a diagnosis of addiction or alcoholism actually recover without treatment or participation in self-help groups. In a 2005 study involving 4,442 people with alcoholism who were not in treatment, researchers found that one year after their initial interview, a full 75% had improved to the point where they were no longer considered to be actively alcoholic.
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Eighteen percent had quit drinking entirely, while another 18% had become low-risk drinkers; 12% were drinking at levels that were considered asymptomatic but potentially risky, and another 27% had cut down but not entirely eliminated their drinking problem. Only a quarter of the sample had gotten any type of outside help, including 12-step meetings.
Longer term studies of multiple types of addiction show similar trends: far more people meet the criteria for addiction in their youth and later recover than ever attend self-help groups or get treatment. Many simply “age out” of the problem and never look back.
Another problem with the ASAM definition is its description of the disorder’s “characteristic bio-psycho-socio-spiritual manifestations.” Addiction clearly involves problems with neurobiology, psychology and social connections, similar to other mental illnesses. But spirituality?
According to ASAM, the “spiritual” manifestations of addiction include “distortions in the connection with … the transcendent (referred to as God by many, the Higher Power by 12-steps groups, or higher consciousness by others).”
When trying to convince doctors and the general public that a condition is a genuine disease, I would argue that it’s probably best to leave God out of it. Definitions of cancer, diabetes, depression and schizophrenia manage just fine without intruding on territory better left to priests, rabbis, imams, ministers and the like.
Like depression, addiction is a real medical disorder that affects the brain. But if we want to reduce the stigma associated with it, emphasizing recovery and resilience is probably more useful than focusing on definitions of brain disease.
To increase the use of effective and non-stigmatizing care, let’s stick to the empirical evidence, not the ineffable.