Thursday, October 8, 2009

Not a Disease? Again?

Recently I heard a radio interview with yet another mental health professional who has determined the addiction (a term that includes alcoholism) is not precisely a disease, but rather a matter of choice. Of course, debates about the nature of alcoholism/addiction go back a very long time. For ages, many viewed it as a moral failing rather than a condition, and perhaps for that reason a number of approaches to eradicate it came from the church. Although I'm sure addiction had been defined in medical terms before in some quarters, a major turning point in this country came in the 1930's, with the concurrent work of Dr. Jellinek at Yale and the formation of AA, itself an offshoot of a religious movement but one which embraced the disease model of alcoholism.

It was and is, of course, obvious to anyone that alcoholism is not the same kind of disease as, say, chicken pox. There is no germ, no contagion. It has, on the other hand, often been likened to diabetes or heart disease; though the analogy is far from perfect, these are illnesses for which there is no cure per se, but for which one can live a generally healthy life by making lifestyle changes. The diabetic avoids sugar (to over-simplify). The cardiac patient, depending on condition, perhaps avoids fats, maintains an exercise regime, etc. The alcoholic/addict refrains from using addictive substances. That is, to be sure, a choice. But it is a very different kind of choice from most of the choices we make – for example, whether to purchase furs, whether to buy a foreign car, or that pressing choice between “paper or plastic” at the supermarket. Those choices involve thought, belief, and behavioral follow-through. Avoiding alcohol, for the alcoholic, is an exceedingly more difficult task. A big part of his or her brain is creating an urge to drink, as powerful an urge as others might feel to eat when deprived of food, and powerful enough that there is often the risk that it will override rational thought (which is the province of a different part of the brain) -- hence, the familiar relapse-enabling rationalizations that seem so foolish in hindsight, which often take the form of: "I can have just one or two drinks this time because [insert reason that defies logic and previous experience]." This is nothing like even a tough non-addictive choice, such as "I got into Harvard, but my gut says I'll be happier at U Mass."

There is, I think, fairly wide agreement now among scientists who study addictions on some points (and a good place to read comprehensible reports on some of the latest research is at the website for NIDA, the National Institute for Drug Abuse). These include:
- Alcoholism, and probably most addictions, run in families, and while culture and learning, and other social/psychological factors are important, genes are of crucial importance;
- On the whole, the brains of alcoholics/addicts (and, it now seems, people with other conditions involving mood, thought, and behavior) are a bit different from the brains of those without addictions;
- Some of these differences are probably built-in from birth, while others are probably acquired as a result of repeated, substantial alcohol/drug use.

None of this means that one is doomed to keep drinking or drugging, or that no choice is involved, and of course recognizing the consequences of substance use can provide an incentive to make a less frightening choice. In fact, choice is critical, and to take a stance of "well, I have a disease, so we'll see what happens" is not at all likely to lead torecovery. But it's nothing like the choice you made this morning about what to wear, or the choice you made in the voting booth.