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Brain disorder: does the new definition of addiction make sense?

Dominika Osmolska Psy.D.'s picture

The American Society of Addiction Medicine (ASAM) has changed the definition of “addiction.” Addiction, instead of being simply a disease, is now a "primary, chronic disease of brain reward, motivation, memory and related circuitry." While the new definition is far more exact in comparison to the old “disease,” many health care professionals and public health advocates are wondering whether the change may not be ill-advised.

The clarification, which was based on consultations with more than 80 experts, is aimed in part at de-stigmatizing addictive disorders. The question is, does it do the job?

Here’s a simple way to test the question: ask yourself whether calling an alcoholic afflicted with a “chronic brain disease of the reward system” changes your perspective in contrast to simply calling the individual as afflicted with a “disease” or even a “mental health disorder.” No? Not even a subtle difference?

As a mental health professional, I must admit to a bias. I do find the new definition far more intellectually satisfying, not to mention clear. After all, diseases run the gamut from amoebic dysentery to schizophrenia. Someone suffering with the former is said, even in common parlance, to have an intestinal parasitic disease, as opposed to a disease of the mind, and I like the verbal demarcation. This is not because I find schizophrenia more repugnant or more blameworthy, but simply more informative.

Studies that have looked at this question in the general population, however, 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, inexplicably, 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%, which may be a reflection of the changing sociopolitical values climate, if anything.

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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 the words "drunk" or "intoxicated." The problem with the term “brain disease” is that it carries a strong stamp of permanence, like “heart disease” or “Alzheimer’s disease.” Where the brain is concerned, however, people may also carry an irrational fear of it being “diseased” – meaning, for many, out of control or dangerous. Genetic, physiological or biological explanations for disease processes always seem to carry along a heavy stigma because they are perceived as incurable.

ASAM’s inclusion of the word “chronic” may even compound the problem, because it implies a long-term – indefinite, perhaps – duration. But it may surprise readers to know that the majority of people who receive a diagnosis of addiction or alcoholism actually recover without treatment or participation in self-help groups. For example, 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.

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.

Studies on other types of addiction bear out similar statistics. Although it is not always the case, many individuals mature “out” of addiction, to a greater or lesser extent.

The point is that addiction is not quite analogous to a disease such as that of a purely physiological system such as the cardiovascular. It is a problem of the inhibition of impulsive behavior, which is, to a large extent, a learned response. In other words, the ability to inhibit impulses is partially a habit of the nervous system. As such, it can be modified, in either direction, well into adulthood. The human brain can learn throughout its lifetime.

Some have also found the ASAM’s definition of addiction as a disorder with “bio-psycho-socio-spiritual manifestations" problematic. The inclusion of a transcendent factor, i.e., God, a Higher Power, or higher consciousness, bother some individuals with a strictly empirical, scientific bent. Aside from the awkwardness of the phrase “bio-psycho-socio-spiritual,” I do not find that inclusion objectionable. Addiction is, in fact, a yearning, albeit a misguided one, to forget oneself, either in a megalomanic frenzy of gambling and risk taking, or the soft cloud of narcotic fuzz.

Whichever route it takes, addiction is a sign that, though we may be broken “in body” (or brain, as ASAM would have it) we as yet have the inherent capacity to be mended. The fact that so many individuals find that mending in a mysterious process which is not and cannot be empirically validated speaks, perhaps, to that maligned transcendent reality.