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Keywords:

  • Addictions;
  • alcohol dependence syndrome;
  • DSM;
  • interdisciplinary research

Griffith Edwards has provided us with a timely reminder of the ways in which our ideas on the nature of, prophylaxis for, and interventions in alcohol-related problems and disorders have been influenced by the predominant political and medical philosophies of each era over the past two centuries [1]. Edwards' piece is timely, because we are again on the verge of a new formulation (DSM-V) that will serve either as a ‘stimulus to enquiry’[2], or as an intellectual straitjacket that hampers the essential interdisciplinary research that would advance our understanding of the multiple influences and pathways into and out of alcohol-related consequences. It is rumored that one innovation coming from DSM-V will be to create a whole new set of categories called ‘behavioral’ addictions to shopping, sex, food, video games and the internet [3]. This should serve to expand the reach of American psychiatry, as well as the scope of the grant portfolio of the National Institute on Drug Addiction (which may require another name change); but it ignores the importance of individual differences with profound public health significance.

In a cri-de-coeur, Nancy Andreasen (the distinguished schizophrenia research psychiatrist) has described a number of unintended consequences of DSM [4]. In the alcohol field, the failure of DSM III–IV to differentiate issues of severity of dependence or of alcohol problems [5] has resulted in the same diagnosis of alcohol dependence in clinical and community populations that cannot explain the different outcomes associated with a return to drinking in these two groups [6,7], or the implications of a moderate drinking outcome in a clinical trial of an experimental or established therapy. Going back to DSM-III, the diagnostic system created by American psychiatry has resulted in a clinical research literature that emphasizes rather than clarifies the comorbidity construct regarding addictive and psychiatric disorders. It has failed to address cultural differences that shape different manifestations of the disorder, and it has inhibited the development of research linkages between animal models and clinical phenomenology. While the creators of DSM-IV considered and rejected a dimensional approach, even though it would ‘increase reliability and communicate more clinical information’ than categorical approaches [8], a dimensional approach in DSM-V that lumps addiction severity across a group of heterogeneous drug- and non-drug-related conditions will not address satisfactorily the problems stemming from DSM-III–DSM-IV.

Andreasen expressed the hope that clinical research on schizophrenia might, some day, be rescued by serious patient-oriented researchers in Europe [9]. She was not optimistic about her colleagues in America. Edwards has highlighted in his paper how American influence has led to a number of wrong pathways, and he expresses the hope that the World Health Organization (WHO) might be helpful. Having participated in discussions convened by WHO in the 1980s, and having witnessed the political influence that can divert its processes, I am less optimistic than Edwards. Looking over the field as I have observed it over the past 40 years (and focusing upon people no longer active so as not to offend anyone by exclusion) I have been most impressed by the contributions of outstanding non-psychiatrists such as Ting Kai Li, Floyd Bloom, Ivan Diamond, Harold Kalant, Harold Holder, Henri Begleiter, Charles Lieber and others, as well as thoughtful psychiatrists such as Jack Mendelson, George Vaillant, Benjamin Kissin, Jerome Jaffe, Abraham Wikler, Arnold Ludwig and Griffith Edwards, who could think outside the box that American psychiatry had created of the addiction field. In the early days of my career American psychiatry was dominated by psychoanalysis, and alcohol-related disorders were lumped with personality disorders. The subsequent iterations of the DSM of the American Psychiatric Association moved the boxes around into categories, but the advances in understanding came from those who worked outside those boxes. If the field of alcohol research is to be saved from another midcourse deflection, it will be necessary for interdisciplinary research organizations to shape an alternative and more relevant paradigm born of the scientific contributions of neuroscientists, geneticists, behavioral scientists, social scientists and serious clinical investigators. The alcohol dependence syndrome crafted as a ‘stimulus to enquiry’ by Professor Edwards and Professor Milton Gross [10] was turned into meaningless categories spanning all addictive disorders in DSM-IIIR–IV. The separate dimensions of alcohol-related problems and dependence severity were never really addressed or incorporated. As I have written elsewhere, the importance of the Edwards & Gross model was its simplicity and relevance to interdisciplinary research [5]. That should be the goal that we should all be striving for, and especially to embrace a view of ‘drink’ that will advance the health of the public.

References

  1. Top of page
  2. Declaration of interest
  3. References
  • 1
    Edwards G. The trouble with drink: why ideas matter. Addiction 2010; 105: 797804.
  • 2
    Edwards G. The alcohol dependence syndrome: a concept as stimulus to enquiry. Br J Addict 1986; 81: 17183.
  • 3
    Francis A. A warning sign on the road to DSM-V: beware of its unintended consequences. Psychiatr Times 2009; XXVI #8: 1, 4–6, 8–10.
  • 4
    Andreasen N. C. DSM and the death of phenomenology in America: an example of unintended consequences. Schizophr Bull 2007; 33: 10812.
  • 5
    Meyer R. E. Finding paradigms for the future of alcoholism research: an interdisciplinary perspective. Alcoholism 2001; 25: 1393406.
  • 6
    Caetano R. The identification of alcohol dependence criteria in the general population. Addiction 1999; 94: 3667.
  • 7
    Helzer J. E., Bucholz K. Five communities in the United States: results from the epidemiological catchment area study. In: HelzerJ. E., CaninoG. J., editors. Alcoholism in North America, Europe and Asia. Oxford: Oxford University Press; 1992, p. 7195.
  • 8
    American Psychiatric Association Committee on Nomenclature and Statistics. Diagnostic and Statistical Manual of Mental Disorders (DSM IV). Introduction.Washington, DC: American Psychiatric Association; 1994, p. xvxxv.
  • 9
    Andreasen N. C. The changing concepts of schizophrenia and the ahistorical fallacy. Am J Psychiatry 1994; 151: 14057.
  • 10
    Edwards G., Gross M. M. Alcohol dependence: provisional description of a clinical syndrome. Br J Med 1: 105861.