Historical reflections on the concept of alcoholism: abuse and dependency, November 29, 1990

Moderator: University of Iowa. History of medicine society. November 29, 1990. This evening's speaker is Peter Nathan, PHD, Vice President for Academic Affairs and Dean of Faculties of the University of Iowa. Dr. Nathan's topics this evening is historical reflections on the concept of alcoholism, abuse, and dependency. Speaker #1: I was pleased to hear Susan say this is still a society with no dues because I was beginning to wonder if that's what I signed up for when I came in the room. I'll just get [inaudible 00:00:49] letter. I think we probably don't take note of it often enough in the college of medicine, but I would like to take this opportunity to emphasize the history of medicine society and the activities and it's sponsors are a very important educational program for it. I'm very pleased to have Susan here to see these activities becoming even more prominent and it's nice to see that she's able to attract a wide spectrum of people. I hope that will continue. Because the history of medicine society is important to us, it's a particular pleasure tonight to have Vice President Peter Nathan here to sort have the informateur of central administration for this activity. Peter has told me that he prefers brief introductions as I do and so I will try to honor that request, buy you should know a little bit something about him. After receiving a lawyer's degree at Harvard, he received the doctoral degree in clinical psychology from Washington University. Then did all of the requisite internships and research associateship and went on to the faculty and psychology at Rucker's University in 1969. He served a number of functions there including being director of the Alcohol Behavioral Research Laboratory and director of the Alcohol Studies program and he was at Ruckers until I believe 1986 when right before coming to the University of Iowa or perhaps I should say being rued to the University of Iowa. He was a health program officer at the MacArthur Foundation. With that, I think I'll stop and let Peter tell you of his accomplishments for himself. He has a long history in the area of substance abuse, particularly as it portrays to behavior aspects, so Vice President Nathan. Peter Nathan: I'm delighted to be with you. And these are my notes, it's not the newspaper. I'm delighted that there is such an active history of medicine program here. What I want to do tonight is to share with you kind of a social history conceptional history, and then diagnostic or history true diagnosis of concepts of alcohol abuse and dependents. It's very interesting, one of my interests has been in examining the ways in which clinicians have utilized the diagnostic process to characterize disorders. One of the best ways, I think to understand how society views a particular disorder is to look at the changes in the way in which it has been diagnosed over the years. The basis for the diagnosis, the criteria, the disorders with which it is generally lumped as time goes on. I think it makes for a fascinating historical overview of in this particular case, alcohol abuse and dependence. So I'm gonna do that, and I'm also going to share with you some of the current conceptions and current thinking on the diagnosis of these conditions, because we're really in the midst of the latest revolution in thinking about alcoholism reflecting data, which is actually rather new in terms of this disorder. For the most part, conceptions, diagnostic, and therapeutic have been relatively free from incumbencies from empirical research. And recently, there have been sufficient numbers of pretty good empirical papers that we're now beginning to characterize both diagnostically and therapeutically of what we know the function in the search. That's interesting, too. I am on a five person work group to revise the nomenclature one more time. There is a task force working very hard now to create DSM four, which is the diagnostic and statistical manual of mental disorders. The latest was published in 1987 DSM3R, before that was DSM3 in 1980. And this latest edition will both reflect our current views of ideology and the social significance and the prospects of treatment of alcoholism and will reflect as I say the recent edition of data to our understanding of the disorder. But let me go way back in history to begin and remind you that alcohol abuse has certainly been a part of human history for virtually as long as it has existed. We have no reason to believe that the fermented product of fruits and grains was not a part of our common history before history began to be written. The old testament goes quite a long ways, at least so far as recorded history is concerned. Describes many of the diagnostic features of alcoholism including physical and psychological dependence, alcohol induced memory problems, and some times fatal consequences of withdraw. The authors of the old testament severely criticize people who lack the moral strength to resist the temptation to drink and in this way anticipate more modern critics of the temptation to drink. May of who continue to view alcoholism as a moral issue even today. We also know that chronic alcohol abusers were stoned to death in the time of the old testament, marginally again to their moral weakness. We know that during the middle ages, along with psychotics and organic brain disorder patients, retardants and others, who were unable to function adequately in society. We know that they were considered to be possessed by demons, and they were consequently tortured and burned at the stake in order to be exercised the demon, which led them to drink without any ability to restrain their drinking. Again, through much of our history alcohol has been viewed in very much the same way the community has viewed others who deserve or receive our moral indignation because they are not able to conform to the usual rules of society. We also know that when they were not burned, that alcoholics, especially those with chronic brain disorders brought on by chronic alcohol abuse and therefore people who were not able to function independently, residents of arms houses, or residents of prisons where with psychotic patients, they spent most of their lives. It's really been only in the past several decades of this century that we have begun to develop a more lightened view of alcoholism. I think that enlightened view coincided with enlightenment as far as other psychiatric disorders are concerned, as far as many physical disorders with behavioral consequences are concerned. A portion of this enlightenment I will describe when I talk about the changes, the progressive changes in the way in which diagnostic criteria for alcohol abuse and dependents as well. But I want to add to that part of the presentation by coming [inaudible 00:10:17] on some other influences on the changes in which we view alcoholism. On the dramatic increase in the state of knowledge about both ideology and treatment, something that has happened only in the last two and a half decades are other influences that I think are important to an understanding of the change and our views about alcoholics and alcoholism. In 1935, two recovering alcoholics Bill W and Dr. Bob, storied founders of Alcoholics Anonymous established a self help group Alcoholics Anonymous, and that group has had, I think, an enormous impact on the stigmatization of alcoholism probably no less than the impact of the research that we've been able to do in the last two or three decades. What Alcoholics Anonymous has done is to convince gradually, slowly, not without great difficulty, but to convince that society that alcoholics are not a special class of person, not a group of people who lack a moral commitment, which the rest of us share, not entirely composed of skid row degenerates, but you and me and everyone and many others we know, work with, have gone to school with. The fact that AA has been able to convey to us that alcoholics are basically not different from everyone else, I think that's been very important. Important too has been that AA, the fellowship of AA has been able to offer the promise of a successful outcome for treatment. A promise that really didn't exist three or four decades ago. Now AA is hardly the only successful approach to treatment available to alcoholic. There are a variety of approaches. My judgment, Alcoholics Anonymous is the treatment of choice for some persons who suffer from alcoholism and not appropriate for others. I would say the same of the range of treatment options available. That's not the topic of my conversation with you tonight. Surprising to say that the last four decades have seen a dramatic change in the way that we view this disorder, which I could probably have been responsible for much pain and misery between the ages as any other single addiction. It continues to be one of the nation's leading public health problems. It continues to be conflict, probably some of our population and in that way effect indirectly about a third of our population. Of this group tonight, probably more than a third of you either have experienced alcoholism yourselves, lived with someone who's had the problem, have a parent or a child who has the problem, you know it's impact. You and your family, there's no question that it has been and continues to be an enormous problem for all of us. Let me turn to the interaction of modern diagnostic science in some sense with a social history of alcoholism, try to fit it into the spec of social history with the developing knowledge of alcoholism through the last, in this case, three decades. Those of you who know about the history of psychiatric diagnosis and there are certainly some of you who do, know that it was not until the mid thirties that a diagnostic system that represented a consensus and made a mission across the country was first developed. Before that time, in this country and in the rest of the world, each institution had its own psychiatric nomenclature. So, as a result it was almost impossible for people to communicate across institutions about the patients for whom they had responsibility. A patient left one institution and went to another, they went home and then went to another institution, had to be diagnosed innovo upon entering the institution. In the mid thirties, a group of state hospital superintendents got to together and created in a space of two or three years a nomenclature, which they were then able to use to permit them to compare and contrast their patient population with those of other institutions, finally for the first time that there were in fact regional differences in the numbers of schizophrenics. At that time, many of them were called, they labeled them as depressive patients. At that time in the mid thirties many of the beds were full with patients who were suffering from tertiary neurosyphilis, general paresis. Probably in the early thirties, more than half of the state hospital beds in fact, were filled with general [inaudible 00:16:52]. The problem with this diagnostic nomenclature is that it only captured the behaviors of those patients who were in stay hospital generally being psychotics, schizophrenics, manic depressives, organic brain disordered patients of a variety of kinds from the chief of whom were general paralytics, but there were lots of other chronic brain disorders, some of them [inaudible 00:17:18] patients who had become unable to remain out in society because of treatment for their disorder insulin coma therapy, orally shock therapy, other kinds of sematic treatments that basically have left psychosurgery, basically left them unable to function independently. It took the second World War for physiatry in this country to recognize that there were a large number of psychiatric patients who were not psychotic who during the second World War were labeled as victims of battle fatigue. Many of these patients were what Aroid had labeled as neurotics, others like we now label as PTSD, post traumatic stress disorder, a variety of the less malignant, somewhat more benign disorders, panic reactions, mild to moderate depression, mild to moderate anxiety disorders, some of the depersonalization disorders, and then the personality disorders. All of which had been basically ignored by the nomenclature of the thirties. And yet it was clear that these disorders had to be characterized. It took the second World War where many, many basically healthy young men and women under the stress of combat or the stress simply of being in the service showed a variety of symptoms that were clearly not psychotics, but were at the same time from one degree or another disabled. The extent and reach and severity of alcoholism, primarily is alcoholism, I think was probably first recognized by mental health depressions at the time though obviously our love, hate relationship with alcohol in this country goes back to the founding of this country and the discovery of America. It's interesting that in 1850, just as a side line, the capital consumption of alcohol in this country was roughly doubled what is now, and that's a lot of alcohol. I think it's about four gallons per person per year of grain neutral spirits. It's hard to know how in the world they consume so much and still were able to conquer the frontier. But that's what happened, and we assume that most children probably didn't consume that much, that means there was an awful lot of drinking. So we're actually in pretty good shape compared to 1850 in this country. After the war, recognition of the range of disorders that were not psychotic disorders but were nonetheless, disabling and honestly troublesome to society. Three distinct groups of clinicians got together. These were veterans of administration, physicians war department physicians, and state hospital superintendents and an emerging group of private practicing psychiatrists. And they began in 1946 to try to develop a nomenclature. The result was the publication in 1952 of the first edition of the Diagnostic and Statistical Manual of Mental Disorders. That history is to enable me to place into the DSM manuals, alcoholism, and drug dependency. In 1952, the first edition of the Diagnostic and Statistical Manual, did categorize alcoholism and drug dependence in a very interesting way that reflected a very long history of morally judgment making about alcoholics. Both alcoholism and drug dependence appeared in DSM1 as subsets of something called sociopathic personality disturbance. Now, if you're not a psychiatrist or psychologist, I don't think you need to be to get a sense of the moral distributional that is associated with sociopathic personality ... I think I'd rather be schizophrenic. Now, what was included in sociopathic personality disturbance was alcoholism, drug dependence, antisocial behavior, and the sexual deviations including homosexuality. Okay, you got a sense of what that meant. DSM2, which was published 16 years later in 1968, categorized all four syndromes the same way. They were all species or varieties of sociopathic personality disturbance. The implication of this placement of these divisions, I think is pretty clear, persons who exhibited any of the four and often they exhibited two or three of the four. Alcoholism is a disorder that is quite prevalent among persons who are homosexual and alcoholism is very, very commonly associated with another diagnosis and social personality disorders. So these things go together, and they in those days merited a great deal of condemnation on moral grounds. Now, I think it's important to put this whole thing in context into theoretical context. In 1952, and to a lesser extent in 1968, the prevailing views on the ideology of most psychiatric disorders, and I think it could be said that could be said of schizophrenia, and the manic depressive psychosis as well as other non psychotic disorders, was that environmental factors and psychodynamic factors were primarily responsible for the development of these disorders. I remember when I was a graduate student, sort of between 1952 and 1968. Most people thought that schizophrenia was an environmentally determined disorder. If you'll remember, the phrase schizophrenia genetic mother. This was a very, very popular phrase of the time and basically a mother whose behavior that was so disturbing and disturbed that she was capable in another self of creating schizophrenia in her child. The mother of the most common theories was the theory of double bond. It's different than double blonde, those of you who ... Well, clinical trials next month, no? Its very different. Double bind is a form of social intercourse between mother and child where the mother makes a statement and then in her behavior makes it impossible for the child to respond to the statement. The common one was the mother who sees her adolescent on a visiting day at a mental hospital, and he approaches her to give her a hug, and she shrinks away because she says, "You haven't clearly haven't taken a shower today." And then about a minute, and a half later she says, "But don't you love me, Tyler?" And this was again, crazy making kind of behavior. And this was characteristically not simply of schizophrenia, which I think most clinicians nowadays will acknowledge is seen as almost certainly a central nervous system disfunction of considerable magnitude involving abrupt and neuro transmission and probably most people would say the same manic depressive psychosis. And nowadays most people would say that alcoholism has at least a genetic component. So I think the move has been as more and more research has accumulated on ... As we've learned more about the central nervous system disfunction and neurodealgia, it's become clear that many of the disorders, which as recently as 30 to 35 years ago were considered environmentally determined, learned, or a product of imperfect, abnormal early childhood, but many of these disorders now are pretty much widely accepted as neuro biological disorders. Well, one has to view the treatment of alcoholism and drug dependency DSM1 in 1952 and DSM2 in 1968, I think in that light. Now, granted, if a disorder is environmentally determined or if it's caused by a schizophrenic genetic mother or if it is acquired or learned, that doesn't necessarily mean that one chooses to adopt that set of behavior patterns, but it's obviously more ... It's easier to make the conceptual leap between this environment causes this behavior, you remain in this environment, you choose not to leave this environment, therefore you bear some responsibility for this disorder than it would be if you agree that the disorder is a disorder of neurotransmission about which there seems to be ... I think most of us would agree, less opportunity for choice. I think the way in which alcoholism is drug dependence or characterized in DSM1 and DSM2, simply reflected what was known and what was inferred and what was believed about the ideology of these conditions as recently as 30 years ago. I mean, it really is extraordinary when you think about it that we believed, not simply about these disorders, but about most of the disorders in the Diagnostic and Statistical Manual that they are caused by imperfect child luring trauma during the early years or choice. Now, DSM3, which was published in 1980 marked the first rather dramatic moving away from this moral stance about a voluntary decision to become and remain alcoholic. In the first place, it removed alcoholism and drug dependence from this sociopathic personality disturbance category and for that matter, it removed the sexual deviations, put them in their own sector diagnostic grouping. Renamed them. Did not call them sexual deviations any more, called them paraphilias, which is a presumably less stigmatizing label, until it gets to be stigmatizing and then it'll have to be called something else. But what it also did was, it removed homosexuality and sharply reduced that portion of homosexuality that would continue to be considered a psychiatric disorder, forgotten the phrase, but basically homosexuals who were unhappy with their sexual identity were considered to merit a diagnosis that homosexuals who were not unhappy, were well adjusted were no longer to be considered psychiatric patients, and they don't appear in DSM3. So again, there was a general de stigmatization across a whole range of disorders in DSM3 and that included alcoholism and drug dependence. This change certainly reflected the enormously productive research programs in the 1970's funded almost entirely by the federal government and the national institute on alcohol abuse and alcoholism was founded in 1967 and by 1970, it was supporting the bulk of the research on alcoholism and much of that research focused on ideology. It supported the ground breaking studies in the early and middle seventies, the adopted out children of alcoholics, which indicated strongly that having a biological parent who was alcoholic was far more influential in determining your own risk of alcoholism than living in an alcoholic cavern. These were studies done in Sweden and in Denmark with large numbers of alcoholics and non alcoholics, some of whom had alcoholic biological parents, some of whom did not, some of whom had alcoholic adoptive parents, some of whom did not, and that research, I think, made quite clear that alcoholism is at least a part of some individuals a genetically transmitted disorder. But having a parent, especially a male parent with a male child, having a male parent whose alcoholic rather remarkably increase the risk of one's subsequent development of alcoholism. Now, we turn to DSM3's treatment of alcoholism. Another very interesting feature of the DSM's is that DSM3 was widely regarded as representing an empirical breakthrough. DSM1 and DSM2 had been created by clinicians basically sitting in arm chairs talking among themselves about their experiences in the clinic and agreeing ultimately among themselves on those categories of disorder that made most sense to them. DSM3 was really the first psychiatric nomenclature to call on some purical research using much more sophisticated statistical techniques to cluster science and symptoms to enable more rational look at syndromes. That having been said, it's interesting that when the drafters of DSM3 got around to creating the nomenclature for what had come to be called the substance use disorders, including alcoholism and the other drug dependencies, they failed to rely on empirical data because there hadn't been an awful lot of that kind. Most of the research on these disorders, especially on alcoholism had focused on ideology in the seventies, not nearly as much on phenomenology. Much more research on phenomenology had focused on schizophrenia, the bipolar effective disorders, which is what now is the phrase for manic depressive psychosis and the other non psychosis. But what the drafters then did was to create a distinction, a diagnostic distinction between alcohol abuse and alcohol dependence. This was and continues to be a very common distinction drawn by clinicians. Generally clinicians who work with alcoholics conceptualize three groups of people: social drinkers, some of whom are perilously close to the margin and could at any time join the ranks of problem drinkers, but social drinkers, alcohol abusers and alcoholics or alcohol dependent persons. That's the common clinical lure and that's what most clinicians, even now, that's the way in which they conceptualize the use of alcohol. Almost no research has ever established that abuse and dependence regardless of how they're conceptualized have differential predictive utility or validity. And yet, the drafters of DSM3, chose to draw this distinction. This was the first time this distinction had been drawn in a nomenclature having to do with alcoholism, and it was notable and has really had an important impact on the field. Substance abuse in DSM3 was defined as including three characteristics. A pattern of pathological use, that's the fist characteristic. The second is that continues for at least a month. And the third is it causes impairment in social or occupational functioning. And persons who meet those three criteria merit the DSM3 merit diagnosis of alcohol abuse. Now, the pattern of pathological alcohol use such things as needing ... The need for daily use of alcohol for adequate functioning, inability to cut down or stop drinking, repeated efforts to control or reduce excess drinking by going on the wagon, occasional consumption of spirits or it's equivalent in wine or beer, and so on. Certainly consumption that is beyond the pale for social drinkers. The one month criteria is an interesting one. That derives from absolutely no data, and it could have been two weeks or three months, but it's just the person who did this part of the nomenclature thought a month was about right and that's why it's in there. Alcohol dependence in DSM3 is diagnosed as follows: if a person meets the criteria for alcohol abuse, that is pathological pattern abuse for one month, and it impairs social or occupational function, and the person shows either tolerance or withdraw symptoms, the person meets the criteria for alcohol dependence. Now, the distinction that is drawn here really for the first time is a distinction between a social dependence and a physiological dependence and this I think is also important. It's probably reflects in a [inaudible 00:38:31] early way, the research that began in the seventies, and it's accelerated in the eighties, again, that suggests that alcoholism contrary to our prevailing view through history may well be a disorder of physiology and biology, every bit as much as it is a transgression of society's moral precepts. And this distinction between abuse, which is largely social, that is drinking so much that you can't function at work, and you can't function at home, and you can't function with your friends, that's abuse. That's more benign than the physiological, which includes abuse but is characterized really by changes in the body, tolerance and or the presence of withdrawal symptoms. Now DSM3 despite the fact that it really didn't utilize the results in empirical research as had much of the rest of DSM3, the rest of the nomenclature called pretty extensively on data. Nonetheless, these conceptualizations of alcoholism and drug dependence have been very, very influential. The distinction between abuse and dependence was a useful one for clinicians. The de stigmatization was awfully important. It accorded with many legal precedents in the seventies that concluded that public drunkenness was no longer a crime. That prescribed treatment rather than jail for people who were chronic offenders, that really emphasized, in many cases, for the first time, the importance of treatment rather than punishment for people who were addicted to alcohol or drugs. None the less, DSM3 was criticized pretty severely for a variety of reasons. Interestingly, one of the most telling criticisms was that the DSM3 conceptualization of alcoholism and alcohol abuse and dependence was a theoretical. Now, that's interesting because one of the majors aims of the drafters of DSM3 was to reoccurred eliminate the overwhelming impact of psychoanalytic theory on the nomenclature in DSM1 and DSM2. So much of DSM1 and DSM2 was influenced by psychoanalytic theory. The drafters of DSM3 who were empirical scientists, rather than theoreticians of clinicians wanted to do away with the impact of theory on diagnosis and therefore, created to the extent that they could a theoretical system. And here were critics of the substance abuse categories who were saying that this was an inadequate nomenclature because there was no theoretical instruction. It was simply an empirical [inaudible 00:42:03]. It really wasn't empirical, but it looked like it was quite empirical, and it was sort of dust bowl and [inaudible 00:42:09], no real theory to permit one to understand the way in which symptoms cohere. Critics also criticized the emphasis on tolerance. Tolerance is not as it turns out such an easy symptom to detect. Patients ... It very depends very much on the drug of abuse. People who abuse heroin or arbitraments develop tolerance very, very quickly. And the degree of tolerance can be dramatic. Alcohol as it turns out is a drug that with some persons, requires a great deal of work to develop an addiction and tolerance, and therefore, the use of tolerance, the reliance on tolerance in DSM2 for the diagnosis of dependence is a problem and was a problem for many of the critics of DSM2. And the additional problem, which isn't so important for my session here tonight, is that there are lots of differences across drugs in criteria for abuse dependence, the drafters of DSM3 developed an over arching categorization system that they felt ought to be applicable to every drug of abuse, alcohol through all of the other paths of drugs of abuse. And yet, in 1980, there was great uncertainty whether a category of tobacco abuse, or caffeine abuse, or amphetamine dependence or even cocaine dependence actually existed. Now I think we would agree there is something called a cocaine dependence, something called an amphetamine dependence, something called an amphetamine withdrawal, but at the time it wasn't so clear that those entities existed, and the nomenclature was criticized for that reason. Well, we have then a nomenclature in 1980 that reflected society's interest in de stigmatizing alcoholism and removing the moral judgments that had been a part of the diagnosis of alcoholism for millennia, for substituting empiricism and data to the extent that it existed in developing a nomenclature and in making a distinction between social addiction and physiological addiction. All of which really coincided with the state of knowledge at the time, and the prevailing move of citizenry of this country as it had to do with alcohol and drugs. Now in 1987, a revision of the DSM was published. This in itself is kind of an interesting funny story. DSM3 was truly a revolutionary document in many, many ways. It's a document of about four times as many pages as either DSM1 or DSM2. It includes diagnostic criteria of far greater specificity than either of the two predecessor documents included. It permitted a formal reliable diagnosis of most disorders and for that reason more useful and more valid diagnosis. None the less, in 1987 a revision of this document appeared. It was kind of a fine tuning the drafters of this revision said. It really didn't change anything very much, but some changes had to be authored to the professions in view of the knowledge that had accumulated in the seven years between the publication of DSM3 and DSM3R. And it is true that for virtually for every other syndrome the changes were extremely modest, basically didn't change the concept of the disorder except so far as the substance abuse disorders. In the case of alcoholism and drug dependence, a radical change in nomenclature happened. The change was very [inaudible 00:47:06] in my field, alcoholism and drug dependence than in anybody else's field. Why did this happen? What changes in society's views of alcoholism and drug dependence were responsible? I think it was people like Mr. Bennett. I think it was the administration in Washington and its view of drug dependence. I think it was a return in some sense to a more judgemental and a more punitive attitude toward those people who were abusing alcohol and drugs. Now, obviously it was directed toward those drug addicts that were causing all of us so much trouble. The homeless on the streets of New York, the cartels in Columbia, on and on and on. And yet, the impact on the diagnosis of alcoholism was just as marked. What happened was that all of a sudden, the nomenclature, the concept underlying diagnosis of the substance use disorders became theoretical again. There was an underlying theory that was adopted that was not psychodynamic, but it was nonetheless intensely theoretical, that it was a concept. It pulled things together and it was based on relatively little data. This was the concept of the substance dependence syndrome. This is a legitimist, most interesting and original piece of work, first offered by Griffith Edwards, a very distinguished English psychiatrist, editor of the British Journal of Addictions, who observed correctly that basing diagnosis of alcoholism on outcomes creates enormous unreliability. That is the impact of alcohol and drugs on different people differs enormously. Some people at relatively low doses of the drug show very pronounced behaviors, some of them approaching the dimensions of psychosis. Others, show no effects at all. Some emphasize one set of behaviors, consequences of ingested drugs, others emphasize others. It's not really possible then to diagnose reliably when the basis for diagnosis is the effects of the drug on the individual. And this basically was most of the criteria included in DSM3. Pathological pattern agrees with parament social and occupational functioning in the wide, tolerance and withdrawal, but the alcohol dependent syndrome as it was originally termed, emphasized the precursors and the coexisting features of abuse and dependence. For example, let me just summarize a few of the features of this alcohol or substance dependence syndrome. The individual narrows his or her pattern of use of the drug. It becomes stereotyped, it becomes incorporated into one's daily schedule and it becomes a continuous and overwhelmingly feature of one's life. The purchase of the drug, the acquisition of money to purchase the drug become more ... And then consumption of the drug become more important to the individual in his or her life than anything else in life and things that ... Despite the fact that often either acquiring the drug or using the drug or recovering from the drug were associated with very negative consequences. Most everything else in the person's life becomes secondary to getting, using, and recovering from alcohol or the drugs. Th tolerance and withdrawal are also part of this syndrome. The person also uses the substance to avoid withdrawal. A very common use to which addicts put their drugs. They feel a subjectively experience compulsion to use the substance. Now, really most of these are really descriptive of the individual's loss of control over the drug. And in the emphasis of loss of control, I should say in the use to which the drafters of DSM3 are put the concept, which focused on loss of control. They reintroduced, whether they meant to or not, a more moral dimension to the diagnosis. Those people who lose control are weak. There is a moral lapse. They ought to be able to control this behavior. They're not controlling it. There's a compulsion, which they're not able to address. The consequence, I think has been in the minds of many clinicians, a return in DSM3R to some of the moral judge mentalism characteristic of earlier versions of the DSM and really a return to the prevailing view of these disorders that has characterized our species for millennium. Now, as I say, I think probably the drafters certainly, Edwards and probably the drafters of DSM3R, didn't really mean for this to happen, but I think the whole complex of concern over drugs, the impact of drugs on crime, and on the moral decay of our cities has impacted, interacted with DSM3R to create this sort of new, old view of the substance abuse disorders as in larger part voluntary that I think most researchers would now allow and now agree to. Now, DSM4, in which I am now engaged with four other colleagues, is trying to find a middle ground. Interesting, a middle ground between DSM3, the de stigmatization of DSM3 that was unfortunately based on virtually data and the new moral judgments associated with DSM3R that were based on at least Griffith Edwards rather extensive data and basically a good idea because it is clear that judging, categorizing diagnosing from precursors and coexisting feature yields a more reliable diagnosis than diagnosing on the consequences of the ingestion of drugs, given the variability in everyone's response to drugs. So there is some good in the DSM3 conceptualization, some good in the DSM3R conceptualization, meanwhile, more research is accumulated making even more certain the likely hood that a good number, a good high percentage of persons who experience alcohol dependence have a predisposition to the development of that disorder that is genetically returning. A variety of other research that is coming closer to understanding the neuro biological mechanisms of that transmission. There is even a group that is beginning to look at the human genome for the alcohol genes. I don't think they're gonna find an alcohol gene or even ten or a hundred, but I think there's lots of genes, which contribute to the development of this disorder. I think I'd like to stop now and respond to questions. I don't have a watch on, I have no idea how long ... Speaker #1: You have a clock ... Peter Nathan: I have a clock. It's 8:27. I began at 7:30. Okay, so that's about right. But let me respond to questions about anything I might have said or anything else that you might want to talk about. Yes. Speaker #2: It's common the clinical physician type of perception in many centers around the country that drug dependence is a very high incidence indeed of [inaudible 00:57:10]. Would you like to comment on how this might be approached in the new manual? Peter Nathan: Well, one of the criticisms, it's a very, very good and most interesting point, one of the criticisms about DSM3 and DSM3R is the failure of the nomenclature to take into account comorbidity. Obviously, depression is very, very common, even more common is the comorbid condition of antisocial personality disorder. Another very, very common comorbid condition is anxiety disorder. Our group actually did a view of literature to determine whether a sub category of alcohol and drug dependence with and without depression or with and without other comorbid conditions would yield differential outcomes. Interestingly it didn't. There didn't seem to be any difference in ... For example, percent alcoholic parents of patients with and without depression, alcoholic patients with and without depression didn't seem to be enormous difference in outcomes between the two groups of patients. It is interesting that more than almost any other disorder in the DSM, alcoholism is associated with psychiatric chromaticity. As you, I'm sure know, a lot of research attention has been paid to the question of whether depression and sort of a chicken and egg problem. Does depression most often occur prior to the development of alcoholism and in that way play a role into the ideology or does the alcoholism proceed the depression and play a role in the development of depression. I think most people nowadays believe that the alcoholism is more often the initial clinical phenomenon that a good deal of the depression may well be a function of the pharmacologic impact of the drug, alcohol and that probably takes a good year for the person to metabolize all the alcohol and actually return to a base line state when the person's preexisting level of depression resets. All of this is to say you're right, it's a big problem. Nobody is sure of the diagnostic relationship and nobody is really sure of the ideological significance of this very common comorbidity. Yes? Speaker #3: About a hundred years ago, Charles Woolson who was a Harvard trained MD, published a book, Secret [inaudible 01:00:21] Medicine. And if it wasn't so tragic, it would be humorous to read the book. He describes various systems where each chemical to create a version of alcohol. It was about a hundred years ago. It has a medical model that comes up with any way of dealing with alcohol that are more effective. Peter Nathan: Well, it's interesting there have been in recent times a variety of chemical aversion treatment techniques by which individuals would be given morphine, other nausea inducing drugs and then given alcohol to drink timed in such a way that the ingestion of alcohol would coincide with the [inaudible 01:01:05] nausea and vomiting. In fact, additional versions did develop, however, certain small percentage of patients died during the treatment from a variety of associated events, and basically aversion therapy hasn't worked out very well. My judgements at this time, we don't have an effective treatment for alcoholism. That is to say that most treatments regardless of what they are, yield about the same outcome there. Those outcome measures turn out to be far more function of what the patient brings to treatment than what the treatment ... If the patient is motivated, has a job, has a family, wants to change his or her behavior and there are reasons to change it, with virtually any treatment in which he or she becomes involved, about 50 percent of those people will be abstinent at the end of the year, 50 percent. That means about 50 percent will be drinking again, but with another group of patients, people that don't have a job, really lost a family, who have their current physical illness, who don't really want to change, with them the data in here is about some 25 percent of them will be sober. So we have outcome figures of between 25 and 50 percent. Not very encouraging. There are no effective treatments, that is treatments that can reliably yield regardless of who the patient is and what he or she brings to treatment, reliably yield positive outcomes EG sobriety after a year of seven to five years. Just hasn't happened yet. I don't tell this to most people, just good friends and colleagues. So I'm not in ...