Substance Abuse

   Before the middle of the nineteenth century, the main substance capable of being abused was alcohol. With the rise of such anesthetic gases as ether (first used medically in 1846), of injectable opiate narcotics (after the introduction of the hypodermic method for administering a drug by Alexander Wood [1817–1884] of Edinburgh in 1853), and with the advent of such psychoactive drugs as the barbiturates, the number of substances capable of abuse became legion. As Emil Kraepelin warned in the fifth edition of his textbook in 1896, "A psychic illness quite similar to alcoholism and still increasing with terrifying rapidity is addiction to morphine, as we have learned in recent decades. And with morphine as well we generally see the combined paralyzing and agitating effects of the poison on the brain" (p. 44). Thus, almost from the beginning, psychiatry recognized the concept of substance abuse. What has changed during the years, however, is the balance between the discipline’s assessment of personal dependency vs. social harm.

   Although there had been much medical writing on substance abuse before the Second World War, the contemporary narrative begins with the first edition of DSM in 1952, where "drug addiction" was an aspect of "sociopathic personality disturbance." No further detail was supplied.

   After a 1964 meeting of the Expert Committee on Addiction-Producing Drugs of the World Health Organization that recommended replacing "addiction" and "habituation" with the concept of "drug dependence," DSM-II in 1968 recognized "drug dependence"; there followed a long list of compounds, including Cannabis sativa (marihuana) and amphetamines, upon which one could become dependent. Alcohol and tobacco were exempted. To make a diagnosis of dependency, evidence was required of "habitual use or a clear sense of need for the drug." Withdrawal symptoms, it was stressed in the Manual were not the gold standard of the diagnosis, because "they may be entirely absent when cocaine or marihuana are withdrawn" (p. 45).

   DSM-III in 1980 introduced a quite different note: the concept of "substance use disorders." The emphasis was upon "behavioral changes" rather than dependency, upon putting the search for drugs high on one’s list of priorities to the disadvantage of other kinds of behavior. Thus, to qualify for a diagnosis of "substance abuse,"one would have to show (1) a pattern of "pathological use," as manifest in criminal behavior, car accidents, or drug-seeking behavior; and (2) "impairment in social or occupational functioning" caused by the abuse. Also recognized in the Manual was "substance dependence," a more pharmacological than social measure of a substance-use disorder, including tolerance (steadily increasing doses) and withdrawal symptoms. Alcohol and tobacco were no longer exempt. The brain consequences of addiction were considered in a section on "substance-induced organic mental disorders," variants of which continued in subsequent editions.

   DSM-III-R in 1987 changed relatively little in this, except to call the group of diagnoses "psychoactive substance use disorders." The distinction between behavior ("substance abuse") and dependency symptoms such as withdrawal was upheld, though a good deal of behavior such as organizing one’s day around drug-seeking was shifted into the dependency category.

   DSM-IV in 1994 called the relevant category "substance-related disorders," grouping the potential drugs of abuse into an ever-widening list that now had 11 categories.

   This edition put some starch into the abuse vs. dependence dichotomy—so strong in 1980—that DSM-III-R had muddied a bit: Dependence meant "a pattern of repeated self-administration that usually results in tolerance, withdrawal, and compulsive drug-taking behavior." Abuse meant behavioral issues resulting in trouble for the abuser or for society ("a maladaptive pattern of substance use"). This edition broke the discussion down into "dependence" (meaning continued use despite problems), "abuse" (social, legal problems), "intoxication" (brain effects), and "withdrawal." DSM-IV set a considerably lower threshold of what would be considered "abuse": Though DSM-III-R had insisted that one of two criteria should be met (continued use despite problems, or in dangerous situations), DSM-IV would accept one out of any four criteria in order to award the diagnosis. Basically, the kinds of problems one might have were split in the Manual into three separate categories, and it was said that significant issues in any one of these gives a patient the diagnosis.

   If there is a central trend in the meandering that psychiatry’s approach to substance abuse has taken during the years, it is an ever-growing impatience with compounds that people ingest for pleasure. Even though nicotine, alcohol, and the barbiturates are all substances capable of damaging their users—and the world about them—the level at which the whistle is blown is vastly lower in DSM-IV than in the days of Emil Kraepelin.

   (See also Alcoholism; National Institute of Mental Health.)