Alcoholism

   (See also Substance Abuse.)

   Since the beginning of modern times, medicine has considered alcoholism a disease rather than a moral failing. In the nineteenth century, with the advent of inexpensive, industrially distilled alcohol, alcoholism became a colossal social problem, filling the asylums with victims of alcoholic dementia and delirium. Emil Kraepelin, himself teetotal, in the fourth edition of his textbook (1893) rather puritanically classed alcoholism among the "poisonings," next to ergotism, and spoke of "misuse" rather than addiction. In his Outline of Psychiatry (Grundriss der Psychiatrie, 1900), Carl Wernicke (1848–1905), professor of psychiatry in Breslau, devoted an entire lecture to "alcoholic delirium," especially delirium tremens. (See Wernicke–Kleist–Leonhard Pathway.) For the pioneers of psychiatry, alcoholism was thus very much on the radar.

   In the late twentieth century, however, the medical emphasis in alcohol came to fall on its addictive rather than toxic qualities. In DSM-I (1952), the accent was mainly on poisoning: delirium, hallucinosis, and alcoholic dementia. Yet, a section on "alcoholism" was added to the Manual: "cases in which there is well established addiction to alcohol without recognizable underlying disorder" (p. 39). DSM-II (1968) enlarged the classification of "alcoholism" considerably, admitting not only "addiction," as before, but "episodic excessive drinking" and "habitual excessive drinking." The pathology thus lay in the pattern of consumption rather than in the brain consequences.

   Then, a sea change: DSM-III (1980) included the usual brain consequences of ethanolic intoxication yet added a concept going beyond "addiction" that permitted classifying alcoholism among all the other "substance use disorders." That word was "dependence." What the substance-use disorders had in common was the induction of dependence: "The essential features of Alcohol Dependence are either a pattern of pathological alcohol use or impairment in social or occupational functioning due to alcohol, and either tolerance or withdrawal" (p. 169). (One knew that one was dependent—as opposed to having brain toxicity—if one kept upping the dose to get the same effect [tolerance] or if one suffered "withdrawal" symptoms.) By DSM-III-R in 1987, "alcohol dependence" had become a "psychoactive" substance use disorder.

   DSM-IV (1994) further augmented the range of alcohol pathology, differentiating between the disorders that alcohol touched-off (ranging from brain toxicity to depression) and those inherent in its use: abuse and dependence. This massed array of pathology was in a sense neo-Kraepelinian, returning to the teetotal spirit of the founder of modern psychiatry.