The danger presented by alcoholism is widely recognized, but many people still overindulge. Now, the doctors charged with defining addiction may label many more of them as alcoholics.
The American Psychiatric Association is in the late stages of revising their influential rulebook: the Diagnostic and Statistical Manual. There are indications that the standards used to differentiate partying from actual addiction will be changed to the point where many college revelers, sports fans who imbibe, and weekend pub denizens will now have a medical diagnosis.
The new Diagnostic and Statistical Manual, or DSM, that is the rulebook used by doctors, will have "Alcohol Use Disorder" on a scale of severity of Mild, Moderate, and Severe. The Alcohol Use Disorder proposed redefinition is defined as a "problematic pattern of alcohol use leading to clinically significant impairment or distress." More specifically, patients are given this label if two or more problems occur during a one year, such as drinking "larger amounts or over a longer period than was intended," a "persistent desire or unsuccessful effort to cut down or control alcohol use," "use in situations in which it is physically hazardous," and similar criteria.
The severity ranking comes from the number of such specific problems that are present. Two or three would rank as "Mild Substance Use Disorder" while six or more would be listed as "Severe." Thus, two sessions of overindulgence in 2012, where you ended up having one drink too many, could very well be enough to get you classified as having a disorder.
Alcohol affects a bewildering variety of sites in the brain. Unlike, say, THC, the active ingredient in marijuana, which binds to a specific receptor, alcohol works its magic all over.
At some point in the past, our clever ancestors learned to harvest not only nutritious fauna, but also those that could be transformed through viticulture, distillation, and brewery into consciousness-altering beverages. Alcoholism is a never-ending feature of human life. Drinking makes people feel good and can inspire them, but people can naturally be prone to excess. Doctors wrestle over distinguishing between healthy drinkers and ones with a problem. The question is where to draw the line? Alcohol causes physiological, emotional, cognitive and behavioral problems. Cells wither if the dose is too high, but people can have compromised functioning without toxicity being an issue.
Alcohol can seem to worsen depression, contribute to serious lapses of judgment and worsen other problems such as diabetes and obesity. It is not exactly a secret that alcohol must be treated with respect by everyone, and that some should avoid it altogether. Yet doctors and laypersons alike are conflicted about defining the boundaries between healthy and dangerous partaking. A glass of wine with dinner seems moderate enough, but what about three with a multi-course meal that takes hours?
One middle-aged person might seem to be fine after the one day in a year they have many drinks on a Super Bowl Sunday at home, while another could have had fewer and made bad decisions nonetheless.
Complicating matters, there are different cultural norms for drinking. While being under the influence and operating heavy machinery is dangerous anywhere, doctors and medical anthropologists recognize the attitude toward drinking is not the same everywhere.
These differences pose challenges for doctors. A culture that creates a safe space around binge drinking after a wedding poses a different challenge for diagnosis than one for whom any use of alcohol is a sin or associated with underclass behavior and low social standing. Alcoholism is about physiological addiction for many, but also about the broader context in which people function more or less effectively in complex social worlds.
As a practical matter, physicians have to agree to make cut-off points and rules for defining disorders. Therefore, this new fifth volume of the DSM rulebook attempts to define those boundaries with some standardization but with room for flexibility. The current reworking of the defining criteria for what are medically problematic levels of drinking is only the latest attempt to draw the line between alcoholism and healthy drinking.
Are the new definitions too broad? Millions more Americans will be classified as having a disease if the proposed new rules are enacted in DSM-V next year. How much effect this will have on the problematic drinking that doctors are concerned about is of course unclear. Over time, social attitudes about norms shift, and public health campaigns try to change how people think about normal but unhealthy behavior. Smoking was considered normal and acceptable in professional and other settings in living memory, but the medical community has helped make it harder to do in public. An open question is whether the proposed new definitions of alcoholism are simply too broad to be embraced as sensible by the public. Doctors already face the problem of patients who rationalize behaviors such as sun tanning, risky sex, overindulgence in caffeinated beverages and much more. It may be that the proposed changes are enacted and then received with skepticism or apathy because the public does not accept having several drinks a night as medically serious.
After decades of activism by teetotalers and the Temperance movement, America had a brief experiment with Prohibition, an historically unusual development for a Western nation. The resilience of drinking in this country turned out to be robust indeed. The DSM may hold back from approving these changes for a variety of reasons, but may be aware it may that the public may not accept their new and improved definition of unhealthy drinking. Will the DSM press on regardless of entrenched attitudes and American love affair with booze? If so, can doctors and public health workers convince Americans to cut back on tippling, imbibing, swilling, and quaffing? You may already be an alcoholic...stay tuned.
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