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The Definition of Alcohol
The Definition of Alcohol
Robert M. Morse, MD; Daniel K. Flavin, MD; for the Joint Committee of the National Council
on Alcoholism and Drug Dependence and the American Society of Addiction Medicine
to Study the Definition and Criteria for the Diagnosis of Alcoholism
To establish a more precise use of the term alcoholism, a 23-member multidis- and failed to recognize the spectrum of
ciplinary committee of the National Council on Alcoholism and Drug Dependence biopsychosocial factors that influence the
and the American Society of Addiction Medicine conducted a 2-year study of the development of alcoholism and its man¬
definition of alcoholism in the light of current concepts. The goals of the com- ifestations.
mittee were to create by consensus a revised definition that is (1) scientifically The Diagnostic and Statistical Man¬
ual of Mental Disorders, Third Edition,
valid, (2) clinically useful, and (3) understandable by the general public. There- Revised9 (DSM-III-R) of the American
fore, the committee agreed to define alcoholism as a primary, chronic disease Psychiatric Association and the Inter¬
with genetic, psychosocial, and environmental factors influencing its develop- national Classification of Diseases
ment and manifestations. The disease is often progressive and fatal. It is char- Ninth Revision (ICD-9)10 of the World
acterized by impaired control over drinking, preoccupation with the drug alco- Health Organization have emphasized
hol, use of alcohol despite adverse consequences, and distortions in thinking, the concept of "alcohol dependence," in¬
most notably denial. Each of these symptoms may be continuous or periodic. troduced in 1976 by Edwards and Gross11
(JAMA. 1992;268:1012-1014) as "alcohol dependence syndrome,"
rather than the term alcoholism. At the
time, Edwards and Gross11 noted that
IN 1972, the National Council on Alco¬ Our knowledge in this area has not the diagnostic use of the term alcohol¬
holism (NCA, now called the National remained static, however, and many ism, as then defined, was overinclusive
Council on Alcoholism and Drug Depen¬ strides have been made toward under¬ and dependent on the mercurial, value-
dence) published its seminal article en¬ standing alcoholism since the creation laden concept of disease. Alcohol depen¬
titled "Criteria for the Diagnosis of Al¬ of the National Institute on Alcohol dence syndrome is based on the more
coholism."1 This was followed in 1976 by Abuse and Alcoholism in 1970. Some of specific formulation that an occurrence
the "Definition of Alcoholism,"2 prepared us have even become impatient for de¬ of a clinical phenomenon distinct from
by the Committee on Definitions of the finitive answers to questions about the (but not mutually exclusive of) alcohol-
National Council on Alcoholism and the causes of and cures for alcoholism. There¬ related disabilities (and consequences
American Medical Society on Alcohol¬ fore, we must be reminded by Gordis3 of or both) is recognizable and quantifi¬
ism (now called the American Society of the "discovery curve." From basic re¬ able. The alcohol dependence syndrome,
Addiction Medicine). This definition em¬ search to clinical practice, the natural as described by Edwards and Gross, is
phasized the progressive nature of al¬ course of scientific discovery is a pro¬ characterized by narrowing ofthe drink¬
coholism, the physical sequelae of alco¬ gressive and time-consuming process. ing repertoire, salience of drink-seeking
hol use, and the phenomena of tolerance One insight gradually leads to another behavior, increased tolerance, repeated
and withdrawal: "Alcoholism is a chronic, so that, with thoughtful direction and withdrawal symptoms, relief and avoid¬
progressive, and potentially fatal dis¬ steady support, progress continues. ance of withdrawal symptoms, subjec¬
ease. It is characterized by tolerance Thus, important contributions, such as tive awareness of a compulsion to drink,
and physical dependency or pathologic the strong evidence for neurogenetic and reinstatement (of drinking) after ab¬
organ changes, or both—all the direct mechanisms in alcoholism4·5 or the mod¬ stinence. Both the DSM-III-R9 and the
or indirect consequences of the alcohol ulation of alcohol intake by neurotrans- proposed 10th revision of the Interna¬
ingested." The authors of this definition mitter (serotonin) inhibitors,6·7 have yet tional Classification of Diseases1*
also clarified and defined several con¬ to pay off in terms of clinical usefulness. include, in addition to alcohol dependence
cepts, including use ofthe terms chronic In addition to research advances, con¬ syndrome, criteria referring to persis¬
and progressive, tolerance, physical de¬ tinuing efforts to develop a uniform, re¬ tent drinking despite adverse conse¬
pendency, and patlwlogic organ changes. liable classification system have led to a quences (or "problems," as in DSM-
modification of terms and to clarifica¬ III-R).
A complete list of the participants in this project ap- tions of concepts used to describe alcohol- Despite this diagnostic use of the term
pears at the end of this article. related problems and alcoholism.8 In this alcohol dependence, the term alcohol¬
Reprint requests to National Council Alcoholism
on
and Drug Dependence, 12 W 21st St, New York, NY context, the 1976 definition emphasized ism continues to be widely used among
10010 (Dr Flavin). the physiologic sequelae of alcohol use professionals and the general public