Is Alcohol Addiction Usefully Called a Disease?

Gabriel Segal presents a defense of the disease concept of alcoholism against criticisms, including some of those by Ian Robertson and me (Heather and Robertson 1997). There is much to admire in this defense and much to agree with. I agree with Segal that some of the alternatives to the disease model that have been offered under the banner of ‘choice models’ of addiction (e.g., Davies 1997; Heyman 2009) fail to confront the baffling nature of addictive behavior or the fact that it is sometimes continued in the face of truly devastating consequences. Regarding the ‘two extreme pictures’ of alcohol addiction Segal sketches in his concluding section—the one where it is simply a matter of bad choices and the other where it is the result of absolutely irresistible urges—we both find ourselves in the middle ground. But that still leaves plenty of room for differences between us and disagreement in particular about one main issue, namely, whether alcoholism or problem drinking (Segal uses these terms interchangeably) is best viewed as a disease.

Segal’s own model of alcoholism as a disease is highly idiosyncratic and would surely be disavowed by most proponents of a disease perspective on alcoholism, including, one suspects, the great majority of affiliates of the fellowship of Alcoholics Anonymous (AA). He strips away from the disease concept almost all the features that have previously been seen as essential to it. Thus, for Segal, it is no longer necessary that problem drinking is chronic, irreversible, or progressive; and alcoholics are not physically dependent on alcohol, can recover without treatment or a recovery program, and can be held legally or morally responsible for their drinking and its consequences. Perhaps most surprisingly, in view of his enthusiasm for Robinson and Berridge’s (1993) incentive sensitization theory of addiction, alcoholism is not a brain disease. (Since the rise of neuroscience, the idea that addiction, including alcohol addiction, is a disease of the brain has been the most powerful, influential, and research-based version of the disease perspective and the incentive sensitization theory is one of the leading expressions of that idea.) The main point here, however, is that, having given up most of the requirements that previous theorists have seen as being entailed in regarding alcoholism a disease and having thereby conceded most of the key arguments of its opponents, one wonders what is meaningfully left and why Segal continues to believe that problem drinking is a disease rather than join those see the limitations of this belief.

One conventional property of a disease that remains in Segal’s account is that alcoholism is allor-none; although among those having the disease it comes in degrees, you either have alcoholism or you do not. This is indeed one of the key points dividing supporters and opponents of the disease concept of alcoholism. In this case, however, Segal’s adherence to the discrete nature of the condition leads him into difficulties. We are told that there exists a large group of heavy drinkers who may drink more than a mild alcoholic, but who are not themselves alcoholics. This is because they do not show what, for Segal, are the key symptoms of the disease of alcoholism: craving, preoccupation with alcohol, and impaired control over drinking, symptoms that can range in severity from mild to severe. The difficulty here is that it is easy to show that these ‘symptoms’ exist on continua throughout the population of regular and heavy drinkers; almost all such individuals would obtain positive scores, for example, on measures of alcohol dependence that assess degrees of desire for and preoccupation with alcohol (e.g., Raistrick et al. 1994) or measures of impaired control over drinking (Heather, Booth and Luce 1998), even those who show no obvious alcohol-related problems. (Ironically, Segal refers to the latter instrument to support his view that impaired control is specific to those suffering from the disease of alcoholism, whereas our recommendation to its users was that it was relevant to all regular drinkers.) To suggest that all...