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Addiction and the Concept of Disorder, Part 1: Why Addiction is a Medical Disorder

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A Letter to this article was published on 01 April 2017

Abstract

In this two-part analysis, I analyze Marc Lewis’s arguments against the brain-disease view of substance addiction and for a developmental-learning approach that demedicalizes addiction. I focus especially on the question of whether addiction is a medical disorder. Addiction is currently classified as a medical disorder in DSM-5 and ICD-10. It is further labeled a brain disease by NIDA, based on observed brain changes in addicts that are interpreted as brain damage. Lewis argues that the changes result instead from normal neuroplasticity and learning in response to the intense rewards provided by addictive substances, thus that addiction is not a brain disease and by implication not a medical disorder at all. I argue that even if one accepts Lewis’s reinterpretation of the brain evidence, his conclusions do not follow. Relying on my harmful-dysfunction analysis of medical disorder, I defend the view that substance addiction is in fact a medical disorder and a brain disorder. In Part 1, I identify five arguments Lewis puts forward against the brain-disease view and evaluate them as arguments that addiction is not a disorder: (1) Addiction is not a chronic, relapsing condition; (2) There is no clear boundary between addiction and other strong desires; (3) Negative consequences are not unique to disorders; (4) The brain disease model does not account for behavioral addictions; and, (5) Addiction is like love. I argue that Lewis’s arguments are invalid because they fail to take account of the context of addiction and its relation to biological design.

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References

  1. American Psychiatric Association. 2013. Diagnostic and statistical manual of mental disorders, fifth edition (DSM-5). Arlington: American Psychiatric Association.

    Book  Google Scholar 

  2. Wakefield, Jerome C. 2015. DSM-5 substance use disorder: how conceptual missteps weakened the foundations of the addictive disorders field. Acta Psychiatrica Scandinavica 132: 327–334.

    Article  Google Scholar 

  3. Wakefield, Jerome C. 2016. Diagnostic issues and controversies in DSM-5: return of the false positives problem. Annual Review of Clinical Psychology 12: 105–132.

    Article  Google Scholar 

  4. Klerman, Gerald. The evolution of a scientific nosology. In Schizophrenia: science and practice, ed. J. Shershow, 99–121. Cambridge: Harvard University Press.

  5. Hoff, Paul. 2015. The Kraepelinian tradition. Dialogues in Clinical Neuroscience 17: 31–41.

    Google Scholar 

  6. Leshner, Alan I. 1997. Addiction is a brain disease, and it matters. Science 278(5335): 45–47.

    Article  Google Scholar 

  7. Leshner, Alan I. 1999. Science-based views of drug addiction and its treatment. Journal of the American Medical Association (JAMA) 282: 1314–1316.

    Article  Google Scholar 

  8. Leshner, Alan I. 2001. Addiction is a brain disease. Issues in Science and Technology 17(3; spring 2001): 75–80.

    Google Scholar 

  9. Volkow, Nora D., and T.K. Li. 2004. Drug addiction: the neurobiology of behavior gone awry. Nature Reviews Neuroscience 5: 963–970.

    Article  Google Scholar 

  10. Volkow, Nora. 2010. Drugs, brains and behavior: the science of addiction. National Institute of drug abuse NIH pub 10–5607. Bethesda: National Institutes of Health.

    Google Scholar 

  11. Volkow, Nora D., George F. Koob, and A. Thomas McLellan. 2016. Neurobiologic advances from the brain disease model of addiction. New England Journal of Medicine 374: 363–371.

    Article  Google Scholar 

  12. Goldstein, R.Z., and Nora D. Volkow. 2011. Dysfunction of the prefrontal cortex in addiction: neuroimaging findings and clinical implications. Nature Reviews Neuroscience 12: 652–669.

    Article  Google Scholar 

  13. McLellan, A.T., D.C. Lewis, Charles P. O'Brien, and H.D. Kleber. 2000. Drug dependence, a chronic medical illness. Journal of the American Medical Association (JAMA) 284: 1689–1695.

    Article  Google Scholar 

  14. Koob, George F., and Nora D. Volkow. 2010. Neurocircuitry of addiction. Neuropsychopharmacology 35: 217–238.

    Article  Google Scholar 

  15. Koob, George F., and M. Le Moal. 1997. Drug abuse: hedonic homeostatic dysregulation. Science 278: 52–58.

    Article  Google Scholar 

  16. Ainslie, George. 1992. Picoeconomics: the strategic interaction of successive motivational states within the person. Cambridge: Cambridge University Press.

    Google Scholar 

  17. Alexander, Bruce K. 2016. Replacing the official view of addiction. In To fix or to heal: patient care, public health, and the limits of biomedicine, ed. Joseph E. Davis and Ana M. Gonzalez, 208–239. New York: NYU Press.

    Google Scholar 

  18. Becker, Gary S., and K.M. Murphy. 1988. A theory of rational addiction. Journal of Political Economy 96: 675–700.

    Article  Google Scholar 

  19. Courtwright, David T. 2010. The NIDA brain disease paradigm: history, resistance and spinoffs. BioSocieties 5: 137–147.

    Article  Google Scholar 

  20. Hall, Wayne, Adrian Carter, and Cynthia Forlini. 2015. The brain disease model of addiction: is it supported by the evidence and has it delivered on its promises? Lancet Psychiatry 2: 105–110.

    Article  Google Scholar 

  21. Levy, Neil. 2006. Autonomy and addiction. Canadian Journal of Philosophy 36: 427–447.

    Article  Google Scholar 

  22. Levy, Neil. 2011. Addiction and compulsion. In A companion to the philosophy of action, ed. T. O’Connor and C. Sandis, 267–273. Oxford: Blackwell.

    Google Scholar 

  23. Rachlin, Howard. 2007. In what sense are addicts irrational? Drug and Alcohol Dependence 90(Suppl): S92–S99.

    Article  Google Scholar 

  24. Pickard, Hanna. 2012. The purpose in chronic addiction. American Journal of Bioethics Neuroscience 3: 30–39.

    Google Scholar 

  25. Pickard, Hanna. 2013. Responsibility without blame: philosophical reflections on clinical practice. In Oxford handbook of philosophy and psychiatry, ed. K.W.M. Fulford, Martin Davies, Richard Gipps, George Graham, John Sadler, Giovanni Stanghellini, and Tim Thornton, 1134–1152. Cambridge: Cambridge University Press.

    Google Scholar 

  26. Pickard, Hanna. 2016. Denial in addiction. Mind & Language 31: 277–299.

    Article  Google Scholar 

  27. Pickard, Hanna, and Serge Ahmed. 2016. How do you know you have a drug problem? The role of knowledge of negative consequences in explaining drug choice in humans and rats. In Addiction and choice: rethinking the relationship, ed. N. Heather and G. Segal. Oxford: Oxford University Press.

    Google Scholar 

  28. Sinnott-Armstrong, W., and Hanna Pickard. 2013. What is addiction? In Oxford handbook of philosophy and psychiatry, ed. K.W.M. Fulford, Martin Davies, Richard Gipps, George Graham, John Sadler, Giovanni Stanghellini, and Tim Thornton, 851–864. Cambridge: Cambridge University Press.

    Google Scholar 

  29. Satel, Sally, and Scott O. Lilienfeld. 2014. Addiction and the brain-disease fallacy. Frontiers of Psychiatry 4: 141. doi:10.3389/fpsyt.2013.00141.

    Article  Google Scholar 

  30. World Health Organization. 1992. The ICD-10 classification of mental and behavioral disorders: clinical descriptions and diagnostic guidelines. Geneva: World Health Organization.

    Google Scholar 

  31. Lewis, Marc. 2017. Addiction and the brain: development, not disease. Neuroethics, this issue.

  32. Lewis, Marc. 2015. The biology of desire: why addiction is not a disease. New York: Public Affairs.

    Google Scholar 

  33. Lewis, Marc. 2012. Why addiction is NOT a brain disease. PLOS Blog. http://blogs.plos.org/mindthebrain/2012/11/12/why-addiction-is-not-a-brain-disease/. Accessed 21 Oct 2016.

  34. Davey, Melissa. 2015. Marc Lewis: the neuroscientist who believes addiction is not a disease. Theguardian.com. https://www.theguardian.com/culture/2015/aug/30/marc-lewis-the-neuroscientist-who-believes-addiction-is-not-a-disease. Accessed 19 Oct 2016.

  35. Wakefield, Jerome C. 1992. The concept of mental disorder: on the boundary between biological facts and social values. American Psychologist 47: 373–388.

    Article  Google Scholar 

  36. Wakefield, Jerome C. 1992. Disorder as harmful dysfunction: a conceptual critique of DSM-III-R’s definition of mental disorder. Psychological Review 99: 232–247.

    Article  Google Scholar 

  37. Wakefield, Jerome C. 1993. Limits of operationalization: a critique of Spitzer and Endicott’s (1978) proposed operational criteria for mental disorder. Journal of Abnormal Psychology 102: 160–172.

    Article  Google Scholar 

  38. Wakefield, Jerome C. 1999. Evolutionary versus prototype analyses of the concept of disorder. Journal of Abnormal Psychology 108: 374–399.

    Article  Google Scholar 

  39. Wakefield, Jerome C. 1999. Disorder as a black box essentialist concept. Journal of Abnormal Psychology 108: 465–472.

    Article  Google Scholar 

  40. Wakefield, Jerome C. 2000. Spandrels, vestigial organs, and such: reply to murphy and Woolfolk’s “the harmful dysfunction analysis of mental disorder”. Philosophy, Psychiatry, and Psychology 7: 253–270.

    Google Scholar 

  41. Wakefield, Jerome C. 2000. Aristotle as sociobiologist: the ‘function of a human being’ argument, black box essentialism, and the concept of mental disorder. Philosophy, Psychiatry, and Psychology 7: 17–44.

    Google Scholar 

  42. Wakefield, Jerome C. 2006. The concept of mental disorder: diagnostic implications of the harmful dysfunction analysis. World Psychiatry 6: 149–156.

    Google Scholar 

  43. Wakefield, Jerome C., and Michael B. First. 2003. Clarifying the distinction between disorder and non-disorder: confronting the overdiagnosis (“false positives”) problem in DSM-V. In Advancing DSM: dilemmas in psychiatric diagnosis, ed. Katharine A. Phillips, Michael B. First, and Harold A. Pincus, 23–56. Washington: American Psychiatric Press.

    Google Scholar 

  44. Wakefield, Jerome C. 1995. Dysfunction as a value-free concept: reply to Sadler and Agich. Philosophy, Psychiatry, and Psychology 2: 233–246.

    Google Scholar 

  45. Wakefield, Jerome C. 2003. Dysfunction as a factual component of disorder: reply to Houts, part 2. Behavior Research and Therapy 41: 969–990.

    Article  Google Scholar 

  46. Wakefield, Jerome C. 2014. The biostatistical theory versus the harmful dysfunction analysis, part 1: is part-dysfunction sufficient for medical disorder? Journal of Medicine and Philosophy 39: 648–682.

    Article  Google Scholar 

  47. Levy, Neil. 2013. Addiction is not a brain disease (and it matters). Frontiers of Psychiatry 4: 24. doi:10.3389/fpsyt.2013.00024.

    Google Scholar 

  48. Ullman, L.P., and L. Krasner. 1975. A psychological approach to abnormal behavior. second ed. Englewood Cliffs: Prentice-Hall Inc..

    Google Scholar 

  49. Castel, Pierre-Henri. 2014. A new history of ourselves, in the shadow of our obsessions and compulsions. Philosophy, Psychiatry, & Psychology 21: 299–309.

    Article  Google Scholar 

  50. Wakefield, Jerome C. 2014. Social construction, biological design, and mental disorder. Philosophy, Psychiatry, & Psychology 21: 349–355.

    Article  Google Scholar 

  51. Wakefield, Jerome C. 2009. Mental disorder and moral responsibility: disorders of personhood as harmful dysfunctions, with special reference to alcoholism. Philosophy, Psychiatry and Psychology 16: 91–99.

    Article  Google Scholar 

  52. Wakefield, Jerome C. 2013. Addiction, the concept of disorder, and pathways to harm: comment on levy. Frontiers in Psychiatry 4: 34. doi:10.3389/fpsyt.2013.00034.

    Article  Google Scholar 

  53. Hyman, Steven E. 2010. The diagnosis of mental disorders: the problem of reification. Annual Review of Clinical Psychology 6: 155–179.

    Article  Google Scholar 

  54. Wakefield, Jerome C. 1998. The DSM's theory-neutral nosology is scientifically progressive: response to Follette and Houts. Journal of Consulting and Clinical Psychology 66: 846–852.

    Article  Google Scholar 

  55. Wakefield, Jerome C. 1999. Philosophy of science and the progressiveness of the DSM's theory-neutral nosology: response to Follette and Houts, part 1. Behavior Research and Therapy 37: 963–999.

    Article  Google Scholar 

  56. Nesse, Randolph M., and Kent C. Berridge. 1997. Psychoactive drug use in evolutionary perspective. Science 278(5335): 63–66.

    Article  Google Scholar 

  57. Campbell, E.J.M., J.G. Scadding, and R.S. Roberts. 1979. The concept of disease. British Medical Journal 2: 757–762.

    Article  Google Scholar 

  58. Wakefield, Jerome C. 2007. What makes a mental disorder mental? Philosophy, Psychiatry, and Psychology 13: 123–131.

    Article  Google Scholar 

  59. Illich, Ivan. 1976. Medical nemesis. New York: Pantheon.

  60. Jellinek, Elvin M. 1946. Phases in the drinking history of alcoholics: analysis of a survey conducted by the official organ of alcoholics anonymous. Quarterly Journal of Studies on Alcohol 7: 1–88.

    Article  Google Scholar 

  61. Jellenik, Elvin M. 1952. Phases of alcohol addiction. Quarterly Journal of Studies on Alcohol 13: 673–684.

    Article  Google Scholar 

  62. Alcoholics Anonymous. 1939. Alcoholics anonymous. New York: Alcoholics Anonymous World Services, Inc..

    Google Scholar 

  63. Alcoholics Anonymous. 1952. Twelve steps and twelve traditions. New York: Alcoholics Anonymous World Services Inc..

    Google Scholar 

  64. Biernacki, P. 1986. Pathways from heroin addiction: recovery without treatment. Philadelphia: Temple University Press.

    Google Scholar 

  65. Robins, Lee N. 1993. Vietnam veterans’ rapid recovery from heroin addiction: a fluke or normal expectation? Addiction 188: 1041–1054.

    Article  Google Scholar 

  66. Heyman, Gene M. 2009. Addiction: a disorder of choice. Cambridge: Harvard University Press.

    Google Scholar 

  67. Heyman, Gene M. 2013. Quitting drugs: quantitative and qualitative features. Annual Review of Clinical Psychology 9: 29–59.

    Article  Google Scholar 

  68. Waldorf, D. 1983. Natural recovery from opiate addiction: some social psychological processes of untreated recovery. Journal of Drug Issues 13: 237–279.

    Article  Google Scholar 

  69. Waldorf, D., C. Reinarmen, and S. Murphy. 1991. Cocaine changes: the experience of using and quitting. Philadelphia: Temple University Press.

    Google Scholar 

  70. Wakefield, Jerome C., and Mark F. Schmitz. 2015. The harmful dysfunction model of alcohol use disorder: revised criteria to improve the validity of diagnosis and prevalence estimates. Addiction 110: 931–942.

    Article  Google Scholar 

  71. Wakefield, Jerome C., and Mark F. Schmitz. 2014. Corrigendum: how many people have alcohol use disorders?: using the harmful dysfunction analysis to reconcile prevalence estimates in two community surveys. Frontiers in Psychiatry 5(144). doi:10.3389/fpsyt.2014.00144.

  72. Wakefield, Jerome C., and Mark F. Schmitz. 2014. How many people have alcohol use disorders?: using the harmful dysfunction analysis to reconcile prevalence estimates in two community surveys. Frontiers in Psychiatry 5(10). doi:10.3389/fpsyt.2014.00010.

  73. Segal, G.M.A. 2013. Alcoholism, disease and insanity. Philosophy, Psychiatry, & Psychology 20: 297–315.

    Article  Google Scholar 

  74. Frances, Allen. 2016. Behavioral addictions: a dangerous and slippery slope. The Huffington Post. http://www.huffingtonpost.com/allen-frances/behavioral-addictions-a-d_b_9959140.html. Accessed 8 Nov 2016.

  75. Zou, Zhiling, Hongwen Song, Yuting Zhang, and Xiaochu Zhang. 2016. Romantic love vs. drug addiction may inspire a new treatment for addiction. Frontiers of Psychology 7: 1436. doi:10.3389/fpsyg.2016.01436.

    Google Scholar 

  76. Wakefield, Jerome C., and Michael B. First. 2012. Placing symptoms in context: the role of contextual criteria in reducing false positives in DSM diagnosis. Comprehensive Psychiatry 53: 130–139.

    Article  Google Scholar 

  77. Kendler, Kenneth S. 2008. Review of The loss of sadness: how psychiatry transformed normal sorrow into depressive disorder. In Psychological Medicine, eds. A. V. Horwitz and J. C. Wakefield, 38: 148–150.

  78. Kraepelin, Emil. 1921. Textbook of psychiatry. eighth edition (George M. Robertson, Ed., and R. Mary Barclay, Tr.). Edinburgh: E. & S. Livingstone, 1921.

  79. Mayberg, Helen S., Mario Liotti, Stephen K. Brannan, Scott McGinnis, Roderick K. Mahurin, Paul A. Jerabek, J. Arturo Silva, Janet L. Tekell, Charles C. Martin, Jack L. Lancaster, and Peter T. Fox. 1999. Reciprocal limbic-c\ortical function and negative mood: converging PET findings in depression and normal sadness. American Journal of Psychiatry 156: 675–682.

    Google Scholar 

  80. Liotti, Mario, Helen S. Mayberg, Stephan K. Brannan, Scott McGinnis, Paul A. Jerabek, and Peter T. Fox. 2000. Differential limbic–cortical correlates of sadness and anxiety in healthy subjects: implications for affective disorders. Biological Psychiatry 48: 30–42.

    Article  Google Scholar 

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Acknowledgements

I thank Reinier Schuur for helpful comments on earlier drafts of this paper.

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  1. Silver School of Social Work and Department of Psychiatry-School of Medicine, New York University, Washington Square N., New York, NY, 10003, USA

    Jerome C. Wakefield

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Wakefield, J.C. Addiction and the Concept of Disorder, Part 1: Why Addiction is a Medical Disorder. Neuroethics 10, 39–53 (2017). https://doi.org/10.1007/s12152-016-9300-9

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