ALCOHOLISM: A DISEASE
In 1956 the American Medical Association decided that alcoholism is a disease, however more than 30 years later this is still debated in certain circles. Besides the medical opinion, there are many others (e.g., legal, sociological, religious) which derive from any number of social pressures. For example, the Supreme Court recently decided that the Veteran's Administration could consider alcoholism an individual choice rather than a disease. This decision, in many peoples' opinion, was made because of the financial implication related to "Service-connected Disability" payments rather than the merits, or lack thereof, of alcoholism as a disease. This in only one example of of the many biased opinions (including the medical one) on whether or not alcoholism is a disease.
What does support the concept of alcoholism as a disease? There is an abundance of information. Alcoholism is often compared to diabetes. Most people are able to eat carbohydrates and metabolize them without difficulty, however this is not the case with people who have diabetes mellitus. Many years ago, we had no idea why people with diabetes got into metabolic difficulty but now we know that it is because of an intrinsic lack of insulin and that this is genetically determined. There is a list of progressive symptoms related to diabetes: polyuria, polydipsia, weight loss, blurred vision, and nausea and vomiting are seen acutely. If the disease goes on untreated, then there is end organ failure disease goes on untreated, then there is end organ failure and patients with diabetes develop failure of their vision and kidneys as well as significant cardiovascular disease with heart attack and stroke. How does one treat this problem? The patient needs insulin and a very controlled lifestyle diet, exercise and very special attention to one's habits. This will at least slow down the progression of the disease.
The same concepts of "disease" apply to alcoholism, and the progression of the disease was defined by Jellinek and is shown on the attached was defined by Jellinek and is shown on the attached Jellinek chart. Alcoholism is a progressive and terminal disease if no intervention occurs. It is clear that alcoholism fits the definition of a disease, and there is additional supportive evidence of this concept based on recent research and literature.
GENETICS AND BIOLOGIC MARKERS OF ALCOHOLISM
Over the past few years investigators have invested a great deal of time, energy and finances into acquiring support for the idea that alcoholism may be a biologically determined disease. There would be many implications of such a discovery not the least of which might be treatment which is more effective than those currently available. As has been the recent tradition in Biologic Psychiatry, many of these investigations have concerned the genetics of these investigations have concerned the genetics of alcoholism-if the illness is determined to be inherited, then there must be a biologic component to the illness which is encoded in one's deoxyribonucleic acid (DNA). The other primary avenue of study has been to look for biologic differences between alcoholics and to look for biologic differences between alcoholics and their family members and normals. From this investigation we have derived a number of "biologic markers" of alcoholism. Unfortunately, we are still in the embryonic stage of this work, and there are no markers with adequate sensitivity and specificity to predict there are no markers with adequate sensitivity and specificity to predict who will and who will not be alcoholic.
GENETIC STUDIES
There have been numerous genetic studies published over the past several years. Many of these have been Scandinavian because of the meticulous record- keeping which is done in Denmark. However recently, a number of studies have been conducted in the U.S. Marc Schuckit, M.D. has been one of the primary investigators in this area. His studies indicate that the offspring from two alcoholic biologic parents are four to eight times as likely to develop alcoholism as the general population. This is a strong indicator that there is a heritable trait for alcoholism. The challenge about this type of research often comes in the form of a question about the social/environmental influence of having two alcoholic parents. That is, is the increased likelihood of developing alcoholism due to the biology or to the fact that these children grew up in a home with two alcoholic parents? How can this be studied? Dr. Remi Cadoret at the University of Iowa published an elegant study in the Archives of General Psychiatry in December of 1986 which examined this issue carefully.
Dr. Cadoret's study examined 443 adoptees-infants adopted out of their biologic families at birth. This provides the opportunity to examine both biologic and birth. This provides the opportunity to examine both biologic and environmental effects on the incidence of alcoholism in the offspring. In addition, he was able to examine other factors which might correlate with the development of alcoholism as well. This study led to a number of interesting findings.
1. There was a genetic influence on the development of
alcoholism--children born to alcoholic parents and reared by
non-alcoholic parents developed alcoholism at the rate predicted by the
other genetic studies.
2. Having alcoholic parents also predicted the development of drug
addiction (other than alcoholism).
3. Parents who were addicted, predisposed their biologic offspring to
developing drug addiction and/or alcoholism.
4. Antisocial personality traits seemed to be inherited and to be
biologically associated with drug addiction.
5. Developmental trauma to children not genetically predisposed to the
development of chemical dependency increased the incidence of
development of the disease.
This study clearly separated the biologic and environmental influences on the incidence of alcoholism. In addition, it suggested that alcoholism and other drug addictions may not be different from each other-an idea that many treatment clinicians have suspected for a long time. The study did not discount the idea that developmental experiences may be of importance. Interestingly, the study demonstrated statistical evidence for heritability of what has traditionally been considered to be environmentally determined-personality style (or disorder)
Other investigators who have contributed greatly to the field of genetics of alcoholism are Kaij, Kaprio, Goodwin, Schulsinger, Winokur, Guze and Cloninger.