(Nathan, 2016) History of The Concept of Addiction

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Peter E. Nathan,1 Mandy Conrad,2

Annu. Rev. Clin. Psychol. 2016.12:29-51. Downloaded from www.annualreviews.org
and Anne Helene Skinstad2

1
Department of Psychology, 2 National American Indian/Alaska Native ATTC (N-AIAN
ATTC), College of Public Health, University of Iowa, Iowa City, Iowa 52242;
email: peter-nathan@uiowa.edu, mandy-conrad@uiowa.edu, anne-skinstad@uiowa.edu
Annu. Rev. Clin. Psychol. 2016. 12:29–51 Keywords

First published online as a Review in Advance on abuse, alcoholism, beer, dependence, distilled spirits, substance use
November 11, 2015
disorder, tolerance, wine, withdrawal
The Annual Review of Clinical Psychology is online at
clinpsy.annualreviews.org Abstract
This article’s doi: Our distant forebears wrestled with concepts of alcohol addiction not unlike
10.1146/annurev-clinpsy-021815-093546
those of today: Is addiction a sin or a disease? Is addiction caused by the
Copyright c 2016 by Annual Reviews. gods, the substance, the individual’s vulnerability, or psychological or so-
All rights reserved
cial factors? Luther, Calvin, and Catholic Church leaders viewed moderate
alcohol use as God’s gift; used intemperately, it was a moral transgression.
The founders of modern scientific psychiatry rejected moral explanations for
addiction in favor of an early biological model. The first two versions of the
Diagnostic and Statistical Manual of Mental Disorders (DSM-I and DSM-II)
stigmatized addiction by listing it with other societally disapproved disor-
ders stemming from personality disorder. DSM-III espoused atheoretical,
descriptive diagnoses but required tolerance or withdrawal to diagnose de-
pendence. Substance dependence in DSM-III-R included physiological and
behavioral symptoms and reflected the substance dependence syndrome.
DSM-IV’s emphasis on biology in its concept of dependence was unchanged
from its immediate predecessors. DSM-5 declared that all drugs taken in ex-
cess have in common the direct activation of the brain reward system. This
article examines evolving concepts of alcohol addiction through 12,000 years
of recorded human history, from the first mention of alcohol consumption
in China more than 12,000 years ago to alcohol use and abuse in the DSM
era, 1952 to the present.
29
Contents
ALCOHOL INTOXICATION, ADDICTION, AND DEPENDENCY
IN ANTIQUITY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
IN THE MIDDLE AGES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
THE BEGINNINGS OF MODERN SCIENTIFIC PSYCHIATRY . . . . . . . . . . . . . . . 32
TEMPERANCE IN THE UNITED STATES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
ALCOHOLICS ANONYMOUS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
DEVELOPMENT OF A US NATIONAL PSYCHIATRIC NOMENCLATURE . . 34
IN THE DIAGNOSTIC AND STATISTICAL MANUALS . . . . . . . . . . . . . . . . . . . . 35

Diagnostic and Statistical Manual of Mental Disorders, First Edition (1952) . . . . . . . . . . . 35
Diagnostic and Statistical Manual of Mental Disorders, Second Edition (1968) . . . . . . . . 37

Diagnostic and Statistical Manual of Mental Disorders, Third Edition (1980) . . . . . . . . . . 39
Diagnostic and Statistical Manual of Mental Disorders,
Third Edition, Revised (1987) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (1994) . . . . . . . . . 43
Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition,
Text Revision (2000) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (2013) . . . . . . . . . . . 45
CONCLUSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47

IN ANTIQUITY
References to alcohol intoxication, addiction, and dependency (AAD) date to the beginnings of
recorded human history, around the time our distant ancestors discovered that fermented fruit
and grain yield intoxicating beverages. A number of different alcoholic beverages were consumed
in China before 10,000 BC. Two thousand years later, the Chinese also began converting some
of the products of their newly created agricultural cooperatives into beer. Alcoholic beverages
have continued to figure importantly in Chinese society as sources of inspiration, for hospitality,
and as a counter for fatigue. Sometimes, of course, these beverages were misused—and those who
misused them were condemned. Egyptian pictographs first portrayed wine around 4000 BC. Beer
and wine were clearly highly valued by the ancient Egyptians, as indicated by the veneration of
Beer: an alcoholic
beverage brewed from Osiris, the Egyptian god of wine, throughout the country. Drinking in Egypt was widespread
fermented grain, but generally moderate. The Babylonians’ preferred beverage was beer; as early as 2700 BC, they
usually 4% to 6% worshipped a wine goddess and regularly offered both beer and wine to their gods (Sasson 1994).
alcohol by volume The Israelites apparently learned to consume wine earlier than 1000 BC, during their captivity in
Wine: fermented Egypt (Patrick 1952).
fruit that yields an Winemaking and wine consumption reached ancient Greece at about 2000 BC. The Greeks
intoxicating beverage
considered wine their main drink. Drinking parties (which Plato is said to have attended) were
of between 12% and
18% alcohol by referred to in Greek as “symposiums”; the word has persisted to the present to describe a serious
volume academic event. The ancient Romans viewed wine as a daily necessity and referred to its con-
sumption as “democratic” because all strata of Roman society apparently had access to it. At the
height of the Roman Empire, many aspects of Roman culture, prominently including viniculture,
spread through much of Europe thanks to Roman soldiers; many of today’s major winemaking
30 Nathan · Conrad · Skinstad

regions in France, Germany, Italy, Spain, and Portugal can trace their beginnings to the Romans.
Many prominent Roman authors wrote of their experiences with wine, including Virgil, Pliny,
and Horace.
The Hebrew and Christian Bibles, the Koran, and many Eastern religious texts refer to wine
and beer intoxication and its negative effects on behavior. Writers frequently conjectured on
why some individuals drank to excess despite the consequences of doing so. The Hebrew Bible
thoroughly reviews the features and effects of wine consumption, which is mentioned more than
130 times (Sasson 1994). Although moderate consumption of wine is generally endorsed in most
of those biblical narratives, the Hebrew Bible vigorously condemns drunkenness. A number of
anecdotes portray drunken behavior and its sometimes-catastrophic outcomes. Such prominent
biblical figures as Noah, Lot, and Samson are said to have overindulged and brought suffering
onto themselves and their loved ones. Thus, “Wine mocks those who use it” (Proverbs 20:1) and
“rewards them with woe, sorrow, strife, and wounds without cause” (Proverbs 23:29–30) (Sasson
1994, pp. 399–419).

Jesus drank wine and appeared to approve of its moderate consumption. However, he was
critical of drunkenness. Paul thought wine was a creation of God and therefore inherently good;
he recommended that it be used for medicinal purposes. He also urged abstinence for persons
who could not control their drinking (Ephesians 5:18; Ewing 1913). The Koran, by contrast,
forbids the use of alcohol in any form, concluding that “intoxicants and games of chance” are
“abominations of Satan’s handiwork, turning people away from God and causing them to forget
about prayer” (Michalak & Trocki 2006). The basic Buddhist teachings on alcohol consumption
are also quite clear. Alcohol, the Buddha taught more than 2,000 years ago, is a poison that clouds
the inherent clarity of the mind (Hanson 1995). Throughout antiquity, wine, beer, nicotine, and
caffeine were consumed by many, largely in socially approved ways. Opium and hallucinogenic
mushrooms were also ingested, the first by priests, the second for medicinal purposes; then as
now, they were not socially approved.
Crocq (2007, p. 360) summarizes views on addiction in antiquity as follows: “The complex
etiology of addiction is reflected in the frequent pendulum swings between opposing attitudes on
issues that are still currently debated, such as: Is addiction a sin or a disease?; Should treatment
be moral or medical?; Is addiction caused by the substance, the individual’s vulnerability, or
psychology, or social factors?; Should substances be regulated or freely available?” How striking
that so many of the same issues have continued to be debated from the time of the ancient Greeks
and Romans to the present.

IN THE MIDDLE AGES
Water was rarely a drink of choice during the early Middle Ages, largely because clean, disease-
free water was generally unavailable; the water that was available was often quite unsafe. Some
contemporary authorities also believed that water was bad for digestion, which it probably was if it
was heavily polluted. Thus, water was generally eschewed in favor of wine, which was believed by
many to be good for health. As a result, wine was a favorite accompaniment of meals in the Middle
Ages, especially in southern Europe. Beers and ales rather than wine were said to be popular
drinks with the lower classes; the nobility preferred good wines. Adults rarely consumed milk;
rather, it was a drink for children. Tea and coffee were rarely consumed in Europe during these
years. Coffee, though, was a drink of choice in the Middle East during the Middle Ages, reflecting
the fact that alcoholic beverages, as noted above, were specifically proscribed in the Koran for
observant Muslims (Engs 1995).
www.annualreviews.org • History of the Concept of Addiction 31

Luther, Calvin and other leaders of the Reformation in the late Middle Ages, along with
many of the leaders of the Catholic Church, viewed alcohol as a gift from God when it was
used in moderation. When used intemperately, however, the drinker was condemned as a moral
transgressor, a sinner. During this time, most Europeans viewed moderate alcohol consumption
positively, although drunken deportment continued to be widely condemned. Those individuals
whose alcohol consumption was out of control were considered to be threatening their salvation as
well as the well-being of society. Nonetheless, throughout Europe, alcohol consumption remained
quite high, substantially higher than it is today. With the onset of the Industrial Revolution and
the consequent need for a reliable and industrious workforce, however, drunkenness began to
come under better social control through much of Europe (Austin 1985).
THE BEGINNINGS OF MODERN SCIENTIFIC PSYCHIATRY

French psychiatrist Philippe Pinel (1745–1826) proposed an early taxonomy of mental disor-
der at the end of the eighteenth century (1806) that attracted attention because it was based on
his extensive observations of psychiatric inpatients. Pinel’s nosology listed four types of mental
illness—melancholia, mania (insanity), dementia, and idiotism. These were the conditions seen
most often in patients at the two Paris psychiatric hospitals at which he worked. Pinel ventured
that melancholia was sometimes brought on by chronic abuse of alcohol, a connection made today
as well. Pinel was also widely recognized for his efforts to develop more humane, nonmedical, non-
violent treatments—moral treatments—for psychiatric patients in Paris’s Bicêtre and Salpêtrière
psychiatric hospitals.
Many consider Benjamin Rush (1745–1813), a signer of the Declaration of Independence and
a member of the Continental Congress, to be the father of American psychiatry. Among other
achievements, he published the first American textbook of psychiatry (1812) and in 1841 founded
the first institution devoted exclusively to the treatment of alcoholics in Boston. Both Pinel and
Rush were early and influential advocates for the proposition that alcoholism is a medical disease
rather than a product of bad character—and that its treatment should reflect this belief.
Many psychiatrists and historians of psychiatry believe that German psychiatrist Emil Kraepelin
(1856–1926) founded modern scientific psychiatry, which prominently included his efforts to
develop psychopharmacology, psychiatric genetics, and classification and diagnosis. Kraepelin’s
views on psychiatric etiology, which were prominently featured in his influential psychiatry text-
books (e.g., Kraepelin 1913), stressed the central role of biological and genetic factors in mental
illness and emphasized the importance of detailed diagnosis and description. These views predom-
inated in psychiatry and clinical psychology well into the twentieth century and have continued
to influence new generations of clinicians and researchers. To this end, the third edition of the
Diagnostic and Statistical Manual of Mental Disorders (DSM-III) and its successors are sometimes
referred to as neo-Kraepelinian because they require careful observation of patient behavior and
thorough identification of signs and symptoms of disorder. Not surprisingly, Kraepelin consid-
ered chronic alcoholism to be a medical disorder. He apparently strongly disliked alcohol and
alcoholism, in part because his father had suffered from the disease, and the relationship between
father and son had been adversely affected as a result.
Eugen Bleuler (1857–1939) was a Swiss psychiatrist whose best-known work, Dementia Praecox
or the Group of Schizophrenias (1911), took issue with Kraepelin’s pronouncement that the syndrome
invariably begins early in the lifespan. Bleuler also delineated several subtypes of schizophrenia,
thereby providing the most thorough description to that time of the signs and symptoms of the
disorder. Like Kraepelin, Bleuler considered schizophrenia to be a physical disease, typically char-
acterized by remissions and exacerbations. Although Bleuler had a generally positive view of the

work of Freud, his contemporary, especially his theory of the unconscious, he ultimately con-
cluded that psychoanalysis was overly dogmatic. Nonetheless, Bleuler referred to Freud’s theories
quite favorably in his 1924 Textbook of Psychiatry. He speculated that acute alcoholic hallucinosis
Dependence:
(delirium tremens) might well be a sign of underlying paranoid schizophrenia released by chronic, a more severe form of
heavy drinking. Gross and colleagues (1963), among many others, sharply disagreed with this substance use disorder
view, considering the syndrome to be a consequence of alcohol toxicity. Although Bleuler’s thesis than substance abuse;
has generally been disproven by more current data, it does highlight the frequency with which for the diagnosis,
requires physiological
schizophrenia and chronic alcoholism co-occurred in Bleuler’s time—as well as in our own.
dependence and either
Sigmund Freud (1856–1939), the founder of psychoanalysis, viewed substance abuse, along tolerance or
with many other character traits, from a developmental perspective (Freud 1915–1916, 1916– withdrawal or both
1917). That perspective concluded that many individuals who abuse alcohol have developed strong
unconscious dependency needs because of a frustrated quest for nurturance from parents during
infancy and early childhood. One result, in the growing individual, is excessive dependence on
others and, ultimately, a dependence on substances. Through the years, efforts have been made
to test the validity of this theory with very limited success. Although Freud rarely drank alcohol,
as a young psychiatrist he became intrigued by the effects of coca, a precursor of cocaine (Markel
2011). Freud originally thought the drug could be ingested without serious consequences and
thus could be used for a variety of useful medical purposes. He tested these assumptions about the
drug, using himself as the subject, but ultimately developed an addiction to cocaine. Forthwith,
he stopped his experiments, withdrew from the drug, ceased his advocacy of it, and refrained from
its further use (Markel 2011).
TEMPERANCE IN THE UNITED STATES

Temperance movements, many of them religiously based and intent on reducing heavy alcohol
consumption and its consequences, grew in strength and numbers in response to a marked increase
in alcohol consumption by men in the industrializing United States as well as Europe. The primary
emphasis of these movements, as their supporters repeatedly professed, was to call the nation’s
attention to the adverse moral and social consequences of alcohol consumption. The so-called
Early Temperance Movement (1784–1861) and Second Wave Temperance Movement (1872–
1893) had a number of substantial effects. The first of these movements was mobilized by Benjamin
Rush’s An Inquiry into the Effects of Ardent Spirits upon the Human Body and Mind (1784), which
recounted in graphic detail the spousal abuse, family neglect, and chronic unemployment brought
on by heavy drinking during the Colonial and post-Revolutionary periods. The end of the first
temperance movement coincided with the onset of the Civil War in 1861. As Reconstruction waned
in the 1870s, white reformers, despairing of efforts to achieve racial equality, invested more effort in
temperance. Such well-known temperance organizations as the Women’s Christian Temperance
Union (founded in 1874) came into being as a result. Because drinking and domestic violence often
co-occur, the temperance movement and the developing women’s rights groups grew alongside
one another. Such well-known advocates for women as Susan B. Anthony, Frances E. Willard,
and Carrie Nation lent their voices to both temperance and women’s rights simultaneously. Due
in large part to the efforts of these women and their compatriots, the Nineteenth Amendment
to the US Constitution, which gave women the right to vote, was passed by Congress in 1919
and ratified in 1920. The Twenty-First Amendment was subsequently passed and ratified in 1933,
ending the nation’s 13-year experiment in Prohibition initiated by the passage and ratification of
the Eighteenth Amendment, which had established Prohibition in 1920.
What some have termed the Third Wave Temperance Movement in the United States took
place between 1893 and 1933. The rise of the Anti-Saloon League, “the church in action against

the saloon,” presaged the passage and subsequent ratification of the Eighteenth Amendment to the
Constitution in 1919 (the Volstead Act) that brought about the period of National Prohibition.
Prohibition in the United States succeeded in markedly reducing arrests for drunkenness in the
National Prohibition:
a period of 13 years short term but did not diminish the social, economic, and medical problems associated with chronic
(from 1920 to 1933) alcoholism, mostly in men. Although some observers also reported substantial increases in crime
during which the sale during National Prohibition, these reports have proven difficult to confirm (Aaron & Musto 1981).
of alcoholic beverages
in the United States
was prohibited ALCOHOLICS ANONYMOUS
Alcoholics
Alcoholics Anonymous (AA) was founded in Akron, Ohio in 1935 by Bill Wilson and Dr. Bob
Anonymous (AA):
founded in 1935, Smith, both recovering alcoholics. Their mutual discovery of a new way to recover from alcoholism
AA is a fellowship of culminated in the publication of “The Big Book,” Alcoholics Anonymous: The Story of How Many
recovering alcoholics Thousands of Men and Women Have Recovered from Alcoholism (1939). It was written largely by Bill
who support each Wilson and contained a thorough description of the Twelve-Step method that is at the heart of the
other as they move
AA treatment philosophy. The central goal of the book, now in its fifth edition (AA World Serv.
toward sobriety;
the 12 Steps Toward 2013), is to help readers find a power greater than themselves to help them deal with their alcohol
Recovery is an AA addiction. This emphasis on finding a power greater than the alcoholic reflects AA’s underlying
hallmark philosophy that it is impossible to quit drinking by oneself. Fellow members of AA groups and
Higher Power: the Higher Power in which the alcoholic is urged to put his or her trust are essential elements of
members of AA recovery.
frequently reference a The ultimate form and emphases of AA were strongly influenced by a meeting Bill Wilson had
Higher Power in
with a friend, who urged him to join the Oxford Group, a spiritually based temperance movement
whom the recovering
alcoholic is to put based on the Four Absolutes: honesty, purity, unselfishness, and love. Prior to the development of
his/her trust as AA, the temperance movements and Prohibition had led to the prevailing view of the nineteenth
recovery proceeds and early twentieth centuries that biology, adverse environments, lapses in faith, and immorality
bring on the host of medical, social, and moral problems associated with chronic abuse of alcohol.
With the publication of The Big Book in 1939, the rapid growth of the AA movement, the increase
in scientific research on alcoholism and addiction, and the publication in 1960 of Jellinek’s The
Disease Concept of Alcoholism, opinion gradually shifted to the view that alcoholism is a disease
with strong spiritual roots. Accordingly, AA members claim that there is no other solution than
a spiritual solution, despite their concurrent belief that alcoholism represents a disease. Research
on the effectiveness of AA has been mixed (e.g., Kaskutas 2009), in part because of continuing
conflict between faith and science among AA members.
DEVELOPMENT OF A US NATIONAL PSYCHIATRIC

NOMENCLATURE
The US Census first attempted an estimate of the frequency of “idiocy/insanity” in the 1840
census. It appears to have been the first formal attempt to count and record mental disorder
in the United States. In response to a question in the 1880 Census (which enumerated more
than 50 million respondents) that asked for a count of deaf, dumb, blind, or insane individuals,
seven categories of mental illness were suggested. The categories included mania, melancholia,
monomania (schizophrenia), paresis, dementia, dipsomania (chronic addiction to alcohol), and
epilepsy. Not surprisingly, these seven conditions were the disorders most often seen in US state
hospitals. The American Medico-Psychological Association (subsequently renamed the American
Psychiatric Association in 1921) and the National Commission on Mental Hygiene jointly began
to develop a taxonomy in 1917 designed to record uniform statistics across the country’s mental
hospitals. A few years later, the newly renamed American Psychiatric Association and the New

York Academy of Medicine began working together to develop a nationally acceptable psychiatric
nomenclature. It was developed for the discrete subgroup of patients who filled the country’s public
psychiatric hospitals and suffered from severe and chronic neurologic and psychiatric conditions.
Diagnostic
By the mid-1920s, most of the nation’s large medical centers and state psychiatric hospitals had unreliability:
developed their own diagnostic systems, which reflected the patients most often seen at each consistent failure of
of these facilities. As a consequence, in the absence of a broadly based national nomenclature, diagnosticians to agree
communication about patients among clinicians who worked in different institutions was extremely on a diagnostic label;
diagnostic unreliability
difficult.
was a particular
In response to the persistent problem of diagnostic unreliability, which afflicted virtually every problem with DSM-I
medical specialty of the time, the first National Conference on Nomenclature of Disease took place and DSM-II
at the New York Academy of Medicine in early 1928. Governmental agencies and representatives
of national medical societies, including psychiatry, attended. A first trial of the new nomenclature
was published in 1932, and in 1933 the first edition of the Standard Classified Nomenclature of
Disease appeared (Baehr 1940). It was followed by second and third editions, the latter appearing
in 1942. The nomenclatures, like their predecessors, largely reflected the inpatient population in
the nation’s large public psychiatric hospitals. It did not include the very large number of persons
experiencing nonpsychotic disorders such as anxiety, depression, and substance abuse, who were
rarely institutionalized.
World War II substantially accelerated the process of development of a more reliable, useful,
and inclusive psychiatric classification system. Because all causes of morbidity and mortality had
to be recorded for the military, every soldier or sailor seen by a mental health professional was
diagnosed. However, only about 10% of them could be diagnosed by the nomenclatures previously
developed to meet the needs of public mental hospitals. An effort to create a more inclusive
system was subsequently begun. It was designed to reflect the array of disorders and conditions
(prominently including chronic alcoholism and the addictive disorders) mental health workers
were called upon to diagnose and treat during World War II (Menninger 1947).

IN THE DIAGNOSTIC AND STATISTICAL MANUALS
Diagnostic and Statistical Manual of Mental Disorders, First Edition (1952)

DSM-I was the nation’s first broad-based psychiatric nomenclature. Its development was begun at
the end of World War II by representatives of the US War Department, Veterans Administration,
and American Psychiatric Association in response to widespread recognition of the inadequacy
of the psychiatric nomenclatures of the time to capture the full range and intensity of the war’s
psychiatric casualties. It was completed and published in 1952.
The members of the Committee on Nomenclature and Statistics of the American Psychiatric
Association, composed primarily of male, senior academic psychiatrists, drew largely on their
clinical experience, rather than research findings, to create the nomenclature. Twenty-seven men
and one woman served during the decade of development of the nomenclature; at any given time
the Committee on Nomenclature and Statistics numbered seven.
The DSM-I nomenclature was heavily influenced by Adolf Meyer (1866–1950), the first
psychiatrist-in-chief of the Johns Hopkins Hospital and one of the most highly esteemed the-
orists and clinicians of the time. His influential psychobiological theory deemed mental disorders
to be reactions to psychological, social, and biological events in patients’ lives. As a result, the term
“reaction” was appended to each DSM-I diagnosis. [See also Blashfield and colleagues (2014) for
their description of the history of this diagnostic nomenclature.]

DSM-I was very brief: It described 106 disorders in 132 pages. None of the disorders was
depicted with enough detail to permit a reliable, replicable diagnosis. The 106 DSM-I disorders
were divided into 11 categories. The first five described acute and chronic brain syndromes, two of
which included alcohol intoxication only; the other three included both alcohol and drug intoxi-
cation. The next four categories portrayed psychotic disorders, psychophysiologic autonomic and
visceral disorders, psychoneurotic disorders, and personality disorders, which listed and briefly de-
scribed four categories. One of the four personality disorder categories was sociopathic personality
disturbance, which included four conditions: antisocial reaction, dyssocial reaction, sexual devia-
tion, and addiction (alcoholism, drug addiction). The final two DSM-I categories were transient
situational personality disorder and mental deficiency.
Alcohol intoxication, addiction, and dependency. Both acute and chronic alcohol and drug
intoxication were labeled brain syndromes in DSM-I. The DSM-I also included personality dis-
orders, described as “disorders of psychogenic origin or without clearly defined tangible cause
or structural change.” One of the four subcategories of disorder included in this section of the
nomenclature was sociopathic personality disturbance (SPD), which included antisocial reaction,
dyssocial reaction, sexual deviation, and addiction. The latter syndrome included alcoholism and
drug addiction. DSM-I describes SPD as follows: “Individuals to be placed in this category are
ill primarily in terms of society and with the prevailing cultural milieu, and not only in terms of
personal discomfort and relations with other individuals” (Am. Psychiatr. Assoc. 1952, p. 38). An-
tisocial reaction, one of the four components of SPD, “refers to chronically antisocial individuals
who are always in trouble, profiting neither from experience nor punishment, and maintaining
no real loyalties to any person, group, or code” (Am. Psychiatr. Assoc. 1952, p. 38). Dyssocial
reaction, another component of SPD, “applies to individuals who manifest disregard for the usual
social codes, and often come into conflict with them, as the result of having lived all their lives
in an abnormal moral environment” (Am. Psychiatr. Assoc. 1952, p. 38). Sexual deviation, a third
component of SPD, “is reserved for deviant sexuality which is not symptomatic of more extensive
syndromes. . . The term includes most of the cases formerly classed as ‘psychopathic personality
with pathologic sexuality’” (Am. Psychiatr. Assoc. 1952, pp. 38–39). Addiction, the final SPD com-
ponent, includes alcoholism, defined as “cases in which there is well-defined addiction to alcohol
without recognizable underlying disorder,” and drug addiction, which is “usually symptomatic of
a personality disorder, and will be classified here while the individual is actually addicted” (Am.
Psychiatr. Assoc. 1952, p. 39). Thus, the drafters of DSM-I succeeded in grouping together under
the SPD heading the four behavioral sets most widely condemned for their assault on societal
morals as well as for their generally negative impact on self and others. It took 28 years and the
appearance of DSM-III (Am. Psychiatr. Assoc. 1980) for the nomenclature to move away from
this harsh moral judgment on these behaviors.
Commentary. Gerald Grob, a prominent historian of psychiatry, traced the history of psychiatric
nosology in the United States from its beginnings in the early part of the nineteenth century to
the appearance of DSM-I in 1952 (Grob 1991). He attributed the core focus of DSM-I to a strong
and growing emphasis in American psychiatry on psychodynamic and psychoanalytic theory and
practice and a corresponding reduction in interest in biological factors, in a movement away from
the prevailing emphasis on biology during the late 1800s and early 1900s. Grob pointed to the
experience of mental health professionals during World War II to explain these changes: They
saw many soldiers disabled by such disorders and conditions as alcoholism, depression, anxiety and
stress, for which biological factors seemed less important and the influence of personality factors
more important than in the psychotic disorders seen in state mental hospitals.

Many observers commented on the DSM-I placement of alcoholism and drug addiction in the
SPD category, along with antisocial reaction, dyssocial reaction, and sexual deviation. Verheul ob-
served, for example, “in the symptomatic model (of personality), which dominated the first half of
this century, addiction was considered a symptom of an underlying personality disorder evidenced
by maladjustment, neurotic character traits (and) emotional immaturity or infantilism. This influ-
ential perspective was adopted by DSM-I and DSM-II” (Verheul 2001, p. 276). Presumably, the
other syndromes included in SPD shared these dominant, negative personality traits.
Key (1952) expressed a common view of the time that alcoholics could be distinguished from
social and recreational drinkers by the purposes for which they drink. According to Key, alcoholics
consistently and intentionally drink uncontrollably and compulsively. Key also concluded that
alcoholism was a strong risk factor for mental disorder, even though he also thought that alcohol
addiction is more commonly a symptom of rather than the cause for a serious, long-standing
mental disorder. Key recommended treating alcohol addiction with conditioned aversion, at
the time a promising behavioral treatment for alcoholism. Adding his observations to those of
Key (1952), Wellman (1954) wrote that problem drinkers could be divided into two groups: the
primary compulsive type that uses alcohol to cope with personality problems present from an
early age, and the secondary type of problem drinker whose transition from heavy social drinking
is a more gradual and insidious process stemming from environmental factors, metabolic disease,
and blood chemistry.
Diagnostic and Statistical Manual of Mental Disorders, Second Edition (1968)

A number of notable challenges to long-held views in psychiatry took place in the 1960s and early
1970s. They ranged from Thomas Szasz’s startling declaration that mental illness is a myth (Szasz
1961) to criticisms by behavioral psychologists such as Ferster & DeMyer (1961) and Skinner
(1953) of psychiatry’s willingness to accept conclusions about etiology and treatment without
suitable empirical support. Only a few of these challenges were resolved. For example, the gay
rights activists and others who opposed the inclusion of homosexuality in the official nomenclature
witnessed with satisfaction its deletion from DSM-II in 1972 following a vote of the member-
ship of the American Psychiatric Association. The advent of more effective psychopharmacologic
treatments, especially the phenothiazines for schizophrenia, as well as promising behavioral and
cognitive-behavioral treatments for depression and anxiety, raised questions about the validity of
the prevailing Meyerian, psychodynamic view of etiology. DSM-II (Am. Psychiatr. Assoc. 1968),
published 16 years after DSM-I, lists 182 disorders and is 134 pages long, with the same mod-
est trim size as DSM-I. Even though the descriptor term “reaction” was dropped from DSM-II
diagnoses because of the waning of Meyerian influence, the nomenclature retained its allegiance
to the psychodynamic view of etiology, which emphasized the influence of repressed conflict
on behavior. At the same time, more attention began to be paid to biological factors, in ac-
knowledgment of both the influence of Kraepelin’s views on the etiology of the psychoses and
advances in etiologic and treatment research between 1952 and 1968. DSM-II distinguishes be-
tween the psychoses and the neuroses, reflecting recognition of significant differences between
the two sets of behaviors in the degree to which they are products of unconscious psychological
conflict.
As in DSM-I, most of the members of the DSM-II Committee on Nomenclature and Statistics
were senior, male, academic psychiatrists; only one was a woman. As before, they largely relied
on their clinical experience to formulate diagnostic categories. The descriptions of diagnostic
conditions in DSM-II, as in DSM-I, are very brief and sketchy, so reliable diagnosis continued to
be a problem for those using DSM-II.

Alcohol intoxication, addiction, and dependency. Four subheadings are listed under “V. Per-
sonality Disorders and Certain Other Non-Psychotic Disorders” in DSM-II: Personality Dis-
orders, Sexual Deviations, Alcoholism, and Drug Dependence. Included under alcoholism are
Withdrawal:
when individuals stop episodic excessive drinking, habitual episodic drinking, alcohol addiction, and other. The para-
drinking alcohol or graph describing alcohol addiction (Am. Psychiatr. Assoc. 1968, p. 45) specifies that this diagnosis
using an addictive drug requires “direct or strong presumptive evidence,” such as the appearance of withdrawal symptoms
or drugs, they develop and “the inability of the patient to go one day without drinking.” Three months or more of heavy
the withdrawal
drinking met the criterion so that “addiction to alcohol has been established.” Few empirical data
syndrome
characteristic of the in support of these decision rules are provided.
substance Drug dependence diagnoses describe “patients who are addicted to or dependent on drugs other
Disease concept of than alcohol, tobacco, and ordinary caffeine-containing beverages”, and the drug dependence
alcoholism: diagnosis “requires evidence of habitual use or a clear sense of need for the drug” (Am. Psychiatr.
Jellinek described five Assoc. 1968, p. 45). Withdrawal is not the only sign of drug dependence, as it is in alcohol addiction,
alcoholism types, all since cocaine and marijuana were not thought to demonstrate withdrawal syndromes.
characterized by
abnormal physiology
but only Epsilon Commentary. Coincident with the appearance of DSM-II in 1968, Spitzer & Wilson (1968)
alcoholism manifested
reviewed diagnostic differences between DSM-I and DSM-II. In discussing changes made in
loss of control,
Jellinek’s criterion for conceptions of alcoholism in DSM-II, they observed that alcoholism could never have been a
disease separate diagnosis so long as it was associated with an underlying disorder, as it was in DSM-I. By
contrast, DSM-II encouraged clinicians to diagnose all disorders they observed in their patients.
Unlike DSM-I, DSM-II does not portray alcoholism as a personality disorder, buttressing this
view by identifying eight specific brain syndromes associated with alcohol. In sum, according to
these authors, DSM-II’s portrayal of alcohol addiction is based to a greater extent than DSM-I
on science and biology than opinion.
In his pioneering The Disease Concept of Alcoholism (1960), E.M. Jellinek (1890–1963), a promi-
nent sociologist at the Yale Center of Alcohol Studies, described a “new approach” to alcoholism
that considered it an addictive disease. Jellinek’s insights were influenced by the experiences of
AA members, the emerging results of research on chronic alcoholism and addiction begun in
the 1930s by Yale Center of Alcohol Studies colleagues, and the failed experiment of national
prohibition. At the heart of the disease concept of alcoholism was Jellinek’s delineation of five
types of alcoholism, differentiated from one another by Greek letter. Although all five of the al-
coholism types were characterized by abnormal physiological processes, only Epsilon alcoholism
met Jellinek’s principal alcoholism criterion, loss of control, so only Epsilon alcoholism met this
criterion for disease. The 1960 classic proposed a concept of alcoholism at substantial variance
from AA’s prevailing belief in the unity of all species of alcoholism. Although the first four types
met Jellinek’s criteria for alcoholism, only Epsilon alcoholics were victims of disease.
In a review of the evolving criteria for alcoholism in DSM in the 30 years between the 1960s and
the 1990s, Alcohol Alert, an online National Institute on Alcohol Abuse and Alcoholism (NIAAA)
publication, observed that Jellinek’s “groundbreaking theory of subtypes” of alcoholism “asso-
ciated these subtypes with different degrees of physical, psychological, social, and occupational
impairment” (NIAAA 1995, p. 1). Evolution of the diagnostic criteria for alcoholism began with
DSM-I (Am. Psychiatr. Assoc. 1952) and DSM-II (Am. Psychiatr. Assoc. 1968), both of which
considered alcoholism to be a result of personality disorder, homosexuality, and neurosis. This
guilt by diagnostic association was an extremely controversial feature of these first two editions of
the DSM.
In response to the diagnostic shortcomings of DSM-I and DSM-II, the Feighner criteria were
published in 1972 (Feighner et al. 1972). On the basis of extensive research, not simply clinical

experience and subjective judgment, these clinical researchers promoted continued investigation
of signs and symptoms of psychiatric disorder, including alcohol abuse and alcoholism.
Four years later, Edwards & Gross (1976) discussed their observations of a group of alcohol-
Tolerance: with
dependent individuals. They described an “alcohol dependence syndrome” and claimed that “the continued use of
essential elements of dependence” were “a narrowing of the drinking repertoire” along with drink- alcohol or another
seeking behavior, tolerance, withdrawal, drinking to avoid or relieve withdrawal symptoms, sub- addictive substance,
jective awareness of the compulsion to drink, and a return to drinking after a period of abstinence. the drinker/user will
require more of the
In 1979, a year before DSM-III appeared, Spitzer, Forman, and Nee contrasted the poor
substance to achieve
interrater reliability of DSM-I and DSM-II with DSM-III field trial data that confirmed the the same effect
much improved diagnostic reliability of DSM-III (Spitzer et al. 1979). Reasons for the reliability
Field trial: DSM-III,
differences were obvious to most readers: DSM-I and DSM-II offered clinicians little guidance, DSM-IV, and DSM-5
direction, and information about diagnostic cues, whereas DSM-III, by design, included a much all developed field
more detailed summary of signs and symptoms, along with the decision rules by which they were trials of groups of
to be integrated for diagnostic purposes. Another influential observation of the unreliability of alcoholics and controls
to test the reliability
DSM-I diagnoses had been chronicled by Schmidt & Fonda (1956) many years earlier.
and validity of new or
modified diagnostic
cues
Diagnostic and Statistical Manual of Mental Disorders, Third Edition (1980)
Robert Spitzer, a professor of psychiatry at the Columbia University College of Physicians and
Surgeons, was named chair of the DSM-III Task Force on Nomenclature and Statistics. Spitzer
brought a lengthy, well-respected record of empirical research on diagnosis to the task. The third
edition of the DSM introduced substantial changes to the nomenclature; many of the changes were
designed to reduce the unreliability of diagnoses, which was a major problem with its predecessors.
The DSM-III volume numbered 494 pages, as compared to 134 in DSM-II and 132 in DSM-I; its
trim size was several inches larger than that of either DSM-I or DSM-II. DSM-III included 265
diagnoses, as compared with 106 in DSM-I and 182 in DSM-II. The diagnoses were accompanied
by extensive additional textual material on age of onset, course, degree of impairment, compli-
cations, predisposing factors, prevalence, sex ratio, familial pattern, and differential diagnosis. As
with DSM-I and DSM-II, the development of DSM-III was coordinated with progress on devel-
oping the latest edition of the International Classification of Diseases (ICD), which was published
in 1975.
The number of diagnoses included in DSM-III was markedly increased in comparison to
DSM-II and was triple the number included in DSM-I. As a result, many behaviors that had not
been described in DSM-I or DSM-II became a part of DSM-III. Although some observers lauded
this change because it called attention to troublesome behaviors that had been ignored previously,
many criticized the proliferation of diagnoses and questioned whether DSM-III had now begun to
label behaviors that were not in fact psychopathological for political and competitive disciplinary
reasons (e.g., Kirk & Kutchins 1992).
A separate chapter on childhood and adolescent disorders was created. Some child psychologists
and psychiatrists supported this addition because it brought enhanced attention to a group of
disorders that many thought had not previously been given sufficient attention. Others, however,
strongly criticized this decision (e.g., Garmezy 1978), believing it conferred diagnostic labels on
some behaviors of childhood that were troubling to parents but were not psychiatric disorders.
DSM-III moved away from the reliance of DSM-I and DSM-II on specific etiologic, largely
psychodynamic, theories in favor of an explicitly atheoretical, descriptive approach to etiology,
including that of alcoholism and substance abuse. This new emphasis, promoted by Spitzer
and his colleagues at Columbia, was buttressed by empirical findings from a number of data
sources, prominently including extensive field trials. DSM-III also established empirically based

operational criteria—symptom descriptions—and decision rules from the field trial data as well
as the journal articles describing the Research Diagnostic Criteria (Spitzer & Robins 1978) and
the Feighner criteria (Feighner et al. 1972). The operational criteria from the latter two sources
had been subjected to substantial initial empirical testing. As a result, the reliability of diagnoses
in DSM-III was much improved over that of DSM-I and II.
The five axes of DSM-III’s new multiaxial system were designed to increase the validity and
utility of diagnosis by providing more information about the patient than was available simply
from his or her diagnosis.
A more diverse group of clinicians, including women, persons of color, and nonpsychiatrists,
participated in the development of DSM-III, which meant that the group was more reflective of
the diversity of the US population than were the groups that developed DSM-I and DSM-II.
Alcohol intoxication, addiction, and dependency. Substance use disorders in DSM-III—

substance abuse and dependence—are detailed in a separate section of DSM-III (chapter 3, “The
Diagnostic Categories: Text and Criteria”), as are 14 other sections describing the other syndrome
groupings. In DSM-I and DSM-II, by contrast, alcoholism and drug addiction are grouped to-
gether with other stigmatizing behaviors (e.g., antisocial and dyssocial reactions, sexual deviations,
personality disorders, sexual disorders).
The preface to the DSM-III Substance Use Disorders section informs the reader, “This diag-
nostic class deals with behavioral changes associated with more or less regular use of substances
that affect the central nervous system. These behavioral changes in almost all subcultures would
be viewed as extremely undesirable” (Am. Psychiatr. Assoc. 1980, p. 163). This statement reflects
the influence of such predecessors as Kraepelin, Jellinek, Feighner and his colleagues, and Spitzer
and Robins on the substance use disorders in DSM-III. As such, it contrasts sharply with psycho-
analytic theory and stigmatizing societal views on these disorders in DSM-I and DSM-II. Further
differentiating it from its predecessors, DSM-III draws clear distinctions among substance use,
substance abuse, and substance dependence. Three criteria distinguish substance abuse from non-
pathological substance use: a pattern of pathological use, impairment in social or occupational
functioning caused by the pattern of pathological use, and duration of use lasting at least one
month. As with many other DSM-III chapter 3 syndromes (Am. Psychiatr. Assoc. 1980, pp. 335–
338), these criteria were adapted from DSM-III field trial data, the Research Diagnostic Criteria,
and the Feighner criteria. Substance dependence, considered to be a more severe form of substance
use disorder than substance abuse, requires one or more signs of physiological dependence, either
tolerance or withdrawal; alcohol dependence and cannabis dependence also require a pattern of
pathological use or impairment in social or occupational functioning.
According to DSM-III, five classes of substances, including alcohol, barbiturates, opioids,
amphetamines, and cannabis, generate both abuse and dependence. Use of cocaine, phencyclidine,
and hallucinogens, by contrast, yields only symptoms of abuse; tobacco is associated only with
dependence. Substance dependence in all drug classes requires only evidence of withdrawal or
tolerance in DSM-III, with the exception of alcohol and cannabis dependence, which require as
well evidence for social or occupational impairment from use or a pattern of pathological substance
use. This decision rule contrasts sharply with the decision rules for substance dependence in both
DSM-IV and DSM-5, which do not accord such a primary role for tolerance and withdrawal in
the diagnosis of dependence.
Like other diagnoses in DSM-III, the text accompanying the substance use disorder opera-
tional criteria draws upon research findings on a range of important issues, including associated
features, age at onset, complications, predisposing factors, prevalence, sex ratio, differential diag-
nosis, course, and familial pattern.

Commentary. Included in a broad-based overview of the changes brought to the US psychi-

atric nomenclature by DSM-III is the observation by Wilson (1993) that the biopsychosocial
model that strongly influenced DSM-I and DSM-II ultimately failed and needed replacement
because it did not distinguish reliably between mental health and mental illness. The result, in
DSM-III, is the research-informed medical model and a return to Kraepelinian descriptive psychi-
atry. This change clearly characterizes the nomenclature’s portrayal of the substance use disorders
by emphasizing the determining role of tolerance and withdrawal—physiological dependence—in
the diagnosis of substance dependence.
A subsequent article by Mayes & Horwitz (2005) echoed Wilson’s reference to the 1970s as
psychiatry’s “crisis of legitimacy” and portrayed DSM-III as a reaction to that crisis. Thus, “in
a very short period of time, mental illnesses were transformed from broad, etiologically defined
entities that were continuous with normality to symptom-based categorical diseases” (Mayes &
Horwitz 2005, p. 249). The authors go on to explain these developments as the product of political,
professional, and economic forces on psychiatry rather than “a product of growing scientific
knowledge and increasing medicalization.”
Caetano (1987) anticipates these positions by listing the marked changes introduced into the
DSM-III substance abuse section and taking issue with several of them. He questions the changes
in DSM-III’s portrayal of alcohol abuse and its expansion of the diagnostic features of alcohol
dependence, failure to specify a time frame for observing the diagnostic cues, and a similar failure
to explore thoroughly the relationship between the new diagnosis with the alcohol dependence
syndrome in ICD-9 (World Health Organ. 1975).
In strong disagreement, several prominent psychiatric researchers extolled the scientific bases
of DSM-III (e.g., Kendler 1990, Klerman et al. 1984). As a consequence, consonant with the
increased emphasis that medicine and psychiatry have placed on scientific research since the 1960s,
DSM-III became virtually synonymous with a Kraepelinian, empirically based view of diagnosis.
That view has largely remained with the publication of DSM-IV and DSM-5.
In a belated rejoinder to criticisms of DSM-III, Spitzer (2001) takes up two specific complaints,
that DSM-III places more emphasis on reliability than on validity and that it is committed to an
explicitly biological view of psychiatric disorders without saying so. Spitzer cites data and his own
values and assumptions, as well as those of fellow psychiatrists with similar views, to conclude that
these two concerns are not valid.
In an article in American Psychologist, Meyer (1983) summarized the views of many fellow psy-
chologists who considered alcohol abuse and alcoholism to be produced by a range of physiological,
psychological, and societal factors. Important as well to understanding the etiology of alcoholism,
according to Meyer (1983, p. 1117), is the likely role of genetics (“that a physiological predisposi-
tion to respond to alcohol in a particular way may be inherited”). Meyer additionally urged efforts
to identify individuals with alcohol problems but not dependence, which he considered essential to
a favorable prognosis. This “middle path” to etiology appears to be consonant with the portrayal
of substance use disorder etiology in DSM-III, despite some disagreement on that issue.
In an inquiry into the etiology of alcoholism published a year earlier in American Psychologist,
psychiatrist George Vaillant and psychologist Eve Milofsky reported findings from “a new 33-year
prospective study of the 456 nondelinquent controls from the Glueck’s delinquency study”
(Vaillant & Milofsky 1982, p. 494). The authors concluded from the study’s findings that
“. . .presence or absence of South European ethnicity (perhaps as a result of attitudes toward
alcohol use and abuse) and the number of alcoholic relatives (perhaps more due to heredity than
environment) accounted for most of the variance in adult alcoholism explained by childhood
variables. . .Thus, the etiological hypotheses that view alcoholism primarily as a symptom of
psychological instability may be illusions based on retrospective study” (Vaillant & Milofsky
1982, p. 499).
Diagnostic and Statistical Manual of Mental Disorders,

Third Edition, Revised (1987)
Substance A revision of DSM-III, DSM-III-R (Am. Psychiatr. Assoc. 1987), was also led by Robert Spitzer.
dependence Both in number of diagnoses and page length, DSM-III-R exceeds DSM-III: It contains 296
syndrome: diagnoses in a volume totaling 567 pages.
physiological,
Dissatisfaction with aspects of DSM-III, including some inconsistencies in the diagnostic sys-
behavioral, and
cognitive phenomena tem and a number of problems with clarity of operational criteria, led to this revision. In addition
in which the to changing the wording of criteria to increase clarity and the resolution of systemic inconsis-
individual’s use of a tencies, DSM-III-R added 32 new diagnoses. Those additions convinced most psychiatrists and
substance takes on a psychologists that DSM-III-R ought to be considered a wholly new edition of DSM.
much higher priority
The drafters of DSM-III-R also made selected terminological changes and alterations in oper-
ational criteria. In addition, many of DSM-III’s exclusionary criteria, lacking empirical support,
were eliminated.
As well, criteria were introduced for schizoaffective disorder in DSM-III-R. DSM-III had
not proposed diagnostic criteria for this psychotic disorder, which includes both symptoms of
schizophrenia and those of mood disorder. Substance abuse and dependence frequently co-occur
with schizoaffective disorder. The affective disorders were retitled mood disorders, which appeared
to describe them more accurately. Substantial revisions in the personality disorders were made in
an effort to bring them into line with diagnostic criteria for other disorders.
Alcohol intoxication, addiction, and dependency. The substance dependence category was ex-
panded in DSM-III-R to include symptoms that had been considered descriptive of substance abuse
in DSM-III. Moreover, DSM-III-R decision rules directed that substance dependence should in-
clude both physiological symptoms (i.e., tolerance and/or withdrawal) and behavioral symptoms
(e.g., impaired control over drinking); DSM-III had specified only physiological symptoms for the
substance dependence diagnosis, with the exception of alcohol and cannabis dependence. Abuse
in DSM-III-R thereby became a residual category for persons who had never met criteria for
dependence but had experienced an array of substance-related problems.
DSM-III-R also made increased use of the substance dependence syndrome (Edwards & Gross
1976), which the ICD-10 defines as “a cluster of physiological, behavioral, and cognitive phenom-
ena in which the use of a substance or a class of substances takes on a much higher priority for a
given individual than other behaviors that once had greater value” (World Health Organ. 2010,
p. 5).
Kosten and colleagues (1987) used the new DSM-III-R criteria to diagnose 83 psychiatric
patients. Fourteen of them had no history of substance abuse; the remaining 69 patients had
abused the following substances: alcohol (52), sedatives (31), hallucinogens (12), stimulants (33),
cannabis (44), cocaine (52), and/or opiates (47). The 10 items developed to assess dependency for
each drug class were then factor analyzed: The dependence syndrome items formed a single factor
for opiates, cocaine, and alcohol (Kosten et al. 1987, p. 834), thereby helping confirm the validity
of the dependence syndrome for a range of drugs of abuse.
Schuckit and colleagues (1994) examined the impact of these criteria changes in DSM-III-R
by comparing DSM-III-R, DSM-IV, and ICD-10 substance use disorder diagnoses in a sample of
1,922 subjects. Subjects were enrolled in the NIAAA-funded Collaborative Study on the Genetics
of Alcoholism; 259 of them had been diagnosed as substance dependent (probands), and the rest
of the subjects were blood relatives of the probands, married to a blood relative, or controls.
Schuckit and colleagues observed that the criteria for the diagnosis of substance dependence were
similar across the three diagnostic systems and reported that “the proportions of individuals being

diagnosed in the three systems were similar, with the highest numbers observed for DSM-III-R,
the lowest for ICD-10, and the numbers for DSM-IV between the two” (Schuckit et al. 1994,
p. 1629). By contrast, the criteria for substance abuse, which differed markedly across the three
diagnostic systems, resulted in substantial differences across the three systems.
Cottler and colleagues (1991) reported on results from a study with comparable aims. Individ-
uals who had been recently admitted to several St. Louis drug treatment centers were interviewed
with an instrument that contained criteria for the diagnosis of dependence from both DSM-III and
DSM-III-R. The authors concluded that the DSM-III-R criteria cast a wider net for dependence
than those for DSM-III for alcohol, tobacco, and amphetamines but did not do so for cannabis,
opioids, and sedatives/hypnotics.
Commentary. The past several decades have witnessed numerous studies designed to determine
the extent to which genetic factors play a role in the development of alcohol dependence and abuse
and by what means those factors exert their influence. Summarizing these decades of research,
Mayfield and colleagues (2008) thoroughly reviewed the data and concluded that both genes and
environment influence the development of alcohol dependence. Among hypothesized genetically
mediated factors responsible for alcohol dependence are heightened feelings of reward from al-
cohol ingestion, higher levels of impulsivity and impaired control of behavior, and vulnerability
to certain psychiatric disorders that increase the risk of alcohol dependence. Substantial genet-
ics research on a wide range of addictive substances besides alcohol during the same period has
established similar roles for genes and environmental factors (e.g., Bierut et al. 1998).
Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (1994)

The DSM-IV Task Force chair was Allen Frances, director of the Payne Whitney Clinic at Cornell
University Medical Center. Midway through the DSM-IV process, Frances left Cornell to become
chair of the Department of Psychiatry at Duke University. He is a well-respected researcher on
personality disorders. DSM-IV, published in 1994, maintained most of the diagnoses included in
DSM-III and DSM-III-R, with a few additions and deletions.
The DSM-IV Task Force commissioned an even larger number of field trials than had its
counterparts in the DSM-III process. Extensive reviews of the field trials for each of the 14
DSM-IV syndrome chapters, as well as analyses of unpublished data, were ultimately published
in a five-volume set (Widiger et al. 1994), thereby permitting researchers and clinicians to have
access to the deliberations of the DSM-IV Work Groups. Marc Schuckit, chair of the Substance-
Related Disorders Work Group, summarized the three-year history of the development of criteria
for these disorders in volume 1 of the five-volume set (Schuckit 1994).
An explicit effort to limit the introduction of new diagnoses to DSM-IV reflected the conviction
held by many, including Task Force chair Allen Frances, that the DSM already included an
overabundance of diagnoses. The developers of DSM-IV were an even more diverse group of
clinicians than had been those of DSM-III.
Alcohol intoxication, addiction, and dependency. The DSM-III Work Group on AAD had
titled the chapter detailing these diagnoses “Substance Use Disorders.” By contrast, DSM-IV
named the chapter “Substance-Related Disorders” to reflect a broader purview. Thus, the chapter
included “disorders related to the taking of a drug of abuse (including alcohol), to the side effects
of a medication, and to toxin exposure” (Am. Psychiatr. Assoc. 1994, p. 175). The chapter grouped
substances into 11 classes, including alcohol, amphetamine, caffeine, cannabis, cocaine, hallucino-
gens, inhalants, phencyclidine, and sedatives, hypnotics, and anxiolytics. The chapter provided

coverage of two distinct categories of disorder, the substance use disorders (which included sub-
stance abuse and substance dependence) and the substance-induced disorders (which included
substance intoxication; substance withdrawal; substance-induced delirium; substance-induced per-
With physiological
dependence: in sisting dementia; substance-induced amnestic disorder; and substance-induced psychotic, mood,
DSM-IV, this modifier anxiety, sexual dysfunction, and sleep disorders).
is given to a diagnosis The DSM-IV text defines dependence as follows: “Dependence (on a substance) is defined
that includes tolerance as a cluster of three or more . . . symptoms occurring at any time in the same 12-month period”
or withdrawal or both
(Am. Psychiatr. Assoc. 1994, p. 176). This definition represents a significant departure from the
Without operational criteria for alcohol use disorder in the two editions of DSM preceding DSM-IV.
physiological
DSM-III required either tolerance or withdrawal for the diagnosis of dependence and an addi-
dependence: in
DSM-IV, this modifier tional, specific behavioral diagnosis for alcohol and cannabis; DSM-III-R required one or more
is given to a diagnosis of the physiological symptoms as well as one or more behavioral symptoms for the dependence
that does not include diagnosis. By contrast, DSM-IV states “neither tolerance nor withdrawal is necessary or sufficient
tolerance or for a diagnosis of Substance Dependence” (Am. Psychiatr. Assoc. 1994, p. 178). This statement
withdrawal
reflects field trial data indicating that cannabis-dependent persons show compulsive use without
any signs of tolerance or withdrawal, and postsurgical patients without opioid dependence may
show signs of tolerance and withdrawal without any signs of compulsive use (Schuckit 1994).
Substance dependence in DSM-IV requires one of two specifiers, with physiological depen-
dence or without physiological dependence, reflecting the presence or absence of tolerance or
withdrawal. A note in the DSM-IV text clarifies: “Tolerance and withdrawal may be associated
with a higher risk for immediate general medical problems and a higher relapse rate. Specifiers
are provided to note their presence or absence” (Am. Psychiatr. Assoc. 1994, p. 179).
Commentary. In comments on the evolution of the concept of alcoholism in successive editions

of the DSM, Schuckit and colleagues (1991) in the DSM-IV Substance-Related Disorders Work
Group explained their decision to examine the impact of these changes on patients’ progress,
course of illness, and treatment needs. The Substance-Related Disorders Work Group, in com-
mon with the other DSM-IV work groups, maintained an explicit goal of making as few changes
in diagnostic criteria as possible. As a consequence, the concept of dependence in DSM-IV re-
mained as it had been in DSM-III and DSM-III-R, emphasizing the role of biological factors,
prominently including genetics, in the development of dependence. A subsequent review of the
principal findings from the DSM-IV field trial for substance use disorders provided useful data in
support of this stance (Cottler et al. 1995).
In recognition of 100 years of research and writing about alcoholism by scientists and clinicians
throughout the world, Mann and colleagues (2000) highlighted several notable accomplishments
during the century, including Jellinek’s description of the disease concept of alcoholism, as well
as marked advances made in research on etiology, psychopathology, and treatment. Another im-
portant event was the founding of Alcoholics Anonymous in 1935 and its subsequent growth
and development. Mann and colleagues consider the current disease concept of alcoholism to in-
clude both psychosocial and neurobiological foundations (including monoaminergic dysfunction
and neuroadaptation and sensitization). Notable new treatment options include pharmacological
approaches and behavior and motivational therapy.
In another prospective/retrospective look at the substance use disorders, including substance
dependence, Frances & Widiger (2012) acknowledge that the DSM has had a substantial impact on
research, funding, and treatment as well as many civil and forensic decisions. Among the lessons
learned during the creation of DSM-IV was the importance of commissioning and publishing
critical reviews, moderating the creativity of “experts,” ensuring that field trials addressed most
important issues and concerns, and conducting meaningful risk analyses. Frances & Widiger

(2012) also suggest that future editions of the DSM should be the responsibility of the Institute
of Medicine. Much of the text of this opinion piece anticipates Frances’s lengthy and emphatic
criticism of the DSM-5 process and outcomes (e.g., Frances 2013).
In a review of progress made in conceptualizing the alcohol dependence syndrome since it
was first proposed by Edwards & Gross (1976), Buhringer (2007) suggests that future DSM
revisions of the criteria for alcohol dependence be more closely tied to research findings on the
syndrome. He proposes incorporation of the four DSM-IV alcohol abuse criteria and the seven
alcohol dependence criteria into a single dimensional scale, enabling judgments about severity
based on the number of criteria observed. In fact, this is the model adopted for diagnosis of
DSM-5 alcohol use disorders. All the criteria included in DSM-IV are among the criteria for
DSM-5, with the exception of the addition of craving and the deletion of legal troubles. Buhringer
(2007) makes additional suggestions for change, including adding “other dimensions of risk” to
the diagnostic criteria and combining a “Quantifiable Alcohol Dependence Severity Scale” with a
measure reflecting the frequency of harmful drinking. Buhringer notes that these changes would
yield an extremely complex diagnostic system.
In an article that recounted a 2002 Research Society on Alcoholism symposium designed to
provide an overview of what is known about the validity of DSM-IV and ICD-10 alcohol depen-
dence and abuse diagnoses, Hasin and colleagues (2003) reported that “the findings supported
the validity of DSM-IV alcohol dependence across numerous study designs and samples . . . and
raised questions about the validity of the diagnosis of alcohol abuse as currently defined” (Hasin
2012, p. 703). This observation supported prior research on the diagnosis of substance abuse and
dependence in DSM-III and DSM-III-R.
Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition,

Text Revision (2000)
DSM-IV-TR was a text revision designed to bring the descriptions of the substance use disorders
up to date as a result of new findings on epidemiology, etiology, and treatment. Nothing substantial
was added to or deleted from the text in the substance-related disorders chapter, and no changes
were made to operational criteria for substance use disorders or substance-induced disorders.
Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (2013)

The latest edition of the DSM has been strongly criticized in a number of books, in many articles,
and in Op-Ed pieces in prominent newspapers and other publications. One of the most critical
books and a number of disapproving essays and Op-Ed pieces were written by Allen Frances,
Task Force chair for DSM-IV. Frances (2013) strongly criticizes the DSM-5 Task Force chairs
for overdiagnosis, facilitated by undue influence on the diagnostic process by large drug com-
panies, and for overpromising the development of biomarkers and dimensional diagnosis (which
went largely unrealized). DSM-5 maintained the number of diagnoses included in DSM-III and
DSM-IV but eliminated the multiaxial system, the separate chapter on childhood and adult dis-
orders, and such well-known categorical distinctions as substance abuse and dependence and the
subtypes of schizophrenia.
Alcohol intoxication, addiction, and dependency. The DSM-5 Substance-Related and Ad-
dictive Disorders covers 10 drug categories and gambling disorders. The Work Group makes its
views on the addiction process explicit at the beginning of the chapter: “All drugs that are taken
in excess have in common direct activation of the brain reward system, which is involved in the

reinforcement of behaviors and the production of memories. . . The pharmacological mechanisms

by which each class of drugs produces reward are different, but the drugs typically activate the
system and produce feelings of pleasure, often referred to as a ‘high’. . . individuals with lower
Mild substance use
disorder: in DSM-5, levels of self-control, which may reflect impairments of brain inhibitory mechanisms, may be par-
characterized by two ticularly disposed to develop substance use disorders” (Am. Psychiatr. Assoc. 2013, p. 481). With
to three behavioral this explicit statement, the drafters of this section of DSM-5 make clear they regard the brain
and/or physiological mechanisms responsible for the brain reward system to be central to the onset and maintenance
symptoms
of addiction; brain-mediated behavioral factors such as craving and reduced levels of self-control,
Moderate substance while influential, are clearly of secondary importance in this formulation, thereby maintaining a
use disorder: in
preference for the biological/genetic model of alcohol addiction begun in DSM-III and perpetu-
DSM-5, characterized
by four to five ated in DSM-III-R and DSM-IV.
behavioral and/or The substance-related and addictive disorders section in DSM-5 includes, for the first time,
physiological a non-substance-related condition. The inclusion of the gambling disorder diagnosis is based on
symptoms substantial evidence accumulated over many years that gambling disorders activate reward systems
Severe substance use like those activated by alcohol and other drugs of abuse and manifest many familiar behaviors that
disorder: in DSM-5, characterize the substance use disorders.
characterized by six or
The DSM-5 substance-related disorders are separated into substance use disorders and
more behavioral
and/or physiological substance-induced disorders. The essential feature of a substance use disorder is “a cluster of
symptoms cognitive, behavioral, and physiological symptoms indicating that the individual continues us-
ing the substance despite significant substance-related problems” (Am. Psychiatr. Assoc. 2013,
p. 483). The substance-induced disorders include substance intoxication, substance withdrawal,
and other substance/medication-induced mental disorders, including psychotic disorders, bipolar
and related disorders, depressive disorders, anxiety disorders, obsessive-compulsive and related
disorders, sleep disorders, sexual dysfunctions, delirium, and neurocognitive disorders.
The distinction between substance abuse and substance dependence first made in DSM-III
and continued in DSM-III-R and DSM-IV has been eliminated from DSM-5. Replacing it is a
dimensional assessment of severity of substance use that reflects the number of symptoms observed.
Thus, a mild substance use disorder diagnosis is triggered by two or three of the eleven symptoms
of substance use disorder listed in DSM-5, a moderate substance use disorder diagnosis by four
or five symptoms, and a severe substance use disorder diagnosis by six or more symptoms.
Bartoli and colleagues (2015) compared prevalence rates for alcohol use disorder diagnoses
among DSM-IV, DSM-IV-TR, and DSM-5. In the 12 prevalence studies Bartoli and colleagues
examined, seven showed an increase in prevalence when DSM-5 criteria were compared to
DSM-IV and DSM-IV-TR criteria, two showed no substantial difference, and three showed a
decrease in prevalence.
The DSM-5 text observes that “the word addiction is not applied as a diagnostic term in this
classification . . . the word is omitted from the official DSM-5 substance use disorder diagnostic
terminology because of its uncertain definition and its potentially negative connotation” (Am.
Psychiatr. Assoc. 2013, p. 485). This decision reflects efforts by the DSM-5 Substance-Related
and Addictive Disorders Work Group to eliminate the confusion that derives from use of the
word dependence to describe both dependence on opiate pain medication and dependence on
illicit dependency-inducing drugs. In a brief article written to clarify reasons for the decision to
use the word addiction to refer to the former condition, O’Brien (2010), chair of the Work Group,
explains that dependence had come “to refer [both] to uncontrolled drug-seeking behavior [as well
as to] the physiological adaptation that occurs when medications acting on the central nervous
system are ingested with rebound when the medication is abruptly discontinued” (p. 866), thereby
creating confusion that “may have propagated current clinical practices related to undertreatment
of pain” (p. 866).

Commentary. In comments on the decision by the DSM-5 Work Group to combine the abuse
and dependence criteria, Hasin (2012) expressed her initial concerns about the decision to do so by
recalling that she was “one of the last holdouts against combining the abuse and dependence criteria
because, to me, the dependence process and its consequences do seem conceptually distinct”
(p. 702). She ultimately changed her mind when confronted by the “overwhelming abundance of
evidence” in favor of combining the two conditions. Hasin also anticipates the possibility that,
in the future, “indicators of the dependence syndrome process at a more endophenotypic level”
(Hasin 2012, p. 703) may be identified. This observation reflects the hopes of psychiatry that
the discovery of physiological biomarkers will make it easier to confirm reliable diagnoses (e.g.,
Frances 2013, Gorman & Nathan 2015, Hasin et al. 2013).
In a 60-year perspective on DSM alcoholism, Sellman and colleagues (2014) anticipate future
research on the decision to eliminate the abuse-dependence dichotomy. That research will likely
include efforts to distinguish among the criteria in terms of predictive power. These authors also
ask for research on the best criteria for the choice between an abstinence treatment goal versus a
controlled-drinking treatment goal. Sellman et al. (2014) also anticipate that DSM-6 will provide
the established link between biomarkers for neurophysiological processes that develop in response
to ongoing alcohol use and behavioral symptoms of alcoholism.
CONCLUSION
For most of recorded history, human beings viewed alcohol and drug addiction/dependence largely
as actions of the gods, often as a consequence of immoral acts committed against their wishes.
It was not until the beginning of the scientific revolution in the eighteenth and nineteenth cen-
turies that psychiatrists Pinel, Rush, Kraepelin, Bleuler, and Freud began to offer evidence from
clinical observations that biological factors also play a role in the addiction process. Reflecting
the influence of psychodynamic theories of etiology after the Second World War, DSM-I and
DSM-II emphasized those theories in attempting to explain the addiction process. In reaction,
the developers of DSM-III explicitly adopted an atheoretical position on the development of ad-
diction, although more-or-less nonspecific biological factors were given considerable credit for
this phenomenon as well. DSM-IV and DSM-5 take an avowedly biological view of the addiction
process; DSM-5 is quite explicit in pointing to growing empirical research findings implicating
specific brain mechanisms in the addiction process.
SUMMARY POINTS
1. Before the beginnings of scientific psychiatry, an array of beliefs about the causes of
alcohol intoxication, addiction, and dependency (AAD) prominently included the super-
natural and moral models.
2. Pinel, Rush, Kraepelin, Bleuler, and Freud exerted marked influences in the nineteenth
century on society’s change in perception of the causes of AAD from moral and behavioral
factors toward biological factors.
3. The first two editions of the Diagnostic and Statistical Manual of Mental Disorders (DSM-I
and DSM-II), the first national nomenclatures, were strongly influenced by psycho-
analytic theory; they proved only marginally useful because of their poor diagnostic
reliability.
4. DSM-III marked a transition point by markedly enhancing diagnostic reliability and
attempting to heighten diagnostic validity and utility.

5. The concept of dependence and addiction in DSM-III, DSM-IV, and DSM-5 reflects
an increasingly strong biological bias.
FUTURE ISSUES
1. Will biological or behavioral models of substance use disorders ultimately become most
useful for clinicians?
2. When will biomarkers for DSM diagnoses become fully developed and diagnostically
useful?
3. Will categorical or dimensional diagnoses of the substance use disorders prove most
useful?
4. When will neuroscience biomarkers for substance use disorders become fully developed
and utilized?
DISCLOSURE STATEMENT
The authors are not aware of any affiliations, memberships, funding, or financial holdings that
might be perceived as affecting the objectivity of this review.
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History of the Concept of Addiction

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Mental Imagery in Depression: Phenomenology, Potential
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Interactive and Mediational Etiologic Models of Eating Disorder
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Paraphilias in the DSM-5

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CP12CH02-Nathan ARI 5 February 2016 17:1

Peter E. Nathan,1 Mandy Conrad,2

and Anne Helene Skinstad2

Annu. Rev. Clin. Psychol. 2016. 12:29–51 Keywords

IN THE DIAGNOSTIC AND STATISTICAL MANUALS . . . . . . . . . . . . . . . . . . . . 35

Diagnostic and Statistical Manual of Mental Disorders, Second Edition (1968) . . . . . . . . 37

ALCOHOL INTOXICATION, ADDICTION, AND DEPENDENCY

30 Nathan · Conrad · Skinstad

1994, pp. 399–419).

ALCOHOL INTOXICATION, ADDICTION, AND DEPENDENCY

www.annualreviews.org • History of the Concept of Addiction 31

THE BEGINNINGS OF MODERN SCIENTIFIC PSYCHIATRY

32 Nathan · Conrad · Skinstad

TEMPERANCE IN THE UNITED STATES

www.annualreviews.org • History of the Concept of Addiction 33

DEVELOPMENT OF A US NATIONAL PSYCHIATRIC

34 Nathan · Conrad · Skinstad

ALCOHOL INTOXICATION, ADDICTION, AND DEPENDENCY

Diagnostic and Statistical Manual of Mental Disorders, First Edition (1952)

www.annualreviews.org • History of the Concept of Addiction 35

36 Nathan · Conrad · Skinstad

Diagnostic and Statistical Manual of Mental Disorders, Second Edition (1968)

www.annualreviews.org • History of the Concept of Addiction 37

38 Nathan · Conrad · Skinstad

www.annualreviews.org • History of the Concept of Addiction 39

Alcohol intoxication, addiction, and dependency. Substance use disorders in DSM-III—

40 Nathan · Conrad · Skinstad

Commentary. Included in a broad-based overview of the changes brought to the US psychi-

Diagnostic and Statistical Manual of Mental Disorders,

42 Nathan · Conrad · Skinstad

Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (1994)

www.annualreviews.org • History of the Concept of Addiction 43

Commentary. In comments on the evolution of the concept of alcoholism in successive editions

44 Nathan · Conrad · Skinstad

Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition,

Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (2013)

www.annualreviews.org • History of the Concept of Addiction 45

reinforcement of behaviors and the production of memories. . . The pharmacological mechanisms

46 Nathan · Conrad · Skinstad

www.annualreviews.org • History of the Concept of Addiction 47

48 Nathan · Conrad · Skinstad

www.annualreviews.org • History of the Concept of Addiction 49

Am. Psychol. 38:1116–21

50 Nathan · Conrad · Skinstad

www.annualreviews.org • History of the Concept of Addiction 51

Contents Volume 12, 2016

The Efficacy of Exposure Therapy for Anxiety-Related Disorders and

Edna B. Foa and Carmen P. McLean p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 1

History of the Concept of Addiction

Resolving Ambiguity in Emotional Disorders: The Nature and Role of

Onset: Evidence from Prospective Studies

Paraphilias in the DSM-5

Cumulative Index of Contributing Authors, Volumes 3–12 p p p p p p p p p p p p p p p p p p p p p p p p p p p p 543

An online log of corrections to Annual Review of Clinical Psychology articles may be

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