Are We Creating Our Own Addiction Surge?
Rather than over-diagnosing, is psychiatry actually causing the maladies it laments?
The American Psychiatric Association creates the gold standard for diagnoses of mental disorders in the United States—and worldwide—through its Diagnostic and Statistical Manual of Mental Disorders. DSM-IV was published in 1994. In 2013, DSM-5 was released.
As I describe in the March, 2014 issue of Reason, there are several notable peculiarities about the manual. DSM-5
eliminates the distinction between dependence and abuse. Instead it classifies substance use disorders as mild, moderate, or severe. Thus the DSM-5 does not explicitly recognize such a thing as drug addiction or dependence. But under "Substance Use and Addictive Disorders" the manual includes a category called "Behavioral Addictions" that so far consists of a lone entry: "Gambling Disorder."
These two major conceptual changes immediately aroused suspicion. Writing in the New York Times, investigative reporter Ian Urbina accused the psychiatric establishment and pharmaceutical industry of expanding the whole treatment enterprise by including "mild" substance use disorders, as well as recognizing things other than substances as being addictive. Keith Humphreys, a Stanford psychology professor, "predicted that as many as 20 million people who were previously not recognized as having a substance abuse problem would probably be included under the new definition."
My argument is more fundamental. The ways of thinking about substance use and disorders embedded in DSM-5 and promoted by American psychiatry are actually causing an epidemic of these disorders.
The DSM-5 chickens have come home to roost, so to speak. The National Institute on Alcohol Abuse and Alcoholism conducts national studies every 10 years about people's lifetime substance use. There have been three such massive studies, called first NLAES, then NESARC, each interviewing from 35,000 to more than 40,000 Americans. I have discussed NESARC's earlier results from 2001-02 in Reason.com and those of its predecessor, NLAES, in Reason.
Both studies found a steady decline in substance abuse with age, despite only a small minority of people (from 20-25 percent) who receive any kind of treatment for their substance problems. People mainly quit their drug use and moderate their drinking as they emerge from their teens and 20s. Needless to say, such "maturing out" refutes both Alcoholics Anonymous' and the "chronic brain disease" model's view of addiction and alcoholism as progressive diseases.
So the stage was set for the first national study based on DSM-5's categorization. Called NESARC-III, the study measured American drinking in 2012-13. The focus of the study report was alcohol use disorders, or AUD. Among adults 18 and older, 14 percent of Americans currently had an AUD, according to their drinking over the past year. That's 32.5 million Americans. And almost 30 percent had an AUD over their lifetimes (68.5 million). This was a sharp increase over 2001-2002 NESARC study, when only 8.5 percent of Americans had a current drinking problem.
One typical reaction came from Tom Horvath, the distinguished president of SMART Recovery, who opined: "It was easy to predict that when AUD came to include a mild option the number of cases would expand."
But that's not true.
How do we know? The NESARC-III researchers also analyzed the study's data using the old DSM-IV criteria. And the increase in past-year substance use disorders (SUDs) from 2001-2002 remained the same—it increased by roughly 50 percent. At the same time, using DSM-IV criteria as the standard, lifetime SUDs showed the same 50 percent increase, rising from below 30 percent in 2001-02 to 44 percent in 2012-13. (Using the DSM-5 criteria, the NESARC-III lifetime figure had not risen.)
Forty-four percent of Americans have experienced a substance use disorder in their lives?! That's heavy. But this measured increase is not due to a change in the measurement instrument. It's due to a shift in Americans' drinking. This shift involved interviewees reporting both higher levels of drinking and more drinking problems (not necessarily the same thing).
At the same time, also proving that the diagnosis was not fatuous, those with an AUD were more likely to suffer disabilities and to have concurrent emotional problems. They had significantly more "major depressive and bipolar disorders and antisocial and borderline personality disorders across all levels of AUD severity." This impact of the DSM-5 AUD diagnosis is not surprising. In order to achieve such a diagnosis, the volume cautions, a person must be both impaired and distressed by their condition.
On the positive side, as with all prior such studies, AUD is still shown to decline radically with age. Despite only a fifth of diagnosed AUD subjects having received any form of treatment for it, AUD in NESARC-III declined for each age-cohort. Of those 18-29, 27 percent had a past-year AUD. Of those 30-44, 16 percent had one. Of those 45-64, 10 percent. Of those 65 and older (my age), 2 percent did.
Why are significant substance use disorders growing overall? The NIAAA, which conducted the study, knows the answer, and how to respond to it. People are in denial, and are afraid to acknowledge their drinking problems. Therefore, the NIAAA concludes, "The NESARC-III data indicate an urgent need to educate the public and policy makers about AUD and its treatment alternatives, [and] to destigmatize the disorder…."
Really? Is the problem in America that we—and especially young people—don't hear enough about the dangers of drinking (remember, the U.S. is virtually unique in the world in restricting legal drinking to those 21 years of age and older) and how alcohol and drugs cause a brain disease? Isn't that strictly the province of American substance use ideology, steeped in our temperance traditions? In fact, research shows, those who believe in the disease theory are more likely to relapse to alcoholism after being treated for a drinking problem!
So what we are actually doing is educating people to engage in, and to experience, problematic, uncontrolled drinking. I guess we can test my theory by seeing whether, in 10 more years, all of our further education about the brain diseases of alcoholism and addiction, in which school kids are currently indoctrinated, reduces substance use problems.
The alternative approach is to normalize substance use, to teach people that they can and should control it, and to bring drinking and drug use under the aegis of individual and community control. Americans, on their own, seem to be inclined to do this. Indeed, there is no alternative.