Alcoholics Anonymous and Alcoholism as a Disease


Alcoholics Anonymous has seen prolific growth since its inception in the 1930s. Official tallies conducted by the organization pegs the number of members at 2.1m internationally, although many feel this is a conservative estimate. As a result, AA's membership has helped popularize the disease concept of alcoholism. However, the consideration of alcoholism as a disease has appeared since the late eighteenth century. Initially, Alcoholics Anonymous avoided the term "disease", backtracking in 1976 where conference-approved literature categorically stated that "we had the disease of alcoholism."


Though cautious regarding the medical nature of alcoholism, AA has let others voice opinions. The Big Book states that alcoholism "is an illness which only a spiritual experience will conquer." Ernest Kurtz says this is "The closest the book Alcoholics Anonymous comes to a definition of alcoholism." In his introduction to The Big Book, non-member Dr. William Silkworth said those unable to moderate their drinking have an allergy. Addressing the allergy concept, AA said "The doctor’s theory that we have an allergy to alcohol interests us. As laymen, our opinion as to its soundness may, of course, mean little." AA later acknowledged that "alcoholism is not a true allergy, the experts now inform us." Wilson explained in 1960 why AA had refrained from using the term "disease":


“We did not wish to get it wrong with the medical profession by pronouncing alcoholism a disease entity. Hence, we have always called it an illness or a malady—a far safer term for us to use. “


More recently Since then medical and scientific communities have defined alcoholism as an "addictive disease" (aka Alcohol Use Disorder, Severe, Moderate, or Mild). The ten criteria are:


  1. Alcoholism is a Primary Illness not caused by other illnesses nor by personality or character defects

  2. An addiction gene is part of its etiology

  3. Alcoholism has predictable symptoms

  4. It is progressive, becoming more severe even after long periods of abstinence

  5. It is chronic and incurable

  6. Alcoholic drinking or other drug use persists in spite of negative consequences and efforts to quit

  7. Brain chemistry and neural functions change so alcohol is perceived as necessary for survival

  8. It produces physical dependence and life-threatening withdrawal

  9. It is a terminal illness

  10. Alcoholism can be treated and can be kept in remission.


What are the Symptoms?


In the DSM-5, Alcohol use disorder is defined as a problematic pattern of alcohol use leading to clinically significant impairment or distress as manifested by at least 2 of the following criteria over the same 12-month period:


  • Alcohol used in larger amounts or over a longer period of time than intended

  • Persistent desire or unsuccessful attempts to cut down or control alcohol use

  • Significant time spent obtaining, using, and recovering from the effects of alcohol

  • Craving to use alcohol

  • Recurrent alcohol use leading to failure to fulfill major role obligations at work, school, or home

  • Recurrent use of alcohol, despite having persistent or recurring social or interpersonal problems caused or worsened by alcohol

  • Recurrent alcohol use despite having persistent or recurring physical or psychological problems caused or worsened by alcohol

  • Giving up or missing important social, occupational, or recreational activities due to alcohol use

  • Recurrent alcohol use in hazardous situations

  • Tolerance: markedly increased amounts of alcohol are needed to achieve intoxication or the desired effect, or continued use of the same amount of alcohol achieves a markedly diminished effect

  • Withdrawal: there is the characteristic alcohol withdrawal syndrome, or alcohol is taken to relieve or avoid withdrawal symptoms.

  • Severity is specified based on the number of criteria met: mild alcohol use disorder when 2 to 3 criteria are met, moderate alcohol use disorder when 4 to 5 criteria are met, and severe alcohol use disorder when 6 or more criteria are met. Remission is specified when no criteria, other than cravings, are met for at least 3 months (early remission) or 12 months (sustained remission).


Recent brain research suggests that this abnormal response to alcohol is an addictive brain response caused by a disruption in the pleasure or reward centres of the brain. This creates an intense sense of euphoria when using and a state of agitated depression when abstinent. This reinforces continued use.


As the brain develops tolerance for the alcohol it takes higher doses to feel the euphoria so the quantity of drinking in increases. This creates a pattern of compulsive use described in AA literature as a loss of control. The metaphor of an allergy to alcohol is easier to understand for a newly sober person than the idea of an addictive brain response, so the metaphor is still useful.


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