The disease concept of alcoholism.
... For decades, theoretical models of addictive behavior have conceptualized negative affect as a precursor to substance use and core to the development of substance use disorders (SUDs; e.g., Baker et al., 2004;Cooper et al., 1995;Jellinek, 1960;Koob & Le Moal, 2001). Some of the first research studies on substance use/problems conceptualized substance use problems as a reliance on substances to decrease emotional/bodily pain (e.g., Jellinek, 1960), and decades of research since have sought to investigate links between higher levels of negative affect (e.g., depression, anxiety, stress) and substance use behavior (e.g., Brière et al., 2014;Dyer et al., 2019;Foulds et al., 2015;Galaif et al., 2007;Grant & Harford, 1995;McHugh & Weiss, 2019). ...
... For decades, theoretical models of addictive behavior have conceptualized negative affect as a precursor to substance use and core to the development of substance use disorders (SUDs; e.g., Baker et al., 2004;Cooper et al., 1995;Jellinek, 1960;Koob & Le Moal, 2001). Some of the first research studies on substance use/problems conceptualized substance use problems as a reliance on substances to decrease emotional/bodily pain (e.g., Jellinek, 1960), and decades of research since have sought to investigate links between higher levels of negative affect (e.g., depression, anxiety, stress) and substance use behavior (e.g., Brière et al., 2014;Dyer et al., 2019;Foulds et al., 2015;Galaif et al., 2007;Grant & Harford, 1995;McHugh & Weiss, 2019). These negative reinforcementbased models posit that engaging in substance use reduces negative affect, which habituates a process in which individuals use substances to alleviate negative affect, but, over time, experience reduced benefits due to increased tolerance. ...
Objective: Negative reinforcement models suggest that negative affect should predict event-level substance use, however, supporting daily-life evidence is lacking. One reason may be an emphasis in ecological momentary assessment (EMA) research on use behavior, which is subject to contextual and societal constraints that other substance outcomes, such as craving, may not be subject to. Therefore, the present study tested momentary, within-person reciprocal relations among negative affect and craving for alcohol and cannabis in daily life. Method: Adults (N = 48) completed 60 days of EMA, consisting of four daily reports spanning 7 a.m.–11 p.m. assessing current negative affect and alcohol/cannabis craving. Preregistered analyses used dynamic structural equation modeling to test whether (a) within-person increases in negative affect co-occurred with within-person increases in alcohol and cannabis craving, and (b) within-person increases in negative affect predicted later within-person increases in craving (and vice versa), and (c) relations differed by substance use frequency. Results: Within-person increases in negative affect were contemporaneously associated with within-person increases in alcohol and cannabis craving. However, increases in negative affect did not prospectively predict increases in craving, and within-person increases in craving did not prospectively predict within-person increases in negative affect. Within-person relations were not moderated by substance use frequency. Conclusions: Negative affect and craving were associated in community adults. However, results advance a growing body of EMA work suggesting that the association of daily-life negative affect and substance use is, at best, not straightforward. Careful attention is needed to better translate existing negative reinforcement theory to the realities of daily life.
... Other well-known and widely used tests include the Brief Michigan Alcoholism Screening Test (BMAST), the MacAndrew Alcoholism Scale (MAC), and the Iowa Alcoholic Stage Index (IASI). Each of these tests consists of five sections (work, family, finances, interactions with police, health status) that help identify the early, middle, and late stages of alcoholism [10]. According to E. Harbutg, BMAST is a useful tool for distinguishing problem drinkers from non-problem drinkers within the general population and for identifying drinking patterns among these individuals [14]. ...
This article presents the results of a study on the development of a methodology for assessing the predisposition to alcohol abuse among personnel of the National Guard of Ukraine engaged in state security tasks. The study involves identifying the personal characteristics of military personnel and categorizing them into one of seven types of predisposition to alcohol abuse. Additionally, it examines the factors in assigned tasks performance that contribute to the development of this predisposition. The article describes the step-by-step actions of officials in utilizing the methodology for assessing the predisposition to alcohol abuse among NGU personnel. The results of the methodology's testing and its effectiveness evaluation in the military units and subdivisions of the National Guard of Ukraine are presented.
... This construct is central to the definition of addictive behaviours, including behavioural addictions (Corless & Dickerson, 1989;O'Connor & Dickerson, 2003;Petry, Zajac, & Ginley, 2018). IC has been studied as a phenomenon that occurs along a continuum, ranging from total control to a complete lack of control over one's behaviour, as described in gambling studies (Baron et al., 1995;Dickerson & O'Connor, 2006;Heather, Booth & Luce, 1998;Heather, Tebbutt, Mattick & Samir, 1993;Jellinek, 1960;Kyngdon, 2004). Although research has reported that GD involves various harms, a current gap in the literature is research that examines the specific association between IC and gaming-related harms. ...
Background: Impaired control over drinking is a central feature of Alcohol Use Disorder (AUD), yet little within-person research on impaired control is available. As a result, there is little research regarding the dynamic impact of social drinking context on impaired control. The current study sought to fill these gaps, testing a sequential mediation model wherein social drinking context predicted episode-specific deviations in perceived impaired control, which indirectly predicted daily negative consequences via drinking more than planned. We also modeled if estimated blood alcohol concentration (eBAC) moderated associations between social context and perceived impaired control.
Methods: Emerging adults (N=131; 51.8% female) completed 21 days of ecological momentary assessments, including assessments of past-night drinking and planned drinking on a given day, and event-contingent reports during acute drinking episodes.
Results: At the episode-level, social drinking context predicted higher perceived impaired control than an individual’s daily average. At the daily-level, social drinking context predicted higher perceived impaired control, which indirectly predicted more negative consequences than a person’s average via drinking more than planned. There was a residual effect of social context on drinking more than planned and negative consequences, and of perceived impaired control on negative consequences above and beyond drinking more than planned. Episode-level relations between social context and perceived impaired control were potentiated at higher vs. lower eBACs than an individual’s daily average, but the same pattern was not observed at the daily-level.
Conclusions: Just-in-time interventions may benefit from increasing perceptions of control over drinking behavior, particularly during social drinking episodes.
Zusammenfassung
Der Beitrag widmet sich aus einer geschlechterhistorischen Perspektive der Geschichte von sowie Diskussionen über einen konstatierten Anstieg von Frauenalkoholismus in der Bundesrepublik. Seit den 1950er Jahren beklagt der psychiatrische, pädagogische und psychologische Diskurs einen zunehmenden weiblichen Alkoholkonsum und macht die Frauenemanzipation als dessen Ursache aus. Der Artikel beleuchtet die männlich dominierten Debatten über Frauenalkoholismus bis 1968 sowie anschließend einsetzende feministische Kritiken. Er analysiert die in den Diskussionen über „die trinkende Frau“ zum Ausdruck kommenden Veränderungen der gesellschaftlichen Rolle von Frauen sowie zeitgleich sich formierende wissenschaftlich-patriarchale Gegenbewegungen. Dabei zeigt der Beitrag zum einen, wie ein klassischer Suchtbegriff aufgrund des Scheiterns medizinischer Behandlungsversuche erodiert und durch neues psychosoziales Erklärungswissen ersetzt wird. Zum anderen verdeutlicht er, wie die Frauenselbsthilfe sich dieses Wissen aneignet und neu interpretiert.
Alcohol is socially accepted and widely consumed as a recreational beverage. Furthermore, it is used as a disinfectant for medicinal purposes and as a cultural asset it is also part of religious rituals. However, it is also an intoxicant and an addictive substance. The deleterious side of alcohol is reflected in the fact that around 3 million people worldwide die every year as a direct or indirect result of alcohol consumption. For several decades, epidemiological studies suggested that drinking alcohol in moderate quantities was beneficial. This was referred to as the “French paradox,” which described differences in mortality between France and Finland mainly, but also other countries, that were found in epidemiological studies. The difference in the levels of alcohol consumption was found to explain the differences in mortality in view of the otherwise similar risk factors. When alcoholic drinks per day were plotted against all-cause mortality this led to a J-shaped curve. This finding represented a window of benefit for moderate alcohol consumption. However, the recent publication by Zhao et al. in 2023 revisited the relationship between the quantity of alcohol consumed and mortality risk and led to a paradigm change, which has influenced not only the recommendations of Canada’s Guidance on Alcohol and Health but also the recommendations and guidelines of major health organizations: “No alcohol is better than a little.” The J‑shaped curve as an explanation of the French paradox became a linear relationship between the amount of alcohol consumption and the increasing mortality from tumors and cardiovascular diseases. The renewed review of several control groups in previous epidemiological studies revealed a recruitment error due to the inclusion of abstinent ex-drinkers. Taking this bias into account, the alcohol-friendly view of small amounts of alcohol being cardioprotective had to be revised. The combined misuse of alcohol and other risk factors for carcinogenesis and heart diseases still needs further attention. The misuse of both alcohol and cocaine led to the conclusion that when the two risky substances are consumed together, it is even more detrimental than the mere sum of the two.
The work aims to analyse the theme of gambling with a multidisciplinary approach. Specifically, the volume collects the proceedings of the conference, held at the University of Siena in December 2023, entitled ‘Gambling: a multidisciplinary perspective’. The work was conceived with the precise intent of providing a broad spectrum of the issues related to gambling and the implications it assumes with respect to law, economics, and with respect to the field of medicine.
In this chapter I briefly survey the current field of addiction studies. Framed around the questions: What is adiction?; What is addictive?; and, When is addiction?; this chapter highlights the points that addiction (a) as a phenomenon, does not exclusively relate to the excessive or problematic use of intoxicants, but can be considered in relation to a broad range of behaviours and pursuits, and (b) has an element of essential material existence and can therefore be considered transhistorically.
Introduction
This study aims to clarify differences in mood, craving, and treatment response between reward and relief/habit individuals in a study of naltrexone, varenicline, and placebo. We hypothesized that relief/habit individuals would have a poorer mood during early abstinence and higher levels of alcohol craving than reward individuals. We hypothesized that reward individuals would demonstrate better drinking outcomes on naltrexone versus placebo.
Methods
Data were culled from a randomized, double-blind, placebo-controlled human trial of 53 individuals (18F/16M) with alcohol use disorder randomized to varenicline (n = 19), naltrexone (n = 15), or matched placebo (n = 19). In this 6-day practice quit trial, participants attempted to abstain from drinking and completed daily diaries. Participants were classified into reward or relief/habit subgroups based on self-reported motivation for drinking. Multilinear models tested differences in mood and alcohol craving between reward and relief/habit individuals. General linear models tested differences between reward and relief/habit individuals’ drinking outcomes on each medication versus placebo.
Results
Relief/habit individuals showed decreases in positive mood and increases in negative mood over the quit attempt across medications, compared to reward individuals (P’s < .05). Reward individuals’ tension decreased on naltrexone, while relief/habit individuals’ tension remained stable (F = 3.64, P = .03). Reward individuals in the placebo group had higher percent days abstinent than relief individuals in the placebo group (P < .001).
Discussion
This study suggests relief/habit individuals’ mood worsens during early abstinence. Our finding that reward individuals’ tension decreased on naltrexone and increased on placebo may suggest a clinical response to the medication.
Evidence of alcohol use in human societies extends to the beginning of recorded history. Nearly all societies have discovered and used some form of beverage alcohol. The emergence of concepts of alcohol‐related problems in the form of alcoholism and repeated patterns of alcohol abuse is a social development of the past 500 years, especially the past 200 years. Alcohol abuse and alcoholism are typically defined in a culture through the emergence of various means of formal social control. Sociology has a long tradition of critical perspectives on the dominant definitions of alcohol‐related problems and accompanying social policies. It is clear that, given its potentially harmful effects, its widespread use, and the politically powerful alcohol production and distribution industry, there is considerable ambivalence around the notions of appropriate and inappropriate uses of alcohol in most of the world today.
Introduction and objective: The term “demoralisation”, which was introduced by Jerome Frank, is used to describe a mental state in which a person has lost the fortitude and strength to endure the hardships associated with carrying out life tasks. According to Otto F. Kernberg’s concept, personality organisation is understood as a relatively stable pattern of functioning that determines the maintenance of internal balance and relationships with others. It was assumed that if personality structures become pathologised during development, it may result in the development of mental disorders. All diseases may be accompanied by a state of helplessness, powerlessness, along with a sense of meaninglessness and emptiness in life, which in turn makes recovery difficult. The aim of the study was to assess the relationship between the dimensions of personality organisation and the demoralisation in a group of alcohol-dependent individuals, taking into account the perceived stress. Materials and methods: The study used the Inventory of Personality Organization, the Demoralization Scale II, the Restructured Clinical Demoralization scale from the MMPI-2 and the Distress Thermometer. A total of 91 alcohol-dependent individuals were assessed, including 65 (71%) men and 26 (29%) women. The average age of the participants was 43.6 years (standard deviation, SD = 12.92). Results: Positive correlations were found between personality dimensions and demoralisation and discouragement. Three clusters of people were identified among the respondents, which differed in the intensity of abnormalities in personality organisation and demoralisation. Conclusions: The presented results are part of the discussion on the importance of personality for the development and formation of demoralisation.
Problematic alcohol use (PAU) has been a marginalised subject within the systemic field. The present article brings PAU into focus and discusses the conceptualisation of PAU. Reflected in the dominance of individually orientated treatment approaches, PAU is widely seen as an individual condition with aetiology and maintenance attributed to individual pathology and behaviour. Pathologising and stigmatising dominant discourses surrounding PAU also appear to perpetuate this individual conceptualisation, the implications of which are discussed in this article. The present article maintains PAU is a relational illness, with relational aetiology and maintenance, thus with relational implications for treatment. Implications for the systemic field, including clinical practice, are highlighted.
Alcohol is a socially accepted food and beverage and as a cultural asset is also part of religious rituals. It can be an intoxicant and an addictive substance. It is also a noxious substance as around 3 million people worldwide die every year as a result of alcohol consumption. With the publication by Zhao et al. 2023 the relationship between the quantity of alcohol consumption and mortality reached a new level and changed the recommendations of Canada’s Guidance on Alcohol and Health. The J‑curve of the French paradox became a linear relationship between alcohol consumption and mortality because the review of several control groups in previous studies revealed a recruitment error from abstinent ex-drinkers. In their systematic analysis, taking this bias into account the assessment of small amounts of alcohol as a cardioprotective stimulant had to be revised. This is a paradigm shift.
In this chapter, we review explanatory frameworks that have been used since the arrival of European colonisers in Australia to interpret Aboriginal alcohol use and provide a foundation for policies and programs. Eight frameworks are discussed: (1) models positing biological differences between Aboriginal and non-Aboriginal people in the effects of alcohol; (2) models of Aboriginal alcoholism as a disease; (3) psychological explanations for drinking among Aboriginal people; (4) policy approaches based on viewing alcohol misuse as a public health problem; (5) sociological and anthropological explanations for alcohol use by Aboriginal people; (6) explanations grounded in critiques of sociological and anthropological explanations; (7) alcohol misuse interpreted as a product of the social determinants of health and (8) interpretation of alcohol misuse as a product of unresolved, intergenerational trauma. Each of these frameworks has implications for policies and programs which are explored in subsequent chapters.
Artwork by Delvene Cockatoo-Collins
Background and aims In 1561, physician and philosopher Pascasius Justus Turq published a monograph on the description and treatment of pathological gambling. When the monograph came to the attention of the authors in 2006, there existed no known translation of it in any modern language. In 2014, it was translated and published in French. This paper analyses the monograph’s key content elements and its place in the history of the concept of addiction. Methods A contextual analysis of the late Italian Renaissance, followed by key excerpts from the text and commentaries on the meaning and significance of the monograph. Findings and conclusions Pascasius Justus Turq’s 1561 monograph on pathological gambling outlines a disease view of gambling, identifies cognitive processes and biological vulnerabilities as aetiological factors, avoids religious or moral judgements, and recommends cognitive treatment to change the beliefs and expectancies of gamblers. This study shows that a “disease formulation” of addiction was enunciated as early as the 16th century, and its contemporary resonance suggests that current clinical features of addictive disorders have existed for centuries.
Keywords: History of the idea of addiction, Alea, Sive de Curanda in Pecuniam Ludendi Cupiditate, disease model, pathological gambling, Pascasius, cognitive therapy, Benjamin Rush, Thomas Trotter.
In this chapter we shall see how stress may cause people to behave in ways which are undesirably different from the ways in which other people behave. In fact, some would propose that the phrase undesirable difference would serve as an adequate definition of the more common term ‘deviance’. The nature of deviance may be viewed from five different angles: (a) the freak, who exhibits abnormal physical, physiological, intellectual and mental qualities; (b) the sinful, who offends against either religious or secular ideologies; (c) the criminal, whose actions are unlawful; (d) the alienated, who turns against cultural and social values; (e) the pathological whose aberrant actions are the result of ‘breakdowns’ in mental health. It is this latter with which we are principally concerned.
The present paper highlights how alcohol use disorder (AUD) conceptualizations and resulting diagnostic criteria have evolved over time in correspondence with interconnected sociopolitical influences in the United States. We highlight four illustrative examples of how DSM-defined alcoholism, abuse/dependence, and AUD have been influenced by sociopolitical factors. In doing so, we emphasize the importance of recognizing and understanding such sociopolitical factors in the application of AUD diagnoses. Last, we offer a roadmap to direct the process of future efforts toward the improved diagnosis of AUD, with an emphasis on pursuing falsifiability, acknowledging researchers’ assumptions about human behavior, and collaborating across subfields. Such efforts that center the numerous mechanisms and functions of behavior, rather than signs or symptoms, have the potential to minimize sociopolitical influences in the development of diagnostic criteria and maximize the treatment utility of diagnoses.
In this paper, I examine Reinforcement Learning (RL) modelling practice in psychiatry, in the context of alcohol use disorders. I argue that the epistemic roles RL currently plays in the development of psychiatric classification and search for explanations of clinically relevant phenomena are best appreciated in terms of Chang’s (2004) account of epistemic iteration, and by distinguishing mechanistic and aetiological modes of computational explanation.
Aim:
To examine whether in Europe perceptions of 'alcoholism' differ in a discrete manner according to geographical area.
Method:
Secondary analysis of a data set from a European project carried out in 2013-2014 among 1767 patients treated in alcohol addiction units of nine countries/regions across Europe. The experience of all 11 DSM-4 criteria used for diagnosing 'alcohol dependence' and 'alcohol abuse' were assessed in patient interviews. The analysis was performed through Multiple Correspondence Analysis.
Results:
The symptoms of 'alcohol dependence' and 'alcohol abuse', posited by DSM-IV, were distributed according to three discrete geographical patterns: a macro-area mainly centered on drinking beer and spirit, a culture traditionally oriented toward wine and a mixed intermediate alcoholic beverage situation.
Conclusion:
These patterns of perception seem to parallel the diverse drinking cultures of Europe.
Around 2009, ‘recovery’ was introduced in the Netherlands as a new approach to drug addiction and addiction services. Recovery is now featured in practice-level policy but is absent in governmental drug policy. To investigate whether the Dutch recovery vision is coherent with governmental drug policy, we apply Bacchi’s What’s the problem represented to be? approach to analyse problematizations of ‘drug addiction’. We analysed two influential practice-level policy documents and one governmental drug policy document. We found that governmental policy addresses the harms and public nuisance of drug addiction, whilst practice-level policy addresses the wellbeing of persons with addiction. Despite these different starting points, the Dutch recovery vision seems coherent with both problematizations. Its adoption in the Netherlands was less subject to political debate compared to other countries. This may be a result of recovery being driven by bottom-up efforts without government intervention, leading to constructive ambiguity between government- and practice-level policies.
“The Natural History of Alcoholism: Causes, Patterns, and Paths to Recovery” by George E. Vaillant was a pioneering longitudinal study about alcoholism and alcoholism recovery. Published in 1983 amid the competitive professional dynamics underlying a clash of the controlled drinking controversy, The Natural History of Alcoholism is a tacit exemplar of the virtues of an interdisciplinary perspective of alcoholism and alcoholism recovery. The book integrates a medical outlook toward alcoholism and alcoholism recovery with ideas from other academic disciplines; it conveys a multidimensionality of alcoholism and alcoholism recovery that necessitates contributions from an interdisciplinary collective of scientific perspectives. The Natural History of Alcoholism serves as a reminder that scientists and scholars need not approach alcoholism and alcoholism recovery by acclaiming the virtues of their own ideas about these matters while downplaying ideas with which they intellectually or ideologically differ. The Natural History of Alcoholism is a reminder of the virtues of an interdisciplinary perspective of alcoholism and alcoholism recovery.
Zusammenfassung
Alkohol ist die dominante Droge in westlichen Gesellschaften mit einer Geschichte, die sich vom Mittelalter über die Kolonialzeit bis in die Gegenwart zieht. Die historische Variabilität seines Konsums hat schon immer das Verständnis alkoholbezogener Probleme beeinflusst. Bis heute sind der öffentliche Diskurs über Suchterkrankungen und die Gestaltung des Versorgungssystems von Versatzstücken überholter Theorien geprägt, was zur Stigmatisierung und Diskriminierung betroffener Personen beitragen kann. Neben einem Überblick über die historische Entwicklung des Alkoholkonsums wird die soziokulturelle Diversität im Umgang und in der Einschätzung des Alkoholgebrauchs in westlichen Gesellschaften beleuchtet und ihre Relevanz für klinische Interventionen bewertet. Die Gründung einer bundesweiten Taskforce zur Gestaltung des Versorgungssystems wird empfohlen, um Kurzinterventionen und weitere wirksame Verfahren in der klinischen Praxis zu implementieren.
Harm reduction psychotherapy (HRP)is an approach to providing psychotherapy to people who use substances in which abstinence is considered neither a prerequisite to treatment nor its predominant mark of success. There is to date scant empirical research on this clinical approach despite its decades-long practice. Ourstudy aims to spur further investigations by asking:1) what are the basic building blocks of HRP; and (2) what theory might explain how its core strategies are unified?Eight leading HRP proponents and practitioners participated in semi-structured interviews to explore the nature of their work and how they came to it. Through an analysis of the interviewsguided by grounded theory, we propose an explanatory model of HRP as practiced in the U.S. In this model, practitioners, informed by an ethos of defiant hospitality, deploy a variety of therapeutic processes whose combined, complex effects are captured in the phrase making room, which conveys opening up space while simultaneously providing safe enclosure. Making room is operationalized in processes comprising: inviting, meeting at, staying with, holding, reframing substance use, leveraging change from within, supporting agency, and signaling the limits. We discuss the model as deeply informed by its socio-historical roots within treatment spacesthat participants experienced as failing to meet their clients' needs. We also consider HRP'simplications for expanding the reach and capacity of addiction care for the majority of individuals with substance use disorders who may initially be unwilling or unable to abstain. Lastly, we describe its potential for furthering the field's understanding of therapeutic practice with marginalized populations.
Si le passé éclaire le présent, existe-t-il sur le plan historique et social des représentations de l’alcoolisme associées à la maladie/sitigmate qui peuvent nous aider à mieux saisir ce phénomène ? Quels sont les acteurs principaux qui ont permis de valider l’équation d’alcoolisme à maladie ? Quelle place occupe le lien social dans ce processus d’étiquetage ? Le but de cet article est de réfléchir et d’analyser la tendance sociale du recours à la stigmatisation de la condition d’alcoolique comme étant une maladie. En premier lieu, nous procéderons à un essai de définition du concept de stigmatisation. En deuxième lieu, nous nous limiterons aux phases importantes ayant associé historiquement les modes de consommation à la déviance, voire à la stigmatisation. En troisième lieu, nous illustrerons des exemples en Amérique du Nord, en Europe et auprès des premières nations (Amérindiens). En guise de conclusion, nous considérerons le facteur du lien social comme une composante majeure dans la saisie de ce phénomène complexe.
Diagnostic terms exist to identify forms of substance use which are causing clinical impairment or risk and to distinguish them from normality. Both repetitive substance use and single-occasion use exist along a gradation of severity. Repetitive substance use which confers the risk of harmful consequences is termed Hazardous Substance Use, which is a new diagnostic term in the latest (eleventh) revision of the International Classification of Diseases (ICD-11). Harmful Substance Use in ICD-10 and ICD-11 denotes repetitive substance use which has caused physical or mental harm but where the guidelines for the diagnosis of Substance Dependence have not been met. At the top of this hierarchy in ICD-10 and ICD-11 is Substance Dependence. This is defined as a psychobiological syndrome that is a disorder of regulation of substance use. It comprises impaired control over substance use, continued use of the substance despite harmful consequences and often increased tolerance and withdrawal symptoms. It is underpinned by enduring neurobiological changes in brain reward, stress, salience and control systems, which result in an “internal driving force” to use and continue to use a substance (or group of substances) in a self-perpetuating way. The most recent (fifth) edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) changed the diagnostic landscape with its deletion of its forerunner, DSM-IV’s diagnoses of Substance Dependence and Substance Abuse (which denoted a maladaptive and repetitive pattern of substance use causing social problems), and replacing them with a broader condition of “substance use disorder” that can exist in varying degrees of severity (mild, moderate or severe) depending on the number of criteria fulfilled. In addition to these forms of repetitive substance use, single-occasion use may lead to substance intoxication (in both ICD and DSM), and episode of Harmful Substance Use (ICD-11). Where substance use is curtailed in substance-dependent individuals, substance withdrawal can occur, this being a cluster of symptoms and features specific to the substance taken. In general, the features of substance withdrawal are opposite to those of the pharmacological effects of the substance concerned. There are also numerous mental and neurocognitive sequelae which occur in both the ICD and DSM systems, some with rather different diagnostic names and definitions. They include substance-induced mental disorders, such as substance-induced mood disorder, and similarly termed anxiety disorder, psychotic disorder, sleep-wake disorder, sexual dysfunction, obsessive-compulsive disorders, and substance-induced delirium. Neurocognitive disorders include substance-induced amnestic syndrome and substance-induced dementia. The ICD system also has comprehensive coverage of all physical disorders induced by psychoactive substance use. DSM-5 does not include the medical/physical complications of substance use and has abandoned the multiaxial system, which included (as Axis III) associated physical conditions. For all these disorders, diagnosis is based on a set of specific diagnostic guidelines (ICD) or criteria (DSM), which reflect the substance used, the pattern of use and the specific features of the disorder.
The alcohol treatment field has seen considerable change over the past 30 years. Some of this has been evidence based, and some has been largely politically driven, particularly in the pursuit of containing health care costs. On the positive side, a shift in policy from a limited number of treatment services catering only for the small minority of severely dependent drinkers, to more community orientated services with a greater emphasis on early identification and intervention, is to be broadly welcomed. However, in some places a move towards services catering for early stage ‘at-risk’ drinkers has been at the expense of losing services for those with more severe alcohol problems. While the evidence in favour of matching treatments to individual needs is still at a relatively early stage of development, and clear evidence of matching effects is not yet available, clinical practice needs to be guided by pragmatic principles by which more intensive treatments are provided to more complex patients, and/or in a stepped care paradigm. It must be concluded that, despite a large research effort in evaluating intensive versus less intensive alcohol interventions, there is still a long way to go in developing pragmatic clinical trials that evaluate effectiveness and cost-effectiveness of treatment in a way that can best advise practitioners in the typical treatment setting. On the positive side, research has begun to address fundamental health economic issues that are highly relevant to the rational funding of treatment services. Important in this is the development of health economic analysis in randomized controlled trials. The assessment of the impact of treatment availability on the prevalence of alcohol-related harm also represents a significant advance. Nevertheless, treatment research cannot occur in a vacuum. Research needs to take account of the funding environment in which treatment takes place. Further, treatment research needs to provide answers to the key issues facing commissioners of health care. With the gradual improvement in the quality of treatment research over the past three decades and the development of more advanced health economic methods to evaluate treatment, the treatment research community is in a much better position than ever before to provide evidence to guide the rational development of treatment services for alcohol use disorders. While many differences between health care systems exist in different countries, the evidence points to the need for a wide spectrum of services to cater for different needs. The development of low-threshold community-based services should not occur at the expense of more specialized services for more severe alcohol use disorders. Similarly, a treatment system that provides only specialist services for the minority of severe cases misses a significant public health opportunity to reduce the prevalence of alcohol use disorders through early, brief interventions.
Abhängigkeitskranke leiden an einer Ich-Konfusion. Sie wechseln, ohne es zu merken, zwischen einem süchtigen und einem gesund erwachsenen Denken hin und her. Störungsspezifische Aufstellungsarbeit kann den Betroffenen helfen, ihre Ich-Konfusion als solche zu erfassen, den Als-ob-Modus in ihr süchtiges Denken zu integrieren und so ihre Ich-Konfusion aufzulösen. TherapeutInnen können sich in der Beziehung zu Abhängigkeitskranken orientieren und aus einer Gegenübertragung befreien, indem sie mithilfe der Aufstellungsarbeit ihre drei aufgabenbezogenen Ich-Zustände aus ihrer Blockade befreien. Das sind die Ich-Zustände der „Therapeutin als begegnender Mensch“, die „kompetente fachkundige Therapeutin“ und die „grandiose Therapeutin“. Der Autor schildert den psychodramatischen Umgang mit den Ich-Zuständen der Patientin oder des Patienten und den Ich-Zuständen der Therapeutin in Theorie und Praxis.
Zusammenfassung
Rauschzustände werden auf die pharmakologisch beschriebenen Substanzwirkungen reduziert. Das „Abhängigkeitssyndrom“ definiert Sucht unabhängig vom kulturellen und situativen Kontext. Beim Konzept der „Kontrollminderung“ handelt es sich um eine Metapher: Die hierarchisch strukturierte Fähigkeit der Persönlichkeit zur Kontrolle ihres Suchtverhaltens wird nicht aufgeklärt. Diagnosen basieren auf nur wenigen Kriterien: Es fehlen die Biografie der betroffenen Person, die Schwere der Störung und soziodemografische Merkmale. Die „Glücksspielsucht“ und der „pathologische PC/Internetgebrauch“ (Gaming disorder) werden als Süchte klassifiziert, obwohl sie sich typologisch als unterschiedliche Störungen abgrenzen lassen. Sucht ist primär sozialer Natur: Sie erwächst aus einem anhaltenden Mangel an sozialer Integration und setzt ein breites Angebot suchtspezifischer Anreize voraus. Das Krankheitskonzept hat zu einer biomedizinischen Blase geführt, wodurch psychosoziale Interventionen zurückgedrängt wurden. Alternativ lässt sich süchtiges Verhalten als ein sinnvoller Bewältigungsmechanismus überstarker Belastungen ansehen. Zur Überwindung einer Sucht ist es erforderlich, die Autonomie der leidenden Person zu stärken. Dies erfordert die aufeinander bezogene Kooperation der beteiligten Berufsgruppen.
Wie bereits im letzten Kapitel betont, ist seit langem bekannt, dass Alkoholabhängige keine homogene Population darstellen. Studien, die zur Gruppenbildung das DSM-IV verwendet haben, konnten zeigen, dass der größte Teil der Patienten entweder eine zweite Achse-I-Diagnose oder eine Achse-II- oder sowohl eine Achse-I- als auch eine Achse-II-Diagnose hat.
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