The Heritage of the 19th Century — a Concept of Addiction, Temperance and Degeneration

The past 100 years witnessed the formation of a disease concept of alcoholism and a rapid increase in the knowledge of its aetiopathology and treatment options. In the first half of the century, public sanctions aimed at the abolition of alcoholism. In the United States, alcohol prohibition was revoked in the economic turmoil of the Great Depression. In Germany, proposed medical procedures to reduce the fertility of alcoholics had catastrophic consequences during the fascist dictatorship. A revived focus on alcoholics as patients with a right to medical treatment came out of self-organized groups, such as Alcoholics Anonymous. The current disease concept includes the psychosocial and neurobiological foundations and consequences of alcoholism. Neurobiological research points to the dispositional factor of monoaminergic dysfunction and indicates that neuroadaptation and sensitization may play a role in the maintenance of addictive behaviour. New treatment options include pharmacological approaches and indicate that behaviour and motivational therapy and the attendance of patient groups may equally reduce the relapse risk. The task of the future will be to apply scientific discoveries in the best interest of the patients and to support their efforts to be respected like subjects suffering from other diseases. *Author to whom correspondence should be addressed. TRYING TO ERADICATE ALCOHOLISM — DIFFERENT APPROACHES In the first 30 years of the 20th century, degenerationism and the successors of the temperance movement sparked widespread political activities in the field of alcohol addiction. In the United States, the Anti-Saloon League followed the approach of the temperance movement and focused on the general problems of alcohol consumption. It succeeded in the implementation of alcohol prohibition, which was legally enforced from 1919 to 1933. Prohibition was initially successful in reducing alcohol intake; however, illegal alcohol consumption slowly increased in the late 1920s (Tyrrell, 1997). Prohibition was finally abolished not so much because it failed to abolish alcohol intake, but because of shifting priorities in the Great Depression, when it was argued that liquor production would create jobs and that alcohol taxes might help to reduce income taxes (Levine, 1984). In Germany, the focus on the individual and their heritable vulnerability to alcohol addiction was imbued with alarmist concerns about the proliferation of the mentally ill, which was supposed to threaten the survival of the nation or ‘race.’ Consequently, compulsory sterilization of ‘severe alcoholics’ was already advocated by some medical doctors before it was legalized during the Nazi dictatorship. The number of alcoholdependent patients murdered during the Nazi regime is unknown (Henkel, 1998). AFTER PROHIBITION — THE CREATION OF A MODERN DISEASE CONCEPT It was in the wake of the failure of prohibition that the current concept of alcoholism was formed, and the worldwide shock about the cruelty and inhumanity of Nazi politics may have promoted the modern disease concept with its focus on individual therapy and its emphasis that alcohol addiction is a disease just like any other physical or mental malady (Levine, 1984; Henkel, 1998). A decisive point was the foundation of Alcoholics Anonymous (AA) in the late 1930s. Similar to previous temperance movements, Alcoholics Anonymous displayed a sympathetic and supporting attitude towards the addicted person, but unlike previous groups, AA was only for alcoholics and was not concerned with the general level of alcohol consumption in the population. In fact, the view that all it would take to create an alcohol addict would be his excessive alcohol consumption was no longer persuasive after the end of prohibition (Levine, 1984). Likewise, the existence of alcohol tolerance and withdrawal was widely neglected in the 1930s and early 1940s, although delirium tremens due to alcohol withdrawal had clearly been described by Hare 1910 in the British Journal of Inebriety (Edwards, 1990). Jellinek (1942) and the Yale Summer School on Alcohol Studies agreed with AA that alcoholism would be a disease with a progressive character and not a moral failing. The 1954 report of the World Health Organization (WHO) reflected this new focus on the individual and stated that ‘the personal make-up is the determining factor, but the pharmacological action (of alcohol) plays a significant role’ (Edwards, 1990). However, it was not until the mid-1950s that convulsions and delirium tremens regained public attention as symptoms of alcohol withdrawal, largely due to the detailed reports of Victor and Adams (1953) and Isbell et al. (1955). In 1955, the WHO acknowledged that ‘very serious withdrawal symptoms’, such as convulsions or delirium, may follow the discontinuation of a prolonged period of very heavy alcohol intake (Edwards, 1990). In his famous book on the disease concept of alcoholism, Jellinek (1960) referred repeatedly to the WHO reports and placed the adaptation of cell metabolism, tolerance and the withdrawal symptoms at the heart of his alcoholism concept, because they would ‘bring about ‘craving’ and a loss of control or inability to abstain.’ In his review of the perception of alcohol withdrawal symptoms in the scientific literature, Edwards (1990) noted that Jellinek’s new focus on withdrawal symptoms was ‘in very sharp contrast to the earlier stance of the Yale school.’ It is possible that it was easier to rediscover the physical complications of alcohol withdrawal, because the new disease concept allowed attribution of these complications to an individual disposition rather than to some general effect that prolonged alcohol intake would have on every consumer. In Germany, the modern disease concept of alcoholism was promoted by Feuerlein (1967, 1996) and others who emphasized that alcohol-dependent patients should have the same entitlement to medical treatment as other patients. It was not until 1968 that a German federal court formally confirmed full insurance coverage of alcoholism-related medical treatment costs, although alcoholism had already been considered a disease since 1915 (Jellinek, 1960). ONE OR MANY TYPES OF ALCOHOLISM — GENETIC FINDINGS AND POTENTIAL SUBTYPES While it had long been observed that the familial risk for alcoholism is increased, it was only because of twin and adoption studies that a genetic contribution to alcoholism was confirmed (Kaji, 1960; Cadoret and Gath, 1978). The observation that family members who share half of their genes are not more likely to develop alcoholism compared with family members who share only a quarter of their genes was incompatible with the simple genetic mechanism of inheritance (Bleuler, 1955; Schuckit et al., 1972). Based on adoption studies, Cloninger et al. (1981) suggested the existence of two types of alcoholism, a mostly environmentally triggered, late-onset type 1 and a malelimited type 2 with a high genetic loading, legal problems and moderate alcohol consumption. The attempt to distinguish between two subtypes of alcoholism stimulated considerable research efforts. Many authors, however, questioned the dichotomy and argued that once patients suffering from comorbid antisocial personality disorder were excluded, the distinction between type 1 and type 2 alcoholics no longer offered clinical subtypes with distinct severity (Irwin et al., 1990). Instead, subgrouping was suggested to be based on age of onset, the presence of childhood risk factors such as hyperactivity, and severity of alcoholism (Schuckit et al., 1995; Johnson et al., 1996). Alcoholism types may thus vary on a continuum of severity, rather than represent distinctly different disease entities (Bucholz et al., 1996). The genetic disposition to alcoholism may manifest in such unsuspicious forms as a low level of response to alcohol intake in subjects not yet accustomed to chronic alcohol intoxication (Schuckit ALCOHOLISM IN THE TWENTIETH CENTURY 11