DSM5 Substance Use Disorders 1: Advance or Retreat?

I recently had a (friendly) exchange with Maia Szalavitz on the changes to the diagnosis of substance use disorders in DSM5. She and I disagree as to what is likely to happen, and whether DSM5 is a step forward or backward, although we agree on the eventual goal of reducing stigma and making treatment more accessible in more places and with more choice concerning the type and format of treatment offered. 

Here are some of my thoughts about the changes in diagnosis in DSM5. This is Part 1 from an email reply to Maia. 

1. First, is addiction a disease? Well, of course it is. it's hereditary, has a predictable onset, course, complications and characteristics. It causes people great harm and even death. It is a disorder of brain regulation of ingestive behavior, similar to eating disorders. Two ideas can make this assertion seem less clear. 

The first is that disordered behavior is caused by something other than a disordered brain. Western analytical philosophy and religions have asserted that there is a "mind" or "soul" that is not produced by a brain, but there certainly is no evidence to that effect. Try behaving or thinking or feeling without a brain. What is the function of a brain? Besides regulating basic physiological functions such as heart rate or blood sugar, it also regulates mood, thinking, perception, memory and behavior. Example: there is an optimal range for mood just as there is an optimal range for blood pressure, temperature or blood sugar. Basically the optimal mood is neither too high nor too low. When the brain/body loses the capacity to regulate blood pressure, we have hypertension. With blood sugar we get hyperglycemia (diabetes) or hypoglycemia. And with mood, we get mania or depression. Depression is almost never a natural response to anything that happens, you've got to be genetically vulnerable. Same goes for ingesting intoxicants. With drinking, for example, there is an optimal range ("moderate" or "social" drinking.) When the brain loses the capacity to regulate intake you get addiction. 

The second idea that gets in the way is that we have to pin down the exact pathophysiology before calling something a disease, but there are many/most diseases where we really do not understand them that well. Alzheimer's disease, multiple sclerosis, arthritis, and macular degeneration are all examples. The hang-up is the false distinction between "physical" (e.g. below the neck) and "behavioral or psychological" meaning roughly above the neck. But this is really just a distinction of scale. It seems "physical" if we can somehow see the pathology (including with a microscope, scanner or blood test), but "psychological" (again, meaning non-material) if we cannot. That's why people make the mistake of thinking that being able to detect blood flow changes in the brain means it is "real," but we don't need an fMRI scan to know that something like addiction is real, we already know that from other data.

An additional concern that is often expressed is that calling addition a disease may absolve a person of moral blameworthiness for what they do, such as commit a crime while high. The mistake is thinking that calling something a disease makes it inevitable and out of any control of an individual, and it quickly gets into the question of free will vs determinism. I thought this one through a long time ago and concluded that in practical terms it makes no difference. That is, if in fact everything is predetermined we cannot know that and it simply means that as we deliberate using our "free will" the resultant decision is predetermined. But so what? We still have to go through the process because that's how things work. Even if you try to "opt out" by saying, "Well, I have no control, so I'm not going to do anything" is a decision that itself would have been predetermined, but it is still a "freely made" decision, meaning that the individual can "change her mind" later and "decide" to take a different course. So in my view, a more practical question is: what would be the effect of absolving everyone of responsibility for their actions if they could show their behavior was due to a genetic abnormality or disease? It turns out, for example, that a tendency towards criminality is inherited, and is triggered by serious abuse or neglect in the first few years of life. This event causes changes in gene expression and is irreversible. Should we hold serial murderers responsible because they lack empathy for others, which is not something they had a choice about? Studies of twins reared apart demonstrate that almost all of our personality traits, career paths, preferences, even the way we part our hair is genetically influenced, often to a remarkable degree. Pedophiles don't choose their urges and preferences for small children. Should they be held accountable? I use these examples to point out that on a practical basis, we have to protect ourselves collectively against these destructive behaviors and the people who carrry them out, whether they "have a choice" or "can't help themselves" or not. So, should drunk drivers be prosecuted for their behavior? Should someone who kills a convenience store clerk during a meth binge be held responsible? Should opioid addicts who steal and rob to obtain opioids be held responsible? Obviously, the answer is yes, because otherwise we will end up with a world that looks like Mad Max, or The Congo.