Sunday, April 14, 2013


For this week's excerpt, I'm going back to my 2010 book, What the Early Worm Gets, for an excerpt on the differences between the disease of Alcoholism and behavior disorder Alcohol Abuse, a main theme of that book.  This isn't an all-inclusive summary of the differences, but begins a lengthy chapter on how to distinguish the distinctly different alcohol use disorders from one another.
 "One of the top researchers, Don Cahalan wrote Problem Drinkers: A national survey (Jossey-Bass) based on four studies he authored or co-authored. He said, “Comparing estimates of Alcoholics and problem drinkers [Alcohol Abusers] is a rather futile exercise because the concepts of Alcoholism and problem drinking are not very similar, do not necessarily apply to the same people and have quite different implications for prevention measures and treatment.”

If Alcoholism was a behavioral or emotional or psychological or moral or social or spiritual failing, lab rats would not get Alcoholism, the physiological disease. Rats do not even like alcohol to begin with—so they are incapable of Alcohol Abuse—and haven’t the capacity of all of those psychological expressions commonly given as causes for Alcoholism. They are biochemically different when Alcoholism is present not morally deficient.

Cahalan and others saw the difference between the Alcoholics and Alcohol Abusers in studies of drinking behavior in the armed services. There’s a lot of heavy drinking in the military. You’d expect it in a population consisting largely of young males away from their families and in a stressful environment. Many drank so much that they were at a high risk of developing Alcoholism. Most however only had disciplinary problems, not telltale changes in body tissues. The medical risks and physiology of Alcoholism weren’t there.

That’s why many people leave Alcoholics Anonymous, the mother of all 12-step programs, in their first year. They walk away saying, “That isn’t me.” They could be right, too. They could be Alcohol Abusers not Alcoholics.

Controlled drinking may be a treatment goal for an Abuser. A treatment goal for an Alcoholic though is abstinence. Only abstinence. Success factors in dealing with either are variables like the client’s motivation, severity of drinking, socioeconomic stability and coercion. The largest predictor of success though is an appropriate match between problem and solution. Dr. Marc Schuckit, author of "Alcohol & Sociopathy: Diagnostic Confusion", in the 1973 “Quarterly Journal of Studies on Alcohol,” put it this way. “It is necessary to distinguish between the Alcoholic who engages in a limited sphere of antisocial behavior and of the antisocial who abuses alcohol as part of his behavior. The process and prognosis of these different varieties are distinct."

To put it another way, an Alcoholic says, “never again” and they mean it but cannot stick to it and when an Abuser says, “never again” they usually don’t mean it and will stick to "never again" only as long as they choose. Alcohol Abusers actually have three choices. They can choose not to drink. They can choose to drink moderately. They can choose to get bombed. Alcoholism is about lack of choice: Once they take the first drink of alcohol, stopping isn't a choice, and they can no longer choose the amount. And an Alcoholic certainly didn't choose the genetics that contribute to their disease."

-- condensed from What the Early Worm Gets, pages 33-35, FIVE STARS on

This summer, the diagnostic manual clinicians use – called the Diagnostic and Statistical Manual or DSM IV – was replaced by an updated DSM 5. The update puts both Alcoholism and Alcohol Abuse under the same "code," however, there will always remain a distinction between the two and in how the two conditions are best treated.