Why alcoholism is a disease

The biopsychosocial model: Its use and abuse

The biopsychosocial model (BPSM) is increasingly influential in medical research and practice. Several philosophers and scholars of health have criticized the BPSM for lacking meaningful scientific content. This article extends those critiques by showing how the BPSM's epistemic weaknesses have led to certain problems in medical discourse. Despite its lack of content, many researchers have mistaken the BPSM for a scientific model with explanatory power. This misapprehension has placed researchers in an implicit bind. There is an expectation that applications of the BPSM will deliver insights about disease; yet the model offers no tools for producing valid (or probabilistically true) knowledge claims. I argue that many researchers have, unwittingly, responded to this predicament by developing certain patterns of specious argumentation I call "wayward BPSM discourse." The arguments of wayward discourse share a common form: They appear to deliver insights about disease gleaned through applications of the BPSM; on closer inspection, however, we find that the putative conclusions presented are actually assertions resting on question-begging arguments, appeals to authority, and conceptual errors. Through several case studies of BPSM articles and literatures, this article describes wayward discourse and its effects. Wayward discourse has introduced into medicine forms of conceptual instability that threaten to undermine various lines of research. It has also created a potentially potent vector of medicalization. Fixing these problems will likely require reimposing conceptual rigor on BPSM discourse.

Defining periodontal health

Assessment of the periodontium has relied exclusively on a variety of physical measurements (e.g., attachment level, probing depth, bone loss, mobility, recession, degree of inflammation, etc.) in relation to various case definitions of periodontal disease. Periodontal health was often an afterthought and was simply defined as the absence of the signs and symptoms of a periodontal disease. Accordingly, these strict and sometimes disparate definitions of periodontal disease have resulted in an idealistic requirement of a pristine periodontium for periodontal health, which makes us all diseased in one way or another. Furthermore, the consequence of not having a realistic definition of health has resulted in potentially questionable recommendations. The aim of this manuscript was to assess the biological, environmental, sociological, economic, educational and psychological relationships that are germane to constructing a paradigm that defines periodontal health using a modified wellness model. The paradigm includes four cardinal characteristics, i.e., 1) a functional dentition, 2) the painless function of a dentition, 3) the stability of the periodontal attachment apparatus, and 4) the psychological and social well-being of the individual. Finally, strategies and policies that advocate periodontal health were appraised.

I'm not sick but I'm not well,

and it's a sin to live so well.

Flagpole Sitta, Harvey Danger

The pursuit of value: sensitization or tolerance?

Two issues are raised. (1) What is the nature of the drug effect Heyman thinks confers value to drugs? (2) What is the evidence that drug use decreases the value of drugs and of conventional incentives over the long-term? There is considerable evidence for the opposite; a persistent increase in the sensitivity of neural systems that mediate drug value.

Future directions for the melioration model of addiction

For use in applied settings, the melioration model will need to incorporate changes in the shapes of local value functions over time, treat current value as a continuous function of time since previous choices, and take into account discounting of the effects of current behavior on future value. The policy implications of the model for regulating drugs are limited.

Behavioral choice theory can enhance our understanding of drug dependence and other behavioral disorders

I support the major theme of Heyman's target article that behavioral choice theory can enhance our understanding of drug dependence, but I raise concerns about the critique of the operant model of drug dependence, the underscoring of melioration to the exclusion of other theories of choice, and assertions about the unique effects of drug reinforcement.

Stimulus factors in addiction

Heyman's analysis of addiction in terms of matching to local relative value can be supplemented by stimulus-control processes. Stimulus equivalence can broaden the set of situations that occasion addictive behavior, and the situation-reinforcer correlation can enhance its persistence. The joint effects of stimulus-control and reinforcement processes may complicate treatment.

Understanding addiction: Conventional rewards and lack of control

The conflict between drug and conventional rewards leads to a paradox: Sanctions against drug use decrease access to conventional rewards and push drug users toward drug abuse, whereas increased access to the rewards of family, friends, and work may help reduce drug abuse. Lack of control is not specific to drug addiction and is unlikely to yield to a shift in bookkeeping.

Who determines the value of drug-taking behavior? Cultural considerations for a theory of behavioral choice

Heyman's analysis of addiction suggests that drug taking is irrational. The irrationality of drug taking, however, may depend on the acceptance of mainstream society's view of what is valuable. Consideration of the addict's viewpoint and cultural aspects of drug taking may be useful in trying to fathom the “rationality” of drug taking.

An economic perspective on addiction and matching

Economic models of addiction are choice-based. These models push the choice paradigm too far by modeling addiction as rational, normative behavior. Heyman's target article provides a sensible alternative to this economic approach by emphasizing that addiction is characterized by ambivalence and a perceived loss of self control. However, matching may not be a satisfactory platform on which to build this alternative model. Matching experiments do not provide evidence of ambivalence or perceived loss of self control.

Resolving the contradictions of addiction

Research findings on addiction are contradictory. According to biographical records and widely used diagnostic manuals, addicts use drugs compulsively, meaning that drug use is out of control and independent of its aversive consequences. This account is supported by studies that show significant heritabilities for alcoholism and other addictions and by laboratory experiments in which repeated administration of addictive drugs caused changes in neural substrates associated with reward. Epidemiological and experimental data, however, show that the consequences of drug consumption can significantly modify drug intake in addicts. The disease model can account for the compulsive features of addiction, but not occasions in which price and punishment reduced drug consumption in addicts. Conversely, learning models of addiction can account for the influence of price and punishment, but not compulsive drug taking. The occasion for this target article is that recent developments in behavioral choice theory resolve the apparent contradictions in the addiction literature. The basic argument includes the following four statements: First, repeated consumption of an addictive drug decreases its future value and the future value of competing activities. Second, the frequency of an activity is a function of its relative (not absolute) value. This implies that an activity that reduces the values of competing behaviors can increase in frequency even if its own value also declines. Third, a recent experiment (Heyman & Tanz 1995) shows that the effective reinforcement contingencies are relative to a frame of reference, and this frame of reference can change so as to favor optimal or suboptimal choice. Fourth, if the frame of reference is local, reinforcement contingencies will favor excessive drug use, but if the frame of reference is global, the reinforcement contingencies will favor controlled drug use. The transition from a global to a local frame of reference explains relapse and other compulsive features of addiction.

In search of the relevant behavioral variables

Heyman s analysis of the relevant complex behavioral variables associated with addiction is evaluated in relation to identifying the appropriate variables in behavior analysis. The model of behavioral allocation and choice known as melioration, discussed by Heyman as a way to understand the complexities of addiction, is examined and contrasted with another model of matching called ratio invariance, which is offered in this commentary as another behavioral account with a significant potential for resolving the contradictions of addiction.

Positive reinforcement, the matching law and morality

Addictive behavior has never seemed rational because it persists in spite of drastic aversive consequences. This is a particular problem for models of addiction such as operant psychology which hold that behavior is controlled by its consequences. Inspite of claims to the contrary, Heymans target article illustrates how operant psychology resolves this contradiction. By using the matching law, Heyman suggests a mechanism that explains why delayed aversive events may not control behavior, and a conceptual framework in which we can understand successful therapies.

Melioration and addiction

I discuss various theoretical issues concerning maximizing, matching, and melioration. The model of addiction based on melioration has the key feature that a reduction in drag use increases both the value of drag-taking and the value of conventional activities. I found Heyman's target article stimulating. I don't feel competent to comment on drags but I do have some thoughts, both general and specific, on the theoretical issues.

Is melioration the addiction theory of choice?

Heyman makes a convincing case that a melioration choice strategy is sufficient to produce addictive behavior. But given a plethora of addiction theories, the question is whether melioration theory is superior to rivals more sophisticated than a simple disease model or operant conditioning account. Heyman offers little direct evidence that melioration actually causes the addictions we observe.

A scientific fix for the classical account of addiction

Heyman's two crucial theses are that people over-value immediate rewards, and that addictive substances “subvert the value of competing commodities.” These perennial ideas were discussed by Plato. Whereas Heyman provides scientific clarification and support for the first, the second remains problematic. I outline how this deficiency might be remedied via evolutionary considerations.

Control versus causation of addiction

Heyman explains useful ways to bring addictive drug use under environmental control. We doubt that relapse is explained by drug features such as immediate reinforcement, clouding of judgment, and so forth. Relapse may require explanation in terms of enduring sensitization of incentive neural substrates, but even if its causal assumptions are wrong, Heyman's model makes useful predictions for behavioral control.

Self-control and impulsiveness: Resolution of apparent contradictions in choice behavior

Choosing the smaller, less delayed reinforcers of drug abuse (including cessation of withdrawal) over the larger, more delayed reinforcers of a healthy life can be described as impulsiveness (the opposite of self-control). Examination of drug abuse using a self-control/impulsiveness framework can help explain many of the puzzles about this behavior, while tying drug abuse into a large research database.

Who is at risk for addiction?

Numerous individual differences determine the effectiveness of the multiple external reinforcement contingencies that control drug seeking behavior. Differences in the capacity to frame reinforcement and also the toxic effects of drugs modulate susceptibility to addiction. As a result, not all individuals are at the same degree of risk for addiction.

Reward deficiency syndrome: a biogenetic model for the diagnosis and treatment of impulsive, addictive, and compulsive behaviors

The dopaminergic system, and in particular the dopamine D2 receptor, has been implicated in reward mechanisms. The net effect of neurotransmitter interaction at the mesolimbic brain region induces "reward" when dopamine (DA) is released from the neuron at the nucleus accumbens and interacts with a dopamine D2 receptor. "The reward cascade" involves the release of serotonin, which in turn at the hypothalmus stimulates enkephalin, which in turn inhibits GABA at the substania nigra, which in turn fine tunes the amount of DA released at the nucleus accumbens or "reward site." It is well known that under normal conditions in the reward site DA works to maintain our normal drives. In fact, DA has become to be known as the "pleasure molecule" and/or the "antistress molecule." When DA is released into the synapse, it stimulates a number a DA receptors (D1-D5) which results in increased feelings of well-being and stress reduction. A consensus of the literature suggests that when there is a dysfunction in the brain reward cascade, which could be caused by certain genetic variants (polygenic), especially in the DA system causing a hypodopaminergic trait, the brain of that person requires a DA fix to feel good. This trait leads to multiple drug-seeking behavior. This is so because alcohol, cocaine, heroin, marijuana, nicotine, and glucose all cause activation and neuronal release of brain DA, which could heal the abnormal cravings. Certainly after ten years of study we could say with confidence that carriers of the DAD2 receptor A1 allele have compromised D2 receptors. Therefore lack of D2 receptors causes individuals to have a high risk for multiple addictive, impulsive and compulsive behavioral propensities, such as severe alcoholism, cocaine, heroin, marijuana and nicotine use, glucose bingeing, pathological gambling, sex addiction, ADHD, Tourette's Syndrome, autism, chronic violence, posttraumatic stress disorder, schizoid/avoidant cluster, conduct disorder and antisocial behavior. In order to explain the breakdown of the reward cascade due to both multiple genes and environmental stimuli (pleiotropism) and resultant aberrant behaviors, Blum united this hypodopaminergic trait under the rubric of a reward deficiency syndrome.

Spontaneous remission from alcohol, tobacco, and other drug abuse: seeking quantitative answers to qualitative questions

A quantitative review of the substance abuse literature revealed a mean general prevalence of spontaneous remission from alcohol, tobacco, and other drugs abuse of 26.2% when a broad definition of remission was employed and 18.2% when a narrow definition was implemented. From the results of this review, it was concluded that few meaningful differences exist between spontaneous remitters and persons who either continue misusing substances or remit through treatment on pre-remission measures of prior drug involvement. Of the factors cited by self-remitters as important in facilitating their desistance from substances, the present review found that health concerns, pressure from friends and family, and extraordinary events were instrumental in initiating spontaneous remission, while social support, non-drug-using friendships, willpower, and identity transformation were pivotal in maintaining change. Evidence is presented to indicate that spontaneous remission from alcohol and illicit drugs and spontaneous remission from tobacco smoking may differ in several key respects.

Dental plaque-induced gingival diseases

Gingival diseases are a diverse family of complex and distinct pathological entities found within the gingiva that are the result of a variety of etiologies. There are several clinical characteristics common to all gingival diseases and these features include clinical signs of inflammation, signs and symptoms that are confined to the gingiva, reversibility of the disease by removing the etiology, the presence of bacterial laden plaque to initiate and/or exacerbate the severity of the disease and a possible role as a precursor for attachment loss around teeth. Defining and classifying gingival diseases has not been an easy task. The tools and methods to identify gingival diseases have varied depending on the criteria used by epidemiologists, researchers, or the practicing clinician. The classification of gingival disease in this review relied upon experimental and/or epidemiological human studies that accurately and reliably assessed an underlying functional derangement that was localized to the gingiva and was reported in a peer-reviewed journal. The classification of gingival diseases that depends on dental plaque to initiate the disease process(es) has been categorized into two groups. The two categories of plaque-induced gingival diseases are those affected by local factors and those that are affected by local factors and modified by specific systemic factors found in the host. In this review, the clinical characteristics of gingival disease associated with plaque, endogenous hormone fluctuations, drugs, systemic diseases, and malnutrition were investigated.

Reply to Lilienfeld: why alcoholism is a disease

Lilienfeld's attack on my conceptual examination of the disease concept of alcoholism suffers from erroneous interpretations, fallacious reasoning, and a lack of familiarity with relevant alcoholism research. He offers an alternative nominalist interpretation of the disease concept of alcoholism based on a fuzzy boundary between disease and wellness. He fails to recognize that the basic issue between nominalist and realist accounts of a lower-order concept such as alcoholism is the presence or absence of general principles that may account for the observed signs and symptoms characterizing a specific disease entity, not fuzzy boundaries between higher-order categories. Extensive evidence (which Lilienfeld ignores) of biological bases for the pathognomic signs and symptoms of alcoholism, particularly loss of control, demonstrates that the disease concept of alcoholism refers to a disease entity that has a biological basis. It is not a "mental construct."

Alcohol and other drugs: the scope of the problem among pregnant and parenting women in California

This introductory article provides background information on America's experience with the use and abuse of alcohol and other drugs (AODs). Following a brief history, the article presents findings from recent large-scale studies of patterns and consequences of AOD use, including a focus on trends among women and costs of the consequences of AOD use. This article also introduces the subjects to be discussed in later articles of this issue.

Addiction as choice? Yes. As melioration? Maybe, maybe not

Melioration is not superior and may be inferior to other extensions of behavioral choice theory to addiction studies. Progress in the addiction field will be accelerated by the demise of the disease model rather than by attempting to resolve the contradictions it has created.

Maximization should sometimes lead to abstinence

Heyman's model, paradoxically, predicts that whereas a maximizing approach to drug choice will prevent escalation of drug use it will never yield complete abstinence. We suggest an alternative model that overcomes this difficulty by focusing on changes in drug tolerance. A small modification allows maximization to predict either abstinence or moderation (e.g., social drinking).

Which behavioral consequences matter? The importance of frame of reference in explaining addiction

The target article emphasizes the relationship between a matching law-based theory of addiction and the disease model of addiction. In contrast, this response emphasizes the relationship between the matching law theory and other behavioral approaches to addiction. The basic difference, I argue, is that the matching law specifies that choice is governed by local reinforcement rates. In contrast, economics says that overall reinforcement rate controls choice, and for other approaches there are other measures or no clear prediction at all. The response also differs from the target article in that there is more emphasis on the finding that stimulus conditions determine whether choice is under local or overall reinforcement rate control.

The contradiction unresolved

Extreme sensations – thirst, pain – can focus attention on local consequences at the expense of the overall, perhaps for good evolutionary reasons. Maybe the same phenomenon evolves from prolonged use of addictive substances. The matching law explains mistaken choice, not how a person who has confronted personal catastrophe manages to ignore it in making a locally induced choice.

Addiction is not as puzzling as it seems

Heyman's target article seeks to resolve the apparent paradox surrounding the issue of control in relation to addictive behaviour. The present commentary argues that addiction is in fact less paradoxical and more easily understandable than Heyman supposes. A fully satisfactory model of addiction, however, requires a more multifaceted approach than that provided by the type of behavioural choice theory favoured by Heyman.

The Janus faces of addiction

Heyman proposes that external stimuli can promote a switch from a local to a global frame of reference for evaluating the consequences of behavior and that such a change might be critical to breaking the grip of drag addiction. Could incentive stimuli promote a switch in the opposite direction and thus contribute to relapse in the recovered addict?

Relationship between melioration and the controlling variables

Knowledge of specific instances of melioration does not imply knowledge of the variables controlling behavior. Drug self-administration has been successfully analyzed in terms of standard variables such as the immediacy and magnitude of the drug reinforcer. An appeal to melioration may not be necessary.

The behavioral economics of addiction: A comprehensive alternative

Heyman's target article makes a strong case for a behavioral approach to addiction, yet some important assumptions require justification, and promising behavioral alternatives to the author's melioration approach should be considered. In particular, the behavioral economic approach to addiction appears well developed and comprehensive. How does the melioration approach complement or improve on a behavioral economic account?

The ameliorating addict: An illusion reviewed

It is difficult to accommodate compulsive drug use that destroys regulation by consequences in a unitary framework of melioration or maximization, especially as both are strategies of behavioral regulation. The “contradiction” of addictive behavior despite aversive consequences is an illusory issue because consequences that do not decrease addictive behavior cannot be considered punishing.

Addiction requires philosophical explanation, not mere redescription

Heyman's model explains the irrationality of addictive behavior, but it does not satisfactorily answer the question of whether this behavior is voluntary because it does not address the issue of the choice of preference functions. Furthermore, although Heyman disconfirms the disease model of addiction, this does not resolve the issue of whether addiction should be classified as a mental illness.

Matching and melioration as accounts of reinforcement and drug addiction

Heyman's view that addiction can be viewed as a natural outcome predictable by melioration and the matching law is provocative. Remaining to be explained more fully, however, are exactly how his view is an improvement on other reinforcement-based accounts. Included in these elaborations should be an account of how different “bookkeeping schemes” are developed and controlled and what new approaches to treatment and prevention of drug addiction are indicated.

How do people choose between local and global bookkeeping?

The matching law accounts for both addictive behavior and the usefulness of a person's evaluating choices in overall categories. To explain why overall bookkeeping, once learned, does not easily win out over local bookkeeping, another implication of matching is needed: intertemporal bargaining. The role of melioration, though probably important for new addiction is separate.

Addiction: Taking the brain seriously

Heyman's target article is an analytical tour de force, but it makes too hard a distinction between voluntary and driven behavior. It is more fruitful to think about brain and behavior as shifting, interacting “agents,” represented by multiple neural circuits. This has the virtue of better connecting behavioral analysis with wet neuroscience.

Heyman's steady-state theory of addiction

Heyman's target article contributes to our understanding of addictions by offering solutions to several paradoxes and by recognizing the stable nature of addictive behavior. Previous classical and operant conditioning models have emphasized molecular processes, such as acquisition and extinction, and have failed to address the aggregate effects of long-term exposure to the contingencies of drug and alcohol use.

Matching observation to addiction theory

Over the years, many theories have been proposed to account for the aberrant behavior of drug dependent individuals. Heyman posits that the existing theories of drug dependence are inadequate to explain the complex processes inherent in human drug-taking. He proposes that incongruous behaviors that comprise addiction, such as continued drug use in spite of adverse consequences, can be explained by application of the matching law approach. While the matching law theory of addiction explains certain aspects of human behavior, its application to the area of addiction must be subjected to experimental verification.

The Natural History of Substance Misuse in an Incarcerated Criminal Population

The natural history of substance misuse was explored in 343 medium security federal inmates. Of the subjects surveyed, 144 (42.0%) acknowledged a prior history of substance misuse, minimally defined as weekly ingestion of a psychoactive substance for a period of 3 or more months. Whereas the majority of subjects reported that they were abstinent due only to incarceration (57.4%), a quarter of the sample (24.8%) affirmed that they stopped using drugs on their own without treatment (spontaneous remission). Differences were observed between subjects who continued using or desisted only because of incarceration and subjects who displayed spontaneous remission. Several interpretations of this finding are possible, one being that subjects in the spontaneous remission group perceived themselves as having experienced significantly fewer problems as a consequence of drug use than subjects in the continued use and incarceration groups.