In response to a video series in which my colleagues and I dismiss the brain disease model of addiction, a viewer asked:
While I agree and have never believed in the disease concept per se, I must say, I myself was in such a pathetically brain dead state, before I got sober from abusing alcohol, I was unable to walk, without shaking like a Parkinson’s patient, and I STILL drank. At that point I don’t believe I had a choice. I do believe at that point one’s brain is hijacked and is physically dependent and truly “diseased.” I begged for help because I woke up and decided I could not go on living this way, and a friend took me to a detox hospital. There, I met another woman who had wet brain. While we may not have had a disease to begin with, before alcohol, we definitely gave ourselves one by drinking, just as a smoker may give himself lung cancer by smoking. If you look at brain scans of heavy drinkers, they are not “healthy.” What are your thoughts?
Easy analysis of a common disease model argument:
I’ve received many responses like this to my criticism of the disease model of addiction over the years. The disease model of addiction proposes a state of involuntary substance use. The smoking example kinda brings this whole response down. Yes, smoking can and often does cause lung cancer. But in this analogy, smoking would have to cause involuntary smoking.
I’m not denying that drinking can cause other diseases and medical conditions such as withdrawal syndrome, wet brain, pancreatitis, cirrhosis, and even cancer. But it does not cause involuntary drinking – the disease of alcoholism.
I’ve heard this smoking example many times. It’s like saying skiing causes broken legs – and since it creates this medical condition, it must also cause a disease of involuntary skiing.
The disease rhetoric of the recovery culture is confusing. She said she thinks her brain was hijacked and that she did not have a choice. But then immediately follows that up by saying she checked in to a detox. Going to detox, and staying there is a choice – and it is a choice to not drink. She was not restrained, and thus could have left at any given moment to drink, and there is nothing they give you at detox that immediately stops you from drinking. She believes she has no choice while, ironically, she clearly chose not to drink.
I don’t want to rake this person over the coals for the smoking example though, or her obvious confusion and contradictory statements. She makes these statements under the influence of maddening addiction and recovery rhetoric. I once believed these sorts of things myself when I had a heroin problem.
My direct answer to her question:
In my mind, I summarized her question as “Do these other medical conditions prove that addiction itself – involuntary substance use – is a disease?” They obviously don’t. But she is confused, because the people who promote the disease model of addiction just throw everything at the wall and hope something sticks. It confuses people. So I thought the best response was to just make it clear that these are separate conditions. I couldn’t tackle the whole brain disease model, because that takes too much work and too much text for a youtube comment (and even for this blog post). So my strategy was to just clear up this piece of confusion so that if she chose to investigate the brain disease model, she could weigh it on its own merits without this baggage. Here is a slightly edited version of my response to her comments on youtube:
Withdrawal and wet brain are medical conditions brought on by excessive drinking – but they are not the cause of excessive drinking. The most important thing we have to remember is that these are 3 separate conditions.
1. Alcohol Use Disorder is said to be a brain disease involving the reward and “self control circuits” of the brain. It is said to be a disease of free will.
2. Wet brain (Korsakoff Syndrome) is a medical condition of the braind similar to dementia, resulting in memory loss. Wet brain is estimated to occur in 13% of people who fit the diagnosis for an alcohol use disorder. It is the result of thiamine deficiency, which can result from excessive alcohol use. There is no implication by the medical world that it causes loss of free will / involuntary drinking.
3. Alcohol Withdrawal Syndrome is the result of alcohol’s effects on the central nervous system, and primarily affects bodily functions. Its symptoms are primarily physical – tremors, seizures, nausea, elevated heart rate and temperature, insomnia, etc. There are psychological symptoms of hallucination in extreme cases, agitation, irritability, etc. It is not implicated in causing loss of free will / involuntary drinking.
These are recognized as 3 separate conditions by medical authorities. We do not question the genuinely physical, medical nature of either Wet Brain or Withdrawal Syndrome. Nor do we deny their seriousness and danger they pose. Neither of those 2 conditions are said to be diseases of free will, like “alcoholism” or “alcohol use disorder” is said to be. These 3 separate conditions apply to separate parts of the body/brain, and are associated with 3 separate sets of symptoms.
1. Alcohol Use Disorder – associated with continued alcohol use despite negative consequences
2. Wet Brain / Korsakoff Syndrome – associated with memory loss
3. Alcohol Withdrawal Syndrome – physical/central nervous system/autonomic function symptoms
It is true that relieving alcohol withdrawal can be a powerful motivation to continue drinking, but withdrawal can be successfully treated. A large portion of those successfully treated for withdrawal eventually return to “alcoholic” drinking, without having the motivation of withdrawal symptoms. This indicates their pursuit of heavy alcohol use is not solely or even primarily motivated by withdrawal symptoms. It is also worth noting that most people who fit the diagnosis for alcoholism/addiction do not experience withdrawal.
There can be no doubt that the memory loss and other symptoms of Wet Brain / Korsakoff Syndrome can seriously impair a person’s functioning, in every part of their life, including drinking. But again, this isn’t said to be a disease of free will.
When we say addiction/alcoholism is not a disease, we are only making a claim regarding whether or not the individual has impaired/lost free will from the “disease of addiction.”
The existence of the distinct medical conditions of withdrawal syndrome and wet brain / Korsakoff syndrome do not prove the existence of the brain disease of addiction any more than broken legs and frostbitten toes would prove the existence of a disease of involuntary skiing.
Here are some sources that refute the brain disease model of addiction:
I refuted the brain disease model of addiction back in 2010 in piece titled “Addiction is NOT a Brain Disease, It is a Choice.” It covers the issue in broad strokes. I also wrote on the brain disease model of addiction in Appendix B of The Freedom Model for Addictions, with the same argument – that the neural adaptations seen with addiction represent the neurology of learning. There is a much more detailed version of the same basic argument in the New England Journal of Medicine titled “Brain Change in Addiction as Learning, Not Disease,” by Neuroscientist Marc Lewis. You can only access it by paying through the nose or using a college library though. It’s written in an academic style as well, and could be a tough and confusing read if you don’t have a background in the issues. Nevertheless, it vindicates my article with more thorough coverage of the scientific data.
I highly recommend the following free article: “Is Drug Addiction a Brain Disease” by Marc Grifell and Carl Hart in American Scientist. Like Lewis’s article, it examines the neuroscience, but it’s much more reader friendly to a wider audience. I recommend it for most readers.
I highly recommend “Addiction and choice: theory and new data” by Gene Heyman in Frontiers in Psychiatry. It is a great article and easy read. If you want a full neuroscience breakdown, you won’t find it here. It highlights some other very important issues that bring down the disease model of addiction though. I highly recommend this to everyone.