Definition of Alcoholism

Alcoholism and Other Drug Problems
by James E. Royce, S.J., Ph.D., David Scratchley, Ph.D.

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There are nearly as many definitions of alcoholism as there are those who write or lecture on the subject. Why bother to define? There are many reasons. The alcoholism worker must have a definition that will stand up in court under cross-examination, whether alcoholism is being used as a defense or as grounds for involuntary commitment. The counselor must be able to proffer a definition that will induce the client to accept treatment and that will be neither so loose nor so rigid that clients can say in their denial, "That doesn't apply to me!" (In this vein, an alcoholic is said to define alcoholism as a disease that others get.) If insurance companies are going to pay health benefits for treatment, they are going to demand a strict definition of the object of their dollars. Physicians need solid criteria for making a diagnosis. Some of the fallacies occurring in the controversy about conditioning alcoholics to drink socially stem from dubious definitions of who is an alcoholic. Industrial alcoholism programs need to be precise in order to protect the rights of both labor and management. Defining alcoholism as a disease has moved it from the criminal justice system and the jail drunk tank to the health care system and treatment centers. It is crucial to any prevention campaign.

Problems in Definition

A good definition must be coterminous with what is being defined. A definition of alcoholism as "a horrible disease that affects the whole person" is unacceptable, because it is so broad it can apply to cancer or schizophrenia. Conversely, to define alcoholism in terms of one type of alcoholic is likewise unsatisfactory, because it misses many other types of alcoholics. Alcoholics cannot be defined as those who get drunk every time they drink, nor as those with a prolonged history of drinking, nor as those who crave alcohol, nor as those with any other single symptom.

A common fallacy is to define alcoholism by the amount or the beverage consumed. "He only drinks beer" ignores the fact that the same alcohol is present in the most expensive liquor and in the cheapest beer or wine. At an upper-class hospital for alcoholics 15 percent of the patients have never drunk anything but beer. People in Australia, New Zealand, and other countries with an incidence of alcoholism as high as that in America drink beer ("grog") as their primary source of alcohol. Yet our laws and our advertising still imply a difference.

The amount of alcohol drunk combined with the frequency of drinking (quantity/frequency index) is also a misleading way to define alcoholism. Because of individual differences some alcoholics might actually drink less than some nonalcoholics. Average consumption per week or month means nothing. An Italian might spread out fourteen ounces of absolute alcohol per week as wine and not be alcoholic, while an American alcoholic might consume the same amount of absolute alcohol in the form of a quart of 86 proof whiskey each Saturday night with total intoxication. More important than how much one drinks is the question of how one drinks. Moreover, alcoholics either lie about the amount they drink or just don't remember.

Some define an alcoholic as one who cannot predict what will happen after one drink. But one can think of many alcoholics who can predict exactly what will happen. (True, most alcoholics cannot predict consistently or accurately.)

Some define alcoholism as drinking alcoholic beverages in excess of customary dietary usage or social use of the community. This confuses average with normal. In a "dry" Southern town one beer on a hot day would exceed custom, but that is hardly alcoholism. In a north Alaska village, where every adult male gets drunk every weekend, the mere fact that this is customary usage does not preclude the presence of alcoholism.

A Working Definition

We define alcoholism as a chronic primary illness or disorder characterized by some loss of control over drinking, with habituation or addiction to the drug alcohol, or causing interference in any major life function, for example: health, job, family, friends, legal or spiritual.

1. Some loss of control is involved, but it need not be total. Most alcoholics can take one or two drinks under certain circumstances without getting drunk, but that does not prove they are not alcoholic. Sooner or later they are in trouble again. Total loss of control is usually seen only in latestage, deteriorated alcoholics. Loss of consistent control is sufficient for diagnosis. The loss can be over how much they drink, or over when they drink, or both. One may not get drunk, but drinking more than one intends or drinking at inappropriate times would indicate alcoholism.

2. Dependence or need can be either psychological or physiological. Psychological dependence or need is habituation (discussed in Chapters 4 and 7). As the poster slogan says, "If you have to drink to be social, that's not social drinking." Discomfort if deprived of alcohol and inability to quit on one's own are symptoms, even if no physical need is apparent. Physiological dependence or need is addiction, with its familiar signs of increased tolerance initially, cellular adaption, and withdrawal symptoms. One physically needs a drink to function. DSM-III-R distinguished abuse from alcoholism largely by using the notion of dependence.

   The tendency in America is to focus on addiction and to dismiss habituation as "only" psychological need. Yet in every respect except the physical dangers of withdrawal, psychological dependence can be more devastating. To appreciate this one has only to look at the way compulsive gambling can destroy a family. Cocaine causes no physical withdrawal, yet it fulfills all the other parts of the definition; nobody would deny it is very addictive. And marijuana users are coming to treatment centers in increasing numbers, saying that they want to quit and can't " obviously addiction.

3. Interference with normal functioning. The interference must be notable or habitual, to exclude the case of the turned ankle from one drink. This is the least subjective criterion and closest to an operational or behavioral definition. It can be quantified for research purposes, which is why it is the major factor in DSM-IV, 303.90 (American Psychiatric Association, 1994). For example, anybody can be arrested for drunk driving once, but three DUIs (Driving Under the Influence) in the same year suggest alcoholism. Likewise if drinking is involved in more than one fight where there is serious injury or a lethal weapon is used. Social disruption and health damage may be very different measures, but both are valid.

This last element complements the earlier parts of the definition, because the fact that one continues to drink after he has been told his health or marriage or job is endangered would indicate dependence and some loss of control; otherwise why continue? "Chronic" means enduring, something that can be arrested but not cured. The complex physical, psychosocial, and spiritual nature of this illness will be explored in Chapters 7 and 8. At least it seems that continuing to drink in spite of such unwanted consequences is sick behavior.

Our definition seems quite congruent with that developed by a joint Committee of the National Council on Alcoholism and Drug Dependence and the American Society of Addiction Medicine (NCADD/ASAM Joint Committee, 1992), which, like that in DSM-IV, is more a clinically useful description than a strict definition. Leaving detailed symptoms to Chapter 6, let us round out our definition by noting three common errors in diagnosis:

1. Joe can drink anybody under the table. He is not safe, but rather in serious danger. Increased tolerance, the ability to function with higher than average amounts of alcohol in the bloodstream, is the first sign of physical addiction.

2. Cutting down or quitting drink for a period of time (going on the water wagon) is not proof that one has it under control. Most do not realize that this is a classic symptom of alcoholism. The true social drinker does not need to play games of control.

3. The assertion, "I can take it or leave it alone," especially when made often or with vehemence, is usually indicative of denial and betrays the alcoholic. The social drinker doesn't feel compelled to say such things. This subtle self-deception is so characteristic that we have long defined an alcoholic as "one who says I can quit any time I want to."

Primary Versus Secondary Alcoholism

The terms primary and secondary have acquired ambiguous and even contrary or reversed meanings. Some old medical literature even uses the term "acute alcoholism" to refer to any severe intoxication. In this book we shall use primary when the alcoholism is the basic pathology, regardless of cause ("essential alcoholism"), and secondary to refer to alcoholism as a symptom of some other disorder ("reactive alcoholism"). Remove the alcohol, and you will find anything: normal people, neurotics, sociopaths, mentally retarded, psychotics. Any psychopathology may then be either the cause of the alcoholism or the effect of the alcoholic drinking on the brain.

Copyright © 1981, 1989 by The Free Press
Copyright © 1996 by James E. Royce and David Scratchley

About the Author

James E. Royce, S.J., Ph.D., is Professor Emeritus of Psychology and Addiction Studies at Seattle University. He is the author of Alcohol Problems and Alcoholism and coauthor of Ethics for Addiction Professionals.

David Scratchley, Ph.D., is a psychologist and addiction specialist with experience in neurosciences and pharmacology.