THE CANADIANMEDICALASSOCIATION LE JOURNAL DB LASSOCIATION MEDICALE CANADIENNE DECEMBER24,1960·VOL.83,NO.26 ALCOHOLISM,A GENUS AND A noted European student of alcoholism said that SOME OF ITS SPECIES° it was an idle question to ask whether alcoholism E. M. JELLINEK, Sc.D., Edmonton, Alta. about alcoholics.This statement does not seem to be cogent,as the approaches towards the reme- INA REcENT publication’ the author came to the dial andpreventive aspects ofalcoholism would necessarily vary a great deal according to whether the speciesrepresents a disease per se,whetherit one,as may be concluded from what is called is the symptom of a disease or whether it is neither alcoholism on the North American continent,in but primarily a social or economic phenomenon, France,in Finland,n Portugal,and in many other countries.Furthermore,within a given nation, and so forth. For the purpose of this paper it would not seem various students of alcoholism, according to their particular experience,may have different specific phenomena in mindwhen they use the generic possible species.It will sufice here to delimit those term alcoholism. four or five species of alcoholism which may be When one scans these various “alcoholisms”, it appearsthatthey haveonlytwoelements tnderlying disease,a disease per se,or neitherAn in common: oneis drinking and the other attempt will be made to present these species in a is damage (individual or social, or both) incumschematicformhavinginmind thepossibletility bentupon the drinking.The two elements form the of such a schematic presentation for purposes of basis for the definition of the genus alcoholism. diagnosis and decisions as to treatment. Evidently,a genusisusuallytoo broad to pemit The tabular presentation of the species of alcospecific questions.The latter will have to pertain to holism to be considered is divided into three main given species of the genus. Let us take such a sections:(1) the etiological elements of various botanical genus as Hibiscuswhich embraces some species of alcoholism,(2)the elements of alcoholic 200-odd species.Even such a simple question as process, and (3) the type of damage incumbent “Is Hibiscus a tree?”cannot be answered with a upon drinking. The division of the matter into these three sections is somewhat arbitrary and to some question would not make much sense as some of extent overlapping, but it seems to contribute to a the species of Hibiscus are herbssome are shrubs, more systematic discussion. and some are trees.It would be,of course, within reason to ask “Are some of the species of Hibiscus ETIOLOGICAL ELEMENTS trees?” Under this heading psychologicalvulnerability, The genus alcoholism has not as many species as physiologicalvulnerability, sociocultural elements and economic elements will be considered. The number of species,which limits greatly meaningful absence orthe presence of these elements and their questions about the termalcoholism as used here degree is designated by the usual notation of zero in a generic sense. If we define the genus as any to four plus. seem that we cannot even ask whether alcoholism is Psychological Vulnerability a disease or not, but we would have to name or describe one or more species of the genus in order This term is used in preference to neurosis, to make it possible to give a reasonable answer to neurotic behaviour pattern,psychopathy,etc.,as n the question. some species of alcoholism one cannot speak of grosspsychological liabilitiesbut sometimesrather of small psychological deficits,such as some lack of optimismoraslightdegreeofself-confidencewhich cannot be regarded as exactly abnormal. The term 1341

1342 JELLINEK: ALCOHOLISM, A GENUS Dec, 24, 1960, vol. 83 Canad, M. A. J. TABL& LCnAsxcreaIs orSELEr SEEs or At0o Eleet te ls Denigssia Phyrio- Soeio- 三 Aegeired fogical tufnergelurel Beomorie festures Nstritional asd Plgyziesl elements ciemesds (see fezt) Natere of depdence plyericsl hobits Progreasint nahire end/er Secis Alpha +++ + Prly plialG t Sight, i the sense that eeonomie aleoholisn 0 to + (+++) (+++) 0 p 0% 0 be aenatho trol but deliberate undisrplined drinking teriorate after hanpeaeop perhaefr ogicaland social behaviour +++ +++ several years of inadequate smeguiltabt drinking, nutrition remorse and resen tment, 十 0 +++ 0 + (Culturally No lost 0 Soe-slessoio No peogreee f increase in sumber of ar- +++ determined control dlisastadf chrosie alco larly for the emergenee of +++ 司 tion beta aleobolism ++++ +++ 10 0 to +++ ++++. Fist, peehleial May start with Srngly mrkd sogres ++++ (+++) (+++) dependence and later, ++++ +++ entleely pendence as maniwithdrawal features e syndrome Drlta + +++ +++ several yrs. aleoboliue + +++ ++++ +to +++ ++++ But vith- ++++ velop to0 15 or’ 20 years drawal instanocsasa ment adeuep several yrs, Knle thpees tridi sllis ts mi friitti psychologicalvulnerability hasavery wide range, from such small psychological deficits as mentioned tate adaptationof the cellmetabolism toalcohol and thus to physical dependence. The presence or to the neuroses and psychoses. In any of thefive species presentedin the table, absence of these physiopathological elements and their intensitymay accountfor thefactsthat some psychological vulnerability of at least one plus heavy drinkersnever developphysical dependence must be postulated.In the species to which is while others do,and that in some heavy users of attached +++ or ++++,the three plus dealcholivraehysialndnvl notes the initialpresence of neuroticresponse patterns and neuroses as wellas other psychopathic after 3 years and in others after 7 to 15 years. conditions except psychoses,while four plus dedictiveprocesinthestritpharmacologicalsense, notes the initial presence of a psychosis or at least develops,one should look for someof thephysiopsychotic predisposition. vulnerabilitiescouldbe either pre-existent to the PhysiologicalVulnerability The role of physiological vulnerability is hypoof the stresses produced byheavy alcoholic intake, thetical.Thereare,wever,sucientndications to consider certain physiopathological elements as fuence upon thealcoholicprocess.The presence or possible factors in some of the species under conabsence of suchphysiopathological elements would sideration. Certain biochemical1 lesions,liver have to be checked also in those species of alcodamage,certain enzyme deficiencies and vitamin holism which donot showanaddictive process, deficiencies as wellas some endocrinopathies have been claimed to be the primary causes for heavy 15or 20 years.The checking of such elements in all alcohol intake. The author does not subscribe to such etiological invalidate the assumption that they play a role in theories,but the fact remains that such physiothe absence or presence of the addictive process in pathologicalelements are frequently seen in alcovarious species. holics.The absence of such elements may protect the cllmetabolism against adapting itself toalco- Sociocultural Elements holand thus avoid the developmentofan addictive process,but,on theother hand,the presence and The sociocultural elements which can play an important role in the genesis of a given species of degree of physiopathologicalclements may facilialcoholism are largely attitudes towardsdrinking

Dee. 24, 1960, vol. 83 Canad, MI. A. J. JELLINEK: ALCOHOLISM,A GENUS 1343 and drunkenness, particularly the degree of inance of high psychological vulnerability required toxication which is socially acceptable,drinking for the addictive process in the Anglo-Saxon customs and drinking patterns.Where there are countries, while in the viticultural countries,instrong social pressures on drinking,such as when it dividualpsychologicalmotivation plays a much is presumed offensive to refuse a drink,when it is smaller role in the addictive process. Volumes taken for granted that a visitor must be offered a could be written and are written on the sociodrink, when at a party it is felt that the pace set cultural elements in the etiology of various species bysomekey figure must be observedby on alcoholism, but in the framework of a brief the others,and when because drinking is conpaper, the above few examples must suffice. nectedwithnearlyeveryothe activitylcoholin As to the notation in the column headed “Sociotake is fostered to such a degree that the drinker cultural elements, what is stipulated is that in the becomes exposed to the risk of the addictive prospeciesofalcoholismpresentedinthe tableaswell cess or, in the absence of such a process, at least as in any other species of alcoholism, at least one of serious damage. plus must be assumed, since the society must be at The predominant drinking pattern among heavy least one that makes the custom of drinking posdrinkers in France and some other viticultural sible.In some species,the effect of social attitudes countries is to distribute large quantities of wine in and customs may be so great that they outweigh small instalments over 16 hours of the day. Thus any individualpsychologicalelement toa high in spite of the possible absence of overt intoxication degree.Intwoofthetabulated species,thenotation the cell metabolism is continuously conditioned to oe unq s (+ o the presence of alcohol. three plus in parentheses means that while in a On the North American continent and in most given society the sociocultural elements may be Anglo-Saxon countries, society accepts the use of highly in favour of a large alcoholic consumption, alcoholic beverages at certain times of the day and in some given species of alcoholism they do not in certain places only, so that the heavy drinkers necessarily play an important role. drink concentrated spirits in what may be calleda concentrated time,and the conditioning of the Economic Elements cellmetabolism differs therefore from the con- Actually some of the cconomic clements that are ditioning as seen in many viticultural countries. sometimes invoked,and in some cultures as ctio. The drinking patterns are never exclusive in any logical factors,could be called cenvironmental given country, but some may be regarded as pre factors,suchas poor housing conditions,which dominant patterns. Thus we might find in Anglodrive thc slum dwcllers into thc tavern or bar Saxon countries a minority, sometimes a sizable (“the poor man’s club”) in order to cscape from one,following the predominant drinking pattemof the drabness of their abodes. viticulturalcountries,while in the latter there More importantly, however, by ccononic elemay be minorities which follow the predominant ments we mean such matters as the price of alcodrinking pattern of Anglo-Saxon countries. Menholicbveragesparicularlyinrlatintotherc tion must be made also of certain ethnic customs of staple foods; the stake of a nation or of a large which expect every male wage-earner to indulge in social group in the production and sale of alcoholic more or less heavy weekend drinking while there beverages;theidentificationornon-identificationof may be little or no drinking during the rest of the society as a whole with the vested interests; the week. structure of the vested interests and the number of As one of the most important factors in the exsales outlets in relation to the adult population. posure to the risk of alcohol addiction must be The economic factors may to some extent be mentioned the general social acceptance of daily responsible for socialatitudesand thus thesocohigh or low consumption.Thus for instance, in cultural elements and the economic elements cannot France,a national survey (Bastide2)has shown always be differentiated by stringent criteria. that the French as a nation regard a daily in- In order to clarify the above statements it may be take of nearly two quarts of wine as not being pointed outthatnFranceorexample,therer harmful either to the body or to the mind of a 8million men who are entirely or partially deworking man.Furthermore, non-users of alcoholic pendent for their livelihood upon the sale and production of alcoholic beverages.Together with their more than 5%of the adult population.On the wives and other adult family members, they repreother hand, on the North American continent and sent close to one-third of the French electorate. in Scandinavian countries we may find a rejection Furthermore,the French nation as a whole tends to of any kind of alcohol consumption in about oneidentify itself with these vested interests which are thirdof the adult population,and the idea ofa composed to a much larger extent of small independaily intake of an alcoholic equivalent of two dent individuals who are struggling to make ends quarts of winewould bemet with consternationin meet rather than of large corporations, Where the the remaining two-thirds of the adult population. vested interests are constituted by large corpora- These differences in the degree of acceptance of tions,t there is no tendency on the part of high daily intake may account for the predominthe nation to identify themselves with them. Where

1344 JELLINEK: ALCOHOLISMI, A GENUS Cannd MA. J Dec. 24, 1960, vol, $3 a strong identification exists between the nation and the vested interests,the attitudes towards alcopharmacological sense only, and that involves strinholic beverages will tend tobe infuenced favourgent criteria.The criteria are acquired increased ably towards their use, as is manifested in Francc tissue tolerance (this has been made separate in by ‘the acceptance of such large daily intakes as the table of schematic presentation as it may ocapproximately two quarts of wine.(For the past few cur to a limited degree only, and without the developmentof addiction)aquantitativeincreasef years,theFrenchgovernment and some voluntary the drug in question,withdrawal symptoms,and societies have been trying to lower this acceptance to about half that amount.) craving. The withdrawal symptoms are evidence that cell metabolism has adapted itself to the pre- In some of the species ofalcoholism givenin the sence of alcohol, and the craving which is largely schematic presentation,the force of the economic the need for elimination of the withdrawal sympelements is denoted as zero or rather O to,(+++), toms – signifes the development of physical deand the parenthetic three plus is to be interpreted pendence upon the drug. In the instance of alcohol theaddictive processis coupledeither withloss of heading “Sociocultural elements. control,but leaving intact the ability to abstain after a bout, or with the inability to abstain even ELEMENTS OF THE ALCOHOLIC PROCESS for 24 hours but without loss of control over the. Under this main heading willbe considered: (1) amounts ingested. Acquired increased tissue tolerance,(2) Main ad- The degree of the main addictive features in the dictive features,(3)Nature of dependence,(4) various species of alcoholism is either Oor Nutritional and physical habits,and (5)Progres- ++++.As addiction develops, one could speak sive nature of alcoholism. of milder and severer degrees of various symptoms, but, by and large, it comes to the question of Acquired Increased Tissue Tolerance presence or absence of such symptoms. The emphasis here is upon tissue tolerance in contrast to acquired psychological tolerance.The Nature of Dependence latter involves learning certain of the effects of Dependence can be on the symbolic level (purely alcohol on psychological functions,and learning psychological) or on the physical level.Furthertheconscious orunconscious compensation for more,symbolicdependencemayprecede thephy such effects.On theotherhandthe acquired tissue sical dependence; in other instances the sequence tolerance refers to psychophysiological functions may be reversed;and lastly there are species of outside of volitional control and, therefore,which alcoholism in which there is neither psychological could not be compensated through the learning nor physical dependence,but largely a dependence process. Evidence for acquired tissue tolerance has on social customs (e.g. the custom of heavy weekbeen produced by experimental research workers, end drinking in certain ethnic groups). We may and as examples may be cited a lowering of the speak in such an instance ofa sociopsychological effect of alconol on flicker fusion positional nystagfactorbhidtssal mus,certain electroencephalographic phenomena dividual psychological deviations. and so forth, in heavy drinkers and alcoholics. Rapid acquisition of increased tissue tolerance, Nutritional and Physical Habits and particularly one of high intensity,may play a Quantityandqulityf thditregulrn majorroleintheprocessofaddiction,thatisofthe habits or their absence, and proper physical exerdevelopment of physical dependence.Yet while there is arelation between acquired tissue tolerance and the adaptation of cell metabolism to the pretent to the damage incumbent upon the heavy drinkinginvariousspecies ofalcoholism.In some sence of alcohol, the two phenomena must be disinstanceooritonalndysialhbitay tinguished from each other. pre-date the onset of heavy drinking and in other Acquired tissue tolerance of a limited degree will instances they may develop only laterin the course developin all regular users of alcoholic beverages of the drinking career. in large or medium amounts, but does not necessarilyforebodetheprogressiveprocessofaddiction. On account of this latter feature, acquired in- Progressice Nature of Alcoholism creased tissue tolerance is arbitrarily separated It is frequently pointed out that“alcoholism is a from the“main addictive features”with which they progressive disease. Generally when this statecould be logically included. ment ismade,students of alcoholismhave in mind one or the other of the two true addictive species Main AddicticeFeatures Addiction in a psychological sense is no more social drinking to symptom-relief drinking andafter various psychological,physiological and social bethan a figure of speech and is extended to such haviour changesthe eventual occurrence of loss of matters as gambling,kleptomania and so forth. control or inability to abstain or both. There are, The term addiction should be used in the strict however, species of alcoholism in which the pro-

Canad. M. A. J. Dec. 24, 1960, vol. 83 JELLINEK: ALCOHOLISM,A GENUS 1345 gression is limited to the ultimate development of drinker’s health.Without the occurrence of such the so-called diseases of chronic alcoholism,without the dramatic changes depicted byJellinek.aThe not be made.In the instance of the two species nature of the progression and its degree is of the designated as delta and gamma alcoholism reutmost importance in diagnosing the species of spectively,it would seem legitimate to regard these alcoholism which a given patient may represent. two species,characterized by theaddictive process, as diseases in their own right,particularly if it DAMACE INCUMIBENT UPON DRINKING shouldbe found thatoriginal oracquiredphysio- Since some damage must be present in any logical vulnerabilities had played a role in facilitat species of the genus alcoholism,the table of characingtheadditiveproces.Asfarasthefthselected teristics of the selected species in question gives in species labelled epsilon alcoholism,which covers the last tvo columns an expression of the degree of true periodic alcoolismsconeredo eval damage in the physical and mental field and the tions have been made under the various headings. socioeconomicfieid respectively.Physical and As amatteroffact,it may be questioned whether mental damage refers not only to the so-called disepsilon alcoholism is a species. There seems to be a eases of chronic alcoholism,but also to subclinical great deal of heterogeneity among the phenomena impairmentofvariousmetabolicaspectslowering which are described as true periodic alcoholism. of^disease resistance, accident proneness and so Knowledge of this species,or rather one should forth. say subgenus,is insufficient for evaluation and con The sociocconomic damage may range from an clusion. From what is known about true periodic undermining of the family budget to the breaking alcoholism,it would appear,however,that the up of the family,impaired earning power,loss of jobs and other behaviour which threatens society. of various underlying diseases rather than diseases The explanation of the various table headings in themselves. discussedabove will make it possible to interpret the entries in the table and to gain a picture of SUMMARY at least four of the selected species. A survey of what is regarded as alcoholism in various The various species delimited in the table could cultures,and even within the subcultures of a given be given names,but it seems preferable to label country, shows that aleoholism is n genus with many them with letters of the Greek alphabet,as the species. Only two factors are common to this genus, variouswords that could be selected fornaming namely drinking and damage resulting from it. Thus the species could have different meanings for the definition of the genus cannot but be a vague one. various readers. Although the designations alpha On theother handvarious species of the genus can be alcoholism,betaalcoholism,etc,appear in the delineated in stringent terms.Five of themost common first column, this is not intended to mean that the species of alcoholism are presented in a schematic form which takes into account the degrees of physiological labels are being defined. The procedure is actually andpsychological vulnerability,as wellas sociocultural that of describing a species and then giving it a and economic factors in the etiology of the species in label,but placing the label in the last column question and various elements of the “alcoholic proseems awkward. cess”It is suggested that only two species ofalco- From the various entries in the table,what is holism,which represent addiction in the strict pharma designated as alpha alcoholism cannot beregarded cological sense,may be seen as diseases. Two other as a disease,but as a symptom of an underlying species may be symptoms of an underlying disorder, disorder.On the other hand,the species designated and one species,although it produces bodily and beta alcoholism seems tobe neither a disease nor a mental complicationsisneither adisease nor a sym symptom of a disease,the drinking pattern in this tom of a disease but is the result of cultural drinking patterms in certain ethnic groups. species leading to serious damage in the form of the so-called diseases of chronic alcoholism.We are dealing here with culturally determined weekend drinking which,coupled with poor nutritional and 1. JELLINgK, E. M.: The disease concept of alcoholism, Haven 1960. physical habits, leads to serious damage of the JgLLINEK,E.M:Quart.J.Stud.Alcohol,7:1,1946. Social drinkingis a lot ljke speling Misssippiit’s mostly a matter of knowing when to stop.Wall Street Journal.