Just outside our house are three large Norway Spruces that line the driveway. Each year, they drop a prodigious quantity of pinecones. Thanks to the local squirrel population, the pinecones find their way throughout the lawn.

Our two-year-old son is fearless; he will not shirk from climbing the highest wall or couch-back. But he does, in fact, have one fear: pinecones. From the time he was crawling, he would avoid them when encountered in the backyard. Even now, at almost three, he'll ask that a pinecone be removed from his path if he's walking along and sees one. He can kick it out of the way, or even throw it aside, but his preference is that someone else get rid of it for him. As psychiatrists, his mother and I have posited all kinds of troublesome diagnoses, but we're smart enough - I think - to have ignored them all under the assumption that this will eventually pass (and if it doesn't, there are worse things in life than a dislike of pinecones).

After writing my last column about some of the denizens I had encountered at Wikipedia, I thought again about the pinecone mystery. As clinicians, we try so hard to figure out why people are fearful of substance use disorders as a disease, fearful of those with substance use disorders, or fearful of mental disorders in general. It is a stigma, we say, based upon some past educational experience (note that not all education is good). Is it possible, however, that like our son and pinecones, there are those who are simply fearful for no reason? Those who will try any argument, no matter how illogical, to support a fiercely held desire that substance use disorders not be a disease?

Thoughts on alcoholism

Let me share with you some of the comments I've seen online at Wikipedia, comments which are separate from the articles we discussed last time, and which are meant by their authors to stimulate debate or to direct article content toward a specific goal. As I read them, I couldn't help wondering whether their authors were fearful of alcoholism's being a disease, and if so, why. The first two comments are from: http://en.wikipedia.org/wiki/Talk:Disease_Theory_of_Alcoholism

"Let me cite a real life example. There's evidence that alcoholism is caused by an excessive production of endorphins when a person drinks. If a person never drinks, then the excessive level of endorphins never results in alcoholism. The excessive production of endorphins is actually a natural variation in human genetics. It allows the people to become more quickly acclimated towards exercise and risky behaviors like hunting and sporting competition. It just happens that the group of people with that particular adaptive trait are also susceptible to becoming addicted to alcohol. Genetic variation is not a disease. It isn't a mutation, it's a naturally occurring variation that's fairly common in the gene pool. It even provides beneficial effects for many of its recipients. Do we call addiction a disease? Since endorphin is a naturally produced chemical that acts like morphine (it's name is derived from "endogenous morphine") what we're dealing with, then, is identical to morphine addiction, except that the triggering mechanism is the consumption of alcohol. If not, then we have a real life example where alcoholism might not be categorizable as a disease. Again I have to reiterate that until we know what the cause is, we cannot state authoritatively one way or the other."

"The difference between alcoholism and things like cancer is that a person is, certainly, not causing a tumor. If indeed there is a biological reason why an alcoholic responds to liquor differently than other persons, it is similar to an allergy. The allergy itself, the susceptibility, is not a disease. Exposure to the stimulus, yes, produces a diseased condition but, like alcohol, if the allergic one does not eat peanuts there is no disease. If he willfully and knowingly eats peanuts, he may be foolish or he may do as a result of dementia, and he will get sick, but the peanut-eating itself is not the disease."

Another author at http://en.wikipedia.org/wiki/Talk:Alcoholism wrote, in part:

• It doesn't seem accurate to say that "physicians agree" that alcoholism is a disease given the fact that at least one in five doesn't agree and with some evidence that the proportion of those who disagree may be higher. I think we could honestly say that the majority agrees.
• It would seem to be incorrect to assume that the American Medical Association (AMA) speaks for American physicians. Its membership has declined over the years and is currently only about 244,000 of the 800,000 active U.S. physicians. At best, it can be said to speak for only about 30.5 percent of active U.S. physicians.
• If we get too narrow in our reference group and report something like "X percent of American psychiatrists whose practice is primarily devoted to treating alcoholics define alcoholism as a disease ... ," then we've provided an unintentionally misleading definition for readers.
  

Is there a misconception?

Some might argue that the authors whom I've quoted have a simple misunderstanding as to what we mean when we say alcoholism is a disease. They may not understand that we are not referring to the use of alcohol. Some of the debate seen online details how people have a choice about their drinking, and therefore alcoholism is not a disease. That, I suppose, might have validity if the act of drinking was what we meant by disease. But then again, scores of allergists would likely take issue with the peanut allergy issue as opined by one contributor.

I still have my suspicion that we are dealing, at least in part, with baseless fear. If my 2-year-old can be afraid of pinecones, why shouldn't at least some people be afraid that alcoholism is a disease?

This article is published in Counselor,The Magazine for Addiction Professionals, December 2006, v.7, n.6, pp.36-37.

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