Satel & Lilienfeld write: "Addiction is not as hopeless or uncontrollable as the brain disease metaphor suggests. Yes, like other bad habits, it is in our brains—but like other bad habits, it can be broken."

I find it odd that the authors assert how addiction is not as "uncontrollable" as the brain disease concept presumably leads one to think, and yet, the authors also believe in 12 step programs. Such programs, in the very first step, maintain that the "powerlessness" the addict has over his or her life and addiction is crucial to admit. I think this lack of control gets at the heart of addiction. (Whether or not a 12 step program can help is debatable. Some are helped; many are not). As another, recent article on Slate shows (The Explainer's column on Lindsey Lohan), relapse with continual addiction is extremely high.

The authors also question if stigma is really so bad. I think it certainly is, if it keeps people from treatment due to shame, which seems highly likely. Physical ailments, on the other hand, carry less shame than perceived moral and mental weaknesses.

Brain scans and other such technology will only improve in accuracy, so let's not be so quick to discard the idea of addiction as disease. There is definately room for improvement in how addiction is both treated and percevied.

This transformation from personal weakness/moral failing to disease has happenend with other illnesses. Epilepsy, once thought to be caused by mental twistedness (and/or witchcraft) is now seen as the brain malfunction it actually is.

I think addiction can also use an overall in image (pun intended) as we learn more about how drugs not only affect, but also *change* the brain. Furthermore, some people seem to have brains extremely primed for addiction while other people are relatively more protected. Improved medication can be speeded up by the idea of addiction as a brain disease, but treatment can also encompass psychotherapy. Addiction as a disease is a necessary enlargement of our ideas about addiction and about treatment.

PS: I meant to say: with addiction *continual relapse* is very common.

I also meant to write "overhaul" rather than "overall".

You make the best sense. And if shame was so compelling, why don't more people respond to it? Evantually it may be that science tells us to back away from the disease model too, but it is still a step in the right direction to move away from the previous perception. Taking some of the emotional weight out of the addiction equation frees the addict from at least some of that baggage and enables them to look at other possiblilites to change the course of their lives.

Disease "model" can be confusing. It brings to mind outdated notions of cognitive or emotional disorders. The AMA has described alcoholism as a primary physical disease since the 1950s. A lot of research since then has stabilized that definition of physical disease, and has begun to unravel its genetic complexity.

Most twelve step programs stress the necessity of realizing that substance abuse is only a symptom of a deeper malaise. The heart and soul of the fist step is admiting this on a personal and group level; It's the realization that it's not the "drug or drink" but denial that makes and keeps addicts powerless.

It's doubtful that epileptic seizures were ever widely seen as "mental twistedness," although they have in some cultures been taken as evidence of a kind of "mental specialness." In general, pre-scientific cultures regarded epilepsy and similar phenomena as possession by a spirit, good, evil or ambiguous, depending on the circumstances--but in any event, not a voluntary behavior.

It is that distinction between voluntary (or, better, "value-seeking") behavior and involuntary, or non-value-seeking, behavior that lies at the root of the idea of disease. Disease, properly (i.e., not metaphorically) speaking, is always involuntary, non-value-seeking. Unquestionably, we treat the decision to drink alcohol or use drugs recreationally as, in itself, a voluntary or value-seeking behavior. If we didn't, alcoholism and addiction would be affirmative defenses to criminal charges, which they aren't. Only if a defendant can establish an underlying mental defect, distinct from addiction, sufficient to negative moral responsibility for his behavior (which is very difficult to do) do we hold him not legally responsible for acts committed under the influence.

Thus, legally, morally and (I am tempted to say) "familialy," we simply do not regard or treat alcoholism and addiction as true diseases. The "disease model" is a metaphor that applies only within the therapeutic community. Perhaps in that setting, it plays a valuable role. But it is often misleading, in these discussions to characterize alcoholism and addiction as "dieases" or all, or even most, purposes.

Eh. A better generalization is that pre-scientific cultures understood causal mechanisms less well so that the "value-seeking" characterization of disease you propose would be invalid. That is, no one would think getting disease A was value seeking, but before people understood how you got the disease, they would imagine that its genesis was in some value-seeking behaviour (you'd opened yourself up to a disease by something bad you or maybe even your ancestors/relation.etc has done). Indeed, this perspectic survives in the human brain to this day in the sory of nutty attachment people develop for their pet theories of disease (people very easily become attached to simplistic causal explanations for ill health). The main point, though, is that you're wrong about epilepsy and it's annoying. Yes, there are exceptions, but epilepsy has been largely stigmatized historically and I would say continues to be so to this day to a lesser degree (although more on socioeconomic grounds in the developed world, now)..

Yes, I would think it is. Stigmatizing? I've heard so. But whether the stigma of epilepsy arises from moral condemnation is another question. The demon-haunted men in the gospels are frightening--who would want them around?--but Jesus' casting out their devils is portrayed as therapy, explicitly associated with his other healings. True, in Jesus' time illness was sometimes explained as punishment for sin, but I take that more as a philosophical than a practical thing. It was intended to make some general sense out of the arbitrariness of evil, not to convey information about how to cure illness or to behave toward the sick. If it had, would have been the point of nursing a sick child?

Should I welcome you back? Considering the venue, it might not be in good taste. One had hoped you'd found more rewarding places than the country of the Gadarenes.

Did you know that Meletus died?

Well, nursing a sick child might be the very method to appease the spirits (etc). Many religions claim that nowadays - that what is sensible for practical reasons is so precisely because it is religiously moral. I won't argue the point that pre-scientifics specifically thought disease was value-seeking since I do not mean that really. My point, more, is that pre-scientifics (definitionally, for me) have a poor idea of causal relationships so they would, at the least, be often confused about what were voluntary vs involuntary "illnesses". This makes the distinction you attempt to draw not a social-histoically useful one, although it has value in analysis now, I think. So, their notions of epilepsy were confused and, yes, probably all twisted up with weird ideas of guilt and associations with voluntary behaviours. Not because they thought that it was voluntary precisely, but because they could not think precisely enough at all to even make the distinction you draw.

More broadly, I would guess people's perspective on disease in ancient days was more about distinguishing between bad luck and bad genes. Epilepsy could well be lumped in with most "voluntary" disorders (which would've suggested bad genes too, except behaviourally). I'm curious for your explanation for why epilepsy is so poorly treated as a disease nowadays. Its sufferers can be young, treatment ranges from brutal to non-existent and yet it doesn't seem to invite empathy in the public they way more obviously extrinsic disorders of the young do (even autism gets a better rap as something that happens to kids, I think). Book comment: The graphic novel Epileptic is highly regarded and might be up your alley (it's a strong book).

I did know Meletus had died. (30 minutes pass). I wonder sometimes, Fritz, if you are my enemy. I am a fairly standard type in that I hate and fear death while it is never too far from my mind. You're the type that is mildly infatuated with it. Usually planning out the necessity for suicide (the person I'm thinkin of most like you also thought a lot about Alzheimer's specifically). Anyway, the reference to Meletus is an appropriate rebuke to me (though you don't know it) since my first thought on hearing of his illness was to wonder if he had smoked. And "rewarding places" is a fair rebuke as well (I have so I should fly). Cheers.

Though I suppose not a friend, either. We're both too self-protective for that.

No rebuke intended, either. It puzzles me that you speak often of rebuking, punishing, dismissing, yourself. Some kind of noblesse oblige? I doubt it. I suspect pain is a bigger part of your life than you'd ever admit. (I wouldn't pretend to know what kind of pain.) You know what sometimes crosses my mind reading your posts? Wherefore I say unto thee, Her sins, which are many, are forgiven; for she loved much . . .

How people feel about death is only a function of how they feel about life. So if you hate and fear death, be exceeding glad. I don't love life, but the reasons aren't entirely personal, e.g., fear of Alzheimer's. I wouldn't be the first man who concluded that existence is a tale told by an idiot. Nor the first such man who also had recurrent moments of Myshkin-like bliss. Such bliss has nothing to do with life, it is foreign to it, apart from it, yet it acts as an anchor holding me here.

I may share Myshkin's ecstasies but I don't have his epilepsy. My ancestor Helmholtz is said to have been epileptic, and my mother said her father sometimes went into quiet trances. I haven't been exposed much to people with the illness, so I don't have much feel for the stigma it is said to bear.

I'm much more familiar with the stigma associated with mental illness. The physically ill person knows he is not in a normal state. The mentally ill person often does not realize this, and by expecting to have his aberrant, and often damaging or frightening, behavior treated as normal, he sabotages our social instincts and responses off. I would guess something similar is behind popular feelings about epilepsy. Someone suddenly collapses, perhaps in a disturbing or frightening manner, and after a time gets up and goes on his way: it looks almost as if staged. (I hope what you say about treatment of epileptics--brutal to non-existent-- is an overstatement. I would have thought the doctors, at least, would treat these patients as patients.)

I've thought about your discussion of perceptions of illness in earlier times. You are probably right that the categories we use for analysis now distort our understanding of the perceptions our ancestors, at least our remote ancestors, had, and that in any event my distinction is too crude to be of much use. But still, what strikes me often when reading about the past is how like us they were. I don't agree that they had a "poor sense of causal relationships" (they simply couldn't see what we can "see") or that they "could not think precisely" (they could about what mattered, which for the most part wasn't abstractions). Of course they were wrong about everything, but then so are we. Others will someday give an account of the world that falsifies ours at least as much as ours falsifies theirs. In fact, it happens as we speak.