Book Review

Addiction Psychiatry: Current diagnosis and treatment

N Engl J Med 1995; 333:1158-1159October 26, 1995

Article

Addiction Psychiatry: Current diagnosis and treatment
By Norman S. Miller. 300 pp. New York, John Wiley, 1995. $54.95. ISBN: 0-471-56201-7

This book has appeared at a propitious time. Last year the American Board of Psychiatry and Neurology began offering a subcertification in the field of addiction, and the Psychiatry Residency Review Committee recently mandated training in alcoholism and addictions during residency. Three decades of clinical research, greatly accelerated in the past decade, have provided abundant data for this book, as evidenced by its 665 references.

Indeed, Miller's greatest challenge must have been in deciding what to exclude from this introductory book. He has succeeded well in these 26 chapters, some only several pages long. Topics needing more substance, such as diagnosis and psychiatric aspects, receive it. Separate chapters deal with the major psychiatric entities, and there is a beefy section on treatment. Esoteric subjects — such as the testing of bodily fluids for alcohol and drugs, personality disorders and addiction, and models of treatment — receive brief attention. The chapter entitled “Neuropsychopharmacology of Abstinence” is especially valuable; it synthesizes new theories and knowledge about neurotransmitter physiology, the addictions, and recovery. The overviews of the genetics and pharmacotherapeutics of addiction are also outstanding.

Miller's style pulls the reader into the subject. His prose is to the point, and it reads well. He documents many of his major points. His critique of the terms and categories used in the addiction field is on target. There are no warnings about treating addicted patients decently, but they are unnecessary; the author's sensitive approach suffuses the entire book. Miller's lucid descriptions of the cascading interactions among substances, patients, and social milieus clarify confusion about cause and effect. Neophytes and scarred veterans alike can appreciate the sections on group therapy, relapse prevention, and the elements of a sober, recovery-focused lifestyle. Areas ripe for future clinical investigations are identified.

With such a large topic, a compact book can neither include everything nor please everybody. I searched in vain for discussions of tobacco dependence and its treatment, contingency contracts (how could an addiction psychiatrist practice without them?), pretreatment motivational counseling, the uses of disulfiram, interactions between abused substances and psychotropic medications, and special approaches to common problems of transference in addicted patients. The absence of such discussions is not a fatal flaw; these issues cannot be avoided by clinicians reading and attending conferences on addiction psychiatry. However, it did concern me that numerous areas of psychiatry that involve coexisting conditions are not discussed to any notable extent.

In addition, Miller presents some clinical phenomena as “all or nothing” conditions, whereas they may actually appear as part of a spectrum. One example is loss of control over the amount and duration of alcohol or drug use. This is presented as a single, clear-cut symptom, but it can occur infrequently in the early stages of disease and increase gradually to happen “most of the time” in the advanced stages. Furthermore, psychiatric patients are presented as commonly having addictions (a well-documented fact), but addicted or alcoholic patients who present to nonpsychiatric facilities are described as having few serious psychopathologic conditions other than brief anxiety or depression. That does not jibe with my experience or interpretation of the literature. Nevertheless, assuming that addicted or alcoholic patients have few serious psychopathologic conditions, Miller recommends that they need a certain level of anxiety and depression (“no pain, no gain”). I agree that some anxiety and remorse are important, perhaps even critical to recovery. But persisting major depressive disorder, panic disorder, and other nonpsychotic conditions may require pharmacotherapy, psychotherapy, or both for a successful outcome.

Miller takes several swipes at the “self-medication theory” of addiction. Although I do not believe that theory explains all addiction, some patients say that they take alcohol or drugs to alleviate symptoms, either psychological or physical. We may label that a rationalization in some cases, but it remains a valid clinical phenomenon nonetheless. Moreover, it could be a symptom related to neurotransmitter damage from substances of abuse — that is, an instrumental cause rather than an ultimate cause.

I have some semantic quibbles. Miller refers to alcoholism as an allergy, a notion stemming from the writings of one of the early associates of the founders of Alcoholics Anonymous, a physician. But using such a technical term does not serve professional terminology well. If professional jargon becomes idiosyncratic, we will not be able to communicate soundly. Elsewhere Miller refers to alcoholism as a “spiritual disease.” Were he a clergyman, that phrase would not bother me, but I am concerned that he, a physician, should label this disorder a spiritual one.

In analyzing denial, Miller creates a category of “denial that is intentional.” I hold that denial as we define it — an unconscious separation of related events or phenomena — cannot be intentional. If a patient intentionally misconstrues an event or a relation between events, that is lying.

Residents in addiction psychiatry and addiction psychiatrists ready for a critical review should read this book, for its factual information as well as for its inclusion of widely held beliefs in the field of “addictionology.” Psychiatrists studying for their subcertification in addiction will find that it does not cover important topics in sufficient depth. On the other hand, it is too technical for nonpsychiatrists interested in the field.

Joseph Westermeyer, M.D., Ph.D.
University of Minnesota, Minneapolis, MN 55455