The nosology of addiction as a medical condition: a concise history and review of contemporary perspectives

Abstract

There is active scientific debate about the nature of addiction as a mental disorder, but with comparatively little discussion of nosology itself. To contribute to the ongoing dialogue, this review provides a concise history of the formal medical diagnoses used to define addiction clinically and vanguard contemporary perspectives. The history of addiction as a medical diagnosis starts at the beginning of the 20th century in the first International Classification of Diseases (ICD) and was present in 1953 in the first edition of the Diagnostic and Statistical Manual (DSM). Across iterations of both systems, the evolving nosology can be broadly divided into three epochs, an early primeval period (1900–1948), reflecting coarse definitions subsumed within personality disorder; a phenomenological period (1948–1980), reflecting descriptive definitions; and an empirically-informed period (1980 to the present), comprising operational definitions of polythetic syndromes, increasingly informed by empirical findings. Contemporary priorities suggest an emerging fourth epoch, prioritizing a diagnostic nomological network of objective etiologically-informed tests via, for example, the Research Domain Criteria (RDoC) and Addictions Neuroclinical Assessment (ANA) frameworks. Both RDoC and ANA focus on using objective mechanistic indicators to decrease subjectivity in diagnosis and increase alignment between etiology and diagnosis. Next-generation diagnostic approaches are anticipated to enhance incisiveness in psychiatric diagnosis and in turn improve clinical outcomes. Tracing the vicissitudes of addiction nosology over the past century reveals an evolution that is both more humane and scientific, from moral weakness and personality defect toward diagnostic definitions and practices that are grounded in empirical evidence.