The spiritual malady is first mentioned as part of Step Three, and spiritual sickness (see pages 66 and 67) is presented as a universal human phenomenon.
There is no mention of it, or anything like it, in the Step One portion of the Big Book (up to page 44).
There are two possibilities: the Spiritual Malady is totally part of Step One, but the writers of the Big Book were too sly or inept to include it. If that's the case, then the writers of the Book are not to be trusted, so we can throw the Book, and the Twelve Steps, out of the window.
The only other reason why it is not mentioned in Step One is that it is not part of Step One.
Were this an oversight, Bill could have rectified this in the Twelve and Twelve. He does not.
How do we reconcile this with the passage in the Doctor's Opinion about alcoholics being restless, irritable, and discontented until they have the first drink? How does this square up with the fact that Rowland Hazard (page 27) and Fred (39) are certainly not restless, irritable, or discontented, and yet drink again, Jim (page 35) is irritated only to an ordinary, universally human extent and yet drinks again, and Bill, on page 15 and in the Mayflower Hotel Incident, is restless, irritable, and discontented yet does not drink.
Did Silkworth get it wrong?
No.
Why do people drink again?
Because they have alcoholism.
What is alcoholism?
Aside from the physical craving that kicks in after the first drink, there is a part of the mind (really the brain) that is programmed to shoot up the 'let's-have-a-drink' impulse to the decision-making centre of the mind, and the decision-making centre sometimes ('at certain times') flags through the impulse, which given our histories, is insane, and we drink.
The part of the mind that originates the impulse is not part of the reasoning mechanism of the mind. Reasoning kicks in to justify it, but the impulse is not generated by reasoning.
Once an alcoholic, always an alcoholic: once the impulse-generating part of the mind has been programmed to shoot drinking impulses up to the decision-making centre of the mind, it will periodically do so until we die.
This is why people who are unhappy often don't slip and people often slip when they are perfectly happy: being handed a glass of champagne at a wedding. There is no sophisticated common denominator in the mental states preceding the first drink, either in real life or the Big Book. The only common denominator is the primitive impulse to drink, which arises without warning or cause.
What we need is a mental defence, in the form of deference to a Higher Power, in other words living in accordance with a set of principles and with dependence on that Higher Power.
In contrast to what? In contrast to living based on self, based on my own reasoning.
If I do what I want to do, when I want to do it, I will drink again.
This means I must never be living on that basis.
Now, someone who is living based on self will usually find themselves fearful and frustrated (see pages 60 to 62), which will lead to being restless, irritable, and discontented.
But not always, and not always straight away: Fred is living a life based on self, as was Rowland Hazard, as was Jim. They were concerned with themselves, not with others. They had no active working relationship with a Higher Power, so, when the desire to drink arose, the needed defence was not there. In them, the centering in self and the consequent disconnection from God were not manifesting on the surface in restlessness, irritability, or discontentment. But they are exceptional in this. That's why they're such great examples of alcoholism: We want to drink because we're alcoholics, for no other reason. And the desire to drink activates drinking because we lack, and will always lack, a permanently adequate mental defence.
Drinking again has nothing to do with happiness, competence, agreeable or orderly circumstances, or any other extraneous factor.
It is permitted by one thing and one thing only: disconnection from God.
The disconnection from God is an (almost) universal feature of humanity, but is fatal only in alcoholics, because connection with God is the only remedy for failed decision-making circuity.
Thus, whilst most alcoholics, prior to relapse, are indeed restless, irritable, and discontented, as Dr Silkworth points out, this is not causative of the relapse; it merely correlates with relapse, because the lack of operative Higher Power, which is the only defence against relapse, quite separately entails reliance on self, which typically results in failure at living, which typically results in being restless, irritable and discontented.
Correlation does not equal causation.
We want to drink periodically, because we are alcoholics.
Our only defence will come from a Higher Power.
Without one, we are reliant on self.
And self-reliance gives rise to two consequences:
(1) Drinking, when the impulse arises.
(2) In most cases, failure at life, which causes restlessness, irritability, and discontentment.