The latest occasion for thinking about addiction is the approaching publication of the American Psychiatric Association’s Diagnostic and Statistical Manual, DSM-5. In February, the APA issued a draft of DSM-5, which is scheduled for publication in May 2013. The DSM is a crucial cultural document because it not only defines disorders for which people—including, increasingly, children—are diagnosed, treated, and medicated, but, even more crucially, it creates templates for how we think about ourselves.
I have been researching, treating, and writing about addiction all my professional life. In over 200 professional publications and books, I have grappled with what addiction is. Based on my work, I was an advisor for the substance abuse disorders section of the current version of the DSM, DSM-IV, first published in 1994. DSM-IV didn’t even use the term addiction, but instead referred to dependence.
I am not part of the new DSM-5 Substance-Related Disorders Work Group, but take a vital interest in its conclusions. The group is recommending significant changes. Chief among them is a return to the term addiction.
The current work group argues that “dependence” is inadequate because symptoms of dependence, such as tolerance and withdrawal, occur with repeated use of any powerful medicine. As I wrote in 1985 in The Meaning of Addiction, “withdrawal is nothing more than a homeostatic readjustment to the removal of any substance—or stimulation—that has had a notable impact on the body.” Since virtually all drugs create such effects, withdrawal and tolerance can’t possibly define addiction. Instead, addiction derives from how damaging people’s drug use is, and how unwilling they are to withdraw from that experience.
DSM-IV lists seven criteria for dependence. In addition to withdrawal and tolerance, five others address how socially, physically, and psychologically destructive people’s use is, and yet how incapable they are of cutting back or stopping. The new addiction category also emphasizes the destructiveness of substance abuse, but suggests there is something biochemically special about addictive agents.
At issue is not just how we should refer to compulsive, damaging drug and alcohol use, but whether addiction is limited to drugs and alcohol. And while we’re at it, just what does addiction refer to? Is it a brain disease? A behavioral pattern? Or is it a larger experiential pattern?
The view of addictive agents has shifted in different eras. Until the 1980s, pharmacologists classified cocaine as nonaddictive. Of course, cocaine had already been used for a century in and out of medicine (think: Freud, Coca-Cola); how was the “fact” of its addictiveness missed all those years?
Redefining cocaine as addictive demonstrates the constant evolution of the concept—one based not on biology but on culture and history. Cocaine is not the only agent recently reclassified as addictive; nicotine and marijuana have been, too. Such changes suggest that the addiction category is expanding. But that is not the case. Throughout history, “addiction” has been used as a general term, which has included habits such as tobacco, rum, and, yes, love. Only in the 20th century was it narrowed and restricted to the use of narcotics, specifically heroin. Any “expansion” is thus a return to addiction’s traditional meaning.
After deciding that compulsive drug use is addictive, the DSM-5 work group has decreed that gambling can be addictive, too. But stuck in a biochemical view of addiction, they wound up creating a new category for pathological gambling—behavioral addiction. And gambling is the only behavior so designated—not sex, not video games. According to University of Pennsylvania psychiatrist Charles O’Brien, chair of the work group, gambling deserves the designation of “addiction” because “substantive research” indicates that “pathological gambling and substance-use disorders are very similar in the way they affect the brain and neurological reward system.”
O’Brien’s statement represents a rear-guard effort to frame addiction as a brain disease. There is, indeed, imaging research on the ways various drugs affect the brain. But that’s not the key to addiction. I designed and administer an addiction treatment program, and I can assure you that not one person is sent to our program—or any other program—because of a PET scan. People enter rehab because of regular, habitual screwups connected to substance use—compulsive involvement and continued use of a drug (or other involvements) despite chronic harm.
Indeed, as O’Brien points out, powerful experiences like gambling impact the same “neurological reward system” that drugs do. But so do many other rewarding activities. If there is some such higher level “neurological reward system,” then it can’t be said to exclude anything, from sex to food to gambling to video games.
Nor is O’Brien correct in suggesting that cocaine, nicotine, alcohol, and marijuana follow the same neurological pathways in the brain. Each substance has a very different chemical profile, including the timing of effects and the rewards people derive.
And if gambling affects the same brain reward system as substances, as O’Brien claims, why is it a “behavioral” addiction and not simply an addiction? DSM-5 further muddies understanding of addiction in its handling of two other non-drug appetites—“hypersexuality” and “binge-eating.” Neither is regarded as an addiction. Is this because they do not follow the same “neural reward pathways” as drugs and gambling? Binge-drinking can bring on addiction, but not binge-eating? How come? And is gambling really more neurologically, or intensely, rewarding than sex?
The problem with the DSM-5 approach is in viewing the nature of addiction as a characteristic of specific substances (now with the addition of a single activity). But think about obsessive-compulsive disorder (OCD): People are not diagnosed based on the specific habit they repeat—be it hand-washing or checking locked doors. They are diagnosed with OCD because of how life-disruptive and compulsive the habit is. Similarly, addictive disorders are about how badly a habit harms a person’s life. Whether people use OxyContin or alcohol, people aren’t addicted unless they experience a range of disruptive problems—no matter how addictive the same drug may be for others.
One fact that gives the lie to the idea that people become addicted to a specific chemical structure or neural pathway is that people rarely become dependent on a single substance. People usually display susceptibility to diverse addictions, in sequence or simultaneously.
Addiction is the search for emotional satisfaction—for a sense of security, a sense of being loved, even a sense of control over life. But the gratification is temporary and illusory, and the behavior results instead in greater self-disgust, reduced psychological security, and poorer coping ability. That’s what all addictions have in common.
In the future, DSM-5 will be looked on as a document of the moment, not as a successful delineation of addictive disorders. Indeed, DSM-5’s current proposals on addiction will not stand the test of even the short time it takes until its scheduled publication.