DSM5 in Distress

The DSM's impact on mental health practice and research

DSM5 Suggests Opening The Door To  Behavioral Addictions

The recently posted first draft of DSM5 (www.dsm5.org) has suggested a whole new category of mental disorders called the "Behavioral Addictions". The category would begin life in DSM5 nested alongside the substance addictions and it would start with just one disorder (gambling). Read More

behavior and brain

So much new information is being found on the relationships between addictive behavior (that is, the action of using something that may not be a chemical, but gets us high) and neurotransmitter levels, i.e. dopamine, in the brain. I used the DSM IV definition of behaviors of an addiction in my post Mending 6.

I've counseled shopping addicts, relationship addicts, hoarding addicts. I am a recovering compulsive gambler. I, and every addict I've known, whether we are tweakers, junkies, compulsive gamblers or compulsive shoppers, have behaved in accordance with the DSM IV criteria.


Addictions aren't fun... or don't cause harm?

Dr. Frances,

Thank you for another thoughtful post about DSM5. However, the concept of addiction remains murky, at least to me. The first part of your post proposes that addictions are not pleasurable by definition. But I've talked to many alcoholics, unquestionably addicted, who told me they still enjoyed the feeling of being drunk. Their drinking wasn't solely to avoid withdrawal or discomfort, although that was present too.

In the second half of your post, you seem to shift to a definition of addiction based on harm, and perhaps popularity. Caffeine is widely used and fairly harmless, so it's not an addiction. But many people drink coffee in the morning to feel "normal', not for pleasure, which would seem to qualify it under your prior argument. And while I realize social convention is inevitably a part of psychiatric diagnosis — who is to say when an affect is "inappropriate"? — I'm uncomfortable giving this much say to the majority. Cigarettes used to be quite popular too.

This isn't meant as personal criticism; I very much admire your reasoning in these blog posts, not to mention your work on DSM. I'm just struck by how much we as a profession and a society rely on a concept, addiction, that defies simple understanding.

lAddiction is hard to define

You have made great comments that point to the heart of the problem - we have no good overall definition of "mental disorder" or clear boundaries demarcating any particular disorder from normality or other disorders. The best, but still fallible, definitions all emphasize distress and impairment. (I will go into the implications of this in more detail in a later piece.) Certainly, the distinction between recreational versus compulsive substance use is often difficult to make. It depends on a judgment whether:
1) the substance use is understandable given the pleasure/cost ratio versus; 2) the harmful consequences clearly overwhelm any residual pleasure. The judgment is often imprecise, subjective, and is greatly influenced by varying individual, family, cultural, and clinical interpretations of what is a reasonable pleasure/cost tradeoff vs what crosses the threshold of clinically significant distress and impairment. I brought up the caffeine example precisely because it illustrates how necessary it is to consider practical utilitarian issues in defining what is or is not a mental disorder. Caffeine "addiction" would make sense only for the very few people who can't give it up despite its worsening their medical (eg atrial fibrillation) or psychiatric (eg anxiety) problem. We chose not to add it to the manual because it would have trivialized psychiatric diagnosis. The term "caffeine addiction" would be loosely applied to the many who are physiologically dependent but who don't have impairment or a pattern of compulsive use. So harm does count a great deal deal in deciding what is an "addiction". And your last point is correct-social convention is a large part of psyychiatric diagnosis. But more on this another time.


I'm not going to be as articulate as I should...

Cannabis would be in the caffeine class (in my most unprofessional yet long term users opinion)
yet I also think the carcinogen and negative effects are the just as destructive as Smoking, Caffeine, (health Issues are health issues) Gambling (cost) i have smoked cannabis for over 10 years and at all times with risk(illegal) yet not only for the "fun" but the anxiety reducing effect... (so in pretend world) treatment for caffeine anxiety could or would be weed if legal for use) in the sense a large populace enjoys the recreational effects yet many are smoking for there health in relativity different ways

plus I had not had such an harsh anxiety attack until I went to seek help for it (being carcinogenic concerns) and received Diazpam 2 mg twice a day dose one month then stopped the pills, under a week later I had the worst anxiety ever ever and I just hope weed will be all i "need" for my now worsen anxiety but when I take them it helps so now what? is that addiction to anxiety pills (i am 1 month in on my second visit new bottle but try not to use it but I can see it's worse now and I wish I would have just smoked and risked jail or cancer.

anyhow I see your point and evolution has a lot more than even you or I know towards shaping what is wanted or needed

Gender Incongruence (Heels have been around since egypt times of past, and in many societies)
Male to female vs female to male will have either a strong MtF "want" F2M "no desire" yet even there thru out history men in mens positions (unfortunately we are unable to know there true gender identity if Incongruence was present) have worn heels. this can also be applied to nail polish and other gender related objects.

while addiction to sex could imply natures resistance to contraceptives, and caffeine making one feel normal could also imply evolutionary tolerance growing to form a need for that chemical.

(what ever body of world a life form lives in, that life form would use any access to possible conversion of energy materials to it's advantage to sustain and adapt to life and circumstance.)

I:e: food groups are now needed to sustain health while at one point in evolution all one needed was either meat or vegetation.

My genes can be traced to those who first started using cannabis and I may or may not have had predetermined inclinations toward cannabis, long before(nearly 3 years) I choose to smoke weed I had urges to buy a Pipe and did so several times, with those pipes I used tobacco what was not inclined towards that substance yet even now after many years of smoking I can get paranoid (mostly due to legal issues) but even than paranoia will only start after the first few minutes and last no more than half an hour (if type of weed has a Paranoid effect it can lead to other areas of paranoia, I:e cheating spouse, misplaced item thought to be theft, rational can subdue any major effect that I know have experienced yet some "weed" is from non fda approved source and may have contained unknown chemicals and or stronger thc levels?

Definitional question....

Great article.

My question is: Are addictions defined objectively or subjectively?

To wit, a heart attack is a heart attack is a heart attack. Doesn't matter if the patient is rich or poor, black or white, married or unmarried, old or young. You got the symptoms, you got the blood test, you got the diagnosis. Ditto lupus. Ditto multiple sclerosis. Ditto...well, you get the idea.

But is it the same for addictions? What do you make of the married woman who uses an ungodly amount of pornography and cruises pickup bars, much to the consternation of husband #1 who divorces her. Husband #2 incorporates the porn into their sex life and believes in open marriage. Poof! Problem gone.

Addicted? Disordered? Or not?

Who's the winner

Doesn't this widening of the definition of mental illness profits to the pharmaceutical industry which will sell more medication? It looks suspect.


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Allen Frances, M.D., was chair of the DSM-IV Task Force and is currently professor emeritus at Duke.


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