DSM5 in Distress

The DSM's impact on mental health practice and research

DSM5 Suggests Opening The Door To  Behavioral Addictions

Behavioral addictions are a slippery slope

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).  None of the other "behavioral addictions"  suggested for DSM5 would gain official status as a stand alone diagnosis. But if a clinician felt that the patient were "addicted" to sex, or to shopping, or to the internet, or to working, or to video games, or to credit card spending, or to surfing, or to suntanning, or (my own personal favorite) to blogging on blackberries, or to whatever else (the list is long and could easily expand into every area of popular activity)-this could be diagnosed as "Behavioral Addiction Not Otherwise Specified" and thus receive the dignity of an official DSM code.

  The rationale for this category is that compulsive behaviors follow the same clinical pattern and may even derive from the same neural network as compulsive substance use. The criteria set for pathological gambling developed for DSM IV was modeled in close imitation to the criteria for substance dependence.  Similarly, the DSM5 draft criteria set for "hypersexuality" also uses the same items as define substance dependence and would seem to fit nicely as a "behavioral addiction" -although for some reason it has been proposed instead for the section on sexual disorders (one placement or the other, this is a bad idea for reasons detailed in a previous blog).

   The notion that underlies the "addiction" concept is that the substance use (or behavior)  originally intended for pleasurable recreation is now  compulsively driven. Although the act is no longer the source of much pleasure, it has become so deeply ingrained that the person continues to perform it in a repetitive fashion despite great and mounting negative consequences.

  The evidence supporting the idea that someone is  "addicted" would consist of  the continuation (or even increase) of seemingly autonomous and driven behaviors despite the ever diminishing gain and the ever increasing cost.  Subjectively, the person feels an escalating loss of  control over the act and instead comes to feel increasingly controlled by it.

  The rationale for a "behavioral addictions" category is that the subjective experience, clinical presentation, neurobiological substrate, and  treatment indications for it are equivalent to   those for substance addiction. But the proposal has one fundamental problem and an assortment of negative unintended consequences that should be more than sufficient to disqualify it from further consideration.

   The fundamental problem is that repetitive (even if costly) pleasure seeking is a ubiquitous part of human nature- while compulsive behavior that is not rewarding is relatively rare. But on the surface it is extremely difficult to tell the two apart. The "behavioral addictions" would quickly expand from their narrowly intended,(perhaps) appropriate usage to become a popular and much misused label  for anything that people do for fun but causes them trouble. Potentially millions of new "patients" would be created by fiat,   medicalizing all manner of impulsive, pleasure seeking behaviors and giving people  a "sick role" excuse for impulsive irresponsibility.

   We, all of us, do short term pleasurable things that can be quite foolish in the long run. It is the nature of the beast. The  evolution of our brains was strongly influenced by the fact that, until recently, most  people did not get to live very long.  Our hard brain wiring was built for short term survival and  propagating  DNA- not for the longer term planning that would be desirable now that we have  much lengthened lifespans. Salience was given to the short term pleasure centers that encouraged us to do things that give an immediate reward. This is why it is so difficult for people to control impulses toward food and sex, especially when the modern world provides such tempting opportunities.
   Thus our massive collective societal weight gain comes from an enduring sense of facing famine that makes it hard to say no to the attractions offered by refrigerators and supermarkets. Pleasure at the mall satisfies survival motivations based on gathering and nesting. And so on (I will leave sex to your own individual  imaginations).

  This type of hard wiring was clearly a winner in the evolutionary struggle when life was "nasty, brutish, and short". But it gets us into constant trouble in a world where pleasure temptations are everywhere and their long term negative consequences should count for more than our brains are wired to appreciate. The late blooming insight of the new discipline of behavioral economics is that we are not rational animals (they would figure this out sooner had they read Darwin or Freud). We all make bad short term decisions because it is hard to resist the immediate fun at the time. Then we suffer the long term consequences.

   In a better world, our forebrains would do a more efficient job controlling impulses and long term planning and would anticipate and/or avoid those pleasures not worth the price.  But we live in this world and exist within an inherently imperfect  human condition - the stuff of tragedy, comedy, and melodrama. In a statistical sense, it is completely "normal" for people to repeat doing fun things that are dumb and cause them trouble. This is who we are. It is not mental disorder or "addiction" - however loosely these much freighted terms are used.

   Instead "addiction" would imply that there has been an override of our average expectable impulsive, pleasure system. The individual does the behavior over and over and over and over again- despite a lack of reward and much negative reinforcement in a way that does not now (and never could have had) any survival value.

    In a previous blog on the sexual disorders, I discussed the difference between the commonplace  fun loving philander and the rare , tortured "sexual addict". The philanderer enjoys his sexual activity so much that he keeps doing it despite the external trouble he gets into or any internal moral qualms he may have. The immediate pleasure it brings has more salience than the eventual pain. This would be  in sharp contrast to that rare person who compulsively repeats  the sexual act without experiencing much or any pleasure, even in the face of great risks or punishments.

   The parallel would apply to all of the possible "behavioral addictions". If a person shops till she drops because this is fun, it should not be called "addiction" no matter how much trouble it causes.  People who prefer the internet or video games to other life pleasures are not addicted so long as the activity remains pleasurable.  

  There are a number of disqualifying problems  with the concept of "behavioral addiction" - some practical, some conceptual, some societal:
1) It will quickly expand to include all impulsive behaviors that lead to trouble. The extent of this risk is already obvious in the media circus surrounding Tiger Woods. There is no bright line to separate "addiction" driven from "pleasure" driven behavior so addiction will widely spread its borders and become ubiquitous. .
2) "Behavioral addiction" will likely become the excuse du jour for all sorts of past irresponsibility when people get in trouble. For many, the twelve steps will augment or substitute for previously popular religious rituals  (confession and expiation). Sometimes accepting that you are powerless over the "addiction" will be the beginning of a sincere effort to change, but often it will be no more than spin. .
3) Being "addicted" reduces ones sense of personal control over, or responsibility for, future indulgences. "The addiction" makes me do it" reduces the burden of personal agency".  And after all, relapse is a an expected part of recovery.
4) Medicalizing self indulgence will dramatically swell the rates of mental disorder and turn normality into a vanishing species.
 5)There are likely to be many  unintended consequences in forensic settings.  Some miscreants will attempt to offload or mitigate culpability on the basis of their new mental disorder.  The diagnosis "Behavioral Addiction NOS" could conceivably be misused as a tool for the indefinite psychiatric  commitment of sexually violent offenders.   
6) On the broadest scale , a vibrant society depends on having responsible citizens who feel in control of themselves and  own up to the consequences of their actions - not an army of "behavioral addicts" who need therapy in order to learn to do the right thing.

  One can argue the pluses and minuses of the very narrowly defined concept of "behavioral addiction". If it could be contained within the narrow confines of its proper intended usage, it might conceivably be a viable idea with a very small role in mental health endeavors. Instead, it is a terrible idea precisely because it cannot be so confined and would have devastating individual and societal consequences .

    This brings us to the responsibility that is in the hands of those preparing DSM5. They should conduct a thorough risk benefit analysis that considers not just the risks of the narrowly defined "behavioral addiction" they intend-but also the broader misuse of the concept once it is in general misuse. We have recently seen one instance of "behavioral addiction" becoming a media darling and its wildfire would be fueled were the concept to become official"

    There is no guarantee that the people preparing DSM5 will come to an appropriately cautious and well considered  decision on this question. Had they conducted the needed risk analysis, the suggestion would never have gotten this far. Why their blindness to risk? First off , the DSM5 work groups were given the dangerous instruction to be innovative. Secondly, those working in the addiction field have a natural bias to see the scope of their specialty extended.  A group of experts with narrow research and clinical experience are making a decision that will have wide societal consequences without any consideration of the larger risks.  

   During its history, psychiatry has gradually, but consistently, spread its purview. In the first official diagnostic system for the United States, developed in the mid nineteenth century, there were six diagnoses intended to be used mostly for inpatients. Now we have close to three hundred mental disorder diagnoses covering all sorts of problems that straddle the boundary of normal. The "behavioral addictions" would be another great leap forward pushing mental disorder into the shrinking realm of normality. Eventually having one, or several,  mental disorders would become the new normal.
      We had an interesting parallel discussion deciding whether caffeine dependence should be included as an official category in DSM IV.  There were excellent arguments in favor of its inclusion. Caffeine is about as addictive as nicotine - which is included in the  DSM IV substance dependence section.  And, unlike nicotine, caffeine can cause a clinically relavent intoxication state and can cause or exacerbate anxiety disorders. On these grounds it could have (and some thought it should have) been included. It was left out of the manual  because caffeine dependence is so ubiquitous and (for most people) so harmless.  It did not seem worthwhile to have sixty million people wake up each morning to the awareness that they had a mental disorder. For those relatively few whose  atrial fibrillation or panic disorder is triggered by caffeine,  the diagnosis Substance Dependence Not Otherwise Specified ,Caffeine does the trick. All other coffee drinkers can have their morning cup(s) unburdened by mental disorder.  

     It seemed pretty obvious that it was wise to draw this line to protect the territory of  normality from this possible large scale invasion by a spurious "mental disorder". If caffeine caused  health problems as severe as those caused by smoking, it might have been reasonable to consider including it (but there would still be strong arguments against).  If smoking caused as few health problems as caffeine, it should not be considered an addiction.

   I would suggest the value of similar constraint and caution leading to the rejection of the category "behavioral addiction" Finally, it seems clear that the decision whether or not to include "behavioral addiction" has far too wide and important implications to be made by a small group of addiction experts.  

 

 

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

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