The Life-and-Death Struggle over the Meaning of Addiction: Do God and Nature Back DSM-V?

There is an earth-shattering struggle going on over the definition of addiction. Yet, not only are few Americans aware of the struggle, but hardly any psychologist or addiction specialist.

The American Psychiatric Association is currently engaged in a secret pitched battle over reformulating its diagnostic manual from its fourth edition to its fifth. In the addiction area, the only small issues remaining are (a) what to call addiction, (b) how to define it, (c) what it includes.

The first medically-oriented DSM was the third edition, which appeared in 1980. It was modified into III-R in 1987. The fourth edition appeared in 1994, which was revised (the current DSM-IV-TR) in 2000.

By simple mathematics, we would have expected to see DSM-V by now. On the other hand, maybe they worked everything out so well in 2000 that hardly any revision is needed. Currently, the plan is that DSM-V will appear in 2011 or 2012. But I bet they won't make it, and the fighting will intensify by then.

What could they fight over? Surely science has plumbed the depths of modern emotional disorders by now, what with the genome and all the major scientific discoveries about schizophrenia, depression, et al.

And the psychiatric bible should reflect this: did God give all those boys ADHD and teen girls bipolar disorder, or didn't He?

The first little conflagration has arisen over the secrecy of the DSM-V deliberations, raised by a previous DSM editor, Robert Spitzer. This contra temps was discussed in an Op-Ed in the Los Angeles Times. Christopher Lane, author of "Shyness: How Normal Behavior Became a Sickness," noted the significance of this matter: "Because large numbers of countries, including the United States, treat the DSM as gospel, it's no exaggeration to say that minor changes and additions have powerful ripple effects on mental health diagnoses around the world."

According to Lane: "Hanging in the balance is whether, four years from now, a set of questionable behaviors with names such as 'Apathy Disorder,' 'Parental Alienation Syndrome,' 'Premenstrual Dysphoric Disorder,' 'Compulsive Buying Disorder,' 'Internet Addiction' and 'Relational Disorder' will be considered full-fledged psychiatric illnesses."

But the problems Lane foresees barely touch the surface of the contentious issues. First, I must confess - I am one of the sinners who believes DSM-V must somehow acknowledge compulsive shopping and Internet addiction. My career has been built around defining addiction irrespective of specific drugs and biological effects.

But before we confront whether there is Internet addiction, we must face a prior problem: there is no addiction section in DSM-IV-TR! The substance use disorder section has two levels of disorders - "abuse" and "dependence" - where dependence is like addiction. (I served as a member of the DSM-IV substance use advisory group around the issue that DSM-IV has no abstinence requirement for remission.)

The first nomenclature objection has been raised by Nora Volkow, Director of the National Institute on Drug Abuse, and her like number at the National Institute on Alcohol Abuse and Alcoholism, who want to jettison "dependence" in favor of returning to the classical "addiction."

Volkow fears that dependence is too generic. She and others believe that people can become dependent on medications for good medical reasons, but that this doesn't comprise a disorder. Hence, her move to label only "bad" drug dependencies as addictions.

Why is there no addiction in DSM-IV? Addiction experts used to consider narcotic withdrawal the penultimate characteristic of addiction. That was called "physical" dependence. But that left out cocaine (and nicotine). We couldn't have that! So physical dependence and what used to be called "psychic" dependence were folded into one big dependence ball of wax.

By 2014 (if DSM-IV lasts that long), while you have naively been going about your daily activities for two decades, if you experienced three of the following seven criteria within the past year, you have had the psychiatric disorder of dependence.

1. Tolerance

2. Withdrawal

3. Taking more than intended

4. Unsuccessful efforts to control

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5. Effort spent on using/recovering

6. Activities reduced

7. Serious physical or psychological problems

Note that since there are five criteria aside from "tolerance" and "withdrawal," you can be dependent if you have tried to control an ivolvement and failed, or spend your time preoccupied with doing something, or cut back other activities because you are so preoccupied with your involvement. These criteria can occur with use of any drug.

But, come to think of it, they can occur with the Internet, video games, porno, love affairs, shopping, exercise, and - well - any powerful and engaging experience! How did this get to be a medical designation, you might ask?

If I give a lecture or workshop to counselors or lay people, everyone in the room agrees addiction can occur with involvements and activities other than drugs. Everyone, that is, except Nora Vokow, NIDA-funded investigators, and addiction physicians.

Here's a quick way to recognize such a stalwart - when you say other things besides drugs can be addictive, they say, "I read the paper every day" or "I love the opera." Then, they pounce (clearly indicating you are a fool), "Am I addicted?" Here's your answer: "If someone takes Oxycontin or smokes marijuana every day, does that make them addicted?" Answer: only if the questioner or drug user meet three of the above criteria.

The difference in perspectives between regular human beings (like parents tearing out their hair because their kids lock themselves in the house playing video games), clinicians (who swear they have seen life-threatening porno, gambling, and sex addiction cases), and addiction experts is creating an irrepressible pressure to include these things in DSM-V. Looking into my crystal ball, that will happen within the next 10-15 years.

And if DSM-V's authors vote to limit addiction to drugs and alcohol, the bible of psychiatric disorders will be outdated at its birth.