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Todd Essig, Ph.D.

Todd Essig Ph.D.

Caught in the web? You need help, not labels

Caught in the web? You need help, not labels

You've probably heard by now that this past week the American Psychiatric Association finally released it's draft for a new set of diagnostic criteria. 

This is big news; the "bible" for sorting the healthy from the sick is getting re-written. One huge change proposed for DSM-5 is in how we think about addiction. The "Substance-Related Disorders" workgroup is recommending replacing "Substance-Abuse" and "Substance-Dependence" with what they call "Addiction and Related Disorders." One reason for this change is to open the door to a wide range of possible "behavioral addictions:" 

"Among the work group’s proposals is the recommendation that the diagnostic category include both substance use disorders and non-substance addictions. Gambling disorder has been moved into this category and there are other addiction-like behavioral disorders such as “Internet addiction” that will be considered as potential additions to this category as research data accumulate. (Substance-Related Disorders | APA DSM-5.)

Let's be clear that when they say "non-substance addictions" they mean behavior. In other words, according to the DSM of the future you can become addicted to what you do, having a substance be part of addiction will no longer be required; we'll literally be getting drunk on love.

At the risk of enabling a "DSM-revision Addiction Disorder" I want to encourage all stakeholders—which pretty much includes everyone who has ever sought help for a mental or behavioral health issue, provided that help, knows someone who did either, or, come to think of it, has a mental life or behaves in any way—to go to and participate in the request for comments.

At this point it looks like pathological gambling will make it into the manual while "Internet addiction" will have to wait for more research, the need for which gets stressed over and over including in the current issue of Addiction. As for other behaviors, there was no mention of any others in this section of the DSM draft. Despite all the attention Tiger Woods and David Duchovny have brought to so called "sex addiction" those problems are in another proposed new illness called "Hypersexuality."

As someone who makes his living as a psychotherapist I know I should shout, "Bravo DSM-5 addiction workgroup!" After all, if "behavioral addictions" makes it through field trials into the eventual manual it will open a a whole new market. Maybe I could even franchise "Internet addiction" clinics to funnel tons of insurance money into my pocket—after all, once "Internet addiction" is in the DSM insurance companies will pay to "treat" and I am sure there are lots of panicked well-insured parents out there who don't like that junior spends so much time playing World of Warcraft.

But I can't bring myself to come close to anything like that.  Making "Internet addiction" an official diagnostic category is just wrong on so many levels, including, I believe, making it more difficult to get the right kind of help to those who have actually become painfully stuck online. Many people are turning from life lived to life online and they need help, but real help for real problems, not newly-minted addictions.

By sanctioning behavioral addictions the new DSM opens the diagnostic door to the full menu of confessional daytime TV problems: gambling, shopping, eating, playing World of Warcraft, visiting porn sites, chatting online, having sex with dozens of women with teased blonde hair (hello Tiger), getting too many tattoos, hoarding newspapers (addicted to print!), or whatever else comes along. Who knows, should the political tide turn Republican Senators might successfully plead they were not ruining the country, they were just suffering from "Anti-American Filibuster Addiction Disorder."

Medically sanctioning the category of "behavioral addictions" also changes how we will think about freedom and responsibility. Making bad choices, developing destructive habits, and attempting solutions to problems in living that then become serious problems themselves will all become less important as the locus of responsibility shifts from the person doing something to the something being done.

The fact of the matter is that when someone is suffering—and like REM sang, "everybody hurts sometime"—they will use whatever is at hand to make the hurt go away. Unfortunately, sometimes the attempted solution makes things worse, sometimes the solution is itself much worse than the problem. But if we ignore why someone spends their life playing World of Warcraft, cruising sex sites, or chatting online with strangers and we focus too much on the "addiction" we will lose the chance to help.

Unfortunately, additional research, which is almost always good to do, will not help determine whether or not "Internet addiction" qualifies as a behavioral addiction. Such research will never be able to clarify whether what people are doing with technology qualifies as a behavioral addiction, unlike research about something like gambling, because of what I call the "Essig Uncertainty Principle." The principle states that "because technology develops so much faster than research gets done, research into the psychology of technology always makes claims about what people used to do and not what they do now." Consequently, all the Internet behaviors being studied as possible "non-substance addictions" will have long since been replaced by the next big thing by the time all the research is done.

For example, a just published paper by researchers at the Addiction Medicine Centre, General Hospital of Beijing Military Region titled "Proposed diagnostic criteria for internet addiction" ends up being of limited value because of the "Essig Uncertainty Principle." In this study of Chinese youth all the online behaviors studied took place before the Chinese government "implemented an 'anti-online game addiction system' to discourage more than 3 hours of daily game use in April 2007." This was a very small technical change that limited the amount of time gamers could game at popular Internet cafes. But as a result the behaviors studied were already 3 years out of date by the time the research was completed and published.

And this was straightforward descriptive study. All of the following would also need to be researched before problematic Internet-use would qualify as an addictive illness: the neuroscience describing the reward circuitry of, for example, using a keyboard to play World of Warcraft; clinical trials comparing the safety and efficacy of different therapeutic interventions; longitudinal follow-ups and relapse studies; and studies of genetic and environmental vulnerabilities, psychiatric co-morbitity, and gender and cultural influences.

But because of the "Essig Uncertainty Principle" we will never have the research we need to decide. The technology that is the destination for someone's flight from life changes so rapidly that it can never be used to define a diagnosis and resulting treatment. So, instead of hunting for new illnesses we will never be able to find, we should hunt for ways to help specific individuals who went online to solve problems and soothe the hurts that everyone feels sometimes, and ended up getting trapped there.



About the Author

Todd Essig, Ph.D.

Todd Essig, Ph.D., is a training and supervising psychoanalyst at the William Alanson White Institute with a clinical practice treating individuals and couples.