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War Over Addiction: Evaluating The DSM-V

Posted Feb 13 2010 9:03am


You've heard about the Drug War? Well there's a war being fought over addiction by the Task Force revising the psychiatric bible in the United States.

Called DSM-Vit will be referred to by every therapistchild development specialistand family court considering mental health issuesas well as criminal court concerning psychiatric defenses. DSM-IV is currently in place (I was an advisor for the DSM-IV substance use disorders section). If you have consulted a therapistthey have diagnosed you using a DSM-IV category - at least if you and they want insurance payments.

This template for diagnosing our "mental disorders" has been struggling with addiction - like so many of us. The term "addiction" does not appear in DSM-IV. Rather"dependence" was introduced as a replacement for addiction in the hope of defining the syndrome more precisely and less emotionally.

DSM-V plans to reintroduce addiction. Every book I've written has the word "addiction" in the titleso I'm glad the term will now be recognized. But the change back may make us wonder whether we will have to reconsider every twenty years or so whether it is more beneficial or harmful to use a word loaded with cultural meanings ("addiction")or a more neutral term ("dependence").

A persistent issue faced by the psychiatric establishment is whether non-drug habits may be considered addictive. DSM-IV has a substance abuse and a substance dependence (i.e.addiction and alcoholism) diagnosis. So only substance addictions are dealt with there. DSM-V will change thisand addiction will be applied more broadly to non-substance-involvements.

Since I wrote Love and Addiction in 1975I find this correct and appropriate. HoweverDSM-V deals with a range of addictions in a range of ways. Instead of saying sexloveor eating can fit the criteria for addictionDSM-V creates "hypersexuality" and "binge eating" disorders. Hypersexuality as a diagnosis (like nymphomania before it) doesn't make sense. If you like to have sex a lot - say four times a day - but you can make time for itwhose business is that but yours and your partner's?

Ifon the other handyou are a politician who hangs out at turnpike rest stops picking up strangers (like the former governor of New Jersey at one time did)you are likely to get into all kinds of trouble. The problem is the combination of the risky and the life-disruptive nature of the behaviornot the frequency or intensity of sexual urges and intercourse. And life-harmingcompulsive involvements arein any caseaddictions.

DSM-V proposes to incorporate some non-substance addictions - notably gambling. (Internet addiction is still up in the air - will the Task Force decide if it is addictive by a PET scan or by majority vote?) But DSM-V will call whatever ends up in this category behavioral addictions. Solet's count up. There is hypersexualitybut it is not an addiction. There is gamblingwhich is a behavioral addiction. Internet fixation may be an addictionor maybe not. And then there are alcohol and drug addictionformerly called dependencein a separate substance addiction category. Clearlythe DSM-V Task Force is confused.

The popular objection to broadening the application of addiction is"We'll be calling everything addictive." But DSM-IV already deals with this issue. Since more than 100 million Americans have used an illicit drugand most Americans drinkwe only call these people addicted when they meet a list of criteria dictating that their drug use or drinking is extremely harmful for the person and others. The same criteria can be applied to gamblingshoppingrelationshipseatingthe Internetetc. There IS no habit that cannot become excessivecompulsivelife-endangering.

Oh wellat least this will give us something to do - consider how the new manual will need to be revised the next go-around - between Super BowlsPresidential electionsand Olympics.

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