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). 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 tothose 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 infuenced 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 philanderer 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.