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How Do We Define Addiction?

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The current issue of the American Journal of Psychiatry has an editorial arguing for the inclusion of "internet addiction" in the forthcoming 5th edition of the Diagnostic and Statistical Manual for Mental Disorders. Jerald J. Block, M.D. states:

Internet addiction appears to be a common disorder that merits inclusion in DSM-V. Conceptually, the diagnosis is a compulsive-impulsive spectrum disorder that involves online and/or offline computer usage and consists of at least three subtypes: excessive gaming, sexual preoccupations, and e-mail/text messaging. All of the variants share the following four components: 1) excessive use, often associated with a loss of sense of time or a neglect of basic drives, 2) withdrawal, including feelings of anger, tension, and/or depression when the computer is inaccessible, 3) tolerance, including the need for better computer equipment, more software, or more hours of use, and 4) negative repercussions, including arguments, lying, poor achievement, social isolation, and fatigue.

Words like "variants", "drives", "withdrawal", and "tolerance" imbue a sense that this "disorder" is somehow akin to opioid or cocaine addiction. It's a slight of hand whereby problematic behaviors are transformed into medical illnesses in need of professional treatment. But what behavior is immune from such conceptualizations?

6 Comments

It's all about getting insurance companies to pay for therapy, right?

Yep, pretty much.

It is no slight of hand. There are many "behavioral" issues that are defined as illnesses. For example, consider Pathological Gambling, Trichotillomania, Eating Disorders, Paraphilias, etc.. Indeed, there is a reasonable effort being made to redefine some illness as falling into a catagory of disorders called "Impulsive-Compulsive Disorders." Other issues that might be added here are binge eating, pyromania, and kleptomania, among others.

It is likely that for some of these disorders, there is a common pathway with regards to "reward circuits "in the brain. Currently, people are looking at the neuro pathways, especially with regard to the neurotransmitters Dopamine/Glutamate and frontal lobe functioning.

I think your concern is that if we medicalize an issue, it will remove the perpetrator's moral and criminal responsibility. I do not think that follows; pedophilia is still a heinous crime, even if it is also considered a mental illness.

Finally, with regards to "getting insurance companies to pay," this is silly. Pathological Computer Use (PCU)is almost always co-morbid along with some other DSM diagnosis (i.e., Depression, Anxiety Disorder, Schizophrenia, Gambling, Paraphilia, ADHD, etc.). Treatment is focused at these issues and the PCU becomes a complicating factor. Billing insurance for these problems is not difficult. The reason why a DSM diagnosis is needed is the very same reason the DSM was originally created. It is about creating a uniform set of diagnostic criteria so that all researchers are on the same page and everyone is communicating about the same disease definition. What is needed is additional research and a DSM listing is critical for that.

I see you points Dr. Block, but I don’t see how your answers really responds to my concerns.

First, I think there’s no question that when we invoke words like "variants", "drives", "withdrawal", and "tolerance" there is an attempt to re-conceptualize behaviors such as using the internet too much as purely biological phenomena in need of biological treatments. The very notion of “drive” to many people suggests a behavior that’s inherent to the human condition and hard to volitionally suppress. One need only think of the term “sex drive” to see this comparison.

Furthermore, stating that there is some sort of biological circuit or pathway involving dopamine or glutamate really isn’t saying much. All behaviors involve biological pathways and all areas of the brain utilize neurotransmitters. Likewise, frontal lobes have been implicated in so many behaviors (like p300 and the ventromedical prefrontal cortex) that one wonders whether we’re saying anything by claiming these behaviors originate there.

You also claim the concerns about the medicalization of behaviors in no way will impinge on moral and legal responsibility. Yet I don’t think that’s true. Our culture is increasingly comfortable with the notion that undesirable behaviors are not due to choice but biological causes largely outside of volitional control. Our language is infected with the rhetoric of being addicted to all sorts of things including food, cell phone use, watching television, etc. In fact, if you google the words addiction and many of these concepts (e.g., cell phones) you will find reports of scientific studies purporting that these are indeed biological addictions. Indeed, the AMA recently considered formally adding “video game addiction disorder” to the growing panoply of compulsive behaviors in need of medical treatment.

Likewise, there are a growing number of legal scholars and court opinions that have suggested compulsive behaviors, including pedophilia and psychopathy, are deserving of mitigation/exculpation because they are classified as mental disorders with presumed biological etiologies (see, e.g., Schiro v. Landrigan, 127 S. Ct. 1933 (Stevens, J. dissenting).

You also state that adding internet addiction to the DSM has nothing to do with insurance reimbursement because of existing co-morbidity. And exactly how many national representative epidemiological studies do we have that show this? Moreover, claiming that using the internet too much is associated with numerous existing DSM diagnoses proves very little: There are surely many behaviors that are found among the population of people with DSM disorders, but that hardly is persuasive evidence that those behaviors deserve their own unique classification as mental illnesses.

And finally, it really is about money in many respects. You say “What is needed is additional research and a DSM listing is critical for that” but fail to mention that without a DSM listing, the chances that internet addiction will receive NIH grants is remote.

Now, I’m not saying that some people don’t use the internet too much and perhaps even need help to cut down on their use. But it’s a far cry from saying that to claiming it is a mental illness.

Mr. Erickson -

You make many valid points, all of which deserve much more discussion and debate. Perhaps we can find a conference or comparable forum to continue such a dialog. However, for now I'll focus on your last paragraph: "Now, I’m not saying that some people don’t use the internet too much and perhaps even need help to cut down on their use. But it’s a far cry from saying that to claiming it is a mental illness."

I have a general adult practice. I see many different issues in many different patients. I am not a full time researcher or academician. So, I come to this argument from the trenches. Simply put, I am seeing many, many patients that are having trouble controlling their use of computers. And, as a physician, I will also note that the problem is serious and can be very difficult to treat.

While there are all sorts of societal arguments that we might engage in, for me the issue comes down to the people that are in front of me -- the people that I am trying to help. Based on my clinical experience, I have no problem, whatsoever, saying that Pathological Computer Use represents a serious mental illness that has been woefully understudied. While there are important issues to consider -- concerns about reimbursement, how the Courts will (mis)manage the diagnose, or the precise language used to define the disorder -- I consider them secondary.

Rather, everyday I see, firsthand, a global problem of great significance that is not being addressed.

From the editorial...
"Dr. Block owns a patent on technology that can be used to restrict computer access. Dr. Freedman has reviewed this editorial and found no evidence of influence from this relationship."

I read this whole editorial off of some other site and I thought it was satire at first.

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