DSM-5 opens the diagnostic door to ‘Internet Addiction’
Image by mandiberg via Flickr
Big news today in the the mental-health world. The American Psychiatric Association finally made public, after years of behind the scenes work by hundreds of people, a draft of new diagnostic criteria. Slated for release in 2012, the DSM-5 will be the ”bible” for clinicians and insurers alike. And for everyone else? Well, it will be the framework that differentiates normal human experience and behavior from the abnormal, it will tell the healthy from the sick.
Among the many changes coming in DSM-5 is a fundamental reformulation of how we think about addiction. The “Substance-Related Disorders” workgroup recommends replacing “Substance-Abuse” and “Substance-Dependence” with what they call ”Addiction and Related Disorders:”
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. Further, the work group has proposed to tentatively re-title the category, Addiction and Related Disorders.
via Substance-Related Disorders | APA DSM-5.
By “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 the source of an addiction will no longer be required; we’ll literally be getting drunk on love. For those interested in all the details (people possibly suffering from “DSM-revision Addiction Disorder”) the entire release is online at www.DSM5.org.
At this point it looks like pathological gambling will make it into the manual while “Internet addiction” will stay out there on the threshold of official recognition until more research gets done, the need for which gets stressed over and over including in the current issue of Addiction. As for other behaviors, there was no specific mention of any—despite all the attention Tiger Woods and David Duchovny have recently brought to so called “sex addiction.”
As someone who makes his living doing psychotherapy perhaps I should be shouting, bravo DSM-5 addiction workgroup! Behavioral addictions could become a whole new market. The smart move would be to set up “Internet addiction” clinics and begin building a pool in the backyard. But I can’t bring myself to come close to anything like that because openning the door to “Internet addiction” as an official diagnostic category is just wrong on so many levels.
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 the Republican Senators might plead that they were 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 be of help determining 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. Consequently, the behaviors studied were already 3 years out of date by the time the research was completed and published.
And this was pretty simple 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. So, instead of hunting for new illnesses and disorders we will never be able to find, why don’t we spend our time hunting for ways to help those specific individuals who went online to solve problems and soothe the hurts that everyone feels sometimes, and ended up getting trapped there.
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I don’t see how “non-substance addictions” can’t be classified as symptoms of existing medical disorders. It seems that Internet addiction (or Spitzeria/Wood’s Disease) could be added to the checklist for diagnosing correlated psychiatric disorders… OCD & anxiety disorders for Internet addiction, narcissism for Wood’s disorder, etc. It’d seem that many things that would fall under the same “non-substance addition” umbrella would be better classified if they were separated into other categories.
No expertise in this what-so-ever; probably some failures of naivete there. I agree that it doesn’t make much sense, and the problem of being untestable is obvious. It’ll be a good way to get new drugs on the market that can then be prescribed off-label in perpetuity though!
Well said, sometimes no expertise lets common sense shine! The issue of “co-morbitity” is diagnostically central. For example, a common symptom of depression is loss of appetite. So you don’t want to say someone developed both a depression and an eating disorder at the same time. Of course, there are also people with eating disorders, and those frequently can include depressed mood as a symptom! Teasing it apart to make sure someone gets the best treatments available is a subtle process. But the inevitably research-poor diagnosis of Internet addictions is not subtle, it is a a sledge-hammer that, I believe, interferes with understanding problems and getting people the help they need.
In response to another comment. See in context »Who cares about Tiger? Elin should dump Tiger, and let him join Amway, along with his “girlfriends”, as Amway also screws anything that moves. Amway is a scam, and here’s why: Amway pays out as little money as they can get away with, so they support the higher level IBOs ripping off their downline via the tool scam.
As a result, about 99% of IBOs operate at a net loss, while the top 1% make several TIMES more from their Amway tool scam than from the Amway products.
Read about it on my blog, I suggest you start here: http://tiny.cc/D5oJh and forward the information to everyone you know, so they don’t get scammed.
As a former IT professional turned therapist, and co-founder of the ReSTART Internet Addiction Recovery Program, I couldn’t agree with your article more with regards to the “Essig Uncertainty Principle.”
While the APA debates the issue, I suppose I will continue to answer the calls I receive each day with stories of individuals losing their loved ones to repetitive virtual activities that result in job loss, relationship conflicts, academic failure, and in one case, the amputation of a young man’s leg. That’s right, he spent most of his time in a room playing video games, developed a blood clot in his leg which went undetected and had to be amputated.
Maybe in the next release of the DSM, say 16+ years or so in the future, we will have accumulated evidence for the intergenerational transmission of virtual addiction. Perhaps we as a society will grow tired of hearing stories of neglected children whose parents couldn’t pull themselves away from the screen long enough to feed their children. Hey, it happens to pets…at least, that’s what my clients tell me.
I’m surprised by your agreement, I’m glad to hear it, but surprised.
It seems we agree THAT people are suffering from how they use technologies, that is beyond dispute. But WHAT is making them suffer remains an open question and is a very real disagreement between us.
I actually believe using “addiction” as a diagnosis for when someone gets trapped by this or that technology does more harm then good. It shifts the focus of attention from the suffering individual or family to the behavior and the tools used in those behaviors. Addiction diagnoses leads to one-size fits all intervention programs rather than individually working to understand and treat the unique pattern of anxiety, depression, avoidance, affect dysregulation, and impulse-control issues present in each case.
In my experience, the focus is wrong when “addiction” is used. An addiction-based approach to treatment focusses attention on getting someone away from the keyboard; the clinical approach I advocate focusses attention on getting someone back into the specific, local actualities of their life.
In response to another comment. See in context »I would very much enjoy speaking with you sometime as I think you might be pleasantly surprised to find our commonalities in approach. Like you, we too advocate for focusing attention on getting someone back into the specific, local actualities of their life, not just disconnecting from the keyboard. Let’s speak shall we?
Restart@netaddictionrecovery.com
Always happy to talk across differences! I’ll shoot you an email.
In response to another comment. See in context »Thank you, Todd, for a relevant and interesting discussion. As a therapist, I can’t help but offer a comment. From “behavioral addictions” to “conduct disorder,” behaviorally-based diagnoses share the problem you so deftly nailed: the risk that by creating the label and all that follows (the clinics, the trainings, the label-specific, evidence-based treatment techniques that end up being rubber stamped onto OTRs) we have once again McDonalds-ized behavioral health care into convenient bite-sized nuggets: Play WoW too much? You’re a gaming addict. Spend an entire sick day watch Lost reruns? You’re a television addict. And so on.
As a novelist, I couldn’t agree more with your conclusion: that labeling behavior as diagnosis may divert attention away from a life – a story. Life is complex and messy, full of functionality within dysfunction and vice versa. To equate treatment with elimination of problematic behavior is to potentially miss the richness. Note, though, that I do qualify my agreement: pathologizing specific behaviors may take attention (the therapist’s and the client’s) away from life to obsessively focus upon behavior. I see it as part of being a therapist to make sure that this doesn’t happen – to go for the whole story and seek to define health (or completion of treatment anyway!) as something more than simply eliminating a behavior, regardless of diagnosis or reimbursement, or any other distraction that gets thrown in my path.
“As a therapist … As a novelist”
Curious how often if ever conflict of interest issues arise in this. It seems that you’d have to avoid novelizing any issue relevant to your therapy sessions or be sued for violating doctor-patient confidentiality by patients who read your novels and believe that, say, a divorce in a novel is based on their own experiences as told to you. I’m not saying that that would be a reasonable outcome, but it seems like a possible one.
Obviously off-topic; sorry for that!
In response to another comment. See in context »Maybe a little off-topic, but hey, who’s counting! So, let me say you’re actually being a bit too strict. Therapists have always written about patients, but in ways that still protects the privacy of the encounter. Here’s the relevant standard from the APA Code of Ethics:
4.07 Use of Confidential Information for Didactic or Other Purposes
Psychologists do not disclose in their writings, lectures, or other public media, confidential, personally identifiable information concerning their clients/patients, students, research participants, organizational clients, or other recipients of their services that they obtained during the course of their work, unless (1) they take reasonable steps to disguise the person or organization, (2) the person or organization has consented in writing, or (3) there is legal authorization for doing so.
Also, let me plug Heather’s first novel, you can check it out on her site http://heatherrolland.com/finders_seekers_losers_keepers which also includes my review-blurb, “A mystery of the heart with a ‘garage band’ feel…”
In response to another comment. See in context »[...] opening might mean that sufficient comment in support of Internet addiction could result in its inclusion [...]
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