The fight over the new psychiatric manual, DSM-V, has escalated. The conflict is due to an underlying flaw in the manual's conception.  Rather than tracing human activity in terms of its impact for people's lives, it instead attempts to list each separate manifestation of abnormal functioning. This is madness.

This post is a response to American Psychiatry Is Facing "Civil War" over Its Diagnostic Manual by Christopher Lane, Ph.D.

 

The Stanton Peele Addiction Website, December 13, 2009. This blog post also appeared on Stanton's Addiction in Society blog at PsychologyToday.com.

Will Sex Addiction Be in DSM-V?

The fight over the new psychiatric manual, DSM-V, has escalated. The conflict is due to an underlying flaw in the manual's conception. Rather than tracing human activity in terms of its impact for people's lives, it instead attempts to list each separate manifestation of abnormal functioning. This is madness.

Christopher Lane has been ably tracking the travails of the birth - the conception - of DSM-V, the updated psychiatric diagnostic manual. (Note: I was part of the advisory group for DSM-IV substance use disorders, but I have no role in DSM-V.)

Among the quandaries faced by a group of experts whose job is to define our mental disorders - and thus how we define our society - is what comprises aberrant behavior worthy of psychiatric attention. The title of Lane's book, Shyness: How Normal Behavior Became a Sickness, indicates his primary concern - that slightly off-center behavior is regarded as sick.

Lane's discussion of DSM-V highlights "the serious risks of manipulation by drug companies who are eyeing every poorly conceived idea and proposal - bitterness disorder, apathy disorder, internet addiction disorder," et al. According to embittered DSM-IV editor Dr. Allen Frances, this will lead to the "medicalization of normality that will trivialize mental disorder and lead to a deluge of unneeded medication treatments."

At the same time, parents and patients are assailing psychiatry with truly pathological cases of absorption in video games and porno, among other things, such that marriages, social functioning - really all normal life functioning - are impaired. These people NEED sex and video games included in DSM-V to validate their experience and to offer them hope.

So, with all due respect to Messers. Lane and Frances, the problem is not in identifying too many debilitating preoccupations as mental disorders. It is in listing the objects of people's preoccupations in separate sections of the diagnostic manual.

For instance, there is a substance use disorder section in DSM-IV - not an addiction section. In fact, "addiction" doesn't appear in DSM-IV, but only the terms substance "dependence" and "abuse." The use of these non-technical words highlights the underlying problem: "You mean the only things human beings can abuse or become dependent on are drugs and alcohol?" Every sentient human being knows that's untrue.

In fact, the DSM-IV substance use section lists a range of problems people may incur through drug-taking and drinking. But what such an approach implicitly recognizes - that drug use and alcohol are themselves not inherently problematic - undercuts the validity of having a separate section designating only substance use disorders.

The section currently, wisely, doesn't define substance problems as diseases. People are diagnosed as being in remission when they cease misusing a subtance - thus, the majority of people who have ever been alcohol dependent in America still drink but are no longer alcoholic, according to DSM-IV categories.

My requests that DSM-IV state this explicitly were rejected. But there is no longer room for pussy-footing. DSM-V can only make sense if it (1) specifies addictions and other problems in terms of the severity of the life disruptions they cause (e.g., schizophrenia not defined by hallucinations, or obsessive compulsive disorder by specific preoccupations), (2) conceives disorders not as traits but as conditions or experiences that vary depending on people's life stages and situations.

Unfortunately people who advocate for these "illnesses" - and psychiatry's diagnostic manual - insist on each condition being separated into its own domain. The very act of designating specific disorders creates a sense that people are defined by their conditions and that they may never escape them. It also leads to an infinite expansion of such conditions.

Categorizing psychological problems in terms of the severity of their consequences has the potential to cut the size and shape of the manual drastically. If DSM-V insists on listing each specific manifestation of dysfunctional behavior and thought, then the kind of turf fights we are witnessing for each disorder are inevitable.

And DSM-V will start looking like the Oxford English Dictionary in its inclusiveness - and size.

Oh, the answer to the question posed by the title of this post is that addiction should be defined, and the list of activities and experiences that potentially meet the criteria sampled but not exhaustively enumerated and described individually.