It only took 55 years. A small group of compulsive gamblers (probably members of AA), recognizing that they suffered from an addiction much as do alcoholics, founded Gamblers Anonymous in 1957, using AA principles as a template. Since then, the addictions field has debated about the nature of gambling and other so-called “process addictions.” But in the grim, gray Diagnostic and Statistical Manual of Mental Disorders, gambling remained in the shadows as an “impulse-control disorder not elsewhere classified.”
The process of developing the latest edition of the diagnostic manual, the DSM-5 (no more Roman numerals), has gone public like no previous revisions, with various constituencies challenging the proposals one after another as they come up on the dsm5.org website. Thus far, arguments over the proposed DSM-5 addictions category have focused on the elimination of the duality of “substance abuse” and “substance dependence,” with the substitute of Substance Abuse and Addictive Disorders, which can present as a mild, moderate or severe variety in use of alcohol, cocaine and so forth. Many addiction professionals have lamented the elimination of a category that they see as a straightforward acknowledgement of dependency on drugs.
It therefore came as a surprise on May 1 when the DSM-5 task force on Addiction and Related Disorders (formerly Substance-Related Disorders) proposed to add gambling under their umbrella, right next to opiates, alcohol and cocaine. The nine proposed diagnostic criteria for a gambling disorder are similar to those for the other addictive disorders, with the three levels of severity that are also found in all of the DSM-5 substance use disorders. In general, there is a lower threshold for diagnosing gambling disorders than there had been under the DSM-IV-TR, and thankfully there is a rule-out of diagnosing a gambling disorder if the patient is bipolar.
Located in the Recommended for Further Study section, which warns of possible new diagnoses in subsequent editions, is another behavioral or process addiction: that of Internet use disorder. Oddly, it focuses exclusively on Internet gaming behavior. This is admittedly an area of concern, but other Internet problems such as compulsive downloading of pornography are not in the mix.
Change regarding symptoms
With the furor over the deletion of abuse vs. dependence, another DSM-5 change in the addictions realm has gone under the radar. This involves expansion of the list of symptoms for substance abuse disorders to 11 (it had been 4 for abuse and 7 for dependence), and increased ease in getting diagnosed. For example, one of the 2 out of 11 symptoms that can garner a diagnosis is tolerance. Now, if you are a drinker of almost any sort, or an individual who is prescribed a sleep medication, you will develop some tolerance. One could even say it is a normal phenomenon, and not necessarily a criterion for diagnosing a disorder if tolerance remains on a mild level.
Another symptom is “hazardous use.” Again, hundreds of thousands of college students have fallen at a frat party and countless people might have driven under the influence one time. Certainly, these behaviors can result in tragedy and should not be minimized, but the jury is out on whether this should be the sole basis for generating an abuse diagnosis.
To some, such as Thomas Babor, PhD, a famous psychiatric epidemiologist and editor of the journal Addiction, the changes in DSM criteria will have the effect of artificially inflating the number of diagnoses, thus burdening the public health system by adding millions to the patient roster. To many others, however, these changes increase opportunities for early intervention and for reducing both harm to individuals and costs to society stemming from health, criminal justice and social services accessed by those who misuse psychoactive chemicals.
A pragmatic middle course would be for vigilance on the part of single state agencies responsible for monitoring the function of addiction treatment centers, as well as from grant providers, other regulatory bodies, and third-party payers, over any attempts to troll for a “checkbook diagnosis” (similar to the concept of “diagnostic creep”) to increase client population and revenue.
Peter L. Myers, PhD, is co-author of Becoming an Addictions Counselor: A Comprehensive Text. He is Past President of the International Coalition for Addiction Studies Education (INCASE; www.incase.org) and is Editor of the Journal of Ethnicity in Substance Abuse. His e-mail address is firstname.lastname@example.org.