MATTERS OF THE MIND – a series which examines the clinician’s bible for diagnosing mental disorders, the DSM, and the controversy surrounding the forthcoming fifth edition.
The term “addiction” is conspicuously absent from the pages of the current Diagnostic and Statistical Manual of Mental Disorders, the DSM-IV. That’s because in the 1980s, the committee working on the DSM-III-R were keen to avoid the cultural baggage and stigma associated with the word addiction. They hoped to provide more neutral and clinically useful terms by using “dependence” and “abuse” in the current category substance-related disorders.
Experience proved this to be a mistake – the terms were confusing and misleading.
“Abuse” turned out to be highly stigmatising, with drug takers being compared with other types of abusers. This was shown clearly in one trial that found patients described as “substance abusers” to health-care professionals were recommended less therapy and more punishment than when they were described as having “substance use disorders”.
“Dependence” too is misleading. Physical dependence occurs not only when people take addictive drugs, it can also occur with psychiatric medication. It is possible to be dependent on a substance without experiencing the full range of symptoms necessary for addiction. By confusing dependence and addiction, the DSM unfortunately added a level of stigma to an otherwise normal response to repeated doses of medication.
We can now happily say goodbye to two very problematic terms. The DSM-5 plans to reintroduce addiction in the new category of substance use and addictive disorders. This new diagnostic category will not only revive the use of the term addiction, it will place substance use disorders and non-substance use addiction together, beginning with moving gambling disorder from impulse-control disorders not elsewhere classified to the new category.
All behaviours large and small
What’s more controversial is an appendix for further research into internet use disorder. This is not an official verification of problem internet use as disordered, but it’s a clear indication that the category is likely to include more behavioural addictions in future.
The question of how useful this will be is yet to be determined. Some argue this is a change long overdue; others worry it opens the door to labelling normal interests and passions as mental disorders.
Determining when doing something a lot is doing it too much is at the core of defining addiction. And despite our best efforts, this line remains unclear.
Is the internet addictive?
The DSM-5 has clearly identified a class of people seeking treatment for a level of internet use that causes distress or suffering to the point of incapacitation. Without denying the reality of that suffering, does this justify a discrete category in future revisions of the DSM for internet addiction?
As I’ve discussed previously on The Conversation, problem gaming does not fit neatly into our existing understanding of addiction, despite the growing amount of research in the area. The scope of games and gamers alone makes it difficult to determine whether videogames could be considered a medium for addiction in any way similar to substances or gambling.
Add to this category the wide array of uses of the internet – everything from text messaging, social networking, porn and blogging – and we end up with a list of behaviours so diverse that research becomes necessarily complex and clinically confusing.
As US psychiatrist and academic Ronald Pies suggests in the journal Psychiatry, given the state of current research, what is being called internet addiction is a diverse and inconsistent range of symptoms most likely with multiple causes. In many cases, it’s unclear whether an individual’s apparent addiction is the cause of behaviour, or a symptom itself of another disorder.
The question then becomes – is the internet inherently addictive, or is the medium through which disorder is presented to blame?
Granted, many of us feel that our use of the internet verges on problematic. I know when I check my email before getting out of bed, or social media sites while waiting for the lights to change I sometimes wonder if this is normal behaviour. But does this classify as addictive? Not really, unless it begins to cause significant distress or impairment.
At worst, it could indicate a maladjustment to a world where the tools for communication and sharing have changed rapidly to become necessary instruments for daily life.
A behaviour by any other name
Without an open mind in further research, we run the risk of only finding what we’re looking for. If it’s assumed that the internet is akin to a substance in that it can cause an addiction, we will almost certainly find evidence for this assumption.
But if we’re open to the idea that the internet may only be the medium through which disorder or maladjustment is presented, we leave space for research that is more comprehensive and reflective of reality.
This is the tenth and final part of our series Matters of the Mind. To read the other instalments, follow the links below:
Part seven: Redefining autism in the DSM-5