As we loom nearer to the publication of the American Psychiatric Association’s (APA’s) publication of the Diagnostic and Statistical Manual of Mental Disorders (DSM), fifth edition, there are some key changes being made. One of the proposals is to include new addictive disorder – "behavioral addictions" such as gambling. It’s simple enough to dismiss an obsession or compulsion as an addiction, but that refers merely to a cycle that is being perpetuated, not the way in which it is being perpetuated. One of the DSM criteria for both obsessive-compulsive personality disorder and substance-use disorders is that the pattern of behavior leads to disruption in normal social functioning due to the behaviors specific to the disorder. Compulsions are behavioral patterns associated with certain beliefs held by the individual with the disorder, whereas substance-use disorders refer more to the effects of the activation of the pleasure-seeking pathways in the brain when that behavior is engaged, through the use of "substances" such as alcohol or hard drugs.
Psychiatrist Charles O’Brien of the University of Pennsylvania attests that there is adequate brain imaging evidence to make a "pretty strong case that [gambling] activates the reward system in much the same way that a drug does" (935). Researchers in Germany have shown that gamblers show an increase in dopamine, stress hormones, and heart rate compared with non-gamblers. At Yale, brain imaging studies by a research group show that the brains of pathological gamblers resemble those of cocaine addicts – specifically, this shows a decrease in activation in regions that indicated judgment and motivation. This evidence collectively suggests that the
effects of being a "degenerate gambler" have about the same impact internally as being addicted to drugs or alcohol.
Behaviorally, we also see similar effects. Gamblers show impaired social functioning, as their behavior is geared toward feeding their attachment to gambling, much as the concerns of someone addicted to drugs are centered on being able to obtain their next fix. But what about other behavior? For instance, can people be "addicted" to things like sex, the Internet, or a certain genre of books? Here is where the fine distinction between addiction and compulsions comes into play. Like physical substances such as alcohol, behaviors are difficult to control because they could take other forms. If you refuse an alcoholic alcohol, he may turn to smoking instead. If someone is "addicted" to sex, their next recourse will take the form of increasing other pleasure-seeking areas in the brain in the same way that sex once did. It is the behavior of addiction itself that needs to be stopped for the obsession to engage in it to decrease. The compulsions are not addictions, but if the need for the addiction is removed, the compulsion may also decrease. Studies need to be conducted to ascertain the relationship between these factors (compulsion, obsession, and addiction) in behavior.
Blanketing addictive behavior into one DSM diagnosis may encompass a large group of people, but not be geared toward the needs of a specific person or group of people. It’s like a one-size-fits-all glove – it will fit most people’s hands generally well; there will always be outliers, and perhaps their issues are serious enough to warrant attention. But if their particular problems aren’t included in the DSM, how can they be treated fairly? The DSM committees need to recognize foremost that with the advance of technology and a deeper understanding of human behavior must come the acceptance that behavior will keep changing. The only thing to do is meet it – and when necessary, make it easier for people who need help with negative behavior patterns, to get it.
Tags: Psychiatry