Do We All Have Behavioral Addictions?

The relentless march to medicalize normality out of existence is opening a new and especially ridiculous front. The DSM-5 suggests providing a new section for "behavioral addictions."
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The relentless march to medicalize normality out of existence is opening a new and especially ridiculous front. The DSM-5 suggests providing a new section for "behavioral addictions." The category would begin life nested alongside the substance addictions and would start with just one disorder (gambling). Fortunately, none of the other "behavioral addictions" suggested for DSM-5 would gain official status as stand-alone diagnoses. But if a clinician felt that someone were "addicted" to sex, or to shopping, or to the Internet, or to working, or to video games, or to model railroading, or to whatever else (the list is long and could easily expand into every area of popular activity), this could be diagnosed as "Behavioral Addiction Not Otherwise Specified" and thus receive the dignity of an official DSM code. This Pandora's Box of diagnostic possibilities could turn all manner of passionate interests into psychiatric illnesses.

The rationale is that compulsive behaviors and compulsive substance use create similar subjective experiences, follow the same clinical pattern, may derive from the same neural network, and respond to similar treatments. The notion that underlies the "addiction" concept is that the substance use (or behavior) originally intended for pleasurable recreation is now compulsively driven. Although the act is no longer the source of much pleasure, it has become so deeply ingrained that the person continues to perform it in a repetitive fashion despite great and mounting negative consequences.

The evidence supporting the idea that someone is "addicted" would consist of the continuation (or even increase) of seemingly autonomous and driven behaviors despite the ever-diminishing gain and the ever-increasing cost. Subjectively, the person feels an escalating loss of control over the drug or the act and instead comes to feel increasingly controlled by it. No surprise that the criteria set for pathological gambling is modeled in close imitation to the criteria for substance dependence.

But there is one fundamental problem with the idea of "behavioral addictions" and an assortment of negative unintended consequences that should be more than sufficient to disqualify it from further consideration. The fundamental problem is that repetitive (even if quite costly) pleasure seeking is a ubiquitous part of human nature -- while compulsive behavior that is not rewarding is relatively rare. But on the surface it is extremely difficult to tell the two apart. The "behavioral addictions" would quickly expand from their narrowly intended, (perhaps) appropriate usage to become a popular and much misused label for anything that people do for fun but causes them trouble. Potentially millions of new "patients" would be created by fiat, medicalizing all manner of impulsive, pleasure seeking behaviors and giving people a "sick role" excuse for impulsive irresponsibility.

We, all of us, do short term pleasurable things that turn out to be quite foolish in the long run -- it is in the nature of the beast. The evolution of our brains was strongly influenced by the fact that, until recently, most people did not get to live very long. Our hard wiring was built for short-term survival and for quickly propagating DNA -- not for the longer term planning that is more desirable now that we have much lengthened lifespans. The greatest salience is given to short term pleasure centers that encourage us to do things that give an immediate reward. This is why it is so difficult for people to control impulses toward food and sex, especially when the modern world provides such tempting opportunities for each.

Thus, our massive collective societal weight gain comes from an enduring sense of facing famine that makes it hard to say no to the attractions offered by refrigerators and supermarkets. Pleasure at the mall satisfies survival motivations based on gathering and nesting. And so on (I will leave sex to your own individual imaginations). This short term hard wiring was clearly a winner in the evolutionary struggle when life was "nasty, brutish, and short." But it gets us into constant trouble in a world where pleasure temptations are everywhere and their long-term negative consequences should count for more than our brains are wired to appreciate. The late blooming insight of the new discipline of behavioral economics is that we are not rational animals (they would have figured this out sooner had they read Darwin or Freud). We all make bad short-term decisions because it is hard to resist the immediate fun at the time. Then we suffer the long term consequences.

In a better world, our forebrains would have caught up to do a more efficient job controlling impulses and long-term planning and would anticipate and/or avoid those pleasures not worth the price. But environments have changed too quickly for glacial evolution to catch up -- we live ill-equipped for this world and exist within an inherently imperfect human condition, the stuff of tragedy, comedy, and melodrama. In a statistical sense, it is completely "normal" for people to repeat doing fun things that are dumb and cause them trouble. This is who we are. It is not mental disorder or "addiction" -- however loosely these much freighted terms are used.

Instead, the term "behavioral addiction" would imply that there has been an override of our average, expectable, impulsive pleasure system. The individual does the behavior over and over and over and over again, despite a lack of any reward and the presence of much negative reinforcement, in a stereotyped way that does not now (and never could have had) any survival value.

Which brings us to the unintended consequences of enshrining "behavioral addiction" as an official psychiatric diagnosis. There are lots of commonplace fun-loving "philanderers," but very few (if any) tortured, pleasureless "sexual addicts." The philanderer enjoys his sexual activity so much that he keeps doing it despite the external trouble he gets into or any internal moral qualms he may have. The immediate pleasure it brings has more salience than the eventual pain. This is in sharp contrast to that rare person who compulsively repeats the sexual act without experiencing much or any pleasure or other reward, even in the face of great risks or punishments. But how convenient for the philanderer to hide behind the medical excuse. "My addiction made me do it" is the modern equivalent and substitute for "the devil made me do it." Personal responsibility is easily dissolved when behavioral choices become fake psychiatric illnesses.

The parallel would apply to all of the possible "behavioral addictions." If a person shops till she drops because this is fun, it should not be called "addiction" no matter how much trouble it causes. And the bills should come due. People who prefer the Internet or video games to other life pleasures may be making lousy decisions and wasting their lives, but they are not addicted so long as the activity remains pleasurable.

Full disclosure: I myself suffer from any number of behavioral addictions and may for purely personal reasons prefer not to have them labeled as psychiatric diseases. The list of my behavioral addictions is long, including but not limited to: compulsive sun, beach and hot-tub worship; pathological exercising and swimming; addictive reading; prolonged movie watching; persistent blogging; and excessive attachment to my wife, to say nothing about chocolate fudge sundaes. Perversely, I am non-compliant to the emerging DSM-5 diagnostic trends and do hope to devote my waning years to indulging my little madnesses to the fullest. It is some small comfort at least that I have been spared a number of other behavioral addictions that commonly afflict acquaintances who share my age and gender -- thank god I am not behaviorally addicted to golf, watching football on TV, crossword puzzles, model railroads, or collecting watches.

But I should not attempt a small joke on a serious matter. The ambitious medicalizing of our interests, passions, indulgences, and eccentricitIes has unfortunate practical consequence. But even worse, it somehow cheapens respect for the wonderful diversity and intensity of human experience. It will be a very dull brave new world indeed when all passionate interests are seen as a pathological targets for treatment.

Allen Frances is a professor emeritus at Duke University and was the chairman of the DSM-IV task force.

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