Underplaying physical aspects of addiction

This controversial change in DSM-5 will emphasise the psychological aspects of dependence at the expense of the physical. One of the arguments put forward for it is that physical dependence to a drug can exist, for example with opioids for chronic pain, without this constituting addiction and that, as a result, some patients have been unnecessarily stigmatised as ‘addicts’ and given inadequate pain control medications.

The main usurper of ‘addiction’ was, of course, the concept of the dependence syndrome. However, addiction is to make a comeback, most likely as ‘addictive disorders’. If you, like me, are puzzled by the prospect of alcohol dependence, say, being renamed alcohol addiction or alcohol use disorder (severe), blurring the clinically useful distinction between dependence and harmful use, then further reading is provided by an extensive debate in the May 2011 issue of the journal Addiction (e.g. Reference O'BrienO’Brien 2011; Reference West and MillerWest 2011).

The alignment, by some, of the ‘substance use disorders’ with compulsive gambling, compulsive buying (shopping addiction), sex addiction and certain forms of eating disorder (Reference CoombsCoombs 2004) is underpinned by a general concept of addiction as involving compulsive use of a substance or activity, loss of control over that use and continued use despite adverse consequences. The proposers of this broader classification say that it is backed up by neurobiological research into brain mechanisms of reward and pleasure and the subsequent development of compulsion or addiction, and they point out the shared neurochemistry of chemical and non-chemical addictive disorders. Indeed, the commonality of psychotherapies for both chemical and non-chemical forms of addiction (Reference Murali, Ray and ShaffiullhaMurali 2012, this issue) is another argument for bringing them together within our classification system. It will be interesting to see whether future advances in pharmacotherapy will also reinforce this nosological linkage.

The disease model of addiction

It is more difficult, however, to carry over to non-chemical addictions the emphasis of some American publications (e.g. Reference Morse and FlavinMorse 1992) that addiction to alcohol and drugs is a progressive and fatal disease. This reclassification might therefore prove an opportunity to examine and challenge some of the unsustainable myths of the disease theory of addiction. The idea of addictive disorders as necessarily chronic and relapsing is also up for debate when a broader epidemiological perspective is taken (Reference Cunningham and McCambridgeCunningham 2012 and its four commentaries). The lens of the clinic, as we know, can distort our view of the natural history of disorders.

Addiction as a cultural construction

Nevertheless, the risks of this conceptual expansion are many. The decision to include or exclude a disorder as an addiction becomes more open to social and moral influence. The profound philosophical issues raised over agency of the individual are unthinkingly swept aside if a deterministic understanding of addiction is applied. Take the example of ‘workaholism’: can work be an addiction for some (Reference Robinson, Flowers and CoombsRobinson 2004) and to what extent can it be defined as an individual problem in a culture that generally encourages long hours and commitment to an employer? Would we see a top athlete sacrificing hours each day and showing unswerving dedication in pursuit of Olympic gold as addicted?

In their discussion of internet sex addiction, a subset of the wider concepts of both sexual addiction and internet or computer addiction, Dunn et al sound a necessary note of caution, showing that the case for such a disorder is far from made. They also raise the question of the extent to which our supposedly scientific classification system may be influenced by consumer demand and the media.

We clearly need to guard against the potential to expand the concept of addiction to other repetitive human activities, thus rendering the core idea meaningless.

With regard to the two articles under consideration here, that on shopping addiction (Reference Murali, Ray and ShaffiullhaMurali 2012) is more of a conventional review of a behavioural disorder that is taken as established and reasonably well-defined, whereas that on internet sex addiction (Reference Dunn, Seaburne-May and GatterDunn 2012) refreshingly takes a stance of scepticism in the face of the expanding boundaries of the addiction concept and introduces the idea that some of this expansion may represent a ‘moral panic’. Murali and colleagues show us that compulsive buying was recognised in the early psychiatric literature. However, it was usually taken to be a symptom or syndrome associated with another psychiatric disorder, rather than a distinct condition. The other theme that emerges in both reviews is that of comorbidity, both between addictive disorders and mental illness and between different forms of addiction. In relation to the latter, one idea that has been put forward elsewhere is that of addiction interaction disorder (Reference Carnes, Murray, Charpentier and CoombsCarnes 2004). Certainly, having one form of addiction greatly increases the chances of having multiple addictive disorders.

The future of ‘addiction’

This is not the first time that there has been a movement to expand the boundaries of the addiction concept beyond what is justified (Reference SmithSmith 2010). I suspect that, as happened in the late 19th and early 20th centuries, there will be a retreat to firmer nosological ground and that the boundaries of addiction will at some future date be redrawn in a less inclusive way.