The rationale for this radical proposal is that compulsive behavior is equivalent to compulsive substance use and is caused by the same brain pleasure centers—an interesting idea for research, but way premature to justify a huge expansion of psychiatric diagnosis.
The term “addiction” is being stretched to include any passionate interest or attachment. It was once narrowly restricted to describe physical dependence on a substance or alcohol—you needed more and more to get high and had painful withdrawal symptoms when you stopped. Then “addiction” was expanded to cover compulsive substance use. The addict is someone who feels compelled to take the drug even though it no longer makes any sense. The fun is gone and there are grave negative consequences, but he is driven to continue. Lately, “addiction” is loosely and incorrectly applied to any frequent drug use—even if it is purely for pleasurable recreational purposes, not yet compulsive. DSM-5 takes the final broadening step that we are just as addicted to our favorite behaviors as someone who is hooked on opium.
The concept of “behavioral addiction” has the fundamental flaw that we are all “behavioral addicts.” Repetitive pleasure seeking is part of human nature and too common to be considered a mental disorder. Millions of new “patients” might be created by fiat, medicalizing all manner of passionate interests and giving people a “sick role” excuse for their impulsive hedonism. I can picture the caption of the New Yorker cartoon: “Sorry, honey, I just couldn’t resist (you fill in the blank). Doc says it’s not my fault—I’m addicted.” Individual accountability may never survive the shock.
We are all ruled by short-term brain pleasure centers that favor our immediate survival or the survival of our DNA into the next generation. 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 both. The evolution of our brains was strongly influenced by the fact that, until recently, most people did not live very long. Given our lengthened life spans, longer term planning has become the much better bet, but instincts don’t change quickly, and balancing short-term gains against long-term consequences just doesn’t come very naturally to most people. Our pleasure systems are still responding to the world of our ancestors and often cause us trouble in our current world.
The proper and narrow definition of the term “behavioral addiction” would reserve it only for those who experience an override in this average expectable pleasure system—who do the behavior over and over and over and over again, despite the lack of even short-term reward and in the face of extremely negative short-term punishments (financial devastation, loss of family, jail). Such a negative reward/risk ratio does not now (and never could have had) any survival value and rightly might be considered a mental disorder. “Behavioral addiction” might be a viable concept if it could be contained within the confines of this very narrow definition. It is instead a terrible idea precisely because it would quickly spread far beyond its proper narrow confines. Compulsive, nonpleasurable repetition is very difficult (or impossible) to distinguish from impulsive self-indulgence.
“Addiction” should be reserved for those who feel compelled to keep repeating the act even when the fun has worn off and the cost is so high that no reasonable person would pay it. But how to tell the difference between this and pleasure seeking? “Behavioral addiction” will undoubtedly expand to become the excuse du jour for all impulsive behaviors that have gotten someone into any sort of trouble. The twelve steps will substitute for the religious rituals of confession and expiation. Sometimes accepting that you are powerless over the “behavioral addiction” will be the beginning of a sincere effort to change, but often it will be no more than spin. A vibrant society depends on having responsible citizens who feel in control of themselves and own up to the consequences of their actions—not an army of “behavioral addicts” who need therapy in order to learn to do the right thing.
We had a parallel discussion whether caffeine dependence should be included as an official category in DSM-IV. Caffeine is as addictive as nicotine, can cause intoxication, and can provoke anxiety disorder and cardiac problems. We left it out for one reason only. Caffeine dependence is so ubiquitous (and mostly harmless) that it did not seem worthwhile to have sixty million people wake up each day to the awareness that their morning pleasure was a mental disorder. Similar constraint and caution would lead to the rejection of the category “behavioral addiction.” The fact that it would be so widely misapplied greatly overwhelms any benefit.
The most likely contender for imminent fad status is “Internet addiction.” All the elements for wildfire spread are in place—the profusion of alarming books; the breathless articles in magazines and newspapers; extensive TV exposure; ubiquitous blogs; the springing up of unproven treatment programs; the availability of millions of potential patients; and an exuberant trumpeting by newly minted “thought leading” researchers and clinicians. DSM-5 showed restraint, relegating Internet addiction to an obscure appendix rather than legitimizing it as an official psychiatric diagnosis. But watch for Internet addiction to pick up steam even without full DSM-5 endorsement. Granted that lots of us are furtively checking e-mails in movie theaters and in the middle of the night, feel lost when temporarily separated from our electronic friends, and spend every spare minute surfing, texting, or playing games. But does this really qualify us as addicts? No, not usually. Not unless our attachment is compulsive and without reward or utility; interferes with participation and success in real life; and causes significant distress or impairment. For most people, the tie to the Internet, however powerful and consuming, brings much more pleasure or productivity than pain and impairment. This is more love affair and/or tool-using than enslavement—and is not best considered the stuff of mental disorder. It would be silly to define as psychiatric illness behavior that has now become so much a necessary part of everyone’s daily life and work.
But what about the small minority of Internet users who really are stuck in a pattern of joyless, compulsive, worthless, and self-destructive use—the 24/7 gamers, the shut-ins, the people trapped in virtual lives. The concept of addiction may indeed apply to many of them, and diagnosis and treatment may someday prove useful. But not yet. We don’t know how to define Internet addiction in a way that will not also mislabel the many who are doing just fine being chained to their electronics. We also don’t know what proportion of excessive users is stuck on the Internet because they have another psychiatric problem that may be missed if Internet addiction becomes an explain-all masking underlying problems. So far, the research on “Internet addiction” is remarkably thin and not very informative. Don’t get too excited by pretty pictures showing the same parts of the brain lighting up during Internet and drug use—they light up nonspecifically for any highly valued activity and are not indicative of pathology. “Internet addiction” needs to be less a media darling, more a target of sober research. South Korea is the most wired country in the world and has the biggest problem with excessive Internet use. The government is attempting to tackle this with education, research, and intelligent public policy—none of which has required declaring “Internet addiction” a mental disorder. This is an excellent model for the rest of the world to follow.
Mislabeling Medical Illness as Mental Disorder
The boundary between psychiatry and medicine presents difficulties for both sides and is well served by neither. Even under the best of circumstances, the distinction between medical and psychiatric illness is often fuzzy and hard to draw. And it doesn’t help that most medical doctors are not very expert at psychiatry and that most psychiatrists are not very expert about medical illness, and that the communication between the two specialties is often incomplete and/or confused. It is the patients who suffer, frequently falling through the cracks and getting second-rate care from both specialties.
I first became personally and painfully aware of the risks of misdiagnosis four decades ago when, as a brand-new psychiatric resident, I
treated a man for what seemed to be depression for two months before discovering that his problems were in fact caused by the brain tumor I had previously missed. During the years since, I have seen in consultation dozens of patients who had a medical illness that had been previously mislabeled psychiatric and dozens of patients who had a psychiatric illness that had previously been mislabeled medical. It is easy to screw up in both directions.
There are four ways mistakes are made. First, some medical illnesses present with severe physical symptoms, but no definitive pathology (typical examples are irritable bowel, chronic fatigue, fibromyalgia, chronic pain, Lyme disease, and interstitial cystitis). Too often the patients are told that it is all in their heads and are called “crocks” behind their backs, thus adding insult to the injury and impairment of their chronic and sometimes debilitating illness.
Second, medical illnesses may present with symptoms that go unexplained for many years before the underlying cause clearly declares itself. Typical examples are multiple sclerosis, lupus, rheumatoid arthritis, peripheral neuropathies, connective tissue diseases, and yes, brain tumors. Uncertainty is hard to live with, but much better than jumping to the false and risky conclusion that the problem is psychiatric.
Third, some people have very strong psychological reactions to their cancer or heart disease or diabetes or other serious illness. And why not? When you are sick, it is understandable that you may become worried about your health, preoccupied with efforts to improve it, and hyperalert to possible new symptoms. That seemingly run-of-the-mill headache could always be a recurrence of brain tumor. People who have medical illnesses should not be casually mislabeled as also having a mental illness just because they are fearful and upset about being sick.
Fourth, the mislabeling also goes in the opposite direction. Many psychiatric disorders present with prominent somatic symptoms that are often mistaken for medical illness. The best example: People with panic attacks typically get far too much unnecessary, costly, and potentially harmful medical testing for the dizziness, shortness of breath, and palpitations that are really just part of the hyperventilation caused by the panic. And depression sometimes also presents with prominent somatic symptoms, especially weight loss.
DSM-5 will make even fuzzier the already fuzzy boundary between medical and mental illness by introducing a new diagnosis, “somatic symptom disorder,” and providing it with a loose and easy- to-meet definition. The result will be dramatically increased rates of mental disorder in all three patient groups: people whose diseases have clearly defined pathology (like cancer); people whose diseases have less well understood causes (like fibromyalgia); and people whose physical symptoms are thus far unexplained but will later show a clear etiology (like multiple sclerosis).
The often incorrect diagnosis of mental disorder will be based solely on the clinician’s subjective and fallible judgment that the patient’s life has become subsumed with health concerns and preoccupations, or that the response to distressing somatic symptoms is excessive or disproportionate, or that the coping strategies to deal with the symptom are maladaptive. These are inherently unreliable and untrustworthy assessments that will open the floodgates to the overdiagnosis of mental disorder and result in the missed diagnosis of medical disorder.
DSM-5’s own field trials produced pretty scary results. One in six cancer and coronary disease patients met the criteria for DSM-5 “somatic symptom disorder.” So did one in four patients with irritable bowel syndrome or fibromyalgia. And get this: so did almost one in ten “healthy” people. Do we really want to so casually burden medically ill (and even healthy) people with an additional diagnosis of mental illness just because they are worried about being sick?
An incautious, inept misapplication of DSM-5’s highly subjective and catch-all criteria will likely result in frequent inappropriate psychiatric diagnosis with far-reaching implications. Possible harms include:
• Stigma
• Missed medical diagnoses through failure to investigate new or worsening somatic symptoms
• Disadvantages in getting or keeping a job
• Reduced medical and disability reimbursement
• Reduced eligibility for social, medical, and education services and workplace accommodations
• A reluctance on the part of patients with life-threatening diseases to report new symptoms that might be early indicators of recurrence, metastasis, or secondary illness for fear of attracting a mental disorder diagnosis
• The patient’s view of herself and her illness may be skewed, as are the perceptions of family and friends
• The prescription of inappropriate psychotropic drugs
The burden of the DSM-5 changes will fall mostly on women because they are more likely to be casually dismissed when presenting with physical symptoms and also are more likely to receive inappropriate antidepressants and antianxiety medications.
The golden rules: An underlying medical illness has to be ruled out before ever deciding that someone’s symptoms are caused by a mental disorder. People suffering from a medical illness should never be casually mislabeled as also being mentally ill just because they are upset about being sick. And finally, there is lots of uncertainty inherent in determining whether a physical symptom springs from a physical or an emotional cause or has elements of both. Much better to live with the uncertainty than to mislabel psychiatric diagnosis.
Dodged Bullets—But Still Beware
This section describes the proposed disorders that almost made it into DSM-5 but got scrubbed at the very last moment. A big relief—none is remotely ready for prime time. But careful vigilance against their fad use is still required. Childhood bipolar disorder was similarly rejected by DSM-IV but nonetheless managed to become a dangerous false epidemic. And Australia is about to embark on a nationwide program, spending almost half a billion dollars, to treat psychosis risk—even though it is not an official diagnosis.
Psychosis Risk Is Far Too Risky
The future is good at keeping secrets and very hard to predict. Particularly with teenagers, who often seem like strangers in a strange land—or perhaps like Alice in Wonderland. The metamorphosis from child to adult has too many puzzling things happening far too fast—body changes, sexual maturation, new roles, new ideas, new feelings, new relationships, new responsibilities, new freedoms, new temptations. Teenagers confront the world fresh, asking unsettling questions that grown-ups know have no answers. They worry about the meaning of life and the mysteries of the universe, often speaking in abstract ways that befuddle busy parents worried about the next mortgage payment. Teenagers are not comfortable in their own skin—their sense of identity is fragile, uncertain, and unstable. Existential fears abound, fantasies are weird, feelings extreme, self-esteem shaky, dress eccentric, behavior erratic, video game play constant. Taste in music, movies, pastimes—all are likely to be abominable. It’s easy for teenagers to feel persecuted, insulted, ganged up against, and misunderstood. They are needy but reject help. Kindly concern is misunderstood as hostile intrusiveness. Parents are often at their wit’s end in trying to understand their previously loving child and imagine the worst for the future.
All of the above gets even more complicated when the troubled teen starts using drugs. The more troubled the teen, the more likely and the heavier will be the usage. The difficulties and confusions of growing up are magnified by mind-altering drugs that have the capacity to mimic every psychiatric condition. Some drugs create a particular good imitation of prepsychotic or psychotic symptoms—seeing or hearing things that aren’t there, developing strange beliefs that approach the delusional, becoming paranoid and hypervigilant, losing motivation, neglecting responsibilities and personal hygiene, and entering into weird countercultures. Under the influence of drugs, eccentricities will be accentuated, thoughts fragmented, beliefs confused, bizarre ideas accepted as plausible. Parents usually are either uninformed completely or greatly underestimate the role of the substance in making their kids even weir
der than they were before. The natural fear is that one’s child is going nuts.
The good news is that being a teenager is usually a self-and-time-limited disease. Most troubled teens grow up to be normal adults. The bad news is that some don’t—their teenage problems just a prelude for later continuing life difficulties. The worst news is that about one percent of all teenagers will develop schizophrenia, a serious psychiatric illness characterized by psychotic delusions, hallucinations, and strange thinking and behavior. Great suffering would be avoided if only we could identify those at risk for schizophrenia and intervene early before they have experienced their first full-blown psychotic episode. Not only would this avoid tremendous short-term disruption, but it might also greatly improve the person’s lifelong prospects. Preventing psychotic episodes is a high priority for psychiatry, a major preoccupation of the field for more twenty years. But how do you find the needle in the haystack—the rare strange teenager who will go on to be psychotic from the many other strange teenagers who will grow up to be normal?
DSM-5 proposed a new diagnosis intended to take on this daunting task. It has gone by two different names: “psychosis risk syndrome” and the tongue-twisting “attenuated psychotic symptoms syndrome.” However named, the high-minded goal is to promote early identification and treatment—to help prevent the onset of schizophrenia, or at least to reduce its lifetime ravages. This effort, were it successfully accomplished, would be the highest achievement in the history of psychiatry. The ambition is to do a very great good, but the risk is that early identification will miss its mark and instead inflict a very great harm.
Good intentions are not good enough; you have to have good tools. The value of early intervention to prevent psychosis rests on three fundamental and necessary pillars—diagnosing only the right people, having a treatment that is effective, and also safe. Psychosis risk syndrome (PRS) strikes out badly on all three counts. It would misidentify many teenagers who are not really at risk for psychosis. They would often receive atypical antipsychotic medications that have no proven efficacy. And most damning, these drugs have extremely dangerous complications.
Saving Normal : An Insider's Revolt Against Out-of-control Psychiatric Diagnosis, Dsm-5, Big Pharma, and the Medicalization of Ordinary Life (9780062229274) Page 21