Week 3 Discussion
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The Emergence of Behavioral Addiction in DSM-5 Gina B. Polychronopoulos, Kristy L. Carlisle, Robert M. Carlisle, Andrea J. Kirk- Jenkins
Abstract The release of the latest edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) has sparked continuous debate about the structure, organization, and inclusion or exclusion of mental disorders. The term addiction made its first appearance in the manual with the category of Substance-Related and Addictive Disorders, after much anticipation from mental health professionals. With the emergence of behavioral (process) addictions in the diagnostic manual such as gambling disorder, it is likely that other mental disorders with similar features will follow suit. Speculation about other behaviors that could potentially be addictive includes Internet use, sex, shopping, exercise, and compulsive eating, among others. The goal of the current review is twofold: to explain the concept of behavioral addictions, including a focus on gambling and Internet gaming disorders, and to discuss how the emergence of process addictions may influence the work of human services practitioners. Clinical implications within the human services profession are also discussed.
The Emergence of Behavioral Addiction in DSM-5 Significant changes in organization and structure were revealed when the
fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM- 5) was released in 2013. What was once a multiaxial system is now combined into 22 categories of mental disorders, each grouped and organized based on etiological and phenomenological similarities. The overarching goal for these changes was an effort to align the manual with the International Classification of Disorders (ICD). Some disorders were removed from the manual, while others were newly added, but there is still debate among clinicians and researchers regarding both the practical and empirical validity of the changes that were made to the diagnostic manual (American Psychiatric Association [APA], 2013a). The following review highlights the emergence of behavioral addiction disorders in the DSM-5.
Gina B. Polychronopoulos, Kristy L. Carlisle, Robert M. Carlisle, and Andrea J. Kirk-Jenkins, Department of Counseling and Human Services, Old Dominion University. Correspondence regarding this article should be addressed to gbond002@odu.edu.
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Literature Review Behavioral addiction is considered an addictive disorder within the category of Substance-Related and Addictive Disorders in the DSM-5, and it describes the experience of cravings, strong urges, and disruptions in one’s functioning related to a particular behavior (APA, 2013a). Specifically, reward system pathways in the brain become activated when one engages in the behavior, just as it does when one uses substances. These experiences showed sufficient support in the literature, and the DSM Task Force has introduced this concept in the new manual because of the similarities between these phenomena (APA, 2013a). Several behaviors have been speculated to be addictive in nature in the past (e.g., sex, shopping, exercise, compulsive eating), and human services practitioners may provide therapeutic interventions that are similar to those offered for substance use disorders.
Although not a new mental health concern, gambling disorder (formerly called pathological gambling) is the first and only behavioral addiction to be formally recognized in the DSM. Prior to the DSM-5, gambling disorder was conceptualized as an impulse-control disorder; however, it is currently included within the category of Substance-Related and Addictive Disorders. This reassignment was justified by the physical, emotional, and neurological similarities that clients experience for substance use disorders and pathological gambling (APA, 2013a), as well as the neurochemical similarities that occur in the reward system pathways of the brain when an individual with gambling disorder engages in the behavior (APA, 2013a; Musalek, 2007; Prakash, Avasthi, & Benegal, 2012).
The diagnostic criteria for gambling disorder are reflective of substance use disorders, such as the need to increase how much money is gambled to achieve the same level of excitement (tolerance), irritability or restlessness when reducing or stopping the gambling behavior (withdrawal), and unsuccessful, repeated attempts to control the gambling. There are also remission specifiers, in which clinicians indicate how long it has been since any of the diagnostic criteria have been met (APA, 2013a). Given that the diagnostic criteria reflect the language of addiction, as well as the phenomenological similarities between gambling and substance use disorders, the reconceptualization of pathological gambling could pave the way for other pathological behaviors to be included in the manual.
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Similar to gambling disorder, Internet gaming disorder is found in Section III of the DSM-5. This section is reserved for emerging models and mental disorders that are still being researched due to lack of evidence to support their inclusion in the manual (APA, 2013a). Currently, however, there is limited empirical support for the existence of this phenomenon, and more research is needed in order to justify its formal inclusion as a mental disorder (APA, 2013a). For this reason, it is considered an emerging disorder that may be included in future manuals (APA, 2013a). Aside from Internet gaming disorder, there are no other addictive disorders under review in Section III. However, it is important to note that, with the presence of one behavioral addiction in the new diagnostic manual (i.e., gambling disorder), and the prospect that another may be included in upcoming editions (i.e., Internet gaming disorder), it is possible that other behavioral addictions could emerge with further research and empirical support. Much of the current research on Internet gaming disorder has been performed in Asian countries, where problematic Internet use has been recognized as a significant enough concern for governments to implement restrictions (Liu, Liao & Smith, 2012; Young, 2009). In a review of the literature, Kuss and Griffiths (2012) note that compulsive Internet gaming can lead to social and psychiatric distress. Symptoms that resemble substance-related disorders include preoccupation with gaming, heavier or more frequent use than intended, and risk of interpersonal or occupational loss (Young, 2009). Neurological studies demonstrate biochemical changes occurring in the brain with excessive Internet gaming that are similar to those seen with substance use (Kuss & Griffiths, 2012). However, additional research is needed in order to clinically legitimize Internet gaming disorder for inclusion in future editions of the DSM, as well as to support the development of evidence-based therapeutic interventions.
Clinical Implications for Human Service Practitioners The reconceptualization of gambling disorder as a behavioral addiction, as
well as the emergence of Internet gaming disorder in Section III of the DSM-5, reflects the theory that some behaviors could be considered addictive due to the similarities in symptoms, neuropathology, and treatment interventions (APA, 2013a). Recognizing these phenomenological similarities may improve accessibility of treatment tailored to addictions for people with a gambling disorder. Human service practitioners can use existing therapeutic interventions, such as Cognitive Behavioral Therapy (CBT), the Transtheoretical Model (TTM)
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or Motivational Interviewing (MI) techniques, when working with people affected by behavioral addictions. Further research is needed regarding specialized therapeutic interventions to treat specific behavioral addictions.
With the emergence of behavioral addictions, it is possible that further changes may occur in the way addictive disorders are conceptualized, assessed, and treated. For example, the diagnostic criteria in the DSM-5 reduce the threshold for a diagnosis of gambling disorder from five to four symptoms; thus, there is speculation that the overall prevalence of gambling disorder might increase (APA, 2013a). Further, although there are other specified and unspecified options for most other mental disorders (including substance-related disorders), the option is not listed in the DSM-5 for Non-Substance-Related Disorders (APA, 2013a). Clinicians are thus limited from diagnosing a behavior, which appears to be problematic or addictive, other than gambling.
As the diagnostic conceptualization of addictive behaviors evolves, the assessment of addictive behaviors would also be influenced. Recently, a social media addiction scale was created to assess the level of one’s excessive use of Facebook, a social media website (Andreassen & Pallesen, 2013). Although the authors chose to create a specific assessment for one website as opposed to all social media networks, the need for this type of assessment supports the notion that behavioral addiction is being recognized as a phenomenon. This recognition is reflective of the current trend in mental health diagnosis. Although training beyond the bachelor’s degree is required to diagnose and assess clients (Neukrug, 2013), human services practitioners may develop and utilize a working knowledge of diagnosis and assessment to identify potential clients who may qualify for services. Ongoing research may continue to focus on better understanding the potentially addictive nature of certain behaviors such as general Internet use, sex, shopping, exercising, binge eating.
Relevance to the Field of Human Services
Human services practitioners work in a variety of settings (e.g., community-based, institutional, residential care) with clients who could be affected by a range of mental health concerns (Neukrug, 2013), which may include addictive behaviors. However, human services practitioners are required to only practice within their knowledge and skill base, as well as to seek out new and effective approaches to working with their clients (National Organization for Human Services, 1996). Therefore, with the emergence of new diagnostic criteria
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for addictive disorders, it would be beneficial for human services practitioners to receive training on the diagnostic criteria so they may effectively provide services and referrals to their clients. As clinicians in multidisciplinary settings develop treatment options for individuals with a behavioral addiction, human services practitioners may benefit from becoming aware of the treatments offered at their agency and in the surrounding community. If human services practitioners receive training to recognize the symptoms and signs of behavioral addiction and become aware of the resources available, they would be better equipped to provide referrals for clients to be assessed and treated by appropriate service providers. Furthermore, human services practitioners also serve as advocates for the mental health profession (Neukrug, 2013) and may do so by seeking to understand behavioral addictions more thoroughly. To better address the phenomenon of behavioral addiction, human services practitioners can advocate for the modification of diagnostic screening and assessment tools, as well as contribute to the development of appropriate mental health skill building interventions.
References Andreassen, C., & Pallesen, S. (2013). Facebook addiction: A reply to Griffiths (2012).
Psychological Reports, 113(3), 899-902. doi:10.2466/02.09.PRO.113x32z6 American Psychiatric Association. (2013a). Diagnostic and statistical manual of mental disorders
(5th ed.). Washington, DC: Author. Kuss, D., & Griffiths, M. D. (2012). Internet Gaming Addiction: A Systematic Review of
Empirical Research. International Journal of Mental Health and Addiction, 10(2), 278- 296. doi:10.1007/s11469-011-9318-5
Liu, C., Liao, M., & Smith, D. C. (2012). An empirical review of Internet addiction outcome studies in China. Research on Social Work Practice, 22(3), 282-292. doi:10.1177/1049731511430089
Musalek, M. (2007). Pathological gambling: Addiction or impulse control disorder. European Psychiatry, 22, S1-S82 (abstract for oral sessions, symposium, S22.04). doi:10.1016/j.eurpsy.2007.01.147
National Organization for Human Services. (1996). Ethical standards for human service professionals. Retrieved from http://www.nationalhumanservices.org/ethical-standards- for-hsprofessionals#section_2
Neukrug, E. (2013). Theory, practice, and trends in Human Services (5th ed.). Belmont, CA: Brooks& Cole.
Young, K. S. (2009). Understanding online gaming addiction and treatment issues for adolescents. American Journal of Family Therapy, 37(5), 355-372. doi:10.1080/01926180902942191
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