Definition of ‘addiction’ clouded by mainstream usage

In 2008, a research paper published by a psychology professor and two undergraduate students at Muhlenberg College in Allentown, Pa., found that 10% of Harry Potter fans surveyed reported showing characteristics of addiction after the final book in the popular series was released.

Looking back now, clinical psychologist David J. Ley, PhD, has a pop culture reference of his own to convey his feelings about the study.

“It was an example,” Ley says, “that the addiction model has jumped the shark.”

The phrase, a nod to the sitcom “Happy Days,” is an expression for the moment when a concept has reached its peak and begins losing its cache. Ley is one of several clinicians interviewed by Addiction Professional who laments that the term “addiction” has lost meaning in large part because it is used so loosely in everyday conversation.

“I’ve even made that mistake myself sometimes when I say I’m a chocolate addict,” says David Mee-Lee, MD, senior vice president for The Change Companies and a board-certified psychiatrist. “I’m not really a chocolate addict, where I would give up family, friends and work to ‘do chocolate.’ That’s when addiction takes over a person’s life. There is a danger in saying I’m a shopping addict or a running addict or a chocolate addict.”

The way the treatment field defines and applies the term "addiction" has significant implications for patients, from the way they are perceived to the type of treatment they receive to the amount of coverage their insurer will provide.

Defining addiction

Providers are divided even on what an addiction is. The American Society of Addiction Medicine (ASAM) defines it, in part, as “a primary, chronic disease of brain reward, motivation, memory and related circuitry.” (See the complete ASAM short definition of addiction on the next page.)

“It’s important that all the disorders that we call addiction actually have neuroscience research that supports that addiction is occurring in the brain,” says Stefanie Carnes, PhD, CSAT-S, president of the International Institute for Trauma and Addiction Professionals. “As long as we have the research evidence to really identify that these brain changes are occurring, I think the addiction label is appropriate. I think it’s appropriate for substance use disorders, I think it’s appropriate for behavioral addictions that we know follow this same pattern from a neuroscience perspective.”

Among the issues around addiction that providers are split on: Do multiple addictions exist, or is addiction in itself a disease with various manifestations? Mee-Lee, who also serves as chief editor for the ASAM Criteria, a set of guidelines for the placement, continued stay and transfer/discharge of patients with addictions and co-occurring disorders, says in his view, the disease is addiction, but that it manifests itself in whole-person ways. Providers not subscribing to this philosophy—opioid overdose treatment centers offering smoking areas, for example—can create challenges for those in recovery.

“If somebody uses while in treatment, many outpatient programs will tell a person to come back tomorrow when they are stable or sober, or they won’t let them into group. You would never do that if somebody had depression and showed up suicidal. You wouldn’t say, ‘come back tomorrow when you’re not suicidal,’ ” he says. “Inpatient facilities and many residential programs have zero tolerance that if somebody uses, they discharge them. You would never have somebody who has cutting behavior, or gets psychotic, manic or suicidal that if they get suicidal and try to hurt themselves, you would discharge them or ban them from treatment.

"Even in the addiction field, we say addiction is a disease and then treat it as willful misconduct and say things like, ‘we can’t have people who use stay in the program because it will trigger other people.’ I say what better place to be triggered, where there’s somebody to help you rather than be triggered on your own?”

Behavioral addictions

The fifth edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-5) recognizes one behavioral addiction: gambling.

Studies on brain activity in relation to hypersexual activity, or compulsive sexual behavior (CSB), however, have found the following in comparison to non-CSB test subjects:

• Greater prefrontal activity to sexual cues, but less brain activity to normal stimuli
• Enhanced attentional bias
• Dysfunctional Hypothalamus-Pituitary-Adrenal (HPA) axis and altered brain stress circuits
• Epigenetic changes on genes central to the human stress response
• Higher levels of Tumor Necrosis Factor, a marker of inflammation

Each of the above findings are consistent with the brain activity observed in those diagnosed with substance use disorder.

Carnes argues that with research showing brain changes around hypersexual activity similar to those triggered by gambling, the addiction model is appropriate for sexual behavior as well. Not having such a diagnosis for hypersexual activity has had critical implications for research in the field, she says.

“There has been one federally funded study grant that has been given in this area, so we’re where alcoholism was 30 years ago,” Carnes says. “We have a huge lack of research and a lot of disorganization in the field because of the lack of diagnosis. If we don’t have an agreed upon diagnosis and constellation of symptoms, it affects how we research, do assessments and look at outcomes research.”

Despite the documented brain activity around hypersexual behavior, Ley, who authored The Myth of Sexual Addiction in 2012, does not concur with the addiction construct in regards to sex or pornography viewing. His reasoning is that there has been no evidence of a threshold at which a level of sexual behavior becomes harmful and that the idea of “too much sex” is a relative concept.

Along those lines, Ley says the primary reason sex and pornography addictions continue to be rejected from the DSM is that they are “inextricably linked with morality concerns,” a topic he explores in detail in his The Myth of Sex Addiction book. The message, he says, is the sex/porn addiction label has become a medicalized term for behaviors disapproved in socially conservative circles.

“The very real danger here is if we allow these models to continue within our healthcare system, then therapists and the mental health industry become the enforcement arm of society enforcing morality rules,” Ley says. “That is a big problem for me because it’s not medical.”

Similarly, video gaming is another behavior facing a moral panic. Anthony Bean, PhD, a licensed psychologist who specializes in video games, children and adolescents, and the virtual worlds played in, says the push to pathologize high-frequency video game playing is “a very poor and negative way of dealing with a situation,” citing other entertainment pastimes over the past century.

“We can pick out parts of decades where there was a focus on certain things,” he says. “For video games, if we go through history, it started with nickel and dime comic books, then straight comic books. Then it went to rock 'n' roll, then pinball machines. After that, there was the war on drugs. Now it’s video games, and I’m sure it will be virtual reality in the next decade.”

Precise language

Ley says the term “addiction” could follow a trajectory similar to other words that once had a precise meaning within medical terminology but had become pejorative.

“Society has taken up the word addiction and used it very broadly in casual language, pop psychology and especially in the media at this point to define anybody who does something more than somebody else likes,” he says. “That’s really unfortunate.”

Mee-Lee concedes that the term probably has jumped the shark in the mainstream parlance.

“In treatment, though,” he says, “we can be more strict about what these addictions look like.”

Tom Valentino is Senior Editor of Addiction Professional.

Addiction, as defined by ASAM

The following is the American Society of Addiction Medicine’s short definition of “addiction”:

Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors.

Addiction is characterized by inability to consistently abstain, impairment in behavioral control, craving, diminished recognition of significant problems with one’s behaviors and interpersonal relationships, and a dysfunctional emotional response. Like other chronic diseases, addiction often involves cycles of relapse and remission. Without treatment or engagement in recovery activities, addiction is progressive and can result in disability or premature death.

Insurers' involvement

According to the American Psychiatric Association website, the DSM-5 was created “to facilitate a seamless transition into immediate use by clinicians and insurers to maintain continuity of care.”

Two of the clinicians who spoke with Addiction Professional for this story on defining addiction, however, expressed unrest over the insurance industry’s involvement with the diagnostic manual’s creation. Overall, Anthony Bean, PhD, says he is concerned that the medical model and the concept of medical necessity relied upon by the insurance industry does not apply well to the behavioral health conditions being treated by clinicians. David J. Ley, PhD, echoes those sentiments.

“I was incredibly disappointed with the degree to which the health insurance industry was over-involved in the DSM-5 development,” says David J. Ley, PhD. “The APA has worked hard to keep the pharmaceutical industry at bay as they were developing these diagnoses, but they welcomed the health insurance industry with open arms. I am very troubled by that. Basically, then, we are developing diagnoses based upon what the insurance companies will pay for. I don’t think that’s the direction it’s supposed to go. We’re letting the tail wag the dog. It pulls away from the research and data in terms of what kinds of things can help.”