When does a vice become an addiction?
Too easily and too soon for some.
The nation's psychiatrists are considering defining addictive acts such as overeating, gambling and compulsive sex as medical disorders in their professional manual.
The proposed changes to the fifth and latest edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) would open the door to better diagnoses and treatments.
However, the new diagnoses also are creating criticism and mirth among some observers, including lawyers and eminent doctors who see the nation's psychiatrists as addicted to overdefining and predict headaches in terms of insurance coverage, businesses' ability to hire and fire, and overtreating the nation's populace.
Workplace disability law is a major concern for employers because "how are you going to be able to determine if someone is a binge eater or not?" Chicago lawyer Steve Miller told the National Law Journal.
Dr. Allen Frances, chairman of the DSM-IV Task Force in the 1990s, predicted a "slippery slope" if gambling is defined as a "behavioral addiction," a process he said would end with video-game use and shopping turned into medical conditions.
This and other changes appear to promote "what we have most feared — the inclusion of many normal variants under the rubric of mental illness," Dr. Frances said. The result can be millions of misidentified "patients" and "massive overtreatment."
Questions like these are being heard until April 20, when the comment period ends for this fifth edition of the DSM.
First published in 1952 by the American Psychiatric Association (APA), the DSM contains a detailed listing of every psychiatric disorder recognized by the U.S. health care system and defines how they are diagnosed. However, DSMs do not list recommended treatments.
Given the authoritative status of the DMS, revisions are made rarely and carefully. The DSM-V is the first revision since 1994, and it is not expected to be complete until May 2013.
However, DSM diagnoses can be cited in child-custody cases, employment background checks and court cases. Drug companies also use it as a guide for what psychiatric ailments exist and for which they can develop remedies.
Among the proposed changes is the creation of a "behavioral addiction" category with a single disorder — pathological gambling, the APA said. Internet addiction was considered for this category but instead will be listed in the DSM-V's appendix to encourage more research, the group said.
A spokeswoman for the American Gaming Association, a trade group for the casino entertainment industry, said her organization did not have an immediate response to the proposed change in the gambling diagnosis.
But in an odd twist, the "gambling addiction" diagnosis is being applauded by conservative family-values groups that are often harshly critical of the psychiatric establishment both for its role in debates over homosexuality and for its perceived willingness to medicalize actions seen as vices or sins by traditional religion.
Chad Hills, policy analyst for Focus on the Family, said the classification will add "legitimacy" to the problem of excessive gambling.
Gambling advocacy organizations have "tried to frame gambling addiction as a person's weakness, a person's irresponsible behavior, as a general malfunction in a person," said Mr. Hills, whose group opposes gambling. "I was glad to see it recognized by the psychiatric community as a legitimate addiction."
Two more DSM-V changes welcomed by practitioners are the creation of a "hypersexual disorder" under the category of Sexual and Gender Identity Disorders, and a new category for "binge eating" under Eating Disorders.
Hypersexual disorder refers to severe problems with sexual fantasies, urges or behaviors.
"If you are losing your job or losing a marriage or having health consequences because you're having sex with prostitutes repeatedly, compulsively, or you are looking at porn at work even though you've been warned — those are above and beyond healthy sexual behaviors," said John O'Neill, former director of addiction services at the Menninger Clinic in Houston.
Hypersexual disorder won't apply to everyone who looks at pornography or has an affair, but it will finally address the serious problems, said Mr. O'Neill, who is now in private practice.
In the past, people have said, "Well, it's not really a problem. … It's a character flaw," he said.
Now brain studies have shown that whether someone is addicted to sex or food or gambling or alcohol, "your brain has been rewired basically, to say, 'This is what I have to have to experience pleasure, to feel good, to cope,'" Mr. O'Neill said.
Rebecca Wagner, who coordinates the eating disorder program at the Menninger Clinic, called the new binge-eating category "a very welcome change."
Binge eating is different from anorexia or bulimia, she explained.
Binge eaters say they "can't stop eating." In a two-hour period, for instance, they will consume so much food that they will feel uncomfortable. They also are likely to eat when they are not hungry, eat secretly because of embarrassment and feel disgusted with themselves.
However, Ms. Wagner said, their attempts to restrict their eating typically leads to hunger and bingeing again. It's a "vicious cycle," said Ms. Wagner, who added that binge eaters often struggle with additional problems such as depression or anxiety.
The new DSM-V criteria should mean better diagnoses of this condition, which in turn should open the doors for insurance-covered treatment and additional research, she said.
Still, gambling, hypersexuality and binge eating all made Dr. Frances' list of "19 worst suggestions" for the DSM-V.
"The tens of millions of people who binge eat once a week for three months would suddenly have a 'mental disorder, subjecting them to stigma and medications with unproven efficacy," Dr. Frances, professor emeritus at Duke University's psychiatry department, wrote in a commentary column.
The new "hypersexuality disorder would be a gift" to "excuse-seekers" and turn into a "potential forensic disaster," he wrote.
Gambling addiction "could provide a slippery slope leading to the back-door inclusion of a variety of silly and potentially harmful diagnoses (i.e., 'addictions' to shopping, sex, work, credit card debt, videogames etc, etc, etc) under the broad rubric of 'behavioral addictions not otherwise specified,'" Dr. Frances predicted.
The DSM-V proposals refer to conditions with severe distress — an eating disorder does not mean overeating on Thanksgiving Day, Dr. Alan Schatzberg, APA president, told PBS' "Newshour" program on Feb. 10, when the revisions were released for comment.
Field trials will "test out whether these proposed kinds of categories make sense," he added, and "I think the DSM-V will reduce the numbers of patients who receive diagnoses."