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Szalavitz is at odds with herself. She says Weiner-who displayed the defining characteristic of addiction, persistence in destructive behavior-may not have been truly addicted because scientists found that sex addicts don't have special brain responses to sexual stimuli. Instead, Weiner may suffer from a destructive sexual compulsion. But that is a distinction without a difference. Szalavitz, who is as well-informed on addiction and drugs as anyone who has ever written for a mainstream news outlet, still gets tripped up by neuroreductionism. According to this way of thinking, if a person behaves like an addict but doesn't produce the right brain scan, he has to be called something else.
Before Cocaine Was Addictive
Although addiction historically referred to just about any strong attachment or hard-to-break habit, physicians began using the term to describe a medical syndrome at the turn of the 20th century. They had in mind addiction to drugs. Specifically, they had in mind addiction to opiates, since they erroneously believed that only opiates caused tolerance (a need for larger doses to achieve the same effect) and "physical dependence" (withdrawal symptoms). Alcohol and barbiturates were added to the list later, but physicians and pharmacologists continued to describe other drugs as merely "habituating." The U.S. surgeon general's landmark 1964 report on the health hazards of smoking, for instance, deemed nicotine habituating but not addictive. The same distinction was applied to cocaine, amphetamines, marijuana, and various other drugs.
By the late 1980s, the federal government had changed its mind: The 1988 surgeon general's report on smoking was titled Nicotine Addiction. The American Psychiatric Association likewise broadened its definition of addiction, noting in the fourth edition of its Diagnostic and Statistical Manual of Mental Disorders (DSM-IV, published in 1994) that "neither tolerance nor withdrawal is necessary or sufficient for a diagnosis of Substance Dependence." The DSM-IV defined substance dependence as "a maladaptive pattern of substance use" resulting in "clinically significant impairment or distress" meeting at least three out of seven criteria. It referred to less severe "substance use disorders" as "substance abuse."
The fifth edition of the manual-the DSM-5, published last May-eliminates the distinction between dependence and abuse. Instead it classifies substance use disorders as mild, moderate, or severe. Thus the DSM-5 does not explicitly recognize such a thing as drug addiction or dependence. But under "Substance Use and Addictive Disorders" the manual includes a category called "Behavioral Addictions" that so far consists of a lone entry: "Gambling Disorder." This term identifies what used to be called "pathological gambling," compulsive gambling that causes severe life problems.
It is unlikely that organized psychiatry will stop at labeling a single nondrug activity as addictive. Already the DSM-5 lists "Internet gaming disorder" as another possible behavioral addiction in Section III, which describes disorders under consideration for future inclusion in the manual. They're holding off for now because they want to see whether "persistent and recurrent use of Internet games, and a preoccupation with them, can result in clinically significant impairment or distress." But we already know that such preoccupations can disrupt people's lives, as commentator after commentator tells us they do, just as preoccupations with gambling, sex, and many other activities can. We are headed one way with addiction, which is to expand the concept.
I have advocated a broader understanding of addiction since 1975, when the Harvard psychiatry researcher Archie Brodsky and I published our book Love and Addiction. We argued not only that the distinction between "addictive" and "habituating" drugs should be abandoned but that nondrug activities, including love, sex, eating, and gambling, could also be addictive, or not, depending on the way people became involved in them and how destructive the involvement was. As we wrote in 1975, "If addiction is now known not to be primarily a matter of drug chemistry or body chemistry, and if we therefore have to broaden our conception of dependency-creating objects to include a wider range of drugs, then why stop with drugs? Why not look at the whole range of things, activities, and even people to which we can and do become addicted? We must, in fact, do this if addiction is to be made a viable concept once again."
While psychiatry is gradually moving in this direction, it is doing so under the pretense of locating addiction in the brain. In a February 2010 press release defending the decision to describe gambling as an "addictive disorder," the head of the DSM-5 working group on substance use disorders, Charles O'Brien, cited "substantive research" indicating that "pathological gambling and substance-use disorders are very similar in the way they affect the brain and neurological reward system." So according to O'Brien, gambling is addictive because it affects the brain as drugs do.
The physician and historian Howard Markel likewise defends the neuroscientific soundness of the DSM-5's approach. "The concept of addiction has been changing and expanding for centuries," he wrote in a 2012 New York Times essay. "Initially, it wasn't even a medical notion." (Imagine!) "'Addiction' entered the medical lexicon only in the late 19th century, as a result of the over-prescription of opium and morphine by physicians. Here, the concept of addiction came to include the notion of an exogenous substance taken into the body. Starting in the early 20th century, another key factor in diagnosing addiction was the occurrence of physical withdrawal symptoms upon quitting the substance in question."
Markel continues: "This definition of addiction was not always carefully applied (it took years for alcohol and nicotine to be classified as addictive, despite their fitting the bill), nor did it turn out to be accurate. Consider marijuana: in the 1980s, when I was training to become a doctor, marijuana was considered not to be addictive because the smoker rarely developed physical symptoms upon stopping. We now know that for some users marijuana can be terribly addictive, but because clearance of the drug from the body's fat cells takes weeks (instead of hours or days), physical withdrawal rarely occurs, though psychological withdrawal certainly can."
Instead of seeing addiction as a constantly shifting idea, Markel retrofits history to define addiction neurochemically. According to him, it was scientific progress when addiction was defined as use of a specific substance that might lead to physical withdrawal. Yet by his reckoning, it also was progress when those conditions were abandoned. Why? Brain scans!
Markel explains why he is now convinced that gambling, like marijuana, is addictive: "A team of scientists led by Nora Volkow at the National Institute on Drug Abuse have used positron emission tomography (PET) scans to show that even when cocaine addicts merely watch videos of people using cocaine, dopamine levels increase in the part of their brains associated with habit and learning. Dr. Volkow's group and other scientists have used PET scans and functional magnetic resonance imaging [fMRI] to demonstrate similar dopamine receptor derangements in the brains of drug addicts, compulsive gamblers and overeaters who are markedly obese." By this light, food is addictive and sex isn't.
Where Are the Sex Parts?
Section III of the DSM-5 does not include sex addiction, hypersexuality, or excessive pornography consumption, so evidently they are not being considered for later inclusion. That omission has prompted intense criticism from the UCLA psychologist Rory Reid. In a 2012 study of people treated for hypersexuality, Reid and his collaborators found that the proposed DSM-5 criteria for the condition were both reliable (leading to diagnostic agreement among clinicians) and valid (corresponding to real-world consequences). Conforming with an essential requirement for inclusion in the DSM, the criteria included "evidence of personal distress caused by the sexual behaviors that interfere with relationships, work or other important aspects of life."
The Reid study, which was reported in the Journal of Sexual Medicine, was produced at the same UCLA research center as the recent EEG study supposedly showing that hypersexuality is not a real addiction. "Science Supports Sex Addiction As a Legitimate Disorder," announced the UCLA press release heralding the 2012 study, while the headline on the press release about the 2013 study asked, "Is Sexual Addiction the Real Deal?"