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Why are Behavioral Addictions not Recognized in the DSM-5?

Updated: Apr 21, 2019

Behavioral addictions are something those in the field of substance use have most likely run into. However, these issues are not formally recognized in our main manual for diagnosing, the DSM-5. Why is this?



What Addictions are Recognized?


Very few addictions are recognized formally in the DSM-5. Substance use disorders are the primary addiction that is categorized. Each substance has its own use disorder with similar diagnostic criteria. These substances include alcohol, cocaine, opioids, and many others. Interestingly, tobacco has it’s own use disorder. Ironically, nicotine is the addictive substance, but tobacco is the disorder. This draws a clear distinction between cigarettes/cigars/chewing tobacco and vaping. However, it is unlikely that there is any diagnostic difference. 


Gambling is the only behavioral addiction that is listed in the DSM-5. Perhaps this is due to the obvious and catastrophic family and interpersonal issues this can cause. However, most addiction diagnostic criteria are not based in external factors such as gambling away your child's college fund. Addiction is more focused on the mental and emotional issues and consequences, though gambling does have some unique criteria that substance use does not.


Food addictions are not actually in the DSM-5 either. However, these behaviors may categorically fall under eating disorders. Certain eating disorders are arguably accurate labels for food addiction. However, no where is it explicitly listed as addiction.



What Addictions are not Recognized?


Much to the chagrin of many an addiction counselor, several addictions that are seemingly obvious and would benefit from being in the DSM-5 are strangely missing. As previously discussed, food is missing, though these may be covered well enough by various eating disorders. Sex addiction is also strangely missing, which is odd because addictive sexual behavior can cause issues for those who are dating, married, or even single. Another similar addiction would be pornography. This highly secretive compulsive behavior can cause great distress individually and can affect families.


Another addiction that is missing is video games. This is a newer addiction on the scene, and appears to have surfaced as online gaming became more popular. It is currently in the DSM-5 for future consideration as internet gaming disorder. Caffeine addiction is also not present, but is also a substance-using behavior that is currently under discussion in the DSM-5.



Why?


Why are these disorders not formally diagnosed? Anyone who has experienced issues with these behaviors may be shocked to read this, as their experiences have been very real and painful. The first issue is lack of evidence. This probably stems from a lack of research studies being conducted. However, simply because something is not researched and listed in the DSM-5 does mean it’s not an issue and the individual is not struggling. Some argue that by pathologizing this behavior it creates issues that aren't real or disordered. They would argue that sexual behavior is normal and it's more a belief system that makes individuals feel guilty. Well, if you talk to anyone that has these issues, they will make very similar statements to this with substance-based addictions. “I did it again,” “I'll stop tomorrow,” or “just one more time,” are all common statements. The last issue is a lack of diagnostic criteria. When informally diagnosed, these issues are compared to the DSM-5 criteria for substance use disorders.



If Not Diagnosable, What are your Options?


While these are not formally diagnosable in the DSM-5, there are workarounds. Other diagnostic tools like ICD-10 can be used to provide codes for billing purposes so you can see a counselor. If you pay privately, you can do whatever you want, but if you want to use insurance, a workaround such as this will be needed so you can still get counseling services. The other is option is 12-step fellowships. These groups are free and provide a group forum for talking with people that identify with the same issue. One example of such a fellowship is Sex and Love Addicts Anonymous.



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