What are the DSM criteria for behavioral addictions?

Behavioral Addictions in the DSM-IV

The DSM-IV (
Diagnostic and Statistical Manual of Mental Disorders

, fourth edition) is published by the American Psychiatric Association. The DSM-IV provides a classification system for the identification and diagnosis of mental disorders. (The updated version of the fourth edition of the DSM-IV has the additional designation of TR, meaning text revision). The DSM-IV provides specific criteria for the diagnosis of mental disorders that are used in clinical and forensic settings.

Behavioral addictions do not have a specific category in the DSM-IV. Also, some controversy exists over the use of the term
addiction
in describing these conditions. Behavioral addictions can be found in the DSM-IV within the impulse control disorders classification. Advocates of applying the term addiction to various behaviors have suggested that the category of behavioral addictions be included in the revision of the DSM.

For each mental disorder that can be considered a behavioral addiction, the DSM-IV provides specific information related to diagnosis. The DSM-IV gives specific diagnostic features or symptoms of the disorder, followed by a section describing associated features that are not central for making a diagnosis. Following a general presentation of the mental disorder, the DSM-IV includes information concerning the disorder’s prevalence, familial patterns, and prognosis, as well as cultural, age, and gender issues surrounding the disorder.

Impulse Control Disorders

The diagnostic category in the DSM-IV that includes the largest number of mental disorders that can be considered to be behavioral addictions is the impulse control disorder section. This group of mental disorders shares the major characteristic of having an irresistible impulse as the core symptom.

Persons with this type of mental disorder report the inability to resist an urge to engage in some action that may be harmful to themselves or others. An internal state of mounting tension precedes the action, and the behavior is followed by a sense of pleasure and satisfaction. As the state of tension grows, the person may actively plan a course of action to relieve the tension and experience the pleasurable aftermath of the behavior.

Persons diagnosed with impulse control disorder typically do not voluntarily seek treatment for the condition because they consider these actions to be a part of their self-identity. Ego-syntonic is the psychiatric term used to indicate this state of congruence between actions and personal perception found among persons with impulse control disorders.

Pathological Gambling

One of the most common impulse control disorders considered to be a behavioral addiction is pathological gambling
. This diagnosis is used with persons who engage in persistent and recurrent gambling despite the negative personal, social, financial, or occupational consequences. Persons diagnosed as pathological gamblers have a preoccupation with gambling, feel an excitement from gambling that requires an ever increasing amount of money used in betting, may engage in illegal activities to finance the gambling activities, gamble excessively to try to recoup losses, and will rely on others to cover mounting financial debts.

This behavioral addiction leads to frequent lies to hide the extensive involvement with gambling and creates disruptions or loss of personal and vocational relationships. Persons with this disorder typically show a pattern of numerous failed attempts to stop or reduce their involvement with gambling.

Pathological gamblers share a number of personal characteristics, including having a high level of energy, being overconfident when placing gambling bets, and being a free spender. Pathological gamblers fail to develop sound plans for saving money and fail to follow any realistic budget. For them, money becomes a major pathway to happiness and the solution to all of life’s problems.

When gambling debts begin to reach excessive levels, the pathological gambler will engage in antisocial actions to finance the gambling. Usually the antisocial actions are nonviolent and can include fraud, embezzlement, and forgery. It should be noted that the person always states an intention to repay the money gained through illegal means, but the addiction to gambling prohibits the repayments, as any winnings are used to finance additional gaming behaviors.

It has been found that pathological gambling usually begins in adolescence and goes through a pattern of four phases in its development and continuation. First is the winning phase, which is marked with a substantial amount of money being won through gambling. A second phase then emerges as a progressive pattern of loss takes place. During this time, persons whose lives are structured around gambling will progressively make foolish bets. It is during this phase that persons begin to miss occupational or social responsibilities and start to borrow money.

The third phase involves a sense of desperation that is marked with frenzied gambling, increasing debt, and possible illegal activities. The final phase in pathological gambling is reached when the gambler becomes hopeless about his or her situation. Even in this phase, the gambling continues, as it is tied closely to arousal and excitement. Persons with this disorder are addicted to the arousal and excitement provided through gambling.

Treatment for pathological gambling can be difficult because persons with this disorder often do not voluntarily want treatment. Entry into treatment is usually the result of legal or family pressures. The treatment of choice for pathological gambling is group therapy through Gamblers Anonymous (GA), which is based upon the principles of Alcoholics Anonymous and includes therapy that is centered on public confession of problematic behaviors, on peer support and pressure for change, and on the involvement of persons recovering from the disorder. Even with GA treatment, the dropout rate of participants is high, and pathological gambling is often seen as a long-term problem once established.

Pyromania

Another impulse control disorder that fits into the behavioral addiction classification is pyromania. Persons diagnosed with pyromania engage in the recurrent, deliberate, and intentional setting of fires. Persons with this disorder are physically aroused and excited before setting fires and find gratification and pleasure when witnessing the resulting fire. Sexual arousal commonly takes place when watching the fire. The fire starter feels no remorse or guilt and lacks concern for the losses experienced by others.

It is common for the fire starter to make elaborate plans and to carefully schedule the timing of a fire. In general, persons with this disorder also have a general fascination and curiosity about fires and anything associated with fire fighting. They will routinely travel to watch fires, and they frequently set false alarms. Pyromania is considered to be distinct from arson, as arson is a crime, not an addiction, associated with setting a fire for financial gain.

Pyromania usually begins in childhood and varies in severity during adolescence and adulthood. The disorder, however, has a chronic course that is maintained through the pattern of arousal and satisfaction gained from the fire setting. It is common for persons with this disorder to deny their problems and to avoid treatment for the condition. Treatment options for pyromania are limited, and for programs that are available, treatment focuses on techniques to quell the undesirable behaviors.

Trichotillomania

Also included in the DSM-IV category of impulse control disorders is trichotillomania: recurrently pulling out one’s hair. The pulling out of one’s hair is preceded with a sense of tension that is followed with a sensation of pleasure when the hair is actually pulled from the scalp. Persons with trichotillomania typically develop bald patches, and the disorder is most often diagnosed in girls and women.

Although all areas of the body with hair can be the target for this behavior, the scalp is the most common area involved. Some persons with trichotillomania ingest the hair after it is pulled. This process, known as trichophagy, can produce intestinal blockage. The occurrence of trichotillomania is often associated with depression, and the process of self-stimulation appears to be an essential factor in its development.

Trichotillomania is usually first seen in adolescence but can develop in childhood. Persons with this disorder usually receive a combination of psychopharmacological agents and behavioral treatment. Treatment includes anti-anxiety and antidepressant medications, and the behavioral therapy option focuses on breaking the cycle of tension and its relief through the pulling of hair.

Kleptomania

The behavioral addiction of kleptomania is also included in the DSM-IV within the impulse control disorder category. Kleptomania is the recurrent failure to resist the impulse to steal things. The thoughts of stealing are usually intrusive and are lessened only through the act of stealing. In most cases, the stolen objects are not needed, and often there is no goal of achieving financial gain from the acquisition. Persons with kleptomania often are financially able to purchase the stolen objects.

Before stealing an object, the person feels increasing tension that is relieved through stealing. The person feels no guilt or remorse for stealing. It is not uncommon for a person to continue stealing despite repeated arrests; however, the person may feel humiliation and anxiety after being caught in the act.

Females more commonly have this disorder. Kleptomania, which appears to be closely tied to the amount of stress in a person’s life, usually first develops in late adolescence and becomes chronic with periods of varying degrees of severity. Persons with kleptomania seldom voluntarily seek treatment. When treatment is undertaken, the person usually receives some combination of antidepressant medication and behavior therapy, which is designed to help the person resist impulses.

Other Impulse Control Disorders

Additional behavioral addictions are diagnosed as impulse disorder not otherwise specified (NOS). This is a general diagnosis that includes a variety of disorders related to behavioral addiction. A number of NOS behaviors are considered to have a compulsive quality. This means that persons with this disorder feel compelled to act out in a problematic fashion despite knowing that doing so is not in their best interests. The NOS diagnosis covers compulsive buying, Internet compulsion, cellular phone compulsion, compulsive sexual behavior, and repetitive self-mutilation.

Compulsive buying
involves a frequent preoccupation with buying or an irresistible impulse to purchase things. It also can be diagnosed in persons who frequently buy objects they cannot afford or do not need. Credit card abuse is usually associated with this diagnosis.

Internet compulsion is also known as Internet addiction. The person with this disorder spends the majority of his or her waking hours on the web. Internet addiction usually involves specific web content, such as pornography, shopping, or interactive games.

Cellular phone addiction involves the compulsive use of mobile phone devices. Frequently contacting friends, family, business associates, or acquaintances, the person with this addiction usually tries to justify his or her actions with a variety of excuses. Persons with this addiction appear to have high dependency needs and fears of being alone.

Compulsive sexual behavior, or sexual addiction, is another NOS disorder, one that involves repeatedly seeking sexual gratification in a socially unacceptable fashion. The person with sexual addiction is identified through a pattern of out-of-control sexual behavior, adverse consequences for the sexual behavior, persistent pursuit of high-risk sexual behavior, increasing sexual activity, severe mood swings associated with having or not having sexual activity, and excessive time spent in sexual activity.

Treatment for sexual addiction (which can include Internet addiction that is focused on pornographic websites) usually involves self-help groups modeled on the twelve-step approach of Alcoholics Anonymous. The self-help programs specializing in sexual addiction are Sexaholics Anonymous, Sex and Love Addicts Anonymous, and Sex Addicts Anonymous.

Bibliography

Grant, Jon E., et al. “Legal Consequences of Kleptomania.” Psychiatry Quarterly 80 (2009): 251–59. Print. The researchers discovered that kleptomania has significant legal outcomes that include incarceration. Recurrence was common with progressively severe legal consequences for the perpetrators.

Hook, Joshua N., et al. “Measuring Sexual Addiction and Compulsivity: A Critical Review of Instruments.” Journal of Sex and Marital Therapy 36 (2010): 227–60. Print. A number of objective instruments have been developed to assess sexual addiction. This review provides descriptions and critiques of seventeen instruments.

Kafka, Martin P. “Hypersexual Disorder: A Proposed Diagnosis for DSM-V.” Archives of Sexual Behavior 39 (2010): 377–400. Print. The author proposes that when the DSM-IV is revised, it should include sexual addiction as a hypersexual disorder. This proposed diagnosis would emphasize the dysregulation of sexual arousal and behavior apparent in this condition.

Lin, Chien-Hsin, et al. “The Effects of Parental Monitoring and Leisure Boredom on Adolescents’ Internet Addiction.” Adolescence 44 (2009): 993–1004. Print. The authors found that increasing amounts of leisure time available to adolescents contributes to Internet addiction. Recommends ways to increase family activities and outdoor recreation to reduce the effects of Internet addiction.

MacKay, Sherri, et al. “Epidemiology of Firesetting in Adolescents: Mental Health and Substance Use Correlates.” Journal of Child Psychology and Psychiatry 50 (2009): 1282–90. Print. The authors examined adolescents in grades 7 through 12 who engaged in fire setting. These adolescents showed high levels of psychological distress, patterns of binge drinking, and high rates of delinquent behaviors.

Nover, Lia, et al. “Recovery in Pathological Gambling: An Imprecise Concept.” Substance Use and Misuse 43 (2008): 1844–64. Print. Pathological gambling is considered to be poorly defined in terms of having imprecise diagnostic criteria. The lack of clear criteria makes is difficult to determine treatment effectiveness for pathological gambling.

Weinstock, Jeremiah, et al. “College Students’ Gambling Behavior: When Does It Become Harmful?” Journal of American College Health 56 (2008): 513–21. Print. The authors examined pathological gambling among college students. Risk factors in the development of this condition included the frequency of gambling on a monthly basis, time spent in gambling activities, percentage of income spent on gambling, existence of a gambling plan, and time spent gambling beyond the initial plan.