What is addiction? In the church, in counseling, and even in the field of recovery, this deceptively simple question gets really confusing, really fast.

In order to overcome addiction, we need to have a clear understanding of what it is, exactly. How is a doctor supposed to treat people for illness if she is not certain what that illness is?

This is the second of a three-part series on addiction. The first article “What We Are Talking About When We Talk About Addiction,” suggests four different ways we use the word.

Today we’re going to talk mostly about behavioral addictions … and why some people are dismissive of "addiction" altogether.

We dismiss it because we don’t understand it

I’ve heard people complain that “addiction” a modern concept, compared to the (idealized) past, where people seemed to just “deal with” their problems. “If someone drank too much, they just stopped.” Did that ever really work?

Today addiction is used to describe almost any kind of negative, compulsive habit. Some people feel it has become a cop-out, an excuse to shift the blame from oneself to the vague and ambiguous culprit we call “addiction.”

The Ebb and Flow of Addiction in Cultures

While it may be true that we talk more about addiction today than in previous generations, it is by no means a new word or modern concept. Historians have noted that there has been an ebb and flow of addiction across societies and time periods. Societies have existed with very little addiction among them for generations, only to be seized by widespread addiction later.

This happened, for example, with Native Americans after European colonization. Before the Europeans came, there is little evidence of
substance abuse among most native peoples. But after their land was taken, the cornerstones of their society were dismantled, and they were moved into reservations, alcoholism emerged as a huge problem. (For more detailed information about this, including data sources, see “The Globalization of Addiction,” by Bruce Alexander.)

“Addiction” is not a new word

As stated in part one of this series, addiction isn’t a new word in the English language. The Oxford English dictionary held an entry for the word as early as 1884: “The giving of oneself to a pursuit.” For a long time, the word was used to describe dedication and commitment, usually to something worthy and good.

That changed in the late nineteenth and twentieth centuries with the Temperance Movement, when writers and speakers began using the word in relation to alcohol and other drugs.

Since then, the word has morphed into one of those confusing concepts with multiple meanings. Even psychologists can’t agree on the concept, as evidenced by the ongoing discussions about using this term in the Diagnostic and Statistical Manual of Mental Disorders (D.S.M.), the standard reference work used in the US to diagnose psychiatric illnesses.

Addiction and the DSM

The latest edition of the DSM — the DSM-5 — now includes a chapter on “Substance-Related and Addictive Disorders.” The chapter’s title was previously “Substance-Related Disorders.”

For years, as addiction researcher Stanton Peele notes, the American Psychiatric Association (APA) has gone back and forth between use of the terms “addiction” and “dependence” to describe alcohol and other drug problems. Now it appears there is a growing consensus around using this word “addiction” … but it is still NOT listed as a specific diagnosis. The diagnosis is “substance use disorder.”

Behavioral Addictions and the DSM-5

When it comes to recognizing “Behavioral Addictions” — such as addiction to gambling, sex, food, video games — things get even more confusing, and continue to be in flux. Here’s where things stand right now:

1. Gambling addiction: The DSM-5 recognizes “gambling disorder” — again, not “addiction” — as a diagnosis. But at least it’s there, as a diagnosable condition.
2. Computer gaming addiction: Internet Gaming Disorder (IGD) — is identified as a behavioral addiction needing further study (ie. not currently diagnosable).
3. Sex addiction is still not officially recognized as a diagnosable disorder, after decades of discussion and controversy about it. Instead, the DSM-5 categorizes compulsive sexual behavior under “Other Specified Sexual Dysfunction” when it causes clinically significant distress or impairment in functioning. (By the way: In contrast to this, the ICD-11 — the International Classification of Diseases, published by the World Health Organization — does include “Compulsive Sexual Behavior Disorder,” aligning more closely with the concept of sex addiction.)
4. Food addiction is also not formally recognized as a diagnosis. Instead, the DSM-5 categorizes problematic eating behaviors under the umbrella of feeding and eating disorders.

Why are These Behavioral Addictions NOT Listed as Diagnosable Disorders? Are They not Addictions?

This is a really important question. I will address it further in the next installment of this series, but let’s start here:

The issue is NOT that behavioral addictions “aren’t real” or that they don’t function in our lives in ways similar to substance addictions, it’s just that there are complicated political and financial issues with getting them included in the DSM-5.

I once heard Dr. Patrick Carnes — an early pioneer in the field of sex addiction and recovery — talk about the long history of debates about getting “sex addiction” listed as a diagnosable disorder in the DSM. His answer was revealing, and helps to understand why sex and food addiction — which seem to be such obvious forms of addiction — are not currently listed (and in my opinion, will likely NEVER be). His answer — and I’m summarizing here — was essentially this:

It’s all about money, insurance, and liability.

Health insurance companies are required by law to cover treatment for diagnosable disorders listed in the DSM. This coverage is mandated by federal parity laws, which ensure that mental health and substance use disorder treatments are covered similarly to medical treatment. And just to be clear, “treatment” includes therapy and medication.

Once sex — or food — addiction is listed as a diagnosable disorder, then insurance companies will HAVE to pay for its treatment.

Conservatively, this would mean billions of dollars annually.

Not sure about that? Well think about the implications of just one dimension of one of these addictions: think about the use of GLP1 medications for diabetes and obesity. Suppose food addiction is listed as a diagnosis in the DSM. Drugs like Ozempic and Wegovy would arguably be considered the best form of treatment, and at least half of the US population would qualify for them.

Right now, most insurance companies refuse to pay for GLP1s for obesity, and will only cover their use if people are diabetic. What if people could be diagnosed with food addiction? 

Imagine this scenario: half of the US adult population qualifying for treatments that cost insurance companies $1000 a month per person (or whatever negotiated rate they can get with the drug companies).

There’s no way.

Now granted, this is not what the American Psychology Association is talking about publicly. In a recent article on the Psychology Today website, What Would Happen If “Food Addiction” Was Made Official?, Claire Wilcox writes that food addiction was not included in the DSM because it “could have negative consequences for people who struggle with overeating or obesity.” Specifically, she says making this a diagnosable disorder might (a) “trigger disordered eating,” or (b) it “could cause negative stigma,” and/or (c) it “could reduce a person’s self-efficacy.”

I’m sorry … I just don’t believe that. Call me cynical, but I don’t buy this explanation at all. It’s patronizing, and its logic falls apart when you apply the same arguments to drug and alcohol addiction. If something is a problem, is damaging someone’s life, and is certain to cause an early death, are we really NOT going to identify and treat the real issue, because it might cause negative stigma?

Now maybe you’re thinking: But are things like “food addiction” and “sex addiction” really real, in the same way that addictions to substances are “real”? Or are they just bad habits that people can overcome if they really want to?

We’ll cover that in the next installment of this series. We’ll also touch on the other thorny issue that Patrick Carnes said was keeping “sex addiction” out of the DSM: liability issues.