Dependence or addiction?

Names matter. In the mid-1980s, the term ‘dependence’ was preferred to ‘addiction’ in DSM-III-R. Dependence was seen as a more neutral term; addiction as pejorative and leading to alienation of patients (O’Brien 2011). While there is a world of difference between ‘non-addictive or therapeutic dependence’ (Starcevic, pp. 250–258) and ‘compulsive, uncontrolled, drug-seeking behaviour’ (O’Brien 2011) the same word, ‘dependence’, was used for both. Have patients and doctors alike conflated the two separate uses of the term? Tolerance, craving and misuse are infrequent in long-term benzodiazepine treatment rather than to be expected (Starcevic, pp. 250–258). Withdrawal symptoms occur alike when selective serotonin reuptake inhibitors (SSRIs) or benzodiazepines are stopped, and suggesting that the ‘discontinuation syndrome’ of SSRIs represents something other is ‘mere semantics’ (Tyrer, pp. 259–262). Have benzodiazepines been underused as a consequence of such ‘seldom-challenged myths’ and is it time to reappraise their role (Starcevic, pp. 250–258)?

Gambling addiction, shopping addiction and internet sex addiction present new naming problems. Should the so-called behavioural addictions be regarded as mental disorders and, if so, are they addictions, compulsions or impulse control disorders? Both shopping addiction (Murali et al, pp. 263–269) and internet sex addiction (Dunn et al, pp. 270–277) are characterised by impulsive and compulsive behaviours. In other words, behaviours that are without foresight and persistently repeated despite adverse consequences (Robbins 2012). As in substance addictions, craving, diminished control, tolerance and withdrawal may all occur (Murali et al, pp. 263–269). Adverse consequences may be severe and there can be little doubt that sometimes treatment is justified (patient 2011). Gambling addiction as a focus for medical intervention is becoming better established (Bowden-Jones 2012) but there are concerns that currently ‘the boundaries of the addiction concept [are expanding] beyond what is justified’ (Smith, pp. 278–279).

Internet sex addiction

So then, do shopping addiction and internet sex addiction pass muster as mental disorders? Are they more akin to drug addictions or normal human behaviours? The article which is my Editor’s pick explores whether internet sex addiction should be medicalised: ‘before excessive interest in an activity or behaviour is declared an illness, effort must be taken to put it into a cultural and societal context’ (Dunn et al, pp. 270–277). The authors highlight the advent of freely available pornography on the internet and consider media, scientific and feminist discourses. Taking a discursive approach, they conclude that internet sex addiction is a construct that lacks validity. They suggest that dispositional factors have been overstated at the expense of external influence and that internet sex addiction is ‘a concept that obscures more than it illuminates’.