Obesity and the Agonizing Choices of Definition

Overweight adults

With the determination to understand what the members of the DSM-5 Work Group (who invented the definitions) were thinking, Drs. Henrietta Bowden-Jones and Luke Clark tackled the subject when the book was still being assembled. They wrote of the similarity of clinical expression and what they characterized as an “overlap” between substance use disorders and what was then called “pathological gambling.”

Like substance abusers, problem gamblers show signs of tolerance, tending to gamble with increasingly high stakes. They become irritable when trying to reduce their habit – in other words, like substance abusers, they go through withdrawal. (Those two traits are universally recognized as “hallmarks of addiction” – yet somehow, when it comes to food addicts, nobody is paying attention.)

In gambling, common risk factors have been identified, such as an impulsive personality and genetic markers that influence the transmission of dopamine in the system. (But when similarities are found between food addicts and other substance abusers, the reaction is “So what?”) Here is a fascinating quotation from Clark and Bowden-Jones:

In addition, the most validated drug medications for pathological gambling are the opioid antagonists (e.g. naltrexone); drugs that were initially trialled in pathological gambling based on their efficacy in drug and alcohol dependence.

They do not mention that, by amazing coincidence, a combination of naltrexone and bupropion has also been auditioned as a weight-loss drug. This is the segue into how, last time, Childhood Obesity News speculated about where food addiction might eventually fit into the next Diagnostic and Statistical Manual, or DSM-6. It will be many years before another edition is published, and who knows what might happen in the interim. Meanwhile, professionals in the addiction field continue to cite the hallmarks of unhealthy dependency upon a substance – one of which is escalating and uncontrollable use. Another sign that addiction might be a proper diagnosis is when the pursuit and use of the substance gains ascendency over all other activities.

Uncomfortable similarities

To an addict, finding employment or even keeping the job one already has seems unimportant. School and other activities slide down the priority list. Human relationships narrow to a bottleneck, reduced to a single question: “Can this person help me get hold of my substance of choice?” Does the friend or relative have money, connections, transportation, and/or the requisite gullibility to help the user score? If so, they might be allowed to stick around a little longer. If not, too bad.

Everyone is totally familiar with tolerance, and knows all about withdrawal, and the culture of addiction has become as routine as a bedtime story we’ve all heard a hundred times. Yet when these same signs and symptoms apply to a morbidly obese person who is committing slow-motion suicide with food, the world does not vigorously affirm – “Yes, that is addiction.”

Unhelpful comparisons

As we mentioned, the guidebook is strangely coy about using the A-word. It’s almost as if time and progress are flowing backward, and we are still in the era where “cancer” was only whispered by genteel people who believed that if they never said it out loud, they couldn’t catch it. Even in the case of nicotine, which is universally acknowledged as being addictive, the people hooked on it have Tobacco Use Disorder, according to the book.

Unsatisfied with the way alcohol is handled by DSM-5, Dr. Stuart Gitlow wrote for Drugfree.org an article explaining his objections in great detail. In his opinion, the terminology and defining structures outlined by the manual are for a “new set of illnesses,” and not applicable to alcoholism as we have come to understand it. He sees adherence to the DSM criteria as leading to absurdity:

A patient who ends up in the ER only once each year due to a suicide attempt, car accident, slip/fall, barroom brawl, each time after imbibing considerable alcohol, does not meet criteria for even a mild alcohol use disorder. And a college student who is not an alcoholic does meet criteria for a mild alcohol use disorder if he has tolerance and hangovers.

Bowden-Jones and Clark did mention that at least 30 percent of pathological gamblers, and probably more like half of them, also have accompanying substance abuse problems. This lends credence to the notion that all addictions are just one big addiction wearing different masks, and it also sounds like a lot of food addicts, who tend to have comorbidities that include alcoholism and drug dependency. In fact let’s return to Dr. Gitlow for a final quotation:

Now it’s up to us to remember that addictive illness is still addictive illness; it remains unchanged despite the arrival of DSM-5.

Your responses and feedback are welcome!

Source: “Pathological gambling: a neurobiological and clinical update
bjp.rcpsych.org, 2011
Source: “Commentary: DSM-5: New Addiction Terminology, Same Disease
Drugfree.org, 06/07/14

Image by Next TwentyEight

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