DSM-5 Shies Away from Addiction

5798335_sAccording to DSM-5, the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, food is not something over which a person can develop a substance use disorder. The recognized disorder-causing substances are alcohol, caffeine, cannabis, hallucinogens, inhalants, opiods, sedatives, hypnotics, anxiolytics, stimulants, and tobacco.

This is straight from the horse’s mouth – a factsheet from American Psychiatric Publishing:

Each specific substance… is addressed as a separate use disorder (e.g., alcohol use disorder, stimulant use disorder, etc.), but nearly all substances are diagnosed based on the same overarching criteria….The revised substance use disorder, a single diagnosis, will better match the symptoms that patients experience.

Those lines contain two key phrases to keep in mind – “same overarching criteria” and “will better match the symptoms that patients experience,” and we will get back to them. But first, the picture becomes more complicated. DSM-5’s “Substance-Related and Addictive Disorders” category is sub-divided.


A substance use disorder is characterized by the “negative consequences of continued and frequent use.” These are not immediate consequences, but ones that occur over time as addiction takes hold. (That being so, couldn’t overeating be considered a substance use disorder? The consequences build and multiply over time – with the continuous gain of weight and the increasing risk of developing an obesity-related morbidity.)

Then, there are substance induced disorders, characterized by the immediate effect of intoxication. If a person discontinues use of the substance, he or she experiences an immediate effect called withdrawal. (Can’t food be intoxicating? Feed a child a bunch of sugar and find out. When adults spend small fortunes at upscale restaurants, it isn’t just the wine getting them high.)

Intoxication is a temporary condition, about which it is useful to remember that the root word, toxic, means poisonous. If the central nervous system is affected, and there is a behavioral and/or psychological impact – but the effect is reversible after the substance has been processed through the body – that’s intoxication. (But wait – food can cause it. Also, abstinence from problem foods can cause withdrawal symptoms.)

Parallels Between Big Food and Big Tobacco

Now, here is a puzzling quotation from this article by Dr. Tom Horvath et al:

Substance intoxication applies to all classes of drugs except tobacco.

Really?  According to other sources, nicotine intoxication is definitely “a thing.” Why are so many humans hooked on it? Of course it is psychoactive. Many hundreds of people contributed to the making of this latest DSM, and it contains important information. But the tobacco section seems to show a certain bias.

Just to make sure there was no misunderstanding, another source was consulted. In a presentation created for doctors, to capsulize the new edition’s changes for them, there it is in Slide #9, “Substance intoxication does not apply to tobacco.” How did this happen? Since it did, may we expect DSM-6 to make a similar statement about food and overeating, excusing them from all culpability in the obesity epidemic?

When a child or adult eats for emotional comfort, part of the impact is psychological (intoxicating) – or else why do it? The whole purpose of comfort eating is to change the mental and emotional state – in other words, it is psychoactive. This descriptive article also says,

Substance withdrawal is diagnosed based upon the behavioral, physical, and cognitive symptoms that occur due to the abrupt reduction or cessation of substance use.

The severity of the patient’s withdrawal experience varies, depending on the specific substance and other factors. And yet the authors also note that, with some drugs, their use followed by discontinuation does not result in withdrawal. Accordingly, some things can be intoxicating and psychoactive, and even potentially addictive, without causing withdrawal pain. But then there is food, which, even though many people have shown definite indications of withdrawal, is not considered a candidate for addictiveness.

Consider the experiences people have with alcohol, caffeine, cannabis, hallucinogens, inhalants, opiods, sedatives, hypnotics, anxiolytics, stimulants, and tobacco – and the reactions that some patients have to food. Now, remember those two phrases – “same overarching criteria” and “will better match the symptoms that patients experience.” Yet food is not considered an addictive substance, and overeating is not seen as a behavioral addiction. Are we confused yet?

Your responses and feedback are welcome!

Source: “Substance-Related and Addictive Disorders,” DSM5.org, 2013
Source: “The Diagnostic Criteria of Substance-Induced Disorders
SevenCounties.org, undated
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Dr. Robert A. Pretlow is a pediatrician and childhood obesity specialist. He has been researching and spreading awareness on the childhood obesity epidemic in the US for more than a decade.
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Dr. Pretlow’s invited presentation at the American Society of Animal Science 2020 Conference
What’s Causing Obesity in Companion Animals and What Can We Do About It

Dr. Pretlow’s invited presentation at the World Obesity Federation 2019 Conference:
Food/Eating Addiction and the Displacement Mechanism

Dr. Pretlow’s Multi-Center Clinical Trial Kick-off Speech 2018:
Obesity: Tackling the Root Cause

Dr. Pretlow’s 2017 Workshop on
Treatment of Obesity Using the Addiction Model

Dr. Pretlow’s invited presentation for
TEC and UNC 2016

Dr. Pretlow’s invited presentation at the 2015 Obesity Summit in London, UK.

Dr. Pretlow’s invited keynote at the 2014 European Childhood Obesity Group Congress in Salzburg, Austria.

Dr. Pretlow’s presentation at the 2013 European Congress on Obesity in Liverpool, UK.

Dr. Pretlow’s presentation at the 2011 International Conference on Childhood Obesity in Lisbon, Portugal.

Dr. Pretlow’s presentation at the 2010 Uniting Against Childhood Obesity Conference in Houston, TX.

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