DSM-5 and the A-Word

Doctor and Nurse Bears

Childhood Obesity News discussed how DSM-5, the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, backed off from using the word “addiction” and went to “substance use disorder” and “substance induced disorder.” The A-word appears in conjunction with gambling, “the only addictive disorder included in DSM-5 as a diagnosable condition.” Gambling disorder is in fact the lone member of the behavioral addiction category. The DSM’s “Substance-Related and Addictive Disorders” chapter says:

This new term and its location in the new manual reflect research findings that gambling disorder is similar to substance-related disorders in clinical expression, brain origin, comorbidity, physiology, and treatment.

But wait. Pathological overeating really is similar to substance-related disorders in clinical expression. It is similar in brain origin, and similar in how it ushers in co-morbidities. There are physiological similarities, and the most successful treatment modality is notably similar. Among alcoholics, hard drug addicts, and the obese, what works best is a 12-step program.

Unhealthy dependency on food and eating is a double whammy, because it involves both a behavioral component and a substance component. It sure sounds like a behavioral addiction.

More Resemblance

We mentioned previously how the DSM is not the only “bible” used to define and categorize certain psychological problems. WHO publishes the widely-used International Classification of Diseases, and the American Society of Addiction Medicine also publishes a guidebook. The RogersHospital.org website notes that according to both the ASAM manual and the DSM, gambling addiction is best understood as part of a spectrum of similar addictive disorders. Dr. Michael Miller explains:

The new ASAM criteria really focus on the treatment aspect of addiction, rather than making a diagnosis and trying to segment a diagnosis into a level of care….This change within the DSM reflects increasing evidence that some behaviors – like gambling – can activate the brain reward system with effects that are similar to those of drug use.

As we mentioned, one of the most exciting developments in the theory of food addiction was the discovery of its similarity to substance-related disorders like cocaine addiction. Also, the ASAM says that addiction is a “chronic disease of brain reward, motivation, memory and related circuitry.” The definition continues:

Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors.

Dare we suggest that food might be one of those substances, and compulsive overeating might be one of those behaviors? The ASAM definition of addiction also speaks of the inability to consistently abstain, or to control one’s behavior, or to recognize how life problems are exacerbated by attachment to the substance or behavior. And a dysfunctional emotional response. And cravings. And cycles of relapse and remission. The nature of addiction is to be progressive, and to result in disability or early death.

Every one of those traits can be found in people whose relationship with food has gone off the rails. Why isn’t this recognized appropriately by DSM-5?

Your responses and feedback are welcome!

Source: “Substance-Related and Addictive Disorders,” DSM5.org, 2013
Source: “DSM-5 Now Categorizes Substance Use Disorders in a Single Continuum,” RogersHospital.org, 02/24/14
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About Dr. Robert A. Pretlow

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.
You can contact Dr. Pretlow at:


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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