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DSM-5 Update: Highlights from a Critical Review by Howard J. Shaffer and Ryan Martin

by: Institute Staff | May 3, 2011

The American Psychiatric Association (APA) has proposed new criteria for a diagnosis of pathological gambling (PG) in the next edition of the Diagnostic and Statistical Manual of Mental Disorders, slated for publication in 2013.  As reported in Issues and Insights and discussed at the 2010 NCRG Conference on Gambling and Addiction, the proposed revisions included moving PG from the impulse control category into a new classification, “addiction and related disorders.” It also proposes dropping illegal acts from the 10 criteria and possibly reducing the number of criteria needed for a diagnosis from five to four. A new review article by Howard J. Shaffer and Ryan Martin in the 2011 Annual Review of Clinical Psychology (Shaffer & Martin, 2011) provides a critical review of these recommendations.

Currently, the DSM-IV-TR defines PG as a “… persistent and recurrent maladaptive gambling behavior … that disrupts personal, family or vocational pursuits” (American Psychiatric Association, 2000, p. 671).

Individuals who concurrently experience five or more of the following 10 criteria meet the diagnostic threshold for PG (American Psychiatric Association, 2000):

1.   Preoccupation with gambling
2.   Needing to gamble with increasing amounts of money in order to achieve the desired excitement
3.   Repeated unsuccessful efforts to control, cut back, or stop gambling
4.   Restless or irritable when attempting to cut down or stop gambling
5.   Gambling as a way of escaping from problems
6.   After losing money gambling, often returning another day to get even (“chasing” one’s losses)
7.   Lying to family members, a therapist, or others to conceal the extent of involvement with gambling
8.   Committing illegal acts such as forgery, fraud, theft, or embezzlement to finance gambling
9.   Jeopardizing or losing a significant relationship, job, or educational or career opportunity because of gambling
10. Relying on others to provide money to relieve a desperate financial situation caused by gambling

In their review, Shaffer and Martin point out that the rationale for eliminating “committing illegal acts” as a symptom for the diagnosis could be used to eliminate other criteria as well. The DSM-5 Task Force argued that research has shown that this criterion has little to no effect on the prevalence of the disorder or diagnosis in the aggregate. However, Shaffer and Martin point out that the criterion of “jeopardizing relationships, work, or education” appears only at high severity levels of PG, and that preoccupation and chasing losses have such high prevalence among both non-PGs and PGs that these criteria alone have little diagnostic value under the current system (Shaffer & Martin, 2011).

The effect of eliminating illegal acts, they argue, will serve to only reduce the diversity of people who meet diagnostic criteria for PG. Lowering the threshold from five out of 10 symptoms to four out of nine symptoms will have a similar effect of reducing diversity because of the fewer number of combinations that can occur with diagnostic criteria (Shaffer & Martin, 2011).

Shaffer and Martin agree with the DSM-5 task force that there is a large body of evidence for the commonalities between PG and substance use disorders. This evidence provides the rationale for the task force’s recommendation to move PG into the new category of addiction and related disorders. Although the task force concluded that there was insufficient empirical evidence to warrant including behavioral disorders other than PG at this time, the creation of such a classification leaves the door open for Internet addiction and other non-substance-based disorders. Shaffer and Martin foresee a potential problem in the DSM ending up with a laundry list of behavioral disorders defined by their objects; e.g., gambling, the Internet, and sex to name several. In their view, such a list only reinforces the incorrect belief that things are addictive.

To avoid this problem, Shaffer and Martin propose the addiction as syndrome model as an organizing principle (Shaffer, LaPlante, et al., 2004). The syndrome model “postulates that there are shared neurobiological, psychological, and social risk factors that influence the development and maintenance of different manifestations of addiction. These risk factors are similar for both substance-based (e.g., cocaine dependency) and activity-based (e.g., disordered gambling) expressions of addiction” (Shaffer & Martin, 2011, p. 488). The authors maintain that conceptualizing “addiction this way avoids the incorrect view that the object causes the addiction and shifts the diagnostic focus toward patient needs” (Shaffer & Martin, p. 496).

These proposed changes to the DSM-5 will have a significant impact on researchers and treatment professionals alike. What do you think of the DSM-5 recommendations? Share your comments below.

References

American Psychiatric Association. (2000). Diagnostic and Statistical Manual of Mental Disorders., Fourth Edition, Text Revision. Washington, DC: American Psychiatric Association.

American Psychiatric Association (2010). 312.31 Pathological gambling. In Proposed Draft Revisions to DSM Disorders and Criteria. Arlington, VA: American Psychiatric Association.

Shaffer, H. J., LaPlante, D. A., LaBrie, R. A., Kidman, R. C., Donato, A. N., & Stanton, M. V. (2004). Toward a syndrome model of addiction: Multiple expressions, common etiology. Harvard Review of Psychiatry, 12, 367-374.

Shaffer, H. J., & Martin, R. (2011). Disordered gambling: etiology, trajectory, and clinical considerations. Annual Review of Clinical Psychology, 7, 483-510.

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