Compulsive reading: Stars with addictions,to Star Wars

‘Tiger Woods enjoys sex with many women’ or ‘Tiger Woods is battling sex addiction’. Which version is more accurate? David Duchovny, Michael Douglas and Charlie Sheen have also reportedly been in recovery for sex addiction. Numerous clinics advertise treatment for addiction to sex, love, gambling, shopping, the Internet, work and food. Are these ‘real’ mental disorders, or does describing these behaviours as psychiatric conditions simply add to community scepticism about psychiatry?

Several papers in this August issue of the Australian and New Zealand Journal of Psychiatry (ANZJP) struggle with the definition and classification of repetitive and problematic behaviours. Gambling is the only one found in both Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) and Diagnostic and Statistical Manual of Mental Disorders 5 (DSM-5). As Starcevic (this issue) notes, in DSM-IV gambling was grouped with the Impulse-Control Disorders. In DSM-5, gambling has been moved into the Substance-Related and Addictive Disorders, where it is the sole entry in the category of Non-Substance-Related Disorders. Internet Gaming Disorder is listed as a Condition for Further Study, and like gambling has criteria that reference addictions, such as tolerance and withdrawal. Starcevic (this issue) notes that, in contrast to DSM-5, International Statistical Classification of Diseases and Related Health Problems 11 (ICD-11) will most likely place pathological gambling in the Impulse-Control Disorders category. Unlike DSM-5, ICD-11 may include ‘sex addiction’ or ‘hypersexual disorder’, and this will also belong with the Impulse-Control Disorders.

Does the DSM-5 classification of repetitive and problematic behaviours as addictions actually make sense? Starcevic (this issue) provides a thoughtful account of attempts to fit these behaviours into the current diagnostic systems. He also highlights the embarrassing proliferation of behavioural addictions, noting that they are being given quasi-scientific status, with the risk of drastic lowering of the diagnostic threshold and spurious epidemics. He describes difficulties with applying an addictions framework and talks about the importance of understanding the purpose of these behaviours for the individual. Negative life situations, unmet needs and distressing emotions can contribute, along with impulsivity and compulsivity. Instead of assuming a person is addicted, and needs help with tolerance, craving and withdrawal, it might be more helpful to understand the reasons why this person is over-using this behaviour at this time.

Stein (this issue) considers that Starcevic may have been a little harsh in describing the classification of repetitive and problematic behaviours as characterised by ‘ongoing uncertainty, arbitrariness and ambivalence’. He takes a more optimistic view, arguing that a 21st-century clinician is well placed to undertake a comprehensive evaluation and develop an appropriate treatment plan for a patient with these behaviours. Stein also questions whether psychiatric classification is itself merely a repetitive and problematic behaviour (nosologomania), driven by academic narcissism or hypomanic energy.

Sellman (this edition) also has concerns about the classification of repetitive and problematic behaviours. He proposes adding a new domain, Behavioural Health Disorders, to the diagnostic classification systems. Substance and Behavioural Addictions would be diagnostic categories within this new domain.

Eapen (this issue) is also concerned with classifying and defining the boundaries of psychiatric disorders. She advocates better screening for autism spectrum disorder (ASD). She comments that the current classification system creates arbitrary divisions between clinical syndromes that do not map neatly onto the underlying pathogenetic processes. In addition, rigid application of diagnostic criteria may create barriers to accessing services; children with developmental problems who would benefit from early intervention may be excluded from services because they do not meet a diagnostic threshold.

Yang et al. (this issue) attempt to explore the underlying biological abnormalities in ASD, reporting a meta-analysis of studies of brain structure in adults with ASD. They observe that most studies involve children and adolescents, but there are 12 studies comparing the whole brains of adults with ASD and healthy controls. Interestingly, they report increased grey matter volume in ASD, mainly in the temporal and parahippocampal regions, along with a positive association between parahippocampal volume and IQ. They found decreased grey matter volume in the anterior cingulate cortex and cerebellum.

Manicavasagar and Silove (this issue) look at the grown-up version of another disorder more commonly associated with childhood. They ask why Adult Separation Anxiety Disorder tends to be missed in clinical practice. However, Adult Separation Anxiety Disorder is a new diagnosis in DSM-5. In Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR), a diagnosis of Separation Anxiety Disorder could only be made if the onset occurred before the age of 18 years. In DSM-5, the duration criteria for Separation Anxiety Disorder are at least 4 weeks for children and adolescents, and typically 6 months or more for adults.

The mental health of young people, and the best ways to provide youth services, have been the subject of ongoing political and community concern. Devenish et al. (this issue) look at psychosocial interventions to reduce suicidality in young people. The conclusions are disappointing, mainly because of a lack of studies with no-treatment control groups. Some preventive interventions are described as ‘promising’, but there is insufficient evidence to draw conclusions or make recommendations. The increased risk of first episode psychosis in young people who have experienced childhood adversities is well known (Varese et al., 2012). Trauelsen et al. (this issue) found that childhood adversity predicted poorer global functioning in the year prior to treatment. Not surprisingly those who had experienced childhood adversity reported less support during childhood and less current contact with family.

As described above, an enormous amount of time and energy has been consumed by the task of trying to classify psychiatric disorders – with the triple peaks of DSM, ICD and Research Domain Criteria (RDoC) dominating the landscape (Carroll, 2014; Goldberg, 2014; McGuffin and Farmer, 2014). One goal has been to develop a classification system informed by the underlying biology. Despite massive research effort including the human genome project, genome-wide association studies on large population samples, and imaging techniques such as structural and functional magnetic resonance imaging (MRI) and diffusion tensor imaging, a biologically based classification system has not yet been achieved. Research into the specific abnormalities associated with the different psychiatric disorders continues. In the August ANZJP, Guo et al. (this issue) investigate functional connectivity in drug-naïve people with major depressive disorder, Bassett et al. (this issue) report on heart rate variability in remitted bipolar disorder and recurrent depression and Phillipou et al. (this issue) describe disturbances of saccadic eye movements in anorexia nervosa.

If DSM-5 included mathematical complexity addiction disorder, Hadaeghi et al. (this issue) might meet the criteria. Their study is a collaboration between the Biomedical Engineering Faculty at Amirkabir University of Technology, Tehran, Iran, and the Department of Psychological Sciences, Swinburne University of Technology, in Melbourne, Australia. They present a mathematical model, informed by chaos theory, of circadian rhythms in bipolar disorder.

Bastiampillai et al. (this issue) continue the bipolar disorder theme, but from a clinical perspective. They propose that clozapine should be available for people with treatment-resistant bipolar disorder. Clozapine is not approved by the Pharmaceutical Benefits Scheme for this indication, so either the individual patient (or their family) or the Mental Health Service need to pay for the drug and the regular blood tests. Patra (this issue) also offers some clinical suggestions for treating bipolar disorder.

Finally, we move on to conversation, music and movies. Jules Angst was born in 1926, and trained under Manfred Bleuler. He talks about his life’s work, the enjoyment he has derived from research, and the future of psychiatry. Asked about one really important but soluble question in psychiatry, his answer is ‘combating stigma’. Coincidentally, this edition of the journal includes an article about how health professionals behave towards people with mental health problems (Morgan et al., this issue). Almost 12% of respondent with mental health problems reported discrimination, presumably reflecting stigma on the part of the health worker. Morgan et al. (this issue) believe that anti-stigma education for health professionals would improve this situation. From a glass half-full perspective, 40.4% reported being treated more positively by their health professional because of their mental health problem.

Suetani (this issue) talks about DSM-5 as the science of psychiatry, and makes an eloquent plea for more awareness of the music of psychiatry. While Suetani was listening out for the music, Anand (this issue) went to the movies, and he shares his musings on the latest Star Wars episode, The Force Awakens. He highlights the rather black and white nature of the characters. In contrast, a recently released movie of the famous Stanford Experiment, undertaken by Philip Zimbardo in 1971, is a compelling account of how rapidly people can change over time – perhaps this might be a good reality check after Star Wars.

Much of this issue of the Journal concerns matters of classification, and research investigations within defined diagnostic groups. A solid diagnostic system and high-quality research are essential to understanding the nature of psychiatric disorders and gathering evidence about what interventions are helpful. However, as Starcevic (this issue) observes, we need to take care that in lumping people together into diagnostic groups, we do not lose sight of the individual.

William James (physician, psychologist and philosopher) wrote (James, 1902),

The first thing the intellect does with an object is to class it along with something else. But any object that is infinitely important to us and awakens our devotion feels to us also as if it must be sui generis and unique. Probably a crab would be filled with a sense of personal outrage if it could hear us class it without ado or apology as a crustacean, and thus dispose of it. ‘I am no such thing,’ it would say; ‘I am MYSELF, MYSELF alone’.