Defining and categorizing disordered gambling will be one of the featured topics at the 11th annual NCRG Conference on Gambling and Addiction this November. In a presentation titled “Conceptualizing Problem Gambling: Cautionary Lessons from the Over-Pathologization of Depression and Substance Use,” Jerome C. Wakefield, DSW, PhD , a professor at New York University School of Medicine, will critique what he sees as psychiatry’s failure to draw adequate distinctions between disordered behavior, eccentric or unconventional behavior, and normal responses to stress (Wakefield, 2010).
Dr. Wakefield’s presentation will be a counterpoint to a preceding conference session focused on the proposed changes to pathological gambling in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) (American Psychiatric Association, 2010). The DSM is the handbook of mental disorders in the United States, used daily by health care providers, researchers, insurance companies and government agencies.
Dr. Wakefield’s criticism of the DSM centers on its use of symptom-based definitions for mental disorders. That is, the fact that individuals are diagnosed with the disorder if they exhibit a certain number of symptoms. For example, the DSM-IV indicates that individuals who have at least five out of 10 symptoms for pathological gambling, such as a preoccupation with gambling or being unable to cut back on gambling, are regarded as having a pathological gambling disorder (American Psychiatric Association, 1994). According to Dr. Wakefield, symptom-based definitions tend to cause “false positives,” categorizing people as disordered when their behavior is better explained by something else.
One of the factors that may not be considered by symptom-based definitions is context. For example, a person who has experienced the death of a loved one may exhibit all of the symptoms of major depression, but is actually just exhibiting a normal response to loss. (Of note, the DSM includes a caveat for symptoms experienced during bereavement in its definition of major depression; however, Dr. Wakefield’s point about context can be applied to other potential causes for depressive symptoms and other disorders listed in the DSM.)
Dr. Wakefield also argues that symptom-based definitions of mental disorders do not leave room for natural human variation. For example, if a person mourns the loss of a spouse for a full year, it could be a sign of a depressive disorder, or just natural variation in the time spent grieving. Dr. Wakefield states that symptom-based definitions are not equipped to deal with these variations, and individuals on the ends of any spectrum should not necessarily be classified as disordered just because they exhibit behaviors outside of more typical behavioral ranges.
Dr. Wakefield contends that clinical definitions based solely on symptoms cast too wide a net, diagnosing people with mental disorders when a consideration of context or natural human variation would better explain the behavior. This can be potentially harmful to people diagnosed with a mental disorder that carries a severe stigma and can lead to the unwarranted use of psychiatric medication.
Dr. Wakefield will apply this critique specifically to pathological gambling at the 2010 NCRG Conference on Gambling and Addiction, taking place on Nov. 14-16, 2010, at the Mandalay Bay Resort & Casino and the Las Vegas Convention Center in Nevada. Dr. Wakefield’s Monday talk sets the stage for a lively debate in the town hall meeting later that day. For details, download the NCRG Conference 2010 Brochure. To register for the conference, visit the Conference link on the NCRG website.
References
American Psychiatric Association. (2010, March 31). DSM-V: The Future of Psychiatric Diagnosis. Retrieved from www.dsm5.org
American Psychiatric Association. (1994). DSM-IV: Diagnostic and Statistical Manual of Mental Disorders. Washington, DC: American Psychiatric Association.
Wakefield, J. C. (2010). Misdiagnosing normality: Psychiatry's failure to address the problem of false positive diagnoses of mental disorder in a changing professional environment. Journal of Mental Health, 19(4), 337-351. doi:10.3109/09638237.2010.492418
