Behavior and Substance Addictions: Is the World Ready for a New Category in the DSM-V?

We read with interest the letter to the editor by Block that identifies some interesting points of discussion in the context of the article by Aboujaoude and colleagues. Block describes the distinction between various terms such as "problematic Internet use? "compulsive computer use" and "computer addiction" rather meticulously and, to conclude, uses the phrase "potential disorder'' Our objection is to the use of the phrase "potential disorder." There has been much discussion about the addition of a new diagnostic category in the forthcoming Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition for behaviors that are considered to be at the interface of obsessive-compulsive disorder, on the one hand, and substance addiction, on the other. In fact, the November 2006, CNS Spectrums Editor's Letter is dedicated to characterizing the neurobiological correlates and similarities in terms of fronto-striatal circuit Impairments. Having received our medical education and some clinical experience in India, we would like to point out that all these proposed categories (Internet addiction, compulsive buying, etc.) have a socioeconomic aspect to them that is getting somewhat lost in the rut of finding neurobiological underpinnings for all psychiatric disorders. If these were to become diagnostic categories what would be their equivalents in the countries of Asia and Africa where thousands die of poverty and hunger everyday? Most of the reported studies are from the United States. Should there not be some international studies across various socioeconomic-cultural backgrounds before new diagnostic categories are created in the DSM-V? It becomes all the more important, since the DSM is a diagnostic system that is followed rather universally across the globe along with International Classification of Diseases. This is not to undermine the need for clinical attention for these problematic behaviors, but just to highlight that if they were to figure in DSM-V it may be a good idea to identify these as problem behaviors identified predominantly in the US population, somewhat similar to the section on culture bound syndromes. In our opinion, for a behavior to be considered a disorder it should have universal features across different ethnic, socioeconomic-cultural backgrounds so that clinicians can communicate across the globe without much confusion. In this day of evidence-based medicine, this would only be possible if there would be large-scale international epidemiological studies to support these as diagnostic categories.