British Journal of Addiction (1990) 85, 1403-1408

COMMENTARY

Addiction: definition and implications

AVIEL GOODMAN, M.D.

Minnesota Institute of Psychiatry, 1347 Summit Avenue, St Paul, MN 55105, USA

Abstract
Integration of addiction into the theory and practice ofpsychiatry has been hampered by the lack of a definition
of addiction which is scientifically useful. A definition is proposed, with diagnostic criteria specified in a format
similar to that ofDSM-III-R. Essentially, addiction designates a process whereby a behavior, that can function
both to produce pleasure and to provide escape from internal discomfort, is employed in a pattern characterized
by (1) recurrent failure to control the behaviour (powerlessness) and (2) continuation ofthe behaviour despite
significant negative consequences (unmanageability). Some practical and theoretical implications of this
definition are then explored.

Introduction tion that is not already conveyed by a term or

The prevalence of alcohol dependence is estimated at concept already accepted in the field. In the DSM-
13%,' and that of dependence on other psychoactive III-R, the word 'addiction' appears only once, in an
substances is probably around 5-7%. Pathological example of Sexual Disorder Not Otherwise Speci-
gambling has an estimated prevalence of 2-3%, and fied, and it is not defined at all.
there are other behavioral syndromes not specifically Meanwhile, the past 30 years have witnessed the
identified in The Diagnostic and Statistical Manual of development of a new field, with various definitions
Mental Disorders^ (DSM-III-R) that have a promi- and manifestations, the central concern of which is
nent addictive component. It is clear that this group addiction. Originating and evolving largely outside
of disorders with addictive features affects a large of the mental health establishment, addictionology
segment of our population. Unfortunately, psychia- and the related '12-step' programs have fostered
trists and psychologists have had less to do with these significant changes in the lives of many, and
disorders than with other mental/behavioral dis- virtually constitute a major cultural movement. The
orders, in terms of both theory and therapy. traditional distruct, lack of communication, and lack
The concept of addiction has been criticized both of cooperation between the psychiatry/psychology
within and outside the mental health disciplines on a systems and the addictionology/12-step system
number of grounds: often it is used without an have seriously impeded the development of more
attempt to define it; many proposed definitions are comprehensive, effective approaches to the under-
vague or imprecise, some being so all-inclusive as to standing and treatment of addictive disorders and
leave the term devoid of pragmatic value; it has those who experience them. It is with the intention
moralistic connotations which are inappropriate to of providing a basis for the integration of these
scientific inquiry; it represents a way of understand- systems that this paper proceeds. The fulcrum of
ing people, behaviour and the mind that is incompa- this integration is a definition of addiction which is
tible with a scientific approach; it adds no informa- scientifically useful.

1403
1404 A. Goodman

Definition of addiction (2) frequent engaging in the behavior to a

A term, or the concept which it represents, may be greater extent or over a longer period than
said to have scientific utility when it meets the intended
following criteria: it has a definition which can be (3) repeated efforts to reduce, control or stop
specified by reference to terms or concepts generally the behavior
accepted as valid within a given scientific discipline; (4) a great deal of time spent in activities
and it designates information (or a level of informa- necessary for the behavior, engaging in the
tion) that is not already represented in that disci- behavior or recovering from its effects
pline by some other term or concept. A new term is (5) frequent engaging in the behavior when
useful in science to the extent that it is both expected to fulfill occupational, academic,
meaningful and non-redundant. domestic or social obligations
The purpose of this paper is to propose a (6) important social, occupational or recrea-
definition of addiction that is both meaningful and tional activities given up or reduced be-
non-redundant, that is clearly grounded in the cause of the behavior
conceptual network of scientific psychiatry and is (7) continuation of the behavior despite
more than merely synonymous with some other knowledge of having a persistent or recur-
psychiatric term. rent social, financial, psychological or
physical problem that is caused or exacer-
bated by the behavior
Diagnostic criteria for Addictive Disorder (8) tolerance: need to increase the intensity or
The DSM-III-R will serve as a guide for organizing frequency of the behavior in order to
the components of this definition of addiction. It achieve the desired effect or diminished
may be expected that a definition which represents effect with continued behavior of the same
an extension of the currently accepted classification intensity
schema is more likely to be accepted than one which (9) restlessness or irritability if unable to
represents a departure from it. The intention is to engage in the behavior
formulate in general terms (not restricted by (F) Some symptoms of the disturbance have per-
reference to a particular behaviour) a set of sisted for at least 1 month, or have occurred
diagnostic criteria for the heirarchically superordi- repeatedly over a longer period of time.
nate category. Addictive Disorder, which will sub-
sume the individual addictive disorders (specified Less formally, addiction may be defined as a process
according to the behavior that is addictively mani- whereby a behavior, that can function both to
fested). This set of criteria will then also constitute produce pleasure and to provide relief from internal
a touchstone for determining whether a given discomfort, is employed in a pattern characterized
behavioral syndrome is an addictive disorder (i.e. an by (1) recurrent failure to control the behavior
addiction). (powerlessness) and (2) continuation of the beha-
vior despite significant negative consequences (un-
The following is the proposed set of diagnostic manageability). This informal definition is compar-
criteria for Addictive Disorder, presented in a able to the initial statement in DSM-III-R regarding
format similar to DSM-III-R: Psychoactive Substance Dependence: "The essen-
tial feature of this disorder is a cluster of cognitive,
Addictive Disorder (or Addiction)
behavioral, and physiologic symptoms that indicate
(A) Recurrent failure to resist impulses to engage
that the person has impaired control of psychoactive
in a specified behavior.
substance use and continues use of the substance
(B) Increasing sense of tension immediately prior
despite adverse consequences."^
to initiating the behavior.
(C) Pleasure or relief at the time of engaging in the
behavior.
(D) A feeling of lack of control while engaging in Comparison with DSM-III-R disorders
the behavior. It is instructive to explore the relationship between
(E) At least five of the following: the proposed diagnostic criteria for Addictive Dis-
(1) frequent preoccupation with the behavior order and the diagnostic criteria for disorders listed
or with activity that is preparatory to the in DSM-III-R which have prominent addictive
behavior features. The DSM-III-R disorders most commonly
 Addiction: definitions and implications 1405

identified as addictive disorders are Psychoactive than those of the DSM-III-R disorders most
Substance Dependence and Pathological Gambling. commonly identified as addictive disorders, provid-
As the sets of criteria for these disorders (see ing prophylaxis against criticism that the definition
Appendix) are compared to the set of criteria for of addiction is too loose or all-inclusive. It is not
Addictive Disorder, it is evident that the latter unlikely that further modifications will be required
essentially includes both of the former (described in in the organization of the criteria (i.e. which of the
behaviorally non-specific terms), yet is more re- items should be on the mandatory list and which on
strictive (less all-inclusive) than either of them. the menu list [section E], and what should be the
Section B of the Psychoactive Substance Depen- minimum number of menu list criteria that must be
dence criteria list is identical to Section F of the met) and in the wording of the criteria (e.g. omitting
Addictive Disorder list. The first seven items of 'immediately' from criterion B). These issues re-
Substance Dependence Section A each correspond main to be determined empirically.
to an item of Addictive Disorder Section E: (1) of
Substance Dependence Section A corresponds to
(2) of Addictive Disorder Section E, (2) to (3), (3) Comparison with other terms
to (4), (4) to (5), (5) to (6), (6) to (7) and (7) to The second objective noted earlier related to the
(8). While only three of these seven criteria from need for a new scientific term or concept to be non-
Section A (about 43%) need be met for Substance redundant: for addiction to be more than merely
Dependence, five of nine from Section E (about synonymous with some other psychiatric term, to
56%) must be met for Addictive Disorder. (The designate a concept with informational content
remaining two Substance Dependence criteria, con- different from that of any concept designated by
cerning withdrawal symptoms, may not apply for some other psychiatric term. The terms that have
some psychoactive substances, and do not need to be been used most frequently to denote a disorder
met if three of the first seven criteria are met.) The referred to here as an addictive disorder or an
set of criteria for Addictive Disorder also includes addiction are dependence (or dependency, as in
four mandatory items, A-D, which are absent from 'Chemical Dependency') and compulsion (or com-
the Substance Dependence list. Although the Addic- pulsive disorder, as in 'Compulsive Gambling' or
tive Disorder criteria are hence more restrictive, it is 'Compulsive Overeating'). While the concepts of
difficult to imagine a case of Substance Dependence dependence and compulsion merit more attention
that would not also meet the criteria for Addictive than will be devoted to them here; for the purpose of
Disorder. this discussion, it is sufficient to observe that
Of the list of criteria for Pathological Gambling, addiction equals dependence plus compulsion. De-
all but item (5) correspond to some item of pendence involves an attempt to achieve a pleasura-
Addictive Disorder Section E: (1) of Pathological ble internal state via gratification of needs, basic or
Gambling corresponds to (1) of Addictive Dis- derived. In the terminology of learning and behav-
order, (2) to (2), (3) to (8), (4) to (9), (6) to (3), iour theory, the process by which dependence
(7) to (5), (8) to (6) and (9) to (7). Again, the gratification motivates behavior would be described
Addictive Disorder criteria are more restrictive, as positive reinforcement. Compulsion involves an
requiring the four mandatory items and five of nine attempt to evade or avoid an unpleasurable/aversive
items from Section E (56%), compared to four of internal state (e.g. anxiety, grief, guilt, shame, rage).
nine (44%) 'menu' items and no mandatory items This corresponds to a negative reinforcement para-
for Pathological Gambling. Yet it would similarly digm. Among the distinguishing features of addic-
be difficult to imagine a case of Pathological tive disorders is this combination of gratification
Gambling that would not also meet the criteria for and escape from internal discomfort (as implied by
Addictive Disorder. items C, B and E(9) in the diagnostic criteria list).
Hence, the concept of addiction represents a
This provisional list of diagnostic criteria for synthesis of dependence and compulsion. While all
Addictive Disorder accomplishes the first of the addictions involve both dependence and compul-
objectives delineated above. It proposes a definition sion; there are dependences and compulsions that
of addiction that is specific, meaningful, grounded are not addictions. The term addiction is thus more
in the conceptual network of scientific psychiatry than merely synonymous with dependence or com-
and presented in a format similar to that in which pulsion, and contains information which neither of
other psychiatric disorders are described. It is these terms alone provides.
significant that this list of criteria is more restrictive
1406 A. Goodman

Implications the individual's life, as specified according to the

A new scientific term or concept is preferably not diagnostic criteria.
only meaningful and non-redundant, but also of Continuing in this theoretical vein, it may be
some practical value. The concept of addiction, as noted that what is being proposed here is not only a
described above, entails theoretical issues which formalized definition of addiction, but also a modifi-
may have practical implications of considerable cation in the way some psychiatric disorders are
significance. Some of these will be briefly surveyed. conceptually organised. A new category of psychia-
tric disorders—Addictive Disorders—is being sug-
gested, which will subsume Psychoactive Substance
Treatment Use Disorders and will include most of the Impulse
At a fairly concrete level, the statement that addiction Control Disorders, some Eating Disorders, and a
equals dependence plus compulsion, that it entails number of other behavioral syndromes which meet
both positive and negative reinforcement, may help the criteria described above but are not represented
explain the tenacity of addictions and the resistance of in the current diagnostic nomenclature.
addictive behavior to modification. An understanding The implications of this proposed shift in concep-
of addictive disorders based on this principle has tual organization extend beyond the logical struc-
important connotations for treatment, in that optimal ture of psychiatry's diagnostic classification system.
treatment would require that both positive and A hypothesis may be submitted, the gist of which is
negative reinforcement processes be addressed. It that similar patterns in behavioral manifestations of
would be necessary to treat the internal discomforts the various addictive disorders (as indicated by the
from which the addictive behavior had provided fact that they all meet the same set of general
escape, by means of phannacotherapy (antidepres- diagnostic criteria) reflect similarities in some set of
sants, lithium, more rarely antipsychotics oranxiolyt- personality and/or biological variables, which may
ics) or psychotherapy (resolution ofinternal conflicts, or may not be measurable by instruments currently
enhanced ego integration associated with improve- available. In other words, addictive disorders would
ment in affect regulation, and so on) or some be more accurately described, not as a variety of
combination. It would also be necessary to foster the addictions, but as a basic underlying addictive
individual's development of healthier, more adaptive process, which may be expressed in one or more of
means for meeting the needs which the addictive various behavioral manifestations. An important
behavior had served to gratify (12-step groups and preliminary step in the investigation of such a
other supportive or therapeutic groups may be hypothesis would entail statistical analysis of
particularly valuable in this regard). A further whether two or more addictive disorders tend to
corollary is that treatments which do not address these occur in the same individual with a frequency
processes, including punishment and aversive condi- greater than would be predicted were they not
tioning, are unlikely to be very effective. related. Studies examining the (lifetime) prevalence
rates of other addictive disorders in the relatives of
probands with a given addictive disorder would also
be valuable in this regard. If significant correlations
Theoretical
are discerned, more specific hypotheses to account
At a more theoretical level, the definition of addiction
for them may then be formulated (in either
proposed here entails a shift in emphasis from the
biological or psychodynamic language) and sub-
customary tendency to focus on a particular behavior
jected to standard procedures for validation.
or the object of that behavior. Addiction here
represents a set of relationships between a behavioral
pattern and certain other processes or aspects of a
person's life. Essentially, it is defined as a process An integrative approach
whereby a behavior, that can function both to produce This hypothesis, concerning an underlying addictive
gratification and to provide escape from internal process, is continuous with an integrative approach
discomfort, is employed in a pattern characterised by to etiology and treatment of addictive disorders. In
loss of control and continuation despite significant the course of healthy growth, people develop
negative consequences. It is not the type of behavior, effective, adaptive means of managing their feelings
its frequency or its social acceptability that determines and of getting their needs met. When some combi-
whether a behavior pattern qualifies as an addiction: nation of genetic and environmental factors inter-
it is how this behavior pattern relates to and affects feres with this process, people learn to avoid being
 Addiction: definitions and implications 1407

overwhelmed by feelings and unmet needs, by taking DSM-III-R. Less formally, addiction was defined as
in a substance (food, alcohol, other drugs) or by a process whereby a behavior, that can function both
engaging in some rewarding activity (sex, gambling, to produce pleasure and to provide escape from
stealing, etc). The essential process, the addictive internal discomfort, is employed in a pattern
process, is the compulsive dependence on an characterized by (1) recurrent failure to control the
(apparently self-initiated and self-controlled) exter- behavior (powerlessness) and (2) continuation ofthe
nal action in order to regulate the internal state. Once behavior despite significant negative consequences
this process has been developed, the intelligent (unmanageability). The criteria for Addictive Dis-
human organism has the fiexibility to shift among order were determined to essentially subsume those
various actions, or to combine them, according to the of DSM-III-R disorders with prominent addictive
requirements and limitations of the situation. It features, yet to be more restrictive (less all-
follows that an effective program for the treatment of inclusive). The concept of addiction was found to be
an addicted person should address not only the a synthesis of dependence (gratification of needs; i.e.
addictive behavior but also the underlying addictive positive reinforcement motivation) and compulsion
process. This is particularly important when the (evasion or avoidance of internal discomfort; i.e.
behavior which has been used addictively also has a negative reinforcement motivation), and hence to
role in healthy functioning, e.g. eating or sexual contain information which neither of these other
behavior. Lifeling abstinence from all forms of the terms alone provides. Some practical and theoretical
behavior is then not a realistic or desirable goal. The implications of this definition were then explored:
all-or-nothing orientation typical of addicted people (1) the necessity for treatment of addictive disorders
is then inapplicable, and it is necessary for the to address both the negative and the positive
individual to undergo the changes in personality that reinforcement processes; (2) a shift in emphasis from
enable healthy moderation. a particular behavior or its object, to a set of
Progress in recovery from addiction is a function relationships between a behavior pattern and certain
of development of healthy, adaptive means for other processes or aspects of a person's life; (3)
handling feelings, getting needs met, and resolving consideration of a hypothesis that the set of addictive
inner confiicts. This in turn depends on awareness disorders is most accurately described, not as a
of inner feelings, needs and confiicts, as well as the multiplicity of addictions, but as a basic underlying
identification and challenging of maladaptive core addictive process, which may be expressed in one or
beliefs. Treatment thus first of all requires absti- more of various behavioral manifestations; and (4)
nence from addictive behavior, which would other- an approach to the etiology and treatment of
wise function to prevent or distort this inner addictive disorders that constitutes a true actualiza-
awareness. Treatment itself may then be conceptu- tion of the biopsychosocial model of illness and
alized as three inter-related processes: (1) fostering health, indicating a practical as well as conceptual
awareness of inner feelings, needs, confiicts and integration of psychodynamic theory and therapy,
core beliefs, particularly as they arise in the context biological psychiatry, family systems theory, addic-
of interpersonal relationships; (2) encouraging de- tionology, cognitive-behavioral psychology, and
velopment of more healthy, adaptive means of group dynamics.
handling feelings, getting needs met and resolving It is hoped that this integration of addictive
inner confiicts; and (3) a more directive, cognitive- disorders into the conceptual network of scientific
behavioral teaching of effective strategies for pro- psychiatry and psychology will provide the basis for a
moting abstinence from addictive behavior (what more comprehensive and effective approach to the
constitutes abstinence for a given person depends on understanding and treatment of people experiencing
which behaviors are being used addictively, and on these disorders, and for an enrichment ofthe mental
how addictive use of behavior may be distinguished health field as a whole.
from healthy behavior in that individual).

Conclusion References
This paper began with the search for a scientifically 1 AMERICAN PSYCHIATRIC ASSOCIATION (1987) Diag-
nostic and Statistical Manual of Mental Disorders, 3rd
useful definition of addiction. A formal delineation
edn (R), (Washington, D.C., American Psychiatric
of diagnostic criteria for Addictive Disorder was Association Press).
presented, specified in a format similar to that of 2 Ibid., p . 166
1408 A. Goodman

Appendix: DSM-III-R Criteria for Selected Note: The following items may not apply to cannabis,
Disorders hallucinogens, or phencyclidine (PCP]:
Psychoactive Substance Dependence (8) characteristic withdrawal symptoms (see specific
(A) At least three of the following: withdrawal syndromes under Psychoactive Sub-
(1) substance often taken in larger amounts or over stance-induced Organic Mental Disorders)
a longer period than the person intended (9) substance often taken to relieve or avoid with-
(2) persistent desire or one or more unsuccessful drawal symptoms
efforts to cut down or control substance use (B) Some symptoms ofthe disturbance have persisted for
(3) a great deal of time spent in activities necessary at least 1 month, or have occurred repeatedly over a
to get the substance (e.g. theft), taking the longer period of time.
substance (e.g. chain smoking) or recovering
from its effects
(4) frequent intoxication or withdrawal symptoms 312.31 Pathological Gambling
when expected to fulfill major role obligations at
work, school or home (e.g. does not go to work Maladaptive gambling behavior, as indicated by at least
because hung over, goes to school or work 'high', four of the following:
intoxicated while taking care of his or her (1) frequent preoccupation with gambling or with obtain-
children), or when the substance use is physi- ing money to gamble
cally hazardous (e.g. drives when intoxicated) (2) frequent gambling of larger amounts of money or over
(5) important social, occupational, or recreational a longer period of time than intended
activities given up or reduced because of sub- (3) a need to increase the size or frequency of bets to
stance use achieve the desired excitement
(6) continued substance use despite knowledge of (4) restlessness or irritability if unable to gamble
having a persistent or recurrent social, psycholo- (5) repeated loss of money by gambling and returning
gical or physical problem that is caused or another day to win back losses ('chasing')
exacerbated by the use of the substance (e.g., (6) repeated efforts to reduce or stop gambling
keeps using heroin despite family arguments (7) frequent gambling when expected to meet social or
about it, cocaine-induced depression, or having occupational obligations
an ulcer made worse by drinking) (8) sacrifice of some important social, occupational, or
(7) marked tolerance: need for markedly increased recreational activity in order to gamble
amounts of the substance (i.e., at least a 50% (9) continuation of gambling despite inability to pay
increase) in order to achieve intoxication or mounting debts, or despite other significant social,
desired effect, or markedly diminished effect occupational, or legal problems that the person knows
with continued use of the same amount to be exacerbated by gambling