Commentary on: Are we overpathologizing everyday life? A tenable blueprint for behavioral addiction research.

This commentary considers a recent article on how the proliferating use of atheoretical, confirmatory and diagnosis driven research approaches is resulting in the over-identification of behavioral addictions. In response to the original article, I reflect on the timeliness and value of its observations and expand on a central point it raises: The importance of thinking beyond diagnostic frameworks in developing a comprehensive understanding of addictive behaviors and associated treatments.

The article by Billieux et al. (2015) titled ‘Are we overpathologizing everyday life? A tenable blueprint for behavioral addiction research’ is timely, important, stimulating and a much needed contribution to a central debate in our field: that of the utility and validity of conceptualizing what are essentially addictive behaviors as behavioral addictions (or psychiatric ‘entities’). The difference between these terms is of crucial importance in demarcating the functional (or process) view of psychopathology (favored by Billieux and colleagues) from the syndromal-diagnostic one. Indeed the term ‘addictive behaviors’ can be interpreted to imply the potential for developing a perseverative behavioral problem, whilst the term ‘behavioral addiction’ can be interpreted to imply a behavioral condition necessitating diagnosis.

The debate regarding the centrality of diagnostic classification, in the understanding and treatment of psychopathology, can be probably traced to Wilhelm Windelband’s (1894/1998) delineation of two forms of evidence-based knowledge, which he termed ‘idiographic’ and ‘nomothetic’. Idiographic knowledge refers to a description or explanation that is specific to an event or thing. Nomothetic knowledge is characterized by the pursuit of general laws and theories.

The idiographic versus nomothetic debate in psychopathology reached its zenith in the late 1940s and early 1950s (Bruch & Bond, 1997; Turkat & Maisto, 1983) as epitomised by the Conference on Graduate Education in Psychology that took place in Boulder, Colorado in 1949 (Benjamin & Baker, 2000; Committee on Training in Clinical Psychology, 1947; O’Sullivan & Quevillon, 1992; Raimy, 1950). At this time, clinicians dealing with psychopathological presentations, especially in psychiatric settings, were mostly expected to define these in terms of nosological categorization and prescribe treatment accordingly. When, in the early 1950s, behavior therapy emerged as an effective form of treatment for various forms of psychopathology, the nosological approach was challenged as hardly any instrumental value could be found in a classification system which aimed at scientific order and communication, but with questionable validity and reliability, as well as limited explanatory power regarding mechanisms for change (Bruch & Bond, 1997; Turkat & Maisto, 1983). Half a century later, these views were reiterated by Bentall (2003) who reminded us of the limitations of the disorder-specific/diagnostic approach in terms of explaining elevated comorbidity, poor construct validity, high prevalence of sub-threshold disorders and high heterogeneity of symptoms among individuals with the same disorder.

Billieux et al. (2015) in a modern incarnation of the views favoring an idiographic approach to the understanding of addictive behaviors, convincingly highlight how the diagnostic approach is neglecting the phenomenology and specificity of addictive behaviors against a backdrop of growing evidence indicating that addictive behaviors are context dependent and decay spontaneously. The focus in the field, which is a matter of concern to Billieux et al. (2015) appears to be the shifting towards atheoretical and confirmatory views characterized by a priori anecdotal observations of behavior as ‘addictive’ and the drawing of comparisons between such behavior and substance addiction, leading to the increasing classification of almost any behavior as, potentially, a behavioral addiction.

Billieux et al. (2015) underscore how this push towards a diagnostic approach to addictive behaviors is undermining the crucial role played by function and process based frameworks in the understanding of such presentations. This view aligns itself, and finds support, in the work of several scientist-practitioners who have stressed the importance of understanding the idiographic and transdiagnostic mechanisms (be they cognitive, affective, motivational or behavioral) which are responsible for the development, maintenance and recurrence of psychopathology (e.g. Bruch & Bond, 1997; Mansell, Harvey, Watkins & Shafran, 2009; Wells & Matthews, 1994). Billieux et al.’s (2015) view also lends support to the idea that the development and validation of individualized transdiagnostic treatment targeting specific mechanisms underlying symptoms and problematic behaviors may be of greater clinical value than the adoption of standardized treatments (Caselli & Spada, 2015; Ezzamel, Spada & Nikčević, 2015; Spada, Caselli, Nikčević & Wells, 2015).

In conclusion, I find myself as a clinician, researcher and teacher in the field, in strong agreement with Billieux et al.’s (2015) views which emphasize how everyday life behaviors are becoming overpathologized, and falling prey to diagnostic speculation and labeling. We must, as Billieux et al. (2015) argue, not lose focus of the specificity of addictive behaviors, their complex inter-functional relationships with other biopsychosocial factors, and their transdiagnostic features. If we do lose this focus, because of an unwillingness to tolerate the challenges that come with such complexity, we may find that the credibility of our field will become increasingly compromised and treatment outcomes inevitably affected for the worse.

Conflict of interest

The author declares no conflict of interest.