The WAGER 6(4) – DSM-IV: Cautionary Ambivalence


Last week’s WAGER examined some clinical ambiguities associated with the DSM-IV diagnostic criteria for pathological gambling. In addition, the WAGER suggested that a careful reading of these criteria should remind clinicians about the discretion that is available to them when they evaluate problem and pathological gamblers. While DSM-IV encourages this discretion in general, it buttresses this need, in part, with a Cautionary Statement.

The American Psychiatric Association includes a Cautionary Statement in DSM-IV to protect against clinical, scientific, and legal criticisms that might arise as a result of its classification system for certain mental disorders. The classification of pathological gambling is a featured example.

By stating that the DSM-IV inclusion of diagnostic categories ". . .does not imply that the condition meets legal or other non-medical criteria for what constitutes mental disease, mental disorder, or mental disability" (APA, 2000, p. xxxvii), and using pathological gambling as one example to illustrate this assertion, the editors of DSM-IV purposefully or inadvertently compromise the nosological schema in general and the diagnosis of pathological gambling in particular.

Is the Cautionary Statement and its reference to pathological gambling simply that, a warning to clinicians and scientists that not all diagnostic categories might meet non-medical criteria for what constitutes mental disorders? Alternatively, is the Cautionary Statement simply an affirmation by DSM-IV editors that the manual is still a work in progress and, as such, reflects ambivalence toward the classification of pathological gambling as a mental disorder? If the latter is true, then the editors also compromise a comprehensive utilitarian application of DSM-IV. Specifically, if the manual cannot commit to its classification of pathological gambling, what does this imply about its commitment to the classification of other mental disorders (e.g., alcohol and cocaine dependence)? Moreover, we can only speculate as to what makes these disorders more acceptably classified than pathological gambling?

Despite such uncertainties, the Cautionary Statement smartly states that classification of mental disorders like pathological gambling might not be wholly relevant to legal judgments (APA, 2000).

We interpret wholly relevant, in this context, to mean that it is indeed partly relevant. As such, the term wholly relevant provides DSM-IV protection from legal challenges that the disorder is without exculpatory power. Simultaneously, it allows clinicians and scientists to make treatment and research decisions with discretion on an individual basis. Without the obligation to match all patients and research subjects with all criteria for pathological gambling, DSM-IV and the Cautionary Statement provide clinicians and researchers with freedom to identify criteria that match an individual’s gambling behavior. While clinical freedom often translates into better treatment of problem and pathological gamblers, it can simultaneously confuse and complicate other activities. Such is the ambivalent state of a youthful field.


Diagnostic and Statistical Manual of Mental Disorders (Fourth ed.)(2000). Washington, DC: American Psychiatric Association.

The WAGER is a public education project of the Division on Addictions at Harvard Medical
School. It is funded, in part, by the National Center for Responsible Gaming, the
Massachusetts Department of Public Health, the Addiction Technology Transfer Center of
New England, the Substance Abuse and Mental Health Services Administration, and the
Center for Substance Abuse Treatment.

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