There’s a good piece today in The New York Times about what may be included in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, considered the Bible of the mental health field.

“The process has become such a contentious social and scientific exercise that for the first time the book’s publisher, the American Psychiatric Association, has required its contributors to sign a nondisclosure agreement,” Benedict Carey writes in The Times. “The debate is particularly intense because the manual is both a medical guidebook and a cultural institution. It helps doctors make a diagnosis and provides insurance companies with diagnostic codes without which the insurers will not reimburse patients’ claims for treatment.”

Due out in 2012, the DSM-V will be critical to framing our understanding of addiction. Will behaviors like compulsive overeating and sexual addiction be included? In my book, America Anonymous, I write about the battle to get sex addiction into the DSM: 

Nowhere in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-IV, published in 1994) is there a diagnostic criteria for sexual addiction or sexual compulsion.

There is “no scientific data to support a concept of sexual behavior that can be considered addictive,” Chester Schmidt, chair of the DSM-IV Sexual Disorder Work Group, wrote at the time. Schmidt told me that what is called sex addiction is more likely a symptom of other psychological problems like depression, obsessive-compulsive disorder, or bipolar disorder.

But believers in a sex-addiction diagnosis point out that for many years, doctors and psychiatrists similarly dismissed alcoholism, refusing to accept that it was a serious problem in itself, not merely a symptom of something else. The psychoanalytic view of addiction in the first half of the 20^th century was that “alcoholic drinking and addictive drug use were not primary disease entities, but symptoms of neurotic conflict or underlying psychosis, or manifestations of a disordered personality,” William White writes in Slaying the Dragon. Treat the underlying psychosis, the theory went, and the addiction will go away.

Psychoanalysts at the time linked alcoholism to a plethora of psychological problems, including “primary maternal identification,” “fear of castration,” and “latent homosexuality.” “Every drinking-bout is tinged with homosexuality,” announced one psychoanalyst. Remarkably, this belief had currency into the second half of the 20^th century.

According to Harry Tiebout, one of the first psychiatrists to see addiction as an illness in its own right, the biggest problem with relying on psychoanalysis alone was that the patient rarely stopped drinking long enough for any of the deeper therapeutic work to happen. “In rather doctrinaire fashion,” he once wrote, “we persisted in treating the alcoholism as a symptom which would be cured or arrested if its causes could be favorably altered. The drinking was something to be put up with as best as one could while more fundamental matters were being studied. The result of this procedure was that very few alcoholics were helped.”

As William White put it, Tiebout believed that alcoholism was “a symptom that had itself become a life-threatening, primary illness.” Most believers in a sex-addiction diagnosis now believe the same thing about compulsive sexuality. Fueled by an unwavering belief in their cause, and confident that large-scale studies of sex addicts—including brain scans—will prove that sex addiction is real, they hope to get some version of the disorder into the DSM-V.

To do that, they know they’ll need to convince both the psychiatric community and the general public that sex addiction is more than just a metaphor, a pop-psychology diagnosis, or an attempt to explain away recklessness and perversion.

Advances in neuroscience may help in that endeavor. Five or ten years ago, Dr. Peter Martin, a psychiatrist and the director of the Division of Addiction Medicine at Vanderbilt, would have dismissed any comparison between sexual compulsivity and alcoholism or drug addiction. Drugs and alcohol are foreign substances. Sex is natural—a basic biological drive critical to our survival as a species. Clearly, Martin thought, a case of apples and oranges.

But using MRI technology, Martin began studying how people’s brains react to sexually arousing images. What he found has radically changed his perspective on addictions. Now he believes that “there are many behaviors, including sex, that appear to be driven by the same brain mechanisms that drive addictions to drugs like cocaine and heroin.” University of Pennsylvania psychologist Anna Rose Childress agrees, telling the journal Science that sex addicts resemble cocaine addicts and probably share a problem with brain “inhibitory circuitry.”

Still, the science of sex addiction is in its infancy, and those hoping to further study the brains of sex addicts struggle to get the funding they need. “People don’t exactly throw money at you when you say you want to study sex addiction,” says addiction researcher Patrick Carnes. “And in the end, getting sex addiction in the DSM is not going to just be about science and empirical evidence. The concept of sex addiction makes so many people uncomfortable, so it’s really going to take a public relations and education effort to get it seen as a serious disorder. Because if we as a culture really accept the idea of sex addiction, then we’re going to have to look at a lot of things we don’t want to. We’ll have to talk openly about what constitutes healthy sexuality, which will invariably bring morality and religion into play. We’ll have to look at gender roles, at how we treat women, at childhood sexual abuse and trauma, at how we use sex and relationships to make ourselves feel worthy and lovable, and at the way anonymous sex has been normalized in gay culture. Sex addiction really has something to offend everyone.”

Among the most offended are some sexologists who see sex addiction as a moralistic construct that portrays human sexuality as something dirty and shameful. Some addiction-treatment professionals, meanwhile, worry that equating sex addiction and drug addiction will detract from their efforts to have alcoholism and drug addiction fully accepted as diseases. And some feminists and victims-rights advocates worry that an official sex-addiction disorder could be used by sex offenders or philandering men to claim that they didn’t have control over their actions.

It’s unclear if a “sex addiction made me do it” defense has ever actually worked, except on an episode of ABC’s “Boston Legal.” There, Shelley Long played a self-described nymphomaniac who compulsively hired male escorts, got arrested, claimed to be powerless over her thundering libido, flirted shamelessly with the judge, and got off (so to speak).