In the evolving landscape of mental health research, the criteria that define addictive disorders continue to be scrutinized and refined. A recent scholarly commentary by S. Amendola challenges a prevailing notion in the field: the classification of salience or preoccupation as a peripheral diagnostic factor in addictive behaviors. Published in the International Journal of Mental Health and Addiction in 2026, Amendola’s incisive critique addresses secondary analyses proposed by Ciudad-Fernandez and colleagues, questioning the robustness of their evidence to support such claims.
Addictive disorders, broadly characterized by patterns of compulsive substance use or engagement with rewarding behaviors despite adverse consequences, have long been subject to diagnostic criteria aiming to capture the multifaceted nature of addiction. The components of these criteria encompass elements such as tolerance, withdrawal, loss of control, and significance of the behavior in the individual’s life. Among these, the concept of salience—or the degree to which an activity or substance dominates an individual’s thoughts and behaviors—has been debated regarding its essentiality or peripheral relevance in diagnosing addiction.
Amendola’s commentary meticulously examines the methodological framework and interpretative lens applied by Ciudad-Fernandez et al. in their secondary analysis. The original study sought to elevate salience/preoccupation as a potential peripheral criterion, grounded on statistical associations observed within their data sets. However, Amendola contends that these associations may suffer from interpretive overreach, given the limitations embedded in secondary data analysis, including potential confounds, sample heterogeneity, and the absence of longitudinal validation.
Key to Amendola’s argument is the imperative for evidence-based criteria that maintain clinical specificity and diagnostic reliability. While preoccupation with addictive stimuli is undoubtedly a salient experience for many individuals with addiction, its episodic nature and susceptibility to contextual triggers challenge its consistency as a stable diagnostic marker. Amendola underscores the importance of distinguishing between transient cognitive engagement—common in a variety of behavioral contexts—and core addictive pathology, which entails more entrenched neuropsychological changes influencing behavior.
Further, the commentary delves into the neuroscience underpinning salience attribution in addiction. Neuroimaging studies have highlighted altered activity within the mesolimbic dopamine system, particularly the ventral striatum, in individuals engaging in addictive behaviors. This neurobiological framework supports the crucial role of salience in the perpetuation of addiction. Yet, Amendola cautions that an overreliance on salience as a diagnostic criterion overlooks the dynamic interplay of other essential features such as impaired inhibitory control, reward processing, and decision-making deficits.
Amendola’s critique also calls attention to the broader implications for diagnostic manuals such as the DSM and ICD. The inclusion or exclusion of certain criteria can significantly influence clinical practice, epidemiological studies, and policy decisions regarding treatment resource allocation. By challenging the sufficiency of evidence provided for salience/preoccupation as a peripheral criterion, the commentary advocates for a cautious and nuanced approach to diagnostic refinement, prioritizing rigorous empirical validation over conceptual enthusiasm.
Moreover, the discussion extends into the methodological challenges inherent in secondary analysis studies. Amendola highlights that while secondary data analysis offers cost-effective and timely opportunities to explore hypotheses, it can suffer from inherent biases related to the original study’s design, participant selection, and variable operationalization. These intrinsic limitations warrant that claims drawn from such analyses remain provisional pending confirmation through dedicated prospective studies.
In the context of mental health addiction research, this debate embodies the ongoing tension between clinical phenomenology and the drive for empirical quantification. Salience, as experienced subjectively by individuals, encapsulates a phenomenological reality that is compellingly real yet complex to measure objectively. Amendola suggests that qualitative investigations coupled with neurocognitive assessments may provide richer, multidimensional insights into the role of salience in addiction.
From a treatment standpoint, the recognition of salience’s role in addictive behavior translates into therapeutic strategies focused on cognitive-behavioral techniques aimed at diminishing preoccupation and attentional biases toward addictive cues. Nonetheless, Amendola’s assertion posits that such interventions should be contextualized within a broader treatment framework addressing other core pathological domains to optimize outcomes.
The commentary underscores the need for interdisciplinary approaches—including psychiatry, neuroscience, psychology, and epidemiology—to converge in refining addiction criteria. Such collaborative efforts are essential to constructively balance the clinical utility and scientific rigor of diagnostic frameworks, ultimately advancing patient care and research efficacy.
In sum, Amendola’s thoughtful and critical examination of existing evidence spotlights an essential discourse in addiction science: the tension between expanding diagnostic inclusivity versus maintaining diagnostic precision. By advocating for stronger empirical substantiation before crystallizing salience as a peripheral criterion, the commentary contributes a vital voice encouraging prudence, methodological rigor, and scientific integrity within addiction research.
As the field moves forward, future investigations incorporating robust longitudinal designs, multimodal assessment tools, and diverse population samples will be pivotal in elucidating the nuanced role of salience in addiction. Only through such comprehensive efforts can the scientific community achieve a consensus capable of informing refined diagnostic categories that accurately reflect the lived realities and neurobiological substrates of those affected by addictive disorders.
The ongoing dialogue prompted by Amendola’s commentary highlights the dynamic and iterative nature of mental health research, where hypotheses are continually tested against emerging data and evolving conceptual frameworks. This iterative process ensures that diagnostic criteria evolve adaptively, informed by robust evidence and clinical relevance—a cornerstone principle guiding the advancement of psychiatry and addiction medicine into the future.
Subject of Research: Diagnostic criteria and conceptualization of addictive disorders, with a focus on the role of salience/preoccupation in addiction.
Article Title: Insufficient Evidence to Claim Salience/Preoccupation as a Peripheral Criterion of Addictive Disorder: A Commentary on Ciudad-Fernandez and Colleagues’ Secondary Analysis.
Article References:
Amendola, S. Insufficient Evidence to Claim Salience/Preoccupation as a Peripheral Criterion of Addictive Disorder: A Commentary on Ciudad-Fernandez and Colleagues’ Secondary Analysis. Int J Ment Health Addiction (2026). https://doi.org/10.1007/s11469-025-01631-x
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