Gambling Behaviors and Disorders in ICD-11 Marc N. Potenza, M.D., Ph.D. Professor of Psychiatry, Child Study, and Neurobiology Director, Yale Gambling Center of Research Excellence (CORE) Director, Women and Addictions Core, Women’s Health Research at Yale Senior Scientist, The National Center on Addiction and Substance Abuse Yale University School of Medicine

Disclosures Consultant to Lundbeck, Ironwood, Shire, INSYS, Rivermend Health, Lakelight Therapeutics/Opiant and Jazz Pharmaceuticals Research Grants from National Center for Responsible Gaming Research Gift from Mohegan Sun Consultant to Gambling and Legal Entities on Issues Related to Impulse Control Disorders KAAP, Seoul, Nov 18, 2016

Perceptions of “Behavioral Addictions” 1997 2007 KAAP, Seoul, Nov 18, 2016

History of PG in the DSM Introduced in DSM-III in 1980 in ICD-NEC Category Revisions in DSM-III-R, DSM-IV Changes in Numbers of Possible Inclusionary Criteria From Which to Select, Number Needed to Make Diagnosis (Cunningham-Williams et al., 2001) Changes in Exclusionary Criteria (e.g., with Respect to Antisocial Exclusionary Criterion) DSM-III, DSM-III-R and DSM-IV Changes Considered by Expert Groups Focusing on Impulse-Control Disorders KAAP, Seoul, Nov 18, 2016

DSM-5 Process Research Work Groups Consider PG Based on Existing Data Substance Use Disorder (SUD) Workgroup Considers Relationships Between PG and SUDs and Whether PG Should Be Considered as an Addiction (Potenza, 2006; Petry, 2006) Obsessive-Compulsive-Spectrum Disorders Workgroup Considers the Extent to Which Impulse-Control Disorders (ICDs) Similar to or Distinct From Obsessive-Compulsive Disorder (Potenza et al., 2009) Materials Used by DSM-5 Committees Interactive Phase for Comments From the Public to be Considered in the Process KAAP, Seoul, Nov 18, 2016

Potenza, Curr Op Neurobio, 2013 Changes for PG in DSM-5 SUD Workgroup Considered Pathological Gambling (PG) and Excessive Patterns of Internet Use and Video-Gaming PG Moved Together with SUDs in Substance-Related and Addiction Category - May Facilitate Integrated Treatment PG Termed “Gambling Disorder” Concerns About Stigma of “Pathological” Term Suggests One Disorder Rather Than Multiple Thresholds Potenza, Curr Op Neurobio, 2013 KAAP, Seoul, Nov 18, 2016

Potenza, Curr Op Neurobio, 2013 Changes for PG in DSM-5 Removal of “Illegal Acts” Criterion Data Suggest No Substantial Difference in Structure of Dx Diagnosis Based on Meeting 4 of 9 Rather Than 5 of 10 Inclusionary Criteria (IC) Based on Data That 4 IC Might be Better Threshold May Complicate Comparability Across Studies Threshold Differences Among Addictive D/O’s Different Threshold Used for SUDs (2 or More) and Gambling Disorder (4 or More) Inclusionary Criteria May Complicate Comparison of GD and SUDs Threshold Influences Prevalence Estimates and Related Considerations Potenza, Curr Op Neurobio, 2013 KAAP, Seoul, Nov 18, 2016

Relationship Between PG and SUDs High Rates of Co-Occurrence - Population and Clinical Samples Similar Clinical Courses - High Rates in Adolescence, Lower Rates in Older Adults - “Telescoping” Pattern in Women Similar Clinical Characteristics - Tolerance, Withdrawal, Repeated Attempts to Cut Back or Quit - Appetitive Urge or Craving States Similar Biologies - Genetic Contributions, Neural Circuits Similar Treatments - Self-Help, Cognitive Behavioral Therapy, Motivational Interviewing, Naltrexone and Nalmefene, N-Acetyl Cysteine KAAP, Seoul, Nov 18, 2016

Will ICD-11 Harmonize with DSM-5? In ICD-10, Pathological Gambling (PG) is Classified as an Impulse Disorder In the Setting of the Rationale for DSM Changes in Classification, Addictions Researchers have Proposed Classifying PG Together with SUDs in ICD-11 (Faith-Buehler et al, in press) This Approach Has Been Challenged, With Core Features of Addictions Being Described as Defining Impulse Disorders (Grant et al, 2014) Other Researchers (Shaffer, 1999; Mann et al, 2016) Have Countered That Continued Engagement in a Behavior Despite Adverse Consequences is Better Considered a Core Feature of Addictions KAAP, Seoul, Nov 18, 2016

WHO-Related Workgroups Three Workgroup Meetings – Tokyo (2014), Seoul (2015) and Hong Kong (2016) First Meeting Focused on Considering the Public Health Impact of Addictive Internet Use Behaviors and Disorders Second Meeting Focused on Defining Internet Use Behaviors and Disorders and Research Priorities KAAP, Seoul, Nov 18, 2016

WHO-Related Workgroups Third Meeting Focused on Public Health and Policy Approaches to Internet Use Behaviors and Disorders In the Third Meeting, Draft Versions of Online and Offline Behavioral Addictions and Related Behaviors Presented and Discussed KAAP, Seoul, Nov 18, 2016

Disorders Due to Addictive Behaviors – Gambling Disorder “Disorders Due to Addictive Behaviors” Proposed for Inclusion in the Section of “Disorders Due to Substance Use or Addictive Behaviors” in Chapter 7 of the ICD-11, Consistent with DSM-5 Approach Gambling Disorder (Replacing Pathological Gambling) Proposed, with F63.0 Code to Be Replaced with 7D60 Code Specifiers for Gambling Disorder Proposed to Include “Predominantly Offline” and “Predominantly Online” Subtypes, With “Unspecified” Descriptor Also Proposed Exclusion Criteria Include Hazardous Gambling or Betting and (Possibly) Bipolar Disorders Types I and II KAAP, Seoul, Nov 18, 2016

Gambling Disorder – ICD-11 Draft “Gambling disorder is manifested by a persistent or recurrent gambling behavior that is characterized by an impaired control over gambling, increasing priority given to gambling over other activities to the extent that gambling takes precedence over other interests and daily activities and continuation of gambling despite the occurrence of negative consequences. The behavior pattern is of sufficient severity to result in significant impairment in personal, family, social, educational, occupational or other important areas of functioning. These features and the underlying pattern of gambling are normally evident over a period of at least 12 months in order for a diagnosis to be assigned, although the required duration may be shortened if all diagnostic requirements are met and symptoms are severe.” KAAP, Seoul, Nov 18, 2016

Hazardous Addictive Behaviors in ICD-11 The International Classification of Diseases (ICD) Considers Conditions and Behaviors Relating to World Public Health Subsyndromal Behaviors Relating to Gambling May Be Particularly Important to Consider Given the Relatively Small Number of Individuals with Disorders as Compared to the Larger Numbers of People Gambling (Shaffer and Korn, 2002) Akin to Harmful Alcohol Use in ICD-10, Hazardous Gambling or Betting (Code QF32) Proposed for Chapter 24 in ICD-11 (“Factors Influencing Health Status or Contact with Health Services”) KAAP, Seoul, Nov 18, 2016

Hazardous Gambling or Betting (Draft) “Hazardous gambling or betting refers to a pattern of gambling and betting that appreciably increases the risk of harmful physical or mental health consequences to the individual or to others around the individual. The increased risk may be from the frequency of gambling or betting, from the amount of time spent on these activities or the context of gambling and betting, from the neglect of other activities and priorities, from risky behaviors associated with gambling or betting or its context, from the adverse consequences of gambling and betting, or from the combination of these. Hazardous gambling and betting has not yet reached the level of having caused harm to physical or mental health of the user or others around the user. The pattern of gambling and betting often persists in spite of awareness of increased risk of harm to the individual or to others.” KAAP, Seoul, Nov 18, 2016

Conclusions & Future Directions The International Workgroups Involving Representatives From Over 30 Countries and Covering the Majority of the WHO World Zones Have Helped to Gather Information Relevant to Many Jurisdictions in the Generation of Disorders and Hazardous Behavior Designations for Addictive Behaviors The Inclusions of Sections and Diagnoses Relating to Hazardous and Disordered Engagement in Addictive Behaviors in ICD-11 Should Greatly Facilitate Public Health, Prevention, Program, Policy and Treatment Efforts Relating to Gambling and Other Addictive Behaviors KAAP, Seoul, Nov 18, 2016

NIH (NIDA, NIAAA, ORWH) VA CASA WHR DMHAS NCRG Mohegan Sun Acknowledgments ICD-11 Vladimir Poznyak Susumu Higuchi Hae Kook Lee Constance Chan Thomas Chung Karl Mann John Saunders Et al. DSM-5 Chuck O’Brien Nancy Petry Stefano Pallanti Lorrin Koran Et al. NIH (NIDA, NIAAA, ORWH) VA CASA WHR DMHAS NCRG Mohegan Sun