1. 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

2. 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

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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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