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Impulse control disorders and “behavioural addictions” in the ICD-11

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Grant, Jon E., Atmaca, Murad, Fineberg, Naomi A., Fontenelle, Leonardo F., Matsunaga, Hisato, Janardhan Reddy, Y.C., Simpson, Helen Blair, Thomsen, Per Hove +4 more·2014·World Psychiatry
DOI 10.1002/wps.20115PMC PMC4102276
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Abstract

Psychiatric classifications have traditionally recognized a number of conditions as representing impulse control disorders. These have included pathological gambling, intermittent explosive disorder, kleptomania, pyromania, and trichotillomania. In 1992, the World Health Organization (WHO) described habit and impulse disorders (F63) as characterized by repeated acts that have no clear rational motivation, generally harm the person's own interests and those of other people, and are associated with impulses the person experiences as uncontrollable 1. In DSM-IV-TR, the American Psychiatric Association further characterized these impulse control disorders as being preceded by a rise in tension before the behaviour or when resisting the behaviour, and followed by pleasure, gratification, or relief of tension 2. In the past two decades, the public health importance of these disorders has become increasingly apparent. For example, pathological gambling and intermittent explosive disorder are prevalent conditions (lifetime prevalence rates of 1% and 3%, respectively) that are recognized to represent a substantial burden of disease (for example, increased health concerns, family discord, and financial problems) 3, 4. Furthermore, there is a growing literature addressing the psychobiology and management of all of these impulse control disorders 5-7. Some animal models and clinical imaging studies suggest that these conditions represent "behavioural addictions", characterized by abnormalities in reward processing 8-11. As a result, proposals have been made to include compulsive sex, compulsive buying, and compulsive Internet use under this rubric, on the grounds that they too represent a large burden of disease and deserve appropriate diagnosis and treatment 7, 12-14. The WHO's development of the ICD-11 provides an important opportunity to optimize the classification and description of impulse control disorders and to address some of the controversies surrounding these putative "behavioural addictions". The WHO has emphasized that ICD-11 should pay particular attention to issues of clinical utility, global applicability, and scientific validity 15. The ICD-11 Working Group on Obsessive-Compulsive and Related Disorders was asked to review the scientific and other information about use, clinical utility, and experience with relevant ICD-10 diagnoses, including impulse control disorders; to review the approach of the DSM-5 to these conditions, with a focus on whether this approach might be suitable and useful for global applications; and to develop proposals for ICD-11, with a particular emphasis on improving clinical utility in a broad range of settings. The Working Group has recommended that a grouping of impulse control disorders be retained in ICD-11. These disorders should be defined by the repeated failure to resist an impulse, drive, or urge to perform an act that is rewarding to the person (at least in the short-term), despite longer-term harm either to the individual or others. Impulse control disorders would therefore include pathological gambling, intermittent explosive disorder, kleptomania, and pyromania, as well as compulsive sexual behaviour disorder. In the ICD-10, many of these behaviours are already conceptualized in this manner under the grouping of habit and impulse disorders. Trichotillomania is also listed under the same heading, but the Working Group has recommended it to be moved to the grouping of obsessive-compulsive and related disorders in ICD-11, and that skin picking (excoriation) disorder also be added to the same grouping. Compulsive sexual behaviour disorder will be new to this grouping, and would replace the ICD-10 category of excessive sexual drive. Other putative impulse control disorders such as problematic Internet use and compulsive buying do not appear at this time to have enough data to support their inclusion as independent mental health conditions. A first key controversy in the field is whether pathological gambling and related conditions should be characterized as "behavioural addictions" and thereby be subsumed under a larger category that is more closely related to substance-related disorders. While a good deal of literature supports the idea that individuals with pathological gambling have altered reward circuitry 6, they also have other brain abnormalities. For example, prefrontal cortical dysfunction appears similar between gamblers and individuals with mania 16, 17. Additionally, although there is a shared genetic vulnerability between gambling and alcohol addiction, pathological gambling also shares genetic vulnerability factors with major depressive disorder 18. Therefore, categorizing gambling behaviour as an addiction, although heuristically appealing, seems premature based on the evidence. Furthermore, the change in categorization does not have clear clinical utility, insofar as a range of treatment approaches, other than those used in the treatment of substance add

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  • The WHO explicitly decided not to classify compulsive sexual behaviour disorder in the grouping of Disorders Due to Addictive Behaviours because the evidence was not considered strong enough to support that model.

    “The WHO explicitly decided not to classify the new diagnostic category in the grouping of Disorders Due to Addictive Behaviours (i.e., with gambling disorder and gaming disorder), because the evidence was not considered to be strong enough to support this model 223,226 .”

    From Emerging experience with selected new categories in the <scp>ICD</scp>‐11: complex <scp>PTSD</scp>, prolonged grief disorder, gaming disorder, and compulsive sexual behaviour disorder (2022) · cites this paper as [226]

    In “Impulse control disorders and ‘behavioural addictions’ in the ICD-11” (page unavailable), the Working Group recommends placing compulsive sexual behaviour disorder among impulse control disorders. The paper describes this as a proposal, not an explicit WHO decision, and does not say that evidence for an addiction model of compulsive sexual behaviour was judged insufficient. Its evidence-based objection to an addiction classification concerns pathological gambling. (LLM, conf=0.88)

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  • ICD-11 Working Groups agreed on the relevance of the clinical phenomenon of compulsive sexual behaviour disorder, but it was less clear where to place the disorder within the classification, how to operationalize it, and how to name it.

    “ICD-11 Working Groups agreed on the relevance of the clinical phenomenon, but it was less clear where to place the disorder within the classification, how to operationalize it, and how to name it 226 .”

    From Emerging experience with selected new categories in the <scp>ICD</scp>‐11: complex <scp>PTSD</scp>, prolonged grief disorder, gaming disorder, and compulsive sexual behaviour disorder (2022) · cites this paper as [226]

    In the paper’s discussion of compulsive sexual behaviour disorder (page not available in our copy), the ICD-11 Working Group recommends its inclusion as an impulse control disorder and proposes replacing the term “excessive sexual drive”; the paper also calls diagnostic thresholds a key controversy. These passages support the clinical relevance and the classification, operationalization, and naming issues, but they do not establish agreement among multiple ICD-11 Working Groups. (LLM, conf=0.82)

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  • The WHO acknowledges the existence of a clinical population of individuals who feel unable to control their own sexual behaviour and as a result experience substantial distress and sometimes severely negative functional outcomes.

    “The WHO has attempted to sidestep many of the controversies in the area while acknowledging the existence of a clinical population of individuals who feel unable to control their own sexual behaviour and as a result experience substantial distress and sometimes quite severely negative functional outcomes.”

    From Emerging experience with selected new categories in the <scp>ICD</scp>‐11: complex <scp>PTSD</scp>, prolonged grief disorder, gaming disorder, and compulsive sexual behaviour disorder (2022) · cites this paper as [226]

    The paper’s discussion of compulsive sexual behaviour disorder (page unavailable) says the ICD-11 Working Group recommended recognizing it as an impulse-control disorder, characterized by failure to control behaviour despite longer-term harm. It also discusses avoiding the pathologizing of normal sexual behaviour and using impairment to distinguish disorder. It does not specifically describe substantial distress or severely negative functional outcomes in this population, and its Acknowledgements caution that the authors’ views do not necessarily represent an official WHO position. (LLM, conf=0.85)

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  • These presentations were considered to meet the basic definition of a mental disorder and to be associated with substantial suffering for which health services might reasonably be provided.

    “These presentations were considered to meet the basic definition of a mental disorder 223,226 and to be associated with substantial suffering for which health services might reasonably be provided.”

    From Emerging experience with selected new categories in the <scp>ICD</scp>‐11: complex <scp>PTSD</scp>, prolonged grief disorder, gaming disorder, and compulsive sexual behaviour disorder (2022) · cites this paper as [226]

    In the section on ICD-11 impulse control disorders (page not specified in our copy), the Working Group recommends including compulsive sexual behaviour disorder and describes repeated behaviour despite longer-term harm. It also says appropriate diagnosis and treatment are desirable for disorders affecting public health. The paper does not explicitly say these presentations meet a basic definition of mental disorder or are associated with substantial suffering. (LLM, conf=0.83)

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  • In the short time since the conceptualization of CSBD as an impulse control disorder has been put forward, there have been numerous new studies, with the focus of this research being significantly broadened by a range of new research groups.

    “In the short time since the conceptualization of CSBD as an impulse control disorder has been put forward [100] there have been numerous new studies, with the focus of this research being significantly broadened by a range of new research groups.”

    From Mental, behavioral and neurodevelopmental disorders in the ICD-11: an international perspective on key changes and controversies (2020) · cites this paper as [100]

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Research works printed but not linked: 2

  1. National Youth Commission. 2007 International Symposium on the Counseling and Treatment of Youth Internet Addiction, Seoul, September 2007.
  2. Grant JE, Potenza MN, Weinstein A et al. Introduction to behav- ioral addictions. Am J Drug Alcohol Abuse 2010;36:233-41.

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Authors
Grant, J. E., Atmaca, M., Fineberg, N. A., Fontenelle, L. F., Matsunaga, H., Janardhan Reddy, Y. C., Simpson, H. B., Thomsen, P. H., van den Heuvel, O. A., Veale, D., Woods, D. W., & Stein, D. J.
Affiliations
  • University of Chicago (US)
  • Fırat University (TR)
  • University of Hertfordshire (GB)
  • Universidade Federal do Rio de Janeiro (BR)
  • Hyogo Medical University (JP)
  • Department of Psychiatry; National Institute of Mental Health and Neurosciences; Bangalore India
  • Columbia University (US)
  • Aarhus University Hospital (DK)
  • Department of Psychiatry; VU University Medical Center; Amsterdam The Netherlands
  • King's College London (GB)
  • Texas A&M University (US)
  • University of Cape Town (ZA)
ORCID
Venue
World Psychiatry
Publisher
Wiley
Published
2014-06
Volume
13
Issue
2
Pages
125-127
ISSN
1723-8617 (ISSN-L)
DOI
10.1002/wps.20115
PMC
PMC4102276
OpenAlex
W2029913776
Cited by
227
References
23
Citations by year
2026: 4 · 2025: 7 · 2024: 6 · 2023: 12 · 2022: 19 · 2021: 28 · 2020: 68 · 2019: 16 · 2018: 11 · 2017: 19 · 2016: 19 · 2015: 16 · 2014: 1 · 2012: 1
FWCI
21.70
Type
journal article
Language
en
Open access
Licence
doi.wiley.com/10.1002/tdm_license_1.1 (tdm, 457 d)
Locations
  • World Psychiatry (publishedVersion)
  • Europe PMC (PubMed Central) (publishedVersion)
  • PubMed Central (publishedVersion)
  • PubMed (publishedVersion)
  • Amsterdam UMC (VU Amsterdam) - Institutional Repository (publishedVersion)
  • Research Portal (King's College London) (submittedVersion, other-oa)
  • DSpace - FIRAT (Fırat University) (submittedVersion, cc-by-nc-nd)
  • Pure Amsterdam UMC (submittedVersion)
  • Data Archiving and Networked Services (DANS) (submittedVersion)
Funders
World Health Organization
Topics
  • Social Sciences › Psychology › Clinical Psychology › Gambling Behavior and Treatments
  • Social Sciences › Sociology and Political Science › Impact of Technology on Adolescents
  • Health Sciences › Medicine › Epidemiology › Substance Abuse Treatment and Outcomes
Keywords
ICD-11, impulse control disorders, behavioral addiction, gambling addiction, intermittent explosive disorder, kleptomania, pyromania, trichotillomania, compulsive buying, compulsive internet use, compulsive sexual behavior, psychiatric classification, diagnostic criteria, obsessive-compulsive and related disorders, reward processing, clinical utility

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