Abstract
Among the important changes in the ICD‐11 is the addition of 21 new mental disorders. New categories are typically proposed to: a) improve the usefulness of morbidity statistics; b) facilitate recognition of a clinically important but poorly classified mental disorder in order to provide appropriate management; and c) stimulate research into more effective treatments. Given the major implications for the field and for World Health Organization (WHO) member states, it is important to examine the impact of these new categories during the early phase of the ICD‐11 implementation. This paper focuses on four disorders: complex post‐traumatic stress disorder, prolonged grief disorder, gaming disorder, and compulsive sexual behaviour disorder. These categories were selected because they have been the focus of considerable activity and/or controversy and because their inclusion in the ICD‐11 represents a different decision than was made for the DSM‐5. The lead authors invited experts on each of these disorders to provide insight into why it was considered important to add it to the ICD‐11, implications for care of not having that diagnostic category, important controversies about adding the disorder, and a review of the evidence generated and other developments related to the category since the WHO signaled its intention to include it in the ICD‐11. Each of the four diagnostic categories appears to describe a population with clinically important and distinctive features that had previously gone unrecognized as well as specific treatment needs that would otherwise likely go unmet. The introduction of these categories in the ICD‐11 has been followed by a substantial expansion of research in each area, which has generally supported their validity and utility, and by a significant increase in the availability of appropriate services.
Keywords: International Classification of Diseases, ICD‐11, diagnosis, complex post‐traumatic stress disorder, prolonged grief disorder, gaming disorder, compulsive sexual behaviour disorder, clinical utility, mental health care
The eleventh revision of the World Health Organization (WHO)’s International Classification of Diseases (ICD‐11) was approved by the World Health Assembly, comprising the health ministers of all WHO member states, on May 25, 2019 1 . Reporting of health statistics to the WHO based on the new diagnostic system began on January 1, 2022 2 . WHO member states are now transitioning from the ICD‐10 to the ICD‐11, a process that will take several years to implement fully around the world. Countries that have not yet implemented the ICD‐11 in their health information and reporting systems will use conversion algorithms in order to comply with the WHO reporting requirement in the meantime.
The primary purpose of the ICD classification is to provide a framework for the collection and reporting of information on mortality and morbidity by WHO member states, including disease surveillance and national and global health statistics. The ICD is also used by member states in the organization of clinical services from the institutional to the national level, and as an integral part of the framework for defining their obligations to provide free or subsidized health services to their citizens 3 . For individual users, the ICD organizes and facilitates clinical practice and research.
Over the past decade and within the context of the overall development of the ICD‐11, the WHO Department of Mental Health and Substance Use has developed Clinical Descriptions and Diagnostic Requirements (CDDR) for ICD‐11 Mental, Behavioural and Neurodevelopmental Disorders, which are intended to provide sufficient information for reliable implementation in clinical settings 4 . The Department had previously published Clinical Descriptions and Diagnostic Guidelines (CDDG) for ICD‐10 Mental and Behavioural Disorders 5 simultaneously with the publication of the ICD‐10. The development of the ICD‐11 CDDR, based on the principles of clinical utility and global applicability, has been the most broadly international, multilingual, multidisciplinary and participative revision process ever implemented for a classification of mental disorders6. In part, the structure and methodology for developing the ICD‐11 CDDR were specifically intended to address some of the shortcomings of the ICD‐10 CDDG 4 . The change in title from CDDG to CDDR relates to the development by the WHO over the past decade of a body of policies that define guidelines in a specific way that is not applicable to the CDDR.
Among the important changes introduced in the ICD‐11 classification of mental disorders 6 is the addition of 21 new categories, shown in Table 1. Proposals to add new categories are invariably intended to increase the recognition and prominence of a disorder that does not appear as a specific entity in the prior edition of the classification. The most frequent rationales for such additions include the needs to: a) collect morbidity statistics on a new but currently unclassifiable mental disorder that has important public health significance; b) facilitate recognition of a clinically important but poorly classified mental disorder so that appropriate management can be provided; and c) stimulate research into the development of more effective treatments for that condition.
Table 1.
New disorders introduced in the ICD‐11 classification of mental, behavioural or neurodevelopmental disorders
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Type 1 additions (novel disorders previously not specifically classifiable) Body dysmorphic disorder Olfactory reference disorder Hoarding disorder Excoriation disorder Prolonged grief disorder Rumination‐regurgitation disorder Body integrity dysphoria Gaming disorder Compulsive sexual behaviour disorder Intermittent explosive disorder Type 2 additions (novel categories emerging from extension, expansion or subtyping of ICD‐10 disorders) Partial dissociative identity disorder Binge eating disorder Avoidant‐restrictive food intake disorder Complex post‐traumatic stress disorder (PTSD) Factitious disorder imposed on another Substance‐induced anxiety disorder Substance‐induced obsessive‐compulsive or related disorder Substance‐induced impulse control disorder Secondary neurodevelopmental syndrome Secondary obsessive‐compulsive or related syndrome Secondary impulse control syndrome |
In principle, there is an ICD category available for every conceivable clinical presentation of a mental disorder, based on the provision of what are called “residual categories”. Residual categories include “other specified” and “unspecified” categories for each disorder grouping (e.g., other specified mood disorder; unspecified neurocognitive disorder). “Other specified” is used when there is no ICD‐11 category that corresponds to a particular presentation, and “unspecified” is used when there is insufficient information about a patient’s condition to assign a more specific diagnosis at a particular point in time.
If the clinician determined, for example, that a particular presentation involved clinically significant abnormal eating behaviours not explained by one of the specific feeding or eating disorders, another mental disorder or medical condition or the effects of a substance or medication, the category “Other specified feeding or eating disorders” could be assigned. If the clinician considered the presentation to constitute a mental disorder but it was not clear to which grouping it belonged, the category “Other specified mental, behavioural or neurodevelopmental disorders” or “Mental, behavioural or neurodevelopmental disorders, unspecified” could be used. However, using such residual categories as diagnoses for frequently occurring clinical presentations runs counter to the core purpose of the ICD to record unambiguous health data, because the same diagnostic label and code could be applied to a wide array of heterogeneous and potentially unrelated presentations. This situation often gives rise to the perceived need to add a new category.
From a classification perspective, new categories can be divided into two types. The first type involves diagnostic entities that represent a novel phenomenon which is qualitatively different from existing entities in ICD and was thus not specifically classifiable. In Table 1, new mental disorder categories in ICD‐11 that fit this description are designated as Type 1. For example, the phenomenology of hoarding disorder bears some resemblance to obsessive‐compulsive disorder (e.g., the irrational need to save items may resemble an obsession; excessive acquisition of possessions may resemble a compulsion). However, unlike in obsessive‐compulsive disorder, in hoarding disorder these behaviours are not undertaken with the goal of neutralizing or reducing concomitant distress and anxiety, and may be associated with pleasure or enjoyment. In addition, important treatments for obsessive‐compulsive disorder are not effective for hoarding disorder 7 . Based on its review, the ICD‐11 Working Group for this diagnostic area concluded that there was sufficient evidence to regard hoarding disorder as a separate mental disorder that had previously been under‐recognized and undertreated 8 . In the ICD‐10, presentations of hoarding disorder would most likely have been classified as “other specified neurotic disorder”, which is neither clinically informative nor statistically useful.
The second type of new disorder category emerges from extending, expanding or subdividing the conceptualization of an existing disorder so that it identifies a group of symptomatic presentations that are relatively homogeneous with respect to the underlying pathophysiology, course, prognosis or treatment, and sufficiently distinct so as to justify being considered a new disorder rather than a subtype of the original category. In Table 1, new ICD‐11 mental disorder categories that fit this description are designated as Type 2. For example, bulimia nervosa is a well‐established disorder defined by recurrent binge eating accompanied by repeated inappropriate compensatory behaviours, such as self‐induced vomiting or misuse of laxatives or enemas, to prevent weight gain. It has long been noted clinically and in the literature that there is a group of individuals who recurrently engage in binge eating but not in purging or other compensatory behaviours. The symptoms of these individuals do not meet the diagnostic requirements for bulimia nervosa, but they experience high levels of distress, elevated rates of other mental disorders, and substantial general health risk 9 , 10 . In the ICD‐10, these individuals might be diagnosed with “atypical bulimia nervosa”, “other eating disorder”, or “eating disorder, unspecified”, making unified statistical reporting and tracking of this group of patients difficult. The new ICD‐11 condition, binge eating disorder, is much more common than bulimia nervosa 11 , and also differs in terms of prognosis and treatment 12 , justifying its addition to the ICD‐11.
Given the major implications for the field and for WHO member states of adding new mental disorders to the official global classification system, it is important to examine the impact that their introduction has had. Although it has been too short a time since the official approval of the ICD‐11 by the World Health Assembly for the effects of these changes to be fully evaluated, a draft version of the ICD‐11 was made publicly available in 2012 13 , and many papers have appeared in the scientific literature related to proposals for the classification of mental disorders in the ICD‐11 6 . Therefore, the WHO’s intention to add the mental disorder categories shown in Table 1 to the ICD‐11 has been publicly communicated for a decade, and relevant research and clinical evidence has become available.
In this paper, we focus on the addition of four new categories to the ICD‐11 classification of mental disorders: complex post‐traumatic stress disorder (PTSD), which represents a modification of the ICD‐10 category “enduring personality change after catastrophic experience” as well as an extension of the category of PTSD; two completely novel disorders, prolonged grief disorder and gaming disorder; and one disorder, compulsive sexual behaviour disorder, which replaces a related but poorly defined disorder that had existed in the ICD‐10, “excessive sexual drive”. The “essential (required) features” from the CDDR for these four disorders are provided in Tables 2, 3, 4, 5.
Table 2.
Essential (required) features for complex post‐traumatic stress disorder in the ICD‐11 Clinical Descriptions and Diagnostic Requirements (CDDR)
The disturbance results in significant impairment in personal, family, social, educational, occupational or other important areas of functioning. If functioning is maintained, it is only through significant additional effort. |
Table 3.
Essential (required) features for prolonged grief disorder in the ICD‐11 Clinical Descriptions and Diagnostic Requirements (CDDR)
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Table 4.
Essential (required) features for gaming disorder in the ICD‐11 Clinical Descriptions and Diagnostic Requirements (CDDR)
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Table 5.
Essential (required) features for compulsive sexual behaviour disorder in the ICD‐11 Clinical Descriptions and Diagnostic Requirements (CDDR)
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Essential features in the CDDR represent those symptoms or characteristics that a clinician could reasonably expect to find in all cases of the disorder 4 . In this sense, they resemble diagnostic criteria in the DSM. However, artificial precision, such as using exact symptom counts and specific duration requirements as diagnostic cutoffs (unless these have been well established with appropriate global evidence), has generally been avoided. This allows for broader exercise of the professional’s clinical judgment depending on the characteristics of the patient – including cultural variations in presentation – and local circumstances. It is important to note that the essential features represent only a portion of the material provided for each disorder; the CDDR also include disorder‐specific information on additional clinical features, which describe important aspects of the clinical presentation that are not diagnostically determinative, boundary with normality (threshold), course features, developmental presentations, culture‐related features, gender‐related features, and boundaries with other disorders and conditions (differential diagnosis) 4 , 14 .
The four disorders discussed in this paper are of particular interest because they have been the focus of considerable activity and/or controversy, which is in part related to the fact that their official inclusion in the ICD‐11 as diagnostic categories represents a different set of decisions than had been made by the developers of the DSM‐5 15 . Categories similar to prolonged grief disorder and gaming disorder were included in the DSM‐5 section on “Conditions for Further Study”, outside the main classification. A counterpart to compulsive sexual behaviour disorder was proposed and then not included in the DSM‐5 at all 16 . Some symptoms similar to those of complex PTSD were added to the DSM‐5 criteria for PTSD 17 , but complex PTSD was not distinguished as a separate disorder.
In developing this paper, the lead authors (GMR and MBF) invited experts on each of these disorders to address the following questions: a) from a clinical perspective, why was this category considered important enough to be added to the ICD‐11 and what was the evidence available at the time?; b) how were individuals with this disorder diagnosed prior to the ICD‐11 and what were the implications for care of the absence of the diagnosis in the ICD?; c) what were the controversies (if any) about adding the disorder?; and d) what evidence has been generated and what other developments have occurred in relation to this category (e.g., changes in availability of clinical services) since the WHO signaled its intention to include it in the ICD‐11 classification?
COMPLEX POST‐TRAUMATIC STRESS DISORDER
The need for a complex PTSD diagnosis
Clinical presentations that extend beyond those described by the ICD‐10 diagnosis of PTSD, particularly among individuals who experienced extreme, prolonged or multiple forms of trauma, have been reported by clinicians and researchers over several decades 18 , 19 .
The WHO conducted two global surveys as a part of the early development of the ICD‐11 classification of mental, behavioural and neurodevelopmental disorders, the first in collaboration with the World Psychiatric Association 20 , and the second with the International Union of Psychological Science 21 . Among 3,222 psychiatrists and psychologists from 35 countries who participated in either survey in English or Spanish, complex PTSD was the most frequent diagnosis suggested for inclusion in the ICD‐11 22 . Participants indicated that the diagnosis was needed to better account for the distinct characteristics and consequences of complex trauma.
Based on its review of the evidence, the ICD‐11 Working Group on Disorders Specifically Associated with Stress recommended inclusion of complex PTSD in the ICD‐11 23 . The essential features of this condition as outlined in the CDDR are shown in Table 2.
The diagnosis of complex PTSD requires the presence of all three core symptoms of PTSD (re‐experiencing in the present, avoidance, and an ongoing sense of threat). In addition, complex PTSD is characterized by what are referred to as disturbances in self‐organization: severe and persistent problems in affect regulation; beliefs about the self as diminished, defeated or worthless; and difficulties in sustaining relationships and in feeling close to others.
The ICD‐11 diagnosis of complex PTSD acknowledges the existence of more diverse and pervasive symptoms that may particularly occur in response to certain types of traumas, such as prolonged or repetitive events from which escape is difficult or impossible (e.g., torture, slavery, prolonged domestic violence, repeated childhood sexual or physical abuse). The new category also flags the potential need for greater mental health resources in the form of longer, multi‐part or multimodal therapies.
History of the disorder
In 1992, the ICD‐10 had introduced a new category called “enduring personality change after catastrophic experience” (EPCACE). The ICD‐10 CDDG indicated that the personality change should be enduring and manifest as inflexible and maladaptive features leading to an impairment in interpersonal, social and occupational functioning. It also required the development of features not previously characteristic of the individual, such as a hostile or mistrustful attitude towards the world, social withdrawal, feelings of emptiness or hopelessness, a chronic feeling of being “on edge”, as if constantly threatened, and estrangement. The ICD‐10 CDDG also noted that PTSD could precede this type of personality change, which could therefore be seen in some cases as a chronic sequela of PTSD when it occurred in response to certain types of events. Examples of potential causes of EPCACE provided in the ICD‐10 CDDG included “concentration camp experiences, torture, disasters, prolonged exposure to life‐threatening circumstances (e.g., hostage situations: prolonged captivity with an imminent possibility of being killed)” 5, p.163 . Conceptually, therefore, EPCACE can be seen as a forerunner of ICD‐11 complex PTSD.
However, the diagnosis was neither widely taken up by clinicians nor subject to much empirical investigation. Reasons for this include the absence of important symptoms that are part of more recent formulations (e.g., problems with affect regulation, negative views of the self) and what seemed to be a narrow range of application. For example, prolonged and severe intimate partner violence or childhood physical or sexual abuse, which are much more common than the types of experiences described in the CDDG as causes of EPCACE, were not mentioned at all. Moreover, the description of symptoms of EPCACE was very broad and general, which made clinical application and research difficult 24 , 25 .
Concurrent with the development of the ICD‐10, the DSM‐IV was considering the inclusion of a new diagnosis based on a formulation of complex PTSD developed by Herman 18 , which was given the name “disorder of extreme stress not otherwise specified” (DESNOS). The DSM‐IV field trial for PTSD 26 , 27 indicated that individuals who had experienced early and chronic interpersonal trauma reported a greater number and severity of DESNOS symptoms particularly related to emotion regulation difficulties, negative self‐concept, and relational disturbances, in comparison to those without such a history. DESNOS did not include any of the symptoms traditionally understood to comprise PTSD, but rather was viewed as a distinct disorder that might complement PTSD. Ultimately, DESNOS was not included in the DSM‐IV on the grounds that there was not enough empirical support to warrant the addition of a distinct trauma‐induced disorder. The symptoms ended up being included in the “associated features” section of DSM‐IV PTSD, which facilitated clinicians’ awareness of their existence as possible post‐traumatic stress reactions.
The ICD‐11 proposal for complex PTSD 23 was derived from the ICD‐10 EPCACE diagnosis, but many aspects of its operationalization were based on the empirical literature that emerged from the DESNOS investigations. First, the ICD‐11 CDDR identify a wider variety of types of chronic and sustained trauma exposures as risk factors for the disorder, including childhood abuse and intimate partner violence. Second, while the diagnosis of EPCACE, like other ICD‐10 diagnoses reflecting personality changes, was intended to describe difficulties in three domains (i.e., affect, identify and relationships), these were only broadly described. The selection of specific symptoms and symptom clusters reflecting difficulties in these domains was guided by the DESNOS formulation in the DSM‐IV field trials 26 as well as by an expert consensus survey on complex PTSD 19 . These aspects of complex PTSD are formulated in the CDDR as severe and persistent problems with affect regulation, a deep and enduring negative sense of self, and persistent difficulties in sustaining relationships and in feeling close to others. Lastly, while ICD‐10 EPCACE had identified the sense of threat as a key symptom, ICD‐11 complex PTSD includes all three PTSD core symptoms as part of the profile (i.e., re‐experiencing in the present, avoidance, and an ongoing sense of threat). This decision was supported by the observation in the DSM‐IV field trial that nearly all individuals whose symptoms met criteria for DESNOS also met criteria for these three symptoms of PTSD 26 .
In summary, ICD‐11 complex PTSD derived from the general conceptualization of EPCACE, which included both traditional PTSD symptoms as well as an emphasis on disturbances in affect, identity and relationships. In the ICD‐10, EPCACE was included in a grouping called “enduring personality changes, not attributable to brain damage” (along with enduring personality change after psychiatric illness), which was adjacent to the specific personality disorders. In contrast, in the ICD‐11, complex PTSD is grouped together with other disorders in which a stressor is required as causal agent.
The presence of re‐experiencing, avoidance and threat symptoms in both PTSD and complex PTSD highlights the continuity between the two disorders. However, the greater number and diversity of symptoms in complex PTSD, the greater impairment associated with it, and the relative dominance of the disturbances in self‐organization (i.e., affect dysregulation, negative self‐concept, and relational difficulties) over the PTSD symptoms indicate the importance of describing complex PTSD as an independent disorder rather than as a subtype of PTSD. The CDDR specify that an individual can be diagnosed with either ICD‐11 PTSD or complex PTSD, but not both.
Controversies related to the diagnosis of complex PTSD
A debate about the clinical utility and validity of the diagnosis of complex PTSD has been ongoing since its formulation in the 1990s28. Several reasons have been given for rejecting its adoption in official classification systems. These include: a) the lack of a consistent definition of the disorder; b) the lack of standardized and validated measures; c) the argument that it simply represents a severe form of PTSD; and d) difficulty differentiating it from borderline personality disorder 29 .
These concerns have been addressed in substantive ways. The introduction of complex PTSD into the WHO’s diagnostic nomenclature has brought with it a clear definition of the disorder. This established definition has provided the foundations for the development of reliable measures. A self‐report measure has now been validated 30 , translated into over 25 languages, and made available to the international community (see www.traumameasuresglobal.com). In addition, there has been significant progress in the testing of a clinician interview 31 . The suggestion that complex PTSD is simply a more severe form of PTSD has not been supported but rather countered by over 15 studies indicating that the two diagnostic categories identify distinct trauma populations with qualitatively different patterns of symptom endorsement 32 , 33 .
Lastly, a growing number of studies indicate that, while complex PTSD and borderline personality disorder have some overlapping symptoms, they are more distinct than similar, particularly in regard to key symptoms and treatment implications. In fact, while the affect dysregulation symptoms overlap between the two disorders, recent research shows that other borderline personality disorder symptoms are quite distinct from the disturbances in self‐organization occurring in complex PTSD 34 . Specifically, borderline personality disorder is marked by instability in identity, fluctuating and volatile relationships, and the salient presence of self‐injurious and suicidal behaviours, while complex PTSD tends to be characterized by a negative but stable identity, a consistent tendency to avoid or break off relationships, and relatively lower levels of impulsivity. There is some indication that differences in identity characteristics may most effectively distinguish the two disorders 35 .
Review of the evidence
The validity of the complex PTSD diagnosis has been supported by a number of studies using a variety of methods and statistical approaches.
Initial investigations focused on determining whether trauma‐exposed populations are best described under the umbrella of a single diagnosis, as has been done by the DSM‐5 (i.e., as a part of PTSD), or if they fall into different groups based on symptom profiles and do so consistently across different settings and cultures.
In an initial validation study 36 , latent profile analyses revealed that trauma‐exposed individuals fell into two different subgroups, with one displaying a complex PTSD symptom profile and the other a PTSD profile. Moreover, membership in the complex PTSD subgroup was strongly predicted by a history of chronic trauma, while membership in the PTSD subgroup was predicted by exposure to single‐incident trauma.
A 2017 review of studies investigating ICD‐11 complex PTSD 32 reported an additional nine investigations using latent profile/class analyses, eight of which replicated the finding of distinct complex PTSD and PTSD subgroups. The studies included a variety of samples, such as individuals with histories of childhood sexual abuse, military veterans, war‐exposed civilians, and mixed trauma samples, and represented research from different regions of the world, including the US, the UK, Israel, Uganda and Bosnia, indicating the consistency of PTSD and complex PTSD profiles over many types of trauma populations and regions in the world.
More recent summaries have indicated that, relative to PTSD, complex PTSD is associated with greater comorbidity, greater impairment, and lower quality of life 33 . A prospective study has found that complex PTSD is associated with poorer health and greater cognitive decline over time 37 . A functional magnetic resonance imaging (fMRI) investigation 38 has provided evidence of distinct neural profiles of complex PTSD and PTSD patients during the processing of threatening stimuli, with increased insula and right amygdala activation in complex PTSD, a finding similar to other studies 39 , 40 and consistent with disturbances in emotion regulation and self‐concept as described for that condition in the ICD‐11.
Clinicians’ capacity to accurately distinguish between the two disorders has also been documented. Using a vignette‐based experimental design, an ICD‐11 field trial assessed whether clinicians would be able to accurately diagnose ICD‐11 complex PTSD as compared to ICD‐10 EPCACE, and whether clinicians would successfully distinguish ICD‐11 complex PTSD from ICD‐11 PTSD on the basis of the presence or absence of disturbances in self‐organization 41 . The accuracy rate for complex PTSD was significantly higher than for EPCACE, indicating the benefits of the conceptual revision and symptom specification in ICD‐11. Clinicians were also able to successfully differentiate complex PTSD from PTSD with high accuracy.
The factor structure of the symptoms comprising complex PTSD is also supportive of its construct validity. Several studies have found that each of the six symptom clusters demonstrates good to excellent internal consistency 42 . In addition, the studies have reported that higher‐order factors of PTSD and disturbances in self‐organization (affect dysregulation, negative self‐concept, and relational difficulties) were either the best fit or a very strong fit to the data. This evidence supports the conceptualization of complex PTSD as having two higher‐level symptom components (PTSD and disturbances in self‐organization). It should be noted that studies with certain populations have not found this higher‐level organizatione.g.,43, a finding that is of interest and requires further investigation.
A series of network analyses assessing the symptoms of complex PTSD across four nationally representative samples (Germany, Israel, the UK, and the US) found that – despite differences in traumatic experiences, symptom severity and symptom profiles – the networks (e.g., clustering of symptoms) were very similar across the four countries, providing evidence of the stability and relative invariance of the symptom clusters 44 . In addition, the analyses indicated that negative self‐concept was the most central aspect of the complex PTSD formulation, followed by affect dysregulation, while the PTSD symptoms were less central to the disorder and significantly influenced by the disturbances in self‐organization. This finding supports the ICD‐11 decision to identify complex PTSD as a separate disorder rather than as a subtype of PTSD, because the most dominant and influential symptoms are those unique to the new diagnostic category. This finding also has implications for assessment and treatment planning.
Implications of the complex PTSD diagnosis
One important implication of the diagnosis of complex PTSD is its potential impact on treatment. Although no systematic data have been published, clinical reports indicate that, prior to the availability of the new diagnostic category, individuals with complex PTSD were likely to be diagnosed with PTSD along with one or more co‐occurring disorders, in an attempt to account for the full range of presenting symptoms 45 . Additional diagnoses might include recurrent depressive disorder, generalized anxiety disorder, panic disorder, social anxiety disorder, and personality disorder, most commonly borderline type, but also schizoid or avoidant.
The implications for care under this scenario are significant. First, multiple diagnoses involve a risk that the patient will “fall through the cracks” or have an overly long and disorganized treatment program. Second, patients might view themselves as very sick or feel stigmatized, including by health professionals, due to being diagnosed with numerous mental disorders. Third, diagnosing complex PTSD as PTSD can lead to treatment needs being underestimated. There is evidence that standard PTSD treatments primarily designed for single traumatic events may provide inferior outcomes for complex PTSD patients. A recent meta‐analysis indicated that patients with childhood trauma, a group of people more likely to have a complex PTSD diagnosis, received less benefit from standard PTSD treatment than those without childhood trauma with respect to numerous symptom outcomes, including PTSD symptoms, emotion regulation difficulties, negative self‐concept, and interpersonal problems 46 , 47 .
While much remains to be determined, particularly about treatment implications, the announcement of the intention to include complex PTSD in the ICD‐11 prompted considerable research interest. A PubMed search (search terms: CPTSD or “complex PTSD” or “complex posttraumatic stress disorder” or “complex post traumatic stress disorder”) identified 16 publications in 2014, the year after the first formal report 23 . In the following years, the number of publications steadily increased each year, such that by 2020 a total of 322 studies had been published on this condition. This is more than double the number of publications in the 21 previous years (1992‐2013) during which the term complex PTSD had existed 18 .
Papers have included psychometric studies of the validity of the diagnosis, development of standardized measures, epidemiological surveys, risk factor and treatment research, and comparisons with PTSD in the DSM‐5. Importantly, and consistent with the mission of the WHO, the validity of complex PTSD has been supported in studies on four continents and in a wide range of cultures. Also of interest are studies supporting the validity of the diagnosis in samples of children and adolescents 48 , and its particular relevance to occupational groups such as police officers exposed to chronic and repeated stressors 49 .
Research funding specific to complex PTSD has emerged, which will contribute to the progress of knowledge about how best to treat the disorder. The existence of the complex PTSD diagnosis should help draw attention to the importance of chronic trauma‐related symptoms as a prominent aspect of mental health. It is hoped that the designation of complex PTSD as distinct from PTSD will have a public health benefit derived from the development of population‐tailored interventions, leading to greater efficiency in the deployment of global health resources as well as better outcomes for people with these disorders.
PROLONGED GRIEF DISORDER
In the ICD‐11, prolonged grief disorder is described as persistent longing or yearning for the deceased and associated intense emotional pain, difficulty accepting the death, feeling to have lost a part of oneself, an inability to experience positive mood, emotional numbing, and difficulty in engaging with social or other activities 14 (see Table 3). The severe grief response needs to persist beyond 6 months after bereavement, or for a time that clearly exceeds the norms of the person’s culture. It is expected that the symptoms be associated with impaired personal, social or occupational functioning.
The need for a prolonged grief disorder diagnosis
There has been accumulating evidence over many years validating prolonged grief disorder as a specific and identifiable condition that can severely impact a minority of bereaved people. There are many factor‐analytic studies indicating that the construct of persistent yearning and emotional pain, together with its associated symptoms, is a well‐defined syndrome, and that this syndrome is distinct from other related disorders such as depression and PTSD 50 , 51 , 52 . Furthermore, studies using network‐analytic approaches to model the centrality of prolonged grief disorder symptoms have converged on the conclusion that yearning for the deceased and associated emotional pain have a cascading effect on other symptoms 53 , 54 .
It is important to note that studies of the nature of prolonged grief disorder symptoms indicate that these symptoms are not different from those typically reported in normal grief reactions 55 . The defining feature of prolonged grief disorder is that these reactions do not abate over time and continue to cause severe distress and impairment.
One of the major rationales for recognizing prolonged grief disorder as a distinct syndrome is that persistent grief can cause many physical and psychological symptoms as well as problems with functioning. Persistent grief reactions have been associated with marked occupational and social impairment 56 , impaired sleep 57 , increased rates of cancer and cardiovascular problems 58 and other medical conditions 59 , and poor health behaviours, such as increased alcohol and tobacco use 60 , 61 . There is also overwhelming evidence that persistent grief reactions are associated with elevated rates of other mental disorders and symptoms, including depression 62 , 63 , PTSD 52 , suicidality 64 , 65 , and panic 66 . Importantly, it has been shown that the symptoms of prolonged grief disorder contribute to impaired functioning beyond the effects of co‐occurring depression and PTSD 67 . Taken together, these findings indicate that there is a public health need for recognition of this new diagnostic category in order to identify and successfully treat a disorder that contributes to considerable impairment amongst people who suffer from it.
Traditional conceptualizations of grief
Although having a diagnostic category for problematic and persistent grief is new, the study of grief has a long tradition in psychiatry. The importance of bereavement and loss in mental health has been extensively theorized about for many years by Freud, Lindemann, Parkes and Bowlby 68 .
In his seminal text Mourning and Melancholia 69, Freud distinguished between normal and pathological grief by postulating that melancholia (which had some similarities to current descriptions of prolonged grief disorder) was a maladaptive form of mourning in which the object loss was so severe that affected individuals could not transfer their attachments to new relationships.
A consistent theme across earlier theorists was the role of fragmented attachments. This was articulated most clearly by Bowlby in his work on how fragile attachment tendencies acquired early in life can predispose people to pathological grief reactions in the wake of bereavement later in life 70 . Comparable to current conceptualizations of prolonged grief disorder, Bowlby recognized that yearning for the bereaved was central to the condition, as the person strives to re‐connect with the lost attachment figure. The emphasis placed on the role of fragmented attachments has been supported by many studies showing that anxious attachment tendencies are associated with prolonged grief disorder 71 , 72 .
Although these earlier theorists paved the way for the current conceptualization of prolonged grief disorder, there has been a long‐standing reluctance to introduce a diagnosis of pathological grief. In the DSM‐III and DSM‐IV, problematic but normal grief reactions were included in the chapter “Other conditions that may be a focus of clinical attention”, which included phenomena that are not mental disorders but might bring a person into contact with a mental health professional, such as parent‐child relational problems. Psychiatric presentations occurring in the wake of bereavement that were sufficiently severe or impairing to be considered a mental disorder would be diagnosed based on the pattern of symptoms; for example, a major depressive episode triggered by bereavement would be diagnosed in the same way as if it had been triggered by the termination of a romantic relationship.
This DSM conceptualization of mood disturbance following bereavement was qualitatively distinct from current conceptualizations of prolonged grief disorder because, rather than placing yearning for the deceased at the core of the condition, bereavement issues were considered through the lens of depression. Moreover, because of the prevalence of depressed mood amongst the bereaved, editions of the DSM prior to the DSM‐5 advised against diagnosing major depressive disorder after bereavement if such episodes were better understood to be manifestations of normal bereavemente.g.,73.
Controversies related to the diagnosis of prolonged grief disorder
For many years, controversy has surrounded the optimal way to categorize the psychological distress that can persist after bereavement. Despite strong proposals being put forward to introduce a problematic grief diagnosis, these were rejected in earlier iterations of the DSM 74 , 75 . This hesitancy has been based, in part, on a view that psychiatry should not be medicalizing a nearly universal experience. That is, most people will experience grief following bereavement, and it was argued that introducing a grief diagnosis would pathologize normal grief reactions and potentially lead to over‐prescription of psychotropic medication for the bereaved 76 . Moreover, the experience of grief is often culturally bound and linked to distinct religious mourning rituals, and so there have been concerns that any attempt to categorize persistent grief as a disorder may ignore this variability. To consider the merits and potential limitations of a prolonged grief disorder diagnosis, it is worth considering the evidence pertaining to the most frequent concerns held by commentators.
The concern that a diagnostic category of prolonged grief disorder may over‐medicalize the common grief response that most people experience after bereavement is countered by the evidence that only a small proportion of bereaved people actually have symptoms that meet the requirements for that diagnosis. Studies estimate that only 7‐10% of bereaved people may suffer from this condition 77 , 78 . Prevalence is low even in groups characterized by exposure to the traumatic deaths of close family members. For example, in a study of refugees fleeing a war zone, only 16% of bereaved people developed symptoms meeting diagnostic requirements for prolonged grief disorder 79 . At the level of the general population, estimates indicate that only 2‐3% of people may experience prolonged grief disorder, in contrast with the nearly universal experience of bereavement 62 , 77 . These findings suggest that prolonged grief disorder does not over‐pathologize problematic grief reactions, because only a small minority of bereaved people would qualify for the diagnosis.
The concern that the prolonged grief disorder diagnosis may be problematic because of cultural differences in how people mourn and express grief can be considered in two ways. First, the diagnosis requires that the persistent grief reaction needs to be outside the realm of what is normative in the person’s cultural context, especially in terms of duration. Second, the diagnostic features of prolonged grief disorder have been observed in Western and non‐Western countries that comprise many different cultures and religions 80 , 81 , 82 .
There have also been concerns regarding the amount of time that needs to elapse before the grief response is considered prolonged. This issue is particularly important, because the symptoms of prolonged grief disorder are not qualitatively different from the manifestations of normative acute grief. The duration requirement, therefore, functions to achieve a balance between capturing a pathological grief reaction and not misdiagnosing normative grief. Empirical studies that have considered this question have concluded that people with severe grief symptoms persisting beyond 6 months typically have ongoing difficulties in functioning at later assessment 83 , 84 .
Review of the evidence
The introduction of the diagnostic category of prolonged grief disorder has been supported by emerging evidence regarding both the construct validity of this category and its differentiation from other disorders. There is increasing evidence that prolonged grief disorder is a distinct syndrome that revolves around longing or yearning for the bereaved. Many factor‐analytic studies have highlighted that this disorder is distinct from depression and PTSD 50 , 51 , 52 , and is responsible for marked functional impairment beyond the effects of co‐occurring depression, anxiety and PTSD 56 , 85 . Evidence is also emerging that prolonged grief disorder worsens the severity of co‐occurring conditions after bereavement, including PTSD 86 and depression 87 .
In recent years, longitudinal findings have also emerged regarding the course of prolonged grief disorder. This is critical, because the lack of evidence regarding the normative time course of grief was one of the major obstacles to the introduction of that diagnostic category in the DSM‐5. Longitudinal studies assessing bereaved people at multiple time points, and using latent growth mixture modelling to map the different trajectories of grief symptoms over time, have noted the presence of a group with high grief symptoms that do not improve over time 88 , 89 , 90 . However, these studies are limited by small sample sizes, relatively short follow‐up assessments, or other methodological issues. Further studies, particularly those with larger sample sizes or longer‐term time frames, have observed distinct trajectories in which most people are resilient to the effects of bereavement, a smaller but significant proportion have grief symptoms improving over time, others have moderate and persistent symptoms, and a smaller group exhibits high levels of grief symptoms that do not improve over time (i.e., prolonged grief) 91 , 92 . It appears that, whereas prolonged grief disorder and depression follow some of the same trajectories after bereavement, there are also trajectories unique to each 93 . Another study found that the ICD‐11 prolonged grief disorder construct is more consistent with the observed patterns than “persistent complex bereavement disorder” as described in the DSM‐5 research appendix 94 . Longitudinal studies also indicate that people with prolonged grief disorder experience deterioration in functioning, and this can persist for at least 3 years post‐bereavement 90 .
Research has started to shed light on the neural underpinnings of prolonged grief disorder, and this work has indicated links between characteristic symptoms of the disorder – in particular, profound yearning – and a differential pattern of activation of the neural reward system compared to normative grief 95 . Affected areas include the amygdala, the orbitofrontal cortex, the subgenual anterior cingulate cortex, the nucleus accumbens and the insula 96 , 97 , 98 , 99 , 100 , 101 . Notably, neural responses of people with prolonged grief disorder are distinct from those of individuals with PTSD or depression 96 .
The notion that prolonged grief disorder may be associated with disturbed reward processes has also been supported by other experimental paradigms. One experiment showed that bereaved individuals with prolonged grief symptoms had a greater tendency to discount the value of future rewards (operationalized as a delayed financial incentive) as compared to bereaved persons without those symptoms 102 .
On behavioural tasks, people with prolonged grief disorder are drawn to stimuli reminiscent of the deceased 103 , 104 . This has led to theories emphasizing the role of conditioned responses associated with a range of environmental stimuli that elicit craving for the deceased and extinguish very slowly 105 . Other studies suggest these individuals avoid reminders of the deceased 106 , 107 . It seems that prolonged grief disorder involves both approach tendencies towards reminders of the deceased and avoidance of these reminders as a strategy to minimize the associated emotional distress 108 , 109 .
Numerous studies have highlighted the role of cognitive processes in prolonged grief disorder 110 , 111 . They include studies that have pointed to the importance of rumination, in which people tend to repetitively think about the causes and consequences of the death, which then contributes to worse emotional states 112 , 113 . Relatedly, engaging in counter‐factual thinking, in which people imagine that if they had behaved differently the situation would have turned out better, is associated with more severe prolonged grief symptoms 114 . The role of cognitions is underscored by evidence that more adaptive appraisals during the course of therapy mediate better outcomes for people with the disorder 115 . Further, longitudinal studies indicate that maladaptive cognitive appraisals, including rumination, mediate longer‐term prolonged grief symptomatology 88 , 116 .
There have also been advances in how we understand emotion regulatory mechanisms associated with prolonged grief disorder. The disorder tends to be associated with avoidance of emotions and thoughts associated with the deceased 117 , 118 , suppression of unwanted emotions or thoughts 117 , 119 , avoidance of external reminders that trigger negative emotions 120 , and impaired emotional flexibility 121 . There is also evidence that people with prolonged grief disorder show a distinctive disconnection between the experience and the expression of emotion; specifically, whereas they report strong affective experiences, they nonetheless are less facially expressive than bereaved controls 122 .
Implications of the prolonged grief disorder diagnosis
The introduction of the prolonged grief disorder diagnosis in the ICD‐11 has contributed to a surge of interest in problematic grief reactions, resulting in greater understanding of these conditions. Importantly, it has clearly influenced the recent decision by the American Psychiatric Association to promote the research category “persistent complex bereavement disorder” from its status as a condition for further study to being a full‐fledged disorder in the DSM‐5 Text Revision (DSM‐5‐TR) 123 . The new DSM‐5‐TR category has adopted the ICD‐11 name and has been placed in the chapter on Trauma and Stress‐Related Disorders. Prolonged grief disorder in the DSM‐5‐TR is defined very similarly as in the ICD‐11, with the exception that it requires 12 months to have elapsed since the loss as compared to 6 months in the ICD‐11 124 . It is a huge advance for the global study of prolonged grief disorder that the two major classification systems of mental disorders used around the world are converging on the definition of this syndrome. This will promote much greater standardization in diagnosis, lead to better estimation of global prevalence rates, and facilitate better dissemination and implementation of evidence‐based treatments.
One of the major aims of introducing the prolonged grief disorder diagnosis was to identify individuals who could benefit from available evidence‐based treatments. There is now convergent evidence from multiple controlled trials that grief‐focused psychotherapy is the treatment of choice, with most patients responding positively to this intervention 125 , 126 , 127 , 128 . There is also evidence that this treatment is more effective than other often‐used psychotherapeutic interventions 125 as well as selective serotonin reuptake inhibitors (SSRIs) 129 . This conclusion is supported by recent meta‐analysis of published prolonged grief disorder treatment studies 130 . This accumulating evidence highlights that a more standardized approach to diagnosing prolonged grief disorder can be helpful in directing persons with this condition to the best available care.
GAMING DISORDER
Video‐gaming has become one of the most popular and accessible leisure activities worldwide, based on which a global multi‐billion‐dollar industry has been built up. In recent years, the gaming landscape has evolved significantly, with the rise of e‐sports (multiplayer video games played competitively for spectators) and streaming platforms fuelled by constant advancements in Internet‐enabled portable and dedicated home gaming hardware.
For the vast majority of consumers of gaming products and services, recreational gaming can confer personal and social benefits 131 , 132 , even with relatively high levels of engagement (e.g., daily use for several hours or longer). Research has shown that gaming is an activity that can fulfil basic psychological needs such as relatedness, autonomy and competence 133 , especially for players able to successfully integrate their gaming activities with other important life domains 134 , 135 , 136 .
In the context of the COVID‐19 pandemic, some preliminary data suggest that involvement in gaming activities may have mental health and social compensatory benefits for those experiencing reduced face‐to‐face social contact due to social distancing or lockdown conditions 137 , 138 .
The need for a gaming disorder diagnosis
Excessive video‐gaming, characterized by loss of control over gaming behaviour, can lead to functional impairment and have negative consequences on physical health, social, educational and occupational domains 139 , 140 , 141 , 142 , 143 . Longitudinal studies have indicated that sustained problematic gaming behaviours are associated with psychopathological symptoms over time (e.g., anxiety and depressive symptoms) and predict decrements in functional outcomes (e.g., school performance) 144 , 145 , 146 .
Problem gaming was recognized as a potential mental disorder by the American Psychiatric Association with its inclusion of “Internet gaming disorder” in the DSM‐5 section on “Conditions for Further Study”. With the approval of the ICD‐11 in 2019, gaming disorder has been officially recognized as a mental disorder 14 , included in the new grouping of Disorders Due to Addictive Behaviours, which also includes gambling disorder. The essential features of gaming disorder according to the ICD‐11 CDDR are presented in Table 4.
There is mounting evidence of a relatively high prevalence of problem gaming in the general population. A recent meta‐analysis based on 53 studies estimated that the worldwide prevalence of problematic gaming was approximately 1‐2% 147 . The clinical research base was initially drawn predominantly from studies conducted in East Asian countries (specifically, South Korea, Japan and China) that were at the forefront of recognizing and responding to the phenomenon, but problem gaming has steadily become an internationally recognized public health issue. For example, specialized treatment services for the disorder have been developed in most American, European and Asian countries, suggesting that the condition is not primarily driven by specific cultural (e.g., collectivist as compared to individualist) or other region‐specific factors.
Clinical studies describing treatment‐seeking cases 148 , 149 , 150 , 151 , 152 , including studies of large samples of patients (N>200) 148 , 150 , have highlighted increasing referrals and associated service demands related to problem gaming. Studies examining problem gaming and co‐occurring diagnoses have noted that the former can be a primary diagnosis 148 , 153 , 154 , but in other cases may be a secondary clinical issue, for example, arising as a maladaptive coping strategy or compensatory mechanism 155 . Health care and counselling facilities worldwide have encountered growing demands for services related to problem gaming since the mid‐2000s156.
Prior diagnostic practice and implications for care
Prior to WHO’s publication of diagnostic requirements for gaming disorder as part of the ICD‐11 CDDR, individuals seeking treatment for problematic gaming behaviours were often diagnosed with alternative conditions (e.g., in the ICD‐10, pathological gambling, another habit or impulse disorder, a mood disorder, an anxiety disorder). This heterogeneity in the assigned diagnosis affected the type of treatment provided and hindered the collection of reliable data regarding individuals seeking treatment. The treatment offered to such individuals varied widely, depending on locally available mental health facilities, which often lacked relevant clinical expertise.
Outside the East Asian context, almost no national health care responses or other organized health service programs had developed in response to this need 139 , 156 , 157 , even in pioneering countries that had highlighted gaming disorder in their national health or addiction strategic plans more than a decade ago 158 , 159 . Lack of recognition of gaming disorder as a diagnostic category in the ICD appeared to be a major obstacle to provision of specialized care for patients and their families 139 , 156 , 160 .
Overall, including gaming disorder in the ICD‐11 has been an important step towards providing more effective, safe and person‐centered care in a timely, integrated and efficient way 161 . However, there remains some uncertainty among health professionals regarding how to respond to problem gaming. While some programs have been developed based on evidence‐based treatments known to be effective for other mental health and addictive disorders, there remains a need for more methodologically robust treatment studies (e.g., large‐scale randomized controlled trials with longer‐term follow‐up) focusing specifically on gaming disorder 162 .
Furthermore, to inform the development of more effective and comprehensive policies, there is a need for improvements in systems for monitoring problem gaming and gaming disorder in the population (e.g., relevant information on prevalence; clinical profiles of individuals presenting with problem gaming; associated morbidity and mortality) as well as indicators of resource allocation, treatment coverage, treatment effectiveness, and health care quality 139 , 163 .
Controversies related to including gaming disorder in the ICD‐11
Debates and controversies related to the recognition of gaming disorder as a mental disorder have existed for decades, echoing similar debates in the field of gambling studies 164 .
Criticisms of gaming disorder intensified following its inclusion in the public draft version of the ICD‐11165‐167 and when the ICD‐11 was officially adopted by the World Health Assembly. Critics have tended to put forward the following arguments: a) supporting evidence has mainly been the product of “confirmatory approaches”; b) recognition of the disorder might result in pathologizing non‐problematic gaming; and c) the notion of problematic gaming has been driven by “moral panic” rather than by scientific evidence.
The criticism of the validity of gaming disorder due to the use of confirmatory approaches 165 , 167 contends that high rates of gaming were conceptualized a priori as an addictive disorder and this conceptualization was then confirmed when excessive gaming was observed, without considering alternative explanations 168 , 169 . A study employing a confirmatory approach would adapt existing addiction‐based screening tools and substitute the term “gaming” for substance use, rather than developing new tools that may better reflect harmful or pathological gaming engagement 170 . The evidence base may be further compromised by lack of rigorous psychometric validation of scales and reliance on non‐clinical convenience samples 171 .
Another argument in opposition to gaming disorder has been the view that its diagnostic formulation, particularly the DSM‐5 diagnostic criteria set intended for further study, may be poor at discriminating between normal (non‐problematic) and harmful or pathological gaming behaviours 132 , 172 , 173 . The concepts of tolerance, preoccupation and withdrawal have attracted scrutiny for their imprecise operationalization when applied to gaming and other addictive behaviours. For example, the DSM‐5 criteria for Internet gaming disorder operationalize tolerance as “the need to spend increasing amounts of time engaged in Internet games”; preoccupation as “the individual thinks about previous gaming activity or anticipates playing the next game; Internet gaming becomes the dominant activity in daily life”; and withdrawal as “symptoms such as irritability, anxiety, or sadness when Internet gaming is taken away” 15, p.795 . Some authors have reported that gamers who do not exhibit evidence of other psychopathology or functional impairment may endorse such items intended to parallel substance addiction 174 , 175 , 176 , thus challenging their diagnostic utility 172 .
In an attempt to address these issues, a recent international Delphi study 177 investigated the clinical validity, utility and prognostic value of the DSM‐5 research criteria for Internet gaming disorder, as well as the proposed ICD‐11 diagnostic requirements. Experts agreed that criteria such as tolerance, deception and mood regulation were less capable of distinguishing between problematic and non‐problematic gaming and should not be used to diagnose gaming disorder. Furthermore, no consensus emerged among experts regarding the validity and clinical utility of the withdrawal or preoccupation criteria, suggesting that more research was needed before accepting them as diagnostic features of gaming disorder. On the other hand, this Delphi study supported the pivotal role of the core ICD‐11 diagnostic requirements: loss of control (over gaming), persistence despite negative consequences, and functional impairment as a result of gaming. Participating experts agreed that the ICD‐11 CDDR were likely to identify the condition adequately, and more likely to avoid pathologizing intensive but healthy gaming behaviours.
Some authors have further argued that support for the concept of gaming disorder may be based on “moral panic” rather than scientific evidence 165 , 178 . Moral panic refers to fear or anxiety that the well‐being of a community or society is threatened by a particular group or by social or technological changes. These authors argue that fears related to Internet gaming are not dissimilar to past concerns about technological developments like radio and television 179 .
The moral panic argument tends to advance the notion that a gaming disorder diagnosis will lead to undue concerns about the risks of gaming and will stigmatize individuals who play games, further perpetuating negative views toward gaming that predate the scientific literature and the WHO’s recognition of gaming disorder. However, the ICD‐11 CDDR are clear in specifying a high threshold for classifying gaming disorder (including significant distress or functional impairment), and do not state that gaming has inherent risks or harms.
Review of the evidence
Research evidence has accumulated since WHO’s proposal to include gaming disorder in the ICD‐11 was made public (approximately in 2012). Epidemiological research on gaming disorder was already increasing, but has accelerated even more in recent years. This increase has been especially marked in Europe 180 , 182 and Asia 183 , 184 . The evidence base includes general population health surveys, large surveys of adolescents in schools, and targeted non‐representative online surveys of adult gamers.
Systematic reviews of large‐scale studies 185 , 186 , 187 , 188 have reported prevalence rates from 1 to 3%, with slightly higher prevalence rates of 4 to 5% for adolescents. Males are 2 to 4 times more likely to report problem gaming than females 188 , and Asian countries have reported higher prevalence rates than Western countries.
Stevens et al’s meta‐analytic review 188 reported that the main variable affecting prevalence rates was the choice of the measurement tool for assessing problem gaming symptoms. The field has employed more than 30 different screening tools across more than 300 studies 171 . Screening approaches based on the DSM‐5 research criteria for Internet gaming disorder may misclassify some highly engaged gamers as disordered 189 , in line with experts’ observations that some DSM‐5 symptoms lack diagnostic utility 178 . Higher‐quality studies (e.g., stringent sampling, cross‐validation with quality of life and impairment measures) tend to report much lower prevalence rates 173 , typically below 1%.
Longitudinal studies on the stability of gaming disorder are limited and have reported inconsistent data 187 , including findings that less than 1% 190 or up to 26% 191 of adolescents with gaming disorder have symptoms that continue to meet diagnostic requirements at 2‐year follow‐up. There is a need for more robust epidemiological studies, including studies of the course of the disorder in higher‐risk groups and clinical samples across different regions. Rigorous studies are needed to examine whether it is possible to predict which adolescent problem gamers are likely to experience problems into adulthood and to explore features associated with persistence (e.g., multiple types of gaming behaviours, substance use), as has been done for adolescent gambling 192 .
Studies utilizing representative samples (e.g., recreational gamers, problematic gamers, treatment‐seeking gamers) and/or strong research designs (experimental or longitudinal) have yielded important evidence regarding neurobiological and psychological factors involved in gaming disorder. At the neurobiological level, Yao et al 193 provided a systematic review and meta‐analysis of case‐control studies reporting functional and structural neural alterations in fronto‐striatal and fronto‐cingulate cerebral regions in problem gamers. A more recent longitudinal study of a large sample of problematic and non‐problematic gamers found that problem gaming was characterized by greater dorsal striatal connectivity with the middle frontal gyrus, suggesting a ventral‐to‐dorsal striatal shift that aligns with other research on substance use and addictive disorders 194 . Further neurobiological similarities with addictive disorders include a stronger response to gaming on fMRI than to food (a primary reward) in problematic gamers but not in recreational gamers 195 .
Numerous studies have investigated the cognitive correlates of problematic gaming (e.g., executive control, attentional bias, decision‐making abilities) 196 , typically involving neuropsychological testing in laboratory settings. There is robust neuropsychological evidence derived from multiple studies that problematic gaming patterns are associated with inhibitory control impairment 197 , supporting the notion that loss of control over gaming is a key feature of gaming disorder. Finally, a number of studies conducted on treatment‐seeking cases showed that gaming disorder is frequently associated with heightened impulsivity, affective instability, and dysfunctional personality traits as assessed using psychometric questionnaires 148 , 198 , 199 .
Research on clinical interventions for gaming disorder has also accelerated during this period, particularly in countries that have developed specialized outpatient services for problem gaming 159 , 200 . East Asian countries – including South Korea, Japan and China – have been more proactive in developing wide‐ranging public health interventions and treatment programs for gaming problems 148 , 201 , 202 . The clinical literature includes data on the experiences of hundreds of gaming disorder patients, including self‐referred adult patients and families seeking help for an adolescent who may or may not be willing to attend treatment 159 , 162 . Moreover, some patient intake data from specialized mental health services are available, which highlight the public demand for these services.
The Kurihama Medical and Addiction Centre in Japan reported treating more than 200 patients with gaming disorder in 2019, which for many adolescent patients involved working with parents and other family members 157 . In the UK, the National Health Service (NHS)‐funded specialist service for gaming disorder, positioned within the National Centre for Behavioural Addictions, received more than 50 patients between January and May in 2021 204 . Other studies have shown that individuals with gaming‐related problems may also seek assistance from gambling treatment services 199 , units that specialize in the treatment of behavioural addictions 151 , 154 , broader treatment providers dealing with addictive disorders in general 204 , or non‐specialized services 200 .
Studies that include the administration of diagnostic interview schedules to identify co‐occurring conditions have reported that individuals diagnosed with gaming disorder experienced negative consequences in multiple life areas 199 , 205 , 206 , 207 , 208 , 209 , 210 . Many adolescent gaming disorder patients reported problems including reversal of day‐night sleep‐wake patterns, skipping meals due to gaming, physical violence toward others and hitting or breaking things when asked to stop or reduce gaming, poor school grades or work performance, and absence from school or work 201 .
Ko et al 207 compared individuals formally diagnosed with gaming disorder with non‐problematic gamers. They found that those with gaming disorder reported significant functional impairment across multiple domains, including academic and work performance, social functioning, and physical health (including problems related to sleep, pain, body weight, vision, and physical exercise). Psychological interventions designed to reduce gaming time and gaming disorder symptoms have demonstrated significant improvements in global measures of functional impairment 154 , 204 .
At the same time, it must be acknowledged that, in the context of the dramatic increase in scientific publications on problem gaming, many low‐quality studies have also been published. Weaker studies have relied extensively on self‐selected samples that do not necessarily include regular and/or problematic gamers, have used unvalidated or psychometrically poor self‐report assessment instruments, or have made causal inferences based on insufficient evidence 167 , 169 , 170 . This has fuelled criticisms about the robustness of the supporting evidence. Opponents of the disorder have selectively cited low‐quality studies to advance their arguments that the totality of evidence in favour of gaming disorder is insufficient or invalid, usually via news media and social media.
Additional research is important to understand more completely the nature of gaming disorder, its pathological mechanisms, its commonalities with gambling disorder and disorders due to substance use, its long‐term course and comorbidities, and its treatment. Nonetheless, there is clearly more than enough evidence to conclude that: a) individuals with gaming disorder are a legitimate clinical population for whom health services can be appropriately provided; b) it is of sufficient clinical and public health interest to WHO member states to collect and report health information about gaming disorder; and c) on this basis, the inclusion of this diagnostic category in the ICD‐11 is justified. If necessary, the CDDR for gaming disorder can be modified in future updates of the ICD‐11 in response to emerging evidence, but such evidence would be much less likely to become available if the category were not included in the ICD‐11.
Implications of the gaming disorder diagnosis
The recognition of gaming disorder in the ICD‐11, as well as its inclusion in the DSM‐5 research appendix, has accelerated basic and applied research endeavours 211 , 212 . Research into problem gaming has advanced particularly in the areas of epidemiology, neurobiology and interventions, and has also stimulated scientific interest in problematic engagement in other online activities (e.g., social networking sites, Internet pornography use, and e‐commerce) 213 , 214 . An advantage of the more streamlined ICD‐11 conceptualization of gaming disorder as compared to DSM‐5’s has been its clarity regarding the scope and clinical description of the condition, eschewing some traditional addiction concepts that have been criticized or have received mixed support as applied to problem gaming 140 , 141 , 172 . The WHO has also supported several initiatives related to problem gaming, including the development of new screening and diagnostic tools, promotion of standardized decision‐making tools, and support for health systems internationally 215 .
Research on psychological interventions for gaming disorder is an area that has grown in conjunction with the recognition of the disorder 159 , 162 . These interventions, particularly cognitive‐behavioural therapy (CBT), have been examined in more rigorous studies and thus far demonstrated strong short‐term efficacy 147 . Recently, a randomized controlled trial evaluating the efficacy of a manualized CBT program for gaming disorder found that most patients (69%) who received the intervention showed remission compared with less than one‐fourth (24%) of those in a waitlist control group 154 . Other approaches that have been tested in clinical trials include motivational interviewing and counseling, family therapy, and psychosocial rehabilitation 204 , 216 .
Government support for research programs and public health responses to gaming disorder have varied greatly by region 217 . In East Asian countries, there have been long‐standing coordinated governmental efforts to support research and public health initiatives 149 , 157 . In comparison, more limited funding for research and fewer public resources for treatment have been available across Western countries 218 . Examples of concrete developments following the release of the ICD‐11 include the opening in the United Arab Emirates of the first outpatient clinic for the treatment of gaming disorder, and the establishment by the NHS in the UK of the National Centre for Behavioural Addictions, which provides treatment for gambling and gaming disorders. Across many countries worldwide, there remains a need for training programs for health care professionals on identifying and managing gaming disorder.
The global gaming industry has adopted a public stance in opposition to the inclusion of gaming disorder in the ICD‐11 218 , 219 . The industry has also used its public platform and reach to endorse scholars who challenge the disorder and to direct public attention to research highlighting the benefits of gaming. To date, there has been very limited collaboration between the industry and public health stakeholders in relation to problem gaming, despite some calls from researchers for the industry to leverage its capabilities to assist in identifying and assisting vulnerable gamers. There have also been some proposals for the industry to consider more ethical game design standards and business practices 141 , particularly in relation to games marketed to children 220 and monetized games (e.g., prohibiting “loot boxes” that enable in‐game purchases of advantageous game features using virtual currencies or real‐world money) 221 .
COMPULSIVE SEXUAL BEHAVIOUR DISORDER
The need for a compulsive sexual behaviour disorder diagnosis
Compulsive sexual behaviour disorder is a new diagnostic category in the ICD‐11, included in the grouping of Impulse Control Disorders. The essential features of this condition in the CDDR are presented in Table 5. The diagnostic category is intended to identify a clinical population of people who experience being unable to control their sexual impulses and for whom health services might reasonably be provided. The inclusion of the category in the classification is responsive to the needs of WHO member states to identify this population and to develop relevant clinical services and policies, including subsidized treatment provided by governments or via other insurance mechanisms.
Compulsive sexual behaviour disorder replaces the ICD‐10 category of “excessive sexual drive”, but is defined and operationalized quite differently. The ICD‐10 CDDG for “excessive sexual drive” contain no specific diagnostic requirements and instead simply state that “both men and women may occasionally complain of excessive sexual drive as a problem in its own right, usually during late teenage or early adulthood” 5,p.152 . However, complaints of excessive desire alone do not identify a clinically relevant problem with public health significance 222 . The challenge in defining compulsive sexual behaviour disorder in the ICD‐11 was to balance its ability to identify people in need of treatment against the risk of pathologizing variants of sexual desire and behaviour that are not inherently harmful or pathological 223 , 224 .
Clearly, the ICD‐10 description of “excessive sexual drive” would encompass a range of individuals whose sexual interests, desires and impulses are not pathological but who may experience them as excessive because they are unwanted or “morally incongruent” 225 (e.g., a woman who believes that she should not have sexual impulses at all; a religious young man who believes that he should never masturbate; persons who are distressed about their homosexual attraction or behaviour). The ICD‐11 makes clear that distress related to the individual’s (or others’) moral judgements and disapproval related to sexual impulses, urges or behaviours that would otherwise not be considered indicative of psychopathology is not an appropriate basis for diagnosing compulsive sexual behaviour disorder. The “additional clinical features” section of the CDDR for the disorder also indicates that particular attention must be paid to the evaluation of individuals who self‐identify as having the condition (e.g., calling themselves “sex addicts” or “porn addicts”) in terms of whether they actually exhibit the clinical characteristics of the disorder 14 .
History of the disorder
The existence of a clinical population of individuals who feel unable to control their sexual impulses and as a result engage in repetitive and problematic sexual behaviour, sometimes with very serious consequences, has long been recognized. Prior to the proposal to introduce compulsive sexual behaviour disorder in the ICD‐11 223 , 226 , there has been more than a quarter century of active research 227 , 228 on the symptomatology, comorbidities, etiology, and linkages to clinical outcomes (such as risk for sexually transmitted infections 229 ) of a condition defined in relation to repetitive sexual behaviour, as well as on the related risks in the forensic context (especially for sexual reoffending 230 ).
It is therefore not the case, as some have claimed, that this diagnostic category is simply a fashionable new label that has emerged in relation to the increased use of digital media for sexual purposes (e.g., use of Internet as a source of pornographic material or a means of finding casual or anonymous sex) 231 . However, there is no question that greatly increased opportunities to engage in sexual behaviour via the Internet without even having to leave one’s home have changed the nature of these behaviours and greatly facilitated their frequent repetition 232 , therefore possibly contributing to an increase in the prevalence of compulsive sexual behaviour disorder.
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 it226. The term “sexual addiction” in the US came mainly from the self‐help group movement 233 . The term “sexual compulsivity” emerged in the field of human immunodeficiency virus (HIV) research, primarily from studies with samples of men who had sex with men 234 , 235 , 236 . “Sexual impulsivity” was described as a symptom of borderline personality disorder 237 , and “hypersexuality” had been used to describe a symptom associated with various other disorders, for example dementia 238 or Parkinson’s disease 239 .
A category called “hypersexual disorder” had been proposed for inclusion in the DSM‐5 228 . This was conceptualized as being “characterized by an increased frequency and intensity of fantasies, urges, and enacted behaviors associated with an impulsivity component” 228, p.385 . The disorder was proposed for inclusion in the DSM‐5 chapter on Sexual Dysfunctions because increased or disinhibited expressions of sexual arousal were considered to be its primary component, although some of its criteria had been modeled after those of substance dependence. There was substantial criticism of the proposal. The main arguments against it were that it represented a pathologization of normal variation (i.e., high sex drive), that there was insufficient evidence of its validity as a distinct clinical syndrome, and fears that the diagnosis could be misused in forensic settings by individuals seeking to evade responsibility for sexual misbehaviour 16 , 240 . In the end, hypersexual disorder was not included even in the DSM‐5 section on “Conditions for Further Study”, despite relatively successful application in a field trial 241 .
Although there is clearly similarity between ICD‐11 compulsive sexual behaviour disorder and hypersexual disorder as proposed for DSM‐5, the ICD‐11 entity is not conceptualized as a sexual desire disorder, and its diagnostic requirements do not focus on determining whether sexual interests and behaviour are excessive in their intensity, frequency, or time spent on them. Rather, the central feature of the ICD‐11 diagnostic category is the persistent pattern of failure to control intense, repetitive sexual impulses or urges, resulting in repetitive sexual behaviour with a variety of negative consequences for the individual, including marked distress or significant functional impairment.
This conceptualization clearly aligns compulsive sexual behaviour disorder with impulse control disorders, although aspects of its description are similar to those of ICD‐11 disorders due to addictive behaviours. The ICD‐11 CDDR explicitly state that a diagnosis of compulsive sexual behaviour disorder should not be assigned to individuals with high levels of sexual interest and behaviour (e.g., due to a high sex drive) who do not exhibit impaired control over their sexual behaviour. 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 . The WHO specifically declines to use the term “sex addiction”.
Controversies related to the diagnosis of compulsive sexual behaviour disorder
Controversies about the nature of this phenomenon and its classification have existed since the 1990s, particularly in relation to the term “sex addiction” and the condition’s etiology 227 . More than 20 years ago, Gold and Heffner 242 reviewed the available literature – comparing the competing conceptualizations as an addictive, obsessive‐compulsive, or impulse control disorder – and subtitled the resulting article Many Conceptions, Minimal Data. These controversies were never definitively resolved, which contributed to a diversification of research in different areas independently of one another, with the result that studies based on different paradigms were often not directly comparable.
These controversies were also reflected in adversarial and sometimes ad hominem comments made on the ICD‐11 platform about the inclusion of compulsive sexual behaviour disorder in response to the public draft version of the classification 13 . One focus of controversy revolved around whether certain patterns of sexual behaviour can reasonably be considered to represent an addiction 243 , 244 . A more extreme perspective reflected in some comments on the ICD‐11 platform was that sex addiction is a false construct that has been promoted by profiteering providers of unvalidated services and is fundamentally based on sex‐negative moral or religious judgments. The disagreement about the diagnostic construct and the lack of uniform diagnostic guidelines has fuelled discussions in the media and questions among the public regarding its legitimacy as a disorder 245 , and has also hindered the development of evidence‐based therapeutic approaches 227 .
Nonetheless, a large number of people describe themselves as having difficulty controlling their sexual behaviour, even though it is not always clear what they mean. In a US nationally representative sample of adult Internet users, 1% of men and 3% of women reported some agreement with the statement “I am addicted to pornography” 246 . In another nationally representative US study, 10.3% of men and 7.0% of women endorsed clinically relevant levels of distress and/or impairment associated with difficulty controlling sexual feelings, urges and behaviours 247 .
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. 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. The CDDR point out that the relevant behaviours do not represent true compulsions (as defined in obsessive‐compulsive disorder), but this term was adopted to describe the behaviour pattern because of the prevalence of its use in the scientific literature.
Review of the evidence
Prevalence data using the ICD‐11 diagnostic requirements are not yet available at the general population level. Castro‐Calvo et al 248 studied compulsive sexual behaviour disorder in two independent convenience samples in Spain, one comprising university students and the other community members who had volunteered to participate in a study about their sexual behaviour. The estimated prevalence of the disorder was 10.1% in the student sample and 7.8% in the community sample. Participants reporting symptoms meeting the requirements for the disorder were mostly heterosexual males, younger than the other respondents, and with higher levels of sexual sensation‐seeking and interest in sex, increased offline and especially online sexual activity, more depressive and anxious symptoms, and poorer self‐esteem.
Another study of US university students found that same‐sex attraction was significantly correlated with compulsive sexual behaviour 249 . However, Gleason et al 250 reported that the prevalence of clinically significant compulsive sexual behaviour among gay men in the US (7.9%) was not higher than in the general population 247 .
Across studies, endorsement of items related to compulsive sexual behaviour seems to be associated with male gender 247 , 248 , younger age 246 , 250 , religiousness 246 , 250 , and moral incongruence (i.e., the experience of engaging in activities that violate one’s moral values) 225 . In the absence of the other essential features, such subjective reports would not be sufficient for a diagnosis of compulsive sexual behaviour disorder in the ICD‐11. In studies of men who have sex with men, self‐reported compulsive sexual behaviour has been found to be correlated with depression 251 , anxiety 252 , and minority stress (i.e., the stress associated with stigma‐related social disadvantage that compounds general life stress) 253 , as well as to be associated with higher rates of sexual risk‐taking behaviours 254 , 255 .
A Swedish study reported a high need for health care specific to experiencing compulsive sexual behaviour 256 . During the first 7 years of its operation, 1,573 participants contacted a Swedish helpline specifically set up to provide counseling and treatment for high‐risk sexual behaviours to men and women with self‐identified out‐of‐control sexual behaviour and unwanted paraphilic arousal patterns. Compulsive sexual behaviour was reported by 69% of helpline users.
Clinical studies often investigate comorbidities between compulsive sexual behaviour disorder and other disorders. In one such study of a convenience sample of Spanish college students 257 , more than 91.2% of participants with that ICD‐11 diagnosis also had symptoms that met the diagnostic requirements for at least one other Axis I mental disorder during their lifetime, as assessed by the Structured Clinical Interview for DSM‐IV‐TR, compared to 66% of those without the diagnosis. Participants with compulsive sexual behaviour disorder were more likely to report disorders due to alcohol and other substances (mainly cannabis and cocaine), major depression, bulimia nervosa, and adjustment disorder.
In another study, 6.5% of treatment‐seeking individuals with gambling disorder reported experiencing compulsive sexual behaviour 258 . The lifetime prevalence of ICD‐11 compulsive sexual behaviour disorder was found to be 5.6% in patients with current obsessive‐compulsive disorder 259 . Elevated rates of compulsive sexual behaviour have also been found among individuals with attention‐deficit/hyperactivity disorder (ADHD) 260 , bipolar disorder 261 , borderline personality disorder 257 , 262 , PTSD 263 , paraphilias 264 , and erectile dysfunction 264 , 265 . Many individuals with compulsive sexual behaviour also report a history of sexual abuse as a child 266 , and the relationship between child sexual abuse and the behaviour appears to be stronger in men 267 .
Neurobiological and neuropsychological evidence about compulsive sexual behaviour and compulsive sexual behaviour disorder has also been accumulating. Individuals who report compulsive sexual behaviour, as compared to individuals who do not, exhibit increased blood flow in the reward system of the brain in response to erotic cues 268 , 269 , 270 , greater responsivity and attention to erotic cues 271 , 272 , 273 , increased gray matter volume in the left amygdala 274 , and decreased right caudate nucleus volume 275 . Men with compulsive sexual behaviour disorder, relative to controls without the disorder, also show increased anticipatory response to cues predictive of erotic rewards in the ventral striatum and anterior orbitofrontal cortex 276 . Current findings suggest that compulsive sexual behaviour disorder shares similar brain region abnormalities with both obsessive‐compulsive disorder and substance addiction, although further work is needed to elucidate the underlying brain mechanisms 277 .
One group of researchers has studied the pathophysiological mechanisms in men who report problems with compulsive sexual behaviour. They found that MIR4456 (an mRNA gene) had lower expression in males reporting vs. those not reporting the behaviour, and posited that this gene may play an important role in the oxytocin signaling pathway related to the expression of the behaviour 278 . They also found subtle deregulation of the hypothalamic‐pituitary‐gonadal axis, with increased luteinizing hormone plasma levels, but not differences in testosterone levels, between men reporting vs. those not reporting issues with compulsive sexual behaviour 279 .
In terms of treatment of the disorder, there have been several relevant advances since earlier reviews on the topic 280 , 281 . Randomized controlled trials have been conducted using a 7‐week CBT group intervention 282 as well as Internet‐administered CBT 283 , both of which showed significant reductions in symptoms as compared to waitlist control groups. Individuals treated with acceptance and commitment therapy reduced their Internet pornography use as compared to a waitlist control 284 , as did participants in a CBT‐based self‐help intervention 285 . Other studies have shown beneficial effects on compulsive sexual behaviour of a 12‐step self‐help group 286 , a mindfulness‐based intervention 287 , an intervention to reduce sexual risk behaviour in HIV‐positive men 288 , and an intervention designed to reduce minority stress 253 .
With regard to pharmacological treatment, a small study with no control group found a reduction in compulsive sexual behaviour in response to 25‐50 mg of naltrexone for four weeks 289 . No clear longer‐term beneficial effects were seen in response to the SSRI paroxetine in a case series 290 , consistent with the results of an earlier study 291 . Single case studies have been published on successful use of transcranial magnetic stimulation 292 , 293 .
In spite of uncertainties about compulsive sexual behaviour disorder, its course, and its relationship to other disorders, there is ample evidence of the existence of a clinical population of individuals who experience themselves as unable to control their repetitive sexual behaviour, in whom the behaviour pattern is manifest over an extended period of time and is associated with significant functional impairment or marked distress that is not solely related to moral judgments and disapproval.
Compulsive sexual behaviour disorder is associated with significant suffering and may have a substantial negative impact on the health and lives of the individuals it affects. It is therefore a legitimate focus of health services and is of interest to WHO member states in their efforts to provide or facilitate subsidized health services to their populations and for the collection and reporting of health information. It is expected that the expansion of research on the disorder will continue given its status as a WHO official diagnostic entity, with its own set of diagnostic requirements for use in identifying clinical and research populations. Researchers who had previously been connected to the DSM‐5 proposal for hypersexual disorder have acknowledged that the inclusion of compulsive sexual behaviour disorder in the ICD‐11 will have a significant impact on clinical research and practice and have suggested possible refinements to the ICD‐11 CDDR that can be tested in future research 294 .
Implications of the compulsive sexual behaviour disorder diagnosis
Since the inclusion of compulsive sexual behaviour disorder in the ICD‐11 was proposed, there has been a major expansion of research in this area 227 . A good deal of the early research was based on a conceptualization of “sex addiction” 242 , that later began to shift to a discussion of compulsive sexual behaviour, that does not entirely map to ICD‐11 compulsive sexual behaviour disorder 258 , 259 , 260 , 261 , 262 , 263 , 264 , 265 , 266 , 267 , 268 , 269 , 270 , 271 , 272 , 273 , 274 , 275 , 276 , 277 , 278 , 279 , 280 , 281 , 282 , 283 , 284 , 285 , 286 , 287 , 288 , 289 , 290 , 291 , 292 , 293 , 294 , 295 , 296 , 297 , or simply “problematic sexual behaviours” 298 or “problematic pornography use” 299 . A good deal of the research in the past several years has focused on “hypersexuality”e.g., 301,302, although this has only occasionally been operationalized as hypersexual disorder as it had been proposed for DSM‐5. So, there continue to be issues with comparability across studies.
The lack of theoretical integration in the literature has also produced discrepancies in the measurement of compulsive sexual behaviour disorder 227 . The most commonly used measures include the Sexual Compulsivity Scale 234 , the Sexual Addiction Screening Test‐Revised 303 , the Hypersexual Behavior Inventory 304 , and the Compulsive Sexual Behavior Inventory 235 . Despite their popularity, there has been little methodologically rigorous research to confirm the validity and reliability of these measures in clinical populations 305 .
Based on the draft ICD‐11 diagnostic requirements for compulsive sexual behaviour disorder, an international group of researchers developed the Compulsive Sexual Behavior Disorder‐19 (CSBD‐19) scale to assess the extent of repetitive sexual urges, thoughts and behaviours and their consequences during the previous six months 306 . The scale yielded a five‐factor structure (i.e., control, salience, relapse, dissatisfaction, and general and domain‐specific negative consequences), and its psychometric properties were robust across the three countries involved in the initial study (Germany, Hungary and the US). In 2021, an expanded consortium of researchers launched the International Sex Survey, a large‐scale multi‐language study involving over 40 countries. Upon its completion, the project will make the CSBD‐19 publicly available in over 30 languages for research and clinical practice 307 .
Resources to equip clinicians to assess and treat ICD‐11 compulsive sexual behaviour disorder have also begun to appear 231 , 245 . An expert group is being formed by the International Society for Sexual Medicine to launch position papers and develop guidelines on this topic. It is noteworthy that the American Psychiatric Association was the first to publish a clinical and treatment‐oriented book on compulsive sexual behaviour disorder 308 , despite its own decisions regarding hypersexuality in the DSM‐5.
In summary, the decision by the WHO to include compulsive sexual behaviour disorder in the ICD‐11 has broken the stasis due to questions about how to best conceptualize the condition. The ICD‐11 CDDR very carefully address concerns about false positives and the stigmatization of non‐pathological sexual behaviour. The inclusion of the disorder in the ICD‐11 has facilitated the provision of appropriate services and the development and testing of empirically‐supported treatments. Our understanding of the etiology, diagnostic classification, assessment, and treatment of the disorder will continue to evolve as we gain new insights from future research efforts. We anticipate that remaining controversies will be resolved over the next few years as scholarship on the disorder and related clinical experience continues to grow exponentially.
DISCUSSION
The rationale for the inclusion of each of the four disorders discussed in this paper illustrates the principles for adding new disorders in the ICD‐11 that we described in the introduction: a) to allow collection of morbidity statistics by WHO member states on health conditions with public health significance; b) to facilitate identification of clinically important but poorly classified mental disorders so that appropriate management can be provided; and c) to stimulate research into effective treatments for the conditions. The ICD‐11 now provides a consistent rubric and definitions for tracking and reporting of these conditions at the health system, national and global level. Having specific diagnostic requirements rather than using vague “other specified” or “unspecified” residual categories to capture the relevant phenomena obviously facilitates the identification of these conditions. Introducing these disorders into the ICD‐11 appears to have been followed by a significant increase in the availability of appropriate services for each condition and an uptick in research to evaluate available interventions.
The research literature on these disorders has expanded substantially since it was publicly announced that the WHO was planning to add them to the ICD‐11. A significant increase of interest in these categories was already underway, but their inclusion in the ICD‐11 has facilitated additional research by providing investigators with standardized definitions and diagnostic requirements, which can be used as a basis for developing appropriate measures, as well as building up a more compelling case for research funding from member state governments and other agencies.
As highlighted earlier in this paper, the decisions made by the WHO to add these categories are different from those taken by the American Psychiatric Association for the DSM‐5. In the case of complex PTSD, the DSM‐5 Workgroup decided to broaden the PTSD criteria to include elements of DESNOS, the earlier version of complex PTSD that had been tested for DSM‐IV, rather than adding a new diagnostic category. This has had the effect of substantially expanding the complexity of the PTSD diagnosis in the DSM‐5 309 . A variety of studies in different populations have since demonstrated the validity of the ICD‐11 approach 31 , 32 . Nonetheless, as the ICD‐11 is adopted in clinical systems, it will be important to examine whether the DSM‐5 PTSD and the ICD‐11 PTSD plus complex PTSD identify different groups and whether the implementation of the ICD‐11 leads to difficulties for some individuals in accessing services. This is a concern that some have expressed 310 , although available data suggest that the DSM‐5 criteria identify fewer cases than either the ICD‐11 or the DSM‐IV311.
In contrast to the situation with complex PTSD, versions of prolonged grief disorder and gaming disorder had been included in the DSM‐5 research appendix under slightly different names. Placement in this appendix suggests that there was substantial interest in the categories as candidate entries in the DSM‐5, but also an overall conclusion that the proposed criteria sets had not been sufficiently validated to include these disorders in the main classification. In the past, several DSM research categories have eventually been moved to the main classification, but this does not occur invariably. The ICD has no equivalent to a research appendix; a category is either included or not. In a few cases the entity in question may be added as an index term for an “other specified” residual category to indicate the recommended ICD‐11 category for classifying it, but there is no provision for including research definitions that can be tested. At the same time, the WHO has to consider the needs of the member states that form its governance. For national governments, the regular occurrence of a condition in clinical systems that appears to demand some specific treatment response is a valid reason for its inclusion in the classification.
The description of “persistent complex bereavement disorder” in the DSM‐5 research appendix in part represented an attempt to reconcile two somewhat divergent models in the field 312 . Based on additional work conducted during the intervening period, the entity has been included in the main classification for the DSM‐5‐TR, the ICD‐11 name has been adopted, and the criteria have been altered to be more similar to the ICD‐11 CDDR 124 . Internet gaming disorder as described in the DSM‐5 research appendix attempts to model more closely diagnostic criteria for substance use disorders, whereas the essential features of ICD‐11 gaming disorder are more streamlined and more strongly emphasize loss of control over gaming behaviour. Still, they are both clearly attempting to describe the same group of people. The complete absence of a hypersexual disorder in DSM‐5 (as opposed to its being placed in the research appendix or listed as an example of a sexual disorder not otherwise specified, as it was in prior editions of the DSM) was ostensibly based on concerns that there was insufficient evidence that this disorder represented a distinct clinical syndrome and that it could be misused in forensic settings, although Workgroup members opined that these concerns had been addressed 240 . The ICD‐11 Working Groups attempted to avoid some of the pitfalls encountered by the proposal for hypersexual disorder, notably by describing it as a disorder of impulse control that is expressed in sexual behaviour rather than as a sexual disorder. The evidence being generated will be helpful to decisions about these categories in a future edition of the DSM.
Looking at the other entries in Table 1, eleven of the 21 disorders listed were either already in the DSM‐IV or were also added to the DSM‐5. These changes in the ICD‐11, therefore, had the effect of enhancing compatibility between the two classifications. The ICD‐11 has included a few additional syndromes caused by substances or medications or by diseases classified elsewhere that are not found in the DSM‐5 17 . This leaves only three discrepant new ICD‐11 categories other than those reviewed in this paper. Olfactory reference syndrome is mentioned in the DSM‐5 as an example of other specified obsessive‐compulsive and related disorders. Body integrity dysphoria (an intense and persistent desire to become physically disabled in a significant way, e.g., major limb amputee, paraplegic, blind) is a very rare though quite distinctive and serious condition for which a large body of evidence with specific methodologies may never be generated if that continues to be a requirement for its inclusion in the DSM. Partial dissociative identity disorder is very similar to what is described in the DSM‐5 as “chronic and recurrent syndromes of mixed dissociative symptoms”, included as an example of other specified dissociative disorders. These categories seem unlikely to generate the same level of interest and controversy as those reviewed in this paper.
CONCLUSIONS
The four disorders introduced in the ICD‐11 that are discussed in this paper – complex PTSD, prolonged grief disorder, gaming disorder, and compulsive sexual behaviour disorder – describe populations with clinically important and distinctive features that have previously gone unrecognized in the ICD classification of mental disorders. These populations also have specific treatment needs that would otherwise be likely to go unmet if these disorders did not have a place in the classification. Overall, the impact of adding these disorders appears to have been positive in terms of health information and reporting, identifying patients in need of service, and the development and testing of interventions. Clearly, there are remaining research needs and specific targeted studies should be undertaken related to each of the four disorders, as reviewed in this paper. However, the WHO’s decision to include these categories appears to balance effectively the status of the available evidence with the information needs of WHO member states and the need of individuals with these conditions to receive appropriate care.
We do not see evidence so far of the hypothesized harms of adding these conditions to the diagnostic system (e.g., harmful stigmatization of non‐pathological gaming or sexual behaviour). However, it is possible that some drawbacks may become more apparent over time as the ICD‐11 is implemented around the world. Regular updates are planned for the ICD‐11 (every 2 years), and it is anticipated that a greater number of changes will be made early on based on the experience of actually using the classification. This will provide an important mechanism for making refinements or clarifications to these categories, should they appear to be necessary.
ACKNOWLEDGEMENTS
The authors of this paper participated in the development of the ICD‐11 classification of mental, behavioural or neurodevelopmental disorders as Working Groups members or consultants. G.M. Reed was a member of the WHO Secretariat, Department of Mental Health and Substance Use. Unless specifically stated, the views expressed in this paper are those of the authors and do not represent the official policies or positions of the WHO.
REFERENCES
- 1. World Health Organization . World Health Assembly Update, 25 May 2019. https://www.who.int.
- 2. World Health Organization . International statistical classification of diseases and related health problems. https://www.who.int.
- 3. International Advisory Group for the Revision of ICD‐10 Mental and Behavioural Disorders . A conceptual framework for the revision of the ICD‐10 classification of mental and behavioural disorders. World Psychiatry 2011;10:86‐92. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4. First MB , Reed GM, Hyman SE et al. The development of the ICD‐11 clinical descriptions and diagnostic guidelines for mental and behavioural disorders. World Psychiatry 2015;14:82‐90. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5. World Health Organization . The ICD‐10 classification of mental and behavioural disorders: clinical descriptions and diagnostic guidelines. Geneva: World Health Organization, 1992. [Google Scholar]
- 6. Reed GM, First MB, Kogan CS et al. Innovations and changes in the ICD‐11 classification of mental, behavioural and neurodevelopmental disorders. World Psychiatry 2019;18:3‐19. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7. Mathews CA. Hoarding disorder: more than just a problem of too much stuff. J Clin Psychiatry 2014;75:893‐4. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8. Stein DJ, Kogan CS, Atmaca M et al. The classification of obsessive‐compulsive and related disorders in the ICD‐11. J Affect Disord 2016;190:663‐74. [DOI] [PubMed] [Google Scholar]
- 9. Claudino AM, Pike KM, Hay P et al. The classification of feeding and eating disorders in the ICD‐11: results of a field study comparing proposed ICD‐11 guidelines with existing ICD‐10 guidelines. BMC Med 2019;17:93. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10. van Hoeken D, Hoek HW. Review of the burden of eating disorders: mortality, disability, costs, quality of life, and family burden. Curr Opin Psychiatry 2020;33:521‐7. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11. Kessler RC, Berglund PA, Chiu WT et al. The prevalence and correlates of binge eating disorder in the World Health Organization World Mental Health Surveys. Biol Psychiatry 2013;73:904‐14. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12. Hilbert A, Petroff D, Herpertz S et al. Meta‐analysis of the efficacy of psychological and medical treatments for binge‐eating disorder. J Consult Clin Psychol 2019;87:91‐105. [DOI] [PubMed] [Google Scholar]
- 13. Fuss J, Lemay K, Stein DJ et al. Public stakeholders’ comments on ICD‐11 chapters related to mental and sexual health. World Psychiatry 2018;18:233‐5. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14. World Health Organization . ICD‐11 for Mortality and Morbidity Statistics (Version: 02/2022). https://icd.who.int.
- 15. American Psychiatric Association . Diagnostic and statistical manual of mental disorders: DSM‐5. Arlington: American Psychiatric Publishing, 2013. [Google Scholar]
- 16. Reid RC, Kafka MP. Controversies about hypersexuality and the DSM‐5. Curr Sex Health Rep 2014;6:259‐64. [Google Scholar]
- 17. First MB, Gaebel W, Maj M et al. An organization‐ and category‐level comparison of diagnostic requirements for mental disorders in ICD‐11 and DSM‐5. World Psychiatry 2021;20:34‐51. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18. Herman JL. Trauma and recovery: the aftermath of violence from domestic violence to political terrorism. New York: Guilford, 1992. [Google Scholar]
- 19. Cloitre M, Courtois CC, Charuvastra A et al. Treatment of complex PTSD: results of the ISTSS expert clinician survey on best practices. J Trauma Stress 2011;24:616‐27. [DOI] [PubMed] [Google Scholar]
- 20. Reed GM, Correia JM, Esparza P et al. The WPA‐WHO global survey of psychiatrists’ attitudes towards mental disorders classification. World Psychiatry 2011;10:118‐31. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 21. Evans SC, Reed GM, Roberts MC et al. Psychologists’ perspectives on the diagnostic classification of mental disorders: results from the WHO‐IUPsyS global survey. Int J Psychol 2013. ; 48:177‐93. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 22. Robles R, Fresán A, Evans SC et al. Problematic, absent and stigmatizing diagnoses in current mental disorders classifications: results from the WHO‐WPA and WHO‐IUPsyS Global Surveys. Int J Clin Health Psychol 2014;14:165‐77. [Google Scholar]
- 23. Maercker A, Brewin CR, Bryant RA et al. Diagnosis and classification of disorders specifically associated with stress: proposals for ICD‐11. World Psychiatry 2013;12:198‐206. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 24. Beltran RO, Silove D. Expert opinions about the ICD‐10 category of enduring personality change after catastrophic experience. Compr Psychiatry 1999;40:396‐403. [DOI] [PubMed] [Google Scholar]
- 25. Beltran RO, Silove D, Llewellyn GM. Comparison of ICD‐10 diagnostic guidelines and research criteria for enduring personality change after catastrophic experience. Psychopathology 2009;42:113‐8. [DOI] [PubMed] [Google Scholar]
- 26. van der Kolk BA, Roth S, Pelcovitz D et al. Disorders of extreme stress: the empirical foundation of a complex adaptation to trauma. J Trauma Stress 2005;18:389‐99. [DOI] [PubMed] [Google Scholar]
- 27. Roth S, Newman E, Pelcovitz D et al. Complex PTSD in victims exposed to sexual and physical abuse: results from the DSM‐IV field trial for posttraumatic stress disorder. J Trauma Stress 1997;10:539‐55. [DOI] [PubMed] [Google Scholar]
- 28. Weiss DS. Introduction to the special feature on complex PTSD. J Trauma Stress 2019;25:239‐40. [DOI] [PubMed] [Google Scholar]
- 29. Resick PA, Bovin MJ, Calloway AL et al. A critical evaluation of the complex PTSD literature: implications for DSM‐5. J Trauma Stress 2012;25:241‐51. [DOI] [PubMed] [Google Scholar]
- 30. Cloitre M, Shevlin M, Brewin CR et al. The International Trauma Questionnaire: development of a self‐report measure of ICD‐11 PTSD and complex PTSD. Acta Psychiatr Scand 2018;138:536‐46. [DOI] [PubMed] [Google Scholar]
- 31. Roberts NP, Cloitre M, Bisson J et al. International Trauma Interview (ITI) for ICD‐11 PTSD and complex PTSD (Test Version 3.1). Unpublished paper, 2018.
- 32. Brewin CR, Cloitre M, Hyland P et al. A review of current evidence regarding the ICD‐11 proposals for diagnosing PTSD and complex PTSD. Clin Psychol Rev 2017;58:1‐15. [DOI] [PubMed] [Google Scholar]
- 33. Cloitre M, Brewin CR, Bisson JI et al. Evidence for the coherence and integrity of the complex PTSD (CPTSD) diagnosis: response to Achterhof et al. (2019) and Ford (2020). Eur J Psychotraumatol 2020;11:1739873. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 34. Hyland P, Karatzias T, Shevlin M et al. Examining the discriminant validity of complex posttraumatic stress disorder and borderline personality disorder symptoms: results from a United Kingdom population sample. J Trauma Stress 2019;32:855‐63. [DOI] [PubMed] [Google Scholar]
- 35. Frost R, Murphy J, Hyland P et al. Revealing what is distinct by recognising what is common: distinguishing between complex PTSD and Borderline Personality Disorder symptoms using bifactor modelling. Eur J Psychotraumatol 2020;11:1836864. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 36. Cloitre M, Garvert DW, Brewin CR et al. Evidence for proposed ICD‐11 PTSD and complex PTSD: a latent profile analysis. Eur J Psychotraumatol 2013;4:20706. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 37. Zerach G, Shevlin M, Cloitre M et al. Complex posttraumatic stress disorder (CPTSD) following captivity: a 24‐year longitudinal study. Eur J Psychotraumatol 2019;10:1616488. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 38. Bryant RA, Felmingham KL, Malhi G et al. The distinctive neural circuitry of complex posttraumatic stress disorder during threat processing. Psychol Med 2021;51:1121‐8. [DOI] [PubMed] [Google Scholar]
- 39. Herzog JI, Niedtfeld I, Rausch S et al. Increased recruitment of cognitive control in the presence of traumatic stimuli in complex PTSD. Eur Arch Psychiatry Clin Neurosci 2019;269:147‐59. [DOI] [PubMed] [Google Scholar]
- 40. Thomaes K, Dorrepaal E, Draijer N et al. Reduced anterior cingulate and orbitofrontal volumes in child abuse‐related complex PTSD. J Clin Psychiatry 2010;71:1636‐44. [DOI] [PubMed] [Google Scholar]
- 41. Keeley JW, Reed GM, Roberts MC et al. Disorders specifically associated with stress: a case‐controlled field study for ICD‐11 mental and behavioural disorders. Int J Clin Health Psychol 2016;16:109‐27. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 42. Redican E, Nolan E, Hyland P et al. A systematic literature review of factor analytic and mixture models of ICD‐11 PTSD and CPTSD using the International Trauma Questionnaire. J Anxiety Disord 2021; doi: 10.1016/j.janxdis.2021.102381. [DOI] [PubMed] [Google Scholar]
- 43. Tay AK, Mohsin M, Rees S et al. Factor structures of complex posttraumatic stress disorder and PTSD in a community sample of refugees from West Papua. Compr Psychiatry 2018;85:15‐22. [DOI] [PubMed] [Google Scholar]
- 44. Knefel M, Karatzias T, Ben‐Ezra M et al. The replicability of ICD‐11 complex post‐traumatic stress disorder symptom networks in adults. Br J Psychiatry 2019;214:361‐8. [DOI] [PubMed] [Google Scholar]
- 45. Herman J. CPTSD is a distinct entity: comment on Resick et al. (2012). J Trauma Stress 2012;25:256‐7. [DOI] [PubMed] [Google Scholar]
- 46. Karatzias T, Murphy P, Cloitre M et al. Psychological interventions for ICD‐11 complex PTSD symptoms: systematic review and meta‐analysis. Psychol Med 2019;49:1761‐75. [DOI] [PubMed] [Google Scholar]
- 47. Karatzias T, Shevlin M, Hyland P et al. The network structure of ICD‐11 complex post‐traumatic stress disorder across different traumatic life events. World Psychiatry 2020;19:400‐1. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 48. Sachser C, Keller F, Goldbeck L. Complex PTSD as proposed for ICD‐11: validation of a new disorder in children and adolescents and their response to trauma‐focused cognitive behavioral therapy. J Child Psychol Psychiatry 2017;58:160‐8. [DOI] [PubMed] [Google Scholar]
- 49. Brewin CR, Miller JK, Soffia M et al. Posttraumatic stress disorder and complex posttraumatic stress disorder in UK police offers. Psychol Med 2020; doi: 10.1017/S0033291720003025. [DOI] [PubMed] [Google Scholar]
- 50. Prigerson HG, Frank E, Kasl SV et al. Complicated grief and bereavement‐related depression as distinct disorders: preliminary empirical validation in elderly bereaved spouses. Am J Psychiatry 1995;152:22‐30. [DOI] [PubMed] [Google Scholar]
- 51. Boelen PA, van den Bout J. Complicated grief, depression, and anxiety as distinct postloss syndromes: a confirmatory factor analysis study. Am J Psychiatry 2005;162:2175‐7. [DOI] [PubMed] [Google Scholar]
- 52. Golden A‐M, Dalgleish T. Is prolonged grief distinct from bereavement‐related posttraumatic stress? Psychiatry Res 2010;178:336‐41. [DOI] [PubMed] [Google Scholar]
- 53. Robinaugh DJ, LeBlanc NJ, Vuletich HA et al. Network analysis of persistent complex bereavement disorder in conjugally bereaved adults. J Abnorm Psychol 2014;123:510‐22. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 54. Malgaroli M, Maccallum F, Bonanno GA. Symptoms of persistent complex bereavement disorder, depression, and PTSD in a conjugally bereaved sample: a network analysis. Psychol Med 2018;48:2439‐48. [DOI] [PubMed] [Google Scholar]
- 55. Holland JM, Neimeyer RA, Boelen PA et al. The underlying structure of grief: a taxometric investigation of prolonged and normal reactions to loss. J Psychopath Behav Assess 2009;31:190‐201. [Google Scholar]
- 56. Boelen PA, Prigerson HG. The influence of symptoms of prolonged grief disorder, depression, and anxiety on quality of life among bereaved adults: a prospective study. Eur Arch Psychiatry Clin Neurosci 2007;257:444‐52. [DOI] [PubMed] [Google Scholar]
- 57. Germain A, Caroff K, Buysse DJ et al. Sleep quality in complicated grief. J Trauma Stress 2005;18:343‐6. [DOI] [PubMed] [Google Scholar]
- 58. Buckley T, Sunari D, Marshall A et al. Physiological correlates of bereavement and the impact of bereavement interventions. Dialogues Clin Neurosci 2012;14:129‐39. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 59. Robbins‐Welty G, Stahl S, Zhang J et al. Medical comorbidity in complicated grief: results from the HEAL collaborative trial. J Psychiatr Res 2018;96:94‐9. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 60. Neria Y, Gross R, Litz B et al. Prevalence and psychological correlates of complicated grief among bereaved adults 2.5‐3.5 years after September 11th attacks. J Trauma Stress 2007;20:251‐62. [DOI] [PubMed] [Google Scholar]
- 61. Sung SC, Dryman MT, Marks E et al. Complicated grief among individuals with major depression: prevalence, comorbidity, and associated features. J Affect Disord 2011;134:453‐58. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 62. He L, Tang S, Yu W et al. The prevalence, comorbidity and risks of prolonged grief disorder among bereaved Chinese adults. Psychiatry Res 2014;219:347‐52. [DOI] [PubMed] [Google Scholar]
- 63. Simon NM, Shear KM, Thompson EH et al. The prevalence and correlates of psychiatric comorbidity in individuals with complicated grief. Compr Psychiatry 2007;48:395‐9. [DOI] [PubMed] [Google Scholar]
- 64. Latham AE, Prigerson HG. Suicidality and bereavement: complicated grief as psychiatric disorder presenting greatest risk for suicidality. Suicide Life Threat Behav 2004;34:350‐62. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 65. Prigerson HG, Bridge J, Maciejewski PK et al. Influence of traumatic grief on suicidal ideation among young adults. Am J Psychiatry 1999;156:1994‐5. [DOI] [PubMed] [Google Scholar]
- 66. Bui E, Horenstein A, Shah R et al. Grief‐related panic symptoms in complicated grief. J Affect Disord 2015;170:213‐6. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 67. Bonanno GA, Neria Y, Mancini A et al. Is there more to complicated grief than depression and posttraumatic stress disorder? A test of incremental validity. J Abnorm Psychol 2007;116:342‐51. [DOI] [PubMed] [Google Scholar]
- 68. Prigerson HG, Kakarala S, Gang J et al. History and status of prolonged grief disorder as a psychiatric diagnosis. Annu Rev Clin Psychol 2021;17:109‐26. [DOI] [PubMed] [Google Scholar]
- 69. Freud S. Mourning and melancholia. In: Strachey J (ed). The standard edition of the complete psychological works of Sigmund Freud, Vol. 1. London: Hogarth, 1953:124‐40. [Google Scholar]
- 70. Bowlby J. Attachment and loss, Vol. 1. Attachment. New York: Basic Books, 1969. [Google Scholar]
- 71. Boelen PA, Klugkist I. Cognitive behavioral variables mediate the associations of neuroticism and attachment insecurity with prolonged grief disorder severity. Anxiety Stress Coping 2011;24:291‐307. [DOI] [PubMed] [Google Scholar]
- 72. Currier JM, Irish JE, Neimeyer RA et al. Attachment, continuing bonds, and complicated grief following violent loss: testing a moderated model. Death Stud 2015;39:201‐10. [DOI] [PubMed] [Google Scholar]
- 73. American Psychiatric Association . Diagnostic and statistical manual of mental disorders, 4th ed. Washington: American Psychiatric Publishing, 1994. [Google Scholar]
- 74. Horowitz MJ, Siegel B, Holen A et al. Diagnostic criteria for complicated grief disorder. Am J Psychiatry 1997;154:904‐10. [DOI] [PubMed] [Google Scholar]
- 75. Bryant RA. Grief as a psychiatric disorder. Br J Psychiatry 2012;201:9‐10. [DOI] [PubMed] [Google Scholar]
- 76. Bandini J. The medicalization of bereavement: (ab)normal grief in the DSM‐5. Death Stud 2015;39:347‐52. [DOI] [PubMed] [Google Scholar]
- 77. Kersting A, Brähler E, Glaesmer H et al. Prevalence of complicated grief in a representative population‐based sample. J Affect Disord 2011;131:339‐43. [DOI] [PubMed] [Google Scholar]
- 78. Lundorff M, Holmgren H, Zachariae R et al. Prevalence of prolonged grief disorder in adult bereavement: a systematic review and meta‐analysis. J Affect Disord 2017;212:138‐49. [DOI] [PubMed] [Google Scholar]
- 79. Bryant RA, Bawaneh A, Giardinelli L et al. A prevalence assessment of prolonged grief disorder in Syrian refugees. World Psychiatry 2021;20:302‐3. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 80. Xiu D, Maercker A, Woynar S et al. Features of prolonged grief symptoms in Chinese and Swiss bereaved parents. J Nerv Ment Dis 2016;204:693‐701. [DOI] [PubMed] [Google Scholar]
- 81. Prigerson H, Ahmed I, Silverman GK et al. Rates and risks of complicated grief among psychiatric clinic patients in Karachi, Pakistan. Death Stud 2002;26:781‐92. [DOI] [PubMed] [Google Scholar]
- 82. Schaal S, Elbert T, Neuner F. Prolonged grief disorder and depression in widows due to the Rwandan genocide. Omega 2009;59:203‐19. [DOI] [PubMed] [Google Scholar]
- 83. Prigerson HG, Shear MK, Jacobs SC et al. Consensus criteria for traumatic grief. A preliminary empirical test. Br J Psychiatry 1999;174:67‐73. [DOI] [PubMed] [Google Scholar]
- 84. Prigerson HG, Horowitz MJ, Jacobs SC et al. Prolonged grief disorder: psychometric validation of criteria proposed for DSM‐V and ICD‐11. PLoS Med 2009;6:e1000121. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 85. Silverman GK, Jacobs SC, Kasl SV et al. Quality of life impairments associated with diagnostic criteria for traumatic grief. Psychol Med 2000;30:857‐62. [DOI] [PubMed] [Google Scholar]
- 86. Simon NM, Hoeppner SS, Lubin RE et al. Understanding the impact of complicated grief on combat related posttraumatic stress disorder, guilt, suicide, and functional impairment in a clinical trial of post‐9/11 service members and veterans. Depress Anxiety 2020;37:63‐72. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 87. Zisook S, Mohamad S, Johnson G et al. Clinical implications of co‐occurring prolonged grief disorder in patients with treatment‐resistant major depressive disorder. World Psychiatry 2021;20:303‐4. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 88. Smith KV, Ehlers A. Cognitive predictors of grief trajectories in the first months of loss: a latent growth mixture model. J Consult Clin Psychol 2020;88:93‐105. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 89. Lenferink LIM, Nickerson A, de Keijser J et al. Trajectories of grief, depression, and posttraumatic stress in disaster‐bereaved people. Depress Anxiety 2020;37:35‐44. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 90. Nielsen MK, Christensen KS, Neergaard MA et al. Exploring functional impairment in light of prolonged grief disorder: a prospective, population‐based cohort study. Front Psychiatry 2020;11:537674. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 91. Lundorff M, Bonanno GA, Johannsen M et al. Are there gender differences in prolonged grief trajectories? A registry‐sampled cohort study. J Psychiatr Res 2020;129:168‐75. [DOI] [PubMed] [Google Scholar]
- 92. Nielsen MK, Carlsen AH, Neergaard MA et al. Looking beyond the mean in grief trajectories: a prospective, population‐based cohort study. Soc Sci Med 2019;232:460‐9. [DOI] [PubMed] [Google Scholar]
- 93. Wen FH, Chou WC, Shen WC et al. Distinctiveness of prolonged‐grief‐disorder‐ and depressive‐symptom trajectories in the first 2 years of bereavement for family caregivers of terminally ill cancer patients. Psychooncology 2020;29:1524‐32. [DOI] [PubMed] [Google Scholar]
- 94. Bonanno GA, Malgaroli M. Trajectories of grief: comparing symptoms from the DSM‐5 and ICD‐11 diagnoses. Depress Anxiety 2020;37:17‐25. [DOI] [PubMed] [Google Scholar]
- 95. Kakarala SE, Roberts KE, Rogers M et al. The neurobiological reward system in prolonged grief disorder (PGD): a systematic review. Psychiatry Res Neuroimaging 2020;303:111135. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 96. Bryant RA, Andrew E, Korgaonkar MS. Distinct neural mechanisms of emotional processing in prolonged grief disorder. Psychol Med 2021;51:587‐95. [DOI] [PubMed] [Google Scholar]
- 97. O'Connor MF, Wellisch DK, Stanton AL et al. Craving love? Enduring grief activates brain's reward center. Neuroimage 2008;42:969‐72. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 98. Gundel H, O'Connor MF, Littrell L et al. Functional neuroanatomy of grief: an FMRI study. Am J Psychiatry 2003;160:1946‐53. [DOI] [PubMed] [Google Scholar]
- 99. McConnell MH, Killgore WDS, O'Connor MF. Yearning predicts subgenual anterior cingulate activity in bereaved individuals. Heliyon 2018;4:e00852. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 100. Fernandez‐Alcantara M, Verdejo‐Roman J, Cruz‐Quintana F et al. Increased amygdala activations during the emotional experience of death‐related pictures in complicated grief: an fMRI study. J Clin Med 2020;3:851. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 101. Arizmendi B, Kaszniak AW, O'Connor MF. Disrupted prefrontal activity during emotion processing in complicated grief: an fMRI investigation. Neuroimage 2016;124:968‐76. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 102. Maccallum F, Bonanno GA. The economics of losing a loved one: delayed reward discounting in prolonged grief. Clin Psychol Sci 2016;4:683‐90. [Google Scholar]
- 103. Maccallum F, Bryant RA. Attentional bias in complicated grief. J Affect Disord 2010;125:316‐22. [DOI] [PubMed] [Google Scholar]
- 104. Maccallum F, Bryant RA. An investigation of approach behaviour in prolonged grief. Behav Res Ther 2019;119:103405. [DOI] [PubMed] [Google Scholar]
- 105. Boddez Y. The presence of your absence: a conditioning theory of grief. Behav Res Ther 2018;106:18‐27. [DOI] [PubMed] [Google Scholar]
- 106. Bullock AB, Bonanno GA. Attentional bias and complicated grief: a primed dot‐probe task with emotional faces. J Exp Psychopathol 2013;4:194‐207. [Google Scholar]
- 107. Yu M, Tang S, Wang C et al. Avoidance of bereavement‐related stimuli in Chinese individuals experiencing prolonged grief: evidence from a dot‐probe task. Front Psychol 2017;8:1201. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 108. Maccallum F, Sawday S, Rinck M et al. The push and pull of grief: approach and avoidance in bereavement. J Behav Ther Exp Psychiatry 2015;48:105‐9. [DOI] [PubMed] [Google Scholar]
- 109. Schneck N, Tu T, Michel CA et al. Attentional bias to reminders of the deceased as compared to a living attachment in grieving. Biol Psychiatry Cogn Neurosci Neuroimaging 2018;3:107‐15. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 110. Boelen PA, van den Bout J, van den Hout MA. Negative cognitions and avoidance in emotional problems after bereavement: a prospective study. Behav Res Ther 2006;44:1657‐72. [DOI] [PubMed] [Google Scholar]
- 111. Boelen PA, de Keijser J, Smid G. Cognitive‐behavioral variables mediate the impact of violent loss on post‐loss psychopathology. Psychol Trauma 2015;7:382‐90. [DOI] [PubMed] [Google Scholar]
- 112. Boelen PA. Variables mediating the linkage between loss centrality and postloss psychopathology. J Nerv Ment Dis 2012;200:801‐6. [DOI] [PubMed] [Google Scholar]
- 113. Boelen PA, Reijntjes A, Smid GE. Concurrent and prospective associations of intolerance of uncertainty with symptoms of prolonged grief, posttraumatic stress, and depression after bereavement. J Anxiety Disord 2016;41:65‐72. [DOI] [PubMed] [Google Scholar]
- 114. Eisma MC, Epstude K, Schut HAW et al. Upward and downward counterfactual thought after loss: a multiwave controlled longitudinal study. Behav Ther 2021;52:577‐93. [DOI] [PubMed] [Google Scholar]
- 115. Lechner‐Meichsner F, Mauro C, Skritskaya NA et al. Change in avoidance and negative grief‐related cognitions mediates treatment outcome in older adults with prolonged grief disorder. Psychother Res 2022;32:91‐103. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 116. Maccallum F, Bryant RA. A cognitive attachment model of prolonged grief: integrating attachments, memory, and identity. Clin Psychol Rev 2013;33:713‐27. [DOI] [PubMed] [Google Scholar]
- 117. Eisma MC, Stroebe MS, Schut HAW et al. Avoidance processes mediate the relationship between rumination and symptoms of complicated grief and depression following loss. J Abnorm Psychol 2013;122;961‐70. [DOI] [PubMed] [Google Scholar]
- 118. Morina N. Rumination and avoidance as predictors of prolonged grief, depression, and posttraumatic stress in female widowed survivors of war. J Nerv Ment Dis 2011;199:921‐7. [DOI] [PubMed] [Google Scholar]
- 119. Harper M, O'Connor RC, O'Carroll RE. Factors associated with grief and depression following the loss of a child: a multivariate analysis. Psychol Health Med 2014;19:247‐52. [DOI] [PubMed] [Google Scholar]
- 120. Meert KL, Shear K, Newth CJL et al. Follow‐up study of complicated grief among parents eighteen months after a child's death in the pediatric intensive care unit. J Palliat Med 2011;14:207‐14. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 121. Gupta S, Bonanno GA. Complicated grief and deficits in emotional expressive flexibility. J Abnorm Psychol 2011;120:635‐43. [DOI] [PubMed] [Google Scholar]
- 122. Diminich ED, Bonanno GA. Faces, feelings, words: divergence across channels of emotional responding in complicated grief. J Abnorm Psychol 2014;123:350‐61. [DOI] [PubMed] [Google Scholar]
- 123. American Psychiatric Association . Diagnostic and Statistical Manual of Mental Disorders: DSM‐5 Text Revision. Arlington: American Psychiatric Publishing, 2021. [Google Scholar]
- 124. Prigerson HG, Boelen PA, Xu J et al. Validation of the new DSM‐5‐TR criteria for prolonged grief disorder and the PG‐13‐Revised (PG‐13‐R) scale. World Psychiatry 2021;20:96‐106. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 125. Shear K, Frank E, Houck PR et al. Treatment of complicated grief: a randomized controlled trial. JAMA 2005;293:2601‐8. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 126. Shear MK, Wang Y, Skritskaya N et al. Treatment of complicated grief in elderly persons: a randomized clinical trial. JAMA Psychiatry 2014;71:1287‐95. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 127. Bryant RA, Kenny L, Joscelyne A et al. Treating prolonged grief disorder: a randomized controlled trial. JAMA Psychiatry 2014;71:1332‐9. [DOI] [PubMed] [Google Scholar]
- 128. Boelen PA, Lenferink LIM, Spuij M. CBT for prolonged grief in children and adolescents: a randomized clinical trial. Am J Psychiatry 2021;178:294‐304. [DOI] [PubMed] [Google Scholar]
- 129. Shear MK, Reynolds CF, Simon NM et al. Optimizing treatment of complicated grief: a randomized clinical trial. JAMA Psychiatry 2016;73:685‐94. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 130. Johannsen M, Damholdt MF, Zachariae R et al. Psychological interventions for grief in adults: a systematic review and meta‐analysis of randomized controlled trials. J Affect Disord 2019;253:69‐86. [DOI] [PubMed] [Google Scholar]
- 131. Snodgrass JG, Dengah HJF, Lacy MG et al. Online gaming involvement and its positive and negative consequences: a cognitive anthropological “cultural consensus” approach to psychiatric measurement and assessment. Comput Hum Behav 2017;66:291‐302. [Google Scholar]
- 132. Snodgrass JG, Dengah HJF, Polzer E et al. Intensive online videogame involvement: a new global idiom of wellness and distress. Transcult Psychiatry 2019;56:748‐74. [DOI] [PubMed] [Google Scholar]
- 133. Ryan RM, Rigby CS, Przybylski A. The motivational pull of video games: a self‐determination theory approach. Motiv Emot 2006;30:344‐60. [Google Scholar]
- 134. Przybylski AK, Weinstein N, Ryan RM et al. Having to versus wanting to play: background and consequences of harmonious versus obsessive engagement in video games. Cyberpsychol Behav 2009;12:485‐92. [DOI] [PubMed] [Google Scholar]
- 135. Przybylski AK, Rigby CS, Ryan RM. A motivational model of video game engagement. Rev Gen Psychol 2010;14:154‐66. [Google Scholar]
- 136. Tóth‐Király I, Bőthe B, Márki AN et al. Two sides of the same coin: the differentiating role of need satisfaction and frustration in passion for screen‐based activities. Eur J Soc Psychol 2019;49:1190‐205. [Google Scholar]
- 137. Barr M, Copeland‐Stewart A. Playing video games during the COVID‐19 pandemic and effects on players’ well‐being. Games Cult 2022;17:122‐39. [Google Scholar]
- 138. Giardina A, Di Blasi MDB, Schimmenti A et al. Online gaming and prolonged self‐isolation: evidence from Italian gamers during the COVID‐19 outbreak. Clin Neuropsychiatry 2021;18:65‐74. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 139. Rumpf H‐J, Achab S, Billieux J et al. Including gaming disorder in the ICD‐11: the need to do so from a clinical and public health perspective. J Behav Addict 2018;7:556‐61. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 140. Saunders JB, Hao W, Long J et al. Gaming disorder: its delineation as an important condition for diagnosis, management, and prevention. J Behav Addict 2017;6:271‐9. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 141. Billieux J, Stein DJ, Castro‐Calvo J et al. Rationale for and usefulness of the inclusion of gaming disorder in the ICD‐11. World Psychiatry 2021;20:198‐9. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 142. Billieux J, King DL, Higuchi S et al. Functional impairment matters in the screening and diagnosis of gaming disorder. J Behav Addict 2017;6:285‐9. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 143. Borges G, Orozco R, Benjet C et al. DSM‐5 Internet gaming disorder among a sample of Mexican first‐year college students. J Behav Addict 2019;8:714‐24. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 144. Gentile DA, Choo H, Liau A et al. Pathological video game use among youths: a two‐year longitudinal study. Pediatrics 2011;127:e319‐29. [DOI] [PubMed] [Google Scholar]
- 145. Teng Z, Pontes HM, Nie Q et al. Internet gaming disorder and psychosocial well‐being: a longitudinal study of older‐aged adolescents and emerging adults. Addict Behav 2020;110:106530. [DOI] [PubMed] [Google Scholar]
- 146. Wartberg L, Kriston L, Zieglmeier M et al. A longitudinal study on psychosocial causes and consequences of internet gaming disorder in adolescence. Psychol Med 2019;49:287‐94. [DOI] [PubMed] [Google Scholar]
- 147. Stevens MWR, King DL, Dorstyn D et al. Cognitive‐behavioral therapy for internet gaming disorder: a systematic review and meta‐analysis. Clin Psychol Psychother 2019;26:191‐203. [DOI] [PubMed] [Google Scholar]
- 148. Han DH, Yoo M, Renshaw PF et al. A cohort study of patients seeking internet gaming disorder treatment. J Behav Addict 2018;7:930‐8. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 149. Ko C‐H, Yen J‐Y, Chen S‐H et al. Evaluation of the diagnostic criteria of internet gaming disorder in the DSM‐5 among young adults in Taiwan. J Psychiatr Res 2018;53:103‐10. [DOI] [PubMed] [Google Scholar]
- 150. Müller KW, Dreier M, Duven E et al. Adding clinical validity to the statistical power of large‐scale epidemiological surveys on internet addiction in adolescence: a combined approach to investigate psychopathology and development‐specific personality traits associated with internet addiction. J Clin Psychiatry 2017;78:e244‐51. [DOI] [PubMed] [Google Scholar]
- 151. Thorens G, Achab S, Billieux J et al. Characteristics and treatment response of self‐identified problematic internet users in a behavioral addiction outpatient clinic. J Behav Addict 2014;3:78‐81. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 152. van Rooij AJ , Schoenmakers TM, van de Mheen D . Clinical validation of the C‐VAT 2.0 assessment tool for gaming disorder: a sensitivity analysis of the proposed DSM‐5 criteria and the clinical characteristics of young patients with ‘video game addiction’. Addict Behav 2017;64:269‐74. [DOI] [PubMed] [Google Scholar]
- 153. Han DH, Hwang JW, Renshaw PF. Bupropion sustained release treatment decreases craving for video games and cue‐induced brain activity in patients with Internet video game addiction. Exp Clin Psychopharmacol 2010;18:297‐304. [DOI] [PubMed] [Google Scholar]
- 154. Wölfling K, Müller KW, Dreier M et al. Efficacy of short‐term treatment of internet and computer game addiction: a randomized clinical trial. JAMA Psychiatry 2019;76:1018‐25. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 155. Kardefelt‐Winther D. A conceptual and methodological critique of internet addiction research: towards a model of compensatory internet use. Comp Hum Behav 2014;31:351‐4. [Google Scholar]
- 156. World Health Organization . Public health implications of excessive use of the internet, computers, smartphones and similar electronic devices: Meeting report. Geneva: World Health Organization, 2015. [Google Scholar]
- 157. Humphreys G. Sharpening the focus on gaming disorder. Bull World Health Organ 2019;97:382‐3. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 158. Achab S. Internet patterns of use and which health promotion in Switzerland? Rev Med Suisse 2021;17:1118‐21. [PubMed] [Google Scholar]
- 159. Zajac K, Ginley MK, Chang R. Treatments of internet gaming disorder: a systematic review of the evidence. Expert Rev Neurother 2020;20:85‐93. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 160. Higuchi S, Nakayama H, Mihara S et al. Inclusion of gaming disorder criteria in ICD‐11: a clinical perspective in favor. J Behav Addict 2017;6:293‐5. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 161. Park JJ, Wilkinson‐Meyers L, King DL et al. Person‐centred interventions for problem gaming: a stepped care approach. BMC Public Health 2021;21:872. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 162. King DL, Delfabbro PH, Wu AMS et al. Treatment of Internet gaming disorder: an international systematic review and CONSORT evaluation. Clin Psychol Rev 2017;54:123‐33. [DOI] [PubMed] [Google Scholar]
- 163. Wegmann E, Brand M. The imperative of integrating empirical and theoretical considerations when developing policy responses to internet‐gaming disorder. J Behav Addict 2018;7:531‐5. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 164. Hunt CJ, Blaszczynski A. Gambling disorder as a clinical phenomenon. In: Heinz A, Romanczuk‐Seiferth N, Potenza MN (eds). Gambling disorder. Cham: Springer, 2019:15‐27. [Google Scholar]
- 165. Aarseth E, Bean AM, Boonen H et al. Scholars’ open debate paper on the World Health Organization ICD‐11 gaming disorder proposal. J Behav Addict 2017;6:267‐70. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 166. Bean AM, Nielsen RKL, van Rooij AJ et al. Video game addiction: the push to pathologize video games. Prof Psychol Res Pr 2017;48:378‐89. [Google Scholar]
- 167. van Rooij AJ , Ferguson CJ, Colder Carras M et al. A weak scientific basis for gaming disorder: let us err on the side of caution. J Behav Addict 2018;7:1‐9. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 168. Billieux J, Schimmenti A, Khazaal Y. Are we overpathologizing everyday life? A tenable blueprint for behavioral addiction research. J Behav Addict 2015;4:119‐23. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 169. Kardefelt‐Winther D, Heeren A, Schimmenti A et al. How can we conceptualize behavioural addiction without pathologizing common behaviours? Addiction 2017;112:1709‐15. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 170. King DL, Billieux J, Carragher N et al. Face validity evaluation of screening tools for gaming disorder: scope, language, and overpathologizing issues. J Behav Addict 2020;9:1‐13. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 171. King DL, Chamberlain SR, Carragher N et al. Screening and assessment tools for gaming disorder: a comprehensive systematic review. Clin Psychol Rev 2020;77:101831. [DOI] [PubMed] [Google Scholar]
- 172. Billieux J, Flayelle M, Rumpf H‐J et al. High involvement versus pathological involvement in video games: a crucial distinction for ensuring the validity and utility of gaming disorder. Curr Addict Rep 2019;6:323‐30. [Google Scholar]
- 173. Przybylski AK, Weinstein N, Murayama K. Internet gaming disorder: investigating the clinical relevance of a new phenomenon. Am J Psychiatry 2017;174:230‐6. [DOI] [PubMed] [Google Scholar]
- 174. Brunborg GS, Mentzoni RA, Melkevik OR et al. Gaming addiction, gaming engagement, and psychological health complaints among Norwegian adolescents. Media Psychol 2013;16:115‐28. [Google Scholar]
- 175. Charlton JP, Danforth IDW. Distinguishing addiction and high engagement in the context of online game playing. Comput Hum Behav 2007;23:1531‐48. [Google Scholar]
- 176. Deleuze J, Nuyens F, Rochat L et al. Established risk factors for addiction fail to discriminate between healthy gamers and gamers endorsing DSM‐5 internet gaming disorder. J Behav Addict 2017;6:516‐24. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 177. Castro‐Calvo J, King DL, Stein DJ et al. Expert appraisal of criteria for assessing gaming disorder: an international Delphi study. Addiction 2021;116:2463‐75. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 178. Markey PM, Ferguson CJ. Internet gaming addiction: disorder or moral panic? Am J Psychiatry 2017;174:195‐6. [DOI] [PubMed] [Google Scholar]
- 179. Orben A. The Sisyphean cycle of technology panics. Perspect Psychol Sci 2020;15:1143‐57. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 180. Wartberg L, Kriston L, Thomasius R. The prevalence and psychosocial correlates of internet gaming disorder. Dtsch Arztebl Int 2017;114:419‐24. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 181. Kewitz S, Vonderlin E, Wartberg L et al. Estimated prevalence of unreported IGD cases in routine outpatient children and adolescent psychotherapy. Int J Environ Res Public Health 2021;18:6787. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 182. Rehbein F, Kliem S, Baier D et al. Prevalence of Internet gaming disorder in German adolescents: diagnostic contribution of the nine DSM‐5 criteria in a state‐wide representative sample. Addiction 2015;110:842‐51. [DOI] [PubMed] [Google Scholar]
- 183. Long J, Liu T, Liu Y et al. Prevalence and correlates of problematic online gaming: a systematic review of the evidence published in Chinese. Curr Addict Rep 2018;5:359‐71. [Google Scholar]
- 184. Wu AM, Chen JH, Tong KK et al. Prevalence and associated factors of Internet gaming disorder among community dwelling adults in Macao, China. J Behav Addict 2018;7:62‐9. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 185. Fam JY. Prevalence of internet gaming disorder in adolescents: a meta‐analysis across three decades. Scand J Psychol 2018;59:524‐31. [DOI] [PubMed] [Google Scholar]
- 186. Feng W, Ramo DE, Chan SR et al. Internet gaming disorder: trends in prevalence 1998‐2016. Addict Behav 2017;75:17‐24. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 187. Mihara S, Higuchi S. Cross‐sectional and longitudinal epidemiological studies of Internet gaming disorder: a systematic review of the literature. Psychiatry Clin Neurosci 2017;71:425‐44. [DOI] [PubMed] [Google Scholar]
- 188. Stevens MW, Dorstyn D, Delfabbro PH et al. Global prevalence of gaming disorder: a systematic review and meta‐analysis. Aust N Z J Psychiatry 2021;55:553‐68. [DOI] [PubMed] [Google Scholar]
- 189. Colder Carras M, Kardefelt‐Winther D. When addiction symptoms and life problems diverge: a latent class analysis of problematic gaming in a representative multinational sample of European adolescents. Eur Child Adolesc Psychiatry 2018;27:513‐25. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 190. Strittmatter E, Parzer P, Brunner R et al. A 2‐year longitudinal study of prospective predictors of pathological Internet use in adolescents. Eur Child Adolesc Psychiatry 2016;25:725‐34. [DOI] [PubMed] [Google Scholar]
- 191. Scharkow M, Festl R, Quandt T. Longitudinal patterns of problematic computer game use among adolescents and adults – a 2‐year panel study. Addiction 2014;109:1910‐7. [DOI] [PubMed] [Google Scholar]
- 192. Carbonneau R, Vitaro F, Brendgen M et al. Variety of gambling activities from adolescence to age 30 and association with gambling problems: a 15‐year longitudinal study of a general population sample. Addiction 2015;110:1985‐93. [DOI] [PubMed] [Google Scholar]
- 193. Yao YW, Liu L, Ma SS et al. Functional and structural neural alterations in Internet gaming disorder: a systematic review and meta‐analysis. Neurosci Biobehav Rev 2017;83:313‐24. [DOI] [PubMed] [Google Scholar]
- 194. Dong GH, Dong H, Wang M et al. Dorsal and ventral striatal functional connectivity shifts play a potential role in internet gaming disorder. Commun Biol 2021;4:866. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 195. Zhou WR, Wang M, Dong HH et al. Imbalanced sensitivities to primary and secondary rewards in internet gaming disorder. J Behav Addict 2021; doi: 10.1556/2006.2021.00072. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 196. Billieux J, Potenza MN, Maurage P et al. Cognitive factors associated with gaming disorder. In: Verdejo‐Garcia A (ed). Cognition and addiction. Cambridge: Academic Press, 2020:221‐30. [Google Scholar]
- 197. Argyriou E, Davison CB, Lee TTC. Response inhibition and Internet gaming disorder: a meta‐analysis. Addict Behav 2017;71:54‐60. [DOI] [PubMed] [Google Scholar]
- 198. Cabelguen C, Rocher B, Leboucher J et al. Attention deficit hyperactivity disorder and gaming disorder: frequency and associated factors in a clinical sample of patients with gaming disorder. J Behav Addict 2021;10:1061‐7. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 199. Granero R, Fernández‐Aranda F, Castro‐Calvo J et al. Subtyping treatment‐seeking gaming disorder patients. Addict Behav 2021;123:107086. [DOI] [PubMed] [Google Scholar]
- 200. King DL, Delfabbro PH, Doh YY et al. Policy and prevention approaches for disordered and hazardous gaming and Internet use: an international perspective. Prev Sci 2018;19:233‐49. [DOI] [PubMed] [Google Scholar]
- 201. Higuchi S, Nakayama H, Matsuzaki T et al. Application of the eleventh revision of the International Classification of Diseases gaming disorder criteria to treatment‐seeking patients: comparison with the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders Internet gaming disorder criteria. J Behav Addict 2021;10:149‐58. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 202. Shao T, Chen X, Huang S et al. The recognition of gaming disorder in China: a case series of 223 patients. PeerJ 2021;9:e10827. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 203. Thomas T. Referrals to UK gaming addiction clinic triple in year of lockdowns. The Guardian, June 20, 2021. [Google Scholar]
- 204. Nielsen P, Christensen M, Henderson C et al. Multidimensional family therapy reduces problematic gaming in adolescents: a randomised controlled trial. J Behav Addict 2021;10:234‐43. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 205. Du YS, Jiang W, Vance A. Longer term effect of randomized, controlled group cognitive behavioural therapy for Internet addiction in adolescent students in Shanghai. Aust N Z J Psychiatry 2010;44:129‐34. [DOI] [PubMed] [Google Scholar]
- 206. González‐Bueso V, Santamaría JJ, Fernández D et al. Association between internet gaming disorder or pathological video‐game use and comorbid psychopathology: a comprehensive review. Int J Environ Res Public Health 2018;15:668. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 207. Ko CH, Lin HC, Lin PC et al. Validity, functional impairment and complications related to Internet gaming disorder in the DSM‐5 and gaming disorder in the ICD‐11. Aust N Z J Psychiatry 2020;54:707‐18. [DOI] [PubMed] [Google Scholar]
- 208. Müller KW, Beutel ME, Wölfling K. Decreased occupational functioning and increased physical health complaints in treatment seekers with internet‐related disorders: compared to patients with gambling disorder. Eur Addict Res 2019;25:229‐37. [DOI] [PubMed] [Google Scholar]
- 209. Starcevic V, Choi TY, Kim TH et al. Internet gaming disorder and gaming disorder in the context of seeking and not seeking treatment for video‐gaming. J Psychiatr Res 2020;129:31‐9. [DOI] [PubMed] [Google Scholar]
- 210. Stockdale L, Coyne SM. Video game addiction in emerging adulthood: cross‐sectional evidence of pathology in video game addicts as compared to matched healthy controls. J Affect Disord 2018;225:265‐72. [DOI] [PubMed] [Google Scholar]
- 211. Brand M, Rumpf H‐J, Demetrovics Z et al. Gaming disorder is a disorder due to addictive behaviors: evidence from behavioral and neuroscientific studies addressing cue reactivity and craving, executive functions, and decision‐making. Curr Addict Rep 2019;6:296‐302. [Google Scholar]
- 212. Stein DJ, Billieux J, Bowden‐Jones H et al. Balancing validity, utility and public health considerations in disorders due to addictive behaviours. World Psychiatry 2018;17:363‐4. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 213. Brand M, Rumpf H‐J, Demetrovics Z et al. Which conditions should be considered as disorders in the International Classification of Diseases (ICD‐11) designation of “other specified disorders due to addictive behaviors”? J Behav Addict 2020; doi: 10.1556/2006.2020.00035. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 214. Torous J, Bucci S, Bell IH. The growing field of digital psychiatry: current evidence and the future of apps, social media, chatbots, and virtual reality. World Psychiatry 2021;20:318‐35. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 215. Carragher N, Billieux J, Bowden‐Jones H et al. Brief overview of the WHO Collaborative Project on the Development of New International Screening and Diagnostic Instruments for Gaming Disorder and Gambling Disorder. Addiction 2021; doi: 10.1111/add.15780. [DOI] [PubMed] [Google Scholar]
- 216. Männikkö N, Mustonen T, Tanner N et al. Effectiveness of a brief group intervention program for young adults with gaming‐related problems. Int J Ment Health Addict 2021; doi: 10.1007/s11469-021-00559-2. [DOI] [Google Scholar]
- 217. Long J, Bhad R, Potenza MN et al. Public health approaches and policy changes after the inclusion of gaming disorder in ICD‐11: global perspectives, actions and needs towards preparedness of health professionals for gaming disorder’s management. BJPsych Int 2021; doi: 10.1192/bji.2021.57. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 218. King DL, Gaming Industry Response Consortium. Comment on the global gaming industry’s statement on ICD‐11 gaming disorder: a corporate strategy to disregard harm and deflect social responsibility? Addiction 2018;113:2145‐6. [DOI] [PubMed] [Google Scholar]
- 219. European Games Developer Foundation . Statement on WHO ICD‐11 list and the inclusion of gaming. http://www.egdf.eu.
- 220.United Nations International Children’s Fund (UNICEF). Recommendations for the online gaming industry on assessing impact on children. https://sites.unicef.org.
- 221. King DL, Delfabbro PH. Video game monetization (e.g., ‘loot boxes’): a blueprint for practical social responsibility measures. Int J Ment Health Addict 2019;17:166‐79. [Google Scholar]
- 222. Štulhofer A, Jurin T, Briken P. Is high sexual desire a facet of male hypersexuality? Results from an online study. J Sex Marital Ther 2016;42:665‐80. [DOI] [PubMed] [Google Scholar]
- 223. Kraus SW, Krueger RB, Briken P et al. Compulsive sexual behaviour disorder in the ICD‐11. World Psychiatry 2018;17:109‐10. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 224. Reed GM, Drescher J, Krueger R et al. Disorders related to sexuality and gender identity in the ICD‐11: revising the ICD‐10 classification based on current scientific evidence, best clinical practices, and human rights considerations. World Psychiatry 2016;15:205‐21. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 225. Grubbs JB, Kraus SW, Perry SL et al. Moral incongruence and compulsive sexual behavior: results from cross‐sectional interactions and parallel growth curve analyses. J Abnorm Psychol 2020;129:266‐78. [DOI] [PubMed] [Google Scholar]
- 226. Grant JE, Atmaca M, Fineberg NA et al. Impulse control disorders and “behavioural addictions” in the ICD‐11. World Psychiatry 2014;13:125‐7. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 227. Grubbs JB, Hoagland KC, Lee BN et al. Sexual addiction 25 years on: a systematic and methodological review of empirical literature and an agenda for future research. Clin Psychol Rev 2020;82:101925. [DOI] [PubMed] [Google Scholar]
- 228. Kafka MP. Hypersexual disorder: a proposed diagnosis for DSM‐V. Arch Sex Behav 2010;39:377‐400. [DOI] [PubMed] [Google Scholar]
- 229. Yoon IS, Houang ST, Hirshfield S et al. Compulsive sexual behavior and HIV/STI risk: a review of current literature. Curr Addict Rep 2016;3:387‐99. [Google Scholar]
- 230. Booth BD, Kingston DA, Watts J. Forensic aspects of hypersexuality. In: Balon R, Briken P (eds). Compulsive sexual behavior disorder: understanding, assessment, and treatment. Washington: American Psychiatric Association Publishing, 2021:143‐66. [Google Scholar]
- 231. Briken P. An integrated model to assess and treat compulsive sexual behavior disorder. Nat Rev Urol 2020;17:391‐406. [DOI] [PubMed] [Google Scholar]
- 232. Park BY, Wilson G, Berger J et al. Is internet pornography causing sexual dysfunctions? A review with clinical reports. Behav Sci 2016;6:17. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 233. Carnes P. Out of the shadows: understanding sexual addiction. Minneapolis: CompCare Publications, 1983. [Google Scholar]
- 234. Kalichman SC, Rompa D. Sexual sensation seeking and sexual compulsivity scales: reliability, validity, and predicting HIV risk behavior. J Pers Assess 1995;65:586‐601. [DOI] [PubMed] [Google Scholar]
- 235. Coleman E, Miner M, Ohlerking F et al. Compulsive sexual behavior inventory: a preliminary study of reliability and validity. J Sex Marital Ther 2001;27:325‐32. [DOI] [PubMed] [Google Scholar]
- 236. Muench F, Parsons JT. Sexual compulsivity and HIV: identification and treatment. Focus 2004;19:1‐5. [PubMed] [Google Scholar]
- 237. Sansone RA, Sansone LA. Sexual behavior in borderline personality: a review. Innov Clin Neurosci 2011;8:14‐8. [PMC free article] [PubMed] [Google Scholar]
- 238. Tucker I. Management of inappropriate sexual behaviors in dementia: a literature review. Int Psychogeriatr 2010;22:683‐92. [DOI] [PubMed] [Google Scholar]
- 239. Weintraub D, Hoops S, Shea JA et al. Validation of the questionnaire for impulsive‐compulsive disorders in Parkinson's disease. Mov Disord 2009;24:1461‐7. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 240. Kafka MP. What happened to hypersexual disorder? Arch Sex Behav 2014;43:1259‐61. [DOI] [PubMed] [Google Scholar]
- 241. Reid RC, Carpenter BN, Hook JN et al. Report of findings in a DSM‐5 field trial for hypersexual disorder. J Sex Med 2012;9:2868‐77. [DOI] [PubMed] [Google Scholar]
- 242. Gold SN, Heffner CL. Sexual addiction: many conceptions, minimal data. Clin Psychol Rev 1998;18:367‐81. [DOI] [PubMed] [Google Scholar]
- 243. Humphreys K. Of moral judgments and sexual addictions. Addiction 2018;113:387‐8. [DOI] [PubMed] [Google Scholar]
- 244. Kraus SW, Voon V, Potenza MN. Should compulsive sexual behavior be considered an addiction? Addiction 2016;111:2097‐106. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 245. Griffin KR, Way BM, Kraus SW. Controversies and clinical recommendations for the treatment of compulsive sexual behavior disorder. Curr Addict Rep 2021;8:546‐55. [Google Scholar]
- 246. Grubbs JB, Kraus SW, Perry SL. Self‐reported addiction to pornography in a nationally representative sample: the roles of use habits, religiousness, and moral incongruence. J Behav Addict 2019;8:88‐93. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 247. Dickenson JA, Gleason N, Coleman E et al. Prevalence of distress associated with difficulty controlling sexual urges, feelings, and behaviors in the United States. JAMA Netw Open 2018;1:e184468. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 248. Castro‐Calvo J, Gil‐Llario MD, Giménez‐García C et al. Occurrence and clinical characteristics of compulsive sexual behavior disorder (CSBD): a cluster analysis in two independent community samples. J Behav Addict 2020;9:446‐8. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 249. Blum AW, Lust K, Christenson G et al. Links between sexuality, impulsivity, compulsivity, and addiction in a large sample of university students. CNS Spectr 2020;25:9‐15. [DOI] [PubMed] [Google Scholar]
- 250. Gleason N, Finotelli I Jr, Miner MH et al. Estimated prevalence and demographic correlates of compulsive sexual behavior among gay men in the United States. J Sex Med 2021;18:1545‐54. [DOI] [PubMed] [Google Scholar]
- 251. Storholm ED, Satre DD, Kapadia F et al. Depression, compulsive sexual behavior, and sexual risk‐taking among urban young gay and bisexual men: the P18 Cohort Study. Arch Sex Behav 2016;45:1431‐41. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 252. Rooney BM, Tulloch TG, Blashill AJ. Psychosocial syndemic correlates of sexual compulsivity among men who have sex with men: a meta‐analysis. Arch Sex Behav 2018;47:75‐93. [DOI] [PubMed] [Google Scholar]
- 253. Pachankis JE, Hatzenbuehler ML, Rendina HJ et al. LGB‐affirmative cognitive‐behavioral therapy for young adult gay and bisexual men: a randomized controlled trial of a transdiagnostic minority stress approach. J Consult Clin Psychol 2015;83:875‐89. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 254. Xu W, Zheng L, Liu Y et al. Sexual sensation seeking, sexual compulsivity, and high‐risk sexual behaviours among gay/bisexual men in Southwest China. AIDS Care 2016;28:1138‐44. [DOI] [PubMed] [Google Scholar]
- 255. Wang X, Wang Z, Jiang X et al. A cross‐sectional study of the relationship between sexual compulsivity and unprotected anal intercourse among men who have sex with men in Shanghai, China. BMC Infect Dis 2018;18:465. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 256. Adebahr R , Söderström EZ, Arver S et al. Reaching men and women at risk of committing sexual offences – findings from the national Swedish telephone helpline PrevenTell. J Sex Med 2021;18:1571‐81. [DOI] [PubMed] [Google Scholar]
- 257. Ballester‐Arnal R, Castro‐Calvo J, Giménez‐García C et al. Psychiatric comorbidity in compulsive sexual behavior disorder (CSBD). Addict Behav 2020;107:106384. [DOI] [PubMed] [Google Scholar]
- 258. Cowie ME, Kim HS, Hodgins DC et al. Demographic and psychiatric correlates of compulsive sexual behaviors in gambling disorder. J Behav Addict 2019;8:451‐62. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 259. Fuss J, Briken P, Stein DJ et al. Compulsive sexual behavior disorder in obsessive‐compulsive disorder: prevalence and associated comorbidity. J Behav Addict 2019;8:242‐8. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 260. Bőthe B, Koós M, Tóth‐Király I et al. Investigating the associations of adult ADHD symptoms, hypersexuality, and problematic pornography use among men and women on a largescale, non‐clinical sample. J Sex Med 2019;16:489‐99. [DOI] [PubMed] [Google Scholar]
- 261. Varo C, Murru A, Salagre E et al. Behavioral addictions in bipolar disorders: a systematic review. Eur Neuropsychopharmacol 2019;29:76‐97. [DOI] [PubMed] [Google Scholar]
- 262. Elmquist J , Shorey RC, Anderson S et al. Are borderline personality symptoms associated with compulsive sexual behaviors among women in treatment for substance use disorders? An exploratory study. J Clin Psychol 2016;72:1077‐87. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 263. Smith PH, Potenza MN, Mazure CM et al. Compulsive sexual behavior among male military veterans: prevalence and associated clinical factors. J Behav Addict 2014;3:214‐22. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 264. Castellini G, Rellini AH, Appignanesi C et al. Deviance or normalcy? The relationship among paraphilic thoughts and behaviors, hypersexuality, and psychopathology in a sample of university students. J Sex Med 2018;15:1322‐35. [DOI] [PubMed] [Google Scholar]
- 265. Grubbs JB, Gola M. Is pornography use related to erectile functioning? Results from cross‐sectional and latent growth curve analyses. J Sex Med 2019;16:111‐25. [DOI] [PubMed] [Google Scholar]
- 266. Slavin MN, Scoglio AAJ, Blycker GR et al. Child sexual abuse and compulsive sexual behavior: a systematic literature review. Curr Addict Rep 2020;7:76‐88. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 267. Slavin MN, Blycker GR, Potenza MN et al. Gender‐related differences in associations between sexual abuse and hypersexuality. J Sex Med 2020;17:2029‐38. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 268. Klucken, T , Wehrum‐Osinsky S, Schweckendiek J et al. Altered appetitive conditioning and neural connectivity in subjects with compulsive sexual behavior. J Sex Med 2016;13:627‐36. [DOI] [PubMed] [Google Scholar]
- 269. Seok JW, Sohn JH. Neural substrates of sexual desire in individuals with problematic hypersexual behavior. Front Behav Neurosci 2015;9:321. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 270. Voon V, Mole TB, Banca P et al. Neural correlates of sexual cue reactivity in individuals with and without compulsive sexual behaviours. PLoS One 2014;9:e102419. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 271. Banca P, Morris LS, Mitchell S et al. Novelty, conditioning and attentional bias to sexual rewards. J Psychiatr Res 2016;72:91‐101. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 272. Gola M, Wordecha M, Sescousse G et al. Can pornography be addictive? An fMRI study of men seeking treatment for problematic pornography use. Neuropsychopharmacology 2017;42:2021‐31. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 273. Sinke C, Engel J, Veit M et al. Sexual cues alter working memory performance and brain processing in men with compulsive sexual behavior. Neuroimage Clin 2020;27:102308. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 274. Schmidt C, Morris LS, Kvamme TL et al. Compulsive sexual behavior: prefrontal and limbic volume and interactions. Hum Brain Mapp 2017;38:1182‐90. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 275. Kühn S, Gallinat J. Brain structure and functional connectivity associated with pornography consumption: the brain on porn. JAMA Psychiatry 2014;71:827‐34. [DOI] [PubMed] [Google Scholar]
- 276. Golec K, Draps M, Stark R et al. Aberrant orbitofrontal cortex reactivity to erotic cues in compulsive sexual behavior disorder. J Behav Addict 2021;10:646‐56. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 277. Draps M, Sescousse G, Potenza MN et al. Gray matter volume differences in impulse control and addictive disorders – an evidence from a sample of heterosexual males. J Sex Med 2020;17:1761‐9. [DOI] [PubMed] [Google Scholar]
- 278. Boström AE, Chatzittofis A, Ciuculete DM et al. Hypermethylation‐associated downregulation of microRNA‐4456 in hypersexual disorder with putative influence on oxytocin signalling: a DNA methylation analysis of miRNA genes. Epigenetics 2020;15:145‐60. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 279. Chatzittofis A, Boström AE, Öberg KG et al. Normal testosterone but higher luteinizing hormone plasma levels in men with hypersexual disorder. Sex Med 2020;8:243‐50. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 280. Hook JN, Reid RC, Penberthy JK et al. Methodological review of treatments for nonparaphilic hypersexual behavior. J Sex Marital Ther 2014;40:294‐308. [DOI] [PubMed] [Google Scholar]
- 281. Von Franqué F, Klein V, Briken P. Which techniques are used in psychotherapeutic interventions for nonparaphilic hypersexual behavior? Sex Med Rev 2015;3:3‐10. [DOI] [PubMed] [Google Scholar]
- 282. Hallberg J, Kaldo V, Arver S et al. A randomized controlled study of group‐administered cognitive behavioral therapy for hypersexual disorder in men. J Sex Med 2019;16:733‐45. [DOI] [PubMed] [Google Scholar]
- 283. Hallberg J, Kaldo V, Arver S et al. Internet‐administered cognitive behavioral therapy for hypersexual disorder, with or without paraphilia(s) or paraphilic disorder(s) in men: a pilot study. J Sex Med 2020;17:2039‐54. [DOI] [PubMed] [Google Scholar]
- 284. Crosby JM, Twohig MP. Acceptance and commitment therapy for problematic internet pornography use: a randomized trial. Behav Ther 2016;47:355‐66. [DOI] [PubMed] [Google Scholar]
- 285. Bőthe B, Baumgartner C, Schaub MP et al. Hands‐off: feasibility and preliminary results of a two‐armed randomized controlled trial of a web‐based self‐help tool to reduce problematic pornography use. J Behav Addict 2021;10:1015‐35. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 286. Efrati Y, Gola M. Compulsive sexual behavior: a twelve‐step therapeutic approach. J Behav Addict 2018;7:445‐53. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 287. Holas P, Draps M, Kowalewska E et al. A pilot study of mindfulness‐based relapse prevention for compulsive sexual behaviour disorder. J Behav Addict 2020;9:1088‐92. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 288. Parsons JT, Rendina HJ, Moody RL et al. Feasibility of an emotion regulation intervention to improve mental health and reduce HIV transmission risk behaviors for HIV‐positive gay and bisexual men with sexual compulsivity. AIDS Behav 2017;21:1540‐9. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 289. Savard J, Öberg KG, Chatzittofis A et al. Naltrexone in compulsive sexual behavior disorder: a feasibility study of twenty men. J Sex Med 2020;17:1544‐52. [DOI] [PubMed] [Google Scholar]
- 290. Gola M, Potenza MN. Paroxetine treatment of problematic pornography use: a case series. J Behav Addict 2016;5:529‐32. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 291. Wainberg ML, Muench F, Morgenstern J et al. A double‐blind study of citalopram versus placebo in the treatment of compulsive sexual behaviors in gay and bisexual men. J Clin Psychiatry 2006;67:1968‐73. [DOI] [PubMed] [Google Scholar]
- 292. Tripathi A, Singh A, Singh H et al. Successful use of transcranial magnetic stimulation in difficult to treat hypersexual disorder. J Hum Reprod Sci 2016;9:207‐9. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 293. Blum AW, Grant JE. Positive response of compulsive sexual behavior to transcranial magnetic stimulation. Prim Care Companion CNS Disord 2020;22:19l02469. [DOI] [PubMed]
- 294. Gola M, Lewczuk K, Potenza MN et al. What should be included in the criteria for compulsive sexual behavior disorder? J Behav Addict 2020; doi: 10.1556/2006.2020.00090. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 295. Klein V, Briken P, Schröder J et al. Mental health professionals' pathologization of compulsive sexual behavior: does clients' gender and sexual orientation matter? J Abnorm Psychol 2019;128:465‐72. [DOI] [PubMed] [Google Scholar]
- 296. Efrati Y, Gola M. The effect of early life trauma on compulsive sexual behavior among members of a 12‐step group. J Sex Med 2019;16:803‐11. [DOI] [PubMed] [Google Scholar]
- 297. Lew‐Starowicz M, Lewczuk K, Nowakowska I et al. Compulsive sexual behavior and dysregulation of emotion. Sex Med Rev 2020;8:191‐205. [DOI] [PubMed] [Google Scholar]
- 298. Bőthe B, Tóth‐Király I, Potenza MN et al. Revisiting the role of impulsivity and compulsivity in problematic sexual behaviors. J Sex Res 2019;56:166‐79. [DOI] [PubMed] [Google Scholar]
- 299. Markert C, Klein S, Strahler J et al. Sexual incentive delay in the scanner: sexual cue and reward processing, and links to problematic porn consumption and sexual motivation. J Behav Addict 2021;10:65‐76. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 300. Bőthe B, Bartók R, Tóth‐Király I et al. Hypersexuality, gender, and sexual orientation: a large‐scale psychometric survey study. Arch Sex Behav 2018;47:2265‐76. [DOI] [PubMed] [Google Scholar]
- 301. de Oliveira L, Carvalho J. The link between boredom and hypersexuality: a systematic review. J Sex Med 2020;17:994‐1004. [DOI] [PubMed] [Google Scholar]
- 302. Engel J, Kessler A, Veit M et al. Hypersexual behavior in a large online sample: individual characteristics and signs of coercive sexual behavior. J Behav Addict 2019;8:213‐22. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 303. Carnes PJ, Hopkins TA, Green BA. Clinical relevance of the proposed sexual addiction diagnostic criteria: relation to the Sexual Addiction Screening Test‐Revised. J Addict Med 2014;8:450‐61. [DOI] [PubMed] [Google Scholar]
- 304. Reid RC, Garos S, Carpenter BN. Reliability, validity, and psychometric development of the Hypersexual Behavior Inventory in an outpatient sample of men. Sex Addict Compulsivity 2011;18:30‐51. [Google Scholar]
- 305. Montgomery‐Graham S. Conceptualization and assessment of hypersexual disorder: a systematic review of the literature. Sex Med Rev 2017;5:146‐62. [DOI] [PubMed] [Google Scholar]
- 306. Bőthe B, Potenza MN, Griffiths MD et al. The development of the Compulsive Sexual Behavior Disorder Scale (CSBD‐19): an ICD‐11 based screening measure across three languages. J Behav Addict 2020;9:247‐58. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 307. Bőthe B, Koós M, Nagy L et al. International Sex Survey: study protocol of a large, cross‐cultural collaborative study in 45 countries. J Behav Addict 2021;10:632‐45. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 308. Balon R, Briken P (eds). Compulsive sexual behavior disorder: understanding, assessment, and treatment. Washington: American Psychiatric Association Publishing, 2021. [Google Scholar]
- 309. Galatzer‐Levy IR, Bryant RA. 636,120 ways to have posttraumatic stress disorder. Perspect Psychol Sci 2013;8:651‐62. [DOI] [PubMed] [Google Scholar]
- 310. Wolf EJ, Miller MW, Kilpatrick D et al. ICD‐11 Complex PTSD in US national and veteran samples: prevalence and structural associations with PTSD. Clin Psychol Sci 2015;3:215‐29. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 311. Stein DJ, McLaughlin KA, Koenen KC et al. DSM‐5 and ICD‐11 definitions of posttraumatic stress disorder: investigating “narrow” and “broad” approaches. Depress Anxiety 2014;31:494‐505. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 312. Maciejewski PK, Maercker A, Boelen PA et al. “Prolonged grief disorder” and “persistent complex bereavement disorder”, but not “complicated grief”, are one and the same diagnostic entity: an analysis of data from the Yale Bereavement Study. World Psychiatry 2016;15:266‐75. [DOI] [PMC free article] [PubMed] [Google Scholar]