Problem Gaming, Sexual Compulsion 'Real Conditions'

Liam Davenport

October 18, 2018

BARCELONA, Spain — Internet gaming disorder and compulsive sexual behavior are clinically relevant conditions that should be included in diagnostic manuals, say two leading experts.

Neither condition is currently included in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), which was published in 2013. However, both have been added to the International Classification of Diseases, Eleventh Edition (ICD-11), which was published this past June.

During a debate held here at the 31st European College of Neuropsychopharmacology (ECNP) Congress, Marc Potenza, MD, PhD, professor of psychiatry, child study, and neuroscience, Yale University School of Medicine, New Haven, Connecticut, argued that Internet gaming disorder and compulsive sexual behavior have an impact on people's lives and need to have a diagnostic status in order to be properly studied, for treatments to be improved, and for the development of public health policy.

Aviv Weinstein, PhD, Department of Behavioral Sciences, University of Ariel, Israel, countered that, in many ways, both conditions conform to the conventional definition of addictions that need to be treated separately from any comorbid conditions.

Session chair Florence Thibaut, MD, PhD, professor of psychiatry, University Hospital Cochin Paris, Sorbonne-Paris Cité University, France, told Medscape Medical News that both conditions are "under-known and under-researched," but that that is especially true for sexual addiction.

"It's very hard to get funding for this research because this topic is still hidden in Europe and the US. Whenever we try to get funds, it's very, very difficult," she said.

It's different for gambling. In Europe, 1% of the profits generated by the gaming industry are funneled into researching its impact. "But for sex addiction, there is nothing," said Thibault.

Controversial Issue

Potenza began his presentation by noting that some of the "more controversial topics considered for DSM-5" included areas such as Internet use behaviors and sex addiction.

The manual's substance use workgroup considered whether Internet use behaviors might be seen as a disorder. It decided that the "most problematic form of Internet use was gaming," he said.

Although Internet gaming disorder was not included in the main text, it was placed in section 3, which is reserved for disorders or conditions that are deemed to require further research.

Its inclusion criteria were similar to those for gambling disorder, which is currently the only condition in DSM-5 considered a nonsubstance addiction.

On the other hand, the World Health Organization (WHO) has been considering Internet use behaviors from public health and clinical perspectives for the past 4 to 5 years, and four workgroups have been convened on this topic.

In part, these meetings led the WHO to include the following criteria for gaming disorder in the ICD-11:

  • impaired control over gaming;

  • gaming taking precedence over other interests and daily activities;

  • the continuation or escalation of gaming despite the occurrence of negative consequences;

  • gaming being severe enough to result in significant impairment in personal, family, social, educational, occupational, or other important areas of functioning; and

  • evidence of problem behaviors of at least 12 months' duration.

On this last point, Potenza said that there is "flexibility, given clinical data that suggest that this may occur more rapidly in some individuals."

Debate With Gaming Industry

There has been a great deal of debate as to whether or not gaming disorder should be a formal disorder. This debate has "played out within the pubic media" and within the academic community, he added.

"The gaming industry, after the WHO released the proposal to include gaming disorder in ICD-11, came out with a statement saying that they were concerned that gaming disorder is contained within the ICD-11," Potenza said.

"I think it should be noted that the gaming industry is a multibillion dollar industry, estimated I think at about $100 billion a year," he noted.

Academics have also tried to pull together different groups. Recently a letter was sent to Addiction that was signed by more than 100 individuals, including those on both sides of the debate.

The letter noted that "there's the danger of the gaming industry deflecting social responsibility with such statements," Potenza said.

Referring to the tobacco industry, "we've seen where industries that have substantial financial stakes have come out with strong statements that historically may not look ideal," he added.

Discussing what happens clinically with problematic gaming, Potenza referred to cases of children and adults "having difficulties controlling their gaming behavior." He mentioned a story of a nine-year-old girl who became violent when her father tried to take away her Xbox video game console.

Potenza argued that problematic gaming has a biological basis. He referred to brain imaging data indicating that problematic gaming is associated with decreases in resting state functional connectivity in executive control networks and is linked to negative cognitive control performance on the Stroop Task.

Other studies have shown that a craving behavioral intervention not only decreased Internet addiction scores and gaming times but also increased cue-induced insula activation and decreased connectivity between the insula and some brain regions, such as the precuneus, that have been implicated in cravings.

Potenza and colleagues consequently proposed a theoretical model of Internet gaming disorder in which specific targets share similarities with those for substance use disorders and behavioral addictions, such as pathologic gambling.

Pornography "Big Business"

Regarding compulsive sexual behavior, Potenza focused on pornography. "Like gaming, [it's] a big business, and it's estimated that about 10% to 30% of traffic over the Internet is related to pornography viewing."

Hypersexual disorder was proposed for the DSM-5 and was studied in field trials, but ultimately it was not included in either the main text or in section 3. "However, compulsive sexual behavior disorder was proposed for inclusion in ICD-11 — not as an addiction but as an impulse control disorder," he said.

Other impulse control disorders in that section include pyromania, kleptomania, and intermittent explosive disorder. "So this, in some ways, is different from what DSM-IV to DSM-5 did in terms of restructuring the impulse control disorder category by including something that might be better considered as a behavioral addiction," Potenza noted.

Nevertheless, he said it is important to have a diagnostic entity in ICD-11 so that people can study it, improve policy efforts, and, importantly, improve treatment for sufferers.

He noted that criteria for compulsive sexual behavior disorder should include the following:

  • failure to control intense, repetitive sexual impulses or urges;

  • repetitive sexual activities becoming a central focus of a person's life to the point of neglecting health and personal care or other interests, activities, and responsibilities;

  • unsuccessful attempts to control or significantly reduce sexual behaviors;

  • continuing repetitive sexual behavior despite adverse consequences;

  • continuing with such behaviors that provide little or no satisfaction; and

  • significant impairment in personal, family, social, educational, occupational, or other important areas of functioning.

He added that some of the central elements of compulsive sexual behavior "resonate with those proposed for addictions."

Brain Imaging

In a study, men whose use of pornography caused problems reacted to sexual imagery to a greater extent and more rapidly. They also showed showed greater ventral striatal activation to cues predicting sexual imagery.

Greater sensitivity to cues suggestive of sexual imagery were also linked to a greater motivation to view sexual images and to hypersexuality, pornography use, and more frequent masturbation.

Another study showed that in men with compulsive sexual behavior, sexually explicit cues elicited greater activation of the anterior cingulate, the ventral striatum, and the amygdala. In addition, there was greater functional connectivity linked to self-reported sexual desires compared with other men.

Regarding treatment, Potenza said, "We're at a very early stage, both with respect to Internet gaming and compulsive sexual behavior disorder."

He noted that pharmacologic treatments are beginning to be studied. One case report described use of the opioid blocker naltrexone. After undergoing adjunctive cognitive-behavioral therapy, "a young man was able to reduce his pornography viewing but had increased craving over time that appeared to be successfully targeted with naltrexone."

Despite the ongoing debate, Potenza said there is an increasing amount of data that shows that Internet gaming disorder and compulsive sexual behavior are relevant clinical entities and that there is a clinical demand for treatment.

He also underlined that there are data from multiple domains that suggest that there are similarities between these conditions and established addictive disorders. However, "there still exists many research gaps that we need to better understand so that we can gather knowledge and translate this knowledge into improved prevention treatment and policy efforts."

Few Treatment Options

During the question-and-answer session that followed, Potenza said there are few data on the use of selective serotonin reuptake inhibitors (SSRIs), although studies with the antidepressant bupropion suggest that the drug may be helpful for people with gaming disorder, particularly inasmuch as these patients often have comorbid disorders, such as depression.

He has tested the use of paroxetine in the treatment of problematic pornography use. With three individuals, he found that the drug decreased anxiety and pornography use, although "there was an emergence of other compulsive sexual behaviors."

Therefore, "one should be mindful of a range of possible outlets for compulsive sexual behaviors and be mindful of the data," he said.

Thibaut added that, apart from the occasional case study, there has been only one small, randomized trial of the use of citalopram to treat hypersexuality in gay men. In that study, the drug was no more effective than placebo. Another study investigated the use of naltrexone with SSRIs. The results suggested that the combination may be effective.

One audience member questioned what he saw as the rush to label phenomena such as problematic Internet gaming as mental health conditions, noting that there are many forms of online gaming, that its impact is not fully understood, and that it may just be the expression of a co-occurring condition.

Potenza replied that he agreed there is a need for further study in this rapidly changing area. "I would bring up that many psychiatric conditions have co-occurring disorders," he added.

Citing the example of gambling disorder, he said there are many different types of gambling and that it is likely that many complex biological and social phenomena underlie gambling disorder. "[I]t's estimated that 96% of individuals with gambling disorder have one or more co-occurring psychiatric disorders," he said.

Potenza said that the field of psychiatry field needs to be "mindful" of what is defined as a disorder and what isn't, but that surveys of men who use pornography have suggested that 1 in 7 individuals have sought or wanted to seek treatment.

"So it's a sizeable clinical need; and if we don't have a condition or some way of defining it to make it seem okay to people that 'I'm not the only one suffering from a problem,' I think it creates more barriers for people who already don't seek treatment," he said.

He reaffirmed that there is a need for more studies and said he would "caution on the harm that we do by not naming a disorder."

Thibaut added that of itself, gaming is not a problem. Rather, it is "a continuum between gaming and addiction, and it's the way you use it that might be a problem. If you can't stop it, it becomes an addiction."

Forms of Addictions?

Weinstein took the floor to argue that Internet gaming disorder and compulsive sexual behavior are, in fact, forms of addiction.

"How do you define, for example, sex addiction or Internet and gaming addiction? Is it the number of hours that you use to play that will define your addiction, or the number of orgasms per week that will define sex addicts?"

He added that it has increasingly been shown that these sorts of criteria are not particularly accurate, especially if the concept of "harm" is regarded as essential.

Therefore, Weinstein turned to the criteria for the diagnosis of behavioral addiction set out by Mark B. Griffiths, PhD, and colleagues, which focus on the following:

  • Salience,

  • Mood modification,

  • Tolerance,

  • Withdrawal,

  • Adverse consequences, and

  • Repeated attempts to quit, followed by relapse.

He said that salience means that the activity becomes the most important activity in their life and dominates their thinking, feelings, and behavior.

Both Internet gaming disorder and compulsive sexual behavior conform to this criterion. Problem Internet users isolate themselves from other forms of social contact and focuse almost entirely on the Internet. People who engage in compulsive sexual behavior constantly seek new partners and encounters, and they engage in compulsive masturbation and frequently use pornography.

Similarly, mood modification, which is the subjective experience that people report as a result of engaging in the activity, is seen with both disorders. Problem Internet users say that they feel aroused or enter into a "flow" whereby they lose a sense of time and place, while compulsive sexual behavior is associated with a desire to escape from or suppress unpleasant emotions and loneliness or stressful life events.

Tolerance, in which greater exposure is required to achieve the same effect, is also found in both conditions, as is withdrawal. In Internet gaming disorder, withdrawal includes anger, tension, and/or depression; and in compulsive sexual behavior, it includes nervousness, insomnia, sweating, and nausea.

Relapse Research "Problematic"

Both Internet gaming disorder and compulsive sexual behavior have adverse consequences. The former leads to arguments, lying, and poor school or vocational achievement; the latter is associated with sexually transmitted diseases, unwanted pregnancies, and risky behaviors.

Weinstein said that the question of relapse is "a bit problematic." He said that there have not been many studies of relapse in Internet gaming disorder and compulsive sexual behavior.

"We know that there is clinical evidence that it happens, but we need to do more research about it, although people with compulsive sexual behavior do try to stop, but they cannot do it," he said.

Weinstein said that, on the basis of brain imaging studies, the neural mechanisms that underlie Internet gaming disorder appear similar to those seen in drug addiction. These include structural changes related to gray matter volume in regions linked to attention, motor coordination, executive function, and perception.

Internet gaming disorder is associated with lower white matter density in brain regions linked to decision making, behavioral inhibition, and emotional regulation, as well as alterations in the ventral striatum. Video game playing is associated with dopamine release at levels similar to those seen in drug abuse.

Weinstein emphasized that in healthy individuals, sexual imagery leads to arousal, but the degree of activation is lower than in individuals with compulsive sexual behavior.

He said that areas of reward, cognition, and emotion are activated in those with compulsive sexual behavior relative to others and highlighted that there has been comparatively little research in that area and that more studies are required.

Regarding comorbidity with psychiatric disorders, Weinstein said that "comorbidity is the rule." Internet gaming disorder is associated with depression, anxiety, attention-deficit hyperactivity disorder (ADHD), and alcohol use, as well as personality disorders in adolescents.

Compulsive sexual behavior is also associated with depression, anxiety, ADHD, and other disorders.

"My argument is that both Internet gaming disorder and compulsive sexual behavior have a closer fit with behavioral addiction, rather than other models that have been proposed, for example, obsessive-compulsive disorder [OCD] and others," Weinstein said.

"We know with OCD there's a significant number of patients who have obsessive thoughts about sex, but this is very different from the types that we see with people with compulsive sexual behavior," he said.

"What is important here, and we see it more and more, is it's not enough to treat anxiety or depression or ADHD in order to solve the gaming or the compulsive sexual behavior," Weinstein added. "You have to treat both. You cannot say that behavioral addiction is an epiphenomenon of other psychiatric disorders."

Addiction Labels

During the post-presentation discussion, an audience member said that Internet gaming disorder is seen less in adults and wondered whether it might be a self-resolving condition and not a real addiction.

Potenza said he agreed that "we should be careful about what we label as addiction, because they've been reports about tanning addiction, reports about dance addiction, reports about taking selfies as addiction."

He added that it is important to understand these behaviors from a developmental perspective, as well as longitudinally.

"That being said...I see both young adults and middle-aged to older adults with gaming problems. Some of this is with video gaming, Internet based, and some of it is with cellphone-based games like Candy Crush," he said.

Potenza noted that people often begin with problematic gaming and then transition to gambling, but the boundary is becoming "blurred." He noted that, with cellphones, games are combined with microtransactions to, for example, buy access to other characters or levels.

"We need to be mindful of the larger, changing environment," he said. He pointed out that people can go on to become professional gamers.

In regard to whether time-based resolution limits the clinical relevance of a disorder, Potenza added that "with substance use disorders, there are peaks in adolescence and young adulthood. [So] should we not be mindful about substance use behaviors in youth and adolescents?"

Thibaut said she believes there is a great deal of catching up to do in terms of understanding both Internet gaming disorder and compulsive sexual behavior.

"There are some anonymous questionnaires but very, very few studies on these topics," she said. "We definitely need more studies. There is a lot of room and need for that."

Dr Potenza has been a consultant to Lundbeck, Ironwood, Shire, INSYS, Rivermend Health, Lakelight Therapeutics/Opiant, and Jazz Pharmaceuticals; has received research grants from the National Center for Responsible Gaming and a research gift from Mohegan Sun and the Connecticut Council on Problem Gaming; and is a consultant to gambling and legal entities on issues related to addictive disorders. Dr Weinstein and Dr Thibaut have reported no relevant financial relationships.

31st European College of Neuropsychopharmacology (ECNP) Congress. Session BS.07, presented October 9, 2018.

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