ICD-11 Criteria for Gambling Disorder (6C50)

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Foundation URI : http://id.who.int/icd/entity/1041487064

6C50 Gambling disorder

Description

Gambling disorder is characterised by a pattern of persistent or recurrent gambling behaviour, which may be online (i.e., over the internet) or offline, manifested by: 1. impaired control over gambling (e.g., onset, frequency, intensity, duration, termination, context); 2. increasing priority given to gambling to the extent that gambling takes precedence over other life interests and daily activities; and 3. continuation or escalation of gambling despite the occurrence of negative consequences. The pattern of gambling behaviour may be continuous or episodic and recurrent. The pattern of gambling behaviour results in significant distress or in significant impairment in personal, family, social, educational, occupational or other important areas of functioning. The gambling behaviour and other features are normally evident over a period of at least 12 months in order for a diagnosis to be assigned, although the required duration may be shortened if all diagnostic requirements are met and symptoms are severe.

Inclusions

• Compulsive gambling

Exclusions

• Bipolar type I disorder (6A60)

• Bipolar type II disorder (6A61)

• Hazardous gambling or betting (QE21)

Diagnostic Requirements

Essential (Required) Features:

• A persistent pattern of gambling behaviour, which may be predominantly online (i.e., over the internet or similar electronic networks) or offline, manifested by all of the following:

• Impaired control over gambling behaviour (e.g., onset, frequency, intensity, duration, termination, context);

• Increasing priority given to gambling behaviour to the extent that gambling takes precedence over other life interests and daily activities; and

• Continuation or escalation of gambling behaviour despite negative consequences (e.g., marital conflict due to gambling behaviour, repeated and substantial financial losses, negative impact on health).

• The pattern of gambling behaviour may be continuous or episodic and recurrent but is manifested over an extended period of time (e.g., 12 months).
  The gambling behaviour is not better accounted for by another mental disorder (e.g., Manic Episode) and is not due to the effects of a substance or medication.

• The pattern of gambling behaviour results in significant distress or impairment in personal, family, social, educational, occupational, or other important areas of functioning.

Specifiers for online or offline behaviour:

6C50.1 Gambling Disorder, predominantly online

• This refers to Gambling Disorder that predominantly involves gambling behaviour that is conducted over the internet or similar electronic networks (i.e., online).

6C50.0 Gambling Disorder, predominantly offline

• This refers to Gambling Disorder that predominantly involves gambling behaviour that is not conduced over the internet or similar electronic networks (i.e., offline).

6C50.Z Gambling Disorder, unspecified

Additional Clinical Features:

• If symptoms and consequences of gambling behaviour are severe (e.g., gambling behaviours persist for days at a time without respite or have major effects on functioning or health) and all other diagnostic requirements are met, it may be appropriate to assign a diagnosis of Gambling Disorder following a period that is briefer than 12 months (e.g., 6 months).

• Individuals with Gambling Disorder may make numerous unsuccessful efforts to control or significantly reduce gambling behaviour, whether self-initiated or imposed by others.

• Individuals with Gambling Disorder may increase the amount of money gambled over time to maintain or exceed previous levels of excitement or to avoid boredom. They may also engage in a pattern of increasing intensity of gambling behaviour, increasing the amount of their wagers, or otherwise altering their gambling strategies in order to try to compensate for significant monetary loses (i.e., ‘chasing’ their loses).

• Individuals with Gambling Disorder often experience urges or cravings to engage in gambling behaviour during other activities.

• Individuals with Gambling Disorder may exhibit substantial disruptions in diet, sleep, exercise and other health-related behaviours that can result in negative physical and mental health outcomes.

• Some individuals with Gambling Disorder may engage in deceitful behaviour to conceal the extent of their losses from loved ones or attempt to obtain money in order to repay their debts.

• Some individuals with Gambling Disorder may engage in gambling behaviour in response to feelings of depression, anxiety, boredom, loneliness, or other negative affective states. Although not diagnostically determinative, consideration of the relationship between emotional and behavioural cues and gambling behaviour can inform treatment planning.

• Gambling Disorder commonly co-occurs with Disorders Due to Substance Use, Mood Disorders, Anxiety or Fear-Related Disorders, and Personality Disorder. Among individuals seeking treatment for Gambling Disorder, suicidal ideation and suicide attempts are common.

• In adults, gambling behaviour is associated with chronic medical conditions, obesity, and poorer subjective health status.

Boundaries with Normality (Threshold):

• Gambling Disorder should not be diagnosed merely on the basis of repeated or persistent gambling (online or offline), such as in the context of social or professional gambling. Typically, these forms of gambling are limited to discrete periods with monetary losses that are acceptable to the individual and occur in the absence of the other characteristic features of the disorder.

• Daily gambling behaviour (e.g., buying lottery tickets) as a part of a routine or the use of gambling for purposes such as changing mood, alleviating boredom, or facilitating social interaction in the absence of the other required features is not a sufficient basis for assigning a diagnosis of Gambling Disorder.

Course Features:

• The course of Gambling Disorder is variable with recovery a common outcome, even in the absence of intervention, especially for adolescents and young adults. However, for many, Gambling Disorder persists across the lifespan.

• Gambling behaviour can follow a continuous or episodic pattern. The intensity of gambling behaviour often fluctuates in relation to stress, depressive symptoms, and substance use.

• Gambling Disorder tends to develop gradually over the course of years as frequency of gambling behaviour and monetary value of wagers increase.

Developmental Presentations:

• Gambling Disorder typically has its onset in adolescence or young adulthood. Early onset is associated with higher levels of impulsivity. Prevalence of Gambling Disorder among adolescents tends to be higher than in adults.

• Onset of Gambling Disorder in older adulthood is uncommon.

Culture-Related Features:

• Prevalence of Gambling Disorder varies by socio-cultural background. For example, community-based prevalence in the United States is lower among immigrants than among US-born individuals. Indigenous populations in several counties (e.g., Canada, New Zealand, and the US) appear to have higher prevalence than other ethnic groups, possibly due to greater financial hardship, the hope that gambling may help advance social goals, and the location of casinos on tribal lands.

• Endorsement of specific symptoms of Gambling Disorder may also vary cross-culturally. For example, among individuals with gambling problems in the United States, Asian Americans may be less likely to describe being preoccupied with gambling, while Latinos and African Americans may be more likely to describe attempts to reduce gambling.

Sex- and/or Gender-Related Features:

• Lifetime prevalence of Gambling Disorder is higher among males. In adulthood, the ratio of men to women diagnosed with Gambling Disorder is approximately 2:1. This gap is wider during adolescence (ratio of 4:1), which may reflect boys’ tendency to start gambling earlier.

• Due to earlier onset, the course of Gambling Disorder is typically more protracted among men. Men also appear more likely to recover without intervention than women. Though onset among women tends to be later, symptoms often intensify more quickly. Women are more likely to seek treatment sooner than men, though treatment-seeking is low (less than 10%) across both genders.

• Women with Gambling Disorder are more likely than men to have co-occurring Mood Disorders or Anxiety or Fear-Related Disorders, whereas men are more likely to exhibit problems with substance abuse and externalizing behaviours.

Boundaries with Other Disorders and Conditions (Differential Diagnosis):

• Boundary with Hazardous Gambling or Betting: The category of Hazardous Gambling or Betting from the ICD-11 chapter on ‘Factors Influencing Health Status or Contact with Health Services’ may be assigned to individuals who exhibit problematic patterns of gambling without the other features of Gambling Disorder. Hazardous Gambling or Betting refers to a pattern of gambling that appreciably increases the risk of harmful physical or mental health consequences to the individual or to others around the individual that may require intervention or monitoring but is not considered a disorder.

• Boundary with Gaming Disorder: Unlike Gambling Disorder, Gaming Disorder does not involve the betting of money or other valuables with the hope of obtaining something of greater value. If gaming behaviour is focused on wagers (e.g., internet poker), Gambling Disorder is generally the more appropriate diagnosis.

• Boundary with Bipolar or Related Disorders: Increased goal-directed activity including impaired ability to control gambling behaviour can occur during Manic, Mixed, or Hypomanic Episodes. A diagnosis of Gambling Disorder should only be assigned if there is evidence of a persistent pattern of gambling behaviour that meets all diagnostic requirements for the disorder and occurs outside of Mood Episodes. Some individuals with Gambling Disorder may exhibit symptoms while gambling that appear similar to those observed during Manic Episodes (e.g., euphoric mood and increased energy level). However, in Mood Episodes, such symptoms are not limited to the gambling context.

• Boundary with Obsessive-Compulsive Disorder: Gambling behaviour can sometimes be described as ‘compulsive’ by lay people and also by some health professionals. Compulsions observed in Obsessive-Compulsive Disorder are almost never experienced as inherently pleasurable and typically occur in response to intrusive, unwanted, and generally anxiety-provoking obsessions, which is not the case with gambling behaviour in Gambling Disorder.

• Boundary with Personality Disorder: Some individuals with Personality Disorder with prominent dissocial features or prominent features of disinhibition may engage in problematic gambling behaviour. A diagnosis of Gambling Disorder can be assigned together with a Personality Disorder diagnosis if the diagnostic requirements for both are met.

• Boundary with Disorders Due to Substance Use: Co-occurrence of gambling and substance use, particularly alcohol, is common. Intoxication due to some substances, including alcohol, can cause disinhibition and impaired judgement, which may exacerbate problematic gambling behaviour. A diagnosis of Gambling Disorder can be assigned together with a Disorder Due to Substance Use diagnosis if the requirements for both are met.

• Boundary with the effects of psychoactive substances, including medications: Use of specific prescribed medications or illicit substances (e.g., dopamine agonists such as pramipexole for Parkinson Disease or Restless Legs Syndrome or illicit substances such as methamphetamine) can sometimes cause impaired control over gambling behaviour due to their direct effects on the central nervous system, with onset corresponding to use of the substance or medication. Gambling Disorder should not be diagnosed in such cases

6C50.0    Gambling disorder, predominantly offline

Gambling disorder, predominantly offline is characterised by a pattern of persistent or recurrent gambling behaviour that is not primarily conducted over the internet and is manifested by:

1. impaired control over gambling (e.g., onset, frequency, intensity, duration, termination, context);
2. increasing priority given to gambling to the extent that gambling takes precedence over other life interests and daily activities; and
3. Continuation or escalation of gambling despite the occurrence of negative consequences. The behaviour pattern is of sufficient severity to result in significant impairment in personal, family, social, educational, occupational or other important areas of functioning.

The pattern of gambling behaviour may be continuous or episodic and recurrent. The gambling behaviour and other features are normally evident over a period of at least 12 months in order for a diagnosis to be assigned, although the required duration may be shortened if all diagnostic requirements are met and symptoms are severe.

Exclusions:             

• Hazardous gambling or betting (QE21)

6C50.1    Gambling disorder, predominantly online

Gambling disorder, predominantly online is characterised by a pattern of persistent or recurrent gambling behaviour that is primarily conducted over the internet and is manifested by:

1. impaired control over gambling (e.g., onset, frequency, intensity, duration, termination, context);

1. increasing priority given to gambling to the extent that gambling takes precedence over other life interests and daily activities; and

1. continuation or escalation of gambling despite the occurrence of negative consequences. The behaviour pattern is of sufficient severity to result in significant impairment in personal, family, social, educational, occupational or other important areas of functioning.

The pattern of gambling behaviour may be continuous or episodic and recurrent. The gambling behaviour and other features are normally evident over a period of at least 12 months in order for a diagnosis to be assigned, although the required duration may be shortened if all diagnostic requirements are met and symptoms are severe.

Exclusions: 

• Hazardous gambling or betting (QE21)

6C50.Z    Gambling disorder, unspecified

REFERENCE:

International Classification of Diseases Eleventh Revision (ICD-11). Geneva: World Health Organization; 2022. License: CC BY-ND 3.0 IGO.

https://creativecommons.org/licenses/by-nc-nd/3.0/igo/