Where to put Compulsive Sexual Behavior Disorder (CSBD)? Phenomenology matters •: Commentary to the debate: “Behavioral addictions in the ICD-11”

Abstract

In this commentary paper, it is discussed if Compulsive Sexual Behavior Disorder (CSBD) is best categorized as an Impulse Control Disorder, an Obsessive-Compulsive Disorder or in light of the overlap of characteristics with both Gaming and Gambling Disorder as an addictive behavior. The overlapping features are: loss of control over the respective excessive behavior, giving increasing priority to the excessive behavior under investigation and upholding such a behavior despite negative consequences. Besides empirical evidence regarding underlying mechanisms, phenomenology also plays an important role to correctly classify CSBD. The phenomenological aspects of CSBD clearly speak in favor of classifying CSBD under the umbrella of addictive behaviors.

Full text

Where to put Compulsive Sexual Behavior
Disorder (CSBD)? Phenomenology matters
Commentary to the debate: “Behavioral
addictions in the ICD-11”
HANS-JÜRGEN RUMPF
1
pand CHRISTIAN MONTAG
2
1
Department of Psychiatry and Psychotherapy, University of Lübeck, Lübeck, Germany
2
Department of Molecular Psychology, Institute of Psychology and Education, Ulm University, Ulm,
Germany
Received: September 30, 2021 •Revised manuscript received: May 10, 2022 •Accepted: May 16, 2022
ABSTRACT
In this commentary paper, it is discussed if Compulsive Sexual Behavior Disorder (CSBD) is best
categorized as an Impulse Control Disorder, an Obsessive-Compulsive Disorder or in light of the
overlap of characteristics with both Gaming and Gambling Disorder as an addictive behavior. The
overlapping features are: loss of control over the respective excessive behavior, giving increasing priority
to the excessive behavior under investigation and upholding such a behavior despite negative conse-
quences. Besides empirical evidence regarding underlying mechanisms, phenomenology also plays an
important role to correctly classify CSBD. The phenomenological aspects of CSBD clearly speak in favor
of classifying CSBD under the umbrella of addictive behaviors.
KEYWORDS
Compulsive Sexual Behavior Disorder, Gambling Disorder, Gaming Disorder, Pathological Gambling, impulsivity,
Impulse Control Disorder, addictive behavior
INTRODUCTION
The investigation of behavioral addictions represents a timely and important research topic
and got rising attention, in particular with the inclusion of Gaming Disorder as an addictive
behavior in the recent International Classification of Diseases - 11th version (ICD-11) which
has been appreciated by scholars and clinicians (Billieux, Stein, Castro-Calvo, Higushi, &
King, 2021;Pontes et al., 2019;Rumpf et al., 2018;Saunders et al., 2017). Beyond Gaming
Disorder, other behavioral conditions are currently discussed to perhaps be included as a
behavioral addiction in the next revision of the International Classification of Diseases
(Montag, Wegmann, Sariyska, Demetrovics, & Brand, 2021). Among these are behaviors
related to excessive buying or excessive social media use (Brand, Rumpf, Demetrovics, et al.,
2022). In this realm, also another disorder has been the focus of debate, namely Compulsive
Sexual Behavior Disorder (CSBD). CSBD is officially recognized in the recent ICD-11, but
interestingly not as an addictive disorder, but as an Impulse Control Disorder.
1
Not all re-
searchers agree upon the correctness of this classification. For instance, Gola et al. (2022)
made the observation that “data suggest similarities between CSBD and addiction”and they
are of the opinion that with additional empirical evidence CSBD might be reclassified as an
addictive behavior (p. 4). Such a reclassification would not happen for the first time. For
Journal of Behavioral
Addictions
11 (2022) 2, 230–233
Debate: Behavioral
addictions in the
ICD-11
DOI:
10.1556/2006.2022.00039
© 2022 The Author(s)
COMMENTARY
pCorresponding author.
E-mail: hans-juergen.rumpf@uksh.de
1
https://icd.who.int/browse11/l-m/en#/http://id.who.int/icd/entity/1630268048.
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instance, whereas Pathological Gambling was categorized as
an Impulse Disorder in ICD-10 (Habit and Impulse Disor-
ders), it now is categorized as Gambling Disorder among the
category of Disorders due to Addictive Behaviours. Ac-
cording to ICD-10, habit and impulse disorders “are char-
acterized by repeated acts that have no clear rational
motivation, cannot be controlled, and generally harm the
patient’s own interests and those of other people.”Moreover,
the afflicted patients report “that the behaviour is associated
with impulses to action.”
2
Although loss of control and
significant impairment due to excessive gambling still play
an important role in the diagnosis of Gambling Disorder in
ICD-11, the “impulses to action”are not included as a
clinical description anymore.
Is it likely that CSBD will also go the way from belonging
to the category of an Impulse Control Disorder to a Disorder
Due to Addictive Behaviours in the near future? Sassover
and Weinstein (2022) come to the conclusion that an answer
to this question cannot be provided at the moment, because
current evidence regarding this question is “anecdotal”and
“insufficient”(p. 1). Although we do not agree with this
view, the authors have to be commended for critically
summarizing the evidence and for the reminder to be
cautious in making premature assignments. But what kind
of evidence would be needed to be observed to speak of an
addictive behavior (and not of a compulsive or impulsive
behavior)? In short, Brand, Rumpf, Demetrovics et al.
(2022) mention three areas to be scrutinized. First, the
observed addictive behavior needs to be clinically relevant
going along with significant impairments in the life of the
afflicted person. Second, the investigated excessive behavior
can be best explained by an addiction framework and third
empirical evidence from psychology, psychiatry and the
neurosciences should back up such a theoretical fit.
COMPARISON OF THE DIAGNOSTIC
GUIDELINES OF CSBD WITH GAMING AND
GAMBLING DISORDER
Sassover and Weinstein (2022) summarize the existing evi-
dence by using the components model of Griffiths (2005)
and come to the conclusion that most studies have not used
all 6 components resulting in a fragmented picture that
provides not sufficient evidence to categorize CSBD as a
behavioral addiction. Although the components model has
been very helpful in the early days of research on behavioral
addictions, it has been criticized because it was used in many
studies as an underlying concept to introduce or confirm
moot behavioral addictions that lack clinical evidence and
pathologize every day behavior (e.g. Starcevic, Billieux, &
Schimmenti, 2018). Moreover, it has been argued that the
components model mixes up core and peripheral criteria
and does not sufficiently include functional impairment as a
prerequisite to constitute a behavioral addiction (Billieux,
Flayelle, Rumpf, & Stein, 2019). In addition, more current
alternative approaches such as frameworks basing on the
criteria of Internet Gaming Disorder in the Diagnostic and
Statistical Manual of Mental Disorders (DSM-5, American
Psychiatric Association, 2013) are available. However, from
our view the most appropriate way to shed light on the
question whether CSBD constitutes a behavioral addiction
would have been to take the definition of Gambling and
Gaming disorder in the ICD-11 as a basis for judgement. By
doing so, it becomes apparent that the clinical description of
both disorders show strong similarities as can be seen in
Table 1, where we contrast diagnostic guidelines of CSBD
with those of Gaming Disorder and Gambling Disorder.
This observation has also been made by Brand, Rumpf,
Demetrovics et al. (2022) who state that “diagnostic
guidelines share several features with those for compulsive
sexual behavior disorder”(p. 4). In all three conditions, the
characteristics of loss of control, giving increasing priority to
the excessive behavior under investigation and continuing
the problem behavior despite negative consequences are
present. Given this strong overlap of diagnostic guidelines,
Table 1. Contrasting the symptoms of Compulsive Sexual Behavior
Disorder (an impulse control disorder) with symptoms of Gaming
Disorder/Gambling Disorder (addictive behaviors) based on the
classifications in ICD-11
Compulsive Sexual Behavior
Disorder (6C72)
Gaming Disorder (6C50) and
Gambling Disorder(6C51)
A persistent pattern of failure
to control intense, repetitive
sexual impulses or urges
resulting in repetitive sexual
behavior
Numerous unsuccessful efforts
to significantly reduce
repetitive sexual behavior
Impaired control over gaming/
gambling (e.g., onset, frequency,
intensity, duration, termination,
context)
Repetitive sexual activities
becoming a central focus of
the person’s life to the point
of neglecting health and
personal care or other
interests, activities and
responsibilities
Increasing priority given to
gaming/gambling to the extent
that gaming takes precedence
over other life interests and
daily activities;
Continued repetitive sexual
behavior despite adverse
consequences or deriving
little or no satisfaction from it
Continuation or escalation of
gaming/gambling despite the
occurrence of negative
consequences
Marked distress or significant
impairment in personal,
family, social, educational,
occupational, or other
important areas of
functioning
Significant distress or
significant impairments in
personal, family, social,
educational, occupational, or
other important areas of
functioning
Please note that the here presented symptoms have been taken
from the ICD-11 website (and were slightly modified and/or
shortened). https://icd.who.int/browse11/l-m/en#/http://id.who.int/
icd/entity/1630268048;https://icd.who.int/browse11/l-m/en#/
http://id.who.int/icd/entity/1448597234.
2
https://icd.who.int/browse10/2019/en#/F63.0.
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one might question that CSBD belongs to the group of
Impulse Control Disorder and might better qualify as
addictive behavior. Although the diagnostic guidelines of
CSBD and behavioral addictions such as Gambling or
Gaming Disorder are clearly convergent, we agree with
Sassover and Weinstein (2022) that the line between
impulsive and addictive behaviors cannot be drawn easily,
because impulse control is not only a central feature of
Impulse Control Disorders, but plays as well an important
role in addictive behaviors as seen for example in substance
use disorders (Moeller & Dougherty, 2002;Perry & Carroll,
2008), for instance, when participants are confronted with a
drug cue (Jones, Vadhan, Luba, & Comer, 2016). Moreover,
CSBD might share commonalities with compulsive behavior.
HOW DO PHENOMENOLOGICAL
CHARACTERISTICS OF DISORDERS IN THE
CATEGORIES OF OBSESSIVE-COMPULSIVE
DISORDERS AND IMPULSE CONTROL
DISORDERS RELATE TO CSBD?
However, the phenomenology of conditions grouped in the
ICD-11 as Obsessive-Compulsive Disorders, Impulse Con-
trol Disorders and Disorders Due to Addictive Behaviours
draw a clear picture. Although Sassover and Weinstein
(2022) argue that findings on compulsive components of
CSBD should be given more attention, CSBD has very little
similarities to the symptomatology of other disorders in this
category such as Obsessive-Compulsive Disorder, Body
Dysmorphic Disorder, Olfactory Reference Disorder, Hy-
pochondriasis, and Body-Focused Repetitive Behavior Dis-
order. In all of these conditions, the avoidance of negative
states such as tension or fears is in the focus and pleasurable
experiences or positive reward is typically missing in most of
the conditions; exceptions can be found partly in Body-
Focused Repetitive Behavior Disorder in which behaviors
such as hair-pulling or skin-picking may lead to gratifica-
tion, pleasure or relief. Given the semiologic discrepancy
described above, CSBD seems not to fit into the area of
obsessive-compulsive disorders. The current taxonomy finds
CSBD in company with other Impulse Control Disorders
such as Pyromania, Kleptomania, and Intermittent Explo-
sive Disorder. Differences between non-pathological and
pathological states in these disorders are more of qualitative
than of quantitative nature. All substance-related or behav-
ioral addictions start with a behavior which is rather
common in society or within the peer group such as
alcohol drinking, smoking, gambling or gaming. Based on
mechanisms described in models of addictive behaviors (e.g.
Brand et al., 2016,2019) such behavior shows increases in
frequency and quantity to an extent that it interferes with
functionality. Contrary, in Kleptomania, Pyromania, and
Intermittent Explosive Disorder, predominantly a qualitative
change in behavior occurs. Individuals suffering from these
disorders start to show “novel”(abnormal) behavior and
repeat it. This might be seen in a similar way in Body-
Focused Repetitive Behavior Disorder. In the course of these
conditions, frequency of behavior might increase over spe-
cific periods, can be intermittent or chronic. However, the
mostly slow and continuous increase of unproblematic
behavior as seen in addictions is not observable. In the light
of these phenomenological considerations, CSBD does not
really match with the category of Impulse Control Disorder.
CONCLUSIONS
It has to be kept in mind that these differences in phe-
nomenology need to be backed up by studies comparing
psychological mechanisms such as cue-reactivity, craving or
attentional bias as well as neurobiological alterations directly
contrasting CSBD with other (addictive and non-addictive)
disorders. Given the evidence, that we see currently, as well
as the similarities and discrepancies in phenomenology as
well as the diagnostic guidelines in the ICD-11, we are
convinced that CSBD appears more likely to be a Disorder
due to Addictive Behaviors than an Obsessive-Compulsive
Disorder or an Impulse Control Disorder.
Nevertheless, the paper of Sassover and Weinstein (2022)
has made an important contribution by stimulating such
discussions and and outlining future research goals. We fully
agree with the authors that it is necessary to use and inter-
pret criteria of addiction homogeneously to move the field
forward. At the same time, their recommendation to use the
DSM-5 criteria for Gambling Disorder for this purpose is
not supported by us. The Gambling Disorder criteria have
been the basis of the description of Internet Gaming Dis-
order (IGD) as a condition for further study in the DSM-5.
The IGD-approach has been criticized to include underlying
processes (Brand, Rumpf, King, Potenza, & Wegmann,
2020) or peripheral criteria (Billieux et al., 2019) besides
core criteria, both of which potentially may lead to over-
pathologization. This is supported by empirical data (e.g.
Besser, Loerbroks, Bischof, Bischof, & Rumpf, 2019) and
expert appraisals in a Delphi-study (Castro-Calvo et al.,
2021). Instead of using the DSM-5 criteria for Gambling
Disorder, we strongly recommend to take advantage of the
diagnostic guidelines for behavioral addictions lined out in
the ICD-11.
Funding sources: No financial support was received for the
preparation of this paper.
Authors’contribution: Both authors contributed equally in
drafting and finalizing the manuscript.
Conflict of interest: One of the authors (HJR) is associate
editor of the Journal of Behavioral Addictions.
Acknowledgment: HJR and CM are supported by the Deut-
sche Forschungsgemeinschaft (DFG, 411232260) and the
Innovationsfonds (01NVF19031).
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