Process Addictions and the Anxiety Spectrum: How Gambling, Sex, and Pornography Compulsions Co-Occur with OCD, Anxiety, and Trauma

If you have searched for help with compulsive gambling, compulsive sexual behavior, or out-of-control pornography use, you have probably already encountered two opposing camps. One camp treats these behaviors as moral failures dressed up in clinical language. The other treats them as standalone “addictions” requiring 12-step abstinence and very little else. After roughly fourteen years of clinical work — including specialty practice in obsessive-compulsive disorder, trauma, and anxiety disorders — my view is that both camps are missing the most clinically important variable: the underlying anxiety, OCD spectrum, or trauma signature that the behavior is regulating.

This article is a clinically grounded look at process addictions — gambling disorder, compulsive sexual behavior disorder, and problematic pornography use — and how they co-occur with OCD, anxiety disorders, and trauma. It is written for the educated adult who wants to understand what is actually happening in their brain and behavior, not for someone looking for slogans. I will name what the research says, what it does not yet say, and what I see in my own practice. The goal is to help you decide whether what you are dealing with might be more than “just” an addiction — and what evidence-based treatment actually looks like when it is done well.

Note on language: “Fact” indicates an empirically established finding with citations provided. “Opinion” or “in my clinical experience” indicates a clinical observation drawn from practice that is consistent with — but not directly replicated in — published research.

What Counts as a “Process Addiction”?

The term process addiction (sometimes called behavioral addiction) refers to compulsive engagement in a non-substance behavior despite mounting negative consequences. The behavior produces a reward — usually some combination of dopaminergic activation, anxiety reduction, dissociative escape, or shame relief — and the brain learns to repeat it. Over time, the person loses meaningful control.

Fact: Currently, only one process addiction has full diagnostic status in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR; American Psychiatric Association, 2022): Gambling Disorder, which was reclassified in the DSM-5 (2013) from the Impulse-Control Disorders chapter to the Substance-Related and Addictive Disorders chapter. This was a significant move — it formally recognized that a non-substance behavior can produce the same clinical syndrome as a substance addiction, with similar neurobiological mechanisms, comorbidity patterns, and treatment responses (Clark, 2014; Stefanovics & Potenza, 2022).

Fact: Compulsive Sexual Behavior Disorder (CSBD) was added to the World Health Organization’s International Classification of Diseases, 11th Revision (ICD-11; WHO, 2018), as an impulse-control disorder, not a behavioral addiction. The ICD-11 defines CSBD as a persistent pattern of failure to control intense, repetitive sexual impulses or urges, resulting in repetitive sexual behavior over six months or more that causes marked distress or functional impairment (WHO, 2018; Kraus et al., 2018). Notably, the DSM-5-TR did not include CSBD or hypersexual disorder. “Pornography addiction” is not a recognized DSM or ICD diagnosis — though clinically meaningful problematic pornography use is captured under the CSBD umbrella in ICD-11 and treated under various adjacent diagnoses in the United States.

This diagnostic asymmetry matters more than most clients realize. It means that when an American clinician treats compulsive sexual behavior, they are working in a space where the dominant diagnostic system has not blessed the construct, and the conceptual lens they choose — addiction model, OCD spectrum model, impulse-control model, attachment/trauma model — will shape every treatment decision they make. Choose the wrong lens, and the treatment underperforms or actively harms the client.

In my practice, the single most common mistake I see — usually committed before the client ever finds me — is the reflexive application of a substance-abstinence model to behaviors that are functioning as compulsions or trauma responses. A person whose pornography use is driven by sexual orientation OCD, for example, will get demonstrably worse with a Sex Addicts Anonymous-style intervention focused on white-knuckle abstinence and shame-based accountability. The behavior is not the disorder; it is the visible tail of something else.

The Three Process Addictions in Focus

Gambling Disorder

Gambling Disorder is diagnosed when an individual exhibits four or more of nine criteria within a 12-month period, including preoccupation, tolerance (need to gamble with increasing amounts), unsuccessful efforts to cut back, withdrawal-like irritability when trying to stop, gambling to escape distress, chasing losses, lying about gambling, jeopardizing relationships or opportunities, and relying on others to bail out from financial situations caused by gambling (American Psychiatric Association, 2022). Severity is rated mild (4–5 criteria), moderate (6–7), or severe (8–9).

Fact: A 2025 meta-analysis of population-based surveys synthesizing data from 1993–2024 found that the weighted average prevalence of any mental disorder among individuals with Gambling Disorder is approximately 82.2%, with substance use disorders (34.2%), mood disorders (30.9%), and anxiety disorders (29.9%) comprising the most frequent comorbidities (Stefanovics et al., as synthesized in recent reviews, 2025). Register-based studies in Finland have found psychiatric comorbidity rates as high as 87% in clinically diagnosed Gambling Disorder cases.

Compulsive Sexual Behavior Disorder (and Problematic Pornography Use)

CSBD captures what the field has variously called sexual addiction, hypersexuality, sexual compulsivity, and out-of-control sexual behavior. The ICD-11 deliberately positioned it as an impulse-control disorder rather than a behavioral addiction because the field has not reached scientific consensus that the addiction model is the correct one (Kraus et al., 2018; Briken et al., 2024). The disorder is characterized by repetitive sexual behavior that becomes a central focus of life to the neglect of health, personal care, and other interests; numerous unsuccessful efforts to control or significantly reduce the behavior; and continued engagement despite adverse consequences.

Problematic pornography use is best understood as a frequent expression of CSBD — but with an important caveat. Moral incongruence, meaning the experience of distress about pornography use that stems from the user’s religious or moral beliefs rather than from the behavior itself causing functional impairment, is explicitly excluded from CSBD as a stand-alone diagnostic basis (Grubbs et al., 2019; Lewczuk et al., 2020). Self-perceived pornography addiction is a real phenomenon, but it is often more about the interaction between use frequency and the user’s value system than about a true behavioral addiction syndrome.

I see this distinction matter enormously in practice. A client raised in a high-control religious environment may use pornography at frequencies that would not raise a clinical eyebrow in a different value framework, but experience profound distress, secrecy, shame cycles, and what looks superficially like addiction. Treating that as CSBD with abstinence-based interventions — without addressing the underlying values clarification, scrupulosity, or religious trauma — does not work. The ACT-informed question I am asking is not ‘how do we stop the behavior’ but ‘what is this behavior doing for you, and what do you actually want your sexual life to look like?’

A Note on “Sex Addiction”

Opinion: The popular term “sex addiction” is clinically unhelpful and increasingly outdated. It collapses three very different presentations — true compulsivity, OCD-driven sexual obsessions, and trauma-driven sexual behaviors — into a single category that gets one treatment (typically abstinence + shame). The empirical literature does not support that the behavioral addiction model fits all of these presentations equally, and using a single label obscures the differential diagnostic work that actually drives good outcomes.

Where OCD Enters the Picture

Obsessive-compulsive disorder is one of the most consistently misdiagnosed conditions in the mental health field, and the misdiagnosis is especially common when OCD presents around taboo themes — sexual intrusive thoughts, harm thoughts, or moral/religious obsessions (scrupulosity).

Fact: A systematic review and meta-analysis of more than 15,000 individuals with OCD found a comorbidity rate of approximately 69% across the lifespan, with mood disorders, anxiety disorders, and other obsessive-compulsive related disorders being the most common (Sharma et al., 2021). OCD also has a meaningful relationship with addictive behaviors: the International OCD Foundation reports that approximately one in four individuals with OCD meets criteria for a co-occurring substance use disorder, and behavioral addictions appear with notable frequency as well, though the latter is less well-characterized in the literature.

The Critical Differential: OCD vs. CSBD

Here is where careful diagnostic work changes everything. Sexual orientation OCD (sometimes called HOCD or SO-OCD), pedophile-themed OCD (POCD), and relationship OCD (ROCD) all involve unwanted, ego-dystonic, anxiety-producing intrusive thoughts about sexual content. The person experiencing them is often horrified by the thoughts. They are not pleasurable; they are deeply distressing. The compulsion that follows — including, sometimes, compulsive pornography viewing — is frequently a covert checking ritual: the person watches material to test their reaction, gauge whether they are aroused or disgusted, and produce momentary reassurance about their identity, orientation, or character.

That is not addiction. That is OCD with pornography being recruited as a compulsion. Treatment for it is exposure and response prevention (ERP) — the gold-standard, evidence-based treatment for OCD — designed to help the person build a different relationship with the obsession so they no longer have to neutralize it. Telling that client to attend a 12-step group and abstain from pornography is, at best, ineffective and, at worst, iatrogenic. It teaches them that the obsessive content is dangerous and must be avoided, which is precisely the cognitive-behavioral pattern that maintains OCD.

Roughly a third of the men I see for what was initially framed as a pornography problem actually present with sexual-themed OCD. The clinical tell is the affect. True compulsive sexual behavior tends to involve craving, anticipation, and at least short-lived reward. Sexual-orientation or pedophile-themed OCD involves dread, horror, and reassurance-seeking. Once you can see the difference, the treatment plan is obvious. But you have to know what you are looking at.

Scrupulosity and the Gambling-OCD Crossover

Scrupulosity — religious or moral OCD — is another area where the line between process addiction and OCD blurs. A devout client who has gambled and now experiences relentless intrusive guilt, ruminative confession-seeking, and compulsive religious behavior to neutralize the distress is not simply suffering from “shame about gambling.” They are running an OCD process layered on top of (or sometimes substituting for) the gambling behavior itself. The same patient may even develop compulsions about gambling thoughts: avoiding certain neighborhoods, certain numbers, certain colors, in case those associations “bring back” the urge.

Opinion: Standalone gambling-disorder treatment (cognitive-behavioral therapy for gambling, motivational interviewing, Gamblers Anonymous) without addressing the underlying OCD is one of the more common reasons I see treatment-resistant cases. The behavior may stop, but the obsessive process continues, often migrating to a new target — overspending checks, ritualized financial behavior, or compulsive avoidance.

Anxiety as the Engine

Anxiety is the most common psychiatric comorbidity across the entire process addiction landscape, and it deserves its own discussion because it is so frequently the actual mechanism of relapse.

Fact: Population-based studies estimate that 14.4–16.6% of individuals with Gambling Disorder meet criteria for generalized anxiety disorder, 13.7–21.9% for panic disorder, and 10.1–14.9% for social phobia (Petry et al., 2005; Dowling et al., 2015; Kessler et al., 2008). For CSBD, although epidemiological data are still maturing, clinical samples consistently show elevated rates of generalized anxiety, social anxiety, and panic — often as both predictor and consequence of the behavior.

The mechanism is what addiction researchers call negative reinforcement. The behavior — placing the bet, opening the browser, escalating an encounter — temporarily reduces aversive arousal. The brain learns: when anxiety spikes, the behavior turns it down. With each repetition, the behavior gets more deeply wired to the anxiety circuit, and the anxiety becomes a more reliable trigger. Over time, the person is no longer chasing pleasure; they are running from a feeling. This is why so many process addiction clients describe the actual experience of the behavior as flat or even unpleasant — they get less and less out of it as the disorder progresses, but they cannot stop because the alternative is to sit with the anxiety they have spent years not learning to tolerate.

From an Acceptance and Commitment Therapy (ACT; Hayes et al., 2012) perspective, this is experiential avoidance — the rigid attempt to control or eliminate unwanted internal experiences (anxiety, urges, intrusive thoughts, shame) at the expense of valued living. ACT’s hexaflex model treats process addictions not primarily as a behavior problem but as a relationship-with-internal-experience problem. The behavior is downstream of avoidance. Treatment, then, is teaching the person to be willing to feel what they have been running from, and to commit to behavior aligned with their values rather than driven by their discomfort.

When I do ACT-integrated work with someone in active gambling or compulsive sexual behavior, the breakthrough usually does not come from a clever cognitive restructuring or a behavioral plan. It comes from a moment when the client realizes viscerally, not intellectually that their entire adult life has been organized around not feeling something. Once that lands, the question shifts from ‘how do I stop the behavior’ to ‘what am I willing to feel in order to have the life I actually want.’ That is the work.

Trauma: The Hidden Co-Occurrence

Trauma is the most underdiagnosed driver of process addiction in mainstream addiction treatment, and the data here are stark.

Fact: While the lifetime prevalence of post-traumatic stress disorder in the general U.S. population is approximately 8.3%, base rates rise to 11–15% among individuals with a lifetime diagnosis of Gambling Disorder, and PTSD prevalence in treatment-seeking and vulnerable gambling populations ranges from 17% to as high as 56% (Kessler et al., 2008; Kilpatrick et al., 2013; Ledgerwood & Petry, 2010). One Australian study of veterans in PTSD treatment found that 28% screened positive for probable problem gambling. The relationship appears bidirectional: each diagnosis increases the risk of developing the other (Scherrer et al., 2007; Parhami et al., 2014).

Fact: Trauma exposure is similarly elevated in OCD populations. A literature review found prevalence rates of OCD ranging from 30–82% among individuals with traumatic histories, compared to a general-population prevalence of 1.1–1.8%, suggesting a strong relationship that supports the existence of a trauma-related OCD subtype (Cromer et al., 2007; Fontenelle et al., 2012; Dykshoorn, 2014).

Compulsive sexual behavior shows the same pattern. Adverse childhood experiences — particularly childhood sexual abuse, emotional neglect, and exposure to early sexualized content — appear consistently in CSBD clinical samples (Reid et al., 2008; Kingston & Firestone, 2008). Pornography use that begins in early adolescence as a self-soothing strategy in a chaotic or neglectful home tends to ossify into adult patterns that look like addiction but function like trauma adaptation.

The neurobiological story here is converging across disorders. Trauma alters the threat-detection system, particularly the amygdala-insula-anterior-cingulate network, and reduces the prefrontal cortex’s capacity to inhibit reactive behavior. Add the dopaminergic reward conditioning produced by repeated process-addictive behavior, and you have a system that is simultaneously hyper-reactive to threat and hyper-reactive to reward, with a weakened brake. That is not a willpower problem. That is a neurobiological reality that requires neurobiologically informed treatment.

This is where Eye Movement Desensitization and Reprocessing (EMDR; Shapiro, 2018) earns its place in process-addiction treatment. EMDR’s Adaptive Information Processing model proposes that maladaptively stored traumatic memories drive present-day symptoms, and that bilateral stimulation paired with focused attention on the memory allows the brain to reprocess and integrate the material. In process-addiction work, EMDR can be used to target the originating trauma feeders, the early reinforcement experiences (the first time the behavior “worked”), and the self-defining negative cognitions (“I am damaged,” “I am dirty,” “I am out of control”) that sustain the cycle.

I cannot count the number of clients who came to me after years of unsuccessful gambling or pornography treatment, who improved markedly once we treated their actual underlying complex trauma. The behavior had been, in their nervous system’s language, the most reliable way they had found to regulate a body that had never felt safe. You cannot take that away without giving them something else, and that something else is usually a combination of EMDR, somatic regulation, and ACT-informed values work. Twelve-step alone, in these cases, is asking the client to give up their main coping strategy with no functional replacement. They will relapse, and they will blame themselves.

What Evidence-Based Treatment Actually Looks Like

Given the complexity above, what does competent treatment of a process addiction with comorbid OCD, anxiety, or trauma involve? In my practice, it is sequenced and modality-integrated, not eclectic in the loose sense but principled in matching modality to function.

Step 1: Differential Assessment

Before any treatment plan, the clinical question is: what is this behavior doing? Is it producing reward (true compulsivity)? Is it neutralizing intrusive thoughts (OCD)? Is it down-regulating arousal (anxiety/trauma)? Is it dissociative escape (trauma)? Most clients have more than one mechanism running at once, and the proportions matter. Validated measures that I commonly use include the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) for OCD severity, the Compulsive Sexual Behavior Disorder Scale (CSBD-19; Bőthe et al., 2020) for ICD-11-aligned CSBD assessment, the Problem Gambling Severity Index (PGSI), the GAD-7 and PHQ-9 for general anxiety and depression load, the Adverse Childhood Experiences (ACE) questionnaire, and the PCL-5 for PTSD symptoms.

Step 2: Stabilization and Harm Reduction

Active financial bleeding from gambling, employment-threatening sexual behavior, or relationship-destroying disclosure events need stabilization before deeper trauma work. This is where motivational interviewing, behavioral commitment work, and relapse-prevention scaffolding earn their place. For high-acuity gambling cases, blocking software, financial-access restructuring, and partner involvement in financial oversight may be appropriate.

Step 3: Modality-Matched Core Treatment

• If OCD is driving the behavior: Exposure and Response Prevention (ERP), grounded in the inhibitory learning model (Craske et al., 2014), targeting the underlying obsessions and the compulsion-maintaining behaviors. Pornography or gambling, in these cases, is a compulsion to be addressed within an OCD treatment frame, not a separate addiction problem.
• If anxiety is driving the behavior: ACT-informed work on experiential avoidance, values clarification, and committed action; CBT for specific anxiety presentations; possible referral for psychiatric evaluation if anxiety is severe.
• If trauma is driving the behavior: phased trauma treatment (Herman, 1992) — stabilization, processing (EMDR or trauma-focused CBT), and reintegration. The behavior usually attenuates as the underlying material is processed.
• If true compulsivity is the primary driver: behavioral addiction-specific cognitive-behavioral therapy with relapse prevention, peer support (Gamblers Anonymous, SMART Recovery, or appropriate equivalent), and pharmacological consultation when indicated (naltrexone for some gambling presentations is supported by emerging evidence; Grant et al., 2008).

Step 4: Values-Based Reintegration

Symptom reduction is necessary but not sufficient. The work that produces durable recovery is the work of building a life the client actually wants — which usually means addressing the relational, occupational, and meaning-level damage the disorder caused, and constructing the kind of daily existence that does not require the behavior to function. This is where ACT’s values and committed action processes do their most important work.

What Premium Treatment Should Not Look Like

Opinion (informed by clinical experience and the empirical literature): Several common features of conventional process-addiction treatment have weak or contradicted evidentiary support, and clients should be skeptical of them as primary interventions:

• Shame-based confrontation: The clinical literature has consistently failed to support confrontational approaches as effective in addiction treatment, and has identified iatrogenic harm in trauma populations (Miller & Rollnick, 2013).
• Moral framing as a primary intervention: Treating sexual or gambling behavior primarily as moral failure obscures the underlying clinical drivers and tends to produce shame cycles rather than recovery.
• Generic “talk therapy” without protocol: Process addictions with comorbid OCD, anxiety, or trauma respond to specific protocols. Open-ended supportive therapy can be a useful adjunct but is rarely sufficient as primary treatment.
• Abstinence-only models for behaviors that are not pure compulsivity: Pornography use driven by sexual orientation OCD does not respond to abstinence; in fact, the avoidance reinforces the OCD.

If You Recognize Yourself in This

The reason I have written this in the level of detail I have is that the people who are likely to be helped by careful treatment are the people who are sophisticated enough to read this far. If you have been in treatment before and felt like the framework did not fit your actual experience — that the behavior was always more complicated than the program acknowledged — that intuition is probably correct.

Effective treatment for process addictions with comorbid OCD, anxiety, or trauma is not mysterious, but it is not generic either. It requires a clinician who can do the differential work, who is trained in the specific protocols (ERP, EMDR, ACT, CBT), and who is willing to take the time to understand what your behavior is actually doing for you before trying to take it away.

Schedule a Consultation

I run a small, intentionally selective private practice. I see between 15 and 20 clients at a time, all private pay at $200 per session, via telehealth in Texas, Washington, New Hampshire, and Florida. My specialty areas include OCD and ERP, trauma and EMDR, anxiety, body-focused repetitive behaviors, and couples work. I take process addictions when they are part of one of those clinical pictures.

If you are considering treatment and want to explore whether this approach is the right fit, you can book a free 15-minute consult call. The consult is genuinely a fit call — not a sales call, not a session. We talk about what is going on, I tell you honestly whether I think I am the right clinician for it or whether someone else would serve you better, and you decide what you want to do next.

Book your free consultation at muradcounseling.com.

Felix Murad, M.Ed., LPC-S, LMHC, CMHC, NCC | Licensed Professional Counselor-Supervisor | Licensed by the Texas Behavioral Health Executive Council, Texas State Board of Examiners of Professional Counselors. Licensed in Texas, Washington, New Hampshire, and Florida (telehealth). Individual results vary; this article is educational and is not a substitute for an individualized clinical evaluation.

References

American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.). https://doi.org/10.1176/appi.books.9780890425787

Bőthe, B., Potenza, M. N., Griffiths, M. D., Kraus, S. W., Klein, V., Fuss, J., & Demetrovics, Z. (2020). The development of the Compulsive Sexual Behavior Disorder Scale (CSBD-19): An ICD-11 based screening measure across three languages. Journal of Behavioral Addictions, 9(2), 247–258.

Briken, P., Bőthe, B., Carvalho, J., Coleman, E., Giraldi, A., Kraus, S. W., Lew-Starowicz, M., & Pfaus, J. G. (2024). Assessment and treatment of compulsive sexual behavior disorder: A sexual medicine perspective. Sexual Medicine Reviews, 12(3), 355–370.

Clark, L. (2014). Disordered gambling: The evolving concept of behavioral addiction. Annals of the New York Academy of Sciences, 1327(1), 46–61.

Craske, M. G., Treanor, M., Conway, C. C., Zbozinek, T., & Vervliet, B. (2014). Maximizing exposure therapy: An inhibitory learning approach. Behaviour Research and Therapy, 58, 10–23.

Cromer, K. R., Schmidt, N. B., & Murphy, D. L. (2007). An investigation of traumatic life events and obsessive-compulsive disorder. Behaviour Research and Therapy, 45(7), 1683–1691.

Dowling, N. A., Cowlishaw, S., Jackson, A. C., Merkouris, S. S., Francis, K. L., & Christensen, D. R. (2015). Prevalence of psychiatric co-morbidity in treatment-seeking problem gamblers: A systematic review and meta-analysis. Australian & New Zealand Journal of Psychiatry, 49(6), 519–539.

Dykshoorn, K. L. (2014). Trauma-related obsessive-compulsive disorder: A review. Health Psychology and Behavioral Medicine, 2(1), 517–528.

Fontenelle, L. F., Cocchi, L., Harrison, B. J., Shavitt, R. G., do Rosário, M. C., Ferrão, Y. A., et al. (2012). Towards a post-traumatic subtype of obsessive-compulsive disorder. Journal of Anxiety Disorders, 26(2), 377–383.

Grant, J. E., Kim, S. W., & Hartman, B. K. (2008). A double-blind, placebo-controlled study of the opiate antagonist naltrexone in the treatment of pathological gambling urges. Journal of Clinical Psychiatry, 69(5), 783–789.

Grubbs, J. B., Perry, S. L., Wilt, J. A., & Reid, R. C. (2019). Pornography problems due to moral incongruence: An integrative model with a systematic review and meta-analysis. Archives of Sexual Behavior, 48(2), 397–415.

Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (2012). Acceptance and commitment therapy: The process and practice of mindful change (2nd ed.). Guilford Press.

Herman, J. L. (1992). Trauma and recovery: The aftermath of violence. Basic Books.

Kessler, R. C., Hwang, I., LaBrie, R., Petukhova, M., Sampson, N. A., Winters, K. C., & Shaffer, H. J. (2008). DSM-IV pathological gambling in the National Comorbidity Survey Replication. Psychological Medicine, 38(9), 1351–1360.

Kilpatrick, D. G., Resnick, H. S., Milanak, M. E., Miller, M. W., Keyes, K. M., & Friedman, M. J. (2013). National estimates of exposure to traumatic events and PTSD prevalence using DSM-IV and DSM-5 criteria. Journal of Traumatic Stress, 26(5), 537–547.

Kingston, D. A., & Firestone, P. (2008). Problematic hypersexuality: A review of conceptualization and diagnosis. Sexual Addiction & Compulsivity, 15(4), 284–310.

Kraus, S. W., Krueger, R. B., Briken, P., First, M. B., Stein, D. J., Kaplan, M. S., Voon, V., Abdo, C. H. N., Grant, J. E., Atalla, E., & Reed, G. M. (2018). Compulsive sexual behaviour disorder in the ICD-11. World Psychiatry, 17(1), 109–110.

Ledgerwood, D. M., & Petry, N. M. (2010). Pathological gambling and posttraumatic stress disorder: A study of the co-morbidity versus each alone. Journal of Gambling Studies, 26(4), 503–514.

Lewczuk, K., Glica, A., Nowakowska, I., Gola, M., & Grubbs, J. B. (2020). Evaluating pornography problems due to moral incongruence model. Journal of Sexual Medicine, 17(2), 300–311.

Miller, W. R., & Rollnick, S. (2013). Motivational interviewing: Helping people change (3rd ed.). Guilford Press.

Parhami, I., Mojtabai, R., Rosenthal, R. J., Afifi, T. O., & Fong, T. W. (2014). Gambling and the onset of comorbid mental disorders: A longitudinal study evaluating severity and specific symptoms. Journal of Psychiatric Practice, 20(3), 207–219.

Petry, N. M., Stinson, F. S., & Grant, B. F. (2005). Comorbidity of DSM-IV pathological gambling and other psychiatric disorders: Results from the National Epidemiologic Survey on Alcohol and Related Conditions. Journal of Clinical Psychiatry, 66(5), 564–574.

Reid, R. C., Carpenter, B. N., Spackman, M., & Willes, D. L. (2008). Alexithymia, emotional instability, and vulnerability to stress proneness in patients seeking help for hypersexual behavior. Journal of Sex & Marital Therapy, 34(2), 133–149.

Scherrer, J. F., Xian, H., Shah, K. R., Volberg, R., Slutske, W., & Eisen, S. A. (2007). Effect of genes, environment, and lifetime co-occurring disorders on health-related quality of life in problem and pathological gamblers. Archives of General Psychiatry, 64(6), 677–683.

Shapiro, F. (2018). Eye movement desensitization and reprocessing (EMDR) therapy: Basic principles, protocols, and procedures (3rd ed.). Guilford Press.

Sharma, E., Sharma, L. P., Balachander, S., Lin, B., Manohar, H., Khanna, P., et al. (2021). Comorbidities in obsessive-compulsive disorder across the lifespan: A systematic review and meta-analysis. Frontiers in Psychiatry, 12, 703701.

Stefanovics, E. A., & Potenza, M. N. (2022). Update on gambling disorder. Psychiatric Clinics of North America, 45(3), 483–502.

World Health Organization. (2018). International classification of diseases for mortality and morbidity statistics (11th rev.). https://icd.who.int/