The World Health Organization (WHO) plans to include Gaming Disorder as a mental health disorder in the next edition of their diagnostic manual, the ICD-11, the International Classification of Diseases, 11th edition. It will be classified under the section “Disorders due to addictive behaviours,” along with Gambling Disorder. At this point, the ICD-11 is a “beta draft,” so the description and diagnostic criteria for Gaming Disorder may change before it is finally published, sometime in 2018. Parents, you may be dealing with a soon-to-be “addictive behavior” when your teen threatens to jump out a second story window if you take their cell phone off of them.
Dr. Richard Graham, an addiction specialist at the Nightingale Hospital in London, told the BBC he welcomed the proposed diagnosis. “It is significant because it creates the opportunity for more specialised services. It puts it on the map as something to take seriously.” He added he was also sympathetic to those who questioned whether the condition should be medicalised. “It could lead to confused parents whose children are just enthusiastic gamers.” He said in his practice, he sees about fifty new cases of digital addiction each year.
He looks for whether the digital activity is affecting basic things like sleep, eating, socializing and education. He asks himself, “Is the addiction taking up neurological real-estate, dominating thinking and preoccupation?” Commenting on the proposed classification, Psychology Today said: “Whether this provides clinical benefits over treating problematic gaming as a generic addiction disorder remains to be seen, but this move acknowledges the prominent psychological role that computing, and gaming in particular, can have in people’s lives.”
The DSM-5, which is the psychiatric diagnostic manual most used in the US, only listed internet gaming disorder as a “condition for further study” when it was published in 2013. However, many other countries have already begun to take steps to restrict the amount of time children and teens can spend gaming. South Korea introduced a law banning access for children under the age of 16 from online games between midnight and 6 am. In China, the online company Tencent limited the amount of time children can play its most popular games. In Japan players are alerted if they spend more than a specified amount on time each month playing games.
Here is a link to a description of Gaming Disorder for the ICD-11. It says: Gaming disorder is characterised by a pattern of persistent or recurrent gaming behaviour (‘digital gaming’ or ‘video-gaming’), which may be online (i.e., over the internet) or offline.” Symptoms or diagnostic criteria include: 1) impaired control over gaming that includes “onset, frequency, intensity, duration, termination, context;” 2) increased priority given to gaming so that “gaming takes precedence over other life interests and daily activities;” and 3) continuing or escalating gaming despite there being negative consequences.
The pattern of gaming behaviour results in marked distress or significant impairment in personal, family, social, educational, occupational, or other important areas of functioning. The gaming 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.
There is an exclusion to diagnosing Gaming Disorder in the ICD-11, the presence of Hazardous Gaming. It refers to “a pattern of gaming, either online or offline that appreciably increases the risk of harmful physical or mental health consequences to the individual or to others around this individual.” The increased risk could be from the frequency of gaming, from the amount of time spent gaming, from neglecting other activities and priorities, from risky behaviors associated with gaming, or from the adverse consequences of gaming. It could also be a combination of these symptoms. “The pattern of gaming is often persists in spite of awareness of increased risk of harm to the individual or to others.”
This may seem like a bizarre claim, but it’s been happening since the 1980s, when a man died playing an arcade game in a bar, according to Simon Parkin in Death by Video Game. According to “Video game addiction” on Wikipedia, in 2007 a Chinese man died after playing video games for three days straight. A New Mexico woman was convicted of second-degree murder and child abandonment for allowing her 3 ½-year-old daughter to die of malnutrition and dehydration while she was playing World of Warcraft online. She received 25 years in prison. An Ohio teen shot his parents, killing his mother, when they took away his copy of Halo 3. He received 23 years to life. Here’s a YouTube video referencing 10 real life deaths associated with video games.
Researchers in a South Korean study found an imbalance in the brain chemistry of young people “addicted” to smartphones and the Internet. Nineteen young people with internet or smartphone addiction and 19 gender- and age-matched healthy controls took part in the study. In order to assess the severity of this addiction, standardized internet and smartphone addiction tests were used to measure the severity of internet addiction. “The addicted teenagers had significantly higher scores in depression, anxiety, insomnia severity and impulsivity.”
MRS (magnetic resonance spectroscopy) exams showed that “the ratios of GABA to creatine and GABA to glutamate were significantly correlated to clinical scales of internet and smartphone addictions, depression and anxiety.” GABA (gamma aminobutyric acid) is a neurotransmitter in the brain that inhibits or slows down brain signals. Glutamate-glutamine (Glx), causes neurons to be more electrically excited. “Previous studies have found GABA to be involved in vision and motor control and the regulation of various brain functions, including anxiety.”
More study is needed to understand the clinical implications of the findings, but Dr. Seo believes that increased GABA in the anterior cingulate gyrus in internet and smartphone addiction may be related to the functional loss of integration and regulation of processing in the cognitive and emotional neural network.
However, after cognitive behavioral therapy, GABA to Gix ratios were significantly decreased or normalized. “The increased GABA levels and disrupted balance between GABA and glutamate in the anterior cingulate cortex may contribute to our understanding the pathophysiology of and treatment for addictions.”
The possibility of internet addiction was investigated as far back as 1998 in a paper for CyberPsychology & Behavior by Kimberly Young, “Internet Addiction: The Emergence of a New Clinical Disorder.” Young found that there were “significant behavioral and functional usage differences” between participants who met her criteria for dependent internet users and nondependent internet users. Kwon et al. developed a self-diagnostic scale called the Smartphone Addiction Scale (SAS). The authors said further research should look at the relationship between smartphone addiction and anxiety, depression, loneliness, low self-esteem and social maladjustment. They hoped the development of their scale would serve as an opening for the clinical diagnosis of smartphone addiction.
It’s not really surprising that some people would become “addicted” to something as reinforcing as video or online games. Compulsive smartphone use is also understandable, given how easily humans develop compulsive behavior patterns. But formally entrenching them as psychiatric disorders in the ICD or the DSM is going too far. Richard Graham’s observation that it could lead to confusion is to the point. Where does the diagnostic, disordering impulse stop? When does the medicalisation of so-called addictive behaviors end? Gambling, and now gaming—why not working or shopping—or pick your own favorite compulsive behavior.
A scale to assess problematic smartphone use or digital gaming has its uses. But adding another diagnostic label isn’t necessary … unless, perhaps, we might want to add something that quantifies the compulsion to create new diagnoses. How does Diagnostic Disorder sound as a label? Its symptoms could be: 1) impaired control over creating diagnoses, including the frequency, intensity and duration of their identification; 2) an increased emphasis on generating diagnoses to the point they take precedence over other psychiatric interests and daily activities; 3) continued or escalating diagnostic generation despite the negative consequences to others of such behavior.
