Tag: Gaming Disorder

10/30/18

When Gaming Gets Disorderly

credit: Pexel

In August of 2016 in his New York Post article, Nicholas Kardaras told an anecdotal story about a six-year old boy and an iPad that read like a Stephen King novel. His mother bought the boy an iPad when he was in first grade, thinking she was helping him “get a jump on things.” He discovered the game Minecraft, which the technology teacher likened to electronic Lego. “Some mornings he would wake up and tell her that he could see the cube shapes in his dreams.” When his behavior worsened and she tried to take the game away from him, he threw temper tantrums. “Then, one night, she realized that something was seriously wrong.”

She went into his room to check on him—he was supposed to be sleeping—and found him sitting up in his bed, seemingly in a trance. “His bloodshot eyes looking into the distance as his glowing iPad lay next to him.” In a panic, she had to shake him several times to snap him out of it. “Distraught, she could not understand how her once-healthy and happy little boy had become so addicted to the game that he wound up in a catatonic stupor.” Kardaras said:

We now know that those iPads, smartphones and Xboxes are a form of digital drug. Recent brain imaging research is showing that they affect the brain’s frontal cortex — which controls executive functioning, including impulse control — in exactly the same way that cocaine does. Technology is so hyper-arousing that it raises dopamine levels — the feel-good neurotransmitter most involved in the addiction dynamic — as much as sex.

Peter Gray was more balanced in his article for Psychology Today, “Sense and Nonsense About Video Game Addiction.” Gray said that Kardaras claiming that “your kid’s brain on Minecraft looks like a brain on drugs” was utter nonsense. He cited gaming researchers who said video gaming doubles dopamine levels in the brain—about the same as eating a slice of pepperoni pizza. “Drugs like heroin, cocaine, or amphetamine raise dopamine by roughly ten times that much.” He went on to say video gaming can positively alter your brain, but did acknowledge research shows that a small percentage of gamers “are suffering psychologically in ways that at least are not helped by gaming and maybe are worsened.”

When the DSM-5, the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders was published in 2013 it did not christen gaming as a distinct behavioral addiction. It did, however, include “Internet Gaming Disorder” in a section called “Conditions for Further Study.” In contrast, the World Health Organization (WHO) included “Gaming Disorder” as a distinct behavioral disorder.

The proposed diagnosis of Internet Gaming Disorder would mean “Persistent and recurrent use of the internet to engage in games, often with other players, leading to clinically significant impairment or distress as indicated by five (or more) of the following in a 12-month period.”  Then the following diagnostic criteria were given: 1) preoccupation with internet games; 2) withdrawal symptoms when gaming is taken away; 3) tolerance—the need to spend increasing amounts of time engaged in gaming; 4) unsuccessful attempts to control participation in gaming; 5) loss of interest in previous hobbies and entertainment activities other than gaming; 6) continued excessive use of gaming despite knowledge of psychosocial problems; 7) deception of family members, therapists or others about the amount of gaming; 8) use of gaming to escape or relieve a negative mood (like feelings of helplessness, guilt or anxiety); 9) gaming that jeopardized or led to the loss of a significant relationship, job, or either an educational or career opportunity.

Gray pointed out that preoccupation, tolerance, loss of interest in previous activities, deception, using to escape or relieve a negative mood could apply to anyone intensely interested in a hobby. “What I’m suggesting here is that a person who has a quite healthy passion for video gaming, who is not at all suffering, could very well check off these five “symptoms” and thereby get a diagnosis of IGD.” The other four seemed to him to be more indicative that something was wrong: withdrawal symptoms, unsuccessful attempts at control; continued excessive gaming despite psychosocial problems; risks of losing significant relationships or employment because of gaming.  He then briefly reviewed several studies of gaming addiction with a wide range of findings. Look at “Sense and Nonsense About Video Game Addiction” for his discussion of and citation of these studies. Here I’ll give an overview of a couple additional studies.

Torres-Rodriguez et al. wrote of their case study of four different types of adolescent problematic gamers in the International Journal of Mental Health and Addiction. The primary objective was to evaluate the effects of PIPATIC, a 22-session specialized treatment for adolescents with Internet Gaming Disorder (IGD). Given that all four cases had different etiologies leading to their problematic gaming, is was interesting that “the PIPATIC treatment was able to significantly reduce the negative symptoms and effects of IGD irrespective of the patients’ pathway and predispositions.” Three of the adolescents had comorbid disorders: autistic spectrum disorder, ADHD with depression and social phobia with depression.

In the American Journal of Men’s Health, Chen et al. examined how Internet Gaming Disorder was an emerging health issue for men. The authors observed where adolescent and adult males “demonstrate far more addictive internet gaming use in terms of screen hours, craving, and negative impacts on health, which have, in isolated incidents, also caused death.” They sought to do a literature review on IGD to raise awareness about IGD as an emergent men’s health issue. An intriguing section looked at studies seeking to conceptualize IGD through neuroscience. Conceived as a behavioral addiction, “a strong neurobiological link to addictive patterns has also been demonstrated in IGD.”

Although IGD is not recognized as an official mental health disorder, it is a significant emergent men’s health issue. If left untreated, IGD can lead to detrimental psychosocial impacts, affecting gamers and their families. PCPs can play an important role in providing early intervention, by knowing how to assess and treat men’s IGD; however, more research is needed to fully understand, accurately diagnose, and effectively treat this mental health condition.

The World Health Organization went further than the APA and classified Gaming Disorder in their eleventh edition of the International Classification of Diseases (ICD-11). When comparing the two descriptions, there are strong similarities, with the WHO definition being a more elegant and readable definition.

The ICD-11 said gaming disorder was defined as a pattern of gaming behavior “characterized by impaired control over gaming, increasing priority given to gaming over other activities to the extent that gaming takes precedence over other interests and daily activities, and continuation or escalation of gaming despite the occurrence of negative consequences.” For diagnosis, the behavior pattern must be severe enough to result in “significant impairment in personal, family, social, educational occupational or other important areas of functioning and would normally have been evident for at least 12 months.”

Writing for Medical News Today, in “What is gaming disorder?” Jayne Leonard reviewed the new ICD-11 disorder and explored what the classification could mean for gamers. She also noted the similarities between IGD and Gaming Disorder. There are also multiple links to additional studies, noting for example, how gaming may co-occur with anxiety, depression or stress. “People who remain physically inactive for extended periods due to gaming may also have a higher risk of obesity, sleep problems, and other health issues.”

Looking at what this could mean for gamers, Leonard said there was no doubt that some gaming behaviors were problematic. “But the majority of people who play computer and video games do not need to worry.” According to research into IGD assessed in a 2017 study by Przybylski et al., only .3-1.0 percent of people are likely to meet the criteria for an IGD diagnosis. More than 2/3 of individuals did not report any symptoms of IGD. Another study found individuals who did meet the criteria for IGD tended to have poorer emotional, physical, mental and social health.

Even though gaming disorder is not widespread, people should be aware of the amount of time that they spend playing games. They should also monitor the effect that gaming has on their other activities, their physical and mental health, and their relationships with others.

It doesn’t appear that like opioids, a gaming disorder epidemic will emerge. But it is wise to monitor gaming for impairment in some area of your life or the life of your children. And if a problem does emerge, there are gaming self help groups, like: “On-Line Gamers Anonymous. Look for the four diagnostic behaviors Peter Gray pointed out.

Do you feel restless when unable to play games (withdrawal)? Do you feel you should play less, but are unable to (unsuccessful attempts at control)? Do you continue gaming despite knowing it has a negative effect on your life (continued excessive gaming despite psychosocial problems)? And have you risked losing significant relationships or employment because of gaming?

04/17/18

Digital Addiction & Diagnosis

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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.