JUN 19, 2018 | 3:00 AM
The World
Health Organization has made it official: digital games can be addictive, and
those addicted to them need help.
In the
latest edition of its International Classification of Diseases, released
Monday, the United Nations agency concluded that people whose jobs, educations,
family or social lives have been upended by video games probably meet the
criteria for a new form of addiction called “gaming disorder.”
If a
person has escalated or persisted in his or her gaming behavior despite clearly
negative consequences, that further seals the deal, the new guidelines say.
The
behavior should be “of sufficient severity to result in significant impairment”
and may be “continuous or episodic and recurrent,” the WHO’s diagnostic manual
notes. While “normally evident over a period of at least 12 months,” a
diagnosis may be in order sooner in cases where impairment is evident, efforts
to cut back have failed and symptoms are sufficiently severe.
Sound
like someone you know? Read on.
Q. Why is the World Health Organization’s decision important?
A. The
WHO’s International Classification of Diseases gives medical professionals
around the world a single standard for identifying a problematic medical or
behavioral issue and accepting it as a disorder worthy of attention and
treatment. Despite differing languages and social, cultural and medical
traditions, the WHO’s 191 member nations recognize these common definitions of
diseases.
In
addition, the classification codes are the foundation for health insurance
billing in the United States. The absence of a diagnostic code makes it
difficult for a healthcare professional to treat a patient and then get paid
for that treatment.
Q. Is gaming disorder diagnosed the same everywhere?
A. The
WHO’s definition is pretty inclusive, sweeping in anyone who could argue their
gaming habit has interfered with important daily functioning. The American
Psychiatric Assn. has proposed — but not yet fully embraced — a set of
diagnostic criteria that are somewhat more detailed.
The
association publishes a handbook of psychiatric diseases called the Diagnostic
and Statistical Manual, also known as the DSM. In 2013, the organization added
internet gambling disorder to the DSM, but opted not to include internet gaming
disorder — at least, not yet.
A draft
diagnostic description for internet gaming disorder would require a
determination that persistent gaming had caused a person to have “significant
issues with functioning.” It also calls for five of the following symptoms to
be present:
• A preoccupation or obsession with internet games.
• Withdrawal symptoms when not playing games.
• A tolerance for gaming, so that a person needs to spend more
time playing to be satisfied.
• At least one failed attempt to stop or cut back on playing
games.
• A loss of interest in other life activities.
• Overuse of digital games despite realizing the impairment they
have caused.
• Lying to others about game usage.
• Using gaming to escape or relieve anxiety or guilt.
•
Relationships have been lost or risked because of gaming.
Q. Who is at risk for having a gaming disorder, and how widespread
is it?
A. In
2013, it appeared that internet gaming disorder was most common in male
adolescents between the ages of 12 and 20, and that the affliction was more
prevalent in Asian countries than in North America and Europe. Experts
estimated that close to 10% of kids in China and 1% to 2% of kids and teens in
the United States were affected. That may explain why WHO recognized it first,
while the APA demurred.
A more
recent study underscores
that gaming addiction is probably a worldwide phenomenon, albeit an uncommon
one. The analysis of close to 19,000 internet users from the U.S., Canada, the
United Kingdom and Germany found that among those who played games, just under
1 in 3 reported at least one symptom of internet gaming disorder. But very few
— between 0.3% and 1.0% of the general population — might qualify for a
diagnosis of internet gaming disorder, according to the 2017 report in the
American Journal of Psychiatry.
"Video
game addiction might be a real thing,” psychologists Patrick M. Markey of
Villanova University and Christopher J. Ferguson of
Stetson University wrote in a commentaryaccompanying
that study. “But it is not the epidemic that some have made it out to be."
Q. How is gaming disorder treated?
A. This
was one of the bits of unfinished business that stayed the American Psychiatric
Assn.’s hand in 2013.
“There
really hasn’t been a good study of what kind of treatment works,” said Dr. Andrew Saxon, professor of psychiatry and
behavioral science at University of Washington’s School of Medicine in Seattle
and chair of the APA’s Council on Addiction Psychiatry. “We’re in the realm of
semi-experts giving recommendations,” he said.
Cognitive
behavioral therapy, which focuses on identifying the problem and devising
strategies and paths to resistance, works well, said Dr. Petros Levounis, an
addiction specialist who chairs the department of psychiatry at Rutgers’ New Jersey
Medical School.
“Gaming
disorder does seem to respond to psychotherapy, and counseling can be quite
effective,” he said.
As in
other addictions, the biggest challenge comes up front, “where people may see
nothing wrong with it,” Levounis added. “There’s a lack of insight into the
consequences of the behavior that’s difficult to address.”
Q. Are certain people more at risk for gaming disorder?
Yes,
people who have other psychiatric disorders.
“Rates of
depression, anxiety, ADHD are very high among this population,” Saxon said. “If
you can treat those, that might make it easier to treat the internet gaming
disorder.”
Q. People love to play games, just like they love watching TV or
working out. How is that an addiction?
A.
Psychiatrists have been debating this question since they first drew
connections between addictions to substances like alcohol or drugs and problems
with excessive engagement in pleasurable (and often unavoidable) behaviors like
eating, shopping and sex.
Q. What are the arguments in favor?
Multiple
studies have found that substance addictions and behavioral addictions share much of the same brain circuitry. Imaging
studies have found that the urge to play video games activates the same brain
regions that light up when compulsive gamblers or those addicted to illicit
drugs ponder the prospect of gambling or drug use.
Some of
the neural consequences may be the same too: A 2012 study suggests that the
effects of excessive online game-playing on working memory may be similar to
those observed in patients addicted to drugs or alcohol. Consequently,
some researchers assume
that problematic gaming might share some of the same neurobiological mechanisms
as pathological gambling and substance dependence.
Q. What are the arguments against?
There’s a
key practical distinction, adherents to this side say.
Dependence
on alcohol or drugs — and for that matter, gambling — can be treated with
abstention or avoidance. By contrast, eating is necessary, sex is key to a
healthy romantic relationship, and shopping is virtually impossible to avoid.
In the
21st century, spending time online is pretty much a fact of life as well. That
makes abstention or avoidance all but impossible, Saxon said.
“Do you
tell people you can’t go online or have devices? Because you can’t go online
without getting that stimulus they’re seeking,” he said. “I’m not sure how we
go about that. A lot more work would have to be done to look at the treatment.”
Q. How do we know that digital gaming isn’t just a fad?
A. With
games like Fortnite, League of Legends and Pokeman Go, digital gaming has taken
the world by storm relatively recently. But it could lose its allure — and vast
audience — just as quickly. Is this any way to diagnose a true psychiatric
disorder?
Opinions
differ on this one as well. Levounis noted that over the years, many diseases
have bubbled up and either died down on their own or been swatted into
obscurity by vigilance and treatments. But they still needed to be identified,
characterized and treated, he argued. Despite having been eradicated by
vaccines, smallpox was once a very real disease, he said.
Saxon
isn’t so sure.
“Substance
use disorders have been with humans through recorded history,” he said. “But
having an electronic device that lets you connect to the rest of the world has
only been widespread for 10 to 20 years. For all we know, some phenomenon will
come on and five years from now, people will be doing other very disruptive
things with their lives. That’s one reason why the framers of the DSM 5 were a
little cautious.”
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