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WHO classifies 'gaming disorder' as mental health condition

Posted at 12:29 PM, Jun 18, 2018

Watching as a video game ensnares their child, many a parent has grumbled about "digital heroin," likening the flashing images to one of the world's most addictive substances.

Now, they may have backup: The World Health Organization announced "gaming disorder" as a new mental health condition included in the 11th edition of its International Classification of Diseases, released Monday.

"I'm not creating a precedent," said Dr. Vladimir Poznyak, a member of WHO's Department of Mental Health and Substance Abuse, which proposed the new diagnosis to WHO's decision-making body, the World Health Assembly. Instead, he said, WHO has followed "the trends, the developments, which have taken place in populations and in the professional field."

However, not all psychologists agree that gaming disorder is worthy of inclusion in the International Classification of Diseases, known as the ICD.

Characteristics of gaming disorder

A diagnosis standard, the ICD defines the universe of diseases, disorders, injuries and other related health conditions. Researchers use it to count deaths, diseases, injuries and symptoms, and doctors and other medical practitioners use it to diagnose disease and other conditions. In many cases, health care companies and insurers use the ICD as a basis for reimbursement.

Poznyak said the expectation is that the classification of gaming disorder means health professionals and systems will be more "alerted to the existence of this condition" while boosting the possibility that "people who suffer from these conditions can get appropriate help."

He said there are three major diagnostic features or characteristics of gaming disorder.

"One is that the gaming behavior takes precedence over other activities to the extent that other activities are taken to the periphery," he said.

The second feature is "impaired control of these behaviors," Poznyak said. "Even when the negative consequences occur, this behavior continues or escalates." A diagnosis of gaming disorder, then, means that a "persistent or recurrent" behavior pattern of "sufficient severity" has emerged, according to the ICD.

A third feature is that the condition leads to significant distress and impairment in personal, family, social, educational or occupational functioning, Poznyak said. The impact is real, he said, and may include "disturbed sleep patterns, like diet problems, like a deficiency in the physical activity."

Overall, the main characteristics are "very similar" to the diagnostic features of substance use disorders and gambling disorder, he said. Gambling disorder "is another category of clinical conditions which are not associated with a psychoactive substance use but at the same time being considered as addictive as addictions."

For a diagnosis to be made, the negative pattern of behavior must last at least 12 months: "It cannot be just an episode of few hours or few days," Poznyak said. However, exceptions can be made when the other criteria are met and symptoms are severe enough.

"Millions of gamers around the world, even when it comes to the intense gaming, would never qualify as people suffering from gaming disorder," Poznyak said, adding that the overall prevalence of this condition is "very low."

"And let me emphasize that this is a clinical condition, and clinical diagnosis can be made only by health professionals which are properly trained to do that," he said.

Poznyak noted that the ICD does not make "prescriptions" in terms of insurance coverage or the development of health services -- these decisions are made by national authorities -- but "prevention and treatment interventions can help people to alleviate their suffering."

Most interventions or treatments for gaming disorder are "based on the principles and methods of cognitive behavioral therapy," he said.He added that different types of support may also be provided, including "psychosocial interventions: social support, understanding of the conditions, family support."

It's something Hilarie Cash is well aware of as co-founder of reSTART, one of the first inpatient treatment programs in the United States for video game addiction. She said it's time to recognize gaming disorder as a legitimate mental health condition.

"I've been surprised it's taken so long for everybody to catch up to the fact. But I also understand that they need to have strong, research-based evidence before they bring on a new disorder," she said.

"I think it's a game-changer, although how quickly the game will change, I don't know."

Whatever the therapy, Poznyak said, it should be based on understanding the "nature of the behavior and what can be done in order to improve the situation." Prevention interventions may also be needed.

Ultimately, WHO hopes that inclusion of gaming disorder in the classification will stimulate debate as well as further research and international collaboration, Poznyak said.

Game over, so to speak, is to "significantly reduce the current gaps in knowledge that we have when it comes to the prevalence of these conditions and when it comes to their nature and management."

'It's a little bit premature'

Anthony Bean, a licensed psychologist and executive director at The Telos Project, a nonprofit mental health clinic in Fort Worth, Texas, counts himself as a member of the camp that opposes inclusion of gaming disorder in the ICD.

"It's a little bit premature to label this as a diagnosis," Bean said. "I'm a clinician and a researcher, so I see people who play video games and believe themselves to be on the lines of addicted." In his experience, they're actually using gaming "more as a coping mechanism for either anxiety or depression."

Forthcoming research shows that gaming is a secondary diagnosis in coping with a primary diagnosis of anxiety and depression, Bean said: "When anxiety and depression is dealt with, the gaming goes down significantly."

The criteria being used by WHO to define gaming disorder in the ICD are "too broad," he said, while the mild, moderate or severe versions of the disorder have not been adequately delineated. Diagnosing a patient with gaming disorder, then, would be based on the "very subjective experience of clinicians," he said.

"And even most clinicians would probably agree that they don't understand the concept for video games because they're not immersed in that world or experience," he added.

The ICD diagnosis is not "appropriately informed," Bean said, since most clinicians -- and the mental health field as a whole -- do not understand the gaming population.

Bean's patients range from "11-year-olds, males and females, all the way up to 36 years old."

Working closely with them and understanding their games, he said, "you can actually see overt qualities of their gaming style and the way they actually interact with the world around them."

This knowledge can be used to help them through depression and anxiety, he says.

Someone playing "Minecraft" is going to be completely different from someone playing "World of Warcraft," he said: "They're two vastly different genres." The first is "an online social interaction," the second "more of a cosmic survival mechanism."

"If we understand what genres each person gravitates towards, it informs who they are as a person and why they choose that," Bean said. Then, clinicians can recommend a new game to guide a gamer toward more healthy behavior.

For parents or other loving ones concerned about a much-too-avid gamer, the first step is becoming "as informed as possible," recommended Bean, who is an author of a guidebook for clinicians wishing to work with gamers. "That's by far the number one thing that comes in with parents who have concerns is, they don't even know what games are being played," he said. The first question to ask, then, is "Why is this interesting to you?"

Ultimately, Bean is not saying gaming disorder doesn't exist, he just thinks "it's not really a good idea to go forward with this [diagnosis]. ... It really opens the door for anything to be a sickness."

Absolutely anything -- watching too much football on TV, doing too much research -- could be considered behaviorally addictive if mental health professionals don't insist on more rigorous study of the issue, Bean said: "Opening that door is a Pandora's box."