Content uploaded by Sophia Achab
Author content
All content in this area was uploaded by Sophia Achab on Jul 29, 2019
Content may be subject to copyright.
382 Bull World Health Organ 2019;97:382–383 | doi: http://dx.doi.org/10.2471/BLT.19.020619
News
Dr Susumu Higuchi has no doubt about
the mental health risks posed by on-line
gaming.
He heads the Kurihama Medical
and Addiction Centre in Kanagawa
Prefecture, Japan, which started the
country’s rst programme for internet
addiction in 2011. ere are now 84
nationwide. Higuchi has watched the
number of patients addicted to on-line
gaming steadily grow.
“Of the 269 patients we now see
for internet addiction, 241 have gaming
disorder as their principal addiction”, he
says. “Of those, 215 are males.”
e patients Higuchi sees display
a range of symptoms, but are generally
unable to limit the time they spend gam-
ing and continue to play despite negative
consequences, such as dropping out of
school (almost three quarters of the
patients are students) or losing a job.
No national survey of gaming dis-
order has been undertaken in Japan.
However, a recent national survey of
the broader category of “internet addic-
tion” reported that approximately 1.82
million males 20 years of age and older,
were living with an internet addiction
in 2018, almost three times the number
reported in 2013. e same survey re-
ported 1.3 million adult females living
with internet addiction, up from 0.5
million in 2013.
Higuchi co-authored a recent lit-
erature review - Cross-sectional and
longitudinal epidemiological studies of
internet gaming disorder – that found a
prevalence of internet gaming disorder
in the samples reviewed ranging from
0.7% to 27.5%.
“The literature review revealed
that geographical region made little
difference to prevalence,” says Vladi-
mir Poznyak, an expert on substance
use and addictive behaviours at the
World Health Organization (WHO),
who points to several surveys showing
internet gaming disorder prevalence
between 1%-10% in Europe and North
America.
“Because of dierences in survey
quality and comparability, the exact size
and nature of that problem is yet to be
dened,” he says, “but it is clear there is
a problem.”
In Switzerland, a report commis-
sioned by the Federal Oce of Pub-
lic Health published in 2018 found that
around 1% of the population (approxi-
mately 70 000 people) are “problematic”
internet users.
One of the experts consulted for
that report – Dr Sophia Achab – runs
a behavioural addiction programme
at the University Hospital of Geneva
where, since 2007, she has been treating
patients for internet-use disorders rang-
ing from addiction to on-line gambling
to internet pornography.
“
Addiction to
gaming is harder to
treat than addiction
to alcohol or drugs
because the internet is
everywhere.
”
Susumu Higuchi
Like Higuchi, Achab has seen a
steady increase in on-line gaming dis-
order patients, as well as an increasing
proportion of younger, male patients.
“Today, 43 of our 110 patients with in-
ternet addiction are primarily addicted
to gaming, 40 of them boys and young
men, and just three girls,” she says.
Among the people that have le
the deepest impression on Achab, was
a 22-year-old man who was brought
in by his mother. “He had dropped out
of school two years earlier and refused
to leave his room where he played for
18 hours a day. He was suering blood
clots in his legs due to physical inactiv-
ity,” she says.
Treating such patients is extremely
challenging, partly because of the
ubiquity of the internet. “In some ways
addiction to gaming is harder to treat
than addiction to alcohol or drugs be-
cause the internet is everywhere,” says
Higuchi.
Another challenge is the way the
games themselves are designed.
e nature of the game played is
one of the three factors considered by
Achab in her assessment of patient expo-
sure to addiction risk, the others being
individual factors, such as self-esteem,
and environmental factors, such as the
home, school or work environment.
For Achab, the presence of reward
systems (oen mediated through virtual
‘loot boxes’) oering virtual items such
as weapons and armour or ‘real’ rewards,
such as video streaming subscriptions,
are red ags. “Rewards drive players to
rack up the hours in pursuit of virtual or
real-world gains,” she explains.
Sharpening the focus on gaming disorder
The definition of gaming disorder is an important first step in developing a public health response to a new problem.
Gary Humphreys reports.
Staff at the Kurihama Medical and Addiction Centre, Kanagawa Prefecture, Japan.
Courtesy of Kurihama Medical and Addiction Centre
383
Bull World Health Organ 2019;97:382–383| doi: http://dx.doi.org/10.2471/BLT.19.020619
News
For Higuchi, multiplayer on-line
games are also a matter of concern. “Such
games provide opportunities to play and
compete with others, which would be
compelling for most people, but particu-
larly for those who might otherwise nd
it hard to socialize,” he says.
Higuchi also points to games that
encourage players to compete in tour-
naments and competitions for prize
money. “Many of my patients talk about
making a living from game play,” he
says. “is belief feeds into the broader
pathology.”
Approaches to treating those with
on-line gaming disorder tend to focus
on getting the patient to recognize their
addiction and to reconnect them with
reality. Higuchi uses a mix of cognitive
behavioural therapy, social skills devel-
opment, and treatment programmes em-
phasising physical activity. Achab uses
psychotherapy to reconnect patients
with themselves, their life objectives and
their social environment.
To date, the task of clinicians
has been made harder by the lack of
consensus regarding the nature of the
condition they are treating. “e lack of
clarity around the denition of gaming
disorder not only makes it harder to de-
velop appropriate treatment and public
health policy, it also stands in the way of
eective monitoring and surveillance,”
Higuchi says.
It was partly to address this issue that
WHO initiated a four-year consultation
process to explore public health impli-
cations of gaming and establish clear
boundaries for ‘gaming disorder’. e
classication derived from that consulta-
tion was published in the 11th edition of
the International statistical classication
of diseases and related health problems
(ICD-11) the diagnostic classication
standard used by health professionals
ranging from hospital administrators to
clinicians and researchers.
According ICD-11, a diagnosis of
gaming disorder is appropriate for a
person who, over a period of at least
12 months, lacks control over their
gaming habits, prioritizes gaming
over other interests and activities, and
continues gaming despite its negative
consequences.
“
The inclusion of
gaming disorder in
ICD-11 will facilitate
appropriate diagnosis
and treatment.
”
Vladimir Poznyak
The decision to establish a new
diagnostic category and include it
in ICD-11 has been welcomed by
psychologists and psychiatrists world-
wide, including members of the Royal
College of Psychiatrists in the United
Kingdom of Great Britain and Northern
Ireland and Division 50 of the Ameri-
can Psychological Association (APA)
– the division focused on addiction
psychology.
Not everyone is happy, however.
Gaming industry associations and
some mental health professionals and
academics have argued that, given the
current state of knowledge regarding
the impact of gaming on individuals, the
inclusion is premature, and is likely to
lead to overdiagnosis while also feeding
into moral panic about on-line gaming
and stigmatization of gamers.
Critics making these arguments
cite the APA’s decision to enter ‘inter-
net gaming disorder’ as a ‘condition for
further study’, in the 2013 Diagnostic
and Statistical Manual of Mental Disor-
ders (DSM-5), a designation signifying
that further research is required before
it can be accepted as a valid diagnostic
ca tego r y.
WHO’s Pozynak points out that the
inclusion of gaming disorder in ICD-11
was based on the conclusions of experts
from more than 20 countries, as well as
evidence of increasing internet-gaming-
related treatment demand.
As for concerns regarding over-
diagnosis and stigmatization, Poznyak
is sceptical. “e inclusion of gaming
disorder in ICD-11 will facilitate ap-
propriate diagnosis and treatment as
well as the monitoring, surveillance and
research required to get a clearer picture
of the prevalence and impact of the
condition,” he says, adding that WHO
is currently working with partners on
the development of an evidence-based
screening and diagnostic interview to
support clinicians.
According to Dr Charles O'Brien,
Professor of Psychiatry at the University
of Pennsylvania, and chair of the APA
committee that decided to include inter-
net gaming disorder in DSM-5 under the
‘condition for further study’ rubric, the
classication is currently under review.
“ere have been a lot of devel-
opments since 2013, and we have the
option to change the disorder classica-
tion if we consider it appropriate,” says
O’Brien.
Higuchi welcomes any move to-
wards clearer diagnosis, and greater
recognition of the disorder. “e ICD-
11 classication will help with that,” he
says. He also welcomes WHO’s decision
to publish guidelines on physical activity
for children under 5 years of age, which
recommend, among other things, that
children in their rst year of life should
have no screen time and very little in
their second, while those aged 2 to 4
years, should spend no more than an
hour a day in front of a screen.
“It’s time to set limits,” Higuchi
says. ■
Patients undergoing treatment for gaming disorder socialize as part of their therapy, Kurihama Medical and
Addiction Centre.
Courtesy of Kurihama Medical and Addiction Centre
