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Sharpening the focus on gaming disorder

382 Bull World Health Organ 2019;97:382–383 | doi:
Dr Susumu Higuchi has no doubt about
the mental health risks posed by on-line
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
“Because of dierences in survey
quality and comparability, the exact size
and nature of that problem is yet to be
dened,” he says, “but it is clear there is
a problem.
In Switzerland, a report commis-
sioned by the Federal Oce 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
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 suering 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
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 (oen mediated through virtual
‘loot boxes’) oering 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
Bull World Health Organ 2019;97:382–383| doi:
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
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 denition of gaming
disorder not only makes it harder to de-
velop appropriate treatment and public
health policy, it also stands in the way of
eective 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
classication derived from that consulta-
tion was published in the 11th edition of
the International statistical classication
of diseases and related health problems
(ICD-11) the diagnostic classication
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
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
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
classication is currently under review.
“ere have been a lot of devel-
opments since 2013, and we have the
option to change the disorder classica-
tion if we consider it appropriate,” says
Higuchi welcomes any move to-
wards clearer diagnosis, and greater
recognition of the disorder. “e ICD-
11 classication will help with that,” he
says. He also welcomes WHOs 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
Patients undergoing treatment for gaming disorder socialize as part of their therapy, Kurihama Medical and
Addiction Centre.
Courtesy of Kurihama Medical and Addiction Centre
... e treatment o ered to such individuals varied widely, depending on locally available mental health facilities, which often lacked relevant clinical expertise. Outside the East Asian context, almost no national health care responses or other organized health service programs had developed in response to this need 139,156,157 , even in pioneering countries that had highlighted gaming disorder in their national health or addiction strategic plans more than a decade ago 158,159 . Lack of recognition of gaming disorder as a diagnostic category in the ICD appeared to be a major obstacle to provision of specialized care for patients and their families 139,156,160 . ...
... e Kurihama Medical and Addiction Centre in Japan reported treating more than 200 patients with gaming disorder in 2019, which for many adolescent patients involved working with parents and other family members 157 . In the UK, the National Health Service (NHS)-funded specialist service for gaming disorder, positioned within the National Centre for Behavioural Addictions, received more than 50 patients between January and May in 2021 204 . ...
... Government support for research programs and public health responses to gaming disorder have varied greatly by region 217 . In East Asian countries, there have been long-standing coordinated governmental e orts to support research and public health initiatives 149,157 . In comparison, more limited funding for research and fewer public resources for treatment have been available across Western countries 218 . ...
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Among the important changes in the ICD-11 is the addition of 21 new mental disorders. New categories are typically proposed to: a) improve the usefulness of morbidity statistics; b) facilitate recognition of a clinically important but poorly classified mental disorder in order to provide appropriate management; and c) stimulate research into more effective treatments. Given the major implications for the field and for World Health Organization (WHO) member states, it is important to examine the impact of these new categories during the early phase of the ICD-11 implementation. This paper focuses on four disorders: complex post-traumatic stress disorder, prolonged grief disorder, gaming disorder, and compulsive sexual behaviour disorder. These categories were selected because they have been the focus of considerable activity and/or controversy and because their inclusion in the ICD-11 represents a different decision than was made for the DSM-5. The lead authors invited experts on each of these disorders to provide insight into why it was considered important to add it to the ICD-11, implications for care of not having that diagnostic category, important controversies about adding the disorder, and a review of the evidence generated and other developments related to the category since the WHO signaled its intention to include it in the ICD-11. Each of the four diagnostic categories appears to describe a population with clinically important and distinctive features that had previously gone unrecognized as well as specific treatment needs that would otherwise likely go unmet. The introduction of these categories in the ICD-11 has been followed by a substantial expansion of research in each area, which has generally supported their validity and utility, and by a significant increase in the availability of appropriate services.
... There is increasing demand for interventions to address digital technology-based problems (Humphreys, 2019;Nakayama & Higuchi, 2015), but the lack of evidence-based guidelines (King, Delfabbro, Griffiths, & Gradisar, 2012;Rodda, Booth, Vacaru, Knaebe, & Hodgins, 2018) means there is some uncertainty about optimal treatment approaches. A survey of 289 psychiatrists reported that 43% were not confident in their ability to manage problem gaming in their practice (Dullur & Hay, 2017). ...
... The region also launched a clinical trial for internet addiction for young people in 2014. The trial offers a multitherapeutic approach with an outdoor program that is overseen by the National Institution for Youth Education in collaboration with the Kurihama Medical and Addiction Center, which launched its own treatment section in 2011 and receives hundreds of patients each year, primarily with problems related to excessive gaming (Humphreys, 2019). ...
Although digital media use confers many personal and social benefits, it is recognized that unrestricted and habitual use can have major negative health consequences, particularly for young people. Problematic gaming in its most serious form, for example, is recognized as an addictive disorder by the World Health Organization. In recent years, there have been calls from researchers and clinicians to also recognize problematic use of a range of online activities (e.g., social media, online shopping, pornography) in mental disorder classification systems, including the DSM-5 and ICD-11. There are continuing debates on the nature and prevalence of these potential conditions in the general population and in special populations (e.g., adolescents, individuals with preexisting disorders). At the same time, some jurisdictions have introduced various public health measures to attempt to respond to these problems. One of the larger areas of literature on interventions has been the study of treatments for gaming disorder, notably cognitive-behavioral therapies. In East Asia in particular, there have been broad prevention measures introduced to address less serious but nevertheless harmful digital technology use. This chapter will review and discuss the literature on interventions for digital technology-based problems, recognizing that the optimal approach to these problems may often entail the coordinated efforts of different areas of influence ranging from families and peers, schools, health providers, government bodies, and the industries that provide online content.
... 22 The effectiveness of CRAFT has been demonstrated especially in the work with CSO of alcohol abusers [23][24][25] and in counseling CSO of PA with problematic gambling. 26,27 Demand for specialized interventions for PA with IUD and CSO is steadily increasing, 28,29 but there is still a lack of evidence-based guidelines and a comprehensive care structure for PA and CSO. [30][31][32][33] ...
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Introduction Internet use disorder is a disorder of the digital age and presents a growing problem worldwide . It appears that due to structural and personal barriers, many persons affected (PA) and Concerned Significant Others (CSO) do not reach the health care system so far and thus a chronification of the pathology can proceed. Methods A telemedicine counseling service for PA and CSO of PA unwilling to enter treatment with two webcam-based sessions of 60 minutes for each group was created with the aim of reaching out to PA and CSO to provide a low-threshold support and refer the participants to the local health care system. Motivational interviewing for PA and CRAFT (Community Reinforcement and Family Training) for CSO were used as methods. Participants answered questions about their Internet use and sociodemographic data and six months after participation, participants were asked via email if they entered the local health care system. CSO answered the questions for themselves and in a third-party rating for PA unwilling to enter treatment. Results 107 PA (34 years ( SD = 13.64), 86% male) and 38 CSO (53 years ( SD = 6.11), 28.9% male) participated in the two telemedicine sessions. After participation, 43.9% of the PA and 42.1% of the CSO reached the health care system. When there was consistency between the location of telemedicine consultation and treatment locally, over 90% of participants arrived (PA: 92.3%, CSO: 100%). Conclusion The results from this study reveal that telemedicine services could be a promising approach to address PA and CSO and build a bridge to the local health care system. Future studies should verify if these results can be replicated in randomized controlled trials.
... According to a meta-analysis on problematic gaming covering the years 2009-2019, the international prevalence of problematic gaming was about 2.09% [5]. Individuals who are excessively involved in gaming are likely to experience negative moods, such as irritability [6], poor physical health, and reduced sleep quality [7], as well as poor performance at work and school [8,9]. ...
Full-text available
Problematic gaming has become a public concern, influenced both by genetic factors and stressful environments. Studies have reported the effects of dopamine-related genes and interper- sonal stressors on problematic gaming, but gene and environment interaction (G × E) studies have not been conducted. In this study, we investigated the interaction effects of dopamine receptor D2 (DRD2) polymorphisms and interpersonal stress on problematic gaming and the mediating effect of avoidant coping to reveal the mechanism of the G × E process. We recruited 168 college stu- dents (mean age = 22; male 63.1%) and genotyped their DRD2 C957T (rs6277) and Taq1 (rs1800497) polymorphisms. The results of the mediated moderation analysis showed that, when experiencing interpersonal stressors, individuals with both the C957T T allele and the Taq1 A1 allele showed more elevated problematic gaming scores than non-carriers. Moreover, the interaction effect of the combined DRD2 polymorphisms and interpersonal stress was significantly mediated by avoidant coping. These findings suggest that the influence of interpersonal stress on problematic gaming can be changed as a function of DRD2 genotypes, which may be because of the avoidant coping styles of C957T T allele and Taq1 A1 allele carriers in response to stress.
... In recent years, there has been increasing recognition that maladaptive patterns of video gaming may lead to functional impairment and psychological distress for some players [2][3][4][5]. In several countries, this issue has generated significant public health concerns [6,7]. ...
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In this brief letter, we report a new World Health Organization (WHO)-led project developing gold standard instruments to detect gaming disorder and gambling disorder following their inclusion in the ‘disorders due to addictive behaviours’ section of the eleventh revision of the International Classification of Diseases (ICD-11)
... The World Health Organization has officially classified (International Classification of Diseases ICD-11; WHO, 2018) continuing to play video or electronic games as an addiction leading to a mania, and has announced that people with this mania have certain characteristics, as the inability to 'stop gambling on winning, and according to the organization, a person is classified as having this disease if their addictive behaviour persists for 12 months. However, the diagnosis can be confirmed in a shorter period of time if it is certain that all symptoms are present, the warning about the severity of electronic gaming addiction is not new, but the formal classification of this addiction as a pathological obsession by the World Health Organization can be a major impetus to raise awareness of this disease and take serious action in families and societies to counter it [3] [4] . For years, research has been going on to study and understand the effect of electronic games on the behavior and health of children, for example, we mention. ...
... However, a significant minority of gamers experience functional, psychological, social and physical impairment as a result of excessive gaming. 1 This has raised public health concerns globally and calls for diagnostic criteria for gaming disorder. 2 In ICD-11 gaming disorder has been defined by the World Health Organization (WHO) as a clinical condition associated with distress or interference with personal functioning. 3 It is included in a new disease category of 'disorders due to addictive behaviours', which was adopted at the World Health Assembly in May 2019 and will come into effect in January 2022. ...
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The World Health Organization (WHO) has added gaming disorder to ICD-11 as a clinical condition associated with distress or interference with personal functioning. This inclusion leads to clinical and public health benefits, such as harmonising terminology, offering clinical landmarks and improving monitoring capabilities and data comparability. Training health professionals to identify and manage gaming disorder is a key challenge for countries. In the present paper we compiled opinions from different countries around the globe on their state of preparedness and needs to tackle this issue. The global views on the topic feed arguments for developing an evidence-based and cross-cultural training tool for gaming disorder management by health professionals.
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Psychosis is the most ineffable experience of mental disorder. We provide here the first co‐written bottom‐up review of the lived experience of psychosis, whereby experts by experience primarily selected the subjective themes, that were subsequently enriched by phenomenologically‐informed perspectives. First‐person accounts within and outside the medical field were screened and discussed in collaborative workshops involving numerous individuals with lived experience of psychosis as well as family members and carers, representing a global network of organizations. The material was complemented by semantic analyses and shared across all collaborators in a cloud‐based system. The early phases of psychosis (i.e., premorbid and prodromal stages) were found to be characterized by core existential themes including loss of common sense, perplexity and lack of immersion in the world with compromised vital contact with reality, heightened salience and a feeling that something important is about to happen, perturbation of the sense of self, and need to hide the tumultuous inner experiences. The first episode stage was found to be denoted by some transitory relief associated with the onset of delusions, intense self‐referentiality and permeated self‐world boundaries, tumultuous internal noise, and dissolution of the sense of self with social withdrawal. Core lived experiences of the later stages (i.e., relapsing and chronic) involved grieving personal losses, feeling split, and struggling to accept the constant inner chaos, the new self, the diagnosis and an uncertain future. The experience of receiving psychiatric treatments, such as inpatient and outpatient care, social interventions, psychological treatments and medications, included both positive and negative aspects, and was determined by the hope of achieving recovery, understood as an enduring journey of reconstructing the sense of personhood and re‐establishing the lost bonds with others towards meaningful goals. These findings can inform clinical practice, research and education. Psychosis is one of the most painful and upsetting existential experiences, so dizzyingly alien to our usual patterns of life and so unspeakably enigmatic and human.
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