WHO Adds Gaming Disorder to Internal Classification of Diseases

On Monday, the World Health Organization (WHO) released the 11th revision of the International Classification of Diseases (ICD-11) with the inclusion of a new diagnosis—gaming disorder.

Although recently, some video games and augmented reality games have been developed and discussed as therapeutic options in the psychiatric and psychologic spaces, this new addition to the ICD-11 has caused some disagreement among experts regarding the condition and its classification.

WHO defines the condition as “characterized by a pattern of persistent or recurrent gaming behavior (‘digital gaming’ or ‘video-gaming’), which may be online (i.e., over the internet) or offline.” The condition, according to the ICD-11, can appear in continuous, episodic, and recurrent patterns and would manifest from 3 characteristics:

1. A diminished control over the onset, frequency, intensity, duration, termination, and context of the gaming behavior.
2. An increasing priority being granted to gaming, to an extent that the behavior takes priority over other life interests and day to day activities
3. The continuation or escalation of gaming activities despite the occurrence of negative consequences as a result.

“The gaming behavior 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,” the ICD-11 reads.

“I see this as a specific example of the more general category of ‘process addictions’ that can also include internet porn, sex addiction, food addictions, etc.,” Steven P. Levine, MD, the founder and CEO of Actify Neurotherapies, told MD Mag. “The specific activity may in some ways be less important overall than the addictive pattern of behavior.”

Levine noted that importantly, it shows a difference between the ICD and the Diagnostic and Statistical Manual of Mental Disorders (DSM). "The DSM seems to be a little more parsimonious, whereas the ICD can be overly specific. I can certianly understand the opinion as to why that it’s so specific."

Douglas Gentile, PhD, an Iowa State University professor of psychology and expert on video games and addiction, said in a statement that “this is a story about the value of science, and science works best when you're not trying to prove something but you're actually trying to disprove something.”

Gentile began studying the issue in 1999 an attempt to show this addiction was not the case but instead found the opposite to be true. He was part of a 2011 study published in Pediatrics, which followed 3000 children over 2 years, in which he and colleagues found gaming addiction to be comorbid with other mental disorders, such as depression, anxiety, social phobias, and ADHD.

“What [the] percentage is, we're not exactly sure because different studies measure different populations,” Gentile said. “The number seems to be somewhere between 1% and 10% in our study, which was a national study of children 8 to 18. We found that about 8.5% of youth gamers would classify as addicted at this clinical level. That means over 90% can play games and they're not having a problem.”

Even Gentile has his reservations about the condition, though. “I tend to think that it's an impulse control disorder. Now, not everyone agrees with me, and this is simply my opinion, but I think it's like that—where you know you should do your homework, but you just can't stop playing. You know that you should go to bed, but just 1 more level. So, you're not able to manage that impulse,” he said.

Although, the importance of the classification for Gentile seems to be that it is, at least, a step in helping the patients with gaming disorder get easier access to the treatments they need.

“Until it's recognized as a real problem by the medical community, you can't really get help,” he said. “No one's treating it, insurance won't pay for it, and so now that it's being recognized as a bona fide problem, hopefully now treatments will become more available. We can start studying what types of treatments are most effective.”

The ICD-11 also included new chapters, including a chapter on traditional medicine—a new classification for the system. A chapter on sexual health was added as well, joining conditions that were previously categorized in elsewhere, such as gender incongruence. It is scheduled to be presented for adoption by the WHO member states in May 2019 at the World Health Assembly and will come into effect on January 1, 2022.

“The ICD is a product that WHO is truly proud of," said Tedros Adhanom Ghebreyesus, PhD, MSc, the WHO director-general, in a statement. “It enables us to understand so much about what makes people get sick and die, and to take action to prevent suffering and save lives."

The full International Classification of Diseases—11^th Revision can be found here.