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Friday Jul 27, 2018

Game Over? WHO Decision on Gaming Disorder Raises Questions

It was supposed to be a simple adolescent well-child visit. A 16-year-old came in with his mother for a routine checkup. However, his mother, who also is a patient of mine, had a complaint.  

[young man playing video games]

"He's not eating," she told my nurse, who relayed the message to me.

My eyes rolled -- internally, of course. I thought to myself, "She is probably just being a worried mother who is stressed that her son is too skinny and isn't eating an entire overloaded plate of food every night."

His weight, however, told a different story. Just as quickly as my internal bias had been raised, it was checked and squashed by the fact that the patient had lost 12 pounds in just six months.

The "well" portion of the well-child visit was now an oxymoron. I quickly did my head-to-toe review of systems trying to figure out what was wrong. This revealed nothing other than the fact that he was annoyed at being at the doctor's office with his mom, who was criticizing him for not eating.

"So, what does he do when you have dinner ready?" I asked.

"He stays in his room and plays on his game box thing," his mother said.

Thus, the crux of the issue was unveiled. By the end of the visit, he admitted to spending close to seven hours a day playing the game Destiny on his PlayStation, so much so that he stopped eating and began to lose weight.

I shared some simple parenting advice with the mom, such as limiting video games to weekends and taking the TV out of his bedroom. A potentially worrisome workup for weight loss in a teenager was averted. When he returned a few months later, after his mother implemented the new rules, his weight had improved, as had his affect and demeanor.

On June 18, the World Health Organization (WHO) released its new International Classification of Diseases(www.who.int) (ICD 11) in which it officially recognized gaming disorder as a mental health condition.(icd.who.int) WHO describes gaming disorder as being "characterized by a pattern of persistent or recurrent gaming behaviour ('digital gaming' or 'video-gaming'), which may be online (i.e., over the internet) or offline, manifested by: 1) impaired control over gaming (e.g., onset, frequency, intensity, duration, termination, context); 2) increasing priority given to gaming to the extent that gaming takes precedence over other life interests and daily activities; and 3) continuation or escalation of gaming despite the occurrence of negative consequences."

Furthermore, the condition must be present for at least 12 months and result in significant impairment in important areas of functioning such as school, work or family life.

There are those who oppose this inclusion(www.ncbi.nlm.nih.gov) in the ICD-11, and with good reason. They argue that depression and anxiety may, in fact, be underlying disorders, and there is concern that these important diagnoses could be missed if the focus is on gaming alone.

I believe the inclusion of video game disorder, though, is a step in the right direction because it opens the door to recognizing that other behaviors involving electronics, such as excess social media use, may in fact be disordered.

As an example, I confess I had a serious problem with Facebook. I was checking it multiple times throughout the day on my phone, sometimes even between patients as I'd wait for them to be roomed. I would be checking it while waiting in line at the grocery store or even while I waited for something to cook in the microwave. Although Facebook offers the promise of feeling more connected with friends and family, I actually felt lonelier after I used it. The mindless and seemingly endless scrolling through the newsfeed left me feeling empty, yet I continued to go back searching for that sense of connection.

When my wife started reminding me to stop looking at my phone, I knew it was time to change. I gave up Facebook for 40 days and have found that my internal sense of well-being has improved dramatically. Looking back, I was definitely in a funk, perhaps even borderline depressed, and I had a lot of anxiety surrounding the "likes" and comments on my Facebook posts. I've tried now to focus on seeing my friends and family more in person, and although I still check it about once per week, I have found that being detached from Facebook has been incredibly liberating.

Research shows that the way I was feeling is not unique. There are increasing reports(www.ncbi.nlm.nih.gov) that correlate heavy use of social media with depression,(www.braininstitute.pitt.edu) thought in large part to be due to the constant comparison to others. Although it would be difficult to establish causation, I can testify that before I began my heavy use of Facebook, I did not have symptoms of anxiety or depression, but I certainly did while using it.

The makers of social media platforms and video games know what they're doing. They want users to not only have an enjoyable experience, but also to spend as much time with their product as possible. Although rare, people have died while playing video games(www.washingtonpost.com) for extended periods of time. These marathon gaming sessions are many times coupled with smoking, unhealthy food, caffeinated energy drinks and immobility, putting these superusers at risk for blood clots, dehydration and arrhythmias.

The vast majority of gamers won't suffer this fate, and video games in general are safe and fun. Some of the most fun times I had in college were when groups of us would get together to play the first-person shooter game HALO. We would connect three or four different systems through a LAN network and play as teams in different rooms. There is something about joining together to fight a mutual enemy that creates a unique sense of comradery; add some colorful banter and those experiences served as the start of great friendships that remain to this day.

But times have changed since then, and with the advent of almost everyone having a computer in their pocket, we need to continuously ask ourselves how these devices and distractions from reality can influence our health.

In addition to its physical and emotional consequences, gaming can hurt people financially. Gambling offers perhaps the closest comparison to video games in its ability to become pathological. Both activities carry a sense of challenge that rewards us along the way with the promise of a big reward at the end. Although most games carry only a modest initial cost or start out free, there are many that allow players to pay real money to get an extra edge in the game. In some cases, this has resulted in the emptying of the players' bank accounts.(metro.co.uk) Further, it's been suggested that some young men are playing video games instead of getting jobs,(www.chicagotribune.com) a problem which I've seen in some of my patients.

So how can we apply this to practice? Although we don't have guidelines or recommendations yet, I think it's important to recognize that video game disorder can be a problem in and of itself (as it was in my patient) but can also be a symptom or coping mechanism for depression and anxiety. It will be our responsibility to help make this distinction and learn more about best practices. For now, we can tell our patients it's OK to share their "heals" on Fortnite, crush their Candy, and keep building in Minecraft, so long as it's done in healthy moderation.

Luis Garcia, M.D., is a family physician in York, Pa., working at Family First Health, a federally qualified health center. He focuses on caring for the Spanish-speaking community and spending time with his wife and two daughters. His hobbies include gardening and photography.

Posted at 06:15PM Jul 27, 2018 by Luis Garcia, M.D.

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