Video game addiction as a diagnosis: what changes in the international classification of diseases mean

The authors of ICD-11 proposed to consider a number of already known disorders in a different way than before, and a new type of addiction will be introduced into medical practice - on computer games. Clinical psychologist Giorgi Natsvlishvili tells more about what the ICD is and how the next edition of this edition changes our understanding of the mental norm.

The creation of a single language in which researchers from different countries communicate is necessary for the development of any science. Medicine is no exception. Here you don't even have to talk about contact with colleagues from different countries. Doctors need to understand each other at the level of one city as well. For this purpose, the nomenclature of diseases and their classifications were invented.

The International Classification of Diseases is the global standard methodology for collecting data on mortality and morbidity. It organizes and codes health information used for statistics and epidemiology, health management, resource allocation, monitoring and evaluation, research, primary health care, prevention and treatment. It helps to gain an understanding of the general health situation in countries and population groups.

The International Classification of Diseases is regularly updated, and at the moment, the eleventh revision of ICD-11 (International Classification of Diseases 11 revision) is being prepared for implementation. Each revision takes into account the latest advances in medicine and the implementation of new approaches both in the administrative records of patients and in the treatment and analysis of various diseases. The ICD is used not only by doctors, but also by nurses, scientific researchers, various administrative staff of medical institutions, insurance companies, and various health care providers.

ICD-11 will be presented to the World Health Assembly in May 2019 and will come into force on 1 January 2022. During the remaining time, a number of changes can be made to the classification, which will change the course of development of medical diagnostics and attitudes towards certain diseases. ICD-11 is the first revision that can be changed not only by a WHO committee of specialists, but also by other stakeholders. To do this, they will need to register on a dedicated WHO web portal.

It should be remembered that the ICD, for all its weight and significance, is not the only and last word that doctors around the world are guided by. There are also national medical associations, so the diagnosis of individual disorders and the criteria for their award from country to country may differ. This also applies to mental disorders, which will be discussed in our article.

For example, the previous revision, ICD-10, International Classification of Diseases of the 10th Revision (ICD-10), adopted in 1990, expanded the boundaries of mental normality by excluding homosexuality from the list of diseases. And although among professionals controversy on this matter continues to this day, and egodistonic homosexuality as a diagnosis was preserved in the ICD-10, this was an important step that influenced the reduction of stigmatization of people with homosexual orientation around the world.

Can we say that the changes in the class of mental and behavioral disorders, which are introduced in the ICD-11 Process for the development of the chapter of the ICD-11. Are mental and behavioral disorders also expanding the boundaries of the norm compared to the previous edition? Let's take a look at this issue in the context of schizophrenia, personality disorders and gambling addiction - which may become a new stigmatizing factor.

Schizophrenia

Schizophrenia is a mental disorder with a very rich history. Until now, when people talk about insanity, they mean schizophrenia. It is one of the most popular mental health conditions in popular culture. Accordingly, the attitude towards schizophrenia, as well as towards any element of mass culture, is fundamentally different both in society and among specialists.

The term "schizophrenia" was coined by Eigen Bleuler in 1908. The disease was characterized as endogenous and polymorphic, the symptomatology was not uniform in its qualitative content, and it was difficult to predict the outcome of the development of the disease. In this regard, there has been debate about how appropriate it is to distinguish schizophrenia as a separate disorder. Later, most experts agreed with the allocation of schizophrenia as a separate disease, but the discussions did not end there.

Throughout the twentieth century, there was a lot of controversy about how to analyze the symptoms of schizophrenia - as a single process, an indivisible whole (Kronfeld) or divide it into negative (suppression of any brain function, for example, memory impairment) and positive (when something new as a product of our psyche, for example, hallucinations) symptomatology (Kraepelin).

They also argued about how schizophrenia should be treated - depending on the understanding of its nature. If we consider it as an endogenous disorder, then schizophrenia is a brain disease that is treated exclusively with medications. If we are talking about an exogenous disorder, then schizophrenia is a disease of the family or society, and in order to cure the patient, it is necessary to change the situation. You can also use a multidisciplinary approach combining the first two.

Ultimately, the structuralist approach, which takes into account the division into negative and positive symptoms, won out in diagnostics. When it comes to treatment, some specialists take a multidisciplinary approach, while others look at schizophrenia as an exclusively endogenous disorder.

Until recently, schizophrenia was proposed to be differentiated according to the type of course and form. So, in the ICD-10, the following forms stand out, among others:

Paranoid form of schizophrenia, in which the clinical picture is dominated by relatively persistent, often paranoid delusions, usually accompanied by hallucinations, especially auditory, and perception disorders. Disorders of emotions, will, speech and catatonic symptoms (excessive muscle tone, in which the patient either moves and talks a lot, or, on the contrary, falls into a stupor and freezes) are absent or relatively weak.
Hebephrenic form of schizophrenia, in which affective (emotional) changes dominate. Delusions and hallucinations are superficial and fragmentary, the behavior is ridiculous and unpredictable, mannered. Mood is changeable and inadequate, thinking is disorganized, speech is incoherent. There is a tendency towards social isolation. The prognosis is usually unfavorable due to the rapid increase in "negative" symptoms, especially affective flattening (the patient ceases to experience and demonstrate emotions) and loss of will.
Catatonic form of schizophreniawhose clinical picture is dominated by alternating psychomotor disorders of a polar nature, such as fluctuations between hyperkinesis (involuntary movements of the limbs) and stupor (freezing) or automatic submission (excessive obedience) and negativism (the patient either acts contrary to the doctor, or does nothing and does not respond on doctor's instructions).

In the new edition of the ICD, we no longer find the division of schizophrenia into various forms. ICD-11 invites specialists to assess the manifestations of symptoms in a patient, paying more attention to descriptors that expand the understanding of the condition of a patient with a specific diagnosis, such as "negative symptoms in primary psychotic disorders", "depressive symptoms in primary psychotic disorders" and so on. Schizophrenia itself is now divided only by the number of episodes and their duration.

Apparently, the descriptors were introduced for a more subtle and flexible diagnosis, a more complete description of the existing symptoms. The fact is that, according to many experts, the current diagnosis of schizophrenia may conceal completely different contents and not always patients with the same diagnosis show a similar picture of the disease. The new approach will allow for a more individual approach to patients, which is likely to expand the boundaries of "normality".

First, people suffering from schizophrenia can no longer be terminologically accurately combined with the word “schizophrenics”. Secondly, it will change the attitude of doctors and medical staff to the process of treatment and care.

Nevertheless, given the active development of neurosciences, in the coming years, we can expect a further change in the view of schizophrenia, as well as the angle of development of psychiatry in relation to this disease.

Personality disorders

Personality disorders, or psychopathies, are also commonly seen in popular culture. We will not go into the diagnostic differences between Western and Russian approaches that exist and are very important for building a dialogue between specialists from different countries. Instead, we will focus on how ideas about personality disorders have changed in the new edition of the ICD.

At the moment, the term "psychopathy" has not been used as a diagnosis for a long time: it has now been replaced by the term "personality disorder". However, in this section we will refer to both the term "personality disorder" and the term "psychopathy" due to the fact that it is still used in academic and professional circles. For further narration, however, one must understand that they are in some way identical.

These disorders span multiple areas of the personality and are almost always closely associated with severe personal suffering and social breakdown.

These disorders usually appear (but are not always detected) during childhood or adolescence and continue into later life.

The doctrine of psychopathies was developed by the domestic psychiatrist Pyotr Borisovich Gannushkin. He called this disorder "constitutional psychopathy" and identified many different types of psychopathies such as schizoid, erratic, hysterical, and so on. Each type was described in detail, but the difficulty in diagnosis was that Gannushkin gave extreme variants of the severity of this disorder, which are not so common.

In the West, a similar approach was developed by Emil Kraepelin, whose concept (like Gannushkin's) is used in modern practice.

However, the division of psychopathies into certain types did not evoke the appropriate confidence of specialists due to the fact that patients are often found showing symptoms that fit several personality disorders.

In ICD-11, the approach was changed: its authors refused to highlight the types of personality disorders. Now the diagnosis of psychopathies is a kind of constructor. The first step is to make sure that the psychopathy in general is taking place. ICD-11 proposes the following criteria for personality disorders in ICD-11:

The presence of progressive disorders in how a person thinks and how he feels himself, others and the world around him, which manifests itself in inadequate ways of cognition, behavior, emotional experiences and reactions.
The revealed maladaptive patterns are relatively rigid and associated with pronounced problems in psychosocial functioning, which is most noticeable in interpersonal relationships.
The disorder manifests itself in a variety of interpersonal and social situations (that is, it is not limited to specific relationships or situations).
The disorder is relatively stable over time and has a long duration. Most often, personality disorder first appears in childhood and manifests itself explicitly in adolescence.

It is worth noting that these criteria are very similar to the criteria proposed by P. B. Gannushkin, the compliance with which confirmed the presence of psychopathy:

totality - certain personality traits affect the entire mental and social life of a person;
stability - during life the symptoms are not leveled;
social maladjustment caused by personality traits.

In the future, ICD-11 proposes to determine the severity of the course and only then - some personality traits in each individual patient.

Thus, we can talk about a shift in focus from establishing a diagnosis in the form of a specific disorder with a description of the corresponding behavior to the mechanism of the disorder and its structure. At first glance, this is done in order to help the doctor establish a more accurate diagnosis. However, this changes the very concept of personality disorders, on which, in particular, the method of treatment depends. It turns out that the innovations in the ICD-11 call into question the psychotherapy of patients with personality disorders. What is offered in return and whether these changes will be for the better is not yet clear.

Gambling addiction

Addictions, in the broadest sense of the word, are of two types: associated with the use of psychoactive substances and associated with addictive (prone to the emergence of various non-chemical addictions) behavior. Gambling addiction included in the ICD-11 belongs to the second type and implies addiction to computer games.

ICD-11 refers to this disorder as "gaming disorder". Note that this is not the same as gambling addiction, or gambling - a pathological addiction to gambling. True, the description of gambling, according to ICD-11, is completely identical to the description of gambling disorder. They have the same criteria:

Violation of control over the gameplay (for example, start, frequency, intensity, duration, cessation, context).
Greater preference is given to gambling / computer games. They are more important than any other activity.
Continuation or even greater involvement in gambling / computer games.
This dependence should be observed for at least 12 months.

Despite the apparent simplicity in the description of diagnostic criteria, many difficulties can arise in the diagnosis of play disorder. The fact is that computer games are a very broad area. To understand the principles of its work, the doctor himself must familiarize himself with a certain number of games or, no matter how funny it may sound, take an educational course in order to understand that games can be different and not all of them can really become a trigger for addictive behavior.

ICD-11 draws attention to a really existing problem - addiction to games as one of the forms of addictive behavior. Often, the very fact of non-chemical dependence suggests that the likelihood of developing chemical dependence increases. This is what you really need to pay attention to. However, the introduction of such a diagnosis raises concerns, and here's why.

To begin with, you can ask a reasonable question: why multiply the symptoms? Gambling addiction can be based on a variety of problems: conflicts with parents, a tendency to escape from their own failures, self-doubt, and so on. Any problem of this kind can be behind many non-chemical dependencies (to which the game also belongs). Should we single out gambling addiction as a separate disorder?

Here, a more successful diagnostic approach seems to be implemented in a situation with personality disorders. Indeed, at first it would be possible to single out the presence of addiction, then move on to its generalized characteristics (for example, it is satisfied at home, or on the street, or in extreme conditions, and the like). Further, you can approach a more specific characteristic.

Another problem is that behind the "gambling addiction" can be a very common story about finding contact with peers or the desire to play games with a good plot - after all, this is akin to the desire to read an interesting book.

Do not forget about e-sports, which can also be the reason for many hours of "freezing" at the computer (we will leave the question of the personal characteristics of those who prefer this kind of sport for behind-the-scenes discussions).

It is worth considering (and this is also indicated in the ICD-11) which games - online or offline - children play. Various researchers (Andrew Przybylski, Daphne Bavelier) have shown that games can be both harmful and beneficial. Complex games with complex control systems and / or an interesting plot are beneficial.

When it comes to online games, things are a little more complicated. Many online games have a different kind of reward system, and if the gameplay turns into a constant pursuit of these achievements, maladaptive inclusion in the gameplay can indeed occur. Only then can we talk about non-chemical dependent behavior.

The criterion for observing such symptoms for a year or more also raises doubts. Most likely, parents who do not know anything about the computer games market will come to see a psychiatrist with a potential "game-addicted" child. As well as the psychiatrist himself. As a result, children will receive an unsubstantiated diagnosis, which causes the most distrust in this approach.

In addition, it is unlikely that the child will be observed all year long. Most likely, we will get a picture of many families in which children are left to their own devices after school: they prepare their own food, do their homework and decide to relax at the computer. This is where their meeting with their parents takes place. How objective will such anamnesis be?

But there is one more important question. Does the new interpretation of disorders in ICD-11 lead to stigmatization of the gaming community? People who play computer games are already being attacked by the older generation, who consider the computer a toy that takes time and money (which is not always true, although this happens).

Of course, addiction to computer games as a coping strategy can and most likely does. But if we are talking about practice, then this is rare, much less common than cases of parental anxiety about their "play-addicted" child.

So, can we say that the introduction of ICD-11 expands the boundaries of the norm? Probably not. But the norm itself is likely to change.

The changes made to ICD-11 are aimed at simplifying the diagnostic process. And this can affect not only the specialists, but also the attitude of the patients themselves to their diseases.

We can definitely talk about a new way of looking at various disorders. In the future, this should help their treatment. Modern science is familiar with situations in which there is no need to come up with new complex solutions, sometimes it is enough to change the concept, the very approach to the problem.