Video Game Overuse Poses Diagnostic Challenge: Behind-the-Scenes Battle Keeping Internet/video Game Addiction Disorder out of the DSM-5

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STEAMBOAT SPRINGS, COLO. -Internet/video game addiction disorder is a diagnosis that's not to be found in the DSM-IV Nor after considerable controversy will it make its way into DSM-5. But it is nonetheless a very real problem, according to Dr. Michael Rich, director of the Center on Media and Child Health at Children's Hospital Boston.

Four elements are common to any addiction, whether it involves alcohol, heroin, or a behavior such as gambling, sex, or shopping.

These four components are excessive use that impedes other aspects of life, increasing tolerance in order to obtain the "high," withdrawal symptoms, and a willingness to sustain negative consequences to maintain the habit.

A survey of a national sample of more than 1,000 8- to 18-year-olds concluded that 8.6% of video gamers are pathological players, according to the criteria established for pathological gambling (Psychol. Sci. 2009;20:594-602). That's consistent with study results from other countries.

In South Korea, a nation of 49 million where Internet addiction disorder (IAD) is a recognized diagnosis, 250,000 patients younger than age 18 are in treatment for this condition, said Dr. Rich, who is also director of the video intervention/prevention assessment program at the hospital and an adolescent medicine specialist at Harvard Medical School in Boston.

American children who meet the Korean criteria for IAD have higher levels of obsessive-compulsive behaviors; more depression, anxiety, and paranoid ideation; and lower scores for interpersonal sensitivity than do controls.

An intriguing but poorly understood interplay exists between IAD and attention-deficit/hyperactivity disorder (ADHD). The prevalence of IAD is significantly higher among American children with ADHD. Moreover, when youths with ADHD play video games, their ADHD symptoms subside. And when children who meet the criteria for IAD but don't have ADHD are placed on methylphenidate (Ritalin), their IAD symptoms decrease, he said at the meeting.

Although the official American Psychiatric Association position is that there are not enough scientific data to support inclusion of IAD in the DSM-5, Dr. Rich said there has been a "huge" behind-the-scenes battle, with some addiction medicine specialists arguing against the entire concept of non-substance-based behavioral addictions.

The skeptics might have carried the day by denying the IAD diagnosis inclusion in the forthcoming DSM-5, he said, but they haven't done clinicians or patients any favors.

"I am seeing an increasing number of kids with not necessarily true addictions, but with problematic use ... where it's getting in the way of their functioning in one way or another. I think we need to be there for them, but unless it's recognized as a diagnosis it's hard to build an infrastructure to care for them and access the services they need," the pediatrician said.

He works around this obstacle by using accepted diagnoses for which the young patients qualify.

"I'm often treating them with the diagnosis of insomnia when what's really happening is they're staying up all night playing World of Warcraft, or [I'm] treating them for generalized anxiety disorder because they're playing a violent video game and they're twritchy as a result. So, please, keep video game addiction in mind when you are assessing a kid for issues of sleeplessness, anxiety, irritability, poor school performance. Put it on the differential diagnosis list along with depression and anxiety and substance use" Dr. Rich urged.

World of Warcraft has close to 11 million subscribers.

Today, 92% of American youth aged 2-17 years play video games. Some 79% of games with an "E" rating on the package (meaning they're supposedly suitable for everyone aged 6 years and older) are violent. In all, 73% of 4th grade boys and 59% of girls list a violent video game as their favorite game. …