Gaming disorder and ICD-11 beta Jung-Seok Choi Department of Psychiatry Seoul National University Boramae Medical Center 2016 Korean Academy of Addiction Psychiatry

Key features in ICD-11 beta Introduction of a section with “Disorders due to substance use and addictive behaviors” Conceptual integration of “Gambling disorders” with “Disorders due to substance use” Impulse control disorders in ICD-10 Introduction of a new diagnostic category “Gaming disorder” Gaming disorder, predominantly online Gaming disorder, predominantly offline

Draft of ICD-11 Disorders due to substance use or addictive behaviors alcohol Nicotine… Disorders due to addictive behaviors Gambling Disorder Gaming Disorder

DSM-5 in Section 3 (Conditions for Further study) Internet Gaming Disorder (IGD) Persistent and recurrent use of the Internet to engage in games, often with others players, leading to clinically significant impairment or distress as indicated by five (or more) of the following in a 12-month period. Preoccupation with Internet games Withdrawal symptoms Tolerance Unsuccessful attempts to control the participation in Internet games Loss of interests in previous hobbies and entertainment as a result of, and with the exception of, Internet games Continued excessive use of Internet games despite knowledge of psychosocial problems Has deceived family members, therapists, or others regarding the amount of Internet gaming Use of Internet games to escape or relieve a negative mood Has jeopardized or lost a significant relationship, job, or educational or career opportunity because of participation in Internet games

Definition in ICD-11 beta Persistent or recurrent gaming behaviour (i.e., ‘digital gaming’ or ‘video-gaming’) characterised by impaired control over gaming, increasing priority given to gaming over other activities to the extent that gaming takes precedence over other interests and daily activities continuation of gaming despite the occurrence of negative consequences. The behaviour pattern is of sufficient severity to result in significant impairment in personal, family, social, educational, occupational or other important areas of functioning. 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.

Definition in ICD-11 beta Non-essential Features Impaired control over gaming Withdrawal symptoms Priority in life Health consequences Continuation despite problems Tolerance

DSM-5 vs. ICD-11 DSM-5 ICD-11 Preoccupation Withdrawal Tolerance Criteria Preoccupation Withdrawal Tolerance Loss of control Loss of interest Continued excessive use Deceived family members To escape or relieve a negative mood Lost a significant relationship, job, or educational or career opportunity (-) Impaired control Priority to game than other daily activities Continuation of game Significant impairment in personal, family, social, educational, occupational or other important areas of functioning.

WHO meetings on behavioral disorders association with excessive use of Internet On public health implications of excessive use of Internet, smartphone, or similar electronic devices Tokyo, Japan, Aug 2014 On clinical description, diagnostic guidelines and priorities for international research Seoul, Korea, Aug 2015 On policy and program response Hong Kong, Sep 2016

2016 WHO meeting in Hong Kong

Neurobiological evidences Key features in gaming disorder of ICD-11 beta Impaired control over gaming Associated with domains as follows: Impaired response inhibition Craving, urge, or cue reactivity Reward sensitivity Impaired decision making

Impulsivity and response inhibition 1 Impulsivity and response inhibition Personality Domain Higher impulsiveness measured by Barratt Impulsiveness Scale in Internet gaming disorder Similar features with gambling disorder or alcohol use disorder Lee and Choi, et al., 2012 Choi, et al., 2014

Impulsivity and response inhibition 1 Impulsivity and response inhibition Neurocognitive Domain Decreased response inhibition ability in Internet gaming disorder measured by Stop signal task Choi, et al., 2013 Choi, et al., 2014

Impulsivity and response inhibition 1 Impulsivity and response inhibition Neuroimaging Domain Association between local connectivity in the inferior temporal cortex and impulsiveness in Internet gaming disorder Kim and Choi, et al., 2015

Impulsivity and response inhibition 1 Impulsivity and response inhibition Neuroimaging Domain Association between frontolimbic activity and aggressive stimuli in Internet gaming disorder Chun and Kim, et al., 2015 Translational Psychiatry (IF=5.538)

Impulsivity and response inhibition 1 Impulsivity and response inhibition Neurophysiological Domain Resting-state beta power decrease associated with impulsivity in Internet gaming disorder ERP maker changes associated with attention and response inhibition in Internet gaming disorder Son and Choi, et al., 2015 Park and Choi, et al., 2016 Translational Psychiatry (IF=5.538)

Impulsivity and response inhibition 1 Impulsivity and response inhibition Neurophysiological Domain Delayed NoGo N2 latency and its relationship with severity of IGD and impulsivity in IGD Kim and Choi, et al. Under revision in Scientific Reports (IF=5.228)

Craving and Cue reactivity 2 Neurophysiological Domain Increased amplitude of P300 responsive to game-related cues in IGD Kim and Choi, et al. Unpublished data

Reward Sensitivity Brain Development 3 developments of striatal regions are more active in adolescents rather than frontal regions Casey and Jones, 2010

Reward Sensitivity Neuroimaging Domain PET study 3 Decreased dopamine receptor binding ability in IGD Kim et al., 2011

Reward Sensitivity Neuroimaging Domain PET study 3 Adult Adolescent Left VC Right VC increased FC in frontal and limbic regions related with reward network increased FC in sensory regions related with sensory-motor system Neuroimaging Domain PET study Increased functional connectivity between the ventral striatum and frontal regions in adolescents with IGD Kim and Choi, et al., Unpublished data

Summary New candidate diagnostic category of Gaming Disorder in the ICD-11 beta Key features of clinical descriptions such as impaired control, priority in life and continuation despite the problems Increasing evidences on the neurobiological basis More extensive field testings to evaluate the validity, reliability and clinical utility of the diagnostic criteria of Gaming Disorder are warranted 2016 Korean Academy of Addiction Psychiatry

Jung-Seok Choi, M.D., Ph.D. choijs73@gmail.com 2016 Korean Academy of Addiction Psychiatry