On May 25, 2019, the World Health Assembly reviewed and approved the Eleventh Revision of the International Classification of Diseases (hereinafter referred to as ICD-11). Among them, “gaming disorder” is included as a new disease in the “block of addiction behavior” disease unit. The National Health and Health Commission's CDC organizes experts to systematically sort out the definition, clinical characteristics, assessment, diagnosis, treatment, and rehabilitation of game obstacles, and form an expert consensus as follows.
I. Definition and clinical features
According to ICD-11 definition, game obstacles refer to a behavioral pattern of using electronic or video games continuously or repeatedly. The behavior of the game is out of control, the game becomes a priority in life, and the game behavior continues regardless of adverse consequences, and lasts for a long time. .
At present, there is still a lack of large-scale epidemiological survey data based on the ICD-11 standard. Previously, there have been many researches on game-related issues in different countries and regions. Because of the different criteria for disease diagnosis, screening tools, and population, the reported prevalence of diseases varies greatly (0.7%-27.5%). A number of relevant surveys in China have shown that the prevalence of game-related problems is 3.5%-17%. Based on the results of previous related studies, the prevalence of game disorders averaged about 5% and remained relatively stable. The obstacles of the game are mainly male, children and adolescents. The prevalence of Asian countries may be higher than that of European and American countries.
The main clinical manifestations of game obstacles include: loss of control over the start, frequency, duration, end, and occasion of game behavior; the game takes precedence over other life interests and daily activities; although it has had negative consequences due to the game, it continues to play and even increase Game strength. There are many similarities between game obstacles and material addiction. Some researchers will play games for more and more people, spend more and more money on games, and increase the tolerance of substance addiction, which will stop the game. Emotional and behavioral responses such as irritability, depression, and impulsivity are analogous to the withdrawal response of substance addiction. Game obstacles may subjectively perceive the thirst for the game, and it may be difficult to distinguish between the virtual world and the real world in the game.
Game disorders can lead to physical problems, mental behavior problems, and social impairment. Physical problems include lack of sleep, circadian rhythm disorder, malnutrition, gastric ulcer, seizures, etc. In severe cases, sedentary formation of lower extremity venous embolism and even pulmonary embolism may cause sudden death; mental behavior problems include irritability, anxiety, assaults and deeds, Depression, guilt, etc.; social impairment includes refusal to go to school and social activities, increased family conflicts, loss of important relationships, academic achievement, and impaired professional performance.
Game disorders often coincide with attention deficit hyperactivity disorder, depression disorder, anxiety disorder, bipolar disorder, sleep disorder, personality disorder, social phobia and other mental disorders. The natural course of game disorders has not been clearly understood, and the conclusions between different studies are quite different. 84% of patients reported that they were still pathological after 2 years of follow-up; however, some studies suggested that only 26.5% of patients still had game-related problems after 2 years of follow-up, and the symptoms were tracked during 5 years. A moderate degree of decline in severity will occur.
Second, the influencing factors of game obstacles
Research at home and abroad shows that game obstacles are related to various factors such as psychology, society, and biology.
(1) Psychological factors
Game obstacles may have high impulsive, high neurotic, introverted personality characteristics. Some may have aggressive and violent problems, and others may have problems such as poor mood regulation, loneliness, low self-esteem, low self-efficacy, low life satisfaction, perceived pressure, and depression and anxiety. Psychological factors such as higher social ability, self-esteem, subjective well-being may reduce the occurrence of game obstacles. In addition, the individual's perception of whether he or she can control the behavior of the game may be an important factor in predicting the behavior of the game.
(2) Social and family factors
Among the people who are bullies, bullies, and game addicted friends, the incidence of game obstacles is high. Insufficient social support and interpersonal communication, poor teacher-student relationship or classmate relationship, and poor school atmosphere are also related to the occurrence of game obstacles. Parental acceptanceeducationLevel and parenting style are related to the risk of childhood and child play disorders; family relationship is not harmonious, single or divorced is related to the risk of adult game play disorders; children and adolescents who cannot be accompanied or poorly guarded by guardians may have a higher risk of onset; The social support system may be a protective factor for game barriers.
(3) Biological factors
The brain imaging findings of patients with game disorders are similar to those of substance addiction patients and gambling disorders, and there are structural and functional abnormalities in brain regions such as multiple frontal lobes, ventral and dorsal striatum. Corresponding functional anomalies include reduced execution control functions, reduced sensitivity to loss, increased response to game-related stimuli, greater impulsivity in making choices, changes in reward-related learning, and reduced cognitive flexibility. . Some game-impaired patients have changed their self-concepts and the self-identity processing of avatar characters in the game. However, the causal relationship between these brain dysfunctions and game disorders remains to be elucidated.
(4) Game type
The more preferred forms of games for game obstacles are online games, not offline games; the more preferred categories of games are massively multiplayer online role-playing games, first-person shooters, fighting and real-time strategy games.
Third, diagnosis and evaluation
Early identification, diagnosis, and intervention are critical to the prevention and treatment of game disorders.
(1) Screening and evaluation of game obstacles
Screening and evaluation of game obstacles in the general population, especially children and adolescents, to achieve early identification, early diagnosis and early intervention, to improve the effect of intervention, improve cost-effectiveness, reduce the pain and burden of patients and their families, and improve the quality of life of patients It is of great significance. To this end, accurate, reliable, and easy-to-use tools are important for screening, assisting diagnosis, assessing severity, and more.
Before the release of ICD-11, the academic community has developed a variety of questionnaires and scales for screening or evaluating excessive game behavior or game obstacles, and has an important reference for understanding the incidence and typical characteristics of game obstacles. However, these tools also have many limitations, including inconsistent definition of core features of game obstacles, inconsistent clinical state boundaries, lack of time dimension, insufficient reliability of symptom indications, and focus on evaluating student groups. Therefore, the World Health Organization is organizing national experts and partner institutions to develop screening assessment tools with high universality, clear standards and easy to use for game obstacles to help medical staff identify the risk of early childhood obstacles. Reduce missed diagnosis, misdiagnosis or over-diagnosis, and promote suspected patients and high-risk individuals to be referred to professional institutions for further diagnosis and evaluation.
Game obstacles may be accompanied by a variety of physical or mental behavior problems, and a comprehensive systematic assessment of suspected patients. The assessment includes: (1) whether there are game obstacles and their severity; (2) whether there are physical health problems or mental health problems; (3) academic functions, occupations, interpersonal relationships, family relationships, quality of life and other social functions and related Background information; (4) Game disorders combined with other mental behavior disorders; (5) Protective factors and risk factors affecting treatment and rehabilitation (such as patient compliance, self-efficacy, family and social support, socioeconomic level, etc.) (6) Judgment of prognosis, etc.
(two) diagnosis and differential diagnosis
For the clinical diagnosis of suspected patients with high-risk games or high-risk individuals, standardized diagnostic guidelines are needed to ensure the accuracy of diagnosis in medical and health institutions and to avoid over-diagnosis.
The core features of the game obstacles proposed in ICD-11 are: (1) continuous or repeated game behavior patterns, which are manifested as out-of-control game behavior (such as the inability to control the occurrence, frequency, duration, termination time, etc. of the game behavior), the game Behavior becomes a priority in life, although the negative consequences of the game (such as broken relationships, occupational or academic influence, health damage, etc.) can not be stopped; (2) the game behavior pattern can be continuous or episode, and lasts for 12 Months, but if the symptoms are severe enough and meet other diagnostic criteria, the duration may be shorter than 12 months; (3) the game behavior pattern leads to significant personal, family, interpersonal, academic, professional or other important functional areas of damage. Depending on the form of the game, game obstacles include online game obstacles and offline game obstacles.
Need to distinguish between game obstacles and normal game behavior. If the repeated game behavior is aimed at promoting socialization, relieving boredom, regulating emotions, and the like, and lacking other necessary features of the game obstacle, it cannot be diagnosed as a game obstacle. In certain ages or social groups (such as adolescent males) or in specific situations (such as as a holiday entertainment), there may be longer or higher frequency game behaviors, including culture, subculture, and companions when diagnosing The influence of factors such as groups. In addition, for game industry related individuals, high-intensity game behavior may be part of their professional content and should not be diagnosed as a game obstacle.
The game obstacle is a continuous development process, that is, starting from not playing games, after entertaining occasional play to high frequency play stage, and finally developing into uncontrolled behavior. Therefore, the diagnosis of game obstacles must not only judge whether the disease state is reached, but also establish the awareness of early recognition and early intervention in the diagnosis work, and provide professional advice to individuals who have some symptoms but do not fully meet the diagnostic criteria, and prevent development in time. Go to the game barrier.
Diagnosing game disorders also requires attention to rule out other diseases. It usually needs to be differentiated from the following: (1) Hazardous game behavior refers to a state in which the game behavior brings the risk of health damage, but there is no health damage, a state that may require intervention or observation; (2) gambling obstacles, game obstacles usually It does not involve money gambling, but many online games currently have gambling forms (pokers, mahjong, etc.) or gambling components (probative lottery); (3) other mental disorders such as anxiety disorders, depression disorders, bipolar disorder, personality Obstacle, etc., excessive game behavior may occur during the above-mentioned disease attack period, only when the excessive game behavior pattern meets the game obstacle diagnosis points, and in the absence of the above-mentioned disease mental symptoms, consider the diagnosis of the game obstacle; if there are game obstacles at the same time Other mental disorders should consider the diagnosis of other mental disorders of game disorders and comorbidities; (4) substance use disorders, game behavior often coexists with substance use (special alcohol), if the diagnostic criteria of both disorders are met, comorbidity diagnosis can be considered .
Fourth, comprehensive intervention principles and measures
(1) General principles
In addition to following the general principles of substance use and addictive behavioral disorders, it is necessary to combine prevention and intervention with high-risk groups and disease characteristics of game obstacles, adhere to prevention, and conduct comprehensive interventions based on evidence and ethical individualization.
1. Prevention is the main one. Game barriers are high in children and adolescents. There are certain processes from the development of recreational game behavior to game obstacles. Preventive interventions for high-risk groups can significantly reduce the incidence of game disorders and the burden of disease.
2. Based on evidence. All interventions should have evidence and should not violate research or clinical practice evidence.
3. ethical. Game barrier interventions should be based on universal medical ethics, respect for human rights and patient dignity, and do not harm the health and interests of patients.
4. Comprehensive intervention. There are currently no specific interventions for game obstacles. Because patients are often accompanied by physical or mental illness, psychological therapy, drug therapy and other means are needed to combine individualized interventions. At the same time, the game barrier is similar to the use of psychoactive substances, which may recur or chronicize the disease. In the process of comprehensive intervention, coordination and supervision of medical care, school, family, and society are needed.
Establish a three-level prevention system including measures for universal prevention, targeted prevention, early detection and treatment, eliminate or reduce pathogenic factors, improve mental health, reduce the occurrence and recurrence of game disorders, and promote timely access to diagnosis and treatment. The hazard is crucial.
1. Universal prevention. To publicize the publicity of mental health knowledge to the public, widely publicize knowledge about game obstacles, improve the mental health of the whole society, and reduce the incentives that cause game obstacles.
2. Targeted prevention. For high-risk groups such as children and adolescents who are prone to game obstacles, take appropriate psychological interventions at the individual level from the aspects of emotional regulation, cognitive control, and interpersonal communication; focus on the family, school, and social environment in which children and adolescents are located. Health knowledge and coping skills science popularization work, improve family relationship and parent-child communication ability, care for children and adolescents psychological needs.
3. Early detection and treatment. Improve the ability of children, adolescents, parents and schools to identify obstacles in the early stage of the game, guide patients and their families to seek medical treatment for patients with suspicious game disorders, confirm diagnosis, and receive reasonable systemic treatment. Conduct targeted training in general hospital mental (psychological) and psychiatric hospitals, so that medical staff have the ability to correctly identify, diagnose, and treat game obstacles; do contact-consultation and specialist counseling to help non-psychiatric doctors find early and timely Referral to game obstacle patients.
(3) Treatment and rehabilitation
1. Treatment measures
At present, there is no authoritative guide to the treatment of game disorders, but in recent years there have been many research or clinical practice tips on the treatment and intervention of game disorders. Comprehensive treatments combining psychosocial intervention, drug therapy, and comorbidity are beneficial to improve the prognosis of patients with game disorders. The main measures include:
(1) Social psychological intervention. At present, many clinical practice and research evidence suggest that psychosocial interventions such as cognitive behavioral therapy, motivational motivational interviews, and family therapy are effective in reducing uncontrolled game behavior and promoting long-term rehabilitation.
(2) drug treatment. At present, there are no drugs with clinical indications for game obstacles, but patients with game disorders may have mental and physical health problems as well as comorbidities and need symptomatic treatment.
(3) Physical therapy. A small number of studies have now conducted interventions such as repetitive transcranial magnetic stimulation in patients with game disorders to enhance brain control or reduce the urge to play games, but there is still a lack of large sample consistency studies.
2. Rehabilitation measures
Similar to the treatment of other diseases, the goal of treatment disorders is to prevent recurrence, promote social function recovery, and return to society through psychosocial rehabilitation and follow-up management. Patients who have been treated and whose condition tends to be stable should continue to receive consolidating psychotherapy and, if necessary, take the medicine on time and in time to prevent the disease from recurring. Regular follow-up work for discharged patients will enable patients to receive timely, targeted medical guidance and services. Mobilize family members to support and participate in the rehabilitation activities of patients, guide family members to develop life plans for patients, and strive to solve patients' mental health problems and practical difficulties in daily life.
It should be emphasized that the game disorder is a chronic recurrent disease. The initial stage of the game disorder intervention, the intervention process and the disease rehabilitation period need to evaluate the symptoms and severity of the game disorder.
V. Future work priorities
In view of the epidemiology, pathogenesis and prevention and treatment methods of game disorders, etc., it is still to be further clarified.
1. With the amendment of the Law of the People's Republic of China on the Protection of Minors, we will introduce relevant laws and regulations to protect the physical and mental health of children and adolescents, and introduce policies and measures to regulate and purify the network environment.
2. Establish a multi-sectoral collaboration mechanism for health, education, industry and commerce, culture, etc., regulate and supervise the game obstacle intervention institutions to ensure that patients and their families can get professional help.
3. With relevant academic institutions and groups as the main body, improve the game obstacle recognition, assessment, diagnosis system, carry out relevant training, and improve the professional ability of game obstacle diagnosis and treatment.
4. Conduct an epidemiological survey of game disorders, understand the impact and mechanism of relevant factors, and follow up on their outcomes and related influencing factors.
5. To carry out research on drugs and psychosocial treatment related clinical and related prevention and control policies for game obstacles.
6. Treat all addictive behaviors including game obstacles and other social maladaptation as a whole, expand the scope and depth of prevention and medical intervention work, and make it play a broader and three-dimensional role.
Chinese Medical Association Psychiatry Branch Chinese Association of Preventive Medicine Mental Health Branch
Chinese Medical Doctor Association Psychiatrist Branch China Mental Health Association
China Drug Abuse Prevention Association
July 15, 2019