The World Health Organization (WHO) voted to approve the draft of the eleventh version of the International Statistical Classification of Diseases and Related Health Problems (ICD-11), which includes both gaming disorder and hazardous gaming as official diagnoses. Gaming disorder has been a controversial diagnostic concept for years, and when the ICD-11 goes into effect on January 1st, 2022, people worldwide will be able to receive this diagnosis from a wide variety of medical and mental health professionals.
What is Gaming Disorder, and What is the Controversy?
Dr. Kelli Dunlap, director of mental health research and design for the nonprofit iThrive Games, wrote a detailed article for Take This when gaming disorder was in the draft stages. In a nutshell, gaming disorder is a chronic pattern (longer than 12 months) of persistent engagement in gaming that disrupts one’s ability to function in life because gaming takes priority, and the person doesn’t stop, despite negative consequences. The diagnosis of hazardous gaming is similar but has no time limit attached to it. For example, if someone plays League of Legends so much that they lose their full scholarship at college, and then they still can’t stop playing, that might meet criteria for hazardous gaming, and if it goes on longer than a year, they might meet criteria for gaming disorder.
Many researchers believe there is a lack of consensus on this topic and the inclusion of the diagnosis is premature. In a 2016 open letter to the WHO, two dozen of the leading researchers on the topic of problematic gaming behavior urged the WHO to refrain from considering gaming disorder as a diagnosis until more agreement could be reached in the scientific community. They pointed to several major problems:
- problems with the quality and quantity of the research itself
- lack of agreement on the symptoms of problem gaming
- reliance on addiction-based definitions without scientific agreement on the underlying cause
Despite the fact that gaming disorder is commonly referred to as “gaming addiction,” the ICD-11’s criteria do not mention the underlying cause of the behavior. When asked for comment on this, Dr. Dunlap expressed concern over, “…the likelihood of misdiagnosis or pathologizing of normal play due to the vagueness of the diagnostic criteria.” There are many behavioral overlaps in different diagnoses, and there are many reasons a person might engage in excessive and/or repetitive patterns of behavior that have nothing to do with addiction (e.g., autism, bipolar disorder, posttraumatic stress disorder, obsessive compulsive disorder). It appears that the only exception that the WHO makes is for bipolar disorder, and it is unclear why that was made an exception.
Dr. Anthony Bean, one of the authors of the open letter to the WHO and author of Working with Video Gamers and Games in Therapy: A Clinician’s Guide, bluntly stated, “While diagnosing a mental health condition is helpful in creating a standardization of treatment, this diagnosis does not do that at this current time. It has been created with poor scientific rigor, resulting in a ‘house of cards’ diagnosis.”
What Does it Mean, if This Diagnosis is Premature?
One of the concerns presented in the 2016 open letter to the WHO was that officially recognizing such a controversial diagnosis gives the public the illusion of professional consensus, and it would shift future research from a place of exploration to a place of confirmation. Dr. Rachel Kowert, Take This’ research director and author of multiple books on video game research, reflected, “Rather than exploring problematic game use as a secondary problem (that is, secondary to depression or anxiety), researchers will now assess addiction to the games themselves without conclusive evidence that the games themselves are the problem.” In other words, instead of asking, “Is game addiction actually a thing?” researchers will be forced skip past that and ask, “How do we treat the thing?”
Treatment in therapy often changes depending on the underlying causes of a diagnosis, even if the behavior might look the same. Adam Johns, a licensed marriage and family therapist and co-founder of the applied gaming nonprofit Game to Grow, echoed this: “Without significant support [this diagnosis] presupposes that the gaming behavior itself is the problem rather than a symptom of a deeper issue. A part of the danger is therapists using this as a guideline for diagnosis without understanding a greater impact on an individual and underlying causes that contribute more to their challenges.”
As an example of this, let’s say a client is engaged in problematic gaming, and the clinician only sees the gaming behavior without understanding the underlying cause of this behavior. Perhaps this person engages in excessive gaming as a means of avoiding symptoms of extreme posttraumatic stress disorder. Assuming an addiction-based model might blindly remove that person’s one strategy of coping with invasive trauma memories and leave them defenseless. Given the social nature of many games, it might also remove that person’s community support.
On the other hand, working with the client to establish a wider variety of coping skills and safety strategies might naturally reduce the problematic gaming since they no longer have to rely on only one strategy. It might also reframe gaming as one of many strategies for coping instead of shaming the client, while still giving them the ability to engage with a beloved hobby. This is an especially desirable outcome, as there is evidence to support games as an effective form of self-comfort, and this might help the client build a greater sense of resilience and self-efficacy.
The Diagnosis is Official… Now What?
While the diagnosis is now official, Take This urges more research into whether or not this diagnosis is warranted. It’s possible that with more research, a more conclusive cause might be established, but we’re not there yet. It’s also possible that with better understanding, this diagnosis is removed. It’s important that we continue to question the worth of diagnoses instead of assuming they are conclusive. Beyond that, citing games as inherently addictive demonizes a wide landscape of experiences that go well beyond black and white labels of “good” or “bad.” Dr. Ryan Kelly, a psychologist and researcher who frequently works with gamers, noted, “To ask, ‘Is it good or bad?’ is moot, and distracts from the more important question: how can we use [games] safely and effectively?”
One interesting note is that the US diagnostic guide the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) does not include gaming disorder or hazardous gaming as official diagnoses, but does encourage what it calls internet gaming disorder as an area for future study. The DSM-5 is generally the guide for US mental health diagnoses, but the current ICD-10 has the codes that healthcare providers use for insurance reimbursement. One is for diagnosis. One is for billing. When they don’t match up, it creates confusion in whether or not insurance companies will provide coverage for treatment.
As all of this is enacted, we encourage clinicians, parents, teachers, and politicians to challenge themselves to step beyond the moral panic, premature conclusions, and vague criteria of these diagnoses. Educate yourselves on gamer culture from the perspective of gamers. Play some video games. Attend some video game conventions. The depth and breadth of the gamer experience and community may surprise you. Better understanding means better treatment. You don’t have to like games, but it behooves us all to understand the experiences of gamers instead of reducing them to poorly understood and prematurely concluded diagnoses.