Gaming Disorder and the World Health Organization

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With the recent news about the inclusion of Gaming Disorder in the draft of the upcoming ICD-11, we asked Dr. Kelli Dunlap (doctor of psychology, game developer, manager of mental health research and design at iThrive games, and Take This volunteer) for her thoughts on the inclusion. While this article is a bit longer and more technical than our usual content, we at Take This feel it’s important to present information on this complex, far-reaching topic, in an effort to fight stigma, sensationalism, and rumor.

In June 2018 the World Health Organization (WHO) finalized its draft of the 11th revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-11). Included in the latest version of the medical classification manual is the controversial diagnosis of “Gaming Disorder.”

Gaming Disorder Debate: Overview

In general, the scholars who support the inclusion of Gaming Disorder in the ICD-11 and those who don’t are not divided over whether a player’s gaming can become problematic; gaming, like any activity, can be done to excess. Instead, the debate centers around whether or not problematic gaming as it is currently understood, measured, and researched, meets the scientific litmus test needed to create a new diagnosis. It is important to note that scholars on both sides of the debate want to do what is best both for those who struggle with problematic gaming and those who engage in normal gaming behaviors. Although estimates vary, the most rigorous studies of problematic gaming have found that a very small percentage of players — between 0.6% – 3% — display behavior that “looks anything like this disorder.”

The Arguments: For

Supporters of the inclusion of Gaming Disorder in the ICD-11 argue that the goal of the diagnosis is not to pathologize healthy players, or even video games themselves, but to provide support and access to treatment and life-improving care for those struggling with debilitating effects of extreme video game engagement (e.g. loss of a job or relationships due to inability to stop playing). Having a recognized diagnosis, they argue, will enable those who rely on insurance for access to mental health care to seek treatment that will help them rectify functional impairments in their lives caused by their extreme engagement. Furthermore, some scholars emphasize that medicalizing gaming addiction will decrease stigma and increase access to treatment in areas of the world, such as China, that use harsh, punitive “addiction boot camps” as a method of gaming “detox.” Pro-diagnosis scholars, Behrang Shadloo and colleagues, argue, “…that in the absence of proper diagnostic guidelines and preponderance of diagnostic-orphan cases, there is the possibility of overuse of restrictive and discriminative approaches, such as involvement of judiciary systems and law enforcement agencies in some countries.”

Lastly, supporters of the Gaming Disorder diagnosis argue that the lack of an “officially recognized and unifying diagnostic framework” may be responsible for the confusion and contradictions in the research and that by having an “officially recognized diagnostic framework,” future research will be improved because scholars will have a clear goal to work toward. In other words, officially defining what it is would help us find better answers and solutions because we would all be speaking about the same ideas. With the same language and constructs, we could also build more effective intervention strategies.

The Arguments: Against

Concern about including Gaming Disorder in the ICD-11 was first expressed in September of 2016, the same month the diagnosis was proposed, via an open letter to the WHO. This letter was signed by more than two dozen scholars whose areas of research specifically pertain to technology use and its impact on health. In the letter, the authors outlined three main areas of concern and three potential negative consequences of including even a proposal of Gaming Disorder. The first concern focused on the existing quality of research on gaming addiction. “The quality of the research base is low. The field is fraught with multiple controversies and confusions and there is, in fact, no consensus position among scholars.”

In fact, there is no consensus on what gaming disorder is even amongst its supporters. Scholars who penned the 2016 open letter of concern highlighted the variety of different conceptualizations of Gaming Disorder they received through commentaries in their follow-up piece:

Would a gaming disorder relate only to gambling oriented games or to video games more generally (James & Tunney, 2017)? Is the problem behavior caused by other underlying mental disorders (Billieux, King, et al., 2017), or is it a consequence of alluring game mechanics (James & Tunney, 2017)? Are we diagnosing people who play online games or offline games, or both (Király & Demetrovics, 2017)? And is gaming disorder just a subcategory of a broader Internet addiction disorder or perhaps just one of many behavioral addictions (Higuchi et al., 2017)?

The second major area of concern voiced in the open letter focused on the diagnostic criteria. According to the ICD-11, Gaming Disorder has only 3 symptoms – impaired control over gaming activities, increased priority given to gaming activities, and increase in gaming activities despite negative consequences. These three symptoms must be present for 12 months, either continuously or in recurrent episodes, and must cause impairment in important areas of functioning (like grades, relationships, work, etc). However, there’s no guidance on what “impaired control” looks like or how it may manifest in different contexts (i.e. age of player, type of game, social vs solo gaming). The criteria of giving games priority over other “life interests and daily activities” is equally problematic. Is preferring to play a video game over doing homework (or in my case, doing the dishes) pathological? Probably not. The last symptom, increasing gaming activity despite negative consequences, is also problematic as there is a tendency by those who may not personally engage in or enjoy gaming to misread gamers’ immersion and interactivity as addiction. Griffiths himself stated, “Any high level commitment (e.g. sports, music, school) will have some detrimental consequences as other important activities are not given as much priority, but it would be a mistake to always confuse this with addictive behavior.”

The vagueness of these criteria becomes even more obvious when you consider that they can occur in recurring episodes, but there’s no guidance on what that means. How long do these symptoms have to be present before they’re considered “an episode?” A month? A week? A day? How often do these episodes need to repeat? Could a week of intense play in January and again in July (when a highly anticipated game is released, for instance), where the three symptoms could (arguably) be met, satisfy the criteria for Gaming Disorder? It’s unclear. And, just to make things even more obtuse, the duration requirement can be shortened “if all diagnostic requirements are met and the symptoms are severe.” This kind of ambiguity is frustrating, unsettling, and most of all a recipe for improper diagnosis, especially given the lack of experience with games and negative perception of games amongst many clinicians.

Even scholars who support having a diagnosis for gaming addiction warn that:

(T)he criteria should be set in a way that healthy gamers are not pathologized and the diagnosis should benefit from adequate specificity…. (W)e also insist that WHO and the affiliated work groups should adopt a conservative approach in developing diagnostic guidelines to prevent overdiagnosis and arbitrary inferences… it should be ensured that the boundary with normality is clearly defined and only a minority of cases with significant impairment are diagnosed with gaming disorder.

The criteria, as currently defined in the ICD-11, do not measure up to the standards of its supporters.

Another problem with the criteria for Gaming Disorder is the construct itself. The construct has been based on the existing diagnostic frameworks around substance addiction and gambling disorder and is categorized as “a disorder due to addictive behavior” in the ICD-11. But using criteria based in the addiction frameworks “too often pathologizes thoughts, feelings and behavior that may be normal and unproblematic in people who regularly play video games.” Also, these criteria ”do not predict problematic outcomes from gaming particularly well because they are not aligned with the gaming context and culture.”

Some research into gaming addiction has found that problematic gaming is more akin to impulse-control disorders, like ADHD or Obsessive-Compulsive Disorder, than to addiction. Because treatment strategies are largely shaped by disorder frameworks (i.e. strategies for treating mood disorders differ from strategies for treating psychotic disorders), it’s critical that the lens through which Gaming Disorder is viewed reflects the actual underpinnings of problematic gaming.

The third issue scholars have raised is that instances of problematic gaming often occur alongside established mental health issues, such as depression and anxiety, and it is doubtful that the criteria for diagnosing Gaming Disorder are nuanced enough to separate the two. In addition, neither anxiety nor depression is listed among the disorders to consider for differential diagnosis, the process of differentiating between diagnoses with similar symptoms and presentations.

If someone is depressed and spends all day in bed, you do not diagnose them with Bed Syndrome, you look at why they spend all day in bed. There is a fear that if a person’s gaming is focused on and not the person themselves, this will lead to inadequate mental health treatment. – PlatinumParagon

The last concern voiced by the scholars in the 2016 open letter concerned the consequences of including Gaming Disorder in the ICD-11. There is a long history of media panic over digital gaming that extends back to the early 1900s and the societal anxiety around the moral dangers of pinball. There are news clips from the 1980s and 1990s about the potential negative impact of children and teens playing video games like PacMan and the original Mortal Kombat, concerns that seem quaint and laughable now.

By including a specific gaming disorder, scholars warn that the media panic around video games could lead to a significant number of misdiagnoses and false-positives. Not only would this render the diagnosis practically useless, but it also threatens to label normal play as pathological and healthy players as “addicts.”

According to games and mental health expert, Dr. Christopher Ferguson, “The evidence we have doesn’t suggest there’s anything particularly addictive about games. Most often when parents talk about their kids being addicted, they’re actually talking about kids doing something they don’t want.” Division 46, the American Psychological Association’s specialized research group on media psychology, commented on the potential harm of recognizing gaming disorder:

We can discern no clear reason why video games are being singled out for a disorder rather than a general “behavioral addiction” category if the concern were truly regarding clinical access for those with problem behaviors. Thus, an obsessive focus of the WHO on VGA would appear to us to be a response to moral panic (e.g., Cohen, 1972;Ben-Yahuda, 2009), one which in turn is likely to fuel more moral panic, including miscommunications that game playing can be compared to substance abuse.

And last, but not least, is the concern that formalizing a diagnosis of gaming disorder will have a significant, increasingly negative impact on society’s attitudes towards games and on people who play games (which is a more varied population than people might think) by pathologizing an incredibly popular pastime. The stigma around games is as old as games themselves. In the past 30 years, games have been blamed for many of society’s ills, especially mass shootings, despite repeated studies debunking such claims. The diagnosis of Gaming Disorder could set us back instead of advancing attitudes in a more evidence-aligned direction.

What’s Next?

There are a few more steps before the ICD-11 goes into effect. First, the ICD-11 has to be presented to the World Health Assembly in the spring of 2019. If it is approved, it will go into effect January of 2022. However, concerns that this diagnosis will re-stoke the moral panic around video games have already begun to be justified. An article titled, “WHO’s Ruling on Video Game Addicts Could Help Prevent Mass Shootings,” published the same day the ICD-11 draft was finalized, is one fear-mongering and completely inaccurate headline that managed to conjure the damaging, stigmatizing imagery of those slapped with the addict label, and the harmful, wildly inaccurate stereotype of the mentally ill as exceedingly violent.

Despite this, there is reason for optimism. New, rigorous research in the area of problematic gaming is emerging (Weinstein et al., 2017; Snodgrass et al., 2017, 2018) and more is on the way. The recent push in psychological research for pre-registered studies and an increase in transparency around research methods, procedures, and analysis will hopefully address and clarify the controversy and confusion in the games addiction research space. The ultimate goal for all researchers, whether they support the inclusion of Gaming Disorder in its current form or not, is to continue to investigate the underpinnings, expression, and treatment of problematic gaming.

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