When the World Health Organization (WHO) decided to include “gaming disorder” in the 11th edition of the International Classification of Diseases (ICD-11) in mid-2018, it did not at all settle the long-standing debate whether electronic gaming — online, by video consoles, or on smartphones— could be addictive enough to be considered pathologic.
Rather, the decision further inflamed the controversy, polarizing researchers who have argued opposite sides and leaving many others trying to make sense of limited evidence.1 At even the most practical level, many researchers note the lack of accompanying guidance for the addition.
“We don’t have the appropriate diagnostic tools, and the WHO did not really bother to define any symptoms,” said Chris Ferguson, PhD, a professor of psychology at Stetson University in DeLand, Florida, who opposed the inclusion. “I think where things went off the rails is focusing on the behavior people are addicted to instead of traits of the individual,” Dr Ferguson told Psychiatry Advisor. Within public discourse, he said, people discuss video games as though they are inherently addictive, yet people overdo a wide range of behaviors.
He offered an example of the absurd: “We do not talk about cat addiction, but almost everything you could say about gaming addiction you could say about cats,” he said. “Stroking a cat tends to release dopamine, and cats have mechanisms to try to keep you petting them.” A quick Google search makes evident the problem of cat hoarding, he noted. “Is it something about video games that makes them different from shopping or exercise or food or sex or other things people can do excessively, or is it that individuals have difficulty regulating a fun thing?”
That was a key question the American Psychiatric Association wrangled with in updating the Diagnostic and Statistical Manual of Mental Disorders-5th edition (DSM-5). Ultimately, the American Psychiatric Association included “Internet Gaming Disorder” as a condition for further study rather than its own diagnosis. “There was not sufficient evidence to determine whether the condition is a unique mental disorder or the best criteria to classify it at the time the DSM-5 was published in 2013,” the organization wrote, but they proposed symptoms and potential criteria (5 or more symptoms within a year) for the disorder.
The WHO, meanwhile, announced in a September 2018 press release that gaming disorder becomes “a clinically recognizable and clinically significant syndrome when the pattern of gaming behavior is of such a nature and intensity that it results in marked distress or significant impairment in personal, family, social, educational or occupational functioning.” Mental health providers remain caught in the debate.
Pushback from Industry and the Profession
Not surprisingly, the Entertainment Software Association pushed back on the WHO’s designation even before its formal announcement. In March 2018, Michael D. Gallagher, president and CEO of the Entertainment Software Association, said, “The WHO’s process lacks transparency, is deeply flawed, and lacks objective scientific support.” The Entertainment Software Association drew attention to “A weak scientific basis for gaming disorder: Let us err on the side of caution,” a paper in the Journal of Behavioral Addictions that responded to an earlier open debate paper on the WHO’s ICD-11 proposal and argued against making gaming disorder its own diagnosis because of the weak evidence base.
Dr Ferguson was among the 36 authors who acknowledged the potential for video gaming to interfere with people’s lives but argued for an “extremely high burden of evidence and the clinical utility…because there is a genuine risk of abuse of diagnoses.” They described what additional research was needed to legitimize a diagnosis.
One central issue is whether gaming is a disorder unto itself or a manifestation, in the form of a coping mechanism or self-medication, of another mental health issue, such as anxiety, depression, attention-deficit/hyperactivity disorder or other established diagnoses. Neurobiology research does not clarify this question, according to Michelle Colder Carras, PhD, one of Dr Ferguson’s coauthors on the opposition paper and a postdoctoral fellow at Johns Hopkins Bloomberg School of Public Health in Baltimore.
“The way [many existing] studies are designed, we don’t have a way of telling the way the brain changes from video games compared to other pleasurable things, so it’s like we are comparing sex to drugs instead of comparing sex to some other decent thing that’s fulfilling,” Dr Carras told Psychiatry Advisor.
Dr Ferguson pointed out exaggerations regarding gaming’s effects on the brain. It’s true that gaming involves an anticipatory dopamine release in the brain — but so does “looking forward to going on a trip, having sex, or eating a pizza,” he said. “It sounds more ominous than it actually is.” The dopamine release associated with gaming is similar to those activities, whereas cocaine or methamphetamine release 3 and 12 times more dopamine, respectively.
The Framing Problem of “Addiction”
Another issue is the addiction paradigm itself: Is there a better way to frame problems of excessive use of a substance or excessive behaviors than saying the brain is addicted to that substance or behavior? Research suggests the underlying cognitive psychology of internet gaming disorder is complex and poorly understood.2
Dr Carras said she and colleagues have advocated for “broader category that could encompass different behavioral problems” when people lose control and excessive behaviors have a negative impact on their lives, although she acknowledged they lack a name for such a thing. “Compulsion” is an ego-dystonic behavior and hence not quite accurate: “You do not want to do it; you have to do it,” she explained.
Vladan Starcevic, MD, PhD, also an opposition paper coauthor and an associate professor of psychiatry at the University of Sydney in Australia, agreed, noting that compulsion “refers to having an urge to do a certain activity because you are afraid if you stop, there will be negative consequences.” Although people who cannot continue gaming may feel “restless, angry, or frustrated,” those are psychological symptoms, not physical withdrawal symptoms, which current evidence has not revealed so far.
For gamers, however, negative consequences exist in the form of lost status in the game, such as lost points or reduced rankings relative to other players, according to a presentation that Barbara Craig, MD, a child abuse pediatrician from Walter Reed National Military Medical Center in Bethesda, gave at the American Academy of Pediatrics annual meeting in November 2018. She agreed with gaming disorder as its own diagnostic problem and described pediatric abuse and neglect, including deaths, resulting from parents’ spending 12 or more hours a day playing games.
Still, is that behavior actually “addiction” per se? Dr Starcevic agrees with Dr Carras that “using the addiction paradigm is wrong” and called for caution in applying that label. “When you cross that boundary and something becomes a disorder, it has implications,” such as the stigma attached to any psychiatric diagnosis, Dr Starcevic told Psychiatry Advisor. He worries about making a pathological reason for excessive indulgence in everyday activities, such as shopping or sexual activity, while existing diagnoses already face challenges.
“There is not much support for many of our existing diagnoses,” Dr Starcevic said. “We are struggling to defend some of the existing diagnoses, and now we are introducing yet another that is difficult to defend.”
That does not mean problematic levels of gaming — or other behaviors — do not exist. However, boundaries distinguishing excessive or problematic gaming are not well defined, Dr Starcevic said, and these blurry boundaries can lead to stigma.
“There is a lot of literature on so-called moral panic and stigma associated with diagnostic labels,” Dr Starcevic said, which can be exacerbated without a “clear boundary of what could still be a variant of normal behavior.”
Supporters Recognize Risks Too
Even those who do believe gaming disorder should be its own diagnosis are cognizant of the risks. Petros Levounis, MD, MA, chairman of the psychiatry department at Rutgers New Jersey Medical School in Newark, believes gaming disorder does need its own diagnosis and told the New York Times that one positive consequence of the WHO’s ICD-11 designation is the potential ability to get reimbursed for treating people. No pharmacologic treatments exist presently, he told Psychiatry Advisor, so treatment consists of psychotherapy, such as cognitive behavioral therapy, motivational interviewing, or 12-step programs, albeit without much evidence.3 Yet he agreed with being cautious.
“The issue in psychiatry is that there is so much stigma associated with mental illness that before you call something a disorder, you had better have your ducks in a row and know what you are talking about,” Dr Levounis said. However, stigma of other diagnoses — including psychiatric issues that potentially contribute to excessive gaming — may supersede stigma associated with gaming as a disease.
“Maybe the internet gaming is a response to the underlying condition,” Dr Levounis said. “It could be that it is easier for parents and young kids to formulate their troubles in terms of internet gaming instead of saying it maybe a sexual or gender or depression issue.”
That brings things full circle to whether making gaming disorder official runs the risk of leaving those problems undiagnosed and/or untreated. Dr Carras takes a pragmatic approach to this question in a way that breaks somewhat with her skeptical colleagues.
“If the behavior is leading to significant life problems — children not getting to school, not going to work,a spouse is going to leave you — then regardless of whether it is because of a disorder or addiction, it makes sense to treat the behavior,” Dr Carras said, agreeing that the stigma associated with treating gaming might be lesser than when treating other conditions.
Research Gaps Remain
The problem remains that the evidence on excessive gaming is spotty, with too many open questions.4 Both Dr Carras and Dr Ferguson pointed out the problem of adequate measurement, for example.5 Even vocabulary presents problems — including even whether gaming should be discussed within the context of the internet, as an offline technology, or both.6
“We need a way of defining technology-related problems that is able to keep up with changes in society,” Dr Carras said. She and Dr Ferguson pointed out the research base’s glaring lack of voices from gamers themselves and the industry, which can only worsen generational problems with characterizing the disorder. Dr Ferguson pointed out that most of the WHO researchers pushing for gaming disorder’s inclusion in ICD-11 are likely over age 50 and not familiar with gaming in general.
“They really missed an opportunity to get a more diverse view of this issue,” he said. “If all people who do not like video games came up with a mental health diagnosis, this would be it.” Dr Ferguson also brought up the complexities of cultural differences in perceptions of gaming and mental health and suspected the WHO felt pressure from some countries in Asia to make gaming disorder official.7
Jeffrey Snodgrass, PhD, a psychiatric anthropologist at Colorado State University in Fort Collins who has researched problematic gaming behaviors, told Psychiatry Advisor that the evidence does suggest “symptoms vary somewhat cross-culturally, pointing to a place for culture-specific ‘problem’ gaming that is not well captured by the ‘addiction’ frame.” Immersed in the research, he goes back and forth on the issue.
“I go where the data take me, and that varies from analysis to analysis,” he said, noting that even 2 of his most recent papers came to different conclusions on whether to support the addiction model.8,9 In fact, it is because Dr Snodgrass follows the data that he felt he was not the best person to offer a full-throated defense of either position in a point-counterpoint discussion. Perhaps that his research has not pointed solidly in one direction or another is a testament itself to how much more research is needed before a real consensus can begin to emerge.
Disclosures: None of those interviewed had disclosures.
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9. Snodgrass JG, Zhao W, Lacy MG, Zhang S, Tate R. The cross-cultural expression of internet gaming distress in North America, Europe, and China [published online November 23, 2018]. Addictive Behaviors Reports. doi: 10.1016/j.abrep.2018.100146