Should ‘gaming disorder’ become a psychiatric diagnosis?
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The recently published draft of the WHO’s diagnostic manual has included gaming disorder and hazardous gaming among its new diagnoses. To some, this is a poorly informed decision which could stigmatise gamers, while others argue that the inclusion could help those struggling with problem gaming.
In 2013, a father named Mr Feng decided to take his unemployed, 23-year old son’s gaming obsession into his own hands by hiring an ‘assassin’ to kill his avatar whenever he logged into an online game. Extreme cases of excessive gaming like these – some funny and some tragic (involving real fatalities) – have stirred discussions surrounding compulsive gaming for years.
For many, gaming addiction is a myth, a moral panic, an example of the overpathologisation of healthy behaviour. For others, it is a public health issue, a medical condition which causes deep distress to individuals and their loved ones.
The particularly high prevalence of problem gaming in South Korea – where up to 25 per cent of young people are estimated to game excessively – has led to the government banning minors from accessing online games between midnight and 6am.
Meanwhile, ‘boot camps’ which apply therapy and militaristic discipline to stamp out problem gaming and internet use in young people have sprung up across China to meet growing demand for treatment. The Nightingale Hospital in London became the first place in the UK to offer specialised treatment for patients who use technology excessively.
Despite action by parents, governments and businesses to address the problem, there is still disagreement about the legitimacy of gaming addiction as a medical complaint.
In 2013, the American Psychiatric Association, in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), concluded that there was insufficient evidence to include gaming addiction in that addition, although it also proposed criteria for “Internet Gaming Disorder” in a section of the DSM-5, Conditions for Further Study.
Now, the WHO looks likely to acknowledge gaming addiction by including it in its upcoming diagnostic manual, the eleventh edition of the International Classification of Diseases (ICD-11).
Gaming disorder is a new addition to the draft ICD’s “mental, behavioural or neurodevelopmental disorders” section, along with gambling disorder. Gaming and gambling disorders are proposed examples of behavioural addictions, which do not involve the ingestion of a substance.
According to the draft ICD-11, a patient could be diagnosed with an online or offline gaming disorder if they persistently or recurrently lose control over their gaming, put gaming ahead of other activities and interests, and continue to game excessively despite negative consequences.
When the diagnosis was first proposed as an addition to the ICD in 2016, it was met with scepticism. An international group of scholars responded to its proposal by writing to the WHO advisory group on Mental Health, recommending that it removes the diagnosis “to avoid a waste of public health resources as well as to avoid harm to healthy video gamers around the world”.
“At this point, suggesting formal diagnoses and categories is premature,” the group wrote. The paper argued that there is a lack of high-quality research into the phenomenon, the field being fraught with confusions and unhelpful comparisons with substance and gambling addictions and no consensus among academics about what constitutes the disorder or how it could be assessed.
The group were resoundingly joined in their criticism by the gaming industry: “The [WHO] knows that common sense and objective research show video games are not addictive,” said Dr Jo Twist, CEO of UK Interactive Entertainment (Ukie), the British trade body for the gaming industry.
Due to the modernity of the phenomenon, compulsive gaming inevitably has not been studied in the depth that conditions such as alcohol dependency have. The inclusion of gaming disorder in the draft ICD-11 could, however, open up funding and opportunities for more sophisticated research.
“Gaming disorder classification is the best thing we can do both in terms of helping those people who have been affected by it as well as in terms of [taking] the research further,” said Dr Daria Kuss, a psychologist based at Nottingham Trent University who specialises in the psychology of internet and technology use.
“We’ll have the funding to continue our research to understand the problem better; particularly in terms of cause and effect relationships, what kind of risk factors contribute to the development of gaming addiction. If we can study that significantly better we can better fund prevention approaches.”
While some governments – particularly those in South East Asia – offer publicly funded treatment for problem gaming, treatment is not available on the NHS. Researchers and clinicians hope that the introduction of the diagnosis could eventually also lead to specialist NHS support for the small number of individuals who could be diagnosed with gaming disorder.
Kuss was among the gaming addiction experts present at a recent WHO meeting to discuss whether the condition should be included in the ICD-11. Disordered gaming, they concluded, causes significant impairment and distress to the extent that the small number of gamers who could be diagnosed lose control of their behaviour, substituting healthier behaviours for more gaming.
Many researchers and clinicians believe that formalising disorders by including them in the ICD and DSM risks stigmatising ordinary behaviour, such as the gaming enjoyed by millions or billions of hobbyists worldwide. Spokespeople for the Ukie and the Entertainment Software Association, the US trade body for the gaming industry, have stated that introducing diagnoses such as gaming disorder risks “trivialising real mental health issues like depression and social anxiety disorder”.
Supporters of the gaming disorder diagnosis, however, argue that there is confusion about the difference between healthy enjoyment of an activity and a disorder. Keith Bakker, founder of the Smith and Jones clinic in Amsterdam, which treated compulsive gamers, told the BBC that 90 per cent of the young people seeking treatment at the facility were not addicted.
“The term ‘addiction’ is used in a very flippant kind of way. Just because I spend a weekend watching something on Netflix does not mean that I’m addicted to using Netflix, for example,” Kuss told E&T. “There has to be a significant impairment and distress on the behalf of the individual for a considerable amount of time where they lose control of their behaviours and they can’t help themselves anymore.”
You can see a number of biological and neurobiological differences in the people who have gaming addictions, she said.
As the ICD-11 nears its final form – which is due by the end of 2018 – debate will continue within and beyond the context of the diagnostic manual as to whether gaming disorder should be considered a behavioural addiction. As with a number of other psychiatric diagnoses, it is likely to remain a controversial subject of debate, even after its likely inclusion in the ICD-11.