When the fun stops: ICD-11’s new gaming disorder
29 August, 2018
Concerns around video game addiction are nothing new, tracing as far back as Space Invaders in the early 80s (Elgi, 1984). Decades later, gaming disorder has been recognised within the pages of The World Health Organisation (WHO)’s updated diagnostic manual: the International Classification of Diseases 11th Revision (ICD-11). Placed within the “disorders due to addictive behaviours” section along with gambling disorder, the condition describes distress or interference with personal functions as a result of persistent or recurrent gaming behaviour.
It’s been a long time coming
Gaming disorder’s inclusion within the ICD-11 was not exactly a given. The USA’s primary diagnostic manual, the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), had included “internet gaming disorder” (IGD) only as a prospective disorder for further study, an inclusion which was controversial at the time (Salloum, 2013), and came amidst concerns that the DSM-5 would pave the way to “make a mental disorder of everything we like to do a lot.” (Gross, 2013). Meanwhile, some members of the WHO’s working group for impulse control disorders suggested there was insufficient evidence to justify gaming disorder’s classification within ICD-11 (Grant, 2014). However, gaming disorder did find a home among the WHO’s addictions experts, who had first looked broadly at problem behaviours involving electronic devices and the internet, acknowledging that further research was needed to understand the phenomenology and prevalence of these problems (WHO, 2015), before honing in on gaming as the object of greatest concern (Saunders, 2017).
By the end of 2016, a group of scholars (Aarseth, 2017) raised concerns about what they felt was the premature inclusion of gaming disorder within ICD-11, noting poor existing evidence, research, lack of consensus on symptoms, and that the description of the disorder seemed all-too-similar to those of gambling and substance use disorders.
We spoke to Professor Andrew K. Przybylski, experimental psychologist and Director of Research at the Oxford Internet Institute, University of Oxford. His team is actively involved with researching video games and other internet media and how we engage with them. He has been critical of the gaming disorder classification, and was a contributor to the Aarseth et al open letter. “Games have really gone from a niche thing to something that the great majority of young people and adults play,” he said. “I think that inertia alone is enough to explain gaming disorder being included in ICD-11.”
Escalating concerns about problem gaming can feel out-of-keeping with how big the problem actually is. There are over a billion people playing video games worldwide, the overwhelming majority of whom wouldn’t exhibit gaming disorder symptoms. “There’s no curiosity whatsoever about the positive side of the coin,” Prof. Przybylski said. “Let’s assume the negative side of the coin is 1% of players, which might be a massive overestimate: what’s going on with the other hundreds of millions of people?”
We also spoke to Dr Henrietta Bowden-Jones, Director of the National Problem Gambling Clinic, and the Spokesperson on Behavioural Addictions for the Royal College of Psychiatrists. She is due to launch the first NHS clinic for behavioural addictive disorders related to internet use, the Centre for Internet Disorders, within CNWL NHS Foundation Trust, aiming to see people with gaming disorder from this autumn. Dr Bowden-Jones was delighted at the inclusion of gaming disorder within ICD-11, in terms of the progress that she believes this will drive: “Having the clarity of thought to be able to start screening for and identifying problems, now the problem is recognised, will lead to skilling up of enough professionals for countries to have dedicated services where people and their families can go to get help.” This echoes the hopes of Higuchi et al (2017), who, since opening a clinic in Japan for “internet addiction” in 2011, have been unable to keep up with treatment demand.
The kids are (not?) all right
Epidemiological research on problem gaming is currently fragmented, generating wildly different prevalence figures worldwide. Beyond cultural differences in of gaming and in attitudes towards people who play games, these disparities are in part due to the lack of consensus on which diagnostic tools to use and at what problem gaming becomes a true disorder. The WHO has been trying to reassure the gaming community that gaming disorder affects only a “small minority” of gamers. Meanwhile, experts including members of the Substance Use and Related Disorders Working Group for ICD-11 expressed that Aarseth et al missing the context of Asia, where of gaming disorder has been found to be higher (Saunders, 2017). Dr Bowden-Jones said the next step forward was to develop a screening tool that could be used worldwide, to obtain prevalence figures that “make sense.” She noted that once we properly understand the scale of the problem, that can “lead to commissioning of research in areas that are less understood, and research in terms of outcomes, and to randomised controlled trials once treatment has been identified.” These are all good things that, she said, wouldn’t be possible without the disorder being recognised. Though even a prospective disorder classification can spur research, as seen with studies from the past few years based on the DSM-5’s IGD criteria.
One thing Dr Bowden-Jones doesn’t expect to uncover from unified prevalence studies is some hidden epidemic. “The numbers of people significantly suffering the kinds of symptoms listed in the ICD-11 won’t be great,” she said. Her National Problem Gambling Clinic has been open for ten and has seen thousands of patients. “I can’t imagine seeing thousands of gamers.”
We tried our luck: what does she think the actual prevalence of gaming disorder is? “It would just be speculating,” she said. “If you asked me to have a guess, I would expect with correct screening tools, it should stay under 1% of the population. If it was higher than that, according to ICD-11 criteria, I would be extremely worried and I would be questioning what is happening in terms of the makeup of these games.” It makes sense: if gaming disorder was truly affecting 1% of people, then the average secondary school would contain nine pupils with significant impairment due to gaming.
Dr Bowden-Jones’s hopes for improved research are shared by Griffiths (2017), who agreed that current data samples in gaming disorder research are too small, but felt a robust and officially recognised diagnostic framework would surely help increase clinical sample sizes. But it has been suggested that by defining gaming disorder this early, research will be locked into a confirmatory approach (trying to find evidence for and understand a disorder, bound by established criteria) rather than an exploratory approach (trying to understand problem gaming from an open perspective) (van Rooij, 2018). “We’re going to miss the chance to actually learn something,” Prof. Przybylski said. “We’re not going to learn anything about the phenomena and we’re just going to stigmatise it.”
Gaming disorder is the only new disorder due to an addictive behaviour to be added to ICD-11, joining gambling disorder. There may be more addictive behaviours (dancing and tanning, for example), but research into these is scanty, and there doesn’t appear to be demand for treatment (Billieux, 2017). Is the behaviour of gaming getting all the attention because of societal stigma? Surely parents would have no issue if their kid was equally into football? “I think it’s all about loss of control,” Dr Bowden-Jones said. “People all over the country are gaming for a lot of hours and nobody’s minding. The ones who are coming forward clinically are the ones where the loss of control has led to direct harm or loss of quality to the young person’s life. If you were playing football five hours a day, that would be okay if you were still getting your homework done and still going to school. If, instead, you ended up missing a year at school, it would not be fine and one could argue this would be some sort of compulsive behaviour and the reason for that would need to be uncovered.”
Much has been made of whether a behavioural addictions framework was the right approach to problem gaming (Király, 2017). After all, the ICD-11 descriptions for gambling disorder and gaming disorder are essentially identical. Dr Bowden-Jones does see the similarity, but notes that gambling disorder can have far more visible harms in terms of money loss. Clients with gaming disorder, often younger and living at home, are less prone to these risks. “So when you’re trying to measure harm you really have to look at loss of control,” she said. This means a look at how the person’s life is impacted. “A lot of them drop out of school or their grades completely slip or they end up losing their friendship groups, becoming isolated. These kind of things indicate that a recreational activity has gone too far.”
The ICD-11’s description of gaming disorder does diverge from substance use disorders in certain ways: for example, there is no mention of tolerance or withdrawal, as it remains unclear if these are indeed common and consistent features of gaming disorder (Saunders, 2017).
The media has run full force with sensational stories of children enraptured by virtual worlds. Such panics are nothing new; two years ago it was Pokémon Go that had everybody worried. But it goes back even further. Prof. Przybylski directed us towards a clinical report (Schink, 1991) featuring cases of “Nintendo enuresis” - boys so transfixed by Super Mario games they would wet themselves rather than visit the bathroom. The problem resolved, according to the report, once the boys “learned to use the pause button.”
Delving further, Prof. Przybylski told us about a phenomenon Wallis (1997) documented during relative youth of the internet. A psychiatrist, Dr Ivan K Goldberg, had effectively dreamed up a diagnosis called “Internet Addiction Disorder” to parody the complexity and rigidity of the DSM. He was alarmed, however, to find people were identifying with the hoax disorder, one symptom of which was that “important social or occupational activities are given up or reduced because of Internet use”. He then re-named his disorder to “pathological Internet-use disorder”, to remove any notion that the internet was an addictive substance. “If you expand the concept of addiction to include everything people can overdo,” Dr Goldberg had said, “then you must talk about people being addicted to books, etc.”
Could it be, then, that we are seeing cases that are more related to media panic than genuine pathology? “You can’t add to the prevalence just because people are worried,” Dr Bowden-Jones stressed. “You have to have cases. The cases need to have to have had the problem for at least a year, which is a long time.” Gaming disorder isn’t about people who dedicate themselves to a game for a few days in order to beat it. “I would not include those,” she said. “I don’t think any professional would do that. I would accept that some people need that challenge. So if the prevalence is high, it will be high because we’re seeing people who are struggling because of an activity.” She acknowledged that the ICD-11 criteria does allow diagnosis of gaming disorder if the problem has persisted for less than a year, if the problems caused are severe enough (though we note that what qualifies as “severe” isn’t defined).
The specific language of the ICD-11 requires that there be “significant impairment in personal, family, social, educational, occupational or other important areas of functioning”, which Billieux et al felt guarded against over-diagnosis: if there is no functional impairment, there is no disorder, no matter how much time is spent playing games (Billieux, 2017). Concerns about over-diagnosis form part of broader worries in psychiatry about of normal behaviour. Prof. Przybylski also feels over-diagnosis is a possibility, noting the ICD-11 criteria are vague and lack specificity. Looking at the broad criteria, it does seem vital that clinicians should be aware of cultural norms of gaming behaviour when deciding if the behaviour is pathological. There are doubts that clinicians would limit the diagnosis appropriately if faced with a “highly engaged” gamer with no functional impairment. Furthermore, society’s labelling of highly-engaged gamers could be even less discretionary, again highlighting concerns about the stigmatisation of gaming behaviour (van Rooij, 2018).
When it comes to the possibility of stigmatising problem gamers by labelling them with a mental disorder, Bowden-Jones referred to her experience with gambling disorder: “It’s been helpful to my patients to know that their behaviour is indeed recognised as an illness; that they’re not evil people taking money. They never took a penny until they developed the illness, so why are they now stealing? I think it’s helpful, but there are two camps and it who you speak to.”
What’s really going on?
While accepting that people can have problems in their lives associated with intense gaming, van Rooij (2018) questioned if gaming was truly the cause of those problems (correlation does not imply causation). Indeed, perhaps problem gaming is a coping mechanism for underlying problems. Dr Bowden-Jones readily states that gaming disorders don’t seem to exist in vacuums: “The cases I have seen that have been significantly debilitating have either been in the context of a family with addiction there, or within the context of existing vulnerabilities in terms of comorbid psychiatric illnesses, or a family that has been disrupted or fragmented by change, whether it’s a death or a separation of parents, or domestic violence: something that the child is taking a refuge from.”
This of course made us wonder: if gaming disorder exists within this bed of existing vulnerabilities, can it be considered an entity in itself, and not merely a behavioural response? “That’s one of the interesting things about behavioural addictions,” Dr Bowden-Jones said. “These people are gaming 10-14 hours a day; that is the thing they can’t stop doing. If they didn’t have the vulnerability, they wouldn’t be doing it, but that probably goes for all other addictions, like problem gamblers. Half of the pathological gamblers we see have a first degree relative who was a gambler, so we are talking about vulnerability for sure. And we are talking about availability, because if they didn’t have the product, they wouldn’t be doing it. So there are issues there.”
When we asked Prof. Przybylski about comorbidities, he discussed his team’s research findings: “Psychological need deprivation--feeling incompetent; feeling unconnected socially; feeling like you can’t make good choices that reflect your values--is intertwined with problematic gaming.” He took the example of someone with problematic gaming behaviour who also has social anxiety, perhaps using an online game world as graded exposure to social interactions. “If there was a correlation between social anxiety and playing World of Warcraft, like Occam's Razor, I would assume that’s the reason such a correlation exists, and not because there’s something about the game that causes social anxiety: that would require some giant influential mechanism in the game to influence someone’s behaviour.”
However, a presentation preceded by depression or anxiety is not necessarily what Dr Bowden-Jones is seeing in her clinical practice. “When I have met people there appears to be, on the whole, some vulnerability there,” she said. “However, what parents are saying is: ‘My child was driven to success with sports, with academia, and now he’s driven to success with games.’ So what they’re saying is ‘you’ve got it wrong, you’ve got to listen to us.’ We’re seeing children who don’t have comorbidities, essentially. With problem gambling, there are several routes in, and it could be that we’ve got several routes in to problem gaming.”
We don’t know much about the biological underpinnings of the disorder, though Dr Bowden-Jones believes that there is certainly something there: “Interestingly, we are seeing gamers whose parents might be pathological gamblers or have alcohol use disorders, so there is that vulnerability towards excessive behaviours. There is a genetic vulnerability there, for sure. Maybe it’s just being uncovered earlier because the young person is doing something that gives them the potential to manifest this behaviour in a way young people didn’t have, before.”
There remains a lack of clarity on what the nature of gaming disorder is, in terms of what kind of games, or what game mechanics, are implicated (van Rooij, 2018). Prof. Przybylski voiced similar concerns: “I would want to know what the ‘cannabinoid’ in the game would be, which would be able to cause, or interact with something to cause, these problems. That would be a very big active ingredient that we’ve never stumbled upon before. I feel like if that thing existed, all the games would do it. All cannabis is more similar to all cannabis than all games are to all games. So I would think that games would homogenise in the way fixed odds betting machines have homogenised… but it clearly hasn’t happened.”
We asked if he’d consider that there was something addictive about games, more addictive than there used to be years ago, even if we have not yet honed in on what that is. Prof. Przybylski prefers to think of games becoming more attractive, and more accessible. “You don’t need a very expensive computer or dedicated console to play them, anymore,” he said. “We have computers in our pockets. You don’t need to drop £60 to get into a game; many games start off as free.” Because of their ubiquity, games are more able to dominate our social time. Gone are the days of arranging a date to play games with your friends. “Because of our phones it can happen anywhere,” he said. “There’s definitely an aspect of social pressure to it; it’s the hip thing.”
It’s no secret that video games companies themselves actively try to attract players, of course: “A lot of games have some pretty problematic business models,” Prof. Przybylski said. “Really, the revenue of many free-to-play games is dependent on extracting a lot of money from a limited amount of players.” And video game companies actively encourage players to stay in their world. “If you deactivate your World of Warcraft account, Blizzard reminds you that you haven’t played for a while and sends you pictures of your avatar, and that kind of persistence is new. As a scientist, I find that something to be interested in; something to study. My first reaction isn’t ‘how does that relate to psychopathology?’”
Dr Bowden-Jones, for her part, is all-too-aware of how broad-brush a term “video games” is, when it comes to thinking about what could be addictive about them. It seems hard to imagine that a game such as Ico could have the same potential for disordered use as a game such as Candy Crush. However, she sees opening the gaming disorder clinic as the first step in understanding this medium. “Are some products more harmful than others?” she asked. “In a year’s time, we might be able to discuss those findings: what are the games that people struggle with and what are their features?”
Perhaps the key question to this whole issue is whether or not a video game can be addictive in the pathological sense. Prof. Przybylski does not see convincing evidence for this, but stresses that absence of evidence is not evidence of absence. Whatever evidence currently exists does not meet the threshold he would set for formulation of a disorder, and he feels psychiatrists are jumping the gun. Whatever their stance on gaming disorder, all experts seem united in pushing for better research. Prof. Przybylski's camp in particular have stressed the importance of transparency in studies, including pre-registration of hypotheses and plans prior to data collection. “It’s the Texas Sharpshooter fallacy,” Prof. Przybylski said of gaming disorder research, referring to the process of forming a hypothesis after the results are known. “They draw the target on the side of the barn only after they’ve sprayed it with the machine gun.” Additionally, he feels a lot of valuable data is held by video games companies about how players engage with their games, but companies don’t share this data. “These companies need to do transparent, open, and reproducible science. I think that if they plan on surviving the next 20 years, it will happen.”
A chance to offer help
Dr Bowden-Jones acknowledges that the field is “definitely divided” when it comes to gaming disorder. “There will always be controversy about classification,” she said. “My line on that has always been: provision of services and provision of instruments will be facilitated.”
In many countries, treatment can be funded through health schemes, e.g. insurance companies, only if the condition being treated is a recognised disorder (Van Den Brink, 2017). While official recognition may reduce many barriers to treatment such as service provision and affordability, Prof. Przybylski warns that we as a profession remain in the dark about treatment. “When anybody talks about technology addiction like it’s a real thing,” he said, “if you get them to tell you what the treatment should be, you learn everything they don’t know. They say things like: ‘stop play’. Or for smartphones: ‘make your screen grey’. Or they say: ‘cognitive behavioural therapy’.”
Prof. Przybylski is aware that some academics are already suggesting medicines which may be of use in the disorder, though he notes the evidence simply isn’t there yet to make such recommendations. “So already you have people rushing to manualise pharmacological intervention for an aetiology we don’t understand… The thing I’m worried about is psychiatrists and psychologists going on a crusade on this topic in a similar way to their pursuit of violent games. But instead of being about whether or not games can be sold to under-18s, this is going to be about Prozac prescriptions. And so the stakes for young people are much higher.”
Bowden-Jones’s own view on pharmacological management is fairly conservative: “With good treatment, such as CBT delivered on a weekly basis, whether it’s online treatment or face to face, abstinence or moderation can be achieved without going down the route of medication.” We asked about Prozac, and she replied “I can’t see SSRIs [a class of antidepressants including fluoxetine/Prozac] helping, to be honest. I might be wrong; don’t forget that just because it has some similarities with disorder, that doesn’t mean gaming disorder is identical. But let’s say that there was significant similarity: we already know that SSRIs have not given us the answer in pathological gambling, unfortunately. Very little is helping enough in terms of pharmacology.” She did mention specialist use of naltrexone within her gambling clinic with adult patients who are resistant to psychological therapy, but it remains to be seen whether that medication has a role in treating gaming disorder, and she can't foresee its use in people under 20.
While Dr Bowden-Jones doesn’t deny that research on gaming disorder is in its early days, she does speak from personal front line experience. “I’ve met with a young person this morning whose mother was desperate for a diagnosis,” she said. “They had dropped out of school and done nothing else for months. This person is roaming around without a diagnosis and yet suffering every single tick on all the criteria. This kind of example makes me feel that this is about trying to do the best you can for a population of young people and families.”
One thing both camps agree on is that there are indeed a small minority of gamers who exhibit problematic gaming behaviour. Given that Prof. Przybylski is not convinced that this represents a disorder in itself, what does he feel the message should be to a concerned player, or a concerned family member? “Subjectively, in terms of things we know from self-reports, people who play video games aren’t necessarily having fun,” he said. “If they’re playing games out of a sense of compulsion, not out of choice, they tend to have both positive and negative feelings about games. So we need to be making sure that the paths of communication between parents and kids are open, not treating games or technology like a black box, and making sure that there’s an environment that is rich in terms of need satisfaction. If what we’re really dealing with is a specific instance of behavioural dysregulation, then we need to leverage what we know about helping people on a subclinical level to better regulate themselves, and that means better environments that foster human thriving. There’s certainly a lot of indirect evidence that people’s behaviour around gaming can become disorganised. Absolutely. There’s far and away enough clinical reports and anecdotal reports. So the thing we have to do, as scientists, is be able to distinguish between that observation and what the WHO and the research literature tries to sell us, and those are fundamentally mismatched propositions.”
On the other hand, Dr Bowden-Jones’s approach for these minority of gamers is to offer assessment and treatment. She hopes for the Centre for Internet Disorders to be an NHS hub where a lot of research takes place, where training can happen, clinical work, and for there to be a few satellite units for engagement with clients across the country. “We need to make the treatment accessible,” she said. “I envisage there will be a significant component of the treatment that will be online.”
She’s still in the early stages of forming her new clinic. Regarding expected treatment demand, she said “I have no idea! When I started the gambling clinic, people at the Royal College told me I’d probably see about thirty people a year. And now it’s many hundreds a year coming to us, requesting help. Our referrals over the last decade have frequently been at around nine-hundred and with these gamers I think this could go one way or it could go another. It could be the quietest service we’ve ever seen. I’m not in favour of sensationalising. When I speak to the media I’m always clear it would be damaging to everybody if they were to sensationalise something without the facts. And we don’t have the facts because we don’t have any good research on gaming disorder in this country. So all we can do is say we feel that due to the ICD-11 decision, and because of the requests we’ve had, we feel a clinic is needed. Then let us see: are there enough people? Are they showing up? And what works?”
A tale as old as
We came away from these discussions thinking about the overlap between the two camps, and what they seem to agree on. Nobody really denies that there exists a small minority of gamers who exhibit problematic play. Both sides suspect the prevalence must be very low. Both agree that the presentation of problematic gaming can be associated with underlying factors that increase vulnerability to that behaviour. There is even agreement that, in terms of evidence, we’re simply not where we need to be, yet.
What seems most apparent in this schism is a matter of philosophy: whether our medical classifications, which have historically had huge positive and negative impacts on individuals and society, should be underpinned by gold standard evidence, or if a pragmatic approach of ‘classify now and find the best evidence later’ is warranted in an aim to reduce suffering. Neither is a simple option and both have their problems. If the ICD had a section for prospective disorders in need of further research, or if decades didn’t pass between editions, perhaps there would be an easier path.
This is a problem of medicine, and more so this is a story of psychiatry, a discipline in which our understanding of conditions develop in tandem with how we treat them. A discipline in which diagnoses have come and gone, some relinquished back into the realm of healthy human behaviour. But some diagnoses do stick, and some evolve. One wonders, when they look back on gaming disorder, what medical historians will say, blessed with hindsight.
Authored by Sachin Shah and Stephen Kaar
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