The Problem with "Gaming Disorder"
With the adoption of the 11th revision of the International Statistical Classification of Diseases and Related Health Problems (the “ICD-11”) by the World Health Organization (WHO), news is once again circling about “gaming disorder.” The response from some of the gaming community is misinformed and misaimed (the typical sarcastic, ableist jokes have been carted out), but may not be completely incorrect in its skepticism of the new diagnosis. I also have problems with the designation of “gaming disorder” that stem from the pairing of the historical scapegoating of gaming as a vice and the fact that the entire concept of behavior-as-addiction is questionable, and I’ll expand upon that below.
To give context to my upcoming criticisms, I want to first address precisely how WHO defines “gaming disorder.” In case their site ever goes down or they (inevitably) change their definitions in the future, here’s a reproduction of what they say on their website defining “gaming disorder”:
“Gaming disorder is defined in the 11th Revision of the International Classification of Diseases (ICD-11) as a pattern of gaming behavior (“digital-gaming” or “video-gaming”) characterized by impaired control over gaming, increasing priority given to gaming over other activities to the extent that gaming takes precedence over other interests and daily activities, and continuation or escalation of gaming despite the occurrence of negative consequences.
“For gaming disorder to be diagnosed, the behaviour pattern must be of sufficient severity to result in significant impairment in personal, family, social, educational, occupational or other important areas of functioning and would normally have been evident for at least 12 months.”
By this succinct definition, “gaming disorder” is nebulously defined as having “impaired control over gaming” with a specific focus on gaming obsessively to the point of causing negative consequences in other parts of one’s life over a long period of time. In general, this criteria seems relatively stringent—“gaming disorder” would only be diagnosed if there were “significant” negative consequences attributed to gaming over a 12 month period. The word “significant” is carrying a lot of weight in this diagnostic criteria considering that “negative consequences” can be subjective. But these criteria are supposed to be a bit vague because they’re supposed to be interpreted by the relevant clinical field to arrive at more specific criteria and to allow for individual clinical assessments and treatment plans.
“Gaming disorder” is essentially treated like a form of substance abuse, and WHO even states that their definition of “gaming disorder” is directly taken from the American Psychiatric Association's (APA) Diagnostic and Statistical Manual of Mental Disorders (DSM-5), which includes a definition of “Internet Gaming Disorder” as a type of “behavioral addiction.” Gaming disorder, along with gambling disorder, is broadly defined in a similar manner to “substance use disorders” except, instead of becoming addicted to specific substances (like alcohol, tobacco, or stimulants), it supposes that patients become addicted to specific behaviors (like gambling or gaming).
The APA’s proposed criteria for diagnosing gaming disorder is experiencing five or more of the following symptoms in a year:
Preoccupation with gaming
Withdrawal symptoms when gaming is taken away or not possible (sadness, anxiety, irritability)
Tolerance, the need to spend more time gaming to satisfy the urge
Inability to reduce playing, unsuccessful attempts to quit gaming
Giving up other activities, loss of interest in previously enjoyed activities due to gaming
Continuing to game despite problems
Deceiving family members or others about the amount of time spent on gaming
The use of gaming to relieve negative moods, such as guilt or hopelessness
Risk, having jeopardized or lost a job or relationship due to gaming
We can see how strongly these symptoms are inspired by the language of “substance abuse disorders.” The terms “withdrawal” and “tolerance” are derived directly from the symptoms defined as criteria for alcohol use disorder, for example. Here are the eleven symptoms of alcohol use disorder:
Alcohol is often taken in larger amounts or over a longer period than was intended.
There is a persistent desire or unsuccessful efforts to cut down or control alcohol use.
A great deal of time is spent in activities necessary to obtain alcohol, use alcohol, or recover from its effects.
Craving, or a strong desire or urge to use alcohol.
Recurrent alcohol use resulting in a failure to fulfill major role obligations at work, school, or home.
Continued alcohol use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of alcohol.
Important social, occupational, or recreational activities are given up or reduced because of alcohol use.
Recurrent alcohol use in situations in which it is physically hazardous.
Alcohol use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by alcohol.
Tolerance, as defined by either of the following: a) A need for markedly increased amounts of alcohol to achieve intoxication or desired effect b) A markedly diminished effect with continued use of the same amount of alcohol.
Withdrawal, as manifested by either of the following: a) The characteristic withdrawal syndrome for alcohol (refer to criteria A and B of the criteria set for alcohol withdrawal) b) Alcohol (or a closely related substance, such as a benzodiazepine) is taken to relieve or avoid withdrawal symptoms.
Look at how similar this list is to the list for gaming disorder. The very concepts of “tolerance” and “withdrawal” have long been used in substance abuse, yet they’re applied to a behavior that involves no external “substances” here.
So how did the APA get from substance abuse disorders to behavioral disorders?
There’s an interesting article by Dr. Stanton Peele, a PhD psychologist and expert in alcoholism and addiction, from Psychology Today way back in 2010 titled “Addiction in Society: Blinded by Biochemistry” that touches on how they made that jump. In it, Dr. Peele discusses that the APA had shifted to seeing “addiction” as a biochemical and neurological condition, and that addiction is seen as being all about a “neurological reward system” which can be triggered by substances (as in “substance use disorders”) or behaviors (as in “behavioral addictions”). From Dr. Peele’s article:
“Indeed, as [University of Pennsylvania psychiatrist Charles] O’Brien points out, powerful experiences like gambling impact the same “neurological reward system” that drugs do. But so do many other rewarding activities. If there is some such higher level ‘neurological reward system,’ then it can’t be said to exclude anything, from sex to food to gambling to video games.”
Dr. Peele made the case back in 2010 that this view of “addiction” would lead to many other activities being defined as “addictive” from a psychiatric perspective, and even directly called out sex, food, gambling, and video games.
And here we are.
My search of the literature in 2019 reveals that there doesn’t appear to be compelling evidence of biochemical or neurological involvement in “behavioral addictions.” This surprises me. I would have assumed based on the strong language involved in the definitions that there was solid evidence that specific chemicals from addictive substances would be well defined. A few are, e.g. nicotine and opiates. But others just seem to be a mystery. And the theory that there’s some kind of internal neurochemical cause of behavioral addiction seems like it is not panning out, either. I assume research into it will continue, but it’s been a decade now.
After searching the literature a bit on this, I was inspired to see if Dr. Peele has discussed “Internet Gaming Disorder” directly and stumbled upon a 2017 article in the Pacific Standard entitled “The Future of Addiction: Stanton Peele’s Predictions for the Next Forty Years.” In it, Dr. Peele expands on his criticism of this current understanding of addiction-as-neurological-disease, and it’s worth a quick read.
The APA’s guidance in the DSM-5 was released prior to the WHO’s ICD-11 and, in fact, directly inspired it. These diagnostic criteria will change and evolve over time as we understand more and more about behavioral addictions. This does mean, however, that the APA’s clear stance that addiction is neurochemical in nature has now passed through to the WHO and is established in the ICD-11.
And, of course, one of their first targets was video games. Why video games?
For decades, video games have been seen as a vice. I still remember the first major attack on them and the people who enjoyed them from pearl-clutching humanoid bloodhound Senator Joe Lieberman in the 90s. After some parents became outraged at what they saw in Mortal Kombat, Joe went after video games as a whole in Congress, claiming (without evidence) that violence in video games is “a causative factor” in real life violence. That line of reasoning continues today whenever it is revealed that some deranged psychopath who shot a bunch of people turned out to be an avid Call of Duty player. As recently as a year ago, President Donald Trump held a roundtable at the White House to discuss a supposed link between violent video games and school shootings.
Of course, there have been countless attempts to prove the theory that video game violence leads to real life violence. An article from July 2018 in Psychology Today titled “Do Violent Video Games Make Kids More Violent?” covers the modern state of research into video game violence and whether it causes real world violence. The conclusion is pretty straightforward: despite many, many attempts at proving otherwise, there does not appear to be a causal link between violent video games and real world violence. (The closest to such a result has been a discovery that aggression is increased immediately following playing a violent video game, but that has nothing to do with playing violent games and committing violent acts.)
Yet the research into it continues. And why? I think it’s because video games are an easy scapegoat.
Being in my late 30s, I’m definitely in the oldest age group that grew up with video games as a mainstream source of entertainment. Like I said, I remember that original battle over violent video games in the 90s. It wasn’t founded in facts—it was founded in fear and puritanism and a desire to pin the blame for violence in our society on something other than bad gun policies, bad mental health policies, and a bad culture of toxic masculinity. Video games have been a scapegoat for violence for decades.
Then there’s the issue of people who actually have experienced severe negative consequences to obsessive video gaming. There have been various tragic cases of people actually dying while binge-playing video games. A quick search found plenty of people discussing the consequences of obsessive video game playing including this sad post of a man who lost everything thanks to an obsession with EverQuest from all the way back in 2002. (As to the veracity of such anecdotes, who knows? But I’ve heard of such “addictions” from people in my own life as well.) And you might have more recently seen viral articles about young men choosing video games over jobs or (brace yourself) even video games over sex.
But the question, to me, isn’t whether or not there are people who become “addicted” to video games. There obviously are. The question is whether “gaming disorder” is a real affliction that is any different from other “behavioral addictions” and whether video games should be specifically targeted as if they’re a special class of “substance”.
Or is it more likely that video games, which have become a common form of entertainment especially among young people who face massive social, cultural, and financial challenges, are a scapegoat for addiction in general, which is a condition that has more to do with the individual’s mental state than with the specific outlet that is being obsessed over?
I want to close with a brief story from my real life. I used to have an acquaintance who I’d known since middle school. I would call him a friend of a friend. I’d been to his house a handful of times as a kid and heard about his family life from our mutual friend. She told me about his father abandoning his family and his mom suffering from depression and so forth. In high school, I heard he was doing drugs (a lot of kids did), but I never did any myself so our social circles never really overlapped. It sounded like he had a really hard life growing up.
He remained friends with my friend, disappearing and reappearing from her life every couple years, and I’d hear about him from her. He was a bartender nearby for a while, apparently, until his drinking problem caused him to lose that job. A few years ago, my friend attended an Alcoholics Anonymous meeting with another person to see what it was all about. This acquaintance happened to be at the AA meeting. Afterwards, she talked to him about getting sober and he told her that he wasn’t an alcoholic; he was addicted to video games, World of Warcraft specifically.
A few months passed and he was apparently over his “addiction” to video games. He stopped attending AA, got his life together, started trying to be a parent to his two kids, but then eventually disappeared again.
My friend happened upon him one last time a few years later and he was looking rough. Dirty, thin, not in good shape. He was living in a burned out cinder block structure in the woods with some other folks, all of whom appeared to be on drugs. Shrooms, he told my friend, though to me it sounded like heroin. My friend told me this was the last time she saw him.
My point in relaying this story is that this acquaintance of mine had a traumatic childhood and a lifetime of addictions. He was on various drugs as a teenager. He was an alcoholic. He was addicted to World of Warcraft. He gave up his family to be addicted to drugs in the woods.
Why, for someone like that, would we focus on any particular substance or behavior? Something caused him to become addicted to all sorts of different things. It wasn’t just alcohol, or drugs, or video games.
It seems like there have been enough cases of addiction to video games that it’s worth thinking about how it might be an outlet for addiction, but if we claim these people have “gaming disorder” and treat them for that specifically, will it actually treat the underlying problem? Or is gaming just an outlet? Maybe obsessive gaming, for those people, is actually a symptom. And if the psychiatric field is missing that, if it’s trying to treat symptoms rather than the actual illness, that’s a major problem.