The World Health Organization (WHO) has added ‘gaming disorder’ to the latest edition of the International Classification of Diseases (ICD-11). This comes after the American Psychiatric Association listed ‘internet gaming disorder’ as a ‘condition for further study’ in the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) in 2013.
This is a big deal. The ICD gives unique codes to diseases and is used by dozens of national governments, including the United Kingdom, to allocate resources throughout their health systems. And whereas the DSM-5 put a question mark over (internet) gaming disorder, there is no such doubt lingering in ICD-11.
There could be huge implications for the games industry, not least a future in which games could carry mandatory warning labels about their addictive qualities. It also means that people who have faced serious life difficulties as a result of gaming addiction could have more access to help. But how did we get here?
What is gaming disorder?
The final draft of ICD-11 was published on 18th June 2018, and it defines gaming disorder as:
“1) impaired control over gaming (e.g., onset, frequency, intensity, duration, termination, context); 2) increasing priority given to gaming to the extent that gaming takes precedence over other life interests and daily activities; and 3) continuation or escalation of gaming despite the occurrence of negative consequences. The behaviour pattern is of sufficient severity to result in significant impairment in personal, family, social, educational, occupational or other important areas of functioning. The pattern of gaming behaviour may be continuous or episodic and recurrent. The gaming behaviour and other features are normally evident over a period of at least 12 months in order for a diagnosis to be assigned, although the required duration may be shortened if all diagnostic requirements are met and symptoms are severe.”
So what exactly is a ‘disorder’, and how is it different from a disease? Mark Coulson, Associate Professor in Psychology at Middlesex University, London, explained it to me: “Disorders develop over time, and are rarely sudden. So for instance, ICD-11 requires the symptoms to be present for at least a year before a ‘diagnosis’ can be made. Also, there is no infectious agent (bacterium or virus) with a disorder. However, addictive behaviours (and ICD-11 classifies gaming disorder as an addictive behaviour) are sometimes treated with drugs, so the distinction is perhaps not all that useful. It is still important to distinguish between dependence (as with alcohol, nicotine, or other drugs) and addiction, as the former is a biochemical process.”
The process of creating the latest revision of the ICD was lengthy and exhaustive: it began in 2011, and for years scientists and health professionals from across the world have been weighing the evidence and debating over what conditions should be recognised and how they should be defined. In the case of gaming disorder, the debate was particularly heated.
The case for gaming disorder
Professor Coulson was one of 26 scientists who co-authored a paper in 2016 arguing that gaming disorder should not be included in ICD-11. They asserted that: “The empirical basis for a Gaming Disorder proposal, such as in the new ICD-11, suffers from fundamental issues.” In particular, they worried that the quality of research in this area was low, that there is no consensus on the symptoms and assessment of problematic gaming, and that there was an overreliance on “applying symptoms reminiscent of substance use disorders to gaming behaviors”, even though there are significant differences between chemical dependence and behavioural addiction, as Coulson notes above.
The paper received around ten formal responses, mostly from academics who were in favour of formalising gaming disorder in ICD-11 - arguments the authors responded to in a follow-up paper published in February. It should be noted that the authors did acknowledge that some gamers do experience “serious problems as a consequence of the time spent playing video games”. Their argument was simply that these problems should not be attributed to a new disorder.
Indeed, scientists on both sides of the debate acknowledge that if someone is playing games so much that it has a detrimental impact on their health, work and social life, then it is a problem. But it is not just games that can cause this, says Coulson. “I think that any pleasurable activity can become an addiction, and think it would be foolish to state otherwise. So I agree that people can become addicted to gaming, I just think the ICD-11 classification is a mistake for a variety of reasons.”
Professor Mark Griffiths is a Chartered Psychologist and Director of the International Gaming Research Unit at Nottingham Trent University, and he was part of the WHO Working Group that provided input on the decision to add gaming disorder to ICD-11. He says that there is overwhelming evidence for gaming disorder:
“Hundreds of studies that have shown that a small minority of people, when gaming to excess, have major problems in their life. I’ve published more papers on video game addiction than anybody else in the world. What we’ve got is country after country, study after study basically showing that a small but significant minority of people where gaming is something that completely takes over their lives - and we’re not talking about kids who play 3 or 4 hours a day, that is nothing to do with gaming disorder. We’re talking about something that completely compromises that person’s life. It’s something where people have withdrawal symptoms if they can’t engage in the behaviour, they’ve built up tolerance over time, needing more and more gaming to get those same mood-modifying effects. They are people that use the behaviour basically as a way of self-medicating: they use it either to get buzzed-up highs, aroused, excited, or they use it for the exact opposite, to tranquilise, to escape, to numb, to destress.”
He is keen to point out that gaming addiction is by no means the same as just playing games a lot. “It’s nothing to do with the amount of time you do something, it’s to do with the negative knock-on effects on that person’s life. I’ve published one case study where a guy was playing over ten hours a day but clearly wasn’t addicted.” He emphasises that based on his studies, only a tiny fraction of gamers - between 1 and 4% - could be considered ‘at risk’ of developing gaming disorder, noting that being at risk of it is not the same as having it. Of that 1-4%, only 0.1-0.2% would have what he considers to be a gaming addiction. But, he notes, “Just because it’s not a huge problem, doesn’t mean that it doesn’t exist.”
“I’m in no way anti-gaming,” he cautions. “I do it, my kids do it. It’s a bit like drinking alcohol: there is no evidence that doing any of these things moderately has any negative effects whatsoever,” adding that gaming can have great therapeutic benefits.
The implications for the gaming industry
I asked Professor Griffiths whether the formal recognition of gaming disorder would lead to labels on game boxes warning of the addictive nature of games, in the same way that gambling machines have warnings attached. He pointed to the “furore about photosensitive epilepsy and playing video games” in the early 1990s, which subsequently led to warnings like the one that greets PS4 users when they boot up their machines, and suggested that game labels could warn that a small proportion of people might end up developing a disorder that negatively affects their life.
“The computer game industry, they’re going to have to do what the gambling industry has done,” he argues. “In the UK, the Gambling Commission will not give you a license for gambling unless you can show what you’re doing in terms of player protection, harm minimisation, responsible gambling and social responsibility. I’ve written a number of editorials in the addiction journals arguing that gaming companies should do the same.”
For its part, the gaming industry has reacted with some alarm to the inclusion of gaming disorder in ICD-11. Six games industry bodies, including the US Entertainment Software Association (ESA), issued a joint statement expressing concern “to see ‘gaming disorder’ still contained in the latest version of the WHO’s ICD-11 despite significant opposition from the medical and scientific community.” The statement ends with a stark warning: “To classify gaming as a disorder under the mental health and addiction category of the ICD-11 list will create moral panic and may lead to abuse of diagnosis as the inclusion is not based on a high level of evidence, as would be required to formalise any other disorder.”
Moral panic in the media
This statement is a direct echo of Coulson and co-authors’ paper, which says that the “presence of a current moral panic regarding video games may cause the medical community to take ill-considered steps, despite ambiguous research evidence, that do more harm than good to the global community of video gamers through the pathologizing of normal behavior.” Coulson himself told me that the moral panic about gaming is reminiscent of similar worries about the advent of rock music, cinema, and TV - and that this may have found its way into ICD-11: “I think it is very revealing that the sort of people who write ICD all use social media and smartphones, but probably don’t game. So as a consequence we see the latter identified as a disorder, but addiction/overuse/compulsion towards the former is largely ignored. As gaming becomes ubiquitous, and more a part of normal life, I imagine the authors of ICD-12 (currently playing Xbox) will laugh at this naïve move.”
It’s clear to see the moral panic over video games in the mainstream media. This week, websites have been awash with stories on how to look out for gaming disorder in your children, and news sites have been quick to link the popularity of Fortnite with gaming addiction. The BBC posted a video titled “WHO: Gaming addiction 'a mental health condition'” that featured children admitting to playing 20 hours of Fortnite a week - the clear implication being that they’re addicted.
Griffiths has been dismayed by coverage of ‘gaming addiction’ in the mainstream media that is clearly not addiction at all. He points out that if there were reports of children watching TV for three hours a night, no one would care, but that playing games is seen as morally reprehensible, a waste of time. “My son is playing two or three hours of Fortnite a day at the moment,” he notes. “It’s just something that’s life enhancing, life affirming, has no effect on his education, the chores around the house or his interaction with his friends, but the media have taken what is essentially a normal behaviour, and it’s been pathologized. This is nothing to do with gaming disorder whatsoever.”
“I’ve commented on story after story about people who are so-called ‘addicted’ to Candy Crush, and it’s just people who are playing it far too much. That’s not an addiction, that’s not gaming disorder. When we’re talking about gaming disorder, we’re talking about an activity that clinically impairs somebody’s life to such an extent that they have to seek treatment for it, and the number of people who do that in this country are few and far between.”
Why is gaming being singled out?
It struck me that in the ICD-11 definition of gaming disorder, the word 'gaming' could easily be substituted for 'eating', 'sex', 'exercise' or anything that people do to excess - so why does gaming require a separate disorder?
Griffiths thinks that a distinction is merited: “I think every addiction, at the end of the day, does have idiosyncrasies - gambling is the only one that features chasing losses. There’ll be things within gaming disorder that only occur within that particular activity. But you’re right, the reason why gaming disorder is in there now, and as you say, you could replace it with the word gambling or whatever, is because those other things you’re talking about are also other things that are potentially addictive.”
I asked Coulson the same question. His response: “My answer to this (which means I know some people share it and others reject it) is that I agree with you. Now, gambling addiction has been very thoroughly researched, and no-one is in any real doubt that it exists as a separate phenomenon. As we move down the evidence chain (i.e., which addictive disorder is next best researched) then some would argue that gaming is next. Whether or not this is the case is open to interpretation. Will we keep adding to this list over time? Probably. One of the key things about inclusion in ICD-11 is that a disorder is formally recognised, which means it will attract more funding for both research and treatment. Indeed, this is one of the reasons we think gaming disorder should not be included. If WHO had proposed ‘digital media use disorder’ then I would be in full support.”
Gaming disorder on the NHS?
Despite what some tabloids have been trumpeting, you can’t now suddenly receive treatment for gaming disorder on the NHS. The current version of ICD-11 won’t be endorsed by the WHO members until a meeting in May 2019, and there is still a chance it might be amended before then. After that, national governments could still take years to formally adopt ICD-11, and they may well add their own amendments.
Even then, Griffiths is sceptical that we would see free NHS treatment for gaming disorder: “Every health trust has a finite budget. Do you really think someone is going to be given treatment for gaming addiction over cancer treatment, diabetes treatment, Parkinson’s treatment, hypertension, heart disease? It’s not going to happen. The people being treated now are paying privately, and the reason they’re paying privately is because this has completely ruined their life, and they’re using every last penny they can to get it sorted out.”
But things could be different in the United States, he argues. “In America this might make a huge difference, because if somebody gets a diagnosis of gaming disorder, then technically health insurance will cover that treatment.” However, he notes that many health policies might add gaming disorder as an exclusion, in the same way that many currently exclude gambling disorder.
This problem isn’t going away
The statement from the ESA and other gaming bodies emphasises that “Video games across all kinds of genres, devices and platforms are enjoyed safely and sensibly by more than 2 billion people worldwide”, concluding that “To classify gaming as a disorder under the mental health and addiction category of the ICD-11 list will create moral panic” - but this is missing the point. Gaming is not being classified as a ‘disorder’ - a disorder is being recognised that affects a tiny fraction of gamers. And whether they want gaming disorder to be in ICD-11 or not, academics on both sides of the debate agree that gaming addiction is a problem that most certainly exists.
What’s more, it’s a problem to which that the games industry may have contributed. As this Guardian article points out, modern games are laden with mechanisms to increase replayability, from leaderboards to loot boxes. As with alcohol or gambling, the vast majority of people will be able to take or leave this kind of thing - but a tiny minority could be hooked. Then again, gaming certainly doesn’t deserve the predictable demonisation it often receives at the hands of the mainstream press.
This is just the beginning, though. Expect to see much more moral panic along the way - not to mention outrage if (when?) those addiction warning labels start coming in.