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Here’s why experts are skeptical of the ‘gaming disorder’ diagnosis

We need better data

The World Health Organization has added “gaming disorder” to its diagnostic handbook, but experts argue that we still don’t know to claim that gaming disorder exists. The evidence is inconsistent, they say, and the criteria are too broad.

According to the WHO, the following criteria indicate gaming disorder: gaming is strongly preferred over other activities, the patient does not stop even when there are negative consequences like doing badly at work, compulsive gaming strains the patient’s life or relationships, and all this has been happening for at least a year.

Here’s how ICD-11 defines gaming disorder:

Gaming disorder is characterized by a pattern of persistent or recurrent gaming behavior (‘digital gaming’ or ‘video-gaming’), which may be online (i.e., over the internet) or offline, manifested by: 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 behavior 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 behavior may be continuous or episodic and recurrent. The gaming behavior 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.

The addition of gaming disorder to the ICD had been in the proposal stage for months, and the WHO already seemed to be moving in this direction. That’s despite the concerns expressed by some mental health professionals, who fear that the likely downsides of codifying gaming addiction in this way would far outweigh any potential benefits.

“It’s really a junk diagnosis,” said Christopher J. Ferguson, Ph.D., in a phone interview with Polygon on Monday. He added that “by and large,” existing research “does not support the existence of gaming disorder.”

The WHO isn’t the only respected health body that has been trying to come up with language to describe video game addiction in a medical diagnosis. The American Psychiatric Association publishes the Diagnostic and Statistical Manual of Mental Disorders (DSM). The organization released the latest DSM update, the fifth edition, in 2013. “Internet gaming disorder” is listed in DSM-5, but only as a “condition for further study” — not a clinical diagnosis.

Last year, Ferguson co-authored a journal article arguing against both the WHO’s and APA’s proposals to define video game addiction as its own disorder. The authors of the article, which was published in the journal Professional Psychology: Research and Practice, said that “little clarity has been achieved regarding diagnostic criteria and appropriate symptoms” for video game addiction, and that the proposals were thus “premature.”

“It really feels like the WHO rushed this, and maybe didn’t put in the effort to listen to a wider array of researchers and scholars,” Ferguson told Polygon.

The WHO disputes this. The organization made the decision to add gaming disorder to ICD-11 “based on a full review of global evidence, as well as consultation with experts from all regions of the world,” said Dr. Shekhar Saxena, director of the WHO’s Department for Mental Health and Substance Use, during a press conference Monday.

But Ferguson feels that the WHO undertook this effort “pretty non-transparently,” and “made no effort to engage with scholars who were more skeptical” of the gaming disorder concept. And there may have been nonscientific factors at play as well.

Anthony M. Bean, Ph.D., is a Fort Worth, Texas-based clinical psychologist who co-authored the journal article with Ferguson. Bean pointed out that there is evidence that the WHO was influenced by pressure from Asian member states in deciding to add gaming disorder to ICD-11. Countries such as China and South Korea have considered gaming addiction a scourge for years, and have worked to address the issue through laws and other means. The WHO refuted the allegations of political pressure last year, telling Polygon that the decision to define gaming disorder in ICD-11 was “based entirely on technical considerations and not political ones.”

Either way, Bean told Polygon in a phone interview on Monday, the considerations are based on what is at best a correlation, not a causation.

“I don’t think that we have enough research to single it out in this capacity,” Bean said of gaming disorder. He clarified that he’s open to the possibility, saying that any decent scientist should always consider new evidence, but said that it would take a lot more study to confirm that gaming disorder should be a distinct clinical diagnosis.

Since the WHO’s classification explicitly says it’s possible to become addicted to video games in the same way one can develop a gambling problem, it’s no surprise that the game industry sides with the people calling for a wait-and-see approach. The Entertainment Software Association, the trade body representing the U.S. gaming industry, issued a news release earlier this year highlighting a paper published by 36 mental health experts and academics — including Bean and Ferguson — that opposed the WHO’s proposal.

World Health Organization classification of gaming disorder
Artwork from the WHO about the addition of a gaming disorder classification to the ICD.
World Health Organization

The ESA referenced those concerns in a statement to Polygon on Monday, saying, “With the significant opposition from the medical and scientific community, the WHO should consider the mounting evidence put before them before making a decision on the inclusion of a ‘gaming disorder’ in the final version of ICD-11 next year.”

Even the WHO acknowledges that further study is needed, and intends for the classification of gaming disorder to spur additional research. In other words, there seems to be a difficult chicken-and-egg problem here: There isn’t enough research on gaming disorder to define it as a diagnosis, but without health bodies defining it as a diagnosis, it may be less likely for researchers to study the phenomenon in the first place.

“The information and evidence in this area is still incomplete, simply because this was not recognized as a disorder,” said the WHO’s Dr. Saxena, describing the gaming disorder classification in ICD-11 as “a very good first step.” He added, “This disorder being identified using common descriptions will really facilitate research in this area.”

In addition to generating research, the WHO hopes that ICD-11’s gaming disorder definition will give mental health professionals the support they need to describe the issue to patients and devise treatments. Think of a psychologist seeing patients who exhibit symptoms that could fit with gaming disorder, but lacking a firm basis to diagnose it. With ICD-11, that doctor would be able to describe the disorder, relying on a medical standard that bears the imprimatur of the WHO.

At the same time, codifying gaming disorder in the ICD carries risks. Dr. Saxena acknowledged the possibility that this classification could further stigmatize video game addiction, but said the only way to treat people who need help is to be able to identify a disorder. “It’s a condition which needs to be identified, and which can be treated by suitable interventions,” said Dr. Saxena. “And we will make our best attempts to decrease that [stigma] and stop that from acting as a barrier for care.”

Ferguson and Bean said they worry that ICD-11’s definition of gaming disorder is too vague to be useful. Bean noted that it doesn’t distinguish between mild, moderate or severe cases, which leaves it up to clinicians — many of whom don’t have experience with video game addiction and “don’t understand gaming culture to the degree that they can work with gamers” — to decide for themselves.

In addition, both psychologists told Polygon that they generally find gaming addiction to be a symptom of a different underlying mental condition, such as depression or anxiety, rather than a unique disorder itself. They said that a potential danger of separating out gaming disorder is that addressing it could leave those deeper, more serious conditions untreated.

“Nothing good is going to come of this,” said Ferguson of the WHO’s classification. He told Polygon that he would prefer that clinical study of gaming addiction examine “specific mechanisms in some games that may be problematic,” such as loot boxes. Government bodies in countries such as Belgium and the Netherlandshave already ruled that loot crates in certain games qualify as illegal gambling, and Dutch officials are pushing for new legislation to tackle the issue throughout the European Union. Even in the case of regulating loot boxes, though, Ferguson said he would like people to wait until there’s more concrete data on the subject before making public policy decisions.

Bean was less pessimistic, characterizing the WHO’s hope — that adding gaming disorder to the ICD will greatly increase the amount of research being done in the field — as the best possible outcome. But as a psychologist who often deals with parents convinced that their kids are addicted to video games, he fears that the WHO’s decision could have negative consequences. For instance, Bean said he worries that it will encourage treatments that don’t address the real mental conditions at issue, such as the so-called summer camps whose administrators promise they can cure game-addicted teens by taking them off the grid and to the wilderness for a while.

“We need much better data than we have now,” said Ferguson. “There are more risks in warning people prematurely about stuff.

But nothing in this criteria has anything to do with gaming specifically, says Andrew Przybylski, a psychologist at the Oxford Internet Institute who has extensively studied video games and mental health. “You could easily take out the word ‘gaming’ and put in ‘sex’ or ‘food’ or ‘watching the World Cup,’” he says. We know how opiates and nicotine work and what makes themaddictive, but we don’t know the same for games. The gaming disorder definition says nothing about what kinds of games or what features of games might be addicting, and so it’s too broad to be helpful. It’s just stating that sometimes people who play games play them too much. This could be true about any activity and such an attitude, Przybylski says, “could lead to a kind of pathologization of every aspect of life.”

It’s undeniable that there are people who suffer because they play too many video games, says Michelle Colder Carras, a public health researcher at Johns Hopkins University focused on the problematic use of technology. But she argues that these people usually can get psychiatric treatment under a more general diagnosis like depression or anxiety. Both Carras and Przybylski were part of a group of researchers who wrote a letter to the WHO in 2016 recommending against adding “gaming disorder” to the diagnostic handbook because there’s no consensus and most studies in the area are low-quality.

So what’s wrong with the studies? First, we don’t even know how many people might have gaming disorder. Most papers collect data from self-help or gaming forums where people post about being addicted to gaming. “It’s like asking, ‘what is the prevalence of heroin?’ and then going to a clean needle exchange and running your survey there,” Przybylski says. As a result, some numbers say that gaming disorder afflicts less than 1 percent of gamers, but other studies suggest rates up to 100 times higher.

Some people studying gaming disorder will ask people about “internet addiction” or “computer addiction,” according to Carras, but it’s not the same thing. And there are more general problems, too: Often, scientists don’t share their data and don’t say what they were testing before they gathered it, which makes it easier for scientists to look at the data and report findings they already expected.

This broad, fuzzy diagnosis could stigmatize gamers and lead to more misconceptions. Carras points to a recent Observer article that suggested that the diagnosis could help prevent school shootings, insinuating that video games cause mass violence. “There’s a danger of a moral panic with people who don’t understand video games making these statements and causing family conflict, and kids being brought to treatment who don’t need to be there,” she says. And it can lead to more of the unfounded fear that screen time is “digital heroin.”

Still, there could be potential upsides to the diagnosis being added. Because the stakes are higher, it might push researchers to do more open and more rigorous science, says Przybylski. Plus, it might encourage gaming companies to be proactive and share their data. “I’m genuinely worried about the mechanics of games taking advantage of vulnerable people,” he says, “but there’s a fundamental asymmetry between the kinds of data I can collect and the data that video game companies — like the ones that create Fortnite or League of Legends — collect every day.”

Finally, it’s worth noting that although plenty of headlines claim that the WHO has decided “gaming addiction” is real, the agency has been careful not to cry “addiction.” Instead, the classification is labeled under “disorders due to addictive behavior.” “If they were going to say ‘addiction,’ it would really require much higher evidence that doesn’t exist yet,” says Przybylski. “I think it’s very intentional that they’ve avoided the term addiction and used an ambiguous term like ‘disorder.’”

If there really are people who suffer, why not just call it an addiction? “I think that dilutes the term ‘addiction,’” says Przybylski. In theory, he adds, “if you had an infinite number of therapists and an infinite number of dollars and medications, it’s fine to medicalize everything because then you can therapy and drug your way out of the problem.” But we don’t live in a world like that and so triage is necessary: “If we start creating all of these ‘addictions’ that are mostly normal behaviors, it may distract resources away from those that we know cause human suffering.”

We have asked the WHO for comment and will update if the agency responds.

Sources- The verge and Polygon

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