News media reported this week that the World Health Organization (WHO) is moving ahead with the inclusion of “gaming disorder” (essentially video game addiction) in the next version of their International Classification of Diseases (ICD.) This is good news for clinicians hoping to get reimbursed for treating the disorder and politicians looking for cover to regulate or censor speech and technology. Arguably, it is worse news for good science and for public perceptions of legitimate mental illnesses. Curiously, this also places the WHO in opposition with another United Nations arm, UNICEF, which, in a 2017 report, appears to caution against using the “addiction” concept to apply to technology.
The WHO’s proposal has been in the works for a couple of years and has already generated controversy among scholars in the field. One group of 28 scholars wrote an open letter regarding the WHO’s proposal, criticizing it for lack of scientific support, lack of transparency, and failure to adequately consider the clinical harms and human rights concerns of the proposed diagnosis. Some scholars certainly support the WHO’s efforts, but they may be in the minority. One survey I conducted of scholars regarding their attitudes toward video games found that only about 30 percent agreed that video game addiction is a serious problem. That the WHO appear to have made little effort to understand the concerns of more skeptical scholars is worrisome.
So too are the apparent politics behind the proposal. WHO officials have previously acknowledged coming “under enormous pressure, especially from Asian countries, to include (gaming disorder)” in their ICD. Although the specific countries go unmentioned, it’s likely they include China which has an authoritarian and censorious approach to media as well as brutal internet addiction camps that have harmed kids, and South Korea. The latter country has a law which prohibits youth from accessing the internet at all between midnight and 6 a.m. Recent analysis suggests this law is ineffective, increasing kids’ nightly sleep by a whopping 1.5 minutes and being ineffective in addressing mental health concerns. The authors of that report also note potential human rights and free speech concerns posed by the “shutdown” law… a law for which supporters will now be able to point to the WHO’s faux diagnosis to support.
Of course, the WHO’s efforts aren’t the only ones to receive controversy. The American Psychiatric Association’s (APA) provisional diagnosis of “Internet Gaming Disorder” (IGD) has proven unpopular among many scholars. In fairness to the WHO their “gaming disorder” may be marginally better insofar as it focuses on interference (i.e., that gaming gets in the way of other responsibilities) rather than the problematic symptoms employed by the APA’s IGD. The APA assumed (incorrectly) that problematic gaming could be directly compared to substance abuse (it can’t), and used symptoms that are bad for, say, alcohol or cocaine, but perfectly normal for hobbies. For instance, “I sometimes use X to make myself feel better after a stressful day” is bad if X is heroin, but not so bad if X is gardening or going for a jog. Similarly, “I have given up other activities to do X more” is not good if X is heroin, but it’s normal to change hobbies from time to time. Increasingly, evidence suggests that gaming is more like other fun activities, ranging from eating food to sex to shopping to exercise to dancing, and less like heroin or methamphetamine. Of course, any fun activity can be overdone (there are even scientific papers on “dance addiction”) but there’s little evidence to suggest video games are more addictive than other behaviors. Indeed, recent prevalence figures put the rates of video game addiction at 1 percent or less among gamers, and it’s not even clear that these 1 percent are really any less psychologically or physically healthy than the other 99 percent. Most of these cases also go away by themselves, without treatment. So, the “video game addiction” concept doesn’t appear to have much clinical value.
This raises the question of why the WHO is so obsessed with video games rather than a catch-all “behavioral addiction” category that could include any behavior that is overdone. This seems to be one of the most difficult issues for the WHO to defend. It can’t be said that video game addiction has received either more or better research than other areas (food and sex addiction have received at least as much research if not more, and the quality of video game addiction research is often criticized as a jumbled mess.) The more likely explanation, in my opinion, is a combination of politics and finances. We’re in the midst of a well-documented moral panic regarding video games (although fears of smartphones and the internet may be replacing that slowly). New diagnostic codes will be a boon to an industry of clinicians who may now receive insurance reimbursement for treating this “disorder.” And the political issues have already been acknowledged by the WHO themselves.
Among the greatest issues of concern, proposing nonsense disorders like gaming disorder, particularly in disregard of evidence that should compel caution, runs the risk of trivializing mental illness. Gaming disorder may panic some among the pearl-clutching set, but is likely to result in a lot of eye rolls as well. There’s the potential that this eye rolling could provoke some individuals to reconsider mental illness more broadly. This could put efforts to de-stigmatize mental illness and achieve parity in insurance coverage in jeopardy. Granted, “gaming disorder” isn’t the only problem diagnosis out there… some disorders such as “Disassociative Identity Disorder” have been received by many psychologists with skepticism for decades. And efforts by the APA to water down everything from ADHD to depression brought on by grief reactions have raised more recent concerns.
Thus “gaming disorder” is indicative of a larger trend to increasingly pathologize normative behaviors, whether for moral reasons (because older adults would prefer kids look at trees or play canasta than play video games) or financial (because there’s money to be made) or political (to regulate behavior or speech). Legitimate mental illness, from depression to schizophrenia do exist and deserve attention. Junk disorders will only distract from this and make the work of mental health advocates harder. Further, stigmatizing games can cause real harm to patients. Clinicians may fail to focus on the real, underlying issues that may result in overgaming, and convince parents to take away the games their kids are using for coping without replacing them with anything else. As the UNICEF report notes “There are risks in employing addiction terminology to describe concerns regarding children’s growing use of digital technology. Careless use of addiction terminology downplays the very real consequences of the behaviour for those who are seriously affected, while overstating the risk of harm for those who at times engage in somewhat excessive, but ultimately not harmful, use of digital technology. Applying clinical concepts to children’s everyday behaviour does not help support them in developing healthy screen time habits.” Unfortunately, on balance, “gaming disorder” appears destined to do more harm than good.