Video Game Addiction, or How the World Health Organization Stumbled into a Diagnostic Quagmire

In 2018 the World Health Organization (WHO) announced plans to include “gaming disorder” in the future International Classification of Diseases (ICD). Far from solidifying a consensus on whether this disorder is “real” or not, the WHO touched off the tinder of an ongoing debate about gaming overuse that had been simmering for decades. This controversy relates not just to the pathologizing of a hobby, but how we conceptualize addictions more generally, and has implications for diagnosis widely.

Unlike the violent video game debate, which always had a reputation for the ad hominem (although see Ferguson & Konijn, 2015 for an alternative), debates about gaming overuse had been historically cordial. I suspect the WHO’s main accomplishment will come in ending that rapprochement. Making “gaming disorder” salient will create camps of those opposed and supportive of the idea in a binary fashion. This, rather than helping patients, will be the chief legacy of the WHO’s clumsy move.

For, unfortunately, current evidence does not support the existence of gaming disorder. Some individuals clearly overgame, although their number appears to be few. A meta-analysis I conducted several years ago (Ferguson, Coulson, & Barnett, 2011) suggested a prevalence rate of 3 percent of gamers, although more recent studies have suggested the prevalence may be closer to 1 percent or less (Haagsma, Pieterese, & Peters, 2012; Przybylski, Weinstein, & Murayama, 2017). Symptoms used to diagnose the American Psychiatric Association’s “internet gaming disorder,” a category proposed for future study in the Diagnostic and Statistical Manual of Mental Disorders (DSM) do not appear to work well. Specifically, they do not distinguish those low in mental or physical problems from those high (Przybylski et al., 2017; Quandt, 2017). The WHO managed to avoid this quandary by simply not including any symptoms—gaming disorder is gaming which is interfering, which is fair on the surface, but also vague enough to leave individuals to the mercy of subjective clinical judgments. Problematic gaming appears to arise as a symptom of underlying mental health conditions rather than functioning as a unique disorder (Ferguson & Ceranoglu, 2014) and has proven to be an unstable construct (e.g., Scharkow, Festl, & Quandt, 2014; Rothmund, Klimmt, & Gollwitzer, 2018). Simply put, “gaming disorder” does not have empirical support as a stand-alone condition.

The mistake made by the WHO came in focusing on the behavior rather than the individual. Unfortunately, this led to a number of scientific urban legends, such as that gaming influenced reward systems in a similar manner to methamphetamines or cocaine, or that variable reinforcement schedules made gaming particularly addictive. Many experts who should know better continue to repeat such rubbish claims as part of a moral panic focused on new technology. Such loose claims could be applied to almost anything. Take, for instance, cats. Stroking a cat releases dopamine in reward centers of the brain, cats will run between one’s feet to keep one engaged, cats have a variable reinforcement schedule (i.e., sometimes they love us, sometimes they do not and we never know when), and we even have anecdotes of people who have continued engaging with cats despite obvious negative, even legal consequences (e.g., try Googling “cat hoarder”). So, if the WHO is concerned about patients addicted to gaming, are they not concerned about cat addicts? Or, for that matter, those who overdo exercise, work, food, religion, and others? There are even papers on “dance addiction” (e.g., Maraz, Urbán, Griffiths, & Demetrovics, 2015).

Undoubtedly, some individuals struggle to regulate fun behaviors and remain on-task with unfun behaviors. Instead of focusing on microdiagnoses related to gaming, gambling, dance, cats., etc., a general “behavioral regulation” disorder that might have applied to any behavior that could be overdone would have made more sense. Unfortunately, the path the WHO is on makes them vulnerable to indulging moral panics related to technology or other “naughty” behaviors society does not like. This path does not benefit patients and certainly does not benefit science, particularly to the extent it relies on repeating pseudoscientific claims about dopamine and reinforcement schedules. The microdiagnosis approach merely reinforces predictable patterns of antitechnology moral panic that have existed throughout human history. It further perpetuates a “mission creep” in psychiatry to overpathologize an increasing range of normal human behaviors. Apparently, even the WHO struggles to learn from our past.

References

Ferguson, C. J., & Ceranoglu, T. A. (2014). Attention problems and pathological gaming: Resolving the ‘chicken and egg’ in a prospective analysis. Psychiatric Quarterly, 85(1),103–10.
Ferguson, C. J., Coulson, M., & Barnett, J. (2011). A meta-analysis of pathological gaming prevalence and comorbidity with mental health, academic, and social problems. Journal of Psychiatric Research, 45(12), 1573–8.
Ferguson, C. J., & Konijn, E. A. (2015). She said/he said: A peaceful debate on video game violence. Psychology of Popular Media Culture, 4(4), 397–411.
Haagsma, M. C., Pieterse, M. E., & Peters, O. (2012). The prevalence of problematic video gamers in the Netherlands. Cyberpsychology, Behavior, and Social Networking, 15(3), 162–8.
Maraz, A., Urbán, R., Griffiths, M. D., & Demetrovics, Z. (2015). An empirical investigation of dance addiction. PloS ONE, 10(5), e0125988.
Przybylski, A. K., Weinstein, N., & Murayama, K. (2017). Internet gaming disorder: Investigating the clinical relevance of a new phenomenon. The American Journal of Psychiatry, 174(3), 230–6.
Quandt, T. (2017). Stepping back to advance: Why IGD needs an intensified debate instead of a consensus. Commentary on: Chaos and confusion in DSM-5 diagnosis of internet gaming disorder: Issues, concerns, and recommendations for clarity in the field (Kuss et al.). Journal of Behavioral Addictions, 6(2), 121–3.
Rothmund, T., Klimmt, C., & Gollwitzer, M. (2018). Low temporal stability of excessive video game use in German adolescents. Journal of Media Psychology: Theories, Methods, and Applications, 30(2), 53–65.
Scharkow, M., Festl, R., & Quandt, T. (2014). Longitudinal patterns of problematic computer game use among adolescents and adults—A two-year panel study. Addiction, 109(11), 1910–7.

Christopher J. Ferguson, PhD

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Christopher J. Ferguson, PhD, is a professor of psychology at Stetson University and fellow of the American Psychological Association. He has conducted dozens of research studies on the impact of video games on human behavior. He has published the book Moral Combat: Why the War on Violent Video Games is Wrong (2017) with coauthor Patrick M. Markey, PhD, and a mystery novel, Suicide Kings (2014), set in Renaissance Florence. He lives in Orlando with his wife and son.