Reevaluating Internet Gaming Disorder
Do we really need a diagnosis just for video games?
Posted April 5, 2019
With the publication of the DSM-5 in 2013, the category “Internet Gaming Disorder” (IGD) was proposed for further study. The disorder appears to tap into a zeitgeist of concern regarding the impact of new technology on those who consume it. IGD has now benefited from just over 5 years of research investigation, and it’s time to take a look to see if this (or some other variant, such as the World Health Organization’s [WHO] “gaming disorder") ought to be further enshrined in a future edition of the DSM. It is worth considering several things. First, whether evidence suggests IGD discriminates healthy from non-healthy individuals. Second, whether evidence supports the existence of IGD as an independent disorder or merely symptomatic of mood, anxiety, ADHD, or autism spectrum disorders. Third, whether video games are unique in addictive qualities, and thus deserved to be singled out for a disorder rather than a myriad other activities people overdo. And fourth, whether a consensus among scholars exists regarding IGD.
It is important to note at the outset that IGD, a proposed category with nine symptoms, has a competitor in the WHO’s “gaming disorder,” although this latter category has no symptoms, only a vague description. Unlike IGD, “gaming disorder” appears definitely headed for inclusion in the ICD, though it has sparked a fierce backlash from skeptical scholars. Most notably, the media and technology psychology divisions of the American Psychological Association and Psychological Society of Ireland cosigned a statement opposing the WHO’s “gaming disorder.” It’s possible the American Psychiatric Association may feel pressure to further enshrine IGD to achieve parity with the ICD, although it’s also arguable that “gaming disorder” serves as a warning for peril ahead.
Does IGD distinguish healthy from non-healthy individuals?
A key issue for any diagnostic category is whether it discriminates clinical from non-clinical groups. The IGD criteria are largely borrowed from symptoms of substance use disorders with an assumption that these symptoms would work as well with gaming overuse. As far back as 2011, before the release of DSM-5, there was already evidence this was not the case, with symptoms such as these having high false positives. A recent, large study in the American Journal of Psychiatry has confirmed this: IGD symptoms do not discriminate between individuals with clinical impairment versus those without.
Looking at the symptoms, it’s not hard to see why. Most reflect normal hobby activity. Some symptoms, such as continuing to use games despite negative consequences, probably work. But others are either nothing to worry about, such as losing interest in other hobbies in order to game (which people routinely do for all new hobbies) and using gaming to reduce stress or depression (which is actually good . . . surely we want people to do something to reduce stress). If one uses heroin to reduce stress, clearly this is bad, but it doesn’t follow that using video games or any other hobby to reduce stress is bad. When I give talks on IGD and ask for volunteers with passionate hobbies, I routinely “diagnose” people with a wide variety of addictions by crossing the 5 of 9 threshold swapping out gaming for their hobby of choice. If the DSM-5 approach is to be take seriously, there is a veritable epidemic of individuals addicted to swimming, golf, skiing, field hockey, knitting, martial arts, etc. The IGD symptoms lack specificity.
Is IGD an Independent Disorder?
In psychiatric nosology, it can be difficult to distinguish behaviors which are symptomatic of an underlying mental health issue, such as a mood or anxiety disorder, or which form a distinct clinical syndrome of their own. In the case of IGD, the evidence against its existence as a stand-alone disorder is considerable. It is virtually unheard of for IGD to exist independent of mood, anxiety, ADHD, or autism spectrum disorders. Longitudinal studies find that mental health disorders sometimes lead to IGD, but rarely the inverse, thus establishing temporal order. And IGD symptoms most often remit spontaneously, without treatment, suggesting they are an idiopathic symptom, not a disorder.
Some scholars argue that substance abuse disorders are also often comorbid. However, some cases of substance abuse are observed to exist independently of other disorders or occur first in temporal sequence. Further, substance abuse disorders also demonstrate tolerance and withdrawal, whereas similar sequelae for gaming has not been observed.
Do We Not Care About the Cat Addicts of the World?
IGD and the WHO’s gaming disorder are sometimes defended on clinical grounds, namely that patients exist and need diagnosis for reimbursement. I’ll ignore for the moment that the universal comorbidity of IGD undercuts such an argument, but this also raises the question of why individuals who overdo other behaviors, such as sex, food, exercise, work, religion, shopping, etc. (there are even research papers on dance addiction and arguments for fishing addiction), don’t deserve treatment. Little evidence has emerged that games display any unique characteristics to make them more addictive than these other behaviors.
Usually, claims about games are made by using pseudo-scientific brain-related claims, but such claims can be applied to almost anything. Consider cat addicts (and one should do an internet search for "cat hoarder" if there is any doubt such people exist). Cats have mechanisms to keep people engaged with them, such as running between one’s feet or purring loudly. Stroking a cat surely "releases" dopamine in the brain (if one is to put things in such a simplistic way). And cats work on variable reinforcement schedules . . . sometimes they love us, sometimes they hate us, and we never know when. Do not the cat addicts of the world deserve a DSM diagnosis just as much as the game addicts?
Obviously, we are on the road to 1,001 micro-diagnoses for every possible thing someone somewhere might overdo. That is, unless we admit that the DSM focus on games has little to do with either science or clinical practice. But more on that in a moment.
Is There Consensus?
Some advocates for IGD claim they have reached a consensus on the existence and validity of such a disorder. In the time-honored tradition of morally valanced consensus statements everywhere, such a consensus is reached by simply ignoring the myriad individuals who disagree with the position at hand.
In 2019, myself and colleague John Colwell presented data from a survey of over 200 psychiatrists, psychologists and other scholars who study game effects at the International Convention of Psychological Science in Paris. We found that, far from a consensus, scholars’ views toward pathological gaming were complex, nuanced, and divergent. A majority did believe that some people have something like a pathological gaming problem, although a significant minority were skeptical of the idea altogether. However, neither the IGD nor the WHO’s “gaming disorder” diagnosis were particularly popular. And scholars were split on whether diagnoses like IGD would do more bad than good . . . particularly in pathologizing normal people for their hobby. Overall, results were hardly a ringing endorsement for IGD and certainly not the kind of numbers that would represent a consensus either for or against the existence of pathological gaming.
Ultimately, we must ask ourselves, “Why games?” It’s probably true that a small number of individuals overdo a wide variety of ego-syntonic activities. But there’s little evidence for either the APA or WHO to single out video games. It thus becomes an inescapable conclusion that the focus on games has little to do with science or clinical practice, and more to do with the societal moral panic around games and other technology. Unfortunately, by not learning the historical lesson of everything from Greek plays, to novels, to the radio, to comic books, rock music, Dungeons and Dragons, and Harry Potter, the APA and WHO have fashioned a classic moral panic into a faux diagnosis. In my correspondence with the WHO, the WHO admitted as such with their gaming disorder, noting that political pressure from Asian countries was one factor that led to the push for gaming disorder.
On balance, the data for IGD just aren’t there. We can only hope that the APA carefully watched the scholarly backlash to the WHO’s gaming disorder and don’t make the same mistake and reify technopanic in a book that is meant to be about mental health.
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