There has been a lot of hype in the media over the last few days due to renewed interest in the concept of a psychiatric disorder involving video games. This has come in response to the WHO releasing details of the beta-draft of the ICD-11 which includes proposed diagnostic criteria for “Gaming Disorder”.
We of the gaming community may be understandably confused and even concerned about this. So we’re here to take you through some information and answer the important questions.
Some Background Information
The paragraphs above might sound pretty intimidating! There are lots of acronyms and fancy medical terminology thrown around that makes all this feel a bit authoritarian and even controlling. If you know the lingo, though, it’s not too bad.
The ICD is the “International Classification of Diseases”. This is basically a handbook which healthcare professionals often use to diagnose people with health problems. It lists all the diagnoses we should use, so that the World Health Organization can compare and contrast data about all health problems around the world. It comes with important classification guidelines which help us diagnose correctly – for example, by telling us what symptoms a person must have to be diagnosed.
We are on the 10th iteration of the ICD, hence ICD-10, and the next version will be the ICD-11. It is being written as we speak! You can keep up to date (if that’s what floats your boat) here.
In psychiatry, there is another manual that exists alongside the ICD. This is called the DSM (Diagnostic and Statistical Manual of Mental Disorders) and it is just about mental health. This is used here in Australia, and also in the USA – in fact it is created by the APA (American Psychiatric Association). There is some debate about which manual is better, but that’s not what we’re here to talk about.
About 4 years ago, the DSM-5 came out. This included the mention of a “condition for further study” – something that the psychiatrists who write the book had noticed would be important soon but that not enough information was available yet. This was Internet Gaming Disorder.
A lot of discussion and research has started because of this exploring the phenomenon. What is an internet gaming disorder? How do we tell if someone has one? And what would we do about it? With all of this talk and the ever increasing role of video games in our society, it was almost inevitable that some sort of gaming related disease would be added to the ICD-11.
What’s The Difference Between Gaming Disorder and Internet Gaming Disorder?
This is a hard question to answer. To someone not familiar with video games, it might seem like…well, not much really.
But to those who understand them, the difference is huge and significant – it’s the word “internet”.
|Gaming Disorder (ICD-11)||Internet Gaming Disorder (DSM-5)|
|New diagnostic guidelines, currently in beta draft, coming 2018
Proposed diagnostic criteria:
Gaming disorder is characterized by a pattern of persistent or recurrent gaming behaviour (‘digital gaming’ or ‘video-gaming’), which may be online (i.e., over the internet) or offline, manifested by:
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.
|Listed as an “area for further study” in DSM-5. Not a “true” diagnosis yet
Proposed diagnostic criteria:
A) Users are involved in repetitive use of video games with other players over the Internet with impairment in lifestyle functioning.
B) Criteria must be met over the past 12 months;
C) Five of the following types of criteria must be present:
So what this means is a person can play the game online or offline and if they still meet the rest of the criteria, they may be diagnosed with a gaming disorder.
Some of the problems that we can see with the DSM version is that it is too similar to the guidelines for a drug or alcohol addiction, and this shows a basic misunderstanding of how video games work on the brain. For example, tolerance (needing more to get the same effect) and withdrawal symptoms don’t have an evidence base with video game play. And point 9 is actually just reiterating the statement in section A.
It’s also important to note that “engagement” is a vague term and actually there is good research to suggest that strong engagement in play isn’t actually a predictor for addiction.
What Is Gaming Disorder?
Even though it looks muddled and confusing, there are a few things that both guidelines agree on. Let’s break them down.
The Main Criteria
There are a few buzz words that appear on both guidelines that mean roughly the same thing. Words like “impaired control” and “compulsive”. What this means is that the player cannot help but play. They may wish to stop playing, reduce play time, or even have tried to quit gaming altogether, but failed, and come back to play.
Both guidelines agree that the player should continue to play despite negative consequences. Now, what might those consequences might be? And who is to state what is “negative” and how negative they need to be before this criterion is met? This is an important distinction that should be made as it may vary from person to person.
Everything in life is a balance, and it’s important to remember that gaming counts too. It was a no-brainer that impairment in function had to be included in any description of gaming disorder. And this really is the deal-breaker.
Function includes the things we really should be doing, as a responsible person, to be safe, secure, healthy and happy. This includes going to work or school, showering and eating well, maintaining friendships and relationships, paying the bills, etc. If gaming has prevented someone from achieving these things, there is an obvious problem. However it is super important to note that you can play games for as many hours as you may please and not be addicted – as long as you are still doing all these things.
Someone, technically, would need to be experiencing the above for at least a year before a diagnosis can be made. This could either be the whole year constantly, or on and off. However, if the symptoms are severe, the ICD-11 would recommend we bring the diagnosis forward so we can get that person the appropriate help. A good example would be someone who has stopped eating and is losing weight, or who has lost their job due to excessive lateness because they were gaming all night.
This is a pretty controversial one, as for some people, gaming really is their main and only hobby (and that’s okay!)
Let’s look at it more broadly, and include interests that are pretty vague and universal, like “parties and social events”, “watching movies” or even just “having dinner with your partner”. This makes the distinction a lot easier to see. If someone is giving up everything else, or things that were previously important for them, in order to play a game, that could definitely indicate something going on.
The Pros and Cons of Diagnosing “Gaming Disorder”
There is no doubt that some people overuse video games, or use them in a way that is toxic and destructive. Those people would benefit from professional help, and this is a way of helping them to get that.
When you introduce something as an official diagnosis, it prompts research, public interest and advances in medicine. What we hope is that the new ICD-11 will encourage more and more people to think about gaming in a balanced way and that new treatments and supports for gaming-related problems will emerge.
In addition it opens up an important conversation. What is it about games that can be addictive? And if there are bad games, are there not-bad games? These sorts of questions will start to validate the work we have been doing at CheckPoint to reduce the stigma against games and introduce more balanced information about the risks and benefits of gaming.
On the other hand, I don’t particularly like the idea of lots of healthcare professionals suddenly feeling empowered to diagnose Gaming Disorder.
Video games are vast and varied, as are their players. Many people (80% in a study we did) feel games improve their mental health and wellbeing. If you are a healthcare professional and you are reading this, I would really implore you to consider these factors in your practice. Could you be doing more harm than good?
1. The Research is Weak
Whilst there are a few studies about gaming addiction, it is a difficult area to study, and so the evidence we have isn’t of a very high quality. There are often small groups involved, and it is impossible to use scientific methods like blinding if the intervention is something as obvious as a video game.
Then there’s the nature of games themselves. I do worry that the researchers rarely understand the vast world of gaming, or the nuances of video games. For example:
- The vast majority of studies have focused on two particular games – World of Warcraft, and Grand Theft Auto. This is in no way representative of the huge variety of video games available.
- Researchers often compare incomparable games without understanding the differences between them – for example, though they are both FPSs with online multiplayer, Call of Duty and Overwatch are completely different experiences.
- There is rarely consideration of game design in outcomes – mechanics and genre are usually the sole focus. This excludes important factors like storytelling, character development, graphic design, and even basic programming – if a game is very buggy it will probably cause more frustration than one which plays smoothly.
2. There Are No Exclusion Criteria
This worries me a lot. Exclusion criteria are ways of making sure you get the right diagnosis – by ensuring you consider things you have to rule out. This means people are at lower risk of getting an incorrect treatment.
The only exclusion listed on the ICD-11 draft is “Hazardous Gaming”. Hazardous Gaming is play which is actually dangerous to health – like the type of gaming that causes death from DVT (deep vein thrombosis).
But what about people who play video games to cope with depression? It could be that the reason they are not functioning – not leaving the house for example – is because of a major depressive disorder, and that meeting friends in game is the only way that person is getting any social input. It may even be a protective factor, preventing the depression from getting any worse.
Then there are those with anxiety, who may use video games to help reduce the symptoms of panic attacks or to tone down the ruminations of a worried mind. Similarly those with social phobia or autistic spectrum disorder may be using the gaming space as a way of making friends.
We must consider whether diagnosing and treating “Gaming Disorder” may put us at risk of missing very important issues that must be addressed.
3. There Is No Guidance on Treatment
It is difficult to see the point in diagnosing an illness when we have no evidence about how to make it better. I do hope that by the time ICD-11 is released we also know how to help these vulnerable people!
And, similarly to point #2, I hope that together we are able to consider the role of other mental health issues in Gaming Disorder treatment, instead of focusing purely on play. It is one thing to state that someone has a video game addiction, but, like all addiction, we must also consider what prompted them to use it in the first place.
4. Games Have Clear Psychological Benefits
There is evidence that moderate amounts of play are better than no play altogether for player wellbeing. When things like this happen in games there tends to be a lot of media hype (as is happening) and fear mongering. Games have been demonised for years as causing violence and aggression – this has been persistently proven to be untrue. Then there has emerged the “addiction” associated with it. It feels like gaming is often a scapegoat for society’s problems.
That is not to say that games can’t be addictive – there is plenty of anecdotal and good quality research evidence to suggest that they definitely can be misused. And for that reason, I do support the move toward understanding gaming addiction better. I just hope we don’t get swept away again with how terrible video games are.
In fact, video games can improve mood, reduce stress and anxiety, reduce depression, improve resilience, emotional regulation, frustration tolerance, and they have benefits for creativity and vitality. Video games have multiple social benefits including improving cohesion and integration. There are even games being developed which can treat anxiety and depression.
Let’s not write video games off completely – they are a valid coping tool when used appropriately. I fear that with these new guidelines, uninformed (but well-wishing) parents and professionals may be at risk of remove this coping tool, causing disruption in children and teenager’s wellbeing and social life.
Balance is key. Gaming can be a valid coping tool, when used together with other skills in your coping toolbox. Make sure you are doing all the things that are needed and expected of you to maintain a healthy, safe and secure lifestyle. Mindfulness is a great tool to become self aware, and you can use it to keep a check on your play.
- How do you feel before and after?
- What are the reasons you play?
- How is it impacting other areas of your life?
If you think you might be overdoing it, don’t be afraid to ask a friend or loved one what they think. You could even go and talk to your GP. We also have some resources listed on our page about Addiction which you can check out.
For Parents and Carers
It is completely normal to have concerns about gaming, and to want to keep an eye on your child’s play. It might feel like everybody has different advice, or that no one really knows what’s going on!
You have your child’s best interests in mind, and that’s the important thing. If you are not sure where to start, you could try to consider the following things:
- Does your child play video games with their friends from school, or siblings? This could be a valid and familiar way for them to socialise – they have never known a world without games or the internet.
- Is gaming balanced with family time, homework, school, household rules and chores? Children’s lives benefit from structure, and gaming should be included in this.
- Are they playing the appropriate games? There are rating scales to guide you, but ultimately it is your decision. Try playing their games first, or watching videos of the game on YouTube.
- Could you use games as a way to bond? There are many family and multiplayer games you could try playing together with your child.
- Talk to your kids! Ask them why they play. What do they get out of it? Do they feel sad when they don’t play? Are they using it to forget about other issues like bullying? Games could be used as a positive or negative coping skill and it is important to teach them how to use it.
- Check out ReachOut Australia’s excellent resources about online gaming (and other internet activities).
And, of course, if you are concerned please do visit your doctor!
Before writing off games completely, consider the many positive benefits they can have. Try looking at our Games For Wellbeing – a series of articles written by people who play and love games, using a combination of personal experience and clinical evidence.
There is an excellent paper published by Dan Johnson of the Young and Well CRC that explores the links between videogames and wellbeing using a structured literature review.
Try to become familiar with the games your patients might play. It could improve the therapeutic alliance, aid in treatment, and help minimise the risk of misdiagnosis.