ICD-11 Gaming Disorder: Needed and just in time or dangerous and much too early?

In their debate contribution, Aarseth et al. (2016) strongly argue against the proposal of WHO ICD-11 (International Classification of Diseases, 11th revision) to include Gaming Disorder as a new diagnostic category emphasizing the fact that no consensus exists on the definition and the risk that gaming will be demonized and gamers stigmatized resulting in a tsunami of false positive referrals to treatment. In this commentary, it is argued that gaming is indeed just another relatively innocent recreational activity with only a small minority losing control resulting in gaming-related problems. It is also argued that - despite a lack of full consensus on the diagnostic criteria - there are clear indications that Gaming Disorder is a relevant clinical entity worldwide and that official recognition as a mental disorder is urgently needed to facilitate the further development, accessibility, and reimbursement of the treatment.

The Issue

In their open debate paper on the proposal for the introduction of “Gaming Disorder” as a new diagnostic category in WHO ICD-11 (International Classification of Diseases, 11th revision), Aarseth et al. (2016) send a strong message: gaming is a recreational activity just like any other, gamers are just normal people, and intensive gaming should not be medicalized and problem gamers not be stigmatized by a scientifically uninformed psychiatric label. If this would all be true, I would of course agree with the authors of the paper. However, reality is more complex and the answer to the question whether the proposal for a Gaming Disorder is justified should consider some additional aspects.

ICD-11 and Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5)

However, before discussing ICD-11 Gaming Disorder, I want to mention that DSM-5 has introduced a similar diagnostic category under the name “Internet Gaming Disorder” as a “condition for further study,” that is, a tentative definition of a tentative disorder that needs further research before it can be accepted as a valid diagnostic category (American Psychiatric Association [APA], 2013). This tentative disorder is not meant for clinical use. Unfortunately, ICD-11 does not have a special category of tentative disorders and the decision has to be made to either not include a certain problem as a diagnostic category or to present it as a definitive disorder with a fixed set of criteria. This is unfortunate, but that seems to be the reality that WHO has to deal with in finding the most optimal solution.

Gaming: Just Another Risky Behavior

I fully agree with the authors of the debate paper that gaming is indeed just another recreational activity and that there is nothing inherently wrong with it, just as there is nothing wrong with having sex, eating, cannabis use, and moderate drinking. However, just like with these other activities, gaming can become a problem when the person loses control over it and gaming replaces important social, occupational, or other recreational activities leading to clinically significant impairment and distress; that is, when gaming becomes a mental disorder (APA, 2013). This is exactly what the definition of a Gaming Disorder in ICD-11 wants to convey in general terms and with no explicit diagnostic criteria and no explicit cut-off rules (WHO, 2016) [“Gaming disorder is manifested by a persistent or recurrent gaming behaviour characterised by an impaired control over gaming, increasing priority given to gaming over other activities to the extent that gaming takes precedence over other interests and daily activities and continuation of gaming despite the occurrence of negative consequences. The behaviour pattern is of sufficient severity to result in significant impairment in personal, family, social, educational, occupational or other important areas of functioning. These features and the underlying pattern of gaming 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.” (WHO, 2016)]. And just like with drinking or cannabis use, probably only a small minority of gamers develop such problems and just as with drinking and cannabis use, genetic predispositions and personality characteristics play an important role in the change from recreational to obsessive gaming and the development of a Gaming Disorder (Müller, Beutel, Egloff, & Wölfling, 2014; Vink, van Beijsterveldt, Huppertz, Bartels, & Boomsma, 2016).

Treatment Demand

With regard to the prevalence of the Gaming Disorder, the authors of the debate paper are absolutely right: we have no idea about the exact magnitude of the problem, because studies were conducted in different populations, and with different disorder definitions and different assessment instruments and procedures. As a consequence, in general population studies, the prevalence of “gaming problems” ranges between a low of 0.5% and a high of 10% (e.g., Petry, Rehbein, Ko, & O’Brien, 2015). Moreover, very little is known about the long-term course of “gaming problems” and the probability of spontaneous recovery. We know, however, that there is a worldwide treatment demand for “gaming problems” in Asia (e.g., Korea, China, and Japan), in Europe (e.g., Spain, Holland, and UK), and in North America and Australia (e.g., Martín-Fernández et al., 2016). Moreover, although treatment research is still in its infancy, there are studies suggesting that psychological and/or pharmacological treatments might be effective (e.g., King & Delfabbro, 2014; Park, Lee, Sohn, & Han, 2016). However, in many countries, treatment is only reimbursed when it concerns an officially recognized disorder, that is, treatment is only reimbursed for disorders mentioned in the ICD or DSM classification. Therefore, it is important that Gaming Disorder will be included in ICD-11 and that Internet Gaming Disorder has already been recognized as a tentative diagnosis in DSM-5.

Diagnosis: Starting Point for Research

But what about the lack of international and interdisciplinary consensus about the definition of a Gaming Disorder? Indeed, there is no general consensus on the symptoms and cut-off points that are most suitable for the definition of the disorder; a point that is explicitly recognized by the authors of the DSM-5 (APA, 2013). In fact, including Internet Gaming Disorder as a tentative diagnosis is just meant to stimulate research. Of course, there is a risk that the current operationalizations will be reified, and research will be locked into a confirmatory approach. However, history has shown that this is not very likely to occur given the ongoing changes in the classification and definition of mental disorders since they were first presented in the ICD and DSM.

Narrowing the Treatment Gap

Finally, the authors of the debate paper fear that introduction of Gaming Disorder in ICD-11 will create moral panic about video gaming and will lead to stigmatization and a tsunami of false positive referrals to medical treatments. Based on what we know from other risky behaviors (horse riding, moderate alcohol consumption, and cannabis use), this is not very likely to occur. For example, of all alcohol consumers, about 4% has a current alcohol use disorder and of these less than 10% are in treatment. Of the remaining 90% with an alcohol use disorder, the vast majority recovers without professional intervention within a year, whereas some seek professional treatment later, often much later and maybe too late (Tuithof, Ten Have, van den Brink, Vollebergh, & de Graaf, 2016). Something similar will probably happen with gaming and gamers after Gaming Disorder has been recognized as a diagnostic category in ICD-11. Many of our youngsters will still play video games, only some of them will lose control and develop a Gaming Disorder and of those most will recover spontaneously without professional help. Only the few who do not recover spontaneously and develop a chronic Gaming Disorder will eventually seek treatment. I hope that they will find treatment that will be reimbursed. For this very small group of unlucky gamers, it is good that their problem will be recognized as a Gaming Disorder in ICD-11. Let us move from psychometric to clinical research, so we can find out who these Gaming Disorder patients are and how we can best characterize and help them. Meanwhile, we will solve some of the classification issues. For me, the ICD-11 proposal for Gaming Disorder is needed and just in time.