ArticlePDF Available


We greatly appreciate the care and thought that is evident in the ten commentaries that discuss our debate paper, the majority of which argued in favor of a formalized ICD-11 gaming disorder. We agree that there are some people whose play of video games isrelated to life problems. We believe that understanding this population and the nature and severity of the problems they experience should be a focus area for future research. However, moving from research construct to formal disorder requires a much stronger evidence base than we currently have. The burden of evidence andthe clinical utility should be extremely high because there is a genuine risk of abuse of diagnoses. We provide suggestions about the level of evidence that might be required: transparent and preregistered studies, a better demarcation of the subject areathat includes a rationale for focusing on gaming in particular versus a more general behavioral addictions concept, the exploration of non-addiction approaches, and the unbiased exploration of clinical approaches that treat potentially underlying issues such as depressive mood or social anxiety first. We acknowledge there could be benefits to formalizing gaming disorder, many of which were highlighted by colleagues in their commentaries, but we think they do not yet outweigh the wider societal and public health risks involved. Given the gravity of diagnostic classification and its wider societal impact, we urge our colleagues at the WHO to err on the side of caution for now and postpone the formalization.
A weak scientic basis for gaming disorder: Let us err on the side of caution
Department of Children & Risky Behavior, Trimbos Institute, Utrecht, The Netherlands
Department of Psychology, Stetson University, DeLand, FL, USA
Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
Rehabilitation Sciences Institute, University of Toronto, Toronto, Canada
Institute for Mental Health Policy Research, Centre for Addiction and Mental Health, Toronto, Canada
Center for Computer Games Research, IT University of Copenhagen, Copenhagen, Denmark
Department of Psychology, Framingham State University, Framingham, MA, USA
Department of Sociology, Stockholm University, Stockholm, Sweden
Department of People and Technology, Roskilde University, Roskilde, Denmark
Department of Psychology, Middlesex University, London, UK
Department of Psychology, Université Catholique de Louvain (UCL), Louvain, Belgium
School of medicine, Western Sydney University, Penrith, NSW, Australia
Department of Applied Educational Science, Umeå University, Umeå, Sweden
Department of Criminology, Stockholm University, Stockholm, Sweden
Psychology of Human Technology Interaction Group, Ruhr University Bochum, Bochum, Germany
Department of Psychology, Bath Spa University, Bath, UK
Department of Psychology and Behavioural Sciences, Aarhus University, Aarhus, Denmark
Developmental Psychopathology, Radboud University Nijmegen, Nijmegen, The Netherlands
Department of Media and Communication, ERMeCC, Erasmus University Rotterdam, Rotterdam, The Netherlands
Westerdals Department of Film and Media, Kristiania University College, Oslo, Norway
Department of Psychology, Edge Hill University, Ormskirk, UK
Department of Occupational Science and Occupational Therapy, University of Toronto, Toronto, Canada
Department of Psychiatry, University of Toronto, Toronto, Canada
Department of Educational Psychology, Danish School of Education, Aarhus University, Aarhus, Denmark
Department of Psychology, Villanova University, Villanova, PA, USA
Department of Psychology, University of Oregon, Eugene, OR, USA
Department of Experimental Psychology, University of Oxford, Oxford, UK
Liberos LLC, Los Angeles, CA, USA
Department of Game Design, Uppsala University, Visby, Sweden
Department of Communication, University of Münster, Münster, Germany
Department of Human and Social Sciences, UKE Kore University of Enna, Enna, Italy
Discipline of Psychiatry, University of Sydney, Sydney, Australia
Clinical Psychologist/Neuropsychologist, New York, NY, USA
Department of Communication Sciences, imec-mict-Ghent University, Ghent, Belgium
Oxford Internet Institute, University of Oxford, Oxford, UK
(Received: January 18, 2018; accepted: February 12, 2018)
* Corresponding authors: Antonius J. van Rooij, PhD; Department of Children & Risky Behavior, Trimbos Institute, Da Costakade 45, 3521
VS, Utrecht, The Netherlands; Phone: +31 30 29 59 343; Fax: +31 30 297 11 11; E-mail:; Christopher J. Ferguson, PhD;
Department of Psychology, Stetson University, 421 N. Woodland Blvd., DeLand, FL, USA; Phone: +1 386 822 7288; Email: cjfergus@stetson.
edu; Michelle Colder Carras, PhD; Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway,
Baltimore, MD 21205, USA; Phone: +1 410 955 3910; Email:; Daniel KardefeltWinther, PhD; Department of Clinical
Neuroscience, Karolinska Institutet, Tomtebodavägen 18A, Stockholm 17176, Sweden; Phone: +44 79 46567850; Email: daniel.kardefelt.; Jing Shi,MSc (OT), OT Reg. (Ont.); Rehabilitation Sciences Institute, University of Toronto, 937500 University Ave., Toronto,
ON, Canada; Phone: +1 416 946 8579; Email:; Andrew K. Przybylski, PhD; Oxford Internet Institute, University of
Oxford, 1 St Giles Oxford, Oxford OX1 3JS, UK; Phone: +44 1865 287230; Fax: +44 1865 270708; Email:
This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License,
which permits unrestricted use, distribution, and reproduction in any medium for non-commercial purposes, provided the original author and
source are credited, a link to the CC License is provided, and changes if any are indicated.
© 2018 The Author(s)
DEBATE Journal of Behavioral Addictions
DOI: 10.1556/2006.7.2018.19
We greatly appreciate the care and thought that is evident in the 10 commentaries that discuss our debate paper, the
majority of which argued in favor of a formalized ICD-11 gaming disorder. We agree that there are some people
whose play of video games is related to life problems. We believe that understanding this population and the nature
and severity of the problems they experience should be a focus area for future research. However, moving from
research construct to formal disorder requires a much stronger evidence base than we currently have. The burden of
evidence and the clinical utility should be extremely high, because there is a genuine risk of abuse of diagnoses. We
provide suggestions about the level of evidence that might be required: transparent and preregistered studies, a better
demarcation of the subject area that includes a rationale for focusing on gaming particularly versus a more general
behavioral addictions concept, the exploration of non-addiction approaches, and the unbiased exploration of clinical
approaches that treat potentially underlying issues, such as depressive mood or social anxiety rst. We acknowledge
there could be benets to formalizing gaming disorder, many of which were highlighted by colleagues in their
commentaries, but we think they do not yet outweigh the wider societal and public health risks involved. Given the
gravity of diagnostic classication and its wider societal impact, we urge our colleagues at the WHO to err on the side
of caution for now and postpone the formalization.
Keywords: gaming disorder, International Classication of Diseases-11, World Health Organization, diagnosis,
classication, mental disorders, moral panic
This reply reects the personal opinion of the authors
involved. The content of this paper does not necessarily
reect the ofcial opinion of their respective institutions.
In our debate paper, we argued that formalization of a gaming
disorder in International Classication of Diseases-11
(ICD-11) has potentially problematic medical, scientic,
public health, societal, and rights-based repercussions that
should be considered (Aarseth et al., 2017). The difculty of
identifying the divide between normalbehavior and actual
illness has long been a problem in psychiatry and psychiatric
epidemiology, leading to false-positive diagnoses with
signicant economic and societal consequences (Frances,
2013;Wakeeld, 2015). Thus, caution is warranted. Keeping
this in mind, we maintain that the proposed new disorder
lacks the necessary scientic support and sufcient clinical
utility to justify making the jump from research construct to
recognized diagnostic category. Given that ICD-11 has no
category that would allow it to propose a tentative diagnosis
for further study (Van den Brink, 2017), it seems premature to
advance to full classication.
We acknowledge there could be benets to formalizing
gaming disorder, many of which were highlighted by
colleagues in their commentaries, but we think they do not
yet outweigh the wider societal and public health risks
involved. Ultimately, given the gravity of diagnostic classi-
cation and its wider societal impact (Frances, 2013) and the
low quality of the existing evidence base, we urge our
colleagues at the World Health Organization (WHO) to err
on the side of caution for now and postpone the formalization.
We greatly appreciate the care and thought that is evident in
the commentaries that discuss our debate paper (Billieux,
King, et al., 2017;Grifths, Kuss, Lopez-Fernandez, &
Pontes, 2017;Higuchi et al., 2017;James & Tunney, 2017;
Király & Demetrovics, 2017;Lee, Choo, & Lee, 2017;
Müller & Wöling, 2017;Saunders et al., 2017;Shadloo
et al., 2017;Van den Brink, 2017). The authors of this
response paper agree that there are some people whose play
of video games is related to life problems. We believe that
understanding this population and the nature and severity of
the problems they experience should be one focus area for
future research. But even if patients are simultaneously (A)
intensively playing video games and (B) functionally im-
paired to a clinically signicant level, the question remains
whether A causes B and whether there is benetfrom
formalizing a disorder based on this assumption.
The authors of the current response are not opposed to the
creation of new research constructs that cover both exces-
sive forms of behavior and functional impairment (Billieux,
Blaszczynski, et al., 2017;Billieux, Van Rooij, et al., 2017;
Kardefelt-Winther et al., 2017). However, moving from
research construct to formal disorder requires a much
stronger evidence base than we currently have. As has been
extensively debated in the context of psychiatric classica-
tion systems, both the scientic object of study and the
practical utility of the disorder should be clearly and
unambiguously established before formalizing new disor-
ders in disease classication systems (Frances, 2013;
Pingani et al., 2014;Wakeeld, 2015). The burden of
evidence and the clinical utility should be extremely high,
because there is a risk of abuse of diagnoses both within and
beyond the clinical context, as we argued in our original
paper (Aarseth et al., 2017). From our perspective, this
utility has not been sufciently demonstrated at this point
and the scientic evidence base is not yet sufciently clear
to address fundamental ambiguities that are still in play.
To illustrate the latter point about a lack of clarity in the
evidence base, we point to the fact that authors are still found
to be discussing the inherent properties of the proposed
disorder within the 10 commentaries. Much confusion
remains even among authors supporting the diagnosis
regarding what, exactly, the gaming disorder is. Would a
gaming disorder relate only to gambling oriented games or
Journal of Behavioral Addictions
van Rooij et al.
to video games more generally (James & Tunney, 2017)? Is
the problem behavior caused by other underlying mental
disorders (Billieux, King, et al., 2017), or is it a consequence
of alluring game mechanics (James & Tunney, 2017)? Are
we diagnosing people who play online games or ofine
games, or both (Király & Demetrovics, 2017)? And is
gaming disorder just a subcategory of a broader Internet
addiction disorder or perhaps just one of many behavioral
addictions (Higuchi et al., 2017)? What, exactly, are the
symptoms of gaming disorder? Or are we to presume that
clinicians will know it when they see it? As of this writing,
the WHO appears to have proposed four separate categories
for gaming disorders, all of which appear to differ from the
fth edition of the Diagnostic and Statistical Manual of
Mental Disorders (DSM-5)s Internet gaming disorder
(IGD) (WHO, 2017a,2017b,2017c,2017d). This suggests
us considerable confusion in the eld regarding what gam-
ing disorder is. In our view, too many critical questions
remain unanswered to support formalizing the disorder.
With regard to the clinical utility, it remains unclear
what the clinical advantages are of a gaming disorder
label. Clinicians need to be aware of intensive leisure time
behaviors such as gaming and their (positive or negative)
interplay with disorders (Müller, Beutel, & Wöling, 2014;
Van Rooij, Schoenmakers, & van de Mheen, 2017), but the
question is whether a new diagnostic category will lead to
improved treatment for patients. Arguments are made that it
is nancially practical to have a diagnosis, which may very
well be true, but if this is all that is required to formalize a
disorder, then we could make the same argument about
almost every societal issue. The associated risks of stigma-
tization and diagnostic ination should be considered as
Some of the commentaries addressed the issue of
whether gaming disorder is truly a unique stand-alone
disorder or merely symptomatic of other primary causes.
Many existing diagnoses occur together and, in fact, this
has sparked extensive debate about the generally over-
lapping nature of mental health diagnoses (Fried et al.,
2017). However, the issue is not whether gaming disorder
overlaps with other diagnoses, but whether it reects a
patients response to those disorders. Specically, is what
we call gaming disordermerely a coping strategy for
those with depression, attention-decit/hyperactivity dis-
order, or other disorders?
If gaming is a coping behavior in some cases (Kardefelt-
Winther, 2016), it would make more sense to explore the
underlying causes for this behavior rst and be sensitive to
the extent to which treating these rst-order challenges
might resolve gaming problems. This is a concrete research
question that could be operationalized by clinicians who are
actively working in this eld. If existing approaches are
clinically sufcient, we must ask ourselves: Do we need a
new gaming-specic disorder category? This should be
properly established before a disorder is formalized. Re-
cently, some high-quality, preregistered studies have iso-
lated gaming disorder symptoms and failed to nd that they,
in and of themselves, directly link to health over time
(e.g., Przybylski, Weinstein, & Murayama, 2017), which
further questions the value and accuracy of formalizing
gaming disorder as a stand-alone disorder.
Multiple clinicians and researchers also argue, through
the commentaries, that the proposed disorder will be useful
to stimulate research and treatment (e.g., Higuchi et al.,
2017). While ambiguities are indeed conrmed and pro-
blems with evidence are acknowledged (Shadloo et al.,
2017), it is argued by multiple authors that the disorder
will be the start of a process that results in a better
disorder classication. It may indeed be possible that the
formalization of a disorder will generate the momentum
needed to study patients instead of healthy high-school/
college students or non-representative online samples
recruited from Internet gaming forums, as is currently the
case in much of the literature (Van den Brink, 2017).
However, similar expectations were voiced when the
DSM-5 included IGD as a proposed category for further
study (Petry & OBrien, 2013), but we have not seen any
improvements with respect to more patient-centric research
or a stronger evidence base. As some have argued, includ-
ing Internet gaming disorder in the DSM-5 might have
been more harmful than helpful (Billieux, Schimmenti,
Khazaal, Maurage, & Heeren, 2015). It seems to have
locked the research eldintoaconrmatory approach
aiming to prove the existence, utility, and psychometric
properties of the IGD criteria in various populations, rather
than dealing with some of the more fundamental questions
about the nature of problematic gaming raised in the
commentaries, as well as this response paper. Findings
from conrmatory studies are irrelevant if we have not
established the scientic object of study and have some
condence in the accuracy and utility of the criteria that
cover essential components. Such exploratory work was
unfortunately marginalized in the wake of the DSM-5s
IGD proposal and this may continue if gaming disorder is
included in ICD-11.
With respect to the claim that a formal diagnosis is
necessary because it justies treatment administered to those
gamers who seek it: this line of reasoning assumes that there
has to be a diagnosis for every therapeutic modality, which
is clearly not the case. For example, people who consult
family therapists do not do so because they suffer from a
family disorder,but because they need professional help
to deal with a perceived problem. Individuals who seek
professional help for their gaming could receive such help
without their gaming habits being converted into a psychi-
atric diagnosis. If there is a sufcient number of such
individuals, clinics and specialized services would be estab-
lished and would grow. This is analogous to services for
other mental health problems, which are not tied to a
particular diagnosis, such as services for sexual assault
victims or bereavement.
Furthermore, formalizing a disorder with the intention to
improve research quality neglects the wider non-clinical
societal context. Formalization serves the immediate goals
of some of the stakeholders, but not all. For example,
clinicians obtain diagnostic clarity and opportunities for
insurance coverage for their patients and researchers obtain
opportunities to secure research funding. Unfortunately, the
possibly negative societal consequences fall to the general
population of individuals who play video games. Hundreds of
millions of people spend billions of hours each week playing
games (Brown, 2017;Lanxon, 2017;McGonigal, 2011).
Journal of Behavioral Addictions
Weak basis for gaming disorder
A move to pathologize gaming could have important rami-
cations for the potentially stigmatized or misdiagnosed
healthy highly engagedgamers, a group that has
been identied (in representative samples that postulated
its existence) as comprising between 1.1% and 10.9% of the
gaming population (Colder Carras, Van Rooij, et al., 2017;
Colder Carras & Kardefelt-Winther, 2018;Van Rooij,
Schoenmakers, Vermulst, Van den Eijnden, & van de
Mheen, 2011;Wittek et al., 2016). This is a group that
may strongly resemble problematic cases in the current
diagnostic approaches, such as the WHO and DSM-5 frame-
works, but that does not seem to experience signicant life
impairment as a consequence of their gaming (Deleuze
et al., 2017;Snodgrass et al., 2014,2018). While some
commentaries argued that a diagnosis would only apply to
clinical cases and not be applicable to regular healthy
gamers (Müller & Wöling, 2017;Shadloo et al., 2017),
we nd this view to be rather optimistic and not in tune with
todays media climate. The continuous ow of awed and
exaggerated media reporting around the assumed harms of
gaming should serve as a reminder that whatever we may
propose in a clinical setting tends to reach far beyond the
setting for which it was originally meant (e.g., Kardaras,
2016). The inuence of a gaming disorder diagnosis on
wider society and its impact on parents and children every-
where is not something we can afford to ignore in our work.
We will now provide some further arguments as to why it is
necessary to err on the side of caution and limit the
conceptualization of gaming disorder”–or preferably
wider behavioral addiction disorders to the research
context. We remain opposed to enshrining gaming disorder
in diagnostic classication manuals that are widely used and
consulted in policy settings, school systems, and healthcare.
They are used by individuals who might not be knowledge-
able about the nuances of media use, moral panic, and
normative game-related behavior (including parents of
Robust scientic standards are not (yet) employed
In recent years, major concerns have been raised about the
empirical foundations of psychological science in general
(Schimmack, 2012) and the study of technology in particu-
lar (Elson & Przybylski, 2017), in addition to concerns
about psychiatric epidemiology discussed above. We rmly
believe the reproducibility crisis (Cybulski, Mayo-Wilson,
& Grant, 2016) in the clinical (Nosek, Spies, & Motyl,
2012) and psychological (Open Science Collaboration,
2015) sciences have direct implications for the study of
and debates surrounding gaming disorder. Standards exist
for reporting and evaluating evidence for both clinical and
observational studies (McLeroy, Garney, Mayo-Wilson, &
Grant, 2016), and the use of these standards is rare in
gaming disorder literature (as elsewhere). For example,
even the most detailed and comprehensive recent review
of IGD (Mihara & Higuchi, 2017) does not include a
discussion or formal assessment of bias or limitations of
the reviewed studies or the systematic review itself, which is
not consistent with guidelines for systematic reviews of
epidemiological literature (Stroup et al., 2000). In contrast to
our stance, these important meta-scientic concerns were
not apparent in the commentaries, many of which referenced
the exact studies whose low-quality evidence motivated us
to write the original debate paper. In our view, those studies
suffer from a lack of scientic transparency and/or poor
methodological choices that undermine our condence in
the ndings. Much of the literature that seems to reect a
conrmation bias toward proving gaming disorder exists
rather than treating the concept with appropriate scientic
skepticism and curiosity. The inconsistencies in the litera-
ture have been commented elsewhere (e.g., Grifths et al.,
2016;Mihara & Higuchi, 2017;Quandt, 2017). To reiterate
three key points:
First, basic reporting standards need to be improved,
because the provision of data under analysis is not always
clear. For example, several commentaries referred to sepa-
rate publications that arose from a single data set of school-
children in Singapore (Gentile et al., 2011). Subsamples
from this single data set have been used in upward of 19
publications, without proper cross-attribution (Przybylski &
Wang, 2016). This practice, colloquially known as salami
slicing(Chambers, 2017), presents a challenge from a
publication ethics perspective (Šupak Smolčc, 2013),
inates the number of independent investigations one might
conclude have been done on a topic, and thwarts efforts to
systematically review outcomes from what is ultimately a
single study (Mayo-Wilson et al., 2017). In some cases, it
appears that identical constructs from the Singapore data
set are conceptualized and assessed differently across
publications (Ferguson, 2015).
Second, data transparency is generally low (Elson &
Przybylski, 2017;Wicherts, Borsboom, Kats, & Molenaar,
2006). As far as we are aware, only three of the dozens of
publications in the gaming disorder literature openly share
their data and materials (Przybylski, 2016;Przybylski et al.,
2017;Weinstein, Przybylski, & Murayama, 2017). The fact
that so few data sets are publicly available is problematic,
because it raises the concern that errors in these data sets will
go undetected (King, Haagsma, Delfabbro, Gradisar, &
Grifths, 2013). The inaccessibility of raw data prevents
researchers and reviewers from being able to directly inter-
rogate work and precludes the scientic community at large
from building upon the investments, researchers and tax-
payers have already made to study gaming disorder (Morey
et al., 2016). Third, although most of the studies in the
literature are presented as providing conrmatory tests of
research questions, we cannot rule out the possibility that
these are in fact post hoc analyses and interpretations,
because the sampling and analysis plans were not registered
prior to data collection (Wagenmakers, Wetzels, Borsboom,
van der Maas, & Kievit, 2012). This practice, known as
Hypothesizing After the Results are Known, is thought to
be widespread in psychology (Gelman & Loken, 2013) and
increases the likelihood of false-positive ndings (i.e., type
1 error). Until researchers responsibly distinguish between
exploratory (i.e., theory-building) and preregistered conr-
matory (i.e., theory-testing) analysis, much of the present
Journal of Behavioral Addictions
van Rooij et al.
research ndings must be understood as tentative and thus
inappropriate for creating diagnoses that will inuence lives,
health systems, and policies (Chambers, 2017;Munafò
et al., 2017). Furthermore, researchers carefully need to
select appropriate data sources for preregistered conrmato-
ry analysis, including both the choice of cross-sectional or
longitudinal data collection and the choice of population. We
cannot rely on ndings from cross-sectional research con-
ducted with largely healthy populations which arguably
constitutes most research on this topic when undertaking
such a critical activity as formalizing a new disorder (Van
Rooij & Kardefelt-Winther, 2017).
As mentioned previously, the onus to demonstrate that
the evidence base is of sufciently high quality to underpin a
formal diagnosis is on those who advocate for formal
classication. Given the problems listed in this section, we
maintain that the quality of the existing evidence base is
low. We ask those who wish to formalize gaming disorder in
ICD-11 to demonstrate otherwise, as a high-quality evi-
dence base needs to precede a formal disorder classication.
The argument for singling out video games is not convincing
A behavioral addiction denition focused purely on video
games is on its face arbitrary. A convincing rationale for
focusing on gaming, rather than the myriad of other activi-
ties one might overdo, is lacking. We acknowledge that
some individuals may overdo gaming, just as they may
overdo social media, work, or sex, or tan to excess or,
indeed, dance. A brief subject search on PsychINFO using
the terms video game addictionor videogame addiction
or gaming addictionand similar terms for other behavioral
issues, such as food (e.g., food addictionor eating
addiction), exercise, work (work addictionor occupa-
tional addiction), plastic surgery, etc., reveal that other
behaviors have also received considerable scientic atten-
tion. The results are presented in Table 1.
Yet, only gaming disorder has been proposed for ICD-11
inclusion, with no formal or transparent review of the
evidence quality for any of the various addictions. We
suggest that a general behavioral addiction category might
be more initially defensible, both theoretically and in terms
of clinical utility, than a myriad of specic behavioral
addictions. Of course, such a broader disorder suffers from
the same risks of abuse as a narrower one: the discussed
robust scientic standards should be employed.
Moral panic might be inuencing formalization and might
increase due to it
Many of the commentaries sought to ease our concerns
about moral panic by assuring us that a gaming disorder
diagnosis would reduce moral panic. However, a historical
analysis of moral panics nds that they usually work in the
inverse direction ofcial reication promotes the panic,
not eases it (Bowman, 2016;Ferguson, 2013). These can
result in poorly thought out and ineffectual public policy
efforts to restrict gaming time, such as South Koreas
shutdownlaw (which blocked online playing for children
between 12 and 6 a.m.). While such solutionsmay lead
parents, clinicians, and society to feel that something is
being done to address the perceived problem of excessive
gaming, in fact, this intervention has had a negligible
positive effect and even some negative outcomes (Lee, Kim,
& Hong, 2017). Moreover, as the United Nations Childrens
Fund stated in their recent report Children in a Digital
World:applying clinical concepts to childrens everyday
behaviour does not help support them in developing healthy
screen time habits.(UNICEF, 2017, p. 115)
Given that we have already seen a proliferation of both
dubious treatment centers and authoritarian regulations of
speech and content in the name of gaming addiction, we
believe the course of events is predictable. The commentar-
ies on our original paper have given us no reason for
optimism, given how readily some authors equated gaming
disorder with substance abuse (Müller & Wöling, 2017), a
comparison we consider misleading to the public and lack-
ing in sound evidence (Kardefelt-Winther et al., 2017). We
are also concerned that the formalization of gaming disorder
might be a product of moral panic (Bean, Nielsen, Van
Rooij, & Ferguson, 2017). We understand that certain
countries face pressure to formalize gaming disorder as a
response to perceived excessive gaming, but this does not
reect the situation in all participating countries that use the
ICD. For countries where excessive gaming is perceived to
be a problem, it may be more appropriate to seek solutions
on a domestic level. This would enable cultural and context-
specic considerations to be made that the ICD, although
somewhat exible, cannot easily accommodate.
To conclude, we would like to address a question raised by
Grifths et al. (2017) as a point of criticism to our call for
more clinical samples in research: How can there be
clinical samples in relation to a mental disorder that should
not exist in the rst place?The answer is, of course, that
prior to enshrining gaming disorder as a diagnosis, its
clinical utility must be demonstrated in high-quality, trans-
parent research with patients. If no patients are found, this
would suggest that we do not need the formal disorder
category. However, even if we nd patients to study,
patients themselves (or their parents) can also be inuenced
by moral panic and may come to believe they suffer from a
Table 1. Literature citations in PsychINFO for various
Proposed addiction Number of found articles
Food addiction 229
Video game addiction 149
Sex addiction 117
Gambling addiction 71
Work addiction 65
Exercise addiction 55
Shopping addiction 19
Tanning addiction 6
Dance addiction 2
Journal of Behavioral Addictions
Weak basis for gaming disorder
disorder due to news coverage. A highly publicized disor-
dermay offer a simplied explanation for problems that, in
fact, have a deeper meaning. There is no easy solution to this
challenge, but it is clear that clinicians need to be critical
evaluators of underlying disease processes. Unfortunately,
clinicians too can be inuenced by moral panic and, as the
saying goes, If the only tool you have is a hammer,
everything begins to look like a nail.Those who eventually
conduct research with patients need to nd ways to distin-
guish gaming patterns with signicant negative long-term
health effects from coping behaviors or temporary excessive
gaming behavior without any serious long-term harm.
Grifths et al. (2017) also ask, How can such playing of
video games be problematic, yet not be disordered?This is
a logical fallacy, in that the premise of the answer is implied
in the question. Many issues are problems without being
disorders. Experiencing stress due to work demands is a
problem, yet not a disorder. Experiencing body dissatisfac-
tion due to perceived competition with peers over mates can
be regarded as a problem, yet not a disorder. This is because
many problem behaviors are normative reactions to difcult
circumstances. Relegating an excessive, by societal norms,
behavior to the realm of the pathological has come under
heavy criticism recently, e.g., in the removal of the bereave-
ment exclusion for major depressive disorder in DSM-5
(Frances, 2013;Regier, Kuhl, & Kupfer, 2013;Wakeeld,
As indicated above, some people may excessively play as
a method of coping with other mental health issues. For
others, gaming could be a way to avoid unpleasant activities
such as work or school as part of an existential crisis about
the direction of ones life. Much like individuals who have
lost a loved one may experience extreme mental states
similar to major depressive disorder for an extended period;
people who play video games may exhibit extreme behaviors
in reaction to a stressor. The issues can be quite complicated.
If we equate coping or responding to problems with a mental
disorder, this will further expand the elastic boundaries of
psychiatric diagnosis (Frances, 2013). They might stretch to
the point of meaninglessness, potentially resulting in a
dismissive view of behavioral addiction research (Billieux
et al., 2015;Kardefelt-Winther et al., 2017).
We join other researchers in psychiatry, psychiatric epi-
demiology, and the social sciences who propose that a
clinical disorder should rest on the foundation of rigorous,
transparent, and standardized methods. This requires ac-
knowledging the reality that all studies are not created equal.
Empirical evidence derived from gold standard research
featuring standards, such as formal assessment of multiple
sources of bias, preregistration, open data, open materials,
open analytic code, and comprehensive reporting of conicts
of interest, is fundamentally more valuable than the closed
source and non-transparent work, which characterizes most
of the current literature on gaming disorder. Conrmatory
(i.e., hypothesis testing) data analysis plans must be publicly
preregistered in advance of data collection and these must be
distinguished from exploratory (i.e., hypothesis generating)
ndings to facilitate the generation of high-quality evidence.
Such evidence must then be synthesized using appropriate
standards to determine consistency and strengths of effects as
well as sources of bias in a way that can inform policy-
making (Liberati et al., 2009;Stroup et al., 2000). This level
of evidence is not yet reached in gaming disorder research.
Risk of abuse of a formalized new disorder that solely
involves the behavior of playing video games a stigma-
tized entertainment activity can only expand the false-
positive issues in psychiatry. This expansion will likely have
a psychological and societal cost, potential harming the
well-being of our children. We understand the arguments
for wanting a clinical disorder, but maintain that the clinical
utility of the proposed diagnosis is still unclear and the
evidence base is not yet good enough. In short, we believe
this debate is worthwhile and that a case might be made for
diagnostic formalization in the future, but currently it is
How to move forward: Beyond the echo chamber
We agree with Kuss, Grifths, and Pontes (2017) on the
importance of including multiple stakeholders in the process
of formalizing a potential disorder, including not just aca-
demics, but gamers, industry executives, therapists, and
others. We suggest that the WHO solicit input and feedback
from a wider variety of stakeholders, including individuals
who currently seek help or who have sought help for
gaming-related problems and their family members/carers,
as recommended for the development of mental disorder
classications in general (Pingani et al., 2014;Stein &
Phillips, 2013). Children in particular should be included
in this process as one of the primary stakeholder groups
playing games regularly. According to the United Nations
Convention on the Rights of the Child, children have a
fundamental right to have their voices heard in matters that
concern them: formalizing a disorder classication that
involves one of childrens most popular everyday behaviors
certainly concerns them.
Involving the aforementioned groups in the decision-
making process will lead to a more holistic and accurate
view of the diversity of video gaming. Stakeholder engage-
ment has proven to be a fruitful endeavor in participatory
mixed-methods research conducted with gamers (Colder
Carras, Porter, et al., 2017). Indeed, we would take this a
step further and encourage such stakeholders to participate in
the peer review of studies before they are conducted by
following the Registered Reports methodology (
rr/). In this approach, multiple stakeholders must agree on the
value of the study hypotheses, methods, and sampling plans,
so that the ndings of any given study are not subjected to
control by any interested party. Finally, we suggest that the
WHO working group conducts or commissions a critical
review of the existing literature following the highest stan-
dards for evidence evaluation with an eye toward the Open
Science principles mentioned in this paper.
We remain optimistic for the future. Some preregistered
and methodologically rigorous papers have recently been
published in this eld (e.g., Weinstein et al., 2017) and
valuable qualitative work is starting to appear more widely,
challenging the disorder model in some cases (Snodgrass
et al., 2017,2018). In the meantime, we would strongly
encourage the WHO to err on the side of caution, halt further
formalization of new gaming disorders, and stimulate better
research into the role that screen time plays in our lives.
Journal of Behavioral Addictions
van Rooij et al.
Funding sources: MCCs contribution to this research was
supported by the National Institute of Mental Health Train-
ing grant 5T32MH014592-39.
Authorscontribution: AJVR, CJF, MCC, DK-W, JS, and
AKP were directly involved in writing the paper. The
remaining authors intellectually support the content of the
debate paper.
Conict of interest: No conicts of interest were reported by
any author.
Aarseth, E., Bean, A. M., Boonen, H., Colder Carras, M., Coulson,
M., Das, D., Deleuze, J., Dunkels, E., Edman, J., Ferguson,
C. J., Haagsma, M. C., Helmersson Bergmark, K., Hussain, Z.,
Jansz, J., Kardefelt-Winther, D., Kutner, L., Markey, P.,
Nielsen, R. K. L., Prause, N., Przybylski, A., Quandt, T.,
Schimmenti, A., Starcevic, V., Stutman, G., Van Looy, J.,
& Van Rooij, A. J. (2017). Scholarsopen debate paper on the
World Health Organization ICD-11 gaming disorder proposal.
Journal of Behavioral Addictions, 6(3), 267270. doi:10.1556/
Bean, A. M., Nielsen, R. K. L., Van Rooij, A. J., & Ferguson, C. J.
(2017). Video game addiction: The push to pathologize video
games. Professional Psychology: Research and Practice,
48(5), 378389. doi:10.1037/pro0000150
Billieux, J., Blaszczynski, A., Colder Carras, M., Edman, J.,
Heeren, A., Kardefelt-Winther, D., Khazaal, Y., Thege,
B. K., Maurage, P., Schimment, A., & Van Rooij, A. J.
(2017). Behavioral addiction: Open denition development.
Open Science Framework. doi:10.17605/OSF.IO/Q2VVA
Billieux, J., King, D. L., Higuchi, S., Achab, S., Bowden-Jones, H.,
Hao, W., Long, J., Lee, H. K., Potenza, M. N., Saunders, J. B., &
Poznyak, V. (2017). Functional impairment matters in the
screening and diagnosis of gaming disorder. Journal of Behav-
ioral Addictions, 6(3), 285289. doi:10.1556/2006.6.2017.036
Billieux, J., Schimmenti, A., Khazaal, Y., Maurage, P., & Heeren,
A. (2015). Are we overpathologizing everyday life? A tenable
blueprint for behavioral addiction research. Journal of Behav-
ioral Addictions, 4(3), 119123. doi:10.1556/2006.4.2015.009
Billieux, J., Van Rooij, A. J., Heeren, A., Schimmenti, A.,
Maurage, P., Edman, J., Blaszczynski, A., Khazaal, Y., &
Kardefelt-Winther, D. (2017). Behavioural Addiction Open
Denition 2.0 Using the Open Science Framework for
collaborative and transparent theoretical development. Addic-
tion, 112(10), 17231724. doi:10.1111/add.13938
Bowman, N. D. (2016). The rise (and renement) of moral panic.
In R. Kowert & T. Quandt (Eds.), The video game debate:
Unraveling the physical; social; and psychological effects of
digital games (pp. 2238). New York, NY: Routledge.
Brown, A. (2017). Younger men play video games, but so do a
diverse group of other Americans. Retrieved September 11,
2017, from
Chambers, C. (2017). The seven deadly sins of psychology a
manifesto for reforming the culture of scientic practice.
Princeton, NJ: Princeton University Press.
Colder Carras, M., & Kardefelt-Winther, D. (2018). When addic-
tion symptoms and life problems diverge: A latent class
analysis of problematic gaming in a representative multina-
tional sample of European adolescents. European Child &
Adolescent Psychiatry. Advance online publication. doi:10.
Colder Carras, M., Porter, A. M., Van Rooij, A. J., King, D.,
Lange, A., Carras, M., & Labrique, A. (2017). Gamers
insights into the phenomenology of normal gaming and game
addiction: A mixed methods study. Computers in Human
Behavior, 79, 238246. doi:10.1016/j.chb.2017.10.029
Colder Carras, M., Van Rooij, A. J., Van de Mheen, D., Musci, R.,
Xue, Q.-L., & Mendelson, T. (2017). Video gaming in a
hyperconnected world: A cross-sectional study of heavy gam-
ing, problematic gaming symptoms, and online socializing in
adolescents. Computers in Human Behavior, 68, 472479.
Cybulski, L., Mayo-Wilson, E., & Grant, S. (2016). Improving
transparency and reproducibility through registration: The
status of intervention trials published in clinical psychology
journals. Journal of Consulting and Clinical Psychology,
84(9), 753767. doi:10.1037/ccp0000115
Deleuze, J., Nuyens, F., Rochat, L., Rothen, S., Maurage, P., &
Billieux, J. (2017). Established risk factors for addiction fail to
discriminate between healthy gamers and gamers endorsing
DSM-5. Journal of Behavioral Addictions, 6(4), 516524.
Elson, M., & Przybylski, A. K. (2017). The science of technology
and human behavior. Journal of Media Psychology, 29(1), 17.
Ferguson, C. J. (2013). Violent video games and the Supreme
Court: Lessons for the scientic community in the wake of
Brown v. Entertainment Merchants Association. American
Psychologist, 68(2), 5774. doi:10.1037/a0030597
Ferguson, C. J. (2015). Pay no attention to that data behind the
curtain: On angry birds, happy children, scholarly squabbles,
publication bias, and why betas rule metas. Perspectives on
Psychological Science, 10(5), 683691. doi:10.1177/174569
Frances, A. (2013). The past, present and future of psychiatric
diagnosis. World Psychiatry, 12(2), 111112. doi:10.1002/
Fried, E. I., van Borkulo, C. D., Cramer, A. O. J., Boschloo, L.,
Schoevers, R. A., & Borsboom, D. (2017). Mental disorders as
networks of problems: A review of recent insights. Social
Psychiatry and Psychiatric Epidemiology, 52(1), 110.
Gelman, A., & Loken, E. (2013). The garden of forking paths: Why
multiple comparisons can be a problem, even when there is no
shing expeditionor p-hackingand the research hypoth-
esis was posited ahead of time. Retrieved from http://www.stat.
Gentile, D. A., Choo, H., Liau, A., Sim, T., Li, D., Fung, D., &
Khoo, A. (2011). Pathological video game use among youths:
A two-year longitudinal study. Pediatrics, 127(2), e319e329.
Grifths, M. D., Kuss, D. J., Lopez-Fernandez, O., & Pontes,
H. M. (2017). Problematic gaming exists and is an example of
Journal of Behavioral Addictions
Weak basis for gaming disorder
disordered gaming. Journal of Behavioral Addictions, 6(3),
296301. doi:10.1556/2006.6.2017.037
Grifths, M. D., Van Rooij, A. J., Kardefelt-Winther, D., Starcevic,
V., Király, O., Pallesen, S., Müller, K., Dreier, M., Carras, M.,
Prause, N., King, D. L., Aboujaoude, E., Kuss, D. J., Pontes,
H. M., Lopez Fernandez, O., Nagygyorgy, K., Achab, S.,
Billieux, J., Quandt, T., Carbonell, X., Ferguson, C. J., Hoff,
R. A., Derevensky, J., Haagsma, M. C., Delfabbro, P.,
Coulson, M., Hussain, Z., & Demetrovics, Z. (2016). Working
towards an international consensus on criteria for assessing
Internet gaming disorder: A critical commentary on Petry et al.
(2014). Addiction, 111(1), 167175. doi:10.1111/add.13057
Higuchi, S., Nakayama, H., Mihara, S., Maezono, M., Kitayuguchi,
T., & Hashimoto, T. (2017). Inclusion of gaming disorder
criteria in ICD-11: A clinical perspective in favor. Journal of
Behavioral Addictions, 6(3), 293295. doi:10.1556/2006.6.
James, R. J. E., & Tunney, R. J. (2017). The relationship between
gaming disorder and addiction requires a behavioral analysis.
Journal of Behavioral Addictions, 6(3), 306309. doi:10.1556/
Kardaras, N. (2016). Itsdigital heroin: How screens turn kids
into psychotic junkies. Retrieved August 27, 2016, from https://
Kardefelt-Winther, D. (2016). Conceptualizing Internet use dis-
orders: Addiction or coping process? Psychiatry and Clinical
Neurosciences, 71(7), 459466. doi:10.1111/pcn.12413
Kardefelt-Winther, D., Heeren, A., Schimmenti, A., Van Rooij,
A. J., Maurage, P., Colder Carras, M., Edman, J., Blaszczynski,
A., Khazaal, Y., & Billieux, J. (2017). How can we conceptu-
alize behavioural addiction without pathologizing common
behaviours? Addiction, 112(10), 17091715. doi:10.1111/
King, D. L., Haagsma, M. C., Delfabbro, P. H., Gradisar, M., &
Grifths, M. D. (2013). Toward a consensus denition of
pathological video-gaming: A systematic review of psycho-
metric assessment tools. Clinical Psychology Review, 33(3),
331342. doi:10.1016/j.cpr.2013.01.002
Király, O., & Demetrovics, Z. (2017). Inclusion of gaming disorder
in ICD has more advantages than disadvantages. Journal
of Behavioral Addictions, 6(3), 115. doi:10.1556/2006.6.
Kuss, D. J., Grifths, M. D., & Pontes, H. M. (2017). Chaos and
confusion in DSM-5 diagnosis of Internet gaming disorder:
Issues, concerns, and recommendations for clarity in the eld.
Journal of Behavioral Addictions, 6(2), 103109. doi:10.1556/
Lanxon, N. (2017). China Just Became the Games Industry Capital
of the World. Retrieved June 1, 2017, from https://www.
Lee, C., Kim, H., & Hong, A. (2017). Ex-post evaluation of
illegalizing juvenile online game after midnight: A case of
shutdown policy in South Korea. Telematics and Informatics,
34(8), 15971606. doi:10.1016/j.tele.2017.07.006
Lee, S.-Y., Choo, H., & Lee, H. K. (2017). Balancing between
prejudice and fact for gaming disorder: Does the existence of
alcohol use disorder stigmatize healthy drinkers or impede
scientic research? Journal of Behavioral Addictions, 6(3),
302305. doi:10.1556/2006.6.2017.047
Liberati, A., Altman, D. G., Tetzlaff, J., Mulrow, C., Gøtzsche,
P. C., Ioannidis, J. P. A., Clarke, M., Devereaux, P. J.,
Kleijnen, J., & Moher, D. (2009). The PRISMA statement for
reporting systematic reviews and meta-analyses of studies that
evaluate health care interventions: Explanation and elabora-
tion. PLoS Medicine, 6(7), 128. doi:10.1371/journal.pmed.
Mayo-Wilson, E., Li, T., Fusco, N., Bertizzolo, L., Canner, J. K.,
Cowley, T., Doshi, P., Ehmsen, J., Gresham, G., Guo, N.,
Haythornthwaite, J. A., Heyward, J., Hong, H., Pham, D.,
Payne, J. L., Rosman, L., Stuart, E. A., Suarez-Cuervo, C.,
Tolbert, E., Twose, C., Vedula, S., & Dickersin, K. (2017).
Cherry-picking by trialists and meta-analysts can drive con-
clusions about intervention efcacy. Journal of Clinical Epi-
demiology, 91, 95110. doi:10.1016/j.jclinepi.2017.07.014
McGonigal, J. (2011). Reality is broken: Why games make us
better and how they can change the world. New York, NY:
Penguin Books.
McLeroy, K. R., Garney, W., Mayo-Wilson, E., & Grant, S.
(2016). Scientic reporting. Health Education & Behavior,
43(5), 501508. doi:10.1177/1090198116668522
Mihara, S., & Higuchi, S. (2017). Cross-sectional and longitudinal
epidemiological studies of Internet gaming disorder: A sys-
tematic review of the literature. Psychiatry and Clinical Neu-
rosciences, 71(7), 425444. doi:10.1111/pcn.12532
Morey, R. D., Chambers, C. D., Etchells, P. J., Harris, C. R.,
Hoekstra, R., Lakens, D., Lewandowsky, S., Morey, C. C.,
Newman, D. P., Schönbrodt, F. D., Vanpaemel, W.,
Wagenmakers, E. J., & Zwaan, R. A. (2016). The peer
reviewersopenness initiative: Incentivizing open research
practices through peer review. Royal Society Open Science,
3(1), 150547. doi:10.1098/rsos.150547
Müller, K. W., Beutel, M. E., & Wöling, K. (2014). A contribu-
tion to the clinical characterization of Internet addiction in a
sample of treatment seekers: Validity of assessment, severity of
psychopathology and type of co-morbidity. Comprehensive
Psychiatry, 55(4), 770777. doi:10.1016/j.comppsych.2014.
Müller, K. W., & Wöling, K. (2017). Both sides of the story:
Addiction is not a pastime activity. Journal of Behavioral
Addictions, 6(2), 118120. doi:10.1556/2006.6.2017.038
Munafò, M. R., Nosek, B. A., Bishop, D. V. M., Button, K. S.,
Chambers, C. D., Percie du Sert, N., Simonsohn, U.,
Wagenmakers, E.-J., Ware, J. J., & Ioannidis, J. P. A.
(2017). A manifesto for reproducible science. Nature Human
Behaviour, 1(1), 21. doi:10.1038/s41562-016-0021
Nosek, B. A., Spies, J. R., & Motyl, M. (2012). Scientic Utopia:
II. Restructuring incentives and practices to promote truth over
publishability. Perspectives on Psychological Science, 7(6),
615631. doi:10.1177/1745691612459058
Open Science Collaboration. (2015). Estimating the reproducibility
of psychological science. Science, 349(6251), aac4716. doi:10.
Petry, N. M., & OBrien, C. P. (2013). Internet gaming disorder
and the DSM-5. Addiction (Abingdon, England), 108(7),
11861187. doi:10.1111/add.12162
Pingani, L., Luciano, M., Sampogna, G., De Rosa, C., Pinna, F.,
Volpe, U., Del Vecchio, V., & Fiorillo, A. (2014). The crisis in
psychiatry: A public health perspective. International Review
of Psychiatry, 26(4), 530534. doi:10.3109/09540261.2014.
Journal of Behavioral Addictions
van Rooij et al.
Przybylski, A. K. (2016). Mischievous responding in Internet
gaming disorder research. PeerJ, 4, e2401. doi:10.7717/peerj.
Przybylski, A. K., & Wang, J. C. (2016). A large scale test of the
gaming-enhancement hypothesis. PeerJ, 4, e2710. doi:10.
Przybylski, A. K., Weinstein, N., & Murayama, K. (2017). Internet
gaming disorder: Investigating the clinical relevance of a new
phenomenon. American Journal of Psychiatry, 174(3), 230
236. doi:10.1176/appi.ajp.2016.16020224
Quandt, T. (2017). Stepping back to advance: Why IGD needs an
intensied debate instead of a consensus. Journal of Behav-
ioral Addictions, 6(2), 121123. doi:10.1556/2006.6.2017.014
Regier, D. A., Kuhl, E. A., & Kupfer, D. J. (2013). The DSM-5:
Classication and criteria changes. World Psychiatry, 12(2),
9298. doi:10.1002/wps.20050
Saunders, J. B., Hao, W., Long, J., King, D. L., Mann, K., Fauth-
Bühler, M., Rumpf, H. J., Bowden-Jones, H., Rahimi-
Movaghar, A., Chung, T., Chan, E., Bahar, N., Achab, S.,
Lee, H. K., Potenza, M., Petry, N., Spritzer, D., Ambekar, A.,
Derevensky, J., Grifths, M. D., Pontes, H. M., Kuss, D.,
Higuchi, S., Mihara, S., Assangangkornchai, S., Sharma, M.,
Kashef, A. E., Ip, P., Farrell, M., Scafato, E., Carragher, N., &
Poznyak, V. (2017). Gaming disorder: Its delineation as an
important condition for diagnosis, management, and preven-
tion. Journal of Behavioral Addictions, 6(3), 271279.
Schimmack, U. (2012). The ironic effect of signicant results on
the credibility of multiple-study articles. Psychological Meth-
ods, 17(4), 551566. doi:10.1037/a0029487
Shadloo, B., Farnam, R., Amin-Esmaeili, M., Hamzehzadeh, M.,
Raemanesh, H., Jobehdar, M. M., Ghani, K., Charkhgard, N.,
& Rahimi-Movaghar, A. (2017). Inclusion of gaming disorder
in the diagnostic classications and promotion of public health
response. Journal of Behavioral Addictions, 6(3), 310312.
Snodgrass, J. G., Bagwell, A., Patry, J. M., Dengah, H. J. F.,
Smarr-Foster, C., Van Oostenburg, M., & Lacy, M. G. (2018).
The partial truths of compensatory and poor-get-poorer Internet
use theories: More highly involved videogame players experi-
ence greater psychosocial benets. Computers in Human
Behavior, 78, 1025. doi:10.1016/j.chb.2017.09.020
Snodgrass, J. G., Dengah, H. J. F., Lacy, M. G., Bagwell, A., Van
Oostenburg, M., & Lende, D. (2017). Online gaming involve-
ment and its positive and negative consequences: A cognitive
anthropological cultural consensusapproach to psychiatric
measurement and assessment. Computers in Human Behavior,
66, 291302. doi:10.1016/j.chb.2016.09.025
Snodgrass, J. G., Lacy, M. G., Dengah, H. J. F., Eisenhauer, S.,
Batchelder, G., & Cookson, R. J. (2014). A vacation from your
mind: Problematic online gaming is a stress response. Com-
puters in Human Behavior, 38, 248260. doi:10.1016/j.
Stein, D. J., & Phillips, K. A. (2013). Patient advocacy and DSM-5.
BMC Medicine, 11(1), 133. doi:10.1186/1741-7015-11-133
Stroup, D. F., Berlin, J. A., Morton, S. C., Olkin, I., Williamson,
G. D., Rennie, D., Moher, D., Becker, B. J., Sipe, T. A., &
Thacker, S. B. (2000). Meta-analysis of observational studies
in epidemiology: A proposal for reporting. Meta-analysis Of
Observational Studies in Epidemiology (MOOSE) group.
JAMA, 283(15), 20082012. doi:10.1001/jama.283.15.2008
Šupak Smolčc, V. (2013). Salami publication: Denitions and
examples. Biochemia Medica, 23(3), 237241. doi:10.11613/
UNICEF. (2017). State of the Worlds children: Children in a
digital World. New York, NY: UNICEF.
Van den Brink, W. (2017). ICD-11 gaming disorder: Needed and
just in time or dangerous and much too early? Journal of
Behavioral Addictions, 6(3), 290292. doi:10.1556/2006.
Van Rooij, A. J., & Kardefelt-Winther, D. (2017). Lost in the
chaos: Flawed literature should not generate new disorders.
Journal of Behavioral Addictions, 6(2), 128132. doi:10.1556/
Van Rooij, A. J., Schoenmakers, T. M., & van de Mheen, D.
(2017). Clinical validation of the C-VAT 2.0 assessment tool
for gaming disorder: A sensitivity analysis of the proposed
DSM-5 criteria and the clinical characteristics of young
patients with video game addiction.Addictive Behaviors,
64, 269274. doi:10.1016/j.addbeh.2015.10.018
Van Rooij, A. J., Schoenmakers, T. M., Vermulst, A. A., Van den
Eijnden, R. J. J. M., & van de Mheen, D. (2011). Online video
game addiction: Identication of addicted adolescent gamers.
Addiction, 106(1), 205212. doi:10.1111/j.1360-0443.2010.
Wagenmakers, E.-J., Wetzels, R., Borsboom, D., van der Maas,
H. L. J., & Kievit, R. A. (2012). An agenda for purely
conrmatory research. Perspectives on Psychological Science,
7(6), 632638. doi:10.1177/1745691612463078
Wakeeld, J. C. (2015). DSM-5, psychiatric epidemiology and the
false positives problem. Epidemiology and Psychiatric
Sciences, 24(3), 188196. doi:10.1017/S2045796015000116
Weinstein, N., Przybylski, A. K., & Murayama, K. (2017). A
prospective study of the motivational and health dynamics of
Internet gaming disorder. PeerJ, 5, e3838. doi:10.7717/peerj.3838
WHO. (2017a). Gaming disorder. Retrieved November 20, 2017,
WHO. (2017b). Gaming disorder, predominantly ofine. Re-
trieved November 20, 2017, from
WHO. (2017c). Gaming disorder, predominantly online. Retrieved
November 20, 2017, from
WHO. (2017d). Hazardous gaming. Retrieved November 20,
2017, from
Wicherts, J. M., Borsboom, D., Kats, J., & Molenaar, D. (2006).
The poor availability of psychological research data for reanal-
ysis. American Psychologist, 61(7), 726728. doi:10.1037/
Wittek, C. T., Finserås, T. R., Pallesen, S., Mentzoni, R. A., Hanss,
D., Grifths, M. D., & Molde, H. (2016). Prevalence and
predictors of video game addiction: A study based on a national
representative sample of gamers. International Journal of
Mental Health and Addiction, 14(5), 672686. doi:10.1007/
Journal of Behavioral Addictions
Weak basis for gaming disorder
... Despite the few discrepancies in the diagnostic criteria for GD in ICD-11 and DSM-5, the common symptoms of GD include continuation of gaming and impaired control over gaming behavior, which result in functional impairments (Jo et al., 2019). The official listing of GD diagnosis is debatable (Aarseth et al., 2017;Griffiths et al., 2017;Kuss et al., 2017;Van Den Brink, 2017;Rumpf et al., 2018;Van Rooij et al., 2018). Several high-quality studies including epidemiological studies (Lemmens et al., 2015;Pontes et al., 2016;Wittek et al., 2016;Han et al., 2018), clinical outcome studies (see King et al., 2017), neuroimaging studies (Fauth-Bühler and Mann, 2017;Han et al., 2017;Liu et al., 2018), and experimental studies (Sariyska et al., 2017;Kräplin et al., 2021) have been published in the recent years, showing improvements with regard to the quality of studies and methodological issues raised by researchers (Petry and O'Brien, 2013;Van Rooij et al., 2018). ...
... The official listing of GD diagnosis is debatable (Aarseth et al., 2017;Griffiths et al., 2017;Kuss et al., 2017;Van Den Brink, 2017;Rumpf et al., 2018;Van Rooij et al., 2018). Several high-quality studies including epidemiological studies (Lemmens et al., 2015;Pontes et al., 2016;Wittek et al., 2016;Han et al., 2018), clinical outcome studies (see King et al., 2017), neuroimaging studies (Fauth-Bühler and Mann, 2017;Han et al., 2017;Liu et al., 2018), and experimental studies (Sariyska et al., 2017;Kräplin et al., 2021) have been published in the recent years, showing improvements with regard to the quality of studies and methodological issues raised by researchers (Petry and O'Brien, 2013;Van Rooij et al., 2018). Most studies, nonetheless, have relied on self-report assessment tools rather than relying on structured clinical interviews, which is partially due to the inconsistency in definition and the different diagnostic criteria . ...
... Another unresolved but important issue is the association between GD and the symptoms of common mental disorders (see Billieux et al., 2017;Van Rooij et al., 2018). Pontes and Griffiths (2019) commented the importance of key risk factors related to comorbidities. ...
Full-text available
Fit indices provide helpful information for researchers to assess the fit of their structural equation models to their data. However, like many statistics and methods, researchers can misuse fit indices, which suggest the potential for questionable research practices that might arise during the analytic and interpretative processes. In the current paper, the author highlights two critical ethical dilemmas regarding the use of fit indices, which are (1) the selective reporting of fit indices and (2) using fit indices to justify poorly-fitting models. The author highlights the dilemmas and provides potential solutions for researchers and journals to follow to reduce these questionable research practices.
... Nevertheless, qualitative research with relevant treatment-seeker data remains scarce. Arguably, the academic debates regarding the psychiatric relevance and validity of gaming disorder continue largely because the lived experiences of treatment-seekers remain mostly unstudied (see Ferguson & Cowell 2020;van Rooij et al. 2018). Idiographic, in-depth data from people who have sought help for their gaming are much needed to better understand the contexts, reasons, and problems that have so far contributed to or otherwise been associated with gaming-related treatment-seeking. ...
... Other scholars contest that the screen time and dysregulated gaming discourses are but the most recent 'technology panic', founded on biased, low-quality evidence 17 . They argue that clinically important distress around gaming is far less prevalent than current self-report scales suggest; and that heavy gaming is likely not a genuine disorder, but rather a coping strategy or symptom of some other underlying social or mental issues 14,[18][19][20][21] . These latter scholars point to recent large-scale studies that suggest analytic flexibility can produce anything from a positive to a null to a negative correlation between playtime and wellbeing; and that a person's total playtime does not predict substantial variance in wellbeing 18,22 . ...
Full-text available
Governments around the world are considering regulatory measures to reduce young people’s time spent on digital devices, particularly video games. This raises the question of whether proposed regulatory measures would be effective. Since the early 2000s, the Chinese government has been enacting regulations to directly restrict young people’s playtime. In November 2019, it limited players aged under 18 to 1.5 hours of daily playtime and 3 hours on public holidays. Using telemetry data on over seven billion hours of playtime provided by a stakeholder from the video games industry, we found no credible evidence for overall reduction in the prevalence of heavy playtime following the implementation of regulations: individual accounts became 1.14 times more likely to play heavily in any given week (95% confidence interval 1.139–1.141). This falls below our preregistered smallest effect size of interest (2.0) and thus is not interpreted as a practically meaningful increase. Results remain robust across a variety of sensitivity analyses, including an analysis of more recent (2021) adjustments to playtime regulation. This casts doubt on the effectiveness of such state-controlled playtime mandates.
... Some authors questioned the similarity of these diagnostic criteria with those of disorders associated with substance abuse, arguing that there is little evidence to support the assumption that the nosologic rationale underlying substance abuse disorders may be transferred to the maladaptive gaming patterns some players display (Bean, Nielsen, van Rooij, & Ferguson, 2017). It was also argued that diagnostic criteria do not adequately accommodate the specificities of maladaptive gaming patterns Billieux, Flayelle, Rumpf, & Stein, 2019;Kuss, Griffiths, & Pontes, 2017a), Kuss et al., 2017b and do not effectively distinguish between these gaming patterns and healthy use of video games (Billieux et al., 2019;van Rooij et al., 2018). ...
... Most studies included in this review were crosssectional thus causal relationships nor predictive functions of each biopsychosocial variable could not be drawn. As mere correlations are not adequate to support a formalization of a disorder, a more sophisticated and deeper level of evidence of GD is needed (133). As one way to examine longitudinal aspects of gaming, we advise researchers to actively utilize large-scale projects, such as the ABCD [Adolescent Brain and Cognitive Development; (134)] study or the Project M.E.D.I.A (Media Effects on Development from Infancy to Adulthood; to name a few, which are ongoing, longitudinal studies on child development. ...
Full-text available
Background and aims Considering the growing number of gamers worldwide and increasing public concerns regarding the negative consequences of problematic gaming, the aim of the present systematic review was to provide a comprehensive overview of gaming disorder (GD) by identifying empirical studies that investigate biological, psychological, and social factors of GD using screening tools with well-defined psychometric properties. Materials and methods A systematic literature search was conducted through PsycINFO, PubMed, RISS, and KISS, and papers published up to January 2022 were included. Studies were screened based on the GD diagnostic tool usage, and only five scales with well-established psychometric properties were included. A total of 93 studies were included in the synthesis, and the results were classified into three groups based on biological, psychological, and social factors. Results Biological factors ( n = 8) included reward, self-concept, brain structure, and functional connectivity. Psychological factors ( n = 67) included psychiatric symptoms, psychological health, emotion regulation, personality traits, and other dimensions. Social factors ( n = 29) included family, social interaction, culture, school, and social support. Discussion When the excess amount of assessment tools with varying psychometric properties were controlled for, mixed results were observed with regards to impulsivity, social relations, and family-related factors, and some domains suffered from a lack of study results to confirm any relevant patterns. Conclusion More longitudinal and neurobiological studies, consensus on a diagnostic tool with well-defined psychometric properties, and an in-depth understanding of gaming-related factors should be established to settle the debate regarding psychometric weaknesses of the current diagnostic system and for GD to gain greater legitimacy in the field of behavioral addiction.
... These findings seem to support the main theories of craving mentioned previously, as well as the existence of similarities between IGD and well-established addictive disorders (gambling disorder and SUDs), which would justify the inclusion of IGD in the ICD-11. Nonetheless, disagreement among experts remains (Billieux et al., 2015;Van Rooij et al., 2018), as the meaning and operationalization of craving seem to vary across instruments and behavioral domains, i.e., very scant research has been dedicated to substantiating the assumption that 'craving for games', 'craving to gamble', and 'craving for drugs' are processually and phenomenologically similar states. In all cases, craving is understood as intense desire but, as discussed in Muela et al. (2022), intense desire could merely reflect the anticipation of some strong reward, whereas a more restricted definition of craving requires that urge to be overwhelming, to be perceived as intrusive, and to jeopardize control attempts. ...
Full-text available
The role of negative and positive urgency in the relationship between craving and symptoms of problematic video game use. Abstract Craving and emotion-driven impulsivity dimensions (positive and negative urgency) have been suggested as factors involved in the progression of different potentially problematic behaviors. However, their role in severity of video gaming-related problems remains unclear. This study aims to assess the differential capacity of negative and positive urgency to predict craving and the number of internet gaming disorder (IGD) symptoms endorsed (as a proxy to severity of video gaming problems) in majoritarily non-pathological video-gamers. Convenience sampling was used to recruit 232 Spanish and 222 Ecuadorian frequent video game players. Mixed-effects generalized linear (GMLE) and mediation modeling were used to test moderation and mediation hypotheses regarding the association between urgency, craving, and endorsement of IGD symptoms. Results show that (1) craving largely overlaps with endorsement of IGD symptoms; (2) craving for video games is linked to positive urgency, but not to negative urgency, which reinforces the idea that craving, at least in mostly non-pathological gamers, is a positively valenced expectancy state; (3) positive urgency exerts an indirect effect (mediated by craving) on the number of symptoms endorsed; (4) negative urgency exerts a direct effect on the number of symptoms endorsed; and (5) urgency traits do not interact with craving to predict the number of symptoms. These findings are consistent with the proposal that craving is an emotional state, and that dysregulation of positive affect (as measured by positive urgency) influences its emergence and control. In addition, they support the idea that craving is a central feature in the emergence of IGD symptoms.
Full-text available
The relationship between the obsessive-compulsive disorder and the gaming disorder is investigated. A total of 345 undergraduates completed a survey that included demographic information, responses to the obsession-compulsive inventory-revised scale and the internet gaming disorder test. While initial findings showed the obsessive-compulsive disorder can predict the gaming disorder, deeper probe carried the potential of changing how this relationship is conceptualized. Only the checking subtype predicted the internet gaming disorder within the disordered gaming group. A corollary to this finding is that symptoms of the checking subtype of the compulsions component can predict having gaming disorder. Also, there was a significant strong association between a counting symptom and the internet gaming disorder scores of the disordered gaming group. This study indicated that the identified significant impact of the obsessive-compulsive disorder on the gaming disorder is rooted in shared mental functions by a gamer.
Internet addiction refers to what is considered to be abnormal, problematic, heavy, or overuse of the Internet. The significant increase in digital consumption, including online gaming and gambling has been widely researched since the Internet Addiction Test (IAT) was published in 1998. Despite increased digital consumption, including online gaming and gambling, the IAT continues to be utilized with few modifications. There has been much quantitative research into the phenomenon that reinforces the belief that heavy Internet use is abnormal and that dependence on the Internet constitutes a negative addiction. Despite this, the everyday, habitual, frequent use of digital devices and, in particular, dependence on smartphones, suggests the concept of Internet addiction is inadequate.
Full-text available
The aim of this study is to review the available literature investigating the relationship between hikikomori, a pathological condition characterized by severe social withdrawal or isolation, autism spectrum disorder (ASD) and Internet gaming disorder (IGD). Studies on the relationship between ASD and IGD have found significant positive correlations between these two conditions. Individuals with ASD would appear to be at risk of developing a problematic use of the Internet, which, to the right extent, would represent a useful tool for social interaction and cognitive development. Even subjects with hikikomori, in whom rarefied interpersonal relationships and social isolation could be balanced by the use of online connections, appear to be at high risk of developing IGD. On the other hand, the finding of significant autistic traits in populations with hikikomori could lead to considering this psychopathological condition as a particular presentation of autism spectrum, a hypothesis that requires further investigation.
Full-text available
Research on the convergence of gaming and gambling has been around since the 1990s. The emergence of loot boxes in video games in the mid 2010s, a game mechanic with a chance-based outcome that shares structural and psychological similarities to gambling, caused public controversy and lead to the inception of a new field of study, loot box research. Since then, various studies have found a relationship between loot box engagement and problem gambling as well as problem gaming. Due to the cross-sectional nature of this data, however, inferences about causality are limited. While loot box research has extensively investigated the relationship between loot box engagement and problem behaviour, little research has been done to explain the underlying motivations of players that drive them to interact with loot boxes. The goal of this thesis is to provide possible explanations for the relationship between loot box engagement and problem gamblers or problem gamers. In doing so, it draws upon two prominent psychological theories. Self-Determination Theory and the Dualistic Model of Passion. Self-Determination Theory's concept of psychological needs and their satisfaction or frustration is hereby used to explain the development of harmonious or obsessive passions, which are introduced in the Dualistic Model of Passion. These obsessive passions have been shown to be possible antecedents of behavioural addictions, such as problem gambling or problem gaming. Thus, the interplay between needs, passions and loot box opening could elucidate the aforementioned correlations between loot box engagement and problem behaviour. However, further research, especially utilising longitudinal data, is needed to better understand these processes.
Full-text available
The proposed diagnosis of Internet gaming disorder (IGD) in DSM-5 has been criticized for “borrowing” criteria related to substance addiction, as this might result in misclassifying highly involved gamers as having a disorder. In this paper, we took a person-centered statistical approach to group adolescent gamers by levels of addiction-related symptoms and gaming-related problems, compared these groups to traditional scale scores for IGD, and checked how groups were related to psychosocial well-being using a preregistered analysis plan. We performed latent class analysis and regression with items from IGD and psychosocial well-being scales in a representative sample of 7865 adolescent European gamers. Symptoms and problems matched in only two groups: an IGD class (2.2%) having a high level of symptoms and problems and a Normative class (63.5%) having low levels of symptoms and problems. We also identified two classes comprising 30.9% of our sample that would be misclassified based on their report of gaming-related problems: an Engaged class (7.3%) that seemed to correspond to the engaged gamers described in previous literature, and a Concerned class (23.6%) reporting few symptoms but moderate to high levels of problems. Our findings suggest that a reformulation of IGD is needed. Treating Engaged gamers as having IGD when their poor well-being might not be gaming related may delay appropriate treatment, while Concerned gamers may need help to reduce gaming but would not be identified as such. Additional work to describe the phenomenology of these two groups would help refine diagnosis, prevention and treatment for IGD.
Full-text available
Background and aims The DSM-5 includes criteria for diagnosing Internet gaming disorder (IGD) that are adapted from substance abuse and widely used in research and clinical contexts, although evidence supporting their validity remains scarce. This study compared online gamers who do or do not endorse IGD criteria regarding self-control-related abilities (impulsivity, inhibitory control, and decision-making), considered the hallmarks of addictive behaviors. Method A double approach was adopted to distinguish pathological from recreational gamers: The first is the classic DSM-5 approach (≥5 criteria required to endorse the IGD diagnosis), and the second consists in using latent class analysis (LCA) for IGD criteria to distinguish gamers’ subgroups. We computed comparisons separately for each approach. Ninety-seven volunteer gamers from the community were recruited. Self-reported questionnaires were used to measure demographic- and game-related characteristics, problematic online gaming (with the Problematic Online Gaming Questionnaire), impulsivity (with the UPPS-P Impulsive Behavior Scale), and depression (with the Beck Depression Inventory-II). Experimental tasks were used to measure inhibitory control (Hybrid-Stop Task) and decision-making abilities (Game of Dice Task). Results Thirty-two participants met IGD criteria (33% of the sample), whereas LCA identified two groups of gamers [pathological (35%) and recreational]. Comparisons that used both approaches (DSM-5 and LCA) failed to identify significant differences regarding all constructs except for variables related to actual or problematic gaming behaviors. Discussion The validity of IGD criteria is questioned, mostly with respect to their relevance in distinguishing high engagement from pathological involvement in video games.
Full-text available
• Cultural knowledge is important for defining mental disorders in context. • We asked groups of engaged gamers to submit and rank criteria of game “addiction”. • We compared these criteria to proposed domains for Internet gaming disorder (IGD). • Gamers agreed with some criteria and proposed novel ideas from other domains. • Participatory approaches may help refine IGD criteria and improve content validity. In response to calls for further research into the phenomenology of Internet gaming disorder (IGD), we used a community-engaged consensus development approach to evaluate how members of the “gamer culture” describe problematic gaming and the relationship of these descriptions to the proposed IGD criteria. Two focus groups of gamers were recruited at a video game convention. Participants were asked to submit suggestions for signs of game “addiction”. Participants discussed and ranked the criteria in order of conceptual importance. The rankings were analyzed quantitatively, and then a multidisciplinary team compared the ranked criteria to the DSM-5 IGD proposed criteria. The strongest agreement between participants’ rankings and IGD symptomatology was found for harms/functional impairment due to gaming, continued use despite problems, unsuccessful attempts to control gaming, and loss of interest in previous hobbies and entertainment. There was less support for other IGD criteria. Participants also offered new content domains. These findings suggest that collaborative knowledge-building approaches may help researchers and policymakers understand the characteristics and processes specific to problematic video game play and improve content validity of IGD criteria. Future efforts may benefit from multi-stakeholder approaches to refine IGD criteria and inform theory, measurement and intervention.
Full-text available
The American Psychiatric Association has identified Internet Gaming Disorder (IGD) as a potential psychiatric condition and called for research to investigate its etiology, stability, and impacts on health and behavior. The present study recruited 5,777 American adults and applied self-determination theory to examine how motivational factors influence, and are influenced by, IGD and health across a six month period. Following a preregistered analysis plan, results confirmed our hypotheses that IGD criteria are moderately stable and that they and basic psychological need satisfaction have a reciprocal relationship over time. Results also showed need satisfaction promoted health and served as a protective factor against IGD. Contrary to what was hypothesized, results provided no evidence directly linking IGD to health over time. Exploratory analyses suggested that IGD may have indirect effects on health by way of its impact on basic needs. Implications are discussed in terms of existing gaming addiction and motivational frameworks.
Full-text available
Research has established loneliness as a good predictor of intensive Internet use. But it is not fully understood whether Internet activity lessens lonely individuals' felt distress (known as positive psychosocial “compensation”), or by contrast further magnifies it (the “poor-get-poorer” hypothesis). Focused on online videogames in particular, we use qualitative cultural psychiatric interviews (N = 20) and path analysis of online survey data (N = 3629) to model pathways connecting loneliness, videogame involvement, and positive and negative online gaming experiences. Informed by social signaling theory, we hypothesize that lonely individuals who are intensively involved in online videogames (as opposed to playing casually) will experience more positive play experiences, given the way that such gamers’ costly expenditures of time, energy, and resources “signal” their commitment and also their insiderness to gaming communities, thus fostering for them a greater sense of social inclusion and support. By contrast, lonely gamers who fail to engage videogames in this intensive and socially supportive manner can instead compound their life distress with additional problems related to their online play. Ironically, it is thus gamers displaying dimensions of what seems on the surface to be “addictive” play—but is better described in this context as intensive gaming involvement—who experience the greatest psychosocial benefits from their play. Our research aims to add nuance to debates about how the Internet shapes the mental health of distressed emerging adults in particular. Rather than posing a single solution, we posit that the answer depends on the manner in which lonely and distressed individuals engage with life online.
Full-text available
Objective: To determine whether disagreements among multiple data sources affect systematic reviews of randomized clinical trials (RCTs). Study design and setting: Eligible RCTs examined gabapentin for neuropathic pain and quetiapine for bipolar depression, reported in public (e.g., journal articles) and non-public sources (clinical study reports [CSRs] and individual participant data [IPD]). Results: We found 21 gabapentin RCTs (74 reports, six IPD) and seven quetiapine RCTs (50 reports, one IPD); most were reported in journal articles (18/21 [86%] and 6/7 [86%], respectively). When available, CSRs contained the most trial design and risk of bias information. CSRs and IPD contained the most results. For the outcome domains "pain intensity" (gabapentin) and "depression" (quetiapine), we found single trials with 68 and 98 different meta-analyzable results, respectively; by purposefully selecting one meta-analyzable result for each RCT, we could change the overall result for pain intensity from effective (standardized mean difference [SMD]=-0.45; 95%CI -0.63 to -0.27) to ineffective (SMD=-0.06; 95%CI -0.24 to 0.12). We could change the effect for depression from a medium effect (SMD=-0.55; 95%CI -0.85 to -0.25) to a small effect (SMD=-0.26; 95%CI -0.41 to -0.1). Conclusions: Disagreements across data sources affect the effect size, statistical significance, and interpretation of trials and meta-analyses.
Full-text available
Online gaming has greatly increased in popularity in recent years, and with this has come a multiplicity of problems due to excessive involvement in gaming. Gaming disorder, both online and offline, has been defined for the first time in the draft of 11th revision of the International Classification of Diseases (ICD-11). National surveys have shown prevalence rates of gaming disorder/addiction of 10%-15% among young people in several Asian countries and of 1%-10% in their counterparts in some Western countries. Several diseases related to excessive gaming are now recognized, and clinics are being established to respond to individual, family, and community concerns, but many cases remain hidden. Gaming disorder shares many features with addictions due to psychoactive substances and with gambling disorder, and functional neuroimaging shows that similar areas of the brain are activated. Governments and health agencies worldwide are seeking for the effects of online gaming to be addressed, and for preventive approaches to be developed. Central to this effort is a need to delineate the nature of the problem, which is the purpose of the definitions in the draft of ICD-11.
Data from a specialist treatment facility for Internet addiction (IA) in Japan showed that (a) the vast majority of treatment seekers are addicted to online games, (b) their symptoms are often quite severe, and (c) there is a significant demand for IA treatment. In addition, systemic obstacles to the delivery of medical services in Japan exist due to the exclusion of IA criteria from ICD-10. Consequently, the inclusion of GD criteria in ICD-11 will almost certainly increase the capacity and quality of treatment through advances in research and possible changes in national medical systems to meet treatment demand.