A weak scientific basis for gaming disorder: Let us err on the side of caution

Abstract

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.

Full text

A weak scientific basis for gaming disorder: Let us err on the side of caution
ANTONIUS J. VAN ROOIJ
1
*, CHRISTOPHER J. FERGUSON
2
*, MICHELLE COLDER CARRAS
3
*,
DANIEL KARDEFELT-WINTHER
4
*, JING SHI
5,6
*, ESPEN AARSETH
7
, ANTHONY M. BEAN
8
,
KARIN HELMERSSON BERGMARK
9
, ANNE BRUS
10
, MARK COULSON
11
, JORY DELEUZE
12
, PRAVIN DULLUR
13
,
ELZA DUNKELS
14
, JOHAN EDMAN
15
, MALTE ELSON
16
, PETER J. ETCHELLS
17
, ANNE FISKAALI
18
, ISABELA GRANIC
19
,
JEROEN JANSZ
20
, FALTIN KARLSEN
21
, LINDA K. KAYE
22
, BONNIE KIRSH
5,23,24
, ANDREAS LIEBEROTH
25
, PATRICK MARKEY
26
,
KATHRYN L. MILLS
27
, RUNE KRISTIAN LUNDEDAL NIELSEN
7
,AMYORBEN
28
, ARNE POULSEN
10
,
NICOLE PRAUSE
29
, PATRICK PRAX
30
, THORSTEN QUANDT
31
, ADRIANO SCHIMMENTI
32
, VLADAN STARCEVIC
33
,
GABRIELLE STUTMAN
34
, NIGEL E. TURNER
6
, JAN VAN LOOY
35
and ANDREW K. PRZYBYLSKI
28,36
*
1
Department of Children & Risky Behavior, Trimbos Institute, Utrecht, The Netherlands
2
Department of Psychology, Stetson University, DeLand, FL, USA
3
Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
4
Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
5
Rehabilitation Sciences Institute, University of Toronto, Toronto, Canada
6
Institute for Mental Health Policy Research, Centre for Addiction and Mental Health, Toronto, Canada
7
Center for Computer Games Research, IT University of Copenhagen, Copenhagen, Denmark
8
Department of Psychology, Framingham State University, Framingham, MA, USA
9
Department of Sociology, Stockholm University, Stockholm, Sweden
10
Department of People and Technology, Roskilde University, Roskilde, Denmark
11
Department of Psychology, Middlesex University, London, UK
12
Department of Psychology, Université Catholique de Louvain (UCL), Louvain, Belgium
13
School of medicine, Western Sydney University, Penrith, NSW, Australia
14
Department of Applied Educational Science, Umeå University, Umeå, Sweden
15
Department of Criminology, Stockholm University, Stockholm, Sweden
16
Psychology of Human Technology Interaction Group, Ruhr University Bochum, Bochum, Germany
17
Department of Psychology, Bath Spa University, Bath, UK
18
Department of Psychology and Behavioural Sciences, Aarhus University, Aarhus, Denmark
19
Developmental Psychopathology, Radboud University Nijmegen, Nijmegen, The Netherlands
20
Department of Media and Communication, ERMeCC, Erasmus University Rotterdam, Rotterdam, The Netherlands
21
Westerdals Department of Film and Media, Kristiania University College, Oslo, Norway
22
Department of Psychology, Edge Hill University, Ormskirk, UK
23
Department of Occupational Science and Occupational Therapy, University of Toronto, Toronto, Canada
24
Department of Psychiatry, University of Toronto, Toronto, Canada
25
Department of Educational Psychology, Danish School of Education, Aarhus University, Aarhus, Denmark
26
Department of Psychology, Villanova University, Villanova, PA, USA
27
Department of Psychology, University of Oregon, Eugene, OR, USA
28
Department of Experimental Psychology, University of Oxford, Oxford, UK
29
Liberos LLC, Los Angeles, CA, USA
30
Department of Game Design, Uppsala University, Visby, Sweden
31
Department of Communication, University of Münster, Münster, Germany
32
Department of Human and Social Sciences, UKE –Kore University of Enna, Enna, Italy
33
Discipline of Psychiatry, University of Sydney, Sydney, Australia
34
Clinical Psychologist/Neuropsychologist, New York, NY, USA
35
Department of Communication Sciences, imec-mict-Ghent University, Ghent, Belgium
36
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: trooij@trimbos.nl; Christopher J. Ferguson, PhD;
Department of Psychology, Stetson University, 421 N. Woodland Blvd., DeLand, FL, USA; Phone: +1 386 822 7288; E‑mail: 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; E‑mail: mcarras@jhu.edu; Daniel Kardefelt‑Winther, PhD; Department of Clinical
Neuroscience, Karolinska Institutet, Tomtebodavägen 18A, Stockholm 17176, Sweden; Phone: +44 79 46567850; E‑mail: daniel.kardefelt.
winther@ki.se; Jing Shi,MSc (OT), OT Reg. (Ont.); Rehabilitation Sciences Institute, University of Toronto, 937‑500 University Ave., Toronto,
ON, Canada; Phone: +1 416 946 8579; E‑mail: j.shi@mail.utoronto.ca; 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; E‑mail: andy.przybylski@oii.ox.ac.uk
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 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.
Keywords: gaming disorder, International Classification of Diseases-11, World Health Organization, diagnosis,
classification, mental disorders, moral panic
This reply reflects the personal opinion of the authors
involved. The content of this paper does not necessarily
reflect the official opinion of their respective institutions.
INTRODUCTION
In our debate paper, we argued that formalization of a gaming
disorder in International Classification of Diseases-11
(ICD-11) has potentially problematic medical, scientific,
public health, societal, and rights-based repercussions that
should be considered (Aarseth et al., 2017). The difficulty of
identifying the divide between “normal”behavior and actual
illness has long been a problem in psychiatry and psychiatric
epidemiology, leading to false-positive diagnoses with
significant economic and societal consequences (Frances,
2013;Wakefield, 2015). Thus, caution is warranted. Keeping
this in mind, we maintain that the proposed new disorder
lacks the necessary scientific support and sufficient 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 classification.
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. Ultimately, given the gravity of diagnostic classifi-
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.
COMMENTARIES AND DEBATE PAPER
We greatly appreciate the care and thought that is evident in
the commentaries that discuss our debate paper (Billieux,
King, et al., 2017;Griffiths, Kuss, Lopez-Fernandez, &
Pontes, 2017;Higuchi et al., 2017;James & Tunney, 2017;
Király & Demetrovics, 2017;Lee, Choo, & Lee, 2017;
Müller & Wölfling, 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 significant level, the question remains
whether A causes B and whether there is benefitfrom
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 classifica-
tion systems, both the scientific object of study and the
practical utility of the disorder should be clearly and
unambiguously established before formalizing new disor-
ders in disease classification systems (Frances, 2013;
Pingani et al., 2014;Wakefield, 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 sufficiently demonstrated at this point
and the scientific evidence base is not yet sufficiently 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 offline
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
fifth 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 field 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, & Wölfling, 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 financially 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 inflation should be considered as
well.
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 reflects a
patient’s response to those disorders. Specifically, is what
we call “gaming disorder”merely a coping strategy for
those with depression, attention-deficit/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 first and be sensitive to
the extent to which treating these first-order challenges
might resolve gaming problems. This is a concrete research
question that could be operationalized by clinicians who are
actively working in this field. If existing approaches are
clinically sufficient, we must ask ourselves: Do we need a
new gaming-specific 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 find 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 confirmed 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 classification. 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 & O’Brien, 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 fieldintoaconfirmatory 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 confirmatory studies are irrelevant if we have not
established the scientific object of study and have some
confidence in the accuracy and utility of the criteria that
cover essential components. Such exploratory work was
unfortunately marginalized in the wake of the DSM-5’s
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 justifies 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 sufficient 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-
fications for the potentially stigmatized or misdiagnosed
healthy “highly engaged”gamers, a group that has
been identified (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 significant 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 & Wölfling, 2017;Shadloo et al., 2017),
we find this view to be rather optimistic and not in tune with
today’s media climate. The continuous flow of flawed 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 influence 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.
FURTHER ARGUMENTS IN FAVOR
OF CAUTION
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 classification 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
children).
Robust scientific 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 firmly
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-scientific 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 scientific transparency and/or poor
methodological choices that undermine our confidence in
the findings. Much of the literature that seems to reflect a
confirmation bias toward proving gaming disorder exists
rather than treating the concept with appropriate scientific
skepticism and curiosity. The inconsistencies in the litera-
ture have been commented elsewhere (e.g., Griffiths 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 Smolči´c, 2013),
inflates 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, &
Griffiths, 2013). The inaccessibility of raw data prevents
researchers and reviewers from being able to directly inter-
rogate work and precludes the scientific 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 confirmatory 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 findings (i.e., type
1 error). Until researchers responsibly distinguish between
exploratory (i.e., theory-building) and preregistered confir-
matory (i.e., theory-testing) analysis, much of the present
Journal of Behavioral Addictions
van Rooij et al.

research findings must be understood as tentative and thus
inappropriate for creating diagnoses that will influence lives,
health systems, and policies (Chambers, 2017;Munafò
et al., 2017). Furthermore, researchers carefully need to
select appropriate data sources for preregistered confirmato-
ry analysis, including both the choice of cross-sectional or
longitudinal data collection and the choice of population. We
cannot rely on findings 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 sufficiently high quality to underpin a
formal diagnosis is on those who advocate for formal
classification. 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 classification.
The argument for singling out video games is not convincing
A behavioral addiction definition 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 addiction”or “videogame addiction”
or “gaming addiction”and similar terms for other behavioral
issues, such as food (e.g., “food addiction”or “eating
addiction”), exercise, work (“work addiction”or “occupa-
tional addiction”), plastic surgery, etc., reveal that other
behaviors have also received considerable scientific 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 specific behavioral
addictions. Of course, such a broader disorder suffers from
the same risks of abuse as a narrower one: the discussed
robust scientific standards should be employed.
Moral panic might be influencing 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 finds that they usually work in the
inverse direction –official reification 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 Korea’s
“shutdown”law (which blocked online playing for children
between 12 and 6 a.m.). While such “solutions”may 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 Children’s
Fund stated in their recent report “Children in a Digital
World”:“applying clinical concepts to children’s 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 & Wölfling, 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
reflect 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-
specific considerations to be made that the ICD, although
somewhat flexible, cannot easily accommodate.
CONCLUSIONS
To conclude, we would like to address a question raised by
Griffiths 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 first 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 find patients to study,
patients themselves (or their parents) can also be influenced
by moral panic and may come to believe they suffer from a
Table 1. Literature citations in PsychINFO for various
“addictions”
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-
der”may offer a simplified 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 influenced 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 find ways to distin-
guish gaming patterns with significant negative long-term
health effects from coping behaviors or temporary excessive
gaming behavior without any serious long-term harm.
Griffiths 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 difficult
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;Wakefield,
2015).
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 one’s 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 conflicts
of interest, is fundamentally more valuable than the closed
source and non-transparent work, which characterizes most
of the current literature on gaming disorder. Confirmatory
(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)
findings 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
premature.
How to move forward: Beyond the echo chamber
We agree with Kuss, Griffiths, 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
classifications 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 classification that
involves one of children’s 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 (www.cos.io/
rr/). In this approach, multiple stakeholders must agree on the
value of the study hypotheses, methods, and sampling plans,
so that the findings 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 field (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: MCC’s contribution to this research was
supported by the National Institute of Mental Health Train-
ing grant 5T32MH014592-39.
Authors’contribution: 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.
Conflict of interest: No conflicts of interest were reported by
any author.
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Weak basis for gaming disorder