Scholars' Open Letter to the World Health Organization on Gaming Disorder Proposal

Abstract

Concerns about problematic gaming behaviors deserve our full attention. However, we claim that it is far from clear that these problems can or should be attributed to a new disorder. The empirical basis for a Gaming Disorder proposal, such as in the new ICD-11, suffers from fundamental issues. Our main concerns are the low quality of the research base, the fact that the current operationalization leans too heavily on substance use and gambling criteria, and the lack of consensus on symptomatology and assessment of problematic gaming. The act of formalizing this disorder, even as a proposal, has negative medical, scientific, public-health, societal and human rights fallout that should be considered. Of particular concern are moral panics around the harm of video gaming. They might result in premature application of diagnosis in the medical community and the treatment of abundant false-positive cases, especially for children and adolescents. Secondly, research will be locked into a confirmatory approach, rather than an exploration of the boundaries of normal versus pathological. Thirdly, the healthy majority of gamers will be affected negatively. We expect that the premature inclusion of Gaming Disorder as a diagnosis in ICD-11 will cause significant stigma to the millions of children who play video games as part of a normal, healthy life. At this point, suggesting formal diagnoses and categories is premature: the ICD-11 proposal for Gaming Disorder should be removed to avoid a waste of public health resources as well as to avoid causing harm to healthy video gamers around the world.

Full text

Scholars’open debate paper on the World Health Organization
ICD-11 Gaming Disorder proposal
ESPEN AARSETH
1
, ANTHONY M. BEAN
2
, HUUB BOONEN
3
, MICHELLE COLDER CARRAS
4
*, MARK COULSON
5
,
DIMITRI DAS
6
, JORY DELEUZE
7
, ELZA DUNKELS
8
, JOHAN EDMAN
9
, CHRISTOPHER J. FERGUSON
10
*,
MARIA C. HAAGSMA
11
, KARIN HELMERSSON BERGMARK
12
, ZAHEER HUSSAIN
13
, JEROEN JANSZ
14
,
DANIEL KARDEFELT-WINTHER
15
*, LAWRENCE KUTNER
16
, PATRICK MARKEY
17
, RUNE KRISTIAN LUNDEDAL NIELSEN
1
,
NICOLE PRAUSE
18
, ANDREW PRZYBYLSKI
19
*, THORSTEN QUANDT
20
, ADRIANO SCHIMMENTI
21
, VLADAN STARCEVIC
22
,
GABRIELLE STUTMAN
23
, JAN VAN LOOY
24
and ANTONIUS J. VAN ROOIJ
24
*
1
Center for Computer Games Research, IT University of Copenhagen, Copenhagen, Denmark
2
Department of Psychology, Framingham State University, Framingham, MA, USA
3
UC-Leuven-Limburg, CAD Limburg, Hasselt, Belgium
4
Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
5
Department of Psychology, Middlesex University, Hendon, London, UK
6
CAD Limburg, Hasselt, Belgium
7
Psychology Department, Université Catholique de Louvain (UCL), Louvain-la-Neuve, Belgium
8
Department of Applied Educational Science, Umeå University, Umeå, Sweden
9
Centre for Social Research on Alcohol and Drugs (SoRAD) & Department of Sociology, Stockholm University, Stockholm, Sweden
10
Department of Psychology, Stetson University, DeLand, FL, USA
11
GGZ Momentum, Veldhoven, The Netherlands
12
Department of Sociology, Stockholm University, Sweden
13
Department of Life Sciences, University of Derby, UK
14
Department of Media & Communication, ERMeCC, Erasmus University Rotterdam, Rotterdam, The Netherlands
15
Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
16
Independent Researcher, USA
17
Department of Psychology, Villanova University, Villanova, PA, USA
18
Liberos, Los Angeles, USA
19
Oxford Internet Institute, University of Oxford, Oxford, UK
20
Department of Communication, University of Münster, Münster, Germany
21
Psychological Sciences and Technology, UKE, Kore University of Enna, Enna, Italy
22
Discipline of Psychiatry, The University of Sydney, Sydney, Australia
23
Clinical Psychologist/Neuropsychologist, USA
24
Department of Communication Sciences, imec-MICT-Ghent University, Ghent, Belgium
(Received: November 15, 2016; revised manuscript received: November 30, 2016; accepted: December 12, 2016)
Concerns about problematic gaming behaviors deserve our full attention. However, we claim that it is far from clear
that these problems can or should be attributed to a new disorder. The empirical basis for a Gaming Disorder proposal,
such as in the new ICD-11, suffers from fundamental issues. Our main concerns are the low quality of the research
base, the fact that the current operationalization leans too heavily on substance use and gambling criteria, and the lack
of consensus on symptomatology and assessment of problematic gaming. The act of formalizing this disorder, even as
a proposal, has negative medical, scientific, public-health, societal, and human rights fallout that should be
considered. Of particular concern are moral panics around the harm of video gaming. They might result in premature
application of diagnosis in the medical community and the treatment of abundant false-positive cases, especially for
children and adolescents. Second, research will be locked into a confirmatory approach, rather than an exploration of
the boundaries of normal versus pathological. Third, the healthy majority of gamers will be affected negatively. We
expect that the premature inclusion of Gaming Disorder as a diagnosis in ICD-11 will cause significant stigma to the
millions of children who play video games as a part of a normal, healthy life. At this point, suggesting formal
* Corresponding authors: Andrew K. Przybylski, PhD; Oxford Internet Institute, University of Oxford, Oxford, UK; Phone: +44 1865
287230; E-mail: andy.przybylski@oii.ox.ac.uk; Antonius J. Van Rooij, PhD; Department of Communication Sciences, imec‑MICT‑Ghent
University, Korte Meer 7‑9‑11, 9000 Ghent, Belgium; Phone: +32 484 27 63 46; E‑mail: tony.vanrooij@ugent.be; 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; Daniel Kardefelt‑Winther, PhD; Department of Clinical Neuroscience, Karolinska Institutet, Tomtebodavägen
18A, 17176 Stockholm, Sweden; Phone: +44 79 46567850; E‑mail: daniel.kardefelt.winther@ki.se; Michelle Colder Carras, PhD;
Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; Phone: +1 410 955 3910;
E‑mail: mcarras@jhu.edu
This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use,
distribution, and reproduction in any medium for non-commercial purposes, provided the original author and source are credited.
ISSN 2062-5871 © 2016 The Author(s)
DEBATE Journal of Behavioral Addictions 6(3), pp. 267–270 (2017)
DOI: 10.1556/2006.5.2016.088

diagnoses and categories is premature: the ICD-11 proposal for Gaming Disorder should be removed to avoid a waste
of public health resources as well as to avoid causing harm to healthy video gamers around the world.
Keywords: gaming disorder, ICD-11, DSM-5, diagnosis, moral panic, negative implications
This debate paper is a copy of a letter that the authors sent to
the WHO Topic advisory group on Mental Health under the
subject header “Gaming Disorder in ICD-11: Letter of
concern”on November 9, 2016. It reflects the personal
opinion of the authors involved. The content of this debate
paper does not necessarily reflect the official opinion of their
respective institutions.
REGARDING THE GAMING DISORDER
PROPOSAL
We are a group of scholars interested in the role of new
media in society, with a special interest in technologies such
as video games, the Internet, and social media. Some of us
have worked in particular on the problematic aspects of
technology use; our group includes scholars who work on
the epidemiology of healthy and unhealthy use of new
media, the assessment and treatment of problematic use,
as well as potential protective factors. We also work more
broadly in related areas such as children’s rights in a digital
age, on advancing global access to online opportunities and
fostering digital citizenship, as well a range of other positive
aspects related to the use of new media that are important in
the lives of children and adults today. Other signatories
work in a variety of disciplines within the social and natural
sciences, with a common interest in research on addiction
and mental health. We are independent scholars, unaffiliated
with any media industry and receiving no funding from
them. Many of us have published research that debates the
role of video gaming in mental health and the necessity of a
new diagnosis/disorder related to problematic video gaming,
and four of us wrote our doctoral dissertations specifically
on the subject of problematic gaming. Thus, we were keenly
interested to hear about the WHO ICD-11 proposal for a
new category named “Gaming Disorder”(WHO, 2016a,
2016b,2016c).
Concerns about problematic gaming behaviors deserve
our full attention. Some gamers do experience serious
problems as a consequence of the time spent playing video
games. However, we claim that it is far from clear that these
problems can or should be attributed to a new disorder, and
the empirical basis for such a proposal suffers from several
fundamental issues. Thus, we believe that, at this point,
suggesting formal diagnoses and categories is premature and
the proposal should be removed to avoid a waste of resources
in research, health, and the public domain. Removing the
proposal would also prevent significant violations of chil-
dren’s rights to play and participate in digital environments,
preserving their right to freedom of expression.
Our main concerns are the following:
1. The quality of the research base is low. The field is
fraught with multiple controversies and confusions
and there is, in fact, no consensus position among
scholars. This is indicated by a recent publication on
“Internet Gaming Disorder”in the journal Addiction
(Griffiths et al., 2016), coauthored by 28 scholars
in the field. Therefore, it is premature to include
Gaming Disorder as a formal diagnosis in another
classification system. Primary concerns have been
noted in a number of academic publications (see
references). Moreover, the size of the problem is
unclear: mischievous and extreme patterns of partici-
pant responding have been shown to inflate preva-
lence estimates (Przybylski, 2016) and the proprietary
nature of most data do not allow for systematic
synthesis of the existing evidence. Furthermore, near-
ly all of the research in this area is purely tentative or
speculative in nature as clinical studies are scarce and
suffer from low sample sizes: reported patient num-
bers do not always correspond to clinical reality,
where patients can be hard to find (Van Rooij,
Schoenmakers, & van de Mheen, 2017).
2. The current operationalization of the construct leans
too heavily on substance use and gambling criteria.
Comparisons of gaming behavior with substance use
disorders are interesting, but should not be the inter-
pretive framework applied in the exploratory phase
of understanding a problem behavior. Significant
differences between behavioral and substance driven
problematic behavior exist, among which are the
problematic understanding of withdrawal effects or
tolerance to use (Griffiths et al., 2016;Van Rooij &
Prause, 2014). Applying symptoms reminiscent of
substance use disorders to gaming behaviors too often
pathologizes thoughts, feelings and behavior that may
be normal and unproblematic in people who regularly
play video games. These over pathologized symptoms
may include those related to thinking a lot about
games, using them to improve mood or lying to
parents or significant others about the amount of time
spent gaming. These criteria may therefore have low
specificity, and applying criteria with low specificity
may lead to many gamers being misclassified as
having problems when, in fact, they experience little
to no functional impairment or harm as a consequence
of their gaming. Moreover, current criteria have not
been properly evaluated for construct, content, or face
validity, chiefly because of lack of clinical data. In
addition, emerging evidence suggests that current
criteria do not predict problematic outcomes from
gaming particularly well because they are not aligned
with the gaming context and culture.
3. There is no consensus on the symptomatology and
assessment of problematic gaming. Claims regarding
symptoms or predictors of problematic gaming are
often based on flawed interpretations of survey data,
flawed application of statistical analysis, and an
268 |Journal of Behavioral Addictions 6(3), pp. 267–270 (2017)
Aarseth et al.

over-reliance on psychometric evaluations where pa-
tient interviews are necessary to distinguish clinically
significant signs and symptoms from normative be-
havior. This is especially relevant since a few studies
involving actual patients reveal high comorbidity
between gaming behavior and other disorders; in
other words, it has not been convincingly demonstrat-
ed that problematic gaming is not better viewed as a
coping mechanism associated with underlying
problems of a different nature (Kardefelt-Winther,
2014). Misclassifying such problems as Gaming
Disorder could lead to worse treatment outcomes for
patients.
The act of formalizing this disorder, even as a proposal,
has negative medical, scientific, public-health, societal, and
rights-based fallout that should also be considered.
1. Moral panics around the harm of video gaming might
result in premature application of a clinical diagnosis
and the treatment of abundant false-positive cases,
especially among children and adolescents. The
presence of a current moral panic regarding video
games may cause the medical community to take ill-
considered steps, despite ambiguous research evi-
dence, that do more harm than good to the global
community of video gamers through the pathologiz-
ing of normal behavior. The video gaming community
is estimated to comprise up to 80% of the population
in developed countries and is rapidly growing in
developing countries. Furthermore, the proposed cat-
egories are likely to be met with significant skepticism
and controversy by both the scholarly community and
the general public, doing harm to the reputation of the
WHO and the medical community more generally.
This would dramatically reduce the utility of such a
diagnosis, in particular as it is not grounded in
a proper evidence base. There is no substantial dif-
ference between gaming and most other forms of
entertainment, and pathologizing one form of enter-
tainment opens the door to diagnoses involving sport,
dancing, eating, sex, work, exercise, gardening, etc,
potentially leading to a saturation of behavioral
disorders.
2. Research will be locked into a confirmatory approach
rather than an exploration of the boundaries of
normal versus pathological. What we have learned
from the DSM-5 proposal for Internet Gaming Disor-
der is that many researchers will see this as formal
validation of a new disorder, and stop conducting
necessary validity research or developing a proper
theoretical foundation for behavioral addictions. This
type of research will thus provide us with more
screening instruments (confirmatory thinking), in-
stead of stimulating the fundamental validation and
theoretical work (exploratory thinking) that is needed
to understand the phenomenology of problematic
gaming. We fear that resources may be wasted in
pursuing a confirmatory path that inappropriately
relies on theories of substance use disorder, which
have been seemingly –but not actually –validated by
the ICD-11 and DSM-5 proposals.
3. The healthy majority of gamers will be affected by
stigma and perhaps even changes in policy. We
expect that inclusion of gaming disorder in ICD-11
will cause significant stigma to the millions of chil-
dren and adolescents who play video games as part of
a normal, healthy life. Raising concerns around the
dangers of video gaming is known to add tension to
the parent–child relationship, which exacerbates con-
flict in the family and can perpetuate violence against
children. Furthermore, a diagnosis may be used to
control and restrict children, which has already hap-
pened in parts of the world where children are
forced into “gaming-addiction camps”with military
regimens designed to “treat”them for their gaming
problems, without any evidence of the efficacy of
such treatment and followed by reports of physical
and psychological abuse. These consequences would
constitute violations to several rights of children
according to the UN Convention on the Rights of
the Child, which WHO as a UN agency is obliged to
uphold. Finally, a disorder might detract attention
from improving media literacy, parental education,
and other factors that would actually contribute to the
resolution of some of the issues with problematic
gaming.
In brief, including this diagnosis in ICD-11 will cause
significantly more harm than good. Given the immaturity of
the existing evidence base, it will negatively impact the lives
of millions of healthy video gamers while being unlikely to
provide valid identification of true problem cases. There-
fore, as stated previously, we suggest to remove the pro-
posed category for Gaming Disorder.
Funding sources: Michelle Colder Carras’contribution to
this research was supported by the National Institute of
Mental Health Training Grant 5T32MH014592-39.
Authors’contribution: AKP, AJvR, CJF, DK-W, and MCC
were directly involved in writing this debate paper. The
remaining authors intellectually support the content of this
debate paper.
Conflict of interest: The authors declare no conflict of
interest.
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