Internet gaming disorder should qualify as a mental disorder (2018)

PMID: 29701485

DOI: 10.1177/0004867418771189

Dullur and Starcevic assert that the IGD/GD categories carry the risk of pathologising normal gaming, and they refer to various benefits of gaming. While we agree that the bar should be set reasonably high to avoid viewing ‘regular’ or recreational gaming behaviour as a problem, we believe that the purported benefits of gaming are largely irrelevant to the validity of IGD. First, some of these ‘benefits’ may be overstated (see Sala et al., 2018). Second, by the same logic, one could argue that eating disorders or clinical anxiety should not be considered pathological out of fear of stigmatising every worry or eating behaviour. As is also the case with gambling, one should not deny the existence of gambling disorder just because most individuals participate at recreational and non-problematic levels.

The ICD-11 and DSM-5 do not state that gaming is inherently harmful, nor do they suggest that gaming is generally risky or unhealthy. We disagree with Dullur and Starcevic that the boundary between ‘high engagement’ and ‘problematic use’ is ‘blurred’. While there have been some questionable studies employing weak screening approaches (and there are also some very good available instruments, such as Lemmens et al.’s (2015)Internet Gaming Disorder Scale), such evidence should not be used to tarnish the accumulation of convergent evidence used to support the DSM-5 or ICD-11 guidelines nor the observations of clinicians who have encountered numerous cases of IGD. Evidence concerning the intensity and frequency of behaviour would usually be assessed in conjunction with the appraisal of other functional impairments and evidence of impaired control over gaming, which would not be characteristic of normal gaming. Based on the accumulation of evidence, an experienced clinician should be quite capable of differentiating between ‘normal’ gaming and IGD. The imagined and unrealistic threat of IGD misdiagnosis should not be held above the evident needs of people seeking treatment for gaming-related problems.

We agree with Dullur and Starcevic that gaming is a heterogeneous activity and that some components of the addiction model (e.g. withdrawal) may not fit neatly with some gaming experiences. It is difficult, for example, to conceptualise ‘tolerance’ for an activity where it is not always clear to what the user may be addicted; does the gamer have a need for increasing time or something else? (King et al., 2018). IGD may require some refinement, but it would be counterproductive to follow the authors’ call to abandon the entire category in favour of applying generic diagnostic codes to problematic gaming behaviours. This would likely result in more confusion, additional barriers to treatment and a hindrance to research efforts by removing common definitions that may be used across cultures and studies.

Some critics appear to oppose IGD while publishing research that supports the clinical significance of problematic gaming. For example, the first author of the paper to which we respond has recently published a study of 289 psychiatrists’ views on IGD. He reported that the majority supported IGD as a mental health problem and felt underequipped to manage the problem (Dullur and Hay, 2017). It was concluded that IGD ‘screening tools and protocols should be developed to assist in early diagnosis and plan services’ (p. 144). The two views seem contradictory: Why develop a screening tool and protocol if one opposes the disorder? How does opposing IGD serve its status and priority for research and funding, and the best interests of those in need of urgent help?

Relatedly, we disagree with the view that IGD diagnosis is not ‘necessary’ for gamers to seek and receive help. While some can afford private services for IGD, such options would be unaffordable for many. In many contexts, access to a clinician suitably trained in cognitive behavioural therapy (i.e. a main evidence-based approach to treating IGD) requires health insurance that requires a diagnosis. Specialty clinics or services are unlikely to exist without the formal classification.

Here, we have only briefly communicated some of our points of disagreement. However, an overall appraisal suggests that, as in the gambling area, there is sound scholarly and clinical support for the ability to differentiate IGD from ‘regular’ gaming. The known negative impacts of excessive gaming include increased anxiety and depression, social isolation, school disconnection, unemployment and relationship breakdown. Epidemiological data indicate that about 1% of the population may meet the proposed IGD diagnostic criteria. Around the developed world, the demand for specialist services is great and often unmet. New gaming products are continually entering the market with the support of a hundred-billion-dollar industry that largely does not recognise its social responsibilities or acknowledge the existence of gaming-related problems, with many governments similarly largely not supporting research, prevention and treatment initiatives (Potenza et al., 2018). The academic community should not disregard these problems too.

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