The World Health Organization (WHO) made waves earlier this year by including an entry for “Gaming Disorder” in their plans for the 11th International Classification of Diseases (ICD-11). The fault line for the current debate does not seem to concern whether excessive gaming/screen time is a problem in our society—undeniably, it is. The question is whether said overuse can be categorized as a “disorder” in the technical sense of the word: an abnormal condition, something that disrupts one’s life, health, and well-being.
Having read the draft’s diagnostic criteria, which includes “continuation or escalation of gaming despite the occurrence of negative consequences” and a minimum onset/development time of 12 months, I am skeptical. I am not the only one concerned by the specificity of the label.
By training, I am a Social Worker; by profession, I am a therapist, not a psychiatrist. However, with a Master’s degree in Social Work, I am comfortable reading and understanding the diagnostic criteria of not only the WHO’s ICDs (currently on its 10th revision, or ICD-10), but perhaps more importantly the 5th Diagnostic and Statistical Manual of Mental Disorders (DSM-5), published by the American Psychiatric Association (APA).
Unlike the ICD, which attempts to codify all diseases and injuries, the DSM focuses specifically on mental and behavioral health. Its own codifying and diagnosing tends to—sometimes making intentional attempts to—match the ICD. At other times, these two Bible-sized documents butt heads. Considering the WHO is already committed to declaring Gaming Disorder a Real Thing™, the question remains whether the APA will go the same way in the next edition if the DSM. There is no precedent to suggest they will go in one direction or the other.
In the DSM, addiction tends to be broken into two categories: substance and process. The latest jargon for substance addiction is “Substance Use Disorder,” a linguistic change that intentionally divorces dependence from disorder—dependence being considered neutral, while disorder suggests a form of dependence that causes problems for the individual’s health or well-being. Doing so gives a pass to the millions (billions?) of humans who are likely dependent upon caffeine, as evidenced by withdrawal symptoms should they stop caffeine intake. More on this later, as it’s relevant to the discussion.
The DSM’s other primary type of addiction, the process addiction, is equivalent to what the WHO/ICD categorizes as “behavior addictions.” The three criteria driving the labeling of a process/behavior addiction as such are: (1) addictive behavior [x] increases over time in the person’s life; (2) the person can’t stop doing behavior [x] even when they try; (3) the results of behavior [x] is causing harm to the person or others around them. Generally, substance addiction has all of these markers as well, with the added criteria that the substance tends to cause a physiological/chemical dependency, which is not the case for process disorders.
Presently, the only process addiction identified in the DSM-5 is Gambling Disorder. Other frequently-acknowledged process addictions in society—sex, shopping, eating, and now gaming and internet use—can be found elsewhere throughout the DSM. For example, an “addiction to eating” would likely be categorized as BED (Binge Eating Disorder), which falls under the category of eating disorders, not addictions. Compulsive/impulsive sex and shopping may be acknowledged as symptoms of a manic phase in bipolar disorder, or the result of other complex factors.
At the time of the DSM-5’s publishing, the DSM includes a special area called “Section III.” It’s not quite as cool as Area 51, but it is the forefront of the psychological scene, as this is the area where the APA is essentially calling for more research. And, yes, this is where the DSM currently holds gaming disorder: in the “we need more information” zone. And, even though the DSM-5 was first published in 2013, updates to the current version and publication of the next version take time—by which I mean decades (DSM-III first published 1980, DSM-IV first published 1994). To date, DSM-5 has only had one supplemental release added. It was in October 2017, and it did not address Gaming Disorder. Rather, the much-needed update addressed the current opioid epidemic and other substance use disorders.
Specifically, “Internet Gaming Disorder” is what the DSM-5 is considering (as opposed to the WHO, which is proposing a generalized Gaming Disorder that does not require the component of online interaction). Also listed in Section III: “Caffeine Use Disorder.” The editors of the DSM are on the fence about caffeine for a few obvious reasons: (1) for most people, caffeine intake is not progressive (increased tolerance, yes, but not progressive over a lifetime); (2) while withdrawal symptoms can be uncomfortable, individuals who wish and/or need to remove caffeine from their lives can do so without the cravings associated with nicotine, alcohol, and narcotics; (3) caffeine is everywhere in the United States, sometimes intentionally added by a food/beverage producer, other times naturally occurring in the product.
As a process addiction, I can very much see the term “disorder” used as a valid descriptor for what we have seen in worst-case scenario reports about reclusive lifestyles, untimely death, and more in relation to gaming. And certainly, attempts at treatment have already begun in countries all around the world: from support groups and 12-step “anonymous” groups to formal and targeted treatment programs in South Korea and Japan, the healers of our planet are trying to work through this. So, yes, maybe gaming disorder is a disease.Here is my request to the mental health community: it’s time to go all-or-none on process addictions.
But, still worthy of note: sex addiction, shopping addiction, addiction to internet pornography, and more, are not specified in either the ICD-10 or the DSM-5. My theory? The sea change from one generation to the next, the astonishment and horror at how much time our youth can spend in front of a screen, is prompting a counter-reaction to explain it as not only abnormal but highly detrimental. To provide context, imagine you time travel from 400 AD to the present time. The notion that people could even have time to be addicted to vices such as over-spending or looking at images of nude people for pleasure would be shocking. For those many generations, these problems already existed. The novelty of the all-engaging screen-based entertainment format is what seems to horrify older generations. Some in my generation and even younger, self-aware enough to see what’s going on with smartphones alone, can see how technology is changing us, for better or worse. To call it a disorder makes sense in this context if society cannot function around it. The time traveler and the grandfather point and scream, “what sorcery is this?!” However, if society adapts to the dependence on the technology, as society has also adapted to dependence on caffeine, it may no longer be appropriate to consider the language of disorder.
Here is my request to the mental health community: it’s time to go all-or-none on process addictions. Codify all the well-known, easily-identified behavioral addictions and begin to develop diagnostic criteria and targeted treatments for all. Alternatively, remember that you yourselves have developed “Unspecified” ICD codes specifically for F63 (impulsive) and F69 (other unspecified behavioral disorders). It’s what the mental health and social service industries use when coding for sex addiction. Why not leave gaming there as well? Do the numbers suggest one is significantly larger a public health problem than the others? Do we have those numbers?
Not yet. A quick search of PubMed Clinical Trial research articles only nets two results for gaming addiction, but nets over four hundred results for gambling. Worthy of note: a search for Clinical Trial research on sex addiction and compulsive sexual behavior nets results only slightly larger than the few results found on gaming addiction, further justifying the stance that we as a society are not ready to specify these behavioral disorders. We do not have all the necessary information to develop specific treatments.
Until then, a friendly mental health reminder: be aware of your actions, how you spend your time, and how it affects others. In living a balanced life, we can avoid a bevy of pitfalls laid by the world and our own psyches.