All posts by Michelle Colder Carras

WHO says gaming disorder is a disease, Part 1: Limited perspectives

Photo by Artem Kim on Unsplash

Saturday, after years of research and discussion, the World Health Organization (WHO) member states voted to adopt the 11th revision of the International Classification of Diseases, which included for the first time a diagnosis of Gaming disorder in the section called “Disorders due to substance use or addictive behaviours”. Gaming disorder follows the inclusion of Pathological gambling as a “Habit and impulse disorder” in the previous version of the ICD (ICD-10, adopted 1992) and together with Gambling disorder constitutes one of the only two disorders in the subsection “Disorders due to addictive behaviours”. A diagnosis with similar features and controversy, Compulsive sexual behavior disorder, replaces the ICD-10 “excessive sexual drive” and moves from the section “Sexual dysfunction, not caused by organic disorder or disease” to “Impulse control disorders”. The shifting and inconsistent designation of behaviors as addictive or compulsive reflects the challenges of classifying, preventing and controlling mental disorders in the field of psychiatric epidemiology overall, but the decision to move ahead with a narrow designation rather than a broader one reflects a process that dismisses opposing viewpoints and ignores the expertise of those with the first-hand experience of problematic behaviors in themselves, friends or family members. While I recognize that many people need help for their problems related to gaming (perhaps I would have benefited from some myself), this applies to other technology-related behaviors as well, and my position continues to be that a broader diagnosis would be more useful. Unfortunately, since classification systems take at least a decade (28 years in the case of the ICD-11) to change, we are likely to be limited to gaming disorder for a while.

Two things have become clear to me in my years engaged in this controversy. One, the medical establishment has no time or desire to listen to opposing views in this area and considers a consensus opinion as one derived from viewpoints that concur with its own. One of my roles in the debate and discussion papers over the last five years (Aarseth et al., 2017; Griffiths et al., 2016; van Rooij et al., 2018) has been to add the call for a transparent consensus development process that incorporates views of all stakeholders. I was first introduced to the concept of multistakeholder consensus development through experience as a grad student in public mental health. Public health best practices realize the importance of ensuring that knowledge development and sharing between multiple stakeholders informs public health decisions and interventions (see my paper about Gamers’ insights for more of a background: Colder Carras et al., 2018). This is apparently not something that the WHO agree with in this case. Their idea of incorporating public viewpoints is to have the proposed criteria open to public comment online then make decisions without engaging in these comment or otherwise reflecting on them in any transparent way. There is no ongoing attempt to systematically engage those who have the proposed disorders (or even those who may be at risk) in developing research topics or evaluating research, despite this being a WHO-recommended best practice to promote health. Scientific findings from communications, media studies, or really any field outside biomedicine (e.g. clinical psychology, psychiatry, public health, epidemiology) are specifically not included (Rumpf et al., 2018, p. 2 lists the fields of authors whose expertise is considered important).

Even worse, attempts to discuss this hot topic in the scientific literature have devolved into personal attacks by those whose involved in the WHO decision-making process. As a co-author on two papers questioning the need for a diagnosis that targets video gaming specifically, I have been included as a researcher who “perceive[s] themselves as the only “savior[s] of good scientific practice” (Müller & Wölfling, 2017) and who lacks appropriate clinical or public health expertise (Rumpf et al., 2018). I have presented research twice at events where the WHO were present, including the December 3 WHO “Dialogue with representatives of gaming and related industries on the public health implications of gaming”. During that event (slides here), the WHO specifically stated that it could not engage with my 10-minute presentation or that of the other scientist, since we had both been invited to participate in the meeting by the game industry. (This despite the fact that I paid for 100% of my travel, meals and other expenses). Contrast this to several authors of the 2018 paper above (Rumpf et al., 2018) and recipients of a recently awarded European research network grant to study “Problematic usage of the Internet” who have received financial support or honoraria from many pharmaceutical companies (Fineberg et al., 2018) and for whom a diagnosis may mean more of a chance to prescribe medication.

In this post I’ve tried to explain a little about who has been included in the process, who has been left out, and the disagreement itself. Stay tuned for more information about how this process affects the state of the science, treatment and prevention, and why limiting stakeholder perspectives may ultimately cause more harm than good.

Aarseth, E., Bean, A. M., Boonen, H., Colder Carras, M., Coulson, M., Das, D., … Van Rooij, A. J. (2017). Scholars’ open debate paper on the World Health Organization ICD-11 Gaming Disorder proposal. Journal of Behavioral Addictions, 6(3), 267–270. https://doi.org/10.1556/2006.5.2016.088

Colder Carras, M., Porter, A. M., Van Rooij, A. J., King, D., Lange, A., Carras, M., & Labrique, A. (2018). Gamers’ insights into the phenomenology of normal gaming and game “addiction”: A mixed methods study. Computers in Human Behavior, 79, 238–246. https://doi.org/10.1016/j.chb.2017.10.029

Fineberg, N. A., Demetrovics, Z., Stein, D. J., Ioannidis, K., Potenza, M. N., Grunblatt, E., … Chamberlain, S. R. (2018). Manifesto for a European research network into Problematic Usage of the Internet. European Neuropsychopharmacology : The Journal of the European College of Neuropsychopharmacology, 28(11), 1232–1246. https://doi.org/10.1016/j.euroneuro.2018.08.004

Griffiths, M. D., van Rooij, A. J., Kardefelt-Winther, D., Starcevic, V., Király, O., Pallesen, S., … 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), 167–175. https://doi.org/10.1111/add.13057

Müller, K. W., & Wölfling, K. (2017). Both sides of the story: Addiction is not a pastime activity: Commentary on: Scholars’ open debate paper on the World Health Organization ICD-11 Gaming Disorder proposal (Aarseth et al.). Journal of Behavioral Addictions, 6(2), 118–120. https://doi.org/10.1556/2006.6.2017.038

Rumpf, H.-J., Achab, S., Billieux, J., Bowden-Jones, H., Carragher, N., Demetrovics, Z., … Poznyak, V. (2018). Including gaming disorder in the ICD-11: The need to do so from a clinical and public health perspective. Journal of Behavioral Addictions, 1–6. https://akademiai.com/doi/full/10.1556/2006.7.2018.59

van Rooij, A. J., Ferguson, C. J., Colder Carras, M., Kardefelt-Winther, D., Shi, J., Aarseth, E., … Przybylski, A. K. (2018). A weak scientific basis for gaming disorder: Let us err on the side of caution. Journal of Behavioral Addictions, 1–9. https://doi.org/10.1556/2006.7.2018.19