Aust N Z J Psychiatry. 2018 Apr 1:4867418771189. doi: 10.1177/0004867418771189.
King DL1, Delfabbro PH1, Potenza MN2, Demetrovics Z3, Billieux J4, Brand M5.
In their recent ANZJP paper, Dullur and Starcevic (2018) argue that Internet gaming disorder (IGD) should not qualify as a mental disorder. They base this view on several arguments, including the notion that IGD does not fit the concept of a mental disorder, that IGD would pathologise normal gaming, that the addiction model for gaming is misleading and that a diagnosis is not necessary for treatment purposes. In this paper, we provide a critical appraisal of the authors’ points. While there are some aspects of their arguments which we support, there are many with which we disagree. We believe their views would be relevant to other behavioural addictions and would serve to undermine their validity, including with respect to gambling disorder.
The IGD classification is based on research evidence and clinical reality
Dullur and Starcevic (2018) assert that there is a lack of consensus with regard to what constitutes problematic gaming. While it is true that some scholars debate the validity of IGD, one should not expect a total consensus because this is impossible in any scientific field, and arguably it has not been achieved for any mental disorder. The authors also argue that IGD is defined by functional impairment and suggest that this criterion alone may not indicate a mental disorder. However, this overlooks the fact that the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5) and International Classification of Diseases, 11th Revision (ICD-11) systems for gaming disorder (GD) both refer also to the important concept of ‘loss of control’ in addition to other diagnostic features and considerations. The authors claim that there is no ‘widely agreed-upon definition’, but IGD in Section III of the DSM-5 and GD in the ICD-11 share common descriptions of persistent gaming, impaired control and functional impairment in multiple areas of life.
Critics of IGD often draw attention to non-empirical and non-clinical observations and critiques, while overlooking the larger body of robust work that supports the validity of the disorder. The IGD and GD diagnostic categories were carefully developed to capture the clinical realities of individuals seeking treatment for their gaming-related problems. Each classification reflects the majority view of support among researchers as well as practicing psychiatrists and psychologists that recognises (1) the harms associated with gaming excessively and (2) gaming as an addictive disorder.
IGD does not pathologise or stigmatise normal gaming
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.
The IGD diagnosis promotes growth in assessment and treatment areas
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.
Opposing IGD hinders access to services for problematic gaming
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.
|Dullur, P, Hay, P (2017) Problem Internet use and Internet gaming disorder: A survey of health literacy among psychiatrists from Australia and New Zealand. Australasian Psychiatry 25: 140–145. Google Scholar, SAGE Journals, ISI|
|Dullur, P, Starcevic, V (2018) Internet gaming disorder does not qualify as a mental disorder. Australian and New Zealand Journal of Psychiatry 52: 110–111. Google Scholar, SAGE Journals, ISI|
|King, DL, Herd, MCE, Delfabbro, PH (2018) Motivational components of tolerance in Internet gaming disorder. Computers in Human Behavior 78: 133–141. Google Scholar, Crossref|
|Lemmens, JS, Valkenburg, PM, Gentile, DA (2015) The Internet gaming disorder scale. Psychological Assessment 27: 567–568. Google Scholar, Crossref, Medline|
|Potenza, MN, Higuchi, S, Brand, M (2018) Call for research into a wider range of behavioural addictions. Nature 555: 30. Google Scholar, Crossref|
|Sala, G, Tatlidil, KS, Gobet, F (2018) Video game training does not enhance cognitive ability: A comprehensive meta-analytic investigation. Psychological Bulletin 144: 111–139. Google Scholar, Crossref|