Gaming Disorder: Are those joysticks all that innocent?

Friend 1: Up for a game?

Friend 2: Yeah

Friend 3: Letsss

Friend 4: Football?

Friend 1: Ground or FIFA?

Friend 2, 3 & 4: Of course, FIFA!!

I’m sure that leaving your house for game night or shouting excitedly at the screen while carrying out virtual loots plonked on your home couch might have earned you a dismayed shaking of head from your parents at least once—“Gone are those days when you actually went out to play on field.”

Sure, there is a lot of moral panic surrounding the issue of gaming already and amidst this when the International Classification of Diseases (ICD) declared Gaming Disorder (GD) as a clinical diagnosis in its latest 11^th edition; it raged a controversy amongst professionals and laymen alike. ICD, as published by World Health Organization (WHO), helps in identification, research and report of health trends and statistics globally. It defines the universe of diseases, disorders, injuries and other related health conditions including diagnosis pertaining to mental health. Walking in step with it is the Diagnostic and Statistical Manual of Mental Disorders (DSM) published by the American Psychiatric Association (APA) which in its 5^th edition has enlisted Internet Gaming Disorder (IGD) as an area requiring further study.

What do these authoritative texts mean by GD/ IGD?

According to ICD, GD is characterized by a pattern of persistent gaming behavior (either continuous or recurrently episodic), which may be online or offline, manifested by:

1. impaired control over gaming
2. increasing priority given to gaming to the extent that it takes precedence over other life interests and daily activities
3. continuation or escalation of gaming despite the occurrence of negative consequences.

This behavior pattern needs to be severe enough to result in impaired functioning in personal, family, social, educational, occupational or other important areas. For diagnosis, symptoms must be evident over a period of at least 12 months, although the required duration may be shortened if all criteria are met and symptoms are severe.

On the other hand, DSM-5 has hinted at complementary yet more detailed symptoms of diagnosis. Under the proposed criteria, IGD would be detected if five or more of these symptoms are present for a year:

      1. Preoccupation with gaming (on internet or any electronic device)

2. Withdrawal symptoms(sadness, anxiety, irritability) when gaming is taken away or not possible
3. Tolerance: the need to spend more time gaming to satisfy the urge
4. Unsuccessful attempts to reduce/ quit gaming
5. Loss of interest in other activities due to gaming
6. Continuing to game despite problems
7. Deceiving family members or others about the amount of time spent on gaming
8. The use of gaming to relieve negative moods, such as guilt or hopelessness
9. Risk: having jeopardized or lost a job or relationship due to gaming

The Controversy

To begin with, there is a debate surrounding the “goodness or badness” of games itself. Although the negative impact of gaming which is so widely reported (for instance: the recent death of a 16 year old in Madhya Pradesh, India after playing PUBG for 6 hours straight) can’t be denied; there is also equally researched but not very well accepted set of data pertaining to the positive contributions of gaming (e.g. increased experience of positive emotions, valuing of cooperation in team games, stress release, sharpening of cognitive abilities and so on). Thus, since the research body dealing with value judgment of the gaming phenomena is not yet conclusive, the move to pathologize gaming behavior has come under crossfire.

A very obvious area that is found under scrutiny is the vagueness of the criteria used for diagnosis. For instance, a scholar has pointed out that the ICD definition doesn’t distinguish between mild, moderate or severe cases; which means that clinicians — many inexperienced with video game addiction and oblivious to the gaming culture — have to decide this for themselves. Also, the DSM criteria requires the individual to exhibit only 5/9 symptoms to be diagnosed with IGD. While few indicators clearly point that something is wrong viz. experiencing withdrawal symptoms, the desire to stop but not being able to and losses on occupational and interpersonal fronts; checking off any 5 symptoms to the exclusion of these 4 important ones for receiving a diagnosis is quite easy. However, the remaining 5 symptoms are questioned for their credibility in indicating abnormality. For instance, any activity that you are extremely passionate about is likely to keep your mind and schedule preoccupied. If being preoccupied with artistic ideas isn’t considered abnormal then why is being preoccupied with gaming till the point of picking it over engagement in other activities considered problematic? Or, one could argue that tolerance applies to almost any hobby because with increased ability one needs to increase the level of challenge to get the same thrill that one got before from that activity. Hence, it is only normal for a gamer to seek increased stimulation from games as his/her level of proficiency increases.

Thus, more research is required to narrow down on what exactly can be considered as signs indicating the presence of problematic gaming behavior. This is cited as one of the reasons for inclusion of this diagnosis in ICD—the presence of such a diagnosis would accelerate more research in the area. However, a concern raised is that the presence of such a diagnostic category might promote confirmatory rather than exploratory research. So, instead of trying to find out what more can be indicative of this condition, clinicians may get caught up in confirming whether or not the prescribed criteria are displayed by the potential cases.

One last area of heated disagreement is where research has time and again pointed out gaming behavior as being accompanied by (comorbid to) other mental health conditions like depression and anxiety. It is often said that excessive gaming is used as a coping mechanism against the disturbing feelings invited by depression and anxiety and so the focus should be on treatment of these underlying conditions thereby rendering the separate notation of GD/IGD diagnosis redundant. However, a parallel that is often used to argue against this position is that of substance abuse disorders. They exist as a separate category despite of being associated with depression and anxiety because they in themselves pose sufficient risk that needs to be addressed first hand. Furthermore, in some cases, substance abuse has been found to lead to the latter conditions and so is GD found to independently exist. Hence, the symptoms presented by GD/IGD deserve to be treated independently of their comorbid conditions.

Will classifying abnormal gaming patterns as a disorder lead to abuse of diagnosis? Will it create a moral panic that was referred to at the beginning of this post? Will it stigmatize the gaming community even more than it is currently? The answer is not quite certain. However, is it a good idea to miss out on a diagnosis based on ICD’s statement that it is backed by a global consensus of scientists? Is it in the best interest of all to leave out this diagnosis because only a small minority of gamers might be suffering from disordered behavior? Will this even help to avoid the supposed moral panic and stigmatization? The answer is again quite uncertain. All one can say is that cautioning the public prematurely about a sensitive topic may involve more harm than gain and so the focus should be on INFORMING than WARNING.