Video-gaming disorder and behavioural addictions

The article titled ‘Issues for DSM-V: Video-gaming disorder?’ by King and Delfabbro (2013) is a much-needed contribution to a discussion on Internet addiction and online video game use disorders. This was the subject of my paper (Starcevic, 2013), and though we seem to agree on many issues, there are a few key matters where our views perhaps diverge and require some clarification.

The question of behavioural addictions

King and Delfabbro (2013) suggest that ‘video-gaming disorder’ should be included as a diagnostic entity in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) and define it as an ‘addictive use of video games, irrespective of whether the video game is played online or otherwise’. Thus, they equate video-gaming disorder with video game addiction – a view opposed by many in the field (e.g. Kuss and Griffiths, 2012a). I concur that it is premature to reify video game addiction because, as yet, there is no consensus as to the specific meaning of ‘addiction’, including behavioural addiction.

If a relatively broad definition of addiction is endorsed by the DSM-5 so that it refers to an excessive and harmful activity, craving and lack of control, my concern is that this would open the floodgates to label every activity judged to be excessive and thought to have some negative consequences as addiction. Once addiction as a diagnostic label is attached to certain behaviours, it will have the potential to be used loosely in a variety of settings and contexts. We then urgently need to examine whether tolerance and withdrawal manifestations, once considered crucial for the diagnosis of substance dependence, should be the criteria for addictive disorders, including behavioural addictions. Do these characteristics add something essential to the description and understanding of addiction, or are they an unnecessary impediment to the recognition of addiction because they may be ‘evidence of normal adaptations’ (O’Brien, 2011: 896)? My view is that we should be open-minded and thoroughly investigate this issue, rather than leave it to the committees and experts to make decisions that may be arbitrary and merely reflect personal opinions and preferences.

With regards to tolerance that may develop in the course of excessive video game use, it will be almost irrelevant if it is not considered to be necessary for the diagnosis of behavioural addictions, including video game addiction. Still, I agree with King and Delfabbro (2013) that this is an important issue, although opinion is divided. While there are views that tolerance is a component of online gaming addiction (Kuss and Griffiths, 2012b), others are sceptical, as reflected in the following statement by Wood (2008): ‘Playing for longer periods or playing more frequently does not, in itself, increase the overall intensity of the gaming experience’ (p. 170).

Addiction to a delivery mechanism?

King and Delfabbro (2013) state that video games are ‘fundamentally delivery mechanisms’ to which people can become addicted and that ‘most, if not all, addictive activities involve addiction to a delivery mechanism of some kind’. As examples, they mention ‘addiction to cigarettes’ and ‘addiction to blackjack or a slot machine’.

It is difficult to accept this kind of reasoning. With more and more candidates being considered for inclusion into a family of behavioural addictions, will it be appropriate to talk about ‘addiction to knives and forks’ when referring to eating addiction? Or should we start using terms such as ‘addiction to treadmills’ when wanting to describe someone who is addicted to exercising? If people can get addicted to such addiction delivery mechanisms, we will almost certainly end up with hundreds, perhaps thousands, of new addictions. I believe this would only create more confusion and make it more likely for us as a profession to be ridiculed. Therefore, I do not think addiction should refer to delivery mechanisms, whether they are cigarettes, drinking glasses or the Internet. A clear distinction should be made between addiction to an activity (e.g. online video gaming) and use of a delivery mechanism (e.g. the Internet) that makes that addiction possible.

If video games are regarded as delivery mechanisms for playing them (i.e. for video gaming), perhaps we could use the terms ‘video gaming’ or ‘playing video games’. This seems to be a semantic nuance and is very different from the ‘relationship’ between cigarettes and nicotine use or between slot machines and gambling.

What to do with Internet use disorder?

I agree with King and Delfabbro (2013) that the proposed DSM-5 category of Internet use disorder should be used for activities that can only be performed on the Internet, e.g. online social networking. For the sake of greater clarity and precision, it would be better to refer to the specific behaviour in question. For instance, ‘online social networking disorder’ or ‘pathological online social networking’ would seem more appropriate as the diagnostic terms, provided they meet the threshold criteria for a disorder.

Internet use disorder should not refer to video gaming for several reasons: the term is overinclusive, as video games can be played both online and offline, and the proposed criteria in fact denote an online video game addiction. As noted previously, the latter is a premature proposition. Therefore, video-gaming disorder (or video game use disorder) should be separated from disorders strictly related to Internet use. Such a disorder may encompass both games played online and offline, although it seems that games played on the Internet are much more likely to be associated with pathological and perhaps addictive video game use (Czincz and Hechanova, 2009; Kuss and Griffiths, 2012a).

See Viewpoint by King and Delfabbro, 2013, 47(1): 20–22.