Video-gaming disorder and the DSM-5: Some further thoughts

DSM Digest

Starcevic’s (2013a) letter entitled ‘Video-gaming disorder and behavioural addictions’ continues a line of analysis in recent issues of ANZJP on the contentious topic of video-gaming disorder (King and Delfabbro, 2013; Starcevic, 2013b). A key message within these discussions is that allied health practitioners require a better understanding of the features, aetiology, assessment and treatment of video-gaming disorder and those disorders collectively termed ‘Internet Use Disorder’ in the Diagnostic and Statistical Manual of Mental Disorders (DSM)-5. These discussions point to the need for the development of clinical criteria and disorder classifications that achieve parsimony as well as adequate inclusiveness. Here we provide some further reflections on video-gaming disorder in the service of this broad objective.

Criteria for video-gaming disorder may be missing

An examination of the history of ‘video-gaming disorder’ (and its variations of classification) reveals a long-standing assumption that the disorder may be defined by adapting the diagnostic criteria for pathological gambling and substance dependence (King et al., 2013; Kuss and Griffiths, 2012). DSM-5 Internet Use Disorder, which refers primarily to ‘Internet gaming’, has attempted to formalise a clinical definition of video-gaming disorder (King and Delfabbro, 2013). Seven of its nine criteria align directly with the DSM-IV-TR pathological gambling criteria, and five criteria align with the DSM-IV-TR substance dependence criteria. A question arises, however, of whether these nine criteria alone are adequate in defining video-gaming disorder, and whether additional criteria more specific to video-gaming behaviour are required. For example, criterion A refers to ‘preoccupation with Internet gaming’. Studies indicate that general preoccupation (or ‘cognitive salience’) is not useful in differentiating individuals who play video games problematically from those who simply enjoy and frequently play video games (Charlton and Danforth, 2007). Therefore, this criterion may require some revision in order to reflect the distinct cognitive processes that underlie problem video-gaming. Similarly, there is a need to document the distinct behaviours that indicate problematic video-gaming – just as pathological gambling criteria specify a recurrent pattern of ‘chasing’ losses and gambling with increasingly larger sums of money. Unique video-gaming cognitions and behaviours are not currently represented by the Internet Use Disorder classification and could be considered a priority area for future research.

Another issue is that some Internet Use Disorder criteria may not be as relevant to video-gaming as for disorders involving gambling or substance use. For example, criterion H of Internet Use Disorder refers to deception of family members (or others) about the amount of time spent gaming. This criterion suggests that problem video-gaming may often occur covertly or in a private setting, analogous to the problem gambler who attempts to hide his or her betting activities, or fails to disclose significant financial losses. However, clinical case reports suggest that most problem video-gamers play video games openly in the home environment often in the full view of co-habitants and would not usually consider their gaming to be a problem warranting concern or professional intervention. In this connection, and particularly for adolescents, deception and secrecy may not be as clinically relevant. Instead, it may be more useful to consider defiant or oppositional behaviour directed towards others in response to attempts to limit, or remove, video-gaming activities.

Which criteria, and how many?

In its current format, the criteria for DSM-5 Internet Use Disorder are intended as ‘stand-in’ criteria to guide further research undertakings. The classification does not designate a cut-off score, nor specify any single criterion as being more important to diagnosis than others (i.e. primary versus peripheral criteria). The proposed classification also does not specify a range of severity for Internet Use Disorder that would allow a distinction to be drawn between a single episode of problematic video-gaming from a more chronic or long-term pattern of problematic use. Similarly, the disorder lacks guidance for differential diagnosis, such as symptomatology indicative of obsessive-compulsive disorder and/or a manic episode. Research-practitioners working with the Internet Use Disorder classification may therefore encounter some difficulties in classifying borderline and clinical cases, with the associated risk of misclassification. A priority for researchers is therefore to determine which criteria may be more critical than others in determining clinical status. There is also a need for greater consistency in the application of cut-scores using existing measures (King et al., 2013).

What should treatment aim to improve?

Available international evidence suggests that many individuals with video-gaming-related problems (or parents/partners of these individuals) have sought treatment from a mental health or medical service provider (King et al., 2012). Anecdotally, this is particularly prevalent in Southeast Asia, although there is apparently a growing local need for treatment, particularly for adolescents. The treatment literature on video-gaming and Internet-based disorders is limited but has increased in scope and volume over the last decade. Unfortunately, meaningful comparison of treatment outcomes across many studies has been difficult due to the lack of standard assessment protocol and definitions of treatment outcome (King et al., 2011). An important consideration, therefore, is what specific targets for intervention should be prioritised in cases of video-gaming disorder, and whether these targets should be differentially tailored for adolescent and adult clients.

One benefit of the proposed Internet Use Disorder criteria is that the criteria provide a possible basis for the establishment of goals for clinical intervention. However, few studies in this research area have looked beyond clinical criteria in assessing treatment outcomes (King et al., 2011). Future clinical trials may wish to consider and assess change more broadly and across several outcome areas, including: (a) the level of endorsement of Internet Use Disorder criteria; (b) the actual frequency of video-gaming; (c) changes in participation in other hobbies or interests; (d) the quality of family-based or other social relationships; and (e) overall functioning and life satisfaction.

In summary, the Internet Use Disorder criteria present many new opportunities for researchers and clinicians. The extant literature, with its varying conceptualisations and problems of consistency, point to the growing need for consensus on classification and measurement of video-gaming disorder. It is hoped that continuing research on the proposed disorder leads to development of a recognised assessment protocol, and an evidence-based treatment approach.