Internet gaming disorder does not qualify as a mental disorder

The inclusion of Internet gaming disorder (IGD) in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) as a condition for further study has generated much interest. It has led to debates about the validity and utility of IGD as a form of problematic online gaming and to a proposal to include ‘gaming disorder’ among ‘disorders due to substance use or addictive behaviours’ in the upcoming International Classification of Diseases, 11th Revision (ICD-11). In our view, problematic online gaming and its ‘offshoots’ such as IGD and gaming disorder should not be conceptualised as a mental disorder. We put forward several arguments in support of this position.

Problematic online gaming does not fit the concept of mental disorder

While there are various definitions of mental disorder, here we use a simplified definition from ICD-10 that it denotes a clinically recognisable set of symptoms or behaviour associated in most cases with distress and with interference with personal functions. When this definition is applied to problematic online gaming, can it be considered a mental disorder?

No consensus exists on what constitutes problematic online gaming as a clinical syndrome, and it has been demonstrated that there are significant flaws with almost every diagnostic criterion for IGD (Griffiths et al., 2016). Without a widely agreed-upon description of the relevant symptoms and behaviours, it is very difficult to justify problematic online gaming as a mental disorder. This is despite a consensus that problematic online gaming is associated with distress and/or impairment: such interference with functioning by itself does not suggest the presence of a mental disorder as it could be simply a consequence of excessive gaming.

Conceptualisation of problematic online gaming as a mental disorder carries the risk of pathologising and stigmatising normal online gaming

Online gaming is a normal activity for young people, with many potential benefits. These include enhancement of various cognitive functions, cultivation of a persistent and optimistic motivational style, stimulation of creativity, improvement in social skills and fostering of prosocial behaviours, appropriate emotion regulation and better coping in general (e.g. Granic et al., 2014). Considering these aspects of online gaming, some people are attracted to it to the extent that they spend much time engaged in online gaming instead of being involved in other activities – a pattern of online gaming often referred to as ‘high engagement’.

Problematic online gaming and IGD have not been clearly delineated from ‘high engagement’ and criteria such as the excessive amount of time spent playing, preoccupation with gaming and mood-modifying effects of gaming have not been useful in this regard. Although the negative consequences of excessive gaming and the associated functional impairment are important, even they may not be sufficient as the distinguishing criteria because of the uncertainty about the number and type of these consequences and the extent of impairment required for online gaming to denote a mental disorder. Given the fuzzy boundary between problematic online gaming and ‘high engagement’, as well as a relatively low diagnostic threshold for IGD, there is a risk of overdiagnosing IGD or a similar diagnostic label while pathologising and stigmatising normal gamers. This may lead to use of unnecessary and potentially harmful treatments, such as certain medications and coercive methods for modifying gaming behaviour.

The addiction model of problematic online gaming is misleading

The DSM-5 criteria for IGD were derived from those for substance use disorders and gambling disorder, including preoccupation with online games, unsuccessful attempts to control gaming, tolerance (defined as a need to spend increasing amounts of time playing online games) and withdrawal symptoms. Thus, the DSM-5 concept of IGD espouses the addiction model of problematic online gaming, which we consider erroneous for several reasons.

First, even if one were to accept problematic online gaming as an addiction, the heterogeneity of online games (i.e. various types of games) and gamers’ motivations for playing (needs to compete, socialise, belong or be accepted, escape from a painful reality, immerse in a virtual world or adopt a different identity) would make it very difficult to understand what gamers may be addicted to. This is in sharp contrast to substance addictions. Second, the addiction model leads to a premature closure in our thinking about problematic online gaming. In other words, it interferes with the development and testing of the alternative conceptual frameworks and hypotheses, for example, that problematic online gaming may be a maladaptive way of coping or a manifestation of an underlying psychopathology. Third, problematic online gaming lacks longitudinal stability and its natural course has been reported to be transient or episodic rather than chronic and progressive (e.g. Rothmund et al., 2016), unlike the typical course of substance addictions. Fourth, limited evidence suggests that individuals with IGD may experience a particularly prominent and rapid decrease in ‘withdrawal symptoms’ (craving/urge, thoughts about gaming, inability to resist gaming) after cessation of online gaming (Kaptsis et al., 2016). This pattern of diminishing and predominantly emotional withdrawal experiences is unlikely to play an important role in maintaining problematic online gaming, which is in contrast to the presumed role of the avoidance of the predominantly physical withdrawal symptoms in maintaining substance addictions. Finally, a recent review of the phenomenology, co-occurrence and neurobiological studies suggests that IGD is more akin to a disorder of impulse control than a behavioural addiction conceptualised as the initially heightened impulsivity followed by prominent compulsivity (Starcevic and Aboujaoude, 2017).

Conceptualising problematic online gaming as a mental disorder is not necessary for gamers to seek and receive help

Problematic online gaming has also been considered a mental disorder because of the notion that seeking help from mental health professionals should be tied to a diagnosis. However, clinical practice abounds with examples of people seeking professional help for problems that are not officially recognised as mental disorders. These include marital and family conflicts, school refusal, sexual assault, chronic fatigue syndrome and non-cardiac chest pain. Services exist for some of these problems, although they are not disorders. Likewise, services addressing the needs of individuals with problematic online gaming could be introduced without converting this behavioural pattern into a disorder.

Alternative approach

Problematic patterns of online gaming merit attention from clinicians and researchers, not least because of the adverse effects of such gaming. At this stage, however, it is premature to conceptualise problematic online gaming as a mental disorder. Instead, we recommend that it should be classified among ‘other conditions that may be a focus of clinical attention’ (‘V codes’) in the DSM system and in the broad category of ‘factors influencing health status’ (‘Z codes’) and the sub-category of ‘factors associated with health behaviours’ in ICD-11. In fact, the latter domain has been proposed as the home for ‘hazardous gaming’, a construct similar to problematic gaming except that it is presumed to be associated with an increased risk of harmful consequences of gaming, but not yet causing harm.

It is important to have a set of diagnostic criteria for problematic online gaming that would be adopted worldwide and facilitate research. The DSM-5 criteria for IGD are not adequate and should be replaced by the criteria that do not impose a constricting conceptual model and leave the construct of problematic online gaming open to further investigation.