Earlier this year, the World Health Organization (WHO) announced plans to include gaming disorder—video gaming that interferes with other life responsibilities—in their International Classification of Diseases (ICD)—despite considerable controversy, including condemnation by the media, technology and arts divisions of the American Psychological Association and the Psychological Society of Ireland. There is no consensus among scholars as to whether the disorder is real or a phantom created by moral panic. Some people undoubtedly overdo gaming, but that’s also true of many other activities, such as exercise, sex, shopping, work, religion, cats (see cat hoarders), dance and even fishing. Nothing has emerged to justify why the WHO singled out video games—other than that gaming addiction is big news, particularly to older adults, and these other behavioral overuse issues are not.
Evidence suggests that gaming disorder isn’t a disorder at all, but a symptom of other mental health issues, such as depression, anxiety or ADHD. Games are simply a coping mechanism for people with other conditions, so the psychiatric focus on gaming is largely misguided. Although some argue that gaming disorder may represent a challenge for the video game industry, I would suggest that the inclusion of gaming disorder only shows how nonsensical psychiatric diagnoses have become.
Psychiatry has had a controversial history since its emergence in the late nineteenth and early twentieth centuries. Many therapies from those early years now seem blatantly abusive, pseudoscientific and cruel—especially the practice of lobotomy, purposefully damaging the brain to increase compliance in mental patients. Egas Moniz, who developed this horrid procedure, won a Nobel Prize in Medicine for it in 1949. Psychiatrists also used insulin to put people into comas and then burned their brains with electric shocks (in a method far less controlled than modern electroconvulsive therapy). Diagnoses were a hodgepodge of early neuroscience and Freudian psychobabble.
By the mid-twentieth century, psychiatry had been revolutionized by two developments. The first was a shift toward drug-based treatments; the second, the introduction of the American Psychiatric Association’s Diagnostic and Statistical Manual (DSM) which, alongside the ICD, was designed to make psychiatric diagnosis more reliable. Whether it did so remains controversial.
Debates about the inherent validity of psychiatry have persisted for decades. Crucial debates focus less on whether mental illness exists (though some, such as psychiatrist Thomas Szasz, have argued against an illness model of mental health) but on whether the margins of mental illness and normal human complaints are well defined. Specifically, to what degree do conflicts of interest, such as cozy personal and financial relationships between psychiatrists and the pharmaceutical industry, prompt an ever-expanding conceptualization of mental illness? And to what degree do DSM and ICD definitions describe normal behaviors and experiences, rather than pathological ones?
Gaming disorder is the first disorder that specifically pathologizes (and potentially stigmatizes) a hobby. But this is by no means the first time that the continual expansion of psychiatric diagnoses has caused alarm. As Gary Greenburg writes in his study of the DSM, The Book of Woe, the release of DSM 5 in 2013 was met with significant controversy, even among psychiatrists who’d been involved in earlier versions of the manual. There was concern that psychiatrists were using ever sketchier and less reliable definitions of mental illness to expand the reach of psychiatry into normal life.
Perhaps the most famous of these controversies concerned the removal of the grief exemption from the definition of depression. Under previous DSMs, major depression could not be diagnosed in an individual experiencing a major grieving episode, such as following the death of a loved one. The removal of that exclusion was passionately defended by some psychiatrists. However, it undeniably means potentially providing medical care to an individual experiencing a wholly human response to an adverse event.
Maladies of the mind exist. But, in many cases, it has been difficult to identify clear biological sequelae, as we can for conditions such as cancer, heart disease or anthrax. This has made it difficult for psychiatrists to clearly delineate the margins of normal and abnormal behavior—margins which may simply not exist as neatly as they do for physical illness (for example, you either do or don’t have smallpox).
Thomas Szasz argues that, too often, psychiatry medicalizes undesired behaviors or stigmatized groups. Homosexuality, for example, was included in the DSM for many years. This phenomenon may also be at play with gaming disorder, given that lots of older adults just don’t like gamers. The WHO could have avoided controversy by creating a behavioral regulation disorder, applicable to a wide variety of behaviors, rather than singling out gamers for disapproval. This raises the question of who the audience is for the concept of gaming disorder. In several email exchanges, the WHO acknowledged to me that they are under pressure from “Asian countries” (their words) to make the diagnosis happen. This suggests that a mental health disorder has been created for sociopolitical reasons: to appeal to authoritarian political interests and to a cadre of older adults antagonistic toward video games.
One influential study from 1941 refers to the addictiveness of radio. It is not difficult to imagine that—had the ICD been more involved in the formulation of psychiatric diagnoses at that time (their involvement did not begin in earnest until the 1960s)—we might have ended up with concept of radio addiction, which would seem absurd to us today. My prediction is that gaming disorder will appear equally absurd in a few decades—once the older adults who are suspicious of gaming have died. It damages the credibility of psychiatric diagnosis when psychiatry allows itself to be sucked in by a moral panic, and to lend that panic a false veneer of science.
Some people have asked me how long we’re likely to be stuck with gaming disorder. It’s hard to say. Some disorders, such as Dissociative Identity Disorder (formerly Multiple Personality Disorder), have remained official diagnoses, despite decades of controversy as to whether they describe real phenomena. By contrast, homosexuality was removed from the DSM—but only because social attitudes towards homosexuality had finally changed. As the social perception of homosexuality evolved from deviance to a perfectly acceptable sexual orientation, the DSM was forced to follow suit. This points to the alarming degree to which social narratives help define mental illness—something which does not happen with, for example, influenza or colon cancer. As attitudes toward gaming change, so too will perceptions of the validity of gaming disorder. As of yet, the DSM hasn’t followed the ICD in making gaming disorder official, although it has designated an unofficial internet gaming disorder category for future study. Whether the DSM will follow the ICD in creating an official diagnosis is unclear.
The inclusion of gaming disorder in the ICD is a red flag. It’s time to reevaluate the degree to which psychiatry has invaded normal life, and examine the conflicts of interest—particularly the financial and political—that explain why this has occurred. Some disorders should immediately be suspect, namely:
• Disorders that appear to be products of a particular historical moment. Gaming disorder and radio disorder are obvious examples, since neither could exist without their respective technologies. By contrast, depression, schizophrenia or a behavioral regulation disorder could exist at any point in history. Real mental illnesses are not historically specific.
• Nor are they culturally specific. This was the problem with the diagnosis of homosexuality. Culture can contribute to mental health issues. Individuals can be driven to depression or anxiety by an unwelcoming society. But, if those same individuals can be happy and functional in a tolerant society, while causing no harm to others, they are not suffering from a mental illness. Mental illness can express itself differently across cultures. But disorders of the brain result from problems within the brain, not within culture. A focus on culturally dependent disorders invites stigmatization of certain cultures or groups.
• Mental illnesses that appear to promote a moral, political or ideological agenda should be suspect. Many behavioral addictions (possibly even cannabis addiction) fall into this category, insofar as they conform to Szasz’s comments about pathologizing unwelcome behaviors.
Psychiatric diagnosis, when data-based, reliable and valid, can be part of the road to recovery for many people suffering from mental illness. But many diagnoses have gotten out of hand because of increasingly loose and unreliable diagnostic criteria, or the lack of a good scientific or clinical foundation for the disorder in the first place. Such poor quality diagnoses can stigmatize people who are simply different, foster ongoing moral panics, result in overmedication and lead to misdiagnosis of real conditions, such as depression or anxiety, in favor of rubbish disorders like gaming disorder. The system of psychiatric diagnosis is currently experiencing a reliability crisis. We need to reconceptualize the boundaries of mental illness and insist on high quality, pre-registered, transparent science to underpin the reliability and validity of our diagnostic systems.
Gaming disorder does indeed represent a crisis for an industry. However, it is a crisis for the industry of manufacturing mental disease, not for the entertainment industry.