Full disclosure – I am an avid video gamer. I have been since Pong first came out in 1972, and I have enthusiastically indulged in video games all the way to the current virtual reality games. Playing video games has always been one of many recreational activities I engaged in, always in moderation, and has never taken over my life. OK – there was this one stretch in 1994 after Doom was released where I played more than I should have, and I had to delete the game from my computer. But otherwise, video games have been a fun and harmless pleasure.

For some, however, video games do take over their lives. For this reason the World Health Organization (WHO) recently added Gaming Disorder to their official list of health conditions in the International Classification of Diseases (ICD-11). Many are calling the disorder “gaming addiction,” although the term “addiction” should probably be reserved for biological addiction to substances. Gaming disorder, rather, is a pure compulsive behavior.

So what is gaming disorder?

Gaming disorder is defined in the draft 11th Revision of the International Classification of Diseases (ICD-11) as a pattern of gaming behavior (“digital-gaming” or “video-gaming”) characterized by impaired control over gaming, increasing priority given to gaming over other activities to the extent that gaming takes precedence over other interests and daily activities, and continuation or escalation of gaming despite the occurrence of negative consequences.

For gaming disorder to be diagnosed, the behaviour pattern must be of sufficient severity to result in significant impairment in personal, family, social, educational, occupational or other important areas of functioning and would normally have been evident for at least 12 months.

This is a pretty standard pattern for psychologically-based diagnoses. A “disorder” is defined as an impaired ability or function, a symptom, or a behavior that is persistent, perceived as negative, and causes demonstrable harm. There isn’t necessarily any pathology, and therefore there is no disease. That does not mean disorders are not real.

The brain is the organ of mood, thoughts, and behavior. The function of the brain is dependent upon not only the health of the various types of brain cells, but the pattern, strength, and function of connections. There are therefore many potential types of mental disorders that involve only the pattern of connections, without any classical cellular pathology.

The function of the brain is also dependent on biological as well as environmental factors. It’s complicated, and teasing apart the cause(s) of any identified problem behavior is also complex. For this reason mental disorders are primarily characterized by their clinical features – the pattern of mood, thoughts, and behaviors that typify them. Something as complex and chaotic as human behavior defies any attempt at unambiguous categorization, so there is a lot of overlap and fuzzy boundaries, but it is still possible to identify different basic types of disorders.

This is what the new WHO classification attempts to do. The other relevant document to this question is the DSM – the handbook of mental disorders. The American Psychiatric Association (APA) added “Internet Gaming Disorder” as a “condition for further study” in the DSM-V. So it is not yet an official diagnosis, but they want clinicians to give it a try and let them know how it goes. Is it a useful diagnosis, and should it be added to the DSM?

Here is their working definition:

1. Repetitive use of Internet-based games, often with other players, that leads to significant issues with functioning. Five of the following criteria must be met within one year:

  1. Preoccupation or obsession with Internet games.
  2. Withdrawal symptoms when not playing Internet games.
  3. A build-up of tolerance–more time needs to be spent playing the games.
  4. The person has tried to stop or curb playing Internet games, but has failed to do so.
  5. The person has had a loss of interest in other life activities, such as hobbies.
  6. A person has had continued overuse of Internet games even with the knowledge of how much they impact a person’s life.
  7. The person lied to others about his or her Internet game usage.
  8. The person uses Internet games to relieve anxiety or guilt–it’s a way to escape.
  9. The person has lost or put at risk and opportunity or relationship because of Internet games.

I don’t know why they decided to limit the diagnosis to internet-based games. The exact same phenomenon can occur with offline games. I suspect the people involved were not gamers. But that nitpick aside, you can see that there is a reasonable operational definition that includes all the elements of a disorder – persistent, negative, and causing demonstrable harm.

As a compulsive type disorder, there is also an element of loss of control. Those with alleged gaming disorder persist in their behavior even when they know they shouldn’t, when it is causing them harm, even ruining their health and their lives. They engage in behavior that is otherwise not consistent with their personality, such as lying and manipulation – behavior typical of addiction.

Of course not all avid gamers have a disorder. Compulsive behavior is a typical human trait, and can be very adaptive. It can make us industrious, it is how musicians and artists master their craft, and athletes excel. Even if art or sports are for pure recreation (and not a person’s day job), we tend not to criticize avid artists or sports players. But being an avid gamer has a bit of an unfair stigma attached to it. That is not what makes it a disorder, however. Again – it has to have a demonstrable negative impact on your life, it has to cause harm.

Like all behavior-based disorders, there is a continuum, and no sharp demarcation line. But still, at one end of the spectrum there is a clear problem that may respond to intervention. So it makes sense to have a label to identify this harmful pattern of behavior, so we can talk about it and research it. There is also a practical angle in that professionals need to get reimbursed for their time, and insurance companies need to know what they are paying for, and so ICD codes are primarily used for billing.

In the end I think gaming disorder is a real thing, and the working definitions of the WHO and APA are reasonable. It is a type of compulsive behavior, like gambling, and is a harmless recreation in moderation, but can be ruinous if it takes on a life of its own. This may occur if there is an underlying disorder, like anxiety or depression, and someone is using the compulsive behavior to self-treat. Some people may have a compulsive personality type. Others may get into a compulsive pattern of behavior for a variety of non-specific reasons.

Perhaps it is often the case that gaming disorder, or another harmful compulsive behavior, is more of a symptom of deeper problems in someone’s life. It is still a useful entry point to address those deeper problems, and it has become a problem unto itself that needs to be addressed.

Like all such disorders that are one end of a spectrum of behavior, it is important to stick to strict diagnostic criteria, and be wary of diagnosis creep. That’s bound to happen, but it also does not mean that gaming disorder is not real.

Finally, I don’t think that gaming disorder is a unique or entirely new phenomenon. It is simply a cultural manifestation of a more general compulsive behavior disorder. Humans, to an extent, are not much different than rats. We have a reward system wired into our brains. When we pull that lever and get a reward, something that gives us a pleasant shot of dopamine, we will pull that lever again and again. It’s built into the system. We just need to know when to stop pulling that lever. For some people it’s easier said than done, and they may need some help taking their hand off the lever.


Posted by Steven Novella

Founder and currently Executive Editor of Science-Based Medicine Steven Novella, MD is an academic clinical neurologist at the Yale University School of Medicine. He is also the host and producer of the popular weekly science podcast, The Skeptics’ Guide to the Universe, and the author of the NeuroLogicaBlog, a daily blog that covers news and issues in neuroscience, but also general science, scientific skepticism, philosophy of science, critical thinking, and the intersection of science with the media and society. Dr. Novella also has produced two courses with The Great Courses, and published a book on critical thinking - also called The Skeptics Guide to the Universe.