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Is the WHO inventing diseases? There's little evidence for 'internet gaming disorder'

Players compete in the Fornite World Cup (JOHANNES EISELE/AFP via Getty Images)

Players compete in the Fornite World Cup (JOHANNES EISELE/AFP via Getty Images)


November 24, 2021   6 mins

Can you be addicted to video games? In 2018, the WHO decided to create a new entry in its big book of recognised diseases, the International Classification of Diseases, or ICD-11. That entry was “gaming disorder” or “internet gaming disorder” (IGD), also known as gaming addiction, which involves “impaired control over gaming
 gaming [taking] precedence over other life interests and daily activities
 [and] negative consequences”.

You can even be treated for it. You can get specialist treatment at a dedicated NHS clinic. South Korea has gaming “rehab centres”. Gaming addicts have “lost interest in their own lives” and “​​do not feel the passing of time in the real world”, according to a doctor who treats the condition there.

But it is far from clear that “gaming disorder” or gaming addiction exists, at least as a well-defined condition separate from any other compulsive behaviour; and there is a hint that the WHO has made the decision under political pressure from China and other countries. 

The WHO says that its decision was based on “reviews of available evidence and reflects a consensus of experts from different disciplines”. But when you look at WHO-commissioned evidence, the studies are completely wild. This review of the literature carried out on behalf of the WHO found that “the prevalence of IGD ranged from 0.21-57.5% in general populations”. This one was rather less crazy, but the studies it was aggregating found that between 0.16% and 14% of people had the disease. Another found 0.7% to 25%.

For comparison, about 8% of people who take opioids in the US end up addicted. So video games might, if we take those numbers at face value, be several times as addictive as opioid painkillers, which seems
 unexpected. Or, equally, it could barely exist at all.

“The problem,” says Dr Pete Etchells, a psychologist at Bath Spa University and author of Lost in a Good Game, “is that depending on your definition, your understanding of who has or doesn’t have this disease varies wildly in the literature”. That is because, he says, “we don’t know what it looks like, we don’t know what it is, and we don’t know what its unique features are that separate it from other behavioural or impulse disorders”.

Obviously, some people have problems with playing video games too much. You will have read stories about South Korean teenagers wetting themselves rather than getting up from their gaming chair, or people developing blood clots. But rare anecdotes don’t tell us much about the wider problem, and people can develop problematic relationships with almost every form of enjoyable human activity — with exercise, with sex, with tanning.

The question is whether there is something unique to gaming which causes these problems. Dr Andy Przybylski, a psychologist at the Oxford Internet Institute, has worked on gaming addiction in the past, and argues that — as far as we know — there isn’t. He carried out a study in 2017, which looked at people who were classified as “addicted” to gaming at one time, and checked whether they still were six months later. If gaming “addiction” was comparable to, say, tobacco, gambling, or alcohol addiction, then you’d expect that most people would be. 

But as it turned out, of the 6,000 people recruited, none of them met the diagnostic criteria for gaming disorder at both the beginning and the end of the study. That is, no one stayed “addicted” for six months. Dr Netta Weinstein, another author of the study, told me at the time that it’s “a question of whether a diagnosis is stable”, and it suggests that internet gaming probably isn’t an addiction like smoking or alcohol.

Przybylski, then, was surprised to see that the WHO decided to classify IGD as a separate illness, and has been asking the WHO whether or not they have any more evidence. Recently he received an email which said: “It is challenging, if not impossible, to document and communicate through WHO channels the rationale and justification for each decision.” 

But obviously you can prove, or at least provide strong and convincing evidence for, the existence of most illnesses, and the WHO could very straightforwardly point to that evidence. There’s a reason why Covid denialists are considered crackpots and cranks: because it’s pretty straightforward to develop diagnostic tests which show you the presence of a virus, and you can tell that the presence of that virus correlates strongly with a particular set of negative health outcomes.

With psychiatric conditions, of course, the picture is often messier. You can’t swab someone and see if they have depression; you can only ask them a series of questions, or observe their behaviour. But there are established criteria by which to do so, and when you test someone with one twice, a week apart, they usually give the same answer.

But with gaming disorder, as we’ve seen, that doesn’t seem to be the case. So the WHO creating a new diagnostic category is a big deal. It gives clinicians licence to treat the disorder, and — perhaps more importantly — it tells people, and parents, that gaming disorder is a real thing. “It’s a very emotive topic,” says Etchells. “If you say suddenly that games can be addictive, so many people play them that that can be a really scary thing. We already know that parents are scared and concerned. Throwing it out there without any explanation or caveating, I feel it’s quite irresponsible.” He worries that the WHO decision will pathologise normal, healthy behaviour, like playing video games after work to destress.

The question, then, is why has the WHO done it? They didn’t need to; the American Psychiatric Association hasn’t yet added it to the Diagnostic and Statistical Manual of Mental Disorders, and the Royal College of Psychiatrists hasn’t formally recognised it. 

One possible answer is that the WHO has been pressured into doing it. Professor Geoffrey Reed, a medical psychologist at Columbia University and senior project officer for the WHO’s ICD-11, told another psychologist by email in 2016 that the WHO was “under enormous pressure, especially from Asian countries” to include IGD.

(I’ve asked both Professor Reed and the WHO about this; the WHO has declined to comment at short notice, and if Prof Reed gets back to me, I’ll include any response here.)

There has been huge concern about video gaming in several east Asian countries. In Japan and South Korea, there have been years of worries about the “hikikomori”, young adults who shut themselves off from society, living in their parents’ homes, never leaving, eating delivery food, watching Netflix, browsing the internet and playing games. The phenomenon has also been widely reported in China, Hong Kong and Singapore. These countries are huge consumers and producers of video games, and notably of spectator e-sports, and people have been quick to blame video games for the condition.

And this has led to a widespread reaction which looks suspiciously like a moral panic. South Korea banned under-16s from playing internet games between the hours of midnight and 6am in 2011 to improve children’s sleep, a decision that was only overturned in August. Etchells says that research showed the ban was counterproductive — it increased children’s time on the internet and “had no meaningful effect on increasing sleep”. China recently enacted an even more stringent law, banning under-18s from using internet games between 10pm and 8am. 

Societies are entitled to ban anything they want, of course. But the concern is that they’re hiding behind science to do it. “It’s an extreme example of people pathologising things they find distasteful,” says Dr Stuart Ritchie, a psychologist at King’s College London. “Some people find video games distasteful — they don’t like the idea of kids shooting at each other. But you have to ask what the quality of the evidence is.” Przybylski agrees: “If people want to create rules, they should create rules. But if you’re saying it’s based on evidence or science, you should show your notes.”

“We’re talking about very complex generational issues, and trying to explain them by looking at one simple factor, and that’s never the case,” says Etchells. If there was a simple causal link, he points out, given the billions of users, you’d expect to see enormous effects, not weird ambiguous trends in messy data.

The trouble is, as Przybylski says, that mental health provision is poorly resourced and expensive. If a teenager is diagnosed with a mental health condition in the UK, he says, “they can age out of being a teenager before you’re seen by a psychiatrist”. Video game addiction, on the other hand, is shiny and exciting, and it sounds cheap, because it seems like there’s an off switch — just turn off the console!

But it comes at a cost. For one thing, even if hikikomori is a real problem in China and other countries, and even if a causal link can be shown to video games, it makes no sense to create a global diagnosis for a highly region-specific problem. For another, it frightens gamers and their parents, perhaps unnecessarily, and gives cover to any old quack or charlatan who wants to promise to treat “gaming addiction” at their expensive clinic, despite there being no clear diagnostic criteria and no agreed treatment.

Most of all, though, there’s a reputational risk for the WHO. “It’s putting its credibility on the line,” says Przybylski. It’s supposed to be a neutral scientific body: it cannot be seen to be making scientific decisions for political reasons. For the last two years, it’s faced criticism of cosying up to China over Covid – praising the Chinese government for transparency and for “setting a new standard for outbreak response” even as it censured doctors for trying to spread the word about the disease. If it transpires that the WHO has put gaming disorder into the ICD-11 as a result of political pressure, whether from China or elsewhere, its credibility will be even more undermined.

The academic community and the WHO have “really dropped the ball” on gaming disorder, says Etchells, rather than being brave enough to stop, take stock, and work out whether it really exists at all as a coherent concept. “I can see how it’s difficult for the WHO to go against these strong opinions, but they need to,” he says. “They can’t come up with disease classifications built on politics.”


Tom Chivers is a science writer. His second book, How to Read Numbers, is out now.

TomChivers

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Ferrusian Gambit
Ferrusian Gambit
2 years ago

Luckily the WHO hasn’t been pressured into classifying internet addiction yet or half the regulars of this comment section would be receiving visits from men in white coats.

Last edited 2 years ago by Ferrusian Gambit
J Bryant
J Bryant
2 years ago

So long as the cure is a bottle a day of full-bodied Merlot, I’m cool with the diagnosis.

Warren T
Warren T
2 years ago
Reply to  J Bryant

A full bodied Merlot? You might want to try a Cabernet Sauvignon first.

Jon Hawksley
Jon Hawksley
2 years ago
Reply to  Warren T

Full bodied – a Cahors Malbec

Dennis Boylon
Dennis Boylon
2 years ago
Reply to  J Bryant

Sorry. You’ll need a MRNA injection and at least 8 boosters

Chris Wheatley
Chris Wheatley
2 years ago

Perhaps a tongue in cheek comment? Not so for younger people. Of course, there are treatment centres to help to stop you from looking at your phone too much.

Galeti Tavas
Galeti Tavas
2 years ago

Well, that’s me chastised, Ferrusian. My problem is not merely internet addiction, it is that I dislike my work, am 100% self employed, and do not have to work if I do not want to, yet I have unlimited amounts of work if I chose to work…. Therefore my time is all spent actively avoiding going to actual work, and that means sitting here doing this is the default way of spending much of my time, instead of using tools and building stuff – which is no fun: construction is no fun. Having a Boss is a great good; as you have to work, without one you must always beat yourself to get to work, and not working when you stop beating yourself, Like now.

I should be out in a densely wooded, (thicket) wooded lot I am to begin construction on shortly – and putting surveyors tape on the trees that need to be uprooted- which means a lot of work and thought, and making decisions, and dreading the job which this is prepping for…. So much easier to sit here just chatting into the void……

Warren T
Warren T
2 years ago

I’ll wait for the disorder to qualify as a reason for receiving permanent disability checks before I buy a gaming chair.

Dustshoe Richinrut
Dustshoe Richinrut
2 years ago

A kid hooked on playing video games all day and night could just say to the powers-that-be that a child prodigy pianist gets to play the piano all day and all night.
The problem for Western society though is that the great pianists will come through: they are brought up in homes in which it might be shameful to get involved in video-game playing. Too low brow and vulgar and all that; though the great pianists will still come through, guitar maestros will not.
In homes where video gaming is rife, many a talent will go unrealised.
The crutch of the mobile phone or the video game machine has already replaced the crutch of the guitar as far as any dreamy youths with artistic aspirations are concerned.

The invasion of video-gaming is not great for short childhoods. Only seven years are you a teenager.
Music’s had it. Popular music.

Last edited 2 years ago by Dustshoe Richinrut
Chris Wheatley
Chris Wheatley
2 years ago

This is a very interesting idea and one which is new to me. Basically, anything which does not result in a tangible benefit is a waste of time.

About 20 years ago I night have disagreed with you about playing a musical instrument because it can also give other people pleasure to listen. But in the time of Spotify you get music from your phone.

Many times I have heard it said that old people should learn to ay a musical instrument because the discipline of the fingering gives you the best result. This would obviously be true for games.

In fact, playing music as with playing chess is a very automatic thing. You train your mind to react by doing the same thing over and over and you mind recognises patterns rather than individual notes (or moves). I suspect that game playing is less automatic because there are quite a few different games.

Paul Brown
Paul Brown
2 years ago
Reply to  Chris Wheatley

As someone in their mid-60s, who plays guitar and until recently, way too much Call of Duty (I’ve finally gone cold turkey on it, after many years) can I say that they are basically the same in that both involve finger/hand movement sequences that are repetitiously learnt to the point that they become automatic. In the game, sequences like running and firing, aiming and jumping etc become automatic to the point that if someone asked “what buttons do I press for ducking whilst throwing a grenade” I couldn’t tell them, but I could demonstrate it without even thinking about it. You forget how you consciously do it once its in “muscle memory” . Same with guitar, where chord sequences are coordinated with strums and interleaved note picking in a completely automatic manner – or should be – but in any event, there is no time to think about it, especially if also singing. Back to gaming, it becomes automatic not only at the fast movement level, but also in longer game motions of predicting opponent movements based on body glimpses, or a glance at the map, or a sense that the spawn points have flipped. In guitar playing, the same “expectation” builds during, say, a verse, causing you to switch to the chorus without thinking about it. Both gaming and guitar become automatic at several time scales.

Last edited 2 years ago by Paul Brown
Chris Wheatley
Chris Wheatley
2 years ago
Reply to  Paul Brown

Useful comment for me. I have played chess for about 50 years. People always asked me, “How many moves ahead can you calculate?” In fact, during a long game you often calculate only a couples of moves and you aim to reach a pattern which you recognise. Then the rest is a little automatic with a few checks along the way. The top players have memorised tens of thousands of these patterns and play many games in semi-automatic mode.

Dan Gleeballs
Dan Gleeballs
2 years ago
Reply to  Paul Brown

That was thought-provoking. I play the piano and reading that, I was suddenly worried I wouldn’t be able to! 🙂 There’s clearly no time spent deciding ‘what note(s) come next?’ – it just happens. Has anyone looked at this process? How on earth can musicians play faster than they can think?

Lloyd Byler
Lloyd Byler
2 years ago

“With cold and flu conditions, of course, the picture is often messier. You can’t swab someone and see if they have a cold, a flu or other corona diseases, you can only ask them a series of questions, such as how severe their sniffles, headaches, coughs, etc. are, or observe their behavior. ”

But there are established criteria by which to do so, and, you can… test someone with a PCR lab test swab, once, or twice, every week, BUT, they usually give the same answer because they are so afraid of that big BOOGEY MAN called ‘Covid’, that, the media, the WHO, the medical industrial complex and politicians worldwide have beaten the drum on.

The idea that there is a novel corona virus is as old as the common cold and the seasonal flu has been around, because every season there is a variant of the same.

*The BIG MIRACLE*
Normally, people will deal with the sniffles/coughs, etc. as they usually do, but now they believe that by some miracle the flu and the cold has been CURED because people no longer complain of such symptoms.

NOTE:
THIS IS WHAT PROPAGANDA DOES, IT SHAPES PEOPLE’S MINDS TO BELIEVE SOMETHING COMPLETELY DIFFERENT….

Last edited 2 years ago by Lloyd Byler
Geoffrey Wilson
Geoffrey Wilson
2 years ago

Can I criticise this article for two important but silly statements. First “societies are entitled to ban anything they want, of course”. Sorry, but saying that immediately after reporting a new law in China! Was the CCP “entitled” to persecute Uighurs, Mr Chivers? There are philosophical arguments in support of democracies being entitled to make laws on many things, but let’s not legitimise the CCP.
Second, “most of all, though, there’s a reputational risk for the WHO”. Until a proper review of the WHO and the origins of our present pandemic is available, with recommendations implemented, the WHO has no reputation to risk, surely?

Galeti Tavas
Galeti Tavas
2 years ago

‘Phone Sheep’ who clutch their phone 24 hours a day saying internet is not a health problem. Watch out for that pole you are about to walk into……

Chris Wheatley
Chris Wheatley
2 years ago
Reply to  Galeti Tavas

I remember reading an April Fool spoof. Somebody had just invented an app for your phone which projected the pavement ahead onto your screen. With this image on your phone you were safe from walking into something.

Zorro Tomorrow
Zorro Tomorrow
2 years ago
Reply to  Chris Wheatley

The camera in PinP?

Sharon Overy
Sharon Overy
2 years ago

I don’t know where this modern fad for pathologising everything comes from, but I’m very suspicious of it. It seems likely to be a combination of creating a false need for more regulation and micromanagement of people’s lives and a grift.

Chris Wheatley
Chris Wheatley
2 years ago
Reply to  Sharon Overy

And don’t even start me off by mentioning ‘mental problems’.

John Hicks
John Hicks
2 years ago

They can’t come up with a disease classification based on politics! How terrifying a prospect is that? The humanity of our species, regardless of tribe or affiliation, cannot entertain the creation of diseases by evil monsters of this kind.

Andrew Horsman
Andrew Horsman
2 years ago

Would love to know what Tom Chivers’s definition of “Covid denialist” is, or is it just a lazy label that he’s employing to attempt by association to besmirch the many readers – and subscribers – who have criticised his previous articles in which he has, knowingly or not, trotted out the party line on Covid?

As Tom Chivers no doubt well knows, it’s not “pretty straightforward” to develop diagnostic tests to reveal “the presence” of a virus. Implying, as he does, that those who question the accuracy or appropriateness (let alone the ethics) of such fallible tests belong to the same category as those who outright deny the existence of the virus that causes common cold-like or pneumonia-like symptoms that the WHO has decided to label “Covid-19” is actually quite some insult to the intelligence and integrity of his readership.

Tom, please could you offer an explanation or an apology for this? Either would be gratefully and graciously received.

Dennis Boylon
Dennis Boylon
2 years ago

Covid was a hit. Why not more?

Zorro Tomorrow
Zorro Tomorrow
2 years ago

Hush yourselves. National Service. Meh! And not necessarily armed. Building, plumbing, carpentry, electrical skills. Go out and repair something. Insulate an elderly person’s house and pi## of the M25 gang. Best of all keep the young away from universities until they are less impressionable. They may even be worth arming should the need arise.

David Slade
David Slade
2 years ago

Shouldn’t we pathologise the tendency of technocrats to overly pathologise everything?

Addiction proscription addiction? Lots of psychologists suffer from APA; please give what you can etc.

Jon Hawksley
Jon Hawksley
2 years ago

An email from WHO stating “It is challenging, if not impossible, to document and communicate through WHO channels the rationale and justification for each decision.” is a much greater risk to their reputation than a daft classification of a disease. WHO exist to get more out of the national health bodies and researchers than they can achieve on their own. It needs to be a forum that sets high standards for research, gets researchers working to common goals rather than individual glory and ensure consensus is reached with impartial debate.
A meta study of Covid research in the BMJ considered “a total of 36,729 studies, of which 36,079 were considered irrelevent. After exclusions, 650 studies were eligible for full text review and 72 met the inclusion criteria. Of these studies, 35 assessed individual interventions and were included in the final synthesis of results and 37 assessed multiple interventions as a package and are included in supplementary material. The included studies comprised 34 observational studies and one interventional study, eight of which were included in the meta-analysis.”
The studies were small, an average of 400 covid cases in 14 studies. Yet as of 14 October 2021, there were 239,007,759 million cases of confirmed covid-19 and 4,871,841 million deaths with covid-19 worldwide.
The WHO are culpable for letting so many researchers produce such meaningless results when so much could have been done with a collaborative approach using the vast amount of data that should have been available from so many cases.

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