November 24, 2021

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.”