The recent World Health Organisation decision to include 'gaming disorder' in its latest draft of the International Classification of Diseases (ICD-11) has opened the floodgates for criticism in academic, industry, and consumer circles.
Despite what you may have heard, 'gaming disorder' is not officially recognised just yet; the recommendation has been put forward, but review process will take place over the next year.
Even staunch critics of the decision -- such as Oxford University professor Andrew Przybylski who co-authored a paper titled 'A weak scientific basis for gaming disorder: Let us err on the side of caution' in the Journal of Behavioural Addiction -- agree it's by no means final, but rather "another step in a process" and in fact presents a new opportunity to discuss and and dissect the issue.
"It's being published, but it's no more final than it was back in January," Przybylski tells GamesIndustry.biz. "We still obviously think this is premature, but it offers those in the games industry a chance to get realistic about what their role is here.
"As a kid of open, transparent, and robust science... I really think that the people who make games have a role to play here. We really need to collaborate with the industry. Game makers collect and control so much data and the real problem is that this literature is closed.
“We still obviously think this is premature, but it offers those in the games industry a chance to get realistic about what their role is here”
Andrew Przybylski, Oxford University
"There isn't the data, nobody pre-registers their hypothesis -- present company excluded -- and actually this step toward formalising really is a renewed call for solid research. I can envisage those who make games being a really positive part of that... That's going to involve on one end some soul searching with mechanics like loot boxes, and on the other end it's going to require cold, hard data, and I can tell you that data is really hard to get."
Until now, the WHO has kept its process entirely separate from commercial interest -- whether that be trade bodies, developers, or publishers -- and has not consulted with industry stakeholders at any stage.
Speaking with GamesIndustry.biz, Dr Vladimir Poznyak, coordinator for the WHO Department of Mental Health and Substance Abuse, explains the decision which has attracted ire from the industry in particular.
"Developing classification of disorder is a core normative function of WHO, and it does everything possible to avoid interference from commercial and other entities which may have vested interest in the outcome of the process," he says. "So for that reason, and this is exactly in accordance with WHO rules and procedures, we did not consult with the industry."
There is, Dr Poznyak says, still the opportunity for a dialogue with the industry around what role it can play in reducing the burden associated with the condition.
"We consider a possibility to have a dialogue with the gaming industry, to exchange views, and to clarify many things, but the main issue is to discuss what they can do in their role as developers and distributors of games, what they can do in reducing the public health problems," he says. "I don't exclude this possibility, but let's make it clear, it's seperate from the process which lead to normative guidance of the WHO."
A divisive issue to be sure, the inclusion of 'gaming disorder' in the DCM-11 draft has raised a number of questions which went broadly unanswered by the WHO in the immediate wake of the news.
“[The WHO] does everything possible to avoid interference from commercial and other entities which may have vested interest in the outcome of the process”
Dr Vladimir Poznyak, the World Health Organisation
One such question regarded what the clinical utility of formalising 'gaming disorder' as a condition actually was, and what would it achieve.
"The inclusion of gaming disorder into classification is that it provides health professionals the possibility to identify this disorder, to diagnose it if it is present, and to link to the client all of the knowledge there is available about gaming disorder," explains Poznyak. "This allows us to predict its cause and to identify the most appropriate prevention and treatment interventions.
"There are some other aspects, like for example the possibility to assign a code to allow monitoring the trends in treatment demands. There is of course, related to clinical utility, better communication among health professionals -- particularly from different countries -- when they are talking about the same concept."
Essentially, 'gaming disorder' has become an increasingly recognised condition among medical professionals around the world. As such, treatment programs have been set-up without international oversight; the WHO's decision to formalise it as a condition has been done so with the intention of adding cohesion and coherence to how the disorder is defined and treated.
The WHO has offered a very strict definition of 'gaming disorder' as a pattern of behaviour, generally lasting longer than a year, which sees an individual lose control over their gaming habits at the cost of their personal well-being which can lead to "significant impairment in personal, family, social, educational, occupational or other important areas of functioning".
A definition worded explicitly to include only the most extreme cases of 'gaming disorder', Dr Poznyak refutes the assertion from critics that formalisation of 'gaming disorder' will not only result in moral panic, but is itself a product of it, as suggested by Przybylski and his colleagues in the Journal of Abnormal Behaviour.
“This moral panic lives its own life. I would suggest this life is different from developing normative guidance when it comes to clinical conditions”
Dr Vladimir Poznyak, the World Health Organisation
"If you look at mass media, there are sometimes very scandalous stories," Dr Poznyak explains. "But at the same time, in the process which led to the conclusions for ICD-11, we based our deliberations on scientific evidence, on clinical records, on what we are seeing in trends of treatment demand in different countries... These media reports were not a part of our consideration."
Dr Poznyak highlights the decision by the American Psychiatric Association to include 'internet gaming addiction' as a topic for further study in the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition, suggesting it is already a "clinical reality".
"This moral panic lives its own life," says Dr Poznyak. "I would suggest this life is different from developing normative guidance when it comes to clinical conditions, and the diagnostic classification for healthcare professionals. It's a different issue and I can say I don't see any influence of whatever can be described as moral panic on the processes that were involved in ICD-11 development."
Another stance against the decision is that 'gaming disorder' is little more than a symptom or coping mechanism for other mental health issues, as suggested in the article 'A weak scientific basis for gaming disorder: Let us err on the side of caution' where it was argued that conflating gaming disorder with substance abuse is a "comparison we consider misleading to the public and lacking in sound evidence".
"Some people may play excessively as a method of coping with other mental health issues," it reads. "For others, gaming could be a way to avoid unpleasant activities such as work or school as part of an existential crisis about the direction of one's life... If we equate coping or responding to problems with a mental disorder, this will further expand the elastic boundaries of psychiatric diagnosis. They might stretch to the point of meaninglessness, potentially resulting in a dismissive view of behavioral addiction research."
Dr Poznyak and the WHO disagree, saying assessment of an emerging condition requires that attention is paid to differential diagnosis with other conditions, and differential diagnosis with normality. Additionally, the WHO paid particular attention to the prevalence of comorbidity -- the presence of one or more additional diseases or disorders occurring simultaneously with a primary disease or disorder -- with 'gaming disorder' and mental health issues such as depression or anxiety which are also prevalent in substance abuse.
“If we equate coping or responding to problems with a mental disorder, this will further expand the elastic boundaries of psychiatric diagnosis”
'A weak scientific basis for gaming disorder: Let us err on the side of caution' in the Journal of Behavioural Addiction
"For example, if you take gambling disorder, or substance misuse disorder, you will have a very high comorbidity with other conditions," says Poznyak. "It may be more than 50 per cent, but it does not mean the clinical entity itself does not exist. This is exactly right for gambling disorder, [and] for opiate use disorder, for example, where comorbidity is very high. Absolutely the same we can say about gaming disorder. Yes, indeed there are some other conditions that can be diagnosed in the same person -- not always -- but at the same time it is a quite distinct clinical entity which can be diagnosed and differentiated from other conditions."
The assessment process itself was criticised by cultural commentators and academics alike for lacking in transparency, academic rigour, or adherence to the scientific method, something which Przybylski said was a damning indictment of the WHO.
"Like many things, the process of identifying new disorders is a human enterprise so there is going to be political interest, and there's going to be research interests and, whether or not we want to admit it, there's going to be interest in terms of grants and papers and the currencies of academia," he tells GamesIndustry.biz.
"It is damning, but it's also realistic, and so if I join 30-plus of my colleagues pointing out there isn't consensus, and the WHO press release claims there is consensus, there's obviously a disconnect there. The question is obviously about whether that disconnect is good or bad; the question is, what are we going to do about that disconnect? Is this really how we're going to grind forward? I would argue the stakes are too high to imagine that there are people who are right and people who are wrong. The thing that needs to happen is there needs to be open and robust science, because only when we settle on what the facts are can we really start having opinions."
“The thing that needs to happen is there needs to be open and robust science, because only when we settle on what the facts are can we really start having opinions”
Andrew Przybylski, Oxford University
Ultimately, this lack of transparency has been one of the biggest the issues, especially in relation to public discourse. The WHO press release claims there is a scientific consensus on the debate -- there was a unanimous decision, but only within the ranks of WHO experts -- and the organisation confirmed to GamesIndustry.biz that it carried out no new research on the disorder.
"There were no studies which generated knowledge," he says. "We based our deliberations, on the studies which were [already] published. We made special efforts to look at the clinical description in different parts of the world. We commissioned systematic reviews of the literature which can inform deliberation of experts in our group.
"There was a consensus among our experts, but let me emphasise the consensus of WHO experts doesn't mean the consensus of all researchers or people who are looking at this problem. For any condition, we will never have 100 per cent consensus among researchers and clinicians.
"It's very normal, nothing unusual, but our experts were unanimous in conclusions that we had sufficient evidence to speak about gaming disorder as a particular clinical condition, which has particular features, particular cause, and the health professionals around the world need to have an ability to recognise this condition, and prevent and treat when it's needed."
It is worth reiterating that while 'gaming disorder' has been added to the latest version of the ICD-11, it is only a draft. As such, it is subject to change over the forthcoming year-long open consultation process before the WHO General Assembly approves it in May 2019.
Even then, the ICD-11 won't be officially adopted until January 1, 2022 and it could still take many years before countries implement those changes into their healthcare.
Industry trade bodies such as UKIE have been quick to speak out against the WHO's decision, while our own Rob Fahey has suggested the games industry needs to be more cooperative as the organisation proceeds with the next step of the process.