The World Health Organisation is on the verge of officially recognising a phenomenon that researchers have been studying since the Super Nintendo era: video game addiction. Scientists and public health advocates who back the move say that compulsive video-game playing is a discrete disorder that can seriously damage a person's mental and physical health. But other experts say that classifying a common behaviour like gaming as a potential disease is scientifically unsound and might even repopularise an old stigma against gamers.
Since 2011, the WHO has been publicly working to develop the 11th edition of its International Classification of Diseases (ICD) codebook, a handy guide used by doctors and hospitals around the world to diagnose and keep track of most every illness and injury under the sun. Similarly, insurance companies rely on ICD codes when deciding whether to cover a particular treatment. This December, the WHO added the code "gaming disorder" onto the beta draft of the ICD-11, which has been made available online.
The WHO's proposed definition of gaming disorder, nestled under a larger umbrella of disorders caused by behavioural or drug addiction, describes it as "a pattern of persistent or recurrent gaming behaviour" that takes over someone's life - to the point they can hardly think of or do anything else - and causes negative social consequences. That can include ruining relationships, job prospects, or school performance. Lastly, it says this pattern should at least last for 12 months or more to be diagnosable, but that the "required duration may be shortened" if symptoms are severe enough.
Another proposed code for "hazardous gaming" refers to "gaming, either online or offline that appreciably increases the risk of harmful physical or mental health consequences to the individual or to others around this individual."
But how harmful is even the most excessive game-playing? There's no shortage of stories of people's gaming habits getting out of control and becoming unhealthy, particularly in Asian countries where the culture has treated video games like a national sport. For instance, in January 2015, two men in Taiwan died - weeks apart -- after days-long gaming binges at an internet cafe. And in America earlier this year, a 35-year-old Virginia man died of a heart attack near the end of a 24-hour gaming marathon being streamed online via Twitch.
The WHO isn't the only organisation to consider label for video game addiction. In 2013, the American Psychiatric Association placed "Internet Gaming Disorder" on a list of conditions to keep an eye on when they released the 5th edition of their codebook, the Diagnostic and Statistical Manual of Mental Disorders. This classification means the condition could be officially recognised in future editions, if later research verified its existence.
It's clear that compulsive gaming, like compulsive gambling, uncontrollable drug use, or any other obsessive behaviour, can be harmful. The controversy (and it's quite heated) comes in when deciding whether or not gaming could truly become a health disorder. Critics of the WHO decision like Chris Ferguson, a psychology professor at Stetson University in Florida who has studied how video games affect society, say we still haven't come close to demonstrating that video game addiction could be a "real" mental illness in the same sense as schizophrenia or depression.
"This was a very poorly thought out decision [by the WHO]," Ferguson told me in an email. "The evidence we now have suggests that 'gaming disorder' is merely symptomatic of other, underlying mental health problems and that gaming is often used as a coping mechanism for these problems."
"Undoubtedly some people overdo games just as they overdo food, sex, work, dance, etc., but there's no real rationale for an independent gaming disorder diagnosis," Ferguson said.
Another critic, Espen Aarseth, a professor of game studies at the University of Copenhagen in Denmark, said a major flaw underlying the study of video game addiction is that researchers have historically treated it like drug addiction, especially in the checklist of symptoms and survey questions they use to diagnose it. These checklists, he says, "are not suited to uncover any real addiction to purely recreational, cultural, social activities." Unlike heroin, he said, just about everyone has played video games at one point in their lives.
Andrew Przybylski, an experimental psychologist at the University of Oxford, said that, at best, video game addiction could be seen as a subset of gambling addiction. But Przybylski said there have been no careful, high-quality science comparing the two, a problem, he adds, that plagues the entire field of video game addition research.
As an example, Przybylski points out that research into how common video game addiction is often relies on surveys of Reddit users or other online samples. And he notes that there's no still clear consensus on how to even diagnose video game addiction: Different researchers use different criteria, which leads to estimated rates of addiction among regular gamers that range from 0.5 per cent to over 40 per cent. "We are missing rigorous, open, and preregistered science," he told me. "We need open science, good samples, and to stop sensationalising our work for university press releases."
In 2016, Ferguson, Aarseth, and Przybylski were among 26 researchers to send an open letter to the WHO, after a proposal to include "gaming disorder" in the ICD-11 first emerged online. Along with the above criticisms, the letter warned that even proposing video game addiction as a diagnosis would only stigmatised video games for the millions of kids (and increasingly older adults) who play them.
Ferguson believes the WHO's decision was motivated not only by science but politics as well. As proof, he cites an email discussion he had with Vladimir Pozynakv, the technical lead on the ICD-11 proposals for Disorders Due to Substance Use and Addictive Behaviours. In one email, Pozynakv described fielding strong requests "from our stakeholders to take into consideration the health aspects of excessive gaming[.]" A similar email sent to Ferguson by another WHO official discusses the "enormous pressure, especially from Asian countries, to include this," seemingly in reference to the proposed condition.
But Pozynakv denies any characterisation of the WHO being influenced by politics in deciding to code video gaming addiction. He said it was in fact the DSM inclusion in 2013 that sparked the WHO into investigating whether gaming disorder should be part of ICD-11, and that the WHO ultimately decided to recognise it following extensive consultations among WHO researchers, as well as the collective recommendation of experts brought together by the organisation through working groups.
"I can tell you, and this should be considered a statement, that there was no formal pressure or any formal communication from any WHO member states regarding the inclusion of gaming disorder onto the ICD-11," Pozynakv told me over the phone. "What indeed took place is that in a number of countries, there was a concern expressed by public health officials, by clinicians, by other health professionals, about the individuals who suffer from this disorder. And about the implications this condition could have on other domains of health; on family functioning, social functioning, etc."
"[Any formal pressure] did not happen. It did not take place," Pozynakv emphasised.
And while Pozynakv acknowledged there are still swirling debates about the ins-and-outs of gaming disorder, he noted that plenty of researchers have defended the WHO's decision and rebutted the arguments made by Ferguson and others.
That includes Mark Griffiths, a researcher at the International Gaming Research Unit and Professor of Gambling Studies at Nottingham Trent University in the UK, who was one of the first people to ever study gaming addiction in the 1990s.
Griffiths agrees that we need to nail down how to better diagnose video game addiction, even arguing recently that there's still no scientific consensus. But in a paper addressing the criticisms by Ferguson and others, he and his colleagues argued the science underlying video game addiction has improved by leaps and bounds in recent years -- now incorporating research showing it can be found in countries across the world and brain-imaging data that suggests it might manifest similarly to drug addiction. Griffiths also pointed out there are already clinics (in countries including South Korea) that are treating people whose gaming habits are hurting themselves and others around them, indicating the importance of a concrete diagnosis that patients and doctors can use.
"I have published more papers on video game addiction than anyone else in the world so I am absolutely behind this decision as it validates my three decades of research in this area," Griffiths told me in an email. "As far as I am concerned there is more than enough evidence that it exists."
Despite the ongoing dispute, both sides agree that unhealthy gaming shouldn't be seen as something that affects anything more than a slim minority of gamers.
"It's similar to what we have with gambling, alcohol use, tobacco use, etc. People who drink alcohol, most of them don't have any signs of alcohol use disorder; people who buy lottery tickets, most of them don't have anything close to gambling disorder. So we are not at all pathologizing normal behaviours," Pozynakv of WHO said. "We are talking about a very specific condition, with specific criteria. And only a very small proportion - probably no more than one per cent of some populations - who would qualify for the disorder out of all gamers."
The ICD-11, and its inclusion of gaming disorder, is expected to officially debut next year, though it may take years before most countries exclusively use it. But as to whether video game addiction can be considered a disease akin to alcoholism, it's unlikely that even a WHO-endorsed label will settle the fierce debate.