ISS 210 Society, the Individual, & Video Games (W1)

Video Game Addiction: The Push To Pathologize Video Games

Anthony M. Bean Framingham State University

Rune K. L. Nielsen IT University Copenhagen

Antonius J. van Rooij Trimbos Institute

Christopher J. Ferguson Stetson University

With proposals to include “gaming disorder” in both the Diagnostic and Statistical Manual (DSM) and International Compendium of Diseases (ICD), the concept of video game addiction has gained traction. However, many aspects of this concept remain controversial. At present, little clarity has been achieved regarding diagnostic criteria and appropriate symptoms. It is unclear if symptoms that involve problem- atic video gaming behavior should be reified as a new disorder, or are the expression of underlying mental conditions. Nonetheless, the recent proposals around gaming disorder from respected bodies such as the World Health Organization and the American Psychiatric Association seem to lock much of the applied research into a confirmatory trajectory. Since the DSM–5 proposal, research is increasingly focused on the application of the proposed criteria, as opposed to broadly testing validity and necessity of the overarching construct. This raises multiple concerns. First, the current approaches to understanding “gaming addiction” are rooted in substance abuse research and approaches do not necessarily translate to media consumption. Second, some research has indicated that “video game addiction” is not a stable construct and clinical impairment might be low. Third, pathologizing gaming behavior has fallout beyond the therapeutic setting. In light of continuing controversies, it is argued that the currently proposed categories of video game addiction disorders are premature.

Public Significance Statement This article argues the basic question of whether or not “video game addiction” qualifies as a mental disorder, as many aspects of Internet Gaming Disorder conceptually remain controversial among researchers and clinicians. The article raises important questions regarding the validity of the evidence, the stability of the proposed construct, and possible clinical pathologizing of a hobby and normal routine behaviors of playing video games.

Keywords: video games, Internet Gaming Disorder, addiction, ICD, DSM

It is no secret many diverse people play video games across the world (Duggan, 2015), sometimes for extended amounts of time. Therefore, it is of little surprise that concerns about ‘game addiction’ have drawn substantial amounts of attention in the news and academic literature (Charlton, 2002). The interest in video game addiction has

spurred parent groups and some researchers to link video games to children’s problematic behaviors, lack of social integration, and aca- demic dysfunctioning. Many of these concerns also fit with stereo- types of gamers as physically unfit, socially awkward, and disengaged from work and school, despite evidence to suggest these stereotypes

This article was published Online First July 6, 2017. ANTHONY M. BEAN received his PhD in Clinical Psychology with an

emphasis in Depth Psychology from Pacifica Graduate Institute. An Ad- junct Professor at Framingham State University, he currently studies and conducts therapeutic interventions for video gamers using depth psychol- ogy and social interventions focusing on media, video games, and video gamers.

RUNE K. L. NIELSEN received his PhD from the IT University of Copenhagen. He currently is an Assistant Professor at the IT University of Copenhagen and works in the Center for Computer Games Research.

ANTONIUS J. VAN ROOIJ received his PhD on the subject of video game “addiction” from the Erasmus University in Rotterdam. He is currently the project lead for Gaming, Gambling, & Media Literacy at Trimbos Institute in the Netherlands, where he focuses on projects and

research that promote the responsible and healthy use of media, video games, and gambling games.

CHRISTOPHER J. FERGUSON holds a PhD in clinical psychology from the University of Central Florida. He is currently a professor of psy- chology at Stetson University. He is a fellow of the APA. He has coauthored a book on video games, Moral Combat: Why the War on Video Games Is Wrong, as well as a mystery novel set in Renaissance Florence, Suicide Kings.

RUNE K. L. NIELSEN has received funding from the European Research Council (ERC) under the European Union’s H2020 ERC-ADG programme (grant agreement 695528).

CORRESPONDENCE CONCERNING THIS ARTICLE should be addressed to Anthony M. Bean, Framingham State University, 100 State Street, Fra- mingham, MA 01701. E-mail: [email protected]

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Professional Psychology: Research and Practice © 2017 American Psychological Association 2017, Vol. 48, No. 5, 378 –389 0735-7028/17/$12.00 http://dx.doi.org/10.1037/pro0000150

378

of gamers are false (Kowert, Festl, & Quandt, 2014). In recent years various privatized treatment centers across the United States, Western Europe and Asia have emerged, specifically aimed at treating a “video game addiction” disorder (Russon, 2016).

However, most video game players do not appear to experience substantial difficulties with balancing their expected social roles outside games with those inside (Przybylski, Weinstein, & Mu- rayama, 2016). At extreme levels of playing, some video gamers have been shown to be encumbered with some problems, albeit not always directly related to their actual video gaming (Chan & Rabinowitz, 2006). At present, there is debate among scholars about the degree to which concerns about video game addiction represent the emergence of a new disorder as opposed to cycles of moral panic focused on new media (Bowman, 2016; Ferguson & the Entertainment Merchants Association, 2013; Price, 2014; Theis, 2016).

A Brief History of Gaming Disorder

Debates over, and research on, video game addiction have been around nearly as long as video games themselves (e.g., Soper & Miller, 1983 and see Griffiths, 1991). More than three decades of research have resulted in a wide diaspora of conceptualization and assessment instruments, most, if not all, of which suffer from serious problems. The instruments lack clinical validation, lack norm scores, lack information on measurement specificity, lack standardized assessment, lack longitudinal case follow-up, are essentially atheoretical, and suffer from fundamental psychometric issues such as an implicitly assumed, but potentially inappropriate reflective measurement model (King, Haagsma, Delfabbro, Gra- disar, & Griffiths, 2013; van Rooij, Schoenmakers, & de Mheen, 2017; van Rooij, van Looy, & Billieux, 2016). During these three decades, debates persisted over the prevalence, appropriate symp- tomatology, causal nature and even basic existence of video game addiction (e.g., Griffiths, 2008; Wood, 2008; see also Markey & Ferguson, 2017), but no clear resolution has been reached.

Despite the ultimate lack of clarity, there is a current push to institutionalize video game addiction as formal diagnostic catego- ries in the Diagnostic and Statistical Manual (DSM) and Interna- tional Compendium of Diseases (ICD), drafted by the American Psychiatric Association and the World Health Organization, re- spectively. While this type of standardization might have some positive effects, it remains unclear to what extent professional organizations have balanced careful investigation of a prospective psychological phenomenon against the driving potential of a so- cietal narrative, impacting the scientific and medical processes in a negative manner (Bowman, 2016; Copenhaver, 2015).

Arguably, one result might be tunnel-vision like focus by the social science and medical communities on a reduction of video gaming altogether, locked in the substance use or gambling disor- der metaphor (Billieux, Schimmenti, Khazaal, Maurage, & Heeren, 2015). This approach might detract from efforts that aim to under- stand gaming, and problematic gaming in particular, as an every- day and largely normative behavior that may go awry for some individuals as many other behaviors can (APA, 2013; Bowman, 2016; Ferguson & the Entertainment Merchants Association, 2013; Price, 2014; Theis, 2016). Below, we consider the advent of the two formal proposals for video game addiction disorders.

DSM–5: Internet Gaming Disorder Proposal

“Internet gaming disorder” was first proposed by the American Psychiatric Association (APA) in the fifth edition of the Diagnos- tic and Statistical Manual of Mental Disorders (DSM–5; APA, 2013) as a category for further study. The APA currently asserts that Internet gaming disorder (IGD) is also commonly referred to as “Internet use disorder, Internet addiction, or gaming addiction” (APA, 2013, p. 796, emphasis original). In earlier online drafts, IGD was known as Internet Use Disorder only, but for unclear reasons it was respecified in the late stages of DSM–5 development to focus on online games (APA, 2012). The term “internet gaming disorder” has itself been controversial given some confusion over the boundaries of this diagnostic category (King & Delfabbro, 2014) and the somewhat rigorous exclusion of non-online video games without clear rationale (van Rooij, Schoenmakers, & van de Mheen, 2017). In essence, the proposal suggests delineating a subset of human media-facilitated entertainment behavior via me- dia as addictive and excluding others: for example, Netflix addic- tion, offline-game addiction, newspaper reading addiction, et ce- tera. Unlike gambling, where the boundaries are somewhat clearer due to the involvement of harsh and life-impairing financial con- sequences, video gaming is much less clearly disconnected from other media behaviors.

The symptoms listed for IGD are behavioral and psychological in nature (van Rooij et al., 2016), but appear to be devoid of a cultural or phenomenological understanding of the origins of those behaviors (the list of DSM diagnostic criteria are presented in Table 1, a graphic interpretation of the disorder proposal is pre- sented in Figure 1). At present, IGD’s criteria appear to be bor- rowed largely from criteria for substance abuse addictions. They use similar terminology, under the assumption that such criteria can be applied to two different sets of behaviors with only the name of the behavior changed (e.g., “alcohol” and “gambling” to “video games”). This approach to formulating diagnostic criteria has already come under criticism, particularly for the potential for such symptoms to overpathologize normal behaviors (false posi- tives) and it’s essentially atheoretical nature, that defies falsifica- tion efforts (e.g., Billieux et al., 2015; Ferguson, Coulson, & Barnett, 2011; Kardefeldt-Winther, 2015; Markey & Ferguson, 2017; Tuchman, 1978; van Rooij & Prause, 2014; Watters, 2010).

Additionally, there is much left unturned in understanding the video gamer from an ethnographic approach: the culture of video gaming itself is another important piece currently left unconsid- ered. At least one study that applied an ethnographic, anthropo- logical approach to the issue of online gaming engagement sug- gests caution with the use of the concepts “disorder” and “addiction” as “gamer respondents judged commonly used scale items, such as cognitive salience, withdrawal, and tolerance, as not fitting with their own understandings and experiences” (Snodgrass et al., 2017). Additional researchers have discussed the importance of understanding video games, virtual worlds, and the players who participate in them from an ethnographic approach. However, involving the intricacies of player and virtual interactions is an idea that is rarely considered in the concept of video game addic- tion (Boellstorff, Nardi, Pearce, & Taylor, 2012; Colder Carras et al., 2017; Taylor, 2006; Tuchman, 1978; Watters, 2010).

Furthermore, researchers have discussed misrepresentations of high engagement with the term addiction, further muddying the

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379VIDEO GAME ADDICTION

waters of the proposed addiction disorder (Charlton, 2002; Char- lton & Danforth, 2007; Lehenbauer-Baum & Fohringer, 2015). It has been argued that addiction or “disorder” might not be the best conceptual framework to explain excessive play, specifically when it is tied to certain life phases. This research suggests that exces- sive play resolves itself when a new life phase begins, for example, finding a romantic partner, getting a job, graduating, and so forth (Karlsen, 2013). It should be researched whether this spontaneous recovery is higher than that with substance use recovery, but longitudinal research on problematic gaming has shown that it is notably high for gamers (Scharkow, Festl, & Quandt, 2014; van Rooij et al., 2011).

The controversial and sometimes political nature of the DSM process was further illuminated when a group of 14 scholars, including several who were part of the DSM workgroup for behavioral addictions, wrote a paper claiming “international con- sensus” on video game addiction, largely consistent with the DSM framing of IGD (Petry et al., 2014). This, in turn, resulted in 28 other scholars writing a reply that, in fact, no such consensus

existed: Many scholars were concerned that the framing of IGD was problematic (Griffiths et al., 2016). Thus, the DSM concep- tualization of IGD remains highly controversial.

ICD-11 Gaming Disorder Proposal

In late 2016, the World Health Organization (WHO) began to release basic proposals for disorders related to “gaming disorder (WHO, 2016a) and “hazardous gaming” (WHO, 2016b). This was quickly followed by a proposal to delete these same categories by one of the scholars in this field, a proposal which has attracted support comments and an accompanying debate paper from other scholars (Aarseth et al., 2016; Kardefelt-Winther, 2016). As of this writing, these categories are proposals undergoing field testing, and not officially approved.

In conversations with the WHO team running the field trials for the gaming disorder categories, the WHO were very frank in acknowledging that political pressure was part of the decision making regarding these categories (personal communications oc-

Table 1 DSM-5 Proposed Criteria for Internet Gaming Disorder

Criteria Controversy over false

positive results

1) Preoccupation with Internet games/gaming becomes dominant activity High 2) Withdrawal symptoms (anxiety, sadness when the game is taken away) Moderate 3) Tolerance (need to spend more time gaming) Moderate 4) Unsuccessful attempts to control amount of gaming Low 5) Loss of interest in previous hobbies High 6) Continued use despite problems Low 7) Deceived family about time spent gaming High 8) Games to escape negative mood High 9) Lost relationship due to gaming Low

Note. Five or more symptoms endorsed within 12-month period required for diagnosis.

Pre- occupation

Persistent and Regular use of Internet Games leading to…

Clinically significant impairment or distress

Feeling the need to play more and more

Loss of control

Loss of other interests

Continued use despite problems

Lying about amount of gaming

Using games to escape negative

mood

Losing social, school, or career opportunities.

More playing and/or more school/career/social opportunities lost: More severe Internet Gaming Disorder

Internet Gaming Disorder:

Environmental/ Observable level

Content domain

Psychological symptoms

Conceptual level

Withdrawal symptoms

Figure 1. A visual interpretation of the DSM-5 proposal for Internet Gaming Disorder (version 2: reprinted and adjusted with author’s involvement, see Van Rooij et al., 2016, http://dx.doi.org/10.1111/pcn.12404).

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380 BEAN, NIELSEN, VAN ROOIJ, AND FERGUSON

curring with Dr. Vladimir Poznyak and Dr. Geoffrey Reed; August-September 2016). This should not be taken as indicating that the WHO team was unconcerned with the science, only that political issues, as well as scientific issues, arguably drove part of the process behind these proposals.

As of their time as proposals, the published language regarding the gaming disorders was considerably vaguer than for the DSM. For example, the entire extant description for gaming disorder in the ICD proposal is as follows:

Gaming disorder, predominantly offline is manifested by a persistent or recurrent gaming behavior (i.e., “digital gaming” or “video- gaming”) that is not primarily conducted over the internet and is characterized by an 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 of gaming despite the occurrence of negative consequences. The behav- ior pattern is of sufficient severity to result in significant impairment in personal, family, social, educational, occupational or other impor- tant areas of functioning. These features and the underlying pattern of gaming are normally evident over a period of at least 12 months in order for a diagnosis to be assigned, although the required duration may be shortened if all diagnostic requirements are met and symptoms are severe. (WHO, 2016a).

How such a vague description of symptoms might be applied to real life scenarios is unclear. Further, no attempt is made to distinguish between gaming that is directly problematic as opposed to that used to fill time due to dysphoria resulting from another underlying condition (e.g., depression.) Lastly, although time cri- teria is included, such criteria are immediately undone by saying that the time criteria can be waived if the symptoms are “severe”: What this entails is left undefined. This ambiguity could lead researchers and clinicians alike to use subjective judgments about video gaming habits. This could easily cause misconstruing of healthy habits, other mental health factors at play (e.g., depression, anxiety, etc.), and gross overestimation of the undefined disorder appearing across the world.

Diagnostic Advantages

In a recent review article Kuss, Griffiths, and Pontes (2016) argued that the social aspects of video games are what makes them addictive, and massively multiplayer online role playing games (MMORPGs) are considered to be the most addictive games. In addition to the social elements, it is argued that MMORPGs employ partial reinforcement schedules to keep players playing. It is further argued that, for a minority of video gamers, online worlds may be a substitute for the lack of real-life social contexts (Kuss et al., 2016). On the other hand, social aspects of video games, including MMORPGs have been shown to be helpful for positive self-esteem development, appropriate social interaction engagements, and with the help of increasing social aspects of individuals with Autism, a clinical population known for their difficulties with social engagement, but increased video game playing tendencies (Adachi & Willoughby, 2013; Durkin, 2010; Durkin & Barber, 2002; Ringland, Wolf, Faucett, Dombrowski, & Hayes, 2016; Shute, Ventura, & Ke, 2015; Valkenburg, & Peter 2011).

A tentative clinical diagnosis is argued to have a number of advantages by some authors. For instance, it is assumed that a

common reference point will support “efficacious treatment plans that benefit the individuals who require professional help” writes Kuss et al. (2016, p. 5). With known variables to employ treatment plans and interventions upon, best practices can emerge and be utilized for treatment. Additionally, a common point of reference will support research endeavors due to harmonizing the debate. Kuss and Griffiths (2015) suggest that having a diagnosis allows the individual seeking treatment to find validation for a difficulty they are having and a crucial first step in qualifying treatment and treatment modalities for clients. It is further argued that a diagnosis will provide an incentive for treatment and insurance providers to fund treatment (p.5). However, even Kuss et al. (2016) caution that the criteria must be agreed upon including levels of severity, cutoff points, and research supporting a nonconfirmatory approach to the nosology of Internet Gaming Disorder (Carbonell, 2017; Kross- baken, Pallesen, Molde, Mentzoni, & Finserås, 2017; Quandt, 2017; van Rooij & Kardefelt-Winter, 2017). Additionally, and indicative of the level of debate on this subject, this specific paper received multiple critical replies debating these advantages and highlighting the risks associated with the new disorder.

Research Controversies Related to Video Game Addiction

In this section we discuss some areas where research evidence has been mixed, and opinions among scholars are unclear. These controversies all contribute to lack of clarity regarding the validity of video game addiction as a clear diagnosis.

Do Gaming Problems Necessitate a New Disorder, Framed as an Addiction?

One area where there is lack of clarity regarding whether video game addiction represents a unique diagnostic entity or, in the cases of some individuals, is symptomatic of an underlying mental condition. To use one example, hypersomnia (excessive sleeping) is one symptom of a major depressive episode. However, we would not diagnose depressed individuals with hypersomnia with a comorbid “bed addiction.” Further, individuals who read every day, throughout the day, are not considered to have “book addic- tion,” although some parties may be more accepting of this type of “addiction” due to the social appropriateness of reading. Even more, watching American football and participating in fantasy leagues is not considered to be addictive behavior unless mon- etarial betting is involved. Our point is that the conceptual frame- work remains murky to the extent which a behavior is merely a hobby regularly and enthusiastically engaged; and when that hobby becomes a full pathological disorder. Further, it is unclear whether video game addiction represents a “unique” disorder, if the excessive gaming is symptomatic of underlying issues, that are being miscatagorized and misinterpreted as a separate disorder, or if it is simply a useful way to categorize a set of behaviors (van Rooij, van Looy, & Billieux, 2016).

Of course mental disorders can be comorbid and it may entirely be possible for a video game addiction to exist comorbid with other, underlying mental illnesses. However, one key test of the viability of video game addiction as a unique disorder would be documentation of its existence as either a solitary condition or an originating condition, at least within some individuals with the

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381VIDEO GAME ADDICTION

disorder. In other words, it should be possible to document that there are some individuals who start with video game addiction even if that then worsens into depression or other issues. Further, video game addiction would need to be shown to create interfer- ence or impairment independent of underlying mental health is- sues. To date, scholars, clinicians, and researchers have been unable to produce sufficient research and clinical casework show- casing convincing evidence of the solitary condition (Griffiths et al., 2016.; Kardefelt-Winther, 2016; King et al., 2013).

Overall, evidence from specific studies in this realm has been mixed, leading to controversy. For instance, one recent survey study has found that, although Internet gaming disorder appears to be unrelated to other mental health concerns, symptoms of the disorder were not associated with decreased social health or psy- chological impairment, as would be suggested by the DSM and ICD proposals (Przybylski et al., 2017) The authors concluded that these results argued against the robustness of this disorder. Other studies have specifically examined the degree to which video game addiction may even serve as an independent disorder, providing potential evidence against this construct (Griffiths, Kuss, & King, 2012; Wittek et al., 2016). Yet still other studies have indicated that video game addiction is symptomatic, arising from underlying conditions rather than existing as an independent diagnosis (Fer- guson & Ceranoglu, 2014). However, some scholars continue to assert that their data may indicate the existence of a unique disorder (Sakuma et al., 2017). Thus, it is difficult to make defin- itive statements about the existence of video game addiction as a unique disorder.

Case examples, likewise, document that it can be difficult to distinguish the degree to which video game addiction can be identified as a distinct disorder, or symptom of underlying prob- lems. For example, in one paper Griffiths describes the case of “Gary” who escapes into his computer due to social, psychologi- cal, and physical problems:

There is no doubt that this appears to be an unusual case and that Gary’s excessive time spent on the computer appears to be symptom- atic of other underlying problems [. . .] His primary motivation for excessive use of his computer appears to be some sort of escapism into his own world where he can counteract his depression and forget about his social isolation and his medical condition (neurofibromo- tosis). (Griffiths, 2000, p. 213)

Later Griffiths further summarizes,

It is quite obvious that of the five cases, possibly only two of them (Gary and Jamie) were addicted according to the addiction compo- nents criteria. The excessive usage in the majority of cases was purely symptomatic and was where the Internet/computer was used to coun- teract other deficiencies (e.g., relationships, lack of friends, physical appearance, disability, coping, etc.). (Griffiths, 2000, p. 216)

Overall this information suggests a latent cause of the use of Internet/computer usage, rather than a pure addiction component with no masked or additional causes.

Due to such divergent results, a lack of clarity remains regarding the causal and temporal order between the development of video game addiction and other, potentially underlying mental disorders. Few studies are available to examine this causal ordering and without these it remains unclear whether video game addiction

would add value to clinical practice and our understanding of extreme gaming behavior as an independent disorder.

Clinical Significance and False Positives

Since the DSM and ICD classification systems for video game addiction have evolved, scholars and practitioners have become significantly more interested in researching their clinical rele- vance. This has spawned multiple instruments attempting to mea- sure the proposed phenomenon (King et al., 2013). Individuals instruments continue to be produced with heterogeneous assump- tions and potentially problematic psychometric properties (i.e., low specificity and sensitivity), mainly reliant on self-report surveys (Kardefelt-Winther, 2016; King et al., 2013; Przybylski et al., 2017). Unfortunately, the symptoms used in many such surveys are often based on the criterial in the DSM–5 proposed category. This approach does not seem to be sufficiently indicative of actual distress or impairment (Przybylski et al., 2017). The tautological relationship between survey instruments and proposed diagnostic criteria additionally questions the validity of the DSM and ICD proposed diagnostic criteria themselves. For instance, most diag- nostic surveys rely upon the reformulation of criteria from sub- stance abuse or gambling abuse disorders, with the assumption such criteria will easily transfer to video games. Researchers using the same or similar instruments in order to measure gaming be- haviors replace words such as “heroin” with “video games”, with little regard to the construct validity of merely rewording questions without a platform of foundational research (Byrne, Sias, & Kim, 2016; Charlton, 2002; King et al., 2013; Przybylski, 2016), an issue we return to in a moment.

Because of the heterogeneous nature of the existing measures of video game addiction, prevalence rates suggested by studies vary wildly. As examples of these extremes, Wan and Chiou (2006) estimate 45% of their sample to have met acute addiction criteria whereas other researchers have conservatively suggested problem- atic gaming to be closer to 1% of the population (Festl, Scharkow, & Quandt, 2013). In particular, this raises the issue of considerable over identification of false-positive cases, particularly using mea- sures that rely upon the DSM–5 proposed criteria (Kardefelt- Winther, 2016; King et al., 2013; Przybylski, 2016).

This potential problem of false positives is, in part, due to the pathologization of normal behaviors under the assumption that criteria that worked well for substance abuse disorders would also work well for “video game addiction.” In this case, the cart may have been put before the horse. In essence, the DSM–5 criteria appear to have been developed largely based on assumptions rather than sound data, with subsequent study of the DSM–5 criteria arguably designed to find support for them. Examples include symptom items related to using video games to relieve stress or negative moods, or losing interest in old hobbies to pursue gaming. While such behaviors are, indeed, problematic when discussing substance abuse, they are also common for virtually any harmless hobby. In Table 1 we list the DSM–5 proposed criteria, marking those we (and other scholars, see Aarseth et al., 2016; Kardefeldt- Winther, 2015) identify as particular at risk for false-positive results. As we note, concerns about the false-positive potential for the symptoms are, arguably, moderate to high for all but three of the symptoms.

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382 BEAN, NIELSEN, VAN ROOIJ, AND FERGUSON

Clinicians are faced with the difficult task of critically examin- ing psychometrically sound psychological tests in order to provide guidance for clinical disorders. With varying clinical tests being used, adapted, and utilizing poor psychometrics and operational definitions, it appears to be a daunting task. A lack of general consensus on symptomatology, assessment, and use of psycholog- ical tools suggests no clarity on the subject of IGD. The main risk is that a diagnosis lacking such basic clarity may ultimately do more harm than good.

Video Game Addiction Is Not a Stable Construct

A further issue that has been raised in recent research is that video game addiction does not appear to be a stable construct over time. That is to say, identification of the disorder, or elevated symptomatology of the disorder at one time point, is not predictive of later identification of the disorder. Of course some clinical disorders may be fairly transient. However, in such cases, we would expect these disorders to demonstrate short-term impair- ment and potentially require short-term treatment to manage. Fur- thermore, classification of video game addiction appears to resolve spontaneously without intervention (Przybylski et al., 2017; Rothmund, Klimmt, & Gollwitzer, 2016; Scharkow et al., 2014; Strittmatter et al., 2016).

Evidence is lacking that video game addiction displays any of these features, demonstrating low stability with spontaneous re- covery and limited impairment. Taken together, these issues are problematic for the concept of video game addiction, at least as currently conceptualized.

Why Video Game Addiction and Not Other Behavioral Disorders?

Before the invention of video games and video game addiction other behaviors and technologies were considered to be addictive. Computer addiction and addiction to programming caused signif- icant concern in the 1970s and ’80s (Shotton, 1989), but these “machine-code junkies,” “hackers,” and “micromaniacs” have not been given a diagnostic category as of yet.

Weizenbaum, a professor of computer science, warned of the dangers that computers represented for “compulsive” program- mers who, in contrast to “professional” programmers, spent their time programming for programming’s sake producing overly am- bitious, lengthy and poorly documented code (Weizenbaum, 1976). “Professional” programmers, on the other hand, did not code just for the sake of coding, but solely to achieve a certain aim or accomplish a goal. Somewhat provocatively we might ask if the difference between the two could not also be described as intrin- sically motivated creative pursuits versus extrinsically motivated work. It is safe to say that these concerns are no longer prominent in academia, mass media, or anywhere else. It remains an open question whether concerns about Internet gaming disorder will suffer the same fate as computer programming addiction.

The work group that decided to include Internet gaming disorder as a disorder for further study in the DSM–5 consisted of 12 experts and 20 advisors. The scope of this work group included Substance Use Disorders as well as a new and controversial subject: behavioral addictions (Petry & O’Brien, 2013). The work group considered other potential nonsubstance addictive-related

behaviors such as: gambling, Internet gaming, Internet use more generally, shopping, exercise, excessive eating and sexual behav- iors (Petry & O’Brien, 2013). However, only gambling was con- sidered to have sufficient scientific merit as a nonsubstance addic- tive behavior. It was therefore moved from the impulse control disorders due to overlap in etiology, biology, comorbidity, and treatment (Petry & O’Brien, 2013). The authors stress that specific criteria and threshold for diagnosis require systematic investiga- tion and empirical validation before wide-scale adoption. The authors further state that the proposed criteria only apply to Inter- net gaming, and not Internet use more generally, which, according to the authors, may differ in terms of symptoms, etiology, comor- bidity, course, and treatment. This is sound advice, but somewhat curious, because the authors claim to base their criteria on a proposal of criteria for Internet addiction called “Proposed diag- nostic criteria for internet addiction” (Tao et al., 2010). Tao and colleagues view Internet addiction as an umbrella term that en- compasses at least three subtypes: “Internet addiction is comprised of at least three subtypes: excessive gaming, sexual preoccupations and e-mail/ text-messaging” (Tao et al., 2010, p. 556). Petry and O’Brien (2013) warn that care and rigor should be exercised when new psychiatric disorders are proposed. In the words of the au- thors,

Introducing conditions into the DSM-5 that are not well established or that do not cause significant distress and impairment (e.g. chocolate addiction) will lower the credibility of psychiatric disorders more generally, thereby undermining the seriousness of psychiatric disor- ders. Thus, strong empirical data will—and should be—required to include new mental disorders, including internet gaming disorder, in future versions of the DSM. (Petry & O’Brien, 2013, p. 1187)

We, the authors of the present paper, wholeheartedly agree. However, we question whether “video game addiction” is more well established at this point than “chocolate addiction” is. Un- doubtedly there are more research studies on video game than chocolate addiction, but, as we’ve covered, it is likely this schol- arly interest matches a cultural preoccupation with video games and it’s less clear that this body of scholarly work has been precise or foundational in clearly establishing an evidence base for a new diagnostic category. Since evidence comes primarily from ques- tionnaire based prevalence studies, that same method in all likeli- hood would have yielded just as much evidence for “chocolate addiction” had a similar number and type of studies been done on this concept.

This top-down approach to discovering new addictions could potentially define many human activities as an addiction. A bottom-up approach, built on ethnographic and clinical observa- tion would constitute more compelling evidence. This concern is, perhaps, even more considered when examining other areas that may have as much or more research coverage. For instance, a PsycINFO search in December of 2016 of (video game OR vid- eogame OR computer OR Internet game�) AND addiction as subject terms resulted in 790 hits. (Sex� AND addiction) resulted in 2009. Work and addiction resulted in 329. (Food OR eat�) AND addiction) resulted in 704. Although it might presumably be ar- gued that video game addiction research is of better quality than these other fields, our own assessment of the video game addiction literature with its inconsistencies, heterogeneity and contradic- tions, would not appear to support such a contention.

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As such we raise the potential that video game addiction is a “thing” for the psychiatric and medical community less because empirical research has demonstrated a clear foundation; but rather because video game addiction is a “thing” in the general public’s eye. That is to say, video game addiction offers the potential for grant funding, practice opportunities for members of professional societies and political influence not offered by other potential behavioral addictions. With this in mind, we turn our narrative to Moral Panic Theory to explain how and why this occurs.

Moral Panic Theory and Video Games

Moral Panic Theory (Cohen, 1972) concerns itself with the ways in which societies construct narratives about perceived threats and the moral causes of these threats. Moral panics often focus on youth, either their behavior or perceived risks to their well-being (Ben-Yehuda, 2009) There is a long history of moral panics focusing on perceived harms due to media (Bowman, 2016; Kill Screen, 2010; Kutner & Olson, 2008; Markey & Ferguson, 2017), ranging from comic books, to pinball machines, to Elvis Presley, to 1980s rock music to video games. Understanding Moral Panic Theory is essential to understanding the concept of video game addiction. Moral repugnance toward an issue, particularly by older adults, can incentivize scientific (or pseudoscientific) agendas, using the veneer of the scientific process as cover for moral or political causes (Critcher, 2009). This is particularly at issue in light of evidence suggesting that the opinions of clinicians toward video games is determined by age cohorts (Ferguson, 2015a, 2015b), similar to the general population (Przybylski, 2014) as well as scholars in the field (Ferguson & Colwell, in press). As such, decisions by scientific bodies may reflect generational atti- tudes and moral panic, as much as they do scientific evidence. Moral Panic Theory has been detailed comprehensively elsewhere (see Bowman, 2016; Cohen, 1972) and, as such, we discuss it only briefly here (a full coverage of these issues as related to video game addiction are also provided by Markey & Ferguson, 2017).

Figure 2 presents the general model of Moral Panic Theory. Predetermined beliefs ultimately incentivize scholars, politicians and news media to make public claims supporting the moral panic. Moral panics most often decline when the audience does: put bluntly, moral panic beliefs tend to die off when older adults who believe in them do. The environment of moral panic can create enormous pressure on scientific organizations to promote research, reports, or policies consistent with the moral panic so as to combat the perceived threats. This can be observed in some of the reason- ing behind the proposed categories for gaming disorders in the ICD-11. Communications by the current authors with the World Health Organization (WHO) on the new topic of “Gaming Disor- der” and “Hazardous Gaming” in the proposed ICD-11 resulted in acknowledgments by the WHO of this pressure. In speaking with WHO officials (personal communications occurring with Dr. Vladimir Poznyak and Dr. Geoffrey Reed; August-September 2016), these officials reported receiving “enormous pressure” to include video gaming as an addiction disorder particularly from Asian countries and that “we have strong request from our stake- holders to take into consideration the health aspects”

Henceforth we have largely discussed the scientific merits of video game addiction diagnoses. In the following sections, aside from the potential harms to scientific credibility, we note some

areas where premature introduction of video game addiction diag- noses, particularly those based on criteria with high false-positive rates, can cause unintended harms to children.

Video Gaming Benefits Are at Risk

A first concern is that perpetuating a moral panic on video games may create an environment in which the positive use of video games may become less likely. Video games have been shown to have significant positive effects upon players serving a wide range of emotional needs, intellectual stimulation, and phys- ical rehabilitation aspects (Granic, Lobel, & Engels, 2013; Kato, 2010; Redd et al., 1987; Turkle, 1994; Vasterling, Jenkins, Tope, & Burish, 1993). Evidence has also developed suggesting that video games are effective when employed in educational settings (Wexler et al., 2016).

Summarizing the extant literature, Olson (2010) found youth who played video games were able to express creativity easier, had increased social and intellectual curiosity, and a larger focus to discover the real world compared to youth that did not play video games. Within the medical field, video games have been shown to help with the engagement of patients, pain management for che- motherapy treatments, and prevention of asthma attacks (Kato, 2010; Redd et al., 1987; Vasterling, Jenkins, Tope, & Burish, 1993). Furthermore, video games are currently being used in some mental health settings and have resulted in clients being more cooperative and enthusiastic about psychotherapy (Ceranoglu, 2010; Kato, 2010). Finally, video games have been utilized in education to increase grades, learning, reading, and working with abstract ideas (Gee, 2007; Koster, 2005; Squire & Barab, 2004).

Furthermore, competing research of the effects of playing video games suggests that video gamers enjoy positive personality de- velopment and increased stress tolerance (Bean, 2015; Bean et al., 2016; Bean & Groth-Marnat, 2016; Ferguson & Rueda, 2010;

Figure 2. Moral Panic Theory.

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Jansz, 2005), positive beliefs and adolescent development (Durkin & Barber, 2002), social interactions and curricular engagement (Adachi & Willoughby, 2013; Ringland et al., 2016; Shute, Ven- tura, & Ke, 2015), and the promotion of prosocial behaviors, social engagement and empowerment, and problem solving skills (Ada- chi & Willoughby, 2013; Nebel, Schneider, & Rey, 2016; Shute, Ventura, & Ke, 2015).

Evidence about video gaming benefits is not without debate either, and the benefits might be most associated with the motiva- tional properties of the medium (Hamari, Koivisto, & Sarsa, 2014). For instance, suggestions that video games improve IQ or visual spatial cognition remain controversial at best (Simons et al., 2016). For instance nonreplication of previous studies of visuospatial information processing video game research conducted by van Ravenzwaaij et al. (2014) concluded that while playing action video games does not improve the speed of information processing of a video gamer, playing any video game can improve information processing with enough practice. Thus we are cautious to note that, although video games appear to have some real benefits, it is important to not exaggerate the benefits of games in the same manner as the risks.

Concerns and Unintended Consequences

Reviewing the current literature, we express the concern that significant confusion and misinformation exists about the concept of video game addiction. As such, at present, the potential for the misuse of diagnostic categories related to video game addiction remains high. For instance, despite the controversies remaining in the assessment of video game addiction, with the potential for false positives, it remains common for some scholars to suggest poten- tially sensationalistic prevalence estimates in the range of 8 –10% (Choo et al., 2010; Gentile, 2009) despite other data reporting a more conservative range of 0.6 –3% (Charlton, 2002; Mentzoni et al., 2011; Morahan-Martin & Schumacher, 2000; Scharkow et al., 2014; van Rooij et al., 2011). These potentially alarmist statements from experts, researchers, and scholars, particularly when reified in diagnostic categories, can easily confuse the public and clini- cians, promoting beliefs in a false epidemic of video game addic- tion.

Teenagers are the main consumers of video gamers, with 97% of those ages 12–17 playing a form of video games across tablets, computers, and consoles (Lenhart et al., 2008). The push to pathologize an enjoyable pastime and recreational event for a significant amount of video gamers has generated a large number of problematic and confirmatory studies, but has not resulted in solidarity between studies or overall agreement between research- ers (Charlton, 2002; Ferguson, 2016). For instance, past studies have been heavily criticized for a large focus upon preoccupation symptoms of video games and video gamers resulting in a misin- terpretation of addiction versus high engagement play, which is considered to be healthy psychologically (Charlton, 2002).

We also express the concern that the term “addiction” connotes severe consequences that are not supported scientifically. The severity of these negative outcomes may inadvertently promote abusive treatment practices. For example, recent news media cov- erage has detailed youth camps for “video gaming addiction” being implemented across China (Russon, 2016; The Paper, 2016; Top News, 2016). The practices detailed in these accounts are

allegedly abusive and unethical in some cases. While the experi- ences in China may be an extreme, we are skeptical that predatory treatment programs will be limited to Asian countries. In the US, various treatment programs have emerged to intensively treat video gamers as addicts - even without a mental health diagnosis or clear standards for diagnosis or treatment (Addictions.com, 2016; CRC Health Group, 2016; Illinois Institute for Addiction Recovery, 2016). We suspect that the emergence of such clinics will continue internationally, with the market only increased by reimbursable conditions related to video game addiction. At pres- ent, the research base does not support that such a plethora of programs would be in the interest of youth.

We express concern for the lack of basic conceptual research in video game addiction. As we’ve noted earlier, much of the re- search base simply assumed that criteria for substance abuse could be used for video game addiction, without clear foundational research. There has also been a basic lack of qualitative, interview research. It is arguably important for prevalence studies that em- ploy questionnaires and screening tools to validate their results with thorough clinical interviews with those who score as “ad- dicts” (Nielsen, 2015). To the best of our knowledge quantitative studies of game addiction are not validated through in-depth qual- itative research. Nielsen (2015) did not find evidence that individ- uals who was scored to be “pathological gamers” on a screening tool displayed distress or impairment as assessed by thorough interviews. Without such foundational work, it remains difficult to know what survey responses to “video game addiction” criteria, including those promoted by the DSM–5 truly mean.

Conclusion

We agree with the American Psychiatric Association (APA) that significant problems remain for the concept of video game addic- tion and that the extant literature remains problematic, inconsistent and lacking in basic foundational work, particularly as relates to proposed diagnostic categories. In the words of the APA, “The literature suffers, however, from lack of a standardized definition from which to deprive prevalence data. An understanding of the natural histories of cases, with or without treatment, is also miss- ing” (APA, 2013, p. 796).

We further believe that the proposal of this new disorder might encourage confirmatory instead of exploratory research at a time when basic research about the validity, or lack thereof, of the concept itself is inconclusive and theoretically unfounded.

The notion that addiction is not the right framework to under- stand video gamer behavior is sentimentally and resonantly echoed by other scholars (e.g., Aarseth et al., 2016; Ceranoglu, 2010; Charlton, 2002; Ferguson, 2016; Festl, Scharkow, & Quandt, 2013; Griffiths et al., 2016; Kardefelt-Winther, 2015, 2016; Kardefelt-Winther et al., 2017; Lehenbauer-Baum & Fohringer, 2015; Snodgrass et al., 2017). It is premature to propose Internet Gaming Disorder as a distinct psychological disorder at this time.

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en#/http://id.who.int/icd/entity/1602669465?readOnly�true&action�Add NewEntityProposal&stableProposalGroupId�47bfdbcd-524a-4af7- a179-02f29517f23a

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Received April 10, 2017 Revision received May 23, 2017

Accepted May 23, 2017 �

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