Defining behaviours as an addiction or a disorder can create lively debate in the therapy world. Take internet gaming. There are users out there, for sure, who overdo playing video games. But so what, you might say. Individuals overdo lots of stuff, after all, so what is so special about video games? And is it worth asking why we can’t have a general category called ‘behavioural addiction’ that can be applied to anything that people overdo.
The World Health Organisation International Classification of Diseases (ICD) will include the condition “gaming disorder” for the first time when its 11th iteration is due out later this year. The draft document, released a couple of months ago, describes it as a pattern of persistent or recurrent gaming behaviour so severe that it takes “precedence over other life interests”. These things are often slowly adopted, after all it took the NHS over 20 years to adopt ICD10.
The ICD is not exclusively for Mental Health unlike the Diagnostical Statistical Manual (DSM) from the American Psychiatric Association (APA). The DSM currently in its 5th iteration did include internet gaming disorder as a condition for further research but stopped short of recognising it as a disorder in 2013 when the fifth iteration was released. Gambling is the only behavioural disorder (but interestingly not actually called an ‘addiction’) in the DSM5.
There is always a fundamental tension in psychiatry between hightlighting things that have a health or social concern and not pathologising regular and everyday aspects of life. That said a case can be made for recognising internet gaming disorder. The tech companies who design the games understand very well the principles of behavioural psychology. Unpredictable rewards are built into their games, which is the same principle that works in machine gambling. Getting hooked can occur if an action brings about a reward frequently enough, but not too frequently. FMRI scans can show evidence of brain change in addicted users specifically the frontal lobes. Some researchers have concluded that there are similarities and differences between diagnostic symptoms of drug addiction and behavioural addiction. The American Society of Addiction Medicine defines all addictions in terms of brain changes.
Others will have great difficulty in accepting a behavioural activity as a disorder resulting from brain change when there is no ingestion of substance. Brain change can occur from falling in love or learning a new language so should not be seen as concrete evidence of a disorder. Furthermore, some studies show that playing video games has benefits such as increased cognitive efforts and enhanced motivation to hit long-term goals, such as reaching multiple levels and ultimately winning the game, which is similar to the benefit children derive from participating in sports and clubs. Playing games and engaging in a gaming community (albeit online) has also been linked with better memory and improved hand-eye coordination.
The trouble with addiction treatment models is that individuals can potentially get lost in the labelling and people can become defined by their ‘condition’ which can restrict their potential. The risk is that they will assume the ‘addict’ label as a defining identity rather than the problem behaviour being one part of their whole self. There is also the issue of co-morbidities and if the gaming is causing problems per se or whether there are pre-existing problems which users are escaping from by gaming. For instance, is there underlying anxiety or depression or untreated trauma that leads to the behaviour becoming a form of self-medication.
Whether the term ‘behavioural addiction’ can be extended to more behaviours is largely dependent on one’s view of the nature of addiction which will also inform the appropriate treatment model. See my post on choice or disease addiction for more on this lively debate.
I took part in a tv debate the other day on TRT World (Sky Channel 519 HD) which discussed some of these points. For me addiction is slavish attachment to pleasure in search of emotional satisfaction and security with negative consequences on other parts of one’s life. Enthusiastic gaming might be excessive in time consumption but would not meet the diagnostic criteria of the substance abuse treatment model.