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  • 1 Johannes Gutenberg University Mainz, Germany
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The inclusion of Internet Gaming Disorder as a preliminary diagnosis subsumed in Section III of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) has provoked mixed reactions. On the one hand, it has been appreciated as an important sign stressing the negative health-related impact of that disorder. Likewise, the definition of diagnostic criteria helps scientists and clinicians to refer to mandatory indicators associated with a health problem. On the other hand, it has been objected that this new diagnosis bears the danger of pathologizing normal behaviors that are a feature of healthy recreational activity for many people. However, the existence of diagnostic criteria is meant to avoid this danger. This emphasizes the necessity of being able to refer to as accurate defined criteria as possible. In its current version, the DSM criteria display not only strengths but also ambiguities. Both types will be discussed and necessary ideas to resolve those ambiguities will be presented for further research.

Abstract

The inclusion of Internet Gaming Disorder as a preliminary diagnosis subsumed in Section III of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) has provoked mixed reactions. On the one hand, it has been appreciated as an important sign stressing the negative health-related impact of that disorder. Likewise, the definition of diagnostic criteria helps scientists and clinicians to refer to mandatory indicators associated with a health problem. On the other hand, it has been objected that this new diagnosis bears the danger of pathologizing normal behaviors that are a feature of healthy recreational activity for many people. However, the existence of diagnostic criteria is meant to avoid this danger. This emphasizes the necessity of being able to refer to as accurate defined criteria as possible. In its current version, the DSM criteria display not only strengths but also ambiguities. Both types will be discussed and necessary ideas to resolve those ambiguities will be presented for further research.

Internet Gaming Disorder and Other Internet-Related Disorders: A Matter of Confusion?

Using computer games (online and offline) for recreational purposes has attracted scientific interest for almost decades. While for a long period research was mainly focusing on relationships between the use of violent video games and aggression, the last decade was primarily shaped by studies on excessive computer gaming and its addictive use. To no surprise, the latter research has also provoked controversies among different professionals, either doubting that a mere behavior like gaming can become addictive or objecting that a mere recreational activity is being labeled as a disorder and so pathologizing a lifestyle that is related to a new type of media culture (Van Rooij & Prause, 2014; Wood, 2008).

Years have passed and scientific research has progressed a lot – in terms of quantity but especially of quality. We have now a large variety of methodological sound studies from different settings (epidemiological and clinical data) assessing different methods (qualitative approaches, questionnaire-based surveys, and neuroimaging techniques) emphasizing that Internet Gaming Disorder does not only exist but does also cause severe negative consequences for those losing control of the gaming behavior and for their social environment (e.g., APA, 2013; Ko, Yen, Yen, Chen, & Chen, 2012; Kuss & Griffiths, 2012).

Taking the perspective of clinical psychology and psychotherapy, the inclusion of Internet Gaming Disorder as a preliminary clinical condition in Section III of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; APA, 2013) has to be considered not only as a justified but especially as a necessary decision. On the same time, there is no doubt that we are currently witnessing a somewhat unfinished story. Pragmatically spoken, clinicians and researchers have now the opportunity to rely on – more or less – defined criteria for Internet Gaming Disorder. This should solve some of the methodological problems from the past, making it easier to compare findings from different research groups. In contrast, taking a critical view on the future, a further specification of those criteria – and the phenomenon they are relying on – seems to be inevitable.

The position depicted by Kuss, Griffiths, and Pontes (2016) elaborates appropriately on the major unresolved issues, starting with the debate on specific activities under the umbrella of the term “Internet Gaming Disorder”. Indeed, it appears hard to comprehend the reason behind deciding for the term “Internet” and on the same time noting that also offline games may be part of that category. Talking about the umbrella, Kuss et al. (2016) also refer to a similar, but further leading issue: It is true that addiction does not occur regarding the Internet itself. However, there is a evidence that addictive online behaviors can manifest beyond the uncontrolled use of (online) computer games with some online activities bearing a higher addictive potential than others. While the APA (2013) has stated that uncontrolled online gambling has to be classified among Gambling Disorders, other online activities that have been reported to be associated with symptoms of addictive use (like the use of social networking sites, online pornography, or the under-researched phenomenon of generalized Internet addiction; cf. Király et al., 2014; Müller, Dreier, Duven, et al., 2016; Pawlikowski, Nader, Burger, Stieger, & Brand, 2014) are disabled from being classified according to DSM standards. Given the possibility that other forms of addictive Internet-related activities exist, it remains unclear if it is appropriate to simply adapt the DSM criteria for Internet Gaming Disorder. Alternatively, they might be related to these criteria as well but additionally requiring specific criteria. Elucidating this question is a clear challenge for future research. We need to know more on the prevalence of these additional Internet-related disorders, need to examine if they are related to negative psychosocial consequences and distress, need to inquire if they are stable or temporary conditions, and – most important – need to clarify phenomenological similarities and differences compared to Internet Gaming Disorder in order to define appropriate diagnostic criteria.

Mirror, Mirror on the Wall – Strengths and Ambiguities of the DSM Criteria

An even more crucial issue is addressed by Kuss et al. (2016). The authors are providing a detailed discussion on the single diagnostic criteria for Internet Gaming Disorder defined in the DSM-5. Generally, looking at these criteria reveals that they are basically derived from those known from Gambling Disorder (APA, 2013; Griffiths et al., 2016). This makes sense because of empirical findings suggesting a close phenomenological relationship between Internet Gaming Disorder and Gambling Disorder and the notion that both disorders can be perceived as non-substance-related addictions (e.g., Frascella, Potenza, Brown, & Childress, 2010; Grant, Potenza, Weinstein, & Gorelick, 2010). Nevertheless, it remains a vague impression that a further amplification of these criteria would have been an added advantage. For example, Ko et al. (2014) have offered one of the first systematic evaluation studies on the DSM criteria. By additionally considering the criterion craving, they found amendments in the diagnostic accuracy. In order to find out if and how diagnostic accuracy can be enhanced, future researchers should demonstrate enough scientific boldness to test their own diagnostic hypotheses by defining additional, theory-driven criteria and evaluate their impact on classifying Internet Gaming Disorder.

Irrespective of the aforementioned, the paper by Kuss et al. (2016) points to some serious difficulties and ambiguities of the nine diagnostic criteria defined. Particularly, it has to be appreciated that the authors not only refer to these ambiguities but also present first ideas on how to resolve them. For instance, preoccupation – of course – is a central aspect of addictive behaviors, regardless if it is substance-related or not. However, regarding online gaming – especially among adolescents – it is necessary to thoroughly distinguish between a non-problematic engagement in gaming contents (that can be referred to as a pleasant anticipation of the next gaming event) and its harmful counterpart. The latter one should be perceived as being made of compulsion that is accompanied by intrusive thoughts and the resulting irresistible urge to keep using the game – despite more pleasant alternatives available. Undoubtedly, it is not always easy to disentangle these concepts and that is why we need to have more specific research on that topic. Although we are talking about a clinical phenomenon, it might be beneficial to also refer to findings from the field of media psychology in order to define components of positive engagement (e.g., Bartsch & Oliver, 2016).

A lot of controversies have dealt with the withdrawal and tolerance criteria. Both criteria are core features of substance-use disorders and are mainly related – but not necessarily restricted – to the physical effects that a psychoactive substance enacts on the neurophysiological system. Nevertheless, clinical and neuroscientific evidence supports that both criteria can be presented in non-substance-related addictions as well. Here they have to be understood as psychological effects of the addictive behavior, rather than effects of intoxication (e.g., Frascella et al., 2010). Again, a clear and detailed concept of withdrawal and tolerance related to Internet Gaming Disorder is largely missing (cf. Kaptsis, King, Delfabbro, & Gradisar, 2016) although desperately necessary for diagnostic purposes. To repeat this, we need more specific research on that topic! Qualitative research designs could be very useful to shed light into that question and some initial findings are already available (cf. Beranuy, Carbonell, & Griffiths, 2013; Tzavela et al., 2015).

The discussion on the criterion of loss of interests demonstrates again the necessity to have a broad consensus on the concrete contents of the single criteria defined (although we are well aware that this kind of consensus is sometimes hard to reach; cf. Griffiths et al., 2016; Petry et al., 2014). Without being able to refer to clear diagnostic guidelines, we are facing a certain danger of getting important things wrong. Kuss et al. (2016) correctly emphasize that a shift of interests, especially in adolescence, is a normative phenomenon since the young individual is developing in different respects (including manifestation of interests and preferences). Thus, the criterion should not be misinterpreted in being fulfilled when a shift of interests is given. Rather, a rigorous loss of formerly important recreational activities accompanied by a retreat from the possibilities that the environment is offering to the individual are indicative for a problem in progress. Perhaps even more important, clinical experience shows that the criterion can also be broadened. Excessive and addictive computer gaming in adolescence is often accompanied by an impairment of developing new interests (e.g., Müller, Beutel, & Wölfling, 2014). It follows that a “loss” of interests is not necessarily the case but rather a missed chance of discovering such interests and – perhaps – also shifting them after some time.

The detailed depiction of strengths and deficits of the proposed diagnostic criteria by Kuss et al. (2016) emphasizes a further challenge: it seems necessary to think of adapting the criteria for diagnostic purposes depending on the age of the patient. For example, the results of Ko et al. (2014) showed that the deception criterion was of weak diagnostic validity among adults. Accordingly, research has demonstrated that Internet Gaming Disorder is associated with social isolation; so, for a substantial number of patients deceiving on the behavior is not necessary. In contrast, constant attempts to conceal the behavior or lying to trusted persons (e.g., parents) can be of diagnostic value in adolescents.

The Story must go on – Perspectives for Future Research

At the end of their contribution, Kuss et al. (2016) provided some very helpful proposals for future research activities that are essential for advancing our understanding of Internet Gaming Disorder. Indeed, looking at the current body of research reveals certain imbalances. For example, we have plenty of epidemiologic surveys but on the same hand, sound prospective longitudinal studies are largely missing. Consequently, we have a good impression on prevalence rates of Internet Gaming Disorder for different countries but no good idea on its stability – and associated factors predictive for its stability and its remission.

Furthermore, we have a clear lack in clinical studies – regarding different aspects. We need to know more about motivations to change (e.g., comparative studies on treatment seeking populations and data from community-based samples), presence and individual perception of symptoms related to Internet Gaming Disorder, standardized qualitative examinations of the diagnostic criteria, and of course clinical trials to estimate effective types of intervention strategies as well as factors related to positive intervention response (e.g., Jäger et al., 2012). At present, there is only one meta-analysis provided by Winkler, Dörsing, Rief, Shen, and Glombiewski (2013) on the efficacy of treatment in Internet Addiction, so too many question marks are remaining.

Finally, we have a lot of findings on different correlates of Internet Gaming Disorder, ranging from psychological (e.g., personality traits; cf. Floros & Siomos, 2014; Kuss, Griffiths, & Binder, 2013; Müller, Beutel, Egloff, & Wölfling, 2014) and social (e.g., parenting styles; Choo, Sim, Liau, Gentile, & Khoo, 2015; Kalaitzaki & Birtchnell, 2014) to neurobiological factors (e.g., neurochemical transmissions and imbalances; Ko et al., 2011; Park et al., 2010). However, on the same time, efforts to integrate these findings into a holistic theoretical framework are lacking. This becomes particularly obvious with respect to the development of etiopathological models. No doubt, some initial models explaining the development and maintenance of Internet Addiction and Internet Gaming Disorder in particular have been made (e.g., Brand, Young, Laier, Wölfling, & Potenza, 2016; Dong & Potenza, 2014; Kuss, Shorter, van Rooij, Griffiths, & Schoenmakers, 2013; Müller, Dreier, & Wölfling, 2016), but what we need is a systematic evaluation of the underlying assumptions if we want to have a chance of enhancing our understanding of this new phenomenon and striving for a real consensus on its nature.

Conflict of interest

The author declares no conflict of interest.

References

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  • American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (DSM-5). Arlington, VA: American Psychiatric Association

    • Search Google Scholar
    • Export Citation
  • Bartsch, A., & Oliver, M. B. (2016). Appreciation of meaningful entertainment experiences and eudaimonic well-being. In L. Reinecke & M. B. Oliver (Eds.), The Roudledge handbook of media use and well-being (pp. 8092). New York, NY: Routledge, Taylor & Franics Group

    • Search Google Scholar
    • Export Citation
  • Beranuy, M., Carbonell, X., & Griffiths, M. D. (2013). A qualitative analysis of online gaming addicts in treatment. International Journal of Mental Health and Addiction, 11, 149161. doi:10.1007/s11469-012-9405-2

    • Crossref
    • Search Google Scholar
    • Export Citation
  • Brand, M., Young, K. S., Laier, C., Wölfling, K., & Potenza, M. N. (2016). Integrating psychological and neurobiological considerations regarding the development and maintenance of specific Internet-use disorders: An Interaction of Person-Affect-Cognition-Execution (I-PACE) model. Neuroscience & Biobehavioral Reviews, 71, 252266. doi:10.1016/j.neubiorev.2016.08.033

    • Crossref
    • Search Google Scholar
    • Export Citation
  • Choo, H., Sim, T., Liau, A. K., Gentile, D. A., & Khoo, A. (2015). Parental influences on pathological symptoms of video-gaming among children and adolescents: A prospective study. Journal of Child and Family Studies, 24(5), 14291441. doi:10.1007/s10826-014-9949-9

    • Crossref
    • Search Google Scholar
    • Export Citation
  • Dong, G., & Potenza, M. N. (2014). A cognitive-behavioral model of Internet gaming disorder: Theoretical underpinnings and clinical implications. Journal of Psychiatric Research, 58, 711. doi:10.1016/j.jpsychires.2014.07.005

    • Crossref
    • Search Google Scholar
    • Export Citation
  • Floros, G., & Siomos, K. (2014). Excessive Internet use and personality traits. Current Behavioral Neuroscience Reports, 1, 1926. doi:10.1007/s40473-014-0006-1

    • Crossref
    • Search Google Scholar
    • Export Citation
  • Frascella, J., Potenza, M. N., Brown, L. L., & Childress, A. R. (2010). Shared brain vulnerabilities open the way for nonsubstance additcions: Carving addiction at a new joint? Annals of the New York Academy of Sciences, 1187, 294315. doi:10.1111/j.1749-6632.2009.05420.x

    • Crossref
    • Search Google Scholar
    • Export Citation
  • Grant, J. E., Potenza, M. N., Weinstein, A., & Gorelick, D. A. (2010). Introduction to behavioral addictions. The American Journal of Drug and Alcohol Abuse, 36, 233234. doi:10.3109/00952990.2010.491884

    • Crossref
    • Search Google Scholar
    • Export Citation
  • Griffiths, M. D., van Rooij, A., Kardefelt-Winther, D., Starcevic, V., Király, O., Pallesen, S., Müller, K., Dreier, M., Carras, M., Prause, N., King, D. L., Aboujaoude, E., Kuss, D. J., Pontes, H. M., Lopez Fernandez, O., Nagygyorgy, K., Achab, S., Billieux, J., Quandt, T., Carbonell, X., Ferguson, C. J., Hoff, R. A., Derevensky, J., Haagsma, M. C., Delfabbro, P., Coulson, M., Hussain, Z., & Demetrovics, Z. (2016). Working towards an international consensus on criteria for assessing Internet gaming disorder: A critical commentary on Petry et al. (2014). Addiction, 111, 167175. doi:10.1111/add.13057

    • Crossref
    • Search Google Scholar
    • Export Citation
  • Jäger, S., Müller, K. W., Ruckes, C., Wittig, T., Batra, A., Musalek, M., Mann, K., Wölfling, K., & Beutel, M. E. (2012). Effects of a manualized short-term treatment of Internet and computer game addiction (STICA): Study protocol for a prospective randomized controlled multicentre trial. Trials, 13(1), 43. doi:10.1186/1745-6215-13-43

    • Crossref
    • Search Google Scholar
    • Export Citation
  • Kalaitzaki, A. E., & Birtchnell, J. (2014). The impact of early parenting bonding on young adults’ Internet addiction, through the mediation effects of negative relating to others and sadness. Addictive Behaviors, 39, 733736. doi:10.1016/j.addbeh.2013.12.002

    • Crossref
    • Search Google Scholar
    • Export Citation
  • Kaptsis, D., King, D. L., Delfabbro, P. H., & Gradisar, M. (2016). Withdrawal symptoms in Internet gaming disorder: A systematic review. Clinical Psychology Review, 43, 5866. doi:10.1016/j.cpr.2015.11.006

    • Crossref
    • Search Google Scholar
    • Export Citation
  • Király, O., Griffiths, M. D., Urbán, R., Farkas, J., Kökönyei, G., Elekes, Z., Tamás, D., & Demetrovics, Z. (2014). Problematic Internet use and problematic online gaming are not the same: Findings from a large nationally representative adolescent sample. Cyberpsychology, Behavior, and Social Networking, 17(2), 749754. doi:10.1089/cyber.2014.0475

    • Crossref
    • Search Google Scholar
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  • Ko, C.-H., Liu, G.-C., Yen, J.-Y., Chen, C.-Y., Yen, C.-F., & Chen, C.-S. (2011). Brain correlates of craving for online gaming under cue exposure in subjects with Internet gaming addiction and in remitted subjects. Addiction Biology, 18, 559569. doi:10.1111/j.1369-1600.2011.00405.x

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  • Judit Balázs (ELTE Eötvös Loránd University, Hungary)
  • Joel Billieux (University of Lausanne, Switzerland)
  • Matthias Brand (University of Duisburg-Essen, Germany)
  • Anneke Goudriaan (University of Amsterdam, The Netherlands)
  • Daniel King (Flinders University, Australia)
  • Ludwig Kraus (IFT Institute for Therapy Research, Germany)
  • Anikó Maráz (Humboldt University of Berlin, Germany)
  • Astrid Müller (Hannover Medical School, Germany)
  • Marc N. Potenza (Yale University, USA)
  • Hans-Jurgen Rumpf (University of Lübeck, Germany)
  • Attila Szabó (ELTE Eötvös Loránd University, Hungary)
  • Róbert Urbán (ELTE Eötvös Loránd University, Hungary)
  • Aviv M. Weinstein (Ariel University, Israel)

Editorial Board

  • Max W. Abbott (Auckland University of Technology, New Zealand)
  • Elias N. Aboujaoude (Stanford University School of Medicine, USA)
  • Hojjat Adeli (Ohio State University, USA)
  • Alex Baldacchino (University of Dundee, United Kingdom)
  • Alex Blaszczynski (University of Sidney, Australia)
  • Kenneth Blum (University of Florida, USA)
  • Henrietta Bowden-Jones (Imperial College, United Kingdom)
  • Beáta Bőthe (University of Montreal, Canada)
  • Wim van den Brink (University of Amsterdam, The Netherlands)
  • Gerhard Bühringer (Technische Universität Dresden, Germany)
  • Sam-Wook Choi (Eulji University, Republic of Korea)
  • Damiaan Denys (University of Amsterdam, The Netherlands)
  • Jeffrey L. Derevensky (McGill University, Canada)
  • Naomi Fineberg (University of Hertfordshire, United Kingdom)
  • Marie Grall-Bronnec (University Hospital of Nantes, France)
  • Jon E. Grant (University of Minnesota, USA)
  • Mark Griffiths (Nottingham Trent University, United Kingdom)
  • Heather Hausenblas (Jacksonville University, USA)
  • Tobias Hayer (University of Bremen, Germany)
  • Susumu Higuchi (National Hospital Organization Kurihama Medical and Addiction Center, Japan)
  • David Hodgins (University of Calgary, Canada)
  • Eric Hollander (Albert Einstein College of Medicine, USA)
  • Jaeseung Jeong (Korea Advanced Institute of Science and Technology, Republic of Korea)
  • Yasser Khazaal (Geneva University Hospital, Switzerland)
  • Orsolya Király (Eötvös Loránd University, Hungary)
  • Emmanuel Kuntsche (La Trobe University, Australia)
  • Hae Kook Lee (The Catholic University of Korea, Republic of Korea)
  • Michel Lejoyeux (Paris University, France)
  • Anikó Maráz (Eötvös Loránd University, Hungary)
  • Giovanni Martinotti (‘Gabriele d’Annunzio’ University of Chieti-Pescara, Italy)
  • Frederick Gerard Moeller (University of Texas, USA)
  • Daniel Thor Olason (University of Iceland, Iceland)
  • Nancy Petry (University of Connecticut, USA)
  • Bettina Pikó (University of Szeged, Hungary)
  • Afarin Rahimi-Movaghar (Teheran University of Medical Sciences, Iran)
  • József Rácz (Hungarian Academy of Sciences, Hungary)
  • Rory C. Reid (University of California Los Angeles, USA)
  • Marcantanio M. Spada (London South Bank University, United Kingdom)
  • Daniel Spritzer (Study Group on Technological Addictions, Brazil)
  • Dan J. Stein (University of Cape Town, South Africa)
  • Sherry H. Stewart (Dalhousie University, Canada)
  • Attila Szabó (Eötvös Loránd University, Hungary)
  • Ferenc Túry (Semmelweis University, Hungary)
  • Alfred Uhl (Austrian Federal Health Institute, Austria)
  • Johan Vanderlinden (University Psychiatric Center K.U.Leuven, Belgium)
  • Alexander E. Voiskounsky (Moscow State University, Russia)
  • Kimberly Young (Center for Internet Addiction, USA)

Dr. Zsolt Demetrovics
Institute of Psychology, ELTE Eötvös Loránd University
Address: Izabella u. 46. H-1064 Budapest, Hungary
Phone: +36-1-461-2681
E-mail: jba@ppk.elte.hu

Including gaming disorder in the ICD-11: The need to do so from a clinical and public health perspective

Commentary on: A weak scientific basis for gaming disorder: Let us err on the side of caution (van Rooij et al., 2018)