Ulrik punched his keyboard in a blind rage. His girlfriend and pet dog cowered in a corner, as his yells filled their cramped apartment. It was not the first time this had happened. In recent months, these outbursts had become a daily occurrence. “I consider myself a fairly relaxed person, not really one with a lot of anger,” Ulrik, a seemingly calm 21-year-old Norwegian who asked that his last name not be revealed, told Fatherly. But when he played the online multiplayer games League of Legends and World of Warcraft, his anger bubbled to the surface. He became cruel and confrontational. He also made terrible choices.
Ulrik racked up $4,500 in debt, largely due to in-game purchases, on top of his festering pile of student loans. He had no savings. His girlfriend was frustrated, and so was his landlord, who threatened to terminate his lease. “It came to a point where I faced the question of whether to keep playing games or be kicked out of our apartment, which meant losing my girlfriend and my dog,” Ulrik says. “When you’re deep in the rabbit hole, you have a choice — give up, or change.”
Ulrik clearly had a problem. But what exactly that problem was is a bone of contention among mental health professionals. The World Health Organization recently announced that its eleventh revision of the International Classification of Disease would include “Gaming Disorder” as a standalone psychological condition. Experts in some corners hailed the decision as a turning point in the treatment of a unique mental health challenge. But the American Psychiatric Association intentionally excluded video game disorder from its Diagnostic and Statistical Manual of Mental Disorders as recently as 2013, labeling it merely a “condition for further study”. American psychologists largely supported this decision. From their perspective, there was and is little difference between a fixation on video games and a fixation on stamp collecting. The key is the underlying pathology — often anxiety, depression, or a compulsive disorder.
“This is the first time a hobby has been classified as a disease,” Chris Ferguson, a clinical psychologist who studies the impacts of video games at Stetson University, told Fatherly. “Almost anything fun can be overdone by a small percentage of people. It feels like the WHO didn’t really think this through carefully—or are indulging the moral panic over games.”
There’s a history to this moral panic. Concerned parents (and a handful of scientists) have long treated video games as a unique form of media, capable of changing behavior in ways that television, movies, and even internet forums cannot. For every one study on how gaming improves memory and hand-eye coordination, there are two suggesting it may lead to aggressive thoughts and behaviors. True, a 2013 study in The Journal of Adolescent Research found that video games, like sports and afterschool clubs, can enhance children’s motivation by compelling them to complete goal-oriented tasks, but the studies getting ink suggest that kids who spend the most time gaming perform poorly in school and suffer more intense symptoms of ADHD.
When it comes to the question of pathological gaming, the science (and public opinion) is surrounded by a miasma of suspicion that makes it hard to have a neutral conversation. That said, Ferguson published one of the most thorough meta-analyses of pathological gaming in 2011 and concluded that many players defined as “pathological” were, in fact, healthy. And while it’s true that experts have cobbled together a handful of constants (1.2 billion people play video games worldwide; between one and seven percent of gamers of any age are pathological; men are likely more vulnerable than women; gamers living in East Asia may be at greater risk) a hard clinical description of problematic gaming behavior remains elusive.
“There really isn’t a set place in stone about what is considered to be a hobby versus what may be considered to be addictive,” Anthony Bean, a clinical psychologist and author known as The Video Game Doctor, told Fatherly. “The research doesn’t parse this out well at all.”
Similarly elusive is the question of which video games are the most likely to cause problems. Massively multiplayer online games, like World of Warcraft and League of Legends, were Ulrik’s drug of choice. Such games feature complete societies with complex combat, political, and economic systems. “Genres that involve a lot of person-to-person social interaction have been identified as potentially more likely to be overdone,” Ferguson says. “But it’s a complex relationship. This may be more true for people who struggle to get social needs met via other avenues.” Besides, game complexity is not necessarily correlated with compulsive behaviors. Even simple puzzle games like Candy Crush Saga have been linked to obsessive behaviors.
“I don’t think that any genre is more likely to help create that final piece of an addiction disorder,” says Scott J., a support-line volunteer at Computer Gaming Addicts Anonymous (who is following CGAA’s official policy in using only his first name and last initial when talking to the press). “But maybe some games trigger disorders more quickly than others, just as drinking hard liquor might ensnare someone predisposed to alcoholism more quickly than beer.”
Given the shaky, anecdotal quality of much of the science on problematic gaming behaviors, the WHO considered its position carefully before recommending that the ICD recognize gaming disorder. The international body convened a panel of experts from different disciplines and regions, and formed working groups to parse the best available evidence into a tome of final conclusions. Still, the WHO acknowledges that there is limited evidence for the diagnosis.
“The available evidence is not so strong as for some other conditions, but sufficient for inclusion of the gaming disorder in the ICD-11,” Tarik Jasarevic, an official spokesperson for WHO, told Fatherly. The current ICD-11 draft, which will not be ratified until 2019, describes gaming disorder as “impaired control over gaming” which harms “personal, family, social, educational, occupational or other important areas of functioning” for a period of at least one year.
Despite WHO’s misgivings, the organization is confident that it made the right decision for patients and providers. “There are hundreds, rather thousands of scientific publications on this matter, increasing demand for treatment in different parts of the world,” Jasarevic says. “The inclusion of a disorder in ICD is expected to facilitate recognition and appropriate management of a health condition by health professionals, facilitate international collaboration and research, as well as to be considered when planning public health strategies and monitoring trends.” In a word the WHO erred on the side of caution, flagging gaming disorder as an issue, just in case.
Mark Coulson, a psychology professor at Middlesex University London, was at the forefront of the scholar’s open debate on WHO’s gaming disorder proposal. “Both sides have merit, as always,” he told Fatherly. Coulson’s professional opinion is that compulsive gaming is not a standalone disorder, but he has no illusions as to the far-reaching implications of including it in the ICD-11. “Psychologists take the ICD seriously,” he says. “You have to!”
“For those with a genuine problem it may make access to treatment easier,” Coulson adds. “At the same time, I would expect dreadful over-diagnosis, and pathologizing of what is a normal part of life.”
Indeed, the American Psychological Association recently released a policy statement opposing the WHO’s decision, and they are joined by the Irish Psychological Society’s special interest group in Media, the Arts and Cyberpsychology. The overarching theme is that gaming disorder may be but a manifestation of other compulsive or anxiety disorders. If so, isolating and treating gaming disorder as though it is alcoholism or a gambling problem may address the symptoms of a psychiatric condition while failing to provide therapy and medication for its underlying causes.
“Individuals who come into therapy who believe they are addicted tend to have more difficulties with depression and anxiety than with the gaming,” Bean says. “They choose to video game and participate in the online and virtual worlds due to using it as a coping mechanisms to deal with their depression and anxiety from turmoil in their lives.
“Much of the evidence suggests that technology overuse is a symptom of preexisting mental health disorders, not a stand-alone condition of its own,” Ferguson adds. “There are serious risks that people may be bilked by sham providers who are capitalizing on technophobia and the moral panic over games. Some folks with real problems may go to clinics that reduce their gaming behaviors, but leave the real mental illnesses intact, doing little other than taking a coping mechanism away.”
This is, perhaps, the most significant problem with a gaming disorder diagnosis—there is no agreed-upon treatment for the condition. “Cognitive behavioral therapy and pharmacotherapy are both possibilities,” Coulson says. “But I see a whole range of therapies arising, many untested and resting on ideology rather than evidence.” Even seemingly innocuous support groups may serve to normalize unhealthy behavior, Coulson cautions. “Attending one of those groups can make an 80-hour-a-week habit seem normal, or not particularly serious.”
Ferguson agrees. “We don’t even have an agreed upon list of symptoms,” he says. “I would not recommend people go to specialty clinics, but rather seek well-established providers who use cognitive-behavioral therapy and who are qualified to treat a wide range of disorders.”
When Ulrik realized his gaming had spun out of control, he embarked on a less traditional path to recovery. After one particularly ugly outburst, he walked away from his PC cold turkey. “I quit that afternoon, which was the 26th of May last year,” he says. That very day he joined Discord, a chatroom for gamers that reports more than 100 million users worldwide, and began engaging with the platform’s vibrant StopGaming community. His life rapidly turned around. Ulrik started his own business, and began paying off his loans. Soon, he was engaged to his girlfriend.
“Quitting games was uncomfortable,” he recalls. “I lost what felt like hundreds of my friends, I lost my primary source of entertainment and relaxation, I lost something I had found valuable for years.” But his grim determination inspired others, and Ulrik is now an official moderator advising the 3,000 concerned gamers in Discord’s StopGaming community. Users in the process of quitting log on to ask veterans like Ulrik for guidance; others ping the group to celebrate StopGaming milestones, such as one month or one year without video games. The chatroom reads like a loosely organized AA meeting. There are introductions, discussions, triumphs and relapses, all without any judgement. Everyone on Discord was once a gamer.
There are more structured approaches. Computer Gaming Addicts Anonymous boasts daily online meetings, in which members share their gaming histories and work toward solutions. “Meetings typically have a topic or two,” Scott says. “People take turns sharing, one at a time, without any back-and-forth or direct advice. We find it very freeing to be able to talk honestly and openly about our problematic behavior without fear of judgment or ridicule.”
CGAA’s goal is for compulsive gamers to eventually abandon gaming altogether. “If moderation were possible, none of the recovery programs would be necessary,” Scott says. “Compulsive gamers painstakingly try every moderation strategy. We fail with all of them.”
Ulrik briefly considered returning to video games last May, after he had abstained for a full year, but demurred. “An alcoholic has to stay sober for the remainder of his life, so does a drug addict,” he says. “I think of myself as someone in that boat. If I start going down that road again, it will most likely mean I return to my addictive habits. If I can help it, I won’t let that happen.”
Experts, however, caution that most problem gamers need not quit gaming—and that putting down the controller may do more harm than good. Since obsessive gaming is usually a symptom of larger mental health problems, taking away the PC or console may serve only to leave a gamer’s psychological challenges intact, while removing a helpful coping mechanism. “If your child is performing poorly at school, does not spend time with real-life friends, does not engage in physical activity, then there might be a problem,” Coulson says. “But talk to them about this, not the gaming they are doing. Chances are they love gaming, are having fun, and it’s helping them cope. Be another helping mechanism—don’t remove one they already have.”
And when parents do seek professional help for their children’s gaming problems, choosing the right professional is key. The best clinicians “do not immediately go to the idea of addiction, but ask about other areas of the person’s life,” Beard says. “They know about specific video games. They can talk the language, the client doesn’t feel judged, and the parents trust the person by talking with them. They talk about boundaries and can utilize the virtual world to reinforce them.”
“This is the largest problem, overall,” Beard says. “Without a base understanding of the culture, how can one make an assumption and diagnose a condition which they do not understand?”
It’s a salient point. When pundits bemoan “a generation of young men” lost to video games, for instance, their implication is clear: Gaming is a uniquely poisonous medium and, if boys would simply put down their controllers, their mental health problems would evaporate. First of all, this runs contrary to the overwhelming evidence that, whatever gaming disorder may be, it’s almost certainly part of a legitimate mental health crisis. The games are not drugs or alcohol. They’re not the problem. Instead, it’s the human mind, yearning for escape, that falls into an MMO.
When activists focus on the evils of video games as a medium, rather than the legitimate mental health problems that tempt young men like Ulrik, this constitutes a strangely gendered refusal to address men’s mental health issues. They’re dismissing male depression and anxiety as just so many boys playing pixelated soldier. The overwhelming consensus, from the WHO to the APA, is that they’re dead wrong.
Two years after he kicked his habit without professional help, Ulrik is now content. He runs his own tutoring company, stays far away from MMOs, and lends his insight to compulsive gamers who reach out almost daily, hoping to get their lives back. When he heard about the World Health Organization’s decision to enshrine gaming disorder in the ICD, Ulrik had mixed feelings.
“I know that classifying yourself by this addiction is not fun. Coming out to society as an addict, whether it’s poker, video games or heroin — it’s all stigmatized, and that makes it difficult,” he says. “My hope is that WHO’s decision can at least give us some acceptance. Maybe it’ll even give someone like me the chance to get help somewhere other than a Discord chat. Maybe this can help give someone who struggles with video games a place, a real physical institution.”
“It’s an honest admission of a disease,” says Ulrik. “We’ve waited a long time for recognition.”