A new methodology to define and diagnose problematic video gaming

In 2019, the World Health Organization recognized Gaming disorder as a clinical condition, but the proposed diagnostic criteria and clinical guidelines remain the subject of an intense scientific debate.

Some scholars have argued against the recognition of gaming disorder as a mental condition, claiming that such a diagnosis may pathologize healthy gaming. Another view has been that the criteria generally used to identify and diagnose problematic gaming patterns have sometimes failed to distinguish intense but healthy from problematic patterns of gaming.

This is often raised in connection to the criteria proposed by the American Psychiatric Association in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), which correspond to the criteria used to identify addictive usage of drugs (for example tolerance or withdrawal).

In this context, it was important to reach an expert agreement regarding what criteria should be used to define and diagnose gaming disorder in order to avoid pathologization of intensive but healthy gaming behaviors and favour adapted clinical assessment and policy development. Therefore, our objective was to employ a structured and transparent approach - the Delphi technique - to reach an expert agreement on which criteria should be used to define and diagnose problematic video gaming.

The main lessons that emerge

Three central results that emerged from this research:

It was found that there was a strong agreement among experts around the clinical relevance (i.e., diagnostic validity, clinical utility, and prognostic value) of a subset of diagnostic criteria used to define gaming disorder (i.e., loss of control over gaming, continuous involvement in gaming despite harms, conflict/interference due to gaming, and functional impairment). These criteria largely correspond to those proposed by the WHO in the eleventh international classification of diseased (ICD-11).

Some specific criteria that are used in research and clinical practice were rated as not clinically relevant (tolerance, deception of others about gaming, and escape/regulating mood through gaming). All these criteria were proposed in 2013 by the American Psychiatric Association to define pathological video game use but not retained by the World Health Organization 6 years later.

Finally, it was not possible to reach agreement regarding some specific criteria (including withdrawal and preoccupation vis-à-vis gaming activities), implying that further research is needed to determine whether these criteria are or not valid. We would thus recommend cautiousness when considering these criteria.

The methodology used

In this study, we employed the Delphi technique, an empirical method to reach agreement about a debated topic. This technique relies on the concept of "wisdom of crowds": i.e., the combined ability of a group of experts to jointly produce better results than those produced by each expert on his or her own.

A panel of experts with extensive clinical practice and research involvement in the specific field of gaming disorder was recruited based on pre-established criteria (e.g., number of years of clinical practice, international representativeness).

The methods used a structured and iterative method to gather opinions from the experts and to ultimately approach an agreement about the clinical relevance (or irrelevance) of existing gaming disorder criteria. The whole process was carried out anonymously and all experts' opinions are equally weighted, avoiding the domination of the views of one expert or by a reduced pressure group.

We recruited 29 experts from five different continents and 21 countries. These experts were presented with the DSM-5 criteria and the ICD-11 clinical guidelines for the diagnosis of problematic gaming, and asked to rate their diagnostic validity (i.e., their relevance in the manifestation of problematic gaming), clinical utility (i.e., their ability to distinguish normal from pathological videogame use), and prognostic value (i.e., their relevance when it comes to predicting the chronicity of pathological video game use). Our Delphi concluded after three survey iterations, providing an expert appraisal of problematic gaming criteria perceived to have the highest diagnostic validity, clinical utility, and prognostic value and agreement on criteria perceived inappropriate for the diagnosis of this condition.

Implications

This study has important implications for the conceptualization of gaming disorder, its clinical diagnosis, and policy development. Many of the criteria currently employed for the diagnosis of problematic gaming (mainly, those included in the DSM-5 and recycled from the substance-use and gambling disorders) were rated by experts as irrelevant for identifying this condition, distinguishing between normal and problematic gamers, and/or predicting the evolution of this condition.

This is important given that these criteria are widely used in epidemiological, psychometric, clinical, and neurobiological research as diagnostic markers of problematic gaming. As gaming is a mainstream hobby in which people all around the world engage in very regularly and in a healthy way, the use of criteria such as tolerance (defined as a progressive increase in gaming patterns) risks over-diagnosis and pathologization of normal behavior.

The current findings should be considered for future revision of DSM-5. Our study successfully identified an expert agreement that ICD-11 diagnostic guidelines are likely to allow the diagnosis of gaming disorder without pathologizing healthy gaming. This agreement should promote the use of the ICD-11 guidelines instead of the DSM-5 criteria. Further empirical research with clinical samples is needed to determine the precise diagnostic accuracy and prognostic value of existing gaming disorder diagnostic criteria.