Where are the gamers?

Previously, we talked about how the criteria for the proposed psychiatric disorder of Internet gaming disorder may not reflect the experience of engaged gamers, who might have several of the criteria without having the “clinically significant impairment or distress” required for a diagnosis. These criteria and the proposed questions for scales used to test for IGD in the general population were decided on through consensus and voting, but it wasn’t clear how this was done—it wasn’t transparent.² Researchers do agree on the need to move forward with research in a consistent way across disciplines to develop agreement on topics related to video gaming, including IGD.³ This agreement extends across fields, thankfully—a recent conference of video game researchers also agreed on the importance of standardized approaches to research studies.⁴

One thing is missing, though—an understanding of the gamer culture. In psychiatry, the boundaries between normal and abnormal are fuzzy and influenced by social and cultural factors.⁵ What is surprising, though, is that it doesn’t look like the important research that describes gamers’ experiences with gaming, excessive gaming and feelings of game addiction was used to figure out what game addiction is. There is a wealth of research into the experiences of normal and abnormal gaming in the fields of media studies, communication studies, psychology or anthropology. Outside of public health and psychiatry, the idea of a gaming culture is well-known.⁶ So where are gamers in this discussion?

In medical and public health research, scientists are learning about the importance of including patients or end-users of interventions in the design of research studies. Including these stakeholders increases the value of research by making it more likely that the things that are studied are important to everyone, and that the results that scientists come up with will lead to successful ways to treat or prevent health problems.⁷

1.         American Psychiatric Association:  Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington, VA: American Psychiatric Association; 2013. dsm.psychiatryonline.org.

2.         Griffiths MD, van Rooij AJ, Kardefelt-Winther D, et al. Working towards an international consensus on criteria for assessing internet gaming disorder: a critical commentary on Petry et al. (2014). Addict Abingdon Engl. 2016;111(1):167-175. doi:10.1111/add.13057.

3.         Petry NM, Rehbein F, Gentile DA, et al. Moving internet gaming disorder forward: A reply. Addict Abingdon Engl. 2014;109(9):1412-1413. doi:10.1111/add.12653.

4.         All A, Birk M, Bourgonjon J, et al. Research ideas: Digital Games Research Workshop. December 2015.

5.         Kendler KS. The nature of psychiatric disorders. World Psychiatry Off J World Psychiatr Assoc WPA. 2016;15(1):5-12. doi:10.1002/wps.20292.

6.         Grooten J, Kowert R. Going  Beyond the  Game :  Development of  Gamer  Identities  Within Societal  Discourse and  Virtual  Spaces. Load J Can Game Stud Assoc. 2015;9(14):70-87.

7.         Khodyakov D, Savitsky TD, Dalal S. Collaborative learning framework for online stakeholder engagement. Health Expect Int J Public Particip Health Care Health Policy. August 2015. doi:10.1111/hex.12383.

Theorycrafting and the phenomenology of psychiatric disorder

In Part 1, we explored how criteria of Internet Gaming Disorder such as preoccupation might not apply to some of the people who end up in front of a clinician who has to decide whether they have a psychiatric disorder. In our example, a student in his first year of high school is playing video games a lot, his grades are suffering, and he is brought in by parents who worry that he is addicted to video games. We talked about how theorycrafting might be mistaken for the addiction criterion of

Theorycrafting post from the TeamLiquid website, 

preoccupation, which is related to the concept of a single-minded focus of thoughts and behavior on obtaining the next “fix”. The fact that theorycrafting by definition involves putting a lot of thought and effort into optimizing your gaming experience implies that preoccupation as a criterion is not going to be useful for predicting who may have problems related to gaming—it lacks specificity. When criteria for psychiatric disorders lack specificity, it’s harder to separate normal from abnormal.


Separating normal from abnormal is hard for most psychiatric disorders, because unlike medical conditions like diabetes, high blood pressure or asthma; psychiatric disorders lack objective findings. There are no lab tests to tell whether a person has a normal or abnormal pattern of thoughts, feelings and behaviors; these conditions are usually diagnosed by a clinician. Which means that understanding the phenomenology of disorder—separating the normal from abnormal by fully appreciating the experiences of people who have serious and uncontrollable abnormal thoughts, feelings and behaviors and distinguishing those from those who do not— is vital.

It’s hard to tell exactly how new disorders are developed for the Diagnostic and Statistical Manual, however, because the process for establishing new disorders is not systematic or transparent. In the case of IGD, a group of clinicians and researchers debated for years about whether a disorder related to excessive Internet use (or online game use, or video game use) could even exist and what type of disorder it would most closely resemble, reviewing evidence from multiple countries over many years. Several months before the DSM 5 came out, pages related to this discussion were removed from the APA website; at that time the disorder was to be called Internet Use Disorder.¹ When the DSM 5 came out, the proposed new disorder was called “Internet Gaming Disorder” instead and listed as a disorder in the Emerging Measures section.²  Although consensus was lacking as to the strength of evidence to include it as a disorder proper, the inclusion of IGD in DSM 5 in any capacity prompted the initiation of many new research projects.

While the DSM 5 proposed clinical criteria for diagnosing this potential disorder, figuring out how to test for IGD in the general population was another challenge. The first attempt to do so was led by part of the working group that established the DSM diagnosis, who published a paper entitled, “An international consensus for assessing internet gaming disorder using the new DSM-5 approach.”³ However, the consensus process used to choose both group members and items for a scale was not clear. The following year a paper was published by a group of 28 game researchers, led by one of the most-published researchers on behavioral addictions, that questioned the validity of these criteria and of the consensus development process in general.⁴   That process inspired us, FROGHR, to consider how researchers could develop a formal consensus development process to work quickly and effectively toward establishing the phenomenology of problems related to gaming.

One thing was clear: such a process would have to include the voices of gamers and developers in order to establish a sense of what was normal and abnormal about gaming.


1.     American Psychiatric Association. (2012, May 1). APA DSM-5 | Internet use disorder. Retrieved September 29, 2012, from www.dsm5.org/proposedrevision/Pages/proposedrevision.aspx?rid=573. Note: Link now redirects to login.
2. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders: DSM-5. Washington, D.C: American Psychiatric Association.

3. Petry, N. M., Rehbein, F., Gentile, D. A., Lemmens, J. S., Rumpf, H.-J., Mößle, T., … O’Brien, C. P. (2014). An international consensus for assessing internet gaming disorder using the new DSM-5 approach. Addiction (Abingdon, England). http://doi.org/10.1111/add.12457

4. Griffiths, M. D., van Rooij, A. J., Kardefelt-Winther, D., Starcevic, V., Király, O., Pallesen, S., … Demetrovics, Z. (2016). Working towards an international consensus on criteria for assessing internet gaming disorder: a critical commentary on Petry et al. (2014). Addiction (Abingdon, England), 111(1), 167–175. http://doi.org/10.1111/add.13057

Image: http://www.teamliquid.net/forum/diablo-3/394773-marquise-ruby-vs-emerald-theorycrafting?page=4