The DSM-5 is scheduled for publication in 2013, and internet gaming disorder will be included in its Section 3, the research appendix. This editorial reviews the DSM process and rationale for inclusion of this putative disorder, and it suggests directions for much needed research in this area.
The Diagnostic and Statistical Manual of Mental Disorders (DSM), last published in 1994, is the primary classification system for psychiatric disorders in the United States and many other countries. In the past 19 years knowledge about psychiatric disorders has advanced, and a revision, the DSM-5, will be published in 2013.
To prepare for the DSM-5, the American Psychiatric Association convened multi-disciplinary experts in 2007. Researchers and clinicians from the United States and multiple other countries were included, divided into work-groups based on areas of expertise. Their charge was to identify strengths and weaknesses in the DSM-IV approach to diagnosis of psychiatric disorders. The work-groups were not able to design or conduct definitive studies to answer important questions related to psychiatric diagnoses. Instead, they relied upon existing data sets and publications to formulate recommendations. During the past 5 years these work-groups have been meeting regularly to discuss the literature and conduct analyses of existing databases to formulate improvements to the DSM.
One such work-group was the substance use disorder (SUD) work-group. It was comprised of 12 members and assisted by over 20 advisors with expertise in related specialties. One area designated to this work-group was ‘behavioral addictions’. This editorial provides an overview of the evidence that the work-group considered, the status of internet gaming disorder in the DSM-5 and rationale for the recommendations.
The SUD work-group consulted outside advisors and reviewed literature on potential non-substance addictive-related behaviors, including gambling, internet gaming, internet use more generally, shopping, exercise and work. Excessive eating and sexual behaviors were discussed with the eating disorders and sexual disorders work-groups, and it was decided that there was insufficient published data to group these clinical phenomena with SUDs. Gambling disorder (formerly termed pathological gambling) had been included in the impulse control disorders, not otherwise specified section of DSM-IV. Because of its overlap with SUDs with respect to etiology, biology, comorbidity and treatment , it was recommended for inclusion in the SUD chapter in DSM-5, which will be entitled ‘Substance related and addictive disorders’. With the exception of gambling disorder and internet gaming, the literature on the other putative behavioral addictions was relatively limited. Thus, none of these other conditions will appear in DSM-5.
In contrast, well over 250 publications exist on internet gaming disorder, also referred to as gaming or internet use disorder, gaming or internet addiction, gaming or internet dependence, pathological or problematic gaming, etc. Many reports focus on youth, adolescents and young adults from Asian countries [2-8], with some studies also in Europe [9-11]. Some reports are restricted to online gaming activities (e.g. [2, 5, 10, 11]), while others relate to multiple forms of internet use (e.g. [3, 9]).
Despite an extensive literature, the work-group concluded readily that no standard diagnostic criteria were applied across studies. Some studies utilized criteria and scales that parallel SUD criteria , others applied versions of pathological gambling criteria , and still others examined different criteria entirely [14, 15]. Further, no threshold for classification was standard. Some studies classified individuals meeting minimal criteria [4, 8], while others required multiple criteria [7, 10].
Given substantial differences related to classification, it is not surprising that information on the prevalence, course, treatment and biomarkers associated with internet gaming disorder is inconclusive. Depending on the criteria used and sample studied, prevalence rates range from less than 0.1% [10, 16] to more than 50% [4, 8] when minimal thresholds are applied. Although treatment clinics for internet gaming exist in the United States and other countries, limited data are available on the natural course of the condition, comorbidities with other psychiatric disorders or how best to intervene. Brain imagining studies have been conducted, but they similarly used different methods of classifying subjects and applied different tasks; they also revealed different areas of activation (e.g. [17, 18]).
Despite inconsistencies in classification and limited data regarding the course and etiology of the condition, internet gaming disorder will be included in Section 3 of DSM-5. The goal of this section is to foster research on the conditions included therein. Studies are needed to identify the defining features of the condition, obtain cross-cultural data on reliability and validity of specific diagnostic criteria, determine prevalence rates in representative epidemiological samples in countries around the world, evaluate its natural history and examine its associated biological features.
To facilitate this research, the description of internet gaming disorder in Section 3 of DSM-5 includes nine potential criteria, derived from other reports . The text recommends a conservative threshold for classification of five or more criteria, and it notes that classification must include that the internet gaming causes clinically significant impairment, an important feature of all psychiatric disorders. This section states explicitly that the specific criteria, and threshold for diagnosis, require systematic investigation and empirical validation before wide-scale adoption. The text denotes clearly that the proposed criteria apply only to internet gaming, and not internet use more generally, which may differ in terms of it presenting symptoms, etiology, comorbidities, course and treatments.
The inclusion of internet gaming disorder in Section 3 of DSM-5 opens discussions for other ‘behavioral addictions’, a highly controversial topic. Introducing conditions into the DSM-5 that are not well established or that do not cause significant distress and impairment (e.g. chocolate addiction) will lower the credibility of psychiatric disorders more generally, thereby undermining the seriousness of psychiatric disorders. Thus, strong empirical data will—and should be—required to include new mental disorders, including internet gaming disorder, in future versions of the DSM.
Nevertheless, researchers, clinicians and individuals who are struggling with excessive gaming and their families should be encouraged by the placement of this condition in Section 3 of the DSM-5. As science progresses, a better understanding of internet gaming disorder, its etiology and treatment is likely to emerge.
Declarations of interest
Dr O'Brien was Chair of the DSM-5 Substance Use Disorders work-group and Dr Petry was a member of this work-group. This paper represents work of the named authors, and the American Psychiatric Association played no role in the writing of this report. Dr O'Brien has consulted on research to Astra-Zeneca, Embera and Alkermes.