Tackling internet gaming disorder: what are the challenges in its treatment?

KEYWORDS:

• Gaming disorder
• Internet gaming disorder
• treatment
• intervention
• assessment

1. Introduction

Internet gaming disorder was added to the Diagnostic and Statistical Manual of Mental Disorders − 5th edition (DSM-5) [1] in 2013 as a potential mental disorder for further research. It proposed diagnostic criteria parallel symptoms of substance use and gambling disorders, related to gaming both online and offline. A formal diagnosis code for gaming disorder was added to the 11th revision of the International Classification of Diseases (ICD-11) [2], though the definition and symptoms differed some from those included in the DSM-5. Gaming disorder/Internet gaming disorder (henceforth referred to as gaming disorder) should be distinguished from other Internet-related problems, including Internet addiction and smartphone addiction, which lack current research support as distinct behavioral addictions. Problems with online gambling are also distinct and fall under the umbrella of gambling disorder. Although substantial controversy persists over whether gaming disorder should be considered a mental disorder, research in this area has grown exponentially since its inclusion in the DSM-5/ICD-11, and there is also a growing demand for interventions to assist people struggling with gaming problems.

Prevalence estimates of gaming disorder vary widely depending on study design and other factors, but a recent meta-analysis reported a worldwide prevalence of 3.05%, with higher estimates for young people and men [3]. Harms from untreated gaming disorder are substantial; youth and adults with gaming problems have high rates of academic difficulty, unemployment, co-occurring mental health problems, and family conflict, among other negative outcomes [4]. Some countries (e.g. South Korea, China) have met this public health problem with widespread availability of treatment centers for gaming problems, whereas health systems in other countries (e.g. the United States) offer almost no tailored care to address this growing need. Further, there are substantial challenges to effectively treating gaming disorder, even in areas where treatment is available. This editorial’s purpose is to highlight some of the most pressing challenges related to treatment for gaming problems and to suggest pathways for addressing these challenges.

2. The most pressing challenges

2.1. Challenge 1: lack of agreed upon definitions of gaming disorder and related measurement issues

The field lacks consensus about the definition and symptoms of gaming disorder. For example, withdrawal symptoms (e.g. anxiety, irritability) when access to gaming is limited were included in the DSM-5, but studies have produced mixed findings about the presence of withdrawal in gaming disorder, and some researchers have called into question the validity of this symptom [e.g [5]]. Further, the symptoms included in the ICD-11 definition of gaming disorder are substantially different from those described in the DSM-5. A consensus needs to be reached about a) whether gaming disorder should be a distinct diagnosis and b) a definition of gaming disorder, including the core symptoms. However, additional rigorous research is needed to uncover the answers to these pressing questions.

Related to the lack of consensus on diagnosis and symptoms is the lack of consistent measurement strategies across studies. Many measures of gaming disorder used in published research do not align with either WHO or APA symptom definitions, whereas other studies have adopted assessments that reflect either the WHO or APA symptoms (but typically not both). These varied measurement approaches likely account for much of the variability reported on prevalence rates, associations with harms, and treatment outcomes related to gaming disorder. Further, available assessment options skew heavily to self-report, and social desirability and stigma against gaming problems are likely to impact responses on measures relying exclusively on this format. Assessing perspectives of collateral reporters is important to the accuracy of gaming disorder symptom ratings, both in research and clinical practice, particularly in situations where a caregiver or other family member is seeking help on behalf of the individual with the gaming problem; however, this approach is rarely adopted. Further, the development and adoption of gold standard measures of gaming disorder (e.g. clinical interviews) are sorely needed. A recent review documented a wide variety of assessment tools for gaming disorder with varying levels of empirical support; however, they were only cautiously able to put forward a single optimal assessment tool (Internet Gambling Disorder Scale – Short Form; IGDS9-SF), and they highlighted the need for a standard measure and for this measure to be rigorously evaluated in clinical samples [6]. A related issue is that studies of gaming disorder tend to conflate individuals with gaming disorder and individuals with other Internet-related problems (e.g. so-called Internet addiction). This conflation is an ongoing problem in the field that ‘muddies the water’ in terms of understanding the unique treatment needs of people with gaming disorder and leads to overestimates of the impact of treatment on symptoms.

2.2. Challenge 2: lack of evidence-based treatments for gaming disorder

Although some progress has been made in developing and evaluating potential treatments for gaming disorder, there is still a dearth of large-scale rigorously designed studies of such interventions, and no interventions meet criteria to be considered an empirically supported treatment [e.g [7]]. Cognitive-behavioral and mindfulness-based therapies are among the approaches with the most evidence for efficacy. There is little evidence to support the use of pharmacological approaches to treat gaming disorder symptoms directly, although medications for common co-occurring disorders (e.g. ADHD, depression) may confer improvements in gaming disorder symptoms via secondary symptom management. Generally, many published studies of medication treatment for gaming disorder have very small sample sizes and weak designs (e.g. open trials). Further, there is a surprising lack of research on family-based treatments for gaming disorder, considering the most impacted age groups are adolescents and young adults. Findings from substance use treatment literature suggest that family-based treatments are the most effective approaches for adolescents [8]. A few promising studies in this area [e.g [9]] suggest that these same treatment approaches can be adapted to meet the needs of youth with gaming disorder. Similar to substance use disorder, youth with gaming disorder may not recognize that their gaming is causing problems and may be unmotivated to seek and engage in treatment; therefore, effective engagement of caregivers may be critical to effective treatment. However, without more high-quality intervention studies specifically with youth with gaming disorder, we leave families and clinicians without crucial guidance to address the growing need for effective gaming disorder treatment.

2.3. Challenge 3: high rates of co-occurring problems

Individuals with gaming disorder also have substantially greater odds of experiencing symptoms from at least one co-occurring mental health disorder. Depression is present in at least one in three individuals with gaming disorder, with high rates of co-occurring general anxiety, social anxiety, attention deficit hyperactive disorder, and obsessive-compulsive symptoms also reported [10]. Preliminary research shows high rates of gaming among individuals with autism spectrum disorder (ASD); however, gaming disorder symptoms in individuals with ASD may or may not be better accounted for by ASD symptoms [11]. A review of 20 studies exploring the co-occurrence of gaming disorder and engagement in other addictive behaviors, found individuals with gaming disorder engaged in a range of substance use/addictive behaviors (e.g. caffeine, nicotine, alcohol, cannabis, gambling) [12]. Evidence-based assessment strategies for gaming disorder must be sensitive to possible symptom overlap between gaming disorder and another condition, and treatment interventions should be robust and flexible to meet the expected high symptomatic complexity of treatment seekers. Further, we know little as a field about whether treating co-occurring problems will in turn reduce gaming problems and vice versa; thus, the best course of treatment for a patient presenting with co-occurring disorders is often unclear.

3. Expert opinion

Clearly, more high-quality work is needed to reach conclusions about the validity and definition of the gaming disorder diagnosis; how to best assess gaming symptoms; and the most effective approaches to alleviating symptoms and negative outcomes associated with excessive gaming. However, individuals struggling with gaming problems and their families cannot be asked to wait until this research is conducted to seek treatment. Practical suggestions for the field include: (1) incorporating education on gaming disorder into training programs for mental health professionals, particularly those preparing for a career working with youth; (2) utilizing interventions that have the most up to date evidence for their efficacy; at the time of writing this commentary, cognitive behavioral therapy and approaches that incorporate caregiver or family involvement seem to have the most promise; (3) using of assessments that line up with APA or WHO definitions (or both) of gaming disorder and, when possible, gathering input from caregivers and other family members; and (4) recognizing that when gaming disorder is present, a careful assessment and treatment plan for co-occurring conditions will likely lead to better treatment outcomes. In the United States, the formal adoption of the gaming disorder diagnosis will likely lead to the availability of billing codes specific to this diagnosis, which will, in turn, increase treatment access for families. Despite the need for more research on gaming disorder treatment, there are promising developments and related research areas to begin meeting the needs of individuals with gaming disorder and their families. While there have not been meta-analyses pointing to a series of evidence-based treatments for gaming disorder specifically, clinicians are still encouraged to use cognitive behavioral therapy and family-based therapies that work for other addictive behaviors and behavioral problems for the treatment of gaming disorder and co-occurring mental health problems.

Declaration of interest

The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

The authors are supported through the National Institute on Alcohol Abuse and Alcoholism via grant [T32AA007290] and the National Institute on Drug Abuse via grant [R21DA042900]. They are also supported by the Tennessee Department of Mental Health and Substance Abuse Services.