Is World of Warcraft Addiction a real mental illness?

The words 'according to a study' can be used to justify any old garbage, and the average reader has seen enough bullshit 'studies' reported in the media to be suspicious about them all. So this is a new series for TheVine. So far we've looked at whether cute cats actually increase productivity, whether whether bacon actually causes cancer, whether being spiritual makes you more likely to have psychological problems?, and whether people think they actually won't change in the future. This week: is too much online gaming a mental illness?

Okay, so you like playing World of Warcraft (or any online multiplayer game). As this article in the Courier Mail last month reports, psychiatrists in November 2012 decided that there is such a thing as Internet Use Disorder. And the Courier Mail points out that, with the details of the diagnosis, psychiatrists are actually talking more about playing online games like World of Warcraft too much rather than liking Facebook too much. So ...does that mean that if you stay up til 3am playing WoW that you might be mentally ill? 

Funnily enough, the phrase "psychiatrists in November 2012 have decided that there is a such a thing in Internet Use Disorder" probably doesn't mean what you think it means. You probably think it means that psychiatrists have officially confirmed that people who spend too much time playing games on the internet are mentally ill. But this is not at all what the research the Courier Mail article discusses (here, behind a paywall) is really saying. Instead, the Courier Mail - while faithfully reporting the research, more or less - has sort of stumbled into a debate about definitions.

In order to understand why it's misleading and what the research here is actually about underneath the surface, let's ask a question: What is mental illness? We can all name examples of mental illness quickly enough - there's depression, post-traumatic stress disorder, schizophrenia, addiction, bipolar disorder, etc. There's obviously some commonality between depression and schizophrenia - something isn't quite right with how the person acts, how the person thinks. The person with schizophrenia might hear voices or have delusions about the world. The person with depression might feel desperately unhappy for long periods of time, or might have trouble finding the energy to participate in everyday life. So mental illness is stuff like that, right? People whose minds and behaviour isn't quite right. 

But wait a second! Think of other medical disorders, other illnesses - say heart disease, or diabetes, or cancer. With (most of) these medical disorders, diagnosing it is easy. We know exactly what causes heart disease, more or less, we know what causes diabetes. Knowing what causes diabetes, we can figure out how to diagnose the different forms of it. Usually, there's some medical test that looks for elevated levels of this chemical or that in the blood, which is why doctors always seem to want you to do blood tests. Then, once you know the specific diagnosis, you can come up with a treatment that targets the root cause of the disease. And not only that, a treatment that might help you get better.

Mental illnesses are not like other illnesses, are not like diabetes, in this way. Nobody really knows why people get depressed, nobody really knows why people develop schizophrenia. Sure, we know some stuff thanks to fancy brain scanning technology, but we don't know enough to know what's going on to the same extent that we know what's going on with diabetes. There are treatments that work pretty well in treating these things - plenty of people reading this will have gone through Cognitive Behavioural Therapy or taken a drug like Prozac - but clinical psychologists (people who've studied how people think and behave in general, and specialised in treating mental illness) and psychiatrists (medical doctors who've specialised in treating mental illness) aren't exactly sure why they work, or when they work. 

Because mental illnesses are a bit of a mystery, psychiatrists aren't certain whether depression is really different from anxiety. Lots of people who have depression also have anxiety. Maybe the two are really just different sets of symptoms caused by the same underlying thing? Similarly, psychiatrists aren't always certain whether people have bipolar disorder or schizophrenia. It may be that bipolar disorder is a milder form of schizophrenia. 

What this means is that any particular mental illness isn't quite as 'real' as diabetes. Bipolar disorder was literally invented in 1980. This is not to say that nobody had episodes of depression cycling with episodes of mania before that - Stephen Fry, perhaps the most famous person with the disorder, was having those episodes before 1980 according to his autobiography. But to put something that looks like the current version of the diagnosis together and stick the label 'bipolar disorder' on it only happened in 1980.

What happened in 1980 was the Diagnostic and Statistical Manual of Mental Disorders III (DSM-III), a psychiatrists' manual. The DSM-III was deliberately undecided about what caused specific disorders, and made the assumption that nobody knew anything. The DSM-III's way of getting around the dilemma of how little psychiatrists know about what they're treating, was to say, more or less, "this bunch of symptoms happening together is pretty common. Who knows why? We don't. But let's call it a disorder and treat people who have this disorder like they have the same thing." Over the years, the DSM has become the psychiatrists' Bible (as Vaughan Bell mischieviously points out, the way you know it's a sort of Bible is because it's "arcane, contradictory and talks about invisible entities which no-one can really prove"). 

Lots of people have reservations about the DSM (see Richard Bentall's excellent and accessible book 'Doctoring The Mind') and about the new and 'improved' DSM-V which is coming out this May in particular (see Vaughan Bell here). But whether or not these reservations have substance (hint: they do), insurance companies in the US use the DSM religiously. If your symptoms match one of the disorders in the psychiatrists' Bible, in the US, you might get funds from your insurance company to treat it. If you don't quite match a DSM diagnosis, you might not get money from your insurance company to pay your psychiatrist with. So there's lots of money and pride at stake here. Pharmaceutical companies basically have to market drugs based on the categories in the DSM - if someone is diagnosed with 'major depressive disorder', the pharmaceutical companies would want to have a drug that might fix specifically that problem. And, as with many things, the DSM, though from the US, is used fairly extensively in Australia.

So this is where psychiatrists and psychologists are at when they're thinking about problem gamers. If there's a bunch of mental symptoms somewhere that a bunch of people share in common, well...maybe it should be in the DSM! And so, unsurprisingly, the psychs look at some gamers and see a bunch of people who are unhappy with how much time they spend playing World of Warcraft and the like, who seem to have similar symptoms. The psychs think "is this a mental illness that should be in the DSM-V?" There are understandable reasons why psychs might want internet use disorder to be in the DSM-V - they want their patients to have access to their insurance company's money, and they want to see if they can find something out about that particular bunch of symptoms.

What psychiatrists are not debating is whether there are people who spend too much time playing World of Warcraft. There definitely are people like this, whose lives suffer because they seem to be unable to stop playing. These are people who don't really want to be playing but can't stop. Psychiatrists are not saying that these people are making it up, and they're not saying that these people don't have real problems. Psychiatrists also generally do not believe that most people who play World Of Warcraft are mentally ill (as Dr King points out in the Courier Mail's article). Recent research (cited by Vladan Starcevic in another paper in the ANZJP) suggests that it's about one in ten gamers who exhibit 'problem video game use', who have trouble controlling their gaming. The other 90% mostly just like the game a bit, and psychiatrists and psychologists think that's totally cool. Enjoy fighting those orcs and goblins, most of you!

Instead, the debate on whether Internet Use Disorder should be in the DSM-V is more about how to define a mental illness. Some people don't see much need to include an Internet Use diagnosis in the psychiatrists' Bible; they think that online video games are more symptom than cause. For these critics, it's not that people with problem video game use are playing video games because they're addictive. Instead, they're playing the game too much because they have other issues - depression or anxiety, for example - and they're avoiding their actual problems by hiding away and playing video games. Other people think that there are particular features of games like World Of Warcraft - the way you get rewarded for playing more and more - which work on the mind a bit like how poker machines do, which is a bit like addiction. For these psychs, who think the games are addictive, it's useful to specifically put that diagnosis in the manual, because simply diagnosing a gamer with depression is going to mean you're ignoring some pretty important symptoms if the game they're playing too much is totally addictive.

So who's right? The "problem gamers are probably just depressed" people or the "problem gamers are addicted" people? I think it's fair to say that the evidence so far is mixed, partly because up until now nobody's been able to agree how to define the problem. This decision to include 'Internet Use Disorder' in the end, is actually the result of a big debate that left a lot of psychiatrists and psychologists unhappy. The first draft of the DSM-V included 'Internet Addiction Disorder', until there was an uproar of people saying it was a terrible diagnosis (there's lots of very different things on the internet, and so it's very unspecific, and internet overuse is not necessarily an 'addiction', which many argue specifically involves the ingestion of substances). The DSM-V people sort of took this uproar into consideration, reworked the disorder and shunted it to the 'Research Appendix' of the book. Which is why, in the end, that the DSM-V has included Internet Use Disorder only in its 'Research Appendix', as a way of saying, "well, maybe it's a disorder, but more research is needed. Here's a definition, use it." Sadly, as the article that the Courier Mail article is based on points out, the DSM-V's definition of Internet Use Disorder isn't very good, and it may not be super helpful. So it will likely be quite a while before there's an official 'Internet Use Disorder' or something like it in the DSM-V.

In any case, what should you do if you do feel like your gaming is becoming a problem? If you feel it's really affecting your life in bad ways, it looks like there are ways to help. A recent meta-analysis that crunched together the results of lots of studies suggests that cognitive behavioral therapy - which is a standard method of treatment for a reasonably wide range of mental disorders these days - is pretty good at helping problem gamers reduce the amount of hours they spend online, and pretty good at improving their overall levels of happiness. So - whether or not 'internet use disorder' is a real mental illness - if your gaming is affecting your life, you're not stuck like that.

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