Mental Health | Atmospheres | Video Games E-Book

• Herausgeber: transcript Verlag
• Kategorie: Geisteswissenschaft
• Serie: Bild und Bit. Studien zur digitalen Medienkultur
• Sprache: Englisch

Seitenzahl: 439

Veröffentlichungsjahr: 2022

Beschreibung

Gaming has never been disconnected from reality. When we engage with ever more lavish virtual worlds, something happens to us. The game imposes itself on us and influences how we feel about it, the world, and ourselves. How do games accomplish this and to what end? The contributors explore the video game as an atmospheric medium of hitherto unimagined potential. Is the medium too powerful, too influential? A danger to our mental health or an ally through even the darkest of times? This volume compiles papers from the Young Academics Workshop at the Clash of Realities conferences of 2019 and 2020 to provide answers to these questions.

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Jimena Aguilar Rodríguez, Federico Alvarez Igarzábal, Michael S. Debus, Curtis L. Maughan, Su-Jin Song, Miruna Vozaru, Felix Zimmermann (eds.)

Mental Health | Atmospheres | Video Games

New Directions in Game Research II

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First published in 2022 by transcript Verlag, Bielefeld

© Jimena Aguilar Rodríguez, Federico Alvarez Igarzábal, Michael S. Debus, Curtis L. Maughan, Su-Jin Song, Miruna Vozaru, Felix Zimmermann (eds.)

Cover concept: Kordula Röckenhaus, Bielefeld

Cover illustration: Josefine Maier (josefine-maier.com)

Copy-editing: Curtis L. Maughan

Typeset: Miruna Vozaru & Felix Zimmermann

Printed by Majuskel Medienproduktion GmbH, Wetzlar

Print-ISBN 978-3-8376-6264-1

PDF-ISBN 978-3-8394-6264-5

EPUB-ISBN 978-3-7328-6264-1

https://doi.org/10.14361/9783839462645

ISSN of series: 2702-8240

eISSN of series: 2702-8259

Table of Contents

Preface

Gundolf S. Freyermuth

Acknowledgments

Jimena Aguilar Rodríguez, Federico Alvarez Igarzábal, Michael S. Debus, Curtis L. Maughan, Su-Jin Song, Miruna Vozaru, Felix Zimmermann

MENTAL HEALTH

Play, Games, Mental Health

An Introduction

Federico Alvarez Igarzábal, Michael S. Debus, Curtis L. Maughan, Su-Jin Song

Gaming Disorder – a “lousy” and “meaningless” label

Rune Kristian Lundedal Nielsen

Protecting the Youth by Controlling the Ludic

Indexing Practices in 1980s West Germany

Nils Bühler

Mindspaces

The Mind as a Visual and Ludic Artifact

Anh-Thu Nguyen

Reclaiming Agency

Engaging Non-Human Agency for a Nuanced Portrayal of Mental Distress and Recovery

Miruna Vozaru

Digital Fictions: Towards Designing Narrative Driven Games as Therapy

Natali Panic-Cidic

Gamification and Mobile Apps: Allies in Reducing Loneliness Among Young Adults

Rogério Augusto Bordini, Oliver Korn

Mental Health of Twitch Streamers During COVID-19

Kelli Dunlap

The End is Never The End is Never The End

A Conclusion

Miruna Vozaru

ATMOSPHERES

Introduction: Slow Play

Notes on Enveloping Ambience in Video Games

Sonia Fizek

Cool Games, Cool Japan

Staged Atmospheres in CYBERPUNK 2077 and GHOST OF TSUSHIMA

Anh-Thu Nguyen

“Wind’s howling.” Meteorological Phenomena as Atmospheres in Digital Games

Magdalena Leichter

I Don’t Feel at Home in this Game Anymore

A Closer Look at Uncanny Atmospheres in Walking Simulators

Katja Aller

Generative Atmospheres

Ambient Modes of Experience in Digital Games

Vadim Nickel

Sounding the Atmosphere

Björn Redecker

Systemically Implied Atmospheres

Towards a Mechanistic Understanding of Atmosphere in Pen and Paper Roleplaying Games

Jonathan Jung Johansen

Conclusion: Toward an Atmospherology of Digital Games

Felix Zimmermann

Contributors

Preface

GUNDOLF S. FREYERMUTH

Unique to the Clash of Realities – International Conference on the Art, Technology, and Theory of Digital Games, which takes place annually at the Technical University Cologne, is its fundamental principle: the dialectic of diversity and universality, coexistence, and cooperation. The research conference consists, to a part, of several specialized summits. The default subject areas are Game Studies, Game Design, and Media Education. Annually changing topical summits have investigated, e.g., game technologies, game entrepreneurship, or the relationship of games to music, film, and history. The diversity of themes ensures that specialists from very different disciplines and fields attend the Clash of Realities, academics as well as professionals, who otherwise hold their own conferences and rarely exchange ideas with each other.

On the main day of the conference, this diversity merges into one room and one joint discussion. The encounter produces a productive clash of the many disciplines and cultures around digital games. Academics meet artists. Indie developers argue with industry representatives. Humanities scholars, social scientists, and computer scientists exchange experiences. Established experts and professionals discuss with students and games enthusiasts. Together, we assess and debate the artistic design, technological development, economic conditions, social perception, and cultural reception of digital games. This bridge-building fosters research and education as well as creative and professional practice. Year after year, the conference generates strong impulses and surprising synergies.

The third indispensable element is the Young Academics Workshop (YAW). It brings together young researchers from all over the world and a wide range of educational levels—post-docs and doctoral candidates, master’s students, and exceptionally talented bachelor’s students. The workshops, focusing on changing topics, are always held as a prelude to the conference so that the young academics are free to participate in the summits and the main day. However, this third element was only added in 2017, when–obviously–the academic discussion of digital games finally had developed a particular breadth and maturity.

The origins of the Clash of Realities Conference date back to those of the century. At the time, academia, like the general public, suffered from a lack of factual knowledge about digital games. Instead, there was mistrust and even outright hostility toward the new medium, which was falsely portrayed as inherently violent and addictive. The founders of the conference-Winfried Kaminski, director of the Institute for Media Research and Media Education at the then Cologne University of Applied Sciences, and Martin Lorber, at that time head of the press department at Electronic Arts, wanted to counter these prejudices. The first biennial iterations of the conference, in 2006 and 2008, focused on media education issues. The Cologne Game Lab participated in the research conference for the first time in 2010, the year the lab was founded, contributing a Game Studies and Game Design track.

After Winfried Kaminski’s retirement in 2015, the two founding directors of the CGL—Björn Bartholdy and the author of this text—took over the steering of the conference. We repositioned the Clash of Realities more broadly thematically: as an annual international, i.e., English-language, academic and artistic research conference. In addition to the previous partners and sponsors–the Technical University Cologne, the City of Cologne, and Electronic Arts–we recruited new ones, most notably the University of Cologne, the ifs international film school, and as our main sponsor the Film- and Media Board North Rhine-Westphalia. Since 2015, the Clash of Realities has attracted academics, artists, and industry representatives from several dozen countries. Keynote speakers have included game scholars Ian Bogost, Alexander R. Galloway, Celia Hodent, Jesper Juul, Frans Mäyrä, Nick Montfort, Janet H. Murray, Mark J.P. Wolf, Nick Yee, and Eric Zimmerman, as well as artists and game developers Sam Barlow, Chris Crawford, Ian Dallas, Jörg Friedrich, David OReilly, and Nathalie Pozzi.

Perhaps the most important innovation, however, was the Young Academics Workshop. This forum for young researchers was conceived by two CGL research assistants and Ph.D. candidates, Federico Alvarez Igarzábal and Curtis L. Maughan, together with Michael S. Debus, then a Ph.D. student at the IT University of Copenhagen. Among the objectives was stimulating the intellectual growth and academic skills of young researchers, who may present the results of their scholarly research in a safe and encouraging atmosphere to their peers. The approach is as inclusive as possible. Digital games are researched by various disciplines, from literature and film studies to art history and game design theory to theater and performance studies, pedagogy, cognitive science, and computer science. The first two workshops investigated “Perceiving Videogames” (2017) and “Violence and Videogames” (2018). The collected proceedings came out in 2019.1 For some of the contributors, this was their first academic publication.

The subtitle of that volume – “New Directions in Games Research” – can also serve as a motto for the two subsequent workshops, the results of which this volume presents. In 2019, the focus was on “Play, Games, Mental Health,” the connection between mental health and play. In organizing the YAW, Su-Jin Song, research assistant at CGL, joined the founding team. Isabela Granic, professor and chair of the Department of Developmental Psychopathology at Radboud University Njimegen and director of the Games for Emotion and Mental Health Laboratory, could be recruited as an experienced, encouraging, and enthusiastic mentor.

A year later, at the 11th Clash Conference, which was held entirely online due to the COVID-19 pandemic, the topic was “Atmospheric Propositions: Creating and Thinking the Aesthetics of Playable Atmospheres.” A mostly new team organized this workshop: While Su-Jin Song stayed on, Jimena Aguilar, research assistant at the ifs international film school, Miruna Vozaru, a Ph.D. fellow at IT University of Copenhagen; and Felix Zimmermann, a Ph.D. fellow at the University of Cologne, replaced the original YAW team. Dan Pinchbeck, co-founder and creative director of game studio Chinese Room, served as an engaged mentor combining academic and artistic perspectives.

The two parts of these proceedings unite–despite the diversity of the topics–on the one hand, their timeliness and, on the other hand, the freshness of the young scholars’ approaches. Both are evident from the contributions themselves and the commendable introductions and conclusions by the editors and my CGL colleague Sonia Fizek.2

Whether the future of media actually belongs to digital games as we know them or whether, in the coming decades, another new medium will challenge their current cultural supremacy might be a matter of debate. However, what is indisputable is first that the Young Academics Workshops have immensely enriched the Clash of Realities research conference and secondly, that young academics like the ones who participated in these workshops and contributed to this volume are an essential part of the bright future of media and, in particular, games scholarship and research.

1Igarzábal, Federico Alvarez, Michael S. Debus, and Curtis L. Maughan (eds.): Violence | Perception | Video Games: New Directions in Game Research, Bielefeld: transcript 2019.

2Miruna Vozaru: “The End is Never The End is Never The End. A Conclusion,” in this volume, pp. 117-125; Sonia Fizek: “Introduction: Slow Play. Notes on Enveloping Ambience in Video Games,” in this volume, pp. 129-146; Felix Zimmermann: “Conclusion: Toward an Atmospherology of Digital Games,” in this volume pp. 243-254.

Acknowledgments

JIMENA AGUILAR RODRÍGUEZ, FEDERICO ALVAREZ IGARZÁBAL, MICHAEL S. DEBUS, CURTIS LEE MAUGHAN, SU-JIN SONG, MIRUNA VOZARU, FELIX ZIMMERMANN

“It has never been our goal to counsel participants as their seniors but to learn with and from them”—this sentiment from the introduction to the first proceedings of the Young Academics Workshop still rings true and has informed the scholarly exchange with the authors of this anthology. We are more than grateful for the opportunity to work on this second iteration of the “New Directions in Game Research” with so many promising researchers we gladly and proudly call colleagues. Who would have thought that the Young Academics Workshop would become a staple of the renowned Clash of Realities conference and would even bring into being not one but now even two thematically diverse and innovative edited collections?

We consider it a great privilege to support promising young scholars in the early stages of their career. From our own experience we know quite well the importance of collegial support and feedback, and of being provided with opportunities to present and publish while still trying to find your place in academia. Being somewhat responsible for these up-and-coming researchers and the flourishing of their ideas, we hope that we lived up to this considerable responsibility.

Therefore, first and foremost, we want to thank the Young Academics assembled in this book, for their passion and tenacity in working with us on this book–and finishing this work, even in these trying times. We learned so much from you and for this we are grateful.

We want to thank the many people behind the Clash of Realities conference, doing so much for the game studies field nationally and internationally. Especially to Björn Bartholdy and Gundolf S. Freyermuth, supporters of the Young Academics Workshop from day one, we are grateful. It is not for the first time that Gundolf made room in his busy schedule to support our work. Also, we want to thank him and Lisa Gotto, the editors of the book series this volume is a part of, for welcoming the Young Academics again in their renowned series “Studies of Digital Media Culture.”

Finally, we want to give our thanks to the many institutions supporting our research, allowing us this time-consuming endeavor, among them the a.r.t.e.s. Graduate School of the Humanities Cologne, the IT University of Copenhagen, the Cologne Game Lab and ifs internationale filmschule köln. We are very grateful to all professors and staff of the institutes for their support of the Young Academics Workshop over the past years. We would also like to thank Benjamin Beil and the University of Cologne for co-organizing the Clash of Realities 2021 conference. Michael Debus and Miruna Vozaru are also indebted to the European Research Council for the grant that supported the project Making Sense of Games, and also allowed them to bring their contribution to this anthology. Last but not least, we are grateful to the TH Köln for their financial support, to transcript and especially Linda Dümpelmann for her trouble-free collaboration and to the Federal Ministry of Education and Research for making an Open Access publication possible.

Mental Health

Play, Games, Mental Health

An Introduction

FEDERICO ALVAREZ IGARZÁBAL, MICHAEL S. DEBUS, CURTIS LEE MAUGHAN, SU-JIN SONG

Before introducing the workshops and contributions that made this volume possible, the editors would like to address the ways in which world events shaped–and continue to shape–the questions, the concerns, and the ideas explored in the pages to follow. Though the 2019 Young Academics Workshop preceded the initial outbreak of the pandemic and the subsequent lockdowns of spring 2020, the following contributions were composed, compiled, and edited in a world that was continually adapting to the dangers and demands of the deadly global virus. Regardless of whether the following contributions directly thematize COVID-19–and some do–, it goes without saying that the publishing process that produced this volume was not only influenced by the immediate health threats and logistical complications of the pandemic, but it was also burdened with the emotional and intellectual gravity of grappling with a research topic that had taken on–and remains–a crucial, central role of our global discourse: mental health. In this light, the editors were continually heartened and inspired by the resiliency of this volume’s contributors, who worked collectively and individually, in person and online, and who did not give up on this project in the face of truly unprecedented challenges and constraints. While this volume does not purport to have all the answers to the ever-increasing multitude of mental health queries and questions, this volume serves as a testament to the strength of community and the necessity of collaboration that has always been and will continue to be at the heart of scientific inquiry and academic research. 

THE 2019 WORKSHOP

In 2019, the Young Academics Workshop (YAW) at the Clash of Realities conference explored the connection between mental health and play. While video games are at the center of the Clash of Realities—and, accordingly, the workshop—mental health is a matter that concerns play in general, so we chose to frame the issue broadly.

Nowadays, video game addiction is perhaps the first thing that comes to most people’s minds when it comes to the relation between play and mental health. In the same year this workshop took place, the WHO made gaming disorder an official medical condition; a decision that was met both with approval and strong criticism (especially in the scientific community), showing that this is still a polarizing issue that needs to be discussed further.

But games have also been credited for bringing about cognitive and emotional improvements in players. In 2014, Isabela Granic, Adam Lobel, and Rutger Engels published the influential paper THE BENEFITS OF PLAYING VIDEO GAMES.1 This publication contributed significantly to broadening the focus of the discussion, which gravitated primarily around the possible detrimental aspects of video games, to include the medium’s cognitive, emotional, motivational, and social benefits. 

Beyond the benefits of those video games created primarily for entertainment purposes, games can also be designed with the specific intent to diagnose and treat mental illness. Granic and her lab at Radboud University are once again spearheading this movement. Psychologist Daniel Freeman and colleagues see the potential of VR as especially promising, and believe that the technology will usher in “[a] technological revolution in mental health care.”2 Recent projects like VIRTUALTIMES are attempting to develop VR tools to diagnose and treat psychopathologies like depression and schizophrenia.3 And in a landmark achievement, the mobile game ENDEAVORRX obtained approval from the United States’ Food and Drug Administration (FDA) as a treatment for anxiety.4, 5

Video games can also enhance our popular understanding of mental illness by including characters who suffer from them and devising novel forms of representing their symptoms. HELLBLADE: SENUA’S SACRIFICE is a recent popular example of a game whose main character suffers from psychosis.6 Games like Hellblade can also make those suffering from these pathologies feel like they are not alone in their struggle.

But video games are one of myriad ways in which we play. We play sports, we play fight, we play tabletop games, and we play pretend–to name a few examples. Play is a central aspect of human experience and, as scholars like Peter Gray have stressed, a fundamental component of a child’s development.7 Nowadays, with the rise of helicopter parenting, children are at risk of missing the important life lessons that free, unsupervised play provides.8 All work and no play makes Jack not only a dull boy, but also a depressed and anxious adult.

The intersection between play, games, and mental health is as timely a topic now as it was in 2019. All of the above claims are still being openly debated, which is why they were the focus of YAW’s 2019 edition and of this anthology. The articles that make up this part of the volume tackle the issues of representation of psychopathology in games, the design of games for mental health, and different perspectives on the effects of play and games on our mental wellbeing, all from the point of view of game design and a variety of academic disciplines. 

Rune Nielsen discusses the complications the WHO’s decision to include ‘Gaming Disorder’ into the ICD-11 catalogue faced and still faces. He raises and reiterates concerns regarding the effect it has on psychological diagnoses, as well as a lack of scientific evidence for and transparency during the decision-making process.

Nils Bühler deals with the censorship of video games by youth protection law in Germany. For this purpose, he analyzes the indexing documents for video games by the Federal Review Board for Publications Harmful to Young Persons (BPjS) and contextualizes their central arguments in discourses of media effects research and social ethics. The paper conducts a Foucauldian critical genealogy of game indexing in the 1980s.

Anh-Thu Nguyen explores the importance of space in nonverbal storytelling, focusing on spaces that express a character’s cognitive process—mindspaces or mindscapes. In doing so, she takes a closer look at the representation of spaces and mental health in popular culture and games in particular, through an analysis of the Japanese role-playing game PERSONA 5.9

Miruna Vozaru seeks to move away from anthropocentric views of agency in games and analyzes self harm and the representation of recovery in THE MISSING: J.J. MACFIELD AND THE ISLAND OF MEMORIES through changes in its agential network.10 To achieve this, she applies Actor-Network Theory and related game analysis methods to map out and examine changes in the game’s mechanical layer.

Natali Panic-Cidic introduces the benefits and possibilities of using digital fiction for narrative-driven games and deals with issues of body image and the resulting psychological problems faced by young women and female-read individuals. As a case study, she refers to the WRITING NEW BODIES (WNB) a narrative-based, interactive story game application that can be used as an intervention method in therapy for body image issues.

Rogerio Augusto Bordini and Oliver Korn examine the potential of mental health apps and offers valuable insights into their design by walking the reader through the development of NONELINESS, his app to combat loneliness in university campuses.

Kelli Dunlap inspects the role of Twitch streamers during the COVID pandemic in providing mental health support to their communities, and their struggle in maintaining their own mental health in this trying context. She discusses the findings of a specific survey and, on the basis of these results, identifies ways in which streamers can improve their mental health.

We thank all workshop participants and contributors to this volume for their efforts and insightful contributions. We are honored to have their work in this volume’s pages. We also want to thank Isabela Granic for her generous engagement. We had the privilege to welcome her to the workshop as our guest speaker and, while her work is not included in these pages, her invaluable input is reflected in the final result. 

We are deeply grateful to the entire network of people who made this publication and the 2019 workshop possible. First and foremost, we would like to thank the team at the Cologne Game Lab for all of their help. We are especially grateful for the ongoing support we have received from Gundolf S. Freyermuth and Björn Bartholdy, co-directors of CGL and board members of Clash of Realities. We would also like to thank the Clash of Realities’ board, as well as the conference organizing team and the CGL “Events” Student Work Group. We are grateful for the support from the Center for Computer Games Research of The IT University of Copenhagen and for the support from the sponsors of the Clash of Realities conference, in particular the TH Köln-University of Applied Sciences (Cologne, Germany).

Last but not least, we would like to thank the lively audience that enriched the workshop with their thought-provoking questions and comments. And we thank you, the reader, for engaging with this volume and hope that you find the texts that constitute it as thought provoking and inspiring as we did while editing them.

BIBLIOGRAPHY

Freeman, Jeffrey, D./Reeve, Sarah/, Robinson, Amy/Ehlers, Anke/Clark, David, M./Spanlang, Bernhard/Slater, Mel “Virtual Reality In The Assessment, Understanding, and Treatment of Mental Health Disorders,” Psychological Medicine 47(14) (2017), 2393-2400. https://doi.org/10.1017/S003329171700040X.

Granic, Isabela/Lobel, Adam/ Engels, Rutger, C. M. E.“The Benefits of Playing Video Games,” in American Psychologist 69(1), 66-78 (2014). https://doi.org/10.1037/a0034857.

Gray, Peter: Free to Learn: Why Unleashing the Instinct to Play Will Make Our Children Happier, More Self-Reliant, and Better Students for Life, New York, NY: Basic Books 2013.

Skenazy, Lenore: Free-Range Kids, Giving Our Children the Freedom We Had Without Going Nuts with Worry, Hoboken, NJ: John Wiley & Sons 2009.

LUDOGRAPHY

ENDEAVORRX (Akili Interactive Lab, 2021: Akili Interactive Lab)

HELLBLADE: SENUA’S SACRIFICE (Ninja Theory, 2017: Ninja Theory)

PERSONA 5 (P-Studio, 2016: Atlus)

THE MISSING: J.J. MACFIELD AND THE ISLAND OF MEMORIES (White Owls Inc., 2018, Arc System Works)

ONLINE RESOURCES

U.S. Food & Drug Administration: “FDA Permits Marketing of First Game-Based Digital Therapeutic to Improve Attention Function in Children with ADHD,” https://www.fda.gov/news-events/press-announcements/fda-permits-marketing-first-game-based-digital-therapeutic-improve-attention-function-children-adhd, retrieved June 15, 2020

Virtual Times: “Exploring and Modifying the Sense of Time in Virtual Environments,” 2020-2022, https://virtualtimes-h2020.eu/, retrieved July 18, 2022

1Granic, Isabela/Lobel, Adam/ Engels, Rutger, C. M. E.“The Benefits of Playing Video Games,” in American Psychologist 69(1), 66-78 (2014). https://doi.org/10.1037/a0034857.

2Freeman, Jeffrey, D./Reeve, Sarah/, Robinson, Amy/Ehlers, Anke/Clark, David, M./Spanlang, Bernhard/Slater, Mel “Virtual Reality In The Assessment, Understanding, and Treatment of Mental Health Disorders,” in Psychological Medicine 47(14) (2017), 2393-2400. https://doi.org/10.1017/S003329171700040X

3https://virtualtimes-h2020.eu/ from 18.07.2022.

4U.S. Food & Drug Administration: “FDA Permits Marketing of First Game-Based Digital Therapeutic to Improve Attention Function in Children with ADHD,” June 15, 2020. https://www.fda.gov/news-events/press-announcements/fda-permits-marketing-first-game-based-digital-therapeutic-improve-attention-function-children-adhd.

5ENDEAVORRX (Akili Interactive Lab, 2021: Akili Interactive Lab).

6HELLBLADE: SENUA’S SACRIFICE (Ninja Theory, 2017: Ninja Theory).

7Gray, Peter: Free to Learn: Why Unleashing the Instinct to Play Will Make Our Children Happier, More Self-Reliant, and Better Students for Life, New York, NY: Basic Books 2013.

8Skenazy, Lenore: Free-Range Kids, Giving Our Children the Freedom We Had Without Going Nuts with Worry, Hoboken, NJ: John Wiley & Sons 2009.

9PERSONA 5 (P-Studio, 2016: Atlus).

10THE MISSING: J.J. MACFIELD AND THE ISLAND OF MEMORIES (White Owls Inc., 2018, Arc System Works).

Gaming Disorder – a “lousy” and “meaningless” label

RUNE KRISTIAN LUNDEDAL NIELSEN

A NEW DISORDER, A NEW PANDEMIC

On January 1 2022, at the stroke of midnight, millions of people across the globe officially began suffering from a new mental disorder: Gaming Disorder. For the first time in history, the World Health Organization (WHO) introduced two ‘behavioral addictions’ (i.e., addictions that do not involve a psychoactive substance) into its international classification system: The International Classification of Diseases and Related Health Problems (ICD). The 11th and most recent edition of the manual took effect on January 1.1 It is unclear what effect this new diagnosis will have on the societal and individual level. For some, it may be a welcomed change to finally have officially recognized terminology to describe their experiences, for others it may feel like an unwanted stigmatization. One reason it may feel stigmatizing is that the WHO is only introducing two behaviors under the new heading of “Disorders due to addictive behaviors:” gaming and gambling. The new ICD does not recognize other “popular addictions” such as work addiction, shopping addiction, internet addiction, etc.2

THE CURRENT STATE OF SCHOLARSHIP

Scholars sharply disagree over whether ‘gaming disorder,’ more commonly referred to as ‘game addiction,’ exists or not. Most evidence comes from prevalence studies (questionnaire studies that seek to determine how large a proportion of a given sample meet the criteria for the disorder).3 Proponents argue that these provide evidence for similarities between gaming and substance addictions. Detractors argue that prevalence studies do not measure a discrete clinical phenomenon, but in the best case capture a symptom of something else (e.g., problems at school, home, or work, or other underlying psychological issues, such as anxiety, depression, ADHD, etc.). In the worst-case scenario, the new disorder singles out and pathologizes one type of behavior in a sea of problematic behaviors.

THERE IS NO END TO THE CONFUSION IN SIGHT

The inclusion of Gaming Disorder into official diagnostic manuals could be a signal that the new diagnosis rests on a solid empirical and theoretical base. However, this paper aims to show that the WHO expert panel invited to present and discuss scientific evidence on the new disorder fully recognized the significant limitations of the evidence. According to research presented by the experts, it is still unclear how the disorder manifests itself, what separates it from other disorders, if it is a disorder itself or merely a symptom of other disorders, and how widespread the problem is (or is not). The experts convened by the WHO to discuss the evidence base for the new disorder ahead of its inclusion into the ICD-11 thus outlined some of the most severe critiques imaginable for a new disorder. Proponents and detractors of the new disorder appear to agree that the scientific basis for this new disorder is severely lacking.

The basic disagreement is between two camps: The first camp sees the new disorder as real (even if the science that supports it is flawed) and believes that a common language for the disorder will move the science forward and help researchers to achieve consensus. The second camp sees the science as flawed and believes that the disorder does not exist. Furthermore, the second camp sees gaming disorder as a symptom of underlying causes. This paper aims to show that no amount of critique of the research on the addictive properties of digital games is likely to make a difference as the disorder was formalized despite significant flaws in the evidence. In other words, there is a consensus in the research community that it is not clear what “Gaming Disorder” is and whether it exists. The question that divides researchers is whether or not to use the label “Gaming Disorder” despite its scientific shortcomings.

WHAT IS IN A WORD?

All humans, across time and cultures, have categorized their environment. In fact, it is difficult to imagine any complex organism surviving without some sort of rudimentary categorization of its environment into good and bad; edible and non-edible; safe and unsafe, etc. Modern attempts at developing classification systems or taxonomies and common nomenclature have their roots in the 18th century when the likes of Carl Linnaeus, often referred to as “the father of modern taxonomy,” set out to create a comprehensive and scientific classification system of all living organisms.4 However, it is François Boissier de Sauvages de Lacroix, a friend of Carl Linnaeus, who is credited as the original taxonomist of diseases and pathology based on his comprehensive treatise NOSOLOGIA METHODICA.5 The statistical study of diseases and causes of death began a century earlier with the work of John Graunt on the LONDON BILLS OF MORTALITY who attempted to collect and analyze data on, for example, child mortality rates.6

When the ICD-11 officially went into effect on January 1st, 2022, it had been 26 six years since the launch of its predecessor ICD-10 and some 400 years since the first efforts to collect and statistically analyze data on death and disease. Since its inception, disease classification has been recognized as imperfect but useful. In the words of William Farr:7

“The advantages of a uniform statistical nomenclature, however imperfect, are so obvious, that it is surprising no attention has been paid to its enforcement in Bills of Mortality. Each disease has, in many instances, been denoted by three or four terms, and each term has been applied to as many different diseases: vague, inconvenient names have been employed, or complications have been registered instead of primary diseases. The nomenclature is of as much importance in this department of inquiry as weights and measures in the physical sciences, and should be settled without delay.”

Here, Farr argues that we should not wait for science to gain a perfect understanding of the world before we begin to use statistical methods to study the imperfect conceptions of the world. It may be that our current nomenclature does not perfectly match the world as it exists beyond our senses, but the advantages of having a common language far outweigh the disadvantages.

The tricky questions then and today are thus: 1) when do we have enough evidence that a given disorder exists and 2) what do we do with boundary cases? Most proponents of diagnostic manuals would probably agree that to fully classify mental disorders we need to know how patients experience them, what causes them, what symptoms they produce, what the short- and long-term effects are, and how they progress both when treated and left untreated. Disagreement arises when the question turns to how low the bar for the minimum amount of knowledge and evidence can be set.

The United States does not use the WHO’s ICD. Instead, they rely on The American Psychiatric Association (APA) who publishes the DIAGNOSTIC AND STATISTICAL MANUAL (DSM), which is currently in its fifth edition (published in 2013). The APA has chosen to not include game addiction in the manual because of insufficient evidence of its existence.8 Instead, they have opted to add “Internet Gaming Disorder” as a disorder for further study-a sort of beta version of a diagnosis for researchers to use in their work. The WHO and the APA, presumably with access to the same research and evidence, have come to different conclusions. This leads to the peculiar situation that any American wanting to be diagnosed with a gaming disorder must travel abroad to get it.

THE WHO AND THE BLACK BOX

In 2014, the WHO held a three-day meeting about the “Public Health Implications of Excessive Use of the Internet, Computers, Smartphones and Similar Electronic Devices,” a report from the meeting was published in 2015,9 and in 2016 the WHO officially proposed ‘Gaming Disorder’ as a new disorder.10 The meeting featured 16 experts, under the coordination of Dr. Vladimir Poznyak, who discussed the evidence for what came to be Gaming Disorder, which was included in the ICD-11 in “Disorders Due to Addictive Behaviours.” According to the meeting report, it was decided that “a more comprehensive evidence base on behavioral addictions associated with excessive use of the Internet, computers, smartphones and similar electronic devices [will be gathered] by end of 2016.”11

The process behind the inclusion of Gaming Disorder as an official diagnosis has been black boxed. It has been impossible (for me and researchers in my professional network) to gain insight into the process of selecting the experts, the decision-making process, and the evidence that was considered aside from the meeting report.12 It is curious how the group of experts came to the decision to single out gaming as the only addictive behavior to add to the manual. According to evidence presented in the meeting report “the most popular and frequently described behavioral addictions” (pp. 136-142) are:

•Pathological gambling

•Internet addiction; with three subtypes: “excessive gaming, sexual preoccupations (cybersex), and e-mail/text messaging”

•Shopping addiction

•Food addiction

It remains a mystery, at least to researchers skeptical of the new disorder, why the experts ended up only including one of the subtypes of internet addiction in the manual. The evidence considered by the expert group outlines excellent critiques of Internet addiction (and presumably by extension all its subtypes). The following briefly outlines critiques presented in the meeting report:13

1.Definition: It is hard to define what the problem is, is it a problem of impulse control or is it a substance-like addiction?

2.The nature of the problem: the expert group believes that there are prob ably two kinds of Internet related problems – One where there is a primary problem with a compulsive focus on and pattern of behavior centered on the Internet, and one where pre-existing psychiatric problems are closely related to and are exacerbated by the Internet use. These problems might be: “personality disorders, anxiety disorder, depression, bipolar disorders, substance dependence, compulsive control disorder, pathological gambling, eating disorders, etc.”

3.The extent of the problem: Most evidence comes from problematic research designs that cannot establish causal links between specific behavior and their cause. Furthermore, the “most obvious confounds are not controlled for in most surveys, such as pre-existing mental disorders.”

4.Natural course and treatment outcomes: There are very few studies on how Internet addiction develops and progresses with and without treatment. Moreover, these studies are marred by serious design flaws and limitations.

5.The position in the classification system of mental disorders: The relationship or difference between “addiction” and various compulsive or impulsive orders is a source of confusion.

6.The final concern relates to medicalizing pleasure-seeking or impulsive behavior: Adding Internet addiction as a disorder runs the risk of medicalizing behaviors that are part and parcel of being human. Potentially this could create millions of new “patients” who would be given a “sick role” by fiat, which might lead to an excuse for impulsive irresponsibility.

In short, it is unclear what gaming disorder is, what it looks like, what the extent of the problem is, where to place it in the manual, how to differentiate it from other disorders, if it is a disorder itself or a symptom of underlying problems, and whether there might be negative effects associated with introducing it into official diagnostic manuals.

It might seem puzzling that the WHO chose to introduce this new disorder, when their own expert panel presents such harsh critique of its existence. Obviously, it would be a rare thing if 16 individuals were in complete agreement about such a complex issue, so this critique may reflect internal division. It may also reflect the fact that the WHO, on the one hand, is supposed to represent the pinnacle of scientific knowledge, but, on the other hand, is also a political organization that needs to retain its member states if it wants to retain power and influence (politics and science both play a role here as WHO officials have expressed being under “enormous pressure” to include “Gaming Disorder” in the ICD).14 It may also simply be the case that the experts put more emphasis on uniform nomenclature (or a common language) for statistical reporting than on this nomenclature accurately reflecting the world as it exists beyond our senses and social constructions. Balancing out the need for a common language and the need for an accurate representation of the world is an immensely difficult task. Some, however, are less concerned with this balancing act as they see diagnostic categories as conducive to reflection on the part of clinicians. It is unclear how widespread this view is, but it is present in the evidence presented at the WHO meeting:

“Thus, the DSM-V, like all DSM’s before it, will be, almost by definition, incomplete or deficient. It will be a descriptive tool, taxonomy, guidebook, featuring the authors’ best guess as to what might constitute a treatable condition. The danger does not lie in the diagnostic label, but in how we use it. In fact, one might even argue that a lousy label – or a label that is so nonspecific that it applies to a broad swath of the population, including some in the ‘normal’ part of the spectrum (wherever that maybe) – may actually be beneficial, because it will be so meaningless that it will require the clinician to think more deeply about what that label is trying to convey.”15

A counter argument might be that introducing “lousy” and “meaningless” new mental disorders that pathologize otherwise “normal” behavior will not encourage clinicians to reflect more deeply but will instead be a convenient diagnostic trashcan where clinicians can in good faith place people that are not doing well and who also happen to play digital games. In this scenario, the introduction of “lousy” and “meaningless” labels will cause more harm than good as they obscure the root causes of suffering. Classifying “Gaming Disorder” as a “disorder due to addictive behavior” might give clinicians the impression that digital games and gambling are activities that are unique in their ability to cause clinically significant behavioral addiction. If digital games and gambling games are not uniquely addictive, why would the WHO expert panel leave out the Internet, smart phones, sex, exercise, and all the other behaviors that are effectively treated as addiction, and are referred to as “popular addictions” in the presented evidence? Using the words “due to” clearly expresses a causal link from the game to disorder unsupported in the literature.

In the case of Gaming Disorder, the WHO is committing exactly the disservice to science that William Farr tried to eliminate some 200 years ago, namely that they are registering complications instead of primary diseases. This would be the equivalent of recording a complaint, such as a high fever, as a disorder without regard for the underlying cause.

The ICD-10 does not use the term “addiction” when describing disorders related to psychoactive substances (such as alcohol and other drugs) preferring instead the more neutral term “Dependence syndrome.” In the ICD-10, “Disorders Due to Psychoactive Substance Use” are grouped with the “organic mental disorders,” that is, disorders that are a direct result of damage to brain tissue.16 This was done precisely because “Dependence syndrome” in the ICD-10 are believed to be caused by substances; and just like with disorders caused by physical damage to the brain, we know what the cause of the disorder is. We see here two fundamentally divergent views on what a taxonomy should be: is it a) a classification system that does not necessarily reflect the world and how it works, or b) are taxonomies in fact also testable theories about the world? The latter view is championed by such luminaries as Stephen Gould, who says that taxonomies are not trivial, but rather mini theories:

“Taxonomy (the science of classification) is often undervalued as a glorified form of filing – with each species in its prescribed place in an album; but taxonomy is a fundamental and dynamic science, dedicated to exploring the causes of relationships and similarities among organisms. Classifications are theories about the basis of natural order, not dull catalogues compiled only to avoid chaos.” 17

It would appear that the WHO is choosing to err on the side of wanting to have a common language rather than on the side of knowing that the common language accurately corresponds to the world beyond our senses.

The core description of gaming disorder in ICD-11 is the same as for gambling disorder. They revolve around three loosely defined features:

“1.impaired control over gaming (e.g., onset, frequency, intensity, duration, termination, context);

2.increasing priority given to gaming to the extent that gaming takes precedence over other life interests and daily activities; and

3.continuation or escalation of gaming despite the occurrence of negative consequences.”18

Time will tell if the inclusion in the ICD-11 and this description of the core features will lead policy makers, researchers, clinicians, parents, educators, etc. to reflect on the legitimacy of the label or if they will trust that it is based on solid science.

THE GREAT PANDEMIC OF 2022

With the introduction of behavioral addictions into the ICD-11 we are going to see a range of new pandemics in 2022 (though probably mostly in the literature). According to the evidence presented by the WHO expert group, epidemiological studies find that 34% of Chinese college students suffer from social network site addiction.19 Even though the experts also note that such epidemiological research is limited and often based on unreliable data (just like with video games), many more people will qualify for a new disorder in 2022. It is unclear how the behavioral addiction pandemic will interact with the COVID-19 pandemic. The WHO expert group warns of the risks associated with technological addictions in ways not so subtly reminiscent of the concern about needle sharing by drug addicts: “Insufficient hygiene precautions and sharing of mobile devices such as smartphones may enable the spread of pathogens and infectious diseases.”20

Whether this is an actual concern or more of a rhetorical move to make game addiction look like drug addiction is unclear.21 It is clear, however, that it is increasingly rare to go through life without qualifying for a mental disorder. A conservative estimate, from a large-scale study in New Zealand, determined that 83% of the population at one point in time had fulfilled the criteria for a mental disorder before reaching midlife.22 With the addition of disorders due to behavioral addiction, it would appear that we are rapidly approaching a point where it makes more sense to ask what mental disorder someone is suffering from than if they are suffering from one.

EXPERT CONSENSUS OR CONFIRMATION BIAS?

After the WHO decided to acknowledge gaming disorder as a psychiatric disorder, a group of researchers set out to “integrate the views of different groups of experts” in order to reach “expert consensus” on the diagnostic criteria.23 To this end, 29 international experts with clinical and/or research experience in gaming disorder completed three iterative rounds of a Delphi survey. Five experts declined to participate and 11 of the 29 experts were also members of the WHO advisory group on gaming disorder. The authors prioritized experts with both clinical and research experience and intentionally left out researchers from certain fields (e.g., game studies) and disciplines (e.g., anthropology). However, the authors also considered experts with experience in only one setting when they reported more than five years of clinical experience or having published more than 20 papers on gaming disorder.

While it is commendable to try to integrate different opinions, I suspect that the selection method effectively had the result of excluding specific opinions. The selection criteria effectively barred anyone whose clinical or research experience tells them that ‘gaming disorder’ is not a mental disease or disorder, but instead is a coping strategy or a symptom.

CONCLUSIONS

For reasons that remain unclear to outsiders, the WHO has decided to add Gaming Disorder to the ICD-11 list of disorders “due to substance use or addictive behaviours.”24 The decision was completely black boxed to the broader research community who remain unaware of the experts behind this decision, the decision-making process, and on what scientific basis the decision was made. This paper has outlined some of the arguments against the inclusion of the disorder into official diagnostic and taxonomic manuals that was laid out by an expert group under the WHO ahead of the decision. These arguments include:

•We don’t know what gaming disorder is,

•We don’t know what it looks like,

•We don’t know the extent of the problem,

•We don’t know where to place it in the manual,

•We don’t know how to differentiate it from other disorders,

•We don’t know if it is a disorder in itself or if it is a symptom of underlying problems, and

•There might be negative effects associated with introducing it into official diagnostic manuals.

As outsiders, we can only speculate as to why the WHO has chosen to include Gaming Disorder in the ICD-11 in spite of the issues listed above. Some possible reasons behind the decision discussed in this paper are:

1.Balancing two important qualities of diagnostic manuals. Diagnostic manuals need to a) reflect the world beyond our senses and social constructions and b) provide a common language to ensure the ability of researchers, clinicians, and other stakeholders to communicate. It appears that the WHO has chosen to err on the side of ensuring a common language at the cost of accuracy.

2.It may also be that political pressure from member countries has played a role.

3.It may also be the sincere belief that “lousy” and “meaningless” categories encourage clinicians to reflect more deeply about what a given diagnosis reflects.

4.It may also be that this decision is simply the first step towards a future where everything is potentially addictive – a future with an extremely narrow window of normalcy where most people most of the time fulfill the requirements for at least one disorder.

Scholars are still debating whether game addiction exists. This debate is not likely to be resolved any time soon. However, when it comes to diagnostic manuals a decision will have to be made: either Gaming Disorder is retired as a diagnosis again at some point, or diagnostic manuals will have to define addictive behavioral disorder related to everything from gardening to Argentine tango.25 Perhaps the most straight forward solution would be to create a general disorder regarding behavioral addiction that does not single out just two behaviors and one form of media. The current situation, where only digital (as opposed to analogue or physical) games and gambling games (whether off-line or online) are considered to cause addiction, is not tenable.

BIBLIOGRAPHY

Aarseth, Espen/Bean, Anthony M./Boonen, Huub/Carras, Michelle Colder/Coulson, Mark/Das, Dimitri/Deleuze, Jory/Dunkels,Elza/Edman, Johan/Ferguson, Christopher J./Haagsma, Maria C./Bergmark, Karin Helmersson/Hussain, Zaheer/Jansz, Jeroen/Kardefelt-Winther, Daniel/Kutner, Lawrence/Markey, Patrick/Nielsen, Rune Kristian Lundedal/Prause, Nicole/Przybylski, Andrew/Quandt, Thorsten/Schimmenti, Adriano/Starcevic, Vladan/Stutman, Gabrielle/Van Looy, Jan/Van Rooij, Antonius J.: “Scholars’ Open Debate Paper on the World Health Organization ICD-11 Gaming Disorder Proposal”, in: Journal of Behavioral Addictions (2016), pp. 1-4.

American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 5th Edition, DSM-5, Washington, D.C: American Psychiatric Publishing, 2013.

Bean, Anthony M./Nielsen, Rune Kristian Lundedal/Van Rooij, Antonius J./Ferguson, Christopher J.: “Video Game Addiction: The Push To Pathologize Video Games,” in: Professional Psychology: Research and Practice 48 (2017), pp. 378.

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Gould, Stephen Jay: Wonderful Life: The Burgess Shale and the Nature of History, New York, NY: W. W. Norton & Company 1990.

Schaefer, Jonathan D./Caspi, Avshalom/Belsky, Daniel W./ Harrington, Honalee/Houts, Renate/Horwood, L. John/Hussong, Andrea/Ramrakha, Sandhya/Poulton, Richie/Moffitt, Terrie E.: “Enduring Mental Health: Prevalence and Prediction.”, in: Journal of Abnormal Psychology 126 (2017), pp. 212-224.

Targhetta, Remi/Nalpas, Bertrand/Perney, Pascal: “Argentine Tango: Another Behavioral Addiction?”, in Journal of Behavioral Addictions 2 ( 2013), pp. 179-186.etc.

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1https://www.who.int/standards/classifications/classification-of-diseases.

2World Health Organization: ICD-11 Beta Draft-Mortality and Morbidity Statistics.

3World Health Organization: Public Health Implications of Excessive Use of the Internet, Computers, Smartphones and Similar Electronic Devices: Meeting Report, Main Meeting Hall, Foundation for Promotion of Cancer Research, National Cancer Research Centre, Tokyo (2014).

4Calisher, Charles H.: “Taxonomy: What’s in a Name? Doesn’t a Rose by Any Other Name Smell as Sweet?”, in: Croatian Medical Journal 48 (2007), pp. 268-270.

5World Health Organization: History of the Development of the ICD, n.d., p. 10.

6World Health Organization; History of the Development of the ICD.

7Farr, William: “First annual report”, in: Registrar General of England and Wales, London 1839, p. 99. In: World Health Organization, History of the Development of the ICD, p. 1.

8American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 5th Edition, DSM-5, Washington, D.C: American Psychiatric Publishing, 2013.

9World Health Organization: Public Health Implications of Excessive Use of the Internet, Computers, Smartphones and Similar Electronic Devices: Meeting Report, Tokyo 2014.

10Aarseth, Espen et al.: “Scholars’ Open Debate Paper on the World Health Organization ICD-11 Gaming Disorder Proposal”, in: Journal of Behavioral Addictions (2016), pp. 1-4.

11World Health Organization: Public Health Implications of Excessive Use of the Internet, Computers, Smartphones and Similar Electronic Devices: Meeting Report, p. 22.

12I have reached out to several key participants in the 2014 meeting via email and have only heard back from one person, who informed me that: “there is currently no other publicly available documents related to this issue.” (emphasis in original).

13World Health Organization: Public Health Implications of Excessive Use of the Internet, Computers, Smartphones and Similar Electronic Devices: Meeting Report, pp. 139-140.

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