‘Imagine having a debate about addiction to glass bottles, and no one cared what was inside the bottle’

Recently, psychologist Professor Andrew Przybylski reached out to the World Health Organisation (WHO) to understand how it came to classify 'gaming disorder' in its International Classification of Diseases 11th Revision (ICD-11). The response, reported in the NME, stated that: 'It is challenging if not impossible, to document and communicate the rationale and justification for [the gaming disorder] decision.'

We spoke with Przybylski to find out more…

You've been causing trouble again.

Yes… same as any trouble that I cause. I'm curious about something, I look for examples to understand how the thing is understood by others. Those examples are either ones that make me go, 'that seems fine. I understand why you made that decision.' Or they're like the WHO around this topic…

I wanted to know, since the last time I checked in on gaming disorder, what information had changed their mind. I had co-authored a 2018 paper which argued that the burden of evidence around global health policy in this area should be extremely high, because there is a genuine risk of abuse of diagnoses. To create a brand new psychiatric disorder around a very popular activity… there are potentially human rights implications about play and communication, the right of children play… and the evidence isn't particularly strong. 

Fast forward two years, through debates on screentime, social media, smartphones destroying a generation… I checked back in because we've started working with data from video games companies, on what a causal harm or benefit would look like. I wrote in that paper something about World Health Organisation, that ICD-11 officially comes into effect on 1 January 2022. So I tweeted the Director General, Dr Tedros Adhanom Ghebreyesu. He's a perfectly fine guy, I just asked 'earnest question, what's the evidence for this?' That led down the rabbit hole. 

A response 'encouraged experts involved in the WHO's work in this area to publish in the peer-reviewed literature,' and was 'confident that you are aware of numerous publications on this matter.'

That's why I've gone slightly nuclear on this… yes, I've read evidence reviews that they commissioned, proceedings from meeting they had in 2014 (they don't have records of their meetings). When I see articles, they seem to be picked at random. And they commissioned some of the best research chairs in Canada to do a systematic review, which found no quality studies on gaming disorder. But then they kept making decisions. For me, that's where this begins and ends… some decision was made, but there's no chain. 

Chris Ferguson at Stetson University took it a step further though, and got a response mentioning 'enormous pressure' to include gaming disorder. That's where it potentially moves from bureaucracy – 'there is loads of stuff, but I haven't got the time to tell you about it' – to a bit of a conspiracy?

The WHO taking a decision to create a disorder is not the only health decision around technology that people are taking in the world. So in Japan, there's a prefecture that has a some kind of rule or regulation about how parents must regulate their children's video gameplay. In South Korea, we've had the shutdown law going on and off. In China, we have a new set of rules around play at particular times during the week. And we have reactions in the West that are like, 'Oh, I wish we had this law here!' It's pretty clear that there are people who are willing to move forward without the evidence. 

I don't want to be misunderstood here. It's absolutely fine to make rules and laws without evidence from psychological science. When you mess up is when you pretend that your rules are supported by science. That email Chris has is an example of a larger problem: 'That's what your expert says? Well, my expert says something different.' 'Who's your expert?' 'Doesn't matter, I'll find one.' 

Being charitable, the WHO could say, 'we're adopting the precautionary principle here'. You researchers haven't focused directly in on gaming until relatively recently, partly because of all the reasons we've discussed in our previous chats, to do with access to data and aspects like that. But by your own admission, there are people that struggle with the amount that they're a gaming, so why not bung it in ICD, get more funding and more attention on causes and how to help people?

It happens that there are other things on this planet to do besides play video games. Many of those things have much better evidence that they mess you up. There might be a behavioural dysregulation disorder, that has nothing to do with video games. When people say they have these excessive gaming problems, there are no game-specific treatments. You just give people CBT, you medicate them. And gaming isn't the one thing in their life that is not good. They also have major depressive disorder. They also have anxiety disorders. So yes, people do things to excess, they hurt themselves in exercise, in sex, in eating, the things we were doing for the previous 55,000 years.

So why are people so fussed about gaming? Why has it developed into such a battleground?

If you look back at the 2014 documents, at the American Psychiatric Association's deliberations, it all started with the internet – the idea that online behaviours are bad. These conversations happen at the same time as the rise of online video games, so they were the easiest thing to see, the thing that looks like one thing in these different contexts, countries and interviews. 

You've never made any secret of the fact that you personally enjoy gaming. Do you think that's important to be upfront about, an actual benefit in terms of being a researcher in this field? Or are you concerned about researcher bias, either actual or perceived?

Yes, to all those things. That's the most amazing about this entire debate. Nobody can tell you what a video game is. Imagine having a debate about addiction to glass bottles, and no one cared what was inside the bottle. It would be like studying sex only by studying gonorrhoea. If you don't have any curiosity about your object of study…

My bias is I know that there are video games I enjoy, and I know that there are video games I do not enjoy. I want to know, if games are bad for you, what is it about the game that's bad? But it's not like I'm covering up an Overwatch habit or something… I tend to play 25 year old video games!

You mentioned the debates around screentime, and social media. Is it about splitting off from those debates, so that we're not just talking generically about things people do in the digital realms? Jonathan Haidt said recently, 'Yes, there are many studies supporting the skeptics, who say that effect sizes are tiny. But those are mostly studies of "digital media use" or "screen time." It's like looking at blurry pictures of Saturn. Studies that focus on social media and girls find larger effects…'

Yes, it's important we care about those distinctions. With Haidt, and Jean Twenge, you could argue that when directly challenged, they shift the goalposts. There's actually a lot of evidence on that specific thing. Three years ago, Amy Orben and I published a paper that's a large scale study on teenage girls, body appearance, social media use… it happens to not be in his review, even though it's exactly what's there.

What would exist inside of a game that would cause a change in something that a psychologist or a psychiatrist or a parent would care for? 8 per cent of people who take opioids get clinically addicted. Giant problem, across the whole population not a lot of people take pain medication, but it's an epidemic of people dying in America and other places because of different types of overdoses. Then we have the Canadian researchers pull together a study with all the best research on gaming disorder, and they find that the prevalence rate in the general population is somewhere between 1 in 500 and 2 in 3. So they write 'hey, it's either it's either 0.2 per cent or 57 per cent…'. How much more addictive would video games have to be than heroin for that many people to be clinically addicted? There's like something in your decision tree that will never get you to a cure, if you so badly misunderstand the contents of the bottle. If you don't understand the prevalence of the problem, the symptoms and the aetiology, how are you going to solve it? 

So what happens now? 

I would hope that anyone taking money from governments to study gaming disorder would start sharing their data. Because I've seen a bunch of it. Nobody just has gaming disorder. If 90 per cent of the population of teenage boys play video games, and some percentage of them have serious psychological problems, because of 'the world', a lot of them are going to also have a problem playing video games. If there's open data, we can unpick the causality question. 

But I'm not optimistic. If we don't know what games are, we don't know what the disorder is, and we just leave it up to national governments to define it and study it… there are other disorders that we've taken that have been politically questionable, that the evidence wasn't great for, that we had to walk back from. They are some of the worst chapters in psychiatry. I don't think of governments as uniform decision-making bodies, and I think we have to be really careful with what global bodies empower them to do. Many parties have many different motivations, and very few of them appear scientific to me. 

I think it's interesting how practice and policy in this area, across the world, does filter down to younger people… my 17-year-old son will come to me and say 'Dad, have you heard what they've done in China?'

Young people are going to play, communicate and connect. One of the ways they do that is through games. If games keep going the direction of the metaverse, how we negotiate that? What is the evidence? What is the value? How do we want to run our societies, what's the role of science?

For me, it's always 'what evidence would change my mind?' I have a pretty clear idea of what I need to see in the data before I'm 'this is dangerous, this is not good for people, or for this type of person'. And that's my level, it should be very different for a global health body. I'm very worried that the WHO are making other decisions badly. I trust them on stuff that I know nothing about, so if they're so wrong about this, what else are they wrong about? If the whole ICD is an under-resourced, borderline incompetent effort, should they really be doing it? Just seems a really silly way to make global health policy.

Is there anything you'd like to add in terms of messages for psychologists? 

Psychologists are seeing this in practice. Nothing that's happened has convinced me that games aren't an important way to understand the interior and social lives of clients. People spend a lot of their time playing video games; we can 'judge' that if we're a therapist or a counsellor, or we can try to understand it. As a characteristic, a passion like any other – like running, or playing the bass – it offers a road into understanding the interior life of a client. That doesn't mean games are good for you, it means that for therapeutic alliances it's a shared interest, you want to know about that.

Practitioners will also know that creating a new disorder doesn't create new resources. There's a cost-benefit analysis with the whole field of medical epidemiology. What are the costs of stigmatising the most popular form of play? You don't get new therapists… therapists just have more to do.