Case Study 3.1: Gaming Disorder and the WHO ICD-11 — What the Recognition Process Teaches Us About Behavioral Addiction

Background

In May 2019, the World Health Organization's member states formally adopted the Eleventh Revision of the International Classification of Diseases (ICD-11), which included, for the first time, "Gaming Disorder" as a formal diagnostic category (classification 6C51). This decision had been debated intensely within the scientific community for years before its adoption, and it continued to be debated afterward. Understanding the controversy — what evidence was marshaled on each side, what principles were at stake, and what was ultimately decided — illuminates the broader conceptual terrain of behavioral addiction and provides an important context for the book's central concept of algorithmic addiction.

The story of Gaming Disorder's path to formal recognition is not simply a story about video games. It is a story about how medical and scientific institutions navigate the tension between the imperative to identify and respond to genuine suffering and the imperative to avoid over-pathologizing normal variation in human behavior. It is a story about what evidence is required before a behavioral pattern warrants clinical recognition, and about who gets to make that determination and through what process. These questions are directly relevant to the as-yet-unresolved question of whether "social media use disorder" or "algorithmic use disorder" deserves formal clinical recognition.

What Gaming Disorder Is (and Is Not)

Before examining the controversy, it is essential to be precise about what Gaming Disorder in the ICD-11 actually refers to. The ICD-11 defines Gaming Disorder as "a pattern of gaming behavior characterized by impaired control over gaming, increasing priority given to gaming over other activities to the extent that gaming takes precedence over other interests and daily activities, and continuation or escalation of gaming despite the occurrence of negative consequences."

The diagnosis requires that the pattern of behavior be "of sufficient severity to result in significant impairment in personal, family, social, educational, occupational or other important areas of functioning" and that it "normally have been evident for at least 12 months."

Several things are important to note about this definition. First, it focuses on impairment and loss of control, not on heavy use. Playing video games for many hours per day is not Gaming Disorder; it is a hobby, and possibly a profession. Gaming Disorder requires that the use produce significant impairment and that the person be unable to control or stop the behavior despite wanting to do so. Second, the 12-month duration requirement filters out transient periods of heavy use — the summer vacation gaming marathon, the extended play session during a particularly engaging new release — and focuses on persistent, chronic patterns. Third, the definition is explicitly behavioral and functional: it focuses on what the behavior does to the person's life, not on any particular neurological marker.

These definitional features are directly relevant to the question of social media addiction. A parallel definition of "Social Media Use Disorder" would focus on impaired control over use, prioritization of social media over other activities and interests, continuation despite significant negative consequences, and functional impairment lasting at least 12 months. By these criteria, many researchers argue, there is a population of social media users — particularly adolescent heavy users — who would qualify for diagnosis.

The Case For Recognition

The WHO's decision to include Gaming Disorder was supported by a substantial body of research that had accumulated over the decade preceding the ICD-11's adoption. Proponents of recognition made several arguments.

The empirical argument. A significant number of individuals present to clinical settings with patterns of gaming-related impairment that they cannot control. These are not people who simply play a lot of games; they are people whose gaming has displaced work, education, relationships, sleep, and self-care to a degree that they recognize as harmful and cannot stop. The distress is real; the impairment is real; the inability to control the behavior is real. Clinical recognition is necessary to: (a) provide a framework for identifying and treating this population, (b) enable insurance reimbursement for treatment, and (c) stimulate research into effective interventions.

The neurological argument. Research using neuroimaging techniques (fMRI, PET) had documented patterns of brain activity in heavy, problematic gamers that showed meaningful overlap with the patterns seen in substance use disorders — particularly in the reward circuitry (striatum, ventral tegmental area) and in the prefrontal cortex regions associated with impulse control. While the neurological profiles are not identical to those seen in substance dependence, the overlap was sufficient to suggest that Gaming Disorder engages the same fundamental neurological systems as addictive disorders.

The clinical parallel argument. Gambling Disorder had been recognized in the DSM-5 as an addictive disorder despite being a behavioral rather than a pharmacological condition. Gambling Disorder showed the same pattern of impaired control, social impairment, and neurological involvement that characterizes substance use disorders. The argument was that if Gambling Disorder warranted clinical recognition — and the evidence for that recognition was by now well established — then Gaming Disorder, which showed a similar behavioral and neurological profile, should also receive recognition.

The public health argument. Clinical recognition of Gaming Disorder would: stimulate research into its causes and effective treatments; create the conditions for public health responses (prevention programs, treatment guidelines, training for clinicians); and provide a basis for regulatory responses (platform design standards, age-appropriate content restrictions, warning labels). Without formal recognition, none of these responses could be organized coherently.

The Case Against Recognition

The decision was not without serious critics, including many prominent researchers in the fields of psychology, psychiatry, and media studies. The 2018 paper "Scholars' Open Debate Paper on the World Health Organization ICD-11 Gaming Disorder Proposal," signed by 36 researchers from multiple countries, articulated the strongest objections.

The insufficient evidence argument. Critics argued that the evidence base for Gaming Disorder was not sufficiently robust to justify formal diagnostic status. Research in the area was characterized by inconsistent definitions (different studies used different criteria), inconsistent methodologies, largely non-representative samples (often recruited through gaming forums or clinical settings rather than population-based sampling), and a reliance on self-report measures whose validity had not been adequately established. The prevalence estimates for problematic gaming varied enormously across studies — from less than 1% to over 10% — suggesting that what was being measured was not a consistent clinical phenomenon.

The over-pathologizing argument. Critics warned that formal recognition would inevitably lead to the pathologization of normal, intensive engagement with a legitimate activity. Gaming is a hobby, a profession, a creative medium, and a social space for many people. The intense, absorbing engagement that a skilled gamer develops with their craft is not obviously different in kind from the intense engagement that a musician or athlete develops with theirs. Creating a diagnostic category for "too much gaming" risks stigmatizing an activity that is, for most participants, entirely benign or actively beneficial.

The confusion-of-symptom-and-disorder argument. Some critics argued that what presented as Gaming Disorder in clinical settings was more plausibly understood as a symptom of underlying conditions — depression, anxiety, ADHD, social isolation — than as a disorder in its own right. When people who are depressed or anxious or socially isolated use gaming as an escape mechanism, the solution is treatment of the underlying condition, not treatment of gaming itself as the primary disorder. Recognizing Gaming Disorder as a primary disorder risks treating the symptom while missing the cause.

The cultural bias argument. Critics noted that concerns about gaming disorder had been most prominent in East Asia — particularly South Korea, China, and Japan — and suggested that the diagnostic criteria reflected cultural anxieties about gaming that might not be universal. The WHO's decision, critics argued, risked encoding the cultural norms of particular societies into an international health classification.

What Was Ultimately Decided and Why

The WHO proceeded with the Gaming Disorder classification, but with important qualifications. The classification was explicitly designed to be narrow — to capture only the most severely impaired and least controllable patterns of use, not general heavy gaming. The requirement for significant functional impairment lasting at least 12 months was designed to prevent the over-pathologization that critics feared. And the WHO explicitly noted that the vast majority of gamers — estimated at 95% or more — do not and would not meet criteria for Gaming Disorder.

The decision reflected a judgment that the clinical reality — people presenting with severe gaming-related impairment — was sufficiently robust and sufficiently distinct to warrant clinical recognition, even if the evidence base was not as definitive as might be ideal. This is not an unusual situation in clinical medicine; many diagnostic categories are adopted on the basis of moderate rather than definitive evidence and refined over time as research accumulates.

The decision also reflected a public health judgment: the cost of failing to recognize a real clinical phenomenon (leaving affected individuals without a framework for treatment and without insurance coverage) was judged to outweigh the risk of over-recognition (potentially stigmatizing intensive gaming). This is the kind of decision — involving empirical judgment and policy preference simultaneously — that characterizes the expansion of diagnostic categories in general.

What This Teaches Us About Algorithmic Addiction

The Gaming Disorder case illuminates the conceptual terrain of algorithmic addiction in several important ways.

The definition problem is solvable. Critics of Gaming Disorder recognition argued that definitions were inconsistent and criteria were uncertain. The WHO resolved this by establishing a specific, narrow definition focused on impairment and loss of control. The same approach is available for social media use disorder: a definition that focuses on persistent, significant impairment and genuine loss of control over use, not merely on heavy use, would be both clinically meaningful and resistant to the over-pathologization critique.

The structural dimension matters. Gaming disorder critics observed that the most intense gaming use often involved specific game design features — loot boxes, endless progression systems, social guild structures — that were engineered to maximize engagement and retention. This is directly analogous to the algorithmic design features discussed in Chapter 3. The recognition of Gaming Disorder created the regulatory space for scrutiny of these design features; similar recognition of algorithmic social media disorder would create similar space.

The underlying condition question applies here too. Just as some critics argued that problematic gaming was a symptom of depression, anxiety, or social isolation rather than a primary disorder, similar arguments have been made about social media. Understanding algorithmic addiction requires asking: to what extent are social media's negative effects primary (the platform causing harm directly) and to what extent are they secondary (the platform amplifying pre-existing vulnerabilities)? The Persuasion Stack framework suggests both mechanisms are at work and that the distinction matters for intervention design.

Speed of recognition matters. The Gaming Disorder path to recognition took more than a decade. During that decade, millions of individuals suffered from problematic gaming patterns without clinical recognition, treatment protocols, or insurance coverage for treatment. The parallel question for social media addiction is urgent: how long should we wait for unequivocal evidence before moving toward clinical recognition and regulatory response?

What This Means for Users

The Gaming Disorder case has several direct implications for social media users seeking to understand their own experiences.

First, if you experience a pattern of social media use that resembles the Gaming Disorder criteria — impaired control, significant functional impairment, continuation despite harm — there is a clinical framework that takes this experience seriously. It may not yet have a formal diagnostic code, but the recognition that behavioral addictions are real conditions warranting treatment is established in both the DSM-5 and the ICD-11.

Second, the over-pathologizing concern cuts both ways. Not all heavy social media use is disordered. The intensity and duration of use are not, by themselves, evidence of a problem. The relevant questions are: does your use cause you significant harm? Can you control it when you decide to? Is the use organized around genuine goals and values, or has it become an end in itself that displaces other things you value?

Third, the structural dimension of Gaming Disorder — the role of deliberate design features in producing compulsive use — is increasingly recognized in the regulatory and clinical literature. If you experience compulsive social media use, the recognition that this is at least partly a product of deliberate design rather than entirely a personal failing is both accurate and, for many people, psychologically important.

Discussion Questions

1. The WHO ultimately included Gaming Disorder in the ICD-11 despite significant scholarly opposition. Was this the right decision? What standard of evidence should be required before a behavioral pattern receives formal diagnostic status? Is the standard the same as for a pharmacological substance?

2. Critics argued that Gaming Disorder risked pathologizing intensive engagement with a legitimate activity. Apply this concern to social media: at what point does intensive social media use become something that warrants clinical attention, rather than simply a personal choice about how to spend time? What principle distinguishes the two cases?

3. The chapter argues that the role of deliberate design — engineering engagement through variable rewards and other mechanisms — is one of the features that distinguishes algorithmic addiction from general behavioral addiction. Does this design dimension change the ethical or clinical analysis? Should it affect how we think about diagnosis, treatment, or responsibility?

4. The Gaming Disorder recognition process took over a decade. Considering that social media platforms have been growing and engaging users at massive scale since 2004-2010, how should we weigh the costs of delayed recognition (leaving affected individuals without clinical support) against the costs of premature recognition (potential over-pathologization and stigma)?

5. Some researchers argued that Gaming Disorder is better understood as a symptom of underlying depression, anxiety, or social isolation than as a primary disorder. Evaluate this argument as applied to social media: if compulsive social media use is primarily a symptom of depression or loneliness, does this change how we should respond? Does it affect the question of platform responsibility?