Psychiatric nosology should be informed by multiple stakeholder perspectives By Michelle Colder Carras, Ph.D. Independent Researcher (comment button in upper right of page on navbar) The development of ICD-11 has been a monumental task that supports the World Health Organization (WHO) commitment to prevent disease and promote public health worldwide. As part of this development process, one of the tasks given to Technical Advisory Groups for ICD-11 was to “Identify any other aspects of the classification entity that the workgroup believes to be in need of evaluation, including potentially controversial aspects of the pattern/disorder that will need to be addressed” (World Health Organization, 2014). One area of significant controversy in the study of the proposed “Gaming disorder” is the benefits of creating such a diagnosis, given continuing disagreement about whether the current evidence allows us to reliably and validly separate disordered from excessive or engaged gaming (e.g., van Rooij et al., 2018). Studies of gaming disorder often confuse Internet addiction and problematic/disordered gaming either in terminology or measurement (Higuchi et al., 2017; Pápay et al., 2013; Rehbein & Mößle, 2013) and selective outcome reporting has also been observed (Colder Carras, 2015). This conflation is also reflected in the rise of other proposed behavioral addictions such as pornography, social media, and mobile phone use, all of which have received substantial research attention. The challenge to the WHO is great. Creating new mental and behavioral disorders requires attention to the ethical principle of beneficence: diagnoses need to be reliable in order to improve our ability to research and treat disorders, thus reducing suffering and public health burden, but must also prevent adverse consequences such as reduced civil rights or freedom among those diagnosed (Johnson, Barrett, & Sisti, 2013). Video games and other forms of new media have evolved exponentially over their years of existence, causing vast changes in the way children and adults around the world spend their leisure time, and these changes have profoundly altered community and individual behavioral norms. While WHO working group members are experts in their field, development of new nosologies for mental disorders that involve social values (e.g., what constitutes harmful behavior) or have social impact (e.g., may lead to stigma) is improved when knowledge is solicited from the broader community (Colder Carras et al., 2018; Johnson et al., 2013). A process that allows contribution by multiple stakeholders in line with their expertise—e.g., individuals with an understanding of the social dimensions of disorder, scientists from various disciplines, and patient advocates—can help decision makers understand experiences associated with disorder and enhance consensus on diagnostic criteria (Cuthbert & Insel, 2010; Johnson et al., 2013). Given the need to develop a diagnosis for ICD-11 that will allow research to progress and facilitate treatment for those who need it--while still addressing concerns about controversial aspects of the proposed disorder (e.g., problems with the existing evidence base) and inclusivity of the diagnosis development process—I advocate instead for the designation of a general category to encompass potential behavioral addictions. This interim approach would not solve all problems, but would allow foundational work on a variety of potential disorders to flourish while the input of multiple stakeholders is systematically incorporated into the WHO ‘s decision-making process. This approach satisfies the human right to the “results of scientific progress”(United Nations General Assembly, 1976) by providing the public with access to information, including “including information on relevant legislation” (Donders, 2011), and will also provide a new approach to psychiatric nosology that enhances the ability to define problematic behaviors and distinguish them from rapidly-evolving societal norms. References Colder Carras, M. (2015). Video game play, social interactions and friendship quality in adolescents: A latent class analysis (Ph.D.). The Johns Hopkins University, United States -- Maryland. Retrieved from http://search.proquest.com/dissertations/docview/1858804552/abstract/E291D26362C54FB6PQ/5 Colder Carras, M., Porter, A. M., Van Rooij, A. J., King, D., Lange, A., Carras, M., & Labrique, A. (2018). Gamers’ insights into the phenomenology of normal gaming and game “addiction”: A mixed methods study. Computers in Human Behavior, 79, 238–246. https://doi.org/10.1016/j.chb.2017.10.029 Cuthbert, B., & Insel, T. (2010). The Data of Diagnosis: New Approaches to Psychiatric Classification. Psychiatry, 73(4), 311–314. https://doi.org/10.1521/psyc.2010.73.4.311 Donders, Y. (2011). The right to enjoy the benefits of scientific progress: in search of state obligations in relation to health. Medicine, Health Care, and Philosophy, 14(4), 371–381. https://doi.org/10.1007/s11019-011-9327-y Higuchi, S., Nakayama, H., Mihara, S., Maezono, M., Kitayuguchi, T., & Hashimoto, T. (2017). Inclusion of gaming disorder criteria in ICD-11: A clinical perspective in favor. Journal of Behavioral Addictions, 6(3), 293–295. https://doi.org/10.1556/2006.6.2017.049 Johnson, R. A., Barrett, M. S., & Sisti, D. A. (2013). The ethical boundaries of patient and advocate influence on DSM-5. Harvard Review of Psychiatry, 21(6), 334–344. https://www.ncbi.nlm.nih.gov/pubmed/24201823 Pápay, O., Urbán, R., Griffiths, M. D., Nagygyörgy, K., Farkas, J., Kökönyei, G., … Demetrovics, Z. (2013). Psychometric properties of the Problematic Online Gaming Questionnaire Short-Form and prevalence of problematic online gaming in a national sample of adolescents. Cyberpsychology, Behavior, and Social Networking, 16(5), 340–348. https://doi.org/10.1089/cyber.2012.0484 Rehbein, F., & Mößle, T. (2013). Video game and internet addiction: Is there a need for differentiation? Sucht: Zeitschrift Für Wissenschaft Und Praxis, 59(3), 129–142. https://doi.org/10.1024/0939-5911.a000245 United Nations General Assembly. International Covenant on Economic, Social and Cultural Rights, 2200A (XXI) § (1976). Retrieved from http://www.ohchr.org/EN/ProfessionalInterest/Pages/CESCR.aspx van Rooij, A. J., Ferguson, C. J., Colder Carras, M., Kardefelt-Winther, D., Shi, J., Aarseth, E., … Przybylski, A. K. (2018). A weak scientific basis for gaming disorder: Let us err on the side of caution. Journal of Behavioral Addictions, 1–9. https://doi.org/10.1556/2006.7.2018.19 World Health Organization. (2014). Terms of Reference of the Topic Advisory Groups. Retrieved from http://www.who.int/classifications/TOR_TAGs_WGs.pdf?ua=1