Gaming disorder in ICD-11: when does gaming become a disorder?

Gaming disorder in ICD-11 – what is it and which group does it belong to?

Playing digital, console and mobile games is one of the most popular forms of entertainment. For many people it is a way to relax, compete, maintain contact with others and develop skills. The mere fact of gaming intensively, following new releases, spending hours in online games or treating gaming as an important hobby does not indicate a disorder.^[1]

ICD-11 has nonetheless identified gaming disorder as a separate entity with code 6C51, belonging to the group of disorders due to addictive behaviours. This group shares a common mechanism: a repetitive activity that over time slips out of control and is continued despite harm – analogously to gambling disorder (6C50). Earlier ICD-10 had no separate category for problematic gaming, which hampered diagnosis, planning of help and research.^[5,6]

This article is educational and does not replace specialist assessment.

Intense gaming vs gaming disorder – where is the boundary?

The most common misconception around this diagnosis: that gaming a lot equals having a disorder. ICD-11 clearly contradicts this – the time spent in games alone is not a diagnostic criterion.^[1,7]

An enthusiast games because they want to, derives satisfaction from it and is able to set the game aside when life demands it. In gaming disorder, gaming becomes a compulsion – attempts to limit it end in failure, and gaming continues despite awareness of its negative effects.

Three core diagnostic elements of gaming disorder

WHO describes gaming disorder through three main features that must all be present:^[1,2]

Impaired control over gaming. The person has difficulty limiting the time, frequency, intensity or termination of gaming. They may repeatedly promise themselves or others they will play for less time, yet still end up gaming for many hours. Control concerns various aspects – both starting and stopping a game.

Increasing priority of gaming. Gaming begins to displace other interests, obligations and relationships. The issue is not simply that someone loves games very much. It is the situation in which gaming begins to dominate over sleep, study, work, relationships, hygiene, eating or physical activity – important parts of life that recede ever further into the background.

Continuation or escalation of gaming despite negative consequences. The person continues gaming despite visible effects: deteriorating grades, problems at work, family conflicts, neglect of health, loss of a sleep rhythm, social isolation or worsening of psychological functioning. Awareness of this harm does not lead to a change in behaviour.

Diagnosis also requires significant functional impairment – in personal, family, social, educational or occupational domains. The pattern alone without real harm is not sufficient.^[1]

Duration and functional impairment

ICD-11 usually requires that the gaming disorder pattern last at least 12 months. This threshold guards against diagnosing a transient period of intense gaming, e.g. after a game release, during holidays or in a period of life crisis. In a particularly severe clinical picture a clinician may regard a shorter period as sufficient.^[1]

Many people go through phases of intense gaming that resolve on their own and leave no lasting harm. Such an episode is not a disorder. The 12-month threshold separates a temporary engagement from an entrenched, harmful pattern.

The purpose of this requirement is the same as in other ICD-11 diagnoses: the diagnosis should reflect a lasting picture rather than a momentary behavioural fluctuation linked to a specific situation. Assessing whether the threshold is met in a given case falls to the clinician after a full interview.

Online and offline gaming – subcategories of 6C51

ICD-11 distinguishes two subcategories of gaming disorder: 6C51.0 – gaming disorder, predominantly online (gaming mainly over the internet) and 6C51.1 – gaming disorder, predominantly offline (gaming mainly without a network connection).^[2]

The essence of the diagnosis is not the type of game but the pattern of behaviour. Online games may reinforce difficulty of control through rankings, timed events, team pressure, communication with other players and reward mechanisms. Offline games can likewise become problematic if the person loses control and suffers negative consequences.

This distinction does not change the diagnostic requirements – the three core elements and the functioning criterion apply to both subcategories.

Gaming disorder in ICD-11 vs internet gaming disorder in DSM-5-TR

ICD-11 and DSM-5-TR describe this phenomenon differently. The differences are clinically significant:^[3,4,10]

Reviews indicate that ICD-11 criteria may be more conservative – diagnosis rates under DSM-5 criteria were in some studies nearly twice as high as under ICD-11, especially when the functional impairment criterion was not applied rigorously.^[10,9]

Gaming disorder and “internet addiction”

Gaming disorder in ICD-11 applies solely to playing digital or video games. It is not a diagnosis covering general internet use, scrolling social media, watching films, online shopping, pornography, online gambling or general smartphone use.^[1,4]

In everyday language many different behaviours are thrown together as “internet addiction”. ICD-11 has no such broad diagnosis. If the problem concerns online gambling – the central diagnosis will be gambling disorder (6C50), not gaming disorder. If the problem concerns social media or smartphones – that requires a different clinical description, since ICD-11 does not treat these as the same disorder.

This distinction has practical significance: different behavioural patterns may require different therapeutic approaches. The umbrella label “internet addiction” blurs these differences.

Gaming disorder in children and adolescents

In children and adolescents, assessing gaming disorder requires particular care. First, gaming is part of peer culture – for many young people it is a way of social contact, competition and a sense of competence. Second, parents and teenagers may assess the problem in completely different ways: a parent sees “sitting at the computer”, while the adolescent sees friendships, shared goals and a sense of agency.^[1,11]

The assessment must consider not only the number of hours but also functioning: sleep, school, relationships, emotions, physical activity, hygiene, family conflicts, attempts to limit gaming and the response to boundaries. It is also worth checking whether a child games excessively because they are experiencing peer bullying, loneliness, academic overload, depression, anxiety, ADHD or difficulties on the autism spectrum.

With younger people it is especially important to talk with the family, but also to listen to the child or adolescent themselves – gaming may serve various psychological functions and is not always the primary problem.

Differential diagnosis – what to consider?

Intense gaming is sometimes secondary to another disorder. Before making a diagnosis of gaming disorder the clinician assesses whether gaming is not primarily a coping mechanism for another condition.^[11,8]

Depression – gaming may be an escape from emptiness, anhedonia, low self-esteem and lack of energy. The person may game not because gaming has taken over control, but because everything else has become emotionally unavailable. Treating depression may in such cases itself reduce excessive gaming.

ADHD (6A05) – games attract particularly strongly through immediate feedback, stimulation, rewards and rapid switching of attention. Executive difficulties and impulsivity in ADHD may hamper control of gaming time independently of gaming disorder.

Social anxiety – online games may become a safer form of contact in which social exposure is easier to control. Withdrawal from contacts and intense gaming may be a symptom of anxiety rather than a separate gaming disorder.

Autism spectrum (6A02) – games may offer predictability, clear rules, a controlled social environment, intensive interests or a break from sensory overload. This does not rule out gaming disorder but requires assessment of which mechanism is primary.

CPTSD and trauma – withdrawal, hypervigilance and avoidance may lead to intense gaming as a way of regulating emotions and avoiding memories. The key is linking the pattern to a traumatic history.

ICD-11 allows co-occurrence – gaming disorder may be diagnosed alongside another disorder if the overall picture requires it. It is important to establish what the primary problem is and what maintains the gaming pattern.

Game mechanics, loot boxes and the boundary with gambling

Some games are designed to maintain engagement over a long time. This does not automatically indicate a disorder, but may hamper control for susceptible individuals. Particularly significant may be: daily rewards, timed events, rankings, battle passes, team pressure, “just one more round” mechanisms, daily tasks and progression systems.^[12]

In clinical practice it is worth asking not only “how much do you game?” but also: what makes it hard to stop? Is it competition, escape from emotions, contact with people, fear of losing progress, team pressure, daily rewards, a sense of competence, or a lack of alternatives outside gaming? The answer helps distinguish an intense hobby from a pattern that sustains the problem.

Loot boxes and micropayments require separate assessment. If the central problem is random financial risk and a mechanism resembling gambling, gambling disorder (6C50) may be a more appropriate diagnosis. If the central problem is loss of control over gaming itself and functional harm – that points to gaming disorder. Patterns may overlap: a person may have a problem with both gaming and in-game spending.

Controversies: stigmatising gamers vs clinical need

The introduction of gaming disorder into ICD-11 was met with both support and criticism from researchers. Supporters point out that some people genuinely lose control over gaming and need specialist help – the absence of a diagnosis hampered access to treatment, research and the development of therapeutic services.^[6,5]

Critics fear over-diagnosis and stigmatisation of gamers. They argue that problematic gaming often co-occurs with other mental difficulties and tends to be a symptom of depression, anxiety, ADHD or loneliness rather than a standalone disorder. They also point out that studies used many different tools and criteria, leading to highly variable estimates of the prevalence of gaming disorder in the population.^[7,8]

A balanced position: gaming disorder exists as an ICD-11 diagnosis, but should be applied cautiously, with emphasis on loss of control, real harm and differential diagnosis – not on the time spent in games.^[11]

The diagnostic interview – how does assessment proceed?

Diagnosis of gaming disorder should cover several areas. It is worth asking about:^[1,11]

The gaming pattern: when, how long, which games, online or offline, alone or socially, whether there have been gaming binges and whether the daily rhythm is organised around gameplay.

Control: whether the person has tried to limit gaming, what happens when they cannot game, whether they hide gaming, whether they break their own resolutions.

Consequences: sleep, school, work, relationships, health, physical activity, hygiene, finances, family conflicts, wellbeing.

The function of gaming: whether gaming is a source of pleasure, an escape from suffering, a way of regulating emotions, the only available social relationship, a domain of competence, or a mechanism for avoiding life outside the game.

Sample questions: “What usually happens just before you start gaming?” · “Does it happen that you plan to game for an hour but end up gaming for many hours?” · “What do you lose or neglect because of gaming?” · “Have you tried to limit gaming? What happened then?” · “Do you game for pleasure, or more to avoid feeling tension, emptiness, anxiety or loneliness?”

Summary and when to seek help

Gaming disorder in ICD-11 is a diagnosis describing a pattern of loss of control over gaming, increasing priority of gaming and continuation despite real harm – not a diagnosis for people who game a lot or treat gaming as their main hobby. The key elements are functional impairment and persistence of the pattern, usually at least 12 months.^[1,5]

The signal justifying a consultation is not the number of hours but loss of control, neglect of important areas of life and continuation of gaming despite awareness of its negative effects. It is also worth noting the emotional role of gaming – if it becomes the main way of coping with anxiety, sadness or loneliness, and limiting it provokes strong tension, that is a reason to talk to a specialist.

Help is provided by psychiatrists, psychologists and psychotherapists, and in the case of children and adolescents specialist clinics. The content of this article is educational and does not replace clinical assessment.

Frequently asked questions