Following the recent changes to the diagnostic category for addictive disorders in DSM-5, it is urgent to clarify what constitutes behavioral addiction to have a clear direction for future research and classification. However, in the years following the release of DSM-5, an expanding body of research has increasingly classified engagement in a wide range of common behaviors and leisure activities as possible behavioral addiction. If this expansion does not end, both the relevance and the credibility of the field of addictive disorders might be questioned, which may prompt a dismissive appraisal of the new DSM-5 sub-category for behavioral addiction. We propose an operational definition of behavioral addiction together with a number of exclusion criteria, to avoid pathologizing common behaviors and provide a common ground for further research. The definition and its exclusion criteria are clarified and justified by illustrating how these address a number of theoretical and methodological shortcomings that result from existing conceptualizations. We invite other researchers to extend our definition under an Open Science Foundation framework.

Concerns about problematic gaming behaviors deserve our full attention. However, we claim that it is far from clear that these problems can or should be attributed to a new disorder. The empirical basis for a Gaming Disorder proposal, such as in the new ICD-11, suffers from fundamental issues. Our main concerns are the low quality of the research base, the fact that the current operationalization leans too heavily on substance use and gambling criteria, and the lack of consensus on symptomatology and assessment of problematic gaming. The act of formalizing this disorder, even as a proposal, has negative medical, scientific, public-health, societal, and human rights fallout that should be considered. Of particular concern are moral panics around the harm of video gaming. They might result in premature application of diagnosis in the medical community and the treatment of abundant false-positive cases, especially for children and adolescents. Second, research will be locked into a confirmatory approach, rather than an exploration of the boundaries of normal versus pathological. Third, the healthy majority of gamers will be affected negatively. We expect that the premature inclusion of Gaming Disorder as a diagnosis in ICD-11 will cause significant stigma to the millions of children who play video games as a part of a normal, healthy life. At this point, suggesting formal diagnoses and categories is premature: the ICD-11 proposal for Gaming Disorder should be removed to avoid a waste of public health resources as well as to avoid causing harm to healthy video gamers around the world.

We greatly appreciate the care and thought that is evident in the 10 commentaries that discuss our debate paper, the majority of which argued in favor of a formalized ICD-11 gaming disorder. We agree that there are some people whose play of video games is related to life problems. We believe that understanding this population and the nature and severity of the problems they experience should be a focus area for future research. However, moving from research construct to formal disorder requires a much stronger evidence base than we currently have. The burden of evidence and the clinical utility should be extremely high, because there is a genuine risk of abuse of diagnoses. We provide suggestions about the level of evidence that might be required: transparent and preregistered studies, a better demarcation of the subject area that includes a rationale for focusing on gaming particularly versus a more general behavioral addictions concept, the exploration of non-addiction approaches, and the unbiased exploration of clinical approaches that treat potentially underlying issues, such as depressive mood or social anxiety first. We acknowledge there could be benefits to formalizing gaming disorder, many of which were highlighted by colleagues in their commentaries, but we think they do not yet outweigh the wider societal and public health risks involved. Given the gravity of diagnostic classification and its wider societal impact, we urge our colleagues at the WHO to err on the side of caution for now and postpone the formalization.

Commentary to: How can we conceptualize behavioural addiction without pathologizing common behaviours?

Since the turn of the millennium, calls for evidence-based drug policy have become increasingly louder. In response, researchers have generated a large body of evidence in support of measures such as needle exchange programs (NEPs), while another strand of research testifies that policy makers often neglect to take the research evidence into account and hence fail to introduce these programs. This article studies the interplay between research-based knowledge, values, and policy making during 16 years of intense parliamentary debate in Sweden on the needle exchange issue. In 2000, the future of the two existing experimental NEPs was uncertain; in 2006, the regulations were reformed; and in 2015, they underwent a government inquiry. Both the reform and the inquiry aimed at regulating and expanding the programs. The analysis is guided by work done within the tradition of science-policy nexus, where the increased emphasis on evidence-based political measures is problematized. As drug policy arouses normative and ethical concerns, the analysis also explores values. The study illustrates the central role that values play in a policy field which is repeatedly declared to be science based. Within the overall framework of the Swedish drug policy ideology of a drug-free society, the advocates of NEPs framed drug misuse as a consequence of either an unjust society or a disease, arguing that because misuse is a condition beyond the control of the individual, the Swedish welfare state has an obligation to take care of those affected. For their part, the opponents framed drug misuse as a result of misguided attitudes, which would only be corrected by restrictions and prohibition. In their view, NEPs are a tool for drug policy liberalization. In the debate between the two positions, research evidence played only a minor role.

Aim To analyse the Swedish drug question by examining dominant concepts used to portray the problem in the years 1839-2011. Theoretically, we understand these concepts as ideological tools that shape the political initiatives and administrative efforts to deal with the problem. The study is based on two kinds of source material: articles in medical journals from the years 1839-1964 and public reports on vagrancy, the alcohol problem, mental health and the drug problem from the years 1882-2011. Findings During the nineteenth century and the first part of the twentieth century the drug problem remained an individual problem handled by doctors. When the Swedish drug problem was established as a political question from the 1960s on, it also came to disengage itself from the medical frame of understanding. Medically oriented descriptions of “dependence” and “addiction” have appeared adequate or attractive when, for example, the socially motivated coercive treatment solution has been discredited (as in the 1970s), when there has been a desire to connect with an internationally accepted terminology (as in the 1990s) or when a new organisational model with a stronger professional support has been on the agenda (as in the 2010s). But otherwise the social problem description has called for concepts that have more or less explicitly dissociated themselves from speculations in physiological or psychological predispositions for substance abuse.

My aim is to analyse how the alcohol question and its responses were framed in the formative period in 1885-1913, when the international anti-alcohol conferences were taking shape. How was the alcohol problem framed in terms of current discussions on general themes such as the individual's role in society, the challenges of modernity and the contribution of science in solving a problem that was traditionally seen as a moral issue? The anti-alcohol conferences of 1885-1913 can be seen as an arrangement for the modern state where the temperance movement placed itself in the service of the state and at the same time demanded that it be given some responsibility for the future development. These were years when the nation acted as a point of reference in several questions that were chafing within the modern project: population qualities and the condition of future generations, the notion of citizenship, industrial strength and competitiveness, the role and the strength of the state. That nation which desired industrial competitiveness, an efficient infrastructure and a strong military institution also did well to ally itself with those temperance advocates who met at the transnational anti-alcohol conferences. The nation which had such objectives and wanted to see sober and strong citizens was encouraged also by the progressive forces in the temperance movement to take up a whole host of issues from women's political status to an individual's sex life.

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