Video game addiction

While the American Psychiatric Association (APA) does not recognize video game addiction as a disorder, in light of existing evidence, the organisation included video game addiction as a "condition requiring further study" in the DSM-5 as Internet gaming disorder.[9] Video game addiction is a broader concept than internet gaming addiction, but most video game addiction is associated with internet gaming. APA suggests, like Khan,[10] the effects (or symptoms) of video game addiction may be similar to those of other proposed psychological addictions. Video game addiction may be an impulse control disorder, similar to compulsive gambling[11][12] The APA explains why Internet Gaming Disorder has been proposed as a disorder:

This decision was based upon the large number of studies of this condition and the severity of its consequences. ... Because of the distinguishing features and increased risks of clinically significant problems associated with gaming in particular, the Workgroup recommended the inclusion of only internet gaming disorder in Section 3 of the DSM-5.[13]

Some players become more concerned with their interactions in the game than in their broader lives. Players may play many hours per day, neglect personal hygiene, gain or lose significant weight, disrupt sleep patterns resulting in sleep deprivation, play at work, avoid phone calls from friends, or lie about how much time they spend playing video games.[14][15]

The APA has developed nine criteria for characterizing the proposed Internet Gaming Disorder:[9]

1. Pre-occupation. Do you spend a lot of time thinking about games even when you are not playing, or planning when you can play next?
2. Withdrawal. Do you feel restless, irritable, moody, angry, anxious or sad when attempting to cut down or stop gaming, or when you are unable to play?
3. Tolerance. Do you feel the need to play for increasing amounts of time, play more exciting games, or use more powerful equipment to get the same amount of excitement you used to get?
4. Reduce/stop. Do you feel that you should play less, but are unable to cut back on the amount of time you spend playing games?
5. Give up other activities. Do you lose interest in or reduce participation in other recreational activities due to gaming?
6. Continue despite problems. Do you continue to play games even though you are aware of negative consequences, such as not getting enough sleep, being late to school/work, spending too much money, having arguments with others, or neglecting important duties?
7. Deceive/cover up. Do you lie to family, friends or others about how much you game, or try to keep your family or friends from knowing how much you game?
8. Escape adverse moods. Do you game to escape from or forget about personal problems, or to relieve uncomfortable feelings such as guilt, anxiety, helplessness or depression?
9. Risk/lose relationships/opportunities. Do you risk or lose significant relationships, or job, educational or career opportunities because of gaming?

One of the most commonly used instruments for the measurement of addiction, the PVP Questionnaire (Problem Video Game Playing Questionnaire, Tejeiro & Moran, 2002), was presented as a quantitative measure, not as a diagnostic tool.[16] According to Griffiths, "all addictions (whether chemical or behavioral) are essentially about constant rewards and reinforcement".[17] He proposes that addiction has six components: salience, mood modification, tolerance, withdrawal, conflict, and relapse.[17] But the APA's nine criteria for diagnosing Internet Gaming Disorder were made by taking point of departure in eight different diagnostic/measuring tools proposed in other studies. Thus, the APA's criteria attempt to condense the scientific work on diagnosing Internet Gaming Disorder.

The World Health Organization (WHO) had proposed and later included "gaming disorder" in the 11th revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-11), released in June 2018, which was approved by the World Health Assembly in May 2019.[4][18][19] The use and enforcement of the ICD-11 officially began on 1 January 2022.[20][21][22]

The first psychometric test to assess IGD was the Internet Gaming Disorder Test (IGD-20).[23] This test includes 20 questions designed to assess the extent of problems caused by disordered gaming and the degree of symptoms experienced by gamers. The test was first published in a journal article published in the PLoS ONE journal on 14 October 2014.

The Internet Gaming Disorder Scale–Short-Form (IGDS9-SF)[24] is a short psychometric test to assess video game addiction according to the American Psychiatric Association framework for IGD. Recent review studies suggest that the IGDS9-SF presents with robust empirical and clinical evidence and is an effective tool to assess IGD.[25][26] Moreover, the scale was adapted in several languages as Spanish,[27][28][29] Chinese,[30] Czech,[31] German,[32] and many more.

In 2019, the "Gaming Disorder Test", a screening tool for gaming disorder as defined by the World Health Organization, was published.[4]

Some theories focus on the presumed built-in reward systems of video games, such as compulsion loops, to explain their potentially addictive nature.[49] The anticipation of such rewards can create a neurological reaction that releases dopamine in the body, so that once the reward is obtained, the person will remember it as a pleasurable feeling.[40] This has been found to be similar to the neurological reaction of other behavioral addictions such as substance abuse and gambling disorder.[40]

Mark Griffiths has proposed another reason online video games are potentially addictive is because they "can be played all day every day." The fact there is no end to the game can feel rewarding for some, and hence players are further engaged in the game.[17]

Long-term internet video/mobile game playing affects brain regions responsible for reward, impulse control and sensory-motor coordination.[50] Structural analyses shown modifications in the volume of the ventral striatum, possibly as result of changes in rewards, and video game addicts had faulty inhibitory control and reward mechanisms.[50] Video game playing is associated with dopamine release similar in magnitude to that of drug abuse and gambling, and the presentation of gaming pictures activates brain regions similarly to drug pictures for drug addicts.[50] Treatment studies which used fMRI to monitor the brain connectivity changes found a decrease in the activity of the regions associated with cravings.[50] Although there are evidences that video game addiction may be supported by similar neural mechanisms underlying drug abuse, as video game and internet addictions reduce the sensitivity of the dopaminergic reward system, it is still premature to conclude that this addiction is equivalent to substance addictions, as the research is in its early stages.[50] There is evidence of a dual processing model of digital technology addictions characterized by an imbalance between the reactive and the reflective reward systems.[40] Other studies shown increased difficulties in decision making in specific contexts, such as risky situations but not in ambiguous situations, and an increased preference for short-term rewards.[51] Although the number of neuroimaging studies on internet gaming disorder is rising, there are several methodological shortcomings, particularly in the inconsistency of psychometric assessments.[52] Furthermore, the conclusions on reduced inhibition should be moderated, as only one study included a functional control, which then showed no difference in inhibition.[51]

A meta-analytic review of the research concluded the evidence suggests video game addiction arises out of other mental health problems, rather than causing them.[53] Thus it is unclear whether video game addiction should be considered a unique diagnosis.[53]

China was the first country to treat "internet addiction" clinically in 2008.[60] The Chinese government operates several clinics to treat those who overuse online games, chatting and web surfing. Treatment for the patients, most of whom have been forced to attend by parents or government officials, includes various forms of pain including shock therapy.[61][62] In August 2009, Deng Sanshan was reportedly beaten to death in a correctional facility for video game and Web addiction.[63] Most of the addiction "boot camps" in China are actually extralegal militaristically managed centers, but have remained popular despite growing controversy over their practices.[60][64][65]

In 2019, China set up a curfew, banning minors from playing between certain hours.[66] In 2021, China government published a new policy to force corporations to only serve underage teenagers on Friday, Saturday, and Sunday between 8 pm to 9 pm.[67]

In June 2006, the Smith and Jones clinic in Amsterdam—which has now gone bankrupt—became the first treatment facility in Europe to offer a residential treatment program for compulsive gamers.[68] Keith Bakker, founder and former head of the clinic, has stated that 90% of the young people who seek treatment for compulsive computer gaming are not addicted.[69]

At a Computer Addiction Services center in Richmond, British Columbia, excessive gaming accounts for 80% of one youth counselor's caseload.[70]

In 2018, the National Health Service announced its plans to open a treatment center, run by the Central and North West London NHS foundation trust, that will initially focus on gaming disorder, but is planned to expand to cover other internet-based addictions.[71] The specialist treatment center opened in 2019 for treating adolescents and young people aged 13–25 who are addicted to video games.[72]

The most frequent physical health-related outcome are alterations in physical functioning such as somatization and sleep disturbances.[45][73] Preliminary evidence suggest that internet gaming disorder and the induced sedentarity may contribute to a lack of physical exercise, even though the relationship is not causal.[45]

A meta-analytic review of pathological gaming studies concluded that about 3% of gamers may experience some symptoms of pathological gaming.[53] The report noted problems in the field with defining and measuring pathological gaming and concluded that pathological gaming behaviors were more likely the product of underlying mental health problems rather than the inverse.[53]

Barnett and Coulson[75] expressed concern that much of the debate on the issue of addiction may be a knee jerk response stimulated by poor understanding of games and game players. Such issues may lead both society and scholars to exaggerate the prevalence and nature of problematic gaming, and over-focus on games specifically, while ignoring underlying mental health issues. However, Problem gamblers have a higher chance for getting mental illness as well.[76]

Other scholars have cautioned that comparing the symptoms of problematic gaming with problematic gambling is flawed, and that such comparisons may introduce research artifacts and artificially inflate prevalence estimates. For instance, Richard Wood has observed that behaviors which are problematic in regards to gambling may not be as problematic when put into the context of other behaviors that are rewarding such as gaming.[77] Similarly, Barnett and Coulson have cautioned that discussions of problematic gaming have moved forward prematurely without proper understanding of the symptoms, proper assessment and consequences.[75]

Rather than video gaming disorder being a subtype of gambling disorder, a majority of researchers support the idea of video game addiction being a part of a more comprehensive framework of impulse control disorders with "pathological technology use" with similar characteristics, including the pathological use of video games, internet, computers and other interactive medias.[40][78][79] Although internet and video game addictions are generally considered different from gambling disorder and substance abuse, there is a growing body of evidence indicating they share common features, including behavioral and neural features.[40] Indeed, it is suggested that while behavioral addiction may differ with drug addictions in magnitude, they share several characteristics, with Hellman et al. proposing that the concept of addiction should be de-medicalized.[80]

On the contrary, a literature review found that as the video game addiction develops, online gaming addicts spend increasing amounts of time not only playing but also preparing for and organizing their playing sessions, suggesting this addiction may be behavioral rather than a disorder of impulse control.[81] There is recent evidence suggesting that internet gaming disorder can cause two distinct types of dysfunctions: cognitive and metacognitive.[82]

Griffiths has suggested that psycho-social dependence may revolve around the intermittent reinforcements in the game and the need to belong.[17] Hagedorn & Young have suggested that social dependence may arise due to video games occurring online where players interact with others and the relationships "often become more important for gamers than real-life relationships".[83]

Common challenges involve the reliability of the methodology and validity of the results in some studies. Many rely on self-surveys from university students and also lack time frames making it difficult to study the impact, if any, of addiction on a long term scale. Other concerns also address the definition of addiction and how to measure it, questioning whether or not time is a proper unit to determine how addicted someone is to gaming.[84] Daria Joanna Kuss and Mark D. Griffiths have argued the current scientific knowledge on internet gaming addiction is copious in scope and complexity.[85] They state that instead, a simple framework should be provided to allow all current and future studies to be categorized, as internet gaming addiction lies on a continuum beginning with etiology and risk factors all the way through the development of "full-blown" addiction and ending with ramifications and potential treatment. In addition, they caution the deployment of the label "addiction" since it heavily denotes the use of substances or engagement in certain behaviors. Finally, the researcher promotes other researchers to assess the validity and reliability of existing measures instead of developing additional measurement instruments.[85]

Other challenges include the lack of context of the participant's life and the negative portrayal of gaming addicts.[86] Some state that gamers sometimes use video games to either escape from an uncomfortable environment or alleviate their already existing mental issues—both possibly important aspects in determining the psychological impact of gaming. Negative portrayal also deals with the lack of consistency in measuring addictive gaming. This leads to discussions that sometimes exaggerate the issue and create a misconception in some that they, themselves, may be addicted when they are not.[87][88]

The evidence of video game addiction to create withdrawal symptoms is very limited and thus debated, due to different definitions and low quality trials.[89]

The concept of video game disorder is itself being debated, with the overlap of its symptoms with other mental disorders, the unclear consensus on a definition and thresholds, and the lack of evidence raising doubts on whether or not this qualifies as a mental disorder of its own.[90][91][92] Despite the lack of a unified definition, there is an emerging consensus among studies that Internet gaming disorder is mainly defined by three features: 1) withdrawal, 2) loss of control, and 3) conflict.[48] Although the DSM-5 definition of video game disorder has a good fit to current methodological definitions used in trials and studies,[92] there are still debates on the clinical pertinence.[90][92]

Michael Brody, M.D., head of the TV and Media Committee of the American Academy of Child and Adolescent Psychiatry, stated in a 2007 press release that "... there is not enough research on whether or not video games are addictive." However, Brody also cautioned that for some children and adolescents, "... it displaces physical activity and time spent on studies, with friends, and even with family."[93]

A major issue concerns the lack of consistent measures and definitions and of acquisition of follow-up data.[36][48][55][92][94] Furthermore, the study design quality has not greatly improved between the 2000s and 2017.[55] For instance, most studies measured internet gaming behaviors in terms of frequency of use (total time spent), without considering the type of game (e.g., MMORPG), the social context (e.g., physically or virtually with friends), nor the motivations (e.g., competitive, achievement-oriented "grinding").[92] Although the amount of time spent was postulated by Johanssonn and Götestam in 2004 to lead to pathological behaviors, it is unclear whether the time spent is a cause or a consequence of pathological use.[78] These criticisms, however, mostly pertain to Western research since there is more data of higher quality available in Asian regions, where the Internet gaming disorder is more prevalent.[42]

A survey conducted in 2019 of 214 scholars shown that 60.8% agreed that pathological video game use could be a mental health problems, whereas 30.4% were skeptical.[95] However, only 49.7% agreed with the DSM-5 definition of Internet gaming disorder, and 56.5% to the definition of the World Health Organization.[95] Most scholars were worried that WHO's and DSM-5's inclusion of Internet gaming disorder was "overpathologizing normal youth" and "precipitated moral panic over video games".[95] This indicates a lack of consensus on the issue as of 2019.[95]

A study published in 2010 reviewed the findings of video game addiction by use of a motorcycle riding computer game with 17 users. 9 of the users were “abstinent ecstasy users” and the other 8 served as the control group. The 2 groups had their dopamine releases monitored throughout the test. After playing, the control group showed reduced dopamine D2 receptor occupancy of 10.5% in the caudate compared to former baseline levels. The abstinent group reported no changes in their dopamine receptors.[96]

In the draft versions leading to the final ICD-11 document, gaming disorder was included alongside gambling disorder under "Disorders Due to Addictive Behaviors".[104] The addition defines as "a pattern of persistent or recurrent gaming behaviour ('digital gaming' or 'video-gaming')", defined by three criteria: the lack of control over playing video games, priority given to video games over other interests, and the inability to stop playing video games even after being affected by negative consequences.[3] For gaming disorder to be diagnosed, the behavior pattern must be of sufficient severity to result in significant impairment in personal, family, social, educational, occupational or other important areas of functioning and would normally have been evident for at least 12 months.[105] Research shows gaming disorders can be associated with anxiety, depression, loneliness, obesity, sleeping disorders, attention problems, and stress.[106][107]

Vladimir Poznyak, the coordinator for the WHO Department of Mental Health and Substance Abuse, defended the addition of gaming disorder, believing the backlash against the addition to be a moral panic as they chose a very narrow definition that encompasses only the most extreme cases of gaming disorder. He said evaluating a disorder for inclusion is nominally done without any external feedback "to avoid interference from commercial and other entities which may have vested interest in the outcome of the process".[108] Dr. Poznyak asserted that several medical professionals consulting on the ICD-11 did believe gaming disorder to be real, and by including it in the ICD-11, there can now be earnest efforts to define its causes and symptoms betters and methods to deal with it, and now include the video game industry within the conversation to help reduce the effects of video games on public health.[108]

The addition of "gaming disorder" to the ICD-11 was criticized by gamers and the video game industry, while some researchers remained skeptical.[109] Some of these researchers said the evidence remains weak and "there is a genuine risk of abuse of diagnoses."[110] A group of 26 scholars wrote an open letter to the WHO, suggesting that the proposed diagnostic categories lacked scientific merit and were likely to do more harm than good.[111] In counter-argument, a group of fifty academic researchers in behavioral science agreed that the evidence to support gaming disorder was weak, but it would be best that WHO identify gaming disorder in ICD-11 so that it could be considered a clinical and public health need.[112]

A report, prepared by mental health experts at Oxford University, Johns Hopkins University, Stockholm University and the University of Sydney, sponsored by The Association for UK Interactive Entertainment argues that while there may be potential addiction associated with video gaming, it is premature to consider it a disorder without further study, given the stigmatisation that surrounds video, and ask the WHO to use caution when finalizing the ICD draft. This report was promoted by 22 video game industry trade organizations including the Entertainment Software Association of the United States and Interactive Software Federation of Europe[113]

As the final approval of the ICD-11 neared, several video game trade associations issued a statement requesting WHO to reconsider the addition of "gaming disorder", stating that, "The evidence for its inclusion remains highly contested and inconclusive".[114] The Entertainment Software Association had meetings with the WHO during December 2018 to try to convince them to hold off including gaming disorder within ICD-11, with more planned meetings to follow.[115]

According to ABC News, parents have many concerns about their children playing video games, including concerns about age appropriateness, the amount of time spent playing games, physical health, and aggressive behavior.[116]

The first video game to attract political controversy was the 1978 arcade game Space Invaders. In 1981, a political bill called the Control of Space Invaders (and other Electronic Games) Bill was drafted by British Labour Party MP George Foulkes in an attempt to ban the game for its "addictive properties" and for causing "deviancy". The bill was debated and only narrowly defeated in parliament by 114 votes to 94 votes.[117][118][119]

In August 2005, the government of the People's Republic of China, where more than 20 million people play online games, introduced an online gaming restriction limiting playing time to three hours, after which the player would be expelled from whichever game they were playing.[120][121] In 2006, it relaxed the rule so only citizens under the age of 18 would face the limitation.[122][123] Reports indicate underage gamers found ways to circumvent the measure.[124] In July 2007, the rule was relaxed yet again. Internet games operating in China must require users identify themselves by resident identity numbers. After three hours, players under 18 are prompted to stop and "do suitable physical exercise". If they continue, their in-game points are "slashed in half". After five hours, all their points are automatically erased.[125]

In 2011, the South Korean government implemented a law, known as the Shutdown law or the Cinderella Law, which prohibits children under the age of 16 from playing online video games between the hours of 12:00 a.m. to 6:00 a.m.[126] Later on, the law was amended and now children under the age of 16 can play after midnight if they have permission from their parents. In 2021, the South Korean government moved to abolish this law.[127]

As of 2017, there were three main types of governmental policies:

• limiting the availability of video games (shutdown, fatigue system, parental controls),
• reducing the risks and harm (warning messages), and
• providing addiction help services to gamers.[128]

Most of these policies were either not as efficient as intended or not yet evaluated for efficiency,[128] which lead some researchers to prompt for a global public health approach to prevent the onset and progression of this disorder.[129] Some researchers suggest that the video game industry should itself place preventive measures against video game addiction.[128][130]

There have been at least a few deaths caused directly by exhaustion from playing games for excessive periods of time.[131][132][133]

In 2005, thirteen-year-old Zhang Xiaoyi committed suicide by jumping from the top of a 24-story tower block in his home province Tianjin. After previously having spent two straight days playing online role-playing games in an Internet cafe, Zhang had told his parents that he had "been poisoned by games and could no longer control himself".[134] His parents sued Aomeisoft, the China-region publisher of the game World of Warcraft.[135] The head of a software association said to gaming website Play.tm that same year: "In the hypothetical world created by such games, [players] become confident and gain satisfaction, which they cannot get in the real world."[134]

In 2007, a 26-year-old man identified only as "Zhang" died of a heart attack following a seven-day gaming binge,[136] while a 30-year-old man died in a Guangzhou Internet cafe after playing online games for three straight days.[137][138]

In 2005, 28-year old industrial repairman Seungseob Lee (Hangul: 이승섭) visited an Internet cafe in the city of Daegu and played StarCraft almost continuously for fifty hours. He went into cardiac arrest and died at a local hospital. A friend reported: "... he was a game addict. We all knew about it. He couldn't stop himself." About six weeks before his death, he was fired from his job, and his girlfriend, also an avid gamer, broke up with him.[139][140][141]

In 2009, Kim Sa-rang, a 3-month-old Korean girl, starved to death after both her parents spent hours each day in an Internet cafe, rearing a virtual child in an online game, Prius Online.[142] The death is covered in the 2014 documentary Love Child.[143]

In November 2001, 21-year-old Wisconsinite Shawn Woolley committed suicide; it has been inferred that his death was related to the popular computer game EverQuest. Shawn's mother said the suicide was due to a rejection or betrayal in the game from a character Shawn called "iluvyou".[144]

Ohio teenager Daniel Petric shot his parents, killing his mother, after they took away his copy of Halo 3 in October 2007. In a sentencing hearing after the teen was found guilty of aggravated murder, the judge said, "I firmly believe that Daniel Petric had no idea at the time he hatched this plot that if he killed his parents they would be dead forever", in reference to his disconnection from reality caused by playing violent video games.[145][146] On 16 June 2009, Petric was sentenced to 23 years to life in prison.[147]