Once considered a niche market, the video game industry is now a dominant presence in popular culture. Projected figures from Statista estimate that by 2021, 2.7 billion people around the world will be playing a video game of some form. In 2018, the 2.3 billion gamers at the time generated $134.1 billion in revenue.
Most of these people will not struggle to moderate their gaming habits. Research from the Journal of Psychiatric Research and the American Journal of Psychiatry suggests that no more than 3 percent of gamers will become addicted to their games, but even that 3 percent represents many millions who will suffer from a psychological inability to stop playing.
To this point, the World Health Organization included “gaming disorders” in the 2018 International Classification of Diseases, its medical reference book. Controversially, the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders – 5th Edition did not mention video game addiction as an activity that could be a possible addiction. Gambling is the only such behavior to receive this designation.
However, DSM-5 does have information on how to recognize the symptoms of video gaming that has become problematic. The symptoms include:
Most of these behaviors are consistent with other forms of compulsive behavior, such as substance abuse, which is why some health advocates feel that problematic video gaming is, by nature and definition, a video game addiction.
But this is not universally agreed upon. As the research has indicated, most of the people who do enjoy video games will not have a problem with their behavior and use of the games. Assuming that people who are enthusiastic about gaming are addicted to gaming is harmful.
This question was tackled in depth by Vox in December 2018 in “Video Game Addiction is Real, Rare and Poorly Understood,” which pointed out that even the World Health Organization’s designation of video game addiction was challenged by many voices in the video game industry, who felt that their passion was being unfairly targeted as a societal ill.
Even the Journal of Behavioral Addictions called WHO’s decision “a weak scientific basis for gaming disorder.” One of the complaints was that WHO’s categorization of video game addiction was made without solid research.
However, even those who supported WHO’s inclusion of video game disorder noted that most of the people who play games wouldn’t experience the problems that WHO (and DSM-5) listed. As Vox pointed out, “[this] is true for most other addictive activities and substances.”
That said, there are people who have a legitimate compulsion to play video games, one that negatively affects their own lives and the lives of those around them. WHO’s decision was meant to draw attention to the fact that these people are in need of help.
Furthering the point is that there are unique aspects of video games that can make them particularly easy for an addiction to exploit, which may not exist with other forms of behavioral disorders. Video games, especially modern ones, offer unparalleled forms of immersion. They are incredibly easy to access, and recent games have offered mechanics similar to gambling (complete with randomization and the chance of winning something desirable) that can make it impossible for a vulnerable person to quit. Crosscut, for example, writes of a young child with severe ADHD, who channeled his energy and hyperactivity from physical activities into excessive gaming.
What WHO intended, says Vox, is to create a framework to solve this problem. By calling compulsive video gaming an outright addiction, doctors will now have a condition that people can be diagnosed with, and appropriate treatment plans can be drawn up. Additionally, it opens the doors for further research, and health insurers should be motivated to pay for treatment since a video game addiction would now be considered a legitimate mental health illness.
A professor at the University of Luxembourg, who is a clinical researcher in gaming disorder and served on WHO’s committee on this topic, told Vox that WHO’s designation will allow for educational and preventative materials to be put forward to better understand the condition and steer people toward appropriate treatment.
Nonetheless, he acknowledged that shining this kind of light on video gaming would “pathologize normal behavior,” raising the possibility of well-balanced gamers receiving “unnecessary treatment.”
This concern is what motivated a lot of people in the video game industry, and some in health care and medical research, to speak out. A psychologist at Stetson University feared a “moral panic” would arise. Coupled with hyperbolic headlines about “digital heroin,” there is a danger of the public having a strongly negative overreaction.
Speaking to Vox, the editor in chief for the Addiction journal explained that part of the problem is that the very definition of “addiction” remains poorly understood. In the past, addiction was thought of as a physiological or physical need for a drug. Now, the current understanding is that addiction is a behavioral problem.
Certain behaviors (and drugs), in certain people, in certain conditions, lead to the motivation to engage in destructive behavior. That nuance is often lost in sensationalized reporting about the dangers of video games, especially when connecting them to other public health problems.
What WHO did was fit gaming disorder into this modern understanding of addiction. It characterizes persistent or recurring gaming behavior in terms of:
Vox points out that there is no physical symptom of gaming addiction, of which the World Health Organization also took note. Instead, the focus of this approach on the question of video game addiction is “about compulsive use despite negative consequences,” which is the definition broadly applied to other forms of addiction.
This means that there is no set limit for how many hours of gaming a person participates in a week. Simply gaming a lot does not meet the standard of an addiction. High involvement, said the University of Luxembourg professor, is not problematic involvement. Professional gamers (in electronic sports, or esports), for example, should not be thought of as addicts because they can play games in a “totally controlled way,” such that their passion will not disrupt other parts of their lives.
A better way to determine whether video gaming has become problematic is the loss of control. A person who constantly plays more than they expect to play, and loses voluntary control of the time they spend gaming, would be closer to fitting the criteria for video game addiction.
A good example of this is sleep deprivation. A player who regularly loses sleep over video games — and then either does nothing to address that problem or tries to address it, fails, and returns to gaming — is likely suffering from video game addiction.
Again, not everyone who occasionally loses sleep to a video game is addicted, but it is one sign that a doctor might use to diagnose if a person has a compulsive gaming problem.
The question is whether the lack of sleep is part of a bigger picture. A person who gets only a couple of hours rest every night, who is suffering at school or work, who is not attending to their family responsibilities, but consistently returns to gaming (or never leaves gaming) is probably suffering from an addiction. If, however, the picture is more complicated than that, then gaming might be part of the problem, but it might not be the source of the problem or the only problem.
The same logic applies to the addictive properties of other drugs. Many people drink a lot without meeting the criteria for alcoholism. But drinking compulsively, regardless of the resultant damage, is the determining factor.
The question of whether video game addiction is a real phenomenon raises other points, like what makes the minority of people who will struggle with compulsive video gaming more susceptible to the trappings of the experience than other people?
As with most of the debate surrounding all forms of addiction and compulsively unhealthy behavior, there is no consensus. However, there are factors that can make video games a possible source of addiction for people who might have the same risk factors that another form of addiction could exploit.
Easy access is one of those factors. Many games can be played on a mobile device, and a number of mainstream games are even free to play. But the University of Luxembourg researcher told the story of a patient who compared his experiences with skydiving to the thrill of playing Fortnite — an online multiplayer game that, at 250 million players, is “the biggest game in the world,” in the words of Business Insider. But while skydiving would require extensive preparation and planning, Fortnite can be played on a smartphone for free.
Fortnite is on “every single gaming device,” writes Vox, and it is much easier to access than a skydiving experience. The proliferation of work-from-home jobs has meant that a number of people can play a game on one screen while monitoring their job responsibilities on another.
Immersion is another unique factor of video games that might contribute to their unhealthy use. Unlike most other forms of entertainment media, consumers don’t passively follow the actions and stories of the protagonist. Consumers play as the protagonist, effectively becoming the character.
Take a game like World of Warcraft. Released in 2004, it had over 100 million registered accounts by 2014, and it had grossed more than $9.23 billion in 2017, catapulting it to the top of the highest-grossing video gaming franchises in history. A great degree of its popularity is because players can spend literally thousands of hours creating and crafting their characters, embarking on stories where they are the hero, in competition and partnership with millions of players around the world.
This kind of online gaming has led to the formation of some real-world connections, with players befriending each other offline, and some of them even getting married to each other. However, World of Warcraft has also been implicated in many cases of addiction and unhealthy gaming habits. The Verge compares Blizzard, the game’s development company, to a “cruel drug dealer.”
Vox notes that even as other mediums of entertainment can tell deeply engaging stories, nothing compares to the level of immersion that a game can create for its players. As much as this explains the popularity of games, and why many have argued that video gaming is a legitimate form of art, this also creates an environment that may be conducive to the development of an addiction.
Further complicating the problem is that many games are adopting mechanics with elements of gambling, which can introduce an even deeper level of psychological dependence on the game to provide excitement. So-called loot boxes can be purchased with in-game currency (like tokens) or real money, for a chance to unlock items that either enhance the gameplay experience or provide more customization options for the player’s character.
The use of loot boxes has come under stringent criticism from watchdogs for incentivizing the gambling elements. Players often have no control over what items they will get when they open the boxes, and many will continue to pay to unlock more boxes in the hope of finding a desired item.
In February 2019, The Verge wrote of one woman who spent $400 trying to get as many items as she could from the boxes in the game Path of Exile. A 19-year-old gamer posted on Reddit that he had spent $13,000 in so-called microtransactions across three different games. Both players admitted that they had a gambling problem through their video games.
In August 2019, a researcher at York St. John University argued at a Federal Trade Commission workshop that there is a direct connection between the practice of using loot boxes and problem gambling, calling it a “life and death” problem for addicted gamers.
Nonetheless, what numbers exist on the phenomenon suggest that it is only a small fraction of gamers who struggle with compulsive gaming problems. For all those who lose sleep to games and fall prey to the gambling mechanics in modern games, there are millions more who are entertained by games, relaxed by games, intellectually stimulated by games, and even benefit from some mental health treatments that are gamified.
Partly because of this lack of consensus, and because this degree of gaming is still relatively new, research into the question of whether video game addiction is real is scarce. The fundamental questions of how to come up with an agreeable definition for video game addiction are unanswered, so the debate continues on how to prevent and treat compulsive gaming behaviors.
In 2017, Psychiatry and Clinical Neurosciences published a review of the research that existed up to that point and reported on evidence that “pathological gaming symptoms” and game addiction, but not gaming itself, were connected with poor health and social outcomes, including depression and reduced academic achievement. The review further pointed out the “obvious insufficiency” of current research into the detection and prevention of gaming problems, and that studies on how gaming addiction develops are “limited,” highlighting that this is still an emerging field of addiction research.
Even those who criticized the World Health Organization for adding gaming disorder to its International Statistical Classification of Diseases and Related Health Problems (on the basis of the research being scant and there being too many challenges and controversies to fully accept) agreed that “excessive gaming” is a serious problem. But the question remains: Is there enough evidence to determine that excessive gaming is a legitimate mental health disorder?
A public health researcher at Radboud University in the Netherlands argued that there isn’t, pointing to the accepted criteria for drug and gambling addiction. For those conditions, there is a wealth of evidence that must be cited for a person to receive a diagnosis that leads to appropriate treatment
But when it comes to video gaming, there are stark contrasts. For example, saying that video games being used to boost mood is a sign of addiction (in the same way that drugs and gambling are used to boost mood) does not hold up because “just about every hobby is […] about improving a person’s mood.”
When it comes to the science on the treatment of gaming addiction, the research is similarly sparse. To date, there have not been any large-scale randomized trials to examine the different ways to treat excessive gaming. For all the evidence regarding the negative consequences, there is still a dearth of evidence-based treatment. Nonetheless, more people are actively looking for gaming addiction treatment, either for themselves or a loved one.
The Crosscut story about the ADHD patient who became addicted to gaming notes some anecdotal coverage that suggests that “young men are particularly susceptible to gaming addiction,” possibly because video games “provide a full spectrum of what young men are looking for” — specifically, competition, accomplishment, mastery of skills, fun, independence, intellectual stimulation, and varied social interaction. Other experts have argued that girls and women are no less likely to fall prey to video game addiction, but gaming companies understand their male demographic much better and have simply not caught up to what their female consumers are looking for.
In March 2019, the Journal of Abnormal Psychology published a report that found that the rate of depression among children and young adults (between the ages of 14 and 17) increased by 60 percent between 2005 and 2017. This led a Seattle-based therapist who specializes in gaming disorders to direct his treatment to ask “what circumstances were present in the kid’s life,” that made it such that excessive video gaming appeared to be the only way out.
In the same way that treating a more established form of substance abuse or a compulsive behavioral problem can be complicated, treating a video game addiction can be similarly challenging, especially when the addiction covers other forms of technology, such as mobile device use. In the case of drugs or alcohol, the standard approach is total abstinence. Technology, on the other hand, is much more difficult to avoid, and it may be an unrealistic goal.
For that reason, some therapists in this field recommend simply reducing the number of hours spent online or gaming, incentivizing this change and providing positive support and reinforcement when the change is made.
However, abstinence treatment for those with severe gaming addiction does exist, although this form of therapy is still in its infancy. Individuals are completely disconnected from the digital world, “in order to figure out what to do with their boredom,” in the words of the founder of one such program. This is done through the use of teaching (or re-teaching) fundamental life and social skills that may have atrophied during the gaming problem. Clients learn how to take care of themselves (basic cooking classes), but more importantly, how to improve their communication skills to build what organizers call “social confidence” to balance their lives in a healthy way.
Much of the treatment modality is borrowed from traditional substance abuse treatment, with the understanding that in the outside world, people will be subjected to many of the same temptations to go back to gaming, the way that people in alcohol recovery will see relapse triggers. These programs seek to equip clients with coping skills and mechanisms to help them monitor their thoughts and regulate their emotions, so they can function as well-balanced adults who don’t need to use video games as a pathological escape from the real world.
In 2019, many parents are rightfully concerned about how to bring up a child in the smartphone age while setting realistic boundaries for gaming and computer use. Talking to Crosscut, one expert recommends that parents look at not only how much time their children spend playing games, but also how digital entertainment affects their behavior:
In and of themselves, these are not necessarily signs that a child will develop a video game addiction. However, they do strongly suggest a susceptibility to problematic behavior based on gaming. These signs might call for the intervention of a child therapist and necessary lifestyle changes.
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