Video game addiction is generally defined as problematic, compulsive use of video and/or internet games, that results in significant impairment in an individual’s function in various life domains over a prolonged period of time. This and associated concepts have been under considerable research, debate and discussion among experts in several disciplines, and have generated controversy from the medical, scientific and gaming communities. The disorder may present itself as compulsive gaming, social isolation, mood swings, diminished imagination, and hyperfocus on in-game achievements, to the exclusion of other events in life.^\ Such disorders can be diagnosed when an individual engages in gaming activities at the cost of fulfilling daily responsibilities or pursuing other interests, and without regard for the negative consequences.

The World Health Organization included gaming disorder within the 11th revision of its International Statistical Classification of Diseases.^\ The American Psychiatric Association (APA), while stating there is insufficient evidence for the inclusion of internet gaming disorder in the Diagnostic and Statistical Manual of Mental Disorders in 2013, considered it a condition for further study.

Controversy around the diagnosis includes whether the disorder is a separate clinical entity, or a manifestation of underlying psychiatric disorders. Research has approached the question from a variety of viewpoints, with no universally standardised or agreed definitions, leading to difficulties in developing evidence based recommendations.

Causes

Video game on a keypad mobile

Some theorists focus on presumed built-in reward systems of the games to explain their potentially addictive nature. Many video games, particularly massively multiplayer online role-playing games and social network and mobile games, rely on a “compulsion loop” or “core loop” – a cycle of activities that involve rewarding the player and driving them to continue through another cycle, retaining them in the game. The anticipation of such rewards can create a neurological reaction that releases dopamine into the body, so that once the reward is obtained, the person will remember it as a pleasurable feeling. This has been found similar to the same neurological reaction believed to be associated with gambling addiction. In reference to gamers, such as one suicide in China, the head of one software association stated, “In the hypothetical world created by such games, they become confident and gain satisfaction, which they cannot get in the real world.”

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

A high prenatal testosterone load may be a risk factor for the development of video game addiction in adulthood.

Ferguson, Coulson and Barnett in a meta-analytic review of the research, concluded that the evidence suggests that video game addiction arises out of other mental health problems, rather than causing them. Thus it is unclear whether video game addiction should be considered a unique diagnosis.

Researchers at the University of Rochester and Immersyve, Inc. (a Celebration, Florida, computer gaming think-tank) investigated what motivates gamers to continue playing video games. According to lead investigator Richard Ryan, they believe that players play for more reasons than fun alone. Ryan, a motivational psychologist at Rochester, says that many video games satisfy basic psychological needs, and players often continue to play because of rewards, freedom, and a connection to other players.

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.”

Karen Pierce, a psychiatrist at Chicago’s Children’s Memorial Hospital, sees no need for a specific gaming addiction diagnosis. Two or more children see her each week because of excessive computer and video game play, and she treats their problems as she would any addiction. She said one of her excessive-gaming patients “…hasn’t been to bed, hasn’t showered…He is really a mess”.

Diagnosis

American Psychiatric Association

While the American Psychiatric Association do 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 Diagnostic and Statistical Manual of Mental Disordersas Internet gaming disorder.^[ 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, 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 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.

Excessive use of video games may have some or all of the symptoms of drug addiction or other proposed psychological addictions. 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 due to playing, disrupt sleep patterns to play resulting in sleep deprivation, play at work, avoid phone calls from friends, or lie about how much time they spend playing video games.^[

APA has developed 9 criteria for characterizing the proposed Internet gaming disorder:

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), was presented as a quantitative measure, not as a diagnostic tool. According to Griffiths, “all addictions (whether chemical or behavioral) are essentially about constant rewards and reinforcement”. Griffiths proposed that addiction has six components: salience, mood modification, tolerance, withdrawal, conflict, and relapse. But, APA’s 9 criteria for diagnosing Internet gaming disorder were made by taking point of departure in 8 different diagnostic/measuring tools proposed in other studies. Thus, APA’s criteria attempt to condense the scientific work on diagnosing Internet gaming disorder.

World Health Organization

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 Assemblyin May 2019. the use and enforcement of ICD-11 is expected to start on January 1, 2022.

In the draft versions leading to the final document, gaming disorder was included alongside gambling disorder under “Disorders Due to Addictive Behaviors”.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 of playing video games, priority given to video games over other interests, and inability to stop playing video games even after being affected by negative consequences. 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. Research shows gaming disorders can be associated with anxiety, depression, obesity, sleeping disorders, and stress.

Dr. 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 stated that 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”. 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.

The addition of “gaming disorder” to the ICD-11 was criticized by gamers and the video game industry, while some researchers remained skeptical.^] Some of these researchers said the evidence remains weak and “there is a genuine risk of abuse of diagnoses.” 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. 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.

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 stigmatization that video games are perceived as, and request WHO 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^[

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”.^[ The Entertainment Software Association had meetings with WHO during December 2018 to try to hold off on including gaming disorder within ICD-11, with more planned meetings to follow.

Treatment

As a growing concern of video game addiction, the use of psychopharmacology, psychotherapy, twelve-step programs, and use of continuing developing treatment enhancements have proven to show signs of the decrease the side effect of the addiction of video games.

Some countries, such as South Korea, China, the Netherlands, Canada, and the United States, have responded to the perceived threat of video game addiction by opening treatment centers.

China

China is the first country started treating “internet addiction” clinically in 2008. 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, include various forms of pain including shock therapy. In August 2009, Deng Sanshan was reportedly beaten to death in a correctional facility for video game and Web addiction. Most of the addiction “boot camps” in China are actually extralegal militaristically managed centers, but have remained popular despite growing controversy over their practices.

Netherlands

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. 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.

Canada

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

United Kingdom

The National Health Service is opening a treatment centre, run by the Central and North West London NHS foundation trust, that will initially focus on gaming disorder but plans to expand to cover other internet-based addictions.