Gaming Disorder
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Video game addiction (VGA), also known as gaming disorder or internet gaming disorder, is generally defined as the problematic, compulsive use of video games that results in significant impairment to an individual's ability to function in various life domains over a prolonged period of time. This and associated concepts have been the subject of considerable research, debate, and discussion among experts in several disciplines and has generated controversy within the medical, scientific, and gaming communities. Such disorders can be diagnosed when an individual engages in gaming activities at the cost of fulfilling daily responsibilities or pursuing other interests without regard for the negative consequences. As defined by the
ICD-11 The ICD-11 is the eleventh revision of the International Classification of Diseases (ICD). It replaces the ICD-10 as the global standard for recording health information and causes of death. The ICD is developed and annually updated by the World He ...
, the main criterion for this disorder is a lack of self control over gaming. The
World Health Organization The World Health Organization (WHO) is a specialized agency of the United Nations responsible for international public health. The WHO Constitution states its main objective as "the attainment by all peoples of the highest possible level of h ...
included gaming disorder in the 11th revision of its
International Classification of Diseases The International Classification of Diseases (ICD) is a globally used diagnostic tool for epidemiology, health management and clinical purposes. The ICD is maintained by the World Health Organization (WHO), which is the directing and coordinating ...
(ICD). Material was copied from this source, which is available under
Creative Commons Attribution 4.0 International License
The
American Psychiatric Association The American Psychiatric Association (APA) is the main professional organization of psychiatrists and trainee psychiatrists in the United States, and the largest psychiatric organization in the world. It has more than 37,000 members are involve ...
(APA), while stating there is insufficient evidence for the inclusion of Internet gaming disorder in the ''
Diagnostic and Statistical Manual of Mental Disorders The ''Diagnostic and Statistical Manual of Mental Disorders'' (DSM; latest edition: DSM-5-TR, published in March 2022) is a publication by the American Psychiatric Association (APA) for the classification of mental disorders using a common langua ...
'' in 2013, considered it worthy of 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 standardized or agreed definitions, leading to difficulties in developing evidence-based recommendations.


Definition and diagnosis

In its report, the Council on Science and Public Health to the
American Medical Association The American Medical Association (AMA) is a professional association and lobbying group of physicians and medical students. Founded in 1847, it is headquartered in Chicago, Illinois. Membership was approximately 240,000 in 2016. The AMA's state ...
(AMA) used this two-hour-per-day limit to define "gaming overuse", citing the
American Academy of Pediatrics The American Academy of Pediatrics (AAP) is an American professional association of pediatricians, headquartered in Itasca, Illinois. It maintains its Department of Federal Affairs office in Washington, D.C. Background The Academy was founded ...
guideline of no more than one to two hours per day of "screen time". However, the ESA document cited in the Council report does not contain the two-hour-per-day data.


American Psychiatric Association

While the
American Psychiatric Association The American Psychiatric Association (APA) is the main professional organization of psychiatrists and trainee psychiatrists in the United States, and the largest psychiatric organization in the world. It has more than 37,000 members are involve ...
(APA) does not recognise 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 The ''Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition'' (DSM-5), is the 2013 update to the ''Diagnostic and Statistical Manual of Mental Disorders'', the taxonomic and diagnostic tool published by the American Psychiatric ...
as 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 Impulse-control disorder (ICD) is a class of psychiatric disorders characterized by impulsivity – failure to resist a temptation, an urge, or an impulse; or having the inability to not speak on a thought. Many psychiatric disorders feature imp ...
, similar to
compulsive gambling Problem gambling or ludomania is repetitive gambling behavior despite harm and negative consequences. Problem gambling may be diagnosed as a mental disorder according to ''DSM-5'' if certain diagnostic criteria are met. Pathological gambling is ...
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.
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 Sleep deprivation, also known as sleep insufficiency or sleeplessness, is the condition of not having adequate duration and/or quality of sleep to support decent alertness, performance, and health. It can be either chronic or acute and may vary ...
, play at work, avoid phone calls from friends, or lie about how much time they spend playing video games. The APA has developed nine criteria for characterising the proposed Internet Gaming Disorder: # 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? # 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? # 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? # 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? # Give up other activities. Do you lose interest in or reduce participation in other recreational activities due to gaming? # 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? # 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? # 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? # 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 The Problem Video Game Playing Questionnaire (or PVP Questionnaire) is a scale measured by using a survey containing nine yes-or-no questions. It is designed to measure the disorder commonly referred to as video game addiction. The creators of th ...
, Tejeiro & Moran, 2002), 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". He proposes that addiction has six components: salience, mood modification, tolerance, withdrawal, conflict, and relapse. 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.


World Health Organization

The
World Health Organization The World Health Organization (WHO) is a specialized agency of the United Nations responsible for international public health. The WHO Constitution states its main objective as "the attainment by all peoples of the highest possible level of h ...
(WHO) had proposed and later included "gaming disorder" in the 11th revision of the
International Statistical Classification of Diseases and Related Health Problems The International Classification of Diseases (ICD) is a globally used diagnostic tool for epidemiology, health management and clinical purposes. The ICD is maintained by the World Health Organization (WHO), which is the directing and coordinating ...
(ICD-11), released in June 2018, which was approved by the
World Health Assembly The World Health Assembly (WHA) is the forum through which the World Health Organization (WHO) is governed by its 194 member states. It is the world's highest health policy setting body and is composed of health ministers from member states. T ...
in May 2019. The use and enforcement of ICD-11 is expected to start on 1 January 2022.


Screening tools

The first psychometric test to assess IGD was the Internet Gaming Disorder Test (IGD-20). 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) 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. Moreover, the scale was adapted in several languages as Spanish, Chinese, Czech, German, and many more. On 3 June 2019, a screening tool for Gaming Disorder, specifically as defined by the World Health Organization, called the "Gaming Disorder Test" was published in a journal article.


Risk factors

The Internet can foster various addictions including addiction to gameplaying. Addictive playing of
MMORPGs A massively multiplayer online role-playing game (MMORPG) is a video game that combines aspects of a role-playing video game and a massively multiplayer online game. As in role-playing games (RPGs), the player assumes the role of a character (o ...
is associated with negative effects, whereas normal play is not. Younger people and men are more likely to experience a gaming disorder than older people and women respectively. Research shows that the average age of a gamer is 30 years old, and 32% of players are under 18.Adolescents are at a higher risk of sustaining video game disorder over time than adults. An international meta-analysis over 34 jurisdictions quantified the effect size of gender as small, with most effect in Asia, lesser in Europe and Africa, and null in North America, and further finding that economic factors, internet availability, social norms and addiction-related health factors mediate the effect of gender, with nations with a greater GDP per capita having less differences in video game addiction between genders. Comorbid psychiatric disorders act as both risk factors and consequences. Indeed, there is a strong association between video game addiction and anxiety, depression, ADHD, social phobia, and poor psycho-social support.
ADHD Attention deficit hyperactivity disorder (ADHD) is a neurodevelopmental disorder characterised by excessive amounts of inattention, hyperactivity, and impulsivity that are pervasive, impairing in multiple contexts, and otherwise age-inapp ...
and its symptoms, such as impulsivity and conduct problems, also increase risks of developing video game disorder. Although internet gaming disorder has a strong relationship with obsessive-compulsive disorder, it is not specific and internet gaming disorder is both phenomenologically and neurobiologically distinct, which indicates that internet gaming disorder is more characterized by impulsivity than compulsivity. Familial factors appear to play an important role, although not well understood. Some personality traits, such as high neuroticism, high impulsivity, and high aggressiveness are consistently significant predictors of internet gaming disorder, and combination of personality traits seem to play a pivotal role in the acquisition, maintenance and development of the disorder.


Mechanisms

Although there is much research since the 1980s on problematic online gaming use, the mechanisms are not well understood, due to inconsistent definitions used in studies.


Video game structure

Some theories focus on the presumed built-in reward systems of video games, such as
compulsion loop A compulsion loop or core loop is a habitual chain of activities that will be repeated by the user to cause them to continue the activity. Typically, this loop is designed to create a neurochemical reward in the user such as the release of dopamin ...
s, to explain their potentially addictive nature. The anticipation of such rewards can create a neurological reaction that releases
dopamine Dopamine (DA, a contraction of 3,4-dihydroxyphenethylamine) is a neuromodulatory molecule that plays several important roles in cells. It is an organic compound, organic chemical of the catecholamine and phenethylamine families. Dopamine const ...
in the body, so that once the reward is obtained, the person will remember it as a pleasurable feeling. This has been found to be similar to the neurological reaction of other behavioral addictions such as substance abuse and gambling disorder. 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.


Addiction circuits in the brain

Long-term internet video/mobile game playing affects brain regions responsible for reward, impulse control and sensory-motor coordination. 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 Inhibitory control, also known as response inhibition, is a cognitive process – and, more specifically, an executive function – that permits an individual to inhibit their impulses and natural, habitual, or dominant behavioral re ...
and reward mechanisms. 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. Treatment studies which used fMRI to monitor the brain connectivity changes found a decrease in the activity of the regions associated with cravings. 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. There is evidence of a dual processing model of digital technology addictions characterized by an imbalance between the reactive and the reflective reward systems. 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. Although the number of neuroimaging studies on internet gaming disorder is rising, there are several methodological shortcomings, particularly in the inconsistency of psychometric assessments. Furthermore, the conclusions on reduced inhibition should be moderated, as only one study included a functional control, which then showed no difference in inhibition. 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. Thus it is unclear whether video game addiction should be considered a unique diagnosis.


Management

As concern over video game addiction grows, the use of psychopharmacology, psychotherapy, twelve-step programs, and use of continuing developing treatment enhancements have been proposed to treat this disorder. Empirical studies indeed indicate that internet gaming disorder is associated with detrimental health-related outcomes. However, the clinical trials of potential treatments remain of low quality, except for cognitive-behavioral therapies, which shows efficacy to reduce gaming disorder and depressive symptoms but not total time spent. Although there is a scientific consensus that cognitive-behavioral therapy is preferable to pharmacological treatment, it remains difficult to make definitive statements about its benefits and efficiency due to methodological inconsistencies and lack of follow-up. Since efficacious treatments have not been well established, prevention of video gaming disorder is crucial. Some evidence suggest that up to 50% of people affected by the internet gaming disorder may recover naturally. 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 centres.


China

China was the first country to treat "internet addiction" clinically in 2008. The Chinese government operates several clinics to treat those who overuse
online game An online game is a video game that is either partially or primarily played through the Internet or any other computer network available. Online games are ubiquitous on modern gaming platforms, including PC game, PCs, Console game, consoles and ...
s, 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 Electroconvulsive therapy (ECT) is a psychiatric treatment where a generalized seizure (without muscular convulsions) is electrically induced to manage refractory mental disorders.Rudorfer, MV, Henry, ME, Sackeim, HA (2003)"Electroconvulsive the ...
. 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. In 2019, China set up a curfew, banning minors from playing between certain hours. 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.


Netherlands

In June 2006, the Smith and Jones clinic in
Amsterdam Amsterdam ( , , , lit. ''The Dam on the River Amstel'') is the Capital of the Netherlands, capital and Municipalities of the Netherlands, most populous city of the Netherlands, with The Hague being the seat of government. It has a population ...
—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 Richmond most often refers to: * Richmond, Virginia, the capital of Virginia, United States * Richmond, London, a part of London * Richmond, North Yorkshire, a town in England * Richmond, British Columbia, a city in Canada * Richmond, California, ...
, British Columbia, excessive gaming accounts for 80% of one youth counselor's caseload.


United Kingdom

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. The specialist treatment center opened in 2019 for treating adolescents and young people aged 13–25 who are addicted to video games.


Outcomes


Physical health

The most frequent physical health-related outcome are alterations in physical functioning such as
somatization Somatization is a tendency to experience and communicate psychological distress in the form of bodily and organic symptoms and to seek medical help for them. More commonly expressed, it is the generation of physical symptoms of a psychiatric cond ...
and sleep disturbances. 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.


Epidemiology

The prevalence of internet gaming disorder range from 0.7% to 25.5% worldwide, or 1.0% to 26.8% worldwide, and 3.5% to 17% in China, and is higher among males than females and among younger than older people, with geographical region being an insignificant contributor. The prevalence was found to be 5.06% among a high-school student population from Sri Lanka, suggesting an increasing trend in low- and middle-income countries as well. A longer time spent on video games predicts a tendency towards pathological gaming in the future. The studies, however, used various methodologies and definitions, which renders consensus difficult to achieve and may explain the wide range of prevalence.


Research


Debates on the classification

A meta-analytic review of pathological gaming studies concluded that about 3% of gamers may experience some symptoms of pathological gaming. 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. Barnett and Coulson 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. 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. 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. 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 The Internet (or internet) is the global system of interconnected computer networks that uses the Internet protocol suite (TCP/IP) to communicate between networks and devices. It is a '' network of networks'' that consists of private, pub ...
,
computers A computer is a machine that can be programmed to carry out sequences of arithmetic or logical operations (computation) automatically. Modern digital electronic computers can perform generic sets of operations known as programs. These programs ...
and other interactive medias. 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. 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. 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. There is recent evidence suggesting that internet gaming disorder can cause two distinct types of dysfunctions: cognitive and metacognitive. Griffiths has suggested that psycho-social dependence may revolve around the intermittent reinforcements in the game and the need to belong. 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".


Controversy and alternative viewpoints

Common challenges involve the reliability of the
methodology In its most common sense, methodology is the study of research methods. However, the term can also refer to the methods themselves or to the philosophical discussion of associated background assumptions. A method is a structured procedure for bri ...
and
validity Validity or Valid may refer to: Science/mathematics/statistics: * Validity (logic), a property of a logical argument * Scientific: ** Internal validity, the validity of causal inferences within scientific studies, usually based on experiments ** ...
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 Gaming may refer to: Games and sports The act of playing games, as in: * Legalized gambling, playing games of chance for money, often referred to in law as "gaming" * Playing a role-playing game, in which players assume fictional roles * Playin ...
. Daria Joanna Kuss and Mark D. Griffiths have argued the current scientific knowledge on internet gaming addiction is copious in scope and complexity. 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 Etiology (pronounced ; alternatively: aetiology or ætiology) is the study of causation or origination. The word is derived from the Greek (''aitiología'') "giving a reason for" (, ''aitía'', "cause"); and ('' -logía''). More completely, e ...
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. Other challenges include the lack of context of the participant's life and the negative portrayal of gaming addicts. Some state that gamers sometimes use
video games Video games, also known as computer games, are electronic games that involves interaction with a user interface or input device such as a joystick, game controller, controller, computer keyboard, keyboard, or motion sensing device to gener ...
to either escape from an uncomfortable environment or alleviate their already existing mental issues—both possibly important aspects in determining the
psychological Psychology is the scientific study of mind and behavior. Psychology includes the study of conscious and unconscious phenomena, including feelings and thoughts. It is an academic discipline of immense scope, crossing the boundaries between t ...
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. The evidence of video game addiction to create withdrawal symptoms is very limited and thus debated, due to different definitions and low quality trials. 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. 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. Although the DSM-5 definition of video game disorder has a good fit to current methodological definitions used in trials and studies, there are still debates on the clinical pertinence. Michael Brody, M.D., head of the TV and Media Committee of the
American Academy of Child and Adolescent Psychiatry The American Academy of Child and Adolescent Psychiatry (AACAP) is a 501(c)(3) non-profit professional association in the United States dedicated to facilitating psychiatric care for children and adolescents. The Academy is headquartered in Wa ...
, 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." A major issue concerns the lack of consistent measures and definitions and of acquisition of follow-up data. Furthermore, the study design quality has not greatly improved between the 2000s and 2017. 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"). 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. 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. 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. 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. Most scholars were worried that WHO's and DSM-5's inclusion of Internet gaming disorder was "overpathologizing normal youth" and "precipitated
moral panic A moral panic is a widespread feeling of fear, often an irrational one, that some evil person or thing threatens the values, interests, or well-being of a community or society. It is "the process of arousing social concern over an issue", usua ...
over video games". This indicates a lack of consensus on the issue . 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.


History

Video game addiction has been studied since the 1980s, and has seen a significant increase in the number of empirical studies since then. The press has reported concerns over online gaming since at least 1994, when ''
Wired ''Wired'' (stylized as ''WIRED'') is a monthly American magazine, published in print and online editions, that focuses on how emerging technologies affect culture, the economy, and politics. Owned by Condé Nast, it is headquartered in San Fra ...
'' mentioned a college student who was playing a
MUD A MUD (; originally multi-user dungeon, with later variants multi-user dimension and multi-user domain) is a Multiplayer video game, multiplayer Time-keeping systems in games#Real-time, real-time virtual world, usually Text-based game, text-bas ...
game for 12 hours a day instead of attending class. Press reports have noted that some
Finnish Defence Forces The Finnish Defence Forces ( fi, Puolustusvoimat, sv, Försvarsmakten) are the military of Finland. The Finnish Defence Forces consist of the Finnish Army, the Finnish Navy and the Finnish Air Force. In wartime the Finnish Border Guard (which i ...
'
conscripts Conscription (also called the draft in the United States) is the state-mandated enlistment of people in a national service, mainly a military service. Conscription dates back to antiquity and it continues in some countries to the present day und ...
were not mature enough to meet the demands of military life and were required to interrupt or postpone military service for a year. One reported source of the lack of needed social skills is overuse of computer games or the internet. ''
Forbes ''Forbes'' () is an American business magazine owned by Integrated Whale Media Investments and the Forbes family. Published eight times a year, it features articles on finance, industry, investing, and marketing topics. ''Forbes'' also re ...
'' termed this overuse "Web fixations" and stated they were responsible for 13 such interruptions or deferrals over the five years from 2000 to 2005. In an April 2008 article, ''
The Daily Telegraph ''The Daily Telegraph'', known online and elsewhere as ''The Telegraph'', is a national British daily broadsheet newspaper published in London by Telegraph Media Group and distributed across the United Kingdom and internationally. It was fo ...
'' reported that surveys of 391 players of ''
Asheron's Call ''Asheron's Call'' (AC) was a fantasy massively multiplayer online role-playing game (MMORPG) for Microsoft Windows PCs, developed and published by Turbine Entertainment Software. Though it was developed by the Turbine team (with Microsoft's ex ...
'' showed that three percent of respondents experienced agitation when they were unable to play, or missed sleep or meals to play. The article reports that
University of Bolton , established = 2004 – gained University Status 1982 – Bolton Institute of Higher Education , type = Public , endowment = £160,000 (2009) , administrative_staff = 700+ , chancellor ...
lead researcher John Charlton said, "Our research supports the idea that people who are heavily involved in game playing may be nearer to autistic spectrum disorders than people who have no interest in gaming." On 6 March 2009, the
Canadian Broadcasting Corporation The Canadian Broadcasting Corporation (french: Société Radio-Canada), branded as CBC/Radio-Canada, is a Canadian public broadcaster for both radio and television. It is a federal Crown corporation that receives funding from the government. ...
's (CBC) national
news magazine A news magazine is a typed, printed, and published magazine, radio or television program, usually published weekly, consisting of articles about current events. News magazines generally discuss stories, in greater depth than do newspapers or new ...
program '' the fifth estate'' aired an hour-long report on video game addiction and the Brandon Crisp story, titled "Top Gun", subtitled "When a video gaming obsession turns to addiction and tragedy." In August 2010, ''
Wired ''Wired'' (stylized as ''WIRED'') is a monthly American magazine, published in print and online editions, that focuses on how emerging technologies affect culture, the economy, and politics. Owned by Condé Nast, it is headquartered in San Fra ...
'' reported that a man in Hawaii, Craig Smallwood, sued the gaming company NCSoft for negligence and for not specifying that their game, ''
Lineage II ''Lineage II'' is a massively multiplayer online role-playing game (MMORPG) for Microsoft Windows and the second game in the ''Lineage'' series. It is a prequel to ''Lineage'' and is set 150 years before the first game. It has become popular sinc ...
'', was so addictive. He alleged he would not have begun playing if he was aware he would become addicted. Smallwood says he has played ''Lineage'' for 20,000 hours between 2004 and 2009. In 2013, a man from China observed his son's addiction to video games, and decided to take action. He hired online assassins to kill his son's virtual avatar every time he logged in. He hoped that being relentlessly killed would help his son lose interest in this destructive habit.


Inclusion in the ICD-11

In the draft versions leading to the final
ICD-11 The ICD-11 is the eleventh revision of the International Classification of Diseases (ICD). It replaces the ICD-10 as the global standard for recording health information and causes of death. The ICD is developed and annually updated by the World He ...
document, gaming disorder was included alongside
gambling disorder Problem gambling or ludomania is repetitive gambling behavior despite harm and negative consequences. Problem gambling may be diagnosed as a mental disorder according to ''DSM-5'' if certain diagnostic criteria are met. Pathological gambling is ...
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 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. 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 Anxiety is an emotion which is characterized by an unpleasant state of inner turmoil and includes feelings of dread over anticipated events. Anxiety is different than fear in that the former is defined as the anticipation of a future threat wh ...
, depression,
loneliness Loneliness is an unpleasant emotional response to perceived isolation. Loneliness is also described as social paina psychological mechanism which motivates individuals to seek social connections. It is often associated with a perceived lack ...
,
obesity Obesity is a medical condition, sometimes considered a disease, in which excess body fat has accumulated to such an extent that it may negatively affect health. People are classified as obese when their body mass index (BMI)—a person's we ...
, sleeping disorders, attention problems, and
stress Stress may refer to: Science and medicine * Stress (biology), an organism's response to a stressor such as an environmental condition * Stress (linguistics), relative emphasis or prominence given to a syllable in a word, or to a word in a phrase ...
. 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". 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 Oxford () is a city in England. It is the county town and only city of Oxfordshire. In 2020, its population was estimated at 151,584. It is north-west of London, south-east of Birmingham and north-east of Bristol. The city is home to the ...
,
Johns Hopkins University Johns Hopkins University (Johns Hopkins, Hopkins, or JHU) is a private university, private research university in Baltimore, Maryland. Founded in 1876, Johns Hopkins is the oldest research university in the United States and in the western hem ...
,
Stockholm University Stockholm University ( sv, Stockholms universitet) is a public research university in Stockholm, Sweden, founded as a college in 1878, with university status since 1960. With over 33,000 students at four different faculties: law, humanities, so ...
and the
University of Sydney The University of Sydney (USYD), also known as Sydney University, or informally Sydney Uni, is a public research university located in Sydney, Australia. Founded in 1850, it is the oldest university in Australia and is one of the country's si ...
, sponsored by
The Association for UK Interactive Entertainment The Association for UK Interactive Entertainment (Ukie) is a non-profit trade association for the video game industry in the United Kingdom (UK). Ukie was originally founded as the European Leisure Software Publishers Association (ELSPA), and the ...
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 finalising the ICD draft. This report was promoted by 22 video game industry trade organizations including the
Entertainment Software Association The Entertainment Software Association (ESA) is the trade association of the video game industry in the United States. It was formed in April 1994 as the Interactive Digital Software Association (IDSA) and renamed on July 21, 2003. It is based in ...
of the United States and
Interactive Software Federation of Europe The Interactive Software Federation of Europe (ISFE) is an independent federation, representing the interests of the video game industry in Europe to the main stakeholders: EU institutions, international organisations, academics, or the general p ...
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 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.


Society and culture


Parental concerns

According to
ABC News ABC News is the news division of the American broadcast network ABC. Its flagship program is the daily evening newscast ''ABC World News Tonight, ABC World News Tonight with David Muir''; other programs include Breakfast television, morning ...
, 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 behaviour.


Governmental concerns

The first video game to attract
political controversy In politics, a political scandal is an action or event regarded as morally or legally wrong and causing general public outrage. Politicians, government officials, party officials and lobbyists can be accused of various illegal, corrupt, uneth ...
was the 1978
arcade game An arcade game or coin-op game is a coin-operated entertainment machine typically installed in public businesses such as restaurants, bars and amusement arcades. Most arcade games are presented as primarily games of skill and include arcade v ...
''
Space Invaders is a 1978 shoot 'em up arcade game developed by Tomohiro Nishikado. It was manufactured and sold by Taito in Japan, and licensed to the Midway division of Bally for overseas distribution. ''Space Invaders'' was the first fixed shooter and set ...
''. In 1981, a political bill called the Control of Space Invaders (and other Electronic Games) Bill was drafted by
British Labour Party The Labour Party is a List of political parties in the United Kingdom, political party in the United Kingdom that has been described as an alliance of Social democracy, social democrats, Democratic socialism, democratic socialists and trade u ...
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. 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. In 2006, it relaxed the rule so only citizens under the age of 18 would face the limitation. Reports indicate underage gamers found ways to circumvent the measure. 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. In 2008 in the
United States The United States of America (U.S.A. or USA), commonly known as the United States (U.S. or US) or America, is a country primarily located in North America. It consists of 50 states, a federal district, five major unincorporated territorie ...
(US), one of the five
Federal Communications Commission The Federal Communications Commission (FCC) is an independent agency of the United States federal government that regulates communications by radio, television, wire, satellite, and cable across the United States. The FCC maintains jurisdiction ...
(FCC) Commissioners,
Deborah Taylor Tate Deborah Taylor Tate was a Commissioner of the Federal Communications Commission (FCC). She was nominated by President George W. Bush on November 9, 2005, for the remainder of the term expiring June 30, 2007. She was unanimously confirmed by the ...
, stated that online gaming addiction was "one of the top reasons for college drop-outs". However, she did not mention a source for the statement nor identify its position in relation to other top reasons. In 2011, the South Korean government implemented a law, known as the
Shutdown law The Youth Protection Revision Act, commonly known as the Shutdown Law or Cinderella Law, was an act of the South Korean National Assembly which forbade children under the age of sixteen to play online video games between the hours of 00:00 and 0 ...
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. 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. A systematic review identified in 2017 three types of currently attempted governmental policies: 1) limiting the availability of video games (shutdown, fatigue system, parental controls), 2) reduce the risks and harm (warning messages), 3) provide addiction help services to gamers. Most of these policies were either not as efficient as intended or not yet evaluated for efficiency, which lead some researchers to prompt for a global public health approach to prevent the onset and progression of this disorder. Some researchers suggest that the video game industry should itself place preventive measures against video game addiction.


Deaths

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


China

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 Tianjin (; ; Mandarin: ), alternately romanized as Tientsin (), is a municipality and a coastal metropolis in Northern China on the shore of the Bohai Sea. It is one of the nine national central cities in Mainland China, with a total popul ...
. 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". His parents sued Aomeisoft, the China-region publisher of the game ''
World of Warcraft ''World of Warcraft'' (''WoW'') is a massively multiplayer online role-playing game (MMORPG) released in 2004 by Blizzard Entertainment. Set in the ''Warcraft'' fantasy universe, ''World of Warcraft'' takes place within the world of Azeroth ...
''. The head of a software association said to gaming website Play.tm that same year: "In the hypothetical world created by such games,
layers Layer or layered may refer to: Arts, entertainment, and media * ''Layers'' (Kungs album) * ''Layers'' (Les McCann album) * ''Layers'' (Royce da 5'9" album) *"Layers", the title track of Royce da 5'9"'s sixth studio album *Layer, a female Maveric ...
become confident and gain satisfaction, which they cannot get in the real world." In 2007, a 26-year-old man identified only as "Zhang" died of a heart attack due to lack of physical activity following a seven-day gaming binge, while a 30-year-old man died in a
Guangzhou Guangzhou (, ; ; or ; ), also known as Canton () and alternatively romanized as Kwongchow or Kwangchow, is the capital and largest city of Guangdong province in southern China. Located on the Pearl River about north-northwest of Hong Kon ...
Internet cafe after playing online games for three straight days.


South Korea

In 2005, 28-year old industrial repairman Seungseob Lee (
Hangul The Korean alphabet, known as Hangul, . Hangul may also be written as following South Korea's standard Romanization. ( ) in South Korea and Chosŏn'gŭl in North Korea, is the modern official writing system for the Korean language. The let ...
: 이승섭) visited an
Internet cafe The Internet (or internet) is the global system of interconnected computer networks that uses the Internet protocol suite (TCP/IP) to communicate between networks and devices. It is a '' network of networks'' that consists of private, pub ...
in the city of
Daegu Daegu (, , literally 'large hill', 대구광역시), formerly spelled Taegu and officially known as the Daegu Metropolitan City, is a city in South Korea. It is the third-largest urban agglomeration in South Korea after Seoul and Busan; it is ...
and played ''
StarCraft ''StarCraft'' is a military science fiction media franchise created by Chris Metzen and James Phinney and owned by Blizzard Entertainment. The series, set in the beginning of the 26th century, centers on a galactic struggle for dominance am ...
'' 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. 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 ''Prius Online'', also known by its retitled name ''Arcane Saga Online'', is a Free-to-play 3D fantasy massively multiplayer online role-playing game (MMORPG) which revolves around a three character (3C) playing system. The 3C system consists of ...
''. The death is covered in the 2014 documentary '' Love Child''.


United States

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 ''EverQuest'' is a 3D fantasy-themed massively multiplayer online role-playing game (MMORPG) originally developed by Verant Interactive and 989 Studios for Windows PCs. It was released by Sony Online Entertainment in March 1999 in North Americ ...
''. Shawn's mother said the suicide was due to a rejection or betrayal in the game from a character Shawn called "iluvyou". Ohio teenager
Daniel Petric Daniel Petric (; born August 24, 1991) is a convicted murderer from Wellington, Ohio. At age 16, he shot both of his parents after his father confiscated his copy of the video game ''Halo 3''. His mother died, but his father managed to recover ...
shot his parents, killing his mother, after they took away his copy of ''
Halo 3 ''Halo 3'' is a 2007 first-person shooter video game developed by Bungie for the Xbox 360 console. The third installment in the ''Halo'' franchise, the game concludes the story arc begun in 2001's '' Halo: Combat Evolved'' and continued in 2 ...
'' 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. On 16 June 2009, Petric was sentenced to 23 years to life in prison.


See also

*
Behavioral addiction Behavioral addiction is a form of addiction that involves a compulsion to engage in a rewarding non- substance-related behavior – sometimes called a natural reward – despite any negative consequences to the person's physical, mental, social o ...
*
Digital media use and mental health The relationships between digital media use and mental health have been investigated by various researchers—predominantly psychologists, sociologists, anthropologists, and medical experts—especially since the mid-1990s, after the growth of ...
*
Internet addiction disorder Problematic internet use or pathological internet use is generally defined as problematic, compulsive use of the internet, that results in significant impairment in an individual's function in various life domains over a prolonged period of time. ...


References


Further reading

* * * * * * * {{Video game controversy Digital media use and mental health Behavioral addiction Health and video gaming