By Paul Davis
“It’s like heroin, but it’s not heroin.”
That is how my dad describes the experience of his two youngest children’s addictions to video games. My little brother currently struggles with this, exacerbated by confinement during the pandemic, while I went through it some years ago.
My dad went on to list some of the specific behaviours he has observed across both of our experiences: “Unwarranted aggression, disruption of family dynamics, unauthorised use of credit cards, the disappearance of cash, nutritional issues, hiding of food in the gaming room, lying, manipulation, falling school results, foul language use, disinterest in family activities, dental hygiene neglect, weight gain, sloth…”
Digital substance abuse
Private clinics like Priory and Gladstones list eerily similar symptoms on their websites regarding the condition. They also point out the parallels between this behavioural addiction and substance abuse-related maladies. Consequently, they approach treatment analogously, offering a range of counselling services such as Cognitive Behavioural Therapy (CBT) and family therapy, self-help groups, 12-step rehabilitation programmes, and residential treatment programmes. Now, private practices are not alone in trying to tackle this modern affliction.
In 2018, the World Health Organisation officially defined gaming disorder as “a pattern of gaming behaviour characterised by impaired control over gaming, increasing priority given to gaming over other activities to the extent that gaming takes precedence over other interests and daily activities, and continuation or escalation of gaming despite the occurrence of negative consequences.” Soon after, the NHS set up the Centre for Internet and Gaming Disorders as part of the National Centre for Behavioural Addictions to help young people like us grappling with gaming addiction.
Claire Murdoch, the NHS National Mental Health Director, said, “Compulsive gaming and social media and internet addiction is a problem that is not going to go away when they play such a key part in modern life. The NHS is rising to the challenge, but tech giants need to recognise the impact that products which encourage repeated and persistent use have on young people, and start taking their responsibilities seriously too.” This puts the UK amongst countries like South Korea, Japan, and China, where governments and companies have begun to act on growing numbers of gaming-related disorder cases.
The role of gaming companies, as pointed out by Claire Murdoch, is one of delicate corporate social responsibility. Some developers deploy addictive features and tactics in their games to keep players engaged. Free-to-play games, ones without an upfront cost associated with downloading and starting the game, are known for this. In particular, mobile games use time-gating systems such as “energy” to encourage microtransaction spending for continued access.
Established gaming franchises are not free of this, however. EA (Electronic Arts) has been the subject of legislative discussion in Germany over the similarities of its almost ubiquitous “loot box” mechanics to gambling. In essence, players earn or pay for ‘packs’ that contain randomised equipment, cosmetic items, or gameplay advantages. There is a very low chance that players will obtain the item they want and a very high chance that they will receive diddly-squat. The House always wins.
Gaming and gambling: a fine line
The convergence between gaming and gambling and the monetisation of in-game progress are issues of growing concern. Some games include trading-card style mechanics, such as FIFA’s Ultimate Team, where players earn the ability to use footballers randomly through draws, similar to loot boxes. A certain genre of games, “gacha games”, has this as its core mechanic. The most recent commercially successful example is the free-to-play Genshin Impact. Early Pokémon games were partially censored or had their age ratings bumped up in the west for their inclusion of the Game Corner, a direct reference to Japan’s Pachinko parlours. Infamously, the basketball game NBA 2K20 included a not-so-subtle slot machine that served the same function as FIFA’s Ultimate Team, rewarding players with playable basketballers.
More commonplace aspects of mainstream games could also be considered addictive tactics. High scores were brought in during the arcade era to encourage continued use. Social constructs like teams, clans, rivals, and communities fuel engagement in Massively-Multiplayer Online (MMO) games. Clear challenges in the forms of levels or missions that are difficult enough to be interesting, but easy enough to be doable, along with an intriguing narrative, keep players glued to screens. Mobile games like Pokémon GO! provide rewards for continued streaks of activity on consecutive days. Online role-playing games (RPGs) like World of Warcraft dangle substantial in-game incentives before the noses of players, promising great rewards in return for hours of committed gameplay.
When entertainment is too entertaining…
Writing in The Guardian, Alex Hern points out a surprising realisation. Fortnite, a highly successful free-to-play game considered as “the poster child” for video game addiction, does not employ any of these tactics. There are no loot boxes, no energy system, no timers, and no ‘pay-to-win’ microtransactions. Individual games are short, and the rewards are purely cosmetic. Publisher Epic Games is seemingly in the minority of developers of free-to-play games who “hope to make more profit from 100 million happy players than a million exploited ones.”
Hern continues, “this cuts to the core of the debate around gaming disorder. If the poster child for the condition can be linked to that dubious term despite avoiding the exploitative techniques that have been adopted by its peers, what are games supposed to do to protect players from themselves? Can entertainment just be too entertaining for its own good?”
The scientific jury is still out on that one.
Neurobiology at play
Since it is categorised as an impulse control disorder, gaming addiction is significantly more difficult to relate to causation than substance addictions. Moreover, it appears that not everyone may be equally susceptible to developing an addiction to video games.
Generally, gaming results in the release of the ‘happy chemical’ dopamine in the brain, triggering a reward response. The desire for online gameplay appears to be linked to activity in the dorsolateral prefrontal, orbitofrontal cortex, the parahippocampal gyrus, and the thalamus (Han et al., 2011). An MRI study on the differences in brain structure between online gaming-addicted and professional gamer participants suggested that increased grey matter volumes of the left cingulate gyrus in pro-gamers and of the left thalamus in addicts may contribute to the differing clinical characteristics of each group (Han, Lyoo, & Renshaw, 2012). Studying gaming addiction is complicated by the variety of games that exist. There are different motivators for playing single-player vs multiplayer games. It is thought that multi-player games are most likely to cause addiction as there is no official ending like there is with single-player games.
The literature mainly focuses on addictions to multiplayer online games, so some papers define a distinct Internet Gaming Disorder (IGD). Risk factors are repeatedly identified as diminished social competence, low self-esteem, and high impulsivity (Lemmens, Volkenburg, & Peter, 2011), although the latter has been suggested to correlate only to total playtime rather than directly to IGD (Fumero, Marrero, Bethencourt, & Peñate, 2020). Earlier onset of weekly gaming, e.g., before age 5 rather than 10, has also been associated with increased risk of developing problematic gaming (Nakayama, Matsuzaki, Mihara, Kitayaguchi, & Higuchi, 2020).
Other traits associated with IGD are not as well-defined as causes or consequences of problematic gaming. These include increased loneliness, higher anxiety, lower family functioning, and lower school performance (Fumero et al., 2020; Gentile, 2009; Gentile et al. 2010; Lemmens et al., 2011). The latter study also found that those who exhibited problematic gaming behaviours tended to sleep and wake up later.
However, care must be taken when evaluating the results of studies utilising playtime as a metric. Based on a sample of 13,000 gamers, it has been suggested that raw playtime is an uninformative predictor of a gamer’s mental health. Better predictors of risk are reasons for engaging with games, such as achievement, escapism, and social context (Sauter, Braun, & Mack, 2021).
Studies into single-player gaming addiction are far less plentiful, but one recent study found that addiction was more prevalent in online gamers than offline, and that maladaptive cognitions predicted both types of disorder equally, Another study explored whether there was any correlation between the type of game played and incidence of problematic video game usage (Entwistle, Baszczynski, & Gainsbury, 2020). The researchers found no such correlation, and instead found that only self-rated impulsivity and frequency of playtime were uniquely and positively correlated with problem video game usage.
Notably absent from any of the aforementioned causes and effects of gaming disorder is the oft-cited ‘aggression’. The literature suggests that there is only weak evidence that playing violent games at all is correlated with increased aggression, or even that it may not be correlated at all (Grüsser, Thalemann, & Griffiths, 2007; Przybylski & Weinstein, 2019). Instead, it appears that aggression may be either a side-effect of frustration arising from the type of reinforcement and difficulty of a game, or a withdrawal symptom specifically related to gaming disorder, and a poorly understood one at that (Chumbley & Griffiths, 2006, Lemmes, Valkenburg, & Peter, 2011; Kaptsis, King, Delfabbro, & Gradisar, 2016).
As someone with ADHD myself, reading the literature on this topic gave me the spooky feeling of relatability that drives the superstitious to read horoscopes. One paper found that those with ADHD tended to prefer role-playing games, which just happen to be my favourite genre (Mazurek & Engelhardt, 2013). Another found that, while ADHD symptoms were consistently associated with gaming disorder, more frequent associations were displayed with inattention associations with gaming disorder than other ADHD subscales (Dullur et al., 2021).
It happens that my particular flavour of ADHD is the ‘primarily inattentive’ presentation. Yet another study posited that internet video gameplay may be a means of self-medication amongst children with ADHD, and that treatment with methylphenidate hydrochloride, a common drug for treating ADHD, may relieve symptoms of IGD (Han et al., 2009). Anecdotally, I can attest to gaming, in particular the well-defined feedback loops present in games, being one of the reasons I was drawn to gaming when I was unmedicated. After starting treatment with that same medication, my personal recovery from gaming addiction began, and to this day I find it easier to resist the urge to game excessively when I have had my pill.
Is there a cure?
With so many factors to consider, concerned loved ones may find it difficult to distinguish between avid gamers and those with addictions. The Priory Group of clinics recommends looking out for the following features to ascertain whether an addiction has developed:
Those with addiction will be preoccupied by the idea of playing certain games, which may last many months or even years. Even during conversation, they may struggle to talk about anything else other than their gaming exploits, while their hygiene, social integration, college, and work performance may all suffer as a result of intensive and prolonged gaming sessions. Two primary signs of addiction:
- Obsessional thoughts about gaming – a person is so preoccupied by the idea of gaming that they will crave their next gaming session and be focused so much on previous gaming activity that this can get in the way of developing social relationships and can interfere in major aspects of their life such as work performance as well as physical and mental health.
- Uses gaming to alter mood – Another major sign that someone feels a compulsion to play video games is when they appear to be doing so to escape from an uncomfortable situation, or to mask underlying symptoms of stress, depression, or anxiety. The feel-good chemicals released in the brain when playing games can lead to them feeling the need to play for longer as the addiction gets worse.
However, it’s not all doom and gloom. I have already mentioned the psychological and medication-based treatments available for those struggling with gaming addiction. A balanced parenting style, with emphasis on the benefits of emotional warmth in supporting self-efficacy, self-control, and autonomy through the promotion of time management, and avoiding over-protection and parental rejection, has been suggested as a positive influence for avoiding and recovering from IGD (Chen, Lee, Dong, Gamble, & Feng, 2020).
If sufferers can re-establish a healthy relationship with gaming like I have, they stand to benefit from the myriad of positive influences games can have beyond plain and simple fun (Granic, Lobel, & Engels, 2014). Games like Minecraft can be powerful educational tools and drivers of creativity. Feel-good games like Animal Crossing: New Horizons have provided gamers with a powerful creative outlet and recreational tool that has correlated positively with mental well-being during the pandemic (Johannes, Vuorre, & Przybylski, 2021).
My gaming addiction began around the age of 10. I was dependent and impulsive, but with the right diagnoses, treatments, and support from my family, I was able to overcome my addiction. Today, gaming is still my main hobby, one that I consider a ‘healthy obsession’ that does not detract from but rather feeds into my well-being, social life, and career pursuits. Just don’t ask me how many hours I spent reaching 100% completion in Death Stranding.
Illustration: Anna Kuptsova