Video Game Addiction, Not Video-Driven Violence, is the Problem
Objections to classifying gaming as an addiction continue to crumble
Presidential candidates from both major parties have blamed violent video games for contributing to mass shootings, a notion shared by many Americans. Yet researchers at the Stanford Brainstorm Lab were the latest to study all of the available evidence and conclude that nobody has demonstrated a link between playing video games and violent behavior.
While we’re concerned about the non-existent connection between playing video games and hurting others, we’ve been ignoring the very real problem of video game addiction.
For years, many mental health experts rejected the notion that video games could be addicting. They wanted to reserve the term addiction for out-of-control and self-harming consumption of substances like alcohol, cocaine, cigarettes and prescription pain meds. But the more we look, the more similarities we see between substance abuse and how some individuals interact with video games.
The World Health Organization (WHO) declared problematic gaming an addictive disorder, and assigned it the diagnosis code 6C51. (Any connection to the Area 51 alien spacecraft parking lot is completely coincidental.) The American Psychiatric Association, author of the Diagnostic and Statistical Manual for Mental Disorders (DSM) has been studying the inclusion of gaming as an addictive disorder for years, and is expected to follow the WHO’s lead with its next revision.
As a psychiatrist and the parent of young adults, I think these organizations are taking the right action in recognizing that gaming can be addictive. Not only do the actions of problematic gamers closely align with the behavioral criteria for substance abuse of addictive drugs, but an increasing number of studies of brain chemistry and circuitry support the similarity between gaming and substance addictions. Problematic gaming causes real harm, yet is treatable, further eroding arguments against not declaring it an addiction.
Rather than railing against an unproven connection between video gaming and perpetrating violence, we should be identifying and trying to help those afflicted with a gaming addiction.
What are addictive gaming behaviors?
Joey (a fictionalized character) couldn’t stop talking about the upcoming release of the latest version of his favorite game Starship: Intergalactic Capricorn Killers (SICK). He stayed home from work the Friday it came out, and binge played throughout his self-created three-day weekend. He even skipped his regular Saturday gaming night with his college buddies. His girlfriend wasn’t surprised at his behavior, and went on some nice hikes alone over the weekend. A few hours after midnight on Sunday, Joey was crowned a 491st-level Commando Mogul Starshooter. He was back at work, somewhat bleary eyed, on Monday morning.
Is Joey addicted to gaming?
The proposed criteria for addictive gaming in the DSM require an individual to show a pattern of behavior, over the course of at least a year, of excessive time spent obtaining, using, or recovering from video gaming, that causes distress and dysfunction. They must meet at least five of these 9 specific criteria:
- preoccupation with gaming
- persistent desire or unsuccessful effort to cut down or control use
- tolerance: needing to play more to get same effect
- withdrawal: unpleasant symptoms when the game is taken away
- recurrent gaming results in giving up previous hobbies or activities
- continued gaming despite persistent/recurrent social/interpersonal problems
- deceiving others about how much time one spends gaming
- use of gaming to escape or alleviate negative moods
- loss of relationship, school, or job opportunities because of gaming
Some research indicates that giving up other activities, and incurring harm from gaming, are the symptoms most indicative of a gaming addiction. Preoccupation, and escapism, do the poorest job of differentiating normal from problematic gaming. Craving gaming, when deprived of opportunities to play, rather than preoccupation, may also be more reflective of a real problem.
The behavioral criteria for gaming addiction and for addiction to substances are more than superficial resemblances, and represent more than a slight degree of overlap between two separate sets of symptoms.
All of our mental health diagnoses involve some amount of subjectivity. In medical school, some of the non-psychiatric staff flippantly taught us that the definition of an alcoholic was “anyone who drinks more than you do,” highlighting that personal judgment is needed for deciding when someone else’s behavior is out of control. For diagnosing an addictive behavior, usage needs to be problematic, not just excessive. If you can still get all of your work done, and show up for family meals, and get enough sleep at night, you may still be able to cram in ten hours of gaming most days, and not have an addiction.
When assessing others, we also need to take into account different age, gender, and cultural norms. Currently, the average American teenager spends close to seven hours a day in front of screens. Males spend more of that time gaming than do females.
By most criteria, our fictional Joey isn’t addicted to gaming, even though he has developed some problematic patterns, and may be at risk of a future full-fledged addiction.
What’s going on in the brains of gaming addicts?
The brains of addicted gamers and substance abuse addicts show similar excessive activation in regions associated with dopamine mediated reward systems.
Addicted gamers show reduced brain activity within parts of the frontal cortex that are associated with poorer impulse control and impaired decision making. Problematic gamers have aberrant patterns of neural wiring connecting different brain regions involved in motivation, reward, and cognitive control. Researchers have found reductions in the total volume of brain cells (gray matter), and in the density of neuron connecting fibers (white matter) in the brains of gaming addicts that are similar to the findings in brains of substance abusers.
At the levels of behavior, brain chemistry, and brain connectivity, gaming addicts look remarkably similar to those addicted to substances.
Opposition to declaring problematic gamers addicts
Criticism of declaring problematic gaming an addiction arises from three directions. The first is those who cling to the mind-brain distinction. The second is those who fear pathologizing normal behaviors. The third are those who believe problematic gaming is simply a manifestation of another mental health condition.
It’s easy to accept that addictive drugs can change people’s brains, because we can readily visualize (at least at a schematic level) those chemicals binding to neurochemical receptors and altering brain circuitry. Some of us have a harder time accepting that behaviors can alter brain structures and biochemistry.
Many of my patients, and even some of my fellow therapists, accept that antidepressants can change the chemistry of a depressed brain, but believe that effective talking therapies work on some other level. Are they making the spleen happier? Releasing different humors in the body? Redirecting the flow of chi? Chi whiz!
Decades ago researchers showed that cognitive behavioral therapy for depression altered brain chemistry. Humans operate on several levels simultaneously. Thoughts and behaviors can change neurochemistry and neurocircuitry.
The stance of the brain/behavior hold-outs was further weakened in 2013 by the reclassification of problematic gambling, previously considered an “impulse control disorder” as an addictive disorder. Why did gambling become an official addiction before gaming? Was it just because gambling has been around longer? Or because gambling receives greater moral disapproval? Or was it because more “bling” was involved in gam-bling — problematic gamblers tend to lose far more money than do troubled gamers?
Problematic gambling was declaring an addictive disorder because both the behavioral and neuroscience research showed how similar it was to substance abuse disorders. Problematic gaming is following the trail blazed by problematic gambling in being listed as an addictive disorder.
We shouldn’t pathologize normal behaviors. But problematic gaming doesn’t just derail careers and poison relationships, it even kills people. It causes massive losses to societal productivity. Declaring that some people’s unrestrained involvement in games is a real problem doesn’t mean that every gamer is sick. Awareness of gaming addiction will increase the likelihood that those who need help curbing their gaming behavior will seek and find effective treatment.
We do know that the rates of ADHD, depression, anxiety, are two to three times higher among those with problematic gaming than in their peers. Gamers are more likely to be socially awkward and feel lonely. Some earlier studies even found that 100% of gamers had ADHD. Could problematic gaming merely be one symptom of ADHD or one of these other conditions?
Despite the almost universal access to video games, most people with depression, or anxiety, or ADHD, don’t develop patterns of problematic gaming. Subsequent studies suggest that less than a quarter of those addicted to gaming have ADHD. While other conditions may predispose people to developing a gaming addiction, that’s not a reason to avoid declaring gaming addiction a separate diagnosis. ADHD for example, also increases the risk of developing depression, but we don’t ignore the depression diagnosis when it co-occurs with ADHD, or try to address it only with ADHD treatments.
If it looks like a duck, talks like a duck, and walks like a duck, we should no longer duck the issue, but simply agree that problematic gaming is an addictive disorder.
Programmed to be addicts
The politics of addiction seem particularly prone for false demonizing. But we must acknowledge that the gaming industry does routinely try to make their products as addictive as possible.
They hire psychologists and employ algorithms to specifically boost the attractiveness and increase the stickiness of their games. Fast-paced action, colorful graphics, and suspenseful plot points are all designed to keep people playing. Behavioral experts tweak reward/frustration ratios to optimize continued playing. Even calming, soothing, peaceful games are built to lull the user into ongoing engagement.
This doesn’t mean all video gaming is bad. Games have been designed that appear successful in treating ADHD. Surgeons who spend more time gaming work faster and make fewer mistakes.
Taking the concept of gaming addiction seriously conveys social implications.
In many jurisdictions, casinos or online gambling venues pay taxes, part of which is directed to the treatment of those with gambling addictions. Should we tax companies making and marketing video games so that they shoulder some of the costs of those who become addicted?
Historically, game programmers have been predominantly male and white — as we continue to encourage diversity, will we see increased rates of gaming addiction among minoritized individuals, because the new products are more appealing to a broader demographic?
Should shoot-em-up games carry trigger warnings? Should we mandate kill switches for gaming sessions going on longer than a dozen uninterrupted hours?
As humans spend more time in the Metaverse, rather than worrying about the discredited notion that videogames drive people to mass murder, we should be developing new tools to identify those who are cursed with a videogame addiction, and create methods to help them escape.