Tag: Psychology

Content Notes: Discussion of Gambling Addiction, Substance Abuse and Video Game Addiction

I like to play video games. As this is being written, I am slowly making my way through Sea of Stars and have hopes to finish playing In Stars and Time. Although I am a child of the 2000s, I was raised on my older sibling’s consoles, like the Nintendo 64 and PS1. And since then, games have never left my life. Though my tastes are for turn-based RPGs, even I didn’t escape the cultural zeitgeist that is gaming addiction. So today and for the next couple of essays, I want to unpack the psychology behind disordered gaming and if games can be destructive.

An Addiction to Pathology

For as long as there have been video games, there has been psychological discussion of its possible addictive properties. Before the internet was but a gleam in a collection of nerd’s eyes, case studies of Space Invaders Obsession, Computer Catatonia and Video Game Addiction appeared in academic journals.^[1] However, the first large-scale study to examine problematic gamers, the preferred term by researchers, was in 1989 by Shotton.^[2]

Shotton committed an error that is going to become a recurring theme over the course of this essay, as he failed to distinguish between pathological gaming and healthy pre-occupation.^[1][2] The difference is primarily semantics but also key to understanding most clinical disorders.

To rise to the level of a disorder, the person needs to not only think about an activity a lot, but be so fixated that it is detrimental to their physical, mental and/or social health or the wellness of others around them. Merely being a kid who plays for multiple hours on a weekend hardly rises to this.

The issue would continue within the 1990s research and it was not until the early 2000s where there was more empirical studies, driven by the boom in Massive Multiplayer Online Role Playing Game (MMORPG) as a novel vector for possible dependence.^[1] From this wealth of theoretical essays and psychometric studies, we arrive at 2014, when the 5th revision of the American psychiatric manual (DSM-5) was released.

A 12 person panel was convened to evaluate all the evidence for behavioural addictions, that is fixations outside of drugs.^[3] The only clinically recognised behavioural addiction is Gambling Addiction. However, Internet Gaming Addiction (IGA) was included in the conditions for further research, with the following clinical symptoms (as of 2022):^[4]

• Preoccupation with gaming
• Withdrawal symptoms when gaming is taken away or not possible (sadness, anxiety, irritability)
• Tolerance
• Inability to reduce playing
• Giving up other activities, loss of interest in previously enjoyed activities due to gaming
• Continuing to game, despite problems
• Deceiving family members or others about the amount of time spent on gaming
• The use of gaming to relieve negative moods, like guilt or hopelessness
• Risk, having jeopardized or lost a job or relationship due to gaming

The proposed clinical descriptor suggests that experiencing 5 or more of these within a year is sufficient to satisfy the standard of IGA. Following suit, in 2018, the World Health Organisation’s (WHO) official classification for diseases had it’s 11th revision (ICD-11). Included within it was Gaming Disorder, described as:

“a pattern of gaming behaviour (“digital-gaming” or “video-gaming”) characterized 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.”^[5]

So it seems pretty clear cut right? Both the American Psychiatric Association and World Health Organisation have official recognised disordered gaming as a genuine psychiatric problem that exists. Unquestionably there is no dissent amongst researchers about these definitions or psychometric measurements right?…Right?

Of Course There Is Disagreement

From the second the ink dried on the DSM-5, there was controversy in academia around it’s inclusion within the psychiatric manual. This was best shown in an open commentary by 28 authors within the field.^[6] Although Griffiths and colleagues get into granular detail that I must skip over for expediency, I will provide the pixelated highlights.

Despite the fact the DSM-5 is used internationally as a diagnostic manual, there were no African or South American scientists on the behavioural addiction panel. Additionally, all of their Asian researchers were East or South East Asian.^[6] A significant amount of the global populace was unrepresented or lacking substantial consideration when this proposal was drafted.

So only research in the languages the panel members spoke were read and only these countries ideas were synthesised into the condition. Not all disorders are culturally neutral, as many mental health conditions intersect with social and environmental factors. Therefore, it is critical to include a broad pool of academic knowledge and research so that the complexities of these interactions can be considered.

Furthermore, to draft the above symptoms, the panel looked at eight psychometric instruments as well as the clinical classifications for Gambling Addiction and Substance Use Disorder.^[3] Psychometric tools are questionnaires used to measure an aspect of a person’s psychology including whether they have a disorder. They are frequently exercised in conjunction with diagnostic criteria.

Ten measurements overall might sound like a lot until you consider a 2013 study found at least 18 instruments^[7], with Griffiths and colleagues identifying even more available to the panel.^[6] No information is supplied as to a possible exclusion criteria the panel used, so it would be speculative to discuss why this oversight happened.

Nevertheless, failing to read around half of the available psychometric tests and relying very heavily on previous addictive classifications leads to the IGD being extremely similar to other disorders. This means it does not address the unique vulnerabilities of those who suffer the proposed disorder, nor consider how the subject of the addiction may influence behaviours. It is too generic and referential to be useful.

Tolerating Inadequacy

To furnish you with an example of the issue with relying on previous disorders, let us consider tolerance. With substance addictions, tolerance is the idea that the same doses of a drug have diminished returns with persistent use.

The experience feels inferior, so to compensate, people with substance abuse disorder will increase the dose. With gambling addiction, tolerance becomes a resistance to winning. Small stakes become less exciting, so bigger risk is needed. But with IGD, what tolerance looks like, indeed if it even exists, is up for debate.

Petry and colleagues argue that tolerance in IGD would represent an increase in time passed playing video games, an escalation in the exciting qualities of the games and more money spent on equipment.^[3] If you don’t play video games, this may seem reasonable at first, but there are shortcomings to the definition.

For substance abuse, the ceiling for tolerance is a fatal dose, for gambling its the amount of money you have. The ceiling for novelty or money spent on a tangible product is a lot more difficult to define as pathological.

The idea of needing to engage in more thrilling games to experience a similar high doesn’t make sense. Much of the research on problematic gaming with MMORPGs emphasise escapism and dissociation from reality.^[8-11] Gaming addicts wouldn’t require higher stimulation that overwhelms them, the research suggests they desire immersion to lose themselves in. But even if they did, you’d next have to define the qualities that cause excitement.

Graphical increases happen outside of the gamer due to corporate trends treating high fidelity graphics as a marketing gimmick. Gameplay developments are just established trends for most media to constantly innovate on previous work. There isn’t categorically any one factor in all games that could be considered uniquely exciting and causative of addiction. Nor is excitability of a game really a consistently measurable concept.

As for monetary issues, most gamers upgrade their equipment. Games become more complex, performance of technology improves and those with disposable income may save or splash on some modern tech. This in and of itself is not unreasonable. Unlike with gambling addiction, where the disbursal relies on a sunken cost and a desire to gain returns on a chance based investment, the payment of money on equipment gives a market value tangible product.

Gaming and computer companies are absolutely making you pay through the nose for their technology, but that is not a problem of addiction but capitalism. And there is no clinical literature I could find on gamers bankrupting themselves on technological upgrades. Pathologising a typical behaviour to invest in better equipment for a hobby is ludicrous. Unless we wish to establish the people who invest thousands of pounds into art supplies as so-called Painting Addicts.

The only reasonable suggestion is an increase in time spent gaming, but even then there is an issue. Where is the line between too much gaming and engaging in a hobby to de-stress? It can’t be quantifiable, because everyone possesses varying amounts of free time.

And if it is self-report, many problematic gamers may have already reached the maximum temporal threshold.^[6] Unlike in other addictions, the acceleration and threshold for time spent gaming are not inherently problematic or easily identifiable.

Taking everything into consideration, the IGD classification just doesn’t seem developed enough to be worthy of codification. And scholars likewise debated its inclusion in the ICD-11, citing similar concerns. ^[12] Aarseth and colleagues also emphasise how there isn’t even a consensus on if problematic gaming represents a primary or secondary condition. It may exclusively exist in conjunction with further mental health conditions and not constitute its own unique disorder.

The fast tracking of gaming addiction has lead to a focus on top down research. In other words, the theoretical basis for problematic gaming is taken as granted and moved onto supplementary fields. Despite the fact we are not considerably closer to understanding how IGD manifests than we were in 1989.

Although, there have been some interesting developments.

Escaping Reality

As stated previously, one of the most steadfast reasons behind problematic gaming is the desire for escapism.^[8] But the ability to escape in and of itself is not the sole requirement for disordered gaming. A 2014 study by Kardefelt-Winther administered psychometric tests to 702 World of Warcraft players, the most popular MMORPG to date.^[9]

These tests measured stress, negative outcomes related to gaming and self-esteem amongst other metrics. The results suggested that for escapism to become problematic, the person needs to also be experiencing hardship and low-self worth. Otherwise, a desire to escape life’s problems is usually not indicative of problematic gaming.

Now, the directionality of this relationship cannot be ascertained, i.e. whether escapism causes higher stress and lower self-esteem or vice versa.^[9] Regardless, it is clear that the confluence of these factors causes a heightened propensity towards problematic gaming. Though I do wish to emphasise the pool of participants was overwhelmingly male (89% of them) and skewed towards young adults. Therefore, consider this not a broad sweeping truth, but likely one part of a larger whole.

Furthermore, this may be due to the unique mechanics MMORPGs present. As noted by Billieux and colleagues in 2015, MMORPGs have unique structural mechanics compared to other games.^[10] This is one of the few mediums of games to possess a persistent social world.

That is to say, that things happen in-game without the player there. Because there can be thousands, if not millions of users, as well as time based events, interactions between gamers and adventures exist independent of any one individual.

In addition, they are very social games. It is encouraged, even sometimes required, that a player should make friends with others and join teams.^[10] To progress often necessitates a balanced group with different builds of characters, on top of the capacity to use written or audio chats to facilitate teamwork.

Users can become a part of guilds, exclusive clubs in which participation nets rewards. Even outside of the game itself, social media groups for distributing news, updates and strategic developments become integral to improving a gamer’s skills.

These factors facilitate escapism as they promote a heightened self-esteem from playing the game. On top of this they allow for socialisation in a manner that may come easier than non-virtual interaction. I don’t want to pretend that this is innately detrimental, but rather as Daniel Kardefelt-Winther states:

“Gaming provides certain affordances that may facilitate coping but the game itself is not the culprit, it merely acts as a potential facilitator of compensation for psychosocial problems.”^[9]

This idea that gaming could represent a vector of compensation is strengthened via a systematic review conducted by González-Bueso and colleagues in 2018. A systematic review, as the name implies, compiles a wealth of studies and synthesises their data. It is essentially a scientific summation of findings.

Through 24 papers on mental health disorders and disordered gaming, they found that 92% of them established significant correlations between IGD and general anxiety, 89% between IGD and depression, 87% between IGD and ADHD and 75% between IGD and social phobias.^[13] Put more simply, there is a sturdy correlation between other mental health disorders and IGD.

However, once more, directionality is not clear as to if IGD exacerbates these conditions or vice versa. And, as pointed out by González-Bueso and colleagues, the lack of longitudinal data means it is difficult to track the stability of these relationships.^[13]

Furthermore, the use of independent psychometric measurements for the conditions means there is less of a interconnected strength to the results. Though, it is at least clear that IGD co-exists with a variety of clinical conditions and likely is informed by low mental health.

Altogether, the pattern seems to be that games offer a route for people with psychological issues to temporarily escape from their problems. And to even form communal bonds collectively they otherwise couldn’t. However, for a minority of these gamers, this becomes less of a healthy social hobby and more of an over-reliance on the medium to create happiness and peace.

We subsequently see a misuse of the game themselves, to escape, to socialise or to otherwise avoid the issues in other sectors of their life. This isn’t conclusive, but at least presents an promising avenue not explored by the diagnostic manuals themselves.

And there is one more method of elucidation to probe.

Lets Ask The Audience!

Despite how plainly useful it would seem to most of us, psychological researchers frequently refuse to consult people suffering with mental health disorders about their experience. Or even ask for second hand information from those around them.

Whilst these populations may be utilised to examine psychometric tools based on theories by other psychologists. It is rather rare that comprehensive questionnaires are done to ascertain how those with these conditions understand their circumstances.

Part of this is likely impartiality. After all who is more impartial than a clinical researcher getting money and notoriety for delivering results that make an institution look good as well as enriching publishing houses? Another part is that qualitative research is undervalued compared to numerical and statistical data, which is simpler to parse as well as easier to manipulate.

But perhaps more than anything, there is a rather patronising view that clinicians are gatekeepers of ailments and only through their enlightened education can a disorder be understood.

Times are changing, with lived experience starting to guide research, policy and care. Therefore, I hope you can appreciate my elation at Carras and colleague’s study from 2018, which asked gamers at a gaming convention, how they define game addiction.^[11] It is uncommon to observe those with lived experience and expertise being highlighted in their understanding of how their shared pastime can become disordered.

Although part of me suspects this is a clever ploy to obtain tickets to one of the largest conventions around. It is delightful to read research that doesn’t feel disconnected from the experience of the community.

The researchers hosted two panels for MAGfest 2016 and 2017, wherein attendees were asked to write down signs of gaming addiction which were then ranked by the audience themselves.^[11] I think the most interesting section is a table comparing the items generated by gamers to the DSM-5 criteria.

Here we can see a heightened consensus around the ideas of continued use despite a problem being identified, over-prioritisation of gaming, and withdrawal symptoms.^[11] There was less consensus around the ideas of preoccupation with games, habitual playing, failing school and deception. Showing that there is some merit to the symptoms of the DSM-5 but not entirely, and that tolerance itself is never even remotely considered by the sample.

But more interesting to me is the unique items mentioned. An avoidance of socialisation, lack of control over your schedule, a loss of reality and difficulty separating the fictional world from the material world.^[11] Although the lattermost exhibits low consensus.

There is a prioritisation by gamers as to how gaming affects your existence outside of it, an importance placed on socialisation and testimony that the hobby becomes more pivotal than other tasks. For example, you may log onto World of Warcraft to complete an event instead of having lunch, since the event is time locked.

It is vital to stress two factors here, though. Firstly, the sample size comprised around 50 people, thereby hardly constituting a representative group. ^[11] Although I do hope more researchers will conduct similar enquiries. Secondly, it is unlikely there were many, if any, problematic gamers at the panels.

Therefore, this needs to be understood as non-problem gamers utilizing their own lived experience to elucidate unique avenues and ideas. Interviewing self identified or clinically recognised problematic gamers would provide even richer details.

All things considered, the study showcases that the nature of games as a media informs how others understand problematic usage. It is not just as simple as game addiction is gambling addiction is substance addiction. Instead, due to of the role of time gated events, because of the unique social opportunities, and its ability to facilitate escapism into a simpler pixelated world, games cause a unique experience of dependence.

To grasp how gaming addiction manifests, psychologists need to comprehend games and gamers significantly more than they do presently. Otherwise, any clinical condition they propose might as well be created by reading tea leaves.

The Beginning Step

I have difficulty knowing where to fully land with this. Part of me believes game developers should be aware of these issues and seek to counteract the methods by which general problem gamers manifest. But another part of me wonders how possible that is and if gaming is particularly notable in this regard. It is possible we worry about gaming being addictive not only because it is one of the most popular hobbies, but due to its comparative novelty.

Western society does not stress about the kids who lose a sense of reality in books as it valorises the reader. They are educated, intelligent and of better stock than the folk we imagine to be gamers. I think that on a general level, any hobby could be maladaptive to a person.

However, gaming represents a unique crossroads where individuals can gain skills and achieve a sense of accomplishment easily, whilst also losing themselves in a world unlike any other. It is a nexus point of many problems that other people latch onto to cope with stress and mental health issues.

We’ve all binge watched a series to lose ourselves in characters whos lives seem so much better and happier than our own. We’ve all cooked a nice meal, or written a poem or otherwise engaged in a craft to feel that sense of accomplishment when it is completed. Gaming offers these and more, in an easier format, fostering a sense of reliance that would be hard to replicate in other avenues. It is a blessing and curse of games themselves that they remain such an interactive format.

But, I think it would be academic dishonesty to pretend the medium, creators and corportations especially, are wholly innocent in this. Because, if you’ve been in the gaming community long enough, you’ve heard about loot boxes, gacha games and all manner of predatory addictive design. Creations that capitalise on vulnerable populations. So next time, we will explore not just gaming addiction generally, but a specific brand of corporately encouraged leveraging, tailor made to make you pay.

Thank you all so much for reading, let me know your thoughts on game addiction or your own experiences with it.

References

1. Griffiths, M. D., Király, O., Pontes, H. M., & Demetrovics, Z. (2015). An overview of problematic gaming. Mental health in the digital age: Grave dangers, great promise, 27-45.
2. Shotton M. (1989). Computer Addiction? A Study of Computer Dependency. Taylor and Francis, London, UK.
3. Petry, N. M., Rehbein, F., Gentile, D. A., Lemmens, J. S., Rumpf, H. J., Mößle, T., … & O’Brien, C. P. (2014). An international consensus for assessing internet gaming disorder using the new DSM‐5 approach. Addiction, 109(9), 1399-1406.
4. American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.).
5. World Health Organization. (2018). ICD-11: International classification of diseases(11th revision).
6. Griffiths., Van Rooij, A. J., Kardefelt-Winther, D., Starcevic, V., Király, O., Pallesen, S., … & Demetrovics, Z. (2016). Working towards an international consensus on criteria for assessing internet gaming disorder: a critical commentary on Petry et al.(2014). Addiction (Abingdon, England), 111(1), 167.
7. King, D. L., Haagsma, M. C., Delfabbro, P. H., Gradisar, M., & Griffiths, M. D. (2013). Toward a consensus definition of pathological video-gaming: A systematic review of psychometric assessment tools. Clinical psychology review, 33(3), 331-342.
8. Kardefelt-Winther, D. (2014). Problematizing excessive online gaming and its psychological predictors. Computers in Human Behavior, 31, 118-122.
9. Kardefelt-Winther, D. (2014). The moderating role of psychosocial well-being on the relationship between escapism and excessive online gaming. Computers in Human Behavior, 38, 68-74.
10. Billieux, J., Deleuze, J., Griffiths, M. D., & Kuss, D. J. (2015). Internet gaming addiction: The case of massively multiplayer online role-playing games. In Textbook of addiction treatment: International perspectives (pp. 1515-1525). Springer, Milano.
11. Carras, M. C., Porter, A. M., Van Rooij, A. J., King, D., Lange, A., Carras, M., & Labrique, A. (2018). Gamers’ insights into the phenomenology of normal gaming and game “addiction”: A mixed methods study. Computers in human behavior, 79, 238-246.
12. Aarseth, E., Bean, A. M., Boonen, H., Colder Carras, M., Coulson, M., Das, D., … & Van Rooij, A. J. (2017). Scholars’ open debate paper on the World Health Organization ICD-11 Gaming Disorder proposal. Journal of behavioral addictions, 6(3), 267-270.
13. González-Bueso, V., Santamaría, J. J., Fernández, D., Merino, L., Montero, E., & Ribas, J. (2018). Association between internet gaming disorder or pathological video-game use and comorbid psychopathology: A comprehensive review. International journal of environmental research and public health, 15(4), 668.