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Internet Gaming

Online games are very popular, at least one person plays video games in two-thirds of American households, according to the Entertainment Software Association. Roughly 160 million American adults play internet-based games, one recent study estimates. The games can be very entertaining, and it may be easy to get absorbed in the competition, but can they be addictive? That is a question still being debated among researchers and health professionals.

Internet Gaming in DSM-5

Addiction to gaming is described in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-5), which is used by mental health professionals to diagnose mental disorders. There was not sufficient evidence to determine whether the condition is a unique mental disorder or the best criteria to classify it at the time the DSM-5 was published in 2013. However, it recognized internet gaming disorder in the section recommending conditions for further research, along with caffeine use disorder and other conditions.

The DSM-5 includes substance-related addictive disorders, such as alcohol, tobacco, stimulants, marijuana and opioids. Gambling disorder is the only behavioral addiction (as opposed to substance use) identified in DSM-5.

The DSM-5 notes that gaming must cause "significant impairment or distress" in several aspects of a person's life. This proposed condition is limited to gaming and does not include problems with general use of the internet, online gambling, or use of social media or smartphones. The proposed symptoms of internet gaming disorder include:

  • Preoccupation with gaming
  • Withdrawal symptoms when gaming is taken away or not possible (sadness, anxiety, irritability)
  • Tolerance, the need to spend more time gaming to satisfy the urge
  • Inability to reduce playing, unsuccessful attempts to quit gaming
  • 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, such as guilt or hopelessness
  • Risk, having jeopardized or lost a job or relationship due to gaming

Under the proposed criteria, a diagnosis of internet gaming disorder would require experiencing five or more of these symptoms within a year. The condition can include gaming on the internet, or on any electronic device, although most people who develop clinically significant gaming problems play primarily on the internet.

International Perspectives

In late 2017, the World Health Organization (WHO) announced that in the upcoming edition (11th Revision) of the International Classification of Diseases* (ICD), gaming disorder will be identified as a new disorder. In some countries, including South Korea and China, video gaming has been recognized as a disorder and treatment programs have been established.

Research is Ongoing

Whether internet gaming should be classified as an addiction/mental disorder is the subject of much debate and a growing body of research. There is neurological research showing similarities in changes in the brain between video gaming and addictive substances.

A study published in American Journal of Psychiatry in March 2017 sought to examine the validity and reliability of the criteria for internet gaming disorder, compare it to research on gambling addiction and problem gaming, and estimate its impact on physical, social and mental health. The study found that among those who played games, most did not report any symptoms of internet gaming disorder and the percentage of people that might qualify for internet gaming disorder is extremely small.

The research involved several studies of adults in the U.S., United Kingdom, Canada and Germany. They found more than 86 percent of young adults ages 18 to 24 and more than 65 percent of all adults had recently played online games. The percentages of men and women who recently played was roughly equal. However, the research is mixed on whether those who met the criteria for internet gaming disorder had poorer emotional, physical and mental health than those who did not meet the criteria.

The researchers found that 0.3 to 1.0 percent of the general population might qualify for a potential diagnosis of internet gaming disorder. The authors suggest there is an important distinction between passionate engagement (someone enthusiastic and focused on gaming) and pathology (someone with an illness/addiction). Whether the person is distressed with his/her gaming may be the key factor distinguishing the two.

Writing in a commentary about the study in the American Journal of Psychiatry, Patrick M. Markey, Ph.D., and Christopher J. Ferguson, Ph.D., concluded that the study suggests "video game addiction might be a real thing, but it is not the epidemic that some have made it out to be."

The research and the debate are ongoing. Some argue, for example, that gaming could be a symptom of an underlying problem, such as depression or anxiety, and not a disorder or addiction itself.

Even while professionals debate, individual stories in the media point to struggles and devastation from the phenomenon.

The Proceedings of the National Academy of Sciences summarizes the current debate: "Adding video gaming to the list of recognized behavioral addictions could help millions in need. It could also pathologize a normal behavior and create a new stigma."

If you are concerned about yourself or a loved one, talk with your health care provider or a mental health professional.

Physician Review

Ranna Parekh, M.D., M.P.H.

June 2018

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