It's important to note that:
What is gaming addiction? Is this a psychiatric diagnosis now?
The ICD, the International Classification of Disorders, is a universal coding guide for medical conditions. This allows people to report medical statistics and conduct research using an internationally understood system. If you hear world-wide stats about a medical condition, that is likely based on aggregate data reported using ICD codes.
In June 2018 the latest revision of the ICD released with a new subsection under "Disorders due to substance use or addictive behavior"; this subsection is called "Disorders due to addictive behaviors" and includes gambling disorder, gaming disorder, and other specified disorders due to addictive behaviors (the "miscellaneous" category of diagnostic evaluation).
If you read the description in the ICD it seems very broad and ill defined; set next to the description for alcohol use disorder, however, it's comparable to the standard ICD level of detail and therefore our understanding of other addictive disorders can probably be used to interpret the intent of this classification.
In the United States, mental health providers primarily use the Diagnostic and Statistical Manual of Mental Disorders (DSM) which provides significantly more detail for diagnosing mental health conditions, including cultural considerations, environmental contributors, other disorders that should be ruled out as they often share symptomns, and what a typical course of the mental illness looks like. In this manual we can start to see what exactly "addictive disorders" can mean.
That understanding starts by looking at another non-substance based addictive disorder: gambling disorder. First introduced as an "impulse control disorder" in 1994, gambling disorder was reclassified with addictive disorders in the 2013 revision of the DSM 5th edition. The rationale for that decision is telling:
"The rationale for this change is that the growing scientific literature [on gambling disorder] reveals common elements with substance use disorders. Many scientists and clinicians have long believed that problem gamblers closely resemble alcoholics and drug addicts, not only from the external consequences of problem finances and destruction of relationships, but, increasingly, on the inside as well.According to Dr. Charles O’Brien, chair of the Substance-Related Disorders Work Group for DSM-5, brain imaging studies and neurochemical tests have made a 'strong case that [gambling] activates the reward system in much the same way that a drug does.' Pathological gamblers report cravings and highs in response to their stimulus of choice; it also runs in families, often alongside other addictions. Neuroscience and genetics research has played a key role in these determinations.
"Internet addiction was considered for this category, but work group members decided there was insufficient research data for it to be included. Another so-called behavioral addiction, 'sex addiction,' also was not included because the work group found no scientific evidence that 'reward circuitry is operative in the same way as in addictive areas.'"
What does this mean, exactly? And how does it relates to games? Let's take a brief psychology detour.
Driven by basic psychological needs
Decades ago researchers had a theory, more or less based on watching mice learn to push levers for food. That theory was essentially: rewarding people for a certain action will cause them to do that action more. Through these rewards, we can actually train/shape how people act.
This idea was interesting to corporate America because businesses are always looking for ways to make their employees as effective (and compliant) as possible.
So some researchers did a study. They had a group of people rate their enjoyment on a task after engaging in it. Then, they had people do the same task but with a new twist: they would get paid for their work. They expected people to rate the task as more enjoyable when they were paid for it. Instead, they found the opposite. The introduction of an external reward actually decreased their enjoyment rating.
This was baffling. After all, if you like a thing, why wouldn't you like it more when you also get money for it?
Exploring this question led the researchers into the field of intrinsic versus extrinsic rewards which was eventually summarized in Self-Determination Theory. They found that people, even when researching many different cultures around the world, share three universal psychological needs: the need for relatednessness, competency, and autonomy (i.e. a sense of volition). Basically, they found that all people, at an intrinsic, innate level desire to feel connected and known, feel like they can cope with the challenges they face, and have a sense of purpose in life.
When we can't get these needs met, we turn to substitute needs which are similar but ultimately unfulfilling. For example, many people cope with feeling incompetent by becoming either over-controlling or overly-passive, neither of which is the same as feeling capable, but gives the illusion of "everything is under control". Others cope with a lack of purpose by latching onto dogmatic or extremist views...political views, religious views, fandom views...whatever gives that sense of meaning.
I'm not going to try and summarize 50 years of research except to say this: the research consistently revealed innate desires in people to fill these basic psychological needs. These drives are intrinsic to the human experience, and are not motivated by external "rewards."
What does this have to do with video games?
When we have those psychological needs filled, we feel a rush of satisfaction and positivity. This makes sense: our brain is hardwired to reward us for doing the healthy thing of getting our needs met.
And video game designers? They know all about Self Determination Theory and basic psychological needs. There's at least one GDC talk about it every year. There are consultants and groups who research how to keep players engaged in their games, and most (if not all) can talk about design strategies that tap into our desire to have these needs met.
So we know people are driven to fulfill these needs, feel strong satisfaction when these needs are met, and many designers are programming their games to appeal to these drives.
But is it addictive?
With advances in brain imaging, we can actually see which parts of the brain are being used in real-time. We know which parts of the brain are part of our reward system (that's the human chemical equivalent of a dog being given a treat for doing the "right" thing). The current state of research clearly shows that addictive substances activate that specific reward center in our brain.
The newer research shows that gambling activates the same reward center as alcohol or meth. Conversely, current research does not show pornography triggering the same parts of the brain. As of right now, that difference in brain activity defines the definition of addiction in the United States, as opposed to other excessive or harmful--but not "addictive"--behaviors.
So what about gaming?
Right now there isn't enough research to show if it's closer to gambling or pornography in how our brain processes it and why it becomes a repetitive pattern.
The issue is likely complicated by the huge variety of gaming mechanics which seem to hook people. Many games have introduced gambling-like elements with loot boxes. It's not a leap to predict that those mechanics trigger similar reward pathways as traditional gambling.
Many MMOs (World of Warcraft is a classic example) obviously tap a sense of accomplishment, which is a substitute for our basic psychological need for competence. Leveling in WoW may not translate to feeling capable in daily life, but it forms a close enough substitute to hook into that basic need and keep us coming back. Do those mechanics also trigger the addiction-reward pattern in the brain, or something else entirely?
My initial hypothesis
When the ICD released their new gaming disorder code, I sat down to talk about it with a coworker who runs our medical center's substance abuse treatment program. As we talked I realized that I've evaluated many people with substance abuse problems who do not meet criteria for any other mental health disorder; I cannot think of anyone I've met with excessive and harmful gaming habits who didn't also meet criteria for another mental illness.
Can we really call something a mental illness if it never occurs in isolation? Or is it just a symptom at that point?
And that is what several treating providers argue in the U.S.: gaming is a form of coping with other problems like depression and anxiety. Dysfunctional gaming is a visible symptom, but not the root disorder. Alternatively, we have plenty of science to show that substance abuse can occur as its own, discrete disorder. People can have no other "mental illness," but thanks to changes in the reward pathway in their brain, they still engage in addictive substances to a dysfunctional and harmful degree.
We can actually see something similar to this root cause vs. visible symptom focus with obsessive-compulsive disorder. When people hear "OCD", they often think of people who check things obsessively, or organize things in a specific fashion, or are fixated on cleaning things over and over; all of these actions are called "compulsions". What the average person doesn't know is the obsession (unwanted, upsetting, uncontrollable thoughts) is actually the root cause; the visible compulsive behavior is an attempt to manage the anxiety generated by that obsession.
For example, if someone has an obsessive thought "I'm not safe", they will check their locks and appliances over and over and over to try and banish or prove wrong their obsessive thought. Or if someone has the obsessive thought "I'm dirty," they will wash themselves over and over and over to calm the anxious obsession. What we see--the compulsive, repetitive behavior--is their way of managing the obsessive thought.
So my hypothesis (limited as it is by the current state of science)?
The gray zone? Game designers are targeting our basic psychological needs to keep us intentionally hooked on their games. So I can absolutely see a future where we discover actually, yeah, dysfunctional gaming is addictive separate from gambling or symptoms of other problems.
When I listen to designers talk about basic psychological needs with more fluency and nuanced understanding than most doctoral level psychologists, a part of me feels uneasy...and just a little bit like I'm living in a cyberpunk future.
Labelling something an "illness"
Total transparency: the fact games can meet some basic psychological needs can be helpful for short-term coping. I've given some patients the homework of playing video games. (Obivously after an exploration of what they need and how they can get those needs met). If someone is so depressed they can't get dressed or shower or eat or look at their phone etc., feeling a sense of accomplishment from mastering a game mechanic can give them that hit of pleasure missing from the rest of their life.
I've met people who literally got past suicidal thoughts by playing games. Sometimes we don't have very much control over our environment, and if that environment doesn't fill our basic psychological needs, gaming can be a viable stand-in until people are able to change their overall environment or situation.
Gaming, I explain to some patients, can be a little bit like treading water. It doesn't get us to shore, but it can keep us afloat until help arrives or we're able to get our bearings and figure out which direction we need to swim. Or in some cases, gaming can actually help us develop the mental muscles and skills to finally swim to shore, (as seen in numerous accounts of people who formed social communities in games, then turned that into genuine social support and positive action).
And that's perhaps why I hope we examine the idea of gaming disorder as a mental illness with a holistic and nuanced approach. Not many people can say alcohol* or gambling was the key to avoiding suicide during a difficult time in their life; I've met countless people who can say that about gaming.
*In all fairness, I have had some people say they thought about killing themselves and chose getting drunk to silence those thoughts. Those are the same people I see make a lot of headway in their alcohol abuse when they get treatment for the untreated depression, anxiety, and/or trauma. I've seen many, many more people addicted to alcohol who had it push them closer to suicide rather than save them from it.
This blog is where I "think aloud" about the games I'm designing, with occasional pieces analyzing other games or game mechanics. Currently, the focus is on talking through my own design process rather than presenting a polished piece on game design.
I'm known for going on tangents. The only consistent thing in my life is that I spend most of it creating things: novels, games, graphics. I love taking apart how art and games work, then reconstructing my own version from the pieces. I'm also enough of a layout perfectionist to adore eraser shields.