In 2019, the World Health Organization (WHO) announced that they would be adding video game addiction to their list of diagnosable conditions in their diagnostic manual, the ICD-11. This was a bold move and one not followed by other professional organizations including the American Psychiatric Association, who decided instead to list ‘Internet Gaming Disorder’ as a condition that requires future research in the latest iteration of their diagnostic manual, the DSM-5.
This decision by the WHO was followed by an uproar in concern from the scholarly community who believes there is not enough clear evidence to indicate gaming addiction merits a distinct diagnosis, but instead that maladaptive, problematic, and/or addicted gaming (depending on your preferred adjective) is best understood as a by-product of another underlying (primary) condition, such as depression, anxiety, or environmental stress.
Flash forward to today, in a COVID-19 era where video games have become one of the only ways to socially connect in an interactive playful space without the anxiety of continuing the spread of this pandemic. Even the WHO themselves have come forward during these times stating that games are a good way to socially connect during times of physical distancing.
So where does this leave us? In an era of COVID-19, is video game addiction no longer a thing?
The public discourse about games addiction has changed since the advent of COVID-19. There have been far less stories about the perils of how video games are destroying a generation and, instead, many articles touting the potential positive impacts of games for stress reduction and social connection.
Despite this shift in popular media, within research communities there remain many questions about gaming addiction (or gaming disorder, GD) that remain unanswered. Specifically, the prevalence and underlying causes of GD and their relationships with mental health. The answers to these questions will help to explain why we have started to see a shift in the ways we understand and talk about GD in the post-COVID-19 era.
How prevalent is gaming disorder?
Despite the presence of active discussions about GD among research communities for several years, consistent prevalence rates of GD have even yet to be established, making it difficult to determine the severity of the problem. Among adolescent samples, GD has been pinpointed at 1.6% of adolescents in Europe , between 0.2% and 1.16% of German adolescents, and 8% among American adolescents. A 2011 meta-analysis of 33 published studies and doctoral dissertations indicated an overall prevalence rate(among adults and adolescents) of 3.1%. While these rates vary quite widely, it is primarily due to variations in participant demographics (adolescents versus adults) and sample characteristics (whether or not it was an opportunity or representative sample of respondents).
Is gaming disorder chronic or episodic?
The first question here is whether or not GD is chronic or episodic. Historically, GD has been discussed in relation to chronic conditions such as substance abuse and episodic conditions such as problematic gambling. An instability in the symptomatology of GD over time (that is, someone diagnosed with GD at time 1 does not again meet the criteria at time 2), would suggest the latter. Support for this comes from Krossbakken and colleagues, who found that only 35% of their participants that met the threshold for a diagnosis of GD still met that criteria two years later. This instability, combined with fluctuating prevalence rates, questions the framing of GD as a chronic, psychiatric condition akin to substance abuse (see here and here) as it has often been framed and instead suggests it is potentially a behavioral dysregulation, like problematic gambling (see here). This distinction is critical for developing successful assessment and treatment plans as if GD is episodic, short-term interventions focused on environmental change may be more appropriate whereas the chronic conditions would likely require more in-depth, long-term treatment.
Are games themselves the source of the problem?
Discussions of gaming disorder are often built on the research from gambling addiction as it is currently the only recognized behavioral addiction by the APA. Drawing from gambling addiction research, we know comorbidity rates of behavioral addictions and other psychological challenges are high. For example, previous research has found that individuals who exhibit gambling disorder (the only non-substance addiction currently recognized in the DSM-5) show a lifetime prevalence rate of 61% for mood disorders. This is a rate higher than the average population.
Researchers have consistently found more involved video game players to display higher rates of the symptoms associated with depression and social anxiety. A cross-sectional study by Lo and colleagues (2005) found that increased time spent playing online games coincided with higher levels of social anxiety among Taiwanese adolescents. Williams et al. (2008) found higher rates of depression among players than is found in the general population. In one of the more extreme cases, a clinically depressed young man, described by many as addicted to EverQuest (a massively-multiplayer online video game) committed suicide following an extended session of gameplay.
Researchers have also noted that video games may be a management or coping tool for depression and anxiety. These compensation theories (originally developed for research on excessive use of the Internet), highlight the motivational role of pre-existing conditions (such as depression and anxiety) in video game involvement. From this perspective, a pre-existing condition within the player, such as depression or anxiety, drives engagement within gaming spaces.
Due to a lack of longitudinal work in the area, there have been few studies to tease apart the potential antecedent or consequential role of mental health in game play. Lemmens et al. (2011) found loneliness to be both a cause and consequence of disordered game play among adolescents. In my own work, I found lower life satisfaction and social competence to be antecedents, rather than consequences, of game play over time among non-disordered adult players. Stenseg (2019) and colleagues found that symptoms associated with Attention Deficit Hyperactivity Disorder (ADHD) predicted increased gaming from age 8 to age 10 but increased gaming did not predict more psychiatric symptoms. Additional research is needed to assess the role of mental health as an antecedent of GD symptomatology.
Another thing to consider is the role of self-regulation, i.e., the capacity of a person to adapt to contextual circumstances required for healthy development of life (see here and here). Individuals with well-developed self-regulation are adept at evaluating their own abilities, monitoring progress, making strategic decisions, and utilizing opportunities in the environment to help achieve their goals. Higher self-regulation has also been associated with better psychological well-being. The ability for an individual to self-regulate is the ability to manage one’s own behavior through self-monitoring, self-evaluation, and self-consequation. While one’s level of self-regulation can change over time, it typically requires focused intervention.
Previous research from psychology and communication science highlight the importance of self-regulation in the assessment and treatment of behavioral excesses and deficits (see here, here, and here), and many researchers have highlighted the role of self-regulation in managing the timing and amount of play associated with disordered or problematic gaming (7). LaRose and colleagues (2003) have gone so far as to argue that deficient self-regulation is the essential component driving disordered use of the Internet. Building off of this research, Liu and Peng (2009) found players reported a moderate level of deficient self-regulation, and that deficient self-regulation predicted personal life problems and increased weekly play time. Seay and Kraut (2007) also noted the importance of self-regulation in managing the timing and amount of video game play as well as allowing them to avoid negative outcomes like problematic use. They argue that self-regulation may be the key to understanding why players who exhibit the same kinds of behaviors may describe themselves as “addicted” or simply “actively engaged”. Taking a broader approach, Dong and Potenza (2014) proposed a cognitive-behavioral model of understanding GD based on models of motivation and reward seeking. They suggest that individuals with diminished cognitive control over their motivational drives and decision making skills may be more likely to engage persistently with video games and exhibit the symptomatology of GD. It is important to note that this model is strictly theoretical and based on previous research of addictions that exhibit themselves chronically, such as substance-use disorders.
Przybylski and Weinstein (2019) found that daily-life, episodic psychological need frustrations (the inability to achieve a sense of autonomy, competence, and control in everyday life) predicted GD symptomatology and psychosocial functioning among adolescents. The researchers also found that dysregulated gaming accounted for an insignificant share of variability in psychosocial functioning (measured by a broad assessment of social and emotional functioning) as compared to the role played by basic psychological needs. This suggests that everyday stress and pre-existing psychological challenges significantly fuel behaviors associated with GD symptomatology. Whilst this is the only known study to examine the role of psychological need frustration, the findings are notable as the researchers conclude that knowing the extent to which an adolescent’s video-game play is “no practically useful incremental information (p. 1265).”
What do we know about game addiction and psychological well-being?
One of the primary reasons to categorize GD as a diagnosis was the concern that GD undermines physical, social, and mental health. However, the research examining the effects of GD on well-being has been limited.
To account for the lack of research directly examining GD and mental well-being, researchers have drawn inferences from the literature examining the effects of Internet Addiction. This is problematic as it is not possible to generalize findings among non-disordered or addicted game playing populations to disordered and addicted game playing populations. Also, Internet Addiction and Internet Gaming Disorder are distinctly different concepts. Király and colleagues (2014) found that Internet Use Disorder (or Internet Addiction) and Gaming Disorder have vastly different behavioral profiles. For example, Internet Use Disorder was associated with a variety of online behaviors, including online chatting, gaming, and networking while GD was only associated with online gaming.
That said, examining the literature from Internet Addiction and online video game play research provides some insight into the potential impact GD may be having on its players. Internet addiction and online video game play have been independently been associated with negative behavioral and psychological outcomes, including depression and anxiety. For example, a large scale study from 2003 from Whang and colleagues (n = 13, 588) found individuals considered to be internet addicts reported higher degrees of depressed mood as compared to non-addicts. A 2011 study by Akin and Iskender found internet addiction to have a direct relationship with increased depression, anxiety, and stress. It is noteworthy that the relationship between internet addiction and poorer mental health outcomes are potentially cyclical as Ceyhan and Ceyhan (2008) found loneliness, depression, and self-efficacy to predict problematic internet use. However, a lack of longitudinal research examining these relationships makes it difficult to conclude the exact nature of these relationships.
Similar findings have emerged when examining the relationship between online game playing (not identified as problematic, disordered, or addictive) and mental health outcomes. A 2009 study from Liu and Peng found significant relationships between online game playing and a range of negative life-outcomes relating to physical, personal, and academic/professional problems. In my doctoral dissertation, I hypothesized that the relationship between poorer mental health outcomes and online video game use may also be cyclical; however, a lack of longitudinal research makes it difficult to determine the exact nature of these relationships.
A smaller amount of cross-sectional research has emerged pinpointing Gaming Disorder to these outcomes, including depression and anxiety, (see here and here, as well as other poorer mental health outcomes such as lower self-esteem and life satisfaction. A 2010 study by Mehroof and Griffiths found significant associations between trait anxiety, state anxiety, and aggression with online gaming addiction. In 2016, Kim and colleagues found individuals who were classified into a risk group for Internet Gaming Disorder (they met 5 or more of the 9 criteria as outlined by the DSM) scored higher on measures of depression, anxiety, phobic anxiety, interpersonal sensitivity, and hostility, among others. As previously mentioned, Lemmens and colleagues (2011) found loneliness to emerge as a cause and a consequence of problematic play. Low self-esteem and low social competence were also found to predict later pathological gaming, suggesting that they are motivators of problematic play rather than consequences of engagement. This work again points to the potential cyclical nature of these relationships. Interestingly, a follow-up study did not find these same patterns among non-disordered gamers, suggesting that the relationships uncovered by Lemmens and colleagues (2011) is specifically applicable to pathological game players rather than the online game playing community as a whole.
There have only been a handful of studies exploring the psychological consequences of GD over time. Lemmens and colleagues (2011) found loneliness to emerge as a cause and a consequence of problematic play, indicating that lonely individuals are more likely to engage problematically and, over time, problematic use of online games contributes to increased levels of loneliness. Low self-esteem and low social competence were also found to predict later pathological gaming, suggesting that they are motivators of problematic play rather than consequences of engagement. Sharkow and colleagues (2014) found relationships between problematic gaming and perceptions of success and life satisfaction. As it stands today, it remains unclear whether GD undermines psychological health directly or indirectly.
What does this all mean?
It means that there is still a lot left to be known about gaming as a traditional addiction. As a research community we need to determine prevalence and stability of GD within representative populations. We need to examine the extent to which GD symptoms contribute to and/or exacerbate need frustration, self-regulation processes, depression, anxiety, and environmental stress. We need to look at the relationships between GD and psychological well-being over time. And then, maybe then, we can determine whether or not GD is chronic or episodic. Chronic symptomatology would be indicated by the stability of a GD diagnosis over time and significant relationships between GD symptomatology and poor self-regulation and/or an underlying primary diagnosis (depression, anxiety). Episodic symptomatology would be indicated by an unstable GD diagnosis over time and significant relationships between GD symptomatology and need frustration and/or evidence of the relationships between GD symptoms and well-being outcomes are moderated by emotional motivations for play.
Further research evaluating the relationships between GD and well-being will also help determine its place as a primary or secondary diagnosis. If it is the latter, then it may be that GD symptomatology is more accurately conceptualized as a coping or management tool. For example, with the stability of the diagnosis tenuous at best, it is possible that GD is a temporary, coping mechanism used by individuals to help cope with a separate, primary diagnosis, such as major depressive disorder or social anxiety. If this is the case, then established treatment plans for these diagnoses would be more effective than current interventions designed to specifically target gaming behaviors. Furthermore, it would dispute its categorization as analogous to other chemical and behavioral addictions. Using the term “addiction” in relation to video game use, without establishing whether or not it is a primary diagnosis, has the very real effect of trivializing how we talk about addiction more broadly throughout society. It discredits the role video game play may have as a coping mechanism for various mental health challenges as well as potentially catastrophizing the regular use of technology by equating it to chemical addictions.
So what does this mean for you as you look over and see your home-bound, physically distanced, child trying their best to survive a pandemic playing their 15th round of Fortnite matches? It means you do not need to jump to the worst possible conclusion. Can game play become maladaptive? Absolutely. But in these times of high stress, heightened depression and anxiety, it is far more likely that games are being used as a tool to cope with these extreme levels of environmental stress, as a way to safely socially connect and interact with others, and a brief respite from living through (what often feels like) a Black Mirror episode.