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Internet Gaming Disorder: A Hobby or Addiction?

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Since the 1970s, video game sales and hours played have steeply risen as they are now available on nearly every electronic device. Video games are more profitable than movies and sports as the revenue it has generated has been increasing with a value of inflation-adjusted dollars from $20 billion in 1989 to $116 billion in 2017.

At the 2022 American Psychiatric Association meeting, Dr. Anil Thomas and his panel presented recent data on gaming. On average, children up to age 8 use about 2.5 hours of screen media daily. Sixteen percent is for gaming and is seen more in boys than girls. The socioeconomic gap in screen use is widening, as three hours and 48 minutes of screentime is seen in low socioeconomic status (SES) compared to a screen media of one hour and 52 minutes seen in high SES. Media use escalated faster during the pandemic than ever before, and the highest increase is seen among adolescents with a screen time of eight hours and 39 minutes daily. About 5% of girls and 14% of boys spend between four and 10 hours gaming every day, respectively. It also led to an increase in time spent gaming which persists in adults, with men spending three hours on weekends/holidays and women spending 1–2 hours on weekends/holidays. In those who play games, 59% of screen time is spent on gaming. Do parents limit their kids’ screen time? And the answer is variable based on these surveys: a 2014 Entertainment Software Association survey reported that 94% of parents say yes, 48% report a “constant battle” (APA ‘17), and 72% of youth say no (Kaiser Family Survey ’10) and those with no rules play twice as much.

In many cases, games are addictive due to their behavioral game design based on a variable to fixed ratio reinforcement generated in research labs. Also, “games as a service” means games are no longer static and evolve to meet player needs which are addressed through extensive Q&A testing that optimizes the experience to appeal to broad audiences. There have been ongoing improvements in technology leading to more immersive experiences and opportunities for self-actualization. Synaptic pruning continues into the early 20s, with the frontal lobes developing last. Fantasy, shooters, and real-time strategy games have a larger impact on pruning, and achievement and immersion perpetuate neuronal changes. Similar to substance use disorders, behavioral addictions hijack the pleasure reward pathway. Teens with internet gaming disorder (IGD) have a reduced gray matter volume in regions associated with executive function and attention and lower white matter in regions involved in impulse control and decision making. 

Gaming disorder (GD) is an official diagnosis in the ICD 11, and IGD is in the DSM V, whose criteria is largely borrowed from gambling disorder and require further study. Prevalence estimates of IGD vary by region from 0.7% to 27% as in China, video games have been deemed a public health crisis, while in the U.S. (and elsewhere), video games are an accepted part of the social landscape. As per Dr. Thomas, the definition of IGD is not fully ratified and currently appears in the section of the DSM V “requiring further research.” IGD refers to persistent and recurrent use of the internet to engage in games, often with other players, leading to clinically significant impairment or distress.

In terms of psychopathologies, the largest correlations were identified between IGD and anxiety, depression, and ADHD, whereas the weakest were observed between IGD and obsessive-compulsive disorder. Adolescents with high scores in IGD also have negative consequences at the psychosocial level: fewer recreational and social activities and reduced academic performance. Younger adults only experience the symptoms of the addiction as psychological discomfort, whereas older adults have experienced the negative consequences of the disorder for a longer period. This has led them to develop comorbid psychopathology.

As per the systematic review by King DL et al., the game addiction scale (GAS)-7 has incomplete coverage of criteria due to which it cannot be used for screening, whereas the internet gaming disorder scale-9 (IGDS9-SF) and internet gaming disorder test (IGDT)-10 were the only tools that provided total coverage of DSM-5 and ICD-11 criteria. As per Dr. Thomas, some questions should be considered while evaluating a patient with problematic video gaming use. These include: the type of game(s) played, the time spent playing, the reasons for play, the meaning of character choices, in-game relationships and status, does gaming interfere with school or work,  have they neglected self-care (sleep or hygiene) to play more, how much money do they spend on gaming, what effect does gaming have on out-of-game relationships, have others expressed concern over how much they play, have they tried to limit your playtime without success, how uncomfortable do they get if they must stop in the middle of playing, and do they get agitated if servers go down unexpectedly? 

Research into medications for IGD has expanded in recent years. Studies have looked at short-term effects, and the early results are promising; further research and large-scale RCTs are needed. Bupropion and escitalopram (6-week and 12-week courses) and methylphenidate (8-week course) were successful in reducing the IGD symptoms. In the head-to-head comparisons of atomoxetine versus methylphenidate and bupropion versus escitalopram, no medication was superior, and all were efficacious. Many types of psychotherapy have been researched and found effective for treating IGD. Reducing use rather than abstinence should be the treatment goal. Standard CBT and CBT for internet addiction (CBT-IA) are both effective for reducing IGD symptoms in the short term. The medications did not reduce gaming time, and the effects did not last beyond the initial treatment window. Motivational interviewing for IGD has also been proven effective, although progress may be somewhat slowed compared to CBT. There have been treatment centers in Asia and Europe that focus on IGD but now have been developing in North America.

Dr. Patel is employed by Oklahoma State University. He has no conflicts of interest to report.

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