Video game addiction (VGA), also known as gaming disorder or internet gaming disorder, is generally defined as a behavioural addiction involving problematic, compulsive use of video games that results in significant impairment to an individual's ability to function in various life domains over a prolonged period of time. This and associated concepts have been the subject of considerable research, debate, and discussion among experts in several disciplines and has generated controversy within the medical, scientific, and gaming communities. Such disorders can be diagnosed when an individual engages in gaming activities at the cost of fulfilling daily responsibilities or pursuing other interests without regard for the negative consequences. As defined by the ICD-11, the main criterion for this disorder is a lack of self-control over gaming.
The World Health Organization (WHO) included gaming disorder in the 11th revision of its International Classification of Diseases (ICD). The American Psychiatric Association, while stating that there is insufficient evidence for the inclusion of internet gaming disorder as an officially recognized disorder in the fifth edition (DSM-5) of the Diagnostic and Statistical Manual of Mental Disorders published in 2013, considered it worthy of further study, thus including it in its chapter on Conditions for Further Study.
Controversy around the diagnosis includes whether the disorder is a separate clinical entity or a manifestation of underlying psychiatric disorders. Research has approached the question from a variety of viewpoints, with no universally standardized or agreed definitions, leading to difficulties in developing evidence-based recommendations.
Definition and diagnosis
World Health Organization The World Health Organization (WHO) has included "gaming disorder" in the 11th revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-11), released in June 2018, which was approved by the World Health Assembly in May 2019. Material was copied from this source, which is available under a Creative Commons Attribution 4.0 International License. The use and enforcement of the ICD-11 officially began on 1 January 2022.
American Psychiatric Association While the American Psychiatric Association (APA) does not recognize video game addiction as a disorder, in light of existing evidence, the organisation included video game addiction as a "condition requiring further study" in the DSM-5 as internet gaming disorder. Video game addiction is a broader concept than internet gaming addiction, but most video game addiction is associated with internet gaming. APA suggests, like Khan, the effects (or symptoms) of video game addiction may be similar to those of other proposed psychological addictions. Video game addiction may be an impulse control disorder, similar to compulsive gambling. The APA explains why internet gaming disorder has been proposed as a disorder:This decision was based upon the large number of studies of this condition and the severity of its consequences. ... Because of the distinguishing features and increased risks of clinically significant problems associated with gaming in particular, the Workgroup recommended the inclusion of only internet gaming disorder in Section 3 of the DSM-5. Some players become more concerned with their interactions in the game than in their broader lives. Players may play many hours per day, neglect personal hygiene, gain or lose significant weight, disrupt sleep patterns resulting in sleep deprivation, play at work, avoid phone calls from friends, or lie about how much time they spend playing video games.
The APA has developed nine criteria for characterizing the proposed internet gaming disorder:
Pre-occupation. Do you spend a lot of time thinking about games even when you are not playing, or planning when you can play next? Withdrawal. Do you feel restless, irritable, moody, angry, anxious or sad when attempting to cut down or stop gaming, or when you are unable to play? Tolerance. Do you feel the need to play for increasing amounts of time, play more exciting games, or use more powerful equipment to get the same amount of excitement you used to get? Reduce/stop. Do you feel that you should play less, but are unable to cut back on the amount of time you spend playing games? Give up other activities. Do you lose interest in or reduce participation in other recreational activities due to gaming? Continue despite problems. Do you continue to play games even though you are aware of negative consequences, such as not getting enough sleep, being late to school/work, spending too much money, having arguments with others, or neglecting important duties? Deceive/cover up. Do you lie to family, friends or others about how much you game, or try to keep your family or friends from knowing how much you game? Escape adverse moods. Do you game to escape from or forget about personal problems, or to relieve uncomfortable feelings such as guilt, anxiety, helplessness or depression? Risk/lose relationships/opportunities. Do you risk or lose significant relationships, or job, educational or career opportunities because of gaming?
One of the most commonly used instruments for the measurement of addiction, the PVP Questionnaire (Problem Video Game Playing Questionnaire, Tejeiro & Moran, 2002), was presented as a quantitative measure, not as a diagnostic tool. According to Griffiths, "all addictions (whether chemical or behavioral) are essentially about constant rewards and reinforcement". He proposes that addiction has six components: salience, mood modification, tolerance, withdrawal, conflict, and relapse. But the APA's nine criteria for diagnosing internet gaming disorder were made by taking point of departure in eight different diagnostic/measuring tools proposed in other studies. Thus, the APA's criteria attempt to condense the scientific work on diagnosing internet gaming disorder.
Screening tools The first psychometric test to assess IGD was the Internet Gaming Disorder Test (IGD-20). This test includes 20 questions designed to assess the extent of problems caused by disordered gaming and the degree of symptoms experienced by gamers. The test was first published in a journal article published in the PLoS ONE journal on 14 October 2014.
AICA-S is another screening tool, which is based on the criteria of addiction in DSM-IV and is considered one of few scales that have actually been validated in clinical settings.
The Internet Gaming Disorder Scale–Short-Form (IGDS9-SF) is a short psychometric test to assess video game addiction according to the American Psychiatric Association framework for IGD. Review studies from the late 2020s suggested that the IGDS9-SF presents with robust empirical and clinical evidence and is an effective tool to assess IGD. Moreover, the scale was adapted in several languages as Spanish, Chinese, Czech, German, and many more.
In 2019, the "Gaming Disorder Test", a screening tool for gaming disorder as defined by the World Health Organization, was published. The tool has been validated among participants from Singapore, demonstrating excellent reliability and validity.
Risk factors The Internet can foster various addictions including addiction to gameplaying.
Addictive playing of MMORPGs is associated with negative effects, whereas normal play is not. Individuals with low self-esteem use MMORPGs to compensate by creating an avatar that is powerful and competent in these online environments, which allows the player to overcome anxieties that may be impaired in the real world. Spending on microtransactions, and more specifically, loot boxes, has been linked to an increased risk of both internet gaming disorder and gambling disorder.
Younger people and men are more likely to experience a gaming disorder than older people and women, respectively. Research from 2014 has shown that the average age of a gamer was 30 years old, and that 32% of players were under 18. Adolescents are at a higher risk of sustaining video game disorder over time than adults.
Comorbid psychiatric disorders act as both risk factors and consequences. Indeed, there is a strong association between video game addiction and anxiety, depression, ADHD, social phobia, and poor psycho-social support. ADHD and its symptoms, such as impulsivity and conduct problems, also increase risks of developing video game disorder. Although internet gaming disorder has a strong relationship with obsessive-compulsive disorder, it is not specific, and internet gaming disorder is both phenomenologically and neurobiologically distinct, which indicates that internet gaming disorder is more characterized by impulsivity than compulsivity. Familial factors appear to play an important role, although this is not well understood.
Some personality traits, such as high neuroticism, high impulsivity, and high aggressiveness, are consistently significant predictors of internet gaming disorder, and combinations of these personality traits seem to play a pivotal role in the acquisition, maintenance and development of the disorder, while other traits, such as agreeableness and being open to new experiences, were found to possibly offer some protection from engaging in problematic gaming behaviors.
Mechanisms Although there is much research since the 1980s on problematic gaming use, the mechanisms are not well understood, due to inconsistent definitions used in studies.
Video game structure Some theories focus on the presumed built-in reward systems of video games, such as compulsion loops, to explain their potentially addictive nature. The anticipation of such rewards can create a neurological reaction that releases dopamine in the body, so that once the reward is obtained, the person will remember it as a pleasurable feeling. This has been found to be similar to the neurological reaction of other behavioral addictions such as substance abuse and gambling disorder.
Mark Griffiths has proposed that another reason online video games are potentially addictive is because they "can be played all day every day." The fact there is no end to the game can feel rewarding for some, and hence players are further engaged in the game.
Addiction circuits in the brain Long-term video game playing affects brain regions responsible for reward, impulse control and sensory-motor coordination. Structural analyses have shown modifications in the volume of the ventral striatum, possibly as result of changes in reward systems, and video game addicts had faulty inhibitory control and reward mechanisms. Video game playing is associated with dopamine release similar in magnitude to that of drug abuse and gambling, and the presentation of gaming pictures activates brain regions similarly to drug pictures for drug addicts. Treatment studies which used fMRI to monitor brain connectivity changes found a decrease in the activity of the regions associated with cravings.
There is evidence of a dual processing model of digital technology addictions characterized by an imbalance between the reactive and the reflective reward systems. Other studies have shown increased difficulties in decision making in specific contexts, such as risky situations, and an increased preference for short-term rewards.