“He’s addicted to ‘Fortnite’!” is a chief complaint I have heard numerous times over the past 2 years in my treatment of children and adolescents. However, even before “Fortnite” became a household name, I was seeing young patients for whom gaming had transformed into something far more serious than a carefree pastime. It was almost becoming a recognizable pattern: child starts playing a videogame, child won’t stop playing videogame, parents remove access to videogame, child flies into a rage with sometimes terrifying consequences. Yet, while this pattern was often predictable, it was difficult to name.
Gaming disorder seems to be a fitting diagnosis, but its existence as an independent mental health condition remains highly controversial, with many researchers and clinicians divided on this issue. In May 2019, the World Health Organization (WHO) finally took an official stance; gaming disorder will be classified as a medical illness in ICD-11. Gaming disorder should be of “sufficient severity to result in significant impairment in personal, family, social, educational, occupational or other important areas of functioning” and would “normally have been evident for at least 12 months.”1 Their decision is based on “reviews of available evidence and reflects a consensus of experts from different disciplines and geographical regions that were involved in the process of technical consultations undertaken by WHO in the process of ICD-11 development.”
WHO is arguably the most influential organization to weigh in on this debate thus far, and as such, their designation has already generated a significant amount of international criticism. Numerous representatives from the video gaming industry banded together to deliver a joint statement, stating “The World Health Organization knows that common sense and objective research prove video games are not addictive. . . . We strongly encourage WHO to reverse direction on its proposed action.”2 The gaming industry is not alone in its criticism of WHO’s decision.
Andrew Przybylski, experimental psychologist and Director of research at the Oxford Internet Institute responded to the proposed designation as early as last year, stating that “WHO’s tentative move to pathologize digital play is premature.”3 In 2017, Przybylski and more than 20 other researchers published an open debate paper responding to the possible ICD-11 designation; they expressed concerns that with this designation, individuals who play video games without developing pathological use will be inappropriately stigmatized.4 However, criticism of gaming disorder goes well beyond concerns regarding its potential impact on “healthy” gamers.
Preliminary evidence for pathological gaming
One criticism against making gaming disorder an independent disorder is that the neurobiological consequences of other addictive disorders are extensively documented, while those associated with gaming disorder are not. Imaging studies of gaming disorder are few and have significant design limitations (eg, homogenous samples, wide diversity in type of gaming).
However, despite the undeniable need for additional research, preliminary evidence does suggest possible behavioral and physiological changes from increased gaming. Individuals meeting criteria for internet-gaming disorder (IGD) appear to exhibit decreased loss sensitivity, enhanced reactivity to gaming cues, and aberrant reward-based learning, similar to changes seen with pathological gambling behavior.5 Neuroimaging studies, specifically fMRI, also indicate changes in brain regions associated with addiction, rewards, and emotional processing; compared with controls, individuals with IGD may have increased activation in areas such as the nucleus accumbens, amygdala, anterior cingulate, dorsolateral prefrontal cortex, and insula. Moreover decreased gray matter volumes have been found in the cerebellum, orbitofrontal cortex, anterior cingulate cortex, and supplementary motor area of individuals with IGD.6
These neurobiological changes may be more pronounced for certain types of video games, specifically related to how reward delivery is designed within a game. For example, many popular video games now include “loot boxes,” where gamers can pay real money to purchase a random selection of virtual rewards. The gamer hopes that in that selection will be a highly sought-after reward of great value within the video game itself. The trick is that like the slot machine, the odds of obtaining a valuable item are both unpredictable and slim, prompting the gamer, in essence, to gamble. Loot boxes are not the only method video game designers use to perpetuate gaming, but the sheer number of, and variability between, video games makes it tremendously difficult to generalize neurobiological findings to all individuals with pathological gaming issues.
Dr Gansner is Instructor in Psychiatry, Cambridge Health Alliance, Cambridge, MA. She reports no conflicts of interest concerning the subject matter of this article.
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