Julian Lagoy, MD

In Ohio, a 17-year-old boy shot both of his parents, killing his mother, because they took away his Halo 3 video game. His defense was that he was pushed to the brink by his addiction to video games, often playing for 18 hours straight.

This tragic story joins others from around the world. In South Korea, a couple was arrested for being so obsessed with video games that their infant daughter died of malnutrition.

 As Korean internet gaming cafes grew in popularity, so did stories of players who wore diapers just so they could avoid taking bathroom breaks.

 Using the results of a survey of more than 2000 South Korean middle school students, close to 6% were classified as having a gaming disorder, and another 8% were considered to be at high risk for the disorder.

In response to statistics like these, the World Health Organization (WHO) in 2018 officially included 

(ICD) in International Classification of Diseases, 11th Edition, noting that the disorder resulted in “marked distress or significant impairment in personal, family, social, educational, or occupational functioning.” WHO further noted other associated health concerns, including insufficient physical activity, poor diet, problems with eyesight and hearing, musculoskeletal problems, sleep deprivation, aggressive behavior, and depression, as well as poor psychosocial functioning.

Mental health providers in numerous countries, including South Korea and China, welcomed WHO’s decision, saying it formalized a way to better understand the problem and support patients. In the United States, however, the American Psychiatric Association (APA) has been hesitant to label gaming addiction as a psychiatric disorder. So far, gambling is the only behavioral addiction identified as a disorder by the APA; it was added as a DSM-5 disorder in 2013.

Only 0.3% to 1% of the worldwide population qualifies for a diagnosis of acute IGD, according to a 2017 international survey.

 A 2020 American Psychological Association survey of 214 scholars revealed a lack of consensus on gaming addiction.6 About 49.7% agreed with the DSM-5 criteria, and 56.5% supported WHO’s disorder diagnosis. Similarly, 60.8% of scholars agreed that pathological video game use could be a mental health problem, but 30.4% were skeptical.

Clearly, opinions differ, contributing to ongoing confusion and making it difficult for psychiatrists to accurately diagnose and address symptoms.

 dates back to 1940, when an electromechanical machine was introduced at the New York World’s Fair. Public arcades remained the most popular places for gaming until the 1970s and 1980s, when Atari’s new video computer system brought games into homes. Then, video games found a new niche online with the rise of the internet, and it has evolved even further with mobile phones, which makes it easy to play anywhere, anytime. Today, the array of video game genres is vast, including role playing, action- adventure, first-person shooters, and strategy.

As a result, sales of video game products in the United States have swelled over the years. In 2020, consumers spent $57 billion on video games, beating 2019 sales by 27%,

 and the trend continues, with Americans spending $14.92 billion in the first quarter of 2021—a 30% increase over the first quarter of 2020.

 Globally, early 2020 projections were exceeded by $15.6 billion to $174.9 billion in revenues, thanks, in part, to the 

. Sales show no signs of stopping: Projections of 2023 sales are more than $217 billion.

 DSM-5’s Internet Gaming Disorder Scale

Brigham Young University recently released results of a 6-year study, the longest of its kind, on the effects of video game play and the trajectories of addiction. The results show that 10% of video game players exhibited pathological behavior. Pathological behavior includes playing video games excessively, which increases risk of depression, aggression, shyness, and 

, and is associated with the worst outcomes over time. The researchers concluded that it is not a “one-size-fits-all disorder.” Players who displayed pathological behavior tended to be males with low levels of prosocial behavior. They exhibited the worst long-term outcomes, with higher risks of depression, 

, shyness, problematic cell phone usage, and anxiety when compared with the nonpathological control group.

In terms of assessment, DSM-5 has a 9-item IGD Scale used to assess symptoms of gaming addiction. Gaming must cause “significant impairment or distress” in several areas of a person’s life, with the expression of at least 5 symptoms within 1 year for a diagnosis (

). Numerous risk factors are associated with IGD (

Other risk factors include underlying psychiatric illness, such as anxiety or depression, and certain personality traits such as neuroticism, anxiety, sensation-seeking behavior, aggression, and impulsivity.

 Those who play massively multiplayer online role-playing games are also at increased risk, compared with gamers who do not.

 (ADHD) symptoms, compared with those with less severe ADHD symptoms, are more at risk of developing video game addiction and suffering its negative consequences.

A 2017 systematic review of 116 articles linked video game use to several structural and functional brain changes, involving attention, cognitive control, visuospatial skills, cognitive workload, and reward processes.

Compared with nonplayers, gamers were found to have improved attention and visuospatial skills, likely due to increased blood flow and volumetric changes observed in the dorsolateral prefrontal cortex. Researchers also found that video game play is closely tied to the brain’s reward system and involves mechanisms related to impulsivity and loss of control. Gamers had increased activation of several areas in the cortical ventral basal ganglia circuit, a prime network that influences reward-seeking behavior. The hippocampus, parahippocampus, and amygdala, which link emotions and memory to game-related cues, were also involved.

The review noted negative outcomes associated with video game play, such as reduced recruitment in the anterior cingulate cortex, which can negatively affect attention. Exposure to 

 in video games was shown to lower activity in the dorsolateral prefrontal cortex, causing behavioral inhibition, negative effects on social information processing, delays in development of certain brain areas, and lower verbal IQ.

Other studies have noted the impact of video games on the release of dopamine, the neurotransmitter associated with pleasure, learning, attention, reinforcement, and sensorimotor integration. For example, results of a 1998 study using radioligand and positron emission tomography (PET) scans found that dopamine levels were increased in the ventral striatum, which influences motivation and reward.

 Similarly, results of a 2011 study of 154 adolescents, all aged 14 years, leveraged functional MRI scans and found that frequent gamers had increased grey matter in the left ventral striatum of their brains, an effect similar to that present in the brains of gambling addicts.

 The study authors suggested that changes in dopamine receptors and brain reward pathways over time could cause players, particularly addicts, to build up a tolerance and experience less pleasure. This effect is similar to substance abuse addiction, as both exhibit reduced dopamine responses to stimuli.

In addition to its effects on the brain, excessive gaming is associated with a variety of negative psychosocial effects. Studies have found that video game addicts tend to have poorer mental health and cognitive functioning, including poorer impulse control and more 

 when compared with control groups. They also display increased emotional difficulties, such as depression and anxiety, feel more socially isolated, and are more likely to report symptoms indicative of problematic use with internet pornography.

Results of a 2019 study in Germany showed a medium-sized positive correlation of potential problematic gaming with the presence of impaired psychological functioning; symptoms included depression, anxiety, and hostility. There was also a connection to maladaptive coping mechanisms (eg, self-blame, behavioral disengagement, denial, acceptance, 

, self-distraction, and venting), overall negative affect, poor self-esteem, preference for solitude, and poor school performance. However, the authors cautioned about establishing causation, given that it was a cross-sectional study, and also warned that psychological dysfunction can be a cause or an effect of pathological gaming.

How video games influence aggressive behavior has been hotly debated for decades. Concerns that violent video games such as Mortal Kombat and Night Trap could increase aggression in children played out in US Congressional hearings from 1993 to 1994. These led to the creation of the Entertainment Software Association, a trade group that created a standardized rating system of violence in 

Research conclusions are also divided on the topic of aggression. An article in the 

Journal of Personality and Social Psychology

 reviewed 2 studies and concluded that video games provided a dangerous medium for adopting aggressive solutions to conflicts. Video games, the authors wrote, caused short-term cognitive changes in the brain by priming aggressive thoughts. Long-term effects were created by reapplying aggression-related scripts learned during play time to real-life scenarios. Because players got to practice aggressive moves in real-time play, the authors concluded that playing violent video games was more dangerous than watching television or film violence.

Authors of a 2019 study, however, countered this argument and found that no tipping point was associated with the engagement of a violent video game and an increase in aggressive behavior.

Although opinions and research conclusions remain divided, a clear constant remains: Males are generally more likely than females to develop video game addictions.

 Gender differences may also play a role, particularly as it relates to anxiety during late adolescence. Although it is hard to generalize results due to the limited sample, results of a study suggested that boys who played video games experienced the least anxiety, while girls had the most, conditions that were exacerbated when playing with others.

 Possible reasons could be that boys are more likely than girls to make friends online, feel more connected to friends during play, and use video games to engage with friends.

Results of another study indicated that internet gaming addiction seemed to shorten the length of leukocyte telomeres in adolescent Korean males, a result that could be attributed to changes in autonomic functions, such as catecholamine levels.

 Telomeres are genetic components that act as markers of cellular aging and are influenced by many factors, such as lifestyle changes and stress levels. Shorter telomere length is associated with increased pace of aging and increased incidence of diseases over time. 

In 2017, a group of scholars wrote an open debate paper cautioning WHO against listing video game addiction as a disorder, as it could leave the proverbial door wide open to pathologizing other conditions, such as addictions to sex and food.

 Video game addiction rates are generally low, they argued, and there was a lack of consensus on the addiction’s symptoms and assessment. Criteria used to support the diagnosis relied too heavily on benchmarks for substance abuse and gambling disorders, they wrote. The scholars claimed that this distinction would shift the focus of video game addiction research to that of a confirmatory approach, rather than an exploratory one. They also cautioned that the label of disorder would create a moral panic and could trigger premature diagnoses, in addition to creating a stigma for children and youth who play video games as “part of a normal, healthy life.”

Although individuals in China and South Korea see IGD as a dangerous and growing problem, it does not seem to attract the same concern in the United States and elsewhere around the world. Much of this difference in perspective could come down to simple cultural differences. In China, professional esports players train upward of 14 hours a day for a chance to compete in arenas like the League of Legends world championships, where they can earn hundreds of thousands of dollars.

 In South Korea, watching esports competitions is more popular than watching other kinds of television programs. For many individuals raised in working-class families in South Korea, a nation in which access to higher education is intensely competitive, the idea of going professional serves as a way to escape their circumstances.

Perhaps the stakes are not as high in the United States, where passion for the games may be among the strongest motivations to play. According to article authors writing on behalf of the American Psychological Association, 97% of children and adolescents aged 2 to 17 in the United States play video games for at least 1 hour a day. They noted that playing video games could improve cognitive skills, problem-solving abilities, mood, resilience, motivation, social skills, and overall well-being.

A recent study by researchers at the University of Oxford, collaborating with 2 video game companies, surveyed more than 3270 players in the United States, United Kingdom, and Canada to measure their well-being, self-reported play, and motivational experiences during play.

 They found that players genuinely enjoyed playing the games, which had a significant positive impact on a player’s well-being. Further, the findings were aligned with past research results suggesting that people whose psychological needs are not being met in the real world might report negative well-being from play.

Studies have also shown that the length of play time and the type of video game have an impact on the game’s negative or positive effect. Games that featured more online social interaction resulted in fewer problematic gaming symptoms. Males playing nonsocial games appeared to have more social anxiety. Females who played social games had less social anxiety and loneliness but exhibited 

Of note, interest is growing in using video games to treat a range of mental health conditions in youth and adults, such as ADHD, depression, and posttraumatic stress disorder.

In some cases, classifying video game addiction as a disorder could be useful, even if only a small percentage of people experience it. Such a distinction would allow clinicians to detect and treat other coexisting conditions, such as depression, anxiety, and substance addiction.

When considering a potential problem with video games, clinicians should look for symptoms and signs that video game use has become disruptive (

 Signs That Video Game Use Has Become Disruptive

Several treatment options are available to address video game addiction, including cognitive behavioral therapy, family therapy, motivational interviewing, and solution-focused therapy, as well as combinations of these. Additionally, Online Gamers Anonymous, a 12-step recovery program established in 2002, offers an approach to break addiction similar to that of Alcoholics Anonymous and Narcotics Anonymous.

For example, a study examined the efficacy of a 9-day self-discovery camp for adolescents that included 14 cognitive behavioral therapy sessions, 8 personal counseling sessions, 3 medical lectures, a gaming workshop, engagement in positive gaming activities, and abstinence from games during the stay.

 Researchers found that participation in this camp led to decreased gaming time at a 3-month follow-up and that age of onset of IGD and problem recognition were correlated.

Bupropion, a medication commonly used to treat depression and ADHD, has shown some positive effect in treating symptoms of video game addiction. Study results have shown some benefit from treating comorbid video game addiction and ADHD with methylphenidate.

 Unfortunately, these results highlight the paucity of well-designed treatment outcome studies, with limited evidence for the drugs’ effectiveness. Additional studies, ones with better design, are needed before these medications are FDA approved.

is a double board-certified adult and child psychiatrist with Community Psychiatry based in Newark, CA.

 is a staff psychiatrist at Community Psychiatry in San Jose, CA.

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 October 17, 2019. Accessed June 10, 2021. 

https://www.latimes.com/world-nation/story/2019-10-17/south-korea-video-game-addiction-mental-health

Prevalence of internet gaming disorder among Korean adolescents and associations with non-psychotic psychological symptoms, and physical aggression.

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https://www.who.int/news-room/q-a-detail/addictive-behaviours-gaming-disorder

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Internet gaming disorder: investigating the clinical relevance of a new phenomenon.

Lack of consensus among scholars on the issue of video game “addiction.”

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https://www.npd.com/news/press-releases/2021/the-npd-group-fourth-quarter-2020-u-s-consumer-spending-on-video-game-products-increased-26-while-annual-spend-gained-27-compared-to-2019/

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https://www.npd.com/news/press-releases/2021/the-npd-group-first-quarter-2021-u-s-consumer-spending-on-video-game-products-increased-30/

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https://newzoo.com/insights/articles/game-engagement-during-covid-pandemic-adds-15-billion-to-global-games-market-revenue-forecast/

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Pathological video game symptoms from adolescence to emerging adulthood: a 6-year longitudinal study of trajectories, predictors, and outcomes.

Risk factors for internet gaming disorder: psychological factors and internet gaming characteristics

Online gaming addiction: the role of sensation seeking, self-control, neuroticism, aggression, state anxiety, and trait anxiety.

Online gaming addiction? Motives predict addictive play behavior in massively multiplayer online role-playing games.

Video game addiction, ADHD symptomatology, and video game reinforcement.

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Neural basis of video gaming: a systematic review.

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Evidence for striatal dopamine release during a video game.

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Computer and video game addiction—a comparison between game users and non-game users.

Video game addiction in emerging adulthood: cross-sectional evidence of pathology in video game addicts as compared to matched healthy controls

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The association between video gaming and psychological functioning.

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Scholars’ open debate paper on the World Health Organization ICD-11 Gaming Disorder proposal.

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Treatments for internet gaming disorder and internet addiction: a systematic review.

Articles

Is gaming dangerous? A study found 10% of video game players exhibited pathological behavior. 

Is Video Game Addiction a Disorder?

As the world slowly sheds the weight of COVID-19, there is an opportunity for psychiatrists to pause and consider the role they are about to play in the coming months and years. Never before has the entire modern world been subjected to such collective feelings of fear, uncertainty, anxiety, and sorrow—and loneliness.

Individuals around the world did their part to slow the spread of 

 by staying home. Populations that were not used to being alone, like children and teenagers, were suddenly cut off from their social networks. Family members were often isolated from each other. Many individuals have died from COVID-19, often without family, with little comfort or human contact except hospital staff.

About 36% of Americans reported feeling “serious loneliness” in the wake of the pandemic, according to 

 Of these respondents, 61% were aged 18 to 25 years, and 43% reported increases in loneliness since the pandemic began.

The effects of pandemic-related isolation have been felt in every corner of society. It may take the form of exacerbated symptoms in some patients or freshly developing signs of mental illness in others. Medically, loneliness has been linked to 

 It is also linked to increased rates of depression, anxiety, substance abuse, domestic abuse, and suicide.

Psychiatry often relies on pharmaceuticals to treat mental illness; this 

 serves as a good reminder that the best cure for loneliness can be as simple as kindness and compassion.

More than any other species, humans are dependent on others for longer periods of time. In fact, the average individual spends about 80% of their waking hours in the company of others.

 is a state of mind that is characterized by feeling unwanted, empty, and cut off from other human beings.

 It is also described as a negative reaction to the discrepancy between the relationships we desire versus those we have.

Loneliness is not necessarily the result of being alone. One can easily feel lonely even when surrounded by others. Because loneliness is more often a perception, feelings of isolation can trigger hypervigilance, in which the world appears to be a threatening place.

 Individuals who are lonely tend to be more critical of themselves.

 When these negative expectations are confirmed by the behavior of others, this creates a 

 that is accompanied by feelings of hostility, stress, pessimism, anxiety, and low self-esteem.

Loneliness apparently loves company, with studies describing it as 

 It appears to spread through friends, rather than family members, and occurs in clusters, extending up to 3 degrees of separation.

 Loneliness can be addressed both as a group and individually. One way to prevent loneliness is to encourage social activity. Obviously, for some people it is very hard to be social; this is where emphasizing resiliency and perseverance is important. 

“In loneliness, the lonely one eats himself; in a crowd, the many eat him,” Friedrich Nietzsche once said.

 Culturally, loneliness can be seen as a sign of weakness or self-pity. For instance, 1965 study of rhesus monkeys Found that when a group of socially isolated monkeys were reintroduced to their colony, they were driven off or eliminated.

In 2018, the United Kingdom’s BBC Radio 4 released results from 

, the largest survey ever conducted on the subject.

 They study included more than 55,000 participants, aged 16 to 99 years, hailing from 237 countries, islands, and territories. It found that loneliness was higher in individualistic cultures such as the United States and Western Europe, which placed high value on self-reliance, loose social networks, and chosen relationships. In contrast, cultures with strong collectivist norms, including some Asian countries, are built on interdependence, tighter social networks, and stronger family connections. Some of these countries include Brazil, India, and the Philippines.

The study found young individuals experienced the most loneliness, with 40% of 16- to 24-year-olds feeling lonely often or very often, in comparison with 29% of individuals aged 65 to 75. Young men in particular were more susceptible to feelings of loneliness, and their loneliness was more intense and longer-lasting.

Most of the research on loneliness was conducted before COVID-19 sent us into lockdown, so it is too soon to consider the pandemic’s long-term effects. However, recent studies have tracked the impact of social distancing and quarantine, and they have left an intriguing bread-crumb trail of predictions.

When COVID-19 struck, many experts worried suicide rates would skyrocket.

 A 2020 report from the Centers for Disease Control and Prevention showed a 35% increase in suicide mortality in the US from 1999 to 2018, a trend most people expected to continue.

A March 2020 rapid review disseminated 24 studies

 in 10 countries that examined the psychological impact of quarantine.

 It included those affected by SARS, Ebola, H1N1 influenza, Middle East respiratory syndrome, and equine influenza. Common quarantine side effects included posttraumatic stress disorder (PTSD), confusion, and anger. Stressors included the extension of quarantines, fear of infection, frustration, boredom, inadequate supplies and information, financial loss, and stigma.

The review also found health care workers in particular suffered from the loneliness and isolation of quarantine. Theyendured increased severe symptoms of 

, felt stigmatized, and reported greater loss of income. Health care workers also reported feeling lonely, guilty, angry, helpless, isolated, nervous, and sad. Many linked their quarantine experience to alcohol abuse and dependency symptoms. They also engaged in avoidance behavior, often not showing up to work or avoiding direct interactions with patients.

Like every facet of society, health and mental health organizations have had to rethink how to serve their patients, especially when they could not be treated in person. Mental health care providers were encouraged to find alternate ways to deliver services, provide clear pathways for those considering suicide, and quickly offer bereavement services when needed. We can assess for loneliness by using the revised University of California, Los Angeles (UCLA) loneliness scale.

 One way to approach the conversation is to ask patients what they are doing during their free time and if they have any friends or family they spend time with. Since the COVID-19 pandemic, it is likely a lot more patients have indicated they are lonely.

 examined the relationship between 30,000 patients and their therapists.

 In a review of 295 independent studies published between 1978 and 2017, it found that positive clinical outcomes correlated with the strength of the therapeutic alliance between patients and their therapists. The better the relationship, the better the prognosis. The therapeutic alliance has become even more important due to the pandemic and quarantine. As psychiatrists, we must strengthen our relationship with patients so they trust us and improve. This is just as important and essential as medication management.

Individuals need quality information and strategies to cope with loneliness, in addition to help identifying and managing self-defeating thoughts. Comprehensive assessments like the revised UCLA Loneliness Scale and access to round-the-clock counseling networks could throw vital lifelines to patients suffering from loneliness.

In France, the VigilanS suicide prevention system was implemented before COVID-19 began. It rapidly adapted by following up with at-risk patients on the 10th day rather than the 20th. Early data regarding this intervention shows a sharp decrease in 

 by those involved, however this is an ongoing study and final results are not yet published.

 France’s art community also jumped to provide support. Cov’ Art is a public art movement designed to shore up resilience and provide messaging about suicide and interindividual violence. Some programs in the US include the National Alliance on Mental Illness, the National Suicide Prevention Lifeline, and the American Foundation for Suicide Prevention.

, smartphones, and videoconferencing have also played a huge role in maintaining connections. Prior to COVID-19, social media was seen as something that made many individuals feel lonely.

 During the pandemic, however, social media was one of the few safe ways to stay in contact with other people. In one study, it was noted that while adolescents indicated increased social media use during lockdown, it was not associated with increased happiness. It even showed a negative correlation between using social media and happiness. It also noted that using social media as a substitute for physical social relations makes adolescents feel less happy.

More than anything, individuals need to be comforted that they are not alone and shown a way to overcome their loneliness. Often, the solution is to address loneliness with kindness. 

 observed 2 groups for 6 weeks; 1 that performed acts of kindness for themselves and 1 that conducted good deeds for others.

 The group that behaved altruistically flourished psychologically through improved social relationships and feelings of greater joy and wellbeing.

 suggested that how we treat loneliness is a bellwether of not only society’s emotional and physical health but also its moral health.

 In a society where many prioritize themselves, we need to help our patients—and ourselves—commit to being both present and compassionate for each other.

Ironically, suicide rates generally dip after major events that are shared by large populations.

 During COVID-19, CDC statistics found provisional 

 Provisional suicide mortality rate estimates provide an early indication of shifts in suicide mortality trends.

 After the 9/11 terrorist attacks, suicide rates in New York declined significantly during the 180 days after the event.

 Researchers suggest that a “pulling together” effect may be the reason behind this phenomenon. Shared experiences during COVID-19 led to a powerful sense of togetherness that helped to keep suicidal thoughts in check. 

 suggested that the “need to belong is so powerful that, when satisfied, it can prevent suicide.”

 It noticed that fewer suicides occurred on Super Bowl Sundays, likely due to an increase of shared membership and group interaction on those days.

It is this line of reasoning that developed the 

 First, suicide ideation occurs as a reaction to feelings of psychological pain and hopelessness. Second, feelings of connectedness were a key protective factor against escalating ideation. Third, suicide follows ideation when a someone determines they have the disposition and practical capacities to carry out the event.

To be sure, the stress of COVID-19 has affected mental health around the world. 

 reported that more than 40% of respondents had symptoms of anxiety or depression.

 It is interesting that while suicide rates declined, depression rates have increased. Major events that affect a whole population have an interesting effect in decreasing suicide while increasing rates of depression. Additionally, 26% indicated that they had started or increased substance use as a way to cope.

As psychiatrists, we tend to be biased in thinking that everything can be fixed with medication; however, the danger is that we forget to see the human person in front of us. While medication can help, often their problem is much more complex and needs more than medication treatment. We should not overlook patients we think are lonely and instead provide tips, such as being active on social media and staying in touch with friends through Zoom and Facebook. Although in-person relationships are always better than virtual ones, virtual ones are better than nothing. The worst thing to do when lonely is to completely isolate and not talk to anyone through social media. 

As psychiatrists, we are on the front lines and can affect whether some people live or die. Let us rise to the occasion and treat everyone with kindness and compassion and in doing so, save thousands of lives.

is staff psychiatrist at Community Psychiatry in San Jose, CA.

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https://mcc.gse.harvard.edu/reports/loneliness-in-america

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9. Remes O. Loneliness is contagious – and here’s how to beat it. Cambridge University. July 16, 2018. 

https://www.cam.ac.uk/research/discussion/loneliness-is-contagious-and-heres-how-to-beat-it

10. Cacioppo JT, Fowler JH, Christakis NA. Alone in the crowd: the structure and spread of loneliness in a large social network. 

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https://www.seed.manchester.ac.uk/education/research/impact/bbc-loneliness-experiment/

The pandemic has kept people apart. What are the mental health consequences of being alone? And what would be the benefits of getting back together? 

Julian Lagoy, MD

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