Meredith E. Gansner, MD

“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.”

 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.”

 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.”

 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.

 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.

 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.

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.

Another potential barrier to recognizing “gaming disorder” is that there are limited treatment options for the disorder. There is a long-standing adage in medicine that once a physician officially recognizes and documents a problem, the onus is then on the physician to figure out how to fix it. For gaming disorder, the lack of standardized research makes treatment decisions exceedingly challenging.

What little evidence there is suggests that treatment options similar to those used in addictive disorders (eg, bupropion, cognitive behavioral therapy) may provide some benefit, and that treating comorbid conditions (eg, ADHD, depression) may be helpful.

 However, in order to discern effective treatment options for IGD, a standardized definition, diagnosis, and screening method are crucial; therefore, without international recognition of IGD and subsequent standardization of diagnostic criteria and screening, treatment studies will likely continue to be inadequate.

Pathological gaming as a stand-alone diagnosis

Perhaps the most significant debate over the existence of IGD relates to the question of whether pathological gaming and internet use are associated phenomena resulting from mental health disorders, rather than separate entities. IGD has been found to be comorbid with numerous psychiatric diagnoses, including depression and anxiety. A 2016 study found low intercorrelation between addictive online variables and evidence that psychiatric diagnoses contributed significantly to any noted variance between addictive internet and gaming behaviors.

Regardless of these findings, there are few diagnoses that exist in true isolation in psychiatry, and even if pathological gaming is the result of a preexisting psychiatric disorder, a teenager who begins engaging in excessive alcohol use to cope with MDD will often get both a diagnosis of alcohol use disorder and MDD. If another teenager begins engaging in pathological gaming as a coping mechanism for managing the same depressive symptoms, it is worth questioning why giving the dual diagnoses of MDD and the addictive disorder would be appropriate in the former, but not the latter.

Pathological gaming and psychiatric symptoms

Certainly, there are valid points in support of and against the creation of a gaming disorder diagnosis, but it is pathological gaming’s impact on our patient population that should prompt attention from the field of psychiatry. While the percentage of total gamers that meets proposed gaming disorder criteria appears quite small, the noted comorbidity between psychiatric diagnoses and pathologic gaming suggests that individuals who meet IGD criteria may be more likely to be our patients.

 As psychiatrists we must recognize this pathological behavior and help address it, just as we would help manage binge eating or cannabis use disorders-whether maladaptive coping skills or stand-alone diagnoses.

Psychiatry’s recognition of the disorder is especially important considering that pathological gaming may have a more negative impact on those with existing psychiatric illness. Among individuals seeking treatment for IGD, those with higher scores on baseline Beck Depression Inventory (BDI) rating scales required extended IGD treatment and individuals who endorse comorbid ADHD symptoms also appear to have more severe IGD.

Thus, while support of a gaming disorder diagnosis might risk stigmatizing or incorrectly assigning pathologic behavior to healthy gamers, it might also help to advance international knowledge of IGD in vulnerable populations with comorbid psychiatric illness. Moreover, WHO’s designation of gaming disorder may also be a necessary first step toward improving research on internet addiction, or problematic internet use (PIU). PIU research is similarly plagued by use of many different diagnostic criteria and screening tools although individuals with PIU alone appear to be in a different demographic than those with gaming disorder, with different comorbidities (eg, individuals with only gaming disorder are more likely to be male).

 PIU similarly appears to pose a unique risk to those with existing psychiatric illness. For example, psychiatrically hospitalized adolescents with PIU are more likely to exhibit both suicidality and aggression than psychiatrically hospitalized adolescents without PIU.

If the American Psychiatric Association decides to follow WHO’s example and officially recognize gaming disorder in DSM, they will be making an important statement of national support for funding of well-designed studies to elucidate further the effects of digital media on patients. Critics of WHO’s recognition of gaming disorder attribute the designation in part to its caving under political pressure from Asian countries, some of which have been pushing for formal recognition of gaming disorder for years.

 Gaming addiction has become a significant public health concern in countries like South Korea, with governments going so far as to enact public policies and laws to target the problem.

While it’s true that gaming in the US has not yet become the crisis that it has become in other countries, DSM inclusion of the disorder might similarly help to inspire interventions beyond the level of the individual here in the US, ideally including policy proposals for primary prevention. American politicians are already taking notice of gaming and internet addiction. The most notable example is the CAMRA Act, a bipartisan bill drafted by congress in 2018 that proposes the allotment of $95 million for government funding to the NIH in support of projects studying the effects of technology and media on youth.

The internet and video gaming are not going away, and game designers will continue to prioritize habitual gaming over the health of players, leaving the burden of pathological gaming on users and their families. For one couple in South Korea, the burden was the death of their infant child when they neglected the child’s care in order to play video games.

 For a mother in Ohio, it was the loss of her life when she found her 16-year-old son playing Halo, reportedly for up to 18 hours a day; when she took the game away in disapproval, her son shot and killed her.

While these examples are rare and extreme, not every individual who drinks alcohol drinks to the point of cirrhosis, and yet we screen for alcohol use regularly, assessing for when social use has become an alcohol use disorder. For many of our patients and their frustrated parents, the risks of psychiatry’s continued avoidance of a potential gaming disorder may already be too high.

Dr Gansner is Instructor in Psychiatry, Cambridge Health Alliance, Cambridge, MA. She reports no conflicts of interest concerning the subject matter of this article.

1. World Health Organization. September 2018. Gaming Disorder.

2. Entertainment Software Association. 2019. ESA Responds to WHO’s Proposed Disorder Classification.

3. Przybylski A, Orben A. Why It’s Too Soon to Classify Gaming Addiction as a Mental Disorder. February 2018.

4. Aarseth E, Bean AM, Boonen H, et al. Scholars’ open debate paper on the World Health Organization ICD-11 gaming disorder proposal. 

5. Fauth-BÃ¼hler M, Mann K. Neurobiological correlates of internet gaming disorder: similarities to pathological gambling. 

6. Kuss DJ, Griffiths MD. Internet and gaming addiction: a systematic literature review of neuroimaging studies. Brain Sci. 2012;2:347-374.

7. King DL, Delfabbro PH, Wu AMS, et al. Treatment of Internet gaming disorder: an international systematic review and CONSORT evaluation. 

8. Billieux J, Demetrovics Z, Kuss DJ, et al. The relationship between addictive use of social media and video games and symptoms of psychiatric disorders: a large-scale cross-sectional study. 

9. Przybylski AK, Weinstein N, Murayama K. Internet gaming disorder: Investigating the clinical relevance of a new phenomenon. 

10. Evren C, Evren B, Dalbudak E, et al. Relationships of Internet addiction and Internet gaming disorder symptom severities with probable attention deficit/hyperactivity disorder, aggression and negative affect among university students. 

11. Han DH, Yoo M, Renshaw PF, Petry NM. A cohort study of patients seeking internet gaming disorder treatment. 

12. Gansner M, Belfort E, Cook B, et al. Problematic internet use and associated high-risk behavior in an adolescent clinical sample: results from a survey of psychiatrically hospitalized youth. 

13. Good O. Gaming Disorder Officially on World Health Organization’s List of Diseases. May 2019.

14. Markey E, Sasse B, Blunt R, et al. Children and Media Research Advancement (CAMRA). 2018.

15. Salmon A. Couple: Internet Gaming Addiction Led to Baby’s Death. April 2010.

16. Daniel Petric Killed Mother, Shot Father Because They Took Halo 3 Video Game, Prosecutors Say. 

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With internet and video gaming here to stay, game designers will continue to prioritize habitual gaming over the health of players, and the burden of pathological gaming will fall on users and their families.

Gaming Addiction in ICD-11: Issues and Implications

In June 2014, numerous news outlets told the 

 of 2 Wisconsin preteens who had lured their best friend into the woods and stabbed her 19 times. When asked why, these girls reported that the internet meme “Slenderman” drove them to do it.

Following this horrific crime, the typical questions of how and why were asked, but soon came another question: Was the internet, in fact, an accomplice? Had their online activity led to a blurring of fiction and reality in such a way that had allowed them to commit attempted murder?

This case revives a long-standing debate: Does media exposure influence acts of violence in youth? Recently, the American Psychological Association Task Force re-reviewed the existence of a potential link between violent video game exposure and acts of real-life violence.

 The authors examined the literature from 2009 to 2013 and concluded:

Consistent with the literature that we reviewed, we found that violent video game exposure was associated with: an increased composite aggression score; increased aggressive behavior; increased aggressive cognitions. . . . Our task force concluded that violent video game use is a risk factor for adverse outcomes, but found insufficient studies to examine any potential link between violent video game use and delinquency or criminal behavior.

Video games are only a small part of the wide expanse of media readily accessible to youths throughout the day. While teenagers engage in an average of over 6 and a half hours of screen time daily (including social media and online videos), the 

 playing video games was just 56 minutes for boys and 7 minutes for girls.

 With adolescents attached to their devices for so much of the day, what should the practicing psychiatrist know about a potential connection between aggressive behaviors and online activity?

There is limited research to indicate that an increased number of hours on social media correlates directly with aggressive behavior, but there is literature that connects certain types of internet use to increased aggressive behavior. For example, quality of online exposure may be contributory; youths who perpetrated serious crimes were significantly more likely to have viewed violent online content.

 Moreover, similar to the way media coverage of suicide can act as a contagion for “copycat” suicides,

 there is also evidence that some mass killings 

 other violent acts in the immediate past.6 Now that the internet provides unfettered access to images of real-life violence-eg, recent videos of murders and gang violence uploaded to Facebook Live-overall exposure to, and potential for, copycat violence may be increased.

Teens that spend hours “liking” their friends’ pictures on social networking sites may be significantly more likely to have other traits associated with violent behavior.

Quantity of internet use may also be contributory. 

 connect problematic internet use (PIU) or internet addiction (IA) to increased aggressive behaviors, perhaps because of similar neurobiology between the 2 conditions.

 PIU and IA are often broadly defined as internet use that is uncontrollable, markedly distressing, or time-consuming or that results in social, occupational, or financial difficulties.

 A study of more than 2000 Korean high school students found a nearly twofold increase in aggression in severely internet-addicted youth over mildly internet-addicted youth,

 and similar findings have been replicated in other adolescent studies.

 Other measures of aggressive behavior show correlation as well. American high school students who met criteria for PIU were significantly more likely to have been in physical fights than were those in a non-PIU cohort.

Teenagers who spend hours “liking” their friends’ pictures on social networking sites may be significantly more likely to have other traits associated with violent behavior aside from their internet habits. The goal of a large body of research has been to characterize the population of adolescents with PIU and to examine comorbidities. Alcohol use and depressive symptoms both predict violent behavior in adolescents,

 and these factors have also been positively correlated with internet use. Perhaps unsurprising given 

 that suggest brain structural abnormalities in reward circuitry in adolescents with PIU,

 adolescent PIU is associated with higher levels of alcohol use. This association has been found both in cross-sectional analyses, as well as in a longitudinal study in which internet overuse corresponded with heavy alcohol use by early adulthood.

While more contentious, there is growing evidence that pathologic internet use may positively correlate with depressive disorders,

 and even “normal” everyday Facebook scrolling may have long-term consequences. Recent longitudinal studies have found that Facebook use is predictive of a decline in subjective well-being,

 and similar associations have been delineated between depressed mood and overall social network use, as well as with online chatting.

In addition, while PIU can be conceptualized as an addiction, it has also been characterized as an impulse control disorder. Several studies suggest a 

of overlap between PIU characteristics and impulsivity.

 It is this proposed interweaving between impulsivity, depression, aggression, and even increased substance use that may support the idea that adolescents who spend countless hours online may become more violent than they would be if they spent less or no time online.

Does excessive Twitter time or continual scanning of Facebook feeds cause adolescent violence? It may be more clinically helpful for us to reframe the question: Are youths with risk factors predictive of assaultive behavior such as substance use, impulsivity, and mood disorders also more likely to spend excessive time online? The answer, from the preliminary studies above, appears to be yes. It would be near impossible-and unrealistic-to suggest abstinence from internet-based activities in these adolescents, but future studies may benefit from continued exploration of the ways in which adolescents utilize social media and online forums to enact aggression (eg, cyberbullying) as well as incorporation of internet habits within our routine psychiatric evaluation.

Consider asking the following questions within the traditional assessment of an adolescent.

 If the answer is yes, this should prompt further exploration.

Have you ever viewed real-life violent content online?

Have you ever cyberbullied or harassed anyone else online?

Have you ever gotten into trouble or an argument because you were online too much?

Have you ever experienced tension or anxiety that can only be relieved by going online?

This article was originally posted on 7/10/17 and has since been updated.

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http://www.newsweek.com/2014/08/22/girls-who-tried-kill-slender-man-264218.html

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 Younes F, Halawi G, Jabbour H, et al. Internet addiction and relationships with insomnia, anxiety, depression, stress and self-esteem in university students: a cross-sectional designed study. 

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The Slenderman case revives a long-standing debate: does media exposure influence acts of violence in youth?

Author | Meredith E. Gansner, MD

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