Video game addiction is now being recognized—what happens next?
Like millions of kids in the 1980s, Scott Jennings played video games. Sometimes he’d play a little too much, filling up an afternoon with short bouts of Pac-Man or Space Invaders. He grew out of his childhood hobby when he went to college and didn’t play for another 10 years. After graduation he landed a job as a software developer and was doing pretty well.
But his drinking started spiraling out of control. When he began to drink in the morning, it scared him so much that he found help. He entered Alcoholics Anonymous and got sober.
For five or six years life was good. He learned to live with his illness, abstaining from alcohol completely. He stayed away from activities that he thought could be addictive. A friend who liked to go to casinos would invite him along, but Jennings always turned him down. “I didn’t want to play with fire, you know?” he says. “But I’d never heard of gaming addiction.”
He started playing video games again. At first it was just now and then. But when he went through a tough patch, he found that games helped him deal with stress and anxiety. He was terrified of falling back into addiction. “I didn’t want to touch alcohol. I knew what a disaster it would be if I started drinking again,” he says. “So I used games to cope.”
The warning signs were all there. Behaviors from his drinking days were back. He grew obsessive, thinking about games all the time. He played when he should have been sleeping. He’d intend a five-minute break from work and play for two hours.
He knew he was gaming too much and hid it. If people asked him what he’d done that day, he would make something up rather than admit that he’d played four or five hours straight. “So yeah, I was seeing the red flags,” he says. “But I wasn’t that worried about it.”
In the first few years of recovery it is normal for people to find substitute obsessions. Jennings watched a lot of TV, spent many hours in online chat rooms, binged on pornography and Ben & Jerry’s ice cream. “All these escapist, numbing behaviors were temporary crutches,” he says. He figured gaming was another: “I thought I would burn out on it after a while and give it up, but it didn’t turn out like that at all.”
What is it about games that some people find addictive? Or is what looks like gaming addiction simply a symptom of other underlying problems, such as depression? Scientists are trying to make sense of the psychological effects of video games. But despite the large number of players seeking help with a hobby that has them hooked—and in extreme cases is ruining their lives—there is little agreement about what video game addiction is, or even if it is a genuine addiction.
In May this year the World Health Organization added gaming disorder to its International Classification of Diseases, a diagnostic guide for clinicians. The hope is that by giving a label to a set of problematic behaviors, medical professionals—from doctors to insurance providers—can more readily identify and treat them.
The WHO classification is but one instance of growing recognition for video-game disorders in the past few years. Researchers are exploring possible treatments, including cognitive behavioral therapy (CBT), a psychological approach that aims to treat a wide range of disorders by getting patients to analyze their own patterns of thinking and behavior.
Yet many leading experts have concerns about this rush to pathologize one of the most popular pastimes in the world. “I think the jury’s still very much out,” says Peter Etchells, a psychologist at Bath Spa University in the UK. “Not necessarily on whether gaming addiction exists, but in terms of what it actually looks like and how prevalent it is … It probably doesn’t make much more sense to say games are addictive than it does to say food makes you fat. It obviously depends on what food you’re eating and how much. Different types of game are alluring in different ways.”
Depending on which study you read, estimates for the number of people with a gaming addiction range from fewer than 1% of gamers to nearly half. Part of the problem is that there is no clear definition of what counts as an addiction. Many estimates are based on anecdotal or self-reported diagnoses. It also depends on who counts as a gamer: including the most casual players in the denominator makes the ratio appear smaller, perhaps masking the severity of the problem. “We’ve had 30-plus years of research on gaming addiction, and we’re not really anywhere closer to understanding what it is that we’re actually talking about,” says Etchells.
In November 2016, when the WHO was still considering its position on gaming disorder, a group of 26 leading researchers on video games and mental health—led by Andrew Przybylski, an experimental psychologist at the Oxford Internet Institute—wrote an open letter to the WHO advisory group on mental health, in which they outlined grave reservations about the proposal and argued that it was premature to settle on specific criteria for a diagnosis. “Some gamers do experience serious problems as a consequence of the time spent playing video games,” they wrote. “However, we claim that it is far from clear that these problems can or should be attributed to a new disorder, and the empirical basis for such a proposal suffers from several fundamental issues.”
The authors claimed that the WHO was drawing on poor-quality research, that the characterization of gaming disorder leaned too heavily on gambling and substance abuse, and that there was no consensus on symptoms or how to assess them. They said they were concerned that specifying criteria for gaming disorder would lock future research into confirming those criteria, rather than impartially investigating them.
If the concern about video games is nothing but a moral panic, the WHO’s announcement adds fuel to it and risks stigmatizing the millions of people who play games as part of a normal, healthy lifestyle.
It also assumes that gaming is a cause rather than a symptom of people’s problems, which may not be the case. In a study published in Clinical Psychological Science in August, Przybylski and Netta Weinstein at the University of Cardiff, UK, looked at data from more than 2,000 adolescents and their caregivers and found that people with gaming problems are likely to have underlying psychological or social issues. The pair do not believe there is enough evidence for gaming addiction to be considered a clinical disorder in its own right.
Still, those who push for a formal classification argue that it allows people who do have a problem to get access to treatment. Clinicians will be aware of the disorder, and insurance companies will be more receptive to covering medical bills.
“Most of the people who have trouble with alcohol are not alcoholics,” Jennings says. “It’s the same with gaming. Kids can get into all kinds of trouble with it, but that doesn’t mean they’ve developed an addiction. On the flip side, you risk telling people with an actual addiction problem that cutting down might help, instead of giving them the actual support they need.”
Jennings first cut out the more obvious traps, such as multiplayer online role-playing games, which offer vibrant virtual worlds and never-ending adventure. For a while he restricted himself to online bridge. But even that spiraled out of control. So he disconnected and tried playing offline instead. He thought maybe by not playing with other people, he could make the games less compelling. But it didn’t really matter what he played. “I had a period of time where I was compulsively playing Minesweeper on my computer,” he says.
He tried taking time out. After talking to his AA sponsor, Jennings quit playing for a couple of weeks and convinced himself he’d simply had a temporary fixation. He started thinking it would be okay to play again. “That thought recurred over and over again like an itch until finally I scratched it,” he says.
That was when his sponsor told him to look online for a recovery program specifically for gaming. What he found instead were forums filled with gamers and their families going through exactly what he was. With the online support of other gamers, Jennings muddled through a few years of on-again-off-again gaming until the relapsing became worse and worse. “I finally accepted the seriousness of my situation and just completely stopped,” he says. That was in 2012. He has not played a video game of any kind in seven years.
In some ways, Jennings found it harder to quit games than alcohol, mainly because of the lack of support. Drawing on his experiences with AA, he organized daily meetups on a problem gaming forum. Then the group started talking via Skype.
But even that is not enough, he says. Many alcohol or drug addicts need to go to recovery meetings every day and talk to their sponsors on the phone day and night. He says he owes his recovery from gaming addiction to the fact that he was still part of the AA program. If people have not dealt with another addiction, they struggle a lot more with their gaming because they’re not having face-to-face meetings in that other group, he says.
So he set up Computer Gaming Addicts Anonymous (CGAA). New members are expected to commit to quitting games entirely. The group meets mostly via conference calls, but people try to set up in-person meetings if they can. CGAA runs an email list for around 200 cities, alerting people to groups in their area. Yet with only a few hundred members in total, it is hard to arrange meetups even in large cities like New York. Usually only three to five people turn up, says Jennings. But the word is slowly spreading.
One of the London members, Adrian Williams, says he tried other online groups before but never got enough support. Like Jennings, he says the only thing that works for him is complete abstention, which is hard. “Trying to figure out what you can get away with, even in the midst of desperation, is the nature of addiction,” he says. “I have played games that I didn’t even like until I became so infuriated I wanted to break things—and kept on playing.” It helps when someone has your back.
CGAA is not alone in demanding that members give up gaming. In the US, private clinics have been treating patients—typically young men in their teens or 20s, many sent there by desperate parents—for the last few years. ReSTART in Washington state offers a digital detox cum boot camp, putting its patients through forest hikes, gym classes, and long hours of downtime in which they slowly learn how to be device-free. A group called GameQuitters, run by problem gamer turned motivational speaker Cam Adair, recommends The Edge, a rehabilitation center in northern Thailand. Guests are offered treatment that draws on CBT and the methodology of Alcoholics Anonymous.
The GameQuitters site invites gamers and their loved ones to take a quiz with nine questions taken from a list that the American Psychiatric Association suggests can be used to screen for video-game addiction. Sample question: “Do you feel restless, irritable, moody, angry, anxious, bored, or sad when you try to cut down or stop gaming, or when you are unable to play?” Once your answers are submitted, you are told that any score over five is concerning and should be addressed immediately.
Yet as Jennings and Williams admit, pulling the plug entirely is a last resort. The vast majority of players seeking help online are simply looking for a better play-life balance.
Alok Kanojia nearly had to drop out of the University of Texas at Austin because he was playing video games through the night and sleeping through classes in the day. After two years of college, his time with Super Mario Bros and The Legend of Zelda had left him with a GPA of less than 2.0. “A big part of my memory of that time was that I would play to the point of exhaustion,” he says. “I had some vague idea that I wanted to be a doctor but knew that that future was slipping away.”
In 2003, aged 21, he decided to become a monk and went to live in India. For the next six years he moved back and forth between the US and India, spending summers studying meditation and yoga, which he says gave him the self-awareness and self-control he needed to get his career back on track.
With hard work to catch up on credits, and a little luck—including the support of an advisor who was studying tai chi and supported his interest in combining neuroscience with meditation—he eventually made it to medical school at Tufts in 2010. He then continued to a residency at McLean Hospital (one of the world’s preeminent psychiatric facilities) and a fellowship at Harvard Medical School, where he still teaches.
Kanojia never quit playing video games—he continued to spend lots of time on massive multiplayer online games like StarCraft, Diablo, and World of Warcraft. He managed to balance his gaming with a rising career. But he realized that many of his gaming playmates were still stuck—now in their 30s but living with their parents and earning no money. He started chatting with them and other players he met online, using his psychiatry skills to help them out. He talked to people not only from all over the US and Europe but from Pakistan, Saudi Arabia, East Asia. “I would talk to one gamer and then they would send me someone else,” he says.
As a clinician, Kanojia was torn. He could not possibly help all these people, yet he knew they did not have many other options. Most weren’t looking to enter rehab or start a 12-step program. But they did have problems.
His solution was Healthy Gamer, a startup he cofounded earlier this year with his wife, who runs the business. Their aim is to help people by selling videos and access to an online support community. The key insight shaping Kanojia’s approach is that the pull of video games is different for different people. Healthy Gamer starts by getting people to understand what it is about games that has them hooked and encourage them to find ways to get that from a different source. In Kanojia’s case, he’d been bullied at school and was failing at college—games had provided a sense of achievement he wasn’t getting elsewhere. He was good at games and not much else.
People who sink hours into a multiplayer online role-playing game like World of Warcraft do so in part because it becomes their social life; players they meet in the game become friends. They log on to hang out—playing joint missions, racking up points, or just goofing off. Some build close relationships and even marry people they met in a game. That offer of genuine friendship is a big draw for many players, especially those who lack such friendships offline.
“Every human being needs connection, and video games give us that,” Kanojia says. “They also give us challenge, a sense of mastery, a sense of safety, and so on.” Online shooters like Fortnite or Call of Duty demand extreme skill, a cool head, and twitch-perfect reflexes to reach the top. For players who—for whatever reasons—find it hard to meet the same needs outside a game, it is easy to see how the hobby can begin to eclipse activities that are deemed more healthy.
Kanojia notes that researchers are starting to identify different gamer personality types. For example, the BrainHex model, developed by Lennart Nacke at the University of Waterloo in Canada and his colleagues, names seven types: achiever, conqueror, daredevil, mastermind, seeker, socializer, and survivor. The classifications, which support the idea that people play for different reasons, could help individual players understand what it is about games that most attracts them.
After Kanojia started a discussion on the online forum Reddit about gaming addiction, he ended up speaking with a mother in Iran who was worried about her son. She had locked the power cable to his games console in a cupboard but had discovered that he was sneaking downstairs after everyone was asleep, picking the lock, taking the cord out, and playing PlayStation until five in the morning. Then he’d lock the cable up again and go to sleep.
Kanojia avoids models of addiction based on substance use because they assume there is a specific agent—whether alcohol or another drug—that has a specific effect on the brain. “That’s very different from video games,” he says. “Video games can affect so many different parts of the brain, and affect them much more subtly.” There may be some parallels with gambling insofar as it involves behavioral rather than chemical dependencies, but even gambling is a poor stand-in, he says. Still, gambling might explain some of the allure of some types of games. Puzzle games like the popular Candy Crush, for instance, mix an element of luck with the aesthetics of slot machines. They can activate compulsive loops in the mind akin to those implicated in gambling.
Some games explicitly include gambling-like mechanisms, such as “loot boxes” that, when opened, randomly reward the gamer with previously hidden items, some valuable and some not so valuable. A study published this year in PLOS One argues that people with a history of gambling problems are more likely to spend money on such loot boxes than they are on other items sold in games, which suggests that they can tap into existing gambling habits.
The Dutch and Belgian governments have ruled that loot boxes are subject to gambling laws. In response, a handful of games—including popular first-person shooter Counter Strike: Global Offensive and Rocket League, a kind of virtual soccer played with off-road vehicles—have disabled the feature for players in those countries. But gambling-like behavior is only part of the picture. The sheer variety of experiences that draws players into games and keeps them there cannot be reduced to a single effect.
Jennings and Kanojia had to find their own ways out. Both recognized they were playing video games too much, and both managed to do something about it. Yet they came to very different conclusions: Jennings felt he had to quit gaming entirely, while Kanojia did not. Now they each use their different experiences to help others. It is too early to say whether one approach is better than the other—or whether either is better than the CBT-inspired approaches offered by a handful of clinics
For Kanojia, the growing mainstream recognition of gaming disorders is welcome. He hopes it will encourage more open discussion and make people dealing with gaming-related problems feel less isolated. Jennings now has a young son, and he thinks a lot about how to protect him. “I don’t want my son to fall into addiction,” he says. But he is not shielding him from games: “I believe the answer to that is him having as good a childhood as possible. And having good relationships and a good understanding of how to deal with stress. Those are the things that will prevent him from developing a disorder.”
The approach Jennings takes with his son reflects the rich and complex relationships people have with games. Some people may simply be more vulnerable to addictive behaviors. Their problems are rightly starting to be recognized. But there are millions of people who perhaps play more than they should—staying up too late, skipping classes—but are not addicted. Labeling them with a clinical disorder is not helpful.
Anyone debating video-game addiction needs to step back and ask what games are for. Games are, by design, about escaping from the world for a time, among other purposes. But what if the escape becomes too good? Ultimately, as with depression, alcoholism, and other maladies, the questions around video-game disorder are questions about how society chooses to draw lines between pathology and the ordinary varieties of human experience. The answers, of necessity contingent and changing as video games themselves change, inform the demands we make of the games we play and the people who make them.
This piece originally mischaracterized the location of The Edge, a rehabilitation center in northern Thailand, as "beachfront". It is about 180 miles from the nearest beach. We regret the error.
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