Gaming to the exclusion of other life activities is when it gets problematic.
This summer, the WHO issued a new mental health classification: Gaming Disorder. But what constitutes too much video gaming?
Charlie Bracke, 30, can’t remember when he started playing video games, maybe at 3 or 4, but he does recall hitting his first 12-hour gaming day at age 9. Throughout high school, he often played several hours a day, but he was a straight-A student, too. When Bracke headed off to study business management at Indiana University, that’s when his video gaming kicked into high gear. He played over 70 hours a week and eventually dropped out. From there, gaming consumed his life. He lost his job and disconnected with friends and family. Bracke quit gaming cold turkey twice, but never lasted more than a month. He knew he couldn’t stop on his own, but finding help for his gaming problem wasn’t easy.
In June, the World Health Organization, or WHO, classified Bracke’s problem as a real mental health condition — Gaming Disorder — an addiction to playing video games. Like alcohol and gambling addictions, to have a gaming disorder means the behavior is pathological. The player’s gaming is out of control, and he continues to play despite significant, negative consequences to his relationships and life.
It’s hard to pin down exactly how widespread gaming addiction is. What to call it, how to define it, and how to measure it vary. The prevalence of gaming disorder ranges between 1 and 10 percent worldwide, depending on the study design and country. But a growing body of research points to the fact that heavy video game use in some can severely disrupt their lives. A survey of American youth, led by Douglas Gentile, Ph.D., a professor of psychology at Iowa State University, found that nearly one out of 10 children 8 to 18 years of age (or 8.5 percent) show signs of video game addiction.
Gentile has been researching video games for almost 20 years. When he started, parents were anxiously talking about their sons’ excessive video game play and calling it an addiction. Back then, Gentile wasn’t convinced. “I thought my first study would show that video game overuse did not meet the criteria for an addiction,” he said. He assumed that parents called it “addiction” because they didn’t understand why their children spent so much time playing. But his research proved him wrong. A small percentage of the gamers he studied qualified as addicted — their gaming made them dysfunctional and seriously damaged their lives.
When Bracke arrived on campus, Call of Duty, the multiplayer action video game that simulates combat in World War II, was the game of choice in the dorm. Bracke and his friends, each with his own gaming console in his own room, played “together,” leaving their doors open and yelling out into the hall to each other. For Bracke, gaming was a full-time job; he played 40 to 45 hours a week. His grades started to slip. Early in his sophomore year, his grandmother passed away. He got depressed and turned to more gaming. “I didn’t know how to cope with the death. As long as I was gaming, I didn’t have to think about it,” said Bracke. Now he was playing 60 hours a week. He felt like crap. It was hard to get out of bed, but he was still able to grab the game console. He often skipped classes and failed a couple. By his junior year, his video gaming became a vicious cycle: game, skip class, fall behind, feel ashamed, game, avoid feelings, skip class, and fail. At that point, Bracke dropped out.
College provides the perfect environment for a video game addiction to flourish and an academic career to decline, said Gentile. “You give an 18-year-old boy who loves video games high-speed internet access 24/7, and no constraints from mom or dad. He games all night and sleeps through class.” A gamer might go see a college counselor when his grades dip, he added. “But he presents with an academic problem, failing grades. He doesn’t present with a gaming problem. He probably doesn’t mention it.” Gentile’s point: “We don’t know how and when to screen for problem gaming.”
Bracke saw a therapist while in college but considered his nonstop gaming a side effect. “I blamed my poor grades and dropping out on depression,” he said. “But in truth, the gaming fueled the depression. I used gaming to manage any stress I faced.”
The WHO’s criteria for a Gaming Disorder sound a lot like the definition for alcohol and drug addiction. One, the gamer is unable to control when, where, how often, and how long he plays. Two, gaming takes priority over everything in his life. And last, he continues gaming no matter what happens as a result. And this pattern is present for at least a year.
The signs and symptoms of problematic gaming reflect the sedentary, solitary nature of the disorder. The gamer skips meals and eats poorly, which can lead to significant weight gain or loss. His mood is labile. He avoids friends and family and lies about how much he plays. His academic or work performance suffers. He rarely sleeps and never sleeps long enough.
Dr. Petra Steinbuchel, medical director of psychiatry and mental health and child development at Oakland’s UCSF Benioff Children’s Hospital, thinks the WHO’s new guideline for a Gaming Disorder is a good starting point. “It validates that gaming overuse exists and will serve as basis for the problem to get studied, providing the research needed to bring a clearer definition to who’s at risk and how best to intervene,” she said.
While the WHO provides an international framework for the problem, the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, or DSM — the definitive guide for what doctors and insurers in the United States use to define mental health conditions and what to cover — has yet to reach the same conclusion. In the current DSM-V, gambling disorder was the first and only behavioral addiction to be included. Gaming overuse was considered for inclusion but instead identified as an area worthy of more study.
“It’s a chicken and egg problem,” said Gentile. “Video game addiction is only just beginning to be identified as a real problem.” Updated versions of the DSM are released about every 10 years, so it could be a while before gaming disorder is fully recognized by the medical community and treatment reimbursed by insurers. Without a diagnosis and a billing code, it makes it difficult for doctors and therapists to effectively treat the disorder and leaves problem gamers like Bracke with few options.
The growing attraction to video gaming is undeniable. Over 90 percent of children and teens in the United States play video games and spend a lot of time doing it. Why? It’s fun. Gaming elevates dopamine levels, a neurotransmitter tied to pleasure. It feels good.
Fortnite Battle Royale, the gaming world’s latest craze, is a prime example of the ubiquitous and seductive nature of video games. With 125 million gamers playing Fortnite worldwide, Bloomberg recently reported that the game will generate $2 billion in 2018. You can play Fortnite for free with up to 100 virtual competitors. Survival is the goal as players fly and run through the colorful, storm-ravaged game space shooting rapid fire in a fight-to-the-death battle. The game’s revenue comes from the virtual dollars players buy to accessorize with outfits (called skins), dances, and special missions to up their game. And some parents now support their young players with Fortnite coaching sessions to give them an edge.
Oakland’s gaming environment has expanded, too. The city is home to several commercial video game developers as well as the Museum of Art and Digital Entertainment, or The MADE — a one-of-a kind video game museum with playable exhibits and classes aimed at inspiring the next generation of game developers. The MADE, a not-for-profit, has taught 1,200 students how to create games and expects over 15,000 visitors to the museum this year. And recently a 16,000-square-foot eSports arena opened near Oakland’s Jack London Square. For $10 a day or a monthly fee, gamers there can play side by side and watch others compete in video game tournaments.
Video gaming isn’t all bad. There can be a good side to gaming in balance and moderation, said Steinbuchel. “Certain games have a positive impact on executive function and spatial planning, and there is some limited evidence that video games can help with Attention Deficit Hyperactivity Disorder, or ADHD,” she said. Developing an addiction is person dependent, Steinbuchel noted. Gaming to the exclusion of other life activities is when it gets problematic.
Richard Freed, Ph.D., an adolescent psychologist in Walnut Creek, said it’s not unusual for him to be asked to see a teenage boy after he’s put his fist through the wall when a parent tells him to stop playing video games. Freed started examining the impact of technology on kids 15 years ago and found a recurrent pattern. Boys in the third to fourth grades throw tantrums when asked to stop gaming. Parents fight to set limits around the kids’ video game play, but it’s an ongoing battle. By high school, gaming has taken over their children’s lives — high-functioning, bright kids who then underperform, struggle to graduate, and forgo college.
The scenario of a young man living on his parents’ couch, gaming around the clock, is a real-world issue happening far too often, said Freed. “These young men get down on themselves because they see that their lives aren’t progressing. They aren’t taking real steps towards future education,” he added. But getting a gamer to recognize his excessive play time as problematic can be difficult. Like other addictions, excessive gaming is often paired with unhealthy denial, Freed explained. When faced with limiting his game time, the problem gamer often reverts to denying he has a problem.
Berkeley psychotherapist Jason Brand also specializes in helping families and young people manage the digital world. Ten percent of his clients see him specifically for problems related to the internet, social media, or video game use. And he has a subset of male clients, 25 to 35 years old, who have failed to successfully launch into adulthood because their lives revolve around playing video games and smoking a lot of pot.
“The internet is a place where young people can get stuck in their development, where they can hide out from the hard work of having to grow up.” His 20something clients who game excessively have similar traits. They are uniformly male. (Technology troubles in his young female clients tend to center around smartphone use and social media missteps.) These are really smart, young men said Brand. Some have undiagnosed depression. They are shy. They avoid direct eye contact and don’t go out in the world very often.
“A big part of the appeal of gaming is the escape from the social anxiety that these young men deal with,” said Brand. “I like to say that these guys ‘act in’ versus ‘act out.’ When a teenager is trying to figure out his identity and he ‘acts out,’ he’s out in the world.” In contrast, these men seek an identity playing video games alone. They have challenges with intimate relationships as well; their sexuality is a major component of the self that needs to be grown into. Brand finds excessive video gaming and frequent marijuana use common, both the pot and the video games protecting the gamer from the overwhelming feelings of being out in the world.
What makes a video game so good that you can’t stop playing? Ultima Online was one of the games that sucked Bracke in. The massively multiplayer online game, known as an MMO, created a medieval fantasy world where huge numbers of players could interact. “I was absolutely fascinated,” said Bracke. “I could be a blacksmith, a wizard, a knight in shining armor, a thief, a murderer, or a fisherman. I wanted to experience everything the game could offer.”
Part of the pull of the multiplayer online format is being part of the crowd. Although he doesn’t look at it this way now, Bracke said his online friends in the video game world felt like real friends. “Those virtual contacts can have a lot of the characteristics of a real relationship,” said Brand, “but so much happens in our face-to-face interactions and time together, it just can’t be replicated with technology.”
“The most addictive games employ well-established psychological principles,” explained Gentile. The games have no end and encourage online socializing. Plus video games, like gambling, have a variable reinforcement schedule, which means you can’t tell when you will win. Not knowing keeps you playing. And there is the social pressure associated with the MMO games played around the world, around the clock. The game is being played even if you are not — leaving gamers with FOMO, or the fear of missing out.
“These games are engineered by experts to keep your kids playing,” said Freed. Psychologists, neuroscientists, and behavioral scientists use their knowledge of psychology to take advantage of kids’ vulnerabilities: the desire for social acceptance, the fear of rejection, the need to achieve goals, he added. Freed pointed to the concept of persuasive technology — the way video games are configured to create a digital environment to fulfill these basic needs in lieu of the real world.
Teenage boys are developmentally driven to be good at things, to “gain competencies” in psychology parlance, said Freed. Video games work on a reward system. Players pursue points and levels. The rewards come easy at first. The player improves, gets rewarded, and becomes more competent. The game difficulty escalates from there, and gamers get hooked.
At the height of Bracke’s college gaming days, he was one of the top 10 in the world at Guitar Hero, where players use a guitar-shaped game controller to simulate playing rock songs. “I was really good at it,” said Bracke, although he couldn’t read music or play an actual guitar.
Freed has called on his colleagues to address their role in the problem. He has aligned with the Children’s Screen Time Action Network, a coalition dedicated to reducing the amount of time kids spend in front of digital devices, and wants the American Psychology Association to take a stand against psychologists’ involvement in the development of video games that hook kids.
Still not all clinicians are comfortable with calling a gaming disorder an addiction.
Steinbuchel cautioned that an overly inclusive definition for a gaming disorder can be misinterpreted, leaving the door open for doctors and parents to call moderate video game play that is not necessarily causing impairment an addiction because they are not comfortable with it.
Jason Brand doesn’t think problematic gaming can fit neatly in the addiction category, that the definition is too rigid. “I try to not use the word addiction. I’m listening for something else. Why is this young person hiding out in this area? Why did he choose to overuse technology to the exclusion of all other the areas of his life?” He knows video games today are very compelling, but he believes families can set up sensible guidelines around it and suggests starting young. Brand will be doing a series of talks in preschools through out the East Bay in the fall geared toward helping families build a solid foundation with technology.
Freed, on the other hand, feels quite certain gaming can be an addiction. “I believe the video game disorder comes first, and the mental health consequences, like depression, follow,” he said. Freed again pointed to brain science. “A study conducted at Stanford demonstrated that the part of the brain associated with reward and addiction is much more activated in men than in women when playing video games,” said Freed. This may show why young men are more likely to get hooked on gaming.
Although Gentile, the researcher, agreed that gaming can lead to addiction, he doesn’t believe the game is the root of the problem. “Video games aren’t like a drug. Most players don’t get addicted,” said Gentile. “It’s an impulse control problem and comes down to how the individual’s brain interacts with a reward system. Games include features that work like gambling,” he added.
How much video gaming is too much? East Bay resident Alex Rudman (not his real name), 31, has been an intense video gamer since his high school days when he logged six to seven hours a day playing Star Craft, a multiplayer, tactical military game set in the future. But he has never considered himself addicted to video gaming. And he bristles at the stereotype of the young male gamer nerding out for hours on end in his mom’s basement. “I’m not that.”
For Rudman, gaming is all about the immersion experience. Now his games of choice are action role-playing games like the series Elder Scrolls, set in a magical, fantasy world with gladiators and dragons, elves, and orcs. He built his own PC to enhance the visuals, making the colors more vibrant, the edges sharper, and the environment more lifelike. “These games provide a story rich universe, so many places to explore. You can plot your future as whoever you opt to be.”
“There was a period when I thought my gaming might be problematic,” said Rudman. In his early and mid-20s, school held less of a priority. He chugged along with a low-paying job and played video games whenever he could. Rudman recognized that his gaming took him away from face-to-face interactions and kept him from doing things outside with others like hiking in Tilden Park. He asked himself if he could live as an adult whose primary hobby was video gaming, and he felt “tentative” about that. “But I never felt like I needed help to get away from gaming.” (Although he said he has witnessed other gamers who have.) At 28, he decided to go back to school to complete his undergraduate degree. He attributed that decision to growing up and setting new goals. “I couldn’t have the lifestyle I wanted without a better career, and that required more school,” said Rudman. In turn his gaming life has changed dramatically. Between school and working 50 hours a week, he just doesn’t have much time to game these days.
But for Bracke it was different. After leaving school he went through a phase during which he described himself as a functional gaming addict. He worked at Pizza Hut and did well. He was promoted several times and was poised to run his own restaurant. “But outside of work, my life was a shambles. There was nothing but gaming,” said Bracke. Taking a job in real estate pushed his gaming to dysfunction. The flexibility of an independent contractor’s schedule allowed his video game habit to swell to 16 hours a day. He got fired and kept playing. He went days without leaving the house. He barely showered or shaved. Finally he told his family that he needed help.
Eventually, Bracke found his way to reSTART. In Fall City, Wash., a rural community east of Seattle, reSTART is the first and one of only a few residential treatment programs in the country focused on problematic digital media use. “There is a lot of denial about this as problem because playing video games is so culturally normative,” said Hilarie Cash, Ph.D., co-founder of the program. Over the past 10 years, reSTART has treated over 250 clients, almost all young men, 18 to 30 years old, with serious internet Gaming Disorder from all over. ReSTART takes a wholistic, addiction-model approach. Clients abstain completely from video games, the internet, and cellphones, and participate in a 12-step program like Alcoholics Anonymous.
Bracke spent almost two months at reSTART’s residential facility and 10 months in the outpatient program — all completely tech-free. “It was intimidating. I had to give up my identity, my life as a gamer,” he said. Bracke got a sponsor and kept an open mind. At one AA meeting, he had a breakthrough. “ I realized that I was just like everyone in that room. Gaming was my drug of choice, and I played for the same reasons others use drugs, alcohol, or other behaviors, to slow things down, to avoid, to forget.”
ReSTART is a private-pay facility and like any long-term health care, it’s expensive. “Right now there is no insurance reimbursement for treating gaming addiction,” said Cash. The cost of the initial seven-week residential phase of the reSTART program is $30,000; the outpatient program and housing runs $7,000 a month. The treatment was a financial burden on Bracke’s family, which weighed heavily on him during and after treatment, he said.
The younger a child gets exposed to excessive screen time the more problematic the use can be, like getting set in our ways as we age,” said Steinbuchel. She works with families to help children overcome what underlies the excessive video game use, which might be anxiety, ADHD, or depression. Success depends on setting clear limits, structuring video game time as a reward, and finding sources to promote self-esteem in the child outside of gaming, she said.
Video game overuse presents across a spectrum, and there are different ways to manage the problem, pointed out Brand. “It doesn’t always require detox and residential treatment. There are alternative life paths for the young person who gets stuck,” he said. Brand finds the majority of his patients ease out of excessive gaming as they open themselves up to developing and maturing.
Both Freed and Cash think the WHO’s new guideline is having a positive impact. “The World Health Organization’s recognition of Gaming Disorder as an addiction and official diagnosis is already having a profound effect, revealing to the world what researchers are finding about the addictive pull of today’s video and computer games,” said Freed.
For Rudman, he has concluded that playing video games is one of his most favorite things, and he plans to make space for it. He is set to graduate soon, and he’s seeking a career with a rhythm that allows him more time to game than he has now, even all day on a weekend.
Two years after treatment, Bracke’s technology “restart” appears to have been a success. He works full time and takes classes toward a degree in accounting. Bracke said he still has cravings to game but he doesn’t touch it. “I won’t even put Angry Birds or Soduko on my phone.”