Introduction
Video games have become a widespread form of entertainment for people of all ages. What began as a niche hobby has evolved into a major industry that generates billions in annual revenue. As gaming has grown in popularity, so too have concerns over excessive or harmful patterns of gameplay. Some experts argue that for a small subset of players, video gaming can become addictive in a way akin to substance abuse disorders. The concept of video game addiction (VGA) remains controversial within the scientific community due to ongoing debates around its classification, prevalence rates, and the most appropriate treatment approaches. This paper aims to synthesize the current research on VGA by reviewing studies on its diagnostic criteria, associated psychological and physiological correlates, potential risk factors for developing problems with video games, and treatments that have shown promise according to clinical trials and case studies. Overall, while more work is still needed, the accumulation of research over the past two decades provides substantial evidence that VGA should be recognized as a legitimate behavioral addiction.
Literature Review
Diagnostic Criteria
One of the major obstacles inhibiting clinical and research progress regarding VGA has been the lack of a standardized and universally accepted set of diagnostic criteria. Several proposed frameworks have emerged that aim to operationalize VGA in a way that parallels established addictive disorders like gambling disorder or substance use disorder. The diagnostic model that has received the most empirical support is taken from section III of the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) criteria for gambling disorder. According to Griffiths and colleagues (2016), their proposed criteria for VGA would require five or more of the following symptoms over a 12-month period:
Tolerance, defined by the need to spend increasing amounts of time engaged in video games.
Withdrawal, including feelings of irritability, anxiety, and difficulty concentrating when attempting to cut back or stop gaming.
Loss of interest in or reduction of participation in other hobbies, social activities, or entertainment as a result of, and with the exception of, video game use.
Continued excessive gaming despite knowledge of issues it causes or exacerbates, such as social or interpersonal problems.
Giving up or reducing other important life activities or obligations in favor of gaming.
Gaming as a way to escape or relieve uncomfortable feelings such as guilt, anxiety, helplessness, or depression.
Deceiving family members or others regarding the extent of gaming involvement.
Attempting unsuccessfully to reduce gaming.
Risking or losing a significant relationship, job, educational or career opportunity because of gaming.
While more validation is still warranted, empirical studies have found this criteria set shows good discriminant and predictive validity in distinguishing problematic from non-problematic gamers based on validated measures of addiction and psychiatric symptoms.
Psychological Correlates
Gaming-related problems appear to be strongly associated with several psychological factors found in substance and non-substance addictions alike. According to meta-analyses, hazardous and addictive levels of gaming are linked to higher levels of depression, anxiety, loneliness, impulsivity, and difficulty coping with stress or negative emotions (Gentile et al., 2011; Khazaal et al., 2014). Gaming may serve as a maladaptive coping strategy to help regulate or distract oneself from underlying psychiatric vulnerabilities or interpersonal/environmental stressors. Persistent gaming appears to partially fulfill psychological needs for achievement, immersion, escapism, competency, and social interaction in individuals prone to disordered use.
The psychological mechanisms maintaining VGA are thought to involve classical and operant conditioning principles similar to other addictions. Positive reinforcement is derived from gaming through rewards of in-game achievements, levels advanced, or socializing. Playing also serves to negatively reinforce avoidance of unpleasant internal states. Over time, gaming behaviors become conditioned and automated through repetitive associations between gaming cues, the activity itself, and gratification obtained. This conditioning process contributes to loss of control as gaming increasingly dominates one’s thoughts and activities. Operant reinforcement schedules further entrench problematic patterns as intermittent rewards are delivered for repeated gameplay (King et al., 2013).
Physiological Correlates
Neurobiological studies additionally point to VGA sharing commonalities with substance use disorders at the neuronal level. Research indicates addicted gamers experience symptoms of withdrawal resembling drug craving when abruptly separating from gaming. During these states, abnormal brain activity and neurochemistry has been observed in areas implicated in addiction such as the mesocorticolimbic dopamine pathway. Structural and functional MRI studies detect volumetric or activation differences within prefrontal-striatal networks responsible for impulse control, reward processing, and habit formation in patients meeting DSM-5 VGA criteria compared to healthy controls (Han et al., 2010; Zhou et al., 2017).
Biomarkers also reflect VGA’s potential addiction-like etiology. Levels of stress and withdrawal-associated hormones such as cortisol are similarly dysregulated during attempts to reduce problematic play (Bonnaire & Phan, 2017). Heart rate variability assessments further parallel findings in substance use disorders, detecting decreased autonomic flexibility characteristic of addiction phenotypes. This convergence of psychological and physiological correlates provides compelling evidence VGA affects similar neurobiological mechanisms subserving other process addictions and substance dependencies.
Risk Factors
No single factor unequivocally determines if an individual will develop VGA. Research identifies certain psychosocial vulnerabilities that might interact with genetics and environmental exposures to increase susceptibility. Beyond simply playing games excessively, clinical interviews and surveys with adolescents and adults highlight specific risk factors:
Male gender. Prevalence studies consistently find males comprise approximately 75-80% of pathological cases. Rates in females appear to be rising, especially among adolescent and college-aged groups (Mihara & Higuchi, 2017).
Younger age. Onset most commonly occurs during late childhood through early adulthood, ages 8-25 years old. Adolescence in particular presents a heightened period of vulnerability to addictive behaviors due to ongoing brain maturation (Desai et al., 2010).
Psychiatric co-morbidity. Clinical VGA samples manifest high rates of concurrent depression, anxiety, ADHD, ASD, and conduct/impulse disorders compared to gamers without compulsive patterns of play (Bavelier et al., 2012).
Maladaptive coping styles. Individuals relying on gaming to cope with stress, emotional problems, low self-esteem or social deficits exhibit increased risk for developing addictive habits over time (Kardefelt-Winther, 2014b).
Peer and family influences. Associating with others who engage in addictive or problematic gaming themselves can strengthen motivation and learning of disordered behaviors through social modeling effects (Allison et al., 2006). Permissive parenting practices or lack of supervision concerning screen time consumption additionally correlate with children developing VGA (Gentile, 2009).
Treatments
A lack of empirically-supported treatments specifically for VGA has hampered clinical management. Multiple therapies adapted from addiction medicine indicate promise and merit additional controlled trials to evaluate their efficacy. Cognitive-behavioral therapy (CBT) appears most frequently trialed and consists of components aimed at addressing the maintaining cognitions, behaviors and contextual factors upholding problematic play (King et al., 2013).
Motivational enhancement techniques assist patients in recognizing gaming-related harms while strengthening intrinsic motivation for change. Exposure-based strategies systematically confront gaming-related internal and external triggers to mitigate conditioning. Operant-based principles focus on developing alternate rewarding activities to gradually replace gaming habits. Effective models incorporate psychoeducation on VGA’s addiction model, goal setting/monitoring of gaming behaviors/cues, coping skills training, functional analysis of triggers, family involvement for support, and relapse prevention plans.
Pharmacotherapy research shows mixed but potentially beneficial effects for certain drugs. Selective serotonin reuptake inhibitors (SSRIs) seem well-tolerated in VGA treatment based on case reports citing reduction of co-occurring psychiatric conditions and addictive symptoms (Han et al., 2009). More rigorous trials comparing medication management alone or combined with psychosocial approaches are needed before recommending their routine use. Additionally, residential programs grounded in 12-step philosophies adapted for technology/internet addiction plus mutual assistance groups offer alternatives when VGA causes major life disruptions.
Conclusion
Despite being a relatively new area of clinical and scientific inquiry, accumulating evidence demonstrates that VGA shares ample similarities in characteristics and underpinnings with established addictive disorders. Both psychological and neurobiological research provides insights into the maintenance and risk mechanisms of problematic play. Promising treatments focused on operant conditioning principles and tailored adaptation of substance abuse therapies warrant further study. While prevalence remains difficult to approximate, problematic use resulting in significant functional impairment impacts a non-trivial minority segment of avid gamers. Overall, results justify recognizing VGA as a behavioral addiction worthy of increased professional concern and resources devoted to improved assessment and management protocols. More work is still needed to refine diagnostic criteria, elucidate etiology, disseminate effective interventions, and implement clinical guidelines. The last two decades have progressed the field tremendously in demonstrating the validity and importance of properly addressing hazardous video game use as a legitimate public health issue.
Andrew Stroud