Remember June 18. The day online gaming suddenly took an ominous turn.

It’s official. The World Health Organization is now classify gaming disorder—an addiction to playing video games—as a formally recognized mental health condition.

Since introduction of the “World Wide Web” in 1990 the availability and use of the Internet and digital technology has increased considerably throughout the world. The Internet is now as ubiquitous to our lives as Starbucks and yoga pants worn as street wear.

Use of the Internet, computers, smartphones and other electronic devices has dramatically increased over recent decades, and this increase is associated not only increased social connectedness, more shared knowledge and debate, and a multitude of other benefits to users and societies, but also with documented cases of excessive use which often has negative health consequences.

The rising popularity of the Internet and associated electronic devices has seen a commensurate increase in clinical, research, and media focus on the social, family, education, productivity, physical and psychological problems associated with excessive use.

Given that the patterns and extent of use vary widely (at individual and population levels), there is continued debate on how best to define such excessive use from a public health perspective. To this end, on June 18, online gaming suddenly took an ominous turn—the World Health Organization approved the adoption of a formalized category of gaming addiction to the International Classification of Diseases Manual (the “ICD-11”). Specifically:

“Gaming disorder, with its online and offline variants is a clinically recognizable and clinically significant syndrome, when the pattern of gaming behaviour is of such a nature and intensity that it results in marked distress or significant impairment in personal, family, social, educational or occupational functioning.” WHO.

This development is not surprising and has been years in the making. In 2013 “Internet Gaming Disorder” was included in the classification of mental and behavioural disorders of the American Psychiatric Association (DSM-5) as a condition for further study. Since 2014, the WHO has started activities relating to the public health implications of excessive use of the Internet, computers, smartphones and similar electronic devices in response to concerns expressed by professional groups, WHO collaborating centres, academics and clinicians about associated health consequences.

What does gaming addiction look like?

The phenomenology and clinical course of gaming addiction is not yet well described and understood. Currently, the concept of “behavioural addiction associated with excessive use of the Internet, computers, smartphones and similar electronic devices” is typically based on key features of substance use disorders. Hence, one of the many descriptions of behavioural addictions is an irresistible urge, impulse or drive to repeatedly engage in an action and an inability to reduce or cease this behaviour (loss of control) despite serious negative consequences to the person’s physical, mental, social and/or financial well-being.

In more detail, here are the behaviours the WHO would list as characteristic of gaming disorder:

  • Impaired control over the onset, frequency, intensity, duration, termination, or context of gaming.
  • Increasing priority given to gaming to the extent that gaming takes precedence over other life interests and daily activities.
  • The continuation or escalation of gaming despite the occurrence of negative consequences.
  • Withdrawal, including feelings of anger, tension, anxiety and/or depression.
  • Tolerance, including the need for more hours of use.
  • Repercussions and conflict. Including self-imposed social isolation and disintegration, lying, arguing, poor academic and occupational achievement and fatigue.
  • Craving, including urge and obsessions related to online activity.
  • Mood modification, including the use of online activity to cope with the negative emotional states/boredom.

Beyond these psychological-related consequences, gaming addiction can present with physical and social consequences (e.g. insufficient physical activity, unhealthy diet, problems with eyesight or hearing, musculoskeletal problems, sleep deprivation, aggressive behaviour).

What is the prevalence of excessive gaming among teens?

The most active adopters of the Internet and modern technologies have been adolescents and young adults, reflecting the fact that they have grown up in an environment with a well-developed (widely available, high speed) Internet. This has presumably contributed to higher prevalence estimates for internet use disorders among adolescents and young adults.

In Korea internet addiction has been identified as the largest health problem experienced among children and teens.

In China, the highest rate of internet use related problems was 15.6% in the ages of 18-23 (2009 Report on Internet Addiction in Teenagers).

In Switzerland, problematic internet use (defined as Compulsive Internet Use Scale results of 28 points or higher) reaches 6.5% among the 15-19 year age group, but only 0.9% among the general population.

In addition to suspected potential comorbidity with psychiatric conditions (to be determined through more research, but most likely depression), excessive use of the Internet and electronic devices typically presents itself together with other physical and psychosocial problems, e.g., back pain, social withdrawal, sleep deprivation, low self-esteem.

But wait! Before we shun all gamers…

  1. Boundaries between normal and abnormal (or excessive and pathological) use are challenging to define, because behavioural patterns and the extent of use vary widely between individuals and cultures. As well, excessive use of the Internet and other related modern technologies may be a cultural phenomenon for which defining boundaries with normality is culture-, time- and occupation-bound.
  2. In the future, the concept of gaming addiction will need to be increasingly researched and more carefully defined, including potential diagnostic categories and their sub-groups (e.g. variations in exposure, duration, intensity, types and severity of consequences, motivating factors, e.g. social acceptance, boredom, compulsion, dependence).
  3. Epidemiological research in this field is faced with limited and often unreliable data. Prevalence estimates vary up to 90% depending on the country, age group, and epidemiological methods used. As well, estimates vary by geography, with a disproportionate amount of available epidemiological data collected from Asian and Europe.
  4. Easy availability and use of the Internet and electronic devices makes it convenient to collect data. This can result in elevated prevalence estimates.
  5. Absence of longitudinal studies makes it challenging to establish causal relationships, co-relationships and explain natural courses.
  6. Limited qualitative or cross-cultural studies makes it hard to explain the phenomenology.
  7. Whether there are differences between genders (as in substance use disorders) is a matter still up for debate but most studies suggest the incidence of reported problematic gaming behaviour is higher in males than females.
  8. Measurement is a challenge; where data is available, it varies widely in type and quality.
  9. Most epidemiological studies use questionnaires that are not specific enough to identify true prevalence.
  10. There is significant heterogeneity in the definition and naming of conditions associated with excessive use of the Internet and electronic devices.
  11. Many surveys measure screen time, which is technically hard to measure and may not indicate true usage. Additionally, screen time can correlate more clearly with physical than psychological consequences or addiction. Moreover, screen time may be habitual, education- or work-related, and indicate a cultural phenomenon.
  12. Clinical descriptions, diagnostic guidelines and boundaries with “normality” for gaming addiction and other internet use disorders will be important for clarifying the scope of the problem, developing effective interventions, and for building the evidence-base for future knowledge.

Coming In The Next Few Days: Parts II & III.

In part II, I will explore what makes gaming so attractive and addictive, and what, if any good, can be harnessed from gaming activity.

Part III will answer the question “as a parent, what can I do to limit my child and/or teen’s gaming behaviour?