Screenage rampage: What should parents know about videogame playing for children?

Last month, the World Health Organisation (WHO) announced that it was planning to include ‘Gaming Disorder’ (GD) in the latest edition of the International Classification of Diseases. This followed the American Psychiatric Association’s decision to include ‘Internet Gaming Disorder’ in the latest edition of the Diagnostic and Statistical Manual of Mental Disorders in 2013. According to the WHO, an individual with GD is a person who lets playing video games “take precedence over other life interests and daily activities,” resulting in “negative consequences” such as “significant impairment in personal, family, social, educational, occupational or other important areas of functioning.”

I have been researching videogame addiction for nearly 30 years, and during that time I have received many letters, emails, and telephone calls from parents wanting advice concerning videogames. Typical examples include ‘Is my child playing too much?’, ‘Will playing videogames spoil my pupils’ education?’, ‘Are videogames bad for children’s health? and ‘How do I know if a child is spending too long playing videogames?’ To answer these and other questions in a simple and helpful way, I have written this article as a way of disseminating this information quickly and easily.

To begin with parents should begin by finding out what videogames their children are actually playing! Parents might find that some of them contain material that they would prefer them not to be having exposure to. If they have objections to the content of the games they should facilitate discussion with children about this, and if appropriate, have a few rules. A few aims with children should be:

• To help them choose suitable games which are still fun
• To talk with them about the content of the games so that they understand the difference between make-believe and reality
• To discourage solitary game playing
• To guard against obsessive playing
• To follow recommendations on the possible risks outlined by videogame manufacturers
• To ensure that they have plenty of other activities to pursue in their free time besides the playing of videogames

Parents need to remember that in the right context videogames can be educational (helping children to think and learn more quickly), can help raise a child’s self-esteem, and can increase the speed of their reaction times. Parents can also use videogames as a starting point for other activities like painting, drawing, acting or storytelling. All of these things will help a child at school. It needs to be remembered that videogame playing is just one of many activities that a child can do alongside sporting activities, school clubs, reading and watching the television. These can all contribute to a balanced recreational diet.

The most asked question a parent wants answering is ‘How much videogame playing is too much? To help answer this question I devised the following checklist. It is designed to check if a child’s videogame playing is getting out of hand. Ask these simple questions. Does your child:

• Play videogames every day?
• Often play videogames for long periods (e.g., 3 to 6 hours at a time)?
• Play videogames for excitement or ‘buzz’ or as a way of forgetting about other things in their life?
• Get restless, irritable, and moody if they can’t play videogames?
• Sacrifice social and sporting activities to play videogames?
• Play videogames instead of doing their homework?
• Try to cut down the amount of videogame playing but can’t?

If the answer is ‘yes’ to more than four of these questions, then your child may be playing too much. But what can you do if your child is playing videogames too much?

• First of all, check the content of the games. Try and give children games that are educational rather than the violent ones. Parents usually have control over what their child watches on television – videogames should not be any different.
• Secondly, try to encourage video game playing in groups rather than as a solitary activity. This will lead to children talking and working together.
• Thirdly, set time limits on children’s playing time. Tell them that they can play for a couple of hours after they have done their homework or their chores – not before.
• Fourthly, parents should always get their children to follow the recommendations by the videogame manufacturers (e.g., sit at least two feet from the screen, play in a well-lit room, never have the screen at maximum brightness, and never play videogames when feeling tired).

I have spent many years examining both the possible dangers and the potential benefits of videogame playing. Evidence suggests that in the right context videogames can have positive health and educational benefits to a large range of different sub-groups. What is also clear from the case studies displaying the more negative consequences of playing is that they all involved children who were excessive users of videogames. From prevalence studies in this area, there is little evidence of serious acute adverse effects on health from moderate play. In fact, in some of my studies, I found that moderate videogame players were more likely to have friends, do homework, and engage in sporting activities, than those who played no videogames at all.

For excessive videogame players, adverse effects are likely to be relatively minor, and temporary, resolving spontaneously with decreased frequency of play, or to affect only a small subgroup of players. Excessive players are the most at-risk from developing health problems although more research is needed. If care is taken in the design, and if they are put into the right context, videogames have the potential to be used as training aids in classrooms and therapeutic settings, and to provide skills in psychomotor coordination, and in simulations of real life events (e.g., training recruits for the armed forces).

Every week I receive emails from parents claiming that their sons are addicted to playing online games or that their daughters are addicted to social media. When I ask them why they think this is the case, they almost all reply “because they spend most of their leisure time in front of a screen.” This is simply a case of parents pathologising their children’s behaviour because they think what they are doing is “a waste of time.” I always ask parents the same three things in relation to their child’s screen use. Does it affect their schoolwork? Does it affect their physical education? Does it affect their peer development and interaction? Usually parents say that none of these things are affected so if that is the case, there is little to worry about when it comes to screen time. Parents also have to bear in mind that this is how today’s children live their lives. Parents need to realise that excessive screen time doesn’t always have negative consequences and that the content and context of their child’s screen use is more important than the amount of screen time.

(N.B. This article is an extended version of an article that was originally published by Parent Zone)

Dr. Mark Griffiths, Professor of Behavioural Addiction, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Further reading

Griffiths, M.D. (2003).  Videogames: Advice for teachers and parents. Education and Health, 21, 48-49.

Griffiths, M.D. (2009). Online computer gaming: Advice for parents and teachers. Education and Health, 27, 3-6.

Griffiths, M.D., Kuss, D.J. & King, D.L. (2012). Video game addiction: Past, present and future. Current Psychiatry Reviews, 8, 308-318.

Griffiths, M.D., Kuss, D.J. & Pontes, H. (2016). A brief overview of Internet Gaming Disorder and its treatment. Australian Clinical Psychologist, 2(1), 20108.

Griffiths, M.D. & Meredith, A. (2009). Videogame addiction and treatment. Journal of Contemporary Psychotherapy, 39(4), 47-53.

King, D.L., Delfabbro, P.H. & Griffiths, M.D. (2012). Clinical interventions for technology-based problems: Excessive Internet and video game use. Journal of Cognitive Psychotherapy: An International Quarterly, 26, 43-56.

King, D.L., Delfabbro, P.H., Griffiths, M.D. & Gradisar, M. (2012). Cognitive-behavioural approaches to outpatient treatment of Internet addiction in children and adolescents. Journal of Clinical Psychology, 68, 1185-1195.

Király, O., Nagygyörgy, K., Griffiths, M.D. & Demetrovics, Z. (2014). Problematic online gaming. In K. Rosenberg & L. Feder (Eds.), Behavioral Addictions: Criteria, Evidence and Treatment (pp.61-95). New York: Elsevier.

Kuss, D.J. & Griffiths, M.D. (2012). Online gaming addiction in adolescence: A literature review of empirical research. Journal of Behavioral Addictions, 1, 3-22.

Kuss, D.J. & Griffiths, M.D. (2012). Internet gaming addiction: A systematic review. International Journal of Mental Health and Addiction, 10, 278-296.

Money for nothing (and your clicks for free?): Why do gamers buy ‘virtual assets’?

---

Video gaming has evolved from a single-player platform to a multi-player realm where interaction with other players is often a necessity. In order to enter the game, players must first create an avatar, a representation of their self in the game that is used to explore and interact with the virtual environment. When creating an avatar, players can also buy virtual assets to augment and/or enhance their online character. Virtual assets are items or customisations for video game avatars, bases, and characters that are purchased with real money.

In a previous blog, I looked at some of the anecdotal evidence that claimed a few individuals had become ‘addicted’ to buying virtual assets. At the time I wrote that article, there was almost nothing published academically on the psychology of virtual assets and why people bought virtual assets. A few months ago, Jack Cleghorn and I published a qualitative paper in the journal Digital Education Review based on our interviews with gamers that regularly bought virtual assets. Today’s blog looks at some of our findings.

For researchers, the buying of virtual assets provides an opportunity to try and understand why people become so immersed in games and what motivates gamers to spend real money on items that some would consider as having no value. In a multi-player environment, it becomes clear that the avatars seen on screen are graphical representations of someone real and may be part of human desires to be noticed, respected, and interacted with. Furthermore the gamer controlling their avatar has motivations, emotions, thoughts, and feelings. Virtual item purchases are therefore likely to impact on a gamer’s psychological wellbeing.

The growing market for virtual items indicates that transactions are becoming commonplace in gaming. The virtual market functions similarly to real markets in that there is demand, fluctuating markets, and profits to be made. The importance of virtual items to some people is illustrated by a divorce claim in a story on Hyped Talk in which a wife made a claim for over half of her husband’s virtual assets. In a different case (outlined in a 2005 issue of The Lawyer), Qiu Chengwei, a middle-aged man killed a fellow gamer over a dispute involving a virtual item. Obviously these cases are extreme but they highlight the fact that virtual items can have both financial and psychological value for gamers.

But why do people buy virtual items? Performance and general quality of an item is seen to be an important motivation whether the item is real or virtual. Online, an appeal to social status may be a better predictor for purchase behaviour than function. However, some claim that appealing to social status has no motivational significance in purchase behaviour. Another unique element of buying virtual items is the potential exclusivity. Exclusive or limited items tend to be unattainable through gameplay and instead must be bought with money. Exclusivity online has been shown to be of importance, and segmentation is a technique used by the games producers that limits certain items to certain classes, levels, or races. This has been shown to stimulate purchase behaviour. The amount of time invested in a game is also key to understanding spending patterns, and gamers will often buy virtual items after a dedicated amount of gameplay has been spent building an avatar.

Naturally, the longer the amounts of time that are spent online and in-game, the more the player emotionally and psychologically invests in the game. The concept of ‘flow’ (formulated by Mihaly Csikszentmihalyi in many papers and books) has been applied to gaming and can involve becoming emotionally attached to a character (in fact I published a paper on this with Damien Hull and Glenn Williams in a 2013 issue of the Journal of Behavioral Addictions). Flow is the feeling of complete absorption in an activity and affects consciousness and emotions of the individual experiencing it. A key element of feeling ‘flow’ is the experience and perception of the world of the avatar and has been applied to electronic media. The adaptation of ‘flow’ to the virtual world suggests that just like other leisure activities, an individual investing time in an environment where they feel socially accepted can become emotionally attached to their avatar. Gaming has been shown to affect consciousness and emotions of gamers that are both necessary in experiencing ‘flow’. It could be that purchasing of virtual items is also motivated – at least in part – by the feeling of emotional attachment to an avatar.

Gamers are being drawn in to an environment by the appeal of social interaction, manipulation of objects, exploration, and identification with the avatar. To some gamers, the virtual world can takes on more significance than ‘actual’ life and residency in their preferred games is what they consider their actuality. This suggests that the reward of gaming is great, indicating that those individuals who buy virtual items are doing so because they feel involved in an environment that benefits them personally.

Given the lack of empirical research, the qualitative study I published with Jack Cleghorn was based on in-depth interviews with six gamers who all regularly bought in-game virtual assets. We examined the (i) motivations for purchasing virtual items, (ii) psychological impact of purchasing virtual items on self-esteem and confidence, (iii) social benefits of gaming and virtual asset purchasing, (iv) emotional attachment to an avatar, (v) choice of items and customisation of the avatar as a form of self-expression, (v) impulsivity versus thoughtfulness in purchase intentions of virtual items, and (vii) impact of transaction machinery on the ‘game experience’ from a gamer’s perspective.

Using interpretative phenomenological analysis (IPA), the study was exploratory and aimed to understand the psychology underlying purchase intention of virtual items and assets among online gamers. As a result of interviewing the gamers, seven theses emerged: (i) motivation for purchase, (ii) social aspects of the gaming and purchasing, (iii) emotional attachment to the avatar, (iv) psychological reward and impact, (v) self-expression, (vi) ‘stock market gaming’ and gaming culture, and (vii) research/impulse buying. The use of IPA allowed each gamer to share their unique experience of playing and purchase behaviour.

Despite the negative aspects of online gaming, the gamers in our study emphasised a more positive side to buying virtual items and gaming more generally. Item exclusivity and item function were major motivating factors and contributed to an item’s importance in-game. Another key motivation for purchase behaviour was the appeal to social status. Attainment of items demonstrates to others how powerful the gamer is. Naturally, if an item has benefits for the avatar it is more likely that the gamer will spend money to obtain it. Function linked to progression, purchasing items, and buying in-game currency are all sometimes a necessity to progress. Novelty and collectability were also important motivators for some of our gamers. Despite subjective motivations, purchasing virtual items arose out of gaming as a predominant pastime. All of the gamers in our sample were dedicated gamers who spent relatively large amounts of time online and, as perhaps expected, larger gaming commitment to led to purchase behaviour.

An integral part of multiplayer gaming is the interaction with other gamers. The feeling of ‘social presence’ in an online environment is reliant on an emotional response to social interaction and the gamers in our study felt social satisfaction. The game sometimes enabled social interaction that might not otherwise be present. Previous research has shown how emotional attachment to games affects behaviour. Our study highlighted the role of emotional attachment to an avatar as a predictor for purchase intention. As well as emotional attachment increasing likelihood of spending, the spending of real money on items increases the attachment felt. It could be that purchasing virtual items may be a cyclical behaviour. It is also the case that purchasing affects the cognitions and emotions of gamers – ‘pride’ was a feeling that resonated among our interviewed gamers.

Our study also highlighted how gamers research items before purchasing them. It might be expected that easy-to-use transaction machinery might facilitate spending. However, in reality, the gamers we interviewed were guarded with their spending online and recommendations from friends playing a major role in purchase behaviour. Virtual assets can be then researched and the placing of real monetary value on the virtual items indicates the value they may hold to the gamer. Unlike media coverage focussing on the more negative impact of online gaming, our study highlighted the positive aspects of purchasing virtual assets for the gamer. They are able to feel connected socially, feel confidence in themselves and their success, express their inner and ideal self without constraint or fear, build lasting relationships, impress people, and generally benefit from gaming and buying virtual items.

Dr. Mark Griffiths, Professor of Behavioural Addiction, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Further reading

Bowman, N. D., Schultheiss, D., & Schumann, C. (2012). ‘‘I’m attached, and I’m a good guy/gal!’’: How character attachment influences pro- and anti-social motivations to play massively multiplayer online role-playing games. CyberPsychology, Behavior and Social Networking, 15(3), 169-174.

Csikszentmihalyi, M., & Csikszentmihalyi, I. (1992). Optimal experience: Psychological studies of flow in consciousness. Cambridge: Cambridge University Press.

Cole, H. & Griffiths, M. D. (2007). Social interactions in Massively Multiplayer Online Role-Playing gamers. CyberPsychology and Behavior, 10, 575-583.

Griffiths, M. D. (2010). The role of context in online gaming excess and addiction: Some case study evidence. International Journal of Mental Health and Addiction, 8, 119-125.

Griffiths, M.D., Hussain, Z., Grüsser, S., Thalemann, R., Cole, H. Davies, M.N.O. & Chappell, D. (2013). Social interactions in online gaming. In P. Felicia (Ed.), Developments in Current Game-Based Learning Design and Deployment (pp.74-90). Pennsylvania: IGI Global.

Guo, Y., & Barnes, S. (2011). Purchase behavior in virtual worlds: An empirical investigation in Second Life. Information and Management, 48(7), 303-312.

Hamari, J. & Lehdonvirta, V. (2010). Game design as marketing: How game mechanics create demand for virtual goods. International Journal of Business Science and Applied Management, 5(1), 14-29.

Hassouneh, D., & Brengman, M. (2011). Shopping in virtual worlds: Perceptions, motivations and behaviour. Journal of Electronic Commerce Research, 12(4), 320-335.

Huang, E. (2012). Online experiences and virtual goods purchase intention. Internet Research, 22(3), 252-274.

Hull, D., Williams, G. A. & Griffiths, M. D. (2013). Video game characteristics, happiness and flow as predictors of addiction among video game players: A pilot study. Journal of Behavioral Addictions, 2, 145-152.

Hyped Talk (2010). Virtually addicted Chinese woman claims virtual assets in her divorce plea. Available at: http://hypedtalk.blogspot.co.uk/2010/12/virtually-addicted-chinese-women-claims.html [Accessed: 6 March 2013].

Lee, P. (2005). The growth in the computer game market is leading to real legal issues in virtual worlds. The Lawyer, 19 (19), 14.

Lehdonvirta, V. (2009) Virtual item sales as a revenue model: Identifying attributes that drive purchase decisions. Electronic Commerce Research, 9(1-2), 97-113.

Li, Z. (2012). Motivation of virtual goods transactions based on the theory of gaming motivations. Journal of Theoretical and Applied Information Technology, 43(2), 254-260.

Manninen, T. & Kujanpää, T. (2007). The value of virtual assets – the role of game characters in MMOGs. International Journal of Business Science and Applied Management, 2(1), 21-33.

In dependence days: A brief overview of behavioural addictions

Please note: A version of this blog first appeared on addiction.com

Conceptualizing addiction has been a matter of great debate for decades. For many people the concept of addiction involves the taking of drugs. Therefore it is perhaps unsurprising that most official definitions concentrate on drug ingestion. Despite such definitions, there is now a growing movement that views a number of behaviours as potentially addictive including those that do not involve the ingestion of a drug. These include behaviours diverse as gambling, eating, sex, exercise, videogame playing, love, shopping, Internet use, social networking, and work. I have argued in many of my papers that all addictions – irrespective of whether they are chemical or behavioural – comprise six components (i.e., salience, mood modification, tolerance, withdrawal, conflict and relapse). More specifically:

• Salience – This occurs when the activity becomes the single most important activity in the person’s life and dominates their thinking (preoccupations and cognitive distortions), feelings (cravings) and behaviour (deterioration of socialized behaviour). For instance, even if the person is not actually engaged in the activity they will be constantly thinking about the next time that they will be (i.e., a total preoccupation with the activity).
• Mood modification – This refers to the subjective experiences that people report as a consequence of engaging in the activity and can be seen as a coping strategy (i.e., they experience an arousing ‘buzz’ or a ‘high’ or paradoxically a tranquilizing feel of ‘escape’ or ‘numbing’).
• Tolerance – This is the process whereby increasing amounts of the activity are required to achieve the former mood modifying effects. This basically means that for someone engaged in the activity, they gradually build up the amount of the time they spend engaging in the activity every day.
• Withdrawal symptoms – These are the unpleasant feeling states and/or physical effects (e.g., the shakes, moodiness, irritability, etc.) that occur when the person is unable to engage in the activity.
• Conflict – This refers to the conflicts between the person and those around them (interpersonal conflict), conflicts with other activities (e.g., work, social life, hobbies and interests) or from within the individual (e.g., intra-psychic conflict and/or subjective feelings of loss of control) that are concerned with spending too much time engaging in the activity.
• Relapse – This is the tendency for repeated reversions to earlier patterns of excessive engagement in the activity to recur, and for even the most extreme patterns typical of the height of excessive engagement in the activity to be quickly restored after periods of control.

In May 2013, the new criteria for problem gambling (now called ‘Gambling Disorder’) were published in the fifth edition of the Diagnostic and Statistical Manual for Mental Disorders (DSM-5), and for the very first time, problem gambling was included in the section ‘Substance-related and Addiction Disorders’ (rather than in the section on impulse control disorders as had been the case since 1980 when it was first included in the DSM-III). Although most of us in the field had been conceptualizing extreme problem gambling as an addiction for many years, this was arguably the first time that an established medical body had described it as such.

There had also been debates about whether or not ‘Internet Addiction Disorder’ should have been included in the DSM-5. As a result of these debates, the Substance Use Disorder Work Group recommended that the DSM-5 include ‘Internet Gaming Disorder’ [IGD] in Section III (“Emerging Measures and Models”) as an area that required further research before possible inclusion in future editions of the DSM. To be included in its own right in the next edition, research will have to establish the defining features of IGD, obtain cross-cultural data on reliability and validity of specific diagnostic criteria, determine prevalence rates in representative epidemiological samples in countries around the world, and examine its associated biological features. Other than gambling and gaming, no other behaviour (e.g., sex, work, exercise, etc.) has yet to be classified as a genuine addiction by established medical and/or psychiatric organizations.

In one of the most comprehensive reviews of chemical and behavioural addictions, Dr. Steve Sussman, Nadra Lisha and myself examined all the prevalence literature relating to 11 different potentially addictive behaviours. We reported overall prevalence rates of addictions to cigarette smoking (15%), drinking alcohol (10%), illicit drug taking (5%), eating (2%), gambling (2%), internet use (2%), love (3%), sex (3%), exercise (3%), work (10%), and shopping (6%). However, most of the prevalence data relating to behavioural addictions (with the exception of gambling) did not have prevalence data from nationally representative samples and therefore relied on small and/or self-selected samples.

Addiction is an incredibly complex behaviour and always result from an interaction and interplay between many factors including the person’s biological and/or genetic predisposition, their psychological constitution (personality factors, unconscious motivations, attitudes, expectations, beliefs, etc.), their social environment (i.e. situational characteristics such as accessibility and availability of the activity, the advertising of the activity) and the nature of the activity itself (i.e. structural characteristics such as the size of the stake or jackpot in gambling). This ‘global’ view of addiction highlights the interconnected processes and integration between individual differences (i.e. personal vulnerability factors), situational characteristics, structural characteristics, and the resulting addictive behaviour.

There are many individual (personal vulnerability) factors that may be involved in the acquisition, development and maintenance of behavioural addictions (e.g. personality traits, biological and genetic predispositions, unconscious motivations, learning and conditioning effects, thoughts, beliefs, and attitudes), although some factors are more personal (e.g. financial motivation and economic pressures in the case of gambling addiction). However, there are also some key risk factors that are highly associated with developing almost any (chemical or behavioural) addiction such as having a family history of addiction, having co-morbid psychological problems, and having a lack of family involvement and supervision. Psychosocial factors such as low self-esteem, loneliness, depression, high anxiety, and stress all appear to be common among those with behavioural addictions.

This article briefly demonstrates that behavioural addictions are a part of a biopsychosocial process and not just restricted to drug-ingested (chemical) behaviours. Evidence is growing that excessive behaviours of all types do seem to have many commonalities and this may reflect a common etiology of addictive behaviour. Such commonalities may have implications not only for treatment of such behaviours but also for how the general public perceive such behaviours.

Dr. Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Further reading

Berczik, K., Griffiths, M.D., Szabó, A., Kurimay, T., Urban, R. & Demetrovics, Z. (2014). Exercise addiction. In K. Rosenberg & L. Feder (Eds.), Behavioral Addictions: Criteria, Evidence and Treatment (pp.317-342). New York: Elsevier.

Demetrovics, Z. & Griffiths, M.D. (2012). Behavioral addictions: Past, present and future. Journal of Behavioral Addictions, 1, 1-2.

Griffiths, M.D. (1996). Behavioural addictions: An issue for everybody? Journal of Workplace Learning, 8(3), 19-25.

Griffiths, M.D. (2009). Gambling addictions. In A. Browne-Miller (Ed.), The Praeger International Collection on Addictions: Behavioral Addictions from Concept to Compulsion (pp. 235-257). Westport, CT: Praeger.

Griffiths, M.D. (2010). Addicted to sex? Psychology Review, 16(1), 27-29

Griffiths, M.D. (2011). Behavioural addiction: The case for a biopsychosocial approach. Transgressive Culture, 1(1), 7-28.

Griffiths, M.D. (2011). Workaholism: A 21^st century addiction. The Psychologist: Bulletin of the British Psychological Society, 24, 740-744.

Griffiths, M.D., Kuss, D.J. & Demetrovics, Z. (2014). Social networking addiction: An overview of preliminary findings. In K. Rosenberg & L. Feder (Eds.), Behavioral Addictions: Criteria, Evidence and Treatment (pp.119-141). New York: Elsevier.

Griffiths, M.D. (2005). A ‘components’ model of addiction within a biopsychosocial framework. Journal of Substance Use, 10, 191-197.

Király, O., Nagygyörgy, K., Griffiths, M.D. & Demetrovics, Z. (2014). Problematic online gaming. In K. Rosenberg & L. Feder (Eds.), Behavioral Addictions: Criteria, Evidence and Treatment (pp.61-95). New York: Elsevier.

Kuss, D.J., Griffiths, M.D., Karila, L. & Billieux, J. (2014).  Internet addiction: A systematic review of epidemiological research for the last decade. Current Pharmaceutical Design, 20, 4026-4052.

Sussman, S., Lisha, N. & Griffiths, M.D. (2011). Prevalence of the addictions: A problem of the majority or the minority? Evaluation and the Health Professions, 34, 3-56.

Coining it in: Neologisms and ‘New Syndrome’ Syndrome

One of things I am very proud of in my academic career is the coining of the term ‘technological addiction’ back in 1995 (an umbrella term that I invented to describe a number of different person-machine addictions including slot machine addictions, video game addiction, television addiction, etc.). I’m also proud of coining the term ‘aca-media’ (relating to academics like myself that use the media to disseminate our research). A neologism (i.e., the name for a newly coined term) is often (according to Wikipedia) directly attributable to a specific event, person, publication, or period.

In the 1980s and early 1990s, there seemed to be a real upsurge is the naming of ‘new syndromes’ in the medical literature including many relating to excessive use of technology (such as ‘Space Invader’s Wrist’) and other leisure activities (such as ‘Cuber’s Thumb’ relating to excessive use of the Rubik’s Cube) – both of which made their appearance in 1981 issues of the New England Journal of Medicine. Other videogame medical complaints include ‘Pseudovideoma’ (in a 1984 issue of the Journal of Hand Surgery), ‘Pac-Man Phalanx’ (in a 1983 issue of Arthritis and Rheumatism) and ‘Joystick Digit’ (in a 1987 issue of the Journal of the American Medical Association). Another videogame-related medical complaint (in this case an infection), was reported in a 1987 issue of the Western Journal of Medicine by Dr. G.B. Soe and colleagues:

“We wish to focus WJM readers’ attention on another complication associated with video games-one that originally presented as an “infected spider bite. A 17-year-old right-handed boy noted progressive swelling and redness of his left hand seven days before admission. Two days before admission he was given penicillin intramuscularly and oral cephalexin to take at home. The swelling did not subside and the hand became very painful, so he came to the medical center for treatment. On admission his mother reported that she had seen many spiders around the house with a violin pattern on their backs, and that her son had probably been bitten by a spider…After seven days of parenteral antibiotic therapy, the edema, erythema and fever had disappeared and the patient was discharged home. Further questioning revealed that the young man was spending almost all of his time playing his favorite video game, which involved a fighting kung fu character. The patient used his left hand in manipulating a ball-shaped joystick to move the figure up, down, left and right, and his right in operating buttons to kick and jab. Extensive use of the joystick resulted in blisters on his left palm. He rubbed the blisters off, and an infection resulted that progressed to abscess formation. Neuromuscular complications of video games (‘pseudovideoma’, ‘Pac-Man phalanx’, ‘firing-finger syndrome’ and ‘Space Invaders wrist’) have been reported, as well as video game-induced seizures, but we have not come across any reports of an infectious complication of video games. Perhaps video game players should wear gloves to protect their palms, similar to ones worn by golfers and baseball players, who also need to get a firm grip on their respective sticks”.

Another one that I’d never heard of is ‘Nurd Knuckles’ coined by Dr. J.B. Martin in the Canadian Medical Association Journal in 1982:

“I wish to describe a case of painful knuckles associated with the use and manipulation of a new, allegedly therapeutic product, a Nurd. A Nurd is a head 10 cm across with a smiling face and large ears, reminiscent of the character Yoda of ‘Star Wars’. It is made of malleable material that can be stretched, twisted or deformed in any direction, yet with release of tension quickly resumes its original shape without a trace of distortion. A 32-year-old public school teacher presented with painful knuckles of his right hand. His students, perhaps feeling that their teacher was under increased stress during the marking of exams, had given him a Nurd for Christmas, and during a particularly trying day he had found occasion to use it. He repeatedly stretched its ears and twisted its neck without ill effect; however, on punching it he suffered sharp pain of his fourth and fifth metacarpophalangeal joints. On examination the joints were found to be reddened, with point tenderness over the fifth metacarpal head; there was no evidence of deformity. He was advised to stop beating his Nurd, and the pain subsided. While the Nurd is very plastic, yielding to the linear tension of stretching and twisting, it is very resistant to compression. Punching a Nurd does not cause the surface to give way, and, since the force of the blow is returned to the fist, it is conceivable that a fracture might result. Therefore, although stretching and twisting Nurds does not cause any harm, users should be cautioned against punching their Nurd. The Nurd is advertised as being a ‘punchable, stretchable, pushable and likeable alternative to tension, migraine headaches, drug abuse, alcoholism and manic depression’, but these claims are unsubstantiated. A MEDLINE search of the medical literature shows that no retrospective or prospective case control studies or controlled double blind crossover studies have been undertaken. Before the clinical efficacy of the Nurd can be taken seriously in the treatment of this broad spectrum of disease, full clinical trials must be completed. Subjects entering into trials must, however, be duly informed of the hazards of punching Nurds”.

Another one that caught my attention was a new affliction (‘Breaker’s Neck’) caused by the craze of ‘break dancing’ reported by Dr. Bertha Ramirez and her colleagues in a 1984 issue of the Journal of the American Medical Association. (The reason why I say it caught my eye is that I am currently involved in some research on ‘dancing addiction’ with some of my Hungarian colleagues and we have just had a new paper accepted in the journal PLoS ONE concerning the development of our ‘Dancing Motives Inventory’ – see ‘Further Reading’ below).

“To be added to the rapidly growing list of socially acquired injuries, we report a case of traumatic cervical subluxation caused by a new dance technique. This technique, labeled ‘breaking’ by its devotees, involves a modified head stand, in which the dancer, using his arms and hands for balance, spins rapidly on his head, neck, or shoulders to the rhythm of disco music. He then lowers his body to the floor and performs a series of rotational motions using his arms as a fulcrum…A 15-year-old boy was seen in our pediatric emergency room complaining that, on awakening two days previously, he felt a ‘snap’ in his neck, followed by persistent neck stiffness. He reported having ‘danced on his head’ the night prior to this incident. On physical examination, his head was tilted to the left with an inability to flex”.

Engaging in excessive sporting activity has given rise to a number of medical syndromes. One such consequence is ‘Rower’s Rump’ reported by Drs. K Tomecki and J. Mikesell in a 1987 issue of the Journal of the American Academy of Dermatology. In a previous blog I examined addiction to cycling. In the 1980s there were many medical complaints reported as a result of excessive cycling. One such complaint (given the name of ‘Bicycling nipples’) was highlighted by Dr. B. Powell in a 1983 issue of the Journal of the American Medical Association:

“Bicyclists are likely to suffer from a number of maladies, including dysuria, numb penises, and more. During cool or cold weather, another problem, bicyclist’s nipples, may occur. This condition is similar to jogger’s nipples, but it is primarily a thermal injury instead of an irritation secondary to friction, as with the jogger’s complaint. Often the rider is out in the cold weather for some time, and his or her undershirt, jersey, and jacket can become moist from perspiration. Evaporation and the chill of the wind lower the temperature of the nipples. They get downright cold, and they hurt. The pain continues after the ride is over. Indeed, it can continue for several days. The nipples are sore, sensitive to both temperature change and touch”.

After reading this I found out that Dr. Fred Levit had reported a case of ‘Jogger’s Nipples’ in a 1977 issue of the New England Journal of Medicine. All of these related nipple conditions are all examples of fissure of the nipple as they are all caused by friction resulting in soreness, dryness or irritation to, or bleeding of, one or both nipples. The Wikipedia entry also notes that “the condition is also experienced by women who breastfeed, and by surfers who do not wear rash guards”. The article also noted that:

“Jogger’s nipple is caused by friction from the repeated rubbing of a t-shirt or other upper body clothing against the nipples during a prolonged period of exercise. The condition is suffered mainly by runners. Long-distance runners are especially prone, because they are exposed to the friction on the nipple for the greatest period of time. However, it is not only suffered by athletes; the inside of a badge, a logo on normal items of clothing, or breastfeeding can also cause the friction which results in this condition”.

Outside of the leisure sphere, there were two case study reports of ‘Diaper Doer’s Hand’ in a 1987 issue of the journal Clinical Rehabilitation by Dr. J.L. Cosgrove and colleagues:

“Three cases of stenosing tenosynovitis occurred three to six months postpartum. Childcare activities aggravated the symptoms of pain and swelling in both patients. In two cases, a specific method of carrying the child was implicated as the mechanism of injury. Although there was no evidence of generalized inflammatory arthritis, all patients had very low positive titres of anti-nuclear antibodies. While it is likely that tenosynovitis was caused by mechanical factors, the possibility of increased susceptibility to inflammatory disease in the postpartum period cannot be discounted. The patients were successfully treated with a low temperature plastic splint, superficial heat and gentle mobilization”.

All of these new syndromes lead to why I put this article together in the first place. I found this letter in the British Medical Journal by Dr. E.P. Hoare entitled ‘New Syndrome Syndrome’ that I found both funny and poignant:

“Your readers will be familiar with tennis elbow, brazier’s ague, and soap packer’s jig not to mention Achilles’ heel. More recently we have heard of Space Invader’s wrist, jogger’s nipples, and the ultimate futility of Cuber’s thumb. May I point out another occupational disease which I have noticed among patrons of the reading room medical journal correspondence column reader’s neck or, more succinctly, the new syndrome syndrome. Symptoms usually begin with muscular contraction of the eyebrows, hyperventilation, and involuntary utterances, which in severe cases can lead to coprolalia. These may be followed by drowsiness, disorientation, hysterical amblyopia, and double vision (of the deja vu variety). If untreated the condition can result in a chronic pain in the neck. Treatment is 200 ml of gin and tonic stat by mouth and complete rest; music can also be helpful. The long-term prognosis is poor, however, unless journal editors can be persuaded to ban further reports of occupational afflictions or at least print a health warning at the head of their correspondence columns”.

Dr. Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Further reading

Behr, J.T. (1984). Pseudovideoma. Journal of Hand Surgery, 9(4), 613.

Cosgrove, J. L., Welch, D. A., Richardson, G. S., & Nicholas, J. J. (1987). Diaper doer’s hand: stenosing tenosynovitis in the postpartum period. Clinical Rehabilitation, 1(3), 219-223.

Gibofsky, A. (1983). Pac‐Man phalanx. Arthritis and Rheumatism, 26(1), 120.

Griffiths, M.D. (1995). Technological addictions. Clinical Psychology Forum, 76, 14-19.

Griffiths, M.D. (1995). Pop psychology and “aca-media”: A reply to Mitchell. The Psychologist: Bulletin of the British Psychological Society, 8, 537-538.

Griffiths, M.D. (2001). A moral obligation in aca-media? The Psychologist: Bulletin of the British Psychological Society, 14, 460.

Hite, P. R., Greene, K. A., Levy, D. I., & Jackimczyk, K. (1993). Injuries resulting from bungee-cord jumping. Annals of emergency medicine, 22(6), 1060-1063.

Hoare, E.P. (1982). Points: New syndrome syndrome. British Medical Journal, 285(6352), 1429.

Levit, F. (1977). Jogger’s nipples. New England Journal of Medicine, 297(20), 1127.

Maraz, A., Király, O., Urbán, R., Griffiths, M.D., Demetrovics, Z. (2015). Why do you dance? Development of the Dance Motivation Inventory (DMI). PLoS ONE, in press.

Martyn, J. B. (1983). Nurd knuckles. Canadian Medical Association Journal, 129(3), 228.

McCowan, T.C. (1981). Space Invader’s wrist. New England Journal of Medicine, 304,1368.

Osterman, A. L., Weinberg, P., & Miller, G. (1987). Joystick digit. Journal of the American Medical Association, 257(6), 782.

Powell, B. (1983). Bicyclist’s nipples. Journal of the American Medical Association, 249(18), 2457-2457.

Ramirez, B., Masella, P. A., Fiscina, B., Lala, V. R., & Edwards, M. D. (1984). Breaker’s neck. Journal of the American Medical Association, 252(24), 3366-3367.

Soe, G.B., Gersten, L. M., Wilkins, J., Patzakis, M. J., & Harvey, J.P. (1987). Infection associated with joystick mimicking a spider bite. Western Journal of Medicine, 146(6), 748.

Tomecki, K. J., & Mikesell, J. F. (1987). Rower’s rump. Journal of the American Academy of Dermatology, 16(4), 890-891.

Torre, P. R., Williams, G. G., Blackwell, T., & Davis, C. P. (1993). Bungee jumper’s foot drop peroneal nerve palsy caused by bungee cord jumping. Annals of emergency medicine, 22(11), 1766-1767.

Waugh, D. (1981). Cuber’s thumb. New England Journal of Medicine, 305, 768.

Played to death: What turns online gaming into a health risk?

Please note that the following article is a slightly extended version of an article that was first published by CNN International

Last month, a 32-year old male gamer was found dead at a Taiwanese Internet café following a non-stop three-day gaming session. This followed the death of another male gamer who died in Taipei at the start of the year following a five-day gaming binge.

While these cases are extremely rare, it does beg the question of why gaming can lead to such excessive behaviour. I have spent nearly three decades studying videogame addiction and there are many studies published in both the medical and psychological literature showing that very excessive gaming can lead to a variety of health problems that range from repetitive strain injuries and obesity, through to auditory and visual hallucinations and addiction. I have to stress that there is lots of scientific research showing the many educational and therapeutic benefits of playing but there is definitely a small minority of gamers that develop problems as a result of gaming overuse.

But what is it that makes gaming so compulsive and addictive for the small minority? For me, addiction boils down to constant reinforcement, or put more simply, being constantly rewarded while playing the game. Gaming rewards can be physiological (such as feeling ‘high’ or getting a ‘buzz’ while playing or beating your personal high score), psychological (such as feeling you have complete control in a specific situation or knowing that your strategic play helped you win), social (such as being congratulated by fellow gamers when doing something well in the game) and, in some cases, financial (such as winning a gaming tournament). Most of these rewards are – at least to some extent – unpredictable. Not knowing when the next reward will come keeps some players in the game. In short, they carry on gaming even though they may not have received an immediate reward. They simply hope that another reward is ‘just around the corner’ and keep on playing.

Added to this is the shift over the last decade from standalone console gaming to massively multiplayer online games where games never end and gamers have to compete and/or collaborate with other gamers in real time (instead of being able to pause the game and come back and play from the point at which the player left it). Many excessive gamers report that they hate logging off and leaving such games. They don’t like it as they don’t know what is going on in the game when they are not online.

The last five years has seen large increase in the number of scientific studies on problematic gaming. In May 2013, the American Psychiatric Association published the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). For the first time, the DSM-5 included ‘internet gaming disorder’ (IGD) as a psychological condition that warrants future research. Throughout my research career I have argued that although all addictions have particular and idiosyncratic characteristics, they share more commonalities than differences such as total preoccupation, mood modification, cravings, tolerance, withdrawal symptoms, conflict with work, education and other people, and loss of control. These similarities likely reflect a common etiology of addictive behaviour.

So when does a healthy enthusiasm turn into an addiction? At the simplest level, healthy enthusiams add to life and addictions take away from it. But how much is too much? This is difficult to answer as I know many gamers who play many hours every day without any detrimental effects. The DSM-5 lists nine criteria for IGD. If any gamer endorses five or more of the following criteria they would likely be diagnosed as having IGD: (1) preoccupation with internet games; (2) withdrawal symptoms when internet gaming is taken away; (3) the need to spend increasing amounts of time engaged in internet gaming, (4) unsuccessful attempts to control participation in internet gaming; (5) loss of interest in hobbies and entertainment as a result of, and with the exception of, internet gaming; (6) continued excessive use of internet games despite knowledge of psychosocial problems; (7) deception of family members, therapists, or others regarding the amount of internet gaming; (8) use of the internet gaming to escape or relieve a negative mood;  and (9) loss of a significant relationship, job, or educational or career opportunity because of participation in internet games.

The good news is that only a small minority of gamers suffer form IGD. Most online games are fun and exciting to play. But like any activity that is taken to excess, in a minority of cases the activity can become addictive. Any activity if done for days on end could lead to severe health problems and even death – and gaming is no exception. Instead of demonizing games, we need to educate gamers about the potential dangers of very excessive use.

Dr. Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Further reading

Griffiths, M.D. (2014). Gaming addiction in adolescence (revisited). Education and Health, 32, 125-129.

Griffiths, M.D., King, D.L. & Demetrovics, Z. (2014). DSM-5 Internet Gaming Disorder needs a unified approach to assessment. Neuropsychiatry, 4(1), 1-4.

Griffiths, M.D., Kuss, D.J. & King, D.L. (2012). Video game addiction: Past, present and future. Current Psychiatry Reviews, 8, 308-318.

Griffiths, M.D. & Pontes, H.M. (2014). Internet addiction disorder and internet gaming disorder are not the same. Journal of Addiction Research and Therapy, 5: e124. doi:10.4172/2155-6105.1000e124.

King, D.L., Haagsma, M.C., Delfabbro, P.H., Gradisar, M.S.^, Griffiths, M.D. (2013). Toward a consensus definition of pathological video-gaming: A systematic review of psychometric assessment tools. Clinical Psychology Review, 33, 331-342.

Kuss, D.J. & Griffiths, M.D. (2012). Internet and gaming addiction: A systematic literature review of neuroimaging studies. Brain Sciences, 2, 347-374.

Kuss, D.J. & Griffiths, M.D. (2012). Online gaming addiction: A systematic review. International Journal of Mental Health and Addiction, 10, 278-296.

Kuss, D.J. & Griffiths, M.D. (2012). Online gaming addiction in adolescence: A literature review of empirical research. Journal of Behavioral Addictions, 1, 3-22.

Lopez-Fernandez, O., Honrubia-Serrano, M.L., Baguley, T. & Griffiths, M.D. (2014). Pathological video game playing in Spanish and British adolescents: Towards the Internet Gaming Disorder symptomatology. Computers in Human Behavior, 41, 304–312.

Pontes, H. & Griffiths, M.D. (2015). Measuring DSM-5 Internet Gaming Disorder: Development and validation of a short psychometric scale. Computers in Human Behavior, 45, 137-143.

Pontes, H., Király, O. Demetrovics, Z. & Griffiths, M.D. (2014). The conceptualisation and measurement of DSM-5 Internet Gaming Disorder: The development of the IGD-20 Test. PLoS ONE, 9(10): e110137. doi:10.1371/journal.pone.0110137.

Spekman, M.L.C., Konijn, E.A, Roelofsma, P.H.M.P. & Griffiths, M.D. (2013). Gaming addiction, definition, and measurement: A large-scale empirical study, Computers in Human Behavior, 29, 2150-2155.

Strange fascinations: A brief look at unusual compulsive and addictive behaviours

In previous blogs, I have examined lots of strange types of addictive and compulsive behaviours including compulsive singing, compulsive hoarding, carrot eating addiction, Argentine tango addiction, compulsive nose-picking, compulsive punning, compulsive helping, obsessive teeth whitening, compulsive list-making, chewing gum addiction, hair dryer addiction, wealth addiction, and Google Glass addiction (to name just a few).

However, while doing some research for a paper I am writing on ‘fishing addiction’ (yes, honestly), I came across an interesting paper on unusual compulsive behaviours caused by individuals receiving medication for Parkinson’s disease ([PD] a degenerative disorder of the central nervous system) and multiple system atrophy ([MSA] a degenerative neurological disorder in which nerve cells inside the brain start to degenerate and with symptoms similar to Parkinson’s disease).

In the gambling studies field there are now numerous papers that have been published showing that some Parkinson’s patients develop compulsive gambling after being treated for PD. According to the Parkinsons.co.uk website, those undergoing PD treatment can have many side effects including addictive gambling, obsessive shopping, binge eating, and hypersexuality. The website also notes other types of compulsive behaviour that have been associated with PD medication including “punding or compulsive hobbyism [when someone does things such as collecting, sorting or continually handling objects]. It may also be experienced as (i) a deep fascination with taking technical equipment apart without always knowing how to put it back together again, (ii) hoarding things, (iii) pointless driving or walking, and (iv) talking in long monologues without any real content”.

The paper that caught my eye was published in a 2007 issue of the journal Parkinsonism and Related Disorders by Dr. Andrew McKeon and his colleagues. They reported seven case studies of unusual compulsive behaviours after treating their patients with dopamine agonist therapy (i.e., treatment that activates dopamine receptors in the body). The paper described some compulsive behaviours that most people would not necessarily associate with being problematic. Below is a brief description of the seven cases that I have taken verbatim from the paper.

• Patient 1: “A 65-year-old female with PD for 9 years developed compulsive eating, and also felt compelled to repetitively weigh herself at frequent intervals during the day and at night. She found her behavior both purposeless and repetitive. Obsessive thoughts were also a feature, as the patient ‘had to’ weigh herself three times each occasion she used the weighing scales”.
• Patient 2: “A 67-year-old female with PD for 8 years played computer games and solitaire card games for hours on end, often continuing to do so through the night. She did not enjoy the experience and found it purposeless, but did so as she felt she had ‘to be doing something’. She also developed compulsive eating and gambling”.
• Patient 3: “A 48-year-old male with PD for 5 years, with little prior interest, developed an intense interest and fascination with fishing. His wife was concerned that he fished incessantly for days on end, and his interest did not abate despite never catching anything. This patient also developed compulsive shopping, spending large amounts of time and money in thrift stores”.
• Patient 4: “A 53-year-old male with PD for 13 years became intensely interested in lawn care. He would use a machine to blow leaves for 6h without rest, finding it difficult to disengage from the activity, as he found the repetitive behavior soothing. He also developed compulsive gambling”.
• Patient 5: “The wife of a 52-year-old male with an 11-year history of PD complained that her husband now spent all of his time on his hobbies, to the detriment of their marriage. The patient made small stained glass windows, day and night. In addition, he would frequently stay awake arranging rocks into piles in their yard, intending to build a wall, but never doing so. He would start multiple projects but complete nothing. He was also noted to have become hypersexual, demanding sexual intercourse from his wife several times daily”.
• Patient 6: “This 60-year-old male, with a history of alcohol abuse and ultimately diagnosed with MSA, relentlessly watched the clock, locked and unlocked doors and continually arranged and lined up small objects on his desk. He also became hyperphagic and hypersexual, developing an intense fascination with pornographic films”.
• Patient 7: “The wife of a 59-year-old male with PD for 1 year described how her husband dressed and undressed several times daily. On one occasion, while guests were at their house for dinner, he spent most of his time in his bedroom repeatedly changing from one pair of trousers into another. This behavior deteriorated considerably on increasing levodopa dose to 1100mg/day, and on a subsequent occasion after reducing quetiapine from 100 to 75 mg/day”.

These cases highlight that the compulsive behaviours that develop following dopamine agonist therapy often co-occur with one or more other compulsive behaviour and that much of these behaviours are repetitive and unwanted. As the authors noted:

“The temporal association between medication initiation and the onset of these behaviors led to our suspicion that medications were causative. In the aggregate, these patients illustrate that the behaviors provoked by drug therapy in parkinsonism cover a broad spectrum, ranging from purposeless and repetitive to complex, reward-oriented behaviors. Punding is the term typically applied to the former, and was seen in Patient 5 (arranging rocks into piles) and Patient 6 (lining up small objects on a desk)…Previous descriptions of pathological behaviors occur- ring with dopaminergic therapy in PD have been notable for the absence of obsessive thoughts accompanying compulsive behaviors, unlike Patient 1 who was remark- able for a counting ritual accompanying repetitive use of a weighing scale. In six of the seven cases, other reward- seeking behaviors (gambling, shopping, hypersexuality or overeating) were present and contemporaneous with these other unusual compulsive behaviors. This suggests that all of these behaviors, while phenomenologically distinct, are all part of the range of psychopathology encapsulated by obsessive-compulsive spectrum disorders”.

According to the Parkinsons.co.uk website, PD sufferers are more likely to experience impulsive and compulsive behaviour if the person is (i) diagnosed with Parkinson’s at a young age, (ii) male, (iii) single and live alone, (iv) a smoker, and (v) someone with a personal or family history of addictive behaviour. The same article also notes that if the PD sufferer has “a history of ‘risk-taking’, such as gambling, drug abuse or alcoholism, [they] may be more likely to develop dopamine addiction”. This is where the PD sufferer takes more of their medication than is needed to control their Parkinson’s symptoms (and known as dopamine dysregulation syndrome). Similarly, Dr. McKeon and colleagues concluded:

“Previously described associated clinical features include a prior history of depressed mood (four patients in this series), disinhibition, irritability and appetite disturbance…A history of problems with impulse control prior to the diagnosis of PD may be a risk factor for developing compulsive behaviors with dopaminergic therapies…although this only pertained to Patient 6…The compulsions were not found to be troublesome by three patients, with complaints regarding behavioral change coming from the patient’s spouse. Our observations affirm the need to check with both patient and family at follow-up visits for the emergence of a variety of troublesome pathological behaviors that may result from dopaminergic therapy, particularly dopamine agonists”.

Dr. Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Further reading

Dodd, M. L., Klos, K. J., Bower, J. H., Geda, Y. E., Josephs, K. A., & Ahlskog, J. E. (2005). Pathological gambling caused by drugs used to treat Parkinson disease. Archives of Neurology, 62, 1377-1381.

Griffiths, M.D. (1996). Behavioural addictions: An issue for everybody? Journal of Workplace Learning, 8(3), 19-25.

Griffiths, M.D. (2005). A ‘components’ model of addiction within a biopsychosocial framework. Journal of Substance Use, 10, 191-197.

Klos, K. J., Bower, J. H., Josephs, K. A., Matsumoto, J. Y., & Ahlskog, J. E. (2005). Pathological hypersexuality predominantly linked to adjuvant dopamine agonist therapy in Parkinson’s disease and multiple system atrophy. Parkinsonism and Related Disorders, 11, 381-386.

McKeon, A., Josephs, K. A., Klos, K. J., Hecksel, K., Bower, J. H., Michael Bostwick, J., & Eric Ahlskog, J. (2007). Unusual compulsive behaviors primarily related to dopamine agonist therapy in Parkinson’s disease and multiple system atrophy. Parkinsonism and Related Disorders, 13(8), 516-519.

Nirenberg, M. J., & Waters, C. (2006). Compulsive eating and weight gain related to dopamine agonist use. Movement Disorders, 21, 524-529.

Pontone, G., Williams, J. R., Bassett, S. S., & Marsh, L. (2006). Clinical features associated with impulse control disorders in Parkinson disease. Neurology, 67, 1258-1261.

Voon, V., Hassan, K., Zurowski, M., De Souza, M., Thomsen, T., Fox, S.,…& Miyasaki, J. (2006). Prevalence of repetitive and reward-seeking behaviors in Parkinson disease. Neurology, 67, 1254-1257.

Joystick junkies: A brief overview of online gaming addiction

Over the last 15 years, research into various online addictions have greatly increased. Prior to the 2013 publication of the American Psychiatric Association’s fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), there had been some debate as to whether ‘internet addiction’ should be introduced into the text as a separate disorder. Alongside this, there has also been debate as to whether those researching in the online addiction field should be researching generalized internet use and/or the potentially addictive activities that can be engaged on the internet (e.g., gambling, video gaming, sex, shopping, etc.).

It should also be noted that given the lack of consensus as to whether video game addiction exists and/or whether the term ‘addiction’ is the most appropriate to use, some researchers have instead used terminology such as ‘excessive’ or ‘problematic’ to denote the harmful use of video games. Terminology for what appears to be for the same disorder and/or its consequences include problem video game playing, problematic online game use, video game addiction, online gaming addiction, internet gaming addiction, and compulsive Internet use.

Following these debates, the Substance Use Disorder Work Group (SUDWG) recommended that the DSM-5 include a sub-type of problematic internet use (i.e., internet gaming disorder [IGD]) in Section 3 (‘Emerging Measures and Models’) as an area that needed future research before being included in future editions of the DSM. According to Dr. Nancy Petry and Dr. Charles O’Brien, IGD will not be included as a separate mental disorder until the (i) defining features of IGD have been identified, (ii) reliability and validity of specific IGD criteria have been obtained cross-culturally, (iii) prevalence rates have been determined in representative epidemiological samples across the world, and (iv) etiology and associated biological features have been evaluated.

Although there is now a rapidly growing literature on pathological video gaming, one of the key reasons that IGD was not included in the main text of the DSM-5 was that the SUDWG concluded that no standard diagnostic criteria were used to assess gaming addiction across these many studies. In 2013, some of my colleagues and I published a paper in Clinical Psychology Review examining all instruments assessing problematic, pathological and/or addictive gaming. We reported that 18 different screening instruments had been developed, and that these had been used in 63 quantitative studies comprising 58,415 participants. The prevalence rates for problematic gaming were highly variable depending on age (e.g., children, adolescents, young adults, older adults) and sample (e.g., college students, internet users, gamers, etc.). Most studies’ prevalence rates of problematic gaming ranged between 1% and 10% but higher figures have been reported (particularly amongst self-selected samples of video gamers). In our review, we also identified both strengths and weaknesses of these instruments.

The main strengths of the instrumentation included the: (i) the brevity and ease of scoring, (ii) excellent psychometric properties such as convergent validity and internal consistency, and (iii) robust data that will aid the development of standardized norms for adolescent populations. However, the main weaknesses identified in the instrumentation included: (i) core addiction indicators being inconsistent across studies, (iii) a general lack of any temporal dimension, (iii) inconsistent cut-off scores relating to clinical status, (iv) poor and/or inadequate inter-rater reliability and predictive validity, and (v) inconsistent and/or dimensionality.

It has also been noted by many researchers (including me) that the criteria for IGD assessment tools are theoretically based on a variety of different potentially problematic activities including substance use disorders, pathological gambling, and/or other behavioural addiction criteria. There are also issues surrounding the settings in which diagnostic screens are used as those used in clinical practice settings may require a different emphasis that those used in epidemiological, experimental, and neurobiological research settings.

Video gaming that is problematic, pathological and/or addictive lacks a widely accepted definition. Some researchers in the field consider video games as the starting point for examining the characteristics of this specific disorder, while others consider the internet as the main platform that unites different addictive internet activities, including online games. My colleagues and I have begun to make an effort to integrate both approaches, i.e., classifying online gaming addiction as a sub-type of video game addiction but acknowledging that some situational and structural characteristics of the internet may facilitate addictive tendencies (e.g., accessibility, anonymity, affordability, disinhibition, etc.).

Throughout my career I have argued that although all addictions have particular and idiosyncratic characteristics, they share more commonalities than differences (i.e., salience, mood modification, tolerance, withdrawal symptoms, conflict, and relapse), and likely reflects a common etiology of addictive behaviour. When I started research internet addiction in the mid-1990s, I came to the view that there is a fundamental difference between addiction to the internet, and addictions on the internet. However many online games (such as Massively Multiplayer Online Role Playing Games) differ from traditional stand-alone video games as there are social and/or role-playing dimension that allow interaction with other gamers.

Irrespective of approach or model, the components and dimensions that comprise online gaming addiction outlined above are very similar to the IGD criteria in Section 3 of the DSM-5. For instance, my six addiction components directly map onto the nine proposed criteria for IGD (of which five or more need to be endorsed and resulting in clinically significant impairment). More specifically: (1) preoccupation with internet games [salience]; (2) withdrawal symptoms when internet gaming is taken away [withdrawal]; (3) the need to spend increasing amounts of time engaged in internet gaming [tolerance], (4) unsuccessful attempts to control participation in internet gaming [relapse/loss of control]; (5) loss of interest in hobbies and entertainment as a result of, and with the exception of, internet gaming [conflict]; (6) continued excessive use of internet games despite knowledge of psychosocial problems [conflict]; (7) deception of family members, therapists, or others regarding the amount of internet gaming [conflict]; (8) use of the internet gaming to escape or relieve a negative mood [mood modification];  and (9) loss of a significant relationship, job, or educational or career opportunity because of participation in internet games [conflict].

The fact that IGD was included in Section 3 of the DSM-5 appears to have been well received by researchers and clinicians in the gaming addiction field (and by those individuals that have sought treatment for such disorders and had their experiences psychiatrically validated and feel less stigmatized). However, for IGD to be included in the section on ‘Substance-Related and Addictive Disorders’ along with ‘Gambling Disorder’, the gaming addiction field must unite and start using the same assessment measures so that comparisons can be made across different demographic groups and different cultures.

For epidemiological purposes, my research colleagues and I have asserted that the most appropriate measures in assessing problematic online use (including internet gaming) should meet six requirements. Such an instrument should have: (i) brevity (to make surveys as short as possible and help overcome question fatigue); (ii) comprehensiveness (to examine all core aspects of problematic gaming as possible); (iii) reliability and validity across age groups (e.g., adolescents vs. adults); (iv) reliability and validity across data collection methods (e.g., online, face-to-face interview, paper-and-pencil); (v) cross-cultural reliability and validity; and (vi) clinical validation. We aso reached the conclusion that an ideal assessment instrument should serve as the basis for defining adequate cut-off scores in terms of both specificity and sensitivity.

The good news is that research in the gaming addiction field does appear to be reaching an emerging consensus. There have also been over 20 studies using neuroimaging techniques (such as functional magnetic resonance imaging) indicating that generalized internet addiction and online gaming addiction share neurobiological similarities with more traditional addictions. However, it is critical that a unified approach to assessment of IGD is urgently needed as this is the only way that there will be a strong empirical and scientific basis for IGD to be included in the next DSM.

Note: A version of this article was first published on Rehabs.com

Dr. Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Further reading

American Psychiatric Association (2013) Diagnostic and Statistical Manual of Mental Disorders – Text Revision (Fifth Edition). Washington, D.C.: Author.

Demetrovics, Z., Urbán, R., Nagygyörgy, K., Farkas, J., Griffiths, M. D., Pápay, O., . . . Oláh, A. (2012). The development of the Problematic Online Gaming Questionnaire (POGQ). PLoS ONE, 7(5), e36417.

Griffiths, M.D. (2000). Internet addiction – Time to be taken seriously? Addiction Research, 8, 413-418.

Griffiths, M. D. (2005). A ‘components’ model of addiction within a biopsychosocial framework. Journal of Substance Use, 10(4), 191-197.

Griffiths, M.D., King, D.L. & Demetrovics, Z. (2014). DSM-5 Internet Gaming Disorder needs a unified approach to assessment. Neuropsychiatry, under review.

Griffiths, M.D., Kuss, D.J. & King, D.L. (2012). Video game addiction: Past, present and future. Current Psychiatry Reviews, 8, 308-318.

Kim, M. G., & Kim, J. (2010). Cross-validation of reliability, convergent and discriminant validity for the problematic online game use scale. Computers in Human Behavior, 26(3), 389-398.

King, D. L., Delfabbro, P. H., Griffiths, M. D., & Gradisar, M. (2011). Assessing clinical trials of Internet addiction treatment: A systematic review and CONSORT evaluation. Clinical Psychology Review, 31, 1110-1116.

King, D. L., Delfabbro, P. H., & Griffiths, M. D. (2012). Cognitive-behavioral approaches to outpatient treatment of Internet addiction in children and adolescents. Journal of Clinical Psychology, 68, 1185-1195.

King, D.L., Haagsma, M.C., Delfabbro, P.H., Gradisar, M.S., Griffiths, M.D. (2013). Toward a consensus definition of pathological video-gaming: A systematic review of psychometric assessment tools. Clinical Psychology Review, 33, 331-342.

Koronczai, B., Urban, R., Kokonyei, G., Paksi, B., Papp, K., Kun, B., . . . Demetrovics, Z. (2011). Confirmation of the three-factor model of problematic internet use on off-line adolescent and adult samples. Cyberpsychology, Behavior and Social Networking, 14, 657–664.

Kuss, D.J. & Griffiths, M.D. (2012). Internet and gaming addiction: A systematic literature review of neuroimaging studies. Brain Sciences, 2, 347-374.

Kuss, D.J., Griffiths, M.D., Karila, L. & Billieux, J. (2013).  Internet addiction: A systematic review of epidemiological research for the last decade. Current Pharmaceutical Design, in press.

Pápay, O., Nagygyörgy, K., Griffiths, M.D. & Demetrovics, Z. (2014). Problematic online gaming. In K. Rosenberg & L. Feder (Eds.), Behavioral Addictions: Criteria, Evidence and Treatment. New York: Elsevier.

Petry, N.M., & O’Brien, C.P. (2013). Internet gaming disorder and the DSM-5. Addiction, 108, 1186–1187.

Porter, G., Starcevic, V., Berle, D., & Fenech, P. (2010). Recognizing problem video game use. The Australian and New Zealand Journal of Psychiatry, 44, 120-128.

Young, K. S. (1998). Internet addiction: The emergence of a new clinical disorder. Cyberpsychology and Behavior, 1, 237-244.

Press to play: Is gaming as addictive as heroin?

Please note: The following blog was first published earlier today on the GamaSutra website. The original article can be found here.

Last week I appeared in loads of news stories following a double page spread in The Sun newspaper under the headline “Gaming as addictive as heroin”. Before the story went to press, I was asked by The Sun’s gaming editor – Lee Price – if I would provide a set of questions to help readers determine if they had a possible gaming addiction. (I’ve reproduced the ten questions at the end of this blog). I’ve written a number of articles for The Sun over the years and have always been happy to contribute to education concerning gaming issues. In fact, my previous article with The Sun was one published last year under the headline “Video games make us better people”. The gaming editor shared some of the text he was planning to publish and I was asked if I would like to add anything to his main article. The text I submitted for inclusion in the article read:

“Gaming addiction has become a real issue for the psychologists and medics over the last decade. The good news is that playing excessively doesn’t necessarily mean someone is addicted – the difference between a healthy excessive enthusiasm and an addiction is that healthy enthusiasms add to life whereas addiction takes away from it”.

This quote I provided did not appear anywhere on the double-page spread (probably because it didn’t fit the main thrust of the article). The headline “Gaming as addictive as heroin” (almost certainly provided by someone other than the Gaming Editor) was arguably more sensationalist that the article itself. Any regular readers of my blog will know that I believe gaming addictions exist but that the number of gamers that are genuinely addicted comprises a small minority. The Sun’s story began by claiming that: “Britain is in the grip of a gaming addiction which poses as big a health risk as alcohol and drug abuse”. The article also alleged that a London-based clinic claimed it was receiving 5,000 calls a year from parents seeking help for their child’s gaming addiction (I myself get around 2-3 calls or emails a month). It also featured a number of case studies claiming they were addicted to social networking games (like Candy Crush) and online multiplayer games (like League of Legends). There were also a number of references to alleged gaming-related deaths including the recent story that a coroner had linked three male suicides to playing the game Call of Duty.

On the day The Sun article was published, I was contacted by a journalist from Eurogamer for my comments on the piece. The resulting article was basically my interview with the journalist (which then formed the basis of countless stories that appeared in the online gaming press including the Tech Times, The Fix, Digital Spy, Polygon, Kotaku, etc.). I was asked if I thought gaming was as addictive as heroin. I responded by saying:

“It depends how you define addiction in the first place. I’ve spent my whole career trying to say if you’re going to call something an addiction it has to be similar right across the board. The criteria I use for video game addiction would be exactly the same as in heroin addiction in the sense that this is an activity that becomes the most important thing in your life, it compromises everything else in your life including your relationship, work and hobbies. It’s something you use as a way of modifying your mood. It’s something that builds up tolerance over time, so you need more and more. It’s something where you get withdrawal symptoms if you’re unable to engage in it. And it’s something that if you do manage to give up for a short time when you do the activity again you relapse. The good news from my perspective is on those particular criteria, the number of genuine video game addicts is few and far between. If we’re talking about genuine video game addiction, it doesn’t matter what the activity is if we’re using the same criteria. It’s a bit like that trick question my physics teacher used to give us, which was, if you’ve got a ton of feathers and a ton of lead, which weighs heavier? Most kids put down a ton of feathers, but the whole point is it’s a ton. It’s quite clear that some, whether it’s kids or young adults, have some problems around the fact they seem to be unable to control the amount of time they spend gaming, and maybe it’s impacting other areas of their life. But just because there are some addictive-like components there it doesn’t mean they’re genuinely addicted”.

I also told the journalist that to be genuinely addicted to a behaviour (like gaming) that I would expect to see conflict in every area of the person’s life – their relationships, their work and/or education, their other social activities. The Sun also claimed that: “Britain is in the grip of a gaming addiction”. I was asked by Eurogamer whether I thought this to be the case and I said that in my view this was “incorrect”. I then went on to say:

“I’ve spent well over 25 years studying video game addiction. If we’re going to use the word ‘addiction’ we have to use the same concepts, signs and symptoms we find in other more traditional addictions, like withdrawal and tolerance. By doing that the number of people who end up being addicted by my criteria are actually few and far between. The [ten questions] I did for The Sun is actually based on real criteria I use in my research. The number of people who would score seven out of 10 of those items I put in The Sun today, I’d find it very hard to believe there would be more than a handful of people out there that would score high on all those things. You’d probably get a lot of people who might endorse three or four of them, but that doesn’t mean they’re addicted. That might be somebody who has problems with it. Most kids can afford to play three hours a day without it impacting on their education, their physical education and their social networks. Yes, I believe video game addiction exists, and if it is a genuine addiction it may well be as addictive as other more traditional things in terms of signs, symptoms and components. But the good news is it is a very tiny minority who are genuinely addicted to video games…There is no evidence the country is in ‘the grip of addiction’. Yes, we have various studies showing a small minority have problematic gaming. But problematic gaming doesn’t necessarily mean gaming addiction. They’re two very separate things. Yet the media seem to put them as the same…Every time I do a piece of research, if it’s something that’s negative, 90 per cent of the press cover it. If it’s something positive, 10 per cent of the press cover it. Bad news stories sell”.

Speaking to the press (and writing journalistic articles for the press) is something that I do on an almost daily basis and I will not stop doing it as I believe that we as academics have a public duty to disseminate our research findings outside of academia and to the general public. As I noted in a previous blog, I’ve had a few horror stories when what I’ve said is taken out of context but a few bad experiences are never going to be enough to put me off sharing my work with the mass media.

Finally – and as promised above – here are ten simple ‘yes/no’ questions about gaming that I had published in The Sun. If you answer ‘yes’ to seven or more of them, in my view, you may have a gaming addiction.

• Do you think gaming has become the most important thing in your daily life?
• Have you jeopardised your job or education because of your gaming activity?
• Have you experienced relationship problems (with your partner, children or friends) because of your gaming?
• Do you feel irritable, anxious or sad when you try to cut down or stop gaming?
• Do you play games as a way of making your mood feel better?
• Have you lost interests in other hobbies and leisure activities because of gaming?
• When trying to cut down or stop your gaming, do you feel that you can’t?
• Do you feel totally preoccupied with gaming (for example, even if you are not actually gaming you are thinking about it)?
• Have you lied to anyone because the amount of time you spend gaming?
• Have you spent an increasing amount of time gaming every day over the last six months?

Dr. Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Further reading

Griffiths, M.D. (2010). Online video gaming: What should educational psychologists know? Educational Psychology in Practice, 26(1), 35-40.

Griffiths, M.D. (2013). Video games make us better people. The Sun, February 1, p.8.

Griffiths, M.D., King, D.L. & Demetrovics, Z. (2014). DSM-5 Internet Gaming Disorder needs a unified approach to assessment. Neuropsychiatry, 4(1), 1-4.

Griffiths, M.D., Kuss, D.J. & King, D.L. (2012). Video game addiction: Past, present and future. Current Psychiatry Reviews, 8, 308-318.

King, D.L., Delfabbro, P.H. & Griffiths, M.D. (2009). The psychological study of video game players: Methodological challenges and practical advice. International Journal of Mental Health and Addiction, 7, 555-562.

King, D.L., Delfabbro, P.H. & Griffiths, M.D. (2010). Video game structural characteristics: A new psychological taxonomy. International Journal of Mental Health and Addiction, 8, 90-106.

King, D.L., Delfabbro, P.H. & Griffiths, M.D. (2010). The role of structural characteristics in problem video game playing: A review. Cyberpsychology: Journal of Psychosocial Research on Cyberspace. Located at: http://www.cyberpsychology.eu/view.php?cisloclanku=2010041401&article=6.

King, D.L., Delfabbro, P.H. & Griffiths, M.D. (2010). The convergence of gambling and digital media: Implications for gambling in young people. Journal of Gambling Studies, 26, 175-187.

King, D.L., Delfabbro, P.H. & Griffiths, M.D. (2010). Cognitive behavioural therapy for problematic video game players: Conceptual considerations and practice issues. Journal of CyberTherapy and Rehabilitstion, 3, 261-273.

King, D.L., Delfabbro, P.H., Griffiths, M.D. & Gradisar, M. (2011). Assessing clinical trials of Internet addiction treatment: A systematic review and CONSORT evaluation. Clinical Psychology Review, 31, 1110-1116.

King, D.L., Delfabbro, P.H. & Griffiths, M.D. (2012). Clinical interventions for technology-based problems: Excessive Internet and video game use. Journal of Cognitive Psychotherapy: An International Quarterly, 26, 43-56.

King, D.L., Delfabbro, P.H., Griffiths, M.D. & Gradisar, M. (2012). Cognitive-behavioural approaches to outpatient treatment of Internet addiction in children and adolescents. Journal of Clinical Psychology: In Session, 68, 1185-1195.

King, D.L., Haagsma, M.C.^, Delfabbro, P.H.,Gradisar, M.S. &^, Griffiths, M.D. (2013). Psychometric assessment of pathological video-gaming:A systematic review. Clinical Psychology Review, 33, 331-342.

Carry on screening: A brief look at Internet Gaming Disorder

In this month’s issue of the Neuropsychiatry journal, I – and my research colleagues (Dr. Daniel King and Dr. Zsolt Demetrovics) – published a paper arguing that Internet Gaming Disorder needs a unified approach to assessment. Over the last 15 years, research into various online addictions has greatly increased. Prior to the publication of the fifth edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-5) in 2013, there had been some debate as to whether ‘internet addiction’ should be introduced into the text as a separate disorder. Alongside this, there has also been debate as to whether those researching in the online addiction field should be researching generalized internet use and/or the potentially addictive activities that can be engaged on the internet (e.g., gambling, video gaming, sex, shopping, etc.)

Following these debates, the Substance Use Disorder Work Group (SUDWG) recommended that the DSM-5 include a sub-type of problematic internet use (i.e., internet gaming disorder [IGD]) in Section 3 (‘Emerging Measures and Models’) as an area that needed future research before being included in future editions of the DSM. According to Dr. Nancy Petry and Dr. Charles O’Brien writing in a 2013 issue of Addiction, IGD will not be included as a separate mental disorder until the (i) defining features of IGD have been identified, (ii) reliability and validity of specific IGD criteria have been obtained cross-culturally, (iii) prevalence rates have been determined in representative epidemiological samples across the world, and (iv) etiology and associated biological features have been evaluated.

Although there is now a rapidly growing literature on pathological video gaming, one of the key reasons that IGD was not included in the main text of the DSM-5 was that the SUDWG concluded that no standard diagnostic criteria were used to assess gaming addiction across these many studies. A 2013 overview of instruments assessing problematic gaming by my colleagues and I in Clinical Psychology Review reported that 18 different screening instruments had been developed, and that these had been used in 63 quantitative studies comprising 58,415 participants. This comprehensive review identified both strengths and weaknesses of these instruments.

The main strengths of the instrumentation included the: (i) the brevity and ease of scoring, (ii) excellent psychometric properties such as convergent validity and internal consistency, and (iii) robust data that will aid the development of standardized norms for adolescent populations. However, the main weaknesses identified in the instrumentation included: (i) core addiction indicators being inconsistent across studies, (iii) a general lack of any temporal dimension, (iii) inconsistent cut-off scores relating to clinical status, (iv) poor and/or inadequate inter-rater reliability and predictive validity, and (v) inconsistent and/or dimensionality. It has also been noted by a number of authors that the criteria for IGD assessment tools are theoretically based on a variety of different potentially problematic activities including substance use disorders, pathological gambling, and/or other behavioral addiction criteria. There are also issues surrounding the settings in which diagnostic screens are used as those used in clinical practice settings may require a different emphasis that those used in epidemiological, experimental and neurobiological research settings.

Video gaming that is problematic, pathological and/or addictive (i.e., IGD) lacks a widely accepted definition. In a recent book chapter (in the 2014 book Behavioral Addictions: Criteria, Evidence and Treatment edited by Dr. Ken Rosenberg and Dr. Laura Feder), I and some of my Hungarian colleagues argued that some researchers consider video games as the starting point for examining the characteristics of this specific disorder, while others consider the internet as the main platform that unites different addictive internet activities, including online games. Recent studies have made an effort to integrate both approaches Consequently, IGD can either be viewed as a specific type of video game addiction, or as a variant of internet addiction, or as an independent diagnosis.

As I argued in one of my previous blogs, although all addictions have particular and idiosyncratic characteristics, they share more commonalities than differences (i.e., salience, mood modification, tolerance, withdrawal symptoms, conflict, and relapse), and this likely reflects a common etiology of addictive behavior. Consequently, online game addiction may be viewed as a specific type of video game addiction. Similarly, Dr. G. Porter and colleagues in a 2010 issue of the Australian and New Zealand Journal of Psychiatry, do not differentiate between problematic video game use and problematic online game use. They conceptualized problematic video game use as excessive use of one or more video games resulting in a preoccupation with and a loss of control over playing video games, and various negative psychosocial and/or physical consequences. However, unlike my conceptualization of gaming addiction, their criteria for problematic video game use does not include other features usually associated with dependence or addiction, (e.g., tolerance, physical symptoms of withdrawal), as they say there is no clear evidence that problematic gaming is associated with such phenomena. Researchers such as Dr. Kimberley Young view online gaming addiction as a sub-type of internet addiction and that the internet itself provides situation-specific characteristics that facilitate gaming becoming problematic and/or addictive.

In a 2010 issue of Computers in Human Behavior, Dr. M.G. Kim and Dr. J. Kim’s [11] proposed a Problematic Online Game Use (POGU) model that takes a more integrative approach and claims that neither of the approaches outlined above adequately capture the unique features of online games such as Massively Multiplayer Online Role Playing Games (MMORPGs). They argue that the internet is just one channel where people may access the content they want (e.g., gambling, shopping, sex, etc.) and that such users may become addicted to the particular content rather than the channel itself. This is analogous to the argument that I made over 15 years ago in a number of different papers that there is a fundamental difference between addiction to the internet, and addictions on the internet. However, MMORPGs differ from traditional stand-alone video games as there are social and/or role-playing dimension that allow interaction with other gamers.

The POGU model resulted in five underlying dimensions of addictive gameplay (i.e., euphoria, health problems, conflict, failure of self-control, and preference of virtual relationship). I also support the integrative approach and stress the need to include all types of online games in addiction models in order to make comparisons between genres and gamer populations possible (such as those who play online Real-Time Strategy (RTS) games and online First Person Shooter (FPS) games in addition to the widely researched MMORPG players). The POGU model comprises six dimensions (i.e., preoccupation, overuse, immersion, social isolation, interpersonal conflicts, and withdrawal).

Irrespective of approach or model, the components and dimensions that comprise online gaming addiction outlined above are very similar to the IGD criteria in Section 3 of the DSM-5. For instance, my six addiction components directly map onto the nine proposed criteria for IGD (of which five or more need to be endorsed and resulting in clinically significant impairment). More specifically: (1) preoccupation with internet games [salience]; (2) withdrawal symptoms when internet gaming is taken away [withdrawal]; (3) the need to spend increasing amounts of time engaged in internet gaming [tolerance], (4) unsuccessful attempts to control participation in internet gaming [relapse/loss of control]; (5) loss of interest in hobbies and entertainment as a result of, and with the exception of, internet gaming [conflict]; (6) continued excessive use of internet games despite knowledge of psychosocial problems [conflict]; (7) deception of family members, therapists, or others regarding the amount of internet gaming [conflict]; (8) use of the internet gaming to escape or relieve a negative mood [mood modification];  and (9) loss of a significant relationship, job, or educational or career opportunity because of participation in internet games [conflict].

The fact that IGD was included in Section 3 of the DSM-5 appears to have been well received by researchers and clinicians in the gaming addiction field (and by those individuals that have sought treatment for such disorders and had their experiences psychiatrically validated and feel less stigmatized). However, for IGD to be included in the section on ‘Substance-Related and Addictive Disorders’ along with ‘Gambling Disorder’, the gaming addiction field must unite and start using the same assessment measures so that comparisons can be made across different demographic groups and different cultures.

For epidemiological purposes, Dr. B. Koronczai and colleagues in a 2011 issue of Cyberpsychology, Behavior and Social Networking, asserted that the most appropriate measures in assessing problematic online use (including internet gaming) should meet six requirements. Such an instrument should have: (i) brevity (to make surveys as short as possible and help overcome question fatigue); (ii) comprehensiveness (to examine all core aspects of IGD as possible); (iii) reliability and validity across age groups (e.g., adolescents vs. adults); (iv) reliability and validity across data collection methods (e.g., online, face-to-face interview, paper-and-pencil); (v) cross-cultural reliability and validity; and (vi) clinical validation. It was also noted that an ideal assessment instrument should serve as the basis for defining adequate cut-off scores in terms of both specificity and sensitivity. To fulfill all these requirements, future research should adjust the currently used assessment tools to the newly accepted DSM-5 criteria and take much more efforts to reach and study clinical samples, which is an unequivocal shortcoming of both internet and gaming research.

In addition to further epidemiological and clinical research, further research is also needed on the neurobiology of IGD. A systematic review of 18 neuroimaging studies examining internet addiction and IGD by Dr. Daria Kuss and Griffiths in a 2012 issue of Brain Sciences noted that:

“These studies provide compelling evidence for the similarities between different types of addictions, notably substance-related addictions and Internet and gaming addiction, on a variety of levels. On the molecular level, Internet addiction is characterized by an overall reward deficiency that entails decreased dopaminergic activity. On the level of neural circuitry, Internet and gaming addiction lead to neuroadaptation and structural changes that occur as a consequence of prolonged increased activity in brain areas associated with addiction. On a behavioral level, Internet and gaming addicts appear to be constricted with regards to their cognitive functioning in various domains” (p.347).

The good news is that research in the gaming addiction field does appear to be reaching an emerging consensus. We noted in our 2013 Clinical Psychology Review paper that across many different studies, IGD is commonly defined by (a) withdrawal, (b) loss of control, and (c) conflict. However, it is critical that a unified approach to assessment of IGD is urgently needed as this is the only way that there will be a strong empirical basis for IGD to be included in the next DSM.

Dr Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Further reading

American Psychiatric Association (2013) Diagnostic and Statistical Manual of Mental Disorders – Text Revision (Fifth Edition). Washington, D.C.: Author.

Demetrovics, Z., Urbán, R., Nagygyörgy, K., Farkas, J., Griffiths, M. D., Pápay, O., . . . Oláh, A. (2012). The development of the Problematic Online Gaming Questionnaire (POGQ). PLoS ONE, 7(5), e36417.

Griffiths, M.D. (2000). Internet addiction – Time to be taken seriously? Addiction Research, 8, 413-418.

Griffiths, M. D. (2005). A ‘components’ model of addiction within a biopsychosocial framework. Journal of Substance Use, 10(4), 191-197.

Griffiths, M.D., King, D.L. & Demetrovics, Z. (2014). DSM-5 Internet Gaming Disorder needs a unified approach to assessment. Neuropsychiatry, under review.

Griffiths, M.D., Kuss, D.J. & King, D.L. (2012). Video game addiction: Past, present and future. Current Psychiatry Reviews, 8, 308-318.

Kim, M. G., & Kim, J. (2010). Cross-validation of reliability, convergent and discriminant validity for the problematic online game use scale. Computers in Human Behavior, 26(3), 389-398.

King, D. L., Delfabbro, P. H., Griffiths, M. D., & Gradisar, M. (2011). Assessing clinical trials of Internet addiction treatment: A systematic review and CONSORT evaluation. Clinical Psychology Review, 31, 1110-1116.

King, D. L., Delfabbro, P. H., & Griffiths, M. D. (2012). Cognitive-behavioral approaches to outpatient treatment of Internet addiction in children and adolescents. Journal of Clinical Psychology, 68, 1185-1195.

King, D.L., Haagsma, M.C.,Delfabbro, P.H.,Gradisar, M.S.^, Griffiths, M.D. (2013). Toward a consensus definition of pathological video-gaming: A systematic review of psychometric assessment tools. Clinical Psychology Review, 33, 331-342.

Koronczai, B., Urban, R., Kokonyei, G., Paksi, B., Papp, K., Kun, B., . . . Demetrovics, Z. (2011). Confirmation of the three-factor model of problematic internet use on off-line adolescent and adult samples. Cyberpsychology, Behavior and Social Networking, 14, 657–664.

Kuss, D.J. & Griffiths, M.D. (2012). Internet and gaming addiction: A systematic literature review of neuroimaging studies. Brain Sciences, 2, 347-374.

Kuss, D.J., Griffiths, M.D., Karila, L. & Billieux, J. (2013).  Internet addiction: A systematic review of epidemiological research for the last decade. Current Pharmaceutical Design, in press.

Pápay, O., Nagygyörgy, K., Griffiths, M.D. & Demetrovics, Z. (2014). Problematic online gaming. In K. Rosenberg & L. Feder (Eds.), Behavioral Addictions: Criteria, Evidence and Treatment. New York: Elsevier.

Petry, N.M., & O’Brien, C.P. (2013). Internet gaming disorder and the DSM-5. Addiction, 108, 1186–1187.

Porter, G., Starcevic, V., Berle, D., & Fenech, P. (2010). Recognizing problem video game use. The Australian and New Zealand Journal of Psychiatry, 44, 120-128.

Young, K. S. (1998). Internet addiction: The emergence of a new clinical disorder. Cyberpsychology and Behavior, 1, 237-244.

Bitter sweet? A brief look at ‘addiction’ to Candy Crush

Earlier this week, the ‘addictiveness’ of the game Candy Crush made the national newspapers when the Daily Mail published the story with the headline ‘How women blow £400,000 a day playing Candy Crush, the most addictive online game ever’. The Mail article said:

“Look around any busy train or bus and it seems every other person with a smartphone or tablet is hooked on Candy Crush Saga, the latest online game to have taken the world by storm. With its twinkly lights, hypnotic music and comic sound effects, it has millions of people in its grip – and, like 2010’s Angry Birds, which even numbered [British Prime Minister] David Cameron among its fans, it has become an online sensation…An astonishing 700 million games of Candy Crush are played every day on mobile devices alone, according to AppData, a leading authority on social media trends. But, unlike so many video games, it appears that instead of teenage boys and men, it’s mostly women who are in thrall to Candy Crush. According to the game’s creators, King.com, women aged 25-55 are the demographic most loyal to the game…According to ThinkGaming, Candy Crush makes an estimated £400,000 a day for King. That’s £146m a year, figures which have prompted the Office of Fair Trading to voice concern that guidelines are needed to stop firms exploiting young users.King claims that 90 per cent of its players are over 21, but maturity doesn’t seem to prevent women…from falling under Candy Crush’s spell”.

I was interviewed by the journalist that wrote the article [Jill Foster] who wanted to know why it was such an ‘addictive’ game and why so many women played it. I told her that Candy Crush is a gender-neutral games that has a ‘moreish’ quality (a bit like chocolate – although this analogy didn’t end up in the article) and can fit in flexibly around what women do in their day-to-day life. The game takes up all the player’s cognitive ability because anyone playing on it has to totally concentrate on it. By being totally absorbed players can forget about everything else for a few minutes. I speculated that this may be particularly appealing to many women whether they are a stay-at-home mother who has ten minutes to play it in between childcare, or a business executive on her commute. It’s deceptively simple and fun. I also noted that unlike many online games, Candy Crush doesn’t involve killing or fighting, and it doesn’t feature strong male characters or highly sexualized female characters. For those of you reading this that have yet to play Candy Crush, the Mail report provided a good description of the game:

“The rules of Candy Crush are indeed simple. Players move a variety of brightly coloured sweets – or candies – around a grid and line up at least three of the same sweet in a row. Every time a row is completed, the line explodes, making way for more sweets to drop in. With more than 400 different stages, each more difficult than the last, and more being added all the time, players never need run out of challenges. As a so-called ‘freemium’ product, basic access to the game is free, but users must pay for ‘premium’ services. Players aren’t charged to advance through the first 35 levels but after that, it costs 69p for another 20 levels, although it is possible to avoid paying by asking your Facebook friends to send you extra lives. However, the cost can rise as players are encouraged to buy ‘boosters’ such as virtual ‘candy hammers’ for around £1”.

In typical tabloid style, the Mail article had interviewed a number of women that were used as examples to demonstrate the existence of Candy Crush ‘addiction’. For instance, Lucy Berkley, a 44-year old company director from Ashford in Kent told of how she came into her office on a Monday morning with severe back pain. All of her work colleagues could clearly see she was in much discomfort. The cause of her back pain was Candy Crush that she had played for ten hours over the weekend hunched over her iPad. She claimed “I couldn’t help it, it was so addictive. The extraordinary thing was that almost everyone else in the room admitted they too were addicted. Now we’re all competing”. Another woman, Steph, a mother-of-one interviewed for the Mail article said:

“I’m thinking about it all the time. I call it “crack candy” because I imagine giving up is like trying to break a crack habit. I hadn’t heard of it until I saw that many friends – all intelligent, creative women – were playing it on Facebook. I’ve never played any other game on my phone. But I don’t like going a day without my ‘fix’. I play it whenever I have a free moment. In the morning I play on my commute and when I look around the train, nearly every other person seems to be doing the same. I’ll have a sneaky game or two at lunchtime. When I get home, I’ll leave the ironing or the housework and have half an hour – or more – on the iPad. [At the weekend when] I’ve got up and read the papers, I’ll start playing and that’s me sorted for the next three to four hours. In fact, I only usually stop when my iPad runs out of battery. My boyfriend thinks I’m mad. My son Ben, who is at boarding school, can’t understand my obsession. I’ve been known to meet him off a train and rather than give him a hug I’ve said ‘Just a minute Ben, I’m just getting on to the next level!”

She then went on to say:

“Over the past four months I’ve probably spent around £150 playing it. But it’s worth it…I’m thinking about it all the time. I wake up and the first thing I do is pick up my phone to have a game, then I’ll be playing if I get a spare second before work. I play it on my walk from the car to the office. When I come home, I play it while I’m cooking the evening meal or watching TV. [My partner] Martin thinks I’m bonkers. When the lights go out and we’re in bed he’ll say: ‘I know you’re playing it because I can see the light from your phone’ so I have to play it under the covers. My son asks: “Why are you playing that game again Mum?’ It’s as if our roles have been reversed. It’s taking over my life. I don’t know if I’ll ever be able to stop”.

Although none of the cases covered in the piece appear to be genuinely addicted by the criteria I use to assess addiction, that doesn’t mean the cases are uninteresting psychologically or that games like Candy Crush are totally innocuous. I have noted in a number of my more general writings about games played via social networking sites that ‘freemium’ games are psychological ‘foot-in-the-door’ techniques that lead a small minority of people to pay for games and/or game accessories that they may never have originally planned to buy before playing the game (akin to ‘impulse buying’ in other commercial environments. I’ve also argued that many of the games played on social network sites share similarities with gambling. As I noted in my interview with the Mail:

‘On first look, games like Candy Crush may not seem to have much connection to gambling, but the psychology is very similar. Even when games do not involve money, they introduce players to the principles and excitement of gambling. Small unpredictable rewards lead to highly engaged, repetitive behaviour. In a minority, this may lead to addiction”

Basically, people keep responding in the absence of reinforcement hoping that another reward is just around the corner (a psychological principle rooted in operant conditioning and called the partial reinforcement extinction effect – something that is used to great effect in both slot machines and most video games). Another woman interviewed for the Mail story (Jenni Weaver, a 40-year-old mum of four from Bridlington) is worried that she’s addicted to Candy Crush (and based on her interview quotes, she certainly appears to display some signs of bona fide addictive behaviour) She told the Mail that her Candy Crush addiction was beginning to affect family life:

‘I’m playing it for eight hours a day now and it’s become a real problem. My daughter told me about it. I was hooked straight away. The longest I’ve played for is 12 hours with just a few short breaks in between. It’s worse than smoking…Housework has gone to pot. I’ve even been late picking my ten-year-old up from school because I’ve been stuck on a level. I’ve burnt countless dinners and let vegetables boil dry because I’ve been engrossed. I’m trying to limit myself, but I can still spend eight hours a day playing it. It’s ridiculous.’

Earlier this year, I was interviewed at length by Mike Rose (for Gamasutra, the online magazine about gaming issues), who wrote a really good set of articles about free-to-play games. In one of Rose’s articles I argued that even in games where no money is changing hands, players are learning the mechanics of gambling and that there are serious questions about whether gambling with virtual money encourages positive attitudes towards gambling. As I have noted in a number of my recent articles, the introduction of in-game virtual goods and accessories (that people pay real money for) was a psychological masterstroke. It becomes more akin to gambling, as social gamers know that they are spending money as they play with little or no financial return. The real difference between pure gambling games and some free-to-play games is the fact that gambling games allow you to win your money back, adding an extra dimension that can potentially drive revenues even further. The lines between social free-to-play games and gambling is beginning to blur, bringing along with them various moral, ethical, legal, and social issues. The psychosocial impact of free-to-play games is only just beginning to be investigated by people in the field of gaming studies. Empirically, we know almost nothing about the psychosocial impact of gambling or gaming via social networking sites, although research suggests the playing of free games among adolescents is one of the risk factors for both the uptake of real gambling and problem gambling.

Postscript: Following the Daily Mail story I was also interviewed at length for a story that appeared in Yahoo! News – you can read my in-depth comments here.

Dr Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Further reading

Foster, J. (2013). How women blow £400,000 a day playing Candy Crush, the most addictive online game ever. Daily Mail, October 17. Located at: http://www.dailymail.co.uk/femail/article-2463636/How-women-blow-400-000-day-playing-Candy-Crush-addictive-online-game-ever.html

Griffiths, M.D. (2010). Online gambling, social responsibility and ‘foot-in-the-door techniques. i-Gaming Business, 62, 100-101.

Griffiths, M.D. (2010). Gaming in social networking sites: A growing concern? World Online Gambling Law Report, 9(5), 12-13.

Griffiths, M.D. (2012). The psychology of social gaming. i-Gaming Business Affiliate, August/September, 26-27.

Griffiths, M.D. (2013). Social gambling via Facebook: Further observations and concerns. Gaming Law Review and Economics, 17, 104-106.

Hall, C. (2013). Just how addictive are mobile games? Yahoo! News, October 18. Located at: http://uk.news.yahoo.com/how-addictive-are-mobile-games–143654713.html#P1M3U7a

Lagorio-Chaflkin, C. (2013). Candy Crush Saga’s intoxicating secret source. Inc.com, July 25. Located at: http://www.inc.com/christine-lagorio/candy-crush-secret-sauce.html

Pressman, A. (2013). Candy Crush: Insanely addictive today, but likely on borrowed time. The Exchange, July 11. Located at: http://finance.yahoo.com/blogs/the-exchange/candy-crush-insanely-addictive-today-likely-borrowed-time-171103788.html

Rose, M. (2013). Chasing the Whales: Examining the ethics of free-to-play games. Gamasutra, July 9. Located at: http://www.gamasutra.com/view/feature/195806/chasing_the_whale_examining_the_.php?page=7