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.

Arcade fire: A brief look at pinball addiction

“I guess what started my pinball addiction was how it has become the perfect distraction. I like to drink beer. And go out. And recreate. Pinball is often found in bars here in the San Francisco Bay Area, so grabbing a beer and dropping a few quarters and playing a game with a friend is a great way to kick it. That’s kind of how it started, as something I might do here and there, but it’s grown into a full blown addiction as I’ve discovered more about pinball. It’s a hobby, a sport, and a pastime, but for me, it’s all consuming” (Gene X, December 18, 2013).

“PinballJunky.com is a periodic hobby-blog operated by one guy with over 20 years of unbridled collector’s obsession over anything having to do with the Art, Science, History and Culture of Pinball. Armed with an arsenal of over 30 Pins, our Moderator has built, rebuilt, repaired, restored, demolished and labored with an OCD level of passion over 100’s of pinball machines from the 70’s, 80’s and 90’s era. While he has experimented with various EM pins over the years, The Junky is particularly passionate about the SS games of the 90s and present” (from the Pinball Junky website).

As far as I am aware, only one academic paper has ever been published on pinball addiction, and that was a case study that I published in 1992 issue of Psychological Reports. My paper featured the case of a young man (aged 25 years) that I interviewed as part of another study on slot machine gambling (that I published in a 1994 issue of the British Journal of Psychology about the role of cognitive bias and skill in slot machine gambling). During the post-experimental interview, I asked all my participants to complete a questionnaire that included the (1987 revised third edition) Diagnostic and Statistical Manual of Mental Disorders criteria for pathological gambling. None of the nine items was endorsed but after completing my questionnaire, my participant spontaneously added that if he’d been asked the same questions about his pinball playing and videogame playing he would have answered ‘yes’ to a majority of the questions. On the spur of the moment I changed the word ‘gamble’ in the DSM-III-R criteria to the word ‘play’ and asked him to take that part of the survey again. In short, I asked him if he endorsed any of the following

• Frequent preoccupation with playing or obtaining money to play
• Often plays with larger amounts of money or over a longer period than intended
• Need to play more to achieve the desired excitement
• Restlessness or irritability if unable to play
• Repeatedly returns to win back losses
• Repeated efforts to cut down or stop playing
• Often plays when expected to fulfill social, educational or occupational obligations.
• Has given up some important social, occupational or recreational activity in order to play
• Continues to play despite inability to pay mounting debts, or despite other significant social, occupational, or legal problems that the individual knows to be exacerbated by playing

If a person answers ‘yes’ to four of the above questions, the person was deemed to be an amusement machine ‘addict’. This time, my participant answered ‘yes’ to six out the nine questions, that I interpreted as showing signs of pinball pathology. It was at this point he was interviewed further.

The participant began playing pinball machines (and arcade videogame machines) at school when he was around 14 or 15 years of age. This he did with many of his male peers at the start of the ‘videogame explosion’ (as he put it) in around 1979 to 1980. He became “very good” at pinball playing and felt particularly good when lots of people, both male and female, were watching him and he was playing well. This implied he played mainly for social reasons. However, he also enjoyed playing on his own and, at the time of my study, he predominantly played alone. While playing, he reported that he experienced a ‘high’ – a continuous high (as opposed to an immediate high or ‘rush’ reported by some addicted slot machine gamblers (that I had reported throughout my published studies on adolescent slot machine players in 1990 and 1991) which was especially notable when he “started off with a good ball”, got “free replay”, or experienced something intrinsically motivating to him (e.g., someone watching him play).

Back in 1983, Dr. Sidney Kaplan and Dr. Shirley Kaplan reported in the Journal of Popular Culture, that male pinball players may be attracted by the machine’s sexual graphics. However, my participant reported that he was more attracted by the features within the game and liked the idea that he could master a game, something that attracted him to videogames as well. He went on to say that both pinball machines and videogame machines were very similar because they both (i) score through points, (ii) have no financial reward – unlike a fruit machine, (iii) give the players pleasure from gaining a high score, i.e., an intrinsic reward, (iv) have the chance to gain free replays, and (v) require skill to play well. The reasons he didn’t play slot machines were because (i) its financial rewards were too infrequent, (ii) they are mostly chance-oriented, (iii) there are no points to score, and (iv) there is no free replay feature (except of course if the player won and decided to play again).

At the time I published the paper, it had been argued at various gambling conferences that I attended that “videogames are not as bad as slot machines because the better the player gets, the less money the player spends”. At face value this was correct as some adolescents could make 10 pence last over an hour on a videogame. However, the participant explained to me that he (and others) used to spend “hundreds of pounds” learning to play videogames and pinball machines, and then, when they were proficient at them, they would get bored with the game and spend their money learning how to play a new game on another machine. For this participant, pinball machines were different from videogame playing. Although he had played many different pinball machines, he had a personal favourite which he always returned to because it was the one on which he had his first “major success” (i.e., a very high score).

Back in 1992 I argued that it would be beneficial to adapt the criteria for pathological gambling for use in the monitoring of gaming machine addictions. By using such checklists (which can be administered quickly and easily), I argued it would be possible to record objective measures of incidence of probable amusement-machine addicts (including pinball addiction) and possibly show whether these types of addictions are implicated or act as precursors to more established addictions (e.g., pathological gambling). In 2013, criteria for Internet Gaming Disorder were included in Section 3 of the latest DSM-5 (using many of the criteria outlined above). However, given the complete lack of any other academic paper on pinball addiction, it doesn’t look as though pinball addiction will be appearing in any psychiatric diagnostic manual anytime soon. However, this case and other papers that I wrote on slot machine and video game addiction at the time led to my 1995 paper on technological addictions (that has now become one of my most highly cited papers).

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

American Psychiatric Association (1987). Diagnostic and Statistical Manual of Mental Disorders (3rd Edition -Revised). Washington D.C. : Author

Griffiths, M.D. (1990). Addiction to fruit machines: A preliminary study among males. Journal of Gambling Studies, 6, 113-126.

Griffiths, M.D. (1991). Fruit machine addiction: Two brief case studies. British Journal of Addiction, 85, 465.

Griffiths, M.D. (1991). Amusement machine playing in childhood and adolescence: A comparative analysis of video games and fruit machines. Journal of Adolescence, 14, 53-73.

Griffiths, M.D. (1991). The psychobiology of the near miss in fruit machine gambling. Journal of Psychology, 125, 347-357.

Griffiths, M.D. (1991). The observational study of adolescent gambling in UK amusement arcades. Journal of Community and Applied Social Psychology, 1, 309-320.

Griffiths, M.D. (1992). Pinball wizard: A case study of a pinball addict. Psychological Reports, 71, 160-162.

Griffiths, M.D. (1993). Tolerance in gambling: An objective measure using the psychophysiological analysis of male fruit machine gamblers. Addictive Behaviors, 18, 365-372.

Griffiths, M.D. (1993). Fruit machine addiction in adolescence: A case study. Journal of Gambling Studies, 9, 387-399.

Griffiths, M.D. (1994). The role of cognitive bias and skill in fruit machine gambling. British Journal of Psychology, 85, 351-369.

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

Kaplan, S. J. (1983). The image of amusement arcades and differences in male and female video game playing. Journal of Popular Culture, 17(1), 93-98.

Kaplan, S., & Kaplan, S. (1981). A research note: Video games, sex, and sex differences. Social Science, 208-212

Kaplan, S., & Kaplan, S. (1983). Video games, sex and sex differences. The Journal of Popular Culture, 17(2), 61-66.

Flying high? Is the playing ‘Flappy Bird’ excessively something to worry about?

The following blog is an expanded version of an article that first appeared in Nottingham Trent University’s Expert Opinion column

A few weeks ago I was introduced to the game Flappy Bird by my kids while celebrating the 80th birthday of their grandma. Within an hour, everyone – from the toddlers to the octogenarians – was playing it. Flappy Bird is another one of those free games that is very hard to put down once you start playing it. The game’s premise is so simple, almost banal – just keeping a bird flying by tapping one finger on the touch screen of a phone or tablet and guiding the bird between a series of pipes with gaps. For each gap in a pipe that the bird flies through, the player gets one point. Hitting or touching a pipe – or touching the ground – and it’s game over. Embarrassingly, I have yet to get into double figures. As one media commentator noted, it’s a game you love to hate – but end up just loving it!

Do a quick Google search on Flappy Bird and the one phrase that keeps coming up is that the game is “infuriatingly addictive” – and I couldn’t agree more. As soon as the game is over, the only way I can dissipate the feeling of frustration, annoyance, and anger of not doing very well is to play again immediately. For those that do well, they immediately want to play again to beat their high score. As one reviewer of the game noted:

“I was perusing the App Store, as one often does, when I noticed a new title sitting at the top of the free app chart. I decided to download it and take it for a spin as, if it is the most popular free app at the moment, it must at least be worth a look. From that point forward, that title – Flappy Bird – irritated the hell out of me and I couldn’t stop playing it…So, why can’t I stop playing? I’m actually not entirely sure myself. Maybe it’s that the game is incredibly easy to pick up and play. The one-finger gameplay is easy to grasp immediately but Flappy Bird is ridiculously difficult from the get go. Making it through a few sets of pipes feels like a humongous achievement as crashing is so much easier – it’s almost as if the game starts off at the highest difficulty level and just remains that way rather than gradually becoming more challenging. After a few hours playing Flappy Bird a double-digit score would probably be all you could expect. Then there is the ease in which you can start the next game immediately after failing your last effort. As soon as one game ends you can be into the next one in seconds making for an incredibly addictive experience. Each attempt is frustrating and you think you can do better next time, or at least prove that you’re not an idiot incapable of simply guiding a bird past some pipes… Despite all of its obvious and irritating flaws, Flappy Bird remains incredibly addictive and is certainly worth taking a few minutes to check out (although that few minutes may well turn into a few hours). I found that playing it was fun as well as frustrating and, if I’m being totally honest, the game fulfils its own mission entirely. It’s a simple arcade game but unique in its incredible difficulty, just as the developer’s clearly intended.

Earlier this month, the game’s creator, Dong Nguyen, withdrew Flappy Bird from online app stores – even though he was earning over 50,000 a day via in-app advertising revenue. He was quoted as saying:

“Flappy Bird was designed to play in a few minutes when you are relaxed. But it happened to become an addictive product. I think it has become a problem. To solve that problem, it’s best to take down Flappy Bird. It’s gone forever.”

As someone that has spent over 25 years researching into video game play, Flappy Bird is the latest in a long line of fun and deceptively simple games that someone can end up playing for hours on end. The game is gender-neutral and has a ‘moreish’ quality (a bit like chocolate in that it’s really hard just to eat one piece) and can fit in flexibly around what individuals do in their day-to-day life. Most simple games like Flappy Bird take 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. This can be particularly appealing for players that want to use games as a way of temporarily forgetting about everything else that’s going on in their lives. One video game review I came across said:

“Flappy Bird is the latest weirdly addicting game to captivate mobile users. The reason is simple, if not straightforward. In the guise of a cartoonish time-waster, Flappy Bird offers some of the most punishing, hardcore gameplay you can imagine. And it’s sucking in players by the millions”.

Psychologically, casual games like Flappy Bird rely on both positive and negative reinforcement over speedy gameplay. I have noted that many 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 casual games share similarities with gambling. On first look, games like Flappy Bird 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).

Physiologically, these games are likely to increase dopamine levels when people are doing well whereas and failure will most likely cause an increase in noradrenaline. The interaction of two competing neurotransmitter systems is likely to keep players engaged in the game for periods longer than they originally intended. In short, the games are ingeniously simple, highly enjoyable, and (as some players describe them) “emotionally intoxicating”. I’ve only ever come across a few people that I would define as genuinely addicted to these games but all the ingredients are there to make it theoretically possible for almost anyone to be psychologically seduced by such games.

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

Further reading

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

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