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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.