Andrew Fishman LCSW

Video Game Addiction

The argument against video game addiction, many researchers are skeptical that video games are truly "addictive.".

Updated July 3, 2023 | Reviewed by Devon Frye

  • What Is Video Game Addiction?
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  • Video games have many benefits for gamers.
  • Research on gaming disorder—aka video game addiction—is flawed and not sufficiently conclusive.
  • Because video games are less socially acceptable, they may be unfairly targeted.
  • There are other explanations for many reports of video game addiction, including autism, ADHD, and depression.

This is half of a pair of articles that highlight the evidence for and against the existence of video game addiction . Read the counter-argument here .

For decades, psychologists, parents, and gamers have asserted that video games can be addictive. Although video games seem to influence enthusiasts differently from those of other hobbies, there is insufficient empirical evidence to designate them as an actual addiction . Further, video games are a fun and socially beneficial activity for many, so labeling them as addictive would prevent many from accessing these benefits.

For example, video games connect lonely or introverted people with one another , relieve stress , and even help people explore their own identities . Some therefore argue that, because of video games’ benefits and popularity, gaming addiction should not be considered an official diagnosis until overwhelming evidence supports this assertion.

Flawed Research

Several studies have concluded that gaming disorder qualifies as an addiction. Because addictions share several characteristics, researchers created theoretical criteria that a gamer must meet to have the diagnosis. For example, people with addictions suffer consequences in various aspects of their life and struggle to quit without help. This is true regardless of the substance.

Based on the assumption that people with video game addiction must be affected similarly, researchers have surveyed gamers on similar criteria to determine what percent have an addiction. These include questions such as, “How often do you find it difficult to stop gaming?” and “Have you deceived a family member, significant other, employer, or therapist regarding the amount of time spent engaging in gaming activities?”

Although questions like these may reasonably assess someone’s behavior, researchers use too many different questionnaires to be compared cleanly. Even when researchers use the same survey, they sometimes interpret the results differently.

In other words, someone would need to answer “Yes” to six of the eleven Gaming Addiction Screening questions to be considered addicted. They would need to respond “Sometimes” or “Often” to five or more of the ten questions in the Ten Item Internet Gaming Disorder Test to qualify. If the same person took both surveys, one survey might conclude that they had an addiction and the other might not. Further, some studies only measure how many hours per week a person spends gaming instead of targeting the effect games have on their functioning.

This has resulted in wildly different estimates of gaming addiction’s prevalence. It is difficult to draw meaningful conclusions from these data until researchers use standardized measures.

It is also very difficult to estimate one’s actual screen time each week. One meta-analysis of the research found that in 95 percent of studies, participants did not accurately report how much time they spend on screens . This calls into question all studies which rely on participants’ subjective estimates of how they use their time because they have based their conclusions on a statistic that is likely inaccurate.

Why Not Other Hobbies?

Other critics of the diagnosis point out that gaming has been unfairly targeted and pathologized. A person who plays golf instead of spending time with family is inconsiderate. A person who plays video games instead of spending time with family is addicted.

This demonstrates a clear bias . Society considers video games a waste of time, so an enthusiastic gamer is criticized more harshly than someone with a more acceptable hobby.

What Else Might Account for Excessive Gaming

Many of my clients report that they feel addicted to technology. When I continue the assessment process, many report that they were previously diagnosed with autism or ADHD . This complicates the diagnostic process because many people with these disorders already struggle to stop scrolling through social media or playing video games.

Most of us have looked up from our phones and realized that half an hour or more had suddenly passed. The hypnotic “flow” which we experienced blinded us to the passage of time. Autistic people* and those with ADHD are especially susceptible to this phenomenon. So if, for example, a person with ADHD finds it particularly difficult to turn off a game, does that person have an addiction or is it simply how this kind of stimulus affects those with ADHD?

video game addiction essay

Some research has found that heavy gamers have reduced gray matter in areas of the brain associated with attention , impulse control. However, these studies do not sufficiently demonstrate that gaming caused the differences, only that they are associated. Correlation is not causation. Some studies even show that brain scans for people with ADHD look remarkably similar to scans of those with gaming disorder , even after treatment.

One researcher pointed out this conundrum by relating it to depression . “We would not diagnose depressed individuals with hypersomnia with a comorbid ‘bed addiction.’” In other words, someone with depression might stay in bed for days, but this does not mean that they are addicted to the bed. In the same way, an autistic person or someone with depression or ADHD might appear to be addicted to video games even when they are not. In short, many diagnosed with gaming disorder may simply be autistic or have ADHD.

It is possible that video games are addictive. However, the current body of research is too flawed to state decisively that the negative consequences outweigh the benefits the games afford players. It is premature to consider gaming disorder to be an official addiction.

*Although many refer to autistic people as “people with autism” or “people with autism spectrum disorders,” almost 90 percent of autistic adults prefer “autistic person.” This language is used here to respect that preference.

Bean, A. M., Nielsen, R. K. L., van Rooij, A. J., & Ferguson, C. J. (2017). Video game addiction: The push to pathologize video games. Professional Psychology: Research and Practice, 48 (5). Retrieved from http://psycnet.apa.org/record/2017-29288-001

Diament, M. (2022, December 2). 'Autistic' or 'person with autism'? It depends. Disability Scoop. https://www.disabilityscoop.com/2022/12/02/autistic-or-person-with-auti…

Fishman, A. (2019, January 22). Video games are social spaces. Psychology Today. https://www.psychologytoday.com/us/blog/video-game-health/201901/video-…

Fishman, A. (2022, November 7). Why it's so hard to walk away from a video game. Psychology Today. https://www.psychologytoday.com/us/blog/video-game-health/202211/why-it…

Fishman, A. (2023, February 20). How gamers use video games to explore their gender identity. Psychology Today. https://www.psychologytoday.com/intl/blog/video-game-health/202302/how-…

Gentile, D. (n.d.) Gaming Addiction Screening. University of California, Santa Cruz. https://caps.ucsc.edu/pdf/gaming-addiction-screening.pdf

Han, D.H., Bae, S., Hong, J., Kim, S.M., Son, Y.D., & Renshaw, P. (2019). Resting-state fMRI study of ADHD and Internet Gaming Disorder. Journal of Attention Disorders, 25 (8). Retrieved from https://journals.sagepub.com/doi/10.1177/1087054719883022

Király, O., Bőthe, B., Ramos-Díaz, J., Rahimi-Movaghar, A., Lukavska, K., Hrabec, O., Miovsky, M., Billieux, J., Deleuze, J., Nuyens, F., Karila, L.M., Griffiths, M.D., Nagygyörgy, K., Urbán, R., Potenza, M., King, D.L., Rumpf, H., Carragher, N., Lilly, E., & Demetrovics, Z. (2019). Ten-Item Internet Gaming Disorder Test (IGDT-10): Measurement invariance and cross-cultural validation across seven language-based samples. Psychology of Addictive Behaviors, 33 (1). Retrieved from https://www.researchgate.net/publication/328615597_Ten-Item_Internet_Ga…

Parry, D.A., Davidson, B.I., Sewall, C.J.R., Fisher, J.T., Mieczkowski, H., & Quintana, D.S. (2021). Nature Human Behavior, 5 . Retrieved from https://www.nature.com/articles/s41562-021-01117-5

van Rooij, A.J., Ferguson, C., Carras, M.C. Kardefelt-Winther, D., Shi, J., Aarseth, E., Bean, A., Bergmark, K.H., Brus, A., Coulson, M., Deleuze, J., Dullur, P., Dunkels, E., Edman, J., Elson, M., Etchells, P.J., Fiskaali, A., Granic, I., Jansz, J...& Przybylski, A.K. (2018). A weak scientific basis for gaming disorder: Let us err on the side of caution. Journal of Behavioral Addictions, 7 (1) Retrieved from https://www.researchgate.net/publication/323542721_A_weak_scientific_ba…

van Rooij, A.J., Schoenmakers, T., van den Eijnden, R.J.J.M., Vermulst, A.A., & van de Mheen, D. (2012). Video Game Addiction Test: Validity and psychometric characteristics. Cyberpsychology, Behavior, and Social Networking, 15 (9). Retrieved from https://www.researchgate.net/publication/230696095_Video_Game_Addiction…

Andrew Fishman LCSW

Andrew Fishman is a licensed social worker in Chicago, Illinois. He is also a lifelong gamer who works with clients to understand the impact video games have had on their mental health.

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15.9 Cause-and-Effect Essay

Learning objective.

  • Read an example of the cause-and-effect rhetorical mode.

Effects of Video Game Addiction

Video game addition is a serious problem in many parts of the world today and deserves more attention. It is no secret that children and adults in many countries throughout the world, including Japan, China, and the United States, play video games every day. Most players are able to limit their usage in ways that do not interfere with their daily lives, but many others have developed an addiction to playing video games and suffer detrimental effects.

An addiction can be described in several ways, but generally speaking, addictions involve unhealthy attractions to substances or activities that ultimately disrupt the ability of a person to keep up with regular daily responsibilities. Video game addiction typically involves playing games uncontrollably for many hours at a time—some people will play only four hours at a time while others cannot stop for over twenty-four hours. Regardless of the severity of the addiction, many of the same effects will be experienced by all.

One common effect of video game addiction is isolation and withdrawal from social experiences. Video game players often hide in their homes or in Internet cafés for days at a time—only reemerging for the most pressing tasks and necessities. The effect of this isolation can lead to a breakdown of communication skills and often a loss in socialization. While it is true that many games, especially massive multiplayer online games, involve a very real form of e-based communication and coordination with others, and these virtual interactions often result in real communities that can be healthy for the players, these communities and forms of communication rarely translate to the types of valuable social interaction that humans need to maintain typical social functioning. As a result, the social networking in these online games often gives the users the impression that they are interacting socially, while their true social lives and personal relations may suffer.

Another unfortunate product of the isolation that often accompanies video game addiction is the disruption of the user’s career. While many players manage to enjoy video games and still hold their jobs without problems, others experience challenges at their workplace. Some may only experience warnings or demerits as a result of poorer performance, or others may end up losing their jobs altogether. Playing video games for extended periods of time often involves sleep deprivation, and this tends to carry over to the workplace, reducing production and causing habitual tardiness.

Video game addiction may result in a decline in overall health and hygiene. Players who interact with video games for such significant amounts of time can go an entire day without eating and even longer without basic hygiene tasks, such as using the restroom or bathing. The effects of this behavior pose significant danger to their overall health.

The causes of video game addiction are complex and can vary greatly, but the effects have the potential to be severe. Playing video games can and should be a fun activity for all to enjoy. But just like everything else, the amount of time one spends playing video games needs to be balanced with personal and social responsibilities.

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Internet gaming addiction: current perspectives

Daria j kuss.

Psychology Research and Behavior Management, Birmingham City University, Birmingham, UK

In the 2000s, online games became popular, while studies of Internet gaming addiction emerged, outlining the negative consequences of excessive gaming, its prevalence, and associated risk factors. The establishment of specialized treatment centers in South-East Asia, the US, and Europe reflects the growing need for professional help. It is argued that only by understanding the appeal of Internet gaming, its context, and neurobiologic correlates can the phenomenon of Internet gaming addiction be understood comprehensively. The aim of this review is to provide an insight into current perspectives on Internet gaming addiction using a holistic approach, taking into consideration the mass appeal of online games, the context of Internet gaming addiction, and associated neuroimaging findings, as well as the current diagnostic framework adopted by the American Psychiatric Association. The cited research indicates that the individual’s context is a significant factor that marks the dividing line between excessive gaming and gaming addiction, and the game context can gain particular importance for players, depending on their life situation and gaming preferences. Moreover, the cultural context is significant because it embeds the gamer in a community with shared beliefs and practices, endowing their gaming with particular meaning. The cited neuroimaging studies indicate that Internet gaming addiction shares similarities with other addictions, including substance dependence, at the molecular, neurocircuitry, and behavioral levels. The findings provide support for the current perspective of understanding Internet gaming addiction from a disease framework. The benefits of an Internet gaming addiction diagnosis include reliability across research, destigmatization of individuals, development of efficacious treatments, and the creation of an incentive for public health care and insurance providers. The holistic approach adopted here not only highlights empirical research that evidences neurobiologic correlates of Internet gaming addiction and the establishment of a preliminary diagnosis, but also emphasizes the necessity of an indepth understanding of the meaning, context, and practices associated with gaming.

Introduction: the mass appeal of Internet gaming

Internet gaming is a booming market. In 2012, more than one billion individuals played computer games, which fuelled the 8% growth of the computer gaming industry in the same year. 1 A recent report by the market research company Niko Partners has estimated the People’s Republic of China’s online gaming market at $12 billion in 2013. 2 Massively Multiplayer Online games (MMOs) offer the possibility to play together with many other players and can be differentiated based on game content and player experience. A latent profile analysis of survey data from 4,374 Hungarian online gamers (91% male, mean age 21±6 years) indicated that the most prominent MMOs were role-playing games, first-person shooters, real-time strategy, and other games. 3 First-person MMO shooter games are based on skill because they require good reaction time and attention, and competition is a key aspect of these games. In real-time MMO strategy games, players organize teams, develop their skills, and play for status in the game. 4

Massively Multiplayer Online Role-Playing Games (MMORPGs), on the other hand, appear of particular interest to players because they offer a variety of incentives for play relative to other game genres. Of all online gamers, 46% play MMORPGs, 3 confirming their position as the most popular online games. MMORPGs are game universes inhabited by thousands of players at the same time (massively multiplayer) with no spatial or temporal boundaries because they are played online, and they allow players to adopt various virtual personas vis-à-vis their avatars (role playing). 5 Today’s most popular MMORPG is “World of Warcraft”, the latest game in Blizzard’s Warcraft series, situated in the fantasy world of Azeroth that is populated by members of the opposing factions of the Alliance and the Horde. 6 According to a recent report published by the Entertainment Software Association, 7 World of Warcraft’s extension “Cataclysm” was among the top five selling computer games in 2011. In 2013, eight million players immersed themselves in the world of Azeroth, 8 clearly demonstrating the game’s mass appeal. The game tailors to most age groups, both sexes, and various player interests and preferences, 6 making it an MMORPG success story par excellence.

Online games such as World of Warcraft satisfy various gaming motivations. The analysis by Yee 9 of 3,000 MMORPG players’ gaming motivations revealed that MMORPGs allow players to achieve game goals, be social, and immerse in the game. Each of these factors is composed of a number of subcomponents as particularized by the gamers. First, achievement includes advancing in the game, namely progressing via leveling up, acquiring status and power in the game, the game’s mechanics, including the possibilities for optimizing game play, and competition, including challenging and dominating others. 9 Reputation and admiration from the gaming community for gaming achievements are further key factors motivating players to keep playing. 6 The game mechanics or structural characteristics have been claimed to reinforce the potentially addictive qualities of games because they contribute to initiation, development, and maintenance of gaming. 10

Second, the social factor is composed of socializing, including chatting and making new friends in the game, forming new relationships, and working in a team. 9 Research 11 suggests that the social element in MMORPGs is particularly important for gamers because it is an integral component of the enjoyment of playing. Moreover, it denotes a complex interaction between real and virtual social networks, further blurring the boundaries between these networks, making MMORPGs inherently social spaces. 12

Third, immersion in the game is denoted by discovery, ie, exploring the game and “hidden” game content, role-playing via one’s avatar, customization of one’s online character (such as sex, race, profession, appearance), and escapism, ie, playing in order to avoid real life. 9 Escapism is an aspect of mood modification whereby individuals suffering from addictions induce a subjective shift in their mood by way of engaging in an addictive behavior, making the latter a coping strategy to deal with everyday problems. 13

The variety of gaming motivations satisfied by MMOR-PGs indicates that these types of games are particularly versatile because they can be tailored to individual players with different game preferences. Consequently, one could assume that there are many ways that might lead some individuals to get hooked on MMORPGs. In a sample of 696 MMORPG players (93% male, mean age 26±7.4 years), achievement, socializing, and escapism motivations were found to be predictive of addictive play, together with sex accounting for 19% of variance in the MMORPG addiction score. 14 Similarly, in a sample of 175 primarily Dutch MMORPG players (87% male, mean age 21±6.5 years), escapism and game mechanics predicted excessive gaming over and above the contribution of the time spent gaming, together explaining 46% of the variance in problematic gaming. 5 In a nutshell, the mass appeal of MMORPGs rests on their versatility because they are tailored to gamers young and old, male and female, who have different game preferences. MMORPGs are particularly good at meeting various players’ different needs. This mass appeal may have contributed to findings from research which indicate that online games, and specifically MMORPGs, are more addictive than any other types of both offline and online games 15 because they reward players on partial reinforcement schedules, leading to maintenance of play. 16

Internet gaming addiction

In recent years, research about Internet gaming addiction has increased both in quantity as well as in quality. Research on gaming addiction dates back to 1983, when the first report emerged suggesting that video gaming addiction is a problem for students. 17 Shortly thereafter, the first empirical study on gaming addiction was published by Shotton, 18 based on self-reports of young male players who claimed they were “hooked” on their games. The early studies suffered from a lack of standardized psychometric instruments used for assessing gaming addiction. 19 However, research 20 indicates that self-reports correlate with standardized measures. Following on from that, further studies were carried out in the 1990s, initially assessing gaming addiction based on the criteria for pathologic gambling as stipulated in the third and fourth editions of the Diagnostic and Statistical Manual for Mental Disorders (DSM). 21 Although similar, pathological gambling and excessive gaming do not present with the same clinical picture, and some have argued that using the diagnostic criteria for pathological gambling in order to diagnose pathological gaming only taps into obsessive use and preoccupation rather than actual psychopathology. 22 In the 2000s, online games became popular, while studies of Internet gaming addiction emerged. 23 , 24

The studies on Internet gaming addiction in the new millennium reported prevalence estimates which vary significantly and range from 0.2% in Germany 25 , 26 to 50% of Korean teenagers. 27 This discrepancy in estimates is due to various conceptualizations, diverse measurement instruments, as well as the different cutoff points used. Further, dissimilar constructs (“Internet gaming addiction”, “dependence”, “problematic”, and “excessive play”) are measured in various samples (children, adolescents, gamers) and cultures. In most studies, self-reports have been used, which puts the reliability and validity of the potential diagnosis in question. 28 However, research 20 indicates that self-diagnosis correlates with standardized measures of addiction, suggesting that the individual’s perception of problems can be relatively accurate.

In South-East Asian countries, the negative impacts of Internet gaming addiction have led governments and health care providers to take the problem seriously and to develop a series of initiatives to curb and alleviate the problem. In South Korea, Internet gaming addiction is viewed as a significant concern for public health, 29 and up to 24% of children who have been diagnosed with Internet addiction are hospitalized. 30 In Japan, the government has recognized the problem following a study by the Ministry of Education, which has led to the development of “fasting camps” where individuals suffering from Internet and gaming addiction are helped by being cut off from technology completely. 31 It has been stated that the higher the Internet penetration and social acceptance of gaming, the higher the prevalence of gaming problems, 32 partially explaining the higher prevalence rates reported in South-East Asian countries. In addition to this, there is good reason to think that the lower acceptance of excessive gaming in a culture, the more distress (not less) gamers experience in engaging in the activity, potentially fuelling problem perception. Therefore, a lack of acceptance of excessive gaming and thus stigmatization of the behavior might contribute to higher rates of addiction and problematic play in some way. Following growing concern, specialized treatment centers and programs have been established in Europe (including the outpatient clinic for behavioral addictions in Mainz, Germany, and the Capio Nightingale Hospital in London, UK) and the US (including the inpatient centers RESTART Internet Addiction Recovery Program in Seattle and the recently opened digital detoxification and recovery center in Pennsylvania), reflecting the growing need for professional help.

The concerns appear to be grounded as a growing number of studies indicate that Internet gaming addiction is associated with various negative consequences. 15 The psychological consequences include the following: sacrificing real-life relationships, other pastime activities, sleep, work, education, socializing, and relationships, 33 – 40 obsession with gaming and a lack of real-life relationships, 41 lack of attention, 33 , 42 aggression and hostility, 42 , 43 stress, 33 dysfunctional coping, 33 , 44 , 45 worse academic achievement, 38 , 46 problems with verbal memory, 47 and low well-being and high loneliness. 48 Moreover, psychosomatic consequences have been found in a number of studies. These included problems with sleeping, 41 , 47 seizures, 49 and psychosomatic challenges. 33 This long list indicates that Internet gaming problems must be taken seriously as they can affect the individual negatively in a variety of ways.

Internet gaming addiction is a behavioral problem that has been classified and explained in numerous ways. According to Griffiths, 13 biopsychosocial processes lead to the development of addictions, such as Internet gaming addiction, which include the following components. First, the behavior is salient (the individual is preoccupied with gaming). Second, the individual uses the behavior in order to modify their mood (ie, gaming is used to escape reality or create the feeling of euphoria). Third, tolerance develops (the individual needs increasingly more time to feel the same effect). Fourth, withdrawal symptoms occur upon discontinuation of the behavior (the individual feels anxious, depressed, and irritable if they are prevented from playing). Fifth, interpersonal and intra-personal conflict develops as a consequence of the behavior (the individual has problems with their relationship, job, and hobbies, and lack of success in abstinence). Finally, upon discontinuation of the behavior, the individual experiences relapse (they reinitiate gaming). 13

Although the core criteria appear to be established, the etiology of Internet gaming addiction has yet to be studied in detail. Research 15 indicates that a number of risk factors are associated with Internet gaming addiction. These risk factors include certain personality traits, gaming motivations, and structural game characteristics. The personality traits most commonly associated with Internet addiction include neuroticism, 37 , 50 aggression and hostility, 43 , 50 – 52 and sensation-seeking. 43 , 50 Factors that appear to protect frequent online gamers from developing problems with their gaming were found to be conscientiousness and extraversion, 53 suggesting that for different individuals the same behavior can have different psychological repercussions.

In addition to this, the following gaming motivations were found to be most commonly associated with gaming addiction: coping with daily stressors and escapism, 5 , 16 , 44 , 54 – 57 online relationships, 16 , 51 , 57 – 59 and mastery, control, recognition, completion, excitement, and challenge. 34 , 56 , 60 This indicates that the reasons for game play may be an important indicator of potential risk for Internet gaming addiction. Specifically, in comparison with non-MMORPG players, MMORPG players preferred their online friends over their real-life friends. 16 Similarly, significantly more dependent gamers were found to prefer spending time with their online friends than their offline friends relative to nondependent gamers and felt their social needs were met better online than offline. 44 Moreover, while online games provide nonaddicted players with satisfaction, addicted players play to avoid dissatisfaction, 55 which can be an indication of withdrawal symptoms they want to overcome by engaging in gaming compulsively. The motivational differences to play games between dependent and nondependent as well as MMORPG and other gamers appear to be useful clinical information because these motivations can be specifically targeted in treatment sessions. For instance, elements of exposure therapy may be used for the socially fearful in order to decrease discomfort and reintroduce clients to real-life social environments. Also, alternative pastime activities that are perceived as satisfying can be encouraged specifically in group therapy sessions. Encouraging engagement in group sports might satisfy both the need to engage in competitive and satisfying activities and the need to interact with peers in real life.

Moreover, a number of structural game characteristics have been found to increase the risk for developing Internet gaming addiction, namely online relative to offline gaming, 61 positive reinforcement, 62 the enjoyment of particular game features, such as adult content, finding rare in-game items, and watching game cut scenes, 63 and viewing one’s virtual persona as better than oneself. 64 These characteristics indicate that particular games can be more addictive than others, 15 which appears important for game developers and public prevention campaigns that focus on decreasing risk and raising awareness of potential problems. Prevention campaigns could target school-aged children, teachers, and parents in education settings. They could be based on the principles of providing information and a discussion platform concerning Internet and gaming use and possible negative consequences via psychoeducation, with the ultimate goal of encouraging healthy media use. Success could be determined over the long term using triangulation of data and reports obtained from the targeted populations.

Most reviews to date have primarily focused on specific aspects of Internet gaming addiction, including methods used to assess gaming addiction, 65 , 66 structural characteristics, 60 and treatment. 67 – 69 In light of this, the aim of this review is to provide an insight into current perspectives on Internet gaming addiction using a holistic approach, taking into consideration the mass appeal of online gaming, the context of Internet gaming addiction, and associated neuroimaging findings, as well as the current diagnostic framework adopted by the American Psychiatric Association. 70 It is argued that only by understanding the appeal of Internet gaming, its context, and neurobiologic correlates can the phenomenon of Internet gaming addiction be understood comprehensively. An evaluation of the findings will be presented in the overall discussion.

Gaming addiction: context

Research on gaming addiction has paid little attention to the context of online gaming. However, a few studies have now shed some light on the embedding of Internet gaming addiction in the context of the individual, 71 the game and gaming environment, 6 , 72 and the broader framework of culture. 73 Each of these will be addressed in turn.

Griffiths 71 provided case study evidence of two young men who spent an average of 14 hours a day playing MMORPGs in order to emphasize that the context of the individual’s life is an important factor demarcating gaming excess from gaming addiction. Aged 21 years, unemployed and single, “Dave” reported that gaming had a positive influence on his life because his social life revolved almost exclusively around the game, and playing boosted his self-esteem and gave structure to his everyday life. Dave did not perceive that his excessive gaming impacted upon his life negatively at all. For Dave, his extensive gaming did not lead to significant distress or have a negative impact in his daily life, and therefore his behavior cannot be classified as a condition that would fulfill the requirements of a mental disorder classification as outlined in the DSM-5. 74 Upon starting a new job and entering into a relationship with a woman he met in-game, his excessive gaming decreased significantly.

The second case reported was that of “Jeremy”, a 38-year old financial accountant who was married with two children and experienced detrimental consequences due to his “severe gaming addiction”, namely a relationship breakdown, lack of time for family activities, and loss of his job. Moreover, his playing time, craving for the game, and feelings of low mood and anxiety had increased dramatically. He used gaming to escape from his real-life problems and tried to quit on several occasions, but was unsuccessful in staying abstinent. This led to a number of relapse episodes. 71 The examples of Dave and Jeremy make a compelling case for how the same behavior (namely regular online gaming for excessive periods of time) can have almost diametrically opposed consequences due to different individual contexts, with one experiencing gaming as pleasurable and ultimately beneficial, whereas the other’s entire life was negatively affected by his excessive gaming.

In addition to the individual context, the context of the game appears important in determining the extent to which excessive gaming can truly be an addiction. 6 , 72 Karlsen 72 conducted 12 interviews with online gamers (75% male, mean age 23±2.4 years) who play World of Warcraft and used virtual ethnography 75 in order to assess the consequences of their excessive gaming. The results indicated that some of the players experienced behavioral addiction symptoms as specified by Griffiths, 13 namely salience, mood modification, tolerance, withdrawal, conflict, and relapse, with the latter two demarcating excessive from potentially addictive play. However, rather than advocating current diagnostic frameworks for “pathologizing” gaming, Karlsen 72 advocates to view gaming excess from the vantage point of game structure and gaming context, including the social practice and cultural meaning of games as well as the individual’s connection to the game from the perspective of game and media studies. This understanding entails a move away from the overly simplistic approach of focusing on the psychological rewards that reinforce gaming to include an indepth exploration of gaming motivations, gaming structure and mechanics, as well as the meaning of gaming for the individual. 72

Kuss 6 analyzed online gaming and potential gaming excess by interviewing eleven World of Warcraft players (72% male, mean age 27±7.3 years) and used virtual ethnography 75 as well as ludology principles 76 to understand how playing this particular game mirrors participation in popular media culture. In this context, media culture is understood as a flexible and evolving area of engagement that requires active participation. Potential gaming addiction was found to be associated with escapist motivations and in this context gaming was understood as fulfilling a “narcotic” function. The game context gained particular significance in one participant’s life because of two features of the game. First, he was able to enact heroic tales through his avatar and faction membership. As a member of the Horde, he fought the opposing faction, the Alliance, and was involved in killing their king, an episode “he would not forget until the end of his life”. Second, he was enabled to return to a familiar cultural context by means of his guild which consisted of fellow countrymen, after he had physically migrated to a foreign country. In this way, the provisions of the game (namely participation in the game’s narrative, 77 community, and belonging) 78 were utilized to a problematic extent, leaving the participant feeling “addicted to wow [World of Warcraft]”. Eventually, the analysis revealed that the meaning that is attached to the game can lead to excessive play which may cause a retreat from real life. 6

Snodgrass et al 73 surveyed 252 respondents (78% male, mean age 27±9.0 years) using Yee’s 9 motivational factors achievement, social and immersion to assess problematic MMORPG play in World of Warcraft from the perspective of culture under the supposition that gaming allows for formation of communities and cultures. 12 , 79 , 80 The cultural context situates the individual and his potentially addictive game play (assessed using Young’s Internet Addiction Test) 81 within the framework of commonly shared beliefs and practices. 82 Snodgrass et al 73 used an anthropological approach focusing on meaning, practice, and experience, mirrored in their understanding of gaming motivations and problematic play. They found that achievement motivation may lead to problematic play if players are less successful in real life (ie, less “culturally consonant”) and use game success to compensate, 73 causing stress and negative health outcomes. 83 In terms of social motivation, the extent to which online relationships gain significance over offline relationships was analyzed 73 because research indicates that lack of cultural consonance regarding social networks impacts negatively upon health. 84 Regarding immersion, the amalgamation of online and offline life and identities was assessed, 73 because association of the self with the game and the avatar could lead to dissociation. 85 , 86 The results indicated that game play in World of Warcraft mirrors cultural models of success regarding objectives and responsibilities, indicating that the game world can in some ways substitute the real world. Moreover, the culturally sensitive motivations achievement, social and immersion significantly predicted problematic MMORPG play if they were incongruent with real life, that is, if the game was used to compensate for lack of success and relationships in real life, and to dissociate from real life. 73

Taken together, the individual, game, and cultural contexts appear to have a significant impact upon the extent to which problems occur as a consequence of excessive gaming in terms of how Internet gaming addiction is conceptualized. In this way, the cultural context can be seen as a lens through which individuals and others around them perceive and give meanings to behaviors and their consequences. It is critical to understand gaming problems not only by means of the observable symptoms, but to situate them within the broader context of the game, the individual, and culture.

Gaming addiction: neuroscience

In the last decade, psychiatry has increasingly made use of neuroscientific evidence to understand and conceptualize mental disorders. 87 The major funding body for mental health research, the National Institute of Mental Health, has recently introduced research domain criteria to reclassify mental disorders as based on neuroscience and shared underlying pathophysiology rather than the more subjective approach of phenomenology and clinical presentation that has been utilized previously. 88 The ultimate aim is to improve the reliability and validity of clinical diagnosis and accordingly to deliver optimal treatment. 89 In accordance with this approach, research on Internet gaming addiction is now increasingly making use of neuroimaging techniques to allow for analysis of neurobiological changes due to excessive gaming and neurochemical correlates of addiction. 90

Some studies have shown that changes in brain activity and structure related to addiction are relevant for brain regions involved in reward, motivation, and memory, as well as cognitive control. 91 It has been hypothesized that initially the prefrontal cortex and ventral striatum are involved in the decision to initiate the addictive behavior. Over time, the individual habituates to the behavior and develops a compulsion to engage in it, which is accompanied by alterations of activity in the dorsal striatum as it becomes activated through dopaminergic innervation. There is some evidence for the idea that dopamine is released. 92 The longer the engagement continues, the more permanent the changes in the dopaminergic pathways become. It has been suggested that activity in the anterior cingulate, orbitofrontal cortex, and nucleus accumbens is modified in such a way that natural rewards are experienced as less pleasurable, further reducing control over the behavior. 93 , 94 Research suggests that over time, synaptic activity is reduced, leading to long-term depression and neuroadaptation, 95 as well as behavioral sensitization. The synapses in the ventral tegmental area become stronger, glutamate in the nucleus accumbens is reduced, and activity in the amygdala and hippocampus (related to memory) is increased, which can in turn result in craving 91 , 96 and increased response to the availability and particular context of the addictive behavior. 93 , 97 Some studies have shown that the addictive behavior becomes associated with these cues through activity in the nucleus accumbens, which reinforces the effects of the behavior. 98 With time, tolerance to the addictive behavior develops and natural rewards are depreciated, resulting in a reward system deficiency and activation of the antireward system. 99 The consequent lack of dopamine in mesocortical brain regions can lead to withdrawal symptoms, and in order to overcome these, renewed engagement in the addictive behavior ensues, and may ultimately impact upon the functions of the orbitofrontal cortex and cingulate gyrus. 91 , 100 , 101

Over the last decade, a number of neuroimaging techniques have been applied to Internet gaming research, allowing for an analysis of addiction correlates regarding both brain function as well as brain structure. Electroencephalograms measure brain activity via changes in voltage in the cerebral cortex via electrodes, 102 and were used in six studies of Internet and gaming addiction. 103 – 108 Positron emission tomography measures neuronal metabolism through photons from positron emissions via positively charged electrons. 109 Two studies 110 , 111 made use of positron emission tomography to measure Internet and gaming addiction. Like positron emission tomography, single photon emission computed tomography measures metabolic activity in the brain at the level of individual photons, 112 and was applied in one study of Internet addiction. 113 Eight studies 114 – 121 used functional magnetic resonance imaging to measure changes in blood oxygen levels in order to indicate brain activity in individuals with Internet and gaming addiction. 122 Finally, structural magnetic resonance imaging uses methods such as voxel-based morphometry 123 and diffusion-tensor imaging 124 to image brain morphometry, 125 and was used in two studies 126 , 127 in order to assess Internet addiction.

A systematic review of all Internet and gaming addiction studies using neuroimaging methods until 2012 90 revealed that Internet gaming addiction appears similar to other addictions, including substance-related addictions, at the molecular, neurocircuitry, and behavioral levels. From a molecular perspective, gaming results in the release of striatal dopamine. 111 On the other hand, it has been suggested that, in small samples, Internet and gaming addiction is associated with a reward deficiency whereby dopaminergic transporters in the brain are reduced. 110 , 113 In order to reinstate a biochemical equilibrium, 99 individuals whose reward system is deficient seek substances and activities which result in the release of dopamine. Under normal circumstances, pleasure drives (including eating and reproduction) are natural rewards that are craved, whereas unnatural rewards include psychoactive substances and addictive behaviors. 128 Over time, the individual habituates to the hedonic feelings produced by Internet gaming and develops abstinence symptoms, tolerance, and withdrawal. 129 Internet gaming addiction is initiated and maintained. 90 The decreased dopaminergic transporters in Internet gaming addiction may explain its frequent co-occurrence with depression, 130 bipolar disorder, 131 and borderline personality disorder and dissociative symptoms. 132

With regards to neural circuitry, when gaming, brain areas associated with addictions are frequently utilized and therefore the activity in regions such as the orbitofrontal cortex and cingulate gyrus is high, which over time can lead to significant alterations in neuronal connectivity 114 , 116 , 118 , 119 and brain structure. 115 , 126 , 127 Internet gaming becomes increasingly salient and individuals lose control over their gaming. 90 The individual is immanently motivated to play online games as they have learned the behavior, eventuating in continuous engagement. 133

In terms of behavior, excessive Internet gaming can result in problems with impulse control, behavioral inhibition, executive functioning, attention, and general cognitive functioning. 103 , 104 , 107 , 115 , 126 , 127 However, there are plus sides as well, in that the frequent gamer develops and improves a number of other capabilities, namely the integration of perceptual information into the brain and hand-eye coordination. 118 , 120

Taken together, research on Internet gaming addiction has made use of various neuroimaging techniques in order to shed light upon the neurochemical and neuroanatomic correlates of addiction. Although in most studies the direction of the relationship has not been investigated (ie, it is unclear whether Internet gaming addiction causes changes in brain structure and activity or vice versa), the current evidence suggests a relationship between brain alterations and Internet gaming addiction. Neuroimaging studies of Internet gaming addiction contribute to the current understanding of addiction as based on a disease framework. 128 , 134 This indicates that, similar to cardiovascular diseases, lifestyle (ie, excessive gaming) can result in changes to underlying neurobiology. Moreover, the utilization of sophisticated imaging methods in Internet gaming addiction research is in line with research domain criteria, 88 which makes a significant contribution to our understanding of Internet gaming addiction as a chronic neurobiological disease requiring professional care and adequate treatment. 135

Gaming addiction: clinical diagnosis

Following nearly two decades of research, the American Psychiatric Association has now officially recognized Internet Gaming Disorder as a condition that requires consideration by clinicians and researchers. In June 2013, Internet gaming disorder appeared in the appendix of the updated version of the Diagnostic and Statistical Manual for Mental Disorders (DSM-5) for the first time. 70 It stands alongside the only other behavioral addiction, ie, pathological gambling, situating it clearly within the diagnostic category of Substance-Related and Addictive Disorders. Internet gaming disorder has pulled ahead of other behaviors that can become addictive, such as exercise, 136 , 137 work, 138 and shopping. 139

Up until now, researchers have understood Internet addiction or Internet gaming addiction as similar to either impulse control disorders in general or pathological gambling specifically, 140 – 142 substance dependence, 33 , 38 or a combination of the two. 143 , 144 This has led to the development of multiple psychometric instruments, each measuring different aspects associated with Internet gaming problems and addiction. 144 – 153 The multiplicity of conceptualizations used for Internet gaming addiction have led to a diagnostic conundrum leading some researchers to question its existence, 29 and have called for commonly agreed upon criteria which increase reliability across studies and advocate adequate and efficacious treatment. 15

Under the new DSM-5 framework, Internet gaming disorder refers to the “persistent and recurrent use of the Internet to engage in games, often with other players, leading to clinically significant impairment or distress as indicated by five (or more) [criteria] in a 12-month period”. 70 The diagnostic criteria are a preoccupation with gaming, withdrawal symptoms, tolerance (ie, spending more time gaming), lack of control, loss of other interests, use despite negative consequences, deception, mood modification, and losing a relationship, job, and similarly important aspects of life. 70 From a public health perspective, an official diagnosis of Internet gaming addiction is necessary for a number of reasons. First, it will encourage individuals who suffer from associated symptoms to ask for professional help, decreasing morbidity rates, hospitalizations, and potential legal and medical problems. 30 Second, the diagnosis may decrease barriers to care and stigmata with regards to public perception of problematic Internet and gaming use. Third, the diagnosis will support research efforts. 134 Fourth, a diagnostic category will provide the necessary incentive for health care and insurance providers to develop, test, and finance adequate treatment. Ultimately, individuals who require professional care because of substantial distress, suffering, and individual impairment must be helped in an appropriate way. 74 Accordingly, an official diagnosis of Internet gaming addiction is critical for a number of reasons, further emphasizing the need to fully acknowledge and utilize it.

The aim of this review was to provide an insight into current perspectives on Internet gaming addiction using a holistic approach encompassing gaming appeal, context, neuroimaging research, and the diagnostic framework adopted for Internet gaming addiction. It has been shown that Internet gaming has gained increasing popularity since the new millennium, and has led to a substantial growth of the gaming industry and the player fan base. MMORPGs have further been highlighted as offering a wide variety of incentives for players to initiate and maintain playing because they satisfy a variety of needs and tailor to various gaming motives relative to alternative online game genres. Some of these motives, especially escapism, the game’s mechanics, achievement and socializing have been found to be indicative of gaming addiction, 5 suggesting that MMORPGs are more addictive than other offline and online games. 15

This review further shows that until now few studies have investigated the gaming context. Therefore, the context of the individual, the game and gaming environment, and the broader framework of culture are specifically addressed. It has been shown that the individual’s context is a significant factor that marks the dividing line between excessive gaming and gaming addiction. 71 Moreover, it has been emphasized that gaming cannot simply be medicalized if done in excess, but it must be understood from within the context of gaming and the meanings the individual attaches to it. 72 The game context can gain particular importance for players, depending on their life situation and gaming preferences, including the enactment of heroic tales as well as the re-embedding in a (virtual) cultural context that differs from the players’ real-life context. Ultimately, this may lead to a retreat from real life for some individuals. 6 In addition to this, the cultural context is significant because it embeds the gamer in a community with shared beliefs and practices, endowing their gaming with particular meaning. If gaming is used to compensate for lack of success and relationships in real life and to dissociate from real life, Internet gaming addiction can be the consequence. 73 In this context, the “disease” model of addiction can be viewed from the perspective of diseases other than those based on Mendelian genetic mutations or other simple biologically determined pathways. Cardiovascular diseases or adult onset diabetes appear as better models/prototypes for Internet gaming addiction, because these are medical conditions where lifestyles and experiences systematically reshape the body and thus “get under the skin”. That is, the cultural context can become the disease (here addiction) through repeated experiences. Alternatively, cultural norms related to how acceptable game-play is might structure the appeal of the game, which in turn promotes addictive play patterns, which would not be the case in places without such norms.

The cited neuroimaging studies of Internet gaming addiction and associated changes in brain structure and function furthermore correspond with the research domain criteria developed by the National Institute of Mental Health 88 because they emphasize a move away from phenomenology to focus on pathophysiology for clinical diagnosis. Internet gaming addiction was found to share similarities with other addictions, including substance dependence, at the molecular, neurocircuitry, and behavioral levels. These similarities include altered dopaminergic and neuronal activity and brain morphometry, as well as deficient impulse control, behavioral inhibition, and general cognitive functioning. However, there are no known biomarkers of Internet addiction at this point in time. Indeed, there are no known biomarkers of any mental disorder. Ever since Kraepelin, 154 and thus for a century, psychiatrists have been searching to understand mental disorders as underlying physiological diseases, providing an additional incentive to continue research on the neurobiological underpinnings of mental health problems, including Internet gaming addiction.

The findings provide support for the current perspective of understanding Internet gaming addiction from a disease framework. 128 , 134 The dependence classification adopted in previous classification systems 74 , 155 is stigmatizing to patients who require medication because dependence refers to a normal physiological response to the use of a substance (including medication) which, when discontinued, can lead to withdrawal symptoms. 74 The term addiction, on the other hand, denotes a chronic neurobiological disease, 135 which is less stigmatizing because it does not suggest that patients who require medication become “addicted” to their required psychopharmacological treatment. 156 Addiction, unlike dependence, leads to compulsively pursuing rewarding behaviors irrespective of associated biological, psychological, and social problems. 135 Ultimately, the current research base on Internet gaming addiction has led the American Psychiatric Association 70 to include Internet gaming disorder in the appendix of the DSM-5 as the second behavioral addiction alongside pathological gambling, suggesting that the problem is taken seriously. The benefits of such a diagnosis include comparability across research, destigmatization of individuals, development of efficacious treatment, and creation of an incentive for public health care and insurance providers. Once the behavioral problem has an official code, it is worthy of being taken seriously and treated adequately.

However, research concerning the natural course of Internet gaming addiction, the most appropriate interventions, and large-scale epidemiology is scarce, 157 suggesting that more work needs to be done to understand this behavioral problem more fully. King and Delfabbro 158 further question the blurring of the boundaries between Internet addiction and video gaming addiction, as this may “promote further confusion”. Instead, they advocate a conceptualization of Internet addiction which incorporates various subtypes of online behavior, and establishing a diagnostic category of “video gaming disorder” which applies to both online and offline gaming addiction. Ultimately, however, King and Delfabbro 158 concede that the research diagnosis has sparked discussion regarding the nature of behavioral addictions, which testifies to a move away from acknowledging substances only as potentially addictive, and to broaden our understanding of addiction in general.

Moreover, there appear to be problems with regards to the criteria for Internet gaming disorder adopted by the DSM-5 taskforce. Starcevic 29 points out that there exists a debate of whether tolerance is a valid criterion as researchers have validated scales on problematic video game use 159 and compulsive Internet use 160 that do not contain tolerance as a symptom, and some question whether tolerance is a factor involved in gaming. 44 This exemplifies the intricacy of measuring Internet gaming addiction, particularly in light of the reliability of studies as well as the equivalence of findings across studies. Based on these issues, Starcevic 29 recommends the following research approaches: understand when online gaming can be considered a mental disorder; study risk factors and comorbidities, and its position as primary or secondary condition; test a continuum of video gaming problems and video gaming disorder; and revisit its classification as “addiction” rather than an impulse control disorder. 161 Moreover, Pies 134 specifies further that only if the following criteria are satisfied, the condition would qualify to be understood as disease: identify a pattern of genetic transmission; understand its etiology, pathophysiology and/or pathological anatomy; and its course, prognosis, stability, and response to treatment. The current review indicates that research on Internet gaming addiction is on its way to fulfilling these requirements. In terms of understanding the context of Internet gaming addiction, more research is necessary.

Limitations, implications, and suggestions for future research

This review has shown that research on Internet gaming addiction has increased in quality and quantity, particularly over the last decade. Future research is required to overcome the limitations of current research, including closer scrutiny of gaming context (including the individual, game, and culture) and the direction of the relationship between Internet gaming addiction, as well as neuroanatomical and neurochemical changes. Specifically, the following research question requires further exploration: How do individual, game-related, and cultural factors contribute to the etiology, phenomenological experience, and treatment approaches of Internet gaming addiction? Furthermore, the causality of the relationship between neurobiological alterations and neurostructural abnormalities and Internet gaming addiction symptoms should be explored. The further exploration of these issues will enhance our understanding of this potential mental health concern. Moreover, a solid and unequivocal research base will enable the American Psychiatric Association and the World Health Organization to include Internet gaming addiction as an actual diagnosis in their diagnostic systems, which will in turn facilitate future research endeavors as well as clinical parlance.

The context appears crucial to the meaning of the game for the player, and is influenced by individual characteristics, the gaming culture, and the broader society that gamers are situated in. Ultimately, this will allow for developing treatment approaches which can be tailored to different individuals and meet idiosyncratic needs most effectively. The reviewed literature can inform procedures for improving the current treatment of Internet gaming addiction because it puts an emphasis on exploring the life and cultural context of the individual. In terms of neuroimaging studies, the reviewed empirical research has revealed associations between excessive online gaming and alterations in brain structure and function associated with substance addictions. However, understanding the direction of this relationship is crucial because it will provide invaluable insights into the etiology of Internet gaming addiction as well as its status as a primary or secondary disorder. In terms of treatment, establishing the treatment seeker’s most pressing present problem will allow an efficient and efficacious treatment plan to be developed and structuring of treatment sessions. Overall, this literature review suggests that targeting pathogenic neurobiological mechanisms and associated neurological and neurochemical alterations only does not suffice when the clinician’s goal is to alleviate the individual’s idiosyncratic problems. It indicates that Internet gaming addiction must be viewed from a holistic perspective, integrating the neurobiological, individual, game-related, and cultural factors contributing to pathogenesis and symptom experience.

The present review of current perspectives on Internet gaming addiction has shown that research has progressed significantly over the last decade, leading to a larger evidence base which includes important findings from neuroimaging research. Further, it indicates that contextual factors play an important part in our understanding of Internet gaming addiction as a holistic phenomenon. It is suggested that an official diagnosis of Internet gaming addiction must regard embedding of the problematic behavior within the context of the individual, the game, and gaming practices, as well as the broader sociocultural environment as the meaning of the gaming behavior derives from its context. The holistic approach adopted here not only highlights empirical research that confirms neurobiological correlates of Internet gaming addiction and establishment of a preliminary diagnosis, but also emphasizes the need for an indepth understanding of meaning, context, and practices associated with gaming. Ultimately, a holistic understanding will benefit individuals who seek professional help for problematic online gaming as treatment approaches become more targeted and consequently more efficacious.

The author reports no conflicts of interest in this work.

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3.2: Cause and Effect Model Essay 1

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Read the essay and answer the questions that follow.

First Name Last Name

Professor Name

Course Name and Number

Day Month Year

Video Game Addiction

(1) Video game addiction is a serious problem in many parts of the world today and deserves more attention. It is no secret that children and adults in many countries throughout the world, including Japan, China, and the United States, play video games every day. Most players are able to limit their usage in ways that do not interfere with their daily lives, but many others have developed an addiction to playing video games. Regardless of the severity of the addiction, many suffer detrimental effects.

(2) One common effect of video game addiction is isolation and withdrawal from social experiences. Video game players often hide in their homes or in Internet cafés for days at a time—only reemerging for the most pressing tasks and necessities. The effect of this isolation can lead to a breakdown of communication skills and often a loss in socialization. While it is true that many games, especially massive multiplayer online games, involve a very real form of e-based communication and coordination with others, and these virtual interactions often result in real communities that can be healthy for the players, these communities and forms of communication rarely translate to the types of valuable social interaction that humans need to maintain typical social functioning. As a result, the social networking in these online games often gives the users the impression that they are interacting socially, while their true social lives and personal relations may suffer.

(3) Another unfortunate product of the isolation that often accompanies video game addiction is the disruption of the user’s career. While many players manage to enjoy video games and still hold their jobs without problems, others experience challenges at their workplace. Some may only experience warnings or demerits as a result of poorer performance, or others may end up losing their jobs altogether. Playing video games for extended periods of time often involves sleep deprivation, and this tends to carry over to the workplace, reducing production and causing habitual tardiness.

(4) Finally, video game addiction may result in a decline in overall health and hygiene. Players who interact with video games for such significant amounts of time can go an entire day without eating and even longer without basic hygiene tasks, such as using the restroom or bathing. The effects of this behavior pose significant danger to their overall health.

(5) In conclusion, the causes of video game addiction are complex and can vary greatly, but the effects have the potential to be severe. Playing video games can and should be a fun activity for all to enjoy. However, just like everything else, the amount of time one spends playing video games needs to be balanced with personal and social responsibilities. Otherwise, the effects can be detrimental in many ways.

Questions about Model Essay 1

  • Highlight the thesis and the concluding sentences. Is this essay about causes or effects?
  • Which transitions and signal words are used to show cause & effect? NOTE: there are various sentence structures featured in this essay.
  • Underline the topic sentences for each body paragraph—those are the sentences that introduce each new subtopic.
  • List the three subtopics of this essay.

Writing fo success citation

Refer back to the essay “Video Game Addiction” and complete the following outline with the missing information.

I. Introduction:

Thesis: Regardless of the severity of the addiction, many suffer detrimental effects.

II. Supporting Topic Sentence 1: One common effect of video game addiction is isolation and withdrawal from social experiences

A. Hiding at home or an internet cafe

B. some interaction in gaming communities but

C. ___________________________

III. Supporting Topic Sentence 2: Another unfortunate product of the isolation that often accompanies video game addiction is the disruption of the user’s career.

A. some people don’t have problems; some do

1. demerits / poor performance

2. ______________________

B. sleep deprivation

1. ______________________

IV. Supporting Topic Sentence 3: ______________________________

___________________________________________________________

A. days without eating

B. _________________

V. Conclusion: In conclusion, the causes of video game addiction are complex and can vary greatly, but the effects have the potential to be severe.

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video game addiction essay

Can You Really Be Addicted to Video Games?

The latest research suggests it’s not far-fetched at all — especially when you consider all the societal and cultural factors that make today’s games so attractive.

Credit... Concept by Pablo Delcan. Photo illustration by Justin Metz.

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By Ferris Jabr

  • Published Oct. 22, 2019 Updated Oct. 23, 2019

Charlie Bracke can’t remember a time when he wasn’t into video games. When he was 5, he loved playing Wolfenstein 3D, a crude, cartoonish computer game in which a player tries to escape a Nazi prison by navigating virtual labyrinths while mowing down enemies. In his teenage years, he became obsessed with more sophisticated shooters and a new generation of online games that allowed thousands of players to inhabit sprawling fantasy worlds. Ultima Online, World of Warcraft, The Elder Scrolls — he would spend as much as 12 hours a day in these imaginary realms, building cities and fortifications, fighting in epic battles and hunting for treasure.

During his childhood, Bracke’s passion for video games, like that of most young Americans, didn’t cause him any serious problems. At school, he got along with just about everyone and maintained straight A’s. His homework was easy enough that he could complete it on the bus or in class, which allowed him to maximize the time he spent gaming. After school, he would often play video games for hours with his cousin and a small group of close friends before going home for dinner. Then he would head to the den and play on the family computer for a few more hours before bed. When his parents complained, he told them it was no different from their habit of watching TV every night. Besides, he was doing his homework and getting good grades — what more did they want? They relented.

When Bracke went to Indiana University Bloomington, everything changed. If he skipped class or played games until 3 in the morning, no one seemed to care. And only he had access to his grades. After a difficult breakup with a longtime high school girlfriend and the death of his grandmother, Bracke sank into a period of severe depression. He started seeing a therapist and taking antidepressants, but by his junior year, he was playing video games all day and seldom leaving his room. He strategically ignored knocks at the door and text messages from friends to make it seem as though he were at class. Eventually, he was failing most of his courses, so he dropped out and moved back in with his parents in Ossian, Ind., a town of about 3,000 people, where he got a job at Pizza Hut.

His life there fell into a familiar rhythm: He woke up, went to work, returned home, played video games until late and repeated the whole cycle. “It did not strike me as weird at all,” he recalls. It felt a lot like high school, but with work instead of classes. “And the time I used to spend hanging out with friends was gone, because they had moved to different areas,” he says. “And I kind of just thought that was the way of the world.”

When Bracke was 24, he decided to get his real estate license and move from Indiana to Virginia to work at the same brokerage as his brother Alex, a decision that led to another breakup with another girlfriend and a deep sense of loneliness in a town where, once again, he had no friends. He eventually got in touch with his ex, hoping she would take him back, only to find out that she was dating someone else. “At that point, I lost it,” he says. By his estimate, he started playing video games about 90 hours a week. He did the bare minimum amount of work required to pay his bills. When it was time to log his progress in the brokerage’s internal system, he would just make something up: sent an email to this client; left a voice mail message for that one.

His employer got wise to the scheme and put Bracke on probation. Realizing he had a problem, Bracke dismantled his computer, stashed the pieces among a bunch of storage boxes in the garage and tried to focus on work. About a month later, after making a big sale, he talked himself into celebrating by playing League of Legends for an evening. He retrieved the components of his computer, reassembled them and started gaming around 6 p.m. Ten hours later, he was still playing. The week slipped away. He kept playing.

video game addiction essay

In May, the World Health Organization officially added a new disorder to the section on substance use and addictive behaviors in the latest version of the International Classification of Diseases: “gaming disorder,” which it defines as excessive and irrepressible preoccupation with video games, resulting in significant personal, social, academic or occupational impairment for at least 12 months. The latest edition of the Diagnostic and Statistical Manual of Mental Disorders, the American Psychiatric Association’s clinical bible, recognizes “internet gaming disorder” — more or less the same thing — as a condition warranting more research.

The W.H.O.’s decision has received substantial pushback, in part because the modern meaning of “addiction” is an uneasy amalgam of several contradictory legacies: a religious one, which has censured excessive drinking, gambling and drug use as moral transgressions; a scientific one, which has characterized alcoholism and drug addiction as biological diseases; and a colloquial one, which has casually applied the term to almost any fixation. People have written about behavioral addictions — to eating, sex and gambling — for centuries. In recent decades, some psychiatrists and counselors have even specialized in their treatment. But the idea that someone can be addicted to a behavior, as opposed to a substance, remains contentious.

Predictably, some of the W.H.O.’s staunchest critics are leaders in the gaming industry , many of whom fear that the new diagnostic label will further stigmatize their products, which have been smeared as promoting slothfulness, social ineptitude and violence. A sizable faction of scientists also disputes the idea that video games are addictive. The arguments against the validity of video-game addiction are numerous, but they generally converge on three main points: Excessive game play is not a true addiction but rather a symptom of a larger underlying problem, like depression or anxiety; the notion of video-game addiction emerges more from moral panic about new technologies than from scientific research and clinical data; and making video-game addiction an official disorder risks pathologizing a benign hobby and proliferating sham treatments. “It’s absolutely not an addiction,” says Andrew Przybylski, director of research at the Oxford Internet Institute. “This whole thing is an epistemic dumpster fire.” People enjoy and sometimes form all-consuming passions for countless activities — fishing, baking, running — and yet we don’t typically pathologize those.

Throughout history, technological innovations and new forms of entertainment have consistently provoked alarmism. In Plato’s “Phaedrus,” Socrates remarked that writing would “create forgetfulness in the learners’ souls, because they will not use their memories.” In the late 1800s, the sordid tales in penny dreadfuls and dime novels were blamed for juvenile crime. In 1906, the composer John Philip Sousa lamented the “menace of mechanical music,” worrying that children might become “simply human phonographs” without “soul or expression.” As technologies proliferated at an overwhelming rate, so did concerns about their potential harm. Trains, electricity, phones, radios, personal computers: All have been subjected to technophobia. Given the long history of hysteria surrounding technology, it’s tempting to agree with those who dismiss claims that video games are addictive. After all, millions of people around the world enjoy video games without any marked repercussions; some studies have even concluded that the right kind of game play can relieve symptoms of depression and anxiety.

But these denials become more difficult to accept when juxtaposed with the latest research on behavioral addictions. A substantial body of evidence now demonstrates that although video-game addiction is by no means an epidemic, it is a real phenomenon afflicting a small percentage of gamers. This evidence has emerged from many sources: studies indicating that compulsive game play and addictive drugs alter the brain’s reward circuits in similar ways ; psychiatrists visited by young adults whose lives have been profoundly disrupted by an all-consuming fixation with gaming; striking parallels between video games and online gambling; and the gaming industry’s embrace of addictive game design.

Timothy Fong, a professor of addiction psychology at the University of California, Los Angeles, says he is convinced that video-game addiction is real. “It’s quite possible and common to have both addiction and another mental or behavioral disorder simultaneously,” he told me, like depression or anxiety. “At least half the time, compulsive gamers come in with clinical histories and mind-sets that are essentially the same as patients with heroin addiction, alcoholism or gambling disorder. They have all the hallmarks.”

The debate over video-game addiction is about much more than diagnostic nomenclature; at its center is a shifting scientific understanding of addiction itself. For too long the concept of addiction has been fettered by models and frameworks too meager to accommodate its complexity. Addiction has been attributed solely or primarily to weak willpower, or neural circuitry gone awry, or the inherent dangers of drugs themselves. In both the medical community and the public consciousness, the conflation of addiction and chemical dependency has stubbornly persisted.

Researchers in a wide variety of fields — from psychology to public health — are increasingly pushing back against the reductive schema of the past. Addiction is no longer considered synonymous with physiological dependence on a substance, nor can it be reduced to the activity of neurons in a few regions of the brain. Rather, experts now define addiction as a behavioral disorder of immensely complex origins. Addiction, they say, is compulsive engagement in a rewarding experience despite serious repercussions. And it results from a confluence of biology, psychology, social environment and culture. In this new framework, addictions to certain types of modern experiences — spinning virtual slot machines or completing quests in a mythical realm — are entirely possible. In the case of video-game addiction, the most vulnerable population seems to be young men like Bracke.

‘The more I played, the more depressed I got. But the more depressed I got, the more I played.’

— Nate Bowman (right), 20, photographed with Wren Viele (left), 18, in September at reStart’s campus in Carnation, Wash.

Shortly after Bracke’s employers put him on probation, his parents, Sally and Steve, visited him in Virginia. One day, while driving back from the grocery store, Sally worked up the courage to ask her son a question that had been troubling her for some time: “Charlie, are you a gaming addict?” She was terrified of using that word — “addict” — terrified that Bracke would perceive it as an accusation and that their relationship would suffer for it. Bracke contemplated the question silently for a long time as they drove. In truth, the thought had occurred to him, but he had never taken it seriously, let alone said it out loud. Finally he answered: “Yeah, I think I might be.” Back home, he found an online questionnaire that assessed whether someone was an alcoholic. Wherever the quiz mentioned drinking, Bracke substituted gaming. He needed to answer yes to only a few of the questions to qualify as an addict; he affirmed almost all of them.

In the spring of 2015, Bracke was officially kicked off his real estate team. That summer, he stayed at his brother Alex’s house to take care of the dogs while Alex and his wife and son were on vacation. On the first day of his stay, he suddenly realized that his brother’s life — the home, the family, the steady job and income — was everything he wanted and would never have. It was a startling epiphany and the prelude to a period of profound self-loathing. He discontinued his antidepressants because he didn’t think he deserved them. He stopped bathing regularly. He left his brother’s house just twice in nine days, to grab snacks and frozen pizzas from a nearby grocery store. Gaming was the only thing that distracted him from his mental anguish. Nothing felt as good as gaming; nothing else felt good.

By August, he had a detailed suicide plan. He decided he would kill himself in November, around the same time of year his grandmother died; that way, he reasoned, his mother would have to endure only one morbid anniversary. About two months before Bracke intended to take his own life, his parents returned to Virginia to celebrate their grandchild’s birthday. They surprised Bracke with a visit one afternoon. Although they knew their son was struggling, they didn’t know the extent of it. They were shocked at the state of his apartment — cluttered with clothes, trash and empty pizza boxes — and Bracke’s own bedraggled appearance. He knew his gaming had become a terrible problem, he told them, but he felt powerless to stop.

In the following weeks, Sally called every rehab center and addiction hotline number she could find, searching for a program that recognized video-game addiction and knew how to treat it. Every single center turned her away, saying they didn’t offer treatment for her son’s condition. She called so many organizations — some of which used the same telephone switchboards — that she ended up speaking to certain individuals multiple times without realizing it. One day, an exasperated operator interrupted her sobs to tell her that they had already spoken and that he had some good news: His supervisor had recently mentioned a new rehab center in Washington State called reStart , which specialized in internet and video-game addiction.

Bracke and his parents were overjoyed to have finally found some recourse — but the price was staggering. It would cost about $22,000 for the minimum stay of 45 days, and their health insurance wouldn’t cover it. (At the time, there was no official diagnostic code for gaming addiction.) “I remember at one point saying we don’t know how we can afford this, and at the same time we don’t know how we can afford not to,” Bracke’s father told me. Ultimately, they decided to remortgage their house.

In the 1950s, the American psychologist James Olds and the Canadian neuroscientist Peter Milner performed a landmark experiment . They implanted electrodes in various parts of rats’ brains and placed the animals in boxes equipped with levers. Whenever the rats pressed a lever, their brains received a brief jolt of electricity. Zapping some areas of the brain did not change the animals’ behavior, whereas stimulation in other regions seemed to make them avoid the levers. When the researchers placed electrodes near a part of the brain known as the nucleus accumbens, something remarkable happened: The rats became fixated on the levers, pressing them as often as 80 times a minute for as long as 24 consecutive hours. Olds, Milner and other scientists showed that rats would gallop uphill, leap hurdles and even forsake food in order to keep stimulating that region of the brain. It seemed that science had located the brain’s pleasure center, the hypothesized area that made it feel so good to do things conducive to survival and reproduction, like having sex or eating calorie-rich meals. Perhaps, some scientists proposed, addictive drugs had some effect on this same area.

In the following decades, as the tools of neuroscience improved, researchers formed a more complete map of the brain’s reward system, which is a constellation of neural circuits involved in attention, motivation, desire and learning. Studies revealed that healthy rats became obsessed with drug-dispensing levers, but rats whose reward circuits had been disrupted showed little to no interest. Related experiments singled out the neurotransmitter dopamine as the most important chemical messenger in the reward system, demonstrating how certain addictive drugs drastically increased the amount of the dopamine traveling between neurons. With neuroimaging techniques developed in the 1990s, scientists could watch the brain’s reward center respond almost instantly to an injected drug and examine how the brain’s structure and behavior changed with continued use. In parallel, scores of studies identified heritable gene sequences that seemed to be associated with an increased risk for addiction.

These findings formed the core of what has come to be called the brain-disease model of addiction, which has been embraced by most major health organizations, including the National Institute on Drug Abuse and the American Medical Association. According to this model, addiction is a chronic disease of the brain’s reward system caused by continual exposure to particular substances and the dopamine release they trigger. The brain compensates by producing less dopamine in general and becoming less sensitive to it over all, forcing the user to take even larger doses to experience the same level of reward — a development known as tolerance. The neurochemical chaos produced by continued drug use also degrades the neural pathways that connect the reward center to the prefrontal cortex, which is crucial for planning, managing emotions and controlling impulses. The longer an addiction progresses, the higher someone’s tolerance, the stronger their cravings and the harder it may be to quit without relapsing.

From the 1990s to the late 2000s, neuroscientists demonstrated that many of the neurobiological changes underlying drug addiction occurred in pathological gamblers as well. For most of the 20th century, the psychiatric community regarded pathological gambling as a disorder of impulse control — more related to compulsive tics than to addiction. As scientists developed a more sophisticated understanding of the biology underlying addiction, however, many mental-health experts began to change their minds. Like certain drugs, gambling elicits a surge of dopamine in the reward circuit. Over time, compulsive gambling diminishes the ability to experience reward and inhibits circuits in the prefrontal cortex that are crucial for impulse control.

Studies of Parkinson’s disease provided further confirmation . Between 3 and 6 percent of people with Parkinson’s are compulsive gamblers, which is substantially higher than the estimate of 0.25 to 2 percent of the general population. Parkinson’s, which results in part from the death of dopamine-secreting neurons in the midbrain, is sometimes treated with the drug levodopa, which increases the amount of dopamine in the brain and nervous system. Some researchers have proposed that by raising dopamine levels, levodopa essentially mimics certain aspects of addiction, making the brain more susceptible to risk-taking and compulsive behavior. In 2013, after reviewing the mounting evidence, the American Psychiatric Association moved gambling disorder to the addictions section of the D.S.M.

In the last 10 years, scientists have been making similar discoveries about compulsive gaming. Neuroimaging studies have confirmed that video games trigger a release of dopamine in the reward circuit and that dopamine does not behave as it should in the brains of compulsive gamers. In a study performed in China , frequent gamers displayed unusually low activity in their reward circuits when anticipating a monetary prize. Some researchers think an inherently unresponsive reward system predisposes people to addiction by pushing them to seek big thrills; others interpret it as an early sign of tolerance. Last year, the psychologist Daria J. Kuss, part of the International Gaming Research Unit at Nottingham Trent University, and her colleagues published a review of 27 studies investigating the neurobiological correlates of compulsive gaming. They concluded that, compared with healthy individuals, compulsive gamers exhibit worse memory, poorer decision-making skills, impaired emotion regulation, inhibited prefrontal cortex functioning and disrupted electrochemical activity in their reward circuits — all similar to what researchers have documented in people with drug addictions.

“I don’t think we as psychologists can be justified in saying gaming addiction doesn’t exist,” Kuss told me. “From my experience of researching it for over 10 years, I can tell you I am very sure that this is indeed a real addiction requiring professional help.”

There’s a danger, though, in making neuroscience the ultimate arbiter of addiction. In the past decade, many researchers have argued persuasively that the brain-disease model of addiction has gained more prominence than it deserves. Neuroscientists have discovered that the relationship between the reward circuit and addiction is much more convoluted than is typically acknowledged. It turns out, for example, that only some addictive drugs, namely cocaine and amphetamine, dependably provoke huge releases of dopamine; many others — including nicotine and alcohol — do so inconsistently or hardly at all. Moreover, dopamine is not as closely linked to pleasure as once thought; it is much more important for wanting than liking , for anticipating or seeking out a reward than for enjoying it. And dopamine is involved in far more than reward and motivation; it is also important for memory, movement and immune-system regulation. But the explanatory power of neurobiology is so appealing that the basic tenets of the brain-disease model have seeped into public consciousness, popularizing a somewhat reductive understanding of addiction.

Sally Satel, a psychiatrist and Yale University lecturer, puts it this way: “Addiction is not a brain problem. It’s a human problem.” Derek Heim, an addiction psychologist at Edge Hill University in England, agrees completely: “People get very excited when they see pictures of a brain, but we’ve overextended that explanation. We need to think of addiction as an extremely multifaceted problem.” Video-game addiction perfectly exemplifies this multiplicity. It’s not just a biological phenomenon — it’s a cultural one too.

‘I stopped going to class. I stopped caring, and then everything kind of slipped. Second semester I didn’t have a roommate, so I didn’t have anybody to be accountable to. I was just kind of like, Screw it, I can do what I want for however long I want to.’

— Thomas Kuhn, 19, in September at reStart’s campus in Fall City, Washington.

When Bracke was born in the late 1980s, video games were still being assimilated into mainstream American culture. Today they are ubiquitous. Globally, more than two billion people play video games, including 150 million Americans (nearly half the country’s population), 60 percent of whom game daily. Professional athletes routinely perform goofy victory dances from Fortnite. Game Informer has the fifth-highest circulation of any American magazine, surpassed only by AARP’s Magazine and Bulletin, Costco Connection and Better Homes & Gardens. When Grand Theft Auto V was released in September 2013, it generated $1 billion of revenue within three days. No single entertainment product has ever made so much money in so little time. Video games are now one of the most lucrative sectors of the entertainment industry, having overtaken film, television, music and books. Games are also the most popular and profitable type of mobile app, accounting for about a third of all downloads and 75 percent of Apple’s App Store revenue.

A typical gamer in the United States spends 12 hours playing each week; 34 million Americans play an average of 22 hours per week. About 60 percent of gamers have neglected sleep to keep playing, and about 40 percent have missed a meal. Somewhere around 20 percent have skipped a shower. In 2018, people around the world spent a collective nine billion hours watching other people play video games on the streaming service Twitch — three billion more hours than the year before. In South Korea, where more than 95 percent of the population has internet access and connection speeds are the fastest in the world, compulsive game play has become a public-health crisis. In 2011, the South Korean government passed the Shutdown Law, which prevents anyone under 16 from playing games online between midnight and 6 a.m.

Video games are not only far more pervasive than they were 30 years ago; they are also immensely more complex. You could easily spend hundreds of hours not only completing quests but also simply exploring the vast fantasy kingdom in The Legend of Zelda: Breath of the Wild, a gorgeously rendered virtual world in which every blade of grass responds to the pressure of a footstep or the rush of a passing breeze. Fortnite attracted a large and diverse audience by blending the thrill of live events with the strategic combat and outrageous weaponry of first-person shooters, airbrushing it all with a playful cartoon aesthetic. In The Witcher 3: Wild Hunt, the choices players make change the state of the world and ultimately steer them toward one of 36 possible endings. All games — whether tabletop, field or electronic — are simulations: They create microcosms of the real world or gesture at imaginary ones. But these simulations have become so expansive, intricate and immersive that they can no longer be labeled mere entertainment, no more engrossing than an in-flight movie or a pop song. They are alternate realities.

Even games that are intentionally designed with a retro feel can be surprisingly absorbing. Take Stardew Valley, a quaint farming game with 16-bit graphics that reminded me of the early Pokémon titles for Game Boy. Apart from Candy Crush and word puzzles, I hadn’t spent much time playing video games since high school, so, while reporting this article, I decided that Stardew Valley might be an appealing way to reacquaint myself. It seemed like the kind of thing I could play for an hour here or there as my schedule allowed. The premise is simple: You leave your soul-deadening corporate office job and move to the country to revive your grandfather’s neglected farm. It seems refreshingly, perhaps deliberately, distinct from all the frenzied and ultracompetitive first-person shooters and survival games. Each day in the game equals about 17 minutes of real-world time, so a week passes in just under two hours.

At first, I was enchanted by the game’s pastoral setting and its emphasis on collaboration, compassion and discipline. As I became more deeply invested in my pixelated life, though, my attitude changed. I started to lose patience with my neighbors and their daily prattle and stopped noticing all the thoughtful details that once delighted me: the soft glow of fireflies on summer evenings, the fleeting shadow of an owl in flight, the falling petals in spring. And what disturbed me most was the sheer quantity of time I was pouring into the game. It was so easy to play continuously through an afternoon or an evening, in part because the great satisfaction of my achievements was so disproportionate to the effort I expended. I found it extremely difficult to stop playing, even at “nighttime,” when my character went to sleep, which doubles as a natural point to save your progress and quit. If I kept going, just another 20 minutes, I could get so much done. Compared with the game, everything else in my real life suddenly seemed so much harder — and so much less gratifying.

The fact that video games are designed to be addictive is an open secret in the gaming industry. With the help of hired scientists, game developers have employed many psychological techniques to make their products as unquittable as possible. Most video games initially entice players with easy and predictable rewards. To keep players interested, many games employ a strategy called intermittent reinforcement, in which players are surprised with rewards at random intervals. Some video games punish players for leaving by refusing to suspend time: In their absence, the game goes on, and they fall behind. Perhaps the most explicit manifestation of manipulative game design is the rising popularity of loot boxes, which are essentially lotteries for coveted items: a player pays real money to buy a virtual treasure box, hoping it contains something valuable within the world of the game.

As modern video games have become so immersive, their carefully composed dreamscapes have begun to offer a seductive contrast to the indifferent, and sometimes disappointing, world outside screens. Games, by definition, have rules; goals are often explicitly defined; progress is quantified. Although games frequently put players in challenging situations, they continuously offer tutorials, eliminate real-world consequences of failure and essentially guarantee rewards in exchange for effort. Games imbue players with a sense of purpose and accomplishment — precisely the kind of self-worth that can be so hard to attain in their actual lives, especially in a job market that can be punishing for the inexperienced.

From 2014 to 2017, American men in their 20s worked 1.8 fewer hours per week than they had in the three-year period 10 years earlier; in tandem, they increased the time they spent playing video games by the exact same amount. One economics study suggests that this correlation is not a coincidence — that young American men are working less in order to game more. For young men like Bracke, who have either not completed a four-year college degree or have not found work equal to their education and skills, video games can become something like a surrogate occupation — a simulacrum of success. Why suffer in a world that has no place for you when you can slip so easily into one that is designed to keep you happy, and is more than happy to keep you?

‘In my case, it was an avoidant coping mechanism. It was easier for me to go and avoid the anxiety of my recent breakup, the anxiety of my parents, the anxiety of school. It was easy to avoid all of the difficult situations through gaming.’

— Walker Wadsworth, 22, in September at reStart’s campus in Fall City, Washington.

On the evening of Oct. 21, 2015, a relative picked up Bracke from the Seattle airport and dropped him off at reStart’s main facility, a large two-story blue house in Fall City, Wash., surrounded by a garden and acres of forest. He checked in with the staff, dropped off his luggage in the house and joined a small group of young men sitting around a campfire. They were eating hot dogs and conducting their evening meeting, a ritual Bracke would come to know well: Each took his turn sharing what he accomplished that day and what he planned for the next. “Some of the guys, just to help me feel more comfortable, told part of their history about how they ended up here,” Bracke recalls. “Just being around other people who had gone through what I had gone through and knew what it felt like made a huge difference. I felt accepted. It almost sounds corny to say it, but I got there and immediately felt I had made the right choice.”

Because video-game addiction is a relatively new disorder, there are few published studies examining how best to treat it. Some clinicians warn that rehab programs and retreats focused on internet and video-game addiction make unsubstantiated claims, give people false hope and take advantage of desperate parents and adolescents. (In China, there have been disturbing reports of internet-addiction boot camps that use electroconvulsive therapy and corporal punishment, resulting in at least one teenager’s death.) But many compulsive gamers and their families counter that they have no other viable options; treatment centers focusing on substance abuse or gambling addiction often decline to help them or cannot provide a recovery environment that they think is suitable. ReStart opened in 2009, and it remains one of few dedicated long-term rehabilitation programs for internet and video-game addiction in the United States. Hilarie Cash, one of reStart’s founders, estimates that 80 percent of clients complete Phase I and that 70 percent complete Phase II. Former clients think it may be a lot less than that; they have seen many friends relapse or leave the program early.

Bracke spent about seven weeks at the house in an initial “detox” phase, following a strict schedule of chores, exercise, meals, group meetings and therapy sessions. Lights out by 10:30 p.m. No cellphones or computers. One landline for outgoing calls. The program forced him to try new activities — hiking, camping, Frisbee golf — many of which he enjoyed. He developed a “life balance plan,” which focused on strategies for responsible technology use after the program, for example forgoing a computer and limiting internet access. And he learned how to have difficult conversations using a “wheel of communication,” which required him to verbalize what he was feeling and thinking and to reiterate what the other person in the conversation had just said. “Toward the end of my time gaming, I was getting to the point where I felt like I couldn’t converse with people at all, unless it was about video games,” Bracke says. “So going through something like that really made it click that I can actually talk to people, I can really communicate with them.”

A huge component of reStart’s philosophy is the importance of maintaining relationships. “These guys have almost universally what I would call an intimacy disorder,” Cash told me. “They don’t really know how to build and maintain intimate relationships. The solution to addiction is connection. We are building a real recovery community with our guys. It’s all about building friendship and community that is face to face, in person, rather than online.”

Of course, for many people video games are explicitly and gratifyingly social. A raucous multiplayer game like Fortnite can bring large groups of friends and neighbors together online or in someone’s living room. People who struggle with severe social anxiety, or who cannot regularly leave their homes, may find camaraderie through an avatar. But video games are a poor substitute for meaningful human companionship. Virtual interactions are often stripped of behavioral cues and facial expressions; masked identities empower people to mistreat one another; and it’s easier to vanish from someone’s life if you’ve never met them. Games, like online social networks in general, sometimes provide the semblance of genuine connection while actually pushing someone into a dangerously secluded way of life.

The economic and cultural ascendancy of video games has collided with a social crisis that we are only beginning to understand: the isolation, emotional stagnation and profound loneliness of American men. Recent surveys indicate that loneliness is reaching epidemic proportions among Americans. According to a 2018 Cigna survey , more than 40 percent of Americans feel that their relationships are not meaningful and that they are generally isolated from others; 20 percent rarely or never feel close to anyone. Young adults between 18 and 22 score higher on scales of loneliness than any other group.

There’s good reason to think that single men are uniquely vulnerable to social isolation and its repercussions. Studies suggest that men rely primarily on a partner for emotional intimacy, whereas women are more likely to have additional support from close friends; men in their late 30s lose friends at a faster rate than women; and men are more likely to kill themselves because of prolonged emotional or social detachment. In three decades of research , Niobe Way, a professor of developmental psychology at New York University, has observed a striking pattern of behavior among American boys: in early adolescence, they are openly affectionate with one another, speaking freely of love and lifelong bonds; by late adolescence, as they become cultured to project an image of masculinity, heterosexuality and stoicism, they start to distance themselves from their same-sex friends. One 17-year-old told Way that “it might be nice to be a girl, because then you wouldn’t have to be emotionless.”

And while addiction was once regarded as a kind of vice or chemical thrall — and in more recent decades has been framed as dysfunctional neural circuitry — there is now a substantial body of research contextualizing addiction as a consequence of social isolation . People who are deprived of a dependable social network, or who have severe difficulty connecting with others, have a much higher risk of both developing an addiction and relapsing. Addiction itself can drastically magnify loneliness . Video-game addiction afflicts between 1 and 8 percent of gamers, according to estimates published by researchers. As a group, gamers are now more diverse than ever , comprising a wide range of ages and increasingly equal numbers of men and women. Yet as evidenced by both scientific studies and the experiences of clinical psychiatrists, self-identified video-game addicts are overwhelmingly male . To be more specific, they are typically single young adult men — the very segment of the population that may be most prone to social detachment. In the course of my conversations with dozens of compulsive gamers, a familiar narrative began to emerge: A young man repeatedly suffered some form of rejection from his peers; hurt, he turned to video games to soothe and distract himself; the games gave him a pretense of the kinship and achievement he never knew in the real world; when he left home for college or moved into his own place — and the familial checks on his day-to-day activities were lifted — his fixation on games intensified until it consumed him.

This is more or less the story that Cam Adair , perhaps the leading spokesman for the legitimacy of video-game addiction, tells in his public appearances. Like Bracke, he nearly committed suicide but sought help in the 11th hour. In 2011, he posted his story and insights on a blog and received thousands of responses from people with similar experiences. Inspired by this outpouring, Adair founded Game Quitters, an online support community for video-game addicts that today has about 75,000 members from 95 countries. Thanks to his ability to articulate the fraught reality of a fringe diagnosis, Adair is now self-employed as a full-time public speaker.

“I just really inquired, ‘Why do I game?’ ” Adair told me. “For me, it was so obvious that it wasn’t just that games were fun. They allowed me to escape. They allowed me to socially connect. They allowed me to see measurable progress. And they allowed me to feel a sense of certainty.” To Adair, the gaming industry’s repeated disavowal of video-game addiction is embarrassing. “It’s just not honest, and it’s not based in reality,” he says. “People have been coming forward for years, saying they are really struggling. What really matters is that you feel you have to keep playing despite it having a negative impact on your life. That’s addiction. I think, as a society, we should be saying, ‘How can we help?’ ”

Those who deny the reality of video-game addiction often overlook a fundamental ambiguity central to addiction itself. Current diagnostic criteria for addiction are not so much a definitive scientific description as a useful guideline. To insist that addiction must be restricted to certain substances is to presume a level of understanding that we have not yet reached. If addiction is an evolving concept, and an official expansion of that concept would profoundly benefit people who clearly need help, can we justify clinging to the status quo?

In the summer of 2016, shortly after he started working at a Costco near his home in Redmond, Wash., Bracke found himself surrounded, once again, by video games. Niantic had released Pokémon Go, an augmented-reality game for mobile devices that superimposed animated Pokémon onto screen-based images of a player’s actual surroundings — a pidgey in the park, a magikarp on the beach. You could catch them by swiping a finger across the screen. The game was downloaded more than 100 million times by the end of July and for a while was the single most active mobile game in the United States.

Many of Bracke’s co-workers were captivated by Pokémon Go. They would surreptitiously play during their shifts, occasionally keeping the game running in their pockets to increase their chances of encountering a Pokémon. Some of them asked him about it: What level was he? Which Pokémon had he caught so far? Bracke hadn’t tried the game yet, but he was extremely tempted. He decided he would download it so that he could immediately block all access to it using a “screen accountability” program called Covenant Eyes, which was originally designed to help people stop watching pornography.

Today, Bracke — a cordial, brown-bearded 31-year-old — still works at that Costco, though he recently completed a degree in accounting at Bellevue College and has begun his studies at the University of Washington. He owns a Samsung Galaxy smartphone and an “intentionally crappy” laptop, but he doesn’t have an internet connection at home. He hasn’t touched video games since starting rehab in the fall of 2015. Like Adair, he has become an outspoken advocate for video-game addicts, once appearing on the “Today” show .

Rehab taught him that in order to stay sober, he would have to do more than avoid video games — he needed to replace them with something else. In Washington, he started reading more. He broadened his social network, making new friends through work, school and mutual acquaintances. When the weather was nice, he went hiking, took his dog on a long walk or played Frisbee golf. At home, he enjoyed the occasional board game. “I’ve tried to branch myself out into a lot of hobbies that I take shallower dives into, rather than having one that occupies everything,” he told me.

After touring reStart this September, I visited Bracke at the apartment where he was living at the time. When I walked in, I was greeted by several of Bracke’s friends and roommates, all young men in their 20s who participated in reStart (they asked to remain unnamed). The apartment was small, with somewhat shabby furniture. A two-foot-tall artificial Christmas tree stood in one corner, a holdover from last year. Bracke’s small white dog, Minerva, ran between us, yipping and nudging our legs.

I chatted with Bracke and his friends for about two hours. We talked about their experiences in reStart, how they navigate life with so little internet access and their long-term plans. Each of them believed he would have killed himself without some type of formal treatment. Each stressed how important reStart’s emphasis on social connection had been to his recovery. And each said that, at least for the time being, he planned to stay in Washington — the place where they all had finally learned, or relearned, how to connect with others outside the context of multiplayer games. “I still hung out with people before,” one of Bracke’s friends said, “but most of the time, we would just talk about stuff we were going to do, like playing video games or something else that wasn’t particularly serious. I can just walk up to either of them,” he continued, gesturing to the other men beside him, “and be like, ‘This is what’s going on in my life.’ I’ve never really had that before.”

His admission stuck with me, in part because it so closely echoed conversations I had with other self-identified gaming addicts. As Bracke told me at one point, a huge part of his rehab was “allowing myself to rely on others, and being there to support others when they need it as well.” He explained that even if he had technically been socializing while gaming — talking with other players on his headset — he had never been genuinely interested in their lives, nor they in his. In contrast, the relationships he developed during rehab, in the complete absence of games, felt sincere and enduring: “A lot of the guys I met there were some of the only people I could be totally honest with.”

The more I spoke with the young men in Bracke’s living room, the clearer it became that they were not simply friends — they were family. They had suffered in such similar ways. They had arrived in Washington feeling helpless and utterly alone. Most of them had forgotten what it was like to have a meaningful conversation with another person. For months, they cooked and ate together, shared bedrooms and bathrooms and managed the same household. They exchanged mundane niceties and confessed deeply personal fears, hopes and secrets — their abandoned aspirations, their suicide plans. They cried in front of one another, repeatedly, because of anger or guilt or grief. They witnessed one another become more trusting and confident, less anxious and withdrawn, even hopeful.

Although each had his own future to focus on, whether school or work or both, they still lived together and encouraged one another in these pursuits. Perhaps they would never fully understand the reasons for their compulsions or distill the culpability of games from all the other elements of their lives. Perhaps it didn’t matter anymore. If addiction is the compulsive substitution of an artificially rewarding experience for essential human intimacy, then these men had found its opposite in one another.

Ferris Jabr is a contributing writer for the magazine. He last wrote about the evolution of beauty.

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  • Published: 28 November 2022

Psychological treatments for excessive gaming: a systematic review and meta-analysis

  • Jueun Kim 1 ,
  • Sunmin Lee 1 ,
  • Dojin Lee 1 ,
  • Sungryul Shim 2 ,
  • Daniel Balva 3 ,
  • Kee-Hong Choi 4 ,
  • Jeanyung Chey 5 ,
  • Suk-Ho Shin 6 &
  • Woo-Young Ahn 5  

Scientific Reports volume  12 , Article number:  20485 ( 2022 ) Cite this article

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Despite widespread public interest in problematic gaming interventions, questions regarding the empirical status of treatment efficacy persist. We conducted pairwise and network meta-analyses based on 17 psychological intervention studies on excessive gaming ( n  = 745 participants). The pairwise meta-analysis showed that psychological interventions reduce excessive gaming more than the inactive control (standardized mean difference [SMD] = 1.70, 95% confidence interval [CI] 1.27 to 2.12) and active control (SMD = 0.88, 95% CI 0.21 to 1.56). The network meta-analysis showed that a combined treatment of Cognitive Behavioral Therapy (CBT) and Mindfulness was the most effective intervention in reducing excessive gaming, followed by a combined CBT and Family intervention, Mindfulness, and then CBT as a standalone treatment. Due to the limited number of included studies and resulting identified methodological concerns, the current results should be interpreted as preliminary to help support future research focused on excessive gaming interventions. Recommendations for improving the methodological rigor are also discussed.

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Introduction.

Excessive gaming refers to an inability to control one’s gaming habits due to a significant immersion in games. Such an immersion may result in experienced difficulties in one’s daily life 1 , including health problems 2 , poor academic or job performance 3 , 4 , and poor social relationships 5 . Although there is debate regarding whether excessive gaming is a mental disorder, the 11th revision of the International Classification of Diseases (ICD-11) included Gaming Disorder as a disorder in 2019 6 . While there is no formal diagnosis for Gaming Disorder listed in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), the DSM-5 included Internet Gaming Disorder (IGD) as a condition for further study 7 . In the time since the DSM-5’s publication, research on excessive gaming has widely continued. Although gaming disorder’s prevalence appears to be considerably heterogeneous by country, results from a systematic review of 53 studies conducted between 2009 and 2019 indicated a global prevalence of excessive gaming of 3.05% 8 . More specifically, a recent study found that Egypt had the highest IGD prevalence rate of 10.9%, followed by Saudi Arabia (8.8%), Indonesia (6.1%), and India (3.8%) among medical students 9 .

While the demand for treatment of excessive gaming has increased in several countries 10 , standard treatment guidelines for problematic gaming are still lacking. For example, a survey in Australia and New Zealand revealed that psychiatrics— particularly child psychiatrists, reported greater frequency of excessive gaming in their practice, yet 43% of the 289 surveyed psychiatrists reported that they were not well informed of treatment modalities for managing excessive gaming 11 . Similarly, 87% of mental health professionals working in addiction-related institutions in Switzerland reported a significant need for professional training in excessive gaming interventions 12 . However, established services for the treatment of gaming remain scarce and disjointed.

Literature has identified a variety of treatments for excessive gaming, but no meta-analysis has yet been conducted on effectiveness of the indicated interventions. The only meta-analysis to date has focused on CBT 13 , and while results demonstrated excellent efficacy in reducing excessive gaming. However, the study did not compare the intervention with other treatment options. Given that gaming behavior is commonly affected by cognitive and behavioral factors as well as social and familial factors 14 , 15 , 16 , it would also be important to examine the effectiveness of treatment approaches that reflect social and familial influences. While two systematic reviews examined diverse therapeutic approaches, they primarily reported methodological concerns of the current literature and did not assess the weight of evidence 17 , 18 . Given that studies in this area are rapidly evolving and studies employing rigorous methodological approaches have since emerged 19 , 20 , a meta-analytic study that analyzes and synthesizes the current stage of methodological limitations while also providing a comprehensive comparison of intervention options is warranted.

In conducting such a study, undertaking a traditional pairwise meta-analysis is vital to assess overall effectiveness of diverse interventions. Particularly, moderator and subgroup analyses in pairwise meta-analysis provide necessary information as to whether effect sizes vary as a function of study characteristics. Furthermore, to obtain a better understanding of the superiority and inferiority of all clinical trials in excessive gaming psychological interventions, it is useful to employ a network meta-analysis, which allows for a ranking and hierarchy of the included interventions. While a traditional pair-wise analysis synthesizes direct evidence of one intervention compared with one control condition, a network meta-analysis incorporates multiple comparisons in one analysis regardless of whether the original studies used them as control groups. It enters all treatment and control arms of each study, and makes estimates of the differences in interventions by using direct evidence (e.g., direct estimates where two interventions were compared) and indirect evidence (e.g., generated comparisons between interventions from evidence loops in a network 21 . Recent meta-analytic studies on treatments for other health concerns and disorders have used this analysis to optimize all available evidence and build treatment hierarchies 22 , 23 , 24 .

In this study, the authors used a traditional pairwise meta-analysis and network meta-analysis to clarify the overall and relative effectiveness of psychological treatments for excessive gaming. The authors also conducted a moderator analysis to examine potential differences in treatment efficacy between Randomized Controlled Trials (RCTs) and non-RCTs, age groups, regions, and research qualities. Finally, the authors examined follow-up treatment efficacy and treatment effectiveness on common comorbid symptoms and characteristics (e.g., depression, anxiety, and impulsivity).

The protocol for this review has been registered in the International Prospective Register of Systematic Review (PROSPERO 2021: CRD 42021231205) and is available for review via the following link: https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=231205 . Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) network meta-analysis checklist 25 is included in Supplementary Material 1 .

Identification and selection of studies

The authors searched seven databases, which included ProQuest, PubMed, Scopus, Web of Science, PsycINFO, Research Information Sharing Service (RISS), and DBpia. Given that a substantial number of studies have been published particularly in East Asia and exclusion of literature from the area in languages other than English has been discussed as a major limitation in previous reviews 17 , 18 , the authors gave special attention to gaming treatment studies in English and other languages from that geographical area. Additionally, the authors searched Google Scholar to ensure that no studies were accidentally excluded. The authors conducted extensive searches for studies published in peer-reviewed journals between the first available year (year 2002) and October 31, 2022, using the following search terms: “internet”, or “video”, or “online”, or “computer”, and “game”, or “games”, or “gaming”, and “addiction”, or “addictions”, or “disorder”, “disorders”, or “problem”, or “problems”, or “problematic”, or “disease”, or “diseases”, or “excessive”, or “pathological”, or “addicted”, and “treatment”, or “treatments”, or “intervention”, or “interventions”, or “efficacy”, or “effectiveness”, or “effective”, or “clinical”, or “therapy”, or “therapies”. Search strategies applied to each database is provided in Supplementary Material 2 .

The authors included studies that recruited individuals who were excessively engaging in gaming, according to cutoff scores for different game addiction scales. Since there is not yet an existing consensus on operational definitions for excessive gaming, the authors included studies that recruited individuals who met high-risk cutoff score according to the scales used in each respective study (e.g., Internet Addiction Test [modified in game environments] > 70). The authors also sought studies that provided pretest and posttest scores from the game addiction scales in both the intervention and control groups. Studies meeting the following criteria were excluded: (a) the study targeted excessive Internet use but did not exactly target excessive gaming; (b) the study provided a prevention program rather than an intervention program; (c) the study provided insufficient data to perform an analysis of the effect sizes and follow-up contact to the authors of such studies did not yield the information necessary for inclusion within this paper; and (d) the study conducted undefinable types of intervention with unclear psychological orientations (e.g., art therapy with an undefined psychological intervention, fitness programs, etc.).

Two authors (D.L. and S.L.) independently screened the titles and abstracts of articles identified by the electronic searches and excluded irrelevant studies. A content expert (J.K.) examined the intervention descriptions to determine intervention types that were eligible for this review. All treatments were primarily classified based on the treatment theory, protocol, and descriptions about the procedures presented in each paper. D.L. and S.L.—both of whom have been in clinical training for 2 years categorized treatment type, to which J.K., a licensed psychologist, cross-checked and confirmed the categorization. The authors resolved disagreements through discussion. The specific example of intervention type classification is provided in Supplementary Material 3 .

Risk of bias and data extraction

Three independent authors assessed the following risks of bias among the included studies. The authors used the Risk of Bias 2.0 (RoB 2) tool for RCT studies and the Risk Of Bias In Non-Randomized Studies of Intervention (ROBINS-I) tool for non-RCT studies. The RoB 2 evaluates biases of (a) randomization processes; (b) deviations from intended interventions; (c) missing outcome data; (d) measurement of the outcome; and (e) selection of the reported result, and it categorizes the risk of bias in each dimension into three levels (low risk, moderate risk, and high risk). The ROBINS-I evaluates biases of (a) confounding variables; (b) selection of participants; (c) classification of interventions; (d) deviations from intended interventions; (e) missing data; (f) measurement of outcomes; and (g) selection of the reported result, and it categorizes the risk of bias in each dimension into five levels (low risk, moderate risk, serious risk, critical risk, and no information). After two authors (D.L. and S.L.) assessed each study, another author (J.K.) cross-checked the assessment.

For each study, the authors collected descriptive data, which included the sample size as well as participants’ ages, and regions where the studies were conducted. The authors also collected clinical data, including whether the study design was a RCT, types of treatment and control, treatment duration, and the number of treatment sessions. Finally, the authors collected data on the follow-up periods and the measurement tools used in each study.

Data analysis

The authors employed separate pairwise meta-analyses in active control and inactive control studies using R-package “meta” 26 and employed a random-effects model due to expected heterogeneity among studies. A random-effects model assumes that included studies comprise random samples from the larger population and attempt to generalize findings 27 . The authors categorized inactive control groups including no treatment and wait-list control and categorized active control groups including pseudo training (e.g., a classic stimulus-control compatibility training) and other types of psychological interventions (e.g., Behavioral Therapy, CBT, etc.). The authors also used the bias-corrected standardized mean change score (Hedges’ g ) due to small sample sizes with the corresponding 95% confidence interval 28 . The authors’ primary effectiveness outcome was a mean score change on game addiction scales from pre-treatment to post-treatment. Hedges’ g effect sizes were interpreted as small ( g  = 0.15), medium ( g  = 0.40) and large ( g  = 0.75), as suggested by Cohen 29 . The authors used a conservative estimate of r  = 0.70 for the correlation between pre-and post-treatment measures 30 , and to test heterogeneity, the authors calculated Higgins’ I 2 , which is the percentage of variability in effect estimates due to heterogeneity among studies rather than chance. I 2  > 75% is considered substantial heterogeneity 31 .

The authors conducted moderator analyses as a function of RCT status (RCT versus non-RCT), age group (adolescents versus adults), region (Eastern versus Western), and research quality (high versus low). The authors divided high versus low quality studies using median values of research quality scores (RCT: low [0–2] versus high [3–5], non-RCT: low [0–4] versus high [5]). The authors calculated Cochran’s Q for heterogeneity: A significant Q value indicates a potentially important moderator variable. For the subgroup analyses of follow-up periods and other outcomes, the authors conducted separate pairwise analyses in 1- to 3-month follow-up studies and in 4- to 6-month follow-up studies and separate analyses in depression, anxiety, and impulsivity outcome studies.

The authors sought to further explore relative effectiveness of treatment types and performed a frequentist network meta-analysis using the R-package “netmeta” 4.0.4 version 26 . To examine whether transitivity and consistency assumptions for network meta-analysis were met, the authors assessed global and local inconsistency. To test network heterogeneity, the authors calculated Cochran’s Q to compare the effect of a single study with the pooled effect of the entire study. The authors drew the geometry plot of the network meta-analysis through the netgraph function in “netmeta”, and the thicker lines between the treatments indicated a greater number of studies.

The authors presented the treatment rankings based on estimates using the surface area under the cumulative ranking curve (SUCRA) 32 . The SUCRA ranged from 0 to 100%, with higher scores indicating greater probability of more optimal treatment. The authors also generated a league table to present relative effectiveness between all possible comparisons between treatments. When weighted mean difference for pairwise comparisons is bigger than 0, it favors the column-defining treatment. Finally, funnel plots and Egger’s test were used to examine publication bias.

Included studies and their characteristics

Figure  1 presents the flow diagram of the study selection process. The authors identified 1471 abstracts in electronic searches and identified an additional seven abstracts through secondary/manual searches (total n  = 1478). After excluding duplicates ( n  = 765) and studies that did not meet the inclusion criteria based on the study abstract ( n  = 550), the authors retrieved studies with potential to meet the inclusion criteria for full review ( n  = 163). Of these, 144 studies were excluded due to not meeting inclusion criteria based on full-text articles, leaving 19 remaining studies. Of the 19, two studies did meet this paper’s inclusion criteria but were excluded from this network meta-analysis 33 , 34 because the consistency assumption between direct and indirect estimates was not met at the time of this study's consideration based on previous studies 35 , 36 . Therefore, a total of 17 studies were included in this network meta-analysis, covering a total of 745 participants 36 .

figure 1

Flow diagram of the study selection process.

Table 1 lists the characteristics of the 17 included studies. CBT ( n  = 4), Behavioral Treatment (BT) + Mindfulness ( n  = 4), and BT only ( n  = 4) were most frequently studied, followed by CBT + Family Intervention ( n  = 1), CBT + Mindfulness ( n  = 1), virtual reality BT ( n  = 1), Mindfulness ( n  = 1), and Motivational Interviewing (MI) + BT ( n  = 1). Seven studies were conducted in Korea and six were conducted in China, followed by Germany and Austria ( n  = 1), Spain ( n  = 1), the United States ( n  = 1), and the Philippines ( n  = 1). Twelve articles were written in English, and five articles were written in a language other than English. Nine studies conducted a follow-up assessment with periods ranging from one to three months, and two studies conducted a follow-up assessment with periods ranging four to six months. In one study 20 , the authors described their 6-month follow-up but did not present their outcome value, and thus only two studies were included in the four- to six-month follow-up analysis. Among the 17 included studies, eight had no treatment control group, five had an active control group (e.g., pseudo training, BT, and CBT), and four had a wait-list control group. Seven of the studies were RCT studies, and 10 were non-RCT studies.

Pairwise meta-analysis

The results of meta-analyses showed a large effect of all psychological treatments when compared to any type of comparison groups ( n  = 17, g  = 1.47, 95% CI [1.07, 1.86]). The treatment effects were separately provided according to active versus inactive comparison groups in Fig.  2 . The effects of psychological treatments were large when compared to the active control ( n  = 5, g  = 0.88, 95% CI [0.21, 1.56]) or inactive control ( n  = 12, g  = 1.70, 95% CI: [1.27, 2.12]). Substantial heterogeneity was evident in studies that were compared to both the active controls (I 2  = 72%, < 0.01) and inactive controls at p -value level of 0.05 (I 2  = 69%, p  < 0.001).

figure 2

Pairwise Meta-analysis. Psychological treatment effects on excessive gaming by comparison group type (active and inactive controls). SMD standardized mean difference, SD standard deviation,  CI confidence interval, I 2  = Higgins' I 2 .

Moderator analysis

As shown in Table 2 , the moderator analysis suggested that effect sizes were larger in non-RCT studies ( n  = 10, g  = 1.60, 95% CI [1.36, 1.84]) than RCT studies ( n  = 7, g  = 1.26, 95% CI [0.30, 2.23]). However, the results of a Q-test for heterogeneity yielded insignificant results (Q = 0.44, df[Q] = 1, p  = 0.51), indicating that no statistically significant difference in treatment efficacy at p level of 0.05 between RCT and non-RCT studies.

The results of Q-test for heterogeneity did not yield any significant results, indicating no significant differences in treatment efficacy between adults and adolescents (Q = 2.39, df[Q] = 1, p  = 0.12), Western and Eastern regions (Q = 0.40, df[Q] = 1, p  = 0.53), or low and high research qualities among RCT studies (Q = 2.25, df[Q] = 1, p  = 0.13) and non-RCT studies (Q = 3.06, df[Q] = 1, p  = 0.08).

Subgroup analysis

The results demonstrated that the treatment effect was Hedges’ g  = 1.54 (95% CI [0.87, 2.21]) at 1-to-3-month follow-up and Hedges’ g  = 1.23 (95% CI [0.77, 1.68]) 4- to-6-month follow-up. The results also showed that the treatment for excessive gaming was also effective on depression and anxiety. Specifically, treatment on depression was Hedges’ g  = 0.52 (95% CI: [0.22, 0.81], p  < 0.001), and anxiety was Hedges’ g  = 0.60 (95% CI [0.11, 1.08], p  = 0.02), which are medium and significant effects. However, the effect on impulsivity was insignificant, Hedges’ g  = 0.26 (95% CI [− 0.14, 0.67], p  = 0.20).

Network meta-analysis

As shown in Fig.  3 , a network plot represents a connected network of eight intervention types (CBT, BT + Mindfulness, BT, Virtual Reality BT, CBT + Mindfulness, CBT + Family, MI + BT, and Mindfulness) and three control group types (wait-list control, no treatment, treatment as usual). The widest width of nodes was observed when comparing BT + Mindfulness and no treatment, indicating that those two modules were most frequently compared. No evidence of global inconsistency based on a random effects design-by-treatment interaction model was found (Q = 8.5, df[Q] = 7, p  = 0.29). Further, local tests of loop-specific inconsistency did not demonstrate inconsistency, indicating that the results from the direct and indirect estimates were largely in agreement ( p  = 0.12- 0.78).

figure 3

Network plot for excessive gaming interventions. Width of lines and size of circles are proportional to the number of studies in each comparison. BT behavioral therapy, CBT cognitive behavioral therapy, Family family intervention, MI motivational interviewing, TAU treatment as usual.

As shown in Fig.  4 , according to SUCRA, a combined intervention of CBT and Mindfulness ranked as the most optimal treatment (SUCRA = 97.1%) and demonstrated the largest probability of effectiveness when compared to and averaged over all competing treatments. A combined treatment of CBT and Family intervention ranked second (SUCRA = 90.2%), and Mindfulness intervention ranked third (SUCRA = 82.1%). As shown in Table 3 , according to league table, CBT + Mindfulness intervention showed positive weighted mean difference values in the lower diagonal, indicating greater effectiveness over all other interventions. The CBT + Mindfulness intervention was more effective than CBT + Family or Mindfulness interventions, but their differences were not significant (weighted mean differences = 0.23–1.11, 95% CI [− 1.39 to 2.68]). The top three ranked interventions (e.g., CBT + Mindfulness, CBT + Family intervention, and Mindfulness in a row) were statistically significantly superior to CBT as a standalone treatment as well as the rest of treatments.

figure 4

Surface under the cumulative ranking curve (SUCRA) rankogram of excessive gaming. BT behavioral therapy, CBT cognitive behavioral therapy, Family family intervention, MI motivational interviewing, TAU treatment as usual.

Risk of bias

Figure  5 displays an overview of the risk of bias across all included studies. Of note was that in the RCT studies, bias due to missing outcome data was least problematic, indicating a low dropout rate (six out of seven studies). In contrast, bias due to deviations from intended interventions was most problematic, indicating that, in some studies, participants and trial personnel were not blinded and/or there was no information provided as to whether treatments adhered to intervention protocols (six out of seven studies). In the non-RCT studies, bias in the selection of participants in the study was least problematic, indicating that researchers did not select participants based on participant characteristics after the start of intervention (10 out of 10 studies). In contrast, bias in the measurement of outcomes was most problematic, indicating that participants and outcome assessors were not blinded and/or studies used self-reported measures without clinical interviews (10 out of 10 studies).

figure 5

Overview of risk of bias results across all included studies. Cl bias in classification of interventions, Co bias due to confounding, De bias due to deviations from intended interventions, Me bias in measurement of the outcome, Mi bias due to missing outcome data, R bias arising from the randomization process, RoB risk of bias, ROBINS-I risk of bias in non-randomized studies of intervention, Sp bias in selection of participants in the study, Sr bias in selection of the reported result.

Funnel plots and Egger’s test showed no evidence of publication in network meta-analyses. Funnel plots were reasonably symmetric and the result from Egger’s test for sample bias were not significant ( p  = 0.22; see Supplementary Material 4 ).

In this pairwise and network meta-analyses, the authors assessed data from 17 trials and analyzed the overall and relative effectiveness of eight types of psychological treatments for reducing excessive gaming. The pairwise meta-analysis results indicated large overall effectiveness of psychological treatments in reducing excessive gaming. Although the effectiveness was smaller when compared to the active controls than when compared to the inactive controls, both effect sizes were still large. However, this result needs to be interpreted with caution because there are only seven existing RCT studies and several existing low-quality studies. Network meta-analysis results indicated that a combined treatment of CBT and Mindfulness was the most effective, followed by a combined therapy of CBT and Family intervention, Mindfulness, and then CBT as a standalone treatment, however, this finding was based on a limited number of studies. Overall, the findings suggest that psychological treatments for excessive gaming is promising, but replications are warranted, with additional attention being placed on addressing methodological concerns.

The large effect of psychological treatments in reducing excessive gaming seems encouraging but the stability and robustness of the results need to be confirmed. These authors’ moderator analysis indicated that the effect size of non-RCT studies was not significantly different from that of RCT studies. The authors conducted a moderator analysis using the research quality score (high vs low) and found that research quality did not moderate the treatment effect. The authors also examined publication bias using both funnel plots and Egger’s test and found no evidence of publication bias in network meta-analysis. Because most of the studies included in the review were from Asian countries, the authors examined the generalizability of the finding by testing moderator analysis by regions and found no significant difference of treatment effect sizes between Eastern and Western countries. Finally, although limited studies exist, treatment benefits did not greatly diminish after 1–6 months of follow-ups, indicating possible lasting effects.

Network meta-analysis findings provide some preliminary support for the notion that a combined treatment of CBT and Mindfulness and a combined treatment of CBT and Family intervention are most effective in addressing individuals’ gaming behaviors. These combined therapies were significantly more effective than the CBT standalone approach. CBT has been studied and found to be highly effective in addiction treatment—particularly in reducing excessive gaming due to its attention to stimulus control and cognitive restructuring 13 . However, adding Mindfulness and family intervention may have been more effective than CBT alone, given that gaming is affected not only by individual characteristics, but also external stress or family factors.

Mindfulness generally focuses on helping individuals to cope with negative affective states through mindful reappraisal and aims to reduce stress through mindful relaxation training. The effectiveness of Mindfulness has been validated in other substance and behavioral addiction studies such as alcohol 37 , gambling 38 , and Internet 39 addiction treatments. Indulging in excessive gaming is often associated with the motivation to escape from a stressful reality 40 , and mindful exercises are likely to help gamers not depend on gaming as a coping strategy.

Because excessive gaming is often entangled with family environments or parenting-related concerns—particularly with adolescents, addressing appropriate parent–adolescent communication and parenting styles within excessive gaming interventions are likely to increase treatment efficacy 41 , 42 , 43 . Based on a qualitative study focused on interviews with excessive gamers 43 , and per reports from interviewed gamers, parental guidance to support regulatory control and encouragement to participate in other activities are important factors to reduce excessive gaming. However, at the same time, if parents excessively restrict their children’s behavior, children will feel increased stress and may further escape into the online world through gaming 44 as a means of coping with their stress. Our study indicates that appropriate communication among parents and adolescents in addition to parenting styles with respect to game control must be discussed in treatment. However, because only two studies examined the top two ranked combined interventions within this paper, such findings warrant replication.

Limitations and future directions

These authors identified methodological limitations and future directions in the reviewed studies, which include the following. The authors included non-RCTs to capture data on emerging treatments, but a lack of RCT studies contributes to this paper’s identified methodological concerns. Of 17 studies included, seven were RCT studies and 10 were non-RCT studies. The lack of RCT studies has been repeatedly mentioned in previous review studies 17 , 18 . In fact, one of the two identified reviews 17 made the criticism that even CBT (the most widely studied treatment for excessive gaming) was mostly conducted in non-RCT studies, which was commensurate with this paper’s data (only one out of four CBT studies included in this review is a RCT). Including non-RCTs may be likely to increase selection bias by employing easily accessible samples and assigning participants with more willingness (which is an indicator of better treatment outcome) to intervention groups. Selection bias may have increased the effect size of treatments than what is represented in reality and may limit the generalizability of this finding. Thus, more rigorous evaluation through RCTs is necessary in future studies.

While there are concerns surrounding assessment tools, given that all included studies used self-report measures without clinical interviews, this may lead to inaccurate results due to perceived stigma. Additionally, 11 self-reported measurement tools were employed in the included studies—and some of those tools may have poor sensitivity or specificity. A previous narrative review 45 and a recent meta-analytic review 46 suggested that the Game Addiction Scale-7, Assessment of Internet and Computer Addiction Scale-Gaming, Lemmens Internet Gaming Disorder Scale-9, Internet Gaming Disorder Scale 9- Short Form, and Internet Gaming Disorder Test-10 have good internal consistency and test–retest reliability. Thus, there is a need for studies to employ clinical interviews and self-report measures with good psychometric features.

Many studies in this included review did not describe whether participants and experimenters were blinded and there was no information about whether treatments adhered to intervention protocols. Although blinding of participants and personnel may be impossible in most psychotherapy studies, it is crucial to evaluate possible performance biases such as social desirability. Also, a fidelity check by content experts is needed to confirm whether treatments adhered to intervention protocols.

Finally, future studies need to examine treatment efficacy in treating both excessive gaming and its comorbid psychiatric symptoms. Internet/gaming addiction has been reported to have a high comorbidity with attention deficit hyperactivity disorder, depression, anxiety, and other substance abuse 47 , 48 . Our results showed that CBT, BT, and BT + Mindfulness may be effective in reducing depression or anxiety symptoms of excessive gamers. However, other psychological and/or pharmacological treatments such as CBT + Bupropion or Bupropion as a standalone treatment have been also reported as potentially effective treatments for excessive gamers with major depressive disorder 49 , 50 . Thus, it would be worthwile to examine efficacy of treatments on excessive gamers with dual diagnoses.

TO the best of the authors’ knowledge, this is the first pairwise meta-analytic and network meta-analytic study that examined the overall effectiveness of psychological treatments and compared the relative effectiveness of diverse treatment options for excessive gaming. Although the authors intentionally used network meta-analysis because of its usefulness in comparing relative effectiveness of currently existing literature, this finding should be interpreted with caution due to the small number of studies. However, as previously indicated, the global prevalence of excessive gaming highlights the need for greater attention to this topic. Studies focused on the effectiveness of diverse gaming interventions help meet the call for further inquiry and study on this topic placed by the DSM-5 7 , and allow greater advances to be made in treating individuals who may have difficulty controlling excessive gaming habits. As such, this study can provide preliminary support for beneficial treatment interventions for excessive gaming as well as recommendations for more rigorous studies to be directed at helping those who have excessive gaming habits.

Data availability

The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request.

•Indicates studies used in the meta-analysis

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This research was supported by the project investigating scientific evidence for registering gaming disorder on Korean Standard Classification of Disease and Cause of Death funded by the Ministry of Health and Welfare and Korea Creative Content Agency.

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video game addiction essay

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video game addiction essay

Online Video Games Addiction Essay

Online video games have already become an essential component of popular culture. A variety of technological products is actively used to train pilots and other safety occupations for better professional skills. Until recently, there was no specific knowledge or empirical evidence with regard to the effect video games may produce on users’ skills. It appears, however, that video games can become a relevant source of better practical knowledge and abilities which young users are to use in the practice. Unfortunately, there is no sufficient information that could unilaterally confirm the positive nature of video games when used by users in practical performance, but the results of recent researches suggest that video games provide unlimited opportunities for the development of better practical skills and avoiding major mistakes (Soukup 43). Video games are often linked to problems including bad grades and violent behavior of people. The idea has been accentuated in the ScienCentral News video reports. The study suggests that might make users do a better job. Confidentiality relates to information sought, obtained, or held by an organization, the disclosure of which might be detrimental to that organization or to the third party that supplied it. In many cases, it is difficult to control e-mail communication between employees and protect information security (Aarseth, 99). The paper will try to answer and research the question “Why people are addicted to online video games? How does it affect their life?”

Online video games create a new reality and can be interested as a “second life” of the user. Bad communications lead to conflict. In this situation, employees cannot find a unified and single solution for the project or program competing with one another during meetings and negotiations. Also, e-mail is not an ideal form to solve current business problems, because it takes time to type an e-mail instead of “simply calling someone if the message is short” (Hartt n.d.). In some cases, employees must accept e-mails inflexibilities, and learn how to interpret the information provided to them and how to make correct deci­sions based on written short messages. On the other hand, electronic mail systems store and then deliver to electronic ‘mail boxes’ which enable the recipient to retrieve the message when convenient.. The main problems that affected e-mail communication include lack of mutual understanding, lack of openness in relations, and damaged relations, chaos situations (Bates, 45). Critics admit that:

Despite this growing concern, children still seem to be spending time playing video games. A recent report released by the Kaiser Family Foundation (1999) reveals that a majority of 2- to 18-year-old children in this country have access to video game technology in their homes. (Smith 54).

As such, whatever is happening in the society in According the theory of the social construction of reality, each person is undeniably a perception and interaction with others. As such, this proves that culture is a vital component that affects the formation of one’s identity. In line with this, the concept of cultural identity was formed. Cultural Identity is often described as an individual’s feeling or perception of his or her belongingness to a certain cultural group. It is also described as the extent to which this feeling affects him or her and influences him/her to act in accordance with the actions, beliefs, traditions, and behavior imposed by the cultural group. A cultural group, on the other hand, refers to a set of individuals, which may be or maybe not be bounded by time and place. However, it is given that members of a cultural group carry the same set of symbolic meanings used in the interpretation of actions and communication. Normally, cultural groups exist in a common cultural space and time also (Berger, 98).

Through the sense of belongingness to a certain online video game, one tries to modify his/her behavior and practices in such a way that they are in accordance with the norms that are accepted by the online video game, to which the individual belongs. Thus, the end product will be that of identity. However, if an individual identifies himself/herself as a member of online video games that have cultural practices that oppose each other, he or she will be exposed to the question of which tradition to follow. Thus, his or her online video game identity will be compromised. In this case, the sense of free will, motivated by which cultural group he/she thinks he/she can more identify with, acts. In the analysis of the cultural identity of the interviewee, the act that he only tries to stay in line with norms of the “majority” while strongly not acting against the norms of his Islam community emphasizes that he identifies himself more as a member of the latter one. However, the fact that the interviewee acknowledges the norms of the “majority” also signifies his appreciation of the culture of this group, and therefore the concept of online video game assimilation exists (Faber, 76).

The changes are far-reaching: the definition of online video game; the nature of the information ‘commons’ for the citizen; the right of privacy in communicated expressions; the regulation of information infrastructures (computer operating systems and networks); the definition of information goods; and the nature of government communication with its citizens. These changes mostly revolve around information ownership and yet no consistent framework has yet to emerge as the question has mostly been approached in a piecemeal way. It is argued in conclusion that a new information dispensation must be built which guarantees information ownership, as this is the foundation on which systems of trading, governance, and research can be built. More interesting, though, was the extent to which users of the Internet as a news source said that as a result, they are using traditional news. It seems that using online video sites may have a more negative effect on news viewing than news reading. This might be because Internet users most often go online for the sort of information featured by television news, especially cable. In the early days, online companies did their very best to replicate the printed or media product (Berners-Lee, 33).

These emergent online video game standards now pose a major problem for competition regulators around the world as they span jurisdictions and the market dominance they create is not easily broken up by their nature. Although in some markets the developers may license the ‘standard’ technology to widen participation (the digital cellular phone standard GSM is one example), in others the standard-setter may aggressively protect its control over the standard as it regards it as an asset. At present most of the dominant information standards have been developed by US companies and they can only be regulated effectively by the US Department of Justice. These technological questions will, however, mark out the information infrastructures of the next century. In the emerging technological and commercial environment defined by the digital encoding of information representations ‘ownership’ is coming to mean different things (Aarseth, 33).

The internet and online video websites have become a new sales channel uncontrolled by the state and free for mass consumers. If any element of the channel can be provided in a more cost-effective way, either by another organization or the application of technology, then the producer will have a strong incentive to change their sales strategy. Mainstream media is limited by censorship and regulations, channels of communication, and geographical scope. In other words, this situation creates a channel conflict for mainstream media. Whenever there are a number of different sales channel elements that can address the same customer base, then there is the potential for conflict. The computer industry is renowned for having multiple channels which often find themselves in direct competition. There have been many instances when the computer manufacture, its distributors and resellers are all fighting for the same business (Smith et al 54).

The online video game is an area occupied by online companies. Some direct marketers have long suspected that the reliance of media advertising on attitudinal factors, instead of behavioral ones, has resulted in “much ado about nothing.” Moreover, they consider the Internet an information media and therefore antithetical to media advertising. When these capabilities are combined to address traditional business situations, it is possible to generate tangible benefits. The American media marketplace is not only larger but far more specialized than any other environment worldwide (Smith et al 54). Also, historically, marketing and advertising, in particular television and electronic media, have had a far more significant role in the United States than elsewhere. These abrupt turns can best be seen through annual changes. In the light of the Internet and its direct potential, these targeting options remained narrow and one-sided. Based on a broadcast model, they made real-time interactivity impossible. Having assessed the degree to which the Internet will affect the organization, the challenge is to manage the adoption of the new technology and the changes it will cause to existing processes. Decisions will be required about the advisability and cost implications of running multiple sales channels and the conflicts that can be created (Aarseth, 66).

Constraints on the geographic, industry, or application areas of trading, available to each channel element, can suddenly disappear. Perhaps the most important thing that can be done is to recognize that a problem will exist and to ensure that the existing channel elements have been informed of how the changes will affect them. If possible, these existing channel partners should be involved in the use of technology and encouraged to accept the changes by sharing part of the planned benefits. There are several reasons why it may be necessary to reduce the level of margin on media products that are being sold via the Internet-related sales channel. It may be sensible to offer a pricing advantage to encourage customers to use the channel. This does not necessarily affect the overall net margin since the cost structure of maintaining the channel may be significantly lower than the traditional alternatives (Berners-Lee 5).

In sum, it was found that people are addicted to online video games because they help users to change their own identity and create the ideal personality they cannot reach in real life. Jones writes that: “As in a video game, in which players acquire new weapons and capabilities within its digital geography and learn more and more about how to play from the collective knowledge of gamers online, both Lost’s characters and its audience are acquiring sequentially the “tools” they need to play. (51). Aarseth states that: “virtual environment has penetrated identity unevenly, thus marketers and advertising use this medium to promote their” (61). These quotes agree that online video games create a new reality for users but do not have a positive and educational impact on their personalities. Lack of regulations and censorship help video websites better position themselves against mainstream media companies. Online video sites succeed in moving economic activity closer to users (viewers) proposing low transaction costs, low barriers to entry, and improved access to information for the consumer. Thus, they have a negative and threatening impact on mainstream media, its audiences, and media messages. (Jones 51). Taking this measure helps the people to engage themselves in doing different kinds of exercises. The same thing can be told about the classic game Asteroids. This game has many important characteristics. One of these characteristics is the ability to rotate the wrist moves of a spaceship. The game is often associated with the waste of time. This is especially true when we are talking about the vast majority of people who are engaged in the research.

Works Cited

Aarseth, E. Cybertext: Perspectives on Ergodic Literature Baltimore and London: Johns Hopkins University Press, 1997.

Bates, B. Game Design: the Art and Business of Creating Games Roseville, CA: Prima Tech (Game Development Series), 2001.

Berger, A.A. Narratives in Popular Culture, Media and Everyday Life Thousand Oaks, CA: Sage, 1997.

Berners-Lee, Tim. Weaving the Web. London: Orion Business Books, 1999.

Faber, L. Re: Play Ultimate Games Graphics London: Laurence King Publishing, 1998.

Jones, S. E. Dickens on Lost: Text, Paratext, Fan-Based Media. Wordsworth Circle , 38 (2007), 51.

Smith, S. L. et al. Popular Video Games: Quantifying the Presentation of Violence and Its Context. Journal of Broadcasting & Electronic Media , 47 (2003), 54.

Soukup, Ch. Mastering the Game: Gender and the Entelechial Motivational System of Video Games. Women’s Studies in Communication , 30 (2007), 43.

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video game addiction essay

15.9 Cause-and-Effect Essay

Learning objective.

  • Read an example of the cause-and-effect rhetorical mode.

Effects of Video Game Addiction

Video game addition is a serious problem in many parts of the world today and deserves more attention. It is no secret that children and adults in many countries throughout the world, including Japan, China, and the United States, play video games every day. Most players are able to limit their usage in ways that do not interfere with their daily lives, but many others have developed an addiction to playing video games and suffer detrimental effects.

An addiction can be described in several ways, but generally speaking, addictions involve unhealthy attractions to substances or activities that ultimately disrupt the ability of a person to keep up with regular daily responsibilities. Video game addiction typically involves playing games uncontrollably for many hours at a time—some people will play only four hours at a time while others cannot stop for over twenty-four hours. Regardless of the severity of the addiction, many of the same effects will be experienced by all.

One common effect of video game addiction is isolation and withdrawal from social experiences. Video game players often hide in their homes or in Internet cafés for days at a time—only reemerging for the most pressing tasks and necessities. The effect of this isolation can lead to a breakdown of communication skills and often a loss in socialization. While it is true that many games, especially massive multiplayer online games, involve a very real form of e-based communication and coordination with others, and these virtual interactions often result in real communities that can be healthy for the players, these communities and forms of communication rarely translate to the types of valuable social interaction that humans need to maintain typical social functioning. As a result, the social networking in these online games often gives the users the impression that they are interacting socially, while their true social lives and personal relations may suffer.

Another unfortunate product of the isolation that often accompanies video game addiction is the disruption of the user’s career. While many players manage to enjoy video games and still hold their jobs without problems, others experience challenges at their workplace. Some may only experience warnings or demerits as a result of poorer performance, or others may end up losing their jobs altogether. Playing video games for extended periods of time often involves sleep deprivation, and this tends to carry over to the workplace, reducing production and causing habitual tardiness.

Video game addiction may result in a decline in overall health and hygiene. Players who interact with video games for such significant amounts of time can go an entire day without eating and even longer without basic hygiene tasks, such as using the restroom or bathing. The effects of this behavior pose significant danger to their overall health.

The causes of video game addiction are complex and can vary greatly, but the effects have the potential to be severe. Playing video games can and should be a fun activity for all to enjoy. But just like everything else, the amount of time one spends playing video games needs to be balanced with personal and social responsibilities.

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ORIGINAL RESEARCH article

Video game addiction and emotional states: possible confusion between pleasure and happiness.

\r\nLucio Gros,*

  • 1 Research Center for Work and Consumer Psychology, Université Libre de Bruxelles, Brussels, Belgium
  • 2 Department of Psychiatry and Neurosciences, Maastricht University, Maastricht, Netherlands

Internet gaming disorder is characterized by a severely reduced control over gaming, resulting in an increasing gaming time and leading to negative consequences in many aspects of the individual life: personal, family, social, occupational and other relevant areas of functioning (World Health Organization). In the last years, the significant boom in using video games has been raising health issues that remain insufficiently understood. The extent of this phenomenon (the estimated prevalence is between 1.7 and 10% of the general population) has led the mentioned Organization to include gaming disorders in the list of mental health conditions (2018). Several studies show converging findings that highlight the common brain activities between substance use disorders and behavioral addictions (i.e., gaming disorders). Addiction specialists observed that addict subjects tend to confuse pleasure with happiness when linking emotional states to their addictive activities. As far as we know, beyond the mentioned observations, distinguishing the perception of these two emotional states in the frame of an addiction has not been yet the object of formal research. This study aims at examining the possible confusion between pleasure and happiness within the addiction sphere. Video game addiction has been chosen to explore the possible occurrence of this perceptional distortion. A mixed design lab-based study was carried out to compare between video games addicts and non-addicts (between-subjects), and video games-related activities and neutral activities (within-subject). Emotional reactions were gauged by self-reported scales and physiological data acquired through a range of biosensors: Relaxation and Hearth Rate. From a therapeutic standpoint, this research intends to explore alternatives to deal with this sort of disorders. More specifically, at the cognitive level, the idea is elaborating guidelines to develop patients’ insights into these emotional states and thus increasing their ability to handle them. Overall, several indices resulting from this study constitute a bundle of arguments that argue in favor of the confusion between pleasure and happiness made by addict users when associating their affective states to video gaming. Furthermore, this approach illustrates how reappraising emotions may contribute to reducing the perceptional distortion of these emotional states.

Introduction

In the last years, the significant boom in using video games (VG) has been raising health issues that remain insufficiently understood ( Khazaal et al., 2016 ). The World Health Organization [WHO] (2018) has recently included “gaming disorders” in the list of mental health conditions. According to WHO this affliction is a “persistent or recurrent behavior pattern of sufficient severity to result in significant impairment in personal, family, social, educational, occupational or other important areas of functioning.”

The fifth revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) considers the ‘Internet Gaming Disorder’ as a potential new diagnosis that requires further research ( Petry et al., 2015 ). The prevalence of problematic gaming is estimated to range from 1.7% to over 10% among general population ( Griffiths et al., 2012 ).

Compared to the core topics of research in neuroscience such as stress, depression, etc., the chronic use of VG is a rather recent field of investigation. Yet, a growing number of studies have been produced in this field in the last two decades ( Andreassen et al., 2016 ). Indeed, several research projects have been exploring VG addiction from a behavioral, emotional, brain circuits and genetic perspectives ( Griffiths et al., 2012 ; Dong et al., 2017 ).

There seems to be converging findings that highlight the common brain activities between VG disorders (belonging to the cluster of behavioral addictions) and substance use disorders (SUD). It has been shown that the dorsolateral prefrontal cortex, orbital frontal cortex, para-hippocampal gyrus and thalamus were activated in both disorders ( Han et al., 2011 ). The limbic structures appear to be the key circuits linked with reward and addiction ( Cooper et al., 2017 ). In subjects suffering from these disorders, cues associated with SUD and with behavioral addiction can trigger craving, which is connected with the dopamine reward system ( Ko et al., 2009 ; Han et al., 2011 ). In addition, it has been observed that the level of dopamine released in the ventral striatum when playing a competition like video game is comparable to that provoked by psycho-stimulant drugs ( Koepp et al., 1998 ; Yau et al., 2012 ). Few studies have been carried out on the genetic aspects of this topic. Some of them indicate that there would be genetic background similarities between these two disorders. For example, the homozygous short allelic variant of the 5HTTLPR gene (encoding the serotonin transporter) is more prevalent among the excessive Internet user, which is also linked with increased drug consumption ( Serretti et al., 2006 , as cited in Yau et al., 2012 ; Lee et al., 2008 , as cited in Yau et al., 2012 ).

As described later, studying the confusion between pleasure and happiness in the frame of addiction requires as clear a demarcation as possible between these two emotional states. Although a consensus among scientists on how to define and distinguish pleasure and happiness remains to be reached (see next section Pleasure and Happiness ), in this research we have adopted the following distinctive traits to describe and to work with these two emotional states: pleasure relates to a transient emotional state resulting from the satisfaction of a desire, a craving, and happiness refers to a lasting emotional state of contentment, euthymia ( Pollard, 2003 ; Lustig, 2017 ).

According to Lustig (2017) , addictions together with depression are two rampant afflictions in the last decades and constitute the harmful extremes of pleasure (associated with the dopaminergic system) and happiness (associated with the serotoninergic system) respectively ( Üstün et al., 2004 ; Lepine and Briley, 2011 ; Szalavitz, 2011 ; Whiteford et al., 2013 ; Gowing et al., 2015 ; Keyes et al., 2015 ). Based on his long practice on addiction issues, this author argues that confusing pleasure (in the sense of longing, craving, strongly driven by a short term reward) with happiness is linked with SUD and with behavioral addictions (i.e., gambling, eating disorders, excessive use of technology like for example social media and VG, etc.), which could lead to depression ( Lawrence et al., 2014 ). According to the author, confusing pleasure with happiness is related to the growth rate of this disorder insofar as it would encourage seeking immediate gratifications perceived as sources of happiness, which in turn triggers the reward system with the risk to sink into the vicious circle of addiction ( Pollard, 2003 ). Besides, the significant industrial development, through its commercial campaigns, probably tended to lead individuals to equate consumption with happiness ( Schmidt, 2016 ; Lustig, 2017 ). From a physiological standpoint, the author highlights that an over excited reward system engenders an excess of dopamine (DA) release from the ventral tegmental area, which in return decreases serotonin (5HT) level (associated with depression) ( Pollard, 2003 ; MacNicol, 2016 ).

Moreover, Lustig underlines that DA and 5HT amino acids (needed for the production of DA and 5HT) share the amino acid transporters, which poses a problem in case of DA amino acid over presence: that is to say, the more amino acids for DA, the less amino acids transporters are available for 5HT amino acids. In short, this DA-5HT unbalance illustrates one of the facets of the DA-5HT interaction in which the low 5HT level, associated with depression, prevents the serotoninergic system to exert its inhibitory role to imped the over drive of the dopaminergic system ( Esposito et al., 2008 ).

Chronic stress and anxiety may further aggravate this problem by increasing the cortisol level and thus creating a loop with dopamine activating the sympathetic nerve system and reinforcing the reward seeking behavior while down-regulating 5HT -1a receptor, which decreases the serotonin signaling and increases the depression likelihood ( Lustig, 2017 ). These findings are in line with studies that associate stress, anxiety and depression with Internet gaming disorders ( Wenzel et al., 2009 ; Griffiths et al., 2012 ).

Fundamentally, from a phylogenetic standpoint, it is likely that pleasure has contributed more than happiness ( Pollard, 2003 ; Lustig, 2017 ), which could explain the stronger drive of the short term gratifications over the quest for medium and long term euthymia. In sum, this suggests that identifying the possible confusion between the mentioned emotional states associated with the addictive activities may contribute to deepen the understanding of this sort of disorders and consequently to explore new therapeutic options.

The emotional states (and their consequences) associated with VG as felt and perceived by chronic users led to thorough interrogations of health professionals. Several studies intended to explore this issue by focusing on the individual characteristics of addict players. For instance, the general level of happiness appears to be a firm candidate to predict addiction to VG playing ( Hull et al., 2013 ). In effect, it has been shown that gaming disorders are positively correlated with depression and loneliness and negatively correlated with well-being ( Lemmens et al., 2011 ; Sarda et al., 2016 ). These two studies relied on a eudaimonic notion of well-being (i.e., life satisfaction, a life well lived). Thus, based on the mentioned definitions of pleasure and happiness, on the semantic net (see Annex ) and on the analysis made in the next section (Pleasure and Happiness), in this research well-being is assimilated to happiness due to the considerable common ground shared between these two concepts. In line with these findings, another study highlights the association between high frequency of online gaming with depression and social phobia ( Wei et al., 2012 ). Similar results were found in a study in which, compared with no addict Internet user, Internet addict subjects used to play online games reported significantly more depressive symptoms ( Geisel et al., 2015 ).

From a psychological symptoms standpoint, it has also been observed that when playing VG, addict gamers have a sense of well being or euphoria while playing VG, inability to stop the activity, craving more time at playing VG, feeling empty, depressed, irritable when not playing VG, with all the pernicious consequences these symptoms have on the private, social and professional life ( Griffiths, 2008 ). At glance, the coexistence of well being and craving might come across as paradoxical, although the mentioned work ( Lustig, 2017 ) on this issue provides some elements of answer to this finding.

Using a video game clip as a stimulation trial, it has been studied ( Kim et al., 2018 ) the craving state of chronic users when playing VG through measures resulting from addiction questionnaires and several bio signals such as eye blinking, eye saccadic movements, skin conductance and respiratory rate. The results of this work showed that during the stimulation trial video game there was a decrease of eye blinking rate, eye saccadic movement rate and mean amplitude of the skin conductance response whereas there was a significant increase of the mean respiratory rate.

Another study ( Lu et al., 2010 ; as cited in Kim et al., 2018 ) focused on a group of individuals with high risks of developing Internet gaming disorders (IGD) and their sympathetic nervous system responses. When using Internet in this experiment, increases were observed in blood volume, body temperature and respiratory rate. Heart rate (HR) has also been used as a reliable indicator of craving in subjects with SUD ( Kennedy et al., 2015 ).

Pleasure and Happiness

The psychophysiological and brain mechanisms of pleasure and happiness are quite complex and probably more research is required to better discerning these processes. Some studies have underlined that the hedonic system includes wanting and liking and each of these two emotional states may operate in a conscious and unconscious mode ( Berridge and Kringelbach, 2011 ). Studies indicate that unconscious wanting would function as a conditioned desire involving the nucleus accumbens, ventral tegmental area, hypothalamus and dopamine; on the other hand the unconscious liking would relate to a sensory hedonic dimension associated with the nucleus accumbens, ventral pallidum, periaqueductal gray, amygdala, opioids and cannabinoids ( Kringelbach and Berridge, 2009 ; Berridge and Kringelbach, 2013 ). The same studies show that conscious wanting would relate to cognitive incentives, subjective desires and dopamine whereas conscious liking would be linked with subjective pleasures, opioids and cannabinoids; both would involve the orbitofrontal cortex, anterior cingulate and insular.

It has been shown that the level of activation of some of the mentioned areas would be altered in subjects with Internet gaming disorders: sensing craving for gaming is associated with an increased activation of the left orbitofrontal cortex (correlated with desire for VG play) and with a decreased activation in the anterior cingulate cortex (probably linked with the reduced capacity to inhibit craving for gaming) ( Wang et al., 2017 ).

There might be a relation between the complexity of these brain circuits linked to these emotional states and the polysemy of these two terms, happiness and pleasure , which may contribute to the possible confusion between them. Indeed, the intense interrelation between them finds expression in subtle distinctive features and in some connotations with vague borders, to the extent that these words might be regarded as almost synonyms. The semantic analysis of these two terms produced in this research intends to show their core meanings, their nuances and the possible intersections between them ( Procter, 1985 ). Trying to unravel and to understand these two emotional states is not a recent endeavor. For instance, Greek thinkers approached the notion of happiness as a state constituted by two components: Hedonia (pleasure) and Eudaimonia (a life well lived) ( Kringelbach and Berridge, 2009 ).

Due to its nature, defining and studying happiness is a quite uneasy task. Although progress has been made on this rather recent area of study, there is still a lack of consensus when it comes to defining this concept. Some authors distinguish fluctuating happiness (self centered) from durable, authentic happiness (self-transcendent) ( Dambrun et al., 2012 ). Another study uses the value-arousal model on emotions to define it, according to which happiness results from a positive valence, high arousal and engaged and satisfied in life ( Cipresso et al., 2014 ). Lustig (2017) emphasizes the time perspective as one of the distinguishing traits between these two emotional states by opposing the short-term logic of pleasure to the longer-term characteristics of happiness .

These last two studies are quite illustrative of the differences with regard to defining happiness , in particular when it comes to including or not pleasure in it. Whilst there seems to be a consensus on “life satisfaction,” “connecting with others” and “contentment” as the main traits of happiness , it is less clear whether pleasure is part of it. Usually, in the literature there are two understandings to articulate these emotional states: either both ( happiness and pleasure) are seen as inseparable concepts or happiness is regarded as a state free from distress (‘liking’ without ‘wanting’) ( Kringelbach and Berridge, 2010 ; Berridge and Kringelbach, 2011 ; Loonen and Ivanova, 2016 ; Lustig, 2017 ). Whether or not pleasure is included in the definition of happiness , to the best of our knowledge there is no study that includes craving (intense desire, longing) as a trait of happiness .

Thus, based on the mentioned definitions and on the association between craving and arousal ( Kennedy et al., 2015 ), craving for playing VG may subscribe itself within the realm of pleasure , but stands outside of the happiness’ sphere.

Within the frame of this research, Pleasure refers to the hedonic reward processes driven by a desire to obtain a gratification that can lead to craving in certain circumstances ( Berridge and Kringelbach, 2011 ). Pleasure has been associated with the dopaminergic circuit which can, in certain circumstances, function in an addictive mode and can affect also habits, conditioning, motivation and executives functions such as decision making, inhibitory control, etc. ( Volkow et al., 2011 ).

Happiness is understood as contentment and euthymic state, in line with a happy emotional state defined by a positive valence and low arousal ( Jatupaiboon et al., 2013 ). Physiologically, this state implies a reposed mind; akin to the relaxation state measured through the brain electrical activity ( Teplan and Krakovskà, 2009 ). In the literature this mood is related to the serotoninergic circuit ( Lustig, 2017 ).

To the best of our knowledge, there is no existing questionnaire focusing on the association between VG and pleasure/happiness. Thus, our study required a preliminary phase to design such self-report tool whose aim is to explore the perceived emotional states (pleasure/happiness) associated with VG play.

As far as we know, distinguishing the perception of these two emotional states in the frame of an addiction has not been yet the object of formal research, hence the reduced literature on this specific issue, in particular the experimental one.

Consequently this research may be seen as a preliminary study, which aims at examining the possible confusion between pleasure and happiness within the addiction sphere. VG addiction has been chosen to explore the possible occurrence of this perceptional distortion. Emotional reactions of VG addicts and VG non-addicts were gauged via self-report scales and physiological data (Heart rate and Relaxation state) acquired by a range of biosensors.

Resulting from the mentioned background, it is hypothesized that addict VG users:

Are likely to confuse the notions of pleasure with that of happiness when associating their emotional states to VG play.

The results of this study are expected to show that addict VG users associate happiness with VG activities while feeling craving for playing accompanied by an increased HR and a low relaxation level. Given the shortage of previous researches on the specific issue related to the confusion between pleasure and happiness in VG addiction, the outcome of this study is approached in an exploratory manner.

From a therapy standpoint, this project intends to explore alternatives to deal with this kind of scenarios. More specifically, at the cognitive level, the idea is finding means to develop patients’ insights into these emotional states and thus increasing their ability to handle them.

Materials and Methods

Preliminary phase: design of the “pleasure and/or happiness and vg” questionnaire, participants.

In total 105 VG players participated in this survey, out of which 61 filled all the questionnaires required for the design of the “Pleasure and/or Happiness and VG” questionnaire. The mean age of these 61 participants was 24.28 and the standard deviation 5.48. There were 33 males (54.1%) and 28 females (45.9%). The mean of playtime during working days was 4.49 h and the standard deviation 6.82, and during holidays and weekends 4.68 h and the standard deviation 3.13.

An online survey was run via video game forum and Reddit site (network of communities with common interests). The purpose of this survey was to evaluate the internal coherence of our self-report tool (Pleasure and/or Happiness and VG) relative to two validated questionnaires (on Hedonic tone and Happiness). Thus the survey consisted in filling the three questionnaires. Participants completed anonymously and voluntarily the questionnaires through their online gamers groups.

Two validated and known questionnaires were used to construct the ‘ Pleasure and/or Happiness and VG’ questionnaire through which the emotional states associated with VG activities were evaluated: the Snaith-Hamilton Pleasure Scale (SHAPS) ( Snaith et al., 1995 ), an assessment tool of hedonic tone, and the Oxford Happiness Questionnaire (OHQ) ( Hills and Argyle, 2002 ). The French version of these two questionnaires was used ( Loas et al., 1997 ; Bruchon-Schweitzer and Boujut, 2014 ).

The abbreviated SHAPS is composed of 14 items to assess the hedonic tone and the absence of it. The answer scale for each item offers four possible options ranging from ‘Definitely agree’ to ‘Strongly disagree.’ The OHQ is extensively used to evaluate the individual level of happiness. For each of its 29 items, the answer scale has 6 options going from ‘Strongly disagree’ to ‘Strongly agree.’

Several items of the SHAPS and the OHQ are quite adapted to the VG paradigm and lend themselves to be contextualized. For example, the first item of the SHAPS questionnaire is formulated as: “I would enjoy my favorite television or radio program.” In this case “television or radio program” is replaced by “video game.” An example of OHQ concerns the item “I am very happy,” which became “I am very happy when playing VG.” So, these kinds of items constitute the questionnaire whose aim is identifying the emotional states that users associate with VG. Initially, eight items were adapted to VG from these two questionnaires: four items from SHAPS and four items from OHQ. The answer scale provides with six possible options ranging from ‘fully disagree’ to ‘fully agree.’

Statistical Analysis

In order to ensure the usefulness of the designed self-report tool, an Alpha Cronbach test was run on the results of this survey to measure the internal coherence between the ‘VG and Pleasure/Happiness’ and the two other questionnaires (SHAPS and OHQ). Moreover, it has been examined whether there is a correlation between VG play frequency and the two areas explored in this survey: the general happiness level (OHQ) and the emotional states associated with VG (‘Pleasure and/or Happiness and VG’).

The Experiment

The study was announced through the Université Libre de Bruxelles (ULB) scientific social media as well as via leaflets available in public cyber games centers in Brussels. Gamers interested to participate in this study had to answer an on-line survey ( N = 163), in which the following data was gathered: age, play frequency, name of VG played and a validated test to assess the gaming addiction level (Gaming Addiction Scale, Lemmens et al., 2009 ). The French version of this scale was used ( Gaetan et al., 2014 ). Being used to play to at least one of these five popular VG (Fornite, Overwatch, League of Legends, Counter-Strike or Rocket League) and an age ranging from 18 to 70 years old were the inclusion criteria. Competing against another team and playing in groups are the common characteristics of these VG. The exclusion criteria were having vision impairments and neurological problems.

Two groups of gamers were invited to participate in this study: addict users (AU) and non-addict users (NAU). None of the invitees met the exclusion criteria. The selection and recruitment were based on the score obtained in the test on gaming addiction, resulting in: AU ( N = 12) and NAU ( N = 17) (7 females and 22 males, ranging from 19 to 29 years old). They were all French speakers Belgian residents. The mean age was 23 and the standard deviation of 3. The difference between sexes in terms of VG addiction is not statistically significant (3/7 AU females and 9/22 AU males, U 45.5, p = 0.130).

This experiment took place within the frame in the usability laboratory of the Research Centre of Work and Consumer Psychology, Université Libre de Bruxelles (ULB).

Before the experiment all the procedures were explained to participants and their consent was asked on formal basis. They were informed that:

– This experiment aims at better understanding the video game phenomenon (without mentioning the issue relative to the emotional states and VG).

– They have to fill several questionnaires (in French).

– Some non-invasive artifacts are set to gather measurements on physiological signals while they watch video clips.

– The Ethical Committee of ULB approved this study in accordance with the Declaration of Helsinki.

The participants were welcome into the testing room of the laboratory by the examiner. They were seated and given an informed consent form. Once the form was read and signed, the study procedure was explained. Then, the Electroencephalogram (EEG) headset was placed onto the participant’s head and an impedance check was run.

Before the beginning of the experiment, each participant chose his/her favorite VG he/she uses to play among the five initially proposed. During the experiment, the examiner observed the participant through a one-way-glass, avoiding interference.

Finally, participants were thanked for their participation, compensated and given information on obtaining the results of the study. The whole experimental run took around 1 h.

Prior to starting the operational phases of the experiment, all devices are set to initiate the baseline recording of all the physiological signals.

Six phases compose this experiment ( Figure 1 ). In each phase of the experiment the emotional states associated with VG were examined either through self-report questionnaires or via physiological measures. The physiological measures were recorded during the visioning of two sorts of video clips: VG clips whose aim was to induce craving and neutral video clips (documentaries on nature) intending to reduce craving.

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Figure 1. Synthetic view of the experimental phases.

The six experimental phases:

(1) “Pleasure and/or Happiness and VG” (six items): Participants were invited to fill the self-report questionnaire designed in the preliminary phase.

(2) Watching a neutral clip during 2 min while recording physiological signals related the mentioned two emotional states. This phase intends to decrease craving in participants.

(3) Craving score: Participants were asked to express their craving state to play their favorite VG via a one item self-report questionnaire.

(4) Watching a VG clip during 2 min while recording the same physiological signals as in phase two related to the mentioned emotional states. The objective of this phase is to increase craving in participants.

(5) Craving score: the same procedure and self-report tool as in phase 3 were applied.

(6) Submission of three self-report questionnaires:

(6.1) “Pleasure and/or Happiness and VG” (Three bipolar items).

(6.2) “Key words and VG”: participants were invited to associate a list of words to VG activities.

(6.3) “Pleasure and VG or Happiness and VG” (one bipolar item): participants were asked to associate one of the two emotional states to VG play.

The cycle from the 2nd phase to the 5th phase was repeated five times for each participant. In each of these five cycles, different episodes of video clips (the chosen VG and the neutral clip) were shown randomly so as to avoid the habituation phenomenon and minimize the influence that the order of the sequence of episodes could have on participants’ responses.

– Experimental groups: AU and NAU

The Gaming Addiction Scale (GAS) ( Lemmens et al., 2009 ; Gaetan et al., 2014 ) was used to constitute these groups. As a tool to measure game addiction, GAS possesses significant assets. Lemmens et al. (2009) showed the validity of this scale from a cross population point of view and its one-dimensional characteristic resulting from the factorial analysis. In addition, in the same study it has been shown the concurrent validity of GAS insofar as this scale is associated with play frequency as well as with psychological features related with game addiction, namely decreased level of social competence and of well being, and high level of aggression and of loneliness. Moreover, high scores in GAS are also linked with attentional deficiencies in response inhibition when perceiving game cues ( van Holst et al., 2012 ; in Khazaal et al., 2016 ), which converges with results produced by other researches associating impulsivity and cue reactivity with other addictive behaviors ( Billieux et al., 2011 ; Khazaal et al., 2012 ; Torres et al., 2013 ). Relative to other game addiction measurements, GAS has the most complete covering of the Internet gaming disorder criteria of the DSM-5 ( Petry et al., 2014 ). Although it was initially designed for adolescents, there are substantial evidences to state that GAS is applicable for young adults too ( Khazaal et al., 2016 ).

Each of the seven items of this scale starts with the question “How often in the last 6 months…?” to explore the impact of video gaming on different aspects of the subject’s life. The possible answers are: never, rarely, sometimes, often and very often. The first two answers score 0, the last three answers score 1. If the total sum of these scores is 4 or higher, the subject is considered an AU according to this scale.

– The experiment

In the first phase, participants were asked to fill the “ Pleasure and/or Happiness and VG” questionnaire composed by six items: three items that tie Pleasure (P) and VG, three items that tie Happiness (H) and VG (six-items in total).

The answer scale for each item was composed of six options ranging from ‘Fully disagree’ to ‘fully agree.’ Each of these six items is answered separately, thus the overall possible results of this questionnaire can be: (1) P and VG > H and VG or (2) H and VG < P and VG or, (3) P and VG = H and VG.

In the second phase (Neutral video clip), two physiological signals related to Pleasure and Happiness were recorded. Based on the correlates found between HR and craving, this physiological signal is used as an indicator of arousal ( Kennedy et al., 2015 ).

Despite the difficulty in defining and in measuring happiness , the brain electrical activity is recorded (Electroencephalogram, EEG) mainly to detect the relaxation state. This state appears close to the notion of happiness; in the literature it is accepted that the increase of alpha waves is correlated with mental and physical rest ( Teplan and Krakovskà, 2009 ).

In the third phase, participants were asked to express their craving state to play his/her favorite VG. The statement employed in this self-report tool was: “State your present craving for gaming.” Participants have to choose the answer that best fitted their self-assessment among six possible answers offered by the scale ranging from “I do not feel any craving for gaming” to “I feel a very strong craving for gaming.”

In the fourth phase (VG clip), the same physiological signals as in the second phase were measured.

In the fifth phase, the same procedure to assess craving for gaming as in the third phase was employed.

In the sixth phase, three other self-report questionnaires were submitted to participants and used to evaluate the association between the mentioned emotional states and VG:

– “Pleasure and/or Happiness and VG” (three bipolar items). The same six items of the “Pleasure and/or Happiness and VG” questionnaire used in phase 1 were presented in a bipolar structure: three items opposing “Pleasure and VG” vs. “Happiness and VG.” For example, if in the six items questionnaire the items “I would enjoy my favorite VG” (Pleasure/VG) and “I am happy when playing VG” (Happiness/VG) are presented separately, in this questionnaire they are part of the same item: “I would enjoy my favorite VG” vs. “I am happy when playing VG.” By doing so, participants are encouraged to choose which of their emotional states (Pleasure, Happiness) is associated with VG playing. That said, the scale has an uneven number of options (five) between the two extremes, the central option representing the equal association of Pleasure and Happiness with VG play. Thus, the overall possible results are identical as in phase 1.

– “Key words and VG”. Participants were asked to choose three words (out of ten) that they associate most with their VG activities. These 10 key words come from the semantic mapping elaborated in this research of the terms used in the formal statements defining pleasure and happiness in this study. For example, some words from the happiness sphere are contentment and well being , whereas desire and joy relate to pleasure . Besides, they are in line with both definitions Lustig’s (2017) . Only the ten words (French version) were shown to participants. Although the possible results are similar to those of six-item “Pleasure and/or Happiness and VG” questionnaire and three-bipolar item “Pleasure and/or Happiness and VG” questionnaire, this time the same association (emotional states and VG) is tackled via key words directly linked to the two studied emotional states ( Pleasure, Happiness ) but without mentioning them. This self-report format intends to gain accuracy in the identification of gamers’ emotional states associated with VG.

– “Pleasure and VG or Happiness and VG”. The written definitions of both pleasure and happiness , based on work Lustig’s (2017) , were shown to participants. Then they were asked to read carefully these definitions and to take them into account when answering one bi-polar item that opposes “Pleasure and VG” vs. “Happiness and VG.” Unlike in the three-bipolar items questionnaire, the answer scale between these this bipolar item has an even number of options (six). This time is an “either/or” choice they are faced with, therefore the possible results are: P and VG < H and VG or P and VG > H and VG. Basically this questionnaire intends to strengthen consistency in participants’ insights into this issue by inviting them to confront their perception of their emotional states associated with VG play with the mentioned formal definitions, comparable to an emotions reappraisal process ( Seay and Kraut, 2007 ).

In short, four self-report questionnaires (see Annex ) aim at exploring this dependent variable (association between these two emotional states and VG play) by looking at the consistency of participants’ answers to the different formats of questions. The questions’ formats are:

– Pleasure and/or happiness can be associated with VG (six independent items);

– Pleasure and/or happiness can be associated to VG (three bipolar items);

– Pleasure and/or happiness can be associated to VG through key words defining the two emotional states (without mentioning the words pleasure and happiness );

– Pleasure or happiness can be associated to VG (written explicit definitions of pleasure and happiness are given to participants).

This approach aims at exploring the coherence between the self-reported answers and the physiological signals, as a means to objectivize the perceived emotional states associated with VG play by the two mentioned groups of participants (addict gamers and non-addict gamers).

The previously mentioned theoretical framework indicates that the notion of craving relates to an arousal state that could lead to an addictive pattern and consequently stands out of the realm of happiness.

Expected Results

Based on the analysis made on this issue previously as well as on the hypothesis of this study, the expected results could be synthesized as shown in Table 1 .

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Table 1. Summary of the expected results.

– Self-Report Questionnaires

For the self-report questionnaires, it is expected that, compared to NAU, the AU group:

– In “Pleasure and/or happiness associated with VG” (six independent items) associates more happiness than pleasure with VG play.

– Reports more craving for playing after watching VG clip.

– In “ Pleasure and/or happiness associated to VG” (three bipolar items) associates more happiness than pleasure with VG play.

– Associates VG play with key words more related to happiness category than to those of pleasure .

– In “ Pleasure or happiness associated to VG” associates VG play with pleasure (like NAU).

– Physiological Signals

It is expected to observe an interaction between the groups (AU, NAU) and the conditions (VG clip, Neutral clip). Namely, it is assumed that visioning the VG clips has an effect on AU increasing HR while decreasing Relaxation.

After verifying the normality of distributions (Kolmogorov–Smirnov), the means comparison between the two groups (NAU, AU) was calculated for self-report questionnaires measuring the association between VG and Pleasure/Happiness (Mann–Whitney U ) for the six-items “Pleasure and/or Happiness and VG,” the three-bipolar items “Pleasure and/or Happiness and VG” and the one-bipolar item “Pleasure and VG or Happiness and VG.” The Chi square was used for “Key words and VG.” In order to determine whether there are differences between independent groups over time and to identify possible interactions between the two independent variables on the dependent variables, a two-way mixed ANOVA (within and between subjects) was used for the craving scores and the physiological signals recorded ( Table 2 ).

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Table 2. Synthetic view of independent and dependent variables.

The experiment was run on a desktop computer with an Intel Core i7 quad processor and 8 GB RAM, running Windows 10. Stimuli were displayed on a 22-inch monitor and resolution was set to 1680 × 1050. Participants used standard mouse and keyboard as input devices. EEG measurement includes detecting the fluctuation of voltage potential generated by large group of neurons in the brain. The EEG signal was obtained through the use of EPOC headset. This device allows to remotely getting data of brain activity using a wireless set of fourteen electrodes (AF3, AF4, F3, F4, F7, F8, FC5, FC6, T7, T8, P7, P8, O1, O2) sampled at 128 hertz.

The relaxation state was measured by one of the composite metrics of the Emotiv software. HR was measured by using Schimer 3 (Photoplethysmography). The I. Motions software version 7.1 (Imotions Inc. 2018) was used to recording the mentioned data and presenting stimuli to participants. The statistical analysis was conducted with IBM SPSS statistics v.25.

Design of the “Pleasure and/or Happiness and VG” Questionnaire

The Cronbach’s alpha (0.859) showed a high internal coherence between the SHAPS and three items (out of four) of the “Pleasure and VG” within the “Pleasure and/or Happiness and VG” questionnaire. The fourth item has been disregarded; its presence would have dropped the Cronbach’s alpha to 0.685. The internal coherence obtained between the OHQ and the “Happiness and VG” items within the “Pleasure and/or Happiness and VG” questionnaire was quite high for the four items concerned (alpha 0.901). However, the internal coherence between these four items was too weak due to one item (alpha 0.407). The exclusion of this item raised the alpha significantly (0.836). Consequently, only the consistent items have been kept (six out of the initial eight items: three on “Pleasure and VG,” and three on “Happiness and VG,” see Annex ).

Moreover, it has been examined whether there is an association between VG play frequency and the two areas explored in this survey: the general happiness level (OHQ) and the emotional states associated with VG via the “Pleasure and/or Happiness and VG” questionnaire. The constitution of the group of frequent gamers and that of non-frequent gamers was determined by calculated median (18 h per week). In line with several studies linking problematic gaming and well-being and life satisfaction, a moderate negative correlation ( R = −0.249; p = 0.056) was found between VG high play frequency and the OHQ scores ( Griffiths, 2008 ; Lemmens et al., 2011 ). In addition, there is a marginal significant difference [ T (58) = 1.923; p = 0.059] between frequent VG users and non-frequent VG users relative to the OHQ scores.

The “Pleasure and/or Happiness and VG” Six-Items Questionnaire

The Kolmogorov–Smirnov outcome indicates the need for using a non-parametric test to compare the two groups. The Mann–Whitney test shows that there was no significant difference observed between the AU and NAU relative to association between VG play and pleasure (item 1. U = 78, p = 0.30; item 3. U = 75, p = 0.24 and item 5 U = 86, p = 0.49) ( Table 3 ).

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Table 3. Descriptive statistics of “Pleasure and/or Happiness associated with VG” (6-items): [Pleasure (P), Happiness (H) associated with VG].

In contrast, there is a significant statistical difference in the three items where AU associate VG play with happiness (item 2. U = 40, p = 0.005; item 4. U = 54, p = 0.034 and item 6. U = 34, p = 0.002) more than NAU.

Craving Scores

Results in craving ( Table 4 and Figure 2 ) show a statistically significant interaction F (1,25) = 4.78 ( p = 0.038). Indeed, relative to the neutral clip, the VG clip condition has significantly amplified the reported craving difference between the two groups (AU craving score > NAU craving scores).

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Table 4. Descriptive statistics for self-report Craving.

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Figure 2. Self-report craving (groups: AU, NAU; conditions: Neutral clips, VG clips).

Physiological Signals Measurements

The AU’s relaxation is significantly lower [ F (1,24) = 8.616; p = 0.007] than NAU’s in both conditions (Between-Subjects Effects). The relaxation level decreases in both groups during the VG clip. On the other hand, conditions do not influence the relaxation difference between the two groups [ F (1,24) = 0.001; p = 0.98] ( Table 5 and Figure 3 ). Furthermore, there is a significant statistical gender difference in both conditions (Neutral clip: Male 17.36, Female 7.57. U = 25, p = 0.008 – VG clip: Male 17.09, Female 8.43. U = 31, p = 0.019).

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Table 5. Descriptive statistics: Relaxation index (EEG EPOC, Emotiv software).

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Figure 3. Relaxation [groups: AU, NAU; Conditions: (1) Neutral clips, (2) VG clips].

Concerning the other physiological variable (HR) ( Table 6 and Figure 4 ), there is an effect of VG clips on both groups [ F (1,15) = 20.802; p < 0.001]. Nevertheless, there was no statistically significant interaction [ F (1,15) = 0.028; p = 0.86], nor an effect of addiction on VG clip condition [ F (1,15) = 0.083; p = 0.777]. It is important noting that due to corrupted data the number of valid subjects taken into account was 17 (8 AU and 9 NAU).

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Table 6. Descriptive statistics: Heart Rate (HR).

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Figure 4. Heart Rate [groups: AU, NAU; Conditions: Neutral clips (1), VG clips (2)].

The “Pleasure and/or Happiness and VG” Three-Bipolar Items Questionnaire

The descriptive statistics of this three-bipolar items questionnaire ( Table 7 ), indicate that the AU group linked VG activities more with happiness than the NAU group. The Mann–Whitney test shows a significant difference between these two associations ( U = 47; p = 0.013).

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Table 7. Descriptive Statistics: Pleasure/VG vs. Happiness/VG (3 bipolar items).

Key Words and VG

Results state the absence of significant difference between AU and NAU in associating the key words from the Pleasure cluster with VG play, and words from the Happiness cluster with VG (Chi square, p = 0.942) ( Table 8 ). When taking words separately, the biggest gap between the two groups relates to the word well-being (belonging to the happiness cluster) associated to VG play (AU: 25%, NAU: 0%).

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Table 8. Descriptive statistics: number of words per category (Pleasure, Happiness) associated to VG play chosen by NAU and AU.

“Pleasure and VG or Happiness and VG” (One Bipolar Item Questionnaire With Written Definitions)

The outcome of this questionnaire indicates that there is no significant difference between AU and NAU ( U = 102, p = 1). Both groups have clearly associated VG play with pleasure ( Table 9 ).

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Table 9. Descriptive statistics: Happiness/VG or Pleasure/VG (1 bipolar item, with Definitions of Pleasure and Happiness shown to subjects).

The following scheme summarizes the outcomes of the self-report tools used to evaluate the association between the emotional states (Pleasure and Happiness) with VG play ( Table 10 ).

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Table 10. Synthetic view of self-report results (Emotional states associated with VG play).

The following table indicates the mean, standard deviation and Skewness and Kurtosis values of the self-report craving, the HR and the relaxation level for both groups in the two conditions ( Table 11 ).

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Table 11. Descriptive statistics for self-report Craving, Relaxation, Heart Rate.

Overall, the results of this study show that AU associate happiness to VG while reporting craving for VG play and having a low relaxation level. These outcomes observed in this experiment constitute a bundle of arguments that argue in favor of the hypothesis of this study ( Lustig, 2017 ). Indeed, in AU, the high self-report craving score and low Relaxation level during VG clips visioning do contrast with their association of VG more with happiness than with pleasure in the mentioned “Pleasure and/or Happiness and VG” questionnaires (six-items and three-bipolar-items) relative to NAU. Consistent with previous findings in this area, these four measurements highlight the coexistence of the perception of happiness linked with VG play combined with elements related to pleasure such as craving ( strong desire, wanting ) ( Pollard, 2003 ; Griffiths, 2008 ; Waterman et al., 2008 ). Since craving and low Relaxation are rather incompatible with the mentioned notion of happiness ( Pollard, 2003 ; Waterman et al., 2008 ; Lustig, 2017 ), these indices may raise the question as to how accurate are AU’s insights into their emotional states associated to VG play and may support the idea that AU’s perception of their emotional states is somewhat distorted. In the literature, VG addiction would be linked with impairment in the self-regulation process, this finding may be linked with the difficulties AU have to observe and evaluate their own behavior ( Seay and Kraut, 2007 ). Besides, the mentioned results suggest that VG clip effect on self-report craving would depend on the addiction level.

Considering that sensing happiness and craving are probably experienced as positive emotions by AU, and that usually negative and positive emotional events are reported to last longer and shorter respectively ( Gil and Droit-Volet, 2012 ; Tian et al., 2018 ), the arousal triggered by motivating stimuli, may modify the time perception and could mediate the effect of emotions on behavior ( Gil and Droit-Volet, 2012 ). In other words, the level of excitement produced by VG play could make AU underestimate the time spent at this activity, which may be perceived as an alleviating evasion free from stressors and possibly assimilated with the notion of happiness . This hypothetic mechanism would match one of the possible motives for online gaming ( Demetrovics et al., 2011 ). In this sort of precognitive process, several studies mentioned the involvement of the amygdala in interaction with the thalamus together with the dopaminergic system and a poor inhibitory control ( Gil and Droit-Volet, 2012 ; Petry et al., 2015 ).

It is noteworthy underlining that the bipolar structure of the three-items questionnaire increases the relevance of this outcome. In effect, although participants were incited to choose between the two emotional states opposing each other (VG and pleasure vs. VG and happiness), like in the six-items questionnaire, AU again did choose happiness as the main emotional state linked with VG play. This outcome would further state the difference between these two groups when it comes to associating the two emotional states to VG play. Besides, this would reveal to an important extent that the possibility whereby pleasure and happiness were regarded as synonyms could be overcome. In other words, this outcome shows that the similarity of meanings of these two concepts did not prevent these groups to make a clear choice. Finally, the similar scores obtained in the two questionnaires (six-items and three-bipolar items “Pleasure and/or Happiness and VG”), in spite of the different disposition of the same items in these two instances, strengthen the value of the designed scale (“Pleasure and/or Happiness and VG play”).

The absence of interaction between the two independent variables on HR may be explained by the fact that a higher arousal would take place in AU when playing VG rather than when watching at VG clips. Moreover, the reduced number of valid subjects when measuring this physiological parameter (due to technical recording problems) could have contributed to this outcome too. The fact that the independent variables did not produce the expected different HR effects on AU and NAU could also be linked with one of the limitations of this study: the difficulty in integrating in this research the interaction between HR and depression (as mentioned, VG addiction is positively correlated with depression) ( Griffiths et al., 2012 ) that may lead to HR index modifications ( Cipresso et al., 2014 ). In sum, this issue illustrates that the difficulty to circumscribe the notion of happiness is also reflected in the complexity to establish physiological correlates so as to objectify this emotional state ( Cipresso et al., 2014 ).

Associating the clusters of key words with VG did not produce the expected results. Since AU linked VG with both pleasure and happiness , may be these words played a clarification role and facilitated Au’s insights into their emotional states when playing VG. It could also suggest the inadequacy of this self-report tool. However, it is probably worthwhile mentioning an index related our hypothesis: when taking words separately, the word “well-being” associated with VG play was chosen by 25% of AU and by 0% of NAU.

The outcome of the binary question in the “Pleasure and VG or Happiness and VG” one-item questionnaire with the definitions of pleasure and happiness ( Pollard, 2003 ; Deci and Ryan, 2008 ; Waterman et al., 2008 ; Kashdan et al., 2008 ; Lustig, 2017 ) shows that AU ceased associating happiness to VG play and instead, like NAU, clearly linked pleasure to their cyber activity. Caution is required in the analysis of these results because the validity of this questionnaire remains to be demonstrated. Having instructed participants to answer the bipolar question by taking into account the written definitions of the two measured emotional states, did modify the result of AU group relative to both questionnaires (“Pleasure and/or Happiness and VG” six-items and three bipolar items). Within the framework of this careful approach, it could be hypothesized that explicit definitions of the two emotional states induced AU to adopting an introspection mode through a more pronounced involvement of cortical brain structures, akin to a therapeutic process in which the appropriate verbalization of pleasure and happiness facilitates the clarification of one own feeling as a prerequisite to elaborate more adaptive behavior in spite of the constraining psychological characteristics usually associated with VG addicts ( Kim et al., 2007 ; Kashdan et al., 2008 ; Wenzel et al., 2009 ).

This may be regarded as an example of emotions reappraisal which would increase accuracy of insights into one-self, reduce distorted perception of emotions and assess the adequacy of the behavioral response to a given stimulus ( Compare et al., 2014 ). In other words, it could be posited that the mentioned explicit definitions have somewhat constrained AU to use a cognitive approach to examine their emotional states related to VG play rather than merely relying on the sensory information as it tends to occur when sensing craving for video gaming ( Wang et al., 2017 ).

Moreover, the result of this one-item binary questionnaire would further support the hypothesis. In effect, the studied interrelation between hedonia and eudaimonia suggests that a highly rated hedonic activity (VG play in this case) is usually related with low rating in eudaimonia ( Waterman et al., 2008 ). This interpretation would fit with the resounding association between depression and gaming disorders ( Lemmens et al., 2011 ; Hull et al., 2013 ; Sarda et al., 2016 ; Bonnaire and Baptista, 2019 ) together with the confusion between pleasure and happiness occurring in addictive activities (AU associated VG with happiness in the first two self-report questionnaires and ended linking pleasure with VG in the last one-item questionnaire) ( Pollard, 2003 ; Lustig, 2017 ).

Overall, the more explicit the definition of pleasure and happiness and the narrower the choice offered by the self-report questionnaires, the less confusion of emotional states associated with VG occurred in AU group members whereas NAU invariably associated pleasure to VG as illustrated in Figure 5 .

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Figure 5. Shift of AU perception of their emotional states associated with VG according to the self-report tools.

Based on these results, it could be postulated that the tendency of AU to perceive happiness when feeling craving and pleasure linked to VG play, might be moderated by a clarifying cognitive process on the meaning of these studied emotional sates, which would interfere with the behavioral habits linked to the urge of gaming ( Ko et al., 2009 ).

The findings resulting from “Pleasure and/or Happiness and VG” six-items questionnaire could be regarded as an illustration of the confusion that AU might have when linking the studied emotional states with VG play. Unlike NAU, the significantly higher association between VG play and happiness expressed by AU matches the perceived level of well being reported by individuals with Internet gaming disorders ( Griffiths, 2008 ). On the other hand, apart from well-being , the same author cites euphoria as the other main emotional state that addict gamers may report when playing VG. Whilst happiness and well-being rely on each other to define themselves, euphoria would convey the notion of intense excitement, which would rather stand in the pleasure sphere. Moreover, in medical terms, euphoria refers to a feeling of great elation, not necessarily founded (especially when resulting from substances consumption). Since AU also associated VG with pleasure although they did it to a lesser extent than with happiness, it could hypothesized that the feeling of intense excitement derives, at least partially, from satisfying the craving for VG play, which in turn could engender relieve experienced as a sense of well-being ( Loonen and Ivanova, 2016 ).

The impact of VG clips on AU craving and relaxation scores underlines relevant aspects of this study, which support the hypothesis of this research. First of all, it highlights the incongruent perception of AU’s emotional states whereby both craving and happiness coexist as emotional states associated with VG play. Thus, this finding constitutes a relevant component of the confusion that consists in placing a short-term pleasure (VG play) within the sphere of happiness. Besides, the low relaxation state of AU would correspond with their self-reported craving and, therefore, further highlights the contrast between the perceived happiness associated with VG play and the indicators measured during the VG clip visioning (high craving level and low relaxation state level). Finally, it is noteworthy mentioning that relaxation was the only measure in this study where gender differences were observed. The lower relaxation level in female gamers in both conditions might be related to the gender expectation about playing VG in society at large and in the gamers’ community in particular ( Shen et al., 2016 ). Indeed, since female gamers are a minority in these sorts of VG ( Shen et al., 2016 ) (in line with our sample: 7 females, 22 males), it could be posited that they feel under scrutiny in an activity regarded as male oriented.

Putative Reasons of Distorted Perceptions of Emotional States Associated With VG Addiction

The social dimension of popular VG has been identified as one of the factors that may explain the addiction pattern ( Hull et al., 2013 ). In this kind of competitive games, improving the required abilities and obtaining better results would be part of the key motives for VG play ( Demetrovics et al., 2011 ), that usually generates the appreciation and the acceptance of the other group players. Getting this sort of feedback from others can be motivating indeed, especially when taking into account the correlation between IGD and social isolation, low self-esteem, traumatic experiences, depression and low life satisfaction ( Petry et al., 2015 ; Schimmenti et al., 2017 ; Bonnaire and Baptista, 2019 ). In turn, these psychosocial characteristics are probably related also with the high impulsivity level in VG addicts ( Billieux et al., 2011 ), which has been found to be associated with difficulties in interpersonal relationships ( Ryu et al., 2018 ). Thus, it would seem that VG activities are, at least partially, sating the mentioned social and psychological deficiencies. This suggests that AU’s emotional states related to VG play may be quite contrasting, in which components of happiness (i.e., interacting with others, fellowship and belonging to a group) are intertwined with those of short-term pleasure (i.e., craving for getting quick results, praise from others, etc.) ( Loonen and Ivanova, 2016 ). Now, craving for undertaking these cyber activities to respond to the mentioned social isolation issues places this emotional state much closer to the ‘pleasure governed by desire’ than to ‘atmosphere of good fellowship’ (Happiness) ( Lawrence et al., 2014 ; Lustig, 2017 ).

The flow, defined as the emotional state embracing perception distortion and enjoyment produced by VG activities, is another element that can create confusion in gamers’ insights into their emotional states ( Chou and Ting, 2003 ; Hull et al., 2013 ). As described in the mentioned study, experiencing flow implies not only losing the notion of time but also merging oneself with the VG actions. In these conditions, the gamer’s senses and attention are in the here and now , with little or no awareness about sources of stress relative to past, present or future events. In this line, the motivation to experience immersion has been associated with problematic gaming ( Billieux et al., 2011 ). Considering the fact that loneliness and depression have been identified as predictors of VG addiction and of Internet Gaming Disorders ( Hull et al., 2013 ; Sarda et al., 2016 ), it is understandable why in gamers’ mind experiencing flow could equate this feeling with a relieving emotional state ( Loonen and Ivanova, 2016 ). This sense of alleviation could match the notion of happiness as free from distress ( Kringelbach and Berridge, 2010 ; Loonen and Ivanova, 2016 ) if it resulted from the quality of real life being lived. Instead, in AU, this relieving and enjoyable emotional state would be engendered by a virtual activity (VG), possibly used as a means to escape from stress and to forget tensions ( Demetrovics et al., 2011 ; Bonnaire and Baptista, 2019 ). In the literature, the escaping strategy is a way to find relieve from stressors through the engagement in a pleasant activity, which may end up representing a space of happiness ( Seay and Kraut, 2007 ).

In sum, the incongruence lies in the coexistence of regarding VG as a space of happiness while using VG to get quick pleasures and relief. Individuals suffering from this disorder tend to pursuit short-term pleasures rather than long-term gains ( Dong and Potenza, 2015 ). Being driven by short-term gratifications rather belongs to the reward-seeking realm ( Waterman et al., 2008 ; Lustig, 2017 ). Thus, this pleasant emotional state could be associated with the arousal linked to a reward seeking behavior through which quick and positive results are obtained, which in turn reinforce the mentioned behavior. Probably, this intense arousal situates itself within the sphere of pleasure as a dysfunction in the rewarding system ( Pollard, 2003 ; Berridge and Kringelbach, 2013 ; Lustig, 2017 ) and not in that of happiness in spite of the relieving benefits it provides.

Another possible reading on why the emotional states generated by these cyber activities are linked with happiness may be related to the way in interpreting the experienced sensations. This representation is probably shaped by the individual background, experiences, culture, etc. From a brain mechanism stand point, conscious liking does not limit it self to a sensory outcome, it is also translated into a subjective liking through the recruitment of cognitive processes ( Berridge and Kringelbach, 2013 ). Indeed, these authors state that conscious pleasure rating is sometimes detached from affective reactions as people can elaborate reasons to themselves for how they should feel. Therefore, associating VG with happiness may be the result of a rationalization process to reduce the cognitive dissonance. In other words, the unwished consequences of the VG addiction pattern (increased stress, problems at working, studying, socializing, etc.) ( Griffiths et al., 2012 ) probably produce an increasing amount of pressure (due to the difficulty to reduce gaming time, guilt, etc.) that can become overwhelming if it lasts too long. Consequently, if the affected individuals are unable to master the yearning for VG, perceiving VG activities as a source of well being may reduce the mentioned pressures insofar as the notion of happiness usually suggests a socially acceptable mood, a legitimate aim and a safe emotional state. In this perspective, equating happiness with satisfying craving and with short-term pleasure might contribute to feed the addictive pattern ( Lustig, 2017 ).

In a broader perspective, the rationalization process described in the previous paragraph may be also related with coping strategies to deal with adversity. For instance, it has been observed that problematic gamers may use VG play as a means to cope with stressors and to enhance mood ( Demetrovics et al., 2011 ). An association has been found between stressful life events and addiction to Internet activities ( Schimmenti et al., 2017 ), with the mediating role of psychological needs satisfaction and the moderating role of coping styles ( Dongping et al., 2016 ). Several theories and studies support this approach that strives for a more holistic understanding of this issue. The self-determination theory postulates that humans share three universal psychological needs ( Deci and Ryan, 2000 ; in Dongping et al., 2016 ): autonomy (i.e., feeling of being self-determining in one’s behavior), relatedness (i.e., the feeling of connectedness to others) and competence (i.e., the feeling of dealing with issues in a competent manner). Besides, individuals can adopt different strategies to cope with adversity ( Lazarus and Folkman, 1984 ; in Dongping et al., 2016 ). According to Zheng et al. (2012 ; in Dongping et al., 2016 ), the positive coping approach is the set of strategies aiming at problem solving, support seeking and cognitive restructuring to address the stressors. On the other hand, according to the same authors, the negative coping consists in strategies such as blaming, social withdrawing, denial and disengagement so as to avoid the stressful situations. Now, a parallel can be established between these two coping styles and the brain activities involved in the goal-directed learning and the habit learning.

The goal-directed learning would correspond to the positive coping style insofar as it focuses on the relationship between an action and the motivational value of the outcome, and is associated with the activation of the prefrontal cortex, the dorsomedial striatum and the dorsomedial thalamus ( Ballaine and Dickinson, 1998 ; in Schwabe et al., 2012 ). On the other hand, habit learning, would be linked with the avoidant coping style. This learning process encodes the relationship between a response and preceding stimuli without taking into account the outcome caused by the response and is related to the activation of the dorsolateral striatum ( Yin et al., 2004 ; Tricomi et al., 2009 ; in Schwabe et al., 2012 ). According to Schwabe et al. (2012) , stressful situations may modulate the processes involved in instrumental learning in a way that may produce the shift from goal-directed learning to habitual learning.

In line with these findings, it has been observed that, like cocaine cues, psychological stress induction can generate the same craving response in a cocaine abusers population ( Bradley et al., 1989 ; Wallace, 1989 ; in Sinha et al., 2000 ). The relevance of these observations lies in the fact that both SUD and behavioral addictions (including gaming disorders, Han et al., 2011 ) recruit to an important extent common brain regions and produce similar physiological patterns, as quoted in the introduction of this document.

Considering the association between unhappiness and VG disorders mentioned earlier, it could be posited that the gamers concerned could not overcome the causes of their unhappiness. Indeed, studies suggest that subjects with Internet gaming disorders embark in VG play more to deal with negative affect than to achieve a good performance in the game ( Schimmenti and Caretti, 2010 ; Billieux et al., 2013 ; both in Bonnaire and Baptista, 2019 ). In this scenario, based on the mentioned studies, a low level of happiness would imply that psychological needs are somewhat unmet and associated with the avoidant coping style together with the habit learning. Furthermore, this pattern is supported by compensatory Internet use theory, which postulates that adversity can operate as a stimulus to seek psychological comfort (i.e., satisfying the psychological needs via the cyberspace) ( Kardefelt-Winther, 2014 ; in Dongping et al., 2016 ).

In other words, the psychological comfort engendered by the VG activities in this population of gamers, combined with the characteristics of the avoidant coping style (denial, social withdrawal, avoiding stressful situation, etc.) and with the traits of the habitual learning (actions’ outcomes are disregarded, with little or no awareness of actions’ consequences), might explain, at least partially, the biased perception of the emotional states in AU ( happiness associated to VG) and of their causes of craving for VG. This assumption suggests that online gaming might not be the cause of VG addiction, but rather that VG excessive use could be a compensatory strategy to deal with pre-existing psychological characteristics and deleterious social context ( Kowert et al., 2015 ). For instance, some studies suggest that traumatic experiences, poor emotions regulation, elements of impulsivity and the motivation to experience immersion in a virtual world would increase the likelihood of IGD and Internet addiction ( Billieux et al., 2011 ; Schimmenti et al., 2017 ).

In sum, it would seem as if for AU the mentioned behavioral pattern is a manner to mitigate the difficulties to deal with stressors. This interpretation would be in line with the motives for play in problematic gaming ( Demetrovics et al., 2011 ). Through a massive survey these authors observed seven dimensions that would cover the entire spectrum of motives for VG play in all sort of on line games: escape (from reality), cope (with stressors, playing as a way to improve mood), fantasy (trying new identities/things in a virtual world), skills development (improving concentration, coordination, new skills) recreation (relaxing aspects of gaming), competing (sense of achievement), and social (knowing/being/playing with others). This study suggests that there would be positive and beneficial motives for playing (entertaining gaming) as well as harmful ones (problematic gaming). The correlations between these factors appear to shed light on the positive and negative aspects of gaming. Whilst the weakest correlation is between escape and recreation (also low correlation was found between escape and both, skills development and competition), the strongest correlations were observed between escape and cope and fantasy. These results would indicate that escape and coping are motives associated with problematic gaming, however, the authors argue that escapism would facilitate the coping efforts to deal with stressors and negative moods. Moreover, it is noteworthy underlining that escapism had the lowest mean score in this study among the seven dimensions, which would match with the prevalence level of problematic gaming mentioned previously ( Griffiths et al., 2012 ).

Probably, regarding AU, the accuracy in perceiving emotional states, the ability to deal with stressors and the quality of insights into oneself are dimensions that deserve much attention in the therapeutic processes.

Therapeutic Implications

A cognitive-behavioral approach may contribute to the recovery process by enabling problematic gamers to explore the motives that lead them to abuse of VG play ( Orzack et al., 2006 ; in Griffiths, 2008 ). Developing strategies to tackle stressors appears to be a therapeutic priority for treating this disorder. Consequently, this axis of work includes the understanding of the environmental demands that are perceived as exceeding the individual abilities to handle them. In this line, ensuring the accuracy of the individual’s insights into the emotional states linked to the sources of stress as well as to the game habit could increase the awareness of the underlying issues to be addressed. In particular, deciphering the conditioned desires (unconscious wanting) and the hedonic dimension (unconscious liking) ( Kringelbach and Berridge, 2009 ; Berridge and Kringelbach, 2013 ) linked to VG play may produce added value information for understanding and overcoming the problematic gaming pattern. Within this frame, it could be hypothesized that distinguishing between happiness and feeling alleviated could be beneficial to the therapeutic process, although it remains to be demonstrated.

Overall, this sort of therapeutic approach may contribute to reduce the alexithymia, usually associated with this kind of disorders ( Kandri et al., 2014 ).

In problematic internet/gaming several studies have explored and highlighted to role of alexithymia and its links with other therapeutic issues. For instance, it has been shown that alexithymic individuals are more associated with Internet addiction than non-alexthymic ones ( Baysan-Arslan et al., 2016 ). In this research, the authors consider that the difficulty in identifying and differentiating emotions that characterizes alexithymia may lead individuals with this affliction to regulate their emotional states via their addictive activities.

Another study showed that IGD would be related with alexithymia, anxiety and depression ( Bonnaire and Baptista, 2019 ).

Schimmenti et al. (2017) observed that traumatic experiences (mainly in males) and traits of alexithymia (mainly in females) were associated with Internet addiction symptoms, which may enable a tailored prevention and treatment approach. Besides, Internet addiction (including online role-playing) would be correlated with alexithymia, dissociation (protecting one-self in a more pleasant created reality as a means to deal with traumatic experiences) and insecure attachment ( Craparo, 2011 ).

However, the causal link in the association between alexithymia and Internet addiction would still need to be verified, as indicated by Mahapatra and Sharma (2018) . Moreover, discerning the nature of alexithymia remains an uneasy task: this emotional identification and differentiation disorder might be regarded as a stable personality trait that could increase risks of mental disorder development, and also may be seen as a defense mechanism to cope with psychological stressors ( Mikolajczak and Luminet, 2006 ; in Mahapatra and Sharma, 2018 ).

Apart from alexithymia and traumatic memories, high urgency (a dimension of impulsivity defined by the proneness to have strong reactions usually tied with negative affect) and being motivated to experience immersion in a virtual world would be psychological predictors of problematic multiplayer online games ( Billieux et al., 2011 ). These findings led the authors to posit that individuals with the two mentioned traits are more likely to use the immersion in the virtual world as a means to avoiding facing real life adverse issues. According to the authors, this behavior will lead to a deleterious outcome (culpability and embarrassment as a result of feeling unable to deal with problems), which in turn is experienced as a pernicious condition likely to activate behaviors related to high urgency and immersion.

Like the previously mentioned clinical issues, this vicious loop reinforcing escapism also appears to be a therapeutic target.

Considering the possible association between alexithymia and problematic gaming as a manner to regulate emotions ( Baysan-Arslan et al., 2016 ; Bonnaire and Baptista, 2019 ), the Emotion Regulation Therapy (ERT) might strengthen the therapeutic process. The aim being that the observed difficulties in Internet (including VG) addicts to identifying emotions and regulating affects ( Caretti et al., 2010 ; in Craparo, 2011 ) could be, at least partially, overcome through the ERT process. In effect, Compare et al. (2014) , show that ERT operates as a means to reappraise emotions that trigger actions leading to negative consequences. Reappraising emotions is associated with the involvement of the medial prefrontal cortex, which attenuates the amygdala activation and, thus, reduces the intensity of negative affect; these two areas being coordinated by the orbitofrontal cortex ( Compare et al., 2014 ). Since AU would be prone to associate happiness with VG play, ERT might facilitate the perceptional change enabling to link VG play with pleasure [ Caretti and Craparo, 2009 ; in Craparo (2011) consider Internet addiction (including VG) “as a syndromic condition characterized by a recurrent and reiterated search for pleasure derived from dependence behavior, associated with abuse, craving , clinically significant stress, and compulsive dependence actions despite the possible negative consequences”]. Within this approach, it may be postulated that enabling problematic gamers to familiarize with and to see the self-transcendent notion of happiness could favor the distinction between pleasure and happiness and would render them less vulnerable from impulses and from environmental circumstances ( Dambrun et al., 2012 ). The idea is to facilitate the shift from wanting more than liking (or even without liking) toward liking with little or without wanting ( Berridge and Kringelbach, 2011 ). Furthermore, regarding motives for playing, it could be posited that helping problematic gamers to identify and distinguish the emotions tied to escaping/coping from those related to recreational gaming ( Demetrovics et al., 2011 ), would be a necessary condition to orient effectively the ERT toward the escaping issues and targeted emotional states requiring therapeutic input. In this line, based on the previously mentioned studies in this section, it might be useful exploring the possible link that the excessive time spent in cyber activity could have with past traumatic experiences, insecure attachment, impulsivity, anxiety and depression.

In conclusion, this study suggests that the mentioned confusion of emotional states (pleasure and happiness) associated with addiction ( Lustig, 2017 ), could take place in subjects with VG addiction, and potentially in the entire spectrum of addictions. Moreover, from a cognitive therapeutic perspective, it shows the potential benefits of reappraising emotions as a means to contribute to the emotional distortion reduction.

Limitations

The small sample of this study demands cautiousness when making generalizations from its results. Besides, watching VG clips rather than actually playing VG might be less stimulating for chronic gamers and could have influenced the physiological values recorded during the clip visioning phases. That said, many gamers do attend to public competitions to watch other gamers playing VG. Although, to the best of our knowledge, there is no information available to affirm that there are VG addicts in these audiences.

We also faced the usual paradox when assessing craving via self-report tools. Indeed, participants were asked to judge their craving intensity for VG play whereas sensing craving often may imply a compromised self-awareness level and thus a self-assessment whose value needs to be interpreted carefully.

Although the GAS is a validated tool, which has shown its usefulness in screening addict gamers, having complemented this measurement with thorough diagnostic-driven interviews run by specialists when choosing participants to form the AU and the NAU groups would have strengthened the selection process.

The participants’ selection was centered on the gamer status (gaming addiction/non-addiction and names of games usually played) rather than on the cultural and/or educational background of the persons. Future researches could complete this approach by assessing the possible cultural and educational bias in perceiving the studied emotional states.

Moreover, including more physiological parameters related to pleasure and happiness could further complete the self-reported information and may enable reaching more robust results.

Prospective Research

Further research is required to better understand the relationship between the studied emotional states and this addiction. For instance, since VG addiction decreases with age ( Wittek et al., 2016 ) a longitudinal study could reveal the factors (psychophysiological, environmental, etc.) that operate that change. Moreover, VG addiction is only one area of the spectrum of addictions. Undertaking similar researches on other addictions and with larger samples could also contribute to deepening the comprehension of this issue. Finally, keep enhancing the scales that measure pleasure and happiness may provide with more accurate information about the range of nuances intrinsic to these two emotional states.

Data Availability Statement

All datasets generated for this study are included in the article/supplementary material.

Ethics Statement

The studies involving human participants were reviewed and approved by the Université Libre de Bruxelles Ethical Committee. The patients/participants provided their written informed consent to participate in this study.

Author Contributions

LG developed the proposal and the conception of the original project research, searched and articulated the theoretical background, participated in the study and protocol design, elaborated the results interpretation, assembled all the chapters of the study, and in charge of the manuscript writing. ND was involved in the scientific and publication management, participated – as the Research Center Manager – in the study and protocol design, and in charge of the configuration and writing of the physiological measures. JL, as a member of the Research Center, was involved in the study and protocol design, also involved in the configuration of physiological measures, managed the experimental phases in the laboratory, and elaborated the data analysis. CL, as a full Professor at the Faculty of Psychology and Director of the Research Center for Work and Consumer Psychology, assured the scientific and publication management, participated in the study and protocol design, in charge of making the critical reviews of the manuscript along the process, and involved in the manuscript writing.

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Acknowledgments

We would like to express our gratitude to Maastricht University (Department of Psychiatry and Neuropsychology) as well as Université Libre de Bruxelles (Faculty of Psychological Sciences and of Education – Research Center for Work and Consumer Psychology). This work was performed as a partial fulfillment toward the International Master in Affective Neuroscience of Maastricht University and the University of Florence.

Abbreviations

AU, addict users; EEG, Electroencephalogram; ETR, Emotions Regulation Therapy; GAS, Gaming Addiction Scale; H, happiness; HR, heart rate; I.G.D., Internet Gaming Disorders; NAU, non-addict users; OHQ, Oxford Happiness Questionnaire; P, pleasure; SHAPS, Snaith-Hamilton Pleasure Scale; VG, video games.

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Self-Report Questionnaires

– Six items Questionnaire: Pleasure and/or Happiness associated with VG play (Items 7 and 8 were suppressed after the preliminary phase)

(1) I enjoy playing video games.

(2) I am happy when I play video games.

(3) I would find pleasure in my video game activities.

(4) I find video games amusing.

(5) I enjoy playing my favorite video game.

(6) I often experience joy and exaltation when playing video games.

(7) I would feel pleasure when I receive praise from other people on my capacity to play video games.

(8) I don’t have fun when playing video games with other people.

fully disagree disagree slightly disagree slightly agree agree fully agree

<———I——————I——————I————————I——————I—————I———>

– Questionnaire on Craving for playing VG

– After having watched this clip I feel craving for playing video games.

– Three bipolar items Questionnaire: Pleasure and/or Happiness associated with VG play

Bipolar items.

(1) I enjoy playing video games I am happy when I play video games

I——————I——————I——————I—————I

(2) I would find pleasure in I find video games amusing my video game activities

(3) I enjoy playing my favorite I often experience joy and exaltation video game when playing video games

– Ten key words [resulting from the semantic mapping of pleasure (P) and happiness (H)]: 3/10 words to be associated with VG play

– Joy

– Craving

– Well-being

– Impulsivity

– Fellowship

– Desire

– Fun

– Contentment

– Gratification

– Serenity

Pleasure cluster: joy, craving, impulsivity, desire, fun, gratification.

Happiness cluster: well-being, fellowship, contentment, serenity.

– One bipolar item Questionnaire: Pleasure or Happiness associated with VG play (with explicit definitions)

Happiness : emotional state of lasting contentment.

Pleasure : transient emotional state when satisfying a desire, a craving.

A bipolar item

www.frontiersin.org

Keywords : video games, addiction, confusion, pleasure and happiness, emotional states

Citation: Gros L, Debue N, Lete J and van de Leemput C (2020) Video Game Addiction and Emotional States: Possible Confusion Between Pleasure and Happiness? Front. Psychol. 10:2894. doi: 10.3389/fpsyg.2019.02894

Received: 03 July 2019; Accepted: 06 December 2019; Published: 27 January 2020.

Reviewed by:

Copyright © 2020 Gros, Debue, Lete and van de Leemput. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Lucio Gros, [email protected]

Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.

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