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FOREWORD

Video Games and Addiction

Dr. Mark D. Griffiths

Director, International Gaming Research Unit, Psychology Division, Nottingham Trent University, United Kingdom, NG1 4BU

I was delighted to be asked by Ciaran O’Connor to write the ‘Foreword’ to his new book. As you will soon read, Ciaran had his own issues surrounding gaming addiction and has used his own personal experiences to help underpin his own psychological therapeutic interventions in the treatment of gaming addiction. Ciaran’s writing is heartfelt and personal. However, he has also attempted to integrate some of the academic and clinical literature to support his views. He wrote this book because he felt it needed to be written and he wanted others that have or treat (or want to treat) this problem to have a resource they could turn to.

For nearly 30 years I have been studying behavioural addictions (put simply, addictions that don’t involve taking any drugs). In the mid-1980s I began my academic career by studying adolescents that were addicted to ‘fruit machines’ in amusement arcades. It was through this work I began to notice teenagers that would spend all day in the arcade playing on the video game machines. In the early 1990s I began to publish academic papers on video game addiction and saw many similarities (both behaviourally and psychologically) between both playing video games and slot machines. By the mid-1990s, I began researching into ‘internet addiction’ and in 1995 I published an academic paper simply entitled ‘Technological Addictions’ in which I brought all these disparate behaviours (video game addiction, internet addiction, television addiction, slot machine addiction, etc.) under one conceptual umbrella. Since then, the field of technological addictions has expanded greatly – particularly in the area of gaming addiction.

Gaming addiction has changed and evolved greatly since I first started researching in the area. In the 1980s, the focus was on arcade video game addiction. In the 1990s, the focus changed to home console video game addiction. Over the last decade, the focus has been online video game addiction – particularly in relation to Massively Multiplayer Online Role Playing Games (such as World of Warcraft and Everquest). In the 1990s I researched separately into internet addiction and video game addiction but now they have become part of the same area of study.

Over the last 15 years, research into various online addictions has greatly increased. One of the most important consequences of the increased amount of research in this area is that in May 2013, ‘Internet Gaming Disorder’ was officially recognized by the American Psychiatric Association as an area warranting further research and was included in the appendix of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (more popularly known as the DSM-5).

Prior to the publication of the DSM-5 in 2013, there had been some debate as to whether ‘internet addiction’ should be introduced into the text as a separate disorder. Alongside this, there has also been debate as to whether those researching in the online addiction field should be researching generalized internet use and/or the potentially addictive activities that can be engaged on the internet (e.g., gambling, video gaming, sex, shopping, etc.). Following these debates, the Substance Use Disorder Work Group (SUDWG) recommended that the DSM-5 include a sub-type of problematic internet use (i.e., internet gaming disorder [IGD]) in Section 3 (‘Emerging Measures and Models’) as an area that needed future research before being included in future editions of the DSM.

According to leading scholars in the area, IGD will not be included as a separate mental disorder until the (i) defining features of IGD have been identified, (ii) reliability and validity of specific IGD criteria have been obtained cross-culturally, (iii) prevalence rates have been determined in representative epidemiological samples across the world, and (iv) etiology and associated biological features have been evaluated.

Although there is now a rapidly growing literature on pathological video gaming, one of the key reasons that IGD was not included in the main text of the DSM-5 was that that there are no standardized diagnostic criteria used to assess gaming addiction across the many studies that have been published. For instance, I (and some of my Australian colleagues) carried out a review of instruments that have been used to assess problematic, pathological and/or addictive gaming. We reported that 18 different screening instruments had been developed, and that these had been used in over 60 quantitative studies comprising nearly 60,000 participants.

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

Video gaming that is problematic, pathological and/or addictive lacks a widely accepted definition. I argued in a paper that I co-wrote with some of my Hungarian colleagues that some researchers consider video games as the starting point for examining the characteristics of this specific disorder, while others consider the internet as the main platform that unites different addictive internet activities, including online games. Recent studies have made an effort to integrate both approaches. Consequently, IGD can either be viewed as a specific type of video game addiction, or as a variant of internet addiction, or as an independent diagnosis.

Clinical interventions and treatment for problematic and/or addictive video game play vary considerably in the psychological and medical literature, with most of the very few published studies employing some type of cognitive-behavioural therapy (CBT), pharmacotherapy, and/or self-devised psychological interventions. Currently, the evidence based on the treatment of problematic and/or addictive gaming is limited. Furthermore, the lack of consistent approaches to treating problematic video game playing and video game addiction makes it difficult to produce any definitive conclusions as to the efficacy of treatment, although at this stage CBT (as with the treatment efficacy of other addictions) appears to show good preliminary support. There remains a need for controlled, comparative studies of psychological and pharmacological treatments, administered individually and in combination with each other, to determine the optimal treatment approach.

In South East Asia there appears to be significant demand for treatment for online-related problems including gaming addiction. The South Korean government has reportedly established a network of over 140 counselling centres for treatment of online addiction. In Western countries, gaming addiction clinics have also started to emerge in places such as Holland and the UK. There are also treatment groups that are modelled on 12-step self-help treatment (e.g., Online Gamers Anonymous). However, little detail is known about the treatment protocols or their efficacy.

As you will see later in this book when Ciaran outlines some of my thoughts about addiction, I believe that all addictions share more commonalities than differences (i.e., salience, mood modification, tolerance, withdrawal symptoms, conflict, and relapse), and likely reflect a common etiology of addictive behaviour. Consequently, online game addiction is viewed as a specific type of video game addiction.

Some researchers do not differentiate between problematic video game use and problematic online game use. These scholars conceptualize problematic video game use as excessive use of one or more video games resulting in a preoccupation with and a loss of control over playing video games, and various negative psychosocial and/or physical consequences. However, unlike me, their criteria for problematic video game use does not include other features usually associated with dependence or addiction (e.g., tolerance, physical symptoms of withdrawal), as they say there is no clear evidence that problematic gaming is associated with such phenomena. Other researchers such as Dr. Kimberley Young view online gaming addiction as a sub-type of internet addiction and that the internet itself provides situation-specific characteristics that facilitate gaming becoming problematic and/or addictive.

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

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

For epidemiological purposes, my Hungarian colleagues have asserted that the most appropriate measures in assessing problematic online use (including internet gaming) should meet six requirements. Any instrument should have: (i) brevity (to make surveys as short as possible and help overcome question fatigue); (ii) comprehensiveness (to examine all core aspects of PAP gaming as possible); (iii) reliability and validity across age groups (e.g., adolescents vs. adults); (iv) reliability and validity across data collection methods (e.g., online, face-to-face interview, paper-and-pencil); (v) cross-cultural reliability and validity; and (vi) clinical validation. They also noted that an ideal assessment instrument should serve as the basis for defining adequate cut-off scores in terms of both specificity and sensitivity. In addition to further epidemiological and clinical research, further research is also needed on the neurobiology of IGD. A systematic review of neuroimaging studies examining internet addiction and IGD that I co-wrote with Dr. Daria Kuss noted that:

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

The good news is that research in the gaming addiction field does appear to be reaching an emerging consensus. Books such as this one by Ciaran will help legitimize the concept of gaming addiction and how to treat it. For those who have problems concerning their gaming, it may not matter whether it’s called an addiction, compulsion, obsession or a dependency. In short, they simply want help in overcoming their problematic gaming. This book helps make that goal that little bit easier.

Further reading

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

Demetrovics, Z., Urbán, R., Nagygyörgy, K., Farkas, J., Griffiths, M. D., Pápay, O. Kokonyei, G, Felvinczi, K, & Oláh, A. (2012). The development of the Problematic Online Gaming Questionnaire (POGQ). PLoS ONE, 7(5): e36417. doi:10.1371/journal.pone. 0036417.

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

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

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

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

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

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

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

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

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

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

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

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

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

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