Lentis/Game Addictions

Video game addiction (also referred to as Internet Gaming Disorder) is the compulsive, "persistent and recurrent" playing of video games "to the exclusion of other interests," resulting in "clinically significant impairment or distress." While game addiction is generally viewed in terms of video games, game addiction can take many forms. People can be addicted to board games, card games, game shows and other forms of games. Video games are the most visible because they grow more and more relevant in popular culture and are having a greater impact on younger generations. In 2020, the US video game industry was estimated to have a market size of $60 billion, having nearly doubled in the last 10 years. Research into video game addiction can benefit from existing research into other behavioral addictions and impulse control disorders, such as gambling addiction.

History
The idea of video game addiction was first introduced to mainstream media in the early 1980s. U.S. Surgeon General Everett Koop released a statement on November 10, 1982 saying that video games might be hazardous to the health of young people, who, he said, are "becoming addicted to the machines body and soul." At the time he had very little evidence to support his claim but he predicted that statistical evidence would eventually come to light. Almost thirty years of research and advancement in gaming now shows that Dr. Koop may have been accurate in his claims. In July 2006, the world’s first video game addiction clinic opened in Amsterdam. Since then, other countries like the United States, Canada, China, and South Korea have opened treatment centers. These treatment centers and the methods they use to help video game addicts are discussed in the Prevention and Correctional Programs section.

Demographics
According to recent statistics, 2 billion people play video games globally. In the United States there are 150 million gamers, which take 64% of the U.S. population. The average age of video gamers is 35. The average male gamer is 33 years old, and the average female gamer is 37 years old. Studies on video game usage show growth in the average time spent playing video games. While individuals played video games for an average of 26 minutes per day in 1999, it had increased to 32 minutes per day in 2004 and 1 hour and 13 minutes in 2009. The study included video games on consoles, handheld players, and other devices.

Demographics are also studied on the game addiction. Online video game addiction statistics show that anywhere from 1-10% of gamers have compulsive addiction issues. 94% of males and 6% of females represent the gender breakdown among such group of gamers. For the ethnicity, the breakdown is around 69% Caucasian, 13% Asian, and 18% of others. Technological advancements increase the video game accessibility and also raise the risk of game addiction, especially for young adults. According to a set of statistics, young adult males between the ages of 18-24 are at high risk of video game addiction, and more than 6% of teenagers struggle with it. The number is still increasing as the video game industry continues to grow at a rapid rate.

Definition
The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) does not formally recognize video game addiction (referred to as Internet Gaming Disorder) as a mental disorder. Published in 2013, the DSM-5 claimed there was not enough evidence to determine whether the addiction is a distinct disorder or a manifestation of existing impulse control disorders, such as "maladaptive coping or a way of meeting particular needs." The DSM-5, however, recommends video game addiction as a topic for further research. Addiction is an emotionally charged word with negative connotations. It turns out to be much harder to define what it is than it might at first appear. While there is not a universal definition in the DSM-5, there is a definition of the term "dependence". Dependence is defined as "Substance use history which includes the following: (1) substance abuse; (2) continuation of use despite related problems; (3) increase in tolerance; and (4) withdrawal symptoms." Peter Laurie presents a table with various drugs such as amphetamines and caffeine, and qualities of those drugs. To illustrate the point he includes 'trousers' in this table, which tick the boxes for 'Psychic dependence', 'Physical dependence' and 'Psychotoxic on withdrawal'.

Addiction to computer games is often seen as a social problem. Addiction to sports or to games of skill such as chess are more rarely seen as being a problem. Why is this? When does a passion for an activity become an addiction? Looked at more objectively, addictions are compulsive activities that society in general does not approve of. A passion for football or for chess is something society as a whole can approve of, even when pursued to the detriment of other activities. They are less prone to being categorised as an addiction. In approved of and unapproved of activities we can analyse the elements that make the activity 'addictive', the cycles of reward, the emotional circuits that are being tapped into, and the potential for damage that they pose.

A challenge in defining video game addiction is determining the extent to which the activity becomes an addiction, with a general understanding that the addiction is a behavioral dependency that has a negative effect on the user's health. Parameters such as the frequency, duration, and compulsiveness to play video games are not yet well-defined.

Symptoms
Game addiction can include any number of symptoms mentioned below:
 * Preoccupation: the person seems unusually concerned with the game, may seem irritable or distracted, or will talk about gaming frequently to his peers
 * Lack of control: the person feels as if they need to play the game in order to function. The person cannot go for an extended period of time without playing the game. An example of this would be the YouTube sensation "The Greatest Freak Out Ever" from username wafflepwn . The teenager's reaction to the loss of his World of Warcraft account may be a symptom of his game addiction.
 * Lying: fabrications of how much time is spent playing video games. The person may lie to his friends and family about playing video games in order to prevent intervention.
 * Tolerance: the need to spend more time playing the game, and the tendency to lose interest in other activities that do not involve the video game.
 * Continuing to play video games despite ostensive problems doing: this is often considered the "tell-tale" sign of addiction to many substances and behaviors.

Comparison with Gambling Addiction
Many of the symptoms and causes of game addiction are similar to that of gambling addiction, or problem gambling. In fact, gambling addiction and game addiction experience a lot of overlap, especially in terms of card games and slot machines. While many substance addiction disorders are recognized, the only behavioral addiction formally recognized by the DSM-5 is gambling addiction.

Some symptoms of gambling addiction that overlap with video game addiction are:
 * Restless or irritable when trying to cut down or stop gambling. This parallels a video game addict's irritability when not able to play his or her game.
 * Frequent thoughts about gambling (such as reliving past gambling experiences, planning the next gambling venture, thinking of ways to get money to gamble). A video game addict similarly is always thinking about the next time they can play their game.
 * Lying to conceal gambling activity.
 * Repeated unsuccessful efforts to control, cut back on or stop gambling.

Treatment for gambling addiction can include "cognitive behavioral therapy, psychodynamic therapy, group therapy and family therapy." Counseling tries to help the gambling addict understand his or her relationship with gambling and the toll it might be taking on his or her life. Treatment for video game addiction is similar, as discussed in the Prevention section.

Physical

 * Carpal Tunnel Syndrome: One of the most significant and costly physical effects of game addiction is carpal tunnel syndrome. Carpal tunnel syndrome is usually contracted from extensive use of computer keyboards. In the case of carpal tunnel, the patient will usually require extensive surgery in order to repair the hand.
 * Weight Gain: Another side effect of game addiction is weight gain. Many game addicts will form abnormal eating habits, due to their long streaks of playing video games. In order to increase playing time they will more often times eat food that is easy to cook and fast, but consequently bad for you and high in cholesterol or fat. This will result in a weight gain and unhealthy nutrition habits.
 * Migraines: Game addicts will spend hours upon hours staring at a backlit screen. This concentration and the prolonged exposure to bright lights are known to bring on painful migraines.

Social
There are many social consequences of game addiction. Here are the three most prevalent:
 * Withdrawal: Game addicts, once at a certain point, will start to eschew friends and family in order to devote more time to gaming. This can hurt relationships, work and has even resulted in divorce in cases around the world.
 * Lose touch with reality: Many game addicts prefer to be in their game world than to be in the real world. This goes hand in hand with social withdrawal. The gamer will communicate with other people in the language of the game, and in some rare cases, will imagine that they are the character they play, while they in real life.
 * Misuse of Money: One of the major consequences of game addiction is the cost of the upkeep of games and systems. Most online multiplayer games require a subscription to keep the servers up and running. Other expenses come from purchasing new games and updates for hardware and software. Game addicts will put priority on those investments over more legally binding ones like bills and such.

Problem Games
Some games that have been heavily targeted by organizations as being more addictive than others include the following:
 * World of Warcraft: World of Warcraft has gotten the most scrutiny of all video games by far. It's role playing aspects, large following and seemingly endless updates make it a prime target for game addiction. There is a lot more to read about World of Warcraft in our colleague's MMORPG page.
 * The Halo Franchise: This is the World of Warcraft of console games. Halo is one of the most popular game franchises of all time. On its first day, Halo:Reach sold over $200 million worth of games. It's online multiplayer is massive and very popular for its simplicity: kill or be killed. The fan base for the Halo series is also very loyal. On April 15, 2010, Microsoft shut down their servers that supported the original Xbox games' online play. The way they kicked players off of the server was that whenever they logged off, they would not be allowed to log back on. Some Halo 2 players heard this news and made a pact to keep playing as long as possible. So for days upon days, these players kept playing Halo 2. After 26 days, the last player, Apache N4SIR, was booted from the system.
 * Tetris: Tetris is heralded by many gaming authorities as one of the greatest games of all time. However, it is also very addictive. One of the primary reasons for this is the concept of the high score. Since there are no levels in Tetris, one could theoretically play the game forever, so success in Tetris is measured by the highest score. The portability and ease of the game has allowed Tetris to experience a rebirth in the age of cell phones and iPods. As of January 2010, more than 100 million copies of Tetris have been sold on cell phones alone.

Potential Benefits
Surprisingly, a new trend called ‘Exergaming’, proves that physically demanding games can help combat child and teenage obesity in America. An international online survey found that Konami's Dance Dance Revolution improves physical health, endurance, muscle strength, and sense of rhythm in addition to facilitating social interactions. Other reports have found that the wide range of movements required in playing Nintendo’s Wii Fit has made the game an increasingly popular alternative for exercise as well as pediatric and physical rehabilitation. This is sometimes referred to as 'Wiihabilitation'.

Action games that demand multitasking and rapid information processing can enhance a range of visual skills. One study by Dye et al reports that avid video game players experience faster reaction times in a variety of tasks including spatial cueing, inhibition of return, and flanker interference than non-video gamers. The research also showed that non gamers who underwent action game training experienced a greater increase in reaction times than those who had been trained in control gaming. In another experiment by Green and Bavelier, people who typically played action video games for more than five hours a week were able to maintain target identification with distracters in closer proximity than non game players. After given 30 hours of action game training, these non-video game players saw improvements in their visual acuity and were able to decrease their visual crowding threshold. These studies suggest the causal relationship between action games and heightened visual skills. Furthermore, in a Multiple Object Tracking task study by Sun et al, gamers that had ceased to excessive playing as much as two years prior, exhibited superior visuospatial abilities than a control group. Thus, not only can video games improve perceptual reaction times, visual targeting abilities, and selective attention, but their benefits can be potentially long term. In the future, action video games might play an rehabilitative role for people with poor eyesight.

Achievement System
Many video game companies release new versions of their games annually, while most computer games are subscription based. This means it is beneficial for the companies to keep their customers entertained and playing their games. These companies implement certain strategies to ensure this happens.

Video and computer games give the players give the players a sense of achievement to get them hooked. This is analogous to the scenario of a lab hamster on a wheel. As long as the hamster continues to turn the wheel, he will be given food pellets. If the hamster stops running the pellets will be withheld. Most games implement this strategy by having short levels so it is quick and easy to reach some sense of achievement. The players usually get an adrenaline rush while playing, which is sometimes associated with the music in certain games during play. However, as the players' achievements begin to build up their brains release small amounts of dopamine. To use a human example it is like convincing someone to eat a bag of chips. It is easy to convince the person to eat just one, however once they have the taste in their mouths it usually is not long before the entire bag is gone. Another aspect is that in most games the levels or space between checkpoints slowly get longer and more difficult the more that someone plays, making it harder to reach the same sense of achievement. This directly mimics the effect of most drugs, where as the chronic users must take more of a drug to reach the same high as their bodies get used to the effects.

Another way achievement systems are used to get people to keep playing video or computer games is by implementing a play it or lose it strategy. This brings us back to the hamster on the wheel analogy. Now if the hamster stops turning the wheel it will be punished by the lab working, who will administer electric shocks to the rodent until he begins running again. This is similar to many games in which the player will lose achievements the longer they refrain from playing. Most players do not want to lose what they have work so hard to gain.

Escapism
Escapism is a habitual diversion of the mind to purely imaginative activity or entertainment as an escape from reality or routine. Similarly, in psychology, escapism is generally defined as a desire or behavior to ignore, evade, or avoid reality. It has become the continually growing cause of video game addiction and obsessive online behavior. As a high-octane version of virtual escapism, video games create digital reality and offer teens a way to retreat from their everyday problems. With a console and system where a player can control the fate of a surrogate character through their actions in a fantastical world, the sense of control can be intoxicating, and people gradually accept these terminals as hubs for alternate reality. Escapism may also promoted by the sense of achievement. In a video game, challenges can be overcome easily and results usually reach quickly. These outcomes are opposed to real life and bring great satisfaction. Players therefore tend to view the relaxed and satisfying virtual world as their reality.

Social Connection
Social connection is also a reason that makes video games attractive to players. It enables players to communicate and cooperate with other players in the online video games. For offline games, social connections can be established by meeting other players in real life or discussing game contents with friends. From the perspective of the game designers, social connection is a very important element in the design. Game design usually involves the MDA framework, which stands for Mechanics, Dynamics, and Aesthetics. Social connection is formally defined as an aesthetics named fellowship, which is aimed at bringing multiple players to work as a group and achieve a common goal. For players, such connection can make positive impact by encouraging conversations and interactions but may also cause game addiction if goes too far. As game becomes a resolution to loneliness and isolation, virtual friends and environment tend to be more valuable and addictive than the real life.

History
Virtual Reality (VR) started being developed in the early 20th century, but it’s use was limited to primarily medical and military training until the 1990s, when the first VR games came out and more affordable VR headsets were available. By the mid 2010s, VR became an established field and hundreds of companies started actively working on VR technologies. With VR headsets being even more affordable, gaming companies started making VR games due to increased demand.

VRChat
VRChat, released in 2014 for Oculus Rift, and later, in 2017, for Steam, became very popular and highlighted new issues relative to game addictions. The game involves a multiplayer world, where a user can create a character and interact with other players within the game. A unique feature of VRChat is that any kind of character or world can be created, since the models can be designed outside of the game using software such as Unity.

Problems with VR
Due to increased immersion, it can be more difficult for users to take a break from the game. In addition, VR games such as VRChat can be used as a form of escapism, especially for those with limited social interactions. In-game interactions can substitute real life interactions, which can increase the time users spend playing the game. Although VR is a relatively new field, as VR technology becomes more sophisticated and more realistic, people with little satisfaction in their lives may choose to spend the majority of their time in VR, ignoring their real problems. In the future of VR, it may be possible to create a perfect kind of world for each person, which can cause severe addiction to VR to escape reality.

Potential Benefits
General use of VR technologies can potentially bring benefits to individual users. For those that are struggling to exercise or find motivation, physical VR games can simulate a workout in a different, more enjoyable way. It can also be used to practice specific skills, such as driving, flying a plane, etc. It can also be used to overcome personal fears by engaging in such situations within VR. Also, it can be used to connect with family or friends virtually, and be able to “physically” see someone while being far away. Finally, it can also be used to explore different places around the world without the need to travel.

Prevention and Correctional Programs
Over the past ten years, a few treatment centers specializing in game addiction have emerged in Amsterdam, China, and the USA. These facilities, typically residential, tend to utitlize family therapy and social skills training. While some clinics focus on abstinence, others believe that gaming behavior can be relearned. Cognitive Behaviour Therapy has been used to help gamers recognize the emotional reasons behind their excessive game playing, and motivational interviewing techniques have been incorporated to aid in establishing positive goals and time management skills. In 2009, Cosette Rae and Hilary Cash founded one of America's first residential rehab centers in Fall City, Washington. For $15,500 guests can spend 45 days cut off from computers and integrated into a real family's home with chores and daily therapy sessions. The program, called ReStart, also requires mandatory downtime sessions to help game addiction victims learn to deal with boredom in order to prevent relapse in the future.

There are also many online forums for those affected by gaming addiction. One example, Elizabeth Wooley’s self-help site, Online Gamers Anonymous, provides message boards, online meeting places, and a 12 step recovery plan. These online websites attest to the serious withdrawal symptoms that game addicts in detox can experience including anxiety, irritability, restlessness, depression, disrupted sleep pattern, and violent mood swings.

New technologies have been developed offering parents more control over limiting excessive video game playing in children. In 2004, a universal video game controller that's operating time could be limited by parents was patented. The following year, parents could purchase the token-operated PlayLimit to indirectly control the operation time of televisions and video game consoles in their own homes. According to the website, this technology is beneficial because it forces kids to play a more active role in managing their playing time. By requiring children to put tokens in for 15 minutes of play time, this reward based system might actually perpetuate the problem it attempts to solve.

China
Though as one of the world's largest gaming markets, China has repeatedly criticized video games for negatively affecting young people. The government has announced in 2019 to impose a curfew on online gaming for minors. Gamers under 18 will be banned from playing online between 22:00 and 08:00. They will also be restricted to 90 minutes of gaming on weekdays and three hours on weekends and holidays. The new guidelines will apply universally to all online gaming platforms operating in China and will address enforcement concerns directly. This is part of China's latest move to curb video game addiction but not the only move. Earlier in 2018, the government announced the establishment of a gaming regulator to limit the number of new online games, restrict paying time and develop an age-restriction system. Significant supports to such regulations include the concerns about near-sightedness in children.

South Korea
In 2011, the government of South Korea passed the Shutdown Law after a published report indicated teenage students were spending more than 2 hours every day after school playing video games. The law went into effect on November 20, and required online games to block children aged under 16 from playing during a late-night six-hour block. In 2013, a debate entitled “Video Games: Addiction or Art?” was hosted by the Democratic Party of Korea to discuss the merits of video games and focused on the impending Game Addiction Law, which would effectively regulate video games in a similar method to drugs and alcohol in legal context.

United States
In October of 2009, a man named Craig Smallwood filed a lawsuit against NcSoft Corporation for emotional distress and misrepresentation. He claimed to have played Lineage II for 20,000 hours between 2004 and 2009, and the company failed to warn him about the potentially destructive addictive nature of their game Lineage II. He alleged he would not have begun playing if he was aware "that he would become addicted to the game.” In April 2010, the charges of misrepresentation and intentional infliction of emotional were dismissed by Judge Kay. However, after that the company still faces counts of defamation and negligent infliction of emotional distress.