Mind games

The act of playing games, through consoles and increasingly through the internet, has a long history but little research has looked at the psychological impact of gaming. As researchers continue to explore this area, both positive and negative outcomes of gaming are emerging, including disordered gaming behaviour. The Gaming Research Group at The Cairnmillar Institute, in collaboration with a number of international research centres, is investigating gaming behaviour with an aim to develop an evidence-based treatment program for Internet Gaming Disorder (IGD).

Gaming evolved much more radically after the introduction of online video games. The first generation of games were revolutionary at the time, but relatively simple by today’s standards. Modern online video games come in a variety of formats and involve complex reward mechanisms, richly detailed virtual environments and connect players in real time around the world. These elements, along with the unprecedented expansion of internet use worldwide, have contributed to a gigantic increase in the number of ‘gamers’. Considering Australia in particular, almost two-thirds of the population have been reported as playing games. Interestingly, 78 per cent of Australian online gamers are young adults or adults who predominantly play online to positively moderate their feelings and relieve boredom.

“International literature has adopted a balanced position between the potentially positive and negative effects of internet gaming”

Evolution of games

Developments in the gaming industry have over time targeted higher levels of engagement and satisfaction through the enhancement of three main features: online socialisation, systems of progressively increasing challenges and rewards, and the creation of an online ‘persona’ that represents the player in the virtual world. Traditionally, games were either single player or had limited multiplayer versions with gamers required to convene together to play. However, the internet has provided an avenue for gamers to play concurrently while being distant and without requiring any past offline relationship. In that context, progress in contemporary multiplayer online games frequently necessitates ‘group’ action which triggers and reinforces online socialisation.

In addition, game task achievement and progression are designed in such a way that dynamically matches the gradually developing skills of the gamer with higher levels of game-related challenges and rewards, cultivating engagement and commitment (an online flow state – a mental state in which the person is totally immersed and focused on the game). Players become engaged with internet games through often being invited to focus on choosing, customising and generating a fictional online character (i.e., the avatar), which represents the gamer in the virtual world and ‘matures’ in a way that parallels real life. Not surprisingly, the emotional attachment formed between the players and their avatars has been shown to increase their game immersion and subsequently their gaming time.

Sharing online worlds

At this point it should be noted that internet games appeal to a diverse population of users due to the variety of genres, which may include racing, fighting, shooting, and role-playing games, with different genres comprising different skill sets, levels of time engagement, as well as various motivational aspects. Within the broader range of genres, Massively Multiplayer Online games (MMOs) have attracted the highest interest worldwide, both from a game-development and a mental health aspect due to their increasing popularity. These MMOs are co-played online with others (on a massively multiplayer basis) and involve competitive and cooperative goals that are both challenging and immersive. Interestingly, the term ‘MMOs’ is often used interchangeably with that of ‘Massively Multiplayer Online Role-Playing Games’ (MMORPGs) to describe games that also require the player to develop a virtual-game identity.

For example, in the popular game World of Warcraft, a player first picks a side they wish to represent, either the ‘Alliance’ or the ‘Horde’. Each side has five unique races that a player can choose from, each with their own identity and idiosyncrasies. From there, the player can modify the appearance and gender of his or her avatar. Upon completing their avatar selection, they are given a rich cinematic backstory, detailing the struggles of their avatar’s race, and thus infusing the player with a sense of attachment with their character; “it now falls to you to defend the kingdom and uphold the honour of humanity”. Subsequently, the player may become immersed in this world within minutes of starting the game. Besides this, the gamer needs to develop the character over time through enhancing the character’s equipment and customising its features (i.e. a set of skills, equipment, possessions).

The popularity and growth of MMOs in particular would not have been possible without significant strides in internet technology. Not only are players capable of connecting globally, but the internet may also facilitate various non-critical aspects of gaming, such as seeking game-related information, buying and selling game possessions, as well as constantly communicating fluctuating exchange rates between game and real currencies.

The upsides and downsides

In light of these developments, the international literature has adopted a balanced position between the potentially positive and negative effects of internet gaming, associating the potential impact with the intensity of gaming involvement. Specifically, gaming, depending on the game genre, was identified to have possible positive benefits on a player’s cognition, motivation, emotion, and socialisation. For instance, players who frequently play shooter games show greater cognitive flexibility than non-frequent players (Colzato, van Leeuwen, van den Wildenberg, & Hommel, 2010). In another study, Russoniello, Brien and Parks (2009), using electroencephalography monitoring revealed that casual games or puzzle games, such as Bejeweled 2, could elevate mood. On the other end of the spectrum, there is evidence indicating the associations of excessive gaming with significant potential negative consequences including poor emotional and physical health, lower mood and poorer academic achievement (Kuss & Griffiths, 2012).

Defining the disorder

Given the significance of the negative consequences derived from excessive gaming, internet gaming disorder (IGD) emerged in the fifth edition of the Diagnostic Statistical Manual of Mental Disorders as a condition needing further research.

The inclusion of IGD in the DSM-5 not only contributed to the standardisation of the many nomenclatures that were previously used interchangeably (e.g., ‘gaming addiction’ or ‘problematic gaming’), but also the standardisation of assessment tools.

Prevalence at home and abroad

An Australian study by Thomas and Martin (2010) revealed that five per cent of their roughly 1300 participants met the criteria for computer game addiction. It should be noted, however, that their study was isolated to a Tasmanian sample, so these rates may not be representative of the national prevalence. Moreover, the study was conducted before the DSM-5, therefore these rates are not reflective of the current conceptualisation and assessment of the disorder. Thus, there is a void of understanding of the disorder in Australia. Considering international research, a recent epidemiological study using the DSM-5 criteria for IGD and an assessment tool developed in line with the updated diagnostic criteria, 2.5 per cent of a representative sample of Slovenian eighth graders met five or more of the conditions (Pontes, Macur, & Griffiths, 2016). These figures increased to 3.1 per cent among the gamer-only sample. Similar rates were found in a representative sample of German ninth-graders (Rehbeing, Kliem, Baier, Mßle, & Petry, 2015) however, in a representative study of MMORPG players, Yee (2006) found that 50 per cent of the 3000 sample self-reported to be addicted to World of Warcraft. Although more up-to-date research methodology is needed to establish the national prevalence of IGD, there is a general consensus that IGD behaviours tend to be misreported (if not under-reported), while their prevalence and incidence is expected to increase.

Between adaptive and maladaptive

The upcoming 11th edition of the International Classification of Diseases (ICD-11) by the World Health Organization has been suggested to also include the classification of ‘Gaming Disorder’ (GD). A number of scholars claim that this may have detrimental effects, in particular, stigmatising those who play video games in a healthy manner and are advocating for the removal of GD from the ICD-11, even though they recognise that significant consequences can arise from playing games excessively. In line with this debate, an overarching question appears. That is, where does one draw the line between adaptive and maladaptive Internet gaming behaviours?

Griffiths (2010) argued that individual information must be considered before determining the extent to which gaming becomes an addiction and illustrates this in two case studies. In one case, ‘Dave’ argued that the 10 to 14 hours a day playing World of Warcraft had a positive impact on his life and he did not consider himself addicted, despite playing excessively. He reported not having any significant distress or impact to his daily life, hence, this would not meet the DSM-5 criteria for IGD. In fact, his engagement with the game enabled the opportunity for him to make meaningful relationships online when his offline social networks dissipated. Not only did he report building his self-esteem by playing World of Warcraft, but he was able to start a relationship with a woman he met in the game.

In the second case study ‘Jeremy’ experienced detrimental consequences from his excessive gaming. This included withdrawal symptoms, escapism, loss of job, and relationship issues with his wife and children. Although both Dave and Jeremy reported playing more than 10 hours a day, the two had antagonistic experiences and consequences due to their idiosyncratic individual contexts. The line between adaptive and maladaptive gaming behaviours is hence not as clear and simplistic as suggested by the diagnostic criteria in the DSM-5. These case studies demonstrate the importance of delving beyond the examination of IGD symptoms.

Investigating therapies

The use of assessment tools further blurs the distinction between adaptive and maladaptive behaviour. This is not to say that assessment tools are redundant, but rather that their results require cautious interpretation. Before the introduction of IGD a literature review revealed 18 uniquely different instruments to assess problematic, pathological or addictive gaming (King, Haagsma, Delfabbro, Gradisar, & Griffiths, 2011). Since DSM-5 however, new or updated IGD assessment tools have converged around the nine diagnostic criteria. However, instruments that have been shown to be validated and reliable (e.g., IGDS9-SF) do not present as equally applicable across different cultural groups.

As with assessment tools and processes, treatment options for IGD appear to be in development. Adopting a more biological perspective, some scholars have examined pharmacological interventions such as selective serotonin-reuptake inhibitors and norepinephrine-dopamine reuptake inhibitors, both of which have shown significant improvements. Nevertheless, medications may not always be the preferred treatment option for IGD, especially due to their potential side effects for developing individuals, as well as the risk of transforming a form of behavioural addictive behaviour (such as IGD) into a substance-related addiction (Haylett, Stephenson & Lefever, 2004). A comparative analysis of psychological and pharmacological treatments on internet abuse, in general, showed no significant differences (Winkler, Dorsing, Rief, Shen, & Glombiewski, 2013).

Developments in the field

As with other forms of behavioural addictions, several psychological approaches seem promising. For example, both acceptance and commitment therapy and cognitive behavioural therapy (CBT) have demonstrated significant reductions in problematic internet use (e.g., viewing pornography, use of sexual chat rooms and gaming; Twohig & Crosby, 2010; Young, 2007). Others have taken a multimodal treatment approach to assist with alleviating symptoms of internet addiction. For instance, a US program, reSTART, provides a range of approaches such as interpersonal group psychotherapy, mindfulness-based relapse prevention, motivational interview, animal-assisted therapy, and psychoeducation to address IGD and other forms of problematic technology use. The program takes on the form of an in-patient retreat lasting anywhere between eight weeks to 12 months for adolescents and adults. The programs 2015 treatment outcome results reported that over 93 per cent of participants’ family members considered them unable to control internet use before entering the program. Post-treatment (1-4 years), this figure dropped to 28-33 per cent. Overall though, there is much room for improvement and refinement to develop robust findings regarding treatment (for more detail, see King & Delfabbro, 2014).

Recognising this need, The Cairnmillar Institute is initiating a drive to develop and research an effective, sustainable and evidence-based treatment program for Australians exhibiting IGD related symptoms and behaviours. This effort is progressively defined and informed by the findings of the Gaming Research Group maintained in the Institute, as well as the collaborations with the International Gaming Research Centre in the United Kingdom, the Korean Advanced Institute of Science and Technology and the Palo-Alto University in the United States.

The first author can be contacted at [email protected]