Friday, 30 March 2018

ABC's of the DSM-V: Internet Gaming Disorder - Really?


Internet Gaming Disorder. Yes, you read correct, Internet Gaming Disorder (IGD, with “Disorder” being hesitant) is being considered for further research in the DSM-V which means it may be a new entry in the DSM-VI. I have a lot of opinions on this (if you can’t tell already), but I will save them for the end after laying down the facts and rationale for claiming this as a disorder.

What is IGD? Well, basically put it’s exactly what you think. It’s an addiction to online games which is so severe that it results in negative consequences, one of which is limiting real-life experiences (Ko, 2014). Much of the literature so far looks at massive multiplayer online role-playing games (MMORPGs – think World of Warcraft, Runescape, Elder Scrolls Online, etc.) as being the main type of games causing IGD, possibly due to their need for high amounts of social interaction.


First, lets look at the cognitive implications of IGD and some underlying neurobiology to get a better understanding. A study looking at cognitive processes in IGD found that there are increased reward sensations during winning or pleasurable experiences, whilst having impairments in executive control capacities which in turn can lead to poor control over those desires, resulting in urges and cravings, leading to excessive use. The reward seeking behaviours can be reinforced through short term positive experiences (for instance winning a dungeon in WoW or levelling up in Skyrim), whilst ignoring the long term implications of such actions (Dong & Potenza, 2015). Neurobiologically, fMRI studies found an increase in activation in the medial frontal gyrus (MFG), left cingulate gyrus (LCG) and left medial temporal gyrus (LMTG) (Meng et al., 2014), areas that are also highly active in drug addiction studies (Goldstein & Volkow, 2012) and nicotine addiction (Hong et al., 2009). So, cognitively and neurobiologically, there are no really distinct differences between IGD and any other form of addiction – the basis of addiction is located predominantly in the prefrontal cortex, which has been found in IGD as well.


On the other hand, the criteria for problematic video game use doesn’t include some of the things that would be included when assessing other addictions such as physical symptoms of withdrawal and tolerance as they are things that can’t actually be measured in this regard. The symptoms related to IGD are more socialeconomical and psychological than physical, making it distinctly different from substance use disorders in that respect. However, the same could be said for other addictions that don’t require things to be ingested that can result in the physical symptoms – gambling, sex or shopping, and yet they are still recognised and classified as their own disorders because of the negative implications.

Don't even try to tell me blood elves aren't adorable, look at that face! (Yes, I still play. Yes this is my own screenshot). Credit: Blizzard Ent.
Then again, lets look at this from a different perspective for a second – MMORPG’s are being blamed for this predominantly due to the social interactions and exploration aspects, as achievement and escapes from reality are considered lesser motivations (Fuser et al., 2013). I remember MMORPG’s being a huge thing when I was growing up, everyone was addicted to either WoW or Runescape – YouTube is full of videos of what happens when you cancel your kids WoW subscription or when people can’t log on – and I’d like to think we turned out relatively normal with no issues with addiction. When you’re about 13 and you hate school and just about everything (basically become an angsty teenager), then WoW and Runscape and every other MMORPG were the answer, and it was considered standard. Parents were concerned (rightfully so) that their kids were spending time in their rooms all the time, not coming down for meals or playing out with their friends (even though they were; just online), but it didn’t stop us turning out okay, with jobs, kids, healthy social lives; all without medical interventions, isn’t it just a case of growing up and taking responsibility?

I wont lie, this set up is gorgeous. I never knew I wanted a vertical monitor till now. Credit: r/battlestations
Yes and no. We grew up in a time when MMORPGs weren’t as refined as they are today, and studies have found that optimal experiences motivate people to continue playing the games – optimal experiences being effective interaction with the system, and with new technology that allows real-time interactions and incredible graphics, it’s no wonder people are so immersed in these games. Gaming resolutions are incredible compared to the 10-pixel characters we had back in the day, and gaming environments and technology has become so advanced that said environments are amazingly realistic. The way the virtual worlds are also designed allows players to express themselves in ways that they may not be able to do in real life – this idea hasn’t changed from when we were kids, but the technology has improved making those expressions much more vibrant and beautiful to look at, you can change your species, gender, sexuality, appearance, you can give yourself the ability to wield swords or conjure magic spells, the fantasy element is appealing and today's technology has made it so addictions are unsurprising.

Credit: Blizzard Ent.
But does that mean it should be considered a disorder? Children and adolescents are still under the care of their guardians and don’t have the luxury of making choices for themselves and are still looked after, so things such as bathing, going outside and going to school can be forced to do so. Adults however, have that luxury – If you want to eat ice cream for breakfast and eat cake in the bathtub, literally no one is stopping you from doing so. You can drink wine at 7am and walk around your house in nothing but socks if you want, but being a double-edged sword, that also means you can spend your money on a copy of Elder Scrolls Online, stock up on Mountain Dew and Pepsi, buy a family pack of Crème eggs and fill your fridge with Sainsburys own microwaveable meals. You can quit your job, not shower for 23 days and instead of paying your bills, you spend your savings on buying online add-ons for no real gain other than knowing that Sarahi from Denmark thinks your cool and has accepted your party invitation. See the problem? Is it not just a case of being a responsible adult, understanding that the bills won’t pay themselves and those sores on your bum are from sitting on your PC chair all day and won’t go away if you stick a pillow on it for extra cushioning? What is the difference between being lazy and irresponsible and having an addiction?

These are actual photos of battle stations taken from 4chan a few years back. This is why the stereotype of neckbeards living in their mothers basement, playing MMORPGs exists. See the rest here.
But that begs the question, are we not stigmatizing something that is no different to gambling when it comes down to the root of it? You could say the same thing about gambling addiction – take some responsibility and use your money on things that are important, but that compulsive need to gamble is there and it is recognised as a real addiction, so how is that different to IGD? Well, looking at the bare bones of it – it’s not, they are both addictions and a result of compulsion and urges, but because of societal views on gaming, there is a stigma attached which makes it seem implausible. Gambling is a form of gaming, and IGD is just a different form isn’t it? Gambling can also be done online and yet it is still legitimate, so why are we sceptical about IGD?

Credit: r/battlestations
I think there are cultural differences as well – in the west you don’t see very severe cases of IGD, there is a tendency towards what would be considered irresponsible behaviour rather than extremes that may illustrate the severity of IGD, whereas in the East it’s a different story altogether. South Korea is known to be one of the biggest exports of online games, and China and Japan have reported on the internet gaming addictions for over a decade; highlighting the use of adult diapers because gamers would rather sit in their own urine and faeces (essentially) than lose a minute of gaming. It has been considered a clinical disorder since 2007 due to the amount of problems China has faced with internet gaming, something they refer to as “electric Heroin” (Alice Vincent, 2014). The difference in culture may play a role in our views towards IGD as well as the difference in technology: China, Japan and South Korea are known to have far more advanced technology than us here in the west, so it makes sense that the technological differences that are making IGD a recognised disorder have been picked up over there much sooner.


When I first started writing this I thought it was ridiculous, and a silly thing to call IGD a disorder, but looking at it, it makes me question if it’s truly different from other addictions like gambling and that my attitude to it was due to ignorance. A case of “we went through it and we were okay” mentality is no different to the mentality the older generation put forward of “we went through the war but we’re not depressed and all doped up on medication – this generation is weak.” Time has an effect on how things are perceived, and because our generation managed to successfully survive our gaming era without detrimental effects, doesn’t mean that this generation will have the same experience – technology, cultures, ideas are changing constantly and that’s why it makes sense that IGD would be considered a plausible disorder. The neurobiology is all there, the sociopsychological effects are all there, the high sales in adult diapers are there, so maybe it does make sense for IGD to be considered for further research for the DSM-VI. What do you think?

References 
Dong, G., & Potenza, M. N. (2014). A cognitive-behavioral model of Internet gaming disorder: theoretical underpinnings and clinical implications. Journal of psychiatric research58, 7-11.
Fuster, H., Carbonell, X., Chamarro, A., & Oberst, U. (2013). Interaction with the game and motivation among players of massively multiplayer online role-playing games. The Spanish journal of psychology16.
Goldstein, R. Z., & Volkow, N. D. (2011). Dysfunction of the prefrontal cortex in addiction: neuroimaging findings and clinical implications. Nature reviews neuroscience12(11), 652.
Hong, L. E., Gu, H., Yang, Y., Ross, T. J., Salmeron, B. J., Buchholz, B., ... & Stein, E. A. (2009). Association of nicotine addiction and nicotine's actions with separate cingulate cortex functional circuits. Archives of general psychiatry66(4), 431-441. 
Ko, C. H. (2014). Internet gaming disorder. Current Addiction Reports1(3), 177-185. 
Meng, Y., Deng, W., Wang, H., Guo, W., & Li, T. (2015). The prefrontal dysfunction in individuals with Internet gaming disorder: a metaanalysis of functional magnetic resonance imaging studies. Addiction biology20(4), 799-808. 
Vincent, A. (2014, Jan 23). China’s internet rehabs highlighted by Web Junkie documentary. The Telegraph. Retrieved from https://www.telegraph.co.uk/culture/film/film-news/10591750/Chinas-internet-rehabs-highlighted-by-Web-Junkie-documentary.html 

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