The Hidden World of Video Gaming Addiction

Photo by Sean Do on Unsplash

In 2020, as in-person activities were shuttered for months, our online lives took on much more significance and that included increased exposure to video games. Although there has been much handwringing about screen time and the addictive dangers of video games, hard facts have been difficult for both parents and clinicians to come by.

I primarily treat opioid use disorder, most often people with a history of heroin use, so compared to the dangers of a fatal overdose on fentanyl, the risks of being exposed to Animal Crossing can seem almost laughable at times. But just because the dangers are more subtle, does not mean they are not present. For one thing, for each hour per day of video games played, there is a 2-fold increase in the risk of obesity (Lu 2013). It’s not even just gaming that takes up long hours, there is also now the phenomenon of video game streaming (i.e., watching other people play the games) on platforms like Discord and Twitch. This is not a small trend either, as Twitch was acquired by Amazon for over 900 million dollars in 2014.

I personally have 3 children, and our family rules around screen time and free-to-play games on the iPad were dramatically relaxed over the last year. It is understandable to me why video games are an enjoyable way to spend time. Video games offer concrete goals in a modern world, in which many of our school and workdays have been reduced to screen-time without any fun side quests or augmented graphics. Who doesn’t want to tune out and save the world? Especially when the alternative is attending yet another day of back-to-back Zoom work meetings or a day of “Google class.”

In May 2019, the World Health Organization formally recognized Internet Gaming Disorder as a diagnosis to be included in the ICD-11 (International Classification of Diseases)While there is a myriad of games currently available, it is primarily the massive multiplayer role-playing games (such as World of Warcraft) and the free-to-play games (such as Fortnite) that are most reinforcing for people. There are a variety of cognitive strategies that act to make gameplay more addictive, but one particularly pernicious example has been the lure of buying blind loot boxes. In the case of Fortnite, Epic games ended this blind “loot box” structure of purchasing in 2019 and a settlement was offered after it was acknowledged that this was a harmful paradigm (www.epiclootboxsettlement.com). For the World of Warcraft, it is common for players to form guilds, requiring large blocks of time to commit to being present with others counting on you. In the case of the free-to-play games, they are easy to download and start on the ubiquitous smart phones and tablets that surround us, and often suggested by online ads and algorithms. But they are much easier to start than stop and as the saying goes, “free to play, pay to win.”

In May 2019, the World Health Organization formally recognized Internet Gaming Disorder as a diagnosis to be included in the ICD-11 (International Classification of Diseases). The diagnosis hinges on whether game playing is impairing everyday life activities and relationships and not a specific number of hours of being played. This is akin to diagnosis of substance use disorders, which is not made via urine test or a specific pattern of use, but by documenting that use of the substance is impairing one’s health and ability to function. From available evidence, addiction to video games remains very much the exception rather than the rule. In 2017 an article per the American Journal of Psychiatric estimated that 0.3% to 1% of the population may qualify for a diagnosis of internet gaming disorder (Przybylski, AK).

Video gaming, while often portrayed in television shows and movies as the province of young loners, is actually something that 50% of adults in the US enjoy (Pew 2015). Video gaming and screen use is also something that parents worry about intensely. In a recent Pew research study, 66% percent of parents said that parenting now is harder than it was 20 years ago and many of the reasons cited relate to recent changes in technology (26%), social media (21%), and device distractions (6%). In my experience, nothing gets a discussion hopping with other parents like talking about the “right” parameters to guide technology use, such as when it is best to buy a phone, which video games to allow and for how long.

Video games are also played by both men and women in close to equal numbers. Despite this, the gender representations portrayed on the cover of these games seem to beam in from decades past, with bosoms heaving and muscles bulging on idealized body types. Even the culture of many video games has become somewhat entwined with a certain brand of toxic masculinity. Consider #GamerGate, a controversy from 2014 when Zoe Quinn was accused of trading intimacy for a positive review of her game by her ex-boyfriend and subsequently harassed to the point of having to move. Because of this focus, the diagnosis can be overlooked in girls, who may be assumed of not playing because of gender.

For many enthusiastic gamers without a formal problem, once they decide to stop it can be as easy as doing so. And again, to be clear, most of those who play video games, do not have a clinical issue. But for those with an internet gaming disorder, stopping is difficult even as friendships fray and bank accounts whither. Per a recent review by Dr. Zajac in 2020, some forms of therapy and the medication bupropion showed preliminary evidence of being effective for treatment. However, more research is needed to clarify best practices. Certainly, this is an easier problem to address in middle school and high school, when parents have more control over a child’s finances and boundaries. One of the most important interventions to do at home is to work on setting clear limits with gaming, and to work with your child on finding replacement activities for the games that help fulfill the need being met. For example sudoku puzzles, if the goal is cognitive challenge, or a sports team, if the goal is building a friendship group. A good guideline for parents is to limit gaming to 1 hour on weekdays and 2 hours on weekends. It is also important to come up with a strategy for holidays and days off school ahead of time, so that fights don’t begin over it.

In Minnesota, we now offer treatment at Sage Prairie Clinic, where the goal is to first perform a thorough evaluation to rule out other underlying issues, such as ADHD or major depressive disorder which might be leading to the behavior. We are also starting a group for parents, to support each other in setting and maintaining boundaries.


Dr. Emily Brunner is a Distinguished Fellow of the American Society of Addiction Medicine (ASAM) and immediate past president of the ASAM Minnesota chapter. She is board-certified in both family medicine and addiction medicine. She has an interest in internet gaming disorder and is working to establish the first medical treatment program for internet gaming disorder in Minnesota.

Last Updated on March 11, 2021

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