Where are the gamers?

Previously, we talked about how the criteria for the proposed psychiatric disorder of Internet gaming disorder may not reflect the experience of engaged gamers, who might have several of the criteria without having the “clinically significant impairment or distress” required for a diagnosis. These criteria and the proposed questions for scales used to test for IGD in the general population were decided on through consensus and voting, but it wasn’t clear how this was done—it wasn’t transparent.² Researchers do agree on the need to move forward with research in a consistent way across disciplines to develop agreement on topics related to video gaming, including IGD.³ This agreement extends across fields, thankfully—a recent conference of video game researchers also agreed on the importance of standardized approaches to research studies.⁴

One thing is missing, though—an understanding of the gamer culture. In psychiatry, the boundaries between normal and abnormal are fuzzy and influenced by social and cultural factors.⁵ What is surprising, though, is that it doesn’t look like the important research that describes gamers’ experiences with gaming, excessive gaming and feelings of game addiction was used to figure out what game addiction is. There is a wealth of research into the experiences of normal and abnormal gaming in the fields of media studies, communication studies, psychology or anthropology. Outside of public health and psychiatry, the idea of a gaming culture is well-known.⁶ So where are gamers in this discussion?

In medical and public health research, scientists are learning about the importance of including patients or end-users of interventions in the design of research studies. Including these stakeholders increases the value of research by making it more likely that the things that are studied are important to everyone, and that the results that scientists come up with will lead to successful ways to treat or prevent health problems.⁷

1.         American Psychiatric Association:  Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington, VA: American Psychiatric Association; 2013. dsm.psychiatryonline.org.

2.         Griffiths MD, van Rooij AJ, Kardefelt-Winther D, et al. Working towards an international consensus on criteria for assessing internet gaming disorder: a critical commentary on Petry et al. (2014). Addict Abingdon Engl. 2016;111(1):167-175. doi:10.1111/add.13057.

3.         Petry NM, Rehbein F, Gentile DA, et al. Moving internet gaming disorder forward: A reply. Addict Abingdon Engl. 2014;109(9):1412-1413. doi:10.1111/add.12653.

4.         All A, Birk M, Bourgonjon J, et al. Research ideas: Digital Games Research Workshop. December 2015.

5.         Kendler KS. The nature of psychiatric disorders. World Psychiatry Off J World Psychiatr Assoc WPA. 2016;15(1):5-12. doi:10.1002/wps.20292.

6.         Grooten J, Kowert R. Going  Beyond the  Game :  Development of  Gamer  Identities  Within Societal  Discourse and  Virtual  Spaces. Load J Can Game Stud Assoc. 2015;9(14):70-87.

7.         Khodyakov D, Savitsky TD, Dalal S. Collaborative learning framework for online stakeholder engagement. Health Expect Int J Public Particip Health Care Health Policy. August 2015. doi:10.1111/hex.12383.

Why do scientists need to hear from gamers and developers when designing research?

Image: www.paulsizer.com

• If we don’t, we might not understand how gamers think or the gaming culture.

• When scientists don’t understand culture, we find it hard to separate normal from abnormal and science gets messy.

• Other researchers use that science to make decisions about things related to public health (like game addiction perhaps being a mental disorder).

• Based on an incomplete understanding of gaming and the science that follows, money is spent on research and new policies are created that affect gamers.

Internet Gaming Disorder criteria, preoccupation, and theorycrafting.

Theorycrafting is a term used to describe the analysis of game mechanics by gamers who want to do better in the game. This can be as simple as deciding which piece of equipment would be a better choice as a quest reward or as complicated as spending hours researching how to optimize armor, attacks, and strategy.

Internet Gaming Disorder is the name of a new condition proposed by the American Psychiatric Association (APA) as a potential new disorder. It's not considered a formal disorder yet, but  the APA thinks that it is worthy of future research. Here’s part of the description:

…preoccupation some people develop with certain aspects of the Internet, particularly online games. The “gamers” play compulsively, to the exclusion of other interests, and their persistent and recurrent online activity results in clinically significant impairment or distress. People with this condition endanger their academic or job functioning because of the amount of time they spend playing. They experience symptoms of withdrawal when pulled away from gaming.

It’s important to understand that the APA is requiring clinically significant impairment or distress. They’re not suggesting that people who have the symptoms have the disorder—the symptoms have to be impairing (interfere with life in a “clinically significant” way) or distressing (make the gamer feel bad, again in a “clinically significant” way). How the clinical significance part is judged is up to the clinician. The idea is that games “hijack” the brain’s pleasure centers the way drugs and alcohol do and lead to a behavioral addiction that is much like a substance addiction.

Also note that, in addition to that requirement, a number of criteria have to be met. These criteria are chosen from a group and you only have to have five out of the nine:

1. Preoccupation with Internet games. (The individual thinks about previous gaming activity or anticipates playing the next game; Internet gaming becomes the dominant activity in daily life).
• Note: This disorder is distinct from Internet gambling, which is included under gambling disorder.
2. Withdrawal symptoms when Internet gaming is taken away. (These symptoms are typically described as irritability, anxiety, or sadness, but there are no physical signs of pharmacological withdrawal.)
3. Tolerance—the need to spend increasing amounts of time engaged in Internet games.
4. Unsuccessful attempts to control the participation in Internet games.
5. Loss of interests in previous hobbies and entertainment as a result of, and with the exception of, Internet games.
6. Continued excessive use of Internet games despite knowledge of psychosocial problems.
7. Has deceived family members, therapists, or others regarding the amount of Internet gaming.
8. Use of Internet games to escape or relieve a negative mood (e.g., feelings of helplessness, guilt, anxiety).
9. Has jeopardized or lost a significant relationship, job, or educational or career opportunity because of participation in Internet games.

Now imagine that you’re a psychiatrist who doesn’t know a lot about video games. You see a young person in your office who just started high school and was brought in by his parents because he seems addicted to playing online games and his grades are falling. He plays a few hours a day and all day on the weekends. When he’s not playing, he’s frequently watching videos about his games, looking on websites about games, or talking to his friends about gaming. His parents have told him not to play after school until his homework is done, and he’s agreed, but they find that he hasn’t been truthful with them and still plays after school. Does this patient have a mental disorder? If yes, is it because his brain has been hijacked by video games and he has developed something akin to an addiction? Well, let’s see if he satisfies the official criteria:

1. Preoccupation-the kid spends a lot of time theorycrafting so he can do well in the game. He would rather think about this than do homework.
2. Withdrawal symptoms when Internet gaming is taken away. The kid gets mad when his parents make him stop playing.
3. Tolerance—the need to spend increasing amounts of time engaged in Internet games. The kid is now part of a high-powered raiding guild.
4. Unsuccessful attempts to control the participation in Internet games. The kid doesn’t want to control his participation; he’s fine with the amount of time he spends gaming.
5. Loss of interests in previous hobbies and entertainment as a result of, and with the exception of, Internet games. The kid would prefer to game rather than watching TV, going to the movies or participating in sports.
6. Continued excessive use of Internet games despite knowledge of psychosocial problems. The kid doesn’t really care that his parents or mad or that his grades are falling.
7. Has deceived family members, therapists, or others regarding the amount of Internet gaming. He has definitely lied to his parents about his amount of gaming.
8. Use of Internet games to escape or relieve a negative mood (e.g., feelings of helplessness, guilt, anxiety). He plays to make himself feel better sometimes, but also plays for a bunch of other reasons like boredom or having committed to guild members to play.
9. Has jeopardized or lost a significant relationship, job, or educational or career opportunity because of participation in Internet games. This one is really hard to judge. What constitutes “a significant educational opportunity”? Is it being held back a year—failing all your classes? Or dropping from advanced to average-level classes?

Think on this a bit.  We’ll wrap up this post here and revisit it in part 2.

Resources:
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders: DSM-5. Washington, D.C: American Psychiatric Association.