Shooting rampages increase the risk for research into violent video games

“This just in:  Apparently, there is more than one connection between all of the previous rampage killers in the US. Not only did they all play violent video games at some point, they all watched TV news AND had access to guns.”

While the above discussion is obviously fake, according to footage in the Colbert Report of September 18, 2013 one TV journalist has suggested that we could perhaps prevent future firearm violence by keeping a register of video game purchases.

xkcd on reverse causation

 How did the discussion of what is behind these horrible shooting rampages end up being about video games?  Simple:  As a society, we want to understand what caused this so we can prevent it in the future. 

As another video game researcher  puts it,

“We don't have a lot of control over many of the factors that can contribute to violent behavior. But we have some control over violent video games. We can make it more difficult to get access to them. We can strengthen our laws against teens acquiring these games.”

Hold the phone; is he talking about video games or guns?  Let’s rewind and make a substitution:

“We don't have a lot of control over many of the factors that can contribute to violent behavior. But we have some control over guns. We can make it more difficult to get access to them. We can strengthen our laws against teens acquiring these guns.”

Everyone knows that you can’t have firearm violence without firearms. The cool thing about public health is that

• there is (ideally) a scientific approach to understanding the processes that lead to outcomes, and
• there is also (ideally) an approach to deciding what is important to study and regulate. One of the key questions to ask about a potential research subject is:  how much of an effect would being able to change this potential cause have on my outcome of interest?

So,  keeping in mind the important limitations of public health research I discussed in my earlier posts, let’s talk about just a couple of the reasons why keeping video games on the research and policy agenda is a waste of time and resources:

1.       Guns are clearly responsible for firearm violence and can be regulated, even in other countries that have traditionally refused limitations. (Take a look at the Emmy Award winning segment of The Daily Show, where comedian John Oliver discusses the complete absence of shooting rampages in Australia after gun control with former Australian prime minister John Howard.)

2.       Scientists have been studying the effects of video games for decades, and there is still no consistent relationship between violent video games and real-world violent acts. In fact, one recent well-controlled study showed no long-term ties between violent video games (when measured by themselves) and real-world seriously violent acts when other factors like substance use or living in a violent community are taken into account (p.932; remember the previous discussion about statistical levels and coincidence). It did show, however, that visiting websites that “feature real people fighting, shooting or killing” is associated with real-world violent acts. I’ll get back to more of the methodological problems in future blog posts, but feel free to read anything by Chris Ferguson or Craig Anderson for more information and contrasting views on the research to date.

3.       Video games and other media exposures are not proximal causes, only distal links on a chain of other causes (see an excellent article by Krieger for a thorough discussion).   And contrary to the implication above, we actually do have some control over the more proximal causes (e.g, guns).

4.       Multifinality and equifinality. These limitations lead to different ways of viewing how likely or probable something is (risk). And this little bit is going to be our public health lesson for the day.

Multifinality:  People can have the same risk factors (potential causes of a bad event) but different outcomes.

Aaron Alexis and Adam Lanza both played video games (like the majority of people in the US). They also (probably) watched TV, were male, and walked upright.

The above helps us understand questions about risk that are vital to approaching things from a public health perspective. For the terms below, I paraphrase a discussion by Swanson, substituting “violent video games” for “mentally ill”.

Absolute risk:  The vast majority of people who play violent video games are not violent.

Relative risk:  People who play violent video games are no more likely to commit violent crimes than those who do not play violent video games.  (However, people who have access to guns are more likely to shoot people.)

And then there’s equifinality:  A variety of risk factors can lead to the same outcome.

Aaron Alexis was a former Naval reservist with a criminal history of violence and current money troubles. He was also an African-American practicing Buddhist who had sought help from the Veterans Administration for paranoia and hearing voices.  He had a legally-purchased shotgun.

Adam Lanza was a well-off young white man who lived an isolated life after years of being bullied in high school. He also had access to a stockpile of guns with over 1600 rounds of ammunition.

Attributable risk:  Violence is a societal problem caused largely by things other than violent video games (ready availability of guns, for example).

The stories we hear about rampages are just that, stories. They may serve the purpose of trying to make sense of something horrible, but it’s time to move on from investing more time and money into studying video games and consider what could provide “more bang for the buck”.  Some of the key assumptions of the Code of Ethics for Public Health say that a base for action should improve health through seeking and acting on knowledge, and that there is a moral obligation to share what is known.

Yes, there are barriers to getting the knowledge out there (e.g., publication bias, selective outcomes reporting). Yes, it is hard to take action on things that we know (e.g., gun control politics). But given that toddlers with guns seem to have killed more Americans this year here in the US than terrorists did, it’s time to take advantage of this window of opportunity and enact real change in the clearest cause of firearm violence—access to guns.

reprinted from mcoldercarras.com, 9/2013

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.

Theorycrafting and the phenomenology of psychiatric disorder

In Part 1, we explored how criteria of Internet Gaming Disorder such as preoccupation might not apply to some of the people who end up in front of a clinician who has to decide whether they have a psychiatric disorder. In our example, a student in his first year of high school is playing video games a lot, his grades are suffering, and he is brought in by parents who worry that he is addicted to video games. We talked about how theorycrafting might be mistaken for the addiction criterion of

Theorycrafting post from the TeamLiquid website, 

preoccupation, which is related to the concept of a single-minded focus of thoughts and behavior on obtaining the next “fix”. The fact that theorycrafting by definition involves putting a lot of thought and effort into optimizing your gaming experience implies that preoccupation as a criterion is not going to be useful for predicting who may have problems related to gaming—it lacks specificity. When criteria for psychiatric disorders lack specificity, it’s harder to separate normal from abnormal.


Separating normal from abnormal is hard for most psychiatric disorders, because unlike medical conditions like diabetes, high blood pressure or asthma; psychiatric disorders lack objective findings. There are no lab tests to tell whether a person has a normal or abnormal pattern of thoughts, feelings and behaviors; these conditions are usually diagnosed by a clinician. Which means that understanding the phenomenology of disorder—separating the normal from abnormal by fully appreciating the experiences of people who have serious and uncontrollable abnormal thoughts, feelings and behaviors and distinguishing those from those who do not— is vital.

It’s hard to tell exactly how new disorders are developed for the Diagnostic and Statistical Manual, however, because the process for establishing new disorders is not systematic or transparent. In the case of IGD, a group of clinicians and researchers debated for years about whether a disorder related to excessive Internet use (or online game use, or video game use) could even exist and what type of disorder it would most closely resemble, reviewing evidence from multiple countries over many years. Several months before the DSM 5 came out, pages related to this discussion were removed from the APA website; at that time the disorder was to be called Internet Use Disorder.¹ When the DSM 5 came out, the proposed new disorder was called “Internet Gaming Disorder” instead and listed as a disorder in the Emerging Measures section.²  Although consensus was lacking as to the strength of evidence to include it as a disorder proper, the inclusion of IGD in DSM 5 in any capacity prompted the initiation of many new research projects.

While the DSM 5 proposed clinical criteria for diagnosing this potential disorder, figuring out how to test for IGD in the general population was another challenge. The first attempt to do so was led by part of the working group that established the DSM diagnosis, who published a paper entitled, “An international consensus for assessing internet gaming disorder using the new DSM-5 approach.”³ However, the consensus process used to choose both group members and items for a scale was not clear. The following year a paper was published by a group of 28 game researchers, led by one of the most-published researchers on behavioral addictions, that questioned the validity of these criteria and of the consensus development process in general.⁴   That process inspired us, FROGHR, to consider how researchers could develop a formal consensus development process to work quickly and effectively toward establishing the phenomenology of problems related to gaming.

One thing was clear: such a process would have to include the voices of gamers and developers in order to establish a sense of what was normal and abnormal about gaming.


1.     American Psychiatric Association. (2012, May 1). APA DSM-5 | Internet use disorder. Retrieved September 29, 2012, from www.dsm5.org/proposedrevision/Pages/proposedrevision.aspx?rid=573. Note: Link now redirects to login.
2. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders: DSM-5. Washington, D.C: American Psychiatric Association.

3. Petry, N. M., Rehbein, F., Gentile, D. A., Lemmens, J. S., Rumpf, H.-J., Mößle, T., … O’Brien, C. P. (2014). An international consensus for assessing internet gaming disorder using the new DSM-5 approach. Addiction (Abingdon, England). http://doi.org/10.1111/add.12457

4. Griffiths, M. D., van Rooij, A. J., Kardefelt-Winther, D., Starcevic, V., Király, O., Pallesen, S., … Demetrovics, Z. (2016). Working towards an international consensus on criteria for assessing internet gaming disorder: a critical commentary on Petry et al. (2014). Addiction (Abingdon, England), 111(1), 167–175. http://doi.org/10.1111/add.13057

Image: http://www.teamliquid.net/forum/diablo-3/394773-marquise-ruby-vs-emerald-theorycrafting?page=4

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.