Dependent variables: a brief look at online gaming addictions

Over the last 15 years, research into various online addictions has greatly increased. Prior to the 2013 publication of the American Psychiatric Association’s fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), there had been some debate as to whether ‘Internet addiction’ should be introduced into the text as a separate disorder. Alongside this, there has been debate as to whether those in the online addiction field should be researching generalized Internet use and/or the potentially addictive activities that can be engaged on the Internet (e.g. gambling, video gaming, sex, shopping, etc.).

It should also be noted that given the lack of consensus as to whether video game addiction exists and/or whether the term ‘addiction’ is the most appropriate to use, some researchers have instead used terminology such as ‘excessive’ or ‘problematic’ to denote the harmful use of video games. Terminology for what appears to be for the same disorder and/or its consequences include problem video game playing, problematic online game use, video game addiction, online gaming addiction, Internet gaming addiction, and compulsive Internet use.

Following these debates, the Substance Use Disorder Work Group (SUDWG) recommended that the DSM-5 include a sub-type of problematic Internet use (i.e. Internet gaming disorder (IGD)) in Section 3 (‘Emerging Measures and Models’) as an area that needed future research before being included in future editions of the DSM. According to Dr. Nancy Petry and Dr. Charles O’Brien, IGD will not be included as a separate mental disorder until the

• (i) defining features of IGD have been identified,
• (ii) reliability and validity of specific IGD criteria have been obtained cross-culturally,
• (iii) prevalence rates have been determined in representative epidemiological samples across the world, and
• (iv) etiology and associated biological features have been evaluated.

Although there is now a rapidly growing literature on pathological video gaming, one of the key reasons that Internet gaming disorder was not included in the main text of the DSM-5 was that the Substance Use Disorder Work Group concluded that no standard diagnostic criteria were used to assess gaming addiction across these studies. In 2013, some of my colleagues and I published a paper in Clinical Psychology Review examining all instruments assessing problematic, pathological, and/or addictive gaming. We reported that 18 different screening instruments had been developed, and that these had been used in 63 quantitative studies comprising 58,415 participants. The prevalence rates for problematic gaming were highly variable depending on age (e.g. children, adolescents, young adults, older adults) and sample (e.g. college students, Internet users, gamers, etc.). Most studies’ prevalence rates of problematic gaming ranged between 1% and 10%, but higher figures have been reported (particularly amongst self-selected samples of video gamers). In our review, we also identified both strengths and weaknesses of these instruments.

The main strengths of the instrumentation included the:

• (i) the brevity and ease of scoring,
• (ii) excellent psychometric properties such as convergent validity and internal consistency, and
• (iii) robust data that will aid the development of standardized norms for adolescent populations.

However, the main weaknesses identified in the instrumentation included:

• (i) core addiction indicators being inconsistent across studies,
• (ii) a general lack of any temporal dimension,
• (iii) inconsistent cut-off scores relating to clinical status,
• (iv) poor and/or inadequate inter-rater reliability and predictive validity, and
• (v) inconsistent and/or dimensionality.

It has also been noted by many researchers (including me) that the criteria for Internet gaming disorder assessment tools are theoretically based on a variety of different potentially problematic activities including substance use disorders, pathological gambling, and/or other behavioral addiction criteria. There are also issues surrounding the settings in which diagnostic screens are used, as those used in clinical practice settings may require a different emphasis that those used in epidemiological, experimental, and neurobiological research settings.

Video gaming that is problematic, pathological, and/or addictive lacks a widely accepted definition. Some researchers in the field consider video games as the starting point for examining the characteristics of this specific disorder, while others consider the Internet as the main platform that unites different addictive Internet activities, including online games. My colleagues and I have begun to make an effort to integrate both approaches, i.e., classifying online gaming addiction as a sub-type of video game addiction but acknowledging that some situational and structural characteristics of the Internet may facilitate addictive tendencies (e.g. accessibility, anonymity, affordability, disinhibition, etc.).

Throughout my career I have argued that although all addictions have particular and idiosyncratic characteristics, they share more commonalities than differences (i.e. salience, mood modification, tolerance, withdrawal symptoms, conflict, and relapse), and likely reflects a common etiology of addictive behavior. When I started research Internet addiction in the mid-1990s, I came to the view that there is a fundamental difference between addiction to the Internet, and addictions on the Internet. However, many online games (such as Massively Multiplayer Online Role Playing Games) differ from traditional stand-alone video games as there are social and/or role-playing dimension that allow interaction with other gamers.

Irrespective of approach or model, the components and dimensions that comprise online gaming addiction outlined above are very similar to the Internet gaming disorder criteria in Section 3 of the DSM-5. For instance, my six addiction components directly map onto the nine proposed criteria for IGD (of which five or more need to be endorsed and resulting in clinically significant impairment). More specifically:

1. preoccupation with Internet games [salience];
2. withdrawal symptoms when Internet gaming is taken away [withdrawal];
3. the need to spend increasing amounts of time engaged in Internet gaming [tolerance],
4. unsuccessful attempts to control participation in Internet gaming [relapse/loss of control];
5. loss of interest in hobbies and entertainment as a result of, and with the exception of, Internet gaming [conflict];
6. continued excessive use of Internet games despite knowledge of psychosocial problems [conflict];
7. deception of family members, therapists, or others regarding the amount of Internet gaming [conflict];
8. use of the Internet gaming to escape or relieve a negative mood [mood modification]; and
9. loss of a significant relationship, job, or educational or career opportunity because of participation in Internet games [conflict].

The fact that Internet gaming disorder was included in Section 3 of the DSM-5 appears to have been well received by researchers and clinicians in the gaming addiction field (and by those individuals that have sought treatment for such disorders and had their experiences psychiatrically validated and feel less stigmatized). However, for IGD to be included in the section on ‘Substance-Related and Addictive Disorders’ along with ‘Gambling Disorder’, the gaming addiction field must unite and start using the same assessment measures so that comparisons can be made across different demographic groups and different cultures.

For epidemiological purposes, my research colleagues and I have asserted that the most appropriate measures in assessing problematic online use (including Internet gaming) should meet six requirements. Such an instrument should have:

• (i) brevity (to make surveys as short as possible and help overcome question fatigue);
• (ii) comprehensiveness (to examine all core aspects of problematic gaming as possible);
• (iii) reliability and validity across age groups (e.g. adolescents vs. adults);
• (iv) reliability and validity across data collection methods (e.g. online, face-to-face interview, paper-and-pencil);
• (v) cross-cultural reliability and validity; and
• (vi) clinical validation.

We also reached the conclusion that an ideal assessment instrument should serve as the basis for defining adequate cut-off scores in terms of both specificity and sensitivity.

The good news is that research in the gaming addiction field does appear to be reaching an emerging consensus. There have also been over 20 studies using neuroimaging techniques (such as functional magnetic resonance imaging) indicating that generalized Internet addiction and online gaming addiction share neurobiological similarities with more traditional addictions. However, it is critical that a unified approach to assessment of Internet gaming disorder is urgently needed as this is the only way that there will be a strong empirical and scientific basis for IGD to be included in the next DSM.