Treating gaming disorder
What's going on in the brains of those with gaming disorder? How does this compare to someone with, say, a substance addiction? And what can be done to help? Katie Haylor spoke to Henrietta Bowden-Jones, director of the National Centre for Gaming Disorders...
Henrietta: Addiction is a really big word to use and I'm always very keen that it is not misused. I spent much of my life treating heroin addiction, cocaine addiction, alcohol dependency, before moving into behavioural addictions. I know what harm is from addiction, but I will say, you know, having spent 12 years treating gambling disorder at the National Problem Gambling Clinic, that you know, people are losing their family homes, their marriages break down, they lose contact with their children. Behavioural addictions can be just as harmful, but just manifest themselves in a different way.
Katie: Is it the gamer here, or is it the game that is the problem when it comes to gaming disorder?
Henrietta: I'm glad you asked about which bit is which. Because when we look at harm and compulsive behaviours, we always have an interaction of different factors. So we've got the individual with his or her own vulnerabilities - and we know that people with high levels of impulsivity, for example, are more likely to be vulnerable to becoming addicted to behaviours or things. So if we look at the individual's vulnerabilities, we can then look at the environment and say, well, we know that people experiencing difficulties that might lead them to wish to escape from their environment, may also be turning to things to support them. And therefore what we come across sometimes in gaming disorder patients who are quite young, is very complex home environments where there may be reasons for these children to try and spend more time online, or bullying at school, or even just very difficult interactions. So you've got the individual and you've got the environment.
Henrietta: And a third vital factor here is the structural element of the game itself. And so there will be games that are more compulsive than others. We know that the gaming industry spends a lot of money in employing psychologists to work out what is more likely to be appealing to young minds or to minds in general. And if the games have enough features that will retain you online - because psychologically you feel compelled to stay - this, accompanied by an environment that may not be so easy, a hostile environment, and indeed the individual traits, may create a situation that is at least temporarily one very likely to induce too many hours spent gaming.
Henrietta: Of course, when we look at gaming disorder, we don't just say, "Oh, you've gamed for 10 hours, you've got a gaming disorder". Normally this kind of pathological behaviour has to last for many months. Normally it's a year when you look back and you say, well, these behaviours have lasted a year or more, clearly are chronic behaviours now that need to be addressed and the individual needs help. And I say this because young people - who are sensation seeking, they are more impulsive than adults - may have moments when they do game a lot or they may have moments when they watch a lot of Netflix, but I would really not wish to judge or label behaviours that are not harmful and that may indeed exhibit intensity for a short period of time.
Katie: Are there any other elements of a game that might make it more risky and some games are a lot more cooperative than others and you are interacting with people somewhere in the world? Does that factor?
Henrietta: Some games are more likely to keep people playing for longer for a few reasons. One of them is very linked to a sense of achievement and fulfillment. And what I see is sometimes young people who suddenly feel validated by the game because of its recognition, whether it's within a team or individual, they get a status within the game, that somehow they do not have in real life. Other people who are very competitive, transfer their competitiveness from a world of sport, where they're doing physical activity and team games, onto a world of online competitiveness as part of teams.
Henrietta: But there are also the team aspects that are linked to time zones and playing with strangers and not wanting to let them down. So I hear this quite a lot and there are moments when someone may decide to stop playing because their mother is banging on the bedroom door saying "time for bed", but they know that if they stop at that particular moment, their team mates will be one man down and this will impact on the success of the team. And this has been reported to me by players as being a feature that often prevents them from just letting go when they should, the obligation towards team members, but I do feel that the sense of recognition is even more so something that has an impact, particularly if you think that there are a significant number of people exhibiting gaming disorder difficulties, who may also have other issues linked to mental health, that sometimes are about not finding it so easy to engage with others, particularly as part of a group.
Katie: You mentioned impulsivity, but does the evidence indicate that susceptible people break down by any other characteristic? Is age a factor or gender or anything like that?
Henrietta: From what we know at the moment, the majority of people with gaming disorders presenting to treatment centers across the world are male. And I'm talking gaming disorder here remember, I'm not speaking generally about internet compulsion such as social media compulsion, etc, but we are purely talking about gaming. And it does appear to be a predominantly male presentation. Now as with all other diseases, whoever presents for treatment, whatever that ratio is, does not necessarily reflect as an indication of what is actually happening globally. It could be that only men feel that they can come forward for treatment and that there are just as many women not coming forward and when we look at ages, we have roughly 12 - 22, 23 as the majority of presentations.
Henrietta: Having said this, in the service that I run in London, the National Centre for Gaming Disorders, there are people who've called me up who are in their forties who are delighted there is free evidence-based treatment now available, because they've suffered from this illness for a long, long time. So you may have the onset in your 20s but you may, without treating it, continue to experience the symptoms.
Katie: How much do we know about what's happening in the brain of someone with gaming disorder? And how does that compare to an addiction like substance abuse?
Henrietta: The findings, when we look at gaming disorder, neuro-biologically speaking, have some commonalities with other addictions. For example, findings that show impaired decision making ability, impaired emotional regulation, impaired executive functioning, essentially a decision making and also a deficiency in the ventral striatum reward system essentially, and that is something that is not unique to gamers.
Henrietta: The thing that is interesting now to think about is whether some of the gamers with disorders that we see now, might in the past have ended up because of their vulnerabilities actually turning to drugs and or alcohol instead.
Katie: Can gamers get withdrawal?
Henrietta: Gamers can get withdrawals, in a way, just like any other addiction. In this case though, just as it is in problem gambling, the withdrawals are psychological rather than the physical ones. However, when I talk about people becoming violent towards their parents, that is a manifestation of the abrupt cessation of the game and the resulting anger, frustration, irritability and anxiety that can follow.
Katie: Tell me about treatments then. What treatments are available and how much do we know about whether they work?
Henrietta: Treatment in this country has been recently funded by the NHS. It was only a matter of a few months ago when we received the go ahead. So the National Centre for Gaming Disorders is now open and we take people, treat them for free and use evidence based treatments, which at the moment are really cognitive behavioural therapy, roughly eight sessions. Now there are some case studies showing that naltrexone can work, just as it can work in other addictions, but we don't have any large randomized control studies in the UK looking at naltrexone and gaming disorder. So at the moment what we use is cognitive behavioural therapy.
Katie: From your perspective as an expert in gaming disorder, how do you feel about currently how games are developed?
Henrietta: I know very little about how games are developed. However, what I do feel from talking to my patients is things like self exclusion need to be addressed urgently. And if an industry is asked to self-regulate, these are the kinds of things they won't do or won't do quickly and well, because having people who are compulsively using their products is very helpful to their businesses.
Henrietta: So one of the most urgent things, I think, for this country is to have a regulatory body for the gaming industry that decides what needs to be done. And this can be done by the whole group of gaming industry companies. I give you an example. Someone wanted to self-exclude from a game, he was told it would take 30 days. Well we know that's not correct, but this is actually what that particular game, in an era of technology, has asked my patient to do, and it would take 30 days to remove his name.
Katie: A lot of people game without a problem, don't they? A lot of people game as a hobby and enjoy themselves and don't see any significant problems.
Henrietta: The majority of the population in terms of young people is gaming. And in fact we know that many women are gaming, adults are gaming, gaming has become something that is part of our lives. And in fact gaming has been used by colleagues of mine in psychiatry and technology fields to try and improve people's mental health. So although a small percentage of people has enormous issues with gaming, there are also many benefits to gaming. And certainly, just because I am running a national clinic for gaming disorders, this does not preclude me from, although I'm not a gamer myself, appreciating the pleasure that people have from gaming.