When Gaming Gets Out of Control
This month, we're getting to grips with gaming disorder. With the NHS's first specialist clinic to help people with gaming disorder now open, we're asking what's it like to be addicted to gaming, and what can be done to help?
In this episode
01:33 - Removing half a brain
Removing half a brain
Helen Keyes, ARU; Duncan Astle, Cambridge University
Katie Haylor chats to Anglia Ruskin University perceptual psychologist Helen Keyes and Cambridge University cognitive neuroscientist Duncan Astle about the neuroscience news stories that have caught their eyes this month. First up - what happens when you lose half of your brain? It sounds extreme but in severe, rare cases of epilepsy, surgeons may peform a hemispherectomy. And it turns out that the brain can adapt remarkably well to this dramatic event. Duncan told Katie more...
Duncan - So you could remove the part of the brain that you think is the origin of the seizure. Or you could chop connections that you think spread the seizure. So for example there are two halves of the brain and they're connected by a thick bundle of fibers. And sometimes you can chop the bundle of fibers to stop the spread.
Or in very extreme cases, you can perform what's called a hemispherectomy, and that's where surgeons will remove half of the brain to stop the epilepsy. And that's how you can lose half of your brain following epilepsy.
So what this paper’s doing is following six individuals who had a hemispherectomy when they were children. It’s typically done in early childhood so usually before around the age 3. These people are then seen decades later when they're adults and it might surprise you to find out that actually the cognitive and behavioural and motor outcomes are remarkably good. Normally if you met someone you probably wouldn't know that they had had it done. And of course that raises the amazing question of if they've lost half of their brain, how is it they're able to function so well? And that's what's being explored in this paper.
And so they took the individuals and they put them in a functional magnetic resonance imaging scanner or an fMRI scanner. And what that is able to do is look at which parts of the brain are active and use that to identify different brain networks. And the first finding they had is, relative to individuals who have not had this procedure, those who have, their brain networks in the preserved half of the brain are remarkably similar. So all the classic brain networks that we would see in a typical participant are present in these people who have lost half of their brain.
Katie - And just for clarity, are brain networks regions of the brain that talk to each other in particular ways?
Duncan - That's exactly what they are. So they’re different regions of the brain often in different spatial locations within the brain, but we know they're working together because they become active together.
Katie - So the half of the brain that is in use is compensating in some way then. What's going on?
Duncan - Well that's one possible explanation. And so what the authors of this study were able to show, is that whilst the networks themselves are all much the same as they would be in somebody who's not lost half of their brain, the exchange of activity or the exchange of information between these networks is significantly greater in people who have lost half of their brain. I.e. the crosstalk between the networks seems to be enhanced in people who have lost half their brain.
And so one account of this is that what the subjects gradually develop the ability to do over many years, indeed decades, is to bring online extra networks for a particular task that wouldn't typically be used for that task in someone who hasn't lost half their brain. But because they need the additional resource or the additional activity that's recruited in order to support the performance of the network that's really being tapped by the task. So gradually over time as the brain develops, the connections between the networks become stronger.
Katie - That's amazing. Does anybody have this surgery later as an adult, when they've done some of their development? Do you think that would make a difference.
Duncan - I think it would make a difference. And so it can be done in later childhood and adolescence, that is exceptionally rare. And the reason that it's done much more rarely in those ages is because it's seen as much more drastic, and the advantage of doing it early is that it gives time for the rest of the brain to compensate.
Such is the high degree of plasticity, it means that gradually over time, functions tend to be maintained and typical development can happen. Whereas if you wait until the brain is more fully formed and then you remove half of it then the hurdle is that much greater.
Katie - Being able to survive and thrive with half a brain seems amazing to me. As a brain expert, is it surprising to you?
Duncan - Yeah it's really surprising. So we spend all our time thinking about what little pockets of neurons here, there and everywhere are doing, what their special contribution is. And then to find a group of people who have lost half of their neurons in one fell swoop is remarkable. And the very fact that they can function and live normal, happy, highly productive lives is an amazing testament to just how adaptive and plastic the human brain is.
And indeed in these cases, even though there's only six of them, what the authors are able to show is that in those people where the degree of crosstalk between the networks is greatest, their outcomes seem to be the best, which supports the idea that essentially what the brain is doing is compensating for the fact that the other half of the brain is missing.
Have you ever let something slip that, on reflection, you wish you’d kept to yourself? This month, Helen Keyes has been looking at a paper explaining why it is that we might sometimes say things we later regret...
Helen - There's lots of situations in our lives where it's wise for us to conceal information about ourselves, and we don't want to disclose personal details. So think about job interviews, or important work meetings, just situations where you might think “I'll hold back this piece of information about myself”. And the paper shows that, ironically, it's at these particular moments where we're most invested and most highly alert and trying to perform at our best, when we're most likely to over disclose or make these mistakes where we might end up being judged negatively by other people.
Katie - And by alertness, what exactly do you mean?
Helen - Well the authors call it affective arousal and when we say arousal in this context we don't mean sexual arousal, we simply mean a kind of state of readiness. Your systems are really “Go!”, you're in that high alert, very awake place.
When we talk about this affective arousal we can mean cognitively being in a heightened cognitive arousal situation or emotionally aroused or even just physiological like going for a run, that type of arousal, when your systems are really on.
Katie - Okay so it's a heightened state of whatever it may be.
Helen - That's it. So you can imagine that there's lots of situations where in exactly those moments we don't want to disclose personal information. The idea behind this is that it requires quite a lot of effort to suppress information about ourselves. If you think about the famous example of “don't think about a white bear”, and then of course it's all that you can think about, when we're going into these important, heightened situations we often “think don't say this, don't say this, don't tell this piece of information about yourself”, you're concentrating quite hard on not talking about a particular personal piece of information, that it's quite there at the front of your mind.
And unfortunately when we're in this state of heightened arousal - whether it's emotional or cognitive or physiological - the information that's most available to us is that information that's right there at the front of our mind. And that's unfortunately why it tends to come out more in these situations.
Katie - That seems really cruel because the sort of situations you could be talking about like a job interview, a date, those kinds of important events, right?
Helen - Absolutely and they actually looked at it in the context of dating. One of the studies that the authors did was they asked participants to set up a dating profile and they had to list three things about themselves on this dating profile. Now half of these participants were told that immediately following this they were going to have to do a very complicated math challenge, which had that cognitive heightened arousal, people were a bit nervous about that. And the control group weren't told this at all. And then they independently rated the things that people said about themselves in the dating profile. And they found that people who were in this heightened arousal state, so people who were thought they had to do a maths task, self disclosed a lot more and they self disclosed intimate details, potentially embarrassing details, and even incriminating details about themselves.
They also then looked at it in terms of things that you wouldn't want to tell people because you might feel a bit ashamed. So they looked at online trolling, so behaviours some of us sometimes engage in, where the whole nature of it is that it's anonymous and you would be embarrassed to tell people that you've said this in an online forum. And here they showed half of their participants affective pictures. (And by that I mean just highly emotional pictures. They could be pictures and invoking disgust or even positive emotions, just highly affective pictures). And they found that the people in the group who'd seen the affective pictures disclosed more severe transgressions of online trolling, things that they really might regret talking about it at a later date.
Then the authors wondered whether it'd be true about physiological arousal, so they ran a third study where they asked everybody to think about the most embarrassing moment, those moments that really intrude in your thoughts in the middle of the night, that still wake you up with embarrassment.Then they asked half of their participants to go jogging, and half of them didn't go jogging. When the participants came back to the lab, those that had been jogging were much more willing to then disclose to the researcher what that most embarrassing moment was.
Katie - Wow okay so you've got a trio of studies - you're making somebody physiologically aroused, going for a run; you're making someone cognitively aroused by making them to a maths problem; and then emotionally aroused by showing them these affective images. It sounds pretty scary to be honest! Do you have any advice? Would it be that perhaps trying to dampen your state of arousal by being more calm might help in these situations?
Helen - The first thing to remember is that self disclosure isn't always a negative thing. It can be really important for us in terms of bonding and building social relationships with other people that we do self disclose these embarrassing moments or these transgressions. And it can also be important your own psychological well-being and health that we feel we can talk quite openly and disclose these things. So it's not a pure negative.
But we obviously know there are situations where you have to self regulate such as a high level meeting, a job interview, or like you mentioned a potential date. So there are times when things we say could damage our reputation or even cause offence to other people. In those situations it would be best to engage in quite relaxing activities beforehand, whether that's deep breathing or meditation or whatever it is that's gonna get you into that calm state of mind. But on a more practical level, you can do simple things like avoiding drinking caffeine immediately before you're going to enter into one of these situations where you need to self regulate.
Addicted to gaming
John, former gamer
John (not his real name) talks about gaming addiction. This was originally aired on the Naked Gaming podcast, in July 2019...
John - Hi my name is John and I've been in recovery from gaming addiction since 2014. I started gaming as a youngster, I was born in the mid 70s and you know when I was young it was mainly computers, Commodore 64, and I really liked it and never saw it as a problem. I think as it escalated as I got older and it was when the internet really became quite a big thing, back on dial up and then on broadband connections.
People noticed it was a problem way before I ever noticed it was an issue. My partner used to approach me quite a lot when I'd come home from work and try and stop me playing the computer, trying to get me to spend time with her and my children. Even though it was consuming my life outside of work, I never really saw it as an issue. I used to love playing a lot of first person shooter games, used to really get immersed in the online world. I think as I started to get older, it ended up costing me quite a lot of things, I was unemployed for quite a long time. When I was unemployed I just sunk into the world even more. It becomes sort of an escape from me, just a way to get away from the way I was feeling. And just to deal with everyday life.
I finally got help in 2014, and it was going into a treatment centre in Essex called Sanctuary Lodge, where, back when I went in, it was quite new. And when I went in I learned that really the gaming was an escape for me, it became a way to actually deal with everyday life. And it was myself I needed a look at, really what was going on inside that was causing the problems, you know, why I was needing to escape from the real world and into this world and I'd done a lot of really good work on myself. I learned how to live, you know, being me and to deal with everyday life without having to use it as an escape.
Since leaving the treatment centre I've had varying degrees of actually staying completely abstinent. I don't believe for someone like myself that there is any moderating it. For me, it would come under the same category as any other type of addiction. I have, over the last four or four and a half years or so, convinced myself on a couple of occasions that my time away from it would qualify me, you know, to be able to do it normally. So I've downloaded games, I have a PC at home. At one time I even got a console as well. And what I noticed was in a day or so was, I'm back to doing what I was doing and it consuming my life again. So I now have to look at it as complete abstinence from gaming which can be difficult for me, because I always enjoyed the competition. I almost looked at it as like a sport.
Now, I've heard people say that, you know, gaming should be banned, even Prince Harry said that Fortnite should be banned. I don't ever think that you can ban a game as a whole. I don't think really it's the game that's the problem. I think if you really look at it, it's more of a social aspect now, the way people live, the way people are brought up, constantly seeking escapism in social media, gaming, in general. And I think that there are things that needs to be addressed and not actually banned in some game.
18:43 - Gaming disorder is a mental health condition
Gaming disorder is a mental health condition
Louise Theodosiou, Royal College of Psychiatrists
In 2018, the World Health Organisation included gaming disorder in the 11th revision of the International Classification of Diseases. To find out what this inclusion means, and how defining gaming disorder as a mental health condition could help problem gamers, The Naked Scientists show spoke to consultant child and adolescent psychiatrist Louise Theodosiou from the Royal College of Psychiatrists. This is part of an interview originally aired on The Naked Scientists show in July 2018...
Louise - What gaming disorder from the World Health Organisation talks about, is about people who have a pattern of gaming where they’re losing control of their gaming. They’re giving increased priority to gaming and carrying on despite negative consequences. And one of the things that WHO emphasises is the fact that, actually, there’s an impact on people’s lives. Kids are struggling with their education, they’re not maintaining enough sleep, there is an impact on how healthy they are and their social interactions in the real world are suffering. So it’s about that impact on life and about the fact that this is carrying on for over 12 months, so we’re looking to see that impact and that narrowing of behaviour.
One of the brilliant things about the announcement is that we’re now starting to have a clear definition that will mean that we can focus our research more clearly. The American diagnostic system has had a slightly different definition, but a very similar condition: internet gaming, as an area of concern for about five years. And if we look at the literature we can see that there has been an increasing body of literature developing for almost 20 years now. So that situation of problematic internet use, and problematic gaming use has been around and is gathering momentum and I think that’s what makes this announcement so important.
20:29 - Treating gaming disorder
Treating gaming disorder
Henrietta Bowden-Jones, National Centre for Behavioural Addictions
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.