You’ve probably read about internet gaming disorder (IGD), and even heard about a man in Taiwan who died while continuously playing online games for 3 straight days (see http://cnn.it/2EJetN3). There’s still debate over how to classify and treat pathological gaming: Is it its own disorder, or just a symptom of another underlying mental illness?

Currently, the DSM-5 only lists IGD as a “disease to watch.” Current criteria described by the DSM-5 definition include the inability to reduce playing, intense preoccupation, unsuccessful attempts to quit video games, loss of interest in previously enjoyed activities, and deceiving family members about the amount of time spent on internet gaming.

Whether or not it deserves status as its own disorder, you may have patients whose lives are negatively affected by excessive gaming. So far, there’s not a robust amount of research on the effectiveness of evidence-based treatments, but the following is a primer that will provide you with some initial information.

What is internet gaming?
Gaming online includes “massively ­multiplayer online role-playing games” (MMORPGs) and “multi-user domain” games (MUDs). MMORPGs are networks of people, all interacting to play a game to achieve goals, accomplish missions, and reach high scores in a fantasy world. MUDs combine elements of role-playing games, fighting, and killing in a social chat channel with limited graphics. Some individuals may create online personas or “avatars,” altering their identities and pretending to be someone other than themselves.

According to a study by Netherlands online game manufacturer Spil Games, on an annual basis more than 700 million people worldwide participate in some form of internet gaming; of that number, 54% are male and 46% are female.

Addictive nature of gaming
Online games are potentially addictive because game developers—by rewarding players for performing increasingly challenging tasks—employ behavioral conditioning principles. Game environments also encourage people to form social obligations with other players (Turel O et al, PLoS One 2016;11:e0154764:0154764). For some users, these games serve various functional needs, including escapism and socialization (Yee N, Cyberpsychol Behav 2006;9:772–775).

Gamers can use the virtual fantasy world to connect with others via the internet. Doing so can be a substitution for real-life connection, which some people are unable to otherwise achieve. Gamers may develop an emotional attachment to online friends and the activities they partake in. They enjoy socializing and exchanging ideas using the games as a platform. Because some games require many players to log on simultaneously and play together for long periods of time, players may feel an obligation and loyalty to other players. This sense of relationship may further an individual’s justification of excessive gaming, even while progressively ignoring school, work, social, and other obligations.

Males are at higher risk for IGD, and research is showing that IGD’s characteristics and consequences can be like other forms of behavioral addiction (Milani L et al, Int J Ment Health Addiction 2017; 10.1007/s11469-017-9750-2). For example, excessive gaming may lead to not eating or sleeping while dealing with the current tasks or missions of the game.

Known comorbidities
Excessive gaming is thought to be a gradually progressive behavior, with a chronic deteriorating course over time. Functional connectivity (FC) neuroimaging studies in gaming disorder patients show evidence of overlap with internet gambling disorder. For example, one study compared 15 patients with IGD, 14 patients with internet gambling disorder, and 15 healthy controls. The results of an MRI scanner demonstrated an increase in FC within the reward circuitry of those with IGD and internet gambling disorder, while the healthy control group showed no change (Bae S et al, J Behav Addict 2017;6(4):505–515).

Like other behavioral disorders, addicted gamers have a higher association with other co-occurring disorders. Depression is a common comorbidity of IGD, with reportedly higher intensity of anger, guilt, and anxiety. Problem gamers also suffer from severe sleep deprivation. Gamers who use nicotine, alcohol, and marijuana may be twice as likely to be problem gamers, and a strong association has been shown between problematic gaming and decreased well-being and poor school performance (Van Rooij et al, J Behav Addict 2014;3(3):157–165).

Possible withdrawal symptoms
Although the research on withdrawal symptoms remains underdeveloped, researchers looked at 34 studies, including 10 qualitative studies, 17 research reports on psychometric instruments, and 7 treatment studies, and found that some people who attempt to quit internet gaming experience anger, depression, mood swings, anxiety, fear, irritability, sadness, loneliness, boredom, and restlessness (Kpatsis D et al, Clin Psychol Rev 2016;43:58–66).

Treatments for excessive gaming?
Cognitive behavioral therapy (CBT). It’s been surmised that CBT can be used as an IGD treatment to help individuals improve their inhibitory control ability, recognize maladaptive cognitions, and employ more adaptive decision-making. However, no studies have formally examined the efficacy of CBT for IGD (Huang XQ et al, Curr Psychiatry Rep 2010;12(5):462–470).

Medication therapy. Although clinical trials are in the early stages, there is some indication that certain medications help video game addiction by altering brain chemistry to reduce the urge to play. Based on a 6-week trial, bupropion, also used for smoking cessation and depression, appears to offer help by inhibiting norepinephrine and dopamine reuptake (Song J et al, Psychiatry Clin Neurosci 2016;70(11):527–535). Naltrexone, meanwhile, has shown to be an effective treatment for gambling disorders, which share many of the same behavioral addiction traits as IGD.

Recommend support forums for patients
Computer Gaming Addicts Anonymous (www.cgaa.info) and Online Gamers Anonymous (www.olganon.org) both feature 12-step programs.

CATR Verdict: More research is needed to formulate effective treatment strategies and to understand whether excessive gaming is its own, separate disorder. But since excessive gaming can have a significant impact on people’s lives, treat it as you would any other behavioral addiction.