Gaming to excess: Science-backed interventions can help people press pause

Dan’s interest in video games started as many do: at age 5, playing educational games. By age 8, his parents—a working couple in rural Switzerland—tried to cap his PlayStation use to an hour a day.

As a teen, though, Dan, a pseudonym used in a 2021 case study, was spending upwards of 12 hours daily playing mostly first-person shooter games. He rarely saw peers outside of school and lost an apprenticeship because of perpetual tardiness and fatigue (Niedermoser, D. W., et al., International Journal of Environmental Research and Public Health, Vol. 18, No. 4, 2021opens in new window).

It wasn’t until his next job stipulated psychotherapy that Dan and his parents began to view, and treat, his habit as an addiction. According to the study authors, who saw him at their private psychiatric practice, the approach worked: After 8 months of weekly cognitive behavioral therapy, Dan had reduced his gaming time to about 1.5 hours a day and, uniquely, hadn’t “shifted” his addiction to another vice, like pornography viewing or tobacco use, the authors say. Dan’s depression and insomnia—which were severe and moderately severe, respectively, at the start of therapy—receded, too.

Dan’s story—boy overcomes gaming disorder, a condition that the World Health Organizationopens in new window added to the International Classification of Diseases (ICD-11) in 2018—is presented in the researchers’ paper as a success. “In this case,” they wrote, “the patient could keep and probably successfully finish his apprenticeship. This is of major importance for his later prospects to live a self-determined and independent life.”

But not all mental health professionals would tell stories like Dan’s the same way. Some might point to Dan’s often absent parents as the root of the issue and so the first place to intervene, while others might see Dan’s case as a missed opportunity to nurture a young person’s passion and sense of competence. Until arriving in therapy, Dan thought of gaming not as a problem but as a path to wealth and fame. And some psychologists bristle at the term gaming “disorder” or “addiction,” which they see as more about politics than science. “A problematic diagnosis may promulgate policy efforts that restrict free speech and minors’ rights, without appreciable positive impacts,” a group of psychologists wrote in a 2018 APA Division 46 (Society for Media Psychology and Technology) statement expressing concern over the WHO’s classification.

Despite the concept’s controversy, some people’s gaming habits are significantly conflicting with multiple areas of their life, which calls for clinical attention. Many of them, however, are finding balance with psychologists’ interventions—or in some cases, simply time, said Zsolt Demetrovics, PhDopens in new window, chair of the Centre of Excellence in Responsible Gaming at the University of Gibraltar.

“The nature of development of most addictive disorders is progressing to worse, and that’s not clearly the situation in the case of video games,” he said. While more longitudinal research is needed, “there are signs of a much higher proportion of spontaneous recovery or just normalization of gaming after a more problematic period of gaming than in the case of other disorders.”

[Related: Developing games that build skills and promote well-being]

Some data suggest 76% of under-18-year-olds and 67% of adults play video games in the United Statesopens in new window. “Esports,” or competitive video gaming, is a fast-growing extracurricular activity at high schools and colleges across the United States.

But more people are gamers than they realize, including those who compete with their friends through Wordle or fire up Candy Crush on their phone while waiting in line, said Mitu Khandaker, PhDopens in new window, a game designer and arts professor at New York University’s Game Center who served on a panel APA hosted at the Consumer Electronics Show in January.

“Games, and our desire to create them, have always existed,” said Khandaker, the founder and CEO of Glow Up Games,opens in new window which builds games that feature and celebrate Black and Brown characters and storylines. “Games exist at this intersection between whatever our latest technological capability is and whatever it is that we want to express as a culture at the time.”

Still, the ubiquity and history of gaming doesn’t shield games from becoming problematic for some people. To the contrary, their increasing pervasiveness and advanced design is precisely what can make their use harder and harder to control. Researchers have shown how, for instance, even some of the simplest social media and game apps on phones use psychological theories, including the mere exposure effect (the more you see it, the more you like it), the Zeigarnik effect (the tendency to remember interrupted tasks better than completed ones), and social comparison to encourage prolonged usage (Montag, C., et al., International Journal of Environmental Research and Public Health, Vol. 16, No. 4, 2019opens in new window).

“The element that really is a game changer is the online element,” said Mark Griffiths, PhD,opens in new window a distinguished professor of behavioral addiction at Nottingham Trent University in England. “You could technically play 24 hours a day, 365 days a year.”

But most people don’t. According to a 2016 study that looked at a random sample of 3,389 gamers in Norway, just 1.4% were “addicted gamers,” meaning they experienced the so-called four pillars of addiction—relapse, withdrawal, conflict, and problems—at least sometimes, and 7.3% of study participants were pegged as “problem gamers,” meaning they met two or three of the criteria sometimes. The rest of the sample was considered either “engaged” (3.9%) or “normal” (87.4%) (Wittek, C. T., et al., International Journal of Mental Health and Addiction, Vol. 14, No. 5, 2016opens in new window).

A 2022 meta-analysis of 61 studies across 29 countries found other estimates of pathological gaming range from 0.3% to 17.7% (Kim, H. S., et al., Addictive Behaviors, Vol. 126, 2022opens in new window).

“A small but significant minority of people, usually young people, have a genuine problem with their video game playing,” said Griffiths, who is the director of the International Gaming Research Unit. “Whether we call it a disorder, whether we call it addiction or a problem—to me, that’s irrelevant. We have a small group of people where video game playing is basically negatively affecting every other area of their life.”

That appears to be the case for some of the tens of thousands of members in a Reddit community called StopGamingopens in new window.

“Playing video games makes me procrastinate from doing important work. Playing video games prevents me from connecting with others. Playing video games prevents me from making life decisions,” one self-described addict wrote. “I need help.”

According to the American Psychiatric Association—which added “internet gaming disorder” (IGD) to the research appendix of the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) in 2013—the condition is a “persistent and recurrent use of the Internet to engage in games, often with other players, leading to clinically significant impairment or distress.”

The WHO similarly says the condition is characterized by “impaired control over gaming, increasing priority given to gaming over other activities to the extent that gaming takes precedence over other interests and daily activities, and continuation or escalation of gaming despite the occurrence of negative consequences.”

A person is only typically diagnosed with IGD, the organization says, if their behavior patterns are severe enough to impair multiple key areas of their life, such as their employment and their personal relationships, and endure for at least 12 months.

“We’ve got lots of biological studies, lots of nationally representative, large-scale epidemiological studies. We’ve got a massive increase in the number of papers on treatment…and the number of dedicated gaming treatment clinics,” Griffiths said. “So for me, it is quite clearly a genuine disorder.”

But there’s little consensus when it comes to how best to categorize, and study, the concept. Vivien Wen Li Anthony, PhDopens in new window, an associate professor at Rutgers University School of Social Work and scientific director for video gaming and esports at the university’s Center for Gambling Studies, and others view gaming disorder as a behavioral addiction, similar to a gambling, sex, or food addiction.

Anthony points to research showing how, like other behavioral addictions, video games activate the same brain regions associated with reward and reinforcement as psychoactive drugs, but gamers don’t experience the types of physical withdrawal symptoms seen in substance-based addictions (Weinstein, A., & Lejoyeux, M., Dialogues in Clinical Neuroscience, Vol. 22, No. 2, 2020opens in new window). Problem gamers also tend to experience a loss of control and significant impairment in other areas of their life, she said.

Still, gaming has some features that set it apart from other behavioral addictions—namely, its lack of natural guardrails. “If you’re a sex addict, you don’t tend to be having sex for 10 hours in a row, but with gambling and gaming, people have incredibly long playing sessions every single day,” Griffiths said.

Other potentially addictive substances and activities also aren’t introduced in toddlerhood, Demetrovics added. “When we talk about gaming, it’s technically all kids, all adults,” he said. “So whatever intervention or regulation we want to introduce, we have to think about the whole population.” Plus, for a minority of gamers, gaming is indeed a legitimate career trajectoryopens in new window.

Douglas Gentile, PhDopens in new window, who runs Iowa State University’s Media Research Labopens in new window, prefers to conceptualize problem gaming as an impulse-control disorder. In one of his earlier studies, which followed more than 3,000 children in Singapore for 3 years, he and colleagues found that pathological gaming tendencies were persistent over time and, among other traits, predicted by impulsivity (Pediatrics, Vol. 127, No. 2, 2011opens in new window).

“If my belief about this is accurate, then the solution doesn’t need to be you have to quit cold turkey and never play again,” Gentile said. “The issue is one of balance.”

Other psychologists see excessive gaming not as a condition itself, but rather as a symptom of, or coping mechanism for, life circumstances or mental illness.

“Are there people who have allowed games to take up a bigger space in their life because of circumstances? Or because of not knowing positive gaming strategies? Absolutely,” said Ashley Elliott, PsyDopens in new window, a psychologist in private practice in Arlington, Virginia, and a workshop consultant for Take This,opens in new window a mental health nonprofit that serves the gaming community. “But for the majority of people who are experiencing these things, the game is not the culprit. Life is the culprit.”

A 2023 study, for one, found that adolescents with insomnia were more than twice as likely to develop IGD and substance use than those without the sleep disorder (Liu, Y., et al., Journal of Sleep Research, Vol. 32, No. 4, 2023opens in new window). One study that tracked hundreds of kids in South Korea over 4 years also suggests that issues like academic stress can lead to decreased self-control, which in turn raises the risk of pathological gaming (Jeong, E. J., et al., Journal of Youth and Adolescence, Vol. 48, 2019opens in new window).

“What tends to happen is you have someone who started with mental illness, and then they look for something fun that makes them feel important, or at least distracts them from their distress,” study coauthor Chris Ferguson, PhD, a psychology professor at Stetson University in DeLand, Florida, said. “And games are fun, so it’s like self-medication.”

In some cases, like Dan’s from the case study, though, the reverse pattern is plausible, too. Gentile said he was surprised to see his research suggest that psychiatric disorders including depression, social phobias, and anxiety seemed to follow problematic gaming.

“This demonstrates that these are likely comorbid problems, because if you just went in and treated the depression, that’s not going to fix it—the gaming seems to be an independent or interacting factor,” Gentile said. “A good clinician doesn’t say, ‘Well, which one came first? We’ll just treat that one.’ A good clinician has to look at the total picture.”

One thing most psychologists do agree on is that sheer time spent gaming isn’t enough to qualify someone’s gaming as pathological. It’s all about context.

“Anything you love to do, you’re probably sacrificing some other area of life for,” Gentile said. “If you love golfing, you might skip out of work early some days or refuse to do something with your partner on a weekend. Does that harm your work? Yes. Does that harm your relationship? I guess that depends on your partner. But that doesn’t make it an addiction.”

While researchers are still working to understand what sets the “addicted” gamers apart from the “normal” ones, some traits—including being male, young, high in impulsivity and neuroticism, and low in openness and conscientiousness—put people at higher risk for the problem.

One 2023 study also found that people who said they felt less meaning in life were more likely to experience greater gaming disorder symptoms (Fraser, R., et al., Computers in Human Behavior, Vol. 144, 2023opens in new window). Other research shows “psychological needs frustration” and “obsession passion” is related to problem gaming (Remedios, J. C., et al., Addiction Research & Theory, 2023opens in new window).

People’s motives for gaming matter, too. If you play for fun and socialization, for example, your gaming is more likely to remain healthy. But, “if you play games in order to forget about your problems, and you want to overcome your negative feelings with gaming, that predicts a problem,” Demetrovics said, pointing to his work and to Griffiths’s work (Comprehensive Psychiatry, Vol. 94, 2019opens in new window).

Certain conditions, including depression, anxiety, attention-deficit/hyperactivity disorder (ADHD), and social phobias also tend to co-occur with problem gaming, research shows (González-Bueso, V., et al., International Journal of Environmental Research and Public Health, Vol. 15, No. 4, 2018opens in new window). The links make sense: Differences in the dopamine receptors among people with ADHD, for one, may help explain their need for highly stimulating activities, like gaming. Their tendency to hyperfocus, too, might make them especially susceptible to playing for long hours.

Brain differences don’t explain everything. “You can take five people who have a gaming disorder, and they’ll all have a different etiology explaining why they’re hooked on those games,” Griffiths said. “Some of them will be because of a predisposing psychological or physical or neurodevelopmental illness. For others, there may not be any comorbidities at all.”

But for all of them, there are potential solutions.

Cognitive behavioral therapy seems to be especially promising. A 2020 study, for example, found the modality significantly improved problem gamers’ symptoms of IGD, as well as anxiety, impulsivity, and social avoidance, as compared to problem gamers assigned to a “supportive therapy” treatment (Han, J., et al., Clinical Psychology and Psychotherapy, Vol. 27, No. 2opens in new window).

A range of medications, including antidepressants and stimulants typically used to treat ADHD, can also benefit problem gamers, a 2023 meta-analysis found (Clorado de Sá, R. R., et al., Psychiatry Investigation, Vol. 20, No. 8, 2023opens in new window). “Several addiction drugs seem to be helpful here, too, which is interesting because that kind of makes the point plain that this is a brain disease, and it’s not that different from [substance use disorders],” Gentile said.

Anthony’s work has also revealed how mindfulness can curb people’s problematic gaming habits. In a small, 2017 Stage 1 clinical trial, she and colleagues randomly assigned participants to a mindfulness-based intervention or a support group. After 8 weeks, the mindfulness group had significantly greater reductions in the number of DSM-5 criteria they met for IGD, as well as fewer cravings for video gaming and maladaptive cognitions associated with gaming. The benefits held at the 3-month follow-up (Li, W., et al., Psychology of Addictive Behaviors, Vol. 31, No. 4, 2017opens in new window).

“Mindfulness doesn’t just help to regulate the behavior, it also helps cope with any sudden urge or craving,” Anthony said. “And, for people who use gaming as their primary way to cope with negative moods, emotions, or interpersonal conflict, mindfulness teaches alternative coping skills.”

Policy interventions may also help combat problem gaming. One 2023 study found that a year after China implemented policies to curb problematic smartphone use, the amount of time kids spent on their phones significantly dropped (Yang, Q., et al., BMC Psychiatry, Vol. 23, No. 1, 2023opens in new window). The group that had met criteria for addiction also fell below, on average, that threshold a year out.

Household rules can make a difference, too. In one of Gentile’s favorite studies, he and colleagues followed about 1,300 kids in two states over the course of a school year. They found that if parents set limits on the time and content of their kids’ video games, the kids tended to get better sleep, gain less weight, get better grades, and display more prosocial behavior and less aggression, as rated by their teachers (JAMA Pediatrics, Vol. 168, No. 5, 2014opens in new window).

“One simple thing—setting limits on amount and content of your children’s media—influences all of that,” Gentile said.

Even simpler: Learn about your kids’ interest in gaming before condemning it, psychologists stress. “We always encourage parents to play together with their kids, to try to understand what they do and why they do it, because otherwise, it just looks like a stupid, useless activity,” Demetrovics said. “There might be rational reasons or seemingly irrational ones, but we have to go together on this path with them.”