Evidence-Based Reviews

Video games: When does play become pathology?

Current Psychiatry. 2007 December;6(12):27-38

References

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¹¹ define pathologic video game play as incorporating high engagement plus core addiction characteristics such as interference with work or social life, failure to sleep, etc. In video game play, peripheral DSM addiction characteristics—such as high cognitive salience—may indicate high engagement. Characteristics of pathologic video game play, as identified by this group, are listed in Table 3.¹¹

Table 2

ESRB video game ratings system and content descriptions*

Rating	Content may be suitable for:	Examples
Early childhood	Age 3 and older; no material that parents would find inappropriate	Atari/others’ Dora the Explorer (series), Knowledge Adventure/Vivendi Universal’s Jump start (series)
Everyone	Age 6 and older; minimal cartoon, fantasy, or mild violence and/or infrequent use of mild language	Disney Interactive Studios/Buena Vista Games’ Hannah Montana (series), Taito Corporation’s Bubble Bobble
Everyone 10+	Age 10 and older; more cartoon, fantasy, or mild violence, mild language and/or minimal suggestive themes	Electronic Arts’ Need for Speed: ProStreet, Ubisoft’s Rayman Raving Rabbids 2
Teen	Age 13 and older; may contain violence, suggestive themes, crude humor, minimal blood, simulated gambling, and/or infrequent use of strong language	Midway Amusement Games’ Lord of the Rings Online: Shadows of Angmar (MMO), Sony Online Entertainment’s EverQuest (series; MMO)
Mature	Age 17 and older; may contain intense violence, blood and gore, sexual content, and/or strong language	Microsoft Corporation’s Halo (series), Rockstar Games’ Grand Theft Auto (most games in the series)
Adults only	Age 18 and older; may include prolonged scenes of intense violence and/or graphic sexual content and nudity	Vivendi Universal’s Leisure Suit Larry: Magna Cum Laude Uncut and Uncensored, Rockstar Games’ Grand Theft Auto: San Andreas
* On video game boxes, look for rating symbols on the front and content descriptions on the back.
ESRB: Entertainment Software Rating Board
MMO: massively-multiplayer online role-playing game
Source: Reference 7

Table 3

Characteristics of ‘pathologic’ video game play

Feeling agitated when not playing
Feeling “addicted” to play
Not being able to decrease time spent playing
Not sleeping because of video game play
Missing meals because of video game play
Being late because of video game play
Having arguments at home because of video game play
Letting video game play interfere with social relationships
Letting video game play interfere with schoolwork
Spending excessive amounts of money on video game play
Source: Reference 11

CASE CONTINUED: Going with the ‘flow’

Nick says he enjoys playing with people he’s met through a massively-multiplayer online role-playing game (MMORG, or also called MMO or MMP). The “guild” he has joined is a small community that collaborates to complete quests in the game. Nick describes his character—a healer—as a key figure who supports fellow players by replenishing their in-game health. Everyone in the guild thinks he’s important, and he likes to feel respected. Nick says this is quite different from how people treat him in “real” life. He says he often feels worthless and scared that his friends and family don’t think he’s good enough.

Clinical Point

Children who play video games in their bedrooms are twice as likely as others to play >15 hours/week and to play M-rated games

Sometimes Nick gets caught up in the game and plays for several hours past bedtime. The next day he feels tired and unprepared for school. One of his teachers has reprimanded him for not turning in homework on time, and his parents are frustrated by his behavior.

Video game play facilitates the experience of “flow”—a mental state of positive energy and effortless focus experienced while immersed in an activity over which one feels a sense of control. Video game play incorporates components of a flow experience (Table 4), including clear, focused goals that are attainable yet challenging and require a high level of concentration. Individuals who engage in artistic, athletic, or meditative activities often report experiencing flow.¹²

Flow can distort one’s sense of time, setting the stage for frustration on both sides when parents want their video game-playing child to engage in other activities. Their efforts to redirect their child’s attention—whether effective or not—disrupt the pleasurable feeling of flow.

Table 4

Characteristics of flow experiences related to video games

Characteristic	Effect associated with video game play
Clear goals	Discernible objectives are appropriate to player’s abilities
Highly focused concentration	Allows player to become absorbed within a limited field of attention
Lack of self-consciousness	Player’s actions seem effortless
Distorted sense of time	Player lacks accurate sense of how long he/she has been playing
Direct and immediate feedback	Success and failure are quickly evident, allowing player to change strategies
Appropriate level of challenge	Difficulty is balanced with player’s ability
Control	Player has sense of control and self-efficacy
Source: Reference 7

Types of games and devices

Role-playing games (such as Square Enix’s Final Fantasy series) involve players’ assuming identities and managing role-specific tasks and resources to progress through the game (for instance, a ranger befriending animals and tracking enemies in the wilderness).