Episode 13

  • What does the  DSM V have to say about video game addiction?

  • What types of games are part of this proposed disorder?

  • Is video game addiction a real issue?

Video games are often seen as sucking away people’s time and the popularity of games is at an all time high with no sign of stopping. It’s hard to tell what it would look like if someone had a “problem” with video games. The DSM has a proposed disorder and in some parts of the world this diagnosis would potentially be given more often. In the States, the prevalence is estimated to be small.


In this Podcast: 

  • Internet gaming disorder (IGD)  is not officially part of the DSM V. It is included as a subject that “needs further research.” 
  • The term “internet gaming” is referring to video games. 
  • The name internet gaming is misleading as many games that can take a tremendous amount of time aren’t on the internet at all. 
  • There are several types of games (and subtypes). This list is meant to be a general overview. 
  • The main types of games are single player (both off and online), MMO (massive multiplayer online), RPG (role playing games), FPS (first person shooters), mobile games (played on phones and tablets), Battle Royale .
  • There are multiple types of single-player games. Additionally many games have both single and multiplayer versions. 
  • The type of game that a person plays is very specific to each gamer and they will likely be immersed in the culture of gaming around that type of game. 
  • The proposed symptoms for Internet Gaming Disorder are nearly identical to the symptoms of substance use disorder, but the wording is for gaming instead of substances.
  • People who struggle with gaming too much share other characteristics. Some examples are not going to work/school in order to engage in gaming or recover from a game night (needing to sleep because the person was up all night), spending all of their time focused on the game in a way that they are neglecting other things, spending more money than they can comfortably afford to spend, to name a few. 
  • The key in evaluating gaming in your clients is to find out if there is distress or decompensation in functioning as a result. 
  • We should be cautious not to confuse enthusiastic engagement with pathology. 
  • IGD is likely real. The prevalence is said to be about .3-1% of all people who engage in these types of games. There is a higher prevalence in some Asian countries and treatment centers exist to treat IGD. 

Helpful Links:

American Psychiatric Association  https://www.psychiatry.org/patients-families/internet-gaming

Washington Post Article-Next Level  https://www.washingtonpost.com/sf/style/2016/12/07/video-games-are-more-addictive-than-ever-this-is-what-happens-when-kids-cant-turn-them-off/

Gamer Rant: How the Military Uses Call of Duty as a Recruitment Tool  https://gamerant.com/call-duty-modern-warfare-recruitment-tool/

Business Insider Article:  This ‘nerdy’ Special Forces soldier is getting paid to play Call of Duty


Game Quitters  https://gamequitters.com/video-game-addiction/

Gaming Monetization Statistics  https://www.statista.com/topics/3436/gaming-monetization/

Free Treatment Planning Tool  www.betsybyler.com/treatmenttool


You’re listening to the All Things Substance podcast, the place for therapists to hear about substance abuse from a mental health perspective. I’m your host, Betsy Byler, and I’m a licensed therapist, clinical supervisor, and a substance abuse counselor. It is my mission to help my fellow therapists gain the skills and confidence needed to add substance use to their scope of practice. 

I take topics that are typically aimed at substance abuse counselors and share them with mental health therapists in a way that is relevant and tailored to meet our needs. By adding substance abuse to your scope, you can expand your ability to treat the whole person and better meet your client’s needs.  Bringing more hope, healing and freedom to the people you serve.

Doing therapy is hard work. Made harder when addiction is thrown into the mix. Many of us didn’t get the training we needed to deal with substance use and finding the knowledge that you need to fill that gap can be difficult. Each episode, I’ll bring you information on substance abuse, topics that impact our work, helping you gain knowledge and confidence. In a relatable and practical way. So join me each week as we talk about All Things Substance.

Welcome back.  This week, we’re starting a new series where we’re going to talk about different kinds of addiction that aren’t having to do with drugs or alcohol.  Today we’re going to be talking about internet gaming disorder. 

Internet gaming disorder is not in the DSM V, yet. There are plans to put it in the ICD 11 when that comes out and so for now, it’s in the DSM V as areas that need other research.

Internet gaming disorder is kind of an interesting name.  I don’t know that it totally conveys what the authors are wanting it to convey.  To people in the gaming community, it kind of sounds like it was made by a person who doesn’t really know what they’re talking about or doesn’t really have experience with video games.

So in terms of the internet gaming, we’re talking about games that are typically played on the internet, but also can be played offline. We’re not talking about the gambling aspect of games online, like playing poker or other kinds of gambling mechanics, which we’ll talk about in the next podcast.

It’s talking about video games, whether it’s being played by a single person or online.    I’m going to explain a little more about the gaming industry  and how that relates to your clients.

Recent estimates put the prevalence of gaming, meaning playing video games,  at about 40% of the general population. That’s kids and adults.  That 40% number is based on the almost 8 billion people on earth.  So that is a huge amount of people playing games.

In modernized countries, I think that that number is actually fairly low when we talk about gaming as being everything from playing an XBox to playing Candy Crush on your phone. 

39% of people who play games are considered light users, which is five or less hours a week. Moderate engagement in games  is considered between five and 15 hours a week and heavy engagement with games is considered to be 15 hours or more a week.

Of the whole population who’s playing games the breakdown is 39% are considered light, moderate is 32% and heavy is 29%.  Over the last few years, those who are in the moderate and heavy categories, that number is rising.   More people are engaging in playing video games  online or offline, on their phones, et cetera.   

So in order to talk about this, we need to talk about what the different kinds of games are and what that means.   I feel like it’s pretty important with our clients, that if we get someone in our office whose hobby is playing video games, that we understand a little more about it, because it tends to be a big part of their lives.  Video games can often be seen as frivolous and a waste of time.  To the gaming community  it’s not like that at all. They build communities, they work on skill and it’s a hobby, just like anything else.

So one of the first things I’ll ask a person when they tell me they’re playing video games is how they’re playing. Are they playing on their phone? Are they playing on their computer or are they playing on a console?  

In the world of the internet,  there are camps. People who play PC games, meaning games on the computer, they’ll refer to it as the PC master race.   Then refer to people who play on consoles, like Xbox and PlayStation, as console peasants. It’s kind of funny and people are pretty passionate about whether they play on PC or console. 

Now, there are some people who do both because games aren’t available on every platform.  Game availability depends on platform. There are some games that are available on PC, Xbox and PlayStation, and then there are some that are just XBox or just PlayStation , or just PC. When you ask someone that question, they’ll start to tell you more because they’re like, “Oh, so you sort of understand what I’m talking about.” 

So the second thing I’ll ask them is what kind of games?  There’s different categories of games and if you aren’t someone who knows a lot about them, these are the main categories. This can be really involved.  

So I’m going to give you the types and kind of tell you the most popular games at the time of recording.  So we have single player;  MMO, which is massive multiplayer online; first person shooters, otherwise called F P S;  mobile games and battle royal.. 

A single player game can be played offline or online, and a lot of them are offline. This is what it sounds like. You’re playing by yourself. You’re not connected to other people on the internet and if you’re playing on the internet, it’s really about connecting with a server to update stats or update the game.

Within the single player genre, there are a lot of different types of games. So for instance, one of the most popular games is going to be Skyrim. Skyrim is available on the console and on PC and is by far the most popular game. This is a story driven game where you’re building a narrative and going through the lore that’s in the game.

This is a lot like reading a book.  The story is unfolding and you’re participating in it.  It is immersive. It is something that takes hours and hours and that is really detailed. I think about Skyrim a little like I think of Lord of the rings because it is a hero’s journey and it is something that unfolds as you’re moving through it.


Another example of a single-player game is grand theft auto. Although recently grand theft auto became multiplayer.  Minecraft is a single player, open world game, meaning that you are alone in the world and you can go anywhere you want and do pretty much anything. There’s no line moving you in a particular story direction.

Another single-player game that’s really popular is the series called Assassin’s Creed.  It takes place in different historical settings and it’s a little bit different because it’s not following the same storyline. It’s more of an open sandbox world where you can kind of move about and you can interact with things and other what’s called NPCs, which are non-player characters.   It is  single player. So you’re not playing with other people in the world, but you are interacting with non-player characters in the game that are scripted AI.

There are city building games in the single player category. There are things like Sims,  although the Sims game itself isn’t popular, that’s kind of a word that’s coming to mean those types of games where you’re interacting and building something, whether it’s building a town or a city.  You can build lots of different kinds of things and it’s called a SIM game. 

There are also real time strategy games.  So there’s Crusader Kings 3, which is historical and talking about different kingdoms and counties and war and battle, and that kind of thing.  Or another example of that is Civilization 6.  So those two are pretty popular right now.

So MMO basically means that you’re sharing a game world with others.  That at the very same time that you’re in the game world,  other players are also in the same game world. You can see their characters, you can interact with them and you can potentially do things together online. So you’ll do a quest or a battle or something like that  and you can do it with other people.  A really popular game in this category would be Destiny.  Another popular MMO game is Red Dead Redemption.

The third type of games I’ll talk about are first person shooters or abbreviated F.P.S.  This is Call of Duty. So a lot of people have heard of Call of Duty and in fact, it’s super widespread.  I’ll put a link on the website to an article  about there being people in the military whose whole job is to play Call of Duty.  It’s really interesting how games are entering different parts of sectors that aren’t typically known for gaming. 

A first person shooter is called that because you’re playing from a first person perspective.  So when you’re on the screen, all you’re seeing are hands and a gun or something like that. You’re not looking at a whole character, body or person . It’s as though you’re looking through your own eyes or your own helmets.

The focus is on squad based combat, typically where you are playing with a bunch of random other people and fighting against another group of random people. You could play with someone at the same time and be on the same server, but typically it’s just pulling people in from all over the world, and you’re not sure who you’re going to play with or against.   You have your own stats and that’s what you’re competing against, is getting to take out more quote unquote bad guys before you get killed and respawn. These actually take quite a bit of skill. 

There are sports games, but they also fall into the other categories, for instance, FIFA, which is soccer or football, depending on what country you’re in is a really popular MMO game. So you’re playing online in a world with other people.  Another popular game in the sports sub genre is Madden, NFL.

Next we’ll talk about Battle Royale.   There’s a number of games that might have a battle royal in them.  For instance, World of Warcraft is an MMO RPG, but it also has a battle royal component. So a battle royal is like Thunderdome;  40 people enter and one person wins.  Now it could be a team depending on how it goes, but typically these battle royals are about one person winning and there’s lots of different kinds of them.

One of the most popular is called Fortnite. If you work with kids, you’ll typically have heard about Fortnite. That is an example of a battle royal.  It is played online with random others and you’re competing against them in order to be the only one standing.

The last group that we’ll cover is mobile games. So mobile games are things like candy crush or Pokemon Go.  Financially, mobile games are a huge part of the market and we’ll talk about that when we talk about  micro-transactions .

So some of you might be wondering why this is necessary for you to know.  You’re not interested in video games.   Up in the North woods, where I live  hunting is a pretty big sport. When someone’s hunting, I want to know what they’re hunting, how they’re hunting, whether that’s something that they grew up with, how they learned it, how into it they are, because it is a real hobby and games are a real hobby.

So if your client is saying that they like to play video games, this can be a pretty in-depth discussion.  When I talk with someone about what kind of games they like,  I’m interested in a few things. Cause I think it tells me something about this person and what drives them. I want to know: do they play alone or are they playing with other people? And if they’re playing with other people, do they know these people?

Not necessarily in real life,  is it the same people that they’re playing with every day? 

For instance, when I played, I was playing with the same group of 10 people every night. These were real people. I knew their names. I knew about their families. , I knew the sound of their voice.

I knew what things they found, funny, that kind of thing. 

Or are they playing in a multiplayer, but they’re random people and they’re not really interacting with them. That’s a really different experience. If they are playing a multiplayer game, they might have met one or two people over time that they kept getting put in a battle together and they just formed a friendship.

Is the game story or lore heavy? Is it a story or is it an open world where you’re kind of doing your own thing? If it’s a story and there’s a lot of lore, that’s sort of like getting immersed in one world and it just keeps building.   

For instance, Elder Scrolls Online has a story and it’s an MMO RPG.  So you’re playing your own character and you’re interacting in the world, but there is a storyline that you’re following.  What is it about the story that appeals to them? Is it a hero’s journey? Are you playing the antagonist? What about the story is important and what about it interests them?   

This is a point where if you’re having trouble talking to someone and not getting them to really open up, you ask them about their game and all of a sudden they will start talking. Games create passion in people and the communities that are behind each game type are really intense. And they’re very specific about what they like and what they don’t like.

When it comes to the type of game, the reason that I think you should have a passing knowledge of the different categories is so that you understand some follow-up questions and that you have a frame for what it is they’re talking about. 

There’s another factor about games that is going to become really important. We’re going to talk about it a little bit today, but we’re also going to end up talking about it next week when we cover gambling. So there are these things called “free to play” games that have microtransactions.  

So the most notable at time of recording is Fortnite. Fortnite is a free to play game and by 2019, there were 250 million registered users.  So while they’re free to play, they’re not free in general. Fortnite, in 2019 was the top free to play game with a revenue of $1.8 billion. Candy Crush came in at number five with $1.5 billion. This is micro-transactions. 

You can buy things in game with real money to play the game. Now , it’s not “pay to win”, which in the gaming community is super frowned upon, where you have to pay actual money in order to move forward.

But if you want to move forward more easily, you could buy certain things in the game.  Or you can buy additional lives in game currency, personalized avatars,  ad free experiences, that kind of thing. This is a huge market.  

Microtransactions in the mobile game world account for $77 billion each year and that number keeps growing.  This also has implications for therapy, if somebody’s struggling with financial difficulties and they’re playing games, you might want to check into this.  How much are they playing in their game? How much are they spending on the game? 

This isn’t the same as “Oh, the new Fallout came out and I’m going to go buy a physical copy of the game, install it in my machine and play and never have to pay another dime”.

This is that there are extras that come along with it. It could be a downloadable content that you’re going to pay for. When a company has a game that they’re putting out, this isn’t something that’s a one and done,  the industry has created a way to make money.

Some of the tactics are upfront and a lot of them are really sneaky and people are spending an incredible amount of money on these games.  Some games are even sneaky about how much you’re spending on a thing. 

So for instance, let’s say you’re buying credits, that’s an in game currency and a thing you want costs 12 credits.  Well, if you bought 20 credits, But you’re spending 12 of them and it’s not necessarily dollar for dollar. Let’s say 20 credits was five bucks. Well, if it’s only 12 credits and you can buy more credits pretty easily, like how much money is that? 

It’s not that microtransactions are all bad. This is a hobby and so just like you would buy new gear for hunting or for something like that,  people buy new stuff for their games. The question is how much, and is it more than they can afford to spend?

One of the other things I want to talk about when it comes to gaming is the existence of competitive or pro gamers.  There are people and not just a few who play games professionally and competitively, and that is their whole job.  These are typically organized multiplayer game competitions between professional players, individually or as teams.

Pro gamers can earn between one to $5,000 a month with the  top player earning about $15,000 a month. That does not include sponsorships prizes. Or other activities that bring in money each month.

The last nonclinical piece I’ll talk about is the existence of what’s called a “let’s play. ”   Let’s play’s  are filmed video games that are being played by a person, that other people watch.  This, I think sounds bizarre to a lot of people who aren’t anywhere in the gaming world. 

There is a huge market for people on YouTube, Twitch, or other platforms who play video games for hours on end, either live streaming or something that they have filmed and then edited.  People watch those and they like to watch them play these games.  

The people who are doing these videos or live streams this is typically, for the popular ones, their entire job. They make a lot of money either from donations from watchers, which doesn’t seem like it would be a lot, but it happens a ton and they make decent money.  Or from ad revenue or from sponsorships from different companies.

Let’s plays are estimated to be about $107 billion a year revenue generator.  So this is a really big deal.  If your client says that they play video games, the chances are highly likely that they also watch let’s plays.  They’re going to have specific people that they really like to watch  who are better at narrating, what they’re doing or playing, or they’re better skilled and that’s all going to depend on what category of games they like. 

Now that we’ve talked about the different kinds of games and some of the different things surrounding gaming,  we need to tie this in to internet gaming disorder. So, it seems to me, that internet gaming disorder  was really part of a big discussion several years ago.

The research was showing that  in some countries, specifically in a couple of the Asian countries, that gaming was really getting out of hand in some people’s lives. and that treatment centers opened and exist to treat the internet gaming disorder.  There’s a lot of reasons for that, that are really probably not necessary for our purposes, but we do need to know about internet gaming disorder. 

We might wonder how much time is this person spending and what are the benchmarks of when this starts to be a problem?  So the DSM V notes that the gaming must cause significant impairment or distress in several aspects of a person’s life.  The proposed symptoms, I don’t really love them,  because they really look like they just took them from substance use and gambling, and changed them to be about gaming. 

In my experience with people who have had issues with video games, those aren’t the symptoms that I’m most concerned about.   I’m not going to read you the symptoms of internet gaming disorder. They’re in the big DSM, and you can take a look at them or look them up online. I will share with you some of the things I think based on my experience  with people that struggle with video games and my experience in the gaming world, what I think are some things  that are problematic.

You want to evaluate how often they’re playing, whether they’re playing is interfering with normal life, in terms of sleeping, eating, showering, going to work, going to school, that kind of thing.  And whether or not that’s impairing them,   and how they feel about that and whether they feel like there’s a need to change. 

It’s not enough that someone talks about their game all the time and seems to have interest in little else. There are people who have hobbies, like watching sports and that’s kind of all they talk about too.  It’s more a matter of:  are they engaging in things in the rest of their life? Are they spending time with their kids? Do they have any friends that they can see in real life?

Are they getting enough sleep? Are they engaging in normal age appropriate activities like work or school? What about hygiene? There are people who play video games and they only sleep during the times when their friends are not online. 

So typically in whatever time zone you’re in the big, hot time for being in a game is between probably 4:00 PM and like 11 or midnight.  There are people who will be playing with people in other time zones and so they end up being somewhat nocturnal where they’re not going to sleep until people are mostly offline, then they’re sleeping until they get up again and then getting on the computer and doing games. And that’s all they’re doing.

It does interfere with a lot of parts of their life.  They aren’t eating really well because they’re eating at their machine or at their console. They’re not really prioritizing showering.  They’re not having really a well-rounded life. They’re spending all their time doing this hobby,  literally breathing this hobby day in and day out.  Those are the things that I would be looking for. If I had someone in my office who was playing video games.

We want to find out whether they’re distressed by their gaming, whether they feel like they’re gaming too much, or whether they feel like they’re obsessing about it.  Sometimes someone could be playing and then they log out and they log back in to check on stats or to check on various things that they’re crafting or some games have auction houses, where you can sell different things that you got in the game. These are not real things like tangible things. These are things used in game and they want to check on that or when they’re not gaming that they’re spending time watching their game, that kind of thing. 

So you’re looking at not necessarily what we’ve judged as an appropriate amount of gaming, but how that fits into their individual life. There are certainly stories of people whose video game playing has gotten out of hand.  I’m not saying that there isn’t internet gaming disorder and there aren’t people for whom someone’s involvement in video games has torn apart their life, because there are those individual stories. I’m only suggesting that it’s not as bad as people make it out to be.

Overall the percentage of people that might qualify for an internet gaming disorder is extremely small.   Estimates put it  at 0.3 to 1%  of those who play video games. So that’s from psychiatry.org. The research does indicate that for those who struggle with video games in that way, and might even meet the addiction criteria  that the brain may be changing in similar ways as it does with substance abuse.  The research is ongoing and is not conclusive yet.

We want to make sure that we’re distinguishing between passionate involvement and pathology. Passionate involvement in a hobby is not pathology. What we want to look at is the person distressed by their gaming? Did they feel like they’re gaming too much? Or do they feel like it’s an appropriate amount?

The proceedings of the National Academy of Sciences says this about the current debate, “adding video gaming to the list of recognized behavioral addictions could help millions in need. It could also pathologize a normal behavior and create a new stigma”.

In the commentary on a study in the American Journal of Psychiatry, it was noted that the study suggests that video game addiction might be a real thing, but it is not the epidemic that some have made it out to be. As always we’re looking at impairment and distress.  

So the moral of the story with internet gaming disorder is that yes, internet gaming disorder is probably a thing. I don’t know that that’s the greatest name. I don’t know if a video game addiction is going to be the right phrase or game addiction, but. It’s not as prevalent as people would make it seem.

Video games are an art form.  They have a lot of benefit in a lot of ways for people in terms of a hobby.  I think that they’re really misunderstood in a lot of ways and I want to caution all of us to not be dismissive if somebody says they play video games.  Gamers are pretty sensitive to people thinking that their hobby is childish or pointless or a waste of time.

 As therapists, we want to engage with them to understand what makes them tick and their interests are certainly a part of it. Our purposes when talking about addiction is just trying to see, is this having an issue? 

I don’t know that we’re going to be diagnosing internet gaming disorder anytime soon, DSM 6  isn’t even on the radar  and in the States we don’t use the ICD very much. If it goes into the ICD 11, well it’s available, but I don’t know that it’s something that we’re going to be using anytime soon. 

We are not at an epidemic where people are going to be getting sucked into video games left and right. More concerning to me is an internet usage disorder, which isn’t really a thing. But I’m wondering if it should be.  I hear more damage done by social media involvement than by video games in my practice.

I wonder what you guys see, feel free to email me if you have comments about social media or video games and things that you’ve seen in your practice.

Next week, we’re going to be talking about gambling.  Traditional gambling, like casinos, racetracks, sports betting,  and online gambling that has a number of different faces.  So join me next week for our talk about gambling.

If you’re ready to take the next step in addressing your client’s substance use head on over to betsybyler.com/treatment tool. The treatment planning tool I created will help walk you through the process of evaluating your clients use and deciding how and when to intervene. The tool is completely free and will be delivered to your email so that you can use it right away.

Thank you for listening to the All Things Substance podcast. For show notes, links and downloads, please visit betsybyler.com/podcast. If you loved what you heard today, it’d be great if you would share those with your therapist, friends, and colleagues. If there are topics that you think would be useful and you’d like to hear me cover them, please let me know. Just send a message to podcast@betsybyler.com. I’ll see you on next week’s podcast and until then have a great week.

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