eSports and Gaming Disorder

2020/01/20

Last year, 2019, was the year it was decided that "Gaming Disorder" would be included in ICD-11, the diagnostic criteria established by the WHO. At the same time, eSports was held as an event at the National Sports Festival in Japan. Furthermore, with the establishment of vocational schools to train professional gamers and the opening of "eSports clubs" in public high schools, the situation surrounding eSports in Japan is currently undergoing a major transformation.

The Kurihama Medical Center opened its "Internet Addiction Specialized Outpatient Clinic" in July 2011, and over the past eight years, we have seen more than 1,800 cases of internet addiction from all over Japan. Ninety percent of the patients are addicted to gaming. Having witnessed the seriousness and expansion of this problem, and having led the movement to include gaming disorder in ICD-11 as a WHO Collaboration Center, we have complex feelings about these developments.

What was the reason gaming was considered addictive in the first place? The components of addiction include the presence of behaviors specific to addiction (addictive behavior), the occurrence of health, social, and family problems resulting from those behaviors, and the existence of brain mechanisms common to addiction. Because it became clear that excessive use of games satisfies these three components of addiction, gaming was recognized as an addictive behavior, similar to gambling.

First, what is addictive behavior in gaming disorder? It involves impaired control, such as being unable to stop once starting or being unable to reduce play time even when trying; gaming becoming the top priority in life in terms of both time and money; and continuing or escalating gaming despite the occurrence of problems.

Next, what kind of problems result from this addiction? Among patients at their first visit to our hospital, almost all experience problems related to school or social life, such as a decline in grades to the point of being unable to advance to the next grade, long-term absenteeism, or social withdrawal. Many patients also experience health problems such as malnutrition due to irregular meals (e.g., one meal a day), day-night reversal, decreased bone density due to lack of exercise, economy class syndrome, and fatty liver. Furthermore, problems related to family relationships, such as verbal or physical abuse toward family members or spending large sums of money on in-game purchases using a parent's credit card without permission, occur in more than half of the cases.

Furthermore, findings from brain imaging studies are beginning to increase, showing that brain mechanisms common to addiction are occurring in patients with gaming disorder. For example, Chih-Hung Ko found that when images of online games were presented to individuals with gaming disorder and healthy individuals, those with gaming disorder showed more active activation in the orbitofrontal cortex, nucleus accumbens, anterior cingulate cortex, medial frontal cortex, dorsolateral prefrontal cortex, and caudate nucleus. This demonstrated that, similar to drug addicts, strong cravings occur in individuals with gaming disorder even when exposed only to visual stimuli (Ko et al.: 2009). Additionally, Yajun Meng conducted a meta-analysis of ten papers regarding the frontal lobes of individuals with gaming disorder, showing that, like drug addicts, they experience dysfunction in the reward system and the control of behavior and impulses by the frontal lobe (Meng et al.: 2015).

By summarizing these findings, it has come to be understood that individuals with gaming disorder have fallen into a state of addiction similar to other drug or gambling addictions.

So, are eSports players falling into gaming addiction? eSports players continue to train for long hours, which likely causes health issues, but brain imaging research is still insufficient, and much remains unclear as to whether their situation is the same as addiction.

Fanni Bányai and colleagues reviewed research on eSports and stated that there are few empirical studies and a lack of research on the impact on public health (Bányai: 2019). Thomas Chung also reviewed previous research and stated that most information is released from a commercial perspective, making it impossible to clarify conflicts of interest and resulting in an understanding of only a biased current situation. He further noted that as eSports becomes popular, the number of people participating in and watching competitions is already increasing worldwide, and while the number of people playing games is expected to continue increasing, the number of people with gaming disorder will likely increase as well (Chung: 2019).

To summarize what is currently known: games are addictive like drugs and gambling; falling into gaming addiction causes impairment in brain function; and much remains unclear, such as the difference in the impact on brain function between those with gaming addiction and professional gamers as shown by brain imaging studies. In a current situation where neither safety nor danger is clear, we must consider how many children, dreaming of becoming professional players, might fall into gaming addiction and ruin their lives if we easily incorporate eSports into educational settings or promote it as a sport. If eSports is to be promoted as an industry, it is a matter of urgency to implement sufficient measures against addiction.