The AMA, DSM-IV, and Video Games

Kudos to John Timmer over at Ars Technica for keeping up with legislative and activist efforts surrounding video games. Many bills seeking to restrict video game sales to minors have either failed at the federal level or have been overturned at the state level. The legislative efforts have usually centered on alleged links between violent behavior and violent video games, with little concern for any actual research backing up the link.

Perhaps the low concern for research is related to the fact the research is not clear-cut in displaying a link. There does appear to be a link between violent video games (if defined correctly) with “violent cognition,” though there is no strong data supporting a permanent link. For instance, children playing violent video games may feel more aggressive shortly after playing, but not carry aggressive attitudes toward others on a permanent basis due to their video game exposure. Similar thrills may occur shortly after watching stimulating action movies or TV shows.

I strongly suspect many attitudes toward research carried by journalists, legislators, parents, and other people are based on misunderstandings of how research is conducted as well as a lack of understanding as to what can actually be “proven” with research. (I have to laugh and admit I have no way to prove my suspicion, making me guilty of carrying an assumed tenet … just as I suspect others of carrying.)

Now, Timmer brings us news of a report from the American Medical Association’s (AMA) Council on Science and Public Health (CSPH). According to Timmer, the CSPH was charged with reviewing the published research on violence and video games in the 2006 AMA annual meeting, and reporting back at the 2007 meeting. This report has been released, and it will be of high interest to video game academics and others interested in the research.

The report provides a good review of the medical and psychological literature going as far back as 1985. The medical journals, especially, are often overlooked by gaming academics. I recognized some of the references, particularly Anderson and Bushman’s (2001) meta-analysis of studies on the effects of violent video games on behavior. Plenty of other references in the document should prove to be of high interest to those in the field of video game research.

The report addresses the topic of video game addiction. I discussed video game addiction in a prior post, which actually received a comment or two. Dr. Lemoyne Dunn over at the Texas Center for Educational Technology suggested a broader definition of addiction than I felt was justified when discussing video games. The CSPH report, presented by Mohamed K. Kahn who holds a Ph.D. as well as an MD, calls for a definition of addiction that includes not only video games but the Internet as well. The justification for this expanded definition is that the majority of those addicted to video games appear to be playing MMORPGs, and MMORPGs elicit higher opportunities for overuse.

The report further states the term “Internet addiction” was coined in the 1990s, and is not currently a DSM-IV classification. The authors initially shied away from calling video games addictive in nature, preferring the term overuse. Here is the pertinent paragraph (I’ve eliminated footnotes):

Although video game overuse can be associated with any type of video game, it is most commonly seen among MMORPG players, who represent approximately 9% of gamers. This is consistent with prior research on Internet addiction that suggests Internet use involving interactive, real-time applications has the most potential for overuse. MMORPGs are simultaneously competitive and highly social, and provide interactive real-time services. Researchers have attempted to examine the type of individual most likely to be susceptible to such games, and current data suggest these individuals are somewhat marginalized socially, perhaps experiencing high levels of emotional loneliness and/or difficulty with real life social interactions. Current theory is that these individuals achieve more control of their social relationships and more success in social relationships in the virtual reality realm than in real relationships.

Overall, the report states a lot more research is needed (a phrase oft repeated by researchers). One reason: no one really knows how many children may be affected negatively by overusing video games in general and MMORPGs in particular. The report states that “dependence-like behavior” may be evident in children, and may be related to over-using games rated high in violent characteristics. But here the logic fell down in linking video games with Internet addiction through MMORPGs, since most MMORPGs are rated T for Teen rather than the more violent M for Mature (with allowances that circumstances involving other players may change during gameplay (i.e., someone drops the f-bomb or makes some other comment inappropriate for children)). The authors call for the AMA to participate in revamping the ESRB game ratings at some point in the future. Anyway, the key summative sentence suggesting against video game addiction is as follows:

However, as with findings on long-term aggression, there is currently insufficient research to definitively conclude that video game overuse is an addiction.

That sentence will likely find its way into papers arguing against video game addiction, and literary efforts battling game censors. However, the report is careful to note broad characterizations of media, not just subsets of larger media. All such related media can be lumped together as “screen time,” and screen time should be limited for children, they opine. Since Internet addiction can encompass a variety of online activities that carried to an extreme can be detrimental to individuals, the authors end their report by recommending the AMA cooperate with other stakeholders to better define current game ratings, educate parents on potential harmful consequences of their children over-indulging in media, and, most intriguingly:

That our AMA strongly encourage the consideration and inclusion of “Internet/video game addiction” as a formal diagnostic disorder in the upcoming revision of the Diagnostic and Statistical Manual of Mental Disorders-IV.

It is interesting that after stating there is not enough research to say that video game overuse is an addiction, the council nonetheless seeks to lump video games with Internet addiction in general, and recommend it be added as a diagnostic disorder in a future revision of the DSM.

I should point out that just because something is added to the DSM, that does not necessarily make it a mental illness. It’s just what a group of doctors currently believe is a disorder. At one time, recall, homosexuality was listed as a disorder in the DSM. As times change, what is considered a mental disorder changes. So, it begs the question, Why should overuse of the Internet and computer games be listed in the DSM as a diagnostic disorder? If a person has an addictive tendency, they will find some way to express it, whether through electronic means or otherwise. To question further, Why not just say Internet overuse, rather than adding video games, is a diagnostic disorder if the only connection between the two is MMORPGs? Why besmirch video games, too?

This lumping of video game addiction with Internet addiction, under the justification that a small percentage of MMORPG players show signs of overuse, is based on flimsy reasoning. The slash between Internet and video game addiction should be eliminated, or at least replaced by “Internet/MMORPG addiction.” But in my (non-medical) opinion, I have to ask, Why should the Internet and MMORPGs receive special consideration anyway? What is it about a computer screen and an Internet connection that makes a disorder any more noteworthy than pre-electronic disorders? What about the person who frequents social spots, or bars, or night clubs and shows addictive social tendencies in real life? Electronic social interactions are not much different than face to face interactions, they are just performed using different communication tools. If a person has an addictive nature, that nature will find release in some way, even if the Internet were to stop working.

The authors state that the Internet has allowed socially retarded people opportunities to control their online lives to an extent not possible in real life, and this in turn causes some to overuse the new tool. But, I don’t buy it. If a person has a problem, the problem exists with or without the opportunity. I would say what AA says about alcoholism: once an alcoholic, always an alcoholic, even 20+ years since the last drink. But then, here we get into the argument of chemical addictions versus social addictions again.

On a more positive note, the council mentioned benefits of video games, particularly within the medical field. Statements like this in the conclusion displayed their medical bias:

As with most other forms of media, video games do have a potentially positive role, especially in the health care and health education sectors.

I would argue that the statement would have been more accurate if the education sector in general were included, rather than limiting it to the health education sector. Obviously, health education is a subset of education in general. To assert instructional video games are limited to being of service to only health education displays a bias toward the report’s audience. This is perhaps understandable, considering the source.

All told, a very interesting report, and well worth reading. I do like what the authors had to say delineating video game overuse as a more correct term than video game addiction, but I would indeed hate to see video game addiction, even couched within a broader context such as Internet addiction, added as a diagnostic disorder to the DSM.

References

Anderson C.A., & Bushman, B.J. (2001). Effects of violent video games on aggressive behavior, aggressive cognition, aggressive affect, physiological arousal, and prosocial behavior: A meta-analytic review of the scientific literature. Psychological Science 12(5). 353-359.

Council on Science and Public Health (2007). CSAPH Report 12-A-07: Emotional and behavioral effects, including addictive potential, of video games. American Medical Association, Chicago. [Online]. Available:
http://ama-assn.org/ama1/pub/upload/mm/467/csaph12a07.doc