The role of psychoanalytic knowledge in the understanding and treatment of Gaming Disorder

 

Janiri L.¹, Ferri V.R.¹, Giuseppin G.¹, Pivetta E.¹

¹ Institute of Psychiatry and Psychology, Fondazione Policlinico Universitario “A. Gemelli”, Università Cattolica del Sacro Cuore, Rome, Italy 

Abstract:

In recent years, the unregulated use of video games has been dramatically growing to the point that it has been included as a new category in the latest edition of the International Classification of Diseases (WHO). Excessive gaming has been studied mostly within the “addiction” model, however different readings of this phenomenon are possible. Although the psychodynamic and psychoanalytical studies on the issue are limited, we have highlighted some of the contributions that may be mostly useful to provide a better understanding of the excessive use of video games and of their potential role, either direct or indirect, in the care of patients that experience this problem.

Keywords:Gaming Disorder, video games, addiction, virtual reality, psychodynamics
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Introduction

In the last two decades, the widespread use of video games by children and adolescents has remarkably increased public concern about potential harmful effects, including the possibility of developing a real “addiction”. Since, in 2013, the American Psychiatric Association included Internet Gaming Disorder within the “Emerging measures and models” section of the latest edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; APA 2013), the studies on problematic use of video games have drastically increased. In 2018, the World Health Organization (WHO) listed Gaming Disorder in the section “Disorders due to the use of substances or addictive behaviour” of the eleventh edition of the International Classification of Diseases (ICD-11; WHO 2018). Gaming Disorder has been defined by the WHO as a “digital-gaming” or “video-gaming” behavioural game pattern characterised by a lack of control over the game, an increasing priority given to the game compared to other activities to the point that the game takes precedence over daily activities, and the act of continuing to play despite the occurrence of negative consequences. In order to diagnose Gaming Disorder, the behavioural pattern must be of such severity as to cause significant dysfunction in the personal, family, social, educational, occupational and other important areas of functioning and it must be generally present for at least 12 months. The decision to include Gaming Disorder in the ICD-11 was based on the available literature evidence and it received the consent of experts from different disciplines who were involved in the technical consultation process during the development of ICD-11. However, some authors argue that to date there are not sufficient clinical evidence and clinical utility to justify the transition from a research construct to a recognized diagnostic category (van Rooij et al. 2018; Deleuze et al. 2018; Kardefelt- Winther 2014; Kuss et al. 2012). According to the authors, even if a patient was to intensively play video games and, simultaneously, to develop clinically significant impairments, this evidence could be still considered scarce in order to establish a causal relationship between the activity of playing and the dysfunction itself. (van Rooij et al. 2018; Kardefelt-Winther 2014).

The excessive use of video games in the bio-psycho-social model of addiction

In recent years, excessive play has been mainly studied from the point of view of the bio-psycho-social model of Behavioural Addictions. This model claims that Internet Gaming Disorder shares some crucial characteristics with Substance Use Disorders (SUDs), such as excessive use despite negative consequences, abstinence and tolerance phenomena (Weinstein 2017). According to Griffiths (Griffiths et al. 2016) the major components that make up the bio-psycho-social process that leads to Gaming Addiction can be summed up as follows:
1. the person is totally absorbed in the game;
2. the game is a way to escape reality and experience pleasant emotions;
3. the person needs to increase the amount of time spent playing in order to feel the positive effects on himself;
4. the person feels anxious, depressed and irritable if he cannot play;
5. a significant social withdrawal occurs;
6. the person cannot stop or reduce the game despite the negative consequences.
In accordance with this model of addiction, brain imaging studies have highlighted structural and functional changes in the mechanisms of reward (Meng et al. 2015) and control and inhibition (Zhang et al. 2016; Dong et al 2012), while more limited, at present, are the findings concerning the abstinence mechanisms (Weinstein 2017). Internet Gaming Disorder has been associated with reduced striatal dopamine transporter density (DAT) of the brain (Hou et al. 2012) and reduced occupation of dopamine D2 receptor (Kim et al. 2011). It seems that the excessive use of the dopamine reward system in the brain resembles the under-regulation mechanism observed in the case of drug and alcohol abuse, although in both the disorders there are no reference measurement before dependence that preclude any inference on causality (Weinstein 2017). In line with the model of dependence, the existence of a dopaminergic genetic vulnerability has been so extensively documented that some authors classified pathological gaming as a reward deficit syndrome (Weinstein and Weizman 2012; Blum et al. 2008).

The contribution of psychoanalysis

What can be the contribution of psychoanalytic knowledge to the understanding of the emerging phenomenon of excessive video games use? Can virtual reality be understood within the psychoanalytic approach? Can extreme forms of use be treated with analytical methods? To answer these questions we should leave for a moment the traditional concept of “Gaming Addiction” and try to consider the technological evolution we have witnessed in the last three decades as a new framework, within which new pathological patterns, but also new possibilities for understanding and care can emerge.
Video games, by providing the experience of other possible selves (avatars), through the enactment of different roles, the experience of making decisions and performing certain tasks, can allow the acquisition of patterns of mental action, moral judgments and the opportunity to elaborate psychological issues, based on the specific ability to collect symbolic elements (Petry 2011). According to a recent literature review on the use of video games in therapy (Franco 2016), different potential benefits should be considered, including the possibility to establish a solid therapeutic alliance and relationship, and to access personal information concerning the patient. Indeed, knowing the type of video game played by the patient can help us to gain information about the beliefs, inclinations and values of the patient himself. While, on one hand, the review reports that several studies highlighted the possible benefits of using video games in counselling and psychotherapy, on the other hand, it evidences that only few works focused on the integration of video games into an effective therapeutic practice (Franco 2016).
To date, the number of studies that have dealt with the issue of problematic gaming from a psychodynamic / psychoanalytic point of view is still quite limited, yet in many works abput video games, psychoanalytic knowledge is considered not only as a key to understand the phenomenon from a sociological and anthropological perspective, but also as a core part of the background of professionals who produce and market video games. Recurring quotations are those concerning the concept of flow developed by Csikszentmihalyi (Sale and Zimmerman 2004; Shaffer 2006; Novak 2010) and the game rhetorics by Sutton-Smith (Sale and Zimmerman 2004; Schell 2011). Less common but very interesting are the studies on video games from the analytical perspectives of Jung (Novak 2010), Melanie Klein (McDonald 2012), Freud (Boyer 2007; Petry and Petry 2012) and Lacan (Turkle 2011; Petry and Petry 2012).
McDonald, in a 2012 paper, provides some useful tools for approximating psychoanalytic knowledge to the study of the video game phenomenon. As suggested by other authors (Jarvinen 2008; Bogost 2007), McDonald invites us to pay attention to what are called “game mechanics”. A game mechanic is a “means that the game system offers its players to pursue the goals set in the rule set” (Jarvinen 2007, p. 253-8), in other words, it is a rule or a set of rules that associate one or more resources to one or more effects. Isolating the game mechanics would allow us to overcome the interpretative difficulties of reading video games, linked to “their indeterminate and changeable nature, their size, and the intrinsic difficulty of interacting with the medium” (Bizzocchi and Tanenbaum 2011, p.299). Moreover, the author introduces the notion of “playful unconscious”, suggesting that the psychoanalytic unconscious may be involved in the way we manage controls in games. In other words, our actions on game controls would undergo the manifestation of our unconscious, ultimately determining the decision of the gameplay (McDonald 2012). In particular, McDonald (2012) describes the mechanics of the Ico game for playstation 2 from the perspective of the object relations theory postulated by Melanie Klein. Starting from the assumption that every aspect of mental life takes place in and through the unconscious fantasy (Klein 1975), the author claims that every act of play is constantly interpreted by the player through unconscious fantasies, with particular reference to projective and introjective identification. The same concept has been also taken up by Weisel (2015), which highlights how the material selected during the game would serves as a support for unconscious psychic contents, drawing a parallelism between the player’s unconscious expectations and what Bion calls “preconceptions ”(Bion 1962/2013), which, according to the author, are temporarily realized during the game (Weisel 2015).
Esther Bick coined the term “adhesive identification” (Bick 2002) to indicate the first form of identification, a clinging to the outer surface of the object because an internal space has not yet formed, which is limited to the time of play. The author notes that when absorbed into the game the player is in a state of excitement, while outside the game he is in the opposite state of mind, an “empty” state. The author suggests that the game can facilitate parts of the complex organization towards a temporary form of pre-symbolic expression. When the game ends, this organization cannot be implemented in the same way and a further development in real life can be precluded (Bick 2002). The psychoanalytic theory of symbol formation suggests that the capacity for symbolization is acquired in early childhood and it could be undermined under stressful conditions or as a defence against unresolved conflicts. Weisel identifies two forms of breaking of the symbolic function (Ogden, 1985) working as operative defences in the excessive use of video games: in the first, fantasy and reality can actually be preserved but, as it happens in dissociative disorders, they are kept separate from each other and there is no connection between them; in the second, the most extreme form of facing unbearable situations, there is the extinction of any connection between signifier and meaning: a state of “non-experience”.
According to Weisel, during the game the actualization of the internal unconscious relational affectivity patterns occurs in their pre-symbolic form, as a temporary synthesis of what was previously irrevocably separated. Outside the game there is instead an inversion of any attempt at representation because the relationship between signifier and meaning is extinguished, the capacity for imagination is deactivated and emotional experiences are avoided (Weisel 2015).
Another work that offers important insights in the key of a psychodynamic interpretation of the excessive use of technology (video games, social media, pornographic material) is that of Essig (2012). The author highlights how pathological games always include someone who looks at the screen what life can offer, but he is not able to move easily between “online” and “offline”, between “game space” and “real space”, a phenomenon defined as “simulation entrapment” (Essig 2012). Players get confused and they can be blocked, just for a moment or for a long period of time. People lose the ability to regain reflective awareness of the type of experience they are experiencing and, as the author points out, this is an unwanted suspension. The author reports the example of boys who excessively play with World of Warcraft and don’t think they need to go to class, or even sleep or eat, as they would waste time for their glorious journey of character building. They feel they have to return to the game as soon as possible because this is how they will find the next step in their life path. Taking up some concepts from the work of Dreyfus (2000), Essig highlights three important experiential differences between play and real life (Dreyfus 2000): risk, opulence and rational incarnation. As for the first, the virtual world comes without any risk: “If I make a mistake, then I can restart the level”, “If I die, I can take advantage of another life”. The author points out that those who feel they have already lost what they can bear and feel that they will continue to lose because they are not good at being “bodies together”, would be particularly vulnerable to this “simulation entrapment”. The second dimension is that of wealth: in the game any available wealth can be controlled, the surprise is limited because all that is unknown can be known. What is typical of real life experiences is the fact that you can never know in advance which element will be significant (Borgmann 2000). Essig suggests that patients with problematic gaming are not ready to “let the world surprise them” (Essig 2012). The third dimension is that of rational incarnation, that is the way one uses one’s body in and through social connections. The interaction between two humans involved in a face to face conversation depends on a subtle combination of eye movements, head movements, gestures and posture. This “intercorporation”, as Merleau-Ponty (1962) names it, cannot be captured by splitting the interaction into independent channels (video, audio, etc.) or by adding 3D images, stereo sound, remote control, and so on. What is lost in screen-mediated interactions is the ability to control my body to change my position in the world, improving it or making it worse. Essig concludes by suggesting that the main differences between the technologically mediated experience and the traditional experience of being “bodies together” should be highlighted and discussed as an integral part of the therapy of patients with excessive use of video games (Essig 2012).

Conclusions

The understanding of problematic gaming within the framework of pathological addictions has brought a series of advantages, mainly in the field of research. The inclusion of Internet Gaming Disorder in the DSM-V has provided a common language, helping to bring clarity to an entangled world of pre-existing multiple and sometimes incompatible versions of the term “Internet Addiction”, which unevenly included the use of video games, social media, pornographic material, and others. The concept of “Gaming Addiction” is easily accessible to patients and parents and it highlights the compulsive / impulsive, isolated and self-destructive nature of this type of experience, which can easily be compared to that of an addict. However, in our opinion, the framing of the game within the model of dependence should not limit the use of different readings of the phenomenon, nor the range of future research. The concept of “dependence” was formulated in a period that came before the widespread dissemination of technology and virtual reality. Our way of being in the world has changed profoundly and increasingly often accompanied or mediated by technological support; the range of possible experiences in virtual reality is unlimited. Having an open and unconditional eye towards these new types of experience would allow us not only to appreciate the unprecedented innovations that new simulation technologies offer us, but also to develop an adaption of traditional clinical concepts to this emerging world, without assuming that what we already know today will be sufficient to explain these new behaviours and, consequently, these new pathological conditions.

References

American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorder. 5th ed. American Psychiatric Association.

Bion, W. R. (1962/2013). Eine Theorie des Denkens. ‘Second Thoughts’. Frankfurt a.M.: Brandes & Apsel.

Bizzocchi, J. & Tanenbaum, J. (2011). Well read: Applying close reading techniques to gameplay Experiences. In D.

Davidson (Ed.) Well Played 3.0 (pp. 289-315). ETC Press. Retrieved from http://www.etc.cmu.edu/etcpress/content/well-played-30-video-games-value-and-meaning.

Blum K., Chen A.L., Braverman E.R., Comings D.E., Chen T.J., Arcuri V., Blum S.H., Downs B.W., Waite R.L., Notaro A.,

Lubar J., Williams L., Prihoda T.J., Palomo T., Oscar-Berman M. (2008). Attention-deficit-hyperactivity disorder and reward deficiency syndrome. Neuropsychiatr Dis Treat, 4(5):893–918.

Bogost, I. (2007). Persuasive games: The expressive power of video games. Cambridge, MA: MIT Press.

Borgmann, A. (2000). Information, nearness, and farness. In K. Goldberg (Ed.), The robot in the garden: Telerobotics and telepistemology in the age of the Internet (90–107). Cambridge, MA: MIT Press.

Boyer, B. (2007). Gcg Feature: “Saving Ourselves: Psychoanalytic Investigation Of Resident Evil And Silent Hill”. In: Gamasutra.Com, available from: Www.Gamasutra.Com/View/News/103512/Gcg_Feature_Saving_Ourselves_Psychoanalytic_Investigation_Of_Res Ident_Evil_And_Silent_Hill.Php

Deleuze J., Long J., Liu T.Q., Maurage P., Billieux J. (2018). Passion or addiction? Correlates of healthy versus problematic use of videogames in a sample of French-speaking regular players. Addict Behav, 82:114-121.

Dong G., Devito E.E., Du X., Cui Z. (2012). Impaired inhibitory control in ‘Internet addiction disorder’: a functional magnetic resonance imaging study. Psychiatr Res, 203(2–3):153-8.

Dreyfus, H. (2000). Telepistemology: Descartes’ last stand. In Goldberg K. (Ed.), The robot in the garden: Telerobotics and telepistemology in the age of the Internet (pp. 48–63). Cambridge, MA: MIT Press.

Essig T. (2012). The addiction concept and technology: diagnosis, metaphor, or something else? A psychodynamic point of view. J Clin Psychol, 68(11):1175-84.

Franco G.E. (2016). Videogames and Therapy: A Narrative Review of Recent Publication and Application to Treatment. Front Psychol, 7:1085.

Griffiths M.D., Kuss D.J., Billieux J., Pontes H.M. (2016). The evolution of Internet addiction: A global perspective. Addict Behaviors, 53:193–5.

Hou H., Jia S., Hu S., Fan R., Sun W., Sun T., Zhang H. J (2012). Reduced striatal dopamine transporters in people with internet addiction disorder. Biomed Biotechnol, 2012:854524.

Järvinen A. (2008). Games without frontiers: Theories and methods for game studies and design (Doctoral dissertation). Available from: http://acta.uta.fi/pdf/978-951-44-7252-7.pdf

Kardefelt-Winther, D. (2014). A conceptual and methodological critique of Internet addiction research: Towards a model of compensatory Internet use. Computers in Human Behavior, 31, 351–354.

Kim S.H., Baik S.H., Park C.S., Kim S.J., Choi S.W., Kim S.E. (2011). Reduced striatal dopamine D2 receptors in people with Internet addiction. Neuroreport, 22(8):407-11.

Klein, M. (1975). The importance of symbol-formation in the development of the ego. In Love, Guilt and Reparation. London: The Hogart Press.

Kuss D. J., Louws J., & Wiers R. W. (2012). Online gaming addiction? Motives predict addictive play behavior in massively multiplayer online role-playing games. Cyberpsychology, Behavior, and Social Networking, 15(9), 480–485.

Merleau-Ponty M. (2011). Phenomenology of Perception, trans. C. Smith, London: RoutledgE, Abingdon, p. 14.
Mcdonald P. D. (2012). Playing Attention: A Psychoanalytic Reading Of Game Mechanics In Ico. In: The Journal Of The

Canadian Game Studies Association. Vol 6(9): 36-52. Available From: Journals.Sfu.Ca/ Loading/Index.Php/Loading/Article/View/79/112.

Meng Y., Deng W., Wang H., Guo W., Li T. (2015). The prefrontal dysfunction in individuals with Internet gaming disorder: a meta-analysis of functional magnetic resonance imaging studies. Addict Biol, 20(4):799–808.

Novak J. (2010). Desenvolvimento De Games. São Paulo: Cengage Learning.

Petry A., Petry L.C. (2012). Possibilities of encounter between Psychoanalysis and videogames: thinking with Freud and
Lacan. SBS-Proceeding of SB Games 2012, available from:
http://sbgames.org/sbgames2012/proceedings/papers/cultura/C_F2.pdf

Petry A. S. (2011). Heavy Rain Ou O Que Podemos Vivenciar Com As Narrativas Dos Games. In: X Simpósio Brasileiro De Jogos E Entretenimento Digital, 2011, Salvador. Proceedings Of Sbgames 2011. Available from: Sbgames.Org/ Sbgames2011/Proceedings/Sbgames/Papers/Cult/Full/9201 9_1.Pdf.

Sale K., Zimmerman E. (2004). Rules Of Play: Game Design Fundamentals. Cambridge, Massachusetts: The Mit Press.
Schell J. (2011). A Arte De Game Design: O Livro Original. Rio De Janeiro. Elsevier.

Shaffer, D. (2006). How Computer Games Help Children Learn. New York: Palgrave Macmillan.

Snodgrass J. G., Bagwell A., Patry J. M., Dengah II H. F., Smarr-Foster C., Van Oostenburg M., Lacy, M. G. (2018). The partial truths of compensatory and poor-get-poorer Internet use theories: More highly involved videogame players experience greater psychosocial benefits. Computers in Human Behavior, 78, 10–25.

Turkle S. (2011). Alone Together: Why We Expect More From Technology And Less From Each Other. Basic Books. Eua
van Rooij A.J., Ferguson C.J., Colder Carras M., Kardefelt-Winther D., Shi J., Aarseth E., Bean A.M., Bergmark K.H., Brus A., Coulson M., Deleuze J., Dullur P., Dunkels E., Edman J., Elson M., Etchells P.J., Fiskaali A., Granic I., Jansz J., Karlsen F., Kaye L.K., Kirsh B., Lieberoth A., Markey P., Mills K.L., Nielsen R.K.L., Orben A., Poulsen A., Prause N., Prax P., Quandt T., Schimmenti A., Starcevic V., Stutman G., Turner N.E., van Looy J., Przybylski A.K. (2018). A weak scientific basis for gaming disorder: Let us err on the side of caution. J Behav Addict,7(1):1-9.

Weinstein A.M., Weizman A. (2012). Emerging association between addictive gaming and attention-deficit/hyperactivity disorder. Curr Psychiatry Rep,14(5):590–7.

Weinstein A.M. (2017). An Update Overview on Brain Imaging Studies of Internet Gaming Disorder. Front Psychiatry,8:185.

Weisel A. (2915). Virtual reality and the psyche. Some psychoanalytic approaches to media addiction. J Anal Psychol,60(2):198-219.

World Health Organization. (2018). International statistical classification of diseases and related health problems (11th Revision). Available from https://icd.who.int/browse11/l-m/en.

Zhang Y., Lin X., Zhou H., Xu J., Du X., Dong G. (2016). Brain Activity toward Gaming-Related Cues in Internet Gaming Disorder during an Addiction Stroop Task. Front Psychol, 7():714.

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