Gaming disorder: Practical tips for general practice

The video gaming industry is massive, forecast to generate a revenue of US$522 billion in 2025, at an annual growth of 7.01%. This surpasses the combined revenue of the gambling, video streaming, music and film industries.¹

Australia ranked first globally in market penetration, defined as the percentage of a specific population that engages with video games, either by playing or purchasing games (34.7% in 2024).¹

There is a shift in demographics over time, with active gamers (defined as people who either purchased or played any video game in that particular research year) being less predominantly male (53% in 2023 vs 62% in 2006). Gaming is also a predominantly adult activity, with 80% of gamers aged over 18 years, with the largest age grouping (38%) being 18–34 years.¹

With the aim of assisting general practitioners (GPs) when a patient presents with problematic gaming, we present a practical approach to assessing this problem and developing a comprehensive risk assessment, a biopsychosocial formulation and an individualised treatment plan.

Shifting demographics, gaming behaviour and motivation

The COVID-19 pandemic altered gaming behaviour and spending.² The gaming industry invested considerable resources in understanding consumer priorities and spending triggers. The gaming industry’s responses to the findings include promotions, influencers, leveraging social aspects, customisation, rewards for returning gamers and other strategies.²

One particularly lucrative strategy has been the use of ‘loot boxes’, digital items offering randomised rewards in exchange for payment. Revenue generated from ‘loot boxes’ was US$15 billion in 2020 and was forecast to increase significantly.³ Although it shares similarities with gambling,^4,5 it has little regulation in place.⁶ There is evidence that the design feature induces overspending.⁶

Academic research identified reasons for gaming as broadly categorised into escape, coping, fantasy, skill development, recreation, competition and social reasons.⁷ More recent proprietary market research has identified similar motivations, though framed differently, including: stress relief, self-expression, achievement, social connection, escape, challenge, ‘to kill time’ and exploration.⁸

Defining harmful gaming

Concerns about potential harms from gaming span multiple domains, including interpersonal harm,^9,10 financial harm,¹¹ physical health effects¹² and the potential gateway to gambling.^4,5

The International classification of diseases, 11th revision (ICD-11) outlines formal diagnostic criteria for gaming disorder (GD).¹³ In contrast, the Diagnostic and statistical manual of mental disorders, 5th edition (DSM-5) proposes diagnostic criteria for internet gaming disorder but has not yet recognised this as a formal diagnosis.¹⁴ Although there are a lot of similarities between the two, there are differences in how they approach the diagnosis. The DSM-5 requires a patient to meet five out of nine criteria (preoccupation, withdrawal, tolerance, unsuccessful attempts at control, continued excessive use despite problems, deceiving others, use to escape/relieve mood and significant loss in a social domain because of gaming) over 12 months.^15,16 The ICD-11, on the other hand, requires a patient to meet four essential criteria, with some additional features (Box 1).

Many rating scales exist for GD.¹⁷ The Ten-Item Internet Gaming Disorder Test (IGDT-10) is relatively brief, easy to administer and correlates with both the ICD-11 and DSM-5 diagnostic criteria.^17,18 It has been validated across gender, age, cultures and multiple languages.^18-22

Prevalence and common comorbidities

A systematic review from 2023 found the global prevalence of GD was 5% but noted a level of uncertainty regarding the true prevalence within the literature, with a range between 0.8% and 17% and a high level of heterogeneity within the studies included in the systematic review.²³ Among those with GD, there were higher levels of comorbid psychiatric disorders²³ and substance use when compared with the general population.^23-26 Although causality has not been established, there are also associations with attention deficit hyperactivity disorder²⁷ and autism spectrum disorders.²⁸ Impacts on cognition, impulsivity, social relationships and academic performance are common.^23,29

Practical approach

When a patient presents with problematic gaming, the severity of the problem can either be assessed with a screening tool (eg IGDT-10) or mapped against diagnostic criteria (ICD-11 or DSM-5). Exploring the gaming behaviour can be made easier using the timeline followback (TLFB) calendar.³⁰ This tool was originally validated for substance use disorder, but it can be adapted for use to assess video gaming behaviour.³¹ This self-report diary can be used in general practice to track the frequency and duration of weekly gaming as well as time spent on other online activities and screen-free pursuits.

Case study

Ben Smith is a law student aged 22 years who attends the University of Melbourne. He moved from Sydney 5 years ago to study. His parents, worried about his worsening grades and recent failed exams, flew from Sydney to see him. They found Ben in his apartment, surrounded by empty beer cans and food containers.

Ben broke up with his high school girlfriend, Ella, 2 years ago. He was introduced to World of Warcraft (WoW)³² and found it a good way to cope with loss. Initially, Ben gamed only with his friends and continued to pursue his hobbies (hiking and basketball).

His friends drank beer while gaming, so Ben did the same. Over time, Ben found that he was good at WoW, found respect online and found it was becoming harder to stay away. He started to play alone, finding less time to sleep, attend class or complete his university assignments. With increasing gaming, he consumed more beer. He became irritable towards his university friends, spending less time with them and more time online.

Ben is an only child who had an unremarkable childhood. He excelled in school and was motivated to achieve the grades required to enter Law School. He was too busy studying to game during high school. He kept a small group of friends with whom he played basketball.

Ben expresses concern about how gaming is affecting his life and agrees that doing a TLFB calendar might be useful, focusing on his sleep, university work and alcohol use (Table 1).

Formulation

Ben meets the ICD-11 diagnostic criteria for GD, fulfilling all essential criteria and some additional features in Box 1. He should be assessed for alcohol use disorder. Other concurrent conditions may be present and need consideration. Mood symptoms should be addressed; however, caution is advised against prematurely diagnosing a primary mood disorder in the presence of any addictive disorder.

It is practical to classify risks into actionable immediate, medium- and long-term items. For Ben, this looks like the following:

• Immediate risks – aggression risks (fight in the tutorial), worsening of mood, reputational damage, friendship, relationship and social isolation
• Medium-term risks – psychological risks, failing law degree
• Long-term risks – medical (chronic liver disease, cardiovascular disease, diabetes, pancreatitis/gastritis), psychological risks, financial issues
• Others: suicide, self-harm and harm to others (evaluate on an ongoing basis).

One way to do a biopsychosocial formulation for Ben is to use the 4P formulation.³³ This can be used to form actionable treatment goals.³⁴ Ben’s 4P formulation is shown in Table 2.

Treatment options

There have been several recent systematic reviews for the treatment of GD.^35-37 Some of the pharmacological and non-pharmacological treatment options are summarised in Table 3. Using medication to treat GD is considered ‘off-label’, and currently there is not enough evidence to recommend medication solely for the treatment of GD.³⁵ However, medications might have a role in treating other comorbid conditions.

With regard to non-pharmacological treatment, cognitive behaviour therapy (CBT)-based psychotherapy has the strongest evidence base, although other modalities could be useful depending on individual circumstances.³⁵

Developing rapport, supporting Ben in gaining insight into the impacts of his gaming and collaborating to establish treatment goals can be done using brief psychological interventions. An example is ‘the magic wand question’.³⁸ For Ben, say: ‘Imagine that I have a magic wand and can make all your problems disappear. What would you want your life to look like in the next 12 months?’ His answers include finishing his law degree, playing games without feeling guilty, going back to hiking with his university friends, repairing his relationship with his parents and eventually dating. An example for Ben is shown in Table 4.

A comprehensive treatment plan for Ben, therefore, includes:

• risk management strategies
• negotiated goal-specific treatment
• brief interventions during consultations
• goal setting and checking progress
• sleep hygiene, mindfulness and grounding exercises
• cognitive exercises – early warning signs, recognising and challenging automatic thoughts
• treatment of comorbid conditions
• appropriate alcohol-specific interventions
• treatment of possible concurrent mood disorder or unresolved grief from relationship breakup
• referral for CBT
• treatment progress review
• physical health screening.

Summary

The video game industry is a US$522 billion giant, dwarfing the gambling, video streaming, music and film industries.¹ Understanding the commercial motivations and drivers for growth can help establish public health policies and treatment options to mitigate the harms associated with problematic gaming.^4,39

There is a gap in knowledge on effective medication options for GD.^35-37 The evidence base for CBT is stronger,^35,40 although it is still relatively weak when compared with other conditions.^35-37

A thorough clinical assessment of patients presenting with GD can shed light on their gaming behaviour and allow development of a biopsychosocial formulation, risk assessment and negotiated treatment plan for the patient.

Key points

• When a patient presents with problematic gaming, assess the severity of the problem either with a screening tool or by mapping it against diagnostic criteria (ICD-11 or DSM-5).
• Conduct a thorough biopsychosocial assessment, which may include the TLFB calendar, to understand the gaming behaviour, motivations and impact on their life.
• Risk assessment can be used to identify treatment goals.
• CBT has the strongest evidence base for GD; other psychological therapies and medication might be used to address comorbid conditions.
• Collaborate with the patient to set individualised, realistic and achievable treatment goals, focusing on reducing gaming-related harms and improving their overall health and wellbeing.