When does a passion for gaming turn into a full-blown addiction?

Earlier this month, a Canadian law firm proposed a new class-action suit against Epic Games, alleging that the company's wildly popular game Fortnite is as addictive as cocaine. And it's not the first time video games have been accused of fueling addiction-like behavior. Video game addiction has been a curiosity for years, appearing in international headlines and even as a talking point for presidential hopeful Andrew Yang on the campaign trail. And this spring, the World Health Organization (WHO) made the designation official.

In late May of this year, the WHO voted to include 'gaming disorder' as a classification in the 11th Revision of the International Classification of Diseases (ICD-11). This inclusion meant that medical and mental health professionals could follow official, worldwide guidelines to diagnose and treat a patient who is struggling to control their video gaming habits.

Soon after that, companies and representatives within the video game industry protested the classification, claiming video games were being blamed or branded for a person's already underlying mental health issues.

To some in the gaming community, legitimizing gaming disorder is giving weight to people like Jack Thompson — an activist and now-disbarred attorney who gained prominence in the early 2000s with his highly publicized claims that violent video games led to real-life violence. Despite research to the contrary, some politicians still blame video games for violence like mass shootings.

But the WHO's intention isn't to demonize the genre or classify video games as the sole cause of harmful or avoidant behavior. The aim seems to be to define a disorder that stems from irrational dependence on video games in order to escape stressful or traumatic situations.

What is gaming disorder?

In the ICD-11, gaming disorder is defined as a "pattern of persistent or recurrent gaming behavior (‘digital gaming’ or ‘video-gaming’), which may be online (i.e., over the internet) or offline." This pattern of constantly playing video games can be characterized by a few specific symptoms: The inability to control one's gaming habits, an "increasing priority given to gaming," and a "continuation or escalation of gaming," despite negative consequences.The WHO classifies gaming disorder as an "addictive behavior disorder," in the same category as gambling disorder.

This behavior can be a long, continuous pattern or an occurrence that happens in repeating bursts, but isn’t specifically linked to the number of hours one plays. The danger lies, apparently, in a person’s uncontrollable urges to play games. The ICD-11 recommends a formal diagnosis if these symptoms last for 12 months, but a doctor can choose to make a diagnosis sooner if they believe it’s warranted.

So, playing a game for 12 hours on a weekend or doing a 20-hour charity marathon doesn't necessarily indicate a disorder. However, constantly missing work to play games could indicate a disorder.

In May, doctor and gamer John Jiao sent a series of tweets to clarify some of the confusion around the classification of gaming disorder. Referring to gaming disorder as "VGA," he provided examples of what constitutes gaming disorder. A "person with [a] stable job and healthy personal relationships" does not have the disorder just because they take time off from work to binge a beloved video game.

However, someone who "plays [League of Legends] 8 hours a day" and continues to play despite failing classes and ruining their relationships could be suffering from the disorder. The key to realizing when someone might have a gaming disorder is by seeing how much gaming disrupts their personal life.

Gaming Disorder and adults

A lot of news and attention goes to children and teens playing Fortnite or Overwatch, but neglects to address the growing problem in adults. Cam Adair, founder of Game Quitters, believes adults are the ones who hurt the most. "Gaming disorder often develops when parents are no longer around to supervise and set limits, especially when young adult men head off to college," he tells Mic. Without these limits, using video games to hide problems can grow out of control.

Young men are particularly vulnerable to gaming disorder because, according to The New York Times, they’ve been shown to spend the most leisure time strictly playing video games.

A combination of spending more time hooked on video games and hesitancy to seek help for mental health issues can result in an over-dependency on games to escape real-world problems.

According to Adair, these adults can end up "calling in sick to work in order to game, lying or deceiving those around [them] about [their] gaming, spending money regularly and impulsively in games, [and suffer from] poor hygiene and sleep."

Adair knows this firsthand. When he was young, he enjoyed balancing video games as a hobby alongside sports. But, he says, excessive and abusive bullying during his youth caused him to quit his sports team and dive deeply into video games. "In my own experience, gaming wasn't much of a problem until I experienced a lot of bullying," Adair said in an interview about his gaming addiction and recovery. "And that bullying really led me to want to escape, and escaping into gaming was a place where I had a lot more control."

Adair’s dependence on video games got worse as he grew older. He dropped out of high school, lied to his family about working, and would sneak home to continue playing video games for up to 16 hours a day.

While the videos were a salve for his existing depression, they weren’t treatment. Adair says he finally sought professional help on the day he realized he was suicidal. The experience led him to establish Game Quitters, a website that functions as an online group therapy forum and resource for members struggling with quitting video games.

The personal stories from other people recovering from video game dependency detail situations that range from regret over lack of personal development to suicidal ideation.

Why video games can be addictive

Why is it so easy for some adults to escape into games to the point of ruining their health? The answer may partially lie in the design of video games.

Dr. Sophia Achab, a psychiatrist who has led an addiction program at the University Hospital of Geneva since 2007, explained in the Bulletin of the World Health Organization that reward systems — such as the controversial 'loot boxes' — play a big part. "Rewards drive players to rack up the hours in pursuit of virtual or real-world gains," she explained.

It provides players an incentive to keep playing by creating a situation similar to gambling — wins and successes give players a mental thrill; the players will continue playing to seek that thrill again; and with each reward, the game becomes just a little harder to get the next 'hit' of excitement, elongating play time and investment.

This is a form of 'operant conditioning,' a term used by research psychologists that refers to the process of learning behaviors through positive or negative consequences. The most famous example of this is a lab rat in a box that learns to press a lever over and over to receive a reward.

Despite all the high-end graphics and dynamic gameplay, video games can essentially be stripped down to this basic concept: Encouraging continuous play with intervals of in-game rewards or negative consequences (such as being ineligible for in-game events) for halting play.

In combination with video game design, Dr. Susumu Higuchi, head of the Kurihama Medical and Addiction Centre in Japan, noted how the dream of e-sports and streaming success plays a part in hooking people as well. "Many of my patients talk about making a living from game play," he said in the Bulletin. "This belief feeds into the broader pathology."

Games that lack loot boxes, such as multiplayer online games (MMOs) like World of Warcraft, can also be attractive to people who are seeking socialization.

"Such games provide opportunities to play and compete with others, which would be compelling for most people, but particularly for those who might otherwise find it hard to socialize," Higuchi added.

Adair's experience and observations seem to agree with these findings. In 2013, during a five-minute TEDx talk, he explained that video games provided vulnerable people with a temporary escape, allowed them to socialize with new friends, gave them instant gratification and measurable growth, and offered challenges that make them feel important.

These are all good things in moderation. But for people with gaming disorder, video games become the sole source of satisfaction for these needs and can contribute to dependent behavior as they constantly seek that feeling of freedom, distractions from their loneliness and isolation, and a feeling of control in their lives.

Adair said understanding this information is important for someone looking to recover from the disorder. "It's not about the games; it's about why you play the games. If you understand why you play games, you can move on from them."

Seeking help for Gaming Disorder

Unfortunately — and somewhat unsurprisingly, given the video game community's reputation for toxicity — reaching out to online friends or gamemates can be difficult for individuals with gaming disorder. Discussing your struggling with mental health issues can open you up to disparaging and degrading comments; linking mental health issues to video games can be considered an attack on the hobby as a whole.

"Every gamer knows someone who plays too much. It's not like this is a big secret," Adair tells Mic. "The gaming community is defensive because they've felt under attack for decades, especially as it relates to whether gaming is a legitimate hobby and fears over whether or not gaming causes violence.” Ultimately, Adair says, gamers could benefit from recognizing the disorder so that those with it can seek support if needed without judgment.

Thankfully, support can be found both online and offline. On July 16, a German clinical trial reported that cognitive behavioral therapy worked exceptionally well on a group of 143 men with internet and computer gaming addiction. This treatment encouraged the participants to recognize their harmful behaviors without the use of psychiatric drugs. By focusing on what caused the urge to play video games, the subjects were able to adjust their urges into healthier reactions.

Kai W. Müller, one of the authors of the study, told Vice that he encouraged further studies for therapy techniques that can help men and women with gaming disorder. "[I]t is equally important to take these patients seriously and to accept that they are suffering and in need of help. Anything else would be mere ignorance."

For anyone currently struggling with their video game habits, Psychology Today provides an online database for folks to search for nearby video game addiction therapists. Adair's website, Game Quitters, also contains a list of gaming disorder therapists. Other counseling for adults can include 12-step programs and group therapy.

Choosing a treatment method depends on the person, though, as people will inevitably react to various forms of treatment in different ways.

"Your life is a series of chapters and one of them has included gaming," Adair advises. "There's no shame in deciding to move into a new chapter of your life — without gaming — and doing so doesn't mean gaming is bad."