What Constitutes ‘Gaming’ in the Gaming Disorder?: Observations and Recommendations

Gaming disorder (GD) first entered the official classificatory systems in 2013, with the DSM-5 introducing it (Internet Gaming Disorder) as a condition warranting more clinical research. ¹ More recently, in the International classification of disease-11 (ICD-11), GD has been included as a new diagnostic entity under the heading of disorders due to addictive behaviors. ²

The term “Gaming” has been used to represent a heterogenous set of activities that range from seemingly simple puzzle games and online ludo to much more complex massively multiplayer online role-playing games (MMORPGs). The advent of gaming through internet-based digital platforms has not only extended the reach and accessibility of gaming but also added to the heterogeneity of the concept of “gaming”. Over the past decade and a half, many new online activities have been developed that have been presented and promoted as “gaming”. The advent of e-sports and online fantasy sports has added to the complexity.

While ICD-11 and DSM-5 list GD, both these classificatory systems fall short of defining and delineating what is meant by “gaming”. While the debate around the classification and description of GD has been ongoing for at least a few decades, till now, limited attention has been paid to the need to have a clear definition and description of activities entailed as gaming. ³

Why do We Need to Define “Gaming”?

Multiple reasons, including clinical, research, policy, and legislative, warrant clarity on what constitutes “gaming”. First, given that GD is now a diagnosable mental disorder, it is important to be clear about the concept and meaning of the term “gaming”. Second, clinicians working with people suffering from consequences of excessive or maladaptive pattern of gaming should be clear on which all activities are to be included as “gaming”, so that they can screen, diagnose, and intervene appropriately. Third, researchers who aim to study GD (from epidemiological, etiological, and intervention perspectives) should be clear about the operational definition and activities that would be included in this construct. Fourth, the policymakers should have a clear picture of the meaning of the term when they develop policies, plans, and programs aimed at regulating the gaming industry or programs targeted at individuals with gaming and GD. Fifth, people engaged in gaming and the general population need to be aware of this so that they can correctly interpret the information they receive on “gaming” from various sources in their respective contexts. Finally, worldwide, self-regulation by the gaming industry is an important dimension of several existing or proposed regulatory frameworks on gaming. To facilitate this process, the industry needs better clarity on which all activities are included under the purview of gaming.

Other important aspects of this argument too justify the need for clearly defining “gaming”. These include game type and genre as an important descriptor of gaming behavior, delineation of gaming from gambling, and the gamblification of gaming. These are discussed in greater detail in subsequent sections.

Gaming Type and Genre as Important Mediators of Desirable and Undesirable Effects of Gaming

Gaming characteristics have been identified as important mediators of the association of gaming with various outcomes. Published studies that have included information regarding their sample‘s gaming characteristics have found that those who experienced problem gaming differed from those who did not, in terms of gaming characteristics (e.g., highly immersive nature of game in terms of player-specific game avatar creation or presence of an always “on” virtual gaming world, high potential for online-based social activities as inherent part of gameplaying, etc.). ⁴ Certain genres of games and specific games are more popular among those with problem gaming.^5–7 For example, people playing either MMORPGs or first-person shooter games have been reported to be more commonly suffering from disordered gaming as compared to those playing either real-time strategy or sport games. Also, it has been found that gaming genres (e.g., MMORPGs) have been significantly associated with the severity of IGD symptom (persistence), ⁸ and it has also been proposed that gaming characteristics might act as mediators in the relationship between problem gaming and suicidality.^4,9

The beneficial effects of certain game types have also been documented. Playing any sort of video game was beneficial for emotional and overall well-being; playing shooter games at moderate levels was found to confer cognitive benefits. ¹⁰ The increase in the time spent using online multiplayer games during lockdown restrictions of the COVID-19 pandemic had short-term relaxing effects ¹¹ but long-term deleterious effects.^11,12 Similarly, college students and adults who played augmented reality (AR) based games reported less loneliness during the first wave of the COVID-19 pandemic.^13,14 A recently published systematic review concluded that among adolescents and young adults, video games, particularly online multiplayer and AR games, mitigated stress, anxiety, depression, and loneliness during stay-at-home restrictions. However, in the case of at-risk individuals (especially male youth), playing video games had detrimental effects such as stress, anxiety, depression, loneliness, and GD symptoms. ¹⁵

Given that the game type is an important mediator of the beneficial as well as undesirable effects of gaming, it is important to include it as an important descriptor while defining and describing gaming behavior.

Gaming and Gambling

In the current context, the need to clearly define “gaming” has been accentuated by its potential overlap with gambling. Gambling disorder also has been included as an addictive behavior in the ICD-11. Researchers have pointed out that in certain online activities, there is a potential overlap between gaming and gambling. ¹⁰ Moreover, elements of gambling have been incorporated into the activities that have been recognized, marketed, and promoted as gaming and vice versa.^{16, 17} Certain arcade and casino “games” imitate different types of gambling. ¹⁸ In addition, in-game gambling has been described for different “games” such as Poker, Roulette, Blackjack, and Slot Machines. Debates are ongoing about whether gaming and gambling products can be classified based on features of playfulness, interactivity, elements of skills, planning, consideration, and achievements. ¹⁹

With the increasing movement to- wards online platforms, the overlap between gaming and gambling has grown even further. Perception of similarity between gaming and gambling activities has been highlighted by the fact that consumers tend to move between these two. ¹⁹ Though certain activities can be clearly demarcated as gaming or gambling, the consumers perceive many similarities in the case of many others. ¹⁹

The rise of online “fantasy sports” has complicated this issue even further. While these activities are presented, marketed, and promoted as “games”, concerns have been expressed that such activities have several elements of gambling. These include pooling money from players, calculating and distributing rewards based on amounts proposed and received, the players hedging bets on the outcome of winning and losing or performance by others in a competitive activity, and effects of a big win (i.e., a large monetary gain especially during early part of starting a particular gambling behavior).^20–23

Gamblification of Games

Another important theme that warrants closer attention is the transmigration of the gaming and gambling attributes across each other. Many online “games” include financial transactions. These include in-game purchases and other microtransactions. ²⁴ In many video games, there are elements of gambling in the form of microtransactions such as loot boxes (i.e., a consumable virtual item that may give some extra advantage in the game and is often obtained after the player spends real money).^25,26 Studies have observed a significant positive correlation between engagement with loot box (i.e., a virtual consumable item used as a random reward system in digital games that may be accessed through gameplay, as in-game items with virtual currencies, or purchased directly with real-world money) and severity of pro- blem gambling among adolescents. ²⁵ Some in-game purchasing systems have also been observed to be exploitative as these utilize informational advantages (e.g., behavioral tracking data collected during gameplay, without explicit consent or knowledge of the player, could be used to optimize both the type and timing of presenting the in-game purchasing offers), and data manipulation (e.g., developing alogrithms that synthesize and compare individual player-related gaming metrics with that collected from the population database of other gamers and dynamically manipulate in-game item prices based on their purchasing tendencies, available funds, item preferences, inventory, etc.) to influence the user behavior to promote contiuous spending by gamers. This is done to incentivize continuous in-game spending and maximize profits of the game developers. In addition, there are no or limited provisions for safeguarding the users. ²⁶

The legal status of such in-game financial transactions varies across juris- dictions. In some countries, recommendations have been made to consider such transactions as gambling. ²⁶ However, such jurisdictions are very few. Moreover, many such in-game financial transactions may not meet the strict legal definition of gambling, though these are still considered as predatory or exploitative. ²⁶ For example, loot boxes have been considered as gambling and completely banned in certain European countries like Belgium. Alternatively, a few countries like Australia have proposed banning them in games for children below 18 years. But, in many other countries, they are still not banned or regulated by law till now. ²⁷

The discussion above highlights the importance of having a clear operational definition of the term “gaming”, making the distinction clear between what all activities shall be considered as gambling and not a part of gaming, in the context of the rapidly evolving landscape of digital games.

Has “Gaming” been defined in Peer-Reviewed Publications?

Neither DSM-5 nor ICD-11 define gaming. To examine how the peer- reviewed publications have defined or described gaming, we searched PubMed for “gaming disorder” [All Fields] on August 23, 2022. A media release from WHO, dated February 11, 2022, had announced that ICD-11 was officially in effect for the national and international recording and reporting of causes of illness and death. ²⁸ The search was restricted to one-year period prior to the date of this press release. We included articles from February 11, 2021, till August 23, 2022. This was done to capture the changes, if any, since February 11, 2022. The article processing cycle can extend over a period of a few weeks to a few months. We expected that since it had been more than six months since the press release, we shall be able to capture the possible changes after it.

In line with the PRISMA guidelines, two authors established clear eligibility criteria to determine the articles’ eligibility for inclusion. ²⁹ Only studies meeting the following criteria were considered eligible for inclusion: (a) human participants (clinical and nonclinical populations); (b) included GD or problem(atic) gaming in the title, abstract, or main body of text; (c) study design was a meta-analysis or a systematic review; and (d) published since February 11, 2021.

We included only meta-analyses and systematic reviews because they com- ment on the inclusion and exclusion criteria applied for the selection of studies from the available scientific literature. Also, they often draw certain conclusions and make recommendations regarding the gaps identified in the existing literature, based on the synthesis of information from the selected studies.

Our search yielded a total of 27 results. We excluded three articles: One focused on problematic internet use and heart rate variability, ³⁰ one was a commentary on another previously published article, ³¹ and we were not able to access the full text of one. ³²

We searched the title, abstract, and main body of all the remaining articles for any mention of a description/ definition of gaming and GD. The information on the same has been sum- marized and presented in Tables S1 and S2.

Eight of the 24 articles included some definition or description of GD in the abstract section,^33–40 and 20 articles included a definition and/or description of GD in their main text.^4,10,33–50 Seven commented on the lack of definition/description of “gaming disorder” in the articles as a concern or limitation.^{4,10,35,36,38,39,42} Four articles recommended having a definition/description of “gaming disorders” in future studies.^10,36,38,42

On the other hand, only two articles included a definition or description of gaming in the abstract section.^15,35 Six included some description of gaming in the main text.^{10,15,39,46,47,50} These articles referred to e-sports (two articles),^34,39 multiplayer online games (one article), ¹⁵ AR games (one article), ¹⁵ video and/or computer games (five articles),^{10,15,34,46,50} freemium games (one article), ¹⁰ and games that involved microtransactions (one article). ¹⁰ One article mentioned that it excluded studies that are exclusively on offline gaming. None of the articles included a comprehensive definition or description of gaming. Only four articles commented on the lack of definition, description, or details of “gaming” in the included studies.^4,39,45,46 Two articles recommended that there is a need to have a more precise definition of gaming in future studies.^4,45 While 14 articles commented on the type of games, the list of none of the articles was comprehensive and included only some types/genres of games.

Recommendations

Having a clear definition and description of “gaming” is important from clinical, research, policy, legislative, and public awareness perspectives.

Previously, the term “games” has been operationalized in certain publications. However, these descriptions are not comprehensive. For example, Lehdonvita described games as a service and referred to a broad class of online games that provides in-game content on a continuing revenue model. ⁵¹

Defining the Terms Used in ICD-11

It is important to describe what is meant by “digital gaming” and “video gaming” as included in ICD-11. It is also important to specify that gaming behavior can be carried out using different platforms, such as mobile devices, computers, and gaming consoles, among others. Some of the current articles use the terms video game and computer games. The description of the term “gaming” must avoid such ambiguity. While the smartphone is a type of computing devices, these are not commonly referred to as “computers” by the users. It is important that the description of gaming clearly states the different digital devices or platforms that could be used to engage in gaming behaviors included under GD.

GD, as described in ICD-11, includes both online and offline gaming. ⁵² While the diagnostic category of Internet GD used the term “internet” in its title and description, the DMS-5 has stated that it could involve non-internet computerized games. This ambiguity should also be addressed explicitly.

Genre and Type of Games

The different genres of digital games, such as arcade games, puzzles or party games, first-person shooting games, real-time strategy games, multiplayer online games, MMORPGs, or fantasy sports, have been associated with a variable risk of developing disordered gaming.^53,54 At the same time, several of the traditionally played physical games such as cricket, football, or card (e.g., Poker, Rummy not involving money being at stake) or board-based games (e.g., Ludo and Chess) are now also available as “video” and “digital” games that can be played in online as well as offline modes. There should be clarity on whether these are included as “games” or not in the context of GD from public awareness, clinical, and research perspectives. In line with this, an accreditation system should be developed for rating the addictive potential of digital games after assessment of their features, such as social-media-like options (e.g., in-game chatting with co-players, sharing of one’s performance or achievements in the game) for engaging with other people, degree of control and manipulation influencing outcome in the game, degree of immersive experience in the game through means of customized avatar or elaborated storytelling, reward- and punishment-like experiences associated with winning or losing in the game, respectively, and the quality of audio–visual engagement while playing the game, among other game-related structural attributes. ⁵⁵ This shall help inform the general population and guide clinicians to better understand the addictive potential of a particular activity being marketed as a “game”.

Activities Constituting Gaming Behavior

It is also important to describe what constitutes gaming behavior. In its narrowest description, it refers to the behavior of those who are directly playing the game. However, gaming is a much more complex behavior. It extends beyond playing the games directly. Observers too have been conceptualized as a type of gamers. ⁵⁶ The observer is described as a fan who frequently watches e-sports events or streamers’ e-sports gameplay but whose e-sports gameplay is not equaled by their viewing consumption. While such categorization has primarily originated in the context of e-sports consumption, it seems relevant from the medical perspective as well. ⁵⁷ Similarly, prior to the actual playing of games, the users may spend excessive amounts of time, money, and/ or effort in arranging the required things (e.g., arranging access to a particular game, ensuring high-speed uninterrupted internet and power supply, getting expensive digital devices to enhance the gaming experience, etc.). This is somewhat akin to procuring “paraphernalia” required for sustaining drug use behavior or pattern by persons with substance use disorder. This particular aspect has not yet been studied among people with disordered gaming and is likely to be of relevance for both clinicians and researchers.

Demarcation from Gambling

It is important to have a clear demarcation between gaming and gambling. ⁵⁸ This is important to ensure that the users make informed decisions when they engage in a particular activity. The main criterion often relied upon while classifying a particular gaming activity as gambling or not is whether it is a “game of chance” or “game of skill” (i.e., the outcome is determined completely or largely by player-specific factors or skills), with the latter being not considered gambling in several jurisdictions. However, using this yardstick conflates the confusion between gaming and gambling as there has been no standard or universally accepted method to classify an outcome of gaming activity as that due to factors related to an individual’s skill and not any chance occurrences. Moreover, similar online activities have been variably classified as either game of chance or a game of skill by different jurisdictions. For example, the online game Rummy was considered as a form of gambling and banned by some states in India, whereas it has been considered as a game of skill by the Supreme Court of India. One possible approach to remedy this situation could be to make the gaming industry provide ratings about the gambling potential of different games, which are determined by a panel comprising of consumers from the general population and technical experts after playtesting the game before it is launched in the market. ⁵⁹ It has been observed that the regulatory frameworks that demarcate gaming from gambling have mainly focused on the objective characteristics of product offerings based on the viewpoint of manufacturers and technology. But, it is equally important to include the user perspective as an important component of this exercise. ¹⁹ This has implications for both researchers and policymakers.

In certain jurisdictions like Australia, it has been proposed that games with involvement of gambling-like elements should be classified as “R” category games (i.e., for those above 18 years old only) instead of the existing “PG” (i.e., for above eight years or parental guidance recommended) or “G” (i.e., for general audience) categories. This shall help better inform the users about the potential risks associated with a particular game and the need for exercising caution or self-regulation while engaging in a particular activity. This shall also help guide other stakeholders, such as parents of a child or policymakers, to take appropriate steps to ensure adequate supervision or monitoring and regulate different gaming behaviors. In line with this, terminologies that can create confusion should be avoided while describing gambling-related activities. For example, The Public Gambling Act (1987) of India used the term gaming in the context of gambling-related activities. ⁶⁰ The terms “game” and “gaming” should not be used in the context of gambling.

Labeling of Elements of Gamblification in Games

Another important theme is to develop clarity and consensus on aspects related to gamblification of games. Sport gamblification remains a concern globally. ⁶¹ This includes the legal status of in-game financial transactions. The different types of financial transactions that take place while gaming needs to be assessed for the presence of elements of gambling. In case a “game” includes such financial activities, these should be labeled and regulated as gambling activities. Having a clear disclosure on the same is the minimum that needs to be done. The disclosure should include the odds of receiving certain items as a result of such transactions (such as loot boxes). Such regulatory measures are in place in some jurisdictions. ⁶² It shall be even more appropriate not to label such activities as “gaming”. This shall have important implications for the stakeholders from the gaming and gambling industry as well as the law-makers making rules or policies that govern their operations.

Provisions for Consumer Protection

There is a need to have clearly stated and comprehensive legislative provisions for consumer protection. In certain jurisdictions, online games and in-game purchases are under the purview of consumer law. ²⁶ There should be a complete ban on any mislabeling during the marketing and promotion campaigns by the industry. The components and elements of each game should be disclosed. If the game involves any in-game financial transactions, the nature of the same should be clearly stated. This should clearly mention the odds of receiving such financial gains. The regulatory provisions should also include age- appropriate marketing and provisions for parental control of the games targeted at minors.

In conclusion, there has been a limited focus on the need to define and describe “gaming”. This is a concerning observation, especially since a considerable amount of literature has discussed and debated the validity as well as the utility of including GD in the classificatory systems. However, most of this literature has not discussed the importance of having a precise definition and description of “gaming”. We have presented the need and rationale of the same. We have also made recommendations that can help guide this process, highlighting points of particular relevance for different stakeholders such as clinicians, researchers, policymakers, gaming industry partners, players or consumers, and the general public. This is an important and long due issue that should be prioritized as it has significant implications.

Supplemental Material

Supplemental material for this article is available online.