Gaming Disorder: Are those joysticks all that innocent?

Friend 1: Up for a game?

Friend 2: Yeah

Friend 3: Letsss

Friend 4: Football?

Friend 1: Ground or FIFA?

Friend 2, 3 & 4: Of course, FIFA!!

I’m sure that leaving your house for game night or shouting excitedly at the screen while carrying out virtual loots plonked on your home couch might have earned you a dismayed shaking of head from your parents at least once—“Gone are those days when you actually went out to play on field.”

Sure, there is a lot of moral panic surrounding the issue of gaming already and amidst this when the International Classification of Diseases (ICD) declared Gaming Disorder (GD) as a clinical diagnosis in its latest 11^th edition; it raged a controversy amongst professionals and laymen alike. ICD, as published by World Health Organization (WHO), helps in identification, research and report of health trends and statistics globally. It defines the universe of diseases, disorders, injuries and other related health conditions including diagnosis pertaining to mental health. Walking in step with it is the Diagnostic and Statistical Manual of Mental Disorders (DSM) published by the American Psychiatric Association (APA) which in its 5^th edition has enlisted Internet Gaming Disorder (IGD) as an area requiring further study.

What do these authoritative texts mean by GD/ IGD?

According to ICD, GD is characterized by a pattern of persistent gaming behavior (either continuous or recurrently episodic), which may be online or offline, manifested by:

1. impaired control over gaming
2. increasing priority given to gaming to the extent that it takes precedence over other life interests and daily activities
3. continuation or escalation of gaming despite the occurrence of negative consequences.

This behavior pattern needs to be severe enough to result in impaired functioning in personal, family, social, educational, occupational or other important areas. For diagnosis, symptoms must be evident over a period of at least 12 months, although the required duration may be shortened if all criteria are met and symptoms are severe.

On the other hand, DSM-5 has hinted at complementary yet more detailed symptoms of diagnosis. Under the proposed criteria, IGD would be detected if five or more of these symptoms are present for a year:

      1. Preoccupation with gaming (on internet or any electronic device)

2. Withdrawal symptoms(sadness, anxiety, irritability) when gaming is taken away or not possible
3. Tolerance: the need to spend more time gaming to satisfy the urge
4. Unsuccessful attempts to reduce/ quit gaming
5. Loss of interest in other activities due to gaming
6. Continuing to game despite problems
7. Deceiving family members or others about the amount of time spent on gaming
8. The use of gaming to relieve negative moods, such as guilt or hopelessness
9. Risk: having jeopardized or lost a job or relationship due to gaming

The Controversy

To begin with, there is a debate surrounding the “goodness or badness” of games itself. Although the negative impact of gaming which is so widely reported (for instance: the recent death of a 16 year old in Madhya Pradesh, India after playing PUBG for 6 hours straight) can’t be denied; there is also equally researched but not very well accepted set of data pertaining to the positive contributions of gaming (e.g. increased experience of positive emotions, valuing of cooperation in team games, stress release, sharpening of cognitive abilities and so on). Thus, since the research body dealing with value judgment of the gaming phenomena is not yet conclusive, the move to pathologize gaming behavior has come under crossfire.

A very obvious area that is found under scrutiny is the vagueness of the criteria used for diagnosis. For instance, a scholar has pointed out that the ICD definition doesn’t distinguish between mild, moderate or severe cases; which means that clinicians — many inexperienced with video game addiction and oblivious to the gaming culture — have to decide this for themselves. Also, the DSM criteria requires the individual to exhibit only 5/9 symptoms to be diagnosed with IGD. While few indicators clearly point that something is wrong viz. experiencing withdrawal symptoms, the desire to stop but not being able to and losses on occupational and interpersonal fronts; checking off any 5 symptoms to the exclusion of these 4 important ones for receiving a diagnosis is quite easy. However, the remaining 5 symptoms are questioned for their credibility in indicating abnormality. For instance, any activity that you are extremely passionate about is likely to keep your mind and schedule preoccupied. If being preoccupied with artistic ideas isn’t considered abnormal then why is being preoccupied with gaming till the point of picking it over engagement in other activities considered problematic? Or, one could argue that tolerance applies to almost any hobby because with increased ability one needs to increase the level of challenge to get the same thrill that one got before from that activity. Hence, it is only normal for a gamer to seek increased stimulation from games as his/her level of proficiency increases.

Thus, more research is required to narrow down on what exactly can be considered as signs indicating the presence of problematic gaming behavior. This is cited as one of the reasons for inclusion of this diagnosis in ICD—the presence of such a diagnosis would accelerate more research in the area. However, a concern raised is that the presence of such a diagnostic category might promote confirmatory rather than exploratory research. So, instead of trying to find out what more can be indicative of this condition, clinicians may get caught up in confirming whether or not the prescribed criteria are displayed by the potential cases.

One last area of heated disagreement is where research has time and again pointed out gaming behavior as being accompanied by (comorbid to) other mental health conditions like depression and anxiety. It is often said that excessive gaming is used as a coping mechanism against the disturbing feelings invited by depression and anxiety and so the focus should be on treatment of these underlying conditions thereby rendering the separate notation of GD/IGD diagnosis redundant. However, a parallel that is often used to argue against this position is that of substance abuse disorders. They exist as a separate category despite of being associated with depression and anxiety because they in themselves pose sufficient risk that needs to be addressed first hand. Furthermore, in some cases, substance abuse has been found to lead to the latter conditions and so is GD found to independently exist. Hence, the symptoms presented by GD/IGD deserve to be treated independently of their comorbid conditions.

Will classifying abnormal gaming patterns as a disorder lead to abuse of diagnosis? Will it create a moral panic that was referred to at the beginning of this post? Will it stigmatize the gaming community even more than it is currently? The answer is not quite certain. However, is it a good idea to miss out on a diagnosis based on ICD’s statement that it is backed by a global consensus of scientists? Is it in the best interest of all to leave out this diagnosis because only a small minority of gamers might be suffering from disordered behavior? Will this even help to avoid the supposed moral panic and stigmatization? The answer is again quite uncertain. All one can say is that cautioning the public prematurely about a sensitive topic may involve more harm than gain and so the focus should be on INFORMING than WARNING.

The Deconstruction of OCD

“I am such a weirdo. I have strange OCDs.”

“I am so like Sheldon from The Big Bang Theory.”

“Oh, I can’t keep the TV volume on an odd number. I HAVE AN OCD!”

We come from a generation where the word OCD is thrown around with almost little or no thought put into the context surrounding the reference to this term. Part of why this is so can be attributed to the popular yet grossly misinformed portrayal of this and many other mental disorders in media. In fact, the media portrayal of OCD has almost reduced it to a funny illness that is not to be taken seriously. For instance, when you see Sheldon Cooper knock on Penny’s door 3 times in a row with a monotonous “Penny” following each knock, it first makes you laugh and then (maybe) consider this behavior as problematic. But only when we move beyond laughs will we truly understand this psychological disorder and stop trivializing every other quirk of ours as “a full blown OCD.”

OCD—what does it mean?

Obsessive Compulsive Disorder aka OCD is an anxiety disorder characterized by  time consuming and recurring obsessions and compulsions. An obsession is an unwanted thought, word, phrase or image that due to its repeated and persistent presence in a person’s mind causes unease and distress. These unwanted thoughts feel extremely intrusive to the person experiencing them. They drive individuals to engage in some repetitive acts or thoughts which at the first glance may seem quite purposeful but in fact are compulsions that a person performs in order to reduce or neutralize the anxiety generated from the overwhelming fixation on obsessive thoughts. These compulsions are ritualistic or rule based acts and thoughts which have somehow come to be associated with a particular obsession and exclusively hold the power to help regain control over one’s anxiety ridden mind.

Let’s explain the above highlighted keywords with the help of an example. The most commonly heard OCD is related to the need for cleanliness. A person with this OCD may experience an obsession with the idea of that touching any uninspected surface with bare hands poses a serious health hazard. In order to bury the worry that this thought arouses, s/he may wash hands EVERY time they touch a wall or a stool or a window pane. This can be understood as the compulsion that occurs in response to the overwhelming obsession concerned with hygiene needs. In fact, s/he may persist in their behavior even when their skin becomes all raw due to repeated hand washing. Also, we should note here that the distress caused due to the recurring obsession is so huge that it overshadows the distress coming from the physical pain arising due to the irrational, compulsive act of washing. This can be an indicator that the OCD has reached a clinical level of diagnosis wherein it has started interfering with an individual’s everyday functioning and well being.

OCDs—have your pick of the type

The obsession for cleanliness and hygiene coupled with the compulsion for washing is only one type of the many kinds of OCDs that one may suffer from. The need for order and symmetry is another kind which is often followed by the compulsion of putting things in picture-perfect order. Some individuals are overcome by checking compulsions whereby they often fear that they have committed some error that needs to be checked several times. This kind of OCD may not only involve compulsively checking the stove 5 times before you leave the house but may also involve constantly seeking reassurance from someone else about whether the stove was put off before leaving home.

Also, it is not necessary that a compulsion has to be a physical act. Compulsions can also involve mental rituals like counting up to a certain number or reciting a short prayer each time a threatening thought occurs. Although compulsive picking of skin (excoriation), hair pulling (trichotillomania), hoarding compulsions and preoccupation with perceived bodily defects (Body Dysmorphia) are conditions related to OCD and may in fact show similar patterns of expression; they are often diagnosed as separate disorders.

OCD—how does it sustain?

Individuals with OCD are hyper vigilant to danger detection. At the same time, their nervous system is often slow at recognizing that a threat has passed. When combined, this results in extremely high levels of long-lasting anxiety. Since the automatic danger/safety detection system is malfunctional in individuals with OCD, they try to gain control over their paralyzing fears by manually interfering in the form of compulsions. OCDs sustain due to negative reinforcement of the compulsive acts. In simple terms, negative reinforcement refers to an action that is strengthened as it supposedly removes some form of unpleasant stimuli from the said circumstance. For example, if taking a pain killer calms down your terrible headache then the act of ‘popping the pill when in pain’ is strengthened as it removes the unpleasantness experienced due to the said headache.

Thus, the negative reinforcer of hand-washing is strengthened as it illogically gets paired with the idea that it cleans the germs you contact on touching a wall thereby providing relief. However, over time the act of washing almost becomes an addictive behavior that you are dependent on to get rid of your obsessive thoughts and instead of something that helps you deal with the feelings of threat, it becomes something that makes space for you to experience more obsessive images. Instead of serving as a means to an end, the compulsion then becomes an end in itself.

Dealing with OCD: Exposure Response Prevention Therapy

Although several methods of dealing with OCD exist, the one that has most popular use is the Exposure Response Prevention Therapy. This technique seeks to restructure problematic behaviors and thoughts that drive the OCD. It involves gradual exposure to feared obsessions followed by restrictions on performance of the associated compulsion. A hierarchy of least to most anxiety producing thoughts is created and the person is encouraged to test the waters at a comfortable pace. So, a person excessively concerned about hygiene may start out by purposely touching a glass window and wash hands only after a delay of 10 minutes, then 20 minutes, then 45 minutes then an hour and eventually working up to not washing hands at all in response to such minor anxiety provoking situations. After the touching of this one threatening surface is mastered, one can move on to the next in the hierarchy and so on till a total disconnect is established between the obsession and the compulsion.

This technique and many others are easier said than done. Professional support in diagnosis and treatment is always recommended. OCD is much more than a “funny illness”. It is a very real clinical diagnosis that has the potential to reduce one’s potential drastically. Don’t let the unnecessary obsessions and compulsions take up the mental space that can otherwise be utilized to live a life that is worth it.

From Extra-Large Fries to Extra-Large Size

The “Extra Large” trend can be understood by connecting some dots from the point of view of psychology— apart from obvious biological and genetic reasons, of course. Isn’t it pretty obvious that the lieu of stores offering clothing lines for the “Plus-size” people stems from the availability of “Plus-size” meals at every major fast food joint in the town? The McMaharaja, the Doubly Loaded Pizzas, the Jumbo Pepsi cartons, 50% larger Chips packets and Big Scoop Ice Creams have indeed translated into the need for 3XL sized jeans.

So far, we only looked at how being too thin can be problematic. But at the end of this series on body image, it only seems fair to discuss how being Too Large can be problematic too. When I say ‘Too Large’, I don’t refer to a deviation from what the media has come to portray as the ideal. Too large is a body size where you start experiencing discomfort in your everyday functioning and well-being due to the extra pounds of weight lugging you down.

Did you know: researchers have found that the secret behind thin waist lines of the French is their small portion size? Right in the beginning we drew the connection between serving size and body size and this connection has been indeed upheld by Brian Wansink who found that even nutritionists eat 31% more of ice cream when they are given big instead of small bowls and 14.5% more when they are provided with a large instead of a small scoop. Pretty interesting how your mind fools you into eating more when provided with a larger spoon, eh? Hence, a cool DIY hack to try if you wish to lose some unnecessary body fat is to look around your kitchen and replace all those large serving spoons and plates with smaller ones.

Set point is the weight range in which your body is programmed to function optimally. Biologically, we are bound to return to our set point weight or a number around it because our body is designed as such that when we linger too far away from our set point weight, it either reduces or increases the metabolism rate depending in which direction the weighing scale is tipping. Genes ensure that most of the times you end up having a body shape that your ancestors have had. However, if you believe that hunger happens only in the stomach and not the head, then you’re mistaken. One study conducted with amnesic patients found that if offered 3 meals every 20 minutes after being completely satiated, the amnesic will still eat each with equal appetite. Why? Because they have no memory of having eaten earlier! Thus, your mind has a role to play in weight gain and weight loss too!

Another interesting fact that is widely known is that you eat more when you get more variety. So if you find yourself stuffed and slouched in a corner after hogging on a scrumptious buffet at your BFF’s wedding then you know it is psychology at work! In fact, the phenomenon of social facilitation states that we tend to eat more when we share a meal in other people’s presence. Thus, although savoring meals in isolation doesn’t seem like an appetizing idea, you can try to maybe reduce the number of people who share the table with you at your office canteen to somewhat protect yourself from your brain’s tricks!

Ever reach out for a bar of chocolate when feeling a rush of emotions—good or bad? Ever sit with a box of deep-fried snacks in your lap while you mindlessly watch a chick-flick but reflect on the bad events that happened earlier in the day? Ever use COMFORT FOOD to fight nostalgia, loneliness or anger? Only if these starchy foods ever helped you gain long term relief! All they do is momentarily play with your hormones to give you a “feel-good” factor which fades away soon enough to bring you back to reality with a few extra kilos hugging your waist. So eat when you need, not when you want. Be mindful! One hands-on trick for doing this is to maintain a food journal in which you enter everything that you eat and when. Do keep a record of the self-introspected emotions felt before and after eating to red flag comfort eating. Once the triggering points are recognized, try to consciously replace eating with another, physically involving yet pleasing activity like dancing. This shift will go a long way keeping those love-handles at bay.

Lastly, it is not possible that we talk about food and not mention dieting! Dieting is often considered to be an unpleasant, maybe even fear evoking term for many people. After all it involves putting a check on something that provides an instant mood boost—FOOD! In fact, most of the time people fail to keep up with their diet schedules because of what researchers Herman and Polivy explain to be the “What-The-Hell-Logic”. According to this principle, once you break a small rule of your weight management program, you believe that you don’t have it in you to go through with the rest of it either. This is to say that your thought process in such circumstances goes something like this: “If I am no good at this, what the hell! I might as well chug down that left over cheese pizza with a can of Pepsi and make the most out of my failure.” However, one way in which you can minimize this effect is by harnessing social support and self help. For instance, replace the junk food in your fridge with healthy alternatives. Surround yourself with people who’ll help you achieve this ideal and believe in your efforts. Check whether “out of sight, out of mind!” really works.

 DO YOU RATIONALIZE YOUR UNHEALTHY EATING HABITS TOO? This post may seem like the kind of common sense that existed right in front of your eyes but still somehow managed to skip your attention. But sometimes, aren’t simplest of things most required to take a step towards big changes? So, use this "common sense" knowledge from psychology to keep yourself from inching closer to obesity and develop a healthy body image.