For countless generations, youthful pursuits have encompassed a wide array of activities. Every child typically finds something both entertaining and interesting to such extents as to spend hours of time in its endeavor.

The activity is not necessarily useful. Baseball card collecting, for instance, results in a pile of cardboard smelling like bubble gum, with the pile’s contents ordered chronologically, alphabetically, or upon some other basis, which will ultimately be tossed out with the trash once the child has left for college. The discovery of this act of dispatch will be met with gnashing of teeth, disgust and annoyance, not only at the potential financial loss but also psychological loss given the amount of time that went into the collection in the first place. Time was spent finding the cards, especially specific desired cards. Time was spent sorting the cards. Time was spent discussing the cards with friends who were equally obsessed. Sometimes, more money than intended was spent on the cards, particularly later in adolescence when money is more readily available. Collecting baseball cards is an activity that does not result in exercise, outdoor play, or “normal” social interaction. And yet, it has never been suggested that collecting baseball cards represents an addiction.

Not everyone collects baseball cards in the same manner. Some do so as a sideline to their other interests. Some pursue it with near-obsessive need. Some stop as they exit adolescence, while others take it on with even greater gusto as they age. Baseball cards are not inherently harmful, and I’m obviously using them as a metaphor here, but one can replace them with things that are potentially risky. Let’s replace baseball card collecting with baseball playing. Sloth has been replaced by exercise, but there’s also an increase in risk – one can be hit by a ball, injured by repetitive throwing, or beaten up in a brawl, following a bad call. I have only to look over my fence at my young neighbor next door to see how much time he spends thinking about baseball. A little league participant, he spends all his free time outside batting, catching, running bases, and wearing baseball-related gear. I know for a fact that he spends hours watching other people play baseball. It’s a shame that he has no life at all outside his interest in baseball. And yet, no one has suggested that baseball represents an addictive disease.

In the mid-70s, videogames first came into public awareness. They had been around for quite a few years by then, but Tank, Biplane and Pong were among the first widely distributed standup arcade games. Over the decades that followed, two major changes took place. The first was that of increasing degrees of reality within the games – the player no longer saw an animated representation of reality or more typically fantasy, but something that looks quite real and is meant to emulate potential reality. The second is the availability of such reality representations within small devices that are, themselves, within young people’s financial grasp. These reality-based games are divided into multiple groups. Some are violent: the player within these games is tasked with killing other individuals, often representations of other players within a multi-player network of gamers.

These killings are accomplished through the use of extensive weaponry and are accompanied by what one might imagine to be a realistic representation of blood and carnage. The games are designed to be entertaining and interesting. The activity of game play may have some positive aspects, increased hand-eye coordination, for example; but may have many more negative aspects. The active and ongoing use of such games by a single individual may have significant associated morbidity from a psychological standpoint. It has been widely posited within the lay press that such game play represents an addiction.

Can we differentiate these behaviors to such an extent that one represents an addictive disease while the others do not? If indeed baseball playing is never addiction but videogame playing is sometimes addiction, then our definition of addiction must be designed to meet that logic. And if videogame playing is sometimes just a lifestyle choice but sometimes represents addiction, then we need a way to distinguish one from the other, just as we do with alcohol intake or heroin use. That latter point is key, since it requires us to recognize that not all heroin use represents addictive illness. So it is within substance use, we commonly differentiate “use” from “disease.”

Alcohol use can be a social activity, not at all associated with addiction, yet carries an inherent risk. One might have a drink, then trip on the stairs or rather dramatically miss an exit off the highway, even while well within the legal limit. There is no medical disease here — no addiction is necessarily present — and yet the action of use has associated morbidity and mortality. In the disease of alcoholism, an individual might not be drinking at all most of the time, and then might binge only a few times a year. That individual has an addictive disease, but uses the drug less than an average individual without the disease. This brings us back to a point I’ve made before — that quantity and frequency of use are independent of the presence of addictive disease.

So back to videogames — is there a disease here? And if so, how do we define it? It can’t be defined based upon frequency of use, for that would not be in keeping with our definition to date of addictive illness. It can’t be defined based upon typical youthful energetic pursuits, or we would end up defining all such pursuits as addictive, or at least potentially so. Can it be defined based upon physiologic change, biologic findings or neurological evidence? And if so, shouldn’t we wait for such evidence to be localized and replicated before jumping to conclusions? And finally, let’s not forget that even if videogames are not addictive, certain games might still cause significant danger for players. This too requires our attention.

This column represents Dr. Gitlow’s personal opinion and does not imply any position or policy taken by either the AMA or ASAM.

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