There is still a major divide between the public understanding of addiction and the expert view. It's common to hear people casually call an activity "addictive" just because it's fun. Some people continue to see addiction not as a medical condition but as a moral failure, contrary to what major public health and medical organizations have said for decades now. There are still misconceptions that addiction requires some sort of physical component - for example, physical dependence that causes withdrawal - or that physical dependence is conclusive proof of addiction.
Experts, however, have long moved away from these old views of addiction, if they ever held such beliefs at all. Under the expert view, addiction doesn't even require a physical dependence component.
"We long ago moved away from thinking about addiction as a physical or physiological need for a drug," Robert West, editor in chief for the scientific journal Addiction, told me. "In most cases, it's not the physiological [dependence] that's causing the problem, because you can quite easily get people over that" - through, say, supervised detoxification. "It's a behavioral problem. Where the problem lies is that certain drugs and behaviors in certain people lead to such powerful motivation to engage in the behavior that it's damaging or could be damaging."
It's that last part of West's comment that's key to understanding addiction: It's when a person compulsively does something even as it leads to negative outcomes, physical dependence or not.
The WHO's designation of gaming disorder, in so many words, essentially fits games into the modern understanding of addiction:
Gaming disorder is characterized by a pattern of persistent or recurrent gaming behavior ('digital gaming' or 'video-gaming'), which may be online (i.e., over the internet) or offline, manifested by: 1) impaired control over gaming (e.g., onset, frequency, intensity, duration, termination, context); 2) increasing priority given to gaming to the extent that gaming takes precedence over other life interests and daily activities; and 3) continuation or escalation of gaming despite the occurrence of negative consequences. The behavior pattern is of sufficient severity to result in significant impairment in personal, family, social, educational, occupational or other important areas of functioning. The pattern of gaming behavior may be continuous or episodic and recurrent. The gaming behavior and other features are normally evident over a period of at least 12 months in order for a diagnosis to be assigned, although the required duration may be shortened if all diagnostic requirements are met and symptoms are severe.
The key consideration here is not any sort of physical symptom. No physical symptoms are mentioned. It's, again, about compulsive use despite negative consequences. This fits with how other addictions are viewed by experts.
This is not a simple diagnosis. You can't say that someone is addicted just because he plays games for more than a certain number of hours a week. Experts like Billieux, in fact, strongly cautioned against that kind of interpretation.
"We should not mix high involvement with problematic involvement," Billieux said. "You can have a high involvement in gaming, if gaming is your main hobby, but you can do it in a totally controlled way that will not have any negative consequences on your daily life."
"The main thing for me is loss of control - meaning you don't play when you planned to play, you play more than expected, and you lose voluntary control of the time you spend gaming," Billieux added. "The other thing is evidenced negative consequences at, for example, the social level, the academic level, professional level, or personal level."
One commonly cited example is serious sleep deprivation. If someone is consistently losing a lot of sleep over video games, chances are something bad is going on there.
Scott can attest to that. Over time, he got less and less sleep as he stayed up playing games - and it started hurting him throughout his everyday life. "With that small of sleep, my head was a total wreck," he said. "My memory went to hell."
That doesn't mean everyone who loses a bit of sleep to play games or do any other hobby is addicted. But it's one sign that can be used to try to diagnose if someone has a problem.
A good doctor puts these kinds of data points and anecdotes together to gauge whether someone is addicted to games. Are they losing sleep? Are they failing to attend to major responsibilities like school and work? Are they neglecting family and friends? If you put all of this together, and it looks like someone is consistently putting games above everything else despite negative consequences, then that's an indication of an addiction.
This applies to other drugs, too. It's not enough to just use alcohol, marijuana, opioids, or other drugs to be addicted. Even using them a lot isn't a sign of addiction (although it may be unhealthy for other reasons). Addiction is when someone uses these drugs compulsively despite the damage that follows.
So what makes the minority of people with addiction problems different than the majority? Researchers don't have a conclusive answer to the question, but they say it's likely a whole host of factors.
Some of it may be other mental health issues. Scott pointed out that his addiction flared up when he felt despair. When he was at his worst with his gaming, he said, "I was feeling really down about life, not sure what to do with myself." Video games gave him an out, letting him set aside his despair for a little while. Other mental health problems, like anxiety, could play a role too.
It also could be genetic. Some people just experience fewer temptations, or have more willpower, than others. Scientists don't totally know why. (Read Vox's Brian Resnick for more on the science of willpower.)
A person's environment could play a role too. Maybe video games, particularly free-to-play online games, are the only affordable release at the end of a long workday that a low-income person can find, making it easier for him to get trapped in it. Perhaps someone will be forced to move to a place where she doesn't have friends, family, or previous hobbies, so games will quickly become the only thing that gives her joy, and soon enough it's all she does. It could be that, for some people, games are uniquely accessible, making them easy to play too much - as was true in Scott's case, working from home.
And it could be all of these things combined or something else entirely. No one knows for sure, whether for gaming addiction or other forms of addiction.
There are also factors that might make games uniquely risky compared to other activities, making it more likely that someone will become addicted to them and play far too much.
One is easy access.
Billieux cited a patient who compared the rush he gets playing Fortnite, a very popular online multiplayer game, to his experiences skydiving. That may sound hard to believe (especially if you, like me, find Fortnite extremely boring), but it's this person's genuine impression of the game.
Consider what that means for this person. In the past, he would have had to take several steps, from booking a plane to physical travel, to get the rush he got from skydiving. Now, he just needs to turn on whatever device he plays Fortnite on and immediately get that same rush.
And Fortnite is on every single gaming device, including phones. So someone can play Fortnite literally all the time, certainly far more than they can go skydiving.
Scott pointed out that this was a big problem from him: Working from home, he was always a few clicks away from games, and that made it easy to misuse them.